Clarissa Silva Martins*, Daniel Elias, Leandro Machado Colli, Carlos Eduardo Couri, Manoel Carlos L A Souza, Ayrton C. Moreira, Lucila Elias, Milton Cesar Foss and Margaret De Castro
Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil

 

Introduction: A hypothetical role of glucocorticoid (GC) in the pathogenesis of human Metabolic Syndrome (MetS) has been suggested since hypercortisolism shares several similarities with MetS. It has been postulated that excessive activity of CG within the normal physiological range, either by increased GC receptor (GR) sensitivity to the hormone or by altered cortisol metabolism, may contribute to the pathogenesis of insulin resistance and the development of cardiovascular risk factors.

Objectives: To evaluate the hypothalamic-pituitary-adrenal (HPA) axis sensitivity to dexamethasone (DEX), NR3C1 polymorphisms (SNPs), gene expression of GRα and GRβ isoforms, and a panel of cytokines (IL1B, IL2, IL4, IL6, IL8, IL10, TNF and IFNG) in peripheral immune cells of MetS patients and controls.

Materials and Methods: Prospective study with 40 MetS patients and 40 controls was conducted at the School of Medicine of Ribeirao Preto University Hospital. Plasma (PF) and salivary (SF) cortisol were measured by RIA in basal conditions and after 0.25, 0.5 and 1mg of DEX given at 2300h. In addition, p.N363S (rs6195), p.ER22/23EK (rs6189-6190), and BclI (rs41423247) SNPs were evaluated by qPCR allelic discrimination. Exons 3 to 9 and exon/intron boundaries of NR3C1 were sequenced. GR isoforms and cytokines expression were assessed by qPCR.

Results: PF (nmol/l) and SF (nmol/l) after 0,5mg DEX were higher in MetS patients compared to controls (PF: 119.0±24 vs. 57.5±2.9; p=0.07 and SF: 7.6±2.0 vs. 4.5±1.3; p=0.05) and also after 1mg DEX (PF: 70.2±17.3 vs. 37.9±2.6; p=0.02 and SF: 4.9±1.7 vs. 2.2±0.3; p<0.0001). After all DEX doses, a lower number of MetS patients suppressed PF and SF compared to controls. The BclI genotypic frequencies (%) differed between patients and controls (CC:56/CG:44 and CC:50/CG:32.5/GG:17.5; respectively, p=0.03). TheGRβ was overexpressed (fold=100.0; p=0.002) and IL4 (fold=-265.0; p<0.0001) was underexpressed in MetS patients.

Conclusions: MetS patients exhibited decreased hypothalamus-pituitary sensitivity to GC feedback, confirming the HPA axis activation in this condition. The lower frequency of the BclI polymorphism may contribute to this HPA axis dysregulation. Moreover, the MetS low grade chronic inflammation appears to promote GRβ overexpression, resulting in tissue-specific GC resistance, one of the mechanisms through which GCs may consume peripheral subcutaneous adipose tissue and promote the preferential expansion of visceral adipose tissue. Our data support the emerging concept that HPA axis disruption might be involved in the incompletely understood pathogenesis of MetS.

 

Nothing to Disclose: CSM, DE, LMC, CEC, MCLAS, ACM, LE, MCF, MD

PP06-1 21184 1.0000 THR-400 A HPA Axis Dysregulation, NR3C1 Polymorphisms and Glucocorticoid Receptor Isoforms Imbalance in Metabolic Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 11:30:00 AM PP06 5906 11:15:00 AM Adrenal Tumors and Glucocorticoid Action Poster Preview


Gabriela R V Sousa*1, Tamaya C Ribeiro1, Andre M Faria1, Beatriz M P Mariani2, Antonio M Lerario1, Maria Claudia N Zerbini2, Ibere C Soares3, Alda Wakamatsu2, Venancio A F Alves2, Berenice B Mendonca4, Maria Candida B V Fragoso5, Ana Claudia Latronico1 and Madson Q. Almeida5
1Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Hospital do Câncer de Barretos, Porto Velho, Brasil, 4School of Medicine, Sao Paulo University, São Paulo, Brazil, 5Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Introduction: Deregulation of microRNA (miRNA) expression in adrenocortical carcinomas (ACCs) has important prognostic and therapeutic implications. DICER1, an endoribonuclease in the RNase III family, is a key component of the miRNA processing machinery. In cooperation with its cofactor, transactivation response (TAR) RNA-binding protein (TRBP2), DICER1 cuts the pre-miRNA to meet the specification. Low DICER1 expression was associated with poor clinical outcome in ovarian, breast and lung cancer. Recently, DICER1 mutations in the RNase IIIb domain were found in steroidogenic Sertoli–Leydig cell and embryonic tumors. Aim: In this study, we assessed the mRNA and/or protein expression of DICER1 and TARBP2 in adult adrenocortical tumors (ACTs). Additionally, we investigated DICER1 and TARBP2 hot spot mutations. Expression of miRNAs (miR-103, miR-107 and miR-497) involved in DICER1 and TARBP2 regulation was also determined. Patients and methods: DICER1 protein expression was analyzed in 151 adult ACTs (77 adenomas and 74 carcinomas). Messenger DICER1 and TARBP2 expression was assessed in 55 ACTs (30 adenomas and 25 carcinomas) by quantitative real-time PCR. Expression of miR-103, miR-107 and miR-497 was determined in the same cohort. In addition, we sequenced four metal-binding sites (codons 1709 and 1705 in exon 24; codons 1810 and 1813 in exon 25) within the RNase IIIb catalytic center of DICER1 gene, and the (C)5 coding microsatellite repeat of exon 5 of TARBP2 gene in 61 ACTs. Results: Low DICER1 protein expression was significantly associated with reduced overall (p= 0.01) and disease-free survival (p= 0.01) in ACC patients. Among ACC patients with stage 3 or 4, 22 out of 32 (69%) displayed low DICER1 protein expression (X2= 10.1, p= 0.01). DICER1 protein expression was not significantly different between adenomas and carcinomas. At mRNA level, DICER1 expression had an important superposition between adenomas and carcinomas, but it was higher in carcinomas than in adenomas [median (range); 1.96 (-1.4 to 4.54) vs. 0.81 (-1.5 to 99) respectively, p= 0.03]. Among ACC patients, DICER1 mRNA levels did not predict outcome. TARBP2 expression was not associated with histological and clinical parameters. In addition, expression of miR-103, miR-107 and miR-497 did not correlate with DICER1 and TARBP2 expression in ACTs. No variant was identified in the hot spot mutation region of DICER1 and TARBP2 genes. Conclusion: Low DICER1 expression was significantly associated with poor outcome in adult ACC patients. However, DICER1 deregulation in ACCs was not caused by mutations within the RNase IIIb domain and not associated with expression of its regulatory miRNAs. Support: FAPESP (2012/21272-6; 2013/09621-8)

 

Nothing to Disclose: GRVS, TCR, AMF, BMPM, AML, MCNZ, ICS, AW, VAFA, BBM, MCBVF, ACL, MQA

PP06-2 18893 2.0000 THR-384 A Low DICER1 Expression Is Associated with Poor Clinical Outcome Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 11:30:00 AM PP06 5906 11:15:00 AM Adrenal Tumors and Glucocorticoid Action Poster Preview


Petra Bullova*1, Jan Schovanek1, Yasin Tayem1, Alessio Giubellino1, Robert Wesley2, Nikoletta Lendvai1, Svenja Nolting1, Zdenek Frysak3, Shivaani Kummar1 and Karel Pacak4
1National Institutes of Health, 2National Institutes of Health, Bethesda, MD, 3Department of Internal Medicine III – Nephrology, Rheumatology and Endocrinology, University Hospital of Olomouc, Czech Republic, 4National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD

 

Pheochromocytomas and paragangliomas (PHEO/PGL) are neuroendocrine tumors derived from chromaffin cells. Up-to-date, the only curative option for primary tumors is surgery. In case of metastatic disease, CVD treatment and 131I-MIBG radiation therapy remain the most effective ways of stabilization of the disease and decreasing the tumor burden. Unfortunately, these options are effective only in a small portion of the patients as 131I-MIBG therapy is limited to the tumors showing its uptake and tumor cells often become resistant to CVD with time. Therefore, there is an extensive research focused on finding a permanent and effective cure for metastatic PHEO/PGL.

In the present study, we studied a novel topoisomerase I inhibitor, LMP-400, as a potential treatment for this disease. First, we evaluated presence of topoisomerase I in human metastatic tumors. We found a significantly higher expression of topoisomerase I in these tumors compared to normal adrenal medulla and primary tumors, which provided us with a basis for further studies. LMP-400 inhibited cell growth of established mouse and rat PHEO cell lines and also of human primary tumor tissue cells in vitro. In a study performed in athymic female mice, LMP-400 showed a significant inhibitory effect on tumor growth and metastases formation in two evaluated drug administration regimens. Furthermore, we studied effects of the compound on hypoxia pathway and we found that low doses of LMP-400 decreased protein levels of hypoxia-inducible factor 1 alpha (HIF-1α), one of the transcription factors studied as potential metastatic drivers in these tumors. HIF-1α decrease resulted in changes in the mRNA levels of HIF-1α transcriptional targets. In addition, we performed in vitro cell growth inhibition studies combining LMP-400 with other chemotherapeutic drugs currently used in clinics and it showed an increased growth inhibitory effect in the combination than when treated individually.

In conclusion, we believe that based on our results showing the inhibitory effect of LMP-400 on tumor growth in vitro and in vivo and affecting hypoxia pathway, which plays a major role in these tumors, the compound is a promising treatment option for patients with metastatic PHEO/PGL. In addition, its effect at low concentrations in combination with other drugs makes it a very potential candidate for its use in future clinical trials.

 

Nothing to Disclose: PB, JS, YT, AG, RW, NL, SN, ZF, SK, KP

PP06-3 21003 3.0000 THR-385 A Inhibitory Effect of Topoisomerase I Inhibitor LMP-400 on in Vitro and in Vivo Animal and Human Pheochromocytoma Cells and Models 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 11:30:00 AM PP06 5906 11:15:00 AM Adrenal Tumors and Glucocorticoid Action Poster Preview


Annabel Sophie Berthon*1, Fabio R Faucz2, Mihail Zilbermint1, Guillaume Assie3, Maya Beth Lodish1, Eva Szarek1, Giampaolo Trivellin4, Ninet Sinaii2, Rossella Libe3, Stéphanie Espiard1, Ludivine Drougat3, Bruno Ragazzon3, Benjamin Feldman2, Mihaela Serpe5, Jerome Yves Bertherat6 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 4National Institute of Health, Bethesda, MD, 5National Institut of Health, 6INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

Recently, Armadillo Repeat Containing 5 (ARMC5) gene has been identified as a potential tumor suppressor gene for cortisol-producing primary macronodular adrenal hyperplasia (PMAH). These results were confirmed in our cohort of PMAH patients in which germline ARMC5 mutations were found in 15 out 34 patients. According to the expected tumor suppressor role of ARMC5, in silico analysis identified 7 mutations (20.6%) that are predicted to affect ARMC5 expression. Moreover, all patients carrying ARMC5 mutations had clinically significant Cushing’s syndrome. To elucidate the function of ARMC5, which remains unknown, we are using two different strategies. We first developed two transient Danio rerio models: a loss-of-function model created using antisense morpholino-oligonucleotide (MO) to knock down the zebrafish armc5 ortholog, and a gain-of-function created by injection of in vitro synthetized zebrafish armc5 mRNA. To further investigate which signaling pathways are modified in these two models, we performed RNA-seq on both armc5 MO and mRNA-injected embryos at 30 hours post fertilization. The comparative analysis of these two conditions suggests an important role of Armc5 in apoptotic processes, which corroborates in vitro human findings. We also used the CRISP/Cas9 methodology to mutate the Drosophila melanogaster armc5 ortholog. The armc5 null mutant flies appear to be developmental lethal. The results obtained from these two animal models lead to the identification of the ARMC5 pathway that is essential for tumor development in humans. We are also in the process of generating a KO mouse in the laboratory to better understand the role of this gene in adrenocortical pathology.

 

Disclosure: JYB: Investigator, Ipsen, Investigator, Novartis Pharmaceuticals, Advisory Group Member, atterocor. Nothing to Disclose: ASB, FRF, MZ, GA, MBL, ES, GT, NS, RL, SE, LD, BR, BF, MS, CAS

PP06-4 21417 4.0000 THR-386 A Functional Investigation of a New Aimah Suppressor Gene, ARMC5, Using Animal Models 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 11:30:00 AM PP06 5906 11:15:00 AM Adrenal Tumors and Glucocorticoid Action Poster Preview


Cadence True*1, Diana Takahashi1, M Susan Smith2 and Kevin L. Grove1
1Oregon National Primate Research Center, Beaverton, OR, 2OR National Primate Rsrch Ctr, Beaverton, OR

 

The hypothalamic neurocircuitry of metabolically-gated reproductive function has been well-studied in the rodent.  However, recent neuroanatomical data has demonstrated significant differences in the colocalization patterns for some of these key neuropeptides in the human brain.  To determine whether the non-human primate is a better anatomical model of the human we investigated the immunohistochemical localization of several key neuropeptides regulating reproduction and feeding in the infundibular nucleus, the primate equivalent of the arcuate nucleus (ARH), in ovariectomized adult female rhesus macaques.  Kisspeptin, neurokinin B and dynorphin are three important reproductive neuropeptides that are all coexpressed (KNDy neurons) in the ARH of rodents. While colocalization of kisspeptin-immunoreactivity (-ir) and NKB-ir was observed in the non-human primate as previously reported, very few fibers containing both kisspeptin-ir and dynorphin-ir were detected, consistent with recent data from humans.  To investigate the neurocircuitry implicated in food intake we examined the anorexigenic neuropeptides proopiomelanocortin (POMC) and cocaine- and amphetamine-regulated transcript (CART), which are coexpressed in the ARH of the rodent.  Additionally, we investigated the orexigenic neuropeptides, neuropeptide Y (NPY) and agouti-related peptide (AgRP), which are also coexpressed in the rodent.  Colocalized NPY-ir and AgRP-ir fibers were observed indicating preservation of this coexpression pattern in rodents, non-human primates and humans.  As previously reported no coexpression of CART-ir and alpha-melanin-stimulating hormone-ir (a POMC gene product) was observed in the non-human primate. Instead there was abundant colocalization of CART-ir and NPY-ir fibers in the infundibular nucleus similar to observations in humans. CART-ir was also observed in kisspeptin-ir fibers, once again similar to humans, indicating that these cells may be critical for linking metabolic and reproduction function in the primate.  Overall these findings highlight major neuroanatomical differences between rodents and primates including lack of evidence for canonical kisspeptin/neurokinin B/dynorphin and POMC/CART coexpression patterns in the primate.  We propose that compared to the rodent, the non-human primate is a better-suited model organism to study the hypothalamic mechanisms by which negative and positive metabolic states lead to inhibition of reproductive function in humans.

 

Disclosure: KLG: Advisory Group Member, Novo Nordisk, Principal Investigator, Novo Nordisk, Consultant, Ember, Principal Investigator, ERX, Consultant, Sanofi, Employee, Novo Nordisk. Nothing to Disclose: CT, DT, MSS

PP05-2 19082 2.0000 THR-471 A Coexpression of Key Neuropeptides Regulating Reproduction and Feeding in the Non-Human Primate: Differences from the Rodent 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 11:30:00 AM PP05 5912 11:15:00 AM GnRH & Neuroendocrinology Poster Preview


Darwin Omar Larco*1, Madelaine J Cho-Clark1, Shailaja K Mani2 and T John Wu1
1Uniformed Services University, Bethesda, MD, 2Baylor College of Medicine, Houston, TX

 

Gonadotropin-Releasing Hormone (GnRH) neurons originate outside the central nervous system (CNS) in the nasal placode where their migration to the basal forebrain is dependent on the integration of multiple signaling cues during development. The proper migration and establishment of the GnRH neuronal population within CNS is critical for normal pubertal onset and reproductive function. The endopeptidase EP24.15 is expressed along the migratory path of GnRH neurons and cleaves the full-length GnRH to generate the metabolite GnRH-(1-5). Using the GN11 cell model, which is considered an immature GnRH neuronal cell line, we recently demonstrated that GnRH-(1-5) inhibits cellular migration in a wound closure assay by binding the orphan G protein-coupled receptor 173 (GPR173). GnRH-(1-5) activating GPR173 initiates the formation of a complex with b-arrestin 2 and PTEN to subsequently inhibit the STAT3 pathway to regulate migration. In this study, we examined changes in genes, matrix metalloproteinase (MMP) activity, and secreted chemokines, which are implicated in the regulation of cell migration, in GN11 cells treated with GnRH-(1-5). First, we used a PCR array (Qiagen) to measure changes in 84 genes in cells treated with GnRH-(1-5) for 30 min. Acute GnRH-(1-5) treatment significantly decreased members of the cytokine signaling pathway such as IL-1alpha (0.62 relative to 1.0) and IL-4Ralpha (0.73 relative to 1.0), which correlates with our previous finding that GnRH-(1-5) inhibits the normally cytokine-activated STAT3 pathway. We also measured the activity of MMP-2 and MMP-9 by zymography in GN11 cells exposed to GnRH-(1-5) and found no significant changes. Furthermore, we measured the secretion of chemokines that are important regulators of migration in cells treated for 1h and 24h with GnRH-(1-5). Similarly, GnRH-(1-5) did not alter the levels of CXCL1, CXCL2, CXCL9, CXCL10, ccl2, and ccl5. In addition, the TGF-beta family was measured and we found that GN11 cells secrete TGF-beta1 significantly more that TGF-beta2 and -3. However, GnRH-(1-5) did not significantly change the levels of the TGF-beta family members. These results suggest that GnRH-(1-5) may modulate the response of migrating GnRH neurons to external cues present in the extracellular milieu (ECM). Therefore, we examined the effect of GnRH-(1-5) on the migration of GN11 cells in the presence of an in vitro ECM using a matrigel invasion assay. Interestingly, GnRH-(1-5) (100 nM) significantly (p < 0.05) inhibited the ability of GN11 cells to migrate through matrigel environment relative to control cells and is dependent on GPR173 as determined by siRNA experiments. Collectively, our studies demonstrate that the downstream mechanism of GnRH-(1-5) binding GPR173 to decrease cell migration and invasion is ECM-dependent and likely involves changes in the response and sensitivity of GnRH neurons to external cues.

 

Nothing to Disclose: DOL, MJC, SKM, TJW

PP05-3 19928 3.0000 THR-459 A The Extracellular Environment Regulates the Effect of GnRH-(1-5) on the Migration of GN11 Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 11:30:00 AM PP05 5912 11:15:00 AM GnRH & Neuroendocrinology Poster Preview


Ali Abbara*1, Channa N Jayasena2, Shakunthala Narayanaswamy3, Chioma Izzi-Engbeaya3, Alexander N Comninos1, Ailish Coblentz4, Zainab Malik3, Subair Sarang4, Mathini Sridharan4, Deborah Peters4, Mohammad A Ghatei3, Stephen R Bloom2 and Waljit S Dhillo1
1Imperial College NHS Healthcare Trust, London, United Kingdom, 2Imperial College London, United Kingdom, 3Imperial College London, London, United Kingdom, 4Imperial College London

 

Introduction: Ageing in the male is commonly associated with a fall in serum testosterone termed Late-Onset Hypogonadism (LOH). LOH is thought to occur partly due to decreased testicular function, however the compensatory luteinizing hormonal response is also often blunted. This suggests that ageing may be associated with disordered gonadotropin releasing hormone (GnRH) release from the hypothalamus, or reduced gonadotropin release from the pituitary gland. It has not previously been possible to make a distinction between examining hypothalamic and pituitary function in the male reproductive axis; however the recent identification of kisspeptin, which potently stimulates GnRH release, makes this possible. We therefore used kisspeptin-54 (KP54) and GnRH administration to investigate whether hypothalamic or pituitary reproductive function was altered in older males when compared with a young control group.

Methods: Following ethical approval, we carried out a single-blinded placebo-controlled study. A group of older men (mean age 61.0yrs) and a control group of younger men (mean age 28.9yrs) each underwent 3 study visits at least 1 week apart, during which they received vehicle, kisspeptin or GnRH (n=5 per group). Ten minutely blood sampling for luteinizing hormone (LH), follicle stimulating hormone (FSH) and testosterone was performed throughout each 4h study visit. After 1h of baseline blood sampling, a 3h intravenous infusion of vehicle, 0.1 nmol/kg/h of KP54 or GnRH, was commenced and reproductive hormonal response assessed. Mean AUC of change in each reproductive hormone from baseline was compared by unpaired t test with P<0.05 regarded as significant.

Results: Mean BMI and baseline testosterone were 23.6 kg/m2, 20.6 nmol/l in the young men (YM) and 25.4 kg/m2, 16.9 nmol/l in the older male (OM) groups, respectively. No significant differences were observed in the LH responses between young and older men following either KP54 or GnRH infusion (mean±SEM AUC LH change in iU.h/L: KP54 YM 12.1±1.6, KP54 OM 12.1±2.0, P=ns vs. KP54 YM; GnRH YM 19.6±3.2, GnRH OM 18.6±3.4, P=ns vs. GnRH YM). FSH response was not significantly different in the older age group to both KP54 and GnRH (mean±SEM AUC change in FSH in iU.h/L: KP54 YM 1.6±0.3, OM 2.5±0.8, P=ns vs. KP54 YM; GnRH YM 2.3±0.4, OM 4.1±1.8; P=ns vs GnRH YM).

Conclusion: This pilot study suggests that older men without known LOH have similar reproductive hormonal response to KP54 when compared with younger men. Thus KP54 offers a potential novel tool for examining hypothalamic function in older men.

 

Nothing to Disclose: AA, CNJ, SN, CI, ANC, AC, ZM, SS, MS, DP, MAG, SRB, WSD

PP05-4 21182 4.0000 THR-469 A Kisspeptin- a Novel Test of Hypothalamic Function in Older Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 11:30:00 AM PP05 5912 11:15:00 AM GnRH & Neuroendocrinology Poster Preview


Susan Jung*, Mandy Richter-Kraus, Florian Brackmann, Helmuth G. Doerr and Regina Trollmann
University Hospital Erlangen, Erlangen, Germany

 

Background: Perinatal cerebral hypoxia is a main risk factor for acquired brain injury and neurological disabilities. Stabilization of hypoxia-inducible transcription factors (HIF) modulates mitochondrial respiration, glycolysis, angiogenesis, and vasculogenesis mediating adaptation to reduced oxygen concentration. However, HIF stabilization is associated with decreased growth hormone (GH) gene expression in pituitary cells suggesting suppression of GH-induced secretion of neurotrophic factors.

Objective: We hypothesized that exogenous GH modulates hypoxia-induced disturbances of the GH/IGF-1 axis mediating protective effects under global hypoxia during early development.

Methods: A total of 179 mice were randomized at postnatal day 7 (P7) according the complete block design into treatment groups of at least 8 animals and exposed either to normoxia or hypoxia (8% O2) for 6h using an INVIVO400 hypoxia workstation (Baker Ruskinn). Within 30 min after reoxygenation and once daily for three consecutive days, recombinant hGH (Genotropin®, Pfizer) at doses of 0, 10, 50, 250, 1000, and 4000 µg/kg was injected intraperitoneal (i. p.) in the pups. Body weight and length (nose-to-tail length) were monitored and mGH and IGF-1 plasma protein concentrations were quantified at P14 and P21.

Results: Whereas no physiological differences between the treatment groups were observed at P7, treatment with low hGH doses adversely affected perinatal growth and weight gain under normoxia. Mice dosed with 10–250 µg/kg hGH gained 72% less weight (P<0.0001) until P10 and were significantly shorter than non- or sham-treated mice. Thereby, growth retardation persisted until P21 in mice treated with 10 and 50 µg/kg hGH and were correlated to significantly decreased plasma concentration of mGH and IGF-1. Hypoxia-exposed non- and sham-treated animals revealed significantly lower weight gain (P<0.0001) between P7 and P10 than normoxic animals. Simultaneously, exposure to hypoxia significantly decreased plasma mGH (P<0.05) and IGF-1 levels (P<0.05) for at least one week. Notably, treatment with 1000 and 4000 µg/kg hGH restored hypoxia-induced disturbances of the GH/IGF-1 axis compensating growth deficiency in neonatal mice.

Conclusion: Our data indicate that i) perinatal, hypoxia-induced disturbances of the GH-/IGF-1 axis are transient and that ii) hGH treatment stabilizes the somatotropic axis after perinatal hypoxia. Further studies are focused on modification of cerebral neurotropic factors by stabilization of the GH/IGF-1 axis and thus preventing neuronal loss in the developing hypoxic rodent brain.

 

Nothing to Disclose: SJ, MR, FB, HGD, RT

PP03-1 18400 1.0000 THR-146 A Restoration of Hypoxia-Induced Changes of Plasma mGH and IGF-1 Concentrations in Neonatal Mice in Response to hGH Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 11:30:00 AM PP03 5919 11:15:00 AM From the Genome to the Clinic: Growth and Puberty Disorders Poster Preview


María Gabriela Ballerini*, Paula A. Scaglia, Ignacio Bergadá, Alicia Martinez, Mercedes Altube, Ana C. Keselman, Débora Braslavsky, María Gabriela Ropelato, Hector G. Jasper and Horacio M Domene
Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina

 

Background: More than 90 GHR gene mutations have been described in complete GH insensitivity (GHI), nevertheless, only few heterozygous GHR genetic variants have been associated to GHI. Little information regarding the impact of common polymorphisms within coding (Ex) and intronic (In) GHRregions on height and components of the GH/IGF-I/IGFBPs system is available.

Aim: To test if GHR gene polymorphisms are associated to height and components of the GH/IGF-I/IGFBPs system in ISS children.

Methods: GHR gene (Ex/In flanking regions) was PCR-amplified and sequenced in 75 unrelated ISS children. The GHR pseudoexon (6Psi) mutation was investigated by RFLP. GHR gene variants were classified as rare (minor allele frequency (MAF) ≤ 1%), less frequent (1-10%) and common (≥ 10%). To test the genotype influence of SNPs with MAF > 10% (HapMap-Project) on height and GH/IGF-I/IGFBPs system, ISS children were grouped as homozygous for the major allele and carriers of one or two copies of the minor allele. The proportion of variants (less than 3 versus 4 or more) was evaluated according to the median value of: height (-2.86 SDS), GHBP (-0.9 SDS; in house functional assay), maximal stimulated-GH (14.9 ng/L), IGF-I (-1.4 SDS), IGFBP-3 (-1.0 SDS, ICMA) and ALS (-1.3 SDS; RIA). Hardy-Weinberg equilibrium, Fisher´s exact test and Mann-Whitney analysis were used.

Results: Six common and 5 less frequent variants were identified: Ex3 deletion (MAF: 26%), rs6179 (Ex6, 23%), rs6180 (Ex10, 42%), rs12521020 (In1, 32%), rs10941579 (In2, 32%), rs33972388 (In7, 37%), rs34223737 (In7, 1%), rs6880730 (In8, 5%), rs6182, rs6184 and rs115376349 (Ex10, 2%). In ISS, MAF distribution was not different from 41 control children or the HapMap database. We identified 4 heterozygous rare variants in 4/75 children (5.3%): p.R229H (Ex7) and p.R386C (Ex10) with normal IGF-I, IGFBP-3 and ALS levels, 1 of them with low GHBP (<-1.9 SDS); rs143475648 (In3) with low GH-dependent biomarkers and c.618+700_705dupCAGCCA (In6) with low IGF-I levels. These variants were not found in control children. Neither individual GHR gene genotypes, nor the sum of GHR polymorphic variants were associated to height, GHBP, IGF-I, IGFBP-3 or ALS (p>0.06).

Conclusions: The sum of polymorphic variants has no effect on GH sensitivity, measured by levels of serum GHBP, IGF-I, IGFBP-3 and ALS. While p.R229H variant may result in a slight reduction in GHR expression as reflected by low GHBP levels, p.R386C, rs143475648 and c.618+700_705dupCAGCCA variants remain to be characterized by in vitro functional studies.

 

Nothing to Disclose: MGB, PAS, IB, AM, MA, ACK, DB, MGR, HGJ, HMD

PP03-2 21111 2.0000 THR-149 A Influence of GH Receptor Gene Variants within Coding and Intronic Regions in Children with Idiopathic Short Stature (ISS) on Height and Components of the GH/IGF-I/IGFBP System 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 11:30:00 AM PP03 5919 11:15:00 AM From the Genome to the Clinic: Growth and Puberty Disorders Poster Preview


Chiara De Leonibus*1, Pierre Chatelain2, Chris Knight3, Peter Clayton4 and Adam Stevens1
1University of Manchester and Royal Manchester Children’s Hospital, Manchester, United Kingdom, 2Université Claude Bernard, Lyon, France, 3University of Manchester, 4University of Manchester & Manchester Academic Health Sciences Centre, Manchester, United Kingdom

 

Background

The rate of normal growth tends to increase in mid-spring/summer and is greater in children living at higher latitudes(1). This study examined i) the impact of living at different latitudes on height velocity (HV) and ii) the interactions between environmental [latitude, summer daylight exposure (SDE)] and genomic factors [single nucleotide polymorphisms (SNPs), gene expression (GE) profiles] that effect HV in response to treatment with recombinant-human growth hormone (r-hGH) in children with growth hormone deficiency (GHD).

Methods

Pre-pubertal naïve GHD patients (n=118) from the PREDICT prospective long-term follow-up study (NCT00699855) were analyzed. The effect of treatment over one year with r-hGH was measured by HV (cm/yr) and assessed in relation to SDE, carriage of seven SNPs previously associated with high growth response(2) and basal GE determined prior to treatment. Data were submitted from 28 centers in 14 countries SDE and HV were correlated with basal GE using rank regression and network models were constructed from the GE overlap to investigate causal interactions.

Results

GHD patients from latitudes with higher SDE had a better HV in response to r-hGH compared to those with intermediate and lower SDE [median (Q1, Q3): 9.8 (8.5, 11.4) vs 8.1 (7.0, 9.8) and 8.2 (7.0, 10.3) cm/yr, respectively; p=0.019], with HV over all groups correlating with SDE (r=0.256, p=0.006). For SNPs within GRB10, IGFBP3, TGF-α, CYP19A1 and TP53 genes, there was a significant interaction between the SNP and SDE (p<0.05) in relation to growth response. The effect of carriage of SNPs in IGFBP3, TGF-α and TP53 on HV was greater in patients from locations with higher SDE; while the converse was found for GRB10 and CYP19A1 Network models derived from SDE and HV associated basal GE identified i) the developmental transcription factor NANOG as a key regulator, and ii) up-regulation of growth-related and “circadian clock” pathways (p=3.0x10-3).

Conclusion

This study showed complex gene-environment interactions between genes modulating growth and SDE in response to r-hGH, with the biological regulation of the circadian clock as a possible linking mechanism. The transcriptional regulator NANOG was found to be a master regulator of these interactions implicated in the development of circadian oscillator action and bone growth.

 

Disclosure: PC: Investigator, Merck Serono, Speaker, Merck Serono, Advisory Group Member, Merck Serono. PC: Investigator, Merck Serono, Speaker, Merck Serono. AS: Investigator, Merck Serono. Nothing to Disclose: CD, CK

PP03-3 21710 3.0000 THR-145 A Effect of Summer Daylight Exposure and Genetic Background on Growth in Growth Hormone Deficient (GHD) Children 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 11:30:00 AM PP03 5919 11:15:00 AM From the Genome to the Clinic: Growth and Puberty Disorders Poster Preview


Eric G. Vajda*1, Diane J. Plotkin2, Douglas K. Logan3, Yong-Xi Li3, David G Orloff3, J. D. Pipkin4, Lin Zhi4 and Keith B. Marschke4
1Ligand Pharmaceuticals Inc, La Jolla, CA, 2Diane Plotkin Clinical Development Consultation Services, Poway, CA, 3Medpace, Inc., Cincinnati, OH, 4Ligand Pharmaceuticals Incorporated, La Jolla, CA

 

In T2DM, elevated levels of glucagon exacerbate hyperglycemia and its associated complications. Antagonism of glucagon action reduces blood glucose levels and hemoglobin A1c in T2DM patients. We have discovered a novel, selective, orally bioavailable glucagon receptor antagonist, LGD-6972, and investigated its pharmacokinetics (PK), safety, and pharmacodynamics (PD) in a first-in-human, ascending, single-dose, double blind, placebo‑controlled study in normal healthy (NH) and T2DM subjects (NCT01919684). A total of 56 participants were enrolled, 48 NH subjects and 8 T2DM subjects. The dose range was 2 to 480 mg for NH subjects. The T2DM subjects received a dose of 40 mg. LGD-6972 was well tolerated and considered safe up to the highest dose tested in NH and T2DM subjects. LGD-6972 was well-absorbed after oral administration; peak plasma concentrations were reached approximately 5 to 8 hours post dose with a long elimination half-life of about 50 hours, supporting once-daily dosing. The effects of LGD-6972 on fasting and post-prandial plasma glucose, glucagon, insulin, and glucagon-like peptide-1 (GLP-1) were evaluated in NH and T2DM subjects, and a meal tolerance test (MTT) and continuous glucose monitoring (CGM) were performed in T2DM subjects. In NH subjects, treatment with LGD-6972 resulted in small decreases in glucose levels approximating dose-dependency, and also lowered glucose levels in T2DM subjects. The decrease in glucose was most obvious in the fasting plasma glucose (FPG) levels 24 and 48 hours post-dose. The magnitude of decrease in FPG was greater in subjects with T2DM than in NH subjects. No glucose <60 mg/dL was observed in any group during the study. No consistent trend was revealed by CGM in the change in daytime glucose compared to baseline. However, a within-group trend towards lower nighttime glucose was observed, as well as a reduction in 24-hour glucose AUC. The mean glucagon and total GLP-1 levels were increased in NH subjects in a dose-dependent manner up to 240 mg, especially apparent between 24 to 96 hours post-dose. The glucagon and total GLP-1 levels after 480 mg were slightly below the expected levels, indicating that response to LGD-6972 may have reached a maximum. The mean glucagon and total GLP-1 levels were increased compared to placebo treatment in subjects with T2DM; most obvious 24 to 72 hours post-dose and greater than that in NH subjects. LGD-6972 treatment did not generate a consistent trend in the changes in the active GLP-1 or insulin levels across all dose groups after a single dose. The mean changes in glucose, glucagon, insulin, and GLP-1 levels from pre-meal did not generate marked consistent trends at 2 hours post-dose for most of the treatment groups, including subjects with T2DM. LGD-6972 is a promising agent for the treatment of T2DM, demonstrating PD effects after a single dose, and is currently in a multiple-ascending dose clinical trial (NCT02250222).

 

Disclosure: EGV: Employee, Ligand Pharmaceuticals. JDP: Employee, Ligand Pharmaceuticals Incorporated. LZ: Employee, Ligand Pharmaceuticals Incorporated. KBM: Employee, Ligand Pharmaceuticals Incorporated. Nothing to Disclose: DJP, DKL, YXL, DGO

PP01-1 21114 1.0000 THR-669 A Pharmacodynamic Effects of Single Doses of the Glucagon Receptor Antagonist LGD-6972 in Healthy Subjects and Subjects with Type 2 Diabetes Mellitus (T2DM) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 11:30:00 AM PP01 5938 11:15:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Poster Preview


Cecilia C. Low Wang*1, Rebecca Sanagorski2, R Matthew Hawkins1, Joanna Gibbs3, Kenneth Tompkins4, Mark Bridenstine5, Stacey Seggelke6 and Boris Draznin7
1University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, 2Denver VA Medical Center, Denver, CO, 3Univ of Colorado AMC School of Medicine, Aurora, CO, 4Univ of Colorado School of Medicine, Aurora, CO, 5Univ Colorado AMC School of Medicine, Aurora, CO, 6Univ Colorado AMC School of Medicine, 7University of Colorado School of Medicine, Aurora, CO

 

Consistently effective strategies to transition hospitalized patients from intravenous (IV) insulin infusion to a subcutaneous (SC) insulin regimen are lacking. Problems that can occur include rebound hyperglycemia, recurrent diabetic ketoacidosis, and hypoglycemia. We conducted a randomized controlled trial of SC detemir insulin added to continuous IV insulin infusion vs continuous IV insulin infusion without added detemir to determine whether initiation of and concurrent therapy with a basal insulin would be an effective and safe strategy for transitioning patients with diabetes from IV to SC insulin. Methods: After approval of the study protocol by the Colorado Multiple Institutional Review Board, patients with diabetes on IV insulin infusion admitted to the University of Colorado Hospital or the Denver Veterans Affairs (VA) Medical Center who provided written, informed consent were enrolled and randomized to detemir intervention (DET) vs control (CON). Patients randomized to DET were started on detemir insulin 0.25 units/kg/day within 24 hours (hr) of starting the IV insulin infusion, and continued on this until discontinuation of the IV insulin infusion. Patients randomized to CON continued to receive usual care without any changes. For both groups, all decisions regarding titration of insulin infusion rates, timing of discontinuation of IV insulin, and transitioning to a SC insulin regimen were made by the primary team without intervention by the study team. Point-of-care blood glucose (BG) levels were checked as part of usual care: every 1-2 hours (hr) during IV insulin infusion, and every 4-6 hr during SC insulin therapy. Rebound hyperglycemia was defined as any BG over 180 mg/dL in the first 12 hr after discontinuation of IV insulin. Results: 30 patients were randomized (23 males, 7 females), 14 to CON and 16 to DET. Average age was 52.3±11.2 years and 54.1 ±16.2 years, and average weight was 91.0 ±22.1 kg and 91.4 ±20.6 kg in CON and DET, respectively. The incidence of rebound hyperglycemia was 100% in the CON group and 18.8% in the DET group. The overall average BG in the first 12 hr after discontinuation of IV insulin was 219.6 ±57.8 mg/dL in the CON group and 137.0 ±39.9 mg/dL in the DET group (p<0.0001 between groups). Average glycemia was significantly lower in the DET group than the CON group in each of the three 4-hour time periods after discontinuation of insulin infusion. Three patients manifested BG between 50-70 mg/dL, one at 0.5 hr and two at 6-7 hr after stopping IV infusion. Conclusions: The use of SC detemir insulin added to continuous IV insulin infusion was effective for reducing rebound hyperglycemia after discontinuation of IV insulin and during the transition to a SC insulin regimen. Larger studies are needed to confirm these findings and to determine optimal doses to avoid hypoglycemia, for patients with a variety of inpatient diagnoses requiring continuous IV insulin infusion.

 

Nothing to Disclose: CCL, RS, RMH, JG, KT, MB, SS, BD

PP01-2 21323 2.0000 THR-662 A Impact of Subcutaneous Detemir Insulin on Rebound Hyperglycemia in Hospitalized Patients with Diabetes Transitioning from a Continuous Intravenous Insulin Infusion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 11:30:00 AM PP01 5938 11:15:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Poster Preview


Robert C Hood*1, Richard F Arakaki2, Carol H Wysham3, Ying Grace Li4, Julie A Settles5 and Jeffrey A Jackson5
1Endocrine Clinic of Southeast Texas, Beaumont, TX, 2University of Hawaii at Manoa, Honolulu, HI, 3Rockwood Center for Diabetes and Endocrinology, Spokane, WA, 4Eli Lilly and Company, Indianapolis, IN, 5Lilly USA, LLC, Indianapolis, IN

 

Use of recombinant human regular U-500 (U-500R) insulin has increased dramatically in recent years despite gaps in clinical knowledge regarding its initial dosing and optimal dose titration as well as efficacy and other clinical outcomes in severely insulin-resistant patients with inadequately controlled T2D. The unique prandial/basal actions of U-500R allow its use as insulin monotherapy. The current study is the first to compare efficacy and safety of 2 specific dosing regimens of U-500R replacing high-dose U-100 insulins in this target population.

The study was a 24-week, open-label, parallel-arm trial in 325 patients taking 201 to 600 units/day U-100 insulin therapy with or without oral antihyperglycemic agents. Patient demographics (means ± SD) included age, 55.4 ± 9.8 years; duration of diabetes, 15.2 ± 7.4 years; BMI, 41.9 ± 7.5 kg/m2; HbA1c, 8.7 ± 1.0%; U-100 insulin dose, 287.5 ± 80.5 units administered in 5 injections/day (median; range, 2 to 10). Patients were randomized to either thrice-daily (TID, n = 162) or twice-daily (BID, n = 163) U-500R after a 4-week lead-in period. The transition formula from U-100 insulins (predominantly basal–bolus analogue therapy) to U-500R reduced the total daily dose (TDD) by 20% for those with baseline HbA1c ≤8.0% or mean self-monitored plasma glucose (SMPG) <183 mg/dL. Otherwise, a 1:1 transition was used. Initial U-500R dosing proportions were 40:30:30 (breakfast:lunch:dinner) for TID and 60:40 (breakfast:dinner) for BID. Both algorithms adjusted TDD at each visit up to +30% (‑20% for hypoglycemia) to achieve pre-meal SMPG 71 to 130 mg/dL.

After 24 weeks, both treatments demonstrated significant and comparable reductions in HbA1c from baseline (TID, ‑1.12% [endpoint HbA1c, 7.53% ± 1.1%]; BID, ‑1.22% [endpoint HbA1c, 7.41% ± 1.0%]; P < 0.001 for both) and clinical equivalence (difference [BID vs. TID], ‑0.10% [P = 0.37]; 95% CI, ‑0.33% to 0.12%) at the non-inferiority margin 0.4%. Proportions of patients reaching HbA1c target values were similar between the 2 regimens (<8.0%: TID 70%, BID 69%; <7.5%: TID 55%, BID 47%; and <7.0%: TID 29%, BID 31%). Comparable increases in U-500R TDD (TID, 242.7 to 343.1 units; BID, 249.0 to 335.0 units) were observed. Severe hypoglycemia was uncommon and occurred with similar incidence (TID: 3 patients [1.9%]; BID: 6 patients [3.7%]). Incidence and rate of documented symptomatic hypoglycemia (≤70 mg/dL) were lower for TID compared with BID (= 0.003 and P = 0.02, respectively). Weight gain was similar between regimens (TID, 5.4 ± 0.4 kg; BID, 4.9 ± 0.4 kg).

In summary, initiation and titration of U-500R using either algorithm (TID or BID) improves glycemic control effectively and safely with fewer injections in patients with T2D on high-dose/high-volume U-100 insulin. These results provide clinicians with a practical framework for using U-500R in severely insulin-resistant patients with suboptimally controlled T2D.

 

Disclosure: RCH: Consultant, Eli Lilly & Company, Consultant, Novo Nordisk, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Jansen Pharmaceuticals, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Takeda, Speaker Bureau Member, Boehringer-Ingelheim, Speaker Bureau Member, GlaxoSmithKline, Medical Advisory Board Member, Takeda. RFA: Research Funding, Eli Lilly & Company, Research Funding, AbbVie, Research Funding, Merck & Co., Speaker Bureau Member, Astra Zeneca. CHW: Speaker, Jansen Pharmaceuticals, Consultant, Jansen Pharmaceuticals, Speaker, Lilly USA, LLC, Speaker, Novo Nordisk, Consultant, Sanofi, Speaker, Sanofi, Speaker, Astra Zeneca, Consultant, Astra Zeneca, Speaker, Boehringer Ingelheim Pharmaceuticals, Consultant, Boehringer Ingelheim Pharmaceuticals. YGL: Employee, Eli Lilly & Company. JAS: Employee, Lilly USA, LLC. JAJ: Employee, Lilly USA, LLC.

PP01-3 18681 3.0000 THR-658 A A Randomized Clinical Trial Comparing Efficacy and Safety of 2 Titration Algorithms for Human Regular U-500 Insulin in Severely Insulin-Resistant Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 11:30:00 AM PP01 5938 11:15:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Poster Preview


Michael Grimes*1, Peter L Perreiah1, Laura Potoski1, Denise Plis2 and R Harsha Rao3
1VA Pittsburgh Healthcare System, Pittsburgh, PA, 2VA Healthcare Network, Wilkes-Barre, PA, 3Division of Endocrinology, VA Pittsburgh Healthcare System, Pittsburgh, PA

 

Background:  The parallel epidemics of obesity and diabetes are responsible for the rising prevalence of markedly insulin resistant diabetes (MIRD, total daily dose of insulin [TDD] ≥200 units), a potentially high-risk condition that poses a significant therapeutic challenge, with limited options for glycemic management.

Objective:  To determine the impact of U500 insulin on outcomes in MIRD.

Methods:  Retrospective chart reviews of 324 patients on TDD ≥200 units, identified from pharmacy records, who were either transitioned to U500 insulin therapy (U500 cohort, n=180) or maintained on U100 insulin therapy (U100 cohort, n=144) by patient/provider choice.

Outcome Measures: Mortality, microvascular and macrovascular complications between MIRD onset (verified from prescription signatures/progress notes) and date of last contact/death.

Results:  The number of patients with MIRD rose 10-fold between 2001 and 2013, while U500 insulin use rose 25-fold.  MIRD was associated with a high prevalence of diabetes-related vascular complications at onset, both macrovascular (259/324 [80%], principally CAD: 167/324 [51.5%]) and microvascular (199/324 [61.4%], principally nephropathy: 156/324 [48.2%]).  Patients transitioned to U500 insulin had a significantly lower mortality compared to those who remained on U100 insulin (27/180[15%] vs 39/144[27.1%], p=0.011), reflecting a 41% survival benefit on KM analysis (Hazard Ratio=0.59, p=0.0336) over similar follow-up duration (U500:1431±61days [Mean±SE], U100:1501±84), despite virtually identical clinical characteristics at MIRD onset.  Microvascular  complications were significantly reduced in the U500 cohort (105/180[58.3%] vs U100: 107/144[74.3%], p=0.003), specifically diabetic nephropathy (U500: 53/180[29.4%) vs U100: 79/144[54.9%], p<0.0001), both new onset (U500: 25/100[25%] vs U100: 33/68[48.5%], p=0.0016) and progressive (U500: 28/80[30%] vs U100: 33/68[48.5%], p=0.0014).  Macrovascular disease was impacted only marginally (U500: 53/180[29.4%] vs U100: 57/144[39.6%], p=0.056), principally from preventing peripheral arterial disease (PAD; U500:4/180[2.2%] vs U100:16/144[11.1%], p=0. 005), but not CAD (U500: 46/180[25.6%] vs U100: 41/144[28.5%],p=NS) or CVA (U500:6/180[3.3%] vs U100: 8/144[5.6%], p=NS).

Hemoglobin A1c in the U500 cohort decreased 0.91±0.1% (p<0.01), associated with an increase in TDD of 108±10units (p<0.01) and weight gain of 6.9±0.9kg (p<0.01), but A1c, weight and TDD did not change significantly in the U100 group. 

Conclusions:  MIRD is associated with high morality and frequent vascular complications, but substantial reductions in mortality and onset/progression of nephropathy and PAD can result from higher TDD and lower A1c associated with U500 therapy.  By contrast, worse outcomes may be attributable to “dose inertia” associated with U100 therapy in MIRD.

 

Nothing to Disclose: MG, PLP, LP, DP, RHR

PP01-4 21786 4.0000 THR-657 A The Burgeoning Problem of Markedly Insulin Resistant Diabetes Associated with Morbid Obesity: Impact of U500 Insulin Therapy on Outcomes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 11:30:00 AM PP01 5938 11:15:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Poster Preview


La Shondra Ellis*1, Robert Romano2, Jessica Costa-Guda2, Justin Bellizzi3 and Andrew Arnold2
1University of Connecticut Health Center, Farmington, CT, 2University of Connecticut School of Medicine, Farmington, CT, 3University of Connecticut School of Medicine

 

The molecular abnormalities leading to sporadic parathyroid adenomas are heterogeneous and incompletely understood. Previous investigations identified recurrent, clonally selected driver mutations in the cyclin D1 (PRAD1, CCND1) proto-oncogene and MEN1 tumor suppressor gene, and a combination of rare germline variants and somatic alterations in several cyclin-dependent kinase inhibitor genes. Subsequent identification of novel, recurrently altered genes through unbiased sequencing approaches has yielded only a few good candidates, all with low frequencies of observed mutations such as EZH2 (mutated in 1% of adenomas). Recently, compelling genetic evidence was reported implicating the ZFX gene, part of the Krueppel C2H2 type zinc finger protein family, as a likely parathyroid adenoma oncogene involved in almost 5% of cases (Oncoscience 2014; 1:360-366). Recurrent somatic mutations in ZFX were strikingly specific, focused on a hotspot of two consecutive highly conserved arginine residues in the most C-terminal zinc finger domain of the protein. ZFX is situated on the X-chromosome but escapes X-inactivation and is thus transcribed from both alleles in females; in males the highly homologous gene ZFY, on the Y-chromosome, is expressed and provides dosage compensation. Since analogous mutations in ZFY could have similar tumorigenic effects as those in ZFX, and with one such ZFY mutation already noted in a colon carcinoma (COSMIC), we analyzed ZFY in a series of typical sporadic parathyroid adenomas from male patients. Specifically, the 13th zinc finger domain, containing codons R781/R782 (corresponding to mutated ZFX codons R786/R787), was PCR-amplified and Sanger sequenced in 34 adenomas. No mutations were identified. Furthermore, the entire coding region of ZFY was fully sequenced in 20 of these tumors, again with no mutations identified. Therefore, it does not appear that R781/R782 missense mutations in ZFY commonly contribute to the molecular pathogenesis of parathyroid adenomas. However, analyses of more tumors will be necessary to exclude the possibility that ZFY may be involved in a similar percentage of adenomas as is the case for ZFX. The biology of ZFX, and perhaps ZFY, oncogenic mutations in the context of parathyroid tissue will certainly further illuminate the pathogenesis of these neoplasms.

 

Nothing to Disclose: LSE, RR, JC, JB, AA

PP08-1 19904 1.0000 THR-225 A Mutational Analysis of ZFY in Sporadic Parathyroid Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 11:30:00 AM PP08 5965 11:15:00 AM Parathyroid and Bone Metabolism Poster Preview


Richard C. Lindsey*1, Charles M. Abreu1, Andy Cheng2, Sheila Pourteymoor1, Catrina Alarcon1 and Subburaman Mohan3
1Jerry L. Pettis VA Memorial Medical Center, Loma Linda, CA, 2Jerry L. Pettis VA Memorial Medical Center, Redlands, CA, 3VA Loma Linda Healthcare System, Loma Linda, CA

 

Recent studies involving mutant mouse models that are deficient in thyroid hormone (TH) action have provided unequivocal evidence that there is an important window in time prior to puberty when TH plays a critical role in the regulation of skeletal growth and development. TH regulated total body fat negatively during the prepubertal growth period, an observation which is consistent with the well-established effects of TH to accelerate resting energy expenditure. Because adipocytes and osteoblasts are both derived from bone marrow mesenchymal stromal (BMMS) cells, and because a relationship between increased bone marrow adiposity and decreased bone formation has been suggested, we examined whether TH deficiency during the postnatal growth period affects bone marrow adiposity in mice. We found bone marrow adiposity, measured by DEXA, was increased by >20% (P < 0.01) in TH deficient (Tshrhyt/hyt) mice at 3 weeks of age at multiple skeletal sites, and 10 day treatment with T3/T4 at a time when serum levels of T3/T4 normally increase (day 5-14) rescued this phenotype. To examine the mechanism for TH regulation of bone marrow adiposity, we tested the effects of TH treatment on mRNA expression levels of markers of adipocyte differentiation using primary cultures of mouse BMMS cells and the ST2 mouse stromal cell line in vitro. We found that treatment with 10 ng/mL T3 significantly increased expression levels of PGC-1α and UCP1, genes that have been established as markers of brown/beige fat. Real time RT-PCR measurements revealed 7.8-, 7.5-, and 2.5-fold increases in PGC-1α mRNA levels (all P < 0.05) at days 1, 4, and 6 after treatment with T3 in BMMS cells. UCP1 mRNA expression was increased by 3.5-fold (P = 0.01) after 6 days of treatment with T3.  By contrast, expression levels of the white adipocyte markers HOXC8 and HOXC9 were unaffected by 6 days of treatment with T3 in BMMS cells. Similarly, a 24 hour treatment with 10 ng/mL T3 increased expression of PGC-1α (6.0-fold, P < 0.01) but not HOXC8 or HOXC9 in ST2 cells. Based on our data, we conclude that 1) TH is an important regulator of bone marrow adiposity, and 2) the TH effect on energy metabolism may in part be mediated via increased production of thermogenic brown/beige fat.

 

Nothing to Disclose: RCL, CMA, AC, SP, CA, SM

PP08-2 20012 2.0000 THR-200 A Thyroid Hormone Regulation of Bone Marrow Adiposity in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 11:30:00 AM PP08 5965 11:15:00 AM Parathyroid and Bone Metabolism Poster Preview


Presley Garrison*1, Jeffrey Hanson2, Youn Hee Jee3, Ola Nilsson3, Jeffrey Baron4 and Julian Lui3
1NICHD, 2NCI, 3NICHD, Bethesda, MD, 4NIH, Bethesda, MD

 

Articular and growth plate cartilage each comprise three histologically distinct zones of chondrocytes. Articular cartilage is divided into superficial (SZ), mid (MZ), and deep (DZ) zones while growth plate cartilage is divided into resting (RZ), proliferative (PZ), and hypertrophic (HZ) zones. The molecular mechanisms that underlie the spatial regulation of chondrocyte differentiation are not well understood. To explore the role of BMP signaling, we used laser capture microdissection (LCM) and solution hybridization with barcoded probes (NanoString) (1) to quantify mRNA expression of 33 BMP-related genes in all zones of articular and growth plate cartilage of 7-day old mice (n=6). Previously identified zonal markers validated the accuracy of microdissection: Col10a1 mRNA was higher in HZ than in adjacent PZ (180-fold, P<0.01) and Prg4 was higher in SZ than MZ (24-fold, P<0.01). In articular cartilage, specific BMP agonists were primarily expressed in SZ: Bmp2 (3.6-fold greater than MZ) and Bmp6 (3.9-fold) (both P<0.01) whereas BMP functional antagonists were primarily expressed in MZ and DZ: gremlin (6.4-fold MZ vs. SZ), noggin (2.8-fold MZ vs. SZ), and Bmp3 (2.0-fold MZ vs. SZ, 2.7-fold DZ vs. MZ) (all P<0.01), suggesting an overall gradient in BMP signaling. However, antagonist Gdf10 was primarily expressed in SZ (3.8-fold greater than MZ, P<0.01). In growth plate cartilage, several BMP agonists were primarily expressed in HZ: Bmp1 (3.0-fold greater than PZ), Bmp2 (14-fold), and Bmp6 (55-fold) (all P<0.01). However, agonists Bmp5 showed greatest expression in RZ (2.1-fold greater than PZ) and Bmp7 showed greater expression in RZ and PZ (4.2-fold PZ vs. HZ) (all P<0.01). Some BMP antagonists were primarily expressed in RZ:  gremlin (3.7-fold greater than PZ) and Bmp3 (11-fold) (both P<0.01). However, functional antagonists Noggin and Smad7 showed greatest expression in HZ (2.4-, 3.3-fold, respectively, both P<0.01), and Gdf10 showed greatest expression in PZ (9.4-fold PZ vs. RZ, 6.5-fold PZ vs. HZ, both P<0.01). BMP receptors (Bmpr1a, Bmpr1b, and Bmpr2) and downstream effectors of the BMP system (Smad1, Smad4, and Smad5) did not show major expression differences between zones in articular or growth plate cartilage. In summary, we found that expression of multiple BMP agonists and functional antagonists showed striking spatial regulation in postnatal articular and growth plate cartilage. The observed expression patterns suggest that a BMP signaling gradient is present across postnatal articular cartilage such that greater BMP activity occurs in SZ. In the growth plate, some individual genes showed expression patterns analogous to that of articular cartilage, but the overall pattern of BMP agonist and antagonist expression showed greater complexity.

 

Nothing to Disclose: PG, JH, YHJ, ON, JB, JL

PP08-3 21008 3.0000 THR-217 A Spatial Regulation of Bone Morphogenetic Proteins (BMPs) in Postnatal Articular and Growth Plate Cartilage 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 11:30:00 AM PP08 5965 11:15:00 AM Parathyroid and Bone Metabolism Poster Preview


Blandine Poulet1, Andrew A Pitsillides2 and Abir Mukherjee*2
1University College London, United Kingdom, 2Royal Veterinary College, London, United Kingdom

 

Transforming growth factor β (TGFβ) ligands are important in regulating bone mass. Activin, a TGFβ ligand, plays crucial roles in bone development, turnover and mass and deletion of activin in mice leads to skeletal changes including delayed bone development. Control of the activin signalling pathway may, therefore, represent a novel target for limiting excessive bone loss during ageing and osteoporosis. Follistatin-like 3 (FSTL3) is an endogenous inhibitor of activin and related TGFβ ligands. FSTL3 gene deleted mice (FSTL3 KO) are viable and present multiple age-onset phenotypes that appear to be at least partially linked to activin action. We hypothesise that FSTL3 deletion in mice will generate an age-dependent modulation of bone architecture and mass. Cortical and metaphyseal bones from the tibiae of young (8wks), mature (30wks) and old (70wks) FSTL3 KO and WT control mice were analysed by micro-computerised tomography (microCT). Dissected tibiae were fixed in neutral buffered formalin and stored in 70% ethanol. Bones were scanned by microCT with an isotropic 5µm voxel size (µCT, Skyscan 1176). Each dataset was analysed using 3D algorithms in CTAn software (Skyscan), for cortical (0.5mm region at 50% tibial length) and trabecular (between 10 and 15% of total bone length from the proximal end) compartments. Cortical bone area / tissue area, bone perimeter, cortical medullary area and cross sectional thickness and also trabecular bone volume / total volume, trabecular thickness, separation and number, were measured. Our results show that tibiae were significantly longer in FSTL3-deficient mice compared to age-matched WT mice at 8wks but significantly shorter at 30 and 70 wks. Cortical bone parameters at 8wks showed that the tibiae of FSTL3 KO mice had increased bone area/tissue area, which was still evident at 30wks but not at 70wks. Cross sectional thickness was increased at 30wks and medullary area decreased at 30 and 70wks compared to WT controls. The trabecular compartment showed an increase in trabecular thickness at 8wks of age only and no other changes in other trabecular parameters were seen. Taken together our findings suggest that FSTL3 can control bone growth and architecture, particularly in relation to cortical bone. The mechanism by which lack of FSTL3 increases bone mass in young animals is being investigated.

 

Nothing to Disclose: BP, AAP, AM

PP08-4 22028 4.0000 THR-221 A Follistatin-like 3 Regulates Bone Structure in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 11:30:00 AM PP08 5965 11:15:00 AM Parathyroid and Bone Metabolism Poster Preview


W. Patricia Bandettini1, Alexander Karageorgiadis2, Ninet Sinaii3, Margaret Farmar Keil4, Charalampos Lyssikatos5, Marie Helene Schernthaner-Reiter6, Douglas R Rosing7, Vandana Sachdev7, J Aidan Carney8, Andrew E Arai9, Maya Beth Lodish*3 and Constantine A Stratakis6
1National Heart, Lung and Blood Institute, NIH, Bethesda, MD, 2NICHD, NIH, 3National Institutes of Health, Bethesda, MD, 4Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD, 5Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 6National Institutes of Health (NIH), Bethesda, MD, 7National Heart, Lung and Blood Institute, NIH, 8Mayo Clinic, Rochester, MN, 9NHLBI

 

Carney Complex (CNC) is a well-described multiple neoplasia syndrome with a constellation of endocrine manifestations, pigmented skin lesions, and tumors of multiple organ systems, including endocrine, cardiac, cutaneous, and neural, associated with mutations in PRKAR1A (1).  The cardiac myxomas are of particular concern due to the potential for systemic embolization and risk of hemodynamically significant cardiac mechanical obstruction. Up to 15% of patients with CNC present with growth hormone (GH) excess due to GH-producing pituitary macroadenomas and antecedent pituitary hyperplasia is even more prevalent. Substantial evidence supports the role of the GH-IGF-1 axis in cancer incidence, and acromegaly is associated with an increased risk of colon cancer. The current study was performed to evaluate whether a relationship existed between GH excess and the development of cardiac myxomas in patients with CNC that we have followed for the last 20 years (1994-2014) at the National Institutes of Health (NIH) (n=99). These patients underwent serial cardiac imaging, including dynamic magnetic resonance imaging to screen for cardiac myxomas. We used cardiac screening data, and also data of prior myxoma resection, to identify those with a positive history of myxoma. The patients also underwent laboratory testing for GH excess. We found that 60% of the patients with GH excess (n=27/45) had a cardiac myxoma, compared to 37% of those who did not have GH excess (n=20/54, p=0.03). Additionally, patients with a history of GH excess were more likely to have a cardiac mass versus those without GH excess (OR=2.55, 95% CI:1.13–5.75, p=0.02). This is the first study describing the association between GH excess and an increased risk of cardiac myxomas in patients with CNC. The findings have important clinical implications because cardiac myxomas pose the most serious mortality risk in CNC. This association raises consideration of early surveillance for and treatment of GH excess in CNC patients.

 

Nothing to Disclose: WPB, AK, NS, MFK, CL, MHS, DRR, VS, JAC, AEA, MBL, CAS

PP02-1 19378 1.0000 THR-339 A Growth Hormone Excess Is Associated with an Increased Risk of Cardiac Myxomas in Carney Complex: A 20 Year Study (1994-2014) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 11:30:00 AM PP02 5977 11:15:00 AM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster Preview


Carolina R.C. Pieterman*1, Joanne M de Laat1, Jos W.R. Twisk2, Menno R Vriens1, Ad RMM Hermus3, Olaf M Dekkers4, Wouter W. de Herder5, Anouk N A Van der Horst-Schrivers6, Madeleine L. Drent2, Peter H Bisschop7, Bastiaan Havekes8 and Gerlof D Valk1
1University Medical Center Utrecht, Netherlands, 2VU University Medical Center, Netherlands, 3Radboud University Nijmegen Medical Centre, Netherlands, 4Leiden University Medical Center, Netherlands, 5Erasmus Medical Center, Rotterdam, Netherlands, 6University of Groningen, University Medical Center Groningen, Groningen, Netherlands, 7Academic Medical Center, Netherlands, 8Maastricht University Medical Centre, Netherlands

 

Pancreatic neuroendocrine tumors (pNET) are seen in approximately half of the patients with MEN1. PNETs are an important cause of MEN1-related morbidity and mortality. Up to thirty percent of the MEN1 patients with pNETs develop distant metastases, which is the most important prognostic factor for overall survival (1). Size of MEN1-related pNETs and tumor growth are reasons for surgical intervention to prevent metastasis (2). However, at present the natural course of pNETs in MEN1 is incompletely understood, hampering risk stratification and personalized care. In this present study we assess growth rate and determinants of growth in MEN1-related pNETs.

Patients with a pNET were selected from the MEN1 database of the DMSG including >90% of the Dutch MEN1 population >16 years with an average of 21 years of follow-up (n=323) (3). Patients were considered to have a pNET if found at pathology and/or diagnosed on the base of CT,MRI or EUS and confirmed at least once on subsequent imaging. For growth analysis CT/MRI was used and the size (mm) of the largest tumor in the pancreatic head and/or body-tail was followed over time. Size was analyzed from the first moment a tumor was identified until the end of follow-up, surgical removal or start of systemic anti-tumor therapy. Growth analysis was performed using Linear Mixed Models analysis to account for clustering of observations within patients. Gender, age, genotype, use of somatostatin analogues (SSA) and serum calcium were investigated as possible effect modifiers. To correlate tumor growth with disease related outcome, adverse outcome (pNET-related liver metastases or death) was analyzed for possible effect modification.

PNET was present in 159 (49%) patients. Ninety-two tumors from 82 patients were available for growth analysis. Thirthy-six patients (44%) were male. Median age at diagnosis of the tumor was 40 years. Baseline tumor size was 12 mm (range 3-82 mm). Twenty (22%) tumors were eventually surgically removed, baseline tumor size for these tumors was 17 mm (range 5-82). No clinically relevant growth was observed during a median follow-up of 4 (range 0.5-16.5) years:  the average growth rate of pNETs was <1 mm/year. Tumors that were surgically removed had a statistically significant higher growth rate, however this was still <1 mm/year. Growth rate did not differ by gender, age, genotype, use of SSA or serum calcium. Tumors from patients in whom during follow-up an adverse outcome was documented had a statistically significant somewhat higher growth rate, but still <1 mm/year.

In this large patient group during long term follow-up, the growth rate of pNETs in MEN1 appears to be slower than previously thought and was not influenced by gender, age, genotype, use of SSA and serum calcium. Present results do not support a clinically relevant relation between growth rate and adverse outcome indicating that tumor growth rate cannot be used as indicator for surgery.

 

Nothing to Disclose: CRCP, JMD, JWRT, MRV, ARH, OMD, WWD, ANAV, MLD, PHB, BH, GDV

PP02-3 20880 2.0000 THR-325 A Growth Rate of MEN1-Related Pancreatic Neuroendocrine Tumors: New Insights Based on the Results from the DutchMEN1 Study Group (DMSG) National MEN1 Database 1990-2010 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 11:30:00 AM PP02 5977 11:15:00 AM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster Preview


Paul J Newey*1 and Rajesh V Thakker2
1Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland, 2University of Oxford, Oxford, United Kingdom

 

Recent large-scale DNA sequencing projects have provided unprecedented insight into the frequency and spectrum of rare coding variants present within populations. Indeed, the majority of protein-coding variation is rare, evolutionarily recent, and enriched for deleterious alleles1. The contribution of such rare variation to disease susceptibility represents one of the major challenges of contemporary medicine. However, the high frequency of rare coding variation within the population has important implications for the rational interpretation of clinical genetic studies; a failure to consider the inherent frequency of rare variation within control populations may result in a reporting bias when evaluating germline variants in disease-associated genes. To address these potential biases, analysis of sequence data from large control populations may allow the estimation of rare variant frequencies. In this study, 27 genes associated with endocrine disease (e.g. MEN1, AIP, RET, VHL) were evaluated for the frequency of rare (minor allele frequency (MAF): <0.5%), very rare (MAF: <0.01%) and singleton (i.e. occurring only once) germline non-synonymous variants in a population of ~4300 European-Americans using publicly available data from the NHLBI GO Exome Sequencing Project (evs.gs.washington.edu/). Analysis of these genes demonstrated significant variability in the frequency of rare coding variants. As expected, a positive correlation was observed between the number of rare variants in a given gene and protein length. For example, high rare variant frequencies were observed in NF1 (1 in 44 individuals) and RET (1 in 56 individuals), consistent with their large size (i.e. >1000 amino acids). However, even when corrected for amino-acid length, a ~10-fold difference was observed between genes with the lowest (i.e. CDC73) and highest (i.e. CDKN1A) singleton variant frequency rate, whilst genes with no rare coding region variants were also identified (e.g. AP2S1). On average, a singleton missense variant was observed once every ~180,000 amino acids (5.4x105 nucleotides sequenced). Thus, for a protein of 500 amino acids, a singleton variant would be anticipated ~1:360 individuals. To model the situation in which individuals undergo multiple gene testing, collective rare variant frequencies were calculated. For example, using a panel of 11 genes for phaeochromocytoma, a rare variant would be anticipated once in every 8 individuals sequenced, whilst a singleton variant once in every 30 individuals. This analysis confirms the unexpectedly high rate of rare coding-region variation in control populations, and highlights the need to consider this background frequency when undertaking genetic studies. In the absence of robust methods for predicting variant pathogenicity, these studies emphasize the clinical challenges faced as next generation sequencing move into the clinical arena.

 

Nothing to Disclose: PJN, RVT

PP02-4 19775 3.0000 THR-329 A Frequency and Spectrum of Rare Germline Coding Variants in Hereditary Endocrine Disease Genes: Implications for Clinical Genetic Studies 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 11:30:00 AM PP02 5977 11:15:00 AM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster Preview


Naoki Hattori*1, Takashi Ishihara2 and Akira Shimatsu3
1Ritsumeikan University, Kusatsu-City, Shiga, Japan, 2Kobe City General Hospital, Ashiya-Shi, Japan, 3National Hospital Organization Kyoto Medical Center, Kyoto, Japan

 

Objective TSH is a sensitive indicator of thyroid function. In subclinical hypothyroidism, however, serum TSH concentrations are elevated despite normal thyroid hormone levels. Macro TSH is a large molecular sized TSH on gel filtration chromatography. We hypothesized that the bioactivity of macro TSH might be low like macro PRL and that macro TSH may be accumulated in the circulation. Thus, patients with macro TSH may show elevated TSH levels despite normal thyroid hormone levels, similar to subclinical hypothyroidism. This study aimed to characterize the nature of macro TSH.

Patients We screened macro TSH in 1083 patients with subclinical hypothyroidism (634 women and 449 men, aged 64.6 ± 17.7 years) followed at our hospital, and in 54 serum samples that were sent to our laboratory from doctors in other hospitals, suspecting the presence of macro TSH.

Measurements Macro TSH was screened by polyethylene glycol (PEG) method, in which macro TSH was precipitated with 12.5% PEG. The PEG-precipitable TSH (%), which may represent the amount of macro TSH, was calculated as (total TSH - free TSH) / total TSH × 100. Serum samples that exhibited PEG-precipitable TSH ratios greater than 75% (mean + 1.5 SD in controls) were subjected to gel filtration chromatography to confirm macro TSH. The biological activity of macro TSH was examined in the FRTL-5 rat thyroid cell line. Protein G column and HAMA (human anti-mouse antibodies) blockers were used to characterize macro TSH. Macro PRL was examined in patients with macro TSH using the same method as macro TSH.

Results Among 1083 patients with subclinical hypothyroidism, 14 patients had macro TSH (1.3%). Among 54 serum samples that were requested to examine the presence of macro TSH, 5 serum samples were found to containe macro TSH. The nature of macro TSH in these 19 serum samples included 14 anti-TSH autoantibodies of IgG class, 2 non-IgG-associated, and 3 HAMA. Macro TSH showed low bioactivity compared to the immunoreactivity. Three patients with macro TSH also had macro PRL.

Conclusions Macro TSH was heterogeneous, but it is mostly comprised of TSH and anti-TSH autoantibodies. Because 3 of 19 patients with macro TSH also had macro PRL, common mechanisms may be involved in the generation of macro TSH and macro PRL in some patients. When PEG-precipitable TSH exceeds 90% in serum samples with TSH above 10 mU/l, clinicians should strongly suspect the presence of macro TSH and confirm it by gel chromatography. Because macro TSH exhibited low bioactivity, thyroid hormone replacement therapy may not be required in patients with subclinical hypothyroidism due to macro TSH except for those with high serum free TSH levels.

 

Nothing to Disclose: NH, TI, AS

PP11-1 19723 1.0000 THR-012 A Etiology and Bioactivity of Macro TSH 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 11:30:00 AM PP11 6034 11:15:00 AM Thyroid Development, Clinical and Autoimmunity Poster Preview


Thomas Daniel Milner*1, Alexander Lloyd Berry2, Suchitra Raj,3, Ralf Clauss3, John Wright3 and Sue Davidson3
1Royal Surrey County Hospital, Hull, United Kingdom, 2Hull York Medical School, Hull, United Kingdom, 3Royal Surrey County Hospital, Guildford, United Kingdom

 

Background: Establishing an appropriate radioiodine dose in the treatment of hyperthyroidism caused by Grave’s disease, multinodular goitre (MNG) or solitary toxic nodule (STN) requires a balance between effective cure and risk of complications. Several clinical and patient factors are also thought to affect radioiodine outcomes, in particular the use of antithyroid drugs (ATDs) at the time of treatment. This study aims to identify factors associated with optimal radioiodine outcomes

 

Methodology: The introduction of a higher radioiodine dose into the Royal Surrey County Hospital in 2008 generated two treatment cohorts for hyperthyroid patients: a low dose cohort (n=62) receiving 350MBq, and a high dose cohort (n=102) where Grave’s disease patients received 415MBq and MNG or STN patients received 475MBq. A retrospective cohort study was conducted analysing the effect of this dose increase, as well as various other factors, on proportion hyperthyroid and proportion hypothyroid at one year, and time to absence of hyperthyroidism.

 

Results: At one year post-radioiodine, 32 (19.5%) patients were hyperthyroid, 37 (22.6%) patients were euthyroid, and 95 (57.9%) were hypothyroid. The higher radioiodine dose had no impact on all treatment outcomes. The use of ATDs post-radioiodine (OR=2.346; 95%CI=1.071-5.138; p=0.033), and a high free thyroxine (fT4) in the year prior to treatment (OR=8.499; 95%CI=1.231-58.707; p=0.03) were associated with increased risk of hyperthyroidism at one year. ATDs post-radioiodine (adj. HR=0.445; 95%CI=0.308-0.643; p<0.0005) and high fT4 (HR=0.627; 95%CI=0.420-0.935; p=0.022) also significantly prolonging time to absence of hyperthyroidism, with the effect of ATDs being maintained on multivariate analysis.

 

Conclusions: As higher dose radioiodine therapy did not alter treatment outcomes, contrary to current guidelines, the use of lower dose (350MBq) therapy in hyperthyroidism would be most appropriate, to mitigate any risks of long-term complications. In addition, provided a patient’s clinical status permits, the use of carbimazole or PTU post-radioiodine should be avoided due to their effects on radioiodine uptake.

 

Nothing to Disclose: TDM, ALB, SR, RC, JW, SD

PP11-2 21327 2.0000 THR-023 A Optimal Outcomes with the Use of Low Dose Radioiodine Therapy for Hyperthyroidism and the Avoidance of Antithyroid Medications Post-Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 11:30:00 AM PP11 6034 11:15:00 AM Thyroid Development, Clinical and Autoimmunity Poster Preview


David Martin Carty*, Paul Welsh, Elaine Butler and Christian Delles
University of Glasgow, Glasgow, United Kingdom

 

Treatment of overt hypothyroidism (OH) in pregnancy leads to improved foetal and maternal outcomes. Recent guidelines from US and European thyroid associations also indicate that women with subclinical hypothyroidism (SCH, TSH above the trimester-specific reference range, or ≥2.5 mU/L) should be treated with thyroxine. In these women, however, there is limited evidence of improvement in outcomes. In this study we measured thyroid function in early pregnancy to examine the frequency of OH and SCH in a general obstetric population, and to explore its relationship with obstetric outcomes.

4300 women were recruited from obstetric clinics in Glasgow, UK between 2007-2010 as part of the “Proteomics in Pre-eclampsia” study. Plasma samples and clinical data were obtained at the initial antenatal hospital visit at gestational week 12-14. Data on pregnancy outcomes was obtained from hospital databases. Birthweight centiles, corrected for maternal age, ethnicity, baby sex and gestational age were used. Thyroid stimulating hormone (TSH) and free thyroxine (fT4) levels were analysed in 2014 using clinically validated platforms (Roche, UK). In women with abnormal thyroid tests in pregnancy, hospital databases were used to identify more recent thyroid problems.

Delivery information was available on 4179 (97.2%) women: 3889 (90.4%) were Caucasian, 36 miscarried, and 87 (2%) developed pre-eclampsia. 73 women were known to have pre-existing thyroid disease and were not included in the analysis; of them 28 (38%) had a TSH above 2.5mU/L.

58 women were identified as having OH (TSH>5 mU/l), of whom 2 were later diagnosed during pregnancy and 7 have been diagnosed since pregnancy. 8 women were found to have isolated hypothyroxinaemia (fT4 <9 pmol/l) . 406 women (10.6%) were identified as having SCH (TSH >2.5 mU/L but <5mU/L, and fT4 within the non-pregnant reference range). Women with OH delivered babies of lower birthweight than those with normal thyroid function (3196g ± 805 vs 3403g ± 402, p=0.02, corrected centile 37±12 vs 44±14, p=0.05), there was no difference in birthweight between women with SCH and those with normal thyroid function. There was no relationship between early pregnancy thyroid tests and rates of pre-eclampsia, gestational diabetes, miscarriage, preterm delivery or Caesarean section.

Retrospective screening of thyroid function in this unselected obstetric cohort identified 1.4% of women having OH, and these women delivered infants of lower birthweight. In women known to have thyroid disease, more than a third had a TSH above the pregnancy reference range. 10% were identified as having SCH, which did not impact upon obstetric outcomes. Recent guidelines suggest that if identified, women with SCH should be treated with thyroxine. This treatment, and the subsequent monitoring required would have major implications for design and costing of obstetric services.

 

Nothing to Disclose: DMC, PW, EB, CD

PP11-3 20383 3.0000 THR-006 A Frequency of Overt and Subclinical Hypothyroidism in Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 11:30:00 AM PP11 6034 11:15:00 AM Thyroid Development, Clinical and Autoimmunity Poster Preview


Stephanie Clare Cox*1, John V Conaglen2 and Marianne Susan Elston3
1Waikato District Health Board, Hamilton, New Zealand, 2Waikato Clinical School, University of Auckland, Hamilton, New Zealand, 3Waikato Hospital, Hamilton, New Zealand

 

Context

There have been advances in our understanding of Graves’ disease over the last two decades, particularly with regard to the risks of anti-thyroid drugs and increased concern over the long term effects of radiation exposure, as well as advances in surgical techniques. Research into the effects of the disease and it’s treatments during pregnancy have also led to shifts in practice over this time. Multiple surveys were undertaken in the late 1980’s and early 1990’s looking at clinical practice patterns amongst physicians in the US, Europe and Australasia and recently several of these surveys have been repeated to assess the shifts in practice over time.

Objective

The aim of this study was to assess the current management of Graves’ disease by New Zealand (NZ) endocrinology/internal medicine specialists and to compare findings with those of contemporary international studies and a previous 1991 New Zealand survey1.

Methods

We conducted an online case-based survey of all NZ physicians practising in the area of internal medicine, diabetes and/or endocrinology. Physicians were identified from the NZ Medical Council register. The case studies and questions from the previous 1991 NZ study were reformatted into an online survey and the link was emailed to the list of physicians.  A total of 117 physicians were invited to participate. Of these six were unable to be located, two had retired, two were on extended leave throughout the survey time period and one had permanently left NZ. Respondents who treated <2 patients/year with Graves’ disease were asked only to complete the sections on demographics and access to services. 

Results

In comparison to the 1991 NZ survey1 the first-line use of Radioiodine was less, at only 3%, compared with 41%, using the same clinical scenario. This corresponded with an increase in the use of antithyroid drugs, while the rates of surgery as a first line treatment remained fairly static over time. This is more in line with the current practice of our European colleagues than with Endocrinologists in North America who continue to report higher rates of RAI use2. In the index case, all respondents opted for carbimazole as their drug of choice (methimazole is not available in NZ). When the case was altered to a woman desiring pregnancy 28% would instead use PTU pre-pregnancy, while 56% would switch to PTU once the patient became pregnant. Both of these figures suggest NZ physicians use PTU less in pregnancy compared with international practice. Access to services, particularly nuclear medicine imaging, was an issue for 23% of respondents.

Conclusions

Practice in NZ has changed over the last twenty years, with a move away from radioactive iodine treatment. This parallels changes in practice in Europe and to a lesser extent America. NZ physicians appear to use PTU less commonly pre-pregnancy, although the majority would switch to PTU in early pregnancy.

 

Nothing to Disclose: SCC, JVC, MSE

PP11-4 21266 4.0000 THR-007 A The Management of Graves’ Disease in New Zealand 2014 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 11:30:00 AM PP11 6034 11:15:00 AM Thyroid Development, Clinical and Autoimmunity Poster Preview


Ruchi Mathur*1, Manpreet Mundi2, Kathleen Shari Chua1, Paul Lorentz2, Eugenia Lin1, Gillian M Barlow1, Miguel Burch1, Scott Cunneen1, Adrienne Youdim1 and Mark Pimentel1
1Cedars-Sinai Medical Center, Los Angeles, CA, 2Mayo Clinic, Rochester, MN

 

Background

Gut microbes have been shown to play significant roles in metabolic dysfunction and the development of obesity. Of these, the methanogenic archaea have been specifically linked to altered metabolism and weight gain. We have previously shown that the presence of both methane and hydrogen on breath test (a surrogate for gastrointestinal colonization with methanogens) is associated with greater body mass index (BMI), percent body fat, as well as glucose intolerance. Since alterations in gut microbial populations are also associated with weight loss following gastric bypass surgery, we investigated whether methane and hydrogen on breath test was associated with differential weight loss after Roux- en-Y gastric bypass.

Methods

Obese subjects aged 18 to 70 years with a pre-surgery BMI ≥ 35 were recruited at ≥ 4 months after bariatric surgery (Roux-en-Y or gastric sleeve). Pre- and post-surgery weights and BMIs were recorded, and single sample breath tests were performed to determine post-surgery methane and hydrogen levels. BMI and body weight changes were normalized to 6 months post surgery.

Results

A total of 156 subjects were recruited (112 females, 44 males). The average age was 47.9 ± 0.9 years and the average pre-surgery BMI was 42.6 ± 0.3. For all subjects, % change in weight and % change in BMI were normalized for pre-surgery BMI. Using cutoffs of methane ≥3 ppm and hydrogen ≥20 ppm to define methane and hydrogen positivity (M+/H+), M+/H+ subjects (n=13) had a lower % change in BMI than all other subjects (n=144) following surgery (20.6±1.9 vs. 23.5±0.6 respectively, p=0.13), and also had a significantly lower % change in weight (20.05±1.8 vs. 23.9±0.5 respectively, p=0.036). When cutoffs of methane ≥3 ppm and hydrogen ≥10 ppm were used to define methane and hydrogen positivity, M+/H+ subjects (n=18) still exhibited a lower prorated % change in BMI following surgery than all other subjects (n=139) (20.4±1.6 vs. 23.6±0.6 respectively, p=0.057), as well as a significantly lower prorated % change in weight than (20.1±1.5 vs. 24.0±0.5 respectively, p=0.014).

Conclusions

Subjects with gastrointestinal methanogen colonization (as determined by methane and hydrogen levels on breath test) exhibited less % weight loss and % BMI reduction than subjects without detectable methanogen colonization following Roux-en-Y gastric bypass surgery. This was shown regardless of whether a breath hydrogen level of ≥20 ppm or the more stringent level of ≥10 ppm was used to define hydrogen positivity.  Altering methanogenic colonization via pharmacotherapy and/or dietary interventions may provide additional benefit in those achieving less than optimal weight loss post gastric bypass surgery.

 

Nothing to Disclose: RM, MM, KSC, PL, EL, GMB, MB, SC, AY, MP

PP07-1 20644 1.0000 THR-550 A Intestinal Methane Production Is Associated with Decreased Weight Loss Following Bariatric Surgery 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 11:30:00 AM PP07 6045 11:15:00 AM Obesity: Clinical Studies Poster Preview


Jean-Marc Schwarz*1, Susan M Noworolski2, Michael J Wen3, Grace Marie Jones1, Ewan Sinclair1, Artem Dyachenco1, Viva Tai3, Moises Velasco Alin1, Ayca Erkin-Cakmak3, Alejandro Gugliucci1, Kathleen Mulligan3 and Robert H Lustig4
1Touro University California, Vallejo, 2University of California San Francisco, San Francisco, 3University of California San Francisco, 4University of California - San Francisco, San Francisco, CA

 

Background: Previous studies have shown that high sugar (specifically fructose) consumption is associated with liver fat accumulation and/or hypertriglyceridemia, which may increase risk for Type 2 diabetes and cardiovascular disease. The conversion of sugar to fat in the liver (hepatic de novolipogenesis [DNL]) may be an important pathogenic mechanism.

Objective: To determine the effect of 10 days of a fructose- but not calorie- restricted diet on DNL in obese Latino and African American children with high habitual dietary sugar intake.

Design/Methods: Latino (8F, 9M) and African American (4F, 1M) children (ages 9-18; BMI z-score 2.4 ± 0.1), who were high dietary sugar consumers at baseline (average fructose intake >50 g/day), had all meals provided for 10 days with the same caloric and macronutrient composition as their standard diet, but with other carbohydrate substituted for sugar. Subjects were weighed daily and diets adjusted to maintain baseline weight. Fractional DNL and DNL area under the curve (DNL-AUC) were measured over 8 hours of test meal feeding on Day 0 (high fructose) and Day 10 (low fructose). Test meals contained 1-13C sodium acetate tracer.  Post-prandial blood samples were analyzed by gas chromatography/mass spectrometry, and DNL calculated by mass isotopomer distribution analysis. Liver fat percentage was determined by magnetic resonance spectroscopy.

Results:DNL during feeding was significantly reduced with fructose restriction, beginning 50 minutes after initiation of tracer/feeding (2.5±0.3 vs.1.6±0.1% on days 0 and 10 respectively, P<0.003 by paired t-test) and continuing throughout the tracer/feeding procedure (13.3±1.2 vs. 5.8±0.6% at 8 hours on days 0 and 10, P<0.001).  Integrated DNL-AUC decreased by 58.7% from 53.5±6.4 on day 0 to 22.1±3.3 on day 10 (P<0.001). The decrease in DNL-AUC over only 10 days of fructose restriction was accompanied by a 29.5% reduction in liver fat from 11.9±2.3% on day 0 to 9.5±2.2% on day 10 (P <0.001; n=20). These effects remained statistically significant after adjusting by ANCOVA for minor weight loss over the 10 days (1.0±0.3 kg, P<0.001).

Conclusions: Isocaloric dietary fructose restriction for 10 days decreased hepatic DNL and liver fat in Latino and African American children irrespective of weight loss. These results suggest that hepatic DNL is an important mechanism leading to liver fat accumulation in children, which can be reversed by short-term fructose restriction. These data support public health efforts to reduce sugar consumption.

 

Nothing to Disclose: JMS, SMN, MJW, GMJ, ES, AD, VT, MV, AE, AG, KM, RHL

PP07-3 19571 3.0000 THR-549 A Isocaloric Fructose Restriction for 10 Days Reduces Hepatic De Novo Lipogenesis and Liver Fat in Obese Latino and African American Children 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 11:30:00 AM PP07 6045 11:15:00 AM Obesity: Clinical Studies Poster Preview


Ajay Chawla*
University of California San Francisco, San Francisco, CA

 

 

Nothing to Disclose: AC

AL10-1 22249 1.0000 A The Intersection of Inflammation and Metabolism in Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 11:45:00 AM AL/OR10 6078 11:15:00 AM Richard E. Weitzman Outstanding Early Career Investigator Award Lecture


Florian Le Billan*, Junaid Ali Khan, Khadija Lamribet, Say Viengchareun, Jérôme Fagart and Marc Lombes
INSERM U693, Le Kremlin Bicêtre, France

 

Aldosterone exerts numerous pleiotropic functions, notably in the kidney – where it regulates fluid and electrolyte homeostasis – but also in the cardiovascular and central nervous systems. Aldosterone acts mainly by activating the mineralocorticoid receptor (MR), a transcription factor that interacts with multiple transcription coregulators to regulate target gene expression. Dysfunctions in the mineralocorticoid pathway are involved in various pathological disorders such as hypertension, cardiovascular, renal or metabolic diseases.

Aldosterone mechanism of action is extremely complex, involving several intricate aspects (1) whereby kinetic and cross-talk dynamics appeared to play a critical role in the control of vectorial ionic transport. In this context, an overall assessment of MR genomic targets by new genomic tools was highly desirable. Here, we setup the chromatin immunoprecipitation (ChIP) with a specific anti-MR antibody in a highly differentiated human renal cell line expressing GFP-MR treated or not with aldosterone. This approach coupled with the innovative high-throughput sequencing technology (ChiP seq, HiSeq) allowed identification of hundreds of direct genomic MR targets (MACS Software), including the well known SCNN1A gene coding for the alpha subunit of the epithelial sodium channel (αENaC). Computational analysis of these genomic sites defined a specific MR response element (MRE) in which the AGtACAgxatGTtCt sequence was the most prevalent motif. Of interest, genomic MR binding sites were located at various distances (up to 150 kb) and directions from the transcriptional start sites of target genes. Specific aldosterone-induced recruitment of MR on the first most relevant genomic sequences was further validated by ChIP-qPCR and correlated with concomitant and positive aldosterone-activated transcriptional regulation of the corresponding gene as assayed by RT-qPCR. Analyses of the dynamics of MR recruitment and of its transcriptional co-regulators together with the evaluation of the functional role of these genes in the renal mineralocorticoid signaling pathway are underway.

This work provides new insights into aldosterone, MR-mediated signaling and opens germane perspectives for mineralocorticoid-related pathophysiology.

 

Nothing to Disclose: FL, JAK, KL, SV, JF, ML

OR06-1 19789 1.0000 A Identification of Genomic Targets of the Mineralocorticoid Receptor and Transcriptional Regulation of Aldosterone-Regulated Genes in Human Renal Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 1:00:00 PM OR06 5902 11:30:00 AM HPA Axis and Adrenal: Receptors To Clinical Impact Oral


Tracy Choi Sze Mak*1, Dawn EW Livingstone2, Brian R Walker1 and Ruth Andrew1
1University of Edinburgh, Edinburgh, United Kingdom, 2University of Edinburgh, Edinburgh Scotland, United Kingdom

 

Background

Glucocorticoids induce insulin resistance in multiple tissues. Systemic glucocorticoid receptor (GR) antagonism improves insulin and glucose homeostasis in ob/ob mice but the site of action is uncertain, with effects confounded by compensatory hypercorticosteronemia. A-348441, a GR antagonist targeted to the liver by conjugation to a bile acid, is used here for the first time to evaluate the role of hepatic GR in the metabolic complications of short-term diet-induced obesity in mice.

Experimental Design

C57BL6/J male and female mice (n = 6-12 per group; age 12 weeks) were given control, high fat (HF, 58% fat, 26% sucrose) or HF with A-348441 (~100mg/kg/day, kindly gifted by KaroBio AB) diet for 4 weeks. Glucose tolerance tests (ip GTT; 2mg/g body weight) were performed after 3 weeks. After 4 weeks, mice were culled (8am). Plasma insulin, non-esterified fatty acids (NEFA), and corticosterone were analyzed using ELISA, and plasma glucose and liver triglycerides (TG) spectrophotometrically. Data are control; HF; HF+A348441, mean±SEM *p<0.05, **p<0.01 vs control; #p<0.05, ##p<0.01 vs HF.

Results

Plasma corticosterone concentrations were not changed in either gender by HF diet or A-348441.

In male mice, A-348441 prevented HF-induced bodyweight gain (31.8±0.5; 34.3±0.5*; 31.1±0.8g#), expansion of the liver (1.47±0.05; 1.66±0.05*; 1.40±0.04g##) and total adipose depot weight gain (1.26±0.07; 2.46±0.14**; 1.58±0.14g##). A-348441 also attenuated HF-induced elevations in fasting plasma insulin (0.83±0.12; 2.06±0.20**; 0.99±0.17ng/mL##), fasting glucose (132.8±7.5; 166.1±8.2**; 125.1±7.0mg/dL##), and insulin response to GTT (91.7±8.2; 261.3±16.3**; 145.2±20.2ng/mL.min##). Neither HF diet nor A-348441 influenced liver triglycerides, fasting plasma NEFA or insulin-mediated NEFA suppression in male mice.

In female mice, HF diet did not significantly increase body or tissue weights, fasting plasma insulin, or post-GTT plasma insulin; A-348441 also had no effect. HF diet did increase fasting and post-GTT plasma glucose, but the only effect of A-348441 was a trend for reduced fasting glucose (113.6±7.5; 164.9±13.5*; 129.6±10.5 mg/dL). HF diet also increased liver TG and decreased NEFA suppression in female mice, but A-348441 did not influence these parameters.

Conclusion

Liver-specific GR antagonism not only improves insulin sensitivity and glucose tolerance in male mice with short-term diet-induced obesity, but also attenuates weight gain. Further dynamic studies are required to assess effects on energy balance and/or liver triglyceride export and its uptake in peripheral adipose. Females were relatively protected from metabolic dysfunction with diet-induced obesity, and GR antagonism had no discernible effect. These results suggest targeting hepatic GR may have a beneficial role in metabolic homeostasis in diet-induced obesity.

 

Nothing to Disclose: TCSM, DEL, BRW, RA

OR06-2 19257 2.0000 A Liver-Selective Glucocorticoid Receptor Antagonism Improves Insulin Sensitivity and Prevents Adipose Expansion in Diet-Induced Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 1:00:00 PM OR06 5902 11:30:00 AM HPA Axis and Adrenal: Receptors To Clinical Impact Oral


Kevin C.J. Yuen*1, Frank Buttgereit2, Dorothy McCabe3, Sheela Kolluri4, Brinda Tammara4, Riccardo Rojo4 and Juliana Hendrika Hey-Hadavi5
1Swedish Neuroscience Institute, Seattle, WA, 2Charite University hospital, Berlin, Germany, 3Pfizer Inc, New York, 4Pfizer Inc, 5Pfizer Inc, New York, NY

 

Background

PF-04171327 is a non-steroidal ‘dissociated” or partial agonist of the glucocorticoid receptor (DAGR) currently under investigation for anti-inflammatory efficacy, while mitigating unwanted side-effects of glucocorticoids(GCs). Administration of GCs and DAGR is expected to suppress the HPA axis, causing feedback inhibition of cortisol and ACTH secretion. In an 8-week Phase 2b dose-finding study to evaluate the efficacy and safety of DAGR in treating patients with rheumatoid arthritis (RA), 4 doses of DAGR were compared to 2 doses of prednisone (Pred) or placebo (PBO).  The effect of DAGR treatment on HPA axis suppression was evaluated with serial morning cortisol measurements and an ACTH stimulation test. 

Methods

323 adults with active RA therapy were randomized to receive DAGR 1, 5, 10 or 15 mg, Pred 5 or 10 mg, or PBO daily for 8 weeks followed by a 4-week taper. Any use of GCs within 6 weeks of screening was prohibited.  Fasting cortisol levels were measured at each 2-weekly study visit for 8 weeks, and a 250 mcg ACTH stimulation test was performed at Week 13.

Results

Across the dose groups, mean age ranged from 50.4 to 57.4 yrs; proportion of females ranged from 73% to 89.1%; and proportion of Caucasians ranged from 82.6% to 95.6%. Based on aggregate efficacy data, DAGR 10 and 15 mg was found to be efficacious (superior to PBO and comparable to Pred 10 mg, with 20% improvement using the American College of Rheumatology core set measures, and 28-point disease assessment scale, at Week 8). Median suppression of plasma cortisol levels were observed as early as Week 2 with  DAGR 1, 5, 10 and 15 mg doses showing suppression from baseline of  101, 122,  96.4,  110.5 ng/ml by  -14.3%, -79.6%,  -93.7%, -95.3%  respectively; suppression for Pred 5 mg and 10 mg from baseline of 113 and 123 ng/ml by -25.1% and  -42.7%  respectively; and that for PBO  from baseline of 106 ng/ml by  -6.4%. This magnitude of suppression was sustained throughout the 8 weeks of active treatment.  Prompt HPA axis recovery was observed during the 4-week DAGR taper, as morning cortisol levels normalized and a normal response to the ACTH stimulation test was evident in >95% of the patients.  All DAGR doses were well-tolerated, with no clinical manifestations suggestive of adrenal suppression reported.

Conclusions

Profound suppression of plasma cortisol was observed with DAGR 5, 10, and 15 mg, while partial suppression was seen with Pred 5 and 10 mg.  No subjects reported clinical symptoms of adrenal insufficiency at any time.  HPA axis recovery in the taper period was demonstrated by normalization of morning cortisol levels and the ACTH stimulation test. The clinical implications of cortisol suppression by DAGR require further exploration.

 

Disclosure: KCJY: Principal Investigator, OPKO, Ad Hoc Consultant, Pfizer, Inc., Ad Hoc Consultant, Corcept. FB: Scientific Board Member, Pfizer, Inc.. DM: Employee, Pfizer, Inc.. SK: Employee, Pfizer, Inc.. BT: Employee, Pfizer, Inc.. RR: Employee, Pfizer, Inc.. JHH: Employee, Pfizer, Inc..

OR06-3 21844 3.0000 A Profound Suppression of Endogenous Cortisol Secretion with Pf-04171327 (a dissociated agonist of glucocorticoid receptor) Compared to Prednisone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 1:00:00 PM OR06 5902 11:30:00 AM HPA Axis and Adrenal: Receptors To Clinical Impact Oral


Stéphanie Espiard*1, Ludivine Drougat1, Rossella Libe1, Guillaume Assie1, Karine Perlemoine1, Laurence Guignat2, Gaelle Barrande3, Francoise S Brucker-Davis4, Stephanie L Lopez5, Emmanuel D Sonnet6, Florence Torremocha7, Nathalie Chabbert-Buffet8, Marie-Laure Raffin-Sanson9, Lionel Groussin10, Francoise Borson-Chazot11, Xavier Bertagna1, Constantine A Stratakis12, Felix Beuschlein13, Bruno Ragazzon1 and Jerome Yves Bertherat14
1INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 2Department of Endocrinology, Referral Center for Rare Adrenal Diseases, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, 3Department of Endocrinology, Regional Hospital of Orléans, Orleans, France, 4Department of Endocrinology, Diabetology and Reproductive Medicine, University Hospital of Nice, Nice, France, 5Department of Internal Medicine B, Endocrinology and Metabolic Diseases, University Hospital of Limoges, Limoges Cedex, France, 6Department of Endocrinology, Hôpital de la Cavale Blanche, University Hospital of Brest, Brest Cedex, France, 7Department of Internal Medicine and Endocrinology, University Hospital of Poitiers, Poitiers, 8Unit of Endocrinology, Obstetrics, Gynecology and Reproductive Medicine Department, Assistance Publique Hôpitaux de Paris, Hôpital Tenon, Paris, France, 9Assistance publique hôpitaux de Paris, Hôpital Ambroise Paré, Service d'Endocrinologie, France, 10INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, 11Hospices Civils de Lyon, Groupement Hospitalier est, Bron Cedex, France, 12National Institutes of Health (NIH), Bethesda, MD, 13Klinikum der Universität München, Ludwig-Maximilian University, Munich, Germany, 14INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

Context: Primary bilateral macronodular adrenal hyperplasia (PBMAH) is a rare cause of Cushing’s syndrome (CS) and bilateral adrenal tumors. Germline mutations of ARMC5 have been recently identified as a frequent cause of sporadic and familial PBMAH (1-5). 

Objective: The aim of this study was to determine the frequency of ARMC5 mutations in a large cohort of PBMAH index cases with subclinical or clinical CS. Genotype-phenotype correlation was established.

Patients and Methods: 98 patients with PBMAH were investigated. Leukocytes and/or tumor DNA was genotyped for ARMC5 by Sanger sequencing. Clinical data were collected (age, sex, CS, hypertension). Basal (midnight cortisol level, ACTH, androgens, mineralocorticoids hormones) and post-test parameters (overnight dexamethasone suppression test, ACTH 1-24 stimulation test, and illegitimate receptor responses) were assessed. Computed tomography and histological reports were analyzed.

Results: ARMC5 inactivating mutations were characterized for 24 patients (26%). In total, 36 different mutations were found by the sum of the germline and somatic DNA analysis in addition to one germline microdeletion and somatic losses of heterozygosity. The pathogenic role of the 10 missense mutants and the p.F700del deletion was demonstrated in H295R and Hela cell lines using immunofluorescence staining and flow cytometry. ARMC5 mutants were unable to induce apoptosis unlike the wild-type gene. In addition, 23 patients (23.5%) harbored missense variants which are predicted “benign” by in silico models and previously reported in 1000 genomes and Exome Variants Server databases. These patients and those without variations were considered as wild-type. Seven patients were not included in the comparison because of variants of uncertain significance. ARMC5 mutated patients exhibited more severe CS and were younger than wild-type patients. Overt clinical CS, higher midnight plasma cortisol, lower plasma ACTH and higher plasma cortisol after dexamethasone suppression was observed in the mutated patients. Adrenals of mutated patients were bigger with a higher number of nodules. No mutated patients, but 9 wild-type patients presented with food dependent CS.

Conclusions: More than one quarter of unrelated PBMAH patients present a pathogenic germline ARMC5 defect and these index cases present more severe CS and larger adrenal. Systematic genotyping of ARMC5 may help for early diagnosis of PBMAH, familial counseling, and patients’ management.  

 

Disclosure: JYB: Advisory Group Member, atterocor, Investigator, Novartis Pharmaceuticals, Investigator, Ipsen. Nothing to Disclose: SE, LD, RL, GA, KP, LG, GB, FSB, SLL, EDS, FT, NC, MLR, LG, FB, XB, CAS, FB, BR

OR06-4 20748 4.0000 A Armadillo Repeat Containing 5 Gene (ARMC5) in a Large Cohort of Primary Bilateral Macronodular Adrenal Hyperplasia (PBMAH): Genotype-Phenotype Correlations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 1:00:00 PM OR06 5902 11:30:00 AM HPA Axis and Adrenal: Receptors To Clinical Impact Oral


Guillaume Assie*1, Anne Jouinot2, Eric Letouze3, Olivia Barreau4, Martin Fassnacht5, Windy Luscap2, Hanin Omeiri6, Stephanie Rodriguez7, Karine Perlemoine1, Fernande rené-Corail8, Nabila Elarouci9, Silviu Sbiera5, Matthias Kroiss5, Bruno Allolio5, Jens Waldmann10, Marcus Quinkler11, Massimo Mannelli12, Franco Mantero13, Thomas Papathomas14, Ronald R de Krijger15, Antoine Tabarin16, Veronique Kerlan17, Eric Baudin18, Frederique Tissier6, Bertrand Dousset19, Lionel Groussin20, Laurence Amar21, Eric Laurent Clauser22, Simon Faillot20, Xavier Bertagna1, Bruno Ragazzon1, Felix Beuschlein23, Rossella Libe1, Aurélien de Reynies24 and Jerome Yves Bertherat25
1INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 2INSERM U1016, CNRS UMR 8104, Institut Cochin Université Paris Descartes, Paris, 3Ligue Nationale Contre Le Cancer, Paris, France, 4Inserm U1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, 5University Hospital Wuerzburg, Wuerzburg, Germany, 6INSERM U1016, CNRS UMR 8104, Institut Cochin Université Paris Descartes, 7Institut Cochin, INSERM U1016, CNRS 8104, Université Paris Descartes, 8INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, Paris, 9Ligue Nationale Contre Le Cancer, Paris, 10Visceral-, Thoracic and Vascular Surgery, University Hospital Giessen and Marburg, Marburg, Germany, 11Charite Campus Mitte, Berlin, Germany, 12Univ of Florence, Florence, Italy, 13University of Padova, Padova, Italy, 14Department of Pathology, Josephine Nefkens Institute, Erasmus MC-University Medical Center, Rotterdam, Netherlands, 15Erasmus MC, Rotterdam, Netherlands, 16University hospital of Bordeaux, Pessac, France, 17CHUBrest - Hopital De La Cavale Blanche, Brest, France, 18Institut Gustave-Roussy, Villejuif, France, 19Department of Digestive and Endocrine Surgery, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France, 20INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, 21Hopital Europeen Georges Pompido, Paris, France, 22Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France, Paris, France, 23Klinikum der Universität München, Ludwig-Maximilian University, Munich, Germany, 24Ligue Contre Le Cancer, Paris, 25INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

The integrated genomics of adrenocortical carcinomas (ACCs) was recently reported (1), showing the existence of two molecular types, with different outcomes. The tumors with poor outcome include ACCs with global hypermethylation in the CpG islands of the gene promoter regions, and ACCs with mutations in a few recurrent genes, including mainly genes from the Wnt-βcatenin pathway (the newly identified tumor suppressor ZNRF3, and CTNNB1) and from the p53 pathway (TP53, CDKN2A and RB1).

Aim: To build a molecular prognostic predictor, based on tumor DNA alterations, including hypermethylation and mutations of these genes.

Methods:

A cohort of 130 ACCs collected within the COMETE and ENSAT networks were included. Targeted sequencing of 9 genes recurrently altered in ACC (ZNRF3, CTNNB1, TP53, RB1, CDKN2A) was performed by PCR-based capture(LifeTechnologies Ampliseq), followed by next generation sequencing (NGS, LifeTechnologies PGM). Homozygous deletions were identified by SNP arrays (Illumina). CpG island methylation status of each ACC was determined by MS-MLPA (methylation-specific multiplex-ligation-dependent probe amplification), using a commercially available kit (ME002-B1 kit, MRC Holland), and targeting CpGs islands of 4 genes (PAX5, GSTP1, PYCARD, PAX6) previously demonstrated as best reflecting the global methylation status (2); tumors were considered hypermethylated when the mean proportion of methylated alleles was >12% for these 4 genes.

Results:

MS-MLPA showed that 53% of the ACCs were hypermethylated. Hypermethylation was associated with worse survival (Cox p<0.001).

Targeted NGS and SNP arrays showed that mutations and or homozygous deletions of ZNRF3, CTNNB1, TP53, RB1, and CDKN2A were found in 20, 16, 15, 6 and 11 6% of the ACCs respectively. An alteration affecting the Wnt-βcatenin pathway (ZNRF3 or CTNNB1) was observed in 36% of ACCs. An alteration affecting the p53 pathway (TP53, RB1 or CDKN2A) was present in 29%.  Patients with an alteration affecting either the Wnt-βcatenin or p53 pathway presented a worse survival (Cox p=0.019).

Tumors of the poor outcome molecular subtype, defined as the tumors presenting either an hypermethylation, or an alteration of the Wnt-βcatenin or p53 pathways, corresponded to 71% of the cohort. These patients presented a worse survival (Cox p=0.002).

Conclusion:

Tumor DNA can be used to determine the ACC molecular subtype, and therefore the prognosis of ACC patients. This will help to design new prognostic molecular tools.

 

Disclosure: MF: Advisory Group Member, Atterocor. AT: Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals. JYB: Advisory Group Member, atterocor, Investigator, Novartis Pharmaceuticals, Investigator, Ipsen. Nothing to Disclose: GA, AJ, EL, OB, WL, HO, SR, KP, FR, NE, SS, MK, BA, JW, MQ, MM, FM, TP, RRD, VK, EB, FT, BD, LG, LA, ELC, SF, XB, BR, FB, RL, AD

OR06-5 22107 5.0000 A Survival of Adrenocortical Carcinoma Determined from the Tumor DNA : An Application of the Post-Genomics Area 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 1:00:00 PM OR06 5902 11:30:00 AM HPA Axis and Adrenal: Receptors To Clinical Impact Oral


Richard J. Auchus*1, Adina F. Turcu2, Joanna L. Spencer-Segal3, Robert H. Farber4, Rosa Luo4, Dimitri E. Grigoriadis4 and Chris F. O'Brien4
1University of Michigan, Ann Arbor, MI, 2The University of Michigan, Ann Arbor, MI, 3University of Michigan, Ann Arbor, NY, 4Neurocrine Biosciences, San Diego, CA

 

Background: Classic CAH is an autosomal recessive genetic disorder that results in little or no cortisol biosynthesis, which eliminates feedback inhibition of pituitary adrenocorticotropic hormone (ACTH) secretion, increases production of precursor steroids, and leads to adrenal-derived androgen excess.  NBI-77860 is a selective corticotropin-releasing factor type 1 (CRF1) receptor antagonist that has demonstrated an ability to reduce ACTH release and is being developed as a novel oral treatment for classic CAH due to 21‑hydroxylase deficiency (21OHD). 

Methods: This study was a single-blind, placebo-controlled, single center, fixed-sequence, single-dose trial in adult female 21OHD patients.  A total of 8 classic 21OHD females, ages 19 to 58, were administered single doses of NBI-77860 300 mg, 600 mg, and placebo at 2200h during three separate treatment periods separated by a 3-week washout period.  Blood samples were collected over 24-hours to evaluate the pharmacokinetics (PK) of NBI-77860 and the hypothalamic-pituitary-adrenal (HPA) axis biomarkers ACTH, 17-hydroxyprogesterone (17OHP), androstenedione, and testosterone.  The primary analysis of biomarker data was an examination of grouped subject data, for each biomarker, expressed as a mean percent change from predose levels for the two active dosing conditions relative to the placebo condition. 

Results: Plasma levels of NBI-77860 were consistent with previous Phase 1, PK experience with this compound.  There were clinically meaningful reductions from predose levels of both 17OHP and ACTH following administration of NBI-77860 relative to placebo.  The 300 mg and 600 mg doses yielded nearly identical effects on mean percent change from predose in 17OHP and ACTH.  Variable reductions in androstenedione and testosterone levels were observed.  Individual subject responses were also evaluated, and treatment “responders” were conservatively defined as subjects with at least a 50% decrease in 17OHP and ACTH 8-12 hours following NBI-77860 dosing relative to placebo during the peak morning period.  This responder rate, following a single dose, was 50% for the study.  The single bedtime doses of NBI-77860 were well-tolerated in these adult female 21OHD patients.  The overall incidence of adverse events was low and similar among the three treatment conditions. 

Conclusions: Meaningful reductions in HPA axis biomarkers, particularly 17OHP and ACTH, were observed following NBI-77860 dosing in these patients.  These data are promising and provide a rational basis for continuing investigations of the CRF1 receptor antagonist, NBI-77860, and its activity in reducing ACTH and steroid biomarkers in the target population.  Studying the pharmacodynamics and PK of repeated doses of NBI-77860 will be helpful in this regard.

 

Disclosure: RJA: Investigator, Quest Diagnostics, Advisory Group Member, Laboratory Corporation of America, Investigator, Neurocrine Biosciences, Investigator, Novartis Pharmaceuticals, Consultant, Corcept. RHF: Employee, Neurocrine Biosciences. RL: Employee, Neurocrine Biosciences . DEG: Employee, Neurocrine Biosciences . CFO: Employee, Neurocrine Biosciences . Nothing to Disclose: AFT, JLS

OR06-6 20127 6.0000 A A Pharmacokinetic and Biomarker Study of the Corticotropin-Releasing Factor Receptor Antagonist NBI-77860 in Adult Females with Classic, 21-Hydroxylase Deficiency, Congenital Adrenal Hyperplasia (CAH) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 1:00:00 PM OR06 5902 11:30:00 AM HPA Axis and Adrenal: Receptors To Clinical Impact Oral


Kristy M. Heppner*1, Arian F. Baquero1, Camdin Bennett1, Melissa A. Kirigiti2, Sarah R. Lindsley1, Martha A. Bosch3, Oline K. Ronnekleiv3, Kevin L. Grove1 and M. Susan Smith1
1Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, 2Oregon National Primate Research Center, Beaverton, OR, 3Oregon Health & Science University, Portland, OR

 

Reproductive function is tightly linked to energy status, and reproductive disorders are often associated with metabolic dysfunction. Kisspeptin (Kiss1) neurons in the hypothalamic arcuate nucleus (ARC) are key components of the reproductive neuroendocrine axis as they regulate the basal pulsatile release of gonadotropin releasing hormone (GnRH). The identity of factors that regulate energy metabolism that might also modulate ARC Kiss1 neurons is largely unknown. One possible factor is glucagon-like peptide-1 (GLP-1), a neuropeptide produced by preproglucagon (PPG) expressing neurons in the brainstem. PPG neurons project to brain regions that regulate energy metabolism, including the ARC where GLP-1 regulates feeding and body weight. Although GLP-1 action on energy metabolism is well known, its action on the reproductive neuroendocrine axis has been largely unexplored. As GLP-1 fiber projections and the GLP-1 receptor (GLP-1R) are abundant in the ARC, we hypothesized that GLP-1 could modulate ARC Kiss1 action. Using immunohistochemistry, we found that GLP-producing neurons came in close apposition with ARC Kiss1 cells of ovariectomized (OVX) mice. Furthermore, single cell real-time PCR demonstrated that ARC Kiss1 neurons contained Glp-1r mRNA. Loose patch recordings from brain slices revealed that liraglutide (a long-acting GLP-1R agonist) increased action potential firing in ARC Kiss1 cells.  Moreover, current clamp recordings showed that liraglutide caused a membrane depolarization of ARC Kiss1 cells in the presence of presynaptic blockers.    

Calorie restriction (CR) potently suppresses ARC Kiss1 expression and downstream GnRH/luteinizing hormone (LH) release. As we identified GLP-1 as a positive regulator of ARC Kiss1 neurons, we hypothesized that a suppression of CNS GLP-1 action is contributing to reduced ARC Kiss1 action during CR.  First, we found that brainstem Ppg mRNA is reduced following a 48h fast in OVX mice.  However, restoring GLP-1 action using subcutaneous injections of liraglutide, which is known to enter the ARC, did not prevent LH inhibition during a 48h fast in OVX mice. Taken together, these studies demonstrate that GLP-1 is a positive regulator of ARC Kiss1 neurons.  Although suppression of brainstem Ppg mRNA may be contributing to the suppression of ARC Kiss1 and downstream GnRH/LH during CR, restoring GLP-1 action using peripheral injections of liraglutide was not sufficient to prevent LH inhibition during a 48h fast. PPG neurons do not express the GLP-1R, and therefore studies using methods that directly stimulate brainstem PPG neurons will give us a more accurate assessment of whether central PPG activation during CR will prevent LH inhibition. As a whole, more studies are necessary to understand the physiological significance of GLP-1 interaction with ARC Kiss1 neurons.

 

Disclosure: KLG: Principal Investigator, ERX, Consultant, Ember, Principal Investigator, Novo Nordisk, Advisory Group Member, Novo Nordisk, Consultant, Sanofi, Employee, Novo Nordisk. Nothing to Disclose: KMH, AFB, CB, MAK, SRL, MAB, OKR, MSS

OR05-1 19512 1.0000 A Glucagon-like Peptide-1 (GLP-1) Action on the Reproductive Neuroendocrine Axis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR05 5908 11:30:00 AM GnRH & Neuroendocrinology Oral


Alexander N Comninos*1, Jelena Anastasovska2, Meliz Sahuri-Arisoylu2, Xiao Feng Li3, Shengyun Li3, Minghan Hu3, Channa N Jayasena2, Mohammad A Ghatei4, Stephen R Bloom2, Paul Matthews2, Kevin O'Byrne3, Jimmy D Bell2 and Waljit S Dhillo1
1Imperial College NHS Healthcare Trust, London, United Kingdom, 2Imperial College London, United Kingdom, 3King's College London, London, United Kingdom, 4Imperial College London, London, United Kingdom

 

Kisspeptin is a crucial activator of reproductive function. The role of kisspeptin has been studied extensively within the hypothalamus but little is known about its significance in other areas of the brain. Exploring the extra-hypothalamic roles of kisspeptin is of key importance for our understanding of kisspeptin signaling and for the development of kisspeptin as a therapeutic.

Kisspeptin and its cognate receptor are expressed within the amygdala, a key limbic brain structure that has important roles in social and reproductive behaviours. In addition, the amygdala exerts an ‘inhibitory brake’ on reproduction via inhibitory projections to hypothalamic centers involved in reproductive hormone release. We therefore hypothesized that kisspeptin affects neuronal activation and reproductive pathways beyond the hypothalamus and particularly within the amygdala.

In a first test of our hypothesis, we mapped brain neuronal activity (using Manganese-Enhanced MRI) in adult rodents during peripheral (ip) administration of kisspeptin. In a second test of our hypothesis we investigated functional relevance in adult rodents by assessing the gonadotrophin response to direct intra-amygdala (MeA) administration of kisspeptin or kisspeptin antagonist.

Peripheral kisspeptin administration resulted in a marked decrease in neuronal activity in the amygdala compared to vehicle (20% decrease left amygdala kisspeptin vs. vehicle p=0.026; 22% decrease right amygdala kisspeptin vs. vehicle p=0.009)(n=7-8/group). This was associated with a simultaneous increase in luteinizing hormone (LH) secretion (vehicle +0.6±0.2ng/ml, kisspeptin +3.7±0.5ng/ml, p<0.0001 vs. vehicle). In addition, direct intra-MeA administration of kisspeptin resulted in a dose-dependent increase in LH secretion (kisspeptin 100pmol vs. vehicle, p=0.007; kisspeptin 1nmol vs. vehicle, p=0.002; kisspeptin 1nmol vs kisspeptin 100pmol, p=0.002)(n=5-7/group). Finally, blocking endogenous kisspeptin signaling specifically within the amygdala by administering intra-MeA kisspeptin antagonist decreased LH secretion (p=0.041 vs. vehicle) as well as LH pulse frequency (p=0.001 vs. vehicle)(n=5-7/group).

Collectively, these data provide the first evidence for a novel pathway in which kisspeptin inhibits neuronal activity in the amygdala, thereby releasing the amygdala’s ‘inhibitory brake’ on reproduction, resulting in stimulation of gonadotrophin secretion and pulsatility. In addition, this is the first report of kisspeptin signaling outside the hypothalamic-pituitary-gonadal axis influencing reproductive hormone secretion. Therefore, these data have important implications for our understanding of reproductive biology, as well as the development of kisspeptin as a therapeutic.

 

Nothing to Disclose: ANC, JA, MS, XFL, SL, MH, CNJ, MAG, SRB, PM, KO, JDB, WSD

OR05-2 18810 2.0000 A Kisspeptin Signaling in the Amygdala Modulates Reproductive Hormone Secretion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR05 5908 11:30:00 AM GnRH & Neuroendocrinology Oral


Graeme L Fraser*1, Steven Ramael2, Hamid R Hoveyda3 and Jean Combalbert2
1Euroscreen SA, Gosselies, Belgium, 2Euroscreen SA, 3Euroscreen SA, Belgium

 

The role of NK3 receptor (NK3R) signaling in the central neuroendocrine control of the hypothalamic-pituitary-gonadal (‘HPG’) axis is widely recognized based upon both recent genomic and pharmacological research.  We have previously demonstrated in preclinical models that NK3R antagonists selectively inhibit LH, but not FSH, and thereby modulate the HPG axis in a more refined, ostensibly non-castrating, manner than the GnRH ligands currently used for the treatment of sex-hormone disorders. The objective of the current study was to evaluate the safety, pharmacokinetics and key efficacy biomarkers following 21 days of ESN364 administration to healthy premenopausal women.  This was a double-blind, placebo-controlled, multiple-dose study with sequential dose escalation where subjects (N=6/group) were administered placebo, 20, 60 or 180 mg once daily with treatment initiation on Day 3 (±2) after onset of menses.  ESN364 was well-tolerated and rapidly bioavailable after oral administration. The LH surge was delayed in a dose-dependent manner consistent with a significant prolongation of the menstrual cycle, delayed presentation of a dominant follicle and delayed endometrial thickening (p<0.05, in all cases). Dose-dependent decreases in progesterone (up to >70%) and estradiol (up to >50% in both the follicular and luteal phases) were observed, although at no time did estradiol levels decline below 20 pg/mL (levels associated with bone mineral density loss). No inhibition of FSH levels occurred at any time throughout the menstrual cycle. ESN364 effects were rapidly reversed after discontinuation as demonstrated by the immediate restoration of normal menstrual cycle length and associated hormone levels. This is the first demonstration of the clinical effects of an NK3R antagonist to suppress the reproductive endocrine axis in healthy premenopausal women. In total, these data suggest that ESN364 may offer a safe, effective alternative to GnRH ligands in the treatment of reproductive hormone-dependent disease states in premenopausal women.

 

Disclosure: GLF: Chief Scientific Officer, Euroscreen SA. SR: Clinical Researcher, Euroscreen SA. HRH: Management Position, Euroscreen SA. JC: Management Position, Euroscreen SA.

OR05-3 21733 3.0000 A Suppression of Lutenizing Hormone, Estradiol and Progesterone in Premenopausal Women By Oral Administration of the NK3 Receptor Antagonist ESN364 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR05 5908 11:30:00 AM GnRH & Neuroendocrinology Oral


Karolina Skorupskaite*1, Jyothis T George2 and Richard Alexander Anderson3
1The Queen's Medical Research Institute, Edinburgh, United Kingdom, 2University of Oxford, Oxford, United Kingdom, 3University of Edinburgh, Edinburgh, United Kingdom

 

Background

The hypothalamic neuropeptide kisspeptin is a key regulator of GnRH and thus gonadotropin (LH and FSH) secretion. Gonadotropin response to exogenous kisspeptin is increased in the late follicular phase, suggesting a central role of kisspeptin in mediating pre-ovulatory positive estrogen feedback. We hypothesised that exogenous kisspeptin, administered concurrently with appropriately timed estrogen, would further increase gonadotropin secretion, mimicking the physiological mid-cycle surge.

Methods

We used a model of follicular phase administration of transdermal estradiol (200µg/day) to induce positive feedback and increase LH secretion 48 hr later. Eight women with regular menstrual cycles received this regimen on cycle day 9-10 and at 24 hr were randomised to receive kisspeptin-10 (4µg/kg/hour iv) or saline infusion for 7 hours, at the end of which estradiol treatment was discontinued. All women returned in a subsequent cycle to receive the alternate treatment allocation.  Hormone concentrations were compared by ANOVA with Bonferroni multiple comparison post hoc analysis.

Results

Model Validation

In control (saline infusion) cycles, estradiol increased from 302±39 pmol/l pre-administration to 744±98 at 24 hr after patch administration (p<0.0001); and after removal of estradiol patches at 32 hr fell to 351±83 pmol/l at 48 hr. LH increased after 48hr but not 24hr of estradiol treatment (time 0: 4.3±0.6; 24 hr: 3.2±0.3; 48 hr: 8.5±1.2 IU/l, p=0.0007). FSH initially fell during estrogen treatment, then increased significantly after 48hr in the saline group (time 0: 2.6±0.3; 24 hr: 1.8±0.3; 48hr: 3.4±0.6 IU/l, p=0.005).

Kisspeptin Response

Kisspeptin-10 acutely stimulated LH secretion, from 3.8±0.6 to 18.1±4.7 IU/l (p<0.0001) at the end of infusion, while saline had no effect (3.2±0.3 to 2.7±0.3 IU/l, ns). LH remained significantly elevated at 48 and 72 hr after the start of estrogen treatment (16.4±4.4 and 8.5±1.4 IU/l, both p<0.01 vs start of infusion); at those time points LH concentrations were similar to the estrogen-stimulated concentrations in the control group.

Kisspeptin-10 also acutely increased FSH secretion: from 1.7±0.1 IU/l pre-infusion to 3.9±0.6 IU/l post-infusion (p<0.001) while saline had no such effect (1.8±0.3 to 1.3±0.2 IU/l, ns). FSH remained elevated following kisspeptin-10 at 48 and 72 hr (4.0±0.5 and 3.8±0.3 IU/l, both p=0.0001) and was similar to FSH concentrations in controls.

Conclusions

Kisspeptin-10 amplified the positive feedback effect of estrogen with substantial LH secretion in this model of estrogen-induced gonadotropin secretion in women.  Notably, kisspeptin-10 also increased FSH secretion. These data suggest a central role for kisspeptin signalling in mediating the positive estrogen feedback which facilitates the ovulatory midcycle surge in gonadotropin secretion.

Funding: Wellcome Trust-STMTI

 

Disclosure: JTG: Clinical Researcher, Astra Zeneca, Clinician, Eli Lilly & Company, Clinician, Sanofi, Clinical Researcher, Takeda, Advisory Group Member, Novo Nordisk, Advisory Group Member, Bristol-Myers Squibb, Clinician, Astra Zeneca. RAA: Consultant, Astra Zeneca. Nothing to Disclose: KS

OR05-4 19196 4.0000 A Kisspeptin-10 Enhances the Effects of Positive Estrogen Feedback on LH and FSH Secretion in Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR05 5908 11:30:00 AM GnRH & Neuroendocrinology Oral


Magali van Leckwyck*, Weilin Kong, Kathryn Jane Burton, Marco Giacomini, Nathalie Vionnet and Francois Pierre Pralong
Lausanne University Hospital, Lausanne, Switzerland

 

The activity of the female neuroendocrine reproductive axis is intimately linked to nutritional status. Undernutrition has clearly been associated with hypogonadotropic hypogonadism. Obesity is also associated with decreased fertility, but the pathophysiological consequences of excess weight on the hypothalamic control of reproduction are far less understood. To gain insight into these mechanisms, we investigated the effects of short-term hypercaloric intake on the hypothalamic GnRH secretion in seven healthy, lean female volunteers. They were characterized by a mean age of 24.0 ± 0.8 years, a mean BMI of 22.0 ± 0.7 kg/m², and regular menstrual cycles lasting 29.4 ± 0.7 days. Hypothalamic GnRH secretion was evaluated in the follicular phase by assessing LH pulsatility on two different days (baseline assessment and hyperinsulinemic, euglycemic clamp), using frequent (q10’) blood sampling protocols. These protocols were performed at the end of two distinct nutritional interventions: the first intervention consisted of one week of controlled isocaloric diet (calculated as 1.5 times the resting metabolic rate). The second intervention (hypercaloric diet) lasted four weeks: ~50% extra calories were added in the form of sucrose (3 g/kg BW/day) and fat (1g/kg BW/day) to the usual diet of the volunteers (first three weeks), and to the controlled isocaloric diet (last week). This hypercaloric diet induced an average weight gain of 2 ± 0.3 kg (p<0.05), corresponding to a BMI increase of 0.7 ± 0.1 kg/m² (p<0.05). A significant decrease of 14.5 ± 4.5 % in insulin sensitivity was also observed (D = -1.8 ± 0.7 mg glc/kg/min; p<0.05). In these conditions, LH peak amplitude was significantly decreased by 17.9 ± 9.3% (D = -0.4 ± 0.13 U/l; p<0.05), while no change in the LH peak frequency was observed. These results demonstrate for the first time a significant effect of short-term hypercaloric intake on parameters of GnRH pulsatile secretion in normal, lean female volunteers, providing insight into the pathophysiological consequences of obesity on fertility.

 

Nothing to Disclose: MV, WK, KJB, MG, NV, FPP

OR05-5 20305 5.0000 A Short-Term Overfeeding Induces Alterations in Pulsatile LH Secretion in Healthy, Lean Young Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR05 5908 11:30:00 AM GnRH & Neuroendocrinology Oral


Brent S. Abel*1, Ranganath Muniyappa1, Monica C. Skarulis2, Phillip Gorden3 and Rebecca J. Brown4
1NIDDK, Bethesda, MD, 2DEOB, NIDDK, NIH, 3NIDDK, NIH, 4National Institute of Health, Bethesda, MD

 

Background: Leptin replacement in patients with leptin gene mutations improves hypogonadotropic hypogonadism (1-2). Exogenous leptin therapy has also been shown to increase luteinizing hormone (LH) pulsatility and restore ovulation in women with hypothalamic amenorrhea, a model of relative leptin deficiency (3). Patients with lipodystrophy have leptin deficiency due to lack of adipose tissue, and are a natural model to study effects of leptin deficiency and replacement in humans. The effects of leptin replacement on LH secretion in patients with lipodystrophy are unknown.

Objective: We examined LH secretory dynamics in male and female patients with lipodystrophy, on and off exogenous leptin therapy.

Methods: This was a 2 period, non-randomized study, including previously leptin-treated (n=4) and leptin-naïve (n=8) subjects (5 generalized lipodystrophy; 7 partial lipodystrophy).  In period 1 (5 days) the leptin-treated group continued leptin; leptin was withdrawn for the next 14 days (period 2).  Leptin-naïve subjects were studied without leptin in period 1, and with leptin replacement in period 2. Nocturnal LH secretory dynamics were assessed [23:00-7:00, q10 min sampling, analyzed by multiparameter deconvolution and approximate entropy (ApEn) algorithms] at the end of each period. Early morning follicle stimulating hormone (FSH), estradiol (E2), and total testosterone (T) were measured at the end of each period.

Results: There were no period effects between patients initiated or withdrawn from leptin, so data were analyzed in aggregate. Mean (on: 5.0 ± 3.1 U/L, off: 3.2 ± 1.3, p=0.02) and integrated nocturnal LH concentrations (on: 2403 ± 1495 U·L-1·min-1, off: 1534 ± 642, p=0.02) were higher on leptin therapy. LH burst frequency (on: 0.77 ± 0.26 hr-1, off: 0.67 ± 0.24, p=0.04) and secretory burst mass (on: 9.7 ± 15.4 U/L, off: 7.0 ± 11.2, p=0.04) were higher on leptin. Consequently, leptin therapy increased pulsatile production rate (on: 64 ± 101 U·L-1·8hr-1, off: 57 ± 73, p=0.01) but not basal secretion of LH (on: 20 ± 27 U·L-1·8hr-1, off: 21 ± 30, p=0.48). Orderliness of LH release (ApEn) tended to be higher on leptin therapy (p=0.09). FSH tended to be higher on leptin (on: 6.0 ± 6.2 U/L, off: 4.4 ± 3.9, p=0.05). In males (n=4), T was higher on leptin (on: 507 ± 286 ng/dL, off: 360 ± 174, p=0.04), and in females (n=8), E2 was higher on leptin (on: 74 ± 36 pg/mL, off: 29 ± 24, p=0.01).

Discussion: Leptin increases spontaneous nocturnal LH secretion in patients with lipodystrophy. This is consistent with rodent and in vitro studies showing a direct stimulatory effect of leptin on LH secretion. Increased LH frequency suggests additional hypothalamic effects. These novel findings may explicate some of the salutary effects of leptin therapy on the hypothalamic-pituitary-gonadal axis in patients with lipodystrophy.

 

Nothing to Disclose: BSA, RM, MCS, PG, RJB

OR05-6 19226 6.0000 A Recombinant Human Leptin (Metreleptin) Administration Augments Nocturnal LH Secretion in Lipodystrophy Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR05 5908 11:30:00 AM GnRH & Neuroendocrinology Oral


María Teresa Muñoz-Calvo1, Vicente Barrios1, Jesús Pozo1, Gabriel Ángel Martos-Moreno1, Federico G Hawkins2, Horacio M Domene3, Hector G. Jasper4, Shoshana Yakar5, Cheryl A Conover6, John J Kopchick7, Julie Ann Chowen1, Ron G Rosenfeld8, Luis A Pérez-Jurado9 and Jesús Argente*1
1Hospital Infantil Universitario Niño Jesús. Universidad Autónoma de Madrid. CIBERobn, Instituto de Salud Carlos III, Madrid, Spain, 2Hospital Universitario 12 de Octubre, Madrid, Spain, 3R Gutierrez Children's Hosp, Buenos Aires, Argentina, 4Division of Endocrinology, Ricardo Gutierrez Children´s Hospital, and Center for Endocrinology Research, CEDIE/CONICET, Buenos Aires, Argentina., 5New York University College of Dentistry, New York, NY, 6Mayo Clinic, Rochester, MN, 7Ohio University, Athens, OH, 8Oregon Health and Science University, Portland, OR, 9Universitat Pompeu Fabra.Hospital del Mar Research Institute (IMIM). CIBERER, Instituto de Salud Carlos III., Barcelona, Spain

 

PAPP-A2 is a protease that cleaves IGF-binding protein (IGFBP)5 and to a lesser extent IGFBP3. Pappa2 knock-out (KO) mice have a reduction in body and organ size with skeletal abnormalities. However, in humans, mutations in this protease have not been described. We report here, for the first time, a family in which 2 of 4 siblings show blunted postnatal growth due to a homozygous frameshift mutation in exon 3 of the PAPPA2 gene (c.1927_1928insAT, p.D643fs25X) resulting in a premature stop codon. Both affected children; a 10 year old female with height in the 10th percentile and her brother (6 yrs old) in the 25th percentile, while their target height is in the 75thpercentile, were thin (BMI: -1.5 SDS and -1.8 SDS) and microcephalic (-2.78 SDS and -3.3 SDS), but with apparently normal intellectual abilities. Initial biochemical studies showed [represented as case 1 and 2 (normal range)]: IGF-1 [1162 and 917 (102-256 ng/ml)], IGFBP3 [5912 and 4850 (2206-4200 ng/ml)] and ALS [3745 and 3625 (999-2634 mU/ml)]. Mutation analysis of the IGF receptor gene was normal. Exome analysis revealed the above mentioned mutation in the PAPP-A2 gene. The parents (nonconsanguineous) and one sibling, all heterozygous for this mutation, as well as the homozygous wild type 4th sibling, all had normal growth parameters and no other clinical phenotype. Further biochemical analysis of the affected siblings showed: undetectable PAPP-A2, spontaneous GH secretion tested during 8 h in the normal upper range (mean 4.5 ng/ml), low free IGF-1[0.32 and 0.13 (0.45-0.86 ng/ml)]; reduced PAPP-A1 [0.55 and 0.54 (0.82-3.26 ng/ml)]; high insulin [15.1 and 27.0 (4.0-12.95 μU/ml)]; normal IGFBP1 [1.52 and 6.37 (1.22-22.32 ng/ml)] and decreased-normal IGFBP2 [75.6 and 340.6 (176.7-353.9 ng/ml)]; increased intact IGFBP4 [65.5 and 68.4 (6.8-32.9 ng/ml)] and total IGFBP4 [89.5 and 92.6 (18.4-60.7 ng/ml)]; low-normal IGFBP5 [197 and 280 (211-707 ng/ml)] with increased IGF1 binding activity [(87 and 93 (43-70 % active)], but with reduced overall concentrations bound to IGF1 as detected by cross-linking studies (43 and 58 % of control values). Functional studies also showed increased IGF binding capacity of IGFBP3. No other endocrine abnormalities were found and the hypothalamic-pituitary axis was normal by MRI. X-rays showed very thin long bones and normal bone density (DEXA), which is similar to that reported in the Pappa2 KO mice models. In contrast, organ size was found to be normal by ultrasound in these patients. A therapeutic trial with hrIGF1 with monitoring of growth velocity will be attempted in these patients. In conclusion, we have described a new syndrome due to a PAPP-A2 gene mutation, where despite very high total IGF1 levels, lack of this protease activity results in reduced IGF1 bio-availability that produces decreased longitudinal growth, microcephaly and skeletal abnormalities.

 

Nothing to Disclose: MTM, VB, JP, GÁM, FGH, HMD, HGJ, SY, CAC, JJK, JAC, RGR, LAP, JA

OR03-1 21121 1.0000 A A New Syndrome of Short Stature, Mild Microcephaly, Skeletal Abnormalities and High Circulating IGF1, IGFBP3 and ALS Associated with a Homozygous Mutation in the Gene for Pregnancy-Associated Plasma Protein A2 (PAPP-A2, pappalysin2) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 1:00:00 PM OR03 5917 11:30:00 AM From the Genome to the Clinic: Growth and Puberty Disorders Oral


Isabelle Maystadt1, Shayne F Andrew2, Jean De Schepper3, Nathalie Wauters4, Valerie Benoît1, Pascal Joset5, Beatrice Oneda5, Andrew Dauber2, Ron G Rosenfeld6, Anita Rauch5 and Vivian Hwa*2
1Institut de Pathologie et de Génétique, Gosselies, Belgium, 2Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 3Ghent University Hospital, Ghent, Belgium, 4Hopital Civil de Charleroi, Charleroi, Belgium, 5University of Zurich, Zurich-Schwerzenbach, Switzerland, 6Oregon Health and Science University, Portland, OR

 

Background: Heterozygous mutations in the insulin-like growth factor 1 receptor (IGF1R) are often associated with congenital IGF1 resistance, causing variable degrees of intrauterine growth retardation (IUGR) and postnatal short stature. Only one homozygous IGF1Rmutation has been described, associated with a child who presented with severe growth failure, mild intellectual impairment, microcephaly, dysmorphic features, cardiac malformations and disturbed glucose tolerance (1).

Clinical Case: Two siblings, an 11-year-old girl (P1) and a 7-year-old boy (P2), presented with postnatal growth failure (height -6.0 SDS) and dysmorphic features. They were born with severe IUGR (birth weight and length: -6 SDS) to healthy consanguineous short Yemenite parents (mother’s height, 145cm; father’s height, 160cm). A moderate delayed bone age and epiphyseal abnormalities were noted. Severe microcephaly (head circumference, -7 SDS), mild intellectual disability, deafness, congenital cardiac malformations, oligodontia and enamel hypoplasia, and a partial vermis hypoplasia (brain MRI) were also documented in both patients. Endocrine evaluations revealed normal basal growth hormone, elevated IGF1 and normal IGFBP3 concentrations. Fasting glucose levels were normal, although OGTT (2hr) for P1, was in the diabetic range, with elevated glucose (216, normal:70-110 mg/dl), insulin (66.5, normal:5-25 mcU/ml) and c-peptide (9.8, normal:1.1-3.6 ng/ml) levels, consistent with insulin insensitivity. P2 produced a disturbed glucose tolerance OGTT profile. Molecular evaluation by exome sequence analysis identified a novel homozygous, deletion of 12 nucleotides (exon 10) in the IGF1Rgene, which generated an in-frame p.A711_E714del. Functional analysis by fluorescence-activated cell sorting (FACS) of live primary fibroblasts derived from the patients demonstrated normal expression and cell surface localization of the mutant IGF1R. IGF-I-induced signal transduction, however, was significantly reduced, but not abrogated.

Conclusion: Homozygous IGF1R mutations identified to date do not completely ablate IGF1R expression/functions. Severe pre- and postnatal growth failure, mild intellectual disability, microcephaly and dysmorphic features were pronounced compared to patients with heterozygous IGF1R defects. These features, together with congenital cardiac anomalies and marked insulin insensitivity, support critical roles of IGF1R in human development and maintenance of glucose homeostasis, mechanism(s) to be elucidates.

 

Nothing to Disclose: IM, SFA, JD, NW, VB, PJ, BO, AD, RGR, AR, VH

OR03-2 19830 2.0000 A Novel Homozygous IGF1 Receptor (IGF1R) Mutation, p.A711_E714del, in Two Siblings with Severe Growth Failure, Congenital Malformations, Deafness and Insulin Insensitivity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 1:00:00 PM OR03 5917 11:30:00 AM From the Genome to the Clinic: Growth and Puberty Disorders Oral


Giampaolo Trivellin*1, Adrian F Daly2, Fabio R Faucz3, Bo Yuan4, Liliya Rostomyan2, Darwin Omar Larco5, Marie Helene Schernthaner-Reiter1, Eva Szarek1, Leticia F. Leal1, Jean-Hubert Caberg6, Emilie Castermans6, Chiara Villa6, Aggeliki Dimopoulos7, Prashant Chittiboina8, Paraskevi Xekouki1, Nalini Samir Shah9, Daniel Metzger10, Philippe A Lysy11, Emanuele Ferrante12, Natalia Strebkova13, Nadia Mazerkina14, Maria Chiara Zatelli15, Maya Beth Lodish1, Anelia Dafinova Horvath1, Rodrigo Bertollo de Alexandre1, Allison D Manning3, Isaac Levy1, Margaret Farmar Keil16, Maria De La Luz Sierra1, Leonor Palmeira2, Wouter Coppieters17, Michel Georges17, Luciana Ansaneli Naves18, Tim D. Cheetham19, Gustavo Barcelos Barra20, Mauricette Jamar6, Vincent Bours6, Tao-Yiao J Wu5, Catherine S. Choong21, Jerome Yves Bertherat22, Philippe Chanson23, Peter Kamenický23, William E. Farrell24, Anne Barlier25, Martha M Quezado26, Ivana Bjelobaba3, Stanko S Stojilkovic7, Jurgen Wess27, Stefano Costanzi28, Pengfei Liu4, James R Lupski4, Albert Beckers2 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2CHU de Liège-University of Liège, Liège, Belgium, 3National Institutes of Health, Bethesda, MD, 4Baylor College of Medicine, Houston, TX, 5Uniformed Services University, Bethesda, MD, 6University of Liège, Liège, Belgium, 7Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 8National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD, 9KEM Hospital, Mumbai, Maharashtra, India, 10BC Children's Hospital, Vancouver, BC, Canada, 11Université Catholique de Louvain, Brussels, Belgium, 12University of Milan, Milan, Italy, 13Institute of Pediatric Endocrinology, Moscow, Russia, 14Burdenko Neurosurgery Institute, Moscow, Russia, 15University of Ferrara, Ferrara, Italy, 16Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD, 17GIGA-Genomics, Liège, Belgium, 18University of Brasilia, Brasilia, Brazil, 19Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom, 20Laboratorio Sabin, Brasilia, Brazil, 21Princess Margaret Hospital for Children, Subiaco WA, Australia, 22INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France, 23Univ Paris-Sud, UMR-S693, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France, 24Keele University, Stoke on Trent, Staffordshire, United Kingdom, 25Aix-Marseille University, Marseille, France, 26National Cancer Institute, Bethesda, MD, 27NIH-NIDDK, Bethesda, MD, 28American University, Washington, DC

 

Background: High growth hormone (GH) secretion is a rare condition that leads to gigantism in childhood and acromegaly in adults; the causes of gigantism and acromegaly are poorly understood.

Aim of the study: To study the genetic defects underlying infantile gigantism and acromegaly.

Patients and methods: We performed genomic and genetic studies in patients with gigantism (n=46), and then sequenced an implicated gene in an international cohort of acromegaly patients (n=248). In vitro functional studies were performed in rat somatomammotrope GH3 cells to assess the role of an identified genetic variant.

Results: We detected by array-CGH a novel microduplication at chromosome Xq26 in two unrelated kindreds and twelve sporadic cases of various ethnic origins with infantile gigantism (n=16; 11 females). Two smallest regions of overlaps (SRO) were shared by the duplications; breakpoint junctions characterization revealed microhomology, suggesting a replicative mechanism for formation. The common duplicated genomic interval extends for approximately 500 Kb and contains four protein-coding genes. Only one of these genes, encoding a G-protein coupled receptor (GPCR) that strongly activates the cAMP signaling pathway was consistently over-expressed in patients’ pituitary lesions both at the RNA and protein level. We identified a recurrent variant in this gene in 4% of patients with acromegaly, mostly in tumors, whereas no pathogenic mutations were observed in the other three genes located within the SRO. When transfected into GH3 cells the mutation led to increased GH secretion and cell proliferation.

Conclusions: We describe a previously unrecognized genomic disorder caused by Xq26 microduplication (X-LAG for X-linked acro-gigantism) and characterized by early-onset gigantism resulting from GH excess that can be transmitted as a dominant trait. The gene is a GPCR that is dosage-sensitive and over-expressed in patients’ pituitary lesions; it activates the cAMP pathway, whose mitogenic effects in pituitary somatotroph cells are well established; and a recurrent mutation is found in patients with sporadic acromegaly.

G.T. and A.F.D. share the first authorship; A.B. and C.A.S. share the senior authorship of this abstract

 

Disclosure: AFD: Ad Hoc Consultant, NPS, Clinical Researcher, Pfizer, Inc.. PC: Researcher, Ipsen, Researcher, Novartis Pharmaceuticals, Researcher, Novo Nordisk, Researcher, Pfizer, Inc., Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Viropharma, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc.. AB: Investigator, Ipsen, Medical Advisory Board Member, Novartis Pharmaceuticals, Clinical Researcher, Pfizer Global R&D. Nothing to Disclose: GT, FRF, BY, LR, DOL, MHS, ES, LFL, JHC, EC, CV, AD, PC, PX, NSS, DM, PAL, EF, NS, NM, MCZ, MBL, ADH, RBD, ADM, IL, MFK, MDLLS, LP, WC, MG, LAN, TDC, GBB, MJ, VB, TYJW, CSC, JYB, PK, WEF, AB, MMQ, IB, SSS, JW, SC, PL, JRL, CAS

OR03-3 20120 3.0000 A X-Linked Acro-Gigantism (X-LAG) Due to Microduplications of Chromosome Xq26: A New Disorder and Implications for Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 1:00:00 PM OR03 5917 11:30:00 AM From the Genome to the Clinic: Growth and Puberty Disorders Oral


Ana Paula Abreu*1, Victor M. Navarro2, Aysegul Eren3, Joy N. Liang1, John C Gill4, Sekoni D. Noel4, Iain Robert Thompson4, Stephanie A. Roberts5, Rona S. Carroll4, Ana Claudia Latronico6 and Ursula B. Kaiser1
1Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 2Harvard Medical School and Brigham and Women's Hospital, Boston, MA, 3Western Reserve Health Education/ Northside Medical Center, Boston, MA, 4Brigham and Women's Hospital/Harvard Med School, Boston, MA, 5Boston Children's Hospital/Harvard Med School, Boston, MA, 6Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

The identification of loss-of-function MKRN3 mutations in 30% of a cohort of families with central precocious puberty linked this gene to the reproductive axis and GnRH regulation. Subsequent studies in patients with and without family histories of central precocious puberty confirmed these findings. Mkrn3 expression in the arcuate nucleus (ARC) of mice is high in the juvenile period and markedly decreases before puberty. Taken together, human and mouse data show an inhibitory effect of MKRN3 on GnRH secretion, but the mechanism of action of MKRN3 is yet to be understood. Furthermore, factors contributing to regulation of Mkrn3 expression are not known. We hypothesized that sex steroids might regulate Mkrn3 expression to contribute to its decline at the onset of puberty in mice. We assessed Mkrn3 expression in the hypothalamic ARC and anteroventral periventricular nucleus (AVPV) of wild type (WT) and hypogonadal (hpg) male and female mice to determine: (1) if the absence of sex steroids would alter the Mkrn3 expression pattern; and (2) if the Mkrn3 expression pattern is different between these two nuclei. hpg mice are GnRH deficient, resulting in lack of pubertal development and almost absent circulating sex steroids. Mkrn3 expression decreased across pubertal maturation in the AVPV of WT mice, similar to the expression pattern observed in the ARC. There was no difference in Mkrn3 expression levels between WT and hpg male and female mice across pubertal maturation in either the ARC or the AVPV. Estradiol (E2) has a positive feedback action on Kiss1 expression in the AVPV of female mice and is implicated in the LH surge. Conversely, E2 has a negative feedback action on Kiss1 expression in the ARC. We hypothesized that E2 treatment might decrease AVPV Mkrn3 expression to contribute to the pubertal increase in AVPV Kiss1 expression. To further investigate the possibility of E2 regulation of Mkrn3 expression, we treated WT female mice at postnatal day 11 (P11) with 2 μg E2 or vehicle subcutaneously and measured AVPV and ARC Mkrn3 and Kiss1 expression 24 hours later. E2 treatment did not alter Mkrn3 expression in the AVPV or in the ARC of female juvenile mice. As expected, Kiss1 expression showed a significant increase in the AVPV and a significant decrease in the ARC of E2-treated female mice compared to controls. In summary, the decrease in Mkrn3 expression in the AVPV across pubertal maturation suggests that Mkrn3 may be playing an inhibitory role in the AVPV, as previously also suggested for the ARC. Furthermore no global regulation of Mkrn3 expression by sex steroids was detected in the ARC or AVPV, suggesting that the decline in Mkrn3 at the onset of puberty may occur independently of the pubertal increase in gonadal sex steroid production.

 

Nothing to Disclose: APA, VMN, AE, JNL, JCG, SDN, IRT, SAR, RSC, ACL, UBK

OR03-4 21239 4.0000 A Regulation of Mkrn3 Expression By Sex Steroids 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 1:00:00 PM OR03 5917 11:30:00 AM From the Genome to the Clinic: Growth and Puberty Disorders Oral


Julian Lui*1, Kevin Barnes1, Presley Garrison2, Abigail Paulson2, Vijay Shimoga2, Ola Nilsson3 and Jeffrey Baron4
1NICHD, Bethesda, MD, 2NICHD, 3NICHD, NIH, Bethesda, MD, 4NIH, Bethesda, MD

 

EZH2 (Enhancer of zeste 2) is a key member of the Polycomb Repressor Complex 2 (PRC2), which is responsible for methylation of histone 3 lysine 27 (H3K27), a histone modification important for chromatin condensation and gene silencing. In humans, heterozygous mutations in EZH2 cause Weaver syndrome, an overgrowth disorder with skeletal abnormalities and advanced bone age. In addition, the EZH2 gene lies in a locus associated with adult human height variation, suggesting that EZH2, and perhaps H3K27 methylation, play important roles in skeletal and overall body growth. We therefore sought to investigate the regulation of skeletal growth by EZH2. Because Ezh1 and 2 have partially redundant functions in the PRC2 histone methylase complex, we generated a mouse model with a complete homozygous knockout of Ezh1 and cartilage-specific homozygous knockout of Ezh2 (Ezh1-/-, Ezh2fl/fl, Col2­a1-cre). Complete knockout of Ezh1 or cartilage-specific Ezh2 knockout alone showed no growth phenotype. However, the combined knockout mice exhibited postnatal growth retardation that gradually becomes more prominent from birth to 2-wks of age (body weight at 2-wks old, KO 3.7 ± 0.6 vs WT 8.2 ± 0.5 g, P<0.01). Immunostaining showed that dimethyl- and trimethyl-H3K27 were absent in the cartilage of Ezh1-/-, Ezh2fl/fl, Col2­a1-cre mice, indicating loss of PRC2 function in cartilage. Longitudinal bone growth of these mice was significantly impaired by 3 days of age, with decreased tibial length (5.44 ± 0.08 vs WT 6.00 ± 0.11 mm, P<0.01) and decreased proliferation in the proliferative columns (5.07 ± 0.26 vs WT 6.19 ± 0.19 BrdU-labeled cells/column, P<0.01). Knockout mice also exhibited decreased proliferative zone height (291 ± 8mm vs WT 395 ± 11mm, P<0.01), decreased number of proliferative chondrocytes per column (56 ± 2 cells vs WT 73 ± 3 cells, P<0.01), decreased terminal hypertrophic cell size (15.4 ± 0.4mm vs WT 20.5 ± 0.5mm, P<0.01), but increased number of hypertrophic cells per column (13.9 ± 0.5 cells vs WT 11.3 ± 0.5 cells, P<0.01). Collectively, these data indicate that loss of histone methyltransferases Ezh1 and 2 in the growth plate impairs longitudinal skeletal growth by inhibiting chondrocyte proliferation and causing premature hypertrophic differentiation and therefore suggest that H3K27 methylation by the PRC2 complex is essential for normal mammalian skeletal growth.

 

Nothing to Disclose: JL, KB, PG, AP, VS, ON, JB

OR03-5 19252 5.0000 A Histone Methyltransferases Ezh1 and 2 Are Required for Normal Skeletal Growth 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 1:00:00 PM OR03 5917 11:30:00 AM From the Genome to the Clinic: Growth and Puberty Disorders Oral


Adam Stevens*1, Chiara De Leonibus1, Philip Murray1, Ekaterina B Koledova2, Pierre Chatelain3 and Peter Clayton4
1University of Manchester and Royal Manchester Children’s Hospital, Manchester, United Kingdom, 2Merck, Darmstadt, Germany, 3Université Claude Bernard, Lyon, France, 4University of Manchester & Manchester Academic Health Sciences Centre, Manchester, United Kingdom

 

Background: The growth promoting effects of growth hormone (GH) are linked with insulin sensitivity and lipid metabolism; the underlying biological networks are unclear.

Objectives: To identify gene clusters and pathways linking growth and metabolic response in children with growth hormone deficiency (GHD) treated with recombinant human growth hormone (r-hGH).

Methods: Pre-pubertal children with GHD (n=125) were enrolled from the PREDICT short-term (NCT00256126) and long-term follow-up prospective study (NCT00699855). Whole blood gene expression (GE) was determined prior to treatment with r-hGH. One year height velocity (HV) and 1 month change (Δ) in IGF-I on r-hGH were used as clinical markers of growth response; Δ of serum fasting glucose, insulin, triglycerides, LDL and HDL levels were used as clinical markers of metabolic function; the relationships between these variables were identified by partial correlation. Associations were made with basal GE using rank regression (p<0.05). The GE overlap (p<0.05) between clinical markers was used to construct network models and identify gene clusters. Clusters were ranked using their network centrality score (Moduland algorithm) to define associated biological functions (hypergeometric test with Benjamini-Hochberg false discovery rate modification, q<0.05). Causal network analysis (CNA), mapping known literature to the network models, was performed to identify master regulators of GE (Ingenuity Pathway Analysis).

Results: Six paired correlations of clinical markers were identified (p<0.05); HV with ΔIGF-I, HV with ΔLDL and ΔIGF-I/HDL/triglycerides/glucose (individually) with Δinsulin. The intersection between the network models defined by these correlations identified five clusters of genes that linked growth and metabolism. These clusters were associated with adipogenesis, cell cycle checkpoint control and AMPK/mTOR signaling pathways (q<0.001) linked to the master regulators RXR, PLK1 and TSC1, respectively (p<0.001).

Three genes associated with the network models were found in the overlap of the GE correlated with the markers HV, ΔIGF, ΔLDL and ΔInsulin: SPTBN1, RRBP1 and UGGT2. These genes are putative functional markers of the metabolic response to r-hGH and have been previously associated with adult height, obesity and insulin sensitivity.

Conclusions: This study has identified network models, biological pathways and genomic markers linking growth and metabolic response to r-hGH therapy in GHD children.

 

Disclosure: AS: Investigator, Merck Serono. EBK: Employee, Merck Serono. PC: Investigator, Merck Serono, Speaker, Merck Serono, Advisory Group Member, Merck Serono. PC: Investigator, Merck Serono, Speaker, Merck Serono. Nothing to Disclose: CD, PM

OR03-6 21692 6.0000 A Adipogenesis, mTOR and AMPK Pathways Link the Growth and Metabolic Actions of Growth Hormone Action in Children with GH Deficiency (GHD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 1:00:00 PM OR03 5917 11:30:00 AM From the Genome to the Clinic: Growth and Puberty Disorders Oral


Joanna Klubo-Gwiezdzinska*1, Elaine Cochran2, Robert Kenneth Semple3, Rebecca J. Brown1 and Phillip Gorden2
1National Institute of Health, Bethesda, MD, 2NIH, Bethesda, MD, 3University of Cambridge, Cambridge, United Kingdom

 

Background

 Type B insulin resistance due to autoantibodies to the insulin receptor is characterized by diabetes refractory to massive doses of insulin, hypercatabolism resulting in dramatic weight loss, severe hyperandrogenism, and widespread acanthosis nigricans.

The 10 year mortality rate is 54%. In the present study we show the continued efficacy of combination therapy for type B insulin resistance.

 Trial design

 Inclusion criteria– patients with type B insulin resistance confirmed by the presence of insulin receptor antibodies.

 Study design- The patients underwent routine hematological, immunological, and biochemical testing at baseline and in regular intervals during the treatment. The treatment protocol consisted of:

-          Rituximab750 mg/meter body surface area iv in two consecutive doses 2 weeks apart, repeated every 3-4 months if the disease persisted

-          Cyclophosphamide 100 mg po daily continuously until remission was achieved

-          Dexamethasone 40 mg po  daily for 4 days or methylprednisolone 1 g iv for 2 days, repeated  every 3-4  weeks if the disease remained active

-          Once patients achieved remission- maintenance therapy with azathioprine 100 mg daily.

Primary endpoints - remission was defined as the amelioration of the hyperglycemia and discontinuation of insulin therapy and/or normalization of hyperandrogenemia.

Results

Seventeen patients fulfilled inclusion criteria – 14 women and 3 men with mean age of 38.4+/-17.6 years.

The underlying autoimmune background consisted of mixed connective tissue disease in 6/17 patients, lupus in 8/17 patients, Sjogren disease in 1 patient, uveitis in 1 patient and undetermined in 1 patient.

Mean baseline fasting glucose level was 307.5 +/-149 mg/dl, mean HgbA1c 11.3+/- 2.7%, mean baseline insulin level 1428+/-1708 mcU/ml (normal (N) 6.0-27.0), c-peptide 4.8+/-3.9 ng/ml (N 0.9-7.1), average daily insulin requirements ranged between 200 and 19000  units per day, mean total testosterone 463+/-346 ng/dl (N 8-60 for female patients), androstendione 374.4+/-426 ng/dl (N 30-200), total cholesterol 134.6+/-36.4 mg/dl, LDL 58.9+/-36.4 mg/dl, HDL  64+/-20.13 mg/dl, triglycerides 57.13+/-20.13 mg/dl. 

14/17 patients achieved remission after a median 5.5 months of therapy (range 2.5-27.25 months) as documented by normalization of fasting glucose (mean 88.8+/-26.8 mg/dl), HgbA1c (mean 6.1+/-2%), decreased to zero insulin requirements and normalization of testosterone levels to105.3+/-29.25 ng/dl and androstendione to 105.7+/-113 ng/dl. Three patients have yet to achieve remission had been treated most recently for only 1 to 5 months. During the course of the follow up (median 65 months), 2/17 patients developed disease recurrence with hyperandrogenemia, but again responded to combination therapy.

Conclusions

This standardized approach represents a personalized targeted therapy that is effective in this most extreme form of diabetes.

 

Nothing to Disclose: JK, EC, RKS, RJB, PG

OR01-1 21553 1.0000 A Continued Efficacy of Combination Therapy for Type B Insulin Resistance  Due to Autoantibodies to the Insulin Receptor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR01 5933 11:30:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Oral


Donald C Simonson*1, Su Ann Ding2, Florencia Halperin1, Marlene Wewalka2, Kathleen Foster2, Katherine Kelly2, Jennifer Panosian2, Ann Goebel-Fabbri2, Osama Hamdy2, Kerri Clancy3, David Lautz3, Ashley Vernon1 and Allison B Goldfine2
1Brigham and Women's Hospital, Boston, MA, 2Joslin Diabetes Center, Boston, MA, 3Emerson Hospital, Concord, MA

 

Weight loss improves patient-reported outcomes in obese patients with type 2 diabetes (T2D); however, differences between surgical and medical weight management and the durability of these effects are not well established.  We randomized 40 obese patients with T2D (22M / 18F; weight 109 ± 15 kg; BMI 36.5 ± 3.7 kg/m²; age 51 ± 10 yrs; diabetes duration 9 ± 5 yrs; HbA1c 8.2 ± 1.2%; 40% on insulin) to laparoscopic adjustable gastric band (LAGB; n = 18) or a 12-week intensive medical diabetes and weight management program (IMWM; n = 22) with follow-up for 12 months.  At baseline, both groups had comparable SF-36 physical health (PH) (76 ± 14) and mental health (MH) (75 ± 13) status scores, and moderately elevated Impact of Weight on Quality of Life (IWQOL) (59 ± 17) and Problem Areas in Diabetes (PAID) (46 ± 14) scores.  After 10% weight loss or 3 months (if 10% loss was not achieved), LAGB and IWMW achieved similarly significant weight loss (-9.7 ± 0.8 vs. -9.2 ± 0.8 kg) and improvement in HbA1c (-1.0 ± 0.3 vs. -1.7 ± 0.3%; p = 0.06 between groups), respectively.  SF-36 PH (2 ± 2 vs. 6 ± 1) and MH (2 ± 2 vs. 6 ± 2) improved minimally from baseline in LAGB and IMWM, with no differences between groups.  IWQOL (-11 ± 2 vs. -9 ± 2) and PAID (-7 ± 2 vs. -9 ± 2) improved significantly from baseline (p<0.05 to p<0.01), but improvements were similar in both groups.  At 12 months, weight loss was significantly greater after LAGB (-13.5 ± 1.7 vs. -8.5 ± 1.6 kg; p < 0.05) but there was no difference in lowering of HbA1c (-1.2 ± 0.3 vs. -1.0 ± 0.3%).  SF-36 PH and MH changed minimally compared with the earlier assessment with no differences between groups.  Changes in IWQOL (-14 ± 2 vs. -11 ± 2) and PAID (-13 ± 2 vs. -13 ± 2) further improved significantly from baseline in both LAGB and IMWM, respectively (p<0.01 vs. baseline for both groups), but the effects were similar in the surgical and medical treatment arms.  In both groups combined, the improvement in HbA1c correlated with the improvement in patient’s self-assessment of diabetes-specific emotional distress as assessed by PAID (r = 0.51, p < 0.01).  We conclude that in obese patients with T2D: 1) both LAGB and IMWM result in significant weight loss and reduction in HbA1c, 2) weight loss is greater after LAGB, but the improvement in HbA1c is similar, 3) both treatments are associated with small but comparable changes in self-reported physical and mental health status as measured by the SF-36, and 4) both treatments are associated with significant reductions in the impact of weight on QOL and problem areas in diabetes, but there were no differences between groups.  These results should be considered when planning LAGB vs. intensive medical weight management for patients with type 2 diabetes.

 

Disclosure: OH: Research Funding, Metagenics, Research Funding, Neurometrix, Consultant, Abbott Laboratories, Consultant, Merck & Co.. ABG: Advisory Group Member, Novo Nordisk. Nothing to Disclose: DCS, SAD, FH, MW, KF, KK, JP, AG, KC, DL, AV

OR01-2 21557 2.0000 A Patient-Reported Outcomes One Year after Randomization to Laparoscopic Adjustable Gastric Banding or Intensive Weight and Diabetes Management in Obese Patients with Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR01 5933 11:30:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Oral


Michelle L Katz*1, Gabriela Heiden Telo2, Julia Beatrice Cartaya1, Carly E Dougher2, Ming Ding2 and Lori M Laffel2
1Massachusetts General Hospital, Boston, MA, 2Joslin Diabetes Center, Boston, MA

 

Background: Cardiovascular disease (CVD) remains a significant source of premature morbidity and mortality in persons with type 1 diabetes (T1D). However, T1D providers of youth and young adults, who focus on glycemic management, often inadequately treat nonglycemic CVD risk factors.  Large pediatric cohorts in the USA (SEARCH for Diabetes in Youth, Type 1 Diabetes Exchange) have documented widespread under-treatment of CVD risk factors, such as hypertension and hyperlipidemia. 

Methods:  In a T1D cohort of 645 youth and young adults followed for a median of 12.9 years (interquartile range 9.1-16.5), 212 (33%) had hyperlipidemia (LDL ≥130 mg/dl) and underwent detailed chart review. Clinical data, lab results, and provider management recommendations were extracted from 3,222 encounters. Analyses included assessment of patterns of persistent hyperlipidemia, effectiveness of provider recommendations, and acceptance and adherence to lipid-lowering treatments (Rx).  Comparisons of LDL levels before and after provider recommendations were assessed by T test.

Results:   At baseline, youth (37% male) were 16.0±4.8 years old with T1D duration 9.2±5.1 years, A1c 9.9±2.0%, and LDL 149±22 mg/dl. Over a mean of 13.2 years of follow-up, providers appropriately noted LDL elevations in 80.6% of encounters when LDL ≥130 mg/dl. In 51 of youth, ≥50% of subsequent LDLs continued to be ≥130 mg/dl.  To lower LDL, providers commonly recommended improving glycemic control (30% of encounters); dietary changes (24% of encounters); enhancing exercise (16% of encounters); and starting, changing, or reinforcing adherence with Rx (11% of encounters).  Only Rx advice yielded improved LDL levels at subsequent visits (mean improvement of 26.9±51.5 mg/dl vs 10.9±35.5 mg/dl in those without Rx, p=.008).  In our sample, 67 individuals (32%) were eventually started on Rx, and 22 (10%) (n=22) refused Rx. Rx was started after a median of 4 elevated LDLs (interquartile range 2-7) and 3.6 years (interquartile range 0.8-8.8 years), and at a mean age of 20.5±4.4 years. After starting Rx, 61% of youth continued to have 50% or more of subsequent LDLs ≥ 130 mg/dl.

Conclusions:  Youth with T1D frequently have hyperlipidemia. Provider recommendations for lifestyle do not produce major improvements in LDL levels. While Rx is effective, initiation is often delayed, titration inadequate, and patient acceptance limited.  Changes in clinical practice are needed to improve management of hyperlipidemia in youth and young adults with T1D.

 

Nothing to Disclose: MLK, GHT, JBC, CED, MD, LML

OR01-3 21870 3.0000 A Under-Management of Hyperlipidemia in Young Persons with Type 1 Diabetes (T1D) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR01 5933 11:30:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Oral


Mohamed I. Husseiny Elsayed*1, Leah Selby2, Alexander Kaye1, Eba Hathout2, Fouad R Kandeel1 and Kevin George Ferreri3
1Diabetes & Metabolic Research Institute, Beckman Research Institute of City of Hope, Duarte, CA, 2Loma Linda University School of Medicine, 3City of Hope, Duarte, CA

 

Type 1 diabetes (T1D) results from the immune-mediated destruction of the insulin-secreting beta cells of the pancreas. Our previous study demonstrated that the DNA encoding the human insulin gene promoter is uniquely unmethylated in beta cells. We developed a methylation-specific PCR (MSP) assay for unmethylated insulin DNA to identify circulating beta cell DNA as a way to measure beta cell death. This study monitored 10 patients with new onset of T1D age 12y and older starting within the first 3 months of diagnosis, with evaluations throughout their first year post-diagnosis focusing on evidence of beta cell loss as well as glycemic control. All T1D patients were diagnosed based on ADA criteria of elevated blood glucose and, HbA1c, as well as the presence of one or more positive autoantibody titers (insulin, GAD65 and IA-2 antibodies). Blood samples were collected at diagnosis, 1, 2, 4, 6, 9, and 12 months post-diagnosis and analyzed by MSP assays. In addition, 90 min stimulated C-peptide level following a mixed-meal tolerance tests (MMTT) were measured at baseline and quarterly to measure of residual beta cell mass. The longitudinal relationship between these metabolic parameters and the appearance of beta cell DNA in circulation were analyzed using the MSP assay. Our results showed that 70% and 80% of patients were positive for GAD65 and IA-2 autoantibodies, respectively. HbA1C ranged between 9.1% and 18.5% at diagnosis and subsequently decreased after initiation of insulin therapy. Stimulated C-peptide levels at diagnosis were very low but increased with meal stimulation once the patient started insulin therapy, but then in most cases declined again over time. The low levels of C-peptide at diagnosis might have been a reflection of the toxicity of hyperglycemia to the beta cells and the subsequent improvement with initiation of insulin therapy and control of hyperglycemia probably reflected improvement of beta cell function with glucose control. In this trial, most of the patients showed a high signal of C-peptide after stimulation but this was insufficient to control hyperglycemia, indicating that patients still had residual partial beta cells function. Using our MSP assay, we found a significantly increased relative unmethylation ratio (RUR) of insulin DNA that is compatible with the known timeline of beta cell death in early onset T1D. We noted a decrease in the RUR following the development of diabetes suggesting the arrest of further beta cell death in the pancreas. The MSP assay raised the possibility that destruction of beta cells may occur as a result of episodic attacks of autoimmunity in T1D. We conclude that these patients were in a “honeymoon period” during which the ongoing beta cell death was delayed. Therefore MSP assay can provide an effective method to monitor beta cell destruction in early T1D and may be useful in tracking established and innovative measures to ameliorate the disease.

 

Nothing to Disclose: MIHE, LS, AK, EH, FRK, KGF

OR01-4 19100 4.0000 A Methylation-Specific PCR Assay for Detection of Beta Cell Death in Newly Onset Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR01 5933 11:30:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Oral


Ingrid Libman*1, Kellee M Miller2, Linda A DiMeglio3, Kathleen Bethin4, Michelle L Katz5, Avni Shah6, Jill H Simmons7, Michael James Haller8, Sripriya Raman9, William V Tamborlane10, Julie Coffey11, Ashleigh M Saenz2 and Roy W Beck12
1Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 2Jaeb Center for Health Research, Tampa, FL, 3Indiana Univ Sch of Med, Indianapolis, IN, 4University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, 5Joslin Diabetes Center, Boston, MA, 6Stanford University, 7Vanderbilt University Medical Center, Nashville, TN, 8University of Florida, Gainesville, FL, 9Children's Mercy Hospital, Kansas City, MO, 10Yale Univ Sch of Med, New Haven, CT, 11University of Iowa, 12Jaeb Center for Health Research Tampa FL, Tampa, FL

 

Achieving optimal glycemic control is especially challenging in overweight and obese adolescents with T1D, highlighting a need for additional approaches to therapy.  This study was designed to evaluate the efficacy and safety of metformin as adjunct therapy in these difficult to control teenagers who had HbA1c levels above the target range.  

At 26 T1D Exchange pediatric diabetes treatment  centers, 140 adolescents 12-19 years old (mean±SD 15.3 ± 1.7 years ) with T1D duration >1 year (7.0± 3.3 years), body mass index (BMI)  ≥ 85th percentile for age and gender (94± 4th %), total daily insulin dose ≥0.8 units/kg (1.1 ± 0.2 units/kg) and HbA1c 7.5%-9.9% (8.8%± 0.7%) were randomly assigned to either metformin (maximally tolerated dose 1000-2000 mg/day) or placebo for 6 months, in addition to their basal/bolus insulin therapy.  The primary outcome was change in central lab- measured HbA1c after 26 weeks. 

Baseline HbA1c was 8.8% in each group.  At 13 weeks, change in HbA1c from baseline in the metformin group (-0.2%±0.8%) was significantly better than placebo (+0.1%±0.8%, p=0.02). However, this differential effect was not sustained at 26 weeks where mean change in HbA1c from baseline was +0.2%± 0.8 in the metformin group and +0.2%± 0.9 in the placebo group (p=0.92).   At 26 weeks, a 25% or more reduction from baseline in total daily insulin per kg of body weight was achieved by 23% of the metformin group compared with 1% of the placebo group (p=0.003); 24% of the metformin group and 7% of the placebo group had a reduction in BMI z-score >10% from baseline to 26 weeks (p=0.01).    Differences in body composition measures by DEXA scan also favored the metformin group at 26 weeks. More participants in the metformin group reported gastrointestinal adverse events (70% vs. 35%, p<0.001) and at least one severe hypoglycemic event defined as cognitive impairment requiring assistance to treat (8% vs. 0 events; p=0.03).

Six months of adjunctive metformin therapy does not improve glucose control for overweight adolescents with T1D, but does reduce insulin requirements and BMI.

 

Nothing to Disclose: IL, KMM, LAD, KB, MLK, AS, JHS, MJH, SR, WVT, JC, AMS, RWB

OR01-5 19331 5.0000 A Metformin As an Adjunct Therapy Does Not Improve Glycemic Control Among Overweight Adolescents with Type 1 Diabetes (T1D) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR01 5933 11:30:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Oral


Ashu Rastogi*1 and Anil Bhansali2
1Post Graduate Institute of Medical Education and Research, Chandigarh, India, 2PGIMER, Chandigarh, India

 

Context: Diabetic foot osteomyelitis (DFO) and Charcot’s neuroarthropathy (CN) are limb-threatening complications and require quite different treatments. Since the approach to treatment largely determines the outcome, it is important to distinguish each of these entities, early. The clinical and laboratory markers are often nonspecific in the early stages of DFO. MRI for the diagnosis of DFO is relatively sensitive but has poor specificity in the background of CN. 99m Tc  and 111In  labeled leukocyte  scintigraphy have been used to identify DFO but suffer from poor spatial resolution.18F-Flouride is a highly sensitive bone seeking PET tracer and combining 18F-Fluoride PET/CT  (18F- PET) and 18F-FDG labeled autologous leukocyte PET/CT (FDG-LL PET/CT) may accurately diagnose bone infection in presence of acute and/or chronic CN.

Methods:Twenty nine patients with suspected DFO underwent CEMRI, 18F- PET, FDG-LL PET/CT. Patient's plasma was obtained for autologous leukocytes and labelled with 314.5–555 MBq (8.5– 15 mCi) of 18F-FDG. Bone biopsy was considered gold standard for  the diagnosis of DFO. A lesion localized to a bony structure on FDG-LL PET/CT corresponding to clinically suspected site along with 18F-PET/CT uptake was classified as true positive for osteomyelitis, and as a soft-tissue infection if it did not involve the bone. Increased 18F-Flouride uptakes in periarticular areas or underlying multiple bones with or without that of adjacent soft tissues were labeled as acute on CN.

Results: FDG-LL PET/CT showed increased tracer uptake [SUV (max) 8.4±4.7] at clinically involved site in 10 patients who had bone biopsy-proven DFO (true positive). No abnormal labeled leukocyte localization was observed in three patients with biopsy-positive infection (false negative). 10 subjects with suspected osteomyelitis had no abnormal uptake on FDG-LL PET/CT and bone cultures were sterile (true negative). There was no false positive on FDG-LL PET/CT study. CEMRI identified 9 out of 13 cases of osteomyelitis and was false positive in 6 cases. The sensitivity and specificity of concurrent 18F-Flouride and FDG-LL PET/CT is 83.3% and 100% compared to 81.8% and 45.5% of CEMRI, respectively, for the diagnosis of DFO on the background of CN of foot.

Discussion and conclusions: CEMRI had poor specificity for the diagnosis of DFO on background of CN as it relies on identification of marrow edema for diagnosing bone infection, which could be of non-infective etiology like Charcot’s neuroarthropathy.  [18F]-2-fluoro-2-deoxy-D-glucose (FDG)  as the radiotracer  is a non-specific indicator of increased intracellular metabolism compared to 18F-Flouridewhich has affinity for bone. The present study shows high accuracy of 18F-Flouride PET/CT with FDG-LL PET/CT for the diagnosis of osteomyelitis in diabetic CN of foot. Patients showing  PET/CT localization of labeled leukocytes may be spared of bone biopsy.

 

Nothing to Disclose: AR, AB

OR01-6 18487 6.0000 A 18F-Flouride PET/CT and 18F -FDG Labeled Autologous Leukocyte PET/CT for Diagnosis of Osteomyelitis in Diabetic Charcot's Neuroarthropathy of Foot 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR01 5933 11:30:00 AM Clinical Issues in Type 1 and Type 2 Diabetes Oral


Jose Manuel Garcia*1, Jennifer Temel2, David Currow3, Kenneth Fearon4, Ying Yan5, John Friend5 and Amy Abernethy6
1MEDVAMC/Baylor College of Medicine, Houston, TX, 2Massachusetts General Hospital, Boston, MA, 3Flinders University, Adelaide, Australia, 4Western General Hospital, Edinburgh, United Kingdom, 5Helsinn Therapeutics, Inc., Bridgewater, NJ, 6Duke University, Durham, NC

 

Cancer anorexia-cachexia syndrome (CACS) is a multifactorial, debilitating condition common among non-small cell lung cancer (NSCLC) patients. In CACS, altered metabolism and reduced food intake contribute to decreased body weight, mainly through loss of lean body mass (LBM) but also through loss of fat mass (FM). Ghrelin has been shown to activate key pathways in the regulation of body composition, appetite and metabolism. Anamorelin HCl (ANAM) is a novel investigational ghrelin receptor agonist.

Two global, double-blind, Phase III trials (ROMANA 1, NCT01387269, N=484; ROMANA 2, NCT01387282, N=495) assessed ANAM efficacy/safety in patients with unresectable stage III/IV NSCLC and cachexia (≥5% weight loss within prior 6 months or BMI <20 kg/m2). Patients were randomized (2:1) to receive daily oral ANAM (100 mg) or placebo for 12 weeks. Co-primary endpoints were change from baseline over 12 weeks in LBM (measured by DXA) and in hand grip strength (HGS). Secondary endpoints included change from baseline in the anorexia-cachexia domain of the Functional Assessment of Anorexia/Cachexia Treatment (FAACT). Hunger was evaluated using an exploratory Hunger Assessment Scale. Post-hoc analyses evaluated additional body composition parameters from DXA, including total body mass (TBM) and FM.

Over 12 weeks, ANAM significantly increased LBM vs placebo in both studies (p<0.0001). In ROMANA 1, median change in LBM was 1.10 kg (95% CI 0.76; 1.42) for ANAM vs -0.44 kg (95% CI -0.88; 0.20) for placebo; similarly, changes in ROMANA 2 were ANAM 0.75 kg (95% CI 0.51; 1.00) vs placebo -0.96 kg (95% CI -1.27; -0.46). Post-hoc analyses on additional DXA parameters revealed that ANAM significantly increased TBM vs placebo at week 12 in both studies (median changes from baseline of 2.87 vs 0.07 kg, p<0.0001; and 2.04 vs -0.59 kg, p<0.0001). This change was driven by LBM gains, but also included significant increases in FM vs placebo (median changes from baseline of 1.21 vs -0.13 kg, p<0.0001; and 0.77 vs 0.09 kg, p=0.012). Changes in HGS were not statistically different between treatment arms. In both studies, ANAM significantly improved FAACT anorexia/cachexia domain scores vs placebo (mean changes of 4.12±0.8 vs 1.92±0.8; p=0.0004; and 3.48±0.9 vs 1.34±1.0; p=0.0016). Mean changes at week 12 in the Hunger Assessment scores for ANAM vs placebo were 0.93±1.9 vs 0.47±1.8 in ROMANA 1 and 1.00±2.3 vs 0.60±2.4 in ROMANA 2. The most frequent drug-related adverse event (AE) for the ANAM arm in both ROMANA 1 and 2 was hyperglycemia (5.3% and 4.2%), and both studies had few drug-related grade ≥3 AEs in the ANAM arm (0.9% and 2.7% vs 1.2% and 2.5% in the placebo arm).

ANAM for 12 weeks was well tolerated in two global, large-scale, Phase III studies. In both studies ANAM significantly increased LBM and FM, suggesting a restoration of energy balance. Also, ANAM significantly improved patients’ symptoms and concerns related to anorexia-cachexia.

 

Disclosure: JMG: Investigator, Helsinn Therapeutics Inc., Investigator, Aeterna Zentaris Inc. , Investigator, Department of Veterans Affairs , Consultant, Helsinn Therapeutics Inc., Consultant, Aeterna Zentaris Inc. . YY: Employee, Helsinn Therapeutics, Inc.. JF: Employee, Helsinn Therapeutics, Inc.. AA: Director, athenahealth, Inc. , Vice President, Flatiron Health, Inc. , Consultant, ACORN Research, Consultant, Bristol-Myers Squibb, Investigator, Pfizer, Inc., Investigator, Bristol-Myers Squibb, Investigator, Kanglaite, Investigator, Dendreon, Investigator, Helsinn Therapeutics, Inc., Investigator, Celgene, Investigator, GlaxoSmithKline, Investigator, DARA Biosciences, Owner, Advoset LLC , Owner, Orange Leaf Associates LLC. Nothing to Disclose: JT, DC, KF

OR04-1 19188 1.0000 A Analysis of Body Composition Parameters in Patients from ROMANA 1 and 2: Phase III Studies of Anamorelin in NSCLC Patients with Cachexia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR04 5947 11:30:00 AM GH, Prolactin and Metabolism Oral


Laura E. Dichtel*1, Mette Bjerre2, Miriam A. Bredella1, Anu V. Gerweck3, Ariana D. Riccio3, Jan Frystyk2 and Karen K. Miller1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Aarhus University, Aarhus, Denmark, 3Massachusetts General Hospital, Boston, MA

 

Obesity is characterized by a relative reduction in GH secretion and serum IGF-1, but normal IGF-1 bioactivity. This suggests that obese individuals have a higher proportion of bioactive to total IGF-1 than their lean counterparts. We investigated whether the preservation of IGF-1 bioactivity in obesity is linked to low GH levels, abdominal adiposity, or insulin resistance.  We also investigated how GH administration, which modulates these factors in different directions, influences absolute and relative IGF-1 bioactivity. Finally, we hypothesized that increases in bioactive IGF-1, not total IGF-1, would drive changes in body composition with GH administration.

We studied 50 women with abdominal obesity before and after randomization to GH (n=28) or placebo (n=22) administration for 3 mos. Bioactive IGF-1 was measured by a kinase receptor activation assay; relative IGF-1 bioactivity was expressed as “% bioactive IGF-1” [(bioactive IGF-1/total IGF-1) x100]. Body composition was assessed by DXA and insulin resistance by OGTT.

Prior to treatment, visceral adipose tissue (VAT, r= -0.39, p=0.006) and insulin resistance (OGTT glucose area under the curve) (r= -0.46, p=0.001) were negative determinants of bioactive IGF-1; peak GH on glucagon stimulation testing was not a determinant. VAT (r=0.29, p=0.04) was a positive determinant of % bioactive IGF-1, demonstrating a relative preservation of IGF-1 bioactivity with visceral adiposity. GH treatment resulted in an increase in total IGF-1 (144 ± 56 to 238 ± 75 ng/mL, p<0.0001), IGF-1 z score (-1.6 ± 0.5 to -0.4 ± 1.1, p <0.0001), absolute IGF-1 bioactivity (1.29 ± 0.39 to 2.60 ± 1.12 ng/mL, p<0.0001), and a trend toward an increase in % bioactive IGF-1 (1.00 ± 0.45 to 1.14 ± 0.43%, p=0.06).  The increase in absolute IGF-1 bioactivity with GH administration predicted an increase in lean mass (r= 0.31, p=0.03), decrease in VAT (r= -0.33, p=0.03) and increase in fasting glucose (r= 0.41, p=0.005). In contrast, there was no association between increase in total IGF-1 and any variable. The increase in % bioactive IGF-1 with GH treatment was associated with an increase in insulin resistance [OGTT 2H glucose (r= 0.38, p=0.05)] and a decrease in trunk fat (r= -0.54, 0.004) over 3 mos. 

In conclusion, bioactive IGF-1 is inversely associated with abdominal fat and insulin resistance in obese women. Percent bioactive IGF-1 is higher in obese women with more VAT, driven by lower total IGF-1. With GH administration, increases in absolute IGF-1 bioactivity, but not total IGF-1, predict changes in body composition. Moreover, % bioactive IGF-1 increases in parallel with increasing insulin resistance, despite a reduction in abdominal fat. Our data suggest that GH treatment increases absolute bioactive IGF-1 and % IGF-1 bioactivity in parallel with increased insulin resistance. In turn, GH may modulate body composition in obesity through increases in bioactive, not total, IGF-1.

 

Nothing to Disclose: LED, MB, MAB, AVG, ADR, JF, KKM

OR04-2 18811 2.0000 A The Effect of Growth Hormone (GH) on Bioactive IGF-I in Obese Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR04 5947 11:30:00 AM GH, Prolactin and Metabolism Oral


Edward Owen List*, Darlene E Berryman, Kevin Ray Funk, Jesse Kowalski, Ross Comisford, Mathew Buckman, Miranda Vandargriff and John J Kopchick
Ohio University, Athens, OH

 

Growth hormone receptor gene disrupted (GHR-/-) mice have proven useful for determining numerous actions of GH; however, determining the effects of GH on specific tissues in vivo have been challenging.  Fortuitously, the development of the Cre/Lox system in mice permits individual tissues to be targeted for gene disruption.  Thus, several lines of tissue-specific GHR gene disrupted mice have recently been generated by our laboratory and others in order to better characterize the effects of GH specifically on individual tissues.  Currently, eleven published studies have utilized seven different tissue-specific GHR knockout lines.  Of these, five distinct tissues/cell types have been targeted (adipose tissue, liver, muscle, macrophages and beta cells). From the eleven published studies, only three have compared results in both males and females and all of these were done in liver-specific GHRKO mice, resulting in a lack of data regarding the influence of sex on tissue-specific GHR gene disruption in mice.  To this end, muscle-specific GHR gene disrupted mice have been produced in two separate laboratories; however, both research groups have limited their research to male mice exclusively. As a consequence, nothing is known about the muscle-specific effects of GHR gene disruption in females.  Thus, in the current study we examine the effects of muscle-specific GHR gene disruption (MuGHRKO) on glucose metabolism in both male and female mice. We also for the first time in any of the tissue-specific GHR mouse lines report longevity and cause of death.  As expected, our results reveal that male MuGHRKO mice have improved fasting blood glucose, insulin, c-peptide, and glucose tolerance.  However, we discovered that female MuGHRKO mice show no improvement in any of these measures of glucose metabolism. Since improved glucose metabolism is thought to be key mechanism by which global GHR-/- mice are extremely long lived, we expected that male MuGHRKO mice would also have enhanced longevity. However, mean and median lifespan as well as cause of death in MuGHRKO mice did not differ from controls for either sex.  In conclusion, the data from the current study highlight the importance of using both sexes when performing studies in vivo and suggest that females are resistant to improved glucose metabolism when GH action is disrupted specifically in muscle. In addition, improved glucose metabolism in skeletal muscle devoid of GH action as seen in male MuGHRKO mice is not sufficient to increase lifespan. These data suggest that extended longevity of global GHR-/- mice does not appear to be mediated by direct action of GH on muscle.

 

Nothing to Disclose: EOL, DEB, KRF, JK, RC, MB, MV, JJK

OR04-3 20427 3.0000 A Improvements to Glucose Metabolism in Muscle-Specific Growth Hormone Receptor Gene Disrupted Mice Are Sex-Specific and Do Not Result in Extended Longevity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR04 5947 11:30:00 AM GH, Prolactin and Metabolism Oral


Guillaume Osterstock1, Paul R. Le Tissier*2, Violeta Mitutsova1, Alexander Barre1, Manon Granier1, Pierre Fontanaud3, Marine Chazalon1, Danielle Carmignac4, Patrice E Mollard3, Iain Robinson4, Malcolm James Low5, Nikolaus Plesnila6, David Jonathan Hodson7, Chrystel Lafont3, Patrick Samper1 and Pierre-François Méry1
1Institute of Functional Genomics, Montpellier, France, 2University of Edinburgh, Edinburgh, United Kingdom, 3IGF-CNRS, Montpellier, France, 4MRC National Institute for Medical Research, London, United Kingdom, 5University of Michigan Medical School, Ann Arbor, MI, 6Royal College of Surgeons in Ireland, Dublin, Ireland, 7Imperial College, London, United Kingdom

 

Subsets of hypothalamic neurons generate highly-ordered neurohormone pulses to properly regulate basic body functions such as growth and metabolism. However, the electrical origin of the hypothalamic pulse generator has so far remained elusive. In the present study, we show that the inhibitory hypothalamic neuropeptide somatostatin (SST) triggered patterned growth hormone-releasing hormone (GHRH) neuron firing when tonically applied to acute brain slices. These firing patterns were fine-tuned by an initial inhibitory action at the GHRH neuron level due to K+ channel (GIRK) activation, followed by a delayed, sst1/sst2 receptor-dependent unbalancing of glutamatergic and GABAergic inputs. Thus, two intermingled feedforward loops trigger oscillatory firing patterns in hypothalamic (GHRH) neurons. To determine the significance for pituitary GH release, we recreated the patterned GHRH neuron spike firing by direct expression of channelrhodopsin2 (ChR2) specifically in GHRH neurons. This was achieved using a novel GHRH-Cre transgenic mouse model in combination with R26-loxSTOPlox-ChR2-tdTomato and direct in vivo manipulation via a fibre optic to the thinned palate bone.  Application of light pulse trains (5 min ON, 3 min OFF) resulted in long-lasting rises in GH, which contrast with application of a sustained (20-30 min) train of light pulses resulting in a single GH pulse that usually peaks before stimulus termination. Thus, a simple tripartite neuronal circuit allows GHRH neurons to deliver a patterned spike firing code, capable of  stimulating release of a robust and sustained GH pulse into the bloodstream. Such neuronal circuits may represent a basic building block which recurs throughout the hypothalamus to finely adjust neuroendocrine activity in response to physiological demand.

 

Nothing to Disclose: GO, PRL, VM, AB, MG, PF, MC, DC, PEM, IR, MJL, NP, DJH, CL, PS, PFM

OR04-4 20377 4.0000 A Hypothalamic Neuroendocrine Feedforward Loops Generate Patterned GHRH Output Regulating GH Secretion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR04 5947 11:30:00 AM GH, Prolactin and Metabolism Oral


Ronadip R Banerjee*1, Holly A Cyphert2, Xueying Gu1, Roland W. Stein2 and Seung K Kim3
1Stanford University School of Medicine, Stanford, CA, 2Vanderbilt University Medical Center, Nashville, TN, 3Stanford University School of Medicine, HHMI, Stanford, CA

 

Prolactin and placental lactogen signaling through the prolactin receptor (PRLR) are required for the adaptive maternal response to pregnancy.  Lactogens are critical for the expansion of pancreatic beta cell mass necessary to maintain glucose homeostasis in response to increased maternal-fetal metabolic demands.  However, the molecular mechanisms underlying lactogen-induced changes within islets during pregnancy remain poorly understood (1).  As whole-animal PRLR knockout mice (PRLRnull) are infertile, precluding pregnancy studies (2), we have generated a novel conditional loxP allele of PRLR and deleted PRLR specifically within pancreatic beta-cells using RIP-Cre (BPRLRKO mice).  Surprisingly, BPRLRKO mice exhibit no baseline abnormalities in glucose homeostasis, suggesting that the islet defects described in PRLRnull mice are a consequence of PRLR deletion in other tissues (3).  BPRLRKO mice are fertile, and develop gestational diabetes that resolves postpartum but recurs and worsens in a second pregnancy.   At late gestation, BPRLRKO mice show reduced beta-cell proliferation and a 2.5 fold reduction in beta-cell mass compared to littermate controls.  To identify molecular mediators of defective proliferation and beta cell mass expansion we examined gene expression in islets isolated from pregnant BPRLRKO females and controls.  We found BPRLRKO mice failed to induce cyclins A2 and B1 as well as the transcription factor FoxM1, a key regulator of cell cycle progression and proliferation in islets.  Furthermore, BPRLRKO mice did not induce tryptophan hydroxylase 1 (Tph1) expression and lacked the pregnancy-associated increase in islet serotonin, a critical paracrine-autocrine signal promoting beta-cell proliferation (4). Additionally, the transcription factor MafB is normally expressed in a subset of beta cells during pregnancy; the MafB+Ins+ population of beta cells is significantly reduced in pregnant BPRLRKO mice.  To our knowledge, this is the first evidence linking prolactin signaling and regulation of MafB expression.  Taken together, our results demonstrate the requirement for PRLR signaling in the physiologic expansion of beta cells during pregnancy, and identify key mediators of proliferation induced by prolactin signaling.  We also anticipate that the development of the floxed PRLR mouse will allow conditional gene targeting analysis of PRLR signaling and facilitate our understanding of lactogenic hormone action in specific tissues and disease states.

 

Nothing to Disclose: RRB, HAC, XG, RWS, SKK

OR04-5 20102 5.0000 A Loss of Prolactin Receptor Signaling in Pancreatic Beta Cells Causes Gestational Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR04 5947 11:30:00 AM GH, Prolactin and Metabolism Oral


Ying Liu*1, Yue Zhang1, Jing Jiang1, John Fairbanks Langenheim2, Wen Y Chen2, Kurt R. Zinn3 and Stuart J Frank1
1University of Alabama at Birmingham, Birmingham, AL, 2Clemson University, Greenville, SC, 3Univ of Alabama at Birmingham, Birmingham, AL

 

Growth hormone receptor (GHR) and prolactin receptor (PRLR) are transmembrane glycoproteins cytokine receptors that are structurally homologous and activate JAK2-STAT signaling pathways. We previously detected association between GHR and PRLR in T47D human breast cancer cells by coimmunoprecipitation, suggesting that, in addition to forming homodimers, these related receptors may form hetero-assemblages that may have functional consequences. Adding to the potential richness GH and PRL physiology, human GH can activate either GHR or PRLR, while PRL activates only PRLR. We recently reported (1) that the GHR-GHR association can be detected specifically using the split luciferase complementation assay in which coexpressed chimeras encoding GHR fused to Nluc (residues 1-398 of firefly luciferase) and GHR fused to Cluc (luciferase residues 394-550), by virtue of their physical proximity, reconstitute luciferase activity which is detected by bioluminescence imaging and quantitation. Using this assay, we showed that GH acutely augments this bioluminescence, consistent with the induction of conformational changes that bring GHR cytoplasmic tails closer. In the current study, we examined human GHR-Nluc/PRLR-Cluc complementation in a GHR- and PRLR-deficient human fibrosarcoma cell line. We verified expression and signaling capacity of each chimera individually and then found that GHR-Nluc/PRLR-Cluc coexpression yielded specific complementation that was not observed when either chimera was expressed with an erythropoietin receptor-luc fragment chimera. Notably, this basal complementation was monotonically decreased by ~30% by GH treatment over a 40 min period. This GH-induced decrease of complementation was partially inhibited by a GHR-specific antagonist (B2036) alone or a PRLR-specific antagonist (G129R) alone but completely inhibited by a combined antagonist (B2036+G129R) treatment, suggesting GH engages both GHR and PRLR to exert its effect. In contrast, a unique GHR-PRLR heteromer agonist, B2036-G129R (B-G; B2036 and G129R fused in tandem with single binding sites for GHR and PRLR, respectively (2)), augmented GHR-Nluc/PRLR-Cluc complementation. Studies are underway to more fully characterize GHR-PRLR hetero-assemblages using the split luciferase complementation assay, in concert with biochemical and signaling techniques.

 

Nothing to Disclose: YL, YZ, JJ, JFL, WYC, KRZ, SJF

OR04-6 20106 6.0000 A Investigation of Growth Hormone Receptor / Prolactin Receptor Hetero-Assemblage By Split Luciferase Complementation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR04 5947 11:30:00 AM GH, Prolactin and Metabolism Oral


Amanda Leigh Herberger*1, Hanson Ho2, Alfred Li1, Christian Yuzon Santa Maria2, Jenna Hwong1, Zhiqiang Cheng1, Chia-Ling Tu1 and Wenhan Chang1
1University of California San Francisco, San Francisco, CA, 2University of California, San Francisco, San Francisco, CA

 

Previous observations demonstrated that heteromeric complex formation of the calcium-sensing receptor (CaSR) and the type B g-aminobutyric acid (GABA) receptor 1 (GABABR1) mutually suppressed the expression and signaling ability of the receptors.  Heterozygous (PTCCaSRwt/flox) and homozygous (PTCCaSRflox/flox) knockout (KO) of the Casr gene targeted to parathyroid cells (PTCs) specifically produced mild and severe hyperparathyroidism (HPT) in mice, respectively. The PTCCaSRwt/flox mice were viable, but PTCCaSRflox/flox mice died before 3-4 weeks of age.  The 3-month-old PTCCaSRwt/flox and 3-week-old PTCCaSRflox/flox mice had significantly elevated serum PTH (sPTH, 219±19 and 959±122 pg/ml, respectively) and calcium (sCa, 10.91±0.15 and 16.44±0.05 mg/dL, respectively) levels when compared to 3-month-old control littermates (sPTH: 172±10 pg/ml; sCa: 9.61±0.06 mg/dL, p<0.01), recapitulating phenotypes of human Familial Hypocalciuric Hypercalcemia (FHH) and neonatal severe HPT (NSHPT), respectively.  To test whether the expression and signaling of GABABR1 critically mediates PTH secretion and alters the Ca2+-responsiveness of PTCs at basal and at HPT states, we compared sCa2+ and sPTH levels in the heterozygous and homozygous CaSR KO mice to PTCGABABR1flox/flox mice, which have both alleles of Gabbr1 genes deleted in PTCs, and to double knockout (PTCCaSRwt/flox//PTCGABABR1flox/flox or PTCCaSRflox/flox//PTCGABABR1flox/flox) mice, and compared the secretory capacity and Ca2+-set-point of parathyroid glands (PTGs) acutely cultured from these mice. Interestingly, the PTCGABABR1flox/flox mice showed reduced sPTH (115±8 pg/ml, p<0.01) and sCa (9.42±0.04 mg/dL, p<0.01) levels. Furthermore, concurrent GABABR1 KO rescued the early lethality of PTCCaSRflox/flox mice and suppressed the sPTH (659±117 pg/ml, p<0.01) and sCa (12.12±0.44 mg/dL, p<0.01) levels in the PTCCaSRflox/flox//PTCGABABR1flox/flox mice when compared to those in PTCCaSRflox/flox mice.  Similarly, GABABR1 KO suppressed the sPTH (130±24 pg/ml, p<0.01) and sCa (10.0±0.24 mg/dL, p<0.01) levels in the PTCCaSRwt/flox//PTCGABABR1flox/flox vs PTCCaSRwt/flox mice. Studies of PTGs cultured from the PTCCaSRwt/flox mice showed a profound increase in the maximal PTH secretion (3-4 fold) and a right-shift in Ca2+-set-point from 1.3 to 1.5 mM vs control PTGs, but these effects were completely abrogated by concurrent ablation of the Gabbr1 gene in the PTGs of the PTCCaSRwt/flox//PTCGABABR1flox/flox mice. Our data supports the concept that the parathyroid GABABR1 critically controls mineral homeostasis at basal and at HPT states by sustaining tonic PTH secretion and Ca2+-responsiveness of PTCs and may be the molecular basis for dysregulated PTC functions in human FHH and NSHPT.

 

Nothing to Disclose: ALH, HH, AL, CYS, JH, ZC, CLT, WC

OR08-1 20528 1.0000 A Parathyroid GABABR1 Is the Molecular Basis for PTH Hypersecretion and a Right-Shift in Ca2+ Set-Point in Conditions of Mild and Severe Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM OR08 5963 11:30:00 AM Parathyroid and Bone Metabolism Oral


Ruiye Bi*1, Tomoyuki Watanabe2, Yi Fan3, Thomas J Gardella2 and Michael Mannstadt1
1Massachusetts General Hospital and Harvard Medical School, Boston, MA, 2Massachusetts General Hospital, Boston, MA, 3Harvard School of Dental Medicine, Boston, MA

 

Hypoparathyroidism (HP) is characterized by inadequate levels of PTH, hypocalcemia, hyperphosphatemia and low bone turnover, and is most commonly caused by damage or removal of the parathyroid glands during neck surgery. Current treatment is limited to oral calcium and active vitamin D, which can lead to hypercalciuria and renal complications. Novel PTH analogs that can mediate sustained normalization of blood and urine calcium are now being explored as potential replacement therapies.
Evaluation of such therapies in vivo requires an effective animal model of HP.  Surgical parathyroidectomy is a proven animal model of acquired HP, but PTX surgery in mice is challenging due to small gland size and variable gland location.  To facilitate this procedure, we developed a mouse model in which the parathyroid gland cells have been engineered to express green fluorescent protein. In these "PTH-GFP" mice, which were derived by crossing PTH-Cre mice with mTmGFPfl/fl mice, non-parathyroid cells fluoresce red while the parathyroids fluoresce green. The glands are thus easily identified, and PTX surgery, as guided by GFP, is greatly facilitated (surgery times < 20 minutes/mouse and no mortality in 80 PTX mice so far). Blood analyses revealed that three days after surgery, GFP-PTX mice, as compared to sham surgery mice, exhibited a dramatic decrease in serum PTH (31 ± 23 vs. 570 ± 57 pg/mL; n=6 per group; p<0.001), low blood Ca++ (1.05 ± 0.05 vs. 1.31 ± 0.04 mmol/L; n=30; p<0.001) and elevated serum phosphorus (9.5 ± 1.0 vs. 7.6 ± 1.8; n=22-24). This hypoparathyroid phenotype remained stable over a three-month observation period.
We then used the model to evaluate the efficacy of LA-PTH, a new long-acting PTH analog, for normalizing blood Ca in conditions of HP. Single s.c. injection of LA-PTH at 1.5, 3, 5, 10, or 20 nmol/kg into GFP-PTX mice led to a dose-dependent increase in blood Ca++ (1.21 ± 0.02, 1.23 ± 0.04, 1.23 ± 0.06, 1.25 ± 0.06, 1.26 ± 0.05, 1.26 ± 0.06 mmol/L; n=5-6 per group).  LA-PTH was about 5-fold more potent on a molar basis than PTH(1-34) (dose=25, 50 nmol/kg; Ca++=1.21 ± 0.05, 1.27 ± 0.09 mmol/L; n≥5). Importantly, a single injection of LA-PTH was able to normalize serum calcium and phosphate levels for more than 72 hours.
These results thus show that GFP-PTX mice provide a novel model of acquired HP, and they further highlight the potential utility of novel long-acting PTH analogs as therapies for this disease.

 

Nothing to Disclose: RB, TW, YF, TJG, MM

OR08-2 21073 2.0000 A A Novel Mouse Model for Acquired Hypoparathyroidism (HP) and Its Application for Studying Long-Acting Parathyroid Hormone (LA-PTH) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM OR08 5963 11:30:00 AM Parathyroid and Bone Metabolism Oral


Hila Bahar*1, Nancy Doyle2, Aurore Varela2, Luc Chouinard3, Elisabeth Lesage2, Robert Guldberg4, Susan Y Smith2 and Gary Hattersley1
1Radius Health, Inc, Waltham, MA, 2Charles River Laboratories, Senneville, Canada, 3Charles River, 4School of Mechanical Engineering, Georgia Institute of Technology

 

Abaloparatide (ABL) is a PTHrP(1-34) analog being developed for the treatment of osteoporosis. In a completed phase 2 clinical study in postmenopausal women with osteoporosis, a high overall BMD responder rate at the lumbar spine, total hip and femoral neck, was observed after 24 weeks of ABL treatment compared to either teriparatide or placebo treatment. We have investigated the mechanisms by which ABL results in BMD gains in aged, osteopenic, ovariectomized (OVX) rats and monkeys. Three months after surgery, sham and osteopenic OVX rats (n=18 per group) were treated daily with vehicle or ABL (1, 5 or 25 μg/kg sc) for 12 months. Treatment with ABL 25 μg/kg significantly increased serum levels of the bone formation markers osteocalcin (OC) and procollagen type I N-terminal propeptide (PINP) after 3 months, which remained elevated throughout the study. In contrast, the bone resorption markers, C-telopeptide (CTX) and deoxypyridinoline (DPD), were not affected throughout the course of the study by treatment with ABL at any dose level. Consistent with these findings, dynamic histomorphometric analysis showed that ABL treatment resulted in linear, dose-dependent significant increases in bone formation parameters without modifying the bone resorption parameters in trabecular bone at the lumbar spine and proximal tibia, and in femur cortical bone, relative to OVX and sham vehicle controls. Following a 9-month bone depletion period, ≥9 years-old sham and osteopenic OVX cynomolgus monkeys (n=16 per group) were treated daily with vehicle or ABL (0.2, 1 or 5 μg/kg, sc) for 16 months. Serum levels of the bone formation marker PINP increased rapidly and remained elevated throughout the study in ABL treated monkeys compared to OVX controls. In contrast, the bone resorption markers CTX and N-telopeptide (NTX) were comparable to OVX controls in ABL treated monkeys. Consistent with these findings, marked gains in BMD were observed at the femoral neck for all dose levels of ABL as early as 4 months of treatment, and were comparable to or above pre-surgery levels. Dynamic histomorphometric analysis indicated a dose dependent increase in bone formation parameters but absence of meaningful changes in bone resorption parameters. In addition, significant increases in femur diaphysis endocortical BFR (Ec.BFR/BS) were noted with ABL 5 μg/kg. Importantly, μCT analysis of humerus cortical beams showed that cortical bone porosity was not affected by ABL treatment at any dose level, compared to OVX control. Thus, the data suggests that ABL exerts a bone anabolic action at least in part due to significant and early bone formation without a corresponding increases in bone resorption in rats and monkeys.

 

Disclosure: HB: Employee, Nuvios, Inc., Employee, Nuvios, Inc.. GH: Employee, Nuvios, Inc., Employee, Nuvios, Inc.. Nothing to Disclose: ND, AV, LC, EL, RG, SYS

OR08-3 21376 3.0000 A Abaloparatide Treatment Increases Bone Formation without a Corresponding Increases in Bone Resorption Resulting in Marked Bone Gains in Osteopenic Ovariectomized Monkeys and Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM OR08 5963 11:30:00 AM Parathyroid and Bone Metabolism Oral


Joshua Nicholas Farr*, Matthew M Roforth, Koji Fujita, Elizabeth J Atkinson, Louise K McCready, James M Peterson, Matthew T Drake, David G Monroe and Sundeep Khosla
Mayo Clinic, Rochester, MN

 

Precise delineation of the specific pathways and genes altered with aging and estrogen (E) deficiency may lead to the development of novel therapeutics to prevent or reverse age-related bone loss.  Further, such studies may identify new skeletal biomarkers.  At present, knowledge of factors relevant to bone metabolism is largely based on rodent models, although gene expression changes in rodents likely do not completely recapitulate those in humans.  The main limitation of human bone studies to date, however, is that only pre-specified genes and pathways have been examined.  High-throughput RNA sequencing (RNAseq), on the other hand, offers an unbiased approach to unveil the entire genome.

Here we present an RNAseq analysis of human bone samples, obtained from iliac crest needle biopsies, to yield the first in vivo interrogation of all potential genes and pathways that may be altered in bone with aging and E deficiency in humans.  60 healthy women were studied, including 20 young women (mean age ± SD, 30.0 ± 5.4 yrs) as well as 40 old women (n = 20 per group) randomized to receive either no therapy (72.9 ± 6.5 yrs) or 3 wks of short-term estrogen (STE) therapy (70.5 ± 5.2 yrs).  Using fairly stringent criteria (median count ≥ 10, P ≤ 0.05, false discovery rate [q] ≤ 0.10), 678 genes were altered with aging including 446 up- and 232 down-regulated genes, respectively (in old vs young subjects).  In bone tissue, aging significantly altered a total of 60 pathways (all P < 0.05), including a subset known to regulate bone metabolism such as Notch, PTEN, HIF1α, and Wnt/β-catenin signaling.  Interestingly, a large number of the identified pathways and genes were previously unrecognized as changing in bone with aging.  Perhaps unexpectedly, many of these pathways and genes have critical functions in other tissues and disease processes, although their role(s) in the pathogenesis of skeletal fragility requires additional investigation.  Notably, SOST levels did not change with aging, but STE therapy tended to lower SOST levels in bone (P < 0.001; q = 0.46).  Importantly, these changes in gene expression mirrored findings in serum (using the MSD sclerostin assay).  Further, in old women, of the 21 unique genes altered in bone by STE, the expression of INHBB (encoding for activin), which markedly decreases with aging (P < 0.001, q < 0.001), is restored to young adult levels in a robust manner (P < 0.001, q < 0.001) in response to E therapy.

In conclusion, our findings demonstrate that aging alters a substantial portion of the skeletal transcriptome, whereas STE therapy appears to have significant, albeit less wide-ranging effects.  To date, our results provide the most comprehensive assessment of the effects of aging and E therapy on the skeleton’s gene expression profile, and serve as a valuable resource for the identification of novel biomarkers associated with age-related bone loss to better target therapies to specific patients.

 

Nothing to Disclose: JNF, MMR, KF, EJA, LKM, JMP, MTD, DGM, SK

OR08-4 20632 4.0000 A Skeletal Biomarkers Associated with Aging and Estrogen Deficiency Revealed By RNA Sequencing 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM OR08 5963 11:30:00 AM Parathyroid and Bone Metabolism Oral


Serra Ucer1, Srividhya Iyer1, Shoshana M Bartell1, Marta Martin-Millan2, Li Han1, Ha-Neui Kim1, Charles A O'Brien1, Maria S Almeida1 and Stavros C Manolagas*3
1University of Arkansas for Med Science/Central Arkansas Veterans Healthcare System, Little Rock, AR, 2University of Cantabria, Santander, Spain, Santander, Spain, 3University of Arkansas for Medical Sciences/Central Arkansas Veterans Healthcare System, Little Rock, AR

 

In men, androgens are critical for the acquisition of bone mass in both the cortical and cancellous bone compartment during growth and for its maintenance throughout life. Consistent with this, male mice with global deletion of the androgen receptor (AR) exhibit low cortical and cancellous bone mass. Nevertheless, male mice with targeted deletion of AR in osteoblasts or osteocytes have lower cancellous bone mass, but no cortical bone phenotype. We have investigated the possibility that the effects of androgens on the cortical compartment result from AR signaling in osteo-progenitors or cells of the osteoclast lineage; or via ERα signaling in either or both of these two cell types upon local conversion of testosterone to estradiol. To this end, we generated mice with targeted deletion of an AR or ERα allele in the mesenchymal (ARflox;Prx1-Cre or ERαflox;Osx1-Cre) or myeloid cell lineage (ARflox;Lysm-Cre or ERαflox;Lysm-Cre) and their descendants. Male ARflox;Prx1-Cre mice exhibited decreased cancellous bone volume and trabecular number (at both 12 and 26 weeks of age), and increased osteoclast number; cortical thickness, on the other hand, was unaffected. Additionally, ARflox;Prx1-Cre mice did not undergo the loss of cancellous bone volume and trabecular number caused by orchidectomy (ORX) in their littermate controls. Nonetheless, control and ARflox;Prx1-Cre male mice lost similar amount of cortical bone following ORX. ERαflox;Osx1-Cre male mice, in difference to their female littermates, had only a transient low bone mass phenotype in the cortex at 6 weeks of age, but that was normalized by 10 weeks of age; and, following ORX lost cortical and cancellous bone indistinguishably from their littermate controls. Finally, ERαflox;Lysm-Cre males had indistinguishable bone phenotype from their littermate controls, including osteoclast numbers in cancellous or cortical bone. Recapitulation of the effects of ORX by AR deletion in the osteoblast lineage demonstrates that the protective effects of androgen on cancellous bone result from AR-mediated effect of androgen in osteoblast progenitors or their descendants.  The protective effects of androgens on cortical bone mass, on the other hand, do not require AR or ERα signaling in any cell type across the osteoblast or osteoclast differentiation lineage; thus, must be exerted indirectly by actions on some other cell type(s). These results also reveal that as in the case of estrogens (Manolagas et al, Nat Rev Endocrinol., 9:699-712, 2013), the cellular targets of androgen action on cancellous and cortical bone are different; and that the cellular targets of estrogen in bone in the female are different than they are in the male.

 

Nothing to Disclose: SU, SI, SMB, MM, LH, HNK, CAO, MSA, SCM

OR08-5 21192 5.0000 A The Effects of Androgens on Cancellous Bone Require Androgen Receptor Signaling in Osteoblasts, but Not Osteoclasts; And in Cortical Bone Require Neither 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM OR08 5963 11:30:00 AM Parathyroid and Bone Metabolism Oral


Jonathan A. Mitchell*1, Alessandra Chesi2, Okan Elci3, Shana E. McCormack2, Sani M. Roy2, Heidi J. Kalkwarf4, Joan M. Lappe5, Vicente Gilsanz6, Sharon E Oberfield7, John A. Shepherd8, Andrea Kelly9, Babette S. Zemel2 and Struan F.A. Grant3
1The University of Pennsylvania, 2The Children's Hospital of Philadelphia, Philadelphia, PA, 3The Children's Hospital of Philadelphia, 4Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 5Creighton University, Omaha, NE, 6Children's Hospital Los Ange, Los Angeles, CA, 7Columbia University College of Physicians and Surgeons, New York, NY, 8University of California San Francisco, San Francisco, CA, 9Children's Hospital of Philadelphia, Philadelphia, PA

 

Background: Maximizing peak bone mass (PBM) in early life is an important strategy to reduce the risk of osteoporosis later in adulthood. Both genetics and physical activity (PA) are known to contribute to PBM. However, it is not known if all children experience increases in bone mineral density (BMD) in response to PA.

Objective: To determine if known GWAS-implicated adult bone density loci interact with PA to modify the association between PA and BMD and bone mineral content (BMC) in childhood.

Design/Methods: We used a six-year prospective observational study design and all participants were of European ancestry, enrolled in the Bone Mineral Density in Childhood Study (N=689, 52.4% female). The following outcomes were estimated by dual energy X-ray absorptiometry: femoral neck (FN), total hip (TH) and spine areal BMD (aBMD), and total body less head (TBLH) BMC, Z-scores corrected for height and age. DNA was extracted from blood/saliva and genotyped using high-throughput technology; we investigated 77 single nucleotide polymorphisms (SNPs) near adult BMD susceptibility loci identified through GWAS. The participants self-reported their PA levels (hr/d) and trained clinicians measured puberty stage (Tanner I, II-IV and V). Interaction effects of PA with each SNP and with both puberty stage and each SNP were examined by sex using linear mixed models. Age, BMI, and dietary calcium were adjusted in these models.

Results: PA exhibited statistical interactions with 30 loci (P<0.05) and 20 loci exhibited statistical interactions with both PA and puberty stage (three-way interaction, P<0.05) to influence aBMD/BMC. For example, SNP rs4283041 near ERC1/WNT5B interacted with PA to influence TBLH-BMC in males (P=1.1x10-4); each hr/d of PA was associated with higher TBLH-BMC Z-score for CC homozygotes (b=0.04, P=3x10-7); similar findings were observed for spine, TH and FN aBMD.  SNP rs7195617 near AXIN1 interacted with PA to influence total hip aBMD in females (P=3.9x10-4); each hr/d of PA was associated with higher TH aBMD Z-score for females carrying one or more G alleles (GG homozygotes: b=0.06, P=4x10-5); similar findings were observed for FN and spine aBMD. The strongest three-way interactions were observed for spine aBMD in males (rs17691610 near MAPT, P=3.6x10-4) and in females (rs7304170 near KLHDC5/PTHLH, P=4.3x10-4). In females, carrying one or more rs7304170 C alleles was associated with increased spine aBMD during Tanner V (CC homozygotes: b=0.15, P=0.002).

Conclusions: PA was associated with higher aBMD/BMC, but this association was dependent on genetic variation at certain known bone density loci. Our data suggests that not all childhood skeletons respond equally to PA. These findings are particularly important for children born into families with a history of osteoporosis; increasing PA in childhood may not always be an efficacious approach to help prevent later osteoporosis.

 

Nothing to Disclose: JAM, AC, OE, SEM, SMR, HJK, JML, VG, SEO, JAS, AK, BSZ, SFAG

OR08-6 21496 6.0000 A The Skeletal Benefits of Physical Activity in Childhood Are Dependent on Genetic Variation at Known Bone Density Loci 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM OR08 5963 11:30:00 AM Parathyroid and Bone Metabolism Oral


Sudheer Kumar Gara*, Yonghong Wang, Dhaval Patel, Yi Liu-Chittenden, Myriem Boufraqech, Paul S Meltzer and Electron Kebebew
National Cancer Institute, NIH, Bethesda, MD

 

Very little is known about the pathogenesis of adrenocortical carcinoma (ACC) and whether the “multi-hit” hypothesis of cancer is true in ACC (progression from normal-to-adenoma-to-carcinoma). The objectives of this study were to investigate the molecular changes associated with normal-to-adenoma-to-carcinoma, and to determine possible new molecular pathways that may lead to ACC initiation and/or progression. We performed genome-wide gene expression analysis in adrenocortical tissue (normal, cortical adenomas, and ACC) samples. Selected samples from the same cohort were subjected to genome-wide DNA methylation array, microRNA expression array, and comparative genomic hybridization (CGH) analysis. We then performed an integrated analysis by a paired-wise comparison (normal-adenoma, ACC-adenoma and ACC-normal) of gene expression profile and selected genes with 4-fold expression differences and an adjusted p<0.05. We found very small differences in the gene expression profile of normal vs. adrenocortical adenoma while the expression profile was markedly different for ACC vs. adrenocortical adenoma and normal adrenal cortex. The majority of the dysregulated genes in ACC were down-regulated. Integration of CGH data with the gene expression showed that 7% and 11% of the differentially expressed genes had copy number alterations in ACC vs. adrenocortical adenoma and normal, respectively. We found the chromosomal loci spanning CDKN1C and GPM6A, a novel potential tumor suppressor candidate gene was frequently deleted in ACC. Similarly, aberrant methylation of dysregulated genes was present in 7% and 10% of ACC vs. normal and adrenocortical adenoma comparisons, respectively. Several genes including CYP1B1 and TBC1D4 were found to be differentially methylated and downregulated in ACC. We identified 14% and 15% of dysregulated genes were targeted by differentially expressed microRNAs and were inversely correlated in ACC vs. adenoma and ACC vs. normal, respectively. We found that miR-9, miR-25, miR-124 and miR-206 had multiple targets and also genes such as ASPH, FOXO1 and MBNL1 are targeted by more than one miRNAs indicating a tight gene regulation. Collectively, these three mechanisms account 28% and 36% of gene dysregulation in ACC vs adenoma and normal respectively. In addition to the well-known altered pathways in ACC, such as IGF signaling and β-catenin, we discovered Oncostatin, EIF2, CDC42 and RXR signaling pathways to be significantly altered and regulated by at least one of these mechanisms. Our data suggest that adrenocortical tumorigenesis is a multi-step process with cumulative epigenetic and copy number changes altering gene expression from normal-to-adenoma-to-carcinoma. In addition, we have identified novel tumor suppressor genes, molecular pathways and the mechanisms associated with ACC.

 

Nothing to Disclose: SKG, YW, DP, YL, MB, PSM, EK

OR02-1 19384 1.0000 A Integration of Whole Genome Wide Approaches to the Analysis of Gene Regulation and Progression of Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 1:00:00 PM OR02 5972 11:30:00 AM Endocrine Neoplasia: Tumorigenesis and Therapeutics Oral


Anastasia Melin*1, Achim Starke1, Aycan Akca1, Peter Goretzki1, Rajani Maharjan2, Per Hellman2 and Peyman Björklund3
1Lukaskrankenhaus GmbH Neuss, Neuss, Germany, 2Uppsala University, Sweden, 3Uppsala University, Uppsala, Sweden

 

Introduction:

Endocrine pancreatic tumors (p-NETs) occur with an incidence of 0.4 to 1 in 100,000. Insulinomas confine the largest group of p-NETs. Somatic mutations in MEN1 have been found in up to 20% of sporadic p-NETs. Recently, a hot spot mutation was found in the Ying Yang 1 gene in 30% of insulinomas. The YY1 gene can act either as a tumorsupressor or an oncogene in other tumours such as breast, prostate and colorectal cancer. The mutation (YY1 T372R) was associated with a later onset of insulinomas. 

Material and methods: 

Benign sporadic insulinomas (n=39) were snap frozen after surgery. DNA was extracted, subjected to PCR and subsequent automated Sanger sequencing of YY1 and MEN1

Oral glucose tolerance test (OGTT) was performed before the surgery. Fischer exact test and the Mann-Whitney-U-test were used for statistical analysis.

Results:

We found the YY1 T372R mutation in 28% (11/39) of the tumours, mutually exclusive from mutations in MEN1 found in 13% (5/39). The median age of patients with tumour harboring YY1 mutation was 63.0 ± 13.4 years and 45.5 ± 17.2 years in in those without YY1 mutation (p=0.03). There was no significant difference in sex, or the extent of the tumors. OGTT could not show any significant differences between the two groups 36 ±11.5 (mg/dl) in the YY1 mutated group and 41 ± 15.3 (mg/dl) in those without YY1 mutation, (p=1.00) The maximum suppressed insulin value at symptomatic hypoglycemia was 13.4 ± 14 (mU/L) versus 18,2 ± 21,7 (mU/L) p=0.61.

There was no significant difference concerning the time until hypoglycemia of <45 (mg/dl) was achieved in the OGTT test (5 hours versus 4 hours, p=0.15). 

Conclusion:

In accordance to the previously published data, we found the YY1 T372R mutation in 28.2% of  the analyzed sporadic benign insulinomas. We demonstrated a significantly later onset of insulinomas harboring YY1 mutation. Pathophysiological symptoms in the patients investigated by OGTT were not correlated to mutation status. Further investigations are warranted to determine the biological behavior of insulinomas with the YY1 T372R mutation.

 

Nothing to Disclose: AM, AS, AA, PG, RM, PH, PB

OR02-2 21178 2.0000 A YY1 Mutations Are Frequent in Insulinomas, Mutually Exclusive from MEN1 Mutation and Do Not Correlate to Pathophysiological Symptoms 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 1:00:00 PM OR02 5972 11:30:00 AM Endocrine Neoplasia: Tumorigenesis and Therapeutics Oral


Gerard V Walls*1, Mark Stevenson1, Ben Soukup1, Kate E Lines1, Paul T Christie1, Ashley B. Grossman1, Herbert A Schmid2 and Rajesh V Thakker1
1University of Oxford, Oxford, United Kingdom, 2Novartis Pharmaceuticals, Basel, Switzerland

 

Improved therapies for pancreatic and pituitary neuroendocrine tumors (NETs), which may occur in Multiple Endocrine Neoplasia type 1 (MEN1), are needed. We therefore assessed the effects of pasireotide, a somatostatin analogue that has high affinity for 4 of the 5 somatostatin receptor sub-types, in a mouse model for MEN1. Mice deleted for an Men1 allele (Men1+/-) are representative of MEN1 in man, as Men1+/- mice develop pancreatic and pituitary NETs in association with parathyroid tumors from 12 months of age. To study the effects of pasireotide on NET proliferation and apoptosis, we treated Men1+/- mice aged 12 months with either pasireotide 40 micrograms/g body weight intramuscularly (i.m.) once per month (treatment group, n=71) or phosphate-buffered saline (PBS) i.m. (control group, n=73) for 9 months. All Men1+/- mice (n=144) had magnetic resonance imaging (MRI) at 12 and 21 months of age, to assess tumor development, and oral 1 mg/ml 5-bromo-2-deoxyuridine (BrdU) in drinking water for one month from 20 months of age, to assess tumor proliferation. NETs were collected by necropsy at 21 months of age, and proliferation and apoptosis were assessed by immunohistochemical quantification of nuclei containing BrdU and TUNEL assays, respectively. Pasireotide-treated Men1+/- mice had a significantly increased survival, assessed by Kaplan-Meier analysis, compared to PBS-treated mice (82% versus (vs) 64%, respectively, P<0.05), and this was associated with the development of fewer NETs in the pasireotide-treated group vs the PBS-treated group (86% vs 98% pancreatic NETs, and 52% vs 72% pituitary NETs, P<0.05 in both). Furthermore, MRI scans revealed that pasireotide treatment diminished the increase in pituitary NET volumes (pre-treated vs post-treated = 0.933 ±0.099 mm3 vs 3.525 ±1.349 mm3 in the pasireotide-treated group, compared to 0.975 ±0.161mm3 vs 10.583 ±3.187mm3 in the PBS-treated group, P<0.05), while necropy revealed the pasireotide-treated group to have significantly fewer pancreatic NETs when compared to PBS-treated mice (2.36 ±0.25 vs 3.72 ±0.32, respectively, P<0.001). Pasireotide treatment also decreased NET proliferation when compared to PBS treatment (PBS-treated vs pasireotide-treated = 1.81 ±0.15% vs 0.73 ±0.07% in pituitary NETs, and 0.78 ±0.08% vs 0.35 ±0.03% in pancreatic NETs, respectively, P<0.0001), but increased apoptosis (2.35 ±0.44% vs 14.75 ±1.58% in pituitary NETs, and 0.19 ±0.03% vs 0.42 ±0.05% in pancreatic NETs, respectively, P<0.001 for both). Thus, pasireotide treatment in Men1+/- mice increased survival by ~20%, inhibited NET growth and reduced the number and volume of pancreatic and pituitary NETs, thereby indicating its potential use as an anti-proliferative and pro-apoptotic therapy for pancreatic and pituitary NETs.

 

Disclosure: GVW: Researcher, Novartis Pharmaceuticals. ABG: Ad Hoc Consultant, Lecture fees and Advisory Board, Ad Hoc Consultant, Lecture fees and Advisory Board. HAS: Employee, Novartis Pharmaceuticals. RVT: Principal Investigator, Novartis Pharmaceuticals. Nothing to Disclose: MS, BS, KEL, PTC

OR02-3 18709 3.0000 A Treatment with Pasireotide, a Somatostatin Analogue, Results in Decreased Proliferation and Increased Apoptosis in Pancreatic and Pituitary Neuroendocrine Tumors (NETs), in a Mouse Model for Multiple Endocrine Neoplasia Type 1 (MEN1) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 1:00:00 PM OR02 5972 11:30:00 AM Endocrine Neoplasia: Tumorigenesis and Therapeutics Oral


Andrea Estrada*1, Aradhana Venkatesan2, Christopher L Wolfgang3, Elliot K Fishman4, Ihab Kamel4, Syed Z Ali4, Michael Goggins3, Anirban Maitra5, Lori C. Guthrie6, Beth Brillante7, Rachel I Gafni7, Anne Marie Lennon3 and Michael T. Collins8
1NIDCR/NICHD, NIH, Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3Johns Hopkins University School of Medicine, Baltimore, MD, 4Johns Hopkins University School of Medicine, 5MD Anderson, 6Section on Skeletal Disorders and Mineral Homeostasis, Bethesda, MD, 7National Institutes of Health, 8NIDCR, NIH, Bethesda, MD

 

Background:  The McCune Albright syndrome (MAS) exists along a clinical spectrum that includes fibrous dysplasia of bone, café-au-lait macules, and hyperfunctioning endocrinopathies, including precocious puberty, hyperthyroidism, GH excess, FGF23-mediated hypophosphatemia and hypercortisolism.  It is due to somatic activating mutations in GNAS.  The same GNAS mutations have been found as driver mutations in 66% of intraductal papillary mucinous neoplasms (IPMNs). IPMNs are cystic neoplasms of the pancreas that commonly present in the 7th decade of life, and are thought to be pre-cancerous.  Pancreatic ductal lesions, including IPMNs, have been reported in MAS, however the incidence and natural history is not well characterized.

Objective: Determine the prevalence and characteristics of pancreatic neoplasms in MAS.

Patients and Methods:  Thirty patients (aged 7 to 67 years, median 18.5) in the National Institutes of Health cohort of subjects with MAS underwent abdominal MRI and magnetic resonance cholangiopancreatography (MRCP) screening for pancreatic neoplasms.  Identified IPMNs were further categorized according to the 2012 International Consensus Guidelines into those with either high risk or worrisome features; including main duct dilatation ≥5 mm, cysts ≥ 3 cm, mural nodule, thickened wall or solid component, jaundice secondary to the cyst or history of acute pancreatitis.

Results: Nine patients (30%) had pancreatic abnormalities.  Eight of these patients had cystic lesions of the pancreas; one with simple cysts and seven with IPMNs.  Five of the seven IPMNs exhibited worrisome or high-risk stigmata.  IPMN subtypes included the following: one main pancreatic duct IPMN, three branch duct IPMN and three mixed- IPMN.  The median age of patients with pancreatic pathology was 47 (range 17 to 67).  Three patients had pancreatic divisum, including 2 of the subjects with IPMNs. None of them had evidence of exocrine dysfunction. Surprisingly, 5 of the 9 subjects with pancreatic pathology (55%) were diagnosed with diabetes.  The mean BMI and ages were 29 and 33. The mean BMI and age of onset of type 2 diabetes in the general population are 37 and 45, respectively.  <5% of the remaining >170 subjects in the NIH MAS cohort have diabetes   

Conclusions:  Gastrointestinal neoplasms, particularly IPMNs, appear to occur more frequently and at a younger age in patients with MAS compared to the general population. This suggests that pancreatic neoplasms are a clinical feature of MAS.  Given the malignant potential of IPMNs in the general population, screening for pancreatic neoplasms in patients with MAS may be warranted.  Further determination of the natural history and spectrum of IPMNs in MAS is needed. Finally, the unexpected high rate of diabetes in subjects with MAS and anatomical pathology warrants further investigation.

 

Nothing to Disclose: AE, AV, CLW, EKF, IK, SZA, MG, AM, LCG, BB, RIG, AML, MTC

OR02-4 21953 4.0000 A Pancreatic Pathology in the Mccune-Albright Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 1:00:00 PM OR02 5972 11:30:00 AM Endocrine Neoplasia: Tumorigenesis and Therapeutics Oral


Idit Dotan*1, Elliot Jonathan Mitmaker1, Philip Jonathan Rupert Roche2, Lenore Katherine Beitel3, Michael Tamilia3, Mark Anthony Trifiro4 and Miltiadis Paliouras5
1McGill University Health Center, Montreal, QC, Canada, 2Lady Davis Institute for Medical Research-Jewish General Hospital, Montreal, QC, Canada, 3McGill University, Montreal, QC, Canada, 4The Jewish General Hospital, McGill University, Lady Davis Institute for Medical Research, Montreal, QC, Canada, 5Lady Davis Institute for Medical Research-Jewish General Hospital, McGill University, Montreal, QC, Canada

 

Background. The incidence of papillary thyroid carcinoma (PTC) has risen steadily over the past few decades, while surgical and medical treatments are still associated with significant comorbidities. Importantly, recurrence rates of up to 20% expose patients to additional morbidities and increased death risk. The Achilles heel of chemotherapy and biological therapies is heterogeneity within the tumor itself, generated by accumulation of mutations that create multiple sub-populations in a given tumor. These issues emphasize the need for new technology to treat local recurrence and metastatic disease, with higher success rates and minimal compromise to quality of life. It is proposed that targeted ablative physical therapy could represent a therapeutic modality, with limited side effects. Targeted functionalized multi-walled carbon nanotubes (BioNanofluid) act by efficiently converting light energy to heat locally, representing a promising new cancer therapeutic advancing beyond conventional laser ablation and other nanoparticle approaches.

Methods. The presence of the TSH-Receptor (TSH-R) on various cells was established using Western blot analysis. BioNanofluid was conjugated to TSH-R antibody (Ab), purified TSH (Thyrotropin) and recombinant TSH (Thyrogen) through covalent amide bonds to create 3 different types of conjugates. A laser at 532nm was used to illuminate cells for set exposure times. Cell death was assessed using trypan blue staining.

Results. BCPAP, a PTC cell line was TSH-R positive, while NSC-34, a hybrid neuronal mouse cell line was TSH-R negative. A 2:1 BCPAP cell:conjugate ratio and 30 second exposure time eliminated ~60%, 65% and >70%  of the BCPAP cells when using TSH-R Ab, Thyrotropin and Thyrogen conjugates, respectively, with minimal non-targeted killing. Increasing conjugate ratios and longer exposure (40 seconds) yielded higher targeted cell killing rates; however, more than 30% non-targeted killing in the BCPAP Unconjugated BioNanofluid control group was observed, suggesting bulk heating. NSC-34 (control) cell killing was less than 10% under all conditions. With engineered improvement of nanoparticles, chemistry and ligand presentation, targeted killing rate exceeded 90% with ~10% non-specific cell death.

Conclusion. A BioNanofluid platform offering a potential therapeutic path for PTC has been investigated, offering an alternative for more complicated patients, who currently undergo suffering caused by reoperative neck exploration, repeated administration of radioactive iodine (RAI), external beam radiation or chemotherapy. In addition, BioNanofluid treatment may serve as an alternative to RAI therapy, directed at both PTC cells and normal thyroid tissue. This work represents one demonstration of BioNanofluid therapeutic development, where targeted physical therapy can overcome the challenge of tumor heterogeneity.

 

Nothing to Disclose: ID, EJM, PJRR, LKB, MT, MAT, MP

OR02-5 19875 5.0000 A Engineering Bionanofluids to Target Papillary Thyroid Cancer Cell Lines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 1:00:00 PM OR02 5972 11:30:00 AM Endocrine Neoplasia: Tumorigenesis and Therapeutics Oral


Aleck Hercbergs*1, Thangirala Sudha2, Murat Yalcin3, Hung-Yun Lin4, Mary Koeppe Luidens5, Shaker A. Mousa6 and Paul J Davis7
1Cleveland Clinic, 2Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 3Uludag University, Bursa, Turkey, 4Taipei Medical University, Taiwan, 5Albany Medical Center, Albany, NY, 6Albany College of Pharmacy and Health Sciences, Rensselaer, NY, 7Albany College of Pharmacy and Health Sciences

 

Glioblastoma multiforme (GBM) is an aggressive brain tumor with a less than 10% five-year survival rate.  The tumor is relatively chemo- and radioresistant and, despite its vascularity, has shown disappointing clinical response to anti-angiogenic management.  Nanoparticulate tetraiodothyroacetic acid (Nanotetrac) is an anti-cancer/anti-angiogenic agent that acts exclusively at a thyroid hormone-tetrac receptor site on plasma membrane integrin αvβ3 and does not gain entry to cells.  In this formulation, tetrac is covalently bound via a linker to 200 nm poly(lactic-co-glycolic acid)(PLGA) nanoparticles.  From the integrin, the agent disorders a panel of tumor cell defense pathways by downstream actions on expression of differentially-regulated genes and is pro-apoptotic by several mechanisms.  In the C6 rat glioma subcutaneous xenograft in the mouse, standard clinical GBM chemotherapy with temozolomide (TMZ) at 10 mg/kg was wholly ineffective (tumor volumes at 14 d), as was subtherapeutic dosage of Nanotetrac (0.3 mg/kg).  Added to TMZ, Nanotetrac at 0.3 mg/kg reduced tumor volume by 53% at 14 d.  In the subcutaneous  human U87MG (U87-luc) GBM xenograft, Nanotetrac as a single dose at 1 mg/kg injected s.c. together with the implanted cells inhibited tumor growth by 79% at 16 d.  Luminescent scanning revealed no viable cells in the Nanotetrac-exposed tumors, with full viability in the void PLGA-injected lesions.  Systemic (s.c.) Nanotetrac at 1 mg/kg q2 d reduced subcutaneous tumor U87MG xenograft volume by 46% at 10 d.  All Nanotetrac results were significant at p < 0.05.  Studied in vitro, U87MG cells proliferated in response to physiological concentrations of L-thyroxine (T4) and supraphysiological levels of 3,5,3-triiodoo-L-thyronine.  The T4 effect was associated with activation of mitogen-activated protein kinase (pERK1/2), but phosphatidylinositol 3-kinase.  Taken together, these results indicate that 1) GBM is a thyroid hormone-responsive tumor, consistent with clinical observations of the action of induced hypothyroxinemia on GBM (A Hercbergs et al., Anticancer Res 23:617-626, 2003; Oncologist, in press, 2015) and 2) Nanotetrac administered systemically or intratumorally is effective in reducing GBM xenograft volumes/weights and in decreasing tumor cell viability.

 

Nothing to Disclose: AH, TS, MY, HYL, MKL, SAM, PJD

OR02-6 21888 6.0000 A Activity of Nanoparticulate Tetrac (Nanotetrac) on Models of Glioblastoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 1:00:00 PM OR02 5972 11:30:00 AM Endocrine Neoplasia: Tumorigenesis and Therapeutics Oral


Peter James Trainer*1, John Newell-Price2, John Ayuk3, Simon J B Aylwin4, Aled Rees5, William Drake6, Philippe Chanson7, Thierry Brue8, Susan M. Webb9, Carmen Fajardo10, Javier Aller11, Ann I McCormack12, David J Torpy13, George Tachas14, Lynne Atley15 and Martin Bidlingmaier16
1The Christie NHS Foundation Trust, Manchester, United Kingdom, 2Univ of Sheffield, Sheffield, United Kingdom, 3University Hospital Birmingham, Birmingham, United Kingdom, 4King's College Hospital, London, United Kingdom, 5Cardiff University, Cardiff, United Kingdom, 6St Bartholomew's Hospital, London, United Kingdom, 7Univ Paris-Sud, UMR-S693, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France, 8Hopital de la Conception, Marseille, France, 9Hosp de Sant Pau, Barcelona, Spain, 10Hospital Universitario La Ribera, Alzira. Valencia, Spain, 11Hospital Universitario Puerta de Hierro, Madrid, Spain, 12St. Vincent Hospital, Naremburn - NSW, Australia, 13Royal Adelaide Hospital, Adelaide, Australia, 14Antisense Therapeutics, Melbourne, Australia, 15Antisense Therapeutics Limited, Melbourne, Australia, 16Ludwig-Maximilians University, Munich, Germany

 

ATL1103 is a second generation antisense oligomer directed at the GH receptor. It is a 20mer with a phosphorothioate backbone and 2’-O-methoxyethyl modifications of the five nucleotides at either end intended to increase its plasma half-life and affinity for the target RNA to allow post-hybridization RNaseH degradation of the GHr RNA strand.  ATL1103 is relatively rapidly distributed from plasma (Cmax in 2-4 hrs) into peripheral tissues, with a tissue clearance half-life of 2-4 weeks in primates.  We report a phase 2 randomised, open-label, parallel group study of subcutaneously administered ATL1103 in patients with active acromegaly.  Appropriate ethical approval was obtained in every jurisdiction and the study is registered as EudraCT 201200314730.  Patients gave written informed consent.   The protocol entailed appropriate washout from any ongoing medical therapy after which IGF-I had to be at least >1.30 times age-related ULN.  Patients were randomised to receive either ATL1103 200 mg once or twice weekly for 13 weeks (3 doses in the first week).  After completion of drug administration, patients were monitored for a further eight weeks.  The primary objectives as per protocol were to evaluate the safety and to understand the single dose and multiple dose pharmacokinetic profiles of ATL1103 in patients with acromegaly.  35 patients were recruited in 13 centres in Australia, France, Spain and UK. 26 (Mean age 50.4 yr; range 26 to 80, 11 male) were randomised, all of whom completed treatment.  ATL1103 was well tolerated with mild to moderate injection site reactions being the most common drug-related AE.  Four SAEs were reported, of which three occurred in a single patient, but none were felt to be study drug related.   Two patients withdrew from the study at completion of dosing with study drug. There was a significant fall in serum IGF-I of 26% by week 14 (one week past the last dose) with 200 mg twice weekly (577 ± 198 v 411 ± 174 ng/ml (mean ± SD), P <0.0001) although the nadir had not been reached.  Once weekly dosing did not result in a significant fall in IGF-I.   The fall in IGF-I with twice weekly dosing was associated with a mean reduction in ring size of 0.92 (P=0.02) and an increase in GH (AUC during an OGTT, P=0.001).  This study provides proof-of-concept that ATL1103 is able to significantly lower IGF-I in patients with acromegaly and offers a novel therapeutic approach.

 

Disclosure: PJT: Clinical Researcher, Antisense Therapeutics, Clinical Researcher, Antisense Therapeutics, Clinical Researcher, Novartis Pharmaceuticals, Clinical Researcher, Chiasma, Clinical Researcher, Ipsen, Speaker, Novartis Pharmaceuticals. AR: Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Ipsen, Speaker, Ipsen. WD: Clinical Researcher, Antisense. PC: Researcher, Ipsen, Researcher, Novartis Pharmaceuticals, Researcher, Novo Nordisk, Researcher, Pfizer, Inc., Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Viropharma, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc.. TB: Investigator, Pfizer, Inc., Consultant, Pfizer, Inc., Speaker, Pfizer, Inc., Investigator, Novo Nordisk, Speaker, Novo Nordisk, Investigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Consulting speaker, Merck Serono, Consulting speaker, Lilly USA, LLC, Investigator, Ipsen, Speaker, Ipsen, Advisory Group Member, Ipsen, Consultant, Ipsen, Speaker, Sandoz, Investigator, Sandoz. SMW: Ad Hoc Consultant, Antisense Therapeutics, Clinical Researcher, Antisense Therapeutics. JA: Advisory Group Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc., Speaker, Pfizer, Inc., Speaker, Ipsen, Ad Hoc Consultant, Ipsen, Advisory Group Member, Bayer, Inc.. GT: Director Drug Discovery and Patents, Antisense Therapeutics Ltd. LA: Employee, Antisense Therapeutics Ltd. Nothing to Disclose: JN, JA, SJBA, CF, AIM, DJT, MB

OR09-1 20897 1.0000 A A Phase 2 Study of Antisense Oligonucleotide Therapy Directed at the GH Receptor Demonstrates Lowering of Serum IGF-I in Patients with Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR09 5992 11:30:00 AM Pituitary Tumors-Therapeutics Oral


Lillian Ting*1, Anadya Prakash Tripathi2, Christelle Darstein3, Tracy White1 and Nicholas Sauter1
1Novartis Pharmaceuticals Corporation, East Hanover, NJ, 2Novartis Healthcare Pvt Ltd, Hyderabad, India, 3Novartis Pharma AG, Basel, Switzerland

 

Background: LCI699 (osilodrostat) is a potent oral inhibitor of 11β-hydroxylase currently in Phase III clinical development for the treatment of patients with Cushing’s disease. In vitro assessments of osilodrostat suggested potential drug-drug interactions (DDIs) with cytochrome P450 (CYP) enzyme metabolism. Of the numerous CYP enzymes, only five (CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A4) are responsible for metabolizing approximately 90% of medications, with CYP3A4 accounting for nearly half this total. This clinical study evaluated the inhibitory effect of osilodrostat on the pharmacokinetics (PK) of the CYP1A2, CYP2C19, CYP2D6, and CYP3A4 probe substrates, caffeine, omeprazole, dextromethorphan, and midazolam, respectively.

Methods: Single-center, open-label, Phase I, DDI study in healthy adult volunteers. On study day 1 volunteers received a single dose of probe substrates (cocktail approach; caffeine [100 mg], omeprazole [20 mg], dextromethorphan [30 mg], and midazolam [2 mg]), followed by PK assessments over the next 48 h. After a 6-day washout period, subjects then received a single dose of osilodrostat 50 mg (planned therapeutic dose range 2–30 mg bid), followed 0.5 h later with a single dose of probe substrates. PK assessments were conducted over the next 48 h.

Results: 10 males and 10 females with an overall mean age, body weight, and body mass index of 41.8 years, 72.95 kg, and 24.4 kg/m2 were enrolled. One subject discontinued (withdrew consent). AUClast geometric mean ratio (GMR) and 90% confidence intervals (90% CI) of probe substrate exposure with osilodrostat administration were 2.33 (2.10–2.59), 1.91 (1.74–2.11), 1.48 (1.34 –1.63), and 1.50 (1.41–1.60) for caffeine, omeprazole, dextromethorphan and midazolam, respectively. Corresponding values for AUC GMR (90% CI) were 2.54 (2.34–2.75), 1.86 (1.61–2.15), 1.54 (1.40–1.69), and 1.50 (1.41–1.59). Cmax GMR (90% CI) for the change in substrate exposure was 1.07 (0.988–1.15), 1.61 (1.40–1.84), 1.35 (1.21–1.50), and 1.47 (1.32–1.62) for caffeine, omeprazole, dextromethorphan and midazolam, respectively.

Osilodrostat is a moderate inhibitor of CYP1A2 and CYP2C19 (exposures of the respective probe substrates increased ~2.5- and 2-fold, respectively) and a weak inhibitor of CYP2D6 and CYP3A4 (exposures of the respective probe substrates increased ~1.5 fold).

Conclusions: Considering that a 50 mg single dose of osilodrostat is reasonably representative of the upper end of the daily drug exposure expected for clinical use (maximum 30 mg bid), it is encouraging that the most clinically important CYP enzyme, CYP3A4, was only weakly inhibited. As most patients with Cushing’s disease in a Phase II study achieved normal urinary free cortisol levels with ≤10 mg bid osilodrostat, osilodrostat is unlikely to have a clinically relevant impact on the exposures of other medications cleared by CYP3A4.

 

Disclosure: LT: Employee, Novartis Pharmaceuticals. APT: Employee, Novartis Pharmaceuticals. CD: Employee, Novartis Pharmaceuticals. TW: Employee, Novartis Pharmaceuticals. NS: Employee, Novartis Pharmaceuticals.

OR09-2 21061 2.0000 A Evaluation of the Effects of LCI699 (Osilodrostat) on Cytochrome P450 Enzymes in Healthy Volunteers: Low Drug-Drug Interaction Potential 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR09 5992 11:30:00 AM Pituitary Tumors-Therapeutics Oral


Shlomo Melmed*1, Nienke R. Biermasz2, Peter J. Trainer3, Gary Patou4 and Asi Haviv5
1Cedars-Sinai Medical Center, Los Angeles, CA, 2Leiden University Medical Center, Netherlands, 3The Christie NHS Foundation Trust, Manchester, United Kingdom, 4Chiasma Inc,, Newton, MA, 5Chiasma, Jerusalem, Israel

 

Background: Oral octreotide capsules (OOC) contain a transient permeability enhancer (TPE®) which enables effective drug absorption. In a multicenter phase 3 trial, subjects previously controlled on injectable somatostatin receptor ligands (SRLs) were switched to OOC for up to 13 months. OOC was shown to be safe and effective in maintaining IGF-1 and GH control in 62% of subjects enrolled vs. 89% at baseline. The present evaluation analyzes determinants of OOC efficacy.

Methods: At baseline, of 151 evaluable enrolled patients, 93 (62%), were fully controlled (IGF-1 < 1 ULN and integrated GH < 2.5 ng/mL); 41 subjects (27%) were partially controlled with IGF-1 levels between 1 – 1.3XULN and GH < 2.5 ng/mL; and 17 subjects (11% ) were not controlled. 86 subjects (57%)  were previously treated with high doses of parenteral SRLs (Octreotide LAR® ≥30mg/month or Lanreotide Autogel®=120mg/month), and 65 were previously treated with   low to mid doses of injectables (LAR 10 or 20mg or Autogel 60 or 90mg).   In this descriptive analysis we studied the relationship between pre-study SRL dose (post hoc), or baseline disease activity (pre-defined), to OOC efficacy up to 13 months. The correlation between prior SRL dose and oral octreotide dose was also studied.

Results:The degree of baseline control while on injectable SRLs predicted subsequent OOC response. Respective OOC response rates were 76 % (full baseline control), 66% (full or partial baseline control) and 24% (uncontrolled at baseline). Previous injectable SRL dose also predicted OOC response. 72% of subjects previously treated with low to mid SRL doses responded to OOC vs.  56% response for subjects previously treated with high doses. Full biochemical control at baseline and low to mid doses of prior injectable SRLs yielded 85% response on OOC (49 of 58 subjects). The OOC dose distribution in all enrolled subjects was shown to be related to prior injectable SRL dose. While 74% of subjects previously treated with low SRL doses required 40mg OOC, 31% of subjects treated with high SRL dose were controlled by 40 mg OOC. 110 subjects were initially controlled on OOC following dose titration, and entered a fixed dose phase (average 12 weeks from first OOC dose). At the beginning of the fixed-dose phase, 51, 25 and 34 subjects were treated with OOC 40, 60 and 80mg respectively. Initial response to low to mid doses of OOC predicts sustainable response over time as the response up to 13‑months was 88, 84, and 47% for each respective OOC dose.

Conclusions: High dose injectable SRL or partial baseline control portend favorable efficacy to OOC. Full baseline biochemical control, and/or low to mid injectable SRL dose requirements portend  higher OOC response rates. OOC was effective in a subset of patients, uncontrolled at baseline while on injectable SRLs. OOC efficacy can reliably be determined within 12 weeks of initiating therapy and its effect is sustainable for up to 13 months.

 

Disclosure: SM: Planning Group Member, Ipsen, Ad Hoc Consultant, Novartis Pharmaceuticals, Principal Investigator, Pfizer, Inc., Ad Hoc Consultant, ISIS, Advisory Group Member, Chiasma. NRB: Coinvestigator, chiasma. PJT: Clinical Researcher, Chiasma, Clinical Researcher, Antisense Therapeutics, Clinical Researcher, Antisense, Clinical Researcher, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Clinical Researcher, Ipsen. GP: Management Position, Chiasma. AH: , Chiasma.

OR09-3 21142 3.0000 A Determinants of Oral Octreotide Capsules Efficacy in Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR09 5992 11:30:00 AM Pituitary Tumors-Therapeutics Oral


Aart J. van der Lely*1, Peter J. Jonsson2, Patrick Wilton3, Jose Francisco Cara4 and Ezio Ghigo5
1Erasmus University Medical Center, Rotterdam, Netherlands, 2Endocrine Care, Pfizer Health AB, Sollentuna, Sweden, 3Stockholm, Sweden, 4Pfizer Inc, New York, NY, 5University of Turin, Turin, Italy

 

Introduction:

Pegvisomant (PEGV) is a competitive antagonist of growth hormone (GH) approved for the treatment of patients with acromegaly. The recommended starting dose of PEGV is 10 mg/day, and doses are titrated upwards until normalization of serum levels of insulin-like growth factor-I (IGF-I) is attained. The purpose of this analysis was to evaluate data from ACROSTUDY, a Pfizer-sponsored non-interventional post marketing study on the long-term outcomes of pegvisomant therapy, on the clinical characteristics of patients who required PEGV at a daily dose above 30 mg/day for IGF-I normalization and to compare these with the characteristics of patients who attained IGF-I control with a PEGV dose of 10 mg/day.

Methods:

All data available as of June 2014 were included in this analysis. Baseline was defined as start of PEGV. IGF-I was measured at various local labs and expressed as IGF-I /upper normal level (ULN).  A normal IGF-I was defined as an IGF-I/ULN below 1.2. All patients treated for at least six weeks with a PEGV at a dose above 30 mg/day who had two consecutive normal IGF-I values were included in the “High” group (H). Patients who had two consecutive normal IGF-I values and who never received treatment with a dose of PEGV above 10 mg/day were included in the “Low” group (L). Descriptive statistics are expressed as mean (±SD).  Significance level was set to 5%.

Patients:

56 patients (39% males) with a mean (SD) age of 43.6 (13.0) yrs at PEGV start in H and 368 patients (46% male) with a mean age of 51.9 (14.6) yrs (p<0.05) yrs in L were included in the analysis.

Results:

At baseline 84% of H and 77% of L was treated before with surgery and 29% of H and 26% L had received radiotherapy. Time since diagnosis of acromegaly was 6.3 (8.9) yrs and 8.6 (9.0) in H and L respectively (p<0.05).  Of 6 clinical symptoms (arrhythmia, diabetes mellitus, hypertension, osteoarthritis, sleep apnea, surgery for carpal tunnel syndrome) collected in ACROSTUDY, hypertension and sleep apnea, were more frequent in the H group. At baseline 27% and 44% (p<0.05) were on long-acting somatostatin analogs and 18% and 11% were on dopamine antagonists in H and L resp. IGF/ULN at baseline was 2.8 (1.3) and 1.4 (0.7) (p<0.05) in patients in whom IGF-I levels were available (82% in H and 71% in L). The mean starting dose of PEGV was 16.6 (12.9) mg/d in H and 8.8 (2.4) mg/day in L (p<0.05). Duration of PEGV treatment was 6.9 (2.5) yrs in H and 4.4 (2.5) yrs in L (p<0.05). Duration of treatment with a dose >30 mg was 3.5 (2.0) years. IGF/ULN at the end of follow up was 1.0 (0.5) in H and 0.8 (0.4) in L (p<0.05).

Conclusion:

Data from ACROSTUDY suggest that the group of subjects that need high daily doses of PEGV to normalize their serum IGF-I levels have a higher incidence of hypertension and sleep apnea and higher baseline values of IGF-I, which might suggest that they have a more severe form of acromegaly.

 

Disclosure: AJV: Speaker, Pfizer, Inc., Consultant, Pfizer, Inc., Advisory Group Member, Pfizer, Inc.. PJJ: Employee, Pfizer, Inc.. PW: Consultant, Pfizer, Inc.. JFC: Employee, Pfizer, Inc.. EG: Advisory Group Member, Pfizer, Inc., Consultant, Pfizer, Inc., Speaker, Pfizer, Inc..

OR09-4 20373 4.0000 A Treatment with High Doses of Pegvisomant in 56 Patients with Acromegaly: Experience from Acrostudy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR09 5992 11:30:00 AM Pituitary Tumors-Therapeutics Oral


Greisa Vila*1, Ann-Charlotte Akerblad2, Anders F. Mattsson3, Michaela Riedl4, Susan M. Webb5, Vaclav Hana6, Eigil H Nielsen7, Beverly M.K. Biller8 and Anton Luger9
1Medical University of Vienna, Vienna, Austria, 2Endocrine Care, Pfizer Health AB, Sollentuna, Sweden, 3Pfizer Health AB, Sollentuna, Sweden, 4Medical University of Vienna, Vienna, Austria, 5Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain, 6Charles University, Prague, Czech Republic, 7Aalborg University Hospital, Aalborg, Denmark, 8Massachusetts General Hospital, Boston, MA, 9Medical University and General Hospital of Vienna, Vienna, Austria

 

Background: Growth hormone (GH) replacement in growth-hormone deficient (GHD) women is not approved during pregnancy. To date, only a few reports on growth hormone replacement therapy (GHRT) before and during pregnancy are available.

Aim and Methodology: Here we describe pregnancies in a large cohort of patients with hypopituitarism and investigate potential factors determining pregnancy outcomes. All pregnancies reported in KIMS (Pfizer International Metabolic Database), pregnancy outcomes and complications, as well as their relationship to use of GHRT during pregnancy were analyzed with simple and multiple regression methods. Significance level was set to 5%.

Results: A total of 201 pregnancies were reported from centers in fifteen countries, 173 in female patients aged 22-43 years (preliminary data on 115 shown at ENDO12), and 28 in partners of male patients. Ninety percent of female pregnant patients had at least one additional pituitary deficiency and two-thirds of women underwent fertility treatment in order to achieve pregnancy. GHRT was stopped before pregnancy in 7.5% of the female patients, as soon as pregnancy was confirmed in 40.1%, and at the end of the second trimester in 24.7% of the patients, while 27.6% of the female patients continued GHRT throughout pregnancy. GH treatment patterns during pregnancy were not related to the etiology of pituitary disease, extent of pituitary deficiencies or conception method. Birth of a healthy child was reported in 79% of the female pregnancies.  Non-elective abortions occurred mainly in the first trimester, and one fetal malformation (cystic hygroma) was diagnosed in the second trimester. Regression analyses performed to identify parameters related to pregnancy outcomes showed that they were not related to GHRT treatment patterns, IGF-I SDS (last before pregnancy), method of conception or number of additional pituitary deficiencies. Negative pregnancy outcomes were associated with a history of depression and with maternal age at conception below 30 or above 35 years. Pregnancy-associated complications were not related to GHRT during the pregnancy.

Conclusion: These data on pregnancies in a large cohort of women with hypopituitarism receiving GHRT reveal different treatment patterns across countries. Of note is the large number of patients requiring assisted reproductive techniques, extending beyond ovulation induction/ovarian stimulation, indicating that successful reproduction in women with pituitary deficiency often requires more than adequate hormone replacement therapy. In the clinical practice setting, nearly all patients taking GH replacement continue treatment during the time when they seek fertility, and more than half remain on treatment (fully or partially) during the pregnancy. Based on the current data, growth hormone replacement regimens during pregnancy do not appear to affect pregnancy outcomes.

 

Disclosure: GV: Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc.. ACA: Employee, Pfizer, Inc.. AFM: Employee, Pfizer, Inc.. MR: Speaker, Novo Nordisk. SMW: Consultant, Pfizer, Inc., Speaker, Pfizer, Inc.. VH: Ad Hoc Consultant, Pfizer, Inc., Speaker, Ipsen, Speaker, Novartis Pharmaceuticals. BMKB: Principal Investigator, OPKO, Consultant, Novo Nordisk, Consultant, Versartis, Consultant, Pfizer, Inc.. AL: Speaker, Serono, Consultant, Ipsen, Speaker, Ipsen, Consultant, Novo Nordisk, Speaker, Novo Nordisk, Consultant, Pfizer, Inc., Speaker, Pfizer, Inc., Consultant, Serono. Nothing to Disclose: EHN

OR09-5 20337 5.0000 A Pregnancy Outcomes in Women with Growth Hormone Deficiency Are Not Related to Growth Hormone Treatment during Pregnancy - a Long-Term Observational Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR09 5992 11:30:00 AM Pituitary Tumors-Therapeutics Oral


Katarzyna Kryzanowska-Mittermayer1, Anton Luger*2, Dominique Maiter3, Ulla Feldt-Rasmussen4, Anders F. Mattsson5, Ann-Charlotte Akerblad6, Nina Camacho-Hubner7 and Roger Abs8
1Rudolfstiftung Hospital, Vienna, Austria, 2Medical University and General Hospital of Vienna, Vienna, Austria, 3UCL St Luc Hospital, Brussels, Belgium, 4Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 5Pfizer Health AB, Sollentuna, Sweden, 6Endocrine Care, Pfizer Health AB, Sollentuna, Sweden, 7Pfizer Inc, New York, NY, 8Edegem, Belgium

 

Growth hormone deficiency (GHD) may be caused by a malignant lesion of the hypothalamic-pituitary area or the treatment of a cranial tumor or hematological malignancy. It is unclear whether patients who survived such malignancies and who are under GH replacement treatment (GHRT) are at increased risk for a second malignant neoplasia.

We assessed the incidence of new malignant neoplasia in adults on GHRT with GHD caused by a malignancy or its treatment enrolled in KIMS (Pfizer International Metabolic Database). Childhood onset (CO) and adult onset (AO) cancer survivors (CS) were compared to patients with CO idiopathic GHD (IGHD) and with AO non-functioning pituitary adenoma (NFPA), respectively.

We compared 349 CO-CS (176 f, age at disease onset 10.4 yr, age at adult GHRT start 24.5 yr, BMI 26.6 kg/m², IGF-I SDS -2.4) with 619 IGHD (221 f, age at disease onset 9.0 yr, age at adult GHRT start 28.8 yr, BMI 24.9 kg/m², IGF-I SDS -3.4). CO-CS composition: germ cell tumor (112), medulloblastoma (68), astrocytoma (53), glioma (49), leukemia or lymphoma (47), nasopharyngeal tumor (10), chordoma (3), sarcoma (7). Radiotherapy was used in 69% of CO-CS. After a mean 5.2 yr GHRT (3908 patient-years), 3 new malignant neoplasias were observed in IGHD (1 leukemia, 1 breast cancer, 1 melanoma) with a Standardized Incidence Ratio (SIR) of 0.47 (95% CI, 0.09-1.37). After a mean 4.0 yr GHRT (2192 patient-years), 16 CO-CS developed a new neoplasia (7 non-melanoma skin cancer (NMSC), 6 malignant brain neoplasia, 2 cervix uteri cancer, 1 papillary thyroid cancer). The overall SIR for CO-CS was 10.39 (95% CI, 5.93-16.87) and 6.52 (95% CI, 2.97-12.37), excluding NMSC.

We compared 174 AO-CS (74 f, age at disease onset 30.1 yr, age at GHRT start 36.0 yr, BMI 29.4 kg/m², IGF-I SDS -1.4) with 2449 NFPA (933 f, age at disease onset 46.6 yr, age at GHRT start 53.2 yr, BMI 28.9 kg/m², IGF-I SDS -1.0). AO-CS composition: germ cell tumor (59), leukemia or lymphoma (35), astrocytoma (29), glioma (18), nasopharyngeal tumor (13), medulloblastoma (9), chordoma (7), sarcoma (4). Radiotherapy was used in 59% of AO-CS and 34% of NFPA. After a mean 4.1 yr GHRT (1024 patient-years), a new malignant neoplasia occurred in 3 AO-CS (liver cancer, prostate cancer, malignant histiocytosis) SIR 1.11 (95% CI, 0.22-3.24). After a mean 5.3 yr GHRT (15215 patient-years), NFPA patients developed a new malignant neoplasia in 153 cases (34 skin lesions, 35 prostate cancers, 13 lung cancers). The SIR for AO-NFPA was 1.05 (95% CI, 0.89-1.23).

This study shows an increased risk of second malignant neoplasia in CO-CS but not in AO-CS within the time frame of this study. This illustrates the need to follow CO-CS patients for longer time periods, especially when previously irradiated.

 

Disclosure: AL: Speaker, Serono, Consultant, Ipsen, Speaker, Ipsen, Consultant, Novo Nordisk, Speaker, Novo Nordisk, Consultant, Pfizer, Inc., Speaker, Pfizer, Inc., Consultant, Serono. UF: Advisory Group Member, Pfizer, Inc.. AFM: Employee, Pfizer, Inc.. ACA: Employee, Pfizer, Inc.. NC: Employee, Pfizer, Inc.. RA: Advisory Group Member, Pfizer, Inc.. Nothing to Disclose: KK, DM

OR09-6 20890 6.0000 A Incidence of New Neoplasia in Growth Hormone Treated Adult Patients with Pituitary Deficiency Following Childhood or Adulthood Malignancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 1:00:00 PM OR09 5992 11:30:00 AM Pituitary Tumors-Therapeutics Oral


Cheuk Wun Li*1, Francesca Menconi1, Roman Osman1, Erlinda Concepcion1, Chella David2 and Yaron Tomer3
1Icahn School of Medicine at Mount Sinai, 2Mayo Clinic, 3Icahn School of Medicine at Mount Sinai and James J. Peters VA Medical Center, New York, NY

 

Graves’ disease (GD) is characterized by hyperthyroidism, production of thyroid stimulating hormone receptor (TSHR)-stimulating antibodies (TRAb), as well as infiltration of thyroid by T and B cells reactive to thyroid antigens. It is well established that the extracellular domain (ECD) of the human TSHR is the crucial antigen in GD targeted by both T-cells and TRAb. Our lab has previously shown that an HLA-DR variant that contains arginine at position 74 of the DRβ1 chain (DRb1-Arg74) is the specific MHC variant conferring risk for GD while the presence of glutamine at position 74 is protective (Ban et al., Genes Immun, 2004). While several TSHR peptides have been previously proposed as key epitopes, the major TSHR peptide triggering GD remains to be determined. We hypothesized that the key T-cell epitope in GD will bind specifically to the HLA-DRb1-Arg74 pocket. We screened 39 TSHR peptides spanning the ECD using a novel in vitro binding assay developed in our lab. This is an ELISA utilizing Baculovirus-generated recombinant HLA-DRb1-Arg74 and biotinylated TSHR peptides. We identified TSHR.132 and TSHR.197 as the best binders to DRb1-Arg74, with TSHR.132 binding with higher affinity. We then tested these peptides using a “humanized” mouse model, NOD-DR3, which are NOD mice that are null for murine MHC class II and expressing human HLA-DR3 (DRb1-Arg74 positive, confirmed by sequencing). We immunized NOD-DR3 mice with TSHR.132 and TSHR.197 and assessed T-cell responses to the peptides using CFSE test of proliferation and evaluating their cytokine responses. NOD-DR3 mice injected with TSHR.132 showed T-cell proliferation, accompanied by strong cytokine responses, but mice injected with TSHR.197 did not show T-cell responses. In conclusion, our study identified 2 TSHR epitopes; TSHR.132 and TSHR.197 bound in vitro with high affinity to HLA-DRb1-Arg74 which is the key HLA-DR pocket for development of GD. Our data suggest that TSHR.132, that has both high affinity for DRb1-Arg74 and could stimulate T-cell responses, is a major TSHR T-cell epitope. Our findings set the stage of designing inhibitors of binding of TSHR epitopes to HLA-DRb1-Arg74 as a potential novel therapeutic modality in AITD.

 

Nothing to Disclose: CWL, FM, RO, EC, CD, YT

OR11-1 21098 1.0000 A Discovering Thyroid Stimulating Hormone Receptor (TSHR) T-Cell Epitopes in Autoimmune Thyroiditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 1:00:00 PM OR11 6031 11:30:00 AM Thyroid Development, Clinical and Autoimmunity Oral


Enrico Papini*, Rinaldo Guglielmi, Irene Misischi, Filomena Maria Graziano, Agnese Persichetti, Roberta Rendina, Silvia Taccogna and Giancarlo Bizzarri
Regina Apostolorum Hospital, Albano Laziale, Italy

 

Aim of the study: to establish, in a prospective controlled series of benign thyroid cysts, long-term efficacy of percutaneous ethanol injection (PEIT), predictive factors of favourable outcome, tolerability and side-effects of the procedure.

Materials and Methods: from February 2000 to March 2004, 174 of 260 consecutive cystic thyroid lesions were included in the study. Enrolment criteria were:  a. baseline volume > 5.0 mL; b. fluid component > 50% ; c. relapse after complete drainage; d. normal thyroid function; e. repeat benign cytology. Eighty-six patients (33%) were not eligible because of indeterminate or suspicious cytology, large multinodular goiter, or thyroid hyperfunction. Cyst volume at baseline was 5 - 10 mL in 51%, 10 - 20 mL in 27%, and > 20 mL in 22% of cases. Fluid content was > 75% in 56% and 50 - 75% in 44% of the cases. The following parameters were evaluated after the baseline drainage: characteristics of fluid content, rapid refilling after aspiration, uni or multilocular structure. Treatment was performed, according to the previously described technique, by injection under US monitoring of a volume of 95% ethanol corresponding to 50% of the drained fluid. At the 1 month control, a second treatment was performed in case of a fluid relapse > 30%. Clinical and US controls were performed at 1 and 6 months, and at 1, 5 and 10 years.

Results: Mean volume decrease was -38,2% at 1 month (p=0.05), -52,1% at 6 months (P=0.04), -57,5% at 1 year (p=0,03), -56,9% at 5 years (p=0,04) and -56,4% at 10 years (p=0,04). After 10 years volume reduction was -60,8% in cysts <10 mL (p=0,04),  -59,5% in cysts 10 - 20 mL (p=0,01) and 49,3% in cysts >20mL (p=0,02). Ten-year volume reduction was significantly greater in cysts with a fluid content > 75% than in those < 75% (81% vs  51%, respectively; p=0.01). The most favourable outcome was observed in unilocular cysts with > 75% colloid content and the worst in multilocular cysts with 50-75% fluid component and rapidly refilling hemorrhagic content. No changes of thyroid function or autoimmunity were observed. The procedure was described as well tolerated in 94% of cases. Two minor complications were registered during 229 procedures (0.8%): one self- resolving neck hemathoma and one temporary dysphonia. No malignancies were observed during the follow-up period.

Conclusions: PEIT induces a rapid and long-lasting reduction of the volume of benign cystic thyroid lesions. Favourable predictive factors are a fluid content > 75%, unilocular structure and no rapid refilling after drainage. PEIT should be considered as the first line treatment for prevalently cystic benign thyroid nodules.

 

Nothing to Disclose: EP, RG, IM, FMG, AP, RR, ST, GB

OR11-2 18895 2.0000 A LONG-TERM Outcome and Predictive Factors of Efficacy of Ultrasound-Guided Ethanol Injection for Benign Cystic Thyroid Lesions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 1:00:00 PM OR11 6031 11:30:00 AM Thyroid Development, Clinical and Autoimmunity Oral


Sanjay Gawade*1, Katrin Hafen1, Urs Zumsteg2, Werner Krenger1 and Gabor Szinnai2
1Pediatric Immunology, Basel, Switzerland, 2University Children's Hospital Basel, Basel, Switzerland

 

In the differentiating tissues, reversible histone acetylation represents a major epigenetic mechanism regulating gene expression. Acetylation of core histones is regulated by histone deacetylases (HDACs) and histone acetyltransferases (HATs) in a reciprocal way. The aim of the study was to investigate the role of histone deacetylase activity for normal thyroid differentiation.

The effects of pharmacological HDAC inhibition by valproic acid (VPA 0.5-1.5mM) were investigated in an ex vivo murine embryonic thyroid organ culture model. Undifferentiated thyroids were microdissected at embryonic day 13.5 (E13.5), and analyzed at day 3 and 7 (E13.5+3d and +7d) of culture by HDAC activity assay, immunohistochemistry, morphometry, and flow cytometry (FACS).

The effect of HDAC inhibition by VPA 1.0mM induced the following epigenetic changes at E13.5+3d: First, general HDAC activity decreased significantly by 45% vs. control. Second, we observed by FACS a significant epigenetic switch on the histone tail mark H3K9 from trimethylation (H3K9me3) to acetylation (H3K9ac) compared to control in the complete thyroid as well as in the epithelial (EpCAM+), endothelial (CD31+) and mesenchymal (PDGRFalpha+) subpopulations. HDAC inhibition resulted in disturbed thyroid differentiation: By immunohistochemistry VPA treated organs showed 1) significantly lower BrdU+ cells, 2) lower number of blood vessels, and 3) decreased follicle number. These results were quantified by FACS and morphometry. By FACS, we observed at E13.5+7d a significantly decreased number of BrdU+ epithelial and endothelial cells while the number of BrdU+ mesenchymal cells did not change. As a consequence, absolute cell numbers of epithelial and endothelial cells decreased significantly (-57% and -79%, respectively) at day 7 of culture, while the mesenchymal cell mass remained constant. Morphometric analysis revealed a significant and dose dependent decrease of follicle numbers in VPA treated thyroids.

Our results show that normal HDAC activity levels are critical for growth, angiogenesis and follicle formation during thyroid differentiation in the mouse and suggest a putative new molecular mechanism for thyroid dysgenesis in the human.

 

Nothing to Disclose: SG, KH, UZ, WK, GS

OR11-3 21218 3.0000 A Histone Deacetylase Activity Is Critical for Embryonic Thyroid Growth and Differentiation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 1:00:00 PM OR11 6031 11:30:00 AM Thyroid Development, Clinical and Autoimmunity Oral


Tim IM Korevaar*1, Marco Medici2, Henning Tiemeier1, Edward Visser1, Theo J Visser3 and Robin P. Peeters2
1Erasmus Medical Center, Rotterdam, 2Erasmus Medical Center, Rotterdam, Netherlands, 3Erasmus University Medical Center, Rotterdam

 

Context: A decrease in Childhood Intelligence Quotient (IQ) is strongly and independently associated with adverse health and economic outcomes including overall mortality, life-time achievements and gross domestic product. In vitro and animal studies have shown that thyroid hormone (TH) plays a crucial role in early brain development. In humans, neurogenesis starts at the 5th week of pregnancy whereas the fetal thyroid is not fully functional until week 18-20. As a consequence, the fetus heavily depends on the supply of maternal TH during the critical early stages of intrauterine brain development. 
All published clinical studies have investigated the consequences of low TH levels, and therefore little is known about the effects of TSH and FT4 levels over the entire range, including high TH levels. For these reasons, we investigated the association between maternal TSH and FT4 levels during early pregnancy and child IQ.

Participants and Methods: Maternal serum TSH and FT4 levels were determined between pregnancy week 9 and 18, and child IQ was measured at median age 6 years in 3839 mother-child pairs from the Generation R study, an iodine sufficient population. All analyses were adjusted for hCG, TPO-antibody positivity, gestational age, maternal age, parity, smoking, ethnicity, education level, child gender and birth weight. Additionally, in a subset of mother-child pairs (N=2460) child TSH and FT4 levels at birth and at time of IQ measurement were available.

Results: There was a strong and independent, U-shaped association between maternal FT4 levels and child IQ (P=0.003). A similar association with the risk of borderline intellectual functioning (defined as IQ <85) was present (P=0.003).
We performed sensitivity analyses which investigated the maternal FT4 threshold value for significantly decreased mean child IQ levels. Low FT4 levels at or below the 8th percentile were associated with a significantly decreased mean child IQ (range -2.1 to -3.8 points; P≤0.01). For high FT4 levels, mean child IQ levels were significantly decreased at or above the 89th percentile (range -2.0 to -3.8 points; P≤0.01).
TSH levels were also associated with child IQ levels (P=0.04), but this was driven by their reflection of FT4 levels and thus not independent (P=0.37 after adjustment). Results remained unchanged after correction for hCG levels or child TSH and FT4 levels.

Conclusions: This is the first study to show that maternal FT4 levels during early pregnancy are continuously associated with child IQ levels in a U-shape manner. According to our sensitivity analyses, brain development during early life may be affected by maternal FT4 levels in up to 19% of all children. Because high FT4 levels have similar detrimental effects as low FT4 levels, L-T4 treatment aiming for high-normal thyroid function tests may not be completely without risks. 

 

Nothing to Disclose: TIK, MM, HT, EV, TJV, RPP

OR11-4 18809 4.0000 A Novel Insights into the Effects of Maternal Thyroid Function on Child IQ Reveal Detrimental Effects of High FT4 Levels 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 1:00:00 PM OR11 6031 11:30:00 AM Thyroid Development, Clinical and Autoimmunity Oral


Alon Grossman*1, Avraham Weiss2, Nira Koren Morag3, Ilan Shimon4 and Joseph Meyerovitch5
1Rabin Medical Center Beilinson Campus, Petah tikva, Israel, 2Rabin medcial Center, Beilinson Campus, Petah Tikva, Israel, 3Sackler Faculty of Medicine, Tel Aviv University, Israel, 4Rabin Medical Center and Sackler School of Medicine, Tel-Aviv University, Petah-Tiqva, Israel, 5Schneider Children's Medical Center of Israel and Sackler Faculty of Medicine, Tel Aviv University, Ramat Hasharon, Israel

 

Introduction: The association between subclinical hypothyroidism (scH) and hyperthyroidism (scHy) and mortality in the elderly is poorly defined. In this study this association was evaluated and the thyroid stimulating hormone (TSH) values associated with excess mortality in the elderly were defined.

Methods:  A computerized database of a large health care organization (Clalit Health Medical Organization) was reviewed.  All cases of known thyroid disease or cases in which thyroid medications were dispensed were excluded.  Patients older than 65 years evaluated in the years 2002-2012 (end of follow-up 31.12.12) with documented normal free T4 values were included in the analysis and were divided into 3 groups based on TSH values: normal (normal TSH), scH (TSH > 4.2 mIU/L) and scHy (TSH <0.35 mIU/L). Long term Mortality HR was compared between the three groups and a sub analysis according to TSH values was performed in those with scH and scHy.

Results:  Final analysis was performed on 17,440 individuals with subclinical thyroid disease {538 scHy (3.1%), 1956 scH (11.2%), normal 14,946 (85.7%) , average age 83±6.5 years} who were followed-up for 10 years.  Both scH (HR= 1.75 CI 1.63-1.88) and scHy (HR= 2.33 CI 2.08-2.63) were associated with significantly increased mortality that persisted on multivariate analysis for age, gender, chronic kidney disease, chronic obstructive lung disease, smoking, dementia, Parkinson's disease, cerebrovascular disease, congestive heart failure, diabetes mellitus and hypertension (scH HR=1.68 CI 1.56-1.8, ScHy HR=1.93 CI 1.7- 2.17 ).  TSH values > 6.35 mIU/L were associated with the highest mortality in those with scH, whereas in scHy, no threshold for increased mortality was identified.

Conclusions:  Both scH and scHy are associated with increased mortality in the elderly. A threshold TSH value (>6.35 mIU/L) exists for increased mortality in scH, but not in scHy.

 

Disclosure: IS: Advisory Board, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Consultant, Pfizer, Inc., Researcher, Pfizer, Inc., Speaker, Pfizer, Inc., Consultant, Chiasma. Nothing to Disclose: AG, AW, NK, JM

OR11-5 20227 5.0000 A Subclinical Thyroid Disease Increases Mortality in the Elderly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 1:00:00 PM OR11 6031 11:30:00 AM Thyroid Development, Clinical and Autoimmunity Oral


Steffy Wilhelmina Jansen1, Abimbola Akintola1, Ferdinand Roelfsema2, Evie van der Spoel1, Christa M Cobbaert2, Bart EPB Ballieux1, Peter Egri3, Zsuzanna Kvarta-Papp3, Balazs Gereben3, Csaba Fekete4, Petronella E. Slagboom1, Jeroen van der Grond5, Barbara Demeneix6, Hanno Pijl2, Rudi G J Westendorp1 and Diana van Heemst*1
1Leiden University Medical Center, Netherlands, 2Leiden University Medical Center, Leiden, Netherlands, 3Hungarian Academy of Sciences, Hungary, 4Institute of Experimental Medicine, Budapest, Hungary, 5Leiden University Medical Center, 6Muséum National d'Histoire Naturelle, Paris CEDEX 05, France

 

Only few studies have included subjects with a propensity to reach old age in good health, aiming to disentangle mechanisms contributing to staying healthier for longer. Greater longevity has been associated with higher TSH levels in humans and lower thyroid hormones (TH) levels in animals(1), but the mechanisms underlying TSH/TH differences and longevity are unknown. In this study, we assessed TSH and thyroid hormone regulation in relation with familial longevity. We included 112 subject of the Leiden Longevity study cohort consisting of 61 middle-aged offspring of nonagenarian siblings (offspring) together with 51 of their partners (controls) not originated from long-lived families. All subjects underwent measurements of energy metabolism consisting of an indirect calorimetry measurement and continuous core body temperature measurements. We measured bone resorption and bone formation markers as indicators of bone tissue turnover. In a subset of 20 offspring and 18 controls, blood was frequently sampled over 24 hours, from which circulating TSH levels were measured every 10 minutes and levels of TH every hour. Using deconvolution analysis specific features of HTP-axis function were assessed, including secretion rates, number of pulses, and regularity of pulses. Total geometric mean (95% confidence interval (CI)) TSH secretion was significantly (P < 0.007) higher in the offspring (55.0 (43.9-68.9) mU/l/24h) compared to the controls (34.4 (27.1-43.7) mU/l/24h). In line, offspring had on average, 0.8 mU/L higher serum levels of TSH at all time points. In contrast, circulating TH levels were similar between groups. TSH bioactivity was determined by measuring cAMP production in cultured Chinese hamster ovary cells stably transfected with the human TSH receptor. Offspring and partners had similar cAMP/TSH ratios indicating that their TSH molecules had similar bioactivity. Offspring and controls had similar resting metabolic rate and core body temperature. However, mean (95% CI) levels of the bone resorption marker beta-crosslaps were significantly (P = 0.02) lower in offspring (0.30 (0.28-0.34) ng/ml) compared to controls (0.36 (0.33-0.40) ng/ml), indicating a decreased bone turnover. Moreover, markers of bone renewal also tended to be lower in offspring from long-lived siblings. In conclusion, offspring of exceptionally long-lived humans are characterized by high total TSH secretion, decreased bone turnover, without changes in energy metabolism or circulating TH levels. We propose that pleiotropic effects of differences in thyroid status favor longevity by slowing rates of tissue turnover, without altering whole body metabolism. Our findings provide new targets for studying mechanisms to improve healthy life expectancy, including experimental studies to determine the effects of TSH on tissue regeneration and repair.

 

Nothing to Disclose: SWJ, AA, FR, EV, CMC, BEB, PE, ZK, BG, CF, PES, JV, BD, HP, RGJW, DV

OR11-6 21703 6.0000 A Human Longevity Is Characterized By Higher Total Thyroid Stimulating Hormone Secretion and Similar Levels of Thyroid Hormone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 1:00:00 PM OR11 6031 11:30:00 AM Thyroid Development, Clinical and Autoimmunity Oral


Corey J Lager*1, Nazanene H Esfandiari1, Angela R Subauste2, Andrew T Kraftson3, Morton B Brown1, Oliver A Varban1, Catherine K Nay3, Amy L Lockwood1 and Elif Arioglu Oral1
1Univ of Michigan, Ann Arbor, MI, 2University of Mississippi Medical Center, Jackson, MS, 3University of Michigan, Ann Arbor, MI

 

Background:Roux-en-Y Gastric Bypass (GB) and Sleeve Gastrectomy (SG) are the most common bariatric procedures used to treat obesity and its metabolic complications. It has been proposed that these surgeries result in comparable long-term outcomes.

Methods:Using data from the UMHS Post-Bariatric Surgery Program, we performed a retrospective analysis to compare weight loss and change in BP, BMI, A1C, lipids, blood indices as well as common vitamin levels between surgeries. Serum creatinine was evaluated as an indirect marker of lean mass. Data were collected at baseline and 2, 6, 12, and 24 months (m) post-surgery. This analysis does not include the early (30-day) post-operative period and the data on immediate surgical complications. Changes between time points and baseline were compared between groups by the Wilcoxon rank sum test. Results are reported as mean±SE.

Results: Data from 392 patients post-GB (age 44±1 years, 81% females) and 337 patients post-SG (age 45±1 years, 77% females) who had their surgeries at our institution from 1/1 2008 to 11/20/2013 were included. To date, 269 GB and 203 SG patients completed 12m follow up and of these 186 GB and 89 SG had 24m follow up. At baseline, BMI and weight were significantly lower in the GB group compared to the SG group (47.2±0.4 kg/m2 and 133±1 kg vs. 49.8±0.5 kg/m2 and 141±2 kg, p<0.0001). GB experienced greater and more rapid weight loss: GB group lost 68.6±2.6 % of excess body weight by 12m vs. 55.0±1.4 % noted in SG group (p<0.0001). This difference was preserved at 24m (65.6±4.1% vs.52.0 ±2.2 %, respectively, p<0.0001). HbA1C improved in both groups with a decrease of 1.40±0.2% following GB and 0.75±0.15% following SG (p =0.01 at 12m). The GB group displayed a fall in serum creatinine that reached statistical difference at 2m and sustained for long-term while the SG group experienced a less remarkable decrease in serum creatinine (0.10±0.01 mg/dL following GB vs 0.04±0.01 following SG, p<0.0001 at 12 m). Both groups had a fall in Hemoglobin (Hb) at 2m, with GB patients displaying significantly greater fall compared to SG (1.14±0.08 g/dL vs. 0.71±0.07 g/dL, p= 0.0002). The fall in Hb was not protracted and improved back to baseline by 6m. We did not observe a significant difference with respect to circulating B12 or Vitamin D levels at baseline or longitudinally; however, patients completing studies especially at later time points were not sufficient to conclude on true differences between the two groups.

Conclusions: Our data demonstrate greater weight loss and metabolic improvements in patients undergoing GB when compared to SG after 2 years. GB patients experienced a larger decrease in Hb within the first two months, and a sustained decrease in creatinine. A consideration of immediate surgical complications and prospective longitudinal data are required in order to truly assess risks and benefits of SG and GB.

 

Disclosure: EAO: Principal Investigator, GI Dynamics. Nothing to Disclose: CJL, NHE, ARS, ATK, MBB, OAV, CKN, ALL

OR07-1 19028 1.0000 A The Two Obesity Surgeries: Are They Truly Comparable? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 1:00:00 PM OR07 6038 11:30:00 AM Obesity: Clinical Studies Oral


David C Lau*1, Melanie Davies2, F Xavier Pi-Sunyer3, John Wilding4, Linda Shapiro Manning5, Christine Bjørn Jensen5 and Sten Madsbad6
1University of Calgary, Calgary, AB, Canada, 2University of Leicester, Leicester, United Kingdom, 3St Luke's Roosevelt Hosp, New York, NY, 4University of Liverpool, Liverpool, United Kingdom, 5Novo Nordisk A/S, Søborg, Denmark, 6Hvidovre Hospital, Hvidovre, Denmark

 

Liraglutide is a glucagon‐like peptide‐1 analog approved for type 2 diabetes (T2D) at doses up to 1.8 mg. We present here data on the effects of liraglutide 3.0 mg on glycemic excursions and hypoglycemia in overweight and obese adults without T2D from the 56-week SCALE Obesity and Prediabetes trial (Clinicaltrials.gov ID:NCT01272219).

Individuals (BMI ≥27 kg/m2 with ≥1 comorbidity, or ≥30 kg/m2; 78.5% female, 61.2% with prediabetes, 45.1 yrs, body weight 106.2 kg, BMI 38.3 kg/m2 [all means]) were randomized 2:1 to receive once-daily liraglutide 3.0 mg (n=2487) or placebo (n=1244), both as adjunct to 500 kcal/day deficit diet and increased physical activity (≥150 min/week). Changes in fasting (FPG) and postprandial plasma glucose (PPG) (determined during an oral glucose tolerance test; OGTT), were assessed at baseline and week 56. Hypoglycemic events were reported as adverse events (AEs), by individuals based on symptoms (spontaneous, not biochemically confirmed) between visits, or by investigators based on glucose values ≤70 mg/dL during visits (including OGTT), irrespective of symptoms (paleness, shaking, sweating, increased pulse/heartbeat, hunger, vision disorder, unusual behavior or drowsiness).

From baseline to 56 weeks, greater reductions were seen with liraglutide vs placebo in body weight (-8.0% vs -2.6%), FPG (-7.1 mg/dL vs. 0.1 mg/dL) and PPG (-46.8 mg/dL vs -10.4 mg/dL) [observed means LOCF; p<0.0001, ANCOVA]. Improvements in glycemia were more pronounced in individuals with prediabetes than without.

No hypoglycemia AEs required third-party assistance. Similar proportions of individuals on liraglutide (1.3%) and placebo (1.0%) reported hypoglycemia based on symptoms between visits. More individuals with liraglutide vs. placebo had biochemical hypoglycemia AEs during FPG visits (3.6% vs 0.8%) or OGTT (8.3% vs 1.4%), consistent with the observed effects of liraglutide on FPG/PPG. Of biochemical events reported during FPG and OGTT visits, respectively, 31.3% and 41.5% with liraglutide vs. 30.0% and 33.0% with placebo were asymptomatic. As expected with the glucose dependency of liraglutide, only a small proportion of events reported at visits were associated with PG <56 mg/dL; a more clinically relevant threshold for hypoglycemia in individuals without T2D (FPG visits: 0.1% vs 0%, OGTT visits: 2.3% vs 0%, for liraglutide and placebo, respectively). Overall hypoglycemia AEs were less common in those with prediabetes than without (liraglutide: 9.4% vs 15.9%; placebo 2.6% vs 4.3%, respectively), consistent with a higher mean baseline FPG and PPG.

In conclusion, in overweight and obese individuals without diabetes, liraglutide 3.0 mg, as adjunct to diet and exercise, was associated with greater reductions in fasting and postprandial glucose compared with diet and exercise alone. Clinically significant hypoglycemia with glucose <56 mg/dL was rare with both treatments.

 

Disclosure: DCL: Investigator, Astra Zeneca, Investigator, Boehringer Ingelheim, Investigator, Bristol-Myers Squibb, Investigator, Eli Lilly & Company, Investigator, Novo Nordisk, Advisory Group Member, Amgen, Advisory Group Member, Astra Zeneca, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Janssen, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Novo Nordisk, Advisory Group Member, Roche Pharmaceuticals, Advisory Group Member, Valeant, Speaker Bureau Member, Amgen, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Janssen, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Valeant. MD: Advisory Group Member, Novo Nordisk, Consultant, Novo Nordisk, Investigator, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Advisory Group Member, Sanofi, Consultant, Sanofi, Investigator, Sanofi, Speaker Bureau Member, Sanofi, Advisory Group Member, Eli Lilly & Company, Consultant, Eli Lilly & Company, Investigator, Eli Lilly & Company, Speaker Bureau Member, Eli Lilly & Company, Advisory Group Member, Merck Sharp & Dohme, Consultant, Merck Sharp & Dohme, Speaker Bureau Member, Merck Sharp & Dohme, Advisory Group Member, Boehringer Ingelheim, Consultant, Boehringer Ingelheim, Speaker Bureau Member, Boehringer Ingelheim, Advisory Group Member, Astra Zeneca, Consultant, Astra Zeneca, Speaker Bureau Member, Astra Zeneca, Advisory Group Member, Janssen, Consultant, Janssen, Speaker Bureau Member, Janssen, Speaker Bureau Member, Mitsubishi Tanabe Pharma Corp. FXP: Advisory Group Member, Novo Nordisk, Advisory Group Member, Weight Watchers International, Advisory Group Member, Johnson &Johnson, Advisory Group Member, Vivus USA, Advisory Group Member, Eisai, Advisory Group Member, Zafgen. JW: Advisory Group Member, Astra Zeneca, Speaker Bureau Member, Astra Zeneca, Investigator, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Advisory Group Member, Bristol-Myers Squibb, Investigator, Bristol-Myers Squibb, Speaker Bureau Member, Bristol-Myers Squibb, Advisory Group Member, Janssen, Speaker Bureau Member, Janssen, Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Investigator, Novo Nordisk, Speaker Bureau Member, Merck & Co., Consultant, Pfizer Global R&D. LSM: Employee, Novo Nordisk. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. SM: Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Investigator, Novo Nordisk.

OR07-2 19540 2.0000 A Hypoglycemia Reported with Liraglutide 3.0 Mg in Overweight and Obese Adults with and without Prediabetes: Results of the Randomized, Double-Blind, Placebo-Controlled 56-Week Scale Obesity and Prediabetes Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 1:00:00 PM OR07 6038 11:30:00 AM Obesity: Clinical Studies Oral


Jovanna Dahlgren*1, Torsten Olbers2, Eva Gronowitz2, Carl-Erik Flodmark3 and Claude N Marcus4
1Inst of Clinical Sci, Gothenburg, Sweden, 2The University of Gothenburg, Gothenburg, Sweden, 3Skånes University hospital SUS, Malmö, Sweden, 4Karolinska Institute, Stockholm, Sweden

 

Introduction

Few studies have followed prospectively the long-term outcome of gastric bypass surgery in children and adolescents. In morbid obese adults, gastric bypass improves significantly cardiovascular profiles and the weight loss obtained is maintained over several decades. Here we present five-year data from the prospective non-randomized controlled study; Adolescent Morbid Obesity Surgery study (AMOS) using laparoscopic Roux-en-Y gastric bypass (LRYGB).

Methods

Eighty-one young pubertal non-syndromic obese adolescents (13.0 to 17.9 years of age, Tanner stage >3) underwent LRYGB. Inclusion criteria was BMI >40 or >35 with co-morbidities. Follow up visits were scheduled at one, two and five years post-surgery. Body composition was examined with DEXA (Lunar). A group of BMI and age matched adolescents were identified in a national registry and were assessed after five years. A BMI and gender matched adult group (35-45 years of age) undergoing LRYGB was also followed prospectively.

Results

Mean inclusion BMI was 45.5 kg/m2 in young surgically treated (YST), 42.2 kg/m2 in adolescent controls (AC) and 43.5 kg/m2 in adult surgically treated (AST). At five years postop, BMI of YST was 32 kg/m2 (total weight loss 27%, p<0.001) while BMI of AC was 43 kg/m2 (gained 10% in weight) and 31 of AST (weight loss 29%, p<0.001). In YST, waist circumference decreased from 134 to 98 cm (p<0.001) and body composition changes included a reduction in the percentage fat mass (51.8% to 40.9%, p<0.0001) as well as a relative increase in lean mass (47.0% to 56.8%, p<0.0001) over the two post-surgery years. Boys lost more fat mass than girls (-17.3% vs. -9.5%, p<0.0001). Fasting insulin in YST decreased from 32 to 7 mU/L the first post-surgery year and continued unchanged low during two and five years post-surgery, whereas levels in AC were above 30 mU/L (p<0.001). The same pattern was seen for supersensitive CRP, which decreased significantly in YST from 7.2 mg/L to 2.5 the first year post-surgery. 

Conclusion

Laparoscopic gastric bypass appears equally effective in adolescents as in adults regarding weight loss and metabolic improvements up to five years after surgery.  There seems to be substantial gender difference in changes in body composition, with increased loss of fat mass in males. If this has an implication on differences in long-term metabolic outcomes between genders merits further evaluation.

 

Nothing to Disclose: JD, TO, EG, CEF, CNM

OR07-3 21767 3.0000 A A Swedish Nationwide Study on Metabolic Longterm Outcome of Laparoscopic Roux-En-Y Gastric Bypass for Children with Severe Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 1:00:00 PM OR07 6038 11:30:00 AM Obesity: Clinical Studies Oral


Ovidiu A Galescu*1, Andrew Paul Demidowich1, Annie M Altschul1, Sheila M Brady1, Sara A Armaiz Flores1, Van S Hubbard2 and Jack Adam Yanovski1
1Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 2National Institute of Diabetes and Digestive and Kidney Diseases/NIH, Bethesda, MD

 

Background:Pediatric obesity is associated with advancement of skeletal maturation and increase in height during childhood. The accuracy of skeletal age-based adult height predictions among obese children has not been well established. We hypothesized that skeletal age-based height predictions would overestimate final adult height among obese (OB) as compared to non-obese (NO) children.

Methods: A sample of NO (BMI percentile <95th %) and OB (BMI percentile ≥95th %) children ages 5.5- 15y were prospectively enrolled for longitudinal investigation. Age- and sex-specific BMI percentiles were calculated according to CDC 2000 standards. Skeletal age was assigned using the Greulich and Pyle atlas and predicted adult height (PH) was calculated according to the Bayley-Pinneau tables. Participants were followed to near-final adult height (FH) as determined by age / skeletal age >14y for girls; >15.5y for boys).

Statistics:The primary analysis was ANCOVA, with the difference between PH and FH (PH-FH) as the dependent variable, and age, sex, race, obesity status, and the sex * obesity status interaction as independent variables.

Results:A total of 191 patients (mean age 9.3±1.8 y; 52.9% female and 47.1% male; 60.2% white, 37.7% black, 2.1% Asian) were enrolled and followed to FH.  At baseline, the mean bone age was 9.9±1.9y; 50% were prepubertal and 34% were obese.  There were no statistically significant differences between the NO and OB groups in sex, race, or mid-parental target height. At baseline, the OB children were younger than NO (8.7±1.4 vs. 9.5±1.8y, p=0.002) but the bone age relative to chronological age was significantly greater among the OB group (+1.5±1.1 vs. +0.3±0.9y, p<0.0001) and height SD score was significantly greater in the OB group (+1.45±0.97 vs. +0.29±0.99, p<0.0001).  Final adult height was documented at mean age 19.9 ±3.2y. In ANCOVA, PH-FH was significantly predicted by sex, age, and the interaction between sex and obesity status. Among obese girls FH was significantly underestimated by PH (-2.3±1.1, CI -4.5 to -0.08cm, p=0.035); however, among obese boys, FH appeared to be overestimated by PH (+2.4±1.2, CI -0.01 to +4.7cm). Among non-obese children, there were no significant differences found between FH and PH.

Discussion: In a large pediatric cohort enriched for obesity, followed prospectively to adult height, obese children were initially taller and had advanced skeletal age, consistent with adipose tissue aromatase action increasing circulating estrogens. Surprisingly in obese girls, despite their tendency to have earlier onset of puberty, FH was underestimated, while in obese boys, who generally show a delayed entry into gonadarche, FH showed a trend towards being overestimated by the Bayley-Pinneau method. These data suggest the Bayley Pinneau tables for predicting adult height using skeletal age may need to be revised to take into account obesity.

 

Disclosure: JAY: Principal Investigator, Zafgen. Nothing to Disclose: OAG, APD, AMA, SMB, SAA, VSH

OR07-4 19385 4.0000 A Obesity and Predicted Height in Children: A Longitudinal Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 1:00:00 PM OR07 6038 11:30:00 AM Obesity: Clinical Studies Oral


Lena MS Carlsson*1, Kajsa Sjoholm1, Per-Arne Svensson1, Peter Jacobson1, Lars Sjöström1 and Markku Peltonen2
1The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden, 2National Institute for Health and Welfare, Helsinki, Finland

 

Background: Obesity increases the risk for diabetes, and diabetes is associated with microvascular and macrovascular complications. We have shown that bariatric surgery strongly reduces the risk for diabetes in obese patients (1) and prevents microvascular and macrovascular complications in obese patients with diabetes (2). It is unknown if the prevention of diabetes by bariatric surgery also leads to reduced long-term risk for diabetes-associated complications when compared to non-surgical obesity care.

Aim: To determine the effects of bariatric surgery on the long-term risk of microvascular and macrovascular events in obese patients without diabetes at baseline.

Methods: The Swedish Obese Subjects (SOS) study is a prospective matched intervention study conducted at 25 surgical departments and 480 primary healthcare centers in Sweden. Participants were 37 to 60 years of age, and BMI was 34 or more in men and 38 or more in women. The current analyses included 3429 patients in the SOS study that did not have diabetes at baseline. Of them, 1658 patients underwent bariatric surgery (19% banding, 69% vertical banded gastroplasty, 12% gastric bypass) and 1771 obese matched controls given usual care. Microvascular (eyes, kidneys and peripheral nerves) and macrovascular (legs, heart and brain) events requiring hospital or specialist outpatient treatment or that were associated with death during follow-up were traced by searching the Swedish Cause of Death Register and the Swedish National Patient Register. Median follow up time was 18 years.

Results: Bariatric surgery reduced the incidence of microvascular plus macrovascular events, whichever came first, in patients without diabetes at baseline (566 and 411 events in the control and surgery groups, respectively; HR=0.73; 95%CI: 0.64-0.82; P<0.001). When the incidence of microvascular and macrovascular events were analyzed separately, both were reduced in the surgery group compared to controls (HR=0.48; 95%CI:0.38-0.60; P<0.001 and HR=0.80; 95%CI:0.70-0.92; P<0.002 for microvascular and macrovascular events, respectively). The reduction of the incidence of microvascular plus macrovascular events was more pronounced in patients with prediabetes at baseline compared to those with normal glucose status (HR=0.52; 95%CI: 0.40-0.68; P<0.001 and HR=0.79; 95%CI: 0.68-0.91; P<0.001, respectively; interaction P-value=0.005).

Conclusion: Bariatric surgery reduced the long-term risk of diabetes-associated vascular disease in obese patients without diabetes at study start.

 

Disclosure: LMC: Speaker, Johnson &Johnson. LS: Speaker, Astra Zeneca, Speaker, Johnson &Johnson. Nothing to Disclose: KS, PAS, PJ, MP

OR07-5 19794 5.0000 A Bariatric Surgery Reduces the Long-Term Incidence of Diabetes-Associated Vascular Disease in Initially Non-Diabetic Obese Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 1:00:00 PM OR07 6038 11:30:00 AM Obesity: Clinical Studies Oral


Ralph DeFronzo1, Richard Mauritz Bergenstal2, Melanie Davies3, Robert Kushner4, Trine Vang Skjøth5, Birgitte Claudius5 and Ofri Mosenzon*6
1University of Texas Hlth Science Ctr, San Antonio, TX, 2HealthPartners Institute, Minneapolis, MN, 3University of Leicester, Leicester, United Kingdom, 4Northwestern University Feinberg School of Medicine, Chicago, IL, 5Novo Nordisk A/S, Søborg, Denmark, 6Hadassah University Hospital, Jerusalem, Israel

 

SCALE Diabetes (NCT01272232); a 56-week, randomized, double-blind, placebo-controlled trial evaluating the efficacy and safety of liraglutide for weight management in overweight/obese adults with T2D. 846 individuals were randomized 2:1:1 to liraglutide 3.0 mg (n=423), 1.8 mg (n=211) or placebo (n=212) as an adjunct to diet and exercise. 50% male, mean age 54.9 years, BMI 37.1 kg/m2, A1c 7.9%, and T2D duration 7.3 years.

This subgroup analysis compares efficacy and safety in responders (weight loss of ≥5% from baseline at week 56) vs non-responders. Changes from baseline data are least-squares means (efficacy) or observed means (safety) with LOCF. Pulse data are observed means for completers.

Mean weight loss for responders vs non-responders was 10.3% vs 1.6% with liraglutide 3.0 mg, 10.4% vs 1.3% with liraglutide 1.8 mg and 9.7% vs 0.7% with placebo, although more individuals in the liraglutide 3.0 mg (49.9%, n=205) and 1.8 mg (35.6%, n=72) groups than the placebo group (13.8%, n=29) were responders (p<0.0001).

Changes in A1c from baseline with liraglutide 3.0 mg, 1.8 mg and placebo were -1.6 and -1.5 vs -1.1% for responders, and -1.0, -1.0% and -0.2% for non-responders. SBP was reduced by -5.0, -6.2 and -5.3 mmHg in responders with liraglutide 3.0 mg, liraglutide 1.8 mg and placebo respectively and -0.5, -1.9 and 0.5 mmHg in non-responders. Physical function scores using IWQoL-LITE improved by 19.0, 16.4 and 15.5 with liraglutide 3.0 mg, liraglutide 1.8 mg and placebo, respectively, in responders vs 11.1, 10.4 and 7.7 in non-responders.

In responders vs non-responders adverse events (AEs) were reported by 96% vs 92% with liraglutide 3.0 mg, 96% vs 90% with liraglutide 1.8 mg and 94% vs.85% with placebo. For serious AEs no marked differences between responders and non-responders were observed. The most frequent AEs were GI disorders, which were more frequent in responders vs non-responders for liraglutide 3.0 mg (76% vs 55%) but not different for liraglutide 1.8 mg (58% vs 57%) or placebo (41% vs 39%). Rates (events/patient year) of documented symptomatic hypoglycemia (plasma glucose ≤56 mg/dL) were similar in responders vs non-responders across all groups, liraglutide 3.0 mg: 0.9 vs 0.8; liraglutide 1.8 mg: 0.8 vs 1.1; placebo: 0.1 vs 0.3. Mean (SD) change in pulse rate from baseline for liraglutide 3.0 mg, liraglutide 1.8 mg and placebo was 1.3 (9.5), 2.0 (10.7) and -4.4 (10.1) bpm for responders and 3.5 (10.2), 3.1 (10.1) and -1.2 (9.0) bpm for non-responders.

In conclusion, a higher proportion of individuals achieved a clinically meaningful ≥5% weight loss at 56 weeks with liraglutide 3.0 mg and 1.8 mg, compared with placebo. The responder groups had a total weight loss at 56 weeks of approx 10%. Responders in the liraglutide groups had greater improvements in A1c, indicating an additional benefit of treatment above that attributed to weight loss. Similar overall incidence of AEs was observed in subgroups.

 

Disclosure: RD: Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Takeda, Advisory Group Member, Amylin Pharmaceuticals, Advisory Group Member, Novo Nordisk, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Lexicon Pharmaceuticals, Inc., Advisory Group Member, Astra Zeneca, Investigator, Amylin Pharmaceuticals, Investigator, Takeda, Investigator, Bristol-Myers Squibb, Investigator, Boehringer Ingelheim, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Jansen Pharmaceuticals. RMB: Advisory Group Member, Abbott Laboratories, Investigator, Abbott Laboratories, Advisory Group Member, Bayer, Inc., Investigator, Bayer, Inc., Advisory Group Member, Valeritas Inc, Investigator, Becton Dickinson, Advisory Group Member, Boehringer Ingelheim, Investigator, Boehringer Ingelheim, Advisory Group Member, Bristol-Myers Squibb, Investigator, Bristol-Myers Squibb, Advisory Group Member, Calibra, Investigator, Calibra, Advisory Group Member, Eli Lilly & Company, Investigator, Eli Lilly & Company, Advisory Group Member, Halozyme, Investigator, Halozyme, Advisory Group Member, Helmsley Trust, Investigator, Helmsley Trust, Advisory Group Member, Hygieia, Investigator, Hygieia, Advisory Group Member, Johnson &Johnson, Investigator, Johnson &Johnson, Advisory Group Member, Medtronic Minimed, Investigator, Medtronic Minimed, Investigator, Merck & Co., Advisory Group Member, Novo Nordisk, Investigator, Novo Nordisk, Investigator, NIH, Investigator, ResMed, Advisory Group Member, Roche Pharmaceuticals, Investigator, Roche Pharmaceuticals, Advisory Group Member, Sanofi, Investigator, Sanofi, Advisory Group Member, Takeda, Investigator, Takeda. MD: Advisory Group Member, Novo Nordisk, Consultant, Novo Nordisk, Investigator, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Advisory Group Member, Sanofi, Consultant, Sanofi, Investigator, Sanofi, Speaker Bureau Member, Sanofi, Advisory Group Member, Eli Lilly & Company, Consultant, Eli Lilly & Company, Investigator, Eli Lilly & Company, Speaker Bureau Member, Eli Lilly & Company, Advisory Group Member, Merck Sharp & Dohme, Consultant, Merck Sharp & Dohme, Speaker Bureau Member, Merck Sharp & Dohme, Advisory Group Member, Boehringer Ingelheim, Consultant, Boehringer Ingelheim, Speaker Bureau Member, Boehringer Ingelheim, Advisory Group Member, Astra Zeneca, Consultant, Astra Zeneca, Speaker Bureau Member, Astra Zeneca, Advisory Group Member, Janssen, Consultant, Janssen, Speaker Bureau Member, Janssen, Speaker Bureau Member, Mitsubishi Tanabe Pharma Corp. RK: Advisory Group Member, Novo Nordisk, Advisory Group Member, Vivus USA, Advisory Group Member, Zafgen, Advisory Group Member, Retrofit, Consultant, Eisai, Consultant, Takeda, Investigator, Weight Watchers, Investigator, Aspire Bariatrics. TVS: Employee, Novo Nordisk, Employee, Novo Nordisk. BC: Employee, Novo Nordisk, Employee, Novo Nordisk. OM: Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Novo Nordisk, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Astra Zeneca, Speaker Bureau Member, Merck Sharp & Dohme, Speaker Bureau Member, Novartis Pharmaceuticals, Speaker Bureau Member, Sanofi, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Astra Zeneca, Investigator, Novo Nordisk, Advisory Group Member, Sanofi, Advisory Group Member, Novartis Pharmaceuticals.

OR07-6 19542 6.0000 A Efficacy and Safety of Liraglutide 3.0 Mg and 1.8 Mg in Weight Loss Responders from Overweight/Obese  Adults with Type 2 Diabetes (T2D): A Subgroup Analysis of the Scale Diabetes Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 1:00:00 PM OR07 6038 11:30:00 AM Obesity: Clinical Studies Oral


Adi Cohen*1, David W Dempster2, Hua Zhou2, Robert R Recker3, Joan M. Lappe3, Serge Cremers4, Ralph Müller5, Alexander Zwahlen5, Mafo Kamanda-Kosseh1, Mariana Bucovsky1, Emily M. Stein1, Tom Nickolas1 and Elizabeth Shane1
1Columbia University, New York, NY, 2Helen Hayes Hospital, West Haverstraw, NY, 3Creighton University, Omaha, NE, 4Columbia University, College of Physicians and Surgeons, New York, NY, 5ETH Zurich, Institute for Biomechanics

 

Excess visceral adipose tissue (VAT) is associated with low BMD and poor bone structure. We recently reported that healthy premenopausal women with high DXA trunk fat, a surrogate for VAT, had significantly lower trabecular (Tb) bone volume fraction (BV/TV), Tb number and thickness, lower bone formation rate (BFR) on bone biopsies and serum bone formation markers. In postmenopausal women, serum LDL is inversely and HDL directly related to BMD. We therefore investigated relationships between lipids, BMD, bone microstructure and remodeling in premenopausal women.

In 40 healthy premenopausal women (37 ± 8 yrs; BMI 20-39 kg/m2) with normal BMD by DXA and no history of fracture, we measured body composition by DXA; Tb BV/TV, microstructure and BFR/BS on tetracycline-labeled bone biopsies; and serum IGF-1, sclerostin, bone turnover markers (BTM), HDL, TG, and calculated LDL on fasting morning serum.

As expected, LDL (±SD: 100 ± 25 mg/dL) and TG (87 ± 53 mg/dL) were directly and HDL (50 ± 15 mg/dL) inversely related to BMI and DXA trunk fat. HDL was directly related to Tb BV/TV (r=0.40; p=0.01) and BFR (0.40; p=0.01). We compared 23 women with HDL <50 mg/dL, the metabolic syndrome cutoff, to 17 with normal HDL (63 ± 11 mg/dL). BMI (27.8 ± 4.9 vs 23.0 ± 2.3 kg/m2) and %DXA trunk fat (36 ± 8 vs 27 ± 8) were higher in the low HDL group (both p<0.001). Age, BMD, HOMAIR, serum glucose, PTH, 25-OHD and reported exercise did not differ. The low HDL group had significantly lower BV/TV (21.0 ± 7.3 vs 27.3 ± 6.8%; p=0.009) and Tb thickness (148 ± 36 vs 179 ± 32 µm; p=0.008), and lower BFR (0.006 ± 0.004 vs 0.012 ± 0.008 mm2/mm/yr; p=0.01) and serum markers of resorption (C-telopeptide, 214 ± 78 vs 386 ± 241 pg/mL; p=0.01) and formation (osteocalcin, 13 ± 5 vs 19 ± 10 ng/mL, p=0.04; and PINP, 42 ± 11 vs 53 ± 23 µg/L, 0.07). The low HDL group also had significantly lower IGF-1 (168 ± 40 vs 206 ± 65 ng/mL; p=0.03) and higher sclerostin (0.50 ± 0.19 vs 0.36 ± 0.10 ng/mL; p=0.01), both potential mediators of the detrimental relationship between fat and bone. Relationships between HDL and Tb BV/TV and BFR were unaffected by controlling for reported exercise but no longer significant after controlling for DXA trunk fat.  Relationships between HDL and Tb BV/TV remained significant after controlling for serum IGF-1 (0.38; p=0.018) and sclerostin (0.33; p=0.046). Relationships between HDL and BFR remained significant after controlling for serum IGF-1 (0.36; p=0.029) but were attenuated (0.28; p=0.093) by controlling for sclerostin.  

In summary, healthy premenopausal women with HDL levels consistent with the definition of metabolic syndrome (< 50 mg/dL) were distinguished by significantly lower Tb bone formation and bone volume on bone biopsies. We conclude that HDL is an easily measured marker of excess VAT that may identify young women at risk for poor bone health for studies of the skeletal effects of interventions that promote weight loss or increase exercise.

 

Nothing to Disclose: AC, DWD, HZ, RRR, JML, SC, RM, AZ, MK, MB, EMS, TN, ES

LB-OR01-1 22931 1.0000 A Healthy Premenopausal Women with Low HDL (less than 50 mg/dL) Have Significantly Lower Trabecular Bone Volume and Bone Formation Rate 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM LB-OR01 6268 11:30:00 AM New Discoveries in Bone Health and Disease Oral


Skorn Ponrartana*1, Patricia C Aggabao1, Naga L Dharmavaram1, Carissa L Fisher1, Philippe Friedlich1, Sherin U Devaskar2 and Vicente Gilsanz1
1Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, 2Mattel Children's Hospital, UCLA, Los Angeles, CA

 

Background: The cross-sectional area (CSA) of the vertebra is smaller in females than in males throughout childhood, adolescence, and at the timing of peak bone mass – a major determinant of osteoporosis and future fracture risk. We examined whether these sex-related differences in the development of the axial skeleton are also present at birth.

Methods: Vertebral CSA, vertebral height, and intervertebral disc height were measured from the sixth thoracic to the fifth lumbar vertebrae using magnetic resonance imaging (MRI) in 70 healthy full-term newborns (35 male and 35 female). Additionally, measures of the length and CSA of the humerus, musculature, and adiposity were obtained.

Results: Weight, body length, head and waist circumferences, and MRI measures of musculature and adiposity did not significantly differ between sexes (all P’s ≥ 0.060). Compared to newborn boys, girls had significantly smaller vertebral cross-sectional dimensions (1.465 ± 0.11 vs. 1.309 ± 0.12; P < 0.0001) – a disparity that was independent of gestational age, birth weight, and body length. In contrast, sexes were monomorphic with regard to vertebral height, intervertebral disc height, and spinal length (all P’s ≥ 0.108). There were also no sex differences in the length or cross-sectional dimensions of the humerus (both P’s ≥ 0.151).

Conclusions: Factors related to sex influence fetal programming of the axial skeleton. The smaller vertebral CSA in females is associated with greater flexibility of the spine that could represent the human adaptation to fetal load. Unfortunately, it also imparts a mechanical disadvantage that increases stress within the vertebrae for all physical activities and the susceptibility for fragility fractures later in life.

 

Nothing to Disclose: SP, PCA, NLD, CLF, PF, SUD, VG

LB-OR01-2 22524 2.0000 A Differential Effect of Sex in Newborn Vertebrae and Risk of Osteoporosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM LB-OR01 6268 11:30:00 AM New Discoveries in Bone Health and Disease Oral


Paul D Miller*1, Benjamin Zev Leder2, Gary Hattersley3, Edith Lau4, Peter Alexandersen5, Tomas Hala6, Sorica Mustatea7, Bettina Storgaard Nedergaard8, Annesofie Krogsaa9, Jan Slesinger10, Cristiano AF Zerbini11, Ivo Valter12, Zydrune Visockiene13, Beata Jendrych14, Carolina Aguiar Kulak15, Farid Marquez16, Alan G Harris17, Gregory C Williams3, Ming-yi Hu18, Bente Juel Riis19, Luis Augusto Russo20 and Claus Christiansen21
1Colorado Center for Bone Research, Lakewood, CO, 2Harvard Medical School, Boston, MA, 3Radius Health, Inc, Waltham, MA, 4CCBR Hong Kong, China, 5CCBR Vejle, Denmark, 6CCBR Pardubice, Czech Republic, 7CCBR Bucharest, Romania, 8CCBR Aalborg, Denmark, 9CCBR Ballerup, Denmark, 10CCBR Brno, Czech Republic, 11Centro Paulista de Investigação Clinica, São Paulo, Brazil, 12Center for Clinical and Basic Research, Tallinn, Estonia, 13CCBR Vilnius, Lithuania, 14CCBR Warsaw, Warsaw, Poland, 15Federal University of Parana, Curitiba, Brazil, 16Palm Springs Research Center, Hialeah, FL, 17Radius Health, Inc., Waltham, MA, 18Radius Health Inc, Waltham, MA, 19Nordic Biosciences, Copenhagen, Denmark, 20CCBR Rio De Janeiro, Rio de Janiero, Brazil, 21Nordic Bioscience, Copenhagen, Denmark

 

Abaloparatide (ABL) is an investigational osteoanabolic PTHrP analog being developed for the treatment of postmenopausal osteoporosis (PMO). In the ACTIVE double-blind, placebo-controlled (PBO) Phase 3 fracture prevention trial, 2463 PMO women were randomized to receive 18-months of either daily ABL 80-mcg SC, PBO SC or open label teriparatide (TPT) 20-mcg SC. All patients (PTS) received calcium and vitamin D supplements. 2,463 PTS were randomized (ITT population) and 1,901 (77.9%) completed. The groups were well matched for baseline demographics. PTS were 68.8 years old and the mean BMI was 25.1. 16.3% of PTS had 1 vertebral fracture, 28.2% had 2 or more vertebral fractures and 46.8% had at least 1 non-vertebral fracture. The mean spine, femoral neck and total hip baseline T-scores were -2.90, -2.14 and -1.90, respectively. Among the 2,118 PTS who had baseline and post-therapy X-rays, the fracture rate (FR) among those receiving ABL (n=690) was 0.58%, representing a reduction of new incident vertebral FR by 86% as compared to PBO PTS [n=711, FR 4.22%; (p<0.0001)]. The TPT group FR of 0.84% (n=717) was reduced by 80% (p<0.0001 versus PBO). ABL reduced non-vertebral fracture (Kaplan-Meier estimated (KM) FR=2.7%, hazard ratio=0.57, p=0.0489) and clinical fractures (KM FR=3.9%, hazard ratio=0.55, p=0.0112) versus PBO (KM non-vertebral FR=4.7%, KM clinical FR=8.3%). TPT was not significantly different from PBO in non-vertebral fracture (KM FR=3.3%, hazard ratio=0.72, p=0.2157) or clinical fracture (KM FR=4.8%, hazard ratio=0.71, p=0.1127). For wrist fractures ABL (n=824, KM FR 0.5%) and TPT (n=818, KM FR 2.0%) were not were significantly reduced compared to PBO (n=821, KM FR 1.5%); wrist FR was significantly less in ABL than the TPT group (p=0.0149). BMD increased more in ABL and TPT-treated PTS compared to PBO at the spine, femoral neck and hip at 6, 12 and 18 months (p<0.0001 for all comparisons). ABL also increased BMD at the hip at months 6, 12 (both p<0.0001) and 18 (p=0.0003), in the femoral neck at 6, 12 (both p<0.0001) and 18 (p=0.0016) and in the spine at 6 (p<0.0001) and 12 (p=0.0087) significantly more than TPT. ABL was well tolerated the most frequently reported adverse events were back pain, arthralgia, upper respiratory tract infection, hypercalciuria and dizziness. The overall incidence of hypercalcemia (HPC) based on albumin corrected serum calcium measured pre and post injection (4 hours) were 0.37%, 3.41%, and 6.36% for the PBO, ABL and TPT groups, respectively. Both ABL and TPT groups had significantly higher rates of HPC than PBO (p<0.0001), but for ABL was significantly less frequent than for TPT (p=0.0055). These results demonstrate that ABL reduces the incidence and risk of vertebral, non-vertebral, and clinical fractures in in women with PMO and suggest that ABL may prove to be an effective and safe treatment option in the management of PMO.

 

Disclosure: PDM: Principal Investigator, Radius. BZL: Principal Investigator, Radius. GH: Employee, Radius, Employee, Radius. EL: Principal Investigator, Radius. PA: Principal Investigator, Radius. TH: Principal Investigator, Radius. SM: Principal Investigator, Radius. BSN: Principal Investigator, Radius. AK: Principal Investigator, Radius. JS: Principal Investigator, Radius. CAZ: Principal Investigator, Radius. IV: Principal Investigator, Radius. ZV: Principal Investigator, Radius. BJ: Principal Investigator, Radius. CAK: Principal Investigator, Radius. FM: Principal Investigator, Radius. AGH: Employee, Radius, Employee, Radius. GCW: Employee, Radius, Employee, Radius. MYH: Employee, Radius, Employee, Radius. BJR: Collaborator, Radius. LAR: Collaborator, Radius. CC: Collaborator, Radius.

LB-OR01-3 22577 3.0000 A Effects of Abaloparatide on Vertebral and Non-Vertebral Fracture Incidence in Postmenopausal Women with Osteoporosis - Results of the Phase 3 Active Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM LB-OR01 6268 11:30:00 AM New Discoveries in Bone Health and Disease Oral


Michael P. Whyte*1, Katherine L Madson2, Craig Frank Munns3, Amy L Reeves2, Kenji Fujita4, Hui Zhang5 and Nick James Bishop6
1Shriners Hosp for Children, Saint Louis, MO, 2Shriners Hospital for Children, St. Louis, MO, 3The Children's Hospital at Westmead, Sydney, Australia, 4Alexion Pharmaceuticals, Inc., Cheshire, CT, 5Alexion Pharmaceuticals, Cheshire, CT, 6Univ of Sheffield, Sheffield, United Kingdom

 

Hypophosphatasia (HPP) is the rare disease caused by loss-of-function mutation(s) in the tissue-nonspecific alkaline phosphatase (ALP) gene. Resultant low ALP activity can cause a wide spectrum of sequelae in children including premature loss of primary teeth, rickets, poor growth, muscle weakness, fractures, and pain (1 ,2). The clinical course of these manifestations is not well characterized.

This is a retrospective, multi-national, non-interventional chart review of patients (pts) with childhood HPP (symptom onset ≥6 months [mo] to <18 years [y]). Data were collected from 5 to 15 years of age or until Tanner stage >2, whichever occurred first. Study inclusion required HPP-related skeletal abnormalities, ≥1 set of paired radiographs 6 mo–5 y apart, and 2 height measurements ≥3 y apart. Children who previously received experimental or other treatments impacting bone or growth were excluded. Co-primary outcome measures were change in bone health (evaluated by the 7-point Radiographic Global Impression of Change (RGI-C) scale (-3 = severe worsening; +3 = complete healing) and change in height Z-score (Centers for Disease Control and Prevention [CDC] growth charts). Data are reported as median (min, max).

32 pts (69% boys, 97% white, 78% North American) were enrolled at 9 clinical sites, including 22 children from a large natural history database maintained at one site (2). Age at HPP symptom onset was 1.3 y (0.6, 3.4); age at diagnosis was 3.3 y (1.0, 13.1). Common HPP-related disease characteristics in this cohort included gait disturbance (59%), arthralgia (53%), bone pain (50%), muscle weakness (47%), muscle pain (38%), and fracture (34%). 28% of pts reported HPP-related hospitalizations, primarily for surgical correction of HPP-related deformity. 94% required non-pharmacological interventions such as physiotherapy (34%), orthotics (31%), and mobility aids (13%). 63% received medications for HPP-related complaints, most frequently for relief of pain and discomfort. No significant change between first and last assessment (LA) (time elapsed: 4.25 y [0.66, 7.95]) in radiographic assessment of bone health was observed (RGI-C was +0.33 [-2.33, +2.33; p=0.08]). Height and weight z-scores at first assessment varied considerably within the cohort (-0.86 [‑4.9, +2.6]; -0.86 [-5.0, +2.1], respectively) and all subsequent assessments, with no significant change to LA (p>0.05); at LA, height was -0.92 (-4.9, +1.8) and weight -0.98 (-5.7, +2.1).

As demonstrated by this retrospective chart review study, these children with childhood HPP had morbidity and no significant change in rickets or height z-score during childhood and early adolescence.

 

Disclosure: MPW: Principal Investigator, Alexion. KLM: Coinvestigator, Alexion. CFM: Advisory Group Member, Alexion. KF: Employee, Alexion. HZ: Employee, Alexion. NJB: Study Investigator, Alexion. Nothing to Disclose: ALR

LB-OR01-4 22822 4.0000 A A Retrospective, Multi-National, Non-Interventional, Natural History Study of the Childhood Form of Hypophosphatasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM LB-OR01 6268 11:30:00 AM New Discoveries in Bone Health and Disease Oral


Kevin J Basile*1, Alessandra Chesi2, Jonathan A. Mitchell3, Shana E. McCormack2, Sani M. Roy2, Heidi J. Kalkwarf4, Joan M. Lappe5, Vicente Gilsanz6, Sharon E Oberfield7, John A. Shepherd8, Andrea Kelly2, Babette S. Zemel2 and Struan F.A. Grant9
1Children's Hospital of Philadelphia, Philadelphia, PA, 2The Children's Hospital of Philadelphia, Philadelphia, PA, 3University of Pennsylvania, 4Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 5Creighton University, Omaha, NE, 6Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, 7Columbia University College of Physicians and Surgeons, New York, NY, 8University of California San Francisco, San Francisco, CA, 9The Children's Hospital of Philadelphia, Philadelphia

 

Background: Height is a complex trait influenced by environmental and genetic factors operating in a number of biological pathways, including those related to hormone activity and bone accretion. The most recent meta-analysis of genome-wide association studies of adult height identified 697 variants corresponding to 423 distinct genomic loci, which collectively account for up to one-fifth of this trait’s heritability. However, the physiological route by which these genetic variants influence an individual’s overall height is not known.

 

Objective/Methods: Stature reflects skeletal size, which is achieved by bone mineral accretion during childhood growth. Thus, we investigated the effects of genetic variants known to associate with adult height on pediatric bone mineral content and density. We leveraged a prospective observational study of 691 participants of European ancestry enrolled in the Bone Mineral Density in Childhood Study (52% female), then sought further support from an additional cohort of 472 Caucasian subjects (51% female). Bone mineral content (BMC) and areal bone mineral density (aBMD) of the radius, hip, spine and total body (to estimate head and whole body BMC/aBMD) were assessed by dual energy X-ray absorptiometry (DXA) and expressed as age and sex-specific Z-scores. We further tested bone Z-scores adjusted for height-for-age Z-score to account for known effects of size on DXA outcomes. DNA was extracted from blood/saliva and genotyped using high-throughput technology. Genotyping of subjects was performed at the Children’s Hospital of Philadelphia using the Illumina Infinium™ II OMNI Express plus Exome BeadChip technology.

 

Results: Three of the loci previously linked to adult height yielded Bonferroni-corrected significance for association with pediatric bone accretion at specific skeletal sites. These loci were rs3750972 at TPCN2 for head aBMD in males (P = 5.48x10-5; ß = 0.241), rs6952113 at C7orf58 (also known as CPED1) for both BMC and aBMD at the distal radius in females (P = 1.63x10-5; ß = -0.250 and P = 6.30x10-8; ß = -0.317, respectively), and rs2781373 at MAX with aBMD at the distal radius in females (P = 3.22x10-5; ß = 0.243). These loci did not show any degree of significant association with height Z-score, nor did height adjustment of BMC/aBMD outcomes dramatically alter the significance of association of these loci to their respective skeletal phenotypes. Additionally, 19 other adult height loci demonstrated at least a nominally significant, directionally consistent association in both the discovery and replication cohorts for a variety of other skeletal phenotypes.

 

Conclusions: These results indicate that at least some of the genetic variants associated with adult height may be exerting their influence via alterations in pediatric bone accretion. Additionally, our data have implicated TPCN2 and MAX as novel pediatric bone density loci.

 

Nothing to Disclose: KJB, AC, JAM, SEM, SMR, HJK, JML, VG, SEO, JAS, AK, BSZ, SFAG

LB-OR01-5 22633 5.0000 A Multiple GWAS-Implicated Adult Height Loci Operate in the Context of Pediatric Bone Mineral Density and Content Determination 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM LB-OR01 6268 11:30:00 AM New Discoveries in Bone Health and Disease Oral


James Koh*1, Joyce Hogue1, Yuli Wang2, Matthew DiSalvo2, Nancy Lynn Allbritton2, Yuhong Shi3, John A Olson Jr.3 and Julie Ann Sosa4
1Duke University Medical Center, Durham, NC, 2University of North Carolina at Chapel Hill, 3University of Maryland School of Medicine, Baltimore, MD, 4Duke University, Durham, NC

 

We have recently shown that human parathyroid adenomas derived from patients with primary hyperparathyroidism (PHPT) are comprised of distinct cellular subpopulations with variable clonal origin and calcium responsiveness [1].  To gain a clearer understanding of the relationship between cellular identity, tumor composition, and clinical biochemistry in PHPT, we developed a novel single cell platform and computational analysis tool for quantitative evaluation of parathyroid tumor behavior. Dispersed parathyroid adenoma cells prepared from surgically resected tumor tissue are plated onto an indexed array composed of a large number of micron-scale elements (microrafts) doped with paramagnetic nanoparticles. The microrafts serve as releasable, optically transparent, individually addressed culture sites for isolated parathyroid cells.  Quantitative live-cell image analysis of calcium flux visualized by Fluo-4-AM epifluorescence was performed, and the cells were subsequently probed in situ for expression of the calcium sensing receptor (CASR), a canonical component in the extracellular calcium-signaling pathway.  Using this system, we found that the reactivity of individual parathyroid tumor cells to extracellular calcium stimulus is highly variable, with discrete patterns of kinetic response observed both between and among parathyroid tumor isolates. When challenged with 3 mM calcium, the proportion of cells exhibiting a rapid and transient response ranged from 7.1-27.7%, while sustained signaling responses were seen in 1.0–48.1%.  Non-responders at this calcium concentration ranged from 30.8-68.2%. When examined in relationship to each individual cell’s behavior, CASR abundance was not found to be a determinant of calcium responsiveness.  56.2 percent of rapid transient responder cells and 38.4 percent of sustained responder cells did not express detectable CASR protein.  Conversely, 32.3 percent of non-responsive cells were CASR-positive. Finally, we generated dose-response curves to calculate calcium EC50 values from a series of parathyroid adenomas and found that the tumors appeared to group into two distinct categories with respect to calcium responsiveness.  One group manifested a mean EC50 of 2.40 mM (95% CI 2.37–2.41), closely aligned to the published normal range [2].  The second group was clearly less responsive to calcium stimulus, with a mean EC50 of 3.61 mM (95% CI 3.45–3.95). This binary distribution indicates the existence of a previously unappreciated biochemical sub-categorization of PHPT tumors, possibly reflecting distinct etiological mechanisms.  Prospective identification of quantitative differences in calcium sensing could have important implications for the clinical management of PHPT.

 

Disclosure: NLA: Founder, Cell Microsystems. Nothing to Disclose: JK, JH, YW, MD, YS, JAO Jr., JAS

LB-OR01-6 22542 6.0000 A Live Single Cell Imaging of Human Parathyroid Tumor Tissue Reveals Functional Heterogeneity in Calcium Sensing 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 1:00:00 PM LB-OR01 6268 11:30:00 AM New Discoveries in Bone Health and Disease Oral


Dominik Pesta*1, Rachel Perry1, Dongyan Zhang1, Michael J. Jurczak2, Andreas Birkenfeld3, Sanjay Bhanot4, Varman T Samuel5 and Gerald I. Shulman2
1Yale University School of Medicine, 2Yale University, 3Technischen Universität Dresden, 4Isis Pharmaceuticals, Carlsbad, CA, 5Yale University, New Haven, CT

 

INDY as part of the SLC13 protein family is a high-affinity di- and tricarboxylate plasma membrane transporter involved in citrate import. In Drosophila, genetic deletion of INDY alters energy metabolism and extends lifespan. Mice lacking INDY are protected from both diet-induced and age-associated hepatic insulin resistance. Here, we examined the impact of selective hepatic knockdown of mammalian Indy protein (mINDY) expression using 2’-O-methoxyethyl chimeric anti-sense oligonucleotides (ASOs) on hepatic glucose metabolism in 4 week high fat fed rats (n=15 per group) assessed by hyperinsulinemic-euglycemic (HEC) clamp studies. After 4 weeks of 2’-O-methoxyethyl chimeric ASO treatment, mINDY mRNA expression was reduced by 91% (P<0.001) in the treatment group. The mINDY 2’-O-methoxyethyl chimeric ASO treated rats showed a 34% reduction in fasting plasma insulin concentrations compared to the control group (14.5 vs. 9.6 mU/ml, P<0.05) and was associated with ~30% reduction in basal rates of endogenous glucose production [5.9 ± 0.6 vs. 8.4 ± 0.8 mg/(kg-min), Furthermore hepatic insulin responsiveness was increased in the mINDY 2’-O-methoxyethyl chimeric ASO rats as reflected by increased suppression of hepatic glucose production during the HEC [19.7 vs. 61.6%, P<0.05]. Taken together these data suggest that hepatic mINDY may be a novel therapeutic target for the treatment of hepatic insulin resistance and type 2 diabetes.

 

Disclosure: SB: Clinical Researcher, Isis Pharmaceuticals. Nothing to Disclose: DP, RP, DZ, MJJ, AB, VTS, GIS

OR10-1 19199 1.0000 A Prevention of Diet-Induced Hepatic Insulin Resistance By Antisense Oligonucleotides Targeted to Mindy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR10 5926 11:45:00 AM The Intersection of Inflammation and Metabolism in Diabetes Oral


Alexsandra C Malaquias*1, Xenia C C S Couto1, Michelle B Moraes2, Mariana F A Funari3, Alexandre C Pereira4, Sandra M F Villares5, Debora R Bertola6 and Alexander A L Jorge7
1Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Sao Paulo, Brazil, 2Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 3Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo - SP, Brazil, 4Instituto do Coraçao (InCor) da FMUSP, Sao Paulo, Brazil, 5Hospital das Clinicas da Faculdade de Medicina da USP, Sao Paulo, Brazil, 6Instituto da Crianca da Faculdade de Medicina da USP, Sao Paulo, Brazil, 7Faculdade de Medicina da Universidade de Sao Paulo (FMUSP), Sao Paulo

 

Introduction: Noonan syndrome (NS) and Noonan-like syndromes (NLS) are autosomal dominant disorders caused by heterozygous mutations in genes of the RAS/MAPK pathway. Insulin and leptin, two important hormones involved in satiety signals, act also through the RAS/MAPK pathway. It raises the intriguing possibility that mutations associated with NS and NLS could have an influence on metabolism and control of energy storage. Because of that, it will be of great interest to characterize the metabolism of NS and NLS.Objectives: The aim of this study was to describe metabolic profile in children with NS and NLS. Subjects and Methods: We selected 58 children (36M:22F) with previously identified pathogenic mutation in NS/NLS genes (41 PTPN11, 5 SOS1, 5 BRAF, 4 RAF1, 1 SHOC2, 1 KRAS and 1 NRAS) and 96 age-matched controls (41M:55F) to undergo anthropometric measurements, glycemia, insulin and serum lipid levels. Height and BMI were expressed as SDS for age and sex. The differences between controls and genotypes were analyzed by t-test and ANOVA. Results: Patients with NS and control ones had similar sex distribution and age (10.5±3.7 vs 10.6±1.5 yr). Patients with NS were shorter (height-SDS= -2.3 ± 1.2 vs. 0.1 ± 1.0, p<0.001) than control group, whereas BMI-SDS were similar between groups. Both NS and control patients showed normal glycemia and insulin levels. Patients with NS presented total cholesterol (142.4 ± 27.0 vs. 156.4 ± 24.7 mg/dl, p=0.001) and high-density lipoprotein cholesterol levels (HDL-C; 41.4 ± 12.6 vs. 58.0 ± 12.4 mg/dl, p<0.001) lower than controls. Low-density lipoprotein cholesterol (LDL-C) levels were similar in both groups. Triglyceride levels were higher in patients with NS than the control ones (78.3 ± 34.5 vs. 66.2 ± 23.0 mg/dl, p=0,004). Patients with PTPN11 mutation had a slight increase in HOMA-IR (1.4 ± 1.3 vs. 1.0 ± 0.6, p=0.04) than control children. Additionally, RAF1 patients showed the lowest HDL-C levels (36.0 ± 8.7 mg/dl) in comparison to PTPN11 patients (40.8 ± 12.2 mg/dl) and other genotypes (50.8 ± 14.6 mg/dl, p=0.043). Patients with NS were more likely to have a low HDL-C (odds ratio 18.6; 95%CI 7.5-46, p<0.001) and higher triglyceride levels (odds ratio 3.8, 95%CI 1.4-10.7, p=0.011) comparing with control children (corrected by sex, age, BMI). Conclusion: Despite NS and NLS BMI was within normal range, patients with NS presented a low HDL-C and higher triglyceride levels, a lipid profile that resembles features of metabolic syndrome and type 2 diabetes. Since SHP2 and SOS1 seem to have a role in insulin signaling through PI3K/AKT pathway, it is worth noting that other mutated molecules involved in NS could influence serum lipid levels suggesting a role of RAS/MAPK pathway mutations in insulin signaling.

 

Nothing to Disclose: ACM, XCCSC, MBM, MFAF, ACP, SMFV, DRB, AALJ

OR10-2 20679 2.0000 A Metabolic Profile in Patients with Noonan and Noonan-like Syndromes Suggests a Role of RAS/MAPK Pathway Mutations in Insulin Signaling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR10 5926 11:45:00 AM The Intersection of Inflammation and Metabolism in Diabetes Oral


Philippe Klee*1, Emmanuel Somm2, Audrey Guerardel3 and Valerie M Schwitzgebel1
1University Hospitals of Geneva, Geneva, Switzerland, 2University of Geneva School of Medicine, Geneva, Switzerland, 3University Hospital of Geneva, Geneva, Switzerland

 

Background
Type 1 Diabetes (T1DM) results from the auto-immune destruction of > 90% of the pancreatic β-cells. Identifying methods to prevent this process could open interesting perspectives in the prevention of T1DM.

Hypothesis
This work focuses on strategies to increase the resistance of β-cells against auto-immune destruction. We consider the possibility that activation of nicotinic acetylcholine (nACh) receptors protects β-cells against auto-immunity. NACh receptors have been previously implicated in the control of cell death, by the activation of their α7 subunit (1) and are expressed on β-cells.

Methods
Islets isolated from wild type (WT) mice, from mice in which either the α7 or β2 subunit of nACh receptors had been disrupted, as well as Human islets were cultured in presence or absence of nicotine or choline. After 24h, a cocktail of IL-1β+TNFα+IFNg was added. Cell death was quantified by TUNEL analysis. The expression of genes implicated in the regulation of mitochondrial permeability transition was quantified by qPCR.

Results
The exposure of WT mouse islets to the above-mentioned cytokines increased β-cell death, but the pre-culture with nicotine significantly decreased the effect of cytokines (median: 0.7 vs. 1.0 arbitrary units (a.u.); p < 0.01). The experiment was repeated with islets form mice in which either the α7 or the β2 subunit of nACh receptors had been disrupted. We found that nicotine significantly decreased cell death also in the absence of the β2 subunit (median: 0.67 vs. 1.0 a.u.; p < 0.01), but not in the absence of the α7 subunit, indicating that the effect was dependent on this latter subunit. We then repeated the experiment on Human and WT murine islets, with a pre-culture with choline, a specific agonist of the α7 subunit. We found that choline also attenuated (median: 0.78 vs. 1.0 a.u.; p < 0.05) the effect of the cytokines, confirming the importance of the α7 subunit for the protective effect. We then quantified the expression of genes implicated in the regulation of mitochondrial permeability transition by qPCR and found that the cytokines induced the expression of CHOP, a marker of endoplasmic reticulum (ER) stress (2) as well as of PUMA, a protein of the Bcl-2 family (2). For both genes, the effect of the cytokines on their expression was significantly attenuated (4.6 ± 0.3 vs. 11.3 ± 1.8 a.u.; p < 0.01 for CHOP and 0.7 ± 0.07 vs. 1.5 ± 0.2 a.u.; p < 0.05 for PUMA) by pre-incubation with choline.

Conclusion
Our results show that the activation of nACh-receptors via their α7 subunit significantly reduces cytokine-induced β-cell death in mouse and Human islets. This effect was linked to attenuation of ER-stress and modulation of PUMA a pro-apoptotic protein implicated in the regulation of mitochondrial permeability transition. We believe that these results open the exciting perspective of a pharmacological modulation of beta-cell resistance against auto-immunity.

 

Nothing to Disclose: PK, ES, AG, VMS

OR10-3 21756 3.0000 A Choline Protects Human and Murine Beta-Cells in Vitro Against Cytokines By Decreasing Mitochondrial Permeability Transition 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR10 5926 11:45:00 AM The Intersection of Inflammation and Metabolism in Diabetes Oral


Anu Verma*1, Sabareesh Natarajan2, Ajay Chaudhuri3, Kenneth Snyder2, Nitesh D Kuhadiya2, Antoine Makdissi4 and Paresh Dandona5
1State University of New York -Buffalo, University at Buffalo, Williamsville, NY, 2University at Buffalo, Buffalo, NY, 3Diabetes and Endocrinology Center of Western New York, Buffalo, NY, 4State Univ of New York at Buffal, Buffalo, NY, 5State Univ of NY, Buffalo, NY

 

Background: Hyperglycemia at the time of ischemic stroke presentation has been shown to be associated with poor clinical outcomes (1); however, the  effect of hyperglycemia on cerebral blood flow patterns has not been studied.   At our stroke unit, all patients presenting with symptoms of stroke undergo CT Stroke protocol study (CSPS) that includes a 360 slice brain scan, Perfusion CT and CT angiography.  Perfusion CT  delineates  the  ischemic  tissue by  showing increased time to peak (TTP), decreased cerebral blood flow (CBF) and normal or increased cerebral blood volume (CBV), whereas infarcted tissue manifests with markedly decreased CBF and CBV.

Hypothesis: We   hypothesized   that hyperglycemia   induces abnormal   patterns of   cerebral blood flow including diminished cerebral tissue perfusion as reflected in increased TTP in patients investigated for but not found to have ischemic stroke.

Methods: We  studied  the perfusion images of 75 patients who were not found  to have stroke and correlated with their blood glucose level at admission (BGA). 25 patients with BGA <100mg/dl served as the control group whereas 25 with BGA 100-140mg/dl constituted Group A and 25 patients with BGA >140 formed Group B.  Each group was then studied in detail for the cortical and hypothalamic blood flow parameters (CBV, CBF, TTP) using the Vitrea software.

Results: We found that the cortical TTP increased by 17% in both groups A (p=0.019) and B (p=0.033) when compared with the control and  there was a statistically significant rise in TTP  in each sector of the cortex in both hemispheres. Hypothalamic TTP also increased by 12% in group A (p=0.031) and by 1.8% in group B (p=0.386), when compared with  the control group (BGA <100).  There was no significant change in cortical or hypothalamic CBF or CBV.

Conclusion: We  conclude that  in patients without stroke, a blood glucose >100mg/dl, is associated with significant increases in TTP in the cortex and the hypothalamus. Since TTP  is  inversely related  to cellular and  tissue perfusion, our study shows for the first time a reduction in cerebral tissue perfusion at glucose concentrations >100mg/dl. These observations  have  implications  for the pathogenesis of  adverse  outcomes related to hyperglycemia in patients with ischemic stroke and, therefore, similar studies need to be carried out in patients with stroke.

 

Nothing to Disclose: AV, SN, AC, KS, NDK, AM, PD

OR10-4 18771 4.0000 A Reduction in Brain Tissue Perfusion with High Blood Sugars 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR10 5926 11:45:00 AM The Intersection of Inflammation and Metabolism in Diabetes Oral


Mary A. Venneri, Elisa Giannetta, Daniela Fiore, Giuseppe Panio, Rita De Gaetano, Daniele Gianfrilli, Riccardo Pofi, Silvia Masciarelli, Francesco Fazi, Manuela Pellegrini, Andrea Lenzi, Fabio Naro and Andrea M Isidori*
Sapienza University of Rome, Rome, Italy

 

Context: Diabetes is regarded as a state of chronic inflammation. Vascular complications associated with type-2-diabetes mellitus (T2DM) are the leading cause of morbidity and mortality. Our and other groups recently showed that chronic inhibition of phosphodiesterase-5 (PDE5i) has immunomodulatory effects and offers tissue-protection, however the underlying cellular and molecular mechanisms remains to be elucidated.

Aim:To study a subset of proangiogenic monocytes/macrophages expressing TIE2 receptor (TEMs) and its natural ligand, Angiopoietin-1 (ANG1), before and after chronic PDE5i by sildenafil (SILD) in patients with T2DM and mouse models of type1- and -2 diabetes mellitus (STZ and db/db).

Results: We found specific changes in TEMs recruitment in both human and mouse models of diabetes. In this context PDE5i: 1) normalized ANG-1 levels (2.1±0.6 ng/dl; after SILD 6.8±2.8 P<0.01) and circulating TEMs in men with T2DM (TEM frequency 46.1±18.9; after SILD, 76.0±21.5, P <0.01), and restored the angiogenic function of their serum; 2) lowered circulating pro-inflammatory monocytes in patients (CD14+CD16- cells: 29.0±7.3 T2DM; after SILD 12.4±6.4, P<0.01) and in mice (CD11b+Gr-1+cells in STZ: 53.7±7.9 vs. STZ+SILD: 30.4±8.3, P<0.01; db/db 46.1±10.0 vs. db/db+SILD 26.5±7.5, P<0.01); 3) reversed renal and heart organ damage, restoring pericytes regular coverage of endothelial cells, normalizing vascular architecture and increasing proangiogenic TEMs (TEM frequency,  in STZ kidney 6.9±2.7 vs. 30.9±3.6 in STZ+SILD, P<0.01; in STZ heart 5.8± 0.9 vs. 25.1±14.0 in STZ+SILD, P<0.01; in db/db heart: 16.5±2.1 vs. 53.0±16.9 in db/db+SILD, P<0.05; in db/db isoproterenol treated heart 14.0±2.8 vs. 52.2±17.9 in isoproterenol+SILD, P<0.01) 4) antagonized isoproterenol-induced cardiac hypertrophy (p<0.05); 4) inhibited vascular inflammation modulating ANG1/TIE2 pathway.

Conclusion: In summary, we demonstrate that circulating, renal and cardiac TIE2+ proangiogenic myeloid cells are defective in diabetes, especially in injured tissues, and that sildenafil normalizes their levels, by promoting the shift from classic (M1-like) to alternative (M2-like)/TIE2+ macrophage polarization via ANG1. Restoration of TEMs via PDE5i stimulation of angiopoietin-1 improves microcirculation and could help prevent diabetic complications associated with defective tissue repair.

 

Nothing to Disclose: MAV, EG, DF, GP, RD, DG, RP, SM, FF, MP, AL, FN, AMI

OR10-5 20308 5.0000 A Chronic PDE5 Inhibition Restores Defective Angiopoietin-1 and Proangiogenic TIE2-Expressing Monocytes Recruitment in Human and Murine Models of Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 1:00:00 PM OR10 5926 11:45:00 AM The Intersection of Inflammation and Metabolism in Diabetes Oral


Levent Ozsari*1, Liem Phan1, Enrique Fuentes-Mattei2, Guermarie Velazquez-torres2, Kanishka Sircar1, Camilo Jimenez1, Gilbert J Cote1, Marie-Claude Hofmann3, Mong-Hong Lee2, Sai-Ching Jim Yeung1 and Mouhammed Amir Habra1
1The University of Texas MD Anderson Cancer Center, Houston, TX, 2The University of Texas MD Anderson Cancer Center, 3MD Anderson Cancer Center, Houston, TX

 

Background: Adrenocortical carcinoma (ACC) is a rare malignancy with limited treatment options. Hepatocyte growth factor (HGF) and its receptor, c-Met, have been reported to contribute to cancer invasiveness and chemotherapy resistance in different solid tumors, but their significance in ACC has never been studied. Experimental Design: c-Met mRNA expression data were retrieved from an external ACC databases and analyzed. We studied the expression of HGF, c-Met, and activated phosphorylated c-Met in benign and malignant human adrenocortical tissues and an ACC cell line (H295R). We measured circulating HGF levels in ACC patients. The effect of HGF on H295R cells growth was evaluated. The association between HGF/c-Met expressions and markers of cellular proliferation and apoptosis was assessed. We also conducted in-vivo experiments in mouse xenograft model to assess the effect of targeting c-Met on ACC growth by using anti c-Met shRNA or cabozantinib (a multitarget small molecule tyrosine kinase inhibitor including c-Met).Results: Transcriptomics analysis revealed c-Met overexpression in ACC. We confirmed c-Met mRNA upregulation in ACC by using quantitative real-time polymerase chain reaction. An immunohistochemical analysis revealed that HGF, c-Met, and phosphorylated c-Met proteins were more abundant in ACC than in benign adrenal adenomas. Serum HGF levels were significantly higher in ACC patients than in adrenal adenoma and healthy control groups, and HGF was detected in the culture medium of H295R cells. ACC cell growth was stimulated dose-dependently by HGF. HGF/c-Met expression positively correlated with Ki-67% and negatively with apoptosis marker (cleaved caspase 3). Knockdown of cMET mRNA using shRNA and cabozantinib significantly decreased in vitro cell proliferation, induced cell cycle arrest and reduced both mitochondrial respiration and glycolytic metabolism. In xenograft mouse model, targeting c-Met (both by shRNA or cabozantinib) significantly decreased tumor growth. Conclusions:  HGF/c-Met pathway has growth-promoting mechanism in ACC.  Considering the availability of c-Met targeting drugs, targeting this pathway alone or in combination with other therapy is a reasonable therapeutic target that warrants further evaluation.

 

Nothing to Disclose: LO, LP, EF, GV, KS, CJ, GJC, MCH, MHL, SCJY, MAH

20662 1.0000 THR-380 A Hepatocyte Growth Factor/cMET Pathway Activation Enhances Cancer Hallmarks in Adrenocortical Carcinoma: A Potential Therapeutic Target 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Naoko Tsukamoto-Yamauchi*, Tomohiro Terasaka, Kenichi Inagaki and Fumio Otsuka
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

 

Melatonin secreted from pineal gland contributes to the formation of circadian rhythm.  Circulating concentrations of melatonin are low in the daytime and high in the night.  However, in Cushing’s syndrome, the fluctuation of circulating melatonin was shown to be abnormal.  We earlier reported that melatonin MT1 activation augments BMPR-Smad signaling through Akt pathway in cooperation with BMP-4 in corticotrope cells.  In the present study, we investigated the role of melatonin and BMP-4 in the regulation of ACTH and PRL secretion by focusing on the clock gene expression including Bmal, Clock, Per and Cry, which are involved in controlling the circadian rhythm.  First, we examined the correlation of mRNA levels of POMC and clock genes using mouse corticotrope AtT20 cells for 3- to 48-h durations.  As a result, the significant correlations between the expression of POMC and Per mRNA levels were revealed, in particular, at 24-h culture conditions.  The knockdown of Per expression by siRNA resulted in the significant reduction of POMC mRNA in AtT20 cells regardless of the presence or absence of CRH stimulation.  Of note, treatments with BMP-4 and melatonin, both of which suppress POMC expression, reduced Per mRNA as well as protein levels in AtT20 cells.  On the other hand, in rat lactosomatotrope GH3 cells, another correlation was found between the expression of PRL and Clock or Bmal mRNA levels at 6-h culture conditions, although this correlation was attenuated in the presence of forskolin treatment.  The siRNA-mediated knockdown of Clock gene, but not that of Bmal gene, significantly reduced PRL mRNA expression by GH3 cells.  Interestingly, Bmal mRNA and protein expressions were significantly increased by forskolin treatment, whereas Clock mRNA and protein levels were not altered by any of treatment with melatonin, BMP-4 or forskolin.  Collectively, the expressional correlation between POMC and Per and that between PRL and Clock were uncovered in the corticotrope and lactosomatotrope cells, respectively.  The Per expression was inhibited by POMC regulators such as CRH, melatonin and BMP-4, whereas the Clock expression was not affected by any of PRL modulators including forskolin, melatonin and BMP-4.  Thus, the effects of melatonin and BMP-4 on the clock gene expression may imply the difference of stability of circadian fluctuations of ACTH and PRL secreted from the anterior pituitary.

 

Nothing to Disclose: NT, TT, KI, FO

20772 2.0000 THR-381 A Circadian Regulation of Pomc and Prolactin By Melatonin and BMP-4 in Anterior Pituitary Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Karla Margarita Rodriguez*1, Erica Stevenson2 and Courtney Elizabeth Stewart1
1Kent State University, Kent, OH, 2Kent State University, Kent

 

Fibroblast growth factor (FGF) 8 is a potent morphogen during early embryonic development of neuroendocrine cells that reside in the hypothalamus. Previously, we and other researchers have shown that newborn heterozygous (+/neo) and homozygous (neo/neo) Fgf8 hypomorphic mice harbor approximately a 40% reduction in vasopressinergic cells in the paraventricular nucleus (PVN) compared to wildtype (WT) controls. Interestingly, recent studies show that adult Fgf8+/neo hypomorphic mice are more anxious than WT mice, thus suggesting that Fgf8 deficiency in the PVN may have a negative effect on the function of the hypothalamic-pituitary-adrenal (HPA) stress axis. In our first study, we used restraint stress to elicit and measure corticosteroid levels as a function of HPA-function in adult WT and Fgf8+/neo mice. Secondly, we examined brain tissue using immunocytochemistry to visualize, and analyzed corticotropin-releasing hormone (CRH) levels in the PVN of adult WT and Fgf8+/neo mice. These studies showed that Fgf8+/neo mice mounted a faster HPA response compared to their WT counterparts. Moreover, we found that the PVN in Fgf8+/neo mice had higher levels of CRH-immunostaining than WT mice. In general, our study showed significant evidence for the importance of FGF8 function in the development of neuronal circuitry, which enables an animal to cope and regulate the effects of external stressors. Future studies will investigate the molecular and cellular mechanisms that underlie FGF8-dependent embryonic and early perinatal development of CRH PVN neurons in the mouse hypothalamus.

 

Nothing to Disclose: KMR, ES, CES

21561 3.0000 THR-382 A Fibroblast Growth Factor 8 Regulates Corticotropin-Releasing Hormone Expression in the Mouse Paraventricular Nucleus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Waldemar Kanczkowski*1, Ales Neuwirth1, Sylvia Großklaus1, Kai Zacharowski2, Triantafyllos Chavakis1 and Stefan Richard Bornstein3
1Technische Universität Dresden, Dresden, Germany, 2Universitätsklinikum Frankfurt, Frankfurt am Main, Germany, 3University Hospital Carl Gustav Carus, Department of Medicine III, Technische Universität Dresden, Dresden (Germany), Dresden, Germany

 

Sepsis and septic shock in response to bacterial or viral infections remain the major health problem worldwide.  Activation of the adrenal gland stress response is crucial to cope with and to survive these adverse conditions. However, in many critically ill patients, the production of adrenal glucocorticoids, their peripheral action and metabolism are often impaired. Previously, the key role of immune-neuroendocrine interactions including expression and actions of toll-like receptors (TLR) in the regulation of hypothalamic-pituitary-adrenal (HPA) axis during endotoxemia was demonstrated.

In the present study, we have studied whether an intact action of TLRs in the adrenocortical cells or in the immune system within adrenal microenvironment is crucial for activation of adrenal glucocorticoid production, inflammation, immune cell infiltration, and adrenal cell death during endotoxemia-provoked SIRS and polymicrobial sepsis.

In particular, we engaged mice with inactivation of a key adapter molecule involved in TLR signaling (Myeloid differentiation primary response gene 88, MyD88) in adrenocortical cells (Akr1b7-Cre-MyD88 fl/fl) and in the hematopoietic cells only (Vav-Cre-MyD88 fl/fl). By subjecting these mice to LPS, we demonstrated that an intact TLR-signaling in immune but not adrenocortical cells is the major regulator of adrenal gland inflammation, including enhanced expression of pro-inflammatory mediators and immune cell infiltration. In addition, we identified that an intact TLR signaling in immune cells was necessary for a proper activation of the HPA axis.

Our data suggest that an intact immune rather than adrenocortical TLR signaling is critically involved in the regulation of the immune-adrenal crosstalk regulating the adrenal glucocorticoid production and inflammation.

 

Nothing to Disclose: WK, AN, SG, KZ, TC, SRB

20899 4.0000 THR-383 A The Role of Immune and Adrenocortical Cell Specific TLR Inactivation in Adrenal Gland Function and Dysfunction during Systemic Inflammation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Lu Jian*
The Second Military Medical University, Shanghai, NU, China

 

The mechanism of pro-adhesion and anti-apoptotic effects of Dex in human ovarian cancer cells

Li-juan Yin, Fan Fan, Yan Wang, Xinlei Sun , and Jian Lu*

Department of Pathophysiology, the Second Military Medical University, 800 Xiangyin Road, Shanghai 200443, People’s Republic of China.

 

Abstract

Glucocorticoid (GC) can affect tumor biology not only for its immunosuppression and antiinflammatory effects, but also play a direct role in regulating proliferation, differentiation, adhesion, invasion and apoptosis of tumor cells. Our previous works demonstrated that dexamethasone (Dex), a synthetic GC significantly increased cell adhesion to extracellular matrix (ECM) by increasing levels of integrins b1, a4 and  a5, thereby enhancing cell resistance to chemotherapeutics in human ovarian cancer cells. However it is unclear whether Dex also affect the expression of components of ECM as ligands of integrin b1, and whether other membrane molecules besides integrin are involved in pro-adhesion effect of Dex in ovarian cancer cells. In order to further explore the mechanism of pro-adhesion and anti-apoptotic effects of Dex, in the present study we investigated the effect of Dex on the expression of components of ECM, cell adhesion glycoprotein CD44 and mucin antigen 1(MUC1), a large transmembrane epithelial mucin glycoprotein by QRT-PCR, Western blot and Elisa /Radioimmunoassay(RIA). The results demonstrated that 100 nM Dex treatment significantly up-regulated the expression of fibronectin and MUC1 in ovarian cancer HO-8910 and SKOV3 cells, but did not change the expression of collagen I, III and IV,and laminin, as well as CD44 and its principal ligand hyaluronan(HA). Since in addition to binding to integrin a5b1, fibronectin also binds to CD44. While we demonstrated that treatment of ovarian cancer cells with CD44 blocking antibody significantly decreased the pro-adhesion effect of Dex, suggesting that up-regulation of fibronectin may be also involved in the pro-adhesion effect of Dex by fibronectin-CD44 interaction. Moreover Dex could activate PI-3K –AKT pathway probably through enhanceing cell adhesion, which contributed to enhancing cell resistance to chemotherapy. Finally we found that  inhibiting the expression of  fibronectin and MUC1 with specific siRNAs significantly attenuated the pro-adhesion and activation of AKT induced by Dex. In conclusion, these results indicated that  up-regulation of fibronectin and MUC1 and activation of PI-3K-AKT pathway  by Dex are involved in pro-adhesion and anti-apoptotic effects of Dex in human ovarian cancer cells.  

1. Yu-Xia Chen,et al. Endocrine-Related Cancer. 2010, 17 (1): 39 -50; 2. Herr I, et al. Cancer Research. 2003, 63: 3112–3120. 3. Sui M, et al. International Journal of Cancer 2006, 119: 712–717.

Source of Research support: the National Natural Science Foundation of China (91029722 and 81472690)).

 

Nothing to Disclose: LJ

20238 8.0000 THR-387 A The Mechanism of Pro-Adhesion and Anti-Apoptotic Effects of Dex in Human Ovarian Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Karijn J. Pijnenburg-Kleizen*1, Christiaan F Mooij2, Aliesha Griffin3, Nils P. Krone3, Paul N. Span1, Antonius E Van Herwaarden2, Fred C.G.J. Sweep1 and Hedi Claahsen-van der Grinten1
1Radboud University Medical Centre, Nijmegen, Netherlands, 2Radboud University Medical Center, Nijmegen, Netherlands, 3University of Birmingham, Birmingham, United Kingdom

 

Background Congenital adrenal hyperplasia (CAH) patients may show less clinical signs of glucocorticoid deficiency than would be expected based on their low serum cortisol levels. We hypothesize that adrenal steroid precursors and metabolites that accumulate in untreated or poorly controlled CAH patients have clinically relevant glucocorticoid activity and can partially restore cortisol deficiency. We studied the effects of 17-hydroxyprogesterone (17OHP), progesterone (P), androstenedione (Δ4) and 21-deoxycortisol (21DF) on the human glucocorticoid receptor (hGR) in comparison with the effects of cortisol.

Methods In vitro transactivation of the hGR was studied in COS-7 cells co-transfected with the hGR and the luciferase reporter vectors MMTV and pRL-TK. Cells were treated with either cortisol or one of the test compounds in increasing concentrations. Transactivation of the hGR was measured using a dual luciferase assay. Dose-response curves were calculated and the half maximal effective concentration (EC50) was determined for each steroid. Maximal transactivation by the steroids relative to the maximal transactivation by cortisol was calculated. In the second part of our study, nuclear translocation of the hGR was studied by transfection of COS-7 cells with a GFP-tagged hGR and fluorescence microscopy after treatment of the transfected cells with the steroids.

Results The EC50 of cortisol was 1.7 x 10-8 M. 17OHP, P and 21DF transactivated the hGR with EC50s of 2.2 x 10-6 M,  3.0 x 10-6 M and 1.0 x 10-7 M, respectively. For 17OHP and 21DF maximal transactivation was not significantly different from the maximal transactivation by cortisol (respectively 86%, p=0.06 and 97%, p=0.8), but for P maximal transactivation was significantly lower (73%, p=0.004). Δ4 did not transactivate the hGR. Treatment of the cells transfected with the GFP-tagged hGR with 21DF led to complete nuclear translocation of the hGR, whereas treatment with 17OHP or P resulted in partial nuclear translocation of the hGR.

Conclusions Our data suggest that 17OHP, P and 21DF are able to transactivate the hGR and thus may have clinically relevant glucocorticoid activity. For 17OHP and P, high concentrations are needed to achieve transactivation of the hGR. For 21DF however, the concentration needed to reach the EC50 is only approximately 6-fold the concentration of cortisol. Serum concentrations of 21DF reached in untreated CAH patients (up to approximately 4.5 x 10-7 M), might therefore have a clinically relevant agonistic effect on the hGR and could partially compensate the cortisol deficiency in these patients.

 

Nothing to Disclose: KJP, CFM, AG, NPK, PNS, AEV, FCGJS, HC

20848 9.0000 THR-388 A Glucocorticoid Receptor Transactivation By 21-Deoxycortisol, 17-Hydroxyprogesterone and Progesterone in Congenital Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Ana Tiganescu*, Melanie Hupe, Yoshikazu Uchida, Theodora M Mauro, Peter M Elias and Walter M Holleran
University of California San Francisco, San Francisco, CA

 

Glucocorticoids (GC) are frequently prescribed for their anti-inflammatory properties, however side effects including skin thinning and poor wound healing (WH) preclude their chronic use. We previously reported improved WH in aged C57BL/6 mice with a global deletion of the GC-activating enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) and recently demonstrated increased 11β-HSD1 expression during early WH. Here, we topically treated healthy 10 week and 18 month old C57BL6 mice with the 11β-HSD1 inhibitor carbenoxolone (CBX, 30mM) 1 week prior to wounding by double 5mm punch biopsy (n=4-7).

CBX inhibited 11β-HSD1 activity (pmol active corticosterone from inactive 11-dehydrocorticosterone/h) by 66-89% in unwounded skin and during WH (p<0.001). 11β-HSD1 activity was 50% greater in aged mice 2 days post-wounding (5.4 vs. 3.6pmol/h, p<0.01). Aged mice displayed impairments in epidermal barrier function i.e. increased baseline transepidermal water loss (TEWL, g water/h/m2) 7.3 vs. 4.5 (p<0.001) and integrity i.e. increased TEWL per tape strip 9.9 vs. 5.4 (p<0.001). CBX further impaired integrity in aged mice (12.8, p<0.05) with a similar trend for baseline TEWL (9.4, p=0.09). Wounds of aged vs. young mice were 40% smaller at day 2 (6.5 vs. 10.7mm2, p<0.001) but comparable at days 4 and 8. CBX-treated wounds in aged mice were 30% larger at day 2 (p<0.05) with trends indicating altered mRNA expression of pro-inflammatory cytokines (IL1β, 3.9-fold, p=0.12, TNFα, 5.3-fold, p=0.1), extracellular matrix remodelling (COL1, 0.15-fold, p=0.2, MMP9, 5-fold, p=0.17, TIMP1, 0.29-fold, p=0.18) and mesenchymal-epidermal signalling (FGF7, 0.26-fold, p=0.13, IGF1, 0.3-fold, p=0.09). CBX had no effect on any measured outcomes in young mice.

These findings suggest increased local GC activation modestly improve barrier function and early WH in healthy aged mice partly in response to/by suppressing increased inflammation. However, this could predispose aged individuals to the adverse effects of systemic stress e.g. delayed WH. Associations between 11β-HSD1, stress and ageing merit further exploration.

 

Nothing to Disclose: AT, MH, YU, TMM, PME, WMH

20916 10.0000 THR-389 A Increased Local Glucocorticoid Activation Improves Epidermal Function and Early Wound Healing in Healthy Aged Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Takao Hashimoto*1, Li Du1 and Anthony P Heaney2
1University of California, Los Angeles, Los Angeles, CA, 2University of California (UCLA), Los Angeles, CA

 

Cushing’s disease is a life-threatening neuroendocrine disorder due to excess pituitary tumor-derived adrenocorticotrophic hormone (ACTH). No safe and effective medical therapy exists currently to target the corticotroph tumors. Glucorticoid resistance is a common yet largely unexplained phenomenon in many medical conditions and significantly limits therapeutic efficacy of administered glucocorticoids. We previously demonstrated that the orphan nuclear receptor TR4 (nuclear receptor subfamily 2, group C, member 2) binds the proopiomelanocortin (POMC) promoter to potently induce POMC expression and ACTH secretion form corticotroph tumor cells. Our further studies demonstrate that TR4 blocks both glucocorticoid and GR-mediated suppression of POMC transcription. Co-immunoprepicitation studies indicate that TR4 binds the GR in corticotroph tumor cells. In addition to abrogation of GR-directed POMC suppression, our quantitative RT-PCR studies show that TR4 modifies downstream expression of several GR target genes. Our results demonstrate that TR4 binds GR to play an important role in modulating GR actions. Further characterization of this pathway may offer important insights into glucocorticoid resistance.

 

Nothing to Disclose: TH, LD, APH

21983 11.0000 THR-390 A Testicular Receptor-4 (TR4) Modulates Proopiomelanocortin Gene Transcription By Binding the Glucocorticoid Receptor (GR) in Corticotroph Tumor Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Liting Zhu*1, Jing Zhu2, Gen cheng Wu2 and Zhan zhuang Tian2
1Fudan University, 2Fudan University, shanghai, China

 

Background: Electroacupuncture (EA) has been shown to have anti-stress effects in breast surgery, colorectal surgery, prostatectomy and craniotomy in clinical studies. During the surgical trauma induced stress response, hypothalamic corticotropin-releasing factor (CRF) directly activates the hypothalamus-pituitary-adrenal (HPA) axis. This study investigated the hypothesis that gamma-aminobutyric acid (GABA) receptors mediate the effects of EA treatment on hypothalamic CRF in rats experiencing surgical trauma. 

Methods: The surgical trauma model was induced by partial hepatectomy. Ninety-six male rats were randomly divided into 4 groups: the intact group (INT; n=24); the model group, which received partial hepatectomies (M, n=24); the sham group, which included model animals that received acupuncture without an electric circuit (Sham, n=24); and the EA group, which comprised model animals that received EA (EA, n=24). EA treatment was given twice: 24 h before the surgery and immediately after the partial hepatectomy was completed. The expression of hypothalamic CRF and CRFR, the glucocorticoid receptor (GR), the GABA receptor, plasma adrenocorticotropic hormone (ACTH) and plasma corticosterone (Cort) were observed at 2 h, 4 h, 8 h and 24 h after surgery.

Results: Strikingly, there were higher levels of plasma ACTH in M at 4 h and 24 h after surgery, while the plasma Cort expression was higher than INTs at 2 h, 4 h, 8 h and 24 h after surgery. And the ACTH and Cort expressions in EA presented lower than those of Ms. The hypothalamic CRF and GR increased in M at 2 h and 4 h after surgery, while those in EA decreased to normal levels. The expression of the hypothalamic GABAA α2 subunit and the GABAB receptor were enhanced in M compared with INTs, while were normalized with EA treatment compared with M. 

Conclusion: Our data suggest that EA attenuated the hyperactivity of the HPA axis by the regulation of hypothalamic GABAA and GABAB receptors on hypothalamic CRF. The hypothalamic GABAA α2 subunit may play an important role in inhibitory regulation of  hypothalamic CRF expression.

Keywords: Electroacupuncture; Surgical Trauma; CRF; GABAA Receptor; GABAB Receptor

 

Nothing to Disclose: LZ, JZ, GCW, ZZT

18701 12.0000 THR-391 A Electroacupuncture Speeds up the Regulation of HPA Axis Dysfunction in Acute Surgical Trauma Rats: Mediated By Hypothalamic GABAA and Gabab Receptors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Jing Zhu*1, Zhan zhuang Tian1 and Liting Zhu2
1Fudan University, shanghai, China, 2Fudan University

 

The hypothalamic-pituitary-adrenal (HPA) axis is a neuroendocrine system that regulated by corticotrophin-releasing hormone (CRH) and arginine vasopressin (AVP). Electroacupuncture (EA) at zusanli (ST36) and sanyinjiao (SP6) can attenuates HPA axis hyperactivity in hepatectomy rats, but the mechanisms still need to clarify. EA as a traditional Chinese treatment, can maintain homeostasis of neuroendocrine. In this study, the role of AVP in hypothalamus on EA attenuated HPA axis hyperactivity was investigated in hepatectomy rats and the effect of EA was observed in this model. ACTH and CORT level in the serum was detected via RIA at 2 hour and 4 hour after surgery. Besides, AVP and GR level in hypothalamus and hippocampus were detected by RT-PCR, Immunofluorescence and Western Blot. The results showed that a distinct increase of AVP and AVPR1a mRNA and protein level was observed between intact and hepatectomy rats, while AVP and AVPR1a mRNA and protein were significant decreased in EA group compared to hepatectomy rats. Overall, EA application at ST36 and SP6 can ameliorate the hyperactivity of HPA axis via AVP/AVPR1a.

 

Nothing to Disclose: JZ, ZZT, LZ

18896 13.0000 THR-392 A Electroacupuncture Attenuated HPA Axis Disorder By Regulating AVP and AVPR1 in Hepatectomy Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Shingo Murasawa1, Kazunori Kageyama*1, Aya Sugiyama1, Yutaka Oki2 and Makoto Daimon1
1Hirosaki University Graduate School of Medicine, Hirosaki Aomori, Japan, 2Hamamatsu Univ Schl of Med, Hamamatsu, Shizuoka, Japan

 

Cushing’s disease is primarily caused by pituitary corticotroph adenomas, which autonomically secrete adrenocorticotropic hormone (ACTH). ACTH production may be associated with tumor cell proliferation; however, the effects of cell cycle progression on ACTH production are little known in corticotroph tumor cells. A DNA polymerase inhibitor, aphidicolin, arrests cells at the entrance to the S phase and blocks the cell cycle; aphidicolin also induces apoptosis in tumor cells. In the present study, we determined ACTH production and cellular proliferation of AtT-20 corticotroph tumor cells following treatment with aphidicolin. Aphidicolin decreased proopiomelanocortin mRNA levels in AtT-20 cells and the levels of ACTH in the culture medium of these cells. Aphidicolin also decreased cell proliferation and induced apoptosis in AtT-20 cells. Fluorescence-activated cell sorting analyses revealed that this agent increased the percentage of G0/G1 phase cells, and decreased S phase cells. Aphidicolin decreased the phosphorylation of cyclic adenosine monophosphate response element-binding protein and Akt. Aphidicolin increased the levels of tumor protein 27 (p27) and 53 (p53), while it decreased cyclin E levels. Aphidicolin suppresses the synthesis and secretion of ACTH in corticotroph tumor cells. Aphidicolin also increased the levels of Zac1, an upstream regulator of p53, and the mRNA levels of the stress response gene growth arrest and DNA damage-inducible 45β (GADD45β), a putative downstream target of p53. Thus, aphidicolin inhibits ACTH production and cellular proliferation in AtT-20 cells.

 

Nothing to Disclose: SM, KK, AS, YO, MD

18898 14.0000 THR-393 A Aphidicolin Inhibits Adrenocorticotropic Hormone Production and Cellular Proliferation in AtT-20 Corticotroph Tumor Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Ruth Anna Morgan*, John A Keen, Patrick Hadoke and Brian R Walker
University of Edinburgh, Edinburgh, United Kingdom

 

Metabolic syndrome and Cushing’s disease occur in domesticated horses, but whether cortisol contributes to their pathophysiology is uncertain. Equine Cushing’s disease (Pituitary Pars Intermedia Dysfunction, PPID) is characterised by tumours of the pars intermedia, abnormal fat deposition, hirsutism, insulin resistance and elevated plasma ACTH, but paradoxically normal serum cortisol concentrations. We hypothesised that, as in human obesity, increased peripheral cortisol metabolism is a primary abnormality in equine metabolic syndrome (EMS) and in PPID, causing secondary ACTH secretion and increased cortisol and adrenal androgen production.

Body condition score (BCS, obesity) was recorded in female or castrated male healthy horses (n=7), EMS (n=5) and PPID cases (n=6) destined for euthanasia. Plasma ACTH, serum cortisol and insulin were measured by immunoassay; plasma testosterone by LC-MS/MS. Glucocorticoid and androgen metabolites in post-mortem urine samples were quantified by GC-MS/MS and corrected for creatinine. mRNA transcript levels of 11β-HSD1, 5α-reductase (type 1) and 5β-reductase in adipose (neck crest, linea alba, peri-renal) and liver were quantified by qPCR.

20β-Dihydrocortisol, a negligible metabolite in humans, was the most abundant urinary cortisol metabolite (60% of total metabolite excretion) in horses; testosterone was the major urinary androgen. Compared with healthy horses, EMS cases had higher BCS (P<0.001), hyperinsulinaemia (P=0.002) and increased total urinary androgens (1.6 ± 1.5 v 11.4 ± 7.5µg/mmol, P=0.02) and cortisol metabolites (41±3.4 v 132.4 ± 21.0µg/mmol, P=0.002), largely due to increased 20b-dihydrocortisol. Plasma ACTH, serum cortisol and androgens were normal. 11β-HSD1 transcript levels were higher in all adipose depots (P=0.006) but not in liver. Both 5α and 5β reductase were increased in liver (P=0.004). PPID cases were older (P=0.01) than healthy horses with elevated plasma ACTH (257.8 ± 217.1 v 39.6 ± 19.7pg/ml, P<0.001) but were not obese and had normal plasma cortisol (98±50 v 109±20nmol/L) and androgens; urinary cortisol and androgen metabolites were elevated, with increased testosterone (P=0.01), 20b-dihydrocortisol (P=0.02) and, disproportionately, 5b-reduced cortisol metabolites (P=0.03). Transcripts of 11β-HSD1 were increased in peri-renal adipose only (P=0.001).

In conclusion, EMS and PPID are both characterised by enhanced clearance of cortisol and adrenal androgens. This increased clearance may cause activation of the HPA axis contributing to elevated ACTH in PPID and adrenal stimulation in EMS. Given the normal plasma cortisol and androgen concentrations, the equine Cushing’s phenotype may result from altered local steroid metabolism, including by an unidentified 20β-oxoreductase. Glucocorticoid clearance may be a therapeutic target in these horses.

 

Nothing to Disclose: RAM, JAK, PH, BRW

18994 15.0000 THR-394 A Increased Cortisol Clearance As a Primary Abnormality in Equine Metabolic Syndrome and Equine Cushing's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


James Hawley*1, Laura Owen2, Annie Armston3, Phillip Monaghan4, Carrie Chadwick5 and Brian G. Keevil6
1University Hospital South Manchester, Manchester, United Kingdom, 2University Hospital of South Manchester, Manchester, United Kingdom, 3University Hospital Southampton, Southampton, United Kingdom, 4Christie Hospital NHS Foundation Trust, 5Aintree University Hospital, 6Univ Hospital of South Manchester, Manchester, United Kingdom

 

Background:The accurate measurment of serum cortisol is essential in the investigation of the HPA axis. It has been well documented that routine immunoassays are liable to both under- and over-recovery leading to inaccurate results and subsequent inappropriate investigations. This inaccuracy is proposed to be attributed to both the non-specificity of the complementary antibody and an inability to completely liberate cortisol from its binding globulin. This study seeks to provide an up-to-date assessment of the accuracy of the major immunoassay platforms and compares results to a liquid chromatography-tandem mass spectrometry (LC-MS/MS) candidate reference method.

Design: Serum remaining from routine analysis was aliquoted and distributed to four different centres for cortisol analysis by their respective immunoassay. In addition an aliquot was analysed by our routine LC-MS/MS assay and candidate LC-MS/MS reference method to provide a traceable result for comparison of assay bias. Cohort groups included: normal subjects, patients taking the oral contraceptive pill (OCP), pregnant patients, patients taking prednisolone and patients taking the the 11β-hydroxylase inhibitor metyrapone. Cortisol binding globulin (CBG) was measured in the normal, OCP and pregnant cohorts.

Results: Considerable bias was observed in the normal cohort between the immunoassays when compared to the LC-MS/MS candidate reference method whereas excellent agreement was observed between the routine LC-MS/MS assay and LC-MS/MS candidate reference method. Over recovery was greatest in patients taking prednisolone with the Roche platform particularly affected. Analysis of CBG demonstrated that elevated concentrations are observed during pregnancy and in patients taking the OCP when compared to the normal cohort. Elevated concentrations of CBG were associated with under-recovery in the Abbott Architect immunoassay. Of the patients taking metyrapone positive bias was observed across all immunoassay platforms when compared to the LC-MS/MS reference method.

Conclusions: The accurate quantification of cortisol by current immunoassays is compromised by both the non-specificity of the antibody for cortisol and matrix effects including elevated concentrations of CBG. Users should be aware of the limitations of their current assay and consider these when interpreting results, this is especially true of patients taking metyrapone where the dosage is titrated against cortisol concentration.

 

Nothing to Disclose: JH, LO, AA, PM, CC, BGK

21333 16.0000 THR-397 A Serum Cortisol: What Is Your Laboratory Measuring? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Sisitha Udara Jayasinghe*1, Gavin W. Lambert2, Susan Torres1, Steve Fraser1 and Anne Isabella Turner1
1Deakin University, Melbourne, Australia, 2Baker IDI Heart and Diabetes Institute, Melbourne, Australia

 

The magnitude of the stress response may be important in the development of chronic disease (Chrousos 2009). It has been shown in men that increased levels of fitness can attenuate HPA axis and SAM system reactivity to stress (Rimmele, Seiler et al. 2009).  Nevertheless, it is not clear if increased physical activity is associated with lower HPA axis and SAM system reactivity to psychological stress in women.

We tested the hypothesis that women who engaged in higher levels of physical activity will have lower cortisol, adrenaline (Adr), noradrenaline (NA) and dopamine (DA) responses to a TSST compared with their relatively less active counterparts.

High and low fit women (n=22 per group; in the follicular phase of the menstrual cycle) were subjected to a TSST (Kirschbaum, Pirke et al. 1993) at 1500h. Concentrations of cortisol, Adr, NA and DA were measured in samples of blood collected every 7-15min from 1400h-1700h.  Cortisol, Adr, NA and DA were compared within and between groups using repeated measures ANOVA.

Physical activity levels (2.7±0.5 vs 7.1±1.3 hours per week; p=0.004) and VO2 max (27.4±1.0 vs 41.9±1.6 ml/kg*min; p<0.001) were significantly higher in high fit women compared with low fit women Both groups responded to the TSST with a substantial elevation of cortisol (107%; p<0.001), Adr (146%; p<0.002), NA (92%; p<0.001) and DA (44%; p<0.001) but this response did not differ significantly between high and low fit women (time * treatment for cortisol, Adr, NA and DA; p=0.987, p=0.118, p=0.169, p=0.392, respectively). Furthermore, there were no significant differences between high and low fit women in pre-treatment values, peak height, reactivity or area under the curve for cortisol, Adr and NA (p>0.05 for all).  For DA, reactivity was higher in the low fit women (p=0.009) compared with the high fit women.  DA pre-treatment values, peak height, reactivity or area under the curve were similar between the groups.

While both groups had substantial responses to psychological stress, high fit women did not have an attenuated HPA axis and SAM system responses to psychological stress compared to low fit women. These findings suggest that, for low fit women who are aged between 30-50 years, the response of plasma cortisol, Adr, NA and DA to a potent acute psychological stressor is not compromised compared to that in high fit women.  Nevertheless, it is possible that differences between the groups may have been seen with a less potent stressor.  Further research is needed to clarify the role of physical activity in stress responsiveness.

 

Nothing to Disclose: SUJ, GWL, ST, SF, AIT

21379 17.0000 THR-398 A Sympatho-Adrenal Medullary (SAM) System and Hypothalamo-Pituitary Adrenal (HPA) Axis Responses to Trier Social Stress Test (TSST) Is Independent of Physical Fitness in Women Aged 30-50 Years 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Steffy Wilhelmina Jansen*1, Ferdinand Roelfsema2, Abimbola Akintola1, Nicole Oei3, Christa M Cobbaert2, Jeroen van der Grond4, Rudi G J Westendorp1, Hanno Pijl2 and Diana van Heemst1
1Leiden University Medical Center, Netherlands, 2Leiden University Medical Center, Leiden, Netherlands, 3University of Amsterdam, 4Leiden University Medical Center

 

The hypothalamic-pituitary-adrenal (HPA)-axis is the most important allostatic system of our body and is of critical importance for survival. Disability to maintain allostasis is associated with age-related diseases. Previously, we found that subjects enriched for familial longevity, have less frequently cardiovascular disease and diabetes compared to age-matched controls (1). In addition they exhibit a lower area under the curve for morning and evening salivary cortisol levels compared to controls (2). These results indicated that HPA-axis might be a potential candidate mechanism underlying healthy familial longevity. In this study, we aimed to compare features of the HPA-axis between subjects enriched for familial longevity and controls. We included 38 subjects of the Leiden Longevity Study cohort consisting of 20 middle-aged offspring of nonagenarian siblings (offspring) together with 18 of their partners (controls). Circulating ACTH and cortisol levels were measured every 10 min for 24h. Using deconvolution analysis (3) and ACTH-cortisol-dose response curve modeling (4), specific features of HPA-axis function were assessed, including secretion rates, number of pulses, regularity of pulses, and adrenal gland responsivity to ACTH. Total geometric mean (95% confidence interval (CI)) ACTH secretion over 24-hours was comparable in offspring (1333 (1091-1629) ng/l per 24h)) and partners (1235 (1000-1525) ng/l per 24h) (P = 0.60). Also, total geometric mean (95%CI) cortisol secretion over 24-hours was comparable in offspring (5481 (4803-6248) µmol/l per 24h) and partners (5324 (4638-6118) µmol/l per 24h) (P = 0.76). Moreover, no differences in ACTH and cortisol secretory parameters were found, including pulse number, pulse mass, pulse mode and regularity. Furthermore differences were found comprising a significant (P = 0.03) lower geometric mean (95% CI) recovery potency in female offspring -36.1 (-30.6- -42.7) ng/l compared to female controls -27.4 (-22.7- -33.0) ng/l, and a tendency towards a slightly increased sensitivity of the adrenal gland in male offspring expressed by a higher geometric mean (95% CI) of the sensitivity in male offspring 0.81 (0.54-1.2) slope units compared to male controls (0.53 (0.36-0.79) slope units)(P = 0.14). These results suggest that basal HPA-axis activity is not likely playing a key role in familial longevity.

 

Nothing to Disclose: SWJ, FR, AA, NO, CMC, JV, RGJW, HP, DV

21681 18.0000 THR-399 A Familial Longevity Is Not Marked By Differences in Hypothalamic-Pituitary-Adrenal-Axis Function 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Katie Kubek1, Keith Mansfield2, Maria Magnifico2, Amy Erickson2, Salah-Dine Chibout3, Francois Pognan3, Jennifer Marlowe2 and Patrick John Devine*1
1Novartis Institutes for BioMedical Research, Inc, Cambridge, MA, 2Novartis Institutes for BioMedical Research, Inc, 3Novartis

 

The dog is an important species for safety testing, so an in vitro adrenal cell model was established. Dog primary adrenocortical cells were isolated following manual removal of the medulla, characterized and compared to similar primary rat cultures for use in investigative toxicity studies. Cell numbers and viability were similar from adrenals shipped overnight or those processed within 2 hr after resection.  The average viability of the cells was 65%, with about 13 million cells obtained per gland. Collagenase digestion provided more viable cells than when using papain. Centrifugation in a Percoll gradient removed dead cells and permitted adrenocortical cells to be concentrated, but could not separate cells from specific adrenal zones. Cells were plated in 96-well collagen-coated plates and allowed to attach overnight before medium was replaced and experiments begun. Aldosterone production over 24 hr decreased from 198 to 28 to 15 ng/million cells/day on days 1, 2 and 3 of culture, respectively.  Cortisol production also decreased over time, from 517 to 175  to 77 ng/million cells/day on days 1 through 3.  Isolation of primary rat adrenal cells were similar to dog cells.  Cell viability from rat adrenals was 70%, with about 1.5 million cells obtained per gland. Rat adrenocortical cells produced less aldosterone than dog cells, (4 ng/million cells/day on day 2) but similar amounts of corticosteroid (101 ng/million cells/day, corticosterone on day 2).  Both adrenocorticotropic hormone (ACTH) and forskolin increased and prolonged steroidogenesis and expression of certain steroidogenic enzymes. Affymatrix gene expression arrays were used to evaluate gene expression in dog adrenocortical cells over time in culture, normalizing to whole dog adrenals. The isolation protocol enriched for cortical adrenocytes, reducing gene expression of chromaffin cells 20-fold over intact dog adrenals. Culture duration was associated with an progressive loss of gene expression associated with steroidogenesis but an increasing rise in genes involved in cholesterol synthesis, and ACTH only partially abrogated these changes. Cyp11B2 gene expression suggested zona glomerulosa (ZG) enrichment with isolation and increased expression with ACTH stimulation, but loss over time in culture. Over time, a ZG-specific gene expression signature was slightly (2-fold) decreased and zona fasciculata genes remained unchanged; neither was affected by addition of ACTH. These results demonstrate functionality of primary adrenocortical cells for both species, reducing over time. Results suggest these models could be used to make interspecies comparisons of adrenal function, investigate mechanisms of adrenal-specific toxicants, drugs or inhibitors of steroidogenesis. Time-dependent changes in adrenocortical cells in culture should be considered when using these models, as optimal function was seen in the first few days.

 

Nothing to Disclose: KK, KM, MM, AE, SDC, FP, JM, PJD

21921 20.0000 THR-401 A Characterization of an in Vitro Primary Dog Adrenocortical Cell Model and Comparison with Primary Rat Adrenocortical Cells. 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 380-401 5904 1:00:00 PM Adrenal tumours, glucocorticoid regulation and action Poster


Amir H Hamrahian*1, Kevin C.J. Yuen2, Murray B. Gordon3, Karen J Pulaski-libert4, James Bena1 and Beverly M.K. Biller5
1Cleveland Clinic Foundation, Cleveland, OH, 2Swedish Neuroscience Institute, Seattle, WA, 3Allegheny Neuroendocrinology Center, Allegheny General Hospital, Pittsburgh, PA, 4Masscheusetts General Hospital, Boston, MA, 5Neuroendocrine Unit, Boston, MA

 

Context:

The GST is used to evaluate GH and HPA axes in adults with pituitary disorders. Two prospective studies have reported that a GH cut-off level of 3 ng/mL differentiates those with GHD from healthy adults. The Endocrine Society Guidelines recommend a GH cut-off value of 2.5-3 ng/mL for the diagnosis of adult GHD. Recent studies suggest a lower GH cut-off especially in obese patients. Weight-based GST has been used in children, but data are limited in adults.

Objective:

To define GH cut-off values to diagnose adult GHD by GST, and to compare fixed dose (FD, 1 mg, 1.5 mg in patients >90 kg) with weight based (WB, 0.03 mg/kg, maximum 3 mg) GST.

Methods:

28 patients with adult-onset hypothalamic-pituitary disease and 1-2 (G1, n=14) or ≥3 (G2, n=14) pituitary hormone deficiencies were randomized to ITT, FD- and WB-GST (4 hrs) 5-28 days apart at 4 centers. A 3rd group of 14 control subjects (G3) was matched for age (±10 yr), sex, estrogen status and BMI (±5 kg/m2).  A GH response <3 ng/mL to ITT was used to classify patients as GH deficient.  Three subjects aged >65 years classified as GHD based on ≥3 pituitary deficiencies and low IGF-1 did not undergo the ITT.

Results:

Age and sex ratio were comparable between the 3 groups. Median (range) BMI was similar among the groups: G1 28.2 (18.6-36.3), G2 30.2 (19.8-46.2), and G3 27.3 (23.0-46.6). Mean (± SD) standardized IGF-1 levels were higher in controls compared with G1 and G2 (-0.5 ± 1.3 vs. -1.6 ± 1.1 and -1.9 ± 0.7, respectively). Glucagon dose used during the FD- and WB-GST was 1.2 ± 0.2 and 2.4 ± 0.5 mg, respectively.

The best GH cut-point for GHD diagnosis was 1.0 (92% sensitivity, 100% specificity) and 2.0 ng/mL (96% sensitivity and 100% specificity) for FD- and WB-GST, respectively. No significant change in these cut-off values were found if a GH <5 ng/mL was used to define GHD during ITT. Peak GH and BMI negatively correlated during FD- and WB-GST (r= -0.15 to -0.20, p= 0.21 to 0.33), but did not reach statistical significance. Age negatively correlated with the peak GH during FD-GST (r= -0.32, p= 0.04), but not WB-GST (r= -0.21, p= 0.21). Late peak GH (after 3 hours) was seen in 4.8% and 9.5% of the subjects during FD- and WB-GST, respectively.

During FD- and WB-GSTs, 7.1-21.4% of patients developed hypoglycemia (glucose <50 mg/dL) vs. 0% in controls. Nausea was the most common side effect (FD-GST 38% and WB-GST 50% of patients). One patient had a grand mal seizure during FD-GST without hypoglycemia. The FD-GST was preferred by patients over the other two tests, while no significant difference was seen between ITT and WB-GST.

Conclusion:

Our data do not support the use of GH cut-point of 3 ng/mL during FD- or WB-GST. Such a cut-off value may lead to misclassification of some adults as GH deficient. It is unclear whether a lower cut-point is required specifically for patients with higher BMIs. FD-GST was not inferior to WB-GST for GHD diagnosis and was preferred by most patients over the WB-GST and ITT.

 

Disclosure: AHH: Principal Investigator, Novo Nordisk, Consultant, Versartis. KCJY: Principal Investigator, OPKO, Ad Hoc Consultant, Novo Nordisk, Ad Hoc Consultant, Pfizer, Inc., Ad Hoc Consultant, Versartis. MBG: Principal Investigator, OPKO, Principal Investigator, Novo Nordisk, Principal Investigator, Pfizer, Inc.. BMKB: Principal Investigator, OPKO, Consultant, Novo Nordisk, Consultant, Pfizer, Inc., Consultant, Versartis. Nothing to Disclose: KJP, JB

PP05-1 21617 1.0000 THR-457 A Revised GH Cut-Point Needed for the Glucagon Stimulation Test (GST) in the Evaluation of Adult Growth Hormone Deficiency (GHD): Results from a Prospective Randomized Multicenter Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Vivien Bonert*1, John D. Carmichael2, Odelia Cooper3, James Mirocha4, Richard E Reitz5, Anne L Caston-Balderrama6, Michael J. McPhaul7, Michael Phillip Caulfield8 and Shlomo Melmed9
1Cedars Sinai Medical Center, Los Angeles, CA, 2University of Southern California, Los Angeles, CA, 3Cedars sinai Medical Center, Los Angeles, CA, 4Cedars-Sinai Medical Center, Los Angeles, CA, 5Quest Diagnostic Inc, San Juan Capistrano, CA, 6Quest Diagnostics Inc, San Juan Capistrano, CA, 7Medical Director, Endocrinology, San Juan Capistrano, CA, 8Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 9Cedars-Sinai Med Ctr, Los Angeles, CA

 

Background: Accurate measurement of insulin like growth factor 1 (IGF-1) is critical for diagnosis and management of pituitary growth hormone axis abnormalities. As anomalous results, poor reproducibility , low precision and assay bias are often reported with currently  available IGF-1 radioimmunoassays(RIA), mass spectrometry, was employed as an alternative  assay technology.

 Objective: IGF-1 was measured by both RIA and mass spectrometry (LC-MS/MS ) in serum samples from patients with pituitary disorders .

 Methods: Serum samples  prospectively obtained from 101 patients with both naïve and treated secretory and non-secretory pituitary tumors, cysts, hypophysitis,and craniopharyngioma, were evaluated by IGF-1 mass spectrometry (MS) and by Siemens Immulite 2000 IGF-1 assay (reagent lot #512; solid phase, enzyme-labeled chemiluminscent immunometric assay).  After sample accrual, samples were submitted for each assay as a single batch.  

Results: Although results of the two assays were highly correlated (R2=0.97), a significant positive bias was observed in the RIA  compared to the MS assay, reflecting a systematic proportional difference observed between  Siemens and LCMS assays, with the Siemens typically reporting higher results than the LCMS. This is reflected in the slope of the relationship observed in Deming regression y=1.57x – 54.0 and linear regression analyses y=1.55x – 48.3, . where y is the  Siemens assay  value . For classification into normal or abnormal values from each assay, results  were interpreted according to their respective reference intervals. IGF-1 MS assay results were interpreted using published age-adjusted ranges (1) and for the Siemens assay, according to age-adjusted ranges provided in the directional insert. Twenty six of 99 (27.2%) samples for which reference ranges were available for both assays, were classified differently (in range, low, or elevated) by the Siemens and the IGF-1 LCMS assay.  All 26 disagreements occurred with LCMS in the reference range: 14 were with elevated RIA  and 12 with low RIA.  LCMS was in the reference range significantly more frequently than RIA, 72.7% versus 46.5% of the cases, McNemar P < 0.0001.

 Conclusion: While results of  IGF-1 testing with the RIA  and LC-MS/MS assays  were highly correlated, a strong positive bias with higher results was reported using RIA compared to LC-MS/MS.  Twenty seven percent of IGF-1 samples measured by the two assays  were differently classified indicating a large degree of inter-assay variability. Inter-assay variability for IGF-1 results is well established and caution should be used when interpreting results of differing methodologies.The  accuracy of the IGF-1 LCMS methodology, large reference ranges, and concordance of  published LCMS reference ranges with a large published reference population (2 ) reinforces the clinical utility  of the mass spectrometry based IGF-1 assay

 

Disclosure: JDC: Ad Hoc Consultant, Genentech, Inc., Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Novartis Pharmaceuticals. RER: Coinvestigator, Quest Diagnostics. ALC: Employee, Quest Diagnostics. MJM: Principal Investigator, Quest Diagnostics. MPC: Employee, Quest Diagnostics. SM: Advisory Group Member, Chiasma, Ad Hoc Consultant, ISIS, Principal Investigator, Pfizer, Inc., Ad Hoc Consultant, Novartis Pharmaceuticals, Planning Group Member, Ipsen. Nothing to Disclose: VB, OC, JM

21909 2.0000 THR-458 A Immunometric IGF-1 Measurements Frequently Misclassify Clinical Samples Compared to a Mass Spectrometry IGF-1 Assay 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Kevin C.J. Yuen*1, Jan Frystyk2, Sharon A Rhoads3 and Martin Bidlingmaier4
1Swedish Neuroscience Institute, Seattle, WA, 2Aarhus University, Aarhus, Denmark, 3Oregon Health and Science University, Portland, OR, 4Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany

 

Context: Pegvisomant (PegV) is a selective GH receptor antagonist that effectively decreases IGF-I levels in healthy adults and normalizes IGF-I production in more than 90% of patients with acromegaly (1). However, although chronic GH receptor blockade with high dose PegV is known to increase endogenous GH secretion (2) without reducing systemic GH clearance (3), data are limited on its acute effects on GH and IGF kinetics in humans. 

Aims: We assessed the impact of a single bolus dose of PegV on the GH/IGF axis in adults suspected of GH deficiency with low IGF-I levels.

Study Design: In this proof-of-concept pilot study, 10 adults suspected of adult GH deficiency received a single bolus dose of SC PegV (1 mg/kg). Blood GH, GH binding protein (GHBP), total IGF-I, IGF-I bioactivity, IGFBP-2, and IGFBP-3 levels were measured at baseline and 72 hrs after SC PegV administration.

Methods: GH was measured using an automated assay that excludes PegV interference, where a monoclonal antibody that does not cross-react with PegV was combined with a monoclonal antibody specific for 22-kD GH; IGF-I was measured by commercial immunoassays using the automated iSYS platform; GHBP was measured by a modification of the ligand immunofunctional assay with an in-house monoclonal anti-GHBP antibody; in vitro IGF-I bioactivity was measured by an in-house IGF-I receptor kinase receptor activation assay, where the assay detects the ability of serum to phosphorylate the IGF-I receptor in vitro; PegV was measured by a two-site competitive immunofluorometric assay, where serum samples were diluted 100-fold to minimize potential GH interference.

Results: A total of 10 patients [5M/5F; age (mean ± SE) 40.8 ± 2.5 yrs; BMI 29.6 ± 2.5 kg/m2] with hypothalamic-pituitary disease, 1-3 pituitary hormone deficiencies and low IGF-I (IGF-I SDS -2.0 ± 0.3) were recruited. Administration of PegV increased GH (prePegV 0.13 ± 0.04 vs postPegV 0.41 ± 0.15 ng/mL; P < 0.01) and GHBP (626 ± 114 vs 1073 ± 174 pmol/L; P < 0.001), decreased total IGF-I (85.1 ± 8.3 vs 64.8 ± 10.2 ng/mL; P < 0.05) and IGF-I bioactivity (1.09 ± 0.08 vs 0.93 ± 0.08 µg/L; P < 0.05), but did not alter IGFBP-2 and IGFBP-3 levels. Serum PegV levels positively correlated with GH (r = 0.83; P < 0.01), ΔGH (r = 0.85; P < 0.01), ΔGHBP (r = 0.85; P < 0.01), and negatively correlated with IGF-I bioactivity (r = -0.61; P< 0.05). No subject reported any adverse reactions to the PegV injections.

Conclusion: A single bolus high dose PegV not only exerts acute GH receptor blockade and lowers total IGF-I levels but also decreases IGF-I bioactivity acutely, independent of altering IGFBP-2 and IGFBP-3 levels even in states of low IGF-I levels. Further studies are needed to verify if the reduction in IGF-I bioactivity with a single bolus high dose PegV is sustainable over time when high PegV doses are administered daily, as this is clinically relevant especially when treating patients with acromegaly.

 

Disclosure: KCJY: Ad Hoc Consultant, Novo Nordisk, Ad Hoc Consultant, Teva, Principal Investigator, Pfizer, Inc.. Nothing to Disclose: JF, SAR, MB

21428 4.0000 THR-460 A Impact of Acute GH Receptor Blockade with Pegvisomant on GH and IGF Kinetics in Adults Suspected of GH Deficiency with Low IGF-I Levels 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Camelia M. Saffarini*1, Cadence True2, Lacey C Plummer1, Margaret Flynn Lippincott1 and Stephanie Beth Seminara1
1Massachusetts General Hospital, Boston, MA, 2Oregon National Primate Research Center, Beaverton, OR

 

Mutations in POLR3B, encoding the second largest catalytic subunit within RNA polymerase III, have been identified in patients with leukodystrophy syndromes, some of which include pubertal delay.  However, broader populations have not yet been tested.  Therefore, probands with isolated hypogonadotropic hypogonadism (n = 166) and no evidence of ataxia, hypodontia, or chorioretinal dystrophy were screened by whole exome sequencing for mutations in POLR3B to evaluate the prevalence of mutations and define genotype/phenotype relationships.  The remaining 3 probands carried 5 rare coding sequence variants that were considered to be deleterious in 4 prediction programs (SIFT, pMUT, MutationTaster, and PANTHER).  Proband #1 carried two missense changes, one inherited from each parent: p.V523E (c.1568T>A), and p.F400S (c.1199T>C).  The p.V523E (c.1568T>A) change has been previously identified in a patient with Gordon Holmes syndrome (GHS, HH and ataxia) and is present in very low frequency (0.05%) in European controls (Exome Sequencing Project).  Proband #2 carried p. M415T (c.1244T>C) (0.1% European controls) which also been previously identified in a patient with GHS as well as a frameshift (c.2633insT; p.L880SfsX41).  Proband #3 carried the same missense variant (c.1244T>C; p.M415T) as well as a splice-site (c.2818-2 A>T) mutation.  Proband #3 is of particular interest, as he was diagnosed with the “fertile eunuch” form of IHH with initial testicular volumes of 11 cc bilaterally.  At age 27, he underwent therapy with exogenous, pulsatile GnRH (escalating doses) for 29 weeks, but was unable to raise his testosterone into the normal range.  His gonadotropins remained in the low/normal range throughout his therapy.  This data suggests that Proband #3 had resistance to exogenous GnRH, consistent with a primary pituitary abnormality.  Thus, the finding of rare, deleterious nucleotide variants in POLR3B in patients with isolated hypogonadotropism but no neurologic defects extends the phenotype spectrum of this gene.

 

Nothing to Disclose: CMS, CT, LCP, MFL, SBS

21856 5.0000 THR-461 A POLR3B Mutations in Subjects with Isolated Normosmic Hypogonadotropic Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Ali Abbara*1, Channa N Jayasena2, Georgios Christopoulos3, Shakunthala Narayanaswamy4, Chioma Izzi-Engbeaya4, Gurjinder M Nijher2, Alexander N Comninos1, Deborah Peters5, Adam John Buckley5, Risheka Ratnasabapathy4, Julia K Prague4, Mohammad A Ghatei4, Stephen R Bloom2, Geoffray Howard Trew6 and Waljit S Dhillo1
1Imperial College NHS Healthcare Trust, London, United Kingdom, 2Imperial College London, United Kingdom, 3Hammersmith Hospital, London, United Kingdom, 4Imperial College London, London, United Kingdom, 5Imperial College London, 6IVF Unit Hammersmith Hospital, London, United Kingdom

 

Background:In Vitro Fertilization (IVF) treatment is an effective therapy for couples suffering from infertility, but may result in the potentially life-threatening complication termed ‘Ovarian Hyperstimulation Syndrome’ (OHSS). We have previously reported that the hormone kisspeptin-54 can be used to trigger reproductive hormonal release and induce high rates of oocyte maturation in women undergoing IVF treatment. We hypothesized that kisspeptin-54 could be used to safely and effectively trigger oocyte maturation in women at high risk of OHSS.

Methods:Sixty women with subfertility at high risk of OHSS, as identified by high serum anti-mullërian hormone >40 pmol/l and antral follicle count >23 on ultrasound, were randomized to receive a single subcutaneous dose of kisspeptin-54 to trigger oocyte maturation following a standard recombinant FSH / GnRH antagonist protocol. An adaptive dose allocation protocol was utilized, randomizing the first 15 participants to 3.2, 6.4 or 12.8 nmol/kg kisspeptin-54 (n=5 per group). Following interim analysis, remaining participants were randomized to receive either 6.4, 9.6 or 12.8 nmol/kg of kisspeptin-54 (n=15 per group). Oocytes were retrieved 36h after kisspeptin-54 administration, assessed for maturation (primary outcome), and fertilized by intracytoplasmic sperm injection with subsequent transfer of 1-2 embryos. All women were screened for the development of both early and late OHSS by assessment with symptomatology, pelvic ultrasound and blood analysis.

Results:Oocyte maturation was observed in 95% (57/60) of women following kisspeptin-54 administration. Embryo formation did not occur in 3 women, and a clinical decision was made to electively freeze embryos in a further 3 women; thus 51 of 60 women had fresh embryo transfer. Biochemical and clinical pregnancy rates per transfer at all doses of kisspeptin-54 tested were 63% (32/51) and 53% (27/51), respectively. Highest pregnancy rates were seen following 9.6 nmol/kg of kisspeptin-54, which resulted in a 77% (10/13) clinical pregnancy rate per transfer. Eight from 60 women had mild to moderate OHSS, but no woman had severe or life-threatening OHSS requiring medical admission or intervention.

Conclusion: Use of kisspeptin-54 to trigger oocyte maturation with subsequent fresh embryo transfer resulted in high clinical pregnancy rates and low rates of OHSS. Thus kisspeptin-54 shows great potential for future clinical use to safely and effectively trigger oocyte maturation in IVF therapy, even in women at high risk of OHSS.

 

Nothing to Disclose: AA, CNJ, GC, SN, CI, GMN, ANC, DP, AJB, RR, JKP, MAG, SRB, GHT, WSD

21219 6.0000 THR-462 A Kisspeptin-54 Safely and Effectively Triggers Oocyte Maturation during IVF Treatment in Women at High Risk of Developing Ovarian Hyperstimulation Syndrome (OHSS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Martin Bidlingmaier*1, Sara Harperscheid2, Elahu S Sustarsic3, Riia Karoliina Sustarsic3, Amon Horngacher4, Herbert A Schmid5 and Maximilian Bielohuby6
1Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany, 2Endocrine Research Unit, Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians University, 3Endocrine Research Unit, Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians University, Munich, 4Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany, 5Novartis Pharma AG, Basel, Switzerland, 6Medizinische Klinik und Poliklinik IV, Munich, Germany

 

The SSA Pasireotide (PAS) is used to treat acromegaly by controlling GH-excess and thereby normalizing IGF-I secretion. Recently, the long-acting release formulation (“LAR”) of PAS has become available reducing the injection frequency in patients to once a month. Because it is not clear if the degree of drug-mediated suppression of GH is directly correlated to the percentage of IGF-I suppression, we investigated the relation between GH and IGF-I secretion in rats treated with different doses of PAS-LAR.

Methods: Male Lewis rats (n=6/group) were injected with either vehicle (controls) or PAS-LAR (0.1, 0.5, 1, 4, 8, 80mg/kg). Blood samples were collected 24h (all doses) and 14 days (only 4, 8 and 80mg/kg) after a single injection of different doses of PAS-LAR. Serum IGF-I and GH were measured by immunoassay. GH concentrations were determined from serial blood samplings (10 samples during 5h) and analyzed by rank-plots. Genes of interest were quantified in liver tissue by real-time PCR (4, 8 and 80mg/kg groups).

Results: Starting with a dose of 0.5mg/kg, either dose of PAS-LAR strongly suppressed GH secretion after 24h and lowered IGF-I by about 20% (0.5mg/kg), 40% (1mg/kg) or 65% (4, 8 and 80mg/kg) vs. controls (p<0.001). Injection of 0.1mg/kg did not show an effect on GH and IGF-I secretion. 14 days after injection, GH was still suppressed in rats treated with any dose (albeit to a smaller degree compared to GH-suppression after 24h). 80mg/kg was most effective, while 4mg/kg and 8mg/kg did not differ significantly. In contrast, IGF-I was suppressed in a dose-dependent manner 14days after treatment. As expected, hepatic IGF-1 expression was significantly lower after 24h and 14days in all PAS-groups. Interestingly, after 14days, each PAS-LAR dose lowered (approx. 50%) expression of the hepatic GH-receptors (p<0.01).

Conclusion: Suppression of GH and IGF-I was significantly higher 24h after the injection of PAS-LAR compared to 14days after injection pointing towards a tachyphylaxis effect. As expected, PAS-LAR dose-dependently suppressed serum IGF-I after 24h and 14days. In contrast, suppression of GH did not show a dose-dependency. Therefore we may suggest direct effects of PAS-LAR on suppression of serum IGF-I which are independent from pituitary GH inhibition. Furthermore, the observation of significantly lower hepatic GH-receptor expression with PAS-LAR fuels the speculation that PAS may also inhibit IGF-I secretion through extra-pituitary mechanisms.

 

Disclosure: HAS: Employee, Novartis Pharmaceuticals. Nothing to Disclose: MB, SH, ESS, RKS, AH, MB

19840 7.0000 THR-463 A Effects of the Somatostatin Analog Pasireotide on GH- and IGF-I-Concentrations: Correlations and Dissociations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Irina V Trigolosova1, Alexander V Dreval*1, Anna V. Vinogradova1, Irena A Ilovayskaya1 and Bruce H.R. Wolffenbuttel2
1Moscow Regional Research & Clinical Institute, Moscow, Russia, 2University Medical Center Groningen, Groningen, Netherlands

 

BACKGROUND: Patients with acromegaly frequently develop diabetes mellitus (DM), and treatment with long-acting somatostatin analogues (SSA) may worsen blood glucose control.

AIM: To evaluate the efficacy of metformin in newly-diagnosed acromegaly patients during treatment with SSA.

Material and methods: 19 newly-diagnosed acromegaly patients (4 men, 15 women; median  age 55 [IQR 50 -62] years) without known DM underwent an oral glucose tolerance test (OGTT) with glucose and insulin levels assessment every 30 minutes for 2 hours. OGTT performed at baseline and after 6 months of SSA therapy. Early carbohydrate metabolism disturbance  and DM  were diagnosed according to WHO recommendations. From the fasting plasma glucose (FPG) and  insulin (FPI), HbA1c,  index of insulin resistance (НОМА-R), index of insulin sensitivity (MATSUDA-index), area under insulin curves (AUCins) were calculated. Examined patients were randomized into 2 groups: without metformin treatment (group 1), n=13, and with metformin treatment (group 2), n=6.

Results: With SSA treatment, we observed a significant reduction in growth hormone (from 32.4 to 8.4 ng / ml, p <0.01) and the percentage of IGF-1 upper normal limit (from 171 to 26.9 %, p <0.01). In group 1 we observed a tendency of HOMA-R reduction from 2.4 to 2.2 (p=0.08) and increase in the level of Matsuda index from 2.7 to 4.5 (NS). FPI fell from 71 pmol / l to 57.2 pmol / l (p <0.05) and the AUCins ( in 1.3 times), especially its first phase secretion (in 3.7 times) (p <0.05). HbA1c levels and FPG increased from 5.8% to 6.0% (p <0.05), and from 5.3 mmol / l to 6.1 mmol / l (p <0.05) respectively. In group 2 (metformin group) we observed a tendency of a decrease of  HOMA-R from 7.8 to 1.5 (NS ) and the increase of  the Matsuda index from 1.7 to 8.3 (NS), reduction of FPI from 166.5 pmol / l to 38.0 pmol / l (p <0.05), AUCins ( in 2.5 times) (p <0.05), especially its first phase (in 4 times) (p <0.05). HbA1c levels and FPG decreased from 6.5% to 6.1% and  from 8.0 mmol / l to 7.0 mmol / l respectively, (NS).

Conclusions: SSA therapy reduced insulin resistance on one hand, but also reduced the first phase of insulin secretion. Metformin treatment  reduced FPG and HbA1c, but had not effect on the first phase insulin secretion.

 

Nothing to Disclose: IVT, AVD, AVV, IAI, BHRW

21661 8.0000 THR-464 A The Effectiveness of Metformin Therapy in Newly-Diagnosed Acromegaly Patients Receiving Therapy with Somatostatin Analogues 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Chrysanthi Fergani*1, Nora Newcomb2, Robert L. Goodman3, Lique M Coolen1 and Michael N Lehman1
1University of Mississippi Medical Center, Jackson, MS, 2University of Mississippi Medical Center, 3West Virginia University School of Medicine, Morgantown, WV

 

Kisspeptin neurons located in the arcuate nucleus (ARC) of the hypothalamus are primary targets of the tachykinin, neurokinin B (NKB) and this interaction is considered necessary for gonadotropin release. Specifically, kisspeptin cells co-localize NKB and its high affinity receptor neurokinin-3 (NK3R), and it has been proposed that this feedback loop stimulates kisspeptin, and by extension, GnRH/LH release. However, recent evidence suggests that other members of the tachykinin family, namely substance P (SP), may also be involved in the regulation of GnRH/LH release in rodents, via unknown mechanisms. Indeed, SP administered icv, can stimulate LH secretion in the ewe, but only at high doses (Goodman abstract Endo 2015). In the present study, we examined the co-localization of SP and/or its high affinity receptor neurokinin-1 (NK1R) in kisspeptin neurons in the sheep hypothalamus and compared this expression in adult males and females.  Brain tissue from gonadal-intact male and ovariectomized artificial follicular phase female sheep were perfused (n=7/group) and tissue sections containing ARC were processed for double-label immunofluorescent detection of kisspeptin and SP or NK1R.  Preliminary data has revealed an abundance of SP fibers and cell bodies in the ARC, with greater numbers in females compared to males (42±4.1 vs. 18±5.1, respectively, per hemisection).  No co-localization between kisspeptin and SP was observed, however, a high density of fibers was found in close apposition with kisspeptin cells. NK1R immunoreactivity (ir) was observed only in the rostral portion of the ARC, which contains few kisspeptin–ir cells. In the rostral ARC, there was no difference in the number of NK1R-ir cells between sexes (16.5±2.3 vs. 18.5±3.9, in females and males, respectively) and the % co-localization with kisspeptin was low in both sexes (10.6±1.5% vs. 7.5±2.2%). Thus, these results demonstrate that arcuate kisspeptin neurons receive SP-containing inputs, but NK1R expression is limited. Hence, we hypothesize that in the ewe, SP may stimulate LH secretion via a kisspeptin-independent manner. Alternatively, since there is some cross-reactivity among ligands for tachykinin receptors, SP may act via NK3R in kisspeptin cells to stimulate kisspeptin and hence LH secretion. In agreement, an abundance of SP fibers is found in close apposition with kisspeptin cells, and a high dose of SP (100x that of NKB) is needed to increase LH secretion (Goodman abstract Endo 2015).

 

Nothing to Disclose: CF, NN, RLG, LMC, MNL

22178 9.0000 THR-465 A Anatomical Relationships of Kisspeptin to Substance P and Neurokinin-1 Receptor in the Sheep Arcuate Nucleus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Shannon B.Z. Stephens*1, Nagambika Munaganuru2 and Alexander S Kauffman1
1University of California, San Diego, La Jolla, CA, 2University of California San Diego, La Jolla, CA

 

Kisspeptin, encoded by the Kiss1 gene, regulates reproduction by signaling directly to GnRH neurons through the kisspeptin receptor (Kiss1r). Kiss1/kisspeptin neurons are detected in several brain regions, primarily in the hypothalamic anteroventral periventricular (AVPV) and arcuate (ARC) nuclei, as well as a smaller population outside the hypothalamus in the medial amygdala (MeA). As in the AVPV, in the MeA, Kiss1 expression is increased by sex steroids acting via estrogen receptor pathways. However, the pathways and mechanisms by which estradiol signals to increase Kiss1 expression in the MeA is unknown, as is the functional significance of such up-regulation. In the hypothalamus, Kiss1 neurons are regulated primarily through estrogen estrogen receptor α (ERα), despite also coexpressing ERβ. Both ERα and ERβ are highly expressed in the MeA, suggesting that either or both ERs may be involved in Kiss1 regulation in this region. Here, we used mice lacking ERα to examine whether ERα is necessary for estradiol stimulation of Kiss1 expression in the MeA. Heterozygous ERαKO breeding pairs were used to generate male and female ERαKO and WT control littermates. To equalize estradiol levels between genotypes, all ERαKO and WT controls of both sexes were gonadectomized at 7 weeks of age and one week later, half the mice in each genotype received constant estradiol treatment via subcutaneous Silastic capsules; the remaining gonadectomized mice received no hormonal treatment.  Mice were sacrificed 5 days later and blood and brains were collected. Blood serum was analyzed for LH and estradiol levels, while brains were examined for Kiss1 expression in the MeA using in situ hybridization. Kiss1 expression in the MeA was very low in gonadectomized WT and ERαKO male mice that did not receive estradiol treatment. WT males treated with estradiol showed a large increase in MeA Kiss1 expression, both cell number and mRNA per cell. In contrast, MeA Kiss1 levels were significantly lower in estradiol-treated ERαKO males relative to WTs, despite comparable estradiol levels between the two groups.  Thus, ERα appears to be necessary for the ability of estradiol to induce maximal Kiss1 expression in the MeA of male mice, similar to estradiol regulation of AVPV Kiss1 neurons. Current experiments are determining if the same pattern holds true for MeA Kiss1 in females. Uncovering the necessity of ERα for MeA Kiss1 expression may help identify and understand possible functions of this unique extra-hypothalamic kisspeptin population. 

 

Nothing to Disclose: SBZS, NM, ASK

20656 10.0000 THR-466 A Estradiol Regulation of Kiss1 in the Medial Amygdala Involves Estrogen Receptor Alpha 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Charlotte Höybye*1, Jens Sandahl Christiansen2, Birgitte Tønnes Pedersen3, Effie Pournara4 and Beverly M.K. Biller5
1Karolinska University Hospital, Stockholm, Sweden, 2Aarhus University Hospital, Denmark, 3Novo Nordisk A/S, Søborg, Denmark, 4Novo Nordisk Health Care AG, Zurich, Switzerland, 5Massachusetts General Hospital/Harvard Medical School, Boston, MA

 

Background

It is recognised that women are less sensitive to exogenous GH than men, and therefore need higher GH doses than men to achieve the same levels of insulin-like growth factor-I (IGF-I). However, it is not clear whether this knowledge is applied in the clinical practice of GH replacement for patients with GHD.

Objective

To evaluate the changes in IGF-I, serum lipids, waist circumference, fasting blood glucose (FBG) and metabolic status relative to gender and GH dose, during 4-years of GH therapy in adults with GHD. 

Methods

Patients with adult-onset GHD receiving GH therapy (Norditropin®, somatropin, Novo Nordisk A/S) enrolled in NordiNet® IOS with 4 years of follow-up data were evaluated. Descriptive statistics were applied. A t-test was used to analyse change from baseline in GH dose, IGF-I standard deviation score (SDS), BMI, waist circumference, lipids and FBG. Stratification by baseline FBG enabled analysis of conversion of metabolic status (normal: 3.9–5.5 [70–100]; prediabetes/impaired glucose tolerance: 5.6–7.0 [101–126]; diabetes: ≥7.0 [126] mmol/L [mg/dL]) during GH therapy.

Results

Data were analyzed for 822 adult patients (44.9% female). Mean (SD) GH dose (females 0.31 [0.23]; males, 0.28 [0.22] mg) increased significantly from baseline to 4 years, but to a greater extent in females (mean difference [95% CI]: 0.07 [0.03; 0.10] mg/day; p<0.001). A significant increase (and to similar levels) in mean (SD) IGF-I SDS from baseline values (females, –0.88 [1.32]; males, –0.53 [1.38]) was observed at 4 years (females, 1.51 [1.28; 1.75]; males, 1.48 [1.21; 1.75]; p<0.001 vs. baseline for both) in both genders. During 4 years of follow-up, a significant reduction in LDL-cholesterol from baseline was observed in males (p<0.0316) but not in females (females, –0.07 [–0.32; 0.17]; males, –0.24 [–0.46; –0.02] mmol/L) and FBG significantly increased in females but not in males (females, 0.44 [0.15; 0.73]; p=0.0033; males, 0.13 [–0.16; 0.41] mmol/L; ns). Most (84.1%) patients had normal metabolic status at baseline. The proportion of patients with prediabetes at baseline who had normal metabolic status at 4 years was higher in males than in females (females 55% vs. 25%).  

Conclusions

Despite a higher baseline GH dose and dose increase in female than in male patients, 4-year GH treatment outcomes were generally better in males than in females. Although there seems to be clinical awareness of women needing higher GH doses than men, GH doses used may still be insufficient to overcome gender-related GH-resistance.

 

Disclosure: CH: Coinvestigator, Novo Nordisk. JSC: Advisory Group Member, Novo Nordisk. BTP: Employee, Novo Nordisk. EP: Employee, Novo Nordisk. BMKB: Consultant, Pfizer, Inc., Consultant, Versartis, Consultant, Novo Nordisk, Principal Investigator, Inventiv.

18432 11.0000 THR-467 A Is There Still Insufficient Growth Hormone (GH) Replacement of Women with GH Deficiency (GHD)? Analysis of Data from Nordinet International Observational Study (IOS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Nicole H Bellefontaine*1, Margaret B Allison2, Martin Grosvenor Myers Jr.3 and Carol F Elias1
1University of Michigan, Ann Arbor, MI, 2University of Michigan, 3Univ of Michigan, Ann Arbor, MI

 

Central leptin action is an essential signal for energy-intensive homeostatic processes, including reproduction. The ventral premammilary nucleus (PMv) of the hypothalamus has been shown to be a key site for the metabolic control of reproductive physiology. The PMv abundantly expresses the leptin receptor (LepRb), contains sex steroid receptors, responds to olfactory stimuli, and is putatively involved in the sexually dimorphic circuitry.  Nevertheless, relatively little has been described about the specific PMv LepRb expressing cell populations, sex differences, and their potential role in reproductive functioning. Here we set out to define innervation sites and sexual differences of two cell populations within the PMv using transgenic mouse models. The PMv of female and male LepRb-cre mice were targeted with an adeno-associated virus (AAV) expressing synaptophysin-mCherry fusion protein, uniquely allowing for the analysis of synaptic terminals. Our findings indicate that males have a greater number of infected LepRb cells within the PMv when compared to females. As previously described, the PMv had dense and widespread projections across several nuclei of the hypothalamus, including the arcuate (ARH), ventromedial (VMH), paraventricular (PVH), and preoptic area (POA).  Further, the PMv innervates several extrahypothalamic sites such as the central amygdala, periaqueductal gray, and lateral septum (LS). Interestingly, we found that LepRb PMv neurons of males have far denser projections and that the dorsal LS contains mCherry labeled fibers only in males.  We also describe here a novel subset of LepRb cells within the PMv that express the dopamine transporter (DAT). To determine the innervation of the PMv DAT expressing neurons, we targeted the PMv of DAT-Cre mice with the viral tracer as described above. Fewer mCherry labeled cells were seen the PMv of DAT-cre mice compared to the LepRb mice. Terminals were observed in the VMH, ARH, and PVH. However, no fibers were noted rostrally in the POA or in extrahypothalamic sites, suggesting that the DAT expressing neurons of the PMv have a more restricted innervation pattern. Together, we have mapped the innervation pattern of LepRb expressing cells within the PMv and described striking sex differences, lending further evidence for the role of the PMv in sexually dimorphic circuitry. Moreover, we have described for the first time a novel cell population within the PMv, those expressing DAT. Further studies are needed to elucidate the role of the LepRb expressing DAT cells of the PMv, as well as their potential role in the control of reproductive physiology by leptin.

 

Nothing to Disclose: NHB, MBA, MGM Jr., CFE

20518 12.0000 THR-468 A Molecular Mapping of the Sexually Dimorphic Leptin Receptor Populations within the Ventral Premammilary Nucleus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Johannes D Veldhuis*1, Thomas P. Olson2, Paul Y. Takahashi2, John M. Miles2, Michael J. Joyner2, Rebecca Y. Yang3 and Jean R. Wigham3
1Mayo Clinic & Graduate School of Medicine, Rochester, MN, 2Mayo Clinic, Rochester, MN, 3Mayo Cinic, Rochester, MN

 

Context.  Exercise evokes pulsatile GH release acutely, which is followed by autonegative feedback, whereas glucose suppresses GH release acutely followed by rebound-like GH release (feedforward escape).

Objective.  To test the hypothesis that age, sex steroids, insulin, body composition and physical power determine dynamic GH responses, viz., GH autofeedback and feedforward.

Design. Prospectively randomized glucose-blinded design.

Setting.  National Center for Advancing Translational Sciences.

Participants.  Healthy men ages 19-77 yr (N = 23).

Interventions.  Fasting/rest/saline, fasting/exercise/saline and fasting/rest/iv glucose infusions were used to drive GH dynamics during 10-min blood sampling for chemiluminescence GH assay.

Outcomes.  Stepwise correlation analysis to relate peak/nadir GH dynamics to age, sex steroids, insulin, CT-estimated abdominal fat and physical power (work per unit time).

Results.  Compared with the fasting/rest/saline (control) day, fasting/exercise/saline infusion evoked peak GH within 1 h, followed by negative feedback 3-5 h later.  The dynamic GH excursion was strongly (coefficient of determination, R2 = 0.634) influenced by (i) insulin negatively (P = 0.011), (ii) power positively (P = 0.0008), and (iii) E2 positively (P = 0.001).  The dynamic range of glucose-modulated GH release was determined by insulin negatively (P = 0.0039) and power positively (P = 0.0034) [overall R2 = 0.454].  Under control conditions, power (P = 0.031) and total abdominal fat (P = 0.012) [R2 = 0.267] were the dominant correlates of GH excursions. 

Conclusion.  In healthy men, dynamic GH perturbations induced by exercise and glucose are strongly related to physical power, insulin, estradiol, and body composition, thus forging a network of regulatory pathways.

 

Nothing to Disclose: JDV, TPO, PYT, JMM, MJJ, RYY, JRW

18369 14.0000 THR-470 A Multipathway Modulation of Exercise and Glucose Stress upon GH Secretion in Healthy Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Ravikumar Balasubramanian*1, Sheena Chew2, Sarah E Mackinnon2, Peter B Kang2, Caroline Andrews2, Wai-Man Chan2 and Elizabeth C Engle2
1Massachusetts General Hospital, Boston, MA, 2Boston Children's Hospital, Boston, MA

 

Background:  A heterozygous de novo c.1228G>A mutation (E410K) in the TUBB3 gene encoding the neuronal-specific beta-tubulin isotype 3 (TUBB3) causes the TUBB3 E410K syndrome characterized by congenital fibrosis of the extraocular muscles (CFEOM), facial weakness, intellectual and social disabilities, and Kallmann syndrome (anosmia with hypogonadotropic hypogonadism)1. All TUBB3 E410K subjects reported to-date are sporadic cases.

Objective:To report the clinical, genetic, and molecular features of a familial presentation of the TUBB3 E410K syndrome 

Methods: Case report of a mother and three affected children with clinical features of the TUBB3 E410K syndrome. Genetic analysis of the TUBB3 gene was done by Sanger sequencing. Endocrine and non-endocrine phenotypes of the proband and family members were ascertained by clinical history and physical examination.

Results:  A de novo TUBB3 c.1228G>A mutation arose in a female proband who displayed CFEOM, facial weakness, intellectual and social disabilities, and anosmia. However, she underwent normal sexual development at puberty and had three spontaneous pregnancies with subsequent autosomal dominant inheritance of the mutation by her three boys, thus suggesting incomplete penetrance of hypogonadotropic hypogonadism. All sons displayed non-endocrine features of the TUBB3 E410K syndrome similar to their mother, but in contrast to their mother,  had variable features suggestive of additional neuroendocrine abnormalities including hypogonadotropic hypogonadism, hypoadrenalism, growth hormone deficiency and central hypothyroidism.

Conclusions:  This first report of a familial autosomal dominant inheritance of the TUBB3 c.1228G>A mutation  provides new insights into the spectrum of endocrine phenotypes associated with the TUBB3 E410K syndrome. The presence of anosmia without hypogonadotropic hypogonadism in the proband also demonstrates that TUBB3 mutations may have dissociated effects on the ontogeny of olfactory axons and GnRH neurons. These observations emphasize the need for appropriate clinical evaluation and complicate genetic counseling of patients and families with this syndrome.

 

Nothing to Disclose: RB, SC, SEM, PBK, CA, WMC, ECE

21344 16.0000 THR-472 A Expanding the Phenotypic Spectrum and Variability of Endocrine Abnormalities Associated with TUBB3 E410K Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


IIonka Kreitschmann-Andermahr*1, Sonja Siegel2, Bernadette Kleist1, Johannes Kohlmann3, Christa Menzel3, Sven-Martin Schlaffer3, Rolf Buslei3 and Michael Buchfelder3
1University of Duisburg-Essen, Essen, Germany, 2University Hospital Essen, Essen, Germany, 3University Hospital Erlangen, Erlangen, Germany

 

Introduction: We recently conducted a large postal survey on the diagnostic process of acromegaly from the patients’ perspective1. An analysis of the data yielded a mean self-reported time from symptom onset to diagnosis of 4.3 ± 6.1 years. In an earlier study of our group with only 40 participants, the time delay of the diagnostic process was significantly associated with psychosocial impairment, which we hypothesized to be caused by embitterment disorder2. This is defined as a prolonged, adverse psychological reaction on a stressful life event, which is perceived as unjust and humiliating. Against this background, it was the aim of the present study to investigate the possible impact of belated diagnosis of acromegaly on quality of life (QoL), depression and, specifically, embitterment in a large patient group.

Methods:  Patients who had been operated between 2000 and 2012 in a large tertiary neurosurgical referral center and had completed the survey on the diagnostic process also filled in self-rating questionnaires on depression (Beck Depression Inventory II; BDI-II), QoL (Short Form 36; SF-36) and embitterment (Bern Embitterment Inventory; BEI). The data of 165 valid answer sets were analyzed using SPSS.

Results: Patients in the study did not suffer, on average, from increased embitterment or an overall reduced QoL. Male patients had significantly higher performance related embitterment scores than women, who in turn, had a significantly worse psychological Qol than men and were more depressed. Number of doctors consulted in the diagnostic process was significantly associated with emotional embitterment, pessimism and hopelessness, (BEI), physical and mental quality of life (SF-36) and depression (BDI-II). Consistently, time delay from first seeking medical advice to diagnosis was also significantly related to the same parameters of the BEI, SF-36 and BDI-II (p ≤ 0.05 – 0.001).

Conclusion: Delayed diagnosis of acromegaly has severe consequences in terms of psychosocial impairment and is associated with higher scores on many subscales of the embitterment questionnaire in patients with acromegaly. The results underscore the need to maximize efforts to establish better diagnostic algorithms for speedier diagnosis. Furthermore, the results should be taken into account for developing psychological supportive treatments for the affected patients.

 

Disclosure: IK: Clinical Researcher, Novartis Pharmaceuticals, Clinical Researcher, Pfizer, Inc., Clinical Researcher, Ipsen. MB: Investigator, Pfizer, Inc., Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Novo Nordisk. Nothing to Disclose: SS, BK, JK, CM, SMS, RB

19565 17.0000 THR-473 A Depression, Embitterment and Impaired Quality of Life Are Sequelae of Belated Diagnosis of Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Flavia Lucia Conceicao*1, Amanda Araujo Laudier2 and Monique Morgado Loureiro3
1Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 2Universidade Federal do Rio de Janeiro, Rio de Janeiro, 3Universidade Federal do Rio de Janeiro

 

Growth and development abnormalities have long been studied in children with sickle cell anemia. Almost all have detectable growth failure that affects weight more than height. Normal height is often achieved by adulthood but weight remains lower than that of controls. The etiology for the growth disturbances in this population seems to be multifactorial. Primary hypopituitarism, hypogonadism, and hypothalamic insufficiency, besides chronic anemia have been described. Growth hormone and insulin-like growth factor I axis abnormalities were found in children with sickle cell disease and growth failure, however there aren’t studies in adult populations. Our objective was to study the somatotropic axis in adolescent and adult patients with sickle cell disease. Forty-eight patients with sickle cell disease were submitted to a clinical interview and examination. Hematological parameters and IGF-1 were assessed and all patients were submitted to the insulin tolerance test (ITT). Growth hormone deficiency (GHD) was defined as a GH peak < 3ng/mL. Patients with fetal hemoglobin > 8.6g/dL were classified as “good prognosis”, and those with fetal hemoglobin < or = 8.6g/dL were classified as “poor prognosis”. The median age was 25.5 years (range 15-50) and 58% were female. Four patients had GHD (8.3%), 16 had low IGF-1 (33.33%). Six patients were below the genetic target for stature. Patients in the  “poor prognosis” group (fHb < = 8,6) had lower values of IGF-1 (215.72 X 136.07 ng/dL; p=0.003), suggesting that the reduced levels of IGF-1 are correlated with the severity of the sickle cell disease. In conclusion,  it was the first time that the prevalence of somatotropic axis abnormalities in adult patients with sickle cell disease was evaluated. Patients with sickle cell disease in the “poor prognosis” group had lower IGF level, suggesting a chronic state disease, and not GHD.

 

Nothing to Disclose: FLC, AAL, MML

21357 18.0000 THR-474 A Somatotropic Axis Abnormalities in Patients with Sickle Cell Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Megan Doczi*1, Alexandra Palmer1 and Carl Vitzthum2
1Norwich University, Northfield, VT, 2Colby College, Waterville, ME

 

Shaker family voltage-gated potassium channels (Kv1) contribute to the maintenance of resting membrane potential, action potential characteristics, and neurotransmitter release in several populations of neurons. Evidence has shown that a specific Shaker channel, Kv1.3, can be modulated by circulating hormonal factors such as insulin, suggesting that this channel may be a key determinant of neuronal pathways that regulate metabolic function. Since hypothalamic neurons mediate the homeostatic balance between food intake and energy expenditure, the expression and function of insulin-sensitive Kv1.3 channels during early development may directly influence hypothalamic patterning. To determine whether Kv1.3 channels are expressed in the hypothalamus during early development, we performed quantitative RT-PCR analysis on intact microdissections of embryonic avian hypothalamic tissue. Kv1.3 channels were detected at various developmental time points including embryonic day 8 (E8) and embryonic day 12 (E12). Although no significant difference was detected in Kv1.3 mRNA expression between E8 and E12 (p = 0.0661; n = 3), these data indicate the presence of Kv1.3 mRNA in the developing hypothalamus. Previous research in olfactory bulb neurons has demonstrated that tyrosine phosphorylation-dependent current suppression of Kv1.3 can occur via insulin receptor kinase activity. Therefore, we also tested the hypothesis that insulin receptors (IR) are expressed in the embryonic avian hypothalamus at the same developmental time points as Kv1.3. RT-PCR analysis indicated the presence of IR mRNA in both E8 and E12 intact microdissections of embryonic hypothalamic tissue (n = 3), suggesting that IR signaling may play a role in the regulation of hypothalamic Kv1.3 current during development. To determine whether primary neuronal cultures could be used to study Kv1.3 function, we performed RT-PCR analysis on dissociated hypothalamic neurons from E12 embryos. Consistent with the data obtained from intact hypothalamic tissue, dissociated E12 hypothalamic neurons also revealed the expression of both Kv1.3 and IR in vitro (n = 3). These data indicate that gene expression in the dissociated hypothalamic culture model parallels the results obtained from intact tissue and suggests that future studies implementing this model can be used to examine the electrophysiological function of Kv1.3 in response to various metabolic factors. This study is the first to demonstrate hypothalamic mRNA expression of both Kv1.3 and IR in developing avian embryos and suggests a role for voltage-gated ion channel regulation in the physiological patterning of embryonic hypothalamic circuits.

 

Nothing to Disclose: MD, AP, CV

22005 19.0000 THR-475 A Shaker Family Voltage-Gated Potassium Channel (Kv1) and Insulin Receptor (IR) Expression in the Embryonic Avian Hypothalamus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Sean Stackhouse*1 and Siddharth Ramakrishnan2
1University of Puget OSund, Tacoma, WA, 2University of Puget Sound, Tacoma, WA

 

While the role of Gonadotropin releasing hormone (GnRH) neurons in sexual behavior is well studied, their regulation of social behavior is poorly understood. In this research, we examined the effect of early embryonic exposure of R-F-amide Related Protein3 (RFRP-3), a GnRH antagonist, on social behavior in the teleost medaka (Oryzias latipes). We used the mirror approaching behavior, previously demonstrated as shoaling, a basic social behavior found in many teleosts. Using a transgenic line of medaka with GnRH3-neurons tagged with the green fluorescent protein (GFP), we examined the effects of embryonic exposure to RFRP-3 on both GnRH3 neuron GFP intensity and effects on larval social behavior. Unlike the preoptic area GnRH1 neurons (associated with reproduction) or the midbrain GnRH2 neurons (involved in metabolism), the role of the GnRH3 system associated with the terminal nerve (TN) is poorly understood. This work aims to further investigate the role of the GnRH3 neuronal system and its putative role in modulating social behavior.

Transgenic medaka embryos were treated with 1µM of RFRP-3 from day 0 until hatch. GnRH3-GFP intensity in the TN and trigeminal (TG) areas were recorded using an epifluorescent microscope on 2-4 days post fertilization. Social behavior of larvae was tested at 3 weeks post hatch in a 10cm x 8cm enclosure with 2cm of normal fish water. A fish larva was placed in the chamber under the following conditions with a/an – i) opaque wall; ii) mirror; iii) mirror on one side and a live fish separated by a clear barrier on the other; iv) opaque wall on one side and a live fish separated by a clear barrier on the other. Both RFRP-3 exposed and vehicle treated control fish were exposed to each condition. For tracking, the tank was divided into three equal segments, the mirror/wall region, center region, and a non-mirror/live-fish region. Fish behavior was recorded for 3 minutes after starting the trial and analyzed using the Noldus EthoVision software.

RFRP-3 treated fish showed no significant difference in GnRH3-GFP fluorescence intensity at 3dpf but showed 56% increased intensity at 4dpf (n=12, p<0.01) in the TN and 36% increase the TG (n=12, p<0.05). While there was no overall difference between motion between control and RFRP-3 treated medaka, treated fish were found to spend 70% more time near the mirror under condition (ii) as compared to control fish (p<0.05). We suggest that RFRP-3 exposure may be affecting the GnRH3 neuron development, which could then lead to altered social behavior.

 

Nothing to Disclose: SS, SR

21667 20.0000 THR-476 A Rfrp-3 Affects Gnrh3 Neuronal Development and Larval Social Behavior in the Teleost Oryzias Latipes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Fabiana Lucio-Oliveira*1, Juliana Lima2, Fernanda Vechiato2, Ricardo Coletti2, Tatiane Franco2, Lucila Elias3 and Jose Antunes-Rodrigues3
1School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil, 2Universidade de São Paulo, Ribeirão Preto, Brazil, 3Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil

 

The hydroelectrolytic homeostasis is constantly regulated by information concerning the body fluids volume and the concentration of ions. Conformational changes in several regions of CNS cells activate neurons located in the PVN and SON nuclei of the hypothalamus, whose secretion includes oxytocin (OT) and vasopressin (AVP). Several neurotransmitters are involved in the control of AVP and OT release, such as nitric oxide (NO). NO is an important signaling molecule which seems to modulate several physiological processes as neurotransmission, vasodilation and behavioral responses, and has been suggested to exert a prominent regulatory role on hypothalamic-pituitary system. However, there are conflicting data on the role of NO in the release of AVP and OT and studies are scarce and controversial. Thus, the aim of this study was to evaluate the effect of N-Propyl-L- Arginine (NPLA), a selective inhibitor of neuronal NOS, on plasma OT and AVP levels in rats submitted to salt loading. Also, NOS activity was evaluated in medial basal hypothalamus (MBH). Seven days before experiments, every adult male Wistar rat weighing 250 g was unilaterally implanted with a cannula into the right lateral cerebral ventricle (i.c.v). Four days before experiment, the animals were maintained with free access to food and tap water (controls) or 0.3M NaCl solution during 96 hours (salt loading). One hour and thirty minutes before decapitation, the rats were treated with an icv injection of NPLA (250 µg/5 µl) or vehicle (saline NaCl 0,9%). One hour after icv injection, tap water and 0.3M NaCl were reoffered. Trunk blood was collected for determination of osmolality and hormones concentration. The brain was removed and MBH was collected for NOS activity measurement. Our data showed, as expected, an increase in plasma osmolality (p<0.0001; F3,49=20.71) of rats that were submitted to salt loading when compared with control animals. The augment in osmolality was followed by an increase in NOS activity in MBH of salt load rats treat with  icv injection vehicle when compared with control animals under the same treatment (p<0.0001; F2,44=13.10). However, animals submitted to salt loading treated with NPLA had a decrease in NOS activity around 44% when compared with animals treated with vehicle (p<0.0001; F1,44=282.9). In addition, there was a significant increase in plasma AVP (p<0.0001; F3,57=38.30 ) and OT (p<0.0001; F3,51=18.53) concentrations in animals submitted to salt loading when compared with control animals in both treatments, but no difference was observed in treatment with NPLA. These results indicate either that modulation of NO on the secretion of AVP and OT observed in several studies is not likely performed through the neuronal isoform of NOS or that the level of inhibition of NOS (about 44%) was not effective in modulating the response of these hormones during osmotic stimuli such as salt loading.

 

Nothing to Disclose: FL, JL, FV, RC, TF, LE, JA

19838 21.0000 THR-477 A Inhibition of NOS Neuronal Isoform Does Not Alter the Levels of Neurohypophyseal Hormones in Salt Loaded Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Noriyuki Koibuchi*1, Syutaro Toya2, Izuki Amano2, Noriaki Shimokawa3 and Yusuke Takatsuru2
1Gunma Univ Grad Sch of Med, Gunma, Japan, 2Gunma University Graduate School of Medicine, Maebashi, Japan, 3Gunma Univ Grad Sch of Med, Maebashi, Japan

 

Exposure to various stresses during neonatal period may induce several neuropsychological disorders in adulthood.  Such disorders may be induced by functional alteration of glutamatergic system.  However, underling mechanisms have not yet been fully clarified.  Furthermore, the involvement of glucocorticoids that are representative stress hormone has not yet been fully studied.  In the present study, we used maternal deprived (MD) male mice as an early life stress model, and studied the change in glutamatergic system and glucocorticoid homeostasis in adulthood.  Neuronal activity of the somatosensory cortex (SSC) was measured by electrophysiology for cortical field potential, and mechanical nociceptive threshold level by von Frey hair somatosensory test.  Glutamate and corticosterone concentrations were measured by in vivo microdialysis.  The neuronal activity, and glutamate and corticosterone concentration in the SSC increased in MD mice.  Nociceptive threshold level decreased in MD mice.  On the other hand an increase in coticosterone concentration by stressful physical stimulation (SPS) was not observed in MD mice, whereas the concentration of glutamate increased extremely during SPS.  Expression levels of AMPA/NMDA receptor were also changed from those of control mice after stimulation.  These findings indicate that early life stress induces disruption of homeostasis of glutametergic synapses in the SSC.  Such alteration may alter the somatosensory response.  Decreased sensitivity of glucocorticoid to acute stress by maternal deprivation may be involved in this disruption.

 

Nothing to Disclose: NK, ST, IA, NS, YT

18635 22.0000 THR-478 A Disruption of Glucocorticoid Homeostasis and Glutamatergic Neuronal Circuit in Adulthood of Male Mice By Maternal Deprivation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Sarah Orton*1, Marisa Censani2, Alexis Jamie Feuer3 and Maria George Vogiatzi1
1Weill Cornell Medicine New York Presbyterian, New York, NY, 2Weill Cornell New York Presbyterian, New York, NY, 3New York Presbyterian Hospital Weill Cornell Medical Center, New York, NY

 

The use of gonadotropin releasing hormone analogs (GnRHa) is increasing in pediatrics. Previous studies have shown that pubertal suppression with leuprolide acetate may result in an increase in weight and body mass index (BMI). However, the data is limited, conflicting and focused primarily on female subjects with a diagnosis of central precocious puberty (CPP). Sparse data is available on the effect of histrelin on BMI. We hypothesized there would be an increase in BMI during GnRHa treatment. This study aims to establish effects of GnRHa therapy on BMI in both genders and examines patients treated with both leuprolide and histrelin for multiple indications. 

This is a retrospective study of pediatric patients who received GnRHa therapy for 12 months. Age, gender, diagnosis and anthropometric data, including BMI standard deviation score (SDS) were obtained at baseline and at three month intervals.

29 patients (23 females, 6 males; age at start of therapy 10.89 years + 2.3, BMI SDS 0.61 + 0.87 kg/m2) received leuprolide acetate monthly (leuprolide group). 9 patients (31%) had CPP, 9 (31%) had early puberty (puberty between the ages of 8-9 for females and 9-10 for males) and 11 (38%) had short stature treated with leuprolide and growth hormone (GH) (one patient had CPP and GHD). 9 subjects were treated with histrelin (7 females, 2 males; age at start of therapy 11.8 years + 2.3, BMI 0.7 + 0.9 SDS kg/m2, all with the diagnosis of CPP) (histrelin group).

No significant change in BMI SDS was detected in the children with CPP treated with either leuprolide or histrelin. Mean BMI SDS increased significantly from baseline after 12 months of leuprolide therapy in subjects without CPP by 0.165 + 0.073 (p=0.035). When stratified for gender, males had a mean BMI SDS increase of 0.22 + 0.099 (p=0.018). A transient increase in BMI SDS was observed at 6 months only in females treated with both leuprolide and growth hormone (BMI SDS increase of 0.191 + 0.692, p=0.022), whereas no change in BMI SDS was noted after 12 months of therapy.

Our data support that GnRHa therapy does not adversely affect BMI in children with CPP. An increase in BMI SDS, which involved primarily males, was detected in subjects without a diagnosis of CPP treated with leuprolide acetate. These findings need to be confirmed with larger studies and can have significant clinical implications for children who receive such therapy.

 

Nothing to Disclose: SO, MC, AJF, MGV

21867 23.0000 THR-479 A GnRH Agonists May Transiently Decrease BMI in Male and Female Pediatric Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Guangfu Hu, Mu-Lan He, Wendy K.W. Ko and Anderson On-Lam Wong*
University of Hong Kong, Hong Kong, China

 

Neurokinin B (NKB) acting via Type III neurokinin receptor (NK3R) is a key component regulating pulsatile release of luteinizing hormone in mammals.  Recently, the carp TAC3 gene products, NKB and NKB-related peptide (NKBRP), were shown to up-regulate somatolactin α(SLα) expression via NK3R activation in carp pituitary cells.  Although NK3R plays a crucial role in mediating the effect of TAC3 gene products, whether NK3R expression can serve as a regulatory target at the pituitary level to modulate the pituitary actions of NKB/NKBRP is still unclear.  In this study, carp NK3R was cloned and found to be expressed at high level in the pituitary.  Functional expression of carp NK3R also revealed that the receptor exhibited ligand binding selectivity and coupling with post-receptor signaling pathways similar to that of mammalian NK3R.  In carp pituitary cells, NK3R mRNA level could be elevated by IGF-I/-II induction via IGF-I receptor (IGF-IR) coupled to MAPK and PI3K/Akt pathways.  Co-treatment with IGF-I/-II, interestingly, was found to markedly enhance NKB/NKBRP-induced SLα mRNA expression at the pituitary level.  This potentiating effect was dependent on NK3R expression and activation of cAMP/PKA, PLC/PKC and Ca2+/CaMK-II cascades. Co-treatment with IGF, however, did not trigger noticeable enhancement in post-receptor signaling via cAMP/PKA, Ca2+/PKC, MAPK or PI3K/Akt pathways.  These results, as a whole, suggested that the synergistic effect on SLα gene expression induced by IGF and TAC3 gene products is mediated by NK3R up-regulation at the pituitary level but not through modulations in functional crosstalk at the level of post-receptor signaling.

 

Nothing to Disclose: GH, MLH, WKWK, AOLW

19743 24.0000 THR-480 A Novel Synergistic Action of Insulin-like Growth Factor and TAC3 Gene Products on Somatolactin á Gene Expression Via up-Regulation of Type III Neurokinin Receptor at the Pituitary Level 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Thiti Snabboon*1, Natnicha Houngngam2, Paisith Piriyawat3, Sarat Sunthornyothin4 and Sompongse Suwanwalaikorn5
1Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 2Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand, Bangkok, Thailand, 3Texas Tech University Health Sciences Center El Paso, El Paso, TX, 4Hormonal and Metabolic Disorders Research Unit, Excellence Center for Diabetes, Hormone, and Metabolism, and Division of Endocrinology and Metabolism, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand, 5Chulalongkorn University, Bangkok, Thailand

 

Introduction: Isolated hypogonadotropic hypogonadism (IHH) is a clinically and genetically heterogeneous disorder. The underlying cause may be due to developmental defects or impaired functional activities of GnRH neurons, disturbed interaction between the GnRH ligand and its receptor, or the release of intact gonadotropins. Advances in genetic study indicate nearly 40% of patients carrying a mutation in one of the susceptible genes.

Materials and Methods: We examined the clinical and genetic features of 13 IHH patients: 3 cases with anosmia (Kallmann syndrome, KS) and 10 cases normosmic IHH (nIHH). Additional clinical parameters were recorded: testicular volume, cryptorchidism, cleft lip and/or palate, neurological, dental, renal and craniofacial anomalies. All patients were screened for mutations by using direct sequencing of the entire coding region of the KAL1, FGFR1, FGF8, PROK2, PROKR2, NELF, GnRH1, GnRHR, TAC3, TACR3, KISS1, KISS1R, and CHD7 genes.

Results: Of all 13 patients, 11 were sporadic cases and 2 were from one consanguineous family. All patients, aged 20-45 year, were men and were found to have micropenis and delayed puberty. Five patients had cryptorchidism. Among patients with KS, 2 had renal agenesis and 1 had septo-optic dysplasia (SOD) feature. Mutations were identified in all KS patients and the one family of nIHH. The KS group harbored mutations in KAL1 (c.653_654delTG; p.Val218fsX11) and FGFR1 (c.303C>G; p.Cys101Trp). Digenic mutations, KAL1 (c.1540G>A; p.Glu514Lys) and FGFR1 (c.203G>A; p.Arg68Gln), were identified in the patient with SOD feature. One of the nIHH patients was found to carry a novel homozygous mutation in GnRHR (c.721_742+1delGTCCTTCATCAGGACCCCCCACG).

Conclusions: Our study demonstrated the clinical and genetic features of the Thai patients with IHH. Furthermore, we reiterated the expanding phenotypic spectrum of IHH, in particular its impact on the development of the anterior midline forebrain

 

Nothing to Disclose: TS, NH, PP, SS, SS

19534 25.0000 THR-481 A Clinical and Genetic Characteristics of Thai Patients with Isolated Hypogonadotropic Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Louise Cheryl Gregory*1, Mark J McCabe1, Rodrigo Bancalari2, Vaitsa Tziaferi1, Helen Spoudeas3 and Mehul Tulsidas Dattani4
1UCL Institute of Child Health, London, United Kingdom, 2Pontificia Universidad Catolica de Chile, Santiago, Chile, 3Great Ormond Street Children's Hospital, London, United Kingdom, 4UCL GOS Institute of Child Health, London, United Kingdom

 

Background Hypogonadotrophic hypogonadism (HH) is a complex developmental disorder characterized by a reduction in gonadotrophins (LH, FSH) that are released from the anterior pituitary. The phenotype is characterized by a delay in onset or complete absence of puberty, often accompanied by genital abnormalities. Kallmann syndrome (KS) is characterized by the association of HH with anosmia/hyposmia, and variably cleft palate, sensorineural hearing loss, and renal abnormalities.

Methods/Cohort We screened 63 HH/KS (M:F 50:13) patients in our cohort, 41 with isolated HH and 22 KS, with 40% of the total having associated abnormalities, for variants in the five most commonly mutated genes, KAL1, PROKR2, FGFR1, FGF8 and GnRHR, using PCR and direct sequencing analysis.

Results We identified 4 variants, two of which were novel. A novel hemizygous missense substitution, KAL1 c.257G>A, p.C86Y, was identified in a male KS patient. A novel FGFR1 heterozygous deletion (c.915delG, p.[Leu305LeufsX6]), causing a frameshift, was identified in two siblings who presented with anosmia: a male with cleft lip/palate and short stature, and a female with a microform cleft lip. The mutation was inherited from the unaffected father. Two previously described variants, that have not been functionally characterized, were also identified in our cohort: a hemizygous early stop codon, KAL1 c.1267C>T, pR423X, in a KS patient and a heterozygous missense substitution, FGFR1 c.2059 G>A, p.G687R, in a male patient with isolated HH who is currently showing signs of reversal after stopping treatment. His mother had primary amenorrhoea and also carries the variant, his father was unaffected and his DNA was unavailable. All four variants are located at highly conserved residues across multiple species and were not present on any control databases.

Conclusion We report two novel and two previously described variants in two different candidate genes in four unrelated HH/KS patients. The potential genetic cause remains unknown in 94% of our HH cohort, signifying the need for further investigation into genes involved in GnRH neuronal migration and secretion, which might be potentially responsible for the pathogenicity.

 

Nothing to Disclose: LCG, MJM, RB, VT, HS, MTD

19198 26.0000 THR-482 A Genetic Screening of Children and Adolescents with Kallmann Syndrome/Hypogonadotrophic Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 457-482 5910 1:00:00 PM Neuroendocrinology Poster


Delanie B. Macedo*1, Danielle de Souza Bessa2, Ana Paula Abreu3, Vinicius N. Brito4, Ursula B. Kaiser5 and Ana Claudia Latronico6
1Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 4Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo SP, Brazil, 5Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 6Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil.

 

Background: Loss-of-function mutations in the coding region of the imprinted gene MKRN3 have recently been recognized as an important cause of familial central precocious puberty (CPP). The promoter region of MKRN3 is notable for potential transcription factor motifs.

Objective: To investigate potential pathogenic variants in the promoter region of MKRN3 in patients with GnRH-dependent pubertal disorders. Variants in the MKRN3 promoter region could result in changes in gene expression and lead to CPP or constitutional delay of growth and puberty (CDGP)

Methods: We studied fifty patients with idiopathic CPP and 25 patients with CDGP. A family history of precocious or delayed sexual development was present in 28% and 32% patients, respectively. Inactivating mutations in the coding region of MKRN3 were excluded in all patients with CPP. Genomic DNA was extracted from peripheral blood leucocytes and a 1000 bp region (-750 to +350 relative to the transcriptional site) of the MKRN3 gene, including potential transcription factor recognition site motifs (PEA3, SRE, SRF, C/EBP, AP2, testis-R), was amplified and automatically sequenced.

Results: We identified a variant, g.23565509T>A (rs182933790), in the promoter region of MKRN3 in a female patient with CPP, who had the onset of pubertal development at age 6.6 years. This variant was also identified in one male patient with CDGP and in one out of 20 control individual suggesting a lack of genotype-phenotype correlation. Furthermore the variant was identified in 1% of the African population from phase 1 of the 1000 Genome Project and the minor allele frequency of this variant was < 0.01, indicating that it is a rare nucleotide change.

Conclusion: No pathogenic variants were detected in the MKRN3 promoter region of patients with idiopathic GnRH-dependent pubertal disorders.

 

Nothing to Disclose: DBM, DDSB, APA, VNB, UBK, ACL

PP03-4 21493 1.0000 THR-144 A Analysis of the MKRN3 Promoter Region in Patients with GnRH- Dependent Pubertal Disorders 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Pierre Chatelain*1, Oleg Malievsky2, Klaudziya Radziuk3, Heba Hassan Elsedfy4, Evgenia Mikhailova5 and Michael Beckert6
1University Claude Bernard, Lyon, France, 2Bashkir State Medical University, Ufa, Russia, 32nd Children City Clinic, Minsk, Belarus, 4Ain Shams University Hospital, Cairo, Egypt, 5Samara State Medical University, Samara, Russia, 6Ascendis Pharma A/S, on behalf of the TransCon hGH study group

 

Background: TransCon hGH is a long-acting prodrug of recombinant human Growth Hormone (hGH) that releases into the blood compartment fully active unmodified hGH.  Previously presented three-month data demonstrated that TransCon hGH has comparable safety and efficacy (height velocity) to daily hGH following repeated dosing in GHD children.

In addition, TransCon hGH was shown in two Phase 1 studies in Healthy Volunteers and a Phase 2 study in adults with hGH Deficiency (AGHD) to: 1) be safe and well tolerated, 2) possess dose dependent, predictable levels of growth hormone, 3) be suitable for a once-weekly dosing regimen, 4) induce an IGF-I pharmacodynamic (PD) response within the normal range throughout the dosing period.

Objectives: The objective of this study is to investigate 1) safety and tolerability, 2) pharmacokinetics (PK) and pharmacodynamics, and 3) efficacy of TransCon hGH in children with Growth Hormone Deficiency.

Design and methods: Pre-pubertal, treatment naïve GHD children received s.c. injections of one of three once-weekly TransCon hGH doses (0.14, 0.21 and 0.30 mg hGH/kg/week) or daily hGH (Genotropin®; 0.03 mg hGH/kg/day = 0.21 mg/kg/week) over a six-month treatment period, in a  randomized, comparator-controlled dose response Phase 2 study. The patients’ GHD diagnosis were established in accordance with international consensus guidelines, based on auxology (height & height velocity), GH stimulation tests & IGF-I. Children Small for Gestational Age (SGA) were excluded.

Results: Safety and efficacy (annualized height velocity), as well as PK and PD data, of up to 25 patients treated over a six-month period with TransCon hGH or daily hGH will be presented. In an interim analysis conducted following three months of treatment all TransCon hGH doses demonstrated an excellent safety / local tolerability profile and an excellent growth within expected ranges (above 10 cm annualized HV) that was comparable to daily hGH.

Conclusions: To date, TransCon hGH has demonstrated efficacy and safety comparable to that observed with daily hGH. Injection site reactions have generally been mild and similar to what is expected with daily hGH injections, with no nodule formation or lipoatrophy noted. This TransCon hGH Phase 2 study conducted in a pediatric population confirms the excellent safety and efficacy profile observed in previous clinical trials.

 

Disclosure: PC: Investigator, Ascendis Pharma. OM: Investigator, Ascendis Pharma. KR: Investigator, Ascendis Pharma A/S. MB: Employee, Ascendis Pharma. Nothing to Disclose: HHE, EM

20252 4.0000 THR-147 A Six-Month Interim Safety and Efficacy of Different Dose Levels of Transcon HGH Administered Once Weekly Versus Standard Daily Human Growth Hormone Replacement Therapy in Pre-Pubertal Children with Growth Hormone Deficiency (GHD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Zvi Zadik,1, Ron G Rosenfeld*2, Klaudziya Radziuk3, Nataliya Zelinska4, Oleg Malievsky5, Violeta Iotova6, Julia Skorodok7, Ronit Koren8, Leanne Amitzi9, Oren Hershkovitz10, Gili Hart9 and Eyal Fima10
1Kaplan Medical Center, 2Stat 5 LLC, Los Altos, CA, 32nd Children City Clinic, Minsk, Belarus, 4Children Specialized Clinical Hospital, Kiev, Ukraine, 5Bashkir State Medical University, Ufa, Russia, 6UMHAT, Varna, Bulgaria, 7St. Petersburg State Pediatric Medical Academy, St. Petersburg, Russia, 8Prolor, Nes Ziona, Israel, 9OPKO Biologics, Nes Ziona, Israel, 10Prolor Biotech, Nes Ziona, Israel

 

Objective: Growth Hormone (GH) replacement therapy currently requires daily injections, which may cause poor compliance, inconvenience and distress for patients. CTP-modified hGH (MOD-4023) has been developed for once-weekly administration in Growth Hormone Deficient (GHD) adults and children. Pharmacokinetics (PK), pharmacodynamics, (PD) efficacy and safety analysis of weekly treatment with MOD-4023 in GHD naïve children was performed and compared to daily hGH.

 

Design and methods: A randomized, controlled Phase 2 study was conducted in up to 56 pre-pubertal, naïve GHD children receiving subcutaneous injections of one of MOD-4023 doses as a once-weekly regimen (range: 0.25 - 0.66 mg/Kg per week) or daily hGH (34 µg/Kg/day) as a control arm. MOD-4023 and IGF-1 levels were monitored throughout the study. Annual Height Velocity (HV) assessment was evaluated at 12 months.

Results: The baseline characteristics were comparable between all groups. PK/PD profile following administration of MOD-4023 demonstrated a significantly extended half-life as with a dose dependent PK/PD (IGF-1) response was observed between MOD-4023 dose cohorts, reaching steady state with no accumulation or excessive levels by 12 months.  All cohorts demonstrated expected “catch-up” growth, in line with reported age- and GHD severity-matched data. All cohorts demonstrated 12m annual HV above 11 cm/year, correlated with the PK/PD profile in those patients.  Sub analysis of HV response which was based on baseline characteristics confirmed an excellent response is all sub populations.  The 12 months safety analysis suggests a clean and promising profile with no unexpected adverse events.

Conclusions: This is the first report describing PK, PD, efficacy and safety results of extended, 12 months, treatment period with MOD-4023 in pediatric patients with GHD. MOD-4023 administration to GHD children further confirmed its long acting properties. This study further affirmed that a single weekly injection of MOD-4023 has the potential to replace seven consecutive daily injections of currently marketed hGH in pediatric GHD patients and provided data for dose selection for the company’s upcoming Phase 3 trial.

 

Disclosure: KR: Investigator, Ascendis Pharma A/S. OM: Investigator, Ascendis Pharma. Nothing to Disclose: ZZ, RGR, NZ, VI, JS, RK, LA, OH, GH, EF

20955 5.0000 THR-148 A Top Line Results of 12 Months of Once-Weekly Administration of CTP-Modified Human Growth Hormone (MOD-4023): Phase 2 Dose Finding Study in Children with Growth Hormone Deficiency (GHD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Peter A. Lee*1, Judith L. Ross2, Ricardo Maamari3, Thomas Henschel3 and John Germak3
1Penn State College of Medicine, The Milton S. Hershey Medical Center, Hershey, PA, 2Thomas Jefferson University/duPont Hospital for Children, Philadelphia, PA, 3Novo Nordisk Inc., Plainsboro, NJ

 

Treatment with growth hormone (GH) has been approved by the United States Food and Drug Administration (FDA) for a number of pediatric growth disorders, including Noonan syndrome (NS), and Turner syndrome (TS). Although the pathogenesis of NS and TS is different, they share certain phenotypic features and are generally considered non-GH deficient conditions. The present analysis was undertaken to describe the mean GH dose administered over time, and compare the changes in height standard deviation score (HSDS) and corrected HSDS (HSDS minus target HSDS) in NS versus TS patients enrolled in the American Norditropin Studies: Web-enabled Research (ANSWER) Program registry, from treatment start through 5 years of treatment with Norditropin® (somatropin [rDNA origin] injection, Novo Nordisk A/S, Denmark). As of July 2014, 148 patients with NS (112 males, 36 females) and 550 females with TS, naïve to GH therapy, were enrolled in the ANSWER Program registry. Cross-sectional data were analysed and descriptive statistics applied. Data are presented as mean value ± SD. The mean age at treatment start was 9.2±3.8 years versus 8.5±4.0 years for NS and TS patients, respectively. Mean GH dose (mg/kg/day) at initiation of GH therapy and year (y) 5, respectively, were 0.046±0.011 and 0.050±0.012 for NS and 0.051±0.010 and 0.053±0.013 for TS patients. Over 5 years of GH treatment, <20% of NS, and <15% of TS patients, received GH doses up to the maximum currently approved by the FDA. At treatment start the mean HSDS were –2.61±0.74 and –2.53±0.90, and at y5 were –1.21±0.98 and –1.55±0.92 for NS and TS respectively. Mean change in HSDS from baseline (ΔHSDS) increased over 5 years in NS patients (y1: 0.42±0.39, n=97; y2: 0.77±0.57, n=67; y3: 1.05±0.53, n=50; y4: 1.21±0.63, n=36; y5: 1.30±0.71, n=24). After an initial increase to y3 in TS patients, mean ΔHSDS did not increase further (ΔHSDS: y1: 0.46±0.43, n=373; y2: 0.75±0.55, n=293; y3: 0.93±0.66, n=227; y4: 0.93±0.72, n=164; y5: 0.91±0.76, n=113). Mean corrected HSDS improved over 5 years in NS patients (y1: −1.87±1.14, n=82; y2: −1.50±1.28, n=57; y3: −1.40±1.21, n=45; y4, −0.94±1.21, n=30; y5:–0.76±1.14, n= 21). In contrast TS patients had a plateau in corrected HSDS after y3 (y1: −2.12±1.05, n=312; y2: −1.84±1.04, n=255; y3: −1.76±1.01, n=196; y4: −1.76±1.05, n=140; y5:–1.79±1.06, n=94). Negative correlations between ΔHSDS and baseline age were observed at y1, y2 and y5 of GH treatment in NS patients, but only at y1 in patients with TS. NS patients showed increases in mean HSDS and corrected HSDS over 5 years of GH treatment, in contrast to TS patients, for whom further incremental increases appeared to plateau after y3. Differences in GH responsiveness in NS and TS patients may potentially involve gonadal dysgenesis, skeletal dysplasia related to SHOX deficiency in TS and sub-optimal individual GH dose titration.

 

Disclosure: PAL: Advisory Group Member, Novo Nordisk. JLR: Researcher, Novo Nordisk, Researcher, Versartis, Researcher, Eli Lilly & Company, Advisory Group Member, Novo Nordisk. RM: Employee, Novo Nordisk. TH: Employee, Novo Nordisk. JG: Employee, Novo Nordisk.

18914 7.0000 THR-150 A Effect of Growth Hormone Therapy in Patients with Noonan Syndrome or Turner Syndrome: Analysis of 5-Year GH Dosing and Treatment Outcomes Data from the Answer Program 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Gili Hart*1, Zvi Zadik,2, Klaudziya Radziuk3, Nataliya Zelinska,4, Oleg Malievsky5, Violeta Iotova6, Julia Skorodok7, Ronit Koren8, Leanne Amitzi1, Oren Hershkovitz9 and Eyal Fima9
1OPKO Biologics, Nes Ziona, Israel, 2Kaplan Medical Center, 32nd Children City Clinic, Minsk, Belarus, 4Ukrainian Children Specialized Clinical Hospital, Kyev, Ukraine, 5Bashkir State Medical University, Ufa, Russia, 6UMHAT, Varna, Bulgaria, 7St. Petersburg State Pediatric Medical Academy, St. Petersburg, Russia, 8Prolor, Nes Ziona, Israel, 9Prolor Biotech, Nes Ziona, Israel

 

Objective: Growth Hormone (GH) replacement therapy currently requires daily injections, which may cause poor compliance, inconvenience and distress for patients. CTP-modified hGH (MOD-4023) is being developed for once-weekly administration in Growth Hormone Deficient (GHD) adults and children. In the present study the pharmacokinetics (PK) and pharmacodynamics (PD) profile of MOD-4023 in GHD naïve children was assessed for 12 months of treatment.

Design and methods: A randomized, comparator-controlled Phase 2 study was conducted in up to 56 pre-pubertal, naïve GHD children receiving one of three MOD-4023 doses as once-weekly regimen (0.25, 0.48, 0.66mg/Kg per week) or daily hGH (34µg/Kg/day) as comparator arm in subcutaneous injections. In order to introduce naïve patients to the allocated MOD-4023 dose in a gradual manner, a stepwise dose increase approach was implemented. All patients randomized to receive one of the three MOD-4023 doses started treatment for 2 weeks with the low MOD-4023 dose and based on the patient's dose allocation, followed by a dose increase to the next dose level every two weeks until the final allocated dose was reached. Subsequently to the second dose administration of the targeted dose MOD-4023, GH, IGF-1 and IGF-BP3 concentrations were measured on monthly basis and PK-PD analysis was conducted utilizing a population based approach up to 12 months of treatment.

 

Results: MOD-4023 administration confirmed its long acting properties and superior properties compared to daily hGH. The weekly profile suggests extended half-life, increased exposure and reduced clearance for all patients. Pre-dose and trough levels indicated no accumulation of circulating MOD-4023. IGF-1 and IGF-1 SDS following MOD-4023 administration also increased at a dose proportional manner.

The MOD-4023 profile of throughout the 12 months study reached steady state during the first few weeks of treatment with no indication for excessive levels or accumulation as monitored at 6 month by evaluating trough levels. IGF-1 seem to be normalized and stabilized within the normal range during study and prior to completion the 52 weeks of treatment reaching an optimal value of 0 SDS for the two higher MOD-4023 cohorts which was comparable to the daily hGH arm. As anticipated, IGF-BP3 levels increased following MOD-4023 administration reaching steady state levels by week 15 post study initation.

Conclusions: MOD-4023 once-weekly treatment at three different doses for 52 weeks demonstrated an excellent PK and PD profile supporting once weekly injection in pediatric GHD population and therefore can potentially promote proper growth. In addition, the changes observed in IGF-1 and IGF-BP3 demonstrate adequate stimulation of the GH-IGF-1 axes which were shown to be comparable to that observed with daily hGH treatment

 

Disclosure: KR: Investigator, Ascendis Pharma A/S. OM: Investigator, Ascendis Pharma. Nothing to Disclose: GH, ZZ, NZ, VI, JS, RK, LA, OH, EF

20947 8.0000 THR-151 A Twelve Months Pharmacokinetics and Pharmacodynamics Profile of Once-Weekly, CTP-Modified Human Growth Hormone (MOD-4023): Phase 2 Study in Children with Ghd Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Annabel Sophie Berthon*1, Angela Delaney2 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2National Institutes of Health, Bethesda, MD

 

Knockout mice for the kisspeptin receptor, kiss1r, (KRKO) and its ligand kisspeptin, kiss1, (KissKO) replicated the phenotype of isolated hypogonadotropic hypogonadism (IHH) that was first described in association with these genes in humans. Although what leads to adrenarche in humans is unknown, the process precedes and is inextricably linked to pubarche. In this study we analyzed adrenocortical development and function in KRKO and KissKO. At about 5 months of age, in both mouse models, we observe the gradual accumulation of eosinophilic cells at the adrenomedullary boundary. This cell population expressed 20aHSD by immunohistochemistry; Cyp17 is also overexpressed suggesting that these cells are derived from the mouse X-zone which is the transient fetal zone normally disappearing at puberty in male and during the first pregnancy in female mice. Moreover, the KissKO females (but not the males) show corticosterone and aldosterone hypersecretion, which could be due to the documented overexpression of Star. Ongoing studies are focusing at further characterizing the adrenocortical phenotype of these mice. We conclude that KRKO and KissKO mice have a previously unrecognized adrenocortical phenotype that is potentially very interesting and may provide links to the understanding of the long suspected but never proven common regulatory mechanisms of adrenarche and pubarche in humans.

 

Nothing to Disclose: ASB, AD, CAS

21006 9.0000 THR-152 A Fetal Zone Persistence in Adrenal Cortex of Kisspeptin and Kisspeptin Receptor Knockout Mice: Implications for Human Puberty and Adrenal Development 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Kennett Sprogoe*1, Michael Beckert2, David Gilfoyle3, Thomas Kurpiers4, Thomas Wegge4 and Harald Rau4
1Ascendis Pharma, Inc., 2Ascendis Pharma A/S, on behalf of the TransCon hGH study group, 3Ascendis Pharma A/S, Hellerup, Denmark, 4Ascendis Pharma GmbH

 

Background

TransCon hGH is a once-weekly prodrug of recombinant human growth hormone (hGH) intended to improve compliance and treatment outcome of patients requiring growth hormone therapy. TransCon hGH is designed to maintain the same mode of action and distribution within the body as daily administered hGH. TransCon hGH liberates unmodified hGH into the bloodstream via a non-enzymatic self-cleaving process relying only on physiological pH and temperature conditions, which ensures predictable release of unmodified hGH. The hGH released from TransCon hGH has been demonstrated to be identical to hGH for daily administration, for which safety and efficacy has been established through decades of therapy. In clinical studies, TransCon hGH has demonstrated an efficacy, safety, tolerability and immunogenic profile that is comparable to that of daily hGH.

Objectives

To compare the structure and in vitrobiopotency of growth hormone released from TransCon hGH with hGH for daily administration, and compare the exposure of hGH released from TransCon hGH with daily administered hGH, together with the resulting IGF-I levels in GHD adults.

Design and methods

hGH released from TransCon hGH was characterized by high resolution mass spectrometry, circular dichroism, N-terminal amino acid sequencing, peptide mapping and cell based biopotency assays. Pharmacokinetic and pharmacodynamic data of TransCon hGH and daily hGH was obtained in a Phase 2 study in GHD adults.

Results

Characterization of hGH released from TransCon hGH confirmed that it is unmodified and structurally identical to hGH for daily administration.  Cell based biopotency assays confirm that full activity of the growth hormone is restored when it is released from the prodrug. PK/PD data obtained from GHD adults show that maximum levels of both hGH and IGF-I are comparable between weekly administered TransCon hGH and daily administered hGH, with no supraphysiological exposure to either hGH or IGF-I.

Conclusion

Whether released from the pituitary gland or administered as daily injections, growth hormone distributes throughout the body to exert important effects in growth hormone responsive tissue, including bone, muscle, liver and fat tissue. These include anabolic and metabolic effects. Growth hormone released from TransCon hGH has been shown to be identical to hGH in daily administered products. Clinical studies in adults with GHD demonstrate that TransCon hGH has comparable efficacy to daily hGH when administered at the same cumulative weekly dose. Importantly, TransCon hGH does not cause supraphysiological exposure to hGH or IGF-I. 

Designed to maintain the same mode of action and distribution to growth hormone responsive tissues as daily hGH, TransCon hGH has the potential to offer patients requiring growth hormone therapy a long-acting alternative to daily injections

 

Disclosure: KS: Employee, Ascendis Pharma. MB: Employee, Ascendis Pharma. DG: Employee, Ascendis Pharma. TK: Employee, Ascendis Pharma. TW: Employee, Ascendis Pharma. HR: Employee, Ascendis Pharma.

20549 10.0000 THR-153 A Transcon Human Growth Hormone – a Once-Weekly Prodrug of Recombinant Human Growth Hormone: Design, Characterization and PK/PD in Growth Hormone Deficient (GHD) Adults 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Youn Hee Jee*1, Kun Song Lee2, Alan T Remaley3, Young Pyo Chang4, Anton Wellstein5, Jack Adam Yanovski6 and Jeffrey Baron7
1NICHD, Bethesda, MD, 2Dankook University, Korea, Republic of (South), 3NHLBI, NIH, Bethesda, MD, 4Dankook University Hospital, Korea, Republic of (South), 5Georgetown University, Washington, DC, 6Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 7NIH, Bethesda, MD

 

Heparin-Binding Growth Factor Concentrations in Children with Idiopathic Short Stature

Youn Hee Jee, Kun Song Lee, Alan T. Remaley, Young Pyo Chang, Anton Wellstein, Jack A. Yanovski, Jeffrey Baron

Background: Midkine (MDK) and pleiotrophin (PTN) are two closely-related heparin-binding growth factors that in rodents are highly expressed in early life in multiple organs and decrease to undetectable levels by adulthood. The roles of MDK and PTN in human growth and development are unknown.

Objective: To examine associations of plasma MDK and urine PTN with age, sex, adiposity, and growth in children.

Methods: Plasma MDK was measured by ELISA in150 healthy children (mean age, 11.7 y; range 0 to 24 y; BMI SDS range, -2.3 to +3.2) and random urine PTN was measured by ELISA in 87 healthy children (mean age, 15.0 y; range 3 to 24.7 y; BMI SDS range, -2.3 to +2.7). Plasma MDK and urine PTN were also measured in 41 children referred for short stature (mean height SDS, -2.4), including idiopathic short stature (ISS, n=25), constitutional delay (n=12), growth hormone (GH) deficiency (n=1), and small for gestational age (n=3).

Results: In healthy children, plasma MDK concentrations declined with age (R2=0.41, p< 0.001) paralleling height velocity, with values highest in infants. Plasma MDK did not differ significantly between males and females and did not correlate with BMI SDS or percent total body fat. In most of the children with short stature, MDK concentrations did not differ significantly from normal subjects, regardless of diagnosis or GH treatment status, and did not correlate with height SDS or IGF-1 SDS. One 15-year old girl with ISS had 20 fold greater plasma MDK than the mean for age-matched controls (2.9 vs 0.14 ± 0.1 ng/mL, mean ± SD, n=29), and one newborn with intrauterine growth retardation had a low MDK concentrations compared to healthy newborns (0.17 vs 0.9 ± 0.5 ng/mL, mean ± SD, n=9). In healthy children, urine PTN normalized to creatinine (PTN/Cr) also declined with age (R2=0.3, p<0.001). Urine PTN did not differ significantly between males and females and did not correlate with BMI SDS or percent total body fat. However, 11 children with constitutional delay showed significantly higher PTN than age-matched controls or children with other causes of short stature (p<0.001).

Conclusions: In healthy children, plasma MDK concentrations and urine PTN/Cr ratio declined with age, paralleling the physiological decline in growth velocity and were not significantly associated with sex or adiposity. Plasma MDK concentration was markedly increased in one child with ISS and decreased in one SGA newborn. Urine PTN/Cr was elevated in constitutional delay. To establish whether MDK and PTN regulate human growth and whether abnormalities involving MDK or PTN could cause human growth disorders will require further investigation.

 

Disclosure: JAY: Principal Investigator, Zafgen. Nothing to Disclose: YHJ, KSL, ATR, YPC, AW, JB

19343 11.0000 THR-154 A Heparin-Binding Growth Factor Concentrations in Children with Idiopathic Short Stature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


In Ah Jung1, Yeon Jin Jeon*1, Won-Kyoung Cho1, Jae Wook Lee1, Shin-Hee Kim2, Nak-Gyun Chung1, Kyoung Soon Cho1, Bin Cho1, So Hyun Park1, Min-Ho Jung1, Hyo-Jin Kim1 and Byung-Kyu Suh1
1College of Medicine, The Catholic University of Korea, Seoul, Korea, Republic of (South), 2The Catholic University of Korea, Seoul, Korea, Republic of (South)

 

Background: Long-term survivors of childhood acute leukemia can suffer from growth impairment. The purpose of this study was to evaluate longitudinal growth and final height of pediatric patients who were treated with acute leukemia and factors that can cause growth impairment.

Methods: Of 234 patients (133 males and 101 females) who were diagnosed as acute lymphoblastic leukemia (ALL; n=162) or acute myeloblastic leukemia (AML; n=72) before age 18 between June 1996 and June 2009, 27 patients who were diagnosed as hypogonadism or growth hormone deficiency were excluded and 207 patients (123 males and 84 females) were included. The mean age at enrollment was 14.97 ± 4.36 years. Among them, 155 patients treated with chemotherapy only and 52 patients received hematopoietic stem cell transplantation (HSCT). We reviewed height standard deviation scores (SDS) from diagnosis to 5 years after the diagnosis. Final height SDS of 89 patients who reached final height at enrollment and risk factors such as sex, age at diagnosis, diagnosis, pubertal status at diagnosis, radiation and chronic graft-versus-host-disease (cGVHD) that can affect growth were evaluated.

Results: The mean height SDS at diagnosis of 207 patients was 0.47 ± 1.01 and at 5 years after the diagnosis was -0.06 ± 1.06. The mean height SDS from the diagnosis to 5 years after the diagnosis were significantly decreased (Dheight SDS = -0.53 ± 0.82, p<0.001). And the mean final height SDS of 89 patients was -0.64 ± 1.06 that was significantly lower than the height SDS at diagnosis (Dheight SDS = -1.01 ± 1.10, p<0.001). The height loss was more severe in the patients who received HSCT than the patients who received chemotherapy only (-1.42 ± 1.37 vs. -0.81 ± 0.87, p=0.031). In chemotherapy only patients (n=59), the changes in height SDS from the diagnosis to final height were positively correlated with age at diagnosis (r=0.450, p<0.001) and negatively correlated with cranial irradiation (r=-0.297, p=0.022). In multiple regression analysis, younger age at diagnosis was the only significant risk factor of loss in final height in chemotherapy group. In HSCT patients (n=30), the differences of height SDS between at diagnosis and final height were showed positive correlation with age at diagnosis (r=0.664, p<0.001) and negative correlation with pubertal status at diagnosis (r=-0.510, p=0.004) and total body irradiation (TBI) for conditioning (r=-0.422, p=0.020). In multiple regression analysis, younger age at diagnosis and TBI were   significant risk factors cause loss of final height in HSCT patients (p=0.006 and p=0.010, respectively).

Conclusions: Growth impairment in survivors of childhood acute leukemia was significantly related with younger age at diagnosis.

 

Nothing to Disclose: IAJ, YJJ, WKC, JWL, SHK, NGC, KSC, BC, SHP, MHJ, HJK, BKS

20160 12.0000 THR-155 A Growth Impairment in Children with Acute Leukemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Jung Min Ahn*1, Ah Reum Kwon2, Duk Hee Kim3 and Ho-Seong Kim4
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Severance Hospital, Seoul, Korea, Republic of (South), 3Sowha Children's Hospital, Seoul, Korea, Republic of (South), 4Severance Children's Hospita, Seoul, Korea, Republic of (South)

 

Purpose: The purpose of this study was to screen the gene mutations in Korean children with isolated growth hormone deficiency (GHD) and analyze their characteristics.

Methods: One hundred four patients with isolated GHD were recruited from Severance Hospital. The diagnosis GHD was based on the following criteria: short stature as defined by height less than -2 SD of the age- and sex-matched population; reduced growth velocity; and blunted GH response (<10 ng/ml) to two different pharmacological stimulation test. DNA was extracted from peripheral lymphocytes and amplified using primers designed to include coding and splicing regions of individual exons for GH1, GH releasing hormone receptor (GHRHR) and GH secretagogue receptor (GHSR).

Results: Mutations in GH1, GHRHR and GHSR were identified in 12.5% (13/104). These included previously described mutations in GH1 (c.69 A>G, p.T3A), GHRHR (c.214C>T, p.P16L, c.721G>A, p.V225I) and GHSR (c.144T>C, p.L34P). All ten patients with GH1 mutation led to GHD type IB. There were no differences in the age (8.3± 2.9 vs. 8.5 ± 3.6) (P = 0.44), degree of growth failure ( -3.7 ± 0.9 SDS vs. -3.6 ± 0.5 SDS) (P = 0.12), or endocrinologic characteristics (IGF-1, -0.27 ± 0.17 SDS vs. -0.26 ± 0.21 SDS) (P = 0.29) between patients with and without GH1 mutation. MRI results were available from all patients, there was no difference in the incidence of pituitary abnormalities between patients with and without GH1 mutation (15.3% vs. 14.2%).    

Conclusion: We screened the mutations in GH1, GHRHR and GHSR genes in a large cohort of Korean patients with GHD. In our study, the prevalence of mutations was 12.5%, however we did not find any difference in clinical manifestations between patients with and without mutations.

 

Nothing to Disclose: JMA, ARK, DHK, HSK

20184 13.0000 THR-156 A Genetic Analysis in Korean Children with Isolated Growth Hormone Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Mengjie Wang*1, Youjie Zhang1, Dan Lan2 and Jennifer Wootton Hill3
1University of Toledo, Toledo, OH, 2Guangxi Medical University, Nanning, China, 3University of Toledo School of Medicine, Toledo, OH

 

Objective: Our aim was to systematically review and evaluate the efficacy and safety of the addition of recombinant human growth hormone (rhGH) to gonadotropin-releasing hormone analogs (GnRHa) treatment in Chinese children with central precocious puberty (CPP).
Method: We performed a thorough search of the databases (Medline, Embase, the Cochrane Library, Chinese Biomedical Literature Service System, Wanfang Data, Chinese Scientific Journals Fulltext Database, and China National Knowledge Infrastructure). Relevant studies were included, divided and analyzed based on their research arms. Outcome measurements were height, predicted adult height (PAH), the height standard deviation score for bone age (HtSDS-BA) and growth velocity (GV). Adverse effects, including body mass index (BMI) and insulin like growth factor-1 (IGF-1) were evaluated. All analyses were conducted using the software of Stata 11.0.
Results: A total of 13 case-control studies and/or observational studies containing 404 patients were included and analyzed. Compared with placebo groups, administration of GnRHa plus rhGH led to a significant increase in height, PAH, HtSDS-BA and GV, corresponding to a weighted mean difference (WMD) (95% confidence interval (95%CI)) of 8.12 cm (5.70, 10.54), 6.26cm (4.02, 8.49), 0.76 (0.41, 1.11), 3.39 cm/year (2.57, 4.22), respectively. On meta-regression, a negative association was seen between the change in PAH and subjects’ age (β coefficient=-1.489, 95%CI -2.77 to -0.20, P=0.027). Even though meta-regression did not show a statistical significance between the outcomes (height and HtSDS-BA) and subjects’ age, negative trends were seen between the outcomes and subjects’ age. No statistically significant association was found between the changes in the following outcomes (height, PAH, HtSDS-BA and GV) and the therapy duration. In the subgroup analysis, we found that the combined therapy had increased efficacy in subjects younger than 10 years old. However, there was no significant difference between treatment lasting less than 12 months and over 12 months. To further identify the effect of the addition of rhGH to GnRHa, we compared the combined treatment with use of GnRHa alone. The combined treatment was superior with regard to height [3.76 cm (2.46, 5.05)], PAH [3.68 cm (2.82, 4.54)] and HtSDS-BA [0.56 (0.40, 0.73)]. No obvious adverse effects were observed during the GnRHa and rhGH adjunctive therapy.
Conclusion: The results of this meta-analysis may allay concern about the efficacy and safety of rhGH plus GnRHa treatment. The efficacy of the combined therapy could be somewhat increased with use in subjects younger than 10 years old. However, the efficacy did not depend on the therapy duration. Multi-center, long-term and well-designed studies are greatly needed to learn more about the mechanism, the efficacy, and the safety of the addition of rhGH to GnRHa during CPP therapy.

 

Nothing to Disclose: MW, YZ, DL, JWH

19098 14.0000 THR-157 A The Efficacy of Gonadotropin-Releasing Hormone Analogs Alone or in Combination with Recombinant Human Growth Hormone for the Treatment of Chinese Children with Central Precocious Puberty: A Systemic Review and Meta-Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Filippina Filia Dimitriadi*, Anita Azam, Francesco De Luca and Rita Ann Kubicky
St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA

 

Background:  X-ALD is described as a disorder with many different phenotypes: Addison disease, cerebral ALD, adrenomyeloneuropathy (AMN) and carriers.

Clinical Case: J.I. is an AA male who presented at the age of 10 5/12 years with one episode of generalized tonic clonic seizure complicated by a prolonged postictal state and followed by rapid deterioration of mental status requiring endotracheal intubation and ICU admission at St. Christopher’s Hospital for Children. Blood glucose, calcium, and electrolytes were within normal limits. Family reported deterioration in school performance, memory loss and unsteady gait in the past year.

Review of systems was negative for headaches, abdominal pain, and fatigue.

Family history was positive for febrile seizures in the 2 year old sister and epilepsy in the maternal grandfather.

During his hospital stay, he received a 3-day course of solumedrol due to concern of acute disseminated encephalomyelitis. On hospital day 2, he was extubated and his mental status returned to baseline. EEG was normal. MRI of his brain revealed white matter signal abnormality consistent with demyelinating process.

When seen in the Endocrinology Clinic at SCHC 1 month after his discharge, he had a normal neurological exam; and he lacked skin or buccal hyperpigmentation.

Standard dose ACTH stimulation test revealed a peak serum cortisol of 2.6 mcg/dL. PRA was normal (0.15 ng/mL/h) and baseline ACTH elevated at 277.5 pg/mL (normal range, 7.2-63.3); these findings were consistent with the diagnosis of primary adrenal insufficiency with no mineralocorticoid deficiency. J.I. was started on hydrocortisone 10 mg/m2/day.

VLCFAs showed elevation in C26:0, ratio of C24/22 and C26/22 consistent with X-ALD or AMN. Genetic testing of the ABCD1 gene found him to be hemizygous for the c1415_1416delAG mutation.

Given J.I.’s diagnosis, his older brother (although asymptomatic at the age of 16 1/12 years) underwent a diagnostic evaluation that showed elevated VLCFAs, normal MRI brain and he was also found hemizygous for the same mutation. His peak stimulated cortisol was 8.5 mcg/dL with normal PRA level of 0.89 ng/mL/h. He was started on hydrocortisone.

Conclusion: X-ALD is a disorder still incompletely understood, very challenging to diagnose and with very limited treatment options. It should be considered in the differential diagnosis of myelopathy in both males and females. Our case presentation of variable phenotype in two siblings with X-ALD underlines the importance of genetic testing in family members and appropriate counseling and management when the diagnosis is established.

 

Nothing to Disclose: FFD, AA, FD, RAK

20020 15.0000 THR-158 A Variable Phenotype in Two Siblings with X-Linked Adrenoleukodystrophy (X-ALD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Filippina Filia Dimitriadi*1, Shufang Wu2, Wei Yang2, Bruce Bernstein3, Francesco De Luca4 and Rita Ann Kubicky2
1St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, 2Section of Endocrinology and Diabetes, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, 3St. Christopher's Hospital for Children, Philadelphia, PA, 4Section of Endocrinology and Diabetes, St. Christopher's Hospital for Children, Department of Pediatrics. Drexel University College of Medicine, Philadelphia, PA

 

Background:Fibroblast growth factor 21 (FGF21) has been shown to mediate metabolic adaptation to fasting in rodents and humans. In previous studies, we have also demonstrated that increased FGF21 causes Growth Hormone (GH) insensitivity and, in turn, growth failure. Based on this evidence, we hypothesized that serum FGF21 in prepubertal children with short stature are positively associated with serum GH levels, and negatively associated with serum IGF-1, height, weight, and growth velocity.

Methods:To test our hypothesis, we prospectively enrolled prepubertal children undergoing evaluation for short stature in the Section of Endocrinology and Diabetes at St. Christopher’s Hospital for Children. Blood samples were collected between 8 am and 5 pm. Serum FGF21 was measured using an FGF21 Human ELISA kit (Millipore). GH was measured by RIA, while IGF-1 was measured by LC/MS.

Exclusion criteria included diagnosis of chronic disorders, prolonged (> 6 weeks in the preceding 6 months), administration of medications known to be associated with underweight or poor growth velocity/short stature, or pubertal stage of ≥ Tanner stage 2.

Anthropometric data such as height, weight, BMI/Weight-for-length, gender and age (in months) were collected. Using these data, we calculated Height and BMI Z-scores. Growth velocity Z-score was calculated using the height measurements upon enrollment and within the 6 months preceding enrollment.

Results:22 patients (18 males and 4 females) were recruited. Their mean age was 5.6 ± 2.9 years.   Height Z-score -2.6 ± 0.85; BMI Z-score 0.01 ± 1; Growth velocity Z-score  -0.5 ± 1.9. 

Mean FGF21 level was 132.5 ± 162.6 pg/mL (range 0- 591pg/mL, with undetectable level set to 0 pg/mL). No significant difference was identified in the median FGF21 levels between genders (Mann Whitney U test, p = .99). Mean GH level was 3 ± 3.8 ng/mL and mean IGF-1 level was 89.2 ±  41.5 ng/mL.

No significant correlations with height Z-score, growth velocity Z-score, weight Z-score, serum IGF-1 or serum GH levels were found (Spearman’s rank order statistics).

Discussion:To our knowledge this is the first study reporting circulating FGF21 levels in prepubertal children with short stature.

Our results suggest that there is no association between serum FGF21, serum GH and IGF-1 levels in prepubertal children. In addition, we did not find any association between FGF21 levels and anthropometric measures. In contrast to our results, these associations have been demonstrated in two studies on premature infants.  It is possible that differences in age and nutritional status between our patient population and others may explain these discordant findings.

Longitudinal studies on a larger cohort of prepubertal short children with a wider BMI range may further elucidate the role of FGF21 in human growth.

 

Nothing to Disclose: FFD, SW, WY, BB, FD, RAK

19818 16.0000 THR-159 A Serum FGF21 in Prepubertal Children with Short Stature: Relationship to IGF-1 and GH Levels and Growth Parameters 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Peter Davies*1, Andrea Luczay2, Evangelia Charamndari3, Jeremy Kirk4, Ho-Seong Kim5, Ludmila Kostalova6, Marc Nicolino7, Martin Borkenstein8, Maria Dolores Rodriguez Arnao9, Raúl Calzada-León10, Svante Norgren11, John VanderMeulen12, Sandro Loche13, Alicia Belgorosky14, Minlian Du15, George Stoyanov16, Ekaterina B Koledova17, Jeff Zhao18 and Jan Lebl19
1University of Queensland, Herston, Australia, 2Semmelweis University, Budapest, Hungary, 3University of Athens Medical School, Athens, Greece, 4Birmingham Children's Hospital, Birmingham, United Kingdom, 5Yonsei University, Seoul, Korea, Republic of (South), 6Comenius University Medical School, Bratislava, Slovakia, 7Hôpital Femme-Mère-Enfant, Lyon, France, 8Medical University of Graz, Graz, Austria, 9Hospital Universitario Gregorio Marañón, Madrid, Spain, 10Instituto Nacional de Pediatría, México City, Mexico, 11Karolinska University Hospital, Stockholm, Sweden, 12McMaster Children’s Hospital and McMaster University, Hamilton, ON, Canada, 13Ospedale Microcitemico - ASL Cagliari, Cagliari, Italy, 14Hospital de Pediatría Garrahan, Buenos Aires, Argentina, 15The First Affiliated Hospital of SUN Yat-Sen University, Guangzhou 510080, China, 16EMD Serono, Mississauga, ON, Canada, 17Merck, Darmstadt, Germany, 18EMD Serono, Billerica, MA, 19Charles University in Prague, Prague, Czech Republic

 

Background: The easypod™ auto-injector device enables accurate records of patients’ adherence to recombinant human growth hormone (r-hGH) to be collected, providing real-world data for evaluation. ECOS is an observational study, started in 2010 and now active in 23 countries, with 2,403 patients enrolled. ECOS will evaluate adherence and the factors that may influence it in paediatric patients prescribed r-hGH via easypod™.

Objectives: The primary objective of the ECOS study is to evaluate the level of adherence of paediatric patients receiving r-hGH via easypod™. Secondary objectives include assessment of the impact of adherence on clinical outcomes and the concentrations of insulin-like growth factor 1 (IGF-1) and identification of factors that may influence adherence to this form of treatment.

Methods: ECOS will follow children with Growth Hormone deficiency (GHD), Small for Gestational Age (SGA) and Turner Syndrome (TS) receiving r-hGH therapy for up to 5 years, with interim analyses each year. Demographic, auxological and diagnostic data are obtained from medical notes, with accurate adherence data obtained directly from the patients' easypod™ auto-injectors. Adherence during the study period is defined as the number of days with injections received, divided by the number of days with injections planned, expressed as a percentage. An interim analysis was completed in May 2014.

Results: At the time of analysis, 1,972 patients had been enrolled. The majority were male (57.7%), Caucasian (73.1%), with a diagnosis of GHD (65.7%), SGA (15.0%) or TS (7.7%). Baseline mean [Standard Deviation] age was 9.8 [3.7], 8.9 [3.3], 9.5 [3.8] years and height 118.7 [20.9], 113.4 [18.1], 109.7 [19.7] cm for GHD, SGA and TS, respectively. Investigator-assessed mean growth velocity at start of GH treatment was 4.5 [2.6], 4.7 [1.8], 6.3 [12.1] cm/yr for GHD, SGA and TS.

Individual levels of adherence prospectively measured with easypod™ (median [Q1, Q3], 93.0% [82.8%, 97.5%]) were higher than those previously reported in retrospective studies based on questionnaires and were maintained over time. After 1 year, height velocity (HV) was 7.9 [2.1], 8.0 (1.9) and 6.9 [2.4] cm/yr and HV SDS was 2.13 [2.76], 1.81 [2.17] and 1.51 [2.92] for GHD, SGA and TS. Spearman's product-moment correlation for adherence rate and change in height (0.085, 0.101 0.471 for GHD, SGA and TS) and height velocity (0.132, 0.149, 0.488 for GHD, SGA and TS) was only weakly positive. Age at start of treatment was the most important predictor of growth and growth rates improved less in patients who were not naïve to GH treatment or the easypod™ device.

Conclusions: Adherence rates with the easypod™ device are high and maintained over time. The younger the patient, the better was the first-year response to GH treatment. Inclusion of older children with previous GH therapy may have reduced the correlation between adherence rates and growth outcomes.

 

Disclosure: PD: Committee Member, Merck Serono, Investigator, Merck Serono. AL: Committee Member, Merck Serono, Investigator, Merck Serono. EC: Committee Member, Merck Serono, Investigator, Merck Serono. JK: Committee Member, Merck Serono, Investigator, Merck Serono. HSK: Committee Member, Merck Serono, Investigator, Merck Serono. LK: Committee Member, Merck Serono, Investigator, Merck Serono. MN: Committee Member, Merck Serono, Investigator, Merck Serono. MB: Committee Member, Merck Serono, Investigator, Merck Serono. MDR: Committee Member, Merck Serono, Investigator, Merck Serono. SN: Committee Member, Merck Serono, Investigator, Merck Serono. JV: Committee Member, Merck Serono, Investigator, Merck Serono. SL: Committee Member, Merck Serono, Investigator, Merck Serono. AB: Committee Member, Merck Serono, Investigator, Merck Serono. MD: Committee Member, Merck Serono, Investigator, Merck Serono. GS: Employee, Merck Serono. EBK: Employee, Merck Serono. JZ: Employee, Merck Serono. JL: Committee Member, Merck Serono, Investigator, Merck Serono. Nothing to Disclose: RC

21735 17.0000 THR-160 A The Easypod<sup>TM</sup> Connect Observational Study (ECOS): Results from the 2014 Interim Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Charikleia Stefanaki*1, George Paltoglou2, Flora Bacopoulou1, Dario Boschiero3 and George P Chrousos4
1University of Athens Medical School, Athens, Greece, 2Athens University Medical School, Athens, Greece, 3Biotekna, Venice, Italy, 4Athens University Medical School

 

Growth hormone is fundamental in skeletal growth during puberty, however detailed studies of body composition analyses in adolescents on growth hormone replacement therapy are scarce. In this case-control study, we aimed to investigate differences in body composition, based on the measurement of bio-impedance, between adolescents with idiopathic growth hormone deficiency (GHD) who were treated with recombinant human growth hormone (rhGH) for at least 6 months (treatment group) and adolescents with GHD who had not yet received rhGH (control group). Over a period of 1 year, 10 adolescents (8 males, 2 females; mean age±SD: 12.8±2.6 years) on rhGH treatment and 10 controls (5 males, 5 females; mean age±SD: 13.3 ±2.2 years) matched for age, height, body mass index (BMI) and bone age, were enrolled. Participants underwent dual frequency bio-impedance assessment with the use of the BIA-ACC, BIOTEKNA© device. Statistical analysis revealed significant differences in tissue hydration, as total (p=0.017), intracellular (p=0.023) and extracellular water volume (p=0.018) were significantly increased in the treatment vs. the control group. GH anabolic effects were demonstrated in increased body cell mass (p=0.022), extracellular fluid protein mass (p=0.02), skeletal muscle mass (p=0.02), fat-free mass (p=0.02), total body protein (p= 0.023), BMI (p=0.018) and glycogen mass (p=0.022). The most interesting findings were the increased bone (p=0.015), bone mineral (p=0.018) and soft tissue mineral (p=0.016) content, along with total body magnesium (p=0.02) and calcium concentrations (p=0.017). Metabolism, in terms of kcal per day, was also increased in the treatment group (p=0.02), mainly due to the increased metabolism of the bones (p=0.01) and skeletal muscles (p=0.02). Interestingly, no statistically significant differences in fat mass were found between the two groups. In the treatment group, extracellular potassium concentrations (p=0.019) and mass (p=0.02) were increased in relation to the control group but below the maximum critical value that was given by the manufacturer. These findings probably reflect increased metabolism resulting in decreased exchangeable potassium in the body (1). In conclusion this study reveals that bio-impedance analysis may be a potent, non-invasive tool for assaying body composition, while also confirming the expected beneficial changes in muscle and bone mass and bone mineralization following rhGH treatment. Further prospective studies with large numbers of patients are needed to confirm our results.

 

Disclosure: DB: Chief Scientific Officer, BioTekna srl. Nothing to Disclose: CS, GP, FB, GPC

21690 18.0000 THR-161 A Bio-Impedance Body Composition Analysis in Adolescents with Idiopathic GH Deficiency Confirmed Significant Increase in Hydration, Skeletal Muscle Mass, Bone Mineralization, and Metabolism but No Change in Fat Mass 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Gabriela Sobrero*1, Maria Cecilia Aguirre2, Liliana Silvano3, Cintia Soledad Tarifa2, Alejandra Paez Nuñez2, Mariana Ochetti2, Maria Julia Alvarez2, Graciela María Testa1, Silvia Edith Martin4, Mirta Beatriz Miras1 and Liliana Muñoz3
1Hospital de Niños de la Santisima Trinidad, Cordoba, Argentina, 2Hospital de Niños de la Santísima Trinidad. Córdoba, 3Hospital de Niños de la Santísima Trinidad. Córdoba, Córdoba, Argentina, 4Hospital de Niños de la Santísima Trinidad. Córdoba, Argentina

 

Background: The diagnosis of growth hormone deficiency in children is based on clinical, auxological, radiographic and biochemical criteria which include response to pharmacological stimulation tests (PhT). It is well known that GH concentrations vary according to the assay method used. Currently, the proposed cut-off value of serum GH PhT is 4,70 ng/mL measured by ICMA using the IRP 98/574, however there are no data about cut-off using ECLIA methodology with the same IRP in our population.

Objetive: The aims of this study were to define GH cut-off level by ECLIA in our population and to compare the concentrations measured by ECLIA and ICMA.

Method: We analyzed 245 PhT (72 F, 173 M) from 192 children with short stature aged 0,8 to 16 years, arginine PhT n: 175 and clonidine PhT n: 70. GH concentrations was determined by ICMA (Immulite 2000) and ECLIA (Cobas e 601) using the IRP 98/574.

Results: Linear regression analysis was performed in 1120 samples measured by ICMA vs. ECLIA showing highly significant linearity (y= 0.28+0.98 x; R2=0.95). The ECLIA cut-off of 4,65 + / - 0,22 ng/mL is the best match with the proposed by ICMA (association coefficient phi = 0,88). We found 96% agreement in the interpretation of PhT using the cut-off for each method.

Conclusion: GH measurements by ICMA and ECLIA using the IRP 98/574 were highly correlated. The use of uniform standardization and establishment of cut-off values for each methodology and population allow a consistent interpretation of the results and assist in the accurate diagnosis of GH deficiency.

 

Nothing to Disclose: GS, MCA, LS, CST, AP, MO, MJA, GMT, SEM, MBM, LM

21922 19.0000 THR-162 A Serum GH Cut-Off Levels By Eclia Performed in Pharmacological Stimulation Tests in Children with Short Stature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Byung-Ho Kang*1, Mun Suk Park2, You Jung Yang3, Sung Jig Lim3 and Kye Shik Shim2
1Kyung Hee University College of Medicine, Seoul, Korea, Republic of (South), 2Kyung Hee University Hospital, Seoul, Korea, Republic of (South), 3Kyung Hee University Hospital, Seoul, South Korea

 

Purpose

The purpose was to get the basic data of optimum serum concentration of estrogen in pubertal growth spurt, minimizing the decrease of bone mineral density or acceleration of epiphyseal closure of long bones.

Method

1. Fifteen female SD rats (4-week aged) were ovariectomized to inhibit their endogenous estrogen effect and randomly divided into 3 groups. After 1 week, the group 1 were injected subcutaneously with sesame oil, as a control, group 2 were with 100µg/kg/week of estradiol depo as a high-dose, and group 3 were with 200µg/kg/week of it as a super-high-dose for 10 weeks on their posterior neck area.

2. Their crown-lump length, body weight, and bone mineral density of spine and long bones were checked weekly from 1 week before through 10 weeks after injections.

3. Serum levels of GH and estradiol were checked with ELISA before and after injections.

4. After 10 weeks of injections, they were euthanized, pituitary glands were dissected and their pituitary Gh1 mRNA levels were checked with quantitative RT-PCR.

5. Their proximal tibia were dissected and stained with hematoxylin-eosin.

6. The thicknesses of epiphyseal plate including proliferative and hypertrophic zone of the proximal tibias were measured in 20 evenly divided sites with microscope.

7. Statistical analyses were done among the 3 groups before and after injections using ANOVA with multiple comparisons for auxological data, and Kruskall Wallis test for seum levels of GH, estradiol, and pituitary Gh1 mRNA levels with SPSS ver.13.0.

Results:

1. There were no significant differences in body lengths among 3 groups.

2. The body weights were decreased, and the bone mineral densities were increased in group 3 but there were no significant differences.

3. Serum GH levels and pituitary Gh1 expressions were significantly increased in group 3.

4. There was no significant difference in the thickness of total epiphyseal plate, proliferative zone, but that of hypertrophic zone of the epiphyses was significantly increased in group 3.

Conclusion

1. GH secretion and Gh1 gene expression were increased after super-high dose estrogen treatment.

2. There were tendencies that body weight is negative and bone mineral density is positive relation with estrogen dosage, but with no significant differences.

3. The thickness of hypertrophic zone in epiphyseal plate was relatively increased after super-high-dose estrogen treatment, maybe because of increased transdifferentiation of osteoblast to osteocyte.

4. The effects of estrogen on epiphyseal plate in rodents may be different with human.

 

Nothing to Disclose: BHK, MSP, YJY, SJL, KSS

21433 20.0000 THR-163 A Change of Growth Pattern and Bone Mineral Density in Ovariectomized Female Rats According to Estrogen Dosage 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Christopher J Child*1, Charmian A Quigley2, Alan G Zimmermann3, Cheri L Deal4, Judith L. Ross5, Eckhard Schoenau6 and Werner F Blum7
1Eli Lilly and Company, Windlesham, United Kingdom, 2Sydney Children’s Hospital, Sydney, Australia, 3Eli Lilly and Company, Indianapolis, IN, 4Sainte-Justine Hospital, Montreal, QC, Canada, 5Thomas Jefferson University/duPont Hospital for Children, Philadelphia, PA, 6University of Cologne, Cologne, Germany, 7University of Giessen, Giessen, Germany

 

GH treatment in short children born small for gestational age (SGA) has shown a growth-promoting effect in both the short- and long-term, and is an approved indication in both Europe and the USA; recommended GH dosages range from 0.25 to 0.47 mg/kg/wk.

To examine long-term outcomes in patients (pts) receiving GH treatment in routine clinical practice, we assessed final height (FH) and safety outcomes in pts born SGA by using data collected in a multinational observational study (Genetics and Neuroendocrinology of Short Stature International Study [GeNeSIS]). 

At the time of analysis, 1208 GH-treated pts born SGA (114 due to Russell-Silver syndrome; 111, other known causes; 932, unknown SGA cause) were enrolled in GeNeSIS. FH (defined by one or more of the following: closed epiphyses, height velocity <2 cm/year, last bone age >14 years (y) for girls/>16 y for boys) was available for 203 pts (FHPop1). Sub-analyses were performed for a) 62 pts with baseline age ≥4 and <11 y who had ≥5 y GH treatment (FHPop2) and b) a subset of FHPop2 who had initial GH dose ≥0.2 and <0.3 mg/kg/wk (FHPop3, N=26).

For FHPop1, FHPop2 and FHPop3, respectively, key baseline data (mean±SD) were: age (y), 10.9±3.1, 8.3±1.7, 8.9±1.9; height standard deviation score (SDS), -2.6±0.9, -2.8±0.9, -2.6±0.8; and BMI SDS, -0.9±1.6, -1.3±1.8, -1.5±1.8. Mean initial GH dose was 0.28±0.10 mg/kg/wk, increasing at FH by ≤12% for all FH populations. FH SDS, BMI SDS, age, and GH duration at FH for each population were as follows: FHPop1: -1.5±0.9, -0.3±1.5, 16.1±1.5 y, 5.0±2.9 y; FHPop2: -1.3±0.8, -0.4±1.6, 16.0±1.2 y, 7.5±1.8 y; and FHPop3: -1.1±0.8, -0.8±1.9, 16.0±1.2, 6.8±1.5 y. Height gains from baseline were 1.1±1.0, 1.5±0.8, and 1.4±0.9 SDS respectively.  

Of 1111 GH-treated pts born SGA with ≥1 follow-up visit (3.2±2.2 y of follow-up), ≥1 adverse event was reported for 283 (25%) vs. 5552/20060 (28%) for GeNeSIS overall (all short stature diagnoses). Adverse events reported for ≥1.0% were precocious puberty (3%), headache (2%), hypothyroidism (2%), arthralgia (2%), attention deficit hyperactivity disorder (2%), scoliosis (1%), asthma (1%), and acne (1%). Two deaths were reported [1 associated with displaced ventriculoperitoneal shunt; 1 with MELAS syndrome (1)]; one case of malignancy (b-cell lymphoma) and 4 cases of diabetes (2 type 2, 1 type 1, and 1 unknown type) were reported. In pts with ≥1 follow-up visit and available IGF-I data mean IGF-I SDS was -1.5±1.6 at baseline, 0.8±1.8 at 3 y of follow-up, and was >+2SDS for 21% of pts at 1 or more follow-up visits.

The height gains observed for pts born SGA enrolled in GeNeSIS were similar to those in previous studies using GH doses similar to the European approved dose (2,3); younger age at treatment start was associated with greater height SDS gain. No new safety concerns were identified.

 

Disclosure: CJC: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. CAQ: Other activities, please specify:, Eli Lilly & Company, Retiree, Eli Lilly & Company. AGZ: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. JLR: Researcher, Novo Nordisk, Researcher, Versartis, Researcher, Eli Lilly & Company, Advisory Group Member, Novo Nordisk. ES: Collaborator, Eli Lilly & Company. WFB: Retiree, Eli Lilly & Company, Retiree, Eli Lilly & Company. Nothing to Disclose: CLD

18545 21.0000 THR-165 A Final Height and Safety Outcomes in Growth Hormone (GH)-Treated Children Born Small for Gestational Age (SGA): Experience from a Large, Multinational, Prospective Observational Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Hwal Rim Jeong*1, Jungsub Lim2, Young Seok Shim3, Hae Sang Lee1 and Jin Soon Hwang4
1Ajou University School of Medicine, Suwon, Korea, Republic of (South), 2Korea Cancer Ctr Hosp, Seoul, Korea, Republic of (South), 3Hallym University Medical Center, College of Medicine, Hallym University, Seoul, Korea, Republic of (South), 4Ajou Univ School of Med, Suwon City, Korea, Republic of (South)

 

Background: Idiopathic short stature (ISS) is defined auxologically by a height below 2 SD score (SDS) without findings of disease as evident by a complete evaluation by a pediatric endocrinologist including stimulated GH levels. GH responses in ISS are highly variable and are dose dependent. It has been recognized that higher doses of GH are required in ISS patients to achieve similar responses and IGF-1 levels to those seen in GHD.

Objective: To investigate response to same dose of growth hormone (GH) in growth hormone deficiency and idiopathic short stature patient

Methods: This study was conducted retrospectively. Subjects diagnosed with ISS and GHD at Ajou University Hospital were included. ISS group (n= 35) and GHD group (n = 66) were treated with same dose of growth hormone (0.23mg/kg/week SC injection, 6 times a week). All children were prepubertal, and treated with growth hormone for 24months. We reviewed their auxological data, laboratory findings, bone age and change of height SDS (Δ Ht SDS) and growth velocity. And clinical factor associated with 1st year Δ Ht SDS was analyzed.

Result: There was no difference in pretreatment Ht SDS, IGF-BP3 SDS, mid parental height, BMI and bone age delay. ISS group presented higher IGF-1 SDS and GH stimulated peak GH than GHD (-0.19 ± 0.92 and 0.22 ± 0.81, 7.05 ± 2.07 and 21.93 ± 10.00 (ng/ml), p < 0.05, respectively). The same dose of GH presented no difference in GV in both group, but significantly higher 1st year Δ Ht SDS in ISS group than GHD group (0.67 ± 0.31 and 0.82 ± 0.32, p < 0.05). Age was found to be negatively associated with 1st year Δ Ht SDS in both groups.

Conclusion: ISS children can achieve optimal response with same dose of GH compared with those of GHD. Early intervention with GH treatment is best help to attain optimal response in both ISS and GHD.

 

Nothing to Disclose: HRJ, JL, YSS, HSL, JSH

19726 22.0000 THR-166 A A 2 Year Single Center Experience with Same Dose of Growth Hormone on Idiopathic Growth Hormone Deficiency and Idiopathic Short Stature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Mitchell E. Geffner*1, Anders Lindberg2, Nina Camacho-Hubner3 and Michael B Ranke4
1Children's Hospital Los Angeles, The Saban Research Institute, Los Angeles, CA, 2Pfizer Health AB, Sollentuna, Sweden, 3Pfizer Inc, New York, NY, 4Univ Klinikum Tübingen, Tübingen, Germany

 

Background: Children born SGA are thought to have early and/or rapid tempo puberty. The pubertal pattern of children with Silver-Russell syndrome (SRS), a specific cause of SGA, is less well-characterized. 

Objective: To assess pubertal timing and tempo in SGA children. 

Methods/Subjects: Using the KIGS (Pfizer International Growth data base) pharmaco-epidemiological survey, we undertook a comparative study of pubertal timing and tempo in GH-treated children born with SRS, non-specific SGA, and idiopathic short stature (ISS). Using ANOVA, we compared, by gender (M/F), median (n) growth data SDS at birth and 2 yr, target heights, BMI at pubertal onset, and ages (yr) at which various pubertal milestones were achieved and time intervals between them.

Results: Birth weight [SRSM -3.0 (348), SRSF -2.8 (248), SGAM -2.5 (3049), SGAF -2.4 (1958), ISSM -0.8 (1579), ISSF -0.8 (700) (p <0.01)] and length [SRSM -3.1 (245), SRSF -2.9 (195), SGAM -2.6 (2562), SGAF -2.5 (1723), ISSM -0.5 (991), ISSF -0.3 (449) (p<0.01)] followed the pattern of SRS<SGA<ISS, while target height [SRSM -0.8 (338), SRSF -0.5 (229), SGAM -1.3 (2830), SGAF -1.3 (1817), ISSM -2.0 (1534), ISSF -2.1 (689) (p<0.01)] was reversed (SRS>SGA>ISS). Between birth-2 yr, all groups lost weight, albeit less so in SRSM and SRSF. Rank order for BMI at start of puberty was: SRS<SGA<ISS [SRSM -1.1 (58), SRSF -1.8 (51), SGAM -0.6 (406), SGAF -0.9 (346), ISSM -0.4 (261), ISSF -0.7 (188) (p <0.01, except SGAM vs ISSM, p=NS)].

Age of pubertal onset in all 3 groups was normal. Significant differences included: breast TS2 [SRS 10.4 (119), SGA 11.2 (798), ISS 11.9 (363)] (SRS<SGA<ISS; p<0.01); female pubic hair (PH) onset [SRS 10.6 (113), SGA 11.2 (764), ISS 12.4 (271)] (SRS<SGA<ISS; p<0.01); and menarche [SRS 13.0 (69), SGA 13.3 (434), ISS 13.9 (210)] (SRS<SGA<ISS; p<0.01); male PH onset [SRS 11.4 (151), SGA 12.4 (1077), ISS 13.5 (566)] (SRS<SGA<ISS; p<0.01) and testis 4 mL [SRS 12.3 (144), SGA 13.3 (914), ISS 13.9 (542)] (SRS=SGA<ISS; p<0.01). Prepubertal GH treatment duration correlated with earlier onset of puberty only in the SGAF (r=-0.18, p=<0.01) and in SGAM (r=0.10, p<0.05). Ré pubertal progression, rates for girls moving from TS2 to TS4 breasts [SRS 1.9 (50), SGA 2.0 (329), ISS 2.0 (144)] were not different, whereas boys with SRS had significantly faster testicular growth from 4 to 15 mL [SRS 2.6 (47), SGA 2.3 (326), ISS 2.2 (188)] compared to other groups (SRS>SGA=ISS; p<0.05).

Conclusions: In subjects born SGA enrolled in KIGS, timing and tempo of pubertal events in both sexes occurs within normal age ranges, albeit for most parameters SRS<SGA<ISS. Although prepubertal GH treatment duration marginally correlated with earlier onset of puberty only in the SGA groups, there did not appear to be any accelerator effect on pubertal tempo thereafter.   

 

Disclosure: MEG: Principal Investigator, Endo Pharmaceuticals, Principal Investigator, Ipsen, Principal Investigator, Novo Nordisk, Principal Investigator, Versartis, Advisory Group Member, Endo Pharmaceuticals, Advisory Group Member, Ipsen, Advisory Group Member, Pfizer, Inc., Advisory Group Member, Sandoz, Principal Investigator, Genentech, Inc., Principal Investigator, Novo Nordisk, Editor, Up To Date, Editor, McGraw Hill, Principal Investigator, Eli Lilly & Company, Consultant, Daiichi Sankyo. AL: Employee, Pfizer, Inc.. NC: Employee, Pfizer, Inc.. MBR: Advisory Group Member, Pfizer, Inc..

20298 23.0000 THR-167 A Timing and Progression of Puberty in Children Born SGA 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Carole Fournier*, Rene Rizzoli and Patrick Ammann
Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland

 

In developing countries, chronic malnutrition is a major factor of child mortality, frequently characterized by insufficient dietary protein intakes. Similarly to kwashiorkor, a low protein diet precludes optimal whole body growth and leads to fatty liver in growing rats. To combat this scourge, low-cost and local food strategies should be developed. Spirulina alga (Spi) has great potential as supplementation since it contains 60% protein, has all essential amino acids and easily grows in tropical regions. Its specific impact on bone growth and the related secretion of hepatic hormones have not yet been studied. To answer this question, one-month old female rats were fed an isocaloric diet containing 10% casein (Cas10, N=8), 5% casein (Cas5, N=8) or 5% casein + 5% Spi into dried powder form (Cas5+Spi, N=8) during 8 weeks. Tibia geometry and liver mass were evaluated. Trabecular bone microarchitecture in proximal tibia was analyzed by microCT and BMD by DXA. Bone strength was evaluated by proximal tibia compression test. Hepatic gene expressions of IGF-1, FGF21, Follistatin and Inhibin A were assessed by real-time RT-PCR and hepatic steatosis by Oil-Red O staining and image analysis. Serum IGF-I and FGF21 were measured. Low protein diet decreased tibia diameter (-5%, p<0.05) and length (-2%, p<0.01) vs. Cas10 group. It reduced proximal tibia BMD (-10%, p<0.001) and bone trabecular volume (BV/TV; -41% p<0.01) vs. 10Cas group, resulting in a lower bone strength (Maximal load: -18%, p<0.01). Spi completely prevents these effects and even leads to higher energy values for breaking bone vs. 5Cas and 10Cas groups (+60% and +43% respectively, p<0.001). The Cas5 group had higher liver weight ratio (+18%, p<0.0001), serum FGF21 (+500%, p<0.001) and hepatic mRNA FGF21 levels (+400%, p<0.01) while serum and mRNA IGF-1 levels were lower vs. Cas10 group (-13% and -26%, p<0.05). Spi completely prevents these effects and even leads to lower liver weight ratio vs. Cas10 group (-8%, p<0.05). Spi also specifically increased mRNA levels of follistatin (+60% and +66% vs. Cas10 and Cas5 group respectively; p<0.05) and reduced those of Inhibin A (-45% and -41%; p<0.05), a subunit protein of Activin A, while low protein diet did not affect these two parameters. We demonstrate that Spi is an effective nutrient to prevent alterations of bone growth, liver fat content, FGF21 and IGF-1 hepatic production in rats fed a low protein diet. As compared to casein, Spi has specific beneficial impact on hepatic fat content and gene expression of follistatin which, if secreted as hepatokine, may positively act at the bone level. This study supports the use of Spi in undernourished children.

 

Nothing to Disclose: CF, RR, PA

21819 24.0000 THR-168 A Spirulina Alga Prevents Impairment of Peak Bone Mass Acquisition and Fatty Liver Induced By an Isocaloric Low Protein Diet 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Chantacha Sitticharoon*1, Maynart Sukharomana1, Supawadee Likitmaskul2, Malika Churintaraphan1 and Pailin Maikaew1
1Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand, 2Faculty of Medicine Siriraj Hospital, Mahidol University

 

Central precocious puberty is found to be associated with childhood obesity and was diagnosed increasingly in obese girls. There are many hormones that might be involved in early onset of puberty including kisspeptin, leptin, and adiponectin. This study would like to compare serum high-molecular weight (HMW) adiponectin, total adiponectin, kisspeptin, leptin, and neuropeptide Y (NPY) between central precocious puberty (CPP) and age-matched control girls with or without excluding obese girls. 25 CPP girls and 29 aged-match control girls were recruited.  CPP girls had higher BMI and body weight (p<0.05) than control girls even exclusion of obese girls; the higher BMI and body weight might be caused from higher fat-free mass (p=0.059) rather than fat mass (p=0.181). Serum leptin levels were note different between CPP and non-CPP girls and were positively correlated with obesity-related parameters (R≈0.5-0.8, p<0.001 all) indicating that leptin was closely related to obesity but might not be a major factor determining precocious puberty. Serum HMW adiponectin was significantly higher in CPP girls compared to control girls (p<0.05) but serum total adiponectin was lower in CPP girls than in control girls (p<0.05). Furthermore, serum total adiponectin was strongly and positively correlated with HMW adiponectin in CPP girls (R=0.915, p<00.1) while much less correlated in control girls (R=0.371, p=0.081) suggesting that other forms of adiponectin rather than HMW adiponectin might be higher in control girls. Interestingly, total adiponectin was negatively correlated with obesity parameters and Tanner stage, (R≈-0.3, p<0.05 all) but was positively correlated with QUICKI (R=0.339, p<0.05) in control girls, not in CPP girls. Moreover, HMW adiponectin was positively correlated with Tanner stage (R=0.351, p<0.05) and LH levels (R=0.369, p<0.01). These results indicated that while entering puberty, HMW adiponectin might play essential roles in progression of puberty whereas before entering puberty, other forms of adiponectin (as represented by total adiponectin) was associated with increased insulin sensitivity and decreased obesity. Kisspeptin was lower in CPP girls when compared to control girls and was positively correlated with SBP and DBP in CPP girls, not in control girls (R≈0.4, p<0.05 all). Kisspeptin was positively correlated with estrogen in control girls (R=0.574, p<0.01), not in CPP girls but was negatively correlated with FSH (R=-0.372, p=0.067) and LH (R=-0.363, p=0.070) in CPP girls and, not in control girls indicating that kisspeptin might plays roles in increased blood pressure in girls entering puberty and increased estrogen levels in girls before entering puberty. NPY was not different between CPP and control girls. In conclusion, HMW adiponectin might be used as a predictive factor to determine pubertal progression or diagnosis of CPP.

 

Nothing to Disclose: CS, MS, SL, MC, PM

20759 25.0000 THR-169 A Increased High-Molecular Weight Adiponectin and Obesity, but Decreased Total Adiponectin and Kisspeptin in Central Precocious Puberty Girls Compared to Aged-Match Control Girls 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Ah Reum Kwon*1, Duk Hee Kim2, Ho-Seong Kim3, Jung Min Ahn4 and Hyun-wook Chae4
1Severance Hospital, Seoul, Korea, Republic of (South), 2Sowha Children's Hospital, Seoul, Korea, Republic of (South), 3Severance Children's Hospita, Seoul, Korea, Republic of (South), 4Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Introduction: Kisspeptin is well known gatekeeper of puberty onset to date. However, several neuroendocrine factors are also discovered to be associated with puberty onset, especially neurokinin B and dynorphin A participate in the neuronal network integrating reproduction with kisspeptin. Therefore Kisspeptin, neurokinin B and dynorphin A were called ‘KNDys’ and became an object of investigation. However, the interactions between KNDys and the reproductive axis have not yet been fully explored. We report herein the expression profile of KNDy gene in the rat at different developmental stages. Methods: Spraque-Dawley (SD) strain female rats were used. To analysis expression of KNDys  mRNA, samples were obtained from hypothalamus in female rats at 4 day, 8 day, 14 day, 23 day, 27 day, 34 day, 38 day and 40 day. At the same time, blood samples were collected for analysis serum level of kisspeptin and luteinizing hormone (LH). The expression of KNDys mRNAs were assessed by RT-PCR and the serum levels of kisspeptin and LH were analyzed by ELISA. Results: The expression of Neurokinin B mRNAs in hypothalamus was low in neonate and infant stages and steadily increased prepubertal and pubertal stages (between day 27 and day 40). The expression of KiSS-1 mRNA was also increased as according to developmental stages. However, Neurokinin B mRNAs expression was increased more slowly than KiSS-1 mRNA expression. Meanwhile, the expression of dynorphin A mRNA in hypothalamus was also increased until infantile stage and decreased from infantile to prepubertal stages, but were increased again and maintained high level in pubertal and adult stage. Conclusion: KiSS-1, NKB and DYN gene contributed pubertal onset by interaction with each other. Pubertal onset may be induced by increased KiSS-1 mRNA, NKB mRNA expression and decreased DYN mRNA expression. However, KiSS-1, NKB, DYN mRNA were moderately increased in pubertal and adult stages, these may make estrus cycles.

 

Nothing to Disclose: ARK, DHK, HSK, JMA, HWC

19727 26.0000 THR-170 A The Expression of Kndys mRNA in Rat at Different Developmental Stages 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Eirini Meimaridou*1, Michelle Goldsworthy Goldsworthy2, Roger D Cox3 and Louise A Metherell4
1William Harvey research Institute, Queen Mary University of London, London, United Kingdom, 2Medical Research Council (MRC) Harwell, Oxfordshire, 3MRC Harwell Mammalian Genetics Unit, United Kingdom, 4William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom

 

In humans nicotinamide nucleotide transhydrogenase (NNT) dysfunction leads to an adrenal specific disorder, glucocorticoid deficiency. NNT, a ubiquitous protein of the inner mitochondrial membrane, produces high concentrations of NADPH for detoxification of reactive oxygen species by glutathione and thioredoxin pathways.  Certain sub-strains of C57BL/6J mice contain a spontaneous Nnt mutation (an in-frame 5 exon deletion) and display glucocorticoid deficiency along with glucose intolerance and reduced insulin secretion. A BAC transgenic rescue of this mouse strain results in overexpression of Nnt (1.9 fold over WT). To understand the underlying mechanism(s) behind the glucocorticoid deficiency we performed comprehensive RNAseq on adrenals from WT (C57BL6N), mutant (C57BL6J) and overexpressing (BAC transgenic) Nnt mice.

This revealed differential expression (fold change ≥1.5; p value <0.001) of 500 genes between WT and mutant mouse adrenals. For 80 of these genes the expression levels were reversed/rescued in the BAC. A further 200 changed their expression levels in the same direction for the mutant and BAC vs WT and the remaining 220 were unaltered when comparing WT vs BAC.

No alterations in antioxidant genes of the glutathione and thioredoxin pathways (PRDX3, GPX1, SOD2, TXNRD2, GR); in genes involved in the steroidogenic pathway (CYP11A1, STAR, CYP11B1) or in components of the ACTH signalling pathway, with the exception of MRAP, were noted. These findings are in keeping with the findings of our in vitro studies in NNT-knockdown H295R adrenocortical cells.

Pathway analysis identified significant enrichment of several pathways including those involved in 1) metabolic processes; PPARy, HSL, PCK1, adiponectin, IRS2 and Glut4 were upregulated in both mutant and overexpressing mice, indicating that fine tuning of Nnt expression is required for the regulation of this pathway 2) upregulation of haemoglobins (Hba-a1, Hbb-b1) in mutant mice, perhaps representing a compensatory increase to improve the antioxidant capacity of adrenal cells. These levels were restored to WT levels in the BAC and 3) upregulation of heat shock proteins in mutant mice that were rescued by the BAC transgene suggesting that ROS damage to proteins is activating chaperone pathways. Replacement of Nnt by the BAC transgene reverses this process implying this process involves more than simply the clearance of mutant Nnt protein itself.

Our data suggest that loss of Nnt and the resultant reduction in NADPH production affects a number of gene networks within the adrenal. It reveals the up- or down-regulation of important pathways presumably to combat the sustained adversity due to mitochondrial NADPH restriction and the concomitant increase in reactive oxygen species that this causes. Overexpression of Nnt reverses some of these changes but not all suggesting that for some pathways a delicate redox balance is key.

 

Nothing to Disclose: EM, MGG, RDC, LAM

21976 27.0000 THR-171 A High-Throughput RNA Sequencing of Adrenals from Mice with Knockout or Overexpression of Nicotinamide Nucleotide Transhydrogenase Reveals Novel Pathways Perturbed By Redox Imbalance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Carlos Manuel Cossio1, Romina Sainz1, Cristina Patricia Nemer2, Claudia Cannizzaro2, Marco A. Rivarola1, Alicia Belgorosky*3 and Nora Isabel Saraco4
1Garrahan Pediatric Hospital, Buenos Aires, Argentina, 2Garrahan Hospital and R Sarda Hospital, Buenos Aires, Argentina, 3Hospital de Pediatría Garrahan, Buenos Aires, Argentina, 4Hospital de Pediatria Garrhan, Buenos Aires, Argentina

 

Aromatase (Aro) is the key enzyme for estrogen biosynthesis from androgens and is encoded by CYP19A1 gene. In human placenta (Pl), Aro is expressed exclusively in the syncytiotrophoblast.

Several studies have described that abnormal fetal development were related to altered intrauterine environment and particularly placenta deregulation.  It has been reported that small newborns as well as large newborns tend to develop prevalence for metabolic syndrome in adult life. Moreover, patients with Aro deficiency develop lipid and carbohydrate metabolic alterations in adulthood. Our group has previously described in Pl a splicing variant of Aro mRNA (Intron9) that would be translated into inactive Aro protein (1).

The aim of this study was to analyze the expression of Aro mRNA variants in Pl from preterm (PT) (<35 weeks) and term LGA compared to term AGA  newborns. We proposed that the expression of Aro mRNA variants might be involved in the regulation of Aro activity and hence estrogen-androgen balance in intrauterine environment associated with fetal development.

Total RNA was isolated from Pl of PT (GA: 30-35, n=4), LGA (GA: 39-41, n=5) and AGA (GA: 37-41, n=17). Aro mRNA variant expression was analyzed by Real-time RT-PCR with specific primers for total (TotAro, Ex2-Ex3), intron 9 (IN9, Ex8-In9) and active (ActAro, Ex9-Ex10) Aro. β-actin (bAc) was used as housekeeping gene. Statistics (ANOVA and Bonferroni test) were performed on ΔCt data.

TotAro/bAc  was significantly higher in PT (12.83 ± 5.83, AU, mean ± SEM),  compare to AGA (2.38 ± 0.59) and LGA (3.00 ± 1.38) , p<0.05. However, ActAro/bAc  and IN9/bAc were significantly higher in PT (16.29 ± 8.05 and 1.95 ± 0.98), compare to AGA (1.25 ± 0.61 and 0.21 ± 0.09) but not compare to LGA (3.66 ± 1.61 and 0.51 ± 0.23).

Analysis of each transcript variant related to total Aro showed that ActAro/TotAro  and IN9/TotAro were significantly higher in PT (1.33 ± 0.26 and 0.14 ± 0.01) and in LGA (1.22 ± 0.20 and 0.17 ± 0.02) compared to AGA (0.33 ± 0.07 and 0.07 ± 0.01), p<0.05.

The high Aro mRNA expression, particularly Active Aro, in preterm placentas agrees with previous reports of increments in maternal salivary estriol and plasma estradiol in preterm parturition suggesting that Pl Aro plays a role modulating Pl estrogen production associated to prematurity.  Not only in PT but also in LGA higher Active Aro related to Total Aro was observed compare with AGA. These results suggest that Pl Aro mRNA variants might play a role regulating Pl Aro activity and hence androgen-estrogen balance in intrauterine environment. 

1)  Sainz R et al.ENDO2011. Endocr Rev 2011 32: P2-177

 

Nothing to Disclose: CMC, RS, CPN, CC, MAR, AB, NIS

19221 28.0000 THR-172 A Aromatase Transcript Variants Expression in Human Placental Tissues from Preterm Deliveries and Term Deliveries of Large for Gestational Age (LGA) and Adequate for Gestational Age (AGA) Newborns 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Manoj Prasad*1, Randy M Whittal2 and Himangshu S Bose1
1Mercer University, Savannah, GA, 2University of Alberta, Canada, AB, Canada

 

Translocase of the inner membrane (TIM) machinery mediates translocation of proteins into inner mitochondrial membrane (IMM) and matrix. CYP11A1, a mitochondrial IMM resident protein catalyzes the conversion of cholesterol to pregnenolone, the first step of steroid hormone biosynthesis. We found that CYP11A1 interacts with inner mitochondrial translocase Tim50, a part of TIM23 complex at the IMM. Tim50 is anchored to the IMM and exposes a large hydrophilic domain in the intermembrane space which possibly helps docking of CYP11A1. The docking with Tim50 provides CYP11A1 a longer stay into the IMM before its disposal into mitochondrial matix. Native-PAGE experiments followed by antibody shift experiments showed that Tim50 and CYP11A1 are the part of same native complex. Results were further conformed by chemical crosslinking and co-immunoprecipitation experiments. Absence of Tim50, ablated the complex formation and altered pregnenolone synthesis. Furthermore, deletion of more than 50 AA from the N-terminus of CYP11A1 halted its interaction with Tim50. So, we suggest that Tim50 interacts with N-terminal domain of CYP11A1at the IMM to facilitate its translocation and activity.

 

Nothing to Disclose: MP, RMW, HSB

19363 29.0000 THR-173 A Interaction of CYP11A1 with Tim50 at the Mitochondrial Inner Membrane Is Essential for Pregnenolone Synthesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Galit Pinto1, Moshe Phillip2 and Galia Gat-Yablonski*3
1Tel Aviv University, Tel Aviv, Israel, 2Schneider Children's Medical Center of Israel, Petah Tikva, Israel, 3Schneider Children's Medical Center, Rosh Haayin, Israel

 

Our previous data suggested that the histone deacetylase (HDAC) SIRT1 is involved in mediating the effect of nutrition on growth; therefore, the aim of the present research was to study the mechanism by which additional HDACs may be involved in nutrition-induced linear growth. The in vivo studies were performed in young male Sprague Dawley rats that were either fed ad libitum (AL) or subjected to 10 days of 40% food restriction (RES) and then re-fed (CU). For in vitro studies, Huh7 hepatoma cells were used. Food restriction led to significant reduction in liver weight, concomitant with increased autophagy (i.e. a decrease in the levels of P62 and an increase in the expression level of AMBRA1 and ATG16L2 genes in the RES group). At the same time, we found that the level of HDAC10 was significantly increased. Over expression of HDAC10 in Huh7 hepatoma cells led to reduced cell viability and increased autophagy as shown by increased conversion of LC3-I to LC3-II. An increase in the level of HDAC10 was also obtained when mTOR was inhibited by Rapamycin. siRNA directed against HDAC10 abolished the effect of Rapamycin on cell viability. These results suggest that increased levels of HDAC10 may mediate the effect of malnutrition on growth attenuation and autophagy. Deciphering the role of epigenetic regulation in the nutrition–growth connection may pave the way for the development of new forms of treatment for children with growth disorders

 

Disclosure: MP: Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Bristol-Myers Squibb, Study Investigator, Bristol-Myers Squibb, Medical Advisory Board Member, Eli Lilly & Company, Study Investigator, Eli Lilly & Company, Speaker, Medtronic Minimed, Medical Advisory Board Member, Medtronic Minimed, Study Investigator, Medtronic Minimed, Speaker, Novo Nordisk, Study Investigator, Novo Nordisk, Study Investigator, Merck & Co., Study Investigator, Roche Diagnostics, Study Investigator, Pfizer, Inc., Study Investigator, Sanofi, Medical Advisory Board Member, Sanofi, Speaker, Sanofi, Consultant, Andromeda Biotech, Board Member, CGM3 Ltd, Board Member, DreaMed-Diabetes Ltd, Chairman, NG Solutions Ltd. Nothing to Disclose: GP, GG

20251 30.0000 THR-174 A Food Restriction Increases Histone Deacetylase 10-Induced Autophagy in the Liver 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 144-174 5918 1:00:00 PM Pediatric Endocrinology & Growth Disorders Poster


Magdalena Szopa*, Agnieszka ludwig-Galezowska, Julita Machlowska, Jan Skupien, Piotr Radkowski, Tomasz Klupa, Beata kiec-Wilk, Iwona Wybranska, Pawel Wolkow and Maciej Malecki
Ujcm

 

Specific molecular diagnosis of monogenic diabetes mellitus is important for individualized patient care - by understanding the pathophysiology of the disease one can optimize hypoglycemic treatment and define prognosis for the entire family. Next Generation Sequencing-based exome-sequencing (NGS) might provide additional diagnostic potential as it enables simultaneous analysis of multiple genes in a single test.
Our aim was to assess feasibility of NGS usage for detection of mutations in a set of earlier described diabetic genes in a group of patients from the Polish Registry of MODY. We designed a custom Agilent Sure Select exon-capture assay with baits for 13 known MODY genes (GCK, HNF1A, HNF4A, HNF1B, NEUROD1, INS, CEL, PDX1, PAX4, BLK, KLF11, KCNJ11, ABCC8), two genes mutations of which cause lipodystrophy (LMNA, PPARG), mitochondrial genome and 20 neonatal diabetes genes.
A total of 96 DNA samples were tested. Samples were fragmented using Bioruptor (Diagenode), indexed for multiplexing and hybridisied. Sequencing was performed with an Illumina using 75 or 150bp paired end reads.
The analysis was performed for chromosomal genes only. High or medium impact mutations were identified in 74% of the studied patient samples. We identified 16 high impact mutations: 12 of them were located in HNF1A gene, 1 in ABCC8, 1 in GCK, 1 in EIF2AK3 and 1 in LMNA. We identified 107 medium impact mutations. All known mutations in the positive control samples were detected.
Our pilot experiment using NGS for monogenic diabetes screening in the MODY cohort confirmed that its use is feasible in routine genetic testing.

 

Nothing to Disclose: MS, AL, JM, JS, PR, TK, BK, IW, PW, MM

21759 1.0000 THR-586 A Monogenic Diabetes and Targeted Next-Generation Sequencing in the Mody Registry Cohort of Poland 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


Anat Jaffe*1, Shmuel Giveon2, Liat Wulffhart3, Bernice Oberman4, Laurence Freedman4, Arnona Ziv4 and Ofra Kalter-Leibovici4
1Hille Yaffe Medical Center, Hadera, Israel, 2Clalit Health Services, Even Yehuda, Israel, 3Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-Hashomer, Israel, 4Gertner Institute for Epidemiology & Health Policy Research

 

OBJECTIVE

The prevalence of diabetes mellitus in Ethiopian Jewish Immigrants [EJI] was <0.4% on arrival in Israel, while it was 8.3% in new immigrants from the former Soviet Union [FSU]. Both groups immigrated to Israel beginning in the 1980's. We aimed to compare diabetes risk among EJI, non-Ethiopian Jews [NEJ] and Jews from the FSU living in the same geographical area in Israel and assess whether the differences in diabetes incidence are explained by differences in baseline levels of the metabolic syndrome [MetS] components. 

 

RESEARCH DESIGN AND METHODS

Computerized database of the Sharon-Shomron District of Clalit Health Services between 2007 and 2011 was retrieved for 7,325 EJI and age and sex matched controls-NEJ. The controls included 10,374 "born in Israel" NEJ and 1,443 FSU subjects. "Born in Israel" NEJ served as the comparison group. Age and sex-adjusted hazard ratios [HRs] for incident diabetes were calculated in selected age-groups, and further adjusted for the MetS components. The difference in BMI between those diagnosed with diabetes and non-diabetics was determined within each age and ethnic group.

RESULTS

The HR for incident diabetes in FSU participants was not different from the "born in Israel", for all age groups. However, EJI had  greater diabetes risk at a young (<50y) age, HR- 1.8 (95% CI: 1.5, 2.2) and moderate risk at middle age (50 to 59y) HR- 1.3 (95% CI: 1.0, 1.6).  Diabetes risk in the elderly (60y and above) was not significantly higher among EJI HR-0.792 (95% CI: 0.6, 1.1). Adjustments for the MetS components except BMI, in the EJI, did not significantly change the HR estimates. But adjusting for BMI in EJI, increased HR to 2.3 (95% CI: 1.8, 2.8) in the young age group and to 1.4 (95% CI: 1.1, 1.8) in the middle age group. We further compared the BMI increment between non-diabetic and diabetic persons in the young age group and found it lower in EJI compared to NEJ. The BMI of young EJI at diabetes incidence was 25.88 + 4.21 kg/m2, similar to the BMI of non-diabetic NEJ and FSU participants. BMI at diabetes incidence of NEJ and FSU was 30.14+ 5.6 kg/mand 29+5.8 kg/mrespectively.

CONCLUSIONS

Younger Ethiopian immigrants are at greater risk for diabetes as compared to age-matched FSU subjects, and develop diabetes at lower BMI.  

 

 

Nothing to Disclose: AJ, SG, LW, BO, LF, AZ, OK

20887 2.0000 THR-587 A Younger Ethiopian Immigrants Are at Greater Risk for Diabetes As Compared to Age-Matched New Immigrants from the Former Soviet Union 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


Luis Hernandez-Vazquez*1, Carmen V Rivera2 and Rafael Trinidad2
1San Juan City Hospital, 2San Juan City Hospital, San Juan, PR

 

The total number of patients with Human Immunodeficiency Virus is 33 million, with 2.7 million new infections in 2007(1). Puerto Rico has an increasing prevalence trend of Diabetes Mellitus of 12.8% in 2010(3). As treatment of HIV continues to develop, and access to therapy improves, the incidence of HIV associated diabetes is bound to grow. This incidence has augmented with cumulative exposure to combination antiretroviral therapy, as showed in several research studies(1). Concurrent use of opiates may alter beta cell function, while heroin addiction is also associated with insulin resistance. We investigate the prevalence of Diabetes Mellitus and its associated risk factors in a determinate HIV positive population.

In this retrospective study, we reviewed the medical records of 146 HIV positive patients that were evaluated at a hospital of the metropolitan area of San Juan during the years of 2007 to 2010, for the concurrent diagnosis of DM.  For the purpose of this study, a subject was considered to be diabetic if the provider documented a diagnosis of DM in the chart, or the subject was receiving a hypoglycemic and/or insulin-sensitizing agent to treat DM. The prevalence of DM was statistically measured and a Logistic Regression with Pearson X² Square and Fisher’s exact test was used to assess the association between DM and variables such as gender, intravenous drug abuse (IVDA), age intervals, BMI, and Highly Active Antiretroviral Treatment in this population.  The prevalence of DM in the studied population was 13.7% (n=20). There were 59%(n=86) males, 43%(n=63) of patients treated with HAART, 46%(n=67) IVDA, the mean age was 47; with 29% older than 50 years old, and 68% of the patients had a BMI of less than 25.  Gender, IVDA, HAART, BMI, and age were not associated as risk factors for the prevalence of DM in the studied population.  Our data revealed a slightly higher prevalence of DM (13.7%) in HIV infected patients, when compared to that of the general population in Puerto Rico (12.8%).  Still our observations may underestimate reality due to limitations of retrospective analysis; including the possibility of missed testing opportunities for diagnosis. Despite previously reported data(1,2), we observed no significant association between DM and gender, opioid abuse, HAART, overweight, or obesity this time.  This raises concern for yet unrecognized risk factors contributing to a higher prevalence of the disease in this population.  Results of our study alert physicians on the importance of DM screening in the HIV positive patient population.

 

Nothing to Disclose: LH, CVR, RT

22034 3.0000 THR-588 A Prevalence of Diabetes Mellitus in Human Immunodeficiency Virus Positive Patients in Puerto Rico 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


Eun Byul Kwon*1, Hwal Rim Jeong2, Young Suk Shim3, Hae Sang Lee2, Jungsub Lim4 and Jin Soon Hwang5
1Ajou University Hospital, Suwon, Korea, Republic of (South), 2Ajou University School of Medicine, Suwon, Korea, Republic of (South), 3Hallym University College of Medicine, Seoul, Korea, Republic of (South), 4Korea Cancer Ctr Hosp, Seoul, Korea, Republic of (South), 5Ajou Univ School of Med, Suwon City, Korea, Republic of (South)

 

Purposes : It is well-known fact that a increase of type 2 diabetes in children with diabetes mellitus in Korea. But there is no statistical review about the changes of rate in subtype of diabetes in the last 10 years. Therefore, in this study, we looked for changes in subtypes of diabetes in children and evaluated the characteristics of the each group in the past 20 years since 1994. In addition, we also examined the correlation between the glycated hemoglobin values at the time of diagnosis and lipid profile.

Methods : We divided patients into 2 groups in 190 patients under the age of 20 who first dignosed with diabetes in Ajou university hospital. Group I was the patients diagnosed with diabetes from September 1994 to December 2004 and Group II was the patients diagnosed with diabetes from January 2005 to April 2014. Each groups ware classified as type 1 diabetes, type 2 diabetes, and maturity onset diabetes of the young(MODY). We compared the changes of diabetic subtypes in each groups. MODY subtype included the patients who confirmed by genetic test and the patients who had non-immune type diabetes, good responses to treatment of sulfonylurea, and a family history of diabetes onset before the age of 25 over 3 generations. We used multiple regression analysis about the correlation between the glycated hemoglobin values at the time of diagnosis and lipid profile.

Results : 52 patients belonged to Group I (44 with type 1 diabetes(84.6%), 6 with type 2 diabetes(11.5%), and 2 with MODY(3.8%)). And 138 patients belonged to Group II (91 with type 1 diabetes(65.9%), 33 with type 2 diabetes(23.9%), and 14 with MODY(10.1%)). The change of composition in each groups had a statistical significance (p-value=0.040). There was no significant difference in the epidemiological values as followings; the age at the time of diagnosis, gender, height, weight, and body mass index(BMI). The serum cholesterol level, and the serum low-density lipoprotein(LDL) level had a correlation with the serum glycated hemoglobin level in the correction of age, the standard deviation score of weight, and the standard deviation score of BMI. Glycated hemoglobin had a regression coefficient 2.984 with the level of cholesterol (p-value=0.013) and a regression coefficient 4.391 with the level of LDL.

Conclusions : The proportion of type 2 diabetes has been increased in patients diagnosed with diabetes over the past 10 years, and the cases of clinically suspected with MODY also increase. In addition, we will need more research to blood sugar control in the diabetic patients with dyslipidemia because it is that the increase in the level of glycated hemoglobin at the time of diagosis has correlations with total cholesterol level and LDL level.

 

Nothing to Disclose: EBK, HRJ, YSS, HSL, JL, JSH

19304 4.0000 THR-589 A The Change of Proportion in Type 2 Diabetes Mellitus in Korean Children and Adolescents 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


Khaled Abdullah Alswat*1, Turki M. Almalki2, Naif R. Almalki2 and Khalid Balbid3
1Taif University, School of Medicine, Taif, Saudi Arabia, 2Taif University, 3King Abdulaziz Specialist Hospital

 

Background:

Recent cross-sectional studies suggested that the prevalence of T2D in Saudi range from 10-30%.Diabetes knowledge has been shown to improve self-management skills and glycemic control in patients with T2D. There is a lack of studies to assess the level of knowledge among diabetics in Saudi and more specifically in Taif city.  

Methods:

We conducted a cross-sectional study at the King Abdulaziz Specialist Hospital, Taif, Saudi Arabia, Division of Endocrinology. T2D age ≥18 years who had a routine visit to the Endocrine clinic Jun-Oct 2014 were asked to participate. Baseline characteristics and measurement were obtained at the time of visit. Laboratory data was collected from patient’s EMR. We excluded patients with T1D. We used Michigan Brief Diabetes Knowledge Test to assess patient’s knowledge. Those answered ≥65% of the questions considered to have good knowledge about diabetes. The primary goal is to assess the Diabetes knowledge and its impact on diabetes control and complications.

Result:

Total of 200 patients participated, 96 (48%) were male and 104 (52%) were female, mean age 52.62 yrs old (SD 13.7 years), 50% has diabetes >10 yrs and 22.6% has it for 5-10 yrs, mean A1c 9.19%, mean BMI 31.1%, 73.5% were married, 64.5% did high school or less and 35.2% did college degree or higher, 43.5% considered to have low income, 35.2% were on oral medications only, 41.2% were on insulin, 23.5% were on insulin+/-oral, and the mean correctly answered knowledge questions was 47.95%.

25% of the participants think that A1c reflect BG control over the past week, 50% don’t know what is A1c. 29.5% think that diet soda can be used to treat low BG, 36.5% don’t know but 34% don’t think so.

45 patients (22.5%) considered to have good knowledge about diabetes. Compare to those with poor-knowledge, diabetics with good knowledge has mean age of 49.9 yrs vs 53.43 yrs(p .12), 62.2% were male vs 43.9%(p .03), 53.3% vs 29.9% has college degree or higher(p <.05).

81.8% of the diabetics with good knowledge report sedentary lifestyle compare to 82.7% in the poor-knowledge (p .89). 22.86% of the good knowledge diabetics were active smoker compare to 11.3%(p.51).

Diabetics with good knowledge has mean A1c of 7.7 vs 9.6 (p<.05), mean BMI 31.3% vs 31.1%, mean SBP was 138.4 vs 148.4 (p.21), mean resting HR 73.1 vs 73.8 (p.75), mean TC 167.2 vs 176.3 (p.16), mean LDL 108.6 vs 114.2 (p.37), mean HDL 42.7 vs 42.1(p.79), and mean TG 166.7 vs 181 (p.27).

All diabetics with good knowledge aware that poorly controlled diabetes cause retinopathy compare to 69.1%, CHD 84.4% vs 43.4%, and nephropathy 86.7% vs 53.95 (all p<.05) in patients with poor knowledge respectively.

Conclusion:

The majority (77.5%) of the screened T2D patients considered to have poor knowledge about diabetes. Poor knowledge associated with higher A1c, non-significant increase in most of the measured cardiovascular markers, and those are less aware about diabetes related complications.

 

Nothing to Disclose: KAA, TMA, NRA, KB

20629 5.0000 THR-590 A Diabetes Knowledge and Its Impact on Diabetes Control and Complications Awareness 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


Joseph Sack*1, Uri Reicher2 and Abraham Goldstein3
1Bar Ilan University, Tel Aviv, Israel, 2Sack and Reicher, 3Gonda Brain Research Centre, Bar Ilan University

 

Background:

Since 1978 we started screening all the newborns in Israel for Congenital Hypothyrodism (CH). We became interested in seasonality of CH in the different populations in Israel, and therefore the comparative study of overall birth seasonality.

Human populations show seasonal patterns of birth rates, which are stable in any particular population, but vary widely across geographical locations. These differences have been previously attributed mainly to climatic factors, yet additional factors have been proposed. 

Now, we report how a population changes considerably its birth seasonality in only 30 years, and synchronising with another population in the same location. This corresponds to changes in socio-economic factors in the population.

Methods: 

Monthly birth rates were extracted from the Israel Central Bureau of Statistics, and corrected for month length and de-trended using a moving average of 12 months. These were compared with climate, Religious calendar, and socio-economic changes.

Results: 

Over the last 40 years the monthly birth fluctuations of the Arab-Muslim and Jewish populations in Israel changed from qualitatively different patterns to similar ones. 

The peak birth rate of the Arab population moved from winter to late summer, to resemble the Jewish pattern, whereas the Jewish seasonality remained relatively stable. 

Between 1971-80, in January there was a deviation of +12% from the monthly average. In September the deviation was 0%. 

Between 1981-90, in January +5%, and in September +5%. 

Between 1991-2000, in January +2%, and in September +8%.

2001-2010 are similar to 1991-2000 – showing the stabilisation of Arab birth seasonality and synchronisation to the Jewish population.

These changes could not be attributed to climate, religious holidays, or marriage seasonality.

Over the same period, in the Arab population the percent of farmers dropped from 18.8% to 3.2% (in the Jewish from 5.3% to 1.4%), the average number of children per household changed from 3.8 to 2.5 (Jewish - 1.6 to 1.3), the average years of education increased from 8.2 to 11.2 (Jewish - 11.2 to 14).

Conclusions: 

We suggest that the synchronisation of Arab birth seasonality, changing in 40 years to resemble the Jewish one, is probably due to the urbanisation of Arab population, as can be seen in changes in education, profession, birth rate, etc. This is in spite of the Arabs being a native population in Israel, while the Jews are mixed immigrants. The original Arab-Muslim birth seasonality was similar to that of Arabs in neighbouring countries. It is only in Israel that the changed occurred - probably due to the influence of the majority Jewish population.

Changes in seasonal patterns have implications for health services and for research proposing season of birth as a risk factor in various disorders.


 

Nothing to Disclose: JS, UR, AG

21683 6.0000 THR-591 A Change and Synchronisation of Birth Seasonality in the Arab-Muslim Population of Israel (1971 - 2010), Affected By Socio-Economic Factors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


Steven W. Taylor*1, Richard E Reitz1, Nigel J. Clarke2 and Michael J. McPhaul3
1Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 2Quest Diagnostics Nichols Inst, San Juan Capistrano, CA, 3Medical Director, Endocrinology, San Juan Capistrano, CA

 

The incidence of type 2 diabetes mellitus has increased markedly in the United States and worldwide in the past 2 decades. This increase is traceable largely to the dramatic increase in the prevalence of obesity and insulin resistance in developed nations.

Elevated fasting insulin levels have been shown to reflect the presence of insulin resistance and to predict future development of diabetes mellitus. However, the clinical measurement of insulin levels has been largely relegated to the realm of specialized testing employed primarily in research and epidemiological studies examining insulin resistance, prediabetes, and early Type 2 diabetes. Although insulin measurements have a direct relation to more sophisticated assessments of insulin resistance, researchers have not yet defined specific insulin levels that are associated with specific degrees of insulin resistance. This is at least in part to the marked variability among available assays.  C-peptide measurements are less variable than insulin assays, but also suffer from a lack of standardization.

To address these aspects, we developed a multiplexed method to measure insulin and C-peptide using an LC tandem mass spectrometry assay. The assay involves enrichment of the peptides from patient sera using 2 different monoclonal antibodies immobilized on magnetic beads and processing on a robotic liquid handler.  Eluted peptides are directly analyzed by LC-MS/MS.  The assay has a clinical reportable range from 2.5 to 320 µIU/mL for insulin and 0.11 to 27.2 ng/mL for C-peptide.   Intra- and inter-day assay variation is less than 11% for both peptides. Of the 5 insulin analogues commonly prescribed for diabetes treatment, only the recombinant human insulin drug Humalog® (insulin lispro) causes significant interference for the determination of endogenous insulin. There were no observed interferences for C-peptide.

In summary, we have developed a multiplexed method to measure insulin and C-peptide using an LC tandem mass spectrometry assay. This approach offers a highly accurate and reproducible tool to measure insulin and C-peptide. Applying this tool to clinical samples will permit the standardization of both measurements using physicochemical properties of the analytes. This in turn will facilitate comparison of results obtained in different studies and to highly characterized standard reference materials.

 

Disclosure: SWT: Researcher, Quest Diagnostics. RER: Coinvestigator, Quest Diagnostics. NJC: Coinvestigator, Quest Diagnostics. MJM: Principal Investigator, Quest Diagnostics.

21568 7.0000 THR-592 A A High-Throughput Mass Spectrometry Multiplexed Assay to Measure Insulin and C-Peptide 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


Frederick G Hamel*1, Matthew Purbaugh2, Robert Heineman3, Robert G. Bennett4, Gerri Siford2 and Cyrus V Desouza5
1Omaha VA Med Ctr, Omaha, NE, 2University of Nebraska Medical Center, Omaha, NE, 3University of Nebraska Medical Center, 4VA Nebraska-Western Iowa Health Care System, Omaha, NE, 5Univ of Nebraska Med Center, Omaha, NE

 

Recent reports indicate that IDE is present in the bloodstream, and at least a portion of it is associated with exosomes.  We hypothesized that obesity and/or type 2 diabetes (T2DM) would alter the insulin degrading activity in plasma as a response to changes in insulin concentrations.  We recruited healthy (BMI<30, no significant disease), obese (BMI>30) and obese diabetic (T2DM; ICD-9 code) patients and obtained fasting blood samples.  Plasma was centrifuged (100,000 x g) to prepare a microvesicular fraction and supernatant.  Insulin degrading activity was assayed by trichloroacetic acid precipitation of 125I-iodoinsulin, and differences analyzed by ANOVA with a Bonferroni posttest. The presence of IDE in the vesicular and soluble fractions was confirmed by Western blot.  There was little activity detected in the soluble fraction. For the microvesicular fraction, there were no significant differences among the 3 groups, although patients with the highest BMI tended to have lower degrading activity. We saw no statistically significant correlations of degrading activity with a number of clinical parameters including: fasting glucose; triglycerides, age, GFR and albumin. We then post hoc separated healthy and obese patients who were significantly dysglycemic (HbA1c of 6.0 to 6.4) into an additional group, and separated diabetic patients who were on insulin therapy.  Although there was still no difference in degrading activity between healthy and obese patients, there was a decrease in the dysglycemic patients and diabetic patients not on insulin were significantly (p<0.05) lower than healthy.  Interestingly, insulin treatment reversed the effect of diabetes and returned the microvesicular degrading activity to normal levels (p<0.01; diabetic vs insulin-treated diabetic).  As T2DM is associated with a chronic inflammatory state, we examined the effect of lipopolysaccharide (LPS) treatment on plasma IDE in mice.  Mice were treated with LPS or vehicle and 24 hours later plasma isolated.  Insulin-degrading activity was 50% less in animals treated with LPS.  One could speculate that inflammation and/or insulin resistance result in a decrease of vesicular IDE activity and that insulin treatment reverses this through its anti-inflammatory properties, or by overcoming insulin resistance. The results indicate that: a) IDE is present in the non-vesicular portion of human plasma, but is inhibited or inactive; b) a portion of enzymatically active IDE is associated with a fraction consistent with exosomes and is inhibited in diabetes; and c) insulin treatment reverses this inhibition.  Altered IDE activity in the blood could affect clearance of insulin and contribute to hyperinsulinemia.

 

Nothing to Disclose: FGH, MP, RH, RGB, GS, CVD

19099 8.0000 THR-593 A Insulin-Degrading Enzyme Activity in Human Plasma; Alteration with Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


Lynn Ang*1, Nicole Nevarez2, Mamta Jaiswal1 and Rodica Pop Busui1
1University of Michigan, Ann Arbor, MI, 2University of Michigan Medical School, Ann Arbor, MI

 

Introduction: Cardiovascular autonomic neuropathy (CAN) is a serious diabetes complication, and an independent predictor of mortality. Currently available methods to detect CAN, although reliable and sensitive, are either too expensive, time-consuming or require large sample sizes. Diabetic CAN and sudomotor dysfunction result from damage of the small unmyelinated cholinergic sympathetic C-fibers. Sensitive, specific, simple, non-invasive, and affordable tests to detect the earliest stages of autonomic dysfunction most susceptible to therapeutic interventions are needed. We evaluated the correlation between sudomotor function and measures of cardiovascular autonomic dysfunction in patients with T1DM.

 Methods: Cross-sectional study in 38 subjects with T1DM (mean diabetes duration >5 years) and 10 age-and-sex-matched healthy non-obese control subjects. Sudomotor function was assessed by measuring electrochemical skin conductance (ESC) of hands and feet with the SUDOSCAN (Impeto Medical; Paris, France). CAN was assessed with cardiovascular reflex tests, heart rate variability (HRV) studies and by positron emission tomography (PET) scans with the sympathetic analogue [11C] meta-hydroxy ephedrine (HED), that were analyzed as left ventricle retention index (RI). Correlation between mean hands and feet ESC and the measures of HRV and mean RI were estimated using Pearson correlation.

 Results: At baseline mean age was similar in T1D and control subjects, while resting heart rate, blood glucose and HbA1c were higher in T1D. There were no differences in the mean hands and feet ESC between groups (75± 11 mcS vs. 77 ± 11 mcS; P=0.61 and 74 ± 14 mcS vs. 77 ± 10 mcS; P =0.53, in T1D vs. control). In preliminary analyses, we found a significant correlation between the E/I ratio with mean hands ESC (r=0.37, P=0.02), and with standard deviation of normal R-R interval (SDNN). No correlations were found between feet ESC and any measure of CAN.

Conclusion: These preliminary data suggest that assessment of the ESC with the SUDOSCAN may not be the ideal tool for assessing early CAN in T1D. However, these findings may be partly due to a relative limited number of subjects studied. These studies are ongoing and longitudinally followed for at least 36 months.

 

Disclosure: RPB: Consultant, Astra Zeneca. Nothing to Disclose: LA, NN, MJ

20451 9.0000 THR-594 A Measures of Cardiovascular Autonomic Neuropathy and Sudomotor Dysfunction in Patients with Type 1 Diabetes (T1D) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


Lynn Ang*1, Jeffrey W Innis1, Joanna L. Spencer-Segal2, Eleni V Dimaraki1, Shane Quinonez1 and Elif A Oral1
1University of Michigan, Ann Arbor, MI, 2University of Michigan, Ann Arbor, NY

 

Background: MELAS is a multisystem disorder of mitochondrial dysfunction caused by mitochondrial DNA (mtDNA) mutations, and it is transmitted vertically in a non-Mendelian manner by mitochondrial inheritance. The A→G transition at nucleotide position 3243 is the most frequent mutation and accounts for 80% of the detected mutations in patients with MELAS syndrome. The reported age of onset varies between the ages of 5-15 years. Common clinical features include normal early development, short stature, hearing loss, recurrent headache and seizures, muscle weakness, easy fatigability, episodic vomiting, congestive heart failure, cardiac conduction block, optic atrophy, pigmented retinopathy, diabetes and nephropathy. Multiple other endocrinopathies have also been reported. Diagnosis is based on clinical findings and molecular genetic testing. Pathogenic mutations can be detectable from leukocytes, skin, hair follicles or most reliably, skeletal muscle. We report an unusual case with a nearly homoplasmic large mtDNA deletion in nucleotides 12439-14594 affecting MT-ND5 and MT-ND6.

Case: A 25 year old white female with a history of end stage renal disease status post renal transplant, bilateral sensorineural hearing loss, hypoparathyroidism, hypopituitarism, retinitis pigmentosa, short stature, and diabetes was admitted to our institution in April 2014 for recurrent seizures, stroke-like episodes, delusion and increased lactate (5.5 mmol/L).  MRI showed restricted diffusion involving the corpus callosum and cerebellum compatible with acute infarcts. A stroke workup was negative including vessel imaging. Given suspicion for MELAS, reevaluation of a previously obtained muscle biopsy revealed ragged red fibers and type 2 fiber atrophy. Respiratory chain enzyme analysis showed no deficiency in respiratory chain complexes. Mitochondrial genome sequencing identified the presence of a nearly homoplasmic large mtDNA deletion of 2156 base pairs that spanned from m.12439-14594 affecting MT-ND5 and MT-ND6. Given a low plasma concentration of arginine, L-Arginine, levocarnitine and Coenzyme Q10 were started with subsequent improvement in mental status. The family history was largely negative with the mitochondrial deletion not present in maternal peripheral leukocytes, suggesting a de novo mutation in the proband.

Conclusion: Recognition of the various phenotypic presentations and endocrinopathies of MELAS is crucial for the diagnosis of a young patient with a stroke-like episode. No specific consensus criteria for the treatment of MELAS have been established because of the genetic heterogeneity and variable natural history of this syndrome. Sensorineural hearing loss has been treated with cochlear implant; diabetes with insulin or oral agents; seizures respond to conventional anticonvulsant therapy; L-Arginine shows promise in treating stroke-like episodes.

 

Nothing to Disclose: LA, JWI, JLS, EVD, SQ, EAO

19996 10.0000 THR-595 A Rare Case of Nearly Homoplasmic Large mtDNA Affecting NADH Dehydrogenase Subunit 5 (MT-ND5) and Subunit 6 (MT-ND6) in a Patient with Mitochondrial Encephalopathy, Lactic Acidosis, Stroke- like Episodes (MELAS) and Multiple Endocrine Anomalies 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 586-595 5923 1:00:00 PM Diabetes Genetics & Epidemiology Poster


M. Michael Wolfe*1, Patricia A. Glazebrook2, Milos Tatalovic2 and Michael O. Boylan2
1MetroHealth Medical Center and Case Western Reserve University, Cleveland, OH, 2MetroHealth Medical Center, Cleveland, OH

 

Background: Past studies have indicated that GIP functions as an efficiency factor by enhancing both nutrient uptake and storage. Thus, a reduction in GIP signaling should prevent the development of obesity in mice fed a high-fat diet (HFD). AIM: To develop a safe and effective biological agent with the capacity to neutralize circulating GIP. Methods: A hybridoma library was created by fusing splenic B cells isolated from mice immunized with a GIP fragment to mouse myeloma SP2/0 cells. Supernates from hybridomas were screened for GIP-specific monoclonal antibodies (mAbs) using a specific ELISA. To identify GIP-neutralizing mAbs, positive supernates were analyzed with a cell-based reporter assay. After purifying the mAbs using protein A agarose, their effects on intraperitoneal (i.p.) glucose tolerance, oral glucose tolerance (OGT), and diet-induced weight gain were evaluated. For i.p. glucose tolerance tests (IPGTTs), mAbs (30 mg/kg body weight [BW]) were administered i.p. 60 min before i.p. administration of glucose (18 mmol/kg BW) and human GIP (2.5 nmol/kg BW). For OGT tests, mAbs (30 mg/kg BW) were injected i.p. prior to oral glucose (2 mg/g BW) gavage. PBS or GIP mAbs (10 mg/kg BW) were also injected i.p. 5 times/week to mice fed a HFD, and both body weight and food consumption were monitored weekly. At the end of the 17-week study period, magnetic resonance (MR) was used to assess fat deposition, and blood was obtained for measurements of insulin, leptin, glucagon-like peptide-1 (GLP-1), and lipids. Results: 2000 hybridoma clones were generated, with 21 positive for GIP binding, one of which yielded a mAb that effectively neutralized 1 nM of GIP. Although serum glucose levels were unchanged, GIP mAbs given i.p. nearly abolished the insulin response to GIP in the IPGTT and reduced the insulin response to oral glucose by 70%. After 17 weeks on the HFD, control mice gained 21.5±1.0 g, while mice receiving GIP mAbs gained 10.5±0.5 g, a reduction in weight gained of 46.5% (P=0.00000007). When corrected for BW, no difference in the quantity of food consumed was detected between the 2 groups. In addition, MR demonstrated that mice treated with GIP mAbs had significantly less subcutaneous (P=0.0002), omental (P=0.0005), and hepatic fat (P=0.030) than untreated animals. In response to GIP mAbs, serum insulin and leptin levels decreased significantly, but no significant changes in serum GLP-1 levels were detected. Total cholesterol (TC), LDL, and triglycerides were decreased, while the HDL:TC ratio increased, significantly in the treatment group. Conclusion: Immunoneutralization of GIP in mice using a specific mAb effectively attenuates weight gain in mice fed a HFD while decreasing fat deposition and improving the lipid profile. The results of these studies support the hypothesis that a reduction in GIP signaling might provide a useful method for the treatment and prevention of obesity and related disorders.

 

Nothing to Disclose: MMW, PAG, MT, MOB

19568 1.0000 THR-620 A Immunoneutralization of Glucose-Dependent Insulinotropic Polypeptide (GIP) Attenuates the Development of Obesity in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Gaetano Santulli*1, Gennaro Pagano2, Celestino Sardu3, Steven Ross Reiken4, Michele Cannone5, Salvatore D Ascia6, Nicola Marziliano7, Bruno Trimarco8, Theresa Ann Guise9, Alain Lacampagne10 and Andrew Marks11
1Columbia University, New York, NY, 2Federico II University, Italy, 3Leiden University Medical Center (LUMC), Netherlands, 4Columbia University Medical Center, 5Tatarella Hospital, 6Città Study Hospital, 7Ospedale Niguarda, 8Federico II University, Naples, Italy, 9Indiana University School of Medicine, Indianapolis, IN, 10INSERM - Montpellier University, France, 11Columbia University Medical Center, NY

 

Type two ryanodine receptor (RyR2) is a Ca2+ release channel on the endoplasmic reticulum (ER) of many types of cells including pancreatic β-cells. However, the functional role of RyR2 in insulin secretion remains controversial and elusive. To determine the mechanistic role of RyR2 channels in glucose homeostasis we took advantage of RyR2 mutations that render the channel “leaky” in humans, triggering a form of exercise-induced sudden cardiac death known as catecholaminergic polymorphic ventricular tachycardia (1). We found that patients with mutant leaky RyR2 have previously unrecognized yet profound glucose intolerance. To determine whether leaky RyR2 channels in these patients cause glucose intolerance we generated knock-in mice harboring the leaky RyR2 mutations found in humans. These mice exhibited glucose intolerance, significant mitochondrial dysmorphology (fragmented cristae, swelling, lamellar degeneration and outer membrane disruption) and dysfunction (reduced glucose-stimulated and glutamine/leucine-stimulated ATP production, augmented reactive oxygen species generation, decreased mtDNA/nDNA and aconitase) in pancreatic beta cells, impaired insulin secretion, and glucose intolerance. Islets of Langerhans isolated (2) from knock-in mice displayed intracellular Ca2+ leak via RyR2, Ca2+ depleted ER, upregulation of common markers of ER stress BiP and spliced XBP1, and increased expression, most likely compensatory, of Kir6.1. Ca2+ imaging assays (3) confirmed that caffeine-induced Ca2+ release via RyR2 led to mitochondrial Ca2+ accumulation. Intriguingly, human islets from diabetic patients (cadaveric donors) exhibited oxidation of RyR2 and depletion of calstabin2 (an established stabilizer of RyR2) from the channel complex, similar to what observed in knock-in murine islets. We have developed a 1,4-benzothiazepine derivative (Rycal S107) which inhibits stress-induced or genetic mutation induced dissociation of calstabins from RyR channels. Crucially, S107 treatment (10 μM, 4 hr) prevented the loss of calstabin2 from RyR2 channels. Moreover, chronic pharmacological inhibition of intracellular Ca2+ leak (S107, 50 mg/kg/d in drinking water, 1 month) improved mitochondrial fitness and normalized insulin secretion and glucose homeostasis in knock-in mice. We also tested S107 in an animal model of type 2 diabetes mellitus, the ob/ob mouse: oral S107 treatment markedly improved glucose tolerance and increased insulin secretion in islets from ob/ob mice. Taken together, our in vivo and ex vivo data establish that leaky RyR2 channels cause ER stress, mitochondrial dysfunction, impaired insulin secretion, and glucose intolerance.

 

Disclosure: AM: Board Member, ARMGO. Nothing to Disclose: GS, GP, CS, SRR, MC, SDA, NM, BT, TAG, AL

20750 2.0000 THR-621 A Intracellular Calcium Leak Via RyR2 Induces ER Stress and Impairs Mitochondrial Fitness in Pancreatic Beta Cells Leading to Glucose Intolerance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Stanley Hsia1, Monica DesNoyers1, Martin L. Lee1, Candice Goldstein1 and Theodore C Friedman*2
1Charles R. Drew University, 2Charles R. Drew Univeristy of Medicine and Science, Los Angeles, CA

 

Cigarette smoking has been correlated with insulin resistance, but smoking may also lead to weight loss while smoking cessation may lead to weight gain; the exact metabolic changes occurring with smoking or smoking cessation have not been well studied. The address this knowledge gap, we prospectively studied these metabolic changes using hyperinsulinemic euglycemic clamps coupled with stable isotope tracers to measure hepatic glucose output (HGO) and indirect calorimetry to measure substrate utilization, within an innovative study design of enrolling healthy, ½-to-2 pack-per-day smokers into an 8-week smoking cessation program of behavioral counseling plus oral bupropion (Phase I), followed by a 16-week maintenance period without counseling or bupropion wherein subjects either remained abstinent or naturally resumed/increased smoking (Phase II). Cigarettes per day, breath carbon monoxide (CO), urine nicotine metabolites, weight, body composition, fat distribution, free fatty acids, rates of HGO, total and non-oxidative glucose uptake, glucose oxidation, and the respiratory quotient (RQ), adjusted for mean daily caloric intake and expenditure, were measured in 22 subjects before and after Phase I; 19 subjects continued through Phase II and were assessed again at study end. Changes in metabolic measures over time were also correlated to changes in smoking severity within each phase and overall (24-weeks), and adjusted for caloric intake and expenditure. The cessation program (Phase I) reduced the median (interquartile range) cigarettes per day from 8.8 (6.5-12.3) to 1.4 (0.1-3.3), along with reduced CO and nicotine metabolite levels; there were no further significant changes through Phase II. The ratio of central-to-peripheral fat trended higher during Phase I (correlating inversely with CO changes) but then fell significantly through Phase II. Unadjusted basal HGO fell over 24 weeks; changes in weight- and fat mass-adjusted HGO correlated directly with CO changes. Body weight did not change significantly over time, but changes directly correlated with changes in nicotine metabolites in Phase II and overall. Over 24 weeks, changes in CO and/or nicotine metabolite levels correlated inversely with changes in rates of insulin- and weight- or lean mass-adjusted glucose uptake, and basal and insulin-stimulated glucose oxidation and RQ. In summary, smoking cessation over 8 weeks was associated with a transient worsening of central fat distribution, followed by a larger, favorable reversal over subsequent months. Over 24 weeks, HGO improved in relation to lifestyle changes, weight change correlated directly with reduced nicotine metabolites, and reduced CO and/or nicotine metabolites correlated with increased uptake and oxidation of carbohydrate substrates. The metabolic effects of smoking cessation appear to be complex but generally favorable, and should be encouraged.

 

Nothing to Disclose: SH, MD, MLL, CG, TCF

21451 3.0000 THR-622 A Metabolic Effects of Smokers Undergoing Smoking Cessation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Chunxia Lu* and Vasantha Padmanabhan
Univ of Michigan, Ann Arbor, MI

 

The inappropriate programming of the metabolic system by developmental exposure to excess steroids is of concern, especially in the female. Our previous findings indicate that testosterone (T) excess from days 30-90/ 60-90 of gestation a) induces maternal hyperinsulinemia [1] and culminate in insulin resistance in the female offspring [2] and b) changes mRNA levels of members of insulin signaling pathway in a tissue specific manner consistent with the liver and muscle but not abdominal fat being insulin resistant [3]. Whether similar changes are evident at the functional level and the role androgen and insulin plays in disrupting insulin signaling at the tissue level is unclear. The aim of the present study was to determine whether prenatal T treatment disrupts phosphorylation of insulin signaling molecules in a tissue specific manner and postnatal treatment with androgen antagonist, flutamide or insulin sensitizer, Rosiglitazone would reverse these effects. Four groups of female offspring were studied: control (C), prenatal T (intramuscular injections of 100 mg T propionate twice a week from days 60-90 of gestation that produces T levels in the female fetus comparable to that found in normal male fetus), prenatal T plus postnatal flutamide (15 mg/kg/day; T+F) and prenatal T plus postnatal Rosiglitazone (0.11 mg/kg/day; T+R). Postnatal treaments began at weaning. Muscle, liver, abdominal and subcutaneous fat tissues collected at 3 years of age were pre-incubated with saline at 37 °C for 10 min and then incubated with insulin (100 nM/mL) at 37 °C for 2 and 5 min respectively. Prior to insulin stimulation, prenatal T treatment did not alter phosphorylation of AKT in all 3 tissues. Phospho-AKT/AKT ratio increased 150% in control livers after two minutes of insulin stimulation (p=0.03).  This increment was not evident in livers obtained from prenatal T-treated females.  Similarly, phospho-AKT levels were increased to ~243% (p=0.009) and ~221% (p=0.025) after 2 and 5 min after insulin stimulation in muscle from C females.  This increase was also not evident in the muscle of prenatal T-treated females. Postnatal flutamide or Rosiglitazone treatment failed to restore insulin response in muscle and liver. Phospho-AKT/AKT ratio increased to a similar degree in response to insulin stimulation in abdominal and subcutaneous fat from both C and prenatal T-treated animals.  These findings indicate that insulin resistance induced by prenatal T excess is programmed via AKT signaling pathway in muscle and liver and that postnatal androgen antagonist or insulin sensitizer treatment alone are incapable of restoring insulin sensitivity. Altered insulin sensitivity at the level of liver and muscle may account for the peripheral insulin resistance in prenatal T-treated sheep. These findings may be of translational relevance to human PCOS, the characteristics of whom prenatal T- treated sheep recapitulate.

 

Nothing to Disclose: CL, VP

21087 4.0000 THR-623 A Developmental Programming: Prenatal Testosterone Excess Decreases Insulin Sensitivity in Muscle and Liver but Not Fat Via AKT Signaling Pathway in Female Sheep 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Nanyoung Yoon*, Keith Dadson and Gary Sweeney
York University, Toronto, ON, Canada

 

Decreased adiponectin levels or action have been established to contribute to diabetes and its cardiovascular complications, including heart failure. The endothelium acts as a barrier which regulates the movement of endocrine hormones between the vascular compartment and the interstitial space; a critical yet underestimated event in allowing functional effects in target tissues. Little is known about adiponectin biodistribution in diabetes. Using fluorescent molecular tomography and injection of adiponectin labeled with VivoTag-750 to wildtype and streptozotocin-induced diabetic Nu/Nu mice, we conducted temporal analysis of adiponectin biodistribution. Whole mouse images taken every 10 min from 0-90 min indicated, both visually and quantitatively, elevated tissue adiponectin content in the diabetic mice. This was confirmed by post-mortem ex vivo tissue analysis and was most apparent in liver, kidney and heart. We also performed in vitro studies using monolayers of endothelial cells grown on inserts and found that high glucose levels enhanced paracellular and transcellular flux of adiponectin across this monolayer from apical to basolateral side. Our preliminary data suggests that altered adiponectin flux may be mediated via changes in claudin-7 (a barrier-forming tight junction protein) and claudin-10 (a channel-forming protein) expression. In conclusion, in addition to the well accepted lack of adiponectin contributing to disease pathogenesis in obesity and diabetes we believe that the ability of adiponectin to move from circulation to tissue interstitial space is an important determinant of its physiological actions.

 

Nothing to Disclose: NY, KD, GS

21290 5.0000 THR-624 A Transendothelial Flux of Adiponectin Is Altered in Diabetes: Mechanisms and Physiological Significance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Chan-Hee Jung*1, Kyujin Kim2, Bo yeon Kim3, Chul-Hee Kim3, Sung-koo Kang3 and Jioh Mok1
1Soonchunhyang University School of Medicine, Bucheon hospital, Bucheon, Korea, Republic of (South), 2Soonchunhyang University School of Medicine, Bucheon, 3Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon city, Gyeonggi-do, Korea, Republic of (South)

 

It has been shown that omentin is associated with insulin resistance, inflammation and endothelial dysfunction. Visceral adiposity index (VAI) is a recently proposed marker of both visceral fat distribution and dysfunction. Until now, there is no published study to investigate the associations of serum omentin with visceral adiposity index (VAI), cardiac autonomic neuropathy in type 2 diabetes mellitus (T2DM). Therefore, we investigated the relationships between serum omentin, VAI, and vascular complications including cardiac autonomic neuropathy (CAN) in T2DM. We recruited 97 patients (men 56, women 41, mean age: 57.6 years) who evaluated diabetic microvascular complications (nephropathy, retinopathy and peripheral neuropathy) including CAN. CAN was assessed by the five standard cardiovascular reflex tests according to the Ewing’s protocol. CAN was defined as the presence of at least two abnormal tests or an autonomic neuropathy points ≥2.  Serum omentin levels were assessed by ELISA and VAI was calculated by the formula :

(Males:[WC/(39.68+(1.88×BMI))×(TG/1.03)×(1.31/HDL)],Females:[WC/(36.58+(1.89×BMI)×(TG/0.81)×(1.52/HDL)]. We estimated intraabdominal fat area using abdominal dual bioelectrical impedence analysis (BIA). Atherosclerotic burden was evaluated by brachial-ankle pulse wave velocity (baPWV) and ankle brachial index (ABI). Prevalence of CAN was increased borderline significantly across omentin tertiles (p=0.05) and CAN points were significantly increased progressively across omentin tertiles (p=0.01). However, prevalence of diabetic microvascular complications (nephropathy, retinopathy and peripheral neuropathy) was not significantly different according to tertiles of omentin levels. The mean levels of baPWV were significantly increased progressively according to the omentin tertiles (p=0.001). Serum omentin levels showed significant positive correlations with baPWV, CAN points, and HDL-cholesterol, and negative correlations with VAI. The mean levels of serum omentin were not significantly different according to the presence of each micovascuclar complications including CAN. This present study showed that levels of serum omentin are significantly associated with CAN, VAI and arterial stiffness assessed by baPWV, while there are no associations with each microangiopathies in patients with T2DM. Future prospective studies with larger numbers of patients are required to establish a direct relationship between serum omentin levels, VAI and vascular complications in patients with T2DM.

 

Nothing to Disclose: CHJ, KK, BYK, CHK, SKK, JM

19050 6.0000 THR-625 A Associations of Serum Omentin Levels with Cardiac Autonomic Neuropathy and Visceral Adiposity Index in Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Anne E Newell-Fugate*1, Monica Jarboe1, Corinne Bromfield1, Andrea Braundmeier-Fleming2, Sherrie G Clark3, Robert L Rosenfield4, Janice M Bahr1 and Romana A Nowak1
1University of Illinois at Urbana-Champaign, Urbana, IL, 2Southern Illinois University, Springfield, IL, 3Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, VA, 4The University of Chicago, Chicago, IL

 

Fat location is a linked with hyperandrogenemia in polycystic ovary syndrome (PCOS). Short-term administration of testosterone (T) lowers insulin sensitivity in healthy women, and may contribute to insulin resistance in PCOS, but little is known of this relationship in female adipose tissue. We hypothesized that administration of depot-testosterone (cypionate) (DT) to female pigs would reduce insulin signaling. DT-treated females (n=5) were given intramuscular DT (100 mg/m2) every 6 days, with the first of 3 doses administered on the day of estrus (day 0). Six age-matched, cycling females were controls (C). Fasting blood was collected on days 0, 3, 7, 11 and 13 of the estrous cycle and assayed for serum total testosterone (TT), insulin, and glucose. Liver, skeletal muscle, visceral (V) and subcutaneous (SC) adipose tissues were collected post-mortem (D13-15 of the cycle) for RTPCR of INSR and IRS1 and assessment of protein kinase B (Akt) activity by western blot (n=3) in adipose tissue only. Data were assessed for normality and logarithmically transformed as needed. Serum TT, insulin, and glucose were analyzed by repeated measures ANOVA. Gene transcript levels were analyzed relative to housekeeping gene HRPT1 by ANOVA. Akt activity was analyzed by normalization of phosphorylated Akt (pAkt) and Akt to the loading control (GAPDH), followed by calculation of the pAkt/Akt ratio by ANOVA. TT was higher in DT pigs on days 3, 7, 11 and 13 of the estrous cycle, approaching masculine concentrations on D13 (p<0.0001; DT13: 13.42 ± 0.83 ng/ml; C13: 0.09 ± 0.93 ng/ml). There was no significant difference in serum glucose in both groups. Serum insulin was higher in DT pigs on D3, but lower on D13 (p<0.01; DT3: 16.14 ± 3.12 μU/ml; C3: 3.36 ± 3.49 μU/ml; DT13: 2.50 ± 3.12 μU/ml; C13: 9.83 ± 3.49 μU/ml). INSR and IRS1 transcript levels were up-regulated in SC adipose tissue from DT pigs (p<0.01; INSR-DT: 2.52 ± 0.34 fold change; C: 1.00 ± 0.38 fold change; IRS1-DT: 2.75 ± 0.41 fold change; C: 1.00 ± 0.46 fold change). INSR transcript level was up-regulated in V adipose tissue from DT pigs (p<0.001; DT: 2.83 ± 0.34 fold change; C: 1.00 ± 0.53 fold change). There was no significant difference in the fold change of either INSR or IRS1 in skeletal muscle or liver. There was a trend for decreased Akt activity in V adipose tissue from DT pigs (p=0.1; DT: 1.56 ± 1.19 pAkt/Akt ratio; C: 4.07 ± 1.09 pAkt/Akt ratio) but no difference in Akt activity in SC adipose tissue (p=0.5; DT: 1.73 ± 0.53; C: 1.76 ± 0.49 pAkt/Akt ratio). In conclusion, administration of high dosages of DT to female pigs up-regulates INSR and IRS1 transcript levels in SC adipose tissue and may decrease Akt activity in V adipose tissue. These results suggest that virilizing T levels in females may differentially affect insulin signaling in V and SC adipose tissue depots, with V adipose demonstrating insulin resistance and SC adipose demonstrating increased insulin sensitivity.

 

Nothing to Disclose: AEN, MJ, CB, AB, SGC, RLR, JMB, RAN

21271 7.0000 THR-626 A Virilizing Concentrations of Serum Testosterone in Female Pigs May Differentially Affect Insulin Signaling in Visceral and Subcutaneous Adipose Tissue 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Maria Clarissa Yasmin Ong Tio*, Sarah E. Seiler, Dorothy H. Slentz, Timothy R. Koves and Deborah M. Muoio
Duke Molecular Physiology Institute, Durham, NC

 

Skeletal muscle insulin resistance (IR) plays an important role in the progression of diabetes, as the muscle is the primary site of insulin action and glucose uptake in states of feeding and exercise. Animal models and human studies of diabetes have shown signatures of incomplete ß-oxidation to be associated with the disease. Moreover, mounting evidence suggests that the development of IR is linked to mitochondrial-derived oxidative stress. Glutathione (GSH) is the most abundant endogenous antioxidant that mitigates mitochondrial oxidative stress. Diminution of GSH has been reported in aging, diabetes, and other disease states, whereas restoration of GSH status is associated with improved mitochondrial function and metabolic control. We hypothesized that redox imbalance would lead to intracellular acylcarnitine accumulation and IR symptoms in primary human skeletal myocytes (HSkMC). Cultured HSkMC obtained from young subjects with low BMI were utilized in the experiments. Intracellular glutathione depletion was achieved with buthionine sulfoximine (BSO) treatment, and parameters measured included oxidative stress via 2’,7’-DCFDA (2’,7’-dichlorofluorescein diacetate) fluorescence, 2-deoxyglucose uptake, and insulin signaling via Akt phosphorylation. Acylcarnitine profiling experiments were done using flow injection tandem mass spectrophotometry in the Metabolomics Core of the Duke Molecular Physiology Institute. Our results showed that oxidative stress secondary to GSH depletion exacerbated intracellular accumulation of medium chain acylcarnitines induced by fatty acid treatment. Metabolic profiling pointed to impairments in cellular acylcarnitine efflux as a possible cause of metabolite accumulation. Finally, GSH depletion led to diminished insulin-stimulated phosphorylation of Akt. These findings support a role for oxidative stress in tissue accumulation of acylcarntines and concomitant development of insulin resistance in HSkMC.

 

Nothing to Disclose: MCYOT, SES, DHS, TRK, DMM

21052 8.0000 THR-627 A Glutathione Depletion Alters Acylcarnitine Flux and Insulin Signaling in Primary Human Skeletal Myocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Akari Utsunomiya*1, Vladislava Paharkova2, Joe Capri3, Whitelegge Julian4 and Kuk-Wha Lee5
1Mattel Children's Hospital,UCLA, Los Angeles, CA, 2Mattel Children's Hospital, UC, Los Angeles, CA, 3The NPI-Semel Institute, David Geffen School of Medicine,UCLA, Los Angeles, CA, 4The NPI-Semel Institute,David Geffen School of Medicine,UCLA, CA, 5Mattel Children’s Hospital UCLA, David Geffen School of Medicine at UCLA, Los Angeles, CA

 

Humanin (HN) is a putative 24 amino acid polypeptide transcribed from an open reading frame within a region of mtDNA. It has been shown to have cytoprotective properties against Alzheimer’s disease-, myocardial infarction-,and diabetes-associated cellular insults. We have previously reported that HN improves survival of βcells and delays onset of diabetes in the NOD mouse. To understand the potential role of HN inβcells, we investigated binding partners of rat Humanin (rHN) in insulin-producing cells.

All experiments were conducted using rat INS-1 cells in vitro. We performed immunoprecipitation utilizing an anti-rHN antibody to identify potential binding partners of rHN.  MS/MS analysis was performed on the product.  Insulin molecules were identified as binding partners of rHN in INS-1 cells. Additionally, confirmatory immunoprecipitation with anti-rHN antibody was done followed by immunoblot for insulin. We detected bands with molecular weights consistent with insulin molecules,βChain, insulin dimer and insulin hexamer. These results suggest that rat HN directly associates with insulin molecules in insulin-producing cells.  We further performed western blotting in order to examine the glucose-dependent effect of HN expression in INS-1 cells. INS-1 cells were incubated in glucose-containing media at 5, 11, 16, and 32mM glucose in a time course experiment, and cell lysates were subjected to western blot analysis for rHN expression. rHN expression increased in a dose- and time-dependent manner.   These are the first evidence that glycemia regulates rHN expression in insulin-producing cells. 

In summary,we show the rat HN associates directly with insulin molecules and glycemia regulates rat HN expression in insulin- producing cells. Futher experiments will delineate the specific role of rHN in insulin-secreting cells.                                                     

 

Nothing to Disclose: AU, VP, JC, WJ, KWL

20036 9.0000 THR-628 A Glycemia regulates Rat Humanin (rHN) and Rhn associates with insulin molecules in insulin-producing cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Isaac Asare-Bediako*, Rebecca Paszkiewicz, Miguel Burch, Richard N Bergman and Stella P Kim
Cedars-Sinai Medical Center

 

Hyperinsulinemia is an important mechanism by which glucose tolerance is maintained during insulin resistance.  It has become increasingly evident that hepatic insulin clearance can be a primary factor in determining insulin levels, making it of upmost importance to have an accurate method by which insulin clearance is assessed.  While indirect methods of measuring liver insulin extraction are available, they are difficult to validate in humans since it is not possible to access the hepatic portal vein. To evaluate indirect methods, we compared 2 indirect protocols based on the hyperinsulinemic euglycemic clamp (EGC) and the frequently sampled intravenous glucose tolerance test-based (FSIGT) with the direct method of measuring hepatic insulin clearance, the paired portal/peripheral insulin infusion (PPII) in the dog model. Protocols: Indirect: 1) metabolic clearance rate (MCR) from the EGC, which is the ratio between insulin infusion rate and plasma insulin levels at steady-state and 2) fractional disappearance rate of insulin (FCR) during a FSIGT, determined from the rate of decline of plasma insulin after intravneous insulin injection during the test.  Direct: A paired portal or peripheral insulin infusion protocol (PPII), in which insulin is infused on separate days at 3 different rates into either the portal (one day) or peripheral vein (other day).   Insulin clearance is given as (1-mpo/mpe), where m is the slope of the best-fit line relating insulin infusion rates to steady-state plasma insulin concentrations for the 2 routes of delivery (1).  Indirect FCR measured from the FSIGT had a very strong correlation with the direct PPII method (r = 0.64).  Surprisingly, MCR during an EGC was not significantly correlated with hepatic extraction (r = 0.045).  Thus, insulin clearance from the FSIGT is an excellent measure of insulin clearance; whereas MCR from the EGC may not be an acceptable surrogate indirect measure of hepatic insulin clearance.

 

Nothing to Disclose: IA, RP, MB, RNB, SPK

19958 10.0000 THR-629 A Insulin Clearance Cannot be Accurately Measured from a Hyperinsulinemic Clamp 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Brian D Piening*, Wenyu Zhou, Kimberly R Kukurba, Gucci Gu, Kevin Contrepois, Colleen Craig, Dalia Perleman, Tracey L McLaughlin and Michael P Snyder
Stanford University, CA

 

Obesity is a worldwide health epidemic and a major cause for cardiovascular disease and type 2 diabetes mellitus (T2DM). Despite this, our ability to identify the subset of overweight individuals that are at an elevated risk for developing T2DM is woefully inadequate. Here, we developed a longitudinal, multi-omic personalized medicine pipeline for the comprehensive molecular profiling of blood-based analytes that differ between healthy overweight and prediabetic individuals both at baseline and in response to a controlled overfeeding perturbation. We sequenced the genomes of a cohort of 30 individuals (15 insulin-resistant (IR) and 15 insulin-sensitive (IS)) and generated a personalized risk profile for each individual based on known and novel variants associated with T2DM. Multi-omic profiling (transcriptome, DNA methylome, proteome, metabolome etc.) revealed significant differences in multiple ‘omes between IR and IS individuals at baseline, implicating pathways related to chronic inflammation and insulin regulation as well as novel connections to the disease. Participants were then placed on a short-term high caloric diet, followed by additional multi-omic profiling. The dietary perturbation was associated with a wealth of biomolecular expression changes concomitant with weight gain and spanning multiple ‘omes, and this response differed between IR and IS individuals. In total, these large-scale longitudinal data offer a novel view of the dysfunction in cellular networks associated with the progression to T2DM and may offer new strategies for predicting and preventing the disease.

 

Nothing to Disclose: BDP, WZ, KRK, GG, KC, CC, DP, TLM, MPS

21927 11.0000 THR-630 A Comprehensive Longitudinal Multi-Omic Profiling Reveals Molecular Signatures Associated with Prediabetes at Steady State and during Weight Gain 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Hamza Amine1, Yacir Benomar2, Arieh Gertler3 and Mohammed Taouis*4
1University Paris-Sud, 2University of Paris-Sud, France, 3Hebrew Univ Inst of Biochemist, Rehovot, Israel, 4University of Paris XI, Chilly Mazarin, France

 

Palmitic acid enhances TLR4 expression and promotes resistin/TLR4 signaling.

Hamza Amine 1,2, Yacir Benomar, PhD 1,2, Arieh Gertler, PhD3 and Mohammed Taouis, PhD 1,2

1Neuroendocrinologie Moléculaire de la Prise Alimentaire, University of Paris-Sud, UMR 8195, Orsay, F-91405, France.

2 Neuroendocrinologie Moléculaire de la Prise Alimentaire, CNRS, Centre de Neurosciences Paris-Sud UMR8195, Orsay, F-91405, France.

3 The Institute of Biochemistry, Food Science, and Nutrition, Faculty of Agricultural, Food and Environmental Quality Sciences, The Hebrew University of Jerusalem, PO Box 12, 76100 Rehovot, Israel.

Toll-like receptor 4 (TLR4) has a critical role in innate immunity, and the activation of inflammatory pathways play an important role in the induction of insulin resistance. Indeed, we have recently demonstrated that TLR4 is implicated in resistin-induced inflammation and insulin resistance in the hypothalamus (1). We have also shown that TLR4 is up-regulated in the hypothalamus of mice fed a high-fat diet.

Here, we aim to decipher the molecular mechanisms implicated in the regulation of TLR4 expression. For this purpose, human neuroblastoma cells (SHSY-5Y) were exposed during 4h to either palmitic acid (a saturated fatty acid) or the omega-3 polyunsaturated fatty acid docosahexaenoic acid (DHA). Cells were then treated with resistin.

Firstly we analyzed the effect of resistin, palmitic acid and DHA on inflammation markers. We show that only resistin was able to activate NF-κB and to increase the phosphorylation of Akt and p38 MAPK. However, palmitic acid pretreatment increases the expression of inflammatory cytokines (IL-6 and TNF-α), similar to resistin. Interestingly, DHA pretreatment suppresses palmitic acid and resistin induced up-regulation of IL-6 and TNF-α.

Secondly, we studied the possible synergistic interaction between resistin and palmitic acid on TLR-4 expression. We show that palmitic acid pretreatment increases TLR4 expression, at both protein and mRNA levels, while DHA pretreatment had no effect. Importantly, palmitic acid pretreatment potentiates resistin effects.

In conclusion, we show for the first time, to our knowledge, that palmitic acid induces TLR4 expression and this leads to the amplification resistin effects promoting then insulin resistance at the neuronal level.

(1) Benomar et al., Diabetes. 2013, 62:102-14.

 

Nothing to Disclose: HA, YB, AG, MT

18977 12.0000 THR-631 A Palmitic Acid Enhances TLR4 Expression and Promotes Resistin/TLR4 Signaling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Greg Arsenis*
VA Medical Center, Seminole, FL

 

   Epidydimal fat cells are very sensitive to pH changes; alkaline pH stimulates, while acidic pH inhibits, both the insulin receptor binding affinity (IRBA) and glucose transport (GT) activity (1,2). Fat cells possess an amiloride-sensitive Na+/H+ exchange mechanism which regulates intracellular pH (pHi) by a Na+-specific and pH-dependent mechanism (3). The Na+/H+ exchanger is very responsive to insulin and isoproterenol (Iso), the main regulators of GT (3, 4). We studied the activity of the Na+/H+ exchanger, a major regulator of pHi, in the absence of HCO3- and in the presence of ouabain, an inhibitor of Na+/K+ ATPase.  Alterations of the pHi were monitored with 2’,7’-bis (carboxyethyl)-5 (6)-carboxy-fluorescein (BCECF) and Na+ transport was monitored by measuring 22Na+ uptake. The results have shown that Iso (300 nM), which is known to inhibit both IRBA and GT by 50% (5), decreases the resting pHi from 7.26 ± 0.05 to 7.03 ± 0.09, p<0.05. Also, Iso completely inhibited the recovery of the acidified pHi and the 22Na+ uptake by 81% by blocking the Na+/H+ exchanger (control: 0.365 ± 0.019, Iso 0.069 ± 0.006 nmoles/105 cells/2.5 min, p<0.0001). Both of these effects are induced via b2-adrenergic receptor stimulation, adenylate cyclase activation, and a cAMP-dependent mechanism (4). Insulin (1 nM), which is known to increase the IRBA and GT (6), raised pHi by 0.1-0.2 units and increased 22Na+ uptake by >15% over control cells by stimulating the Na+/H+ exchanger. Moreover, insulin blocked the inhibitory effect of Iso and alkalinized the Iso-acidified pHi from 7.03 ± 0.09 to 7.18 ± 0.04, p<0.05; an effect mediated via the activation of the Na+/H+ antiport. Also, insulin blocked the inhibitory effect of Iso on 22Na+ uptake and increased Na+ influx by >400% (Iso: 0.059 ± 0.007, insulin+Iso: 0.244 ± 0.014 nmoles/105 cells/2.5 min, p<0.009). Thus, pHi is regulated mainly through the antagonistic actions of insulin and Iso on the Na+/H+ exchanger. The effects of insulin and Iso on pHi and GT occur simultaneously, suggesting the regulatory role of pHi on GT: acidic pHi inhibits while alkaline pHi stimulates glucose transport. Whether the two functions are taking place at the same time in parallel without affecting each other or whether pHi changes affect one of the intermediate steps of the insulin or Iso signaling pathways, still needs to be elucidated.

 

Nothing to Disclose: GA

19366 13.0000 THR-632 A Novel Counter Regulatory Effects of Insulin and Isoproterenol on Na+/H+ Exchange in Rat Adipocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Kathryn Hinchee-Rodriguez*, Rekha Kar, Martin L Adamo, Linda J Roman and Bettie Sue Masters
Univ of Texas Hlth Sci Ctr, San Antonio, TX

 

Type 2 Diabetes (T2DM) is the seventh leading cause of death in the United States, and results from reduced insulin sensitivity coupled with a relative failure of insulin secretion. Reduced insulin sensitivity itself has been associated with decreased nitric oxide synthase (NOS) activity and impaired glucose uptake in T2DM human skeletal muscle. Upon insulin stimulation, NO synthesis increases in normal adult skeletal muscle, whereas no such increase is observed in T2DM adults. We have previously shown that neuronal NOS (nNOS) is phosphorylated at Ser1446, resulting in its activation, in response to insulin in mouse skeletal muscle in vitro and in vivo. But it is still unclear which kinase is responsible, and how insulin resistance in skeletal muscle affects nNOS Ser1446 phosphorylation. In C2C12 myotubes, nNOS phosphorylation was dependent on one or more AKT isoforms, as AKTi, which prevents AKT1/2 activation, and the AKT2-specific inhibitor, AKT2i, both inhibited nNOS phosphorylation. As AKT's activity is inhibited in insulin resistance, we utilized a 45% high fat diet (HFD) mouse model of obesity-induced insulin resistance. In this HFD model, basal levels of phospho-nNOS increased compared to those in a control diet. However, insulin failed to stimulate nNOS phosphorylation in skeletal muscle of the HFD mice, whereas insulin robustly increased phospho-nNOS in control diet mice. Taken together, these results suggest that while nNOS may depend on AKT2 for Ser1446 phosphorylation, this phosphorylation is attenuated under insulin resistance in mice. However, basal nNOS phosphorylation overall is increased, suggesting that alternative mechanisms for nNOS phosphorylation exist in mice compared to humans.

 

Nothing to Disclose: KH, RK, MLA, LJR, BSM

22129 14.0000 THR-633 A Neuronal Nitric Oxide Synthase Phosphorylation Under Normal and Insulin-Resistant Conditions in Mouse Skeletal Muscle 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Samim ALI Mondal*1, Manoj Kumar2, Deep Dutta3, Parna Choudhury4, Sasanka Chakrabarti5 and Satinath Mukhopadhyay6
1Institute Of Post Graduate Medical Education & Research,SSKM Hospital, Kolkata, India, 2Institute of Post Graduate Medical Education & Research, SSKM Hospital, Kolkata, 3Post Graduate Institute of Medical Education & Research & Dr. Ram Manohar Lohia (RML Hospital, 4Institute of Post Graduate Medical Education & Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, 5Institute Of Post Graduate Medical Education & Research,SSKM Hospital, Kolkata, 6IPGME&R, Calcutta

 

Serum free vitamin-D levels may be better predictors of insulin resistance in individuals with prediabetes


Background:

High prevalence of Vitamin-D deficiency (VDD) in some populations have recently been attributed to low vitamin-D binding protein (DBP) levels. Although studies from India report one of the highest prevalence rates of VDD seen anywhere in the World, the possibility of underlying DBP deficiency has never been studied in these populations. The relationships between free, bioavailable and total 25-hydroxy-vitamin-D (25OHD) with metabolic syndrome (MetS)were evaluated across the spectrum of glycemia in 102 treatment naïve subjects with glucose intolerance.

Methods:

Individuals with normoglycemia (NGT, n=34), prediabetes (preDM, n=64)and type-2 diabetes (T2DM, n=38) were selected from the ‘Eastern India vitamin-D in prediabetes study’ (CTRI/2011/091/000192). Serum 25OHD levels were measured using125I radioimmunoassay kit (Cat. no. REF68100E, Diasorin, USA). Serum DBP levels were measured using sandwich ELISA (Cat. no. MBS161429; My Biosource; San Diego, CA, USA), having detection range 5-1000 ng/L,Intra and inter assay coefficient of variation was <10% & <12% .Free, bioavailable, and DBP-bound 25OHD were calculated using equations adapted from those described by Vermeulen and colleagues.Serum insulin was estimated using CLIA (Immunite-1000, Gwynedd, UK). IL6, IL1b, sTNFR1 and sTNFR2 were estimated using sELISA. IR was estimated using HOMA2-IR (homeostatic model of insulin resistance).

Results:

NGT (age: 50.29±13.2 yrs), prediabetes (age: 46.9±12.3 yrs)and T2DM (age: 49.73±13.4 yrs) patients had significant difference in mean serum DBP (276.42±32.69,318.18±62.65 and 279.41±49.01mcg/ml, P=0.001), total 25OHD (30.50±18.37, 31.95±23.25, 42.07±20.23ng/ml, P=0.075), free 25OHD (9.04±5.33, 8.44±5.91 and 13±6.78pg/ml, P=0.005) and bioavailable 25OHD (3.52±2.08, 3.29±2.32, 5.08±2.64ng/ml, P=0.005). Free 25OHD had significant inverse correlation with HOMA2-IR in NGT (r=-0.532, P=0.007) and prediabetes (r=-0.36, P=0.010). DBP had positive correlation with HOMA2IR in prediabetes (r=0.349, P=0.013) only. 25OHD had inverse correlation with HOMA2IR only in NGT (r=-0.468,P=0.021). Regression analysis revealed free 25OHD to be the best predictor of HOMA2IR at baseline(β=-2.024, P=0.007) and after adjusting for IL6, IL1b, sTNFR1 and sTNFR2 (β=-2.620, P=0.003).  Free, total 25OHD and DBP were not predictive of HOMA2IR in T2DM

Conclusion:

Free 25OHD, in contrast to  total 25OHD may be a better predictor of insulin resistance prediabetes among Indians. Further studies are warranted to study the impact of changes in serum free 25OHD following vitamin-D supplementation on glycemic outcomes in prediabetes. In addition, serum DBP levels may predict the severity of insulin resistance in prediabetes.

 

Nothing to Disclose: SAM, MK, DD, PC, SC, SM

21633 15.0000 THR-634 A Serum Free Vitamin-D Levels May be Better Predictors of Insulin Resistance in Individuals with Prediabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Shiliu Tian1, Xiwen Liu2, Yong Wu3, Adaku Ume3, Guadalupe Navarro2, Desean L. Lee4, Michael Mangubat2, Theodore C Friedman3 and Yan Jun Liu*3
1Shanghai University of Sport, Shanghai, China, 2Charles R. Drew Univeristy of Medicine and Science, Los Angeles, CA, 3Charles R. Drew University of Medicine and Science, Los Angeles, CA, 4Charles R Drew University of Medicine and Science, Los Angeles, CA

 

The pre-receptor activation of glucocorticoid (GC) metabolism in adipose tissue by NADPH-dependent 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1) has emerged as a potential mechanism in the pathogenesis of visceral obesity and metabolic syndrome. Hexose-6-phosphate dehydrogenase (H6PDH) mediates 11ß-HSD1 amplifying intracellular GC production by driving NADPH exposure to 11ß-HSD1 and requires glucose-6-phosphate transporter (G6PT) to maintain its activity. Here, we examined whether specific modulation of G6PT affects tissue GC action by examining the possible effects of G6PT inhibitor ASO (G6PT ASO) on adipose 11ß-HSD1 and H6PDH in diabetic db/db mice. We observed that specific G6PT ASO treatment of db/db mice markedly reduced adipose G6PT mRNA and protein expression and substantially decreased adipose 11ß-HSD1 and H6PDH levels. Reduction of G6PT expression was correlated with the suppression of adipose G6Pase and AMPK and corresponded to the improvement of hyperglycemia and insulin resistance in db/db mice. These findings suggest that G6PT plays an important role in the modulation of pre-receptor activation of glucocorticoid and provides new insights into the role of G6PT in the development of type 2 diabetes.

 

Nothing to Disclose: ST, XL, YW, AU, GN, DLL, MM, TCF, YJL

19504 16.0000 THR-635 A Reduction of Glucose-6-Phosphate Transporter Expression in Adipose Tissue Ameliorates Glucose Homeostasis and Insulin Resistance in Diabetic Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Thais Bento Bernardes*1, Jéssika Geisebel Neto2, Thaiane Gadioli Gaique2, Renata Frauches Medeiros2, Carmen C Pazos Moura3 and Karen Jesus Oliveira4
1Federal University of Rio de Janeiro, Rio de Janeiro, 2Federal Fluminense University, 3Federal University of Rio de janeiro, Brazil, 4Federal Fluminense University, Niteroi

 

Cinnamon is a spice widely used in cooking and in alternative medicine in many cultures. Studies showed that cinnamon can influence key endocrine-metabolic systems. Furthermore, it is well known that the maternal nutrition during pregnancy and lactation is crucial for the health of their offspring. Thus, we hypothesized that the maternal cinnamon intake during lactation may modify endocrine parameters of the mothers and their offspring. In order to investigate this, one day after birth female Wistar rats received water (Control group-Ct) or aqueous cinnamon extract (Cinnamon group-Cin, 400mg cinnamon/kg body weight/day) by gavage during the entire lactation. After weaning to adulthood (180 days of life, P180) the Control and Cinnamon male offspring received standard diet. Maternal cinnamon intake did not affect body mass gain or food intake of dams or of their offspring. However, cinnamon intake decreased lipid content in the dams carcass (Ct: 7.08 ± 0.6 n=8; Cin: 4.26 ± 0.6% n=10; p=0.007). Moreover, Cinnamon dams showed no differences in serum levels of adiponectin, leptin, insulin, estradiol, but showed higher serum progesterone (Ct: 12.69 ± 2.5 n=8; Cin: 43.44 ± 13.2ng/mL n=9; p=0.04). Cinnamon offspring at P180 exhibited higher lipid content in the carcass (Ct: 14.26 ± 1.0 n=10; Cin: 20.73 ± 1.5% n=10; p=0.002) without differences in serum adiponectin but higher serum levels of leptin (Ct: 11.50 ± 1.4 n=10; Cin: 33.05 ± 5.15ng/mL n=15; p=0.002).  Cin P180 group exhibited higher serum insulin (Ct:1.80 ± 0.3 n=10; Cin: 2.70 ± 0.2ng/mL n=15; p=0.02) without differences in fasting blood glucose. In soleus skeletal muscle the cinnamon offspring at P180 showed lower expression of insulin receptor beta subunit (IRβ) (Ct: 1.0 ± 0.1 n=11; Cin: 0.73 ± 0.04 a.u.; n=16; p=0.02) associated with increased pIRβ (phospho T1162/1163 Ct: 1.0 ± 0.03 n=11; Cin: 1.44 ± 0.05 a.u.; n=16; p<0.0001). In addition, the expression of the protein threonine phosphatases 1 B (PTP1B), which has an essential role inactivating the pIRβ signaling, was lower (Ct: 1.00 ± 0.05 n=9; Cin: 0.79 ± 0.05 a.u.; n=12; p=0.01). The Akt/protein kinase B protein expression was similar among the offspring groups, although the Cin P180 group exhibit higher protein levels of pAKT (phospho S473) (Ct: 1.01 ± 0.07 n=10; Cin: 1.41 ± 0.1  a.u.; n=13; p<0.05). Despite the lower IR protein expression, the insulin actions may not be completely compromised due to the higher pIRβ and one of its target, the pAKT. Therefore, the maternal cinnamon intake during lactation promoted mild hormonal and metabolic changes in dams. Although, their male offspring exhibit negative alterations of endocrine parameters in adulthood and changes in insulin signaling pathway expression pattern in skeletal muscle. Despite the visceral obesity and higher serum insulin in the offspring they probably have compensatory mechanisms which leads to an euglycemia.

 

Nothing to Disclose: TBB, JGN, TGG, RFM, CCP, KJO

22140 17.0000 THR-636 A Maternal Cinnamon Intake during Lactation Leads to Higher Serum Insulin and Leptin Levels of Their Adult Male Offspring in Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Bruna Kelly Sousa Hirata*, Renata Mancini Banin, Ana Paula Segantine Dornellas, Luciana Chagas Caperuto, Lila Missae Oyama, Eliane Beraldi Ribeiro and Monica Marques Telles
Universidade Federal de São Paulo

 

Due to the high incidence and severity of obesity and its related disorders, it is highly desirable to develop new treatment strategies. Ginkgo biloba extract (GbE), one of the most worldwide used plant extracts, has been pointed as an alternative therapy for the treatment of hyperglycemia and insulin resistance.  In this context, it was aimed to evaluate the effect of GbE on insulin signaling in retroperitoneal white adipose tissue depot of diet-induced obese rats. Rats were fed with high fat diet for 2 months and thereafter treated for 14 days with 500mg/kg of GbE. Rats were then euthanized and samples from retroperitoneal fat depot were removed before and 90 seconds after insulin i.v. injection for the measurement of IR and Akt phosphorylation levels by Western blotting. It was also evaluated the gene expression of both adiponectin receptors Adipo-R1 and Adipo-R2 in retroperitoneal fat depot. The treatment with GbE promoted a significant reduction on both food/energy intake (6.3%, p=0.031) and body weight gain (62%, p=0.013). In addition, the treatment significantly increased Adipo R1 gene expression (33%, p=0.013) and the phosphorylation levels of both IR (281%, p=0.004) and Akt (67%, p=0.039) in retroperitoneal fat depot. The data suggest that GbE might have potential as a therapy to treat obesity and its comorbidities, especially for obese subjects resistant to adhere to a nutritional education program. Other studies are needed for better understand the beneficial effect of GbE herein described.

 

Nothing to Disclose: BKSH, RMB, APSD, LCC, LMO, EBR, MMT

21172 18.0000 THR-637 A Ginkgo Biloba Extract Improves Insulin Signaling in Retroperitoneal Adipose Tissue Depot of Obese Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Jennifer B Hao*1, Arthur Schuna2 and Juan Carlos Jaume3
1University of Wisconsin-Madison, Madison, WI, 2University of Wisconsin-Madison, 3University of Toledo, College of Medicine and Life Sciences, Toledo, OH

 

Anti-insulin antibodies have been described long ago in patients with insulin-treated diabetes (before the introduction of human insulin and insulin analogues) and in patients with Insulin Autoimmune Syndrome (Hirata’s Disease), where the presence of antibodies manifests itself as postprandial hyperglycemia (insulin bound to antibody) and fasting hypoglycemia (dissociation of bound insulin from antibodies).

We present the case of a 65 year-old man with type 2 diabetes and extreme insulin resistance.  At the time he was first seen, patient’s insulin regime was 930 units/day with a hemoglobin A1C (HbA1C) of 10.  Because of the presence of many signs of insulin resistance (acanthosis nigricans included), patient was assessed for type B diabetes with antibodies to the insulin receptor.  Antibodies to the insulin receptor were undetectable however, insulin antibody titers were present at 8.7 U/ml (normal <0.4).  In order to control patient’s hyperglycemia and decrease his insulin needs, we attempted to treat him with prednisone 10 mg daily for 1 month.  We noticed a paradoxically modest decrease in insulin requirements with the steroid treatment.  However, because of the hyperglycemic effects of steroids, we decided not to increase the prednisone dose.  Instead, we offered patient treatment with anti-CD20 monoclonal antibody (Rituximab®).  Patient agreed and received two Rituximab infusions 1 month apart.  Patient’s insulin requirements significantly decreased to 220 units/day.  Repeat insulin antibody titers after infusion were 7.6 U/ml (1:2 dilution was 6.5 U/ml).  Subsequent insulin autoantibody titers were somewhat lower at 5.0 U/ml (1:2 dilution was 2.5 U/ml).  Patient’s glucose control was steadily improving with average insulin requirements below 200 units daily (HbA1C of 8.7) for two months.  Ten weeks after the second infusion of rituximab, patient again experienced poor glycemic control.  Patient’s HbA1C went up to 13.1%.  Patient was then started on mycophenolate mofetil.  Repeat anti-insulin antibody titers measured 3U/ml two weeks after and 0.4 U/ml a month after the start of therapy.  Patient also had remarkable glycemic control and more than a 50% decrease in daily insulin requirements.  Five months went by and glycemic control started to deteriorate again.  Hence, a third dose of Rituximab was given.  Repeat insulin antibody titers were low at 0.4 U/ml two weeks after the infusion and total daily insulin requirements decreased to 325 units daily.

This is the first case report in the literature of “extreme” insulin resistance because of insulin antibodies in an adult patient successfully treated with combination immunosuppressive therapy.  The unexpected presence of antibodies against the insulin molecule in a patient with severe insulin resistance and the response to immunosuppressive treatment raises the question of screening for these antibodies in similar patients.

 

Nothing to Disclose: JBH, AS, JCJ

18838 19.0000 THR-638 A Extreme Insulin Resistance from Insulin Antibodies (not Insulin Receptor Antibodies) Successfully Treated with Combination Immunosuppresive Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Cemre Robinson*1, Elaine Cochran2, Phillip Gorden2 and Rebecca J. Brown3
1The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2NIH, Bethesda, MD, 3National Institute of Health, Bethesda, MD

 

Background:  Management of diabetic ketoacidosis (DKA) in extreme insulin resistance (IR) is not well-described in the literature.

Clinical case: The patient is an 18-year old young man with extreme IR due to Rabson-Mendenhall Syndrome (mutation of the insulin receptor). Two weeks prior to a routine visit at the National Institutes of Health (NIH), he underwent a root canal for an abscessed tooth, and did not take prescribed antibiotics. At NIH, labs showed A1c 14%, bicarbonate 26-30, and chronic glucosuria and ketonuria. He continued his home insulin regimen of 1500 units/day of U-500.  Antibiotics were initiated; he was discharged in hemodynamically stable condition.  Two days later, he was admitted to another hospital with DKA, pH 7.08, pCO2 27, bicarbonate 8, and worsened jaw pain.  Insulin drip was started at 100 U/hr, increased on day 1 to 1000 U/hr, and 2000 U/hr on day 2 without resolution of acidosis.  CT showed a dental abscess extending to adjacent soft tissue, the likely trigger for DKA.  Due to lack of improvement despite IV antibiotics, bicarbonate was given, and dental extraction was performed, after which the patient developed septic shock requiring pressor support for 24 hrs.  He improved thereafter, and was transitioned back to subcutaneous insulin. 

Conclusion:  This case demonstrates the complexity of managing DKA in a patient with extreme IR.  Routine diabetes care in extreme IR requires high-dose insulin, typically >200 U/day.  Despite high-dose insulin, good glycemic control is often not achieved.  DKA management in extreme IR is a major challenge due to the unusually high doses of insulin required, raising major safety concerns for providers not experienced with extreme IR.  As seen in this case, insulin as high as 2000 U/hr can be safely administered. At very high insulin doses, the dose-response curve is extremely shallow, requiring aggressive dose increase.  Doubling of the insulin dose every 1-2 hours was recommended in the context of worsening acidosis.  The primary safety concern with high-dose insulin is hypoglycemia; however, patients with extreme IR are at very low risk for this during DKA.  If hypoglycemia occurs, it can be managed with IV dextrose. Due to the rarity of DKA in extreme IR, there are no guidelines regarding other toxicity associated with high-dose insulin use. This case highlights the importance of aggressive management of refractory DKA in extreme IR, including high-dose insulin, fluids, bicarbonate, and treatment of underlying infection, regardless of the risks associated with these therapies.  Ultimately, the key to resolving DKA was treating the underlying infection; insulin alone was not sufficient. In patients with extreme IR, aggressive evaluation and early treatment of infections should be considered to reduce the risk of DKA, as once DKA occurs, management is extremely challenging.

 

Nothing to Disclose: CR, EC, PG, RJB

19014 20.0000 THR-639 A Management of Diabetic Ketoacidosis in Extreme Insulin Resistance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 620-639 5929 1:00:00 PM Insulin Signaling and Resistance Poster


Kanika Shanker*, Kelly Rouster-Stevens, Tanicia Cheri Daley Jean-Pierre and Jee-Young Nina Ham
Emory University, Atlanta, GA

 

Autoimmune Hypoglycemia in a young girl with Autoimmune Overlap Syndrome

 

Kanika Shanker, M.D.1, Kelly Rouster-Stevens, M.D. 1, Tanicia Daley, M.D. 1,J Nina Ham, M.D.1

 1Emory School of Medicine, Emory University, Atlanta, GA 30322

Background: Evaluation of hypoglycemia in a patient with type 1 diabetes mellitus is challenging. Type B insulin resistance syndrome is a rare heterogeneous metabolic disease, described in middle aged women, associated with autoimmune disorders, characterized by abnormalities in glucose homeostasis, with poor response to treatment, high relapse and mortality rate.

Clinical case: A 8 year-old Hispanic female with a known diagnosis of dermatomyositis was diagnosed with antibody positive type 1 diabetes mellitus. Three months later, she presented with progressive severe hypoglycemia, and she continued to have post-prandial hyperglycemia despite withdrawal of insulin therapy. She later developed autoimmune overlap syndrome constituted by dermatomyositis, systemic lupus erythematosus with class 5 lupus nephritis, C4 deficiency and Raynaud’s phenomenon. On physical examination, she had thin body habitus (BMI-15Kg/m2), severe acanthosis nigricans in multiple skin folds, hypertrichosis of upper body and lower extremity edema. Following five hours of diagnostic fasting, her blood sugar dropped from 81mg/dl to 46mg/dl with a positive glycemic response to glucagon challenge (delta of 56mg/dl). Further laboratory evaluation showed paradoxical hyper-adiponectinemia, normal triglyceride levels inappropriately elevated insulin level (937.6uIU/ml, normal: 1.7-55.9) and C-peptide (7.1ng/ml, normal: 0.8-3.5). With signs of insulin resistance, hyperandrogenism, simultaneous hypoglycemia and post prandial hyperglycemia, we hypothesized occurrence of type B insulin resistance due to insulin receptor auto autoantibodies. Laboratory evaluation confirmed the presence of a high titer of insulin receptor auto antibodies by western blot.

For the prevention of severe hypoglycemia, she was managed initially by frequent feeding followed by overnight G-tube feeds. She received cycles of rituximab, IVIG, plasmapheresis, and bortezomib. Episodes of hypoglycemia decreased but continued highlighting poor response to B cell and plasma cell immunomodulation. We present a unique case of autoimmune hypoglycemia, type insulin resistance given the young age at presentation, presence of autoimmune overlap syndrome and treatment with bortezomib, a novel therapy targeting proteasomes causing apoptosis of monoclonal plasma cells.

Conclusions: Presence of hypoglycemia in the setting of multiple rheumatological disorders should prompt consideration of autoimmune-mediated hypoglycemia. More studies are needed to understand mechanisms of simultaneous occurrence of hypoglycemia and hyperglycemia.

Nothing to Disclose: KS, KRS,TCDJP, JNH

 

Nothing to Disclose: KS, KR, TCD, JYNH

18749 1.0000 THR-596 A Autoimmune Hypoglycemia in a Young Girl with Autoimmune Overlap Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Undine Schubert*, Susann Lehmann, Henning Morawietz, Stefan Richard Bornstein and Barbara Ludwig
University Hospital Carl Gustav Carus, Dresden, Germany

 

A major limiting factor for long-term survival and function of islet transplants is the inappropriate microenvironment after intraportal transplantation. We aim to evaluate the microenvironment of the adrenal as a potentially beneficial transplantation site that promotes beta cell engraftment, survival, proliferation and long-term function.

For in vitro analysis of reactive oxygen species (ROS) a co-culture system of adrenal cells and islets was established. Basal ROS levels were similar in islets cultured alone compared to islet-adrenal cell culture. However, treatment with rotenone induced significantly higher ROS levels in the co-culture group compared to control. A high response in ROS production following rotenone treatment has been shown to be indicative for mitochondrial integrity.

For in vivo studies, Streptozotocin induced diabetic NuNu-mice were used as islet recipients. For islet transplantation, the adrenal was exteriorized via retroperitoneal incision and 300 islets were injected through the upper pole of the gland or the kidney. Animals showed a fast decrease in blood glucose levels within the first days after transplantation in both groups, at around 10 days the curves between adrenal and kidney site drifted apart in favor of the adrenal site. Regardless of the transplantation site, islets showed a well preserved morphology and intense insulin staining. The intra-adrenally engrafted islets show higher vascularization compared to the kidney capsule control.

The preliminary work underlined the feasibility of islet transplantation into the adrenal with first promising results on the restoration of normoglycemia. The results achieved could prove the beneficial effect of the adrenal microenvironment on islet engraftment and function in vitro and in vivo and elucidate the underlying mechanisms in regards to promoting islet revascularization and protection from oxidative stress.

This novel concept might allow reducing the islet mass that is currently needed to reverse diabetes.

 

Nothing to Disclose: US, SL, HM, SRB, BL

20856 2.0000 THR-597 A Engraftment, Function and Beta Cell Regulation in the Adrenal Transplant Model 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Husam Ghanim1, Manav Batra2, Nitesh D Kuhadiya2, Sanaa Abuaysheh3, Kelly Green4, Antoine Makdissi1, Ajay Chaudhuri5 and Paresh Dandona*5
1State University of New York at Buffalo, Buffalo, NY, 2University at Buffalo, Buffalo, NY, 3Suny at Buffalo, 4SUNY at Buffalo, 5Diabetes and Endocrinology Center of Western New York, Buffalo, NY

 

Glucocorticoids have been used as the major class of anti-inflammatory agents for over 60 years. However, they have well known side effects including weight gain, adiposity, and a series of catabolic effects with loss of musculature osteoporosis and diabetogenicity. We have recently described the induction of expression of specific pro-inflammatory genes including HMG-B1, TLRs, LIGHT, LTBR and MMP-9 by a single large dose of hydrocortisone (HC), In addition, these subjects experienced a significant increase in plasma glucose and FFA concentrations. Since our group discovered the anti-inflammatory actions of insulin in 2001, we have now hypothesized that a combination of insulin with a high dose of a glucocorticoid may neutralize the proinflammatory effects of HC and offer an ideal and safe anti-inflammatory combination. Healthy subjects were randomized into a cross over study to be injected in two separate days (a week apart) with 300 mg of hydrocortisone (=60 mg prednisolone) intravenously with or without an infusion of 2U/h of insulin with 5% dextrose for 8 hours. HC injection alone induced a significant anti-inflammatory effect including suppression of CCR-2 (by 69±6%), IL-4 (by 52±7%) and TNF-α (by 55±8%) expression in mononuclear cells (MNC) and plasma MCP-1 (by 64±9%) and TNF-α (by 32±8%) concentrations. However, the HC injection also induced an increase in the MNC expression of HMG-B1, TLR2, TLR9 and LIGHT (by 102±13%, 67±11%, 84±7% and 126±14% over the baseline, respectively, P<0.05) and in plasma levels of MMP-9, LIGHT and TGF-b1 (by 186±15%, 94±9% and 167±17% over the baseline, respectively, P<0.05). Plasma glucose and FFA concentrations also increased significantly following the HC injection alone. Insulin infusion along with the HC injection increased the magnitude of the overall anti-inflammatory effect and completely inhibited the increase in glucose and FFA. In addition, the infusion of insulin with HC injection inhibited the HC induced increase in TLR-2 and TLR-9 expression and significantly reduced the HC induced increases in the MNC expression of HMG-B1 and LIGHT (to only 21±11% and 34±14% over the baseline, respectively, NS) and in plasma LIGHT and TGF-b1 concentrations (to only 21±12% and 12±10% over the baseline, respectively, NS) but not in plasma MMP-9 levels. Thus, the infusion of insulin at a low dose with a high dose of HC or other corticosteroids may constitute an ideal anti-inflammatory cocktail in the in- patient setting.

 

Nothing to Disclose: HG, MB, NDK, SA, KG, AM, AC, PD

21040 3.0000 THR-598 A Insulin and Hydrocortisone Combination As an Anti-Inflammatory Cocktail 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Munmun Chattopadhyay* and Vikram S Thakur
Texas Tech University Health Sciences Center, EL PASO, TX

 

Peripheral sensory neuropathy is one of the most common complications of diabetes. Accumulating evidence suggests that chronic low-grade inflammation involved in the pathogenesis of the disease. We hypothesize that continuous release of inflammatory mediators in the peripheral nervous system causes the sensory neuropathy in diabetic animals; therefore blocking this increase will prevent or delay the development of neuropathy. High mobility group box 1 (HMGB1), a nuclear protein released by injured and severely stressed cells, promotes cytokine release via its interaction with the Toll-like receptor (TLR). In this study we investigated the changes in cytokine/chemokine profiles in the dorsal root ganglia (DRG) and compared the changes in behavior with treatment with TLR4 inhibitor in Type 1 diabetic (T1D) model of pain. At 6 weeks after hyperglycemia, T1D rats demonstrated significant changes in thermal hyperalgesia manifested by a decrease in withdrawal latency to heat, mechanical hyperalgesia measured by the Randall Sellito method of paw pressure. T1D rats exhibited marked increases in IL1β and TLR4 at 4 weeks after diabetes as determined by the Western blot analysis and increases in the levels of TNFα, pp38, HMGB1, RAGE by 6 weeks after diabetes. To determine whether increased TLR4 level is responsible for the painful neuropathy in diabetic animals, we injected TLR4 antagonist TAK242 for 3 days at a dose of 1.5 mg/kg per day I.P. in STZ-diabetic animals, at 4 weeks after diabetes. We tested the pain behaviors in these animals one day before and one day after the injection. The behavior testing shows that animals treated with TAK242 had significant decrease in mechanical hyperalgesia. This preliminary study suggests that TLR4 plays an important role in the inflammatory aspect of the painful neuropathy in T1D animals. Understanding the mechanisms of diabetic neuropathy may provide a novel treatment approach for this difficult-to-treat complication of diabetes.

 

Nothing to Disclose: MC, VST

22179 4.0000 THR-599 A Alterations of Inflammatory Mediators in DRG of Type 1 Diabetic Animals with Neuropathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Alice Liu*1, Cindy A Lamendola1, Sun H Kim1, Danit Ariel1, Fahim Abbasi1, James Cardell1, Shiming Xu1, Shailja Patel1, Vanessa Tomasso1, Hafasa Mojaddidi1, Kaylene Grove1, Philip S Tsao2, Clete A Kushida3 and Gerald M Reaven1
1Stanford University School of Medicine, CA, 2VA Palo Alto Health Care System, 3Stanford Sleep Medicine Center

 

Obstructive sleep apnea (OSA) is frequently associated with insulin resistance, type 2 diabetes (T2DM), and cardiovascular disease (CVD), yet their pathophysiological relationships have not been fully elucidated. Traditional investigations have focused on potential mechanisms by which sleep-disordered breathing may promote insulin resistance. However, there is also evidence that fasting hyperinsulinemia predicts the development of observed apneas, suggesting that insulin resistance per se may play a role in the pathogenesis of OSA. The study aim was to evaluate whether enhancing insulin sensitivity in individuals with untreated OSA would improve sleep measures, as well as decrease risk factors for T2DM and CVD.

Insulin-resistant, nondiabetic, overweight/obese adults with untreated OSA were randomized (2:1) to pioglitazone (n=30) or placebo (n=15) for 8 weeks in this single-blind study. Insulin resistance was directly quantified by the insulin suppression test. Insulin secretory function was measured by the graded glucose infusion test. Change in the apnea-hypopnea index (AHI) by overnight polysomnography was the primary outcome measure. Fasting lipid/lipoprotein concentrations and hsCRP were measured. Peri-umbilical subcutaneous adipose tissue (SAT) biopsies were performed.

Whole-body insulin sensitivity improved 31% in the pioglitazone-treated group. However, pioglitazone therapy did not alter quantitative (i.e. AHI, minimum or mean oxygen saturation, oxygen desaturation index) or qualititative (i.e. Functional Outcomes of Sleep Questionnaire, Beck Depression Inventory) measurements related to OSA symptomatology. On the other hand, pioglitazone treatment led to decreases in fasting plasma glucose (P<0.01), reduction in the integrated glucose-stimulated insulin secretion rate (GS-ISR) by 20% (P<0.001), and increase in the metabolic clearance rate of insulin by 22% (P<0.001). Insulin-mediated suppression of isoproterenol-stimulated lipolysis in SAT adipocytes improved by 1.5-fold in response to pioglitazone (P<0.05). Decreases in hsCRP, triglycerides, VLDL, LDL4, ApoB, and increases in HDL cholesterol and its subgroups (HDL2, HDL3) and ApoA1 (P<0.05) were also observed with pioglitazone.

While enhanced insulin sensitivity via pioglitazone therapy in insulin-resistant patients with untreated OSA did not ameliorate OSA severity or symptoms, risk for T2DM and CVD was substantially reduced as manifested by a right shift in the GS-ISR dose response curve, increased adipose tissue sensitivity to insulin, and mitigation of inflammation and an atherogenic lipoprotein profile.

 

Nothing to Disclose: AL, CAL, SHK, DA, FA, JC, SX, SP, VT, HM, KG, PST, CAK, GMR

19228 5.0000 THR-600 A Effect of Pioglitazone on Obstructive Sleep Apnea, Insulin Sensitivity, and Cardiovascular Disease Risk Markers: A Randomized Placebo-Controlled Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Peng Chin Kek*1, Hong Chang Tan2, Yst Kee2, Su-Yen Goh1 and Yong Mong Bee3
1Singapore General Hosp, Singapore, Singapore, 2Singapore General Hospital, Singapore, 3Singapore General Hospital, Singapore, Singapore

 

New onset diabetes after transplantation (NODAT) is a serious metabolic complication of kidney transplantation that predisposes patients to graft dysfunction and death. The aim of this study was to determine the effect of degree of glycemia, as measured by HbA1c, at diagnosis of NODAT on long term graft and patient survival after kidney transplantation in our centre.  This was a single centre retrospective review of solitary kidney recipients transplanted in our centre between January 1998 and December 2007. Of a total of 432 patients, 388 were eligible for the study. Reasons for exclusion were pre-existing diabetes mellitus (n=16), death (n=3) and graft loss (n=10) within the first 2 weeks after transplantation, and follow-up duration of less than 6 months (n=15). Data were collected from electronic patient records and transplant charts. NODAT was diagnosed in patients who had at least two abnormal glucose concentrations (i.e. fasting plasma glucose ≥7.0 mmol/l or random plasma glucose ≥11.1 mmol/l) after the first two weeks post-transplant. NODAT were reported in 94 of the 388 recipients (24.2%). HbA1c on diagnosis of NODAT were not available in 33 subjects and they were excluded from analysis. Higher glycemic exposure was defined as HbA1c ≥8.0%. Mean age at transplant was 46.9 ± 7.7 years and 52.5% were female. The median follow up time was 48.2 ± 39.5 months. Mean HbA1c at diagnosis was 9.0 ± 3.1% and mean glucose level at diagnosis was 20.9 ± 15.1 mmol/l.  Median time to onset of NODAT was 7.4 months and 50.9% developed within the first 6 months. Thirty-three (54.1%) had HbA1c ≥8.0%. Subjects with HbA1c ≥8.0% had poorer long term survival (7 deaths) using Kaplan-Meier analysis (p=0.041) compared to those with HbA1c <8.0% (1 death). Overall patient survival was 97.0%, 78.2% and 54.1% at 1-, 5-, 10-year post-transplant for those with HbA1c ≥8.0% and 100.0%, 96.2% and 96.2% for those with HbA1c <8.0% at 1-, 5-, 10-year post-transplant. No difference in graft survival was noted in the 2 groups. Patients with NODAT had poorer outcomes in both graft and patient survival. Our data suggest that the degree of glycemic exposure at the onset of diabetes, as measured by HbA1c level, might be associated with a poorer long term survival. It is thus important to closely monitor glucose levels early post-transplantation so that high glycemic exposure can be avoided to improve the long term outcomes.

 

Nothing to Disclose: PCK, HCT, YK, SYG, YMB

20333 6.0000 THR-601 A Higher Glycemic Exposure at Diagnosis of New Onset Diabetes after Kidney Transplant May be Associated with Reduced Patient Survival 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Tatiana Gandrabura*1, Shant Manoushagian2, Jeydith Gutierrez-Perez2, David Berman2 and Daniel J Rubin1
1Temple University Hospital, Philadelphia, PA, 2Temple University Hospital

 

Background: Diabetic myonecrosis, also known as diabetic muscle infarction, is a rare condition that usually occurs in patients with long-standing and uncontrolled diabetes. The exact pathogenesis is unknown but may involve hypoxia-reperfusion injury, atherosclerotic occlusion, or vasculitis with thrombosis. The disease is self-limited, and most patients recover in several weeks with supportive treatment. Most often it affects the thigh muscles, although other areas are occasionally involved. Diabetic myonecrosis can be difficult to diagnose as a similar presentation may also be seen in soft tissue abscess, necrotizing fasciitis, deep vein thrombosis, polymyositis, and acute compartment syndrome. Although biopsy has been done in many cases for diagnosis, some authors have argued against biopsy because of potential complications and delayed recovery.

Clinical Case: We present the case of a 64-year-old male with type 1 diabetes mellitus who presented with severe left anterior thigh pain and leukocytosis, bandemia, tachypnea and tachycardia, but no fever. On examination, the left thigh was edematous, warm, and tender, without erythema or subcutaenous emphysema. The patient was in rapid atrial fibrillation and was admitted to the cardiac intensive care unit for heart rate control and vasopressor support. Broad-spectrum antibiotics were initiated. Venous and arterial duplex ultrasounds of the legs were negative for a blood clot, and initial blood cultures were negative. Creatine kinase was moderately elevated at 1,187 U/L (NL 30-390 U/L). A CT scan of the left leg demonstrated thickening and loss of the normal pattern of the left vastus lateralis muscle, which suggested a differential diagnosis of diabetic myonecrosis or infectious myositis. MRI showed enlargement and loss of the normal fibrillary architecture of the quadriceps with diffusely increased T2 signal, which favored diabetic myonecrosis. Subcutaneous air was absent on imaging. A muscle biopsy was surgically obtained to confirm the diagnosis. The pathology results were consistent with a combination of necrotizing fasciitis and myonecrosis. The patient’s hospital course was complicated by an iatrogenic wound infection and bacteremia with Methicillin-resistant Staphylococcus aureus, which required multiple surgical debridements.

Conclusion: Most cases of diabetic myonecrosis can be diagnosed by the clinical presentation and imaging. MRI is 90% sensitive for the condition. Although biopsy remains the gold standard for diagnosis, it generally should be avoided as biopsy can lead to iatrogenic complications. Biopsy should be reserved for atypical presentations.

 

Nothing to Disclose: TG, SM, JG, DB, DJR

21429 7.0000 THR-602 A Diabetic Myonecrosis: Is Biopsy Needed for Diagnosis? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Faraj Kargoli1, Fady Hannah-Shmouni*2 and Tom Nickolas3
1Montefiore Medical Center, Bronx, NY, 2Yale-New Haven Hospital, New Haven, CT, 3Columbia University, New York, NY

 

Increased Fracture Risk in Co-Prevalent Diabetes and Chronic Kidney Disease in the United States

Background: Over the past twenty years, fracture rates have doubled in patients with chronic kidney disease (CKD) (1). Etiologic mechanisms driving increased fracture rates are not clear. Diabetes mellitus (DM), most common cause of CKD in the United States (U.S.), has reached epidemic proportions, and both DM and CKD increase fracture risk compared to the general population (1). Whether co-prevalent CKD and DM (CKD-DM) is associated with higher fracture rates than CKD or DM alone and is partly responsible for increasing fracture rates observed in CKD populations is not known. We used a large nationally representative sample of the U.S. non-institutionalized civilian population to test the hypothesis that CKD-DM is associated with higher fracture prevalence rates than either disease alone.

Methods: We conducted a cross-sectional analysis of the continuous National Health and Nutrition Examination Survey (NHANES) of subjects ≥40 years old enrolled from 2000 to 2010 (n=26,070, weighted sample= 22,088,010). DM status and fracture status were ascertained from responses to NHANES questionnaires; CKD status was based on an estimated glomerular filtration rate (eGFR) <60 ml/min. The cohort was divided three groups: DM, CKD and CKD-DM. Uni-and multivariate logistic regression models were used to determine associations.

Results: In the DM group (n=2048): age 60±14, female 48% [25% black], eGFR 98±32 ml/min, body mass index (BMI) 32±7; CKD group (n= 1239): age 74±11, female 54% [12% black], eGFR 47±12, BMI 28±5); CKD-DM group (n=529): age 71±10, female 54% [22% black], eGFR 44±14, BMI 32±8). Fracture prevalence at any-site was 14%, 16% and 15%, respectively (p<.0001). Multivariate models adjusted for age (>65), gender, race, BMI, serum calcium, phosphorus and creatinine demonstrated that: (1) compared to DM alone, co-prevalent CKD-DM was associated with 60% and 66% increased risk of hip and spine fractures respectively (hip: OR 1.6, CI 1.59-1.62; spine: OR 1.66, CI 1.64-1.67); and (2) compared to CKD alone, co-prevalent CKD-DM was associated with 43% and 14% increased risk of hip and spine fractures respectively (hip: OR 1.43, CI 1.41-1.44, spine: OR 1.14, CI 1.13-1.15).

Conclusion: These data suggest that co-prevalent CKD-DM is associated with higher rates of hip and spine fractures than CKD or DM alone. These data have high public health impact and epidemiologic and mechanistic studies are required to evaluate the effects of CKD-DM on the biochemical and micro architectural basis of fragility.


 

Nothing to Disclose: FK, FH, TN

18465 8.0000 THR-603 A Increased Fracture Risk in Co-Prevalent Diabetes and Chronic Kidney Disease in the United States 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Kathryn M Thrailkill*1, Robert Clay Bunn1, Jeffry S Nyman2, Mallikarjuna Rao Rettiganti1, Gael Cockrell1, Elizabeth Wahl1, Charles K Lumpkin1 and John Leslie Fowlkes1
1University of Arkansas for Medical Sciences, Little Rock, AR, 2Vanderbilt University Medical Center, Nashville, TN

 

Renal glucose resorption is regulated by the sodium glucose co-transporter 2 (SGLT2), a high affinity transporter expressed in the proximal tubule.  SGLT2 inhibitors are FDA-approved for treatment of type 2 diabetes (T2D), due to their anti-hyperglycemic properties resulting from enhanced urinary glucose excretion.  Clinical trials are also examining their efficacy in T1D.  Persons with T1D or T2D have increased risk of fracture, related to deficits in the microarchitecture and strength of diabetic bone; therefore, we examined the effects of an SGLT2 inhibitor on glucose and bone homeostasis in a model of diabetic bone disease.  Male, 10-week old, DBA/2J mice with streptozotocin (STZ)-induced diabetes were fed Teklad 8640 chow containing the SGLT2 inhibitor, Canagliflozin (CANA, 50 ppm, n=19) or control chow without CANA (n=18).  Non-diabetic mice were fed chow containing 62.5 ppm CANA, to offset the polyphagia in diabetic mice (n=20), or control chow (n=20).  CANA intake during the 10 week study was 17.7-20.6 mg/kg/day in the STZ (diabetes) group and 14.2-19.6 mg/kg/day in the non-diabetes group.  At sacrifice, serum glucose, PTH, P1NP and RatLAPs levels were measured; the left femur was harvested to assess fracture resistance by combined µCT analysis and three-point bending tests. In the metaphysis, long-term diabetes (DM) induced significant deficits in trabecular bone microarchitecture, including decreased trabecular bone volume fraction (BV/TV), trabecular number (Tb.N), trabecular thickness (Tb.Th) and trabecular tissue mineral density (Tb.TMD), along with increased trabecular spacing (Tb.Sp; p<0.0001 for all parameters).  In the diaphysis, a decrease in cortical bone area (Ct.AR), cortical thickness (Ct.Th) and minimal moment of inertia (Imin), occurred in DM (p<0.0001 for all), in addition to an increase in cortical porosity (Ct.Po; p<0.0001). These changes in DM were associated with reduced fracture resistance (decreased material strength and toughness as well as decreased structural strength and rigidity; p<0.001 for all).  DM was also associated with a ~4-fold increase in PTH (p<0.0001) and a ~2-fold increase in RatLAPs, a marker of bone resorption (p=0.0002), and RatLAPs was negatively correlated with Ct.Th, Tb.Th, and Tb.N (p<0.05 for all).  CANA treatment improved blood glucose in DM mice by ~40% (CONTROL: 101.2 ± 18.8 mg/dL; STZ: 525.2 ± 53.6; STZ + CANA: 338.9 ± 131.4; p<0.001 for STZ vs. STZ+CANA).  Glucose improvement, however, was not associated with significant improvement in trabecular microarchitectural parameters.  Instead, in CANA-treated diabetic mice, a further increase in RatLAPs was seen in the STZ + CANA group (CONTROL: 15.2 ± 3.4 ng/mL; CONT+CANA: 15.3 ± 4.0; STZ: 28.8 ± 6.3; STZ + CANA: 39.1 ± 17.9; p=0.005 for STZ vs. STZ+CANA).  This finding might suggest a drug-related further increase in bone resorption, perhaps induced by increased renal loss of bone minerals.

 

Nothing to Disclose: KMT, RCB, JSN, MRR, GC, EW, CKL, JLF

18680 9.0000 THR-604 A SGLT2 Inhibitor Treatment Improves Blood Glucose but Does Not Correct Diabetic Bone Disease in a Mouse Model 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Hyun Ae Seo* and Eui Hyun Kim
Daegu Fatima Hospital, Korea, Republic of (South)

 

Aims: Coronary artery disease is the major cause of morbidity and mortality in patients with type 2 diabetes. The coronary artery calcium score infers the presence of coronary atherosclerosis by measuring the total amount of calcium in the coronary arteries and has been known to predict the risk for cardiovascular disease. In this study, we investigated the relationship between coronary artery calcium scores and biochemical markers, especially lipid profiles and apolipoproteins.

Methods: We calculated the coronary calcium scores of 496 subjects with type 2 diabetes (229 males and 267 females) via multi-detector row computed tomography (MDCT). Coronary calcium levels were represented by Agatston score. Height, body weight, blood pressure, biochemical markers including lipid profiles (low-density lipoprotein, high-density lipoprotein, triglycerides and total cholesterol) and apolipoproteins (apolipoprotein A-1 and apolipoprotein B) were assessed concurrently.

Results: The mean age of total subjects was 58.46±12.44. The mean Agatston score was 229.81±675.56. The square root of Agatston score was made to achieve a normal distribution curve. Systolic blood pressure and blood urea nitrogen levels were significantly related to Agatston score. In patients with type 2 diabetes, Agatston score was highly associated with high density lipoprotein (HDL) (r = -0.212, P = <0.001). We performed subgroup analysis according to gender. Agatston score and HDL were significantly negatively correlated in both males and females (r = -0.183, P = 0.005 and r = -0.217, P = <0.001 respectively). The negative correlation between Agatston score and HDL after adjustments for age, BMI, systolic blood pressure, blood urea nitrogen, smoking status,  and use of lipid lowering drugs was retained in both males and females (r = -0.151, P = 0.034 and r = -0.229, P = <0.001 respectively).

Conclusion: These results suggest that HDL is a useful independent indicator of coronary artery calcification in patients with type 2 diabetes.

 

Nothing to Disclose: HAS, EHK

19650 11.0000 THR-607 A The Association Between Coronary Artery Calcium Score and High Density Lipoprotein 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Yassin M Mustafa*, Ana Shahnazi, Armana Saeed, Hassan Brim, Gail Nunlee-Bland, Saha Shrabonti, Seyed-Mehdi Nouraie and Hassan Ashktorab
Howard University Hospital, Washington, DC

 

Background: Type 2 diabetes mellitus (T2DM) patients are at increased risk for colorectal carcinoma (CRC). Obesity, insulin resistance and hyperinsulinemia either endogenous or exogenous are believed to be some of the risk factors. Metformin (MT), an insulin sensitizer, was suggested to decrease the risk of colorectal neoplastic lesions. As a result MT may reduce the mortality and increase survival in patients with established CRC.

Aim: To evaluate the association between MT therapy and colorectal neoplasia among African Americans (AAs) with T2DM

Methods: We retrospectively reviewed the medical records of patients who underwent diagnostic colonoscopy in our institution between 2000-2012. A group of predominantly AAs diabetic patients who had colonic neoplasia and a control group with no colonic neoplasia were identified. Data was analyzed using chi-square tests and multivariate logistic regression.

Results:We identified 214 patients with T2DM who were on anti-diabetic medications for at least 6 months prior to colonoscopy. Of these patients 156 (72.9%) had histopathologically confirmed colorectal neoplastic lesions and 58 (27.1%) were lesions free. Of patients with CRC or colorectal adenoma, 67 (43%) were on MT therapy compared to 35 (60%) patients without evidence of colorectal neoplasia(P=0.02). Multivariate logistic regression adjusted for age and gender demonstrated that patients on MT for more than 5 years had significantly decreased risk OR=0.2(95% CI: 0.1-0.4, P<0.001).

Conclusion: Our findings suggest that MT therapy is associated with a lower risk of colorectal neoplastic lesions in AAs with T2DM. Its protective effect appears to increase with duration of therapy.

 

Nothing to Disclose: YMM, AS, AS, HB, GN, SS, SMN, HA

21394 12.0000 THR-608 A Chronic Use of  Metformin Is Associated with a Reduced Colorectal Neoplasia Risk in Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Pinar Karakaya*1, Meral Mert2, Yildiz Okuturlar2, Asuman Gedikbasi2, Filiz Islim2, Didem Acarer2, Nursel Kocamaz2, Ozlem Soyluk2, Teslime Ayaz3, Pinar Alarslan4, Ozlem Harmankaya2 and Abdulbaki Kumbasar2
1Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, 2Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, 3Recep Tayyip Erdogan University Training and Research Hospital, Rize, Turkey, 4Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey

 

Human paraoxonase 1/arylesterase (PON1) is a calcium dependent ester hydrolase with paraoxonase, arylesterase and diazoxonase activities along with antioxidant and anti-atherogenic properties (1-3). Low PON-1 activity has been associated with susceptibility to coronary artery disease and increased risk of diabetic complications among patients with diabetes (3-5). Therefore the present was designed to evaluate the relation of serum PON-1 activity with biochemical variables as well as brachial artery diameter (BAd) and intima media thickness (BA-IMT) in diabetic patients with or without diabetes related complications. A total of 201 diabetic patients (mean±SD age: 52.4±13.4 years, 73.6% were females) with (n=50) or without (n=150) microvascular and with (n=91) or without (n=108) macrovascular complications were included. Data on patient characteristics, microvascular (neuropathy, retinopathy and nephropathy) and macrovascular [hypertension, coronary artery disease (CAD), past history of coronary artery bypass (CABG), peripheral artery disease (PAD), stroke and past history of myocardial infarction (MI)] complications, blood biochemistry, HOMA-IR, microalbuminuria and BAd and BA-IMT were evaluated with respect to serum PON-1 activity. Mean paraoxonase (107.5±30.7 vs. 123.9±38.8 U/L, p=0.007) and arylesterase (132.1±30.2 vs. 154.7±41.2 U/L, p=0.001) values were significantly lower in patients with than without microvascular complications. There was a negative correlation of HOMA-IR to paraoxonase (r=-0.383, p=0.001) and arylesterase (r=-0.252, p=0.035) levels in patients with macrovascular complications, whereas no correlation of HOMA-IR to paraoxonase or arylesterase was evident in patients with microvascular complications (r=-0.247, p=0.083 and r=-0.196, p=0.173, respectively). Arylesterase values was positively correlated with right BA-IMT in patients with microvascular complications (r=0.374, p=0.042). In conclusion, our findings in  a cohort of diabetic patients revealed no influence of gender, age and macrovascular complications on serum paraoxonase and arylesterase activities, whereas significantly lower PON-1 activity in patients with microvascular complications and negative correlation of both serum paraoxonase and arylesterase activities to HOMA-IR only in patients with macrovascular complications. Serum paraoxonase activities were not correlated to BAd and BA-IMT, regardless of diabetic complications. Our findings emphasize the possible role of low serum paraoxonase and arylesterase activities in predicting diabetic microvascular complications among diabetic patients and poor glycemic control in patients with diabetic macrovascular complications along with the role of arylesterase but not paraoxonase values in predicting early atherosclerosis in patients with diabetic microvascular complications.

 

Nothing to Disclose: PK, MM, YO, AG, FI, DA, NK, OS, TA, PA, OH, AK

18636 13.0000 THR-609 A Relation of Serum Paraoxonase-1 Activity with Biochemical Variables and Brachial Artery Diameter and Intima Media Thickness in Diabetic Patients with or without Diabetes Related Complications 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Gilberto J. Paz-Filho*, Teresa Neeman, Claudio Alberto Mastronardi and Alexander J. Rodriguez
The Australian National University, Canberra, Australia

 

Background: Diabetes is a significant cause of global morbidity. Patients with type 2 diabetes are at an increased risk of developing microvascular complications, including retinopathy, nephropathy and neuropathy. The adipocytokine leptin has been associated with vascular inflammation involved in these complications, and some cross-sectional studies have shown positive correlations between serum leptin levels and prevalence of diabetic microvascular complications. However, there is no comprehensive data examining blood leptin concentration with the presence of these complications.

Methods: A systematic review of the Scopus, MEDLINE and the Cochrane Library databases was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Clinical studies were sought that assessed the association between circulating leptin concentrations and diabetic microvascular complications. Study quality was evaluated using a modified version of QUADAS 2, an instrument for the quality assessment of studies included in systematic reviews. Meta-analysis was performed on pooled data using an inverse-variance random-effects model, using RevMan v5 software. The standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated for concentrations of leptin in diabetic patients with and without microvascular complications. Heterogeneity was determined by the Q and I2 statistics.

Results: A total of 262 unique abstracts were identified, of which 13 satisfied our inclusion and exclusion criteria. Study quality ranged from 37.5% to 87.5%, and most studies failed to report medication use. Higher leptin levels were associated with nephropathy [0.51 SMD (95% CI: 0.12, 0.90), p=0.01; n=1,165 participants from nine studies]. A leave-one-out sensitivity analysis showed the result remained significant. Leptin was not associated with retinopathy [0.17 (-0.30, 0.65), p=0.48; n=1,012 from five studies] or neuropathy [0.12 (-0.19, 0.43), p=0.45; n=791 from four studies]. Heterogeneity (I2) for studies reporting nephropathy, retinopathy and neuropathy were 87%,  89% and 73%, respectively.

Discussion: Adipocytokines have been variously associated with diabetic microvascular complications. This meta-analysis suggests that relative to patients without complications, higher leptin is associated with nephropathy. A sensitivity analysis of leptin results demonstrates the strength of this finding. Therefore, adipocytokines are clinically relevant to diabetic microvascular complications and may have future potential as novel therapeutic targets or biomarkers for diagnostics, surveillance or risk prediction. Studies were limited by their cross-sectional design and thus large prospective analyses are required to confirm these findings independent of other risk factors.

 

Nothing to Disclose: GJP, TN, CAM, AJR

20210 14.0000 THR-610 A Associations Between Leptin and Diabetic Microvascular Complications: Systematic Review and Meta-Analysis of Cross-Sectional Data 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Akshata Desai*1, Manisha Garg2, Sartaj Sandhu3, Simmanjeet Mangat3, Garima Thapar3, Rujuta Katkar3, Aditya Mehta2, Naven Kang3, Nitesh D Kuhadiya2, Sandeep S Dhindsa3, Ajay Chaudhuri2 and Paresh Dandona2
1SUNY at Buffalo, NY, 2Diabetes and Endocrinology Center of Western New York, Buffalo, NY, 3Diabetes and Endocrinology Center of Western New York, Williamsville, NY

 

Our recent data show that exenatide treatment in type 2 diabetes induces an increase in the expression of the genes of key anti-oxidant enzymes, NQO-1, GST-P1 and HO-1, which are modulated by the key transcription factor, Nrf-2, and suppresses Keap-1, the inhibitor of Nrf-2 (1).These observations are important since Nrf-2 regulated genes reduce oxidative stress and protect the kidneys from developing nephropathic changes in mice rendered diabetic by streptozotocin. These actions are in addition to the potent and comprehensive anti-inflammatory effects exerted by exenatide previously demonstrated by us (2). Furthermore, our data also show that exenatide suppresses TGFβ-1, the key cytokine involved in the pathogenesis of diabetic nephropathy (1). Since our initial observations on the cellular and molecular actions of liraglutide confirm these data, these actions thus are probably applicable to other GLP-1 receptor agonists. In animal models, streptozotocin induced diabetes related nephropathy has been inhibited by GLP-1 receptor agonists through their anti-inflammatory and ROS suppressive actions.

 On the basis of the above, we retrospectively analyzed data from patients treated at our center and found that albuminuria in diabetic patients taking GLP-1 receptor agonists was significantly better than that in those on other anti-diabetic drugs. Thus, in those who presented with micro-albuminuria and were treated with GLP-1 receptor agonists, 61% became normoalbuminuric and no one developed macro-albuminuria. In the other group, 11% developed macro-albuminuria while 42% became normoalbuminuric (p<0.01)(3). In normoalbuminuric patients, 11.3% developed either microalbuminuria or macroalbuminuria in the group on GLP-1 receptor agonists while in the other group, 20% developed either microalbuminuria or macroalbuminuria. These differences were independent of glycemic control since HbA1c levels were similar in the two groups. BP, lipids, use of ACE inhibitors/ARB and statins were also similar between the two groups. No patient in either group developed ESRD. Thus, clearly, the evolution of albuminuria in patients treated with GLP-1 receptor agonists was significantly better than those in the rest as shown below in Figure 1. Clearly, a prospectively randomized study investigating the effect of a GLP-1 receptor agonist on albuminuria or GFR in patients with diabetes needs to be carried out.

 

Nothing to Disclose: AD, MG, SS, SM, GT, RK, AM, NK, NDK, SSD, AC, PD

19227 15.0000 THR-611 A GLP-1 Receptor Agonists Reduce the Progression of Proteinuria in Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Jung Soo Lim*1, Ji Hye Huh1, Young Ju Choi2, Byoung Wook Huh2, Mi Young Lee1, Jang Yel Shin1, Choon Hee Chung1, Eun Jig Lee3 and Kap Bum Huh2
1Yonsei University Wonju College of Medicine, Wonju, Korea, Republic of (South), 2Huh’s Diabetes Center and the 21C Diabetes and Vascular Research Institute, Seoul, Korea, Republic of (South), 3Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Background Calcium homeostasis has been shown to affect insulin resistance and secretion. Moreover, several studies have reported that elevated serum calcium is associated with an increased risk of developing metabolic abnormalities, including type 2 diabetes mellitus (DM). However, it remains unclear whether serum calcium level can affect the presence of nonalcoholic fatty liver disease (NAFLD), which has been considered as the hepatic expression of metabolic syndrome. The aim of this study was to investigate the relationship between serum calcium level and NAFLD in Korean type 2 DM with normocalcemia.

Methods A total of 5,711 diabetic subjects who visited our clinic from Jan 2003 to May 2012 were enrolled. Subjects were divided into four groups according to the baseline quartiles of serum calcium levels: Q1 (8.4-8.8 mg/dL), Q2 (8.9-9.2 mg/dL), Q3 (9.3-9.5 mg/dL), and Q4 (9.6-10.4 mg/dL). Insulin sensitivity was assessed by the rate constant of plasma glucose disappearance (Kitt, %/min) using a short insulin tolerance test. Moreover, fatty changes of liver were examined by ultrasonography.

Results The prevalence of NAFLD was 58.8% in the whole study population. As serum calcium levels increased, NAFLD also significantly increased (53.5% in Q1, 58.8% in Q2, 59.7% in Q3, and 61.5% in Q4, respectively). In addition, blood pressure, total cholesterol, LDL cholesterol and plasma triglyceride levels were significantly higher in subjects in the highest quartile compared with those in the lowest, although there were no differences in age, gender and body mass index among the groups. Moreover, insulin sensitivity was significantly reduced in the highest quartile than in the lowest one. Multiple regression analyses showed that the odds ratio (OR) for NAFLD was about 33% higher in individuals with calcium concentration≥9.6 mg/dL than in those with calcium concentration <8.9 mg/dL (OR 1.33 [95% confidence interval 1.08-1.63]).

Conclusion These findings suggest the possibility that increased serum calcium may in part be involved in developing NAFLD in subjects with type 2 DM, even in normal levels. Further investigations are needed to establish a casual relationship.

 

Nothing to Disclose: JSL, JHH, YJC, BWH, MYL, JYS, CHC, EJL, KBH

21475 16.0000 THR-612 A Association Between Serum Calcium Level and Nonalcoholic Fatty Liver Disease in Korean Type 2 Diabetes Mellitus with Normocalcemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Ho Jin Kim*, Jun Ho Lee, Jae Ho Cho, Jun Sung Moon, Ji Sung Yoon, Kyu Chang Won and Hyung-Woo Lee
Yeungnam University College of Medicine, Daegu, Korea, Republic of (South)

 

Introduction : Red blood cell (RBC) deformability is an ability of RBC to change shape under stress. RBC deformability has been demonstrated to be impaired in diabetes mellitus. But, little is known about the association between impaired RBC deformability and type 2 diabetes mellitus (T2DM). The aim of this study was to determine the influence of RBC deformability on T2DM.

Methods :We conducted a cross-sectional study with 198 patients with T2DM who visited in Yeungnam university hospital from Mar. to Jul. 2014. Patients with end stage renal disease and who are taking a pentoxifylline and ginkgo biloba were excluded. RBC deformability was measured by using a Rheoscan-D (Rheo-Meditech, Seoul, Korea), and expressed as elongation index (EI). The EI was measured at 3 Pa. We divided the EI into quartile (Q1, Q2, Q3 and Q4 from lowest to highest EI).

Results : 193 patients (mean age 59.82 ± 12.29 years, M:F = 100:93) were finally included. EI had significantly negative correlation with the levels of glycated hemoglobin, and positive correlation with HOMA-B, respectively (β -23.52 , P=0.01 and β 520.03, P=0.02, respectively). Patients with micro complications had lower EI compared with patients without complications (EI 0.303623 vs. 0.310637, p=0.01). Of them, patients with retinopathy had lower EI compared with patients without retinopathy (EI 0.300449 vs. 0.309653, p=0.00), whereas patients with nephropathy or neuropathy and macro complications had no significant difference in EI. After adjustment for age, sex, hypertension, smoking, and lipids, lower EI remained significantly associated with the prevalence of diabetic retinopathy (Odds ratio for Q1 compared with Q4, 4.16; 95% confidence interval, 1.43-12.13).

Conclusion : In patients with T2DM, there are significant relationship between RBC deformability and glycemic control, beta cell function and diabetic retinopathy. These results suggest that decreased RBC deformability is a useful surrogate marker for predicting diabetic retinopathy.

 

Nothing to Disclose: HJK, JHL, JHC, JSM, JSY, KCW, HWL

20382 17.0000 THR-613 A Association Between Red Blood Cell Deformability and Diabetic Complications in Patients with Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Mohamed I. Husseiny Elsayed*1, Weiting Du1, Ding Wang1, Jeffrey Rawson1, Alexander Kaye1, Fouad R Kandeel1 and Kevin George Ferreri2
1Diabetes & Metabolic Research Institute, Beckman Research Institute of City of Hope, Duarte, CA, 2City of Hope, Duarte, CA

 

Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by destruction of pancreatic insulin-producing beta cells due to loss of tolerance to specific self-antigens (autoantigen). The attack on the beta cells is accompanied by the development of antigen-specific antibodies and cytotoxic T lymphocytes (CTLs). One of the most promising approaches to restore balance within the immune system is oral administration of diabetic autoantigens, which can result in deletion of destructive islet-specific responses and induction of regulatory responses. Studies in animal models and in the clinic have shown that administration of autoantigens, especially orally to the gut associated lymphoid tissue (GALT), can slow or even stop the progression of disease. We recently reported the development of an oral vaccine based on live attenuated Salmonella for the prevention of diabetes in non-obese diabetic (NOD) mice. That study used mouse preproinsulin (mPPI) gene as the autoantigen fused to SseF effector protein of type-III secretion system (T3SS) encoded by Salmonella Pathogenicity Island-2 (SPI2) under the control of an intracellular regulated promoter (Pro sseA) required for intracellular survival and replication. The SPI2-T3SS prevents extracellular expression and allows preferential delivery of fused protein into the cytosol of antigen-presenting cells (APCs) for optimal immunogenicity. The Salmonella-based delivery of autoantigen was co-administered with Salmonella-based delivery of DNA for mammalian expression of transforming growth factor beta (TGFbeta) by the host APCs. We showed that oral vaccination with the combined mPPI+TGFbeta prevented diabetes in the majority of mice and restored normal glucose tolerance, while untreated or autoantigen alone mice became diabetic. In this study we extended the method to another diabetic autoantigen, Glutamic Acid Decarboxylase (GAD)-65. Similar to preproinsulin, oral co-vaccination with Salmonella carrying GAD65 and TGFbeta prevents diabetes in the majority of animals but GAD65 alone does not. To better understand the mechanism of vaccine action the populations of CD4, CD8, CD25, and FOXP3 were quantified as well as the levels of cytokines in circulation and cytokines released after autoantigen stimulation. We conclude that a Salmonella-based oral vaccine expressing autoantigens in combination with tolerogenic cytokines is a promising therapy for prevention of T1D.

 

Nothing to Disclose: MIHE, WD, DW, JR, AK, FRK, KGF

19112 18.0000 THR-614 A Oral Immunotherapy for Type 1 Diabetes Based on Live Attenuated Salmonella 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Mingfeng Zhang*1, Qing Lin1, Limin Wu1, Nainong Li1, Jeremy Racine1, Qi Tong2 and Defu Zeng1
1Beckman Research Institute of City of Hope, Duarte, CA, 2City of Hope, Duarte, CA

 

We previously reported that induction of mixed chimerism under a radiation-free anti-CD3/CD8 conditioning regimen cures new-onset type 1 diabetes (T1D), and induction of mixed chimerism in combination with administration of growth factors cures late-stage T1D in autoimmune NOD mice. Due to unavailability of anti-human CD3 and CD8 mAb, we need to develop a new regimen with clinically available reagents. Cyclophosphamide, Pentostatin, and ATG has been used to condition patients in clinical hematopoietic cell transplantation (HCT). In the current studies, we conditioned NOD mice with cyclophosphamide (50mg/Kg, daily, 14 days), pentostatin (1mg/Kg, every 3 days, total four injections), and ATG (50mg/Kg, every 4 days, total three injections). The conditioned NOD mice were transplanted with donor BM (50x106) and CD4+ T-depleted spleen cells (25x106) from MHC-mismatched C57BL/6 donor mice. About 85% (10/12) of overt diabetic NOD recipients developed mixed chimerism with no signs of graft versus host disease (GVHD). The mixed chimerism cured new-onset (3 days after onset) T1D via elimination of insulitis and replication of residual β cells. The mixed chimerism in combination of administration of gastrin and EGF cured more than 50% of late-stage (3 weeks after onset) T1D via augmenting β cell replication and neogenesis. These results indicate that induction of mixed chimerism with clinically applicable conditioning regimen has the potential to cure overt T1D.

 

Nothing to Disclose: MZ, QL, LW, NL, JR, QT, DZ

19685 19.0000 THR-615 A Induction of Mixed Chimerism for Cure of Overt Type 1 Diabetes in NOD Mice, Using Clinically Available Reagents without Radiation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Mustafa Tosur*1, Pamela J Lupo2, Jianli Dong2, Ketan N Patel2 and Phillip D K Lee2
1Texas Children's Hospital / Baylor College of Medicine, Galveston, TX, 2University of Texas Medical Branch, Galveston, TX

 

Introduction: We report an adolescent male with incidentally discovered non-ketotic diabetes mellitus (NKDM), who was also found to have involuntary muscle cramping and severe hypertriglyceridemia.  

Clinical Case: During evaluation for possible viral meningitis, a 14 year-old lean athletic male was incidentally found to have NKDM with negative anti-glutamic acid decarboxylase and islet cell antibodies, and elevated C-peptide. Treatment with glipizide XL 30 mg daily, metformin XR 500 mg bid and carbohydrate limited diet reduced HbA1c from 9.0 to 7.4%. During the course of the diabetes evaluation, he complained of pre-existing painful muscle cramping, intermittently and unpredictably affecting all muscle groups; he had been reluctant to describe this previously. Electromyography was technically difficult due to severe cramping, and was reported as widespread fasciculations and cramp potential without any evidence of myopathy. Lipemic serum noted during a blood draw resulted in a diagnosis of hypertriglyceridemia (>1500 mg/dl) without significant hypercholesterolemia; this has been partially controlled with omega-3 oil and diet with triglyceride 572 mg/dl after a year of treatment. Other clinical findings include unilateral pelvic kidney, moderate proteinuria and elevated blood pressure; renal biopsy pending. Chromosomal microarray analysis showed loss of heterozygosity on chromosomes 4p15.2, 5q13.2, and 19q13.11, which includes total of 24 disease-causing genes in OMIM, increasing the risk of recessive conditions. A 1.28 Mb loss of chromosome 16p11.2 was also identified without disease-causing genes in OMIM. The clinical significance of the microarray results is unknown. LMNA sequencing and targeted gene testing for Kennedy disease were negative. Whole exome sequencing revealed a heterozygous ATM mutation with unknown clinical significance (c.1595G>A); expanded report pending. The patient’s clinical condition has shown virtually no change over 3 years of treatment except for partial biochemical response to medical treatment and diet.

Conclusion: We report a unique association of NKDM with intrinsic muscle disorder, severe hypertriglyceridemia, proteinuria and possibly unrelated renal anomaly. ATM mutation has been previously shown to be associated with insulin resistance and diabetes; however, the role of patient’s heterozygous mutation on his clinical condition is not clear.

 

Nothing to Disclose: MT, PJL, JD, KNP, PDKL

19008 20.0000 THR-616 A An Unusual Case of Non-Ketotic Diabetes in an Adolescent Male 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Sharad S Singhal, James L Figarola, Jyotsana Singhal*, Samuel Rahbar and David Horne
Beckman Research Institute of the City of Hope, Duarte, CA

 

Growing evidence indicates that oxidative stress is increased in the diabetic condition due to overproduction of reactive oxygen radicals and decreased efficiency of antioxidant defenses.  Glutathione S-transferases (GSTs) are a large, multi-gene family of proteins that may play an important role in protecting tissues from oxidative damage because they function in the transport of cellular components or metabolites (or conjugation of metabolites with glutathione) formed during diabetes.  The present study was designed to evaluate the effect of “COH-SR4” on glutathione (GSH)-dependent xenobiotic metabolism and oxidative stress in mice with diabetes.   Profound changes in the levels of GSH-linked antioxidant enzymes such as GST, glutathione peroxidase, glutathione reductase, glucose 6-phosphate dehydrogenase and gamma-glutamyl cysteine synthetase, and oxidative stress markers such as lipid hydroperoxides (LOOH) and thiobarbituric acid reactive substances (TBARS) were assessed in the liver of normal and diabetic (db/db) mice with and without treatment with “COH-SR4”.  In diabetes mellitus, lipid peroxides formed due to oxidative stress serve as endogenous substrates for GSTs.  Mammalian GSTs are highly efficient in the detoxification of these compounds.  Lower levels of GSH and GST, and higher levels of oxidative stress markers were found in the diabetic mice.  The concentration of malondialdehyde (MDA) measured in the liver of normal mice was 630 ± 103 nmol/g tissue.  The changes in the concentration of MDA measured in the liver of db/db mice (2428 ± 235 nmol /g tissue, p < 0.01) and db/db mice treated with SR4 (894 ± 76 nmol /g tissue, p < 0.01) were statistically different from the db/db mice.  SR4 feeding to db/db mice (5 mg/kg b.w., 4-weeks treatment on alternate days by oral gavage) significantly decreases oxidative stress markers, brought the level of LOOH and MDA approximately to the level found in control mice, which could be explained by its anti-hyperglycemic effect.  GSH concentration was significantly lower of db/db mice compared to control (~ 58%; p < 0.01).  Feeding of COH-SR4 to db/db mice markedly increased GSH concentration.  These results are consistent with prediction of our model that higher sugar levels caused by lower AMPK expression in db/db mice should result in accumulation of their precursor lipid hydroperoxides and their degradation products.  These results suggest that the antioxidant deficiency and excessive peroxide-mediated damage may appear early on in non-insulin-dependent diabetes mellitus, before the development of secondary complications.  In conclusion, SR4 is a safe and inexpensive product, causes a significant reduction of the glycation of proteins in diabetic animals.  In summary, the present study on the anti-diabetic effects of a novel dichlorophenyl urea compound “COH-SR4” holds great future promise for further development in diabetes treatment.

 

Nothing to Disclose: SSS, JLF, JS, SR, DH

20465 21.0000 THR-616 A Role of COH-SR4 in Diabetes: Glutathione-Linked Enzymes and Oxidative Stress 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Vera Fernandes*1, Maria Teresa Pereira2, Susana Garrido2, Andre Carvalho2, Claudia Amaral3, Cláudia Freitas2, Helena Neto2, Joana Martins2, Isabel Gonçalves2, José Muras2, Sara Pinto2 and Rui Carvalho2
1Hospital de Braga, Braga, Portugal, 2Hosp Santo Antonio, Porto, Portugal, 3Hospital de Santo Antonio, Porto, Portugal

 

Introduction: The proportion of diabetic patients undergoing a major amputation, preceded by an unsuccessful minor amputation, is not known. Therefore, it’s not clear if a conservative or aggressive attitude is being adopted at the beginning, and what are the consequences.

Aim: To compare diabetic patients undergoing a major amputation preceded by a recent minor amputation (same limb, in the last 30 days), with patients undergoing a major amputation at the beginning, concerning demographic and clinical characteristics. 

Methods: Observational, analytical and retrospective study of diabetic patients undergoing a major amputation at a central hospital, between 2011 and 2013.  The chi-square, exact Fisher’s test, Mann-Whitney and Kruskal-Wallis tests were used.

Results: Of the 195 major amputations included in this study, 51% occurred in females, 35% were previously autonomous and 67.7% were 65 years or over. In 44 major amputations (22.6%) there had been a previous minor amputation and the time between amputations was mostly less than 14 days. Only 6 amputations were performed in patients considered purely neuropathic and none of these subjects had a recent minor amputation. The patients with a recent minor amputation showed to be younger (p=0.028) and autonomous (p=0.025); they presented higher HbA1c levels (p=0.003) and this group had a longer hospital stay (p<0.001). Regarding diabetic complications, it was found that diabetics with major amputation at the beginning had more often cerebrovascular disease (p=0.047) and they presented also a higher number of macrovascular complications (no statistical significant). The proportion of major amputation preceded by a minor was 20.3% in 2011, 16.9% in 2012 and 29.2% in 2013.

Conclusion: This study shows that an important number of major amputations is preceded by a unsuccessful minor amputation, especially in younger and autonomous patients. The older patients and those with more chronic diabetic complications appear to be more often targeted to have a major amputation from the beginning.

 

Nothing to Disclose: VF, MTP, SG, AC, CA, CF, HN, JM, IG, JM, SP, RC

21221 22.0000 THR-617 A Diabetes & Lower Extremity Amputation - Major Amputation: An Expectable Result?- 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Muge Keskin1, Nese Ersoz Gulcelik*2, Cavit Culha3 and Yalcin Aral4
1Ankara Training & Res Hosp, Ankara, Turkey, 2Ankara Training Hospital, 3Ankara Training and Research Hospital, 4Ankara Training and Research Hospital, Ankara, Turkey

 

Fetuin- A levels predict cardiovascular risk in young diabetic patients

Objective: Young adults with type 2 diabetes (T2DM) were demonstrated to have increased cardiovascular disease risk. Fetuin-A (FETUA) levels are associated with insulin resistance, impaired glucose tolerance, hepatosteatosis, subclinical inflammation and increased cardiovascular risk. Apolipoprotein (apo) B/Apo A1 ratio is a well-defined cardiovascular risk assessment marker. In this study, we aimed to investigate the potential role of FETUA in demonstrating cardiovascular disease risk in young adults with type 2 diabetes.

Material and methods: We performed a prospective study on 18 controls, 18 diabetic and 19 prediabetic patients (age 20-40 years). History, physical examination and anthropometric measurements were done for each subject. Fasting serum samples were obtained from all subjects and glucose, insulin, FETUA, LDL, triglyceride, HDL, VLDL, apoB, apoA1, lipo A, HSCRP levels were measured. Serum FETUA levels were determined by ELISA.

Results: FETUA levels were significantly lower in control patients than diabetic and prediabetic patients (33,46±22,10 vs. 51,68±17,10ng/ml, p<0,05 and 33,46±22,10 vs 47,70±10,47ng/ml, p<0,05, respectively). FETUA levels did not differ between diabetic and prediabetic patients (51, 68±17, 10 vs. 47, 70±10, 47ng/ml, p>0, 05). BMI adjusted correlations revealed a positive correlation between FETUA levels and glucose, Apo B levels and Apo B/Apo A1 ratio.

Conclusions: Studies showed that FETUA levels may play a role in the pathophysiology of cardiovascular diseases. In our study, we found a significant increase in FETUA levels in young type 2 diabetic and prediabetic patients. Thus, FETUA may be a useful marker in determining cardiovascular risk of young patients with diabetes or at risk for diabetes.

 

Nothing to Disclose: MK, NE, CC, YA

19590 23.0000 THR-618 A Fetuin- a Levels Predict Cardiovascular Risk in Young Diabetic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Mohammed Abdulrahman Alshehri*1, Khaled Abdullah Alswat2, Sameer R. Alharthi3 and Ahmed A. Alsuwat3
1King Abdulaziz Specialist Hospital, Taif, 2Taif University, School of Medicine, Taif, Saudi Arabia, 3Taif University

 

Background:

The IDF has released an estimates 382 million with T2D in 2013.The T2D is associated with an increased risk of depression with subsequently increased risk of diabetes complications. Few studies assessed the impact of media consumption and metformin (MET) on risk of depression.

Methods:

We conducted a cross-sectional study at the King Abdulaziz Specialist Hospital, Taif, Saudi Arabia. T2D patients (pts) > 18 years who had a routine visit to the Endocrine clinic from Jun 2013 to Aug 2014 were asked to participate. Baseline characteristics and measurement was obtained. Laboratory data was collected from the pts EMR. We excluded pts with T1D, existing psychiatric illness, untreated hypothyroidism and history of active cancer. We used PHQ-9 to screen for depression and Berlin questionnaire to screen for obstructive sleep apnea (OSA). We measured media mass by hours that include watching TV, using computer, video game and using smart devices for fun. The primary goal of this study is to assess the impact of media mass and MET on the risk of depression and OSA and its relation to the cardiovascular (CV) markers in T2D.

Result:

283 pts participated, 134 (47.3%) were male vs 149 (52.7%), mean age 56.8yrs, mean HbA1c 8.54%, mean duration of T2D of 11.17 yrs, mean BMI 31.8 kg/m2,88.3% were married, 18% did college degree or higher, 65.7% were low income, 41% were on OHA only, 52.7% were on insulin +/- OHA, and 3.9 % were on diet control only. Mean media consumption were 3.3 hrs and 25.4% were exercising regularly.

41.3% met the criteria for depression and 49% were at high risk for OSA. 53.7% consume media ≤ 2 hrs vs 46.3% consume it > 2hr/d, with mean age of 57.1yrs vs 56.5yrs (p .66), 42.5% were male vs 53.1% (p .07), mean BMI 31.4 vs 32.3 kg/m2(p.23), 40.5% vs 42.3% were depressed (p .76), and 50.3% vs 49.2% were at high risk of OSA (p .85).

In regards to the CV markers, those who consume it ≤ 2 vs > 2 hrs/day, their mean HbA1c 8.4% vs 8.6% (p .54), SBP 141.7 vs 139.1 mmHg (p .35), DBP 80.4 vs 81.1 mmHg (p .68), resting HR 80.9 vs 82.0 bpm (p .5), LDL 99.1 vs 103.4 mg/dl (p .42), HDL 43.8 vs 41.4 mg/dl (p .26), and triglyceride 145.8 vs 162.2 mg/dl (p .15).

Those who consume media ≤ 2 hrs, 27.5% exercise regularly compare to 23.1% (p .4), 5.9% are active smoker compare to 10.8% (p .75), to those who consume it > 2 hrs/d respectively.

188 (66.4%) pts were on MET, 37.2% of pts on MET compare to 49.5% of those who weren’t met the criteria for depression (OR 0.66, CI 0.37-0.99). After adjustment of age, gender, duration of T2D, income, education, media mass, FHx of depression, BMI and HbA1c, this association remains significant (p 0.046). 46.3% in the MET group vs 56.8% in those who weren’t, considered as high risk for OSA.

Conclusion:

Pts who consume media >2 hrs/d were non-statistically significant at higher risk of depression, poor glycemic control, worse most of the measured CV markers and reports more unhealthy habits .Pts on MET were at lower risk of depression.

 

Nothing to Disclose: MAA, KAA, SRA, AAA

20609 24.0000 THR-619 A Impact of Media Consumption and Metformin on Risk of Depression and Sleep Apnea in Diabetics 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 596-619 5931 1:00:00 PM Diabetes Immunology, Diabetes Complications Poster


Grigorios Rombopoulos1, Elena Panitti1, George S Vernikos*1, Katopodis Panagiotis2 and Skoutas Dimitrios3
1Novartis Hellas S.A., Athens, Greece, 2Peristeri Clinic, Athens, Greece, 3Sarafianos Lysimachos General Clinic of Thessaloniki, Thessaloniki, Greece

 

Introduction: Management of type 2 diabetes mellitus (T2DM) poses unique challenges in the rapidly growing elderly patient population due to age-related morbidity and mortality. There is limited real world evidence on DPP-4 inhibitors in elderly T2DM patients in Greece. This study evaluates the effectiveness and tolerability of vildagliptin in addition to metformin in elderly patients with T2DM in Greece.

Methods:This was a multicenter observational study with duration of 12-14 weeks. Data recording was completed in two visits (Day 1, Week 12-14/end of study). Patients aged ≥70 years with a diagnosis of T2DM who have, within the previous 2 weeks, been prescribed vildagliptin as add on to metformin therapy or sulfonylurea on top of metformin monotherapy, or T2DM patients inadequately controlled HbA1c ≥7.0% and ≤9.0% on stable doses of metformin monotherapy for at least 3 months prior to entering the study, were recruited. The primary endpoint was change in HbA1c from baseline after 12 weeks of treatment with vildagliptin in addition to metformin or vildagliptin plus metformin single pill combination. Secondary assessments included proportion of patients reaching the glycemic target of HbA1c ≤7.0% and ≤6.5%, change in fasting plasma glucose (FPG) and body mass index (BMI), safety and tolerability, estimation of the incidence rate of confirmed hypoglycemic events and description of the demographic characteristics of the patient population. To assess the incidence rate of confirmed hypoglycemic events, a descriptive control arm of patients who recently initiated sulfonylurea on metformin monotherapy was also exploited.

Results: Of the total of 336 patients at study entry, 50.3% of patients were men, mean age (± SD) was 75.9 ± 4.8 years, mean BMI 28.5 ± 4.1 kg/m2, mean baseline HbA1c 7.9 ± 0.5% and mean FPG 167.8 ± 33.1 mg/dl. For the 285 patients receiving vildagliptin and metformin (245 receiving a fixed combination and 40 receiving a free combination), the mean change in HbA1c from baseline to 12 weeks was -0.97% (95% CI -1.04, -0.91), mean change in FPG was -42.8 mg/dl (95% CI -46.4, -39.3) and mean change in BMI was -0.69 kg/m2(95% CI -0.81, -0.57); p<0.0001 in all cases. Overall, 55.6% of patients reached HbA1c ≤7.0% and 20.4% reached HbA1c ≤6.5%. Overall, two patients reported three adverse events namely, lung infection, hyperpyrexia and constipation; according to the investigator these were not related to the drug. Hypoglycemia occurred in 3 (1.2%) patients receiving vildagliptin and metformin.

Conclusions: Vildagliptin in combination with metformin showed improved glycemic control in daily clinical practice in elderly Greek patients with no increased incidence of adverse events.

 

Disclosure: GR: Employee, Novartis Pharmaceuticals. EP: Employee, Novartis Pharmaceuticals. GSV: Employee, Novartis Pharmaceuticals. KP: Principal Investigator, Novartis Pharmaceuticals. SD: Principal Investigator, Novartis Pharmaceuticals.

19159 1.0000 THR-640 A Effectiveness and Safety of Vildagliptin in Addition to Metformin in Elderly (>=70 years) Greek Patients - the Esteem Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Byung-Wan Lee1, Jae Hyeon Kim2, Se Eun Park3, Chang Hee Jung4, Seung-Hwan Lee5, Sunghwan Suh6, Woo Je Lee4, Younghwan Jang7, Sung-Ho Kim7 and Cheol-Young Park*3
1Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South), 3Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South), 4Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South), 5Seoul St. Mary’s Hospital, The Catholic University of Korea School of Medicine, Seoul, Korea, Republic of (South), 6Dong-A University Medical Center, Seoul, Korea, Republic of (South), 7LG Life Sciences, Seoul, Korea, Republic of (South)

 

Background and aims: Glycemic variability and chronic sustained hyperglycemia are the main components of dysglycemia in diabetes. The purpose of this study was to assess whether there is a difference between- or within drug classes on glycemic variability and glucose control as initial combination therapy with metformin in drug-naive patients with type 2 diabetes.

Materials and methods: A multi-center, randomized, active controlled, open-label, parallel design study was performed in 69 patients with HbA1c greater than 7.5%. Subjects were randomized (1:1:1) to receive gemigliptin 50 mg qd, sitagliptin 100 mg qd, or glimepiride 2 mg qd for 12 weeks. The mean amplitude of glycemic excursions (MAGE) and standard deviation (SD) were used for assessing glucose fluctuations at baseline and after 12 weeks. Glycosylated hemoglobin (HbA1c), glycated albumin (GA), fructosamine, C-reactive protein and other metabolic parameters were also measured. Safety and tolerability based on adverse events (AEs) were assessed. To strengthen the reliability of the study results, data from continuous glucose monitoring system (CGMS) was evaluated independently by a blinded central evaluator.

Results: A total of 69 subjects were randomized to receive gemigliptin 50 mg (n = 24), sitagliptin 100 mg (n = 23) or glimepiride 2 mg (n = 22). Mean baseline characteristics were similar across the groups (age, 50.0 years; HbA1c, 9.4%; GA, 26.4%; fructosamine, 412.8 mol/L). At 12 weeks, MAGE was significantly lower in the DPP-4 inhibitor groups, gemigliptin and sitagliptin, than in the glimepiride group (-43.1, -38.3, and -21.7 mg/dl, respectively). Furthermore, the SD of mean glucose was significantly lower in patients with gemigliptin (vs sitagliptin p=0.01; vs glimepiride p=0.007) when compared with sitagliptin and glimepiride. Mean HbA1c was reduced from baseline by 2.75%, 2.24% and 2.75% for gemigliptin, sitagliptin and glimepiride, respectively. A similar profile was also observed in other glycemic control parameters (FPG, glycated albumin, and fructosamine). A greater decrease in total- and LDL-cholesterol and nitrotyrosine was observed for DPP-4 inhibitor groups versus glimepiride, although there were no significant differences between the groups. In addition, only gemigliptin significantly decreased C-reactive protein levels from baseline. Drug-related AEs including symptomatic hypoglycemia were reported more frequently in glimepiride group than in other groups.

Conclusion: In summary, gemigliptin was more effective than glimepiride and sitagliptin in reducing glucose variability as initial combination therapy with metformin in drug-naïve patients with T2DM.

 

Disclosure: CYP: Investigator, Merck & Co.. Nothing to Disclose: BWL, JHK, SEP, CHJ, SHL, SS, WJL, YJ, SHK

21425 2.0000 THR-641 A Effects of Gemigliptin Versus Sitagliptin or Glimepiride on Glycemic Variability As Initial Combination Therapy with Metformin in Drug-Naïve Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Andrew J Lewin*1, Ralph DeFronzo2, Sanjay Patel3, Dacheng Liu4, Renee Kaste4, Hans-Juergen Woerle5 and Uli C Broedl5
1National Research Institute, Los Angeles, CA, 2Univ of Texas Hlth Science Ctr, San Antonio, TX, 3Boehringer Ingelheim Ltd., Bracknell, United Kingdom, 4Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, 5Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany

 

A randomized, double-blind, parallel group Phase III study evaluated the efficacy and safety of combinations of empagliflozin/linagliptin (EMPA/LINA) in subjects with type 2 diabetes (T2DM) who were not receiving anti-diabetes therapy for ≥12 weeks. Subjects were randomized to EMPA 25 mg/LINA 5 mg (n=137), EMPA 10 mg/LINA 5 mg (n=136), EMPA 25 mg (n=135), EMPA 10 mg (n=134), or LINA 5 mg (n=135) for 52 weeks. Efficacy was evaluated in 667 subjects (mean [SD] age 54.6 [10.2] years; weight 87.9 [20.1] kg; BMI 31.6 [5.6] kg/m2; HbA1c 8.02% [0.96]). At week 52, adjusted mean (LOCF [SE]) changes from baseline in HbA1c were −1.17% (0.08) with EMPA 25 mg/LINA 5 mg, −1.22% (0.08) with EMPA 10 mg/LINA 5 mg, −1.01% (0.08) with EMPA 25 mg, −0.85% (0.08) with EMPA 10 mg, and −0.51% (0.08) with LINA 5 mg. Compared with LINA 5 mg, HbA1c was significantly reduced with EMPA 25 mg/LINA 5 mg (difference: −0.66% [95% CI: −0.90, −0.43; p<0.0001]) and EMPA 10 mg/LINA 5 mg (difference: −0.71% [95% CI: −0.94, −0.48; p<0.0001]). Compared with EMPA 10 mg, EMPA 10 mg/LINA 5 mg led to significant reductions in HbA1c (difference: −0.37% [95% CI −0.60, −0.14; p=0.0017]). There were no significant differences in HbA1c changes from baseline with EMPA 25 mg/LINA 5 mg vs EMPA 25 mg. In subjects with baseline HbA1c ≥7% the percentages of subjects with HbA1c <7% at week 52 were 50.4% with EMPA 25 mg/LINA 5mg, 50.8% with EMPA 10 mg/LINA 5 mg, 45.8% with EMPA 25 mg, 33.1% with EMPA 10 mg, and 27.6% with LINA 5 mg. Compared with LINA 5 mg, adjusted mean (LOCF) body weight was significantly reduced at week 52 with EMPA 25 mg/LINA 5 mg (difference: −1.7 kg [95% CI: −2.8, −0.7]; p=0.0016) and EMPA 10 mg/LINA 5 mg (difference: −1.3 kg [95% CI: −2.4, −0.2]; p=0.0172). Combinations of EMPA/LINA did not significantly reduce weight vs their respective EMPA monotherapies. Adverse events (AEs) were reported in 75.7%, 72.8%, 68.9%, 81.5% and 71.9% of subjects on EMPA 25 mg/LINA 5 mg, EMPA 10 mg/LINA 5 mg, EMPA 25 mg, EMPA 10 mg and LINA 5 mg, respectively, over 52 weeks. Confirmed hypoglycemic AEs (glucose ≤70 mg/dL and/or requiring assistance) were reported in 1 patient each on EMPA 25 mg and LINA 5 mg and 4 subjects on EMPA 10 mg; none required assistance. AEs consistent with urinary tract infection were reported in 12.5%, 15.4%, 10.4%, 16.3% and 10.4% of subjects on EMPA 25 mg/LINA 5 mg, EMPA 10 mg/LINA 5 mg, EMPA 25 mg, EMPA 10 mg and LINA 5 mg, respectively, and AEs consistent with genital infection were reported in 5.9%, 2.9%, 4.4%, 5.2% and 3.0% of subjects in these groups, respectively. In drug-naïve subjects with T2DM, EMPA 25 mg/LINA 5 mg and EMPA 10 mg/LINA 5 mg for 52 weeks significantly reduced HbA1c vs LINA 5 mg. HbA1c reductions were significant with EMPA 10 mg/LINA 5 mg vs EMPA 10 mg, but not with EMPA 25 mg/LINA 5 mg vs EMPA 25 mg. Combinations of EMPA/LINA were well tolerated, with overall safety profiles similar to those known for the individual components.

 

Disclosure: RD: Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Astra Zeneca, Advisory Group Member, Novo Nordisk, Advisory Group Member, Lexicon Pharmaceuticals, Inc., Advisory Group Member, Bristol-Myers Squibb, Investigator, Jansen Pharmaceuticals, Investigator, Astra Zeneca, Investigator, Boehringer Ingelheim, Investigator, Bristol-Myers Squibb. SP: Employee, Boehringer Ingelheim. DL: Employee, Boehringer Ingelheim. RK: Employee, Boehringer Ingelheim. HJW: Employee, Boehringer Ingelheim. UCB: Employee, Boehringer Ingelheim. Nothing to Disclose: AJL

19873 3.0000 THR-642 A Empagliflozin and Linagliptin As Initial Combination for 52 Weeks in Subjects with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Sanjay Patel*1, Andrew J Lewin2, Ralph DeFronzo3, Dacheng Liu4, Renee Kaste4, Hans-Juergen Woerle5 and Uli C Broedl5
1Boehringer Ingelheim Ltd., Bracknell, United Kingdom, 2National Research Institute, Los Angeles, CA, 3Univ of Texas Hlth Science Ctr, San Antonio, TX, 4Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT, 5Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany

 

A randomized, double-blind, parallel group Phase III study evaluated the efficacy and safety of combinations of empagliflozin/linagliptin (EMPA/LINA) as second-line therapy in subjects with type 2 diabetes (T2DM). Subjects were randomized to EMPA 25 mg/LINA 5 mg (n=137), EMPA 10 mg/LINA 5 mg (n=136), EMPA 25 mg (n=141), EMPA 10 mg (n=140), or LINA 5 mg (n=132) as add-on to stable-dose metformin (MET) for 52 weeks. Efficacy was evaluated in 674 subjects (mean [SD] age 56.2 [10.2] years; weight 86.1 [18.7] kg; BMI 30.9 [5.5] kg/m2; HbA1c 7.97% [0.85]). At week 52, reductions in HbA1c with EMPA/LINA were greater to those with EMPA or LINA alone. At week 52, adjusted mean (LOCF [SE]) changes from baseline in HbA1c were −1.21% (0.07) with EMPA 25 mg/LINA 5 mg, −1.05% (0.07) with EMPA 10 mg/LINA 5 mg, −0.64% (0.07) with EMPA 25 mg, −0.69% (0.07) with EMPA 10 mg and −0.48% (0.07) with LINA 5 mg. Compared with LINA 5 mg at week 52, HbA1c was reduced with EMPA 25 mg/LINA 5 mg (difference: −0.73% [95% CI −0.93, −0.53]; p<0.0001) and EMPA 10 mg/LINA 5 mg (difference: −0.57% [95% CI −0.77, −0.37]; p<0.0001). Compared with EMPA 10 mg, HbA1c was reduced with EMPA 10 mg/LINA 5 mg (difference: −0.36% [95% CI −0.56, −0.17]; p=0.0003). Compared with EMPA 25 mg, HbA1c was reduced with EMPA 25 mg/LINA 5 mg (difference: −0.57% [95% CI −0.77, −0.37]; p<0.0001). In subjects with baseline HbA1c ≥7% the percentages achieving HbA1c <7% at week 52 were 48.0% with EMPA 25 mg/LINA 5 mg, 51.6% with EMPA 10 mg/LINA 5 mg, 32.6% with EMPA 25 mg, 32.0% with EMPA 10 mg, and 28.6% with LINA 5 mg. Compared with LINA 5 mg, adjusted mean (LOCF) body weight was significantly reduced at week 52 with EMPA 25 mg/LINA 5 mg (difference: -2.9 kg [95% CI −3.8, −2.0]; p<0.0001) and EMPA 10 mg/LINA 5 mg (difference: −2.4 kg [95% CI −3.3, −1.5]; p<0.0001). Combinations of EMPA/LINA did not significantly reduce body weight vs their respective EMPA monotherapies. Adverse events (AEs) were reported in 71.5%, 69.1%, 73.0%, 68.6% and 68.9% of subjects on EMPA 25 mg/LINA 5 mg, EMPA 10 mg/LINA 5 mg, EMPA 25 mg, EMPA 10 mg and LINA 5 mg, respectively, over 52 weeks. In these groups, confirmed hypoglycemic AEs (glucose ≤70 mg/dL and/or requiring assistance) were reported in 3.6%, 2.2%, 3.5%, 1.4% and 2.3% of subjects, respectively; none required assistance. AEs consistent with urinary tract infection were reported in 10.2%, 9.6%, 13.5%, 11.4% and 15.2% of subjects on EMPA 25 mg/LINA 5 mg, EMPA 10 mg/LINA 5 mg, EMPA 25 mg, EMPA 10 mg and LINA 5 mg, respectively, and AEs consistent with genital infection were reported in 2.2%, 5.9%, 8.5%, 7.9% and 2.3% of subjects, respectively. As second-line therapy for 52 weeks in subjects with T2DM, EMPA 25 mg/LINA 5 mg and EMPA 10 mg/LINA 5 mg significantly reduced HbA1c compared with their respective monotherapies. Combinations of EMPA/LINA were well tolerated, with overall safety profiles similar to those known for the individual components.

 

Disclosure: SP: Employee, Boehringer Ingelheim. RD: Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Astra Zeneca, Advisory Group Member, Novo Nordisk, Advisory Group Member, Lexicon Pharmaceuticals, Inc., Advisory Group Member, Bristol-Myers Squibb, Investigator, Jansen Pharmaceuticals, Investigator, Astra Zeneca, Investigator, Boehringer Ingelheim, Investigator, Bristol-Myers Squibb. DL: Employee, Boehringer Ingelheim. RK: Employee, Boehringer Ingelheim. HJW: Employee, Boehringer Ingelheim. UCB: Employee, Boehringer Ingelheim. Nothing to Disclose: AJL

21286 4.0000 THR-643 A Combination of Empagliflozin/Linagliptin for 52 Weeks As Add-on to Metformin in Subjects with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Molly Corbett Carr*1, June Ye2 and Jane E Reusch3
1GlaxoSmithKline, King of Prussia, PA, 2GlaxoSmithKline, Research Triangle Park, NC, 3Denver Veterans Administration Medical Center, Denver, CO

 

Background

Type 2 diabetes (T2DM) prevalence increases with age, and ~ 26% of people > 65 have T2DM.[i] Diabetes management in older adults with T2DM can be more difficult due to complex medication regimens needed to treat multiple comorbidities. For this post-hoc analysis, we hypothesized that albiglutide would be efficacious across all age groups.

Methods

In the Phase III program, albiglutide was evaluated in 1391 patients included in the pooled population of placebo (PBO) comparator studies (analyses funded by GSK): 923 patients in the albiglutide group and 468 in the PBO group. Pooled studies included patients treated with albiglutide or PBO monotherapy or in combination with metformin, thiazolidinediones or SUs (Harmony studies 1, 2, 3 and 5).The primary efficacy endpoint of the studies varied between 1 and 2 years, but the pooled efficacy analyses presented here represent data after 6 months of treatment. Demographics and baseline characteristics were representative of patients with T2DM and were, in general, well-balanced between the albiglutide and PBO groups. Treatment effects were assessed across 3 age categories (<65 years, ≥65 to <75 years, and ≥75 years). The number of elderly subjects was well represented (15% were ≥65 to <75 years of age, and 1.4% were aged ≥75), median duration of T2DM was 5.5 years, and approximately 68% had some degree of renal impairment (eGFR <90).

Results

In patients < 65 years old, change from baseline in HbA1c was -0.85% ± 0.85 in the albiglutide group (n = 757) and +0.01% ± 1.0 in the PBO group (n = 383); treatment difference = -0.87 (95%CI -0.98,-0.77). In patients ≥65 to < 75 years, change from baseline in HbA1c was -0.72 ± 0.68% in the albiglutide group (n = 136) and
-0.21 ± 0.79% in the PBO group (n = 68); treatment difference of -0.50% (95%CI -0.75,-0.26).  Although there were small numbers of patients aged ≥75 years (n = 19), HbA1c reduction was consistent with younger subgroups: change from baseline = -0.94 ± 0.68% in the albiglutide group (n = 11) and +0.06 ± 0.4% in the PBO group (n = 8) with a treatment difference of -0.97% (95%CI -1.73,-0.2). The incidence of on-therapy SAEs differed among age categories (<65, ≥65 to <75, ≥75 years) for both the albiglutide (10.5%, 14.4%, and 8.3% for the ascending age groups) and placebo (11.8%, 21.4%, and 37.5%) groups. Incidence of on-therapy AEs differed among the age categories for both the albiglutide (85%, 89%, and 75% for the ascending age groups) and placebo (82%, 83%, and 100%) groups.  

Conclusions

Efficacy and safety variables were assessed with albiglutide therapy across 3 age categories, and there were few subjects in the ≥75 year category, which limited interpretation of the data in this subgroup. The efficacy and safety profile of once weekly albiglutide was generally consistent across all age groups.

 

Disclosure: MCC: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. JY: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. JER: Advisory Group Member, GlaxoSmithKline, Researcher, BMS, Merck, Astra‐Zeneca;, Researcher, VA Merit, Denver Research Institute, ADA, CVP T32 (5 T32 HL7171‐35), CVP HL‐14985, CCTSI (UL1RR025780), and the Center for Women's Health Research).

21332 5.0000 THR-644 A Positive Treatment Effect of Once Weekly Albiglutide Across All Age Subgroups 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Susan Johnson*1, Michelle A Anderson2, Robert Enns3, Jason M Mallory4, Margaret Sowell5, Tim Wilson1 and Firas H AL-Kawas6
1GlaxoSmithKline, Research Triangle Park, NC, 2University of Michigan Hospital and Health Systems, MI, 3Pacific Gastroenterology Associates; St Paul's Hospital, Canada, 4GlaxoSmithKline, King of Prussia, PA, 5GlaxoSmithKline, Collegeville, PA, 6Johns Hopkins University; Sibley Memorial Hospital, Washington, DC

 

GLP-1 receptor agonists (GLP-1Ra) and DPP-IV inhibitors have been associated with acute pancreatitis (AP). Although the nature of the association remains unclear, labels for these agents contain precautions regarding pancreatitis.

Albiglutide (albi) is a once-weekly GLP-1Ra approved to improve glycemic control in adults with T2DM. The Phase 3 (P3) development program included 8 clinical studies evaluating the efficacy and safety of albi in a broad spectrum of patients with T2DM. The comparators included placebo (pbo) and/or active comparators (SU, TZDs, DPP-IV inhibitors, insulin or another GLP-1R agonist).  

To prospectively adjudicate suspected AP events, the sponsor (GSK) established an independent, blinded pancreatitis adjudication committee (PAC), comprised of 3 external gastroenterologists. Cases of potential pancreatitis were identified using a broad search strategy that encompassed investigator reported AEs of pancreatitis, other potentially associated AEs, and abnormal amylase and lipase values (³3 × ULN) which were routinely collected in one study.  

Classification by the PAC as definite/probable pancreatitis was consistent with clinical practice guidelines for the diagnosis of acute pancreatitis, requiring at least 2 of the following features: 1) characteristic abdominal pain, 2) serum lipase >3X ULN and/or amylase >5X ULN, and 3) characteristic findings on imaging (e.g., positive CT, MRI, or US). The PAC also assessed the relationship to study treatment considering available relevant information.

The P3 program enrolled 2365 patients on albi (4263.8 person-years [PY] of exposure; mean exposure 86.1 weeks) and 2530 treated with active or pbo comparators (4605.4 PY of exposure; mean exposure 87.0 weeks).

Across the program, the PAC adjudicated events in 11 patients treated with albi and 10 patients treated with pbo or active comparators.  In addition, there were 14 patients on albi and 9 patients on comparators with post‑randomization lipase values ³3 × ULN. Among these 44 total patients, the incidence of AP was 1.4 cases per 1000 PY in albi (6/2365 patients [0.3%]) and 0.4 cases per 1000 PY in comparator treated patients (0/468 patients on pbo and 2/2062 patients on active comparators [0.1%]); Chi-square p=0.15. The 2 active comparator cases were in patients treated with a GLP-1Ra.  For this analysis, cases of AP were those adjudicated as definite or probable pancreatitis at least possibly attributed to study drug.

In conclusion, in the albi P3 program, adjudicated cases of AP were uncommon.  The frequency of pancreatitis was higher among patients treated with albi compared to pbo and active comparators.  Of note, both cases in the active comparator group adjudicated as AP were in patients treated with a GLP-1Ra.  Within the limitations of available data, the incidence rate for AP with albi appears to be in the range described for other GLP-1Ra.

 

Disclosure: SJ: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. MAA: Consultant, GlaxoSmithKline. RE: Consultant, GlaxoSmithKline, Consultant, Jansen Pharmaceuticals. JMM: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. MS: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. TW: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. FHA: Consultant, GlaxoSmithKline.

20501 6.0000 THR-645 A Incidence of Adjudicated Acute Pancreatitis Across the Albiglutide Phase 3 Clinical Program 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Leticia Ferri* and Elise Hardy
AstraZeneca, Wilmington, DE

 

Multiple clinical studies have investigated the glucagon-like peptide-1 receptor agonist (GLP-1RA) exenatide once weekly (QW), a novel microsphere-based therapy, in patients with T2DM. In this analysis, we summarize the efficacy and safety of exenatide QW across 8 comparator-controlled, phase 3, 24–30-week clinical studies including 6 trials from the DURATION clinical program and 2 trials in solely Asian populations (1-8). Patients received exenatide QW as monotherapy or with oral antidiabetic drugs. Efficacy data were summarized while safety data were pooled across all trials. In total, 1934 patients received exenatide QW 2.0 mg; 2396 patients received comparators (non-GLP-1RAs [metformin, sitagliptin, pioglitazone, insulin glargine; n=1338]), exenatide twice daily (BID), or liraglutide. The mean age of patients was 53–58 y, and 52–68% were male. Mean duration of diabetes was 5.7–9.0 y, except in one  study in treatment-naïve patients (mean: 2.7 y). Exenatide QW reduced A1c in 7 of 8 trials with patients on stable background therapy (mean change from baseline: −1.3% to −1.9%); proportions of patients achieving A1c ≤7.0% ranged from 42–73%. Exenatide QW resulted in fasting glucose reductions ranging from −25 mg/dL to −47 mg/dL and mean body weight reductions  from −2.3 kg to −3.7 kg in 6 non-Asian studies and −1.6 kg and −1.7 kg in 2 Asian studies. Efficacy has been observed in all patient subpopulations (eg, by age, sex, baseline A1c, baseline BMI, renal function, exenatide antibody status) and therapy combinations studied to date. Overall, 71.5% of patients treated with exenatide QW experienced ≥1 treatment-emergent adverse event (AE), 4.4% discontinued due to AEs, and 3.2% had ≥1 serious AE. In patients receiving a non-GLP-1RA , 65.8% experienced ≥1 treatment-emergent AE, 2.4% discontinued due to AEs, and 4.5% had ≥1 serious AE. The most common AEs with exenatide QW were gastrointestinal issues (34.6%), which subsided over time. Nausea, diarrhea, and vomiting occurred in 14.4%, 10.5%, and 6.7% of exenatide QW patients, respectively. Minor hypoglycemia was more frequent when exenatide QW was taken with sulfonylureas (SU) than without SU (12.9% vs 2.0%). Major hypoglycemia was experienced by one patient treated with exenatide QW (without SU), one treated with exenatide BID (with SU), and two treated with insulin glargine (one with SU and one without SU). Exposure-adjusted incidence per 100 patient-years calculated for AEs of renal failure-related AEs, thyroid neoplasms, and pancreatitis, was 0.1, 0.2, and 0.5 with exenatide QW, respectively, and 0.3, 0.5, and 0.5 with non-GLP-1RA comparators, respectively. No cases of pancreatic cancer, thyroid cancer, or medullary c-cell carcinoma were reported. In conclusion, 8 studies show consistent efficacy for exenatide QW with A1c reductions of 1.3%–1.9% in patients with T2DM with no new or unexpected safety findings in the integrated population.

 

Disclosure: LF: Consultant, Astra Zeneca. EH: Employee, Astra Zeneca, Employee, Astra Zeneca.

20066 7.0000 THR-646 A Clinical Trial Results for Exenatide Once Weekly: Summary of Efficacy and Safety Data from Eight Randomized Trials of 4330 Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Carol H Wysham*1, Denise Vieke2, Marion Vetter3, Yaohua He3, Nayyar Iqbal3, Elise Hardy4, Anna Ryden5 and Julio Rosenstock6
1University of Washington, 2Mercury Street Medical, Butte, MT, 3Bristol-Myers Squibb, Princeton, NJ, 4AstraZeneca, Wilmington, DE, 5AstraZeneca, Gothenburg, Sweden, 6Dallas Diabetes and Endocrine Center, TX

 

Once-weekly (QW) exenatide reduces A1C and body weight in patients with T2DM, but the original QW microsphere aqueous solution formulation requires reconstitution. A QW formulation containing exenatide dispersed in microspheres suspended in a triglyceride carrier was developed to eliminate the need for reconstitution and allow delivery via an autoinjector pen to facilitate patient education, administration, and acceptance. In the open-label DURATION-NEO-1 study, patients with inadequately controlled T2DM on diet/exercise or oral medications (metformin, sulfonylurea and/or pioglitazone) were randomized (3:2 ratio) to EQW-SAI 2 mg (n=229) or EBID 10 mcg (n=148). The primary endpoint was change from baseline in A1C at Week 28. Secondary outcomes included change from baseline in patient-reported treatment satisfaction and health-related quality of life (HRQoL) at Week 28 (exploratory analysis; nominal P-values). The Diabetes Treatment Satisfaction Questionnaire status version (DTSQs) evaluates treatment satisfaction and perceived frequencies of hyper- and hypoglycemia. Each of the 8 items is scored from 0-6, with higher scores representing greater satisfaction, except for frequency of hyper- and hypoglycemia (which do not contribute to total score [range 0-36]). The Impact of Weight on Quality of Life-Lite version (IWQOL-Lite; validated in T2DM) assesses 5 domains (physical function, self-esteem, sexual life, public distress, and work). Scores range from 0 (worst) to 100 (best). The EQW-SAI group vs the EBID group had a greater least-squares (LS) mean reduction in A1C (–1.39% vs –1.02%; P=0.007) and similar body weight reduction (–1.49 vs –1.89 kg; P=NS) at Week 28. The EQW-SAI group had significantly greater LS mean improvement than the EBID group on the DTSQs total score (+4.8 vs +2.9; P=0.002; mean score Week 28, 32.2 vs 30.2); notably, improvements in item scores for treatment convenience (+0.7 vs +0.3; P=0.002) and flexibility (+0.8 vs +0.2; P=0.0002) were greater with EQW-SAI. Scores for satisfaction with current treatment, understanding of diabetes, continuing treatment, and perceived frequencies of hyper- and hypoglycemia also improved more with EQW-SAI (all P<0.05 vs EBID). Both groups reported improvements on some IWQOL-Lite domains, with no significant between-group differences. Thus, EQW-SAI and EBID both improved patient-reported treatment satisfaction, but the simplified administration of EQW-SAI was associated with greater improvement in treatment satisfaction (including satisfaction with flexibility and convenience), potentially improving treatment acceptance, adherence and compliance.

 

Disclosure: CHW: Consultant, Boehringer Ingelheim Pharmaceuticals, Speaker, Boehringer Ingelheim Pharmaceuticals, Speaker, Jansen Pharmaceuticals, Consultant, Jansen Pharmaceuticals, Speaker, Lilly USA, LLC, Speaker, Novo Nordisk, Consultant, Sanofi, Speaker, Sanofi, Speaker, Astra Zeneca. MV: Employee, Bristol-Myers Squibb. YH: Employee, Bristol-Myers Squibb. NI: Employee, Bristol-Myers Squibb. EH: Employee, Astra Zeneca, Employee, Astra Zeneca. AR: Employee, Astra Zeneca. JR: Advisory Group Member, Sanofi, Advisory Group Member, Novo Nordisk, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, GlaxoSmithKline, Advisory Group Member, Merck & Co., Advisory Group Member, Daiichi Sankyo, Advisory Group Member, Takeda, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, MannKind, Advisory Group Member, Halozyme, Advisory Group Member, Intarcia , Advisory Group Member, Lexicon Pharmaceuticals, Inc., Investigator, Merck & Co., Investigator, Pfizer, Inc., Investigator, Sanofi, Investigator, Novo Nordisk, Investigator, Roche Pharmaceuticals, Investigator, Bristol-Myers Squibb, Investigator, Eli Lilly & Company, Investigator, GlaxoSmithKline, Investigator, Takeda, Investigator, Novartis Pharmaceuticals, Investigator, Astra Zeneca, Investigator, Amylin Pharmaceuticals, Investigator, Jansen Pharmaceuticals, Investigator, Daiichi Sankyo, Investigator, MannKind, Investigator, Boehringer Ingelheim, Investigator, Intarcia . Nothing to Disclose: DV

19324 8.0000 THR-647 A Patient-Reported Treatment Satisfaction with Exenatide Once Weekly Suspension for Autoinjection (EQW-SAI) Vs Exenatide Twice Daily (EBID) in Patients with Inadequately Controlled Type 2 Diabetes Mellitus (T2DM) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Maria Batool*1, Sarah Bellefeuille2, Melissa Atwood2, Thomas S Rector3 and Nacide G Ercan-Fang1
1University of Minnesota Medical Center, Minneapolis, MN, 2Minneapolis VA Health Care System, 3Minneapolis VA Health Care System, Minneapolis, MN

 

Background:

Exenatide is a glucagon-like peptide (GLP-1) receptor agonist approved for use in type 2 diabetes (T2DM) regardless of insulin use.  The purpose of this study was to evaluate whether concurrent insulin treatment affects weight, glycemic control and insulin dose in patients treated with exenatide (EXE+INS)  compared to patients on exenatide only (EXE).

Hypothesis:

Patients treated with both exenatide and insulin (EXE+INS) have less improvement in their glycemic control and lose less weight compared to patients using exenatide without insulin (EXE).

Methods:

Minneapolis Veterans Affairs Health Care System  electronic medical records reviewed from 2006 identified 154 eligible patients (Hemoglobin A1c (A1C) >9%, body mass index >35), prescribed exenatide either with (n= 83) or without (n=71) insulin. A1c, weight, basal and bolus insulin doses were collected at the beginning and end of exenatide treatment or the most recent follow up. Changes in A1c and weight in each group were compared by linear regression adjusting for influential baseline characteristics. 

Results:

Patients were mostly white (91%) males (97%). Mean age was 62 (±8) years. They were treated with EXE for a median (interquartile range) of 69 (27- 157) weeks. At baseline, the mean A1c was 9.7±1.7% and 9.5±2.3 % in the EXE+INS and EXE groups, respectively. Mean (95% confidence interval) A1C changes at the end of treatment were -0.7% (-0.2 to -1.1) and -1.3% (-0.7 to -1.8) for EXE+INS and EXE groups, respectively. Adjusting for age, baseline A1c  and duration of exenatide therapy, the decrease in mean A1c in the EXE+INS group was significantly less by 0.8% (0.2 to 1.4; p = 0.005) than the decrease in the EXE group. In the EXE+INS group, a 10 unit increase in the total daily insulin dose was associated with a 0.05% (0.01 to 0.1; p=0.01) smaller decrease in A1c.

At baseline, the mean weight was 299±50 lbs (EXE+INS) and 262±52 lbs (EXE). Mean changes in weights were -12 lbs (-7 to -17) and -10 lbs (-6 to -15) for EXE+INS and EXE groups, respectively. Adjusting for baseline weight, duration of exenatide therapy, use of weight altering medications and participation in an intensive VA weight management program , the weight loss in the EXE+INS group was less, 6.0 lbs (-0.9 to 13; p = 0.09) but not statistically significant. In the EXE+INS group, a 10 unit increase in the total daily insulin dose was not associated with less weight loss.

At baseline, the median total daily insulin dose was 114 (60 to 195) units. The median change was 0 (-32 to 40) units during exenatide treatment. The basal and bolus doses of insulin did not change significantly either.

Conclusion:

In patients with T2DM, exenatide was associated with improved glycemic control and weight loss regardless of insulin use. However, the glycemic response was attenuated as the dose of insulin increased.  Surprisingly, increasing doses of insulin did not affect ongoing weight loss.


 

Nothing to Disclose: MB, SB, MA, TSR, NGE

18947 9.0000 THR-648 A Effect of Insulin on Changes in Glycemic Control and Body Weight during Treatment with Exenatide in Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Sophia Y Ali*1, Aditya Mehta2, Nitesh D Kuhadiya2, Husam Ghanim3, Antoine Makdissi3, Manav Batra4, Jeanne Hejna5, Ajay Chaudhuri2 and Paresh Dandona2
1Wayne State University, Dearborn, MI, 2Diabetes and Endocrinology Center of Western New York, Buffalo, NY, 3State University of New York at Buffalo, Buffalo, NY, 4University at Buffalo, Buffalo, NY, 5Suny at Buffalo

 

Title:  Reversal of Effects of Liraglutide As Additional Treatment to Insulin in Patients With Type 1 Diabetes After Cessation of Therapy

Abstract Body:

Objective

In the first prospectively randomized study, we have recently demonstrated that addition of 1.2mg and 1.8mg of liraglutide to insulin in patients with type 1 diabetes, significantly reduced HbA1c, mean blood glucose, insulin dose, body weight, carbohydrate intake, systolic BP and CRP over a period of 12 weeks; it also improved quality of life significantly. We have now conducted this study to demonstrate the reversal of effects of liraglutide after its discontinuation. 

Methods

Out of 72 patients randomized in this 12 weeks study, 30 patients (liraglutide group =20 and placebo=10) were followed up at 12±1 weeks after completing the study and discontinuing liraglutide.  These thirty patients (placebo=10; liraglutide = 20) with T1D for at least one year, on insulin therapy and with no detectable c-peptide in plasma (mean BMI: 30±1; mean body weight: 195±8 lbs; mean HbA1c: 7.66±0.11%; mean age: 50±2 years; mean age of T1D diagnosis: 23±2 years; 18 GAD positive, 13 GAD negative, 16 males, 14 females, 29 Caucasians, 1 African American) were randomized to receiving placebo(n=10), 0.6mg(n=8), 1.2mg(n=7) and 1.8mg(n=5) of liraglutide daily for 12 weeks. All patients in liraglutide group have been combined for the purpose of this analysis.

Results

In liraglutide group HbA1c that fell by 0.42% from 7.58±0.14% to 7.16±0.14% (p=0.004) rose by 0.63% to 7.79±0.22% (p=0.003, p=0.06 vs placebo). The average total insulin dose had fallen by 8.54 units from 62.39±4.21 to 53.85±4.69 (p=0.01), which then increased by 7.16 units to 61.01±4.42 (p=0.003,p=0.03 vs placebo). The body weight which fell by 10 lbs from 194±8 to 184±7.91 (p<0.0001) went up by 7 lbs to 191±8 (p=0.001, p=0.01 vs placebo). The daily carbohydrate intake which was reduced by 33 grams from 167±16g to 134±15g (p=0.006) went up by 21 grams to 155±13g (p=0.08). The systolic blood pressure (SBP) which was reduced by 10 mmHg from 125±2.88 to 115±3.54mmHg (p=0.0003) went up by 9mmHg to 124±2.8mmHg (p=0.07). In 1.8 mg group, SBP which had fallen by 20 mmHg from 123±5 to 103±6 (p=0.016) went up by 21 mmHg to 124±4 (0.004). There was no change in any of these indices in the placebo group.

Conclusion

Our data demonstrate the near total reversal of the effects of liraglutide on glycemia, body weight, carbohydrate intake and systolic blood pressure in patients with type 1 diabetes three months after cessation of liraglutide therapy. Thus, while the addition of liraglutide therapy benefits these patients dramatically, it needs to be continued in order to maintain its benefits. These findings have important implications for future treatments of patients with type 1 diabetes.

 

Nothing to Disclose: SYA, AM, NDK, HG, AM, MB, JH, AC, PD

21975 10.0000 THR-649 A Reversal of Effects of Liraglutide As Additional Treatment to Insulin in Patients with Type 1 Diabetes after Cessation of Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Alaaeldin Bashier1, Azza Abdulaziz Bin Hussain*2, Elamin Abdelgadir2, Ahmed Altinay2, Puja Murli Thadani3, Fatheya Fardallah Alawadi4 and Salah Abusnana5
1Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates, 2Dubai Hospital, Dubai Health Authority, 3Dubai Hospital, Mumbai, 4Dubai Hospital, Dubai Health Authority, Ash Shariqah, United Arab Emirates, 5Rcdr Centre. Ajman, UAE.

 

Background: The pathophysiology of type2 diabetes differs between different ethnic groups, with Asians developing type2 diabetes at younger age, at lower body mass index, and in relatively short time. Not only that, some ethnicities has different responses and dosing regimens to different classes of anti-diabetic agents. Data from Japanese population showed that the optimal doses used are smaller than other population and that weight loss is not as effective as seen in Caucasians. Objective: we aimed to assess liraglutide efficacy in reducing weight and HbA1c in Arab population when used as add on to other anti-diabetic agents. Methodology: we prospectively followed patients who were recruited to treatment with liraglutide for a six months period, at the start of the study we checked patients demographics, weight, BP, fasting blood glucose, HbA1c, lipid panel, LFTs and creatinine. Patients were checked at 3 months and at the end of the study at 6 months. Results: mean weight was 96.01±19.2; after 3 months of starting Liraglutide the mean weight reduction was highly significant (94.8±20 with (P< 0.001)). At 6 months the mean weight was 94.5±19 with (p<0.001). Mean HbA1c at baseline was 8.3±1.7 dropped to 7.7±1.4 (p<0.001), and 7.6+1.6  (p<0.001) at 3 and 6 months respectively. Conclusion: Liraglutide is effective in reducing weight and HbA1c as well as other metabolic parameters in Arab population with type2 diabetes.

 

Nothing to Disclose: AB, AAB, EA, AA, PMT, FFA, SA

19564 11.0000 THR-650 A Liraglutide Effect in Reducing Hba1c and Weight in Arab Population with Type2 Diabetes, a Prospective Observational Trial. Short Title: Lead-Arab Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Kristine Santos de Luna*1, Erick Sta. Rosa Mendoza2 and Leilani Basa Mercado-Asis2
1University of Santo Tomas Hospital, Manila, Philippines, 2University of Santo Tomas, Manila City, Philippines

 

INTRODUCTION
Liraglutide, a glucagon-like peptide 1 agonist, stimulates insulin and suppresses glucagon secretion producing significant reductions in blood glucose and beneficial effects on blood pressure. This drug is used in combination with other anti-diabetic medications or as monotherapy because of its low risk for hypoglycemia and moderate weight loss. In a developing country like the Philippines, this efficacy may be limited by its cost leading to noncompliance and treatment failure. 

METHODOLOGY
This is a observational study of patients with type 2 diabetes mellitus who were on liraglutide for 12 months. Weight, body mass index (BMI), blood pressure (BP) and glycosylated hemoglobin (HbA1C) were the primary parameters determining the efficacy of the drug. The measurements were obtained at baseline and at follow-up after 3, 6 and 12 months. Descriptive statistics and measures of proportions were used in the analysis.

RESULTS
A total of 16 patients on liraglutide were included in the study. The age range was 43 to 72 years (6 males and 6 females). The mean duration of diabetes was 8.4 years. Seven patients were on insulin and all were taking one or more oral anti-diabetic drugs. The baseline weight, BMI, BP and HbA1C were 85.0 kg (74.5 to 95.0), 34.8 kg/m2 (28.3 to 49.3) 128/72 mm Hg (110 to160/66 to 83) and 7.6% (5.2 to13.0), respectively. The reduction from baseline in weight (14% at 3 moths and 57% at 6 months) and BMI (21% at 3 months and 69% at 6 months) were sustained. A sustained reduction in HbA1C from baseline was also observed (19% and 52% at 3 and 6 months, respectively). There was also a modest decrease in blood pressure. However, a rebound increase at 12 months in weight (85.1 kg), BMI (32.1 kg/m2), BP (137/81 mm Hg) and HbA1C (7.15%) comparable to baseline levels was observed. The main reason for the deterioration among these parameters were poor compliance (n=11) or discontinuation (n=5) of the drug because of the cost.

CONCLUSION
Liraglutide is an attractive armamentarium for glucose control among diabetic patients with added weight loss and favorable blood pressure control. However, the sustainability of efficacy is limited by cost especially in a developing country. Compliance may be improved by emphasis on its benefits outweighing the cost of hospitalization for possible future complications.

 

Nothing to Disclose: KSD, ESRM, LBM

21654 12.0000 THR-651 A Sustainability of Weight Loss and Glycemic Control with Liraglutide Is Limited By Cost and Compliance in a Developing Country: A One-Year Observational Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Bruno Guerci*1, David A D'Alessio2, Carol H Wysham3, Nan Jia4 and Fady T Botros5
1Hôpital Brabois Adultes, 2Duke University, Durham, NC, 3Rockwood Center for Diabetes and Endocrinology, Spokane, WA, 4Lilly USA, LLC, Indianapolis, IN, 5Eli Lilly and Company

 

Dulaglutide (DU) is a once weekly glucagon-like peptide-1 (GLP-1) receptor agonist that has been recently approved by the US Food and Drug Administration for the treatment of type 2 diabetes. Glycemic efficacy of DU has been demonstrated in six Phase 3 studies. The objective of this analysis is to determine major baseline factors that are associated with the reduction in glycosylated hemoglobin A1c (A1C) in response to treatment with DU and to evaluate the role of baseline glycemic factors.

DU patient (pt) covariates from across the 6 DU Phase 3 clinical trials were analyzed using gradient boosting analysis to assess their relative contribution to the change in A1C at 26 weeks of treatment. Glycemic variables which had the greatest amount of influence on A1C change were further evaluated in univariate and multivariate modeling to assess the magnitude and direction of impact. Analyzed baseline factors included age, race, ethnicity, gender, duration of diabetes, serum glucose measures, fasting serum C-peptide and insulin (FSI), weight, BMI, cardiovascular disease history, estimated glomerular filtration rate (eGFR), and albuminuria.

This analysis included 2806 DU treated pt with mean age 56.3 ± 9.8 years, duration of diabetes 7.8 ± 6.0 years, baseline A1C 8.0 ± 1.0%, BMI 32.4 ± 5.2 kg/m2, eGFR 89.5 ± 16.9 mL/min/1.73m2. Based on gradient boosting, the top 5 baseline factors associated with reduction in A1C (and their relative influence) are baseline A1C (48.8%), age (9.1%), fasting serum glucose (FSG) (8.2%), FSI (6.7%), and eGFR (5.4%). The role of baseline glycemic factors (A1C, FSG, FSI) was evaluated. Univariate regression demonstrated that higher baseline A1C and FSG values and lower FSI values were associated with greater reduction in A1C (coefficient estimates of A1C change: -0.598%, -0.101%, and 0.002%, respectively, p<0.0001 for all). Multivariate regression showed similar results for baseline A1C (-0.594 ± 0.027%) and FSI (-0.197 ± 0.045% for FSI ≤55 pmol/L), but greater baseline FSG was associated with smaller decrease in A1C when adjusted for the other 4 factors (0.047 ± 0.010%, p<0.0001). Subgroup analysis by baseline A1C confirmed that higher FSG is associated with smaller decreases in A1C within a subgroup of pts with comparable baseline A1C. 

In conclusion, these data indicate that baseline factors associated with poorer glycemic status (higher A1C and lower FSI) are associated with greater reduction in A1C in response to treatment with DU.

 

Disclosure: BG: Consultant, Abbott Laboratories, Consultant, Menarini Diagnostic, Consultant, Medtronic Minimed, Consultant, Roche Diagnostics, Consultant, MSD, Consultant, Pfizer, Inc., Consultant, Metacure, Consultant, Intarcia, Consultant, Jansen Pharmaceuticals, Consultant, Boehringer-Ingelheim, Consultant, Eli Lilly & Company, Consultant, Novo Nordisk, Consultant, Novartis Pharmaceuticals, Consultant, GlaxoSmithKline, Consultant, Sanofi, Consultant, Bristol-Myers Squibb, Consultant, Vitalaire, Consultant, Dinno Sante, Consultant, Orkyn. DAD: Consultant, Intarcia, Consultant, Boehringer-Ingelheim , Consultant, Jansen Pharmaceuticals, Consultant, Eli Lilly & Company, Consultant, Merck & Co., Consultant, Novo Nordisk. CHW: Consultant, Astra Zeneca, Consultant, Boehringer-Ingelheim, Consultant, Eli Lilly & Company, Consultant, Jansen Pharmaceuticals, Consultant, Novo Nordisk, Consultant, Sanofi, Investigator, Intarcia , Investigator, Merck & Co.. NJ: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. FTB: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company.

19892 13.0000 THR-652 A Baseline Glycemic Factors Are Associated with the Glycemic Response to Treatment with Once Weekly Dulaglutide in Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Jaime A Davidson*1, Guntram Schernthaner2, Laura Hieronymus3, Holly Jodon4, Ujjwala Vijapurkar5, Gary Meininger5 and William Canovatchel5
1Touchstone Diabetes Center, The University of Texas Southwestern Medical Center, Dallas, TX, 2Rudolfstiftung Hospital-Vienna, Vienna, Austria, 3DiabetesCare and Communications, Lexington, KY, 4Metabolic Disease Associates, Erie, PA, 5Janssen Research & Development, LLC, Raritan, NJ

 

Many patients with type 2 diabetes mellitus (T2DM) are obese or overweight, so treatments that improve glycemic control and reduce body weight may be beneficial.  Canagliflozin (CANA), a sodium glucose co-transporter 2 (SGLT2) inhibitor approved for the treatment of T2DM, inhibits renal glucose reabsorption by lowering the renal threshold for glucose (RTG) and increasing urinary glucose excretion (UGE), resulting in lowered plasma glucose levels and a net caloric loss.  CANA has been shown to provide reductions in A1C and body weight compared with sitagliptin (SITA) in patients with T2DM inadequately controlled on metformin (MET) or MET plus sulfonylurea (SU; CANA 300 mg only) in two 52-week, randomized, double-blind, active-controlled, Phase 3 studies.  This analysis evaluated the proportion of patients who responded to treatment in terms of both A1C and body weight.  In Study 1 (N = 1,284; mean baseline A1C, 7.9%; body weight, 87.2 kg), least squares (LS) mean changes from baseline in A1C at Week 52 were –0.73%, –0.88%, and –0.73% with CANA 100 and 300 mg and SITA 100 mg, respectively; LS mean percent changes in body weight were –3.8%, –4.2%, and –1.3%, respectively.  In Study 2 (N = 755; mean baseline A1C, 8.1%; body weight, 88.3 kg), LS mean changes from baseline in A1C were –1.03% and –0.66% at Week 52, and LS mean percent changes in body weight were –2.5% and 0.3% with CANA 300 mg and SITA 100 mg, respectively.  In Study 1, the proportion of patients with reductions in A1C were 77.8%, 84.7%, and 80.5% with CANA 100 and 300 mg and SITA 100 mg, respectively; 82.7%, 84.7%, and 58.8% of patients had reductions in body weight.  A greater proportion of patients in Study 1 had reductions in both A1C and body weight with CANA 100 and 300 mg versus SITA 100 mg (67.7%, 74.7%, and 50.6%, respectively; differences [95% confidence interval (CI)] of 17.1% [9.7, 24.5] and 24.2% [17.1, 31.3], respectively).  In Study 2, the proportion of patients with reductions in A1C with CANA 300 mg and SITA 100 mg were 86.6% and 74.2%, respectively; 78.6% and 47.1% of patients had reductions in body weight.  Similar to Study 1, a greater proportion of patients in Study 2 had reductions in both A1C and body weight with CANA 300 mg (70.6%) versus SITA 100 mg (37.8%; difference [95% CI] of 32.8% [25.7, 39.8]).  The overall incidence of adverse events (AEs) was similar across treatment groups in both studies; CANA was associated with increased rates of genital mycotic infections and osmotic diuresis–related AEs compared with SITA.  In Study 1, the incidence of documented hypoglycemia (≤70 mg/dL) was 7%, 7%, and 4% with CANA 100 and 300 mg and SITA 100 mg, respectively; in Study 2, the incidence of documented hypoglycemia was 43% and 41% with CANA 300 mg and SITA 100 mg, respectively.  In conclusion, CANA provided greater attainment of reduction in both A1C and body weight compared with SITA at 52 weeks and was generally well tolerated in patients with T2DM as add-on to MET or MET plus SU.

 

Disclosure: JAD: Advisory Group Member, Amgen, AstraZeneca, Eli Lilly, Janssen, Merck, Novo Nordisk, and Aspire Bariatrics, Consultant, Amgen, AstraZeneca, Eli Lilly, Janssen, Merck, Novo Nordisk, and Aspire Bariatrics, Speaker, AstraZeneca, Janssen, and Novo Nordisk. LH: Speaker, Janssen. HJ: Speaker, Janssen. UV: Employee, Janssen Research & Development, LLC. GM: Employee, Janssen Research & Development, LLC. WC: Employee, Janssen Research & Development, LLC. Nothing to Disclose: GS

21070 14.0000 THR-653 A Canagliflozin Is Superior to Sitagliptin in Reducing Both A1C and Body Weight in Patients with Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Farid Saad*1, Gheorghe Doros2, Abdulmaged M Traish3 and Aksam A Yassin4
1Bayer Pharma AG, Berlin, Germany, 2Boston University School of Public Health, Boston, MA, 3Boston University School of Medicine, Boston, MA, 4Segeberger Kliniken, Norderstedt, Germany

 

Introduction and Objectives:

In men with T2DM, achieving and maintaining stable glycaemic control remains challenging. Several short-term studies on the use of testosterone (T) in men with T2DM have shown mixed results, with longer-term studies demonstrating significantly better results than short-term studies. We investigated effects of long-term treatment with TU in 77 hypogonadal men with T2DM.

Methods:

Single-center, cumulative, prospective, registry study of 262 hypogonadal men. 77 men (29.4%) had T2DM. All patients had presented with ED and were found hypogonadal (total T 12 nmol/L (~350 ng/dl). All men received TU for up to 11 years. In almost all men, T2DM had been diagnosed previously and was being treated by their respective family physicians. Patients were enrolled into the registry once they had received 1 year of TU. 77 men were treated for a minimum of 2 years, 76 for 3 years, 75 for 4 years, 73 for 5 years, 56 for 6 years, 23 for 7 years, 18 for 8 years, 17 for 9 years, and 7 for 10 years. Measures were taken at every other visit. Results at the end of 10 years follow-up are reported.

Results:

Mean age was 61.54 ± 7.28 years (minimum: 41; maximum: 74 years). 9 of 77 men (12%) were overweight, and 68 (88%) were obese.

Total T increased from 7.59 ± 1.89 nmol/L to trough levels (measured prior to the following injection) between 17 and 20 nmol/L, free T from 150.31 ± 65.24 to 400-500 pmol/L.

Waist circumference decreased from 115.03 ± 10.61 to 96.43 ± 4.72 cm. Weight decreased from 109.52 ± 13.01 to 86 ± 8.98 kg. Mean BMI decreased from 34.66 ± 3.87 to 27.54 ± 2.61 kg/m2 (p<0.0001 vs baseline, statistical significance vs previous year for the first 6 years for all). Weight reduction was -18.97%.

Fasting glucose decreased from 146.26 ± 41.48 to 76.21 ± 5.34 mg/dl (p<0.0001 vs baseline). HbA1c declined progressively from 7.87 ± 1.05 to 7.17 ± 0.96 after 1 year, 6.76 ± 0.92 after 2 years, 6.54 ± 0.9 after 3 years, 6.35 ± 0.85 after 4 years, 6.17 ± 0.66 after 5 years, 6.13 ± 0.76 after 6 years, to 5.69 ± 0.33% after 10 years (p<0.0001 vs baseline, statistical significance vs previous year for the first 5 years). At baseline, 16 patients (20.8%) were within the HbA1c target of 7.0%, 9 (10.7%) within 6.5%. At the last observation for each individual patient, 70 men (90.9%) were within the HbA1c target of 7.0%, 57 (74.0%) within 6.5%. Only 7 patients (9.1%) did not reach either of these HbA1c targets.

The triglyceride:HDL ratio as a surrogate marker of insulin resistance decreased from 8.05 ± 4.29 to 2.67 ± 0.39 (p<0.0001 vs baseline). The major decrease occurred during the first 3 years with statistical significance each year vs previous year.

No patient dropped out.

Conclusions:

Long-term T therapy improved glycaemic control in hypogonadal men with T2DM. The majority of patients achieved the HbA1c targets previously not achieved on standard therapy. Increased lean mass and sustained weight loss may have contributed to the observed improvements.

 

Disclosure: FS: Employee, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. AAY: Investigator, Bayer Schering Pharma. Nothing to Disclose: AMT

20222 15.0000 THR-654 A Long-Term Effects of Treatment up to 11 Years with Testosterone Undecanoate Injections (TU) in Hypogonadal Men with Type 2 Diabetes Mellitus (T2DM) on Glycaemic Control and Anthropometry: Real-Life Data from an Observational Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Farid Saad*1 and Aksam A Yassin2
1Bayer Pharma AG, Berlin, Germany, 2Segeberger Kliniken, Norderstedt, Germany

 

Introduction:

While several studies have been performed in hypogonadal men with type 2 diabetes mellitus, little information is available on effects of TRT in hypogonadal men with T1DM.

Methods:

Single-center, cumulative, prospective, registry study of 262 hypogonadal men (total testosterone ≤ 12 nmol/L). All men received TU injections every 12 weeks following an initial 6-week interval for up to 11 years. 9 men had a diagnosis of T1DM. 5 men were followed for 10 years, 3 men for 9 years, and 1 man for 6 years. In 7 men, TRT was temporarily interrupted for 1 year in a patient diagnosed with prostate cancer, and for 1.5 to 2 years in 6 men due to reimbursement issues. I all 7 men, TRT was resumed for 1 to 2.5 years (end of observation time). Anthropometric parameters, fasting glucose and HbA1c were measured every 6 months. Since an auto-immune component is discussed in the etiology of T1DM, C-reactive protein was also determined.

Results:

Patient age at baseline was between 52 and 68 years. 7 patients were obese (2 with excessive obesity) and 2 overweight.

Weight decreased in all obese patients while on TU by 8 to 41 kg. 1 of the overweight patients (baseline BMI: 25.6 kg/m2) did not experience weight loss, the other overweight patient (follow-up: 6 years) lost 6 kg. During TRT interruption, weight regain ranged from 1 to 9 kg. After resuming TRT, weight dropped again by 1 to 13 kg. 

Waist circumference decreased in all patients from 3 to 25 cm. During interruption of TRT, waist circumference increased in all but 1 patient by 1 to 8 cm. After TRT resumption, waist circumference remained stable in 2 and dropped again by 2 to 8 cm in 5 men.

Baseline fasting glucose was between 126 and 233 mg/dl in all except 1 patient who had 80 mg/dl. Under TRT, fasting glucose dropped to a maximum of 103 mg/dl, increased during TRT interruption by 33 to 116 mg/dl, and dropped again upon resuming TRT.

HbA1c was 8.4 to 9.7% at baseline. Upon TRT, HbA1c decreased from baseline to end point or last observation before TRT interruption between a minimum of 1.7 and a maximum of 3.5%. After discontinuation of TU, HbA1c increased quickly in all patients by a minimum of 0.6 and a maximum of 3.0%.

After resuming TRT, HbA1c decreased again in all men by between 0.5 and 2.5%. At the end of observation time, all patients had an HbA1c < 7%, and 3 out of 9 had an HbA1c < 6.5%. 

3 patients had elevated baseline CRP levels at 1.7, 4.1, and 2.3 mg/dl. I all 3 men, CRP levels dropped to 1 mg/dl within the first 2 years of TRT.

Conclusions:

In hypogonadal men with T1DM, long-term TRT progressively and sustainably improves weight, waist circumference, and glycaemic control. These benefits are partly reversed after discontinuation but recovered after resuming therapy. Reduction of CRP under TRT supports the anti-inflammatory effect of testosterone. Hypogonadal men with T1DM may benefit from life-long TRT.

 

Disclosure: FS: Employee, Bayer Schering Pharma. AAY: Investigator, Bayer Schering Pharma.

21704 16.0000 THR-655 A Long-Term Testosterone Replacement Therapy (TRT) and Temporary Withdrawal in Hypogonadal Men with Type 1 Diabetes Mellitus (T1DM) – a Series of 9 Case Reports 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Natalya Volkova*1, Ilia Davidenko2, Maria Antonenko3, Igor Reshetnikov4, Aida Gulmagomedova5, Irina Dzherieva5 and Julia Rudakova4
1The Rostov State Medical University, Rostov-on-Don, Russia, 2Rostov State Medical University, Rostov-on-Don, Russia, 3Rostov State Medical University, Rostov-on-don, Russia, 4Rostov State Medical University, Rostov-on-Don, Russia, 5Rostov State Medical University, Rostov on Don, Russia

 

Lipohypertrophy (LH) is a chronic complication of diabetes mellitus that caused by frequent subcutaneous injections of insulin. It may develop in any age, any injection site, and it could be any size (1). Nowadays, LH were modified due to good quality modern insulin and expansion their concentration. As a result, new method, as ultrasonography of subcutaneous fat, of LH diagnostics were appeared (2). The aim of this study has been to estimate efficiency of insulinotherapy in diabetic patients after LH was diagnosed by ultrasonography. This study was done on 50 diabetic patients (31 females and 19 males) who had been under the treatment with insulin a mean 10 years. Ultrasonography of subcutaneous fat was used in assessing LH in these diabetics. Evaluation of subcutaneous fat was made in typical injection sites: paraumbilical and buttocks regions, lateral surfaces of hips and shoulders. All patients injected insulin in physiological (basis-bolus) regimen. HbA1c level, fasting and postprandial glucose, episodes of hypoglycemia, body mass and body mass index (BMI) were evaluated at the moment of LH and after 6 month in all patient. Results were considered to be statistically significant p<0,05. After changing injected sites because of detected by ultrasonography LH, there were received next results. BMI reduced from 26,34 ± 6,07 kg/m2 to 25,25 ± 4,06 kg/m2 (p<0,05, ). Body mass decreased from 72,44 ± 15,75 kg to 70,08 ± 15,02 kg (p<0,05). Also good glycemic control was demonstrated by measuring glucose and HbA1C level. Thus fasting glucose reduced from 9,03 ± 3,98 mmol/l to 7,11 ± 2,95 mmol/l (p<0,05). Postprandial glucose decreased from 10,27 ± 3,72 mmol/l to 9,34 ± 2,61 mmol/l (p<0,05). HbA1C level reduced from 9,27 ± 2,32% to 7,43 ± 1,52% (p<0,05). Frequency of hypoglycemia reduced from 1,97 ± 2,23 to 1,10 ± 0,91 in month (p<0,05). According to results received, there were significant improvement of all estimated parameters which characterized the diabetes compensation after changing injected sites because of detected by ultrasonography LH. Since ultrasonography of subcutaneous fat is more sensitive than classic LH diagnostics, it might be used in general clinical practice instead of common detection of LH.

(1) Rowe AH, Garrison OH. Lipodystrophy: atrophy and tumerfaction of subcutaneous tissue due to insulin injections. // JAMA. 1932. №99. P. 16-18. (2) N.I. Volkova, I.Y. Davidenko, J.A. Rudakova, K.V. Segida. Ultrasonography of insulin injection sites in diabetic patients: a new method of lipohypertrophy diagnostics.. // ENDO 2013: The Endocrine Society 95th Annual Meeting. Final Program. San-Francisco, USA, 2013. P. 15-18.

 

Nothing to Disclose: NV, ID, MA, IR, AG, ID, JR

20826 17.0000 THR-656 A Diabetes Compensation after Changing Injected Sites Because of Detected By Ultrasonography Lipohypertrophy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Charlene Ann Vicencio Balili*1, Erick Sta. Rosa Mendoza2 and Leilani Basa Mercado-Asis3
1University of Santo Tomas Hospital, Manila, Philippines, 2University of Santo Tomas, Manila City, Philippines, 3University of Santo Tomas, Manila, Philippines

 

Introduction: Over 90% of patients on oral hypoglycemic agents will eventually need insulin to maintain the HbA1c goal of <7% in the long-term clinical course of type 2 diabetes mellitus. The use of biosimilar insulin preparations has become popular to address the economic aspects of treatment. 

Objective: To determine whether biosimilar insulin preparation is a cost-effective alternative among diabetic patients requiring insulin to achieve appropriate glycemic control. 

Methodology: This  is  an analytical chart review of 24   patients  seen   at  a  private  clinic  at   two  tertiary hospitals in  the  Philippines  from 2008-2014.  The patients included were  using premixed  NPH and regular insulin (Humulin 70/30,  Mixtard 30 and Scilin M30)  and  who  later  on  have   been   switched  to  a biosimilar preparation (Wosulin 70/30). We compared the total insulin requirement and HbA1c levels of the patients before and after switching to Wosulin 70/30.

Results:  Twenty four patients (16 females and 8 males) aged   40  to  77  years  with  an  average duration of diabetes of 7-8 years  were  included  in the study.
After switching to  Wosulin 70/30  the  mean  HbA1c decreased by  1.27%  while the  total insulin dose  per  day increased by 2.4 units. Even with minimal increase in insulin dose, Wosulin 70/30 was still 30-40% more affordable.

Conclusion: After switching to a biosimilar insulin, target  HbA1C  was  still achieved with minimal  increase  in  dose.  Biosimilar  insulin preparation  is  a  cost-effective  alternative among  diabetic  patients  requiring insulin to maintain appropriate glycemic control.

 

Nothing to Disclose: CAVB, ESRM, LBM

20823 20.0000 THR-659 A Shifting to Biosimilar Insulin Preparation: Impact on Glycemic Control and Cost 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Luigi Meneghini*1, Ildiko Lingvay1, Jason Chao2, Andreas Stuhr3, Mahmood Kazemi3 and Mehul Dalal3
1University of Texas Southwestern Medical Center, Dallas, TX, 2Xinyi, Inc., Bridgewater, NJ, 3Sanofi US, Inc., Bridgewater, NJ

 

EDITION 3 was a 6-month efficacy and safety study comparing the new formulation insulin glargine 300 U/mL (Gla-300) with insulin glargine 100 U/mL (Gla-100) in insulin-naïve patients with type 2 diabetes mellitus (T2DM).

Real-world diabetes performance measures based on American Diabetes Association guidelines and the US National Committee for Quality Assurance-Healthcare Effectiveness Data and Information Set (HEDIS) 2014, which measures and documents health plan performance in diabetes care, were applied to the EDITION 3 dataset to assess glycemic control and incidence of hypoglycemia.

Patients were randomized to once-daily Gla-300 or Gla-100 in the evening and discontinued sulfonylureas. Insulin was titrated to a fasting plasma glucose target of 80–100 mg/dL. Patients were stratified into low risk (LR) or high risk (HR) groups based on age (< 65 or ≥ 65 years) and presence of HEDIS-defined comorbidities. For LR patients (without comorbidities and age < 65 years), the percentage achieving A1C < 7.0% without severe/confirmed hypoglycemia (blood glucose < 70 mg/dL) from baseline to 6 months follow-up was analyzed. For HR patients (age ≥ 65 years and/or having ≥ 1 selected comorbidity), the percentage achieving A1C < 8.0% without severe / confirmed hypoglycemia at follow-up was analyzed.

At baseline 862 patients were included: LR n = 629, mean age 53.5 years, T2DM duration 8.8 years, and A1C 8.6%; and HR n = 233, mean age 69.4 years, T2DM duration 12.5 years, and A1C 8.3%.

At 6 months follow-up in the LR cohort, comparable percentages of Gla-300 and Gla-100 treated patients achieved A1C < 7.0% (45.2% vs 45.1%, respectively; P = 0.984). A numerically higher proportion of Gla-300 treated patients did not experience hypoglycemia (56.4% vs 50.5%, respectively; P = 0.136). A significantly higher proportion of Gla-300 treated patients achieved A1C < 7.0% without severe or confirmed 24 h hypoglycemia compared with Gla-100 treated patients (22.1% vs 15.1%; P= 0.025).

In the HR cohort, comparable percentages of Gla-300 and Gla-100 treated patients achieved an A1C level < 8.0% (82.5% vs 87.6%, respectively; P = 0.275). A non-significant higher proportion of Gla-300 patients did not experience severe or confirmed hypoglycemia compared with Gla-100 treated patients (45.8% vs 35.4%; P = 0.105). Similarly, a numerically higher proportion of Gla-300 treated patients achieved A1C < 8.0% without severe or confirmed hypoglycemia compared with Gla-100 treated patients (36.7% vs 28.3%, respectively; P= 0.174).

Thus, using real-world diabetes performance measures, patients in the LR cohort treated with Gla-300 are more likely to achieve target A1C levels without severe or confirmed hypoglycemia compared with Gla-100 treated patients, an important consideration for health care decision-makers in the context of diabetes management.

 

Disclosure: LM: Medical Advisory Board Member, Novo Nordisk, Speaker, Novo Nordisk, Consultant, Sanofi, Medical Advisory Board Member, Sanofi, Consultant, Novo Nordisk. IL: Advisory Group Member, Novo Nordisk, Principal Investigator, Novo Nordisk, Principal Investigator, Novo Nordisk, Principal Investigator, Merck & Co., Principal Investigator, Pfizer, Inc., Ad Hoc Consultant, Astra Zeneca, Principal Investigator, GI Dynamics. JC: Consultant, Sanofi. AS: Employee, Sanofi, Employee, Sanofi. MK: Employee, Sanofi, Employee, Sanofi. MD: Employee, Sanofi, Employee, Sanofi.

20340 21.0000 THR-660 A Efficacy and Safety of New Insulin Glargine 300 Units/ML in Insulin Naïve Patients with Type 2 Diabetes Mellitus (EDITION 3) Using Selected HEDIS Measures 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Jae Min Lee*, HEA MIN Yu and Kang SEO PARK
Eulji University Hospital, Daejeon, Korea, Republic of (South)

 

The aim of this study was to compare the HbA1c changes of between two groups of poorly controlled type 2 diabetic patients treated with oral antidiabetic drugs when added to insulin glargine.: one group with insulin glargine add-on to a fixed-dose combination of glimepiride 1mg and metformin 500mg twice daily, and the other group with insulin glargine add-on to glimepiride 4mg once daily. An open-label, parallel, 16-week trial was conducted in 4 study centers. 127 patients were screened, 97 patients were randomized into two groups.The primary efficacy end point was HbA1c change and the secondary efficacy end point were insulin resistance, changes of FPG and PPG2hr and hypoglycemic incidence. After 16 weeks of treatment, adjusted mean HbA1c changes from baseline were -0.97% and -0.22% in glimepiride/metformin and glimepiride groups respectively. Adjusted mean fasting plasma glucose level changes were -51.2mg/dl and -39.8mg/dl from baseline. 2 hr postprandial glucose levels changed by average -69.7 mg/dl for glimepiride/metformin group and -37.8 mg/dl for glimepiride group.The glimperide/metformin group required less insulin than the glimepirde group. Hypoglycemic events were experienced in 19 patients (39.6%) in glimepiride/metformin group and 20 patients (41.7%) in glimepiride group, and night time hypoglycemic events were experienced in 9 patients (18.8%) in both groups, but there was no any serious hypoglycemic adverse events. Insulin add-on to glimepiride/metformin was more effective than insulin add-on to glimepiride in glycemic control and this group required lesser insulin without increasing hypoglycemic incidence.

 

Nothing to Disclose: JML, HMY, KSP

20259 22.0000 THR-661 A A Multi-Center, Open, Randomized, Parallel-Group, 2 Arm Study to Compare the Efficacy and Safety of Insulin Add-on to Glimepiride/Metformin 1/500mg b.I.d Vs. to Glimepiride 4mg Qd in Type 2 DM Patients with Inadequate Glycemic Control 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Amy Kraus1, George Serbedzija1, Praveen Dhankhar*2, Taisia Isupov2, Alexander Brun2 and Iftekhar Kalsekar3
11T1D Exchange, Boston, MA, 2AstraZeneca, Fort Washington, PA, 3AstraZeneca, Fort Washington

 

Pramlintide acetate is a synthetic analog of amylin, a small neuroendocrine hormone co-secreted with insulin by pancreatic β-cells to regulate blood glucose levels. Pramlintide is approved as an adjunct to insulin therapy in type 1 diabetes (T1D), yet no information exists on the characteristics of patients receiving pramlintide. We used the T1D Exchange clinic registry to describe the pramlintide user population in a large heterogeneous sample of adults with T1D.

The T1D Exchange clinic registry contains data on patients with T1D from 70 US-based pediatric and adult endocrinology practices. In this study, we describe two cohorts from a large, cross-sectional sample of adults with T1D whose data were obtained through medical chart review and patient questionnaires from 2010–2012. One cohort included participants who reported using pramlintide at enrollment and the other had no history of pramlintide use. Both cohorts were comparable in age, gender, race, disease duration, and insulin delivery method (pump vs injections).

At enrollment, 160 participants reported using pramlintide (mean age = 44.7 y; 6%, 18–25 y; 56%, 26–49 y; 38%, >50 y). Pramlintide users were mostly female (62%), white/non-Hispanic (93%), college-educated (72%), and employed full-time (59%), with an annual household income >$75,000 (63%) and had private health insurance (86%). Mean age at diagnosis was 21.4 y, and mean disease duration of 21.5 y. Approximately 74% reported using an insulin pump and 42% reported regularly using a continuous glucose monitor. At enrollment, mean HbA1c was 7.5% and median weight was 85.4 kg. The prevalence of reported diabetes-related complications during the year before enrollment included <1% nephropathy, 21% neuropathy, and 17% treatment for retinopathy. Overall, 84% of participants reported being in good to excellent health. However, 52% reported a major life stress in the past year and 49% reported sometimes experiencing diabetes-related stress.

In contrast, non-pramlintide users (n=10,659) had a mean age at diagnosis of 17.7 y, and a mean disease duration of 16 y. Approximately 56% reported using an insulin pump and only 15% reported regularly using a continuous glucose monitor. At enrollment, mean HbA1c was 7.7% and median weight was 76.2 kg. The prevalence of reported diabetes-related complications during the year before enrollment included 2% nephropathy, 14% neuropathy, and 13% treatment for retinopathy. Overall, 83% of this cohort reported being in good to excellent health. However, 52% reported a major life stress in the past year and 42% reported sometimes experiencing diabetes-related stress.

In conclusion, this observational study reports characteristics of pramlintide users from the T1D Exchange clinic registry. Data were limited to current pramlintide users at registry enrollment, and did not include the start date of pramlintide use, dosage, or treatment indications.

 

Disclosure: AK: Employee, T1D Exchange. GS: Employee, T1D Exchange. PD: Employee, Astra Zeneca. TI: Employee, Astra Zeneca. AB: Employee, Astra Zeneca. IK: Employee, Astra Zeneca.

21089 24.0000 THR-663 A Demographics and Disease Characteristics in Patients with Type 1 Diabetes Receiving Pramlintide 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Benjamin Udoka Nwosu Sr.*, Louise Maranda and Mary Min-Chin Lee
University of Massachusetts Medical School, Worcester, MA

 

Context:  Insulin resistance has been proposed as the primary cause of poor glycemic control in overweight/obese youth with type 1 diabetes (T1D). However, the role of adjunctive metformin, an insulin sensitizer, on glycemic control in these patients is unclear.

Objective: To compare the effect of metformin vs. placebo on glycemic control, body mass index (BMI), waist circumference (WC), total daily dose (TDD) of insulin, and hypoglycemia in overweight/obese youth with T1D receiving multiple daily injections of insulin.

Hypothesis: Adjunctive metformin therapy will improve glycemic control in overweight/obese youth with T1D.

Design/Methods: A 9-mo randomized, double-blind, placebo controlled trial of metformin and placebo in 28 subjects (13 m/15f); consisting of 15 cases (age 14.96 ± 2.47y) and 13 controls (age 14.82 ± 2.99y).  Inclusion criteria: HbA1c >8% (64 mmol/mol), BMI >85%, and T1D > 12 mo. To ensure uniformity of glycemic control, all participants employed a self-directed treat-to-target insulin regimen based on a titration algorithm of (-2)-0-(+2) to adjust their long-acting insulin dose every 3rd day from -3mo through +9mo to maintain fasting plasma glucose (FPG) between 90-120 mg/dL (5.0-6.7 mmol/L).

Results: Statistical analysis by ANOVA showed no significant differences between the groups for WC (p=0.709), systolic blood pressure (BP) (p=0.524), diastolic BP (p=0.170), weight SDS (p=0.949), and BMI SDS (p=0.351). The absolute total daily dose (TDD) of insulin per kg body weight (p=0.004), and the TDD of long-acting insulin per kg body weight (p=0.001) increased significantly in the placebo group compared to the metformin group, but the TDD of short-acting insulin per kg did not change (p=0.129). There was no difference in HbA1c between the groups (p=0.089).  

Conclusions: This long term study showed that the significantly reduced insulin requirement in overweight/obese subjects with T1D treated with adjunctive metformin therapy vs. placebo was not associated with a reduction in HbA1c level. Modalities to reduce insulin resistance alone may be inadequate to improve glycemic control in overweight/obese youth with T1D.  

 

Nothing to Disclose: BUN Sr., LM, MMCL

19937 25.0000 THR-664 A A Randomized, Double Blind, Placebo Controlled Trial of Metformin in Overweight/Obese Children and Adolescents with Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Anne E Bunner*1, Cameron L Wells1, Elham Bayat2 and Neal D Barnard3
1Physicians Committee for Responsible Medicine, Washington, DC, 2George Washington Medical Faculty Associates, Washington, DC, 3George Washington University School of Medicine, Washington, DC

 

Diabetic peripheral neuropathy occurs in 60-70% of diabetes patients. Symptoms include pain, loss of sensation, and autonomic symptoms, with pain occurring in 15-30% of cases. Dietary interventions appear to have been helpful for diabetic neuropathy pain in investigations carried out by several research teams. We performed a pilot study in two replications evaluating the role of a low-fat plant-based dietary intervention for diabetic neuropathy pain. In this 20-week study, 35 individuals with type 2 diabetes and painful diabetic neuropathy were randomly assigned to a diet-plus-supplement group or a supplement-only group. The supplement taken by both groups was vitamin B12, which is needed for healthy nerve tissues. The diet group was asked to consume only plant-based foods and to limit oils, nuts, and other fatty foods. The diet group was also asked to attend weekly nutrition classes which provided education and support for following the prescribed diet. At baseline, midpoint, and 20 weeks, clinical, laboratory, and questionnaire data were collected. After 20 weeks, change scores for body weight, McGill pain questionnaire, Michigan neuropathy screening instrument patient questionnaire, and several other pain and symptom scales showed significantly (p<0.05) more improvement in the diet group. In addition, improvements in HbA1c, Norfolk quality of life score, and neuropathy total symptoms score were significant (p<0.05) within the diet group, although the between-group differences did not reach statistical significance. This study demonstrates the potential of diet interventions for treating diabetic neuropathy pain and lays the groundwork for a larger study.

 

Nothing to Disclose: AEB, CLW, EB, NDB

19217 26.0000 THR-665 A Nutrition Intervention for Diabetic Neuropathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


JongHwa Kim and Su Jin Jeong*
General Hospital, Bucheon, Korea, Republic of (South)

 

We performed to determine the impact on quality of life and to understand the clinical characteristics of diabetic peripheral neuropathy. Diabetic peripheral neuropathy (DPN) is the most common complication associated with diabetes. DPN can present as a loss of sensation, may lead to neuropathic ulcers, and is a leading cause of amputation. Many DPN patients experience pain or discomfort, anxiety, depression, and limitations in activity, and may lose workdays or show decreased productivity as a result.
 A cross-sectional study was carried out on type 2 diabetic patients from the diabetic clinics in Korea. The study pool consisted of 200 randomly selected people with type 2 diabetic peripheral neuropathy.  A standardardized questionnaires such as  MNSI, BPI-DPN, MOS 6 items sleep scale and EQ-5D  were used to diagnosis and estimate the quality of life in people with diabetic peripheral neuropathy. A patient with diabetic peripheral neuropathy was defined as the patient who showed positive patients medical records or neuropathic symptoms(MNSI >2) or who showed a positive response on the basic neurological examination(Monofilament test)
 200 patients had DPN and Pain severity index and pain interference items such as general activity, mood, walking, normal work, relationship, sleep and enjoyment of life in BPI-DPN were higher in patients with painful DPN compared to those in patients without painful DPN. Pain substantially interfered with mood, general activity, and caused decrements in many aspects of patients’ lives; physical and emotional function, affective symptoms and sleep problems. MOS 6 items-sleep adequacy, respiratory problem during sleep, sleep initiation problem, sleep maintenance problem, and somnolence- sleep scale were lower in patient with painful DPN than non painful DPN.EQ-5D index were lower in patients with painful DPN compared to those in patients without painful DPN.
Patients with painful DPN have greater discomfort during daily activities and sleep, and reduced QoL compared to patients with nonpainful DPN.
This study provide on the nature and extent of the impact of pain on QoL in patients with painful DPN. DPN decreases quality of life profoundly in patients with type 2 DM.

 

Nothing to Disclose: JK, SJJ

19142 27.0000 THR-666 A Impact of Quality of Life in People with Diabetic Peripheral Neuropathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Grigorios Rombopoulos1, Elena Panitti1, George S Vernikos*1, Christos Katsinas2, Ioannis Stefanidis3 and Dimitrios Goumenos4
1Novartis Hellas S.A., Athens, Greece, 2General Hospital of Ptolemaida "Mpodosakeio", Hemodialysis Unit, 3University Hospital of Larissa, Clinic of Nephrology, 4University Hospital of Patras, Clinic of Nephrology

 

Objective: Management of patients with type 2 diabetes (T2DM) and stage 3 to 5 chronic kidney disease (CKD) is challenging. The aim of the ‘LEARN’ study was to depict treatment patterns employed in this population and to record comorbidities, glycemic control and hypoglycemia episodes in the routine clinical practice in Greece.

Design: ‘LEARN’ was a non-interventional, multicenter, cross-sectional study conducted in Greece between 15-February-2013 and 04-July-2013. A total of 120 adult patients were enrolled from four hospital sites in different geographic regions of Greece.

Results: Participants had a mean age of 69.1±10.3 years and a male:female ratio of 2:1. Nearly all patients (99.2%) suffered from at least one comorbidity, with hypertension (95.8%) and hyperlipidemia/dyslipidemia (78.3%) being the most prevalent. Of the overall study population, 57.5% was managed with insulin therapy only, 30.8% with oral antidiabetics only and 11.7% with a combination of insulin and oral antidiabetics. The overall rate of glycemic control, defined as glycated hemoglobin (HbA1c) ≤7.0% during the most recent assessment, was 55.0%. This rate was significantly higher among those receiving oral antidiabetics only (73.0%) compared to insulin only (47.8%) or a combination of both types of treatment (42.9%) (p=0.03). Moreover, patients receiving oral antidiabetics only had experienced fewer hypoglycemia episodes over the last 7 days prior to the study visit (0.1±0.4) compared to patients receiving insulin only (0.9±1.7) (p=0.03).

Conclusions: Oral antidiabetic therapy appears to be advantageous for the heavily burdened T2DM patients with moderate or severe CKD in terms of glycemic control and hypoglycemia episodes.

 

Disclosure: GR: Employee, Novartis Pharmaceuticals. EP: Employee, Novartis Pharmaceuticals. GSV: Employee, Novartis Pharmaceuticals. CK: Investigator, Novartis Pharmaceuticals. IS: Investigator, Novartis Pharmaceuticals. DG: Investigator, Novartis Pharmaceuticals.

19720 28.0000 THR-667 A A Multi-Center, Epidemiological Study of the Treatment Patterns, Comorbidities and Hypoglycemia Events of Patients with Type 2 Diabetes and Moderate or Severe Chronic Kidney Disease – the ‘Learn' Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Zachary M Novakovic, Brian M Anderson and Patricia Grasso*
Albany Medical College, Albany, NY

 

We have previously described the pharmacokinetics of mouse [D-Leu-4]-OB3, a synthetic peptide amide with leptin-like activity, following delivery by subcutaneous (SC), intraperitoneal (IP), and intramuscular (IM) injection, and by oral gavage and intranasal instillation.  These profiles suggested that the observed efficacy of [D-Leu-4]-OB3 on energy balance, glycemic control, and bone turnover in ob/ob and db/db mice might be improved by efforts directed toward improving its bioavailability, i.e., increasing maximum uptake (Cmax), extending serum half-life (t½), and reducing plasma clearance (CL).  To address these issues, myristic (tetradecanoic) acid was conjugated to the N-terminal of [D-Leu-4]-OB3 (designated MA-[D-Leu-4]-OB3), and the pharmacokinetics of MA-[D-Leu-4]-OB3 in male Swiss Webster mice following SC, IP, and IM injection in PBS, and by oral and intranasal delivery in dodecyl maltoside (DDM, trade name Intravail®), a transmucosal absorption enhancing agent, were compared to those of [D-Leu-4]-OB..  At a dose of MA-[D-Leu-4]-OB3 10-fold lower than that used previously for [D-Leu-4]-OB3 (0.1 mg vs.1.0 mg, respectively), Cmax of MA-[D-Leu-4]-OB3 was 11.1-, 7.5-,1.9-, and 1.7- fold higher,  t1/2 was 3.5-, 5.0-, 9.1-, and 86.7- fold longer, and CL was 17.0-, 11.6-, 5.7-, and 5.0-fold slower than [D-Leu-4]-OB3 following SC, IP, IM, and oral delivery, respectively. Furthermore, in leptin-resistant obese male db/db mice, oral delivery of MA-[D-Leu-4]-OB3 in DDM at concentrations up to 10-fold lower than those used with [D-Leu-4]-OB3 reduced fasting blood glucose levels in a dose-related manner.  Although caution must always be taken in relating the results from animal models to the treatment of human disease, the findings of the present study clearly indicate that myristic acid conjugation of [D-Leu-4]-OB3 significantly improves its pharmacokinetic profile and efficacy.  They further suggest that MA-[D-Leu-4]-OB3 may have potential for development as a novel, oral, noninvasive therapeutic approach to the management of obesity and/or diabetes in humans.

 

Nothing to Disclose: ZMN, BMA, PG

18238 29.0000 THR-668 A Myristoylation of [D-Leu-4]-OB3, a Biologically Active Leptin-Related Synthetic Peptide Amide, Significantly Improves Its Pharmacokinetic Profile and Efficacy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Jean Lin Chan*1, Joy Koda2, Joseph Heilig3, Elaine Cochran4, Phillip Gorden4, Elif Arioglu Oral5 and Rebecca J. Brown6
1Bristol-Myers Squibb, San Diego, CA, 2Bristol-Myers Squibb, San Diego, 3AstraZeneca, 4NIH, Bethesda, MD, 5Univ of Michigan, Ann Arbor, MI, 6National Institutes of Health, Rockville, MD

 

Metreleptin, a recombinant leptin analog that differs from human leptin by an additional methionine, was recently FDA-approved as an adjunct to diet as replacement therapy for complications of leptin deficiency (e.g. diabetes mellitus and/or hypertriglyceridemia) in patients with generalized lipodystrophy (LD).  Administration of protein therapeutics can lead to development of antibodies (Ab) that may or may not have clinical relevance (e.g. neutralizing activity).  We present data from clinical studies of metreleptin administration in obese or LD patients to describe the characteristics of anti-metreleptin Ab development. 

In 2 randomized controlled studies in obese patients receiving metreleptin (alone or in combination with pramlintide; N=83 and N=456), binding (non-neutralizing) Ab developed in ≥96% of patients by study end (20 or 28 weeks). Ab titers ranged from 1:5 to 1:78,125 with peak titer usually between week 8 and 16 depending on metreleptin dose (most frequent peak titer 1:625 to 1:3125).  There was no correlation between Ab titer and efficacy (weight loss) or safety except for increased frequency of inflammatory injection site reactions with higher Ab titer.  In 2 open-label studies in patients with generalized or partial LD receiving metreleptin (N=24 and N=43 sampled), binding Ab developed in 86-92% of patients over 0.3 to 12.5 years of treatment with similar range of titers as for obese patients. In both groups, higher Ab titers were associated with higher leptin levels (leptin assay measures both endogenous leptin and metreleptin).   

In these studies, 3 obese and 4 LD patients were identified with in vitro neutralizing activity (NAc) using a cell-based assay.  The 3 obese patients had substantial weight regain or gain in association with the initial NAc report.  In 2 obese patients who entered a safety follow-up program, 5-year follow-up in one showed resolution of weight gain to baseline despite persistent NAc, and 2-year follow-up in the other showed slightly increased weight.  Development of NAc in the 4 LD patients (all with generalized LD) was concurrent with poor or worsened metabolic control.  Two of these patients had episodes of sepsis, but also had advanced liver disease and poor dentition.  Sepsis was not reported in the other 2 LD patients or the 3 obese patients who did not have severe liver disease.  One LD patient had resolution of NAc (while continuing metreleptin) that was associated with substantial improvement in metabolic abnormalities.         

Binding Ab develops in the majority of metreleptin-treated individuals (obese or LD) and increases leptin levels but does not appear to impact efficacy or safety.  In vitro NAc develops in some patients and may be associated with loss of efficacy, but has not been consistently associated with adverse clinical consequences. Whether NAc blocks endogenous leptin (in addition to metreleptin) with clinical consequences remains unclear.

 

Disclosure: EAO: Advisory Group Member, Astra Zeneca, Principal Investigator, Bristol-Myers Squibb, Principal Investigator, Astra Zeneca, Principal Investigator, Amylin Pharmaceuticals, Principal Investigator, GI Dynamics. Nothing to Disclose: JLC, JK, JH, EC, PG, RJB

19339 31.0000 THR-670 A Immunogenicity Associated with Metreleptin Treatment in Patients with Obesity or with Lipodystrophy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Anthony Emeka Ojieh*1, Eseroghene Cecilia Adegor2, Anthony Chukunweike Okolo3, Lawrence Oberhiri Ewhre4 and Innocent Onyesom2
1Delta State University, Abraka Delta State, Nigeria, 2Delta State University, Abraka, Nigeria, 3Imperial College London, London, United Kingdom, 4Emma-Maria Scientific Research Laboratory, Abraka, Nigeria

 

Type 2 diabetes is a global public health crisis that threatens the economies of all nations, particularly developing countries. It is generally characterized by hyperglycaemia hyperlipidaemia culminating on severe morbidities. Epidemiologic studies and randomized clinical trials show that type 2 diabetes is largely preventable through diet and lifestyle modifications without major recourse to pharmacological measures. This present study aimed to assess the antidiabetic and antilipidaemic activities of Allium cepa (onions) in streptozotocin-induced diabetic male Wistar rats. Adult male Wistar rats were randomly divided into ten (10) groups of five rats each (n=5). Groups 1a and 3 served as the control group. Diabetes was induced in the rats by an intraperitoneal injection of streptozotocin (60mg/kg). The normoglycaemic groups (1e, 1b, 1c and 1d) and the streptozotocin-induced diabetic groups (2a, 2b, 2c and 2d) were treated with metformin (50mg/kg) and different doses of A. cepa (EXTRACT) (0.2g/100gbw, 0.4g/100gbw, and 0.6g/100gbw). The body weights and fasting glucose level of the animals were monitored weekly. At the end of the experiment the rats were sacrificed, blood samples were centrifuged to obtain the serum for biochemical analysis. The pancreases were harvested for histological study. Data were analyzed using SPSS package and expressed as mean± SEM. From the results of the present study, Allium cepa EXTRACT caused an increase in the average weight at the end of the experiments in the both the untreated, non-diabetic (control) and non-diabetic animals treated with metformin  and varying doses of Allium cepa. 0.2g/100gbw of Allium cepa caused only about 2.85% decrease in fasting blood glucose levels; it was about 50.00% and 35.05% with respect to 0.4g/100gbw and 0.6g/100gbw of Allium cepa. Treatment with Allium cepa significantly (p<0.05) decreased the total cholesterol level (control [1a] 198.95±6.34, diabetic control [3] 330.80±38.05, Allium cepa EXTRACT, 0.2g/100gm[275.99±54.90], 0.4/100gm[230.22±15.79], 0.6g/100gm[220.75±21.06]), in a dose dependent manner. The levels of triacylglycerides (180.10±15.64), high density lipoprotein (80.15±2.97) and low density lipoprotein (224.22±32.88) were significantly (p<0.05) higher in the streptozotocin- induced diabetic rats studied.  Finding from the histology of the pancreas showed evidence of aplastic islet cells that were not healed by the Allium cepa or metformin. In conclusion, Allium cepa (EXTRACT) demonstrated significant antidiabetic and antilipidemic activities in diabetic rat, but the mechanism need to be established.

 

Nothing to Disclose: AEO, ECA, ACO, LOE, IO

19399 32.0000 THR-671 A Antidiabetic and Antilipidemic Properties of Allium Cepa in Streptozotocin-Induced Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Mustafa Unubol*1, Fatih Firat2, Basak Karasu3, Ali Akbas4, Velid Unsal4, Fikret Erdemir5, Volkan Yazak6, Bilal Acar7 and Imran kurt Omurlu8
1Adnan Menderes University Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology, Aydın, Turkey, Turkey, 2Tokat State Hospital, Urology Department, 3Turhal State Hospital, Pathology Department, Turkey, 4Gazi Osman Paşa Faculty of Medicine, Clinical Biochemistry Department, Turkey, 5Gazi Osman Paşa Faculty of Medicine, Urology Department, Turkey, 6Nazilli State Hospital, Internal Medicine Department, Turkey, 7Cankiri State Hospital, Internal Medicine, Turkey, 8Adnan Menderes University, Medical Faculty, Department of Biostatistics, Turkey

 

Objective:Acute kidney injury(AKI) is a classical complication of diabetic ketoacidosis. Amifostine is a thiol compound amongst the cytoprotective agents which provides a wide cytoprotection spectrum. In this study we aim to show the effectiveness of amifostine on preventing diabetic ketoacidosis related AKI on Streptozotocin induced diabetic rats.

Method:We used 18 Albino Wistar adult male rats (8-12weeks old,200-250gr). Rats(n=12) were given an intraperitoneal injection of streptozotocin to induce diabetes as described previously. Group 1 (n=6) contains the healthy subjects whith blood sugar level below 120gr/dl and no medications given. Group 2(n=6) is the diabetic control group. Group 3 (n=6) is the diabetic +Amifostine group. The rats in Group 3 have been adminstrated 200mg/kg Amifostine (IP) single dose after they developed diabetes.Five days after the first dose of STZ they developed DKA. At the end of the eighth day, were performed left side nephrectomy and sampling for further histopathological and biochemical studies.Malondialdehyde(MDA), Superoxide Dismutase(SOD), Nitric Oxide(NO) and Gluthatione peroxidase (GSHPx) levels were measured.The Kruskal Wallis test and Tthe Dunn’s post hoc test were used. Data are shown as median and 25th-75th percentiles.

Results:Plasma SOD values of group 1,2 and 3 were  5.2 (4.2-5.9) (U/L), 3.1 (1.6-5.7) and 7.9 (5-8.4), respectively (p 0.048).The difference was statistically significant  between Group 2 and  Group 3. Plasma NO values of group 1,2 and 3 were  45.2 (41.6-49.3)¥ (mmol/L), 63.7 (62.6-65.1), 62.8 (50.9-80), respectively (p 0.005). ¥ The difference were statistically significant  between Group 1 and  Group 2-3. Plasma (GSHPx) values of group 1,2 and 3 were  506.1 (409.7-723) (u/dL), 650.7 (457.9-921.8), 626.6 (229-1138.7), respectively (p=0.780). Plasma MDA values of group 1,2 and 3 were 0.47 (0.43-0.51) (micromol/L), 1.66 (0.7-2.6), 1.1 (0.7-1.5), respectively (p=0.006). The difference was statistically significant  between Group 1 and  Group 2. The diameter of glomerules were 114 (110.25-116.75)micron, 128.2 (124.75-137.75), 120.5 (113-129) in group 1,2 and 3, respectively (p=0.006).The difference was statistically significant  between Group 1 and  Group 2

Conclusion:The average glomerule diameter in group 2 is the biggest among all and group 3 is slightly bigger than the group 1. On group 2 samples we observe glomeruler capillary basement membrane thickening and focal mesangial matrix increase. Tubular dilatation on group 2 samples and diabetes indicating symptoms on glomerules with decreased tubules number on the group 3 samples were observed. We think that amifostine can slow patological progression in acute kidney injury model related with diabetic rats in this study. We believe that the protective effects of amifostine in acute kidney injury should be evaluated in the future studies.

 

Nothing to Disclose: MU, FF, BK, AA, VU, FE, VY, BA, IKO

21687 33.0000 THR-672 A The Effects of Amifostine to ACUTE Kidney Injury with Diabetic Ketoacidosis in RATS 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM THR 640-672 5935 1:00:00 PM Type 2 Diabetes Therapies Poster


Aditi Khokhar*1, Salvador Castells2 and Sheila Perez-Colon3
1SUNY upstate medical university, Syracuse, NY, 2Kings County Hospital Center, Brooklyn, NY, 3SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY

 

Background: Vitamin D dependent Rickets Type 1 (VDDR1) is a rare autosomal recessive condition associated with CYP27B1 gene mutation, characterized by impaired activity of 25-hydroxyvitamin D 1 alpha hydroxylase enzyme and low serum levels of 1,25 dihydroxy vitamin D (1,25(OH)2D). Affected patients present with hypocalcemia, secondary hyperparathyroidism, failure to thrive, muscle weakness, and bone abnormalities typical of rickets. 

Objective: To report Yemenite siblings presenting with history of hypocalcemia ultimately diagnosed with Vitamin D dependent Rickets Type 1.

Clinical Case: Three brothers born to non-consanguineous Yemenite parents presented with history of hypocalcemia of unknown origin. Patients were recent immigrants to United States and had been receiving calcitriol treatment for unclear reasons. Family History: 1st child-now 15 year old male, healthy; 2nd child-a girl, died as an infant secondary to hypocalcemic complications; 3rd child-now 8 years old male, had severe hypocalcemia in infancy leading to seizures and cardiac decompensation, required treatment with iv calcium and diuretics. His calcium levels eventually improved with calcitriol treatment; 4th and 5th child- now 7 and 4 years old males respectively, had low calcium levels in neonatal period and were started on calcitriol treatment. 6th child- now 3 months old female, normal labs currently.
Patients (3rd, 4th and 5th child) had normal serum level of calcium, PTH and 1,25(OH)2D at presentation. They were asymptomatic with normal physical exams except for poor dentition. Since the diagnosis and reason for calcitriol treatment was unclear, patients were weaned off their calcitriol doses slowly with close monitoring of labs and clinical status. As calcitriol doses were reduced, 1,25(OH)2D and Ca levels started to trend down while PTH levels began to rise. Patients remained asymptomatic during this time. The calcitriol doses were later increased back to normalize the laboratory parameters. Genetic testing for all three brothers revealed a homozygous CYP27B1 mutation-exon 8 c.1357 C>T transition, previously reported as a mutation associated with VDDRI in a Haitian patient (1). It is likely that 2ndchild also had same condition. The genetic testing for parents and other siblings is in progress.

Conclusion: VDDRI is rare in most populations but higher incidence rates have been reported in the Canadian French population of Quebec province (2).  To our knowledge, VDDRI has not been reported in Yemeni population. Although the above mutation is a known one, it has been reported in only one patient who was of Haitian descent (1,3). Given an autosomal recessive condition, it is unusual that 4 out of 6 siblings in one family had this condition.

 

Nothing to Disclose: AK, SC, SP

19334 1.0000 THR-226 A Four Yemenite Siblings with Vitamin D Dependent Rickets Type 1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Jasmine J Zhu*1, Jas-mine Seah2, Ego Seeman3, Spiros Fourlanos4, Suresh Varadarajan5, Lachlan Hayes6 and Richard James MacIsaac7
1St Vincent's Hospital Melbourne, Fitzroy, Australia, 2Austin Health, Australia, 3The University of Melbourne, Australia, 4Royal Melbourne Hospital, 5The Northern Hospital, Melbourne, Australia, 6The Northern Hospital, 7St Vincent's Hospital Melbourne, Australia

 

Introduction: Mastocytosis is a rare cause of secondary osteoporosis. There have been no previous reports of osteoporosis presenting in the post-partum period that have been complicated by a diagnosis of mastocytosis. We present two cases of systemic mastocytosis being diagnosed in the setting of post-partum osteoporosis.

Clinical cases: Case 1: A 35 year old G2P2 woman presented with subacute on chronic back pain 4 weeks post-partum. She was breast feeding at the time of her presentation. Imaging confirmed the presence of multi-level vertebral fractures. Her average T-score was -4.5 at the lumbar spine and -2.8 at the left hip. Vitamin D was 39nmol/L (N > 50), and calcium and PTH were not elevated. Given the severity of her osteoporosis, screening tests for secondary osteoporosis were performed. These revealed an elevated serum tryptase of 23.8ng/ml (N < 11ng/ml) and a subsequent bone marrow biopsy confirmed the presence of mastocytosis. When she was treated with a zoledronic acid infusion, she developed a sinus tachycardia, hypotension and a fever of 40°C. A recent report suggests that acute phase reactions may be a common reaction related to the use of zoledronic acid in patients with mastocytosis (1). Her future treatment options are being considered. Case 2: A 29 year old G2P1 woman presented with acute on chronic back pain 3 months post-partum upon lifting her baby. She was breast feeding at the time of her presentation. Imaging confirmed a compression fracture of lumbar vertebrae 4-5. Her average T-score was -3.19 at the lumbar spine and -1.99 at the left hip. Her Vitamin D was 54nmol/L. She was treated with calcium and vitamin D supplements only. After a further 12 months there was only marginal improvement in her bone mineral density. Due to ongoing pain in her back and hip, she was re-imaged and this revealed new compression fractures in the thoracic spine. Given that her osteoporosis failed to improve and her history of an intermittent urticarial rash, her serum tryptase level was checked and was elevated at 25.7ng/ml. Bone marrow biopsy demonstrated collections of spindle shaped mast cells consistent with a diagnosis of mastocytosis. She was commenced on a proton pump inhibitor for some mild symptoms of reflux, started on an anti-histamine, and is due for a zoledronic acid infusion following a dental review.

Conclusion: Although pregnancy and lactation may contribute to bone loss, it is also important to consider secondary causes of osteoporosis. These above cases suggest that a diagnosis of systemic mastocytosis should be considered in severe cases of post-partum osteoporosis.

 

Nothing to Disclose: JJZ, JMS, ES, SF, SV, LH, RJM

19424 2.0000 THR-227 A Post-Partum Osteoporosis Due to Systemic Mastocytosis: 2 Case Studies 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Barbara Angel*1, Cecilia Albala2 and Lydia Lera1
1INTA, University of Chile, 2INTA University of Chile, Santiago, Chile

 

Introduction: Recently it has been postulated that inflammatory processes and innate immune system activation would be linked to the pathogenesis and complications of T2D. It has been suggested that low levels of vitamin D would be a risk factor for T2D. At present there are few studies that have evaluated the functional role that would have the presence of certain VDR genotypes on levels of vitamin D, inflammatory markers and glucose tolerance. BsmI and FokI polymorphisms have been associated with obesity and T2D in some populations. Aim: The present study aimed to investigate raised the frequencies of two VDR polymorphisms (BsmI and FokI) in T2D and control subjects. Methodology: We analyze their genotypes with levels of 25 hydroxyvitamin D (25 (OH)D3), and a marker inflammation (CRP). As well as investigate the role of 1,25 (OH)2D3 on the expression of pro-inflammatory markers in peripheral mononuclear cells (PMCs) of patients with T2D and controls. The case-control study was conducted in 160 T2D, men and women between 30-74 years and 160 control subjects. In these subjects were determined genotypic and allelic frequencies of BsmI and FokI polymorphisms. Subsequently included a group of 20 T2D and 20 control subjects, to which PMCs were removed by Ficoll-Paque method from 20 ml peripheral blood. The PMCs were activated extracted PHA (5 mg/ml) for 72 hrs. The culture medium was supplemented with two concentrations of 1,25 (OH)2D3 10-8M and 10-10M. Were analyzed by q-PCR, expression profiles of two pro-inflammatory markers (TNFα and IL-6), we used β-actin and GAPDH as housekeeping genes. Results: the results of case-control study show that control subjects have an increased frequency of genotype FF, no differences were observed for the BsmI polymorphism. By analyzing the levels of Vitamin D and plasma CRP no differences in levels of vitamin D to be analyzed by the study groups and by genotypes of both polymorphisms. The in vitro study showing a lower expression of TNFα mRNA in the PMCs of subjects with FF genotype at a concentration of 10-8M of vitamin D, this expression is reversed in subjects with Ff and ff genotypes in the presence of a lower concentration (10-10M) of 1,25(OH)2D3. Conclusions: These data indicate a possible functional role of FokI polymorphism of VDR.  Our proposal brings a new aspect to the conventionally known for vitamin D postulated possible anti-inflammatory properties in type 2 diabetes.

 

Nothing to Disclose: BA, CA, LL

21013 3.0000 THR-228 A FokI Polymorphisms in Vitamin D Receptor Gene: Differential Expression of Tnfa in Peripheral Mononuclear Cells of Type 2 Diabetic Subjects 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Yuhong Shi*1, Monica Gutierrez2, Meng Yang2, Wei Zhou1, Joyce Hogue2, Susan Elizabeth Spratt2, James Koh2 and John A Olson Jr.1
1University of Maryland School of Medicine, Baltimore, MD, 2Duke University Medical Center, Durham, NC

 

Background: The calcium sensing receptor (CASR) modulates parathyroid hormone (PTH) production in the parathyroid gland in response to changes in ambient serum calcium concentrations.  Failure of appropriate calcium sensing in patients with primary hyperparathyroidism (PHPT) is not due to mutations in CASR and is believed to stem from an intrinsic defect in calcium responsiveness manifested by adenomatous cells that have overgrown normal gland tissue. In familial hypocalciuric hypercalcemia (FHH), inactivating mutations in the CASR impair calcium feedback leading to multiple gland enlargment that is not helped by parathyroidectomy.  Patients suspected of having FHH may benefit from CASR gene sequencing although uncharacterized sequence variants may be identified leaving a diagnosis of FHH in question.  A patient presenting with non-familial hypercalcemia (calcium 11.1-11.4 mg/dl, intact PTH 53 pg/ml, Mg 2.4 mg/dl, 24 hr UCa 107 mg/24 hrs, 25OH Vit D 10) was suspected of having FHH and was evaluated for molecular evidence of compromised CASR activity. 

Method:  Genomic DNA was isolated from the patient and the full length CASR coding sequence was determined.  A missense substitution variant identified in one of the patient’s CASR alleles was evaluated functionally in cellular assays measuring subcellular localization, CASR-dependent intracellular calcium flux response, and downstream signaling events following stimulation with extracellular calcium. 

Results:  A novel missense mutant allele resulting in an arginine to cysteine substitution at codon 752 of CASR was identified.  The R752C mutant form of CASR is stable and localizes appropriately to the cell surface but is functionally compromised with an EC50 of 4.23 +/- 0.589 mM Ca2+ compared to 2.24 +/- 0.1411 mM for the wild type protein when expressed alone.  ERK phosphorylation, evaluated as a readout of CASR downstream signaling activity, is similarly disrupted by the R752C mutation.  When co-expressed with WT CASR to model the patient’s heterozygous state, the presence of the R752C allele attenuates cellular calcium responsiveness (EC50 = 2.79 +/- 0.1054 mM) and diminishes ERK phosphorylation.

Conclusions: Functional characterization of a novel CASR missense mutation reveals an intrinsic dominant-negative defect in calcium sensing when co-expressed with WT CASR.  This outcome is not consistent with a diagnosis of PHPT in the heterozygous R752C patient and likely indicates FHH. CASR sequencing with functional characterization of novel sequence variants may become an important diagnostic approach in patients with atypical PHPT and FHH.

 

Nothing to Disclose: YS, MG, MY, WZ, JH, SES, JK, JAO Jr.

20566 4.0000 THR-229 A A Novel Patient-Derived Missense Mutation in Casr Shifts the Calcium Setpoint As a Dominant Negative Allele and Makes a Functional Diagnosis of Fhh 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Caroline K Thoreson1, Stephanie T Chung1, Madia Ricks1, Michelle T Duong1, Paola C Aldana1, Lilian Mabundo1, Alan T Remaley2, James C Reynolds3 and Anne E Sumner*1
1NIDDK, NIH, Bethesda, MD, 2NHLBI, NIH, Bethesda, MD, 3National Institutes of Health, Bethesda, MD

 

Vitamin D is essential for bone health. However, excessive vitamin D supplementation has been associated with significant toxicity. The Endocrine Society defines Vitamin D insufficiency as total 25(OH)D between 20 and 30 ng/mL and Vitamin D deficiency as total 25(OH)D <20 ng/mL. As African ancestry is associated with low total 25(OH)D but high bone mineral density (BMD), the relevance to Africans of these thresholds for 25(OH)D is unknown. Our goal was to determine in African immigrants: (1) the prevalence of vitamin D insufficiency and deficiency, (2) the relationship of total 25(OH)D levels to whole body BMD as defined by T-scores and (3) biochemical vitamin D deficiency defined as elevated parathyroid hormone (PTH) (>65 pg/mL) and low 25(OH)levels (<30 ng/mL). In addition, we assessed vitamin D binding protein (VDBP) and calculated bioavailable vitamin D levels (sum of free and albumin-bound 25(OH)D). Participants were 173 immigrants from equatorial Africa enrolled in the Africans in America cohort (70% male, age 38±10y, (mean±SD) range 20 to 64y, BMI 27.7±4.5 kg/m2).  All participants had total 25(OH)D levels,  95% had whole body BMD determined by dual-energy absorptiometry and 50% had PTH and bioavailable D. Total 25(OH)D levels were 21±8 ng/mL. Bioavailable D levels were 7±4ng/mL. Total 25(OH)D and bioavailable D were highly correlated, (r = 0.8, P<0.001). VDBP levels were 78±59 µg/mL. There was no seasonal variation in total 25(OH)D, bioavailable D or VDBP (all P>0.5). Low total 25(OH)D levels occurred in 84% of African immigrants, specifically 37% were insufficient and 47% were deficient. PTH levels were: 44±15, range 20-93 pg/mL. The correlation between PTH and total 25(OH)D was inverse (r = -0.21, P<0.04). Overall, biochemical vitamin D deficiency occurred in 10% of African immigrants, osteopenia in 6% (T-scores between -1.0 to -2.5) and no one had osteoporosis (T-scores <-2.5).  The presence of low 25(OH)D (<30 ng/mL) was not a risk factor for  osteopenia (OR = 0.64, 95%CI 0.13, 3.25 P=0.6) or elevated PTH ((OR = 0.87, 95%CI 0.38, 1.99 P=0.7).  In summary, the majority of African immigrants met the definition of vitamin D insufficiency, but the low frequency of either decreased bone density or hyperparathyroidism suggests metabolic adaption to these lower 25(OH)D levels. Therefore, total 25(OH)D <30 ng/mL may be sufficient in African immigrants and the definition of vitamin D insufficiency as well as the need for vitamin D supplementation may need to be race-specific.

 

Nothing to Disclose: CKT, STC, MR, MTD, PCA, LM, ATR, JCR, AES

18906 5.0000 THR-230 A Vitamin D Status and Bone Health in African Immigrants: The Africans in America Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Martin Kuzma1, Peter Jackuliak1, Peter Vanuga2, Zdenko Killinger3 and Juraj Payer*1
1University Hospital Bratislava, Bratislava, Slovakia, 2National Institute of Endocrinology and Diabetology, Lubochna, Slovakia, 3Medical Faculty, Bratislava, Slovakia

 

Introduction: Growth hormone deficiency (GHD)is associated with reduced bone mineral density (BMD) and growth hormone (GH) replacement leads to BMD increase. BMD response to GH is influenced by type of GHD onset, gender and dose of GH but vitamin D deficiency possibly plays important role.

Objective: To assess the effect of vitamin D on bone status of GHD adults.

Methods: A prospective study was conducted in adult GH-deficient patients treated with GH for 2 years in IGF-1 normalization treatment regimen. Lumbar spine (LS) BMD, total femur (TF) BMD were assessed at months 0, 12, and 24. Levels of 25-OH-D3, calcium and bone turnover markers were evaluated at baseline and months 3, 6, 12, and 24.Vitamin D deficiency was defined as levels of 25OH-D3 under 30 nmol/l. Patients with vitamin D deficiency were treated with dose of 800 IU vitamin D.

Results: One hundred thirty five patients were included (mean 35.3 years of age, 80 males, 94 adult onset (AO) GHD) who suffered mostly from post surgical GHD (n = 80). At baseline 63 patients were vitamin D deficient. In GHD patients with vitamin D deficiency a lower BMD (LS= 0.83 ±0.01 g/cm2; TF= 0.81±0.02 g/cm2) in comparison to vitamin D non-deficient GHD patients (LS=0.95 ±0.01 g/cm2; TF = 0.94±0.01 g/cm2) was demonstrated (p<0.001). GH replacement together with vitamin D led to greater LS BMD increase than GH treatment alone, 14% and 11% (p=0.04), respectively. No difference was observed in TF BMD. Patients treated with vitamin D showed at month 24 greater level of 25-OH-D3 in comparison to untreated patients, 66.6±6.9 and 31.07±3.2 nmol/l (p<0.001), respectively.

Conclusion:  In this study it was observed that vitamin D deficiency is important risk factor of bone loss in GHD adults. GH treatment together with vitamin D led to greater increase in BMD than GH treatment alone.

 

Nothing to Disclose: MK, PJ, PV, ZK, JP

21123 6.0000 THR-231 A Vitamin D - a Contributing Factor of Bone Mass Increase in Hypopituitary Adults after Growth Hormone Replacement 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Pablo F Florenzano*1, Daniel Ernst2, Claudia Campusano3 and Pablo Ramirez4
1Pontificia Universidad Católica de Chile, Santiago, Chile, 2Pontificia Universidad Católica de Chile, Chile, 3Pontificia Universidad Catolica de Chile, Santiago, Chile, 4Pontificia Universidad Católica de Chile

 

INTRODUCTION: The increase in survival of hematological patients has determined the need to consider factors related to quality of life and late mortality. Among them, osteoporosis (OP) is an important problem. Patients undergoing hematopoietic cell transplantation (HCT) are at increased risk of OP, mainly due to chemotherapy, immunosuppressive drugs and the hypogonadism frequently associated to those treatments. Despite this, there is lack of strong evidence and HCT guidelines are not clear on the appropriate study and management of these issue.

OBJECTIVES: To evaluate bone health parameters in patients undergoing HCT and to determine the frequency and severity of alterations in this group of patients.

PATIENTS AND METHODS:  Observational study of patients undergoing HCT in our institution. All patients were recommended to have determination of 25-OH vitamin D (25OHD), parathyroid hormone (PTH), calcium, phosphorus and bone densitometry (DXA). We included all patients with the evaluation before HCT (preHCT) and 1 year after HCT (postHCT). We determined the frequency of vitamin D deficiency, hyperparathyroidism and low bone mass (Z score <-2.0).

RESULTS: We obtained data from 19 patients preHCT and 22 patients postHCT. Main diagnoses were acute myeloid leukemia (n=13; 32%), multiple myeloma (n=11; 26%), acute lymphoblastic leukemia (n=9; 21%) and Hodgkin's Lymphoma (n=5; 12%). Median age was 40 years (range: 17-67) and 64% were males. 68 % of patients received vitamin D supplementation during the transplant period. In the preHCT group, the median 25OHD levels were 10,1 ng/ml (4,9-26,7), 100% of the patients were in the insufficiency range (<30 ng/ml) and 84% in the deficiency range (<20 ng/ml). Median PTH levels were 57,1 pg/ml (24-112 pg/ml), and 38,5% of the patients had secondary hyperparathyroidism. In the postHCT group, median 25OHD levels were 11,2 ng/ml (4-29,4), 100% had insufficiency levels and 95% were in deficiency range. Median PTH levels were 67,1 pg/ml (33-135), and 50% of the patients had secondary hyperparathyroidism. Those patients who developed Chronic Graft Versus Host Disease (GVHD) had significantly higher PTH levels than those who did not (p<0,05), without a significant difference in the prevalence of Vitamin D deficiency. 12 patients had DXA before HCT and 3 (25%) of them had lumbar Z score less than -2.0. In 19 patients postHCT, 4 (21%) had lumbar low bone mass. No difference could be established between autologous or allogeneic HCT in any measurement.

CONCLUSIONS: HCT patients represent a high risk group of developing vitamin D deficiency, secondary hyperparathyroidism and decreased bone mass. These data are a warning that this population of patients requires early intervention to prevent long-term complications. This report is the initial evaluation for the development and treatment of bone health in a prospective protocol in HCT patients in our institution.

 

Nothing to Disclose: PFF, DE, CC, PR

18534 7.0000 THR-232 A High Frequency of Vitamin D Deficiency, Secondary Hyperparathyroidism and Decreased Bone Mass in Patients Undergoing Hematopoietic Cell Transplantation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Sri Harsha Tella*1, Vinod Yalamanchili2 and J Christopher Gallagher3
1National Institutes of Health, Bethesda, MD, 2Creighton University School of Medicine, Omaha, NE, 3Creighton University Medical Center, Omaha, NE

 

BACKGROUND: Vitamin D deficiency is often implicated in depressive symptoms of post menopausal women, however there are no systematic studies on effect of increasing doses of vitamin D supplementation on depression.

METHODS: We conducted a randomized, placebo-controlled trial in 163 post menopausal Caucasian women (mean age:67 (±7.3) years) with vitamin D insufficiency (serum 25-hydroxyvitamin D ≤20 ng/dl [50 nmol/liter]). Subjects were randomized to placebo, vitamin D3 400, 800, 1600, 2400, 3200, 4000, or 4800 IU daily; calcium supplements were given to maintain total calcium intake of 1200-1400 mg/day. The Geriatric Depression Scale-Long Form 30(GDS-LF30) was used to collect data on depressive symptoms at baseline and at end of 12 months. Pearson’s correlation was used to find a relationship between baseline 25OHD level with depression scores. Multiple regression analysis was used to determine the effect of vitamin D dose and serum 25OHD on depression scores adjusting for BMI, antidepressant use, smoking status, alcohol consumption, caffeine use, thyroid disease, educational status, living status and physical activity. We also explored the relationship between improvement in GDS score (Baseline GDS minus 12 month GDS) and serum 25OHD and vitamin D dose.

RESULTS: The serum 25OHD levels at baseline did not correlate significantly with GDS scores (X2= -0.065, p=0.408). There was no difference in GDS between subjects who had serum 25OHD level less than 10 ng/ml compared to those who had greater than 10 ng/ml at baseline (X2= -0.065, p=0.408). At the end of 12 months, there was no effect of dose on change in GDS score in women treated with different doses of vitamin D (p=0.507). The 12 month GDS scores were significantly related to baseline GDS scores (p<0.0001) but not to the BMI (p=0.507), hypothyroidism (p=0.507), living status (p=0.507), final serum 25 0HD levels (p=0.689), antidepressant use and educational status (p=0.507). Mean GDS score at baseline was 3.8(SD±4.2) and at the end it was 3.6(SD±4.1). A subgroup analysis of 12 women depressed at baseline showed no improvement in the GDS score after vitamin D treatment.

CONCLUSION: Increasing doses of vitamin D3 from 400 IU/d through to 4800 IU/d did not influence the depression scores in vitamin D insufficient women after 1 year. It remains to be seen whether there is any effect of vitamin D3 supplementation in patients having both clinical depression and vitamin D insufficiency.

 

Nothing to Disclose: SHT, VY, JCG

18966 8.0000 THR-233 A Effect of Vitamin D3 Supplementation on Depression in Post-Menopausal Women: A Multi-Dose Randomized Placebo Controlled Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Brett Holmquist*1, Joseph L Shaker2 and Donald Walt Chandler1
1Laboratory Corporation of America Holdings, Calabasas Hills, CA, 2Medical College of Wisconsin, Milwaukee, WI

 

Summary:           A sensitive, simple and fast LC-MS/MS method has been developed to allow quantitative measurements of 24R,25-Dihydroxyergocalciferol (24,25VD2) and 24R,25-Dihydroxycholecalciferol (24,25VD3) from serum or plasma.

Introduction:     Many different vitamin D metabolites in serum are measured in the modern clinical laboratory.  The most commonly measured vitamin D test is 25-hydroxyvitamin D (25OHD), which is a marker of vitamin D sufficiency.  Another commonly ordered vitamin D test is 1,25-dihydroxyvitamin D, which can be useful in diagnosing disorders of calcium homeostasis.  Another less commonly ordered vitamin D test is for the metabolite that is made directly in the skin or is consumed through foods or dietary supplements.  In addition to these metabolites, the measurement of 24,25VD has been reported to be useful in identifying disorders arising from CYP24A1 mutations that impact 24-hydroxylation of 25OHD.  A new method was developed specifically for the 24,25VD metabolites of 25OHD arising from both vitamins D2 & D3. 

Methods:            An analytical method was developed using HPLC with tandem mass spectrometry.  Independent calibration curves were prepared for 24,25VD2 and 24,25VD3 in depleted serum.  Sample preparation consisted of isotope dilution using internal standards for both analytes followed by supported liquid extraction and derivatization with 4-phenyl-1,2,4-triazoline-3,5-dione (PTAD).  An octadecylsilane (ODS) analytical column was used with a solvent gradient to achieve chromatographic resolution of all relevant interferences.  Positive mode electrospray ionization (ESI) was used for detection in Multiple Reaction Monitoring (MRM) mode.

Validation Data:               Analytical sensitivity was 0.25 ng/mL for each analyte.  Inter-assay precision ranged from 2.8 – 11.4% (24,25VD2) and 3.1 – 6.3% (24,25VD3).  Accuracy ranged from 99.5% – 103.6% (24,25VD2) and 92.9 – 96.2% (24,25VD3).  Reference intervals were developed for total 24,25VD using discarded routine wellness screening specimens and found to be 1.8 – 9.1 ng/mL total 24,25VD.

Clinical Significance:      It has been shown that loss-of-function mutations in 25-hydroxyvitamin D-24-hydroxylase (CYP24A1) are associated with idiopathic infantile hypercalcemia (IIH) as well as calcitriol-induced hypercalcemia and hypercalciuria in adults.  We used this method to measure 24,25VD in a 24 year old woman with PTH-independent, calcitriol-induced hypercalcemia.  The hypercalcemia was not responsive to prednisone and extensive evaluation revealed no cause.  The 24,25VD was undetectable, compatible with a loss-of-function mutation of 25-hydroxyvitamin D-24-hydroxylase (genetic testing not yet performed).  Utilization of this method, along with a validated, CDC-HoSt accuracy verified method for 25OHD, will enable further investigation into patients with suspected mutations in 25-hydroxyvitamin D-24-hydroxylase.

 

Disclosure: BH: Employee, LabCorp. JLS: Consultant, Alexion. DWC: Employee, LabCorp.

21465 9.0000 THR-234 A Validation of a Bioanalytical Method for 24R,25-Dihydroxyvitamin D By LC-MS/MS:  Clinical Applications Beyond Idiopathic Infantile Hypercalcemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Ryan Spears, Neil Parker, James Freeman, Kimberly Wilson, Paul Sibley and Ross Molinaro*
Siemens Healthcare Diagnostics, Inc., Tarrytown, NY

 

Background. Vitamin D is a steroid hormone involved in the intestinal absorption of calcium and the regulation of calcium homeostasis, and assay standardization in laboratory medicine has become increasingly important. Apart from being able to assess the Vitamin D status of an individual, it is necessary to accurately determine the concentration of Vitamin D in patients on supplementation. The Siemens ADVIA Centaur® Vitamin D Total assay has been standardized to the University of Ghent ID-LC/MS/MS reference measurement procedure (RMP) and has achieved the Centers for Disease Control (CDC) Vitamin D Standardization Certification (VDSCP). The assay performance has been assessed in patient samples and compared to a VDSCP certified LC-MS/MS assay. In addition, samples from subjects containing 25(OH)vitamin Dand 25(OH)vitamin D3 were included in the study to demonstrate the ability of the assay to measure both forms of 25(OH)vitamin D, and also to demonstrate the equimolarity of the test.

Method. A comparison between ADVIA Centaur Vitamin D Total Assay and Endocrine Sciences Laboratory (LabCorp) VDSCP certified 25(OH)vitamin D LC/MS/MS method was achieved by running 149 samples across the range of both methods. The samples were tested on the ADVIA Centaur Vitamin D Total assay and subsequently run on LabCorp’s VDSCP certified method. These data were analyzed with a Deming fit comparison plot as well as a Bland-Altman plot comparing the total vitamin D dose data between the two methods. Deming fits and Bland-Altman plots were also generated for the samples containing both 25(OH)vitamin D2 and D3, and for samples containing 25(OH)vitamin D3 only, in order to assess the assay’s equimolarity. 

Results: The data obtained showed good correlation between the ADVIA Centaur Vitamin D Total assay and the VDSCP Certified 25(OH)vitamin D LC/MS/MS method. The Deming fit comparison between the two methods yielded a Deming slope of 0.97, an intercept of + 2.22 ng/mL, and a Pearson’s coefficient of 0.95.  When focusing specifically on the 55 samples containing 25(OH) Vitamin D2 , the Deming slope was 1.02, with an intercept of + 1.92 ng/mL and a  Pearson’s coefficient of 0.93. When analyzing the 94 samples that only contain 25(OH)vitamin D3, the Deming slope was 0.95 with an intercept of + 2.13 ng/mL and a Pearson’s coefficient of  0.97. 

Conclusions: In comparison to a VDSCP certified 25(OH)vitamin D LC/MS/MS method, the ADVIA Centaur Vitamin D Total assay produced comparable results across the full range of the assay and was able to measure both forms of 25(OH)vitamin D accurately. These data indicate the importance of standardization to improve clinical confidence in the comparability of vitamin D measurement.

 

Disclosure: RS: Employee, Siemens Healthcare Diagnostics, Inc.. NP: Employee, Siemens Healthcare Diagnostics, Inc.. JF: Employee, Siemens Healthcare Diagnostics, Inc.. KW: Employee, Siemens Healthcare Diagnostics, Inc.. PS: Employee, Siemens Healthcare Diagnostics, Inc.. RM: Employee, Siemens Healthcare Diagnostics, Inc..

18901 10.0000 THR-235 A The Value of a Standardized and Certified Vitamin D Total Assay for Clinical Confidence 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Jie Li, Elsa Garcia, Zhu Teng, Martin Drinan, Roland Janzen, Chris Larson, Michelle Stranz, Douglas Clark, Barbara Wessel, Pratap Singh, Manoj Sharma, Tie Q. Wei and Ross Molinaro*
Siemens Healthcare Diagnostics, Inc., Newark, DE

 

Background. Vitamin D is a steroid hormone involved in the intestinal absorption of calcium and the regulation of calcium homeostasis. Assay standardization in laboratory medicine has become increasingly important. The Dimension EXL System incorporates multiple detection technologies, including LOCI technology, which enables high sensitivity immunoassay formats. Siemens is currently developing a standardized Vitamin D Total assay utilizing LOCI® technology on the Dimension® EXL™ System. 

Method. The Dimension EXL Vitamin D Total assay (VitD) is a homogeneous competitive chemiluminescent immunoassay based on LOCI technology. It measures the total 25(OH)vitamin D concentration (25(OH) D2  and 25(OH) D3) in both serum and plasma. The LOCI VitD components include a releasing reagent, two synthetic bead reagents and a biotinylated monoclonal antibody. The first bead reagent (Sensibeads) is coated with streptavidin and contains a photosensitive dye. The second bead reagent (Chemibeads) is coated with a 25(OH) vitamin D3 analog and contains a chemiluminescent dye. The sample is incubated with the releasing reagent to release vitamin D molecules from their binding proteins. The reaction mixture is then incubated with biotinylated antibody to form a 25(OH)vitamin D/biotinylated antibody complex. Chemibeads are added to remove the excess free biotinylated antibody, and then Sensibeads are added to trigger the formation of Chemibead-analog/antibody-biotin/streptavidin-Sensibeads complexes. Illumination of the reaction mixture at 680nm generates singlet oxygen from Sensibeads, which diffuses into the Chemibeads and triggers a chemiluminescent reaction. The resulting signal is measured at 612nm and is inversely proportional to the concentration of total 25(OH)vitamin D in the sample. The assay is equimolar for 25(OH)vitamin D2 & D3 and is standardized to the Ghent University ID-LC/MS/MS reference measurement procedure (RMP).

Results: The method requires 8 µL of serum or plasma and is linear from 4 to 150 ng/mL. Repeatability and within-lab CVs were less than or equal to 3.6% and 4.5% CVs for values between 10-100 ng/mL, respectively.  Method comparison studies demonstrated the following Passing-Bablok regression fits: EXL VitD = 1.01 x ADVIA Centaur Vitamin D Total assay - 3.6ng/mL, (n=346, r=0.931, range = 8-149 ng/mL); EXL VitD = 1.04 x ID-LC/MS/MS - 3.86 ng/mL, (n=90, r=0.932, range = 5.8-79.1 ng/mL). No significant cross-reactivity was observed with 3-epi-25(OH) D3 ,1,25(OH)2 D2 and1,25(OH)2 D3,  D2 and D3.

Conclusions: The Dimension EXL Vitamin D Total assay demonstrates acceptable precision, accuracy, and turnaround time for total 25(OH)vitamin D measurement on the Dimension EXL System, and is standardized to the 25(OH)vitamin D RMP.

* Under development. Not available for sale. Due to local regulations, not all products will become available in all countries.

 

Disclosure: JL: Employee, Siemens Healthcare Diagnostics, Inc.. EG: Employee, Siemens Healthcare Diagnostics, Inc. . ZT: Employee, SIemens Healthcare Diagnostics, Inc.. MD: Employee, Siemens Healthcare Diagnostics, Inc.. RJ: Employee, Siemens Healthcare Diagnostics, Inc.. CL: Employee, Siemens Healthcare Diagnostics, Inc.. MS: Employee, Siemens Healthcare Diagnostics, Inc.. DC: Employee, Siemens Healthcare Diagnostics, Inc.. BW: Employee, Siemens Healthcare Diagnostics, Inc.. PS: Employee, Siemens Healthcare Diagnostics, Inc.. MS: Employee, Siemens Healthcare Diagnostics, Inc.. TQW: Employee, Siemens Healthcare Diagnostics, Inc.. RM: Employee, Siemens Healthcare Diagnostics, Inc..

19070 11.0000 THR-236 A Development of a Vitamin D Total Assay with LOCI Technology on the Dimension Exl System 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Sathit Niramitmahapanya*1, Surasak Kaoiean2, Varaporn Sangtawesin3, Anusorn Patpanaprapan4 and Narisa K Bordeerat5
1Endocrinology and metabolism Unit , Department of medicine, Rajavithi Hospital, Bangkok, Thailand, 2Division of Maternal Fetal,, Bangkok, Thailand, 3Neonatal Unit,, Bangkok, Thailand, 4Endocrinology and metabolism Unit ,, Bangkok, Thailand, 5Department of Medical Technology, Pathumthani, Thailand

 

Background: Vitamin D deficiency in pregnancy increases risk of gestational diabetes mellitus, pre-eclampsia, preterm birth, low birth weight and cesarean section. To against these adverse events, vitamin D supplementation in pregnancy and lactation is recommended, but dose ranges are varied.

Objective: To determine whether vitamin D3 1,800 IU/d supplementation in lactating mother improves vitamin D status of breast-fed infant.

Materials and methods:  A randomized, placebo–controlled trial in Thai pregnancy was conducted. The lactating mothers (n=76) and their breastfed infants with maternal 25 Hydroxy-vitamin D (25OHD) levels of 25-75 nmol/L in third trimester were randomly assigned to 1,800 IU/d compared with maternal and infant controls receiving placebo. Maternal serum 25OHD and milk vitamin D were measured during lactation, cord blood and 6 weeks breastfed infant serum by LC–MS/MS. The Ethics committee, Rajavithi Hospital approved this study. A signed consent form was given.

Results: Mean maternal age (±SD) was 27±5 years, and pre-gestational BMI was 22.29+5 kg/m2. Maternal serum 25OHD at baseline was 56.01+13.90 nmol/L. At 6 weeks, infant 25 OHD levels increased significantly compared to controls (24.28+17.20 nmol/L (placebo) vs 40.40+12.56 nmol/L (vitamin D (VD); p <0.001). The changes in 25OHD  level was strongly increased in VD group by 17.49+16.27 nmol/L vs -1.34+19.23 nmol/L (placebo); p<0.001).

Conclusions: Vitamin D3 supplementation during lactation increases serum 25OHD in Thai breastfed infants and decreases vitamin D deficiency status. Further work is needed to determine the duration of vitamin D supplement to normalized breast-fed infant 25OHD level >75 nmol/L.

 

Nothing to Disclose: SN, SK, VS, AP, NKB

20221 12.0000 THR-237 A Maternal Vitamin D3 Supplementation during Lactation Ameliorate Vitamin D Status of Breast–Fed Infants: Randomized Controlled Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Lauren Ross*1, Tiffanny Jones1, Sue Ann Ingles1, Raj Pandian2, Frank Z Stanczyk1, Karine Chung1, Richard J Paulson1, Briana Rudick3 and Kristin Bendikson1
1University of Southern California, 2Pan Laboratories, 3Columbia University

 

Background:  Vitamin D deficiency has been shown to decrease pregnancy rates with IVF.  However, this role has been found to vary by ethnicity with vitamin D deficiency being associated with lower pregnancy rates in non-Hispanic whites (NHW), but not in Asians [1].  It has been suggested that vitamin D binding protein (VDBP) levels vary among different ethnicities and thus the common measurement of 25-hydroxyvitamin D (25OHD) may not be an accurate assessment of bioavailable 25-hydroxyvitamin D (BAVD) [2,3].  Given the variable impact of vitamin D deficiency (measured by 25OHD) on IVF outcomes in the NHW and Asian populations it is important to further characterize and examine the correlation of 25OHD with BAVD in these ethnicities and examine pregnancy rates.

 

Objective:  To characterize BAVD levels in both non-Hispanic white (NHW) and Asian women undergoing IVF and correlate these values with pregnancy rates. 

Materials and Methods: Between 2008 - 2011, first IVF cycles of NHW and Asian women were identified. Frozen serum was measured for 25OHD, albumin, and VDBP allowing calculation of BAVD (Pan Laboratories). Vitamin D status was classified as deficient (25OHD<20 ng/mL), insufficient (25OHD=20-30ng/mL), or replete (25OHD>30ng/mL). The normal reference range for BAVD is 1.92-8.82 ng/mL. Clinical pregnancy was defined by presence of cardiac activity. Statistical analysis was performed with t test, Fisher’s exact and Chi Square analysis as appropriate.

Results: Baseline characteristics (age, BMI, diagnosis) did not vary between the Asian (N=88) and NHW (N=161) populations.  25OHD was significantly lower in Asians compared to NHW at 30.4 ± 11.1 ng/ml vs 34 ± 12.0 ng/ml respectively (p = 0.02).  VDBP was significantly lower in Asians compared to NHW at 257 ± 147 ug/mL vs 338 ± 157 ug/mL respectively (p < 0.001).  As VDBP was significantly lower among Asians, BAVD was found to be significantly higher in the Asian population.  Asian BAVD levels were 5.12 ± 4.23 ng/mL compared to 3.71 ± 2.37 ng/mL in the NHW population (p < 0.001).

There was a trend that women with BAVD levels exceeding the normal reference range had lower clinical pregnancy rates than those with normal BAVD levels at 26.1% vs 46.9% (p=0.056). A large proportion of Asians who were 25OHD replete had BAVD levels exceeding the normal range 29% (8/29), compared to only 6% (3/51) of NHW patients. 

Conclusions:  With the variation in VDBP between the NHW and Asian populations and the resulting differences in BAVD, consideration of ethnicity should be made prior to vitamin D supplementation based solely upon 25OHD levels. Given that 25OHD levels do not seem to be an accurate assessment of BAVD in all cases, especially in Asian women, ethnicity should be considered before supplementation is started. Measurement of BAVD should particularly be considered prior to supplementation in Asian women, given the trend of reduced pregnancy rates when levels exceed the normal range.

 

Nothing to Disclose: LR, TJ, SAI, RP, FZS, KC, RJP, BR, KB

20517 13.0000 THR-238 A Redefining the Diagnosis of Vitamin D Deficiency in IVF Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Claudia L Pop1, Xiangbing Wang*2, Sun Wei2, Brian Chang1 and Sue Shapses1
1Rutgers University, New Brunswick, NJ, 2Rutgers University-RWJMS, New Brunswick, NJ

 

Background: Vitamin D–binding protein (DBP), the primary vitamin D carrier protein, binds 85-90% of total circulating 25-hydroxyvitamin D (25OHD).  Physiological or pathological conditions could alter serum DBP concentrations and thereby vitamin D status. Studies have shown that exogenous estrogen increases serum DBP concentrations.  The relationship between total DBP, 25OHD, calculated free and bioavailable 25OHD concentrations and estradiol, was addressed in pre- and post-menopausal women.

Methods: Serum concentrations of 25OHD, DBP, estradiol, parathyroid hormone (PTH) and albumin were measured in 165 healthy women (ages 26-75 y), grouped by menopausal status (49 premenopausal and 116 postmenopausal). Free and bioavailable 25OHD (free + albumin-bound) were calculated from total 25OHD, DBP, and serum albumin levels.  

Results and Conclusion: Premenopausal women had higher serum 25OHD (31.5 ± 7.9 ng/mL), DBP (45.3 ± 6.2 mg/dL) and estradiol (52.8 ± 35.0 pg/mL) than postmenopausal women (26.5 ± 4.9 ng/mL, 41.7 ± 5.7 mg/dL and 12.9 ± 4.9 pg/mL, respectively; p<0.01). In addition, the calculated free and bioavailable 25OHD were higher in pre- than post-menopausal women (p<0.05). Serum PTH, albumin and calcium did not differ between groups.  There was an inverse correlation between DBP and age (r = 0.28; p < 0.05).  Serum estradiol correlated with DBP (r = 0.22; p < 0.01) and total 25OHD (r = 0.27; p < 0.01), but not with free or bioavailable 25OHD.  In multivariate regression models (with or without serum 25OHD) estradiol was independently associated with DBP (p< 0.05).  In conclusion, besides well-known factors such as age, gender and race influencing DBP, these data indicate that estradiol concentrations are also a predictor of DBP concentration in healthy women.

 

Nothing to Disclose: CLP, XW, SW, BC, SS

22068 14.0000 THR-239 A Serum Estradiol and Vitamin D Binding Protein in Healthy Pre and Postmenopausal Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Charikleia Stefanaki*, Maria Papaefthymiou, Evangelia Kolias, Georgios Landis, George P Chrousos and Flora Bacopoulou
University of Athens Medical School, Athens, Greece

 

Obesity, overweight and hypovitaminosis D are common in adolescents living in developed countries. Obesity is associated with low vitamin D plasma concentrations. This has been explained as a result of selective sequestration of vitamin D in subcutaneous and visceral adipose tissues. The aim of this study was to evaluate potential differences and predictors of circulating 25-hydroxyvitamin D [25(OH)D] concentrations among otherwise healthy Greek male and female adolescents according to body mass index (BMI). A total of 97 adolescents (62 males, 35 females) aged (mean±SD) 14±2.5 years were enrolled. Among those, 41 had normal BMI (23 males, 18 females), 17 were overweight (12 males, 5 females) and 39 obese (29 males, 10 females). Morning serum concentrations of 25(OH)D, calcium (Ca), phosphorus (P) and parathyroid hormone (PTH) were measured in each participant. Vitamin D deficiency was defined as 25(OH)D levels <20 ng/ml and vitamin D insufficiency as  25(OH)D of 21-29 ng/ml (1). Overall, study adolescents had mean (±SD) serum 25(OH)D of 23.0±8.7ng/mL, with only 20.6% having adequate levels (≥30ng/mL). Vitamin D insufficiency and deficiency were detected in 43.3% and 36.1% of participants, respectively. Mean 25(OH)D levels were relatively stable in males irrespective of BMI, but were decreased in females with increasing BMI. One-way factorial ANOVA revealed significantly higher 25(OH)D concentrations in females (28.0±7.8 ng/mL) than males (23.4±10.50 ng/mL) of the normal BMI group and in males (23.9±7.50 ng/mL) than females (17.6±8.50 ng/mL) of the obese group [F(2, 91)=3.7617, p=0.026]. Overweight females had significantly higher mean serum PTH concentrations (64.8±22.50 pg/ml) than overweight males (34.8±10.55 pg/ml), and obese (46.1±18.21 pg/ml) and normal BMI (41.9±16.51 pg/ml) females [F(2, 86)=3.8179, p=0.025]. There were no significant differences in Ca or P concentrations among study groups. Pearson’s correlation analysis of the total sample revealed a weak positive correlation of PTH concentrations with BMI (r=0.22 p<0.05), but no significant associations between vitamin D concentrations and BMI. Multiple stepwise regression analysis was performed to test if age, BMI, PTH, Ca and P significantly predicted vitamin D concentrations. There were no statistically significant predictors for 25(OH)D when each group (normal BMI, overweight, obese males and females) was studied separately; in the whole sample, however, PTH was the best predictor for vitamin D concentrations, which explained 24.5% of 25(OH)D variance [R2=0.06, F(1,89)=5.6824, SE=8.51, β=-0.24, SEβ=0.102, t(89)=-2.38, p<0.019]. We conclude that Greek adolescents had high prevalence of vitamin D deficiency and insufficiency and serum PTH was the best predictor for serum vitamin D concentrations. Obesity was associated with lower serum 25(OH)D concentrations only in the female adolescent participants.

 

Nothing to Disclose: CS, MP, EK, GL, GPC, FB

21265 15.0000 THR-240 A Concentrations and Predictors of Circulating Vitamin D in Greek Adolescents in Association with Body Mass Index 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Maria F Contreras*1, Raphael R David2, Resmy Palliyil Gopi1, Laura Malaga-Dieguez3, Howard Trachtman1 and Brenda Kohn1
1New York University School of Medicine, New York, NY, 2New York University School of Medicine, 3New York University School of Medicine, New york, NY

 

BACKGROUND

Recent progress in the identification of Magnesium (Mg) transporters and channels has advanced our understanding of Mg homeostasis. The TRPM6 gene, which encodes an ion channel, contributes to the understanding transepithelial Mg transport. An association was identified between hypomagnesemia with secondary hypocalcemia and the TRPM6 gene. Recently a missense mutation in TRPM6 gene was reported (1). Several other genes have also been reported in hereditary renal Mg loss. No definite phenotype-genotype correlation has been established. Paracellular transport of magnesium was clarified by the claudin 16-19 mutations. Claudins are tight junctions proteins located in the kidney; mutations in these key proteins are responsible for the condition called familial hypomagnesemia with hypercalciuria and nephrocalcinosis (2).

Hypomagnesemia occurs in malabsorption, vitamin D deficiency and hypoparathyroidism. The syndrome of hypomagnesemia with secondary hypocalcemia is a rare disorder characterized by a defect in renal or intestinal Mg absorption, which can result in brain damage if not recognized early.

We report a newborn who presented with convulsions, profound hypomagnesemia with hypocalcemia.

CASE REPORT

A full term male, born to Yemenite parents with no parental consanguinity nor any significant family history, presented at 12 days of life with new onset generalized convulsions. Initial studies showed: Mg <0.6 mg/dL (1.6-2.3 mg/dL), calcium 6.4mg/dl (8.3-10.3 mg/dL), phosphorus 10.3 mg/dl (2.7-4.5 mg/dL), glucose 81mg/dl. Genetic investigation is in progress.

 The baby was initially treated with anticonvulsants and calcium gluconate. Despite this treatment, seizures persisted. IV Mg boluses (50mg/kg) and Ca (100mg/kg) were then administered. Within 24 hrs serum Ca normalized, but Mg remained below normal. The baby was transitioned to PO Mg and Ca supplements. Serum 25 hydroxy vitamin D was <13ng/mL ergocalciferol 2000 units were supplemented.

Fractional Mg excretion (FEMg) was elevated at 15% (1-8%) with a low serum Mg 1 mg/dL suggestive of renal loss of Mg. Renal ultrasound was normal.

 After 24 hrs of IV Ca and Mg, the seizures ceased. However, Mg levels remained suboptimal (highest 1.5mg/dl) despite high PO doses of Mg. The baby was discharged on high doses of Mg (100 mg q 6 hrs), Ca and Vit D supplementation. During follow up calcium and vitamin D were tapered then stopped. Supplemental Mg was increased to 200mg q 6hrs to maintain Mg levels at least >1.0 mg/dl.

 CONCLUSION

Primary hypomagnesemia can occur with other electrolyte abnormalities and may be life threatening. The diagnosis can be a challenge, and a high index of suspicion is needed. An inherited disorder should be suspected, and genetic studies are recommended. Despite high doses of Mg levels may remain subnormal. Early diagnosis and appropriate treatment are important to avoid irreversible neurologic damage.

 

Nothing to Disclose: MFC, RRD, RP, LM, HT, BK

19240 16.0000 THR-241 A Profound Neonatal Hypomagnesemia with Secondary Hypocalcemia: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Maria F Contreras*, Brenda Kohn, Resmy Palliyil Gopi and Preneet Cheema Brar
New York University School of Medicine, New York, NY

 

BACKGROUND:

Circulating levels of 25 (OH) vitamin D (VD) mediate deterioration of beta cell function in vitamin D deficiency (VDD) states. Higher parathyroid hormone (PTH) levels have a negative impact on the beta cell function and insulin sensitivity (1, 2). Understanding the independent effect of VD and PTH on different aspects of glucose homeostasis may be paramount, especially when treating obese adolescents with VDD.

 OBJECTIVE:

 To study the independent effects of VD and PTH on surrogates (sensitivity and secretory indices derived from oral glucose tolerance test: OGTT) before and after Rx for VDD.

 METHODS:

 In a single blinded randomized placebo controlled study (cross over design with sample size= 7) obese adolescents with VDD (25 (OH) < 20 ng/dl) were recruited. Adolescents received 50,000 IU of ergocalciferol (group A) once weekly or placebo (group B) for 6 weeks. At week 7, subjects were reassigned to receive VD if they were in group B or placebo if they were in Group A. Study subjects had an OGTT and screening labs (25 (OH) Vitamin D, PTH, CMP, calcium, phosphorous and urine calcium/creatinine ratio) at baseline, week 7 and then again at week 12 on the completion of study. 

OGTT indices: Insulin sensitivity was assessed by homeostatic model assessment index of insulin resistance (HOMA-IR) (3) and Whole body insulin sensitivity index (WBISI) (4), while B cell function was evaluated by insulinogenic index (IGI) (5) derived from an OGTT.

 RESULTS:

  • Six of the seven patients were female (mean ± SD): age 15.4±1.9 years, BMI 34 ± 3.7, preRx VD 17.8± 2, postRx VD 22 ± 5.7(> 19ng/ml); preRx PTH 58 ± 20.8, postRx PTH 51 ± 12.6 (15-75 pg/mL).
  • When stratified by changes in VD postRx (group1= increase of 30% or more in VD level; group 2= <30 % change) indices derived from OGTT were: WBISI4.3 ± 0.5 vs. 3.4 ± 1.9, HOMA-IR: 2.7 ± 0.4 vs. 4.1 ± 3, IGI: 1.9± 0.6 vs. 1.6± 1. IGI to be statistically significant between groups (independent sample t test: p= 0.031). 
  • When stratified by change in PTH levels postRx (group 1= decrease in PTH level n=4 vs. group 2 increase in PTH level n=3) indices derived from OGTT were: WBSI 4.1 ± 0.7 vs. 3 ± 2.2 HOMA-IR: 3± 0.3 vs. 4.1± 3.7, IGI: 1.6± 1 vs. 1.8± 0.6. HOMA-IR and WBISI were found to be different between groups (p= 0.010 and p=0.07 respectively)

CONCLUSIONS: VD and PTH work synergistically in bone health though they likely influence glucose metabolism through independent mechanism. a) Optimization of vitamin D may require using 2-3 fold higher doses (as suggested by the Endocrine society for adults) to achieve levels of 25(OH) D levels >30 ng/ml thereby maximizing the beneficial effects of vitamin D on glucose homeostasis. b) Preliminary results show that VD levels postRx correlate with secretory index IGI and PTH levels postRx with sensitivity indices: HOMA-IR and WBISI. The relative contributions of VD and PTH on aspects of glucose metabolism may have unique therapeutic implications for glucose dysregulation.

 

Nothing to Disclose: MFC, BK, RP, PCB

19548 17.0000 THR-242 A Evaluation of the Effects of PTH-Vitamin D Axis on Glucose Homeostasis in Obese Adolescents with Vitamin D Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Gabriel Ikponmosa Uwaifo1, Amy G Varughese*2, Joseph Nicholas Bodor3 and Stephanie Moss2
1Louisiana State University Healt, New Orleans, LA, 2LSUHSC, New Orleans, LA, 3University of Maryland, Baltimore, MD

 

Obesity is a suggested risk factor for hypovitaminosis D (Hypovit D). African Americans(AA) have a higher prevalence of Hypovit D compared to Caucasians(C) .

That vitamin (Vit) D repletion in Hypovit D with Vit D 50, 000 units once wkly x 12 wks) would be less effective in obese subjects than reported in normal weight subjects.

A retrospective EMR review of obese patients seen at LSUHSC was done. Data collected included age, sex, race, height, weight and BMI before and after Vit D supplementation. 168 patients were screened for inclusion. Patients whose post treatment (Rx) Vit D levels were obtained post bariatric surgery and/or who had bariatric surgery preceding the pre Rx Vit D level were excluded. Total of 117 patients were included for analysis.

 Pre Rx Hypovit D prevalence  didn’t differ by gender. Pre Rx Vit D  did differ by race and BMI. AA were more likely to be deficient than C(OR 2.725). Patients with higher BMI were more likely to be deficient (p value 0.021, OR 1.042). Among those who received Vit D supplements there were no significant difference by race or BMI on Vit D levels correction. In those with BMI> 60,  88.2% had Hypovit D (< 30) post Rx ( p value 0.012).The mean Vit D level in those with BMI> 60 was 17.650 ng/ml. The mean Vit D in C was 24.897 ng/ml and in AA was 19.228 ng/ml.  In those with BMI >60, 70.6% had Vit D <20 (p-value 0.072). 63.8% of AA had Vit D <20% (p-value 0.031). 36.4 % of males had hypovitaminosis D corrected compared to 48 % of females. For C patients with Hypovit D 50 % were corrected compared to 42.9 % of AA patients. Of the patients with post Rx Vit D levels, 55.6% of them did not have hypovitaminosis D corrected. In those with BMI>60, 58.3% did not have Hypovit D corrected. Compared to males 48% of the females did not correct Hypovit D. The average dose of Vit D was 50000 units wkly for 12 weeks. For patients with BMI <40 the Hypovit was corrected with the standard Vit D treatment in all.

Vit D deficiency is prevalent among markedly obese subjects especially if AA. The recommended dose of Vit D for Rx is not adequate to raise blood levels of 25(OH) D to > or =30 ng/ml. The standard recommended dose for Hypovit D was adequate for correction for those with BMI < 40. Since more than 50 % of obese individuals do not correct with current recommended doses, a higher dose or increased frequency and/or duration may be required. A prospective randomized study may be able to define an adequate dose for his population.

 

Nothing to Disclose: GIU, AGV, JNB, SM

22154 18.0000 THR-243 A Is Standard Vitamin D Replacement Adequate in Obese Individuals to Correct Hypovitaminosis D? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Marlene Toufic Chakhtoura*1, Elie Akl2, Nancy Fawzy Nakhoul1 and Ghada El-Hajj Fuleihan3
1American University of Beirut, Beirut, Lebanon, 2American University of Beirut, Lebanon, 3AUB, Beirut, Lebanon

 

Introduction:

Obesity is a global public health problem that carries substantial social and economic costs.  Bariatric surgery has the most substantial impact on weight loss; however, it leads to nutritional deficiencies requiring long term supplementation.

Objective:

To systematically review and assess (1) the predictors of vitamin D status and (2) current guidelines for vitamin D replacement in obese patients undergoing bariatric surgery.

Methods:

We searched Medline, PubMed, the Cochrane Library and EMBASE for relevant English articles and the National Guideline Clearinghouse for clinical practice guidelines, with no time restriction.  Two reviewers rated the quality and reporting of the guidelines, independently, using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) tool (www.agreetrust.org/).

Results:

We identified 25 large observational studies, and 3 clinical practice guidelines on the peri-operative nutritional care of patients undergoing bariatric surgery: the Endocrine Society (ES) Guidelines (2010), the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and American Society for Metabolic & Bariatric Surgery (ASBMS) Guidelines (2008 and 2013) and the Interdisciplinary European Guidelines on Metabolic and Bariatric Surgery (2007 and 2013). 

Prior to surgery, mean 25-hydroxyvitamin D (25(OH)D) level was found to be consistently below 30ng/ml.  The etiology of hypovitaminosis D post-surgery is multifactorial, related to both, obesity and the surgical procedure.  There was a large variability in the vitamin D regimens and doses administered and in the mean 25(OH)D levels reached post-surgery.  There is scarce evidence (only 2 small trials) supporting the use of lower doses in restrictive procedures.

The ES and the AACE/TOS/ASBMS guidelines recommended high doses of vitamin D, varying from 3,000 IU daily to 50,000IU 1-3 times weekly.  In terms of guidelines quality assessment, their search methodology was not clearly defined, the quality of evidence was low, or limited to a single high quality trial. The target population preferences, the resources implications, and the applicability of these guidelines were not assessed rigorously by any of the concerned societies.  We rated them as low (AACE/TOS/ASMBS and the Interdisciplinary European Guidelines) to average (ES Guidelines) in quality. 

Conclusion:

Based on observational studies, the optimal dose of vitamin D replacement in individuals undergoing bariatric surgery is unclear.  The few (2) available trials do not support the hypothesis that the dose varies according to the surgical procedure.  The recommendations by the 3 societies were mostly based on expert opinion.  Evidence for these key questions is best reached by a systematic review and meta-analysis of relevant randomized trials.

 

Nothing to Disclose: MTC, EA, NFN, GE

19717 19.0000 THR-244 A Hypovitaminosis D in Bariatric Surgery: Systematic Review 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Yeoloon Woo1 and Se Young Kim*2
1Bundang Jesaeng General Hospital, Seongnam, Korea, Republic of (South), 2Bundang Jesaeng Gen Hosp, Seongnam, Korea, Republic of (South)

 

Purpose

The recent articles showed a kind of associations of the serum vitamin D levels and chronic diseases, for example, autoimmune diseases, vascular disorders, as well as malignancies. Also vitamin D deficiency impacts normal growth and maximal bone mineral accretion in puberty. Of pediatric population in Korea, the prevalence of cases of vitamin D deficiency and precocious puberty were continuously increasing nowadays. So, we investigated whether there is the relationship of vitamin D level and precocious puberty, or not, in accordance to increasing cases in Korea.

Methods

In this cross-sectional study, we enrolled total 135 girls composed of 84 Korean girls with central precocious puberty and 51 control  girls. The serum 25-hydroxyvitamin D (25OHD) levels of all subjects were measured by radioimmunoassay. The anthropometric data and bone age were recorded. The definitions of the vitamin D status according to their 25OHD serum levels were as follows: deficient for patients with levels < 20 ng/mL, insufficient for levels of at least 20 but < 30 ng/mL, and normal for levels ≥ 30 ng/mL. The data of precocious puberty group and control group were compared using the Student t-test, and Chi-square test. The odds ratio of central precocious puberty depending on vitamin D levels were investigated by binary logistic regression. Statistical significance was defined as P<0.05.

 Results

Their mean ages were 7.7±1.2 yr (central precocious group) and  8.96±1.8 yr (control group).The prevalence of vitamin D deficiency in all subjects was 62.2% (97 out of 135), that of vitamin D insufficiency was 37.8% (38 out of 135). There was a statistically significant difference in mean serum 25OHD level between the central precocious puberty group and control group(16.9±4.7 ng/mL vs. 19.18 ng/mL, P<0.05). Seventy eight percent of CPP girls (66 out of 84) have revealed vitamin D deficiency, and 21.4% (18 out of 84) were vitamin D insufficient. In the control group, sixty percent(31/51) had vitamin D deficiency and thirty-nine percent(20/51) were vitamin D insufficient. After Chi-square test, there was a statistically significant difference in both groups(P<0.05). Vitamin D deficient girls had a significantly higher odds ratio(OR, 2.36; 95% CI, 1.09-5.09, P=0.028).

Conclusion

This study indicated that vitamin D deficiency is more prevalent in girls with central precocious puberty than normal control girls with same ages. So, vitamin D-deficient state might influence sexual maturation and hormone metabolism. Because vitamin D-deficient effect on pubertal progression is not known, further studies about the mechanism of vitamin D deficiency on the onset of precocious puberty would be needed.

 

Nothing to Disclose: YW, SYK

19471 20.0000 THR-245 A The Relationships Between Serum Vitamin D Level and Precocious Puberty in Korean Girls 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Camila Frade Oliveira1, Natalia Lima*1, Ruth Ellen Fernandes Castro Dantas1, Maria Lucia Coelho Nobrega2, Lucia Helena Coelho Nobrega3 and Josivan G Lima3
1Hospital Universitario Onofre Lopes, UFRN, Natal, Brazil, 2Centro de Endocrinologia de Natal, Natal, Brazil, 3Hospital Universitario Onofre Lopes, UFRN, Natal RN, Brazil

 

Introduction. Although Brazil is a tropical country, vitamin D deficiency is relatively common among us. The usual recommended treatment is the administration of oral cholecalciferol and the dose is variable. We aimed to assess which factors may interfere with effective dose of cholecalciferol to normalize the 25-OH-vitamin D. Methods. We retrospectively evaluated 95 patients (86 women), age 57,2±15,6 years, with 25-OH-vitamin D <30 ng/ml (23.2 ± 4.0 ng/ml) who were submitted to treatment with cholecalciferol oral and had a new dosage of 25-OH vitamin D measured subsequently. Based on this second test, the patients were divided into Group 1 (<30 ng/ml, n=31) and Group 2 (>30 ng/ml, n=64) and weight, BMI, age, PTH, 25-OH vitamin D, calcium corrected and phosphorus were evaluated. Data are shown as mean ± SD or as median (Q1-Q3), if nonparametric. Results. The interval between doses was 114 (83-195) days and the daily cholecalciferol supplemented dose was 2000 (1600-5000U). After supplementation, 25-OH vitamin D in Group 1 increased from 18,7ng/ml to 25,8ng/ml and, in Group 2 from 25,5ng/ml to 36,6ng/ml. There was no difference by sex, age (57.0 ± 15 vs. 57.4 ± 16 years), serum calcium (9.6 ± 0.8 vs. 9.7 ± 0.8 mg/dl), phosphorus (3 8 ± 0.6 vs. 3.7 ± 0.7 mg/dl), corrected calcium (9.5 ± 0.8 vs. 9.6 ± 0.8 mg/dl) interval between measurements (136 vs. 109 days) and dose of cholecalciferol (2000 vs 2142 U/d). In Group 1, BMI was greater (29.5 ± 5.3 s. 26.7 ± 5.1 kg/m2, p <0.05) and 25-OH-vitamin D initial was lower (18.7 ± 2.9 vs. 25.5 ± 2.3, p <0.05). After supplementation, PTH significantly reduced in both groups (Group 1, 87.7 ± 53.9 to 62.6 ± 27.8 pg/ml; Group 2, 57.5 ± 22.9 to 51.6 ± 24.9 pg/ml). Initial PTH was higher in Group 1 than in Group 2, but this was not statistically significant (87.7 ± 53.9 vs. 57.5 ± 22.9 pg/ml, p = 0.09). Conclusion. A value of 25-OH-vitamin D lower, a higher BMI and probably a higher PTH are indicative of a need for higher cholecalciferol doses for supplementation.

 

Nothing to Disclose: CFO, NL, REFCD, MLCN, LHCN, JGL

20953 21.0000 THR-246 A Factors Interfering in Cholecalciferol Effective Dose for Correction of Vitamin D Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Goknur Yorulmaz*1, Aysen Akalin2, Narguler Tomus3, Murat Senol3, Pinar Yildirim4, Emel Gonullu3 and Muzaffer Bilgin4
1Eskisehir State Hospital, Eskisehir, Turkey, 2Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey, 3Eskisehir State Hospital, 4Eskisehir Osmangazi University

 

Introduction:

The status and the role of vitamin D during pregnancy has been already lead to an increasing interest because of the evidence that the vitamin D status can be related with the pregnancy outcomes. Some other endocrinologic abnormalities as thyrotoxicosis can also be seen during pregnancy. Although hyperthyroidism due to thyroid disease is rare, transient gestational hyperthyroidism is a common state. The relationship with the thyrotoxicosis and vitamin D was demonstrated in some studies but these investigations are very rare among the pregnant women.

Objective:

Our objective is to find out if there is a relationship with the thyrotoxicosis and vitamin D status.

Methods:

Fifty-eight pregnant women with thyrotoxicosis and 22 age and gestational weeks matched pregnant healthy women were included to the study. The thyroid function tests, anti thyroglobulin, anti-thyroid peroxidase, TSH-receptor antibody, thyroid ultrasound, 25 hydroxyvitamin D, 1,25 hydroxyvitamin D levels were evaluated.

Results:

None of the individuals in both groups had thyroid disease in the past. One patient with positive TSH-receptor antibody was excluded from the study. Two women from the patient group and one woman from the control group were positive for anti thyroglobulin. Twenty-two of patient group and 6 of the control group were positive for the thyroid nodules. The vitamin D levels of both patients and control group were low and the difference was not statistically significant. The 1,25 hydroxyvitamin D levels also showed no difference and was in normal range in both groups. The 25 hydroxyvitamin vitamin D levels were low among the entire study group and this means that all of the the pregnant women with or without thyrotoxicosis tend to have low 25 hydroxyvitamin vitamin D levels. According to our opinion, the status of vitamin D needs to be studied further especially among the pregnant women with endocrinologic abnormalities.

 

Nothing to Disclose: GY, AA, NT, MS, PY, EG, MB

20985 22.0000 THR-247 A The Effect of Thyrotoxicosis to Vitamin D Status during Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Anawin Sanguankeo*1, Sikarin Upala2 and Nitipong Permpalung2
1Bassett Medical Center, United States, NY, 2Bassett Medical Center, Cooperstown, NY

 

Background
Low serum concentrations of 25 hydroxy vitamin D (25(OH)D) is reported to be with associated with increased mortality rate, length of hospital stay, and acute kidney injury in the critically ill patients. It is also lead to more susceptibility to bacterial infection in animal models. We conducted a systematic review and meta-analysis of observational studies to determine the association between vitamin D deficiency and the incidence of sepsis

Methods
Established procedures were followed (PRISMA guidelines) to complete this study. Relevant observational studies indexed in the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE, and EMBASE up to October 2014 were analyzed and data were extracted from ten studies. All studies were included in the meta-analysis. The quality of observational studies was assessed using the Newcastle-Ottawa quality assessment scale.

Results
A search of the databases resulted in 677 articles, of which 626 were excluded. The ten studies from which data were extracted involved over 33,810 subjects. The pooled odds ratio of sepsis in participants with vitamin D deficiency compared with controls was 1.77 (95 % CI 1.55 to 2.03; p-value<0.01), indicating a significant increased odds of sepsis among patients with vitamin D deficiency. Standardized mean difference (SMD) of 25(OH)D level in patients with sepsis and controls was -0.24 (95 % CI -0.49 to -0.00; p-value=0.05) lesser in the sepsis group compared with control participants.

Conclusions

To the best of our knowledge, this is the first study of its nature to demonstrate the association between vitamin D defiiency and sepsis. Further studies to evaluate the role of supplemental vitamin D to decrease the risk of sepsis are warranted.

 

Nothing to Disclose: AS, SU, NP

21362 23.0000 THR-248 A Vitamin D Deficiency Is Associated with Increased Risk of Sepsis: A Systematic Review and Meta-Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Hanan A Al Kadi* and Hala Salim Sonbol
King Abdulaziz University, Jeddah, Saudi Arabia

 

Background:

Vitamin D deficiency is highly prevalent in Saudi women, however not all women show a rise in parathyroid hormone (PTH) in response to low vitamin D status. The aim of this study was to examine the differences in the characteristics of vitamin D deficient women with or without a blunted PTH response.

Methods:

This was a cross-sectional study conducted in the “Center of Excellence for Osteoporosis Research” (CEOR). A total of 381, otherwise healthy women (aged 25-45 years), with vitamin D deficiency (serum 25(OH)D<50 nmol/ L) participated in this study. Women were divided into quartiles according to PTH levels and the highest and lowest quartiles were compared with regard to different anthropometric and biochemical factors.

Results:

Women in the lowest PTH quartile (n=88) were significantly younger, had smaller waist circumference (WC), lower body mass index (BMI) and lower blood pressure compared with the highest PTH quartile (n=100). They also had higher total serum calcium, and phosphate levels. There were no significant differences in serum magnesium level or in kidney function.

Conclusion:

These results suggest that a rise in PTH in response to vitamin D deficiency may be determined by extent of body fat, with a rise in PTH seen in vitamin D deficient women with higher BMI. Future studies to confirm these findings and to determine other factors affecting the vitamin D – PTH relationship in obese women who are at higher cardiovascular risk are indicated.

 

Nothing to Disclose: HAA, HSS

22156 24.0000 THR-249 A Characteristics of Vitamin D Deficient Saudi Women with or without Blunted PTH Response - a Cross-Sectional Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Chhaya Makhija*1, Lynn Renee Mack1, Fedja Rochling1, Baojiang Chen1, Tricia L Hultgren2 and Jennifer L Larsen1
1University of Nebraska Medical Center, Omaha, NE, 2Dermatology Specialists of Omaha, Omaha, NE

 

The prevalence of Vitamin D deficiency in patients with malabsorption syndromes syndrome is high due to inadequate absorption of dietary and oral vitamin D supplements. 

Our objective was to assess if UVB (Ultraviolet B) light with a portable UV device can raise total 25 hydroxy vitamin D [25(OH)D] levels in Intestinal Rehabilitation Clinic patients.

We report initial data from a prospective, randomized, controlled and unblinded pilot study conducted at our Intestinal Rehabilitation clinic. Eligibility criteria included adult patients with initial 25(OH)D of 30 ng/ml or below, intake of same dose of vitamin D supplement for 3 months and a diagnosis of malabsorption secondary to short bowel syndrome, multiple intestinal resections, abdominal fistulae, or altered gastrointestinal motility. Subjects were recruited from October 2013 to May 2014.  11 subjects were randomized into one of two arms: Control or UVB light. Subjects in both groups continued their maintenance oral or parenteral vitamin D supplements. Doses ranged from daily or weekly 200 IU to 100,000 IU of oral vitamin D. Limited patients were only on a thrice weekly parenteral formulation of 200 IU of vitamin D3 in a multivitamin injection.  Subjects in UVB group came to the clinical research center once a week for 12 weeks for UVB sessions using a FDA approved portable UVB lamp. They received supervised UVB light sessions to 3 different areas for 5 minutes each. Areas of skin exposure included lower back, legs, arms or abdomen. Serum samples for 25(OH)D and intact PTH (iPTH) were collected at baseline, 4 weeks, 8 weeks and 12 weeks.

3 out of 5 subjects in UVB group and 4 out of 6 subjects in control group completed the study. Mean 25(OH)D and iPTH at baseline in UVB group was 19±9 ng/dl and 139.3±37.8 pg/ml respectively. Mean 25(OH)D rose by 79% to 34 ±13 ng/dl at 8th week and dropped to 26.3 ± 14.2 ng/dl at 12th week but was 38% higher than baseline (P= 0.25). Mean iPTH decreased to 61.7±59.2 pg/ml at 12th week (P= 0.25). No adverse events were reported. In the control group, mean 25(OH)D and iPTH at baseline were 24.2±3.3 ng/dl and 57.2±33.0 pg/ml respectively. Mean 25(OH)D decreased to 19.5±8.4 ng/dl at 12th week. iPTH remained stable. At 12thweek, difference in the mean 25(OH)D between the two arms was not significant (P>0.10). In addition, the UVB group demonstrated elevation of 25(OH)D3 whereas 25(OH)D2 remained undetectable despite continuing previous oral vitamin D2 therapy.

This pilot study demonstrates that in patients with malabsorption syndromes, use of a portable UV lamp raises 25(OH)D levels with concomitant reduction in iPTH levels. Since UVB light treatment did not maintain optimal vitamin D status throughout the 12 week duration, we plan to continue recruitment this fall with some modifications in our methods. An increase in frequency of UVB sessions or exposure of additional body surface area will likely help with further rise in vitamin D3 production.

 

Nothing to Disclose: CM, LRM, FR, BC, TLH, JLL

18333 25.0000 THR-251 A Treatment of Vitamin D Deficiency in Intestinal Rehabilitation Clinic Patients with Portable Ultraviolet -B Lamp 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 226-251 5957 1:00:00 PM Vitamin D and Bone Genetics Poster


Christian Yuzon Santa Maria*1, Alfred Li2, Zhiqiang Cheng2, Fuqing Song1, Chia-Ling Tu2 and Wenhan Chang2
1University of California, San Francisco, San Francisco, CA, 2University of California San Francisco, San Francisco, CA

 

Intermittent parathyroid hormone (iPTH) is the only FDA-approved therapy that produces bone anabolism. However, PTH dosing is limited to a short-term use with a relatively low dose due to its adverse hypercalcemic effects and oncogenic potential in bone. A better understanding of the mechanisms underlying the actions and adverse effects of iPTH is required to devise strategies to enhance its use as a therapy. Recent studies suggest that changes in local calcemic activities in bone may be critical for the anabolic actions of PTH. The objective of this study is to determine if the hypercalcemic effects of PTH is required to activate the extracellular calcium-sensing receptors (CaSR) in the osteoblast (OB) to produce osteoanabolic responses and if combined treatment with CaSR agonists enhances the osteoanabolic effects of iPTH. A pharmacological approach was taken to test whether activating CaSRs in OBs by co-injecting a calcimimetic enhances osteoanabolism of iPTH without producing hypercalcemia. Injections of PTH(1-34) produced hypercalcemia in mice, while injections of calcimimetic produced hypocalcemia 3 hrs after injections. The latter action is due to the inhibitory effects of calcimimetics on the secretion of endogenous PTH by activating the parathyroid CaSR. In support of our hypothesis, co-injections with calcimimetic normalized the Ca2+-elevating effects of PTH (p<0.01).  Skeletal analyses by µCT showed that PTH alone increased trabecular bone mass and thickness by ≈8% (p<0.05) in distal femurs when compared to vehicle-injected controls. When calcimimetics were co-injected with PTH(1-34), there were robust increases in trabecular bone mass (≈21% or 2.5 fold over PTH treatment alone, p<0.05) and in thickness (≈17%, p<0.05). Co-injection of calcimimetic with PTH also significantly increased cortical total volume, bone volume and thickness by 8-10% (p<0.01) in contrast to PTH treatment alone, which had no effects on cortical parameters. To determine whether the expression of CaSRs in OBs is required for the anabolic effect of PTH and/or calcimimetic treatments we compared the effects of the treatment in 2.3Col(I)CaSRDflox/Dflox mice, which had the ablation of CaSRs early in the OB lineage. In the latter mice, osteoanabolism of PTH/calcimimetic combined treatment was completely abrogated, supporting our hypothesis that OB CaSRs play an essential role in mediating skeletal responses to the treatment. Further analysis, including bone histomorphometry is currently underway to assess the onset and closure of anabolic windows in trabecular and cortical bone and their underlying mechanisms. Our study has revealed novel synergistic actions of iPTH and calcium in promoting skeletal anabolism and may help in establishing more robust clinical regimens to restore osteoporotic skeleton and augment healing of bone injuries.

 

Nothing to Disclose: CYS, AL, ZC, FS, CLT, WC

21268 2.0000 THR-201 A Skeletal Anabolism By Concurrently Targeting the PTH1R and Casr 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Kevin Matthew Curtis*, Kristina Katharine Aenlle, Rachel N Frisch and Guy A Howard
Miami VA Medical Center, Miami, FL

 

The transcription factor p63 is required for skeletal formation [1] and regulation of the 1α,25(OH)2D3 receptor (VDR) [2]. Moreover, studies involving total p63 knock-out mice demonstrated decreased endochondral bone formation, suggesting that p63 is required for bone formation [1, 3] through regulation of chondrogenesis, indirectly impacting endochondral ossification and bone formation [4-6]. However, the role of p63 during osteoblastic differentiation and its regulation by the vitamin D3endocrine system remains unclear. Hence, we examined the role of  the p63 isoforms/variants during osteoblastic differentiation of primary human mesenchymal stem cells (hMSC).

        The p63 gene is complex, producing TAp63 isoforms (complete NH2 terminus) and truncated ΔNp63 isoforms (lacking NH2 terminus).  In addition, mRNA splicing results in different C-terminal lengths producing α, β, and γ variants, thus generating 6 different variants: TAp63α,β,γ and ΔNp63α,β,γ.

        TAp63γ and ΔNp63β appear to be an integral part of the osteoblastic differentiation of hMSC and are differentially regulated by 1α,25(OH)2D3 and 24R,25(OH)2D3.  Comparing the endogenous expression of  TA- and ΔNp63 isoforms, and p63α, -β, -γ variants in naive hMSC versus during osteoblastic differentiation of hMSC revealed that TAp63α and -β were the main variants in naive hMSC, while TAp63γ and ΔNp63β were predominant during osteoblastic differentiation. In contrast, under osteoblastic differentiation conditions, expression of p63 changed from TAp63α and -β to TAp63γ and ΔNp63β.  To elucidate the mechanism of these changes, we transiently overexpressed the p63 variants and  demonstrated that TAp63β, DNp63β and DNp63γ increased alkaline phosphatase activity and DNp63α and -γ increased expression of pro-osteogenic genes osteocalcin and osterix. Our results support the hypothesis that TAp63α and -β promote a naive state in hMSC.  Moreover, TAp63γ increased during osteoblastic differentiation and promoted expression of pro-osteogenic genes VDR, Osterix, Runx2 and Osteopontin.  ΔNp63β supported osteogenic maturation through increased alkaline phosphatase activity. Mechanistically, treatment with 1α,25(OH)2D3 increased mRNA expression for DNp63, while 24R,25(OH)2D3 increased the expression of TA- and ΔNp63γ variants. 

        These novel findings demonstrate for the first time that p63 variants are differentially expressed in naive hMSC (TAp63α,β), are important during osteoblastic differentiation of hMSC (TAp63γ and ΔNp63β), and are differentially regulated by the vitamin D3 metabolites 1α,25(OH)2D3 and 24R,25(OH)2D3.  The molecular nuances and mechanisms of osteoblastic differentiation presented here improve our understanding of bone development, complications in bone repair (mal- and non-union fractures), osteoporosis, and could possibly lead to new therapeutic modalities.

 

Nothing to Disclose: KMC, KKA, RNF, GAH

18348 3.0000 THR-202 A TAp63γ and ΔNp63β Promote Osteoblastic Differentiation of Human Mesenchymal Stem Cells: Regulation By Vitamin D3 Metabolites 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Quang Vutrong Ton*1, Victoria C Hsiao2, Ellen J Giampoli1 and Jacob Moalem3
1University of Rochester School of Medicine & Dentistry, 2University of Rochester Medical Center, Rochester, NY, 3University of Rochester School of Medicine & Dentistry, Rochester, NY

 

Parathyroid carcinoma and parathyromatosis are rare causes of primary or recurrent primary hyperparathyroidism. Parathyromatosis is defined as nodules of hyperfunctioning parathyroid tissue arising from either a low grade malignancy, increased growth of embryologic parathyroid tissue foci, or most commonly, inadvertent spillage of parathyroid cells during parathyroidectomy. We present a unique case of recurrent primary hyperparathyroidism.

The patient is a 47 year old male with a history of HIV and bilateral nephrolithiasis who presented with fatigue.    

In 2011, he underwent unilateral parathyroidectomy, wherein an enlarged hypercellular left upper adenoma and a normocellular lower gland were removed. No operative complications were noted. Post-operatively, his lab values normalized with calcium of 9.5 mg/dL (10.5 preoperatively) and PTH of 27.9 mg/mL (64 preoperatively).

In 2013, he re-presented with calcium of 13.3 mg/dL and PTH of 478.6 pg/mL. His interval history and examination were unremarkable. 4D CT scan of the neck showed a left inferior enhancing nodule consistent with a parathyroid adenoma, suggesting incomplete resection of the parathyroid adenoma. He received pamidronate 60 mg. He underwent repeat left parathyroidectomy with operative course significant for the discovery of multiple masses in the central neck and lateral compartment of the neck.  Additional masses were seen encasing the left recurrent laryngeal nerve, and were left in situ. Final histopathologic evaluation revealed hypercellular, chief cell predominant atypical parathyroid lesions with irregularly thick fibrous capsule and irregular borders. Also noted were nuclear atypia with frequent mitoses, and an elevated proliferation index (Ki-67 8 to 10%).  The findings were suspicious for parathyroid carcinoma. Intraoperative PTH levels remained in the 400s. Repeat scan did not reveal metastatic disease and confirmed a hypoenhancing amorphous mass at the junction of the left subclavian and jugular veins. He was taken for comprehensive resection of left lateral and central neck with pathology again revealing atypical parathyroid neoplasm and several negative lymph nodes. Post-operative laboratory values were calcium of 7.4 mg/dL and PTH of 33.9 pg/mL.

Distinguishing parathyromatosis from parathyroid carcinoma is difficult as they lack precise clinical and histologic criteria. The diagnostic criteria for parathyroid carcinoma, such as thick fibrous trabecular growth pattern, vascular invasion, and lymph node metastasis are not fully fulfilled in this case. However the chief cells showed focally increased mitoses and the presence of a lateral neck mass that also contained atypical parathyroid tissue strongly suggested the diagnosis of parathyroid cancer. Physicians and surgeons should be aware of the characteristics of both entities, and close clinical follow up is warranted in these patients.

 

Nothing to Disclose: QVT, VCH, EJG, JM

21857 4.0000 THR-203 A Parathyromatosis or Parathyroid Carcinoma? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Luís Carlos Spolidorio*, Maria Carolina Costa Albaricci, Daniel Olivio Ribeiro and João Paulo Steffens
School of Dentistry at Araraquara, São Paulo State University, Araraquara, Brazil

 

Many conditions have been related to high (e.g., hirsutism and polycystic ovary syndrome) or low (e.g., low libido and fatigue) androgen levels in females. However, the role of androgens on inflammation is still controversial. We tested the hypothesis that androgens participate in the progression of periodontitis in females by evaluating the impact of androgen receptor blockade or androgen supplementation on experimental periodontitis in rats. Fifty female Holtzman rats (approx. 200g) were included in this study. They received treatment with flutamide (FLU, an androgen receptor antagonist; n=10) or testosterone (TES) with or without anastrozole (ANA), an aromatase enzyme inhibitor (n=10/group). After 14 days, all rats received ligature around the lower first molars (periodontitis induction). Twenty other rats received no previous treatment, serving as negative (n=10) or periodontitis (n=10) controls. Rats were killed at day 28. Bone loss was evaluated using digital radiographic linear analysis on the mesial aspect of the teeth. The serum levels of estradiol, progesterone, testosterone, C-telopeptide (CTX) and prostaglandin E2 (PgE2) were measured using ELISA. PgE2 was also measured in the mucogingival tissue. All data were analyzed using appropriate statistical tests. Testosterone treatment significantly increased serum testosterone (Kruskal-Wallis;p<0.001), decreased progesterone (p<0.05) and had no impact on estradiol levels for TES and TES+ANA groups when compared to control animals. Bone loss was significantly increased in all periodontitis animals when compared to non-ligated controls (ANOVA;p<0.05), but only FLU significantly increased bone loss compared to periodontitis controls (p<0.05). CTX was similar among the groups (p>0.05). Serum PgE2 was significantly increased in TES when compared to all other groups (p<0.001) whereas gingival PgE2 was significantly increased in TES only when compared to control animals (p<0.01). We conclude that androgens play a role on the progression of periodontitis in female rats but only androgen receptor blockade resulted in increased bone loss.

FAPESP São Paulo Research Foundation Process number 2013/12014-6

 

Nothing to Disclose: LCS, MCC, DOR, JPS

18591 5.0000 THR-204 A Androgens Modulate Periodontitis Progression in Female Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Takayuki Katsuyama* and Fumio Otsuka
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

 

Osteoblasts and osteoclasts play important roles in the bone remodeling.  When the balance between these cells is disrupted, bone loss or aberrant bone formation occur.  In rheumatoid arthritis, pro-inflammatory cytokines such as TNF-alpha play a predominant role in joint destruction.  We earlier reported that TNF-alpha inhibits bone morphogenetic protein (BMP)-induced osteoblast differentiation via activation of JNK and NF-kB pathways.  The fibroblast growth factor (FGF) family constitutes of at least 25 structurally related proteins and known to be involved in various biological processes including cell migration, differentiation, growth and survival.  In particular, FGF-2, -8 and -18 have been implicated as key factors for the bone and cartilage homeostasis.  It has also been reported that joint destruction of arthritis patients is involved in the increase of endogenous FGF-2 in synovial fluids.  Among the FGF family, FGF-8 is known to be a key regulator for limb development and cranial formation.  However, functional relationship between FGF-8 and BMPs in the osteoblast differentiation and the signal interaction of FGF-8 and proinflammatory cytokines remain unclear.  Here we studied the effects of FGF-8 in relation to TNF-alpha actions on BMP-2-induced osteoblast differentiation.  Mouse myoblast cell line C2C12, osteoblast precursor cell line MC3T3-E1 and rat primary osteoblast were used to clarify the effects of FGF-8 and TNF-alpha on BMP-induced osteogenesis.  Quantitative real-time PCR was performed to evaluate mRNA levels of osteoblast differentiation markers.  Immunoblot analysis for the phosphorylation of Smads and MAPKs was performed to analyze the signal interaction induced by FGF-8, TNF-alpha and BMP-2.   We found that FGF-8 inhibited BMP-2-induced expression of osteoblast markers in a concentration-dependent manner in the experiments using myoblast C2C12, MC3T3-E1 and rat osteoblasts.  Of note, the inhibitory effects of FGF-8 on BMP-induced osteoblastic differentiation and Smad1/5/8 activation were enhanced under the co-treatment with TNF-alpha.  FGF-8 also inhibited BMP-2-induced expression of Wnt5a, a non-canonical Wnt signaling, which is known to be involved in Smad-independent signaling induced by BMPs.  FGF-8 had no influence on the expression levels of TNFRs, whereas FGF-8 increased the expression levels of ALK-3 (BMPR1A) and reduced inhibitory Smads6/7, suggesting a possible feedback activity of FGF-8 to BMPR signaling.  Moreover, experiments using MAPK inhibitor showed that FGF-8 inhibited BMP-induced osteoblast differentiation through MAPK pathways.  Collectively, it was uncovered that FGF-8 inhibits BMP-induced osteoblast differentiation via MAPK pathway and the effects were amplified by TNF-alpha activity.  This FGF-BMP interaction may be involved in the regulatory process of inflammatory bone damages as shown in inflammatory bone diseases.

 

Nothing to Disclose: TK, FO

18833 6.0000 THR-205 A Effects of FGF-8 and TNF-Alpha on the Regulation of Osteoblast Differentiation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Tomohiro Terasaka*, Kenichi Inagaki and Fumio Otsuka
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

 

Osteoblasts, which arise from mesenchymal stem cell precursors, undergo differentiation in response to a number of factors including growth factors and steroids.  Among these factors, bone loss in the patients with hypogonadism or hypopituitarism is closely related to the decreases in sex steroids and growth hormone (GH).  Estrogens are critical to maintain bone mass in woman.  In male patients, decrease of androgen level also reduces bone mass and testosterone replacement is beneficial for the maintenance of bone density.  In this mechanism, both of androgen and the converted estrogen effects are likely to be involved.  On the other hand, GH-IGF-I system also plays a key role in the bone development.  It has been reported that bone mass is diminished in GH-deficient patients and GH replacement is effective to reverse the bone loss.  However, the functional relationship of androgens and GH in bone formation remains unclear.  In the present study, we investigated the mutual effects of androgen and GH-IGF-I system on the osteoblastic differentiation using a mouse myoblastic cell line C2C12, with focusing on the interaction between BMP-Smad signaling and the pathways of androgen receptor and GH-IGF-I system.  First, we found that dihydrotestosterone (DHT) and GH increased BMP-2-induced expression of Runx2 mRNA.  The effects of DHT and GH on BMP-2-induced expressions of the matured osteoblast differentiation markers, osteocalcin and collagen-1, were not apparent.  It was found that DHT and GH augmented BMP-2-induced phosphorylation of Smad1/5/8 in C2C12 cells.  On the contrary, androgen receptor (AR) and GH receptor (GHR) mRNA expressions were rather suppressed by treatments with BMP-2.  In addition, IGF-I mRNA level was amplified by GH treatment; however, DHT treatment decreased the IGF-I expression in C2C12 cells.  The mRNA level of IGF-I receptor (IGF-I-R) was not significantly altered by GH effects, while it was increased by IGF-I treatment.  Furthermore, IGF-I treatment increased collagen-1 mRNA expression, whereas blockage of endogenous IGF-I activity using anti-IGF-I antibody failed to suppress the GH effects on BMP-2-induced osteoblastic differentiation, suggesting that endogenous IGF-I was the least involved in the enhancement of GH actions.  Collectively, androgen and GH individually enhanced osteoblast differentiations induced by BMP-2.  Of note, DHT had inhibitory effects on IGF-I expression, and BMP-2 downregulated the expression of AR as well as GHR.  These data suggested that both androgen and GH facilitate BMP-2-induced osteoblast differentiation by upregulating Smad signaling pathway, but inversely, the interfering effects on androgen and GH should also be considered in the mutual effects.

 

Nothing to Disclose: TT, KI, FO

19197 7.0000 THR-206 A Mutual Interaction of Androgen and Growth Hormone in Osteoblast Differentiation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Julianna Barsony*, Qin Xu and Joseph G. Verbalis
Georgetown University Medical Center, Washington, DC

 

Chronic hyponatremia is a common disorder in the aging population due to multiple factors, including comorbidities (cardiac, liver and renal disease, hypothyroidism), medications (diuretics and antidepressants), and changes in the aging brain causing the syndrome of inappropriate antidiuretic hormone (AVP) secretion (SIADH). Our previous studies indicated that hyponatremia caused bone loss in a well-established rat model of human SIADH due to increased osteoclastic bone resorption. We also found increased odds for osteoporosis via epidemiological analysis of the NHANES III data base in hyponatremic subjects over age 50 compared to participants with a normal serum sodium concentration ([Na+]). Several international observational studies and prospective clinical trials have confirmed an increased fracture risk in patients with hyponatremia. Our previous studies on cultured cells have indicated that prolonged reduced extracellular [Na+] directly stimulates osteoclastogenesis and osteoclastic bone resorption. To better understand the signaling mechanisms involved in osteoclast activation, we studied the rapid effects of reduced extracellular [Na+] on cultured murine RAW264.7 derived osteoclasts. We exposed RAW264.7 cells to normal [Na+] (137 mmol/L) media (control) or matched isotonic low [Na+] (120 mmol/L; 290 mOsm/kg H2O) media. Isotonic low [Na+] treatment did not reduce cell viability. Gene expression (microarray and real time RT-PCR) analyses revealed significant activation of the RANK, TRAF2, NF-kB pathway and the PI3kinase-Akt pathway after 24 h of low [Na+] exposure. Western blot analyses confirmed that reducing [Na+] for 24 h increased p53 expression, Akt phosphorylation, NF-kB p65 phosphorylation and S6 ribosomal protein phosphorylation, all consistent with RANKL hypersensitivity. Fluorescence assays and confocal imaging using RAW264.7 derived mature osteoclasts indicated that reduced extracellular [Na+] elicited multiple rapid cytoskeletal changes: increased cellular ATP levels by 80% (p<0.001), increased actin ring formation over 2-fold in 2 h (p<0.0001), increased osteoclast motility in 30 min, increased acidification of lysosomes in 5 min (p<0.001) that was sustained over 24 h (p<0.05), and re-localized acidic lysosomes along the ruffled borders of osteoclasts starting at 1 h and peaking by 24 h. These aggregate findings are consistent with a membrane sodium-sensing mechanism that rapidly stimulates osteoclast activity in response to reduced extracellular [Na+] via activation of RANKL and PI3kinase signaling. These events are similar to the signaling observed in the overactive osteoclasts in Paget’s disease. Our results therefore lay the foundation for using genetic manipulations to elucidate sodium sensing by osteoclasts and develop strategies to prevent hyponatremia-induced bone fragility.

 

Disclosure: JGV: Consultant, Cornerstone Therapeutics, Consultant, Ferring Pharmaceuticals, Consultant, Otsuka America Pharmaceutical, Inc., Investigator, Otsuka America Pharmaceutical, Inc.. Nothing to Disclose: JB, QX

19582 8.0000 THR-207 A Mechanisms of Osteoclast Activation By Hyponatremia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Akitoshi Nakayama*1, Tomohiko Yoshida1, Hidekazu Nagano1, Sawako Suzuki1, Hisashi Koide1, Yutaka Suzuki2, Sumio Sugano2, Koutaro Yokote1, Ichiro Tatsuno3 and Tomoaki Tanaka1
1Chiba University Graduate School of Medicine, Chiba, Japan, 2Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan, 3Toho University Sakura Medical Center, Sakura-City, Japan

 

NFATc1 (nuclear factor of activated T cells c1) is a key transcription factor that regulates osteoclast differentiation through transactivation of a wide variety of target genes in response to RANKL (receptor activator of NF-κB ligand) stimulation. Actually, it has been shown that bone-specific NFATc1 knockout mice displays osteopetrosis phenotype due to dysregulation of osteoclast functions and differentiation, a testament of NFATc1 as a master regulator for osteoclast differentiation. NFATc1 has been shown to transactivate various osteoclast-related genes during osteoclast differentiation in differentiation stage-specific manner, including TRAP (tartrate-resistance acid phosphatase), calcitonin receptor, cathepsin K, β3- integrin and so on. Despite its importance, a little is known about how NFATc1 regulates and selects functionally distinct target genes differentially in each differentiation stage. To approach and elucidate this question, we performed 1)RNA-sequence analysis and examined time-kinetics of gene expression profile of RAW264.7 cells differentiation after RANKL stimulation 2)LC-MS/MS analysis and identified the novel NFATc1 binding proteins as well as its post-translational modification. As a result, RNA-seq revealed that genes related with signal transductions such as TRAF1, a key transducer for TNF receptor signal and non-coding RNA were induced at early-time point after RANKL treatment, whereas the induction of NFATc1 and genes associated with osteoclastic functions such as Mmp9, Nhedc2, Ctsk, Atp6v0d2 was observed at relatively maturation stage for 3 to 7 days after RANKL stimulation. Importantly as well, we found the different induction pattern of NFATc1-dependent genes, for example, peak in early-phase; Calcr, Ctsk, Mmp9 associated with NFATc1, peak in late-phase; Oscar, Clcn7, Serpind1 although those were NFATc1 target genes. To clarify the molecular mechanism of differential regulation of NFATc1 targets, we examined NFATc1 complex using LC-MS/MS analysis and then identified WHSC1(Wolf-Hirschhorn syndrome candiate 1), a methyltransferase for H3-K36, as a NFATc1 binding protein. Intruguingly, WHSC1 associated with NFATc1 and its knockdown by siRNA compromised the induction of certain target genes of NFATc1 in RANKL-dependent manner, resulting the imapairment of maturation of osteclast differentiation. Moreover we identified the novel phoshophorylation and acethylation sites of NFATc1. Taken together, our data suggest that WHSC1 associates with NFATc1 and then regulates RANKL-dependent signaling pathway through modulating certain target genes of NFATc1, possibly linking to the coordination of differentiation and functional regulation of osteoclasts.

 

Nothing to Disclose: AN, TY, HN, SS, HK, YS, SS, KY, IT, TT

20156 9.0000 THR-208 A WHSC1 Associates with NFATc1 and Regulates RANKL-Dependent Osteoclast Differentiation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Wenbin Chen*1, Ling Gao1 and Yanping Li2
1Shandong Provincial Hospital affiliated to Shandong University, Jinan, China, 2Shandong Provincial Hospital

 

Objective

Some metabolic diseases such as hyperparathyroidism cause renal tubular acidosis (RTA). It has been unclear if there is some specific antibodies against the transmembrane transportor of hydrion.

B subunit of vacuolar H+-adenosine triphosphatease (v-H+- ATPase) was found to be specifically expressed in kidney. Our aim of this study was to detect the presence or absence of autoantibodies against B1 and/or B2 subunits of v-H+- ATPase in sera of patients diagnosed with RTA.

Methods

Eleven untreated patients diagnosed with RTA (10 of these cases were associated with Sjogren syndrome), eight untreated patients with simple Sjogren syndrome (sSS) and eight healthy controls (HC) were enrolled in the study. Immunofluorescence assay was performed on normal kidney tissue to test the binding of autoantibodies. 

Results

The sera from 6 cases of all 11 RTA patients showed positive staining in renal tubular epithelial cells, the staining intensity decreased following the increased dilution of sera from patients with RTA. None of those sera from patients with either sSS or HC showed positive conjugation in renal tubular epithelial cells.

when sera were incubated prior to commercial antibodies against B1 subunit of v-H+-ATPase, fluorescence intensity decreased in 6 cases of the 11 patients with RTA, which implied that blocking effect of the sera of patients with RTA to anti-B1 subunit of v-H+-ATPase antibodies was occurred. The sera induced blocking effects decreased following the increased dilution of sera from patients with RTA. Meanwhile none of sera from patients with either sSS or HC showed the blocking effect. The results of B2 subunit of v-H+-ATPase were as the same as that of B1 subunit.

Conclusions

Autoantibodies against B1 and B2 subunits of v-H+-ATPase are two kinds of autoantibodies against renal tubular epithelial cells in sera of patients with RTA.

 

Nothing to Disclose: WC, LG, YL

20232 10.0000 THR-209 A Detection of Autoantibodies Against B1/B2 Subunits of v-H+- Atpase in Sera of Patients Diagnosed with Rta 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Majdi Masrawi1, Yankel Gabet2, Oleg Dolkart3, Tamar Brosh2, Biana Shtaif2, Raanan Shamir4, Moshe Phillip5 and Galia Gat-Yablonski*2
1Tel Aviv University, 2Tel Aviv University, Tel Aviv, Israel, 3Tel Aviv Medical Center, Tel Aviv, Israel, 4Schneider children's Medical Center, Petach Tikva, Israel, 5Schneider Children's Medical Center of Israel, Petah Tikva, Israel

 

The ratio of casein to whey, the two most prevalent milk proteins, differs between human milk and cow milk used in infant formulas. The aim of the present study was to determine if the type of milk protein ingested influences catch up (CU) growth. Young male Sprague-Dawley rats were either fed ad libitum (controls) or subjected to 36 days of 40% food restriction followed by short (24 days) or long (40 days) periods of re-feeding with an iso-caloric, iso-protein diet containing either a vegetarian source of protein (standard rat chow) or an animal source of protein (milk proteins casein or whey). In terms of body weight, catch-up growth was incomplete in all study groups. Despite their similar food consumption, casein-re-fed rats had a significantly higher body weight and longer humerus than whey-re-fed rats in the long-term. Both casein and whey groups had a higher epiphyseal growth plate (EGP) than the rats re-fed normal chow. Micro-computed tomography (μCT) yielded significant differences in bone microstructure between the casein and whey groups, with the casein-re-fed animals having greater cortical thickness in both the short and long term in addition to a higher trabecular bone fraction in the short term, although this difference disappeared in the long term. Mechanical testing confirmed the greater bone strength in the rats re-fed casein. In conclusion, bone quality during CU growth significantly depends on the type of protein ingested. The higher EGP in the casein and whey-re-fed rats relative to the rats re-fed regular chow suggests a better growth potential of milk (animal protein)-based diets. The results of our study suggest that whey may lead to slower bone growth with reduced weight gain and as such, may serve to circumvent long-term complications of CU growth

 

Disclosure: MP: Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Bristol-Myers Squibb, Study Investigator, Bristol-Myers Squibb, Medical Advisory Board Member, Eli Lilly & Company, Study Investigator, Eli Lilly & Company, Speaker, Medtronic Minimed, Medical Advisory Board Member, Medtronic Minimed, Study Investigator, Medtronic Minimed, Speaker, Novo Nordisk, Study Investigator, Novo Nordisk, Study Investigator, Merck & Co., Study Investigator, Roche Diagnostics, Study Investigator, Pfizer, Inc., Study Investigator, Sanofi, Medical Advisory Board Member, Sanofi, Speaker, Sanofi, Consultant, Andromeda Biotech, Board Member, CGM3 Ltd, Board Member, DreaMed-Diabetes Ltd, Chairman, NG Solutions Ltd. Nothing to Disclose: MM, YG, OD, TB, BS, RS, GG

20237 11.0000 THR-210 A Skeletal Effect of Casein and Whey Protein Intake during Catch-up Growth in Young Male Sprague-Dawley Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Dalia Somjen*1, Sara Katzburg2, Roi Gigi3, Oleg Dolkart3, Orli Sharon4, Moshe Salai3 and Naftali Stern5
1Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 2Tel-Aviv Sourasky Med Ctr, Tel Aviv, Israel, 3Tel Aviv med ctr, Tel Aviv, Israel, 4Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, 5Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

 

The use of anticoagulants has been associated with systemic osteoporosis and increased risk for poor fracture healing but is inevitable following major orthopedic surgery of lower limbs. Rivaroxaban A (R) is an anticoagulant recently introduced in the clinical setting, which is a specific factor Xa inhibitor. We reported previously that R significantly inhibited cell growth, energy metabolism and alkaline phosphatase activity in human osteoblastic cell line SaOS2, with no effect on mineralization, indicating transient interference with bone physiology. We now investigated the effects of R on human cultured pre- and post- menopausal female osteoblastic cells (pre Ob and post Ob) response to osteoblast-modulating hormones. At sub-confluence, cells were treated with: 30nM estradiol-17b (E2), 390nM the estrogen receptor a (ERa) agonist PPT, 420nM the estrogen receptor b (ERb) agonist DPN, 50nM parathyroid hormone (PTH) and 1nM the vitamin D analog JKF with/without R (10micro gr/ml) for 24h. All hormones tested stimulated significantly DNA synthesis (DNA) by E2 185%, DPN 178%,and PPT by 225% in pre Ob and 165%, 125% and 198% respectively in post Ob. PTH stimulated DNA by 160% in pre Ob and by 150% in post Ob and JKF simulated by 150% and 130% respectively. Similar results were obtained when creatine kinase (CK) specific activity was assayed. All these stimulations were totally inhibited when given together with 10micro gr/ml R. R by itself had no effect on mRNA expression of ERa, ERb and 25 Hydroxy- vitamin D3- 1α hydroxylase (1OHase) and vitamin D receptor (VDR), but inhibited hormonal stimulations of mRNA expressions. ERα was stimulated in both pre and post Ob by E2 (120% and115%), by DPN (0% and 15%), by PPT (133% and 130%) by PTH (145% and 125%) and by JKF (125% and 130%). ERb was stimulated in both pre and post Ob by E2 (155% and130%), by DPN (157% and 145%), by PPT (175% and 135%) by PTH (175% and 135%) and by JKF (150% and 135%). VDR was stimulated in both pre and post Ob by E2 (125% and140%), by DPN (150% and 145%), by PPT (150% and 135%) by PTH (145% and 140%) and by JKF (160% and 150%). 1OHase was stimulated in both pre and post Ob by E2 (125% and128%), by DPN (0% and 15%), by PPT (130% and 128%) by PTH (125% and 130%) and by JKF (130% and 140%). In conclusion R inhibited significantly estrogen-, PTH- and vitamin D-induced cell growth and metabolic rate, thus indicating inhibition of not only the early stages of bone formation, but also the stimulatory effects of bone modulating hormones with a yet unclear mechanism. The relevance of these findings to human bone physiology is yet to be investigated, but attention should be given to bone integrity in R-treated subjects until this relationship is evaluated in vivo.

 

Nothing to Disclose: DS, SK, RG, OD, OS, MS, NS

20261 12.0000 THR-211 A The Xa Coagulation Factor Direct Inhibitor Rivaroxaban Blocks Estrogen-, PTH- and Vitamin D-Induced Cell Growth and Energy Utilization in Human Cultured Female Osteoblastic Cells: A Call for a Focus on Bone Integrity in Treated Humans 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Katherine J Motyl*1, Clifford J Rosen2 and Karen L Houseknecht3
1Maine Medical Center, Scarborough, ME, 2Maine Medical Center Research Institute, Scarborough, ME, 3University of New England, Biddeford, ME

 

Atypical antipsychotics (AAs) are widely prescribed to treat schizophrenia, bipolar disorder, and other mental health disorders. Metabolic side effects of AAs are common and include hyperphagia, obesity and Type 2 Diabetes.  The AA risperidone (RIS) has also been documented to cause bone loss clinically. We have modeled bone loss from RIS in 8 wk, female C57BL/6J (B6) mice dosed 0.75 mg/kg RIS (q.d.,p.o.), resulting in clinically relevant plasma levels of RIS and its active metabolite 9-OH RIS (a.k.a paliperidone). In this model, we have shown that RIS uncouples bone remodeling at least in part through increased sympathetic nervous system (SNS) output, but other mechanisms are likely involved. Another potential mechanism is that RIS antagonizes dopamine receptor (D2R), which leads to hyperprolactinemia and hypogonadism. To determine the role of hypogonadism in RIS-mediated bone loss, we obtained sham (SH) or ovariectomized (OVX) B6 mice at 5 wks of age. At 8 wks of age, a subset of each group was administered VEH or RIS daily as above, such that we had a total of 4 treatment groups (SH+VEH, SH+RIS, OVX+VEH and OVX+RIS, N=15 per group). After 8 wks of treatment, we performed dual x-ray absorptiometry (DXA) for areal bone mineral density (aBMD), fat and fat-free mass and collected bones for μCT and histomorphometry. Consistent with our previous observations, RIS did not alter body mass in SH operated mice. Also as expected, OVX significantly increased body mass in VEH treated mice (p<0.001). However, there was a significant treatment by operation interaction by 2-way ANOVA (p=0.0065). Within the OVX operated mice, RIS treatment resulted in a significant attenuation of weight gain (27.4 ± 0.7 g in OVX+VEH compared to 24.6 ± 0.5 g in OVX+RIS, p<0.01). A similar pattern was observed with fat mass, but not lean mass, indicating that the changes in body mass from both the RIS treatment and the OVX operation were due entirely to changes in fat mass. This may be explained by our previous findings of RIS-induced thermogenesis and increased energy expenditure. Also consistent with previous experiments, femur aBMD was reduced by RIS in the SH operated mice (64.9±0.7 mg/cc in VEH compared to 62.1±0.8 mg/cc in RIS mice, p<0.01). Within VEH treated mice, OVX also reduced femur aBMD to 57.4 ± 0.5 mg/cc (p<0.001) compared to VEH+SH mice. Interestingly, there was a significant treatment by operation interaction effect on femur aBMD by 2-way ANOVA (p=0.033). OVX+RIS mice had lower aBMD (57.4 ± 0.6 mg/cc) than VEH+RIS mice (p<0.001), but RIS treatment did not cause any further bone loss than that caused by OVX alone. Further studies are underway to analyze trabecular and cortical compartments and bone remodeling. Nonetheless, these experiments indicate that RIS-mediated bone loss is multi-modal, with estrogen and the SNS playing important roles that need to considered when designing therapies and making treatment decisions.

 

Nothing to Disclose: KJM, CJR, KLH

20485 13.0000 THR-212 A The Atypical Antipsychotic Risperidone Modulates Fat Mass and Bone Density through Estrogen-Dependent Mechanisms in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Luca De Toni*, Elena Speltra, Andrea Di Nisio, Giuseppe Taglialavoro, Alberto Ferlin and Carlo Foresta
University of Padova, Padova, Italy

 

Osteocytes are the most abundant cells in bone, accounting nearly the 95% of all cells in the adult skeleton [1]. They represent the cellular descendants of former bone matrix producing osteoblasts that become entrapped at regular intervals within the newly formed/mineralized bone matrix [2]. The osteocyte network plays a central role in directing bone response either to mechanical loading or to unloading, leading correspondingly to bone formation or resorption. Sclerostin (SOST) is a glycoprotein integral to osteocyte function as a signal to damp the action of osteoblast bone deposition through the negative modulation of Wnt-signaling pathway [3]. Any agent targeting the osteocyte functions and SOST release will have a major impact on the bone-remodeling process, such as osteoporosis. Steroid sex-hormones are major determinants of bone mass and hypogonadal men are at increased risk of osteoporosis [4], but the possible effect of androgens on osteocyte function is not known.

The aim of this study was to investigate the possible action of androgens on human osteocytes in vitro and in vivo.

The expression of the androgen receptor (AR) on osteocytes in EDTA-decalcified human trabecular bone samples by double-immunofluorescence showed colocalization of AR on SOST-positive osteocytes embedded in bone extracellular matrix. This expression was also confirmed on human primary osteocyte culture, obtained from digested bones specimens [5] enriched in SOST+/alkaline-phosphatase- cells by fluorescence assisted-cell sorting. Finally, western blot analysis confirmed  the specific band of AR at 110 kDa [6].

Serum SOST levels were determined in 25 young hypogonadal men with total T <10.4 nmol/L (HP, mean age 34.2 ± 3.7 years) and in 58 age-matched eugonadal controls (CTRL, mean age 36.8 ± 4.2 years). Serum SOST was significantly higher in HP with respect to CTRL (138.6± 55.3 pg/mL vs 115.7 ± 55.3 pg/mL; P=0.045), and serum LH was positively correlated with SOST levels (r=0,84; P=0.036). Taken together, these data suggest for the first time a direct role of androgens on sclerostin release by osteocytes in a AR-dependent manner and increased SOST levels in hypogonadal men. Studies are ongoing to identify the signalling pathways and cell process associated to androgen stimulation in this cell population.

 

 

Nothing to Disclose: LD, ES, AD, GT, AF, CF

20886 14.0000 THR-213 A Sclerostin Serum Levels in Hypogonadal Men and Evidence of Androgen Effect on Human Osteocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Nader Lessan1, Zara Hannoun1, Adam John Buckley*1, Michael F. Holick2 and Maha Taysir Barakat1
1Imperial College London Diabetes Centre, Abu Dhabi, United Arab Emirates, 2Boston University Medical Center, Boston, MA

 

Introduction

In spite of its sunny climate and low latitude, vitamin D deficiency is highly prevalent in the UAE; serum 25(OH)D was < 50 nmol/l in 58.1% of 36728 adult and pediatric patients attending our own centre who reported taking vitamin D supplementation.  The UAE is subject to environmental factors such as atmospheric dust, high ground level ozone and high humidity, that affect the scattering of incident solar radiation; we therefore investigated their impact on vitamin D photosynthesis in vitro.

 

Aim

To assess in vitro conversion of 7-dehydrocholesterol into previtamin D, vitamin D, and the inactive isomers tachysterol and lumisterol, by direct sunlight at ground level in Abu Dhabi. 


Methods

Borosilicate ampoules containing 7-dehydrocholesterol dissolved in ethanol were sealed under argon1.  The ampoules were exposed to direct, unobstructed sunlight at the Imperial College Diabetes Centre, Abu Dhabi at hourly intervals from 0800 to 1600 on one day each month between January and December 2012.  The resulting proportions of previtamin D, lumisterol and tachysterol formed in each ampoule were determined by high performance liquid chromatography at Boston University.

Results

The highest measured proportion of previtamin D and vitamin D synthesised was 7.51 %, in the ampoule exposed between 1200 and 1300, in July.  By comparison, 3.5% was converted during the time period between 1200 and 1300 in January.  The production of previtamin D varied with time of day, with < 2% conversion at 0800-0900 and 1600-1700 time periods regardless of time of year.  Conversion to previtamin D and vitamin D correlated with predicted UVB intensity by the SPCTRL2 calculator2, weighted by the action spectrum for vitamin D synthesis3 (Spearmann r = 0.925, p < 0.0001).  Total daily previtamin D conversion, estimated as the AUC of the graph of % conversion versus time of day, varied throughout the year; at the January nadir, the total converted was only 34% of the July peak.

Conclusions

The proportion of 7-dehydrocholesterol converted into previtamin D in vitro by sunlight in Abu Dhabi was comparable with observations from similar studies performed worldwide 4-7.  Hence the high prevalence of vitamin D deficiency reported in the UAE is better explained by individual, rather than environmental, factors.

 

Nothing to Disclose: NL, ZH, AJB, MFH, MTB

20927 15.0000 THR-214 A Clinical and Environmental Determinants of Vitamin D Status in Abu Dhabi 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Said M Shawar*1, Ahmad R Ramadan1, Ferial M Hudaib1, Ravikumar Muttineni2 and Noureddine Ben Khalaf1
1Arabian Gulf University, Manama, Bahrain, 2Schrodinger, Bangalore, India

 

Loss of function mutations in FGF23 cause hyperphosphatemic familial tumoral calcinosis (HFTC). Recently we showed that mutant FGF23-S129F is secreted at high levels to the circulation of HFTC patients and to the cell media of HEK293 cells transfected with plasmids containing FGF23-S129F gene. Apparently, the secreted hormone is not functional in HFTC patients despite its high concentration in their circulation. It is not known if the mutant hormone is folded properly in the ER. To investigate this question, we evaluated the impact of Phenylalanine substitution for Serine 129 on the protein stability by running folding free energy calculation (ΔΔG) using Shroderiger software (BioLuminate). Our results indicate that S129F substitution was significantly destabilizing the conformation at (300K, 60uC), with a score of -7.94 Kj/mol compared to the wild type (WT). The modeling data were substantiated by determining the mutant half-life (T1/2) and rate of degradation by zinc dependent serum proteinase. Highly purified WT or FGF23-S129F proteins obtained from stably transfected HEK293 cells were incubated with similar amounts of serum. Our results reveal that S129F mutant protein is highly susceptible to degradation by the serum metalloproteinase compared to the WT. Furthermore, we used two monoclonal antibodies that recognize discontinuous epitopes on WT FGF23. We found that both monoclonal antibodies failed to recognize the mutant hormone, suggesting that FGF23-S129F is improperly folded; however, it escapes the ER quality control (ER associated degradation, ERAD). Taken together, these data reveal that Serine 129 substitution by Phenylalanine modulates stability, structure and function of the hormone. More investigations are needed to elucidate the mechanism by which FGF23-S129F escapes from ERAD, also, whether FGF23-S129F can bind to its dyad receptor on kidney cells.


 

Nothing to Disclose: SMS, ARR, FMH, RM, NB

20938 16.0000 THR-215 A Secreted Mutant Hormone FGF-S129F Is Significantly Destabilized and Does Not Fold Properly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Tielin Yang*1, Yan Guo1, Ji-Gang Zhang2, Jian Li2 and Hong-Wen Deng2
1Xi'an Jiaotong University, Xi'an, China, 2Tulane University, New Orleans, LA

 

Runs of homozygosity (ROHs), in which both parental alleles are identical, have been proposed to have potential recessive significance for complex diseases. Osteoporosis is a common complex disease characterized by low bone mineral density (BMD), which is mainly determined by genetic factors. And recessive loci that contribute to BMD variation have been identified. In this study, we adopted ROHs, to perform a two-stage genome-wide association study using our current high-density SNP genome-scan data in 9,347 subjects. Combining evidence from all the samples, we identified 8 ROH regions, including ROH1p31.1, ROH3q26.1, ROH6q16.3, ROH11q12.1, ROH12q23.1, ROH1q31.3, ROH15q22.3 and ROH21q22.1, were significant associated with hip BMD, with combined p values 0.01-0.001.  Among these ROHs, ROH1p31.1 and ROH12q23.1 were found to significantly increase the risk of hip fractures with the odds ratio (OR) of 3.709 (P = 0.032) and 3.035 (P = 0.044), respectively. ROH15q22.3 was found to be nearly associated with hip fractures (P = 0.078), and OR was estimated to be 0.589 (95% confidence interval (CI): 0.325-1.068). To investigate the functional relevance of the identified ROHs associated with BMD or fracture, we performed expression quantitative trait locus (eQTL) analysis. Eleven genes (ELTD1, HACE1, OR5F1, OR5I1, CA12, CSNK1G1, DAPK2, HERC1, PPIB, SNX1 and TRIP4) mRNA expression levels were significantly associated with ROH, with the PeQTL of 0.049 - 2.78×10-9. Our findings open a new avenue for identifying loci with recessive contributions to osteoporosis. Further molecular and functional studies are needed to explore and clarify the potential mechanism.

 

Nothing to Disclose: TY, YG, JGZ, JL, HWD

20975 17.0000 THR-216 A Genome-Wide Runs of Homozygosity Analyses Identified Recessive Loci for Osteoporosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Alessandra Bitto*1, Gabriele Pizzino1, Natasha Irrera1, Domenica Altavilla2 and Francesco Squadrito1
1University of Messina, Messina, Italy, 2University of Messina

 

Glucocorticoid-induced osteoporosis (GIO) is the most important secondary cause of bone loss, and a well recognized animal model to study osteoporosis. Polydeoxyribonucleotide (PDRN) is a mixture of deoxyribonucleotides with a length between 50 and 2000 bp obtained by extraction from sperm trout. Several researches demonstrate that PDRN is capable to act as agonist of A2A adenosine receptor, causing an increase of VEGF expression during pathological low-perfusion conditions. Considering the role of adenosine in maintaining the balance between bone deposition and bone resorption, and taking into account that the four adenosine receptors were identified in bone tissue, we investigated whether PDRN could be useful in prevention and/or treatment of GIO in an experimental rat model. Moreover, as a secondary outcome we assessed if PDRN administration could prevent the onset of femoral head osteonecrosis. In addition, we decided to compare the effect of PDRN with zolendronic acid, a gold-standard for GIO management. GIO and osteonecrosis were induced, in female Sprague-Dawley rats (aged 4 months), by daily s.c. injections of methylprednisolone (30 mg/kg; MP) for 60 days. GIO rats were subdivided (in groups of 7 each) as follows: 1) MP alone for 60 days (induction), 2) received concomitantly MP and PDRN (8 mg/kg/i.p.; prevention) for 60 days; 3) received MP for 60 days and saline solution for additional 60 days (spontaneous recovery); 4) MP for 60 days and PDRN for the following 60 days (PDRN treatment); 5) MP for 60 days and zolendronic acid (7.5 μg/kg/i.p. for 3 times/week) for additional 60 days (zolendronate treatment). Control animals (Sham) were administered with saline solution for all the duration of the experiment.

At the end of the treatment, serum was collected to determine bone-alkaline phosphatase (b-ALP) and carboxy-terminal collagen crosslink (CTX) levels. Femurs were removed and tested for breaking strength, X-rays, and histology. Results suggest that PDRN was able to prevent GIO in terms of reduced histological damage and CTX serum levels. In addition, PDRN was as effective as zolendronic acid in reverting an established osteoporosis, demonstrating reduced CTX levels, improved bone breaking strength and bone histological features.

In conclusion, PDRN could be useful to prevent the onset of osteoporosis and complications of osteonecrosis in long-term GC-treated patients. Moreover, if confirmed in a clinical setting, PDRN might represent a valid alternative to zolendronic acid in the treatment of an already established GIO.

 

Nothing to Disclose: AB, GP, NI, DA, FS

21093 19.0000 THR-218 A Purinergic A2A Receptor Stimulation Restores Bone Loss in a Model of Glucocorticoid-Induced Osteoporosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Dorothea Barbara Szczawinska*1, Hee-chang Mun1, Halah Albar2, Leigh Walter Delbridge3, Donald T Ward2 and Arthur David Conigrave1
1University of Sydney, University of Sydney, Australia, 2University of Manchester, Manchester, United Kingdom, 3University of Sydney, St Leonards NSW, Australia

 

The parathyroid provides continuous surveillance of the plasma calcium concentration. Physiological serum calcium levels (ionized 1.1-1.3 mM) activate the calcium-sensing receptor (CaSR) and tonically suppress PTH secretion. Thus, the parathyroid synthesizes and secretes PTH continuously, and the CaSR provides a brake on the process to provide ‘long-loop’ endocrine negative feedback. However, the mechanism of spontaneous PTH secretion and its intrinsic control within the gland are not well understood. We hypothesized that the intrinsic PTH secretion mechanism is dependent on locally produced prostanoids and locally expressed prostanoid receptors. Firstly, parathyroid cDNA microarray analyses were positive for the prostaglandin E receptor type-4 (EP4) and prostacyclin IP1 receptor and the EP4 receptor was detected in a parathyroid particulate fraction by Western blotting. Secondly, the enzymes required for the synthesis of prostaglandins and prostacyclin, PGE synthase and prostacyclin synthase respectively, were present in the cDNA array. Thirdly, the COX2 inhibitor NS398 (10-50 μM) acutely and reversibly suppressed intrinsic PTH secretion by approximately 50% from perifused human parathyroid cells stimulated to secrete by exposure to low Ca2+o (1.0 mM). Finally, the broad-spectrum prostanoid receptor inhibitor AH6809 and selective inhibitors of the EP4 receptor L-161,982 (1-10 µM) and prostacyclin IP1 receptor (Ro1138452, 0.5-5 μM) all acutely and reversibly suppressed intrinsic PTH secretion.

The results demonstrate that the intrinsic mechanism underlying PTH secretion is supported by the local production of prostanoids and autocrine or paracrine-dependent signaling via EP4 and IP1 receptors. The findings imply that the CaSR acts to disrupt the intrinsic signaling mechanism.

 

Nothing to Disclose: DBS, HCM, HA, LWD, DTW, ADC

21547 20.0000 THR-219 A An Intrinsic Mechanism of Parathyroid Hormone Secretion Based on Prostanoid EP4 and IP1 Receptors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Nisan Bhattacharyya*1, Xin Hu2, Juan J. Marugan3, Andrea Estrada4, Noel T. Southall3, Marc Ferrer3 and Michael T. Collins5
1National Institutes of Health, Bethesda, MD, 2NCATS, NIH, Rockville, MD, 3NIH Chemical Genomics Center, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, 4NIDCR/NICHD, NIH, Bethesda, MD, 5National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD

 

Somatic missense mutations in the α-subunit of the small G-protein, Gsα, are responsible for fibrous dysplasia of bone/McCune-Albright Syndrome (FD/MAS), a disease that is manifested by fibrous dysplasia of bone (FD) as well as hyperfunctioning endocrinopathies. The biochemical outcome of these mutations (R201C/R201H) results in increased intracellular cAMP in the affected tissues. Increased cAMP results in a wide array of downstream effects depending on the affected tissue. In bone, it induces FD and, osteomalacia, recurring bone fractures and age-dependent apoptosis of mutation-bearing cells. In order to identify small molecule activators and inhibitors of the mutant Gsα, quantitative high-throughput screening (HTS) of the NCATS ~350,000 compound small molecule libraries was performed (Bhattacharyya et al, PloS One, 2014). A subsequent screen, using mutant and WT cells isolated from a FD patient, narrowed the candidate small molecules down to 92 antagonists and 125 agonists.  To further validate the candidate molecules, an orthogonal functional screening assay using growth hormone (GH)- and prolactin (PRL)-secreting rat pituitary cell lines overexpressing the WT and mutant Gsα was developed. This assay system further narrowed the number of molecules with activity down to 19 antagonists and 13 agonists. The aim of the current study was to assess the ability of candidate molecules to directly bind to mutant versus WT Gsα.

A novel in vitro Gsα-GTP binding assay was established. Coding regions for the WT and mutant Gsα (R201C and R201H) were cloned into a proprietary pPAL7 [Bio-Rad] system that allows for the Gsα protein to be bead-bound.  35S-GTPγS, in the presence or absence of selected compounds were allowed to compete and equilibrate, washed, eluted, and bound radioactivity counted. Cold GTPγS and ATP were used as the positive and negative controls, respectively. Purified Gsα proteins bound to 35S-GTPγS and the binding could be competed out by adding cold GTPγS but not ATP. Results also indicated that most of the antagonists could compete for the GTP- binding pocket in this competitive binding assay.

In summary, these results suggest that this novel assay is useful for assessing Gsα binding and that the antagonist and agonist activity of the screened compounds may be through direct interaction with Gsα. This suggests molecular specificity and supports further study in in vivo systems.

This study was supported by the DIR, NIDCR, a part of the IRP, NIH, DHHS.

 

Nothing to Disclose: NB, XH, JJM, AE, NTS, MF, MTC

21905 21.0000 THR-220 A Identification of Small Molecule Activators and Inhibitors of the Mutated Gsα Responsible for Fibrous Dysplasia of Bone: Results from the Novel in Vitro Gsα-35s-Gtpγs Binding Assays 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Hila Bahar*1, Aurore Varela2, Nancy Doyle2, Luc Chouinard3, Elisabeth Lesage2, Robert Guldberg4, Susan Y Smith2 and Gary Hattersley1
1Radius Health, Inc, Waltham, MA, 2Charles River Laboratories, Senneville, Canada, 3Charles River, 4School of Mechanical Engineering, Georgia Institute of Technology

 

Abaloparatide (ABL) is a PTHrP(1-34) analog being developed for the treatment of osteoporosis. To determine the effects of daily administration of ABL on the femoral neck in aged, osteopenic rats and monkeys, animals were ovariectomized (OVX) and subjected to a bone depletion period before ABL treatment initiation. Three months after surgery, sham and osteopenic OVX rats (n=18 per group) were treated with vehicle or ABL (1, 5 or 25 μg/kg sc) daily for 12 months. DXA analysis of the femur (total, proximal, mid and distal) demonstrated rapid and marked dose dependent gains in bone mineral content (BMC) and bone mineral density (BMD) with ABL at 1, 5 and 25 ug/kg, relative to OVX vehicle and sham controls. Increases in bone mass with ABL treatment were higher than pre-OVX levels as early as 3 months of ABL treatment. These increases in bone mass resulted in increases in bone strength parameters at the femoral neck, with gains up to 50%, for ABL 25 μg/kg relative to OVX control; peak load 81 N vs. 54 N, respectively, and stiffness 455 N/mm vs. 307N/mm respectively (P ≤ 0.05). Furthermore, increases in strength at the femoral neck were correlated with the increases in bone mass (peak load vs. DXA BMC, r=0.47, stiffness vs. DXA BMC, r=0.54). After a 9-month bone depletion period, ≥9 years-old sham and osteopenic OVX cynomolgus monkeys (n=16 per group) were treated daily with vehicle or ABL (0.2, 1 or 5 μg/kg, sc) for 16 months. Marked gains in BMD were observed at the femoral neck for all dose levels of ABL as early as 4 months of treatment, and were comparable to or above pre-surgery levels. After 16 months of ABL 0.2, 1 or 5 μg/kg treatment, increases in BMD at the femoral neck, were +14%, +19% and +18%, respectively, relative to the end of the bone depletion period (compared to a 10% changes in OVX control). Dynamic histomorphometric analysis indicated a dose dependent increase in bone formation parameters but an absence of meaningful changes in bone resorption parameters. These effects contributed to the slight increases in femoral neck bone volume (BV/TV), wall thickness, and minor effects on trabecular thickness (Tb.Th) and trabecular number (Tb.N). Although there were no meaningful changes in strength parameters, increases in bone mass were positively and significantly correlated with bone strength parameters (peak load vs. proximal femur DXA BMC and BMD, r=0.54 and r=0.67).  Thus, the data suggest that ABL treatment improves bone architecture and stimulate gains in bone mass and volume, which correlate with strength at the femoral neck.

 

Disclosure: HB: Employee, Nuvios, Inc., Employee, Nuvios, Inc.. GH: Employee, Nuvios, Inc., Employee, Nuvios, Inc.. Nothing to Disclose: AV, ND, LC, EL, RG, SYS

22029 23.0000 THR-222 A Improved Bone Mass and Architecture at the Femoral Neck with Abaloparatide Treatment in Monkeys and Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Tristan William Fowler*1, Kristy M Nicks2, Nisreen Akel1, Archana Kamalakar1, Larry John Suva1 and Dana Gaddy3
1University of Arkansas for Medical Sciences, Little Rock, AR, 2NIAMS, NIH Kelly Government Solutions, Bethesda, MD, 3Texas A&M University, College Station, TX

 

Post-menopausal osteoporosis is associated with the loss of sex steroids, primarily estrogen, in females at the end of the menopause transition. However, the cause of peri-menopausal bone loss remains still unclear. We and others have shown that other hormones in the hypothalamic-pituitary-gonadal skeletal (HPGS) axis, such as Activin A (ActA), gonadal Inhibins (InhA and InhB) and pituitary FSH, contribute to bone health, with Inhibin suppression of bone cell differentiation dominating over any role of FSH. Since the menopause transition is associated with an increase in osteoclasts (OCLs) we explored the mechanism of InhA action in OCLs. InhA treatment significantly suppresses any RANKL-stimulated OCL development in both PBMCs and CD14+/CD11b+ OCL precursor cells in vitro, which was reversed by the soluble form of the Inhibin-specific receptor Betaglycan (BG).  Both cell populations expressed Inhibin receptor complex components, including BG, Type IIA Activin Receptor (ActRIIA), and BMP Receptor II (BMPRII), but not Type IIB Activin Receptor (ActRIIB).   Murine bone marrow and stroma-free bone marrow macrophage (BMM) cultures expressed similar receptor expression patterns. Activins and Inhibins utilize similar signaling mechanisms, and the usual function of Activin is to stimulate responses whereas Inhibin usually antagonizes/inhibits responses. Therefore, we hypothesized that ActA and InhA would have opposing actions in OCLs.  In contrast to consistent suppressive action of InhA on osteoclastogenesis, the ability of ActA to stimulate OCL differentiation was context-dependent. In human PBMC, murine bone marrow, and murine OCL precursors, a stromal component was necessary for ActA stimulation of OCL differentiation. However, ActA inhibited RANKL-induced stroma-free macrophage (BMM) OCL development. Moreover, in BMM, ActA also completely inhibited any RANKL-stimulated increase in OCL motility, differentiation and bone resorption, via a mechanism mediated by SMAD2, AKT and IkB signaling.  Collectively, these data demonstrate context-dependent actions of InhA and ActA on RANKL-induced OCL development. We propose that differences in the cellular milieu of PBMCs and murine bone mediate the effects of ActA and InhA on RANKL-induced osteoclastogenesis that is the consequence of the integration of endocrine signals in vivo.

 

Nothing to Disclose: TWF, KMN, NA, AK, LJS, DG

22053 24.0000 THR-223 A Context-Dependent Effects of Inhibin a and Activin a on Osteoclastogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Gang Xi*, Christine Wai and David R Clemmons
University of North Carolina at Chapel Hill, Chapel Hill, NC

 

Our previous study showed that activation of AMP-activated protein kinase (AMPK) at an early phase is an absolute requirement for osteoblast differentiation but the underlying mechanism by which AMPK is activated has not been explored. The ataxia-telangiectasia mutated (ATM) gene encodes a Ser/Thr kinase which has been show to active AMPK and defective osteoblast differentiation has been reported in ATM deficient mice.  In this study, we determined whether ATM is involved in the AMPK activation at an early stage of osteoblast differentiation. The results showed that ATM protein concentration was increased between Days 3 - 9 after the addition of differentiation medium and decreased dramatically after Day12. Activation of ATM, as indicated by Ser 1981 phosphorylation, peaked between Days 3 - 9 and decreased after Day12. This change correlated with the time course of AMPK activation. Importantly, osteoblast differentiation was significantly impaired when an ATM inhibitor (KU55933) was applied early in the differentiation cycle (e.g., Days 0, 3 or 6). In addition, AMPK activation was also inhibited following exposure to this inhibitor.

Our prior studies show that IGF-I- and IGFBP-2 stimulate osteoblast differentiation via stimulating RPTPβ polymerization which inhibits its tyrosine phosphatase activity. Therefore, we determined whether ATM tyrosine phosphorylation status was altered during the early stage of differentiation. Interestingly, ATM tyrosine phosphorylation was increased between Day3 and Day9, and decreased after Day12, indicating ATM tyrosine phosphorylation was positively correlated with ATM activation and AMPK activation. Importantly, IGF-I stimulated ATM activation, indicated by ATM Ser1981 phosphorylation, at the early stage of differentiation. This was consistent with our previous data which showed that IGF-I stimulated AMPK activation (Thr 172 phosphorylation) at the same stage of differentiation. Both ATM and AMPK activation were prevented by pre-incubation with PQ401, an IGF-I receptor tyrosine kinase inhibitor. To determine whether ATM tyrosine phosphorylation was regulated by RPTPβ, RPTPβ knockdown cells were used. The results showed that knockdown RPTPβ enhanced ATM tyrosine phosphorylation, indicating that RPTPβ was involved in this pathway. A coimmunoprecipiation study showed that RPTPβ was associated with ATM in response to the addition of differentiation medium. In addition, knockdown IGFBP-2, which has been shown to increase RPTPβ enzymatic activity and decrease osteoblast differentiation, impaired ATM tyrosine phosphorylation.  Taken together, these results demonstrate that IGF-I/IGFBP-2 inhibits RPTPβ tyrosine phosphatase activity, resulting in an increase of ATM tyrosine phosphorylation and its enzymatic activity, thereby stimulating AMPK activation which is required for osteoblast differentiation.

 

Nothing to Disclose: GX, CW, DRC

22100 25.0000 THR-224 A IGF-I/IGFBP-2 Stimulates ATM Tyrosine Phosphorylation Is through Rptpβ Leading to AMPK Activation Which Is Required for Osteoblast Differentiation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM THR 200-225 5964 1:00:00 PM Parathyroid and Bone Metabolism Poster


Laura Owen*1, Joanne Adaway2, Frederick C. W. Wu3, Wendy Macdowell4 and Brian G. Keevil5
1MAHSC, 2University Hospital of South Manchester, Manchester, United Kingdom, 3Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom, 4London School of Hygeine and Tropical Medicine, 5Univ Hospital of South Manchester, Manchester, United Kingdom

 

Background: Testosterone is known to show a diurnal variation in males and females. Liquid chromatography tandem mass spectrometry (LC-MS/MS) assays have the ability to combine testosterone analysis with other androgens such as androstenedione, dihydrotestosterone (DHT) and dehydroepiandrosterone (DHEA). We have used this panel of androgens to further investigate their biological variability in both males and females.

Methods: Serum samples were collected from 12 male and 12 female subjects. Samples were collected early in the morning and in the evening of the same day for each subject to assess diurnal variation. Subsequent samples were collected early morning on 6 different days to assess intra-individual variation. Inter-individual variation was assessed using all the data form the samples collected in the mornings.

 Analysis of testosterone, androstenedione, DHT and DHEA was performed using LC-MS/MS with on-line solid phase extraction.

Results: The analytical CV of the assay in the female range was 4, 7, 7 and 10%.  In males it was 3, 4, 9 and 9% for testosterone, androstenedione, DHT and DHEA respectively. All androgens gave higher results in the morning compared to the evening. This difference was statistically different for all androgens for both sexes (paired sample t test <0.005).

The mean inter-individual CVs were similar in males and females for testosterone, androstenedione and DHEA. DHT showed a higher inter-individual (55% vs 37%) and intra-individual (24% vs 12%) CV in females compared to males.

The reference change values for females were 28, 34, 42 and 72% for testosterone, androstenedione, DHT and DHEA respectively. In males the reference change values were 22, 41, 25 and 48% for testosterone, androstenedione, DHT and DHEA respectively.

Conclusions:  Determination of the biological variation for androgens in males and females separately enables the clinician to better interpret results obtained. The calculation of the reference change value incorporates the analytical CV to aid in the determination of significant changes within individuals.

Acknowlegements: The NATSAL team

 

Disclosure: FCWW: Consultant, Besins Healthcare, Consultant, Repros Inc, Research Funding, Besins Healthcare, Research Funding, Bayer Schering Pharma. Nothing to Disclose: LO, JA, WM, BGK

20343 1.0000 THR-270 A Biological Variability of Androgens in Males and Females 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Carmela Campana*, Juilee Rege and William E. Rainey
University of Michigan, Ann Arbor, MI

 

Context: The androgen receptor (AR), mediates the majority of androgen effects on target cells. The DNA cis-regulatory elements that respond to AR share sequence similarity with cis-regulatory elements for glucocorticoid (GR), mineralocorticoid (MR) and progesterone (PR) receptors. Many of the current AR screening models are flawed due to activation of reporters by one of these receptor pathways.  Identification of more selective androgen tests systems would be beneficial for clinical, pharmacology and toxicologic screening of regulators of AR activation.

Objective:  To develop an androgen-responsive reporter cell line that expresses AR but does not express GR, MR and PR.

Design and methods: RNA analysis of cell levels of AR, GR, MR and PR transcripts using quantitative RT-PCR (qPCR). Stable transduction of cells with AR and an androgen responsive gaussia luciferase (AR-luc) reporter with lentiviruses. Gaussian luciferase reporter assay was used to monitory cell reporter activity. The widely used MDA-kb2 androgen test model was used for comparison.

Results: The MDA-kb2 cell line increased luciferase activity following incubation with either dihydrotestosterone (10-fold) and cortisol (16-fold). To develop a more selective model, three cell lines (SW13, U2-OS and CV-1) were screened for low expression of AR, PR, GR and MR. The human SW13 cell line was found to have low transcript levels for each receptor. Lentiviruses were used to initially produce a stable SW13 cell line with the AR response element driven luciferase reporter (SW13-luc). Treatment of cells with testosterone, progesterone, aldosterone or cortisol did not increase luciferase activity by more than 1.6-fold. Lentivirus was then used to develop the SW13-ARluc which expressed AR and the luciferase reporter (10,000-fold over SW13-luc). Incubation of SW13-ARluc with testosterone caused a 9-fold increase in luciferase activity while cortisol, progesterone and aldosterone had only modest effects. 

Conclusions: The current study describes the development and testing of a new androgen screening model. A stable androgen responsive cell line can provide an important model system for screening of new androgen receptor agonists and antagonists. Clonal populations of SW13-ARluc are currently being isolated to improve response.

 

Disclosure: WER: Scientific Board Member, Atterocor. Nothing to Disclose: CC, JR

22120 2.0000 THR-271 A Development of a Novel Cell Based Androgen Screening Model 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Shin Hye Kim*1, Man-Ho Choi2 and Mi Jung Park3
1Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea, Republic of (South), 2Korea Institute of Science and Technology, Seoul, Korea, Republic of (South), 3College of Medicine, Inje University, Sanggye Paik Hospital, Seoul, Korea, Republic of (South)

 

Background : Few studies have investigated the association between body fat mass and steroid profiles in children.

Objectives : To examine whether body fat mass is associated with steroid profiles/steroidogenic enzyme activity in girls.

Methods: A total of 242 girls (54 obesity, 47 overweight, 141 normal; 125 prepubertal, 117 pubertal ; aged 7 to 13yr) were enrolled. Anthropometry and body composition were measured. Serum steroid profiles were analyzed by gas chromatography/mass spectrometry. Steroidogenic enzyme activities were assessed from the ratios of steroid metabolites.

Results: Prepubertal obese girls showed significantly higher progestins (pregnenolone, 17-hydroxypregnenolone), androgens [dehydroepiandrosterone (DHEA), androstenedione (A-dione), testosterone (T), androsterone], compared with prepubertal normal-weight girls. Body fat mass was positively correlated with pregnenolone(r=0.31, P=0.001), DHEA (r=0.29, P=0.02), A-dione(r=0.29, P=0.001),T (r=0.30, P=0.001), and androsterone (r=0.21, P=0.02). It also showed positive correlations with activity of 17,20 lyase (r=0.21, P=0.03), which is a major regulatory steroidogenic enzyme in adrenarche. Pubertal obese girls demonstrated significantly higher T, androsterone than pubertal normal-weight girls, however body fat mass was correlated with neither T nor androsterone. In multivariate logistic regression analysis [Odds ratio (95% Confidence Interval)], higher DHEA [5.61 (1.43-22.0)] and 17,20 lyase activity [2.15 (1.02-4.49)] were associated with odds of having increased body fat mass especially in prepubertal girls.

Conclusion :Increased body fat mass in prepubertal girls was associated with higher 17,20 lyase activity, which is a key enzyme in DHEA production and adrenarche. Increased risk of premature adrenarche in obese girls might result from their increased body fat mass and 17,20 lyase activity.

 

Nothing to Disclose: SHK, MHC, MJP

20971 3.0000 THR-272 A Steroid Profiles and Steroidogenic Enzyme Activity ; An Association with Body Fat Mass in Obese Girls 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Liezl Margaretha Bloem*, Karl-Heinz Storbeck and Amanda C Swart
University of Stellenbosch, Stellenbosch, South Africa

 

The catalytic activity of 11β-hydroxysteroid dehydrogenase (11βHSD) isozymes towards cortisol and corticosterone has been studied extensively in the context of glucocorticoid activation and inactivation. 11βHSD activity has been intricately linked to the tissue in which these isozymes are expressed as well as cofactor availability. Less studied is the role of these isozymes in prostate cancer (PCa). We have shown that 11OHA4 and 11OHT are novel substrates for 11βHSD2 and that 11βHSD1 can catalyse the reverse reactions in the presence of H6PDH (1). Early studies describing 11βHSD activity in the androgen-dependent prostate cancer cell line, LNCaP, showed the cofactor-dependent conversion of cortisol to cortisone with NAD+ showing significantly higher conversion relative to NADP+. These assays were performed with carbenoxolone and 18β-glycyrrhetinic acid, inhibitors of both the reductase activity of 11βHSD1 and the dehydrogenase activity of 11βHSD2 (2, 3). A subsequent study detected 11βHSD2 protein and no 11βHSD1 in LNCaP cells using Western blot analyses (4). We have identified a novel 11OHA4 steroid pathway catalysed by 11βHSD, SRD5A and 17βHSD in LNCaP cells giving rise to active androgens – with 11KDHT capable of activating the AR to the same extent as DHT (1, 5, 6]. The 11βHSD-catalyzed reactions included the conversion of 11OHA4 and 11OHT and their hydroxy-derivatives, 11OH-5α-dione and 11OHDHT to their more active keto forms, highlighting the importance of 11βHSD in the development of PCa. We undertook further investigations into the dehydrogenase activity of 11βHSD towards 11OHA4 (1μM) and 11OHT (1μM) in HEK293 cells transiently transfected with either 11βHSD1 or 2 in the presence or absence of PF915275 (1μM), an 11βHSD1 specific inhibitor, and 11αOHPROG (10μM), an inhibitor of both isozymes. The metabolism of 11OHA4 (1μM) and 11OHT (1μM) was also assayed in LNCaP cells in the presence of either PF915275 or 11αOHPROG, together with dutasteride (1μM), preventing metabolism by SRD5A. All steroids were quantitated by UPLC-MS/MS following deconjugation. In HEK293 cells, 11βHSD2 catalysed the complete conversion of 11OHA4 and 11OHT, with full inhibition by 11αOHPROG. 11βHSD1 also exhibited dehydrogenase activity, converting 11OHA4 (12.21%) and 11OHT (24.91%) in the absence of H6PDH, reactions which were inhibited by PF915275. In LNCaP cells 11OHA4 and 11OHT were converted to 11KA4 (0.26μM) and 11KT (0.16μM) in the presence of dutasteride, conversions which were inhibited in combination with 11αOHPROG. The production of 11KA4 and 11KT was not inhibited by PF915275, implicating 11βHSD2 as the active isozyme in LNCaP cells. It is in the novel 11OHA4 pathway in PCa that the role of 11βHSD2 is clearly evident − the data underlie 11βHSD2’s role of activator of C11-hydroxy androgens in PCa, in stark contrast to its role of inactivator of the glucocorticoids.

 

Nothing to Disclose: LMB, KHS, ACS

21720 4.0000 THR-273 A The Dehydrogenase Activities of the 11betaHSD Isozymes Towards 11OHA4 and 11OHT 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Hee Young Kang1, Young-Kwon Choi*2 and Eui-Bae Jeung3
1Chungbuk National University, CheongjuCheongju Chungbuk, Korea, Republic of (South), 2Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South), 3Chungbuk National University, Cheongju, Korea, Republic of (South)

 

Introduction : 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) is converted from inactive 11-keto form to glucocorticoid (GC or cortisol). Glucocorticoids (GCs) are a steroid hormone found in the body and produced by the adrenal cortex, the outer layer of the adrenal glands. GCs regulate carbohydrate, fat, and protein metabolism. Method : In a previous study, we established porcine fibroblasts overexpressing 11β-HSD1. Based on these, transgenic piglets overexpressing 11β-HSD1 were born without obesity through somatic cell nuclear transfer (SCNT) and re-cloning method, which use somatic cells derived from stillborn TG piglets. Transgenic piglets were identified by PCR methods using specific primers for the targeting cassettes from the genomic DNA of piglets. Result : Six live piglets, one stillborn piglet, and three mummies were born. Integration of target gene into the genomic DNA was confirmed from all of them. However, all six live piglets died within one month, and showed the hypoglycemia. Excessive expression of 11β-HSD1 in metabolic tissues induced up-regulation of gluconeogenesis related genes (G6PT, G6Pase, PEPCK, HNF4α, FOXO1) in liver and kidney, and up-regulation of lipogenesis related genes (SREBP1c, FASN, DGAT, ACC, SCD) in muscle. To compensate for energy loss by anabolism, it stimulates AMPK and SIRT signaling, which controls energy balance and mitochondrial biogenesis. Conclusion : We proposed that the constitutive expression of 11β-HSD1 might cause continuous activation of complementary energy gaining processes and these problems would lead to development of more fatal diseases causing death even in piglets.

 

Nothing to Disclose: HYK, YKC, EBJ

20330 5.0000 THR-274 A Overexpression of 11β-HSD1 Disturbs Energy Balance Between Anabolic Process and Energy Recovery Process 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Young-Kwon Choi*1, Myoungho Lee1, Jae-Hwan Lee2 and Eui-Bae Jeung1
1Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South), 2Chungdaero-1, Cheongju, Korea, Republic of (South)

 

Introduction : Mouse embryonic stem cells (mESCs) have the ability to form aggregates, called mouse embryonic bodies (mEBs), which are required for early development of mES cells. These mEBs differentiated spontaneously into cardiomyocytes. Sex steroid hormones work in the early developing embryo of mice. We researched the influence of sex steroid hormones during early differentiation of mESCs. Methods : The mESCs were performed hanging-drops for three days, which were then suspended in differentiation medium without LIF for one additional day. Four-day-old mESCs-derived mEBs were attached onto 6-well culture plates and differentiated into cardiomyocytes. Differentiated mESCs were harvested every two days for 10 days. We analyzed expression of cardiomyogenesis-related genes, and sex steroid hormone receptors, and observed beating-rate during differentiation of mEBs. We replaced FBS with charcoal-dextran treated FBS (CD-FBS) to investigate the effects of sex steroid hormones during differentiation of mESCs. mEBs were treated with progesterone or mifepristone (progesterone receptor antagonist). Results : The highest beating-rate (92.64%) of mESCs (E14) was reached at differentiation 6d. We observed time-dependent increased expression in mRNA levels of various cardiac markers, including Tbx20, Isl1, Foxh1, cTn1, and Ryr2. In addition, we identified expression of cardiac markers, including alpha-actinin, troponin I, and atrial natriuretic peptide (ANP) via immunocytochemistry method. Thus, our mESCs (E14) were differentiated into cardiomyocytes. To examine effects of sex steroid hormone, we measured mRNA expression of steroid hormone receptors. Expression in mRNA level of ERα, ERβ, and AR showed a time-dependent increase. However, expression of mRNA of PR showed an opposite pattern of beating-rate during differentiation. In CD-FBS treated mEBs, beating-rate (39.56%) was remarkably decreased compared with mEBs cultured in CD-untreated FBS, meaning that steroid hormones have an influence on beating of cardiomyocytes. Beating rate (22.22%) of progesterone treated mEBs was more decreased. Conclusions : In our study, we confirmed that sex steroid hormones affected the differentiation of mESCs into cardiomyocytes. The expression profile of PR gene suggests that progesterone might repress cardiac beating, and other sex steroid hormones might have an effect on increase of beating-rate.

 

Nothing to Disclose: YKC, ML, JHL, EBJ

20170 6.0000 THR-275 A Effect of Sex Steroid Hormones on Beating Rate of Differentiation of Mouse Embryonic Stem Cells into Cardiomyocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Valentina Laura Crudo*1, Juilee Rege2, Adina F. Turcu2 and William E. Rainey2
1University Of Michigan, Ann Arbor, MI, 2University of Michigan, Ann Arbor, MI

 

Background: 3β-hydroxysteroid dehydrogenase type 2 (HSD3B2) is a key enzyme in the adrenal steroidogenic pathway, that catalyzes transformation of Δ5 steroids to Δ4 steroids. Since HSD3B2 competes with CYP17 (17α–hydroxylase/17,20-lyase) and SULT2A1 (sulfotransferase type 2A1) for the metabolism of pregnenolone and 17α-hydroxypregnenolone, its activity is a fundamental gatekeeper for adrenocortical steroid pathways. Within the adrenal this enzyme is highly expressed in the zona fasciculata (ZF) where it plays a key role in cortisol synthesis. In contrast, the zona reticularis  (ZR) is deficient in HSD3B2, which has been proposed to facilitate the production of dehydroepiandrosterone (DHEA) and DHEA sulfate.

Objective: To test the hypothesis that deficient HSD3B2 expression causes adrenal cells to adopt a ZR steroidogenic phenotype.

Methods: Cultured adrenocortical cells (HAC15) were stably transduced with lentiviral shRNA (short hairpin RNA) for HSD3B2 (shHSD3B2). HSD3B2 knockdown was examined by quantitative real-time RT-PCR. Steroid production was quantified by liquid chromatography mass spectrometry and immunoassays.

Results: HSD3B2 mRNA was significantly decreased in HAC15 cells with an efficiency >90%. Production of cortisol in shHSD3B2-HAC15 decreased to less than 1% of that seen in WT HAC15. In contrast, compared to WT cells, DHEA production increased by 12-fold in the shHSD3B2-HAC15 cells. To examine the capacity of cells to produce steroids, they were incubated with the precursor pregnenolone (Preg) (10 µM). Preg incubation increased WT HAC15 aldosterone and cortisol production by 18-fold and 4-fold, respectively. However, in shHSD3B2-HAC15 cells Preg caused only a negligible increase in both steroids, with the total amount of aldo and cortisol representing less than 3% of that seen in WT cells. However, in shHSD3B2-HAC15 Preg increased DHEA production by 4-fold above basal and 3-fold above that seen in Preg treated WT HAC15. 

Conclusion: We have successfully developed a stable HSD3B2-deficient adrenocortical cell line. Silencing HSD3B2 expression eliminated mineralocorticoid and glucocorticoid production but significantly increased DHEA synthesis. These findings support a role for blocking HSD3B2 expression during the development of the DHEA-producing ZR phenotype.

 

Disclosure: WER: Scientific Board Member, Atterocor. Nothing to Disclose: VLC, JR, AFT

22071 7.0000 THR-276 A HSD3B2-Deficient Adrenocortical Cells Adapt a Zona Reticularis Steroidogenic Phenotype 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Enrico Campioli*, Jinjiang Fan, Andrew Stephen Midzak, Martine G Culty and Vassilios Papadopoulos
The Research Institute of the McGill University Health Centre, Montreal, QC, Canada

 

Translocator protein (TSPO, 18 kDa) is an outer mitochondrial membrane high affinity cholesterol- and drug-binding protein abundant in steroid synthesizing cells.  Previous pharmacological, biochemical and genetic studies, as well as in vivo experiments, provided several lines of evidence demonstrating that TSPO is a key member of the mitochondrial cholesterol transport complex in steroidogenic tissues. Moreover, in vitro and in vivo studies, performed in various species, demonstrated the crucial role of TSPO in mitochondrial function and cell viability.  However, the recently reported genetic ablation of Tspo gene in mice, via either conditional (using the Amhr2-Cre) targeting to Leydig and Sertoli cells of the testis or global (using Tspofl/fl female mice crossed with Ddx4-Cre to generate a germ cell-specific Tspo) approaches reported that TSPO has no role in steroid formation and viability (Morohaku et al., & Tu et al., 2014).  To clarify the role of TSPO in steroidogenesis and viability, we generated two lines of Cre-mediated Tspo conditional knockout (cKO) in mice and two lines of zinc finger nuclease (ZFN)-based Tspo gene mutation in rat.  Amhr2-Cre mice were crossed with Tspofl/fl mice for two rounds of breeding to obtain F1 Tspo cKO mice (Tspofl/fl; Amhr2Cre /+ ) to study the role of Tspo under disturbed genetic condition compared to wild-type (wt) mice. Six cKO out of 135 mice were obtained indicating an unexpected Mendelian ratio of 4.4% instead of 25% for the cKO mice. To confirm the observed abnormal Mendelian ratio, we genotyped embryos obtained at dpc 12.5, when Amhr2-Cre is expressed in gonads. The results obtained showed that there was only one Tspo cKO in 22 embryos obtained, corresponding to the same 4.5% ratio seen in adults. The normal embryonic development in the uteri extirpated on dpc 12.5 suggests that there is a Tspo-dependent preimplantation selection. Interestingly, using ZFN technology in rats to develop a global rat cKO for Tspo, we obtained an unexpected low birth rate of 1.2 and 3.5% cKO rats using two different mRNAs leading to 0 and 2 mutant survivors, respectively. Taken together, these findings indicate embryonic lethality when Tspo is removed or mutated although there are rare cases of survival, likely through adaptation. To further establish Tspo steroidogenic cell-specific cKO mice, we used the Nr5a1-Cre (Sf1-Cre) mice crossed with Tspofl/fl mice for two rounds of breeding to obtain the F1. The resulting 36 Tspo cKO (Tspo fl/fl; Nr5a1 Cre /+) from a total of 185 F1 mice showed a normal Mendelian ratio and steroidogenic tissue-specific reduction of Tspo mRNA and protein. Tspo cKO mice lost their ability to produce increased testosterone and corticosterone levels in response to hCG and ACTH treatment, respectively. Taken together these studies demonstrate that TSPO is required for embryo development and confirm its critical role in mediating steroid hormone formation.

 

Nothing to Disclose: EC, JF, ASM, MGC, VP

19086 8.0000 THR-277 A Global Knockout and Steroidogenic Cell-Targeted Deletion of the Translocator Protein (18-kDa) Unveil Its Crucial Role in Viability and Hormone-Dependent Steroid Formation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Daniel Marcus Kelly*1, Samia Akhtar1, Vakkat Muraleedharan2 and Thomas Hugh Jones3
1University of Sheffield, Sheffield, United Kingdom, 2Barnsley Hospital NHFST, Barnsley, United Kingdom, 3Barnsley Hospital NHS Foundation Trust, Barnsley, United Kingdom

 

Testosterone deficiency is associated with adverse effects on cardio-metabolic function promoting insulin resistance, dyslipidaemia and fat accumulation. Excess deposition of fat resulting from poor lipid and glucose control and inadequate storage capacity in subcutaneous adipose depots can lead to ‘overspill’ into visceral fat, liver and the arterial wall. This further worsens tissue-specific metabolic function. We have examined the effects of testosterone status on the expression of key genes and proteins involved in glucose utilisation (carbohydrate-responsive element-binding protein, ChREBP; insulin receptor substrate 1, IRS1; glycogen synthase, GyS; glucose-6-phosphate dehydrogenase, G6PD; glucose transporter 4, GLUT4; hexokinase, HK2 and 4; phosphofructokinase, PFK) and lipid metabolism (stearoyl-CoA desaturase-1, SCD1; sterol regulatory element-binding proteins, Srebp-1 and Srepb-2; acetyl coA carboxylase, ACC; fatty acid synthase, FAS; lipoprotein lipase, LPL; hormone sensitive lipase, HSL) in muscle, liver, subcutaneous (abdominal) and visceral fat depots. Expression was assessed via qPCR in all tissues and western blotting in liver and muscle. Using the testicular feminised (Tfm) mouse model we compared three groups; wildtype XY mice, testosterone deficient Tfm mice with non-functional androgen receptor, Tfm mice treated with testosterone replacement. Testosterone deficiency was associated with higher total body weights, increased hepatic adiposity and increased aortic lipid accumulation in Tfm mice compared to XY littermates. Targets of glucose utilisation were negatively altered in liver (G6PD, PFK, HK), muscle (PFK, GLUT4, HK) and subcutaneous adipose (PFK, GLUT4, HK) at the gene and protein level of Tfm mice. Gene and protein targets of lipid metabolism were negatively altered in liver (FAS, ACC), and gene targets in subcutaneous (SREBP1, SREBP2, LPL) and visceral adipose (SCD1) of Tfm mice. Other genes of glucose (ChREBP, IRS1, GyS) and lipid (HSL) metabolism were not altered in all tissues. Testosterone treatment of Tfm mice reduced liver adiposity, aortic lipid deposition and beneficially altered the expression of hepatic targets of glucose (G6PD, HK) and lipid (FAS, ACC) regulation; muscle targets of glucose (PFK); subcutaneous targets of lipid (SREBP1); and visceral targets of lipid regulation (SCD1). Mouse weights were not significantly altered by treatment. This evidence suggests that testosterone is important in tissue-specific control of metabolism and may differentially promote metabolic function. Improving glucose utilisation in liver and muscle tissue, testosterone may prevent the conversion of excess glucose to fat. Additionally, by beneficially modulating subcutaneous adipose metabolism testosterone may increase its buffering capacity to protect against energy imbalance and fat overspill.

 

Nothing to Disclose: DMK, SA, VM, THJ

22067 9.0000 THR-278 A Evidence That Testosterone Improves Glucose Utilisation and a ′Buffering′ Effect of Subcutaneous Fat to Protect Against ′Overspill′ of Lipid Deposition into Visceral Fat and Non-Adipose Tissues 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Yutaka Nakachi*, Mioko Iseki, Tomotaka Yokoo, Yosuke Mizuno and Yasushi Okazaki
Research Center for Genomic Medicine, Saitama Medical University, Japan

 

Gender Dysphoria (GD), previously known as gender identity disorder, is characterized by dissociation between psychological gender identity and physical sex. This condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Clinical care decisions for peripubertal adolescents with GD should be made carefully. Furthermore, the identification of biomarkers is very important for rapid and accurate diagnosis of GD in young people.

Studies of the biological mechanisms in GD have been reported continually. However, in terms of steroidogenic enzymes and sex hormone receptors, there are no reports of genetic variants that are strongly associated with GD. It is inadequate to consider that only steroidogenic enzymes and sex hormone receptors drive determination of gender identity because these genes are partly responsible for disorders of sexual development.

Thus, we present a novel hypothesis that genes directly related to GD are target genes of sex hormones and/or downstream genes of sex hormone signaling pathways as well as steroidogenic enzymes or sex hormone receptors. However, the specific gene regulation and molecular mechanisms during sexual differentiation of the mammalian brain are still unclear. The aim of this study was to investigate gene expression profiles during masculinization of the neonatal female mouse brain by testosterone and to identify biomarkers related to GD.

To identify GD-related genes as biomarkers for diagnosis, microarray analysis was performed using RNAs extracted from the brains of neonatal mice treated by intraperitoneal injection of testosterone propionate during the sexual determination period. Sequence motif enrichment analysis for sex hormone receptor responsive elements was performed for the flanking regions of genes that showed significant expression changes following administration of testosterone propionate.

We identified 334 genes that showed differential expression in the masculinized neonatal female brain after testosterone propionate treatment. Interestingly, most of these genes are not reported to be expressed in a sexually dimorphic manner. Moreover, sequence motif enrichment analysis suggested that masculinization of the neonatal female brain by testosterone was controlled more by estrogen receptors than androgen receptors.

Differences in genes that are expressed differentially following administration of testosterone injection from known sexually dimorphic genes suggest that many GD-related genes are upregulated during female brain masculinization. The gene set identified in this study provides a basis to better understand the mechanisms of GD and delineate its associated biomarkers.

 

Nothing to Disclose: YN, MI, TY, YM, YO

20904 10.0000 THR-279 A Gene Expression and Sequence Analysis of the Neonatal Female Mouse Brain after Administration of Testosterone Propionate 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Richard J. Auchus*1, Jiayan Liu2, Robert Chomic1 and William E. Rainey1
1University of Michigan, Ann Arbor, MI, 2University of Michigan

 

Background: LCI699 is a potent inhibitor of the human steroid hydroxylases P450 11B1 (11β-hydroxylase) and P450 11B2 (aldosterone synthase).  In a 10-week proof-of-concept study, LCI699 normalized urinary free cortisol in 11 of 12 patients with Cushing’s disease and elevated urinary free cortisol (Bertagna et al, J Clin Endocrinol Metab 99: 1375–1383, 2014).  It is not known if LCI699 will be effective in ACTH-independent Cushing syndrome due to adrenal tumors.  We studied LCI699 in preclinical models of adrenal Cushing syndrome.

Methods: NCI-H295 cells were cultured in serum-free medium containing 10 mM forskolin for 72 h prior to incubation with 0-1000 nM LCI699, 1000 nM ketoconazole, or 1000 nM metyrapone in fresh serum-free medium.  The medium was removed at 24 h, and 10 steroids were assayed by liquid chromatography-tandem mass spectrometry (LC-MS/MS).  V79 cells stably expressing P450 11B1 were incubated with 1 mM 11-deoxycortisol and 0-1000 nM LCI699 to directly assess inhibition of 11β-hydroxylase activity. 

Results: LCI699 inhibited cortisol and aldosterone production in a dose-dependent manner to 13% and 2% of baseline with IC50 values of 10 and 5 nM, respectively. In parallel, 11-deoxycortisol rose to 150% of baseline, while the sum of cortisol + 11-deoxycortisol remained within 8% of baseline with all concentrations of LCI699.  Corticosterone fell to 2% of baseline, while 11-deoxycorticosterone and 17-hydroxyprogesterone rose inconsistently to not more than 146% and 135% of baseline, respectively.  Cortisol and aldosterone fell to 53% and 89% of baseline with 1000 nM ketoconazole and to 39% and 15% of baseline with 1000 nM metyrapone, respectively.    In V79 cells expressing P450 11B1, LCI699 inhibited conversion of 11-deoxycortisol to cortisol with an IC50 of 10 nM.

Conclusions: LCI699 is a potent inhibitor of human P450 11B1 and P450 11B2 in these cell models of ACTH-independent adrenal Cushing syndrome with IC50 values of 10 and 5 nM, respectively.  In NCI-H295 cells, 11-deoxycorticosterone rose inconsistently and less than 11-deoxycortisol.  The use of LCI699 in ACTH-independent Cushing syndrome warrants further study.

 

Disclosure: RJA: Consultant, Corcept, Investigator, Novartis Pharmaceuticals, Investigator, Quest Diagnostics, Advisory Group Member, Laboratory Corporation of America. WER: Scientific Board Member, Atterocor. Nothing to Disclose: JL, RC

22038 11.0000 THR-280 A LCI699 Inhibits Cortisol and Aldosterone Production in NCI-H295 Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Mathieu D Squires*, Matharage Shenali Ireha De Silva, Joseph T Johnson, Jared C Reese, Andrew P Dalley, Logan S Greenburg, James P Porter and Allan M Judd
Brigham Young University, Provo, UT

 

AMP-activated protein kinase (AMPK) regulates cellular metabolism and mediates the effects of interleukin-6 (IL-6) in some tissues.  During chronic inflammatory stress, IL-6 has a role in stimulating cortisol release directly at the adrenal gland. We have previously determined that IL-6 increases cortisol release from bovine adrenal zona fasciculata (ZF) through increasing the expression of steroidogenic acute regulatory protein (StAR) and cholesterol side-chain cleavage enzyme (P450scc).  In addition, IL-6 increases the expression of the nuclear factor steroidogenic factor-1 (SF-1), a stimulator of steroidogenesis, and conversely decreases the expression of the nuclear factor DAX-1, an inhibitor of steroidogenesis.  In the present study, we examined the role of AMPK in the regulation of steroidogenic proteins in bovine ZF.  This tissue was isolated by dissection and fragments incubated in medium under an atmosphere of 95% oxygen; 5% carbon dioxide, and treated with IL-6 in both concentration-dependent (1 hour at 0.025 ng/mL to 25 ng/mL) and time-dependent (15 min to 120 min) trials.  The protein was then extracted from the fragments and the expression of steroidogenic proteins, AMPK, phosphorylated  AMPK (PAMPK), and phosphorylated acetyl CoA carboxylase (PACC) determined by western blot.  IL-6 increased the expression of PAMPK (the activated form of AMPK) in a manner dependent on both time and concentration.  Expression of PACC, an indicator of AMPK activation, was also increased.  The increase in PAMPK and PACC suggests that AMPK is activated by IL-6.  Treatments with the AMPK activator 5-aminoimidazole-4-carboxamide ribonucleotide (AICAR) were then applied to ZF tissue in a similar manner in both concentration-dependent (1 hour at 0.1mM to 3 mM) and time-dependent (30 min to 180 min) trials.  AICAR increased the expression of AMPK, PACC, StAR, P450scc, and SF-1, but decreased the expression of DAX-1.  Therefore, the changes in StAR, P450scc, SF-1, and DAX-1 expression caused by IL-6 may be mediated by the activation of AMPK.  To test this hypothesis, the adrenal fragments were exposed to IL-6 and AICAR in the presence and absence of the AMPK inhibitor compound C.  Compound C blocked the effects of IL-6 and AICAR on StAR, P450scc, SF-1, and DAX-1.  Thus, IL-6 probably alters the expression of the steroidogenic proteins in the ZF through AMPK activation.

 

Nothing to Disclose: MDS, MSID, JTJ, JCR, APD, LSG, JPP, AMJ

20505 12.0000 THR-281 A Interleukin-6 Alters the Expression of Steroidogenic Proteins in Bovine Adrenal Zona Fasciculata through Activation of AMP-Activated Protein Kinase 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Jared C Reese*, Matharage Shenali Ireha De Silva, Joseph T Johnson, Mathieu D Squires, Logan S Greenburg, Andrew P Dalley, James P Porter and Allan M Judd
Brigham Young University, Provo, UT

 

In chronic inflammatory stress, interleukin-6 (IL-6) may play a direct role in cortisol release from the adrenal zona fasciculate (ZF) and this increase may be mediated through the activation of AMP-activated protein kinase (AMPK).  Activator protein-1 (AP-1) is a family of nuclear factors consisting of the homo and heterodimers of the FOS and JUN family including cFOS, cJUN, JUN B, and JUN D.  These nuclear factors have an integral role in regulating steroidogenesis.  In the current study, the interaction of IL-6 and AMPK in the expression of AP-1 transcription factors and the role that the AP-1 complex may have in regulating steroidogenesis mediated by IL-6 in the adrenal ZF were investigated.  Bovine ZF was isolated by dissection and fragments incubated in medium under an atmosphere of 95% oxygen; 5% carbon dioxide, and treated with IL-6 in both concentration-dependent (1 hour at 0.025 ng/mL to 25 ng/mL) and time-dependent (15 min to 120 min) trials.  The proteins were extracted and the expression of steroidogenic proteins,  AP-1 subunits, AMPK, the activated (phosphorylated) form of AMPK (PAMPK), phosphorylated acetyl CoA carboxylase (PACC) (an index of AMPK activation), and both total JUN kinase (JNK) and activated (phosphorylated) JNK (PJNK) determined by western blot.  IL-6 increased the expression of cFOS, cJun, phosphorylated cJUN (PcJUN), JUN B, JUN D, PJNK, PACC, and PAMPK in a manner dependent on time and concentration.  The AMPK activator, 5-aminoimidazole-4-carboxamide ribonucleotide (AICAR) similarly increased the expression of these proteins suggesting that AMPK activation may mediate the expression of AP-1 subunits by IL-6.  Supporting this hypothesis, the AMPK inhibitor compound C blocked the increased expression of AP-1 subunits due to either IL-6 or AICAR.  In support of the role of AP-1 subunits in the regulation of steroidogenesis induced by IL-6 and AICAR, the AP-1 blocker SR11302 blocked the effects of IL-6 and AICAR on steroidogenic proteins and nuclear factors involved in ZF steroidogenesis without affecting the expression of PAMPK and PACC.  These results support the hypothesis that IL-6 activates AMPK, which in turn increases the expression of AP-1 subunits and the phosphorylation of cJUN by JNK.  The AP-1 complex subsequently increases the expression of genes involved in steroidogenesis.

 

Nothing to Disclose: JCR, MSID, JTJ, MDS, LSG, APD, JPP, AMJ

20464 13.0000 THR-282 A Activator Protein-1 Complex Functions As a Biochemical Intermediate in the Interleukin-6 and AMP-Activated Protein Kinase Regulation of Steroidogenic Enzymes in the Bovine Zona Fasciculata 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Timothy James Cole*1, Anthony Daniel Bird1, Kuan Liew2 and Gareth Geoffrey Lavery3
1Monash University, Melbourne, Australia, 2Monash University, 3University of Birmingham, Birmingham, United Kingdom

 

Endocrine steroid hormones including estrogens, androgens, glucocorticoids and mineralocorticoids play clinically important and specific regulatory roles in human development, growth, metabolism, reproduction and brain function. The 11-beta hydroxysteroid dehydrogenase enzymes have key roles in the pre-receptor modification of glucocorticoids, modifications that directly regulate blood pressure, fluid and electrolyte homeostasis, as well as modulating metabolic and brain function. An analysis of the human genome has located a novel largely uncharacterized 11bHSD-like gene on human chromosome 19q13.3, a distinct gene from the very well characterized 11bHSD1 (human chromosome 1q32-q41) and 11bHSD2 (human chromosome 16q22) genes. Strikingly, a search in other mammalian genomes has revealed the complete absence of this third 11bHSD gene from the mouse, rat and rabbit genomes. This human 11-beta-hydroxysteroid dehydrogenase 1-like protein (HSD11B1L) gene and its encoded enzyme are completely uncharacterized for substrate specificity and detailed cellular expression pattern. The human HSD11B1L gene is encoded by 9 exons and analysis of EST library transcripts indicates the use of two alternate ATG start-sites in exons 2 & 3, and alternative RNA splicing in exon 9. HSD11B1L shares a 40% amino acid sequence homology with 11bHSD1 and the strong conservation of the NAD+/NADP+ nucleotide binding and dehydrogenase/reductase catalytic site domains. We show by qPCR analysis that HSD11B1L is strongly expressed in non-human primate and the sheep in total RNA from the brain and ovary. Immunohistochemistry detects specific cell localisation to gonadotroph cells of the anterior pituitary, the granulosa cell layer of the sheep and marmoset ovary, and Leydig and Sertoli cells of the marmoset testis. Steroid substrate conversion assays in HSD11B1L-transfected Hek293 cells showed no activity when incubated with cortisol or cortisone. Localisation of HSD11B1L in pituitary gonadotrophs and reproductive gonadal tissues indicates a potential role in the regulation of human reproductive function that remains to be explored.

 

Nothing to Disclose: TJC, ADB, KL, GGL

21752 14.0000 THR-283 A A Novel Species-Restricted 11β-Hydroxysteroid Dehydrogenase 11βHSD1L Is Expressed in Pituitary Gonadotrophs and Steroidogenic Cells of the Ovary and Testis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Jasmeet Kaur*1, Randy M Whittal2 and Himangshu S Bose3
1Mercer Univ Sch of Med, Savannah, GA, 2University of Alberta, Edmonton, Canada, 3Mercer Univ Schl of Med, Savannah, GA

 

3βHSD1 ACTIVITY OR INACTIVITY DEPENDS ON THE TOPOLOGY

3β-hydroxysteroid dehydrogenase isomerase (3βHSD, 1 and 2) plays a key role in the biosynthesis of active steroid hormones in humans. 3βHSD has been reported to be equally distributed between the mitochondrial and microsomal fractions prepared from human placentae. 3βHSD1 is found to be a membrane-bound enzyme in the endoplasmic reticulum and two membrane binding domains (residues 72-89 and 283-310) have been predicted in this protein. We have found that 3βHSD1 is targeted to endoplasmic reticulum (ER) and is an integral membrane protein.

3βHSD1 cDNA was translated using rabbit reticulocyte in absence and presence of canine pancreatic rough microsomal membranes (MM). Cell-free translation of 3βHSD1 in the absence of MM showed a 42kDa protein band and addition of rough microsomes to the translation mixture, appeared an additional protein with a decreased mobility (60kDa). We next treated the translated product with endoglycosidase H (endo H). Endo H is a highly specific endoglycosidase that cleaves asparagine-linked mannose rich oligosaccharides. However, endo H treatment did not digest the higher molecular weight protein, showing that the modification is not glycosylation. So, the N-terminus must be located in the cytoplasm. To examine the extent of integration of 3βHSD1 into the ER membrane, aliquots of translated product, with and without MM, were incubated with freshly prepared Na2CO3, and then ultracentrifuged to separate the membrane pellet from supernatant fractions. In the absence of MM, washing with buffer as a control resulted in recovery of the protein predominately in the pellet fraction. However, alkali treatment resulted in recovery of the protein predominately in the soluble fraction. Addition of MM led to the recovery of precursor and the higher molecular weight 3βHSD1 protein in the pellet fraction, both in buffer and alkali-treated samples, suggesting that the protein needed a membrane environment for integration. Thus, specific localization of 3βHSD1 in the endoplasmic reticulum and topology in the ER membrane affects its activity in the cell.

 

Nothing to Disclose: JK, RMW, HSB

19354 15.0000 THR-284 A 3βHSD1 Activity or Inactivity Depends on the Topology 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Terri L Provost* and Alexis Lancaster
Utica College, Utica, NY

 

Dymethazine is an anabolic pro-steroid hormone composed of two molecules of methasterone bound by a nitrogen atom. Dietary supplements containing dymethazine are used by athletes to take advantage of the claimed ability to increase performance and build muscle. Few studies have tested the true effects of dymethazine, but studies have focused on the adverse effects of methasterone, the building blocks of dymethazine. We hypothesized that mice exposed to supplements containing dymethazine will have similar adverse effects as methasterone. To test this hypothesis, we measured body weight, relative organ weights, hind-leg muscle mass, hemoglobin, hematocrit, blood glucose, and liver protein in 20 adult, male mice that were randomly assigned to one of two treatments for 4 weeks. Ten mice were fed ground standard rodent chow ad libitum, another ten were fed standard rodent chow spiked with 5 ppm of dymethazine. Based on consumption data this provided 0.33mg/kg body weight of dymethazine. The results indicate that the dymethazine group had significantly decreased relative testes weights when compared with control animals. Both the thymus and leg muscle weights showed trends toward elevation in treatment animals, although values were not significant. Change in body weight in the treatment group was significantly greater than the controls, and hematocrit percent was significantly lower in the treatment group. No significant difference was found in liver protein, hemoglobin, or blood glucose levels. Mean blood calcium was higher in treatment mice. Testosterone and estradiol levels are currently being analyzed. These data suggest that further research on reproductive success in these animals is warranted.

 

Nothing to Disclose: TLP, AL

22169 16.0000 THR-285 A Effects of Dymethazine Steroid Supplement on Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Kumud Joshi1 and Pandurangan Ramaraj*2
1KCOM, Kirksville, MO, 2KCOM, A T Still University, Kirskville, MO

 

Androgens such as dehydroepiandrosterone (DHEA), androstenedione (AD) and testosterone (T) are essential for healthy skin. They play important roles in growth and differentiation of sebocytes, hair growth and wound healing in the skin (1). It has been reported that decrease in DHEA level with age is responsible for cancer and other problems associated with aging (2). So, it is natural to check for the effect of DHEA on melanoma, a fatal form of skin cancer. It has also been reported that DHEA’s purported beneficial effects (such as anti-cancer) were observed in mouse and other rodents, but not in humans (3). So, we decided to compare the in-vitro effects of DHEA between mouse (B16F10) and human (BLM) melanoma cell lines. Dose response and time course studies were carried out with both cell lines. The mechanism of cell death, mediated through androgen receptor (AR) was also determined. Co-incubation with progesterone (4) or RU-486 (5) was carried out to determine co-operativity between sex steroids in decreasing the cell growth.

Research work on mouse melanoma cell line showed a cell growth of 30% at 200μM concentration of DHEA, whereas human melanoma cell line showed a cell growth of 69% at 200 μM concentration. The mechanism of inhibition of mouse melanoma cell growth was due to autophagy as shown by rescue of cell growth by 0.25 mM of 3-methyl adenine (3-MA) (6). But inhibition of human melanoma cell growth was due to apoptosis, as shown by condensation of nuclei by DAPI staining and rescue of cell growth by 20 μM of pan-caspase inhibitor (CI). Co-incubation and pre-incubation experiments with androgen receptor (AR) antagonist bicalutamide (10 μM), showed a partial rescue in cell growth in both cell lines indicating that DHEA action was mediated through androgen receptor. DHEA co-incubation with progesterone or RU-486 showed an additive effect in decreasing cell growth in mouse cell line, but not in human cell line.

Though DHEA actions were mediated through AR in both cell lines, DHEA showed significant growth inhibition and induced autophagy in mouse cell line, but it showed a muffled inhibition and induced apoptosis in human cell line. Additive effect in decreasing cell growth was observed when progesterone or RU-486 was co-incubated with DHEA in mouse cell line, but not in human cell line. These differential in-vitro effects between mouse and human melanoma cell lines were in line with the published in-vivo effects (2,3) and suggested a possible difference in intracellular processing of DHEA between two cell lines.

 

Nothing to Disclose: KJ, PR

19224 17.0000 THR-286 A Comparison of in-Vitro Effects of Dehydroepiandrosterone (DHEA) Between Mouse and Human Melanoma Cell Lines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Loren W Kline*1 and Edward Karpinski2
1Univ of AB/Fac of Med & Dentist, Edmonton, AB, Canada, 2University of Alberta, Edmonton, AB, Canada

 

The sex steroids estrogen (17B-estradiol, E2), progesterone (P), and dihydrotestosterone (DHT)  relax cholecystokinin octapeptide (CCK)-induced tension in male and female guinea pig gallbladder strips.   This study compared the responses in male guinea pig gallbladder strips with those in female guinea pig gallbladder strips to determine if a sex difference in the response to the steroids existed.  A pharmacologic approach was used.  When 10, 50, and 100 mm E2 was used there was no significant difference in the amount of E2-induced relaxation (10 mm 14.2+2.1% female vs. 17.8+1.9% male, 5mM 57.4+2.6% female vs. 58.0+3.2% male, 100 mm 65.9+4.8% female 63.7+3.5% male).  No significant difference was observed when the response to E2 was compared between young female guinea pigs and late stage pregnant guinea pigs (51.8+2.7 non-pregnant vs. 52.4+3.3% pregnant).  When 10, 50, and 100 mm P was used , the amount of relaxation induced by 10 and 50 mm were not significantly different; however, 100 mm P caused significantly more (p<0.05) relaxation in the female (91.9+6.2%) than the male (77.8+2.3%).  When 10 or 100 mm 17-OH P or 20-OH P were used, there was no significant difference in the amount of relaxation observed in the male and female strips.  The use of 10 or 100 mm DHT produced no significant difference in the amount of relaxation of CCK-induced tension in male and female guinea pig gallbladder strips (10 mM; 24.1+2.9%  female vs. 26.9+3.0% male; 100 mM; 65.8+3.4 female vs. 71.9+3.6% male).  In conclusion, there was little difference in the response to the sex steroids by male and female guinea pig gallbladder strips.

 

Nothing to Disclose: LWK, EK

18317 18.0000 THR-287 A The Effects of 17B-Estradiol, Progesterone, and Dihydrotestosterone on Male and Female Guinea Pig Gallbladder Strips 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Nathan Long*, Dream Le, Lam Nguyen and Kevin Sinchak
California State University, Long Beach, Long Beach, CA

 

In an ovariectomized (OVX), estradiol benzoate (EB, 2 µg)-primed rat, sexual receptivity (lordosis) can be rapidly induced in 30 minutes by infusing nonesterfied 17β-estradiol (E2) into the arcuate nucleus of the hypothalamus (ARH) instead of progesterone (1).  E2 is acting through G protein-coupled estrogen receptor 1 (GPER; aka GPR30) to facilitate lordosis (1).  EB-priming initially inhibits lordosis through a multi-synaptic circuit originating in the ARH that stimulates β-endorphin release to activate µ-opioid receptors (MOP) in the medial preoptic nucleus (MPN). Subsequent deactivation of MPN MOP by progesterone or E2 infusion into the ARH facilitates lordosis.  Lordosis is also facilitated through deactivation of MPN MOP in EB-primed rats by peripheral treatment with the SERMs, tamoxifen (TAM) or ICI 182, 780 (ICI).  Although ICI and TAM are considered antagonists of classical estrogen receptors, they have been shown to activate GPER.  Therefore, we tested the hypothesis that infusion of ICI or TAM into the ARH will rapidly deactivate MPN MOP and facilitate lordosis in EB-primed OVX rats via the activation of GPER.  Infusion of either ICI or TAM facilitated lordosis and reduced levels of MPN MOP activation compared to rats that received vehicle control infusion.  Infusion of the GPER antagonist, G15, prior to ICI or TAM significantly reduced MPN MOP activation and blocked facilitation of lordosis.  These results indicate that TAM and ICI activate GPER in the ARH to facilitate lordosis.  Thus, these and other estrogenic effects by TAM and ICI may be attributed to the activation of GPER.

 

Nothing to Disclose: NL, DL, LN, KS

21644 19.0000 THR-288 A Tamoxifen and ICI-182780 Activate G Protein-Coupled Estrogen Receptor 1 (GPER) to Facilitate Sexual Receptivity in 30 Minutes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM THR 270-288 5971 1:00:00 PM Steroid Hormone Actions and Biosynthesis Poster


Jonathan Sagum*1, Rama Poola1, Carmel Maria Fratianni2, Michael G Jakoby IV2 and Chaitanya Kumar Mamillapalli3
1SIU School of Medicine, Springfield, IL, 2Southern Illinois University School of Medicine, Springfield, IL, 3HSHS Medical Group, Decatur, IL

 

Background: MEN1 is a rare autosomal dominant disorder characterized by tumors of parathyroid, anterior pituitary and pancreatic islet cells. Pituitary adenomas in MEN1 can be aggressive and invade surrounding structures including the skull base. However, acute bacterial meningitis in patients with untreated pituitary macroadenomas is an exceptional finding reported in only a few cases. We present the case of a young man with suppurative meningitis complicating an invasive macroprolactinoma as the initial manifestation of MEN1.

Case: A 33-year-old male was admitted to hospital for management of Haemophilus influenza bacterial meningitis.  Initial computed tomography (CT) and subsequent magnetic resonance imaging (MRI) of the sella turcica revealed a 5 x 3.5 cm pituitary mass invading both cavernous sinuses and the right sphenoid sinus. Laboratory evaluation was notable for significantly elevated serum prolactin level (2,484 ng/mL) and evidence of hypopituitarism. Primary hyperparathyroidism was indicated by hypercalcemia (13.5 mg/dL, 8.5-10.5), low serum phosphorus (2.0 mg/dL, 2.5-4.9), and elevated intact parathyroid hormone (PTH) level (290 pg/mL, 15-60).  No visual field deficits were identified. The patient was managed with hydrocortisone, levothyroxine, and cabergoline.  However, CSF rhinorrhea compelled subtotal transphenoidal resection of the tumor and repair of CSF leak. Three-and-a-half gland parathyroid resection was performed after recovery from pituitary surgery and successfully treated hypercalcemia.  Abdominal MRI revealed a 3 mm cystic mass in the neck of the pancreas, and pancreatic polypeptide was approximately 2-fold elevated on two measurements.   A clinical diagnosis of MEN1 was made based on occurrence of macroprolactinoma, multiple parathyroid adenomas, and pancreatic findings.  Testing for a MEN1 germline mutation is being arranged.

Conclusions: Pituitary adenomas occur in approximately 40% of MEN1 cases and are the initial manifestation of MEN1 in 15-20% of patients.  The significant majority of tumors are macroadenomas.  Prolactinomas are the most frequent type of adenoma in MEN1 and much more likely to present as invasive tumors than sporadic prolactinomas.  Though meningitis usually complicates macroprolactinomas after interventions that reduce tumor volume, erosion of the floor of the sella turcica into the sphenoid sinus can provide entry for nasopharyngeal bacteria into the central nervous system.  In a recent series of 82 male patients, three were hospitalized with bacterial meningitis as the initial presentation of macroprolactinoma.   Pituitary macroadenoma is a potential endocrine etiology of acute bacterial meningitis, and MEN1 should be considered in the differential diagnosis due to the propensity for large and invasive pituitary tumors.

 

Disclosure: MGJ IV: Speaker, Sanofi. Nothing to Disclose: JS, RP, CMF, CKM

19356 1.0000 THR-341 A Multiple Endocrine Neoplasia Type 1 (MEN1) Presenting As an Invasive Macroprolactinoma Complicated By Acute Bacterial Meningitis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Derek D Hem*1, Ma. Conchitina Manas Fojas1 and Kyaw Kyaw Soe2
1The Ohio State University Wexner Medical Center, Columbus, OH, 2The Ohio State University Wexner Medical Center, Hilliard, OH

 

INTRODUCTION

Primary Aldosteronism (PA) and Pituitary Adenoma have been described in case reports as rare components of MEN 1 syndrome. We present three patients with these diagnoses. Whether two common endocrine disorders were incidentally discovered in the same patient or whether we discovered early presentations of a sporadic variant of the MEN 1 syndrome remains uncertain.

CASES

1st patient: 76-year-old male with hypokalemia and resistant hypertension (HTN) who presented with 2.3 cm non-secretory pituitary macroadenoma causing low testosterone due to mass effect.

2nd patient: 37-year-old female with gynecomastia, galactorrhea, hypokalemia and HTN. Initial MRI Brain was negative for pituitary adenoma, follow-up MRI revealed suspicion of a pituitary microadenoma.

 3rd patient: 54-year-old male with diplopia due to 2.6 cm prolactinoma. He was found to have low testosterone and high PRL. During follow-up, he was noted to have resistant HTN and hypokalemia.

All patients had significantly elevated aldosterone-renin ratio (ARR). The 1st patient had saline suppression test, but the 2nd and 3rd patients did not undergo confirmatory testing as clinical suspicion was very high. CT Adrenal glands were negative for adenoma. They all underwent adrenal vein sampling (AVS). For the 1st patient, the lesion was localized on the left side; he had adrenalectomy with improvement of HTN and hypokalemia. The 2nd patient had AVS done twice; both showed suboptimal results (no cortisol gradient between IVC and right adrenal vein). She insisted on having left adrenalectomy as she had markedly high aldosterone level from the left adrenal vein. She did not improve postoperatively and is maintained on spironolactone. The 3rd patient underwent AVS, which showed inconclusive results.  

DISCUSSION

PA affects 5 to 15% of patients with HTN and constitutes 17-23% of resistant HTN cases. It is clearly underdiagnosed. Timely diagnosis is crucial because of its independent adverse effect on cardiovascular morbidity and mortality. The standard screening test is ARR, which has 95% sensitivity and 75% specificity. CT scan of the adrenal glands may fail to identify a small adenoma or hyperplasia. There is currently no gold standard for confirming PA. If surgery is contemplated, localization of the source by adrenal vein sampling (AVS) is mandatory. AVS is highly operator dependent, which could limit the reliability of results.

We have presented 3 interesting cases of PA with Pituitary Adenoma. None of our patients had evidence of hyperparathyroidism or a family history suggestive of MEN 1 syndrome. While our patients do not qualify to have the syndrome, it is important to reiterate that we cannot rule out the clinical syndrome just yet, as it may take time for MEN syndrome to manifest most features. These patients need long-term monitoring and active surveillance for the development of other endocrine tumors.

 

Nothing to Disclose: DDH, MCMF, KKS

22011 2.0000 THR-342 A Three Cases of Primary Aldosteronism with Pituitary Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Neha Bansal*
Winthrop University Hospital, Mineola, NY

 

Background: Multiple Endocrine Neoplasia type 1 (MEN1) is a rare inheritable disorder with even more rare sporadic variations that are classically characterized by neuroendocrine tumors of the pituitary, parathyroid and pancreas.  However, MEN1 can commonly be affiliated with benign mesenchymal lesions such as angiofibromas, collagenomas, lipomas and leiomyomas, but never has been reported in conjunction with an infiltrating mesenchymal tumor.

A 22 year old man with recent onset of a right sided thigh swelling presented to the endocrine office after preliminary work up for hypercalcemia by his primary care physician. Serum calcium was 11.6 mg/dl (8.7-10.2mg/dL) and PTH was elevated to 92ng/mL (14-72ng/mL). Thyroid/parathyroid ultrasound was normal but abdominal ultrasound demonstrated renal cysts. Abdominal CT scan for evaluation of the renal cysts demonstrated a pancreatic mass. The patient had a negative medical history prior to this time and denied headaches, changes in vision, polyuria, polydipsia, fatigue, constipation, kidney stones, abdominal pain, or changes in skin or bowel habits.  On physical exam vital signs were normal with a BP of 120/80 and HR of 76 BPM.  Visual fields were intact to confrontation bilaterally, thyroid was palpable with no enlargement or nodules.  There was mild gynecomastia with no breast masses and no abdominal organomegaly.  The extremity exam elicited a large firm painless right inner thigh mass with no abnormality of the surrounding skin. There was no family history of endocrinopathies or malignancies; however, further blood work was done for the suspicion of MEN 1 given the primary hyperparathyroidism and pancreatic mass. Anterior pituitary and pancreatic endocrine work up was negative except for a slightly elevated Prolactin of 16.9ng/mL (4-15.2ng/mL).  Brain MRI ruled out pituitary mass, and MRI of large thigh mass demonstrated a solid enhancing 10cm mass.  Pathology studies performed on surgical specimen’s demonstrated parathyroid adenoma and hyperplasia, pancreatic neuroendocrine tumor and mesenchymal soft tissue tumor invading skeletal muscle. Ultimately, genetic testing confirmed the patient to have MEN1.

Conclusion: This is the first reported case of sporadic MEN1 demonstrating the presence of an infiltrating mesenchymal tumor along with a nonfunctional pancreatic neuroendocrine tumor and hyperparathyroidism.  This case illustrates the diversity of presentation capable of MEN1.

 

Nothing to Disclose: NB

21874 3.0000 THR-343 A Looking Beyond the Three P's: A Novel Presentation of Sporadic Multiple Endocrine Neoplasia Type 1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Katsutoshi Takahashi*, Yuichi Takashi, Noriko Makita, Seiji Fukumoto, Kazuhiro Yoshiuchi and Masaomi Nangaku
University of Tokyo Hospital, Tokyo, Japan

 

Background:

Genetic testing and counseling is critical in the management of both multiple endocrine neoplasia type 2 (MEN 2) and hereditary breast and ovary cancer (HBOC). Given the similarities between MEN 2 and HBOC as an autosomal dominant familial cancer syndrome with predictive genetic testing and prophylactic surgery, we integrated the Angelina Jolie Effect into a multi-step genetic counseling in a family of MEN 2A.

Clinical case:

A 34-year-old woman was referred to us for the treatment of bilateral pheochromocytoma. One month earlier, she had been brought to the ER because of abdominal pain and dyspnea. After ICU admission, she underwent intensive treatment because of pheochromocytoma crisis. Then, she was diagnosed with MEN 2 based on elevated serum calcitonin level and the FNA cytology of a thyroid nodule. Based on p.C634Y RET germ-line mutation, she underwent elective surgery for bilateral pheochromocytoma, followed by total thyroidectomy for MTC. After complete stabilization, her two children, 5 year-old boy and 8-year-old girl, were clinically screened for MEN 2A pathology. During this course, we provided the following genetic counseling: In the first session, we restricted the client to the patient only, illustrating Ms. Angelina Jolie as a patient fighting familial cancer. In the second session, we restricted the clients to the partner and the patient. This session focused on family ties and communication, illustrating Mr. Brad Pitt as a spouse caregiver of a familial cancer patient. In the third session, we interviewed the mother of the patient, the patient and the partner. Then, we performed genetic testing of the patient. In the fourth session, we provided the result of RET gene mutation, to the patient and the partner. During and after the genetic counseling sessions, we repeatedly assessed psychological distress using a validated self-report questionnaire, the Hospital Anxiety and Depression Scale (HADS). Although negative psychological impact was reported for MEN 2 patients and the partners after genetic testing, our patient and the partner showed no negative psychological distress: the patient, HADS anxiety score 4-5, HADS depression score 1-3; her partner, HADS anxiety score 2-3, HADS depression score 1-2.

Conclusion:

This is the first case demonstrating the possible beneficial effect of the multi-step genetic counseling in a family of MEN 2A, emphasizing family ties and communication using the Angelina Jolie effect. Our new approach may open an avenue for implementing the effective psychological care of the MEN 2 patients and the family.

 

Nothing to Disclose: KT, YT, NM, SF, KY, MN

21092 4.0000 THR-344 A The Application of the Angelina Jolie Effect on a Multi-Step Genetic Counseling in a Family of MEN2A 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Chheki Sherpa* and Ying Hu
Geisinger Medical Center, Danville, PA

 

Background: Multiple endocrine neoplasia (MEN) type 2 is a rare autosomal dominant monogenic disorder caused by missense mutations in the RET (REarranged during Transfection) proto-oncogene.  It is characterized by medullary thyroid carcinoma (MTC), pheochromocytoma (Pheo) and hyperparathyroidism. Genetic screening of family members in MEN 2 kindred is recommended because it changes management and improves clinical outcome.

Case presentation: 46 year old male with past medical history of kidney stones was seen in emergency room for abdominal pain. Abdominal CT showed incidental finding of 1.8 cm left adrenal mass and he was referred to Endocrinology.  MRI of abdomen showed bilateral adrenal nodules (left 1.6x1.1 cm; right 1.3x0.8 cm) with characteristics compatible with a lipid-poor adenoma.  Hormonal work up showed elevated 24 hour urine epinephrine 29.1 ug/24 hours (normal 0-20 ug/24 hours), metanephrine 509.8  ug/24 hours (normal 60-275 ug/24 hours); elevated plasma metanephrine 192 pg/ml (normal <=57 pg/ml).  He had normal 24 hour urinary free cortisol and aldosterone/renin ratio.  Pheo was suspected and MIBG scan showed bilateral hyperactive adrenals.  Further history revealed that he has 72 family members diagnosed with MEN syndrome by genetic testing in Florida in early 1990s. The patient didn’t know the specific mutation and was never tested.  Screening lab showed calcitonin 6.6 pg/ml (normal 0-18.2 pg/ml), calcium 9.4 mg/dl (normal 8.3-10.5 mg/dl), intact PTHi 68 pg/ml (15-65 pg/ml), 25-hydroxyvitamin D 10.1 ng/ml (normal 30-100 ng/ml). Genetic testing showed RET mutation p. C634F, also known as c.1901G>T. He was diagnosed with MEN2A syndrome.  He underwent bilateral laparoscopic adrenalectomy. Pathology confirmed bilateral Pheo. Subsequently he underwent prophylactic total thyroidectomy, which showed focal nodular goiter. His PTHi level returned to normal (33 pg/ml) after vit D normalization. He has been followed up in Endocrine clinic for hydrocortisone, fludrocortisone, levothyroxine supplement.

Discussion:  C-cell hyperplasia (CCH) or MTC occurs with nearly 100% penetrance in patients with MEN 2A syndrome. It usually precedes Pheo for about 10 years.  Codon 634 mutations occur in 80% of MEN 2 A kindreds and are most commonly associated with classic MEN 2 A features.  The average age at diagnosis of Pheo was 39.8 years in patients with mutation at codon 634.  There have been few case reports with Pheo as the first manifestation with reduced penetrance of medullary thyroid carcinoma in patients with MEN2A, such as with mutation C609S, S891A.  This patient has C634F mutation, which is a relatively rare mutation at codon 634. It is possible that this particular C634F mutation has unique clinical features different from other common mutations at codon 634.

Conclusion: Pheochromocytoma can be the initial presentation in patients with MEN2A with C634F mutation.

 

Nothing to Disclose: CS, YH

18932 5.0000 THR-345 A Pheochromocytoma As the Initial Manifestation of Men 2 a Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Blandine Tramunt1, Alexandre Buffet1, Solange Grunenwald1, Delphine Vezzosi1, Antoine Bennet1, Eric Huyghe2, Slimane Zerdoud3 and Philippe Caron*1
1CHU Larrey, Toulouse, France, 2CHU Rangueil, Toulouse, France, 3Institut Universitaire du Cancer, Toulouse, France

 

CONTEXT

In Multiple Endocrine Neoplasia type 2A, local recurrence of pheochromocytoma  after total adrenalectomy is a rare occurrence in which diagnosis and therapy are not clearly defined.

CASE DESCRIPTION

We report a 33-year old patient with a MEN 2A syndrome (p.Cys634Arg) diagnosed within the framework of a family survey. He had a left adrenalectomy by retroperitoneal laparoscopy for a 6-cm pheochromocytoma. Histological examination confirms a pheochromocytoma with KI-67 less than 2% and a continued fibrotic capsula. This surgery has spent without any complication and then hormonal and radiological evaluation was normal. Because of increased calcitonin (26 pg/ml) and a positive pentagastrin test (291 pg/ml), a total thyroidectomy and lymph node dissection were performed and bilateral medullary thyroid microcarcinomas were found. After eight years of follow-up, recurrence in the bed of adrenalectomy was observed and a second surgery by laparotomy was performed.  Four years later, increased urinary metanephrines levels and MIBG scintigraphy fixation only on the left adrenal bed lead to a third surgery with large excision of all tissues (left adrenal bed, diaphragm and psoas).  Histology confirms chromaffin origin of all tissues after each surgery and pheochromocytomatosis was evocated. Interestingly, urinary metanephrines increased with inverted physiological ratio between urinary normetanephrines and metanephrines before each recurrence, and preceded the radiological and isotopic diagnosis. Because of increased urinary metanephrines levels and persistent fixation on scintigraphy scan, a 131I MIBG therapy (3 cures of 150 mCi) was administered between August 2011 and March 2012. Since then, normal urinary metanephrines levels and free-disease abdominal CT scan were obtained .

 CONCLUSION

We report a case of pheochromocytomatosis in a MEN 2A patient. On one hand, inverted physiological ratio between urinary normetanephrines and metanephrines could represent an early marker of recurrence in epinephrines-secreting pheochromocytoma. On the other hand 131I MIBG treatment seems to be a useful therapeutic option in order to avoid multiple invasive surgeries.

 

Nothing to Disclose: BT, AB, SG, DV, AB, EH, SZ, PC

21109 6.0000 THR-346 A Local Recurrences of Pheochromocytoma in Multiple Endocrine Neoplasia Type 2A: A Diagnosis and Therapeutic Challenge 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Orlando Vicente Jaramillo*1, Chistopher Mora2, Su-Yen Araya2, Mariela Chacon2 and Carlos Santamaría2
1National Children's Hospital, San Jose, Costa Rica, 2Hospital Nacional de Niños, San Jose, Costa Rica

 

Introduction: 
Multiple endocrine neoplasia type IIA is an autosomal dominant syndrome with various endocrine neoplasms, including medullary thyroid carcinoma (MTC), pheochromocytoma, and parathyroid adenomas. It is the most common form of MEN and, although almost all patients develop MTC, there is still much controversy on which is the ideal age to perform  the risk-reducing surgery. 
Our case regards the first patient to have undergone a prophylactic thyroidectomy in Costa Rica and the rest of Central America, because of a molecular biology diagnosis of a RET gene mutation. 

Clinical Case:
Eleven-year-old male patient with a personal history of allergies and anxiety, but otherwise in apparent good health, is given follow up in the endocrinology department at the children's hospital in Costa Rica, since 2011 given that the mother had been diagnosed with primary hyperparathyroidism and has undergone surgery for thyroid medullar carcinoma and pheochromocytoma, clinically suggestive of MEN2A.
The patient is tested extensively, where all lab and image tests return apparently normal. The patient's mother was diagnosed as harboring a C634G mutation (RET exon 11) in our laboratory. Then, the same mutation was detected in a blood sample from our patient. Molecular RET analysis of of the asymptomatic patient's sister (8 yeasrs old) was negative. 

Taking into account that he has close to 100% risk of developing medullar thyroid carcinoma, the patient undergoes a prophylactic thyroidectomy, and suffers no major postsurgical complications, besides hypocalcemia for which the patient is given 600mg every 8 hours of calcium and 0,25 ug/d of vitamin D, along with 0,1 mg/d of levothyroxine. 

The postsurgical pathology shows a thyroid medullar carcinoma of less than 0,5 cm of diameter, without neural or vascular invasion, clean margins, no metastases to lymph nodes and with the resection of the  four parathyroid glands.

Conclusion: To the best of our knowledge this is the first case documented in Costa Rica and the rest of Central America, where a patient is diagnosed by molecular biology with MEN2A and undergoes  a prophylactic thyroidectomy. 


 

Nothing to Disclose: OVJ, CM, SYA, MC, CS

22146 7.0000 THR-347 A First MEN2A Pediatric Patient with Prophylactic Thyroidectomy in Costa Rica and Central America 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Orlando Vicente Jaramillo*1, Chistopher Mora2, Su-Yen Araya2, Mariela Chacon2 and Carlos Santamaría2
1Hospital Nacional de Ninos, San Jose, Costa Rica, 2Hospital Nacional de Niños, San Jose, Costa Rica

 

Introduction: Multiple endocrine neoplasia 2B is a rare autosomic dominant disease, caused by mutations of RET gene, characterized by aggressive medullary thyroid carcinoma, pheochromocytoma and marfanoid features, among others. Multiple endocrine neoplasia 2B had never been documented in all of Central America and the Caribbean, until this case.

Clinical Case: A 12 year old boy is brought to a general practioner's consult because of a long term cervical adenopathy, without additional symptoms. The adenopathy was biopsied and found to have metastatic medullary thyroid carcinoma tissue. The patient was referred to the National Children's Hospital where he was found to have marfanoid features, and in the physical examination a nodular thyroid with a augmented consistency along with multiple palpable adenopathies on the cervical chain and multiple mucosal tumors. Blood samples demonstrated an elevation of calcitonin and carcinoembrionary antigen. Images showed a thyroid tumor and left and right lung metastases. The patient was diagnosed with multiple endocrine neoplasia 2B and taken into surgery for an immediate thyroidectomy. The mutation responsible in this case, M918T of the RET gene, was later documented by molecular biology. The patients parents and siblings were then analyzed, none of which presented the mutation. 

Conclusion: This is the first case documented of Multiple Endocrine Neoplasia 2B in all of Central America and the Caribbean.

 

Nothing to Disclose: OVJ, CM, SYA, MC, CS

22109 8.0000 THR-348 A Multiple Endocrine Neoplasia 2B: First Documented Case in Central America and the Caribbean  2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Leena Shahla*1, Hiren Patel2, Nelly Awkar2 and Mickael Maroules2
1St.Joseph's Regional Medical Center, Paterson, NJ, 2St.Joseph's Regional Medical Center

 

Introduction

We report an interesting case of primary hyperparathyroidism with features of parathyroid carcinoma that turned out to be adenoma after resection.

Case Report

A 51-year-old black male was brought in by the family to the hospital because of change in mental status. When the former symptom resolved,  patient reported  polyuria ,polydipsia ,nausea, generalized weakness and decrease in appetite with 9lb weight loss over one  month duration.

Past medical history is HTN. No family history of malignancy.

On physical examination, a firm non tender mass was palpated in the left neck, the patient also had dry mucosal membranes with poor skin turgor.

Labs showed  Albumin 4g/dl ( n 3.5-5.7) , Ca 20.1mg/dl (n 8.6-10.3) ,P 4.5  mg/dl (n 2.5-5) ,Mg 1.2 mg/dl (n 1.7-2.5), BUN 44mg/dl (n 7-23) ,   Cr 3.05 mg/dl  (n 0.6-1.3) , PTH intact 2355.1 (n 11.1-79.5) , 25 OH VD 7.3 (n 30-100)  ,TSH 0.99 (n 0.35-5.6)

The patient was admitted to the intensive care unit, started on aggressive IV fluids and calcitonin for 48 h, pamidronate was also given. Subsequently Ca level dropped to 10.4 mg/dl .

Ultrasound of the neck showed large heterogeneous mass measuring 6.0 x 2.2 x 2.6 cm , extrinsic to the upper pole of the left lobe thyroid gland. Parathyroid scan revealed a large, elongated focus of persistent elevated tracer uptake in the left side of the neck superior to the upper pole of the left thyroid lobe. Patient was evaluated for surgery and taken to the OR. During surgery, a large left superior parathyroid mass was identified and removed, no invasion into surrounding tissue was seen. Pathology showed no vascular or capsular invasion, no dense fibrous banding or high mitotic figures and that was consistent with parathyroid adenoma. The next day after surgery Ca was 9.4 mg/Dl . We closely monitored the electrolytes with appropriate replacement due to a possibility of hungry bone syndrome. Patient was discharged home with the Ca and Vitamin D supplementation. 1 month later the patient is asymptomatic, repeat labs showed BUN 17mg/DL (n 7-25),  Creatinine 1.65 mg/dl (n 0.7-1.33)  , Ca 8.7 mg/DL (n 8.6-10.3)

Conclusion:

Differentiating benign adenoma from a malignant parathyroid carcinoma can be difficult based on pathology alone.

Palpable neck masses,high calcium values (>13.5 mg/dL) and very high intact parathyroid hormone (iPTH) values raise the suspicion of carcinoma.

When absolute histologic Criteria for diagnosis of carcinoma (Invasion into surrounding tissues:Thyroid,Esophagus,Nerves, Soft tissues) are not present, clinical course and rapid rate of recurrence are major clues to help differentiate benign adenomas from malignant parathyroid carcinoma.

In some cases there are some features associated with malignancy but they are insufficient for a definite diagnosis of carcinoma to be made. A designation “Parathyroid neoplasm of uncertain malignant potential “ may be appropriate in such cases. We can consider our case one of those.

 

Nothing to Disclose: LS, HP, NA, MM

21536 9.0000 THR-349 A Hyperparathyroidism: Adenoma or Carcinoma? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Ishita Singh*1 and Shalini Bhat2
1David Geffen School of Medicine at UCLA, Los Angeles, CA, 2David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare Systems, Los Angeles, CA

 

Introduction

McCune-Albright Syndrome (MAS) is a rare genetic disorder caused by a somatic mutation in the GNAS1 gene and includes the classic triad of polyostotic fibrous dysplasia, hyperfunctioning endocrinopathies and café-au-lait spots. GNAS-activating mutations are reported in intraductal papillary mucinous neoplasms (IPMNs) and in MAS. Through disorders in the cAMP pathway, somatic GNAS-activating mutations may be responsible for carcinogenesis of hepatobiliary and pancreatic tissues arising from the endoderm of the foregut. Four cases of IPMN associated with MAS have been previously reported. We describe a case of IPMN found during routine imaging in a patient with MAS. This case highlights the rare but important association of MAS and pancreatic neoplasms, namely intraductal papillary mucinous neoplasms.

 

Clinical Case

A 47 year-old male with a history of MAS with polyostotic bone disease, toxic multinodular goiter post radioactive iodine ablation, and acromegaly presented with fatigue. Vitals were unremarkable, exam revealed coarse facial features, craniofacial fibrous dysplasia, and enlargement of the jaw, hands, and feet. The patient had a unilateral café-au-lait macule with borders like the “coast of Maine” on the left side of his face, back and gluteal region. Laboratory evaluation showed an elevated IGF-I 515 ng/mL (50-317), GH 1.24 ng/mL (<0.4), alkaline phosphatase 214 U/L (37-113), amylase 598 U/L (11-54), lipase 769 U/L (10-73). An abdominal computed tomography revealed a large dilated pancreatic duct. Fine needle biopsy was consistent with IPMN with high-grade dysplasia. The patient had a pancreaticoduodenectomy and the surgical pathology revealed IPMN.

Conclusion

MAS with IPMN is a rare clinical scenario but can have potentially fatal consequences. This case highlights the need for early recognition and the importance of routine screening by dedicated computed tomography or magnetic resonance imaging including pancreatobiliary sequences in patients with MAS for hepatopancreatobiliary neoplasms associated with MAS.

 

Nothing to Disclose: IS, SB

18872 10.0000 THR-350 A Intraductal Papillary Mucinous Neoplasm As New Manifestation of Mccune Albright Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Firas Riyazuddin*1, Mihail Zilbermint1, Elena Belyavskaya2, Charalampos Lyssikatos3, Margaret Farmar Keil2, Maya Beth Lodish1, Prashant Chittiboina4 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 4National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD

 

Background: Carney complex (CNC) is a syndrome1 of myxomas, pigmented skin lesions, testicular tumors, psammomatous melanotic schwannomas (PMS), and various endocrine tumors with hyperactivity, including GH-producing pituitary adenomas leading to acromegaly. CNC is often confused with other syndromes; in our experience, syndromic acromegaly is among them the most frequent. We present a case of gigantism/ acromegaly (G/A) with schwannoma and a femoral fibroma who did not have CNC but rather a yet unknown genetic condition.

Clinical Case: A 16 year old male was diagnosed with a pituitary macroadenoma by CT/MRI when he presented with a concussion at another institution. Subsequent referral to the National Institutes of Health revealed symptoms and signs of acromegaly and a visual field defect in his right eye. He underwent transsphenoidal surgery (TSS) with partial excision of macroadenoma followed by craniotomy for excision of residual mass with partial success with  restoration of vision. A year later he had proton beam radiation. Earliest available IGF-1 was 1222 ng/mL (reference range: 182 – 780 ng/mL) at age 17. He was on pegvisomant and octreotide since diagnosis until age 26 when he discontinued due to social issues. By age 21, pituitary MRI showed a pituitary mass 2x3 cm without mass effect. Post TSS he developed central hypothyroidism, secondary adrenal insufficiency and hypogonadotropic hypogonadism requiring hormonal replacements. He was later diagnosed with lower limb-length discrepancy due to a non-ossifying fibroma in his distal left femur. Serial echocardiograms were negative for tumors. Scrotal ultrasound showed microlithiasis in both testes unchanged since age 22. At age 27, a right sided infratemporal mass was found on routine pituitary MRI measuring 4x9 mm that grew to 29x19 mm by age 30, consistent with a schwannoma of the mandibular branch of the trigeminal nerve.The pituitary itself was without a discrete mass, however extending into the cavernous sinus abutting the left carotid artery, with IGF-1 level 226 ng/mL (reference range 115-307 ng/mL). He reported no new symptoms on an unchanged dose of his medications. Given concern for compressive neuropathy, the infratemporal lesion was excised by a sub and infratemporal approach. Pathology revealed schwannoma but not PMS, with diffusely strong S100 staining. Glial fibrillary acidic protein and Epithelial Membrane Antigen staining were negative. Testing for mutations in PRKAR1A, the CNC gene, was negative.

Conclusion: Syndromic G/A is often confused with CNC; schwannomas can occur along with G/A and fibromas in the context of conditions other than CNC.

 

Nothing to Disclose: FR, MZ, EB, CL, MFK, MBL, PC, CAS

20675 11.0000 THR-351 A Syndromic Acromegaly/Gigantism As a Mimicker of Carney Complex 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


So Young Park*1, Yu Jin Kim1, Soo Min Hong1, In Jin Cho1, Joo Young Kim2, Sang Youl Rhee1, Suk Chon1, Yoo Chul Hwang1, In-Kyung Jeong1, Seungjoon Oh1, Kyu Jeung Ahn1, Ho-yeon Chung1, Jeong-taek Woo1, Sung-Woon Kim1 and Young-Sul Kim1
1Kyung Hee University School of Medicine, Seoul, Korea, Republic of (South), 2Dongsuwon General Hospital, Suwon, Korea, Republic of (South)

 

Introduction

Carney complex is an autosomal dominant hereditary disease which is caused by PRKAR1A gene mutation. It appears as skin pigmentation, cutaneous or cardiac myxomas, and multiple endocrine tumors. In 2012, the authors reported a novel PRKAR1A mutation in Carney complex family for the first time in Korea. In this study, we investigated clinical changes of twenty one family member with Carney complex due to the PRKAR1A gene mutation for the past seven years after report in 2012.

 

Clinical case

The first patient was diagnosed with acromegaly after two years of diagnosis with Carney complex, showing abnormal result of oral glucose tolerance test and a pituitary macroadenoma on the sellar magnetic resonance imaging. After surgery, IGF-1 and GH level were measured repeatedly during follow-up period and not increased. But, the next five years later, the patient underwent another surgery for recurrent cardiac myxoma. The 2.0 cm x 0.8 cm sized irregular and heterogenous right atrial mobile mass at posterior wall was detected on follow up echocardiography. The result of biopsy was cardiac myxoma. The second patient, the mother of the first patient, died of cerebral hemorrhage during the observational period. This patient was presumably under the effect of bilateral adrenal hyperplasia with hypercortisolism which was found during the initial gene mutation study. The third patient underwent an additional surgery due to a recurrent cardiac myxoma and a newly developed anal angiomyxoma. The fourth patient also received an additional surgical treatment to remove perineal myxoma. During the observational period, six babies were born, and eight children including two who had been born before the observational period were screened for PRKAR1A gene mutation. No clinical condition was found, but one child was confirmed to possess the identical genetic mutation.

 

Conclusion

Among twenty one family members including newly born eight children, four of them showed new Carney complex features and one of children was confirmed to have the PRKAR1A gene mutation without clinical symptoms of Carney complex. Continuous various Carney complex associated clinical symptoms were developed during the observational period among them, severe operations were performed. Therefore, further observation with close follow-up is required for these patients.

 

 

Nothing to Disclose: SYP, YJK, SMH, IJC, JYK, SYR, SC, YCH, IKJ, SO, KJA, HYC, JTW, SWK, YSK

20982 12.0000 THR-352 A 7-Year Follow-up Observation Study of Family Members with Carney Complex 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 341-352 5974 1:00:00 PM Neoplasia Case Reports Poster


Marilia Almeida Cardoso*1, Fernanda Cavalieri Costa2, Vanessa Porto Araújo3, Raquel S Jallad4, Marcello D Bronstein5, Jose Luiz Chambo2, Marcio Carlos Machado6 and Maria Candida B V Fragoso7
1School of Medicine, Sao Paulo University, Sao Paulo, Brazil, 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3USP, Brazil, 4Hosp das Clinicas Univ of Sao Pa, Sao Paulo SP, Brazil, 5University of São Paulo Medical School, São Paulo, Brazil, 6Univ of Sao Paulo Med School, Sao Paulo, Brazil, 7Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

Background: Etomidate is an effective parenteral medication to control hypercortisolism, especially in situations which require rapid reduction of cortisol levels. The use of etomidate preoperatively can improve clinical outcomes in patients with severe and refractory Cushing’s syndrome before underwent to bilateral adrenalectomy.

Case Report: 39 years old man, with history of AIDS on antiretroviral therapy (undetectable viral load), developed in last  year a typical signals and symptoms of Cushing’s syndrome (CS).  Laboratory tests confirmed hypercortisolism ACTH-dependent: ACTH 834 pg/mL (up to 46 pg/mL), cortisol after 1 mg dexamethasone suppression test: 30.1 ug/dL (n < 1.8 ug/dL), midnight serum cortisol: 34.1 ug/dL (n <7.5 ug/dL), midnight salivary cortisol: 2.74 ug/dL (n <0.13 ug/dL) and urinary total cortisol: 3280 µg/24h (n < 300 µg/24 h). Pituitary gland MRI was absolutely normal. Abdomen CT scan presented a pancreatic lesion suggestive of lymph node metastasis and a inoperative large tumor extension on liver. Liver’s biopsy revealed a metastatic neuroendocrine carcinoma. The serum tumor’s marker revealed high levels of gastrin (74712 pg/mL; normal range 13.0 to 115.0 pg/mL). The immunohistochemistry confirmed ACTH stain on hepatic lesion. The hypercortisolism control was attempted with somatostatine analogue, dopamine agonist and ketoconazole, without success. Due to the unfavorable clinical outcome, with severe electrolyte disturbances and recurrent infections, the etomidate was indicated for rapid control of hypercortisolism and for improving the preoperative status before bilateral adrenalectomy. The etomidate was started with 5 mg bolus followed by continuous infusion 0.02 mg/kg/hr). The degree of sedation was evaluated by Richmond Agitation Sedation Scale (RASS), with dose adjustments as necessary. The viral load remained undetectable. The serum cortisol levels reduced in 51.4% (from 42.2 µg/dL to 21.7 µg/dL) on day 1 (D1) and 75.3% (from 42.2 µg/dL to 10.7 µg/dL) on D4, and the electrolyte disturbances reversed, without further infections episodes. After 5 days using Etomidate, the patient was undergone to bilateral adrenalectomy, and started glucocorticoid and mineralocorticoid replacement. Currently, he is on palliative chemotherapy with XELOX regimen (capecitabine and oxaliplatin).

Conclusion: Etomidate may be an alternative to improve the preoperative status of patients with severe Cushing’s syndrome before undergoing bilateral adrenalectomy, improving intra and postoperative outcomes. The slow doses did not cause sedation and cortisol levels fall down in 10 hs after the bolus doses.

 

Nothing to Disclose: MAC, FCC, VPA, RSJ, MDB, JLC, MCM, MCBVF

21165 1.0000 THR-312 A Preoperative Management with Etomidate of Hypercortisolim of Metastatic Ectopic Cushing's Syndrome: Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Serena Piacentini*1, Francesca Lugli1, Donato Iacovazzo1, Antonella Giampietro1, Antonio Bianchi1, Linda Tartaglione1, Sabrina Chiloiro2, Marilda Mormando2, Marco Raffaelli1 and Laura De Marinis1
1Università Cattolica del Sacro Cuore, Rome, Italy, 2Catholic University of the Sacred Heart, Rome, Italy

 

INTRODUCTION: Cushing's syndrome (CS) is a complex endocrine disorder associated with potentially serious consequences if not adequately treated. The incidence of CS varies in different studies from 0.7 to 2.4 per million per year.  A more recent study reported a prevalence of 79 per million and an incidence of 1.8 per million per year for CS. Nearly 80% of the cases of endogenous hypercortisolism are adrenocorticotropic hormone (ACTH) dependent, the ACTH source being pituitary in about 70-80% and ectopic in 10-15%. The ACTH source may remain occult in few cases for many years in spite of extensive investigations.

MATERIAL AND METHODS: we describe a retrospective series of 13 patients (7 females and 6 males) collected from 1989 to 2013 and affected by ectopic ACTH dependent CS.

The origin of ectopic ACTH secretion was: bronchial carcinoid for 8 patients (7 typical and 1 atypical), 1 atypical thymic carcinoid and in 4 cases the origin remained occult.

At the time of diagnosis all patients presented with severe clinical syndrome, characterized by hypokalemia, hypertension, diabetes and osteoporosis. The presence of pituitary disease was excluded with suppression tests, dynamic tests, MRI and, when required, with inferior petrosal sinus sampling.   

Once pituitary disease had been excluded, both radiological imaging (total body CT) and nuclear medicine imaging (octreoscan and more recently Gallium PET-CT) were used in order to identify the ectopic source of ACTH.  

RESULTS: in 9/13 cases the ectopic origin was found (8 cases of bronchial carcinoid and the 1 thymic carcinoid), while in 4 patients the source of ACTH secretion remained unknown.

Among the nine patients with an identified malignancy, five patients recovered from CS after surgery and one after locoregional treatment, while 3 patients  needed medical therapy after surgery (ketoconazole or mitotane).

Regarding the 4 patients with unknown origin of disease, all of them underwent bilateral adrenalectomy after several years of medical treatment with poor control of the clinical syndrome. In two patients, about one year after the adrenalectomy, the ACTH-secreting neoplasm became overt (1 pancreatic neuroendocrine tumor and 1 breast cancer), and in both cases the neoplasms positively stained for ACTH.

The remaining two patients are still in follow up and the primary site of ACTH secretion is still hidden.

CONCLUSIONS: bilateral adrenalectomy is a possible therapeutic tool in patients with CS due to occult ectopic ACTH secretion, expecially in case of poor disease control with medical treatment.  These patients need to be closely followed up, as the source of ACTH secretion might rapidly become overt after the adrenalectomy.

 

Nothing to Disclose: SP, FL, DI, AG, AB, LT, SC, MM, MR, LD

21873 2.0000 THR-313 A Cushing's Syndrome Due to Ectopic ACTH Secretion of Occult Origin: The Role of Bilateral Adrenalectomy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Paul David Zito1, Mohammed Zaidan1, Adam G Hartman2, Pratima V Kumar3 and Steven Taylor*4
1University of Texas Southwestern Austin Residency Program, Austin, TX, 2UTMB Galveston, 3University of Texas at Austin Dell Medical School, Austin, TX, 4Brackenridge Hospital, Austin, TX

 

Background: Ectopic ACTH syndrome due to esthesioneuroblastoma ( olfactory neuroblastoma ) is rare,

has been reported in children and adults, often requiring multiple treatment modalities. Successful

treatment of hypercortisolemia due to ACTH-producing metastatic esthesioneuroblastoma has not been

reported with ketoconazole monotherapy.

Clinical case: A 67-year old man with a history of paranasal and bifrontal esthesioneuroblastoma treated

with surgical resection and external beam radiation in 2003 with local recurrence in 2008 which

required bilateral radical neck dissection and external beam radiation presented to our institution with

a six week history of progressive proximal muscle weakness, fatigue, anorexia, weight loss and polyuria.

Physical exam revealed a thin hypertensive man with evidence of prior neck surgery, no

lymphadenopathy or stigmata of Cushing’s syndrome, 3/5 proximal muscle strength globally, and 2+

bilateral lower extremity edema. An initial laboratory evaluation showed hypokalemia, metabolic

alkalosis, hyperglycemia, and normocytic anemia. Plasma aldosterone level and plasma renin activity

were inconsistent with primary hyperaldosteronism and HgbA1c was found to be 7.3% in this patient

with no known history of diabetes. Abdominal CT scan demonstrated bilateral adrenal hyperplasia, and

subsequent laboratory assessment showed a markedly elevated 24 hour urinary free cortisol of 7,647

mcg (normal < 60 mcg). 8 am serum cortisol level was found to be > 120 mcg/dL (normal 6.7-22.6

mcg/dL) with an ACTH level of 253 pg/mL (normal 7-69 pg/mL) . With concern for malignancy-related

ectopic ACTH syndrome, additional imaging was undertaken that suggested metastatic disease involving

the right lower lung lobe and diffuse regions of the spine. A nuclear medicine octreotide scan showed

abnormal tracer uptake in the region of the right lower lung and a lesion within the L3 vertebral body. A

CT-guided biopsy of the patient’s L3 vertebral lesion showed findings consistent with metastatic

esthesioneuroblastoma, and immunohistochemical staining of the specimen was positive for ACTH.

While awaiting a final diagnosis, the patient required three anti-hypertensive medications, daily

potassium replacement, and large doses of post-prandial insulin to control his glucocorticoid-induced

metabolic complications. He was started on ketoconazole 200 mg bid, the dose of which was rapidly

uptitrated to 400 mg bid. Within days, his 8 am cortisol level had fallen to 13.6 mcg/dL, where it

stabilized. He experienced no untoward side effects or drug-related toxicity, his proximal muscle

strength improved, and he was able to be weaned from his anti-hypertensive medications, potassium

replacement and insulin.

Conclusion: Ectopic ACTH syndrome due to metastatic esthesioneuroblastoma is rare but may be

responsive to ketoconazole monotherapy, as demonstrated here for the first time.

 

Nothing to Disclose: PDZ, MZ, AGH, PVK, ST

20181 3.0000 THR-314 A Cushing's Syndrome Due to ACTH-Producing Metastatic Esthesioneuroblastoma Successfully Treated with Ketoconazole 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Esther Irina Krug1, Shruti Bhandari*2 and Dinesh Edem2
1Johns Hopkins University/ Sinai Hosp of Baltimore, Baltimore, MD, 2Sinai Hospital of Baltimore, Baltimore, MD

 

Introduction:Insulinoma is a rare neuroendocrine tumor characterized by autonomous insulin secretion and fasting hypoglycemia. Average duration of symptoms prior to diagnosis is less than 1.5 years (1). Change in size of the mass and symptoms severity over time is not well described in sporadic insulinomas. We are presenting a case of a patient with confirmed insulinoma with duration of symptoms of 7 years prior to resection.

Case: 44 year old women presented to our clinic with 3-year history of diaphoresis, confusion, tremors, palpitations and anxiety associated with documented fasting hypoglycemia with blood glucose <40 mg/dL. During in-patient fast study she became severely hypoglycemic in 8 hours. Laboratory studies revealed insulin 10.9 uIU/mL, blood glucose 28 mg/dL, C-­peptide 2 ng/mL, pro-insulin 254.2 pmol/L, and negative hypoglycemic drug screen. Endoscopic ultrasound (EUS) and MRI were negative. We referred the patient to NIH for tumor localization and surgery, but she elected not to undergo further work-up and treatment at that time. She returned to our clinic 4 years later due to progression in frequency and severity of hypoglycemia, occurring after 2-3 hours of fasting, forcing her to wake up every 2 hours nightly and consume concentrated sweets to prevent hypoglycemia.  She was admitted and started on D10 drip of 75 cc/hr, with blood glucose in 50­-120 mg/dL range. During fast study she developed symptomatic hypoglycemia after 3 hrs of fasting. Labs revealed insulin 9.8 uIU/mL, blood glucose 43 mg/dL, C­-peptide 1.8 ng/mL, pro-insulin 93.9 pmol/L and beta-­hydroxybutyrate 1.3 mg/dL. Repeat EUS, done by the same gastroenterologist on the same equipment, revealed a 8x7mm hypoechoic irregular mass in the tail of pancreas. EUS-guided FNA revealed well differentiated pancreatic neuroendocrine neoplasm. Selective arterial calcium stimulation (SACS) localized insulinoma to the tail of pancreas. She had laparoscopic enucleation of 6 mm Insulinoma from the tail of pancreas. The patient has remained euglycemic and asymptomatic following surgery.

Discussion: Our findings suggest positive relationship between tumor growth and progression in frequency of hypoglycemia despite overall small tumor size. Considering reported threshold of detectability on EUS (2), we presume that during initial work-up tumor size had been less than 5 mm. EUS sensitivity for detection of lesions in tail of pancreas was reported to be as low as 40% (2). In some cases SACS, that was reported to have detection rate of 89% (3), may be the only option for pre-operative localization. In our case we observed excellent correlation between EUS and SACS in tumor localization.

 

Nothing to Disclose: EIK, SB, DE

22043 4.0000 THR-316 A Natural History of Untreated Insulinoma over a Course of 7 Years 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Khalid Ramadan Zarug*1, Natalie Ronshaugen2, Vaibhav Mehendiratta2, Kamal C Shoukri3 and Peter William Butler4
1Baystate Medical Center, Springfield, MA, 2Baystate Medical Center, springfield, MA, 3Baystate Medical Center, Unionville, CT, 4Peter W. Butler, M.D., Endocrinology, LLC, Florence, MA, Florence, MA

 

Introduction:

Insulinomas are uncommon with a reported incidence of 0.4 per 100,000 person-years. 7.6% are associated with MEN1 and 5.8% are malignant. For benign insulinoma, treatment of choice is surgical resection, which is curative and results in normal long-term survival(1).For non-surgical candidates, therapeutic options are limited.  Several medications are available to decrease hypoglycemia; however, they are not curative, have side effects and are less effective than tumor removal(2).

Ethanol ablation has been used for renal cysts, hepatic cysts, and liver and adrenal tumors. It causes cell death by lysing cell membranes, causing protein denaturation, and vascular occlusion. It is cost effective, readily available, and works rapidly(3).A handful of case studies describe endoscopic ultrasound-guided ethanol ablation for insulinoma as a safe and effective treatment modality for patients who refuse or are ineligible for surgery.

Case:

A 56 year old man, with a history of liver cirrhosis secondary to hepatitis C and alcoholism, presented with increasing falls and unsteadiness for 1 week, and possible seizure activity. Workup revealed a plasma glucose of 37 mg/dL. During a 48-hour supervised fast a plasma glucose of 47 mg/dL was obtained with a corresponding serum insulin level of 36.3 micro IU/mL, C-peptide level of 6.6 ng/mL, and a pro-insulin level of 420 pmol/L. A sulfonylurea screen was negative. CT of the abdomen revealed a 1.1cm mass in the head of the pancreas. Endoscopic ultrasound (EUS) confirmed a well-circumscribed 1.3 cm hypoechoic mass in the head of the pancreas. Extensive varices were noted. The mass did not appear to invade vasculature or compress the common bile duct or main pancreatic duct. A Whipple’s procedure was discussed, but he was considered a poor surgical candidate given the history of cirrhosis with portal hypertension. Following treatment with intravenous 10% dextrose, EUS-guided alcohol ablation was performed using a 22 gauge needle to inject 1.5 mL of dehydrated ethanol. The patient tolerated the procedure well without complications.

Results:

24 hours following ablation, IV dextrose was stopped without further hypoglycemia. At 6 month outpatient follow-up he remained free of hypoglycemia, corroborated by glucometer data.

Discussion:

Surgical resection is the standard treatment for insulinoma.  For poor surgical candidates, EUS-guided ethanol ablation may be an option.  There are few case reports studying ethanol ablation in insulinoma and no long term or case control studies. The optimal techniques, number of treatments and ethanol dose have not been established.

Conclusion:

EUS-guided alcohol ablation is a promising and effective treatment for insulinoma in non-surgical candidates. Further research is needed to establish optimal treatment protocols and long term outcomes.

 

Nothing to Disclose: KRZ, NR, VM, KCS, PWB

20051 5.0000 THR-317 A EUS-Guided Ethanol Ablation As a Treatment Option for Insulinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Farheen Kassim Dojki*1, Oliver Chen2, James Louis Hinshaw2 and Jennifer Lee Poehls3
1University of Wisconsin - Madison, Madison, WI, 2University of Wisconsin, 3University of Wisconsin, Madison, WI

 

Introduction/Background: Surgery is considered to be the only curative treatment modality for insulin secreting tumors. We present microwave ablation as a novel treatment for insulinoma.

Clinical case: A 60 year old male with morbid obesity (430lbs) and stage 4 lung cancer (poorly differentiated adenocarcinoma) was found to have a 3.0 x 2.3 x 3.0 cm exophytic pancreatic neck mass on imaging done for staging. He underwent 5 cycles of chemotherapy and 33 sessions of radiation for lung cancer. Course was complicated by pulmonary embolus and paroxysmal atrial fibrillation for which he was treated with anti-coagulation. Four months after diagnosis he developed symptoms of intractable fasting hypoglycemia requiring 2 admissions for dextrose infusion. He had no prior history of diabetes or hypercalcemia and no family history of parathyroid, pituitary or pancreatic disease. Fasting labs showed low serum glucose at 63 (60-99mg/dL), elevated serum insulin at 85.8 (2.6-37uU/ml) and pro-insulin at 350 (3-30pmol/L) with low B-hydroxybutyrate at 0.04 (0.03-0.30mmol/L).  Sulfonylurea screen was not collected. He underwent endoscopic ultrasound and biopsy of the mass, which revealed neuroendocrine tumor. Immunohistochemistry for insulin was diffusely positive within the tumor cells. He was started on Diazoxide with improvement of symptoms but was unable to tolerate it, due to side effects. Octreotide was tried without success, despite titrating up to 500mcg three times a day. Surgical consult deemed the patient a poor surgical candidate due to morbid obesity, advanced lung cancer, anti-coagulation and history of abdominal hernia surgery with mesh. Oncology, Radiation Oncology and Radiology were consulted. He underwent palliative therapy with microwave ablation under CT fluoroscopic guidance. Microwave ablation was performed at 65W for 5 minutes. Post-ablation CT showed an exophytic lobule off the superior margin of the tumor that may not have been ablated. Since the intent of the procedure was palliative, further ablation was not attempted to avoid morbidity. Octreotide and dextrose infusion were weaned and he had no recurrent hypoglycemia. There were no post procedure complications and he was discharged to home the next day.

Conclusion/Clinical lesson: The definitive treatment of choice for insulin secreting tumors is surgical resection. Radiofrequency (RF) ablation is also known to be a safe method used in recent years for the treatment of selected solid tumors of the liver, adrenals, kidney, bone, lung and pancreas. To the best of our knowledge, there have been no reported cases of microwave ablation for treatment of insulinoma. We present this case to highlight alternative means of treatment if surgery is contraindicated and medical therapy is not tolerable. Due to the novelty of this method, more studies are necessary.

 

Disclosure: JLH: Stockholder in Neuwave Medical, Neuwave Medical. Nothing to Disclose: FKD, OC, JLP

21348 6.0000 THR-318 A Microwave Ablation: A Novel Treatment for Insulinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Patricia Louise Whitfield* and Richard William Carroll
Capital and Coast District Health Board, Wellington, New Zealand

 

Introduction:

Tumoural secretion of PTH-related peptide (PTHrP) is the leading cause of humoral hypercalcaemia of malignancy (HHM).  Whilst supportive therapies exist for the management of hypercalcaemia, treatment resistance is common, and is associated with increased morbidity and mortality. In gastroenteropancreatic neuroendocrine tumours (GEP-NETs), there is a 40% mortality rate attributable to hypercalcaemia.(1) There is a need for effective, long-term treatment options. 

In this case report, we discuss the use of cinacalcet, a calcimimetic, to treat hypercalcaemia secondary to a PTHrP secreting GEP-NET. 

Case Presentation:

A 54 year old female was found to have a pancreatic mass on imaging after presenting with back pain and constipation.  Cytology was highly suggestive of a neuroendocrine tumour with positivity for chromogranin, NSE and synaptophysin.  Treatment with octreotide, a somatostatin analogue, was commenced as the tumour was inoperable. 

Within one year, the patient developed worsening constipation and fatigue, despite radiological stability.  Laboratory results demonstrated severe hypercalcaemia with a serum calcium of 3.03mmol/L (2.15-2.55mmol/L).  PTH was suppressed at <0.6pmol/L (1.5-6mmol/L).  PTHrP was elevated at 3.3pmol/L (0-1.5pmol/L) confirming the diagnosis of HHM secondary to PTHrP secretion.  Despite three weekly infusions of zoledronic acid (4mg) and 2000mL normal saline, the patient remained symptomatically hypercalcaemic.  Further treatment options were limited, due to failed tumour embolisation and lack of access to funded sunitinib therapy in New Zealand.   Oral cinacalcet was commenced and titrated to 60mg twice daily, with improvement in calcium to 2.89mmol/L within one month.  The patient has remained minimally symptomatic with improved serum calcium levels (2.50-2.87mmol/L) for the past 18 months on combination octreotide/cinacalcet therapy. 

Conclusions:

PTHrP secretion leads to hypercalcaemia, due to its ability to stimulate the PTH receptor (PTHR1).  Cinacalcet is a calcimimetic agent, which stimulates calcium sensing receptors, leading to suppression of PTH synthesis and release, and a reduction in renal reabsorption of calcium.  Few studies have examined the effect of cinacalcet administration in the setting of HHM, however it is theorised that reduction in serum calcium may occur via the same mechanism, as well as through suppression of PTHrP secretion.  Cinacalcet has been shown to lower serum calcium levels in mice with increased PTHrP,(2) and has reduced PTHrP and serum calcium in one patient with squamous cell lung cancer.(3)  To our knowledge, this is the first case report detailing the successful use of cinacalcet in the setting of PTHrP secreting GEP-NETs.  It is therefore suggested that cinacalcet may be a useful therapeutic option in the management of this condition, and further research into this area should be encouraged.

 

Nothing to Disclose: PLW, RWC

19728 7.0000 THR-319 A Cinacalcet Use in PTHrP-Secreting GEP-NETs: A New Management Option for Humoral Hypercalcaemia of Malignancy? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Patricia Louise Whitfield* and Richard William Carroll
Capital and Coast District Health Board, Wellington, New Zealand

 

Background:

Approximately one third of patients with a phaeochromocytoma or paraganglioma (PPGL) will have an underlying germline mutation.(1)  Correct identification of patients with these mutations is important as they may be associated with younger presentation, increased malignancy and therefore mortality risk, and an increased likelihood of disease recurrence, when compared to individuals with sporadic disease.  Identification has implications for both patients and their wider families. 

The recent Endocrine Society Phaeochromocytoma and Paraganglioma clinical guidelines have provided guidance for when germline mutations should be considered.(2)  It is recommended that genetic testing occur in patients presenting at a young age, if there is a family history of tumours or syndromic features, or in the presence of multifocal or extra-adrenal disease. 

Aims:

We aimed to assess the current genetic screening practices at a New Zealand tertiary referral hospital in patients with PPGL as compared to the 2014 Endocrine Society guidelines recommendations.  

Methods:

Clinical data was collected on all patients diagnosed with a PPGL at Wellington Regional Hospital between January 1st 2004 and December 31st 2013.  Hospital records were analysed to assess whether criteria for germline testing were met and if so, whether testing occurred.  An assessment of lead speciality for each patient was also performed. 

Results:

17 individuals with a new PPGL diagnosis were identified, including 8 (47%) with phaeochromocytoma and 9 (53%) with paraganglioma.  Using Endocrine Society guidelines, 10 patients (59%) met criteria for genetic testing.  Of these, only 3 (30%) were offered it.  One patient who did not meet criteria was offered genetic testing.  Of those offered testing, 1 (25%) was diagnosed with an SDHB mutation; 1 (25%) was not found to have a known mutation and 2 (50%) declined testing.  In those who met criteria for testing but were not offered it, none had involvement from Endocrine services.  In those who were offered genetic testing, 100% of testing was arranged by the Endocrine team.  Only 10/17 (59%) of all patients had Endocrine involvement, with most presenting to a variety of surgical sub-specialities. 

Conclusions:

The pattern of screening for germline mutations in patients with PPGL did not meet contemporary clinical practice guidelines.  The presentation of the majority of these patients to surgical sub-specialities emphasises the importance of a multidisciplinary approach for these patients.  Differences in screening tendencies between Endocrinology and the surgical sub-specialities underpins the importance of expert Endocrinology involvement in these cases.  Publication of the recent Endocrine Society guidelines will increase awareness of the need for genetic testing in these patients.

 

Nothing to Disclose: PLW, RWC

19741 8.0000 THR-320 A Germline Mutation Screening in Phaeochromocytoma and Paraganglioma: An Audit of Historical Cases at a New Zealand Tertiary Referral Hospital 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Hans Kumar Ghayee*1, Brandon Isaacson2, Megan Frone2, Victor Stastny2, Yair Lotan2, Lucien Nedzi2, Lori Watumull2, Jerry Shay3, Adi Gazdar2, Theodora Ross2, Jack Michael Raisanen2 and Payal Kapur2
1University of Florida College of Medicine, Gainesville, FL, 2University of Texas Southwestern Medical Center, 3University of Texas Southwestern Medical Center, Dallas, TX

 

SDHC Paragangliomas: More than Head and Neck Tumors

Background: Paragangliomas (PGLs) are extra-adrenal pheochromocytomas. Patients that have PGLs with an SDHC mutation usually have benign, non-functional, head and neck PGLs.

Clinical Case: A 28 year-old male presented for evaluation of left sided hearing loss and pulsatile tinnitus, which was confirmed with an audiogram. He had a history of a left jugular foramen PGL at the age of nine for which he underwent resection. He experienced recurrence in the middle ear in 2002 and underwent a second resection. Magnetic resonance imaging (MRI) scan confirmed suspicion of recurrent PGL tumor. He was found to have recent onset of hypertension where his systolic blood pressure had been in the 150s. On physical exam, he had a scar on the left side of his neck, heart and lung exams were normal. However, on genitourinary exam, he was found to have a paratesticular mass. Laboratory evaluation included normal plasma metanephrines: <0.20 (<0.50 nmol/L) and elevated plasma normetaneprhines: 1.7 (<0.90 nmol/L). Germline genetic studies revealed an SDHC deletion. Surgery was performed to debulk his jugular foramen PGL. His paratesticular mass was completely excised and pathology was consistent with a PGL. He is currently undergoing radiation treatment for his residual jugular foramen PGL. Whole genome sequencing of this patient’s germline DNA and tumor has been performed.

Conclusion: Paratesticular paragangliomas are rare with only 7 cases reported in the literature at this time. To date, none of have been associated with germline SDHC mutations which are currently thought to mainly predispose to head and neck PGLs. We present the first reported case of a patient with an aggressive head and neck PGL with a paratesticular PGL associated with a germline SDHC mutation.

 

Nothing to Disclose: HKG, BI, MF, VS, YL, LN, LW, JS, AG, TR, JMR, PK

21631 9.0000 THR-321 A Sdhc Paragangliomas: More Than Head and Neck Tumors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Kusuma Chaiyasoot*, Chanin Limwongse, Jiraporn Sriprapaporn and Paweena Chunharojrith
Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

 

Background

Bilateral malignant pheochromocytoma (PHE) is an extremely rare first presentation of multiple endocrine neoplasia type 2A (MEN 2A). Utility of 131I-Metaiodobenzylguanidine (MIBG) scan is diagnosis of PHE and metastases before tumor removal. However, a benefit of immediately postoperative 131I-MIBG scan has never been reported.

Clinical case

A 30-year woman presented with classical symptoms of catecholamine excess. She developed a few episodes of severe hypertension with flash pulmonary edema. She had no a family history of endocrine cancers. Physical examination revealed neither palpable abdominal mass nor thyroid nodule. Laboratory tests revealed a mildly elevated 24hr urinary vanillylmandelic acid (11.29 mg/24hr, n<10 mg/24hr) and normal 24hr urinary metanephrine and normetanephrine. CT scan of abdomen showed bilateral mixed cystic and solid hypervascular adrenal masses (tumor diameter right 8 cm, left 5 cm), suspicious of partial hepatic invasion, multiple hypervascular hepatic metastases, multiple pulmonary nodules. 131I-MIBG scan showed large 131I MIBG avid tumors at both adrenal glands with multiple bony metastases at sternum, left scapula and distal part of left humerus. Otherwise, hepatic and pulmonary lesions on the previous CT scan had no abnormal uptake.

The patient underwent bilateral adrenalectomy and biopsy of hepatic nodule. The pathological findings were compatible with bilateral malignant PHE with liver metastases. Surprisingly, 2 weeks postoperative 131I-MIBG scan showed multiple new hot spots at the liver, right scapula, ilium, ischium, left superior pubic ramus and vertebrae. Three doses of 131I-MIBG therapy (200 mCi) were given for metastatic disease. Biochemical markers of PHE returned to normal after the surgery.  

Genetic testing showed a missense mutation at codon 634 in exon 11 of the RET proto-oncogene, causing substitution of an adenine for a guanine residue (Cys to Tyr) consistent with MEN 2A. Evaluation of medullary thyroid carcinoma (MTC) revealed a right thyroid nodule (0.5 cm) and markedly elevated levels of serum calcitonin and CEA. Total thyroidectomy was performed and histopathology confirmed 2 foci (tumor size < 1 cm) of MTC without spread to lymph node. The serum calcitonin and CEA levels normalized after thyroidectomy within 2 months while 131I-MIGB scan still showed uptake in liver and bony metastases. Eventually, 131I-MIBG scan at 28 months after 131I-MIBG therapy showed overall improvement due to no visualization of 131I-MIBG avid lesion.

Conclusion

Enhanced uptake of 131I-MIBG in metastatic sites after resection of PHE is the advantage of 131I-MIBG scan in localization of metastatic PHE.  PHE patients who have the high suspicion of malignancy should perform 131I-MIBG scan after resection of PHE for early detection of metastases. Screening for RET mutation should be considered in sporadic bilateral malignant PHE patient.

 

Nothing to Disclose: KC, CL, JS, PC

20407 10.0000 THR-322 A Enhancement of 131I-Metaiodobenzylguanidine Uptake in Metastatic Regions after Resection of Bilateral Malignant Pheochromocytoma in Multiple Endocrine Neoplasia Type 2A Patient 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Masayasu Iwabuchi*
Seirei Mikatahara Hosp, Hamamatsu, Japan

 

Background: Malignant paraganglioma is a rare tumor with a poor prognosis because of its potentially lethal complications such as hypertension, paralytic ileus and heart failure caused by increased production of catecholamines. The chemotherapeutic regimen, consisting of cyclophosphamide, vincristine, and dacarbazine (CVD), has been reported to be effective against malignant pheochromocytoma.  Iwabuchi reported palliative chemotherapy with cytosine arabinoside (ARA-C) for malignant pheochromocytoma to control potentially lethal complications without toxicity (1). 

Case report: In 2006, a woman with schizophrenia suffered from paralytic ileus caused by paraganglioma. Her retroperitoneal lesion was resected and histological diagnosis of paraganglioma was confirmed. In 2007, the diagnosis of malignant paraganglioma was confirmed with metastases to her chest wall and lumbar vertebrae. The CVD treatment was continued for 33 months until her psychiatric condition worsened in 2009.  Because of delusion, she could not share any medical information. Worsened pain persuaded her to re-start cytoreductive treatment, to chose palliative chemotherapy of subcutaneous administration of 20 mg of ARA-C twice a week reported by Iwabuchi (1).  The chemotherapy discontinued because of delusion of pregnancy in 2011.  During the discontinuation of the treatment, paralytic ileus and pulmonary edema and bone pain worsened with the progression of the disease.  Abdominal pain, dyspnea and bone pain made her decide to re-start the cytoreductive chemotherapy in 2013. In1999, Iwabuchi reported that non-cardiogenic pulmonary edema was controlled by CVD reducing norepinephrine to less than 10,000 μg/day in urine, and that bone metastases were controlled by ARA-C. With urinary noradrenaline as an index of the treatment, the target of the chemotherapy was set to decrease the secretion to less than 10,000 μg/day in urine. Her symptoms were controlled with the decrease of urinary norepinephrine from 14,759 to 6,708 μg/day (normal range: 26-121 μg/day).  During the continuation of the treatment, she suffered from ARDS caused by aspiration pneumonia and died in 2014. Iwabuchi devised the palliative chemotherapy for malignant pheochromocytoma and paraganglioma with ARA-C in reference to the articles by Castaigne and Spriggs, demonstrating the efficacy of small doses of ARA-C without marrow aplasia and the ARA-C pharmacology of the variability in response and toxicity in treating leukemias (2, 3).  Further discussion should be considered to improve the efficacy of palliative chemotherapy with ARA-C.

Clinical Lesson: Malignant paraganglioma and pheochromocytoma with increased secretion of urinary norepinephrine more than 10,000 μg/day should be treated with cytoreductive chemotherapy to control potentially lethal complications.

 

Nothing to Disclose: MI

19754 11.0000 THR-323 A Urinary Norepinephrine Level Is Related to Onset and Curative Effect of Lethal Complications of Malignant Paraganglioma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Joanne M de Laat*1, Olaf M Dekkers2, Carolina R.C. Pieterman1, Wouter P Kluijfhout3, Menno R Vriens1, Ad RMM Hermus4, Alberto M. Pereira5, Anouk N A Van der Horst-Schrivers6, Madeleine L. Drent7, Peter H Bisschop8, Bastiaan Havekes9, Wouter W. de Herder10 and Gerlof D Valk1
1University Medical Center Utrecht, Netherlands, 2Leiden University Medical Center, Netherlands, 3University of California, San Francisco, San Francisco, California and University Medical Center Utrecht, Utrecht, Netherlands, 4Radboud University Medical Center, Nijmegen, 5Leiden University Medical Center, Leiden, Netherlands, 6University of Groningen, University Medical Center Groningen, Groningen, Netherlands, 7VU University Medical Center, Amsterdam, Netherlands, 8Academic Medical Center, Amsterdam, Netherlands, 9Maastricht University Medical Centre, Netherlands, 10Erasmus Medical Center, Rotterdam, Netherlands

 

Pituitary tumors (PITs) are, next to hyperparathyroidism and duodenopancreatic neuroendocrine tumors, among the three neoplasms that are characteristic for Multiple Endocrine Neoplasia type 1 (MEN1). Based on previous data mainly from before 2001 and tertiary referral centers, PITs in MEN1 patients are considered to be larger, more often functioning, more aggressive and more resistant to medical treatment compared to sporadic PIT (1). For this reason screening has been introduced in recent guidelines, which even suggest that PIT in MEN1 patients more often require surgical treatment (2). The aim of our study was to assess the results of systematic pre-symptomatic PIT screening and long-term follow-up in an unselected cohort of MEN1 patients (3). A longitudinal study was performed using the national DutchMEN1 database including >90% of the MEN1 population >16 years with an average of 21 years of follow-up (n=323). Reference standard for the presence of PIT were (1) pathology or (2) MRI detection. A PIT diagnosed on MRI had to be confirmed at least once by subsequent imaging, or by repeatedly elevated levels of pituitary hormone secretion.

PIT was diagnosed in 123 (38.1%) of MEN1 patients. The number of new cases of PIT during follow-up was 34 per 1000 patient years, and stable over calendar-time. In patients with PIT diagnosed as a result of pre-symptomatic tumor screening, the proportion of macroadenomas was lower compared to patients who had a PIT already at time of MEN1 diagnosis (18.8% vs. 51.9%; P<0.001). Incident cases predominantly presented with non-functioning microadenomas (n=31; 47%). Of 37 incident cases of non-functioning micro- or macroadenomas, 35 had no increase in size or aspect on follow-up MRI without treatment with a median follow-up of 3 years (range 0- 29). In 52 patients diagnosed with prolactinoma (PRL) hormonal control was achieved in 35/37 (95%) with medical treatment only. Five patients with PRL were primarily operated on. Ten patients with PRL (19.2%) had stable disease without treatment during a median follow-up of 10.5 years (range 0 - 29). In contrast to the previous reports, pathological examination of PITs showed that only one of 23 (4.4%) patients had a Ki-67 index ≥ 3% (formalin fixation).

In conclusion, screening for PIT in MEN1 patients results in detection of especially non-functioning microadenomas with a benign course at long-term follow-up. PIT in MEN1 patients were less aggressive at presentation and at long-term follow-up than reported in previous studies. Therefore, surgical treatment of PIT also not seems more often required in MEN1 patients. Given the course of MEN1 related PIT which is comparable to sporadically occurring PIT, the guidelines for treatment of sporadic PIT seem to be generalizable to the MEN1 population.

 

Nothing to Disclose: JMD, OMD, CRCP, WPK, MRV, ARH, AMP, ANAV, MLD, PHB, BH, WWD, GDV

20021 12.0000 THR-324 A Pituitary Tumors in Patients with Multiple Endocrine Neoplasia Type 1 Syndrome Revisited: Outcomes of Systematic Pre-Symptomatic Tumor Detection and Follow-up 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Ranjit Singarayer*1 and Boji Varghese2
1Northern Ontario School of Medicine, Thunder Bay, ON, 2Health Sciences North, Sudbury, Canada

 

Disclosure Statement: The authors have nothing to disclose.

Background:

We report a novel case of a de novo parathyroid neuroendocrine tumor in a re-implanted left forearm parathyroid gland in a patient with known multiple endocrine neoplasia type 1 (MEN1).

Clinical Case:

A 41-year-old male patient with a past history of type 2 diabetes mellitus, dyslipidemia, Perthes disease of the hip, obesity, obstructive sleep apnea, nephrolithiasis, surgical excision of esophageal leiomyoma in 2010, wedge resection of pulmonary nodule in 2010, was initially diagnosed with multiple endocrine neoplasia type 1 (MEN1) in 2002. At the time he was found to have hypercalcemia (calcium 3.08 mmol/L, reference range 2.10-2.55) and hyperparathyroidism (PTH 14.4 pmol/L, RR 1.3-7.6). He underwent parathyroidectomy with three and one-half parathyroid glands removed with re-implantation of one-half of the gland in the left forearm. He was clinically well for over a decade and routine calcium and PTH levels were regularly within normal limits.

He then presented in 2013 with a painful mass in his left forearm. Hypercalcemia (2.65 mmol/L, RR 2.10-2.55) and hyperparathyroidism (11.4 pmol/L, RR 0.8-5.7) were both noted. MRI of the forearm was concerning for a neoplastic process in the area around the re-implanted parathyroid gland (size 12.8mm x 10mm). Core biopsy revealed cells with strong cytoplasmic staining with antibodies against cytokeratin AE1/AE3 and CD56; synaptophysin immunostaining was also positive. The cells showed neuroendocrine features. As such, he went on to have complete excision of the mass in February 2014. The specimen, which was analysed at Mayo Clinic Laboratories, was confirmed to be a de novo neuroendocrine tumor. The tumor was strongly positive with antibodies to keratin AE1/AE3, synaptophysin, chromogranin, and CD56.

An indium octreotide scan was then obtained showing uptake in the tail of the pancreas and the left parotid gland. CT scan of the abdomen obtained subsequently, revealed a 2.8 x 1.8 x 0.5 cm lesion just anterior to the pancreatic tail and a 0.6 cm focus adjacent to it which was not present in 2009. 

Conclusion:

There have been no reported cases of patients with MEN1 develop either NET of the parathyroid gland, or de novo NET in a re-implanted parathyroid gland in a forearm. A multitude of genes are known to be involved in NET tumorigenesis, including the MEN1 tumor suppressor gene, which is the most common genetic predisposition to NET. Mutations in the MEN1 gene are found in 95% of patients with MEN1 and 21% of parathyroid adenomas (1). Although the pathology of the pancreatic tail lesion in our patient is yet to be determined, it is plausible that an underlying MEN1 gene mutation predisposed him to developing a de novo NET in the forearm, which further demonstrates the interconnectedness between these two disease processes.

 

Nothing to Disclose: RS, BV

19420 14.0000 THR-326 A A Novel Case of De Novo Parathyroid Neuroendocrine Tumor in a Re-Implanted Forearm Parathyroid Gland in a Patient with Known Multiple Endocrine Neoplasia Type 1 (MEN1) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Flavia M Melo*1, Marta MS Sarquis2, Flavia M Passos1, Luciana Bastos-Rodrigues3, Eitan Friedman4 and Luiz De Marco5
1Universidade Federal de Minas Gerais, Belo Horizonte, Brazil, 2Universidade Federal de Minas Gerais, UFMG, Belo Horizonte, Brazil, 3Universidade Federal de Juiz de Fora, Governador Valadares, Brazil, 4Chaim Sheba Medical Center, Tal Hashomer, Israel, 5Universidade Federal de Minas Gerais, UFMG, Belo Horizonte MG, Brazil

 

Multiple endocrine neoplasia type 1 (MEN1) is a rare autosomal dominant disorder typically associated with MEN1 gene mutations. However, these mutations are not either present or detected in a subset of MEN1 patients. Two other genes, CDKN1B and AIP, have also been associated with MEN1 phenotype. The aim of this study was to perform a comprehensive analysis of MEN1, CDKN1B and AIP genes in a Brazilian family with MEN1 phenotype. The proband (28 yrs old) was referred because of persistent diarrhea. Biochemical data revealed hypercalcemia, hypergastrinemia and hyperprolactinemia. Imaging studies (MRI, PET/CT) disclosed a Prolactin macroadenoma, parathyroid tumor as well as multiple carcinoids. Subsequently his father was also diagnosed as MEN1-affected patient and died of multiple liver metastases. Genomic DNA was isolated from peripheral blood leukocytes of the proband, three unaffected family members and 96 healthy controls. DNA was also extracted from tumor tissue of the proband and his father. Sequencing of the MEN1 and CDKN1B genes were performed and shown to be wild-type in all family and controls. AIP screening revealed a heterozygous germline missense mutation, c.47G>A (p.Arg16His) in exon 1 of AIP, restricted to the affected members of the family. Loss of heterozygosity (LOH) within the available tumor tissues of the patient (carcinoid) was not present. In silico using 2LKN template analysis was performed and shown to be deleterious. This mutation has been previously reported as a rare polymorphism as it was found in unaffected controls in addition to lack of co-segregation of the mutation in some families. Previous two-hybrid experiments showed that the interaction between AIP and PDE4A5 decreases by approximately 60% when p.Arg16His is present indicating a causal role for this molecular alteration. In this report, the co-segregation of this rare AIP missense mutation and disease phenotype suggests a deleterious role of this mutation in the pathogenesis of MEN1, with incomplete penetrance. However, other gene-gene interactions cannot be ruled out.

 

Nothing to Disclose: FMM, MMS, FMP, LB, EF, LD

21197 15.0000 THR-327 A Association of AIP p.Arg16His Variant with Familial MEN1 Phenotype 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Rino Buzzola*, Mariana Garcia Touza, Norman S Litofsky and Stephen A Brietzke
University of Missouri, Columbia, MO

 

Background:  Multiple Endocrine Neoplasia (MEN) type 1 syndrome is a relatively uncommon inherited disorder characterized by the occurrence of tumors involving two or more endocrine glands. These tumors include pheochromocytoma, adrenal cortical and neuroendocrine tumors (NET) including (bronchopulmonary, thymic, gastric), lipomas, angiofobromas, collagenomas, meningiomas. MEN 4 an uncommon inherited disorder is characterized by the occurrence of parathyroid and anterior pituitary tumors in association with tumors of the adrenals, kidneys, and reproductive organs. 

Clinical Case:  Here we report a 40 year old male without significant family history of endocrine disease who was found to have primary hyperparathyroidism, an anterior pituitary tumor causing acromegaly, a thyroid cancer, renal cell carcinoma, and pancreatic cysts.  His medical history included obesity, irritable bowel syndrome, chronic diarrhea and depression and elevated serum calcium and parathyroid hormone (PTH) levels was referred to Endocrinology for evaluation of possible primary hyperparathyroidism and acromegaly.  He had a neck ultrasound for localization of possible parathyroid adenoma, which showed a complex right mid lobe nodule that measured 18.7 x 19.7 x 19 mm and the left inferior lobe nodule that measured 9 x 7.5 x 6.7 mm.  However the neck ultrasound failed to reveal a lesion that could be characterized as a parathyroid adenoma.  Magnetic resonance imaging (MRI) of the abdomen was performed as part of the work up for MEN type 1, revealing multiple small pancreatic cysts, and a left renal mass. Endoscopic ultrasound confirmed simple multiple pancreatic cysts (which were not biopsied); colonoscopy revealed small benign polyps, which were endoscopically excised.   For the renal mass lesion, the patient underwent a partial left nephrectomy for pathologically-confirmed clear cell renal carcinoma, measuring 3.9 cm in greatest dimension.  

Conclusion:  To our knowledge this is the first case reporting the association of MEN 1 and/or MEN 4 phenotype with this unique constellation of tumors, including renal cell carcinoma. Renal tumors (angiomyolipoma) have been reported as part of the MEN 4 phenotype.   Interestingly this patient tested negative (DNA sequencing /deletion) for MEN 1 (menin), MEN 4 (CDKN1B) and VHL genes. Thus, this patient may represent a case of MEN with novel genetic and phenotypic characteristics.

 

Nothing to Disclose: RB, MGT, NSL, SAB

22104 16.0000 THR-328 A A Possible New Men Mutation in a Patient with a Prototypic Men 4 Presentation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Lucieli Ceolin1, Mirian Romitti1, Debora R Siqueira1, Carla Vaz Ferreira1, Jessica O Scapineli1, Rodolfo Maximiano2, Tauanne D Amarante2, Miriam Souza Nunes2, Gerald Weber2 and Ana Luiza Maia*1
1Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, 2Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

 

Background: The RET S836S genetic variant has been associated with early onset and increased risk for metastatic disease in sporadic medullary thyroid carcinoma (MTC). However, the mechanism by which this neutral variant modulates the pathogenesis or clinical course of MTC is still open to discuss. One of the proposed mechanisms suggests that the S383S polymorphism might be in linkage disequilibrium (LD) with unknown functional variants. Of interest, strong LD between S836S and RET 3'UTR variants has been reported in patients with Hirschsprung's disease. Objective: To evaluate whether the RET 3’UTR variants (rs76759170 and rs3026785) are in LD with S836S polymorphism and correlate with disease presentation in MTC patients. Methods: Our sample comprised 127 patients with sporadic MTC. The RET variants S836S and 3’UTR (rs76759170 and rs3026785) were genotyped using Custom TaqMan Genotyping Assays. Haplotypes were inferred using the phase 2.1 program. RET mRNA structure and flexibility was assessed by Vienna Package and TfReg software. Results: The mean age at diagnosis was 48±15.5 years and 53.5% was women. The frequency of lymph node and distant metastasis were 57.4 and 24.5%, respectively. The minor allele frequencies observed for the RET variants were follows: S836S (5.5%), rs76759170 (5.6%) and rs3026785 (5.6%). We observed a strong LD between 3’UTR variants (|D’|= -1, r²= 1) and between these variants and the S836S polymorphism (|D’|= -1, r²=0,989). The haplotype carrying the S836S and 3’UTR genetic variants presented a greater number of double helices sections and lower levels of minimal free energy as compared with the wild-type haplotype, which may affect the RET mRNA stability and flexibility. Interestingly, patients harboring the haplotype with S836S and 3’UTR variants had higher serum calcitonin (1747.5 vs. 579 pg/mL, P=0.028) and CEA (585 vs.28.3 ng/mL, P=0.005) levels, and larger tumor size (3.4(2.2-4.0) vs 2.3(1.5-3.3), P=0.050). The S836S/3’UTR RET haplotype was also associated with higher rates of lymph node or distant metastatic disease (100 vs. 52.9%, P=0.003, and 69.2 vs. 25.0%, P=0.003, respectively). Accordingly, Kaplan–Meier estimates of cumulative lymph node and distant metastasis yielded distinct curves for patients with or without the S836S/3’UTR haplotype (P<0.001), further demonstrating that metastatic disease occurred earlier in those individuals harboring the S836S/3’UTR variants. Conclusion: Our results demonstrated that the neutral RET S836S polymorphism and RET 3’UTR genetic variants are in strong LD and that these variants may affect the secondary structure of RET mRNA. Individuals carrying the RET S836S/3'UTR haplotype present more aggressive disease, further supporting the hypothesis of functional involvement of RET genetic variants in sporadic MTC patients.

 

Nothing to Disclose: LC, MR, DRS, CVF, JOS, RM, TDA, MS, GW, ALM

19623 18.0000 THR-330 A Effects of S836S and 3'UTR RET Genetic Variants on RET mRNA Secondary Structure and Disease Presentation in Sporadic Medullary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Steven I Sherman*1, Martin Schlumberger2, Makoto Tahara3, Bruce Gregory Robinson4, Kate Newbold5, Andrew George Gianoukakis6, Manisha H Shah7, Matthew H Taylor8, Naomi Kiyota9, Corina E Dutcus10, Angela Teng10 and Lori Wirth11
1The University of Texas MD Anderson Cancer Center, Houston, TX, 2Gustave Roussy and University Paris-Sud, Villejuif, France, 3National Cancer Center Hospital East, Kashiwa, Japan, 4University of Sydney, Sydney NSW, Australia, 5Royal Marsden Hospital National Health Service Trust London, 6Harbor-UCLA Medical Center, Torrance, CA, 7The Ohio State University Comprehensive Cancer Center, Columbus, OH, 8Knight Cancer Institute, Oregon Health and Science University, Portland, OR, 9Kobe University Hospital, Kobe, Japan, 10Eisai Inc., Woodcliff Lake, NJ, 11Massachusetts General Hospital, Boston, MA, USA

 

Introduction: In the SELECT trial, lenvatinib (LEN)–an oral, multikinase inhibitor of VEGFR1-3, FGFR1-4, PDGFRα, RET, and KIT–significantly prolonged progression-free survival (PFS) vs placebo (PBO) in patients with 131I-refractory differentiated thyroid cancer (RR-DTC; median 18.3 vs 3.6 months, respectively; hazard ratio 0.21 [99% confidence interval 0.14–0.31]; P<0.0001). This exploratory analysis examines how thyroid abnormalities may have influenced the safety and efficacy outcomes in SELECT.

Methods: SELECT–a phase 3 double-blind study–randomized patients with RR-DTC to 24 mg/d of LEN or PBO until disease progression, unacceptable toxicity, or death. Key inclusion criteria included independently verified disease progression within 13 months, 0 or 1 prior VEGF-targeted therapy, and serum thyroid-stimulating-hormone (TSH) levels ≤5.5mIU/L. When tolerated, active TSH suppression (≤0.5 mIU/L) by concomitant levothyroxine treatment was added.

Results: 392 Patients were randomized (LEN=261; PBO=131). Median baseline TSH levels were LEN, 0.05 mIU/L; PBO, 0.04 mIU/L. All patients received concomitant levothyroxine. Patient TSH levels in the LEN arm were already elevated relative to baseline (median 0.10 mIU/L; range, 0–39.1) by the time of first assessment (cycle 1 day 15). TSH levels peaked at cycle 2 (median TSH 0.16 mIU/L; range 0–93.2), but steadily declined after cycle 4. At study end, the median TSH level for the LEN arm was 0.08 mIU/L (range 0–17.8). There were no consistent changes in TSH levels in the PBO arm. Patients receiving LEN had worst post-baseline TSH levels of ≤0.5 mIU/L (n=99; 37.9%), >0.5-2.0 mIU/L (n=53; 20.3%), >2.0-5.0 mIU/L (n=25; 9.6%), and >5.0 mIU/L (n=80; 30.7%). 5 Patients experienced LEN-related hyperthyroidism and 9 patients experienced LEN-related hypothyroidism; all were Grade 1–2 events. There were no substantial differences in rates of dose modifications, study drug withdrawals, treatment exposure, or LEN-related adverse events based on worst post-baseline TSH levels. Objective response rates based on worst post-baseline TSH levels were: ≤0.5 mIU/L, 65.7%, >0.5-2.0 mIU/L, 69.8%; >2.0-5.0 mIU/L, 48.0%, and >5.0mIU/L, 68.8%. There was also no significant difference in PFS between patients based on worst post-baseline TSH levels (adjusted log-rank P=0.747).

Conclusions: An increase in TSH levels was a frequent complication; its direct relationship to LEN therapy has not been established. In this analysis, there was no evidence of a relationship between the maximum worst post-baseline TSH level and LEN dosing, or increased toxicities. There was also no evidence that TSH levels affected tumor responses to LEN treatment. This may be indicative of properties intrinsic to LEN, or reflective of frequent adjustment of thyroid hormone dosing by the treating physician to maintain low TSH levels. Further analyses are warranted.

 

Disclosure: SIS: Consultant, Roche Pharmaceuticals, Consultant, Genzyme Corporation, Consultant, Eli Lilly & Company, Consultant, Novo Nordisk, Consultant, Veracyte, Inc., Consultant, Astra Zeneca, Research Funding, Pfizer, Inc., Consultant, Bayer, Inc., Consultant, Exelixis, Inc., Consultant, Eisai. MS: Consultant, Genzyme Corporation, Consultant, Eisai, Consultant, Bayer, Inc., Consultant, Astra Zeneca. MT: Advisory Group Member, Lecture Fees, Speaker, Bristol-Myers Squibb, Advisory Group Member, Merck & Co.. BGR: Advisory Group Member, Bayer, Inc., Advisory Group Member, Astra Zeneca. KN: payment of registartion fees and flight to attend European Thyroid Association Annual Meeting topresent work arising from this trial in September 2014 , Eisai. AGG: Consultant, Eisai. MHS: Clinical Researcher, Bayer, Inc., Consultant, Exelixis, Inc., Consultant, Eisai. MHT: Advisory Group Member, Eisai. NK: Consultant, Eisai. CED: Employee, Eisai. AT: Employee, Eisai. LW: Consultant, Novartis Pharmaceuticals, Consultant, Eisai.

20459 19.0000 THR-331 A Relationship Between Thyroid-Stimulating Hormone Levels and Outcomes from the Randomized, Double-Blind, Phase 3 Study of (E7080) LEnvatinib in Differentiated Cancer of the Thyroid (SELECT) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Yi Liu-Chittenden*1, Meenu Jain1, Parag Kumar2, Dhaval Patel1, Rachel Aufforth1, Vladimir Neychev1, Samira Mercedes Sadowski3, Sudheer Kumar Gara1, Bharat H Joshi4, Candice Cottle-Delisle1, Roxanne Merkel1, Lily Yang5, Markku Miettinen1, Raj K Puri4 and Electron Kebebew1
1National Cancer Institute, NIH, Bethesda, MD, 2National Institutes of Health, Clinical Center, Bethesda, MD, 3University Hospitals of Geneva, Geneva, Switzerland, 4Center for Biologics Evaluation and Research, FDA, Silver Spring, MD, 5National Institutes of Health, Bethesda, MD

 

Introduction: Adrenocortical carcinoma (ACC) is a rare but lethal malignancy without effective current therapy for locally advanced and metastatic disease. Interleukin-13 receptor α2 (IL-13Rα2) is overexpressed in ACC and other solid malignancies and represents a promising therapeutic target for therapy as it is absent in normal tissue. IL-13-PE is a recombinant cytotoxin consisting of human Interleukin-13 (IL-13) and a truncated form of Pseudomonas exotoxin A (cintredekin besudotox, hIL13-PE38QQR).  It can bind to IL-13Rα2 positive tumor cells and is highly cytotoxic to these cells in both in vitro and in vivo models of multiple malignancies. Here we report a Phase I dose-escalation trial to assess the maximum-tolerated dose (MTD), safety, and pharmacokinetics (PK) of IL-13-PE in patients with metastatic ACC. Neutralizing antibody production and patient response were also assessed. This is the first clinical trial to evaluate systemic administration of IL-13-PE in humans. Methods: Eligible patients had confirmed IL-13Rα2 expressions in their tumors. IL-13-PE at dose of 1 to 2µg/kg was administered intravenously (IV) on day 1, 3, and 5 in a 4-week cycle. Results: Six patients received 1µg/kg and two patients received 2µg/kg of IL-13-PE. Dose-limiting toxicity was observed at 2µg/kg, at which patients developed thrombocytopenia and renal insufficiency without requiring dialysis. At the MTD, 1µg/kg, the most common adverse events included Grade 1 or 2 anemia (50%), proteinuria (50%), increase in alanine aminotransferase (ALT, 33.3%), aspartate aminotransferase (AST, 33.3%), creatinine (33.3%) and fatigue (33.3%). PK of IL-13-PE showed overall rapid elimination from serum and linear disposition among drug dose levels of 1µg/kg and 2µg/kg. At MTD, the mean maximum serum concentration of IL-13-PE (Cmax) was 21.0ng/mL, and the terminal half-life of IL-13-PE was 30-39 minutes. Two (25%) of the eight patients had baseline neutralizing antibodies against PE. Three (75%) of the remaining four tested patients developed neutralizing antibodies against IL-13-PE within 14-28 days of initial treatment. Of the 5 patients treated at MTD and assessed for response, one patient had stable disease for 5.5 months before disease progression; the others progressed within 1-2 months. Conclusions: Systemic IV administration of IL-13-PE is safe at 1μg/kg. All tested patients developed high levels of neutralizing antibodies during IL-13-PE treatment. Use of strategies for immunodepletion before IL-13-PE treatment should be considered in future trials.

 

Nothing to Disclose: YL, MJ, PK, DP, RA, VN, SMS, SKG, BHJ, CC, RM, LY, MM, RKP, EK

19345 20.0000 THR-333 A Phase I Trial of Systemic Intravenous Infusion of Interleukin-13-Pseudomonas Exotoxin (IL-13-PE) in Patients with Metastatic Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Narjust Perez Florez*1, Nisha Suda1, Sandra Aleksic1, Elaine Zhai1, Chad Glisch2 and Martin Gutierrez3
1Rutgers-New Jersey Medical School, Newark, NJ, 2St. George's University, 3John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ

 

Background: Primary pulmonary neuroendocrine tumors account for less than 5% of all lung malignancies and 30% of all carcinoid tumors.  Despite an increasing incidence over the past few decades, there is limited data regarding the clinical characteristics of these tumors, and consequently no major advances have been made for patient treatment. The aim of this study was to investigate the clinical characteristics and predictors of survival in primary pulmonary neuroendocrine tumors.

Methods:We reviewed the records of all patients (pts) diagnosed with pulmonary neuroendocrine tumors at our institution from 1997 to 2013. Demographics, tumor characteristics, recurrence and survival rate were analyzed. Chi-square test was used to estimate differences in categorical data; Kaplan-Meier and Cox regression were used for survival and multivariate analysis. 

Results: A total of 66 pts were identified, mean age at diagnosis was 69 years (45-80). There was a higher prevalence in males than females (67% vs. 33%, p<0.0002). Only 36% (24) of pts had any family history of cancer and 68% (45) of the pts were current or former smokers.  The most common initial presentations were: dyspnea (38%), incidental finding in imaging (22%) or recurrent pneumonias (15%). Our pts were more likely to have upper lobe tumors than all other tumor locations combined (45% vs. 38%, p<0.005). 32% of the tumors were 3 to 4 cm in diameter and large cell neuroendocrine carcinoma represented 52% of all the histologic subtypes, while 78% were poorly differentiated or anaplastic tumors. At diagnosis, 61% (40) of the pts were stage IV, with brain (33%) and liver (21%) representing the most common distant metastases. Only 18% (12) of the pts qualified for surgical treatment, 71% (47) received systemic chemotherapy and 29% (19) radiation.  Median overall survival was 10.5 months (95%CI: 3.5-17.6). There was a significant difference in median overall survival between genders, being 9.5 months for females (95%CI: 4-13) and 16 months for males (95%CI: 6-26), p<0.002. Female gender (OR: 1.98, p<0.001), upper lobe tumors (OR: 2.36, p<0.002), large cell neuroendocrine subtype (OR: 1.21, p<0.003), and radiation therapy (OR: 0.50, p<0.008) were independent and significant predictors of survival by multivariate analysis.  In 67% of the pts this cancer was the primary cause of death.

Conclusions: In our cohort, we observed that pulmonary neuroendocrine tumors are very aggressive malignancies, as evidence by 61% of pts presenting with stage IV disease. Tumor location was a detrimental factor in prognosis with upper lobe tumors having 2.4 times greater mortality risk.  Females have lower incidence but shorter overall survival and radiation therapy may offer an unproven survival benefit. Further research is needed to identify other clinical characteristics that would help us achieve earlier diagnosis as this could potentially impact management and survival. 

 

Nothing to Disclose: NP, NS, SA, EZ, CG, MG

18295 21.0000 THR-334 A Pulmonary Neuroendocrine Tumors: Clinicopathological Characteristics and Survival, a Single Institution's Experience over 15 Years 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Franco Grimaldi*1, Claudia Cipri1, Cecilia Motta1, Maria Antonietta Pellegrini2, Sabrina Piussi2, Alessandro Purinan2, Laura Tonutti2 and Fabio Vescini1
1Endocrinology and Metabolism Unit University-Hospital of Udine, Udine, Italy, 2Endocrinology and Metabolism Unit Udine

 

Introduction It was decided to do an epidemiological study on patients with neuroendocrine neoplasms (NEN) referred to the Endocrinology and Metabolic Diseases Unit of the Hospital in Udine, the referral center for this disease in the Region Friuli Venezia Giulia.

Methods Data were collected on 344 patients diagnosed with NEN between 1990 and 2013 regarding: town of residence, age at diagnosis, type of NEN, survival, metastases at diagnosis, the lenght of the clinical course, diagnostic tools used, specialist visits and prescribed therapies. Survival and progression-free survival (PFS) were analyzed according to sex, type of NEN, and the presence of metastases at diagnosis.

Results The average age at diagnosis was 59.8 years (range 19-87 yrs), 50.3%  males and 49.7% females. Most of the patients came from the Udine province, the most populous. The two sites most affected by NENs were lungs and pancreas; the most frequent was the non-functioning of the pancreas, followed by a typical pulmonary carcinoid. The number of diagnoses of NEN per year increased progressively to over 30 cases a year from 2009 onwards, the highest increase in GEP-NEN compared to T-NEN. In the period 2003-2013 there were 19.7 cases per 100 000 inhabitants; 20.8% of patients had liver metastases at diagnosis. The survival ranged from 1 month to 23.7 years;  31.6% of patients had died, and of these 71.1% due to the disease.

We compared the lenght of the clinical course of patients  diagnosed prior to 2006 with those diagnosed from 2006 onwards (the year a Network was started to provide  information about NEN at the local medical level). In the first group, the percentage of patients seen by the endocrinologist within 3 months of diagnosis, was 44.9%, but  in the second group it was 68.8%.

Computed Tomography was the most frequent test (63.1%) for diagnosis; 44.5% of patients did not receive any medical treatment; of the remaining, 40.7% were treated with somatostatin analogues (24.1% with Octreotide and 16.6% with Lanreotide). Survival and PFS were more frequent in females than in males, in patients without liver metastases at diagnosis and in patients with typical carcinoid. Among all kinds of NEN the typical carcinoid is the one with the greatest survival time.

Conclusions. The data obtained confirm the increased incidence of NEN in our Region and provide additional information on the epidemiology and natural history of these tumors.

 

Nothing to Disclose: FG, CC, CM, MAP, SP, AP, LT, FV

18498 22.0000 THR-335 A Neuroendocrine Tumors: Identification, Diagnosis and Therapy in Friuli Venezia Giulia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Robert Y Osamura*1, Midori Matsuda2, Mai Kato3, Chie Inomoto4 and Hiroshi Kajiwara4
1Intl Univ of Health and Welfare, Tokyo, Japan, 2International University of Health and Welfare, Tokyo, Japan, 3International University of Health and Welfare Mita Hospital, Tokyo, Japan, 4Tokai University School of Medicine, Isehara, Japan

 

It has been reported that approximately 45% of pancreatic sporadic well-differentiated neuroendocrine tumors(NET) harbor mutations in ATRX(alpha thalassemia/mental retardation X-linked) or DAXX(death domain associated protein) genes with mutual exclusive manner. In contrast, pancreatic adenocarcinoma reveals KRAS mutation and no ATRX/DAXX mutations. ATRX and DAXX proteins form dimers to function as chromatin stabilizers. It has been reported that negative immunohistochemistry for ATRX and DAXX proteins correlates with mutations. In order to clarify the histogenetic and phenotypic background of NEC, this study is aimed at to elucidate the mutation of ATRX/DAXX genes in pancreatic(P)NETs and gastric(G) NENs by immunohistochemistry.

Formalin-fixed paraffin embedded (FFPE) sections from total 30 cases were used(see below). The tumors were classified according to WHO 2010, NET G1, NET G2, neuroendocrine carcinoma(NEC) and mixed adenoneuroendocrine carcinoma(MANEC). The NEC with typical neuroendocrine histology was sub-classified as NET G3. Two cases of gastric MANEC were also included. Deparaffinized sections were reacted with anti-ATRX (CL0537, Abcam) or anti-DAXX (36H11,Abcam) mouse monoclonal antibodies. KRAS mutation was analyzed in selected cases by i-densy®(Arkray)

The staining was interpreted as positive if immunohistochemical reaction (ATRX, DAXX) was present in the nuclei of the tumor cells. If ATRX or DAXX or both were negative, the overall staining was interpreted as negative indicating the ATRX/DAXX mutations. The results of the immunohistochemical staining were as follows. 

PNET G1( 3 cases):ATRX(1/3)/DAXX(1/3)-overall 0/3, PNET G2(4cases):     ATRX(2/4)/DAXX(0/4)-overall 0/4, NET G3(3cases):ATRX(3/3)/ DAXX (2/3) -overall 2/3, PNEC(3 cases):ATRX(2/3)/DAXX(3/3) -overall 2/3

GNET G2(2 cases):ATRX(2/2)/DAXX(2/2)-overall 0/2, GNET G3( 5 cases)  ATRX(1/5)/DAXX(2/5)-overall 1/5, GNEC(8 cases):Small cell ca.: ATRX(0/3)/DAXX(0/3)-overall 0/3, Large cell ca.:ATRX(2/5)/DAXX(1/5)-overall 1/5, GMANEC( 2 cases):NEC-ATRX(2/2)/DAXX(2/2)-overall 2/2, ADCA -ATRX(2/2)/DAXX(2/2)-overall 2/2     *ADCA:adenocarcinoma

KRAS mutation in codon 12 and 13 was found in four cases, two cass of PNET G3 and two cases of PNEC., 

Conclusions: Our immunohistochemical study suggested that ATRX/DAXX genes are frequently mutated, more frequently in DAXX, in NET G1 and G2 and support the concept of their origin from the neuroendocrine cells. It was also suggested that NET G3 and NEC would be composed of heterogeneous histogenetic components, i.e., neuroendocrine or epithelial cells.  The cases of gastric MANEC suggested the common epithelial origin of both components.

Our studies suggested that NET G1 and G2 are the neuroendocrine origin and that NEC is composed of complexity of histogenetic and phenotypic diversities.

 

Nothing to Disclose: RYO, MM, MK, CI, HK

19562 23.0000 THR-336 A Mutations of Atrx/Daxx Genes in the Pancreatic and Gastric Neuroendocrine Neoplasms(NEN)-NET, NEC and Manec:Immunohistochemical Approach 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Natalia Aristizabal*1, Luis Felipe Fierro2, Gimena Mejia3, Isaac Guzman4, Andres Cuellar2, Leonardo Rojas2, Lina Marulanda2, Raul Pinilla2, Alfredo Ernesto Romero2 and Alfonso Lozano2
1Universidad Pontificia Bolivariana, Medellín, Colombia, 2Instituto Nacional de Cancerología, Bogota, Colombia, 3Hospital Universitario San Jose, Bogota, Colombia, 4Hospital Militar Central, Bogota, Colombia

 

Background: Type 1 gastric neuroendocrine neoplasms (NENs) are increasingly identified at endoscopy as incidental findings. These tumors develop because of hypergastrinaemia causing hyperplasia of ECL cells. Hypergastrinaemia originates from achlorhydria in atrophic gastritis by auto-immune attack. The vast majority of type 1 gastric NETs are G1 tumors with low proliferation index that present at stage I with compromise to local lymph nodes occurring in few cases and distant metastases being extremely rare.  The indicated treatment in majority of cases is endoscopic surveillance and resection in selected patients and their prognosis is excellent.

Clinical Case: A 43 year women was evaluated because a several years of epigastric pain, dyspepsia, nausea and vomiting, treated with antacids and no proton pump inhibitors. Upper digestive endoscopy demonstrated the presence of 10 lesions in the fundus and body gastric, ranging from 3 to 15 mm in diameter. Biopsy of the major lesion reported a NEN histologic grade 2 (Mitotic count of 0 per 10 High Power Field and Ki67 of 3%). A biopsy of another lesion in the fundus informed a NEN grade 2 with Ki67 of 5% and mitotic count of 1 per 10 HPF. Moreover, histopathological study indicated the presence of atrophic gastritis in fundus and corpus.

Gastrin serum levels were elevated (425pg/ml, ECLIA Normal 13-115) and parietal cells antibodies were positive confirming a type 1 Gastric NEN. Due to the size greater than 1 cm in endoscopy and the histologic grade, a 3 phase arterial contrast enhanced abdominal computerized tomography (CT) was performed showing a polypoid lesion in major curvature and thickening of gastric walls near to the lesion, without any other lesions and no metastases. Somatostatin receptor scintigraphy was positive only in the gastric chamber. The case was discussed in a multidisciplinary board and the patient was undergone to laparoscopic total gastrectomy with D1 nodal dissection with a curative approach. Surgical pathology reveals the presence of 4 NEN (the biggest being 10x7 mm in size) with infiltration to the submucosa, mitotic count of 1 per 10 HPF, no evidence of angioinvasion or neuroinvasion. Also, there were three of twelve lymphatic nodes compromised by tumor. Surgical margins were negative for tumor. The Immunohistochemistry staining for chromogranin A, AE1-AE3 were positive and synaptophysin was negative in tumor cells. Ki67 in the gastric tumor cells was <2% but in nodal metastasis was 5%. (pT2N1M0 Stage IIIb AJCC). Four months after surgery the patient feels well and there is no evidence of relapse in the CT scan.

Conclusion The vast majority of type I gastric NEN have a benign behavior and the endoscopic resection is the only required treatment  We presented a Type 1 gastric NEN with an unusual histologic grade 2 and nodal involvement not detected preoperatively by 3 phase abdominal CT nor Somatostatin receptor scintigraphy.

 

Nothing to Disclose: NA, LFF, GM, IG, AC, LR, LM, RP, AER, AL

20344 24.0000 THR-337 A Type 1 Gastric Neuroendocrine Neoplasm with KI-67 INDEX > 2% Zshould WE Have Other Therapeutic Implications? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Ozgur Mete*, Karen G. Hernandez, Shereen Z Ezzat and Sylvia L. Asa
University Health Network, Toronto, ON, Canada

 

Background: Hyperglucagonemia is usually associated with a pancreatic neuroendocrine tumor (pNET); multiple glucagon-producing pNETs are characteristic of MEN1 and MEN4 syndromes, and VHL disease. Recently, glucagon cell adenomatosis (Mahvash disease) unrelated to MEN1, CDKN1B, and VHL mutations was identified in six patients showing glucagon cell hyperplasia-neoplasia sequence and glucagon resistance, i.e. without glucagonoma syndrome or feedback response in pancreatic B cells to glucagon. Three of the six individuals were found to harbor germline mutations in the glucagon receptor. We present the clinicopathologic features of an additional patient with morphologic features of glucagon resistance.

Material and Methods: The pathology files of UHN were reviewed to identify pancreatic pathology characterized by isolated A cell proliferative disease.  One case was found and the clinical and morphological features were reviewed.

Results: The patient, a 45 year old man, presented with no clinical evidence of hereditary endocrine tumor syndromes or manifestations of glucagon excess. He was being investigated for non-specific abdominal symptoms but had no evidence of diabetes mellitus or necrolytic migratory erythema.  A pancreatic lesion was identified on endoscopic ultrasound and biopsy was suspicious for an endocrine tumor.  A distal pancreatectomy was performed. The pancreas exhibited numerous glucagon-expressing pancreatic neuroendocrine micro-tumors (pmNETs; ranging from 0.05-0.5 cm) with peliosis throughout the pancreatic tissue; there was diffuse A cell hyperplasia and dysplasia with significant reduction in B cells, scattered D cells, and no G cells. There was no evidence of nesidioblastosis or nesidiodysplasia. All pmNETs were negative for VIP, serotonin, somatostatin, insulin, PP, calcitonin, and gastrin. The patient had been referred to our endocrine clinic on Sandostatin LAR, and baseline levels of glucagon were unknown; postoperative levels were within the normal range.

Conclusions: The lack of hyperplastic feedback response in B cells seems to be one of the key morphologic features of glucagon resistance suggesting impaired functions of glucagon or its receptor. The case we present exhibited a distinct A cell hyperplasia -neoplasia sequence unassociated with plurihormonality or concomitant proliferations of other pancreatic endocrine cells, which distinguishes these lesions from those associated with MEN1, MEN4, and VHL. We propose the terminology “glucagon resistance syndrome” to reflect the distinct pathogenesis of these unique proliferations.

 

Nothing to Disclose: OM, KGH, SZE, SLA

22086 25.0000 THR-338 A Pancreatic a Cell Hyperplasia and Neoplasia Consistent with Glucagon Resistance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Safak Akin1, Senem Noyan2, Selcuk Dagdelen1, Ilhan Pasaoglu1, Volkan Kaynaroglu1, Melike Mut Askun1, Hayyam Kiratli1, Dilek Ertoy Baydar1, Sevgen Onder1, Cenk Sokmensuer1, Kudret Aytemir1, Gul Erkin1, Mehmet Alikasifoglu1 and Tomris Erbas*1
1Hacettepe University Medical School, 2Damagen, Ankara, Turkey

 

Introduction:The disorder known as Carney Complex is a multiple neoplasia syndrome that is characterized by skin tumors and pigmented lesions, myxomas, and various endocrine tumors.

Clinical case: The patient was a 46 year old man with a medical history of operation for cardiac myxomas at the age of 39. He was admitted to our hospital because of four newly developed heart masses located in the right and left atrium chamber. Surgical excision of tumors was performed; histological examination confirmed cardiac myxomas. The patient’s physical examination revealed several pigmented lesions on his lower lip, palm and fingers, prognathism, acromegalic appearance, enlargement of his right testes, and right inguinal mass. On pathological examination, the right testicular mass was presumed to be a large-cell calcifying Sertoli cell tumor and the inguinal mass was consistent with superficial angiomyxoma. Serum IGF-1 concentration was 522 ng/mL (N: 64-336 ng/mL) on a basal hormonal assay. There was no GH suppression on OGTT. Pituitary MRI showed pituitary macroadenoma (12x7.5 mm). The tumor was removed and based on immunohistochemistry findings, the patient was diagnosed with a GH and PRL secreting mixed pituitary adenoma. Multiple thyroid nodules were detected on ultrasound along with suspicion of malignancy on thyroid biopsy. He underwent total thyroidectomy and histological examination revealed adenoma. The Liddle’s test for primary pigmented nodular adrenocortical disease showed a paradoxical increase in the urine cortisol from baseline (122 µg/dL) to 820 µg/dL six days later. He underwent bilateral adrenalectomy and pathological examination revealed adrenal adenoma. Two years after the second cardiac operation, an interatrial septum-derived tumor was detected in a routine echocardiography follow-up. Then the patient underwent resection of the cardiac mass. An atrial myxoma was confirmed histologically. The genetic analysis showed that a novel insertion mutation (c171-172insT) in the type 1A regulatory subunit of the cAMP-dependent protein kinase A gene (PRKAR1A) in exon 2 was present in our patient.

Conclusion: The presence of multiple myxomas and endocrine abnormalities should be an indication to clinicians to further investigate for Carney Complex. Functional disturbance of the protein kinase A system associated with the PRKAR1A mutation played an important role in the pathogenesis and progression of Carney Complex. Here, we described a case of Carney Complex, with a novel mutation in exon 2 of the PRKAR1A gene, with typical clinical features including cardiac myxomas, skin pigmentations, multiple endocrine neoplasms and with less common clinical features including large-cell calcifying Sertoli cell tumor of the testis and superficial angiomyxoma.

 

Nothing to Disclose: SA, SN, SD, IP, VK, MM, HK, DE, SO, CS, KA, GE, MA, TE

20070 27.0000 THR-340 A A Novel PRKAR1A Mutation in a Patient with Carney Complex 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM THR 312-340 5976 1:00:00 PM Endocrine Neoplasia: Tumorigenesis and Therapeutics Poster


Andres Ventura Ebison Jr.*
Makati Medical Center, Makati City

 

Background: Congenital Adrenal Hyperplasia (CAH) is an autosomal recessive disorder affecting steroid biosynthesis. It is relatively prevalent in pediatric population affecting 1:10,000 – 20,000 live births. Such condition has limited data in adult stage, more so its occurrence in a patient with a possible disorder of sexual development.

Clinical case:  A case of a 49 year old, phenotypically male, married, who presented with “urethral bleeding”. It was associated with hypogastric fullness and occasional colicky pain. Physical examination showed male pattern hair distribution, no breast enlargement, non-tender palpable hypogastric mass and circumcised genitalia with empty scrotal sac. Imaging studies showed hypogastric mass, resembling uterus with no identifiable ovarian or testicular structures and hyperplastic adrenals, bilateral. Hormonal assays revealed: low anti-mullerian hormone (<0.17, 1.3-14.8 ng/ml), normal cortisol levels (320.95, 138-690 nmol/L), elevated aldosterone (44.21, 4-31 ng/dl), DHEAS (19.44, 1.2-8.98 umol/L), testosterone (775.96, 245-1,836 nmol/L, male), ACTH (314.37, <50 pg/mL) and 17-hydroxyprogesterone (303.10, 0.5-3 ng/mL). The patient underwent exploratory laparotomy & unexpectedly, mullerian structures such as the ovaries, fallopian tube, vagina and uterus were identified and neither prostate gland nor testes were seen. Histopathology reported myoma uteri with unusual ovarian structure consisting of ovarian stroma, Leydig cells and epididymis seen bilaterally. Karyotyping was done and revealed 46,XX chromosome.

Impression is Congenital Adrenal Hyperplasia in Adult due to elevated 17-hydroxyprogesterone, inspite having normal aldosterone and cortisol levels which are not typically seen in such patients. This is a neglected case of CAH where severe virilization gives rise to his male phenotype – deep voice, hair distribution, phallus development and labioscrotal fusion (Prader IV). His “urethral bleeding” is due the Myoma uteri eroding the blood vessels in the endometrium. While he had a 46,XX genotype, investigation is still being pursued regarding the presence of Leydig cells and Epididymis in the resected ovaries for a possible disorder of sexual development. At present, the patient is treated with steroid as replacement. His other metabolic conditions such as hypertension, impaired fasting glucose and dyslipidemia and social issues particularly sex assignment are addressed accordingly.

Conclusion: This is a rare case of Congenital Adrenal Hyperplasia diagnosed in an adult with a possible disorder of sexual development.

 

Nothing to Disclose: AVE Jr.

20711 1.0000 THR-402 A Congenital Adrenal Hyperplasia in Adult with Disorder of Sexual Development: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Paula C. L. Elias*1, Sara R Teixeira1, Andreia F Melo1 and Jorge Elias Jr.2
1Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 2Ribeirao Preto Medical School- University of Sao Paulo, Ribeirao Preto, Brazil

 

A morphological hallmark in congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) is bilateral enlarged adrenal glands. Imaging studies have addressed mainly morphological aspects and dimensions of the adrenal glands. However, no function imaging was used to evaluate changes in the adrenal glands in patients with CAH. We performed adrenal magnetic resonance imaging (MRI) in 25 patients with CAH (12 females; 13 males; median age 10.7 years, range: 0.2–26.3 yrs) followed at our tertiary hospital. Quantitative MRI parameters, particularly quantitative apparent diffusion coefficient (ADC) derived from diffusion-weighted MRI (DWI), were correlated with hormonal status. Volume and ADC values of the adrenal glands were compared to 23 age-matched controls (17 females; 6 males; median age 11.7 years, range: 0.2–30 yrs). Two radiologists reviewed all images and performed ADC and volumetric measurements. Hormonal status of controlled or uncontrolled disease was determined by serum androstenedione levels, measured by RIA, within or above normal ranges for age and Tanner stage, respectively, considering levels on the day of MRI study (short-term) and from mean androstenedione levels of at least two sampling on the 12 months (long-term) prior to the study. Volumetric measurements were significantly higher in patients compared to controls (P 0.04). Considering short-term hormonal status, adrenal volumes were significantly greater in uncontrolled compared to controlled patients (right adrenal: 5.33 ± 3.65 vs 2.86 ± 1.44 cm3; and left adrenal: 7.13 ± 6.97 vs 2.67 ± 1.34 cm3; P 0.01 – 0.04). A positive correlation was found between hormonal status and bilateral adrenal volumes for short-term (r = 0.56 (left adrenal); r = 0.57 (right adrenal), P < 0.01) and long-term (r = 0.56 (left adrenal); r = 0.50 (right adrenal), P< 0.01) parameters. These positive correlations between adrenal volume measurements and hormonal status in children and young adults CAH patients are not only in accordance with previous studies performed in adult patients, but also extend the evidence that short-term hormonal measurements have a significant correlation with the gland size. There was no difference between patients and controls regarding ADC values, nor correlation with hormonal status. Apparently, although cell structure modifications in the adrenal glands in patients with CAH are described, it was not detectable by DWI. Intraobserver reliability was strong regarding both volume and ADC measurements, with intraclass correlation coefficients >0.90 for all parameters, supporting feasibility and reproducibility of performing ADC measurements of the adrenal glands. In our series of young CAH patients, none of the adrenal glands had nodules identified on imaging. The shorter lifetime exposure to the high ACTH concentrations could be accounted for those negative findings.

 

Nothing to Disclose: PCLE, SRT, AFM, JE Jr.

21187 2.0000 THR-403 A Quantitative and Functional Magnetic Resonance Imaging in Evaluation of Adrenal Glands in Children and Young Adults with Congenital Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Lisal J Folsom*1 and Amale A Lteif2
1Riley Hospital for Children/Indiana University, Indianapolis, IN, 2Richard L Roudebush Veterans Administration Medical Center, Indianapolis, IN

 

Background:  Nonclassic congenital adrenal hyperplasia (CAH) most often presents in children with signs of hyperandrogenism and accelerated growth, however in adulthood it may present with adrenal and testicular nodules.

Clinical case:  A 63 year-old man presented for evaluation of a left adrenal nodule discovered incidentally on CT/PET scan performed to evaluate asymmetrical tonsils.  CT/PET scan revealed a large left adrenal mass.  Abdominal MRI revealed a 7 x 3 cm left adrenal mass, isointense on T1 and T2 with minimal dropout, as well as nodular thickening of the right adrenal gland.  Hormonal evaluation revealed normal aldosterone, renin activity, and plasma metanephrine levels, and an appropriate cortisol suppression with dexamethasone.  Due to mass size, left adrenalectomy was performed.  Pathology was read as adrenocortical cells interspersed with lymphocytes and hematolymphoid tissue with rare mitotic figures, with some extra capsular extension.  Using Weiss criteria for malignancy the lesion scored 3 out of 9, indicating a potential for malignancy.  The patient’s oncologist diagnosed low grade adrenocortical carcinoma and adjuvant therapy with mitotane was initiated.  Four months after beginning mitotane repeat PET/CT revealed increased nodularity and metabolic activity in the right adrenal gland and a hypermetabolic right testicular lesion.  Right orchiectomy was performed revealing two lesions with histology similar to the previously resected adrenal gland neoplasm.  Upon further consultation at a more specialized center, a review of the pathology slides from the adrenal gland and testis was consistent with adrenal hyperplasia rather than neoplasia, and adrenal rest tumors in the testis.  Additional history revealed the patient had early puberty and his sister was born with ambiguous genitalia.  Of note, 17-hydroxyprogesterone levels were elevated during monitoring of mitotane therapy, as high as 2515 ng/dL.  Based on this information he was diagnosed with nonclassic CAH with testicular adrenal rest tumors, rather than adrenocortical carcinoma.

Conclusion:  This is a rare case of nonclassic CAH diagnosed in the 7th decade of life, after initially being identified as adrenocortical carcinoma with testicular metastasis.  There are reports of bilateral adrenal myelolipomas mimicking adrenocortical carcinoma in CAH, however this is the first report of adrenal hyperplasia with testicular rest tumors originally presenting as an adrenal incidentaloma, then treated initially as adrenocortical carcinoma with testicular metastasis.   It emphasizes the need for an in-depth clinical evaluation of adrenal incidentalomas, especially in the presence of bilateral adrenal involvement, history of precocious puberty, or concerning family history.  This also highlights the need for a highly experienced pathologist to differentiate adrenal neoplasia from hyperplasia.

 

Nothing to Disclose: LJF, AAL

19235 3.0000 THR-404 A Nonclassic Congenital Adrenal Hyperplasia Masquerading As Metastatic Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Lynn Ang*, Richard J. Auchus, Thomas J Giordano, Adnan Ajmal and Craig Alan Jaffe
University of Michigan, Ann Arbor, MI

 

Background: CAH is a group of autosomal recessive disorders resulting from deficiency of one of five enzymes required for adrenal steroid synthesis, the most common being 21-hydroxylase deficiency. Prior to newborn screening, the diagnosis of incomplete CAH was often delayed or missed, especially in males. We report a case of CAH presenting in adulthood as an adrenal mass misdiagnosed as adrenal cancer.

Case: A 64 year old man was referred to our institution for a second opinion regarding metastatic adrenocortical cancer (ACC). PET/CT done for suspected right tonsillar malignancy demonstrated bilateral adrenal enlargement with a discrete 6.9 cm left adrenal mass. Adrenal cancer was suspected and laparoscopic left adrenalectomy was performed. Pathology was interpreted as having features of ACC and he was treated for low-grade ACC with mitotane. Follow-up PET/CT showed increased metabolic activity in the right testicle and he underwent right orchiectomy. Pathology showed two small, yet distinct masses, which were initially interpreted as metastatic ACC. He had no electrolyte abnormalities and DHEA-S and testosterone were normal. At our institution, we noted short stature and normal virilization; his skin was diffusely tanned. Of his 4 siblings, 3 also had short stature, including a sister, who was born with ambiguous genitalia. Review of the adrenal and testicular pathology revealed identical adrenocortical masses with focal pigmentation. The masses lacked the usual features associated with malignant behavior, i.e. invasion, mitotic activity and necrosis. Foci of myelolipoma and tight collections of lymphocytes were also present in the left adrenal mass. Mitotane was discontinued, and laboratory testing 4 months later demonstrated markedly elevated ACTH (1,415 pg/ml) and 17-hydroxyprogesterone (17OHP) (4,530 ng/dl), low cortisol (2.3 mg/dl) and 11-deoxycortisol (50 ng/dL), and normal 17-hydroxypregenolone (67ng/dL).

Conclusion: This case illustrates the clinical spectrum of CAH in men. Our patient has a less severe form of classic 21-hydroxylase deficiency, which was not diagnosed for 64 years. The case also shows how occult CAH can present as a discreet adrenal mass and be misdiagnosed as ACC. Whereas CAH is expected to cause bilateral adrenocortical hyperplasia, bilateral ACC is very rare. PET-positive testicular adrenal rest tumor tumors (TARTs) are common in CAH, whereas testicular metastasis from ACC has not been reported. ACC often have multiple enzyme deficiencies and elevation of several adrenal steroids, such as 11-deoxycortisol. In contrast, steroid elevation in CAH generally is more limited to the steroid preceding the enzyme block, such as 17OHP. Finally, histopathology can differentiate ACC and CAH-associated adrenocortical hyperplasia with TART.

 

Disclosure: RJA: Consultant, Corcept, Investigator, Novartis Pharmaceuticals, Investigator, Quest Diagnostics, Advisory Group Member, Laboratory Corporation of America. TJG: Clinical Advisory Board member, Asuragen, Consultant, Interpace Diagnostics. Nothing to Disclose: LA, AA, CAJ

20482 4.0000 THR-405 A An Unusual Presentation of Congenital Adrenal Hyperplasia (CAH) with Testicular Adrenal Rest Tumor (TART) Interpreted As Metastatic Adrenocortical Carcinoma (ACC) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Ashwini Mallappa*1, Nilo A Avila2, Suzanne Collier3, Adam Gonzalez4 and Deborah P. Merke5
1National Institutes of Health Clinical Center, Bethesda, MD, 2Radiology Service, Washington D. C. Veterans Affairs Medical Center, Cardiovascular and Pulmonary Branch, NHLBI, NIH, Washington, D.C., DC, 3National Institutues of Health, Clinical Center, Bethesda, MD, 4National Institutes of Health, Clinical Center, Bethesda, MD, 5National Institutes of Health, Bethesda, MD

 

Background: Congenital Adrenal Hyperplasia (CAH) due to 21-hydroxylase deficiency is characterized by cortisol and aldosterone deficiency and androgen excess. A common complication in males with classic CAH is the development of benign testicular tumors called testicular adrenal rest tissue (TART), and referred so due to their morphological and functional resemblance with adrenal tissue. Although not malignant, longstanding TART can cause irreversible damage to the surrounding testicular tissue and result in infertility. TART may be confused with malignancies if the diagnosis of CAH is not considered and this may lead to unnecessary biopsy or orchiectomy. Much is unknown regarding age of onset and clinical course of TART.

Objective: Evaluate age of onset and longitudinally follow TART characteristics.

Materials and Methods: Scrotal ultrasound (US) images of males with CAH due to 21- hydroxylase deficiency were retrospectively reviewed.  For patients with TART, the number, location, and echogenicity of the lesions were evaluated.  Changes in echogenicity and patterns of growth were documented over time.

Results: 101 males (age range:  1 - 66, mean ± S.D:  17.7 ± 13.7 years; classic CAH: 87; non-classic CAH: 14) were studied.  Thirty-four (34%) patients with classic CAH had TART. TART was not detected in non-classic CAH males. Of those with TART, 15/34 (44%) exhibited TART at baseline and 19/34 (56%) developed TART during the course of follow-up. 

In those who developed TART, serial imaging (duration of follow up (mean ± S.D)): 6.2 ± 3.2 years) showed that TART was stable in 2/19 (10.5%), increased in 9/19 (47.6%), decreased in 3/19 (15.8%) and resolved in 5/19 (26.3%) patients. The age of detection (mean ± S.D): 12.9 ± 3.1 years. At initial appearance, the lesions were bilateral in 24/34 (71%) of patients, with 5 more patients developing bilateral masses during follow-up. At initial appearance, the lesions were hypoechoic in 30/34 (88%) and heterogeneous in 4/34 (12%) patients.

Conclusions: TART is commonly seen in males with classic CAH. The initial detection of TART is typically during adolescence; about one-half exhibit an increase in TART size over time and one-quarter become undetectable by US.   In most patients, the lesions are bilateral and hypoechoic. Future studies are ongoing regarding possible hormonal correlations with TART development.

 

Disclosure: DPM: Principal Investigator, Diurnal, Principal Investigator, Medtronic Minimed. Nothing to Disclose: AM, NAA, SC, AG

19885 5.0000 THR-406 A Onset and Natural History of Testicular Adrenal Rest Tissue in a Large Cohort of Patients with Congenital Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Aikaterini A. Nella*1, Ashwini Mallappa1, Verena Gounden1, Ashley F. Perritt1, Lori-Ann Daley1, Steven J. Soldin2 and Deborah P. Merke1
1National Institutes of Health, Bethesda, MD, 2Georgetown University, Bethesda, MD

 

Background: Treatment of classic congenital adrenal hyperplasia (CAH) aims to replace cortisol and aldosterone and prevent ACTH-driven androgen excess. Conventional oral glucocorticoid treatment often fails to effectively suppress adrenal androgen production without supraphysiologic doses. Continuous subcutaneous hydrocortisone infusion (CSHI) is a promising alternative treatment that aims to mimic physiologic cortisol secretion. We report here data on 5 patients who received 6 months of CSHI.  

Methods: We are conducting a phase I-II clinical trial assessing the safety and tolerability of 6-month CSHI in adults with difficult-to-treat classic CAH due to 21-hydroxylase deficiency, and hypothesize that near-physiologic cortisol replacement via CSHI will improve CAH control compared to conventional glucocorticoid therapy. To date, we have recruited 8/8 subjects, and 5 (3 women) have completed the study. Difficult-to-treat was defined as the coexistence of hyperandrogenism (7 a.m. 17-OHP > 1200 ng/dL or androstenedione > 210 ng/dL), hypercortisolism (treatment with supraphysiologic glucocorticoid), and one or more glucocorticoid-related comorbidities.  Patients were admitted to the National Institutes of Health (NIH) Clinical Center and underwent serial sampling at baseline, and at 2, 4 and 6 months of CSHI. Infusion dose adjustments were based on cortisol levels. Primary endpoint was the percent of patients with 17-OHP ≤ 1,200 ng/dL at 7 a.m. Secondary endpoints included changes in androstenedione, testosterone, ACTH, HOMA-IR, weight, BMI, AST/ALT, bone mineral density, total lean and fat mass (by DXA), fatigue and quality-of-life (QOL).

Results: All patients tolerated CSHI well, with minor local skin reactions reported. Cortisol pharmacokinetic profiles approximated physiologic cortisol secretion. At 6 months, 17-OHP levels were 2 to 6 times lower than baseline in all but one patient (who was non-compliant); however only one patient achieved 7 a.m. 17-OHP ≤ 1,200 ng/dL. CSHI glucocorticoid dose was similar or lower than conventional therapy in all but one patient who had high cortisol clearance. Compared to baseline, ACTH decreased (549 ± 149 vs. 170 ± 74 pg/mL, p = 0.023) and lean mass increased (63.2 ± 4.5 vs. 67.1 ± 5.19 kg, p = 0.024) at 6 months. QOL and fatigue improved, but failed to reach statistical significance.

Conclusions: CSHI is a safe and well-tolerated therapy. CSHI, when approximating physiologic cortisol secretion, effectively suppresses adrenal androgens in difficult-to-treat classic CAH patients at doses similar to or lower than conventional therapy. Long-term outcomes need to be determined.

 

Disclosure: DPM: Principal Investigator, Diurnal, Principal Investigator, Medtronic Minimed. Nothing to Disclose: AAN, AM, VG, AFP, LAD, SJS

20171 6.0000 THR-407 A A Pilot Study Assessing the Use of Continuous Subcutaneous Hydrocortisone Infusion in the Treatment of Difficult-to-Treat Classic Congenital Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Soamsiri Niwattisaiwong*1, Ula Abed Alwahab1, Leann Olansky1 and Kevin M Pantalone2
1Cleveland Clinic Foundation, Cleveland, OH, 2Cleveland Clinic, Cleveland, OH

 

Background

Classic 21-hydroxylase deficiency (21OHD) typically presents with salt-wasting crisis in childhood and requires treatment with glucocorticoids (GC) and mineralocorticoids (MC). Unlike children, many adults with 21OHD maintain relatively normal blood pressure and functional capacity without treatment.

Clinical cases

Case 1: A 24-year-old man with classic 21OHD presented to adult endocrinology clinic for reestablishing care. He was diagnosed with CAH at 3 weeks of age. He stopped taking GC and MC for a year prior to presentation. He felt well with normal blood pressure and electrolytes. His laboratory values were as follows: 17-hydroxyprogesterone (OHP) 12,781 ng/dL (normal 40-180), 2 PM cortisol 2.5 μg/dL (0.9-15.8), 2 PM ACTH 38 pg/mL (8-42), DHEAS 265 μg/dL (49-438), and testosterone 279 ng/dL (220-1000). 

Case 2: A 20-year-old man with classic 21OHD diagnosed in neonatal period was referred to endocrinology for pre-operative evaluation prior to ventriculomyotomy. He stopped taking GC and MC at age 12. He was doing well without treatment.  His ACTH was 254 pg/mL. His 11 AM cortisol and OHP were 6.4 μg/dL and 49,650 ng/mL respectively. Sixty minutes after 0.25 mg ACTH IM, his cortisol and OHP were 6.9 μg/dL and 52,580 ng/mL.

Clinical lessons

These 2 cases illustrate clinical presentation of adult classic 21OHD. Case 1 reveals unique biochemical profiles of adult classic 21OHD. Despite markedly elevated OHP seen in classic 21OHD, his DHEAS was normal. This phenomenon can be seen even in patients with poorly controlled classical 21OHD, making DHEAS levels unreliable for disease monitoring. Such observation might be explained by an increased activity of the backdoor pathway in the adrenal steroidogenesis. OHP can be converted to DHT via the backdoor pathway that bypasses the intermediates DHEA and testosterone (1). 

Both patients were relatively well off steroids. Chronic ACTH elevation in poorly controlled 21OHD may eventually lead to adrenal hyperplasia. Hypertrophic adrenal tissue may contain enough residual 21-hydroxylase activity to produce cortisol for non-stress conditions. However, risk of adrenal crisis during serious illness remains, as evidenced by failure to increase cortisol level after ACTH stimulation in case 2. Patients with 21OHD can sometimes regain their ability to retain salt. This may be due to an increased dietary sodium, increased MC sensitivity or increased activity of other enzymes that can 21-hydroxylate progesterone into aldosterone.

Conclusion

Children with classic 21OHD require GC and MC replacement to prevent adrenal crisis, while adult patients may survive without such replacement. However, GC is still required during periods of stress. Lack of continuity in transition from pediatric to adult endocrinology care put these patients at risk of infertility and adrenal crisis. Patient education and a solid transition plan should be emphasized.

 

Nothing to Disclose: SN, UAA, LO, KMP

18835 7.0000 THR-408 A Clinical Presentation and Biochemical Characteristics of the Adult with Classic Congenital Adrenal Hyperplasia: How They Differ from Pediatric Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Alan Sacerdote*1, Taiga Inoue2, George Ezeji2, Annpia Baby2 and Gul Bahtiyar3
1SUNY Downstate Medical Center, Brooklyn, NY, 2Woodhull Medical & Mental Health Center, Brooklyn, NY, 3NYU School of Medicine, New York, NY, New York, NY

 

Background: Interventions that are effective in treating  PCOS are often effective in treating CAH. Both Vitamin D replacement and HMGCoA inhibitors (statins) have been reported to be effective in treating PCOS, while we have reported that ergocalciferol is effective in treating patients with both classical and non-classic 11-hydroxylase deficiency. Use of these agents in treating non-classic 21-hydroxylase deficiency has not been previously reported, with the exception of one previous report in 4 women with non-classic 21-hydroylase deficiency treated with simvastatin only.

Clinical case: A 56 year old woman presented with complaints of hirsutism, male pattern alopecia, and acne; reproductive history was normal. Physical examination was remarkable for the above as well as for acanthosis nigricans in the axillae, neck, and  groin. Investigation revealed  a serum 17-OH-progesterone (17OHP) concentration by liquid chromatography/ tandem mass spectrometry (LC/MS/MS) of 46 ng/dl (<45) and a baseline serum 25-OH-Vitamin D (25OHD) concentration by immunoextraction of 15 ng/dl (30-100). LDL cholesterol by calculation was 171.0 mg/dl (<100).  Treatment was commenced with ergocalciferol  50,000 IU every 2 weeks and simvastatin 10 mg daily at bedtime. Thirteen months later 17-OHP was 27 ng/dl; 25OHD was 37 ng/dl. LDL fell to 157.4 mg/dl. There were no new acne lesions, alopecia had resolved, and hirsutism had diminished.

Conclusion:  This is the 5th patient reported whose non-classic 21-hydroxylase deficiency improved with simvastatin and the first patient with this disorder who responded to  Vitamin D replacement. Further studies may confirm that this combination is an effective treatment for patients with non-classic 21-hydroxylase deficiency with hypercholesterolemia and Vitamin D deficiency. Our findings are consistent with our earlier reports showing that reduction of insulin levels is associated with improvement in CAH parameters.

 

Nothing to Disclose: AS, TI, GE, AB, GB

18442 8.0000 THR-409 A Effect of Ergocalciferol and Simvastatin on a Post-Menopausal Patient with Non-Classic 21-Hydroxylase Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Maria Laarni Subang*1, Sarada Jaimungal2, Myrto Eliades3 and Elizabeth A. Streeten1
1University of Maryland Medical Center, Baltimore, MD, 2University of Maryland, Baltimore, MD, 3University of Maryland School of Medicine, Baltimore, MD

 

OCCULT CLASSICAL CAH IN AN ADULT PRESENTING AS A GIANT ADRENAL MYELOLIPOMA: CASE REPORT AND REVIEW OF THE LITERATURE

Background:  Classical congenital adrenal hyperplasia (CAH) occurs in 1:15,000 live births, usually diagnosed in infancy. Rarely, CAH presents in adulthood with pain from adrenal myelolipomas that develop from chronic ACTH stimulation. Here we report such a case and review similar cases in the literature.

Clinical Case: A 39yo man presented with a 4-day history of abdominal pain, nausea and vomiting. He  also noticed increasing abdominal girth over one year. Abdominal CT revealed 20 x15 x 27 cm left and 4 x 2.2 x 5.5 cm right adrenal masses, consistent with myelolipomas. His pre-operative workup showed: normal plasma free metanephrines, aldosterone 2 ng/ml (nl 3- 35), plasma renin activity (PRA) 19.99 ng/ml/hr (nl 0.65- 5 ), normal 1mg overnight dexamethasone suppression test and   24 hr urine free cortisol.

At surgery, a 1900g left adrenal mass was removed; on pathology, an adrenal myelolipoma. Immediately after surgery, he became hypotensive, hyperkalemic and hyponatremic; all improved after receiving IV hydrocortisone.  He was discharged on hospital day 7 on prednisone.

The patient was seen in Endocrine Clinic one week after discharge. Additional history of scrotal surgery at age 5 and a sister with CAH were obtained. Physical exam revealed bronzed skin, a 1.5 x 0.5 cm soft left scrotal mass, surgically absent right testicle, normal phallus and male hair pattern. Laboratory studies off prednisone showed: AM cortisol 2.52 mcg/dl, 17-hydroxyprogesterone 3487 ng/dl (normal 0-220), ACTH 1102 pg/ml (normal 7-50), aldosterone 4ng/dl, PRA 51.4 ng/ml/hr. Testosterone, FSH and LH were all low. Results were consistent with glucocorticoid and mineralocorticoid deficiency and central hypogonadism due to adrenal androgen excess, all consistent with classical CAH. His massive adrenal hypertrophy compensated for his adrenal insufficiency but then decompensated after his left adrenal was removed. He was started on hydrocortisone and fludrocortisone.

On literature review, we found 22 cases of CAH associated with giant myelolipomas (> 8cm), 77% due to 21-OH-lase deficiency. Similar to our case, 10 were newly diagnosed with CAH after resection of an adrenal myelolipoma.  Of these 10 cases, 4 were male , 6 were female, mean age was 54.7 + 13.1 years, half  were bilateral, tumor size range 5-34 cm with the largest tumor measuring 34 x 24 x10.5 cm.

Conclusion: Classical CAH can present atypically in adults with pain from a large adrenal myelolipoma, with adrenal insufficiency symptoms developing only following surgical resection of adrenal masses.

 

Nothing to Disclose: MLS, SJ, ME, EAS

20929 9.0000 THR-410 A Occult Classical Congenital Adrenal Hyperplasia in an Adult Presenting As a Giant Adrenal Myelolipoma: Case Report and Review of the Literature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Mariana Telles-Silveira*1, Felícia Knobloch2, Carolina C. P. S. Janovsky1 and Claudio E. Kater3
1Federal Univesity of São Paulo, São Paulo, SP, Brazil, 2Catholic University of São Paulo, São Paulo, SP, Brazil, 3Federal University of São Paulo, São Paulo, SP, Brazil

 

Background: CAH due to 21-hydroxylase deficiency (21OHD) is a common disorder of sex development (DSD), resulting in ambiguous external genitalia in the female. Delayed diagnosis and treatment, prompt perinatal adrenal androgen exposure to accelerate growth velocity and develop premature male sex characteristics, including male behavior, mood and sexual orientation, and a gender-identity disorder in the female. Aim: Discuss a case of gender dysphoria in an elderly patient, raising the pros and cons of performing corrective surgery later in life. Clinical case: A 62yo 46,XX DSD patient, was registered and reared as a girl in a rural area in Brazil. Diagnosis of CAH was only established at age 10y and hormonal treatment began in an endocrine reference center. However, replacement therapy was discontinued on several occasions and, due to poor compliance, subtotal adrenalectomy was performed at age 17y. Without proper psychological management, gender dysphoria became evident. Pretending to be and secretly living for years as a male (but no ID and no fix job or residence) in different cities, at the age of 59y he decided to apply for a legitimate male ID; 3 years later, the patient unexpectedly requested for a genital sex-reassignment surgery. Although being male-sex oriented, he has never had any sexual experience. This request was reasoned, in his own words, as: “When I die, in my funeral, I’m afraid they will know who I am!” Since no other reasons were pondered, the risks of surgery and the possibility of an unsuccessful outcome (including chances of suicide) were openly discussed with the patient and family. Decision was then reached to postpone surgery and start a centered analytical therapy. This allowed the group to evaluate the real wish for surgery, as well as to care for the issue of existence itself. Along the process, surgery was ultimately disregarded by the patient. Conclusion: Only when the wish for a corrective surgery, justified on an odd reasoning was brought up to the doctors, the role of death urged the group to rethink the course of treatment. During the psychological process, it became clear that the patient’s will for reassignment surgery, more than a wish for simply changing the genitalia, expressed a momentum when his issues had to do with endorsement and acceptance of his male identity by the society. This case report brings interesting questions about sexuality in a social context, independently of the sexual act; it also surfaces the idea that sexuality is much broader than sex and opens new questions about the psychological risks that one faces when considering a body change after living for so many years with a DSD.

 

Nothing to Disclose: MT, FK, CCPSJ, CEK

19782 10.0000 THR-411 A Gender Dysphoria in an Elderly Mismanaged Patient with Congenital Adrenal Hyperplasia (CAH) - a Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Rafaela Fontenele*, Marivania da Costa Santos and Claudio E. Kater
Federal University of São Paulo, São Paulo, SP, Brazil

 

BACKGROUND: 17-alpha hydroxylase deficiency is the second most prevalent form of congenital adrenal hyperplasia in Brazil; its clinical hallmarks are mineralocorticoid hypertension (htn) and hypergonadotropic hypogonadism, usually diagnosed around puberty. AIM: 10y after reporting data from a Brazilian cohort of 24 patients (pts), we present follow-up (FU) data of 18 and add another 16 from 11 new families. The remaining 6 pts were lost to FU but their data computed where appropriate. PATIENTS/METHODS: 34 pts with a proven diagnosis (dx) of 17OHD from distinct centers (18XY/16XX, 16-55y; 26 index cases) had physical, psychological, hormonal, and genetic data gathered, revised and updated from charts and/or personal consultations. RESULTS: At dx, median chronological and bone age were 17y and 11y; 71% were Tanner-I and 2 had spontaneous menarche; 75% had an increased span:height ratio. Current height and span are 169.7±6.4 and 173.4±10.6cm, respectively. Of note, 2/3 of the pts was previously misdiagnosed as gonadal dysgenesis/androgen resistance (31%), essential htn (26%), or idiopathic primary amenorrhea (12%). The most frequent CYP17A1 mutations were W406R (36%), R362C (29%), Y329D (10%), and P428L (8%), totaling 83% of the 68 alleles (71% in homozygosis). Spanish, Portuguese, and Italian ancestries were reported in 23%, 15%, and 8%, respectively, and consanguinity in 33% of parents. At dx, 95% and 92% of the pts had htn and hypokalemia, respectively; normal blood pressure and normokalemia were achieved in >90% within 2y of glucocorticoid therapy, but only with additional anti-hypertensive therapy in half of them. At present, 5/31 pts have had strokes (with 2 deaths), 2 are in renal failure and 4 remain hypertensive on treatment. Echocardiogram was normal in 52%, but 28% had mild LV hypertrophy and 13%, tricuspid reflux. Except for one pt with a mild ambiguous genitalia, all others were phenotypically and socially female. In spite of estrogen therapy years before dx of 17OHD, 38% of pts still have osteopenia and 35%, osteoporosis. Regarding psychological and sexual data, 9 of 26 pts referred active sexual life (4 are married); libido is present in 58%, and sporadic orgasms in 46%; 39% complains of dyspareunia. Besides estrogen replacement, low-dose androgen therapy was attempted in 3 pts to improve libido, sex hair and well-being and was effective in 2. DISCUSSION: A cohort of 34 pts followed for >10y pose several questions and difficulties, especially regarding: 1) control of htn and prevention of renal and cardiovascular damage, 2) psychological and sex consequences of late and poorly treated hypogonadism, including inability to get pregnant, 3) reaching a tall/eunuchoid stature. Medical management includes adequate glucocorticoid replacement, estrogen (+ progestogen for XX) and occasionally androgen treatment, and individualized therapy for hypertension and osteopenia/porosis.

 

Nothing to Disclose: RF, MDCS, CEK

20030 11.0000 THR-412 A Long-Term Experience with a Large Brazilian Cohort of Patients with 17-Alpha Hydroxylase Deficiency (17OHD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Ariella Genny Barhen*, Ahmed M Khattab, Mabel Yau and Maria I New
Icahn School of Medicine at Mount Sinai, New York, NY

 

Background: Steroid 17-hydroxylase deficiency is a rare form of congenital adrenal hyperplasia (CAH) most commonly identified by genital ambiguity in 46XY males. We present the follow-up of two 46 XX female patients with 17-hydroxylase deficiency diagnosed in adolescence. They presented with hypertension and delayed puberty with infantile genitalia. They have been studied with sequential hormone evaluations as well as molecular genetic analyses confirming the diagnosis of 17-hydroxylase deficiency. The patients were treated with hydrocortisone and estrogen replacement and remained on this treatment regimen until the present. Progesterone administration induced uterine bleeding. One patient is 43 years old, while the other is 27 years of age. Neither patients have been pregnant.

Case follow-up: The first patient diagnosed with CAH owing to 17-hydroxylase deficiency at 15 years old by Dr. Edward Biglieri, the discoverer of 17-hydroxylase deficiency. Gene sequencing of the CYP17 gene showed the genotype of a compound heterozygote with mutations in Exon 2 and Exon 8. She is now 43 year old. She continues to be mildly hypertensive (142/94 mm Hg) requiring treatment with amlodipine. There is no evidence of hypertensive end organ damage. The major abnormal outcome is osteopenia despite chronic estrogen therapy.

A second patient diagnosed at 14 years old is now 27 years old. Gene sequencing of the CYP17 gene showed that she is heterozygous for an exon 6 mutation and gene deletion. She has always been normotensive (124/87 mm Hg) without antihypertensive treatment. In contrast to the older patient, the bone mineral density is normal.

Conclusions: These two 46XX females with similar presentations have a different history and different outcomes. Early osteopenia was noted in the older patient despite estrogen replacement. The younger patient should be followed for potential development of osteopenia.

 

Nothing to Disclose: AGB, AMK, MY, MIN

21104 12.0000 THR-413 A The Long Range Follow up of Two 46XX Females with 17-Hydroxylase Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Nilufer Ozdemir Kutbay*1, Banu Sarer Yurekli1, Ilgin Yildirim Simsir1, Emine Kartal1, Gokcen Unal Kocabas1, Huseyin Okan1, Mehmet Erdogan2, Sevki Cetinkalp3, Fusun Saygili4 and Ahmet Gokhan Ozgen1
1Ege University Faculty of Medicine, Izmir, Turkey, 2Ege University Hospital, 3Ege University Faculty of Medicine, Izmir, 4Ege University School of Medicine, Izmir, Turkey

 

A Novel Mutation in Deficiency of 11β-Hydroxylase: An Association with Severity of the Disease?

Deficiency of 21-hydroxylase (CYP21) is the most common cause of CAH which  corresponds to more than 90% of all cases; it is followed in frequency by 11βOHD, reported in between 3 and 5% of the cases. Congenital adrenal hyperplasia (CAH) is an autosomal recessive disorder caused by the loss of one of five steroidogenic enzymes affecting cortisol synthesis. 11β-hydroxylase gene is located in 8q21-q22 chromosome. In Deficiency of 11 β- hydroxylase, 11-Deoxycortisol cannot be converted to cortisol and Deoxycorticosterone cannot be converted to corticosterone. In the classical form of 11βOHD, hypertension in both sexes, ambiguous genitalia in women and increased penile length with normal external genitale and gynecomastia in men is detected. We present our 11βOHD case whom we follow due to medical-treatment resistant hypopotasemia and hypertension and in whom we have found a novel mutation.

CASE

A 20-year-old male patient who had been on steroid replacement treatment for adrenal insufficiency for 18 years applied to our ER department with spasm, dyspnea and syncopal attacks. His potassium level was 1.4 meq/L so potassium infusion treatment was started. The patient history revealed a surgery due to ileus. Laboratory results: AST:358U/L ALT: 163U/L CK:12740 U/L CKBM:117U/L creatinine:0.81 mg/dl Na:149 meq/L K:1.4 meq/L  myoglobin>3000 ng/ml   ACTH:16.6 cortisol:5.14 µg/dL  fT3: 2.15 pg/mL fT4: 1.40 ng/dL TSH:1.51 µIU/ml  Total Testosterone:3.44 ng/mL  Free Testosterone: 23.1 pg/mL DHEAS: 114.9 µg/dL. 17-OH-PG: 9.4 ng/mL. 11βOHD related CAH was suspected as the patient had adrenal insufficiency, hypertension and hypokalemia. Aldactone treatment was started to the patient who had resistant hypokalemia despite potassium infusion. Potassium levels were back to normal in the follow-up. Hypokalemia-related rhabdomyolysis regressed. The steroid dose was reduced to physiological replacement level. MRI showed that adrenal cruris was longer and thicker than in normal view. In the genetic examination of the patient, “pAla199pro and pArg448his compound heterozygous mutation” was detected in CYP11B1 whole genome sequencing analysis.

RESULTS

In CYP11B1 whole genome sequencing analysis, pAla199pro and pArg448his compound heterozygous mutation was detected. pArg448his mutation was previously defined in the database and associated with the disease; however, pAla199pro mutation was never defined before. The analysis conducted with modeling programs indicates that pAla199pro mutation could disrupt protein functioning and “splicing”. Thus, these two compound heterozygous mutations were thought to be associated with the severity of the disease.

 

Nothing to Disclose: NO, BS, IY, EK, GU, HO, ME, SC, FS, AGO

19001 13.0000 THR-414 A A Novel Mutation in Deficiency of 11β-Hydroxylase: An Association with Severity of the Disease? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Esther Dono1, Taiga Inoue1, George Ezeji1, Annpia Baby1, Gul Bahtiyar2 and Alan Scott Sacerdote*3
1Woodhull Medical & Mental Health Center, Brooklyn, NY, 2SUNY Downstate Medical Center, Brooklyn, NY, 3NYU School of Medicine, New York, NY

 

Background: We have previously reported that weight loss (WL) resulted in amelioration of non-classic aldosterone synthase deficiency and that vitamin D replacement in patients with both classic and non-classic 11-hydroxylase deficiency, who were vitamin D deficient/insufficient, normalized their biochemical profiles.

Clinical Case: A 44 year old woman presented with chief complaints of infertility, irregular menses, and male pattern scalp hair loss. Investigation revealed a serum 11- deoxycortisol concentration by RIA after extraction and chromatography of 68 ng/dl (<62), which suppressed to reference range after 1 mg dexamethasone. Serum 25-OH-vitamin D (25OHD) by immunoextraction was 14 ng/dl (30-100). She weighed 63.5 kg and her BMI was 22.5 kg/m2. Treatment was commenced with ergocalciferol 50,000 IU weekly and the patient was prescribed metformin 500 mg daily after supper, but she never took the latter. When she returned 7 months later her weight had fallen to 61.2 kg, BMI to 21.68 kg/m2, and her serum 11-deoxycortisol to 19 ng/dl; serum 25OHD had risen to 28 ng/dl. Her male pattern hair loss had resolved and her menses were normalized.

Conclusions: Weight loss may be effective in treating non-classic 11-hydroxylase deficiency as it is in non-classic aldosterone synthase deficiency by improving insulin resistance (hyperinsulinemia). Ergocalciferol may work by the same mechanism and in addition, the presence of vitamin D receptors in the adrenal cortex suggests the possibility of a direct effect of vitamin D on adrenal steroidogenesis.

 

Nothing to Disclose: ED, TI, GE, AB, GB, ASS

18409 14.0000 THR-415 A Amelioration of Non-Classic 11-Hydroxylase Deficiency in a Vitamin D Deficient Patient with Weight Loss and Ergocalciferol 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Annpia Baby1, Taiga Inoue1, George Ezeji1, Judith Giunta2, Gul Bahtiyar2 and Alan Scott Sacerdote*3
1Woodhull Medical & Mental Health Center, Brooklyn, NY, 2SUNY Downstate Medical Center, Brooklyn, NY, 3NYU School of Medicine, New York, NY

 

Background: We have previously reported that the Ayruvedic herb, Ashwagandha (Withania somnifera) (WS), which is known to be an insulin sensitizer, is effective in treating both non-classic 3-β-ol-dehydrogenase deficiency, and non-classic aldosterone synthase deficiency. Here we report the effects of its use in a patient with non-classic 11-hydroxylase deficiency.

Clinical Case: A 78-year old woman with a history of hypothyroidism, hypertension and stage III chronic kidney disease presented complaining of acne and alopecia. Investigation revealed a serum 11-deoxycortisol concentration by liquid chromatography/tandem mass spectrometry of 91ng/dl  (<37) on 6/18/2013. Treatment was initiated with a standardized preparation of Ashwagandha root at a dosage of 400 mg twice daily. Repeat serum 11-deoxycortisol concentration on 4/9/2014 was 64ng/dl. The Ashwagandha dose has been raised to 400 mg in the morning and 800 mg in the evening. Biochemical improvement has been accompanied by improvement in acne and hair loss.

Conclusions: Ashwagandha root may be effective in treating some patients with non-classic 11-hydroxylase deficiency, as it is in some patients with non-classic aldosterone synthase deficiency and non-classic 3-β-ol-dehydrogenase deficiency. Reduction in insulin resistance/hyperinsulinemia is likely to be one the underlying mechanisms of this observed treatment effect.

 

Nothing to Disclose: AB, TI, GE, JG, GB, ASS

18454 15.0000 THR-416 A Ashwagandha Root in the Treatment of Non-Classic 11-Hydroxylase Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 402-416 5985 1:00:00 PM Congenital Adrenal Hyperplasia Poster


Shwetha Mallesara Sudhakar*1, Neda Hashemi-Sadraei2, Omar Manlapaz3, Mary Y Yang4 and Jeena Varghese1
1University Of Texas Health Science Center At Houston, Houston, TX, 2University Of Texas Health Science Center At Houston, Houston, 3Univ of Texas Med Sch at Houston, Houston, TX, 4University Of Texas Health Science Center At Houston

 

Introduction: Metastases to the adrenal glands are common in patients with malignancy but malignant disease presenting as Addison’s disease is rare. Herein, we report a case of stage IV metastatic poorly differentiated lung adenocarcinoma with initial presentation of Addison’s disease.

Case presentation:A 61 yo male patient presented with 1 month of lightheadedness, decreased appetite and weight loss. He had no known significant past medical problems, reported tobacco abuse and denied taking any medications. Initial vital signs were significant only for symptomatic orthostatic hypotension. On physical exam he was thin and had areas of hyperpigmentation on his abdomen. Laboratory studies revealed hyponatremia (124 meq/dL) and hyperkalemia (5.4 meq/dL). Further evaluation showed low morning cortisol level of 4.5 mg/dL and inappropriate response to cosyntropin stimulation (4.2 mg/dl).  ACTH was elevated at 474.3 pg/ml. A diagnosis of Addison’s disease was made and treatment with hydrocortisone was started with clinical improvement. A CT of the abdomen showed enlarged bilateral adrenal glands. Abdominal MRI confirmed this finding and showed a pancreatic head mass with local lymph node enlargement. Endoscopic ultrasound-guided biopsy of pancreatic lesion was inconclusive while celiac lymph node biopsy was consistent with metastatic adenocarcinoma. Adrenal biopsy showed poorly differentiated carcinoma, the primary site of which was inconclusive on immunohistochemistry. PET CT revealed multiple FDG avid lesions in the right lung, liver, pancreas, bilateral adrenals, and extensive nodal metastasis in the neck, mediastinum, retro peritoneum and pelvis.However due to the imaging findings, he was thought to have  stage IV  lung cancer and he was started on chemotherapy. His cancer did not respond to chemotherapy and patient is under the care of home hospice.

Conclusion: Adrenal metastases occur in 13-27% of patients with malignancies. However, only 4% of this population develops Addison’s disease. We emphasize clinicians to recognize Addison’s disease as a possible initial manifestation of cancer, to avoid under diagnosis, and guide prompt corticosteroid therapy.

 

Nothing to Disclose: SM, NH, OM, MYY, JV

21490 1.0000 THR-354 A Adrenal Insufficiency Leading to Diagnosis of Metastatic Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Baker Machhadieh*1, Wentao Li2, Yuval Eisenberg3 and Tahira Yasmeen4
1University of Illinois, Chicago, IL, 2UIC College of Medicine, 3University of Illinois at Chicago, Chicago, IL, 4The University of Illinois/Advocate Christ Medical Center

 

Background:

Adrenal hemorrhage is often an under-recognized phenomenon due to the latent phase between the hemorrhagic event and clinical adrenal failure.  Here we describe a case of potentially Rivaroxaban (Xaeralto)-induced clinically relevant bilateral adrenal hemorrhage.

CASE:

A 75 year old man with history of polycythemia vera and hypertension initially presented for abrupt abdominal pain, altered mental status and weakness. He had recently undergone total knee replacement for which he was placed on DVT prophylaxis with Rivaroxaban 10 mg daily.  Abdominal CT performed on presentation showed non-specific bilateral fat stranding around both adrenal glands; however, cortisol level on admission was 48 mcg/dl.

The patient was admitted to medical ICU with differential diagnoses of sepsis, metabolic encephalopathy and questionable bilateral adrenal hemorrhage. He was started on IV hydration, broad spectrum IV antibiotics, and stress doses of hydrocortisone.  Xaeralto was replaced with low molecular weight heparin for DVT prophylaxis.  Patient developed thrombocytopenia during admission with a positive heparin-induced thrombocytopenia (HIT) work up.  Antibiotic therapy was modified to clindamycin and platelet count subsequently normalized.

He showed no further signs of adrenal insufficiency or bleeding and hydrocortisone therapy was terminated.  Patient was discharged with clindamycin and restarted on home medications including Xaeralto. 

Four days after discharge, patient was readmitted to the ICU for management of hypovolemic shock.  He was intubated and placed on IV antibiotics, vasopressors and fondaparinux for DVT prophylaxis.  Despite improvements in mental status, patient was unable to weaned from the ventilator prompting tracheostomy placement.  Post-procedure he again developed hypotension requiring re-initiation of vasopressors.

Cortisol level was measured to be 0.9 mcg/dl and adrenal insufficiency was again considered.  Abdominal CT scan demonstrated interval development of bilateral adrenal nodules suggestive of hematomas.  Patient showed dramatic response to stress doses of IV hydrocortisone and was weaned off all vasopressors by the following morning, thus further confirming the diagnosis of acute adrenal crisis secondary to bilateral adrenal hemorrhage.

Conclusion:

To our knowledge, this is the first case of bilateral adrenal hemorrhage secondary to Rivaroxaban (Xaeralto). Patient initially presented with some evidence of early bleeding on abdominal CT with bilateral fat stranding.  Adrenal insufficiency likely followed thereafter due to exacerbation by the development of HIT during his ICU course.

 

Nothing to Disclose: BM, WL, YE, TY

21958 2.0000 THR-355 A Bilateral Adrenal Hemorrhage Presenting with Delayed Adrenal Crisis in a Patient on Rivaroxaban (Xaeralto) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Anbar Ahmad*1, Mazen Al Mushref2 and Max E. Stachura2
1Georgia Regents University, Augusta, GA, 2Georgia Regents University

 

Objective:  We describe an unusual case of primary adrenal insufficiency (AI) as a manifestation of antiphospholipid syndrome (APS)

Case:  A 29 year old male presented to the ED with right testicular pain and swelling after he sustained an injury at work. Patient underwent scrotal exploration that showed disruption of tunica albuginea and after stabilization he was discharged home with outpatient follow up. A week later he returned to the emergency room with fatigue and abdominal pain. His vital signs were: temperature: 38.1oC, pulse: 84 bmp, blood pressure 125/84 mmHg. Physical exam was significant for diffuse abdominal and left costovertebral angle tenderness. Basic metabolic panel was normal and a complete blood count was consistent with thrombocytopenia, prolonged activated partial thromboplastin time (77 sec; normal, 28-35 sec) which did not correct on a mixing study, positive anticardiolipin antibodies and positive ANA.  CT scan showed right testicular hematoma, bilateral adrenal and left perinephric hemorrhage. Cosyntropin stimulation test revealed a baseline cortisol of 0.8 mcg/dl, 30 min cortisol 1.66 mcg/dl, 60 min cortisol 2.48 mcg/dl. The patient was diagnosed with SLE and along with being treated for lupus therapy with hydrocortisone and fludrocortisone was initiated for primary adrenal insufficiency (AI).

Discussion:  Our patient presented with nonspecific abdominal pain and fatigue without any other symptoms of AI. The patient had recent trauma and surgical intervention which is known to trigger antiphospholipid syndrome (APS). In one review study Espinosa et al were able to determine that in half of the cases of APS, the initial presentation was related to surgical procedure or trauma.  The incidence of AI in the setting of antiphosholipid syndrome is rare. In a series of 201 patients with catastrophic APS, adrenal involvement was found in 3 patients (1% of the cases).   Involvement of adrenal gland in non-catastrophic APS is believed to be much less common (0.04%).  The outcome of patients who survive the acute phase of disease appears to be favorable. AI in these cases is usually irreversible with rare cases of recovery. Morbidity and mortality are usually associated with bleeding events due to anticoagulation use and recurrent DVTs.

Conclusion:   Symptoms of AI can range from mild and non-specific to shock and death.  Primary AI more commonly is an autoimmune process; however, APS is a rare cause of presentation. It is important to suspect the disease in patients with APS even in the absence of full constellation of symptoms given the relatively high prevalence and the grave prognosis associated with unrecognized AI.

 

Nothing to Disclose: AA, MA, MES

20974 3.0000 THR-356 A Bilateral Adrenal Hemorrhage - an Unusual Manifestation of Antiphospholipid Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Rupendra T Shrestha1, M Luiza Caramori2 and Angela Ionela Radulescu*3
1University of Minnesota Medical Center, Minneapolis, MN, 2Univ. of Minnesota, Minneapolis, MN, 3University of Minnesota, Saint Paul, MN

 

Bilateral adrenal infarction without hemorrhage is exceedingly rare, but a well-recognized cause of adrenal insufficiency. The ischemia secondary to venous thrombosis during pregnancy is exceedingly rare cause of adrenal insufficiency.  we present a 30-year-old female with abrupt onset of acute right flank pain and dysuria on the fourth post-partum day following the delivery of a preterm baby at 32 weeks. Her pregnancy was uneventful and reason for preterm labor was unclear. She had spontaneous uncomplicated normal vaginal delivery. Her past medical history was significant for PCOS, Roux-En-Y Gastric Bypass 2 years ago and DM that resolved after the surgery. There was no history of bleeding or clotting disorders in the family. On physical exam, her vital signs were stable and abdominal exam revealed mild tenderness in the right flank. Her labs revealed normal sodium and potassium. Urinalysis did not show any evidence of hematuria. Initial CT scan of the abdomen was obtained without contrast with the concern of renal stone that revealed inflammation and stranding about the adrenal glands bilaterally. The following morning patient was noted to be orthostatic which improved with gentle IV hydration. ACTH stimulation test was normal. She was hydrated and her BP improved. An MRI of the abdomen revealed bilateral adrenal gland stranding with size at the upper limits of normal and no hemorrhage. This was consistent with inflammatory changes surrounding the adrenal glands, nonspecific. Her pain worsened 48 hours later and therefore CT abdomen was repeated with contrast. Repeat CT revealed further enlargement of the right adrenal gland with hypoenhancement consistent with ischemia with thrombosed adrenal vein. A near-complete resolution of inflammatory changes on the left adrenal gland was noted.  A thrombosed hepatic vein was also noted confirmed by Doppler US. She was started on Low molecular weight heparin and Coumadin with marked improvement of the pain. On the day of discharge, she felt dizzy a repeat ACTH stimulation test revealed lack of response to high dose ACTH. She was started on replacement therapy with Hydrocortisone for adrenal insufficiency.  Interestingly, after 3 months an ACTH stimulation test was done that was normal and she was taken off Hydrocortisone. Bilateral adrenal infarction without hemorrhage is exceedingly rare cause of adrenal insufficiency of venous thrombosis during pregnancy could be reversible

 

Nothing to Disclose: RTS, MLC, AIR

21530 4.0000 THR-357 A Reversible Bilateral Adrenal Insufficiency after Ischemic Injury 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Shipra Bansal* and Sheila Perez-Colon
SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY

 

Background: Autoimmune adrenal disease (AAD) is rare in children(1) . Antibody to major auto-antigen, 21-hydroxylase (21OH), is highly specific for AAD and leads to primary adrenal insufficiency (PAI) (2). Its presentation could be isolated or part of Autoimmune Polyglandular Syndrome (APS). Adrenal dysfunction evolves through 4 stage (3):
Stage 1: Increased plasma renin activity (PRA) with normal/low aldosterone
Stage 2: Low cortisol response after i.v. administration of ACTH
Stage 3: Increased ACTH
Stage 4: Low basal cortisol.

Clinical case: 15 day old term male infant was admitted for failure to thrive. Vital signs and exam were normal. Laboratory findings revealed hyponatremia of 110-116mmol/L, hyperkalemia >10mmol/L (non-hemolyzed specimen), elevated PRA 127.06ng/mL/h with a corresponding Aldosterone <1ng/dL. Rest of the adrenal function was wnl [17 OH progesterone 112mcg/dL( 11-170), Deoxycorticosterone 29ng/dL (7-57) and unstimulated cort 8.73mcg/dL] . Hence, he was diagnosed with isolated hypoaldosteronism and started on Fludrocortisone and salt tablets. He was doing well until 1 year of age, when an 8 am Cortisol was <0.2 mcg/dl which warranted an ACTH stimulation test. Cortisol at 30 and 60minutes post-stimulation was <0.2mcg/dL. Unexpectedly, baseline ACTH was extremely elevated 2371pg/mL, repeat 3313pg/mL, suggestive of PAI. Therefore, he was initiated on Hydrocortisone while continuing Fludrocortisone and salt tablets.

Further workup for PAI revealed positive 21OH antibody, with negative adrenal cortex antibody at 1year of age, confirming isolated AAD without features suggestive of APS. Very long chain fatty acids analysis was normal, therefore, Adrenoleukodystrophy, was unlikely. Even though ACTH was elevated, Familial Glucocorticoid deficiency was less likely as patient has initially isolated mineralocorticoid dysfunction with preserved glucocorticoid axis. No clinical evidence of achalasia or alacrima. MRI brain and pituitary did not reveal any abnormality. Although DAX1 mutation is pending at present, MRI adrenal gland revealed normal size glands which make Adrenal hypoplasia congenita unlikely.

Conclusions: We report a 15 day old term male with stage 1 AAD. To our knowledge, this is the first case of autoimmune adrenalitis in the newborn period.

 

Nothing to Disclose: SB, SP

19812 5.0000 THR-358 A Autoimmune Adrenalitis during Newborn Period 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Julia Rodica Broussard*1 and Kristin Johansen2
1Children's Mercy Hospital, Kansas City, MO, 2Children's Mercy Hospital, kansas city, MO

 

Autoimmunity is now the most common cause of primary adrenocortical insufficiency (Addison’s disease), surpassing adrenal tuberculosis[1]. The disease has an insidious onset and there can be a delay in the diagnosis[2,3].  A 6-year-old previously healthy male, referred from an outside hospital for concern of tick borne illness, presented to the emergency room with symptoms of fatigue, headache, decreased appetite, abdominal pain and vomiting. The patient underwent a lumbar puncture and based on results, diagnosed with aseptic meningitis. He was admitted to the hospital and received treatment with doxycycline for the supposed tick-borne illness.  Later, results showed positive IgG antibodies for Ehrlichia chaffeensis and Anaplasma.  During admission, the patient's electrolytes revealed low sodium levels (126 mmol/L), with intermittent normal sodium levels, normal potassium levels, metabolic acidosis. Secondary pancreatitis was also noted (Lipase 1,121 units/L). One month after admission, the patient presented to the endocrine clinic with increased fatigue, decreased appetite, weight loss, salt craving and darkening of the skin.  At this time, the patient had low sodium of 132 mmol/L, high potassium of 5.5mmol/L, non-measurable serum cortisol. A high-dose ACTH stimulation test was performed and cortisol levels were less than 1 mcg/dL at 0, 30 and 60 minutes. Adrenal antibodies were positive with a titer of 1:20 [<1:10]. Serum ACTH was 3,742 pg/mL [9-57], aldosterone < 1 ng/dL, plasma renin activity 24.27 ng/mL/h (high) before treatment initiation. Transitory compensated hypothyroidism was present. Fludrocortisone and hydrocortisone treatment was started.  The patient followed a low-fat diet and had temporary sodium supplementation. On follow up visit, electrolytes had normalized and the patient's symptoms had improved.  At this visit, the patient also had a positive celiac screen with elevated tissue transglutaminase IgA and positive endomysial antibody. It is unclear if this patient was adrenal insufficient at initial presentation but it is possible that the systemic illness due to Ehrlichia and Anaplasma infection may have triggered the autoimmune pathology of his Addison’s disease. Considering the potential detrimental outcomes of missing or delaying the diagnosis of Addison’s disease, ranging from poor growth to circulatory collapse and death, it is critical that clinicians have a high index of suspicion for adrenal insufficiency in the acutely ill patient with non-specific symptoms that do not readily improve after treatment for the acute disease.

 

Nothing to Disclose: JRB, KJ

18529 6.0000 THR-359 A Autoimmune Primary Adrenal Insufficiency Associated with Aseptic Meningitis from Tick-Borne Infection 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Abha Choudhary*
University of Arkansas for Medical Sciences, Little Rock, AR

 

Background

Allgrove syndrome, also known as Triple A syndrome is characterized by achalasia, alacrima and adrenal insufficiency. Severe malnutrition has not been described in the literature in this syndrome.

Clinical Case

An 18 year old male presented at 6 years of age with hypoglycemia with low cortisol at 0.2 ug/dl (4.5- 22.4 ug/dl) and elevated ACTH levels of 1424 pg/ml (normal: 5-46 pg/ml) and was diagnosed with Addison’s disease. Treatment was initiated with hydrocortisone at 10 mg/m2/day. At 10 years of age, he reported absent tears. He also reported vomiting and heart burn which started at 11 years of age. This progressed over the years to the point of severe weight loss. He was thought to be non- adherent with medications since his ACTH levels were elevated and this was attributed as the reason for weight loss. Upon detailed history, he reported that he was scared to eat due to constant vomiting after eating. His weight Z score was -4.8 and the BMI Z score was -6.5. An official diagnosis of alacrima was made at 17 years of age and genetic testing was sent at that time which showed heterozygous mutation c.43 C>A splicing mutation in the AAS gene and a heterozygous c.1144-1147delTCTG mutation in the AAAS gene which are associated with Triple A syndrome. Eventually, he was evaluated by gastroenterology at 17.5 years of age. An upper GI series was done which showed achalasia with high grade obstruction at the gastroenteric junction with no passage of ingested contrast into the stomach in supine position, limited passage in the upright position. There was also a significant superior mesenteric artery impression on the duodenum.  He underwent Heller’s myotomy at 18 years of age which resulted in resolution of vomiting.

Conclusion

Delayed diagnosis of Triple A syndrome led to severe malnutrition to the point of superior mesenteric artery obstruction in a patient initially diagnosed with Addison’s disease.

 

Nothing to Disclose: AC

19396 7.0000 THR-360 A Severe Malnutrition Causing Superior Mesenteric Artery Obstruction Syndrome in an Adolescent with Allgrove Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Neta Loewenthal*1, Ruti Parvari2, Alon Haim3, Judy Tavashi4 and Eli Hershkovitz5
1Pediatric Endocrin Unit Soroka Medical Center and Faculty of Health Saience Bengurion University, Beer sheva, Israel, 2Faculty of Health Sience Ben Gurion University , Beer Sheva ,Israel., 3Pediatric Endocrin Unit Soroka Medical Center and Faculty of Health Saience Bengurion University, Beer-Sheva, Israel, 4Pediatric Endocrin Unit Soroka Medical Center and Faculty of Health Saience Bengurion University, 5Pediatric Endocrinology Unit Soroka Medical Center and Faculty of Health Saience Bengurion University, Beer Sheva, Israel

 

Background:                                                                                            

Phosphoglucomutase type 1(PGM1) deficiency is classified among the  congenital disorders of glycosylation which are genetic multisystem syndromes resulted from abnormal glycolysation and impaired glycoproteins production. Varied range of clinical manifestations recently described  includes hepatopathy, bifid uvula, malignant hyperthermia, hypogonadotropic  hypogonadism, growth retardation, hypoglycemia, myopathy, dilated cardiomyopathy, and cardiac arrest, ACTH deficiency has been reported but this finding is uncommon

Objective and hypothesis:

To report the clinical picture of 7 patients  with PGM 1 deficiency from a consanguineous family presented with ketotic hypoglycemia .

Methods:                                                                                                                   

Medical records of the patients were reviewed for clinical details and  endocrine evaluation. Whole exome sequencing (WES) was performed.

Results:

Seven patients ages between 2-29 are included, one patient died at 13 years old when gets off the school bus. All patients have abnormal palatine structure (cleft palate, bifid ovule),4/7 had short stature (<-2.5SD ) one was diagnosed with growth hormone deficiency. Abnormal liver function was noted in 6/7 patients. Recurrent episodes of ketotic hypoglycemia were present in 6/7 patients.  Hypoglycemic episodes have been spontaneously resolved in 2 of them later in life, while  3/5  patients have deteriorating adrenal function with  abnormally low cortisol and ACTH levels during hypoglycemia and subnormal response of cortisol to low dose ACTH test . Serum electrolytes were within normal range.  Hydrocortisone replacement therapy improved but not entirely eliminated hypoglycemic episodes.Pubertal development appeared normal including the older patient who fathered an affected patient.

WES revealed previously described homozygous mutation c.112A>T, p.Asn38Tyr in the PGM1 gene.

Conclusion:

ACTH deficiency may be a common manifestation in patients with PGM1 deficiency  having recurrent hypoglycemia.

 

Nothing to Disclose: NL, RP, AH, JT, EH

18791 8.0000 THR-361 A Phosphoglucomutase -1 Deficiency Presented As Adrenal Insufficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Kunal Mehta*1, Irene A Weiss2 and Michael D. Goldberg1
1New York Medical College, Valhalla, NY, 2New York Med Colg, Valhalla, NY

 

Introduction:

Megestrol acetate (MA) is a potent activator of the progesterone receptor; the resulting suppression of the hypothalamic-pituitary-gonadal axis underlies its effectiveness for the palliative treatment of advanced breast and endometrial cancers. High doses of MA also have an orexigenic effect, and the agent is approved for the treatment of anorexia or weight loss in patients with AIDS. MA is also an activator of the glucocorticoid receptor (GR), with a binding affinity almost twice that of cortisol. Cases of new-onset or exacerbated diabetes mellitus, as well as frank Cushing’s syndrome, have been reported in patients receiving MA therapy.  Also reported are cases of symptomatic adrenal insufficiency, both after withdrawal of MA therapy, as well as during active treatment.  The latter observation suggests that MA may possess either agonist or antagonist properties at the GR. The incidence of clinically significant MA-induced adrenal dysfunction is not well described, nor is the dose threshold at which this adverse effect is more likely to develop.  

Clinical Case:

A 60-year-old female with type 2 diabetes presented with progressive nausea, vomiting, asthenia and dizziness over a period of several weeks.  Physical exam was significant for cachexia, orthostatic hypotension, and signs of dehydration. Laboratory evaluation revealed hyponatremia, metabolic acidosis, and hypercalcemia.  Blood glucose was 141 mg/dl and hemoglobin A1c was 5.5%. Suspicion was raised for adrenal insufficiency, and hydrocortisone was started after sending blood for cortisol and ACTH levels. These came back at 0.6 mcg/dl and <5 pg/ml, respectively, and the patient’s clinical status improved significantly on hydrocortisone therapy. TSH, Free T4, and prolactin were normal; gonadotropins were in the normal menopausal range, and IGF-1 was slightly elevated.  MRI showed a 3 mm hypoenhancing focus in the left side of the pituitary.  The findings were felt to represent isolated ACTH deficiency, with an incidental and likely nonfunctioning pituitary microadenoma. The etiology was unclear, as the patient denied using any oral, injectable, inhaled, or topical steroids.  A urine synthetic glucocorticoid screen was performed, and MA was detected, with the remainder of the glucocorticoids undetectable. Though initially the patient continued to deny using MA, it was later revealed that she was being treated for HIV infection, a fact that she had withheld from her family and her treating physicians in the hospital.  Her infectious disease specialist had been prescribing MA to manage AIDS-related weight loss.

Conclusion:

This case highlights the potential impact of megestrol acetate on adrenal gland function, and the usefulness of urine synthetic glucocorticoid screening when the etiology of isolated ACTH deficiency in an adult is unclear.

 

Nothing to Disclose: KM, IAW, MDG

20734 9.0000 THR-362 A Megace Mystery: A Case of Isolated ACTH Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Eun Kyung Koh* and Lorena Alarcon-Casas Wright
University of Washington, Seattle, WA

 

Clinical Presentation

  A 38 year-old woman with a history of type 1 diabetes mellitus, primary hypothyroidism, chronic kidney disease stage 3b (baseline creatinine of 1.5 mg/dL), chronic anemia, gastroparesis and hypertension presented to the emergency room with complaints of inability to walk short distances, easy fatigability and lightheadedness. Physical examination was remarkable for blood pressure of 120/67 mmHg with orthostatic changes, heart rate of 110 per min and temperature of 36° C. Laboratory investigations revealed serum sodium 120 mg/dL (reference range, 136 - 145), potassium 5.2 mg/dL (3.7 - 5.2), creatinine 2.5 mg/dL (0.38 - 1.02), BUN 46 mg/dL (8 - 21), glucose 126 mg/dL (62 - 125), serum osmolality 276 mosmol/kg (280 - 300) with urine osmolality of 180 mosmol/kg (100 - 850) and TSH 3.2 mIU/mL (0.4 - 5). Given her clinical presentation and history of autoimmunity, suspicion of adrenal insufficiency was raised. Random AM cortisol was 0.6 mcg/dL (5 - 22.6) while ACTH was inappropriately normal at 30 pg/mL (0 - 46). High dose cosyntropin stimulation test showed suboptimal response with a peak cortisol of 10.9 mcg/dL at 60 min. She was started on high dose hydrocortisone. Her condition dramatically improved and serum sodium normalized to 136 mg/dL over 48 hours. She was discharged on hydrocortisone 20 mg in AM and 10 mg in PM and did not require the addition of fludrocortisone.

  Outpatient follow-up demonstrated negative serum 21-hydroxylase antibody. As her clinical picture was not consistent with primary adrenal insufficiency, further history was obtained. Upon questioning, she stated that she had been applying liberal amounts of topical ketoconazole to lower extremities, abdomen and chest for a history of rash. She was also on medroxyprogesterone for menometrorrhagia. Topical ketoconazole was stopped and a repeat cosyntropin stimulation test showed an appropriate response with peak cortisol of 21.3 mcg/dL. ACTH was 56 pg/mL. Consequently, she was taken off of hydrocortisone replacement and remained clinically stable.

                                                               

Discussion

  This case describes a rare cause of adrenal insufficiency due to use of excessive topical ketoconazole. Systemic ketoconazole inhibits the effect of 11b-hydroxylase and 17a-hydroxylase. The effect of ketoconazole is dose-dependent, and the therapeutic effect for Cushing’s syndrome is usually achieved with 600-1200 mg/day. It has also been suggested ketoconazole may also have inhibitory effects on ACTH secretion. To the best of our knowledge, there are no case reports showing the association between topical ketoconazole use and adrenal insufficiency. Although the absorption is minimal when used appropriately, extensive and continual usage may cause systemic effects on the ACTH- cortisol axis.

  We hypothesize that the concomitant use of medroxyprogesterone in this patient may have had a synergistic inhibitory effect on the ACTH-cortisol axis.

 

Nothing to Disclose: EKK, LACW

21572 10.0000 THR-363 A A Case of Adrenal Insufficiency Induced By Topical Ketoconazol 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Fraser W Gibb*1, Mark W J Strachan1 and Alexandra Stewart2
1Edinburgh Centre for Endocrinology & Diabetes, Edinburgh, United Kingdom, 2Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

 

It has long been recognised that long-term opioid analgesia can be associated with adrenal insufficiency, as attested to by a number of published case reports involving a range of oral and transdermal preparations.  Morphine is associated with reduced ACTH and cortisol response to exogenous CRH administration in humans.   Despite these associations there has not been a systematic assessment of the prevalence of adrenal insufficiency in opioid-treated patients.

 We sought to assess the prevalence of adrenal insufficiency in opioid-treated patients (n=48, 52% women, median age 53 [IQR 17], median BMI 31.2 [IQR 11.0]) attending a specialist chronic pain outpatient service and associations between cortisol and well-being as determined by the SF-36 health questionnaire.  Adrenal function was assessed by measurement of 8am basal cortisol and ACTH-stimulated cortisol. 

 3 women (ages 36, 37 and 31 years; BMI 37.7, 31.5 and 37.9 kg/m2; transdermal fentanyl, oral morphine sulphate and transdermal fentanyl) failed to mount a sufficient cortisol response to ACTH stimulation (64 to 424; 91 to 385 and 84 to 270 nmol/L [normal >430 nmol/L]).  Full anterior pituitary function testing did not reveal any additional abnormalities in these women.   Two patients were commenced on oral hydrocortisone with symptomatic benefit reported; the remaining patient had normal adrenal function on repeat testing.

 ACTH-stimulated cortisol was not associated with any domains in the SF-36 health questionnaire.  The lowest tertile of basal morning cortisol was associated with ‘role limitations secondary to emotional problems’ (p 0.047) but not with any of the remaining 7 SF-36 domains.  BMI was negatively correlated with morning cortisol (R -0.435, p 0.002) with the converse true of the cortisol increment following ACTH (R 0.385, p 0.008).  Morning cortisol was positively associated with age (R 0.398, p 0.005) with a trend towards the opposite relationship with respect to cortisol increment (R -0.238, p 0.052).   No significant relationships were observed with respect to ACTH-stimulated cortisol.

 6.25% of patients in this cohort were found to have adrenal insufficiency.  Associations with BMI and age raise the possibility that younger, heavier patients may be at greater risk of opioid-induced adrenal insufficiency, which is consistent with the features observed in the cortisol deficient patients in this cohort.

 

Nothing to Disclose: FWG, MWJS, AS

20529 11.0000 THR-364 A Long-Term Opioid Analgesia and Risk of Adrenal Insufficiency in Chronic Pain Clinic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Selcuk Dagdelen*1, Emrah Seyhoglu2 and Tomris Erbas1
1Hacettepe University Medical School, Ankara, Turkey, 2Hacettepe University

 

Background: Tuberculosis involvement of the adrenal gland is rare, while adrenal failure secondary to tuberculosis is an even rarer combination (i.e. 30 cases of adrenal failure out of 323 852 patients, by Willis AC, 1997). Here we present a case of miliary tuberculosis who developed adrenal crisis following the initiation of anti-tuberculosis treatment.

Case Report: A 58-year-old male patient admitted with constitutional symptoms, found to have increased erythrocyte sedimentation rate and widespread pulmonary nodules in thorax CT suggesting miliary tuberculosis. The QuantiFERON ® test was positive. Rifampicin, isoniazid, ethambutol and pyrazinamide regimen was started without waiting for the results of bone marrow culture, which confirmed the diagnosis later. On the second day of anti-tuberculosis treatment, the patient described extreme fatigue, and then became hypotensive, hypothermic and hyponatremic. Blood samples were taken for ACTH and cortisol (which were found to be 160 pg/ml and 8.39 mcg/dl, later), and emergent MRI of the adrenals demonstrated bilateral enlargement and  infiltration. The patient clinically diagnosed tuberculous adrenalitis with adrenal crisis unmasked by initiation of rifampicin therapy. Methylprednisolon 100 mg/d, I.V. was administered and tapered down. On the 8th month of antituberculosis treatment, he was clinically well, and adrenal CT showed totally regression of the bilateral adrenal masses.

Conclusion: Tuberculosis of the adrenal glands complicating with adrenal failure must be considered in such a clinical context of hypotension, hypothermia and hyponatremia upon rifampicin therapy. In such a clinical suspicion, as the serum ACTH/cortisol results would take further time, emergent adrenal imaging can be used to initiate steroid replacement, as in this case here.

 

Nothing to Disclose: SD, ES, TE

20767 12.0000 THR-365 A Adrenal Crisis Precipitated with Antituberculosis Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Stina Willemoes Borresen*1, Bo Baslund1, Marianne C Klose1, Aase Krogh Rasmussen1, Lennart Friis-Hansen1, Linda Hilsted1, Henning Locht2, Annette Hansen3, Merete Lund Hetland4 and Ulla Feldt-Rasmussen1
1Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 2Copenhagen University Hospital, Frederiksberg Hospital, Copenhagen, Denmark, 3Copenhagen University Hospital, Gentofte Hospital, Copenhagen, Denmark, 4Copenhagen University Hospital, Glostrup Hospital, Copenhagen, Denmark

 

BACKGROUND: Adrenal insufficiency is a potentially life-threatening side effect to glucocorticoid treatment. The side effect occurs both after glucocorticoid withdrawal and during treatment if there is a mismatch between glucocorticoid requirements and production/intake. High-dose glucocorticoid treatment is often sufficient to overcome most stressful situations. However long-term low-dose glucocorticoid treatment is widely used. A low dose of 5 mg prednisolone daily is equivalent to 20 mg hydrocortisone, a dose often used as basal glucocorticoid replacement dose in adrenal insufficiency. Where patients in replacement therapy for adrenal insufficiency are instructed in self-administration of supplemental doses in stressful situations, patients treated for various conditions with long-term low-dose glucocorticoids are often not instructed in taking any supplemental doses at all.

OBJECTIVE: We aimed to assess the prevalence of glucocorticoid-induced adrenal insufficiency in patients treated with only 5 mg prednisolone daily to investigate whether adrenal insufficiency is a frequent and thereby clinically significant problem in long-term low-dose glucocorticoid treatment.

SUBJECTS AND MEASURES:As part of a larger study 37 patients with rheumatoid arthritis (26 women, aged 36-85 years) treated with 5 mg prednisolone/day for at least 6 months (mean 108, range 6-336 months) had a 250 μg Synacthen® test performed fasting, in the morning, after a mean prednisolone pause of 47 hours (range: 36-96 hours). P-cortisol was measured before and 30 min after Synacthen® injection. The cut-off for normal adrenal function was set at 500 nmol/l as this has previously been validated for our local cortisol assay. As a cut-off of 550 nmol/l is often used these data are also shown.

RESULTS: Of the 37 patients 11 (30%) had an insufficient adrenal response to the Synacthen® test. Using cut-off of 550 nmol/l 16/37 (43%) had adrenal insufficiency.

CONCLUSION: We found adrenal insufficiency in approximately one third of patients treated with 5 mg prednisolone daily. Since the prednisolone treatment is often sustained for years in these patients, adrenal suppression is likely equally prolonged. Our findings raise the question whether patients on long-term low-dose glucocorticoid treatment need to be handled with some of the same precautions as patients with verified adrenal insufficiency and whether a Synacthen® test should be routinely performed in these patients. Like other patients with adrenal insufficiency, patients treated with 5 mg prednisolone daily could benefit from supplemental glucocorticoid treatment during physical and psychological stress to prevent adrenal crisis and to reduce less severe symptoms of hypoadrenalism important for patients’ overall health status. More awareness of adrenal insufficiency in long-term low-dose glucocorticoid treated patients is urgently needed.

 

Nothing to Disclose: SWB, BB, MCK, AKR, LF, LH, HL, AH, MLH, UF

21329 13.0000 THR-366 A Adrenal Insufficiency in Patients Treated with Long-Term Low-Dose Prednisolone - Need for Revision of Cortisol Replacement Strategies? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Richard I Dorin*1, Zhi George Qiao1, Matthew Frederick Bouchonville1, Frank K. Urban III2 and Clifford R. Qualls3
1University of New Mexico School of Medicine, Albuquerque, NM, 2Florida International University, Miami, FL, 3University of New Mexico Health Sciences Center, Albuquerque, NM

 

Chronically subnormal concentrations of ACTH associated with secondary adrenal insufficiency (SAI) lead to reversible decrease in the cortisol secretory response to exogenous ACTH. The defect in ACTH-cortisol secretion coupling is important to the pathophysiology and diagnosis of SAI. We hypothesized that CSRmax is reduced in patients with SAI, and sought to characterize cortisol secretion in response to maximal concentrations of ACTH (maximal cortisol secretion rate (CSRmax)) compared to controls. A secondary objective was to assess the influence of secretion rate, elimination rate, and other parameters on baseline and stimulated cortisol concentrations using a multivariate model. CSRmax and free cortisol half-life were obtained by numerical modeling using least squares solution of simultaneous, non-linear differential equations (1); input data included total cortisol concentrations measured before and following cosyntropin stimulation (ACTH1-24, 250 μg) and measured concentrations of free cortisol, corticosteroid binding globulin (CBG), and albumin (1,2). Subjects included SAI (n=10) and healthy controls (n=21); CSRmax and free cortisol half-life were assessed during both dexamethasone (1 mg) and placebo pre-treatment (given at midnight) on separate study days, with  iv cosyntropin (250 μg) and frequent cortisol sampling commencing at 0800 hr. CSRmax was significantly reduced in SAI compared to controls for both placebo (0.17 ± 0.88 nM/sec [mean ±SD] vs. 0.46 ±1.39, P<0.001) and DEX pre-treatment (0.18 ±1.28 vs. 0.43 ± 1.29, P<0.001). Free cortisol half-life was similar (≈ 2 min) between SAI and control groups for both placebo and DEX conditions (both P>0.19). In a multivariate models, the strongest predictors of stimulated total cortisol were CSRmax, free cortisol half-life, and [CBG], with standardized beta (STB) >0.5 for each parameter. Albumin and baseline total cortisol concentration were significant but weaker predictors of stimulated cortisol (STB ≤ 0.25). The predictive effect of CSRmax and CBG concentration differed (P<0.03) between control and SAI groups. We conclude that CSRmax is reduced in SAI. The decrease in CSRmax in SAI contributes to the lower than normal stimulated cortisol concentrations associated with cosyntropin stimulation testing, however cortisol concentrations are predictably influenced by many other factors identified in multivariate analysis. These factors, in addition to previously identified assay differences (3), likely contribute to variability in the clinical assessment of post-test probability of SAI. Future studies are needed to determine the potential role of CSRmax determination in the clinical diagnosis of SAI.

 

Nothing to Disclose: RID, ZGQ, MFB, FKU III, CRQ

20158 14.0000 THR-367 A Decreased Maximal Cortisol Secretion Rate in Secondary Adrenal Insufficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Christine G Yedinak*1, Isabelle Cetas2, Marika Gassner3, Shirley McCartney1, Aclan Dogan1 and Maria Fleseriu1
1Oregon Health & Science University, Portland, OR, 2Oregon Health & Science University, OR, 3Henry Ford Health System

 

Progressive change of the hypothalamic-pituitary-adrenal (HPA) axis function in patients with pituitary adenomas (PAs) as assessed by dynamic testing, prior to and after long-term treatment is currently poorly described.  

To study and compare the prevalence and recovery of adrenal insufficiency (AI) among patients newly diagnosed with non-functioning (NF) PAs, acromegaly and prolactinomas pre- and post- transsphenoidal surgery (TSS) or dopamine agonist (DA) therapy; and to investigate the relationship to hypersecretion and tumor size, we performed a retrospective review.

All 230 patients underwent uniform baseline and 52 week cortrosyn stimulation testing. Prolactinomas were treated with either DA therapy or TSS, and NFPAs and acromegaly with TSS. Patients with a history of prior TSS, DA or radiation treatment were excluded.

There were 85 acromegaly, 92 NFPAs, and 53 prolactinomas; 82 microadenomas and 148 macroadenomas.  Mean age was 44.4±15.9 years and there were 125 females. Baseline AI in acromegaly, NFPAs and prolactinomas was 25.9% (22), 36.6% (34), and 35.8% (19) (X2 P=0.247), respectively. AI prevalence at 52 weeks was significantly less than at baseline (X2 P=0.001) and was significantly different between acromegaly 11.8% (10), NFPAs 33.3% (31), and prolactinomas 20.8% (11) (X2 p=0.002). Acromegaly and prolactinomas showed significant improvement over NFPAs (P=0.05). Recovery from baseline in acromegaly, NFPAs and prolactinomas was 54.5% (12), 32.4% (11), and 57.9% (11), respectively and was significantly greater for acromegaly and prolactinomas vs. NFPAs (X2 P=0.002). Males showed more AI at baseline and 52 weeks (X2 P=0.001 and X2 P=0.048).

AI prevalence significantly improved over 52 weeks regardless of TSS or DA for acromegaly, NFPAs and prolactinomas alike. Interestingly, AI for acromegaly and prolactinomas showed greater improvement vs. NFPAs. AI recovery was also more likely in females than males for acromegaly and NFPAs.  Rates of recovery and changes in prevalence were independent of tumor size or age.

HPA axis can significantly recover by 52 weeks post-surgery and DA treatment in PAs patients. This study represents a large patient sample size with a uniform HPA dynamic testing protocol performed by the same clinical team and supports the need for ongoing dynamic assessment of HPA axis function.

 

Disclosure: MF: Researcher, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Cortendo, Researcher, Ipsen, Consultant, Ipsen, Researcher, Pfizer, Inc., Consultant, Pfizer, Inc., Consultant, Genentech, Inc.. Nothing to Disclose: CGY, IC, MG, SM, AD

20104 15.0000 THR-368 A An Argument for Long-Term Dynamic Assessment of Hypothalamic-Pituitary Adrenal Axis after Treatment of Pituitary Adenomas: A Large Single Center Experience 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Kentaro Fujii*, Kazutoshi Miyashita, Isao Kurihara, Sakiko Kobayashi, Kenichi Yokota and Hiroshi Itoh
School of Medicine, Keio University, Tokyo, Japan

 

Introduction
Glucocorticoid replacement is needed for patients after surgery for Cushing’s syndrome. However, the adequate dose is not easily determined. Here we show a case of adrenal insufficiency after hemi-lateral adrenalectomy for Cushing’s syndrome, which was occurred despite she was treated with more than 30 mg/day of hydrocortisone.

Clinical Case
A 62 year old woman presented hypertension 5 years ago and since then she showed muscle weakness, easy bruising and edematous face. Because facial edema, general fatigue, and muscle weakness were progressively worsened, she consulted us. Radiological examinations detected a 30 mm left adrenal mass. Endocrinological evaluations revealed an elevated urinary free cortisol (114 mg/day), without suppression of serum cortisol in midnight and with suppression of ACTH (<1.0 pg/ml) in the morning. After overnight 8 mg dexamethasone challenge, the serum cortisol level was maintained at 34.4 mg/dl and ACTH was <1.0 pg/ml. 131-IAdosterol scintigraphy revealed higher uptake in the left adrenal mass. Under a diagnosis of Cushing’s syndrome due to an adrenal adenoma, laparoscopic left adrenalectomy was performed and 200 mg/day of hydrocortisone was administrated during peri-operative days. The dose was reduced gradually and she discharged on 14th post-operative day with 30 mg/day of hydrocortisone. However, she felt severe nausea and fatigue just after discharge and was transferred to emergency unit with a clinical suspicion of adrenal insufficiency. After an infusion of hydrocortisone 200 mg, the symptoms were immediately disappeared. The dose of hydrocortisone was slowly decreased under hospitalization; however, reduction of hydrocortisone lower than 60 mg/day was difficult because of nausea and fatigue. She discharged on 92nd post-operative day at the dose of 30 mg/day.

Conclusion
We presented a case of adrenal insufficiency after hemi-lateral adrenalectomy for Cushing’s syndrome who was resistant to reduction of glucocorticoid replacement. The glucocorticoid receptor would be down-regulated due to long-term exposure to excessive cortisol before surgery. Complicated heart failure was suggested to reduce absorption of hydrocortisone from intestine. In such cases, we should consider enough hydrocortisone administration with a dose of more than 30 mg/day to avoid adrenal insufficiency after surgery of Cushing’s syndrome.

 

Nothing to Disclose: KF, KM, IK, SK, KY, HI

19153 16.0000 THR-369 A Adrenal Insufficiency after Hemi-Lateral Adrenalectomy for Cushing's Syndrome Which Was Occurred Under Sufficient Glucocorticoid Replacement: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Phuong Thao Hoang*, Carrie Graves, John Mace and Eba Hathout
Loma Linda University School of Medicine

 

Background:In pediatric clinical practice, it is frequently difficult to confirm insufficiency of the hypothalamic–pituitary–adrenal (HPA) axis.  Results of current stimulation tests with either synthetic ACTH or insulin are often inconclusive and require time and financial resources. 

Objective:To prospectively evaluate the diagnostic value of DHEA-S on HPA function in pediatric patients with suspected HPA insufficiency.

Methods:Baseline serum Cortisol and DHEA-S were determined in 18 pediatric patients with suspected HPA insufficiency. Serum DHEA-S results were to be compared among three groups: group A with baseline Cortisol ≤ 5 µg/dL, group B with baseline Cortisol from 6 to 12 µg/dL, and group C with baseline Cortisol ≥ 12 µg/dL. Patients in groups A and B were evaluated with low dose cosyntropin (LDC) stimulation test to determine adrenal function.

Results:There were no patients in group A. There were normal responses to LDC tests for all 7 patients in group B.  Three of them (43%) had low DHEA-S.  Ten out of 11 patients (91%) in group C had normal DHEA-S.

Conclusion: The diagnosis of adrenal insufficiency is unlikely for pediatric patients with baseline serum Cortisol level ≥ 12 µg/dL, or a normal DHEA-S level, or both.  A low level of serum DHEA-S alone is inadequate to confirm the diagnosis of central adrenal insufficiency and dynamic testing is recommended. A normal level of DHEAS can be used as a screen to rule out central adrenal insufficiency.  Thus, measurement of serum DHEA-S may provide a practical initial approach to the assessment of the hypothalamic-pituitary-adrenal axis, especially in children, as it is both less invasive and less costly than conventional diagnostic testing.

 

Nothing to Disclose: PTH, CG, JM, EH

19711 17.0000 THR-370 A Using Serum Dehydroepiandrosterone Sulfate (DHEA-S) in the Assessment of the Hypothalamic –Pituitary –Adrenal Axis in Children 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Yutaka Oki*1, Kazumi Iino2, Miho Yamashita3 and Shigekazu Sasaki1
1Hamamatsu Univ Schl of Med, Hamamatsu, Shizuoka, Japan, 2Enshu General Hospital, Hamamatsu, Japan, 3Hamamatsu Univ Schl of Med, Hamamatsu, Japan

 

[AIM] It has been reported that growth hormone releasing peptide-2 (GHRP-2), a growth hormone secretagogue, stimulates the ACTH secretion through activation of hypothalamic corticotropin-releasing hormone (CRH) in rats. We investigated whether GHRP-2 can be used to evaluate the ACTH secretion in patients with hypopituitarism.

[Subjects and methods] Sixty patients with pituitary or hypothalamic lesions, e.g. pituitary adenoma and craniopharyngioma, participated in this study. Insulin tolerance test (ITT) and CRH test were performed and the patients were divided into three groups. In 21 patients, plasma ACTH increased in response to both tests (normal). In 27 patients, plasma ACTH increased after CRH test but not ITT (hypothalamic pattern). In 12 patients, plasma ACTH did not increase in response to CRH (pituitary pattern). GHRP-2 (100 µg) was administered intravenously, and plasma ACTH and cortisol were evaluated at 0, 15, 30, 60, 90 and 120 min.

[Results] In patients with normal pattern, plasma ACTH responses to GHRP-2 were 328 ± 50% (mean ± SEM) of basal values. Plasma ACTH responses to GHRP-2 in patients with hypothalamic pattern were significantly higher than those in patients with pituitary pattern (397 ± 46% vs. 153 ± 26%, P < 0.05).

[Discussion] In patients with hypopituitarism due to hypothalamic dysfunction, ITT cannot increase plasma ACTH but CRH stimulates the ACTH secretion. It has been reported that GHRP-2 stimulates the ATH secretion through hypothalamus in rats. Therefore, we thought that we might be able to use GHRP-2 as a substitute for ITT. However, GHRP-2 increased plasma ACTH in those patients. It suggests that GHRP-2 can act on pituitary to stimulate the ACTH secretion in human. 

[Conclusion] GHRP-2 test can be used to distinguish patients with hypothalamic dysfunction from those with pituitary pattern. In addition, it is possible that GHRP-2 may stimulate the ACTH secretion from pituitary directly in contrast to in vitro studies.

 

Nothing to Disclose: YO, KI, MY, SS

20380 18.0000 THR-371 A The Evaluation of ACTH Secretion with Growth Hormone Releasing Peptide-2 in Patients with Hypopituitarism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Rosario Pivonello*1, Chiara Simeoli2, Andrea M Isidori3, Alessandro Ciresi4, Silvia Savastano2, Renata Simona Auriemma5, Chiara Graziadio3, Carolina Di Somma2, Carla Giordano4, Andrea Lenzi3 and Annamaria Colao2
1Università Federico II di Napoli, Naples, Italy, 2Università Federico II, Naples, Italy, 3Sapienza University of Rome, Rome, Italy, 4Section of Endocrinology and Metabolic Disease, DIBIMIS, University of Palermo, Italy, 5Federico II University of Naples, Naples, Italy

 

Adrenal Insufficiency (AI) requires life-long glucocorticoid (GC) treatment, which is associated with an increased risk of metabolic syndrome (MS), probably due to cortisol overexposure for multiple drug daily doses, together with an impairment of quality of life (QoL). Moreover, treatment compliance (TC) is reported to be suboptimal in AI patients. The current study aimed at investigating the impact of the switch from twice/thrice daily conventional GCs to once daily dual-release-hydrocortisone (DR-HC) treatment on metabolic profile, QoL and TC in patients with primary AI (PAI) and secondary AI (SAI). Thirty-five patients [12 with PAI (7F, 5M, 33-60 yrs), 8 treated with cortisone acetate (37.5-75 mg/day) and 4 with hydrocortisone (20-30 mg/day), and 23 patients with SAI (9F, 14M, 20-77 yrs), 15 treated with cortisone acetate (18.75-37.5 mg/day) and 8 with hydrocortisone (15-20 mg/day)] entered the study and were evaluated before and 6 months after the switch to DR-HC (PAI: 20-60 mg/day; SAI: 20-40 mg/day). At 6-months follow-up, in PAI patients, body weight (BW) (p=0.036) significantly improved and a trend to a significant improvement was also found for waist circumference (WC) (p=0.086). A diagnosis of MS, performed in 2 patients (17%) at baseline, was not confirmed after 6 months. In SAI patients, BW (p=0.001), BMI (p=0.003) and WC (p=0.007) significantly improved. A clear diagnosis of MS, performed in 7 patients (30%) at baseline, was confirmed only in 4 (17%)  of these patients after 6 months. In a subgroup of 12 patients with AI, visceral adiposity index (VAI), an indicator of adipose function and distribution, which seems to indirectly express the cardiometabolic risk, significantly improved (p=0.05) while an improvement in glucose levels (p=0.064) and in Insulin Sensitivity Index (ISI 120) (p=0.052) was reported 120 minutes after glucose load. In a subgroup of 10 patients considered for the evaluation of QoL and TC, working ability ameliorated in 6 patients (60%), vitality in 5 (50%), general health perception and depression in 3 (30%) and body pain perception in 2 (20%) patients. Moreover, nine (90%) of these 10 patients improved TC, changing from low to medium adherence. In conclusion, the switch from conventional GCs to DR-HC in patients with AI improved BW, BMI, WC, prevalence of MS, glucose tolerance and insulin sensitivity, QoL and TC in patients with AI.

 

Disclosure: RP: Principal Investigator, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Clinical Researcher, Viropharma, Consultant, Viropharma, Speaker, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Speaker, Shire, Principal Investigator, Hra pharma, Coinvestigator, Ipsen. CS: Consultant, Viropharma. AMI: Consultant, Shire, Consultant, Novartis Pharmaceuticals, Consultant, Otsuka, Consultant, Besin, Speaker, Menarini. CG: Principal Investigator, Novo Nordisk, Principal Investigator, Lilly USA, LLC, Speaker, Novo Nordisk, Speaker, Lilly USA, LLC, Speaker, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Consultant, Pfizer, Inc., Consultant, Ipsen, Consultant, Italfarmaco, Consultant, Shire. AC: Principal Investigator, Novartis Pharmaceuticals, Principal Investigator, Ipsen, Principal Investigator, Pfizer, Inc., Principal Investigator, Lilly USA, LLC, Study Investigator, Merck & Co., Study Investigator, Novo Nordisk, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen, Consultant, Pfizer, Inc., Consultant, Italfarmaco, Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Pfizer, Inc.. Nothing to Disclose: AC, SS, RSA, CG, CD, AL

20484 19.0000 THR-372 A Effect of the Switch from Conventional Glucocorticoids to “Dual Release Hydrocortisone” in Adult Patients with Primary and Secondary Adrenal Insufficiency: A Six-Months Multicenter Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Evelien F Gevers*1, Sarra Ahmed2, Karen Logan3, Peter C. Hindmarsh4 and Mehul Tulsidas Dattani5
1William Harvey Research Institute / Barts Health NHS Trust, London, United Kingdom, 2Great Ormond Street Hospital, London, United Kingdom, 3Imperial College Health Care Centre, 4Univ College London, London, United Kingdom, 5UCL Institute of Child Health, London, United Kingdom

 

Background: The aim of therapy in ACTH deficiency is to replace glucocorticoids in a physiological pattern at the lowest effective dose. Marked variability exists in hydrocortisone (HC) metabolism among individuals, resulting in the need for individual assessment and titration of treatment.
Objective and hypotheses: We evaluated the use of cortisol profiles in patients with (suspected) hypopituitarism with and without HC treatment to optimise treatment.
Methods: We constructed 24h serum cortisol profiles by drawing blood samples at 2h intervals for 24h in 81 children with hypopituitarism on HC (group A, mean age (SD) 7.12 (4.5) yr) and in 51 children (group B, mean age 7.09 (4.0) yr) who had not as yet received HC. After profiling, 13 patients of group B were started on HC (B1) and 38 were not (B2).
Results: Mean (SD) 24h cortisol concentrations were higher in the HC-treated children compared to non-treated children (A: 220.4±107.4 vs B: 177.7 ± 50.3 nmol/l, p< 0.05) but not compared to those that remained off HC treatment (B2: 193.6±47.9 nmol/l). Mean HC dose was 15.8±5.0, 10.6±3.1 and 9.6±3.3 mg/m2/d in infants, prepubertal and pubertal children respectively. Children on HC had more frequent low (< 50 nmol/l) and high (>700 nmol/l) cortisol concentrations (p< 0.05 group A vs B2). BMI SDS, but not height SDS, was higher in the HC-treated group (A: 1.41 ± 1.7 vs B2: -0.07 ± 1.3, p< 0.0001). HC-treatment was adjusted in 54% of patients, with a dose increase (21%), dose decrease (14%), change in frequency (9%) or change in timing (19%).
Conclusions: In children with hypopituitarism receiving HC treatment, cortisol profiling demonstrated greater mean cortisol concentration, but frequent supraphysiological peaks or suboptimal troughs. Profiling may aid in the adjustment of treatment leading to a more physiological cortisol exposure. The increased BMI in these children is a further reason to aim for the most physiological HC replacement.

 

Nothing to Disclose: EFG, SA, KL, PCH, MTD

21649 20.0000 THR-373 A Optimization of Hydrocortisone Treatment in Children with Hypopituitarism Using 24 Hour Serum Cortisol Profiling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Gioia Mia Guerrieri*1, Rivi Ben Dor1, Karla D Thompson1, Natalie Kress1, Pedro E Martinez1, Lynnette K. Nieman2, David R Rubinow3 and Peter John Schmidt1
1National Institute of Mental Health, Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3Univ of North Carolina at Chapel Hill, Chapel Hill, NC

 

Disturbances of hypothalamic-pituitary-adrenal (HPA) axis function are consistently identified in depression.  Women with premenstrual dysphoric disorder (PMDD) experience distressing mood and behavioral symptoms during the luteal phase of their menstrual cycle (MC), as well as abnormal stress responsivity (1). Both clinical and preclinical studies have reported ovarian steroid modulation of the HPA axis, but reports of abnormal HPA function in PMDD are inconsistent. Previously, we employed combined dexamethasone (dex) suppression/CRH testing of HPA axis function in women with PMDD and asymptomatic controls (AC) during GnRH agonist-induced ovarian suppression with and without ovarian steroid add-back (2). Despite the recurrence of typical PMDD symptoms during either estradiol (E) or progesterone (P) in women with PMDD (but not AC), we found no diagnostic-related differences in response to CRH stimulation, though progesterone add-back increased the ACTH and cortisol response in both PMDD and AC.  Despite the value of the controlled hormonal states in the GnRH agonist/add-back model, the obtained results do not clearly replicate the conditions occurring during the normal menstrual cycle. Thus, we repeated dex/CRH studies under naturalistic conditions across the menstrual cycle. Studies were performed in 17 women with prospectively confirmed PMDD and in 25 AC during the mid- follicular (day 5-10 post menses) and luteal (day 4-8 post LH surge) phases of the MC. Symptoms were measured with standardized cross-sectional rating scales. Data was analyzed with ANOVA-R.  

 Women with PMDD but not AC reported significantly more symptoms during the luteal compared with the follicular phase (MC phase x diagnosis [Dx] interaction: F1,40= 5.3, p=0.03). As expected, significant MC phase effects were observed in baseline plasma E and P levels (F1,40=12.4 and 136.8, p<0.001, respectively), reflecting higher plasma levels of E and P in the luteal phase. We observed no significant effects of Dx or Dx by MC phase in either baseline or stimulated (AUC) plasma ACTH and cortisol levels ([Dx]:F1,40= [range] 0.1 -3.3, p=ns; Dx by MC phase:F1,40= [range] 0.1-2.6,  p=ns). Additionally, there was a significant luteal phase increase in AUC ACTH and cortisol compared with the follicular phase in both PMDD and AC. (MC phase: F1,40=5.1 and 6.4, p<0.05, respectively).

These preliminary findings show that PMDD is not uniformly associated with HPA dysregulation and suggest that the underlying pathophysiology of PMDD is distinct from that of major depression. However, these data do confirm a luteal phase increase in ACTH and cortisol response similar to previous findings that employed an exercise stimulation paradigm (3) and during GnRH agonist induced ovarian suppression with P add-back (2).

 

Disclosure: LKN: Editor, Up To Date, Clinical Researcher, HRA Pharma. Nothing to Disclose: GMG, RB, KDT, NK, PEM, DRR, PJS

18927 21.0000 THR-374 A Hypothalamic-Pituitary-Adrenal Axis Function in Premenstrual Dysphoric Disorder 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Naykky Maruquel Singh Ospina*, Alaa Al Nofal, Asma Javed, Khalid Benkhadra, Irina Bancos, Ekta Kapoor, Aida N Lteif, Hassan Murad and Neena Natt
Mayo Clinic, Rochester, MN

 

Background

 The diagnosis of secondary adrenal insufficiency (SAI) is a challenge.  ACTH stimulation tests of different doses are used in cases in which the clinical features, morning serum cortisol and ACTH levels are equivocal or inconsistent. A delayed or incorrect diagnosis of SAI can severely affect the overall health and well-being of these patients.

Objective

 Determine the diagnostic accuracy of the high dose ACTH stimulation test (250 mcg) and low dose ACTH stimulation test (1 mcg) for the diagnosis of SAI in adults.

Methods

 We performed a computerized bibliographic search of published articles and citation review  by an experienced medical reference librarian. We included studies that evaluated the diagnostic accuracy of ACTH stimulation tests in patients at risk for SAI excluding those on glucocorticoid therapies or with critical illness when compared with a reference standard (insulin tolerance test or metyrapone test).   Trained reviewers independently screened for eligible studies, assessed risk of bias (using the QUADAS-2 instrument) and extracted data in duplicate.

Results

 The electronic search yielded 1284 articles for abstract screening of which 26 studies were included for data extraction. A total of 1,209 patients at risk for SAI were evaluated and 36.1% had a positive reference standard test for SAI.

The diagnosis odds ratio (DOR) for SAI in adults was similar for the high and low dose stimulation test, using a peak serum cortisol cut off of 500 nmol/L (High dose DOR: 18.06 [95% CI, 8.07-40.4] vs. Low dose DOR: 26.75 [95% CI, 16.2 – 44.10]; P= 0.415) as well as with the a peak serum cortisol cut off of 550 nmol/L (High dose DOR: 16.77 [95% CI, 8.08 – 32.35] vs. Low dose DOR: 17.02 [95% CI, 8.1-35.4]; P=0.977). 

Overall, studies had moderate risk of bias which was mainly driven by unclear or inappropriate patient selection and referral bias leading to high prevalence.

Interpretation and Conclusions

 Both tests had moderate diagnostic accuracy for SAI. However, no statistically significant difference was found between low dose and high dose ACTH stimulation tests in diagnosing SAI when compared to a gold standard in populations at risk for SAI, using cutoff values of stimulated cortisol level of 500 nmol/l and 550 nmol/l. 

 

Nothing to Disclose: NMS, AA, AJ, KB, IB, EK, ANL, HM, NN

20196 22.0000 THR-375 A Diagnostic Performance of ACTH Stimulation Tests for the Diagnosis of Secondary Adrenal Insufficiency in Adults. Systematic Review and Meta-Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Hae Soon Kim*1, Young Min Youn2, Ye Jin Han3, Seung Joo Lee2 and Su Jin Cho4
1Ewha Mok-dong Hospital, Seoul, Korea, Republic of (South), 2Ewha Womans University School of Medicine, 3Ewha Womans Uniersity School of Medicine, 4Ewha Womans University School of Medicine

 

Hyponatremia with hyperkalemia in infancy may be seen in many endocrinologic and metabolic disorders such as congenital adrenal hyperplasia, congenital adrenal hypoplasia, and other forms of hypoadrenalism in infancy. Here, we report an infant who presented with failure to thrive and was finally diagnosed as pseudohypoaldosteronism (PHA) due to urinary tract infection (UTI) with reflux nephropahy. A 5-month-old female initially was evaluted for poor weight gain for the past 2 months. The body weight was 5.0kg (<3rd percentile). She looked pale and not so ill looking. Virilization of external genitalia or pigmentation were not noted. Initial serum sodium was 125 mEq/L and serum potassium was 6.1 mEq/L. The serum CRP level was 4.08 mg/dL, and serum ESR level was 60 mm/hr. Urine analysis revealed pyuria. Intravenous saline and antibiotics were started after urine culture. Catheterized urine culture was positive for Serratia marcescens. The initial serum 17-Hydroxyprogesterone level was 0.73 ng/ml (0.13-0.106ng/ml) and aldosterone level was markedly elevated 17,800 pg/mL (50-900pg/mL), urinary sodium centration was 30mg/L, so pseudohypoaldosteronism (PHA) was diagnosed. Her serum sodium and potassium were normalized after 48 hours of intravenous sodium replacement and antibiotics therapy, and inflammatory markers were also normalized. The renal sonography showed mild atrophy of right kidney and compensatory hypertrophy of left kidney. Renal DMSA scan showed multiple renal cortical defects in both kidneys. The VCUG showed right-sided grade 5 and left-sided grade 4 vesico-ureteral reflux. The follow-up electrolyte levels remained within normal range and aldosterone level was decreased without oral sodium replacement and proper weight gain was achieved. It is important to consider transient PHA due to urinary tract infection in infants particularly after the first one month of life with hyponatremia and hyperkalemia without virilization.

 

Nothing to Disclose: HSK, YMY, YJH, SJL, SJC

18889 23.0000 THR-376 A Transient Pseudohypoaldosteronism and Failiure to Thrive in a 5-Month-Old Infant 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Mihail Zilbermint*1, Yael R. Nobel2, Maya Beth Lodish1, Jaydira Del Rivero3, Smita Baid Abraham1, Margarita Raygada1, Charalampos Lyssikatos4, Elena Belyavskaya5 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2Perelman School of Medicine at the University of Pennsylvania, 3Albert Einstein College of Medicine, 4Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 5Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD

 

Introduction: Autosomal recessive pseudohypoaldosteronism type 1 (PHA1) is a rare disorder, affecting one in 80,000 births.  It is characterized by diminished response to aldosterone in the renal distal collecting tubule, as well as in the lungs, colon, and sweat glands. PHA1 is due to a mutation in the amiloride-sensitive epithelial sodium channel (ENaC). Patients may present with life threatening hyperkalemia, which has to be recognized and appropriately treated.

Case presentation: A 32-year-old African American female was referred to the National Institutes of Health (NIH) for evaluation of hyperkalemia and muscle pain. Her condition started at the second week of life, when she was brought to an outside hospital lethargic and unresponsive. On evaluation, the infant was hypovolemic, hyperkalemic, and acidotic. She had a prolonged hospitalization, eventually improving on sodium bicarbonate and potassium chelation via gastrostomy tube until being transitioned to oral medications at 3.5 years of age.  Her past medical history was significant for pulmonary embolism and pulmonary hypertension. Family history was significant for amyotrophic lateral sclerosis in her father. The patient was not aware of other endocrinopathies in the family.  At the time of the evaluation at the NIH, her physical exam was notable for blood pressure 128/75 mm Hg, heart rate of 110 beats per minute, BMI 41.4 kg/m2, and mild acanthosis nigricans of the posterior neck. Laboratory evaluation revealed serum potassium 5.1 mmol/L (reference range, 3.4-5.1 mmol/L), bicarbonate 20 mmol/L (reference range, 22-29 mmol/L), aldosterone 2800 ng/dL (reference range, < 21 ng/dL), and plasma renin activity 90 ng/mL/hour (reference range, 0.6-4.3). Patient was treated with sodium polystyrene sulfonate, sodium chloride, and sodium bicarbonate. Diagnosis of PHA type 1 was suspected.

Genetic evaluation: Sequencing of the SCNN1B gene revealed that the patient is a compound heterozygote for two novel variants (c.1288delC and c.1466+1 G>A), confirming the suspected diagnosis of PHA1.

Treatment: We continued treatment with sodium polystyrene sulfonate 15g/60mL/day, sodium chloride 3 g/day, and sodium bicarbonate 950 mg/day that led to normalization of serum potassium levels. Recently, the patient was admitted to an outside hospital’s critical care unit due to a severe hyperkalemia requiring an urgent hemodialysis treatment; possibly due to non-adherence to her medical regiment.

Conclusion: We report a patient with novel variants of SCNN1B gene, casing persistent, symptomatic hyperkalemia, due to pseudohypoaldosteronism type 1.

 

Nothing to Disclose: MZ, YRN, MBL, JD, SBA, MR, CL, EB, CAS

18629 24.0000 THR-377 A Pseudohypoaldosteronism Type 1 Due to a Novel Variant of SCNN1B Mutation: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Jitske Tiemensma*1, Cornelie D. Andela2, Johannes A. Romijn3, Nienke R. Biermasz4 and Alberto M. Pereira2
1University of California Merced, 2Leiden University Medical Center, Leiden, Netherlands, 3Academic Medical Center, Amsterdam, Netherlands, 4Leiden University Medical Center, Netherlands

 

Background: Patients with primary adrenal insufficiency (PAI) are treated with hydrocortisone replacement with the highest dose taken early in the morning in order to mimic the circadian rhythm of cortisol secretion. Nevertheless, patients with stable treatment for PAI report impairments in quality of life. The brain is a major target area for cortisol considering its high density of glucocorticoid receptors. Previous studies in patients treated for Cushing’s disease (CD) that have been exposed to cortisol excess suggest that hypothalamic-pituitary-adrenal axis dysregulation is related to cognitive impairment.

Objective: To evaluate cognitive functioning in patients with PAI and to examine the possible effect of postponing early morning hydrocortisone intake on cognition. Furthermore, we aimed to assess cognitive functioning of patients with PAI relative to patients in remission of CD.

Patients and Method: Cognitive functioning was measured using eight neuropsychological tests, which evaluated memory, verbal intelligence and executive functioning. We included 31 patients with PAI and 31 controls matched for gender, age and education. In addition, we included 29 patients with PAI who postponed their hydrocortisone intake until after the cognitive evaluation. Cognitive functioning scores of patients in remission of CD were obtained from previous research (1).

Results:  Compared to controls, patients with PAI performed worse on auditory and visual memory tasks (all P≤0.024) and worse on executive functioning tasks (all P≤0.012). In contrast, patients performed better on a concentration task (P=0.015) and made less errors during a focused attention task (P=0.041). No differences were observed between patients after hydrocortisone intake and those that postponed hydrocortisone intake, except for a slightly better score on a verbal fluency task (P=0.025) in patients that postponed hydrocortisone intake. Patients with PAI performed generally similar to patients in remission of CD.

Conclusions: Patients with stable treatment for PAI demonstrate mild cognitive deficits compared to controls, and perform generally similar to patients in remission of CD. Future longitudinal studies are needed to provide more insight into the development and course of the found cognitive alterations.

 

Disclosure: NRB: Coinvestigator, chiasma. Nothing to Disclose: JT, CDA, JAR, AMP

21320 25.0000 THR-378 A Mild Cognitive Deficits in Patients with Stable Treatment for Primary Adrenal Insufficiency: A Case-Control Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


Dennis J Brenner*1 and Asaad Elbashir2
1Saint Barnabas Medical Center, Livingston, NJ, 2Newark Beth Israel Medical Center, Newark, NJ

 

Background:X-linked adrenal hypoplasia congenita is caused by the mutation of DAX-1 gene (dosage-sensitive sex reversal, adrenal hypoplasia critical region, on chromosome X, gene 1). It is usually associated with hypogonadotropic hypogonadism, although in rare cases, it has been reported to occur in normal puberty or even central precocious puberty. This case report addresses a case in which central precocious puberty developed in a boy with X-linked adrenal hypoplasia congenital.

NR0B1 (DAX1) plays a crucial role in the development of the adrenals and of the hypothalamic-pituitary-gonadal axis. NR0B1 (DAX1) gene disruption can result in various clinical phenotypes and may lead to congenital adrenal hypoplasia. This is characterized by salt loss early in life, hypoglycemia in early infancy or childhood, development of a life-threatening state, poor weight gain, emesis, prolonged postnatal jaundice, skin hyperpigmentation, hyponatremia, hyperkalemia, low cortisol level, low aldosterone level, high ACTH level and a higher plasma renin activity.

Clinical case: The patient initially presented with severe hyponatremia and adrenal crisis. His skin was quite bronzed at presentation. Undetectable 17-OH Progesterone prompted screening for a DAX-1 mutation, which revealed the presence of a Hemizygous Nonsense mutation C.913C>T; p. Gln305X. The patient has been treated with glucocorticoids, mineralocorticoids and salt with typical weight-appropriate doses. He was noted to have laboratory evidence of central precocious puberty with enlargement of the phallus and continued elevation the gonadotropins and testosterone to mid-pubertal levels past the typical timing of the mini-puberty of infancy. At 9 months of age, the Total Tesosterone was 220 ng/dl (normal <10), LH was 0.97 MIU/mL (noraml 0.02-0.3) , and FSH was 1.3 mIU/mL (normal 0.26-3.0). MRI of the pituitary gland did not reveal neoplasm. He has been treated with Depot Leuprolide with moderate but not perfect suppression of the puberty . We are going to place a Histrelin implant soon. Bone age at chronologic age 2 years was 4 years. Linear growth has been at about the 80% percentile.

Literature search did not reveal reports of this specific Dax-1 mutation.

Conclusion: We report a rare case of X-linked adrenal hypoplasia congenita associated with central precocious puberty with a hemizygous Nonsense mutation in the DAX1gene. While most cases of this disorder exhibit hypogonadotropic hypogonadism, it is important to also observe for signs of central precocious puberty as well.

 

Nothing to Disclose: DJB, AE

19891 26.0000 THR-379 A Central Precocious Puberty Associated with a Dax-1 (NROB1) Mutation Causing Adrenal Hypoplasia Congenita 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM THR 354-379 5986 1:00:00 PM Adrenal Insufficiency Poster


John Michael Felt Jr.*1, Sarah Depaoli2, Alberto M. Pereira3, Nienke R. Biermasz4 and Jitske Tiemensma5
1University of California, Merced, Merced, CA, 2University of California, Merced, 3Leiden University Medical Center, Leiden, Netherlands, 4Leiden University Medical Center, Netherlands, 5University of California Merced

 

Context: Acromegaly is a rare disease characterized by chronic exposure to growth-hormone caused by a pituitary tumor. Impaired quality of life (QoL) is common in patients after long-term remission of acromegaly. The acromegaly QoL (AcroQoL) is a disease specific questionnaire that measures QoL in patients diagnosed with acromegaly. The summed total score is recommended by the AcroQol developers, which is based on exploratory methods, with no studies making use of confirmatory methods. However, the total score does not capture all aspects of QoL, as recommended by the World Health Organization (WHO).

Objective: The aim of the present study was to use novel and sophisticated confirmatory methods to identify the optimal number of subscales of the AcroQoL.

Design and Patients: Patients in remission from acromegaly were recruited from the Leiden University Medical Center, and asked to complete the AcroQoL questionnaire (n = 72). The AcroQoL consists of 22-items measured on a 1-5 Likert type scale reflecting psychological, appearance, and social relation concerns with QoL.

Results: Models compared included a single-scale version, a two-subscale version consisting of subscales reflecting Physical Complaints and Psychological Complaints, and a three-subscale version consisting of subscales reflecting Physical Complaints, Appearance Issues, and Personal Relations Issues related to QoL. Model fit indices (i.e. CFI and RMSEA) indicated the three-subscale version represented the data better than the total score and two-subscale models. Furthermore, all items loaded strongly onto each of the three-subscales (βs > .40), but for the single- and two-subscale versions, two items loaded onto the factors weakly. A chi-square difference test indicated the three-subscale model was a significantly better fit than the total score and two-subscale model (p’s < .05).

Conclusion: Model fit and comparison statistics indicate the three-subscale model is a better scoring method than the total score and two-subscale version of the AcroQoL. The three-subscale version also reflected the data patterns more accurately, as seen by the higher beta coefficients. Furthermore, the three-subscale version reflected the WHO’s recommendation of a multidimensional measure of QoL better than the total score and two-subscale method. Therefore, it is recommended that values from the three-subscales of the AcroQoL be reported in future research.

 

Nothing to Disclose: JMF Jr., SD, AMP, NRB, JT

PP09-3 19080 1.0000 THR-483 A Using Novel Confirmatory Statistical Methods to Compare Scoring Options of the Acromegaly Quality of Life (AcroQoL) Questionnaire 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Christian J Strasburger*1, N Karavitaki2, S Stoermann3, P J Trainer4, I Kreitschmann - Andermahr5, M Droste6, Márta Korbonits7, B Feldmann8, K Zopf1, V Fazal-Sanderson2, D Schwicker9, S Katz10, D Gelbaum10, A Haviv10 and Nienke Biermasz11
1Charite Universitätsmedizin, Berlin, Germany, 2Oxford University, Oxford, United Kingdom, 3Ludwig-Maximilians University, Munich, Germany, 4Christie Hospital, Manchester, United Kingdom, 5University of Erlangen, (current: University of Essen), Germany, 6Endocrine Practice, Oldenburg, Germany, 7Queen Mary University, London, United Kingdom, 8Endocrine Practice, Stuttgart, Germany, 9Phase IV, Basel, Switzerland, 10Chiasma, Inc., Newton, MA, 11Leiden University Medical Center, Leiden, Netherlands

 

Background:Somatostatin analogues are at present the most widely used medical treatment in acromegaly. The available long-acting formulations are administered parenterally (intramuscular or deep subcutaneous injections). This patient-reported outcomes survey was designed to assess for the first time the impact of chronic injections on the well-being of subjects with acromegaly.  

Methods:The survey was conducted in nine endocrinology centers in Germany, UK and The Netherlands. The questionnaire was developed by leading international endocrinologists and was approved by the local Ethics Committees.  It covered aspects of acromegaly symptoms/signs, injection-related manifestations, emotional and daily life impact of injections, treatment satisfaction and unmet medical needs. The questionnaire was administered by trained research nurses in each centre. This observational survey was descriptive in nature and analyses were pre-defined.   

Results:Of the 301 acromegaly patients invited, 195 (65%) agreed to participate.  112 patients (57%) were on octreotide (Sandostatin LAR®) and 83 (43%) on lanreotide (Somatuline Depot®).

The majority of patients (>70%) reported acromegaly symptoms/signs, with fatigue, joint pains, snoring, excessive sweating and headaches being the most frequently described. More than half of the patients reported that their complaints became worse towards the end of the dosing interval and interfered with their daily life.

Administration site pain lasting up to a week following injection was the most frequently reported injection-related symptom (70% of patients). Other injection site reactions included nodules (38%), swelling (28%), bruising (16%), scar tissue (8%) and inflammation (7%). Injection burden was remarkably similar between octreotide and lanreotide. Differences included longer duration of pain following octreotide injections (43 vs.27% for days; 18 vs. 12% up to a week), and more frequent skin nodules after lanreotide injections (54 vs. 27%).

Only the minority of patients received injections at home (17%) and 5% were self-injecting. Over a third of patients indicated a feeling of loss of independence due to the injections and 16% reported repeated work loss days. Problems with the preparation and administration of the injections were frequently encountered (44%).

Despite the physical, emotional and daily life impact of injections, patients were satisfied with their treatment. When asked about potential future treatment modifications that would offer major improvement over current care, the most frequently selected alternatives were “avoiding injections” (44%) and “better symptom control” (41%).

Conclusions: The results of this comprehensive observational survey suggest that life-long injections of long-acting somatostatin analogues impact considerably the functioning, well-being and daily lives of patients with acromegaly.

 

Disclosure: CJS: Advisory Group Member, Chiasma, Advisory Group Member, Ipsen, Advisory Group Member, Pfizer, Inc.. PJT: Clinical Researcher, Chiasma, Clinical Researcher, Antisense Therapeutics, Clinical Researcher, Antisense, Clinical Researcher, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Clinical Researcher, Ipsen. IK: Clinical Researcher, Novartis Pharmaceuticals, Clinical Researcher, Ipsen, Clinical Researcher, Pfizer, Inc.. MD: Advisory Group Member, Pfizer, Inc.. DS: Consultant, Chiasma. SK: , Chiasma. DG: Employee, Chiasma. AH: VP Clinical Development , Chiasma . NB: Investigator, Chiasma. Nothing to Disclose: NK, SS, MK, BF, KZ, VF

PP09-4 19974 2.0000 THR-484 A Patient Reported Outcomes Survey in Acromegaly Patients Treated with Parenteral Somatostatin Analogues 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Mônica R. Gadelha*1, Marcello D Bronstein2, Thierry Brue3, Mihail Gr Coculescu4, Laura De Marinis5, Maria Fleseriu6, Mirtha Guitelman7, Vyacheslav Pronin8, Gérald Raverot9, Ilan Shimon10, Juergen Fleck11, Albert Kandra11, Alberto M Pedroncelli11 and Annamaria Colao12
1Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 2University of São Paulo Medical School, São Paulo, Brazil, 3Hôpital de la Timone, Aix-Marseille University, Centre National de la Recherche Scientifique, and Assistance Publique-Hôpitaux de Marseille, Marseille, France, 4Academy of Medical Sciences of Romania University of Medicine and Pharmacy ‘Carol Davila’, National Institute of Endocrinology ‘CI Parhon’, Bucharest, Romania, 5Università Cattolica del Sacro Cuore, Rome, Italy, 6Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, 7Hospital Carlos G Durand, Buenos Aires, Argentina, 8IM Sechenov First Moscow State Medical University, Moscow, Russia, 9Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France, 10Rabin Medical Center, and Sackler School of Medicine, Tel-Aviv University, Petah-Tiqva, Israel, 11Novartis Pharma AG, Basel, Switzerland, 12Università Federico II di Napoli, Naples, Italy

 

Introduction: In a 24-week core phase of a randomized, Phase III study (PAOLA) which enrolled 198 patients with inadequately controlled acromegaly, significantly greater proportion of patients achieved biochemical control (defined as growth hormone [GH] level <2.5 μg/L andnormalized insulin-like growth factor [IGF]-1) with pasireotide long-acting release (LAR) 40 mg and 60 mg than with continued treatment with octreotide LAR 30 mg/lanreotide Autogel 120 mg (15.4% and 20.0% vs. 0%).  Results from a preliminary analysis (data cut-off 3 June 2013) from the 28-week extension phase of this study are reported here.

Methods:After completion of the core phase, patients continued receiving the same treatment during a 4-week bridging phase. Patients in pasireotide LAR (40 mg/60 mg) arms who had biochemical control at week 24 of the core study continued receiving double-blind pasireotide LAR at the same dose; those who were uncontrolled were started on open-label pasireotide LAR 60 mg. Patients in the active control arm (octreotide LAR/lanreotide Autogel) who were uncontrolled at week 24 of the core study were switched to open-label pasireotide LAR 40 mg (crossover arm). Key efficacy endpoints included (a) proportion of patients with biochemical control at extension week 28 (b) proportion of patients with GH< 2.5 μg/L or normal IGF-1 alone at extension week 28. Additionally, safety and tolerability were evaluated.

Results:Of the 181 patients completing the core phase, 173 entered the extension (pasireotide LAR 40 mg, n=57; pasireotide LAR 60 mg, n=54; crossover, n=62). Among the patients with available data at extension week 28, the proportion of patients with (a) biochemical control was 18.4% (9/49), 33.3% (15/45), and 20.0% (10/50) (b) GH< 2.5 μg/L was 38.8% (19/49) 46.7% (21/45), and 42.0% (21/50); normal IGF-1 was 32.7% (16/49), 37.8% (17/45), and 24.0% (12/50), in the pasireotide LAR 40 mg, pasireotide LAR 60 mg, and crossover arms, respectively. Pasireotide LAR maintained biochemical control during the 28-week extension. Safety was consistent with the findings in the core phase; the most frequently reported adverse events were hyperglycemia, diabetes mellitus, cholelithiasis, and diarrhea.

Conclusions: During the 28-week extension of PAOLA study, pasireotide LAR maintained biochemical control and was generally well tolerated in patients with acromegaly who were previously inadequately controlled by first-generation somatostatin analogues. These preliminary data seem to be consistent with data from the core study: around 20% of patients in the active control group achieved biochemical control after switching to pasireotide in the extension. Pasireotide LAR is a potential, viable, long-term treatment option for patients with acromegaly.

 

Disclosure: MRG: Consultant, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Principal Investigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Researcher, Pfizer, Inc., Principal Investigator, Ipsen, Speaker, Ipsen. TB: Investigator, Pfizer, Inc., Consultant, Pfizer, Inc., Speaker, Pfizer, Inc., Investigator, Novo Nordisk, Speaker, Novo Nordisk, Investigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Consulting speaker, Merck Serono, Consulting speaker, Lilly USA, LLC, Investigator, Ipsen, Speaker, Ipsen, Advisory Group Member, Ipsen, Consultant, Ipsen, Speaker, Sandoz, Investigator, Sandoz. MGC: Principal Investigator, Novartis Pharmaceuticals. LD: Speaker, Lilly USA, LLC, Consultant, Ipsen, Principal Investigator, Novartis Pharmaceuticals. MF: Researcher, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Cortendo, Researcher, Ipsen, Consultant, Ipsen, Researcher, Pfizer, Inc., Consultant, Pfizer, Inc., Consultant, Genentech, Inc.. MG: Speaker, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals. GR: Consultant, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Consultant, Ipsen, Researcher, Ipsen. IS: Speaker, Pfizer, Inc., Researcher, Pfizer, Inc., Consultant, Pfizer, Inc., Speaker, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Consultant, Chiasma. JF: Employee, Novartis Pharmaceuticals. AK: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. AMP: Employee, Novartis Pharmaceuticals. AC: Researcher, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Chair of the European advisory board , Novartis Pharmaceuticals. Nothing to Disclose: MDB, VP

PP09-1 20213 3.0000 THR-485 A Biochemical Control Is Maintained with Pasireotide LAR in Patients with Acromegaly: Results from the Extension of a Randomized Phase III Study (PAOLA) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Annamaria Colao*1, Feng Gu2, Mônica R Gadelha3, Aart J. van der Lely4, Maria Fleseriu5, Vanessa Passos6, Shoba Ravichandran6, YinMiao Chen6 and Marcello D Bronstein7
1Università Federico II, Naples, Italy, 2Ministry of Health, Peking Union Medical College Hospital, Beijing, China, 3Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 4Erasmus University Medical Center, Rotterdam, Netherlands, 5Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, 6Novartis Pharmaceuticals Corporation, East Hanover, NJ, 7University of São Paulo Medical School, São Paulo, Brazil

 

Background: Pasireotide is an effective treatment for acromegaly because of its high affinity binding for both sst2 and sst5. However, these receptors also regulate insulin and glucagon secretion. Pasireotide decreases secretion of insulin, incretins (GLP-1 and GIP) and, to a lesser extent, glucagon. Metformin may be a good option in patients with acromegaly experiencing hyperglycemia with pasireotide as it improves GLP-1 secretion and therefore improves insulin sensitivity, countering the effect of GH/IGF-1 excess. This analysis aimed for a better understanding of the effects of antidiabetic agents used during pasireotide treatment in the 12-month Phase III randomized study in medically naïve patients with acromegaly.

Methods: Patients received pasireotide LAR (n=176) or octreotide LAR (n=182) for 12 months. Starting doses were pasireotide LAR 40mg/28 days and octreotide LAR 20mg/28 days, respectively; at months 3 and 7, titration to pasireotide LAR 60 mg or octreotide LAR 30 mg was permitted. For the current analysis, only patients randomized to pasireotide who were not receiving antidiabetic medication at baseline and who initiated such medication at some point during the study were included (n=57). Three main groups were analyzed: those who received 1) metformin alone; 2) metformin + another oral antidiabetic (OAD); and 3) insulin ± OAD.

Results: Metformin was the most commonly initiated antidiabetic; 24 patients received metformin alone, 19 received metformin + another OAD and 10 received insulin ± OAD. Baseline mean (SD) fasting plasma glucose (FPG) and HbA1c were 94.7 (13.0) mg/dL and 5.8% (0.4%) for metformin alone, 99.7 (12.8) mg/dL and 5.8% (0.4%) for metformin + another OAD, and 106.7 (19.7) mg/dL and 6.1% (0.5%) for insulin ± OAD. Mean (SD) FPG values at month 3 were 131.0 (37.2), 153.2 (41.6) and 170.0 (88.6) mg/dL in the three groups, and at month 12 were 126.7 (17.4), 132.6 (25.0) and 137.1 (31.7) mg/dL. HbA1cvalues at month 3 were 6.6% (0.5%), 7.0% (1.0%) and 8.7% (1.9%), and at month 12 were 6.6% (0.7%), 6.7% (0.6%) and 7.2% (1.2%).

Conclusions: Mean HbA1c at month 12 in patients treated with metformin monotherapy or in combination with oral antidiabetic agents met the ADA/EASD goal of <7%. Patients who received metformin monotherapy had lower baseline FPG and HbA1c levels than those who received combination therapy. Metformin-based OAD therapy effectively controls hyperglycemia associated with pasireotide in patients with acromegaly.

 

Disclosure: AC: Chair of the European advisory board , Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals. FG: Consultant, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Principal Investigator, Ipsen, Speaker, Ipsen. MRG: Consultant, Novartis Pharmaceuticals, Principal Investigator, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Researcher, Pfizer, Inc., Principal Investigator, Ipsen, Speaker, Ipsen. AJV: Advisory Group Member, Novartis Pharmaceuticals. MF: Researcher, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Cortendo, Researcher, Ipsen, Consultant, Ipsen, Researcher, Pfizer, Inc., Consultant, Pfizer, Inc., Consultant, Genentech, Inc.. VP: Employee, Novartis Pharmaceuticals. SR: Employee, Novartis Pharmaceuticals. YC: Employee, Novartis Pharmaceuticals. Nothing to Disclose: MDB

PP09-2 21680 4.0000 THR-486 A Metformin-Based Oral Antidiabetic Therapy Is Effective at Controlling Hyperglycemia Associated with Pasireotide in Patients with Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Luciana Ansaneli Naves*1, Daniel Higor Barros2, Alan Carvalho Dias3, Juliano Oliveira Zakir1, Carolina Saldanha Horta1, Gabriella Mendes Motta1 and Luiz Augusto Casulari4
1University of Brasilia, Brasilia, Brazil, 2University of Brasilia, Brasilia, 3Laboratório Sabin De análises Clinicas, Brasilia, Brazil, 4University de Brasilia, Brasilia, Brazil

 

Background: There is a lack of data on the impact of treatment with somatostatin analogs, hormonal control and liposoluble vitamins in patients with acromegaly. Objective: To evaluate vitamins A,D,E before and after 90 and 360 days of treatment with octreotide and its association with disease control in acromegalic patients. Methods: A cross sectional, case series study, composed of 35 acromegalic patients recruited from the University Hospital of Brasilia. Blood samples were collected, and concentrations of calcium, GH, IGF-1, PTH, Vitamin A, D and E were determined.  Tests D-xylose and fecal fat were performed. A dietary survey was conducted to determine the profile of intake of the main food sources of fat-soluble vitamins. Statistical analysis was performed using the MedCalc 12.3.0 and SPSS 17.0. Results: GH and IGF-1 reduced after 90 days of exposure to Octreotide (p <0.05), and maintained to 360 days. Vitamin D deficiency was observed in 71.42% of patients at the first evaluation. Concentrations of  25 OH vitamin D increased after 90 days (31.70 ± 14.86) but did not sustained after 360 days (20:27 ± 5:23). There was a negative correlation between PTH and Vitamin D in the first sampling (r = -0595), but not at the second (r = -0.138) and the third collection (r = -0171). Vitamin A and vitamin E did not change over time. There was no correlation between GH and IGF-1 and the concentration of vitamins nor with D-xylose and fecal fat tests. Conclusion: Hypovitaminosis may be related to the impairment on pancreatic enzyme secretion and bile salts under octreotide treatment. Further studies are necessary to clarify the relationship between drug treatment, hypovitaminosis and its role in the pathogenesis of comorbidities.

 

Nothing to Disclose: LAN, DHB, ACD, JOZ, CSH, GMM, LAC

18581 5.0000 THR-487 A Liposoluble Vitamin Status and Activity of Disease and Octreotide Treatment in a Cohort of Acromegalic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Ryusaku Matsumoto*1, Hidenori Fukuoka2, Genzo Iguchi2, Hironori Bando1, Kentaro Suda1, Hitoshi Nishizawa1, Kenichi Yoshida1, Michiko Takahashi1, Shozo Yamada3, Masako Izawa4, Naoko Inoshita3, Wataru Ogawa1 and Yutaka Takahashi1
1Kobe University Graduate School of Medicine, Kobe, Japan, 2Kobe University Hospital, Kobe, Japan, 3Toranomon Hospital, Tokyo, Japan, 4Aichi Children's Health and Medical Center, Aichi, Japan

 

Background: Mutation in aryl hydrocarbon receptor interacting protein (AIP) causes pituitary adenoma including somatotropinoma, which is characterized by a relatively rare prevalence in sporadic cases (4.1%) (1), large and invasive tumor, and poor response to somatostatin analogues (SSA). The aim of this study was to investigate the prevalence of AIP mutation or deletion in Japanese patients with sporadic somototropinoma and the effect of medical therapy in patients with AIP mutation.

Design and Methods: Sixty-eight patients with apparently sporadic somatotropinoma (28 males and 40 females; age, 47.5 ± 14.1-year-old; serum GH levels, 1.3-77.5 ng/mL; serum IGF-I SDS, 6.9 ± 2.9; tumor diameter, 13.7 ± 6.7 mm) were included in this study. The entire coding sequence of the AIP gene was analyzed in genomic DNA of all patients. A multiplex ligation-dependent probe amplification (MLPA) was performed in a subgroup of patients with a young age (< 40-year-old) at diagnosis, invasive, or macro adenoma (≥ 10 mm), but negative for mutation in AIPgene, for the screening for deletion.

Results: AIP mutations were detected in 3 (4.4 %) of the 68 patients. MLPA analysis in 28 patients did not reveal any deletions. In all patients with AIPmutation, macro and invasive tumor was detected and postoperative medical therapy was necessary. A 7-year-old male patient with gigantism revealed R81X mutation. Because disease control was not achieved by the first surgery and the residual tumor became enlarged, he underwent 2nd surgery 2 years after the first one. His father also revealed the same mutation but no pituitary tumor was detected thus far. A 18-year-old male patient with gigantism revealed Y261X mutation and also exhibited postoperative SSA-resistance. Intriguingly, SSA and cabergoline combined therapy normalized his GH and IGF-I levels. His father and sister also revealed the same mutation but no pituitary tumor was detected thus far. A 46-year-old female patient with acromegaly revealed Y261X mutation. After the surgery, the disease was well-controlled with SSA. However, she eventually stopped visiting the hospital. After the cessation of SSA for 1year, because serum IGF-I was slightly elevated (2.11 SDS), we tried cabergoline mono-therapy. Thereafter, serum GH and IGF-I levels were normalized by cabelgoline.

Conclusions: The prevalence of AIP mutations in Japanese patients with sporadic somatotropinoma was comparable with the previous report. Our clinical findings suggest that although SSA-resistance is generally observed, cabergoline as a mono- or combined therapy is a potential therapeutic option in somatotropinoma with AIP mutation.

 

Nothing to Disclose: RM, HF, GI, HB, KS, HN, KY, MT, SY, MI, NI, WO, YT

18592 6.0000 THR-488 A Prevalence of AIP Gene Mutations in Japanese Patients with Sporadic Acromegaly and the Efficacy of Cabergoline Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Elena Valassi1, Iris Crespo2, David Vilades3, Ruben Leta3, Anna Aulinas4, Betina Biagetti5 and Susan M. Webb*6
1Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain, 2Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII,IIB- Hospital Sant Pau, Universitat Autònoma de Barcelona, 3IIB- Hospital Sant Pau, Universitat Autònoma de Barcelona, 4Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII,IIB- Hospital Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain, 5Vall d’Hebron Hospital, Universitat Autònoma de Barcelona. Spain, 6Hospital Sant Pau Barcelona, UAB and CIBERER unit 747, Spain

 

Introduction: The main cause of death in acromegaly is cardiovascular, but clinically relevant coronary artery disease (CAD) is uncommon, despite high prevalence of hypertension (HT), diabetes and insulin resistance. Aim: Identify CAD in acromegaly using cardiac multidetector CT (MDCT) angiography and compare to matched controls.

Patients & Methods: 26 non-diabetic patients with acromegaly (16 males; 16 with active disease defined as GH > 1mcg/L and elevated IGF-I), mean age 45.9±8 yrs (range 28 to 65) underwent a cardiac MDCT scan angiography, using a Philips iCT 256-slice MDCT (Brilliance iCT; Philips Healthcare, Cleveland, OH).  Twenty-three matched controls (for age, gender, & BMI) were also studied. Seventeen/12 patients/controls had hypertension (HT), 2/5 had dyslipidemia, 9/6 were active smokers and 6/9 ex-smokers, respectively. Extension of coronary disease was evaluated with the Segment Involving Score (SIS), while extension and severity were evaluated with the Segment Severity Score (SSS) (Min JK et al, J Am Coll Cardiol 2007;50:1161-70). 

Results: No severe (>70-100%) or moderate (50-69%) stenosis were identified in patients or controls.  Thirteen patients and 13 controls had a normal MDCT angiography; 8 patients (6 active, 2 cured) and 8 controls showed minimal (<25%) stenosis, while 5 patients (2 active and 3 cured) and 2 controls showed mild (25-49%) stenosis.  Stenosis was localized mainly in the left anterior descending (46%), coronary descending (19%), left circumflex (15%), and diagonal (8%) arteries. Of those with stenosis, 4 acromegalic patients had HT associated in 1 with dyslipidemia, 7 were smokers and 3 ex-smokers; among the controls, 5 had HT, 4 dyslipidemia, 2 were smokers and 3 ex-smokers.

Independently of the prevalence of HT or dyslipidemia, acromegalic patients who were active smokers (but not controls) had higher SIS and SSS scores than non- and ex-smokers (SIS: 0.17±0.13 vs. 0.02±0.04; 0.17±0.13 vs. 0.02±0.03 and SSS: 0.07±0.06 vs. 0.01±0.02; 0.07±0.06 vs. 0.01±0.01, respectively; p< 0.05 for all comparisons).  No differences in SIS or SSS were observed related to the presence or not of HT or dyslipidemia.

Conclusions: Non-diabetic acromegalic patients who are active smokers are at greater risk for CAD evaluated by MDCT angiography, than non-smokers, despite similar prevalence of other cardiovascular risk factors.

 

Nothing to Disclose: EV, IC, DV, RL, AA, BB, SMW

18903 7.0000 THR-489 A Coronary Heart Disease in Acromegaly. a Multidetector CT Angiography Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Elena Valassi1, Iris Crespo2, Jorge Malouf3, Jaume Llauger4, Ana Maria Marin4, Betina Biagetti5, Anna Aulinas6 and Susan M. Webb*7
1Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII and Universitat Autònoma de Barcelona (UAB), Endocrinology/Medicine Departments, Spain, Barcelona, Spain, 2IIB-Sant Pau, Hospital Sant Pau, Universitat Autònoma de Barcelona (UAB), ISCIII; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unit 747), ISCIII. Spain, Barcelona, Spain, 3Universitat Autònoma de Barcelona, Barcelona, Spain, 4IIB-Sant Pau, Hospital Sant Pau, 5Vall d’Hebron Hospital, Universitat Autònoma de Barcelona. Spain, 6Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII,IIB- Hospital Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain, 7Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain

 

Introduction: Results of bone mineral density (BMD) using Dual-energy X-ray Absorptiometry (DXA) in acromegaly are usually normal, but cannot discriminate between trabecular and cortical bone; furthermore, bone size increases in acromegaly, but this is not reflected in bidimensional measurements given by DXA. Bone quantitative CT (QCT) offers a volumetric, tridimensional measure of BMD and may be better to evaluate bone quality in acromegaly.  

Aim: Investigate bone in patients with acromegaly and matched controls, using both DXA and QCT.

Patients & Methods: Thirty one patients with acromegaly (17 males; 18 with active disease defined as GH > 1mcg/L and elevated IGF-I), mean age 48.2±7.5 years (range 28 to 65) underwent a DXA scan and  a QCT scan using Mindways software. Thirty-two matched controls (for age, gender, & BMI) were also studied. Subjects with diabetes were excluded.

Results: With DXA no differences were observed in the T-scores of femoral, lumbar and total BMD between patients with acromegaly and controls. With QCT, however, highly significant differences were observed for many parameters; specifically, volumetric BMD (vBMD) was lower in acromegaly than controls for total Intertrocantheric vBMD (333.5±68.9 vs 367±60.7 mg/cm3, p<0.05), cortical total hip and cortical trocantheric vBMD (826.4±63.2 vs. 874.9±61 mg/cm3 and 776±199.4 vs 937±346.4 mg/cm3, respectively, p<0.05) and trabecular total hip, trabecular femoral neck, trabecular trocantheric and intertrocantheric vBMD (121.4±20.6 vs 142.8±22.8 mg/cm3; 122.5±27.6 vs 147.1±24.1 mg/cm3; 122.5±20.1 vs 139.7±19.4 mg/cm3 and 119.6±23.5 vs 144.5±26.7 mg/cm3, respectively, p<0.01). Regarding the spine (average of L2, L3 and L4), vBMD was significantly decreased in acromegalic patients as compared to controls (102.9±41.8 vs 130.2±29.7 mg/cm3, p<0.01).  When the 18 patients with active acromegaly were compared with 13 in whom disease activity was controlled, none of these volumetric BMD measurements were different.

Conclusions: Despite apparently normal BMD with DXA, patients with acromegaly exhibit significantly lower bone quality when QCT is used, showing lower volumetric BMD, most marked for trabecular bone.

 

Nothing to Disclose: EV, IC, JM, JL, AMM, BB, AA, SMW

19182 8.0000 THR-490 A Bone Evaluation in Acromegaly with Quantitative CT (QCT) Is More Informative Than with DXA 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Guoxiang Shen*1, Christelle Darstein2, Karina Hermosillo Reséndiz1 and Ke Hu1
1Novartis Pharmaceuticals Corporation, East Hanover, NJ, 2Novartis Pharma AG, Basel, Switzerland

 

Introduction: In a 24-wk, phase III study (PAOLA), pasireotide long-acting release (PAS-LAR; 40 mg and 60 mg) demonstrated superior efficacy (15.4%, 20.0% vs. 0%) compared to continued treatment with octreotide LAR 30 mg (OCT-LAR) or lanreotide Autogel 120 mg (LAN-ATG) at providing biochemical control (GH< 2.5 μg/L and normalized IGF-1) in patients with acromegaly previously inadequately controlled by these first-generation SSAs. Results from PK/PD analyses of PAS-LAR are reported here.

Methods: 198 pts were randomized to PAS-LAR 40 mg (n=65) or PAS-LAR 60 mg (n=65) in double-blind fashion, or continued receiving open–label OCT-LAR 30 mg / LAN-ATG 120 mg, the active control group (n=68) for 24 wks. Dose-proportionality was explored and possible covariate effects were determined by use of linear mixed-effects models. Relationship between PAS plasma concentration and efficacy endpoints (GH and IGF-1) was analyzed using nonlinear Emax model and logistic regression models. Relationship between exposure and safety (FPG, ECG, and liver function tests [LFT]), including between PAS exposure and odds of hyperglycemia were also analyzed.

Results: PAS concentrations attained steady state after three consecutive monthly injections. PAS exposures were approximately dose proportional for the tested dose range (40–60 mg). Gender, age, and baseline total bilirubin levels were statistically significant PK covariates for PAS but their impact was not clinically significant. There was a clear exposure-response relationship between PAS concentration on GH and IGF-1 levels. The estimated maximum GH suppression (mean±SE) was 83.0±6.5%  and estimated effective concentration of PAS to suppress GH to 2.5 µg/L was 12.3±3.3 ng/mL; estimated maximum IGF-1 suppression was relatively lower (67.1±5.8%) and estimated effective concentration to suppress IGF-1 to 1×ULN was much higher (42.3±16.6 ng/mL), in line with the observed higher response rate for GH vs. IGF-1 with 40 mg and 60 mg  (40 mg: 35.4% vs. 24.6%; 60 mg: 43.1% vs. 26.2%). In logistic regression analyses, a 1.5-fold increase in PAS trough concentration (corresponding to dose increase from 40 mg to 60 mg) was associated with a 54%, 44%, and 51% increase in the odds of GH+IGF-1, GH and IGF-1 responses, respectively; the corresponding increase in the odds of having hyperglycemia was relatively low (36%). No clinically significant effect was found between PAS exposure and other safety parameters (QTcF/QTcB/LFT).

Conclusions: PK/PD analyses demonstrated a positive relationship between PAS exposure and efficacy endpoints (GH and IGF-1), and also support the clinical finding of higher GH and IGF-1 response rates at 60 mg than that at 40 mg. PK/efficacy and PK/safety analyses results support the clinical observation of a positive benefit/risk profile for PAS-LAR treatment in patients with acromegaly inadequately controlled by first-generation SSAs.

 

Disclosure: GS: Employee, Novartis Pharmaceuticals. CD: Employee, Novartis Pharmaceuticals. KH: Employee, Novartis Pharmaceuticals. KH: Employee, Novartis Pharmaceuticals.

19302 9.0000 THR-491 A Analysis of Pharmacokinetic (PK) and Pharmacodynamic (PD) Data for Efficacy and Safety from a Randomized Phase III Study of Pasireotide LAR in Patients with Acromegaly Inadequately Controlled on First-Generation Somatostatin Analogs (SSA) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Se Hee Park*1, Cheol Ryong Ku1, Eui Hyun Kim2, Sun Ho Kim1 and Eun Jig Lee3
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Yonsei University College of Medicine, 3Yonsei University College of Medicine, Korea, Republic of (South)

 

Objective: Transsphenodial adenomectomy (TSA) is a treatment of choice in patients with acromegaly. Although TSA has been applied in most acromegalic patients for several decades, long term endocrinologic outcomes including natural courses of biochemical remission and hypopituitarism had not been fully evaluated. In this study, we evaluated the endocrinologic outcomes of growth hormone secreting pituitary adenomas with huge number of patients.

Method: Five hundred and fifty two patients with acromegaly underwent TSA between January 1993 and April 2014. Among them, we evaluated the natural courses of 499 acromegalic patients who had at least twice follow up of biochemical results with 75 g oral glucose tolerance test (OGTT) and combined pituitary function test after TSA. Immediate postoperative GH levels were measured serially at 6, 12, 18, 24, 48, and 72 hours after TSA. All patients were operated by single neurosurgeon.

Result: The overall surgical remission rates were 95.6%, 96.4%, 78.6%, 82.0%, and 56.1% for modified Hardy classifications I, II, IIIA, IIIB and IV, respectively. Most of the patients (339/355; 96%) with biochemical remission in immediate postoperative OGTT presented the persistently suppressed IGF-1 and nadir GH in follow-up OGTTs. The discrepancy between immediate postoperative OGTT and low term postoperative OGTTs was observed mostly within 5 years after TSA. Ten of four hundred and nine (2.4%) remitted patients experienced the recurrences. 80% of recurred patients had invasive macroadenoma which had been confirmed no remnant tumor in immediate postoperative MRI. Aggravated hypopituitarism after TSA developed in 32 (6.4 %) subjects.

Conclusion: Radical surgical resection is essential to achieve the biochemical remission in acromegalic patients without aggravating hypopituitarism. Long term surgical outcomes could be predicted even during immediate postoperative period.

 

Nothing to Disclose: SHP, CRK, EHK, SHK, EJL

19710 10.0000 THR-492 A Endocrinologic Outcomes after Microscopic Transsphenoidal Adenomectomy in 499 Patients with Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 483-492 5994 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Natalia Branis*1, G Edward Vates2 and Laura Maria Calvi3
1University of Rochester Medical Center, Rochester, NY, 2University of Rochester, Rochester, NY, 3University of Rochester School of Medicine, Rochester, NY

 

Introduction: Axenfeld-Riegel syndrome is an autosomal dominant condition characterized by structural anomalies in anterior segments of the eye and various extraocular manifestations. 40-60% of affected individuals carry an identifiable mutation either in PITX2 or in FOXC1 gene (1). Although the genotype-phenotype correlation is not precise the type of extraocular manifestations in patients with Axenfield-Riegel syndrome follows along the lines of a specific genetic mutation. Here we present a case of a young woman with a FOXC1 mutation and novel phenotypical features.

Case description: 27 year old female with Axenfeld-Riegel syndrome due to FOXC1 mutation, congenital blindness presented with galactorrhea. Patient reported expressive and spontaneous galactorrhea for two years prior to her presentation. Patient denied headaches, change in shoe or ring size, easy bruisablity, mood swings, sleep problems.  She had regular periods. Physical exam revealed oligodontia but otherwise was unremarkable. Review of the records revealed that previously prolactin was 58 and 63 ng/ml (2.2-30.3 ng/ml) on two separate occasions. At that time patient was started on Cabergoline 0.5 mg twice a week. Due to persistence of her symptoms Cabergoline dose was escalated to 1 mg twice a week. Biochemical workup demonstrated TSH 1.68 µIU/ml (0.27-6.2), free T4 1.1 ng/dl (0.9-1.7), ACTH 15 pg/ml (7-63), random cortisol 2.6 µg/dl, GH 7.27 ng/ml (0.13-9.88), IGF-1 262 ng/ml (87-368), LH 18.5 mIU/ml (14-95.6), FSH 3.4 mIU (4.7-21.5), estradiol 69 pg/ml (34-170), testosterone LC/MS 50 (8-60), SHBG 46 nmol/l (20-130).  MRI pituitary with and without contrast revealed 3x4 mm pituitary adenoma, thinning and underdevelopment of corpus collosum, mild prominence of ventricles. Long-term dopamine agonist therapy with the dose escalation did not result in cessation of galactorrhea and it was discontinued. Prolactin remained elevated at 94 ng/ml (2.2-30.3). Patient continued to have occasional spontaneous galactorrhea but otherwise was feeling well.

Conclusion: Here we presented a patient with Axenfield-Riegel syndrome due to a FOXC1 mutation and pituitary microadenoma with hyperprolactinemia. Although brain abnormalities  are common in patients with PTX1 mutation (2), to our best knowledge this is the first case describing anterior pituitary abnormalities in a patient with a FOXC1 mutation. Phenotypic overlap in FOXC1 and PTX1 mutations suggest functional sensitivity between the two transcription factors encoded by these genes. In this case genetic alterations could attenuate the response to medical therapy. Clinicians taking care of patients with Axenfield-Riegel syndrome should remain alert to the great variety of phenotypical manifestations even when a precise mutation is known.

 

Nothing to Disclose: NB, GEV, LMC

20592 1.0000 THR-493 A A Novel Case of Pituitary Microadenoma, Hyperprolactinemia in a Patient with Axenfeld-Rieger Syndrome Due to a FOXC1 Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Suzi Kochar*1, Maguy Maurice Chiha2 and Janice L Gilden3
1Rosalind Franklin University of Medicine and Science at Chicago Medical School and Captain James A. Lovell Federal Health Care Center, North Chicago, IL, 2Mount Sinai Medical Center, Chicago, IL, 3Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL

 

Background:

The literature describes case reports of hyperprolactinemia (HPrl) following spinal cord injury (SCI) that is generally self-limiting in duration. However, we present a case of HPrl post SCI which persisted several years.


Case Description:

A 36-year-old female G4P4 presented to Endocrine clinic for evaluation of galactorrhea. Three years previously, she had sustained SCI at T1 level following  a gunshot wound with multiple comminuted fractures of spine (now healed), resulting in paraplegia, loss of sensation from T1 dermatome to below and chronic hypotension. Approximately, 2 months later, she started to have galactorrhea.  She denied breast tenderness, enlargement, masses, or areolae stimulation. Menses continued to be regular. There was no head trauma or thyroid disorder. There is urinary retention from neurogenic bladder requiring intermittent catheterization and bowel retention requiring intermittent bisacodyl suppository. Occasional muscle spasms were well controlled with tizanidine. No other medications were taken. She does not smoke, use illicit drugs, or drink alcohol.  Mother has hypothyroidism. Father’s medical history is unknown. Examination-BP sitting =74/51 mmHg, HR=84 bpm. Visual field-intact to confrontation. Breast exam-no masses or lesions, normal chest wall with mild bilateral expressible milky discharge. CNS-paraplegia, hyperreflexia of upper extremities and spasticity in lower extremities. Hormonal evaluation revealed normal thyroid function, IGF-1 levels, and renal function. Prolactin = 26 ng/ml. MRI exam-unable to perform due to disability. Therefore, we elected to observe the patient at this time.


Discussion:

HPrl following SCI is a rare condition reported to develop in 1-9.8 % of women, aged 20-33 years, who have sustained SCI. Severity of SCI does not correlate with level of involvement. Mechanisms for HPrl post SCI are possibly due to contusion or concussion of pituitary stalk, spinal shock with elevated CNS endorphins, altered nerve sensation with inhibition of dopamine release as seen in patients with chest wall abnormalities (burn, trauma or herpes infection), and stress. A large number of prolactin-releasing factors have been postulated to be involved, such as B-Endorphins, leuenkephalin, dysnorphin, alpha and beta neoendorphins, bombesins, substance P, neurostensin, histamine, melatonin , vasoactive intestinal peptide, Peptide-Histidine-Isoleucine and bradykinins. SCI can also affect hypothalamus-pituitary axis in men, producing hypogonadotropic hypogonadism with/without HPrl, and in women cause amenorrhea and low bone mass. Although HPrl following SCI usually resolves after 3-6 months, our patient continued with galactorrhea for 3 years post injury and demonstrates that hyperprolactinemia can continue for a longer duration of time after spinal cord injury with symptoms only of galactorrhea without amenorrhea.

 

Nothing to Disclose: SK, MMC, JLG

19823 2.0000 THR-494 A Hyperprolactinemia and Galactorrhea Following Spinal Cord Injury 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Ivan E Laboy-Ortiz1, Sharon Velez2, Jose Hernan Martinez3, Rafael Trinidad3, Michelle M Mangual4, Alfredo Sanchez5, Madeleine Gutierrez3, Paola Mansilla-Letelier3, Carmen V Rivera3, Coromoto Palermo*6, Maria de Lourdes Miranda3 and Ricardo Brau7
1San Juan City Hospital, Caguas, PR, 2Internal Medicine, 3San Juan City Hospital, San Juan, PR, 4Sa, San Juan, PR, 5San Juan City Hospital, PR, 6San Juan Hospital, San Juan, PR, 7University District Hospital, San Juan Puerto Rico

 

Introduction: Secondary resistance to dopamine agonist following initial biochemical and radiology response is very rare, and only a few patients after good primary response to dopamine agonists develop so called secondary resistance. We report a case of male patient with prolactinoma who developed drug resistance 13 months after initial dopamine agonist therapy.

Case presentation: The present case is a 42 year-old-man, seen with initial symptoms of headache, weight gain, decreased libido but no visual changes. Brain MRI showed sellar mass of 3 x 1.4 x 2.4 cm with displacement of the pituitary stalk. Laboratory evaluation revealed marked hyperprolactinemia (2278 ng/ml). Carbegoline was started and doses gradually increased up to 3mg per week with adequate lowering of prolactin levels to 42 ng/ml. Eight months after oral treatment started MRI showed significant decrease in the size of the lesion with much less mass effect in the pituitary gland and stalk.  After 13 months treatment compliance, the patient suddenly complained of headache, left eye pain and blurred vision, prolactin levels increased to 682 ng/ml and  repeated pituitary  MRI indicated further  enlargement of sellar mass with invasion inferiorly  and into the left cavernous sinus. Transcraneal followed by transsphenoidal pituitary surgery was performed. Pathology reports were not conclusive since the material obtained (a few tiny fragments) stains for several markers suggestive of normal pituitary tissue. After surgery the patient developed pan-hypopituitarism, and currently is being treated with proper hormone replacement and dopamine agonist was re-started with adequate biochemically response

Conclusion: The etiology of secondary resistance remains unknown and impossible to predict. The management and prognosis are still poorly understood. However one possible explanation of this phenomenon is loss of dopamine receptors at the tumoral cell surface. Nevertheless close observation of prolactinoma patients on treatment is advised, including, continued evaluation of prolactin levels especially on those who shows a good initial response to standard therapy.

 

Nothing to Disclose: IEL, SV, JHM, RT, MMM, AS, MG, PM, CVR, CP, MDLM, RB

21968 3.0000 THR-495 A Secondary Resistance to Dopamine Agonist after Thirteen Months of Successful Treatment in a 42 Years Old Man 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Vivek Bansal*1 and Laure Sayyed Kassem2
1University Hospitals Case Medical Center, Cleveland, OH, 2University Hospitals,Case Medical Center, Cleveland, OH

 

Background: Septo-optic dysplasia (SOD) is a rare congenital condition with variable combinations of optic nerve dysplasia, absent septum pellucidum, and pituitary hypoplasia. Visual defects, developmental delay, and short stature are the most common findings. Pituitary function ranges from normal to partial or complete hypopituitarism.  The radiological appearance of the pituitary ranges from normal to aplastic anterior pituitary and normal to ectopic posterior lobe.

Case Summary: A 41 year-old female presents for evaluation of new onset bilateral galactorrhea. Her initial evaluation is most notable for blindness, short stature, obesity, and fully developed secondary sexual characteristics. Menstrual cycles remain regular since menarche. She has polyuria and polydipsia since childhood and partial anosmia. She was given a diagnosis of optic nerve hypoplasia in infancy. She can not recall any prior endocrine evaluation or hormone replacement. Her medical history includes asthma for which she rarely takes prednisone. Serum prolactin is 176 mcg/L. Insulin-like growth factor-1 levels are 33 ng/ml commensurate with her short stature. Thyroid function and pituitary-gonadal axis testing are normal. Morning serum cortisol is 7.7 mcg/dl and ACTH 54 pg/ml, with low adrenal androgens for age and gender (DHEA-S 27 mcg/dl and DHEA 99 ng/dl) suggesting possible partial secondary adrenal insufficiency (AI). Low dose cosyntropin test shows a borderline cortisol response and persistently low adrenal androgens. Water deprivation test reveals an inability to concentrate urine (urine osmolality of 112 mOsm/kg with concomitant serum osmolality of 302 mOsm/kg H2O) and undetectable plasma ADH levels. Following administration of desmopressin, urine osmolality rises appropriately. MRI of the sella reveals hypoplastic optic nerves, absent septum pellucidum and a 1.1 cm sellar mass. Based on these findings, she is diagnosed with SOD causing growth hormone deficiency, possible partial secondary AI, diabetes insipidus and a concomitant prolactinoma of more recent onset. Hormone replacement with DDAVP is initiated. Treatment with cabergoline results in a significant decline in prolactin, resolution of galactrorrhea and a 78% decrease in tumor volume over 1 year.

Conclusion: To our knowledge, this is the first report of a pituitary adenoma arising in a subject with SOD. The hypoplasia of anterior and posterior pituitary tissue in SOD is less likely to provide substrate for the development of adenomas. Mild hyperprolactinemia with SOD is thought to be due to interrupted dopaminergic inhibition and has so far not been associated with prolactinoma. In this case mild, partial hypopituitarism suggests the presence of viable pituitary tissue that gave rise to a functional adenoma. A diagnosis of SOD should therefore not exclude the possibility of a pituitary adenoma in the appropriate clinical context.

 

Nothing to Disclose: VB, LS

21304 4.0000 THR-496 A An Unexpected Combination of Septo-Optic Dysplasia and Prolactinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Rahim Khorassanizadeh*, Vishnu Sundaresh and Steven N Levine
Louisiana State University Health Sciences Center, Shreveport, LA

 

Background: Elevated TRH levels in primary hypothyroidism can potentially result in thyrotroph and lactotroph hyperplasia leading to pituitary gland enlargement and hyperprolactinemia. The case discussed below concerns a patient with primary hypothyroidism with a prolactin level of 386 ng/mL.

Clinical Case: A 30 year old female, with complaints of temporal headaches 2-3 times weekly for 1 year, bilateral galactorrhea for 6 months and irregular, heavy menstrual cycles every 2-4 months was referred for an elevated prolactin of 240 ng/mL. In 2002, at age 17, she was treated with radioactive iodine for Grave’s hyperthyroidism. Levothyroxine was prescribed for post radioactive iodine hypothyroidism but for over 12 years she did not take any medications. She has had two successful pregnancies in 2005 and 2008, with a bilateral tubal ligation in 2008. She denied nipple stimulation or use of any over-the-counter supplements and prescription medications.

The patient described an increased appetite with weight gain, decreased energy level, chronic headaches 2-3 times a week, dizziness, blurred vision, and cold intolerance. She denied constipation, chest pain, dyspnea on exertion, or loss of vision. On exam she had a pulse rate of 76/min, no palpable thyroid tissue, normal visual fields, a delayed relaxation phase of the deep tendon reflexes, and bilateral galactorrhea. The remainder of the exam was unremarkable. Laboratory tests included a TSH of 263 uIU/mL (0.36 - 3.74), FT4 0.37 ng/dL (0.76-1.46) and a prolactin of 323.4 ng/mL (2.2-30.3). A pregnancy test was negative. Renal function, IGF-1, LH, FSH, ACTH and cortisol levels were normal.

The patient was started on levothyroxine 112 mcg daily. An MRI of the brain demonstrated a hyperplastic pituitary gland with no adenoma. Two weeks after initiation of levothyroxine, her TSH was 130 uIU/mL and total prolactin was 386 ng/mL (monomeric prolactin 92.6, macroprolactin 293.4). Two months after the initial visit, she continued to have a low energy level, headaches, cold intolerance and a small amount of galactorrhea, with a weight loss of approximately 9 lbs. Repeat TSH was 143 uIU/mL, FT4 0.37 ng/dL, and total prolactin was 149 ng/mL (monomeric prolactin 48.8, macroprolactin 100.2).

Conclusion: In patients with primary hypothyroidism and hyperprolactinemia it is essential to investigate other etiologies of hyperprolactinemia if the prolactin level exceeds 90 ng/mL in (1).

 

Nothing to Disclose: RK, VS, SNL

21548 5.0000 THR-497 A Primary Hypothyroidism with Exceptionally High Hyperprolactinemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


James C. Clifford*
Walter Reed National Military Medical Center, Bethesda, MD

 

Prolactinomas often present with hypogonadism and typically respond to treatment with dopamine agonist (DA) therapy.  We present a patient with a DA-resistant macroprolactinoma and hypogonadotropic hypogonadism who achieved restoration of gonadal function, normalization of prolactin (PRL), and increased responsiveness to DA therapy with the use of the selective estrogen receptor modulator (SERM) clomiphene.

Patient is a 62yo male with metabolic syndrome referred for evaluation of erectile dysfunction and poor libido.  Patient endorsed normal pubertal development, had children without difficulty, and denied familial syndromes.  He denied galactorrhea, vision change, new headaches, polyuria, testicular trauma, orchitis, or STDs.  Exam was notable for obesity, pseudogynecomastia, normal 25mL testes, intact visual fields, normal neurologic exam, and absent acromegaloid or Cushingoid features.  Labs were notable for PRL 848 (2.1 - 17.7 ng/mL), total testosterone (T) 15 (250-1100 ng/dL), free T 2.6 (35-155 pg/mL), LH 0.43 (1.7-8.9 IU/L), and FSH 0.8 (1.5-12.4 mIU/L). There was no biochemical evidence of additional pituitary dysfunction.  MRI showed a 2.1 x 1.1 x 1.9 cm anterior pituitary mass with right cavernous sinus extension and uninvolved optic chiasm.  Patient was treated with cabergoline 1mg/wk with improvement of PRL to 42 ng/mL.  T therapy was initiated for persistent hypogonadism and negligible improvement was obtained.  He did not achieve optimal T values despite increased doses and various T formulations.  However, escalating doses of cabergoline (max 10mg/wk) were required whilst on T therapy to maintain PRL in the 40’s ng/mL.  T therapy was stopped due to rising PRL, increasing cabergoline dose, and inability to normalize T.  PRL decreased to the 40’s ng/mL on cabergoline 2mg-4mg/wk after cessation of T.  Patient was treated with clomiphene 50mg daily with resultant normalization of PRL to 3.5 ng/dL and free T to 92.5 ng/dL on cabergoline 2mg/wk dose.  Patient experienced restoration of libido and erectile function.  The macroadenoma was stable on serial MRI’s.

Hypogonadism caused by a prolactinoma can persist despite normalization of PRL.  Hypogonadism treated with T therapy can lead to diminished effectiveness of DA therapy and cause secondary elevations in PRL.  The mechanism of this is presumed due to aromatization to estrogens; case reports have shown aromatase inhibitor use with a DA facilitated the use of T therapy and eventual recovery of T function in macroprolactinoma patients.  Estrogens contribute to prolactinoma progression by stimulating PRL secretion through disruption of dopamine’s inhibitory effect and therefore can serve as a target for therapy.  This case was notable for the ability to normalize PRL and restore T production in a DA-resistant macroprolactinoma and demonstrates how clomiphene can be utilized as a beneficial adjuvant in the management of a prolactinoma.

 

Nothing to Disclose: JCC

19265 6.0000 THR-498 A Restoration of Endogenous Testosterone Production and Normalization of Prolactin with Clomiphene in a Dopamine Agonist-Resistant Macroprolactinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Yasaman Mohtasebi*1, Rachel Anne Steinman2, Elizabeth M Lamos3, Rana Malek4, Kashif M. Munir2 and Stephanie Stein2
1Univ of Maryland Med Ctr, Baltimore, MD, 2University of Maryland Medical Center, Baltimore, MD, 3University of Maryland School of Medicine, Baltimore, MD, 4University of Maryland Medical C, Baltimore, MD

 

A Case of Giant Prolactinoma Initially Misdiagnosed as Sinonasal Neuroendocrine Carcinoma

 

Yasaman Mohtasebi M.D., Rachel A. Steinman M.D., Elizabeth M. Lamos M.D., Rana Malek M.D., Kashif M. Munir M.D., Stephanie A. Stein M.D.

 

Introduction: Giant prolactinomas are defined as pituitary tumors greater than 4 cm in diameter with high baseline prolactin levels (often above 1000 µg/L). They are rare, representing approximately 2-3% of prolactin-secreting tumors, and are most commonly found in young to middle-age men. The diagnosis may be surprisingly delayed in some cases due to the atypical mode of presentation compared with typical pituitary tumors. Giant prolactiomas can be highly invasive resulting in neurologic complications. Correct diagnosis is paramount to ensuring appropriate therapy with dopamine agonists.   

Clinical Case: A 27 year old female presented to the ER with progressively worsening headache and left eye ptosis. Her condition rapidly declined, she developed asymmetrical pupil dilation and required intubation. Initial head CT showed a large destructive mass centered at the central skull base, measuring at least 8.1 cm in craniocaudal dimension with extensive bony destruction, intracranial and intra-orbital extension, and acute obstructive hydrocephalus. An urgent ventriculostomy catheter was placed. Initial pathology from nasal endoscopy and biopsy read sinonasal neuroendocrine carcinoma. Pertinent history from patient revealed primary amenorrhea and galactorrhea. Labs showed: serum prolactin 27,400 ng/mL (measured at 1:100 dilution) (Ref: 4.8-23.3ng/mL),TSH 0.15 mIU/L(Ref: 0.47-4.68 mIU/L), FT4 0.7 ng/dL(Ref: 0.6-2.5ng/dL), LH <0.2 mIu/mL, FSH <0.7mIu/mL, estradiol 5.3pg/mL(Ref: 12.5-211pg/mL), IGF-1 171 ng/mL(Ref: 78-270 ng/mL) and 12 pm cortisol 8.3 µg/dl. Given history and laboratory findings, re-review of pathology with additional immunohistochemical staining , confirmed the diagnosis of prolactinoma. With 2 months of Cabergoline treatment, currently 1 mg 3x/week, her prolactin level is 1005 ng/mL and there has been a marked reduction in tumor size.

Conclusion: Given their atypical presentation and potential for sharing common immunohistochemical stains with other neuroendocrine neoplasms, giant prolactinomas extending into the nasal cavity can be misdiagnosed as other neuroendocrine neoplasms which may develop at this site. This case highlights the importance of taking a good history along with full pituitary hormonal evaluation in the assessment of large skull base tumors. Accurate diagnosis is necessary to prevent unnecessary surgery and/or radiation and to ensure implementation of dopamine agonist therapy.

 

 

Nothing to Disclose: YM, RAS, EML, RM, KMM, SS

19024 7.0000 THR-499 A A Case of Giant Prolactinoma Initially Misdiagnosed As Sinonasal Neuroendocrine Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Lisa A Owens*1, Marie Louise Healy2, James Gibney3, Mark Sherlock4 and Niamh Angela Phelan2
1St James's Hospital, Limerick, Ireland, 2St James's Hospital, Dublin, Ireland, 3Tallaght Hospital, Dublin, Ireland, 4Trinity College Dublin, Ireland

 

A 24 year old lady presented with galactorrhea in 2004 and was found to have an elevated prolactin level of 1927mU/I (normal 102-496 mU/I). MRI showed a 5mm left sided pituitary microadenoma. The rest of her pituitary function testing was normal. She was taking the oral contraceptive pill (OCP). She commenced bromocriptine but did not tolerate it due to nausea and subsequently commenced cabergoline, with normalisation of her prolactin (187 mU/I) and resolution of her symptoms.

In 2007 she opted to discontinued cabergoline and her prolactin subsequently rose to 2900 mU/I. She restarted treatment and in 2009 had an uneventful pregnancy, stopping cabergoline after conception. 8 months after delivery she recommenced cabergoline. She had an MRI in 2011 on which the initial lesion was no longer visible. At this stage she moved to Australia and became pregnant without difficulty or complication. After this pregnancy she was not seeing an Endocrinologist and did not recommence cabergoline. She did recommence the OCP.

In mid 2014 she represented to Endocrinology when she returned to Ireland. Prolactin was found to 23581mU/I (post fract 19282 mU/I). She was not pregnant, was on the OCP and the rest of her pituitary function testing was normal. Repeat MRI surprisingly showed a large, irregular, poorly-enhancing pituitary mass, measuring 24 x 21 x 18mm, not abutting the optic chiasm. The inferior extent of the mass invaded the sphenoid bone. She has recommenced cabergoline and her most recent prolactin is 565 (102-496). The plan is to monitor her prolactin and image periodically.

This unusual case raises several intersting and educational points. We postulated as to the reason why her pituitary lesion grew. Was it spontaneous? Or was it related to treatment withdrawal? Or was it related to her pregnancy? Or to the use of the oral contraceptive pill?

Microprolactinomas rarely (less than 5%) develop into large tumors. Hyperestrogenemia has been shown to cause lactotroph hyperplasia. Prolactinomas have been induced in rats exposed to large doses of estrogen. However, despite the pituitary growth/lactotroph hyperplasia that happens during pregnancy, observational studies show that pregnancy usually has a favorable effect on the natural history of pre-existing prolactinomas. Prolactin levels are often lower after pregnancy than before and remission of hyperprolactinema is not infrequent post pregnancy. Only 2.7% of micradenomas have been shown to have symptomatic increase in size during pregnancy. Thirdly and similarly the oral contraceptive pill, again through effect of estrogen, has been shown inconsistently in studies to increase prolactin levels. However it has not been shown to enhance tumour growth and is felt to be safe in use, especially in microprolactinomas. Lastly around one in five prolactinomas will remain the same size or reduce in size despite withdrawal of treatment.

 

Nothing to Disclose: LAO, MLH, JG, MS, NAP

18985 8.0000 THR-500 A Microprolactinoma Enlarging to Become Large Invasive Macroprolactinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Namrata Bose*, John David Carmichael and Jonathan S. Lopresti
University of Southern California, Los Angeles, CA

 

Introduction:
Prolactinomas are the most common functional pituitary tumors. A serum prolactin >200 ng/mL is highly indicative of a prolactinoma. Mild prolactin elevations <200 ng/mL can result from either microadenomas or parasellar lesions that interrupt the tonic inhibitory effect of dopamine on prolactin secretion, i.e., the “stalk effect.” Parasellar aneurysms are known to mimic pituitary adenomas radiographically. Cases of giant aneurysms resulting in pituitary compression and hormonal dysfunction have also been reported. However, serum prolactin (PRL) levels >1000 ng/mL in the absence of a macroprolactinoma are virtually unheard of.

Clinical case:
58 year old female presented with headaches and blurry left eye vision. She denied galactorrhea and is post menopausal. Physical examination revealed left temporal hemianopsia. CT head without contrast showed a 3.5cm x 3.1cm sellar mass suggestive of a pituitary macroadenoma. Pituitary function was then assessed, and she was noted to have a serum PRL of 1537 ng/mL (2-29 ng/mL). A diagnosis of macroprolactinoma was made based on the degree of prolactin elevation and a presence of a 3cm sellar mass. MRI brain was obtained and she was started on cabergoline 1.0mg twice weekly. MRI brain showed an aneurysm within the sella measuring 3.0 x 2.8 x 2.7cm arising from the right internal carotid artery. The mass showed contrast enhancement and was suggestive of a patent lumen within an aneurysm. No pituitary lesion was noted. CT angiography was then obtained which confirmed the presence of a giant multilobulated aneurysm arising from the right cavernous internal carotid artery measuring 3.1 x 3.0 x 3.0cm. Again, no additional pituitary lesion was noted. Serum prolactin as this time was noted to be 56.9 ng/mL, showing a significant response to cabergoline treatment. Interestingly, no change in mass size was noted on CT angiography compared to the MRI brain performed six months prior, as would typically be expected in the treatment of prolactinomas with dopamine agonists. Neurosurgery recommended a pipeline embolization and coiling of the aneurysm but she refused. Her headaches continued to worsen and her vision progressively deteriorated. Her prolactin levels fluctuated between 7.4 ng/mL and 199.8 ng/mL over the next few months on cabergoline treatment. One year later she decided to undergo treatment and underwent successful pipeline embolization and coiling of her aneurysm.

Conclusion:
We report a case of a parasellar aneurysm resulting in a prolactin level significantly higher than associated with the “stalk effect.” Significantly elevated prolactin levels can strongly guide clinicians towards a diagnosis of macroprolactinoma, however it is important to recognize cerebral aneurysm as potential cause of marked hyperprolactinemia in order to minimize risks and complications of transphenoidal surgery or subsequent aneurysmal rupture.

 

Nothing to Disclose: NB, JDC, JSL

22007 9.0000 THR-501 A Aneurysm Masquerading As a Macroprolactinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Juan Carlo Pascual Dayrit*1 and Elaine Cheeay Cunanan2
1University of Sto. Tomas Hospital, Manila, Philippines, 2University of Sto. Tomas Hospital, Quezon City, Philippines

 

BACKGROUND:

Medical management with dopamine agonists such as bromocriptine is considered the treatment of choice for prolactinomas. However, bromocriptine resistance, presenting as tumor growth despite normalization of serum PRL, may be encountered. 

CLINICAL CASE:

A 29-year old female presented with a 2-year history of amenorrhea and headache. Initial diagnostics revealed elevated prolactin levels (3008.98 ng/ml, N: 125-637) and a suprasellar mass (1.8 x 2.2 x 2.1cm) by cranial MRI. Bromocriptine 2.5mg OD was started, with noted resumption of menses initially but with recurrence of the amenorrhea after 4 months on therapy, with no improvement despite maximal dosage at 2.5mg TID. Repeat PRL levels showed normalization (77 ng/mL, N: 125 – 637) but with increased size of the mass lesion on repeat MRI (2.8 x 2.5 x 2.7cm) with compression of the optic chiasm. Transphenoidal surgery was subsequently done.

Prolactinomas are the most common secretory pituitary tumor, and GH/PRL-secreting adenomas are the most frequent mixed tumors. In the diagnosis of prolactinomas, PRL levels >200 μg/L are usually diagnostic, with levels >250 μg/L typically associated with macroadenomas. Hyperprolactinemia in the presence of an MRI-detected pituitary adenoma is usually consistent with but not unequivocally diagnostic of prolactinomas, since any pituitary mass that compresses the pituitary stalk may cause hyperprolactinemia. Empirical confirmation is obtained by treatment with dopamine agonists for months, with serial assessment of serum PRL levels and adenoma size. In the treatment of macroadenomas, the primary goal is restoration of gonadal and sexual function by normalization of PRL levels, and reduction of tumor size. Medical management with dopamine agonist drugs (Bromocriptine) is recommended as the treatment of choice, with dosages adjusted until 2.5mg 2x - 3x daily is reached. Dopamine agonist treatment normalizes serum PRL levels (50% reduction), and reduces tumor size in most patients (80% of prolactinomas shrinking by >25% of original volume). Occasionally, bromocriptine may lower PRL levels despite continued tumor expansion. Among the 3 outcomes possible after therapy (PRL normalization + reduction in tumor size (75%); PRL normalization + no change/small reduction in tumor size; no change in PRL + no reduction in tumor size), our patient presented with the 2nd outcome and is suggestive of a pituitary adenoma other than a prolactinoma. Among the additional options available, pituitary transphenoidal surgery was done, and final histopathology revealed a pituitary adenoma, with further immunohistochemistry staining ordered.  

CONCLUSION:

Despite typical presentation of hyperprolactinemia with an MRI-confirmed pituitary adenoma, infrequent outcomes of bromocriptine resistance may be encountered, and further options such as surgery may be entertained.

 

Nothing to Disclose: JCPD, ECC

21717 10.0000 THR-502 A Pituitary Macroprolactinoma Resistant to Bromocriptine Therapy: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Shira B Eytan*1 and Maya P Raghuwanshi2
1Rutgers University New Jersey Medical School, Newark, NJ, 2UMDNJ-NJ Med Sch, Newark, NJ

 

Background:

Multiple pituitary adenomas with different histologies are rarely described in the literature. Usually, these are associated with an endocrine syndrome or familial mutation. We report a rarely reported case of a bilateral unassociated pituitary adenoma, one with silent ACTH production and another with prolactin production.

Case Presentation:

A 27 year old woman presented with a 5 year history of amenorrhea, bilateral galactorrhea, and history of migraines.  She was diagnosed with prolactinoma with preoperative prolactin level of 83.9 ng/ml, and cranial MRI of the head revealed a solid/cystic lesion in the left half of the pituitary gland measuring 17.5 mm TV x 12.5 mm AP x 13.5 mm CC. There was an additional region of mild signal heterogeneity in the right half of the sella, with associated hypoenhancement on the post-contrast sequences. This region measured 6 mm TV x 7 mm AP x 9 mm CC.  Her other pituitary hormones were intact, with ACTH 31.4 pg/mL (7.2-63.3 pg/mL), FSH 2.5 mIU/mL (1.4-5.5 mIU/mL), LH 0.4 mIU/mL (0.9-9.3 mIU/mL), TSH 0.819 uu/mL (0.27-4.0 uu/mL), FT4 1.0 ng/dL (0.7-1.5 ng/dL), GH 1.7 ng/mL (0-10 ng/mL). Calcium levels ranged 8.5-10.1 mg/dL (8.4-10.2 mg/dL), making hyperparathyroidism and MEN syndrome unlikely. She did not know of any family history of pituitary adenoma.

Patient refused dopamine agonist therapy, and opted for transphenoidal resection of her tumor. She underwent an uneventful resection of the left sided macroadenoma, but post-operative prolactin level was 78.1 ng/mL. Therefore, she underwent a second endoscopic transphenoidal surgery to remove the right sided microadenoma. She tolerated this procedure well and her post-operative prolactin level at this time was 23 ng/mL.

Pathology from the first resection showed sheets of tumor cells consistent with pituitary adenoma, with a minority of the tumor cells strongly stained with an antibody to ACTH, with a densely granular pattern.  Pathology from the second resection showed a histological appearance different from the earlier resection, this time staining for prolactin and showing more of a glandular histological appearance.

Discussion:

Pituitary adenoma multiplicity is a rare entity, although prevalence is unknown. It may present silently, or with combinations of hormone over-production.  We present a case of silent ACTH-producing macroadenoma and functional pituitary microadenoma. Our case highlights the difficulty in choosing which adenoma to remove when there is clinical hormone overproduction. In our case, removal of the larger macroadenoma did not resolve prolactinemia, and a second surgery for the smaller microadenoma was necessary. Clinicians need to be aware of the possibility of multiple adenomas prior to surgery and MEN syndrome or familial pituitary adenomas need to be considered in such situations.

 

Nothing to Disclose: SBE, MPR

21560 11.0000 THR-503 A An Unusual Case of Bilateral Pituitary Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Pilaiporn Palakawong*, Matthew Hagen and Abid Yaqub
University of Cincinnati, Cincinnati, OH

 

Background: Plurihormonal pituitary adenoma is an unusual tumor in which a single tumor produces two or more pituitary hormones.  The incidence is approximately 1.3% of all pituitary adenomas. The most common combinations are growth hormone (GH), prolactin, and glycoprotein hormone subunits (TSH/LH/FSH) due to the common pathway of cytodifferentiation. We report an unusual case presentation of co-secretion of ACTH and Prolactin from a pituitary adenoma.

Clinical case: A 24-year-old Hispanic male, presented with excessive weight gain since the age of 8, multiple fractures, and hypertension. He also had delayed growth with short stature, absence of male secondary sexual characteristics, gynaecomastia and galactorrhea.  Dynamic hormonal work up confirmed pituitary ACTH hormone-dependent hypercortisolemia, and hyperprolactinemia (470 ng/dL, n 2.5-17.0 ng/dL). Other pituitary hormonal work up showed low total testosterone, and IGF-1 levels presumably secondary to mass effect.  Pre-operative MRI visualized a 2.5x2.1 cm enhancing pituitary macroadenoma. He was initially started on cabergoline, which normalized his prolactin level, and Mifepristone.  He underwent a successful transphenoidal pituitary adenomectomy. Histological examination revealed two separate components; the first component was 5 mm in greatest dimension, consisting of monomorphous cells immunoreactive for ACTH, with increased mitotic activity and elevated Ki-67 labeling, compatible with an atypical adenoma. The second component, immunoreactive for prolactin, appeared to comprise most of the remaining tumor. Post-operative he developed secondary adrenal insufficiency with serum morning cortisol of 4 mcg/dL (n 5-25 mcg/dL) and he required hydrocortisone at time of discharge. Cabergoline was stopped prior to surgery and his prolactin level remained normal postoperatively (6.7 ng/dL, n 2.5-17.0 ng/dL).

Conclusion: This case represents unusual co-secreting plurihormonal ACTH and prolactin pituitary adenoma.  Reviewing the reports from literature, the combination of ACTH and prolactin pituitary adenoma were mostly described as double pituitary adenoma base on two separate tumors on MRI imaging or  histopathologic examination.  Plurihormonal pituitary adenomas with combination of different hormone groups from same cell lineage (GH and prolactin or FSH and LH) are relatively common but true plurihormonal adenomas with immunoreactivities that cross the cytogenetic lineage are very rare. We discuss the case presentation, the challenging in diagnosis and management as well as review literature of previous case reports of similar phenomena.

 

Nothing to Disclose: PP, MH, AY

21474 12.0000 THR-504 A Plurihormonal ACTH and Prolactin Co-Secreting Pituitary Adenoma Presenting with Cushing's Disease and Hyperprolactinemia: A Case Report and Review of the Literature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Sasha Nair*1, David Squirrell2, Richard G Cutfield3 and Simon Christopher James Young3
1North Shore Hospital, Auckland, 2Greenlane Clinical Centre, Auckland, New Zealand, 3North Shore Hospital, Auckland, New Zealand

 

Background:

Central serous chorioretinopathy (CSR) is associated with leakage of fluid under the retina which may cause blurred spots in the visual field.  The condition is usually idiopathic but may rarely be associated with cortisol excess.

Clinical Case:

A 48 year old man was diagnosed with chronic bilateral CSR in the 1990s.  A bilateral exacerbation was noted in 2012 requiring laser surgery with persisting disease subsequently.  In 2013 cortisol levels were checked upon his request.  At the time he had dyslipidaemia, mild hypertension, impaired glucose tolerance, mild central obesity and subtly thinned skin but did not otherwise have an obviously Cushingoid appearance. However a screening morning serum cortisol was elevated at 1161 nmol/l (200-500) and 24 hour urinary cortisol was >1435nmol/day on 3 occasions (100-400).  Cortisol (770 nmol/l) was not suppressed by a 1mg dexamethasone test (<50nmol/L) and was only partially suppressed (69nmol/l) after an 8mg dexamethasone challenge.  ACTH was not suppressed on two occasions at 4 and 20 pmol/l (2-11).  A CT scan of the adrenal glands was normal.  Pituitary MRI revealed a 31mm pituitary macroadenoma with sphenoid sinus and suprasellar extension displacing optic nerves and chiasm, displacement of intracranial carotid arteries, left-sided invasion into the cavernous sinus with complete encasement of the cavernous ICA.  The entire tumour was surgically resected and histology confirmed positive staining for ACTH.  The patient was not given perioperative steroid cover and at day six post-operation his serum morning cortisol was in the normal range at 383nmol/l.  However he started to feel fatigued two weeks post-operatively. Eighteen days post-resection his morning cortisol was low at 88nmol/l and he was started on hydrocortisone replacement.  One month after the pituitary surgery his CSR had fully resolved without the need for further laser therapy. The hydrocortisone was able to be weaned one year post-resection and a subsequent 1mg dexamethasone test (cortisol level 21nmol/l) and MRI do not show any evidence of recurrence of the pituitary tumour to date.  There has also been no recurrence of his CSR.

Conclusion:
His CSR is presumed to have been exacerbated by the cortisol excess.  Unusually, the patient had very minimal clinical signs of cortisol excess despite a very large secretory tumour.  This case thus demonstrates that Cushing’s disease may be unmasked by the development of or exacerbation of CSR.  Cushing’s disease should be suspected in patients with CSR and Cushingoid features or atypical/chronic CSR.  This case also highlights that CSR should be considered in patients with Cushing syndrome complaining of visual disorders.  Finally this case serves as a reminder that adrenal suppression can manifest relatively late after pituitary surgery for ACTH-secreting tumour.

 

Nothing to Disclose: SN, DS, RGC, SCJY

21790 13.0000 THR-505 A A Case of Chronic Central Serous Chorioretinopathy Associated with Cushing's Disease with Marked Biochemical Cortisol Excess Due to a Large ACTH-Secreting Pituitary Macroadenoma but Minimal Clinical Signs of Cortisol Excess 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Jared A Dendy*, A Mannan Khan, Susana L Dipp and Alan L Burshell
Ochsner Clinic Foundation, New Orleans, LA

 

Background: We present a rare case of a patient with a difficult-to-treat submandibular infection after a dental procedure. Actinomyces, the causative genus, has previously been associated with other immunocompromised states but rarely reported with Cushing's syndrome.

Clinical Case: A 40-year-old female with a medical history significant for diabetes mellitus type 2, osteoporosis, vitamin D deficiency, and hypertension was referred to the endocrine clinic for evaluation of bilateral fibula and multiple rib fractures. Upon presentation the patient reported having had a recent infection with actinomyces. The infection first developed after a left mandibular tooth extraction. The mass was inferior to the mandible and measured 5 x 4 cm. Aspiration revealed purulent material and pathology was benign for malignancy.  She was then given a diagnosis of actinomycosis. She was placed on multiple courses of oral antibiotics with no improvement.  Referral was then made to an infectious disease specialist, peripherally inserted central catheter (PICC) was placed and intravenous (IV) penicillin G was started. The IV antibiotics were discontinued after 3 weeks of therapy due to the development of a deep venous thrombosis necessitating removal of the PICC and treatment with warfarin. The infection required an additional two months of oral antibiotics before resolving after nearly 1 year of therapy. 

She reported having several spontaneous fractures in the past year.  A BMD scan performed by an outside physician revealed osteoporosis, but the etiology was not elucidated.  She had a 50lb wt gain over the previous 5 years, easy bruising, muscle weakness and depression. On physical examination she exhibited abdominal striae, central obesity, facial plethora, and dorsocervical/supraclavicular fullness. Baseline ACTH was 67 pg/mL (nml 0-46 pg/mL), 8AM cortisol 24.4 ug/dL (nml 4.3-22.4 ug/dL), 24-hour urinary free cortisol 97.4 mcg/L (nml 4-50 mcg/24h), cortisol after 1mg dexamethasone suppression 22.5 ug/dL (nml 4.3-22.4 ug/dL) and cortisol after 8mg dexamethasone suppression 17.8 ug/dL (nml 4.3-22.4 ug/dL). Computed tomography of the chest/abdomen/pelvis did not reveal a source of ectopic ACTH secretion. Magnetic resonance imaging of the brain revealed a subtle thickening of the right side of the pituitary gland. Inferior petrosal sinus sampling showed a pituitary-to-peripheral ACTH ratio greater than 6:1 fifteen minutes after CRH administration. She was then referred to neurosurgery for surgical evaluation.

Conclusion: Actinomyces is a Gram positive filamentous bacterium most commonly found in the oropharynx. In the setting of endogenous hypercortisolism the actinomycosis was difficult to treat likely due to the effect of glucocorticoids on cell-mediated immunity. The degree of cortisol excess has been shown to predict the severity of various infections in patients with Cushing’s syndrome.

 

Nothing to Disclose: JAD, AMK, SLD, ALB

20633 14.0000 THR-506 A Submandibular Actinomycosis Refractory to Treatment in a Patient with Undiagnosed Cushing's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Karla M Arce*1, Ferdinand Hui2, Pablo Recinos2 and Laurence Kennedy3
1Cleveland Clinic, Cleveland, OH, 2Cleveland Clinic, 3Cleveland Clinic Foundation, Cleveland, OH

 

Background

Adrenocorticotropin (ACTH)-secreting pituitary adenomas causing Cushing disease (CD) can be difficult to identify because of their variable size and locations. Inferior petrosal sinus sampling (IPSS) ideally helps to differentiate CD from ectopic ACTH secreting tumor. However, in 0.6%-7% of individuals, there is no connection between the internal jugular vein and the inferior petrosal sinus (IPS), making standard sampling impossible. We report the case of a patient in whom a rare IPS anatomical variant complicated the accurate diagnosis of an ectopic ACTH-secreting pituitary adenoma within the cavernous sinus.

Clinical case

A 24-year-old woman presented with a history of weight gain, hirsutism, easy bruising, ankle swelling, proximal muscle weakness for over one year, and recently diagnosed diabetes and hypertension. She had a typical cushingoid appearance, with round plethoric face, excess supraclavicular fat pads, abdominal striae,  proximal myopathy and back pain resulting from multiple compression fractures. Endocrinological evaluation was consistent with ACTH-dependent Cushing syndrome. Morning serum cortisol was 57.8 ug/dL, ACTH 154 pg/ml (range 8-42 pg/ml), DHEAS 1242.6 ug/dl (range 41-247 ug/dl), HbA1c 13.3%, glucose 473 mg/dl (range 65-100 mg/dl) and potassium 2.7 mmol/l (3.5-5.0 mmol/l). Her 24-hour urine free cortisol was 361 ug/L and midnight salivary cortisol 250 ng/dl. Serum cortisol after 8 mg dexamethasone suppression decreased to more than 50%. Pituitary MRI revealed a 15x7x7 mm soft tissue intensity at the right aspect of the sella extending from the cavernous sinus, separate from the pituitary gland. CT of the abdomen and pelvis did not suggest any potential ectopic source of ACTH and chest X-ray was normal. Attempted bilateral inferior petrosal sinus sampling was unsuccessful due to variant IPS anatomy with drainage into the vertebral venous plexus. Samples from the right and left internal jugular veins showed no gradient for either ACTH or prolactin compared with peripheral vein sampling. Whole body octreotide scan combined with SPECT/CT imaging was negative. The findings are most suggestive of an ectopic ACTH-secreting pituitary adenoma. Because the location within the cavernous sinus made surgery both unduly hazardous and unlikely to be curative we have elected to treat the patient medically in the first instance.

Conclusion

Distinguishing CD from ectopic ACTH syndrome remains potentially challenging, particularly so in this case given that IPSS was not possible due to the patient’s anomalous IPS drainage. Ectopic intracavernous pituitary adenomas have been described in only a few reports; to our knowledge this is the first case of a patient with ectopic ACTH-secreting pituitary adenoma within the cavernous sinus associated with a rare anatomical IPS variant.

 

Nothing to Disclose: KMA, FH, PR, LK

21918 15.0000 THR-507 A Intracavernous ACTH-Secreting Pituitary Adenoma and a Rare Inferior Petrosal Sinus Anomaly: How Likely Is That? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Maria Francesca Cassarino1, Mariarosa Terreni2, Alberto G. Ambrogio3, Davide Gentilini4, Marco Losa2, Francesco Cavagnini1 and Francesca Pecori Giraldi*3
1Istituto Auxologico Italiano IRCCS, Cusano Milanino, Italy, 2Ospedale San Raffaele, Milan, Italy, 3Dept. Clinical Sciences & Community Health, University of Milan & Neuroendocrine Research Laboratory, Istituto Auxologico Italiano IRCCS, Milan, Italy, 4Istituto Auxologico Italiano IRCCS, Cusano Milanino (Milan), Italy

 

Introduction. ACTH-secreting pituitary adenomas present considerable variability both in terms of clinical presentation, responses to endocrine testing, surgical outcomes and efficacy of medical therapy. Heterogeneity is evident also at molecular level with variable responses to known modulators of ACTH secretion in vitro (Pecori Giraldi et al J. Neuroendocr. 2011) as well as diversity in receptor, transcription factor and miRNA expression. Microarray analysis provides a powerful means to evaluate the expression pattern of thousands of genes and has yielded interesting results in several endocrine tumors, such adrenal carcinoma and thyroid neoplasia. Aim of the study was to evaluate transcriptome expression pattern in human ACTH-secreting adenomas and verify whether gene profiles are associated with clinical variables.

Methods. Forty-six human ACTH-secreting pituitary adenoma formalin-fixed paraffin-embedded specimens were cut into 20 µm thick sections and RNA extracted using Recover All Total Nucleic Acid Isolation Kit (Invitrogen, Carlsbad CA). One normal pituitary tissue block was used as control. Real-Time PCR with house-keeping RPL13A gene attested to the efficacy of RNA recovery. RNA (300 ng) was hybridized to Human HT-12V4 expression bead Chip (approx 29,000 transcripts) and analyzed with the WG-DASL-HT assay (Illumina, San Diego CA). Results were processed with Genome Studio software.

Results. Hybridization yielded informative data in 41 pituitary adenoma specimens. POMC was overexpressed in all corticotrope adenomas attesting to validity of microarray analysis. Unsupervised clustering analysis revealed several different clusters, all clearly distinct from the normal pituitary gene expression profile. Clustering according to surgical outcome revealed distinct expression profiles.

Conclusion. Microarray analysis on archival pathology specimens proved a valid and informative technique for the study of Cushing’s disease molecular features. Human ACTH-secreting adenomas appear to present several, distinct gene expression profiles.

 

Nothing to Disclose: MFC, MT, AGA, DG, ML, FC, FP

19000 16.0000 THR-508 A Gene Expression Profiling in Human ACTH-Secreting Pituitary Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Ozlem Haliloglu*1, Esra Suheda Hatipoglu2, Fatma Ela Keskin1, Nurperi Gazioglu3 and Pinar Kadioglu1
1Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey, 2Liv Hospital, Istanbul, Turkey, 3Istanbul University , Cerrahpasa Medical School, Istanbul, Turkey

 

Introduction: The heterogeneity of the disease and the contraversies about the biochemical tests and imaging techniques can sometimes put the diagnosis of Cushing’s Disease and localization of hypercortisolism into a big challenge.

Clinical Case: A 54 year old male patient admitted to hospital with the complaints of nausea and dizziness. Brain MRI revealed a 17x14x22mm pituitary macroadenoma. The anterior pituitary functions were investigated and the tests were consistent with hypercortisolism: Abnormal 1mg and 2 days-2mg dexamethasone supression ( 6,5 and 5.8µg/dl respectively) and increased 24 hour urinary cortisol levels ( 264 µg/day). He had a pituitary adenomectomy but the hypercortisolism persisted and he was admitted to our center to find out the localization of the cortisol-secreting tumor.

In his past history, he has been followed up for bilateral adrenal lesions for 6 years. Upper abdominal CT, taken 1 year ago, represented a 25x32mm in the right and 10x19mm in the left solitary lesions of the adrenal gland showing a very strong, diffuse enhancement at the early arterial (R/L: 86/60HU) and also late venous (R/L: 100/67 HU) phases. At admission, adrenal MRI obtained at our center showed bilateral nodular lesions, 10x7mm on left – 28x20mm on the right side, which didn’t lose signal intensity on chemical shift imaging. Imaging characteristics of adrenal lesions placed adrenal Cushing Syndrome and pheochromocytoma at the first line of differential diagnosis. A PET scan was done for the exclusion of malignancy of the adrenal lesions and SUVmax was 3.6; not consistent with malignancy. The serum and urinary cathecholamines and metanephrine levels were within the normal range.

Hypercortisolism was also being evaluated by the suppression tests and they targetted the pituitary. Cavernous sinus sampling was done and consistent with pituitary. The post-operative pituitary MRI showed an 8x3mm residual tumor and the patient underwent second pituitary operation with the diagnosis of Cushing’s Disease. The pathology of the tumor was “corticotroph cell adenoma”.The third month post-operative MRI showed no residual tumor and the patient was in remission based on the supression tests. The patient again became hypercortisolemic at the 18th month post-operatively and the new sella MRI showed a 14x11x13mm adenoma.

Conclusion: Localization of the tumor and management of Cushing Syndrome can be very challenging and may necessitate advanced diagnostic procedures including PET/CT.

 

Nothing to Disclose: OH, ESH, FEK, NG, PK

19776 17.0000 THR-509 A A Challenge to Diagnose and Manage: A Patient with Hypercortisolism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Maliha Jumani*1, Rahul Ravilla2, Sowmya Chandra Reddy1 and Peter Anthony Goulden3
1University of Arkansas for Medical Sciences, Little Rock, AR, 2University of Arkansas for Medical Sciences, 3University of Arkansas for Medical Sciences/ Central Arkansas Veterans Health Care System, Little Rock, AR

 

Background: Cushing’s syndrome encompasses a large group of signs and symptoms, some of which are common in the general population. Poorly controlled hyperglycemia in an obese patient may provide a clue to the presence of Cushing's syndrome but requires a significant index of suspicion. Several biochemical investigations may be required.

Clinical case: We describe the case of a 68 year old female with diabetes mellitus with rapidly deteriorating glucose control, who required intensive high dose insulin therapy to achieve normoglycemia during a hospital admission. History and physical exam were remarkable for proximal myopathy and easy bruising. Initial biochemical assessment was consistent with Cushing’s disease: an abnormal 1mg dexamethasone suppression test (cortisol- 4.3 mcg/dl, n <1.8 mcg/dl), elevated midnight salivary cortisol levels (0.216 and 0.416 mcg/dl, n <0.145mcg/dl), two 24 hour urine free cortisol values one of which was elevated (58 and 35.1 mcg/24hr, n <45 mcg/24hr) and an ACTH which was inappropriately normal (22 pg/mL, n 6-58pg/mL). However, a 48 hour low dose dexamethasone suppression test showed a significant degree of suppression of the serum cortisol to 2.2 mcg/dl.

MRI pituitary showed a right sided 6 x 8 mm pituitary adenoma. Inferior petrosal sinus sampling was then performed which clearly demonstrated an elevated central to peripheral ACTH gradient (peak central to peripheral ACTH ratios of 28 and 110 pre and post CRH respectively). The patient underwent transphenoidal surgical resection with pathology showing an adenoma diffusely positive for ACTH on immunohistochemistry. Following surgery, the patient’s insulin requirement for diabetes management significantly decreased and she reported a subjective improvement in symptoms of fatigue and bruising. 

Discussion: We highlight a case of Cushing’s disease where a high index of clinical suspicion was required, particularly in relation to the suppression of cortisol to almost normal levels on the 48 hour low dose test. We think the case highlights the pitfall of relying on this investigation in the work-up of Cushing’s disease. Although the incidence has been reported as 2-3 cases per million per year, health care professionals should be conscious of Cushing’s syndrome as a secondary cause of conditions such as obesity, depression, diabetes and uncontrolled hypertension.

 

Nothing to Disclose: MJ, RR, SC, PAG

19966 18.0000 THR-510 A Pitfalls of the 48 Hour Low Dose Dexamethasone Suppression Test in Diagnosing Cushing's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Beatriz Lecumberri*1, Carlos Pérez1, Maria Jose Gonzalez-Beato1, Remedios Frutos1, Juan Alvarez-Linera2, Jose Ramon Arribas1, Eduardo Lopez-Granados1, Cristina Alvarez3, Isabel Esteban1, Teresa Sancho1, Pedro Herranz-Pinto1 and Luis Felipe Pallardo3
1La Paz University Hospital, 2Hospital Ruber Internacional, 3La Paz University Hospital, Madrid, Spain

 

Background: Kaposi Sarcoma (KS) is a vascular highly malignant tumor involving blood and lymphatic vessels caused by human herpesvirus 8 (HV8) infection associated with immunosuppression. It has been described in patients with AIDS, transplant patients, and after corticosteroid therapy. There are only 3 reported cases of KS in patients with endogenous Cushing's Syndrome (CS): 1 pulmonary KS in a patient with ACTH-independent adrenal CS (1), and 2 cutaneous KS in patients with ACTH-dependent CS (ACS) (2, 3). All were HIV-negative. We present the first case of simultaneous intrathoracic and cutaneous KS in a patient with ACS.

Clinical Case: A 67-year-old HIV-negative man presented to our emergency room in April 2014 with worsening swelling of both legs in the last 2 weeks and nocturia. Physical examination revealed mild facial plethora and dorsal hump, bilateral pitting edema up to the mid-thigh and several subcentimetric purple lesions in both feet's toes and left arm. Biochemical evaluation detected persistent hypokalemia at 2.5 mEq/L, serum cortisol of 46.9-59.5 μg/dL (nv 4.3-22), ACTH 131-353 pg/mL (5-46), 24-hour urine free cortisol 1229-1486 μg/24 h (<90 μg/24 h) and low TSH, Free T4, FSH/LH, total testosterone, GH and IGF-1 levels. Suppression tests were not able to differentiate an ectopic vs a central source of his abnormal ACTH. Metyrapone treatment at 750 mg/daily achieved normocortisolism. Progressive regression of the cutaneous lesions and normalization of FSH/LH, TSH and IGF-1 levels were observed afterwards. 1.5-TESLA pituitary MRI and 18F-FDG PET were described as normal, octreoscan demonstrated bilateral-symmetric uptake in the adrenals only, and thoracic CT scan showed a 10 mm right inferior lung nodule and mediastinal lymph nodes. Histopathology after videothoracoscopy resection of these lesions revealed a HV8 positive KS in a lymph node of the right pulmonary ligament. Cutaneous biopsy confirmed a KS. Inferior petrosal sinus sampling found a > 3 central to peripheral ACTH ratio with lateralization to the right, and 3-TESLA pituitary MRI identified a 5 mm right lesion suggestive of pituitary microadenoma that was removed through transsphenoidal endoscopic surgery. ACTH levels remained high during the uncomplicated early postoperative period.

Conclusion: Cutaneous and intrathoracic KS manifestations may appear in HV8 positive patients with ACS, facilitated by cortisol-induced immunosuppression, and are able to improve after hypercortisolism control without further specific treatment. The gradual regression of KS observed in our patient, and similarity between KS cutaneous lesions and those typically produced by CS's capillary fragility suggest that KS in patients with ACS may easily pass unnoticed. At imaging detection intrathoracic KS lesions may also resemble metastasis from other malignancies. KS long-term outcome in patients with cured ACS is still unknown.

 

Nothing to Disclose: BL, CP, MJG, RF, JA, JRA, EL, CA, IE, TS, PH, LFP

20026 19.0000 THR-511 A Intrathoracic and Cutaneous Kaposi's Sarcoma in an HIV-Negative Patient with ACTH-Dependent Cushing's Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Ricardo R Correa*1, Giampaolo Trivellin1, Yulong Li2, Maria Batsis3, Fabio R Faucz4, Prashant Chittiboina5, Adrian F Daly6, Albert Beckers6, Maya Beth Lodish3 and Constantine A Stratakis3
1National Institute of Health, Bethesda, MD, 2NIH, 3National Institutes of Health (NIH), Bethesda, MD, 4National Institutes of Health, Bethesda, MD, 5National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD, 6CHU de Liège-University of Liège, Liège, Belgium

 

*RC and GT shared first authorship

Introduction: Cushing disease (CD) is the most common cause of Cushing syndrome (CS).  Although several gene mutations (e.g., MEN1, CDKN1B and AIP) have been identified in patients with familial CD, these mutations only account for about 5% of all pituitary adenomas.  There is a great need to identify other genetic alterations to understand the pathogenesis of CD, especially in sporadic cases. We herein report two cases of sporadic CD associated with two missense variants (p.G31S and p.T293I) in GPR101, an orphan G-protein coupled receptor (GPCR).

Cases: The first patient is an adolescent female who presented with excessive weight gain, moon face, buffalo hump, headache and blurry vision at 16 years of age. The laboratory workup supported the diagnosis of CD and a right pituitary mass was found on MRI. She underwent transsphenoidal resection of the pituitary lesion and the pathology was consistent with pituitary adenoma, including immunoreactivity for ACTH. Two years after the initial surgery, some of her symptoms recurred. The results of laboratory workup supported relapse of CD, including elevated serum ACTH and 24-hour urine cortisol, CRH testing and 8 mg dexamethasone testing were consistent with CD. The new imaging showed a 4 mm hyper-enhancing microadenoma in the right side of the pituitary gland. She went on to have the residual pituitary tumor resected, and she remained in remission until her most recent follow up one year later. The second patient is a 12 year-old female who presented with obesity, headache, and growth failure for the preceding two years. On examination, her BMI was 29 with acaththosis nigricans and buffalo hump. The laboratory workup showed elevated serum ACTH level and 24-hour urine cortisol excretion, increased plasma ACTH and cortisol levels after CRH injection, and suppressed serum cortisol level after 8 mg dexamethasone. Imaging did not reveal pituitary or adrenal lesions.  She underwent surgical exploration of the pituitary, and the biopsy showed clusters of corticotroph cells. Postoperatively, her ACTH and serum cortisol level significantly decreased, one year post surgery she remained in remission.

Discussion: GPR101 is an orphan GPCR that is strongly expressed in the hypothalamus in rodents and humans, where it may play a role in hypothalamic control of energy homeostasis and possibly pituitary hormone secretion. Both variants are reported in the dbSNP database of controls. While p.T293I is a relatively common variant with a minor allele frequency (MAF) of 5%, p.G31S is a very rare variant, with a MAF of 0.045%. Although the role of these GPR101 mutations in CD requires further elucidation, our findings suggest a potential relationship between genetic alterations in this GPCR that may be responsible for some cases of CD.

 

Disclosure: AFD: Ad Hoc Consultant, NPS, Clinical Researcher, Pfizer, Inc.. AB: Investigator, Ipsen, Medical Advisory Board Member, Novartis Pharmaceuticals, Clinical Researcher, Pfizer Global R&D. Nothing to Disclose: RRC, GT, YL, MB, FRF, PC, MBL, CAS

21472 20.0000 THR-512 A An Orphan GPCR May be Mutated in Patients with Cushing Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Adam Hassan Maghrabi*1, Madiha Iqbal Khan1, Vicki J. Schnadig2 and Ligia Maria Belalcazar3
1UTMB, Dickinson, TX, 2UTMB, Galveston, TX, 3UTMB, Galvetson, TX

 

Background: The advances in diagnostic measures and management of Cushing's disease made Nelson’s syndrome a rare occurrence in endocrine practice. Nelson’s syndrome may be defined by the presence of an expanding pituitary mass following bilateral adrenalectomy for Cushing’s disease, elevated adrenocorticotropin hormone (ACTH) levels, and in its classical form, by accompanying skin hyperpigmentation. The predominant cause of morbidity in Nelson’s syndrome results from tumor extension, possible malignant transformation, and loss of pituitary function (1,2), complications that make early diagnosis a clinical priority.

Clinical Case: A 42 year-old Hispanic male, was diagnosed at age 39 with ACTH-dependent Cushing syndrome. He was found to have elevated 24-hour urine cortisol (1968 µg/24 h) and ACTH (144 pg/ml) levels. In addition, high-dose dexamethasone suppression test was negative, and brain MRI at that time was unremarkable. Workup for presumed ectopic ACTH did not reveal a source, including negative CT and octereotide scans, negative ACTH-stains in thyroid nodules aspirates. He was managed medically with ketoconazole and metyrapone, but due to a poor response and worsening metabolic complications, subsequently underwent bilateral adrenalectomy, was placed on fludrocortisone and prednisone replacement, which lead to improvement of his metabolic disease. 2.5 years later, after a history of partial non-compliance with steroid therapy, he presented with fatigue, diplopia, headaches, nausea and skin hyperpigmentation. His biochemical workup showed a low AM cortisol level and an extremely high ACTH level (14,220 pg/ml). A brain MRI showed a mass occupying the body of the sphenoid bone and the superior clivus, compressing and deforming the pituitary gland and slightly displacing the optic chiasm. Head CT confirmed extension into the sphenoid sinuses. Imaging studies were reported suggestive of a chordoma, chondrosarcoma, metastasis, or of an atypical pituitary neoplasm. Ophthalmology evaluation showed left ptosis and no visual field defects. Prednisone was reinitiated; ACTH levels dropped to 2,190 pg/ml. The patient underwent transphenoidal resection of the tumor. Ptosis and headaches resolved. Pathology showed strong immuno-staining for ACTH, p53 nuclear staining in approximately 50% of tumor cells, and Ki67 proliferation index of 10-15%, categorizing the tumor as an atypical pituitary adenoma, and raising concern for a possible pituitary carcinoma. Repeat biochemical evaluation and MRI are pending.

Conclusion: Nelson’s syndrome is a rare endocrine condition associated with significant morbidity due to the development of aggressive ACTH-producing pituitary tumor. A history of Cushing’s disease and bilateral adrenalectomy should alert the clinician to the possible presence of this aggressive endocrinopathy.

 

Nothing to Disclose: AHM, MIK, VJS, LMB

18505 21.0000 THR-513 A An Aggressive Pituitary Tumor in a Patient with Skin Changes: The Challenge of Nelson's Syndrome Persists in the Twenty-First Century 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Kharis Burns*1 and Jenny Elizabeth Gunton2
1Westmead Hospital, Sydney, Australia, 2Westmead Millennium Institute, Westmead, Australia

 

Background: Ketoconazole was a first-line agent for suppressing adrenal steroid production in Cushing’s disease. It is now unavailable. Fluconazole, another azole antifungal, represents an alternative although its in-vivo efficacy is unclear.

Clinical Case: A 61 year old Indian female presented with features of weight gain, facial swelling, abdominal striae and worsening depression. Background history included type 2 diabetes, hypothyroidism, hypercholesterolaemia, hypertension, depression, osteoporosis and fibromyalgia. Her HbA1c had increased to 9.1% (76mmol/mol) despite increasing doses of insulin. She had noticed facial swelling, easy bruising, fatiguability and swelling over the cervical prominence. Blood and urine investigations confirmed cortisol excess, a random afternoon cortisol was 599nmol/L (ref 70-325) with ACTH 11.1pmol/L (ref 0-12.0), a urinary free cortisol/ creatinine ratio was elevated at 150.4nmol/mmol (normal range <30) and there was failure to suppress with high dose dexamethasone with cortisol 480nmol/L (ref 138-650) and ACTH 10.2pmol/L (ref 0-12.0) at 48 hours. MRI revealed a 4mm pituitary microadenoma and inferior petrosal sinus sampling confirmed Cushing’s disease. Transsphenoidal resection was performed and symptoms improved. Six months later, symptoms returned with biochemical evidence of glucocorticoid excess including paired morning cortisol 944nmol/L (reference range 138-650) and ACTH 22.0pmol/L (reference range 0-12). A 24 hour urine free cortisol was abnormal at >2200nmol/day (normal range 300-900). Metyrapone was commenced at 500mg three times daily with good effect though the patient became clinically Addisonian and a block and replace regimen with hydrocortisone was implemented. Ketoconazole was later added for further inhibition of cortisol production, at 400mg daily, and the dose of metyrapone was decreased to 500mg twice daily. Due to difficulties with access to ketoconazole, fluconazole was substituted with dose escalation to 400mg daily. The patient’s serum cortisol and urinary free cortisol remained normal on this regimen at 6 months.

Conclusion:To our knowledge this is the first case demonstrating prolonged in vivo efficacy of fluconazole in combination with low dose metyrapone for the treatment of Cushing’s disease. Given fluconazole has a more favourable toxicity profile and worldwide issues with ketoconazole access, we suggest that fluconazole is a suitable alternative in the medical management of Cushing’s disease where surgery is unsuccessful, contraindicated or the effects of radiation treatment are pending.


 

Nothing to Disclose: KB, JEG

19426 22.0000 THR-514 A Fluconazole in the Treatment of Cushing's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Amy M DeGueme*, Elizabeth E King and Sasan Mirfakhraee
UT Southwestern Medical Center, Dallas, TX

 

Background: Patients with Cushing’s disease (CD) are not always successfully treated with or are not candidates for surgery and thus may require alternate treatment strategies. The following case series reviews 6 patients with refractory CD subsequently treated with the selective glucocorticoid receptor antagonist, mifepristone (MIFE).

Clinical Case: The series includes 6 patients with CD between 21-65 years of age: 5 women and one man, who were treated with MIFE. Of the 6 patients, 5 had a history of transsphenoidal pituitary surgery (TSS) (3 with repeat surgeries) while the sixth patient was treated with mifepristone perioperatively. Other previous therapies included ketoconazole, cabergoline plus ketoconazole, pasireotide, and Gamma Knife therapy (GK).

Patients 1-4 were previously treated with ketoconazole, yet had persistent metabolic issues (such as hypertension, weight gain, and hyperglycemia), or had intolerability to the drug necessitating cessation. Of these 4 patients, 3 were switched from ketoconazole to MIFE with maintenance doses ranging from 600-1200 mg daily, which was accompanied by clinical improvements in weight, glycemic control, and blood pressure. The 4th patient was treated with GK followed by ketoconazole but did not tolerate the medication and was initiated on MIFE 300 mg daily; his dose was adjusted to 300 mg every other day due to cortisol-withdrawal symptoms and both his symptoms and metabolic parameters improved.

Patient 5 was a 21-year old woman with CD, complicated by severe obesity (BMI 60 kg/m2) and type 2 diabetes mellitus, who received TSS and GK therapy but continued to have hypercortisolism. MIFE was initiated and titrated to a maintenance dose of 900 mg daily, which was continued as bridging therapy after GK. One year after GK, while on MIFE, her total daily insulin dose decreased from 105 to 22 units and she had lost 30 lbs.

Patient 6 was a 36 year-old man with rapid onset CD over 1 month (ACTH 132 pg/mL, normal 10-60 pg/ml) and 8 am serum cortisol 71 mcg/dL (5-23 mcg/dL), in the context of diabetes mellitus, hypertension, bilateral pulmonary emboli, and persistent hypokalemia. Due to severe complications related to hypercortisolism, he was started on MIFE 300 mg daily as bridging therapy for TSS. During treatment with MIFE, his total daily insulin requirement dropped from 51 units to 5 units, one antihypertensive medication was discontinued, and potassium supplementation decreased from 160 mEq to 80 mEq daily.

Conclusion: We describe 6 complex cases of Cushing's disease, all involving treatment with mifepristone. Several beneficial outcomes were noted, including improvements in blood pressure, HbA1c, weight, and reduction in concomitant medications.

 

Nothing to Disclose: AMD, EEK, SM

21281 23.0000 THR-515 A Medical Treatment of Cushing's Disease with Mifepristone: A Clinical Case Series 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Iram Hussain*1, Elizabeth E King1 and Sasan Mirfakhraee2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Medical Center, Dallas, TX

 

Background: Primary treatment of most patients with Cushing’s disease is surgical, with failure rates of 10–30% and recurrence rates of 20–25% at ten years following surgery. Subsequent radiosurgery can take years to achieve biochemical control, requiring continued pharmacotherapy. Mifepristone, a glucocorticoid receptor antagonist indicated for the treatment of hypercortisolism in adults with type 2 diabetes mellitus or glucose intolerance who have failed surgery or are not surgical candidates, may improve metabolic parameters in these patients, but clinical experience is limited.  

Clinical Case: The patient is a 21-year-old female with Cushing’s disease, diagnosed two years prior in the context of morbid obesity, hypertension, and diabetes mellitus with severe acanthosis nigricans.  She underwent transsphenoidal surgery shortly after diagnosis but developed recurrence of disease ten months later.  At the time of recurrence, her urinary free cortisol was 85 mcg/24 hr (normal 3.5 – 45 mcg/24 hr) and blood pressure was 147/83 mmHg. She had regained the 30 lbs that she lost after surgery (weight 320 lbs) and developed worsening glycemic control (HbA1c increased from 8.1% to 9.8%); her total daily insulin dose was 130 units.  After discussion of her therapeutic options, she agreed to Gamma Knife radiosurgery, and mifepristone was started 2 months prior as a bridging therapy. Her glycemic control improved within weeks of starting mifepristone (titrated up to 900 mg every day) and her insulin dose was decreased in subsequent visits to prevent hypoglycemia. Her clinical course was complicated by hypokalemia (thought to be largely attributed to her non-adherence with spironolactone and potassium supplementation). After twelve months of mifepristone therapy, her weight dropped by 30 lbs, her glycemic control markedly improved (HbA1c 6%) and her insulin requirement decreased to only 22 units daily. Her repeat MRI pituitary ten months after radiosurgery showed an interval decrease in the size of her residual tumor.

Conclusion: The complete effect of radiosurgery on Cushing’s symptoms can take years to be evident, requiring concomitant pharmacotherapy for many patients. In this patient with Cushing’s disease, mifepristone was associated with weight loss and decreased insulin requirements, which helped to bridge the transition to efficacy with radiosurgery.

 

Nothing to Disclose: IH, EEK, SM

21299 24.0000 THR-516 A Mifepristone As a Bridging Therapy to Gamma Knife Radiosurgery in Recurrent Cushing's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Samata Basani*1, Elizabeth E King2 and Sasan Mirfakhraee3
1UT Southwestern Medical Center, 2University of Texas Southwestern Medical Center, Dallas, TX, 3UT Southwestern Medical Center, Dallas, TX

 

Background: Cushing’s disease (CD) is associated with significant comorbidities, including hypertension, diabetes mellitus, impaired immunity, and hypercoagulability, which can lead to increased risk when undergoing surgical resection. Medical management of severe hypercortisolism may be beneficial for some patients prior to surgical resection. Mifepristone is a selective glucocorticoid receptor antagonist indicated for the control of hypercortisolism in adults with type 2 diabetes mellitus or glucose intolerance who have failed surgery or are not surgical candidates. We review a case where mifepristone was used preoperatively in a patient with severe CD.

Clinical Case: A 36-year old African-American man presented with features of severe CD, including fatigue, easy bruising, generalized muscle wasting, and facial swelling in the setting of new-onset diabetes mellitus, hypertension, severe hypokalemia (2 meq/L), and bilateral pulmonary embolism. His BMI was 27 kg/m2 with blood pressure of 140/95 mmHg on four-drug antihypertensive therapy (losartan, amlodipine, hydralazine, and spironolactone). Examination revealed facial puffiness, palmar erythema, ecchymoses of non-stress regions, and proximal muscle weakness. Laboratory evaluation revealed 24 hour urinary-free cortisol of 13,943 µg, ACTH of 190 pg/mL, and HbA1c of 10%. Morning serum cortisol was 46 µg/dL (baseline 71 µg/dL) after high-dose dexamethasone suppression test. In order to evaluate the source of hypercortisolism, he underwent CRH stimulation testing, which showed a tenfold increase in the serum ACTH level and doubling of the cortisol level compared with baseline. MRI pituitary showed a 6 mm area of hypoenhancement on the left side. Inferior petrosal sinus sampling confirmed a central source of hypercortisolism. He was treated preoperatively with mifepristone for five weeks at a maximum dose of 300 mg daily, during which his insulin requirement decreased from 65 units to 5 units daily, losartan was discontinued, and his potassium supplementation was decreased from 160 mEq to 40 mEq daily. Mifepristone was discontinued 2 weeks before surgery without worsening glycemic or blood pressure control. He underwent sublabial trans-sphenoidal resection of the pituitary adenoma; immunoperoxidase staining confirmed ACTH expression. Insulin and potassium supplementation were stopped, an additional antihypertensive medication was discontinued, and his glucocorticoid dose continues to be tapered.

Conclusion: Patients with CD are at increased risk of complications in the perioperative period. In this patient with severe CD, preoperative treatment with mifepristone was associated with improved metabolic outcomes. Treatment with mifepristone may help improve surgical outcomes and decrease the risk of surgical complications associated with CD.

 

Nothing to Disclose: SB, EEK, SM

21301 25.0000 THR-517 A Mifepristone Administration for Preoperative Treatment of Severe Hypercortisolism Associated with Cushing's Disease: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Mostafa Alfishawy1, Alexandria Ajoa Atuahene2, Lekha Tummalapalli3, Gabrielle Page-Wilson4, Sharon L. Wardlaw4, Kalmon D. Post2 and Eliza B. Geer*2
1Icahn School of Medicine at Mount Sinai/Queens Hospital Center, New york, NY, 2Icahn School of Medicine at Mount Sinai, New York, NY, 3Icahn School of Medicine at Mount Sinai, NYC, NY, 4Columbia University College of Physicians & Surgeons, New York, NY

 

Background:

Mifepristone is a glucocorticoid and progesterone receptor antagonist that is used to treat hyperglycemia due to inoperable persistent or recurrent  Cushing’s syndrome (CS). Occult ectopic CS, which occurs when the ACTH tumor is not identified by standard imaging or octreotide scans, represents a management challenge for the endocrinologist.

Case Report:

We report a 50 year-old female who presented in April 2012 with progressive psychological decline, amenorrhea, hirsutism, central weight gain, and muscle weakness, and was found to have severe ACTH-dependent CS. Twenty four hour UFC was 1361 mcg/24h, salivary cortisol 1.28 and 2.23 µg/dL (normal to 0.09, Esoterix) and plasma ACTH 107 pg/ml. Eight mg overnight dexamethasone suppressed serum cortisol was 31.3 ug/dl, pituitary MRI did not reveal a tumor, and plasma POMC concentration was elevated (75 fmol/ml), consistent with ectopic disease. However, inferior petrosal sinus sampling showed a strong central to peripheral ACTH gradient (3468 to 165 pg/ml), with 5-fold lateralization to the right, and there was petrosal vein stimulation in response to 10 mcg of DDAVP (382 increasing to 3468 pg/ml at 10 minutes). She underwent trassphenoidal surgery (TSS) but no tumor was identified and cortisol concentrations remained elevated even after right hemihypophysectomy. Repeat TSS or bilateral adrenalectomy were offered but not pursued by the patient and her family. After a brief course of ketoconazole treatment, mifepristone 300 mg daily was started in November 2012, with a dramatic improvement in psychiatric manifestations. Mifepristone was uptitrated to 900 mg daily over 5 months, but the patient was subsequently lost to follow up for 18 months. In October 2014, she presented to our emergency room with hypertensive urgency while still taking mifepristone 900 mg daily. Endocrine testing revealed a marked elevation of plasma ACTH (622 pg/ml), DHEAS (817 mcg/dl) and total testosterone (789 ng/dl). Pituitary MRI revealed a new lesion within the right cavernous sinus region surrounding the internal carotid artery, not contiguous with the pituitary gland, consistent with a newly identified parasellar ectopic ACTH producing tumor.

Conclusions:

Despite the lack of cortisol response to acute dexamethasone suppression in our case, there may be an effect of long-term glucocorticoid antagonism on ACTH tumor enlargement, similar to Nelson’s syndrome occurring after bilateral adrenalectomy. Thus, mifepristone treatment may facilitate the identification of occult ACTH tumors. Patients with ACTH tumors receiving long-term mifepristone therapy should be monitored carefully with serial imaging to assess for tumor enlargement.

 

Nothing to Disclose: MA, AAA, LT, GP, SLW, KDP, EBG

20984 26.0000 THR-518 A Mifepristone Treatment Uncovers an Occult Ectopic Parasellar ACTH Tumor: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Eliza B. Geer*1, Aida Glamocak2, Ghulam Warsi3, William Chang2, Dheepa Chari2 and William H Ludlam3
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Novartis Pharmaceuticals, East Hanover, NJ, 3Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

The ACCESS study (NCT01995734) is an open-label, uncontrolled, single-arm, multicenter, expanded-treatment, protocol safety study designed to provide acromegalic patients access to pasireotide long-acting release (LAR) while regulatory approval is sought. This interim analysis examined the safety of pasireotide LAR in patients who have received treatment through September 19, 2014.

A total of 27 patients, 10 males and 17 females, with elevated levels of IGF-1 and random GH >1 µg/L received pasireotide LAR 40 mg IM depot injection every 28 days. All adverse events (AEs) and serious AEs were monitored and recorded.

The mean age was 43.5 years (range, 22-67 years), and the mean body mass index at baseline was 33.4 kg/m2. Four of 27 patients (15%) had dose increases to 60 mg IM, and 1 of 27 patients (4%) had a dose decrease to 20 mg IM. The mean duration of treatment was 116.1 days (range, 28 to 252). One patient had a prior history of impaired fasting glucose, and 9 had a history of diabetes. AEs were reported in 21 of 27 (78%) patients. The most common AEs included diarrhea (22%), nausea (22%), abdominal pain (15%), and increased blood glucose (15%). Three of the 27 patients (11%) experienced a total of 5 grade 3 AEs (abdominal pain, nausea, vomiting, muscle spasms) and 1 grade 4 AE (adenocarcinoma of the colon). The patient with the grade 4 AE discontinued therapy because of non–drug-related causes (progression of colorectal cancer).

Seventeen patients (63%) had evaluable data for glycemic parameters for a minimum of 3 months after initiation of treatment. Among these patients, the mean duration of treatment was 154.8 days (range, 112-252). Mean HbA1cvalues increased from 5.88% (range, 5.1%-7.5%) at baseline to 6.88% (range, 5.2%-9.3%; p < 0.0001) at 3 months. A reduction in fasting insulin levels was observed from 23.1 microU/mL at baseline to 16.4 microU/mL at 3 months. The reduction in insulin levels likely contributed to an increase in mean fasting plasma glucose in patients receiving pasireotide LAR, which rose from 100.3 mg/dL at baseline to 134.9 mg/dL at 3 months. Eight of 17 patients (47%) initiated antidiabetic treatment or received an increased number of concomitant antidiabetic medications while receiving treatment with pasireotide.

The ACCESS study assessed safety of pasireotide in patients with acromegaly within a “real world” setting. This interim analysis demonstrated low rates of serious AEs and discontinuation, providing evidence for the favorable safety of pasireotide LAR in patients with acromegaly. As expected, moderate elevations in mean HbA1c and fasting plasma glucose were observed in patients treated with pasireotide LAR but, notably, there have been no discontinuations of treatment due to hyperglycemia, suggesting that clinicians and patients felt the hyperglycemia was manageable and that it is beneficial to remain on therapy.

 

Disclosure: AG: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. GW: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. WC: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. DC: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. Nothing to Disclose: EBG

21009 27.0000 THR-519 A An Acromegaly, Open-Label, Multi-Center, Safety Monitoring Program for Treating Patients with SOM230 (Pasireotide) LAR Who Have Need to Receive Medical Therapy (ACCESS)—Interim Analysis Results 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Mohammad Tufail Ijaz*1, Neven Pesa2 and Dat Nguyen2
1Genesis Medical Group, Zanesville, OH, 2Corcept Therapeutics, Menlo Park, CA

 

Background: Surgical treatment for Cushing’s Disease (CD) is not always successful and repeat surgery may not be an option for some patients due to the increased risk and lowered success rate with each reoperation. Even in cases with postoperative biochemical remission, clinical and metabolic manifestations (e.g., cushingoid appearance, obesity, diabetes) may still persist. There is a need for therapies that can offer sustained clinical and metabolic benefits. The following case reviews a patient with refractory CD despite multiple treatment modalities and who subsequently responded to treatment with a competitive glucocorticoid receptor antagonist, mifepristone.

Clinical Case: A 44-yr old female patient presented in 2012 with uncontrolled CD after several unsuccessful interventions.

Past treatments included 2 failed transsphenoidal surgeries (TSS), radiation therapy, bromocriptine and ketoconazole.

Her first TSS was performed in 2008 but her preoperative Cushingoid appearance was unchanged a year later. Her BMI 39.1, A1c (6.4%) and urine cortisol levels (85µg/24h [nl<45]) were high while taking bromocriptine 2.5mg BID.  Her MRI showed a 1.1x1.4cm pituitary mass. Ketoconazole 200mg BID was initiated but stopped after 1 month due to elevated ALT (97 units/L) and AST (52 units/L). A second TSS was performed in 2010 followed by Intensity Modulated Radiation Therapy 2 months later. A year after the 2nd TSS, the ACTH (54pg/mL) and urine cortisol (74µg/24h) were elevated. Her BMI (38.4) remained high and she continued to exhibit Cushingoid features.

In 2012, the patient’s AM cortisol (28mcg/dL) and ACTH (108 pg/mL) remained high. UFC was normal despite signs and symptoms of Cushing’s syndrome (central obesity, BMI 37, moon facies, striae, easy bruising, thin extremities, and depression). Her BP was stable, and her A1c was 6%. Concomitant medications included levothyroxine 100mcg/d, sitagliptin/metformin 50mg/500mg BID, rosuvastatin 10mg/d, fenofibrate 145mg/d.

Mifepristone (Korlym®, Corcept Therapeutics) was initiated at 300mg/d and currently stabilized at 900mg/d. After ~2yrs of treatment, improvements in her signs and symptoms were observed: BMI 31.6, A1c 5.2% (without the use of diabetic medications), waist circumference decreased by 11cm to 108cm. Physical appearance was normal with minimal striae. The patient describes feeling ‘completely normal’; her depression resolved with mifepristone.

Conclusion: Control of metabolic and clinical manifestation of Cushing’s is often difficult to achieve and maintain. Prior to FDA approval, multiple therapies (e.g., 2xTSS, radiation, bromocriptine, ketoconazole) were tried without success in this patient with CD. The addition of mifepristone therapy resulted in several beneficial and sustained outcomes - including reductions in A1c, weight, and elimination of anti-diabetes medications.

 

Disclosure: MTI: Speaker, Astra Zeneca, Speaker, Eli Lilly & Company, Speaker, Boehringer Ingelheim, Speaker, Corcept, Speaker, Bristol-Myers Squibb, Speaker, Pamlab, Speaker, Merck & Co.. NP: Employer, Corcept. DN: Employee, Corcept.

19115 28.0000 THR-520 A Mifepristone for the Successful Treatment of Cushing's Syndrome after Multiple Failed Interventions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 493-520 5998 1:00:00 PM Prolactinoma, Prolactin and Cushing's Syndrome Poster


Kevser Onbasi*1, Hande Peynirci2, Orcun Kuet3, Canan Ersoy2 and Ahmet Bekar4
1Dumlupınar University, Kutahya, Turkey, 2Uludag University Medical School, Bursa, Turkey, 3Dumlupinar University, Kutahya, Turkey, 4Uludag University, bursa, Turkey

 

Acromegaly is chronic disorder that results from the excess of growth hormone (GH). Acromegalic patients may develop benign or malign neoplasms with a higher rate than the healthy population. Colon cancer is one of the most reported cancers in acromegalic patients. Also thyroid, skin and other gastrointestinal tumors have been reported also.  The malign cancer glioblastoma multiforme has been reported rarely in acromegalic patients. Here we wanted to describe two patients with glioblastoma and acromegaly.

 Case 1:  M. Y.  A 58-year-old man was admitted to our Hospital in October 2011 with hyperhidrosis and polyuria.  He was diagnosed to have acromegaly (GH level: 8ng/mL; IGF-1: 986 ng/mL), diabetes and pectus excavatum.  He was treated for his coexisting diabetes and dyspnea and was advised to be operated for acromegaly. The patient denied operation for his acromegaly and medical therapy for acromegaly was started. After 3 year treatment with lanreotide with 120 mg every 28 days his GH levels were still elevated and the pituitary mass was not shrinking. After several recommendations he was convinced for surgery. The pituitary tumor was removed.  He developed panhypopituitarism after surgery and replacement therapy was started. He was well after operation for one month, but after one month he experienced difficulties in walking and he told about weakness in muscles of the right side. A new CT scan revealed a new 3x3x3 cm mass lesion beginning from left centrum semiovale and extending to thalamus.  Neurosurgery advised a biopsy for this new lesion. Biopsy undertaken in another hospital revealed glioblastoma multiforme.

Case 2: M. U. A 40-year-old man was admitted to the Hospital with mild headache, and acromegalic limb appearance. His GH level was above 40 ng/mL and IGF-1 level was 1068 ng/mL. He was operated through the transsphenoidal route for his 3x2 cm mass lesion in the sella.  Postoperative GH levels were still elevated and octreotid 20 mg for every 28 days was started. At the sixth month after operation he experienced seizures. Control MR findings were consistent with two separate mass lesions in the parietooccipital region and residual tumour in the left cavernous sinus. After two months the mass in the temporal region was growing and extended to 7x4 cm and the patient was operated. The pathological diagnosis was consistent with glioblastoma multiforme.  

To the best of our knowledge there are only rare cases reported in the literature with glioblastoma multiforme in acromegalic patients. The most accompanying tumors are colon cancer and thyroid cancer.

 

Nothing to Disclose: KO, HP, OK, CE, AB

21727 1.0000 THR-418 A A Rare Combination of Tumors: Glioblastoma Multiforme in Two Cases of Pituitary Tumor (acromegaly) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Hee Sun Kwon, Jang Won Son, Sung Rae Kim and Soon Jib Yoo*
The Catholic University of Korea, Bucheon St. Mary’s Hospital, Bucheon, Korea, Republic of (South)

 

Acromegaly is associated with an increased risk for a variety of cancers such as colorectal, breast, bronchi and thyroid carcinoma. However, there have been a few reports of other malignancies in acromegaly patients. We report 3 cases of uncommon malignancy during the course of acromegaly.

A 46-year-old woman was diagnosed acromegaly in June 2011 (GH: 40 ng/ml, IGF-1: 582.42 ng/ml). After a transsphenoidal surgery (TSA), her IGF-1 was 333.95 ng/ml, and GH was 2.33 ng/ml under suppression test. She had been taking a dopamin agonist, cabergoline to treat acromegaly for 2 years (IGF-1 69.61, GH 3.34 in March 2013). She was told to have papillary thyroid carcinoma and had a total thyroidectomy around the same time. In May 2014, she was diagnosed serous cystadenoma in right ovary and underwent operation and chemotherapy.

A 35-year-old woman presented with acromegaly in 2012 (GH: 12.6 ng/ml, IGF-1: 592.26 ng/ml). Considering her fertility, cabergoline was administered to treat acromegaly in March 2012 (GH: 10.6 ng/ml, IGF-1: 426.57 ng/ml). She presented with bicytopenia and hepatosplenomegaly in February 2014. A bone marrow examination showed acute B-cell lymphoblastic leukemia. She underwent chemotherapy and bone marrow transplantation.

A 62-year-old woman was diagnosed acromegaly and had a TSA in Febrary 2003 (GH 68.19 ng/ml before TSA, GH 1.19 ng/ml after TSA). She had been taking lanreotide every 4 weeks for 11 years without complication. In Mar 2014, she complained of dyspnea at rest, we found out left renal cell carcinoma with lung and multiple bone metastasis. She has been taking conservative treatment without surgery considering her age.

 

Nothing to Disclose: HSK, JWS, SRK, SJY

21676 2.0000 THR-419 A Various Carcinomas Developed in Patients with Acromegaly : A Report of 3 Cases 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Dat Ha*1 and Karyne Lima Vinales2
1Phoenix VA Health Care System, Phoenix, AZ, 2Phoenix VA health Care system, Phoenix, AZ

 

BACKGROUND: Although hirsutism is common among women of reproductive age and in PCOS, it rarely is the initial presenting feature in acromegaly. In a series of 47patients with acromegaly, 50% had PCOS and 55.5% were noted to have hirsutism1. To our knowledge, only a couple of cases have been documented in which acromegalic patients presented with hirsutism2,3.

CASE: 33 year-old female with history of PCOS presents with progressively worsening hirsutism and menstrual irregularity since 2008.  She reports frequent need of shaving her face and chest daily, abdomen every couple of days and upper extremities weekly. She has a history of infertility. She also has noted hyperhidrosis, skin tags, deepening of her voice, widening gap of her teeth, mild frontal headache, increasing ring and shoe sizes, weight gain and development of pre-diabetes. Patient has carpal tunnel syndrome since 2002, which has progressively worsened.  She denies galactorrhea and visual impairment. She denies family history of endocrine tumors.  Physical exam revealed: BMI 33, BP 138/96, prognathia, macroglossia, mild diastema, frontal bossing, broad nose, dark coarse hair on face, thorax, upper extremities, back and pubic area, mild clitoromegaly, axillary acrochordon and acral enlargement. Visual field was grossly intact.

Labs revealed elevated DHEAS (364 mcg/dL; normal 40-325) and total testosterone (54 ng/dL; normal 2-45), elevated free (10.8 pg/mL; normal 0.2-5.0) and bioavailable testosterone (20.3 ng/dL; normal 0.5-8.5), low SHBG (16 nmol/L; normal 17-124) normal androstenedione (197 ng/dL) and 17-OH-progesterone (61 ng/dL), and pelvic US consistent with PCOS. She also had elevated IGF-1 (1447 ng/mL; normal 53-331) and elevated GH post OGTT (18.4 ng/mL). ACTH was normal (21 pg/mL), ACTH stimulation test was positive (cortisol 6, 14, 16 ug/dL at 0, 30, 60 min), normal FT4 (0.92 ng/dL; 0.70-1.48), and PRL was also normal (12.6 ng/mL). MRI confirmed 1.2cm pituitary macroadenoma. She underwent transsphenoidal surgery, with pathology confirming a mammosomatotroph.  

CONCLUSION: Recognizing that hirsutism and PCOS as part of the presentation of acromegaly may lead to earlier diagnosis, reduce morbidity and mortality of this rare disease.

 

Nothing to Disclose: DH, KLV

21604 3.0000 THR-420 A A Hairy Case:  Acromegaly Presenting As Hirsutism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Anupa Sharma*1, Eric Richfield2 and Sara E Lubitz1
1Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, 2Rutgers Robert Wood Johnson Medical School, Piscataway, NJ

 

Background: The concomitant presence of three histopathologically different lesions in the pituitary gland is a rare occurrence.  We present a unique case of a woman with a large pituitary mass, composed of a growth hormone producing microadenoma, lymphocytic hypophysitis, and a Rathke’s cleft cyst.

Clinical Case: A 35-year-old woman presented to the emergency room in June 2013 with complaints of fever and persistent headache for one year.  Evaluation revealed a suprasellar mass measuring 2.1 x 1.7 x 2.7 cm with upward mass effect on the optic chiasm.  The patient complained of amenorrhea for one year, snoring, increase in shoe size over three months, and hand swelling.  Hormonal evaluation revealed a prolactin level of 52 ng/mL(nl 2-23 ng/mL), FT4 1.11 ng/dL (nl 0.9-1.8 ng/dL), TSH 0.75 mIU/L (nl 0.35-5.5 mIU/L), FSH 2.5 mIU/mL, LH 0.9 mIU/mL (nl 0.8- 104 mIU/mL),  growth hormone 16 ng/mL (nl 0.01- 3.61 ng/mL) and IGF-1 683 ng/mL (nl 73-244 ng/mL).  Formal visual field testing revealed no deficits.  Physical exam was pertinent for frontal bossing, wide spaced teeth, prognathism, and sausage digits.  She underwent a transsphenoidal resection in September 2013 with the presumed diagnosis of acromegaly.  The patient received glucocorticoid and thyroid hormone replacement postoperatively. Final pathology revealed a growth hormone producing microadenoma, lymphocytic hypophysitis, and possible ruptured Rathke’s cleft cyst.  The microadenoma stained for growth hormone and surrounding cells were positive for FSH, prolactin, LH, ACTH, and minimal TSH expression. Lymphocytic hypophysitis was identified involving the normal pituitary tissue.  There was fibrosis present which may indicate a long-standing process. A large Rathke’s cleft cyst was also identified as part of the pituitary. Only a small portion of the cyst remained and contained ciliated epithelium without clear mucinous secretion.  It is presumed the Rathke’s cleft cyst likely ruptured, resulting in lymphocytic hypophysitis.

Conclusion: Case reports have identified a link between ruptured Rathke’s cleft cysts, lymphocytic hypophysitis and the presence of Rathke’s cleft cyst with growth hormone producing pituitary adenomas.  No reports have demonstrated the presence of three coexisting pathologies in a single pituitary adenoma.  It is a possibility that the Rathke’s cleft cyst rupture resulted in an inflammatory state predisposing to tumor formation and requires further investigation.

 

Nothing to Disclose: AS, ER, SEL

20736 4.0000 THR-421 A Acromegaly, Lymphocytic Hypophysitis, and Rathke's Cleft Cyst, Occurring in a Single Pituitary Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Joie Dj Quiba Isip*
Makati Medical Center, Makati City, Philippines

 

Background: Acromegaly is a rare pituitary tumor with an annual incidence of three to four cases per million people per year. Because of its insidious onset, diagnosis is often delayed or often overlooked by clinicians.

Clinical scenario: 37 year old male referred to the Endocrinology clinic due to elevated blood sugar. Upon examination frontal bossing, enlarged hands and feet with 2 cm diameter circumscribed mass at the right lobe of the thyroid gland were noted. 75 gram glucose stimulated Growth hormone was requested revealed: 0 hour 35.6ng/ml(NV 0-3 ng/ml), first hour 32.6 ngml, second hour 34.6 ngml. MRI of the pituitary gland showed sellar/suprasellar mass with cystic and solid components measuring 2x2x2.2cm without identifiable residual pituitary gland. Pre operative hormonal work up showed normal Prolactin: 7.85 ng/ml(NV 4.04-15.20 ng/ml),  and cortisol: 10.66ug/dl(NV 6.2-19.4 ug/dl), low TSH: 0.22 pmol/L (NV: 0.25-4 pmol/L)  High  FT4: 27 pmol/L(NV: 11.5-23 ug/dl). Patient denies symptoms of palpitation, diarrhea, tremors or insomnia. Thyroid scan showed homogenous with hypofunctioning nodules in both lobes. Thyroid ultrasound showed enlarged homogenous thyroid with multiple solid and cystic nodule.  

 3 weeks prior to admission, patient complained of anterior neck pain at the area of the thyroid most prominent on head turning and swallowing. He had bout of colds few weeks before. Anti-TPO, ESR were normal, relieved with intake of NSAIDs.

Patient was admitted for transphenoidal surgery. Histopathology revealed large deeply stained irregular nuclei, reactive to synaptophysin, growth hormone, TSH and chromogranin, non reactive to CK20 and focally reactive to CK7.  Diagnosis: Consistent with atypical pituitary adenoma growth hormone positive, TSH positive.

Conclusion: Acromegaly is frequently associated with thyroid disorders. Manifestations of hyperthyroidism were not observed possibly masked by the features of acromegaly. This patient presented with acromegaly on top multiple thyroid disorders: acute thyroiditis, nodular goiter and TSH secreting pituitary tumor.

 

Nothing to Disclose: JDQI

19800 5.0000 THR-422 A Growth Hormone, TSH Co Secreting Atypical Pituitary Macroadenoma in an Acromegaly Patient Complicated By Acute Thyroiditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Mahnaz Mellati*, Manuel Ferreira Jr. and Anthony Joseph De Santis
University of Washington, Seattle, WA

 

Background:

Despite the advances in diagnostic techniques in medicine, diagnosis of acromegaly remains a challenge. The insidious onset of physical manifestations associated with acromegaly result in long diagnostic delay. Even when acromegaly diagnosis is confirmed biochemically, localization of pituitary somatotroph adenoma can be difficult with modern imaging modalities. Although FDG PET/CT is becoming more readily available for use to localize and stage certain malignancies, its utility to localize pituitary tumors is not well studied. Here we present two cases of acromegaly, in individuals with underlying conditions that obfuscated physical exam findings of acromegaly, in whom PET scan aided the identification of a GH producing tumor.

 

Clinical Cases:

Our first case is a 62 years old man with fibrous dysplasia causing prominent facial dysmorphia and high-grade osteosarcoma of the chest wall. A PET scan obtained for sarcoma staging, showed a hypermetabolic focus in the left sella. Upon further investigation he complained of tongue swelling, jaw enlargement and sweating, but no change in his ring or shoe size. Pituitary hormone analysis was normal except for an elevated serum IGF1 of 648 ng/ml (70-207). A sellar MRI confirmed the presence of a hypoenhancing mass in the left aspect of the sella measuring 13x13x7mm, with extension into the left cavernous sinus. Due to his disfigured forehead and skull he was not deemed to be a surgical candidate, and was treated with medical therapy, which decreased his IGF1 level by half.

The second case is a 20 year old man with partial deletion of chromosome IX causing multiple developmental abnormalities and dysmorphic facial phenotype, who presented for gynecomastia. Initial evaluation for gynecomastia revealed hypogonadotropic hypogonadism, with an LH of 10mIU/ml (0-14), total testosterone of 1.6ng/ml (2.2-7.8), and complete pituitary hormone analysis showed an elevated serum IGF1 of 527ng/ml (132-457). He had mild tongue enlargement and increased shoe size. An OGTT was done, and his growth hormone increased from baseline of 0.2ng/ml (0.01-0.97) to 1.2ng/ml, 2 hours after ingestion of 75gm oral glucose. A pituitary MRI ordered to identify GH producing tumor was read as normal. A PET Scan was obtained for persistent serum thyroglobulin levels in the setting of papillary thyroid carcinoma. This revealed focal FDG uptake within the pituitary gland, more prominent on the left side. The patient underwent endoscopic transnasal transsphenoidal removal of a left-sided pituitary adenoma, pathology confirmed a densely granulated GH microadenoma. Following surgical resection, his serum IGF1 level has remained within the age adjusted normal range.

Conclusion:

Once the diagnosis of acromegaly is confirmed, clinicians could consider PET/CT imaging for localization of a pituitary adenoma if conventional imaging modalities fail to detect a sellar lesion.

 

Nothing to Disclose: MM, MF Jr., AJD

18848 6.0000 THR-423 A FDG PET/CT Imaging As a Modality for Diagnosing Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Anna Beth Barton*1, Kristen Anne Hyland1 and Jennifer Brigitte Green2
1Duke University Medical Center, Durham, NC, 2Duke Univ Med Ctr, Durham, NC

 

Background:

In pituitary disease, it is not uncommon to see a discrepancy between clinical features or biochemical tests and surgical pathology immunohistochemical results (1). We present a patient with a history of a resected prolactinoma who re-presented years later with a residual pituitary mass as well as clinical and biochemical evidence of acromegaly. She underwent another resection but interestingly, the tissue removed did not stain positive for growth hormone as expected.

Clinical Case:

A 48 year-old female presented to endocrinology in 2007 after an abnormal MRI. She had a history of a macro-prolactinoma in 1999 that was discovered due to headaches and galactorrhea, then resected while she was serving overseas. At re-presentation, her brain MRI demonstrated a 2 cm heterogeneously enhancing, irregularly shaped pituitary mass impinging on the optic chiasm. Her primary symptoms were weight gain and worsening visual acuity. Laboratory testing revealed normal TSH, free T4, prolactin, and adrenal response to cosyntropin, but an IGF-1 level was elevated at 272 ng/mL (94-252 ng/mL). Neurosurgical intervention was not initially recommended based upon minimally abnormal laboratory values and absence of visual field deficit.

At follow-up in 2009, she was noted to have new diagnoses of type 2 diabetes, secondary hypothyroidism, and thyroid nodules. She had no prominent acromegalic features on exam but IGF-1 level was again elevated at 284 ng/mL. This was followed by a normal GH suppression test.

Subsequently in 2013, history and exam was notable for a new diagnosis of obstructive sleep apnea and clinical features of acromegaly including doughy skin, macroglossia, and enlarged hands with an increased ring size. IGF-1 level was elevated at 355 ng/mL (53-191 ng/mL). She again underwent GH suppression testing, results of which were not normal, but not consistent with obvious GH excess. MRI revealed a slightly larger pituitary mass measuring 27 x 22 x 17 mm and abutting the cavernous sinus bilaterally.

She was referred back to neurosurgery and subsequently underwent resection of the residual tumor. Surgical pathology confirmed pituitary adenoma, however the tumor cells did not stain positive for prolactin or GH.

Post-operatively, our patient’s IGF-1 level is in the normal range, with some improvement in symptoms and diabetes control.

Conclusion:

This case demonstrates a recurrent pituitary adenoma with GH excess as evidenced by a persistently elevated IGF-1, along with insidious development of signs and symptoms consistent with acromegaly. The negative GH staining on histology and borderline GH suppression testing was contradictory to the clinical presentation, but has been described previously in the literature (2). Endocrinologists should be aware of this phenomenon when evaluating immunohistochemical results to avoid allowing surgical pathology to influence the majority of a diagnosis.

 

Nothing to Disclose: ABB, KAH, JBG

20764 7.0000 THR-424 A Subclinical Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Kevin C.J. Yuen*
Swedish Neuroscience Institute, Seattle, WA

 

Background: Acromegaly is a rare hormonal disease characterized by chronic hypersecretion of growth hormone (GH) and insulin-like growth factor-1 (IGF-1) from benign somatrophic pituitary adenomas. Pasireotide long-acting release (LAR) is a second-generation, multireceptor-targeted somatostatin analog that has higher binding affinity than octreotide or lanreotide to somatostatin receptor type 5. In a recently completed phase 3 clinical study (C2305 study, ClinicalTrials.gov identifier: NCT00600886), pasireotide LAR demonstrated significantly improved biochemical control and comparable rates of reductions in tumor volume compared with octreotide LAR in medically naive patients with acromegaly (1). However, hyperglycemia-related adverse events were observed more frequently in the pasireotide LAR group (1). Although the patient was treated for 43 months, here we report on the 12-month outcomes of a patient who received treatment with pasireotide LAR as part of the study.

Clinical case: The patient was a 48-year-old male (weight: 156 lbs/70.6 kg; body mass index: 24.4 kg/m2). The patient had a baseline IGF-1 level of 402 ng/mL (reference range: 94-252 ng/mL), which decreased to 127 ng/mL after 5 months of treatment with pasireotide LAR. The patient achieved control of GH levels, which decreased from a baseline level of 5.4 ng/mL to 0.1 ng/mL after 5 months of treatment. Both IGF-1 and GH remained under control while the patient remained on pasireotide LAR therapy of 40 mg/28 days for 12 months. Additionally, evaluation by MRI revealed a large pituitary macroadenoma (1216 mm3). After 1 month of treatment, a reduction in total tumor volume of 60% from baseline to 481 mm3 was observed, and at month 8, a further reduction in tumor volume by 77% from baseline to 285 mm3 was noted. The patient did not develop hyperglycemia while on treatment, as fasting plasma glucose (baseline: 78 ng/dL; range during treatment: 83-118 ng/dL) and glycated hemoglobin (<6.0%) levels remained below diabetic cut points throughout the 12 months of the study. Mild sludge in gallbladder detected by ultrasound was the only adverse event reported, but the patient was able to continue therapy.

Conclusion: As part of the C2305 study, we are reporting data on the first 12 months of therapy for a patient treated with pasireotide LAR 40 mg/28 days. Marked and sustained control in GH and IGF-1 levels, as well as significant reductions in tumor volume were observed during the first year of treatment. In addition, hyperglycemia, which is a notable adverse event in the C2305 study (1), was not observed in our patient.

 

Disclosure: KCJY: Ad Hoc Consultant, Corcept, Ad Hoc Consultant, Pfizer, Inc., Principal Investigator, OPKO.

20478 8.0000 THR-425 A Management of a Patient with Acromegaly Treated with Pasireotide LAR without Worsening of Glycemia: A Case Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Rashim Gupta*1 and D. Sudhaker D. Rao2
1Henry Ford Hospital, Detroit, MI, 2Henry Ford Health System, Detroit, MI

 

McCune-Albright Syndrome (MAS) is associated with several endocrinopathies including hyperthyroidism, precocious puberty, hyperprolactinemia, and acromegaly. The underlying mechanisms for the associations are unknown. Whereas most non-MAS patients with acromegaly have a pituitary tumor, only about one- to two-thirds of those with MAS and acromegaly have a pituitary tumor. Acromegaly without pituitary tumor has been noted previously along with elevated growth hormone releasing hormone (GHRH). Proposed mechanisms of increased growth hormone include hypothalamic dysregulation and embryological defect in pituitary cell differentiation and function. However, other possibilities include GHRH secretion from dysplastic bone and constitutively activated receptors considering the known activating mutations in stimulatory G proteins in MAS. Understanding the pathophysiology of acromegaly in MAS is important to render appropriate treatment, and help elucidate the reason why somatostatin analogs are not successful in treating acromegaly in a substantial number of MAS patients.

We report two cases of acromegaly in the setting of MAS and normal pituitary gland on imaging. The first case is of a patient who was diagnosed with GH excess at the age of 13 when father noticed bony protrusion on skull. MRI showed hyperintensity of the sella related to fibrous dysplasia but no underlying pathology of pituitary itself. She was initially on bromocriptine and then cabergoline without improvement. She was switched to somatostatin analogue which led to improvement in IGF-1 levels as well as improvement in acromegalic symptoms and features.

The second case is of a 40 year old woman who was being followed for polyostotic fibrous dysplasia. At a follow up appointment, she complained of increased acne and noted enlarging left jaw. She was found to have elevated IGF-1 levels and was subsequently diagnosed with acromegaly. MRI pituitary also showed normal pituitary but with fibrous dysplasia of sella turcica floor. She was referred for a research study and has been on an investigational treatment protocol probably with pasireotide. Both have had excellent clinical responses.

 

Nothing to Disclose: RG, DSDR

20073 9.0000 THR-426 A Development of Acromegaly in Two Patients with Mccune-Albright Syndrome without Pituitary Tumor: Case Report, Review of the Literature, and Response of Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


James Field*1, Kellie L. Spiller2 and Murray B. Gordon1
1Allegheny Neuroendocrinology Center, Allegheny General Hospital, Pittsburgh, PA, 2Allegheny Neuroendocrinology Center, Pittsburgh, PA

 

Background: Patients with uncontrolled acromegaly have a high burden of comorbidities, increased healthcare-related costs, and significantly increased rates of mortality. As part of the C2305 study (Clinicaltrials.gov identifier: NCT00600886), we treated 3 patients with acromegaly at our institution; 2 patients were randomly assigned to receive octreotide long-acting release (LAR) and are not discussed in this presentation. Here, we report the 1-year outcome of 1 patient who was treated with pasireotide LAR, a second-generation, multireceptor-targeted somatostatin analog with greater binding affinity for somatostatin receptor 5.

Clinical case: The patient is a 56-year-old woman with acromegaly who, at initial diagnosis, had elevated insulin-like growth factor-1 (IGF-1) 3.0-fold greater than ULN (68.51 nmol/L; reference range, 5.8-22.5 ng/mL) and elevated growth hormone (GH) (average of 14.9 mcg/L over 2 hours); the patient was normoglycemic. As first-line therapy, the patient underwent transsphenoidal pituitary surgery but did not achieve biochemical control or improved symptoms. Before enrollment in C2305, the patient was naive to medical treatment for acromegaly. The patient was enrolled and received pasireotide LAR (40 mg). Levels of IGF-1 and GH were measured at baseline, at months 2 and 3 after treatment initiation, and every 3 months thereafter. Additionally, because pasireotide LAR has been associated with higher rates of hyperglycemia, fasting plasma glucose (FPG) and glycated hemoglobin (HbA1c) levels were assessed every 1 and 3 months, respectively.

After 12 months of treatment, the patient demonstrated sustained reductions in IGF-1 to levels within or slightly above normal as well as sustained reductions in GH levels. Measured reductions were 2.8-fold for IGF-1 and 2.92-fold for GH at 12 months. Diabetes was diagnosed based on FPG of 308 mg/dL and HbA1c of 10.1% at month 3, and glimepiride 4 mg QD was started followed by sitagliptin 50 mg/metformin HCl 500 mg (Janumet®) BID. After initiation of antidiabetic therapy, the patient’s values rapidly decreased to FPG of 119 mg/dL and HbA1c of 7.0% at month 6. Glycemic parameters remained stable through month 12, except for a slight increase in HbA1c level at month 12 that required further antidiabetic dose modification (increase to sitagliptin 50 mg/metformin HCl 1000 mg BID), with normalization of glycohemoglobin. Other adverse events reported during the first year of treatment included headache, injection-site reaction, and alopecia.

Conclusion: In our case study, pasireotide LAR provided acceptable biochemical control in a patient with persistent elevations in IGF-1 levels after surgery, with average reductions from baseline of nearly 2.9-fold observed. While hyperglycemia was observed during the course of treatment, proactive management with antiglycemic agents quickly led to sustained glycemic control.

 

Disclosure: MBG: Principal Investigator, Pfizer, Inc., Principal Investigator, Novo Nordisk, Principal Investigator, OPKO. Nothing to Disclose: JF, KLS

20628 10.0000 THR-427 A Management of Hyperglycemia in a Patient with Acromegaly Treated with Pasireotide LAR: A Case Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Alex Ramirez*1, Claudia Monsalve1, Natalia Aristizabal1 and Luis Vicente Syro2
1Universidad Pontificia Bolivariana, Medellin, Colombia, 2Clinica Medellin, Medellin, Colombia

 

Background: The association of the pituitary adenoma with systemic sclerosis has been described, but its pathophysiological relationship is to be clarified. The articular and dermatologic manifestations of acromegaly secondary to a GH (Growth Hormone) producing adenoma can be confused with the gradual stablishment of a systemic sclerosis with diffuse cutaneous involvement; this aspect influences proper and timely diagnosis (1,2). It is possible that the temporary relationship between the two diseases is based on the activation of autoimmunity due to excessive exposure to GH (3). Recent studies even suggest the action of GH as cytokine, with a potential role in the systemic immune response (4).

Clinical Case: 47 years old male evaluated for acral growth, soft tissue edema, facial changes (enlarged nose, thickened lips) and husky voice. Laboratories reported IGF-1 (Insulin-like Growth Factor 1) 551 ng/ml and GH 110.4 ng/ml, and diagnosis of acromegaly was performed. In the nuclear magnetic resonance a solid sellar lesion of 18 mm, isointense in T1 and T2 is identified, which enhances heterogeneously with the contrast media, localized to the right lateral aspect of the sella with deviation to the left of the pituitary infundibulum. A densily granulated adenoma is determined morphologically. Three months after the surgery, IGF-1 2333 ng/ml GH 47 ng/ml is required. In nuclear magnetic resonance control with residual lesion; has been decided then to initiate somatostatin analogs, with consequent objective diminishment of the tumoral volume. Subsequently, the patient presented with progressive intensity arthralgias and skin changes of scleroderma, associated with Raynaud's phenomenon, ANAS (antinuclear antibodies) nucleolar pattern; diagnosis was diffuse cutaneous scleroderma. In this regard, his initial treatment was with methotrexate, ciflofostamida was subsequently initiated for rapid progression of skin changes.

Conclusion: The systemic sclerosis has a rare association with pituitary adenomas. This case suggests a specific relationship between acromegaly secondary to a functional pituitary GH-producing adenoma and diffuse systemic sclerosis. An early and specific diagnosis, will allow to perform timely therapeutic interventions in the dermatological autoimmune component.

 

Nothing to Disclose: AR, CM, NA, LVS

21449 11.0000 THR-428 A Pituitary Functional Adenoma Associated with Systemic Sclerosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Madeleine Gutierrez1, Jose Hernan-Martinez2, Samuel Sanchez3, Maria de Lourdes Miranda1, Ricardo Brau4, Coromoto Palermo*1, Rafael Trinidad-Hernandez5, Michelle M Mangual6, Alfredo Sanchez7, Paola Mansilla-Letelier1, Ivan E Laboy-Ortiz8 and Carmen V Rivera-Anaya7
1San Juan City Hospital, San Juan, PR, 2San Juan City Hospital, 3Hospital Universitario, 4University District Hospital, San Juan Puerto Rico, 5San Juan City Hospital, Carolina, PR, 6Sa, San Juan, PR, 7San Juan City Hospital, PR, 8San Juan City Hospital, Caguas, PR

 

Introduction: Acromegaly has been found in patients with empty sella after having undergone pituitary irradiation and/or surgery or after pituitary tumor hemorrhage. Pituitary apoplexy is quite rare in patients with microadenomas.(1)

Case Report: A 46 year-old nulligravid female patient was seen at our endocrinology clinics.  For the last seven years she noticed oily and thick skin, severe acne and weight gain. She attributed her weight gain to smoking cessation.  At the same time an increase in shoe and ring finger size were evident. Rhinoplasty was done due to progressive broadening of her nose provoking a low self-esteem on her.  She obtained a second opinion with another Dermatologist due to mild improvement with topical and oral antibiotics for many years.  On this encounter acromegalic features were obvious mainly prognathism, frontal bossing, macroglossia, enlarged hands and, feet, lips and nose. She denied menstrual irregularities, galactorrhea or  visual abnormalities. However loud snoring and frequent headaches were remarkable. Laboratory evaluation revealed significantly increased growth hormone (67.42 ng/ml) and Somatomedin C levels (723 ng/ml). Pituitary MRI with IV contrast showed an empty sella with small hyperintense hemorrhagic lesion at T1-T2 over the left paramedian area approximately 3-4 mm with pituitary stalk minimally displaced towards the left and Empty  sella findings.  ACTH was elevated  at 75.9 pg/ml, FBS: 117 mg/dl, Hgb A1C: 5.8%, the rest of anterior pituitary hormones were within normal range, as well as hemoglobin, liver and kidney function testing, colonoscopy and 2D-ECHO.  A gross total resection of a whitish necrotic tumor was removed through a transphenoidal approach. Following surgery patient experienced marked clinical as well as biochemical improvement.

Conclusion: Acromegaly is a slowly progressive disease with increased risk of cardiovascular and respiratory complications as well as malignancies. Early recognition is necessary to improve survival of these patients and their quality of life.  An empty sella seen on imaging, does not exclude the possibility of a coexisting pituitary tumor.

 

Nothing to Disclose: MG, JH, SS, MDLM, RB, CP, RT, MMM, AS, PM, IEL, CVR

22111 12.0000 THR-429 A Acromegaly with Empty Sella What's the Link? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Masayasu Iwabuchi*
Seirei Mikatahara Hosp, Hamamatsu, Japan

 

BACKGROUND: Sarcoidosis is a multisystem granulomatous disease of unknown etiology, which may contribute to the pathogenesis of some nonischemic cardiomyopathies causing ventricular tachycardia or to the development of conduction abnormalities. Noncaseating granulomas are the pathologic hallmark of sarcoidosis. Imaging abnormalities can commonly be seen on Ga scans, FDG PET, and PET/CT. FDG uptake from sarcoidosis is nonspecific. Cardiac sarcoidosis is a potentially fatal complication of sarcoidosis. It has been also recognized that acromegaly may contribute to the pathogenesis of some nonischemic cardiomyopathies. Patients with acromegaly in whom surgery is inappropriate have indications for long-acting somatostatin analog. Sandostatin® LAR® should be injected intramuscularly into right or left gluteus alternately.

CASE REPORT: 55-year-old man visited a cardiologist for the treatment of atrial fibrillation, ventricular tachycardia and heart failure. He had a past medical history of uveitis that is common complication of sarcoidosis. Because of his acromegalic features, endocrinological and image examinations were performed and diagnosis of acromegaly was confirmed. His GH was 7.17 ng/mL, IGF-1 566 ng/mL (Normal range: 59-2159) and 75 gram glucose tolerance test without suppression of GH levels. Endocrinological examinations were confirmatory of acromegaly. An MRI indicated pituitary adenoma. Cardiologist had started warfarin for his atrial fibrillation. Concerning excess of GH may cause nonischemic cardiomyopathy, administration of 20 mg of Sandostatin® LAR® once a month has been started. Prior to  LAR®, subcutaneous treatment of 50µg of Sandostatin every 12 hours was performed. Two month after starting intramuscular injection to the gluteus of Sandostatin® LAR®, 18F-FDG PET imaging was performed to confirm sarcoidosis cardiomyopathy. With the uptake of PET to the heart muscle, diagnosis of sarcoidosis cardiomyopathy was confirmatory. Additionally, PET uptake was positive for two points of gluteus, to which the intramuscular injection were done. 18F-FDG is a glucose analog that is useful for imaging organ involvement in patients with sarcoidosis because of its ability to differentiate between normal and active inflammatory regions. This ability is due to its increased uptake in macrophage-dense regions, where the activated macrophages show a high metabolic rate making them more reliant on external glucose. Histological examination of his gluteus did not indicate sarcoidosis. Therefore, PET uptake in gluteus was considered to be false positive due to intramuscular injection of LAR®.

CLINICAL LESSON: This is the first report of false positive result of 18F-FDG PET/CT imaging in a patient with acromegaly treated with Depot long-acting somatostatin analog (Sandostatin® LAR®) injected intramuscularly.

 

Nothing to Disclose: MI

21688 13.0000 THR-430 A False Positive Result of 18f-FDG PET/CT Imaging in a Patient with Acromegaly Treated with Depot Long-Acting Somatostatin Analog (Sandostatin® LAR®) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Fabio Rotondo*1, Ali A Ghazi1, Kalman Thomas Kovacs1, Luis Vicente Syro2, Hussein Fathalla1, Antonio Di Ieva1 and Michael D Cusimano3
1St. Michael's Hospital, Toronto, ON, Canada, 2Clinica Medellin, Medellin, Colombia, 3St Michael's Hospital, Toronto, ON, Canada

 

Introduction Pituitary tumors can be are either micro or macroadenomas. Aggressive adenoma is the term used to describe a subgroup of tumors that rapidly increase in size and may invade adjacent structures. Management of these tumors is difficult because most of them recur after surgery. Temozolomide (TMZ), a second generation alkylating agent has recently been used with promising results in some cases. Most patients treated with TMZ had either PRL or ACTH producing tumors. Here, we present the case of a young man with an invasive silent somatotroph pituitary macroadenoma treated with TMZ after surgery without response.

Clinical MRI on a 39 year old man with blurred vision in right eye and recurrent headaches revealed a pituitary mass with suprasellar and parasellar extension with complete encasement of the internal carotid artery. Laboratory evaluations were within normal limits and there were no signs or symptoms of pituitary hormone hypersecretion. A densey granulated GH pituitary adenoma was diagnosed following a first debulking procedure.  Temozolomide (TMZ) was started and continued for 8 cycles followed by a second, subtotal resection and decompression of the optic chiasm and cavernous sinus.

Pathology Histology revealed a chromophobic, PAS negative pituitary adenoma with abundant hyalinised connective tissue stroma.  Tumor cells were small and contained a dark, mildly irregular chromatin rich nucleus and a very narrow rim (cytoplasm). Immunohistochemistry (IHC) showed immunopositivity for GH, PRL, TSH, alpha subunit, VEGF, COX-2 and synaptophysin (SYN) and immunonegativity for ACTH, FSH and LH. Ki67 nuclear labeling index was 1-3%. The tumor at the second surgery was firm and fibrous and was not substantially changed in its texture or fibrosity by the 8 cycles of TMZ.  Histopathologic evaluation revealed the same tumor cells with massive fibrosis.

Conclusion Our patient is one of a few cases with invasive silent somatotroph adenoma treated with TMZ. TMZ has been shown to be effective in the management of several pituitary carcinomas and aggressive adenomas but data is limited on the effects of TMZ in patients with somatotroph pituitary macroadenomas. Responsive tumors usually decrease in size and hormonal secretion is reduced. Due to the invasive nature of these tumors and limitations in treatment modalities, patients should be given the chance for probable benefit from TMZ.  Further studies on a greater number of patients will shed more light on the problem.

 

Nothing to Disclose: FR, AAG, KTK, LVS, HF, AD, MDC

21002 14.0000 THR-431 A Treatment of Silent Somatotroph Pituitary Adenoma with Temozolomide 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Resmi Premji*1, Nira Amrita Roopnarinesingh2 and Joshua Lewis Cohen3
1George Washington University, Washington, DC, 2George Washington University School of Medicine and Health Sciences, Washington, DC, 3The George Washington University School of Medicine and Health Sciences, Washington, DC

 

Introduction: Malaria remains a major public health challenge worldwide; in 2012, the estimated prevalence was 207 million cases per year with an estimated 0.6 million deaths. Cerebral Malaria (CM) is a life-threatening complication of malaria. Diabetes Insipidus (DI) is an uncommon feature of CM. Here we describe an unusual case of DI complicating CM.

Case: A previously healthy 72 year old man presented with a four day history of fever, rigors, back pain and altered mental status. He had recently returned from a trip to Liberia, a country with endemic chloroquine-resistant falciparum malaria. He took doxycycline chemoprophylaxis during his trip, however he discontinued it prematurely upon his return.

Investigations confirmed plasmodium falciparum parasitemia with acute kidney injury. The serum sodium was 132 mEq/L (nl 135-145 meq/L) at admission. One week later the serum sodium rose to 166 mEq/L and the urine output increased from 75 ml/h to 600 ml/h. Other studies were notable for a high serum osmolality (354 mOsm/kg, nl 285-295 mOsm/kg), low urine osmolality (199 mOsm/kg, nl 50-1200 mOsm/kg) and low urine specific gravity (1.010, nl 1.003-1.035). The hypernatremia did not respond to hypotonic fluids. DI was suspected and parenteral desmopressin was started with a prompt decrease in urinary output to <150 ml /h. The serum sodium decreased over the next several days and his mental status improved. Additional testing revealed morning cortisol 15.5 mcg/dl (nl 4.5 - 23 mcg/dl), free T4 1.3 ng/dl (nl 0.7 - 1.8 ng/dl) and prolactin 34 ng/ml (nl 3.7 - 17.9 ng/ml). At discharge, the serum sodium was 134 mEq/L. He was discharged on oral desmopressin 0.05 mg at bedtime, which was discontinued 2 weeks later with complete resolution of thirst and polyuria.

Discussion: The classic presentation of malaria with relapsing and remitting fevers occurs only in 50-70% of cases. A combination of parasite–specific and host-specific factors are responsible for the pathophysiology of severe manifestations of malaria including CM. As the parasites grow within RBCs, the RBCs become less deformable, causing mechanical obstruction and impaired microvascular circulation. Non-parasitized RBCs adhere to the parasitized RBCs (rosetting) and parasitized RBCs adhere each other (agglutination).  A variety of proinflammatory cytokines, including TNF-alpha also increases cytoadherence. DI occurs likely as a result of obstruction of the neurohypophyseal microvasculature.

Few case reports have described DI as a complication of CM. In a study reported by Grimwade et al, 37 of 175 patients with severe malaria had polyuria, 10 of those patients had low urine osmolality and high serum osmolality consistent with DI. Schubert et alreported central DI in a patient with CM that responded to desmopressin.

Although DI is a rare feature of CM, clinicians need to be aware of this manifestation since delayed diagnosis has a high mortality rate.

 

Nothing to Disclose: RP, NAR, JLC

18341 15.0000 THR-432 A Diabetes Insipidus, an Atypical Presentation of Malaria 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Han Xin Chin*, Timothy Peng Lim Quek and Melvin Khee Shing Leow
Tan Tock Seng Hospital, Singapore, Singapore

 

Background: Patients with intra-cerebral metastases frequently receive glucocorticoids, particularly in the presence of peri-lesional vasogenic cerebral oedema. We present a case of presumptive lung carcinoma with cerebral metastases in whom central diabetes insipidus (CDI) was unmasked after glucocorticoid administration and correction of undiagnosed central hypocortisolism.

Clinical Case: A 71-year-old lady with a past history of bronchial asthma was admitted to the Neurosurgery department for lethargy, poor oral intake, functional decline and progressive confusion on a background of visual blurring for a number of months. Imaging studies of the brain with CT and MRI revealed a suprasellar mass and multiple intracerebral hypodensities associated with perilesional oedema suggestive of metastases.

On admission, the patient was clinically dehydrated and had mild hyponatremia (serum sodium 130 mmol/L, reference interval (RI) 134-144 mmol/L). Her early morning serum cortisol was low at 147 nmol/L (RI 240-618 nmol/L). Thyroid function test was normal.

The patient was rehydrated with 0.9% saline drip and sent for contrast-enhanced CT thorax, abdomen and pelvis which showed findings consistent with a primary lung malignancy and normal bilateral adrenal glands. In view of her history of asthma, hypocortisolemia and intracerebral metastases, intravenous hydrocortisone was initiated shortly before her scans and switched to dexamethasone subsequently.

Soon after glucocorticoid administration, the patient was noted to become polyuric, with serum sodium and osmolality rising up to 163 mmol/L and 355 mOsm/kg (RI 275-305 mOsm/kg) respectively on the third day. The paired urine osmolality was also inappropriately dilute (392 mOsm/kg) despite the high serum osmolality.

The Endocrinology service was consulted and we accordingly diagnosed partial CDI initially obscured by concomitant central hypocortisolism and possible bronchogenic carcinoma-associated SIADH, only becoming overt after steroid replacement. Prompt treatment was initiated with DDAVP and hypotonic fluids, with normalisation of her serum sodium levels. Due to her guarded prognosis, the patient was eventually transferred to an inpatient hospice on nasal DDAVP and oral dexamethasone.

Conclusion: In patients with pituitary lesions and newly diagnosed hypocortisolism, one should be wary of unmasking CDI after glucocorticoid replacement. Urine output and serum electrolytes should be monitored closely with a high index of suspicion for CDI.

 

Nothing to Disclose: HXC, TPLQ, MKSL

18696 16.0000 THR-433 A Development of Hypernatremia after Glucocorticoid Administration: Unmasking Central Diabetes Insipidus in a Patient with Newly Diagnosed Central Hypocortisolism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Rachel A. Steinman*1, Sara E. Schwab1 and Kashif M. Munir2
1University of Maryland School of Medicine, Baltimore, MD, 2University of Maryland Medical Center, Baltimore, MD

 

Background: Cyclophosphamide has been noted to induce hyponatremia by an unknown mechanism.  It may produce a syndrome of inappropriate anti-diuretic hormone–like  phenomenon  through impairment  of the kidney’s ability to dilute urine.  Whether cyclophosphamide or its metabolites have a direct vasopressin-like effect on the kidney or whether they indirectly cause vasopressin release is unknown (1, 2, 3).

Clinical Case: A 28 year old man with a history of intracranial germinoma diagnosed at age 11 was primarily treated with chemo-radiation and subsequently developed a recurrence  17 years later.  He developed panhypopituitarism with resulting central diabetes insipidus requiring desmopressin (DDAVP).  He was recently admitted  for chemotherapy with cisplatin, cyclophosphamide and MESNA.  His admission serum sodium was 142 mmol/L (normal range: 136-145).    His serum sodium declined slowly over the course of a few days to 135 mmol/L while receiving cisplatinin and his home dose of DDAVP.   A significant decline in serum sodium to 125 mmol/L occurred while undergoing chemotherapy with cyclophosphamide and MESNA and with the initiation of hydration with 5% dextrose / 0.45 % normal saline despite holding two doses of DDAVP.  There was an accompanying decline in serum osmolality from 282 to 264 MoM/kg (normal range: 275-295).  The sodium then improved to 142 mmol/L with 20 mg intravenous furosemide.

A similar episode occurred several weeks later, while again receiving cisplatin, cyclophosphamide and MESNA chemotherapy.  His serum sodium declined from 141 mmol/L to a nadir of 122 mmol/L and serum osmolality declined from 288 to 258 MoM/kg despite receiving isotonic saline fluids and holding DDAVP during cyclophosphamide treatment.  Serum sodium did not improve with three doses of 10 mg intravenous furosemide but surprisingly improved without intervention to 134 mmol/L on discharge

Conclusion:  The mechanism of cyclophosphamide induced hyponatremia remains unknown.  Given that this patient’s central diabetes insipidus prevents him from secreting increased amounts of antidiuretic hormone, hyponatremia may be induced by a direct tubular effect of cyclophosphamide or its metabolites.

 

Nothing to Disclose: RAS, SES, KMM

19619 17.0000 THR-434 A Cyclophosphamide Induced Hyponatremia in a Patient with Diabetes Insipidus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Tarandeep Kaur*1, Daniela Ciltea2, John M Moorman1 and Jodi Dreiling1
1Akron General Medical Center, Akron, OH, 2Akron General Partners Physician Group, Akron, OH

 

Objective: To describe a patient with SIADH caused by a single dose of venlafaxine.

Methods: We present clinical, laboratory and pathological findings of patient with SIADH presumed to be caused by a single dose of venlafaxine. We also review the mechanism of action by which venlafaxine may cause SIADH, as well as factors which may predispose patients to developing the same.

Results: A 55 year old Caucasian male presented with nausea and vomiting of three day duration along with altered mental status. Upon presentation, he denied any abdominal pain, fever, diarrhea, or other signs of infection. Initial laboratory findings showed a serum sodium of 112 mEq/L (reference range 135-145 mEq/L), serum osmolality of 232 mOsm/kg (reference range 275-295 mOsm/kg), urine osmolality of 703 mOsm/kg (reference range 250-1200 mOsm/kg), and a urine sodium of 55 mEq/L (reference range >20 mEq/L). A CT of the head showed no abnormalities, and the patient had no prior history of renal or hepatic dysfunction, congestive heart failure, hyponatremia, or seizure disorder.

Within few hours of admission, the patient developed generalized tonic clonic seizures, and a repeat serum sodium was 117 mEq/L. Further investigation was conducted to identify the cause of the hyponatremia, which included a TSH of 1.020 mIU/L (reference range 0.358-3.740 mIU/L) and a morning serum cortisol of 12 mcg/dL (reference range 7-28 mcg/dL). On further questioning, the patient admitted to taking a single dose of venlafaxine 37.5 mg three days prior to admission. He stated that he had used citalopram in the past without any complications, but had stopped taking this four years prior to presentation following improvement in his depressive symptoms.

Based on the above findings, the diagnosis of venlafaxine-induced SIADH was made. Venlafaxine was discontinued, and the patient was treated with conivaptan and hypertonic saline. The patient’s serum sodium and mental status subsequently improved with no further seizure activity.

Conclusion: Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that has been implicated in causing SIADH, but to our knowledge no cases have been reported following a single dose. The mechanism by which SNRIs cause SIADH is thought to be related to either an increased release of ADH or an enhancement of its physiologic action. This is an interesting case of SIADH thought to be induced by a single dose of venlafaxine. It is important to consider medications, specifically antidepressants, as an important cause for SIADH when other causes are ruled out. Early discontinuation of the offending agent is warranted to prevent life-threatening complications of hyponatremia.

 

Nothing to Disclose: TK, DC, JMM, JD

20624 18.0000 THR-435 A A Case of Syndrome of Inappropriate Antidiruetic Hormone Caused By a Single Dose of Venlafaxine 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Ferhat Deniz*1, Seyid Ahmet Ay1, Emel Saglar2, Hatice Mergen2, Kamil Baskoy1 and Arif Yonem1
1GATA Haydarpasha Training Hospital, Istanbul, Turkey, 2Hacettepe University, Ankara, Turkey

 

Nephrogenic Diabetes Insipidus is a rare hereditary disorder of the kidney. NDI is characterized by chronic excessive thirst and excessive urine production and mostly caused by the mutations in the arginine vasopressin type-2 receptor gene (AVPR2). We found a mutation in exon 2 of the AVPR2 gene in a large Turkish pedigree and we performed the genetic analysis. The genomic DNA of the proband and all the other family members were isolated and the amplification of the AVPR2 gene was carried out with polymerase chain reaction. We were sequenced all exons and intron-exon boundaries of the AVPR2 gene of all family members. Additionally, all family members were genotyped with polymerase chain reaction–restriction fragment length polymorphism. The clinical features of the proband and the other family members were recorded and evaluated. Nephrogenic Diabetes Insipidus was confirmed with water deprivation-desmopressin test according to unresponsive in urine osmolality after desmopressin acetate enjection. He had severe polyuria (12 L/day), polydipsia (13.5 L/day), fatique, and deep thirstiness. His condition was severe which resembles all other family members on history, physical examination, and laboratory findings.In conclusion we have analyzed codon 162 mutation in the 2nd exon of AVPR2 gene in a large Turkish pedigree and reveal that the mutation was also a genetic etiology of NDI patient.

 

Nothing to Disclose: FD, SAA, ES, HM, KB, AY

21145 19.0000 THR-436 A V88M Mutation in AVPR2 Gene Causing Nephrogenic Diabetes Insipidus in a Large Turkish Pedigree 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Sana Ghaznavi* and Gregory A Kline
University of Calgary, Calgary, AB, Canada

 

Background

Over the last forty years, marathon running has evolved from a sport of elite athletes to a social phenomenon embraced by the masses.  The number of US marathon finishers has risen from 25,000 in 1976 to over 460,000 in 2009 (1,2). 

Alongside this popularity of running has emerged a dogma, which associates hydration with athletic performance and healthy living.  This culture of over-hydration presents a particular challenge in patients with central diabetes insipidus (DI) using DDAVP.  Here we present two cases of patients with central DI using DDAVP who developed severe hyponatremia following intentional increased low-electrolyte fluid intake as part of perceived healthy living promoted on the Internet or other health advocates.

Case

A forty-six year old woman with central diabetes insipidus from histiocytosis X presented to hospital with hyponatremia (Na 117 mmol/L, reference range 135-145 mmol/L), weakness and paresthesias of her hands.  Her medications included DDAVP 10 mcg intranasally daily, with no recent dose change.  In management of her hypertension, the patient’s family doctor gave her general advice on sodium restriction and increased hydration as part of a presumed healthy lifestyle.  Subsequently, the patient increased her water intake to four litres per day over the two weeks prior to presentation.  After diagnosis of self-induced water toxicity in the setting of DDAVP use, the patient’s hyponatremia required hospitalization and complex management including hypertonic saline, free water, DDAVP, and fluid restriction at different phases to avoid rapid over-correction of serum osmolality with central pontine myelinolysis.

 

The second case involved a twenty-six year old man who presented to hospital with hyponatremia (Na 115 mmol/L).  He had a childhood diagnosis of Cushing disease treated with two transphenoidal resections and pituitary irradiation resulting in central diabetes insipidus requiring DDAVP.  After reading about the association between health and the need for hydration online, the patient also increased his fluid intake while self-adjusting his DDAVP from 20 mcg to 50 mcg each day.  

 

Conclusion

Popular culture strongly encourages hydration for various perceived health benefits and athletic performance.  Patients with central DI using DDAVP are at increased risk of severe hyponatremia from excessive consumption of water or other hypo-osmolar sports drinks.  For such patients, appropriate fluid management education may help prevent life threatening electrolyte disorders. Endocrinologists should specifically discuss patients’ fitness regimes and help develop safe hydration strategies around times of exercise.

 

Nothing to Disclose: SG, GAK

20686 20.0000 THR-437 A Water Intoxication in Persons with Diabetes Insipidus Using DDAVP: Caution in a Cultural Obsession with Hydration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Bryan John McColgan*1 and Tyler Francis Aguinaldo2
1Stanford University, Stanford, CA, 2Santa Clara Valley Medical Center, San Jose, CA

 

Background:

Central diabetes insipidus (DI) has been well described in patients with lymphoma as well as acute myeloid leukemia (1).  This is the first report of a patient with central DI secondary to hairy cell leukemia.

Clinical Case:

A 47 year old man with no significant past medical history presented with fevers, abdominal pain, and excessive urination and thirst.  The patient noted the acute onset of severe thirst for cold water and frequent urination about one week prior to admission.  He denied any history of head or back trauma, and had taken no regular prescription medication prior to this admission.  In the emergency room, he was noted to have a lipase of 889 U/L.  He was started on continuous intravenous fluids of 5% dextrose and normal saline at 100 mL/hour out of concern for pancreatitis.  An abdominal ultrasound revealed an enlarged spleen with numerous hyperechoic lesions.  Perpheral blood flow cytometry and a bone marrow biopsy were both consistent with hairy cell leukemia.  He began Cladribine 0.1 mg/kg/day with a twenty-four hour infusion over seven days.  Throughout his admission until consultation with endocrinology, he had maintained serum sodium measurements between 145 and 154 mmol/L while receiving 100 mL per hour of intravenous fluids noted above.  He was drinking about five liters of water daily, and his urine output was in excess of seven liters daily.  His urine had remained dilute with a urine specific gravity between 1.001 and 1.002, and a urine osmolality of 118 mOsm/kg.  He was trialed on 1 mcg SQ DDAVP.  His serum sodium then decreased to 139 mmol/L, and his urine specific gravity and urine osmolality increased to 1.009 and 456 mOsm/kg, respectively.  The patient then began on twice daily doses of 0.1 mg oral DDAVP to keep his sodium within normal, but after three days he became hyponatremic to 132 mmol/L.  A brain MRI was done that showed an absence of the normal posterior pituitary bright spot, a 5 mm left anterior pituitary nonenchancing T1 hypointensity, and a bulbous pituitary stalk that was enlarged to 4 mm superiorly.  His morning cortisol and free T4 were assessed given his hyponatremia and persistent vomiting, and these returned at 35 mcg/dL and 0.8 ng/dL, respectively.  After conclusion of his chemotherapy, a water deprivation test was done with the patient’s sodium increasing to 147 mmol/L, and his serum osmolality increasing to 305 mOsm/kg after about six hours.  The patient left on 0.05 mg oral DDAVP at bedtime with plans to have anterior pituitary testing, MRI, and DI labs prior to follow up.

Conclusion:

This is the first case demonstrating central DI as a presenting symptom and consequence of hairy cell leukemia.  Although the follow up labs and imaging are still pending, it is possible given his hospital course that the DI could be improving or even resolve after chemotherapy with Cladribine.

 

Nothing to Disclose: BJM, TFA

19632 21.0000 THR-438 A Acute Onset of Central Diabetes Insipidus Secondary to Hairy Cell Leukemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Ngaruiya Kariuki*1 and Patricia Park2
1Baylor College of Medicine, Houston, TX, 2Maimonides Medical Center, Brooklyn, NY

 

INTRODUCTION

MDMA (3,4-methylenedioxy-methamphetamine or “Ecstasy”) is known to cause hyponatremia by stimulating ADH secretion and polydipsia1,2. However, the effect of this drug in the setting of Diabetes Insipidus and Desmopressin (DDAVP) replacement has yet to be reported.

 

CLINICAL CASE

A 24 year-old male presented to the emergency room with complaints of worsening nausea, vomiting and dizziness for five days. The symptoms commenced shortly after trying MDMA at a party. Past medical history was significant for isolated central diabetes insipidus secondary to a pituitary tumor diagnosed nine years previously by brain MRI, which showed a germinoma or lymphocytic hypophysitis with a subsequently inconclusive biopsy. He had been on a stable dose of DDAVP 0.1mg five times daily up until the onset of his symptoms. He then increased the dose of DDAVP to 0.1mg seven times daily, attributing his symptoms of nausea and malaise to dehydration. Physical examination was unremarkable; vital signs were stable with apparent euvolemia in the absence of neurologic deficits. Preliminary tests were consistent with hyponatremia alongside SIADH: low serum sodium (112 mmol/L, n 133 to146 mmol/L), low serum osmolality (260 mOsm/kg, n 275 to 295 mOsm/kg), normal serum TSH (2.78 mcIU/mL, n 0.73 to 4.60 mcIU/mL), normal serum morning cortisol (15.4 ug/dL, n 6.7 to 23.99 ug/dL) as well as inappropriately high urine sodium (105 mmol/L) and urine osmolality (665 mOsm/kg). CT Head demonstrated an old right frontotemporal craniotomy with no acute intracranial disease. MRI Pituitary with IV contrast further revealed projection of the right side of the pituitary gland into the suprasellar cistern compatible with post-surgical change or residual tumor. Initial management included fluid restriction and cessation of DDAVP with subsequent resolution of symptoms. DDAVP was then restarted and the dose was titrated to his rising serum sodium level and urine output. He was counselled on illicit drug use and the importance of not increasing the dose of DDAVP by himself.

 

CONCLUSION

Desmopressin over-replacement and MDMA abuse have both been reported as isolated causes of hyponatremia3,4. This is the first case report of severe hyponatremia and SIADH resulting from the use of both agents. Conceivably, in the context of diabetes insipidus, MDMA may exacerbate thirst to such a degree that unwittingly prompts an increment in the dosage of Desmopressin. Thus, we emphasize the need to obtain a careful substance abuse history in patients with hyponatremia, especially in the context of concomitant Desmopressin use.

 

Nothing to Disclose: NK, PP

19649 22.0000 THR-439 A Desmopressin & Ecstasy: An Unlikely Combination Resulting in Severe Hyponatremia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Zeina Ali*1 and Shadi Abdelnour2
1University of Nevada School of Medicine, 2University of Nevada School of Medicine, Las Vegas, NV

 

Background: Erdheim-Chester disease (ECD) is a rare non-Langerhans disease that can manifest as an asymptomatic bone or cutaneous lesion, or with multi-organ system involvement.  We report a case of ECD that presents with a lower extremity skin lesion, hypogonadism, and diabetes insipidus (DI).

Clinical Case: A 43-year-old man with a history of diabetes mellitus type 2 presented with a sudden-onset of polyuria and polydipsia for five months. He was consuming 3.5 gallons of water daily and urinating every hour. He also reported fatigue, decreased libido, and erectile dysfunction that started one month after the onset of polyuria and polydipsia. He denied any head trauma or changes in medications. Physical examination was unremarkable except for tenderness of the right lower extremity and a small-to-normal-sized penis with normal-sized testes. Laboratory studies showed low anti-diuretic hormone < 0.8 pg/mL (reference 0–4.7), follicular stimulating hormone 0.8 mIU/mL (reference 1.6–8.0), luteinizing hormone < 0.7 mIU/mL (reference 1.5 –9.3), total testosterone 14 ng/dL (reference 250–1100) and free testosterone 1.4 pg/mL (reference 35–155). Serum osmolarity was slightly elevated at 312 mosm/kg (reference 282-300). His diabetes mellitus was well controlled with an A1c of 5.7%.  MRI of the brain showed thickening and enhancement of the pituitary infundibulum but no hypoenhancing lesions within the pituitary gland to suggest microadenoma. The pituitary fossa and clivus were normal. He was diagnosed with central DI and central hypogonadism. He was treated with desmopressin and testosterone gel with improvement in his symptoms. A bone biopsy  of the right lower extremity lesion, initially thought to be osteomyelitis,  was consistent with ECD which exhibited histiocytic infiltrates including spindle cells, xanthocytes, and touton giant cells staining diffusely positive for CD68 and CD4 but negative for S-100 and CD1a. The patient was started on treatment with interferon alpha.

Discussion: Erdheim-Chester Disease is a rare non-Langerhans disease with about 500 cases reported in literature. Clinical manifestations of ECD can be very broad, ranging from asymptomatic bone or cutaneous lesions to multi-organ system involvement.  Long bones are frequently involved and bone pain as the most common symptom. Extra-skeletal manifestations include lungs, skin, kidneys, large vessels, endocrine system, and retroperitoneum. The presence of DI and hypogonadism can be seen in multiple pituitary and hypothalamic disorders, but the biopsy of the non-healing leg lesion was the least invasive mean for diagnosing the patient with ECD.

 

Nothing to Disclose: ZA, SA

20522 23.0000 THR-440 A Erdheim-Chester Disease: A Common Presentation of an Uncommon Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 418-440 5999 1:00:00 PM Acromegaly, Diabetes Insipidus, Vasopressin Poster


Asim Hassan1, Muhammad Shoaib Zaidi*2 and Ebtehal AlMogbel3
1King Abdul Aziz University Hospital, Riyadh - K.S.A., 2King Abdul Aziz University Hospital, Riyadh, KSA, Saudi Arabia, 3AlQassim University, Buraidah,AlQassim region, Saudi Arabia

 

INTRODUCTION

Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome combines features ranging from congenital absence of the vagina,to a rudimentary bicornuate uterus that may not open into the vaginal canal,to a virtually normal uterus. The incidence of the syndrome is one in 4,500 female newborns. MRKH syndrome  patients have a correctly timed pubarche and thelarche with a normal female karyotype (46, XX). 

We describe a case of 19 years old Saudi woman with Type 1 diabetes for 6 years and primary hypothyroidism, having presented to the Endocrinology Clinic in July 2013 with primary amenorrhoea, associated with cyclical abdominal pain for 4 years. Her secondary sexual characteristics had appeared at the age of 14 years. There was no history of galactorrhea, hirsutism, visual disturbance or anosmia. The patient was born pre-term at 8 months of gestation and had  mild cerebral palsy. The family history was unremarkable. Her younger sister, aged 17 years had normal menstrual cycles. On examination the patient’s BMI was 18.41  kg/m²  and she was hemodynamically stable. There were no dysmorphic features.  The neurologic examination revealed a limping gait and atrophy of right hand and right lower-limb muscles. No syndactyly or scoliosis was observed. The rest of the systemic examination was unyielding.

The patient had normal secondary sexual characteristics (Tanner 4). She was seen by the gynecologist who reported a blind vagina. Subsequently, a progesterone challenge had failed to induce withdrawal bleeding.

Investigations revealed a normal CBC along with normal renal, hepatic, thyroid & bone profiles. Random blood glucose was 163 (70.2-162mg/dl) and HbA1c was 9.7(<6.5 %). Serum Estradiol, FSH, LH, Testosterone and DHEA levels were within normal limits. Urinalysis was normal. Karyotyping showed normal 46 XX female karyotype.

Radiology studies including the chest film, skeletal survey and the echocardiogram were unremarkable. MRI of abdomen & pelvis revealed an atretic uterine cervix without visualization of the vagina. Otherwise, the uterine anatomy, ovaries & kidneys were  normal.

The patient was on Glargine & Aspart insulin and 50µg of Thyroxine daily, besides 3 monthly depot Medroxy-progesterone acetate(150 mg) injection for the control of her cyclical abdominal pain. 

Our patient was finally diagnosed to have the rarest form of Mayer-Rokitansky-Kuster-Hauser syndrome,as she had isolated vaginal atresia with normal uterus. She was referred to a higher center for possible vaginoplasty.

CONCLUSION

In MRKH syndrome there is an uncommon occurrence of malformations of the distal genital system ,while the spectrum of abnormalities occur more commonly in the proximal part, with adnexal and extragenital malformations. Our patient was unique in the sense, that she had the rarest type of MRKH syndrome with vaginal atresia and normally functioning uterus,along with Type 1 diabetes and hypothyroidism.

 

Nothing to Disclose: AH, MSZ, EA

19295 1.0000 THR-081 A Diabetes & Primary Amenorrhea 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Nadine E Palermo*, Elizabeth M Herman, Pavani Srimatkandada and Andrea D Coviello
Boston University School of Medicine, Boston, MA

 

BACKGROUND:  Hirsutism, alopecia, and acne are hyperandrogenic (HA) symptoms that can present at anytime in the life-course in women.  HA disorders include polycystic ovary syndrome (PCOS), non-classic congenital adrenal hyperplasia (NC-CAH), Cushing’s disease, and virilizing adrenal or ovarian tumors.  While PCOS is the most common affecting ~10% of premenopausal women, the prevalence of other disorders is <1%. 

CLINICAL CASE: A 55 yr postmenopausal woman was referred to the endocrine clinic for further evaluation of severe facial hirsutism and elevated DHEAS levels of 318, 240 mcg/dl (Ref 14-180). PMH is notable for precocious puberty; hirsutism at age 8; irregular menses; and premenopausal balding, worsening hirsutism, deepening voice and clitoromegaly at age 48 with bloodwork notable for Testosterone (T) 309 ng/dl (Ref 14-76), androstenedione (A) 124 ng/dl (Ref 30-285), DHEAS 211 mcg/dl (Ref 28-290). CT scan showed a 14cm left ovarian mass and a 2cm left adrenal tumor. She underwent TAH-BSO with omentectomy and left adrenalectomy.  Surgical pathology: 1) complex ovarian tumor 14x13x9 cm  composed of 3 distinct tumor types (25% mucinous cystadenoma, 25% benign Brenner tumor, 50% sertoli-leydig cell tumor) and 2) left adrenocortical adenoma 1.8x1.5 cm with background nodular hyperplasia. Serial CT scans have been without evidence of recurrent metastatic disease. Family history is notable for deep voice and hirsutism in multiple female relatives and ovarian cancer in one aunt and breast cancer in another aunt.  PE notable for BP 91/64, HR 81, BMI 24, severe facial hirsutism, prominent larynx, deep voice.  Labs (Post-Menopausal Ref):  Total T 11 ng/dl (Ref 2-45), Free T 1.0 pg/ml (Ref 0.2-5.0), A 54 ng/dl (Ref 20-74),  *DHEAS 227 mcg/dl (Ref 14-180), Cortisol 7.8 mcg/dl (Ref 4.0-23.0), 17OH-progesterone (17OHP) 12 ng/dl (Ref ≤45), 17OH-pregnenelone (17OHPreg) 37 ng/dl (Ref ≤ 286), Aldosterone  5 ng/dl (Ref<28 ), PRA 1.09 ng/ml/h (Ref  0.25-5.82). Cortrosyn (250 mcg) Stimulation Test:  Baseline ACTH 10 pg/ml (Ref 6-50), Baseline => 60 minutes:  Cortisol 6.9 => 26 mcg/dl, DHEAS 315 => 343 mcg/dl (Ref 14-180), 17OHP 11 => 312 ng/dl (Ref ≤45/<1000), *17OH-Preg 26 => 1937 ng/dl (Ref ≤200/<1000).  Stimulated 17OHPreg:17OHP ratio=6.2 (Ref<5).  Adrenal MRI:  Normal right adrenal, absent left adrenal with nodular anterior limb remnant.  Her elevated DHEAS and stimulated 17OHPreg in the absence of adrenal or ovarian tumors on imaging is consistent with 3BHSDII deficiency NC-CAH.

CLINICAL POINTS:  3BHSDII deficiency NC-CAH presents with an HA phenotype and may be more common than previously recognized.  Alopecia, hirsutism, or acne with an elevated DHEAS in a woman should be evaluated further with AM adrenal steroids including 17OHP & 17OHPreg and cortrosyn stimulation testing.  HA symptoms respond well to treatment with contraceptives and off-label use of spironolactone through blockade of the androgen receptor.

 

Nothing to Disclose: NEP, EMH, PS, ADC

21302 2.0000 THR-082 A 3BHSDII Deficiency Non-Classic CAH Masked By a Virilizing Ovarian Tumor: When Do You Evaluate Adrenal Androgen (DHEAS) Elevation? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Vijaya Surampudi*1, Teeranun Jirajariyavej2 and Ronald S. Swerdloff3
1Harbor-UCLA Medical Center, Los Angeles, CA, 2Harbor UCLA Medical Center, Torrance, CA, 3Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA

 

Background:

In adult women virilization includes hirsuitism plus deepening of the voice, increased muscle mass and clitoromegaly. Virilization is a consequence of hyperandrogenism and the differential diagnosis includes ovarian neoplasms and adrenal neoplasms.

Clinical Case:

Two unrelated women presented with vilirization. The first woman was a 23 y/o who was initially seen by OB-Gyn for work up of secondary amenorrhea. Patient also noticed that she had increased hirsutism over 3 months prior to her initial visit and enlargement of her clitoris. Lab tests: Total serum testosterone 478 [2-45 ng/dL], 17-OH progesterone 1,062 [<285 ng/dL], DHEA-S<13 [45-320 ng/dL] and cortisol 19.8 [4-22 mcg/dL]. Pelvic US revealed a right ovarian mass 2.5 x 2.4 x 2.9 cm hyperechoic mass with internal color Doppler flow. The patient had a cosyntropin stimulation test for evaluation of non-classical CAH that did not increase the values of 17-OH progesterone or testosterone. This suggested the androgens were not from an adrenal source and likely had an androgen producing ovarian tumor.  She underwent a right salpingo-oophorectomy and pathology revealed a steroid cell tumor. Post-op, patient’s testosterone came down to 12 [2-45 ng/dL].

The second woman was a 50 y/o F G1P1 who presented hirsutism, male pattern baldness, clitoromegaly and deepening of her voice that progressed over the past year. Total testosterone was measured to be 478 [2-45 ng/dL], 17-OH progesterone 420 [<285 ng/dL], DHEA-S 56 [45-320 ng/dL] and cortisol 8.1 [4-22 mcg/dL]. She underwent a dexamethasone suppression test that did not result in suppression of her testosterone or 17-OH progesterone. In this case also, this suggested the androgens were not being produced by the adrenal gland and likely had an androgen producing ovarian tumor.  An MRI of the abdomen revealed a 3.9 x 3.8 x 3.5 cm heterogeneous mass in the left adnexa and patient underwent a laparoscopic bilateral salpingo-oophorectomy. Pathology revealed an ovarian Sertoli-Leydig cell tumor. Post-op, patient’s testosterone came down to 19 [2-45 ng/dL].

Conclusion:

Women presenting with new onset virilization with serum testosterone levels > 200 ng/dl should be evaluated for possible neoplastic processes. The adrenal glands are a prominent source of androgens. When 17-OH progesterone is markedly elevated, the adult patient should be evaluated for non-classical CAH but also reviewed in context of the DHEA-S. Majority of DHEA-S derives from the adrenal glands (1) and in both cases, despite elevation of 17-OH progesterone, had normal DHEA-S suggesting an ovarian source.  In a patient presenting with rapid virilization, elevated testosterone and normal DHEA-S an ovarian tumor should be suspected.

 

Disclosure: VS: Clinical Researcher, Novartis Pharmaceuticals. RSS: Investigator, Novartis Pharmaceuticals, Investigator, Lipocine, Principal Investigator, Aptys, Consultant, Antares, Investigator, Antares, Investigator, AbbVie, Investigator, Endo Pharmaceuticals, Medical Advisory Board Member, Clarus, Consultant, Clarus, Principal Investigator, Clarus, Consultant, Quest Diagnostics. Nothing to Disclose: TJ

20570 3.0000 THR-083 A Evaluation of Pre-Menopausal Women Presenting with Virilization Resulting in Two Cases of Androgen Producing Ovarian Tumors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Preethi Krishnan*1 and Naveen Kakumanu2
1Michigan State University, Holt, MI, 2Michigan State University, Okemos, MI

 

Ovarian Hyperthecosis Causing Hyperandrogenism in a Postmenopausal Woman With Normal Imaging

Background: Ovarian hyperthecosis is a disorder characterized by hyperandrogenism and insulin resistance that occurs primarily in postmenopausal women and contributes to less than 1 % of cases in this population.

Clinical Case:

A 59 year old woman presented with hirsutism of 3 years duration after the onset of menopause. She attained menopause at age 46. Laboratory evaluation for hirsutism demonstrated elevated total testosterone of 153 ng/dl (1.0-55.0 ng/dl) and free testosterone of 5.4 ng/dl (0.3-1.9 ng/dl) with normal adrenal steroids including dehydroepiandrosterone sulphate (DHEAS) indicating ovarian source of androgens.

Follicle stimulating hormone (FSH) and luteinizing hormone (LH) were both elevated at 125 mIU/ml (23-116.3 mIU/ml) and 65.5 mIU/ml (13.3-43.0 mIU/ml) respectively with estradiol concentration of 23 pg/ml (<20 pg/ml). Hemoglobin A1C was 6.4% and 75 gm 2 hr oral glucose tolerance test (OGTT) was 171 mg/dl indicating impaired glucose tolerance. Cushing's disease was ruled out by normal low dose dexamethasone suppression test. Ultrasound and computed tomography (CT) scans of the abdomen and pelvis demonstrated normal adrenal glands and ovaries.

She subsequently underwent laparoscopic bilateral salpingo-oophorectomy. Pathology demonstrated a small benign fibroma in one ovary. Testosterone concentration after surgery was normal at 14.7 ng/dl. She had the characteristic clinical and biochemical features of ovarian hyperthecosis which is insulin resistance and a slowly progressive gonadotropin-dependent ovarian hyperandrogenism which resolved with oophorectomy.

Conclusion:

Less than 1 % of hyperandrogenism cases in women is attributed to ovarian hyperthecosis and typically there is enlarged ovaries or ovarian masses visualized on imaging. However, this must be considered as an important differential of this clinically significant condition in postmenopausal women despite normal radiologic studies.

 

Nothing to Disclose: PK, NK

20701 4.0000 THR-084 A Ovarian Hyperthecosis Causing Hyperandrogenism in a Postmenopausal Woman with Normal Imaging 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Preethi Mohan Rao*1, Anne Straffen2 and Thomas Hugh Jones3
1Barnsley Hospital NHS FoundationTrust, Barnsley, 2Barnsley Hospital NHS Foundation Trust, Barnsley, 3Barnsley Hospital NHS Foundation Trust, Barnsley, United Kingdom

 

Successful pregnancy in a patient with biologically inactive LH or partial LHCGR resistance

Introduction:

LH resistance is very rare and there are only a few case reports in the literature. We describe a patient who presented to us with secondary amenorrhea and very high isolated LH levels who subsequently had a successful pregnancy with IVF.

Case report:

A 16 year old girl was referred to us to investigate the cause of her oligomenhorrea. She had attained menarche at the age of 13 and had only 5 periods in 3 years. She had no symptoms/signs of any endocrine abnormality.

Her blood results showed elevated LH levels more than 250 U/l. Her FSH, prolactin & the rest were normal. There was no evidence of interference from heterophile antibodies. MRI scan of her pituitary was normal. We suspected she had LHCGR mutation causing LH resistance, however genetic analysis did not identify any such mutation in exon 11.

She was started on OCP. There was some suppression of LH from the baseline although incomplete. She was having regular bleeding on the OCP.  In 2008 she wanted to start family. Since she did not have LHCGR gene mutation, we wondered if the receptor function was normal and hence decided give a trial of IVF cycle. She received Zoladex to induce pituitary down regulation followed by recombinant FSH to induce follicular growth and hCG. She had a successful pregnancy. Currently her LH is not fully suppressed inspite of being on OCP confirming that the hypothalamic pituitary dysfunction persists.

Conclusion:

LH resistance in women is a very rare phenomenon. Our patient is likely to have either partial LHCGR resistance or biologically inactive LH. Our patient had a positive pregnancy with IVF making it a success story however the molecular diagnosis for her LH resistance is still unclear.

 

Nothing to Disclose: PMR, AS, THJ

19060 5.0000 THR-085 A Successful Pregnancy in a Patient with Biologically Inactive LH or Partial Lhcgr Resistance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Chinenye Usoh*1 and Victoria C Hsiao2
1University of Rochester School of Medicine and Dentistry, Rochester, NY, 2University of Rochester Medical Center, Rochester, NY

 

Introduction: The differential for hirsutism in a post-menopausal woman can be broad.  A step-wise approach will systematically rule out certain etiologies and lead to the correct diagnosis.

Clinical Case: A 73-y.o woman presented with typical symptoms of hirsutism including increased hair growth on chin, back, breasts, and abdomen for the past few years. 

Initial tests were consistent with excess testosterone production: total testosterone 308 ng/dL (normal 8-60 ng/dL) and free testosterone 5.5 ng/dL (normal 0.3-1.9 ng/dL).  Kaltsas et al. (1) proposed that lack of androgen suppression in a low dose dexamethasone suppression test (LDDST) suggests androgen-secreting tumor of either the ovaries or adrenal glands.  Further imaging should only be done in patients with hyperandrogenism who fail to achieve 40% or more testosterone suppression.  In the patient’s LDDST, total and free testosterone levels did not suppress after patient received dexamethasone 0.5 mg by mouth every 6 hours for 2 days. On day zero, total and free testosterone levels were 318 ng/dL and 4.8 ng/dL, respectively.  On day two, total and free testosterone levels were 344 ng/dL and 5.8 ng/dL.  DHEA-sulfate and 17-hydroxyprogesterone levels were normal at 33 µg/dL and 191 ng/dL, respectively.  Brain MRI with and without contrast showed a 3 mm lesion in right pituitary gland which exhibited delayed enhancement.  LH level was normal at 46.9 mIU/ml and thus an LH secreting pituitary adenoma was unlikely to be cause of her findings. 

She had a transvaginal ultrasound which showed a 1 cm x 1.2 cm cyst in the right ovary. She underwent laparoscopic bilateral salpingo-oophorectomy.  Pathology revealed a 1.4 cm Leydig cell tumor in the center of the right ovary.  There was no necrosis, hemorrhage, cytologic atypia or mitosis identified.  Postoperatively, her symptoms improved and total and free testosterone levels normalized to 17 ng/dL and 0.3 ng/dL, respectively.

Clinical Lesson:  This case demonstrates the importance of using a step-wise approach to determining the etiology of hirsutism and the usefulness of the low dose dexamethasone suppression test.  Leydig cell tumors of the ovary are a rare benign etiology of hyperandrogenism in women and should be considered in patients with consistent biochemical and physical findings.

 

Nothing to Disclose: CU, VCH

19328 6.0000 THR-086 A Leydig Cell Ovarian Tumor Causing Hirsutism in a Post-Menopausal Woman 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Rhea Bhargava*, Saad Ashraf and Nalurporn Chokrungvaranon
University of Missouri-Kansas city, Kansas city, MO

 

Introduction: Diabetes insipidus(DI) during pregnancy is a rare disorder with an incidence of 6 cases per 100,000 pregnancies and is sometimes very difficult to diagnose. It is characterized by polyuria, polydipsia and increased thirst manifesting mostly in the third trimester of pregnancy but can occur at any stage of gestation. The mechanism is thought to depend on excess vasopressinase activity which can lyse arginine-vasopressin but not 1-deamino-8-D-arginine vasopressin which is a synthetic form of the hormone. We report a case of diabetes insipidus that was diagnosed during third trimester of twin pregnancy.

Case: A 26 years old female G1P0A0 presented at 33 weeks of her gestation with dichorionic dizygotic twin pregnancy with elevated blood pressures for which she was admitted. She was noted to have polyuria and polydipsia in the hospital with urine output of >200 cc/hr and total 24 hour urine output of more than 7 liters. On physical examination, her blood pressure was 150/90 mmHg with a heart rate of 81 per min and temperature of 98.1 F. The rest of the physical exam was within normal limits. Her plasma osmolality was 281 mOsm/kg while the serum sodium was 141 mEq/l and serum glucose was 75 mg/dl. Her urine osmolality initially was 81 mOsm/kg with a specific gravity of 1.010 and no glycosuria. Her liver function tests were not elevated and no evidence of thrombocytopenia or hemolysis was noted. On the fluid restriction test, her serum osmolality increased reasonably with an inappropriately low urine osmolality of 272mOsm/kg. The DDAVP challenge was started and the patient was found to have good response with a urine osmolality measurement of 524 mOsm/kg post test. We hence diagnosed her with gestational versus central DI. She was started on oral desmopressin and her symptoms resolved with a good response to treatment. Desmopressin was stopped after the patient underwent a C-section with stable sodium levels and reduction of urine output to baseline post removal of placenta.

Conclusion: Gestational DI is underdiagnosed, as polyuria can occur during pregnancy and needs to be kept in mind when caring for this population. Twin pregnancy and pre-eclampsia are both risk factors and were present in our patient.  It is a rare disorder and can be treated successfully with synthetic DDAVP. This disorder can be associated with serious underlying pathology and may be the first sign of a tumor inducing DI and hence these patients need to be followed post removal of the placenta by an endocrinologist.

 

Nothing to Disclose: RB, SA, NC

19241 7.0000 THR-087 A A Case of Diabetes Insipidus Diagnosed during Twin Pregnancy Associated with Preeclampsia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Jessica Kaur Bhathal*1, Roberto X Calix2, Shams Halat3 and Brandy Ann Panunti4
1Ochsner Medical Centre, Jefferson, LA, 2Ochner Clinic Foundaton, Jefferson, LA, 3Ochsner Clinic Foundaton, Jefferson, LA, 4Ochsner Clinic Foundaton, New Orleans, LA

 

Background:

Hirsutism is a common endocrine disorder and age of onset and rate of progression help determine the etiology. Signs of new onset hyperandrogenism in a post-menopausal woman are rare and prompt evaluation is essential.

Clinical Case:

56 year-old Caucasian female presented to endocrine clinic with new onset hirsutism present for 3 years, but worsening over past 6 months. Other associated symptoms and signs included deepening of her voice, scalp hair loss, and weight gain from muscle mass development. Her libido was “excellent” despite being menopausal since age 40 and being off hormone therapy. Due to complete resolution of vaginal dryness and hot flushes, she stopped her estrogen therapy 18 months prior to the visit. On physical exam, she was hirsute (Ferriman-Gallwey score: 14) with well-developed musculature, deep voice, and temporal hair recession and clitoromegaly.

Androgen excess was confirmed on labs: Total testosterone 575 ng/dL (5-73 ng/dL), Free Testosterone 12.4 (0.2-2.2 pg/mL), DHEAS-S04 137.6 ug/dL (29.7-182.2 ug/dL), SHBG 28 (12-166). Hemoglobin A1C was 6.9%. Imaging included a normal trans-vaginal ultrasound of the ovaries. Based on biochemical studies, the diagnosis of an androgen secreting ovarian tumor was made. She underwent robotic -assisted laparoscopic hysterectomy with bilateral salpingo-oophorectomy with LN sampling. Operative findings showed slightly enlarged left ovary. Intra-operative frozen section was performed and consistent with final pathology; sex cord stromal tumor, most consistent with Leydig cell tumor. Post-operative labs confirmed biochemical cure: Total Testosterone 21 (5-73 ng/dL), Free testosterone 0.5 (0.2-2.2 pg/mL).

Leydig cell tumors constitute <0.5% of ovarian neoplasms, with 75% occurring under age 40. They are capable of producing androgens with about two-thirds being biochemically functional. Treatment is surgical and prognosis is good as it is a slow growing tumor with 75% being benign.

Conclusion:

New onset, rapidly progressive androgenization in a post-menopausal female should prompt the clinician to test for androgen secreting tumors, with ovaries and adrenal glands as the possible source. In the post-menopausal state, even with normal ovarian imaging, a markedly elevated testosterone with normal DHEA-S levels confirms an ovarian-based tumor and treatment is surgical.

 

Nothing to Disclose: JKB, RXC, SH, BAP

20661 8.0000 THR-088 A A Case of Rapid Verilization in a Post-Menopausal Female 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Cristina Ghervan*1, Codruta Nemes1, Daniel Muresan1, Doinita Crisan2 and Liviu Ghervan1
1University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania, 2University of Medicine and Pharmacy, Cluj-Napoca, Romania

 

Background: Virilizing syndrome in a postmenopausal woman is a concerning matter, raising the suspicion of androgen-secreting tumor. Leydig cell ovarian tumors are a very rare cause of androgen secretion, representing less than 0.1% of all ovarian tumors; they are usually benign and curable after surgery.

Clinical case: We report the case of a 65 years old woman with severe virilization features: severe hirsutism, androgenic alopecia, clitoromegaly and deepening of voice, evolving rapidly over 4 years. One year ago the patient was diagnosed with polyglobulia (interpreted as Polycythemia Vera) and she had repeated phlebotomy, subsequently receiving treatment with Hydroxyurea. The hormonal dosages showed elevated levels of both testosterone (15.5 ng/ml, n.r. 0.2-1 ng/ml) and estradiol (299 pg/ml, n.r. 15-60 pg/ml), meanwhile DHEAS level was normal, indicating an ovarian pathological secretion. The endovaginal ultrasound examination and CT scan revealed: severe uterine fibromatosis (11.5/15.6/19 cm) compressing both ureters, producing first degree hydroureteronephrosis, and an enlarged right ovary of 5.5/2.8 cm. A total hysterectomy and bilateral oophorectomy was performed. Pathological examination confirmed the diagnosis of right ovarian Leydig cell tumor. After surgery, the testosterone and estradiol levels normalized (concordant to the age and menopausal status) and the clinical features progressively improved, including polyglobulia.

Conclusion: We present a very rare case of secreting ovarian Leydig cell tumor in a postmenopausal woman, showing besides the virilizing syndrome, two unusual features: polyglobulia, due to androgen hypersecretion, that was completely reversible after tumor removal, and severe compressive uterine fibromatosis, that was the consequence of the estrogen excess.

 

Nothing to Disclose: CG, CN, DM, DC, LG

19577 9.0000 THR-089 A Severe Virilizing Syndrome Produced By a Rare Secreting Leydig Cell Ovarian Tumor Showing Polyglobulia and Uterine Fibromatosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Shwetha Mallesara Sudhakar*1 and Shahla Nader-Eftekhari2
1University of Texas Health Science Center at Houston, Houston, TX, 2University Of Texas Health Science Center At Houston, Houston, TX

 

Introduction

Androgen insensitivity syndrome (AIS) occurs in 2-5 cases per 100,000 live births and is caused by loss of function mutation of the gene that encodes the androgen receptor(AR) giving a spectrum of clinical presentations depending on the severity of androgen insensitivity. We present a case with a rare phenotype.

Case presentation

An 18 Y/F patient was evaluated for primary amenorrhea. Examination showed a normally developed female with Tanner 5 breasts, normal clitoris, a full length vagina but no uterus was felt. She had clinically significant hirsutism on her chest and lower abdomen. Laboratory testing showed the following: FSH- 3.2 mIU/ml, LH 28.6 mIU/ml, prolactin 9.9 ng/ml, estradiol 51 pg/ml, testosterone 800 ng/dl with free testosterone 91.9 pg/ml(both within normal range for males), DHEAS 746 mcg/dl, 17 OH-progesterone 128 ng/dl. Her karyotype was 46 XY. Abdominal imaging revealed absence of uterus but gonad like structures were seen at the level of common iliac vessels. Genetic testing showed that she was hemizygous for partial duplication of AR gene at exon 2-4 which has previously been reported in androgen insensitivity. The patient had gonadectomy confirming testes and  is on estrogen replacement therapy.

Case Discussion:
The androgen receptor gene is X-linked recessive. A large number of mutations have been reported in the AR gene. The degree of loss of androgen function directly determines the phenotypic features in these XY subjects. In complete AIS, the subjects are born as phenotypic females who present with primary amenorrhea with normal breast development and absence of terminal axillary and pubic hair. Mullerian derivatives namely uterus and tubes are absent secondary to production of antimullerian hormone by the testes while in utero, resulting in a blind vaginal pouch. The gonads may be felt in the groin. In partial AIS, a spectrum of phenotypes may be seen varying from females with clitoromegaly to males with varying degrees of masculinization encompassing hypospadias, micropenis, bifid scrotum and undescended testes. The mildest variants may present with gynecomastia or infertility. This patient had hirsutism without virilization such as clitoromegaly and a high LH/FSH ratio suggestive of polycystic ovary syndrome. However her extremely high serum testosterone concentration as well as her absent uterus lead to the correct diagnosis of partial androgen insensitivity, which was confirmed genetically. Appreciation of this phenotypic spectrum in androgen insensitivity is important. This case represents minimal but clinically significant androgen action in a XY individual presenting as a female with primary amenorrhea and hirsutism.

 

Nothing to Disclose: SM, SN

19657 10.0000 THR-090 A A Case of Androgen Insensitivity with a Rare Phenotype 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Erika Villanueva*1, Nirali Shah2 and Eliza B. Geer1
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Icahn School Of Medicine at Mount Sinai, New York, NY

 

Introduction:

Gestational gigantomastia is a rare condition with a quoted incidence of 1/28,000 to 1/100,000 pregnancies.  We present a case of gestational gigantomastia that improved post-partum with bromocriptine therapy. 

Case presentation:

A 21 year old G1P1001 African American female with no past medical history was evaluated for post-partum gigantomastia after normal vaginal delivery.  She reported breast engorgement starting in the 7th month gestation with worsening symptoms on post-partum day 1.  Breast pumping was attempted, with no resolution of pain and tenderness.

On examination, both breasts were grossly enlarged and extended to the level of iliac crest.  Non-bloody galactorrhea was present.  The skin covering the breasts showed dilated veins with no signs of ulceration, erythema or marked pigmentation. 

Laboratory work revealed a TSH of 0.62uIU/ml, prolactin 305.1 ng/ml, WBC 9.8, and Hct 24.8%.  Breast ultrasound revealed bilateral diffuse skin thickening and edema, multiple dilated retro-areolar ducts but no discreet abscess or mass.  Plastic surgery was consulted and recommended conservative management with pain control, breast compresses, and empiric antibiotics.  Bromocriptine 2.5 mg twice daily was initiated by endocrinology and titrated to 7.5 mg three times daily over 3 days.   The patient symptomatically improved and was discharged to home on hospital day 7.

She was seen in endocrinology clinic 1 month later.  She noted dramatic improvement in breast size and cessation of lactation with bromocriptine.  Bromocriptine was tapered to 7.5 mg twice daily for 2 weeks, followed by daily dosing for 2 weeks, then discontinued.   She followed up with plastic surgery with plans for eventual mastectomy prior to possible future pregnancies.

Discussion:

Gestational gigantomastia, first described in 1684 by Palmuth, is a severely debilitating condition characterized by rapid and disproportionate enlargement of breasts which can be complicated by thinning of the skin, necrosis, infection and hemorrhage.  The etiology is unknown, but proposed to be hypersensitivity to or overproduction of hormones including prolactin, estrogen, human chorionic gonadotropin or human placental lactogen.  Histological studies reveal dense fibrosis of the stroma associated with normal breast lobules with no evidence of adenosis or epithelial proliferation.  Treatment options include medical therapies such as tamoxifen, bromocriptine, testosterone, hydrocortisone, diuretics and medroxy progesterone acetate.   Bromocriptine is the drug of choice as it has been reported to reduce progression, promote regression, and decrease the need for surgery in 39% of patients.  Surgical treatment including reduction mammoplasty or simple mastectomy is indicated in cases of massive hemorrhage, ulceration, or breast necrosis.   Recurrence in future pregnancies remains extremely high.

 

Nothing to Disclose: EV, NS, EBG

19950 11.0000 THR-091 A A Case of Post-Partum Gigantomastia Treated Successfully with Bromocriptine 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Swaytha Yalamanchi*1 and Adrian Sandra Dobs2
1John Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine

 

Menopause is characterized by relative hyperandrogenism (HA) with declining estrogen and SHBG and increased gonadotropin levels.  In pre-menopausal women HA, especially when seen as a characteristic of PCOS, may be associated with an adverse cardiometabolic phenotype. We sought to better characterize the etiologies of HA in postmenopausal women (PMW) based on clinical and biochemical features We performed a retrospective chart review of PMW with biochemical evidence of HA seen in the Johns Hopkins Endocrinology Clinic over the last 2 years.

We enrolled women above the total testosterone (TT) upper limit of normal of 43 ng/dl and excluded women who were premenopausal or on testosterone replacement . We stratified women into 2 groups: 1) those with mildly elevated TT levels (57-62 ng/dl ng/dl) (n=4) and 2) those with TT levels greater than twice the upper limit of normal (ULN) (143-487 ng/dl) (n=8).

Women in group 1 were diagnosed at a mean age of 62.5 years (range 54-68 yrs). Signs of HA included hair loss (n=4) and hirsutism (n=4). One woman had a history of PCOS and none  had a history of cardiovascular disease (CVD). Work up including androstenedione (A), DHEA-S, 17-hydroxyprogesterone (17OHP), LH, FSH, and prolactin levels were unremarkable in this cohort. Cushing’s syndrome screen was also negative.  Only 1 woman in this group had glucose data and she was euglycemic. One of 2 women with lipid data had dyslipidemia (DLD). One woman had a DXA and did have osteopenia.  

Women in group 2 were diagnosed with HA at a mean age of 60.50 years (range 46-70 yrs). Signs included hirsutism (n=8), hair loss (n=8) including male pattern baldness (n=5), voice deepening (n=4), increased libido (n=4), and clitoromegaly (n=2). The following diagnoses were made: adrenal cortical carcinoma (n=1) (TT level of 487 ng/dl, DHEA-S 909mcg/dl [12-133 mcg/dl]); bilateral ovarian stromal hyperthecosis (n=2) (TT’s of 356 ng/dl and 216 ng/dl and A levels 168 and 202 ng/dl respectively (20-75 ng/dl); leydig cell tumor in the setting of hyperthecosis (n=1); hilus cell hyperplasia (n =1) (TT 184 ng/dl and A 144 ng/dl); (TT 187 ng/dl); two additional women were suspected of having an ovarian source of androgen excess, but opted against surgical management.  One woman had suspected ovarian HA based on ovarian vein sampling. She had a 50% reduction in TT levels, despite negative pathology after bilateral salpinoophrectomy. Of the 4 women with available glucose data, 2 women had impaired fasting glucose and 1 woman had well-controlled diabetes mellitus (A1C 6.8%). Two of the 3 women with available data had DLD. One woman had a DXA and had osteopenia. None of the 8 women had a history of PCOS or CVD.

In conclusion, we found that 6 (75%) of the 8 PMW with TT levels greater than twice the ULN, had surgical pathology. Of these, 83% had an ovarian vs. 17% adrenal etiology. None had CVD.  We recommend that PMW with signs of HA be evaluated similarly to premenopausal women.


 

Nothing to Disclose: SY, ASD

21825 12.0000 THR-092 A Hyperandrogenism in Post-Menopausal Women:  a Case Series 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Iram Ahmad*
University of Washington, Seattle, WA

 

Background: Adrenal causes of hyperandrogenism in postmenopausal women are much less common than ovarian causes.  LH receptors have been reported in human adrenal cells and represent a potential cause of hirsutism in women with high LH/hCG concentrations.

Methods: We describe the clinical and biochemical features of a postmenopausal woman with hyperandrogenism and virilization due to high circulating LH concentrations.

Clinical case: A 62-year woman presented with a 2-year history of increased facial hair, male pattern baldness, and clitoromegaly.  Initial assessment revealed markedly elevated total testosterone concentration (230; nl <45 ng/dL) and calculated free testosterone concentration (42.4; nl <6.4 pg/mL), but normal DHEA (117; n <1185 mcg/dL), DHEA-S (92, nl <278 mcg/dL), 17-hydroxyprogesterone (26; nl <40 ng/dL), estradiol (23; nl <5-38 pg/mL), LH 42.7 (nl <0-14 IU/L), IGF-1 (131; nl <41-279 ng/mL), and low-normal ACTH (9; nl 6-50 pg/mL). Initial CT scan done by her primary care physician was interpreted as normal except possible left adrenal thickening.  The patient was diagnosed with hyperthecosis and underwent bilateral oophorectomy.  Serum hormone concentrations were unchanged after oophorectomy. and the patient was referred to our medical center.

Repeat CT showed a 7 mm L adrenal adenoma and no evidence of pelvic ovarian remnants.  Bilateral adrenal venous sampling after cosyntropin stimulation revealed the following: left adrenal vein testosterone 572 ng/dL and cortisol 1464.2 mcg/dL (ratio of T to C 0.39); right adrenal vein testosterone 343 ng/dL and cortisol 817.5 mcg/dL (ratio of T to C 0.41).  Our interpretation was a) the adrenals were the source of the androgen excess; b) there was no lateralization; and c) the androgen excess was ACTH-responsive.  A 3-day course of dexamethasone decreased testosterone concentration significantly, but incompletely, by 44% to 131 ng/dl.  A single dosage of leuprolide (3.75 mg) decreased the LH concentration from 42.7 IU/L to 5.8 IU/L and nearly normalized the serum testosterone concentration (58 ng/dL).

Summary:  This woman developed significant hyperandrogenism due to the normal menopausal rise of LH concentrations and likely presence of ectopic LH/hCG adrenal receptors.

Conclusion:   Ectopic adrenal LH/hCG receptors are an unusual cause of peri-menopausal hyperandrogenism, but should be suspected when the suppression of ACTH does not normalize hyperandrogenemia and there is no lateralization on adrenal vein sampling.

 

Nothing to Disclose: IA

20807 13.0000 THR-093 A High Concentrations of LH Cause Virilization in a Postmenopausal Woman 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Amrita Kaur Dhillon*1, Arunpreet Singh Kahlon1, Nidhi Bansal1 and Roberto Emilio Izquierdo2
1SUNY Upstate Medical University, Syracuse, NY, 2Joslin Ctr for Diab, Syracuse, NY

 

Introduction-Struma ovarii is a specialized teratoma predominantly composed of thyroid tissue and accounts for approximately 5% of all ovarian teratomas. Malignant transformation of struma ovarii is rare (5-10%) and metastatic spread occurs in approximately 5% of cases. We present a rare case of malignant struma ovarii with widespread metastases and rapid disease progression, which presented a management dilemma.

Case-67 year old female with history of hypertension, hyperlipidemia, COPD presented to our hospital with 5 month history of abdominal pain, nausea, vomiting and 35 pound weight loss. She has had laparoscopic hysterectomy with bilateral salpingo-oophorectomy about a month prior for a left ovarian mass, with the biopsy showing poorly differentiated follicular carcinoma arising in the struma ovarii. Labs showed CEA 81.7 ng/ml(<3.4ng/ml), CA-125 107 units/ml(<35 units/ml), normal LDH, AFP and thyroid function tests. CT scan of thorax and abdomen showed widespread metastases to left lung, liver, kidney and adrenal. MRI brain showed a right frontal lobe lesion. Given the patient’s extensive smoking history, there was a concern for a primary lung malignancy. CT guided lung biopsy revealed high grade carcinoma with thyroid differentiation. After extensive literature review and multidisciplinary meetings it was decided to treat this rare malignancy with radioactive iodine (RAI). She underwent surgical resection of the isolated metastatic brain lesion and total thyroidectomy and was subsequently discharged home with plan for RAI therapy. Within 2 weeks she presented again with significant hemoptysis. CT thorax showed expanding left lobe mass with erosion into the pulmonary artery and was treated with radiation therapy to the lung. RAI therapy could not be initiated as she had received iodine contrast for imaging and was discharged with plan for RAI therapy in 4-6 weeks. Sadly she died 10 days later following a severe hemoptysis episode.

Discussion– So far there is no consensus on optimal treatment of malignant struma ovarii. The management of this rare tumor is based on summaries of single case reports and small case series. Our literature review showed that currently malignant struma ovarii is approached initially like ovarian cancer with surgical staging with total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymph node sampling and pelvic washings. RAI should be strongly considered in the management of metastatic disease as the recurrence rates in patients who undergo surgery without subsequent radioablation has been cited as high as 50%. A thyroidectomy is suggested before adjuvant treatment to potentiate the effects of radioablation. Due to the rarity of this tumor and lack of clear consensus on management, the care of a patient suspected of having this tumor should be led by an expert multidisciplinary team right from the initial presentation.

 

Nothing to Disclose: AKD, ASK, NB, REI

21513 14.0000 THR-094 A Struma Ovarii - a Management Dilemma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Helen ifeyinwa Anaedo*1, Christian KIM2 and Hassan Shawa3
1Albany Medical Center, Albany, NY, 2Albany Medical Center, 3Albany Medical College, Albany, NY

 

Background

There are conflicting studies on intermediate CGG repeat lengths on the Fragile X mental retardation gene locus 1(FMR 1) and development of premature ovarian failure(POF) which could be primary or secondary. The Fragile X mental retardation 1 (FMR1) gene is on the X chromosome and contains a polymorphic 5′ CGG-triplet repeat which is transcribed into mRNA but not translated into a protein. Full mutations (≥200 repeats) FXS is predominantly in males. Premutations (59–200 repeats) are associated with Fragile X Tremor and Ataxia Syndrome and premature ovarian failure.  In women with history of idiopathic POF ∼5% were found to be premutation carriers. The intermediate or grey zone was reported to be 35-58 and was associated with mostly secondary ovarian failure. More recent large cohort studies have shown that POF in the grey zone is a rare occurrence and could not replicate the previous findings. In this case report,we describe an unusual association of primary ammenorrhea, Graves ’disease and intermediate CGG repeats on the FMR I gene in a known carrier of fragile X syndrome (FXS)with a strong family history.

Case Description:

 A 20-year-old female, with recent history of Graves ‘disease status post radioactive iodine ablation and primary ovarian failure diagnosed 5 years ago. Her genetic testing as well as that of her mother and sister revealed carriers of the fragile X syndrome. Her pelvic ultrasound revealed small uterus and the unvisualized ovaries. She and her sisters had problem with math in school with attention deficit problem in only one of the sisters. The patient also has flat feet not common to other family members. We report a rare occurrence of primary amenorrhea not only in our patient but in her sister who have only 49 CGG repeats (grey zone). In addition she also has Graves’ disease which has been reported in only few patients in the grey zone as most of them have other autoimmune diseases.

Conclusion:

We emphasize that intermediate sized FMR1 CGG repeat alleles is a potential risk factor for Primary ovarian failure. Based on current conflicting evidence and anecdotal reports, we advocate further studies to confirm the role of expansions in this intermediate category and its association with primary ammenorrhea.

 

Nothing to Disclose: HIA, CK, HS

20691 15.0000 THR-095 A Primary Ovarian Failure,a Rare Occurence in Intermediate Cgg Repeat Fragile X Carrier:a Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Vanessa Kasarah Madrigal*1, Ariela Agress1, La-Toya Williamson2, Vikram Kamdar3, Tristan Grogan4, David Elashoff4, Gregorio Daniel Chazenbalk1 and Daniel Anthony Dumesic1
1David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, 2University of Guelph, Ontario, 3David Geffen School of Medicine, University of California Los Angeles (UCLA), CA, 4University of California Los Angeles (UCLA)

 

Background: PCOS is characterized by ovarian hyperandrogenism, ovarian dysfunction and polycystic ovaries, with some PCOS women showing insulin resistance that persists despite correction of androgen excess (1, 2). This case report describes inflammatory subcutaneous (SC) abdominal adipose dysfunction accompanying massive growth of polycystic ovaries in a severely insulin-resistant PCOS woman despite correction of ovarian hyperandrogenism by GnRH analog. 

Clinical case: A 30-year overweight woman with PCOS experienced abdominal pain for several months. Abdominal CT showed bilaterally enlarged polycystic ovaries that filled the entire abdomen. Past medical history was significant for metabolic syndrome, nonalcoholic steato-hepatitis and multiple pulmonary emboli. Glucose intolerance (fasting, 91 mg/dL [nl <100 mg/dL]; 2-hr postprandial, 187 mg/dL [nl <140 mg/dL]) with hyperinsulinemia (fasting, 56 μU/mL [nl <25 μU/mL]; 2-hr postprandial, 598 μU/mL [nl <41 μU/mL]) (3) was accompanied by dyslipidemia (total cholesterol 237 [nl <200], LDL 130 [nl <130], HDL 29 [nl >50], triglycerides 388 mg/dL [nl <150 mg/dL]), hyperandrogenemia (total testosterone [T], 153 ng/dL [nl <45 ng/dL]; free T, 26.5 pg/mL [nl <6.4 pg/mL]) and elevated liver enzyme levels following metformin and spironolactone therapies. Right and left ovaries measured 7.1 x 3.9 x 6.9 cm (100 cm3) and 7.9 x 4.0 x 7.4 cm (122 cm3 [nl <10 cm3), respectively, and contained multiple peripheral follicles 3-15 mm in size. Administration of the GnRH analog, Depot Lupron 3.75 mg IM monthly, successfully corrected ovarian hyperandrogenism (T, 10 ng/dL; free T, 1.4 pg/mL), but did not improve metabolic dysfunction or prevent continued growth of polycystic ovaries. Eventual exploratory laparotomy with bilateral salpino-oophorectomy showed massively enlarged right and left ovaries measuring 17.5 x 11.4 x 8.1 cm (846 cm3) and 23.0 x 17.0 x 8.5 cm (1740 cm3), respectively. Histological evaluation confirmed multiple benign ovarian follicular cysts surrounding cystadenofibromas. SC abdominal adipose removed at surgery was used for adipocyte size determination by manual cell circling of intact tissue stained with H&E. Histological evaluation showed large adipocytes (mean area, 4533 μm[nl 3253 μm2] infiltrated by macrophages (CD68+/ DAPI+ positive cells: 1 macrophage every 3-4 adipocytes [3-fold increase vs. controls]). A novel population of small adipocytes (mean area, 264 μm[17-fold smaller vs. large adipocytes]) also was identified near vascular regions.

Conclusion: SC abdominal adipose dysfunction can persist in a severely insulin-resistant PCOS woman despite correction of ovarian hyperandrogenism by GnRH analog and can be linked through inflammatory atherothrombotic insulin resistance with massive enlargement of polycystic ovaries.

 

Nothing to Disclose: VKM, AA, LTW, VK, TG, DE, GDC, DAD

20134 16.0000 THR-096 A Inflammatory Subcutaneous (SC) Abdominal Adipose Dysfunction Accompanies Massively Enlarged Polycystic Ovaries in a Severely Insulin-Resistant PCOS Woman Receiving GnRH Agonist 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Sasha Marcelle Nair*1 and Stella Ruth Milsom2
1Auckland Hospital, Auckland, New Zealand, 2Greenlane Clinical Centre, Auckland, New Zealand

 

Background

17-beta hydroxysteroid dehydrogenase 3 dehydrogenase (17-βHSD3) converts androstenedione to testosterone in human testes.  Deficiency of 17-βHSD3 is a rare autosomal recessive disorder of sex development manifesting in XY karyotype individuals. The presentation can range from partial or incomplete virilisation at birth to primary amenorrhoea and virilisation at puberty of an externally phenotypically female individual. 

Clinical Cases

A 19 year old Niuean woman presented with primary amenorrhoea, poor breast development, hirsutism, cliteromegaly and vagismus with sexual intercourse. 

The serum testosterone (T) was 9.3nmol/l (0.2-2.5 in adult females). The serum androstenedione (A) was 32.9nmol/l (2-12). The T:A ratio was low (0.28) (sensitivity for 17-βHSD3 deficiency 100% in adults, 57% pre-puberty at a ratio of <0.8)1.  The karypotype was XY.

Pelvic MRI showed inguinal testes, normal adrenal glands, a 3.5cm blind vagina and absent internal female structures.  Gene analysis revealed a homozygous mutation of the 17-βHSD3 gene, c845C>t, p.Pro282Leu, previously reported in another patient2.  She underwent bilateral orchidectomy, was commenced on oral estrogen and was taught to use vaginal dilators.  This resulted in satisfactory breast development and sexual intercourse was more comfortable.

The other two cases were sisters of Samoan descent.  The older sister presented with rapid virilisation and primary amenorrhea aged 13 years.  Serum T was 7.4nmol/L. T:A was 0.74 and rose to 0.99 after hCG stimulation.  The karypotype was XY. USS showed absent internal female structures.  Treatment was initially with leuprorelin and ethinyloestradiol while gender identity was confirmed. She later had clitoroplasty and gonadectomy aged 14 years.  She was troubled by depression at the age of 21 years but responded well to cognitive behavioural therapy. Her sister was significantly virilised from the age of 6 years and underwent orchidectomy aged 9 years.  Both sisters continued on estrogen replacement and have satisfactory development of female secondary sexual characteristics.  All three patients attended appointments with a psychologist.

Conclusion

These are the first three reported cases of 17-βHSD3 deficiency in patients of Pacific Island descent and the first three cases described in New Zealand.  Counselling of individuals with 17-βHSD3 deficiency and their families is important to determine gender identity.  For patients who have a female gender identity, management includes orchidectomy to reverse virilisation and to remove gonads with malignant potential. Estrogen replacement is provided to maximise female secondary sexual characteristics and to prevent bone loss.  Counselling from a psychologist is also important with regards to infertility, compliance with estrogen replacement, any ongoing gender identity issues and regarding screening of other family members.

 

Nothing to Disclose: SMN, SRM

20193 17.0000 THR-097 A Three Cases of 17-Beta Hydroxysteroid Dehydrogenase 3 Deficiency in Patients of Pacific Island Descent 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Lizandra Moura Paravidine Sasaki1, Bruno Ramalho de Carvalho2, Adelino Amaral Silva2, Luiz Augusto Casulari3 and Adriana Lofrano-Porto*4
1Department of Obstetric and Gynecology, Faculty of Medicine, University Hospital of Brasília, University of Brasilia, Brasilia, Brazil, 2GENESIS – Center for Assistance in Human Reproduction, Brasilia, Brazil, 3University de Brasilia, Brasilia, Brazil, 4University of Brasilia, Faculty of Health Sciences, Molecular Pharmacology Laboratory; University Hospital of Brasilia, Gonadal and Adrenal Diseases Clinics, Brasilia DF, Brazil

 

Background: Selective luteinizing hormone (LH) deficiency has been described in only two women, who presented with normal pubertal development, but secondary amenorrhea and anovulation. Both women harbored homozygous inactivating mutations in the LHB gene and their clinical presentation was predicted by the phenotype of lhbknock-out female mice. In this animal model, exogenous human chorionic gonadotropin (hCG) administration rescued the ovarian expression of steroidogenic and ovulatory markers and provided normal response to exogenous gonadotropins induction, when compared to wild-type controls.

Clinical case: After informed consent, an individualized ovarian induction protocol with highly purified urinary hCG (hp-hCG) was performed in one of the previously described LH-deficient women, who harbored a homozygous IV2+1G>C mutation in the LHB gene. She was 36 years old and had normal FSH levels and spontaneous development of small antral follicles, which exhibited growth arrest at the mid-follicular phase. In the first appointment, when a 14 mm follicle was identified by ultrasound, hp-hCG (Brevactid 5,000 IU/mL, Ferring Arzneimittel GmbH, Berlin, Germany) was started as 500 IU aliquots for daily subcutaneous administration.  Hormonal levels (FSH, estradiol, progesterone and beta-hCG), ovarian follicle growth and endometrial thickening were monitored during the following 9 days, after which, a 22 mm follicle was obtained. Ovulation was, then, triggered by a single hp-hCG 5,000 IU dose, and patient was oriented to have intercourse every two days. Pregnancy was confirmed after 14 days. Luteal phase support was provided from the second day after trigger until the end of the 12thweek with oral dydrogesterone, 30 mg/day, combined with subcutaneous hCG 500 IU dose every 3 days. After an uneventful 40-weeks gestation, a healthy girl was born by cesarean section.

Clinical lessons: The reproductive outcome in this woman with selective LH deficiency phenocopied the findings in lhb knock-out female mice, in which impaired late follicular development was the most striking feature. Traditionally, ovulation induction protocols employ high doses of hCG to simulate LH surge. Alternatively, low doses of hp-hCG or recombinant LH have been proposed from mid-follicular phase to the day of trigger, based on the physiological roles of progressively increasing secretion of LH on late follicular maturation. The treatment protocol we describe herein reinforces the efficacy of exogenous hCG on inducing late stages of follicular development, when FSH-dependent early follicular growth is assured. Moreover, it represents a valuable human model of assisted reproduction under controlled gonadotropin administration.

 

Nothing to Disclose: LMPS, BRD, AAS, LAC, AL

20623 18.0000 THR-098 A Full Term Pregnancy in a Woman with Selective LH Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 081-098 6009 1:00:00 PM Female Reproductive Endocrinology - Case Reports Poster


Latrice Doreen Faulkner*1, Abigail Rebecca Dowling2, Ronald Stuart3, Eduardo A. Nillni3 and Jennifer Wootton Hill4
1Univerisity of Toledo, Toledo, OH, 2The University of Toledo, Toledo, OH, 3The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, 4University of Toledo School of Medicine, Toledo, OH

 

Pro-opiomelanocortin (POMC)-derived peptides like α-melanocyte-stimulating hormone (α- MSH) are critical regulators of energy expenditure and glucose homeostasis. Melanocortinergic agents are also powerful inducers of sexual arousal and are currently being investigated for a possible therapeutic role in erectile dysfunction in diabetic patients. POMC neuron activity and melanocortin production are regulated by pancreatic insulin and leptin released into the circulation by adipose tissue. In obese states, POMC neurons can become resistant to these factors.  It is currently unclear whether reduced melanocortin activity may contribute to the sexual dysfunction accompanying obesity and type 2 diabetes. In this study, we demonstrate that male rodents with leptin and insulin resistance targeted to POMC neurons (LepR/IRPOMC mice) exhibit obesity, hyperinsulinemia, hyperglycemia, and systemic insulin resistance. This phenotype is also seen with the deletion of the leptin receptor alone. However, our data also indicate that, unlike littermates lacking a single receptor type, LepR/IRPOMC males are subfertile due to dramatic alterations in sexual behavior. Remarkably, these reproductive changes are accompanied by decreased α-MSH production, which is not present when a single receptor type is deleted. Unexpectedly, behavioral sensitivity to α-MSH and melanocortin 4 receptor expression is also reduced in LepR/IRPOMC males, a potential adaptation of the melanocortin system to altered α-MSH production. Together, these results suggest that concurrent insulin and leptin resistance in POMC neurons in individuals with obesity or T2D may reduce endogenous α-MSH levels and impair sexual function.

 

Nothing to Disclose: LDF, ARD, RS, EAN, JWH

21050 1.0000 THR-113 A Reduced Melanocortin Production Causes Sexual Dysfunction in Male Mice with Pomc Neuronal Insulin and Leptin Insensitivity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Enver Simsek*1, Luciana Ribeiro Montenegro2, Cigdem Binay1 and Ana Claudia Latronico3
1Eskisehir Osmangazi University School of Medicine, Eskisehir, Turkey, 2Division of Endocrinology and Metabolism, São Paulo, Brazil, 3Sao Paulo Medical School, University of Sao Paulo, Sao Paulo-SP, Brazil

 

Background: Few male patients with selective hypogonadotropic hypogonadism due to FSH deficiency have been reported.

Objective: To describe the clinical, hormonal and genetic analysis of a male adolescent with isolated FSH deficiency.

Patient and Methods: Clinical, hormonal and genetic features of a male adolescent with short stature and small testicular. Amplification and automatic sequencing of the three exons of the FSH beta gene were performed.

Case Report: A 14.5-years-old boy presented with short stature. His past-medical history and family history were unremarkable. On physical examination, weight was 38 kg (-1.83 SDS); height, 146 cm (-2.39 SDS); BMI, 16.5 (-0.58 SDS); axillar hair, Tanner stage II, pubic hair, Tanner stage V, testicle sizes 1/1 ml (Tanner stage I). Bone age was 13.5 years old. Thyroid function tests were in normal references. IGF-1 was 343 ng/ml (N, 268-512); FSH, 0.12 mIU/ml; LH, 22.3 mIU/ml; total testosterone 261 ng/dl; inhibin B 31.5 pg/ml (N, < 360 pg/ml); and anti-Mullerian hormone 4.4 ng/ml (N, 4.0-169 ng/ml). GnRH stimulating test revealed that peak LH and FSH levels were 298 mIU/ml and 0.14 mIU/ml, respectively. According to the findings of physical examination and hormonal tests, isolated FSH deficiency was suspected. The diagnosis was confirmed by molecular genetic study. A new homozygous missense mutation (c.364T>C resulting in p.Cys122Arg) in the FSHß was identified in this patient.

Discussion and Conclusion: We described a male adolescent with typical selective hypogonadotropic hypogonadism due to FSH deficiency confirmed by genetic study. Notably, the small testicular size contrasts with normal virilisation and pubertal testosterone levels in the affected patients by this very rare genetic condition.

 

Nothing to Disclose: ES, LRM, CB, ACL

19209 2.0000 THR-114 A Isolated Follicle-Stimulating Hormone Deficiency Caused By a New Missense Mutation in the FSHb Gene in a Male Adolescent with Normal Virilisation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Raghuveer Kavarthapu*1, Chon-Hwa Tsai-Morris2 and Maria L Dufau3
1National Institutes of Health, Bethesda, MD, 2National Institutes of Health, 3NIH-NICHD, Bethesda, MD

 

Gonadotropin-Regulated Testicular RNA Helicase (GRTH/Ddx25) is a testis specific member of the DEAD-box protein family, which is essential for round spermatid elongation and completion of spermatogenesis, is expressed in germ (spermatocytes, round spermatids) and Leydig cells. The transgenic (Tg) mice model carrying 5’ flanking regions of the GRTH-GFP reporter provides a unique in vivo system that permits differential elucidation of 5’ UTR regulatory regions of GRTH gene that directs its expression in germ cells and Leydig cells. The 5’ UTR distal region directs its expression in germ cells (GC) and the downstream region in Leydig cells. We showed an indirect action of androgen on GRTH expression in GC of Tg mice carrying this specific -6.4 Kb/-3.6 Kb 5’ flanking sequence which lacks ARE (Androgen Response Element) (1), and autocrine regulation via androgen/androgen receptor/ARE in Leydig cells.  A putative cis-binding element for a germ cell specific nuclear factor (GCNF/RTR), predominantly expressing in the developing GCs and required to direct gene expression in the postmeiotic phase of GC of the testis, was identified on -5270/-5252 of GRTH gene. In subsequent studies we explore the potential androgen action through GCNF on GRTH gene transcription in GC.  Western blot analysis showed GCNF protein expression significantly decreased in the testis of Tg mice carrying -6.4 kb/-3.6 kb sequence upon flutamide (androgen receptor antagonist) treatment, indicating the presence of a regulatory network for androgen/ GCNF-upstream 5’ GRTH sequence to direct GRTH expression in GC. A marked reduction of GCNF level was also noted in purified round spermatids from wild type mice treated in vivo with flutamide. ChIP analysis and gel shift further demonstrated the association of GCNF with GRTH sequence spanning the GCNF binding site on -5270/-5252 in both round spermatids and spermatocytes. This interaction was abolished by flutamide treatment. In vitro studies with seminiferous tubules in culture (dark zone stages VII-VIII), from -6.4 kb/-3.6 kb-GFP Tg mice using GCNF siRNA revealed marked decrease in the expression of GFP expression. Also tubules exposed to flutamide showed mark reduction of GFP expression. Our studies provide evidence for indirect action of androgen on GCNF regulation of GRTH specific expression in GC. This model permits to elucidate the mechanism of indirect actions of androgen via Sertoli cells in GC and thus facilitate the identification of androgen regulated factors that control expression of critical gene(s) required for GRTH expression in GC involved in the progression of spermatogenesis. This could lead to the development of effective male contraceptive strategies in Sertoli cells to block sperm formation without impacting other aspects of androgen action.

 

Nothing to Disclose: RK, CHT, MLD

22035 3.0000 THR-115 A In Vivo and In Vitro Transcriptional Regulation of Gonadotropin-Regulated Testicular RNA Helicase (GRTH/DDX25) By Germ Cell Specific Nuclear Factor (GCNF/RTR) in Transgenic Mice Model 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Anja Schrade*1, Antti Kyrönlahti1, Marjut Pihlajoki1, Jorma Toppari2, David B Wilson3 and Markku Heikinheimo1
1University of Helsinki, Helsinki, Finland, 2University of Turku, Turku, Finland, 3Washington University in St. Louis, Saint Louis, MO

 

Transcription factor GATA4 is expressed in somatic cells of the mammalian testis. Gene targeting studies in mice have shown that GATA4 is essential for proper differentiation and function of Sertoli cells (1). The role of GATA4 in Leydig cell development, however, remains controversial because targeted mutagenesis experiments in mice have not shown a consistent phenotype, possibly due to context-dependent effects or compensatory responses, as reviewed in (2). We therefore undertook a reductionist approach to study the function of GATA4 in Leydig cells. Using microarray analysis and quantitative RT-PCR, we identified a set of genes that are downregulated or upregulated following siRNA-mediated silencing of Gata4 in the murine Leydig tumor cell line mLTC-1 (Gata4 mRNA levels were reduced by 80±8%; P<0.01; n=3). Among the downregulated genes were enzymes of the androgen biosynthetic pathway [Cyp11a1, fold change (FC)=0.30±0.03; Hsd3b1, FC=0.14±0.01; Cyp17a1, FC=0.34±0.07; Srd5a, FC=0.49±0.13; for all P<0.01 and n=3-4]. These same genes were dysregulated when primary cultures of Gata4flox/flox adult Leydig cells were subjected to adenovirus-mediated cre-lox recombination in vitro. Silencing of Gata4 expression in mLTC-1 cells was accompanied by reduced production of sex steroid precursors, as documented by mass spectrometric analysis. Notably, the level of androstendione, the immediate progenitor of testosterone, was marked reduced in the knockdown cells (Gata4 siRNA: 24.2±4.8 nM vs. non-targeting siRNA: 172.7±48.1 nM; P<0.01; n=3). Comprehensive metabolomic analysis of GATA4-deficient mLTC-1 cells showed disruption of other metabolic pathways, notably glycolysis. GATA4-depleted mLTC-1 cells had reduced expression of glycolytic genes (Hk1, FC=0.59±0.10; Gpi1, FC=0.85±0.10; Pfkp, FC=0.81±0.16; Pgam1, FC=0.68±0.27; for all P<0.05 and n=8), lower intracellular levels of ATP (30±12%; P<0.01; n=4) through impaired glycolysis, and increased extracellular levels of glucose (Gata4 siRNA: 3.57±0.043 g/L vs. non-targeting siRNA: 3.28±0.025 g/L; P<0.001; n=8). Altogether, our results suggest that GATA4 is linked to cell metabolism and regulation of steroid production in adult Leydig cells.

 

Nothing to Disclose: AS, AK, MP, JT, DBW, MH

19774 4.0000 THR-116 A GATA4 Is a Key Regulator of Steroidogenesis and Glycolysis in Mouse Leydig Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Paula Aliberti*1, Suresh Ramaswamy2, Tony M. Plant2, Roberto Ponzio3, Diego Chirico1, Marco A. Rivarola4, Alicia Belgorosky5 and Esperanza Beatriz Berensztein1
1Garrahan Pediatric Hospital, Buenos Aires, Argentina, 2University of Pittsburgh School of Medicine and Magee Womens Research Institute, Pittsburgh, PA, 3School of Medicine, University of Buenos Aires, Buenos Aires, Argentina, 4Hospital de Pediatria Garrahan, Argentina, 5Hospital de Pediatría Garrahan, Buenos Aires, Argentina

 

There is evidence that the growth hormone (GH)-insulin like growth factor (IGF) axis is involved in regulating Leydig cell differentiation, and in modulating androgen steroidogenesis (1). IGF-1 is a critical factor in the control of adult Leydig cell number and maturation (2). In addition, IGF-2 is able to regulate steroidogenesis in rat Leydig cells (3). We have previously proposed that IGF-2, mainly through the insulin receptor (IR), is also involved in Leydig cell differentiation in prepubertal human testes (4). In vivo stimulation with either LH or FSH+LH in early juvenile monkeys induced testosterone secretion (5).

Aim of this study: 1) to compare the immunoexpression of IGF1R by interstitial cells in testis from human (HT) and rhesus monkey (Macaca mulatta)(MT)from birth to adulthood, and 2) to examine the effect of precocious in vivo stimulation with FSH and LH (either alone or in combination) on immunoexpression of this receptor in the testicular interstitium of juvenile monkeys.

Clinical Material and Methods: Chemicon Mab1120 specific anti-IGF1R antibody was used for immunohistochemistry. HT (n=18) were collected at the time of necropsy from subjects without endocrine or metabolic diseases. Samples were grouped according to age: neonatal (< 1 month [mo], n=3), infantile (1-8 mo, n=4), juvenile (1year [y] to puberty, n=4), pubertal (13 -15 y, n=7). MT (n=17) were obtained at the time of castration: neonatal (1-2 day [d] , n=3), infantile (4-5 mo, n=3), juvenile (14-36 mo, n=6), pubertal (38-51 mo, n=2) and adult (60 mo, n=3). To evaluate the effect of in vivo gonadotropin stimulation on IGFR immunoexpression by prepubertal interstitial cells, juvenile monkeys received 11-day treatments (n=3) with vehicle, FSH, LH or LH+FSH (5).

Results: In both species, all cells exhibiting the characteristic histological appearance of Leydig cells (LC) were positive for IGF1R expression in neonatal, infantile, pubertal and adult testes; positive cells, however, were not observed in early and mid-juveniles: stages of development devoid of morphologically identified LC. In juvenile monkeys in vivo LH or FSH stimulation for 11 days failed to induce immunoexpression of IGF1R in LCs, while the combined FSH+LH treatment resulted in some lightly positive LCs.

Conclusion: In HT and MT, IGF1R expression by the LC throughout postnatal development was directly correlated with stages of elevated gonadotropin and testosterone secretion. IGF1R expression may therefore be considered as a marker of LCs. However, precocious LH and FSH stimulation of the juvenile MT resulted in an adult pattern of testosterone secretion but did not induce full pubertal IGF1R expression. These findings indicate that in primates IGF1R is not involved in LCs functional differentiation, reinforcing the hypothesis that IGF-1/IGF-2 might act through IR, which is highly expressed in immature HT(4).

 

Nothing to Disclose: PA, SR, TMP, RP, DC, MAR, AB, EBB

19796 5.0000 THR-117 A Role of Gonadotropin in the Control of IGF1R Expression By Interstitial Cells in Human and Monkey Testis throughout Postnatal Development: Implications for Leydig Cell Differentiation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Alexandr Simonov1, Jessica Holien2, Joyee Yeung1, Ann Dung Ahn Nguyen3, C. Jo Corbin4, Jie Zheng5, Vladimir Kuznetsov6, Richard J. Auchus7, Alan James Conley8, Michael Parker2, Raymond J Rodgers9 and Lisandra Martin*1
1Monash University, 2University of Melbourne, 3UC Davis, Moraga, CA, 4UC Davis, Davis, CA, 5UC Davis, 6Boreskov Institute of Catalysis, 7University of Michigan, Ann Arbor, MI, 8Univ of CA at Davis, Davis, CA, 9University of Adelaide, Adelaide, Australia

 

The steroidogenic enzyme cytochrome P450 17α-hydroxlase (P450c17; encoded by CYP17) is the enzyme needed to synthesize both androgens (male hormones) and glucocorticoids (e.g. cortisol, essential for metabolism). P450c17 has a single enzymatic activity, 17a-hydroxylase, in the zona fascicularis of the adrenal gland which produces cortisol.  However, it has two activities, 17a-hydroxylase and 17,20 lyase, in the gonads and adrenal zona reticularis and these two enzymatic activities are essential for the conversion of pregnenolone to the androgen precursor dehydroepiandrostenedione (DHEA). The first enzymatic activity, 17a-hydroxylase, is a single hydroxylation and the second enzymatic reaction requires an additional hydroxylation leading to scission of the 17,20 carbon bond. Therefore, both activities of P450c17 require electrons from NADPH delivered via cytochrome P450 reductase (CPR). However, 17,20-lyase activity is regulated (enhanced) by a non redox-dependent interaction with cytochrome b5 (cyt b5).

We have used a combination of in vivo, in vitro and in silico approaches to discover then mechanistic function for the regulation of P450c17 activity, by protein-protein interaction, with cyt b5. We provide in silico analysis to confirm the allosteric binding site and disruption of this interface by the double mutant E48G,E49G cyt b5. In live cells we demonstrated using FRET analyses that P450c17 interacts tightly with cyt b5. Using a quartz crystal microbalance analysis we created an artificial lipid membrane and introduced purified proteins which bound and showed that the cyt b5, but not the E48G,E49G cyt b5, formed a complex with the P450c17 and CPR. Finally we employed protein electrochemistry and revealed that P450c17 and cyt b5, but not P450c17 and E48G,E49G cyt b5, were electronically coupled. We identified that the kinetics of electron transfer by P450c17 was slower when the cyt b5 was present and suggest that this may be part of the mechanism that substantially enhances the 17,20 lyase activity of P450c17.

 

Nothing to Disclose: AS, JH, JY, ADAN, CJC, JZ, VK, RJA, AJC, MP, RJR, LM

21452 6.0000 THR-118 A Mechanistic Analysis of 17, 20-Lyase Activity for Cytochrome P450c17 Identifies That Cytochrome b5 Influences the Rate of Electron Transfer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Paula Aliberti1, Carolina Mondillo2, Adriana Maria Belen Abiuso2, Omar Pedro Pignataro2, Marco A. Rivarola3, Alicia Belgorosky4 and Esperanza Beatriz Berensztein*5
1Garrahan Pediatric Hospital, Buenos Aires, Argentina, 2Institute of Biology and Experimental Medicine (IBYME-CONICET), Buenos Aires, Argentina, 3Hospital de Pediatria Garrahan, Argentina, 4Hospital de Pediatría Garrahan, Buenos Aires, Argentina, 5Endocrine Service, Garrahan Pediatric Hospital, Buenos Aires, Argentina

 

Histamine (HA) is an endogenous biogenic amine synthesized from L-histidine exclusively through the catalytic activity of histidine decarboxylase (HDC). HDC is expressed by testicular mast cells and germ cells (1). HA is now known to elicit a vast spectrum of physiological and pathological actions, including the pathogenesis of several tumors, through binding to four G protein-coupled receptors, designated as HRH1-4 (2). Accordingly, numerous studies have documented the ability of HA to modulate steroidogenesis through H1R and H2R in rodents Leydig cells, and their proliferation under pathological conditions [3]. In human testes of fertile and infertile patients, the expression of H1R, and H2R by germinal, interstitial, and peritubular cells was reported (4). The H4 receptor (H4R), the newest member of the family, is considered a promising drug target for allergy, inflammation, autoimmune disorders, and cancer [5]. Very recently, we reported for the first time that H4R is functionally expressed in murine Leydig cells, and that its selective activation can significantly inhibit gonadotropin-stimulated stereoidogenesis via a reduction in cAMP levels [6). However, there is no information available on HR4 expression in immature human testes.

Aim of the study: 1) to evaluate the developmental immunoexpression of H4R in normal immature human testis from neonatal period to late prepuberty, and 2) to compare the H4R immunoexpression pattern in normal immature testis vs Leydig cell tumors.

Material and Methods: Human normal testes (n=10) were collected at the time of necropsy from subjects without endocrine or metabolic diseases. For the analysis of results, samples were divided according to age: neonatal (< 1 month old, n=3), infant (postnatal activation, 1 to 7 months old, n=4), and prepubertal (stage of development devoid of morphologically identified LC), (1 to 12 years old, n=3). Leydig cell tumors were collected from two patients at time of surgery: 3.92- and 6.0-years old. Santa Cruz (sc-33967) specific anti-H4R antibody was used for immunohistochemistry.

Results: We detected positive H4R expression in cells exhibiting the characteristic histological appearance of Leydig cells (LC) in all normal newborns and in only the youngest of the four infants (age: 2 months). Positive H4R in some interstitial cells was also found. No H4R was detected in prepubertal testes. In contrast, LC tumors showed high H4R staining not only in tumor LC but also in inflammatory- or fibroblastic-like cells.

Conclusions: Since H4R was only detected in all neonatal and only in 1 infant human LC it could be proposed that HR4 pathway activation might be involved in the preservation of LC pool. This mechanism might also be involved in the in LC tumor development.

 

Nothing to Disclose: PA, CM, AMBA, OPP, MAR, AB, EBB

20450 7.0000 THR-119 A The Histamine H4 Receptor Is Detected in Neonatal Human Leydig Cells, and in Prepubertal Leydig Cells Tumors. Possible Involvement in Neonatal Leydig Cells Pool Preservation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Sonia L. Laulu1 and Joely A. Straseski*2
1ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, 2University of Utah & ARUP Laboratories, Salt Lake City, UT

 

Background: Measurement of testosterone provides an overall assessment of androgen status and aids in diagnosis of several endocrinopathies in men, women, and children.  Testosterone concentrations are commonly determined using commercial immunoassays.  However, there are well-documented concerns regarding the reliability of these assays at low testosterone concentrations.  This is particularly troublesome for patient populations where low testosterone concentrations are expected, such as women and children.  While mass spectrometry methods have proven to provide more accurate results, adopting these methods is not feasible for all laboratories.  The objective of this study was to assess the functional sensitivity (FS) of 2 automated testosterone immunoassays.

Methods: Residual serum samples were obtained following measurement of testosterone using LC-MS/MS.  Samples with similar results were pooled together to prepare 12 human serum pools (pool concentrations 1.2 – 962.5 ng/dL by LC-MS/MS) which were aliquoted and stored at -70°C until use.  All pools were tested for total testosterone using the Roche MODULAR E170 and Abbott ARCHITECT i2000SRusing 2 reagent lots and at least 2 calibrations.  Each pool was assayed once per day, 2 days per week for 5 weeks, totaling 10 replicates per pool. FS was estimated by fitting a power function to the imprecision data and calculating the testosterone concentration that gave a CV of 20% using Excel.

Results: Both manufacturers define limit of quantitation (LoQ) as the lowest analyte concentration that can be reproducibly measured with an imprecision of ≤ 20%.  The FS for the E170 was 15.8 ng/dL, which did not meet the manufacturer’s LoQ claim of 12.0 ng/dL. The true FS of the ARCHITECT could not be adequately assessed because none of the pools tested had CVs >20%.  However, the lowest pool measured on the ARCHITECT had a testosterone concentration of 4.1 ng/dL (1.2 ng/dL by LC-MS/MS) with a CV of 2.6%, which confirmed the manufacturer’s LoQ claim of ≤ 4.3 ng/dL.  This same pool was below the analytical measurement range of the E170 (< 2.5 ng/dL), therefore no data was generated.  Overall, the second lot of E170 reagent demonstrated significantly lower testosterone concentrations (p values ≤ 0.009); contributing to the final CV used in FS calculations.  With few exceptions, the E170 and ARCHITECT over-recovered with an average % recovery of 107 and 119, respectively.

Conclusions:  The E170 FS did not meet the LoQ claim provided by the manufacturer while the ARCHITECT demonstrated acceptable performance at low testosterone concentrations and met manufacturer’s claim.  In comparison to LC-MS/MS, both methods had a greater tendency to over-recover.  It is critical to understand the performance of testosterone immunoassays in populations with low testosterone concentrations, therefore patient-specific comparisons would prove useful to further assess assay sensitivity.

 

Nothing to Disclose: SLL, JAS

21054 8.0000 THR-120 A Zooming in on the Low End: Functional Sensitivity of Automated Testosterone Immunoassays 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


David Muram*1 and Xiao Ni2
1Eli Lilly and Company, 2Eli Lilly and Company, Indianapolis, IN

 

There are inherent biological and technical difficulties in measuring serum total testosterone (TT) levels that may reduce the diagnostic accuracy of a single TT determination. Consequently, evidence-based guidelines suggest that although the measurement of morning TT level is the initial diagnostic test for hypogonadism, confirmation of the diagnosis by repeating the TT measurement is recommended. While repeat measurements are recommended for the diagnosis of hypogonadism, a single testosterone determination is required for dose titration in hypogonadal men receiving testosterone replacement therapy. This post-hoc analysis evaluated the diagnostic accuracy of a single serum TT measurement in men receiving testosterone replacement therapy who had a serum average concentration (Cavg) of TT in the normal range. In an open-label, multi-center, titration trial, androgen-deficient men (N=155) were started on a daily morning dose of a 60-mg testosterone 2% solution (Axiron®) applied to axillae (30 mg/axilla). Serum testosterone Cavg was determined on Days 15, 60, and 120. If necessary, the dose was adjusted to maintain Cavg in the normal range (300-1050 ng/dL). This analysis included subjects (n=85) whose Cavg was within the normal range on Days 15, 60, and 120. A generalized linear mixed model was fitted to assess the visit and hour effects with indicator of hourly concentration within the normal range as the outcome variable (assuming a Bernoulli distribution with a logit link function), including visit, hour, and visit-by-hour interaction as the fixed effects and subject as random effects in the model. Main outcome measures were the proportion of men with normal serum testosterone levels at 2, 4, 8, 12, 16, or 20 hours post-dose on Days 15, 60, and 120. Between 79% and 92% of subjects had testosterone serum levels within the normal range at 2, 4, 8, 12, 16, or 20 hours post-dose. No significant differences were found in the proportion of men whose TT levels were in the normal range in the samples obtained at the three different days, whereas there were significant hour effects on the diagnostic accuracy (p=0.01), with the accuracy peaking in the 4- to 8-hour window and tapering at around 16 hours. The diagnostic accuracy of a single TT measurement in men whose Cavg was within the normal range was up to 93%, varying at different time points post-dose, which reflects the pharmacokinetic profile and may be related to the circadian rhythm of endogenous testosterone. Because all of these men had a normal Cavg and required no dose adjustment, relying on a single TT determination would have resulted in an unnecessary dose adjustment in up to 20% of men.

 

Disclosure: DM: Employee, Eli Lilly & Company. XN: Employee, Eli Lilly & Company.

19338 9.0000 THR-121 A Diagnostic Accuracy of a Single Serum Testosterone Measurement 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Xiao Ni1 and David Muram*2
1Eli Lilly and Company, Indianapolis, IN, 2Eli Lilly and Company

 

To diagnose hypogonadism, evidence-based guidelines recommend, in addition to clinical signs and symptoms, a measurement of morning total testosterone (TT) level by a reliable assay followed by a repeated measurement of TT for confirmation. While at least two measurements are recommended for the diagnosis of hypogonadism, only one measurement of TT level is recommended 3 to 6 months after treatment initiation to determine if dose adjustment is needed.  The aim of this post-hoc analysis was to evaluate the diagnostic accuracy of a single serum TT measurement in men receiving testosterone replacement therapy who had serum average concentration (Cavg) below normal range (<300 ng/dL). Androgen-deficient men (N=155), enrolled in an open-label, multi-center, titration trial, were started on 60-mg daily morning dose of testosterone solution 2% (Axiron®) applied to axillae (30 mg/axilla). On Days 15, 60, and 120, TT levels were measured at 2, 4, 8, 12, 16 and 20 hours post-dose and serum testosterone Cavg was determined. If necessary, dose was adjusted on days 45 and 90 to maintain Cavg in the normal range (300-1050 ng/dL).  Cavg was determined to be below normal (<300 ng/dL) for 31 patients on day 15, 16 patients on Day 60, and 17 patients on Day 120; per protocol, these patients were titrated up at the next visit from the 60-mg dose to the 90-mg daily dose, or from the 90-mg dose to the 120-mg daily dose. In total, there were 64 instances when Cavg was determined to be below normal. However, 12 (40%) patients on Day 15, 10 (63%) patients on Day 60, and 6 (35%) patients on Day 120 with a Cavg below normal had a 2-hour serum TT determination within the normal range in.  The average percentage (across all days) of discordant results between Cavg and serum TT measurements, where TT was in the normal range, declined as the time from application increased, from 44% at 2 hours, to 38% at 4 hours, 22% at 8 hours to as low as 3% at 16 hours.  In conclusion, the diagnostic accuracy of a single TT measurement in men whose Cavg was below the normal range was as low as 56% at 2 hours, varying at different time points post-dose, which may reflect the pharmacokinetic profile and may be related to the rate of testosterone absorption and  clearance. In men receiving topical testosterone therapy, whose Cavg is below normal, relying on a single TT determination could result in less than optimal dosing which may lead to discontinuation of therapy due to perceived lack of treatment effect.

 

Disclosure: XN: Employee, Eli Lilly & Company. DM: Employee, Eli Lilly & Company.

18925 10.0000 THR-122 A Diagnostic Accuracy of a Single Serum Testosterone Measurement: The False Negative Rate 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


E. David Crawford1, Wendy Poage2, Allen Nyhuis3, David Alan Price3, Sherie A Dowsett3 and David Muram*3
1University of Colorado, 2Prostate Conditions Education Council, 3Eli Lilly and Company

 

Introduction

Serum testosterone levels exhibit a circadian variation, with peak levels in the morning. Evidence-based guidelines recommend that morning total testosterone (TT) levels be measured using a reliable assay as the initial diagnostic test for androgen deficiency (1). However, it is not known whether adherence to a morning blood draw is truly necessary. It has been argued that the circadian rhythm is diminished in older men such that TT measurement need not be limited to morning sampling, and patients who are seen later in the day can be sampled outside the recommended window, avoiding the need to return for a morning blood draw on a subsequent day. The purpose of this analysis was to determine whether it is appropriate to expand the 8-11 AM blood sampling window for the measurement of TT levels.

Methods

The study sample comprised men who elected to be screened during the September 2013 Prostate Cancer Awareness Week (PCAW), a US community-based prostate cancer screening program sponsored by the Prostate Conditions Educational Council (PCEC). Men undergoing screening provided informed consent, completed a series of health questionnaires, underwent a medical evaluation and, for a large subset, had blood drawn for laboratory assays, including measurement of TT levels. Analyses were performed using data from men with sufficient data for evaluation. TT levels measured in blood samples drawn from 8-11 AM (n=229) were compared with those measured during the rest of the day (n=442) (using the 2-sample t-test) as well as with those values from specific time windows (using ANOVA): 11 AM-2 PM (n=202), 2-5 PM (n=99), 5-8 PM (n=103), and 8 PM-8 AM (n=38). Analysis of variance methods were also used to adjust comparisons for age and BMI.

Results

TT levels measured in blood drawn from 8-11 AM differed significantly from those drawn outside this time window (411.7 vs 368.3 ng/dl; p=0.0028). Differences in TT levels were evident across the 5 blood draw time windows (p=0.0006). These differences persisted after adjustment for age and BMI. TT levels in blood drawn from 2-5 PM (344.3 ng/dl) and 5-8 PM (334.4 ng/dl) differed significantly when compared directly with blood drawn from 8-11 AM (p<0.05), while TT levels in blood drawn from 11 AM-2 PM (396.5 ng/dl) and 8 PM-8 AM (373.4 ng/dl) did not (p>0.05).

 Conclusion

In this analysis, TT levels in blood drawn from 11 AM-2 PM did not differ significantly from and, in fact, were numerically similar to TT levels in blood drawn from 8-11 AM. There may be clinical utility in expanding the blood draw window for TT measurement to early afternoon.

 

Disclosure: EDC: Consultant, Genomic Health, Consultant, Jansen Pharmaceuticals, Consultant, Dendreon, Consultant, Ferring Pharmaceuticals, Employee, Ferring Pharmaceuticals, Consultant, MDx, Consultant, Bayer, Inc.. WP: CME Programming, Independent Contractor, Bayer, Inc., Collaborator, Abbott Laboratories, Collaborator, Genomic Dx, Collaborator, Strand Diagnostics, Collaborator, MDx Health. AN: Employee, Eli Lilly & Company. DAP: Employee, Eli Lilly & Company. SAD: Employee, Eli Lilly & Company. DM: Employee, Eli Lilly & Company.

18929 11.0000 THR-123 A Measurement of Testosterone: How Important Is a Morning Blood Draw? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


E. David Crawford1, Wendy Poage2, Allen Nyhuis3, David Alan Price3, Sherie A Dowsett3 and David Muram*3
1University of Colorado, 2Prostate Conditions Education Council, 3Eli Lilly and Company

 

Introduction

Lower urinary tract symptoms (LUTS) are common in older men, with moderate-to-severe symptoms being reported in 45% of men aged 70-80 years (1). Benign prostatic hyperplasia (BPH) is commonly associated with LUTS. Testosterone has a stimulatory effect on prostate cells and prescribing information for testosterone replacement therapies (TRT) warns that the therapy may worsen BPH symptoms. While the relationship between BPH and endogenous total testosterone (TT) levels has been widely studied, there is less understanding of the relationship between TT and LUTS symptoms (2,3). The purpose of this post hoc analysis was to determine the relationship, if any, between TT level and LUTS as assessed by the International Prostate Symptom Score (IPSS) score. 

Methods

The study sample comprised men who elected to be screened during the 2013 Prostate Cancer Awareness Week. Men undergoing screening provided informed consent, completed a series of health questionnaires, including the IPSS, underwent a medical evaluation and, for a large subset, had blood drawn for laboratory assays, including measurement of TT level. Prostate size was determined by digital rectal examination. Analyses were performed using data from men with TT levels measured from an 8-11 AM blood draw. Spearman correlation coefficients were calculated between TT levels and prostate size categories, IPSS categories and QoL ratings as well as between TT levels and total, irritative symptom and obstructive symptom subscores. Analysis of covariance was used to adjust the IPSS variables for prostate size.

Results

Mean TT levels (ng/dl) by prostate size category were: Normal 419.2 (n=106), Enlarged 394.7 (n=71), Abnormal 416.4 (n=7), and Abnormal/Suspicious 515.2 (n=19). There was no significant correlation between prostate size category and TT level (r= +0.03; p=0.69). Mean TT levels by IPSS category were: None 468.5 (n=15), Mild 414.0 (n=138), Moderate 397.4 (n=66), and Severe 437.9 (n=7). There was no significant correlation between IPSS category and TT level (r= -0.06; p=0.40). Mean TT levels by IPSS QoL rating were as follows: Delighted 474.5 (n=43), Pleased 424.6 (n=65), Mostly Satisfied 361.2 (n=63), Mixed 448.2 (n=29), Mostly Dissatisfied 337.2 (n=17), Unhappy 435.8 (n=6). There was no significant correlation between IPSS QoL rating and TT level (r= -0.13; p=0.055). There were no significant correlations between TT level and IPSS total, irritative symptom and obstructive symptom scores. Adjustment for prostate size yielded similar findings.

 Conclusion

Endogenous TT levels did not correlate with LUTS or prostate size. This supports the saturation theory in which TT is not able to induce further androgen-stimulated prostate tissue growth due to receptor saturation. Any LUTS worsening following TRT in hypogonadal men may be related to stimulation of prostatic cells previously deprived of testosterone.

 

Disclosure: EDC: Consultant, Ferring Pharmaceuticals, Consultant, Dendreon, Consultant, Jansen Pharmaceuticals, Consultant, Genomic Health, Consultant, MDx, Consultant, Bayer, Inc., Employee, Ferring Pharmaceuticals. WP: Collaborator, MDx Health, Collaborator, Strand Diagnostics, Collaborator, Genomic Dx, Collaborator, Abbott Laboratories, CME Programming, Independent Contractor, Bayer, Inc.. AN: Employee, Eli Lilly & Company. DAP: Employee, Eli Lilly & Company. SAD: Employee, Eli Lilly & Company. DM: Employee, Eli Lilly & Company.

18984 12.0000 THR-124 A Effects of Testosterone Level on Lower Urinary Tract Symptoms 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


María Fernanda Riera*, Mariana Regueira, María Noel Galardo, Eliana Herminia Pellizzari, Selva Beatriz Cigorraga and Silvina Beatriz Meroni
Centro de Investigaciones Endocrinológicas, Dr César Bergadá-CONICET-División de Endocrinología-FEI, Ciudad Autónoma de Buenos Aires, Argentina

 

Sertoli cells (SC) actively metabolize glucose and the majority of it is converted to lactate. Spermatocytes and spermatids are unable to use glucose and they do prefer lactate as an energy source. In this context, it is widely accepted that one of the most important SC nurse functions is to provide lactate for germ cells and that the mechanisms that regulate its production may be relevant to the maintenance of spermatogenesis.

The availability of pyruvate, which is converted into lactate, might be regulated by FSH and bFGF in SC to ensure lactate supply to germ cells. The aim of this study was to analyze two possible mechanisms which may be involved in pyruvate availability. Firstly, regulation of the expression of 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase isoform 3 (PFKFB3) responsible for fructose-2-6-biphosphate (Fru2,6P2) production. Fru2,6P2 is an allosteric regulator of phosphofructokinase 1, the rate limiting step in glycolysis, which increases glycolytic flux. Secondly, negative regulation of pyruvate dehydrogenase complex (PDC) activity by phosphorylation, which will increase pyruvate availability as a consequence of a lower conversion of pyruvate to acetyl-CoA.

Cultures of SC obtained from 20-day-old rats were incubated for 48 h without (basal) or with FSH (100 ng/ml) or bFGF (30 ng/ml). Lactate levels were determined in conditioned media. Cell extracts were utilized to evaluate phosphorylated PDC (P-PDC) levels by Western blot and mRNA levels by RQPCR. Results are expressed as mean±SD (n=3).

Analysis of PFKFB3 expression showed that FSH increased PFKFB3 mRNA levels (2.1±0.32*; *p<0.05 vs. basal) while bFGF did not modify it. The physiological relevance of this mechanism was revealed by the fact that FSH-stimulated lactate production was inhibited in the presence of the specific PFKFB3 inhibitor 3-PO (10μM) (basal: 12.3±0.7; FSH: 17.6±1.8**; FSH+3-PO: 12.7±1.1# μg/μgDNA, **p<0.01 vs. basal; #p<0.01 vs. FSH).

As for the regulation of PDC, expression of pyruvate dehydrogenase kinases (PDKs) isoforms and levels of P-PDC were analyzed. We observed that FSH increased PDK3 and decreased PDK4 mRNA levels (PDK3: 1.8±0.4*; PDK4: 0.5±0.1*; *p<0.05 vs. basal) and that these variations were not accompanied by changes in P-PDC levels. On the other hand, bFGF increased the expression of all isoforms (PDK1: 1.9±0.2*; PDK2:1.7±0.4*; PDK3: 1.7±0.3*; PDK4: 1.6±0.2*; *p<0.05 vs. basal) and increased P-PDC levels. The physiological relevance of PDC regulation was evidenced by the fact that bFGF-stimulated lactate production was inhibited in the presence of the PDK inhibitor dichloroacetate (DCA, 10μM) (basal: 7.5±1.5; bFGF: 14.3±1.7*; bFGF+DCA: 10.3±0.7# μg/μgDNA, *p<0.05 vs. basal; #p<0.5 vs. bFGF). 

Altogether, these results suggest that regulation of pyruvate availability may be a mechanism involved in FSH- and bFGF-regulation of lactate production in SC.

 

Nothing to Disclose: MFR, MR, MNG, EHP, SBC, SBM

19941 13.0000 THR-125 A Participation of 6-Phosphofructo-2-Kinase/Fructose-2,6-Biphosphatase Isoform 3 and Pyruvate Dehydrogenase Complex in the Regulation of Lactate Production By FSH and bFGF in Rat Sertoli Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Hamed A Benghuzzi*1 and Michelle Tucci2
1Univ of MS Med Ctr, Jackson, MS, 2Univ of Mississippi Med Ctr, Jackson, MS

 

Previous studies conducted in our labs have demonstrated that sustained delivery of exogenous testosterone (3-5ng/ml) markedly suppressed serum LH, FSH and testicular testosterone levels. Consequently, spermatogonial number declined to approximately 72% of control levels while spermatids were completely devoid from seminiferous tubules. The specific aim of this study was to explore the possible restoration of spermatogenesis in previously induced  azoopermic rats through sustained delivery of supraphysiological level of testosterone acetate (TE) loaded hydroxyapatite (HA) ceramic devices.  A total of 36 adult Sprague Dawley rats were randomly divided into three (Control, Sham and Experimental) equal groups (BW 280-300 gm). Animals in the experimental group initially received TE (40 mg/SC) loaded HA ceramic implants for 12 weeks to induce azoospermia, followed by 8 weeks of exogenous sustained delivery of TE using HA implants loaded with 90 mg TE (15-22 ng/ml; SC).  At the end of 8 weeks of second phase, the animals from each group were sacrificed and the testes were collected by following approved laboratory techniques. The tissues were fixed, processed, embedded, sectioned and stained (H&E) for histopathological evaluation. Germ cell numbers were evaluated using stereological methods and expressed as germ cell number per testis. The results of the study revealed that following the initial TE treatment, serum LH and FSH levels were reduced to 65% and 53% compared to sham operated and intact animals.  At the end of 8 week of second phase, exogenous sustained delivery of TE, resulted in restoring testicular weights to 62-79% of controls while serum LH and FSH levels were remained reduced to 60% and 46% respectively; compared to sham operated and intact animals. On the other hand, as expected, sustained delivery of supraphysiological level of TE was capable of restoring spermatogonial number by 78% at the end of 8 week phase compared to control group. Furthermore, increased number of round and elongated spermatids (p < 0.05) was evident in TE treated animals. We conclude that:  (a) sustained delivery of TE by means of HA delivery devices is a dose dependent (i.e. low dose of TE induced azoospermia and suprphysiological level maintained spermatogenesis), and (ii) TE loaded HA delivery system can be utilized to regulate fertility in males.  

 

Nothing to Disclose: HAB, MT

19358 14.0000 THR-126 A Restoration of Spermatogenesis By Sustained Delivery of Supraphysiological Levels of Testosterone Acetate in Azoospermic Induced Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Maria Eugenia Matzkin*1, Ricardo S Calandra2 and Monica Beatriz Frungieri1
1Instituto de Biología y Medicina Experimental (IBYME-CONICET), Caba, Argentina, 2Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina

 

We have previously described the presence of catecholaminergic neuronal elements (CNE) in testes of men suffering from idiopathic infertility (1). Contrary to that observed in the normal human testis, increased numbers of testicular MAC (2,3) and CNE (1), as well as the expression of cyclooxygenase 2 (COX2) (4), key enzyme in prostaglandin synthesis, are limited to infertility status. Also, a close anatomical proximity between CNE and other cell populations of the testis such as Leydig cells (LC) and macrophages (MAC) has been reported, therefore suggesting a role for catecholamines in MAC or LC function. In this context, we have found that testosterone production in Syrian hamster LC is regulated by epinephrine (E) and norepinephrine (NE) via α1 and β-adrenergic receptors (AR) (5). In this study, we addressed a possible effect of E/NE in COX2 expression in MAC. Laser capture microdissection of CD68-positive testicular MAC in infertile testes, followed by RT-PCR allowed to determine the expression of β-AR. Since no functional assays can be performed in testicular biopsy tissues, two alternative experimental models were used: non-testicular human MAC (THP1 cell line) and testicular MAC purified from adult Syrian hamsters. Both MAC models expressed β1, β2 and β3-AR. After 1 h incubations, COX2 expression (determined by qPCR) in THP1 MAC was up-regulated by 1mM E, NE, Isoproterenol (I: β-AR agonist) and Salbutamol (S: β2-AR agonist). In addition, stimulatory effects exerted by E, NE, I and S were reverted in the presence of 1mM Propranolol (P: β1-β2-AR antagonist) (qPCR COX2/GAPDH, Control: 1.0±0.6, E: 6.9±0.5*, E+P: 0.9±0.6, NE: 3.1±0.7*, NE+P: 1.5±0.7, I: 3.0±0.9*, I+P: 1.3±0.6, S: 1.7±0.4+0.6*, S+P: 0.3±0.3, P: 0.9±0.6; X±SEM *P<0.05). In contrast, the addition of 10 nM Atenololol (A: β1-AR antagonist) did not affect COX2 expression (Control: 1.0±0.2, E: 3.1±1.0*, E+A: 2.3±0.4*, NE: 2.4±0.6*, NE+A: 2.9±0.1*, I: 4.6±1.4*, I+A: 7.9±1.2*, S: 2.3±0.8*, S+A: 2.2±0.8*, A: 1.0±0.1; X±SEM *P<0.05)

When testicular MAC purified from adult hamsters were assayed, COX2 expression was induced in the presence of 1mM E (Control: 1.0±0.2 vs. E: 3.5±0.0*; X±SEM *P<0.05), NE (Control: 1.0±0.2 vs. NE: 5.6±0.8*; X±SEM *P<0.05), I (Control: 1.0±0.3 vs. I: 10.8±0.9*; X±SEM *P<0.05) and S (Control: 1.0±0.2 vs. S: 2.5±0.3*; X±SEM *P<0.05).

In summary, we hereby describe the expression of β-AR in testicular MAC from biopsies of infertile men. Our data indicates that E/NE up-regulation of COX2 expression in MAC is mediated, most likely, by β2-AR, although a β3-AR-mediated effect cannot be ruled out at this point. Overall, these results suggest the importance of E/NE as modulators of inflammatory events in the testis.

 

Nothing to Disclose: MEM, RSC, MBF

20515 15.0000 THR-127 A ß-Adrenergic Receptors Modulate COX2 Expression in Macrophages: Possible Implications in Testicular Inflammatory Events 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Maricedes Acosta-Martínez*1, Victoria Boughton Nelson2, Ariel L. Negrón3 and Richard Z Lin2
1Stony Brook University Medical Center, Stony Brook, NY, 2Stony Brook University, Medical Center, Stony Brook, NY, 3Stony Brook University, Stony Brook, NY

 

There is a strong association between obesity and a higher risk for infertility in males.  Several factors contribute to the detrimental effects of obesity on male fertility, including alterations in hormonal profiles and reduced sperm quality.  Despite the increasing prevalence of obesity worldwide, a paucity of studies has examined the underlying mechanisms of obesity-associated male infertility.  White adipose tissue is a major mediator of inflammation and metabolism, and an important source of hormones and proteins, such as estrogen and leptin. Hence, excessive fat accumulation is thought to contribute not only to the metabolic imbalance but also to the impaired reproductive function observed in obese patients.   In adipose tissue, the enzyme phosphatidylinositol-3-kinase (PI3K) plays a critical role in the regulation of systemic glucose and lipid homeostasis, and is a major mediator of insulin responsiveness in this organ.  Using Cre recombinase driven by the aP2 (fatty acid binding protein 4) promoter, we generated mice in which the gene encoding class IA PI3K catalytic subunit, p110α is deleted in white and brown adipose tissue.  aP2-Cre/p110αflx/flx mice have increased adiposity, glucose intolerance, and liver steatosis.  In addition, these mice exhibited low energy expenditure due to low cellular respiration in brown adipocytes.  In the present study we describe the reproductive phenotype of aP2-Cre/p110αflx/flx male mice.  Compared to WT littermates, aP2-Cre/p110αflx/flx males displayed delayed onset of puberty, as determined by the age of balanopreputial separation and anogenital distance.  This was accompanied by a significant reduction in testis weight at postnatal day 30 (PD30).  However, serum testosterone (T) levels were not significantly different between WT and aP2-Cre/p110αflx/flx males at PD30 (15.5 ± 8.8 ng/ml vs. 6.4 ± 1.8 ng/ml, KO (n= 5) and WT (n = 4), respectively).  In contrast, fasted leptin levels were significantly increased in aP2-Cre/p110αflx/flx at PD30 (1.21 ± 0.05 ng/ml (n=5) vs. 1.03 ± 0.02 ng/ml (n=4), KO and WT respectively).  In contrast to WT littermates, aP2-Cre/p110aflx/flx males (2.5 – 3 months of age) were unable to sire pups in proven fertile WT females (mating success of 0 % (n=5) and 60% (n=5) for KO and WT, respectively).   Basal luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels were similar between WT and KO at 2 months of age.  In contrast, serum T levels were significantly increased in aP2-Cre/p110αflx/flx males  (12.8 ± 1.2 ng/ml (n=7) vs. 4.5 ± 1.2 ng/ml (n=10), KO and WT respectively).  No genotype effect was observed on testis weight in adult males.  Our studies suggest that compromised PI3K signaling in adipose tissue is involved in the subfertility associated with impaired metabolic status.

 

Nothing to Disclose: MA, VBN, ALN, RZL

21900 16.0000 THR-128 A Loss of PI3K p110 Alpha in the Adipose Tissue Results in Infertility and Delayed Puberty Onset in Male Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Leslie M McKee*1, James D Oliver1 and Yvette M Huet2
1Univ. of NC Charlotte, Charlotte, NC, 2Univ of NC-Charlotte, Charlotte, NC

 

It is commonly found that males exhibit a higher susceptibility to infectious diseases. While the underlying mechanism for this disparity is not fully understood, one significant contributing attribute is the presence of specific sex hormones. Testosterone, the primary male sex steroid hormone, has been shown to elicit an immunosuppressive effect, depressing certain aspects of immune function; whereas estradiol, the primary female sex steroid hormone, has a protective immunological effects. Various types of sex steroids also may have a direct effect on bacterial metabolism, although the range of responses (proliferation or inhibition) appears to be bacterial-species specific. Vibrio vulnificus, a gram-negative bacterium found in the estuarine environment, is one example of a bacteria that produces an infection exhibiting a sexually dimorphic mortality rate. In this case, 85% of cases are male, with clinical symptoms ranging from gastroenteritis, to purulent wound infection, to fatal septicemia. Previous studies have suggested that the presence of estradiol protects against the endotoxic shock induced by the lipopolysaccharide (LPS) present in the outer membrane of this bacterium. We hypothesize that the presence of sex steroid hormones in serum will affect the viability of this bacterium. The present study uses serum from female rats in the various stages of the estrous cycle to determine bacterial counts of V.vulnificus at 0h, 0.5h, 2h, and 6h following bacterial inoculation as a model for a septicemic infection. Results indicate that higher endogenous estradiol levels produce an inhibitory effect on bacterial proliferation. Therefore, it appears that the presence of estrogen in higher concentrations may affect bacterial growth rates in the bloodstream, leading to a decreased burden of bacterial LPS exposure in females. This response to steroid hormones was further investigated using ratio-dependent doses of exogenous estradiol and testosterone. The bacterial response to these hormones may be one factor producing sexually dimorphic disease progression. Understanding the influence of sex steroid hormones on bacterial viability may provide further insight into sex disparities of infectious diseases.

 

Nothing to Disclose: LMM, JDO, YMH

20677 17.0000 THR-129 A The Relationship of Reproductive Hormones and Host Susceptibility to the Opportunistic Pathogen, Vibrio Vulnificus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Eva Szarek*1, Christopher Mercier1, Mones Abu-Asab1, Louis Dye1, Leticia F. Leal1, Edra London1, Malgorzata Kotula-Balak2, Barbara Bilinska2 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2Jagiellonian University, Krakow, Poland

 

Phosphodiesterases(PDEs) play a critical role in regulating cAMP levels and PKA signaling. Among them PDE8B, a cAMP-specific PDE, is highly expressed in the testis. Genetic aberrations in cAMP-signaling predispose to endocrine tumors but they are also known to affect reproduction. We previously described that Pde8b-/- testis show regressive changes in seminiferous tubules(ST), containing increased numbers of atrophied tubules by 12 months with ST diameter significantly decreased; Atrophied tubules resembled Sertoli-cell only syndrome. We also described germ cell loss in Pde8b-/- resulted from increased apoptosis due to accumulation of spermatogonia undergoing defective spermatogenesis. The functions that PKA play and how such diversified PKA signaling is regulated during spermatogenesis remain less understood. We know that PKA regulates gene transcription and sperm motility. Here we focused on examining in more detail the ultrastucture of germ cells, Sertoli cells(SC) and mitochondria in mature testis, as well as focused on spermatogenesis and the importance of Wnt signaling for postnatal testis function; new data has shown that Wnt signaling is required at multiple stages of spermatogenesis. We examined testes isolated from wild-type(WT) and Pde8b-/- knock-out mice at 3 and 12months(n=3-8/group). At the ultrastructural level in Pde8b-/- SC and germ cells were packed with cystic-looking mitochondria without cristae and with intra-mitochondrial membranous inclusions. Some mitochondria were small and round while others thin and elongated with tubular cristae. There is clear mitochondrial dysfunction that raise an, as yet, undefined question: how do these ultrastructural defects influence spermatogenesis? Furthermore, using the Mouse Male Infertility Signaling Targets Array, we identified that in all Pde8b-/- mice there was a 4-fold increase in the spermatogenesis transcript Piwili1; aberrant expression of human PIWI orthologs has been observed in various cancers including epithelial ovarian cancer. Piwili1, an RNA binding protein, is expressed in developing spermatids and forms complexes with sperm-specific mRNAs that are distributed in the cytoplasm of spermatocytes. Additionally, transcriptional profile of key Wnt signaling components in whole mouse Pde8b-/- testis revealed a 52-fold upregulation of Fzd1, and a 5-fold down-regulated of Fgf4. Fzd1 mediates sustained activation of the Wnt/beta-catenin pathway whereas Fgf4 acts as a survival factor for germ cells. Thus, we conclude that deletion of Pde8b has a previously unknown role in SC function and proliferation; its wider role in fertility remains poorly characterized. PDE8B may be a therapeutic target for male infertility, especially that related to SC dysfunction.

 

Nothing to Disclose: ES, CM, MA, LD, LFL, EL, MK, BB, CAS

21936 18.0000 THR-130 A PDE8B: A New Gene for Male Infertility 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Alberto Ferlin*1, Andrea Garolla2, Riccardo Selice1, Nicola Caretta2, Damiano Pizzol1 and Carlo Foresta1
1University of Padova, Padova, Italy, 2University of Padua, Padua, Italy

 

Male factors are responsible for half of the cases of couple infertility. Whatever the cause, spermatogenic disruption is clinically and hormonally recognized by low sperm count and Sertoli cell markers. However, recent evidence showed that Leydig cell impairment is also frequent in subjects with primary testicular damage, as evidenced for example by reduced INSL3 and 25(OH)-vitamin D levels. The latter is caused by reduced expression of CYP2R1, a major enzyme involved in 25-hydroxylation of cholecalciferol, and lower 25(OH)-vitamin D levels are well known cause of low bone mass. Furthermore, testosterone (T) production by the Leydig cells might be also impaired in men with primary spermatogenic damage. To clarify these aspects that previous reports analyzed only separately and on limited number of subjects, in this study we evaluated the presence and type of hypogonadism, 25(OH)-vitamin D status and bone mass in a very large cohort of infertile males. Among subjects referred to our tertiary Universitary Centre for semen analysis during the period January 2011-June 2014 (11,516 semen analysis) we report here the data of men who completed the andrological program, including semen culture (n: 10,394), history and physical examination (n: 7,527), hormone analysis (FSH, LH, T, 25(OH)-vitamin D; n: 5,884), and ultrasound of the testes (n: 5,177). Men with total sperm count <10 million/ejaculate (n: 2,583) underwent also genetic analysis (karyotype, Y chromosome microdeletions, CFTR mutations; n: 2273) and DEXA (n: 855). Azoospermia was present in 9.3% of cases (n: 481/5,177), oligozoospermia (with or without reduced motility and/or normal sperm morphology) in 40.6% (n: 2302), asthenozoospermia in 12.2% (n: 632), and normozoospermia in 34.5% (n: 1787). Main causes or risk factors were varicocele (28%), genetics (15%), obstruction/sub-obstruction of seminal tract (12%), cryptorchidism (6%), infections/iatrogenic causes/ejaculation disorders/prior surgery (14%) and idiopathic forms (25%). Primary hypogonadism (T<10.4 nmol/L, LH>8 IU/L) was found in 25.7% of cases, secondary hypogonadism (T<10.4 nmol/L, LH<1.5 IU/L) in 1.3%, subclinical hypogonadism (T>10.4 nmol/L, LH>8 IU/L) in34.2%. Men with all forms of hypogonadism have frequently insufficient (48.5%) or deficient (25.4%) 25(OH)-vitamin D levels and higher risk of low bone mass, osteoporosis (16.8%) and osteopenia (31.5%). This study, performed in a very large cohort of subjects, showed that hypogonadism and low vitamin D levels are very frequent in infertile males. Both conditions, caused by Leydig cell dysfunction, are implicated in the frequent low bone mass seen in these patients. Metabolic and other clinical conditions associated with low T and low vitamin D levels need therefore to be accurately evaluated in these subjects, and treatment should consider also these aspects other than specific treatment only of infertility.

 

Nothing to Disclose: AF, AG, RS, NC, DP, CF

21066 19.0000 THR-131 A Infertile Men Have Frequently Leydig Cell Dysfunction: Study on Hypogonadism, Vitamin D and Bone Mass in 5,177 Subjects 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Lena Salgado*, Helene B Lavoie and Ariane Godbout
Centre de recherche du Centre hospitalier de l’Université de Montréal (CR-CHUM), Montreal, QC, Canada

 

Background: Obesity is increasingly recognized as a cause of infertility in men. One of the underlying mechanisms is the inhibition of gonadotropin production by estrogens aromatised from androgens in adipose tissue. Testosterone levels and sperm quality can be restored with the use of aromatase inhibitors, the most potent being Letrozole. Some series suggest that a low dose (one tablet of 2.5 mg weekly) is sufficient to normalize testosterone levels(1,2). However, data on spermatogenesis and fertility are lacking.

Objective: To review the efficacy of low-dose letrozole to normalize testosterone, sperm count, and fertility in men with obesity-related hypogonadotropic hypogonadism (OrHH).

Method: Retrospective observational study of 12 men consulting for infertility, and diagnosed with OrHH. Obesity was defined as a body mass index (BMI) greater than 30 kg/m2. All patients had a total testosterone below the lower limit of normal with normal to low FSH and LH, and/or decreased sperm count as defined by the World Health Organisation. After excluding other causes of hypogonadism, patients were given low-dose letrozole.

Results: At baseline, mean age was 35.3 ± 5.9 years and mean BMI was 43.0 ± 7.0 kg/m2. Three subjects were diabetic and two were treated for sleep apnea. Mean duration of infertility was 2.9 ± 2.0 years. Eight had primary infertility and four, secondary infertility. Partners’ mean age was 31.1 ± 5.1 years and five were treated for polycystic ovary syndrome. After starting low-dose letrozole, estradiol decreased from 119.5 ± 57.2 to 72.2 ± 35.1 nmol/L. Mean FSH increased from 4.4 ± 2.0 to 8.0 ± 2.5 IU/L, mean LH increased from 4.4 ± 1.8 to 6.6 ± 1.1 IU/L, and mean total testosterone increased from 7.4 ± 1.7 to 21.1 ± 6.9 nmol/L. Mean sperm count rose from 14.8 ± 16.2 to 64.5 ± 67.2 x 109/L.

Discussion: Three response patterns were identified: full responders (increase in testosterone and sperm count; three patients), mixed responders (increase in testosterone but not in sperm count; two patients), and non-responders (one patient). Six patients’ sperm counts are pending, but testosterone levels normalized in eleven patients (92%). Three couples conceived: two spontaneously and one with in vitro fertilization. Four pregnancies ensued:  two reached term, successfully; the other two were a spontaneous abortion and an ectopic pregnancy.

Conclusion: Letrozole seems to be an effective treatment to help restore fertility in obese infertile men, with an interesting safety profile and some great advantages in term of route of administration and cost when compared to the use of gonadotropins injections for spermatogenesis induction. More studies are needed to determine which patients might benefit most from this treatment, as well as to compare it with other treatments such as gonadotropins and clomiphene citrate.

 

Nothing to Disclose: LS, HBL, AG

21162 20.0000 THR-132 A Successful Pregnancies after Spermatogenesis Induction with Letrozole in Men with Obesity-Related Hypogonadotropic Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Leena Nahata*1, Laurie E. Cohen2, Ilina Rosoklija2 and Richard N. Yu2
1Nationwide Children's Hospital, Columbus, OH, 2Boston Children's Hospital, Boston, MA

 

Objective:  Klinefelter syndrome occurs in 1 in 600 males and >95% experience infertility.  Methods such as micro-dissection sperm extraction (micro-TESE) can be used for sperm retrieval, but these methods are only successful in 40-50% of adults with Klinefelter syndrome. Younger men appear to have higher retrieval rates, suggesting that adolescence may be the optimal time for extraction, but this has not been confirmed by prospective studies.  The primary objective of this clinical trial was to assess sperm retrieval rates in a younger cohort of patients with Klinefelter syndrome, with the ultimate goal of increasing potential for fertility in this patient population.

Design: Patients 12-25 years of age with Klinefelter syndrome (karyotype 47, XXY) who were not on testosterone therapy were recruited for an IRB-approved clinical trial at Boston Children’s Hospital (www.ClinicalTrials.gov NCT01817296).  After undergoing physical examination, biochemical evaluation, and scrotal ultrasonography, patients were encouraged to produce an ejaculate for semen analysis.  Micro-TESE was offered to pubertal patients (LH>0.7 IU/L) who were unable to produce an ejaculate, as well as those who did not have sperm in their ejaculates.  

Results: Fifteen subjects were enrolled in the study, ranging from 15-23 years of age (median 17 years).  Fourteen of these individuals produced an ejaculate; semen analysis showed no sperm in any of these samples.  Ten patients opted to undergo micro-TESE.  Preliminary analysis of the biopsies showed sperm in 40% of these subjects (ages 16, 16, 19, 23).  All six remaining samples, in which no sperm were found on preliminary analysis, are currently being sent to a fertility lab for more detailed analysis via microscopy.          

Conclusions: Based on the preliminary data analysis, sperm retrieval rates via micro-TESE in this younger cohort of patients with Klinefelter syndrome are comparable to what has been reported in older men.

 

Nothing to Disclose: LN, LEC, IR, RNY

18913 21.0000 THR-133 A Sperm Retrieval in Adolescents and Young Men with Klinefelter Syndrome: A Prospective Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Shoulei Jiang*1, Chung Seog Song1 and Bandana Chatterjee2
1Univ of Texas Hlth Science Ctr, San Antonio, TX, 2Univ of Texas Hlth Science Ctr & South Texas Veterans Health Care System, San Antonio, TX

 

Benign Prostatic Hyperplasia (BPH) is an age-associated progressive disease, afflicting ~90% of men at the ninth decade of life. BPH presents as new glandular or stromal growth of human prostate at the transition zone, which usually is not the site where adenocarcinoma develops.  Pro-inflammatory factors secreted from senescent cells that emerge in prostate during aging are thought to chronically stimulate androgen-induced prostate cell proliferation that leads to enhanced prostate growth, enlargement of the prostate tissue and culminates in BPH(1).  We have developed a novel in vitro model to assess the impact of cellular senescence on the proliferation of epithelial and stromal cells and to identify the mediators, which are drivers of benign prostate growth during physiological aging. Cellular senescence was induced by γ-irradiation (10Gy) of BPH-1 (immortalized epithelial cells from human BPH tissue) and HPS-19I (stromal cells from human prostate; a generous gift from David Rowley, Houston), and the irradiated cells were confirmed to exhibit biomarkers for senescence such as i) senescence-associated lysosomal β-galactosidase (SA-β-gal) activity; ii) elevated expression of p16INK4a, a cell cycle inhibitor and tumor suppressor; and iii) increased levels of hypophosphorylated retinoblastoma protein (pRb).  Judging from biomarker levels, induction of senescence peaked at 9 days post-irradiation. BPH-1 cells proliferated more rapidly upon exposure to the conditioned media from irradiated BPH-1 cells (p = 0.024). BPH-1 proliferation also accelerated upon exposure to the conditioned media from γ-irradiated HPS-19I stromal cells. Pro-inflammatory cytokines IL-1β, IL-6, TNF-α and the CXC-type chemokine CXCL-12 were induced in irradiated cells, revealed from quantitative RT-PCR assay. CXCL-12, one of the major secreted chemokines from senescent cells, markedly enhanced BPH-1 proliferation when added (as a recombinant protein, 1nM) to the culture media for 72 hours (p=0.00095). N-cadherin and Snail, the markers for epithelial-messenchymal transition (EMT), were induced in irradiated cells, suggesting that EMT may partly account for enhanced cell proliferation. Understanding the molecular basis for the interplay of androgen-induced androgen receptor (AR) signaling with senescence-induced EMT and inflammatory signal, and impact of this interplay on prostate growth in vivo can potentially reveal novel avenues for therapeutic intervention of BPH.

 

Nothing to Disclose: SJ, CSS, BC

21138 22.0000 THR-134 A A Role for Cellular Senescence in Accelerated Prostate Cell Proliferation: Implication for Benign Prostatic Hyperplasia (BPH) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Giuseppe Grande*1, Domenico Milardi1, Silvia Baroni2, Chiara Autilio2, Renato Morelli2, Cecilia Zuppi2, Laura De Marinis3, Riccardo Marana2 and Alfredo Pontecorvi2
1Catholic University of the Sacred Heart, Rome, Italy, 2Catholic University, Rome, Italy, 3Università Cattolica del Sacro Cuore, Rome, Italy

 

The association between MAGI (Male Accessory Gland Infection) and infertility is a major andrological debate (1). Standard semen analysis, leukocytospermia and microbiological tests are not often enough for the diagnosis. A large amount of biochemical parameters in seminal plasma have been suggested as inflammation markers, nevertheless there is not yet a sensitive and specific  biomarker that accurately identify MAGI (2).

We investigated in semen the presence of suPAR (soluble urokinase-type Plasminogen Activator Receptor), known marker of systemic inflammation (3), to evaluate its possible involvement in urogenital tract inflammation.

On the basis of andrological evaluation, including spermiogram and ultrasound signs of MAGI, we selected 76 patients with MAGI and 30 healthy men as control group. Patients were  classified according to semen culture in group A (n=28) with bacterial MAGI and group B (n=48) with abacterial MAGI. C-reactive protein (CRP), total protein (TP), procalcitonin (PCT), leucocytes peroxidase (LP) and suPAR concentrations were assayed on seminal plasma.

 Spermiogram parameters were significantly lower in patients than in controls. CRP, TP, PCT and LP were not different in all subjects. suPAR was detectable in all semen samples; it was significantly increased in A and B groups (median: 78.5 vs 41.0 ng/ml in controls) and inversely correlated to sperm parameters. We selected by ROC curve a suPAR cut-off value of 55.3 ng/ml as diagnostic threshold to detect MAGI.

We report the first evidence of suPAR presence in seminal plasma, focusing on its interesting role as reliable, sensitive and specific marker of inflammation in differential diagnosis of MAGI.

 

Disclosure: LD: Principal Investigator, Novartis Pharmaceuticals, Consultant, Ipsen, Speaker, Lilly USA, LLC. Nothing to Disclose: GG, DM, SB, CA, RM, CZ, RM, AP

21186 23.0000 THR-135 A Seminal Soluble Urokinase Plasminogen Activator (suPAR) Is a Marker of Male Accessory Gland Inflammation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Matea Belan*1, Karine Duval1, Farrah Jean-Denis2, Marie-Helene Pesant1, Marie-France Langlois1, Youssef Ainmelk1, Belina Carranza-Mamane1 and Jean-Patrice Baillargeon1
1Université de Sherbrooke, Sherbrooke, QC, Canada, 2Research Center of the Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada

 

BACKGROUND:Although weight loss was shown to improve reproductive health in obese women, it is still unknown whether lifestyle modifications in men improve couples’ fertility. In order answer this question, we assessed the impacts of a lifestyle intervention targeting obese infertile women on their male partners and whether anthropometric or lifestyle changes in partners could influence couples’ fertility.

METHODS:All interested male partners were recruited in a controlled prospective cohort study nested in a randomized-controlled trial. Couples were referred to the Fertility Clinic of a Canadian Academic Center. Participants were considered exposed to lifestyle modifications if their spouse were randomized to the intervention. Partners were evaluated after 12 months or at the time of a pregnancy for their anthropometry and lifestyle. Results are presented as means ± SD. Groups were compared using Student’s t tests. Independent male predictors of pregnancy were determined using stepwise multiple logistic regression.

RESULTS: Compared to the Canadian male population aged 18-39 years1, the 65 participating male partners (age 33.1 ± 6.2 years) were more often obese (47% vs 23%, p<0.001) or abdominally obese (WC ≥102cm : 53% vs 21%, p<0.001), less active (29% vs 58%, p<0.001), and ate less often ≥5 fruits and vegetables (F&V) daily (12% vs 35%, p<0.001) or a breakfast (43% vs 81%, p<0.001). After 12 months (n=46), anthropometry and lifestyle tended to improve in the exposed group, but not significantly. Nonetheless, male partners who conceived lost more weight (-0.32kg ± 4.55 vs 2.68 ± 3.19, p=0.016; % with weight loss: 38.5% vs 10%, p=0.029) and improve more some of their lifestyle. Significant independent male predictors of pregnancy were losing weight (p=0.038 for BMI), eating more breakfasts weekly (p=0.016) and begin to consume ≥5 F&V daily (p=0.050).

CONCLUSION: Our preliminary results suggest that male partners of obese infertile women are often obese themselves and display worst lifestyle habits than the Canadian male population. Furthermore, this is the first prospective study suggesting that male partners who improve their weight and dietary habits also increase the odds for their couple to conceive. Since exposure of male partners to their spouse lifestyle intervention is not effective enough, these results support to develop lifestyle interventions targeted to male partners in order to improve couples’ fertility.

 

Nothing to Disclose: MB, KD, FJ, MHP, MFL, YA, BC, JPB

21409 24.0000 THR-136 A Impacts of Lifestyle and Anthropometric Changes in Male Partners of Obese Infertile Women on Couples' Fertility - Preliminary Results from a Cohort Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Jenny Pena Dias*1, Denise Melvin2, Chee W. Chia3, Josephine Mary Egan3 and Shehzad Basaria4
1NIH/NIA, Brooklyn, MD, 2NIH/NIA, Baltimore, MD, 3National Institute on Aging, Baltimore, MD, 4Brigham and Women's Hospital - Harvard Medical School, Boston, MA

 

Background:  Testosterone (T) therapy is being increasingly prescribed to older men with age-related decline in circulating T levels. The prostate is an androgen-responsive organ. Randomized trials of T replacement in older men have demonstrated a greater increase in prostate- specific antigen (PSA) levels in the T group compared with placebo while some studies have reported an increase in prostate volume (PV) in response to T therapy. Testosterone is metabolized to dihydrotestosterone (DHT) and estradiol (E2)(1). Although some studies have investigated the role of DHT on PV and PSA levels, the relative contribution of E2 on these parameters remain unclear. Furthermore, the differential effects of T or E2 on lower urinary tract symptoms (LUTS) are understudied.

Objective: To investigate the relative contribution of T or E2 on PV, PSA levels and LUTS in older men with age-related low T levels.

Methods: In a 12-month randomized, double-blind, placebo-controlled, proof-of-concept study, we randomized men age 65 years and older (range: 65-82) with serum T levels <350 ng/dl to transdermal T gel (5gm daily, n=10), anastrazole (1mg daily, n=10) or placebo (n=11). Serum PSA and LUTS [using International Prostate Symptom Score (IPSS) questionnaire] were measured at baseline, 3, 6 and 12 months. PV was measured using a transrectal ultrasound at baseline and 12 months.

Results: The change in serum PSA was significantly higher than baseline at 3 and 6 months in T-group (ΔPSA at 3 month=0.2±0.1 (p-value<0.05), ΔPSA at 6 month=0.3±0.2 (p-value<0.01), ΔPSA at 12 month=0.04±0.10 (p-value:0.47)) and AI-group (ΔPSA at 3 month =0.3±0.1 (p-value<0.05), ΔPSA at 6 month =0.4±0.1 (p-value<0.001), ΔPSA at 12 month=0.02±0.08 (p-value:0.58)).  There was no significant change in PSA levels in the placebo arm. At 12 months, PV significantly increased by 4.5±1.7 cc (p-value: 0.03) in the T-group while no significant change was observed in the AI-group (PV= -1.7±3.5 cc) or Placebo group (PV= -1.1±1.5 cc). At 12-month, the total IPSS score was higher in the T-group compared with the Placebo group (p-value: 0.04) while no change was seen in the AI-group.

Conclusion: In this proof-of-concept study, we show that the increase in PSA level is primarily an androgen-driven process. However, the trophic effects of T on PV are mediated via its aromatization to E2. Further studies are needed to confirm this observation.

 

Disclosure: SB: Consultant, Eli Lilly & Company, Principal Investigator, Abbott Laboratories, Consultant, Endo Pharmaceuticals. Nothing to Disclose: JP, DM, CWC, JME

20990 25.0000 THR-137 A Effects of 12-Month Treatment with Transdermal Testosterone Gel or an Aromatase Inhibitor on Prostate Volume and PSA Levels in Older Men with Low Testosterone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 113-137 6014 1:00:00 PM Testis Cells: Control, Regulation and Functions Poster


Haidong Zhao1, Qiang Liu*2 and Jianxin Hou3
1The Second Affiliated Hospital of Dalian Medical University, Dalian, China, 2Affiliated Zhongshan Hospital of Dalian University, Dalian, China, 3Dalian Medical University, Dalian, China

 

Abstract 

Objective To discuss the relationship between preoperative serum thyroid-stimulating hormone (TSH) level and the differentiated thyroid cancer(DTC),we explored the clinical features of Hashimoto thyroiditis (HT) co-existing nodules and evaluated the prognostic factors.Method Retrospective analysis of 5785 patients whom were treated in the second affiliated hospital of Dalian medical university, from January 2002 to December 2010. All of the patients were found nodules and categorised based on their final pathological diagnosis. Among all the patients with thyroid nodules there were 166 cases co-existing HT. Through the analysis of some prognostic predictors, age, gender, tumor size and stage, lymph node metastasis and preoperative serum TSH level et al, expound their relationship with thyroid cancer. Results There were 166 patients confirmed by the final pathology for Hashimoto thyroiditis with nodular goiter or postoperative thyroid cancer. 62 cases (8.45%, 62/734) were HT with papillary thyroid cancer(PTC), compared with goiter nodule patients, the mean age, nodule numbers, neck lymph node metastasis and mean TSH level can be used as prognostic factors of disease. In addition, the elevated TSH level may relate to high incidence of PTC. Conclusion Ultrasound plays very important role in preoperative diagnosis of thyroid nodule by-detecting intra-nodule vascularity and micro-calcification ,which has important diagnostic value in thyroid cancer. The HT patients co-existing PTC display greater female preponderance, younger, and higher serum TSH level. The multivariate analysis reveals solitary nodule, some ultrasonic image characteristics like intra-nodule vascularity and micro-calcification, serum TSH level were associated with increased risk of tumor.

 

Nothing to Disclose: HZ, QL, JH

20256 1.0000 THR-044 A Hashimoto Thyroiditis with Nodule: The Clinical Characteristics and Prognostic Risk Factors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Kyong Yeun Jung*1, Yul Hwangbo1, Seok-Mo Kim2, Ye An Kim1, Tae Hyuk Kim1, Jae Hoon Moon1, Kyung Won Kim1, Ka Hee Yi1, Do Joon Park1, Seong Yeon Kim1, Hang-Seok Chang2 and Young Joo Park1
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Backgrounds: The increase in thyroid screening with ultrasound in general population may lead to the earlier detection of medullary thyroid carcinoma (MTC) similar to papillary thyroid carcinoma in recent years. The aim of the study was to evaluate the secular trends in the clinicopathologic characteristics, long term prognosis and its risk factors in MTC patients.
Methods : Total 331 patients with MTC were included from 1982 to 2012, and followed up for median 4.6 (0.2-30.8) years. Patients were grouped based on the year of diagnosis; 1982–2000, 2001–2005, 2006–2010 and 2011–2012 for the comparison of clinicopathological characteristics, 1982-2005 and 2006-2012 for the prognosis.
Results : The mean age had been increased over time, but the proportion of male was similar. The mean tumor size (from 2.5cm to 1.7cm, p<0.001) and the proportion of extrathyroidal extension (from 52% to 26%, p=0.026) had been decreased. In addition, the proportion achieved postoperative biochemical remission of serum calcitonin (BCR) had been continuously increased with time (from 39% to 76%, p<0.001). The 5-year overall recurrence rate was significantly decreased in 2006-2012 compared to 1982-2005 (10 % vs. 18% respectively, p=0.031), although 5-year disease specific survival was not improved (8 % vs. 8%, p=0.929). On multivariate analysis, postoperative BCR was the most strong predictive factor associated with recurrence (HR=50.26, 95% CI 6.24–405.09; p<0.001). The increased BCR with periods was related with the improvements of surgical techniques as well as the decrement of pathologic aggressiveness. For the mortality, male sex (HR=3.37, 95% CI 1.36–8.33; p=0.008), tumor size larger than 2cm (HR=10.83, 95% CI 2.42–48.54; p=0.002), or distant metastasis (HR=4.31, 95% CI 1.56–11.95; p=0.005) was resulted as a significant prognostic factor.
Conclusions: The clinicopathlogic characteristics of MTC have been improved over the 3 decades, and the recurrence was also decreased with times. The postoperative BCR was the most strong predictive factor for recurrence reflecting both the pathological aggressiveness and surgical completeness. However, the proportion of distant metastasis and the mortality remain unchanged over time and that suggest the necessity of earlier detection of tumors larger than 2cm.

 

Nothing to Disclose: KYJ, YH, SMK, YAK, THK, JHM, KWK, KHY, DJP, SYK, HSC, YJP

21579 2.0000 THR-045 A Secular Trends of the Clinicopathologic Characteristics and Prognosis of Medullary Thyroid Cancer and the Changes of the Predictive Factors for the Recurrence over the 30 Years 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Min Jin Lee*1, Ji Young Seo1, Sangchang Kwon1, Jong Ho Kim1, Su Bin Park1, Yoon Jeong Nam1, Kang Hee Ahn1, Sun Hye Shin2, Yun Kyung Jeon1, Sang Soo Kim1, Bo Hyun Kim1 and In Joo Kim1
1School of Medicine, Pusan National University, Busan, Korea, Republic of (South), 2Bongseng Memorial hospital, Busan, Korea, Republic of (South)

 

Objective : The aim of this study was to investigate BRAF mutation status based on the

histological variant of papillary thyroid carcinoma (PTC) and to determine the significance of

BRAF V600E mutation in follicular variant of PTC (FVPTC) in Korean patients.  

Methods : In all, 691 PTC cases were classified to each histological variants. BRAF

mutation analysis was performed routinely using multiplex PCR by applying dual priming

oligonucleotide(DPO). Clinicopathological characteristics were compared between BRAF

V600E mutation-positive and -negative groups in FVPTC.

Results: The classic type, FVPTC, diffuse sclerosing variant, and tall cell variant

represented 656(94.9%), 24(3.5%), 7 (1.0%) and 4 (0.6%), respectively. The classic

type, FV, DSV, and TCV harbored 300(45.7%), 9(37.5%), 1 (14.3%) and 2 (50%) in BRAF

V600E mutation, respectively. The BRAF mutation-positive FVPTC was marginally associated

with larger tumor size (P = 0.067) and old age (P = 0.052) due to small sample size. However,

there was no significant association in extrathyroidal extension, multifocality,

lymphovascular invasion, lymph node metastasis and higher (III/IV) TNM stages.

Conclusions: BRAF V600E mutation in FVPTC was not uncommon and it may be a potential

prognostic factor as it is in classical PTC. However, further studies with a larger patient

population and extended follow-up period may be required for verification of prognostic

predictors.

 

Nothing to Disclose: MJL, JYS, SK, JHK, SBP, YJN, KHA, SHS, YKJ, SSK, BHK, IJK

20843 3.0000 THR-046 A BRAF V600E Mutation Status and Its Clinical Implication As Prognostic Predictors in Patients with Follicular Variant of Papillary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Sangchang Kwon*1, Ji Young Seo1, Min Jin Lee1, Jong Ho Kim1, Su Bin Park1, Yoon Jeong Nam1, Kang Hee Ahn1, Sun Hye Shin2, Yun Kyung Jeon1, Sang Soo Kim1, Bo Hyun Kim1 and In Joo Kim1
1School of Medicine, Pusan National University, Busan, Korea, Republic of (South), 2Bongseng Memorial hospital, Busan, Korea, Republic of (South)

 

Background: Recently, many studies have linked oxidative stress to thyroid cancer by showing its association with abnormally regulated oxidative or antioxidative molecules. Bilirubin is a potent anti-oxidant that effectively scavenges peroxyl radicals. The study aimed to evaluate the relationship between serum total bilirubin (TB) levels and clinicopathologic characteristics in patients with papillary thyroid cancer (PTC).

Methods: A total of 563 patients who underwent total thyroidectomy for PTC from June 2012 to May 2013 were included. Blood samples were obtained within 2 weeks prior to surgery. Patients were excluded if their serum TB levels were >1.2 mg/dL because of the potential for confounding hepatobiliary or hemolytic diseases. Patients were also excluded if they had gallstones, cirrhosis, hepatitis, alcoholic liver disease or malignant diseases. Patients were categorized into 4 quartiles by preoperative serum TB levels. The clinicopathologic features of PTC were analyzed retrospectively.

Results: Preoperative TB was associated with age (P = 0.031), body mass index (P = 0.011), and extrathyroidal extension (ETE) (P = 0.038). However, after adjusting for age, there was no correlation between TB and ETE (P = 0.065). No significant trends in several clinicopathologic features such as tumor size, lymph node metastasis, lymphovascular invasion, multifocality, and BRAF mutation were observed in relation to increasing serum total bilirubin concentrations. Although advanced T stage and ETE showed lower serum TB levels, there was no statistical significance (P = 0.060). Univariate and multivariate logistic regression with unadjusted ORs in which the 4th quartile of TB as a reference showed no significant correlation between poor clinicopathologic features and age, BMI, and TSH on serum TB levels

Conclusion: Lower preoperative TB seems to be associated with advanced T stage and ETE in patients with PTC. However, these findings require confirmation in large prospective, multicenter studies.

 

Nothing to Disclose: SK, JYS, MJL, JHK, SBP, YJN, KHA, SHS, YKJ, SSK, BHK, IJK

21624 4.0000 THR-047 A Relationship Between Serum Total Bilirubin and Clinicopathologic Characteristics in Patients with Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Kwanhoon Jo*, Yejee Lim, Dong Jun Lim, Min Hee Kim, Jeonghoon Ha, Bong-Yun Cha and Moo-Il Kang
Seoul St. Mary’s Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea, Republic of (South)

 

Objective: Aim of this study was to define the significance of thyroglobulin(Tg) changes caused by thyrotropin(TSH) rise between diagnostic whole body scan(DxWBS) and radioablation therapy.

 Method: 394 patients with papillary thyroid cancer, who underwent total thyroidectomy between Jan. 2009 and Dec. 2010, were included. They were treated by remnant ablation with 131 I. Tg levels at the time of DxWBS(Tg1) and just before therapeutic iodine intake(Tg2) were measured in all patients. Time interval between Tg1 and Tg 2 measurement was a week. Patients with positive Tg antibody (≥70ng/mL) were excluded. The mean follow up duration was 46.1 months (range 5-114). In response to further elevation of TSH, patients were categorized into 2 groups; group A (n=223): Tg2-Tg1<1ng/mL, group B (n=171): Tg2-Tg1≥1ng/ml.

 Result: The presence of lymph node metastasis was significantly different between two groups (58% in group A vs 71.1%  in group B, p 0.005). Recurrence was more prevalent in group B (n=14, 8.2%) than in group A (n=6, 2.7%) (p<0.001). When Tg1 levels were less than 5ng/ml, no significant difference in recurrence between group A and B was found. However, in cases with Tg1≥5ng/mL, recurrence rate was significantly different in group A and B (10.3% and 29.0%, respectively, p=0.047).

 Conclusions : Tg increase during the time of DxWBS and just before iodine intake was associated with node metastases and recurrence. In high risk patients whose Tg1 levels are 5ng/mL or more, Tg increase according to further TSH rise is helpful to predict recurrence of cancer.

 

Nothing to Disclose: KJ, YL, DJL, MHK, JH, BYC, MIK

21033 5.0000 THR-048 A Clinical Significance of Change in Thyroglobulin Due to Increase in Thyrotropin during Radioisotope Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Jennifer Hong Kuo*1, John Chabot1, Mary Beth Terry2 and James A Lee1
1Columbia University Medical Center, New York, NY, 2Mailman School of Public Health, Columbia University, New York, NY

 

BACKGROUND: An increased incidence of thyroid cancer among patients with breast cancers has been recognized in single institution studies. We sought to further elucidate the relationship between these two disease processes in a population based setting.

METHODS: A retrospective cohort analysis using the SEER-9 database was conducted on patients with breast and thyroid cancer from 1990-2011. Statistical analyses were performed using SPSS software.

RESULTS: 499,402 patients with breast cancer and 53,853 patients with thyroid cancer were included in the study. Age stratification demonstrated that the incidence of thyroid cancer among breast cancer patients was higher (81.8%) than the general population (54.8%%) in patients ≥ 50 years old. Breast cancer survivors (B1T) developed thyroid cancer at a median of 4.0±0.1 years (SE) after their primary diagnosis. When compared to patients with breast cancer (TC) only, B1T patients were younger (55.0±0.36 vs 61.4±0.02, p<0.0001) with smaller breast cancers (15.0±0.52mm vs. 20.5±0.03mm, p<0.001) and there was no difference in ER/PR positivity or lymph node involvement. However, a greater number of patients did receive adjuvant radiation therapy (48.9% vs 44.0%, p=0.001).

B1T patients developed thyroid cancer at an older age (61.4±0.37 vs 48.3±0.07, p<0.0001) than the general population (TC). These patients have smaller thyroid tumors (11.0 ± 0.6mm vs 14.0 ± 0.10mm, p<0.0001) with less cervical lymph node involvement (2.3±0.03 vs 1.0±0.11,  p<0.0001),  and less radioactive iodine (41.8% vs 46.2$, p=0.003) positivity. B1T patients also have a greater percentage of follicular variant papillary thyroid cancer (31.0% vs 27.8%).

CONCLUSION: Breast cancer survivors are at higher risk for developing thyroid cancer than the general population. Adjuvant radiation therapy is a risk factor for the development of thyroid cancer. These patients have a higher percentage of follicular variant papillary thyroid cancer. Recognition of this association between thyroid and breast cancer should prompt vigilant screening in these cancer patient populations. In addition, further investigation into the relationship of breast and thyroid cancer is warranted.

 

Nothing to Disclose: JHK, JC, MBT, JAL

20363 6.0000 THR-049 A Increased Incidence of Thyroid Cancer Among Breast Cancer Survivors: An Analysis of the SEER 9-Database 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Lily J Kwatampora*1, Maria E Cabanillas2, Brinda Rao Korivi3, David Fogelman2, Ramona Dadu2 and Naifa L Busaidy2
1Baylor College of Medicine, Houston, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3The University of Texas MD Anderson Cancer Center

 

Background: Tyrosine kinase inhibitors [TKIs] are the main stay for therapy for patients with advanced thyroid cancer. While not curative, these drugs can more than double progression-free survival. However, adverse effects such as weight loss limit their use. Weight loss is reported in 10-50% of patients in randomized phase III trials of the approved agents. Cabozantinib in particular results in weight loss in almost 50% of pts with medullary thyroid cancer [MTC]. Although this may partly result from gastrointestinal [GI] adverse effects such as diarrhea and anorexia seen with these drugs, recent evidence suggests a direct effect on both skeletal muscle [SM] by direct inhibition of protein synthesis and on adipose tissue [AT] by inhibition of adipogenesis. Currently the effect of cabozantinib on body composition remains unknown. We hypothesize that cabozantinib will cause SM loss independent of gastrointestinal adverse effects.

Methods: This is a retrospective analysis performed at MD Anderson Cancer Center. We evaluated patients with advanced progressive MTC on cabozantinib for weight loss and body composition changes. We collected date on weight, height and BMI, GI related and other adverse effects and tumor response. We are now quantifying skeletal muscle and adipose tissue correlated to whole body fat and skeletal muscle using crossectional images at the 3rdlumbar spine using validated software over a 12 month period for each subject.

Results: 21 patients were evaluated. At 3 months 12/21 [57.1%] of subjects had >5% [grade 1] weight loss and of these 3/21[14%] had lost >10% [grade 2] of their weight compared to baseline. At 6 months and 12 months 9/16 [56%] and 9/14 [64%] had lost >10% weight compared to baseline respectively. Grade 3 weight loss [>20%] had occurred in 3/14 [21%] subjects by 12 months. Weight loss in the first 3 months predicted additional weight loss at later time points. SM and AT are being assessed. Grade 2 weight loss was noted in at least 2 subjects without reported GI adverse effects such as diarrhea or anorexia.
 
Conclusion: This study is the first to demonstrate cabozantinib’s effects on body composition in advanced medullary thyroid cancer patients. Understanding these effects on body composition will guide identification of at-risk patients, dose selection at initiation of therapy and identification of patients who would benefit from interventions to decrease sarcopenia. We hope that ultimately ameliorating this adverse event would improve tolerance to therapy, decrease treatment interruptions and early withdrawal from treatment. This study provides preliminary data to instigate larger intervention studies to prevent TKI induced weight and skeletal muscle loss and to improve drug tolerability and response.

 

Disclosure: MEC: Consultant, Exelixis, Inc., Principal Investigator, Exelixis, Inc.. Nothing to Disclose: LJK, BR, DF, RD, NLB

22148 7.0000 THR-050 A Effect of Cabozantinib on Body Composition in Advanced Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Su Kyoung Kwon*1, Min Jung Jung2, Bu Kyung Kim3, Young-Sik Choi3 and Yo-Han Park4
1Kosin University College of Medicine, Busan, Korea, Republic of (South), 2Kosin university College of Medicine, Busan, Korea, Republic of (South), 3Kosin Univ Sch of Med, Busan, Korea, Republic of (South), 4Kosin University College of Medicine, Busan

 

Background

Incretin-based therapies are rapidly becoming one of the main treatment tactics of glycemic control strategy in diabetes. Considering the large number of papillary thyroid carcinoma (PTC) and possible effects of Glucagon-like peptide-1 (GLP-1) on cell proliferation, the expression of GLP-1 receptor (GLP-1R) in PTC is likely to have clinical significance. We performed this study to evaluate the existence of GLP-1R in PTC and clinical meaning of GLP-1R expression in PTC.

Methods

56 cases of PTC, 4 cases of medullary thyroid cancer (MTC), 7 cases of nodular hyperplasia and 56 cases of normal thyroid tissue were selected for immunostaining for GLP-1R. Clinical parameters were obtained by review of medical records retrospectively.

Results

Immunohistochemical staining for GLP-1R exhibited immunoreactivity in 18 of 56 cases (32.1%) in PTC. All four cases of MTC exhibited cytoplasmic GLP-1R expression. Nodular hyperplasia also exhibited immunoreactivity in 2 of seven cases (28.6%). All normal thyroid follicular cells showed negative immunoreactivity. In univariable and multivariable analysis, multifocality of tumor was negatively correlated to GLP-1R expression (OR 0.257, 95% CI 0.071-0.926, P=0.044, Adjusted OR 0.172, 95% CI 0.037-0.797, P=0.024 respectively). Extrathyroidal extension showed marginal significance (OR 3.022, 95% CI 0.947-9.646, P=0.057, Adjusted OR 3.46, 95% CI 0.879-13.618, P=0.076 respectively). Sex, Age, tumor size and LN metastasis were not significantly associated with GLP-1R expression.

Conclusion

Some parts of PTC tissue express GLP-1R and GLP-1R expressed PTC showed negative correlation with multifocality of tumors. Long-term influence of pharmacologically increased GLP-1 to thyroid follicular cells and development and progression of tumors originated from thyroid follicular cells should be monitored


Conflicts of Interest

All authors of this study report that they have no conflicts of interest.


 

Nothing to Disclose: SKK, MJJ, BKK, YSC, YHP

20385 8.0000 THR-051 A The Expression of GLP-1 Receptor in Papillary Thyroid Cancer and Its Clinical Significance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Lizette Kristine Lopez*, Kristine Saunders, Glenda Amog-Jones, John Matchette and Beejal Ashok Shah
Phoenix VA Health Care System, Phoenix, AZ

 

Background: Encapsulated follicular variant of papillary thyroid carcinoma (EnFVPTC) is a controversial pathological diagnosis because there is no consensus on the diagnostic criteria or its malignant potential, though it is generally thought to be indolent. The current criteria are nuclear features of papillary thyroid carcinoma in a follicular architecture without capsular or vascular invasion. There is no agreement on the number of the nuclear changes needed or its distribution (focal versus diffuse) which can translate into challenges in management decisions. (1)

Clinical Cases: A 53-year old male had a right hemithyroidectomy for a benign adenoma 10 years ago due to dysphagia. Four years later, he was found to have a recurrent neck mass and US revealed a solid 1.95 cm right thyroid mass extending from the isthmus. FNA showed cells in a microfollicular pattern. A completion thyroidectomy was delayed due to other illnesses and over time he developed compressive symptoms. He had the surgery recently and the report showed a multifocal neoplastic pattern. There was a 1.8 cm well differentiated isthmus tumor and a 1.4 cm moderately differentiated left thyroid tumor, both with minimal capsule invasion and no ETE. Histopathology showed extensive compact follicles composed of epithelial cells with irregular nuclei with fine chromatin, nuclear grooves, and intranuclear inclusions. The diagnosis was EnFVPTC stage I pT1bNXMX. Three months post-operatively TG levels were detectable. He is on LT4 with the goal of TSH suppression, and is awaiting RAI ablation.

The second case is a 58-year old female who noted a progressively enlarging hard neck lump over 6 months. TSH was normal, while thyroid US showed a multinodular goiter with a 4.3 cm solid right thyroid nodule; FNA was insufficient for diagnosis. The patient opted to have a total thyroidectomy, which revealed a 3.2 cm cystic nodule on the right lobe. Histopathology showed compact follicles with enlarged irregular ground glass nuclei, very few having intranuclear inclusions and no grooves. There was no capsular or vascular invasion. The diagnosis was EnFVPTC stage I pT1aNXMX. She was placed on LT4 replacement but not TSH suppression; TG post-operatively was nearly undetectable. She was deemed to have low risk for recurrence and thus not needing RAI ablation.

Conclusion: These 2 cases demonstrate the wide variation in the malignant potentials and appearance of EnFVPTC which translates into variable rates of cure vs risk of recurrence. This leads to the realization that the individual patient’s presentation must be taken into account.  We emphasize the importance of clinical correlation with meticulous analysis of the pathology report to guide subsequent therapy and predict risk of recurrence, especially for ill-defined variants such as EnFVPTC.

 

Nothing to Disclose: LKL, KS, GA, JM, BAS

20217 9.0000 THR-052 A The Challenges of Diagnosing Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: Different Histological Appearances of the Same Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Nithya Mani*, Vafa Tabatabaie, Eric Jason Epstein and Renee Moadel
Montefiore Medical Center, New York, NY

 

Introduction

Production of thyroid hormone by metastases of thyroid carcinoma is an extremely rare finding and its pathogenesis is still unknown.

Clinical Case

A 60-year-old man had a history of thyroid cancer and total thyroidectomy in 2007. Pathology from that surgery is unknown. He did not have RAI ablation following thyroidectomy. In 2/2014, he presented to our ER with syncope and CT chest showed multiple, bilateral lung nodules measuring up to 1.5 cm. Lung nodule biopsy tissue stained positive for thyroglobulin. Neck ultrasound showed a 2 cm nodule in the right thyroid fossa and FNA biopsy was positive for neoplastic follicular cells. Thyroglobulin level in 3/2014 was 594 ng/dL (n <60 ng/dL) and thyroglobulin antibody was negative. He subsequently had neck dissection in 4/2014, but pathology from the resection was benign thyroid tissue. He was lost to follow-up after surgery, but in 7/2014 he presented to the ER with chest pain and was admitted to the hospital. Due to his homelessness, the decision was made to treat with RAI ablation and isolate him in the hospital following treatment. On Levothyroxine 75 mcg daily, TSH on admission was 13.5 uU/mL (n 0.4-4.6 uU/mL) and fT4 0.81 ng/dL (n 0.8-1.7 ng/dL). Levothyroxine was held for two weeks while he was in the hospital in preparation for RAI ablation. At the end of the two weeks, repeat TSH was 2.95 uU/mL and fT4 1.07 ng/dL. The decrease in TSH and increase in fT4 in the setting of thyroid hormone withdrawal for two weeks was evidence that the metastases were producing thyroid hormone. He was treated with 106.5 mCi of I-131. Whole body scan one week later showed uptake in the thyroid bed and multiple foci in bilateral lungs. He was discharged on Levothyroxine 100 mcg daily. On follow-up two months later, TSH was 22.3 uU/mL and fT4 1.06 ng/dL indicating decreased thyroid hormone production by metastases.

Conclusion

This case is unique because the lung metastases demonstrated the ability to produce thyroid hormone. The pathogenesis of thyroid hormone production by metastases of thyroid carcinoma remains unknown, but a few suggestions have been made. Lang and Flesch proposed that long-standing goiter and iodine deficiency contributed to hormone producing ability of metastases.1 Ottevanger et al. suggested that endogenous TSH stimulation may enhance the production of thyroid hormone by metastases2 and Paul and Sisson proposed that thyroid stimulating immunoglobulin may play a role by direct stimulation of metastases.3 However, none of these proposals are conclusive and further studies of the underlying pathophysiology are needed to identify the exact mechanism of this rare finding.

 

Nothing to Disclose: NM, VT, EJE, RM

21527 10.0000 THR-053 A Thyroid Hormone Production By Lung Metastases of Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Eun Yeong Mo*1, Je ho Han2, Sungdae Moon3 and Eun sook Kim2
1Catholic Univ, Incheon, Korea, Republic of (South), 2Catholic Univ, Incheon, 3Catholic Univ of Korea, Incheon, Korea, Republic of (South)

 

Tuberculosis of the thyroid gland is rare disease. The coexistence of malignant lesions and tuberculosis at the thyroid gland is extremely rare, only four cases have been reported. The current study presents the case of a 67-year-old female, with thyroid nodules of Bethesda category III showing signs of malignancy under B-mode ultrasonography and PET CT. A total thyroidectomy and selective neck dissection were performed. A histopathological examination revealed thyroid tuberculosis coexisting with incidental micropapillary thyroid cancer. This report presents a rare case of coexisting tuberculosis and papillary thyroid cancer diagnosed by the histopathologic examination of a resected thyroid specimen.

 

Nothing to Disclose: EYM, JHH, SM, ESK

20117 11.0000 THR-054 A Primary Thyroid Tuberculosis Coexisting with Papillary Thyroid Cancer: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Vallikantha Nellaiappan*1, Boby G Theckedath2, Peter Morawiecki3 and Janice L Gilden4
1Rosalind Franklin University of Medicine and Science/ Chicago Medical School, Captain James A. Lovell Federal Healthcare Center, North Chicago, IL, 2Rosalind Franklin University of Medicine and Science/ Chicago Medical School, and Captain James A. Lovell Federal Health Care Center, North Chicago, IL, 3Captain James A. Lovell Federal Healthcare Center, North Chicago, IL, 4Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL

 

Background:

Although thyrotoxicosis is generally considered protective against thyroid malignancy, recent literature has shown conflicting evidence. We present an unusual case of Graves’ disease developing papillary thyroid carcinoma.

Clinical Case:

A 43 year old Asian female was referred to Endocrine Clinic for management of Graves’ disease. Graves’ disease was diagnosed one year previously and she had been taking methimazole (MMI) 10 mg daily. However, two years previous to the onset of hyperthyroidism, she was treated with levothyroxine for Hashimoto’s thyroiditis. Prior labs done at that outside institution showed TSH 0.02 mcIU/ml (normal 0.40-5.00 mcIU/ml), free T4 3.11 ng/dl (normal 0.8-1.9ng/dl), free T3 7.05 pg/ml (normal 2.5-6.0 pg/ml). Her current physical examination was normal except for mild thyromegaly with no palpable nodules. Labs: TSH 24.72 uIU/mL (normal 0.34 - 4.82 uIU/ml), Free T3 2.3 pg/mL (normal 2.3 - 4.2 pg/ml), free T4 .52 ng/dl (normal 0.76-1.46 ng/dl), TSH Receptor AB 23 IU/L (normal 0 - 1.22 IU/L), TSI <89% (Ref: <130 %), Peroxidase AB 1348.4 U/mL (normal 0 – 60 U/ml), Thyroglobulin AB 1127.6 U/mL (normal 0 – 60 U/ml). Due to the above lab results,  methimazole was stopped. Thyroid Ultrasonogram revealed a 1.7 cm complex mass lesion in the right thyroid lobe, USG-guided FNA biopsy of the nodule was benign. She underwent a right lobectomy that revealed 1.5cm papillary thyroid carcinoma with a separate focus of 6 mm papillary thyroid microcarcinoma and negative lymph nodes. A complete thyroidectomy was then performed.

Conclusion:

Thyroid stimulating hormone (TSH) is an important factor associated with the development of thyroid malignancy. Differentiated thyroid cancers are shown to have TSH receptors and hence TSH stimulates the growth of these cancers (1,2). In Graves’ disease, it is assumed that suppressed TSH is protective against cancer development. But recent literature suggests that TSH receptor antibodies in Graves’ disease might also stimulate the TSH receptors and lead to the development of malignancy (3).  Malignancy in Graves’ disease patients is more aggressive and caries a poorer prognosis (4). Our patient is one of the few cases with initial hypothyroidism followed by Graves’ disease (5) and the development of papillary thyroid carcinoma. Therefore, it is important to recognise that thyroid nodules and thyroid malignancy can also be seen in patients with Graves’ disease.

 

Nothing to Disclose: VN, BGT, PM, JLG

20651 12.0000 THR-055 A A Case of Graves' Disease with Papillary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Janna Prater*1, Arthur Chernoff2 and Catherine Anastasopoulou1
1Einstein Medical Center, Philadelphia, PA, 2Albert Einstein Med Ctr, Philadelphia, PA

 

Case #1: 76 yo F was followed since 2007 for MNG. FNA 2007: left – adenomatous goiter with lymphocytic thyroiditis; right also benign. US 2012: 6.8x4.6x5.8 cm left, 1.2x1.5 cm right lobe nodules. Pt came in 2014 for “second opinion” because of thyroid growth on the right, sore throat, unintentional 30 lbs. weight loss. PE: breathing unlabored sitting, stridor lying down, hoarse dysphonia upon speaking; thyroid 8x6 cm on the left, wooden texture, right lobe equally large with hard nodules, trachea deviated to the right. TFT’s normal. She was sent to ER & admitted to ICU. CT neck: massively enlarged thyroid gland with necrosis, invasion of surrounding tissues, multiple enlarged, partially necrotic neck & mediastinum lymph nodes. FNA (done prior to her visit with us, became available later): anaplastic, poorly differentiated squamous carcinoma or malignant melanoma. A total thyroidectomy & tracheostomy was done. Pathology: undifferentiated anaplastic thyroid carcinoma 11 cm with invasion of vascular spaces & tumor thrombi. She died on day 7 after developing bradycardia & PEA with unsuccessful CPR.

Case #2: 73 yo F, immigrant from Liberia with MNG for 30 years, came to ER with 2 days dyspnea & stridor, thyroid growth & unintentional 30 lbs weight loss over 2 months. She had never had thyroid US or FNA. PE:  ill-appearing, HR 119, BMI 18, neck asymmetrically enlarged with more prominent right thyroid lobe 9x6 cm, wooden texture, fixed, non-tender, no lymphadenopathy. TFT’s normal. CT: large thyroid mass with multiple coarse calcifications 9x8cm extending into prevertebral soft tissues, displacing trachea to the right. CT brain, chest, abdomen & pelvis with pulmonary & lytic osseous metastases, no brain metastases. She had total thyroidectomy & tracheostomy. Pathology report: poorly differentiated follicular cell derived carcinoma with insular features, poorly differentiated spindle & epithelioid malignant neoplasm likely anaplastic/sarcomatoid thyroid cancer. Postoperatively she developed ventilator dependent respiratory failure, PE & sepsis. Patient died of complications on day 19.

Conclusion: ATC is a rare aggressive form of thyroid cancer with median survival of 5 months.  ATC may arise de novo or through transformation of a preexisting differentiated thyroid carcinoma (DTC). The highest incidence of ATC has been reported in countries with endemic goiter. Decreased incidence of ATC after iodine salt supplementation had been shown. Due to the uniform fatality of ATC, low predictive value of FNA in detecting thyroid carcinomas in MNG, benign nodules or long-standing MNG should be followed carefully & considered for resection if they grow. Total thyroidectomy for malignant disease is currently the only method available to prevent anaplastic transformation of preexisting DTC or MNG. In the future, targeted next-generation sequencing panel may help in the optimal management of these patients.

 

Nothing to Disclose: JP, AC, CA

19225 13.0000 THR-056 A 2 Case Reports of Anaplastic Thyroid Carcinoma (ATC) Arising from Multinodular Goiter: Could the Outcome be Different? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Carmen V Rivera*1, Jose Hernan Martinez1, Coromoto Palermo1, Luis R Hernandez-Vazquez1, Michelle M Mangual2, Alfredo Sanchez3, Rafael Trinidad1, Madeleine Gutierrez1, Ivan Laboy4 and Paola Mansilla4
1San Juan City Hospital, San Juan, PR, 2Sa, San Juan, PR, 3San Juan City Hospital, PR, 4San Juan City Hospital

 

Background:  Even though thyroid microcarcinomas may metastasize regionally, lymph node metastasis is more often encountered in larger PTMC (greater than 5 mm to 8 mm) (1).  This phenomenon is rare in the setting of papillary microcarcinomas smaller than 5mm, reported to occur in solely 4.4% of the cases (2,3).   In the face of times in which the incidence of thyroid cancer increases faster than any other malingnancy, unexpectedly aggressive presentations of such will, undoubtedly, draw our attention (4,5). 

Clinical case:  A clinically and biochemically euthyroid 49-year-old man with history of T2DM, HTN, dyslipidemia, obesity class I, carpal tunnel, and bipolar disorder was referred to our service due to the diagnosis of  metastatic thyroid cancer.   The patient had experienced hoarseness and mild dysphagia for a year.   However, it was during tomographic imaging after trauma, that prominent adenopathy and associated vocal cord thickening were incidentally discovered.  An US revealing bilateral thyroid sub-centimeter nodules and suspicious right internal jugular chain lymphadenopathy prompted further evaluation.  A right neck core needle biopsy reported a Pax-8 and TTF-1 positive “metastatic adenocarcinoma, favoring thyroid origin,” and recommended repeating the test.  Two thyroid nodules located in the right lobe (largest diameters: 1.4 cm and 0.8 cm)  were identified by a second FNAB (US-guided), reported as negative for malignancy.  The diagnosis of chronic lymphocytic thyroiditis was suggested.  On the other hand, two lymph nodes in right neck level III (largest diameters:  1.6 cm and 1.5 cm), also evaluated by FNAB, resulted positive for papillary carcinoma, with tissue thyroglobulin levels of 6.2 ng/ml.  The patient was referred for surgical evaluation.  During vocal cord assessment, compression of area was noted.   He underwent total thyroidectomy, and resection of 39 right neck lymph nodes corresponding to anatomical levels IIb, III, IV, V, and VI.  This time, pathological analysis of the resected specimen revealed the presence of an unifocal papillary carcinoma of follicular variant with greatest dimension measuring only 1.8 mm.  Described lesion was encapsulated in its entirety and located to the isthmus.  No capsule or blood vessel invasion was identified.  Two out thirty-nine right neck lymph nodes resected showed involvement.  Staging as per Bethesda Classification was pT1a pN1b. The patient was afterwards scheduled for radioiodine ablation. One month after surgery, the patient referred improvement of hoarseness.

Conclusion:   Physicians must remain vigilant.  Whereas the increasing incidence of thyroid cancer has been linked with the nowadays earlier and improved detection, regional and distant metastatic disease has also raised over the years.  With a reported 3.7 fold increase in papillary cancer (4), this case of occult PTMC poses an alert on the potential hazards of even the smallest PTMC.

 

Nothing to Disclose: CVR, JHM, CP, LRH, MMM, AS, RT, MG, IL, PM

22033 14.0000 THR-057 A Small Size Does Not Equal Harmless; The Case of an Occult Metastatic Papillary Thyroid Microcarcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Saumya Saini*1 and Sreenija Suryadevara2
1Dartmouth-Hitchcock Medical Center, Lebanon, NH, 2Dartmouth Hitchcock Medical Center, Lebanon, NH

 

Background:

Reidel’s thyroiditis is a rare entity characterized by infiltrative thyroid gland fibrosclerosis resulting in a firmly enlarged thyroid gland which is adherent to surrounding tissues. Reidel’s thyroiditis has been predominantly treated surgically with good outcomes. In cases of inoperable Riedel’s thyroiditis, some success has been reported with prednisone, tamoxifen, and combination regimes of prednisone and mycophenolate mofetil. To date however, there are no reports of concurrent Reidel’s thyroiditis and papillary thyroid cancer (PTC), and treatment regimens have not been established. 

Clinical Case:

A 73-year old woman presented with a firm enlarging neck mass. Thyroid ultrasound revealed an enlarged heterogeneous thyroid gland containing multiple nodules in the right lobe, and a large solid nodule occupying the left lobe measuring 2.6x3.7x4.0, with an abnormal ipsilateral lymph node. FNA biopsy of the left lobe nodule was suspicious for papillary thyroid cancer. A total thyroidectomy and neck dissection were planned. Intra-operatively, the patient’s thyroid gland was found to be necrotic and adherent to multiple tracheal rings, and therefore inoperable. Intra-operative biopsies returned with extensive areas of chronic inflammation, fibrosis, and necrosis involving fibro-muscular tissue as well as papillary thyroid cancer. Congo red staining for amyloid was negative, and features of anaplastic carcinoma were not seen. With this information, the diagnosis of PTC in the context of Reidel’s thyroiditis was made. After a multi-disciplinary discussion at thyroid tumor board, the patient was referred to radiation oncology for external beam radiation with pre-treatment with prednisone.

Clinical lesson:

Unresectable Reidel’s thyroiditis has been treated with immune-modulators in some reports. Advanced PTC is traditionally treated with RAI ablation. This case however proves particularly complex due to the presence of both Reidel’s thyroiditis and PTC. In areas of fibrosis and necrosis, RAI ablation is not predicted to be effective due to limited I131 uptake. In addition, RAI ablation may worsen ongoing fibrosis due to the presence of some residual thyroid tissue which would become severely inflamed with I131 treatment. For these reasons, pre-treatment with prednisone has been decided upon, followed by external beam radiation. Depending on treatment response, second-line treatment with tyrosine-kinase inhibitors may be needed.  There are currently two immune-modulators being studied in patients with inoperable thyroid cancer who have failed RAI ablation, currently in phase 1 (1) and phase 2 (2) studies. The success of these approaches has yet to be determined. However, this would be a promising second line treatment modality for our patient, as this may hopefully address both her Reidel’s thyroiditis and PTC.

 

Nothing to Disclose: SS, SS

21279 15.0000 THR-058 A Management Conundrum: A Case of Inoperable Riedel's Thyroiditis Mingled with Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Zahily Sardinas*1, David S Rosenthal2 and Kenneth H Hupart3
1Nassau University Medical Center, East Meadow, NY, 2NUMC SUNY - Stony Brook, East Meadow, NY, 3Nassau Univ Med Ctr, East Meadow, NY

 

Anatomic and Tumor Marker Response to Vandetanib in a Patient with Aggressive Metastatic Medullary Thyroid Carcinoma (MTC)

Background:

Treatment success of MTC requires early diagnosis and treatment; only complete tumor resection is associated with the possibility of cure. Tyrosine Kinase Inhibitor(TKI) therapy has become available for patients with persistent or metastatic disease that has not been controlled surgically. We report a patient with sporadic MTC, metastatic at diagnosis, pursuing an aggressive course despite other therapies, in whom TKI therapy was associated with lesion regression and marked reductions in serum calcitonin and CEA.

Case:

21 yo female was diagnosed with MTC in Peru in 2012. She underwent total thyroidectomy and left radical neck dissection in January 2013 revealing a 6.5x5.4 cm MTC with vascular and lymphatic invasion and extension into the surrounding tissue. 12/16 left cervical lymph nodes revealed tumor. Preop calcitonin was 29,644 pg/ml, rising postoperatively to 50,204 pg/ml. In February EBRT was begun delivering a dose of 6000cGy to the left neck in 30 divided doses. Later she received one dose of Paclitaxil before she came to the USA and presented to our medical center in early October 2013. Calcitonin was 34,901pg/ml; CEA 736.1ng/ml. CT revealed a left upper paratracheal mass measuring 2.9 x 0.9 cm with non-critical tracheal compression and multiple pulmonary and subpleural nodules with bilateral hilar lymphadenopathy. In March 2014 Vandetanib 300mg a day was begun. After 7 months of treatment, calcitonin decreased to 704pg/ml, CEA to 223.3ng/ml. Follow up CT has shown  reduced pulmonary nodularity.

Discussion:

The recommended initial management of MTC is total thyroidectomy and central neck dissection. Conventional chemotherapy and RT have limited efficacy. Although there is no cure for advanced MTC, therapy targeting tyrosine kinase pathways has been shown to increase survival. Two TKIs, Vandetanib and Cabozantinib are approved by the FDA for MTC.

 Our patient had persistent, progressive disease which was not controlled with post-surgical RT. After 7 months on Vandetanib, improvement in disease control is evident biochemically and structurally. Calcitonin has dropped from 51,021 to 704 pg/ml, CEA from 736.1 to 223.3ng/ml, and structural improvement is seen on CT scans. This partial response to Vandetanib highlights the promise of this agent in this high mortality disease. Whether the magnitude of the biochemical response predicts the clinical response is still not determined.

 

Nothing to Disclose: ZS, DSR, KHH

21590 16.0000 THR-059 A Anatomic and Tumor Marker Response to Vandetanib in a Patient with Aggressive Metastatic Medullary Thyroid Carcinoma (MTC) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 044-059 6025 1:00:00 PM Thyroid Cancer Poster


Abdulghani Habib Alsaeed*1, Rania Ahmed Ahmed2, Ayman Al Hayek3, Sohail Inam4 and Fahad al Sabaan3
1Prince Sultan Military Medical City, Riyadh, Central Region, Saudi Arabia, 2Prince Sutan Military Medical City, Riyadh, Saudi Arabia, 3Prince Sultan Military Medical City, 4Prince Sultan Military Medical City, Riyadh, Saudi Arabia

 

Case study: Unusual challenging presentation of Graves’ disease; a middle-aged male with hyperthyroidism, hepatitis, electrolyte disturbances and leukopenia managed with carbimazole

Abdulghani Al-Saeed, Rania Ahmed, Ayman Al-Hayek, Sohail Inam, Fahad Al-Sabaan

Department of Endocrinology and Diabetes, PSMMC, Riyadh, Saudi Arabia

Introduction: Management of Graves’ disease if coincident with acute hepatitis and leukopenia is a therapeutic challenge. It has been well-known side of effect of carbimazole to cause leukopenia and hepatitis. So, management options get limited

Case study: A 49-year-old male presented with history of recurrent vomiting, generalized fatigue, subjective fever, and 15 kg weight loss over four weeks. Clinical examination revealed an emaciated middle-aged male who had clubbing, fine tremor, exophthalmos and lid lag. The pulse was 120/min, and it was regular, BP 160/51 mmHg. He had also a small diffuse goiter with bruit. Blood tests demonstrated high FT4 >100 pmol/L (NR 12-22), FT3= 27.9 pmol/L (3.1 - 6.8), TSH <0.005 uIU/mL (0.27 – 4.2), TSH receptor Antibody 22.68IU/L ( 0 -1.75), Cortisol 970 nmol/L, Sodium 123 ( 135-145), Potassium 2.9 (3.2-5.0, Magnesium 0.51 (0.74 – 1.00) nmol/L, White Blood cell Count (WBC) 2.8 10^9/l  (4-10), Neutrophils 1.2 (1.8 -7.5), Total Bilirubin 29 U/L ( 2 -21), Direct Bilirubin 4 ( 0-6), Alkaline Phosphatase 69 U/L ( 40- 129),Alanine Transaminase(ALT) 581 U/L (2-40), and Aspartate Transaminase(AST) 279.

Discussion: This patient was suffering from hyperthyroidism due to graves’ disease, with high liver enzymes, leukopenia, hypokalemia, hyponatremia, and hypomagnesaemia. A liver biopsy was performed which showed stage I-II portal fibrosis. The patient was thyrotoxic , so beta-blocker( Atenolol) was commenced, then  carbimazole was added with meticulous monitoring of  the liver function tests. The patient clinically felt better; the vomiting stopped, palpitation resolved and he started to gain weight. Biochemically,  ALT was gradually going down till it normalized, the WBC also increased till became within the normal range and electrolytes imbalance corrected. After a significant improvement in thyroid function tests, the patient underwent  total thyroidectomy. The postoperative course was uneventful and then the patient was discharged home with thyroxine in a satisfactory condition.

Conclusion: this case study demonstrates that graves’ disease may present with acute hepatitis, leukopenia, and electrolyte disturbances. These manifestations might resolve with anti-thyroid  drugs.

 

Nothing to Disclose: AHA, RAA, AA, SI, FA

20800 1.0000 THR-024 A Case Study: Unusual Challenging Presentation of Graves' Disease; A Middle-Aged Male with Hyperthyroidism, Hepatitis, Electrolyte Disturbances and Leukopenia Managed with Carbimazole 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Ryan Christopher Kennedy1, Michael I Anstead1, Umo U Eko1, William N O Conner1 and Kenneth Bruce Ain*2
1University of Kentucky, Lexington, KY, 2VA Medical Center & University of Kentucky, Lexington, KY

 

Background: Pediatric thyroid cancer, while rare, remains the most common endocrine malignancy in children. Initial presentation is frequently complicated by lymph node or distant metastases. Despite this, consequent to usually excellent radioiodine avidity, prognosis remains excellent, and thus aggressive treatment is often warranted.  

Objective/Purpose: We report the clinical outcome of a patient with T3 N1b M1 well differentiated papillary thyroid cancer diffusely metastatic to the lungs, treated with radioiodine (I-131), and subsequently developing pulmonary venocclusive disease (PVOD).

Clinical Features: A 12 year old girl presented to the pediatric ICU with a two week history of increasing dyspnea rapidly progressing to acute hypoxic respiratory failure necessitating mechanical ventilation.  She had recently been found to have papillary thyroid cancer complicated by neck and pulmonary metastasis, treated with thyroidectomy and radical neck dissection, then given adjuvant radioactive iodine ablation utilizing 154.6 mCi of I-131. Evaluation revealed acute respiratory distress syndrome with right ventricular failure from pulmonary hypertension. Despite the use of multiple pulmonary vasodilators and inotropic medications, her right heart failure continued to worsen and she was placed on comfort care with eventual terminal extubation.  Autopsy revealed histological features of venooclusive disease within the pulmonary vasculature along with metastatic papillary thyroid carcinoma.

Conclusion: PVOD is an extremely rare entity in children which has been associated with chemotherapy, total body irradiation in the setting of bone marrow and stem cell transplant, or certain genetic mutations. On review of the literature, no prior report of PVOD associated with differentiated thyroid cancer or the related treatment modalities could be identified. Thus further consideration of PVOD as a possible complication in this setting is warranted.

 

Nothing to Disclose: RCK, MIA, UUE, WNO, KBA

21295 2.0000 THR-025 A Venoocclusive Disease after Radioiodine Therapy of Distantly Metastatic Pediatric Papillary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


An VO1, Musa Sharkawi2, Noormuhammad Abbasakoor*3 and Lawrence M Crapo1
1Santa Clara Valley Medical Center, San Jose, CA, 2Lahey Hospital And Medical Center, Burlington, MA, 3Stanford Hospital and Clinics, Sunnyvale, CA

 

Background:
Pre-existing structural cardiac dysfunction or hypertensive heart disease may predispose the hyperthyroid patient to develop heart failure, resulting in respiratory failure; thus painting the manifestations of thyrotoxicosis like a thyroid storm.

Clinical Case:
A 59-year woman with a background history of hepatitis C, hypertension, alcohol abuse, hyperthyroidism status post partial thyroidectomy seven years ago presents to the emergency room with one day history of chest pain radiating to the jaw/left arm, palpitations, dry cough, diarrhea and weight loss for 2 months. Initial laboratory studies show suppressed TSH <0.01 (N 0.4-4.0), elevated free T4 2.9 ( N < 1.7), elevated free T3 636 and TSI 667. A few hours later, she decompensated and developed respiratory failure, requiring intubation. Aggressive treatment was started which included high dose methimazole ,propanolol and steroids . She was successfully extubated on the third day. She underwent cardiac catheterization which showed no obstructive coronary disease, and transthoracic echocardiography showed borderline-mild global hypokinesis, severe mitral regurgitation, severe left atrial enlargement, with ejection fraction of 53%.

Discussion:

Recurrence of hyperthyroidism after total thyroidectomy is 6 months to 50 years [1]. A thyroid storm is a life-threatening, extreme manifestation of thyrotoxicosis. Burch and Wartofsky have created a point system assessing the degree of dysfunction of the various systems (thermoregulatory, central nervous, gastrointestinal, cardiovascular); with a score 45 or higher suggestive of thyroid storm [2].It has been shown that long standing hyperthyroidism could cause Takotsubo cardiomyopathy or reversible stress-induced cardiomyopathy [3].

Physiologically, thyroid hormone has demonstrated enhancement of cardiac output and cardiac contractility[4]. This can be explained in patients with both severe and chronic hyperthyroidism in that exaggerated sinus tachycardia or atrial fibrillation can produce rate-related left ventricular dysfunction and heart failure [4]. This explains the observation that many patients with the combination of hyperthyroidism, low cardiac output, and impaired left ventricular function are in atrial fibrillation at the time of diagnosis. Hyperthyroidism is also associated with a high prevalence of pulmonary artery hypertension and right sided heart failure. β-adrenergic blockade to reduce heart rate should be first-line therapy in heart failure related to thyroid disease [5]. In patients with overt heart failure involving pulmonary congestion, the use of diuretics and angiotensin converting enzyme inhibitor is appropriate. Cure of the hyperthyroidism and a restoration of the euthyroid state frequently results in a reversion of the atrial fibrillation to sinus rhythm and a resolution of the cardiac manifestations [6].

 

Nothing to Disclose: AV, MS, NA, LMC

21464 3.0000 THR-026 A Thyroid Storm in the Setting of Prior Partial Thyroidectomy and Structural Cardiac Dysfunction. a Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Ravi Papu Manglani*1, Jigar Patel2 and Tasneem Zahra3
1Lincoln Medical Center, New York, NY, 2Lincoln Medical Center, 3Lincoln Medical Center, Roslyn Heights, NY

 

A case of thyrotoxicosis causing acute pericarditis

Introduction

Thyroid disease, either hyperthyroidism or hypothyroidism may manifest with cardiovascular complications such as congestive heart failure, atrial tachyarrhythmias, atrioventricular conduction disorders and pericardial effusion. Pericarditis secondary to thyroid disease is rare, (2,3,4,5) and there are only a few reported cases of this in literature. The cause is as yet uncertain, although some mechanisms have been postulated.

 Case report

The patient is a 42 year old male with Type 1 Diabetes and Hyperthyroidism presenting with sharp retrosternal chest pain since 3 days, worsening on leaning forward and deep inspiration decreasing on lying flat. His vitals on admission are significant for tachycardia. Physical exam is benign. Investigations revealed an undetectable TSH, an elevated T3 and T4 along with positive Thyrotropin binding immunoglobulin and Thyroid stimulating immunoglobulin. EKG revealed ST elevations in anterolateral leads and PR segment depression in inferior leads, typical of acute pericarditis.

An uptake scan to confirm the diagnosis could not be done as the patient was already taking methimazole. HIV as a cause of pericarditis was not explored, as the patient refused testing and self – reported negative for HIV.The patient did not have any prior antecedent illness in the weeks prior to the symptoms. A negative quantiferon and ESR ruled out tuberculosis as a cause of pericarditis. The patient was treated with Propranolol for the thyrotoxicosis and colchicine along with indomethacin for the pericarditis. The patient was followed in the out-patient clinic and is assymptomatic one year later.

Since other causes of pericarditis were reasonably ruled out, and the patient improved after treatment with methimazole, we ascribed the cause of the episode to be thyrotoxicosis.

Discussion

The co-existence of grave’s disease and Acute pericarditis has been demonstrated in rare cases but a common etiology has never been postulated. Possibly, pericarditis is part of the serositis from the systemic vasculitis process in patients, although it is difficult to establish a causal relationship between the two. Clarke et.al. proposed a mechanism similar to pretibial myxedema and ophthalmopathy as a possible cause of pericardial disease.(4) Nevertheless, more large scale studies are warranted in order to further elucidate the relationship between the two entities.

 

Nothing to Disclose: RPM, JP, TZ

18232 4.0000 THR-027 A A Case of Thyrotoxicosis Causing Acute Pericarditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Vishnu Vardhan Garla1 and Jose S. Subauste*2
1University of Mississippi Medical center, Jackson, MS, 2University of Mississippi Medical Center, Jackson, MS

 

Aim:

To report a rare case of seizures secondary to Graves disease.

Case description:

A 16 year old girl was transferred from an OSH to UMC for evaluation of seizures. Patient had two grand mal seizures five minutes apart witnessed by the mother.EMS was called and she was given narcan on the way. At the OSH she was confused and agitated with a systolic blood pressure >200. The patient was sedated and intubated and transferred to UMC.Prior to this episode ,she was seen by a physician for tooth ache and was prescribed antibiotics.

Upon arrival, the temp was 100.9, pulse of 128. Meningeal signs were negative. The patient was started on antibiotics and dexamethasone and a lumbar puncture was done. CSF culture showed no growth and the viral titres were also negative. EEG did not reval any epileptogenc foci.MRI was negative for structural anomalies. She was extubated the next day.

Endocrine was consulted for management of  severe hyperthyroidism/thyroid storm as her TSH was <0.01 and free t4 was >7.7. Examination was significant for enlarged thyroid with bruit, exophthalmos and weakness in  her proximal extremities (2/5). She was started on propylthiouracil then changed to methimazole, hydrocortisone, pottassium iodide and metoprolol. She did extremely well and her mental status and strength improved (4/5) by the next day.Thyrotropin receptor antibody and thyroid stimulating immunoglobulin were positive confirming the diagnosis of Graves disease. She was sent home on methimazole and metoprolol.

Further it was revealed that the patient had been diagnosed with “tachycardia” about 2 years ago and was started on metoprolol. A few months ago she was also admitted to a psychiatry facility for depression. All of these indicatethat this may have been a chronic problem.

Unfortunately the patient has not shown up for folllow up appointments.

Discussion:

Thyrotoxicosis can cause hyperexcitation, irritability and changes in consciousness. It can also precipitate seizures in a small percentage of patients. The prevalece varies from 0.2% to 9%. Although the exact mechanism is not known, however lowered TRH in the limbic part of the brain has been implicated as a cause. The EEG findings were either normal or showed a generalized slowing of wave forms. The prognosis is usually very good once a euthyroid state is achieved.

Conclusion:

Thyrotoxicosis is  a rare cause of seizures and physicians need to keep this differential in mind especially if there is a history suggestive of hyperthyroidism.

 

Nothing to Disclose: VVG, JSS

18677 5.0000 THR-028 A A Rare Case of Seizures Secondary to Graves Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Chantal Lewis*, Olga Achildi and Stephen G Rosen
Pennsylvania Hospital, Philadelphia, PA

 

Intramuscular Levothyroxine Treatment in a Hypothyroid Patient with Acute Psychosis.  Chantal Lewis, Olga Achildi, and Stephen Rosen.  Pennsylvania Hospital and the University of Pennsylvania Health System.  Philadelphia, PA 19107.

Background:   Oral synthetic levothyroxine (LT4) is the standard of care for replacement therapy in hypothyroidism.  There are rare patients who do not tolerate or refuse oral treatment.  Intramuscular LT4 treatment has been described in a hypothyroid patient with malabsorption.  We report the clinical improvement after intramuscular LT4 treatment in a hypothyroid patient with acute psychosis who refused oral replacement therapy.

Clinical case: A 71-year-old woman with a history of schizophrenia, hypertension and hyperlipidemia was brought by police to Pennsylvania Hospital after exhibiting disruptive behavior in public.  On admission, this hostile and uncooperative woman provided limited information.  In the Emergency Department, she was treated for hypertensive urgency and multiple abrasions on her face and limbs.  On psychiatric admission, intramuscular antipsychotics were initiated for management of acute psychosis after she refused intravenous and oral medications.  Hypertension control was inadequate despite intramuscular hydralazine.  Serum chemistries, urine drug screen, serum levels of vitamin B12 and folate, blood and urine cultures, and brain CT scan were all normal. Her serum levels of free thyroxine, TSH, and antithyroid peroxidase antibodies were 0.72 ng/dL (normal range 0.93-1.70 ng/dL), 60.39 mU/L (normal range 0.27-4.20 mU/L), and 459 U/mL (normal range <20 U/mL), respectively.  Her thyroid ultrasound showed a small heterogeneous gland with no discrete thyroid nodules and normal vascularity. She was diagnosed with primary hypothyroidism secondary to Hashimoto’s thyroiditis.  As the patient agreed only to intramuscular medications with no change in clinical condition, intramuscular LT4 treatment was initiated.  She received an initial 350 mcg dose followed by 250 mcg twice weekly.  Her dose was gradually escalated to 400 mcg twice weekly that caused a progressive decrease in serum TSH to 1.67 mU/L.  She had gradual mood improvement and began to accept oral medications.   After she was changed to oral LT4 112 mcg daily, her serum TSH concentration remained stable at 2.42 mU/L. There was mood improvement although she remained paranoid.  Her hypertension was controlled adequately with oral amlodipine and lisinopril.

Conclusion: Twice weekly intramuscular LT4 treatment is a safe and effective long-term option in a hypothyroid patient who is unwilling or unable to tolerate standard oral replacement therapy.

References

Anderson, L, Joseph F, Goenka N, Patel V.  Isolated Thyroxine Malabsorption Treated with Intramuscular Thyroxine Injections.  Am J Med Sci.  2009; 337:150-2.

 

Nothing to Disclose: CL, OA, SGR

18868 6.0000 THR-029 A Intramuscular Levothyroxine Treatment in a Hypothyroid Patient with Acute Psychosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Maryam Sharifi*, Christina M Lovato and Patricia L Kapsner
University of New Mexico Health Sciences Center, Albuquerque, NM

 

Background: Thyroid storm is a rare condition characterized by high levels of circulating thyroid hormones, usually precipitated by endogenous or exogenous critical events, illness/ injury, acute iodine load, thyroid or non-thyroid surgery; it can lead to multi-organ failure and carries a significant mortality rate. It is usually treated with thionamides, iodine, steroids and beta-blockers.  Rarely additional interventions are necessary and can be lifesaving (1, 2).

Clinical case:  We present a 53-year-old male with no significant past medical history who presented to the emergency room with shortness of breath and palpitations. He was found to have bilateral eye proptosis, atrial flutter and hypertension. He was started on diltiazem, however, subsequently developed confusion, fever, tachycardia and cardiogenic shock requiring vasopressors and intubation. Initial labs were suggestive of thyrotoxicosis in the setting of Graves’ disease with TSH below the level of detection (< 0.007 UIU/ml, nl 0.385-3.740 UIU/ml), high free T4 (5.8 ng/dl, nl 0.7-1.6 ng/dl), elevated total T3 (240 ng/dl, nl 55-172 ng/dl), high TSI (370 %, nl <122%), and high TSH receptor Ab (>40 IU/l, nl <1.75 IU/l). Patient was started on methimazole, hydrocortisone, potassium iodide and propranolol. Cultures were negative.   Liver enzymes were normal on admission however increased to greater than five times the upper limit of normal over the next few days.  He continued to deteriorate clinically with persistent fever and inability to adequately control ventricular rate in spite of optimal medical therapy.  Re-evaluation showed no source of infection. Methimazole was discontinued and plasmapheresis was initiated. Patient received plasmaphresis on hospital days 4, 5, 6 and 9.  Thyroid function tests and antibody levels were repeated before and after each plasmapheresis session with significant improvement in not only his thyroid function tests and antibody levels but also in clinical status. His cardiogenic shock, confusion, fever, and tachycardia resolved and he was extubated. Patient underwent total thyroidectomy on day 10 and was discharged home on levothyroxine.

Conclusion: This case illustrates the use of plasmapheresis as a life saving measure in thyroid storm in a critically ill patient who continued to deteriorate on acceptable therapy, and developed significant elevations in transaminases while on methimazole.  We will review the use of plasmapheresis in the setting of thyroid storm.

 

Nothing to Disclose: MS, CML, PLK

19392 7.0000 THR-030 A Thyroid Storm Successfully Treated with Plasmapheresis and Thyroidectomy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Mary-Anne Doyle*, Bertha Wong and Amel Arnaout
University of Ottawa, Ottawa, ON, Canada

 

Background: Moyamoya disease (MD) is a rare cause of chronic progressive cerebral vasculopathy in children and young adults with an incidence ranging from 0.086 to 0.35 per 100000. In a very small subset of patients, moyamoya syndrome (MMS) has been described in association with distinct clinical conditions, such as Graves’ disease (GD).

Clinical Case: We present the case of a 25-year-old right-handed woman of Chinese descent who presented with acute-onset dysphagia, severe global aphasia, right facial droop, and right-sided motor weakness on a background of several months’ history of heat intolerance. She was previously healthy except for a history of “thyroid dysfunction” detected on blood work a year ago which was never treated. She did not have a goiter or exophthalmos on exam. MRI brain showed an acute infarct in the left MCA territory with involvement of the basal ganglia, corona radiata and centrum semiovale. Both MRA and cerebral angiography revealed severe bilateral stenoses of the proximal ICA with left-sided occlusion as well as bilateral narrowing of the proximal MCA and ACA, suggestive of MMD. She did not have a family history of MMD.

Extensive investigations for autoimmune and hypercoagulable conditions, including C3, C4, RF, and ANCA were negative. Unexpectedly, laboratory blood work revealed low TSH (0.14 mU/L, N = 0.30 – 5.60 mU/L) and significantly elevated free T4 and free T3 levels (62.1 pmol/L, N = 7.0 – 17.0 pmol/L and 19.4 pmol/L, N = 3.3 – 7.6 pmol/L respectively). Both anti-thyroid receptor and anti-TPO antibodies were positive (9 U/L, N ≤ 1 U/L; 224 kIU/L, N ≤ 6 kIU/L).

She was diagnosed with GD and started on Methimazole. Beta-blockade was not started for sinus tachycardia to avoid cerebral hypoperfusion. Her neurologic deficits improved over the course of her hospitalization. Despite her complete neurologic recovery, repeat CT angiogram two months later showed persistent multiple proximal occlusions of the ICA, MCA, and ACAs.

Clinical Lessons: This case illustrates the interesting rare coexistence of MMS and GD, where cerebrovascular events arise during a thyrotoxic state. Elevated thyroid hormones and thyroid autoantibodies are hypothesized to play a pathogenic role in the evolution of MMS. Clinicians should be aware of this association as traditional beta-blockade treatment for GD may result in cerebral hypoperfusion. Furthermore, early recognition of the disease and prompt initiation of antithyroid therapy is crucial. Antithyroid therapy rather than surgical revascularization alone is considered the initial first-line therapy for GD-associated MMS as antithyroid medications may stabilize and even reverse ischemic symptoms. Should surgical intervention be required, an optimized thyroid state has been positively correlated with improved perioperative outcomes.

 

Nothing to Disclose: MAD, BW, AA

19647 8.0000 THR-031 A A Thyrotoxic Puff of Smoke Leading to Stroke in the Young: Therapeutic Implications of Moyamoya Disease with Concomitant Graves' Thyrotoxicosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Anitha Somasundaram1, Melinda Ukrainski1, Intekhab Ahmed1 and Joseph James Fallon Jr.*2
1Thomas Jefferson University Hospital, Philadelphia, PA, 2Inspira Medical Center, Woodbury, Marlton, NJ

 

Background: In patients with metastatic melanoma, Ipilimumab, an antibody blocking cytotoxic T-Lymphocyte antigen 4 (CTLA-4), and pembrolizumab, a programmed death-1 (PD-1) molecule inhibitor, increase immunologic rejection of the tumor by enhancing the immune response (1). However, these immune check point inhibitors also cause side effects described as “immune-related adverse events” (IRAEs). We describe a patient, who developed thyroiditis and pancreatitis following treatment with ipilimumab and pembrolizumab.

Clinical case: 45 year old Caucasian female with a history of stage III melanoma of scalp and hypertriglyceridemia presented to ED with abdominal pain, intractable nausea, vomiting, and watery diarrhea over 2 weeks. In addition, review of symptoms was significant for fatigue, decreased oral intake, and 16 lb weight loss. Despite wide excision of her scalp lesion, her melanoma recurred and she underwent treatment with chemotherapy, including 3 out of 4 cycles of ipilimumab and subsequently 5 cycles of pembrolizumab. Her last infusion of pembrolizumab was a week prior to her presentation. She was taking fenofibrate 135 mg daily.

On exam, her BMI was 25.4, BP was 106/51 and HR was 103/min.  She had multiple scalp lesions. There was no thyroid enlargement or tenderness and no hand tremors.

Labs revealed ESR of 52 (0-20 mm/h), CRP 12.9 (0-0.9 mg/L) bicarbonate of 15 (24-32 mEq/L), ALP of 131 (38-126 U/L), AST of 64 (14-36 U/L), triglycerides of 168 (10-150 mg/dL), lipase of 1880 (23-300 U/L). TSH was 0.015 (0.465 4.68 mIU/L) with free T4 of 3.81 (0.78 – 2.19ng/dL), free T3 of 8.9 (2.77 -5.27 pg/mL). Thyroperoxidase antibodies was 4.7 (0-9 IU/cc), thyroglobulin antibodies was <0.9 (0-4 IU/cc) TSI was 105 % (<125 %). Thyroid ultrasound revealed normal texture gland. Patient was admitted and received intravenous fluids. CT of abdomen and pelvis demonstrated mild thickening of right colon wall. PET scan showed mild increased uptake in right thyroid and pancreas. Based on her clinical symptoms, lab and imaging results, a diagnosis of thyroiditis and pancreatitis was made, presumably autoimmune response to her chemotherapy.  She was started on methylprednisolone intravenously, with significant clinical improvement. She was discharged on metoprolol and prednisone taper.

Conclusion: Though rare, thyroiditis has been described as a side effect of anti-cancer immunotherapy. Polymorphism in CTLA4 gene confers increased susceptibility to variety of autoimmune thyroid disorders (2). Exact mechanism of IRAEs from pembrolizumab still remains to be elucidated; however, they are inflammatory in nature and may represent a breakdown of tolerance to self-antigens. Monitoring of thyroid and pituitary function at baseline and before each cycle is required, and medication discontinuation may be required.

 

Disclosure: JJF Jr.: Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Astra Zeneca, Scientific Board Member, Abbott Laboratories, Speaker Bureau Member, Takeda, Speaker Bureau Member, Vivus USA. Nothing to Disclose: AS, MU, IA

19678 9.0000 THR-032 A Ipilimumab and Pembrolizumab Induced Thyroiditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Mohsen Tabrizi*1, Maryam Sharifi2 and Matthew Frederick Bouchonville1
1University of New Mexico School of Medicine, Albuquerque, NM, 2University of New Mexico Health Sciences Center, Albuquerque, NM

 

Background: Traumatic brain injury (TBI) may result in significant impairment of thyroid function tests (TFTs) manifesting mainly as low T3 and TSH which may be transient.

Clinical case: A previously healthy 29-year-old female was involved in a motor vehicle accident.  She developed skull, spine and pelvic fractures as well as a subdural hematoma. Prior to admission, she had not been on any thyroid medications.  

On day 4 after TBI, she was found to have low TSH 0.06 (Ref. range 0.358-3.74 μIU/mL), low Free T3 1.4 (Ref. range 1.7-5.2 pg/mL) and normal Free T4 1.1 (Ref. range 0.7-1.6 ng/dL). MRI of the brain did not reveal any pituitary lesion. On day 6 after TBI, TSH 0.061 was still suppressed and she had low Total T3 37 (Ref. range 55-172 ng/dL). On day 6 after TBI, result of prolactin 12.3 (Ref. range 2.8- 29.2 ng/mL), ACTH 18 (Ref. range 0- 46 pg/mL) and repeat Free T4 0.9 were within normal limits. One week after TBI, the patient had a normal TSH 0.615, low Total T3 32 ng/dL (Ref. range 55-172 ng/dL) and normal Free T4 0.8. Two weeks after TBI, the patient had a normal TSH 0.981 and normal Free T4 1.2. The patient did not require any thyroid medications during her hospital stay. The differential diagnoses included: sick euthyroid syndrome vs transient thyroid function tests alteration after traumatic brain injury. The unique pattern of TFT alteration associated with TBI made the latter diagnosis more likely. 

Conclusion:  Having the knowledge of the pattern of transient TFTs alteration after TBI is very important for proper managment of these patients who are often in critical condition. We will present a review of the literature including suggested pathophysiology, prognostic indicators and therapeutic interventions related to transient TFTs alteration after TBI.

 

Nothing to Disclose: MT, MS, MFB

19706 10.0000 THR-033 A A Case of Transient Thyroid Function Test Alteration after Traumatic Brain Injury 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Nirali Shah*1, Erika Villanueva2 and Caroline Korsten Messer2
1Icahn School Of Medicine at Mount Sinai, New York, NY, 2Icahn School of Medicine at Mount Sinai, New York, NY

 

Introduction

Thymic hyperplasia is a relatively common and reversible phenomenon associated with Graves’ disease (GD).   Concern for malignancy leads to unnecessary procedures (fine needle core biopsy) and complications.  We present a case report of a patient with GD found to have an anterior mediastinal mass on CT imaging.   

Case

A 31 year old female with history of asthma was referred to endocrinology for evaluation of hyperthyroidism.  Initially, she presented with abdominal pain, diarrhea, heat intolerance, chest pain, tremors and a 15 pound weight loss over an 8 week period.  Subsequent workup was consistent with Graves’disease including TSH <0.016 uIU/ml, FT4 of 6.99 ng/dl, TT3 of 3.6ng/ml and positive TSH receptor antibodies.  Thyroid ultrasound revealed an enlarged and hypervascular thyroid gland consistent with Graves’ disease.  Methimazole 10mg twice daily and propranolol LA 80 mg daily were initiated.  CT abdomen/pelvis performed to evaluate abdominal pain and weight loss revealed possible pericardial effusion/thickening and subsequent CT chest showed an anterior mediastinal mass, which was further evaluated with PET scan.  Pet scan showed enlarged hypermetabolic thymus.  Patient underwent CT guided biopsy of the thymic mass to rule out malignancy which was complicated by left hemothorax requiring percutaneous drainage post op. 

Pathology results were consistent with a thymic process and not a lymphomatous disorder.   Given the radiographic appearance, the patient’s concomitant autoimmune thyroid disease and the biopsy results, this likely represented evidence of thymic hyperplasia and not thymoma.

Patient’s hyperthyroidism was managed with six months of methimazole followed by 10mCi I-123 radioactive iodine ablation for definitive therapy. Follow up CT imaging showed resolving thymic hyperplasia (31% decrease) after 5 months of methimazole therapy.   

Discussion:

This case illustrates the association between GD and the benign course of thymic hyperplasia.  The underlying etiology may related to thyrotropin receptors in thymus tissue which are stimulated by the autoimmune antibodies present in GD.  The true incidence of massive thymic hyperplasia is unknown because mediastinal imaging is not routinely performed in these patients.

There are no current guidelines for surveillance of thymic hyperplasia in GD, because the expected timeline of thymic hyperplasia regression after treatment is unknown.  Thymic biopsies are performed to evaluate for malignancy, but it is important to note that there is no known increased risk of malignancy in GD patients with thymic hyperplasia.  Raising awareness of the benign course and resolution of GD-associated thymic hyperplasia with GD treatment can avoid unnecessary procedures and complication risks.

 

Nothing to Disclose: NS, EV, CKM

19956 11.0000 THR-034 A Graves' Disease and Thymic Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Vicente T. San Martin Montenegro*, Ana M. Kausel, Gregory B. Dodell and Edward Colt
Mount Sinai St. Luke's and Mount Sinai Roosevelt Hospitals, New York, NY

 

Background: Acute suppurative thyroiditis caused by H. influenzae is exceedingly rare, with only a handful of documented cases. A very uncommon complication of acute suppurative thyroiditis is thyroid abscess formation.

Clinical case: 55-year-old woman with a history of multinodular goiter. She had undergone two FNAs with benign results. She presented after an acute increase in the size of her thyroid associated with neck pain. She was tachycardic (145 beats/min) and febrile (101.7 F). Neck examination revealed an enlarged tender thyroid, with a firm nodule occupying two-thirds of the left lobe and a soft nodule in the right lobe. Initial labs showed leukocytosis (WBC 12.2, 88.1% neutrophils), an elevated ESR (78 mm/hr), an elevated CRP (31.1 mg/dL), suppressed TSH (0.26 mIU/mL), normal free T3 (2.6 pg/mL) and normal free T4 (1.36 ng/dL). TSHR and anti-TPO antibodies were within normal limits. She was started on propranolol and ibuprofen for suspected thyroiditis. Ultrasound revealed a 5.8 x 4.3 x 5 cm nodule occupying most of the left thyroid lobe and a 1.2 x 0.8 x 1 cm nodule at the mid level of the right lobe. Culture from the left nodule aspirate grew H. influenzae beta lactamase positive. Blood cultures grew the same organism and the patient was started on Ceftriaxone. The patient had no other source of infection and the rest of her workup was negative. A neck CT showed a massively enlarged mixed-attenuation left thyroid lobe containing small areas of abscess formation. A radioactive iodine uptake was compatible with severe thyroiditis. A laryngoscopy was performed and showed no anatomical defects. The patient continued to be tachycardic and to spike fevers. Propranolol was increased to its maximum dose and the antibiotic coverage was broadened to Imipenem. Free T3 and free T4 persistently continued to increase, reaching a peak of 7.1 pg/mL and 4.1 ng/dL, respectively. The patient was started on cholestyramine and her thyroid hormone levels eventually normalized, but her fevers and neck pain continued. Finally a left hemithyroidectomy was performed and the pathology demonstrated an extensively infarcted adenomatoid nodule, showing acute and chronic inflammation with abscess and granulation tissue formation. No anatomic variants were found. There were no procedural complications and the patient was discharged one day after surgery.

Conclusion: Acute suppurative thyroiditis should be considered in any patient with known thyroid abnormalities who presents with neck pain. The etiology of H. influenzae-related thyroiditis in our patient is unclear, but may be related to hematogenous spread in the setting of bacteremia from a previous subclinical infection. Early diagnosis of this entity is vital to guide the proper antimicrobial therapy and the required surgical interventions.

 

Nothing to Disclose: VTS, AMK, GBD, EC

20198 12.0000 THR-035 A Haemophilus Influenzae As a Rare Cause of Acute Suppurative Thyroiditis with Thyroid Abscess Formation in a Patient with Pre-Existent Multinodular Goiter 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Hani Shalabi*1 and Hussein Saad Elbadawi2
1Wayne state university, Detroit, MI, 2Wayne State University, Detroit, MI

 

Background : Myxedema coma is usually associated with high TSH levels unless it is due to secondary hypothyroidism. We describe a patient who presented with the typical features of myxedma coma with mildly elevated TSH secondary to non-thyroidal illness. This has not been reported yet.

Clinical Case: A 62-year-old male with a history of end stage renal disease, recurrent squamous cell cancer of the neck and primary hypothyroidism from neck radiotherapy on levothyroxin 100 mcg daily. He was treated for C. difficile and discharged from a different hospital three days prior to presentation to our emergency department where he was found upon arrival to be unresponsive, hypotensive, hypothermic and hypoglycemic with glucose level of 17mg/dl. The patient has a history of medication noncompliance and was admitted 3 months prior with severe hypothyroidism with thyroid function tests showing TSH: 51.3 micro IU/ml (Ref. Range 6.2 - 14.6), Free (T4) 0.3 ng/dl (Ref. Range 0.8 - 1.8). He was well thereafter until this recent admission.

Vital signs: Rectal temperature: 31.7 °C, BP: 109/79, Pulse: 78, Respiratory Rate: 22, Physical exam: Glasgow coma scale of: (7), Stuporous typical features of hypothyroidism, markedly delayed relaxation phase of deep tendon reflexes, cool dry skin, a palpable non-enlarged thyroid gland without nodules, Cardiovascular auscultation with muffled, heart sounds and a regular rate and rhythm with no additional sounds and pedal edema.

Per the scoring system  of Geanina Popoveniuc, et al.(1) for myxedema coma he scored  >60 so empiric treatment was started immediately after blood samples were drawn and was given IV hydrocortisone 100 mg , IV Levothyroxine 250 mcg , broad spectrum antibiotics IV in addition to IV  D10w 50 ml/h for refractory hypoglycemia. Blood tests showed  ACTH  177 pg/ml (Ref. Range 7 - 69) ,random Cortisol  97.8 mcg/dl , Total T3  <10 ng/dl (Ref. Range 60 - 180), (Total T4) 4.5 mcg/dl (Ref. Range 6.2 - 14.6) ,(T4- Free) 0.6 ng/dl (Ref. Range 0.8 - 1.8), TSH 7.899 micro IU/ml (Ref. Range 0.200 - 4.780) , sulfonylurea and insulin screening  were negative ,EKG showed extremely low voltage across the standard limb and precordial leads. Chest x-ray showed cardiomegaly with amount of vascular congestion and pleural effusions. CTscan of the brain showed chronic subdural hematomas. Blood Cultures were negative.

Within 24 hours of therapy the patient’s temperature went up to 36°C, he became more responsive and started communicating minimally. We continued levothyroxine 100 mcg IV daily, repeated thyroid function after 3 days showed: T3 - Free 0.9 ng/dl, Thyroxine - Free 1.6 ng/dl   (TSH) 1.496 micro IU/ML.

 The patient expired on the fifth day as he developed cardiac arrest.

Conclusion: Myxedema coma is a clinical diagnosis and biochemical evidence can support the diagnosis but is not essential. We find this case a good example to show that not every myxedema coma case requires a very high TSH level.

 

Nothing to Disclose: HS, HSE

20339 13.0000 THR-036 A Myxedema Coma in a Patient Recovering from Non Thyroidal Illness Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Uzma Mohammad Siddiqui*, Anupam Kotwal and Shirin Haddady
University of Massachusetts Medical School, Worcester, MA

 

Introduction:Hypercalcemia in the setting of hyperthyroidism has been reported, but not commonly seen.  The mechanism is most likely due to increased osteoclastic activity mediated by thyroid hormones. It has been estimated that approximately 17% of hyperthyroid patients may be hypercalcemic. Hereby, we report a patient with thyrotoxicosis and severe hypercalcemia. Initially, thyrotoxicosis was thought to be the cause of hypercalcemia. Hypercalcemia improved, but did not resolve completely after establishment of euthyroid status. Careful work up revealed another underlying condition contributing to hypercalcemia.

Clinical Case:A 71 year old female with a history of hypertension and hypothyroidism was admitted to an Emergency Department (ED) with disorientation, constipation, palpitations and dizziness. Laboratory investigation revealed a calcium of 14 mg/dL (normal: 8.4-10.2) and a suppressed thyroid stimulating hormone (TSH) of 0.02 mIU/L (normal: 0.35-5.50). Parathyroid hormone was found to be lower than 3 pg/mL (normal: 10-65). The results of serum protein electrophoresis, angiotensin converting enzyme, vitamin A, vitamin D, parathyroid hormone related protein, alpha fetoprotein and Ca 19-9 were unremarkable. CT scans of head, chest, abdomen and pelvis did not reveal any abnormality, except for left axillary lymphadenopathy. Prior to admission, the patient had been taking dessicated (Armour) thyroid hormone for hypothyroidism and hydrochlorothiazide for hypertension. She was treated with intravenous fluids, furosemide, calcitonin and pamidronate. It was concluded that her hypercalcemia was due to thyrotoxicosis and hydrochlorothiazide use. Her Armour thyroid and hydrochlorothiazide were stopped and serum calcium level improved to 9.9 mg/dL; she was discharged from the hospital and referred to Endocrinology Clinic for further management. In follow up- euthyroid state was established by resuming thyroid hormone replacement by Levothyroxine. However, her serum calcium started to rise and was found to be as high as 11.5 mg/dL in three months. Measurement of 1,25dihydroxy vitamin D showed a high level of 130 pg/mL (normal: 19-67). She then had a biopsy from an enlarged left-sided axillary lymph node that had been found initially by CT scans in the ED and was diagnosed with a B-cell Lymphoma.

Conclusion:This case signifies how a period of thyrotoxicosis unmasked hypercalcemia in a previously eucalcemic patient, and this led to the diagnosis of a lymphoma. Serum calcium levels should be followed after improvement of hyperthyroidism to ensure no additional underlying reason for hypercalcemia, specially if the plasma calcium concentration does not normalize within eight weeks. Also, the treatment of hypercalcemia in such patients may be improved with the early administration of calcitonin .

 

Nothing to Disclose: UMS, AK, SH

20773 14.0000 THR-037 A Hypercalcemia Due to Lymphoma : Unmasked in the Setting of Thyrotoxicosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Ling Zhu*, Tunn Lin Tay and Joan J C Khoo
Changi General Hospital, Singapore, Singapore

 

Background

Thyroid disorders and diabetes have an intertwined relationship. Observational studies demonstrate a higher prevalence of thyroid disorders in diabetic patients, particularly those with type 1 diabetes. Hyperthyroidism, for instance, can worsen glycaemic control by reducing the half-life of insulin and promoting enteric absorption of glucose.

Case Report

A 53 year old male with type 1 diabetes diagnosed at age 17 presented with three days of fever and dizziness. His capillary blood glucose record revealed hyperglycaemia for two days, with frequent post-prandial excursions to more than 20 mmol/L, despite good compliance with diet and insulin. His HbA1c ranged from 6.9% to 8.1% in the three years prior to the admission. Apart from microalbuminuria, there were no other micro- or macrovascular complications of diabetes. Serum dengue NS1 antigen and dengue IgM were positive, indicating acute dengue viral infection. HbA1c had risen from 7.2% to 9.7% in three months. Full blood count, renal and liver function tests were unremarkable. He was given supportive treatment, and insulin doses were increased. However, glycaemic control did not improve with resolution of dengue. There was no evidence of other infections. He had no recent weight change, no Cushingoid features and denied the use of steroid-containing substances. Further investigations for the cause of hyperglycaemia revealed thyrotoxicosis with free T4 of 26.46 pmol/L [NR 10 – 20 pmol/L], free T3 6.53 pmol/L [NR 2.6 – 5.7 pmol/L], and suppressed TSH of 0.007 mIU/L. TSH receptor antibodies were negative. ESR was elevated at 51 mm/h [NR 1 – 10 mm/h]. Tc-99m pertechnetate thyroid uptake scan showed diffusely reduced tracer uptake throughout both lobes, suggestive of subacute thyroiditis. Neck examination was unremarkable. He denied symptoms of thyroiditis and thyrotoxicosis on retrospective questioning. A repeat thyroid function test six weeks later revealed free T4 of 7.92 pmol/L and TSH of 0.493 mIU/L, without the use of antithyroid drugs. Over this period of time, his previous insulin regime could be resumed with good glycaemic control, demonstrating that transient hyperglycaemia was due to high circulating levels of preformed thyroid hormone rather than ongoing hyperthyroidism.

Conclusions

The present case illustrates the importance of excluding thyrotoxicosis as a cause of worsened glycaemic control even in the absence of classical signs and symptoms. The association between dengue fever and subacute thyroiditis is not clear, but given the significant increase in HbA1c and hyperglycaemia preceding the onset of illness, it is possible that subacute thyroiditis, rather than dengue fever, may have been the root cause of the deterioriation in glycaemic control.

 

Nothing to Disclose: LZ, TLT, JJCK

20976 15.0000 THR-038 A Thyroiditis As a Silent Cause of Hyperglycaemia in Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Denise Auberson*, Prathap Naini, Corrina Oxford-Horrey and Stephen G Rosen
Pennsylvania Hospital, Philadelphia, PA

 

Molar Pregnancy Complicated by Thyroid Storm.  Denise Auberson, Prathap Naini, Corrina Oxford-Horrey, and Stephen G. Rosen.  Departments of Medicine and Obstetrics and Gynecology.  Pennsylvania Hospital and the University of Pennsylvania Health System.  Philadelphia, PA 19107.

Background:  Gestational trophoblastic disease is a proliferative disorder of trophoblastic cells.  Molar pregnancy occurs in 0.1% of pregnancies in the United States.  Hyperthyroidism is a rare complication of molar pregnancy.  There are five reported cases of thyroid storm complicating molar pregnancy.  We report the case of thyroid storm complicating new-onset hyperthyroidism in a pregnant woman who was found to have a molar pregnancy. 

Clinical case: A 39-year-old woman with no history of thyroid disease was admitted to an outside hospital with fatigue, tachycardia, palpitations, and diaphoresis at week 19 of her fifth pregnancy.  She was found to have hyperthyroidism.  As she met criteria for thyroid storm, she was started on methimazole and dexamethasone.  Three days after discharge, she was admitted to Pennsylvania Hospital with fatigue, tachycardia, palpitations, peripheral edema, abdominal pain, nausea, and diaphoresis.  Her family history was positive for thyroid disease (father).  Physical examination was significant for a heart rate of 104 beats/min and regular and a blood pressure of 172/92 mmHg.  Her temperature was 99.2F.  Her thyroid gland was mildly enlarged; no bruits were audible.  Cardiopulmonary examination was normal.  There was 1+ peripheral edema.  Her deep tendon reflexes were brisk.  A fine tremor was present.   Laboratory testing revealed serum levels of free thyroxine and TSH of 3.17 ng/dL (normal range 0.93-1.70 ng/dL) and 0.01 mU/L (normal range 0.27-4.20 mU/L), respectively.  Her serum HCG concentration was 8934 mIU/mL (normal range 9,649-55,271 mIU/mL at week 18).   Her thyroid storm score was 45 based on Wartofsky and Burch criteria.  Methimazole was increased, dexamethasone was continued, and iodine and propranolol were started.  Obstetrical ultrasound was consistent with a molar pregnancy.  Her repeat serum HCG concentration with manual dilution was 1,000,000 mIU/mL.  Her pregnancy was terminated.  Her symptoms resolved as methimazole, iodine and dexamethasone were discontinued.  Her serum free thyroxine concentration was 1.00 mU/L at discharge.

Conclusion: Molar pregnancy should be considered with the abrupt onset of hyperthyroidism or thyroid storm in a pregnant woman.  Her initial low serum HCG concentration was consistent with “hook effect” observed with the 2-site immunometric sandwich assay using electrochemiluminescence detection.  This effect occurs when the serum antigen level is so high that there is not enough labeled antibody to attach to all of the antigen, leading to antigen wash-out.  A normal serum HCG level from this assay must be confirmed with manual dilution in these women.

 

Nothing to Disclose: DA, PN, CO, SGR

21550 16.0000 THR-039 A Molar Pregnancy Complicated By Thyroid Storm 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Maria T Vamvini*1, David Miller1 and Raffaella M Colzani2
1Mount Auburn Hospital, Cambridge, MA, 2Mount Auburn Hospital, Waltham, MA

 

Introduction:PTU is known as a potent trigger for the formation of antineutrophilic cytoplasmic antibodies (ANCA) and subsequent development of vasculitides whereas ANCA positivity and related vasculitis is rare with use of methimazole (MMI). We report herein the case of a patient with Graves’ disease with MMI induced MPO ANCA related lung vasculitis.

Clinical case: A 61-year-old Asian female with recent diagnosis of Graves’ disease treated with methimazole for 11 months (20mg daily) presented with persisent nonproductive cough, not responding to antibiotics for presumed bronchitis. The physical exam was unremarkable but chest x-ray showed diffuse reticular and nodular opacities with CT scan of her chest confirming the presence of new diffuse bilateral poorly formed nodular opacities in a broncho-vascular distribution. Laboratory tests were significant for elevated MPO ANCA titers (443 AI). BAL revealed multiple reactive bronchial cells, macrophages and many acute inflammatory cells including eosinophils. Tissue from a trans-bronchial biopsy showed nonspecific intra-alveolar hemorrhage but did not confirm the presence of vasculitis. A diagnosis of lung vasculitis was presumed based on the characteristic radiological and immunological findings, given the low sensitivity of transbronchial biopsy for vasculitis. A drug-induced mechanism was considered as a possible cause with MMI being the culprit medication. One month after MMI withdrawal, MPO ANCA titers decreased with concomitant resolution of imaging findings. Given her rapid clinical improvement, and resolution of her radiologic findings, treatment with steroids was not pursued. For the same reason, an open lung biopsy, which is most sensitive test for establishing the diagnosis of vasculitis, was not performed.

Conclusions: ANCA vasculitis is a rare side effect of MMI treatment. Noh et al had calculated the incidence of MPO ANCA vasculitis for PTU as 39.2 times higher the one for MMI (1). Our case is unique since the patient presented with mild respiratory symptoms but significant radiological findings. Although there is a limitation in inferring causation in the development of MPO ANCA vasculitis to MMI, the decrease of ANCA titer and the rapid resolution of laboratory and imaging findings after withdrawal of MMI are suggestive of causative association between MMI and ANCA vasculitis. Awareness of this rare but potentially serious adverse drug reaction is important since prompt discontinuation of medication is essential for clinical improvement.

 

Nothing to Disclose: MTV, DM, RMC

21789 17.0000 THR-040 A Methimazole (MMI) Induced Antineutrophilic Cytoplasmic Antibody (ANCA) Lung Vasculitis in a Woman with Graves Disease. 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Mehmet muhittin Yalcin1, Fusun Toruner1, Huseyin Demirci2, Alev E. Altinova1, Mujde Akturk*1 and Nuri Cakir1
1Gazi University Faculty of Medicine, Ankara, Turkey, 2Turgut Ozal University, Ankara, Turkey

 

Subacute thyroiditis (SAT) is an extremely rare cause of thyrotoxicosis in pregnancy. Very few case reports reveal that mild cases may be followed without any medical treatment as nonsteroidal anti-inflammatory drugs and corticosteroids may cause adverse effects during pregnancy. We report a case with SAT in early pregnancy who needed corticosteroid therapy.

A 31-year-old woman at 12 week gestation was referred to our department because of neck pain and tenderness and fatique of two weeks’ duration. The patient reported no personal or family history of thyroid disease, and no use of any medication. Her physical examination revealed a hard, very tender and diffusely enlarged thyroid gland. Laboratory results obtained at the initial visit revealed increased ESR (93 (0-20) mm/h) and CRP (104 (0-6) mg/L). The thyroid function tests (TFTs) were consistent with thyrotoxicosis with fT4: 2.51 (0.70-1.48) ng/dL; fT3: 7.41(1.71-3.71) pg/dL; TSH: 0.005(0.27-4.20) µIU/mL.  TRAB and anti-TPO were negative while anti-TG was slightly positive. Ultrasound examination demonstrated enlarged thyroid gland and focal thyroiditis with areas of low echogenicity especially in the lateral areas.

In order to protect the mother and the child from the effects of high dose corticosteroids, we preferred to start the initial dose of prednisolone with 15 mg/day with tapering by 5 mg every 2 weeks. The tenderness and pain in the neck was totally disappeared within the next 2 weeks. However, in the dose of 10 mg/day, the pain recurred and the dose was increased to 15 mg/day again for two weeks. Then by tapering down again, prednisolone was stopped after 8 weeks.  Hypothyroidism developed (TSH 5.3 µIU/mL) 10 days after discontinuation of the therapy and she was followed on L-thyroxine (LT4) until delivery. The patient delivered a healthy female infant with a birth weight of 3340g, at 37 weeks of gestation without any complications. LT4 therapy was discontinued after delivery and the patient was re-evaluated 8 weeks later and TFTs were found to be normal.

Corticosteroids carry some risks for the mother and fetus in pregnancy. On the other hand, untreated thyrotoxicosis may have adverse outcomes in pregnancy. It has been reported recently that initial treatment with 15 mg/day of prednisolone may be used in SAT. Therefore, we used low dose prednisolone in our case and suggest that low dose prednisolone is effective and safe in the treatment of SAT in pregnancy if corticosteroids are needed.

 

Nothing to Disclose: MMY, FT, HD, AEA, MA, NC

21934 18.0000 THR-041 A Subacute Thyroiditis in a Pregnant Woman Treated with Low Dose Prednisolone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Aren Skolnick1 and Isabela J Romao*2
1Hofstra North Shore-LIJ School of Medicine, Great Neck, NY, 2Hofstra North Shore LIJ School of Medicine, Great Neck, NY

 

Introduction

Acute suppurative thyroiditis due to bacterial infection is a serious, but rare endocrine emergency. We present a case of suppurative thyroiditis arising in an immunosuppressed patient with a history of renal transplant and myasthenia gravis who had a urinary tract infection.

Case Report

A 54-year-old woman with a history significant for polycystic kidney disease treated with bilateral nephrectomy and right renal transplant in 1994 had been on immunosuppressive therapy with prednisone (10mg/day) and tacrolimus (1mg twice a day) since then. She also had a history of myasthenia gravis taking azathioprine. She presented with a one week history of progressive dyspnea on exertion and generalized weakness. She reported a three week history of an enlarging painful neck mass, palpitations, weight loss, tremors, and diarrhea.  On admission she was tachycardic and febrile and she was started empirically on ertapenem for bacteriuria and bandemia. CT scan of the neck was performed without contrast revealing a large right neck mass intimately associated with the thyroid, with deviation of the subglottic trachea and mass effect on the right internal jugular and right common carotid artery. Laboratory evaluation confirmed hyperthyroidism with a TSH of 0.01 Uiu/ml (0.27-4.2 Uiu/ml), FT4 5.15 ng/Dl (0.9-1.8ng/dl), total thyroxine 18.26 ug/dL (15.1-13 ug/dl). Endocrinilogy was consulted at that time. Physical exam revealed a non-toxic woman with a cushingoid appearance. A firmly enlarged thyroid with right sided prominence was appreciated. She had tenderness to palpation along the right side of the gland, and a visible surgical scar from her parathyroidectomy 8 years prior due to tertiary hyperparathyroidism. There was no evidence of lid lag, proptosis, or hypereflexia. A resting tremor was appreciated. Thyroid ultrasound revealed a 5.5 x 5.8 x 5.4cm complex collection or necrotic mass. TSH receptor antibody was negative and ESR was 121 mm/hr (<30 mm/hr). Thyroid uptake and scan revealed 2% uptake in the left lobe and a non-functioning right thyroid lobe. Bedside aspiration of the thyroid mass revealed purulent material and grew E.coli, the same as her urine culture. She was started on imipenem and went for further incision and drainage with improvement in her symptoms. On repeat thyroid function testing two weeks later her TSH was 5.68Uiu/ml and FT4 1.1 ng/dL with subsequent normal thyroid function testing 1 month after her initial diagnosis.

Conclusion: There are limited reports of suppurative thyroiditis in immunocompromised patients and only one prior case specifically in a renal transplant patient (1). The diagnosis can be challenging in immunocompromised patients where the clinical cues of infection may be blunted. Suppurative thyroiditis should be included in the differential diagnosis in an immunocompromised patient presenting with a neck mass.

 

Nothing to Disclose: AS, IJR

22101 19.0000 THR-042 A Acute Suppurative Thyroiditis in an Immunocompromised Patient 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Isabela J Romao*1 and Aren Skolnick2
1Hofstra North Shore LIJ School of Medicine, Great Neck, NY, 2Hofstra North Shore-LIJ School of Medicine, Great Neck, NY

 

Introduction: Follicular thyroid carcinoma with a solitary skull base metastasis is rare.

Case: 57-year-old woman who underwent the removal of an enlarged right thyroid lobe with associated airway compression twenty years ago. Histologic examination revealed a benign nodular goiter and a benign lymph node. After years of experiencing headaches, a CT revealed a mass in the sphenoid bone, thought to be a chordoma twelve years ago. She underwent transsphenoidal surgery to resect the tumor in the area of the clivus. Histology demonstrated that this was a focus of metastatic follicular carcinoma of the thyroid. Although initially apprehensive, she underwent completion thyroidectomy four years later. Pathology was consistent with a multinodular colloid goiter with no focus of thyroid cancer. Postoperatively levothyroxine was initiated and calcitriol and calcium carbonate was started for hypoparathyroidism. Serum thyroglobulin level after thyroidectomy was 16.1 ng/ml (<0.20) with thyroglobulin antibodies <20.0 IU/ml (0-40). Approximately one year after surgery, thyroid metastatic survey with thyrogen was performed with a stimulated thyroglobulin of 4162ng% and multiple foci of uptake in the head/upper neck, chest, pelvis, and left thigh. Follow-up MRI revealed stable postoperative changes involving the clivus and sphenoid sinus. MRI of the cervical and lumbar spine exhibited hemangiomas within L1 and L2, thought to correspond to a false positive uptake on the iodine scan. An indeterminate lesion within the C5 vertebral body was identified, which may represent an atypical hemangioma, but a metastatic lesion was unable to be excluded. PET/CT revealed no evidence of fluorodeoxyglucose (FDG)-avid disease. A non–FDG-avid small sclerotic focus in the right iliac bone and left 5th lateral rib were identified. She never had any symptoms related to the lesions found on imaging. The patient was treated with 200 mci of radioactive iodine with thyrogen stimulation. One year after the radioactive iodine treatment her thyroid metastatic survey had no uptake and her thyroglobulin has been <0.20 ng/ml with negative thyroglobulin antibodies.

Conclusion: Only 5 cases of follicular thyroid cancer metastatic to the skull base have been reported. A review by Rosahl et al. [1] demonstrated that all cases were differentiated follicular tumors, located around the clivus, and resembled that of chordomas or chondrosarcomas. The thyroid gland itself showed no evidence of primary malignancy in all cases. Treatment consisted of postoperative I-131 and TSH suppression therapy. Long-term prognosis appears to depend on tumor size, location, and histologic appearance.

 

Nothing to Disclose: IJR, AS

21945 20.0000 THR-043 A Metastatic Follicular Thyroid Cancer Presenting with Lesion in the Clivus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 024-043 6026 1:00:00 PM Clinical Thyroid Poster


Dinesh Edem1 and Esther Irina Krug*2
1Sinai Hospital of Baltimore, Baltimore, MD, 2Johns Hopkins University/ Sinai Hosp of Baltimore, Baltimore, MD

 

Introduction: Hashimoto’s thyroiditis (HT) is frequently associated with other autoimmune endocrine diseases as a part of autoimmune polyglandular syndrome 2 (APS2). Prevalence of pernicious anemia (PA) and autoimmune gastritis (AIG) is between 4- 12% in patients with HT1. AIG is characterized by atrophy of gastric mucosa and achlorhydria. Vitamin B12deficiency and AIG frequently escape timely diagnosis due to non-specific symptoms, and may lead to gastric cancer, neurologic complications or anemia. Difficult to control hypothyroidism may present a clue leading to early diagnosis of AIG and PA. We present a case series of 3 patients with HT who were found to have AIG and severe vitamin B12 deficiency.

Case: Case 1: 50 year old man with 7 year history of HT presented with complaints of fatigue and memory problems. Over the course of treatment his TSH levels fluctuated widely requiring frequent Levothyroxine (LT4) dose adjustments despite excellent adherence and use of the same brand of LT4. Case 2: 66 year old woman with 25 year history of HT presented with fatigue and worsening depression. Over last 6 years her LT4 requirements increased from 88 mcg to 125 mcg/day. She had elevated TSH despite good compliance and use of the same brand of LT4. Case 3:65 year old woman with a 4 year history of HT presented with worsening anxiety, fatigue and constipation. Due to her fluctuating TSH level despite good compliance with same brand of LT4, her LT4 dose required frequent adjustments.

Clinical evaluation:LT4 malabsorption was suspected. Laboratory testing revealed positive anti-parietal cell antibodies (PCA), intrinsic factor (IF) antibodies, low vitamin B12 levels and elevated gastrin levels. None of the patients had anemia, and 2 out of 3 patients had no overt macrocytosis.

Management:Patients were switched to LT4 gel capsules, resulting in normalization in TSH levels in 3 months without additional dose increases. Intramuscular cyanocobalamin replacement normalized vitamin B12 levels and improved most of neurologic symptoms. Patients were also referred to gastroenterology for EGD to rule out gastric cancer.

Discussion: AIG and PA should be considered in patients with difficult to control HT. Timely recognition and treatment may help avoid adverse health outcomes. Treatment of hypothyroidism in such patients is challenging due to achlorhydria. Levothyroxine tablets require liquification in acidic environment for absorption and as a result are malabsorped in patients with AIG resulting in fluctuating thyroid hormone levels and frequent  LT4 dose adjustments to maintain euthyroidism.  LT4 gel capsule based liquid formulation of LT4 has shown consistent dissolution with variable gastric pH2  resulting in steady absorption. Our patients were able to achieve improved control of HT using LT4 gel capsules.

 

Nothing to Disclose: DE, EIK

22015 1.0000 THR-001 A Difficult to Control Hypothyroidism Despite Good Compliance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Tugba Arkan*, Selen Sipal Bastas and Hasan Terzi
Kocaeli Derince Education and Research Hospital, Kocaeli, Turkey

 

Objective: To determine whether control of hypothyroidism during pregnancy reduces the risk of low or high birth weight infants.

Methods: Postpartum records of 37 hypothyroid women were retrospectively reviewed for maternal and fetal outcomes. Subjects whose records were complete, were separated into two groups based on their thyroid status: controlled (n=19), including women who were euthyroid with LT4 treatment; and uncontrolled (n=18), including women who were hypothyroid with no treatment.

Results: Both groups birth weight means compared, were statistical insignificant. (Uncontroled group 3016,66±430,8 gr, controled group 3315,62±473,6 gr; p=0,098)  Elevated TPO or TG antibody levels were not related to birth weight. Maternal LT4 therapy did not affect neonatal outcomes.

Conclusion: Lack of control of hypothyroidism in pregnancy have no effect on the birth weight, maybe long time follow up can show the complications in infants.

 

Nothing to Disclose: TA, SS, HT

21810 2.0000 THR-002 A Birth Weight in Pregnancies Complicated By Hypothyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Mehtap navdar Basaran*1, Dilek Berker2, Bercem Aycicek Dogan2, Ersen Karakilic1 and Serdar Guler3
1Ankara Numune Education and Training Hospital, Ankara, Turkey, 2Ankara Numune Education and Research Hospital, Ankara, Turkey, 3Hitit University, Faculty of Medicine, Corum, Turkey

 

Aim: Several studies demonstrated  that efficacy of L-thyroxine treatment on atherosclerotic risk markers in patients with subclinical hypothyroidism whose TSH level between 4-10 mU/L. Our study investigated the efficacy of L-thyroxine treatment on atherosclerotic risk markers in patients whose TSH levels between 2.5-5 mU/L.

Methods: Fifty-seven subjects whose TSH levels between 2.5-5 mU/L (Group 1)  and 20 healthy women whose TSH levels below 2.5 mU/L (Group 2) were included. Subjects with atherosclerotic diseases and/or equivalent of the disease, also who had any atherosclerotic risk markers were not included. Lipid parameters, inflammatory markers, (homocysteine, high sensitive-CRP) were performed. Endothelial dysfunction was also performed by FMD% (brakiyal arter flow-mediated dilation). The study aimed to diminish the TSH levels under the 2.5 mU/L with L-thyroxine treatment. All markers  were repeated two times after 3 months and 6 months of the treatment in whose TSH levels reached below 2.5 mU/L.

Results :

There was no significant difference in terms of age and BMI between group 1(mean age:41;BMI:32 kg/m2) and group 2 (mean age:35 ; BMI:29 kg/m2). Mean TSH level was 3.9 mU/L (3.5-4.7) for group 1  and  1.5 mU/L (1.2-2.2) for group 2.  Thyroid autoantibody, total cholesterol (T-chol), LDL, T-chol/HDL, triglycerides  levels were significantly higher at group 1 (respectively; (p=0.001, p=0.001, p=0.006, p=0.005, p=0.001, p=0.021). There was no significant difference between the groups in terms of inflamatuar markers and FMD%. After three months of L-thyroxine treatment, there was no difference at  atherosclerotic risk markers of the individuals who has reached target TSH level.

 Conclusion:

We demonstrated that serum lipid levels was higher among women whose TSH level was between 2.5-5 mU/L than women whose TSH level was up to 2,5 mU/L with normal levels. L-thyroxine treatment has not improved the results. We suggest that  long term results may be more illuminative for usefulness of  levothyroxine treatment for this group of patients.

 

Nothing to Disclose: MNB, DB, BAD, EK, SG

21972 3.0000 THR-003 A Efficacy of L-Thyroxine Treatment on Aterosclerotic Risk Markers in Patients with TSH Levels Between 2.5-5 Mu/L Preliminary Outcome of Prospective Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Muge Bilge*1, Mine Adas2 and Aysen Helvaci3
11SB Okmeydani Training Hospital, Istanbul, Turkey, 2Okmeydani Training Hospital, Istanbul, Turkey, 3SB Okmeydani Training Hospital, Turkey

 

Aim of study: Neutrophil/Lymphocyte Ratio (NLR) is a  simple index of systemic inflammatory response and has been shown to be a prognostic indicator in some types of cancer. NLR might be also a prognostic factor  in papillary thyroid carcinoma.The aim of this study is to investigate the relationship of these parameters with thyroid autoimmunity.
Methods: The study sample consisted of  185 women with  euthyroid Hashimoto thyroiditis and   92 age and sex matched healty controls Serum TSH, free thyroxine (fT4), free triiodothyronine (fT3), leukocyte, neutrophil, lymphocyte and platelet count,  NLR, PLR,  iron, total iron binding capacity, ferritin, vitamin B12, folic acid,  anti-TPO, anti-TG were measured.
Results: In patient group TSH(μIU/ml), Anti-TPO(IU/ml) and Anti TG(IU/ml) values were significantly higher than control ( 2,83±1,68 vs 2,02±0,92; 300,9±301,7 vs 8,68±5,23 and 311,5±66,82 vs 16,7±12,4, respectively, p<0.001). There were no significant differences between patient and control groups in terms of age, leukocyte, neutrophil, lymphocyte and platelet count, NLR, PLR, iron, total iron binding capacity,ferritin, vitamin B12, folic acid,  free thyroxine (fT4) and free triiodothyronine (fT3).
Conclusion: NLR ve PLR were not found to be useful markers in Hashimoto thyroiditis patients.

 

Nothing to Disclose: MB, MA, AH

20422 4.0000 THR-004 A Neutrophil/Lymphocyte Ratio (NLR) and Platelet/Lymphocyte Ratio (PLR) in Patients with Hashimoto's Thyroiditis and Their Relationship with Thyroid Autoimmunity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Adriana Rebeca Boyanovsky*1, Mirta Beatriz Miras2, Graciela María Testa2, Malvina Del Valle Signorino2, Liliana Muñoz1, Gabriela Sobrero2, Liliana Silvano1 and Iván Collet3
1Hospital de Niños de la Santísima Trinidad. Córdoba, Córdoba, Argentina, 2Hospital de Niños de la Santisima Trinidad, Cordoba, Argentina, 3Hospital de Niños de la Santísima Trinidad, Córdoba, Argentina

 

INTRODUCTION: To minimize the risk of not detecting newborns with congenital hypothyroidism (CH), screening programs have gradually lowered TSH cut-offs, which has generated discussions about the contribution to the increase in CH incidence and the possible etiology of mild forms of this condition.

OBJECTIVE: To describe the clinical, biochemical and diagnosis imaging parameters contributing to etiological diagnosis and evolution in newborns with CH detected by neonatal screening with mildly elevated TSH values.

MATERIALS AND METHODS: Medical records of 212 infants with CH detected by neonatal screening in the province of Córdoba between 1996 and 2013 were analyzed, with CH incidence of 1/2000 newborns. Those cases whose TSH levels ranged between 10 and 20 uUI/ml (ELISA Tecnosuma) in whole blood samples collected in filter paper between the 2nd and 10th day after birth were selected. Diagnosis was performed by means of serological determinations of TSH, total T4, free T4, T3, TPO Ab, Tg Ab antibodies and Thyroglobulin (ECLIA Roche). The contributions of neck ultrasound, Tc-99 scintigraphy and knee x-ray were evaluated. Children presenting eutopic gland of normal size and/or positive anti-TPO antibodies were reevaluated at 3 years of age due to probable transient TSH rise.

RESULTS: The entire sample comprised 32 (15%) Term newborn/AGA, with an F/M ratio of 1.2/1. 16 (50%) presented eutopic thyroid gland, with serum TSH levels between 13.5-321 uUI/ml; Total T4 3-14 ug/dl and free T4 0.26-1.8 ng/dl. Tg determination (ng/ml) presented normal values according to regional reference values in 5 newborn (Tg: 60-100), high values in 10 (Tg 156-1000) and without data in 1, with TPO Ab and Tg Ab (-) antibodies in the entire sample. Thyroid dysgenesis was observed in 16  (50%) with serum TSH levels between 11-250 uUI/ml; total T4 5-13 ug/dl; free T4 0.5-1.6 ng/dl; Tg 49.5-1000 ng/ml. Three children (9.4%) with eutopic thyroid gland were reevaluated, and one of them had to restart treatment because serum TSH was 90 uUI/ml. Congenital anomalies were reported in 10 patients (10/32; 3 %): Down syndrome (n= 6), isolated congenital heart disease (n=3) and Frasier syndrome (n=1).

CONCLUSION: Our results do not show differences in the proportion of eutopic thyroid  and dysgenetic glands in newborns with mildly increased TSH levels, indicating the importance of generating complementary data for the etiological diagnosis of this condition as well as the need to have appropriate biochemical reference values in the first days of life, which contribute to the diagnosis of a thyroid dysfunction.

 

Nothing to Disclose: ARB, MBM, GMT, MDVS, LM, GS, LS, IC

21876 5.0000 THR-005 A Etiology and Evolution in Newborns with Congenital Hypothiroidism and Mildly Elevated TSH Screening CUT-Off 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Tanja Diana*1, Michael Kanitz1, Jennifer Glang2, Malte Cronau2 and George Jean Kahaly2
1Johannes Gutenberg University Medical Center, Germany, 2Johannes Gutenberg University Medical Center, Mainz, Germany

 

Objective: Functional TSH receptor (TSHR) autoantibodies play a relevant role in the pathogenesis of autoimmune thyroid diseases (AITD). While TSHR stimulating autoantibodies (TSAb) have been closely associated with Graves’ hyperthyroidism and orbitopathy, the role and prevalence of TSHR blocking autoantibodies (TBAb) are less defined. Therefore we looked for the presence of TBAb in a large collective of patients with AITD and healthy controls.

 Methods: Serum TBAb and TSAb were measured with two cell-based bioassays that utilize Chinese Hamster Ovary cells expressing a chimeric TSHR and a cAMP response element-dependent luciferase. All samples were diluted 1:11 in reaction buffer, added to the cell monolayers and each plate was incubated for three hours at 37°C, 5% CO2. Blocking activity was defined as percent inhibition of luciferase expression relative to induction with bovine TSH alone (cut-off >40% Inhibition). Results of TSAb activity were reported as percentage of specimen-to-reference ratio (SRR%, cut-off >140%).

 Results: A total of 1762 serum samples of patients with AITD (1175 female, 285 male, aged 43±17 years, mean value ± SD) and healthy euthyroid controls (155 female, 147 males, aged 28±8 yrs.) were investigated for the presence of TBAb and TSAb. All controls were TBAb (-15.05±30.8% inhibition) and TSAb (53.2±16.1 SRR%) negative. TBAb was detected in 102/1762 (5.8%) samples; 67/609 (11%) patients with Hashimoto’ thyroiditis (HT) and 35/795 (4.4%) patients with Graves’ disease (GD) during antithyroid drug therapy. Mean serum TBAb values differed in HT (64.6±22.6% inhibition) vs GD (81.1±20.8% inhibition, p=0.0008). Ten samples were both TBAb and TSAb positive with serum values of 51.9±10.5% inhibition and 173.6±23 SRR%, respectively. A total of 51/102 (50%) TBAb positive samples showed values >70% inhibition, 7/102 (6.9%) 61-69%, 11/102 (11%) 51-60% and 33 (32.4%) samples showed inhibition values of 41-50%. All TBAb serum levels >50% inhibition were reproducibly confirmed and thyroid binding assay positive while approximately 20% of TBAb levels with 40-49% inhibition showed variable results. Serum TBAb levels were markedly different (p=0.006) in 49/102 (48%) euthyroid patients (baseline serum TSH 1.9±1.3mU/L, 68±24.3% inhibition) versus those with thyrotoxicosis during medical treatment (n=27/102, 26.5%, TSH 0.1±0.1 mU/L, 82±19.6% inhibition). In comparison, hypothyroid samples (n=26/102, 25.5%, TSH 41±52.5mU/L) showed 65.1±21.9% inhibition.

 Conclusions: A novel bioassay for measurement of blocking TSHR autoantibodies has shown that, independently of the thyroid function, TBAb are prevalent in patients with AITD, foremost in HT. The clinical significance of blocking antibodies merits further study and may indicate the potential for developing hypothyroidism.

 

Disclosure: GJK: Consultant, Quidel. Nothing to Disclose: TD, MK, JG, MC

20885 8.0000 THR-008 A Thyroid-Blocking Autoantibodies Are Prevalent in Autoimmune Thyroid Diseases – a Controlled Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Carol Jarvis*1, Kim Simcox1, Kim McAnulty1, Goswin Y Meyer-Rochow2, John V Conaglen1 and Marianne Susan Elston1
1Waikato Hospital, Hamilton, New Zealand, 2University of Auckland, Hamilton, New Zealand

 

Introduction:  There are few studies published on the incidence of thyrotoxicosis following intravenous (IV) contrast in iodine deficient regions such as New Zealand. Despite exposure to a total iodine load during a typical contrast-enhanced CT scan equivalent to 200000 times the recommended daily intake, contrast-induced thyrotoxicosis is considered rare. Older patients and those with impaired renal function are thought to be at increased risk of iodine-induced thyrotoxicosis but the incidence in our population is unknown.

Aims:The aim of the study was to determine the incidence of iodine-induced thyrotoxicosis following IV administration of iodinated contrast used in CT investigations and to evaluate changes in thyroid function in older patients (≥70 years) compared to those under 70 years of age.

Methods: Adult patients undergoing CT with contrast at Waikato Hospital between 08/02/2013 – 08/07/2014 were invited to participate in the study. Exclusion criteria included current treatment of hypo- or hyper-thyroidism and recent (<6 months) iodinated contrast or amiodarone exposure. Prior to the CT, blood was obtained for thyroid function tests (TFTs) (including Free T3, Free T4, and TSH) and urine collected for iodine and creatinine measurement. Repeat TFTs were collected at 4- and 8-weeks post CT scan and changes from baseline analysed.

Results: A total of 102 patients were included in the final analysis, 52 female and 50 male, with a mean age of 64 years. There were no statistically significant differences in FT4, FT3or TSH levels in the overall group between baseline and 4- or 8- weeks (TSH 1.78 mU/L (SD 1.14, n=102), 1.58 mU/L (1.12, n=99), and 1.74 mU/L (1.23, n=93), respectively (reference range 0.27 – 4.2 mU/L)), or for the >70 years compared to the <70 years age group at any of these time points.

Three patients developed subnormal TSH values at either week 4 or week 8 and were referred for endocrine review. Of these, one woman was found to have an enlarged right thyroid lobe and underwent hemithyroidectomy to alleviate compressive symptoms. Histological examination demonstrated Hashimoto’s thyroiditis and a 90mm follicular variant papillary thyroid carcinoma. The second patient had a normal thyroid assessment, including ultrasound, and TFTs normalised within 3 months of the iodinated contrast. The third patient is awaiting review.

Conclusions: In this small prospective study of patients from an iodine deficient region, 3% of patients developed subclinical hyperthyroidism following a standard dose of iodinated contrast for CT investigations. The incidence of iodine-induced thyroid thyrotoxicosis in this population was low. No differences were identified between the two age groups, <70 years and ≥ 70 years. There is no indication that routine pre-CT thyroid function testing is necessary in an unselected group of patients receiving iodinated contrast in our region.

 

Nothing to Disclose: CJ, KS, KM, GYM, JVC, MSE

20861 9.0000 THR-009 A A Prospective Study of Iodine-Induced Thyrotoxicosis Following Administration of Intravenous Contrast during Computed Tomography in New Zealand 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Aoife Garrahy*, Tomas Griffin, Matthew Murphy and Patrick Sheahan
South Infirmary Victoria University Hospital, Cork, Ireland

 

Postoperative hypocalcaemia is a well recognized complication after thyroidectomy, with symptomatic hypocalcaemia affecting 10-36%.  Parathyroid hormone (PTH) and Vitamin D play important roles in calcium homeostasis.  Vitamin D deficiency (<50nmol/l) is common affecting 30% of patients undergoing total thyroidectomy in our institution.  Vitamin D deficiency may lead to a compensatory secondary hyperparathyroidism and has been hypothesised to be a risk factor for hypocalcaemia post thyroidectomy.  Magnesium is an important co-factor in both PTH secretion and PTH receptor sensitivity.  Accurate prediction of risk can allow personalised management strategies and possibly reduce the risk of this complication. 

The purpose of our study was to investigate whether Vitamin D status and hypomagnesemia after thyroid surgery have any impact on early post-thyroidectomy hypocalcaemia and / or permanent hypoparathyroidism. 

A retrospective review of a prospectively maintained database of patients undergoing total thyroidectomy or completion total thyroidectomy at our institution, with postoperative magnesium levels available, was carried out.  The incidence of biochemical and symptomatic hypocalcaemia and permanent hypoparathyroidism was correlated with postoperative hypomagnesemia, Vitamin D and other risk factors.  Hypocalcaemia was defined as the occurrence of any single corrected calcium less than 2.0mmol/L in the postoperative period.

Of 243 total or completion total thyroidectomies, 201 had postoperative magnesium levels available and were included in the study.  26 patients (13%) developed postoperative hypomagnesemia (<0.70 mmol/l). 46 patients (22.9%) developed temporary hypocalcaemia and 10 patients (5%) developed permanent hypocalcaemia, all due to hypoparathyroidism. On univariate analysis, predictors of temporary hypocalcaemia were low parathyroid hormone (PTH) levels (p<0.0001), hypomagnesemia (p=0.002), cancer diagnosis (p=0.008), central neck dissection (p=0.02), and inadvertent parathyroid resection (p=0.02).  A significant association was not found for Vitamin D. On multivariate analysis, only hypomagnesemia (p=0.05) and hypoparathyroidism (p<0.0001) remained statistically significant.  Significant predictors of permanent hypoparathyroidism on multivariate analysis were hypomagnesemia (p<0.0001) and cancer diagnosis (p=0.03). 

Early post-thyroidectomy hypomagnesemia is a significant predictor of both early hypocalcaemia and permanent hypoparathyroidism, while Vitamin D deficiency is not.  It is unclear whether correction of hypomagnesemia may protect against development of either early or permanent hypocalcaemia in patients undergoing total thyoidectomy.

 

Nothing to Disclose: AG, TG, MM, PS

19604 10.0000 THR-010 A Low Postoperative Magnesium Levels but Not Vitamin D Deficiency Predicts Early Hypocalcaemia and Permanent Hypoparathyroidism in Patients after Thyroidectomy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Gulsum Gonulalan*1, Mustafa Kulaksizoglu2, Erkan Tasyurek3, Suleyman Hilmi Ipekci4, Mehtap Cakir5, Mustafa Sait Gonen6 and Ahmet Kaya2
1Konya Numune Hospital, Konya, Turkey, 2Necmettin Erbakan University, Konya, Turkey, 3Karaman Health Care Laboratuary, Turkey, 4Selcuk University Med Faculty, Konya, Turkey, 5Kent Cigli Hospital, Izmir, Turkey, 6Bilim University, Istanbul, Turkey

 

Hypothyroidism is a frequently seen disease with cardivascular complications and absence of thyroid hormone. We aimed to investigate the Carotid Intima Media Thickness (CIMT) measurements and blood Heart Type Fatty Acid Binding Protein (H-FABP) levels in patients with overt and subclinical hypothyroidism. We also aimed to evaluate the alteration in CIMT and H-FABP levels after six months of levothyroxine treatment. We evaluated 40 patients with overt hypothyroidism, 40 patients with subclinical hypothyrodism and 30 patients as control in our clinic. We compared the groups according to demographic datas, blood lipid and thyroid hormon levels, CIMT measurements and blood H-FABP levels. We also compared the patients with overt hypothyroidism after levothyroxine treatment. In results, blood total cholesterol, LDL cholesterol and H-FABP levels were significantly increased in patients with overt hypothyroidism (p<0.05). CIMT was also significantly increased in patients with overt hypothyroidism (p<0.05). There was not a significant correlation between CIMT and H-FABP levels in patients with overt hypothyroidism. The CIMT and H-FABP levels significantly decreased after levothyroxine treatment in patients with overt hypothyroidism (p<0.05). According to our knowladge, this is the first study that aimed to investigate the relationship between hypothyroidism and H-FABP levels. Our results showed that H-FABP might be used as marker to detect the subclinical atherosclerosis in patients with hypothyrodism. Levothyroxine treatment could protect patients from the cardiovascular complications in hypothyrodism according to decreased levels of H-FABP and CIMT.

 

Nothing to Disclose: GG, MK, ET, SHI, MC, MSG, AK

21106 11.0000 THR-011 A Serum Hearth Type Fatty Acid Binding Protein Level Is a Subclinical Atherosclerosis Marker in Patients with Hypothyrodism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Izumi Hiratsuka*, Hiroya Yamada, Mitsuyasu Itoh and Shunji Hashimoto
Fujita Health University, School of Medicine, Toyoake, Japan

 

Autoimmune thyroid diseases (AITDs), such as Graves’ diseases (GD) and Hashimoto’s thyroiditis (HT), are the most common autoimmune diseases. MicroRNAs(miRNA) are small noncoding RNAs, which can play an important role in regulating the immune response. We previously revealed that different levels of serum miRNAs were detected in patients with GD and HT, which may play a role in the pathogenesis of these diseases 1).  The aim of this study was to further characterize the difference in circulating levels of miRNA in patients with GD, depending on diseases activity and thyroid function.

Microarrays were used to analyze the expression patterns of miRNA in serum obtained from patients with GD and healthy subjects. Seven patients with intractable GD, 7 patients with GD in remission and 6 healthy subjects were recruited. The thyroid function of patients were as the following: in intractable GD, FT4 1.27±0.53 ng/dl, TSH 0.0038±0.0032 μU/ml, anti-thyrotrophin receptor antibody (TRAb) 114.6±104.3 IU/l, in remission FT4 1.08±0.19 ng/dl, TSH 1.41±0.80μU/ml, TRAb 0.87±0.71 IU/l, and in control  FT4 1.17±0.19 ng/dl, TSH 1.73±0.95 μU/ml, TRAb 0.37±0.05 IU/l. The patients with intractable GD had been treated with daily dose of more than 15mg of methimazole or 300mg of propylthiouracil for at least 2 years and were still positive for TRAb. To obtain cell free RNA from serum, we centrifuged samples at 5000g for 10 min and used only the supernatant for RNA extraction. Circulating miRNAs from serum were isolated with the NucleoSpin miRNA Plasma kit (Macherey-Nagel) according to the manufacturer’s protocol. Circulating miRNA profiling was performed with miScript miRNA PCR array human miRNome (Qiagen). Relative levels of each miRNA was calculated using the comparative cycle threshold (CT) method (2−ΔΔCT). Data are expressed as the mean (SE), and statistical significance was evaluated with the Student for the comparison between two groups, and one-way ANOVA was used for multiple comparisons.

More than 10 different miRNAs were expressed in intractable GD patients compared with healthy subjects by microarray analysis. There were also more than 10 serum miRNAs expressed differently from GD patients in remission compared with healthy subjects. Furthermore, other different serum miRNAs were expressed in patients with intractable GD compared with GD patients in remission. These increased or decreased expressions of serum miRNAs were independent each other.           

Our results revealed that different levels of serum miRNAs were associated with clinical activity in patients with GD. Further investigation is required to find possible surrogate markers to predict the responsiveness to treatment, especially in intractable GD.

 

Nothing to Disclose: IH, HY, MI, SH

20301 13.0000 THR-013 A Different Expression of Circulating microRNAs in Autoimmune Thyroid Diseases in Relation to Clinical Activity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Albert Hsieh*1, Stephen Adelstein1, Susan McLennan2, Paul F Williams3, Stephen Morris Twigg4 and Elizabeth Lian Chua4
1Royal Prince Alfred Hospital, Camperdown, Australia, 2University of Sydney, Sydney, Australia, 3The University of Sydney, Sydney NSW, 4Royal Prince Alfred Hospital, Sydney, Australia

 

One of the greatest challenges in managing Graves’ disease (GD) is the high recurrence of hyperthyroidism after achieving remission. Approximately 50-80% of individuals with GD who do not have definitive treatment with either radioactive iodine or thyroidectomy will experience disease recurrence. Although some evidence suggests that male gender, smoking, and geographical variation may contribute to the risk of recurrence, the factors that affect recurrence have not been fully explored (1). We performed a review of the Royal Prince Alfred Hospital Thyroid Clinic adult database from 2000 to 2012 inclusive, examining the factors associated with GD recurrence. Recurrence was defined as developing thyrotoxicosis after achieving American Thyroid Association defined remission, i.e. having “normal serum TSH, FT4, and T3 for 1 year after discontinuation of anti-thyroid therapy” (2). If patients developed thyrotoxicosis within 12 months of delivery, they were excluded from the analysis.

There were 183 patients with GD who had both clinical and biochemical hyperthyroidism. Forty out of 183 had a GD recurrence. Among the 40 patients, 80% were female; 55% had East and South East Asian ancestry and 32.5% of patients had European ancestry; 60% had a family history of thyroid disorder; 22.5% were active smokers and 5% were ex-smokers.

Univariate analysis showed that age of GD onset < 30 years was significantly associated with the risk of recurrence (P=0.02) while gender, ancestry, family history, and smoking history were not. Age of GD onset was divided into 4 subgroups: ≤ 20, 21 to 30, 31 to 40, and > 40 years. The percentage of recurrence was 40%, 29%, 21% and 11% in each age group, respectively. Multivariate logistic regression showed a strong inverse relationship of GD recurrence with initial age of diagnosis. The odds ratios for recurrence in ascending order of age groups using > 40 years as the reference group, were 6.5 (95% CI 1.3-33.1), 3.6 (95% CI 1.2-11.0), and 2.3 (95% CI 0.7-7.2).

Using less stringent criteria of recurrence, defined as development of thyrotoxicosis at any time after cessation of medication, having had at least 12 months of anti-thyroid therapy or during the post-partum period, 49.2% of the 183 patients recurred. The significant inverse relationship of GD recurrence with age of onset <30 years was again observed. (P<0.001)

In conclusion, this analysis demonstrates the novel finding that earlier age of GD onset is significantly and progressively associated with disease recurrence. We recommend taking age of GD onset into account in decisions about GD treatment, monitoring, and planning for definitive therapy.

 

Nothing to Disclose: AH, SA, SM, PFW, SMT, ELC

19048 14.0000 THR-014 A Recurrence of Graves' Disease Is Predicted By Lower Patient Age at Initial Diagnosis: Implications for Care 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Albert Hsieh*1, Stephen Morris Twigg2 and Elizabeth Lian Chua2
1Royal Prince Alfred Hospital, Camperdown, Australia, 2Royal Prince Alfred Hospital, Sydney, Australia

 

The diagnosis of Graves’ disease (GD) is traditionally based on the clinical features of persisting hyperthyroidism, enlarged thyroid gland, and often the presence of ophthalmopathy. However, when the clinical presentation of thyrotoxicosis is not diagnostic of GD, the 2011 American Thyroid Association guideline recommends “a radioactive iodine uptake scan should be performed” (1). Although it is long recognised that Thyrotropin (TSH) receptor antibody (TRAb) is the pathogenic agent of thyrotoxicosis, measurement of TRAb for diagnostic purpose is only recommended “when the thyroid scan and uptake are unavailable or contraindicated.” With the availability of highly sensitive TRAb assays, we performed an audit on the Royal Prince Alfred Hospital (RPAH) Thyroid Clinic encounters between years 2000 to 2012, examining the diagnostic utility of TRAb versus thyroid scan in confirming GD.

Thyroid scans were performed using technetium-99m sodium pertechnetate isotope. Positive thyroid scan was defined as diffuse thyroid uptake of the tracer and thyroid activity not being low. TRAb were analysed within the first 3 months of hyperthyroidism and the analysis were performed on newer generation TRAb assays (BRAHMS TRAK human RIA & Roche Elecsys Anti-TSHR assay). TRAb was considered positive if the antibody was above the upper limit of the population reference range.

Our audit showed 231 patients diagnosed with GD were seen in our clinic from 2000 – 2012; 183 had both clinical and biochemical hyperthyroidism during their contact with our service. Among the 183 patients, mean age was 37.2 and median was 35; 81.4% were female; 47% had East/South East Asian ancestry while 41% had European ancestry; 61.2% had a family history of thyroid disorders. Seventy nine out of 183 had both a thyroid scan and TRAb to confirm GD. All 79 thyroid scans were positive; 76 out of 79 cases were TRAb positive, making TRAb 96% sensitive against the thyroid scan. Of the total cohort of 183, 178 were TRAb positive. With the year by year audit of GD clinic management, TRAb was increasingly used as a first line confirmatory test over the last decade. Correspondingly, thyroid scan utilisation rate dropped from 55% in the early 2000 to only 31% in 2012 (P = 0.02).

From the cost effectiveness perspective, RPAH TRAb assay report time is within 5 working days and is one sixth the direct cost of the Thyroid scan (2). Furthermore, whilst technetium-99m sodium pertechnetate exposes the thyroid gland to less radiation than Iodine-123, it is twice the general background radiation dose (3).

In conclusion, considering the economic rationalisation required in health care delivery and increasing awareness of radiation exposure associated with nuclear medicine imaging, as well as the high sensitivity of TRAb in GD diagnosis, we suggest use of the TRAb assay as the first line confirmatory test for GD, and to reserve the use of thyroid scan for equivocal cases only.

 

Nothing to Disclose: AH, SMT, ELC

19056 15.0000 THR-015 A Changing Trend in Diagnostic Methods for Graves' Disease: Is an Immunological Diagnosis Preferred? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Shoichiro Izawa*1, Kazuhiko Matsuzawa1, Hiroko Ohkura1, Kyoko Shoji1, Risa Nakanishi1, Ayumi Murawaki1, Youhei Fujioka1, Tsuyoshi Ohkura1, Akio Yoshida2, Masahiko Kato1, Shin-ichi Taniguchi1 and Kazuhiro Yamamoto1
1Tottori University Faculty of Medicine, Yonago, Japan, 2Tottori University Graduate School of Medicine, Yonago, Japan

 

Background: Maternal hypothyroidism in early pregnancy can be associated with pregnant outcomes and fetal development. Recent guidelines recommend TSH target levels of ≤ 2.5 mIU/L for the first trimester and ≤ 3 mIU/L for the subsequent trimesters. However, there is little knowledge about the clinical parameters associated with the requirement of levothyroxine (LT4) for this condition. The objective of our study was to explore the clinical indicators associated with LT4 dose for newly diagnosed hypothyroidism in early pregnancy.

Patients and Methods: Universal TSH screening in the first obstetrical care was provided to every woman without history of thyroid disease in our institution. If their TSH level was ≥ 2.5 mIU/L, they were consulted to endocrinologists with the additional measurement of thyroid autoantibodies (TgAb and TPOAb) and free T4. They were evaluated by thyroid ultrasound (US), and checked the following 5 manifestations related to autoimmune thyroid disease (AITD): hypoechogenity, heteroechogenity, marginal irregularity, increased blood flow signal, and diffuse goiter. They were treated by LT4 or carefully observed by the monthly measurement of TSH and free T4 until delivery. The dose of LT4 that allowed a TSH of ≤ 2.5 mIU/L to be reached in the first trimester or one that allowed a TSH of ≤ 3 mIU/L to be reached during the second and third trimesters was considered the appropriate one.

Results: A total of 28 pregnant women newly diagnosed hypothyroidism was enrolled. Mean age was 31.4±5.7 years old, and the first obstetrical care was provided in 10.8±1.2 gestational weeks. Thyroid autoantibodies were positive in 12 of 28 patients. As to US evaluation, manifestations associated with AITD was obtained 17 of 28 patients. However, 13 of these 17 patients revealed only one US manifestation, and the most common was heteroehogenity. LT4 was started in 17.9±5.7 gestational weeks for 21 patients, and mean maximum dose was 40±20 µg/day. The doses in 24, 28, 32, and 36 gestational weeks were significantly higher than those in 8, 12, and 16 gestational weeks (p<0.05). No significant increase of LT4 requirement was observed after 24 gestational weeks. We finally divided the enrolled patients to 18 with AITD and 12 with hypothyroidism of unknown origin (HYPO). Mean LT4 doses of AITD after 16 gestational weeks were significantly higher than those of HYPO (p<0.05).

Conclusion: AITD was the major cause of hypothyroidism newly diagnosed in early pregnancy. However, the clinical manifestation of AITD was equivocal in many cases. Because the requirement of LT4 in AITD was significantly more than those of HYPO, differential diagnosis of hypothyroidism was beneficial for planning the adequate doses and follow-up interval for LT4 replacement therapy.

 

Nothing to Disclose: SI, KM, HO, KS, RN, AM, YF, TO, AY, MK, SIT, KY

19502 16.0000 THR-016 A Clinical Parameters Associated Levothyroxine Doses for Newly Diagnosed Hypothyroidism in Early Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Elena Kampmann*1, Tanja Diana2, Michael Kanitz2, David Hoppe3 and George Jean Kahaly2
1Johannes Gutenberg University Medical Center, Mainz, Germany, 2Johannes Gutenberg University Medical Center, Germany, 3Technical University, Darmstadt, Germany

 

Objective: The presence of autoantibodies to the thyrotropin receptor (TSH-R) is a parameter used for the diagnosis of Graves’ disease (GD). Functional TSH-R autoantibodies can be divided into two groups: thyroid blocking antibodies, TBAb and thyroid-stimulating antibodies (TSAb). The clinical relevance and utility of serum TSAb and TBAb was prospectively evaluated in unselected patients with autoimmune thyroid eye disease (TED).

Methods: At an academic referral multidisciplinary orbital center with a joint thyroid-eye clinic, ophthalmic, endocrine and serological investigations were performed in patients with TED. Serum TSAb and TBAb levels were measured with two novel bioassays using cells that express a chimeric TSH receptor and CRE-dependent luciferase. TSAb results are expressed as percentage of specimen-to-reference ratio (SRR%). Blocking activity is defined as percent inhibition of luciferase expression relative to induction with bovine TSH alone.

Results: All 101 consecutively recruited patients with severe and active TED were TBAb negative. In contrast, 91 (90%) were TSAb positive of whom 90 had Graves’ disease (GD). Median serum value of TSAb was SRR% 418 (range 28-795). Of the 10 TSAb negative patients four had had a thyroidectomy, two radioactive iodine treatment (seven and 10 years before), one was treated with antithyroid therapy, and three were diagnosed with Hashimoto’s thyroiditis (HT). GD and HT were present in 97 (96%) and four (4%) patients, respectively. Median duration of TED was 11 months. Median age was 52 years (23-75 years, 76 female, 53 current smokers). Diplopia was present in 63 patients with 12 having constant double vision. Chemosis, corneal lesions and asymmetric TED were present in 27, 14 and 20 patients, respectively. Median clinical activity (CAS) and severity (CSS) scores were 4 (3-6) and 5.75 (1-11), respectively. Upper or lower lid retraction was present in 52 or 42 patients. Median palpebral aperture and proptosis were 12 mm (6-17) and 22 mm (13–30). TSAb correlated with the diplopia score (p=0.016), total severity eye score (p=0.009), proptosis (p=0.007), lid aperture (p=0.003), upper lid retraction (p=0.006), keratopathy (p=0.04), thyroid binding inhibiting immunoglobulin (TBII, p<0.001) and negatively with the duration of TED (p=0.002). Daily cigarette consumption or pack years had no significant impact on clinical activity and severity scores, intraocular pressure or levels of TSAb.

Conclusions: Two novel cell-based bioassays for the measurement of functional TSH-R autoantibodies have demonstrated that TSAb, but not TBAb, are highly prevalent in TED and serum TSAb levels correlate with clinical disease severity.

 

Disclosure: GJK: Consultant, Quidel. Nothing to Disclose: EK, TD, MK, DH

20913 17.0000 THR-017 A Functional Thyroid Stimulating but Not Blocking Autoantibodies Are Prevalent in Thyroid Eye Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Jee Hyun An*1, Yoon Jung Kim2, Kyeong Jin Kim1, Sun Hwa Kim1, Nam Hoon Kim1, Hye Jin Yoo1, Hee Young Kim1, Ji A Seo1, Nan Hee Kim1, Kyung Mook Choi1, Sei Hyun Baik1, Dong Seop Choi1 and Sin Gon Kim1
1College of Medicine, Korea University, Seoul, Korea, Republic of (South), 2College of Medicine, Hallym University, Seoul, Korea, Republic of (South)

 

Hypothyroidism patients experience fatigue-related symptoms despite adequate levothyroxine replacement. Thyroid hormone plays an essential role in carnitine-dependent fatty acid import and oxidation and carnitine depletion has been observed in hypothyroidism. We hypothesized that the fatigue-related symptoms in patients with hypothyroidism may be related to relative carnitine deficiency and investigated the effects of L-carnitine supplementation on fatigue-related symptoms in hypothyroidism patients.

We conducted an investigator-initiated, randomized, controlled, double-blinded, single-center clinical trial of L-carnitine supplementation in patients with hypothyroidism receiving levothyroxine treatment. A total of 77 hypothyroid subjects were enrolled. After excluding 17 subjects having other causes of fatigue and taking other medications influencing thyroid function, 60 patients (Age 51.4 ± 8.5 years, 3 males and 57 females) were given either L-carnitine (N=30, 990 mg L-carnitine twice daily) or placebo (N=30) for 12 weeks. The primary outcome was change in fatigue severity scale (FSS) score. The secondary outcomes were: 1) change in Wessely and Powell score composed of physical (PFS) and mental fatigue score (MFS); 2) changes in plasma L-carnitine levels (total carnitine, and acylcarnitine); 3) serum triglyceride, total-, HDL-, and LDL-cholesterol levels; 4) AST, ALT, and γ-GTP; and 5) body fat mass.

After 12-weeks of treatment, serum total carnitine and acyl-carnitine levels have significantly increased in L-carnitine group as expected (from 67.3 ± 16.2 to 84.6 ± 18.9 μmol/L and from 15.3 ± 7.0 to 19.9 ± 9.5 μmol/L, respectively). Although both FSS and PFS have not significantly changed after 12 weeks, MFS values were significantly decreased by treatment with L-carnitine compared with placebo treatment (-23 % vs +12 %, p< 0.01). Serum lipid profiles, liver function parameters and body fat mass were not significantly changed in both groups. In subgroup analysis, both PFS and MFS were significantly improved in patients younger than 50 years-old and those with free T3 ≥ 4.0 pg/mL by treatment with L-carnitine. In addition, MFS was significantly improved in patients whose serum total carnitine level ≥ 60.9 mmol/L and those taking levothyroxine after papillary thyroid cancer surgery.

These results suggest that L-carnitine supplementation may be useful in alleviating fatigue symptoms in hypothyroid patients, especially in those younger than 50 years old and those who underwent thyroidectomy for papillary thyroid cancer. Elucidating the cellular mechanism of the fatigue-relieving effects of L-carnitine should be a subject of future research. (ClinicalTrials.gov: NCT01769157)

 

Disclosure: SGK: Principal Investigator, Ildong Pharmaceutical. Nothing to Disclose: JHA, YJK, KJK, SHK, NHK, HJY, HYK, JAS, NHK, KMC, SHB, DSC

20730 18.0000 THR-018 A L-Carnitine Supplementation for the Management of Fatigue in Patients with Hypothyroidism on Levothyroxine Treatment: Randomized, Double-Blind, Placebo-Controlled Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Jee Hyun An*1, Kee-Ho Song2, Dong-Lim Kim2 and Suk Kyeong Kim2
1College of Medicine, Korea University, Seoul, Korea, Republic of (South), 2Konkuk University School of Medicine, Seoul, Korea, Republic of (South)

 

Thyroid dysfunction has a great impact on lipid profile as well as a number of other cardiovascular risk factors. In this study, we investigated the effects of severe hypothyroid state induced by withdrawal of thyroid hormone (T4) replacement for the preparation of radioactive iodine (RAI) therapy in differentiated thyroid cancer patients on metabolic and cardiovascular parameters.

A total of 48 patients (female 77.1 %, age 49.4 ± 10.5 years) who had been scheduled to receive RAI ablation were enrolled. Blood samples were taken immediately before and 4 weeks after T4 withdrawal (on the day of RAI), and 4 weeks after reinstitution of T4.

Body mass index, systolic blood pressure and heart rate were decreased after withdrawal of T4, which were recovered after reinstitution of T4. Total and LDL-cholesterol, triglyceride and free fatty acid (FFA) levels were significantly increased after T4 withdrawal as expected but HDL-cholesterol levels were also increased in this condition and all these changes were reversed by T4 replacement. Interestingly, fasting plasma glucose and insulin levels were significantly decreased after T4 withdrawal as were HOMA-B and HOMA-IR, which were all reversed after recovering to euthyroid state. Regarding the markers of vascular inflammation and atherosclerosis, hs-CRP, fibrinogen, and cystatin C levels were decreased while serum homocysteine levels were significantly increased by T4 withdrawal. All of these changes were reversed by T4 reinstitution except for the cystatin C. Those patients who already have metabolic syndrome components showed greater increase in TG, LDL-cholesterol, FFA and ApoB while those without metabolic syndrome, especially in female, exhibited greater increase in HDL-cholesterol levels.

To summarize, induction of severe hypothyroid state by acute withdrawal of T4 in thyroidectomized patients resulted in mixed response in lipid and metabolic profiles and also in major atherosclerotic biomarkers; some in favorable direction while the others in unfavorable direction. The specific meaning of these markers and the overall effects should be the subjects of future research. (ClinicalTrial.gov: NCT 01744769)

 

Nothing to Disclose: JHA, KHS, DLK, SKK

20186 19.0000 THR-019 A Effects of Thyroid Hormone Withdrawal on Metabolic and Cardiovascular Parameters during Radioactive Iodine Therapy in Differentiated Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Sarah S.R. Kim*1, Radhika R. Narla1, Xuemei He2, Angela M. Leung1 and Lewis E Braverman3
1UCLA David Geffen School of Medicine, Los Angeles, CA, 2Boston University School of Medicine, Boston, MA, 3Boston Medical Center, Boston, MA

 

Introduction:  With the rising popularity of the juicing trend and “green smoothies,” the demand for kale has quickly risen. Thiocyanate, a byproduct of cyanide found in certain foods and cigarette smoke, inhibits iodine uptake by the sodium-iodine symporter (NIS), thus reducing iodine transport into the thyroid and potentially decreasing the production of thyroid hormone. Plants within the Brassica genus, which include cauliflower, broccoli, cabbage, turnips, rapeseed, and kale, contain natural detectable levels of thiocyanate and if consumed in high amounts, may be goitrogenic.  The effects of eating foods with high thiocyanate content on iodine nutrition and thyroid function have yet to be fully elucidated.  This study assessed urinary thiocyanate concentrations before and after ingestion of  commercially available kale juice to test the hypothesis that  ingestion of kale-containing juice ingestion results in increased urinary thiocyanate levels.

Methods:  Ten adult nonsmoking subjects without any known thyroid disorder history were studied. Spot urine samples were collected at baseline prior to and at the first void up to 240 minutes following ingestion of a single 15.2 ounce bottle of a commercially available kale-containing juice product over 5-10 minutes.  Thiocyanate and creatinine levels were measured by mass spectrometry-liquid chromatography in all urine and ingested juice samples.  Statistical analysis was performed using a two-tailed paired t-test with a p-value of <0.05. Approval was obtained from the local Institutional Review Board.

Results:  Mean±SD thiocyanate concentrations in the kale juice product were 2,411 ± 122 mcg/L (n= 10).  Ten subjects (60% men, 80% Asian, mean±SD age: 31.7 ± 4.6 years) were studied. Following kale juice ingestion, urinary thiocyanate levels significantly increased (mean±SD: 0.97±0.40 mcg/mg creatinine) compared to baseline levels (0.63±0.38 mcg/mg creatinine) (p<0.01). 

Conclusions:  Kale juice is thiocyanate-rich and increases urinary thiocyanate concentrations following ingestion.  Although kale should remain part of an overall healthy diet, it may represent a source of thiocyanate exposure if consumed in large, frequent amounts.  Larger scale studies are needed to help further understand the relationship between ingestion of thiocyanate-rich foods such as kale and kale juices, iodine nutrition, and thyroid function, including thyroid 123I uptake.

*SSR Kim and RR Narla: co-first authors

 

Nothing to Disclose: SSRK, RRN, XH, AML, LEB

19945 20.0000 THR-020 A Increased Urinary Thiocyanate Concentrations Following Ingestion of Thiocyanate-Rich Kale Juice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Mostafa A. Al-Alusi*1, Lin Du2, Ning Li1, Xuemei He3, Michael W. Yeh4, Lewis E Braverman5 and Angela M. Leung4
1UCLA David Geffen School of Medicine, 2UCLA Fielding School of Public Health, 3Boston University School of Medicine, Boston, MA, 4UCLA David Geffen School of Medicine, Los Angeles, CA, 5Boston Medical Center, Boston, MA

 

Introduction: Levothyroxine (LT4) absorption is affected by concomitant ingestion of certain minerals, medications, and foods. It has been hypothesized that metformin may suppress serum thyroid-stimulating hormone (TSH) concentrations via alteration of LT4 absorption or effects at the receptor or central levels. We examined the effect of metformin on LT4 absorption, as measured by serum total T4 (TT4) concentration.

Methods: A modified Food and Drug Administration LT4 bioequivalence protocol was applied to healthy, euthyroid adult volunteers without a history of recent metformin use. Following an overnight fast, 600 μg LT4 was administered orally.  Serum TT4 concentration was measured at baseline and at 0.5, 1, 1.5, 2, 4, and 6 hours following LT4 administration.  Measurements were performed before and after one week of metformin ingestion (850 mg three times daily). Peak serum TT4 concentration, time to peak TT4 concentration, and area under the concentration-time curve (AUC) were calculated.

Results: Twenty-six subjects (54% men, 27% White, age 33 ± 10 [SD] years) were studied. There were no significant differences in peak serum TT4 concentration (p=0.13) and time to peak TT4 concentration (p=0.19) before and after one week of metformin use. We observed a trend toward reduced TT4 AUC after metformin ingestion (pre-metformin 3893 ± 568 [SD] mcg/dL-min, post-metformin 3765 ± 588, p=0.09).

Conclusions: Our findings indicate that LT4 absorption is unchanged or mildly reduced by concomitant metformin ingestion.  Therefore, mechanisms other than increased LT4 absorption may be responsible for the suppressed TSH concentrations observed in patients taking both drugs.

 

Nothing to Disclose: MAA, LD, NL, XH, MWY, LEB, AML

19381 21.0000 THR-021 A The Effect of Metformin on Levothyroxine Absorption 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Natalie M. Villa*1, Ning Li1, Michael W. Yeh2, Sara A. Hurvitz1, Nicole A. Dawson1 and Angela M. Leung2
1UCLA David Geffen School of Medicine, 2UCLA David Geffen School of Medicine, Los Angeles, CA

 

Background: The potential relationship between hypothyroidism and breast cancer demonstrated in some studies remains controversial and incompletely understood.  The present study investigated the relationship between serum TSH concentration and markers of aggressive breast cancer biology.  We hypothesized that breast cancer patients with higher serum TSH concentrations are at greater risk for developing tumors with more aggressive biology (as defined by AJCC stage characteristics and receptor expression [estrogen receptor (ER), progesterone receptor (PR), and Her2/neu] status).

Methods: A retrospective cohort study was performed on 437 breast cancer patients from a single academic institution who had complete receptor data and at least one pre-diagnosis TSH measurement during the period 2002-2014, including fifteen who had missing AJCC staging data.  Primary outcome measures were receptor expression profile (estrogen receptor [ER], progesterone receptor [PR], Her2/neu) and AJCC stage characteristics.  Multinomial and logistic regression was used to analyze the effect of TSH values prior to the diagnosis of breast cancer on overall AJCC stage; the individual tumor size (T), lymph node positivity (N), and presence of metastasis (M) components; and the six subtypes of receptor status combinations (including, in increasing order of aggressiveness, ER+ PR+ Her2/Neu-, ER+ PR- Her2/Neu-, ER+ PR+ Her2/Neu+, ER+ PR- Her2/Neu+, ER- PR- Her2/Neu+, ER- PR- Her2/Neu-).  TSH values were log-transformed and weighted by duration to account for patients who had multiple values recorded.  The analyses were adjusted for age, family history, and race.

Results: 437 subjects (99% women; mean ± SD age at diagnosis: 62.3 ± 15.3 years; 68% Caucasian, 15% Asian, 9% African-American, 8% other) were studied.  Increase in TSH concentration was significantly related to a lower probability of having the receptor expression profile ER+ PR+ Her2/Neu+ (more aggressive breast cancer subtype) compared to patients with the ER+ PR+ Her2/Neu- profile (less aggressive tumor subtype) (OR = 0.52, p=0.0045) but there was no significant consistent trend between the other five receptor expression profiles and serum TSH concentration.  All time-weighted and unweighted median serum TSH concentrations were within normal limits.  No significant associations between serum TSH concentration and overall AJCC stage or the individual tumor size (T), lymph node positivity (N), or presence of metastasis (M) characteristics were observed.  

Conclusions: Serum TSH was not associated with breast cancer receptor expression profile or AJCC stage characteristics, suggesting that serum TSH is not a conclusive predictor of breast cancer aggressiveness in this sample.

 

Disclosure: SAH: Clinician, Genentech, Inc., Clinician, Novartis Pharmaceuticals, Clinician, OBI Pharma, Clinician, Boehringer Ingelheim, Clinician, Genentech, Inc.. Nothing to Disclose: NMV, NL, MWY, NAD, AML

19567 22.0000 THR-022 A Serum TSH Is Not Associated with Aggressive Breast Cancer Biology 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 001-023 6032 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Eva Gronowitz*1, Andrew Beamish2, Torsten Olbers3, Claude N Marcus4, Carl-Erik Flodmark5 and Jovanna Dahlgren6
1of Clinical Sciences, Göteborg, Sweden, 2Clinical Sciences, Göteborg, Sweden, 3Clinical sciences, Gothenburg, Sweden, 4Karolinska Institute, Stockholm, Sweden, 5Skånes University hospital SUS, Malmö, Sweden, 6Inst of Clinical Sci, Gothenburg, Sweden

 

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is known to cause changes in bone metabolism and structure, yet little is known about its effects in the adolescent. No previous study has reported serum bone markers to assess bone turnover after bariatric surgery in the adolescent.

Methods: Seventy-two adolescents (22 males; mean age 16.5years; mean BMI 44.8kg/m2) undergoing LRYGB for morbid obesity underwent prospective DXA body composition and serum bone marker analysis preoperatively and at one- and two-year follow up.

Results: Mean BMI reduction at two years was 15.1kg/m2. Body composition changes included a reduction in the percentage fat mass (51.8% to 40.9%, p<0.0001) and relative increase in lean mass (47.0% to 56.8%, p<0.0001). Boys lost more fat than girls (-17.3% vs. -9.5%, p<0.0001). Bone mineral density Z-score (BMD-Z) at baseline was within or above the normal range of -1 to 1 in all subjects. The mean BMD-Z was 1.85 +/-1.24.at baseline, decreasing to 0.52 +/-1.18 at two years. Four patients reached more than one standard deviation below the accepted mean for age and gender at two years, all of whom began from a low baseline (-0.6 to -0.5).

Bone markers demonstrated a greater bone turnover in boys than girls at baseline. Increased concentrations of serum markers of bone resorption (CTX p<0.0001) and synthesis (osteocalcin p<0.0001, P1NP p=0.003) were observed after LRYGB, rising in the first year, before more modest reductions in the second. Absolute levels of these markers were higher in boys, in whom skeletal maturity is known to occur later.

Conclusion: Bone turnover increased significantly following LRYGB. Marked differences exist in the changes in body composition of adolescent males and females following LRYGB, males losing more fat and preserving more lean mass than females. The downward trend in BMD-Z appears to bring the majority of individuals back in line with the non-obese population within two years, but it will be crucial to observe and test this cohort in the longer-term, remaining particularly vigilant for potential or actual clinically relevant reductions.

 

Nothing to Disclose: EG, AB, TO, CNM, CEF, JD

PP07-2 21990 3.0000 THR-551 A Bone Health in Adolescents Following Roux-En-Y Gastric Bypass 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Anastasia-Stefania Alexopoulos*1, Maya Fayfman2, Liping Zhao3, Jeff Weaver1, Lauren Buehler1, Dawn Smiley2, Francisco J Pasquel2, Priyathama Vellanki2, Jeehea Haw2 and Guillermo E Umpierrez2
1Emory University, 2Emory University, Atlanta, GA, 3Research &Woodruff Health Sciences

 

We aimed to investigate the interplay between body mass index (BMI) and presence of hyperglycemia and diabetes (DM) status on hospital complications and clinical outcome.

We conducted a retrospective analysis on BMI, hospital complications, and hyperglycemia/diabetes among 47,962 patients (male 50.1%, age 59±17 years) admitted to two academic medical centres between 01/2012 and 12/2013. Patients were subdivided by BMI into underweight (BMI <18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), obesity grade 1 (BMI 30-34.9) and obesity grade 2 (BMI >35). Hospital complications included a composite of pneumonia, myocardial infarction (MI), respiratory failure, acute kidney injury (AKI) and bacteremia. Hyperglycemia was defined as a maximum blood glucose (BG) of >140 mg/dl during hospitalization. Further information was also obtained about type and number of comorbidities in patients across all BMI groups.

A total of 2,455 subjects were underweight (5%), 15,561 normal (32%), 13,916 overweight (29%), 8563 obesity grade 1 (18%) and 7467 obesity grade 2 (16%). There were 14,894 (31%) with DM and 33,068 (69%) without DM. Lower BMI was associated with higher rates of composite complications (29.5% underweight, 22.2% normal, 19.3% overweight, 20.3% obesity grade 1, 21.5% obesity grade 2, p=<0.0001). Patients with low and normal BMI had higher rates of in-hospital mortality (p=0.0002), pneumonia (p=<0.0001), acute respiratory failure (p<0.0001), AKI (p=<0.0001) and bacteremia (p=0.0120) compared to obese-range BMI. Non-diabetic patients with hyperglycemia experienced higher rates of composite complications across all BMI groups, with higher complications in underweight and normal BMIs (41.4% underweight, 31% normal, 26.9% overweight, 26.6% obesity grade 1 and 27.1% obesity grade 2, p<0.0001).  Obese patients had significantly more baseline comorbidities compared to those with normal and low BMI however there were higher rates of COPD and malignancy at lower BMIs (p<0.0001).

In summary, hyperglycemia and low BMI are associated with worse hospital outcomes compared to normoglycemia and overweight/obese-range BMI. Our results indicate the presence of an interesting and yet unexplained obesity paradox in hospitalized patients with and without hyperglycemia and diabetes.

 

Nothing to Disclose: ASA, MF, LZ, JW, LB, DS, FJP, PV, JH, GEU

19995 4.0000 THR-552 A Obesity Paradox in Hospitalized Patients with and without Hyperglycemia and Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Kevin D. Hall*1, Thomas Bemis1, Robert J Brychta1, Kong Chen1, Amber B Courville2, Stephanie Goodwin1, Juen Guo1, Lilian Howard1, Nicolas D Knuth3, Bernard V Miller III1, Carla M Prado4, Emma Preuschl1, Mario Siervo5, Monica C. Skarulis1 and Laura Yannai1
1NIH, Bethesda, MD, 2Clinical Center, NIH, Bethesda, MD, 3Towson University, Towson, MD, 4University of Alberta, Edmonton, AB, Canada, 5MRC Human Nutrition, Cambridge, United Kingdom

 

Dietary carbohydrate restriction has been hypothesized to induce metabolic and endocrine changes that promote increased adipose tissue lipolysis and fat oxidation thereby leading to greater body fat loss than isocaloric dietary fat restriction. While clinical weight loss trials have typically found that low carbohydrate diets cause greater short-term weight loss, diet adherence during outpatient interventions is uncertain and all three macronutrients were likely to have been altered. Therefore, the selective effect of restricting carbohydrate vs. fat on energy and macronutrient balance has yet to be determined.

We investigated whole-body energy expenditure and metabolic fat balance resulting from selective restriction of dietary carbohydrate vs. dietary fat in 19 obese, non-diabetic adults (10M/9F) with mean (±SE) age of 34±2 y and BMI of 36±1 kg/m2. Subjects were admitted to a metabolic ward and fed a eucaloric baseline diet (50% carbohydrate, 35 % fat, 15% protein) for 5 days followed by random assignment to 6 days of a 30% reduced energy diet achieved solely by restriction of either dietary fat (LF) or carbohydrate (LC). Volunteers were crossed-over and readmitted after a 2-4 week washout to repeat the baseline diet and alternate LC or LF diet. Subjects resided in a metabolic chamber on days 2 and 5 of the baseline diet and days 1, 4, and 6 of the reduced energy diets. Body fat loss was calculated as the cumulative metabolic fat imbalance during each LC and LF diet period.

After 5 inpatient days consuming 2720±50 kcal/d of the eucaloric baseline diet, the LC diet selectively removed 790 ± 20 kcal/d of carbohydrate such that the subjects were eating 30% carbohydrate, 49% fat, and 21% protein. The alternate LF diet selectively removed 800 ± 20 kcal/d of fat from the baseline diet such that the subjects were consuming 72% carbohydrate, 7% fat, and 21% protein. Daily energy expenditure decreased similarly on LC and LF diets (72±30 vs. 81±20 kcal/d; p=0.76) but more weight was lost with LC vs. LF (1.9±0.2 vs. 1.3±0.1 kg; p=0.05). Whole-body fat oxidation rapidly increased during the LC diet and reached a plateau at 426±40 kcal/d (p<0.0001) but was unchanged on the LF diet (-53±40 kcal/d; p=0.15). However, body fat loss was ~67% greater after 6 days of LF vs. LC (394±40 vs. 236±30 g; p=0.0003).

Long-term extrapolation of our results is fraught with difficulties. However, our data demonstrated that the LC diet increased fat oxidation rapidly and plateaued at ~400 kcal/d above fat intake. In contrast, the isocaloric LF diet demonstrated no change in fat oxidation despite reducing fat intake by ~800 kcal/d, thereby leading to a greater degree of fat imbalance. While fat oxidation during prolonged LF and LC diets would be expected to slowly wane over time, our data suggest that the greater fat imbalance is likely to persist with the LF diet leading to more long-term body fat loss than with the LC diet.

 

Nothing to Disclose: KDH, TB, RJB, KC, ABC, SG, JG, LH, NDK, BVM III, CMP, EP, MS, MCS, LY

20716 5.0000 THR-553 A Is a Calorie a Calorie? Metabolic Fat Balance Following Selective Isocaloric Restriction of Dietary Carbohydrate Vs. Fat in Obese Adults 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Stamatina Iliodromiti*, Naveed Sattar, Jason Gill and Mary Ann Lumsden
University of Glasgow, Glasgow, United Kingdom

 

The burden of diabetes and cardiovascular disease (CVD) is increasing worldwide but disproportionately within some ethnic groups, such as South Asians. South Asians in the western world have a 3-5 fold higher risk of developing type 2 diabetes (1, 2) and 2-fold risk of CVD than their comparators of white descent (3). A striking observation is that middle-aged South Asian women exhibit a disproportionately higher prevalence of type 2 diabetes compared with women from the background white population or South Asian men of similar age (2), but they have been largely overlooked and the majority of ethnic specific research has targeted South Asian men.

To study the impact of lifestyle factors and adiposity on insulin resistance (IR) and the interaction with ethnicity we recruited healthy women over the age of 40 years of South Asian (n= 68) and white descent (n= 64) who did not have overt disease. Age (54.4 ± 8.3 versus 54.9 ± 7.0 years, p=0.7) and BMI (27.1 ± 4.8 versus 26.8 ± 4.6 kg.m-2, p=0.66) did not differ between the groups. The South Asian women exhibited an insulin resistant phenotype with greater HOMAIR, higher levels of triglycerides and lower levels of HDL than their white comparators. Dietary intake and cardiorespiratory fitness did not differ substantially among the groups. However, the South Asians stored more fat centrally (assessed by the summation of central skinfolds; 71.7 ± 16.5 versus 63.6 ± 19.7 mm, p=0.01) for any given BMI. Interestingly, ethnicity modified the association between central adiposity and HOMAIR (p= 0.004 for interaction) and one standard deviation (SD) increase in central skinfolds was associated with a substantially higher increase in HOMAIR in the South Asian women than in the Europeans (56% (95% CI: 36%, 79%) versus 25% (95% CI: 14%, 38%)). On the contrary, one quintile increase in objectively measured moderate to vigorous physical activity had a similar impact on IR for both ethnic groups (8% (95% CI: 15%, 1%) decrease in HOMAIR). MRI of the abdomen and spectroscopy of the liver demonstrated that the South Asians stored similar amounts of subcutaneous adipose tissue (SAT) to the women of white descent (259.6 ± 92.9 versus 264.5 ± 103.6 cm2, p=0.8), but greater visceral adipose tissue (VAT) (127.7 ± 68.9 versus 93.0 ± 51.6 cm2, p=0.01) and ectopic liver fat (7.2% versus 4.9%, p=0.04) than their white comparators. The effect size of increasing VAT on IR was greater than the effect size of SAT for both ethnic groups. We concluded that central adiposity has a greater effect size than other lifestyle factors on IR and this is substantially larger in women of South Asian than in women of white descent. In addition, our findings supported the “adipose overflow theory” suggesting that South Asian women start storing fat in deeper or ectopic compartments, which are associated with greater IR, at a lower threshold of adiposity than women of white descent.

 

Nothing to Disclose: SI, NS, JG, MAL

21648 6.0000 THR-554 A Central Adiposity Has a Greater Impact on Insulin Resistance (IR) in Healthy Women of South Asian Descent Than in Women of White Descent Living in Scotland 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Andrew Paul Demidowich*, Dimitri Koutzoumis, Angela Davis, Nicket Dedhia, Robin Roberson, Ovidiu A Galescu, Joo Yun Jun, Dezmond Taylor-Douglas, Sara Anais Armaiz, Sheila M Brady and Jack Adam Yanovski
Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD

 

Background:  The melanocortin receptor family plays a prominent role in energy homeostasis. The melanocortin 4 receptor and melanocortin 3 receptor (MC3R) appear to exert independent actions on energy intake, energy expenditure and nutrient partitioning to alter body composition. In vitro, the C17A (Thr6Lys) + G241A (Val81Ile) human MC3R haplotype, which has high prevalence among African Americans, impairs melanocortin 3 receptor (MC3R) function. In vivo, homozygosity for the C17A + G241A MC3R haplotype is associated with obesity and reduced lean body mass percentage among children. Recent knock-in mouse studies from our group have found that homozygosity for the C17A + G241A MC3R haplotype is also associated with a favorable metabolic phenotype despite a propensity for greater fat mass and less fat-free mass.  However, to date the effects of these MC3R polymorphisms on metabolism and body composition in adults have not been well characterized.

Objective: We investigated whether the MC3R C17A + G241A MC3R haplotype is associated with metabolic or phenotypic consequences in overweight adults.

Methods: A convenience sample of obese (BMI ≥ 30 kg/m2) otherwise healthy African American adults was examined at the NIH Clinical Center.  Serum samples to assess components of the metabolic syndrome, insulin resistance, and inflammation were obtained in the morning in the fasted state.  Genotype analyses for the MC3R allelic variants C17A (rs3746619) + G241A (rs3827103) were performed using Taqman assays. Body composition (n=75) was assessed by dual-energy X-ray absorptiometry (DXA).  The primary statistical analyses were performed using an analysis of variance.

Results: We studied 82 obese African Americans (age 35.9±11.0y; BMI 38.6±7.1; 82% female), of whom 30.5% (n=25) were homozygous wild-type, 45.1% (n=37) were heterozygous and 24.4% (n=20) were homozygous for the MC3R C17A + G241A haplotype.  Groups had similar BMI, waist circumference and fat mass (all p’s NS). However, homozygous C17A + G241A MC3R subjects demonstrated significantly lower serum triglycerides than heterozygous or homozygous wild-type MC3R subjects (65.7±7.8 vs. 93.2±5.6 vs. 81.4±6.8 mg/dL, p<0.05), even after correction for age, sex and BMI.  Decreased lean mass was also seen among homozygous C17A + G241A subjects versus other groups (p<0.05).  Blood pressure, fasting glucose, insulin resistance (measured as HOMA-IR), LDL-cholesterol, HDL-cholesterol, free fatty acids and hsCRP were not significantly different among genotypes after adjusting for confounding variables (ps>0.05).

Conclusion: Among obese African Americans, the MC3R C17A + G241A haplotype is associated with decreases in total body lean mass and lower serum triglycerides.  These results suggest this haplotype might be protective for cardiovascular disease associated with obesity in African Americans.

 

Disclosure: JAY: Principal Investigator, Zafgen. Nothing to Disclose: APD, DK, AD, ND, RR, OAG, JYJ, DT, SAA, SMB

20011 7.0000 THR-555 A The Melanocortin 3 Receptor C17A + G241A Haplotype Is Associated with Lower Serum Triglycerides and Reduced Lean Mass in Obese African American Adults 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Milana Kokosar*1, Anna Benrick1, Alexander Perfilyev2, Emma Nilsson3, Manuel Maliqueo4, Carl Johan Behre5, Antonina Sazonova6, Charlotte Ling2 and Elisabet Stener-Victorin7
1Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2Lund University Diabetes Centre, Lund University, Clinical Research Centre, Malmö, Sweden, 3Lund University Diabetes Centre, Clinical Research Centre, Malmö, Sweden, 4University of Chile, Santiago, Chile, 5Institute of Medicine, Göteborg, Sweden, 6Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 7Karolinska Institutet, Stockholm, Sweden

 

Background: Adipose tissue abnormalities may explain metabolic dysfunction in women with polycystic ovary syndrome (PCOS). Our hypothesis is that aberrant gene expression and DNA methylation in adipose tissue explain metabolic and endocrine abnormalities that often proceed to the development of type 2 diabetes mellitus in women with PCOS.

Objectives: To investigate genome-wide expression and DNA methylation in adipose tissue from women with and without PCOS.

Patients: In this cross-sectional study subcutaneous abdominal fat biopsies were collected after an overnight fast in 64 women with PCOS and 30 controls. Insulin sensitivity has been determined with a euglycemic hyperinsulinemic clamp and circulating Hba1c, adipokines, lipid profile and sex-steroids have been analyzed.

Methods: For analysis of gene expression Illuminas direct hybridization whole- genome expression assay (HumanHT-12 Expression Bead Chip) was used. Differentially expressed genes were integrated with known pathways using Ingenuity Pathway Analysis (IPA). DNA methylation in adipose tissue was analyzed by using Illumina Infinium HumanMethylation450 BeadChip, which covers 485,577 CpG sites.

Results: In total, 1899 genes remained significantly differentially expressed in adipose tissue after application of false discovery rate (FDR) correction (q < 0.05) between women with and without PCOS. Of these were 1019 genes down-regulated and the expression difference ranged between 3 − 57% and 880 genes were up-regulated and ranged between 1.4− 57 %. The most down-regulated genes were: LOC100132761, DEFB32, C6, SLC7A10, PKD1L2, LOC389342, MYOC, C21org81 and, LOC729222, and the most up-regulated genes were: ERAP2, LBP, CCL19, HSD11B1, CD74, SNORD48, APOLD1, IDO1, MYL9, and NRCAM.

The following pathways in our data set were found to be activated: PI3K/AKT signaling, ILK signaling, HIPPO signaling, ERK/MAP and p70S6K signaling.  Up regulated gene sets include pathways involved in estrogen biosynthesis, glucocorticoid regulation and IGF-1 signaling; and down regulated gene sets include pathways involved in lipids and carbohydrates metabolism.

A total of 63 213 sites were significantly differentially methylated (p < 0.05) in adipose tissue between cases and controls. After applying FDR correction only one CpG site (cg13496119; LOC100129345) remained significantly different (q < 0.05). Currently gene expression and methylation data with q < 0.15 are merged and correlations between molecular analyses and clinical variables will be performed.

Conclusions: Women with PCOS exhibit aberrant adipose tissue gene expression associated with metabolic and steroid signaling. Whether these, in part, can be explained by epigenetic changes needs further exploration.

 

Nothing to Disclose: MK, AB, AP, EN, MM, CJB, AS, CL, ES

PP07-4 20279 8.0000 THR-556 A Genome-Wide Gene Expression and DNA Methylation Profiles in Adipose Tissue from Women with and without PCOS 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Sarah Anne Robert*1, Rohana Abdul Ghani2, Suehazlyn Zainudin1, Shamsul Azhar Shah3, Wan Nazaimoon Wan Mohamud4 and Nor Azmi Kamaruddin1
1Universiti Kebangsaan Malaysia Medical Centre, Malaysia, 2Universiti Teknologi Mara, Malaysia, 3Universiti Kebangsaan Malaysia, Malaysia, 4Institute of Medical Research, Malaysia

 

Obesity is one of the leading non-communicable diseases, associated with the development of metabolic syndrome, cardiovascular disease and diabetes mellitus. Binge eating behavior (BEB) has been increasingly described in a subset of obese individuals. It is characterized by eating a large amount of food uncontrollably in the absence of purging. It has been hypothesized that appetite hormones in individuals with BEB may be affected. This study aimed to investigate potential differences in  ghrelin, leptin, GLP-1, NPY, insulin and glucose; and their associations to appetite ratings between obese individuals with and without binge eating behavior. Obese subjects attending the weight management clinic were screened for BEB with a validated binge eating scale questionnaire. Sixty-five obese, non-diabetic individuals consisting of 44 with BEB and 21 without BEB were recruited. Baseline clinical and biochemical characteristics were comparable in both groups. Following a 12 hour overnight fast, subjects were subjected to a standardised meal test and blood was drawn at seven time points (-15, 0, 15, 30, 60, 90, 120 mins). Hunger and fullness ratings were also obtained. Ghrelin and insulin was found to be significantly lower at time 60 min in those with BEB compared to those without BEB (7.36±2.49 ng/ml vs 8.96±2.77ng/ml, p= 0.023 and 88.1±58.0uIu/ml vs 128.9±70.1uIu/ml, p=0.016). GLP-1 was found to be significantly lower at time 15 min in those with BEB compared to those without BEB (38.4±14.7pmol/L vs 47.3±19.6pmol/L, p=0.047). Leptin, NPY, glucose and appetite ratings did not differ between the 2 groups. In conclusion, obese individuals with BEB had lower ghrelin, GLP-1 and insulin levels compared to those without BEB. We postulate that the differences in ghrelin, GLP-1 and insulin represent postprandial downregulation and desensitization of the hormones as a result of binge eating permitting the individuals to persist with their food consumption albeit unregulated.

 

Nothing to Disclose: SAR, RA, SZ, SAS, WNW, NAK

20919 9.0000 THR-557 A Prandial Downregulation of Ghrelin, GLP-1 and Insulin Levels Is Observed in Obese Individuals with Binge Eating Behavior Following Standard Meal 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Charlotte Verroken*, Jean-Marc Kaufman, Stefan Goemaere, Kaatje Toye and Bruno Lapauw
Ghent University Hospital, Gent, Belgium

 

BACKGROUND: The osteoblast-derived protein osteocalcin has been proposed as a mediator in the cross-talk between bone and energy metabolism. However, results from human studies investigating the associations between osteocalcin and metabolic parameters are inconsistent. Moreover, few studies have investigated these relationships in young and healthy individuals.

OBJECTIVE: We aimed to investigate the associations between osteocalcin levels and parameters reflecting metabolic health in a cohort of young, healthy men.

METHODS: A cross-sectional, population-based sibling pair study was conducted, including 1001 healthy men aged 25-45 years. Clinical assessments included height, weight, waist/hip ratio (WHR), DXA-derived body composition and blood pressure. Total cholesterol, glucose, insulin, leptin, adiponectin, SHBG and total osteocalcin levels were determined in fasting serum samples. Insulin resistance was evaluated using the homeostasis model assessment of insulin resistance (HOMA-IR). Testosterone levels were determined using LCMS-MS, free and bioavailable testosterone levels were calculated. Cross-sectional relationships were assessed using linear mixed-effects modeling.

RESULTS: Osteocalcin levels were available in 996 men (mean 22.7+/-6.5 ng/mL, normal range 14-42 ng/mL) and were inversely associated with age (β=-0.37; p<0.001), BMI, fat mass, waist circumference, WHR, truncal and appendicular fat mass and total lean mass (β=-0.07--0.29; p<0.001 for all associations except for total lean mass: p=0.019), whereas they were positively associated with percentage lean mass (β=0.28; p<0.001). In addition, osteocalcin levels were inversely related to fasting glucose and insulin levels and to HOMA-IR index, as well as to total cholesterol levels, leptin, diastolic blood pressure and mean arterial pressure (β=-0.10--0.26; p<0.001 for all associations except for mean arterial pressure: p=0.001). Moreover, a positive correlation existed with adiponectin levels (β=0.08; p=0.033) and with total, bioavailable and free testosterone levels (β=0.07-0.14; p<0.001, p=0.001 and p=0.024, respectively). After adjustment for age and fat mass, most of these associations attenuated and were no longer significant, except for the inverse associations between osteocalcin and fasting glucose (β=-0.07; p=0.034) and leptin levels (β=-0.04; p=0.031). Fat mass, on the other hand, was independently associated with a less favorable metabolic profile and lower testosterone levels.

CONCLUSION: In this cohort of young, healthy men, the relation between lower serum osteocalcin levels and a less favourable metabolic profile was mediated through fat mass. This may reflect an inverse association between fat mass and bone turnover or, more hypothetically, the reciprocal differentiation of mesenchymal stem cells towards the osteogenic versus adipogenic lineage.

 

Nothing to Disclose: CV, JMK, SG, KT, BL

20983 10.0000 THR-558 A In Young, Healthy Men, the Relationship Between Serum Osteocalcin Levels and Metabolic Profile Is Mediated through Fat Mass 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Loan Nguyen, Shuguang Li*, Bingfang Yue and Wenzhe Li
NMS Labs

 

Background:Leptin has been proposed to be an essential signaling factor to regulate body weight homeostasis and energy balance.  It is synthesized in adipose tissue and binds to specific receptors in the hypothalamus to control appetite and energy intake.  Increased plasma Leptin concentration suppresses appetite and elevates thermogenesis. Leptin deficiency leads to hypopituitarism and massive obesity.

Methods:  The leptin assay is performed according to the instructions supplied by the manufacturer with some modifications. Serum (50 µL) is first diluted with standard diluent 1:4 and then diluted with sample diluent 1:10 before aliquoted in duplicate onto a 96-well microplate. The calibrator is first serially diluted with standard diluent and then each level is diluted with sample diluent 1:10 before aliquoted onto the microplate in duplicate. Data analysis is performed with Bio-Plex Manager software version 6.1.

Results and Discussion: Although the Bio-Plex 200 system has a signal output (fluorescence intensity) up to ~25,000 for the leptin assay, the linear signal output is around 10, 000, due to signal saturation.  Thus, a linear calibration curve is opted instead of a five-parametric sigmoidal dose-response curve fitting recommended by the manufacturer. The linear calibration greatly improves accuracy and precision with a reasonable linear dynamic range and it is necessary to dilute samples of high concentration level. The within-run coefficients of variance (CV) are < 6.4% for three levels of quality control samples while between-run CVs are <8.9%.

In an effort to harmonize the assay, specimens are sent to another reference laboratory for leptin measurement by a quantitative chemiluminescent immunoassay (CIA). The correlation coefficient (r, EP Evaluator 8, Deming regression) is 0.9523, n=46. Considering the apparent signal saturation with the CIA method, data points with high concentration levels (leptin by CIA >10.5 ng/mL) were removed, and the correction coefficient r for the latter data set is 0.9655, n=35 . In order to investigate the discrepancy observed in regression slope, recovery study using metrological traceable standard solution (Sigma, recombinant leptin human) was performed with mean recovery of 98.5%.  Large differences in absolute leptin concentration levels were found, and the assay is calibrated traceable to the reference laboratory to facilitate lab-to-lab patient comparison.

Conclusions: The leptin assay on the Bio-Plex platform (multiplex immunoassay) is successfully validated and is suitable for clinical use in reference laboratory settings. Caution must be exercised when comparing absolute concentration levels from different manufacturers and platforms. It is also necessary to note the assay performance dependence on assay platform, sample type and concentration levels when interpreting clinical results.

 

Nothing to Disclose: LN, SL, BY, WL

21227 11.0000 THR-559 A Validation of Human Serum Leptin Assay on Multiplex Immunoassay Platform 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


David R. Saxon*1, Erin Leister2, Rebecca B. Speer3, Hildegard Ayora3, Adam G. Tsai4, Elizabeth H. Kealey5, Elizabeth Juarez-Colunga2, Sara Bleich6, Jeanne M. Clark7, Kimberly A. Gudzune7 and Daniel H. Bessesen8
1University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, 2University of Colorado Anschutz Medical Campus, 3Denver Health Medical Center, Denver, CO, 4Kaiser Permanente, Denver, CO, 5University of Colorado Anschutz Medical Campus, Aurora, CO, 6Johns Hopkins University/Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 7The Johns Hopkins University School of Medicine, Baltimore, MD, 8University of Colorado School of Medicine, Anschutz Medical Campus, Denver, CO

 

Primary care providers (PCPs) are on the frontlines of addressing the obesity epidemic. However, evidence based weight loss strategies are often difficult to discuss and implement in a busy clinical environment. We are conducting a pragmatic trial that offers a variety of weight loss interventions to patients through 4 primary care clinics serving an ethnically diverse medically underserved population. Prior to study initiation, PCPs were surveyed regarding their perceptions about obesity as a problem for their patients, their comfort discussing specific weight loss strategies with patients, thoughts on the effectiveness of specific evidence based weight loss strategies, and views on barriers to providing weight loss advice to their patients.

A total of 85 PCPs were anonymously surveyed (72% MDs, 30% male). All questions were answered on a 0 to 10 scale with 10 being a highly positive rating. Overall, providers identified obesity as a very significant problem for their patients (median 9.0, IQR 8.0-10.0) and they were generally comfortable discussing weight with their patients (median 8.0, IQR 7.0-9.0). However, they felt less strongly that the advice they provided had an impact on weight (median 6.0, IQR 5.0-7.0). When asked about specific weight loss interventions, providers felt most comfortable discussing exercise as a weight loss strategy (median 8.0, IQR 7.0-9.0), were less comfortable discussing portion control (median 6.0, IQR 4.0-7.0), and least comfortable discussing phentermine-topiramate ER (median 3.0, IQR 1.5-6.0). They also ranked exercise as the most effective weight loss option for their patients (median 8.0, IQR 5.0-9.0) and felt that lifestyle intervention, portion control, phentermine, and phentermine-topiramate ER were less effective weight loss tools. Lack of time (median 8.0, IQR 7.0-9.0) and patient non-adherence (median 8.0, IQR 7.0-9.0) were the highest rated barriers to providing advice on weight loss, whereas insufficient training (median 6.0, IQR 5.0-7.0) and ineffective treatment options (median 6.0, IQR 4.0-7.0) were less significant barriers.

The results of this survey of PCPs highlights the need for continued education about obesity management. Providers appeared to overvalue exercise as a weight loss method and were less comfortable and confident with several weight loss tools that are known to be of greater effectiveness (i.e. portion control and medications). Strategies to improve PCPs knowledge and distribution of effective and readily available weight loss tools requires further evaluation, particularly because provider beliefs about the diet-related causes of obesity translate into actionable nutritional counseling topics which physicians could use with their patients (1).

 

Nothing to Disclose: DRS, EL, RBS, HA, AGT, EHK, EJ, SB, JMC, KAG, DHB

19692 12.0000 THR-560 A A Toolbox Approach for the Treatment of Obesity in Primary Care: Results of a Provider Survey Regarding Weight Loss Management 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Amy E Rothberg*, Laura N McEwen, Andrew T Kraftson, Nevin N Ajluni, Christine E Fowler, Nicole M Miller, Katherine R Zurales and William H Herman
University of Michigan, Ann Arbor, MI

 

Background:  We sought to identify factors associated with participant retention in a 2-year, physician-lead, multidisciplinary, clinical weight management program that employs meal replacements to produce weight loss and intensive behavioral interventions and financial incentives for weight loss maintenance. 

Methods:  Prospective observational study of 300 consecutive participants enrolled in 2010 and 2011.  Sociodemographic factors, health insurance, distance traveled, body mass index, comorbidities, health-related quality-of-life, and depression were explored as potential predictors of retention.

Results:  Mean age was 49 ± 8 years and BMI was 41 ± 5 kg/m2.  Retention was excellent at 3 months (90%) and 6 months (83%).  Attrition was greatest after participants were transitioned to regular foodstuffs and fell to 67% at 12 months and 51% at 2 years.  Weight decreased by 33 ± 26 pounds and BMI decreased by 5.1 ± 4.0 kg/m2 in 2-year completers.  Older age, lower baseline BMI, and financial incentives for program participation were independently associated with retention.  Fewer depressive symptoms at baseline were associated with retention. 

Conclusions:  This multidisciplinary clinical, weight management program demonstrated high retention and excellent outcomes.  Older age at baseline, less extreme obesity, financial incentives, and fewer depressive symptoms were associated with program retention.

 

Nothing to Disclose: AER, LNM, ATK, NNA, CEF, NMM, KRZ, WHH

18359 13.0000 THR-561 A Factors Associated with Participant Retention in a Clinical, Intensive, Behavioral Weight Management Program 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Adaku Ume*1, Petra Duran2, Elizabeth Driscoll3, Juan De La Cruz Mayhua2, Cindy Nativi2, Felicia Eugenio2, Jasmine Eugenio4 and Theodore C Friedman5
1Charles R. Drew University of Medicine and Science, Los Angeles, CA, 2Charles R. Drew University, Los Angeles, CA, 3Martin Luther King, Jr. Outpatient Center, Los Angeles, CA, 4Martin Luther King, Jr. Multi-Service, Ambulatory Care Center, Los Angeles, CA, 5Charles R. Drew Univeristy of Medicine and Science, Los Angeles, CA

 

Obesity disproportionately affects minorities, the poor and those with little or no insurance making it an important health disparity. Obesity contributes to high rates of diabetes, cardiovascular disease, strokes, cancers, depression, arthritis and other diseases that also contribute to health disparities. Because of the volume of obese minority and underserved, innovative, high-volume, high-quality programs are needed to reduce this health disparity. Group models for care of patients began in 1907 at the Massachusetts General Hospital, when Pratt developed the first group program for tuberculosis. More recently, the “shared medical care” model, also known as a “group medical visit” as first described by Scott or “shared medical appointment” as described by Noffsinger has received increased attention. Traditional provider-patient visits usually involved one provider with one patient. The group visit model is one provider with multiple patients and the patients themselves supply support and information to each other. This model is ideal for treating obesity.

In January 2013, we started an obesity group visit program at Martin Luther King, Jr. Multi-Service, Ambulatory Care Center (MLK-MACC) named the POWER clinic (P-prevent, O-obesity, W-with, E-eating, R-right) that meets weekly on Monday afternoons with 4 cadres of patients each attending monthly. We have consented 125 patients for our pilot study. From date of IRB approval (9/2013), 28 weekly clinic group visits occurred. Approximately 80% of the patients attending the group visit clinic consented to be in the study and have their data collected. Fifteen (12%) patients lost at least 8 pounds, 9 (7%) patients lost 5% of their weight, 2 (2%) subjects lost 10% of their weight. 53 (42%) subjects came to all of their visits and 84 (67%) subjects came to at least half of their visits. The majority of patients had pre-diabetes with 50% of them having an HbA1c between 5.7% and 6.4%. Nine (3%) patients either strongly disagreed or disagreed that they felt comfortable to share and discuss their medical information in a group setting. Overall, satisfaction was high with a reasonable percentage of patients losing a significant amount of weight. Group visits can lead to improved patient access, increased provider productivity, improved outcomes and life style changes, and high patient satisfaction scores. It is estimated that having 20 patients in a 2-hour group visit saves the medical center $12,600/session compared to individualized visits. From January 2013 to June 2014, having 72 group visit sessions conducted resulted in an approximate cost avoidance of $882,000. We conclude that obesity group visits are a viable model for treating a large number of obese patients in an inner city medical center.

 

Nothing to Disclose: AU, PD, ED, JD, CN, FE, JE, TCF

21652 14.0000 THR-562 A Obesity Group Visits: A New Approach for a Big Problem of Inner City Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Raphael Hulkower*1, Nichola Davis2, Clyde Schechter3 and Elizabeth Walker3
1Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, 2North Central Bronx, Albert Einstein College of Medicine, 3Albert Einstein College of Medicine of Yeshiva University

 

Background

It is not known if perceived health risk is related to dietary behavior among obese individuals. Belief that weight is not a health risk has been associated with fewer attempts at weight loss (1,2). We sought to determine the associations between BMI, calories purchased in fast food restaurants (FFR), and risk perception among overweight and obese adults.  We hypothesized that participants with higher BMI would have greater risk perception related to their weight, and would purchase fewer calories from FFR.   

Methods

145 participants completed an obesity risk perception survey as part of the Calorie Health Education Knowledge and Skills (CHEKS) study.  The 20 item survey was modified from the Risk Perception of Diabetes survey and included four subscales related to obesity: perceived control (3 items), personal disease risk (13 items), worry (2 items), optimistic bias (2 items), and a composite score for perceived risk (3,4).  These subscales were based upon factors identified in previous risk perception research not related to obesity (5,6).   Participants were recruited from municipal hospital clinics in Bronx NYC, a largely Latino and Black population.  Participants were age >18 years, fluent in Spanish or English and frequented fast food restaurants at least once per week. Over 1-2 weeks, participants submitted all food receipts from visits to fast food restaurants from which calories were calculated.  Height and weight were measured at baseline and the risk perception survey was completed.   Unpaired t-tests and Pearson’s correlations examined the relationship between obesity risk perception scale scores, BMI, and calories purchased. 

Results

At baseline, participants had a mean (SD) age of 49 (12) and 73 % were female.  Mean BMI was 34 (7).  On average participants purchased 970 (1690) calories from FFR.  Composite risk, personal disease risk, and worry positively correlated with BMI (r=0.247; r= 0.291; r= 0.375 p=<0.05 for all).  Optimistic bias negatively correlated with BMI (r=-0.237, p=0.004).  Participants who considered themselves overweight, and who considered losing weight to be very important had higher worry scores, p<0.005.  Participants trying to lose weight also had higher worry scores, p<0.005. There was no significant correlation between perceived control and BMI.  There was no correlation between composite risk or any subscales and calories purchased from fast food restaurants.

Conclusions

As BMI increases, participants reported higher perceived risk and worry about health complications.  Despite this perceived risk, participants purchased high calorie foods from FFR.  Participants also reported lack of perceived control over their health risk, which may explain the lack of association between risk perception and fast food behavior.  These findings suggest that strengthening perceived control regarding obesity may be an important aspect of lifestyle interventions.

 

Nothing to Disclose: RH, ND, CS, EW

18721 15.0000 THR-563 A Risk Perception of Obesity and Fast Food Behavior Among Obese Adults in Primary Care 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


V Daniel Castracane*1, Lauren Hermann2, Maria Aguas2, Evelyn Mitchell2, Andrew Tang2, Robert Vasquez2 and William Meachum3
1Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX, 2TTUHSC of the Permian Basin, 3TX Tech University Health Sciences Center of the Permian Basin, Odessa, TX

 

Introduction: The Institute of Medicine has recently revised the weight gain considered to be appropriate during gestation, in an attempt to reduce excess weight gain during gestation.   Obesity is known to be associated with health risks to both mother and fetus.

Materials and Methods:  In this study we have used chart reviews to plot maternal weight throughout pregnancy and to determine GWG for the 1st, 2nd and 3rd trimester.  For the first aspect, we used those subjects whose first obstetrical visit was in the first trimester (which is not common in our clinic).  We have included a group of gestational diabetic pregnant women in this group as well.  We have also studied those subjects whose first visit was in the second trimester of pregnancy to calculate GWG for the 2nd and 3rd trimester.  Subjects were studied in the normal weight, overweight, obese and morbidly obese (MO)  groups.  A total of 221 obstetrical records were used for these studies.

Results: -  In the 1st trimester all groups had minimal gestational weight gain and the morbidly obese group actually lost weight.  In the 2nd trimester, the normal, overweight and obese groups gained between 9 and 13 lbs while the MO group gained only 5.6 lbs.  A similar distribution was seen in the third trimester.   For those subjects studied only in the 2nd and 3rd trimesters, results were similar except that the MO group gained a similar amount to all other groups 14-15 lbs).  In the graphs of these weight gains it clear that little weight gain occurs in the first trimester and the first sign of weight gain (if it occurs) is seen at about mid gestation.  The Gestational diabetic subjects  did not gain as much weight as normal controls. Maternal weight in the first trimester would be similar to prepregnancy weight.

Conclusion:   GWG can be variable, but is generally greatest in normal lean pregnant women) and lowest in the morbidly obese pregnant women.

 

Nothing to Disclose: VDC, LH, MA, EM, AT, RV, WM

20588 16.0000 THR-564 A Longitudinal Study of Gestational Weight Gain Across the Range of BMI 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Abraham Stijn Meijnikman*1, An Verrijken2, Ilse Mertens3, Christophe E De Block4 and Luc F Van Gaal5
1Univeristy of Antwerp, Wilrijk, Belgium, 2Antwerp University Hospital, Edegem, 3Antwerpen University Hospital, Edegem, 4Antwerp University Hospital, Edegem (Antwerp), Belgium, 5Faculty of Medicine, Antwerp University Hospital, Edegem, Belgium

 

The Findrisc score helps in assessing diabetes status in an overweight or obese population

Context: The Findrisc score is a valuable screening tool for patients at risk of developing diabetes, but it was never used in an exclusively overweight/obese population.

Methods: A total of 651 apparently healthy overweight and obese subjects (M/F: 193/458, BMI 38.2±6.1 kg/m², age 43±13 y) were tested for glucose status using OGTT and HbA1c. Anthropometric measures including CT visceral fat, and Findrisc score were determined.

Results: Exactly 50.4% were found to have pre-diabetes and 11.1% were newly diagnosed with type 2 diabetes (M/F= 22.2/8.8%). Subjects without diabetes had a Findrisc score of 11±3, those with pre-diabetes 13±4 and subjects with previously unknown diabetes 15±5 (p<0.0001). BMI was 37±6 kg/m² in non-diabetic subjects compared to 39±6 kg/m² in both pre-diabetic and diabetic subjects. Waist circumference increased in the 3 groups from 111±14 cm in non-diabetic, to 118±14 cm in pre-diabetic, to 123±14 cm in subjects with screen detected diabetes (p<0.001). Visceral fat area increased with worsening of glucose status from 148(98-192) cm² in non-diabetic subjects to 201(147-264) cm² in pre-diabetic and 245(192-325) cm² in diabetic subjects (p<0.001).

Subjects with a Findrisc score <12 had less visceral fat [158.5(105-210) vs 203(146-272) cm², p<0.001] and a lower HbA1c [5.4(5.2-5.6) vs 5.6(5.4-5.9)%, p<0.001] compared to those with a Findrisc score ≥12. Fasting [83(78-90) vs 89(82-98)mg/dl, p<0.001] and 2h post-OGTT glycaemia [130(111-148) vs 152(126-181)mg/dl, p<0.001] also differed. 81% of the subjects with screen detected diabetes had a risk score ≥12. The sensitivity of the Findrisc when using 12 as cutoff value was 80.6%, the specificity was 47.8%. Logistic regression analysis with diabetes status as dependent variable identified the Findrisc score (B=0.156,p<0.0001), and visceral fat (B=0.06,p<0.0001) as independent risk factors. From the risk factors which are included in the Findrisc model, age (B=-1.3,p<0.021), history of hyperglycemia (B=-0.863,p<0.006), and increased blood pressure (B=1.378,p<0.002) were identified as independent risk factors, but not BMI, waist, physical activity, eating habits, nor familial diabetes in this overweight/obese population.

Conclusion: In an exclusively overweight/obese population, 50.4% of the subjects had a pre-diabetic state and 11.1% were newly diagnosed with type 2 diabetes. The Findrisc score increased with worsening of glucose tolerance status (11 in non-DM, 13 in pre-DM and 15 in DM), and proved to be an independent predictor of diabetes status, as well as visceral fat area. Using the Findrisc score to predict the diabetes risk in overweight/obese subjects, age, systolic blood pressure and history of hyperglycemia are the most important discriminating parameters.

 

Nothing to Disclose: ASM, AV, IM, CED, LFV

19771 17.0000 THR-565 A The Findrisc Score Helps in Assessing Diabetes Status in an Overweight or Obese Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Joshua Eugene Burkholder*1, Irene Beck1, Maximilian Hohenadel1, Jonathan Krakoff2, Marie S Thearle3 and Marci Gluck1
1Phoenix Epidemiology and Clinical Research Branch, NIDDK/NIH, Phoenix, AZ, 2Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, 3National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ

 

Background

Cross sectional studies have reported that individuals with excess adipose tissue perform worse on behavioral tasks assessing executive function (EF) compared to healthy weight controls. The reproducibility of these tests and whether longitudinal changes of task performance are related to changes in adiposity is not known. In a longitudinal sample, we assessed measures of EF: decision making by the Iowa Gambling Task (IGT), cognitive flexibility by the perseverative error score on the Wisconsin Card Sorting Test (WCST), and inhibition response by the Stroop Word Color Test interference score (SWCT).

Methods

                Twenty subjects who participated in different studies on our clinical research unit with baseline and follow-up measures of BMI, body composition by DXA (mean follow up time= 1.3±0.7 years; range= 0.5 to 3) and EF, including IGT (raw mean score ± SD=4.1±23.9), WCST (18.9±12.6) and SWCT (23.7±12.2) were selected for analysis (18m/2f; 3AA, 3H, 5C, 1A, 8NA; baseline age 34±9 years; %fat 29±13%; BMI 30±8 kg/m2; waist circumference (97.5±20 cm), fat mass (FM)(28±17 kg) and fat free mass (FFM)(62±13 kg).

Results

                There was no directionality to the changes on the IGT (-0.5±21) or SWCT (-1±13) however, the average WCST perseverative error score improved over time (-6±13), consistent with a learning effect (p=0.05). Intraclass correlation coefficients (ICC) demonstrated modest reproducibility for the IGT (0.52) and WCST perseverative error scores (0.44) but only slight reproducibility for the SWCT interference score (ICC = 0.19). For comparison purposes, the ICC for weight was 0.98.

 The rate of change in waist circumference (1.8±3.3 cm/year) and rate of BMI change (0.4±1.3 kg/m2/year), were negatively associated with the rate of change in IGT score per year (BMI r= -0.5 p=0.01; waist r=-0.5 p=0.02). A higher IGT score represents an improved performance. There was also a trend for weight (p=0.06), FM (p=0.06) and FFM (p=0.07) change per year to be negatively associated with change in IGT score per year. There was no association with the rates of change in adiposity measures with the rates of change in the WCST or SWCT.

Conclusion

The IGT and WCST have a moderate reproducibility over time, indicating they likely represent stable, individual traits even in a diverse population with varying adiposity. This association between rate of weight change and change in IGT score indicates that increases in BMI and waist circumference lead to declines in performance on specific decision making tasks. These deficits in decision making could result in difficulty formulating choices which could lead to weight loss.

 

Nothing to Disclose: JEB, IB, MH, JK, MST, MG

21378 18.0000 THR-566 A Decision-Making Is Reproducible and Is Associated with Changes in Body Composition over Time 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Yoon Jung Kim*1, Sin Gon Kim2, Hee Young Kim2, Doo-Man Kim1, Juri Park1 and Ho Young Son1
1College of Medicine, Hallym University, Seoul, Korea, Republic of (South), 2College of Medicine, Korea University, Seoul, Korea, Republic of (South)

 

Background : The number of North Korean refugees (NKRs) residing in South Korea has gradually increased. But to date, there is no available data of weight gain and metabolic syndrome among NKRs who settled in South Korea.

Methods From the NOrth Korean Refugee health iN South Korea (NORNS) study, we investigate the association of weight gain and residence duration in South Korea with the risk of metabolic syndrome among NPRs.

 Results There is no significant association between residence duration and risk of metabolic syndrome among NKRs. A logistic regression model adjusted for smoking, alcohol, exercise, education (North Korea), income (South Korea), defection period (3rd country) found that NKRs who experienced weight gain in South Korea had higher risk of developing metabolic syndrome (no increase : 1, less than 5% weight gain : odds ratio (OR) 3.47 [95% CI 1.11-10.78], more than 5% weight gain : OR 6.04 [95% CI 2.26-16.17]). Additionally, NKRs who were underweight when they arrived in South Korea had higher risk for excess weight gain than normal or overweight subjects (overweight : 1, normal weight : OR 2.63 [95% CI 1.49-4.63], underweight : OR 10.91 [95% CI 4.12-28.92] ).

Conclusions   The risk of metabolic syndrome is associated with weight gain in South Korea, but not with residence duration. Among NKRs who were underweight when arrived in South Korea have higher risk of excess weight gain.

 

Nothing to Disclose: YJK, SGK, HYK, DMK, JP, HYS

21382 19.0000 THR-567 A The Association Between Weight Gain and Metabolic Syndrome Among North Korean Refugees in South Korea 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Elena Kharlamova*, Julia Samoylova, Oxana Oleynik, Nadejda Suslyaeva and Vera Zavadovskaya
Siberian State Medical University, Tomsk, Russia

 

Evaluate the significance of radiological methods of diagnosis of visceral obesity in patients with obesity and metabolic syndrome (MS)

Examined 78 obese patients with MS, mean age 45,9 ± 15,5 years, including 38 men and 40 women. Comparison group: 20 obese patients with varying degrees (8 males, 12 females, mean age of 48,2 ± 9,3 years) without having criterion MS. The control group included 25 people (10 males and 15 females, mean age 46,3 ± 4,1 years) with no obesity. Diagnosis of MS was carried out according to the recommendations of the Committee of Experts The National Cholesterol Education Program (NCEP), Adult Treatment Panel III (ATPIII),takes into account the anthropometric indicators data, lipid and carbohydrate metabolism, blood pressure and insulin resistance. Methods used computer (СT) and magnetic resonance imaging (MRI), ultrasonography (USG) visceral obesity (VO).

Radiation exposure during CT, significant time spent in the performance of MRI in conjunction with the economic burden justify the appropriateness of including in the scheme of studies of patients with obesity ultrasound to determine VO as an indicator of MS. Standard ultrasound technique identified during a highly informative, comparable (r = 0,66 at p = 0,0005) with tomographic methods (CT, MRI). Her performance (visceral adipose tissue - VAT, visceral adipose tissue /subcutaneous adipose tissue- VAT / SAT) highly correlated with indicators of disorders of carbohydrate (glucose, insulin, insulin resistance index) and lipid metabolism (LDL, VLDL). When using a standard ultrasound VAT thickness in patients with MS averaged 110,43 ± 18,34 mm, and significantly higher than the rate in the comparison group VAT (67,20 ± 16,63 mm) and the control group (70.22 ± 15,54 mm). Threshold VAT above which diagnosed in, according to the standard ultrasound in patients with MS was 109.11 mm.

Ultrasonography can be used for screening of patients with obesity, including -in children, adolescents and pregnant women in order to diagnose visceral obesity as a risk factor for MS Recommended for dynamic ultrasound evaluation with all indices  (the thickness of the VAT, preperitoneal fat, SAT and  VAT / SAT)  in the treatment and control of the therapy of obesity and MS , as indicators of these methods are associated with carbohydrate and lipid metabolism and insulin resistance.

 

Nothing to Disclose: EK, JS, OO, NS, VZ

21082 20.0000 THR-568 A Ultrasonography Visceral Obesity As a Screening Method for the Diagnosis of Metabolic Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Brandon T Suehs*1, Pravin Kamble2, Joanna Huang3, Mette Hammer3, Boris Stevenin3, Jonathan R Bouchard4, Neil Wintfeld5 and Andrew Renda6
1Comprehensive Health Insights, Inc., 2Comprehensive Health Insights, 3Novo Nordisk, 4Novo Nordisk, Inc., Princeton, NJ, 5Novo Nordisk, Inc., 6Humana

 

Background

The healthcare utilization and economic burden associated with obesity and related comorbidities are significant, and the increasing prevalence of obesity represents an important public health concern.

Objective

To examine the association between Body Mass Index (BMI) classification and inpatient, outpatient, and emergency room utilization among Medicare Advantage (MA) members.

Methods

This was a retrospective cohort study using Humana MA claims data. BMI was assessed using ICD-9-CM status codes (V85 hierarchy). The date of first observed BMI (V85 code) between 2008 and 2012 was defined as index date. Continuous enrollment of at least one year before and at least one year after index date was required. Members were assigned based on V85 codes into BMI categories: Normal (N), Overweight (Ow), Obese class I (ObI), Obese class II (ObII), and Obese class III (ObIII). Healthcare resource utilization (HRU) was measured during the 12-month post index period. Descriptive statistics were used to examine demographics, clinical characteristics, and HRU across BMI classes. Multivariable regression models were used to examine the association between BMI class and service utilization [inpatient (IP), outpatient (OP), and emergency room (ER)] after controlling for demographic and clinical characteristics. Odds ratio (OR), incidence rate ratio (IRR), and 95% confidence intervals (CI) are reported for each BMI class with N BMI as reference category.

Results

A total of 172,866 MA members were identified. BMI distribution was: N, 21%; Ow 37%; ObI, 24%, ObII, 10%; and ObIII, 9%. Increasing BMI class was associated with greater prevalence of many cardiometabolic conditions, including hypertension, type 2 diabetes, and metabolic syndrome. The number of unique medications and use of specific medication classes such as antihypertensives, lipid-lowering agents, antihyperglycemic agents, analgesics, and antidepressants increased with increasing BMI class. The odds of having IP admission increased with greater BMI class [Ow: OR 1.01(CI 0.97-1.05); ObI: OR 1.15 (CI 1.11-1.20); ObII: OR 1.45(CI 1.37-1.52); ObIII: OR 3.41 (CI 3.26-3.58), respectively]. Likewise, odds of ER encounter increased with greater BMI class [Ow: OR 0.99 (CI 0.96-1.03); ObI: OR 1.00 (CI 0.96-1.04); ObII: OR 1.07 (CI 1.02-1.12); ObIII: OR 1.43 (95%CI 1.37-1.51), respectively]. Increasing BMI class was also associated with greater rate (IRR) of IP, ER, and OP utilization.

Conclusions

This burden of illness study in an MA population used BMI level as recorded via ICD-9 diagnosis codes. This study found that increasing BMI class was associated with increased prevalence of cardiometabolic conditions, increased utilization of key medication classes, and greater HRU. There is an urgent need to control the epidemic of obesity and its excessive human and economic burden on the healthcare system.

 

Disclosure: BTS: Researcher, Comprehensive Health Insights, wholly owned subsidiary of Humana. PK: Researcher, Comprehensive Health Insights, a wholly owned subsidiary of Humana . JH: Researcher, Novo Nordisk. MH: Employee, Novo Nordisk. BS: Employee, Novo Nordisk. JRB: Employee, Novartis Pharmaceuticals. NW: Employee, Novo Nordisk. AR: Employee, Humana.

18664 21.0000 THR-569 A Impact of Obesity on Healthcare Resource Utilization Among Medicare Advantage Members Enrolled in a Large U.S. Health Benefits Organization 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Pravin Kamble1, Brandon T Suehs*2, Joanna Huang3, Mette Hammer3, Boris Stevenin3, Jonathan R Bouchard4, Neil Wintfeld5 and Andrew Renda6
1Comprehensive Health Insights, 2Comprehensive Health Insights, Inc., 3Novo Nordisk, 4Novo Nordisk, Inc., Princeton, NJ, 5Novo Nordisk, Inc., 6Humana

 

Background

The economic burden of obesity and related co-morbidities has been estimated at $190 billion per year in excess medical costs in the United States, and the increasing prevalence of obesity represents an important public health concern.

Objective

To examine the association between Body Mass Index (BMI) and healthcare costs among Medicare Advantage (MA) members enrolled in a large health benefits organization.

Methods

This was a retrospective cohort study using Humana MA claims data. BMI was assessed using ICD-9-CM status codes (V85 hierarchy). The date of first observed BMI (V85 code) between 2008 and 2012 was defined as index date. Continuous enrollment of at least one year before and at least one year after index date was required. The index V85 code was used to classify members into BMI categories: Normal (N), Overweight (Ow), Obese class I (ObI), Obese class II (ObII), and Obese class III (ObIII). Medical, pharmacy, and total costs were measured over the 12-month post-index period. Descriptive statistics were used to examine demographics, clinical characteristics, and healthcare cost across BMI classes. Multivariable analysis (generalized linear model with log link and gamma distribution) was used to examine the association between BMI class and healthcare costs.

Results

A total of 172,866 MA members were identified. The BMI prevalence distribution compared to the cumulative cost distribution was [BMI class, percent of subjects within BMI class (percent of cumulative cost)]:  N, 21% (15%); Ow, 37% (30%); ObI, 24% (23%), ObII, 10% (11%); and ObIII, 9% (20%). Health plan members with a V85 code documenting assessment of BMI were primarily white, female, and located in southern geographic region.  In multivariable models controlling for demographic characteristics, comorbidity burden, and number of unique medications, greater BMI level was associated with statistically significant greater total healthcare, medical, and pharmacy costs. Mean adjusted healthcare costs by BMI class were: N, $7,579; Ow, $7,815; ObI, $8,361; ObII, $9,380; and ObIII, $13,093 (P value for all < 0.001 with N BMI as reference category). Mean adjusted medical costs by BMI class were: N, $5,972; Ow, $6,082; ObI, $6,626; ObII, $7,544; and ObIII, $11,167 (P value for Ow, 0.031; for all others < 0.001 with N BMI as reference category). Mean adjusted pharmacy costs by BMI class were: N, $1,459; Ow, $1,515; ObI, $1,517; ObII, $1,597; and ObIII, $1,690 (P value for all < 0.001 with N BMI as reference category).

Conclusions

This burden of illness study in an MA population used BMI level as recorded via ICD-9 diagnosis codes. This study found that increasing BMI class was associated with increased total healthcare, medical, and pharmacy costs. The relationship between BMI class and healthcare costs remained statistically significant after controlling for comorbidity burden and other demographic and clinical characteristics.

 

Disclosure: PK: Researcher, Comprehensive Health Insights, a wholly owned subsidiary of Humana . BTS: Researcher, Comprehensive Health Insights, wholly owned subsidiary of Humana. JH: Researcher, Novo Nordisk. MH: Employee, Novo Nordisk. BS: Employee, Novo Nordisk. JRB: Employee, Novartis Pharmaceuticals. NW: Employee, Novo Nordisk. AR: Employee, Humana.

20608 22.0000 THR-570 A Impact of Obesity on Healthcare Costs Among Medicare Advantage Members Enrolled in a Large U.S. Health Benefits Organization 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Alice Tang*1, Katherine Thuy Trang Tonks1, Nicholas Pocock2, Lesley V Campbell1, Don Chisholm1, Dorit Samocha-Bonet1 and Jerry R Greenfield3
1Garvan Institute of Medical Research, Sydney, Australia, 2St Vincent's Clinic, Sydney, Australia, 3Garvan Institute of Medical Research, Darlinghurst, Australia

 

Background:  Insulin-sensitive obese humans have lower cardiovascular risk than insulin-resistant obese humans. The ability to distinguish between these groups can help target clinical management.  Visceral fat (as measured by MRI or CT) has been shown to predict insulin resistance.  However, these imaging modalities are costly, not widely available and, in the case of CT, associated with high radiation exposure.   A cheaper and safer alternative of measuring visceral fat is by DXA.   

Aim:  To determine which DXA-derived fat region distinguishes insulin-sensitive from insulin-resistant overweight or obese healthy men and women.

Methods:  We studied 36 non-diabetic participants and 21 participants with type 2 diabetes (T2DM): 27 men (mean age 59±8 years) and 30 women (mean age 58±9 years).  Their average BMI was 31.2±5.1 kg/m2.  Insulin sensitivity was measured by 2.5 hour hyperinsulinaemic-euglycaemic clamp (80 mU/m2/min).  Non-diabetic participants were stratified as insulin-sensitive (IS) or insulin-resistant (IR) based on median glucose infusion rate (GIR) during clamp hyperinsulinaemia (above or below median, respectively, with separate cut-offs for men and women).  Regional fat mass was assessed by DXA (Lunar Prodigy; GE Healthcare).  Visceral and total android (central) and total gynoid (hip and thigh) fat mass regions were defined using enCORE software, version 15.

Results:  The IS, IR and T2DM groups were optimally matched for BMI (P=0.4) and total body fat mass (P=0.5). By design, insulin sensitivity was highest and almost double in the IS vs. IR and T2DM participants (91±33 vs. 55±18 and 45±13 µmol/min/kgFFM, respectively, P<0.01). The IS women had approximately half the visceral android fat mass compared to the IR and T2DM women (0.65±0.44 vs. 1.32±0.71 and 1.20±0.61 kg, respectively, P=0.02). In men, values were much higher and were not significantly different between groups (2.22±1.14 vs. 2.48±0.69 and 2.06±0.58 kg, respectively, P=0.5). Total android and total gynoid fat mass were not different between groups in either women (P=0.4 and P=0.2, respectively) or men (P=0.7 for both).  In women, visceral android fat mass was significantly correlated with insulin sensitivity (r=-0.43, P=0.02), but in men, no significant relationship was detected (r=-0.19, P=0.3). 

Conclusions:  Despite much greater visceral android fat mass in men, it was only a predictor of insulin sensitivity in women.  Use of DXA to measure this fat region may help identify overweight / obese but insulin-sensitive women in clinical practice.

 

Nothing to Disclose: AT, KTTT, NP, LVC, DC, DS, JRG

19449 23.0000 THR-571 A Lower Visceral Android Fat Mass Identifies Insulin-Sensitive Overweight / Obese Women, but Not Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Yoshimi Tatsukawa*1, Munechika Misumi1, Young Min Kim1, Michiko Yamada1, Keiko Ueda1, Ikuno Takahashi1, Waka Ohishi1 and Masayasu Yoneda2
1Radiation Effects Research Foundation, Hiroshima, Japan, 2Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan

 

Background: General obesity, as defined by body mass index (BMI), is a major risk factor for diabetes. Asian populations have a higher risk of diabetes than Caucasians, despite having a lower incidence of overweight and obesity. In addition to general obesity, body composition is also associated with risk for diabetes. However, only a limited number of longitudinal studies have examined the association between diabetes risk and body composition using direct estimates with methods such as dual energy X-ray absorptiometry (DXA).

Objectives: The objective of this cohort study was to determine the association of DXA-based body composition with development of diabetes, independently of BMI, in a Japanese population.

Methods: A total of 1,532 subjects without diabetes (463 males and 1,069 females, with an average age of 65.8) in the Hiroshima Adult Health Study, consisting of atomic bomb survivors and their controls, were eligible for the study. Body composition was estimated by whole body DXA during the period from 1994 through 1996. We used the ratio of appendicular lean mass/height2 (ALM/H2) as a surrogate indicator of appendicular muscle mass volume, and percentages of trunk, leg, and arm fat in relation to total soft tissue mass as surrogate indicators of body fat distribution. Diabetes was defined by fasting glucose ≥126mg/dl or non-fasting glucose ≥ 200mg/dl; a history of diabetes diagnosis by a medical institution (self-reported); or current treatment for diabetes. We followed up with this population with biennial health examinations through 2011. 

Results: During the follow-up period, 212 subjects developed diabetes. After multivariate analysis with adjustment for BMI, presence of hypertension and dyslipidemia, radiation dose, and smoking and alcohol consumption status, no significant association was observed between ALM/H2and diabetes risk. Regarding body fat distribution, higher percentages of trunk fat were positively associated with the incidence of diabetes and higher percentages of leg fat were negatively associated with the incidence of diabetes, especially in women.  In women, the relative risks with a 1% increase in trunk and leg fat were 1.06 (95% CI 1.01-1.13) and 0.86 (95% CI 0.79-0.93), respectively. Significant association between the percentage of arm fat and diabetes risk was not observed in either sex.

Conclusions: Trunk and leg fat were associated with incidence of diabetes, independently of BMI. The assessment of body composition, especially body fat distribution, might also be useful in the prediction of diabetes.

 

Nothing to Disclose: YT, MM, YMK, MY, KU, IT, WO, MY

18477 24.0000 THR-572 A Body Composition and Development of Diabetes in a Japanese Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Maya Fayfman*1, Lauren Buehler2, Anastasia-Stefania Alexopoulos2, Liping Zhao3, Farnoosh Farrokhi2, Jeff Weaver2, Dawn Smiley1, Francisco J Pasquel1 and Guillermo E Umpierrez1
1Emory University, Atlanta, GA, 2Emory University, 3Emory University School of Public Health

 

The impact of overweight and obesity on perioperative complications in general surgery patients, with and without hyperglycemia/diabetes, is not known.  Accordingly, we analyzed the effects of obesity on clinical outcomes and hospitalization costs in patients undergoing the most common gastrointestinal, hepato-biliary and pancreatic surgeries. Inpatient hyperglycemia was defined as BG ≥ 140 mg/dl. Overweight was defined by BMI between 25-30 kg/m2 and obesity as a BMI >30 kg/m2. Hospital cost was calculated using cost-charge ratios from Centers for Medicare & Medicaid Services. Hospital complications included a composite of major cardiovascular events, pneumonia, bacteremia, acute kidney injury, respiratory failure, and death. Among 2366 consecutive surgery patients, hyperglycemia was present in 1799 patients (76%), of whom 506 (28%) had history of DM, and 1293 (72%) had no DM prior to surgery. Compared to patients with normoglycemia, those with DM and non-DM with hyperglycemia had a higher number of hospital complications (5% vs. 21% vs. 20%, p<0.0001), longer hospital stay (5 days vs. 9 days vs. 9 days, p<0.0001), more hospital readmissions within 30 days (10% vs. 18% vs. 17%, p<0.0001), and higher hospitalization costs ($20,212 vs. $78,690 vs. $72,550, p<0.0001). Multivariate analysis adjusted for age, gender, BMI and type of surgery (laparotomy/open surgery) revealed that hyperglycemia in DM and non-DM patients was associated with a ~4-fold increased risk of complications compared to patients with normoglycemia [OR 4.4 (95% CI: 2.8,7.0) and 4.0 (2.6,6.1)]. In contrast, the presence of overweight and obesity was not associated with increased risk of complications (17.3% vs. 15.7% vs. 16.1%, p=0.77), or hospitalization costs ($58,313 vs. $58,173 vs. $66,644, p=0.41) compared to normal-weight subjects (BMI 18.5-25 kg/m2). Open surgery was associated with higher rates of complications (19.2% vs. 8.9%, p<0.0001) and higher hospitalization costs ($67,191 vs. $43,767, p<0.0001) compared to laparoscopic surgery; however, there were no differences between normal weight vs. overweight/obese subjects.

In conclusion, perioperative hyperglycemia but not higher BMI was associated with increased risk of perioperative complications and hospitalization costs in patients with and without diabetes undergoing gastrointestinal surgery.

 

Nothing to Disclose: MF, LB, ASA, LZ, FF, JW, DS, FJP, GEU

19980 25.0000 THR-573 A The Impact of Obesity on Clinical Outcome and Hospitalization Costs in General Surgery Patients with Hyperglycemia and Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Sikarin Upala*1 and Anawin Sanguankeo2
1Bassett Medical Center, Cooperstown, NY, 2Bassett Medical Center, United States, NY

 

Background

Obesity is found to be associated with high mortality risk and graft loss in kidney and liver transplant recipients in previous meta-analyses. Many observational studies also found that lung transplantation recipients with pre-transplant obesity had higher mortality and increased incidence of primary graft dysfunction. Our meta-analysis was conducted to determine mortality and graft dysfunction in lung transplant recipients with obesity compared to those with normal body mass index (BMI).

Methods

Eligible observational studies assessing the association between obesity in lung transplant recipient and post-transplant mortality or primary graft dysfunction were comprehensively searched in PubMed/MEDLINE, EMBASE, and CENTRAL from their inception to September 2014. Two authors independently assessed article quality and extracted the data. Primary outcome was number of participants, prevalence, odds ratio or risk ratio of post-transplant mortality or primary graft dysfunction in overweight or obese and normal BMI groups.

Results

From 28 full-text articles, 7 observational studies involving 9,865 participants were included in the meta-analysis that were based on the random effects model. Compared with controls, obese participants had significantly higher prevalence of primary graft dysfunction with a pooled odds ratio of 2.47 (95% CI: 1.46- 4.17, p-value<0.01). However, there is no significant association between obesity and post-transplant mortality (OR=3.22, 95% CI: 0.87- 11.91, p=value=0.08).

Conclusions

Obese patients had higher risk of developing primary graft dysfunction post lung transplantation compared to recipients with normal BMI. Further study is needed to establish selection criteria for lung transplantation to reduce risk of post-transplantation morbidity and mortality.

 

Nothing to Disclose: SU, AS

19269 26.0000 THR-574 A Obesity Is Associated with Primary Graft Dysfunction after Lung Transplantation: A Systematic Review and Meta-Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Alexandre Hohl*1, Jhonathan Alcides Elpo2, Marcelo Fernando Ronsoni1, Carina Gabriela Correa3, Giovana De Nardin2, Bruno da Silveira Colombo3, Emerson Leonildo Marques2, Cristina da Silva Schreiber de Oliveira4, Marisa Helena Cesar Coral3 and Simone van de Sande-Lee2
1Federal University of Santa Catarina, Florianopolis-SC, Brazil, 2Federal University of Santa Catarina, Florianopolis, Brazil, 3Federal University of Santa Catarina, Brazil, 4Federal University of Santa Catarina, Florianopolis - Santa Cat, Brazil

 

Background:Obesity in recent years has steadily increased, now being defined by some authors as a pandemic. Clinical treatment failure is one of the reasons for patients being evaluated as candidates for bariatric surgery. In these patients' preoperative approach, the exclusion of Cushing's syndrome (CS) associated with obesity is crucial and difficult to implement. The choice of the ideal screening test for CS is still a subject of discussion in the current literature. In our department, routine screening is performed through the 1 mg overnight dexamethasone suppression test (ODST).

Objectives: Analyze the use of ODST as a method of pre-operative screening of patients undergoing evaluation for bariatric surgery in the Endocrinology and Metabolism Department, University Hospital, Federal University of Santa Catarina, Florianópolis- SC, Brazil.

Results: We performed a cross-sectional study, including 109 obese adults (86.2% women), evaluated in 2013, with a mean age of 38 ± 10 y.o. (median: 36 y.o.). The mean weight and body mass index (BMI) were, respectively: 124.2 ± 23.5 kg and 47.2 ± 7.2 kg/cm2. The metabolic profile of patients was (mean): fasting glucose 110.8 ± 36.5 mg/dL (NR <100), total cholesterol 185.4 ± 32.8 mg/dL (NR <200), HDL-cholesterol 44.0 ± 13.4 mg/dL (NR >40) calculated LDL cholesterol 116.9 ± 26.9 mg/dL (NR <130) and triglycerides 140.0 ± 86.5 mg/dL (NR <150). The mean value of cortisol after ODST was 1.29 ± 0.9 mcg/dL. Using the cut-off of 5 mcg/dL, 98.2% of patients suppressed cortisol. Reducing the cut-off to 1.8 mcg/dL, 90.8% had suppression of its levels. Patients who had cortisol values higher than 1.8 mcg/dL continued investigation for CS and no case has been confirmed. Stratifying patients into two groups from the cut-off 1.8 mcg/dL, we identified statistically significant difference in weight (125.8 ± 23.8 vs 108.7 ± 12.4, p = 0.028) and total cholestrol (183.2 ± 31.1 vs 207.5 ± 42.2, p = 0.025).

Conclusions: There is the need for the exclusion of Cushing's syndrome in obese patients undergoing evaluation for bariatric surgery. In this analysis, the use of 1 mg overnight dexamethasone supression test demostrated high specificity for excluding CS, regardless of t he cut-off point selected. Besides being easy to perform, the ODST decreased the need for further costly investigations, especially where financial resources are limited.

 

Nothing to Disclose: AH, JAE, MFR, CGC, GD, BDSC, ELM, CDSSD, MHCC, SV

19539 27.0000 THR-575 A Evaluation of 1 Mg Dexamethasone Overnight Supression Test in Patients Undergoing Bariatric Surgery 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Alexandre Hohl*1, Francielle Sordi da Veiga2, Marcelo Fernando Ronsoni1, Carina Gabriela Correa3, Giovana De Nardin2, Bruno da Silveira Colombo3, Emerson Leonildo Marques2, Cristina da Silva Schreiber de Oliveira4, Marisa Helena Cesar Coral3 and Simone van de Sande-Lee2
1Federal University of Santa Catarina, Florianopolis-SC, Brazil, 2Federal University of Santa Catarina, Florianopolis, Brazil, 3Federal University of Santa Catarina, Brazil, 4Federal University of Santa Catarina, Florianopolis - Santa Cat, Brazil

 

Background: Vitamin D deficiency is highly prevalent worldwide. Observational studies have consistently shown an association between hypovitaminosis D and obesity.

Objective: The aim of this study was to evaluate vitamin D status in a group of severely obese subjects from a coastal subtropical area in the South of Brazil, and the correlation between 25(OH)D3 levels and metabolic markers.

Methods: We performed a cross-sectional study, including 170 obese adults undergoing bariatric surgery, attending the endocrinology clinic at the University Hospital in Florianopolis – Brazil. They were not taking any vitamin D supplements. Blood samples were collected throughout all seasons of the year, as subjects were included.

Results: Mean age was 40 ± 10 years, 87.1% were female, 81.2% were Caucasian and 24.7% had type 2-diabetes. Mean body mass index (BMI) was 48.05 ± 7.1 kg/m². The average serum level of 25(OH)D3 was 26.3 ± 8.4 ng/mL. Vitamin D deficiency (lower than 20 ng/mL) and insufficiency (20-29.9 ng/mL) was found in 23.5% and 45.3% of subjects, respectively. There was not any significant correlation between 25(OH)D3 and age, BMI, fasting glucose, HbA1c or lipid levels.

Conclusion: We conclude that there is a high prevalence of hypovitaminosis D in severely obese subjects from Florianopolis – Brazil. However, the prevalence is lower if compared with most of the studies that analyzed similar groups in other countries, probably reflecting peculiarities of our environment.

 

Nothing to Disclose: AH, FSDV, MFR, CGC, GD, BDSC, ELM, CDSSD, MHCC, SV

19543 28.0000 THR-576 A Vitamin D Status in Severely Obese Subjects from the South of Brazil 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Lev M Berstein*1, Dmitry A Vasilyev1, Igor V Berlev2 and Tatyana E Poroshina3
1N.N.Petrov Research Institute of Oncology, St.Petersburg, Russia, 2N.N. Petrov Research Institute of Oncology, St.Petersburg, Russia, 3N.N.Petrov Research Institute of Oncology, St. Petersburg, Russia

 

Background and aims: Metabolically healthy obese state, or MHO, presents a variant of excessive body weight without metabolic disturbances characteristic for ‘standard’ obesity (SO). Although the need of reliable definition of this state was stressed several times, MHO continues to attract attention in its contemporary version. Very scarce data are published on connections between MHO and cancer morbidity and traits. We aimed to see: what is the prevalence of MHO in endometrial cancer (EC) pts and whether there are any distinctions in clinical features of this cancer in pts with MHO and SO. Materials and methods: Totally 192 EC pts were observed, 74 in 1999-2001 and 118 in 2012-2014. Into MHO group were included pts not having at least 3 of 5 of the following: glucose intolerance, hypertriglyceridemia, high waist circumference, low HDL-cholesterol, or hypertension evaluated according to recommendations of National Cholesterol Education Panel (2001). Results: Among all EC pts body mass index (BMI) >25 and >30 was discovered respectively in 82.8% and 54.2%. HOMA-IR value was in average expectedly higher in SO than in MHO group.  Prevalence of MHO in the two compared time periods was the same in groups with BMI 25.0-29.9 (51.9±9.6% in 1999-2001 and 53.6±9.5% in 2012-2014) while it decreased in 2012-2014 in pts with BMI >30 (16.4±4.3% vs 35.8±8.4% in 1999-2001, p < 0.05). The measure of EC differentiation (G-grade) demonstrated tendency to better while the depth of myometrium invasion - to worsen values in EC pts observed in 2012-2014; no difference in these indices was discovered in the whole studied group and in two separate times periods (1999-2001 and 2012-2014) between pts with MHO and SO. At the same time, when 2010 FIGO staging system was used, EC pts with MHO had less advanced disease than pts with SO (2.17±0.12 vs 2.53±0.12 cond.un. in pts with BMI >30 and 2.31±0.12 vs 2.60±0.12 cond.un. in pts with BMI >25). Conclusions:  In EC patients with MHO the signs of more favorable course of endometrial cancer can be expected while prevalence of metabolically healthy obese state unfortunately decreases with years. It is not known at the moment whether the last observation reflects evolution of this cancer or evolution of obesity itself due to its epidemic. Also, besides the role of insulin resistance other factors (including adipose tissue characteristics) may be involved into formation of MHO/SO ratio and MHO/cancer relations.

 

Nothing to Disclose: LMB, DAV, IVB, TEP

18262 29.0000 THR-577 A Metabolically Healthy Obesity: Changing Prevalence in Endometrial Cancer and Relation with Clinical Features of This Tumor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Khaled Abdullah Alswat*1, Moustafa H. Abdel Wahab2 and Ahmed A. Aboelil2
1Taif University, School of Medicine, Taif, Saudi Arabia, 2Taif University

 

Background:

Obesity is a growing health problem internationally. Dental caries and obesity are multifactorial diseases and are associated with dietary and lifestyle habits. Few data showed association between BMI and caries in children/adolescence but limited data about such association in adult.

Methods:

We conducted a cross-sectional study at Taif University outpatient clinic, Taif, Saudi Arabia. Any individuals ≥ 18 years who had a visit to the Dental clinic from Mar-Jun 2014 were asked to participate. Baseline characteristics were obtained by the participated physician. We used the Decayed, Missing, and Filled (DMF) index (range 1-18) to determine the total number of teeth or surfaces that are decayed (D), missing (M), or filled (F) in an individual.

Information about healthy eating, smoking, exercise, sleep pattern and teeth brushing were collected. We also measured the media consumption by hours that include watching TV, using computer, video game and using smart phone for entertainment.  We used SPSS to analyze the data. The primary goal of this study is to assess the relationship between obesity and the prevalence of dental caries

Result:

Total of 199 individuals participated, all were male with mean age 27.15 yrs, mean BMI 26.45 kg/m2, 94.5% were married, 28% were faculty members and 72% were students, 5% have T2D and 5.5% have HTN. 18.6% brush teeth >1/d, 36.2% brush it daily, 18.1% brush at least once wkly, and 27.1% ≤ 4 monthly. 11.5% were active smokers, 47% were passive smokers, 89% reports sedentary lifestyle, 82% reports optimal sleep (6-8 hrs/night). 65.5% drinks soda at least daily, 38.7% eats ≥1 serving of fruit/vegetable daily, and only 24.6% consume media < 3hrs daily.

Mean DMF index was 6.45, 60.1% have DMF index ≤6.45 (considered as low dental caries group, LDC group) compare 39.9% have DMF index >6.45(high dental caries group, HDC group). LDC group vs HDC group has mean age of 26.76 yr vs 27.8 yrs (p .50), mean BMI 26.1 vs 27.0 (p .28) and 42.3% of the faculty and 37.6% of the students among the HDC group.

Regarding the habits, 11.8% of the LDC vs 11.7% in the HDC group were active smokers (P .98), 44.5% vs 57.1% were passive smokers (P .18), 87.4% vs 92.2% reports sedentary lifestyle (p .19), 10.9% vs 11.7 reports sleeping < 6 hrs (p .39), 71.4% vs 57.14% reports drinking soda daily (p .04), 37.82% vs 38.96% eating fruits daily, 23.5% vs 24.7% consume media <3 hrs/d, and 57.14% vs 51.94% brush their teeth daily (p .67).

Regarding the measured CV markers, SBP 127.34 vs 127.9 (p .82), DBP 75.6 vs 76.7 (p .31), and resting HR 75.3 vs 76.94 (p .09).

After adjustment of age, soda/fruit/vegetable intake, and teeth brushing no correlation found between BMI and passive smoking with the DMF index (p .55).

Conclusion:

39.9% were found to have high dental caries according to the DMF index; those were more likely to have non-statistically significant higher BMI, SBP, DBP and resting HR when compared to the low dental caries group.

 

Nothing to Disclose: KAA, MHA, AAA

20574 30.0000 THR-578 A Does Obesity Increase Risk of Dental Caries? Cross-Sectional Study at Taif University 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Julia Passyn Dunn*1, Robyn A. Tamboli1, Bruce W. Patterson2, Pamela Marks-Shulman1 and Naji Nicholas Abumrad1
1Vanderbilt University, School of Medicine, Nashville, TN, 2Washington University School of Medicine, St.Louis, MO

 

Disinhibition is an eating characteristic common in obesity that occurs with poor response to weight loss interventions. In patients with type 2 diabetes mellitus, those with increased disinhibition scores have  poorer glycemic control and quality of life compared to patients with lower disinhibition (1).  We hypothesized that in individuals with obesity, increased disinhibition would occur with a more detrimental metabolic phenotype. The Three Factor Eating Questionnaire (TFEQ) was used to measure the eating characteristics of disinhibition, restraint,  and hunger. Disinhibition scores ≤7 or >7 were defined as low and high respectively (1). Binge eating scale (BES) was used to measure binge eating behavior. Beck depression inventory –II (BDI-II) was completed and those with clinical relevant levels of depression (scores >20) were excluded. Insulin sensitivity index for glucose disposal (SI) was estimated using the oral glucose minimal model. Body composition was measured by air-displacement plethysmography. Fasting insulin, leptin, and acyl ghrelin levels were measured. Data are presented as mean±SD, low vs high disinhibition groups respectively. We investigated 17 non-diabetic, weight stable, age similar (39±8 vs 37±6 years) females with obesity. Eight had low disinhibition (4±1) and nine had high disinhibition (11±1). The BMI was similar in the 2 groups (41±6 vs 38±6kg/m2), as was total body weight (both 106±18kg). Body fat mass (42±12 vs 44±6 %) and lean mass (58±12 vs 57±6 %) were all similar in the 2 groups.  TFEQ restraint scores were comparable (10 vs 8) while hunger scores trended to be higher in those with high disinhibition scores (3 vs 6, p=0.05). BES scores were not significantly different between the 2 groups. BDI-II scores were significantly different between the groups (4±4 vs 11±7, p=0.036). Despite similar body weight and composition, those with high disinhibition were twice as insulin resistant as those with low disinhibition scores [5.5±2.8 vs 2.7±1.5 (10-4min-1/µU*mL), p=0.032]. Fasting insulin, leptin, and acyl ghrelin levels were comparable in both groups. High disinhibition occurs with more severe insulin resistance and more symptoms of depression when comparing females with obesity and similar body weight and composition. Previous work has demonstrated that increased  disinhibition occurs with poorer clinical outcomes and this may be due to worse insulin resistance.  

 

Nothing to Disclose: JPD, RAT, BWP, PM, NNA

22050 31.0000 THR-579 A High Disinhibition Occurs with Worse Insulin Resistance in Females with Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Khalid Altalhi*1, Thamer Almalki1, Abdulelah Almutairi1, Bader Almansouri1, Abdullah Alharthi1 and Khaled Abdullah Alswat2
1Taif University, 2Taif University, School of Medicine, Taif, Saudi Arabia

 

Background:

Lack of exercise, sleep deprivation, unhealthy diet, unbalanced media consumption and smoking are considered among others, to be one of the leading causes for the chronic diseases epidemics. The level of physical activity and former mentioned habits estimation and their impact on patients admitted to Emergency Room (ER) remain unanswered.

Methods:

We conducted a cross-sectional study at Taif General Hospital, Taif, Saudi Arabia. Male patient’s age ≥ 18 years who were admitted to the ER, Jan-Sep2014 were asked to participate. Baseline characteristics and measurement were obtained by the participated physicians. We used the International Physical Activity Questionnaire to evaluate the physical performance. We excluded bedridden and unconscious patients. The primary goal of this study is to evaluate the level of physical activity in relation to BMI and media consumption and their impact on patient’s disposition/admission, and the cardiovascular markers.

Result:

Total of 322 patients participated, all were male with mean age 36.48 yrs old (SD 14.13), 62.6% were married, 20.6% did college degree or higher,66.3% have low income, mean BMI 26.97, 14% were diabetics, 14.6% were hypertensive, 30% presented with either chest or abdominal pain, 91.3% live in urban area, 39.6% reports active style job, 59.3% were smokers with 56.7% smoker >10 yrs, 58.2% don’t eat fruit/vegetable at least daily, 18.6% energy drinks regular consumers, 27.2 % owned 1 electronic device and 68.7% owned ≥2 devices, 55.2% use the smart devices <3 hrs/day, 43.8% sleep 6-8hr/night, 98.7% believed exercise is beneficial, and only 6.6% weight themself at least weekly.

At least once weekly, 16.9% of the screened patient’s reports doing vigorous activity, 13.4% reports doing moderate activity, and 37.9% reports regular walking. Overall, 63% of the screened patients considered to be active.

Active patients, compare to inactive have mean age of 34.7 vs 39.63 yrs (p< .05), 45.3% vs 41.4% were smoker (p .5), mean BMI 25.8 vs 27.8 (p< .05), mean SBP 139.6 vs 134.8 (p .071), mean DBP 81.8 vs 82 (p .91), mean pulse rate 87.4 vs 89.1 (p .34), 43% eat healthy vs 39.8% (p .62), 22.7% regularly consume energy drinks vs 17.1% (p .43), 73.13% vs 60% own ≥ 2 devices (p <.05), and 41.9% vs 50.94% use them >3 hrs daily (p .64).

Active vs inactive, 44.4% vs 43.6 (p .31) had multiple (≥2) ER visit in the past year, 30.7% vs 31.03% were discharged (p .81), 9.4% vs 6.9% were admitted (p .74). Subgroup analysis for vigorous&moderate group compare to walking&inactive group yield similar disposition pattern.

Conclusion:

63% of the screened ER male patients were active; they are younger and they have lower BMI. No statically difference found in cardiovascular markers, the No. of ER visit nor discharge but active patients were non-significantly more likely to be admitted; possibly due to higher rate of unhealthy habits (i.e. smoking) which may omit the good exercise effect.

 

Nothing to Disclose: KA, TA, AA, BA, AA, KAA

20648 32.0000 THR-580 A Impact of Obesity, Physical Activity and Media Consumption Patterns on Emergency Department Patients Disposition 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 549-580 6041 1:00:00 PM Obesity: Clinical Studies Poster


Varinder Kambo*, Wakim Wakim and Leonid Poretsky
Lenox Hill Hospital, New York, NY

 

Individuals with diabetes comprise 8.3% of the United States population, however a disproportionate number (19.4%) of hospitalized patients have diabetes. The cost associated with diabetes in the US has steadily climbed from $174 billion in 2007 to $245 billion in 2012. The largest proportion of this cost, 43%, is associated with inpatient hospital care. This cost is compounded by patients readmitted to the hospital within one year. In all Medicare recipients, 19.6% of patients are re-hospitalized within 30 days of discharge, 34% in 90 days, and over half within a year (1).  It has been reported that readmission rates for patients with secondary diagnosis of diabetes are higher than without diabetes (2), but it is not clear whether these increased rates are seen across the board, or are associated with specific primary diagnosis codes. 

We evaluated the rates of readmissions at an urban teaching hospital for patients with and without diabetes.  In 2013 there were 31,936 discharges of which 2,642 resulted in readmission within thirty days, for an overall readmission rate of 8%. Out of the 31,936 patients, 6,090 discharges (over 20%) were for patients with either primary or secondary diagnosis of diabetes. Of these, 849 were readmitted within thirty days, for a readmission rate of 14%.  For the hospitalist service, out of 826 discharges for patients with diabetes, 151 were readmitted, for a readmission rate of 18%. Thus overall readmission rates in patients with diabetes may be twice as high as in patients without diabetes.

We further evaluated the top 10 DRG medicine admission codes associated with patients with and without diabetes as a secondary diagnosis from January 2012 through April 2014.  Out of the top 10 DRG codes for each group, 7 were common to both groups.  These DRG codes included: 690 (kidney and urinary tract infections); 378 (GI hemorrhage); 313 (chest pain); 603 (cellulitis); 392 (gastrointestinal disorders); 871 (septicemia or severe sepsis); and 641 (miscellaneous disorders of nutrition, metabolism, fluids and electrolytes).  The readmission rates for each of these DRG codes were higher for patients with diabetes, with increases varying from 51% to 78%.  We conclude that readmission rates for patients with secondary diagnosis of diabetes are increased regardless of primary diagnosis. We hypothesize that improving post-discharge management of diabetes may reduce these rates.  To confirm or refute this hypothesis will require further study.

 

Nothing to Disclose: VK, WW, LP

21004 1.0000 THR-184 A Readmission Rates for Patients with Secondary Diagnosis of Diabetes Are Increased Regardless of Primary Diagnosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Sena Cantas Orsdemir*, Rebecca Feinberg, Holley F Allen and Ksenia N Tonyushkina
Baystate Medical Center, Springfield, MA

 

Title

Are families of children with Type 1 DM ready for televisits?

Background

In children with Type 1 Diabetes Mellitus (T1DM), frequent insulin dose adjustments in response to the changing needs of the growing child are crucial to achieve optimal glycemic control. Therefore, quarterly visits are recommended, but may be a financial and emotional burden for families. Studies have shown that use of telecommunication in the care of patients with T1DM improves compliance with diabetes self-management and glycemic control.

Objective

To evaluate the interest and preparedness for televisits among T1DM patients and their families at Baystate Children’s Hospital located in Springfield, MA provides coverage for western Massachusetts and northern Connecticut.

Design/Methods

Patients with T1DM and their families completed a quality improvement survey during routine clinic visits in the summer 2014. The questionnaire consisted of yes/no and open-ended questions was developed to assess families’ willingness to participate in televisits and ability to transfer glycemic data online. Descriptive statistics and correlates of positive answers were analyzed.

Results

We obtained responses from 81 families, about 10% of our T1DM patients. Respondents were aged 3-21 years; mean age (+/-SD) was 14 (+/-4.1) years. The average HbA1C was 7.9 (+/- 1.4) %. Seventy percent of patients expressed interest in televisits. These patients had a lower mean A1C (7.76 vs. 8.55%, p = 0.04) and lived further away from clinic (p=0.0004). Among interested families, 77% were willing to have at least 2 out of 4 visits per year as televisits. Phone calls were preferred by 54% of interested families; while 22% chose video calls and 21% did not express a preference. In addition to physician visits, 67% requested a televisit with either a diabetes educator or nutritionist. Fifty-one patients (89%) were willing to download their insulin pumps and meters; 41 of them (71%) did not need assistance with the download and 10 (18%) were willing to learn. Ninety-six percent of families can transfer the glycemic data online. Half of the patients preferred to have previsit HbA1C done in a lab closer to their home as opposed to clinic and 60% preferred late evenings for televisit appointments.

Conclusion

Two thirds of our families with T1DM children are willing to participate in televisits. The majority of them has Internet access and are capable of transferring glycemic data online or willing to learn. The high level of interest leads us to design a pilot study to evaluate the clinical impact of televisits as part of routine diabetes care in pediatrics.

 

Nothing to Disclose: SC, RF, HFA, KNT

20402 2.0000 THR-185 A Are Families of Children with Type 1 DM Ready for Televisits? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Wael Emad Eid*1, Shehata Farag Shehata2, Dan Cole3 and Krista Doerman4
1St Elizabeth Healthcare, Covington, KY, 2High Institute of Public Health, Alexandria, Egypt, 3St. Elizabeth Physicians, Covington, KY, 4St. Elizabeth Physicians, Crestview Hills, KY

 

Background

Non-attendance into the endocrine clinic constitute a significant barrier that limits access to care & might lead to compromised clinical outcomes.

Objectives;

To find out the predictors for missing endocrine clinic appointments, in particular those visits related to diabetes.

Methods;

Record-based cross-sectional study was conducted where data were collected from the electronic medical records (EMR) for the period January 1st 2013 till Dec 31st2013 for all patients who were scheduled to clinical provider (MD or APRN) visits in our center. Last glycosylated hemoglobin A1c (HbA1c) results were collected, where the last value might have been prior to the study duration. Logistic regression model was used. Three groups were analyzed. Uncontrolled diabetics with HbA1c >= 8%. Borderline diabetics with HbA1c < 8%. Non-diabetics are those patients whose visits were not for diabetes.

The data collected included patients’ demographics, details related to the appointment being missed and other related appointments, clinical data & active prescriptions from the clinic as well as the use of the personal patient chart “MyChart”.

Results;

The total number of patients included in the analysis was 9305 patients. The total visits analyzed were 29178.

7043 visits were for uncontrolled diabetes and 10589 visits were for  borderline-controlled diabetes and 11546 visits were not for diabetes. Of the uncontrolled diabetics, 48% of the newly diagnosed patients cancelled or no-showed their appointment in contrast to 37% of the follow up group.

Uncontrolled diabetics have higher odds of missing their appointments (OR=1.21, 95%CI=1.12-1.31) specially if they are new consults into the practice (OR=1.4, 95%CI=1.2-1.50).

Borderline Controlled diabetics (OR=0.80, 95%CI=0.74-0.86) even if new consults (OR=0.91, 95% CI=0.77-1.1) and those scheduled for new non-diabetes related visits (OR= 0.65, 95%CI=0.51-0.83) are more likely to attend their visits.

The most significant predictor of not showing or cancelling the clinic appointments is a history of no-show or cancellation in the past (OR 24.92, 95%CI=19.62-31-64). Nine other factors are significantly predicting the none-attendance to the endocrine clinic, including but not limited to certain insurance carriers, longer time between scheduling the appointment and the appointment itself (OR=1.7, 95%CI=1.0-3.8).

Patients with certain characteristics (active MyCHart account, or having a future appointment) will mostly attend their clinic appointments

Conclusion;

Uncontrolled diabetes is a significant predictor for missing the endocrine clinic appointments especially for new diabetes-related consults. Patients that have the significant predictors in this study can be screened-for thru the EMR. These high-risk groups are to be enrolled in atypical focused clinical programs that tailor to their needs for better clinical outcomes.

 

Nothing to Disclose: WEE, SFS, DC, KD

21532 3.0000 THR-186 A Uncontrolled Diabetes As a Predictor of None-Attendance into the Endocrine Clinic 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Elamin Abdelgadir*1, Fauzia Rashid1, Alaaeldin Bashier2, Suada Makeen3, Fatheya Fardallah Alawadi4 and Mohamed Hassanein5
1Dubai Hospital, Dubai Health Authority, 2Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates, 3Dubai Hospital, 4Dubai Hospital, Dubai Health Authority, Ash Shariqah, United Arab Emirates, 5Dubai Hospital, Dubai, United Arab Emirates

 

INTRODUCTION:

Ramadan fasting is an obligatory duty for all the healthy Muslims in the world. Many studies have been done in different part of world and showed a heterogeneous beneficial effect of Ramadan fasting on metabolic markers and weight in healthy subjects. Some researchers have checked the effect of fasting on blood glucose as well, but few of them did observe changes of HBA1c pre or post Ramadan, and none compared the data in Muslims from different ethnic background. We conducted this prospective observational study to see effect of Ramadan fasting on Body Mass Index (BMI) and metabolic parameters in healthy Muslims from different ethnic background residing in Dubai, United Arab Emirates (UAE).

METHODOLOGY:

We studied the effect of one month of fasting during Ramadan on body mass index and certain metabolic parameters including fasting lipid profile, blood glucose and HBA1c in 49 healthy Muslim volunteers. These individuals belong to three different ethnicities; Pakistanis, Sudanese and Emiratis, with age range between 30 to 50 years; all were not known to have any medical problem and were not on any medication. The blood samples and anthropometric measurements were taken on two occasions; the first one was taken one week before Ramadan and the second reading was during the two weeks after Ramadan.

RESULTS:

There was a significant difference in body weight and BMI in all subjects of three nationalities at in of Ramadan fasting. There was no significant difference in fasting total cholesterol, triglyceride, HDL and LDL observed in Sudanese and Emiratis group, but subjects belong to Pakistani group showed statistically significant rise in total cholesterol by end of Ramadan. Females showed some difference in lipid profile compare to males; that is the HDL has increased by about 6% among females, while decreased by 3.7% among males, with statistically significant difference by using Mann Whitney test. Same finding was observed for total cholesterol that showed a rise in female at end of study with statistically significant difference in comparison to the average total cholesterol level before Ramadan. Not a single patient had any episode of hypoglycemia during this period.

CONCLUSION:

Our study concludes that fasting the month of Ramadan led to a statistically significant reduction in weight and BMI in all participants in same model of fasting. No beneficial effect was observed in lipid profile, fasting blood glucose and HBA1c in any group as a whole as observed previously in many such studies. Rather one group of subjects belong to Pakistan exhibit higher total cholesterol reaching statistically significant value at the end of Ramadan. We observed a statistically significant reduction in the HDL in females in comparison to males by the end of Fasting Ramadan.

 

Nothing to Disclose: EA, FR, AB, SM, FFA, MH

19575 4.0000 THR-187 A Effect of Ramadan Fasting on Lipid Profile, HBA1C, Fasting Blood Glucose and Body MASS INDEX in Healthy Muslim Adults from Three Different Nationalities in Dubai Hospital, United Arab Emirates 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Henry Jorge Zelada Castro*1, Antonio Bernabe-Ortiz1, Helard Manrique Hurtado2 and Jose S. Subauste3
1Universidad Peruana Cayetano Heredia, 2Hospital Nacional Arzobispo Loayza, Peru, 3Univ of Mississippi Med Ctr, Jackson, MS

 

Objective: 

To identify socio-demographics and clinical risk factors associated with inpatient mortality in patients with type 2 diabetes (T2D) in the inpatient service of a referral public hospital in Lima, Peru.

Introduction:

In developing countries, infections are considered the first cause of inpatient mortality among these patients; whereas cardiovascular diseases are the first one in developed countries (1,2). In Peru, a previous study performed approximately 20 years ago showed that infections were the main cause of inpatient mortality in T2D patients (3). 

Methods:

This is a prospective cohort study. Exposition variables included socio-demographic and disease characterization variables, as well as causes of hospital admission as diagnosis at the moment of hospitalization. Association between exposures and the outcome of interest evaluation was assessed by using Log-Rank test. Kaplan-Meier curves were also utilized to evaluate proportional hazard assumptions. Finally, Cox regression crude and adjusted models were created to assess the association between inpatient mortality and causes of hospital admission controlling for socio-demographic and disease characterization variables. 

Results: 

A total of 500 patients were enrolled. Among infections, the main causes of hospital admissions were urinary tract infections (23.0%) and diabetic foot (22.4%), whereas, from the non-communicable perspective, the main cause of was chronic renal failure (18.8%). During the study, 42 (8.4%) of the patients died, with a median of survival of 7 (IQR: 2 – 17) days. Among those who died, the principal cause of death was chronic renal failure (38.1%), followed by respiratory infections (35.7%) and stroke (16.7%). There was not significant association between socio-demographic variables and inpatient mortality. After adjusting for gender, age, place of birth, education level, time of disease, type of admission, treatment before hospitalization and glycated hemoglobin, inpatient mortality was positively associated with respiratory infections (HR = 6.55; 95%CI: 2.09 – 20.50), hyperosmolar state (HR = 17.69; 95%CI: 2.88 – 108.78), stroke (HR = 7.05; 95%CI: 1.91 – 26.07), acute renal failure (HR = 16.89; 95%CI: 3.10 –91.96). On the other hand, diabetic foot was inversely associated with inpatient mortality (HR = 0.13; 95%CI: 0.02 – 0.74). Estimates were pretty similar when multiple imputation models were generated. 

Conclusions:

Chronic renal failure, respiratory infections, and stroke were the main causes of death. These results differ from previous literature.

Respiratory infections, hyperosmolar state, stroke, acute renal failure and renal chronic failure increased the risk of dying during hospital admission.

Diabetic foot reduced the risk of death during hospital admission.

This mortality rate (8.4%) is much higher than expected when compare with India (4.4%) (4) or England (2.4%) (5)

 

Nothing to Disclose: HJZ, AB, HM, JSS

19579 5.0000 THR-188 A Not Only Infectious Diseases Increase the Risk of Mortality in Inpatient Type 2 Diabetic Patients in Peru 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Solange Grunenwald1, Jérôme Goddard2, Edvie Oum Sack2, Eric Bauvin2, Philippe Caron*1 and Pascale Grosclaude3
1CHU Larrey, Toulouse, France, 2Réseau ONCOMIP, Toulouse, France, 3Registre des Cancers du Tarn, ALBI, France

 

Context: During the past two decades, multiple countries have had a substantial increase in thyroid-cancer incidence without a concomitant increase in mortality reflecting an increase of small cancers - witch diagnosis are often fortuitous and whose natural evolution is not known. It is essential that the benefit of treatment and supervision provided to these patients is higher than the inconvenience caused. Recommendations of national societies and interventional studies are in favor of less therapeutic intervention. It seemed interesting to assess support in "real life" of differentiated thyroid cancers in particular studying the impact of multidisciplinary rounds (MDR) in their care.

Objectives: 1) Establish indicators of the quality of management of differentiated thyroid cancers 2) Identify the factors affecting the quality of care for patients with differentiated thyroid cancer.

Methods: A list of 24 indicators drawn from national, regional and international guidelines has been validated by 36 medical experts - who accepted to participate among 180 health professionals involved in the management of thyroid cancer in the region requested (South West of France) with a Delphi process. The medical history of 149 patients (77% women, aged 53 ± 14 years) diagnosed with a differentiated thyroid cancer mostly good prognosis (54% less than 1 cm, 85% pT1/2, 87% pN0/x, 99% M0/x) in the Tarn between 2010 and 2012 were studied retrospectively. The identification of cases was exhaustive through a cancer registry.

Results: The results of the indicators vary between 19% and 100%. The MDR do not improve their results. A more recent diagnosis improves the rate of MDR and the number of TSH into the reference range. We created two composite indicators: one defines the minimum care of patients with thyroid cancer with a low or intermediate risk: results increase if surgery was performed in an academic hospital (OR 4.1 CI 1.4-12.4) or when patient was less than 45 years old (OR 6.2 CI 1.2 -1.7). The second groups the indicators of therapeutic abstention in patients with a very low risk of recurrence: tumor bigger than 1 cm (OR 7.4 CI 2.7-20.4), no MDR (OR 0.2 CI 0.1-0.8) and treatment in 2010 (OR 2.1 CI 1.2-3.7 per year) are risk factors for overtreatment.

Conclusion: In patients with differentiated thyroid cancers the quality of initial management varies by patient age, place of management and presence of MDR. During the studied period we observe an improvement of therapeutic management of patients.

 

Nothing to Disclose: SG, JG, EO, EB, PC, PG

20263 6.0000 THR-189 A Evaluation of the Quality of the Initial Management of Differentiated Thyroid Cancers in the Tarn (France) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Michael J Campbell*1, Yingjia Chen2, Rosemary D Cress2, Alison Marie Semrad3, Thomas Semrad4 and Jessica E Gosnell5
1University of California, Davis, Sacramento, CA, 2University of California, Davis, 3UC Davis Medical Center, Sacramento, CA, 4University of California, Davis Comprehensive Cancer Center, Sacramento, CA, 5University of California, San Francisco

 

Background:  Race, gender and socioeconomic disparities have been suggested to adversely influence stage at presentation, treatment options and outcomes in patients with cancer.  Underserved minorities and those with a low socioeconomic status (SES) present with more advanced disease and have worse outcomes for differentiated thyroid cancer, but this relationship has never been evaluated for medullary thyroid cancer (MTC).

Methods: We used the California Cancer Registry (CCR) to evaluate the influence of race, gender and SES on the presentation, treatment and survival for patients with MTC.

Results: We identified 634 patients with MTC from the CCR between 1988 and 2011. Mean tumor size was larger for men than women (3.4 cm vs 2.3 cm, p < .0001). Tumor size did not differ between Hispanic (3.0 cm), White (2.8 cm), Black (2.2 cm) or Asian/Pacific Islander patients (2.6 cm, p = 0.3356) or in patients in the lowest (2.6 cm), lower-middle (2.8 cm), middle (2.6 cm), higher-middle (2.6 cm) or highest (2.5 cm) SES categories (p = 0.8027).  Neither race nor SES were associated with regional or distant metastatic disease; however women were less likely than men to present with regional metastatic disease (OR = 0.389, CI = 0.248-0.611) or distant metastatic disease (OR = 0.133, CI = 0.067-0.266). Race, SES and gender did not influence the likelihood of having a total thyroidectomy, but women had fewer lymph nodes removed than men, patients in the lowest SES group had fewer lymph nodes removed than higher-middle SES patients, and Black patients had fewer lymph nodes removed than White patients.  Patients in the highest SES category had a better overall survival than those in the lowest SES (HR=0.097, CI=0.024-0.387).   

Conclusion:  In MTC, men present with larger tumors and are more likely to have regional and distant metastatic disease than women. Underserved minorities and patients with a low SES present with similar sized tumors, but tend to have less lymph nodes removed during surgery than White and higher SES patients.  Patients with a high SES have improved survival over patients with a lower SES. These differences suggest an ongoing disparity that warrants further investigation.

 

Nothing to Disclose: MJC, YC, RDC, AMS, TS, JEG

21019 7.0000 THR-190 A Race, Gender, and Socioeconomic Disparities in the Presentation, Treatment and Outcomes of Patients with Medullary Thyroid Cancer: An Analysis of 634 Patients from the California Cancer Registry 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Julie Gilmour*1, Alanna Weisman2, Jonathan Vecchiarelli3, Steven Orlov4, Robert Joshua Goldberg4 and Alyse Goldberg1
1University of Toronto, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, 3University of Toronto, 4University of Toronto, Thornhill, ON, Canada

 

Background

As healthcare costs continue to rise, stewardship of finite healthcare resources is of paramount importance. Preventing laboratory overuse by reducing inappropriate free thyroxine (fT4) and free triiodothyronine (fT3) testing in the assessment of suspected thyroid disease is one strategy [1, 2, 3].  In most scenarios, free thyroid indices are not required in the setting of a normal TSH. We aimed to evaluate the frequency of inappropriate fT4/fT3 testing, prior to conducting a quality improvement initiative that aims to reduce this phenomenon.


Methods

Laboratory indices of serum TSH, fT4 and fT3 were reviewed between October 1, 2013 and September 30, 2014 at Women’s College Hospital, an academic ambulatory care hospital in Toronto, Canada.  Inappropriate fT4/fT3 tests were defined as any measurement in the setting of a normal TSH level (0.5-5.0mIU/L). We analyzed the proportion of inappropriate fT4/fT3, frequency of abnormal fT4/fT3 with a concurrent normal TSH (balancing measure) and estimated costs of inappropriate testing. To estimate the frequency of central hypothyroidism, which can present with a normal TSH and low fT4, billing data was assessed as a proxy to capture diagnostic codes for pituitary disease.  Chi-Square analysis was used to determine differences in inappropriate fT4/fT3 by ordering specialty.  


Results

Among 9,898 unique patients, a total of 13,702 TSH, 4,828 fT4 and 1,991 fT3 tests were performed over the study period. A normal TSH was observed in 11,134 (81.2%) tests. Inappropriate testing was noted for 3,101 (64.2%) fT4 and 1,154 (58.8%) fT3 tests. There was a significant difference in proportions of inappropriate fT4/fT3 by specialty of ordering physician, with 49.4%, 61.4% and 68.5% of fT4 and 42.9%, 22.1% and 34.3% of fT3 being inappropriate as ordered by general internists, endocrinologists and family physicians, respectively (p values <0.0001). The estimated cost associated with these inappropriate tests was $53,814CAD. Assessment of our balancing measure demonstrated 172 (5.5%) abnormal fT4 and 19 (1.6%) abnormal fT3 levels, among patients with a normal TSH.  The frequency of diagnostic codes representing a pituitary condition was rare, occurring in 0.74% of all patients.

 

Conclusions

Inappropriate testing of free thyroid indices occurs frequently, varies by ordering specialty and is associated with significant costs. The occurrence of abnormal fT4/fT3 in the presence of a normal TSH was infrequent, as was the clinical concern for central hypothyroidism. This data provides rationale for a quality improvement intervention that aims to reduce inappropriate testing of fT3/fT4, in the absence of an abnormal TSH test. We plan to use the model for improvement framework to implement a quality improvement initiative with a laboratory forced-function “reflex” fT4/fT3, which will only be performed in the setting of an abnormal TSH, after educating physicians.

 

Nothing to Disclose: JG, AW, JV, SO, RJG, AG

19603 8.0000 THR-191 A Reducing Inappropriate Thyroid Function Tests at an Academic Ambulatory Hospital: Baseline Assessment for a Quality Improvement Initiative 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Jennifer Poste*1, Irene A Weiss2, Matty H Mozzor1 and Monica D Schwarcz3
1New York Medical College, Valhalla, NY, 2New York Med College, Scarsdale, NY, 3Westchester Medical Center, NY

 

Background:

There are over 6 decades of experience on the use of radioactive iodine-131 (RAI) for hyperthyroidism, yet despite these years of experience, controversy remains regarding the optimal method required to achieve long time treatment in patients with benign hyperthyroid disease. In 2011, the American Thyroid Association (ATA) released official guidelines on the management of hyperthyroidism and other causes of thyrotoxicosis. The goal to control hyperthyroidism due to Graves’ disease with RAI is to render the patient essentially hypothyroid.  (2) Despite this consensus, there is still disagreement on the most appropriate dosing regimen to achieve this goal. While some prefer fixed doses of 10-15 milliCuries (mCi), others attempt to individualize the dose using calculations based on Quimby-Marinelli formula which is dependent on the estimated thyroid gland size and the 24-hour RAI uptake.

Underlying question:

At Westchester Medical Center, we use a individualized calculated dose method when treating patients with benign hyperthyroid disease, taking into account the size of the gland and the 24-hour RAI uptake. We analyzed our outcome data in our patient population and compared it to previous studies.

Methodology:

We included patients 18 years and older who underwent RAI ablation for Graves’ disease. Data collection included age, sex, cause of hyperthyroidism, thyroid function tests 1 to 2 months prior to RAI ablation-including thyroid stimulating hormone (TSH), free thyroxine (FT4), and total triiodothyronine (TT3) , 24-hour RAI uptake, estimated size of thyroid gland, thyroid function tests 6-12 months after treatment, need for thyroid hormone supplementation 6-12 months after treatment, and treatment failure. Treatment failure was defined as the need for retreatment with antithyroid medication, repeat RAI, or surgical resection within 6-12 months after initial therapy. Basic descriptive statistics were used to characterize our patient population and outcomes. Data is expressed in percentages and averages.

Results:

The clinical outcomes of 40 patients with Graves’ disease treated with a wide doses of RAI were analyzed retrospectively. The average initial dose was 9.21 mCi (+/-3.34). Six to twelve months after the first dose of RAI 27/40 patients (67.5%) were hypothyroid (requiring thyroid hormone supplementation) and 5/40 patients (12.5%) were euthyroid, while 8 patients (20%) were treatment failures. The overall cure rate was 80% (32/40 patients).

Interpretations and Conclusions:

With our RAI dosing the overall cure rate of 80% was similar or better than most studies (3-6).  However a study by Sztal et al. reported a success rate of 86%, with higher success rate of 89% associated with a higher dose of RAI(20mCi)(7). A study by Lewis et al. also reported a high success rate of 93% associated with higher doses of RAI (15mCi)(1).

 

Nothing to Disclose: JP, IAW, MHM, MDS

20044 9.0000 THR-192 A Clinical Outcomes after Calculated Activity of Radioiodine for the Treatment of Benign Hyperthyroid Disease at Westchester Medical Center: A Retrospective Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Julianne Cook Botelho*, Enada Archibold and Hubert W Vesper
Centers for Disease Control and Prevention, Atlanta, GA

 

The CDC Hormone Standardization Program is assisting clinical, research, and public health laboratories in enhancing the quality and comparability of measurements by creating measurement results that are traceable to one accuracy base and thus comparable across methods, time, and location.

Laboratory results obtained in research and patient care need to have the same accuracy to effectively use research findings and to treat patients.  However, problems with accuracy and overall performance of hormone tests exist.  This includes testosterone (T), estradiol (E2), and 25 hydroxyvitamin D (25OHD) as well as other hormones.  Inaccurate measurements affect the diagnosis, treatment, and prevention of hormone related diseases and disorders. 

Standardization is needed to improve hormone measurement.  To achieve standardized measurements, a reference system is necessary to assess the accuracy and performance of assays and serve as an accuracy base.  This system includes reference methods and reference materials.  The CDC has developed mass spectrometry-based higher-order reference methods calibrated with certified, pure-compound reference materials to create reference systems for T, E2, and 25OHD. 

The CDC is using the reference systems to operate CDC Standardization-Certification Programs, HoSt and VDSCP.   Through these programs, the CDC is working closely with collaborators to help insure that assays are properly calibrated and evaluated on an ongoing base.  Currently, there are over 50 laboratories enrolled.  

The certification programs show overall improvements in assay calibration.  With the implementation of the certification program for T, the calibration bias has improved over the last 6 years.  The among-laboratory absolute bias of participants has dropped from 16.5% to 3.6% from 2007 to 2013.  Similar results are expected for both E2 and 25OHD as the programs continue into their 1st and 2nd year, respectively.

In addition, the CDC is working to evaluate methods for sex-hormone binding globulin (SHBG), a critical measurement principal in the determination of free testosterone (fT). The reporting of fT has shown high variability with different measurement principles for determining fT; for further evaluation and future standardization of measurements, a reference system needs to be implemented. 

Additional analytes are also being explored by the CDC through the development of new methods, collaborations, and method performance evaluations.  This includes both free and total thyroid hormones thyroxine (T4) and triiodothyronine (T3), as well as parathyroid hormone (PTH).

CDC collaborates closely with stakeholders such as the Partnership for Accuracy in Hormone Testing (PATH) and The Endocrine Society to assure clinical and public health needs are met.  Through these efforts and collaborations, the CDC is working towards standardization of hormone measurements.

 

Nothing to Disclose: JCB, EA, HWV

22066 10.0000 THR-193 A Standardization of Hormone Measurements 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Takao Ando*1, Aya Nozaki1, Satoru Akazawa2, Ikuko Ueki Sagara1, Ichiro Horie1, Misa Imaizumi1, Toshiro Usa1 and Atsushi Kawakami1
1Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan, 2Nagasaki University Graduate School of Biomedical Sciences, Japan

 

Backgrounds: The precise reasons remain unknown why patients with central diabetes insipidus (CDI) prefer oral tablet of desmopressin (DDAVP) than nasal. We hypothesized CDI patients improve their QOL by changing from nasal DDAVP to oral disintegrating tablet (ODT).

Aims: To create and evaluate a questionnaire to survey QOL focusing on fluid intake and urination in patients with CDI under different formulations of DDAVP.

Methods: Our questionnaire contains 12 queries, for example, asking frequency of fluid intake and urination in daytime and night-time, and asking if there is worry of urination in transportation for a long time. It also includes 2 queries regarding DDAVP treatment. Each query has 4-graded answers given a score from 1 to 4; higher the score, better the QOL. Informed consent was obtained from patients with CDI visited our hospital from May 2013 to May 2014 (N=31). Among 25 CDI patients under nasal DDAVP treatment, 21 changed their treatment to ODT. Patients with newly developed CDI (N=6) were also included. Patients were instructed to indicate the most appropriate answer in the questionnaire at the enrollment and three months after treatment of ODT. CDI patients who unchanged nasal DDAVP (N=4) and healthy controls (N=18) were surveyed only at the enrollment. Results are expressed as the mean ±SD.

Results: Our questionnaire detected improvement in QOL in the CDI patients after changing from nasal DDAVP to ODT in 10 out of 12 queries (p<0.05 in sign test and Wilcoxon signed-rank test). The total score of the 10 queries significantly improved from 26.1± 5.3 (nasal) to 33.2± 4.3 (ODT) (p<0.001 in Wilcoxon signed-rank test). After excluding the two queries that failed to detect QOL change and the two queries regarding DDAVP treatment, we compared the total score of the 8 remaining queries among all the participants. There was treatment-dependent increase in the total score: 13.0 ±5.15 in untreated patients (N=6), 21.2 ±4.8 in those with nasal DDAVP (N=25), 25.6 ±4.7 in those with OTD (N=27). The differences among each group were significant (p<0.05 in Steel-Dwass test). There was no significant difference between patients treated with ODT and healthy control (26.3 ±3.4).

Conclusions: We have successfully created the questionnaire to survey QOL in CDI patients. This study suggested that ODT treatment seemed to bring QOL in CDI patients similar to that in healthy control. This would be the chief reason why patients prefer ODT than nasal DDAVP.

 

Nothing to Disclose: TA, AN, SA, IUS, IH, MI, TU, AK

18233 11.0000 THR-194 A QOL in the Patients with Central Diabetes Insipidus Under Different Formulations of Desmopressin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Qian Li1, Joanna Huang*2, Mette Hammer2, Steve Blume1 and Todd M Hobbs2
1Evidera, Bethesda, MD, 2Novo Nordisk, Inc., Plainsboro, NJ

 

Background and objective: Obesity can lead to a number of costly diseases. The study aims to estimate the economic burden of obesity-related comorbidities (ORCs) in the Unites States (US).      

Methods: The Geisinger Health System provided electronic medical records and insurance claims between January 2004 and May 2013 for a sample of 153,561 adults (50% males and 97% white). The study period was the continuous enrollment in health plans with full year coverage. We excluded adults with <2 years of study period, underweight (BMI <18.5 kg/m2), or diseases causing major weight change (e.g. malignancy). A total of 21 chronic conditions linked with obesity were identified from the literature, including hypertension, dyslipidemia, type 2 diabetes, depression, chronic obstructive pulmonary disease, osteoarthritis, and other diseases. The ORCs were detected in the database by diagnosis codes and lab test results, and the status was kept to the end of study period. The incident case of ORC was defined as the first occurrence after a one year “wash out” from the start of study period. We measured the annual healthcare costs (from medical and pharmacy claims, in 2013 $) in each year during the study period, as well as the costs in the 1st year after the incident cases (i.e. 1st year incident costs). The association between the annual costs and the prevalent ORC (for all the ORCs) was assessed by a generalized linear regression model (GLM) , adjusted for socio-demographics (age, gender, race, smoking, employment, insurance type, and year) and BMI levels (normal: 18.5-24.9, overweight: 25-29.9; class I obesity: 30-34.9; class II: 35-39.9; class III: ≥40 kg/m2) in each year. For each ORC, we also used GLM to estimate the 1st year incident costs, using the 2nd year costs in the study period of the adults without the ORC as control; the regression was adjusted for socio-demographics, BMI levels, and the status of the other ORCs in the 1-year baseline period.             

Results: We identified 56,895 adults (mean years in study period: 5; mean age: 48; mean BMI: 30kg/m2 ). The annual prevalence of ORCs ranged from 1% for pulmonary embolism (PE) to 46% for dyslipidemia. The regression estimated that annual costs associated with one prevalent ORC, without occurrence of the other ORCs, ranged from $1,670 for angina to $3,400 for PE. The ORC-associated annual total costs were higher than the annual total costs without any ORC ($1,556, all P<0.05 except for angina). The estimated 1st year incident costs were higher than the annual costs with prevalent case for all the ORCs. Compare with controls, the 1st year incident costs were noticeably higher for cardiovascular diseases (by >$14,000, all P<0.05).

Conclusions: ORCs are associated with substantial economic burden on US healthcare system especially during the first year after diagnosis.

 

Disclosure: QL: Employee, Evidera . JH: Employee, Novo Nordisk. MH: Employee, Novo Nordisk. SB: Employee, Evidera . TMH: Chief Medical Officer , Novo Nordisk.

19916 12.0000 THR-195 A Economic Burden of Obesity-Related Comorbidities in an Electronic Health Records System in the United States 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Qian Li1, Joanna Huang*2, Steve Blume1 and Mette Hammer2
1Evidera, Bethesda, MD, 2Novo Nordisk, Inc., Plainsboro, NJ

 

Background and objective: The presence of obesity-related comorbidities (ORCs) increases the cost burden of obesity. The study aims to assess how ORCs are associated with high healthcare costs in the United States.
Methods: The Geisinger Health System provided electronic medical records and insurance claims between January 2004 and May 2013 for a sample of 153,561 adults (50% males and 97% white). The study period was the continuous enrollment in health plans with full year coverage. We excluded adults with <2 years of study period, underweight (BMI <18.5 kg/m2), or diseases causing major weight change (e.g. malignancy). We examined the annualized healthcare costs (from medical and pharmacy claims, in 2013 $) during the study period and defined 5 cohorts based on the cost distribution in the sample: <50, 50-<80, 80-<94, 94-<99, and ≥99 percentile (%tile). We compared the demographics (age, gender, race, smoking, employment, insurance type, and year at the end of study period) and clinical characteristics (ORCs, Charlson comorbidity index excluding ORCs, and mean BMI in study period) between the cohorts (reference cohort: <50 %tile). We included 21 ORCs (e.g. hypertension, dyslipidemia, type 2 diabetes, depression, chronic obstructive pulmonary disease, and osteoarthritis), identified by diagnosis codes and lab test results. We used logistic regression models to assess the likelihood for adults with ORCs to be in high cost cohorts vs. <50 %tile cohort, adjusted for demographics and clinical characteristics.
Results: We identified 56,895 adults (mean years in study period: 5; mean age: 53; mean BMI: 30kg/m2). The adults in the top 50 %tile of cost distribution contributes to >90% of the total costs in the study sample . The average annualized costs were $1,031, $4,405, $10,899, $25,617, and $79,922 in <50, 50-<80, 80-<94, 94-<99, and ≥99%tile cost cohorts. Among the 21 ORCs, the average annual prevalence was highest (42.3%) for dyslipidemia and lowest (0.5%) for pulmonary embolism. Higher cost cohorts had higher mean age (from 47 in <50 %tile to 69 in ≥99 %tile), higher mean BMI (from 29 kg/m2 in <50 %tile to 32 kg/m2 in 94-<99 %tile), and higher prevalence of all ORCs (all P<0.05 vs. <50 %tile). Adults with any of the ORCs were more likely to be in a high cost cohort (adjusted odds ratio [AOR] >1, P<0.05). Myocardial infarction, ischmeic stroke and heart failure have the highest increase in AOR; in particular, myocardial infarction, has AOR ranged from 5.5 for 50-<80 %tile to 26.7 for ≥99 %tile. Age and BMI had minimal association with high costs (AORs=1, P<0.05), given that we adjusted for ORCs.
Conclusions: ORCs have independent positive association with higher healthcare costs. Weight loss could help to reduce healthcare costs by lowering the risk of obesity-related complications.

 

Disclosure: QL: Employee, Evidera . JH: Employee, Novo Nordisk. SB: Employee, Evidera . MH: Employee, Novo Nordisk.

21015 13.0000 THR-196 A Obesity-Related Comorbidities Are Independent Drivers of High Healthcare Costs in the United States 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Hala H Mosli*, Lama Adnan Banjar, Afaf Ghunaim, Hanan Faruqui, Haifa Alshaikh, Mashael Alsamti and Amal Almalki
King Abdulaziz University, Jeddah, Saudi Arabia

 

Introduction: Breastfeeding is the optimum way of nutrition for the growing infant. It has been suggested that breastfeeding also benefits the mothers. It is proposed that lactation is an efficient way of promoting postpartum weight loss. Furthermore, postpartum depression can be challenging for both mothers and their infants. It is likely that postpartum depression leads to early cessation of breastfeeding. Breastfeeding may alter the risk of depression. The aim of this study is to further understand the adherence and outcomes of breast milk feeding on mothers in King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia.

Objectives: The aims of this study were to measure the adherence and frequency of breast milk feeding among mothers in KAUH and identify the relationship between breastfeeding and the development of postpartum depression. A secondary objective was to calculate the postpartum weight reduction percentage in comparison to pre-pregnancy weight.

 

Materials & Methods: A cross sectional study was conducted in KAUH among 150   mothers, whose infants are less than two years of age. Data regarding the pattern of feeding and the suggested outcomes was collected by interviewing the mothers using a standard questionnaire designed for the study and the HAMD depression scale. Measurement of height, weight and waist circumference were also carried out. 

Results: 85.62% of the study sample mother’s breastfed and 43.38% breastfed their child for 1 to 2 months and 24.18% for 6 months or more. However, the relationship between postpartum depression and breastfeeding was not significant with a p-value>0.05. We also found that 84.97% of the mothers had the same or larger weight than before pregnancy.

Conclusions: Mothers in KAUH have a high frequency of breast milk feeding initiation and adherence. The outcomes of breast milk feeding in mothers in the context of weight loss were not observed. Depressed women were less adherent to the practice of breast milk feeding.

 

Nothing to Disclose: HHM, LAB, AG, HF, HA, MA, AA

19525 14.0000 THR-197 A Maternal Outcomes of Breast MILK Feeding in King Abdulaziz University Hospital, Saudi Arabia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Thursday, March 5th 3:00:00 PM THR 184-197 6047 1:00:00 PM Health Outcomes/Quality Improvement Research Poster


Elisabet Stener-Victorin*1, Milana Kokosar2, Manuel Maliqueo3, Antonina Sazonova4, Carl Johan Behre5, Kurt Højlund6, Anna Benrick2, Åsa Tivesten7 and Claes Ohlsson8
1Karolinska Institutet, Stockholm, Sweden, 2Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 3University of Chile, Santiago, Chile, 4Institute of Clinical Science, Göteborg, Sweden, 5Institute of Medicine, Göteborg, Sweden, 6Odense University, Odense, 7Institute of Medicine, Gothenburg, Sweden, 8University of Gothenburg, Gothenburg, Sweden

 

Background: Women with polycystic ovary syndrome (PCOS) commonly have impaired glucose regulation, hyperinsulinemia and insulin resistance (IR). Acupuncture with combined manual and low-frequency electrical stimulation (EA) has been demonstrated to increase ovulation rates and decrease circulating androgens in women with PCOS (1,2). In DHT-induced PCOS rats, 5 weeks of low-frequency EA treatments ameliorated IR to the same extent as exercise (3,4). If acupuncture has such an effect in women with PCOS is unknown. In the present study we tested the hypothesis that 5 weeks of acupuncture treatment increases whole body glucose uptake in women with PCOS.

Primary outcome: Changes (before vs after 5 weeks of treatment) in insulin sensitivity measured by an euglycemic hyperinsulinemic clamp and calculation of glucose infusion rate (GIR; M value and M/Cclamp value).

Secondary outcomes: Changes in Hba1c, calculation of HOMA-IR, C-peptide index (CPI), anthropometrics, body fat distribution and circulating sex steroids measured with GC-MS/MS.

Design: In total, 17 women with PCOS were enrolled in this prospective, uncontrolled trial. Six-teen women give an 80% power to detect a 15% change in M/Cclamp and M-value. Eligibility criteria for women with PCOS were a BMI between 25 and 40 and two of the following symptoms: polycystic ovaries, oligo/amenorrhea, or signs of hirsutism/acne.

All measures were taken at baseline and again after 5 weeks of acupuncture treatments given 3 times/week for 30 min each. After an overnight fast, the clamp was performed and insulin was infused (40mU/min/kg) for 120 min to reach steady state. The clamp after 5 weeks of treatment was repeated within 48 h of the last treatment and on cycle day 1-10 if ovulation.

Acupuncture needles were placed in the abdominal and quadriceps muscles and in the muscles below the knee in somatic segments corresponding to the innervation of the ovaries and pancreas. Needles were stimulated by manual rotation every 10 min and by 2 Hz electrical stimulation.

Results: Five weeks of acupuncture treatment increased M/Cclamp (difference (D) before vs after; 2.22 ± 3.21, P = 0.009), whereas M-value did not change. Circulating Hba1c decreased (-1.29 ± 1.40, P = 0.004), and HOMA-IR and CPI tended to decrease (-0.62 ± 1.21, P = 0.051 and -1.26 ± 2.35, P = 0.051 respectively). Circulating testosterone and DHT decreased after 5 weeks of treatment (-10.6 ± 10.0 pg/ml, P = 0.0007 and -1.55 pg/ml ± 2.06, P= 0.007 respectively). There were no changes in anthropometrics.

Conclusion: This is the first study to demonstrate that five weeks of acupuncture treatment with combined manual and electrical stimulation of the needles improves whole body glucose uptake and decreases circulating Hba1c and androgens in overweight women with PCOS.

 

Nothing to Disclose: ES, MK, MM, AS, CJB, KH, AB, ÅT, CO

19925 1.0000 THR-099 A Repeated Acupuncture Treatments Increases Whole Body Glucose Uptake and Decrease Circulating Testosterone in Women with Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Fabio Vasconcellos Comim*, Karina Gutierrez, Alessandra Bridi, Guilherme Bochi, Raisa Chemeris, Melania Lazzari Rigo, Alfredo Skrebsky Cezar, Rafael Moresco and Paulo Bayard Dias Gonçalves
Federal University of Santa Maria, Santa Maria, Brazil

 

Polycystic ovary syndrome (PCOS) is the commonest hyperandrogenic disorder in women, usually aggravated by weight gain and/or obesity. Adiponectin, a product from fat tissue, has been suggested in PCOS as a connector between metabolic and reproductive systems. Indeed, previous studies in vitro have shown that treatment with adiponectin reduced androstenedione synthesis in bovine theca cells. Adiponectin also has actions against oxidative stress pathways that were not entirely understood in the ovary. Therefore, the aims of this study using an in vivo model were to address the impact of administration of adiponectin on androstenedione secretion and oxidative stress parameters.
Seven-week-old female Balb/c mice (n=38) with weight [mean + SD] of 19.98 + 2 g were synchronized with equine gonadotropin chorionic (eCG) 10 UI intra-peritoneal (IP) 2 days before the experiment. At day zero these animals were submitted to one of the four different treatments: 1) Group 1- control (PBS), Group 2 - adiponectin 0.1 µg/mL, Group 3 - adiponectin 1 µg/mL, and Group 4 - adiponectin 5 µg/mL. All treatments were administrated in 50µl IP adjusted to (estimated) total blood volume. After 24 hours animals were euthanized and had blood and ovary tissue collected. Androstenedione serum levels were accessed by ELISA; advanced oxidation protein products (AOPP), nitrogen oxide (NOx) and total oxidant capacity (TOS) were evaluated in the homogenized ovary by spectrophotometric protocols. All procedures were carried out with the approval of the Federal University of Santa Maria Committee for Ethics in the Use of Animals.
Female mice treated with adiponectin exhibited a significant reduction in serum androstenedione in comparison to controls. Androstenedione levels were respectively [mean + SD] 0.78 + 0.4 ng/mL in controls, 0.28 + 0.2 ng/mL in Adiponectin (0.01 µg/mL), 0.30 + 0.1 ng/mL in Adiponectin (1 µg/mL), and 0.28 + 0.06 ng/mL in Adiponectin (5 µg/mL) (p=0.01). Moreover, a remarkable decrease in ovarian AOPP was demonstrated in adiponectin-treated mice. AOPP levels [mean + SD] observed in controls were 11.5 + 1.7 µmol/L in comparison to 2.62 + 0.5 µmol/L in Adiponectin (0.01 µg/mL), 3.6 + 1.5 µmol/L in Adiponectin (1 µg/mL), and 4.3 + 2.1 µmol/L in Adiponectin (5 µg/mL) (p=0.0002)
Our results in vivo demonstrated that adiponectin reduced oxidative stress proteins in the ovary and androstenedione secretion suggesting that both mechanisms may be potentially involved in the pathogenesis of PCOS associated to obesity.

 

Nothing to Disclose: FVC, KG, AB, GB, RC, MLR, ASC, RM, PBDG

18862 2.0000 THR-100 A Adiponectin Promotes a Decrease in Androstenedione Secretion and Ovarian Oxidative Stress Parameters in Vivo: Possible Implications for Polycystic Ovary Syndrome (PCOS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Karen Elkind-Hirsch*, Martha Paterson, Ericka Seidemann and Hanh Gutowski
Woman's Hospital, Baton Rouge, LA

 

Oral contraceptives (OCs) are often used to regulate menses and suppress hyperandrogenism in women with polycystic ovary syndrome (PCOS); however, their use has been associated with negative changes in glucose-insulin metabolism.  Studies evaluating the impact of OCs on carbohydrate metabolism in PCOS have obtained conflicting results leading us to hypothesize that the effects of OCs in PCOS may be dependent on body mass.  We evaluated 24 weeks of a low-dose OC regimen of ethinyl estradiol-drospirenone (EE/DRSP) with levomefolate calcium on clinical, hormonal and cardiometabolic parameters in women diagnosed by NIH criteria for PCOS stratified into 3 groups by body mass index (normal BMI=18-24.9 kg/ m2; overweight BMI 25-29.9 kg/ m2 and obese class 1 BMI =30-35 kg/ m2).  Fifty-six PCOS women (18-35 yr) were enrolled; 46 subjects (11 normal, 16 overweight, and 19 obese) completed the study protocol.  BMI, waist-to-hip ratio [WHR], androgens (DHEAS, T, SHBG, free androgen index [FAI]), lipids, folate, glucose (G) and insulin (I) levels during an OGTT were measured before and after 24 weeks.  Insulin sensitivity and ß-cell function measures were computed from G-I values obtained during the OGTT.  Factorial repeated measures ANOVAs were used to make comparisons between the BMI groups and measures of time (baseline and post 24 weeks treatment).  Hyperandrogenism, irregular menses and insulin resistance were found at baseline in all study participants.  Body weight had no impact on efficacy of EE/DRSP therapy in normalizing androgens, improving menstrual cyclicity (mean of 6 cycles to 11.2 cycles annually) and increasing SHBG and folate levels (p<0.001).  The FAI decreased significantly in all BMI groups (mean value of 5.5 +/-0.4 to 0.75 +/-.07, p =0.001) with EE/DRSP treatment.  OC therapy did not lead to change in BMI or WHR and all BMI groups had similarly altered lipid profiles.  Both glucose stimulated insulin resistance and β-cell function were negatively affected by OCs in obese PCOS subjects.  The insulin secretion-sensitivity index (ISSI) significantly decreased after 24 weeks with EE/DRSP treatment in obese users (378.5+/-77 to 279.5 +/- 108) in contrast  to nonobese women with PCOS where we observed no change or saw a slight improvement in the ISSI (605.65+/-62 to 696.7 +/- 88; p<0.05).  In conclusion, EE/DRSP treatment was effective in attenuating hyperandrogenism independent of BMI.  Whereas EE/DRSP improves or is neutral on carbohydrate metabolism in normal and overweight PCOS women, negative changes in glucose and insulin sensitivity were seen in the present study among obese PCOS contraceptive users.  The differences in response to OC treatment between obese and non-obese patients with PCOS suggest that obesity has to be considered as a characteristic when determining the metabolic impact of contraceptive therapy (ClinicalTrials.gov number, NCT03160996 [ClinicalTrials.gov]).

 

Nothing to Disclose: KE, MP, ES, HG

18363 3.0000 THR-101 A Impact of Low-Dose Folate-Supplemented Oral Contraceptive (OC) on Hyperandrogenism and Insulin Action in Women with Polycystic Ovary Syndrome (PCOS) Stratified By Body Mass Index (BMI) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Jie Qiao*1, Mengxia Fan2, Bing Han3, Tong Cheng4, Hui Zhu4, Wei Liu4 and Wen-jiao Zhu4
1Shanghai Jiao Tong University, School of Medicine, Shanghai, China, 2Shanghai Jiao Tong University School of Medicine, Shanghai, 3Shanghai Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 4Shanghai Jiao Tong University School of Medicine

 

Context: P450c17, encoded by CYP17A1, is the microsomal P450 that catalyzes both 17-hydroxylase (17OHase) and 17,20-lyase (lyase) activities in the synthesis of glucocortocoids (17OHase only) and sex steroids (both activities); thus lyase is the qualitative regulator of steroidogenesis, determining the class of steroid produced. The mechanisms responsible for expression of lyase activity in the adrenal zona reticularis, but not fasciculata, are unclear, but it is developmentally regulated at adrenarche, and contributes to the hyperandrogenism of polycystic ovary syndrome (PCOS). Increased adrenal and ovarian C19 steroid production and insulin resistance in PCOS may be connected by a signal transduction pathway that increases the Ser/Thr phosphorylation of both P450c17 and either the insulin receptor or its substrate. Drug inhibition and siRNA knockdowns in adrenal cells implicate p38 pathways in P450c17 phosphorylation and hyperandrogenic states.

Objectives: Saturated fatty acids, such as palmitate, activate stress kinases, resulting in insulin resistance in 3T3-L1 adipocytes and C2C12 myotubes. We sought to determine whether palmitate and other oxidants regulate lyase activity in adrenal cells, which might suggest an environmental component to hyperandrogenism in PCOS. 

Methods: NCI-295R adrenal cells were treated with palmitate, hydrogen peroxide (H2O2) and 4-hydroxy-2-nonenal (HNE). Enzyme activities were analyzed by thin-layer chromatography (TLC) and ELISA. 17OHase activity was assayed by conversion of progesterone (P) to 17OH-progesterone and lyase activity was measured by conversion of 17OH-pregnenolone to DHEA. Reactive oxygen species (ROS) were assayed by hydroethidine (HE) probe. Phosphorylation of p38α MAPK was observed by western blot. Pharmacological inhibition was utilized to probe the signal pathway. Expression of StAR, P450c17, POR and cytochrome b5 were measured by real-time PCR and western blot.

Results: Lyase activity increased more than 17OHase activity following treatment with palmitate, H2O2 and HNE. Compared to control cells, 0.75 mM plamitate did not influence 17OHase significantly but increased lyase by 74.3% (P<0.05). The elevation of lyase activity was also observed under the treatment of H2O2 (0.5-1mM) and HNE (100µM) .The p38 MAPK inhibitors SB202190 and SB203580 lessened the increase in lyase activity with H2O2treatment.  The amounts of P450c17, POR and cytochrome b5 proteins did not change, but the phosphorylation of p38α MAPK was increased, which should increase Ser/Thr phosphorylation of P450c17 and androgen synthesis.

Conclusions: Oxidative stress may induce the activity P450c17, especially lyase activity. As a sensor of reactive oxygen species, p38α MAPK is involved in the post-translational regulation lyase activity, and may be a mechanism of androgen overproduction in PCOS.

 

Nothing to Disclose: JQ, MF, BH, TC, HZ, WL, WJZ

19497 4.0000 THR-102 A Oxidative Stress------ a Nexus Between Insulin Resistance and Hyperandrogenism: Augment of 17,20-Lyase Activity of Adrenal P450c17 through Phosphorylation of p38α  MAP Kinase 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Fanny Beland*, Jessica Fortin-Mimeault, Marie Claude Battista and Jean-Patrice Baillargeon
Université de Sherbrooke, Sherbrooke, QC, Canada

 

BACKGROUND: Polycystic ovary syndrome (PCOS) is mainly characterized by hyperandrogenism. Previous work from our laboratory suggests that lipotoxicity, defined as the deleterious effects of non-esterified fatty acids (NEFA), may induce hyperandrogenism. The enzyme P450c17 is responsible for androgen production, specifically through activation of its 17,20-lyase activity that is facilitated by: 1) Serine phosphorylation of P450c17; 2) the cofactor Cytochrome b5 and 3) P450 oxidoreductase (POR) activity. The objective of this project was to determine whether NEFA amplifies androgen production through increased protein expression of P450c17 and POR.

METHODS: Accordingly, bovine adrenal fasciculata/reticulata cells were stimulated or not with forskolin (Fsk 0,001-100 μM; once for 48h, non-specific activator of adenylate cyclase simulating ACTH stimulation), in the absence or presence of palmitate or oleate (100 or 200 μM; twice daily; saturated & monounsaturated fatty acid). After 48 hours, media was collected to measure DHEA levels (main adrenal androgen) by ELISA. Proteins extraction was conducted to determine P450c17 and POR expression by Western blot (reported on actin expression). Results were analyzed using Wilcoxon signed-rank test.

RESULTS: Dose-response curves were performed using 4 glands. In the presence of increasing doses of Fsk, DHEA production increased up to a maximum at 10 µM of Fsk. In the presence of Fsk 10 µM, DHEA production was increased by 23 ± 27% with palmitate 100 µM, by 56 ± 25% with oleate 100 µM and by 112 ± 26% with oleate 200 µM (all Ps>0.05). Palmitate 200 µM was lethal for the cells. Protein expression experiments were thus performed using Fsk at 10 µM and oleate at 200 µM, with 7-10 glands. Under Fsk stimulation, oleate increased DHEA production by 106 ± 24% when compared to Fsk alone (P=0.002). However, P450c17 and POR expression were not modified by the presence of oleate. In fact, under Fsk stimulation, oleate decreased P450c17 expression by 2 ± 6% and increased POR expression by 18 ± 13%, compared to Fsk alone (P=0.74 and 0.22, respectively).

CONCLUSION: Overexposure of bovine adrenal cells to NEFA increases androgen production without significantly increasing P450c17 or POR expression. These results suggest that the impact of lipotoxicity on androgen production may occur through other mechanisms, such as increasing serine phosphorylation of P450c17 or expression of Cytochrome b5, which remain to be determined.

 

Nothing to Disclose: FB, JF, MCB, JPB

20966 5.0000 THR-103 A Non-Esterified Fatty Acid Increases Androgen Production By Bovine Adrenal Cells without Affecting P450c17 and P450 Oxidoreductase Expression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Alice Y Chang*1, Gregory Jenkins2, Rickey Carter1, Ravinder J. Singh2 and K Sreekumaran Nair1
1Mayo Clinic, Rochester, MN, 2Mayo Clinic

 

Polycystic Ovary Syndrome (PCOS) is a condition of androgen excess and chronic anovulation that is frequently associated with impaired insulin sensitivity. An untargeted metabolomics approach identified specific metabolic pathways that distinguish PCOS from obese controls with the traditional metabolic syndrome. These pathways included branch chain amino acids, lipids and vitamin D metabolism. We sought to determine whether measurement of targeted metabolite concentrations distinguish PCOS from obese controls.

METHODS: Twenty obese untreated women diagnosed with PCOS demonstrating androgen excess and oligomenorrhea were compared to 18 women without PCOS who met criteria for the metabolic syndrome as defined by the NHLBI. Plasma samples were obtained fasting at baseline during a frequently sampled intravenous glucose tolerance test. We utilized liquid chromatography/mass spectrometry techniques to quantify amino acid, free fatty acid metabolites and vitamin D concentrations. Logistic regression was used to model PCOS vs. metabolites; while the effect of clinical variables on metabolite levels was modeled using linear regression.  The joint effect of multiple metabolites on PCOS was modeled using a GLMM implemented in the R package globaltest. Surrogate variables were created using the R package sva and adjusted for to address the metabolomic assay’s technical variation.

RESULTS: When analyzing by groups of amino acids, branch chain amino acids and essential amino acids were found to be associated with PCOS (p=0.024, 0.027). Within these groups, the most associated metabolites seem to be the branched chain amino acids: valine, leucine and isoleucine; as well as the essential amino acid, lysine and its metabolite, alpha-aminoadipic acid. There was no association found of PCOS with free fatty acids or vitamin D concentrations. Among the additional characteristics measured in both PCOS and controls, insulin sensitivity was also associated with essential and branched chain amino acids related to PCOS. There was no significant association of any measured metabolites with androgens, lipids, or measures of body composition.

CONCLUSIONS: Concentrations of branched chain and essential amino acids and alpha-aminoadipic acid seem to distinguish PCOS from obese controls with metabolic syndrome. How these specific amino acid elevations in PCOS may contribute or results from PCOS remains to be determined. A potential explanation is that more severe insulin resistance in PCOS causes these changes in amino acids and metabolites. The current study demonstrates the importance of a targeted approach for follow-up of an untargeted analysis in the discovery of biomarkers.

 

Nothing to Disclose: AYC, GJ, RC, RJS, KSN

21125 6.0000 THR-104 A Targeted Analysis of Amino Acid, Free Fatty Acid Metabolites and Vitamin D Concentrations in Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Hui Peng*1, Steven J. Soldin2, Mihriye Mete3, Suzette VanBuren Hayes4, John Maynard5 and Vanita R. Aroda6
1Georgetown University Hospital, DC, 2Georgetown University, Bethesda, MD, 3MedStar Health Research Institute, Hyattsville, MD, 4Medstar Health Research Institute, MD, 5Veralight, 6Medstar Health Research Institute, Hyattsville, MD

 

Background: Polycystic ovary syndrome (PCOS) is a common endocrine abnormality in women of reproductive age. Women with PCOS are at a higher risk of abnormal glucose tolerance and type 2 diabetes. Vitamin D insufficiency has been implicated in diabetes risk, potentially through effects on insulin secretion, insulin sensitivity, and systemic inflammation. Noninvasive assessment of dermal advanced glycation end products (AGEs) via skin fluorescence spectroscopy (SFS) measurements has been suggested for opportunistic type 2 diabetes screening.   

Objective: To evaluate the relationship among glucose tolerance, sex steroid and vitamin D levels, and SFS in women with PCOS.  

Methods: We enrolled 31 women with PCOS using the Rotterdam criteria. A total of 29 premenopausal control age- and BMI-matched women without PCOS were enrolled.  Consented participants had 75 g OGTT, SCOUT DS® measurement of SFS, and serum simultaneously assayed for 13 steroid levels, including 25-OH-vitamin D levels, by isotope dilution liquid chromatography-tandem mass spectrometry.  

Results: In the overall group (n=60), there was a significant though modest relationship between SFS scores and 2 hr post-challenge glucose levels (r=0.28, p=0.03). SFS scores also significantly correlated with serum triglyceride (r=0.29, p=0.03), DHEA (r=-0.41, p=0.002), deoxycortisol (r=-0.32, p=0.02), and 25-OH vitamin D (r=-0.34, p=0.01), with a trend for correlation with aldosterone (r=-0.21, p=0.11), corticosterone (r=-0.24, p=0.07), androstenedione (r=-0.23, p=0.09), and no significant relationship with DHEAS, testosterone, hydroxyprogesterone, estradiol, estrone, or estriol. In the PCOS group, there was a more pronounced relationship between SFS scores and deoxycortisol (r=-0.42, p=0.02), DHEA (r=-0.63, p=0.0003); 25-OH vitamin D (r=-.46, p=0.01).  

Discussion/Conclusions: A positive relationship of SFS scores with glucose intolerance has previously been demonstrated (1). Further, low vitamin D levels have been implicated in risk of diabetes, as well as insulin resistance in PCOS. There are also reports suggesting a  relationship between vitamin D level and AGEs: vitamin D reduces deposition of AGEs in the aortic wall and systemic oxidative stress in diabetic rats (2) and increases serum levels of the soluble receptor for advanced glycation end products in women with PCOS(3). Our report is the first to show a significant negative relationship between noninvasive assessment of AGEs via SFS and vitamin D levels. The relationship between SFS and vitamin D levels may simply reflect the relationship between vitamin D and glucose intolerance or perhaps contributions of the underlying PCOS pathophysiology, as AGEs have also been shown to be involved in the pathogenesis of PCOS(4). Further studies are required to delineate the causality and potential clinical implications of these associations.  

 

Disclosure: JM: former employee, VeraLight , Consultant, Miraculins . Nothing to Disclose: HP, SJS, MM, SV, VRA

21961 7.0000 THR-105 A Evaluation of Relationship Between Glucose Tolerance, Steroid Levels, Including Vitamin D Levels, and Skin Fluorescence Spectroscopy in Women with and without Polycystic Ovary Syndrome ** 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Narendra Kotwal*1, Yogesh Asija2, Vimal Upreti2, Srikanth Somani2, Vishesh Verma2 and Vishesh Verma2
1Army Hospital Research & Referra, New Delhi, India, 2Army Hospital Research and Referral, Delhi, India

 

Purpose: To evaluate the effect of treatment with oral contraceptives, metformin alone and as combination therapy in PCOS patients on insulin sensitivity, body composition, and inflammatory markers at diagnosis and 06 months after treatment.

Study design: Prospective study with ninety new PCOS patients aged between 18 to 40 years, attending Endocrinology / Gynaecology OPD were included and randomized into three groups of 30 each. First group received OCP (Ethinyl estradiol 35 ug + cyproterone acetate 2 mg), second group received tab metformin (1500mg /day) and third group received OCP and metformin combined therapy. All 90 patients completed the six month follow up.

Methodology: Biochemical and hormonal profile, insulin resistance (HOMA IR), inflammatory markers, and body composition analysis were done at baseline and after six months of therapy in each patient.

Results: After comparing the three groups for treatment response with six months of therapy, we found significant reduction in clinical and biochemical hyperandrogenism with OCP and as well as with combined therapy. In lipid profile there was significant change in cholesterol (p<0.001), triglycerides (p<0.001), cholesterol to HDL ratio (p<0.001) in favor of metformin and combined therapy in comparison to OCP.

Insulin resistance was reduced (p<0.001) in favor of metformin and combined treatment group in comparison to OCP. Significant reduction (p<0.01) in inflammatory markers also in favor of metformin and combined treatment group in comparison to OCP was seen. Significant improvement in body composition (total fat percentage, trunk to limb fat percentage ratio, android to gynaecoid fat percentage) with metformin and combined treatment group as compared to OCP was seen.

Conclusion: Treatment with OCP has resulted in significant reduction in clinical and biochemical hyperandrogenism. with worsening of insulin resistance, inflammatory markers and body composition. Treatment with metformin alone or in combination was associated with improved lipid profile, insulin resistance, inflammatory markers, and body composition.

 

Nothing to Disclose: NK, YA, VU, SS, VV, VV

19277 8.0000 THR-106 A Body Composition Analysis, Inflammatory Markers, and Insulin Sensitivity in PCOS Patients at Diagnosis and after Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Aritro Sen*1, Xiaoting Ma2, Rajesh K Srivastava1 and Stephen R Hammes1
1University of Rochester, Rochester, NY, 2University of Rochester School of Medicine and Dentistry, Rochester, NY

 

Obesity, in general, is detrimental to a woman's reproductive health. Although most attention has been focused on the impact of obesity on hypothalamic function, some studies suggest a multifactorial impact. In fact, obesity is associated with reduced fecundity in women with regular cycles, indicating that there may be local effects within the ovary that modulate normal follicle development and ovulation. Here we describe a novel mechanism for leptin actions directly in the ovary that may account for some of the negative effects of obesity on ovarian function.  Our studies in mouse and human samples show that elevated leptin levels linked with obesity induce the expression of the neuropeptide Cocaine and Amphetamine Regulated Transcript (CART) in the granulosa cells (GC) of follicles. In normal mice, CART mRNA is low in GCs of mouse ovary. However, we find that, in GCs isolated from ovaries of obese mice fed with high fat diet (HFD), CART mRNA level is significantly elevated compared to control lean animals fed with normal diet (ND). Intriguingly, although these obese animals cycle normally and have equal numbers of litters relative to controls, they are sub-fertile (Pups/litter:  8 ± 0.5 vs 4.6 ± 0.6, n=9) and ovulate fewer oocytes (9.3 ± 0.7 vs 5 ± 0.4, n=7) compared to ND animals. In addition, primary culture studies reveal that GCs isolated from HFD-mice have lower Cyp19 mRNA and produce less estradiol relative to controls, but siRNA-mediated knockdown of CART reverse this effect. Moreover, in vitro and in vivo studies show that GC Cyp19 mRNA expression, estradiol levels, and the number of ovulated oocytes (9.1 ± 1 vs 5.6 ± 0.9) are significantly lower with CART treatment of lean mice suggesting a direct link between GC CART expression, estradiol production, and sub-fertility in obese mice. We also find that CART inhibits FSH-induced increase in cAMP levels as well as Akt and Erk activation in GCs in vitro, thereby suggesting that the negative effects of CART are likely mediated by inhibiting FSH actions. Importantly, we find that leptin signaling in the ovary promotes CART expression both in vitro and in vivo. Furthermore, leptin treatment both in-vitro and in-vivo inhibits ovarian Cyp19 mRNA expression and subsequent estradiol production in a CART-dependent fashion.  Based on these observations, we propose that increased leptin levels seen in obesity promote CART-mediated negative effects on ovulation in the ovary, at least in part, by suppressing estradiol production. Finally, using human tissues from patients undergoing in-vitro fertilization, we show that CART expression is significantly elevated in the GCs of obese and overweight women compared to women of normal BMI. This suggests that, similar to mice, leptin may be promoting CART expression in the GCs of the human ovary, and that CART production and signaling in the ovary may be playing a role in obesity-related reproductive dysfunction in women.

 

Nothing to Disclose: AS, XM, RKS, SRH

19850 9.0000 THR-107 A Cocaine and Amphetamine Regulated Transcript (CART) Is a Novel Intra-Follicular Mediator of Obesity Related Infertility 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Ronald C Ma*, Kin Hung Liu, Guozhi Jiang, Tiffany Yau, Andrea O Luk, Po Mui Lam, Michael H Chan, Chung Shun Ho, Alice Pik-shan Kong, Wing Yee So, Juliana CN Chan, Winnie Chu, Francis CC Chow, Lai Ping Cheung and Wing Hung Tam
The Chinese University of Hong Kong

 

Background

Women with polycystic ovary syndrome (PCOS) have increased risk of diabetes, subclinical atherosclerosis and visceral adiposity. We previously demonstrated increased visceral adiposity among women with PCOS compared with control. In this study, we aim to compare the relationship between visceral adiposity, as measured by sonographic assessment of mesenteric fat thickness, with different cardiometabolic risk factors in Chinese women with PCOS as well as control subjects.

Methods

We recruited 123 women with PCOS diagnosed according to the Rotterdam criteria. Control subjects were 415 healthy women with normal glucose tolerance from a mother-offspring cohort. All subjects underwent detailed assessment, including oral glucose tolerance test, biochemical assessment, and sonographic assessment with measurements of mesenteric, preperitoneal and subcutaneous fat thickness, carotid intima-media thickness and presence of fatty liver. We performed bivariate correlation using Pearson’s coefficient with their significance levels and examined the relationship between visceral adiposity and different cardiometabolic traits in PCOS and control subjects. The slopes of the regression line between mesenteric fat thickness and different cardiometabolic traits were compared between PCOS subjects and controls.

Results

PCOS subjects were older, had higher BMI, waist circumference, waist-hip ratio and systolic blood pressure (all p<0.01). PCOS subjects also had higher fasting insulin, fasting glucose and 2 hour glucose, and had significantly higher triglyceride, ALT, and mesenteric fat thickness (p<0.01). Mesenteric fat thickness was strongly correlated to waist circmference in both PCOS subjects (r=0.869, p<0.001) and control subjects (r=0.726, p<0.001), and less so to BMI. Mesenteric fat thickness was strongly correlated to different cardiometabolic traits including fasting glucose, 2-hour glucose, TG, LDL-cholesterol and was negatively correlated to HDL-cholesterol. Mesenteric fat thickness was correlated to insulin resistance as measured by HOMA-IR in both PCOS subjects and controls, though PCOS subjects were more insulin resistant than control subjects at any given level of visceral adiposity Mesenteric fat thickeness was correlated to carotid intima-media thickness in PCOS subjects (r=0.334, p<0.001) as well as the combined cohort.

Conclusions

Visceral adiposity is increased in subjects with PCOS. Mesenteric fat thickness is strongly asscoiated with cardiometabolic risk factors in subjects with PCOS. Subjects with PCOS are more insulin resistant compared to controls after adjusting for the degree of visceral adoposity.

 

Nothing to Disclose: RCM, KHL, GJ, TY, AOL, PML, MHC, CSH, APSK, WYS, JCC, WC, FCC, LPC, WHT

20409 10.0000 THR-108 A Relationship Between Visceral Adiposity and Cardiometabolic Risk in Chinese Women with Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Kai I Cheang1, Bhavi Modi1, Maria Shulleeta1, William S Evans2, Lubna Pal3, Jerome F Strauss III1 and John E Nestler*1
1Virginia Commonwealth University, Richmond, VA, 2University of Virginia, Charlottesville, VA, 3Yale University, Orange, CT

 

BACKGROUND: Studies have suggested that single nucleotide polymorphisms in OCT1, MATE1, MATE2, STK11 and FTO genes affect responsiveness to metformin in terms of insulin, glucose and lipid metabolism.  This study evaluates the relationship between ovulatory responsiveness to metformin in women with PCOS and combinations of genetic variants 

METHODS: Women with PCOS by the Rotterdam criteria were administered metformin up to 2000 mg daily for 9 months.  During the study, they collected daily early morning urine for determination of pregnandedio-3-glucuronide (PdG) and maintained menstrual diaries.  Subjects attended study visits monthly for compliance check and submission of urine samples.  A polymorphism score was calculated from 6 subscores.  A subscore of +1 was given per response allele in OCT1 rs628031 (G), MATE1 rs8065082 (T), MATE1 rs2289669 (A), MATE2 rs12943590 (G), STK11 rs8111699 (G) and FTO rs9939609 (A).  

RESULTS: Twenty-six women with PCOS participated in the study (27.9±4.2 years, BMI 35.0±7.6 kg/m2). The sample consisted of 12 Caucasians, 13 African Americans and 1 Asian individual.  The ovulation rate (ovulations per month, as determined by PdG and menses) was 0.51±0.30 in Responders (n=18) and 0.03±0.05 in Non-Responders (n=8). Polymorphism scores were not associated with baseline menstrual rates (r2=0.051, p=0.7407). Polymorphisms scores were also not different between metformin Responders (4.4±0.80) and Non-responders (3.9 ± 1.07), p=0.1737.

CONCLUSIONS: In this small sample, genetic polymorphisms do not appear to affect ovulatory responsiveness to metformin in women with PCOS. Interpretations of our findings are limited by the small sample size.

 

Disclosure: JFS III: Consultant, Takeda, Scientific Board Member, NIH NICHD, Principal Investigator, NIH, Consultant, Burroughs Wellcome Fund, Editor, Elsevier, Editor, Elsevier. Nothing to Disclose: KIC, BM, MS, WSE, LP, JEN

20386 11.0000 THR-109 A Genetic Polymorphisms and Ovulatory Responsiveness to Metformin in Women with Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Eleanor Hutchens, MD1, Amy Denise Anderson2, Jessicah S. P. Collins, MD3, Christine M. Burt Solorzano*2, John C. Marshall4 and Christopher R. McCartney2
1University of Virginia Medical Center, Charlottesville, VA, 2University of Virginia, Charlottesville, VA, 3Augusta Health, Fishersville, VA, 4University of Virginia Health System, Charlottesville, VA

 

Polycystic ovary syndrome (PCOS) is marked by hyperandrogenemia (HA) and is associated with obesity and insulin resistance. Adolescent HA is often a precursor to adult PCOS. A majority of adolescent girls with obesity demonstrate HA, but the source(s) of excessive androgen is (are) unclear. Androgen production in females occurs in both the adrenals and the ovaries, but the relative contribution from each organ to adolescent HA is unknown.  Both morning luteinizing hormone (LH) and fasting insulin have been correlated with HA in obese girls, but more detailed assessments of LH and insulin in combination with assessments of ovarian and adrenal androgen responses to stimulation (in the same individual) are not available. We have studied 6 obese girls to date: age 13.7 ± 1.9 y (mean ± SD); Tanner stage 4.6 ± 0.5; BMI-for-age-percentile 98.3 ± 0.8, free testosterone (T) 29.4 ± 12.8 pmol/L. Subjects underwent  (a) q10min blood sampling for LH from 1800-0900 h, allowing an estimate of 24-hour LH; (b) sampling for insulin from 1 h before to 2 h after a standardized mixed meal (at 1900 h) and while fasting (0700-0900 h), allowing an estimate of 24-hour insulin; (c) adrenal stimulation protocol (250 mcg synthetic ACTH iv at 0800 h; 17-hydroxyprogesterone [17-OHP], T, and androstenedione [Δ4A] drawn at 0800 [before ACTH], 0830, and 0900 h); and (d) an ovarian stimulation protocol (immediately after the 0900 h sample above, 25 mcg iv recombinant hCG was administered, with 17-OHP, T, and Δ4A obtained the next morning at 0800 h).  Absolute changes in Δ4A after hCG stimulation (defined as the value 23 h post-hCG minus the pre-ACTH value) were correlated with estimated 24-hour LH and estimated 24-hour insulin using Spearman partial correlation (correcting for differences in estimated 24-h insulin and 24-h LH, respectively). After correcting for differences in insulin, hCG-stimulated changes in Δ4A correlated strongly with 24-h LH (r = 0.98, p = 0.003). After correcting for differences in LH, hCG-stimulated changes in Δ4A also correlated with 24-h insulin (r = 0.95, p = 0.01). Similar relationships with ACTH-stimulated Δ4A were not evident. Moreover, 24-h LH and 24-h insulin were not correlated with ACTH- or hCG-stimulated changes in either 17-OHP or T.  These results suggest that, in late pubertal girls with obesity, ovarian Δ4A responses to stimulation are independently influenced by ambient LH and ambient insulin concentrations; similar relationships with 17-OHP or T were not evident in the subjects studied to date. We propose that simultaneous detailed assessments of LH, insulin, and end organ (adrenal, ovarian) responsiveness to stimulation will provide a powerful tool to determine the origins of HA in girls with obesity.

 

Nothing to Disclose: EH, ADA, JSPC, CMB, JCM, CRM

20010 12.0000 THR-110 A LH and Insulin Independently Predict Androstenedione Responses to Exogenous Hcg, but Not ACTH, in Obese Adolescent Girls 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Viviana Mesch*1, Patricia Maidana1, Mónica Rosales1, Diego Gonzalez1, Yamile Mocarbel2, Maricela Villanueva2, José Zaporta2, María Celeste Balonga2, Bibiana Fabre1 and Graciela Cross3
1School of Pharmacy and Biochemistry, University of Buenos Aires, Argentina, 2Hospital de Clínicas “José de San Martín”, University of Buenos Aires, Argentina, 3Hospital de Clínicas “José de San Martín” Universidad de Buenos Aires, Argentina

 

Introduction: hyperandrogenism is a common clinical condition in women from the early reproductive stages. An androgen excess correlates with abdominal fat deposition, which increases cardiovascular disease risk. The relationship between adipokines secreted by adipose tissue, in particular adiponectin, with androgens has been studied but results are controversial. The aim of this study was to evaluate the association between androgenic parameters and abdominal obesity with adiponectin in hyperandrogenic women of different etiologies.

Subjects and methods: 34 hyperandrogenic women (18-45 years) and 20 healthy controls were studied. In all of them, total testosterone (To) was determined by radioimmunoassay, SHBG by a chemoluminiscent immunometric method and adiponectin by ELISA. Free androgen index (FAI: To/SHBG x 100) was calculated and waist circumference (WC) was measured as an indicator of abdominal obesity. Statistical analysis was performed using SPSS 19 software and GraphPad Prism 3.0

Results: all evaluated parameters showed significant differences between hyperandrogenic and control women: To (ng/ml): 0.78 (0.26-2.00) vs 0.49 (0.25-0.73), p< 0.0001; SHBG (nmol/L): 30.4 (9.9-105) vs 57.2 (30.4-121), p=0.0031; FAI: 7.8 (1.3-37.8) vs 3.2 (0.8-8.7), p< 0.0001; adiponectin (ug/ml): 9.9 ± 4.7 vs 16.0 ± 5.1, p=0.0003; WC (cm): 98.1 ± 17.9 vs 85.4 ± 9.1, p=0.0016, hyperandrogenic vs control women, respectively. Adiponectin showed a tendency to correlate negatively with To (r: -0.30, p=0.061), was positively associated with SHBG (r: 0.477, p=0.002) and negatively with FAI (r: -0.488, p=0.001) and WC (r: -0.485, p=0.002). Additionally, FAI showed a significant positive correlation with WC (r: 0.479, p=0.001).

Conclusions: in this study To and adiponectin levels showed only a tendency to be associated, but this adipokine correlated negatively with FAI and WC, and in turn, FAI was associated with WC as well. Moreover, hyperandrogenic women showed lower adiponectin levels than healthy controls. Taking together these results indicate that androgens could influence the decrease in adiponectin levels through their action on abdominal fat deposition.

 

Nothing to Disclose: VM, PM, MR, DG, YM, MV, JZ, MCB, BF, GC

21594 13.0000 THR-111 A Association Between Androgens, Abdominal Obesity and Adiponectin in Adult Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Jingwen Hou*1, Heidi Cook-Andersen1, Rana Shayya1, Christine M. Burt Solorzano2 and R Jeffrey Chang1
1University of California, San Diego, La Jolla, CA, 2University of Virginia, Charlottesville, VA

 

Objective: We have previously shown that some adult women with PCOS exhibit exaggerated 17-OHP responses to hCG stimulation (high responders, HR-PCOS) whereas others reveal responses that are similar to that of normal women (normal responders, NR-PCOS). The 17-OHP responses in PCOS subgroups were accompanied by similar patterns of androgen production following hCG. Whether concomitant patterns of 17-OHP and androgen responses to hCG exists in adolescent women with PCOS has not been investigated. To address this issue, we evaluated androgen responses to hCG in subgroups of adolescent NR-PCOS and HR-PCOS as well as that of normal adolescents. We hypothesized that hormonal profiles in adolescent PCOS would be similar to that observed in adult women with PCOS.

Design: A prospective study in an academic center.

Materials and Methods: Adolescent women (12-18 yr) with PCOS (n=14) and age-matched normal controls (n=10) underwent iv administration of recombinant hCG (r-hCG) following dexamethasone suppression. Blood samples were obtained before and 24 hours after r-hCG injection. Serum 17-OHP, LH, testosterone, androstenedione, dehydroepiandrosterone and estradiol levels were measured. Unpaired Student's T-test or one-way analysis of variance using Tukey’s post hoc comparisons was used for data analysis, with adjusting for BMI values.

Results: Following r-hCG stimulation, 5 adolescent PCOS subjects exhibited exaggerated 17OHP responses (HR-PCOS) while 9 had responses equivalent to those of normal adolescents (NR-PCOS). Both HR- and NR-PCOS groups had similar BMI values and LH levels, which were higher than those observed in control group. For all androgens, the fold changes after r-hCG stimulation were similar, while estradiol was significantly higher in HR-PCOS compared to NR-PCOS.

Conclusions: Similar to adults, adolescent women with PCOS may be designated as HR-PCOS or NR-PCOS according to responses to r-hCG. Unlike their adult counterparts, in adolescent PCOS subjects there were no differences between NR-PCOS and HR-PCOS in terms of the fold change of androgen levels. This could be related to similar increases of basal LH in both subgroups, which suggests that hyperandrogenemia is primarily driven by altered GnRH-LH secretion during pubertal transitional. Conversely, distinction of androgen production among PCOS subgroups may reflect an acquired alteration of steroidogenesis that emerges in adulthood.

 

Nothing to Disclose: JH, HC, RS, CMB, RJC

20774 14.0000 THR-112 A Androgen Responses to Human Chorionic Gonadotropin (hCG) Administration in Adolescents with PCOS 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM THR 099-112 6091 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Kevin Wai-ching Lee*1, Shyuan Ngo1, Teresa Xie1, Johannes D Veldhuis2, Chen Chen3 and Frederik Steyn3
1University of Queensland, Brisbane, Australia, 2Mayo Clinic & Graduate School of Medicine, Rochester, MN, 3The University of Queensland, Brisbane, Australia

 

Growth hormone (GH) is a key anabolic hormone that determines body composition and overall metabolism. The release of GH is known to change during neonatal development, puberty, and throughout adult life. To this extent, the progressive decline in GH release that occurs with old age (somatopause) is thought to contribute to cognitive decline, muscle wasting and loss of physical strength, and morbidity. By defining natural age-associated changes to GH release, we hoped to acquire a better understanding of age-associated the processes that dictate altered GH release with increasing age. We first assessed naturally occurring age-associated changes in GH release in wild-type C57BL6 mice throughout life. Using a validated method for the assessment of GH output in mice1, serial measures for pulsatile GH release were collected at 5, 10, 17, 24, 52, 78, and 104 weeks of age. Results revealed a significant age-associated decline in pulsatile measures of GH release, with the predominant decline in GH output in mice occurring by 24 weeks of age. This was reflected by an overall decline in peak and total GH release, whereas changes in pulse number and entropy were only seen during pubertal maturation. A second set of measures of pulsatile GH release was collected from animals at 5, 10, 17, 24, 52, 78, and 104 weeks of age, and tissue and blood were collected for the assessment of factors thought to contribute to altered GH output. Of interest, a decline in pituitary GH content did not occur until 52 weeks of age, suggesting that the reduction in GH output by 24 weeks of age was driven by factors that mediate hypothalamic and pituitary control of GH release. Observations demonstrate interactions with a number of peripheral and circulating factors that might predict altered GH output with age. In particular, the decline in GH output was significantly correlated to a rise in insulin and white adipose tissue mass, suggesting that metabolic profile may be a key determinant for reduced GH output in early-adult mice. In summary, we present the first comprehensive serial-assessment of pulsatile GH secretion during the life-span of any mammal, and demonstrate critical interactions that predict GH output with age.  Results highlight the interrelationship between GH and key factors that may predict the development of age-associated diseases such as diabetes mellitus, obesity, and sarcopenia.

 

Nothing to Disclose: KWCL, SN, TX, JDV, CC, FS

PP04-1 21276 1.0000 THR-441 A A Comprehensive Assessment of Serial-Pulsatile GH Release in Mice to Reveal Critical Factors That Determines GH Output with Increased Age 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Jeannette J Connerney*, Andy Rampersaud and David J Waxman
Boston University, Boston, MA

 

Endocrine Society Meeting, San Diego California 2015

Growth Hormone Pulse-Dependent Chromatin Accessibility in Male Mouse Liver

Pituitary growth hormone (GH) secretion is sex-dependent – intermittent/pulsatile in males and more frequent (near continuous) in females – and regulates the sex-dependent expression of hundreds of genes in adult mouse liver. The GH-activated transcription factor STAT5 is dynamically activated by each plasma GH pulse in male liver and is essential for liver sexual dimorphism, but the impact of STAT5 activation on liver chromatin accessibility and downstream transcriptional events associated with sex-specific gene transcription are unknown. To address these questions, we investigated the impact of a single physiological GH pulse given to hypophysectomized mice on chromatin accessibility [DNase hypersensitive site (DHS) analysis of mouse liver nuclei by global DNAse-Seq], transcription rates [hnRNA analysis], and gene expression [qPCR and RNA-Seq] assessed 30’, 90’, and 240’ later. Liver chromatin accessibility and gene transcription, both of which were strongly down regulated for the STAT5-dependent (and sex-independent) early GH response genes Igf1 and Cish following hypophysectomy, showed rapid, time-dependent increases following a single GH pulse. GH pulse stimulation also induced rapid increases in chromatin accessibility and transcriptional activity at some but not all STAT5-dependent male-specific genes. Further, in intact male mice, male-specific genes such as Ces2b displayed remarkable cycles of increased and then decreased chromatin accessibility and gene transcription in response to each natural (endogenous) pulse of liver STAT5 activity, as determined by analysis of a panel of 18 individual livers isolated from individual male mice at times of STAT5-high (n=8) and STAT5-low activity (n=10). Several thousand such dynamically regulated STAT5-binding sites were identified by global differential DHS analysis of the STAT5-high versus STAT5-low livers. Thus, male plasma GH pulses induce a widespread, dynamic opening and closing of liver chromatin at discrete, localized regulatory sites that is temporally associated with transcriptional activation of Igf1 and Cish and a subset of STAT5-dependent male-specific genes. GH regulation of chromatin accessibility is also a feature of female-biased DHS, a subset of which open in association with the strong de-repression of certain female-specific genes in hypophysectomized male liver.

 

Nothing to Disclose: JJC, AR, DJW

PP04-2 21834 2.0000 THR-442 A Growth Hormone Pulse-Dependent Chromatin Accessibility in Male Mouse Liver 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Frederik Steyn*1, Sarushen Gounden2, Johannes D Veldhuis3, David R. Grattan4 and Chen Chen1
1The University of Queensland, Brisbane, Australia, 2The University of Queensland, 3Mayo Clinic & Graduate School of Medicine, Rochester, MN, 4University of Otago, Dunedin, New Zealand

 

Growth hormone (GH) is a pituitary hormone that is critically involved in the regulation of energy flux. In lactation GH promotes fatty acid deposition in maternal milk, while regulating involution of the mammary gland through actions on IGF-1. It remains unclear whether endogenous GH levels change in lactation, and whether alterations in GH release may occur as a consequence of feedback from maternal hormones associated with lactation. Prolactin is the key maternal hormone that regulates events underlying lactation. While the actions of prolactin in respect to milk production are well defined, it remains unknown whether prolactin modifies milk production indirectly though regulating the anabolic actions of GH. To address this we characterised the pulsatile release of GH in lactating female mice and investigated the role of prolactin in regulating the pulsatile release of GH. Following established methodology (1), we assessed pulsatile GH release in C57Bl/6J mice at days 10 and 17 of lactation. Observations were compared to non-lactating virgin and reproductively experienced mice. We observed a significant increase in total GH release in lactating mice when compared to non-lactating mice. At day 10 of lactation the overall rise in GH release was coupled to a rise in peak pulsatile GH secretion and by day 17 of lactation we observed an overall rise in basal GH secretion. The number of GH pulses seen during the sampling interval increased significantly in lactation, suggesting that events specific to lactation altered interactions between hypothalamic regulators of GH pulsatility. This was verified by the return of pulse frequency following weaning. The pulsatile pattern of GH release is under the reciprocal control of hypothalamic inhibitory somatostatin (SRIF) and stimulatory growth hormone releasing hormone (GHRH). We anticipated that the rise in GH pulse frequency in lactation is coupled to an overall shift in the interaction between these hypothalamic regulators of GH release. To address this we assessed the onset of peak GH release in mice following a single peripheral (i.p.) injection of prolactin (1mg/kg.bw & 3mg/kg.bw). Injections were delivered immediately following the cessation of a GH pulse, corresponding to an anticipated period of elevated SRIF release. Observations show the advancement of the onset of a GH secretory event. This was not associated with a rise in peak or total GH release. Measures are complemented by site-specific assessment of SRIF activity and through the validation of hypothalamic expression of Srif and GhrhmRNA throughout lactation. Collectively, our observations demonstrate that PRL modifies SRIF interactions within the hypothalamus, potentially reversing the suppressive effects of SRIF on GHRH induced GH release, thereby mediating GH pulse frequency. We proposed a novel action for PRL, and propose that PRL is a key regulator of GH release during lactation.

 

Nothing to Disclose: FS, SG, JDV, DRG, CC

PP04-3 21447 3.0000 THR-443 A Prolactin As a Key Regulator of Growth Hormone Pulsatility in Lactation, Acting Via Somatostatin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Zhongbo Liu*, Tianzhen Han and Shoshana Yakar
New York University College of Dentistry, New York, NY

 

Studies have shown that the risk for osteoporosis is programmed early during growth, and is determined by peak bone acquisition at that time. Growth hormone (GH) and its downstream effector, insulin-like growth factor-1 (IGF-1), are known as key regulators of bone acquisition during growth, and together with the parathyroid hormone (PTH), which is a key regulator of calcium homeostasis, they orchestrate bone accrual. To determine how PTH interacts with GH in regulation of bone acquisition, we used the cre/loxp system. Mice with loxP flanked ghr gene that carried the dentin matrix protein-1(10Kb) (DMP-1) promoter-driven cre (DMP-GHRKO) showed ghr gene ablation specifically in mature osteoblasts/osteocytes. DMP-GHRKO mice showed normal linear growth, but a compromised bone phenotype (by microCT). Injection of intermittent PTH (iPTH) (80ug/kg/day) from 4-8 weeks of age (puberty) revealed significantly increased cortical bone area (17%), cortical bone thickness (13%) and relative trabecular bone volume (85%) in control mice, while the DMP-GHRKO mice showed blunt responses to iPTH in the cortical compartment and an insignificant tendency of increase in relative trabecular bone volume (~20%). Using the osteocyte-like cell line IDG-SW3 we found that pretreatment with 10-8M PTH enhanced GH-induced STAT5 phosphorylation. Surprisingly, JAK2 and GHR protein levels in IDG-SW3 cells increased by PTH treatment. These findings were confirmed in vivo, where bones from control mice treated with iPTH for 4 weeks showed increases in JAK2 protein levels, while those extracted from iPTH treated DMP-GHRKO mice did not.  Overall, our data suggest that the anabolic effects of PTH in bone are partially mediated by osteocyte-specific GHR action and maybe mediated via increases in JAK2 protein levels.

 

Nothing to Disclose: ZL, TH, SY

PP04-4 22010 4.0000 THR-444 A Anabolic Response of Bone to Intermittent PTH Requires the Presence of the Ghr in Osteocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Minglan Li, Clint Gray, Clare Reynolds, Stephanie Segovia, Rachna Patel and Mark Vickers*
University of Auckland, Auckland, New Zealand

 

Maternal undernutrition (UN) is well established to result in a range of metabolic and cardiovascular disorders in offspring including obesity, insulin resistance and hypertension. Few studies, however, have investigated intervention strategies during critical periods of developmental plasticity to reverse some of the adverse sequelae associated with early life programming. Maternal UN leads to alterations in the growth hormone- insulin like growth factor (GH-IGF) axis in offspring. We therefore utilised a rat model of moderate maternal UN to examine the effects of pre-weaning GH treatment on metabolic and cardiovascular outcomes in offspring. Female Sprague-Dawley rats were fed either a standard control diet (CON) or 50% of CON intake throughout pregnancy (UN). From neonatal day 3 until weaning (day 21), CON and UN pups received either saline or GH (bGH, 2.5 ug/g/day). All dams were fed ad libitum throughout lactation. Male offspring were fed a standard diet until the end of the study (day 150). Maternal UN resulted in increased adiposity, elevated systolic blood pressure, endothelial dysfunction, impaired insulin sensitivity and a pro-inflammatory phenotype in adult offspring. These effects were reversed in UN offspring treated with GH in the pre-weaning period.  Although the underlying mechanisms are not yet fully determined, they include lasting changes of early GH treatment on the hepatic GH-IGF axis and altered cardiovascular (including differential DNA methylation and miRNA profiles), macrophage and adipocyte phenotypes. Many of these effects were specific to offspring of UN mothers and may therefore offer a targeted intervention strategy to reverse metabolic and cardiovascular dysfunction arising as a consequence of early life maternal undernutrition.

 

Nothing to Disclose: ML, CG, CR, SS, RP, MV

19621 5.0000 THR-445 A Pre-Weaning Growth Hormone Treatment Reverses Metabolic and Cardiovascular Disorders in Offspring Arising As a Consequence of Maternal Undernutrition 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Zhongbo Liu*1, Hyunsoo Park2, Hailing Liu2, Tianzhen Han1, Bruce Cronstein2 and Shoshana Yakar1
1New York University College of Dentistry, New York, NY, 2New York University

 

The population of young obese children is increasing and the negative effects of increased body adiposity on the skeleton have been reported. We hypothesized that dyslipidemia desensitize bone cells to growth hormone (GH), which is a key regulator of bone acquisition during growth and plays important roles in lipoprotein, cholesterol, and TG metabolism. To investigate the effects of lipids on bone accrual, we generated a mouse model in which growth hormone receptor (GHR) gene was ablated specifically in the liver (Li-GHRKO) by using cre/loxp system. The Li-GHRKO mice exhibited increased serum FFA (33%), TG (32%) and cholesterol (72%), as well as increased TG content in the liver and hepatosteatosis. Micro CT evaluation of femurs from the Li-GHRKO mice revealed significant reductions in both trabecular and cortical bone. To exclude the possibility that reductions in liver derived IGF-1 caused the compromised bone phenotype, we have restored liver igf-1 via expression of hepatocyte-specific igf-1 transgene (HIT) to generate the Li-GHRKO-HIT. The Li-GHRKO-HIT showed normal serum IGF-1 levels, however, exhibited dyslipidemia, hepatic steatosis, impaired trabecular bone architecture, and reduced BMD (12.5%). To further study the relationship between dyslipidemia and GHR action in bone, we used the osteocyte-like cell line IDG-SW3. We found that pretreatment of these cells with increased levels of FFA led to attenuation of GH-induced STAT5 phosphorylation and increase in cleaved caspase 3. Overall, our data suggest that dyslipidemia may reduce bone accrual via impairments in the GHR signaling pathway.

 

Nothing to Disclose: ZL, HP, HL, TH, BC, SY

22094 6.0000 THR-446 A Dyslipidemia Impairs GH-Mediated Bone Accrual during Growth 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Sheila Leone1, Annalisa Chiavaroli1, Rugia Shohreh1, Adriana Ricciuti1, Lucia Recinella1, Claudio Ferrante1, Chiara Di Nisio1, Giustino Orlando1, Roberto Salvatori2, Michele Vacca1 and Luigi Brunetti*1
1G. d'Annunzio University, Chieti, Italy, 2Johns Hopkins University School of Medicine, Baltimore, MD

 

Objective: Growth hormone-releasing hormone (GHRH), growth hormone (GH) and insulin-like growth factor-1 (IGF-1) play an important role in cognitive functions. Previous studies have shown that hypopituitary Ames dwarf and GH receptor/GH binding protein knockout  mice do not exhibit the same age-related decline in cognitive ability as their wild type siblings in the Morris water maze test. The aim of this study was to examine the effects of aging on cognitive ability in a mouse model of isolated GH deficiency due to deletion of the GHRH gene (GHRH knockout,GHRHKO).

Design: We evaluated learning and memory in young (2–3 months old) and old (12–16 months old) male mice homozygous for GHRH ablation (-/-; n = 16) and controls homozygous for the wild-type allele (+/+, controls; n = 16). Mice -/- and their +/+ littermates were tested in the open-field test, Morris water maze test and eight-arm radial maze test.

Results: Both young and old -/- mice showed increased locomotor activity compared to their respective +/+ controls (p < 0.005 and p < 0.05, respectively). Moreover, both young and old -/- mice showed decreased learning ability (p < 0.05 and p < 0.005, respectively) and working and reference memory (p < 0.05 and p < 0.005, respectively) in Morris water maze test and eight-arm radial maze test, when compared to +/+ mice. However, -/- mice showed reduced cognitive decline in learning and memory ability (p< 0.005 and p < 0.001, respectively) and working and reference memory (P< 0.001), compared to +/+ mice.

Conclusion: These results suggest that both young and old GHRHKO mice have a reduced performance in learning and memory tests, despite an increased locomotor activity, when  compared to controls. However, -/- mice showed reduced age-related cognitive decline.

 

Nothing to Disclose: SL, AC, RS, AR, LR, CF, CD, GO, RS, MV, LB

19748 7.0000 THR-447 A Impaired Learning and Memory in Both Young and Aged Growth Hormone-Releasing Hormone (GHRH) Knockout Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Anne-Lise Lecoq*1, Philippe Zizzari2, Say Viengchareun3, Laurent Kappeler4, Johannes D Veldhuis5, Valérie Geoffroy6, Marc Lombes3, Virginie Tolle2, Auli Karhu7, Philippe Chanson8 and Peter Kamenický8
1INSERM U693 - Faculté de Médecine Université Paris Sud, Le Kremlin Bicêtre, France, 2INSERM UMR-S 894, Université Paris Descartes, Paris, France, 3Inserm U1185, Le Kremlin-Bicêtre, France, 4INSERM, Sorbonne Universités, UPMC Univ Paris 06, IHU ICAN, Paris, France, 5Mayo Clinic, Rochester, MN, 6INSERM UMRS1132- Université Paris Diderot, Paris, France, 7University of Helsinki, University of Helsinki, Finland, 8Univ Paris-Sud, UMR-S693, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France

 

Germline mutations in the Aryl hydrocarbon receptor Interacting Protein (AIP) gene predispose to pituitary adenoma tumorigenesis, affecting in particular the somatotroph cells. Mice with heterozygous inactivation of the Aip gene (Aip+/- mice) develop pituitary adenomas, with a complete penetrance reached at the age of 15 months, but the early steps of the AIP-related pituitary tumorigenesis are unknown. Clinical experience and in vitro studies indicate a close relationship between AIP and the somatotroph cell function, but the impact of endogenous AIP-deficiency on growth hormone (GH) secretion before the occurrence of pituitary adenomas has not been investigated in vivo.

In this study, we compared the somatic growth, the body composition and the ultradian pattern of GH secretion in wild-type (WT) and Aip+/- male mice at the age of 3 and 10-12-months. Total body weight was higher in Aip+/- mice than in WT mice at 3 and 7 months of age, without difference in body length. Both young and old Aip+/- mice had decreased total body fat mass assessed by DEXA, associated with a decrease in the weight of both subcutaneous and peri-gonadal white adipose tissue depots. These early changes in body composition may result from increased water content and enhanced lipolysis in Aip+/- mice due to increased GH secretion and/or GH sensitivity. In the same animals followed longitudinally, blood samples were collected by tail bleeding every 10 minutes over a period of 6 hours. Analysis of the pattern of pulsatile GH secretion by deconvolution showed that GH was secreted in an ultradian manner in both WT and Aip+/- mice. At the age of 3-months the genotype difference was not significant. In 10-12-month-old Aip+/- mice the area under the curve of the major GH secretory bursts was increased compared to WT, the deconvolution analysis and plasma IGF-I measurements are currently being performed. In addition, GH release from pituitary explants after stimulation by Growth-hormone-releasing hormone (GHRH) 100 nM and after repression by Somatostatin 100 nM was evaluated at the same ages. 3-month-old Aip+/- mice had greater GHRH-induced GH release from the pituitary explants than in WT mice, indicating precociously increased sensitivity of AIP-deficient somatotroph cells to GHRH, probably due to enhanced cAMP signaling. There was no genotype difference in the response to Somatostatin.

This study shows that heterozygous inactivation of Aip in male mice leads to GH hypersecretion by the age of 10-12 months, without significant impact on the linear growth but according changes in the body composition. Somatotroph cells of growing Aip-deficient males have enhanced sensitivity to GHRH stimulation, suggesting a dysregulation of the cAMP pathway. Whether this greater responsiveness to GHRH results in early somatotroph proliferation and hyperplasia, occurring before pituitary adenoma formation, is currently being investigated.

 

Nothing to Disclose: ALL, PZ, SV, LK, JDV, VG, ML, VT, AK, PC, PK

21027 8.0000 THR-448 A Increased GH Secretion and Greater Responsiveness to GHRH Stimulation in AIP-Deficient Male Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Kevin Ray Funk*1, Ross Comisford2, Edward O List2, Darlene E Berryman2, Grant Gase2, Misako Hata1, Ana Carolina Coutinho1, Ana Virginia Guimaraes1, Jonathan A Young2, Debbie Essman1 and John J Kopchick3
1Ohio University, Edison Biotechnology Institute, Athens, OH, 2Ohio University, Athens, OH, 3OH Univ/Edison Biotech Inst, Athens, OH

 

Mice with decreased growth hormone (GH) action exhibit small body sizes with increased obesity; however, these mice generally have a healthy metabolic profile with increased insulin sensitivity and an increased lifespan. In contrast, the opposite is also true as mice with increased GH action are large and lean with impaired glucose metabolism and decreased lifespan.  Determining the mechanisms involved in this shift in glucose homeostasis may prove crucial for understanding GH’s influence on lifespan.  In the current study, we isolated mitochondria from livers of mice with both decreased and increased GH action, and measured mitochondrial respiration in vitro using a Seahorse XF24 Analyzer.  Mitochondria were treated with oligomycin to block Na+/K+ ATPase, FCCP to uncouple respiration, and then Antimycin A to block the electron transport chain.  Using succinate as a substrate, we determined that mitochondria from mice with reduced GH action have reduced basal respiration, decreased oxidative ATP production, and decreased maximal respiration capacity.  The opposite was observed in mice with increased GH action.  These results suggest that changes in insulin sensitivity alone may not be solely responsible for altered metabolic profiles observed in these mouse lines.  GH may directly or indirectly affect components of the electron transport chain, and the oxidative capacity of isolated mitochondria.  Further studies of this type may reveal how the aerobic capacity of the entire organism is altered as a function of GH action, which may ultimately affect longevity.

 

Nothing to Disclose: KRF, RC, EOL, DEB, GG, MH, ACC, AVG, JAY, DE, JJK

21129 9.0000 THR-449 A Isolated Mouse Liver Mitochondria Reveal That Growth Hormone Action Is Correlated with Respiration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Amrita Basu*1, Hewlet G. McFarlane2 and John J Kopchick1
1Ohio University, Athens, OH, 2Kenyon College, Gambier, OH

 

The presence of growth hormone (GH), its receptor (GHR) and the downstream effector, IGF-1,  in various regions of the mammalian brain indicates a potential significant influence of action on different aspects of development and function of the central nervous system (CNS), such as neuronal regeneration, memory, cognition, behavior and aging. The present study assessed spatial memory and learning employing the Barnes maze between 12 months old, male bovine GH transgenic (bGH) mice, transgenic GHR antagonist (GHA) mice,  and their corresponding wild-type (WT) littermate controls. In parallel, quantitative estimation of genes relevant to the GH/IGF-1/Insulin (INS) action and the memory processing pathways (GH,GHR, IGF-1,IGF1R, INS, INSR, MAO-A, MAO-B, NR2A, NR2B) were performed in four different regions of the brain (cortex, cerebellum, hypothalamus and hippocampus) by qPCR in 6 months old, male, bGH and GHA mice and  their respective littermate controls. In the Barnes Maze, poor memory performance and retention were observed in bGH mice, compared to WT controls while GHA mice performed better or similar to the control mice during the acquisition period as well as short and long term memory probe trials. The qPCR study revealed normal levels of GH and IGF-1 and reduced expression of the other mRNA transcripts of interest (NR2A, NR2B, MAO-A, MAO-B, etc.) in the brain of the bGH mice with respect to the control group. Expression of GH and IGF-1 and their receptor mRNA transcripts were reduced in the brain areas of the GHA mice but increased expression of NR2A and NR2B genes compared to the WT was found.  This may be important in the observed increase in spatial memory and learning retention found in GHA mice versus controls. Analysis of spatial memory along with comparison of expression of relevant genes and proteins in the brains of bGH and GHA mice will offer a more comprehensive understanding of the significance of the role of the GH/IGF-1 axis related to the brain physiology and might reveal novel therapeutic strategies for neuropathological conditions.

 

Nothing to Disclose: AB, HGM, JJK

21955 10.0000 THR-450 A Analysis of Gene Expression and Spatial Learning and Memory in Growth Hormone Transgenic Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Nicole E Brooks*, Edward O List, John J Kopchick and Darlene E Berryman
Ohio University, Athens, OH

 

Obesity and type 2 diabetes mellitus (T2DM) are serious health concerns affecting large proportions of the population. Fibroblast growth factor 21 (FGF21) is a protein of great interest as it has been implicated as a possible therapeutic agent for treatment of obesity and T2DM. As a metabolic regulator, FGF21 greatly improves metabolic profiles, improves insulin sensitivity, and can even reverse obesity. GH also has profound effects on adipose tissue (AT), decreasing adiposity by promoting lipolysis and reducing lipogenesis, and on metabolism, causing insulin resistance. Interestingly, mice with no GH action and mice with increased FGF21 signaling both have increased lifespans. It has been suggested that these signaling pathways may interact since GH induces FGF21 production and FGF21 negatively influences GH expression. To better understand this relationship, this study analyzed levels of FGF21 in mice with modified GH action. Three separate mouse lines and their wild type (WT) littermates were used in this project: GH antagonist (GHA), GH receptor gene disrupted (GHR-/-), and bovine GH transgenic (bGH) mice. GHA mice have decreased GH signaling, low to normal insulin levels, slightly decreased body size, normal lifespan, and are obese. GHR-/- mice have an absence in GH signaling via GHR, very low levels of insulin (insulin sensitive), decreased body size, increased lifespan, and are obese. In contrast, bGH mice have excess GH signaling, very high insulin levels (insulin resistant), increased body size, decreased lifespan, and are lean. Serum FGF21 levels were measured in GHA and bGH mice and will be measured in GHR-/- mice using ELISAs to determine whether mice with modified GH have differences in levels of circulating FGF21. Serum FGF21 levels were significantly lower in GHA mice compared to their WT controls (p=0.0135) and significantly higher in bGH mice compared to their WT controls (p<0.0001). This latter finding might be expected as GH has been found to increase FGF21 expression. These results may also suggest that bGH mice are FGF21 resistant, as they have elevated FGF21 in response to GH, but do not benefit from the improved metabolic profile and increased lifespan associated with FGF21. Decreased serum FGF21 levels in GHA mice likely reflect the decreased action of GH. Serum FGF21 levels in GHR-/- mice will also be assessed and reported. To date, these results imply that the improved metabolic profiles seen in GHA mice are not due to FGF21. Results of this study support reported interactions between GH and FGF21, with GHA mice having decreased GH action and decreased FGF21 expression and the increased GH action of bGH mice possibly inducing FGF21expression.

 

Nothing to Disclose: NEB, EOL, JJK, DEB

21930 11.0000 THR-451 A Analysis of Circulating Levels of FGF21 in Growth Hormone Modified Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Gwen V. Childs*, Melody Lyn Allensworth-James, Angela K. Odle, Anessa C. Haney and Angus M. MacNicol
University of Arkansas for Medical Sciences, Little Rock, AR

 

The purification of somatotropes is vital for studies of molecular signaling pathways regulating growth hormone (GH). Successful purification approaches have depended on the production of GH protein stores,(1-3) or functional receptors for Growth hormone releasing hormone (GHRHR).(4) We recently developed a GH-deficient mouse model in which leptin receptors were selectively ablated in somatotropes (5) and needed to purify this population to study signaling pathways mediating leptin regulation of somatotropes. However, the cells are deficient in GH protein stores (5) and GHRHR(6), products needed for purification by established approaches. Therefore, to facilitate identification of somatotropes, we introduced a Cre-reporter transgene into our rGHp-cre control and somatotrope-Lepr exon 1 null mutant mice.(7) All cells express the red fluorescent tdTomato in their membranes. In somatotropes producing Cre recombinase, floxed tdTomato is deleted, and the cells exhibit green fluorescence (eGFP). However, because of deficiencies in our somatotrope Lepr exon 1 null mutant line, we were concerned that eGFP expression might be compromised. To assess this, we studied heterozygotes bearing one allele of the Cre-reporter transgene, rGHp-cre and one allele of floxed Lepr exon 1, which show a partial GH deficiency.(5) After dissociation and overnight culture, pituitary cells from male mice were plated and immunolabeled for GH with 1:20,000 anti-rGH, 1:200 biotinylated goat anti-rabbit IgG, and streptavidin-Alexa-fluor 350 (blue fluorescence). Photographs from 50 fields were collected, to allow the analysis of >100 GH cells. As expected, there was a significant reduction in overall percentages of immunolabeled GH cells from 30±1% in controls to 11-23% in fields from the mutants (average 18±5% of pituitary cells p<.001).  Of the 130 GH-immunolabeled cells collected, 83±17% expressed the Cre-recombinase marker, eGFP. There was variability in expression from field to field with a range from 54%-100% of GH cells. The overall counts of the Cre-bearing eGFP cells, however showed that they were 33±9% of total pituitary cells, which is not different from GH cell percentages in normal, unstimulated populations.(6) To further validate Cre-reporter expression, we developed new in situ hybridization techniques, with 1 ng/ml biotinylated oligo-probe for GH detected by streptavidin Alexa-fluor-350.  Analysis of 30 images showed that 95±2% of somatotropes expressed eGFP and GH mRNA, thus validating the identity of cells expressing the Cre-reporter. Thus, mRNA content is needed to fully validate the Cre-reporter expression in these GH-protein deficient somatotropes. The variability in expression of the eGFP marker by mutant somatotropes may be alleviated by introducing two alleles of the Cre-reporter transgene. The Cre-reporter approach will allow us to use FACS or Laser Capture for purification.

 

Nothing to Disclose: GVC, MLA, AKO, ACH, AMM

22108 12.0000 THR-452 A Validation of Cre-Reporter Strategies to Address Challenges in the Purification of GH-Deficient Somatotropes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Ashiya Buckels*, Yue Zhang, Jing Jiang and Stuart J Frank
University of Alabama at Birmingham, Birmingham, AL

 

Melanoma is a particularly aggressive cancer.  The oncogenic BRAFV600E mutation is found in ~50% of melanomas and promotes progression by constitutive activation of the extracellular signal-regulated kinase (ERK) signaling cascade. Targeting BRAF is an effective therapy for advanced melanoma, but patients often progress due to the development of several forms of treatment resistance.  Recent examination (1) of 60 diverse human cancer cell lines (the NCI 60 panel) revealed that melanoma isolates are enriched compared to other cancers for expression of the growth hormone receptor (GHR) mRNA. Our survey of eight human melanoma cell lines (one – WM35 – not included in the NCI 60 panel) confirmed these findings, in that GHR was detected by immunoblotting in four of the eight. In each, including WM35, GH induced dose- and time-dependent GHR, JAK2, and STAT5 phosphorylation. Not surprisingly, ERK was constitutively activated in each, as revealed by anti-pERK immunoblotting and GH caused little change in ERK phosphorylation status. Also as anticipated, treatment of WM35 (which harbors BRAFV600E) with the MEK inhibitor, PD98059 for as little as one hour, greatly diminished constitutive ERK phosphorylation. We asked whether GH affected WM35 cell growth by performing MTT cell viability assays. Treatment with GH (50-250 ng/ml for 24 hours) did not cause increased cell number, instead variably reducing the MTT signal marginally. In contrast, treatment of WM35 with PD98059 (0-30 µM for 48 h) reduced MTT signal by 40-50%, consistent with results reported for other melanoma cell lines.  Interestingly, treatment with GH for 24 h after 24 h pretreatment with PD98059 markedly blunted the negative effects of PD98059 on WM35 cell viability (reversing the PD98059 effect by up to 60%). Studies are underway to learn whether positive effects of GH on growth-promoting and/or anti-apoptotic pathways in these melanoma cells are unmasked upon inhibition of constitutive ERK pathway activation. Such results could be important as a potential mechanism of emergence of treatment resistance.

 

Nothing to Disclose: AB, YZ, JJ, SJF

20637 13.0000 THR-453 A Effects of GH on WM35 Human Melanoma Cell Viability in the Setting of ERK Pathway Inhibition 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Dana Lau-Corona*, Gracia M Bonilla, Alexander N Suvorov and David J Waxman
Boston University, Boston, MA

 

Epigenetic Analysis of Temporal Changes in Continuous Growth Hormone-Responsive Sex-Biased Genes In Male Mouse Liver

Sex-dependent pituitary growth hormone (GH) secretion regulates the sex-biased expression of hundreds of genes in mouse and human liver, impacting sex differences in metabolism and in liver and cardiovascular disease. In male mice, GH is secreted in a pulsatile manner with virtually no plasma GH detectable between pulses. In females, GH secretion is more frequent, resulting in shorter GH-free periods and persistent activation of downstream GH signaling to the nucleus via the liver transcription factor STAT5. Continuous GH infusion of intact male mice overrides the endogenous male, pulsatile plasma GH pattern. RNA sequencing of continuous GH-infused male mouse liver revealed time-dependent patterns of male-biased gene repression and female-biased gene de-repression: 61% (233/383) of male-biased genes were down-regulated and 52% (207/394) of female-biased genes were up regulated after 14 days GH infusion. Global analysis of six chromatin marks and DNase-I hypersensitivity sites (DHS) in male and female mouse liver was previously used to identify genes in an active, poised or repressed chromatin state (Sugathan & Waxman, Mol Cell Biol 2013; PMID:23836885). Here, sex-biased genes responding to continuous GH early were found to be enriched in an active chromatin state in male liver; and late GH responding genes were enriched in an inactive chromatin state. Thus, the basal chromatin environment dictates temporal patterns of responsiveness to continuous GH infusion. For several highly sex-biased genes, we found striking, time-dependent, GH-induced changes in chromatin modifications marking active enhancers (H3-K27ac, H3-K4me1) that coincided with or preceded the GH-induced changes in gene expression. Further, continuous GH decreased the repressive mark H3-K27me3 at highly female-biased genes in parallel to the de-repression of gene expression. Differential DHS analysis identified large numbers of continuous GH-responsive regulatory sites: induced DHS were strongly enriched for being near female-biased genes, and repressed DHS were strongly enriched nearby male-biased genes, indicating their functional roles in sex-biased gene regulation. Sequence motifs enriched at both early- and late-responding DHS identified transcriptional regulators that are proposed to contribute to the temporal changes in sex-specific gene expression induced by continuous GH treatment. Further integration of these GH-differential histone mark and chromatin accessibility maps with gene expression data will help elucidate global transcriptional and epigenetic networks that dictate sex-differential liver gene expression.

 

Nothing to Disclose: DL, GMB, ANS, DJW

22097 14.0000 THR-454 A Epigenetic Analysis of Temporal Changes in Continuous Growth Hormone-Responsive Sex-Biased Genes in Male Mouse Liver 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Ross Comisford*, Lara A Householder, Kaitlin Baker, Kevin Ray Funk, Edward O List, John J Kopchick and Darlene E Berryman
Ohio University, Athens, OH

 

Down regulation of the GH/IGF-1 pathway consistently results in improved health and longevity in numerous animal models including humans. Three mouse strains commonly used to study GH action include  bovine GH (bGH) transgenic mice that have excess GH action, GH receptor knockout (GHR-/-) mice, which have no GH induced signaling, and GH receptor antagonist transgenic (GHA) mice, which have reduced GH action due to expression of a GH receptor antagonist. bGH mice are giant and lean, yet they exhibit hyperinsulinemia, inflammation, increased cancer  incidence, and decreased lifespan. Conversely, GHR-/- mice are dwarf and obese yet, highly insulin sensitive, resistant to cancer, and have increased lifespan. GHA mice are dwarf and obese like the GHR-/-; however, they gain more fat as they age and do not experience improvements in glucose metabolism or lifespan. The contradictory relationship between adiposity and health in these mice suggests that adipose tissue physiology may play an important role in the metabolic health of these mouse lines. Dysfunctional adipose tissue in obese mice and humans is characterized by adipose tissue fibrosis which is associated with insulin resistance, immune cell infiltration, dyslipidemia, and altered adipokine secretion. Moreover, abrogation of AT fibrosis has been shown to improve glucose and lipid metabolism in several mouse models.  Interestingly, GH increases collagen gene expression in several tissues including bone and kidney, however, its impact on the adipose extracellular matrix is not well known. Recently, we showed that bGH mice exhibit increased fibrosis in both the subcutaneous (subq) and epididymal AT depots along with up regulation of multiple extracellular matrix proteins. Thus, in this study we tested the hypothesis that, contrary to bGH mice, GHR-/- mice and GHA mice are less prone to developing adipose tissue fibrosis.  We stained adipose tissue samples from four distinct adipose depots from GHR-/- , GHA, and WT mice at 6, 12, 18, and 24mo of age (n=2 for each age) with picrosirius red and quantified the amount of staining using ImageJ software. The results showed a trend for decreased collagen staining in the GHR-/- mice that was strongest in the subq depot. Similarly, female GHA mice showed a significant decrease in picrosirius red staining in the subq depot along with a decreased trend for collagen staining in all other depots. Male GHA mice were not significantly different from WT in terms of picrosirius red staining. The lack of fibrosis in these two mouse strains of decreased GH induced signaling, along with the previous finding that bGH mice have increased AT fibrosis, indicates that elevated GH action is directly or indirectly promoting the development of AT fibrosis. Thus, AT fibrosis may be contributing to the unhealthy metabolic phenotype of bGH mice compared to GHR-/- and GHA mice.

 

Nothing to Disclose: RC, LAH, KB, KRF, EOL, JJK, DEB

20599 15.0000 THR-455 A Analysis of Adipose Tissue Fibrosis in Growth Hormone Receptor Knockout and Growth Hormone Antagonist Transgenic Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Sheila Leone1, Adriana Ricciuti1, Annalisa Chiavaroli1, Rugia Shohreh1, Lucia Recinella1, Claudio Ferrante1, Chiara Di Nisio1, Giustino Orlando1, Roberto Salvatori2, Michele Vacca1 and Luigi Brunetti*1
1G. d'Annunzio University, Chieti, Italy, 2Johns Hopkins University School of Medicine, Baltimore, MD

 

Objective: In addition to activating of the hypothalamic-pituitary-adrenal (HPA) axis, pain and inflammatory processes are also known to activate the somatotropic axis. Both anti- and pro-inflammatory effects have been described exerted by growth hormone-releasing hormone (GHRH) and growth hormone (GH). The aim of this study is to elucidate the consequences GHRH deficiency on responsiveness to acute nociceptive stimulation and inflammatory stimuli in a mouse model of GH deficiency due to generalized ablation of the GHRH gene (GHRH knock out, GHRHKO).

Design: Homozygous GHRHKO (-/-) and heterozygous (+/-, controls) male mice were compared.  Responsiveness to acute nociceptive stimulation was measured by means of a conventional hot plate apparatus, set at the temperature of 54.0 ± 0.4°C, and the response latency (in seconds) was calculated. Responsiveness to inflammatory stimulation was evaluated by formalin test. Ten microliters of 5 % formalin solution were injected subcutaneously under the plantar surface of the left hindpaw, and time (in seconds) spent in lifting, licking and biting was measured during the first and second phase of inflammation. Prostaglandin (PG)E2 levels were measured in exudates by radioimmunoassay in air pouch model of inflammation after administration of  1% carrageenin. Differences between groups were analyzed by Student-test. P < 0.05 was considered statistically significant.

Results: Compared to controls -/- mice showed decreased response latency during the hot plate test (P <0.05) and increased licking/biting time in formalin test (P <0.05), particularly in the second phase (P<0.005). PGE2 release was significantly increased in -/- mice (P < 0.005).

Conclusion: Generalized GHRH ablation increases thermal sensitivity and experimentally-induced inflammatory pain, consistent with increased PGE2 production in the lesion. Whether this is the result of lack of GH or GHRH remains to be established.

 

Nothing to Disclose: SL, AR, AC, RS, LR, CF, CD, GO, RS, MV, LB

18890 16.0000 THR-456 A Increased Nociceptive Sensitivity in Growth Hormone-Releasing Hormone (GHRH) Knockout Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM THR 441-456 6095 1:00:00 PM GH, IGF and Posterior Pituitary Poster


In-Hyuk Chung*1, Sangshin Park2, Mi Jung Park3 and Eun-Gyong Yoo4
1National Health Insurance Service Ilsan Hospital, Kyonggi, Korea, Republic of (South), 2The Warren Alpert Medical School of Brown University, Providence, RI, 3College of Medicine, Inje University, Sanggye Paik Hospital, Seoul, Korea, Republic of (South), 4College of Medicine, CHA University, Sungnam, Korea, Republic of (South)

 

Background

This study was performed to describe the relationship between waist to height ratio (WHtR) and cardiometabolic risk factors (CMRFs), and to evaluate the validity of WHtR in identifying adolescents with metabolic syndrome.

Methods

We analyzed data from a pooled population of 4,068 adolescents aged 10-19 years from the Korean National Health and Nutrition Examination Surveys conducted between 1998 and 2008. To describe the trend of CMRFs with increasing WHtR, participants were divided into WHtR quartile groups. For subgroup analysis, participants categorized according to body mass index (BMI; <85th or ≥85th percentile) and waist circumference (WC; <90th or ≥90th percentile) were further stratified by WHtR (<0.5 or ≥0.5). Metabolic syndrome was defined by the presence of ≥3 CMRFs.

Results

The WHtR was significantly related with systolic blood pressure (P<0.0001), diastolic blood pressure (P<0.0001), high-density lipoprotein cholesterol (P<0.0001), and triglyceride (P<0.0001) after adjusting for age in both genders. The prevalence of metabolic syndrome was very low in the 1st to 3rd quartile groups in both genders, but increased to 12% in boys and to 8.5% in girls in the 4th WHtR quartile group (P for trend <0.001 in each gender). The prevalence of metabolic syndrome further increased with higher WHtR in adolescents screened by BMI or WC (5.5% in those with increased BMI/low WHtR vs. 18.0% in those with increased BMI/high WHtR (P<0.0001), and 8.6% in those with increased WC/low WHtR vs. 20.1% in those with increased WC/high WHtR (P=0.0235).

Conclusions

WHtR is a simple and valid index for identifying adolescents with increased cardiometabolic risks.  Our results suggest that additional use of WHtR can be helpful when screening obesity with BMI in adolescents, because the WHtR represents central adiposity. Since the WHtR is an index adjusted for height, it might be useful when used together with WC.

 

Nothing to Disclose: IHC, SP, MJP, EGY

18950 1.0000 THR-542 A Waist to Height Ratio As an Index for Cardiometabolic Risk in Adolescents: Result from Knhanes 1998-2008 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 542-548 6096 1:00:00 PM Obesity: Pediatric and Surgery Poster


Tara Kaushal*1, Morri Markowitz2, Jinny Cai3 and Ping Zhou4
1The Children's Hospital at Montefiore, Bronx, 2Albert Einstein College of Medicine, Bronx, NY, 3University of Southern California, 4Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY

 

Background

 Numerous studies have pointed out an association between obesity and abnormalities in thyroid function tests (TFT).  The results are, however, inconsistent.  Thyroid hormone and thyroid-stimulating hormone (TSH) concentrations have been described as normal, elevated or reduced in adult obese individuals in different studies.  In obese children, the most common thyroid abnormality is hyperthyrotropinemia.  Population-based studies for pediatric subjects are lacking.  The U.S. National Health and Nutrition Examination Survey (NHANES) conducted in 2001 to 2002 provided a unique opportunity for such a study, because thyroid hormone and thyroid antibody measures were sampled in the pediatric population.

 Objective  

Using a large, national data set (NHANES 2001-2001), to examine the relationship of thyroid function and weight in a pediatric population, and compare the results with the previous studies.

Method Design, Data Management, and Analysis

From NHANES 2001-2002, data on anthropomorphic and thyroid related measures (TSH, T4, FT4, T3, FT3, anti-thyroglubin antibody, and anti-thyroid peroxidase antibody) were extracted from the files DEMO_B, L06VID_B, and SSNH4THY.  Only pediatric subjects between ages of 12 and 20 with negative thyroid antibodies were selected for the study.  BMI Z-scores were calculated by using the CDC BMI percentile for specific age and gender.

A Pearson correlation matrix was calculated to examine the relationship between BMI Z-score and thyroid hormone measures.  We also divided the group into 4 BMI subgroups: lean, normal, overweight, and obese (0.0%-4.9%, 5.0%-84.9%, 85.0%-94.9%, and =>95.0% respectively). The means of thyroid hormone measures are compared among the groups by using t-tests.

All analyses were performed in a SAS statistical package (Version 9.3, SAS Institute, Cary, NC).

 Results

 Data from 611 subjects were included. BMI Z-score showed significant positive correlations with T3 (r=0.17, p<=0.0001), TSH (r=0.11, p=0.008), and FT3 (r=0.10, p=0.02), but no significant correlation with T4 and FT4 .

Compared with the normal group, the means of T3 (129 vs. 141), FT3 (3.6 vs. 3.8), TSH (1.48 vs. 1.79), and T4 (8.1 vs. 8.5) in our obese group are significantly higher with p-values of  <0.01, 0.004, 0.02, and 0.03 respectively.

No statistically significant differences were found in comparisons between the normal group and either the lean or overweight groups, except that the mean FT4 level is slightly lower in the overweight group.  However, this difference was not found in the comparison with the obese group.   

Overall, thyroid functions of our subject population fall in normal reference range which are 5.4 -12.8 mcg/dl for T4 and 0.47-5.01 mIU/L for TSH.

 Conclusion

 Our analyses suggest that TSH and thyroid hormone levels are higher in the obese pediatric population.  However, overall thyroid functions remain in normal ranges.

 

Nothing to Disclose: TK, MM, JC, PZ

19496 2.0000 THR-543 A Thyroid Function and Obesity in US Pediatric Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 542-548 6096 1:00:00 PM Obesity: Pediatric and Surgery Poster


V. Sri Nagesh*1, Rakesh Kumar Sahay2, Neelaveni Kudugunti3, Vishnu Vardhan Rao.M4, Aditya Vikram B5, Sridhar Bathula6, Syed Mustafa Hashmi3, Sana Hyder3, Sania Jiwani3 and Hari Mohan R3
1CARE Out Patient Centre, CARE Hospital, Hyderabad, 2Osmania Medical College, Hyderabad, 3Osmania Medical College, 4National Institute of Nutrition, 5Gandhi Medical College, 6Kakatiya Medical College

 

Background: Recent studies have shown that pediatric obesity is on the rise, especially in the developing countries, possibly due to a sea change in lifestyle. While multiple studies have shown a rising trend in pediatric obesity, especially in the developing countries, studies dealing with the ultimate metabolic consequences of pediatric obesity and the means of accurately predicting these consequences are limited. Also, most studies have only focused on body mass index (BMI), and not evaluated waist height ratio (WHtR), which is a better tracking marker of central obesity, especially in adolescents.

Objective: To study the utility of WHtR as a marker of insulin resistance, especially the relevance of its association with lifestyle factors, other anthropometric markers like Body Mass Index and Waist Circumference and the strength of its association with biochemical markers of insulin resistance like HOMA-IR, fasting insulin; markers of cardiovascular risk like hs-CRP. Also, to validate the presently used cutoffs (≥0.5) and validate its utility in populations studies.

Methods: 96 children of both sexes  in the 11-16 yr age group were evaluated for lifestyle factors conducive to obesity, like frequent meat and snack consumption, greater screen time and eating meals while watching television, lesser physical activity and lesser access to parks and playgrounds; body mass index (BMI), WC, WHtR, triceps skin fold thickness and fat percentage measured and fasting samples drawn for fasting insulin, glucose, lipids, adiponectin, hs-CRP; & HOMA-IR was also calculated.

Results: Waist Height Ratio showed significant association with lifestyle factors, other anthropometric markers and biochemical markers,(p< 0.05), except for adiponectin. 40 children out of the total 96 had a BMI< 85th centile, among whom, 8 children had raised WHtR and greater incidence of frequent snack consumption, family history of obesity and increased fat percentage (p< 0.05). When the entire study group was divided into tertiles, the tertile with WHtR - 0.49-0.53 had HOMA-IR and hs-CRP values similar to cut-offs determined in previous studies.

Conclusions: WHtR performed as well as BMI and WC in assessing obesity and insulin resistance in children. Children with normal BMI and high WHtRcan still have increased central obesity & consequent metabolic risks. The presently used WHtR cutoff ≥0.5  for central obesity, correlates well with insulin resistance and future cardiovascular risk. WHtR has the potential to become “the anthropometric marker” to define insulin resistance and cardio-vascular risk in future community studies.

 

Nothing to Disclose: VSN, RKS, NK, VVR, AVB, SB, SMH, SH, SJ, HMR

21297 3.0000 THR-544 A Waist Height Ratio As a Marker of Obesity and Insulin Resistance in Adolescents 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 542-548 6096 1:00:00 PM Obesity: Pediatric and Surgery Poster


Ayça Törel Ergür*, Fatih Atik and Enver Ekici
Ufuk University, Ankara, Turkey

 

Background:The goal of this study was to compare the left ventricle structure and  functions in obesity without established  complication with none obese children.

Methods:Anthropometric and conventional echocardiographic parameters of cardiac geometry and left ventricular function were obtained in 29 obese children without any other disease and complication of obesity like hypertension, hypercholesterolemia, etc. (13 females, 16 males, age 10.14 ±2.06 years) and a control group of 19 (11 females, 8 males, age 8.18±2.26 years) healthy lean. Fasting plasma glucose, insulin levels were obtained and homeostatic model assessment of insulin resistance (HOMA‐IR) were calculated.

Results: Age, body surface area, blood pressure, and heart rate were comparable. in the obese group was evidently higher than the control group. Height, weight, body surface area  and body mass index (BMI) were found significantly higher in the obese group (p<0.001). Insulin and HOMA‐IR levels were higher in obese group. No significant differences  were observed for left ventricular systolic and diastolic diameter (p>0.05). Left ventricular mass (LVM), LVM/ht2.7, LVM/BMI and relative wall thickness (RWT) were significantly increased in obese children than the controls (p<0.001) and most of them had eccentric left ventricular (LV) hypertrophy. Ejection fraction was significantly decreased. A positive correlation was seen between BMI and LV  posterior wall thickness and interventricular septal thickness (r>0.45, P<0.05). Both types of hypertrophy were seen in insulin resistant obese group.

Conclusions: Childhood obesity without any detectable complication leads to morphologic alterations in left ventricle structure and functions as in adults. The known causes are altered homeostatic and neurohumoral mechanisms and compensation of higher metabolic demands and increased left ventricular mass, reduced myocardial performance due to  hemodynamic load associated with higher cardiovascular morbidity and mortality rates.

 

Nothing to Disclose: AT, FA, EE

18478 4.0000 THR-545 A Impact of Childhood Obesity on Cardiac Structure and Functions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 542-548 6096 1:00:00 PM Obesity: Pediatric and Surgery Poster


Giovanna Mozardo Duarte*1, Victor Sousa da Silveira2, Christiane Andrade de Azevedo2, Vanessa Castro Ramos2, Ana Heloisa Correia Bresque3, Evandro S Portes4, Ricardo A Guerra4 and Marcio Faleiros Vendramini1
1Hospital do Servidor Público Estadual de São Paulo, 2Hospital do Servidor Público Estadual, 3Hospital do Servidor Público Estadual, Sao Paulo, Brazil, 4Hospital do Servidor Publico Estadual de Sao Paulo

 

Background: The presence of hypoglycemia in postoperative gastric bypass with Roux-en-Y reconstruction is a rare complication and it is hypothesized that its pathophysiology is related to hypersecretion of GLP-1. Furthermore, there are few reports of this complication in non-obese patients undergoing this type of surgery for gastric cancer.

Case report: a 61-year-old woman was diagnosed with gastric adenocarcinoma in antral region and underwent total gastrectomy with Roux-en-Y reconstruction and D2 lymphadenectomy. In the immediate postoperative period, she presented severe diarrhea, being prescribed octreotide LAR. After 10 months since the surgery, the patient began to show signs and symptoms of postprandial hypoglycemia and was hospitalized for investigation. She was assessed by the Endocrinology department of the hospital, and a fasting test was indicated. The test was discontinued after 60 hours, when the patient presented plasma glucose = 41 mg/dl (NR: 70-99 mg/dL) with insulin <2.0 mIU/ml (NR: 2.5-25 mIU/ml). At this time, she was treated with nutritional orientations and maintained prescription of octreotide LAR. After discharge, the patient remained with frequent hypoglycemia episodes (2-3 per day) and was hospitalized again. On the first day of admission, 1 hour after the meal, the patient developed new hypoglycemia episode, at that time with plasma glucose = 40 mg/dl and insulin = 11.1 mIU/ml. A CT scan of the abdomen showed no abnormalities. It is known that after gastric bypass, there are brief introduction of nutrients to the intestine, which stimulates the release of high levels of GLP- 1 in the bloodstream and causes hypertrophy of the pancreatic beta cells, increasing postprandial insulin secretion. Therefore, the diagnosis of hypoglycemia related to hypersecretion of GLP-1 was suspected. As the alpha glucosidase inhibitors prolong absorption of saccharides after meals, they attenuate the rise in insulin and GLP-1 levels. So, treatment with acarbose was initiated, reducing the frequency and severity of hypoglycemic crisis.

Clinical lessons: The hypersecretion of GLP-1 resulting from gastric bypass and subsequent postprandial hypoglycemia can also occur in non-obese patients. Treatment with acarbose is beneficial in these patients.

 

Nothing to Disclose: GMD, VSDS, CADA, VCR, AHCB, ESP, RAG, MFV

21303 5.0000 THR-546 A Diagnosis and Management of Hypoglycemia in a Non-Obese Patient after Roux-En-Y Gastric Bypass: Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 542-548 6096 1:00:00 PM Obesity: Pediatric and Surgery Poster


Karyne Lima Vinales*1 and Allison Peckumn2
1Banner Good Samaritan Medical Center, Phoenix, AZ, 2Banner Good Samaritan Medical Center, Goodyear, AZ

 

Background: Hyperinsulinemic hypoglycemia (HIH) after bariatric surgery is a rare entity. Its treatment is challenging, and no cases with associated eating disorders have been described.

Clinical case: 33 year old nurse with a history of Roux-en-Y gastric bypass surgery in 2003 was transferred to the hospital from an inpatient treatment center where she was being treated for bulimia nervosa for severe hypoglycemic episodes. These episodes started in 2009, and even resulted in an MVA in 2012. She had classic symptoms of hypoglycemia. Her eating disorder, diagnosed in 2006, started with restriction and later progressed to purging after meals. Patient also has bipolar disorder and panic attacks. At the treatment center, she was initially placed on enteral feedings, as she refused to eat, and there was no reported hypoglycemia. Once on an oral diet, she had frequent post-prandial hypoglycemia. Patient was on multiple psychiatric medications; none were felt to be related. Patient was treated with IV dextrose, and was later weaned off. As soon she was placed on a regular diet, she had a blood sugar of 47 mg/dL with concomitant insulin level of 11 uIU/mL, C-peptide 4.2 ng/mL, Beta-Hydroxybutyrate 0.8 mg/dL, pro-insulin 27.8 pmol/L. Hypoglycemia responded to glucagon.

Anti-insulin antibody, sulfonylurea and glinide levels were undetectable. CT scan of abdomen was negative for visible pancreatic lesion. Patient would not adhere to a low carbohydrate diet as she was afraid she would gain weight.  She failed treatment with acarbose up to 100 mg TID. She also failed to respond to octreotide up to 50 mcg TID, plus she was very resistant to using subcutaneous medications chronically. She responded partially to diazoxide. Because of her profession and her mental health history, the question of factitious hypoglycemia was raised, but was ruled out after lab results were received and patient was continuously supervised.  The patient underwent endoscopic ultrasound and was found to have a suspicious 1cm pancreatic lesion, with negative fine needle aspiration for pathologic cells. On selective arterial calcium stimulation, there was an overall three-fold increase in insulin, but no difference between arteries.  The patient’s most likely diagnosis is nesidioblastosis. Near total pancreatectomy was discussed. She was not felt to be a good surgical candidate while she was actively struggling with bulimia.  She returned to inpatient treatment for her eating disorder with persistent sporadic mild post-prandial hypoglycemic episodes.

Conclusion: This is the first case described of hyperinsulinemic hypoglycemia after gastric bypass surgery case complicated by an eating disorder, and it illustrates the difficulty of treatment of not only HIH, but also addresses ethical dilemmas encountered in a patient with a psychiatric condition.

 

Nothing to Disclose: KLV, AP

20749 6.0000 THR-547 A Hyperinsulinemic Hypoglycemia after Bariatric Surgery: Challenges with a Patient with an Associated Eating Disorder 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 542-548 6096 1:00:00 PM Obesity: Pediatric and Surgery Poster


Haleigh James*, Paul Lorentz and Maria L Collazo-Clavell
Mayo Clinic, Rochester, MN

 

Bariatric surgery is an increasingly popular treatment for medically complicated obesity, but is associated with micronutrient deficiencies.  Despite this known risk, randomized controlled trials evaluating vitamin/mineral supplement regimens in this setting are lacking.  Observational studies have evaluated nutritional deficiencies in bariatric populations, but few have assessed patient compliance with and efficacy of empiric regimens at preventing deficiencies.  The aim of this study was to assess adherence to and efficacy of Mayo Clinic’s post Roux-en-Y gastric bypass (RYGB) vitamin/mineral supplement protocol and the related incidence of common nutrient deficiencies.

We performed a retrospective study of prospectively gathered data in the follow-up of 287 patients who underwent RYGB at Mayo Clinic between May 1, 2010 and April 30, 2012.  Supplement adherence was assessed via medication reconciliation performed at hospital dismissal (HD) and at patients' 6, 12, and 18-36 month post-operative visits.  Micronutrient deficiencies were assessed via laboratory values obtained at the same time points.

At HD, the median number of vitamin/mineral supplements was 3, correlating with Mayo Clinic’s standard post-bariatric surgery prescription of a chewable multivitamin with minerals twice daily, 1000 mg of elemental calcium daily, and 1000 mcg of subcutaneous vitamin B12 monthly.  The median number of supplements on patients' medication lists increased to 4 at 6, 12, and 18-36 months post-surgery.  Adherence to the multivitamin and vitamin B12 supplementation protocol was >92% at all follow-up time points while rates of calcium supplementation decreased from 94.1% at HD to 78.7% at 18-36 months.  Vitamin D supplementation increased from 39.7% at HD to 50%, 64.5%, and 65.8% at 6, 12, and 18-36 months post-surgery, respectively.

Hemoglobin was assessed and used as a surrogate marker of nutritional deficiency.  Anemia was present in 13.1%, 9.5%, and 16.4% of patients at 6, 12, and 18-36 months, respectively, and was more common in men than women (22% vs. 11.2%, 19.6% vs. 6.6%, and 34.3% vs. 12.2% at 6, 12, and 18-36 months, respectively).  Low ferritin was also more common in men at 6 (8.2% vs. 3.8%) and 18-36 (17.2% vs. 6.7%) months.  Vitamin B12 deficiency was present in 0% and 3.7% of patients at 12 and 18-36 months post-surgery, respectively.  Vitamin D deficiency (25-hydroxyvitamin D <25 ng/mL) was seen in 13%, 15.4%, and 16.2% of patients at 6, 12, and 18-36 months, respectively.  These data show sustained patient adherence to the multivitamin and vitamin B12 protocol, but decreased supplemental calcium intake with time after surgery.  Rates of vitamin D supplementation increased with each post-surgical time point in the setting of increasing rates of vitamin D deficiency.  Anemia and low ferritin were especially common in men suggesting possible undertreatment of iron deficiency in male RYGB patients.

 

Nothing to Disclose: HJ, PL, MLC

19566 7.0000 THR-548 A Adherence to Empiric Vitamin/Mineral Supplementation Protocols and Related Micronutrient Deficiencies in Patients after Roux-En-Y Gastric Bypass 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM THR 542-548 6096 1:00:00 PM Obesity: Pediatric and Surgery Poster


Adegbenga BOLANLE Ademolu*1, Abiola Olanike Ademolu2, Anthonia Ogbera3 and Augustine E Ohwovoriole4
1Lagos State University Teaching Hospital (LASUTH), Ikeja, Nigeria, 2Olabisi Onabanjo University Teaching Hospital, Ogun, Nigeria, 3Lagos State University, Nigeria, 4University of Lagos, Yaba Lagos, Nigeria

 

Though the biochemical structure of cholesterol,high density lipoprotein and low density lipoprotein are the same in both gender ,yet their  distribution  differs.These observed differences provoke the question how many  male and female  with high abdominal adiposity have high plasma cholesterol level(hyperlipidaemia)?This paper aim to study these disparity in the lipidology of both sexes in Southwest Nigeria,among Lagosian.These data were obtained during a free health screening services in surulere area of Lagos.The fasting total cholesterol level was taken by the use of a cholesterol meter,a fasting cholesterol of 200mg/dl or less was taken as normal.ln this study,abdominal adiposity was assessed clinically with the use of a non stretch tape to measure waist circumference at the level of the umbilicus.A waist circumference of 94cm and above and greater than or equal to 80cm were taken as high abdominal adiposity(central obesity)for male and female respectively.A total of 22 males and 49 females were involved in the study making a total of 71 participants.The age range among male studied was 31-70years with a mean age of 49.45years. Of these 72.72%(16)men had normal abdominal adiposity while  27.27%(6)had high abdominal adiposity.Also 18.18%(4)had hyperlipidaemia,only 25%(1)of those with hyperlipidaemia had high abdominal adiposity  while the remaining 75% had normal abdominal adiposity despite being hyperlipidaemic.Similarly among those (6)with high abdominal adiposity,only 16.67%(1)had hyperlipidaemia,ln the female gender,the age range  was 18-88years with a mean age of 46.29years.Of these 20.41%(10)had normal abdominal adiposity while 79.59%(39)had high abdominal adiposity.Also 28.57%(14)had hyperlipidaemia. Of the female subjects with hyperlipidaemia,78.57%(11)had high abdominal adiposity while 21.43%(3)had normal abdominal adiposity. However,among those with high abdominal adiposity in the female gender,only 28.21%(11)had hyperlipidaemia.In both gender,it is not all that have high abdominal adiposity that have hyperlipidaemia and it is not all that have hyperlipidaemia that have high abdominal adiposity.A marked disparity was noticed between gender with respect to those with hyperlipidaemia and high abdominal adiposity.ln male subjects with hyperlipidaemia the subject with high abdominal adiposity is in the minority(25%)while in  female subjects with hyperlipidaemia,those with high abdominal adiposity are in the majority(78.57%).The disparity here is marked and of significant prognostic importance.In both gender minority number of those with high abdominal adiposity have hyperlipidaemia though with female having sizable minority number.Conversely a marked disparity is seen among female subjects with hyperlipidaemia. 

 Nothing to Disclose: ABA ,AA,OA,AO                                                                                                                                                                                                                                                                                                                                                                                                                      

 

Nothing to Disclose: ABA, AOA, AO, AEO

18772 1.0000 THR-522 A Disparity in Fasting Plasma Cholesterol and Abdominal Adiposity within and Between Gender in Lagos,South West Nigeria 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Jennifer Kelley*1, Vaneeta Bamba2, Daniel Katz1, Kamini Anbil1, Philippe Backeljauw3 and Iris Gutmark-Little3
1Children's Hospital of Philadelphia, Philadelphia, PA, 2The Children's Hospital of Philadelphia, Philadelphia, PA, 3Cincinnati Children's Hospital Medical Center, Cincinnati, OH

 

Acquired cardiovascular disease (CVD) is a leading cause of morbidity and mortality in females with Turner Syndrome (TS). Turner syndrome guidelines recommend early detection of CVD risk factors, including measurement of annual fasting lipid panels beginning at age 10 years. Recent recommendations advocate for screening of non-high-density lipoprotein cholesterol (non-HDL-C) as a marker of atherogenic lipoproteins as it is a predictor of atherosclerosis in the general population. Limited data has been published on cholesterol profiles in the pediatric TS population; specifically, non-HDL-C profiles have not been described. The aim of this cross-sectional study is to assess the distribution and correlations of non-HDL-C in a heterogeneous group of young TS females (n=158), ages 3-29 years. Data of genetically-confirmed TS patients followed in Endocrine Specialty Clinics within two academic children’s hospitals were included for analysis. Anthropometric and laboratory data were obtained through retrospective chart review. At the time of initial lipid evaluation, mean (± SD) age was 13.49 years (4.66), BMI was 23.45 kg/m2 (5.38) and age- and gender-adjusted BMI Z-score was 1.04 (0.82). Overall mean non-HDL-C level was 118.91 mg/dL (31.96). The prevalence (95% CI) of borderline elevated non-HDL-C levels (>120-144 mg/dL) was 24.7% (17.9-31.5%). The prevalence of dyslipidemia according to high non-HDL-C level (≥145 mg/dL) was 17.7% (11.7-23.7%). Mean non-HDL-C level in subjects with high non-HDL-C was 171.65 mg/dL (22.95). Recent NHANES data showed the prevalence of high non-HDL-C, measured between 2007-2010, in males and females in the general pediatric population, ages 6-19 years, was 10% (8.4%-11.5%). In comparison, applying the parameters used by NHANES for ages and dates of measurement to our cohort of TS females, prevalence of high non-HDL-C levels was 15.9% (4.66-27.2%), n=44. Non-HDL-C was positively correlated with age (r=0.175, p<0.005), BMI (rs=0.275, p<0.005), and BMI z-score (rs=0.185, p<0.05). In multivariate analysis, the significance of association with age was lost when adjusted for BMI (p=0.4). BMI accounted for 10% of the variance in non-HDL-C levels (β coefficient=1.5, p=0.002). Addition of genotype to the model showed no significant association. Additional anthropometric data were available in 71 participants; no significant associations were noted between non-HDL-C level and ethnicity or pubertal stage. In conclusion, this cohort of TS females has higher prevalence of elevated non-HDL-C than the general pediatric population reported by NHANES. This may contribute to the higher risk of CVD in TS and supports a clinical approach aimed at reducing this risk. Although BMI is associated with the non-HDL-C profile, it does not fully explain elevated non-HDL-C concentrations and suggests that screening is indicated in all TS patients.

 

Nothing to Disclose: JK, VB, DK, KA, PB, IG

20770 2.0000 THR-523 A Assessment of Non-High-Density Lipoprotein Cholesterol Profile in Young Females with Turner Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Ingvars Rasa*1 and Linda Kucane2
1Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga Stradins University, Riga East Clinical University Hospital, Riga, Latvia

 

Hypertriglyceridemia (HTG) is quite common, including familial forms that are mostly polygenic. Severe HTG is associated with increased risk of pancreatitis but its contribution to atherosclerosis is still evolving. Methods: Cross-sectional, descriptive, one hospital study. 4679 medical records of patients (pts) discharged from Endocrinology Dpt. RECUH, in years (yrs): 2010 – 2013 were used; records with serum triglycerides (TG) ≥5.6 mmol/L (500 mg/dL) were analysed. Results: 114 medical records were eligible: 99 pts in total, 11% were admitted repeatedly. Mean age 48.3±13.6 yrs (95%CI: 38.4-51.6), male 67%, female 33%. Mean serum TG 11.2±9.5 mmol/L (95%CI: 9.3-13.1), max. TG level 63.39mmol/L; 25% (n=25) had TG >11.2mmol/L; 30% (n=30) had lactescent plasma. 93% (n=92) had diabetes (DM): 75% (n=69) type 2 DM, 16% (n=15) type 1 DM, 7% (n=6) pancreatogenic DM, 2% (n=2) other types of DM. 33% (n=30) were diagnosed upon hospitalization. 89% (n=79) had HbA1C ≥8.0%. 72% (n=62) were obese; mean BMI 31.9±6.1kg/m2. 83% (n=81) had steatosis on ultrasound scan. 5% (n=5) had hypothyroidism. 17% (n=17) had glomerular filtration rate (GFR) under 60mL/min/1.73m2; 1% (n=1) under 30ml/min/1.73m2. 30% (n=21) had high uric acid, it was higher in type 2 DM pts than pts with type 1 or pts with no DM (p=0.025); it correlated with GFR (CC= -0.276; p=0.02), TG (CC= -0.301; p=0.01) and BMI (CC=+0.360; p=0.004). 21% (n=21) had the history of pancreatitis, 9% (n=9) had plasma exchanges, and 1% (n=1) had continuous renal replacement therapy while hospitalized in RECUH. 19% (n=19) received lipid-lowering therapy prior to hospitalization; 8% (n=8) were not recommended pharmacologic treatment upon discharge. 75% (n=74) had hypertension; 15% (n=15) had coronary artery disease, 8% (n=8) have had cerebrovascular event and 6% (n=6) had peripheral artery disease. 3% (n=3) had no DM, obesity, had normal thyroid and renal function. Total Cholesterol (TC) was <6.2mmol/L in 15% (n=15), in this group HDL-C was under 1.0mmol/L, TG under 10.0mmo/L. 22% (n=21) had roughly twice as high TG as TC, what can be seen in primary simple HTG.  61% (n=60) had nearly the same TG and TC levels, which is more characteristic to combined hyperlipidemia. 17% (n=16) had TC higher than TG. Conclusions: Our study shows 2% (1 in 50) prevalence of very high serum TG in secondary care. Patients mostly have decompensated diabetes, obesity, less often - hypothyroidism, renal failure. One fifth had a history of pancreatitis - it’s important to treat and educate HTG pts to prevent pancreatitis in the future.  Education of health care professionals is important as HTG is often undertreated. Under 10%, had data about symptomatic atherosclerosis that  might contribute to other risk factors as well. We can assume that at least part of these study pts might have combined hyperlipidemia (HLP type 2B) or primary simple HTG(HLP type 4), which often are associated with secondary factors.

 

Nothing to Disclose: IR, LK

21198 3.0000 THR-524 A Very High* Plasma Triglyceride - Prevalence, Clinical Features and Complications in Hospital Setting: 4-Year Data in Riga East Clinical University Hospital (RECUH) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Joshua Tarkoff*1, June Tester2, Alex Quinn1, Meredith Renee Russell1, Robert H Lustig1, John P. Kane1 and Mary Malloy1
1University of California - San Francisco, San Francisco, CA, 2Children’s Hospital Oakland Research Institute, Oakland, CA

 

Arteriosclerotic cardiovascular disease is the leading cause of death (myocardial infarction) and disability (stroke) in the industrialized world. Abnormalities of lipid metabolism underlying vascular disease are traceable to childhood. Prebeta-1 HDL, the quantum HDL species, acts as the primary acceptor of cholesterol effluxed from the vessel wall. Prebeta-1 HDL is a strong independent risk factor for cardiovascular disease (CVD) in adults (1). High levels of prebeta-1 HDL reflect increased risk of CVD due to impaired removal of cholesterol. Levels of prebeta-1 HDL have not been measured previously in children. Subjects (n=54) with BMI >95th percentile for age and sex were recruited from obesity clinics. Controls (n=8) were relatives of patients referred to our Pediatric Lipid Clinic with normal BMI and fasting lipid profile. Fasting blood samples were obtained for quantification of prebeta-1 HDL (mg/dL as apolipoprotein A-I) via a newly developed immunofixation method validated by ultrafiltration/isotope dilution (manuscript in preparation).

Prebeta-1 HDL concentration did not differ between the two groups (4.53±0.14 vs. 3.95±0.3 mg/dL, p=0.11). However, a subset of obese subjects with at least 1 metabolic abnormality (MA) (dysglycemia, dyslipidemia, NAFLD, or hypertension) did differ from controls (4.76±0.19 vs. 3.95±0.3 mg/dL, p=0.04). Further subgroup analysis based on the number of MAs did not reveal significant differences in prebeta-1 HDL concentrations, but a positive trend with increasing MAs was noted. Multiple linear regression analysis with traditional metabolic markers vs. prebeta-1 HDL revealed a positive correlation with triglycerides and HDL-C but failed to show statistical significance with BMI, BMI percentile, age, and sex.

Taken together, these data suggest that children with MAs already have elevated prebeta-1 HDL concentrations when compared to their peers. It also appears that obesity alone does not confer additional risk through prebeta-1 HDL. Prebeta-1 HDL provides new insight into the relationship of metabolic dysfunction to vascular disease. This independent risk factor for CVD appears to emerge at an early age and should be considered in the decision to treat young patients with metabolic dysfunction aggressively.

 

Disclosure: JPK: Consultant, Boston Heart Diagnostics . MM: Consultant, Boston Heart Diagnostics . Nothing to Disclose: JT, JT, AQ, MRR, RHL

21638 4.0000 THR-526 A Elevated Prebeta-1 HDL Accompanies Metabolic Dysfunction in Obese Children 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Abdelghani El Rafei*1, Sara E. Schwab2, Rachel A. Steinman2, Rana Malek2 and Kashif M. Munir3
1University of Maryland Medical Center, 2University of Maryland School of Medicine, Baltimore, MD, 3University of MD Medical Center, Baltimore, MD

 

Introduction:

Lipoprotein X (LP-X) is an abnormal lipoprotein that can appear in the sera of patients with cholestatic liver disease and is considered one of the most specific markers of hepatic cholestasis (1). Bile salts reflux into the plasma and bind albumin to form LP-X, which is rich in phospholipids and unesterified cholesterol (2). Unlike low-density lipoprotein (LDL), LP-X does not contain Apo B nor is it removed by the LDL receptor; it is mainly taken up by the reticuloendothelial system (2-3).

We report a case of elevated cholesterol in the setting of sarcoidosis-induced cholestasis.

Case:

A 34 year old man with a recent diagnosis of biopsy confirmed hepatic sarcoidosis was admitted with lower extremity weakness. His serum cholesterol was 537 mg/dl, repeat testing confirmed levels of > 650 mg/dL. Lipid panel done one year prior showed an LDL of 106 mg/dL. 

Statin therapy was initiated with no improvement in lipids. Hospitalization was complicated by acute liver failure, with an alkaline phosphatase 1685 units/l, bilirubin 5.5mg/dl, AST 1592 units/l and ALT 1545 units/l. Apo-A levels were low, 53mg/dL (110-180 mg/dl), and Apo-B levels were elevated, 160 mg/dl (0-79 mg/dl).

Discussion:

Causes of hypercholesterolemia of this magnitude include homozygous familial hypercholesterolemia or cholestatic obstructive jaundice. Given that our patient had normal cholesterol levels one year prior to his presentation it is highly unlikely that he had familial hypercholesterolemia.

While his Apo B level (LDL marker) was elevated, this alone cannot explain a total cholesterol level > 650 mg/dl, and indicated the presence of another lipoprotein in the serum.

LP-X levels do not decrease with statin therapy, but do dissipate with resolution of cholestasis. We describe a unique case of probable LP-X induced hyperlipidemia in the setting of hepatic sarcoidosis.

 

Nothing to Disclose: AE, SES, RAS, RM, KMM

21854 5.0000 THR-527 A Lipoprotein X Leading to Severe Hypercholesterolemia in a Patient with Sarcoidosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Nuntakorn Thongtang*1, Apiradee Sriwijitkamol1 and Sutin Sriussadaporn2
1Siriraj Hospital, Mahidol University, Bangkok, Thailand, 2Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

 

Background: Data has suggested that statins usage in Asian population resulted in greater LDL-C reduction than in Caucasians. An ACC/AHA guideline has recommended using moderate or high potency statins in diabetic patients. We aim to examine the usage and efficacy of statin potency on lipid levels that was able to attain LDL-C goal in Thai diabetic patients.

Methods: Type 2 diabetic patients who were treated with statins at diabetic clinic during November to December 2013, and had calculated LDL-C levels < 100 mg/dl were enrolled. Demographic data, ASCVD, and ASCVD risk factors were collected. Statin potency was classified into low, moderate and high potency statin according to ACC/AHA 2013 guideline. Study was approved by Siriraj Ethic committee.

Results: Subjects (n=182) had a mean age of 63.9 years (60% female). Mean duration of diabetes was 11.4 ± 8.4 years, and mean HbA1c was 7.26 ± 1.1%. Prevalence of ASCVD was 6%. Mean plasma calculated LDL-C, direct LDL-C, non-HDL-C, and apoB levels were 73.2, 82.6, 96.4, and 74.7 mg/dl, respectively. Of the 182 patients who had LDL-C levels < 100 mg/dl, 36% were on low potency statins, 61% moderate potency statins, and only 3% were on high potency statins. There were 80 subjects (44.0%) who had plasma LDL-C levels < 70 mg/dl. The proportion of different statin potency usages between subjects who had plasma LDL-C levels < 70 mg/dl (n= 80, 44%) and LDL-C levels between 70-100 mg/dl (n=102, 56%) were compared using Chi-square test. Among subjects who had plasma LDL-C levels < 70 mg/dl, 35% were on low potency statins, 61.2% were on moderate potency statins, while only 3.8% were on high potency statins. Among subjects who had LDL-C levels 70-100 mg/dl  36.3%, 59.7%, and 4% were on low, moderate and high potency statin respectively. There were no statistically significant difference (p>0.05) between the proportions of different statin potency usages between the two groups.

Conclusion: Our study suggested that in Thai type 2 diabetic patients, 97% of the study subjects were able to maintain an LDL-C goal of <100 mg/dl with low or moderate potency statins.

 

Nothing to Disclose: NT, AS, SS

21122 6.0000 THR-528 A Statin Potency Usage to Attain an LDL-c Goal in Thai Type 2 Diabetic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Rodolfo J Galindo1, Justin Yoon2, Craig Devoe3 and Alyson K. Myers*1
1Hofstra University - School of Medicine, Great Neck, NY, 2Hofstra University - School of Medicine/ NS-LIJ Health System, Manhasset, NY, 3Hofstra University - School of Medicine, New Hyde Park

 

Background: Asparaginase (ASP) is a chemotherapeutic agent traditionally used in children with Acute Lymphocytic Leukemia (ALL). There has been a recent use of ASP in adults, particularly the less toxic pegylated formulation (PEG). Unfortunately, one of the rare complications of PEG use is hypertriglyceridemia (HTG) which can be seen in both populations.

Cases: Patient 1 is a 44-year-old obese (BMI 54) woman with controlled Type 2 Diabetes, Graves’ disease (currently euthyroid) and ALL. Twelve days after the fifth dose of PEG the serum was reported to be lipemic. The lipid panel revealed severe HTG: 1320 mg/dL, for which fenofibrate was started and PEG therapy was held. Three weeks later, TG level declined to 306 mg/dL, thus the patient was re-challenged with the same PEG dosing. After completing two more cycles of PEG, TG increased to 4330 mg/dl, and she was admitted. She denied abdominal pain, nausea and vomiting. Serum lipase and imaging did not indicate pancreatitis. Diabetes was controlled with insulin therapy. There was no family history of dyslipidemia. She was not taking any other medications associated with HTG, and she did not drink alcohol. Based on this and the temporal association, we concluded that HTG was caused by PEG. She was continued on insulin therapy and a low-fat, diabetic diet. Fibrate and fish oil therapy were added. The patient has since continued chemotherapy without PEG and TG improved.

Patient 2 is a 32-year-old obese (BMI 31) man with ALL admitted with neutropenic fever and methotrexate-induced acute kidney injury (AKI). Incidentally, he was found to have severe HTG: 4420 mg/dl. The admission occurred 3 weeks after the fourth PEG dose. He had no personal or family history of dyslipidemia, diabetes or thyroid disorders.  As seen in patient 1, there was no evidence of pancreatitis. Fasting glucose levels ranged between 72 – 116 mg/dl and Hb A1C was 6.6 %. We concluded that HTG was induced by PEG. A low-fat diet was initiated and PEG was discontinued. Insulin therapy was not started given his glucose levels. Fibrates were also avoided due to his AKI. Coincidentally, he was receiving heparin infusion – an alternative HTG therapy - for an acute deep vein thrombosis. TG level decreased in four days. Three weeks later, the patient was re-challenged and received PEG at a half dose. He also received fibrate after AKI resolved. Six months after discharge, TG level was 835 mg/dl which was attributed to medication non-adherence. Nonetheless, TG level trended down (75-209 mg/dl) in 4 months while he was continued on a fibrate.

Conclusion: HTG is a rare but clinically important adverse effect of PEG. Most patients are asymptomatic. Patients with obesity and diabetes may have higher risk. Clinicians should monitor for HTG during PEG therapy. Conservative management includes: diet, insulin, heparin, fibrates and omega-3. Rechallenging with PEG may also be a safe option(1).

 

Nothing to Disclose: RJG, JY, CD, AKM

19133 7.0000 THR-529 A Peg-Asparaginase Induced Hypertriglyceridemia in Adults Patients with Acute Lymphocytic Leukemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Alejandro Gonzalez Campos*1, Manivel K Eswaran2, Gurinder P Singh1, Alexander Indrikovs1, Shawn Nishi1 and Ligia Belalcazar1
1University of Texas Medical Branch, Galveston, TX, 2UTMB, Galveston, TX

 

Background: Severe hypertriglyceridemia is a metabolic emergency and when associated with acute pancreatitis, a potentially fatal condition. Prompt reduction of serum triglyceride-rich lipoproteins may slow the progression of pancreatic injury when already present and support patient recovery. We present two cases of severe hypertriglyceridemic pancreatitis treated successfully with one session of plasma exchange.

Case 1: A 39-year old obese woman with recently diagnosed nephrotic syndrome presented with 2 months of worsening epigastric and back pain and 2 days of nausea and vomiting. She denied family history of elevated triglycerides and had no history of alcohol use or gallstones. Patient was on cyclosporine, but not on steroid or estrogen therapy. Within 12 hours of admission she required initiation of mechanical ventilation, vasopressors, and broad-spectrum antibiotics. Triglycerides were 1,451 mg/dL, lipase 1,513 U/L. Abdominal ultrasound and computed tomography (CT) showed no gallstones or bile duct dilation; pancreatic inflammation and fluid tracking into the paracolic gutters were identified.  After plasma exchange (PEX) of 1.5 volumes using 5% albumin fluid replacement, triglyceride levels were 118 mg/dL.  The following day, vasopressors were stopped; enteral nutrition and fish oil therapy were started.  Patient was successfully extubated a week later and had complete resolution of her pancreatitis. Three months after discharge, she was asymptomatic, compliant with fish oil therapy and her triglycerides were 286 mg/dL.

Case 2: A 40 year-old woman with type 2 diabetes was transferred from a community hospital in diabetic ketoacidosis (DKA) after presenting with a 16-hour history of diffuse abdominal pain, nausea and vomiting. Initial treatment included insulin infusion, fluid replacement and antibiotics, but she developed respiratory failure, requiring intubation and vasopressors.  Triglycerides were 1,200 mg/dL, lipase 11,691 U/L, anion gap 35; CT showed severe inflammation and findings suggestive of necrotizing pancreatitis in ~50% of the pancreas.  Despite treatment and resolution of the DKA, triglycerides remained > 1,575 mg/dL.  She received a 1 volume PEX session with 5% albumin as replacement solution; triglycerides decreased to 343 mg/dL.  Enteral nutrition was started the next day. Patient’s hospital course was complicated by an iliopsoas abscess and upper extremity vein thrombosis. She was transferred out of intensive care after 25 days, on subcutaneous insulin therapy and enteral feeds. She is now recovering in the general wards. Her most recent triglycerides were 232 mg/dL.

Conclusion: Severe hypertriglyceridemia in the setting of acute pancreatitis is an endocrinological emergency.  Plasma exchange is an effective approach for the treatment of this high-risk metabolic condition.

 

Nothing to Disclose: AG, MKE, GPS, AI, SN, LB

20204 8.0000 THR-530 A Rapid Correction of Severe Hypertriglyceridemia in the Setting of Acute Pancreatitis: Treatment of a Metabolic Emergency with Plasma Exchange 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Iram Hussain* and Abhimanyu Garg
University of Texas Southwestern Medical Center, Dallas, TX

 

Background: Laminopathies can present with either partial or generalized loss of subcutaneous (sc) fat. While familial partial lipodystrophy, Dunnigan type, has been reported in ~500 patients, generalized fat loss due to LMNA variants is extremely rare. Interestingly, patients with Hutchison-Gilford progeria are not predisposed to metabolic complications but those with atypical progeroid syndromes (APS) with generalized lipodystrophy have marked metabolic abnormalities. Since ~8 APS patients with generalized lipodystrophy have been reported, we report phenotype of an additional patient with unusual presentation.

Clinical Case: A 9-year-old Caucasian girl presented with inability to gain weight since infancy.  She also developed mottled skin pigmentation on the neck at 3 months of age that progressed to her axillae and groin. She remained in the 10th percentile for weight and at 5 years of age, fat loss was noticed in her hips, and then in the extremities and face. Administration of cyproheptadine and nocturnal tube feeds for ~ 3 months each did not result in weight gain. Physical examination was remarkable for bird-like facies, generalized absence of sc fat; mottled hyperpigmentation, mild scoliosis and joint contractures especially in the knees, ejection systolic murmur with sinus tachycardia and hepatomegaly 10 cm below the costal margin. Genotyping for LMNA revealed a de novo LMNAheterozygous c.29C>T (p.The10Ile) mutation.

Further work up revealed hepatic steatosis on abdominal ultrasonography.  A transthoracic echocardiography showed normal cardiac function and valves with mild mitral regurgitation and a patent foramen ovale. Her truncal and peripheral skinfold thicknesses ranged from 2–4 mm (age- and gender-matched 10th to 90thpercentiles: 5–40 mm) and her total body fat was 13.6% (normal: 22 – 48%) on dual energy X-ray absorptiometry. Her bone mineral density was low for age (Z-score: -2.5). Her fasting serum triglycerides were 475 and 753 mg/dL (normal: 33 – 115 mg/dL) on two separate days, total cholesterol was 146 mg/dL (normal: 125 – 170 mg/dL) and high density lipoprotein cholesterol was 16 mg/dL (normal: 37 – 75 mg/dL).  She had mild elevations of aspartate aminotransferase: 37 U/L (normal: 12 – 32 U/L) and alanine aminotransferase: 54 U/L (normal: 8 – 24 U/L). Her fasting serum glucose was 103 mg/dL (normal: ≤ 99 mg/dL) with a hemoglobin A1c of 6.4% (normal < 6.5%). 

She was asked to switch from a high fat diet (recommended previously to induce weight gain) to a low fat diet. Increase in physical activity and fish oil 2-4 g daily was advised to lower triglycerides.

Conclusion: Our patient illustrates the difficulty in reaching the correct diagnosis of APS with generalized lipodystrophy due to LMNA variant because of unusual presentation and lack of awareness of this extremely rare syndrome. Recognition of metabolic complications in this patient led to change in the therapeutic plan.

 

Nothing to Disclose: IH, AG

21274 9.0000 THR-531 A De Novo Heterozygous LMNA p.T10I Mutation Presenting As Generalized Lipodystrophy with Metabolic Derangements 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Hanaa S. Sallam*1, Arham Ali2, Oscar Suman2, Clark R. Andersen2, Manisha Chandalia1, Celeste C. Finnerty3, David N. Herndon3 and Nicola Abate3
1Internal Medicine, UTMB, Galveston, TX, 2Surgery, University of Texas Medical Branch, Galveston, TX, 3University of Texas Medical Branch, Galveston, TX

 

Introduction: Children with severe burn injury develop insulin resistance and hyperglycemia that persist up to 3 years post-injury. They also develop increased hepatic triglyceride deposition. We hypothesized that use of metformin would reduce hepatic triglyceride content after 3-6 months treatment.

Methods: Fifteen patients (12 males, 3 females) with 30-90% of the total body surface area burns were randomized to metformin-treated (n=6) or placebo-treated (n=9) controls. All patients also followed an exercise program which is standard of care at Shriners Hospital in Galveston. Before and after 3-6 months intervention, each patient underwent: 1) dual x-ray absorptiometry (DEXA) to evaluate body fat content and distribution and 2) liver magnetic resonance spectroscopy to estimate hepatic triglyceride content calculated as percent relative to water. Data were analyzed using paired t-test analysis (SAS 9.2. SAS Institute, Cary, NC) and are presented as means ± SE.

Results:

1)      Neither metformin nor placebo halted the deposition of hepatic triglycerides. In fact, Metformin increased hepatic triglyceride content significantly (p=0.01 vs. baseline). However, the change in the  hepatic triglyceride content percentage was not significantly different between the two groups (54±80% and 238±38%; p=0.2).

2)      These results were observed in absence of changes in body fat content or distribution in both groups. Whole body fat/Kg body weight was 27±2% vs. 26±2%, and 28±3% vs. 29±3% at baseline and after intervention for placebo and metformin groups, respectively; p³0.1 each. Peripheral body fat/Kg body weight was 17±1% vs. 16±1%, and 16±2% vs. 17±2% at baseline and after intervention for placebo and metformin groups, respectively; p³0.2 each.

Conclusions:

These preliminary data reveal that severe burn injury results in persistent deposition of hepatic triglyceride regardless of the intervention (metformin or placebo). Given the importance of hepatic triglyceride content in predicting risk for type 2 diabetes, the role of metformin on modulating β-cell dysfunction warrants further studies.

 

Nothing to Disclose: HSS, AA, OS, CRA, MC, CCF, DNH, NA

21205 10.0000 THR-532 A Adipose Tissue Dysfunction in Burn: Contribution to Ectopic FAT Deposition 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Samata Basani*1 and Abhimanyu Garg2
1UT Southwestern Medical Center, 2University of Texas Southwestern Medical Center, Dallas, TX

 

Introduction: Bexarotene is a selective retinoid X receptor agonist, currently used as chemotherapy for cutaneous T-cell lymphoma and is being evaluated for treatment of other cancers and Alzheimer’s disease. Bexarotene blunts TSH secretion from the pituitary gland in response to TRH stimulation and causes central hypothyroidism 1. It is also implicated in causing hyperlipidemia, but lowering of HDL cholesterol has not been previously reported. We report marked dyslipidemia and lowering of HDL cholesterol with bexarotene therapy which reversed upon discontinuation of the drug. 

Case: A 49-year-old African female with a history of non-Hodgkin’s lymphoma S/P stem cell transplant, developed cutaneous T cell lymphoma requiring bexarotene therapy. She was referred to lipid clinic for management of mixed hyperlipidemia with extremely low HDL cholesterol dyslipidemia in-spite of taking Atorvastatin 80 mg daily with fish oil 2 g daily. She also developed bexarotene-induced central hypothyroidism (TSH 0.01 to 0.00 mIU/L) requiring levothyroxine replacement which was progressively increased from 50 mcg to 200 mcg daily. However, despite increase in free thyroxine level to1.2 ng/dL, lipid levels did not normalize and HDL cholesterol stayed low.  HDL level normalization was noted within 3 months of discontinuation of bexarotene.

Discussion: Bexarotene can induce mixed dyslipidemia by increasing hepatic VLDL production via Liver-X-Receptor (LXR) activation 2 and also secondary to central hypothyroidism. Although, the contribution of central hypothyroidism to bexarotene-induced dyslipidemia remains unclear, dyslipidemia persisted despite normalization of free thyroxine level. Marked lowering of HDL cholesterol with bexarotene has not been previously reported 3. In a prior study of 10 patients receiving bexarotene 300 mg daily for 6 wk, HDL cholesterol decreased by 30%, and triglycerides increased by 150%. Activity of cholesterol ester transfer protein (CETP), which mediates the exchange of cholesterol from HDL to VLDL or LDL particles, increased by 44% but without increase in CETP mass4. Interestingly, serum HDL cholesterol levels in our patient normalized upon discontinuation of bexarotene providing further support for the link between bexarotene therapy and low HDL cholesterol levels. Statins are preferable due to lack of drug interactions, whereas gemfibrozil has been shown to raise plasma bexarotene level. Omega-3 fatty acids are safe and well tolerated option for hypertriglyceridemia.

 

Disclosure: AG: Ad Hoc Consultant, Amgen, Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, BIOMARIN, Ad Hoc Consultant, HYPERION THERAPEUTICS, Ad Hoc Consultant, BACKBAY LIFE SCIENCES, Ad Hoc Consultant, MEDA CORP, Ad Hoc Consultant, ENGAGE HEALTH, Ad Hoc Consultant, GERSON LEHMAN GROUP, Ad Hoc Consultant, Eli Lilly & Company, Principal Investigator, Amylin Pharmaceuticals, Principal Investigator, Bristol-Myers Squibb, Principal Investigator, Pfizer, Inc., Principal Investigator, Astra Zeneca. Nothing to Disclose: SB

21278 11.0000 THR-533 A Marked Lowering of HDL Cholesterol with Bexarotene Therapy: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM THR 522-533 6098 1:00:00 PM Lipids Poster


Zia Ur Rahman*1, Khushi Muhammad Saqib2, Saeed Ahmad3 and Farheen Asad4
1University of Agriculture, Faisalabad, Pakistan, 2Government Elementary College, Faisalabad, 3University of the Punjab, Lahore, Pakistan, 4Govt. Collage for Women, Jaranwala, Faisalabad, Pakistan

 

Present study was designed to adopt a rat model that has been tested for many weightlessness studies and estimated successfully the response and complexity of weightlessness. Bigbee et al. (2006) did not observe any significant change by the thyroid gland of hind limb unloading adult Sprague Dawley male rats during 1, 4 and 8 weeks of study. The aim of the present study was to determine the impact of experimental weightlessness on thyroid activity. In the present study, two hundred and forty healthy albino male (n=120) and female (n=120) rats were used during winter (20°C to 23°C) and summer (30°C to 33°C) season. Rats were divided into two groups consisting of male (n=30) and female (n=30) in each season. A control group (CC), horizontal restrained group (HR) and head down suspended group (HDS) were established and a 12 hours light/12 hour’s dark cycle with ad libitum food and fresh water was provided every day from 9-10 h.  Rats were decapitated on day 7th (n=5) and day 28th (n=5) of experimental period from all groups to collected the blood in a heparinized tubes for the estimation of thyroid hormones by ELISA kit. Appropriate statistical analysis was performed to estimate the difference between treatments and Pearson’s correlation was also estimated. In winter and summer the overall mean concentration of T3 and T4 was low (P≥0.01) in HR and HDS groups of male and female rats irrespective of their days of treatment. During summer in male rats overall serum T3 concentration was significantly low in HDS groups as compared to normal and HR groups and while analyzing the data for different days of  treatment, serum T3 concentration was low (P≥0.01) in HDS group on day 28th of experimental period. Also overall mean serum T3 concentration in female rats was significantly low in HR and HDS groups as compared to normal group irrespective of their days of treatments. Overall mean serum T4 concentration of male and female rats was significantly low in HR and HDS groups as compared to normal rats irrespective of their days of treatments during winter. During summer overall serum thyroxin concentration was significantly low in HR and HDS groups as compared to normal male rats irrespective of their days of treatments. In contrast in female the overall mean serum T4 concentration did not differ significantly between CC, HR and HDS groups irrespective of their days of treatments.  In conclusion it is evident that weightlessness of male and female for 28 days did decrease the thyroid activity significantly during winter and summer while during summer female did not show any alteration in thyroid hormones.

 

Nothing to Disclose: ZUR, KMS, SA, FA

19784 1.0000 THR-061 A Effect of Weightlessness on the Thyroid Hormones 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Farheen Asad*1, Muhammad Zaffar Ullah Saleemi2, Munir Ahmad Sheikh2 and Zia Ur Rahman2
1Govt. Collage for Women, Jaranwala, Faisalabad, Pakistan, 2University of Agriculture, Faisalabad, Pakistan

 

It has been reported that incidence of diabetes and hypertension is low in Japanese and Latin people and phenolic structure of thyroid hormones particularly high concentration of serum TSH causes oxidative stress that leads to after cholesterol level and DNA damage to vascular tissue and hence increases coronary artery diseases (CVD). In this study, we aimed to study the role of serum thyroid hormone in CAD with patient suffering from diabetes and hypertension. As abnormal serum thyroid hormones may lead to various forms of CVD and particularly subclinical hyptothyraidism has been known to cause coronary atherosclerosis (Duntas, 2002; Biondi and Kelin, 2004). Further (Garduno-Garcia et al., 2010; Jung et al., 2008) FT4 concentration near the upper limit was associated with metabolic markers in normal subject and with CAD. In the present study, fifteen (15) individuals in each group having male and female were taken as normal (N), with coronary artery disease (CAD), diabetic with CAD (D), hypertensive with CAD (H) and diabetic/ hypertensive with CAD (D/H). Blood was drawn from normal and CAD groups for harvesting serum to determine free T3 and T4, total T3 and T4 and TSH by ELISA. In diabetic with CAD, hypertensive with CAD and diabetic/hypertensive with CAD group did reveal that TSH level was high while total T3 and T4 were significantly low in male and female individuals. On the other hand, TSH serum concentration was high while free T3 was low (P≤0.05) and free T4 was high (P≤0.05). Low T3 is depicted for in poor progressive of patients suffering CVD. Thyroid hormones through their phenolic group can per se is involved as oxidants and causes DNA-damage Serum total oxidant capacity, C-RP, ceruloplasm, GSH reductase, GSH peroxidase, homocysteine, lipid peroxidase concentration were significantly increased in diabetes, hypertensive and diabetes/ hypertensive patients with CAD. Above all these variations vary in their intensity and may be related to gender related hormones as well duration and intensity of the diabetic, hypertensive and diabetic/hypertensive individuals. Also contributed by the duration of the treatment and care taken by the individual patients itself.  It is concluded that pro-oxidant in the hypothyroid environment may have been responsible in the progression of atherosclerosis.

 

Nothing to Disclose: FA, MZUS, MAS, ZUR

19798 2.0000 THR-063 A Thyroid Hormones in Coronary Artery Disease with Diabetes and Hypertensive Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Alexis G Grimaldi1, Nicolas Buisine1, Vincent Jonchere1, Adeline Couve2, Corinne Blugeon2 and Laurent M. Sachs*1
1Muséum National d'Histoire Naturelle, Paris, France, 2ENS Paris, Paris, France

 

Amphibian metamorphosis is the fast, post-embryonic, and irreversible process by which an aquatic tadpole switches to an air-breathing lifestyle by transforming into an adult frog. This dramatic ecological transition comes with spectacular modifications allowing the individual to change its diet, locomotor organs, and respiratory system. This complex process is regulated by thyroid hormones (TH), which have also been shown to govern post-embryonic remodeling in most chordates. However, TH do not act alone. In particular, glucocorticoids (GC) play important roles during this process. GC are known to be involved in proper timing of metamorphosis, they are also one of the main mediator of the stress response. Thus, the physiological processes of metamorphosis and stress coping are very much intertwined. Indeed, depending on its developmental stage, the metamorphosis of a stressed tadpole can be either delayed or accelerated, making GC an important interface between environmental cues and a spontaneous developmental process such as Anuran metamorphosis. Additionally, stress during metamorphosis might induce modifications of key genes expression, and potential phenotype propagation to adult forms, highlighting its importance in driving adaptation to fluctuating environments. In order to probe the effects of TH, GC, and the crosstalk between these two hormones on the transcriptome of hind-limbs, we performed systematic sequencing of RNA (RNA-Seq). The RNA-Seq analysis suggest a robust regulatory networks for limb development. We found that TH and GC crosstalk is mediated by a limited diversity of transcriptional responses. The biological functions affected by crosstalk are mostly related to extracellular matrix remodeling and the immune system. However, the crosstalk also affects expression of a restricted number of genes, mostly involved in skeletal development and homeostasis and thus causing the appearance of phenotype.

 

Nothing to Disclose: AGG, NB, VJ, AC, CB, LMS

19731 3.0000 THR-064 A Glucocorticoids Affect Gene Regulation By Thyroid Hormones during Limb Development in Xenopus Tropicalis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Kaleb Fischer Short*, Jessa Gute, Brennan Nygaard, Penny Knoblich and David S Sharlin
Minnesota State University Mankato, Mankato, MN

 

Low thyroid hormone (TH) in adulthood is associated with increased risk of cardiovascular disease, including risk of hypertension. The Spontaneously Hypertensive Rat (SHR), exhibits alterations in thyroid function when compared to normotensive controls. Interestingly, inhibiting thyroid gland function before 4 weeks of age prevented hypertension in the SHR, indicating that TH is involved in the etiology of SHR hypertension. However, these studies utilized tail-cuff photoplethysmography (PPG), which is known to have stress-induced artifacts, and did not compare effects in the normotensive parent strain WKY.  Therefore, it is uncertain whether TH is responsible for an elevation in baseline blood pressure or whether hypertension in the SHR is caused by abnormal TH action in the cardiovascular system. It is hypothesized that hypertension in SHR is caused, in part, by abnormal thyroid hormone action in the cardiovascular system. To study the effect of thyroid hormone on blood pressure, we inhibited TH production in WKY and SHR male rats with 1% KClO4 and 0.05% MMI in drinking water from 4-15 weeks-of-age. Blood pressure was monitored weekly by tail-cuff PPG from 4-15 weeks and by implantable remote transmitters from 11-14 weeks. Urine sodium excretion was evaluated in response to an artificial rise in blood pressure using flame photometry.  Tail-cuff analysis confirmed previous reports that indicated hypothyroidism induced at 4 weeks of age prevents hypertension in SHR and that the observed reduction was greater than that seen in WKY.  However, remote monitoring demonstrated a comparable reduction in systolic arterial pressure between hypothyroid SHR and hypothyroid WKY versus their respective euthyroid controls (SHR, 164.5±1.7mmHg vs.136.3±4.1mmHg; WKY, 121.0±4.6mmHg vs. 91.6±1.7mmHg).  Remote monitoring also indicated that mean arterial pressure and diastolic arterial pressure were significantly reduced in hypothyroid WKY (81.8±2.1mmHg vs.103.1±3.2mmHg; 71.6±2.5mmHg vs. 87.85±2.1mmHg; respectively), but not in SHRs. These observations demonstrate inhibiting thyroid gland function does not prevent the development of hypertension in SHR as previously reported. Additionally, heart rate was significantly reduced in both hypothyroid WKY rats and SHRs compared to respective controls (WKY, 302.7±7.3mmHg vs. 357.1±4.7bpm; SHR, 292.8±5.3mmHg vs. 335.5±5.7bpm).  Lastly, both hypothyroid SHR and WKY were found to have significantly elevated sodium excretion during baseline and during a rise in mean atrial pressure when compared to controls. Together, these results indicate that the effect of low TH on blood pressure is multifaceted. The observed bradycardia and increased sodium excretion also suggest a reduction in sympathetic tone.

 

Nothing to Disclose: KFS, JG, BN, PK, DSS

21071 4.0000 THR-065 A A Comparison of the Effect of Hypothyroidism on Blood Pressure of the Wistar Kyoto (WKY) Rat and the Spontaneously Hypertensive Rat (SHR) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Aniket Sidhaye*1 and Fredric Edward Wondisford2
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins University School, Baltimore, MD

 

Maintenance of circulating thyroid hormone levels within a narrow range is important for normal whole body homeostasis and is accomplished by a negative feedback system involving the hypothalamus, pituitary and thyroid gland.  Our group is interested in developing a more complete mechanistic model for thyroid hormone down-regulation of thyrotroph Tshb mRNA levels.  The mouse thyrotroph cell line TalphaT1.1 may be a useful model system to carry out more mechanistic studies of thyroid hormone action in thyrotrophs. For example, others have shown that these cells demonstrated dose dependent down-regulation of Tshb in response to thyroid hormone as well as to rexinoids. We have shown that shRNA mediated knock-down of Thrb blocks T3 mediated down-regulation of Tshb, recapitulating the resistance to thyroid hormone phenotype in Thrb knock-out mice. Based on these data, we sought to identify novel thyroid hormone regulated genes in thyrotrophs, using the TalphaT1.1 cells system. Briefly, cells were incubated in DMEM with 10% charcoal-resin stripped serum for 24 hours and then treated overnight with either vehicle or T3 (10nM) after which total RNA (Trizol and RNAeasy) was harvested.  After verifying RNA integrity, samples were submitted to the SKJCC microarray core facility where mouse Agilent 4X44K array plates were used for microarray hybridization, wash, stain, and scan. Differential gene expression was analyzed to identify genes up-regulated by a co-efficient of +0.7 to -0.5 (log 2 scale) with an adjusted p-value of <0.005 and FDR of < 0.05.  This preliminary analysis yielded 11 down-regulated genes and 40 up-regulated genes.             To confirm the findings from microarray data analysis we performed qPCR to validate a small subset of genes confirming up-regulation (Agrp, PDE2a, Rab27, Cxcr7 and Sema3c) and down-regulation (Dio2, Otor, Tshb, and  Rxrg) identified by microarray hybridization.  Our preliminary analysis suggests that amongst annotated genes Agrp up-regulation was the strongest signal. Others have shown the effect of Agrp signaling to suppress hypothalamic Trh. To our knowledge this data is the first suggestion that T3 regulates Agrp mRNA levels.  In summary we believe that this analysis will help provide data for further more detailed studies of thyroid hormone action in the HPT-axis.

 

Nothing to Disclose: AS, FEW

21574 5.0000 THR-066 A Microarray Analysis in a Mouse Thyrotroph Cell Line Reveals Potential Novel Thyroid Hormone Regulated Genes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Hao Ying*
Institute for Nutritional Sciences, SIBS, CAS, Shanghai, China

 

Thyroid hormone (TH) plays important roles in growth, differentiation, and metabolism. The TH actions are mainly mediated through its receptors (TRs), which are transcriptional factors. It is known that TH positively regulates de novo hepatic lipogenesis. However, the increase of de novo lipogenesis by TH actually will not lead to abnormal lipid accumulation. The underlying molecular mechanisms are not very clear. MicroRNAs (miRNAs) are small non-coding RNAs (~22 nucleotidies) that regulate target gene expression post-transcriptionally. Whether miRNAs are involved in the metabolic regulation by TH in liver remains unclear. To identify TH-regulated miRNAs in liver, we performed miRNA array to analyze the miRNA expression in the liver of hypothyroid mice and hypothyroid mice receiving TH treatment for five days. The array data showed that miR-378 expression was elevated after TH treatment for five days in the liver of hypothyroid mice. This result was further confirmed by real time RT-PCR. To test whether miR-378 also plays a role in the regulation of hepatic lipid metabolism in the presence of TH, we infected the hypothyroid mice with adenoviral miR-378 before TH treatment. Interestingly, we found that miR-378 negatively regulated the expression of lipogenic gene expression (acetyl-CoA carboxylase 1 and fatty acid synthase) regardless of the thyroid status. Similar results were obtained in primary hepatocytes. Consistently, we observed that lipogenic gene expression was increased when the expression of hepatic miR-378 was inhibited by antagomiRNA in primary hepatocytes. Taken together, we proposed that miR-378 is a negative regulator of hepatic lipogenesis and induction of miR-378 by TH could prevent lipid accumulation when de novo lipogenesis is activated by TH.

 

Nothing to Disclose: HY

19863 6.0000 THR-067 A The Role of Hepatic Mir-378 in the Metabolic Regulation By Thyroid Hormone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Angelica Amorim Amato*1, Juliana Fattori2, Ana Carolina Mancusi Valeije3, Paulo Oliveira3, Ana Carolina Migliorini Figueira3, Guilherme Martins Santos4 and Francisco de Assis Rocha Neves1
1University of Brasilia, Brasilia, Brazil, 22 Spectroscopy and Calorimetry Laboratory, LNBio, Campinas, Brazil, 3Spectroscopy and Calorimetry Laboratory, LNBio, Campinas, Brazil, 4Molecular Pharmacology Laboratory, University of Brasília, Brasilia, Brazil

 

Background: a number of clinical studies have linked subclinical and overt hypothyroidism to low-grade systemic inflammation and increased risk of cardiovascular disease. Although the effects of thyroid hormone (TH) on lipid and vascular homeostasis are well established, these clinical findings raise the question whether TH could be also directly implicated in modulating the inflammatory response. 

Methods and results: Using reporter gene assays we found that both unliganded TRβ1 and TRα1 activated TNFα promoter, and T3 significantly repressed its activity in a concentration-dependent manner. We also observed that, T3-dependent negative regulation of TNFα promoter by T3 required the receptor’s DNA binding domain on the region between -125 and -82 of TNFα promoter. Anisotropy fluorescence assays supported this finding, indicating that both TRa and TRb bind with high affinity to the region between -125 and -82 of TNFα promoter, in a ligand-independent manner. In silico screening of full TNFα promoter (-1044 to +93) for TR binding sites indicated high affinity binding of TR-RXR heterodimer for a DR3 element in the promoter. Chromatin immunoprecipitation experiments confirmed that TRa was present on TNFa promoter under basal conditions, and was cleared following T3 stimulation. 

Conclusions: Our results indicate that T3-dependent negative regulation of TNFα promoter involves the displacement of TR from the DNA, suggesting that TH might directly regulate the inflammatory response. It is possible that this effect represents and additional mechanism to explain the proinflammatory state seen in TH deficiency.

 

Nothing to Disclose: AAA, JF, ACMV, PO, ACMF, GMS, FDARN

21489 7.0000 THR-068 A Regulation of Tumor Necrosis Factor Alpha Promoter By Thyroid Hormone Receptor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Ching-Ying Chen*1 and Kwang-Huei Lin2
1Chang Gung University, Tao-Yuan, Taiwan, 2Chang Gung University, Taoyuan, Taiwan

 

Thyroid hormone (T3) regulates growth, development, and differentiation. These activities are mediated by the nuclear thyroid hormone receptors (TRs), which belong to the steroid/TR superfamily of ligand-dependent transcription factors. Recent studies have demonstrate critical roles of T3/TR in tumor progression. The effect of T3 treatment on target gene regulation was investigated in a TRα1-overexpressing hepatoma cell line, by performing cDNA microarrays. Approximately 148 of 7600 genes (1.9%) were positively regulated by T3. Among them are several transcription factors including COM1. COM1 is a stress-induced protein with multiple functions and bio-chemically related to the architectural factor HMG-I/Y. To confirm the microarray results, COM1 was further investigated using quantitative RT-PCR. The T3-induction ratios observed by quantitative RT-PCR were 50-fold after 48 h of T3 treatment. Furthermore, using northern blot analyzed HepG2-TRα1 cell lines, revealed a 6.7-fold induction of COM1 transcription after 48 h of T3 treatment (compared with 6h of T3 treatment). In addition, the expression level of COM1 protein was increased in time and dose dependent manner in HepG2-TRα1 cell after T3 treatment. Similar results were observed on the regulation of COM1 by T3 using the thyroidectomized (TX) rats as an in vivo model. Using 80 paired clinical hepatoma sample, COM1 mRNA expression level were upregulated in cancerous tissues (80%).  The overall survival rate of the lower COM1 expression group was significantly better than that of the higher expression group. Serial deletion mutants were constructed from the COM1 fragment to identify the region binding by TR. Using luciferase reporter assay as well as ChIP assay indicated the -2344/-1996 region was targeted by TR on COM1 promoter. The gain-of-function studies showed that COM1 is capable of enhancing metastatic potential of hepatoma cells. Taken together, this study demonstrate that COM1 expression level is upregulated by T3/TR and might play an important role in hepatoma progression.

 

Nothing to Disclose: CYC, KHL

18839 8.0000 THR-069 A Expression and Regulation of COM1 By Thyroid Hormone Receptor in Human Hepatoma Cell Lines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Brenda J. Mengeling* and J. David Furlow
UC Davis, Davis, CA

 

The essential role of thyroid hormone (TH) signaling to initiate amphibian metamorphosis through thyroid hormone receptor (TR) transcriptional regulation is well known. With a few exceptions, the role of retinoid X receptors (RXR), the principle heterodimer partner of TRs, has been that of “silent partner,” where ligand binding by the RXR does not effect the transcriptional output of the TR-RXR heterodimer. We adapted an in vivo, precocious metamorphosis assay in one-week old Xenopus laevis tadpoles to validate and characterize potential TR active “hits” from an in vitro, high-throughput screen. We discovered that both synthetic RXR agonists and environmental contaminants that can bind RXRs, such as organotins, greatly potentiated the morphological changes associated with metamorphosis, such as Meckel’s cartilage extension, brain expansion, and tail resorption. Furthermore, these changes were abrogated by exposure to RXR antagonists in lieu of the agonists. The RXR agonists had no observable effect on tadpole morphology in the absence of TH, demonstrating their effect depended upon coincident TH exposure. Gene regulation analysis showed that TR target genes like Collagenase 3, which is involved in cartilage remodeling and resorption, were not activated by RXR agonist alone but showed potentiated activation when tadpoles were exposed to RXR agonist in addition to TH, compared to exposure to TH alone. In agreement with our morphological data, RXR antagonists abrogated TH induced target gene activation. Taken together, these data strongly suggest that RXR may be a far less “silent partner” in TH signaling than previously thought, and that endocrine disruption of RXR signaling may have profound effects on TH signaling.

 

Nothing to Disclose: BJM, JDF

21247 9.0000 THR-070 A RXR Agonists Potentiate and RXR Antagonists Block Thyroid Hormone Induced Precocious Metamorphosis in Xenopus Tadpoles 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Poupak Fallahi1, Roberto Vita2, Stefania Camastra1, Ilaria Ruffilli1, Salvatore Benvenga2, Alessandro Antonelli*1 and Silvia Martina Ferrari1
1University of Pisa, Pisa, Italy, 2University of Messina, Messina, Italy

 

After bariatric surgery, drug malabsorption constitutes one of the potential troubles.

In the present work, we report 10 cases of hypothyroid patients (7 females, 3 males; age 34-57 years) who were well replaced with thyroxine tablets (for >1 year) to euthyroid thyrotropin (TSH) levels before surgery (7 Roux-en-Y gastric bypass; 3 biliary pancreatic diversions).

From 2 to 7 months after surgery, these patients presented elevated TSH levels. Patients were then switched from oral tablets to a liquid formulation of Levo-thyroxine (with the same dosage, 30 minutes before breakfast). TSH was evaluated after 1-3 months after the switch and it significantly reduced: a- gastric bypass, from 5.2±3.9 to 2.4±2.5 μIU/mL, p<0.05; b- biliary pancreatic diversion, from 7.7±1.7 to 4.1±1.8 μIU/mL, p<0.05). These data suggest that the Levo-thyroxine oral liquid formulation could prevent the problem of the malabsorption after bariatric surgery.

 

Nothing to Disclose: PF, RV, SC, IR, SB, AA, SMF

20898 10.0000 THR-071 A Serum TSH Levels Normalized in Patients Undergone to Bariatric Surgery after Switching from Levo-Thyroxine in Tablet Form to an Oral Liquid Formulation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Poupak Fallahi, Riccardo Giannini, Silvia Martina Ferrari, Fulvio Basolo and Alessandro Antonelli*
University of Pisa, Pisa, Italy

 

Thyroid nodules are routinely evaluated by fine needle aspiration (FNA). However, in approximately 30% of the cases, the results are inconclusive. Because the assessment of BRAF mutations seems to improve diagnostic accuracy, we evaluated BRAF mutations in 650 consecutive thyroid FNA to clarify the role of this gene as a molecular diagnostic marker of thyroid nodules malignancy.

Additionally, we studied the expression of a large number of genes involved in basement membrane (BM) remodeling, extracellular matrix (ECM) proteolysis and in cell adhesion in both benign and malignant nodules with hopes of identifying new diagnostic tools.  

In this prospective series, we observed that despite the use of a very sensitive BRAF mutational testing method, the frequency of a BRAF alteration identified in undetermined Thy3 FNA samples was very low (2 out of 68).

Expression analysis revealed several genes that were differentially expressed between benign and malignant nodules (Transforming growth factor, Cadherin1, Collagen alpha1, Catenin alpha1, Integrin alpha3 and Fibronectin1), between follicular adenomas and follicular variant of papillary thyroid carcinomas (PTCs) (Fibronectin1, Laminin gamma1, Integrin beta2, Connective tissue growth factor, Laminin beta3, Catenin delta1 and Integrin alphaV) and between BRAF wild type and BRAF mutated PTCs (Secreted phosphoprotein1, Catenin alpha1, TIMP metallopeptidase inhibitor1, fibronectin1, ADAM metallopeptidase with thrombospondin type 1 motif 1 and SelectinL).

In conclusion, taking into account the cost benefit ratio of the procedures, BRAF mutational testing fails to increase diagnostic accuracy in undetermined Thy3 FNAs. However, the additional analysis of the expression of specific molecular markers could have possible utility as a diagnostic tool, although further evidence based on large series of samples is needed before definitive conclusions can be proposed.

 

Nothing to Disclose: PF, RG, SMF, FB, AA

20930 11.0000 THR-072 A Braf Genotyping and Expression Profiling of a Consecutive Large Series of Thyroid Fine Needle Aspiration Cytology Samples 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Silvia Martina Ferrari, Andrea Di Domenicantonio, Alda Corrado, Alessandro Antonelli* and Poupak Fallahi
University of Pisa, Pisa, Italy

 

In patients with lactose intolerance L-T4 malabsorption is often present, and usually high L-T4 doses in the substitutional treatment of hypothyroidism are necessary. We report reversible normalisation of serum TSH levels in five patients with lactose intolerance who received L-T4 in tablet form after switching to an oral liquid formulation lactose free.

After switching from oral tablets to a liquid formulation (with the same dosage, 30 minutes before breakfast) TSH was significantly reduced (TSH, evaluated 1-3 months after the switch, decreased: from 7.1±3.1 to 3.3±2.4 μIU/mL, p<0.05). The return back to tablets (with the same dosage, 30 minutes before breakfast) caused thyrotropin levels to worsen. This result leads us to believe that the absorption of oral liquid formulation of thyroxine is greater in these patients.

The result that the change from tablets to liquid oral formulation normalised serum TSH levels, and that switching back to tablets caused thyrotropin levels to worsen, leads us to believe that absorption of thyroxine is greater with oral liquid formulation in these patients.

These data suggest that the L-T4 oral liquid formulation could prevent malabsorption in patients with lactose intolerance.

 

Nothing to Disclose: SMF, AD, AC, AA, PF

20939 12.0000 THR-073 A In Patients with Lactose Intolerance Oral Liquid L-Thyroxine (L-T4) May be Better Absorbed Compared to L-T4 Tablets 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM THR 060-70 6104 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Stephanie Degroote*, Darel Hunting and Larissa Takser
University of Sherbrooke, Sherbrooke, QC, Canada

 

BACKGROUND: Epidemiological data suggests that prenatal exposure to either phthalates or flame retardants can affect mental and motor development, and can provoke internalizing behavior and attention deficit. We hypothesize that the simultaneous exposure to low-dose phthalates and flame retardants, which are endocrine disruptors, can alter brain development and lead to Autism Spectrum Disorders (ASD).

OBJECTIVE: To characterize behavior relevant to ASD feature in rat offspring exposed prenatally to a mixture of low-dose phthalates and flame retardants (DEHP, DBP, DiNP, BDE-47, BDE-99).

METHODS: Pregnant Lewis rats were divided in three groups: negative control, exposed to the mixture of endocrine disruptors, and a positive control for autistic feature in rat well-established in the literature, the valproic acid induced model of autism. Following prenatal exposure by daily gavage, behavioral tests were administered to offspring: nest-seeking behavior, auditory startle reflex, open field, elevated plus maze, prepulse inhibition and test of social interactions.

RESULTS: Offspring exposed to the mixture of phthalates and PBDEs showed hyperactivity and altered sensorimotor gating, and males specifically had lower maternal bonding and feminization in their social behavior. Three of five dams exposed to valproic acid did not have delivery, and offspring from the two remaining dams had a general developmental delay associated to their autistic features.

CONCLUSIONS: Low-dose phthalates and flame retardants exposure provoke alterations in all behaviors tested relevant for autistic features. The dosage of valproic acid used for the rat model of autism provokes teratogenicity and dosage should be diminished in order to have a more specific behavioral model of autism.

 

Nothing to Disclose: SD, DH, LT

19355 1.0000 THR-290 A Perinatal Exposure to a Mixture of Common Low-Dose Phthalates and Flame Retardants Leads to Autistic Features in Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Laura Tapella1, Antonella Sesta2, Marco Losa3, Francesco Cavagnini2 and Francesca Pecori Giraldi*4
1University of Milan, Milan, Italy, 2Istituto Auxologico Italiano IRCCS, Cusano Milanino, Italy, 3Ospedale San Raffaele, Milan, Italy, 4Dept. Clinical Sciences & Community Health, University of Milan & Neuroendocrine Research Laboratory, Istituto Auxologico Italiano IRCCS, Milan, Italy

 

An increased prevalence of acromegaly and pituitary tumors has recently been observed in high industrial density areas (Cannavò 2010) or after dioxin exposure (Pesatori 2008).  These data as well as vitro studies on endocrine disruptors (EDs) suggest that environmental pollutants may affect hormonal secretion and pituitary cell proliferation (Dang 2009; Dang 2009; Dang 2007; Maruyama 1999; Elango 2006; Blake 1997; Wilson 1998). The aim of our study was to verify the effect of endocrine disruptors on rat pituitary and human pituitary adenoma proliferative activity. Methods: Pituitary primary cultures were incubated with 250 pM – 1.25 nM phenol or bis-(2-ethylhexyl)-phthalate for 24 and 96 hours. Cell viability, apoptosis and proliferation were assessed by ATP lite (Perkin Elmer, USA), MTT assay (Sigma, USA), Caspase 3-7 (Promega, USA) and 5-bromo-2'-deoxyuridine labeling (BrdU-labeling; Roche, Switzerland). Results: In rat pituitary primary cultures, ATP cell content was reduced by phenol (100±2 vs. 75.3±3.4%, p<0.0001,  control vs. treatment) and bis-(2-ethylhexyl)-phthalate (100±2 vs. 83.2± 3.1%, p<0.0001) at 24h. After 96h, ATP was clearly increased by phenol (100±2 vs. 123.9±7%, p<0.05, control vs. treatment), less by bis-(2-ethylhexyl)-phthalate (100±2 vs. 111.4±13%, N.S.). BrdU-labeling and MTT were also increased at the latter timepoint (BrdU-labeling: 100±12 vs. 136±12%, p<0.05, and 100±12 vs. 137±8%, p<0.05, for phenol and bis-(2-ethylhexyl)-phthalate, respectively; MTT: 100±4 vs. 118±5%, p<0.05 and 100±4 vs. 123±10%, p<0.05, for phenol and bis-(2-ethylhexyl)-phthalate, respectively). No changes in caspase activation were observed at 24h or 96h. In two human GH-secreting primary adenomas, ATP content was increased by 40% and 100%, respectively, after 24h incubation with 650 pM phenol. Conclusions: Our findings show than phenol and bis-(2-ethylhexyl)-phthalate initially reduce then increase pituitary cell energy content; further, long-term incubation with EDs is associated with increased cell proliferation. This study indicates that both normal and adenomatous pituitary cell proliferation is modulated by endocrine disruptors, thus supporting the role of pollutants in pituitary adenoma etiology.

 

Nothing to Disclose: LT, AS, ML, FC, FP

19778 2.0000 THR-291 A Effect of Phenols and Phthalates on Rat and Human Pituitary Cell Proliferation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Jessica F Briffa*1, Andrew J Jefferies1, Tania Romano2, Andrew J McAinch3, Karen M Moritz4, Mary E Wlodek1 and Deanne H Hryciw1
1The University of Melbourne, Victoria, Australia, 2La Trobe University, Victoria, Australia, 3Victoria University, Victoria, Australia, 4University of Queensland, Queensland, Australia

 

Uteroplacental insufficiency is the leading cause of growth restriction in the Western world. Being born small alters renal development and reduces nephron endowment increasing the risk of developing adult cardio-renal disease. Previous research has demonstrated that leptin antagonism in rats during early postnatal (PN) life reduces nephron number and glomerular size, suggesting that leptin plays a role in renal development. However, the effect uteroplacental insufficiency has on offspring plasma leptin concentrations during nephrogenesis is unknown. To study the effect uteroplacental insufficiency has on offspring plasma leptin concentrations and renal leptin mediated signaling pathways, female WKY rats underwent either sham surgery or bilateral ligation of the uterine vessels (n = 6 - 8/group) at embryonic day 18 (E18; term = E22). Post mortem of offspring and mothers were performed at E20, PN1, PN7 and PN35. Offspring and maternal blood was collected at each time point for plasma leptin ELISA analysis and offspring kidneys were collected for ‘real – time’ PCR analysis of leptin transporters (leptin receptor (ObR) and megalin) and their signaling mediators (JAK2, STAT3, STAT5a, SOCS3, AMPKα, AMPKβ, Akt3, mTOR and PI3K). Growth restriction reduced male and female offspring body weight (E20, PN1 and PN7), with a decrease also present in males at PN35 (P < 0.05). Growth restriction decreased male and female offspring plasma leptin concentrations (PN1 and PN7), with a reduction also observed in females at E20 and PN35 (P < 0.05). Conversely, plasma leptin concentrations were increased in restricted mothers (PN1 and PN7) (P < 0.05), possibly as a compensatory mechanism. Interestingly, body weight to kidney weight was lower in restricted offspring (PN1), and an increase was observed in female restricted offspring at PN7 (P < 0.05). Growth restriction increased the expression of ObR (PN35), JAK2 (PN1 and PN7), STAT3 (PN7), AMPKβ (PN1, PN7 and PN35) and Akt3 (PN35), and decreased megalin (PN7) and Akt3 (E20) expression in males (P < 0.05). Conversely, growth restriction increased the expression of SOCS3 (PN1 and PN35) and Akt3 (PN35), and decreased megalin (PN1 and PN35), STAT3 (PN35), PI3K (PN1 and PN7) and AMPKα (PN35) expression in females (P < 0.05). We have demonstrated that growth restricted offspring have reduced plasma leptin concentrations in a sex-specific manner, despite an elevated maternal plasma leptin concentration. Additionally, we quantified changes in leptin signaling pathways in the kidney in growth restricted offspring in an age-dependent and sex-specific manner. As leptin is suggested to play a role in kidney development, it is possible that the alterations in offspring plasma leptin concentrations and leptin signaling may be a mechanistic pathway impairing nephrogenesis in restricted offspring increasing their risk of cardio-renal disease in adulthood.

 

Nothing to Disclose: JFB, AJJ, TR, AJM, KMM, MEW, DHH

20755 3.0000 THR-292 A Uteroplacental Insufficiency in Rats Reduces Offspring Plasma Leptin Concentrations and Alters Leptin Signaling Mediator Expression in the Kidney in a Sex-Specific Manner 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Sung-Ho Lee*1, Da Kyung Yoo2, Hye Rim Byeon2 and Eun Young Jeon2
1Sangmyung University, Seoul-City, Korea, Republic of (South), 2Sangmyung University, Seoul, Korea, Republic of (South)

 

Methoxychlor(MET) is an organochlorine insecticide that causes endocrine disorders. The present study was undertaken to examine whether prepubertal exposure to MET effects on the onset of puberty and the associated reproductive parameters such as hormones and their receptor expressions in female rats.

MET(1, 10, and 100mg/kg/day) was administered(oral gavage) daily from postnatal day 25(PND 25) through the PND 34, and the animals were sacrificed on the last day of administration. The first V.O. day was monitored, and the weights of reproductive tissues were measured. To assess the structural alterations in the ovary and uterus, the tissues were embedded in paraffin and stained for histological analysis. The transcriptional activities of hypothalamus(GnRH, Kisspeptin, GnIH, GPR147, ERα and ERβ,) and pituitary(LH, FSHβ, ACTH and GH) were measured using quantitative RT-PCRs.

As a result, 100mg group showed advanced V.O. than control, 1mg group and 10mg group. The wet weight of ovaries from MET-treated animal were increased dose-dependently. The weight of uteri were increased at 1mg group and 10mg group, but 100mg group were not significantly different from control animals. However, adrenal, kidney, spleen and thymus weights were not shown any significant change. In the semi-quantitative RT-PCR studies, the levels of FSHβ, ACTH, GH in pituitary from 10mg group and 100mg group were higher than those from the control group. Corpora lutea and mature follicles were observed in the ovaries from the 100mg group, while numerous primary and secondary follicles were observed in the ovaries from control group. Thickness of myometrium from MET-treated group was dose-dependently increased. Hypotrophy of the glandular epithelium was observed only in the uterus from the 10mg groups.

The present study demonstrated that the acute exposure to MET during the critical period of prepubertal stage could activate a reproductive endocrine system resulting the early onset of puberty in immature female rats.

 

Nothing to Disclose: SHL, DKY, HRB, EYJ

21650 4.0000 THR-293 A Effect of Methoxychlor on the Onset of Puberty in Immature Female Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Christopher D Kassotis*1, Chung-Ho Lin2, Donald Tillitt3 and Susan Carol Nagel2
1Univ of Missouri, Columbia, MO, 2University of Missouri, Columbia, MO, 3United States Geological Survey, Columbia, MO

 

Hydraulic fracturing, in combination with horizontal drilling, is now being used to unlock previously inaccessible or unprofitable deposits of shale oil and natural gas. The hydraulic fracturing process involves the high-pressure injection of water, chemicals, and suspended solids several thousand feet under the surface to fracture shale or coal bed layers and release trapped natural gas or oil. More than 750 chemicals are reportedly used throughout the country, including many known or suspected endocrine disrupting chemicals (EDCs). Spills of wastewater associated with the process are common and have been shown to contaminate surface and ground water. We previously reported elevated estrogen and androgen receptor activities in surface and ground water near sites with known industry-related spills (1). We have also tested 24 chemicals used in hydraulic fracturing for EDC activity, 23 of which were capable of disrupting one or more receptors. Specifically, we have 21, 21, 10, 10, and 7 chemicals that can act to inhibit the estrogen, androgen, progesterone, glucocorticoid, and thyroid receptors, respectively.

Current work extends this to in vitro and in vivo studies of mixtures of chemicals used in hydraulic fracturing. Previous work has reported additivity of EDCs with the same mechanism of action, so several mixtures were tested in estrogen, androgen, thyroid, progesterone and glucocorticoid receptor reporter gene assays in human breast cancer cells to test this hypothesis: 1) 24 fracturing chemicals at equimolar concentrations, 2) nine chemicals at equimolar concentrations that our team has analytically measured in hydraulic fracturing wastewater, and 3) five different receptor-specific mixtures of chemicals at equipotent concentrations. This work has provided evidence of additive antagonist activity for several of these mixtures.

We have also tested a mixture of 23 chemicals in an in vivo mouse model. Pregnant C57 mice were administered the mixture in drinking water at 4 concentrations (spanning 3 orders of magnitude) from gestation day 11 through 18. Offspring were weighed and anogenital distance was assessed on postnatal day (PND) 7, and weights were monitored through PND 21. At PND 21, necropsies were performed on one male and female from each litter, with organ weights and tissue histology examined. Timing of puberty was assessed for all remaining animals through PND50, and a second collection of one male and female from each litter was performed on PDN85. Completion of these studies should substantially increase our knowledge of consequences of prenatal exposure to a complex mixture of hydraulic fracturing chemicals and of potential health risks associated with this process.

 

Nothing to Disclose: CDK, CHL, DT, SCN

18968 5.0000 THR-294 A Endocrine Disrupting Activity of Oil and Gas Operation Chemicals and Health Outcomes Following Gestational Exposure in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Sunni Mumford1, Rajeshwari Sundaram2, Kurunthachalam Kannan3, Germaine Buck Louis1 and Jennifer Weck*2
1Eunice Kennedy Shirver National Institute of Child Health and Human Development, Rockville, MD, 2Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, MD, 3Wadsworth Center, Albany, NY

 

Background:  Endocrine disrupting chemicals are reported to be associated with endometriosis.  A matched cohort design comprised 495 premenopausal women undergoing laparoscopies/laparotomies at 14 clinical sites between 2007-2009 (operative cohort) and 131 women sampled from the same geographic area who were matched on age and menstruation status (population cohort).  Previous work showed that persistent environmental pollutants (organochlorine compounds and select perfluorochemicals) and phthalates (quickly metabolized; anti-androgenic) were associated with disease state while there was no association between levels of urinary Bisphenol A (quickly metabolized; estrogenic) and endometriosis.

Objective: We assessed urinary concentrations of phytoestrogens (quickly metabolized; estrogenic) and incident endometriosis in the described study cohorts.

Design:  To assess endometriosis women in the population cohort underwent pelvic magnetic resonance imaging (MRI) while disease in the surgical cohort was the clinical gold standard of surgically visualized.  Levels of daidzein, enterodiol, enterolactone, equol, genistein, and O_DMA were quantified in urine (nmol/L).  Logistic regression analysis was used to estimate the odds of an endometriosis diagnosis for each cohort after adjusting for age and body mass index.   Separate models were run for each phytoestrogen.

Results:  Geometric mean concentrations of phytoestrogens were not significantly different by endometriosis status in either cohort.  Adjusted odds ratios (95% confidence intervals) for endometriosis ranged from 0.98 to 1.03 for the 6 phytoestrogens measured, with all confidence intervals including one.  No associations were observed even when restricting the analysis to women with rASRM moderate/severe staged disease.  No associations were observed between self-reported high soy intake and disease.

Conclusion: Despite endometriosis being an estrogen-dependent disease, we found no evidence that urinary phytoestrogens were associated with a higher odds of an endometriosis diagnosis.  As the estrogenic BPA was also not associated with disease incidence while anti-androgenic phthalates were, further investigation into the mechanisms of biologically relevant amounts of these endocrine disruptors, particularly in the context of exposure to persistent environmental chemicals, is warranted.

 

Nothing to Disclose: SM, RS, KK, GBL, JW

22055 6.0000 THR-295 A Phytoestrogens and Endometriosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Jae-Hwan Lee*1, Myoungho Lee2, Kipung Kim2 and Eui-Bae Jeung2
1Chungdaero-1, Cheongju, Korea, Republic of (South), 2Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South)

 

Introduction :. Oxygen, carbon dioxide, calcium, copper, iron, and glucose are essential factors in fetal growth. These molecules are transferred by specific receptors located on cell membrane or cytoplasm in placenta. Cation (e.g. calcium, copper, iron, etc.) transfer genes are regulated by estrogen, vitamin D, and human placental lactogen. During pregnancy, expression of these receptors is controlled by the nutritional status of the maternal and fetal. Some synthetic plastics contain endocrine disrupting chemicals (EDCs), which have similar structures to steroid hormones or endogenous hormones related to reproduction. These substances disturb action of reproduction-related hormones (e.g. estrogen, progesterone) by interacting with their receptors, or affecting the expression of transporting genes for cations. Method : We used a human trophoblast cell line (BeWo cells) to test the impact of EDCs during pregnancy. We used well-known EDCs and applied different doses of octyl-phenol (OP; 10−7, 10−6, and 10−5M), nonyl-phenol (NP; 10−8, 10−7, and 10−6M), and bisphenol A (BPA; 10−7, 10−6, and 10−5M) in BeWo cells for 48 h. Ethinyl estradiol (EE), which activates estrogen receptors, was used as a positive control. Result :. EDCs have been known to interfere with the endocrine system through various mechanisms. Treatment with OP, NP, or BPA in a human trophoblast cell line (BeWo cells) affected expression of calcium transporting genes (PMCA1, TRPV6), copper transporting genes (CTR1, ATP7A), and iron transporting genes (IREG1, HEPH) like positive control, EE. When EDCs were treated by concentration, expression of the gene could be determined. To clarify the effects of EDCs mediated by estrogen receptor, ICI 182 780 was treated as an estrogen receptor antagonist. A control group was treated with EE 10-8M, OP, NP, and BPA 10-6M, and an experimental group was treated with addition of EE 10-8M, OP, NP, and BPA 10-6M after treatment with ICI 182 780 10-6M. Expression of the gene was confirmed in the control group and the experimental group. Conclusion : Therefore, we proposed that tested EDCs act as estrogen-like chemicals and regulate essential cation transporters in placenta.

 

Nothing to Disclose: JHL, ML, KK, EBJ

19781 7.0000 THR-296 A Impact of EDCs on Placental Transporters in Human Placental Bewo Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Kieun Kim*1, Youn-Ho Shin2, Sang-Yong Eom3, Yu-Mi Kim4, Yong-Seoub Hong5, Hee-Soo Pyo6, Seok-Joon Sohn7, Jung-Duck Park8, Byung-Sun Choi8 and Hye-Jung Shin9
1CHA Gangnam Medical Center CHA University, Seoul, Korea, Republic of (South), 2CHA Gangnam Medical Center CHA University, Seoul, 3Chungbuk National University, Cheongju, 4Dong-A University, Busan, 5Dong-A University, BUSAN, 6Korea Institute of Science and Technology, Seoul, 7Chonmam National University, Gwangju, 8Chung-Ang University, Seoul, 9National Medical Center, Seoul, Korea, Republic of (South)

 

The industry environmental pollution threatens humans and nature world widely over a century and recently metabolic or endocrine disorders in youths are rapid increasing in Korea.We examined the exposures of heavy metals such as lead, cadmium, mercury, and the effects on adiposity and pubertal development in Korean children and adolescents.We analyzed the nationwide data of 551 subjects aged 8-15 years (boys 281 and girls 270) who were enrolled in this study from 2010-2011. Waist circumference (WC), hip circumference (HC), blood pressure of subjects and body mass index (BMI) and W/H ratio were examined and pubertal development by parents report was estimated. We measured serologic markers, blood Pb, Cd, Hg, and verified the associations between blood heavy metals levels and metabolic risks, and onset age of pubertal development.

Blood lead level was increased in boys (boys vs girls, median 1.49 μg/L vs 1.23μg/L; p<0.0001), cadmium level was higher in girls than boys (boys vs girls, median 0.28 μg/L vs median 0.31μg/L, p=0.0415).  BUN, Cr, day urine Cr, AST/ ALT, gamma GTP were increased in boys (p<0.001, respectively), however total cholesterol and LDL Cholesterol were higher in girls than boys (p<0.0001, respectively).  In boys, mercury concentration was positively associated with BMI (r=0.139, p<0.05), WC (r=0.223, p<0.01), HIP C (r=0.257, p<0.01) and systolic blood pressure (r=0.191, p<0.05), and cadmium concentration was positively associated with WC (r=0.224, p<0.01), HC (r=0.208, p<0.01), systolic BP (r=0.130, p<0.05). However, blood lead level was associated with lower WC (r=-0.128, p<0.05), lower HC (r=-0.122, p<0.05). In girls, cadmium level was associated with higher BMI (r=0.024, p<0.01), WC (r=0.28, p<0.01), HC (r=0.279, p<0.01) and systolic BP (r=0.153, p<0.05). However, blood lead level was associated with lower BMI (r=-0.291, p<0.01), WC (r=-0.256, p<0.01), HC (r=-0.300, p<0.01). Mecury in boys and cadmium in girls were correlated with higher BMI, however, lead levels were correlated with lower BMI in both sex . In boys, higher blood lead level was associated with earlier onset age of pubic hair (mean age 14.60±1.47, r=-0.265, p<0.01) and higher cadmium level was associated with later onset age of pubic hair (r=0.386, p<0.01), mustache (r=0.291, p<0.01) as well as higher mercury level was associated with later onset age of pubic hair (r=0.374, p<0.01), mustache (r=0.255, p<0.05). In girls, higher lead level was associated with earlier breast budding (r==-0.334, p<0.01) also higher mercury was associated with earlier breast budding (r=-0.269, p<0.01). Higher cadmium level was associated with later onset of menarche (r=0.209, p<0.05) and pubic hair (r=0.182, p<0.05).

In conclusion we suggested that several heavy metals may be exposed from contaminated foods increase metabolic risk and affect in pubertal development in children and youth in Korea.

 

Nothing to Disclose: KK, YHS, SYE, YMK, YSH, HSP, SJS, JDP, BSC, HJS

21251 8.0000 THR-297 A Impacts of Heavy Metal Exposure on Adiposity and Pubertal Development in Koran Children and Adolescents 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Terri L Provost* and Cody Plasterer
Utica College, Utica, NY

 

Melamine is an organic compound used to produce plastics, fire retardants and many other common household products.  Production of melamine in 2010 caused an estimated 6,000,000 metric ton to be dumped in the environment.  High nitrogen content of melamine caused it to be added to cattle food, pet food and baby formula to falsely raise measured protein producing reproductive abnormalities and kidney malfunction.  We hypothesized that exposure to melamine concentrations found in the environment will impact juvenile mice exposed through food and hermaphroditic snails exposed through habitat negatively.  To investigate these effects, we exposed male Swiss-Webster mice to 20, 200, and 2000ppm of  dietary melamine and Ramshorn snails to the same doses in water for three weeks. In mice we determined corticosterone, calcium, glucose, and total protein in blood.  After measuring body weight and relative organ weights, we examined the kidneys for anomalies.  Change in body weight, shell-to-body ratio and egg masses per snail were determined. Corticosterone, calcium and protein were measured in soft body tissue. Our results show that mice exposed to 20ppm had significantly enlarged thymus while the 2000 ppm melamine exposed mice had significantly higher serum protein when compared with all other groups.  Snails exposed to 200ppm of melamine or higher had significantly lower reproductive success as well as lower body weight.  Snail mortality rate was significantly elevated with 2000ppm exposure.  This study provides support that environmental exposure to melamine has detrimental effects in animals exposed through ingestion as well as aquatic animals exposed through habitat.

 

Nothing to Disclose: TLP, CP

21901 9.0000 THR-298 A Impact of Melamine on Juvenile Swiss-Webster Mice and Hermaphroditic, Ramshorn Snails 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Helena Fedora Schteingart*1, Clara Valeri2, Nadia Yasmín Edelsztein1, Marina Riggio3, Sebastian Guilianelli3, Claudia Lanari3 and Rodolfo A Rey2
1Hospital de Niños R. Gutiérrez, Buenos Aires, Argentina, 2Cedie-Conicet-FEI, Buenos Aires, Argentina, 3Instituto de Biología y Medicina Experimental (IBYME), Buenos Aires, Argentina

 

AMH is expressed at high levels in prepubertal Sertoli cells of the testis. FSH increases, whereas androgens inhibit, testicular AMH production. In patients with Androgen Insensitivity Syndrome or with Peutz-Jeghers Syndrome, AMH testicular production is increased, concomitantly with estradiol. The AMH promoter contains an estrogen response element hemi-palindrome (½-ERE) at position -1772. In this work we assessed whether estrogens are involved in the increase of the AMH promoter activity in a prepubertal Sertoli cell line, SMAT1.

Methods and Results: Reporter assays were performed in SMAT1 cells co-transfected with AMH promoter-luciferase plasmids and expression vectors for human estrogen receptor α (ERα) and/or β (ERβ), and incubated with 17β-estradiol (E2) at concentrations ranging from 10-12 to 10-6 M and/or the antiestrogen ICI 182,780 (10-6 M) for 24 h. Luciferase activity was used to estimate the AMH promoter activity, and results were expressed as % of the respective control (mean ± SEM). One sample t-tests were used to compare the results of the stimulated conditions to a 100% value corresponding to the basal activity.

The expression of ERα and ERβ was ascertained in transfected SMAT1 cells by immunofluorescence and Western blotting. Maximum AMH promoter activity in ERα-transfected cells was observed with E2 between 10-10 and 10-8 M; subsequent experiments were performed with E2 10-9 M since it is a physiologic concentration within the testis. In ERα-transfected cells, E2 induced a significant increase of the AMH-3068-1 promoter activity (263.5 ± 12.5%, P<0.001). Conversely, in ERβ-transfected cells no significant changes were observed (96.4 ±14.2%, P=0.405). In cells co-transfected with both ERs, E2 induced a similar activation in the AMH-3068-1 promoter as that observed in cells transfected only with ERα. E2 effect was abolished in presence of ICI 182,780 (118.8 ± 24.2%, P=0.260). To verify that the effect was mediated by the ½-ERE at -1772, luciferase vectors with different AMH promoters were used. E2 increased the activity of another AMH promoter (-1916-1) containing the ½-ERE (160.4 ± 21.1%, P=0.032), but not that of promoters lacking the ½-ERE (AMH-3068-1916: 63.4 ± 47.7%, P=0.089; AMH-2580-1916: 75.01 ± 6.2%, P=0.077; AMH-423-1: 111.4 ± 24.1%, P=0.331 and mutated ½-ERE at -1772: 105.3 ± 47.7%, P=0.465).

Conclusions and Discussion: E2 stimulates the transcriptional activity of the AMH promoter in SMAT1 cells in the presence of ERα, but not ERβ. The effect is abolished by the antiestrogen ICI 182,780 and by the absence of the normal ½-ERE present at -1772 of the AMH promoter. These results indicate that estrogens are involved in the activation of the AMH promoter in SMAT1 cells, at least in part through the ½-ERE present at -1772. This mechanism may be involved in the increase of AMH in conditions like androgen insensitivity and Peutz-Jeghers Syndrome.

 

Nothing to Disclose: HFS, CV, NYE, MR, SG, CL, RAR

19357 10.0000 THR-299 A Estrogens Are Involved in the Activation of Anti-Müllerian Hormone (AMH) Promoter through an Estrogen Response Element Hemi-Palindrome Present at -1772bp 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Csilla S. Molnár1, Miklós Sárvári1, Csaba Vastagh1, Csilla Maurnyi1, Csaba Fekete2, Zsolt Liposits2 and Erik Hrabovszky*2
1Institute of Experimental Medicine, Hungarian Academy of Sciences, Budapest, Hungary, 2Institute of Experimental Medicine, Budapest, Hungary

 

Neuropeptides of the hypothalamic arcuate nucleus (ARC) regulate important homeostatic and endocrine functions and also play a critical role in pubertal development. Altered peptidergic and amino acidergic neurotransmission underlying the pubertal maturation of the ARC are poorly understood. Here we studied the pubertal shift in the gene expression profile of the ARC of male mice. RNA samples for quantitative RT-PCR studies were isolated from the ARC of day-14 prepubertal and day-60 adult male mice with laser-capture microdissection. The expression of 18 neuropeptide-, 15 neuropeptide receptor-, 4 sex steroid receptor and 6 classic neurotransmitter marker mRNAs were compared between the two groups. Adult animals showed increased mRNA levels encoding cocaine- and amphetamine-regulated transcript, galanin-like peptide, dynorphin, kisspeptin, proopiomelanocortin, proenkephalin and galanin and reduced expression of mRNAs for pituitary adenyl cyclase activating peptide, calcitonin gene-related peptide, neuropeptide Y, substance P, agouti-related protein, neurotensin and growth hormone-releasing hormone. From the tested neuropeptide receptors, melanocortin receptor-4 showed the most intriguing (5-fold) increase. Melanocortin receptor-3 and the Y1 and Y5 neuropeptide Y receptors increased 1.5-1.8-fold, whereas δ-opioid receptor and neurotensin receptor-1 transcripts were reduced by 27 and 21%, respectively. Androgen- progesterone- and α-estrogen receptor transcripts increased by 54-72%. The mRNAs of glutamic acid decarboxylase 65, and 67, vesicular GABA transporter and choline acetyltransferase remained unchanged. Tyrosine hydroxylase mRNA increased by 44%, whereas type-2 vesicular glutamate transporter mRNA decreased by 43% by adulthood. In ongoing studies, the functional significance and causal relationship to pubertal development of these changes are addressed with transgenic methodologies and the neuronal phenotypes showing altered receptor and glutamate marker coexpression are investigated with in situ approaches.

 

Nothing to Disclose: CSM, MS, CV, CM, CF, ZL, EH

19305 11.0000 THR-300 A Pubertal Changes in Neuropeptide Gene Expression of the Hypothalamic Arcuate Nucleus in Male Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Jerrold Joseph Heindel*1, Lesley Skalla2, Claudia L. Thompson3 and Kimberly A Gray3
1NIEHS/NIH, RTP, 2MDB Inc, 3NIEHS, Research Triangle Park, NC

 

The scientific field of Developmental Origins of Health and Disease (DOHaD) originated over 20 years ago. It posits that programming of tissue development can be modified by environment (poor nutrition, stress, environmental chemicals) which leads to increased susceptibility to disease/dysfunction across the lifespan. We set out to determine the strength of the data supporting the DOHaD hypothesis by developing a systematic analysis of the scientific literature focusing on the role of environmental chemical exposures. We identified peer-reviewed original research in humans that examined prenatal or early childhood exposure (up to 8 years of age) to any environmental chemical other than tobacco smoke, alcohol, drugs, and pharmaceuticals except DES. Studies needed to assess at least one health outcome occurring later in life (either after one month of age or one month after the exposure of interest). We searched Medline (via PubMed) and ISI Web of Science on May 29, 2013. We identified 343 publications by examination of key descriptive information from each publication. All data were imported into a Microsoft database and we utilized the data pivot module of HAWC (Health Outcomes Workspace Collaborative) to display descriptive information on studies with associated forest plots of reported effect estimates. Examination of disease focus showed the largest number of publications were related to neurological/cognitive outcomes (n=169), followed by cancer (45), respiratory (33), reproductive health (25), immune disorders (23), metabolic outcomes including obesity (23) and cardiovascular dysfunctions  (15) with less than 10 publications each focusing on skin, thyroid, visual problems and liver. Overall 60 different chemicals and mixtures were examined across publications, with the most studied chemicals being POPS (176), air pollutants (129) and metals (103) in contrast to fewer articles focusing on phthalates (9) and bisphenol A (6). A preliminary examination of all the reported outcomes in the data set showed that 283 publications reported a significant positive or negative association between a developmental exposure and some disease/dysfunction outcomes, while there were 60 non-significant associations, indicating a more detailed analysis would be worthwhile. We plan to conduct a detailed analysis of the state of the data supporting the DOHaD hypothesis as well as to outline data needs and gaps for each of the outcomes with a sufficient number of publications (>=10 publications). This presentation will report our initial findings with a focus on the obesity data and discuss future directions.

 

Nothing to Disclose: JJH, LS, CLT, KAG

19952 12.0000 THR-301 A Preliminary Data Supporting the Development of a Systematic Analysis of the Strength of the Association Between Developmental Exposures to Environmental Chemicals and Later Life Disease/Dysfunctions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Esha Ganguly*, Yan Jin, Margaret E Bock and Peter A Cattini
University of Manitoba, Winnipeg, MB, Canada

 

The human (h) growth hormone (GH) and chorionic somatomammotropin (CS) gene family has been used as a model system to study tissue-specific expression, and specifically the role of histone or DNA modifications, chromatin remodeling as well as transcription factor availability and accessibility. In spite of considerable (>90%) nucleotide sequence similarity, hGH-N is preferentially expressed in the pituitary, while the genes coding for chorionic somatomammotropin (hCS-A and hCS-B) and placental GH (hGH-V) are expressed efficiently in the placenta; the fifth gene, hCS-L, is a pseudogene. Less is known about the control of placental gene members, although they are expressed differentially (hCS-A>hCS-B or hGH-V), and transcripts are detected at low levels in human choriocarcinoma BeWo, JAR and JEG-3 cells. There are, however, reports of hGH/CS transcripts detected outside of the placenta, including tissue/cells of breast, dermal, ovarian, testis and uterine origins. Here, we have begun to assess: (1) the relative expression of hGH/CS gene expression in human term placenta versus cells of placental and non-placental origin, and if detected the relative expression of hCS-A, hCS-B and hGH-V; and (2) whether the expression observed corresponds to availability of transcription factors capable of trans-activating the hCS promoter and/or (downstream) enhancer region. Assessment of relative hGH/CS RNA levels by PCR using a common set of exon 3/exon 4 primers reveals that expression is ~80-fold higher in human term placenta versus non-placental tissue. As expected, transcripts were detected in placental BeWo, JAR and to a lesser extent JEG-3 cells, but were ~90-fold lower than in term placenta. Low levels, comparable to JEG-3 cells, were also detected in non-placental HeLa (cervical carcinoma), MCF-7, T47D (breast cancer) and Hec1A (uterine adenocarcinoma) cells. Specific assessment of hCS-A, hCS-B and hGH-V transcripts reveal >4-fold higher levels in placental BeWo and JAR versus JEG-3 cells, which in turn was comparable to non-placental HeLa and MCF-7 cells. To assess available levels of CS promoter and enhancer factors, placental and non-placental cells (~60% confluent) were transfected with hybrid luciferase genes; the activity of the hCS-A and hGH-N promoter (0.5 kilobase) region was compared, as well as the effect of the hCS-B downstream enhancer region on CS promoter activity. There was no apparent preference for use of the hCS versus hGH promoter, but a >10-fold potential for activation by the CS enhancer region was observed in BeWo, JAR and JEG-3 versus non-placental HeLa and MCF-7 cells. These observations suggest that low hCS expression in placental and non-placental cells versus term placenta is related, at least in part, to inaccessibility of regulatory sequences, but predict different outcomes if these regions, including the enhancer, were exposed.


 

Nothing to Disclose: EG, YJ, MEB, PAC

19400 13.0000 THR-302 A Effect of Transcription Factor Accessibility on Endogenous Versus Ectopic Expression of Placental Members of the Human Growth Hormone Gene Family 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Victoria D Balise*1, Christopher D Kassotis2, Chun-Xia Meng3 and Susan Carol Nagel4
1University of Missouri, 2Univ of Missouri, Columbia, MO, 3University of Missouri, Columbia, MO, 4Univ of MO-Columbia, Columbia, MO

 

Hydraulic fracturing is a drilling technique to produce natural gas and oil that has been increasing in use. This process uses over 750 chemicals, including known neurotoxins, carcinogens, and endocrine disruptors. Previously our lab has shown an association between hydraulic fracturing spills and an increase in endocrine disrupting chemical (EDC) activity in surface and ground water. Our lab has found antagonist activity in 23 of 24 chemicals tested for estrogen, androgen, progesterone, glucocorticoid, and/or thyroid receptors. Estrogens and androgens are key regulators of the reproductive system and disruption can impair reproduction. We hypothesized that exposure to a mixture of chemicals found in hydraulic fracturing fluid would alter 1) estrus cyclicity, 2) implantation, 3) fecundity, and anogenital distance and 4) semen quality in mice. To test this hypothesis, a mixture of 23 hydraulic fracturing chemicals with both anti-estrogenic and anti-androgenic activity was administered to mice via drinking water in a series of experiments. 1) Females were exposed for 3 weeks while cyclicity was monitored by daily vaginal cytology. 2) Mice were time-mated and exposed from gestation day 1 to 11 of pregnancy during the time of implantation, and necropsies were performed on GD 11 and the number of embryos were counted. 3) Fecundity after exposure from gestation day 1 to birth was measured via the fertility index and pup survival. Gestational exposed pups will have anogenital distance measured, as decreased anogenital distance is a measure of antiandrogen activity. 4) Male reproductive health is governed by androgens and estrogens, and both are required for healthy sperm. We hypothesize that exposure to a mixture of the 23 hydraulic fracturing chemicals with antiestrogenic and anti-androgenic activity would decrease quantity and quality of semen in mice. Mice were exposed for 6 weeks to cover all stages of spermatogenesis, necropsies performed, and testis and sperm counted and analyzed for motility. Completion of these studies will increase our knowledge about potential adverse health effects associated with chemicals used in hydraulic fracturing.

 

Nothing to Disclose: VDB, CDK, CXM, SCN

21134 14.0000 THR-303 A Reproductive Toxicity of Endocrine Disrupting Chemicals Present in Hydraulic Fracturing Fluids 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Dongoh Lee*1, Myoungho Lee1, Changhwan Ahn2 and Eui-Bae Jeung2
1Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South), 2Chungbuk National University, Cheongju, Korea, Republic of (South)

 

Introduction : Interrupting of the organism’s hormonal balance by intervening with the hormone and their target receptor arise various problems such as developmental disorder or cancer related to reproduction. Though some chemicals contained in natural creature like Red clover are inducing these problems, most chemicals not found in natural compound take part in disrupting endocrine system. We call these chemicals altogether as an endocrine disrupting chemicals (EDCs). Some chemicals included in EDCs influence to estrogenic, androgenic or thyroid specifically or more than one of these. Silicone is widely used in medical devices, cleaning products and cosmetic products. Cyclic volatile methylsiloxanes (cVMSs) are group of silicone that including octamethylcyclotetrasiloxane (D4), decamethylcyclopentasiloxane (D5) and dodecamethylc-yclohexasiloxane (D6). These chemicals have a property that high vapor pressure, high octanol/water partition coefficient and low molecular weight. Due to its properties, they can be easily found in air and well absorbed in lipid. In human, because of higher exposure probability other than creature and its characteristics, human can significantly be affected. In recent study, hazardousness of D4 was evaluated and its estrogenicity was noticed. Method : GH3 cells, rat pituitary cell, were exposed to vehicle, 17β-estradiol (E2; 1.0x10-9M) or D4 (1.0x10-5M). For approving the pathway of D4, ICI 182 780 (ICI; 1.0x10-7M) was exposed before those chemicals. Transcription level of CaBP-9K, estrogen receptor alpha (ER α) and progesterone receptor (PR) were quantified by qRT-PCR. And those protein quantities were measured by western blot. Result : CaBP-9K and PR were up-regulated by E2 and D4. Elevated levels of those were down-regulated by ICI. ER α is decreased by E2 and D4. A decreased level of it was increased by ICI. Conclusion : We sustained estrogenicity of D4 on in vitro assay using calcium binding protein 9K (CaBP-9K) as a biomarker for estrogen.

 

Nothing to Disclose: DL, ML, CA, EBJ

20322 15.0000 THR-304 A Induction of Estrogenic Biomarker Cabp-9K By Octamethylcyclotetrasiloxane on GH3 Cell 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Thursday, March 5th 3:00:00 PM THR 290-304 6106 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Rashmi Jain*1, Ignacio Valencia2 and Elizabeth A Suarez3
1Section of Endocrinology and Diabetes, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, 2Section of Neurology, St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, 3Section of Endocrinology and Diabetes, St. Christopher's Hospital for Children, Department of Pediatrics. Drexel University College of Medicine, Philadelphia, PA

 

Background: Type 1 DM is characterized by a chronic progressive immune-mediated destruction of the beta cells of the pancreas, and it can occur in association with other autoimmune diseases.  The risk for type 1 DM in siblings of an affected child is approximately 3-6%.  Here we report a family of four siblings, all of whom have Type 1 DM. Two of them also have Hashimoto’s thyroiditis and partial epilepsy, associated with abnormal EEG and brain MRI findings.

Clinical Cases:

Patient 1: 19 yr old female diagnosed with Type 1 DM at 5 yrs of age, and with Hashimoto’s thyroiditis at 12 yrs (on thyroid hormone replacement). At 14 yrs of age, she was diagnosed with complex partial seizures, manifesting mainly as staring episodes. Blood glucose levels remained normal during and after these episodes.  An EEG was reported as abnormal, demonstrating seizures from the left anterior and mid temporal regions.  MRI of the brain showed signal hyperintensity in the left hippocampus. Her seizures were refractory to 3 antiepileptic drugs. She then received a course of IVIG for suspected autoimmune epilepsy and reported minimal improvement in the staring spells.

Patient 2: 14 yr old female diagnosed with Type 1 DM at 2 yrs of age and with euthyroid Hashimoto’s thyroiditis at 12 yrs of age. She was diagnosed with complex partial seizures at age 13 after presenting with staring episodes. Her blood glucose levels remained normal during and after these episodes. Her EEG was reported as abnormal due to three brief focal left-sided seizures. Interestingly, her brain MRI also showed a region of hyperintensity in the left hippocampus.

Patient 3 & 4 are 12 yr old twin brother and sister of the above patients. The sister was diagnosed as having Type 1 DM at 2 yrs of age and her brother at 3 yrs of age. Both of them have negative thyroid autoantibodies. Thus far, they have not experienced any seizure activity; both have had normal EEGs.

Discussion:  We present an unusual family where all 4 children have been diagnosed with Type 1 DM. In addition, 2 of the 4 siblings also have associated autoimmune thyroid disease and partial epilepsy. Further investigation is warranted to determine whether the partial epilepsy in 2 siblings is autoimmune in nature.

 

Nothing to Disclose: RJ, IV, EAS

21275 1.0000 THR-175 A Coexistence of Type 1 DM, Hashimoto's Thyroiditis and Partial Epilepsy in Two Siblings 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 175-182 6115 1:00:00 PM Pediatric Thyroid Disorders Poster


Izumi Nakamura*1, Satoru Suzuki2, Sanae Midorikawa3, Toshihiko Fukushima1, Hiroki Shimura3, Tetsuya Ohira3, Akira Ohtsuru3, Masafumi Abe1, Yoshisada Shibata3, Satoshi Suzuki1, Shunichi Yamashita3 and Shinichi Suzuki1
1Fukushima Medical University, Fukushima-shi, Japan, 2Fukushima Medical University, Fukushima, Japan, 3Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan

 

Although several reports have defined normal thyroid volume depending on either age or body surface, there are no sequential reference values on childhood thyroid volume by using ultrasonography and its epidemiological analyses in Japan. The study aim was to establish updated reference values for thyroid volume by ultrasound examination and epidemiological analysis in 0-19-y-old Japanese children. This study was a cross-sectional study from October 9th, 2011 to March 31st, 2012. The subjects were 37,818 children who were examined by ultrasonography after the accidents at the Fukushima Daiichi Nuclear power plant as the initial preliminary survey of the Fukushima Health Management Survey in Oct 9, 2011-March 31, 2012. The width, thickness and height of each lobe were measured and the volume of each lobe was calculated by the mean of the elliptical shape volume formula. The values of thyroid volume at the 2.5 and 97.5 percentiles of age and body surface area for each gender group were obtained from 0-19 years old children. Positive correlation was observed between thyroid volume and either age or body surface. Right lobe was significantly larger than left lobe. The thyroid volume in females was larger than that in males after adjusting body surface area. The reference values of childhood thyroid for each age or body surface area were obtained by this extensive survey using ultrasound. This reference may be able to define normal size of thyroid gland by echosonography in Japanese children. Thyroid volume may be affected by dimorphic factors such as sex hormones.

 

Nothing to Disclose: IN, SS, SM, TF, HS, TO, AO, MA, YS, SS, SY, SS

18886 2.0000 THR-176 A Systematic Determination of Thyroid Volume By Ultrasound Examination from the Infant to Adolescence in Japan: The Fukushima Health Management Survey 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 175-182 6115 1:00:00 PM Pediatric Thyroid Disorders Poster


Jeesuk Yu*1, Seung Ho Lee1 and Young Pyo Chang2
1Dankook University Hospital, Cheonan, Korea, Republic of (South), 2Dankook University Hospital, Korea, Republic of (South)

 

Background: Sufficient iodine intake is required for the synthesis of thyroid hormone which is very important for normal growth and development, especially in newborn period. Iodine excess as well as iodine deficiency may cause adverse effect on thyroid function.

 Objectives: This study was designed to find the iodine status in the neonates with euthyroid function and to compare the values with those obtained from the neonates with thyroid dysfunction using random spot urine.

 Methods: Neonates with euthyroid function were classified into group 1, and neonates referred for the elevated TSH were classified into group 2. Neonates with thyroid agenesis or ectopic thyroid were excluded in the study. A total of 646 urinary samples were collected for the assay of iodine concentrations from group 1, and 26 urinary samples were obtained from group 2. A Pvalue less than 0.05 was considered statistically significant using the SPSS software program (version 20.0).

 Results: Most neonates (83%) showed excessive iodine status (UIC ≥ 300 ug/L). The mean value of urinary iodine was statistically higher in the neonates with thyroid dysfunction compared to the neonates with normal thyroid function (131.2 ± 197.1 umol/g Cr in group 1 vs. 243.7 ± 297.6 umol/g Cr in group 2, P<0.05). The free T4 and TSH levels were also significantly different between two groups (1.74 ± 0.59 ng/dL vs. 1.14 ± 0.52 ng/dL, P<0.001 for freeT4; 1.82 ± 1.62 mIU/L vs. 65.26 ± 93.36 mIU/L, p<0.001 for TSH). Percentage of thyroid dysfunction was higher in neonates with excessive urinary iodine concentrations (UIC ≥ 300 ug/L).

 Conclusion: This study showed that excessive iodine exposure in neonate may contribute to thyroid dysfunction, although there is no significant correlation between TSH and urine iodine concentrations. It seems to be worthwhile to check the iodine status as well as TFT for the evaluation of thyroid function in neonates

 

Nothing to Disclose: JY, SHL, YPC

19837 3.0000 THR-177 A Iodine Status and Its Effect on Thyroid Function in Neonates 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 175-182 6115 1:00:00 PM Pediatric Thyroid Disorders Poster


Ana Paula Dassie-Leite1, Mara Behlau2, Suzana Nesi-Franca*3, Julita Maria Pelaez4, Monica Nunes Lima5 and Luiz De Lacerda3
1State University of Midwest, Irati, Brazil, 2Federal University of São Paulo, São Paulo, Brazil, 3Federal University of Parana, Curitiba, Brazil, 4Federal University of Parana, Brazil, 5Federal University of Paraná, Curitiba, Brazil

 

Congenital hypothyroidism (CH) is the second most prevalent endocrine chronic disease in childhood. Despite advances in neonatal screening programs, intrauterine thyroid hormones deficiency can cause mild neuropsychomotor developmental deficits. Aims: to evaluate phonological characteristics of a group of children with CH and their association with clinical, laboratory and therapeutic profile. Methods: Two hundred prepubertal children, aged 3 to 12 y-old, were enrolled: 100 with CH (Study Group, SG) and 100 euthyroid (Control Group, CG). Parameters evaluated: 1) Speech Language Pathology Interview (identification and complaints); 2) Phonological Assessment by the Child Language ABFW test (Andrade, Béffi-Lopes, Fernandes, Wertzner, 2004), 3) Medical records data (SG): CH etiology, age at onset of treatment, severity of the disease (TT4<2.5µg/dL), quality of treatment and neuropsychological tests: [CAT (Cognitive Adaptive Test), CLAMS (Clinical Linguistic and Auditory Milestone Scale) and Cognitive Quotient (CQ) (Accardo, Capute, 2005) in the first three years of life; WPPSI-R and WISC III for preschool and school age children]. Results: SG comprised 65% of females, median chronological age (CA) at start of treatment was 18.0 days; regarding etiology, 41.2% had dyshormonogenesis, 35.5% ectopic gland, 13.3% hypoplasia and 10% agenesis. On diagnosis, 48.4% had TT4<2.5µg/dL. At phonological evaluation, mean CA was 7.3±2.2y, thyroid function tests were normal in the majority of patients (8% had TSH above 10 mIU/L). SG and CG were different according to gender (p<0.001) and schooling (p=0.001) and not different in CA (p=0.91). As for phonological assessment by age, SG had higher incidence of simplification of consonant clusters at seven years for the imitation (p=0.006) and for the naming task (p=0.06). In terms of phonological acquisition, differences were observed in the groups 4 plus 5 and 6 plus 7 years once the system was completed earlier by the CG (p = 0.02). Thyroid agenesis (p=0.04) and abnormal scores in CLAMS (p = 0.007) and CQ (p=0.008) tests were associated with the presence of phonological disorders. Conclusion: CH children, despite early diagnosis and adequate treatment, exhibit a delay in phonological acquisition, especially between ages six and seven, probably related to etiology and neuropsychological development.

 

Nothing to Disclose: APD, MB, SN, JMP, MN, LD

20937 4.0000 THR-179 A Phonological Acquisition of Early Treated Congenital Hypothyroidism Children: Relationship with Clinical and Laboratory Parameters 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 175-182 6115 1:00:00 PM Pediatric Thyroid Disorders Poster


Resmy Palliyil Gopi*1, Maria F Contreras2 and Preneet Cheema Brar3
1NYU School of Medicine, New York, NY, 2NYU School of Medicine, NY, 3New York University School of Medicine, New York, NY

 

Introduction:

Acute myopathy occurs in both hyperthyroid and hypothyroid states, the mechanism of which is not clearly understood (1). Some cases of myopathy are attributed to a relative hypothyroid state at the cellular level (2). Elevated levels of creatine kinase (CK) are observed in hypothyroid myopathy but not in hyperthyroid myopathy. However, CK elevations have been associated with antithyroid drug treatment (3). We report an adolescent with Graves’ disease who had CK elevation on methimazole (MMI) treatment and after radioactive iodine ablation.

 Case report:

13 year old female diagnosed with Graves’ disease who on diagnosis had the following labs: Free T4: 5.6 ng/dl (Normal range: 0.9-1.9 ng/dl), Free T 3: 19 pg/ml (2.3-4.2pg/ml), TSH: <0.008 uIU/ml (0.35-4.8 uIU/ml), TSI: 338% (<140 %) and she was started on methimazole (MMI: 30mg/day) and propranolol.

The teenager reported muscle aches 4 months after starting MMI and on testing CK levels were elevated at 516 U/L (35-155 U/L) (3X normal) and MMI was discontinued. The patient tested negative for rheumatologic conditions like polymyositis where testing included ANA, anti Smith ab, dsDNA ab, anti RNP ab, Jo-1 ab, Scl- 70 ab and centromere B ab. The teenager experienced rapid and marked improvement in her muscle symptoms and CK levels decreased to 153 U/L (35-155 U/L) in a week. As thyroid hormones rebounded rapidly on discontinuation of MMI: Free T4: 2.03 (0.9-1.9ng/dl), Free T3: 8.4 (2.3-4.2pg/ml)), the treatment options were restarting MMI at a lower dose or radioablation and the family opted for the latter. The patient underwent radioactive iodine ablation (131I) with 12.5millicuries.

Two months status post radio ablation, the patient became hypothyroid: Free T4:0.33 (0.9-1.9 ng/dl), TSH: 102 uIU/ml (0.35-4.8 uIU/ml)) and she developed acute myopathic symptoms which were again associated with CK elevation (higher than preablation) of 1093 U/L (35-155 U/L). On initiation of levothyroxine at 50mcg daily, CK levels decreased to 266 U/L (35-155U/L) in 10 weeks and symptoms improved.

Conclusion:

True incidence of acute myopathy associated with pediatric Graves’ disease is higher than described in literature. Learning points from our case are: a) Pediatric Graves’ disease families should be counseled about muscle symptoms and CK levels be measured when warranted by clinical history; b) Trending CK levels during the course of treatment may be prudent as our case demonstrates reemergence of myopathy in the hypothyroid state status post radio ablation; c) Addition of levothyroxine along with antithyroid medication may offset the local hypothyroid state within the muscle tissue resulting in CK augmentation.

 

Nothing to Disclose: RP, MFC, PCB

18798 5.0000 THR-180 A Myopathy in Adolescent Graves' Disease in Both Hyperthyroid and Hypothyroid States - a Cautionary Tale 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 175-182 6115 1:00:00 PM Pediatric Thyroid Disorders Poster


Isabelle Oliver-Petit1, Frédérique Savagner2, Solange Grunenwald3, Thomas Edouard4 and Philippe Caron*3
1CHU Toulouse, Toulouse, France, 2CHU Purpan, France, 3CHU Larrey, Toulouse, France, 4CHU TOULOUSE, Toulouse, France

 

Background: The familial nonautoimmune hyperthyroidism (FNAH) is a hereditary disease caused by stimulating mutations of the TSH receptor (TSHR) gene and is rare in the paediatric population.

Clinical case: A 20-month girl was referred for tachycardia (180/mn). In personal history, she was delivered at 35 weeks of gestation by caesarean for fœtal tachycardia; she had been hospitalised at 1 and 5 months for diarrhea and tachycardia was noticed. Clinically she presented with advanced growth (+2 SD) and bone age (5 years), hypotrophy, scaphocephaly and craniostenosis, hyperactivity but motor delay with proximal amyotrophy. Discrete ophthalmopathy without inflammatory signs was observed. Thyroid function tests revealed severe hyperthyroidism with free T3 > 20 pg/ml (normal range: 2-4.3 pg/ml), free T4: 52 pg/ml (9.3-17 pg/ml) and TSH: 0.005 μU/ml (0.27–4.2 μU/ml). No antibody anti-TSH receptor was identified. Ultrasonography showed diffuse enlargement of thyroid gland (volume: 4 cm3, normal for age < 2.5 cm3). Because of same history of advanced growth, her 5-year old sister was tested with less severe but similar hormonal (free T3: 15.3 pg/ml, free T4: 40 pg/ml, TSH: 0.006 μU/ml) and ultrasonography (thyroid volume 5.5 cm3; normal for age <3 cm3) presentation. For the two sisters, a treatment with thiamazole was administered (1 mg/kg/d) and hyperthyroidism was partially controlled after 3 months; total thyroidectomy was then performed. In familial history, father and father's mother have been treated for hyperthyroidism: the father had total thyroidectomy and revealed papillary microcarcinoma, while the grandmother had voluminous and recurrent goiter after partial thyroidectomy.

We identified in this proband, her sister and father a germline mutation in exon 10 of the TSHR gene; mutation C678W resulting for a cysteine to tryptophan substitution. Functional in vitro studies are on-going to explore the role of this residue in the modulation of TSHR activity. Interestingly, the 3 family members with identified mutation presented with mitral valve prolapse, as previously described in FNAH patients with C639 mutation in the same TMD 7.

Conclusion: We report a French family with severe FNAH caused by a new germline mutation in TDM7 of TSH receptor gene.

 

Nothing to Disclose: IO, FS, SG, TE, PC

19589 6.0000 THR-181 A Severe Hyperthyroidism in an Infant Revealed a Familial Nonautoimmune Hyperthyroidism with Novel Stimulating Thyrotropin Receptor Germline Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 175-182 6115 1:00:00 PM Pediatric Thyroid Disorders Poster


Christie De La Vega*1 and Adriana Herrera2
1Miami Children's Hospital, Miami, FL, 2Children's Hospital of Philadelphia, Philadelphia, PA

 

BACKGROUND: Several case reports describe hypokalemia and distal renal tubular acidosis (RTA) as the presenting forms of autoimmune disorders and short stature. This case report describes a 12 year old female with known hypothyroidism and growth retardation found to have hypokalemic paralysis secondary to distal RTA.

CLINICAL CASE: A 12- year old female presented with sudden onset muscle paralysis after strenuous physical activity during a swim meet. Health records reveal evaluation for growth retardation (height < 3rd percentile) one year prior, at which time she was found to be mixedematous with a TSH­>800 uU/mL (n: 0.6-5.5 uU/mL) and anti-thyroid peroxidase Ab ­>6600 IU/mL (n: <9.0 IU/mL). Evaluation for GH deficiency did not reveal any abnormalities. She was started on Levothyroxine 100mcg daily and followed on a monthly basis. During this time, labs showed intermittent episodes of hypokalemia (2.9 mmol/L, n: 3.5-5.2 mmol/L), decreased carbon dioxide (16 mmol/L, n: 20-32 mmol/L), and hyperchloremia (109 mmol/L, n: 97-108 mmol/L). 

Upon evaluation for sudden onset muscle paralysis, labs revealed low potassium (2.5 mmol/L, n: 3.5-5.1 mmol/L), mildly elevated chloride (114 mmol/L, n: 98-115 mmol/L), low carbon dioxide (11.0 mmol/L, n: 17-30.0 mmol/L), and elevated alkaline phosphatase (395 IU/L, n: 93-386 IU/L). Remaining electrolytes were normal. A total creatinine kinase was elevated at 1,488 IU/L (n: 30-170 IU/L). Over the course of several hours her hypokalemia and metabolic acidosis acutely worsened (K 1.8 mmol/L, Cl 122 mmol/L, CO2 13 mmol/L, pH 7.20, bicarb 12.6 mmol/L). She required multiple potassium chloride boluses and was placed on 2x maintenance IV fluids to stabilize potassium levels. Thyroid function tests were normal.

Neuromuscular function improved once hypokalemia was corrected. Distal RTA was diagnosed after infectious and autoimmune causes ruled out.  Additional workup revealed bone demineralization with thinned cortices in distal femoral metaphysis, bilateral nephrolithiasis, and nephrocalcinosis. She started on oral potassium supplements with Uroci-K and continued on Levothyroxine 100mcg daily.

On follow up 5 months later, patient continues with stable electrolytes and thyroid function. She continues on oral Uroci-K supplementation and Levothyroxine 100mcg daily. She has had excellent growth velocity, now within the 44th percentile.

CONCLUSION: Several case reports describe RTA as the presenting form of thyroiditis and growth retardation, with resolution of acidosis and improvement of stature once thyroid function improves. However, our patient had a history of growth failure and hypothyroidism, on adequate thyroid replacement, with new onset hypokalemic paralysis diagnosed as distal RTA. On review, she had slight improvement of growth velocity after starting levothyroxine but markedly improved growth velocity after starting treatment for RTA.

 

Nothing to Disclose: CD, AH

19629 7.0000 THR-182 A Hypothyroidism and Growth Failure with Sudden Onset Muscle Paralysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM THR 175-182 6115 1:00:00 PM Pediatric Thyroid Disorders Poster


Ju Ying Tang1, Shao Ling Zhang*2, Diao Zhu Lin1 and Li Yan1
1Sun Yat-sen University, Sun Yat-sen Memorial Hospital, 2Sun Yat-sen University, Sun Yat-sen Memorial Hospital, Guangzhou, China

 

The mid-night salivary cortisol has been widely recommended as one of the first-line screening tests for Cushing's syndrome (CS), with both of its sensitivity and specificity higher than 90%. The common methods to measure salivary cortisol are radioimmunoassay (RIA) and enzyme-linked immunosorbent assay (ELISA). But RIA has the problem of nuclear radioactive contaminations and ELISA is time-consuming and costly. The purpose of the study is to evaluate the laboratory performances of the CLIA system for the detection to salivary cortisol and to establish the reference interval of mid-night salivary cortisol (MSC) in healthy controls, and finally to evaluate its reliability in diagnosis of CS. A total of 27 patients with clinically confirmed Cushing’s syndrome (CS) (included 7 cases of recurrent Cushing’s disease), 55 patients (NCS), with obesity concomitant with essential hypertensions,uncontrolled diabetes, polycystic ovary syndrome or non-functional adrenal adenoma were recruited in the study. There were 120 healthy adults (NS) serves as controls. Saliva samples were collected at 24:00 by commercially available Salivettes. Blood samples were collected at the same time. Concentrations of salivary cortisol were detected by both ELISA (DRG, Germany) and CLIA (SIEMENS, USA), while serum samples were assayed by CLIA. Laboratory performance evaluations showed very good results. The average recovery rate was 97.6% (93.8% - 101.6%). The with-run and the day-to-day imprecision variation coefficients were from 3.9% to 6.1% at three different levels of SC. At 99.7% confidence interval, the lower limit of detection (LLD) of salivarycortisol assayed by CLIA system was 2.09nmol/L.The linear evaluation results got the regression equation: y=1.001x-0.039(r2=0.997,p<0.001),when the measured range was 6~200nmol/L. According to CLSI, the performance is excellent. In clinical evaluation, Spearman correlation analysis showed the results of MSC and Mid-night serum total cortical (MSTC) by way of CLIA were in good correlation (r=0.885,p=0.000). Compared with different assays, CLIA and EILSA in detection of MSC were the same too, with AUC by CLIA 0.996(0.987~1.000), ELISA 0.955(0.978~1.000).Levels of MSC were higher in CS patients than in NS and NCS subjects (72.8±38.5nmol/L vs 5.6±2.5nmol/L, 6.9±4.6nmol/L, P=0.002). Levels of MSC of 120 healthy adults showed normal distribution with the 95% upper limit as 10.4nmol/L. When using 10.4nmol/L as cut-off for CS, the sensitivity and specificity were 96.3% and 76.1% respectively. If using 15.6nmol/L, 1.5 fold of the upper limit, the specificity rose to 93.5%. The study indicated CLIA system can be used to detect to mid-night salivary cortisol in diagnose of CS, which is as reliable as ELISA with good performance and accuracy. In addition, CLIA is less costly and takes as short as 30 minutes of detection time.

 

Nothing to Disclose: JYT, SLZ, DZL, LY

22368 1.0000 LBT-064 A Detection of Mid-Night Salivary Cortisol By Chemiluminescence Immunoassay for Diagnosis of Cushing's Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Shao Ling Zhang*1, Ya Juan Deng2 and Li Yan2
1Sun Yat-sen University, Sun Yat-sen Memorial Hospital, Guangzhou, China, 2Sun Yat-sen University, Sun Yat-sen Memorial Hospital

 

Background:

Unilateral adrenal aldosterone-producing adenoma (APA) is a common subtype of primary aldosteronism(PA), while bilateral APA is very rare. The diagnosis of bilateral APA can be evidenced by imaging findings and clinical remission after surgery. However, distinguishing nonfunctioning adenoma(NFA) from APA still remains a big challenge. Retrospective immunohistochemical analysis of the resected adrenal lesion may provide valuable clues. But reported zona glomerulosa(ZG)-specific and aldosterone producing-related biomarkers are few and reveal poor specificity. We here report that Disabled-2 and Nox-2 (gp91phox of NADPH oxidase), both of which had been reported to be associated with aldosterone secretion, can potentially be new biomarkers for diagnosis of bilateral APA.

Clinical case:

A 27-year-old female was admitted for weakness, paroxysmal numbness, thirsty and polyuria. With blood pressure (BP) 180/160mmHg, laboratory findings was consistent with PA: hypokalemia of 2.93mmol/ with hyper urine potassium excretion (43.64mmol/24h), elevated plasma aldosterone concentration (PAC) (137.5ng/dl), with suppressed plasma renin activity (PRA) (0.04ng/mL/h, normal range 0.15- 2.33 ng/mL/h), and the hyperaldoteronism couldn’t be suppressed by both captopril challenge test and intravenous sodium loading test. CT scan revealed a mass of 1.5 x 1.0cm in size in the left adrenal gland and a similar one (0.9 x 1.0 cm) in the right, but the source of the right mass is indecisive. Due to failures in catheterization of adrenal vein during AVS, left adrenal adenomectomy was performed. But clinical symptoms and abnormalities of laboratory data persist after the surgery (BP156/110mmHg, serum K 3.31mmol/L, PAC 56.4ng/dl with suppressed PRA). Consequently, right adrenal adenomectomy was conducted after confirming the right mass by MRI four months later. Clinical remission was achieved postoperatively (BP 128/80mmHg, serum K 3.9mmol/L, PAC 8.7ng/dl). Histologically, both of the resected adrenal nodules were mainly composed of adrenocortical ZG-like cells with positive immunostaining for inhibin, melan-A and CK (cytokeratin) , and negative for CgA(chromogranin A) , Syn (synaptophysin), NSE(neurone specific enolase) and S100. Also, they demonstrated positive immunostaining for Disabled-2 and Nox-2, suggesting functioning bilateral APA, which was accordant with the clinical course.

Conclusion:

This is the first case demonstrating the potential role of new immunohistochemical markers (Disabled-2 and Nox-2) in the functional diagnosis of bilateral adrenal adenoma.

 

Nothing to Disclose: SLZ, YJD, LY

22374 2.0000 LBT-065 A A Case of Bilateral Adrenal Adenoma with Immunohistochemical Analysis of Disabled-2 and Nox-2 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


David Dai*1, Ishita Singh2 and Jerome M. Hershman1
1David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare Systems, Los Angeles, CA, 2David Geffen School of Medicine at UCLA, Los Angeles, CA

 

Introduction

Licorice consumption resulting in metabolic abnormalities including hypokalemia and metabolic alkalosis along with hypertension has been described in the literature as far back as the 1950s (1,2). Licorice extract is used widely in various herbal supplements, foods; toxicity has been described by the ingestion of such products. There are no published reports of toxicity from the ingestion of lozenges, as in the case that we now describe.


Clinical Case                                                             

A 66 y/o man with peripheral neuropathy and recently diagnosed hypertension was noted to have hypokalemia for 4 months. He was hypertensive with BP 152/79, serum potassium 2.5 mmol/L (normal 3.5-5.3) and bicarbonate level 34.6 mmol/L (24-31).

Workup was initiated to evaluate the hypokalemia. Urine studies were consistent with renal potassium wasting based on urine potassium of 92 mEq/L and Trans-Tubular Potassium Gradient (TTKG) of 16.9 (UK >15 mEq/L, TTKG >7). Serum renin activity was low at 0.11 ng/dL/hr (0.25-5.82) and serum aldosterone low at 1 ng/dl (≤ 28). The possibility of Cushing’s disease was investigated. AM cortisol was normal at 9.4 µg/dl (4-22), while the 24-hour urine cortisol was elevated at 128 µg (4-50) for a normal urine creatinine of 0.9 g/24 hr. The AM cortisol after a low dose dexamethasone suppression study was 1.58 µg/dl (<2.0), which is inconsistent with Cushing’s disease. He was referred to Endocrinology for further evaluation.

There was no history to suggest the intake of medications that cause renal or gastrointestinal loss of potassium (including laxatives, diuretics, corticosteroids or antibiotics like aminoglycosides, amphotericin and penicillins). Additional history revealed that he had been taking an unusually large amount of cough lozenges for the past 3-4 months in order to distract his attention from neuropathic pain. The ingestion of the lozenges coincided with his hypokalemia. He had been consuming approximately 160 tablets/day of a licorice-containing lozenge, “Fisherman’s Friend – Extra strong”, amounting to approximately 240 grams of cough drops per day containing 288 mg glycyrrhizin. For reference, the European Commission Scientific Committee on Food has proposed an upper limit of 100 mg/day of glycyrrhizin (3), which is found in approximately 60-70 g of licorice candy (4).


Conclusions 

Glycyrrhetic acid, an active metabolite of licorice, inhibits the enzyme 11-ß-hydroxysteroid dehydrogenase (5, 6), thus preventing the metabolism of cortisol to cortisone and resulting in a state of mineralcorticoid excess similar to that seen in congenital adrenal hyperplasia due to 11β-hydroxylase deficiency. This leads to hypokalemia, metabolic alkalosis and hypertension, all of which were observed in our patient. Eliciting a detailed history of medications was the key to the diagnosis of licorice toxicity in this case.

 

Nothing to Disclose: DD, IS, JMH

22534 3.0000 LBT-066 A Licorice Lozenge-Induced Hypermineralcorticoid State 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Awais Masood*
University of Florida, Gainesville, FL

 

Background

Adrenal lymphoma is a rare entity, and is usually fatal; we report a case of bilateral adrenal lymphoma, presenting with adrenal insufficiency and bilateral adrenal masses, with response to chemotherapy.

Clinical case

Patient is a 72 year-old male, with hypertension and COPD (not on chronic oral or inhaled steroids) who presented with recurrent syncope, hypotension and 30 lbs. weight loss. Initial work up revealed hyponatremia (Na 124mg/dl), a WBC of 4.72 k/cmm with lymphocytocis (69.9% neutrophils, and 17.2% lymphocytes).  ACTH stimulation test was consistent with adrenal insufficiency. Baseline cortisol was 6.73 ug/dl, ACTH 45 pg/ml (n 6-50). After Cosyntropin 250 mcg IV, cortisol was 6.41 ug/dl and 6.52 ug/dl at 30 and 60 minutes respectively. Thyroid levels were normal: TSH 2.6 (n 0.27-42 uIU/ml), free T4 1.19 (n 0.93-1.7 ng/dl). Aldosterone was undetectable (< 1 ng/dl) with elevated plasma renin activity of 10.6 (n 0.25-5.8 ng/ml/hr). MRI of the abdomen showed bilateral adrenal masses measuring, 3.3 x 2.7 cm on the right and 3.3 x 2.5 cm on the left. Biopsy of the adrenal mass was advised but patient refused. Patient was initiated on Hydrocortisone 20 mg q am and 10 mg q pm and Fludrocortisone 0.1 mg daily. He was discharged home after initial improvement.

In follow up a PET CT (performed three months after initial abdominal imaging) showed bilateral enlarged adrenal masses measuring 4.2 x 3.9 cm on the right and 7.3 x 5.8 cm on the left, with diffuse lymphadenopathy and no involvement of CNS. Left inguinal lymph node excisional biopsy was histologically consistent with large B-cell lymphoma, intermediate grade, negative cyclin-D1, negative CD138 and Ki-67 > 60% (high).  Patient was diagnosed with stage IVB diffuse large B-cell lymphoma and was started on chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). After 6 cycles of chemotherapy the right adrenal mass was reduced in size to 1 cm and left adrenal mass to 1.5 cm. Patient is currently on maintenance chemotherapy with Rituximab. His hyponatremia has corrected. Despite almost complete resolution of adrenal masses, adrenal insufficiency is persistent as evidenced by a low morning cortisol of 1.30 ug/dl  (n 6.2-23) after holding pm and am dose of hydrocortisone. He is continued on hydrocortisone and fludrocortisone.

Discussion

There are two types of adrenal involvement in lymphoma: primary adrenal lymphoma, defined as originating from and confined to the adrenal glands solely, and non-Hodgkin lymphoma with adrenal involvement. Primary adrenal lymphoma is rare with less than 100 cases reported and carries a poor prognosis. R-CHOP had been used with encouraging results in a series of patients with adrenal lymphoma (Kim YR, 2012). Our patient has shown good response to chemotherapy but with persistent adrenal insufficiency suggesting the destructive nature of the adrenal involvement.

 

Nothing to Disclose: AM

22656 4.0000 LBT-067 A Diffuse Large B Cell Lymphoma Presenting with Bilateral Adrenal Masses and Adrenal Insufficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Thamara E Osinga*1, Paraskevi Xekouki2, Joan Nambuba1, Fabio R Faucz3, Maria De La Luz Sierra4, Thera P Links5, Ido P Kema5, Karen T Adams1, Anouk N A Van der Horst-Schrivers5, Constantine A Stratakis6 and Karel Pacak7
1Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2National Institute of Health, Bethesda, MD, 3National Institutes of Health, Bethesda, MD, 4National Institutes of Health (NIH), Bethesda, MD, 5University of Groningen, University Medical Center Groningen, Groningen, Netherlands, 6Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 7National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD

 

Introduction: Pheochromocytomas (PHEOs) and paragangliomas (PGLs) are rare neuroendocrine tumors. In about 35% of patients diagnosed with these tumors, an underlying germline mutation is detected, of which mutations in the succinate dehydrogenase (SDH) subunit B (SDHB) and subunit D (SDHD) are the most prevalent ones. Genetic testing for family members of patients is recommended in order to offer regular screening for PHEO/PGL. Obtaining high quality DNA for human genetic studies is essential in the disease gene discovery process. Blood samples are favored, obtaining leukocytes for high quality DNA, however, leukocytes can also be obtained by collecting saliva. 

Objective: The aim of this study was to determine whether SDHB and SDHD gene mutations in patients with PHEO/PGL could be determined using a salivary sample.

Methods: This single center study was performed at the National Institutes of Health, Bethesda, USA. Paired blood and salivary samples were collected from 15 patients; 6 patients had a known SDHB mutation, 4 patients had a known SDHD mutation and 5 patients were screened negative for any SDHx mutation. The Oragene DISCOVER (OGR-500) (DNA Genotek Inc. Ottawa, Canada) was used to collect and extract DNA from saliva. DNA from EDTA blood samples was extracted as previously described (1). The DNA purification and concentration was measured by spectrophotometry. The four exons of SDHD and the eight exons of SDHB were amplified and sequenced by PCR-based bidirectional Sanger sequencing using the saliva-extracted and blood-derived DNA.

Results: Total DNA yields from saliva were similar to the ones obtained from blood DNA (mean (±SD) saliva vs. blood DNA concentration 455 (±344) ng/µL and 400 (±250) ng/µL). The purity of the saliva DNA samples was lower than blood (mean OD260/OD280 ratio 1.7 vs. 1.9, respectively) indicating more protein contamination in the saliva extracted DNA. All salivary DNA samples were successfully genotyped for all 10 single-nucleotide mutations. No mutations of SDHB and SDHD genes were detected in controls.

Conclusions: The present results show that salivary DNA collected from PHEO/PGL patients is a good alternative for extraction of genomic DNA for its high concentration and acceptable purity and can be used as an alternative to blood-derived DNA to screen for SDHB and SDHD mutations. Saliva collection is noninvasive, in contrast to blood collection, which can be a major obstacle particularly in children and even adults. In addition, the sample can be collected at home and send to the hospital by regular mail, which increases the patient’s comfort significantly.

 

Nothing to Disclose: TEO, PX, JN, FRF, MDLLS, TPL, IPK, KTA, ANAV, CAS, KP

22769 5.0000 LBT-068 A Confirming Sdhx Genetic Status in Saliva: A Novel Method of Genetic Testing in Patients with Pheochromocytoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Manjusha S Rathi*
Sherwood Forest Hospitals NHS Foundation Trust, Sutton in Ashfield, United Kingdom

 

Introduction:
Incidentally discovered bilateral adrenal masses can present challenges both in diagnosis and management. They are more likely due to metastatic disease, haemorrhage, infective / infiltrative disease or neoplasia e.g. bilateral pheochromocytoma or adrenocortical carcinoma. Since bilateral disease is more likely to be pathologic, a refined diagnostic approach is warranted.

Case report:
A 52 year old Caucasian male presented with symptoms of increased urinary frequency and during investigation he was noted to have bilateral adrenal mass (CT abdomen: Right 6 cm & Left 7.6 cm adrenal mass containing areas of calcification and multiple loculii of fatty attenuation). His other concerns were tiredness & lethargy for past 6 months. No symptoms of postural hypotension or weight loss.
His past medical history (PMH) consisted of Basal cell carcinoma (BCC) left cheek - operated 2 years ago, hypertension and osteoarthritis. Medication: Amlodipine 10 mg OD.
Examination: weight 78 kg, BMI 33, BP 148/89 (no postural hypotension), no clinical features of Cushing’s, no skin pigmentation.
Endocrine evaluation revealed baseline ACTH 59 nmol/L (Ref <49), adrenal insufficiency (post ACTH stimulation: peak serum cortisol 175 nmol/L),  normal 24hr urinary metanephrine excretion. Renin 864 mU/L (8.3 – 46.3),  Aldosterone 3103 pmol/L (ref 111- 860).
In view PMH of BCC and presence of bilateral adrenal tumour, diagnosis of adrenal metastasis was considered and whole body CT scan was arranged. This did not reveal any evidence of metastasis or tumor elsewhere in the body.
Subsequent investigation: Serum testosterone 13.8 nmol/L (8-27), Androstendione > 35 (ref Adults Up to 10.8 nmol/L), Post ACTH stimulation: peak 17OH progesterone >189 nmol/L (ref 1.8  – 10.3), 24Hr urinary steroid profile showed gross elevation in pregnanediol, pregnanetriol, 17 hydroxypregnanolone, 11 oxo-pregnanetriol, consistent with Congenital adrenal hyperplasia (CAH) due to 21OH deficiency which was later confirmed on genetic testing. He is currently on Hydrocortisone 10 mg am, 5 mg pm & Fludrocortisone 100 mcg per day.
Conclusion:
CAH infrequently manifests as bilateral adrenal disease. It is unlikely to present as an adult, since most patients are diagnosed in childhood or have symptoms of adrenal insufficiency, virilisation, or salt-wasting. Interestingly this patient did not have any symptoms suggestive of salt wasting during childhood and was able to live without adrenal crisis.
This is a rare case of bilateral adrenal mass - myelolipoma associated to CAH due to 21OH deficiency presenting during adulthood. It is speculated that chronic exposure to high ACTH concentrations induces transformation of adrenal cortical precursor cells into fat cells leading to development of adrenal myelolipoma. This case highlights the need to rule out CAH in incidentally detected adrenal masses to avoid unnecessary surgical procedures.

 

Nothing to Disclose: MSR

22346 6.0000 LBT-069 A Bilateral Adrenal Incidentaloma: A Diagnostic Challenge 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Marko Poglitsch*
Attoquant Diagnostics, Vienna, Austria

 

Primary aldosteronism (PA) is severe form of hypertension characterized by a strongly increased aldosterone secretion mediated by adenomas or other forms of adrenal hyper-activity. Once detected, PA can be usually cured by either surgical intervention or by appropriate pharmacologic treatments. This is also reflected in clinical guidelines of Endocrine Societies in Europe and the US, suggesting extensive PA screening activities among resistant hypertensive patients. The incidence of PA among hypertensive patients varies strongly between different studies, which is in part caused by the complex state-of-the-art testing procedure that unfortunately is far away from being a versatile PA screening tool. Despite strong limitations regarding selectivity, sensitivity and the interference with multiple anti-hypertensive drugs, the aldosterone-renin-ratio (ARR) is widely used for PA case detection. However, there is still a strong demand for accurate and reliable and patient friendly PA case detection. The use of novel and more accurate technologies for quantification of aldosterone and renin activity might help to improve the power of the ARR as a diagnostic tool for PA. However, there is a big need for a versatile PA screening assay that doesn’t interfere with anti-hypertensive treatments and therefore allows the clear identification of PA patients without complex corrections and adaptions being necessary and without increasing the patient’s cardiovascular risk in the course of the diagnostic process. The Aldosterone-to-Angiotensin-II-Ratio (AA2-Ratio) is a novel mass-spectrometry based high-throughput test for PA that combines the plasma levels of aldosterone and physiologically active angiotensin II into a diagnostic ratio. The test performance is superior to the ARR in terms of the diagnostic window and method accuracy. The AA2-Ratio does not interfere with standard anti-hypertensive drugs including ACE inhibitors. First data obtained in a proof-of-concept study investigating PA positive and negative patients proved the AA2-Ratio to be a powerful and cost-effective diagnostic tool for the diagnosis of PA in clinical practice.

 

Disclosure: MP: Management Position, Attoquant Diagnostics.

22856 7.0000 LBT-070 A The AA2-Ratio: A Novel Screening Test for Primary Aldosteronism in Hypertensive Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Hande Peynirci1, Kevser Onbasi*2, Pinar Sisman3, Güven Özkaya4, Nagehan Dik5, Nihal Yilmaz5, Riza Karaduman6, Özen Öz Gül3, Canan Ersoy1 and Erdinc Erturk7
1Uludag University Medical School, Bursa, Turkey, 2Department of Internal Medicine, Division of Endocrinology and Metabolism, Dumlupýnar University,Kütahya, Turkey, 3Department of Internal Medicine, Division of Endocrinology and Metabolism, Uludag University Medical School, Bursa, Turkey, 4Uludag University Medical School, Bursa, Turkey Department of Biostatics, 5Department of Internal Medicine, Uludag University Medical School, Bursa, Turkey, 6Department of Internal Medicine,Uludag University Medical School, Bursa, Turkey, 7Department of Internal Medicine, Division of Endocrinology and Metabolism, Uludag University Medical School, Bursa, Turkey, Bursa, Turkey

 

Introduction: Adrenocortical carcinomas (ACC) are rare malignancies with an annual incidence of 0.6-2 per million. It is an important issue for both of the physicians and the patients due to the poor prognosis of disease. Therefore we aimed to compare the clinical features, hormonal status, results of imaging modalities and treatment of patients diagnosed ACC and non-functional incidentaloma for a 3-year period retrospectively.

Methods: Patients identified with adrenal mass during radiologic imaging due to non-adrenal complaints and diagnosed as non-functional (NF) adrenal incidentaloma after hormonal evaluation or diagnosed as adrenocortical carcinoma in pathological examination were classified into 2 groups. There were 9 patients in both groups. Age, gender, comorbid diseases, symptoms, results of endocrinologic and radiologic evaluation with computerized tomography (CT) and size of the masses in patients referred to the surgery were compared between groups. 

Results: In both groups, 5 (%55,6) and 4 (%44,4) of the patients were male and female, respectively. There was no statistical difference between mean age of patients with ACC (57.33 ±11.18) and NF adenoma (57.22 ± 10.99). There were no statistical differences between groups in terms of diabetes mellitus, hypertension, coronary arterial disease, osteoporosis and thyroid nodule rates. When symptoms were evaluated, it was found that abdominal pain, weight gain, central obesity, pleatore, hirsutism rates were higher without statistically significance in ACC group. 3 patients had supressed adrenocorticotropic hormone and elevated cortisole level although there were no suppression with 1 and 2 mg of dexamethasone administration in ACC group. In addition, median dehydroepiandrosterone sulfate (DHEA-S) value was 738 ug/dL (106-1263) in ACC group and 91.75 ug/dL (20-225) in other group (p:0.011). There was no side difference between groups according to CT. The median size was 100 mm (35-150) in ACC group whereas size was 22.5 mm in other group (p:0.000) when CT imaging results were evaluated. Nearly all of the masses were non-adenomatous in ACC group whereas all masses were adenomatous in NF adenoma group. It was found that all patients in ACC group were referred to surgery whereas patients in other groups were followed-up. The median size was found 90 mm (30-185) in masses resected with surgery which were similar to the radiologic images.

Conclusion: Although ACC has been repored to be seen more frequently in females and approximately 60% hormonally active, in our study ACC was more common in males and 33.3% were hormonally active. DHEA-S seemed to be a prominent hormone for the evaluation of ACC in our study. Adrenal masses < 4 cm are generally considered to be benign. In our study, one patient with ACC had a mass < 4 cm. For that reason, it is reasonable to consider that mass size is not enough for the evaluation of malignancy in adrenal gland tumors.

 

Nothing to Disclose: HP, KO, PS, GÖ, ND, NY, RK, ÖÖ, CE, EE

22847 8.0000 LBT-071 A Comparison of Clinical, Laboratory and Imaging Features of Adrenocortical Carcinomas and Non-Functional Incidentalomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Ryaz Chagpar*, Pinar Yazici, Jessica Marquard, Shamil Aliyev, Allan E Siperstein, Charis Eng and Eren Berber
Cleveland Clinic, Cleveland, OH

 

Background: Current Endocrine Society guidelines suggest that genetic testing should be considered in every patient with pheochromocytoma or paraganglioma (PCPGL). We therefore sought to evaluate current practices and variation in the patterns of referral to genetic counselling for patients with PCPGL.

Methods: A prospectively maintained pathologic database comprising patients diagnosed with PCPGL from 2000-2014 at our institution was queried and cross-referenced with electronic medical records to obtain information on clinical presentation, family history, previous genetic testing, biochemical profile, intraoperative and pathologic tumor features, as well as referral for and results of genetic evaluation.  Univariate and multivariate analyses were performed to assess factors associated with referral for genetic testing.

Results:  A total of 253 patients comprised the analytic cohort, of which 215 (85%) presented with pheochromocytoma (PHEO) and 38 (15%) presented with paraganglioma (PGL).  Ten (4%) patients had been previously diagnosed with a syndrome or deleterious germline mutation associated with PCPGL and were not referred for genetic evaluation.  Of the 95 (37.5%) patients who were referred, 62 were seen by a genetic counselor and 48 (77.4%) underwent selective panel testing.  A deleterious mutation in a known PCPGL susceptibility gene was found in 20.8% of patients that received testing.  Of those patients who did not fulfill classic criteria for referral, none tested positive for such a mutation.  Individuals who were referred for genetic testing were more likely to be younger (age<45, 47.5% vs 33.0%, p=0.03), with a family history of PCPGL or associated tumor syndrome (53.3% vs 33.9%, p=0.05), have a dopamine secreting tumor (66.7% vs 37.5%, p=0.05), received surgical treatment by an endocrine surgeon (vs other surgeon, 70.1% vs 17.3%, p<0.001), and been diagnosed within the last 7 years of the study (52.6% vs 20.3%, p<0.01).  Factors which were not significant included tumor type (PHEO or PGL), higher BMI, larger tumor size (≥4cm), the presence of bilateral tumors, a Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) score ≥4, and pathologic or intraoperative evidence of malignancy or metastatic disease. On multivariate analysis, only family history (OR 5.3, 95% CI: 1.1 – 25.2; p=0.04) and treating surgical department (Endocrine surgery vs. Other, OR 7.3, 95% CI: 2.8-18.9; p<0.01) were significant independent predictors of referral for genetic evaluation.

Conclusion: Fewer than 40% of patients with PCPGL are referred for genetic evaluation, despite the presence of traditional indications.  Complex clinical and demographic criteria for referral may undermine referral to genetic professionals. Given the data and routine of panel testing, we conclude that all diagnoses of PCPGL be referred for genetic counseling and testing.

 

Nothing to Disclose: RC, PY, JM, SA, AES, CE, EB

22867 9.0000 LBT-072 A Genetic Evaluation for Patients with Pheochromocytoma and Paraganglioma: Variation in Patterns of Referral 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Sonakshi Sharma* and Ian MacMurray Holdaway
Greenlane Clinical Centre, Auckland, New Zealand

 

Background: The adrenal gland is the most commonly involved endocrine organ in autopsy studies of patients who die of Acquired Immunodeficiency Syndrome (AIDS). The most common finding at autopsy is the presence of intranuclear or intracytoplasmic inclusion bodies in enlarged adrenal cells, indicative of Cytomegalovirus (CMV) adrenalitis. Recognition of CMV-related primary adrenal insufficiency in patients with AIDS requires a high clinical suspicion in patients already on glucocorticoid treatment, especially if the treatment is to be withdrawn.

Case Presentation: We report the case of a 67 year old man with a new diagnosis of Human immunodeficiency virus infection and multiple AIDS defining illnesses including disseminated CMV infection. Use of six weeks of prednisone therapy for an exacerbation of chronic obstructive pulmonary disease resulted in a delay in the diagnosis of primary adrenal insufficiency from Cytomegalovirus in the patient resulting in marked hypoadrenal symptoms when prednisone therapy was stopped.

Conclusion: Our case highlights the importance of investigating for adrenal insufficiency in AIDS patients with disseminated CMV infection, regardless of prior or concurrent treatment with glucocorticoids, particularly if glucocorticoids are to be withdrawn.

 

Nothing to Disclose: SS, IMH

22527 10.0000 LBT-073 A Cytomegalovirus Adrenalitis Leading to Adrenal Insufficiency in a Patient with AIDS, Disguised By Concomitant Corticosteroid Administration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Alejandro Roman-Gonzalez*1, Maria del Pilar Londono2, James Diaz2, Carlos Alfonso Builes-Barrera3 and Johnayro Gutierrez4
1Hospital San Universitario Vicente Fundacion, Medellin, Colombia, 2Universidad de Antioquia, Medellin, Colombia, 3Hospital Universitario Vicente Fundacion, 4Universidad de Antioquia

 

Background: The increasing use of technology for diagnostic purposes has allowed the discovery of adrenal lesions in patients without suspicion of an adrenal disease, known as adrenal incidentaloma. Some of these lesions are hormonally active, others can be benign or easily treated such as myelolypoma, tuberculosis, fungal infections or infrequent lesions like schwanomas; however, in the worst cases they are adrenal carcinomas. The prevalence of adrenal incidentaloma in radiological studies is 0.6% to 4.4%. The epidemiology of adrenal incidentaloma from developing countries is currently unknown with only one report from India. To our knowledge there are no studies from Latinamerica.Hypothesis: To establish the epidemiology of adrenal incidentaloma in radiological studies from real life clinical practice in a tertiary care hospital in Colombia.Methodology: Review of the computed tomography (CT) reports from adults (>18 years old) performed at the Hospital Universitario San Vicente Fundacion, Medellín, Colombia from different indications (2011-2014). All studies reporting an adrenal lesion were documented with a review of the indication and the performed studies. An adrenal incidentaloma was defined as an adrenal lesion > 1 cms in a patient with an unsuspected adrenal disease or cancer. Adrenal lesions from studies done to cancer staging were excluded. The preliminary results from 2014 are reported.Major results: 606 CT reports were reviewed. The mean age was 56 years (min 18, max 98 years), 275 were female and 331 were male. 12.37% of the studies were unenhanced CT and 87.62% were enhanced CT. 17 adrenal lesions were found (2.80%), 6 of them were excluded because they were not considered adrenal incidentalomas (traumatic hematoma: 1, metastasis: 4, diffuse enlargement <1 cms: 1). 10 adrenal incidentalomas were found corresponding to 1.65%. The mean age was 67.3 (min 52, max 76). The mean size was 13.3 mm. 4 were adenoma, 1 was a metastasis in a patient without cancer diagnosis. In the rest of the cases a specific diagnosis was not done. Interestingly 80% of the cases did not have any hormonal studies, in the other cases the studies were ambulatory and one the hormonal studies was performed in hospital.Interpretation of results and conclusions:Adrenal incidentaloma was found in 1.65% of radiological reports in real clinical practice from a tertiary care hospital from a developing country. Most of them were not studied properly in terms of hormonal production despite 50% being adenomas. Awareness of the possibility of hormonal production in adenomas should be encouraged in our institution.

 

Nothing to Disclose: AR, MDPL, JD, CAB, JG

22876 11.0000 LBT-074 A Adrenal Incidentaloma in Real Clinical Practice in a Developing Country Are Not Studied for Hormonal Production 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Gemy Maria George*1 and Anoopa Annie Koshy2
1John H. Stroger Jr. Hospital of Cook County, Chicago, IL, 2John H. Stroger, Jr. Hospital of Cook County, Chicago, IL

 

Introduction

     Malignant pheochromocytoma is a rare disease, constituting 5-10% of all pheochromocytomas and paragangliomas.  Plasma free and urine fractionated metanephrines are used to assess biological activity and monitor tumor burden.  However, there have reports of patients with pheochromocytomas and paragangliomas with normal metanephrines.  Here, we describe a patient with a metanephrine-positive malignant pheochromocytoma, whose metanephrines became negative 6 months post resection of the primary tumor despite large tumor burden.

Clinical Case

     A 62-year old man presented with abdominal pain, hypertensive urgency, unintentional weight loss, and a protruding intra-abdominal mass.  An abdominal CT scan revealed a 16 x 23 cm necrotic mass in close proximity to the liver, with enlarged periaortic lymph nodes. He had elevated plasma free metanephrines (plasma MN 131 pg/ml, n<57 pg/ml) and urine fractionated metanephrines (urine MN 1460 mcg/24hr, nl 90-315 mcg/24hr; urine NMN 9816 mg/24 hr, nl 122-676/24 hr).  After alpha blockade, he underwent exploratory laparotomy, right adrenalectomy, and para-aortic lymphadenectomy which revealed a 2650 g. necrotic, hemorrhagic, adrenal mass.  Pathology confirmed metastatic pheochromocytoma, with evidence of extracapsular and lymphovascular invasion and metastasis to lymph nodes.

     He was lost to follow-up until he presented 6 months later with left hip pain, and was noted to have a pathological fracture of the left femoral head.   His repeat CT chest/abdomen showed multiple pulmonary, parasternal, retrosternal, retroperitoneal and pelvic masses concerning for metastases.  His MIBG scan was negative, and plasma free and urine metanephrines were within normal limits (plasma MN 30 pg/ml, n <57 pg/ml; urine MN 128 mcg/24 hr, nl 90-315 mcg/24 hr; urine NMN 283 mcg/24 hr, nl 122-676 mg/24 hr).  However, his serum chromogranin A was elevated (118 ng/ml; nl 1.9-15 ng/ml) and biopsy of the retroperitoneal mass confirmed metastatic pheochromocytoma. Genetic testing for SDHB and VHL mutations were negative.  He received palliative radiation to left hip, was placed on Sunitinib, and is being considered for possible debulking surgery.

Conclusion

     This is the first case demonstrating a metanephrine-positive malignant pheochromocytoma that became metanephrine-negative despite extensive metastases. Defective catecholamine synthesis from absence of tyrosine hydroxylase as part of tumor dedifferentiation may explain these normal levels.  Our case also supports the utility of Chromogranin A as an alternate biochemical parameter to assess tumor burden even in pheochromocytomas that have been previously known to be functional.

 

Nothing to Disclose: GMG, AAK

22550 12.0000 LBT-075 A The Utility of Chromogranin a in an Unusual Case of a Malignant Pheochromocytoma That Lost Ability to Secrete Metanephrines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Ishrat Naz Khan*1, Khine Sabai Phyu1, Mohamed Ahmed Adlan2 and Lakdasa DKE Premawardhana3
1YYF Hospital, Aneurin Bevan University Health Board, Caerphilly, United Kingdom, 2Ysbyty Ystrad Fawr Hospital, Aneurin Bevan University Health Board, Caerphilly, United Kingdom, 3Ysbyty Ystrad Fawr Hospital, Aneurin Bevan University Health Board, Cardiff, United Kingdom

 

Introduction

Adrenal suppression is a potentially dangerous side effect of long-term steroid therapy and an aspect of therapy, which is often neglected. Despite current specialist society guidelines, knowledge amongst both patients and health care professionals is poor about “sick day” rules, the use of “steroid cards” and bracelets, and the utility of parenteral steroids in appropriate circumstances.

 Methods and Results

We tested the knowledge of these aspects of long-term steroid therapy in patients (n=38), and healthcare professionals (n=38), in a secondary care hospital setting.

Patients

Their median age was 62.5 years. They were on steroids for rheumatological (40%), chest (26%), endocrine (11%), colonic (8%) and other (15%) indications. The duration of therapy with steroids ranged from 6 weeks - 20 years. The main steroid preparations used were prednisolone (66%), hydrocortisone (8%) and dexamethasone (8%). Out of 38 patients, only 12 (32%) carried a steroid card or wore an identifying bracelet regularly, and only 6 (16%) had received instructions about “sick day” rules from a healthcare professional. Four patients (11%) had access to parenteral steroids at home. When asked about “sick day” rules and steroid dose increase in several scenarios of minor and major “stress”, 6 (16%) said they would continue to take the same dose and 16 (42%) did not know i.e. only 42% said they would consider some form of dose increase.

Healthcare professionals

The majority (55%) were GIM and Endocrine physicians, or physicians in training; 34% were nurses working in the acute medicine unit. Only 3 of 38 were aware of the minimal duration of steroid therapy for issuing a “steroid card”. 14 (37%) of them advised patients on “sick day” rules at commencement of therapy but only 16 (42%) recommended issue of parenteral steroids for emergency home use. Of concern was that 8 (21%) healthcare professionals did not recommend steroid dose increase at times of minor or major “stress”. 13 (34%) were aware of sources for advice about long-term steroid therapy.

Discussion

We have demonstrated a significant lack of awareness of an important safety aspect of long-term steroid therapy amongst both patients and health care professionals. The prevention of a potentially life threatening adrenal crisis due to relative cortisol insufficiency at times of minor or major “stress”, by increasing steroid dosage and the use of parenteral steroids, is of paramount importance. This is an area of management currently neglected in our practice. We recommend urgent and intense education about this aspect of steroid therapy, of both patients and healthcare professionals, involved in prescribing long-term steroid therapy and in caring for acutely ill patients.

 

Nothing to Disclose: INK, KSP, MAA, LDP

22646 13.0000 LBT-076 A Poor Knowledge of the Effects of Adrenal Suppression during Long-Term Steroid Therapy Among Patients and Healthcare Professionals 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Thursday, March 5th 3:00:00 PM LBT 064-076 6271 1:00:00 PM Late-Breaking Adrenal/HPA Axis I Poster


Navinder K Jassil*1, Michael A. Levine2 and Gauri Dhir3
1Cooper Medical School of Rowan University, Camden, NJ, 2The Children's Hospital of Philadelphia, Philadelphia, PA, 3University of Florida, Gainesville, FL

 

Objective: Hereditary hypophosphatemic rickets with hypercalciuria (HHRH) differs from other forms of hypophosphatemic rickets as patients have elevated levels of serum 1,25(OH)2VitD and urine calcium and depressed serum levels of PTH and FGF23. In addition, bone demineralization and fractures are common in patients with HHRH. In this case report we describe an adult male who presented with severe and symptomatic osteoporosis that was discovered to be due to HHRH.

Case Presentation: A 54-year-old, 65” tall Vietnamese male presented for evaluation of low back and rib pain that required treatment with narcotics. Previous studies revealed multiple rib and sacral fractures, and bone densitometry by DXA showed T scores at L1-4 of -2.8 and at FN -1.4. Evaluation was negative for a history of bone problems as a child, hypogonadism, glucocorticoid steroid use or malignancy. The patient had previously been diagnosed with osteoporosis and treated unsuccessfully with bisphosphonates, calcium, and vitamin D.

Evaluation in the Endocrine Clinic revealed normal serum calcium level of 8.9 mg/dL, low normal iPTH 14-18 pg/mL, normal 25(OH)VitD 35.1 ng/mL, normal alkaline phosphatase 90 IU/L; serum phosphorus  was low at 1.7 mg/dl and 1,25 (OH)2VitD was markedly elevated at 188.2 pg/ml. Urinary excretion of calcium  (649.4-864 mg/24 hr) and the fractional excretion of phosphorus (40%, ref 5-20%) were both elevated. Renal ultrasound showed bilateral 5 mm non-obstructing kidney stones. The biochemical features and low bone density suggested HHRH, and analysis of the SLC34A3gene, which encodes Napi2c sodium phosphate cotransporter, revealed that the patient was a compound heterozygote for two missense mutations, c.2788 G>A; p.G191S and c.2168G>A pR67H. The patient was treated with phosphate replacement and bisphosphates were discontinued. Patient had marked improvement in bone pain and no further bone fractures. One year later a repeat DXA scan showed improved bone density with T score at L1-4 of -1.4 and FN +0.9

Discussion:  HHRH is very rare autosomal recessive disease due to biallelic loss of function mutations in SLC34A3gene, and typically presents in childhood. Our patient presented in adulthood with symptomatic osteoporosis with biochemical and genetic confirmation of HHRH.

Conclusion: This case of HHRH highlights the importance of determining the serum phosphorus level in patients with osteoporosis, and extends previous observations of an association between hypophosphatemia due to heterozygous mutations of SLC34A1 and nephrolithiasis and/or osteoporosis. Correct diagnosis and treatment of hypophosphatemic disorders are essential to prevent bone sequelae and kidney stones.

 

Nothing to Disclose: NKJ, MAL, GD

22312 1.0000 LBT-033 A Late Diagnosis of Hypophosphatemic Rickets with Hypercalciuria As Adult Osteoporosis: Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Shanshan Gao, Yan Cheng, Lingling Zhao, Yuxin Chen and Yu Liu*
Jilin University

 

Irisin, a recently idenfied myokine, whose function is to transform white adipose tissue (WAT) to brown adipose tissue (BAT) , thereby inducing thermogenesis (1, 2). Hence,some scientists speculate the potential role of irisin in preventing from type 2 diabetes and metabolic diseases associated with obesity (such as polycystic ovary syndrome). To study the role of irisin on metabolic diseases, we detected the level of irisin and other metabolism indexes in the serum of 44 women with PCOS ,19 new onset type 2 diabetes patients and 39 age and BMI matched women. We found BMI, Weight, Waist, WHR and levels of LH, T, LH/FSH, triglyceride, total cholesterol and LDL-cholesterol of PCOS patients were significantly higher than those of control women. Serum irisin level of PCOS didn’t show significant difference compared with control subjects although it was decreased.T2DM female patients (N = 19, BMI = 22.48 ± 3.60, age =23.26 ± 7.59) had significantly reduced levels of irisin and adiponectin as compared with control and PCOS women. Levels of adiponectin in PCOS patients were significantly decreased compared to control women. No correlation was observed between irisin and BMI (r = 0.217, p = 0.185; r = 0.187, p = 0. 224) and age (r = 0.181, p = 0.269; r = 0.129, p = 0.405) either in control (N = 39) or PCOS (N = 44) groups. Partial correlations analysis indicated a positive correlation between serum irisin levels and bone mineral density and a negative correlation in head fat mass in control group. Pearson correlations analysis found that irisin concentrations were significantly correlated with Right Arm Area (r = 0.656, p = 0.039) in PCOS patients (N=10). This study demonstrated that PCOS subjects display significantly higher total cholesterol, FIN and HOMA-IR and lower HDL-cholesteroland adiponectin levels. There was no difference in serum irisin concentrations between PCOS and control groups. Irisin levels are decreased in patients with T2DM and are positively associated with bone mineral density in control group.

 

Nothing to Disclose: SG, YC, LZ, YC, YL

22677 2.0000 LBT-034 A The Level of Irisin in PCOS and Type 2 Diabetes Patients and the Positive Association with Bone Mineral Density 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Muhammad Houri*
Al Ain Hospital, Al Ain, United Arab Emirates

 

24 year old female was found to have hypokalemia on routine investigations. She has no history of hypertension. 

 She had history of bronchial asthma, but no other medical problems

 Review of symptoms  significant for  of fatigue, polyuria, nocturia,  cramps of the arms and legs. Menstrual cycles were regular.

Work up revealed hypokalemia, metabolic alkalosis, hypomagnesemia, inappropriate high potassium level in urine collection along with elevation in urinary sodium and urinary chloride.  Urine calcium was low. 

 On questioning, the patient denies chronic use of abuse of laxatives or diuretics.  Her parents are related (distant cousins)

 Physical exam unremarkable, with normal vital signs.

 Few months after initial presentation, she reported amenorrhea, prolactin was 102, MRI revealed pituitary micraodenoma. Treatment with Cabergoline lead to normalization of prolactin level  and restored regular cycles.

Data

Two years prior to presentation to our office potassium has been  in the range of 2 to 3. 

 At the time of presentation in this office, potassium was 2.8, chloride 97,  CO2 34, aldosterone 0.22 nmol/l (normal less than 0.86), rennin more than 128 ng/l (normal range 4 -37), these were done in upright position.  On the same day potassium 3.1, sodium 138.

 Urine electrolytes revealed urine potassium 66 mmol/L, urine sodium 193 mmol/L, urine chloride 243 mmol/L.

 ABG showed pH 7.44 with PO2 16, HCO3 33.4

 On questioning the patient reports that her sister has similar history of hypokalemia without hypertension. Her sister refused to complete work up.

 Conclusion and Discussion

The patient has clinical picture suggestive of Gitelman syndrome.  Since she has evidence of hypokalemia along with metabolic alkalosis, inappropriately high level of potassium in urine along with elevated urinary sodium and chloride and low urinary calcium.  The patient was treated with potassium supplement along with magnesium supplement and Aldactone. To my knowledge,the association between Gitelman  syndrome and  prolactinoma has not been reported.however, since prolactionma is fairly common ,This may be a co-incidence.

Gitelman's syndrome is a rare autosomal recessive disorder, characterized by hypokalemia, metabolic alkalosis, hypomagnesemia, and hypocalciuria. It is caused by mutations in the SLC12A3 gene encoding the thiazide-sensitive sodium chloride contrasporter. The clinical manifestations  are highly variable. Diagnosis may be delayed for years. Treatment consists of  K and Mg supplements along with aldactone.

 

Nothing to Disclose: MH

22840 3.0000 LBT-035 A Gitelman Syndrome Diagnosed in Young Patient with  Chronic Hypokalemia, and Incidental Finding of a Microprolactinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Juliette L. Sandifer Kum-Nji*1 and Richard Dale Childress2
1University of Tennessee Health Science Center, Memphis, TN, 2VA Medical Center, Memphis, TN

 

Introduction: Hypercalcemia in renal cell cancer has been associated with several etiologies including elevated 1,25 dihydroxyvitamin D, osteolytic induced, and parathyroid hormone-related peptide (PTH-rp) mediated humoral hypercalcemia. More rarely, hypercalcemia of malignancy has been associated with other tumor derived humoral factors including transforming growth factor alpha, granculocyte macrophage colony stimulating factor, interleukin 1 and 6, prostaglandin E, procathepsin D, and tumor necrosis factor alpha.

Case: A 67-year old white male presented to the VA hospital with hypercalcemic crisis (serum calcium 19 mg/dL, previously 7.3 mg/dL seven weeks prior to admission) and altered mental status. The patient had a past medical history of T11 paraplegia, squamous cell carcinoma of the larynx T2N0MX first diagnosed in 2009 status post total largynectomy, total thyroidectomy, parathyroidectomy, bilateral neck dissection, chemotherapy, and radiation. For the last several months, the patient noted painful bilateral upper and lower extremity sensory neuropathy associated with edema of his hands. A CT scan of the abdomen was done due to suspected paraneoplastic syndrome and revealed an 18mm lesion in the inter pole of the left kidney with peripheral calcification suspicious for renal cell carcinoma. Bone scan showed no foci of activity suspicious for malignancy. PET scan showed intense activity (SUV max 6.5) in a 2.4 cm solid nodule in the lateral inter pole region of the left kidney. PTH-rp <0.74 pmol/L, nl <2 pmol/L, 1,25-dihydroxyvitamin D 45.8 ng/mL, nl 35-126 ng/mL, 25 hydroxyvitamin D 15.5 ng/mL, nl 35-126 ng/mL, and PTH <3.4 pg/mL, nl 16.5-78.8 pg/mL. SPEP was significant for alpha 2 fraction of undetermined significance. UPEP was unremarkable. TSH <0.015 ulU/mL, nl 0.4-4.7 ulU/mL, Free T4 1.09 ng/dL, nl 0.75-2.45 ng/dL, and free T3 3.7, nl 2- 4.4 pg/mL. The patient received medical treatment with IV fluids, calcitonin, and 4mg of Zolendronic acid. Hospital course was complicated by iatrogenic hypocalcemia after bisphosphonate treatment requiring calcitrol, ergocalciferol, and a calcium drip which was eventually discontinued and levels remained stable on calcium carbonate by mouth. He underwent cryoablation of the suspected renal cell carcinoma. TNF alpha level prior to ablation was 15 pg/mL, nl <5 pg/mL and subsequently decreased to 9.2 pg/mL post operatively. Interleukin 1B was 9.8 pg/mL preoperatively, nl <3pg/mL and 4.8 pg/mL post operatively.

Discussion: Humoral hypercalcemia of malignancy is commonly associated with tumor derived humoral factor PTH-rp. PTH-rp is reportedly elevated in up to 15% of all patients with renal cell carcinoma. However other cytokines such as tumor necrosis factor alpha and interleukin 1 have also been associated with hypercalcemia in renal cell carcinoma and should be investigated as a cause of hypercalcemia in these patients.

 

Nothing to Disclose: JLS, RDC

22499 4.0000 LBT-036 A Humoral Hypercalcemia of Malignancy with Elevated TNF Alpha in Renal Cell Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Arti Dilipkumar Shah*1, Edward C. Hsiao2, Betsy O' Donnell3, Kirsten Salmeen3, Robert Nussbaum3, MIchael Krebs4, Sabina Baumgartner-Parzer5, Martin Kaufmann6, Glenville Jones6, Daniel D Bikle7, Allen S Mathew8, Dolores M. Shoback7 and Ingrid Juliana Block-Kurbisch9
1UCSF, San Francisco, CA, 2University of California-San Francisco, San Francisco, CA, 3University of California, San Francisco, 4Medical University of Vienna, Vienna, 5Medical University of Vienna, 6Queen's University, Kingston, ON, Canada, 7University of California San Francisco, San Francisco, CA, 8Redwood Renal Associates, 9St. Mary's Medical Center

 

Introduction: Calcium (Ca) needs in pregnancy are met by increased intestinal Ca absorption and bone resorption. Enhanced production of 1,25-(OH)2-vitamin D (1,25-D) by renal and placental 1α-hydroxylases is an important contributor. In addition, renal Ca reabsorption plays a major role in lactation. However, with intact feedback mechanisms, hypercalcemia is rare in pregnancy.

Case: A 28-year-old pregnant (G4P3) female with a history of nephrolithiasis, nephrocalcinosis and gestational hypertension presented with hypercalcemia. In prior pregnancies, while taking prenatal vitamins, she was hypercalcemic (Ca 14 mg/dL [normal 8.5-10.1] in her third pregnancy). Work-up revealed an elevated 1,25-D (157 pg/mL; normal [non-pregnant] 18-72), normal 25-OH-vitamin D (25-D; 56 ng/mL; normal 30-100), high 24–h urine Ca (417 mg; normal < 200), low parathyroid hormone (PTH; < 3 pg/mL; normal 10-65), normal PTH-related protein (PTHrp; 18 pg/mL; normal 14-27), and normal angiotensin-converting enzyme (ACE; 36 U/L; normal 9-67). Post-partum, serum Ca normalized to 10.2 mg/dL with a 1,25-D level of 48 pg/mL, and remained normal on subsequent monitoring. However, 14 weeks into her fourth pregnancy, an elevated 1,25-D (176 pg/mL) was noted with normal serum Ca 9.5 mg/dL, normal phosphorus 3.1 mg/dL (normal 2.5-4.6), normal 25-D (74 ng/mL), suppressed PTH (3 pg/mL), normal PTHrp (16 pg/mL), and normal ACE (27 U/L) without vitamin D and Ca supplements. She was referred for evaluation. At 18 weeks, serum Ca had risen to 10.6 mg/dL and 1,25-D to 211 pg/mL. Given her prior history, reduced 1,25-D clearance was considered. Vitamin D metabolite analysis (1) revealed a high 25-D (63.4 ng/mL; normal 20-50) and low 24,25-(OH)2-vitamin D (0.74 ng/mL), with a ratio of 86 – in the range (> 80) seen in (patients with) idiopathic infantile hypercalcemia (IIH). This suggested a problem with 1,25-D degradation. 24-hydroxylase gene (CYP24A1) sequencing showed she is a compound heterozygote with an in-frame deletion, E143del, and missense mutation, R396W.

Discussion: This case illustrates an important cause of hypercalcemia of pregnancy and enlarges the spectrum of presentations due to CYP24A1 mutations. CYP24A1 encodes an enzyme whose activity is critical when placental 1α-hydroxylase adds to the total circulating 1,25-D and when vitamin D and Ca supplements are commonly given. This patient proved to have two different CYP24A1 mutations, which when homozygous cause loss-of-function in vitro and are associated with IHH and hypercalcemia in adults (2,3).

 

Nothing to Disclose: ADS, ECH, BO, KS, RN, MK, SB, MK, GJ, DDB, ASM, DMS, IJB

22317 5.0000 LBT-037 A Recurrent Hypercalcemia in Pregnancy in a Patient with Compound Heterozygous Mutations in CYP24A1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Connie Newman*1, Robert Clarke2, Harold Hin3, Joseph Tomson2, Rijo Kurien2, Jolyon Cox2, Michael Lay2, Jenny Sayer2, Michael Hill2, Jonathan Emberson2 and Jane Armitage2
1NYU School of Medicine, New York, NY, 2University of Oxford, Oxford, United Kingdom, 3Hightown Surgery, Banbury, United Kingdom

 

Background Observational studies indicate that plasma levels of vitamin D (25[OH]D) are inversely associated with risk of fracture, cardiovascular and non-cardiovascular diseases, with the lowest risks associated with plasma levels >90 nmol/L (36ng/ml). (1)  Previous large trials of vitamin D3 supplementation for prevention of fracture or other disease outcomes have reported conflicting results, possibly because the doses tested were insufficient to maintain optimum levels of 25(OH)D. (2)

Methods With the aim of establishing the most appropriate dose of vitamin D to assess in a large outcome trial, the BEST-D (Biochemical Efficacy and Safety Trial of vitamin D) trial compared the biochemical and other effects of 100 μg (4000 IU) vs 50 μg (2000 IU) D3 daily vs placebo administered for 12 months in ambulant community-dwelling people ≥65 years living in Oxfordshire, England. The co-primary outcomes were mean plasma 25(OH)D levels at 12 months and the proportion of participants with plasma 25(OH)D >90 nmol/L, by allocated treatment.

Results Mean age of the 305 randomized individuals was 72 years, 51% were male and mean body mass index was 27 kg/m2. At baseline, the mean (SE) plasma 25(OH)D concentrations were 49 (1.5) nmol/L, 55 (2.3) nmol/L and 47 (1.5) nmol/L, among those allocated 100 μg daily, 50 µg daily or placebo, respectively. By 12 months, the baseline-adjusted mean (SE) levels of 25(OH)D were 137 (2.4) nmol/L, 102 (2.4) nmol/L and 53 (2.4) nmol/L, respectively.  Plasma 25(OH)D >90 nmol/L at 12 months was seen in 88% of participants allocated 100 μg daily and 70% of those allocated 50 μg daily (p<0.0001). There were no significant differences in the percent outside the normal range for parathyroid hormone or albumin-corrected calcium (p=0.36 and p=0.21 for 100 μg vs placebo, respectively). Allocation to either dose of vitamin D compared with placebo had no significant effects on muscle or joint pains, physical activity, grip strength or a short physical battery. 

Conclusions Significantly more participants allocated 100 µg vitamin D3 daily achieved plasma levels of 25(OH)D >90 nmol/L than with 50 μg daily and mean levels were also significantly higher. Neither dose was associated with any significant adverse effects. Large, long-term trials of 100 μg vitamin D daily are now required to assess whether the associations of vitamin D with risk of fracture, cardiovascular disease and cancer seen in the observational studies are causal and whether such events are preventable by vitamin D supplementation.

 

Nothing to Disclose: CN, RC, HH, JT, RK, JC, ML, JS, MH, JE, JA

22682 6.0000 LBT-038 A Estimation of the Optimum Dose of Vitamin D for Older People: Results of the Best-D Clinical Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Erico Higino de Carvalho*1, Francisco Farias Bandeira2, Democrito Barros Miranda-Filho3, Maria Militão Albuquerque4, Heloisa Ramos Lacerda1, Thais Gelenske Braga e Oliveira5, Zoraya Medeiros Barros1, Ulisses Barros Montarroyos3 and Ricardo Arraes Ximenes1
1Federal University of Pernambuco, Recife, Brazil, 2Division of Endocrinology, Diabetes and Bone Diseases, Agamenon Magalhaes Hospital, Univertsity of Pernambuco Medical School, Recife PE, Brazil, 3Pernambuco University, Recife, Brazil, 4The Aggeu Magalhães Research Centre (CPqAM) - Oswaldo Cruz Foundation (FIOCRUZ –PE),, Recife, Brazil, 5Institute of Integrative Medicine Professor Fernando Figueira - IMIP, Recife, Brazil

 

Low bone mass (LBM) has frequently been described in the HIV-infected population. The risk factors associated with osteoporosis in HIV-infected women, including the role of infection and antiretroviral therapy (ART) have not been clarified. Our aim therefore, is to describe the prevalence of LBM and its association with different risk factors in HIV-infected outpatient women attending two HIV referral centres in the state of Pernambuco, Northeastern Brazil. A cross-sectional study was undertaken measuring the bone mineral densitometry (BMD) by DXA (DPX- Lunar) in 418 HIV-infected women, 47 of whom were treatment-naïve. The association of LBM was investigated by multivariate analysis with variables grouped into demographic and socioeconomic characteristics, lifestyle, anthropometric measurements, menopausal status, related to the disease and use of ART. The prevalence of LBM was 44% for osteopenia and 19.4% for osteoporosis. The mean age was 44 years (± 9.3 years), 63.1% were premenopausal, there was a mean time of 7 years since HIV diagnosis, and almost 90% were using ART (>6 years). Multivariate analysis indicated that the chance of presenting LBM was higher in HIV-positive women with a lower BMI (p<0.04; OR 5.77; 95%CI 2.3 to 14.3), taking Tenofovir (p= 0.016; OR 1.86; 95%CI 1.12 to 3.09), with no steady partner (p=0.033; OR 1.69; 95%CI 1.04 to 2.73) and under took moderate physical activity (p= 0.029; OR 2.11; 95%CI 1.08 to 4.13). Higher levels of education (p=0.01; OR 0.26; 95%CI 0.12 to 0.58) and moderate alcohol consumption (p=0.052; OR 0.55; 95%CI 0.3 to 1.02) were associated with a lower risk of LBM.
LBM was very prevalent in HIV-infected middle-aged women, in Northeastern Brazil. LBM was directly associated with low socioeconomic status, the use of Tenofovir, low BMI and age, regardless of their menopausal status. Densitometric evaluation should be performed on HIV-infected women going through perimenopause, considering the use of Tenofovir, low levels of education and low income as additional risk factors for osteoporosis within this population.

 

Nothing to Disclose: EHD, FFB, DBM, MMA, HRL, TGBEO, ZMB, UBM, RAX

22767 7.0000 LBT-039 A Tenofovir and Low Socioeconomic Status Associated with Low Bone Density in HIV-Infected Brazilian Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Monika Pawlowska*1, Qun Yang2, Basia Hamata1, Indy Sekhon1, David L Kendler1 and Raewyn Broady1
1University of British Columbia, Vancouver, BC, Canada, 2Prohealth Clinical Research Center, Vancouver, BC, Canada

 

Allogeneic stem cell transplantation (allo-SCT) is associated with multiple factors that may adversely impact bone.  Significant bone loss occurs within the first six months of allo-SCT (1), and includes pronounced cortical bone loss, however, information regarding earlier changes is limited.   The aim of this study was to examine changes in bone mineral density (BMD) within the first 100 days following allo-SCT, to help determine the optimal timing for intervention with antiresorptive medications.  An additional goal was to identify patient and transplant-specific bone loss risk factors. 

We assessed BMD changes at the lumbar spine, total hip, and femoral neck in patients who had allo-SCT between August 2011 and 2014, and had both a baseline and day 100 DXA scan.  By multivariate analysis we assessed the impact of certain variables on the absolute change in BMD (day 100 g/cm2 – baseline g/cm2).  Variables examined were: gender, age ≥50, chemotherapy type, total body irradiation (TBI), donor source, graft vs host disease (GvHD), cumulative steroid dose, and weight change.  

139 patients had both baseline and 100 days DXA scans.  Two patients received zoledronic acid before SCT and were excluded from analyses.  At 100 days, the mean absolute decrease in BMD at the lumbar spine was 0.03 g/cm2 (3.0%), 0.05 g/cm2 (4.6%) at the total hip, and 0.04 g/cm2 (4.7%) at the femoral neck.  Women had greater decline in BMD at all sites.  Two patients sustained 6 clinical vertebral fractures.  Change in lumbar spine BMD was significantly associated with female gender (p = 0.049), GvHD (p < 0.029), and cumulative post transplant prednisone doses >5000mg (p = 0.026).  Total hip BMD change was significantly associated with female gender (p < 0.004), myeloablative chemotherapy (p = 0.017,), and cumulative prednisone dose >1500mg (1501-3000mg p = 0.008; 3001-5000mg p = 0.016; >5000mg p < 0.001).  No risk factors were significantly associated with femoral neck BMD change. 

This is the largest cohort analysis of change in BMD following allo-SCT.  Even very early after transplant, there was a statistically significant decrease in BMD at both trabecular and cortical bone sites.  Since bone resorption clearly starts very early after allo-SCT, it may be prudent to administer antiresorptive therapy prophylactically to patients who have osteopenia prior to transplant; particularly women and patients planned for myeloablative chemotherapy.  The lack of association between glucocorticoid exposure and femoral neck bone loss suggests that cortical bone resorption occurs by a distinct mechanism post allo-SCT.   In this clinical setting, cytokines driven osteoclastogenesis by way of upregulating RANK ligand expression, may account for cortical bone loss (2).  Additionally, hyperparathyroidism is known to induce cortical bone loss and lymphoid cells express PTH receptors, thus immune cells interacting with circulating PTH may also contribute (3).

 

Disclosure: DLK: Principal Investigator, Eli Lilly & Company, Principal Investigator, Astra Zeneca, Member of advisory committees or review panels, Merck & Co., Principal Investigator, Amgen. Nothing to Disclose: MP, QY, BH, IS, RB

22773 8.0000 LBT-040 A Bone Density Change and Factors Impacting Bone Loss 100 Days Following Allogeneic Stem Cell Transplantation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Samia Abdullah Bokhari*1, Areej a Bokhari2, Khalid s Aljabri3, Muneera Alshareef3, Ahmad Alhumaidi4 and Bandari K Aljabri5
1king fahad armed force hospital, Jeddah, Saudi Arabia, 2king khalid university hospital , king saud university ,Riyadh, 3king fahad arrmed force hospital , Jeddah, 4Khalid University Hospital ,King saud University,Riyadh, 5Faculty of medicine, Um Al Qura University, Makkah

 

 

Wide Spread Skeletal Bones involvement of Brown Tumors in a

patient with Ectopic mediastinal parathyroid adenoma: Case Report

of a rare entity and review of literature

Areej A. Bokhari, MD,SSC-Surg 1,Khalid S.Aljabri, MD, FRCPC, FACP 2,Samia A. Bokhari, MD, SBEM 2,Muneera A. Alshareef, MD,SBIM 2,Ahmad,Alhumidi,MD 3,Bandari K. Aljabri,MS 4

 

Background

Primary Hyperparathyroidism often presents with unusual clinical manifestations and

ectopically located Parathyroid gland adenomas. Brown tumor is an osseous lesion

that develops in bones affected by primary or secondary hyperparathyroidism. We

report a case of 29 years old woman with diffuse brown tumor and parathyroid gland

adenoma in ectopic mediastinal location which presented with diagnostic problems.

 

clinical scenario:

A 29 year Indian female reported to our hospital on wheel chair with non-healing fracture

 of both left arm and left leg . She complained from

 multiple areas of severe pain associated with swellings in her face, hand, arm and lower

limbs and inability to stand up from sitting position without support .

 When examined, she has multiple facial bony swelling mainly on right and left mandible

and right maxilla. Fingers were tenders bilaterally with proximal

bony joints swellings and there were Limited range of movement in the hips

with limping gait. Her corrected calcium was 3.1 mmol/L (2.1-2.55,), Inorganic

phosphorus : 0.86 mmol/L(0.87-1.45), Alkaline phosphates: 566 U/L (50-136,

Parathyroid hormone ( PTH ): 41.1 PM/L (1.65-6.9) 25-Hydoxyvitamin D: 34.3

nmol/L (75-250) . Skeletal survey x-rays showed several Lytic lesions . DEXA

Bone mineral density scan showed osteprorsis . Sestamibi scan showed ectopic parathyroid adenoma in left upper mediastinum superior to the aortic arch.

bone scan showed multiple brown tumors in different skeletal  sites

Neck and Chest CT scan showed mediastinal parathyroid adenoma located in the

prevascular space in front of the aortic arch 1.8 cm x11.1 cm , correlating

with the sestamibi scan .

She was given zoledronic acid and Vitamin 45000 IU weekly with bone profile

monitoring as follow: Corrected Ca: 2.9 mmol/L, Inorganic phosphorous: 0.71

mmol/L, Alkaline phosphates: 502 U/L , PTH: 37.7 PM/L, Vit D: 31.01 mmol/L

 As her localizing studies showed that it's ectopic in the mediestanium in front

of the aortic arch she was approached laparoscopic. Post excision PTH was  5.740 PM/L and corrected calcium 2.3 mmol/L

. histopathology showed parathyroid adenoma . She was seen last time in clinic walking

 with almost total resolution of her facial brown tumor .

Conclusion:  This is the first reported case of wide spread skeletal involvement of a brown tumor presented as the first sign of primary hyperparathyroidism due to an ectopic parathyroid . our patient did not have hungry bone syndrome as she was treated with vitamin D and biphosphonate preoperatively.

 

Nothing to Disclose: SAB, AAB, KSA, MA, AA, BKA

22351 9.0000 LBT-041 A Wide Spread Skeletal Bones Involvement of Brown Tumors in a Patient with Ectopic Mediastinal Parathyroid Adenoma: Case Report of a Rare Entity and Review of Literature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Naser Hazza Alkahtany1, Abdulrahman AL Hathlool2, RIM Braham2, Fahad Alsabaan2 and Mohammed Aldawish*1
1Prince Sultan Military Medical City, Riyadh, Saudi Arabia, 2Prince Sultan Military Medical City

 

Pregnancy and lactation-associated osteoporosis (PAO) has been mentioned mainly on case reports as a rare entity with unclear pathogeneses. It should be exclude other cause of secondary osteoporosis before confirm PAO diagnosis.

A 42-year-old multiparous and breast-feeding Saudi Arabian woman was referred to accident and emergency department because of sever back pain.

She developed moderate pain in the thoracolumbar spine on third trimester period of her the tenth pregnancy with progressive worsened at four months postpartum period with difficulty to perform her daily activities.

She reported mild to moderate similar back pain during her last three pregnancies which relived by analgesic medication without hospitalization.

There was no history of trauma or underlying diseases such as diabetes mellitus, thyroid problem or renal failure with no history of smoking or alcohol use. She had never used medications like steroid or antiepileptic drugs. Her Obstetrical history revealed total of ten pregnancies, seven children and three miscarriage abortions.

On physical examination, there was significant thoracolumbar paravertebral spasm with movement restriction mainly on flexion. The severity of pain, according to the Visual Analogic Scale (VAS) was 9/10. Neurological examination was unremarkable with no focal signs.

Laboratory tests (including serum calcium, phosphate, alkaline phosphatase, thyroid And parathyroid hormone levels, liver and renal function tests,  vitamin D3, Immunoglobulins level, C-Reactive Protein, Albumin/Globulin Ratio, CA 19-9, CA-125 and CEA )were performed and did not show any abnormal values.

MRI  images  of  the  cervical,  dorsal  and  lumbar  spine revealed multiple reduced  vertebral  body  height  from  D11  to  L4  which  shows  faint  low  signal  intensity  in  T1  and  intermediate  high  signal  intensity  on  T2  with  faint  enhancement  in  post  contrast  image.

Dual-energy X-ray absorptiometry (DXA) revealed L1-L4  T-score  -3  and  Z -score  is  -3.6 , Left  femur  neck  T-score   -1.6  and  Z  -  score  of  -1.8  ,Right  femur  neck  T-score  of  -1.1  and  Z-score  of  -1.4  .   

The patient was diagnosed with PLO based on the above investigations. She was advise to stop lactation and given cabergolin for a month period. She was started on calcium carbonate 1.2 gm twice daily, Vit D 2000 units daily and alendronate 70mg/week. Also, she was given thoracolumbar corset.

After 3 months the back pain has gradually improved with almost free of back pain at 8 months from her presentation.  DXA measurements showed interval  improvement  in  lumbar  spine  BMD  by  about  13%  and  by  about  4%  in  left  femoral  BMD  while  no  significant  interval  changes  could  be  seen  right  femoral  neck  BMD at one year follow-up.

After 22 months of medical treatment, repeated DXA measurements showed improvment of lumbar  spine  BMD  by  about  23.1%,  8.7%  in  left  femoral  neck  and 0.6% at right  femoral  neck  .

 

Nothing to Disclose: NHA, AA, RB, FA, MA

22415 10.0000 LBT-042 A A Case Report: A Rare Endocrine Cause of Postpartum  Multiple Vertebral  Fracture 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Adi Cohen*1, J. Sanil Manavalan1, Stavroula Kousteni1, Robert R Recker2, Joan M. Lappe2, David W Dempster3, Hua Zhou3, Donald J McMahon4, Mariana Bucovsky4, Mafo Kamanda-Kosseh1, Julie Stubby2 and Elizabeth Shane1
1Columbia University, New York, NY, 2Creighton University, Omaha, NE, 3Helen Hayes Hospital, West Haverstraw, NY, 4Columbia University, College of Physicians and Surgeons, New York, NY

 

Among premenopausal women with idiopathic osteoporosis (IOP), those with low bone formation have the most substantial bone microarchitectural deficits and may respond less well to TPTD. IGF-1 stimulates bone formation and is critical for teriparatide (TPTD) action on osteoblasts. We therefore studied IGF-1 related mechanisms of osteoblast response by measuring IGF-1 receptor (IGF-1R) density on circulating osteoblast progenitor (COP) cells in premenopausal women with IOP, both in a cross sectional study and a longitudinal study of TPTD treatment.

Peripheral blood mononuclear cells (PBMCs) were subjected to flow cytometry. After excluding hematopoietic lineage cells, COPs were identified by antibodies against osteocalcin and Runx2. The percent of PBMCs expressing these markers was reported as %COP. IGF-1R density on COPs was measured by mean channel fluorescence (MCF) of antibodies to IGF-1R.

We performed transiliac bone biopsies and measured %COP in 25 premenopausal women with IOP and no secondary cause of osteoporosis (±SD; age 38 ± 7), 18 with fragility fractures (Fx) and 7 with low BMD (Z score <-2.0) and no Fx. %COP correlated directly with cancellous surface bone formation rate (BFR; r=0.41, p=0.04), mineral apposition rate (r=0.75, p<0.0001) and wall width (r=0.51, p<0.01) on biopsies. IGF-1R density also correlated with BFR (r=0.57, p=0.003). Based on tertiles of BFR, we categorized subjects as low (LT), middle, or high (HT) bone turnover.  Compared to HT-IOP, women with LT-IOP had significantly fewer osteoblasts on biopsies (0.7 ± 0.3 vs 1.5 ± 1.1 #/mm; p=0.002). They also had significantly lower %COP (13.3 ± 8.0 vs 29.0 ± 8.8%; p=0.004) and IGF-1R density on COPs (MCF: 863 ± 217 vs 1547 ± 806; p=0.04).

We also investigated changes in COPs in 11 women with IOP participating in an open-label study of TPTD, 20 mcg daily for 2 years. PBMCs were obtained at baseline and 1, 3 and 18 months. BMD increased substantially by 12.9 ± 5.7% at the lumbar spine (LS) and 6.9 ± 4.6% at the femoral neck (FN), but the response was quite variable. %COP increased by 221% by 3 months (p=0.02). Serum IGF-1 did not change in response to TPTD, but IGF-1R MCF increased by 128% at 3 months (p=0.009). %COP at baseline and %COP increase at 3 months did not predict BMD response to TPTD. In contrast, the 3 month increase in IGF-R MCF in COPs correlated significantly and directly with 6 month increase in BMD (LS: r=0.7, p=0.02; FN: r=0.7, p=0.02), with a trend at 12 months (LS: r=0.6, p=0.08; FN: r=0.5, p=0.1).

In summary, %COP and IGF-1R density measured on COPs correlate with indices of bone formation measured on biopsies and increase markedly in women with IOP treated with TPTD. The increase in IGF-1R density on COPs correlates directly with the early BMD response. We conclude that an early increase in IGF-1R density may play an important role in the osteoanabolic response to TPTD, and may have utility as a predictor of clinical response to TPTD.

 

Disclosure: AC: Coinvestigator, Eli Lilly & Company. RRR: Investigator, Eli Lilly & Company. JML: Coinvestigator, Eli Lilly & Company. DWD: Investigator, Eli Lilly & Company, Consultant, Eli Lilly & Company. ES: Investigator, Eli Lilly & Company. Nothing to Disclose: JSM, SK, HZ, DJM, MB, MK, JS

22943 11.0000 LBT-043 A Circulating Osteoblast Progenitors and IGF-1 Receptor Density on These Cells Correlate with Bone Formation on Transiliac Biopsies and Predict Response to Teriparatide in Premenopausal Women with Idiopathic Osteoporosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Naser Hazza Alkahtany1, Eyad Alkharashi2, Sohail Inam1, Ahmed Refaey2, RIM Braham2, Khalid Alhajri2 and Mohammed Aldawish*1
1Prince Sultan Military Medical City, Riyadh, Saudi Arabia, 2Prince Sultan Military Medical City

 

Prevalence of Primary hyperparathyroidism in children and adolescence is rare and has been described mainly in case reports and small series. Most of studies reported parathyroid adenoma is the most common pathology occurs in this group of population. A 14-year-old girl was referred to emergency department because of sever hypercalcemia.

She was fairly well till five weeks back when started to have moderate epigastric pain associated with frequent vomiting. There was no hematemesis or diarrhea. She gave history of polyuria, polydipsia, fatigability and proximal myopathy.

She sought medical advice at secondary hospital where she was admitted for 10 days and managed as case of primary hyperparathyroidism with aggressive intravenous fluid, calcitonin and Cinacalcet. Three weeks after discharge, she was presented to our hospital with same previous symptoms.

On examination, she looks unwell with blood pressure   100/50mm Hg, pulse 110 beats /min and Temperature of 37.2 °C. Her BMI was 20.5 %

There does not have dysmorphic feature and normal cardiovascular and chest examination.

Her abdominal exam revealed mild epigastric tenderness with on skin lesions or organomegaly.

 There was significant proximal myopathy with no muscular or bony tenderness. The remainder of the examination was normal

Initial blood works showed hemoglobin 12 g/dl (N 11.5-16.5), urea 2.5 mmol/l (N 2-6.7), potassium 3 mmol/l (N 3.5-5), and creatinine 48 umol/l (N 40-68). Calcium 3.9 mmol/l (N 2.06-2.4) and parathyroid hormone (PTH) 1167 pg/ml (N 15-65).

Alkaline Phosphatase 812 u/l (N 0-187) and liver function tests were normal.  Prolactin level was 125 mIU/L (N 102-496)           

Management: IVF (0.9 normal saline) was started at rate of 200ml/hour, Calcitonin 200units IM TID. Her calcium was reduced to 2.9mmol/l. the abdominal pain and vomiting were improved substantially.

On third day of admission, her gastrointestinal symptoms reoccurred with increase calcium level of 4.2 mmol/l. Zeldronic acid 4 mg IV was given .her calcium reduced to 2.6 mmol/l.

Neck Ultrasound showed large right inferior parathyroid adenoma measured 1.3 x 2.3 x 2.5 cm.

Skeletal survey showed   Subperiosteal bony resorption noted at the mid phalanges of hands, Salt and pepper appearance of the skull and Rugger-jersey spine.

 She had right parathyroid adenoma resection which confirmed by the pathology report.

Hungry bone syndrome was suspected because of Volume of the resected adenoma

Preoperative PTH and alkaline phosphatase concentration. Her calcium dropped to 2.1 mmol/l with hypocalcemia symptoms and signs requiring IV calcium gluconate dose of 300 mg elemntal calcium .she was started on Alfacalcidol 1 mcg BID and calcium carbonate 1.2gm TID.

Four days after surgery, the patient remained free of symptoms and maintained   calcium level of 2.3mmol/l and given one week appointment to adjust the dose of Alfacalcidol and calcium carbonate doses.

 

Nothing to Disclose: NHA, EA, SI, AR, RB, KA, MA

22455 12.0000 LBT-044 A A Case Report: Treating Severe Primary Hyperparathyroidism in a Young Girl Is a Challenge 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Racha Dermesropian*1, Amanda Kost2 and Pamela Taxel3
1Univeristy of Connecticut Health Center, Avon, CT, 2University of Connecticut Health Center, 3Univ of Connecticut Health Center, Farmington, CT

 

BACKGROUND: Aromatase inhibitors(AI) are used as adjuvant treatment for postmenopausal patients with hormone receptor –positive breast cancer. Aromatase inhibitors act by decreasing levels of circulating estradiol and would be expected to decrease bone mineral density and possibly increase the rate of fractures.

Previously published sub-studies of the ATAC trial, looking at the effect of anastrozole and tamoxifen on bone mineral density, demonstrated accelerated bone loss with anastrazole over the 5-year duration of the treatment. However, this bone loss did not persist 2 years after the cessation of anti-estrogen therapy.

METHODS: We reviewed data on 104 women seen in our Breast Cancer and Bone Health Clinic between the years 2004 and 2008 and were placed on adjuvant therapy with aromatase inhibitors. We excluded all women who had osteoporosis at the initiation of anti-estrogen therapy or had received bisphosphonates within 1 year of initiation of treatment.

We collected data on lumbar spine, total hip or femoral neck bone mineral densities at the start of anti-estrogen therapy, after 5 years of therapy and 1 or 2 years after cessation of treatment. 44 women were eligible in total and only 30 patients had evaluable data.

Results: Thirty women had Bone Mineral Density (BMD) evaluated at baseline and 5 years on AI Treatment: 18 or 60% had bisphosphonate(BP) therapy during AI treatment for an average of 33 +/- 22 months, and 12 remained on conservative treatment with calcium and Vitamin D only.  Women on AI and BP showed preserved BMD at both the-L-spine and total hip. Those not treated with BP had decrease of BMD at the spine of 2.8% from baseline (BL) to 5 years (p=0. 03), but remained stable at the hip. Twenty-four women were evaluated at 1 or 2 years off AI therapy; of those, 14 remained on BP therapy and in 10 it was discontinued or never started. Women who remained on BP had a significant increase at the spine from 5 to 1 to 2 years off AI therapy with no changes at total hip. In those not on BP or in whom BPs were discontinued, no change at the spine or hip was found.

 After AI therapy was discontinued for 1 to 2 years, those remaining on BP continued to increase BMD at the spine by 1.8% (p=0.01), and remained stable at the hip. Those not receiving BPs did not demonstrate spine or hip changes in BMD.

 Conclusion: Women on AIs and BPs were protected from bone loss as expected from prior literature, and continued to gain bone mass after AI therapy was discontinued, but remained on BP. Women on conservative treatment with calcium and Vitamin  D only had a small but significant decline at the spine, but not at the hip, which was unexpected.  This may have occurred due to sufficient Vitamin D intake; however, this is a small group and further analysis of a large group is required.

 

Nothing to Disclose: RD, AK, PT

22897 13.0000 LBT-045 A BMD Changes during and after Cessation of Aromatase Inhibitors in Women Treated for Breast Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Thursday, March 5th 3:00:00 PM LBT 033-047 6274 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D I Poster


Yu Ji Kim1, Sun Hee Kim1, Ji Hye Kim2 and Ji Hyun Park*3
1Chonbuk National University Hospital, Jeonju, Korea, Republic of (South), 2Presbyterian Medical Center, Jeonju, 3Chonbuk National University Medical School, Jeonju, Korea, Republic of (South)

 

Background: The associations between specific RET mutations and the age of onset and aggressiveness of medullary thyroid cancer (MTC) and the presence or absence of other endocrine neoplasms such as pheochromocytoma or hyperparathyroidism have been well documented. The mutations most frequently associated with MEN 2A and familial MTC are substitutions of specific extracellular cysteines. Conversely, RETmutations in MEN2B fall almost entirely in codon 918, but a few families have a codon 833 mutation. These mutations occur in the catalytic region of the intracellular tyrosine kinase domain, enabling activation without the need for ligand stimulation or RET dimerization. Mutations of the TM domain (codon 636-657), where codon 641 is located, are the least frequently reported.

Clinical case: A 37-year-old female presented with an anterior neck mass, which was confirmed to be MTC by biochemical tests and pathologic findings. The patient had no identifiable family history of MTC. After the thyroidectomy, the patient’s calcitonin level was normalized to 0.1 pg/mL. Histology revealed a single MTC lesion (21mm × 16mm) in the right thyroid lobe without cervical lymph node metastasis. Genetic testing under the informed consent revealed a germline Ala641Thr missense mutation in the RET gene. The RETgene variant was inherited by one of her children.

Conclusion: For newly identified or rare mutations in the RET gene, the causative role of the mutation and the genotype-phenotype relationship must be evaluated to define the mutation’s codon-specific risk level. This is the first case of a germline variant of Ala641Thr in the transmembrane domain of the RETgene in a patient presented with stage 2 MTC. Although molecular structure-function studies and more clinical cases are needed to fully elucidate its clinical significance, this new genetic variant may be associated with relatively less aggressive MTC, as shown in this case.

 

Nothing to Disclose: YJK, SHK, JHK, JHP

22356 1.0000 LBT-001 A A New Germline Ala641Thr Variant in the Transmembrane Domain of the RET Gene Associated with Medullary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Romana T. Netea-Maier*1, Sander Tuit2, Bas Heinhuis3, Leo Joosten3, Joachim Schultze2, Johannes W.A. Smit1 and Mihai G. Netea1
1Radboud University Medical Center, Nijmegen, Netherlands, 2University of Bonn, LIMES, 3Radboud University Nijmegen Medical Center

 

Background. Tumor-associated macrophages (TAMs) with a dysregulated inflammatory phenotype have been proposed to play an important role in carcinogenesis. In thyroid carcinoma (TC), excessive release of proinflammatory cytokines such as tumor necrosis factor (TNF) and interleukin-1ß (IL‑1ß) decrease the expression of the sodium-iodine transporter (NIS) and inflammation potentiates tumor progression.

Aim.  The aim of the study was to assess the impact which TC cells exert on the differentiation of TAMs at the level of transcriptome and metabolic pathways, and assess their influence proinflammatory phenotype of the TAMs.

Methods: TC cell lines TPC1, BC-PAP and FT133 were co-incubated with human monocytes in a trans-well system. Release of cytokines and transcriptomics profiles of the immune cells and of the TC cell lines were investigated.

Results. TC cell lines grown in homeostatic conditions in-vitro did not release proinflammatory cytokines, even after stimulation with TLR ligands. In contrast, co-incubation of TC cell lines with human monocytes in a trans-well system led to differentiation of the immune cells into TAMs with a strong proinflammatory profile, that produced 3- to 5-fold more proinflammatory cytokines such as TNF, IL-1ß and IL-6 compared to control macrophages (p<0.05 for all cytokines). This effect was specific for TC cell lines, as a control experiment using U87 and U251glioblastoma cell lines failed to exert a similar effect. Transcriptome profiling by RNA-sequencing of the TC-induced TAMs identified metabolic pathways such as glycolysis and pentose-phosphate pathway to be strongly up-regulated, while pathways that stimulate specific T-cell responses were down-regulated. The importance of the metabolic reprogramming was validated by metabolite assessment and perturbation experiments, with a central role for lactate-mediated effects as one of the mechanisms inducing the differentiation of proinflammatory TC-induced TAMs.

Conclusions. Transcriptional regulatory nodes involving metabolic pathways such as aerobic glycolysis regulate the interplay between TC cells and TAMs, resulting in a microenvironment with a strong inflammatory profile. These pathways may represent novel therapeutic targets in TC.

 

Nothing to Disclose: RTN, ST, BH, LJ, JS, JWAS, MGN

22695 2.0000 LBT-002 A Complex Immunometabolic Pathways Mediate the Interaction Between Thyroid Carcinoma Cells and Tumor-Associated Macrophages 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Ali Saeed Alzahrani*1, Bedri Karakas2, Ebtesam Qasem1, Dania M Alkhafaji2, Hindi Al-Hindi2 and Mai Almohanna3
1King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia, 2King Faisal Specialist Hospital & research center, Riyadh, Saudi Arabia, 3King Faisal Specialist Hospital & research center

 

Background

Serum thyroglobulin (Tg) is an accurate tumor marker in the follow up of patients (pts) with papillary thyroid cancer (PTC).  However, there is still a need to identify other markers, especially in pts with positive anti Tg antibodies and in cases of poorly differentiated thyroid cancer where Tg might be falsely negative.  BRAFV600E is a somatic mutation (BRAF) that occurs in 29-83% of cases of PTC (median about 45%)1.  In this study, we investigated:

1. Whether BRAF mutation can be detected in the plasma DNA of pts treated for PTC using a highly sensitive molecular technique

2. Explore its potential use as a tumor marker in those pts

Patient and methods

We tested for BRAF mutation using PCR and conventional Sanger sequencing of DNA obtained from tumor Paraffin blocks of 41 non-selected PTC pts who were previously treated with total thyroidectomy and RAI remnant ablation.  BRAF mutation was positive in 20 of them.  Those served as cases while the other 21 pts with negative BRAF mutation were used as controls.  We then tested for BRAF mutation in plasma DNA of all 41 pts using a bead-based emulsion PCR and flow cytometer commonly known as BEAMing (beads, emulsion, amplification, magnetics)2.  BEAMing is capable of detecting a single mutant DNA copy in the background of 10,000 wild type DNA copies. The percentage of BRAF mutant/total BRAF in the plasma was matched to the tumor status at the time of blood collection.

Results

Of the 20 BRAF-positive pts, all pts (9 pts) in remission (stimulated Tg < 1ng/dl, negative WBS and other imaging studies) had a ratio <1% while 9/11 (82%) pts with persistent/metastatic disease (stimulated Tg > 1 ng/dl, positive Whole body scan or positive FNA) had a ratio >1%.   This gives the BEAMing testing using mutant/wild type plasma ratio of 1% a sensitivity, specificity, positive and negative predictive values of 82%, 100%, 100% and 82%, respectively.  The median (range) mutant/wild type ratio was 0.04% (0.01-0.12) in pts in remission and 3.4% (0.01-22.7) in pts with persistent/recurrent disease. In pts with BRAF negative tumors (controls), the ratio was extremely low (median 0.03 (0-0.13} except in 3 patients (14.3%) where the ratio came back surprisingly high.  We tested DNA from tumors of those pts using the BEAMing and found that they had BRAF mutation that was missed by Sanger sequencing suggesting that tumors in those patients were heterogeneous composed of mainly non-BRAF mutant cells and a fraction of BRAF positive cells that was not detected due to the low sensitivity of the conventional method.

Conclusions

We have described preliminary findings of the potential use of plasma DNA for detection of BRAF mutation (and possibly other known mutations) using BEAMing in pts with PTC.  This may serve as a highly sensitive technique for follow up of those pts and is of particular interest in pts with anti Tg antibody positive or poorly differentiated tumors.

 

Nothing to Disclose: ASA, BK, EQ, DMA, HA, MA

22476 3.0000 LBT-003 A Detection of BRAFV600E Mutation from Plasma DNA in Patients with Treated Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Johannes W.A. Smit*1, Randa Abdulrahman2 and Guido Hovens3
1Radboud University Medical Center, Nijmegen, Netherlands, 2Leiden University Medical Center, Leiden, Netherlands, 3Leiden University Medical Center, Netherlands

 

Background:

The equivalence of preparation with recombinant human thyroid stimulating hormone (rhTSH) and thyroid hormone withdrawal for radioactive iodide (RAI) therapy in patients with metastases of differentiated thyroid carcinoma (DTC) has not been proven in a randomized fashion. The assumption of rhTSH preparation is that the continuation of thyroid hormone therapy itself has no direct effects on RAI uptake. This has however not been demonstrated.

Aim:

To study whether triiodothyronine (T3) directly affects expression of the sodium iodide symporter (NIS) and RAI uptake, independently of TSH.

Methods:

Fischer rat thyroid cells (FRTL5) were cultured in Coon's modified Ham's F-12 medium supplemented with 10% charcoal stripped calf serum, 10 μg/mL human recombinant insulin, 10 ng/mL somatostatin, 10 nM hydrocortisone, 5 μg/mL transferrin, 10 ng/mL glycyl-L-histidyl-L-lysine acetate and 1 mU/ml bovine TSH. Cells were treated with T3 (1nM, 10nM & 1μM) for 1 to 4 days. The effects of T3 on NIS protein expression were examined by western blot using anti-rat NIS ab (1:1000, gift of Dr.Carrasco) standardized for GAPDH expression. RAI uptake was studied after 30 min incubation with 0.1 μCi Na125I and 20 μM unlabeled NaI in HBSS, with or without 80 μM of sodium perchlorate to control for specific uptake. Transcriptional regulation of NIS gene by T3 was studied by transient transfection of FRTL5 with rat NIS promoter constructs containing luciferase. Luciferase activity was studied in presence or absence of T3 and corrected for co-transfected renilla luciferase activity.

Results:

T3 1 uM reduced RAI uptake by 12% (24h) and 35% (48h) vs. control (p<0.05). After 4d 1 T3 1 nM reduced RAI uptake by 30% (p<0.05). NIS protein levels were significantly decreased in a dose dependent manner after 4 days of T3. T3 reduced NIS promoter activity to 68.3% (1 nM) and 50.1% (1 uM, p<0.001).

Conclusion:

We found that T3 reduces NIS protein expression and subsequent RAI uptake in FRTL5 cells, independently of TSH. The effect can be explained by decreased NIS gene transcription. The finding may have important consequences for rhTSH aided RAI therapy in patients with metastases of DTC.

 

Nothing to Disclose: JWAS, RA, GH

22703 4.0000 LBT-004 A Thyroid Hormone Decreases Expression of Sodium Iodide Symporter (NIS) and Iodide Uptake in the Thyroid, Independently of TSH 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Sharifah Faradila Wan Muhamad Hatta*1, Rohaya Abdul Razak2 and Rohana Abdul Ghani3
1Universiti Teknologi MARA, Malaysia, 2Universiti Teknologi MARA, Shah Alam, Malaysia, 3Universiti Teknologi Mara, Malaysia

 

Objective:

Hypothyroidism is defined as deficiency of thyroid gland activity resulting in reduced secretion of both thyroxine (T4) and 3,5,3'-triiodothyronine (T3)(1). Decrease in T4 and T3 concentrations lead to hyper secretion of the pituitary thyrotrophs with an increase in serum thyroid stimulating hormone (TSH) levels, a main laboratory finding, particularly in the early detection of thyroid disorder. Dyslipidaemia is associated with hypothyroidism due to the decreased activity of the lipoprotein lipase(2) and reduced fractional clearance of LDL by a reduction in the number of LDL receptors in the liver(3). This study demonstrated the improvement in dyslipidaemia with thyroxine therapy and the impact on the 10-year Framingham risk score.

Subjects and Method:

We observed the lipid profiles of 43 individuals (7 males and 36 females) between the ages of 30 to 78 years old with the diagnosis of hypothyroidism. Standard oral L-thyroxine therapy was initiated and lipid profiles were measured before and at least 3 months after L-thyroxine replacement. Dyslipidaemia was defined by presence of any of the following: total cholesterol(TC) > 5.2mmol/L, triglyceride(TG) > 1.7mmol/L, low density lipoprotein-cholesterol(LDL-C) > 2.4mmol/L and high density lipoprotein-cholesterol(HDL-C) < 1.0mmol/L)

Results:

Dyslipidaemia was present in 86% of the subjects. The baseline mean values of free thyroxine(fT4) and TSH were found to be 11.24±0.65SDpmol/L, and 22.99±4.21SDmIU/ml respectively. The fT4 and TSH improved significantly following treatment with a mean of 15.61±0.52SDpmol/L (p<0.05, 95% CI 11.61,28.02) and 3.17±0.51SDmIU/ml (p<0.05, 95% CI 2.99,5.74) respectively. The mean TC, TG, LDL-C and HDL-C prior to treatment were 6.30±2.28SDmmol/L, 1.68±1.30SDmmol/L, 3.97±1.96SDmmol/L and 1.49±0.75SDmmol/L, respectively. There were significant positive correlations between baseline levels of TSH and TC (R2=0.175,p=0.006) and LDL-C (R2=0.343,p=0.000).

After at least 3 months of oral L-thyroxine  therapy, apart fro TG, there was significant improvement in all the individual lipid profile variables, with a mean reduction of 0.92±0.93SDmmol/L(p=0.03), 0.86±0.85SDmmol/L(p=0.002) and 0.06±0.24SDmmol/L(p=0.02) for TC, LDL-C and HDL-C respectively.

The 10-year Framingham Risk Score showed no decline between pre and post treatment of 2%±3%SD and 3%±4%SD respectively, p= 0.481.

Conclusion:

Mild elevations of TSH are associated with changes in lipid profile significant enough to raise the cardiovascular risk(4). The higher prevalence of hypothyroidism among middle-aged individuals is associated with hyperlipidaemia(5). This is in agreement with our findings which showed that hypothyroidism is associated with hyperlipidemia which improved with short term LT4 replacement. This thus, emphasized the importance of normalising TSH levels in these high-risk individuals.

 

Nothing to Disclose: SFW, RA, RA

22652 5.0000 LBT-005 A Improvement in Lipid Levels Following Levothyroxine Therapy and the Impact on Cardiovascular Risks 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Larry A Fox*1, Tomonobu Hasegawa2 and Satoshi Narumi3
1Nemours Children's Clinic, Jacksonville, FL, 2Keio Univ Sch of Medicine, Tokyo, Japan, 3National Research Institute for Child Health and Development, Tokyo, Japan

 

Background: Thyroid peroxidase (TPO) deficiency is the most common inborn error of thyroid hormone synthesis. Over 50 mutations have been reported. We describe a boy with TPO deficiency who had atypical biochemical and clinical findings.

Case presentation: An 8 9/12-yr-old boy presented with asymptomatic goiter.  No hearing loss. Newborn screen was reported as normal. Family history was positive for maternal grandfather and maternal great uncle both having thyroid cancer (tissue types unknown). On exam his thyroid was enlarged, R > L, no nodules; it was nontender & soft. Labs were as follows: T4 3.5 mcg/dL, TSH 5.93 mIU/mL, T3 220 ng/dL, TBG 19.7 ug/mL.  TPO and thyroglobulin (TG) antibody titers were negative. Thyroid ultrasound revealed a prominent gland without cysts/nodules. 123I scan demonstrated increased uptake at 6 (42%) and 24 hr (51%). L-thyroxine treatment (37.5 ug/day) was started. He was lost to follow up for two years, presenting again with increased goiter, still on l-thyroxine. Labs were as follows: free T4 0.4 ng/dL, TSH 5.37 mIU/mL, T3 229 ng/dL, T4 4.3 ug/dL. Repeat 123I scan revealed increased uptake at 4 (72%) and 24 hr (62%). L-thyroxine dose was increased to 50 ug/d. The thyroid continued to increase in size, and he underwent thyroidectomy at 17 years old. Blood was obtained at the time of surgery for mutation analysis.

Methods: Genomic DNA was isolated from peripheral blood. Eleven genes associated with congenital hypothyroidism were sequenced using SureSelect Target Enrichment System (Agilent Technologies; Santa Clara, CA, USA) and the MiSeq NGS (Illumina, Inc; San Diego, CA, USA).

Results: The homozygous mutation c.1581G>T, p.Trp527Cys was detected and validated by conventional Sanger sequencing. This missense (inactivating) mutation has previously been described (1,2).

Discussion: Our patient had a previously-reported homozygous mutation in exon 9, but two features of his presentation were atypical. First, his newborn screen was normal, indicating some residual function. This has been reported in four cases (3,4), and is also evidenced by the only mildly elevated TSH at the time of presentation. Further, our subject had an increased T3/T4 ratio, something more commonly seen in the TG deficiency. Only three cases of increased T3/T4 ratios in TPO deficiency have been reported in the literature (5,6), and may be explained by elevated type 2 deiodinase activity in the thyroid. It is not clear, however, how his specific mutation affects activity of this enzyme. The very low free and total T4 with only mildly increased TSH in our patient support increased conversion of T3 to T4 with increased type 2 deiodinase activity. 

Summary: Congenital hypothyroidism due to a homozygous inactivating mutation in TPO may not be detected on newborn screen and instead may present later in childhood with goiter, mildly abnormal TFTs with an increased T3/T4 ratio, and abnormal uptake on thyroid scan.

 

Nothing to Disclose: LAF, TH, SN

22376 6.0000 LBT-006 A Residual Thyroid Function and Increased T3/T4 Ratio in Congenital Hypothyroidism Due to Thyroid Peroxidase Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Ning Qu*, Ling Zhang and Qing-hai Ji
Fudan University Shanghai Cancer Center, Shanghai, China

 

The purpose of the present study was to investigate the frequency of TERT promoter mutations in papillary thyroid cancer (PTC), and evaluate the association of the mutation with the clinicopathological features of invasiveness and outcomes. We performed a retrospective study in 457 consecutive PTC patients (356 women and 101 men) age 42.8±13.0 years (mean±SD) with a median follow-up of 75 months (13 to 83 months) at the Fudan University Shanghai Cancer Center in 2007. The data on patient clinical features, tumor histological characteristics, and outcomes were abstracted from patient records. Genomic DNA was isolated from primary PTC tumors and subjected to classical Sanger sequencing for the detection of TERT promoter mutation. The results showed that the TERT promoter mutation was identified in only 9 of 457 (2.0%) specimens. The TERT promoter mutation was associated with male gender (p=0.025) and the aggressive features of primary tumors, such as great tumor size (p=0.042), extrathyroidal extension (p=0.001). According to TNM staging classifications, the frequency of TERT promoter mutation in different stages were 0 (I, 0/310), 50% (II, 3/6), 3.8% (III, 3/79) and 4.8% (IV, 3/62), and the TERT promoter mutation was significantly associated with advanced stages (p=0.029). Moreover, survival analysis suggested that the TERT promoter mutation was an independent indicator for poor prognosis, including cancer-specific death (p=0.001), neck recurrence (p=0.001) and distant metastasis (p=0.048). In summary, TERT promoter mutation may occur uncommon but as a genetic event in advanced PTC, and indicate an aggressive behavior and poor prognosis. The acquisition of status ofor TERT promoter mutation could be significant in routine histopathological workup related to advanced PTC.

 

Nothing to Disclose: NQ, LZ, QHJ

22694 7.0000 LBT-007 A The Relationship Between TERT Promoter Mutation and the Clinicopathologic Outcomes in Papillary Thyroid Cancer Based on a Series in Southern China 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Paulina Aleksander1, Oliver Blankenstein2, Annette Grüters-Kieslich1 and Heiko Krude*3
1Charite-Universitymedicine, 2Charité Universitätsmedizin Berlin, Berlin, Germany, 3Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany

 

Background: Several studies of young adults with CH diagnosed in newbornscreening  have so far shown a gap in global IQ of up to 8 IQ points compared to control groups, however within the normal range of metal status. In these cohorts an initial dose of app. 6µg LT4 per kg body was used. Several other studies with younger children suggested a better mental outcome with a higher dose >10µg/kg BW.  However a recent study in 11 year old children treated with the higher dose claimed a less favourable IQ outcome in those children with suppressed TSH values; nevertheless the final subgroups of this study were very small (Bongers-Shokking JCEM 2013). We present here the cognitive outcome in a cohort of 76 CH patients diagnosed in the Berlin screening program born after 1979 who were treated early and with a high LT4 dose >10µg/kg BW.

Methods: We recruited 76 patients and 40 control siblings. We performed a variety of cognitive tests and the SF36 questionaire. Episodes of over- and underteatment were calculated based on the individual TSH ssc (steady state concentration) (Bongers-Shokking JCEM 2013).

Results: Mean age of CH patients and controls was 18.0 and 19.7 years respectively. Initial mean LT4-dose was 12.8µg/kg at an age of 9 days (range 1-18d); TSH normalization at a median treatment-time of 13.5 days.  Global IQ in CH patients and sibling controls (after adjusting for social status) was 101. Global IQ was not correlated with number of episodes (within 2 first years of life) of overtreatment (percent of reduced TSH) or undertreatment (percent of increased TSH).

Conclusions: There is no gap of global IQ or quality of life any longer in adult CH patients if treated with a high dose (>10µg/kg) and within 14 days of life. Such treatment is associated with a significant number of episodes of suppressed TSH that is NOT correlated with individual IQ outcome.

 

Nothing to Disclose: PA, OB, AG, HK

22713 8.0000 LBT-008 A No Gap in Cognitive Outcome and Normal Quality of Life in Adults with Congenital Hypothyroidism (CH) after Early Diagnosis Based on Newborn-Screening and Treatment with High LT4 Dose 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Patricia C Lisboa*1, Egberto Gaspar Moura2, Ellen Paula Santos Conceição3 and Elaine de Oliveira1
1Department of Physiological Sciences, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil, Brazil, 2Department of Physiological Sciences, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil, Rio de Janeiro, Brazil, 3Department of Physiological Sciences, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil

 

Early overnutrition during lactation leads to obesity, leptin resistance and lower serum thyroid hormones (TH) levels at adulthood. In order to know the biological significance of this thyroid hypofunction, we studied the long-term effects of postnatal early overnutrition on the function of hypothalamic-pituitary-thyroid (HPT) axis as well as on the TH metabolism and action. To induce overnutrition early in life, litter size was reduced to 3 pups per litter (SL group) on the 3rd day of lactation. In controls (NL group), litter size was adjusted to 10 pups per litter. The Animal Care and Use Committee of the UERJ (CEUA/012/2014) approved our experiment model. Rats were euthanized at 180 days-old. The thyrotropin release hormone (TRH) content and in vitro thyrotropin (TSH) were evaluated. The iodothyronine deiodinase (D1 and D2) activities were measured in different tissues. Also, the mitochondrial alpha-glycerol-3-phosphate dehydrogenase (mGPD) activity, a TH-dependent enzyme, and TH receptors (β1 and β2) content were evaluated to address the TH tissue sensitivity. The SL group presented lower intra-pituitary TSH and basal TSH release, which are in agreement with the reduced hypothalamic TRH content, despite unchanged serum TSH levels. Adult SL rats presented lower D1 activity in thyroid and white adipose tissue (WAT) and higher D2 activity (hypothalamic, pituitary, brown adipose tissue and WAT), which are in accordance to its hypothyroid status. However, despite the lower TH levels, thyroid, heart and testis D2 activities were unchanged, suggesting that other factors, which were programmed by postnatal early overnitrition, are more important regulators of these enzymes than TH, at least, in these specific tissues. Hepatic D1 and mGPD activities as well as TRb1 content were unchanged in adult SL rats, suggesting that the TH conversion and cellular action were preserved in the liver in the programming model of litter size reduction, even with the presence of lower TH levels. Concerning TH receptors, TRβ2 in hypothalamus and pituitary were unchanged in SL group, however the TRβ1 content in WAT was decreased, which can contribute to the lower catabolic WAT status. The amount of our data evidence that postnatal early overnutrition can change the thyroid function in adult life. The present findings link nutritional status alteration in early life with later thyroid dysfunctions and help to understand the obesity development.

 

Nothing to Disclose: PCL, EGM, EPSC, EDO

22826 9.0000 LBT-009 A Long-Term Effects of Postnatal Overnutrition on Thyroid Hormone Metabolism and Function in Adult Rat Progeny 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Shahnawaz Imam*1, Rodis Paparodis2 and Juan Carlos Jaume1
1University of Toledo, College of Medicine and Life Sciences, Toledo, OH, 2University of Toledo, Toledo, OH

 

Division of Endocrinology, Diabetes and Metabolism, Department of Medicine and Center for Diabetes and Endocrine Research (CeDER) , College of Medicine and Life Sciences, University of Toledo,  Toledo, OH.

The inflammatory microenvironment of thyroid cancer appears to be different as that of autoimmune thyroid disease.  The effect of T lymphocytes and other immune cells like Tumor Associated Macrophages (TAM) is still being defined.

Our previous studies showed that the risk of thyroid cancer in euthyroid Hashimoto thyroiditis patients is almost 50% (1, 2) whereas the risk of thyroid cancer in patients with Graves disease appears to be low (3). Our data showed that presence of the M1 macrophage phenotype was associated with a benign outcome (3).  Previously we had also shown that functionally active NK cell produce large amount of IFNg also known as Macrophage Activating Factor (MAF) which promotes the M2 to M1 phenotype conversion (3).  

Here we have functionally characterized the intrathyroidal macrophage population for a group of patients with euthyroid Hashimoto thyroiditis (EHT) (n=5) and Graves diseases (GD) (n=6). 

CD68+ macrophage presence was significantly higher in the setting of GD as compared to EHT (P<0.05).  Moreover, populations of freshly sorted M1 and M2 macrophages from GD and EHT patients were significantly (P<0.05) higher in GD as compare to EHT.  The combined presence of M1 macrophage markers CD68+CCR2, CD68+CXCR1, CD68+IL12 and CD68+TNFa was significantly (P<0.05) higher in GD as compared to EHT.  In contrast, the combined presence of M2 macrophage markers CD68+ARGINASE1, CD68+IL10, CD68+iNOS and CD68+DECTIN1 was significantly (P<0.05) higher in EHT as compared to GD.

Induction and activation of these intrathyroidal samples for 54 hrs. with high dose LPS (100 ng/ml) significantly increased the combined expression of M1 phenotype markers CD68+CCR2, CD68+CXCR1, CD68+IL12 and CD68+ TNFa and M2 phenotype markers CD68+ARGINASE1, CD68+IL10, CD68+iNOS  and CD68+DECTIN1in EHT whereas there was no effect of LPS in the activation of M1 and M2 macrophages in GD samples.

We conclude that in the setting of EHT, the M1 and M2 phenotype was not just different but also had a higher degree of plasticity than in GD setting.  This plasticity may help understand the reason for the higher risk of thyroid cancer in patients with EHT.

 

Nothing to Disclose: SI, RP, JCJ

22904 10.0000 LBT-010 A Does Macrophage Plasticity in Thyroid Microenvironment Decide the Fate of Thyroid Cancer? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Trevor E Angell1, Norra Kwong*1, Marco Medici2, Xiaoyun Liu3, Matthew Ian Kim1 and Ellen Marqusee1
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 2Erasmus medical center, Rotterdam, Netherlands, 3The First Affiliated Hospital of Nanjing Medical University, Nanjing, China

 

Background: Molecular diagnostic tests have been developed to improve the preoperative risk assessment of cytologically indeterminate thyroid nodules. Though initial investigation of the Afirma GEC confirmed high sensitivity, long-term assessment of cytologically indeterminate / GEC-benign (C-I/GEC-B) nodules is needed. This study compares the follow-up of C-I/GEC-B nodules to cytologically benign (Cyto-B) nodules to determine if these cohorts behave equivalently.

Methods: We analyzed prospectively collected follow-up data for all patients with C-I/GEC-B thyroid nodules >1cm at the Brigham & Women's Hospital. We then compared these to 260 Cyto-B nodules, matched 5:1 for age, sex and nodule size, with similar ultrasound (US) follow-up duration. Nodule growth and rate of false negative malignancy were assessed.

Results: Between 2010-2013, 87 C-I/GEC-B nodules were identified. Cytological classification was Bethesda III in 53 of 87 (61%) cases and Bethesda IV in 34 of 87 (39%) cases. We identified 52 (60%) with long term US follow-up [median = 14 months (mo); maximum = 37 mo]. The proportion of nodules that grew >20% in 2 dimensions was 9.6% in C-I/GEC-B nodules versus 8.1% in Cyto-B nodules (p=.78). These proportions remained similar when US follow-up was stratified into <12mo or 12-24mo after diagnosis. Surgical resection was performed in 6 of 52 (11.5%) C-I/GEC-B nodules, versus 6 of 260 (1.2%) Cyto-B nodules, (p<.01). However, a similar proportion in both cohorts proved malignant [1 of 52 versus 3 of 260 (p=.52)]. No deaths were documented in either group. Of nodules assessed by US at <12mo, there were no malignancies (false negatives) identified in either C-I/GEC-B or Cyto-B nodules.

Conclusion: The follow up of cytologically indeterminate yet Afirma GEC benign nodules confirms similar growth to nodules that are cytologically benign, irrespective of the follow up interval. C-I/GEC-B nodules were more likely to be resected, though the proportion of identified malignancies during follow-up was similar to that of the Cyto-B cohort. These data support extending guidelines recommending sonographic follow up of Cyto-B nodules at 12-24 months to nodules that are C-I/GEC-B.

 

Disclosure: EM: Investigator, Veracyte, Inc.. Nothing to Disclose: TEA, NK, MM, XL, MIK

22913 11.0000 LBT-011 A Long-Term Follow-up of Cytologically Indeterminate/GEC-Benign Thyroid Nodules in Comparison to Cytologically Benign Nodules 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


R Michael Tuttle*1, Moraima Pagan2, Jing Huang3, Bamboo Lin3, James Diggans2, Ed Tom3, Bryan R Haugen4, Steven I Sherman5 and Giulia C Kennedy3
1Memorial Sloan Kettering Cancer Center, New York, NY, 2Veracyte, 3Veracyte, Inc., South San Francisco, CA, 4University of Colorado Medical School, Aurora, CO, 5The University of Texas MD Anderson Cancer Center, Houston, TX

 

RATIONALE. In addition to improving disease specific survival, a risk adapted approach to thyroid cancer therapy should also minimize the risk of disease recurrence. Currently, this risk adapted approach to initial management is based in large part upon post-operative classification of patients as either high, intermediate or low risk of recurrence utilizing the 2009 American Thyroid Association staging system. While this anatomic staging system has proven clinically useful, it cannot be accurately assessed prior to thyroidectomy, and it does not include any molecular predictors of outcome. The goal of this study was to determine if transcriptional data obtained during diagnostic fine needle aspiration of malignant thyroid nodules could be used to augment risk stratification prior to thyroid surgery.

METHODS. We used FNA material from samples preoperatively collected as part of a previous study (n=81) and post-surgically diagnosed by a panel of experts as papillary thyroid carcinoma (PTC), including classic histologic subtypes. Each patient was categorized as either ATA low risk or ATA intermediate/high risk using established guidelines for recurrence risk stratification (2009 ATA). Genome-wide microarray expression data on 36,079 transcripts was obtained on all samples and supervised learning was used to train classifiers, including Support Vector Machine (SVM), Random Forest (RF), penalized logistic regression (PLR), and an ensemble of the three. Performance was measured using 10-fold cross-validation on the same sample (ie training) cohort.

RESULTS. Classifiers were built using the top 70 genes from LIMMA models that controlled for BRAF status. Maximum classification performance of ATA low risk vs. ATA intermediate/high risk was observed for an ensemble classifier with a maximal area under the ROC curve (AUC) of 0.83. Individually, all the classifiers achieved similar AUCs: SVM 0.82, RF 0.82, and PLR 0.82. Genes useful in classification belong to a variety of transmembrane signaling pathways including ECM-receptor interaction, focal adhesion, and cell adhesion molecules. When applied to the current sample cohort, the ensemble classifier correctly identified 72.4% (21/29) of ATA low risk tumors and 82.6% (43/52) of ATA intermediate/high risk tumors.

CONCLUSIONS. Transcriptional data obtained during diagnostic evaluation of thyroid nodules has the potential to improve the pre-operative prediction of risk of recurrence.  If independently validated in a sufficiently large number of patients, such molecular classifiers may provide information that could be used to augment initial risk stratification and allow further individualization of patient management.

 

Disclosure: RMT: Advisory Group Member, Veracyte, Inc.. MP: Coinvestigator, Veracyte, Inc.. JH: Coinvestigator, Veracyte, Inc.. BL: Coinvestigator, Veracyte, Inc.. JD: Coinvestigator, Veracyte, Inc.. ET: Coinvestigator, Veracyte, Inc.. BRH: , Veracyte, Inc.. GCK: Coinvestigator, Veracyte, Inc.. Nothing to Disclose: SIS

22909 12.0000 LBT-012 A Augmenting Pre-Operative Risk of Recurrence Stratification in Differentiated Thyroid Carcinoma Using Machine Learning and High Dimensional Transcriptional Data from Thyroid FNA 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Martin Adrian1, Christina Schuermeyer2, Denise Roos2 and Thomas H Schuermeyer*2
1Klinikum Mutterhaus der Borromäerinnen, Trier, 2Klinikum Mutterhaus der Borromäerinnen, Trier, Germany

 

Hypoparathyroidism resulting in hypocalcemia is a major complication of thyroid surgery. Recently a trend toward radical surgery is demonstrated. We analysed the rate of short term, postoperative (day 1 – 3) hypocalcemia < 2,0 mmol/l in 1996 patients having surgery of bilateral nodular goiter (BG, n=1515), unilateral nodular goiter (UG, n=333) and Grave´s disease (GD, n=124). 872 patients had total thyroidectomy (TT), 474 near total thyroidectomy (NT, remnant < 5 g), 546 subtotal thytoidectomy (ST, remnant 5 – 8 g) and 44 less than ST (LT, remnant > 8 g). Persistence of hypocalcemia was evaluated in 281 of 412 patients (68 %) suffering from short-term hypocalcemia at a follow-up 8,5 ± 4 years after surgery. 32 % of the patients had no follow-up: 2 % had died, 17 % moved to an unknown address and 11 % refused to participate in the evaluation.

Results showed short-term hypcalcemiain in 26.7 % (TT), 25.9 % (NT), 16.1 % (ST), 9.4 % (LT) and in 23,4 % (BG), 2,4 % (UG) and 38.7 % (GD).  1 year postoperatively in 34 % of the follow-up patients symptoms of hypocalcemia persisted. 30 %, had to take calcium and 20 % short-acting vitamin D analogues. Thus, symptoms of hypocalcemia persisted for at least 1 year in 10.3 % (TT), 6.2 % (NT), 5.6 % (ST), 0 % (LT), in 8.4 % (BG), 0.4 % (UG) and 8.7 % (GD) patients.

We conclude that a higher rate of short-term hypocalcemia persisting for at least 1 year results from more radical modes of thyroid surgery especially in patients with Grave`s disease and bilateral goiter.

 

Nothing to Disclose: MA, CS, DR, THS

22930 13.0000 LBT-013 A Long-Term Outcome of Short-Term Hypocalcemia Following Various Modes of Thyroidectomy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Thursday, March 5th 3:00:00 PM LBT 001-014 6277 1:00:00 PM Late-breaking Thyroid/HPT Axis I Poster


Toshihiro Fujiwara*, Chisa Tabata and Osamu Tsutsumi
Sanno Hospital, Tokyo, Japan

 

Background: Assisted reproductive technology (ART) is often applied to breast cancer survivors in order to achieve pregnancy.  Although aromatase inhibitor (AI) is used in controlled ovarian stimulation (COS) to prevent hyperestrogenic condition, influence of low estrogen to oocyte/embryo quality is not clear.

Clinical case: A 40-year woman who had both surgical and hormonal treatment to breast cancer at age of 35 visited our hospital for pregnancy.  ART is applied and daily letrozole (5 mg/day x 11 days) in the first cycle and daily clomifen citrate (100 mg/day x 11 days) in the second cycle was administered, after which one embryo from three oocytes retrieved and two embryos from five oocytes retrieved were cryopreserved, respectively.  In later cycles each of them were thawed and transferred to the uterus, but none of them was successful.  In the third cycle COS under GnRH antagonist protocol was applied, in which daily letrozole (5 mg/day) was administered along with FSH (225 IU/day) injection for 10 days and ganirelix (0.25 mg/day) injection in the last four days.  Oocyte maturation was triggered by 600 μg of nasal buserelin.  Two days later a total of 12 oocytes were retrieved transvaginally, nine of which were mature and microinseminated with husband’s sperm.  All of them were fertilized and consequently five blastocysts of good morphology were cryopreserved.  Due to concomitant use of letrozole the peak serum estradiol level was 173.4 pg/ml in spite of large number of grown follicles.  The rate of mature oocyte (9/12; 75%), fertilization rate (9/9; 100%) and rate of good morphological embryos (5/9; 55.6%) were comparable to the result in ordinal COS under GnRH antagonist protocol.  In later cycles each blastocyst was thawed and transferred to the uterus.  Although it just ended in slight increase of serum hCG in the first cycle, ongoing pregnancy was established in the second cycle.  This also showed the quality of embryos is not impaired even though they are acquired under low estrogenic condition.

Conclusion: In COS with AI there is a dissociation of number of follicles and serum estradiol level.  It is suggested this dose not affect the quality of oocytes retrieved as well as that of embryos derived from them and thus this protocol is well tolerated to breast cancer survivors as infertility treatment.

 

Nothing to Disclose: TF, CT, OT

22857 1.0000 LBT-015 A Dissociation of Folliculogenesis and Estrogen Production Dose Not Affect the Oocyte/Embryo Quality: A Case Report of Successful ART Pregnancy Using GnRH Antagonist Protocol with Aromatase Inhibitor after Treatment of Breast Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM LBT 015-023 6280 1:00:00 PM Late-breaking Reproductive Endocrinology I Poster


Heping Zhang*1, Hongying Kuang2, Susan Jin3, Karl R Hansen4, Michael P Diamond5, Christos Coutifaris6, Peter Raymond Casson7, Gregory M Christman8, Ruben Alvero9, Hao Huang10, Gordon W Bates11, Rebecca Usadi12, Richard Scott Lucidi13, Valerie Lynn Baker14, Nanette Santoro15, Esther Eisenberg16 and Richard S Legro17
1Yale University, New Haven, CT, 2Heilongjiang University of Chinese Medicine, 3Yale University, 4University of Oklahoma College of Medicine, 5Augusta University, Augusta, GA, 6Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 7UNIV OF VERMONT Coll of Med, Burlington, VT, 8Shands Hospital, University of Florida, Gainesville, FL, 9University of Colorado-Denver, Aurora, CO, 10Yale University School of Medicine, New Haven, CT, 11University of Alabama, 12Carolinas Medical Center, 13Virginia Commonwealth University, San Antonio, TX, 14Stanford School of Medicine, 15University of Colorado Anschutz Medical Campus, Aurora, CO, 16NICHD, Nashville, TN, 17Penn State College of Medicine, Hershey, PA

 

CONTEXT:  Predictive models for ovulation and pregnancy outcomes in infertile women with polycystic ovary syndrome have been reported, but such models require validation.

OBJECTIVE: To confirm previously reported and identify new predictors of ovulation and pregnancy outcomes among Pregnancy in Polycystic Ovary Syndrome II (PPCOS-II) participants.

METHODS:  This is a secondary analysis of the PPCOS-II data which included 750 infertile women with PCOS. Participants were randomized to letrozole or clomiphene citrate for up to 5 treatment cycles. Linear logistic regression models were fitted using treatment, BMI, and other published variables as predictors of ovulation, conception, clinical pregnancy, and live birth as the outcome one at a time. We first evaluated previously reported significant predictors, and then constructed new prediction models. We constructed receiver operating characteristic (ROC) curves and calculated area under the curve (AUC) to compare performance using different models and data.

RESULTS:  Predictive factors were similar between PPCOS-I and II, although the two participant samples differed (statistically significant but clinically minor) on key baseline characteristics and hormone levels. Women in PPCOS-II had an overall more severe PCOS phenotype than did women in PPCOS-I. The clinically minor and statistically significant differences can be due to the large sample sizes. Younger age, lower baseline FAI and insulin, shorter duration of attempting conception and higher baseline SHBG significantly predicted at least one pregnancy outcome. ROC curves had AUCs of 0.66-0.76, indicating a stable predictive power of the identified variables.

CONCLUSIONS: Simple clinical and biochemical criteria may be useful for predicting pregnancy outcomes in women with PCOS.  We have largely confirmed the predictors that were identified in the PPCOS-I trial.  Duration of attempting conception is the most consistent predictor among all considered factors for pregnancy outcomes.

 

Disclosure: KRH: Ad Hoc Consultant, Ferring Pharmaceuticals. GMC: Ad Hoc Consultant, Bayer, Inc.. Nothing to Disclose: HZ, HK, SJ, MPD, CC, PRC, RA, HH, GWB, RU, RSL, VLB, NS, EE, RSL

22316 2.0000 LBT-016 A Identification and Replication of Prediction Models for Ovulation, Pregnancy and Live Birth in Infertile Women with Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM LBT 015-023 6280 1:00:00 PM Late-breaking Reproductive Endocrinology I Poster


Snigdha Alur*1, Emily Barrett1, Dongmei Li2, Kathleen M Hoeger1, Martha Wojtowycz3, Pamela Parker3 and Tim Dye1
1University of Rochester, Rochester, NY, 2University of Rochester, 3SUNY Upstate Medical University, Syracuse, NY

 

Infertility, defined as failure to achieve clinical pregnancy after 12 consecutive months of unprotected intercourse, is highly prevalent across the world. In the United States, the number of women with infertility is expected to increase to up to 7.7 million by the year 2025. (1) Assisted reproductive technology (ART) is an increasingly employed form of treatment, prompting interest in which factors could predict or influence its success. Despite African Americans having the highest prevalence of infertility and ample investigation on racial disparities influencing pregnancy outcomes, few have evaluated whether race also affects ART outcomes. (2) This study’s objective was to explore whether adverse pregnancy outcomes were significantly different between Caucasian and African American women using ART. At the time of birth certificate completion, mothers who delivered in the Central and Finger Lakes regions of New York completed the Perinatal Data System (PDS) questionnaire including items on socio-demographics, reproductive history and use of ART in the index pregnancy. These data were then paired with obstetric records including birth size and gestational age. For the current study we examined 1871 singleton births to African American and Caucasian women resulting from ART (from 322656 total births) between January 2005 and December 2013. Primary analyses focused on differences in birth outcomes between African American and Caucasian women in relation to use of ART. Logistic regression models were used to examine racial differences in the odds of having a preterm birth (<37 weeks) or very preterm birth (<34 weeks) or a small-for-gestational-age (SGA) or very SGA infant (defined as gender-adjusted weight being < 10% and <5% respectively). All analyses were adjusted for covariates including maternal age, smoking status, pre-pregnancy weight, gestational weight gain and highest level of education. 47 of the ART singleton births were to African-American women and 1824 of births were to Caucasian women. After adjusting for covariates, African American women were significantly more likely to have preterm births (OR=2.63, 95%CI: 1.33, 5.20) but not very preterm births (OR=2.17, 95% CI: 0.72, 6.50). They also had significantly increased odds of having a SGA (OR=2.71, 95% CI: 1.16, 6.34) or very SGA infant (OR=3.01, 95% CI: 1.02, 8.91) compared to Caucasian women. In summary, African American women with singleton pregnancies resulting from ART were more likely to have preterm births and deliver SGA infants compared to Caucasian women using ART even after adjusting for all covariates. Despite similarities in socioeconomic status between these 2 groups using ART, our results suggest that racial disparities in birth outcomes remain. Further research into these racial disparities is warranted and could impact whether counseling on ART outcomes should incorporate the influence of race.

 

Nothing to Disclose: SA, EB, DL, KMH, MW, PP, TD

22511 3.0000 LBT-017 A Differences in Birth Outcomes Between Caucasian and African American Women Undergoing ART 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM LBT 015-023 6280 1:00:00 PM Late-breaking Reproductive Endocrinology I Poster


Zona Batacchi*1 and Bradley D. Anawalt2
1University of Washington, Seattle, WA, 2University of Washington

 

Clinical Presentation:

A 33-year old transgender man was self-referred for care at 13 weeks of pregnancy. He has a history of papillary thyroid cancer (PTC) and post-surgical hypothyroidism.

He was born genotypically female but has identified as male since childhood. By 21 years of age, he began the transition process with testosterone injections followed by bilateral mastectomy. He has male pattern alopecia, male distribution of hair including facial and chest hair, deep voice and increased muscle mass. He has been taking testosterone cypionate injections, 200mg every 10 days. 

He was diagnosed with PTC 7 years ago when he detected a lump in his neck. Fine needle aspiration revealed cytology that was suspicious for PTC. He underwent total thyroidectomy and central compartment dissection. Pathology revealed a 1.5 cm PTC with clear surgical margins and 2 of 8 lymph nodes positive for PTC. In September 2008 he was treated with 100mCi of I-131 as radioactive iodine (RAI) remnant ablation with recombinant human thyrotropin (rhTSH) priming.  

Post-operative serum thyroglobulin concentrations have been <0.1 ng/mL (0.0-0.1) with undetectable thyroglobulin antibody concentrations. Post-operative imaging with neck ultrasound and rhTSH-primed whole body scan have revealed no sign of recurrence. 

In August 2013 he discontinued testosterone injections in order to conceive via intrauterine insemination (IUI), using donor sperm. He conceived after 4 cycles of IUI. The pregnancy has progressed without complications.  Intrauterine ultrasound revealed a normal singleton fetus with size concordant with expected date of delivery. During pregnancy he has required increased dosages of levothyroxine, with doses incrementally increasing to maintain TSH concentrations.

Discussion:

This case describes a female to male pregnant transgender patient with a history of stage 1 differentiated thyroid cancer post thyroidectomy and remnant ablation. 

Despite being on testosterone therapy for 11 years, he was able to conceive only 10 months after discontinuing testosterone indicating rapid recovery of the hypothalamic-pituitary-ovarian axis. As expected, he has required higher dosages of levothyroxine since discontinuing testosterone therapy (a hormone known to decrease thyroid binding globulin concentrations [TBG]) and become pregnant (a condition known to increase TBG concentrations) to maintain TSH concentrations. Conclusions:  1) female to male transsexuals can conceive rapidly after sex steroid therapy is discontinued; 2) understanding the opposing effects of androgens and estrogens is important in the management of patients with thyroid cancer who have conditions or are on therapies that affect these sex steroid hormone concentrations.

 

Nothing to Disclose: ZB, BDA

22865 4.0000 LBT-018 A Pregnancy in a Transgender Man with a History of Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM LBT 015-023 6280 1:00:00 PM Late-breaking Reproductive Endocrinology I Poster


Maria Fernanda Garces*1, Elizabeth Sanchez1, Luisa F Cardona1, Elkin L Simanca1, Iván González1, Luis G Leal1, José A Mora1, Andrés Bedoya1, Juan P. Alzate1, Ángel Y. Sánchez1, Javier H Eslava-Schmalbach1, Roberto Franco-Vega1, Mario O. Parra1, Ariel I. Ruíz-Parra1, Carlos Dieguez2, Rubén Nogueiras2 and Jorge Eduardo Caminos1
1Universidad Nacional de Colombia, Bogota, Colombia, 2University of Santiago de Compostela/CIBERobn, Santiago de Compostela, Spain

 

Meteorin (METRN) is a recently described neutrophic factor, with angiogenic properties, that does not share homologous motifs with VEGF-A or FGF-2, angiogenic factors previously documented to play an important role during pregnancy. Thus, METRN forms a new family, named Meterorin-like (METRNL), which conserves about 40% of its identity [1-3]. This is a nested case-control study in a longitudinal cohort study with the objective to describe the serum profile of METRN during different periods of gestation in healthy and preeclamptic pregnant women.

After written informed consent was provided, 37 patients that had normal maternal and perinatal outcomes and delivering at term (at week 38.4-39.6 of gestation), were studied during early, middle, and late pregnancy (during weeks 11.6-12.6, 24.2-24.6, and 34.1-35.1, respectively) in the period 2012-2014. Additionally, 16 women of the same longitudinal cohort who developed mild preeclampsia were included and studied during the same time periods. Twenty healthy eumenorrheic women were included in this study, and their serum levels of METRN were measured during the follicular (days 3- 4) and luteal phase (days 21-23) of the menstrual cycle. Serum METRN was measured by ELISA to assess levels and correlations with other metabolic parameters. Immunostaining for METRN was performed in embedded human adipose tissue and placenta at 11 weeks of gestation, provided from the Pathology Department Services of the School of Medicine at the Universidad Nacional de Colombia.

The results of this study revealed for the first time that serum METRN levels did not differ significantly in eumenorrheic healthy women studied during the follicular and luteal phase of the menstrual cycle. However, serum METRN levels were significantly elevated in the first trimester in healthy pregnant women whereas they decrease in the second and third trimesters reaching similar levels to the ones observed in eumenorrheic women. Contrary, serum levels of METRN remained unchanged throughout gestation in preeclamptic women, being significantly lower in the first period of gestation when compared with serum levels of healthy pregnant women. Finally, we detected METRN immunoreactivity in the cytoplasm of cytotrophoblast cells, syncytiotrophoblast cells, and decidual cells in first trimester placenta.

 

Nothing to Disclose: MFG, ES, LFC, ELS, IG, LGL, JAM, AB, JPA, ÁYS, JHE, RF, MOP, AIR, CD, RN, JEC

22668 5.0000 LBT-019 A Maternal Serum Meteorin Levels during Normal Pregnancy and Preeclampsia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM LBT 015-023 6280 1:00:00 PM Late-breaking Reproductive Endocrinology I Poster


Natalia E. Poveda1, Maria Fernanda Garces1, Carlos E. Ruíz-Linares1, Diana Varón1, Sergio Valderrama1, Elizabeth Sanchez1, Adriana Castiblanco-Cortes1, Luis G Leal1, Edith Ángel-Müller1, Ariel I. Ruíz-Parra1, Angélica M González-Clavijo1, Rubén Nogueiras2, Carlos Dieguez2 and Jorge Eduardo Caminos*1
1Universidad Nacional de Colombia, Bogota, Colombia, 2University of Santiago de Compostela/CIBERobn, Santiago de Compostela, Spain

 

Adipsin is a serine protease that is expressed and secreted at high levels by adipose tissue. It is involved in both complement activation and metabolic control. Existing evidence suggests that adipose tissue plays an important role in the physiology and pathology of gestation. [1,2] The objective of this study was to find possible relationships between serum adipsin levels, its changes during different stages of normal pregnancy, and its association with obstetric outcomes, such as preeclampsia.

The present study reports the data of 54 out of 264 healthy pregnant women recruited between the 11th and 13th week gestation as determined by early ultrasound and last menstrual period. All these women had a normal pregnancy, delivering at term, with no medical or obstetrical complications. They were studied during early (12.1, range: 11.5-12.5 weeks of gestation), middle (24.3, range: 24.13-24.6 weeks of gestation), and late pregnancy (34.4, range: 34.2-35.2 weeks of gestation), and followed up until three months after delivery. Additionally, 18 women of the same longitudinal cohort who developed mild preeclampsia and 20 healthy non-pregnant women were included in the study. Healthy non-pregnant women were studied during the follicular (days 3–5) and luteal phase (days 21–23) of the menstrual cycle. All patients provided written informed consent. Adipsin serum levels were determined by an ELISA assay.

The present study shows for the first time that serum adipsin levels were decreased during the entire normal pregnancy, recovering its basal levels at three months postpartum. Moreover, adipsin was positively correlated with weight and BMI during early and late pregnancy. Adipsin levels in preeclamptic pregnant women in early and middle pregnancy were very similar to the ones observed in normal pregnant women. However, serum adipsin levels were significantly higher in preeclamptic women towards the end of gestation, when adipsin levels were negatively correlated to glucose, total cholesterol, and LDL-cholesterol. Serum adipsin levels did not vary throughout the menstrual cycle of eumenorrheic women. Our results suggest that adipsin may be involved in reproductive function and in pregnancy-associated metabolic changes. Moreover, the increase of adipsin levels towards the end of gestation in preeclamptic women could contribute to a dysfunctional placentation characteristic of this disease.

 

Nothing to Disclose: NEP, MFG, CER, DV, SV, ES, AC, LGL, EÁ, AIR, AMG, RN, CD, JEC

22844 6.0000 LBT-020 A Serum Adipsin Levels throughout Normal Pregnancy and Preeclampsia in Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM LBT 015-023 6280 1:00:00 PM Late-breaking Reproductive Endocrinology I Poster


Yuyong Ke*1, Renaud Gonthier1 and Fernand Labrie2
1EndoCeutics Inc., Quebec City, QC, Canada, 2EndoCeutics Inc, Quebec, QC, Canada

 

7-alpha hydroxyl, 7-beta hydroxyl and 7-keto dehydroepiandrosterone (7-α OH DHEA, 7-β OH DHEA and 7-oxo DHEA, respectively) are oxidation metabolites of the important precursor steroid DHEA [1,2]. While their serum concentrations are low, an accurate and sensitive measurement of these compounds should help understanding the mechanisms for DHEA’s multiple potential functions, specifically in the brain [2]. The aim of this study is to develop a sensitive LC-MS/MS method for the simultaneous measurement of 7-α OH DHEA, 7-β OH DHEA and 7-oxo DHEA in the serum of post and premenopausal women using deuterated internal standards. Due to their low ionization efficiencies and low concentrations, these metabolites and their internal standards were derivatized using a ketone reagent. The system chosen for method development assay was an UPLC (Nexera Shimadzu)-Qtrap 6500 (AB Sciex) combination. Two hundred µL of serum were used for liquid-liquid extraction using chlorobutane. The dry residues were derivatized at 30 ~ 37 ºC for half of an hour under weakly acidic conditions before being reconstituted with 200 µL of 30% methanol while 20 µL was injected into the UPLC-MS/MS system.

These three compounds are well separated from each other. All signal to noise ratios of low limit of quantitation  (LLOQs) are larger than 10. The calibration ranges are from 10 (LLOQ) to 2000 pg/mL for all three compounds. The linear regression model fits well all the calibration curves with R > 0.99. Using this method, 24 lots of postmenopausal and 10 premenopausal sera were screened.

The concentration ranges for 7-α OH DHEA, 7-β OH DHEA and 7-oxo DHEA were 20 - 250, 20 – 160 and 10 – 70 pg/mL, respectively, for postmenopausal serum while  the ranges were 20 - 400, 20 – 300 and 10 – 170 pg/mL, respectively, for premenopausal serum. These preliminary results indicate that such a sensitive and accurate method validated according to the FDA guidelines is necessary for reliable measurement of these steroids in clinical samples.

(1) Labrie et al., J. Steroid. Biochem. Mol. Biol. 2006; 103:178-88. (2) Li et al., Biomed. Chromatogr. 2010; 24: 833–37

 

Nothing to Disclose: YK, RG, FL

22592 7.0000 LBT-021 A Isotope-Dilution LC-MS/MS Method for the Simultaneous Serum Assay of 7-Alpha Hydroxyl, 7-Beta Hydroxyl and 7-Keto Dehydroepiandrosterone in Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Thursday, March 5th 3:00:00 PM LBT 015-023 6280 1:00:00 PM Late-breaking Reproductive Endocrinology I Poster


Eric K Chang* and Himala Kashmiri
Loyola University Medical Center, Maywood, IL

 

CHARGE syndrome is an autosomal dominant condition that occurs as a result of mutations in the chromodomain helicase DNA-binding protein-7 (CHD7) gene. The syndrome has well described phenotypic findings such as colobomas, atresia choanae, and growth retardation. DiGeorge syndrome is another autosomal dominant condition that is caused by a heterozygous chromosomal deletion at chromosome 22q11.2. This syndrome can present with phenotypic findings such as cardiac anomalies and hypoplastic thymus. There can often be an overlap of features between CHARGE syndrome and DiGeorge syndrome such as cardiac anomalies, ears abnormalities, and hypocalcemia. In DiGeorge syndrome, the hypocalcemia is considered a classic finding that is likely attributed to hypoparathyroidism due to hypoplasia or aplasia of the parathyroid glands. However, hypocalcemia can also present in CHARGE syndrome, although it is not often considered one of the classical findings. The hypocalcemia can be secondary to hypoparathyroidism but no precise etiology for the hypoparathyroidism has been determined.

In this case report, we report a 14 year old male with genetically confirmed CHARGE syndrome who presented to our pediatric endocrinology clinic with hypocalcemia since infancy, per chart review. He was first diagnosed with hypocalcemia at around 22 months of age. His calcium was as low as 5.6 mg/dl (9.0-11.5 mg/dl). His intact parathyroid hormone (iPH) was found to be inappropriately normal. He was presumptively diagnosed with hypoparathyroidism based on the laboratory findings. However, the exact etiology was still unknown. Given recent advancements in commercially available genetic testing and sequencing of the calcium sensing receptor, the patient eventually underwent subsequent genetic testing of his calcium sensing receptor which revealed a mildly activating mutation of the calcium sensing receptor (CaSR) on exon 7 (c.2968A>G) resulting in an altered set point for PTH secretion. This mutation can also cause increased renal excretion of calcium and so a renal ultrasound was also done demonstrating bilateral nephrocalcinosis. Our literature reviews found that the incidence of individuals with CHARGE syndrome and hypocalcemia may be higher than originally expected. The hypocalcemia is thought be secondary to hypoparathyroidism. We hypothesize that a CaSR mutation is the molecular basis for the hypoparathyroid phenotype in patients suggesting a unique association with patients with CHARGE syndrome.

In the future, we recommend further molecular analysis for this unique association between the activating mutation in the CaSR and patients with CHARGE syndrome as it may provide further utility in the management of these patients.

 

Nothing to Disclose: EKC, HK

22397 1.0000 LBT-024 A Hypocalcemia Secondary to a Calcium-Sensing Receptor Mutation in a Patient with Charge Syndrome: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM LBT 024-030 6283 1:00:00 PM Late-breaking Pediatric Endocrinology I Poster


Hyun-wook Chae*1, Jae Hwa Jung1, Jung Min Ahn1, Yejin Kim1, Ah Reum Kwon1, Choon-Sik Yoon1, Duk-Hee Kim2 and Ho-Seong Kim3
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Sowha Children’s Hospital, Seoul, Korea, Republic of (South), 3College of Medicine Yonsei University, Seoul, Korea, Republic of (South)

 

Purpose: Central obesity is important prognostic factor to metabolic syndrome in children. In adult, abdominal computed tomography or dual energy X-ray absorptiometry is used to measure central obesity, however, exposure to radiation, high cost and low availability prevent the wide use in children. The measurement by ultrasound may have much advantage especially in children and adolescents, although it might be dependent on operator proficiency.

 Methods: We enrolled 103 subjects (age 6-16) who were evaluated for fatty liver and abdominal adipocity by ultrasound. The subcutaneous fat thickness (SFT) was defined as the thickness of the fat tissue from the skin-fat interface to the linea alba and visceral fat thickness (VFT) defined as the thickness from the linea alba to the aorta. Anthropometric, body composition and biochemical measurements including serum glucose, insulin, lipid profiles, aspartate transaminase, alanine transaminase (ALT), and other metabolic parameters were collected.

 Results: There was a strong positive correlation between abdominal fat thickness and obesity indices, such as, serum ALT, C-reactive protein and high density lipoprotein. BMI SDS was highly correlated with VFT (R2=0.458, P=0.002). The VFT was correlated with the presence of fatty liver (P=0.034). The homeostatic model assessment of insulin resistance was correlated with VFT in this study(P=0.011).

 Conclusion: The ultrasound could be useful to measure abdominal fat thickness, and effective to assess central obesity in children and adolescents. Further studies should be needed to evaluate childhood central obesity accurately.

 

Nothing to Disclose: HWC, JHJ, JMA, YK, ARK, CSY, DHK, HSK

22403 2.0000 LBT-025 A Measurement of Abdominal Subcutaneous and Visceral Fat Thickness By Ultrasound in Children: Correlation with Anthropometric and Metabolic Profiles 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM LBT 024-030 6283 1:00:00 PM Late-breaking Pediatric Endocrinology I Poster


Jonathan Kraus*1, Loreto Reyes2, Maria Isabel Hernandez3, Katherine Rossel4, German Iniguez3 and Maria Mericq5
1Institute of Maternal and Child Reserach, University of Chile, Santiago, Chile, 2Pediatric Endocrinology, Catholic University of Chile, 3Institute of Maternal and Child Research, University of Chile, Santiago, Chile, 4Neonatology Unit, San Borja Arriaran Hospital, 5University of Chile, Santiago, Chile

 

Nutritional imbalance during critical windows in early life can permanently influence long term metabolic profile and body composition (BC). VLBW born infants accumulate nutrient deficit during hospital stay and demonstrate catch up in weight after this time, a period equivalent to that in term infants associated with later metabolic risk and altered BC. Available data is from studies in the 1980´s which limit applicability to contemporary practice. In this population differences in BC by birth weight SDS and early CUG have not been consistently found at this age. We tested this hypothesis and further analyzed whether differences in BC were associated to adipokines profiles collected from 3 months up to 3 years of corrected age (CA).  VLBW preterm infants prospectively recruited had BC (DXA; Lunar DPX-L, Madison, WI; software 1.3) at CA 2 (n=39,19 AGA,15 male)  and 3 years  (n=31,19 AGA,11male).These infants belong to the National program of follow up for VLBW infants, which standardize feeding and follow up from birth to 7 years. Statistics: student t test or Mann Whitney test according to the data distribution and univariate spearman´s Rho correlations were performed. BC was expressed in SDS and data was adjusted by height SDS by regression analysis. Mean gestational age, birth weight/length of these children were 29 ± 2.0 weeks, -2.03 ± 1.02 and -1.27 ± 1.40 SDS respectively. Weight and length at age 2 and 3 yr were persistently lower in SGA children (p<0.001). SGA children had lower total lean mass at 2 years (p<0.003) and at 3 years had lower subcapital mineral content (p<0.011), total (p<0.021), trunk (p<0.026) and limb fat mass (p<0.05) and total lean mass (p<0.031) compared to their counterparts. Blood adiponectin and visfatin concentrations decreased (p=ns) during infancy up to 3 years without differences by BW SDS. Only  in those infants born SGA, adiponectin at 12 months was inversely associated to subcapital mineral bone content, fat percentage and trunk fat mass at 24 months (r=-0.861**, -0.726* and -0.867** respectively) and with fat percentage at 36 months (r=-0.9469**), and adiponectin at 24 months with total fat mass at 24 months (r=-0.6853*). Conversely, only in those born AGA inverse correlation were obtained for visfatin at 12 months with fat percentage at 24 months (r=-0.984*) and with total fat mass at 24 months (r=-0.4841*). In conclusion, in these contemporary cohort  BC differs early in childhood in spite of using standardized feeding up to 1 year, and associations with adipokines are BW SDS dependent suggesting a different fat tissue functioning.*p<0.05  **p<0.01

Sources of support: Fondecyt #1090028

 

Nothing to Disclose: JK, LR, MIH, KR, GI, MM

22632 3.0000 LBT-026 A Early Infancy Body Composition (BC) in Very Low Birth Weight (VLBW, <1500 grs) Preterm  Is Dependent on BW SDS and Is Differently Associated to Adipokines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM LBT 024-030 6283 1:00:00 PM Late-breaking Pediatric Endocrinology I Poster


Serife Nur Boysan*1, Seref Olgar2, Ekrem Aksu1, Durmus Eren Cabioglu1, Eylem Sahin1, Hasan Temizdemir1, Besra Dagoglu1, Serkan Caglar1 and Mustafa Sait Gonen3
1Kahramanmaras Necip Fazil City Hospital, Kahramanmaras, Turkey, 2Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey, 3Gayrettepe Florence Nightingale Hospital, Istanbul, Turkey

 

Background:Kearns-Sayre Syndrome(KSS) is a rare mitochondrial cytopathy with multisystem involvement. A very few Bartter-like phenotype association was reported. KSS has also been associated with short stature, gonadal failure, diabetes mellitus, thyroid disease, hyperaldosteronism, and calcification abnormalilities.

Clinical Case: A 18-year old boy was admitted to hospital for evaluation of short stature and delayed puberty. His height  was 1.32 m and his  weight was 22.3 kg;both of were below the third percentile. Blood pressure was 90/60 mm Hg and pulse rate was 52/min.  Seconder sexual features were not developed. Ptosis and retinitis  pigmentosa in fundoscopic examination were showed. Neurologic examination revealed 4/5 muscle strength with extremities and bilaterally facial diplegy.

Biochemical tests showed hypokalemia: 2.7 mmol/L(3.5-5.5),hyponatremia: 128mmol/l(138-145), hypophosphatemia: 1.88 mg/dl(2.7-4.5),  hyperglycemia: 111 mg/dl, high CK: 1977 U/L(35-308), alkali and diluted urine: PH 8 and SG1.005.  Hormonal tests showed hyperthyroxinemia: 1.73 ng/dl(0.93-1.7),  hypoparathyroidism: 12 pg/ml(15-65), low somatostatin-c level: 96.4 ng/ml(197-958),  hyperreninemia:132 ng/ml/hr (0.20-1.90) and normal levels of cortisol, FSH, LH,and prolactin.

ECG revealed complete heart block and 24 –hour Holter monitorisation confirmed the diagnosis. Bone age was  compatible  with 14 years in direct graphy .US showed atrophic testes (RT 4 cc and LT 3 cc). In pituitary MR the height of the gland was 5 mm. Cranial MR showed high signals  in the basal ganglions, thalamus and brain stem  in T2A sequences and also mild atrophy in cerebral and cerebellar hemispheres causing prominency of sulcus.

During hospitalisation carpopedal spasm was occured.  We checked for arteriel blood gas sampling: PH 7.57, ionized calcium 1.03 mmol/L(1.15-1.29),and  lactate 4.2 mmol/L(0.5-1.6). Potassium and calcium replacement treatment began.  Medical intervention as intravenous atropin was applied two times when heart rate was below the 30 beats/min. We planned to implant permanent pace maker.

Conclusion: In KSS, as a result of spontaneous mitochondrial DNA reaarrangements respiratory chain proteins in different tissues are affected. Severity of clinical symptoms is  related not only  to the proportion of mutated to normal mtDNA and also to the exposed oxidative stress of each tissue. . This heteroplasmy  causes the  presence of the different endocrinological features correlated with the duration of the disease and the renal  involvement presented as Bartter-like phenotype.

 

Nothing to Disclose: SNB, SO, EA, DEC, ES, HT, BD, SC, MSG

22715 4.0000 LBT-027 A Kearns-Sayre Syndrome: A Case Report Presenting Endocrine Features and Associated with Bartter-like Phenotype 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM LBT 024-030 6283 1:00:00 PM Late-breaking Pediatric Endocrinology I Poster


Sani M. Roy*1, Carrie C. Coughlin1, N. Scott Adzick1, Albert C. Yan1, Adam I. Rubin2 and Diva D. De Leon3
1The Children's Hospital of Philadelphia, Philadelphia, PA, 2The Hospital of the University of Pennsylvania, Philadelphia, PA, 3The Children's Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA

 

Introduction: Necrolytic migratory erythema (NME) is a rare cutaneous finding, characterized by painful, pruritic, scaly red patches and superficial bullae that erode; it is typically considered a paraneoplastic phenomenon related to increased glucagon secretion in patients with glucagonomas. NME has rarely been reported in the setting of glucagon administration and even more rarely in children1. Herein, we report a case of an infant developing histologically confirmed NME arising from glucagon therapy for congenital HI.

Clinical Case:

The patient was a full-term infant who presented with hypoglycemia on the 1st day of life (DOL) to 11 mg/dL (normal >70), with inappropriately elevated insulin level of 80.5 uU/mL (normal <2) but appropriate levels of cortisol and growth hormone. She was not a candidate for diazoxide therapy given cardiac finding of anomalous left coronary artery arising from the pulmonary artery (ALCAPA). She had hypoglycemia despite an elevated glucose infusion rate of 20 mg/kg/minute and was placed on continuous intravenous glucagon, which was titrated to the lowest-effective dose to maintain euglycemia, with doses ranging from 0.3-1mg/24 hours over the next 3 months. Genetic testing for congenital HI revealed a paternally-derived autosomal recessive mutation in ABCC8, consistent with focal HI.

After 1.5 months of glucagon therapy, the patient was noted to have a new rash, characterized by scaly, red patches, some in geometric patterns, and more prominent on her extremities and dependent areas. The rash was initially attributed to irritant dermatitis but progressed with migratory involvement of new areas despite applications of mid-potency topical steroids. A glucagon level was found to be markedly elevated at 1,010 ng/L (normal <65). She underwent sub-total pancreatectomy for removal of her focal HI lesion at the age of 3 months along with concomitant skin biopsy to assess the etiology of the eruption. Histopathology showed a psoriasiform dermatitis, including lack of an epidermal granular layer.  There was pallor of the upper epidermal layers and parakeratosis.  These histologic features were consistent with NME. Within 2 days of sub-total pancreatectomy, her glucagon infusion was discontinued. The eruption showed marked improvement 1 day after discontinuing glucagon and near clearance 5 days after discontinuation.

Conclusion:

This case illustrates characteristics of NME, an extremely rare phenomenon among children, arising in the context of an infant with congenital HI receiving glucagon therapy, one of the mainstays of HI treatment. The eruption of NME is painful, pruritic, and recalcitrant to topical therapy, but discontinuation of glucagon results in resolution of the condition, presenting a unique clinical phenomenon of which practitioners caring for HI patients receiving glucagon should be aware.

 

Nothing to Disclose: SMR, CCC, NSA, ACY, AIR, DDD

22414 5.0000 LBT-028 A Iatrogenic Necrolytic Migratory Erythema in an Infant Receiving Glucagon Therapy for Congenital Hyperinsulinism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM LBT 024-030 6283 1:00:00 PM Late-breaking Pediatric Endocrinology I Poster


Iee Ho Choi*1, Min Sun Kim2, Sun Young Kim1 and Dae-Yeol Lee2
1Department of Pediatrics, Chonbuk National University Medical School, Jeonju 561-712, Korea, 2Department of Pediatrics, Chonbuk National University Medical School, Jeonju 561-712, Korea, Jeonju, Korea, Republic of (South)

 

Background : The IGF system is involved in the development of metabolic and cardiovascular disease. This study aimed to investigate the association of insulin-like growth factor-1 (IGF-1), IGF-binding protein-1 (IGFBP-1) and IGFBP-3 with insulin resistance and type 2 diabetes in children.

Methods : We included 40 children aged 10 to 16 years without known diabetes, medication, chronic disease. They were classified into 3 groups according to the results of oral glucose tolerance test and other clinical/laboratory findings. We performed anthropometric measurement and laboratory tests. The fasting levels of serum IGF-1, IGFBP-1 and IGFBP-3 were measured.

 Results : 1) Serum IGF-1, IGFBP-3 and IGF-1/IGFBP-1 molar ratio levels were significantly higher in glucose intolerance group. Serum IGF-1(r=0.396, P=0.023) and IGFBP-3(r=-0.628, P<0.001) had negative correlation with IGFBP-1. 2) Serum IGFBP-1 was negatively correlated with age, body mass index (BMI), systolic blood pressure, serum c-peptide, insulin, and HOMA-IR. And serum IGF-1/IGFBP-1 was significantly related with serum c-peptide, insulin and HOMA-IR.  3) Serum IGFBP-1 had no correlation with fasting plasma glucose level, lipid profile, apoprotein A/B and HbA1c. It was not different between normal glucose tolerance group and glucose intolerance group. 4) In normal glucose tolerance group, serum IGFBP-1 and IGF-1/IGFBP-3 was no significantly different between obese and non-obese groups. But IGFBP-1 had negatively associated with age, BMI, systolic blood pressure, serum c-peptide, IGFBP-3 and HOMA-IR.

CONCLUSION: Serum IGF-1/IGFBP-1 molar ratio was significantly elevated in Korean children with glucose intolerance sate and especially, serum IGFBP-1 correlated with insulin resistance state. These findings suggest that IGFBP-1 may related glycemic control and/or obesity in children.

 

Nothing to Disclose: IHC, MSK, SYK, DYL

22814 6.0000 LBT-029 A IGF-1/IGFBP-1 Axis Are Closely Associated with the Presence of Insulin Resistance in Korean Children 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM LBT 024-030 6283 1:00:00 PM Late-breaking Pediatric Endocrinology I Poster


Shana E. McCormack*1, Sani M. Roy1, Alessandra Chesi1, Jonathan A. Mitchell2, Heidi J. Kalkwarf3, Joan M. Lappe4, Vicente Gilsanz5, Sharon E Oberfield6, John A. Shepherd7, Soroosh Mahboubi8, Andrea Kelly1, Struan F.A. Grant9 and Babette S. Zemel1
1The Children's Hospital of Philadelphia, Philadelphia, PA, 2University of Pennsylvania, 3Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 4Creighton University, Omaha, NE, 5Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, 6Columbia University College of Physicians and Surgeons, New York, NY, 7University of California San Francisco, San Francisco, CA, 8Children's Hospital of Philadelphia, 9The Children's Hospital of Philadelphia, Philadelphia

 

Background: Previous studies have suggested that advanced skeletal maturation in African-American children compared to their non-African-American counterparts is largely accounted for by their greater adiposity (1).

Objective: To evaluate the effects of population ancestry and body composition on skeletal maturation in a cohort of non-obese, pre-pubertal children.

Subjects/Methods: The Bone Mineral Density in Childhood Study (BMDCS) included serial simultaneous bone age assessments (for skeletal maturation), anthropometrics, Tanner staging, and body composition data by DXA (2), along with self-reported population ancestry. The first available bone age assessment for each child was included. In BMDCS, two expert raters with established reliability rated the hand-wrist radiographs according to the standards of Greulich and Pyle. To i) compare bone ages across age and sex and ii) account for increased variance related to diverse ancestries, a within-cohort bone age z-score was generated. Body mass index (BMI) z-scores were calculated using CDC 2000 standards. For this investigation, pre-pubertal (Tanner I for both breasts/genitalia and pubic hair) children with BMI >3rd and <95th percentile were included.

Results: The sample included 1,011 subjects, mean age 7.5±1.7 years, 48% female, and 17% African-American. 13% were overweight (BMI ≥85th%ile and < 95th%ile) and 1% were underweight (BMI >3rd%ile and <5th%ile). Bone age z-score was higher in African-American (AA) vs non-AA girls (by 0.55 SDS, p=0.0004) and also higher in AA vs non-AA boys (by 0.57 SDS, p=0.0002). This corresponds to advancement of around 4.8 months in AA (vs non-AA) girls (p=0.0008) and 5.4 months in AA (vs non-AA) boys (p=0.0001). In multivariate regression analyses after accounting for lean mass, fat mass, height, and age, AA ancestry was independently associated with more advanced skeletal maturation in both girls (b=0.27, p=0.039) and boys (b=0.36, p=0.014). In addition, increased lean mass was independently associated with skeletal maturation after accounting for ancestry and the clinical covariates in both girls (b=0.07, p=0.041), and boys (b=0.13, p=0.001). The effect of fat mass did not reach statistical significance in either sex (b=0.04, p=0.09 in girls and b=0.04, p=0.19 in boys). In an exploratory analysis, whole-body bone mineral density z-score was correlated with bone age z-score in both AA (r=0.35, 95% CI 0.22 to 0.48, p<0.0001) and non-AA (r=0.16, 95% CI 0.093 to 0.23, p<0.0001).

Conclusions: In non-obese, pre-pubertal girls and boys, skeletal maturation is more advanced in African-Americans as compared to non-African-Americans, even after accounting for body composition and size. A better appreciation of ancestry-specific differences in skeletal maturation may inform our understanding of corresponding variation in bone mineral density.

 

Nothing to Disclose: SEM, SMR, AC, JAM, HJK, JML, VG, SEO, JAS, SM, AK, SFAG, BSZ

22827 7.0000 LBT-030 A Skeletal Maturation, Population Ancestry, and Body Composition in Non-Obese, Pre-Pubertal Children 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Thursday, March 5th 3:00:00 PM LBT 024-030 6283 1:00:00 PM Late-breaking Pediatric Endocrinology I Poster


Sylvester Jusu*1, John Presley2, Benoit Ochietti2, Loan Nguyen-Yamamoto2 and Richard Kremer3
1McGill University Health Centre, Montreal, QC, Canada, 2McGill University, Montreal, Canada, 3McGill University Health Center, Montreal, QC, Canada

 

Human Retinoid X receptor alpha (hRXRα) plays a critical role in DNA binding and transcriptional activity through heterodimeric association with several members of the nuclear receptor superfamily including the human vitamin D receptor (hVDR). hVDR/ hRXRα heterodimerization and co-activator recruitment are required for downstream signalling and biological activity. We previously reported that the malignant human keratinocyte HPK1Aras cell line is resistant to the growth inhibitory action of 1,25(OH)2D3,and that 10-100 fold higher concentrations of 1,25(OH)2D3are required to achieve inhibition of cell growth compared to the non-malignant normal HPK1A cell line. We showed that phosphorylation of hRXRα on serine 260 was responsible for this resistance.

In this study, we first looked at the intra-nuclear mobility of the receptors by Fluorecent Recovery After Photobleaching (FRAP) using green fluorescent protein (GFP)-tagged hVDR or hRXRα wt and the non-phosphorylatable hRXRα ala260 mutant transfected into HPK1A and HPK1Aras cell lines and treated with 1,25(OH)2D3. We showed that the residence time and immobile fractions of hRXRαwt in the nucleus of HPK1Aras cells decreased compared to the non-transformed HPK1A cells. In contrast, treatment with UO126 or expression of the non-phosphorylable hRXRα ala260 mutant reversed the effect on residence time and immobility. This was further confirmed by subcellular partitioning studies of hVDR, hRXRα and hVDR /hRXRα respectively. Next we showed that hVDR/hRXRα complex binding to DNA was impaired in the HPK1Aras cells but could be improved upon pre-treatment with UO126 or transfection of the non- phosphorylatable hRXRα ala260 mutant. Lastly, we showed that in the ras-transformed cells, the vitamin D receptor- interacting protein DRIP205 co-activator recruitment was also impaired.

We conclude that blocking the MAPK phosphorylation of hRXRα in the ras-transformed keratinocytes either by using the MEK inhibitor UO126 or transfection of the non- phosphorylatable hRXRα ala260 mutant could restore the function of 1,25(OH)2D3 on VDR/RXRα binding and co-activator recruitment.

 

Nothing to Disclose: SJ, JP, BO, LN, RK

22883 1.0000 LBT-048 A Ras/ Mitogen –activated protein kinase (MAPK) phosphorylation of the Human Retinoid X Receptor α at serine 260 impairs VDR, RXRα interaction, DRIP205 coactivator recruitment and 1α, 25-Dihydroxyvitamin D3 signaling in ras transformed keratinocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM LBT 048-050 6287 1:00:00 PM Late-breaking Nuclear Receptors and Steroid Hormone Action I Poster


Henriette Uhlenhaut*1, Florian W Blaschke2 and Norbert Huebner2
1Helmholtz Zentrum Muenchen, Munich, Germany, 2MDC, Berlin, Germany

 

The liver X receptors (LXRs) have essential roles in the regulation of cholesterol metabolism and in the integration of sterol, fatty acid and glucose metabolism. They are activated by oxysterols and are known to affect reverse cholesterol transport, inflammatory responses and hepatic lipogenesis. The two family members, LXRα and LXRβ, bind DNA as RXR heterodimers at DR4 elements. Known LXR targets genes include Srebp1c, ABC transporters and Glut4.

Several lines of evidence point to a role for LXRs in the pathogenesis of cardiovascular disease, such as dilated cardiomyopathy. We therefore set out to identify the direct LXRα and LXRβ target genes in the murine heart using genomic approaches such as ChIP-Seq and RNA-Seq.

Our next generation sequencing studies show that LXRs regulate cardiac energy metabolism and signaling. We present unique features of LXRα- and LXRβ- specific as well as common target enhancers, as defined by bioinformatic motif analyses of the respective cistromes. We show that both LXRs selectively interact with distinct cardiac transcription factors in the regulation of lipid and glucose metabolism. These experiments led us to the identification of the LXR-directed gene expression programs and cis-regulatory mechanisms that underlie the development of cardiovascular disease.

 

Nothing to Disclose: HU, FWB, NH

22447 2.0000 LBT-049 A Regulation of Cardiac Glucose and Cholesterol Metabolism By Lxrs 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Thursday, March 5th 3:00:00 PM LBT 048-050 6287 1:00:00 PM Late-breaking Nuclear Receptors and Steroid Hormone Action I Poster


Robert Romano*1, Chen-Pang Soong1, Madison Rose2, Jessica Costa-Guda1, Justin Bellizzi2 and Andrew Arnold1
1University of Connecticut School of Medicine, Farmington, CT, 2University of Connecticut School of Medicine

 

The molecular pathogenesis of sporadic parathyroid adenoma, a common endocrine neoplasm, is only partially understood. Two genes have been firmly established as genetic drivers: somatic mutations in the MEN1 tumor suppressor gene being the most frequent finding, and activation of the cyclin D1/PRAD1 oncogene. Additional strong evidence implicates mutation in the CDKN1B/p27 cyclin-dependent kinase inhibitor (CDKI) gene and other CDKI genes as contributors. Recently, the enhancer of zeste 2 (EZH2) polycomb repressive complex 2 subunit gene, a histone methyltransferase involved in maintaining the transcriptional repressive states of genes over successive cell generations, was implicated in the development of tumorigenesis. Somatic missense mutation Y641N was identified in 2/193 parathyroid adenomas (1); Y641N and other Y641 mutations are also found, at greater frequency, in B cell lymphoma. Additionally, copy number amplification and overexpression of EZH2 were reported in a subset of parathyroid tumors (2), emphasizing its potential importance as a candidate parathyroid oncogene. We sought to further investigate the frequency and role of EZH2 copy number changes and Y641 mutation in sporadic parathyroid adenomas.

Copy number variations of EZH2 were analyzed in sixty-one parathyroid adenomas using quantitative PCR and TaqMan Copy Number Assays under conditions recommended by the manufacturer. Samples were run in technical triplicates using RNase P as the duplexed, endogenous control; GAPDH and PGK1 were used as additional control genes. When copy number variation of EZH2 or a non-duplexed control gene was observed, assays were repeated using a different, duplexed endogenous control (TERT) for independent confirmation. No copy number variations of EZH2 were found in any of the parathyroid adenomas. In two cases, initial qPCR results suggested the presence of 3 copies of EZH2 and the control genes, GAPDH and PGK1. However, this result could not be confirmed with a second endogenous control (TERT), which produced normal diploid copy number for EZH2, GAPDH and PGK1. Haploid copy number in RNase P would explain the initial observation. Copy number of PGK1, located on the X-chromosome, correctly reflected sex in 100% of cases. Additionally, 82 sporadic parathyroid adenomas were examined for EZH2 Y641 mutations by PCR and Sanger sequencing. No mutations were identified.

Our results are consistent with previous observations that EZH2 Y641N mutations are uncommon, albeit potentially important, as candidate drivers of parathyroid neoplasia. Increased EZH2 gene copy number was not a frequent finding in our series, suggesting that alternative mechanisms may also cause EZH2 overexpression in sporadic parathyroid adenomas. Further investigation will continue to enhance our understanding of the involvement of EZH2 in parathyroid tumorigenesis.

 

Nothing to Disclose: RR, CPS, MR, JC, JB, AA

22855 1.0000 LBT-056 A EZH2 Copy Number and Mutational Analyses in Sporadic Parathyroid Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM LBT 056-063 6290 1:00:00 PM Late-breaking Tumor Biology I Poster


Giulia C Kennedy*1, Moraima Pagan2, P. Sean Walsh1, Hajime Matsuzaki3, Jing Huang1, Kevin Travers1, Ed Tom1, Mei Wong1, Su Yeon Kim1 and Richard T Kloos1
1Veracyte, Inc., South San Francisco, CA, 2Veracyte, 3Veracyte, Inc., South San Francisco

 

RATIONALE. Recent advances in next-generation sequencing (NGS) technology have vastly increased the rate of detection of cancer-associated mutations and fusions. In thyroid nodules, some mutations are highly specific for detecting cancer, while less is known about the accuracy of others. The number of thyroid cancer-associated genomic aberrations will continue to grow as more data emerges using this sensitive technology. Yet, the value of ever-increasing numbers of loci in the preoperative diagnosis of thyroid FNA remains unclear. Here we assess the accuracy of four point mutation and fusion panels.

METHODS. FNA material was preoperatively collected (n=77) and post-surgically diagnosed by a panel of experts as malignant (PTC, mPTC, FVPTC, PTC-TCV, MTC, WDC-NOS, HCC, FC) or benign (BFN, FA, HCA, HTA, LCT). We also evaluated surgical tissues (n=41) with histopathology truth, and a consecutive series of indeterminate FNAs without histopathology from our CLIA lab (n=121). Samples were subjected to NGS and 14 genes were evaluated, with increasing numbers of interrogated loci (n=15, 183, 918, and 3363) plus 43 fusions. Several stringency filters were applied to score the data. Samples were scored negative when no fusions or point mutations were present, and scored positive if at least one fusion or point mutation was detected.

RESULTS. Sensitivity to detect malignancy improved in all cohorts with increasing number of loci, while specificity showed the opposite trend, falling dramatically. In FNAs, the smallest 15 loci panel rendered a sensitivity of 18-34% and a specificity of 97%; while the largest panel renders a sensitivity of 74-100% and a specificity of less than 36%. In surgical tissues, a similar trend was observed: in the smallest panel >75% specificity was associated with <50% sensitivity; in the densest panel a sensitivity of >81% was associated with <25% specificity. Overall, the two larger panels wrongly called 47-65% benign samples malignant, while the two smaller panels missed 48-61% of known cancers. The frequency of mutations and fusions in CLIA samples across the four panels was 3-7%, 10-26%, 46-97% and 72-100%, respectively.

CONCLUSIONS. The sensitivity gained by detecting increasingly larger numbers of point mutations and fusions comes at the cost of specificity, and runs the risk of overcalling malignancy in truly benign samples. A further understanding of the significance of point mutations and fusions detected in benign nodules is warranted.

 

Disclosure: GCK: Coinvestigator, Veracyte, Inc.. MP: Coinvestigator, Veracyte, Inc.. PSW: Employee, Veracyte, Inc.. HM: Employee, Veracyte, Inc.. JH: Coinvestigator, Veracyte, Inc.. KT: Employee, Veracyte, Inc.. ET: Coinvestigator, Veracyte, Inc.. MW: Employee, Veracyte, Inc.. SYK: Employee, Veracyte, Inc.. RTK: Employee, Veracyte, Inc..

22938 2.0000 LBT-057 A Detection of Increasing Numbers of Point Mutations and Fusions in Thyroid Nodules Using Next-Generation Sequencing Dramatically Reduces Marker Panel Specificity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM LBT 056-063 6290 1:00:00 PM Late-breaking Tumor Biology I Poster


Hari Singhal* and Geoffrey L Greene
University of Chicago, Chicago, IL

 

Estrogen receptor alpha (ER) and progestin receptor (PR) are widely used biomarkers in breast cancer. PR remodels nucleosomes to initiate opening of chromatin and reprogramming of gene regulation. While estrogen signaling is the key pathway in breast cancer, there is a long standing controversy as to whether and how PR independently modulates estrogen signaling and breast cancer biology. These gaps in knowledge impede the optimization of breast cancer biomarkers and receptor targeted therapies. We report that PR is both necessary and sufficient to abrogate and override estrogen signaling genome-wide. PR remodels estrogen signaling through non-competitive interactions with ER. Progestin activated PR forms complexes with ER that are recruited to the enhancers and genomic regulatory loci enriched for BRCA1, nuclear factors and forkhead family proteins. Ligand-activated PR expands global ER binding events four-fold by recruiting ER genome-wide. PR is required for this reprogramming of ER binding and activity across the genome. These gained ER binding events occur at genomic loci that are enriched in response elements for PR and factors critical for PR-mediated gene expression, such as nuclear factors, kruppel like factors, specificity proteins and forkhead family proteins. Although nuclear factor C1 and forkhead A1 are critical for gene expression for ER and PR, neither of the two cofactors had a significant effect in the modulation of estrogen signaling by PR.

Enhanced estrogen signaling is an indicator for better prognosis in breast cancer. We report that PR is an agonist and enhancer for ER mediated gene expression. This genomic agonism between PR and ER correlates with improved survival of patients with ER+/PR+ tumors. PR regulated genes are enriched in breast cancer gene signatures and that they can diagnostically differentiate tumor subtypes. In addition, analysis of over three thousand patient tumors revealed that ER is not able to differentiate patient survival outcomes in the absence of PR. Furthermore, PR alone is sufficient to prognostically differentiate patient survival. It suggests that PR is required to predict patient survival in breast cancer. Furthermore, PR has two isoforms, PRA and PRB, and patients with breast tumors rich in isoform A have a poorer prognosis. In support of these clinical observations, we found that PRA is a more potent inhibitor of ER signaling compared to PRB and that PRA preferentially regulates processes involved in cellular migration and invasion.

In summary, our results provide evidence for genome-wide synergistic agonism between ER and PR through global non-competitive interactions. These findings strongly suggest a basis for understanding improved patient survival for ER+/PR+ tumors as well as a reason to test joint ER- and PR-targeted therapies in breast cancer.

 

Nothing to Disclose: HS, GLG

22333 3.0000 LBT-058 A Progestin Receptor Is a Non-Competitive Agonist of Estrogen Receptor Alpha and Is Required to Predict Survival in Breast Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM LBT 056-063 6290 1:00:00 PM Late-breaking Tumor Biology I Poster


Shih-Tse Jason Lai*, Jia Wang, Brad Hart, Kristine Van Natta, Marta Kozak, Jorge Valdivia, Haibo Wang and Erkan Diri
Thermo Fisher Scientific, San Jose, CA

 

There is an increasing interest in using LC-tandem MS in clinical laboratories because users can develop their own tests, use a smaller amount of samples, and measure several analytes in a single run. Starting from the 1950's breath samples had been analyzed by MS, followed by body fluids and other complex biological matrices.  Various innovative mass spectrometry technologies have been developed for the detection of a wide range of compounds, including parent compounds and metabolites. Mass spectrometers coupled in series (tandem MS) provide definitive identification and quantitation of target compounds using specific transitions from precursor ions to product ions.  Different sample cleanup techniques and chromatographic separations are used prior to delivering compounds into the mass spectrometer.  In addition to choosing proper technologies for analysis of target compounds, clinical laboratories often encounter challenges with sample clean-up (pre-analytical phase) and data processing (post-analytical phase) when facing the demand to provide test results in a timely manner with increasing numbers of incoming samples.  In this study, we evaluated three medical devices to address these challenges: two channel HPLC, tandem MS and data processing software. The HPLC instrument consists of two separate channels, both of which include an online sample cleanup turboflow column for removing sample matrix, and an analytical column for chromatographic separation. This HPLC is capable of cross-channel sequencing by only introducing the portion of the chromatogram of target compounds into the mass spectrometer therefore doubling the sample throughput.  The data processing software includes three levels of user permissions for technicians, supervisors, and lab directors.  This software has built-in flexibility in assigning roles and responsibilities, and audit trail function is provided for streamlining record keeping.  The ability to run tests overnight, unattended was conducted using the example compound alprazolam.  A total of 500 crashed synthetic serum samples spiked with alprazolam and isotopically-labeled internal standard were analyzed continuously for 24 hours, with an additional 11 QC samples inserted at intervals during the same 24 hours. Cross-channel RSD% (n=500) of retention time and concentration was observed at 0.85, 1.39, respectively. The precision studies of different ionization modes on HESI probe and APCI probe were conducted using four example compounds in polarity switching mode (+/-) in synthetic urine and synthetic serum (n=40, 5 replicates, 4 runs, 2 channels).   HESI: Reserpine(+); Chloramphenicol (-). APCI: Testosterone (+); Estradiol (-).  The corresponding %RSD’s of concentrations are 1.73, 4.48, 1.84 and 7.20, respectively. In conclusion, these devices demonstrated stability, robustness and time efficiency. For in vitro diagnostic use.

 

Disclosure: STJL: Employee, Thermo Fisher Scientific. JW: Employee, Thermo Fisher Scientific. BH: Employee, Thermo Fisher Scientific. KV: Employee, Thermo Fisher Scientific. MK: Employee, Thermo Fisher Scientific. JV: Employee, Thermo Fisher Scientific. HW: Employee, Thermo Fisher Scientific. ED: Employee, Thermo Fisher Scientific.

22619 4.0000 LBT-059 A Evaluation of a New HPLC, a New Tandem MS and a New Data Processing Software for General Clinical Use 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM LBT 056-063 6290 1:00:00 PM Late-breaking Tumor Biology I Poster


Javier Esteban Jimenez-Salazar*, Rosa Isela Garcia-Vázquez, Jonathan González-Ruiz, Carlos Lara-Cruz, Marcela Arteaga-Silva and Pablo Damian-Matsumura
UNIVERSIDAD AUTONOMA METROPOLITANA, Mexico City, Mexico

 

We have recently proposed a novel pathway by which Estradiol (E2) may promote Epithelial-Mesenchymal Transition (EMT) by disruption of Tight Junction (TJ) proteins in two estrogen receptor (ER)-positive breast cancer cell lines (MCF-7 and T47D). We demonstrated that E2 induces Src-Tyr-416 phosphorylation and subsequent p-Src/ZO-1complex formation, leading to ZO-1 and of ZONAB disruption and nuclear translocation and finally, cell migration increases (Horm Cancer 5:161, 2014). In order to show that these effects are triggered by c-Src phosphorylation, we treated cells with either E2, a c-Src inhibitor PP2, or the combination to further explore the effects on cell motility in in vitrowound healing assay. Results were verified by c-Src gene silencing.

Treatment of MCF-7 or T47D cells with PP2 (5 μM) and E2(1 nM) decreased c-Src-Tyr-416 phosphorylation after 15-30 minutes of incubation, inhibited c-Src/ZO-1 complex formation and blocked cell motility, which was also inhibited after c-Src silencing.

Unexpectedly, when the ER-negative breast cancer cells (MDA-MB-231) were incubated with E2+PP2, phosphorylation of Tyr-416-Src significantly increased (p<0.05) when compared to E2-treated cells or vehicle-treated cells. In cell motility experiments, incubation with E2+PP2 outstandingly induced MDA-MB-231 cells migration (>3X).

Our results confirm that E2-induced c-Src activation plays an important role during TJ´s signal transduction and migration in ER-positive breast cancer cell lines. Additional experiments are required in order to explain the effects of E2+PP2 in ER-negative cells.

 

Nothing to Disclose: JEJ, RIG, JG, CL, MA, PD

22790 5.0000 LBT-060 A Inhibition of c-Src Blocks Estrogen-Induced TJ Signaling Pathway and Cell Motility in ER-Positive Breast Cancer Cell Lines and Has Opposite Effects in ER-Negative Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM LBT 056-063 6290 1:00:00 PM Late-breaking Tumor Biology I Poster


Lisa Kate Philp*1, Martin C Sadowski1, Michelle S Liberio1, Gregor Tevz1, Melanie Lehman1, Jennifer H Gunter1, Laszlo Otvos Jr.2 and Colleen C. Nelson1
1Queensland University of Technology - Translational Research Institute, Brisbane, Australia, 2Temple University, Philadelphia, PA

 

Objective: Androgen deprivation therapy (ADT) is a common treatment in advanced prostate cancer (PCa) and while it slows progression and improves survival, prolonged ADT itself triggers adaption in metabolic pathways. Side-effects incurred are often likened to features of metabolic syndrome, including elevated serum leptin. Leptin is best-known for regulating weight and energy balance in metabolic organs; however its receptor, LEPR, is also present in benign and malignant prostate. Leptin also modulates inflammation, proliferation and apoptosis, all of which foster PCa progression. LEPR antagonism may have therapeutic benefits in PCa, especially as leptin promotes PCa proliferation and migration, and as both leptin and LEPR transcripts are upregulated by ADT and anti-androgens in vitro. We therefore aimed to determine the effects of leptin ± LEPR antagonist, Allo-Aca (A-A), on the migration, proliferation and growth of androgen-deprived LNCaP and C4-2B PCa cells. Methods: LNCaP and C4-2B cells subjected to ‘androgen-deprivation’ (48h RPMI +charcoal stripped serum (CS)) were then treated with leptin (0, 0.5, 1, 2.5, 5, 10 nM) ± LEPR antagonist (1, 10, 100 nM A-A) in serum-free RPMI (SF; RPMI +0.2% BSA). Migration and invasion were assessed by transwell and Matrigel assays. Confluence, a marker for growth, was examined by incucyte. Proliferation was determined by Cyquant following 72h treatment in ‘androgen-deprived’ conditions. Leptin and A-A action were tested by α-screen of P-38 and ERK phosphorylation. Results: LEPR mRNA was confirmed ubiquitous in a malignant and non-malignant prostate cell line panel. Transwell migration increased with leptin, irrespective of dose, in C4-2B (vs SF, P<0.01), while 2.5nM leptin alone increased LNCaP migration (vs SF, P<0.05). Leptin-stimulated migration was prevented by 100nM A-A in LNCaP and C4-2B (vs leptin, P<0.05). LNCaP grown on Matrigel demonstrated an invasive “protrusive” phenotype in high-dose 20nM leptin, but not when co-treated with 10nM A-A. Cell confluence changes were limited following leptin and A-A. Cell proliferation increased with 10nM leptin in LNCaP, and 1 and 2.5nM leptin in C4-2B (vs CS, P<0.05); adding A-A had limited response under these conditions. Downstream LEPR targets, p-P38 and p-ERK, confirmed leptin signaled via LEPR and LEPR antagonism by A-A. Conclusion: Leptin stimulated PCa cell proliferation and migration, which if translated to the clinic supports a role for leptin in fostering an aggressive tumor phenotype in ADT-treated PCa. A-A was efficacious in preventing leptin-stimulated PCa cell proliferation in vitro. In vivo investigation of A-A treatment effects on PCa growth, invasion and progression in mice bearing human PCa cell xenografts warrants investigation, especially as A-A has conferred significant growth-inhibition in breast tumor xenografts.

 

Nothing to Disclose: LKP, MCS, MSL, GT, ML, JHG, LO Jr., CCN

22674 6.0000 LBT-061 A Leptin Receptor Antagonist, Allo-Aca, Prevents Leptin-Stimulated Migration of Androgen-Deprived Prostate Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM LBT 056-063 6290 1:00:00 PM Late-breaking Tumor Biology I Poster


So Y Park1, Min J Kim1, Sang A Park1, Jung S Kim2, Jeong S Nam3, Young J Park4 and Yhun Y Sheen*5
1Ewha womans university, 2Ewha Womans University, seoul, Korea, Republic of (South), 3Gacheon University, 4Korea University, Sejong, Korea, Republic of (South), 5Ewha Women's Univ, Seoul, Korea, Republic of (South)

 

In order to investigate, if EW-7197 would improve the efficacy of chemotherapy, we investigated the effects of EW-7197 and combinatorial treatment with paclitaxel on the characteristic markers of breast cancer recurrence-associated as well as cancer stem cell in MDA-MB-231 orthotropic xenograft NOD/SCID mice. EW-7197 combinatorial treatment with paclitaxel significantly inhibited the elevated level of NANOG and OCT4 compared to that of either EW-7197 or Paclitaxel alone treatment. Likewise, EW-7197 combination treatment with paclitaxel significantly inhibited the elevated levels of NANOG, OCT4 and SOX2 mRNAs compared to that of either paclitaxel or EW-7197 alone treatment. Also paclitaxel combination with EW-7197 significantly inhibited the ALDH. We compared the effect of either EW-7197 alone or combination treatment on the characteristic markers of cancer stem cells such as NANOG, OCT4, SOX2, MYC, and KLF4 mRNAs in attached and sphere cultured MDA-MD-231 cells. Paclitaxel dramatically increased NANOG mRNA, and concomitant treatment with EW-7197 decreased the elevated NANOG mRNA by paclitaxel in only sphere but not in attached cultured MDA-MB-231 cells. Likewise, paclitaxel increased SOX2, MYC and OCT4 mRNAs, and concomitant treatment with EW-7197 decreased them in sphere but not in attached cultured MDA-MB-231 cells. Paclitaxel did not change KLF4 mRNA which was inhibited by EW-7197 alone or in combination with paclitaxel only in sphere cultured MDA-MB-231 cells. Combination therapy of EW-7197 and paclitaxel increased the life span of BALB/c-nu/nu MB231 cells xenograft mice compared to those of paclitaxel mono treated.  In summary, EW-7197 and paclitaxel combination therapy could be more effective than paclitaxel alone therapy for anti-metastatic effect and survival. [This work was supported by 2014R1A1A2005644]

 

Nothing to Disclose: SYP, MJK, SAP, JSK, JSN, YJP, YYS

22810 7.0000 LBT-062 A Combination of EW-7197 and Paclitaxel Inhibits Breast Recurrence-Associated Markers in MDA-MB-231 Orthotropic Xenograft NOD/SCID Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM LBT 056-063 6290 1:00:00 PM Late-breaking Tumor Biology I Poster


Jennifer H Gunter*, Lisa Kate Philp, Phoebe Sarkar, Brett Hollier, Martin C Sadowski, Melanie Lehman and Colleen C. Nelson
Queensland University of Technology - Translational Research Institute, Brisbane, Australia

 

Androgen regulated pathways drive proliferation, differentiation, and survival of benign and malignant prostate tissue. Androgen deprivation therapy (ADT) exploits this dependence to systemically treat advanced prostate cancer (PCa) resulting in tumour regression. However, the initial therapeutic response from ADT eventually progresses to CRPC which is currently incurable. Recent advances in treatments for CRPC have continued to target androgen signalling leading to prolonged androgen deprivation. A major side effect of ADT is the development of insulin resistance resulting in hyperinsulinaemia which is specifically associated with poor outcomes, including rapid progression and increased cancer mortality, however the endocrine side-effects of ADT are not clinically addressed.  Metformin is used widely to normalize systemic insulin levels in the treatment of diabetes and insulin resistance. We hypothesized that metformin, in addition to systemic effects, may act directly on insulin-induced cancer survival pathways in androgen-deprived PCa cells and aimed to provide rationale for its combined therapeutic use with ADT. Microarray was performed on LNCaPs following 10nM insulin treatment +/- androgen (1nM R1881) and Ingenuity pathway analysis used to identify pathways upregulated by insulin including genes associated increased survival, Bcl2 (8.5-fold) and Bcl-XL (3.1-fold) and a paradoxical increase in Bad were observed following insulin treatment in the absence of androgens.  Insulin-induced changes were validated in LNCaP and C4-2B cells by QRT-PCR with upregulation of Bcl2 and Bcl-XL (3.2 and 2.1-fold, respectively) and decreased expression of pro-apoptotic genes Bim and Bax (0.5 and 0.7-fold), but 2.6-fold increase in Bad. Seahorse XF analyser was used to measure changes to metabolic phenotypes and glycolytic capacity (glycolysis) of insulin-treated, androgen-deprived cells. Androgen deprivation was associated with a 15% reduction in spare respiratory capacity which was restored with 10nM DHT, or with 10nM insulin and correlated to resistance to doxyrubicin-induced apoptosis, measured via Caspase 3 cleavage. These results suggest the increased levels of Bad may play a role in stabilisation of hexokinase and increased glycolytic flux. The addition of 5mM metformin increased basal respiration but ameliorated spare respiratory capacity of insulin-treated PCa cells. We found that metformin counteracts insulin-driven survival pathways in androgen-deprived PCa cells which support the use of adjuvant metformin therapy in men receiving ADT.

 

Nothing to Disclose: JHG, LKP, PS, BH, MCS, ML, CCN

22758 8.0000 LBT-063 A Insulin Increases Apoptotic Resistance and Metabolic Capacity in Prostate Cancer Cells, That Is Inhibited By Metformin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Thursday, March 5th 3:00:00 PM LBT 056-063 6290 1:00:00 PM Late-breaking Tumor Biology I Poster


Peter Herbert Kann*1, Raluca Simona Bergmann2, Martin Bidlingmaier3, Melanie Bub4, Christina Dimopoulou5, Birgitte Tønnes Pedersen6, Günter K. Stalla7, Matthias Max Weber8 and Stefanie Meckes-Ferber9
1University Hospital Marburg, Marburg, Germany, 2Philipp's University Marburg, Marburg, Germany, 3Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany, 4Johannes Gutenberg University Mainz, 5Max Planck Institute for Psychiatry, 6Novo Nordisk A/S, Søborg, Denmark, 7Max Planck Institute of Psychiatry, Munich, Germany, 8Universitätsmedizin Johannes Gutenberg Universität Mainz, Mainz, Germany, 9Novo Nordisk GmbH Germany, Bodenheim

 

Growth hormone (GH) is a pleiotropic hormone. Growth hormone deficiency (GHD) in adulthood affects quality of life, ability to work, bone metabolism and osteoporosis risk, body shape, lipid metabolism and body composition. It was the aim of this study to establish a score which enables to integrate and display the different features of GHD as well as the effects of GH substitution in GHD adults. This GET score should be evidence-based, weighted according to clinical relevance, and include items which can be determined easily and decentralized.

Within the GET score, assessment of quality of life contributes 40% (SF-36 and EQ-5D each 20%, both chosen because they are freely available), disease-related days off work 10%, bone mineral density (DXA) 20%, waist circumference 10%, LDL-cholesterol 10%, and body fat component (BIA) 10%. The GET score was designed according to data available in literature to cover a range of 100 score points, and herein to position a cohort of GHD adults at baseline at a score of about 50 points with a sufficient individual scattering. If the GET score is able to display the pleiotropic effects of GH substitution, a mean difference of about 10 score points in comparison to a control group during study follow up should be obtained.

After having designed this score, a prospective, non-interventional, non-randomized, 2-years study including 121 GHD adult patients has been performed. Descriptive statistics was applied for all parameters and the GET score analysis was performed using a repeated measures model to account for a correlation of data when patients are observed at several time points over a period of time.

In 106 patients (40 females, age 49±14 years, 22 untreated controls [9 females], GH dose: females 0,30±0,16 / males 0,25±0,10 mg/d ), the GET score could be calculated at baseline and at least one follow up visit during the study, whereby calculation of the GET score required the availability of at least 70% of the GET score items. Baseline GET score was calculated: female controls 51,1±21,6; male controls 49,8±19,0; treated females 47,0±22,3; treated males 54,9±19,8 score points. The estimated difference in the GET score between control and treated groups during follow up was +10,0±4.01 (p=0.015).

In conclusion, the GET score has been shown to be a suitable instrument to display the multidimensional features of GHD as well as the response to GH substitution therapy in an integrative way.

 

Disclosure: BTP: Employee, Novo Nordisk. Nothing to Disclose: PHK, RSB, MB, MB, CD, GKS, MMW, SM

22326 1.0000 LBT-077 A The Growth Hormone Deficiency and Efficacy of Treatment (GET) Score Study: A Non-Interventional Prospective Study to Establish an Integrative Score to Summarize the Pleiotropic Clinical Features of Growth Hormone Deficiency and the Effect of Growth Hormone Substitution. 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Pierre Chatelain*1, Oleg Malievsky2, Klaudziya Radziuk3, Heba Hassan Elsedfy4, Evgenia Mikhailova5 and Michael Beckert6
1University Claude Bernard, Lyon, France, 2Bashkir State Medical University, Ufa, Russia, 32nd Children City Clinic, Minsk, Belarus, 4Ain Shams University Hospital, Cairo, Egypt, 5Samara State Medical University, Samara, Russia, 6Ascendis Pharma A/S, on behalf of the TransCon hGH study group

 

Background: TransCon hGH is a long-acting prodrug of recombinant human Growth Hormone (hGH) that releases into the blood compartment fully active unmodified hGH. TransCon hGH was shown in two Phase 1 studies in Healthy Volunteers and a Phase 2 study in adults with hGH Deficiency (AGHD) to: 1) be safe and well tolerated, 2) possess dose dependent, predictable levels of growth hormone, 3) be suitable for a once-weekly dosing regimen, 4) induce an IGF-I pharmacodynamic (PD) response within the normal range throughout the dosing period. This interim analysis consists of 25 patients (approximately 50 % of the total enrollment in the study) completing all six months of treatment, and demonstrate that TransCon hGH has a safety and efficacy profile comparable to daily hGH.

Objectives: The objective of this study is to investigate 1) safety and tolerability, 2) pharmacokinetics (PK) and pharmacodynamics, and 3) efficacy of TransCon hGH in children with Growth Hormone Deficiency.

Design and methods: Pre-pubertal, treatment naïve GHD children received s.c. injections of one of three once-weekly TransCon hGH doses (0.14, 0.21 and 0.30 mg hGH/kg/week) or daily hGH (Genotropin®; 0.03 mg hGH/kg/day = 0.21 mg/kg/week) over a six-month treatment period, in a randomized, comparator-controlled dose response Phase 2 study. The patients’ GHD diagnosis were established in accordance with international consensus guidelines, based on auxology (height & height velocity), GH stimulation tests & IGF-I. Children Small for Gestational Age (SGA) were excluded.

Results: Mean annualized height velocities among the three dosing levels administered weekly ranged from 11.9 cm for the 0.14 mg/kg/week dose to 14.5 cm for the 0.30 mg/kg/week dose, which were comparable to 11.5 cm for the active comparator, daily injections of Genotropin® at a 0.21 mg/kg/week dose. There have been no reports of serious or unexpected adverse events, injection site reactions were generally mild and transient and occurred in only a few patients. Maximum hGH blood concentration is comparable between equivalent weekly doses of TransCon Growth Hormone and daily hGH; and a dose-proportional increase in IGF-I levels into the normal range was observed following dosing of the three TransCon Growth Hormone dose levels.

Conclusions: To date, TransCon hGH has demonstrated efficacy and safety comparable to that observed with daily hGH. Injection site reactions have generally been mild and similar to what is expected with daily hGH injections, with no nodule formation or lipoatrophy noted. This TransCon hGH Phase 2 study conducted in a pediatric population confirms the excellent safety and efficacy profile observed in previous clinical trials.

 

Disclosure: PC: Investigator, Ascendis Pharma. OM: Investigator, Ascendis Pharma. KR: Investigator, Ascendis Pharma A/S. MB: Employee, Ascendis Pharma. Nothing to Disclose: HHE, EM

22563 2.0000 LBT-078 A Six-Month Interim Safety and Efficacy of Different Dose Levels of Transcon HGH Administered Once Weekly Versus Standard Daily Human Growth Hormone Replacement Therapy in Pre-Pubertal Children with Growth Hormone Deficiency (GHD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Mônica R Gadelha*1, Thierry Brue2, Maria Fleseriu3, Ilan Shimon4, Karina Hermosillo Reséndiz5, Albert Kandra6, Alberto M Pedroncelli6 and Annamaria Colao7
1Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 2Hôpital de la Timone, Aix-Marseille University, Centre National de la Recherche Scientifique, and Assistance Publique-Hôpitaux de Marseille, Marseille, France, 3Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, 4Rabin Medical Center, and Sackler School of Medicine, Tel-Aviv University, Petah-Tiqva, Israel, 5Novartis Pharmaceuticals Corporation, East Hanover, NJ, 6Novartis Pharma AG, Basel, Switzerland, 7Università Federico II, Naples, Italy

 

Background: Pasireotide is a multireceptor-targeted somatostatin analogue with high affinity for sst2 and sst5. By targeting these receptors, it is not only an effective treatment for Cushing’s disease and acromegaly but also decreases insulin secretion. In pts with inadequately controlled acromegaly in PAOLA, pasireotide provided superior efficacy over continued treatment with octreotide/lanreotide; hyperglycemia-related AEs were observed in 64% of pts given pasireotide LAR. This analysis from PAOLA explores the effect of the timing of antidiabetic medication (ADM) intervention on fasting plasma glucose (FPG) during pasireotide LAR treatment.

Methods: Pts randomized to pasireotide LAR 40/60mg, who received ≥1 dose of pasireotide and had a valid post-baseline safety assessment (safety population), were included. Pts were categorized by baseline diabetic status: non-diabetic (ND); pre-diabetic (PD; FPG 100–<126mg/dL or HbA1c 5.7–<6.5% or 2h post-OGTT glucose 140–<200mg/dL); diabetic (D; current/prior ADM use or FPG ≥126mg/dL or HbA1c ≥6.5% or 2h post-OGTT glucose ≥200mg/dL). Hyperglycemia was defined as: first occurrence of FPG ≥126mg/dL or HbA1c ≥6.5% in ND/PD pts; or first occurrence of FPG or HbA1c increase ≥20% from baseline in D pts.

Results: Of the 125 patients included, 5/19 ND, 9/24 PD and 68/82 D pts experienced hyperglycemia. The FPG results focus on the 68 D pts because of low patient numbers in the ND/PD groups. ADM was initiated/adjusted in 36/68 pts. When ADM was initiated/adjusted after 0–<15 (n=7), 15–<30 (n=8) or ≥30 (n=21) days, mean FPG changed by –110.0±96.3mg/dL (from 255.9±89.8mg/dL at the time of hyperglycemia), –7.3±91.1 (from 186.9±92.2) and 2.1±78.9 (from 178.7±38.0) at study end, respectively. In 32 pts who did not receive ADM, mean FPG change was –10.7±91.5mg/dL (from 152.4±44.0). A univariate logistic regression analysis in ND/PD/D pts showed that BMI ≥25kg/m2 (odds ratio [OR] 2.3), higher baseline HbA1c (OR 4.3), diabetes at baseline (OR 4.8) and history of dyslipidemia (OR 3.6) were significant (P<0.01) factors predicting hyperglycemia.

Conclusions: These data suggest that early intervention with ADM is associated with a greater decrease in FPG. Interestingly, not all pts who experienced hyperglycemia (n=32/68) received ADM, and their FPG at study end was similar to that observed in pts who received early treatment. These data suggest that pasireotide-induced hyperglycemia can be managed with proactive monitoring and early intervention.

 

Disclosure: MRG: Consultant, Novartis Pharmaceuticals, Principal Investigator, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Researcher, Pfizer, Inc., Principal Investigator, Ipsen, Speaker, Ipsen. TB: Advisory Group Member, Ipsen, Consultant, Ipsen, Speaker, Ipsen, Investigator, Ipsen, Speaker, Lilly USA, LLC. MF: Researcher, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Cortendo, Researcher, Ipsen, Consultant, Ipsen, Researcher, Pfizer, Inc., Consultant, Pfizer, Inc., Consultant, Genentech, Inc.. IS: Advisory Group Member, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Consultant, Pfizer, Inc., Investigator, Pfizer, Inc., Speaker, Pfizer, Inc., Consultant, Chiasma. KH: Employee, Novartis Pharmaceuticals. AK: Employee, Novartis Pharmaceuticals. AMP: Employee, Novartis Pharmaceuticals. AC: Other activities, please specify:, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals.

22571 3.0000 LBT-079 A Proactive Monitoring and Early Intervention in the Management of Pasireotide-Induced Hyperglycemia: Lessons from the Phase III, 24-Week Paola Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Lesly Portocarrero-Ortiz*, Paulina Briseño-Hernández, Mariana Sandoval-Diez and Claudia Cervera-Martínez
Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Distrito Federal, Mexico

 

Introduction: Acromegaly is a disorder characterized by growth hormone (GH) hypersecretion, multisystem-associated morbidities, and increased mortality. Specific psychological and physical limitations are present even after long-term cure of acromegaly. Chronic effects of acromegaly are not only disabling but also disfiguring and make acromegaly a disease with considerable impact on Health Related Quality of Life. This is the first study about quality of life of patients with acromegaly in Mexico.

Objective: To evaluate Health Related Quality of Life (HRQL) of mexican acromegalic patients in relation to control status of the disease.

Design and Methods: An observational, cross-sectional, descriptive and comparative study including 50 patients  with acromegaly recruited to complete the Short Form 36 Health Survey (SF-36), the Acromegaly Quality of Life Questionannaire (AcroQol), Beck Depression Inventory and Beck Anxiety Inventory.

Results: The cohort consisted in 50 patients with acromegaly. Fifty- eight percent of patients were femeale, fourty two percent were male. The mean age was forty years. Thirty seven patients had a macroadenoma and 13 a microadenoma.

Trans-sphenoidal surgery was the most frequent therapeutic modality in 29 patients (58%).Eight patients (16%) were in biochemical remission, 22 patients (44%) had persistent acromegalic activity and 20 patients (40%) were in control.

Depression and anxiety inventories correlated with p=.001, anxiety and global Acro Qol correlated with p=0.000. Depression inventory and global Acro QoL correlated with p=.000, and the Short Form 36 Health Survey (SF-36) social function that measures  the degree in which  problems of physical or emotional health interfere in ordinary social life shows a correlation (p=.929) between cured, controlled and active patients.

Patients with acromegaly control or cured had total scores (indicating better HRQoL) than patients with persistent disease.

Conclusion:

The assessment of quality of life by the disease-specific questionnaire AcroQoL allows us to evaluate separately the impairment of both physical and psychological dimensions of well-being in patients with acromegaly.

 

Nothing to Disclose: LP, PB, MS, CC

22928 4.0000 LBT-080 A Assessment of Health Related Quality of Life in Mexican Patients with Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Kadapalakere Reddy*1, Robin Girdhar2, Manav Batra3 and Manisha Garg4
1State University of New York at Buffalo, Amherst, NY, 2Suny at Buffalo, Williamsville, 3University at Buffalo, Buffalo, NY, 4Diabetes and Endocrinology Center of Western New York, Buffalo, NY

 

Background- Pituitary abscess is a rare but potentially life-threatening lesion if not appropriately diagnosed and treated. Its presenting manifestations are nonspecific; therefore diagnosis is usually made postoperatively.  We report a case of pituitary abscess presenting as Panhypopituitarism.

Clinical case- A 37 year old Caucasian female was admitted with worsening headaches and progressive decline in vision for 4 months duration. She also complained of polyuria and polydipsia.  Her vitals were stable and physical examination revealed decreased visual acuity and left temporal field impairment on confrontation.  Rest of her exam was unremarkable.  She had no other medical condition and was on birth control pills. CT scan showed 1.8 cm suprasellar cystic mass with intracystic nodule.  MRI with contrast confirmed this finding with mass effect on optic chiasm, widening of sella with bone erosions of floor.  Lab showed WBC count of 11.4 with no left shift and serum sodium of 141. Endocrinological evaluation showed moderate increase in prolactin (93 ng/ml), TSH -1.241, free T4 -0.40 (0.8-1.8), Low ACTH of <1.1pg/ml with cortisol of 12.6. Her serum osmolality was 280 and urine osmolality of 131. Water deprivation test was confirmative of central diabetes insipidus. Patient was started on hormonal replacement including hydrocortisone, levothyroxine and DDAVP.  Formal visual field evaluation was consistent with left temporal hemianopia. Patient was taken for transsphenoidal resection of cystic mass with differential of Rathke cleft vs Arachnoid cyst or cystic pituitary adenoma. However, on gland penetration, purulent fluid was obtained and no tumor was identified. The culture yielded coagulase negative staphylococcus. Histopathology of pituitary lesion demonstrated abscess with degenerative changes and neutrophils. She is currently on antibiotic for 6 weeks and hormonal replacement. Following surgery, her vision improved dramatically.

Conclusion-Pituitary abscess can occur denovo in otherwise normal pituitary gland or in a preexisting pituitary pathology. In absence of any pathology, it may be result of direct extension or hematogenous spread of sphenoid sinusitis, meningitis, cavernous sinus thrombophlebitis. Previous pituitary surgery also increases risk of infection. It usually manifests similar to any other pituitary masses with headaches, visual field defects, hormonal disturbances and rarely with signs of infection.  This case is unique in its presentation with no underlying risk factors and no identified source of infection. Hence we conclude that findings of a suprasellar cystic mass associated with mild hyperprolactinemia, panhypopituitarism and diabetes insipidus may be suggestive of a pituitary abscess.

 

Nothing to Disclose: KR, RG, MB, MG

22643 5.0000 LBT-081 A A RARE Case of Panhypopituitarism Due to Pituitray Abscess 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Holly Kilim*1, Laura Hyeson Zemany2 and Pamela Irene Hartzband3
1Beth Israel Deaconess Medical Center, Watertown, MA, 2Beth Israel Deaconess Medical Center, Brookline, MA, 3Beth Israel Deaconess Medical Center, Boston, MA

 

Introduction

Pituitary apoplexy is a rare complication of pituitary adenomas with an estimated incidence of 0.6-9% and can cause hormonal deficiencies, visual loss and cranial nerve palsies(1). Anticoagulation is a risk factor for apoplexy based on case reports, although the precise risk is unknown. We report a case of a patient with a known pituitary macroadenoma who developed pituitary apoplexy and permanent blindness after being started on enoxaparin for a DVT. This case highlights the risk of initiating anticoagulation in a patient with a pituitary adenoma.

Clinical Case

A 74 woman with metastatic thigh sarcoma presented to the ER with several days of right lower extremity swelling and was found to have a right common femoral vein DVT. Given her known malignancy, a head CT was obtained prior to initiating anticoagulation. This showed the incidental finding of a 2 cm pituitary mass abutting the optic chiasm. The patient was asymptomatic and denied any visual complaints. Her cranial nerve exam was unremarkable. A pituitary MRI confirmed a 2.3 cm mass most consistent with a macroadenoma causing lateral displacement of the optic chiasm. Visual field testing was normal. Labs were consistent with central hypogonadism (FSH 4.1 mIU/mL n25.8-134 mIU/mL and LH <1.0 mIU/mL n7.7-58.5 mIU/mL), but thyroid and adrenal axes were intact. She was discharged on therapeutic dose enoxaparin.

The patient returned to the ER 5 days later after being found confused by family. She had a right 3rdnerve palsy and absent vision bilaterally. A head CT showed acute hemorrhage into the pituitary mass. She was treated with stress dose steroids and went for emergent transphenoidal resection. Surgery was uncomplicated. An IVC filter was placed. She was treated with thyroid hormone and hydrocortisone. Her mental status improved significantly during her admission however despite urgent surgical decompression she did not recover any vision at the time of discharge or at 4 month follow-up. Pathology showed pituitary adenoma with areas of hemorrhage and necrosis consistent with apoplexy.

Clinical Lesson

To our knowledge this is the first reported case of permanent blindness due to apoplexy following treatment with anticoagulation. This case highlights the risks of initiating anticoagulation in a patient with a pituitary adenoma.  Risks and benefits of anticoagulation should be carefully weighed in a patient with a known pituitary adenoma and alternative treatments considered, particularly as newer anticoagulants cannot be reversed. Clinicians should be aware of this potential complication of anticoagulation since pituitary incidentalomas are common (average frequency 10.7% based on autopsy reports(2)). Although the frequency of incidental macroadenomas is much lower, patients with larger tumors are at greater risk of complications due to apoplexy.

 

Nothing to Disclose: HK, LHZ, PIH

22655 6.0000 LBT-082 A Permanent Blindness Due to Pituitary Apoplexy after Initiation of Anticoagulation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Ahmad Elayyan*1, Joseph Ramzy2, Vaishali Thudi3, Kamran Mushtaq2, Susan Smith1 and Wael Taha4
1McLaren Regional Medical Center, Flint, MI, 2McLaren Regional Medical Center, 3Henry Ford Hospital, Detroit, MI, 4Wayne state University, West Bloomfield, MI

 

INTRODUCTION:

 Prolactin (PRL) production is limited to pituitary gland lactotroph cells. The prevalence of prolactinoma is between 10-50 per 100,000.1,2 Lactotroph adenomas can elevate PRL up to 10,000 µg/L but rarely exceeds 200 µg/L from other causes.3 We present a case of hyperprolactinemia above 200 µg/L secondary to haloperidol.

 CASE DESCRIPTION:

 A 40 year old female with a PMH of ESRD, bipolar disorder, HTN and Hepatitis-C presented with bilateral, milky nipple discharge for one month. She reported occasional headaches, weight loss and cold intolerance. She denied changes of her vision, skin, hair, ring or hat size; diarrhea; constipation; fatigue; dizziness; easy bruisability; frequent illnesses or decreased libido. She had a prior hysterectomy. Family history was positive for an unspecified pituitary tumor in a maternal uncle. Home medications included lisinopril, nifedipine, labetalol, clonidine, haloperidol, citalopram, alprazolam, sevelamer, calcium and a phosphate binder. Physical exam was normal except for milky nipple discharge. Initial lab showed: PRL 397.4 µg/L and TSH 4.1 µU/mL. At that time, haloperidol was changed to quetiapine. MRI pituitary without contrast showed heterogenous enhancement of the pituitary gland. A repeat MRI with dynamic enhanced imaging showed a possibility of a 4 mm microadenoma. Three months later she continued with milky discharge with PRL still grossly elevated at 277.8 µg/L, IGF-1412 µg/L, TSH 1.64 µU/mL, FT4 1.0 µg/dL, LH 28.2 mU/mL and FSH 66.2 mU/mL. After another three months, PRL was 14.2 µg/L. A repeat level the next day was 12.6 µg/L and remained the same on 1:100 dilution. Her IGF-1 level normalized. She never required treatment with a dopamine agonist.

 DISCUSSION:

 Human prolactin was first assayed  in 1971.4 Dopamine from the hypothalamus suppresses PRL synthesis and secretion from the pituitary.5 Nontumoral hyperprolactinemia is frequently caused by medications, of which antipsychotics are common.6,7 Newer atypical antipsychotics except risperidone have low affinity for D2 receptors and cause PRL elevation, usually less than 100 µg/L. Higher levels are frequently symptomatic with galactorrhea, oligomenorrhea and impotence.6 In this case, the PRL level was unusually high for haloperidol, but normalized after its discontinuation. The effect of haloperidol on PRL may be greater in the presence of ESRD, but not to this degree. This suggests that haloperidol was the culprit and that the pituitary tumor, if present, is not a prolactinoma. Normal PRL levels on quetiapine is consistent with a Turkish study which noted less elevation with quetiapine than with haloperidol.8

CONCLUSION:

Medications such as haloperidol can be associated with very high PRL levels.  A repeat PRL should be checked in follow-up after discontinuation of this medication.

 

Nothing to Disclose: AE, JR, VT, KM, SS, WT

22669 7.0000 LBT-083 A Antipsychotic-Induced Hyperprolactinemia; A Common Entity with Unusual Presentation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Eddy Tabet*, Angela Lee, Elizabeth Lian Chua and Stephen Morris Twigg
Royal Prince Alfred Hospital, Sydney, Australia

 

Background:

Opioid-induced hypoadrenalism may be an under-recognised entity with potential serious adverse outcomes. Up to 15% of people receiving ongoing opioids may develop biochemical hypoadrenalism (1). We report a case of acute, transient secondary hypoadrenalism in a hospitalised patient who received fentanyl and tramadol.

Clinical Case:

An 18 year-old female with a long history of hollow visceral myopathy presented with a small bowel obstruction. Intravenous fentanyl was administered initially followed by high dose oral opioid analgesia (QID tramadol) for eight subsequent days. She then had multiple episodes of documented fasting hypoglycaemia fulfilling Whipple's triad, occurring despite adjustment of parenteral carbohydrate administration. There was no history of diabetes mellitus, exogenous insulin or oral hypoglycaemic medication use. Investigation for what was determined to be non-insulin mediated hypoglycaemia revealed a low morning cortisol of 109nmol/L (NR 200-600) and an inappropriately low ACTH level of 2.2pmol/L (NR < 10).

A diagnosis of secondary adrenal insufficiency was confirmed on repeat cortisol and ACTH testing and moreover by a sub-normal short SynACTHen test. After cessation of opioid therapy, there was recovery of adrenal function at ~24 hours with normalisation of both morning cortisol and propensity to hypoglycaemia. Interestingly, this hypocortisolemic pattern was replicated when fentanyl was readministered 5 days later. Subsequent short SynACTHen test and ACTH level undertaken nine days after opioid cessation reflected HPA axis recovery.

Conclusion:

This case of transient opioid-induced secondary hypoadrenalism caused secondary fasting hypoglycaemia. Given the widespread use of opioids, there should be appropriate awareness of adrenal insufficiency as a recognised potentially serious adverse-effect of opioid usage. Acute secondary adrenal insufficiency should be suspected with a morning (0800-0900) cortisol < 250nmol/L or a post 250 microgram synACTHen cortisol of < 550 nmol/L at 30 minutes (2).

There are reported cases involving commonly prescribed opioids including fentanyl, tramadol and methadone. Both ACTH and β-endorphin are peptide derivatives of proopiomelanocortin (POMC). This patient’s HPA axis was particularly susceptible to exogenous opioid causing negative feedback on ACTH, possibly via its relationship to β-endorphin. Given the prevalence of opioid prescription, further studies are required to define what percentage of patients are affected by clinically significant acute and more long-term hypoadrenalism. Delineating the factors potentially modulating this relationship at the receptor and post-receptor level may help to unveil which patients are more predisposed to this adverse effect of opioid administration.

 

Nothing to Disclose: ET, AL, ELC, SMT

22675 8.0000 LBT-084 A Opioid-Induced Transient Secondary Hypoadrenalism: Are Some Clinically Significant Cases Being Overlooked? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Sidney A Jones1 and Stephanie Amber Smith*2
1Ridgeview Medical Center, Chaska, MN, 2Ridgeview Medical System, Chaska, MN

 

Klippel-Feil syndrome is a rare disorder (est. 1:40,000 births, F>M), characterized by fusion of two or more cervical vertebrae, a short webbed neck, and occasionally other non-vertebral defects. It has been associated with mutations of growth differentiation factor 6 (GDF6) and growth differentiation factor 3 (GDF3) genes which are involved in bone growth.   We present a case of a woman with Klippel-Feil syndrome with congenital pituitary hypoplasia and pan-hypopituitarism.  At birth, she had ambiguous genitalia which led to gender mis-assigngment as female – karyotype XY.  Her MRI showed fusion of C2-C3 with occipitalization of altas, consistent with type 1 Klippel-Feil defect, and hypoplastic pituitary tissue.  She is currently treated with growth hormone, estradiol, levothyroxine and hydrocortisone as hormone replacement.  A review of literature revealed no similar case reports.

 

Nothing to Disclose: SAJ, SAS

22869 9.0000 LBT-085 A Klippel-Feil Syndrome; An Unusual Association with Hypoplastic Pituitary. a Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Oscar Ruiz-Bermudez*1, Margarita Ramirez2, Myriam Zahydee Allende3, Milliette Alvarado2, Monica Alexandra Vega2, Dalitza Marie Alvarez-Valentin4 and Anette Garces-Dominguez4
1Puerto Rico University Hospital, Medical Sciences Campus, San Juan, PR., San Juan, PR, 2Puerto Rico University Hospital, University Of Puerto Rico, Medical Science Campus, School of Medicine, San Juan, PR, 3Puerto Rico University Hospital, Medical Sciences Campus (MSC), San Juan, PR., San Juan, PR, 4Puerto Rico University Hospital, Medical Sciences Campus (MSC), PR

 

Background: Adenomas are benign tumors of the pituitary gland and prolactinoma are the major sub-type. Microprolactinomas (< than 1 cm) tend to occur more in females, while macroadenomas (>1 cm) occur predominantly in males. On the other hand, Giant Prolactinoma is a subset of macroadenomas, defined as ≥4 cm, with over 1000 ng/mL of prolactin levels and clinical symptoms of hyperprolactinemia or mass effect. Based on retrospective analyses, the prevalence of Giant Prolactinomas may be estimated to range from 05 to 44% of all pituitary tumours.

Clinical case: 31 y/o male with no medical history presented to ER c/o headache and blurry vision. Brain MRI revealed an enhancing mass at the suprasellar and parasellar region of 3.6 x 4.6 x 4 cm, with bilateral carotid artery encasement, venous sinus invasion and superior displacement of the optic chiasm. Visual field test showed no defects and the extra ocular muscles were intact. The patient refused neurosurgery and came to our clinic seeking a second opinion. Upon further questioning patient referred generalized fatigue, lethargy, decreased libido, and impotence since the last 6 years. Denied gynecomastia, galactorrhea, hearing loss, nasal discharge, visual paralysis with upward gaze or seizures. Family history was unremarkable. On PE vital signs were normal, BMI was 25 kg/m2, was alert and oriented x 3, with no acute distress. He had a poor muscular development, increased body fat, high-pitched voice, sparse male-pattern of body hair. Had a testicle volume of 12ml. Rest of the exam was unremarkable. Laboratory revealed hyperprolactinemia at 2000.00 ng/ml, LH at 0.88 mIU/ml and low IGF-1 at 80.50 ng/ml. Patient was started on cabergoline 0.5 mg twice week. 2 months later patient reported improvement of headache and resolution of hypogonadic symptoms. He recovered somatotroph secretion (LH= 1.01 mIu/ml), prolactin decreased to 8.11 ng/ml and pituitary mass reduced to 0.6 cm.

Conclusion: Giant prolactinomas are rare invasive tumors, usually identified in men. Surgical debulking may be employed to induce rapid optic decompression and visual improvement, or to prevent pituitary apoplexy. However complete removal of giant tumors that extend into the suprasellar, parasellar, and infrasellar areas is difficult and bio- chemical cure is rare.This case reinforces the effectiveness of cabergoline treatment and emphasizes the potential reversibility of pituitary function in patients harboring invasive and aggressive prolactin-secreting pituitary tumors, without developing hypopituitarism. This case also supports medical treatment over surgery for giant prolactinomas and demonstrates that cabergoline is a safe and effective treatment and should be recommended as a first line therapy.

 

Nothing to Disclose: OR, MR, MZA, MA, MAV, DMA, AG

22874 10.0000 LBT-086 A Invasive Giant Prolactinoma; No Surgery Required  2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Anna Z Feldman*, Ekkehard Kasper and Anand Mahadevan
Beth Israel Deaconess Medical Center, Boston, MA

 

Background: TSH secreting pituitary adenomas are rare and an even smaller number cosecrete other hormones, usually GH. We describe an unusual case of a plurihormonal adenoma cosecreting TSH, LH, FSH, and Alpha subunit.

Clinical case: A 67 year old male was found to have visual field loss on routine ophthalmology exam. Pituitary MRI showed a 5 x 3.4 x 3.7 cm lobulated sellar mass, most compatible with a macroadenoma with suprasellar extension, mass effect on the optic chiasm, and extension into the cavernous and posterior sphenoid sinuses. Review of systems was positive for intermittent diplopia, a 25 lb unintentional weight loss over the previous year, mild proximal muscle weakness, and normal erectile function. He denied scrotal enlargement. Physical exam was unremarkable except for mild hypertension. Initial laboratory workup (2 pm) revealed PRL 30 ng/mL (verified by dilution, n <15 ng/mL), FSH 83 mIU/mL (n <12 mIU/mL), LH 27 mIU/mL (n <10 mIU/mL), Total Testosterone 1184 ng/dL (n 280-800 ng/dL), SHBG 108 nmol/L (n <48 nmol/L), Free Testosterone 118 pg/mL (n 60-185 pg/mL), Alpha Subunit 2.4 ng/mL (n <0.6 ng/mL), TSH 12 uIU/mL (n 0.27-4.2 uIU/mL), FT4 1.7 ng/dL (n 0.93-1.7 ng/dL), T3 177 ng/dL (n 80-200 ng/dL), TT4 8.7 ng/dL (n 4.6-12 ng/dL), IGF-1 38 ng/mL (n > 41 ng/mL), Cortisol 4.9 ug/dL (n 2-20 ug/dL). Due to visual compromise, he underwent transsphenoidal debulking of the mass without complications. Postoperative MRI showed good decompression but residual 2.7 x 2 x 2.7 cm tumor extending into the cavernous sinuses bilaterally. Pathology was consistent with pituitary adenoma and stained positive for TSH, LH and FSH, negative for PRL and GH. Visual fields postoperatively were normal in the right eye and significantly improved in the left. One week postoperatively, his labs showed PRL 8.6 ng/mL, FSH 36 mIU/mL, LH 5.9 mIU/mL, Total Testosterone 170 ng/dL, SHBG 93 nmol/L, Free Testosterone 15 pg/mL, Alpha Subunit 1.2 ng/mL, TSH 4.4 uIU/mL, FT4 1.2 ng/dL; cortisol was normal. Two months postoperatively, his labs showed FSH 22 mIU/mL, LH 3.9 mIU/mL, Total Testosterone 64 ng/dL, SHBG 84 nmol/L, Free Testosterone 6 pg/mL, Alpha Subunit 0.7 ng/mL, TSH 6 uIU/mL, FT4 1.5 ng/dL, T3 147 ng/dL, and TT4 9 ug/dL. Given the improved visual field test in the setting of residual disease, the patient opted for adjuvant radiation therapy.  He completed hypofractionated stereotactic radiation in December 2014 with a cumulative dose of 30Gy given in 6 fractions using the Cyberknife TM system. Subsequent labs included TSH 3.6 uIU/mL, FT4 1.1 ng/dL, and TT4 8.5 ng/dL. Repeat imaging showed stable pituitary mass.

Conclusion: We report the extremely rare occurrence of a pituitary macroadenoma cosecreting TSH, LH, FSH and Alpha subunit. The TSH appeared biologically active, while the activity of LH and FSH are less certain. Clinicians should be alert to the possibility of uncommon patterns of hormonal cosecretion in pituitary tumors

 

Nothing to Disclose: AZF, EK, AM

22921 11.0000 LBT-087 A TSH, FSH and LH Cosecreting Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Monica Loto*1, Mariana Scandizzo2, Melina Saban2, Juliana Valeria Gomez3, Marina Ines Curria4 and Karina Danilowicz5
1Hospital Britanico, Buenos Aires, Argentina, 2Hospital Británico de Buenos Aires, CABA, Argentina, 3Hospital Británico de Buenos Aires, Buenos Aires, Argentina, 4Hospital Britànico de Buenos Aires, Buenos Aires, Argentina, 5Hospital de Clínicas “José de San Martín” Universidad de Buenos Aires., Buenos Aires, Argentina

 

Background: Empty sella turcica is defined as the herniation of the subarachnoid space within the sella turcica. Primary empty sella (PES) unlike the secondary one is not due to previous pathological or traumatic process in the hypophysis.

Objectives: To retrospectively analize medical records of patients with diagnosis of PES, on the basis of their clinical presentation. To assess risk factors for this condition: multiparity MP), obesity, diabetes (DM) and arterial hypertension (HT), as well as baseline endocrine function (LH, FSH, ACTH, serum cortisol, prolactin, TSH, T4; FT4, IGF-1, urinary free cortisol, and total and bioavailable testosterone levels in men); Synacthen test was performed in some patients to rule out adrenal insufficiency; no dynamic tests were done for evaluation of GH axis.

 Results: 34 medical records of patients with PES were examined; 26/34 (76%) were female. Mean age (SD) at diagnosis was 53 (15) in women and 50 (18) in men. Regarding risk factors in women, overweight-obesity (Ow/O) was the most prevalent one (45%), followed by MP (33%), HT (26.9%); and DM (15%). As for men, Ow/O, HT and DM were observed in 50, 37.5 and 12.5% of them, respectively. Brain MRIs were principally requested for symptoms of pituitary dysfunction (PD) (50%), headache (3%), and only in one case for visual disturbances. PES was incidentally found on images in 35,2% of patients (43% of women and 12.5% of men); of these patients, 27% had some degree of pituitary dysfunction. PD was identified in 50% of women, in whom central hypothyroidism (CH) was the most frequent insufficiency (23%), followed by hyperprolactinemia (19,2%) , hypogonadotrophic hypogonadism (Hh) (8,3%) and central hypocortisolism (7,7%). Six men (75%) had some degree of hypopituitarism (50% multiples deficiencies); Hh was the most usual affection in them (62,5%).

Discussion: PES is a frequent condition, reported in up to 35% of radiological series, and consistently more prevalent in females. PD has been described in 8-60% of patients. In our study we found a high proportion of pituitary insufficiency probably explained by the fact that only 12% of men and 42% of women were incidentally diagnosed, since in most cases deficiency symptoms or headaches prompted their evaluation. Somatotrophic axis was not adequately assessed, so we cannot rule out this deficiency. The most common dysfunctions were hypogonadism in men, and central hypothyroidism in women. This high prevalence of CH has been described in some series, but more often associated with other deficiencies, especially Hh. Obesity and multiparity were the most important risk factors detected, in agreement with other publications.

Conclusions: Patients with PES should always be evaluated to rule out hypopituitarism. In women, hypothyroidism and adrenal insufficiency can be detected as a single deficiency. Obesity and multiparity are the most relevant risk factors.

 

Nothing to Disclose: ML, MS, MS, JVG, MIC, KD

22966 12.0000 LBT-088 A Primary Empty Sella: Clinical Presentation and Pituitary Function in a Cohort of 34 Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Monica Loto*1, Lucrecia Mutti2, Mariana Scandizzo3, Maria Fernanda Verdaguer4, Karina Danilowicz5 and Marina Ines Curria6
1Hospital Britanico de Buenos Aires, Buenos Aires, Argentina, 2British Hospital, Buenos Aires, 3Hospital Británico de Buenos Aires, CABA, Argentina, 4Hospital Britanico de Buenos Aires, 5Hospital de Clínicas “José de San Martín” Universidad de Buenos Aires., Buenos Aires, Argentina, 6Hospital Britànico de Buenos Aires, Buenos Aires, Argentina

 

Background

Neuropsychiatric abnormalitites are commonly associated with hypercortisolism. But acute psychosis is infrequent.

Case report

A 53-year-old woman was referred for endocrine evaluation. Medical history: long-standing obesity, arterial hypertension, hepatic steatosis, facial hirsutism, 10 month-amenorrhea. Physical exam: blood pressure 145/90, central obesity with (BMI 45 kg/m2), facial hirsutism, and interscapular fat pad. No violet striae, proximal myopaty, or minor bruising.

Screening tests for Cushing's syndrome were requested. ACTH-dependent hypercortisolism was confirmed (Urinary free cortisol 1390 ug/24h; cortisol post 1 mg dexamethasone 27 ug/dl; 11 PM salivary cortisol 6ug/dl; ACTH 45 pg/ml) Primary hyperparathyroidism (PH) was also detected, (calcemia 11,1; PTH 273 pg/ml) making a diagnosis of Multiple Endocrine Neoplasia type 1.

Sellar MRI showed a 5mm cystic lesion. Abdominal and thoracic TC scan revealed only bilateral adrenal hyperplasia. Parathyroid MIBI scan and ultrasonography (US) were negative for adenoma, so parathyroid hyperplasia was then suspected. No evidence of nephrolitiasis was shown on abdominal US; bone mineral density detected osteoporosis only at 1/3 distal radius. Gastrin levels were normal and no pancreatic tumor was found on TC. A few days after diagnosis, she developed acute psychosis (hallucinations and paranoid delirium) being hospitalized. Antipshychotics were indicated, in association with ketoconazole 400 mg, and pamidronate infusion. Despite calcium levels normalization, psychiatric symptoms worsened, and a severe psychomotor excitement prompted her move to UCI, and hastened surgical treatment.

Trans-sphenoidal surgery was done with a total removal of a cystic microadenoma. After surgery, she gradually improved psychiatric symptoms concomitant with the reduction in urinary free cortisol levels .Late remission was observed, with low cortisol levels only after 30 days of surgery. Postoperative course was complicated by deep venous thrombosis and bilateral pulmonary thromboembolism. Thrombolytic agents and heparin were contraindicated due to recent neurosurgery, so a vena cava filter was indicated.

Germline MEN1 mutational testing was done but results are not still available. Surgical treatment of primary hyperparathyroidism was postponed considering her clinical condition,

Conclusions

Hypercortisolism must be considered among the diferential diagnosis of patients with psychotic crisis, with hallucinations and paranoid delirium

Likewise, hypercalcemia also must be ruled out in these cases

But the association of both, Cushing´s disease and PH (MEN Type-1) in a patient with acute psychosis is extremely infrequent

Late remissions can be observed even after complete removal of the corticotropinoma, may be in response to autonomic cortisol production from hyperplastic adrenal glands.

 

Nothing to Disclose: ML, LM, MS, MFV, KD, MIC

22979 13.0000 LBT-089 A Acute Psychosis in a Patient with a Recently Diagnosis of Cushing’s Disease and Primary Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Thursday, March 5th 3:00:00 PM LBT 077-089 6293 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary I Poster


Whitney Ratliff* and Brant R Burkhardt
University of South Florida, Tampa, FL

 

Pancreatic-Derived Factor (PANDER, FAM3B) is an important regulator of glucose and lipid metabolism and increased expression has been found to induce the accumulation of lipids within the liver via the induction of hepatic insulin resistance and lipogenesis. This suggests a role of PANDER as an important factor in the pathogenesis of nonalcoholic fatty liver disease (NAFLD) and Type 2 Diabetes. PANDER has been primarily characterized with regards to its expression from the pancreas; however recent research suggests that PANDER is also produced within the liver itself. To investigate the regulation and expression of hepatic derived PANDER, we examined the regulation of the PANDER promoter via transcription factors. Our prior studies identified the glucose-responsiveness of the PANDER promoter within the liver and we have mapped the minimal glucose-responsive element. The minimal element was identified between -293 to -3 of the hepatic transcriptional start site. The region between -193 to -93 of the TSS was demonstrated as being necessary for basal promoter activity. This minimal element contains three E-box elements, which may serve as a binding site for carbohydrate responsive element binding protein (ChREBP). ChREBP is a critical hepatic transcriptional factor responsible for activating genes in response to elevated levels of glucose. Co-transfection reporter studies revealed that PANDER promoter activity is upregulated in response to increased levels of ChREBP under both starved and elevated glucose conditions. In order to identify a binding region of ChREBP to the PANDER promoter, we performed a chromatin immunoprecipitation study. Primary hepatocytes were isolated from C57BL/6 mice and characterized under glucose stimulatory conditions (11mM and 22 mM glucose). The high (22 mM) glucose condition revealed significant binding of ChREBP to the -193 to -3 region of the PANDER promoter. This region encompasses the third E-box element within the promoter, suggesting that this element is most important for ChREBP binding and PANDER promoter activation. ChREBP may play a role in mediating the glucose-responsiveness of the PANDER promoter within the liver, and indicates a potential mechanism for post-prandial regulation of hepatic PANDER expression.

 

Nothing to Disclose: WR, BRB

22873 1.0000 LBT-090 A Chrebp Mediated Hepatic Pander Expression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM LBT 090-092 6296 1:00:00 PM Late-breaking Cardiovascular Endocrinology I Poster


Jane Lee*1, Jane Weinreb2 and Tannaz Moin3
1Cedars-Sinai Medical Center; VA Greater Los Angeles Healthcare System, Los Angeles, CA, 2David Geffen School of Medicine at UCLA; VA Greater Los Angeles Healthcare System, Los Angeles, CA, 3David Geffen School of Medicine at UCLA; VA Greater Los Angeles Healthcare Systems; VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA

 

Background:

Patients with co-morbid diabetes and hypertension have high rates of cardiovascular complications. Thus, national guidelines recommend a blood pressure goal of <140/80 in all patients with diabetes. The goal of this project was to implement and evaluate the impact of a blood pressure management algorithm for providers in a diabetes clinic.

Methods:

This pilot study used a prospective, pre-post design to assess quality of blood pressure management by providers in one diabetes clinic. Medical records were reviewed to assess what actions, if any, providers took to address elevated blood pressures (defined as either a systolic above 140 or diastolic above 80 mmHg) for patients during a diabetes follow-up visit. Data on provider actions and patient characteristics were collected pre- and post-implementation of the blood pressure management algorithm, which was adapted from JNC 8 guidelines. McNemar test of the difference between correlated proportions was used to compare provider behavior before and after the intervention.  

Results:

Between October and December 2014, 95 patients with diabetes were evaluated in clinic. Among these, 71% (n=68) had an elevated blood pressure reading >140/80. There were no significant differences in mean age, BMI, A1c, and duration of diabetes between patients who presented for follow-up pre- and post-implementation of the blood pressure algorithm. Among the 35 patients seen at baseline with elevated blood pressures, providers only acted on the results 34% of visits (n=12/35; 5 patients were started on a new antihypertensive medication, 5 patients had a repeat blood pressure within normal range, 1 patient refused any intervention, and 1 patient forgot to take their blood pressure medication and was counseled on consistent use). Post-implementation, 33 patients with elevated blood pressures were seen and providers acted on the results in 97% of visits (n=32/33; 2 patients were started on a new antihypertensive medication, 5 patients had their existing medication dose increased, 2 patients were referred to lifestyle interventions, 5 patients had a repeat blood pressure within normal range, 2 patients refused any intervention, 12 patients forgot to take medication on day of appointment and were counseled on consistent use, and 4 patients were to follow up with their PMD.)

Conclusion:

Providers were significantly more likely to take action to address elevated blood pressures post-implementation of a blood pressure management algorithm (34% vs 97%, p=<0.0001). Paper-based blood pressure algorithms are easy to implement and a cost-effective means of improving blood pressure management in accordance with JNC guidelines. Larger and long term studies are needed to assess changes in blood pressure measurements and sustainability of blood pressure algorithms.

 

Nothing to Disclose: JL, JW, TM

22529 2.0000 LBT-091 A Improving the Quality of Blood Pressure Management By Providers in Diabetes Clinic 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM LBT 090-092 6296 1:00:00 PM Late-breaking Cardiovascular Endocrinology I Poster


Hadrien-Gael Boyer*1, Julien Wils2, Arnaud Arabo3, Céline Duparc4, Isabelle Boutelet5, Herve Lefebvre6 and Estelle Louiset7
1INSERM U982, Institute for Biomedical Research and Innovation, University of Rouen, Mont Saint Aignan, France, Mont Saint aignan, France, 2INSERM U982, Institute for Biomedical Research and Innovation, Mont Saint Aignan, France, 3Rouen University, Mont Saint Aignan, France, France, 4Normandie University, UNIROUEN, INSERM U982, ROUEN, France, 5Inserm U982, Laboratory of Neuronal and Neuroendocrine Differentiation and Communication, Institute for Research and Innovation in Biomedicine, Rouen University, Mont-Saint-Aignan, France, 6Normandie University, UNIROUEN, INSERM U982, Laboratoire Différenciation et Communication Neuronale et Neuroendocrine, Rouen, France, 7Normandie University, UNIROUEN, INSERM U982, Laboratoire Différenciation et Communication Neuronale et Neuroendocrine, ROUEN, France

 

Primary hyperaldosteronism is a classic endocrine cause of hypertension associated with hypokalemia and hyporeninemia and is frequently due to adrenocortical aldosterone-producing adenomas. In physiological conditions, aldosterone secretion is controlled by the circulating factors angiotensin II and potassium. In patients with hyperaldosteronism, these factors are reduced, indicating that other regulatory mechanisms may stimulate aldosterone secretion. In this respect, the high density of mast cells detected in aldosterone-producing adenomas was positively correlated with plasma aldosterone levels. In the normal human adrenal, mast cells are present in zona glomerulosa and their degranulation stimulates in vitro aldosterone secretion. These data suggest that mast cells release factors which activate adrenal mineralocorticoid production. We have used mast cell-deficient transgenic mice (C57BL6 Kit W-sh/W-sh) to elucidate the role of mast cells in the regulation of aldosterone production. Under low-sodium diet, mast cell-deficient mice developed a polyuria-polydipsia syndrome associated with lower urinary osmolality and potassium concentration than wild type (WT) animals. Moreover, transgenic mice showed higher aldosterone plasma concentration and presented with a paradoxical increase in systolic blood pressure under low-sodium diet. Adrenal RT-PCR analysis revealed a significant increase in CYP11B2 mRNA, encoding aldosterone synthase, in mast cell-deficient mice compared to WT animals. Similarly, aldosterone synthase immunoreactivity was more pronounced in adrenals of transgenic mice than WT animals. These results show that, in mast cell-deficient mice, low-sodium diet exacerbates aldosterone production responsible for hypokalemia and consecutive polyuria. This observation likely results from renin-angiotensin system hyperactivity aimed at compensating mast cells deficiency. Globally, our data indicate that mast cells are involved in the regulation of aldosterone production and hydromineral homeostasis.

 

Nothing to Disclose: HGB, JW, AA, CD, IB, HL, EL

22584 3.0000 LBT-092 A Mast Cell Deficiency Causes Dysregulation of Aldosterone Secretion and Hydromineral Homeostasis in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Thursday, March 5th 3:00:00 PM LBT 090-092 6296 1:00:00 PM Late-breaking Cardiovascular Endocrinology I Poster


Chloë Goossens*, Steven E Thiessen, Sarah Derde, Marc Jenniskens, Greet Van den Berghe and Lies Langouche
KU Leuven, Leuven, Belgium

 

Introduction: The stress response to critical illness (CI) is characterized by high plasma concentrations of cortisol, glucagon and catecholamines. These hormones may promote a lipolytic response within adipose tissue. In contrast, adipose tissue mass appears preserved during the first week of human CI [1]. We here aimed to characterize in detail the impact of CI on adipose tissue lipolysis in a mouse model.

Methods: In a centrally catheterized mouse model of cecal ligation and puncture-induced septic critical illness (CI), and in sham operated controls (surgical stress only), lipolysis was assessed during the acute (day 1 and 3) and the prolonged (day 5 and 7) phase. Mice received fluid resuscitation, antibiotics, pain medication and parenteral nutrition. To match the human intensive care setting, macronutrient intake was restricted to 45% of normal (5.8kcal/24h). Ad libitum fed healthy animals served as control group (labeled “ALcontrols”). Also, as macronutrient restriction by itself may induce lipolysis, at each time point a healthy control group with restricted access to chow (5.8kcal/24h) (labeled “pair fed”) was added. At sacrifice on day 1, 3, 5 or 7, epididymal adipose tissue was harvested (n=11 animals per group). Lipolysis was assessed by quantifying epidydimal fat pad weight corrected for total body weight, ex vivo glycerol release and lipolytic proteins ATGL, CGI-58, HSL, pHSL-Ser565, -Ser563 and -Ser660, and p-perilipin-Ser517 with use of Western blots.

Results: CI and sham-operated mice behaved largely similar, suggesting that the surgical stress was as severe as that of the abdominal sepsis. Compared to ALcontrols, weight of epididymal fat pads of CI mice decreased over time (from day 3 onwards) (p<0.0001) similar to that of pair fed healthy mice (p≤0.001). However, from day 5 onwards the loss of fat pad weight was much more pronounced in the CI than in the pair fed mice (p≤0.004). During acute CI, more glycerol was released ex vivo from fat of CI mice than of ALcontrols (p=0.03). This corresponded with more ATGL and pHSL-Ser660 protein in fat (p<0.01). During prolonged CI, ex vivo glycerol release returned to the ALcontrol levels, in the presence of a doubling of the lipolysis-inhibiting pHSL-Ser565 protein (p≤0.003). In contrast, compared with ALcontrols, pair fed animals revealed increased glycerol release only on day 7 (p=0.002), which corresponded with increases in ATGL, CGI-58, pHSL-Ser660 and pHSL-Ser565 proteins. The amount of p-perilipin-Ser517 and pHSL-Ser563 was unaltered.

Conclusion: In this sepsis- and surgery-induced model of CI, loss of adipose tissue mass occurred early and aggravated over time. This coincided with an acute, albeit only transient, stimulation of lipolysis, which was not explained by macronutrient restriction alone. Macronutrient restriction in otherwise healthy animals increased lipolysis only at a much later stage.

 

Nothing to Disclose: CG, SET, SD, MJ, GV, LL

22573 1.0000 LBT-093 A Critical Illness Induces a Dynamic Lipolytic Response Unexplained By Macronutrient Restriction Only 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM LBT 093-096 6299 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite I Poster


Yimin Shao*, Geheng Yuan, Junqing Zhang and Xiaohui Guo
Peking University First Hospital, Beijing, China

 

Liraglutide, a glucagon-like peptide-1 (GLP-1) analogue, has been proved to reduce body weight and visceral adipose tissue (VAT) in human studies. In this study, we aimed at examining lipogenetic signals changes in VAT after weight-loss with liraglutide in db/db mice. The mice were divided into 2 groups: liraglutide-treated group (n=14, 8-week old, fasting glucose>10mmol/l, liraglutide 300μg/kg twice a day for 4 weeks) and control group (n=14, saline). We found body weight gain, food intake were reduced after liraglutide treatment (p<0.05).  Compared to the control group, the VAT weights were significantly lower in the treated group (2.32±0.37g vs. 3.20±0.30g, p<0.01) than that in control group.  In VAT, compared with control group, the lipogenetic transcription factors peroxisome proliferator-activated receptor-γ (PPARγ) and CCAAT/enhancer-binding protein-α (C/EBPα) expressions were both reduced with phospho-Adenosine 5’-monophosphate-activated protein kinase (pAMPK) and phospho-acetyl-CoA carboxylase (pACC) increased 3.5-fold and 2.31-fold respectively, while the phospho-serine/threonine kinase Akt (pAkt) and phospho-p38 mitogen-activated protein kinase (pP38MAPK) were reduced 0.38-fold and 0.62-fold respectively (p<0.01).  In conclusion, VAT was reduced after weight loss with AMPK activation and Akt suppression with liraglutide treatment, which was associated with reduction of lipogenetic process in VAT.

 

Nothing to Disclose: YS, GY, JZ, XG

22599 2.0000 LBT-094 A Visceral Adipose Tissue Is Reduced with AMPK Activation and Akt Suppression after Liraglutide Treatment in Db/Db Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM LBT 093-096 6299 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite I Poster


Obin Kwon*1, Min-Seon Kim2, Young Kee Shong2 and Chul Hoon Kim1
1Department of Pharmacology, Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South)

 

Estrogen plays an important role in the control of energy homeostasis in the hypothalamus. Recently, G protein-coupled receptor 30 (GPR30) was suggested as the estrogen receptor that mediates the anorexigenic effect of estrogen through the STAT3 pathway in the hypothalamus(1). In this study, we investigated whether this GPR30-mediated anorexigenic effect can overcome the leptin resistance in which most forms of obesity are involved. Female ERα KO mice were used as a mouse model of obesity and leptin resistance, which showed significant body weight gain compared to wild-type littermate control. Intracerebroventricular (ICV) injection of G-1, an agonist of GPR30, significantly decreased food intake and body weight gain in ovariectomized ERα KO mice compared to vehicle injection. In double immunohistochemistry, G-1-injected mice showed increased number of pSTAT3-immunoreactive pro-opiomelanocortin (POMC) neurons in the arcuate nucleus, but not in vehicle-injected mice. This colocalization was found in both ERα KO mice and wild-type C57BL/6J mice, which implies that GPR30 can provoke anorexigenic signal in ERα-independent manner. This possibility was further supported by the experiment using ICI 182,780, an antagonist of classical estrogen receptors and also an agonist of GPR30. ICV injection of ICI 182,780 significantly decreased food intake and body weight gain in C57BL/6J mice compared to vehicle injection. In conclusion, GPR30-mediated anorexigenic effect in hypothalamus may overcome leptin resistance accompanied by obesity in ERα-independent manner, which provides a novel basis for future therapeutic interventions of obesity.

 

Nothing to Disclose: OK, MSK, YKS, CHK

22782 3.0000 LBT-095 A GPR30-Mediated Anorexigenic Effect May Overcome Leptin Resistance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM LBT 093-096 6299 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite I Poster


Priyanka Ram*, Manjot K Nagyal, Xing Gao, Elizabeth P. Bless, Vanja Klepac-Ceraj and Marc J Tetel
Wellesley College, Wellesley, MA

 

The steroid hormone, estradiol, elicits profound effects on growth, reproduction, and metabolism. For example, estrogens act as an anorectic in humans and rodents.  In support, postmenopausal women gain fat weight, increasing the likelihood of heart disease, cancers and type 2 diabetes.  Recent work from our lab (Bless et al., 2014, J Neuroendo.) and others reveals that estradiol treatment protects against high fat diet (HFD)-induced obesity in female mice. However, the mechanism by which estradiol prevents HFD-induced obesity is not well understood.  Studies on the human and rodent gut microbiome reveal that microbial communities present in the intestines are a key player in obesity, and diet profoundly affects this microbial structure and activity.  The current study tested the hypothesis that estradiol treatment alters the gut microbiome of ovariectomized mice fed a HFD.  Sixteen adult C57BL6 mice were ovariectomized and implanted subcutaneously with silastic capsules containing either 17β-estradiol (50 ug, E2) or oil (Veh).  Mice in each group were maintained on a standard rodent chow for 10 days and then fed a HFD for 25 days.  Weight measurements and fecal samples were collected over the 35 days and then mice were sacrificed and tissue samples from the brain, small intestine, large intestine, and cecum, as well as their contents, were collected. Bacterial DNA from the fecal and gut samples was extracted, and the microbiome from each fecal sample was analyzed by high-throughput 16S rRNA gene Illumina sequencing and compared longitudinally and across treatment groups.  Consistent with our previous findings (Bless et al., 2014), Veh mice gained 35% more weight than E2 mice over the 35 days.  Interestingly, the gut microbiota of Veh mice responded to the change in diet immediately after the mice were put on a HFD, while the gut microbiota of E2 mice were more resistant to the change.  In Veh mice, the abundance of the order Bacteroidales within the phylum Bacteriodetes decreased, while the abundance of sequences belonging to the Erysipelotrichi class within the phylum Firmicutes increased.  These microbial abundance shifts at the phylum level in diet-induced obese mice have been observed in other microbiome-obesity studies.  However, in the present study, the levels of both Bacteriodetes and Firmicutes remained constant in E2 mice, suggesting a strong link between estradiol treatment and the gut microbial community composition in the regulation of obesity.  Firmicutes are known to harvest more energy from food and believed to alter fat storage in adipocytes.  We are continuing to investigate hormone and diet interactions on the gut microbiota of female mice.  Identification of estrogen-induced changes in the gut microbiome is critical to understanding the mechanisms by which estrogens protect against obesity.

 

Nothing to Disclose: PR, MKN, XG, EPB, VK, MJT

22849 4.0000 LBT-096 A Estradiol and Diet Alter the Gut Microbiome in Female Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Thursday, March 5th 3:00:00 PM LBT 093-096 6299 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite I Poster


Anastasia Susie Mihailidou*1 and Anthony W Ashton2
1Royal North Shore Hospital, Sydney NSW, Australia, 2The Kolling, Royal North Shore Hospital & University of Sydney, Sydney, Australia

 

Hyperglycemia (HG) is an independent predictor of higher incidence of myocardial infarction (MI) and in-hospital complications in diabetic and non-diabetic individuals. While chronic HG has adverse cardiac actions, there continues to be controversy whether acute HG is a marker for disease severity, or has a direct adverse effect on the ischemic myocardium. Aim: Our aim was to determine the direct effect of acute (3 hours) exposure to HG during experimental MI and identify the mechanisms activated. Methods: Hearts from male Sprague Dawley (SD) rats were isolated and perfused with buffer solution in which glucose was increased to 22 mM followed by our ex-vivo ischemia-reperfusion (I-R) model of ischemia for 30 min. and reperfusion for 2.5 hr. At completion of reperfusion, hearts were stained with monastral blue and triphenyl-tetrazolium to highlight area-at-risk (AAR) and infarct area (IA) respectively. In separate studies, hearts from SD rats were exposed to 22 mM glucose buffer alone without I-R. We also included a subset of studies with hearts from Zucker diabetic (ZDF) rats, an animal model of Type 2 diabetes. Results: Acute HG of 22 mM glucose was selected, comparable to blood glucose levels of the ZDF rats (19 ± 1 mM, N=10) and produced significantly larger infarct area [58 ± 2%, N=8] compared to I-R alone [43 ± 1%, N=7, *p<0.05] and hearts from ZDF rats [49 ± 1%, N=7, *p<0.05]. Since expression of multiligand receptor for advanced glycation end products (RAGE) is activated during I-R and HG, we measured RAGE protein levels and found I-R induced activation of RAGE [1.11±0.03, N=5 vs 0.79±0.05 (sham I-R), N=4, *p<0.05] and a trend in preliminary studies with acute HG (1.70±0.29, N=3). RAGE stimulation activates a proapoptotic caspase cascade and we identified that acute HG aggravated caspase-3 processing induced by I-R [1.3±0.04 vs 0.99±0.07, *p<0.05 respectively], but not caspase-8 processing [0.94±0.06 (N=3) vs 0.88±0.06, (N=8)], indicating a mitochondrial-mediated rather than death receptor-mediated apoptotic pathway. Since AMPK is an important regulator of apoptosis and autophagy pathways during I-R, we measured expression levels of phosphorylated AMPK (p-AMPK) in preliminary studies (N=3). I-R suppressed p-AMPK levels [0.45±0.03 x 105 vs 1.57±0.35 x 105 (sham I-R)] while there was further decrease in the levels of p-AMPK in heart tissue from hearts exposed to acute HG (0.19±0.03 x 105), with similar levels in heart tissue from ZDF rats (0.11±0.011 x 105). Conclusion: Acute exposure to hyperglycemia aggravates cardiac damage during I-R to a similar extent of sustained, chronic hyperglycemia by shifting the balance between apoptosis and autophagy.

 

Nothing to Disclose: ASM, AWA

22817 1.0000 LBT-097 A Acute Hyperglycemia Disrupts Autophagy:Apoptosis Balance during Experimental Myocardial Infarction 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Eman M Alfadhli*
Taibah University, Medina, Saudi Arabia

 

BACKGROUND:

The new criteria proposed by the International Association of the Diabetes and Pregnancy Study Group (IADPSG) for diagnosing gestational diabetes (GDM) increased the prevalence of GDM worldwide. There are some contradictions regarding the impacts of the IADPSG recommendations on the pregnancy outcome between the studies. In addition, there are no studies that have looked at the increase in GDM prevalence after applying the IADPSG criteria among Saudi women.

OBJECTIVE

To compare between the IADPSG criteria for GDM diagnosis and the former ADA criteria with regard to prevalence, clinical characteristics, and the pregnancy outcomes of the GDM group identified by each set of criteria among Saudi women. 

METHODS

This prospective cohort study was conducted at the Maternity and Children Hospital, Madinah, Saudi Arabia from October 2011 to August 2012. Two hundred seventy seven pregnant Saudi women underwent a 2-h 75 g oral glucose tolerance test (OGTT) at 24-28 weeks of gestation, and both IADPSG criteria and the former ADA criteria were used for GDM diagnosis, respectively. Those with multiple risk factors for GDM were screened earlier in the first antenatal visit with OGTT. The women were divided into three groups; group 1 included those who were identified to have GDM by both criteria (classical GDM, N= 47), group 2 included those who had GDM identified with IADPSG only but not ADA criteria (additional IADPSG-GDM group, N=68), and group 3 included those who were considered to have normal glucose tolerance (NGT group, N= 162) by both criteria. Comparisons between the three groups were made in terms of clinical and metabolic characteristics and pregnancy outcomes. For the handling of the GDM cases during the study, the IADPSG criteria were used.

RESULTS

Forty seven (16.9%) of women were diagnosed as having GDM by both ADA and IADPSG criteria. An additional 68 women (24.5%) had GDM by IADPSG criteria.

Group 2 had the same clinical characteristics as group 1 except for lower blood pressure (P= 0.001), and less frequent glycosuria (P= 0.01). On the other hand, they were older (P = 0.004), heavier (P = 0.000) and had higher frequencies of past GDM (P = 0.000) and history of recurrent abortions (P = 0.003) than group 3. In addition, they had significantly more cesarean deliveries (P = 0.040), longer hospital admissions (P = 0.001), neonatal hypoglycemia (P = 0.000), and low Apgar score (P = 0.024) than group 3.

CONCLUSIONS

The IADPSG criteria increased GDM prevalence. The additional GDM cases identified by IADPSG have the same clinical characteristics and adverse pregnancy outcomes as GDM identified by the older criteria and differ from non GDM cases.

 

Nothing to Disclose: EMA

22314 2.0000 LBT-098 A Comparison Between the International Association of the Diabetes and Pregnancy Study Group Criteria for Diagnosing Gestational Diabetes and the Former American Diabetes Association Criteria: A Prospective Study Among Saudi Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Bagher Larijani*1, Mohammad Abdollahi2 and Ozra Tabatabaei-Malazy3
1Endocrinology and Metabolism Research Institute, Tehran, Iran, 2Department of Toxicology and Pharmacology, Faculty of Pharmacy, and Pharmaceutical Sciences Research Center, Tehran University of Medical Sciences, Tehran, Iran., 3Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

 

There exists an increasing interest in shifting from synthetic drugs to herbal medications as an alternative treatment. Herbal formulations are generally considered safe and more easily available, are not as costly as synthetic drugs, and their use is less limited by side effects. As it is documented that oxidative stress mechanisms are involved in pathogenesis of diabetes and its complications, it seems reasonable to consider that herbal formulations containing different anti-oxidant components  might be effective in the management of diabetes due to their synergic effect. Having performed a comprehensive systematic searches in the literature, we hypothesized a particular mixture of polyphenols-derived components with a high antioxidative effect for treatment of type 2 diabetes mellitus (T2DM). Cytotoxicity, pharmacokinetic and safety of the mixture were assessed in vitro and in vivo studies in diabetic rats and the results were compared with those of non-diabetic animals. Diabetic rats divided into 5 groups: three groups were under-treatment with different dosages of poly-herbal mixture, one group received glibenclamide, and the last group did not receive any medication. The results of our study demonstrated that the formula was beneficial in terms of  islet cells’ viability, radical oxygen species (ROS) production, insulin secretion, total antioxidant power, lipid peroxidation, DNA damage, and was protective in terms of glycemic control. It can be concluded that our polyherbal formulations with antioxidative effect could be candidate in development of new medications for T2DM. It should be mentioned that clinical trials are in progress for testing the effectiveness of the medication in humans.

 

Nothing to Disclose: BL, MA, OT

22800 3.0000 LBT-099 A Development of a Novel  Polyherbal Formulation for Management of Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Meital Grafi-Cohen1, Dalia Somjen1, Orli Sharon1, Nadav Sagiv1, Rona Limor1, Naftali Stern2 and Sigal Shaklai*1
1Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, 2Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

 

Reduction in functional β-cell mass is a sine qua non for the development of diabetes mellitus types 1 and 2. Estradiol-17β (E2), the predominant female sex hormone, has come to focus as a protective factor for β-cell function and survival. Human and rodent β-cells express the three estrogen receptors (ER); ERα, ERβ and the G-protein coupled ER (GPER) also called GPR30. Foxo1, belonging to the Fork head (Foxo) family of transcription factors, plays a major role in β-cells, integrating signals regulating β-cell mass and stress response. Foxo1 activity is regulated by phosphorylation, which leads to nuclear-cytoplasmic translocation rendering it transcriptionally inactive. In estrogen responsive tissues Foxo1 has been shown to interact with ERα influencing transcription and cell cycle. In light of their mutual involvement in proliferation and evidence of collaboration we examined whether Foxo1 and E2 also co-operate in E2 induced β-cell proliferation. Using siRNA, Foxo1 protein expression was knocked down (KD) in INS1 (rat insulinoma) cells by approximately 60%. INS1 control and Foxo1 KD cells were treated for 24h with E2 and ER subtype specific agonists (to ERα, ERβ and GPER) and proliferation was assessed by 3[H]-thymidine incorporation. In control cells, proliferation was increased by up to three fold in response to E2 and all ER agonists. In KD cells, while proliferation in the basal state was increased by almost two fold the effect of E2 and ER agonists was completely abrogated. Having seen that Foxo1 resides in the pathway of E2 induced proliferation we went on to examine whether E2 affects Foxo1 phosphorylation state and hence activity. INS1 cells treated with E2 were examined for expression of Foxo1, pAKT and pFoxo1 by western blot analysis. At 30 and 60 min of E2 treatment Foxo1 was reduced by 60% in the cytoplasmic compartment with no evidence of translocation to the nucleus. 24h exposure to E2 resulted in reduced Foxo1 expression within the first 2h, with return to baseline at 24h. pAKT levels rose and fell concomitant to Foxo1 in a near mirror image. pFoxo1 increased by approximately six fold during the entire 24h period of exposure to E2 . As Foxo1 did not appear to translocate to the nucleus we explored whether its decrease was due to proteasomal degradation. Treatment with MG132 (a proteasome inhibitor) in addition to E2, did not prevent Foxo1 reduction. This suggests that the seeming reduction of Foxo1 may be due to its sequestration in lysis resistant complexes. Such nuclear complexes comprising ERα, Foxo1 and additional co-factors, have been identified on estrogen response elements in MCF7 cells. Our findings support a novel co-operation in pancreatic β-cells, between E2 and Foxo1, in stimulation of proliferation.

 

Nothing to Disclose: MG, DS, OS, NS, RL, NS, SS

22805 4.0000 LBT-100 A Estradiol-17β Induced Pancreatic Beta Cell Proliferation is Foxo1 Dependent 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Nilma Malik*1, Mohammad Islam2, Reema A Patel3 and Abdalla Yousif4
1University Of Utah, Salt Lake City, UT, 2Raritan Bay Medical Center, 3Rraitan Bay Medical Center, sayreville, NJ, 4Raritan Bay Medical Center, Perth Amboy, NJ

 

Background: Metabolic ketoacidosis has been frequently associated with three major etiologies which include diabetes, alcohol and starvation. Treatment is tailored towards the cause and usually involves crystalloid infusion in alcohol and starvation ketosis and implementation of insulin drip in diabetic ketoacidosis[1]. On the contrary our patient presents with a challenging scenario which warrants further insight to the treatment strategies of metabolic ketoacidosis.

Clinical Case: A 59-year-old male with past medical history of diabetes and alcoholism presented to the ER with coffee ground emesis for 3 days. One week prior to admission the patient fell off the stairs and injured his left shoulder. Thereafter he consumed alcohol for pain relief and had not eaten anything. He admits to not taking his insulin for last 2 days. Upon admission vitals were stable. His labs were significant for Hb- 10.4 (n 11.6-16.8) g/dL, INR- 1.0 (n 0.9-1.1), blood glucose- 106 (n 70-115) mg/dL, BUN- 15 (n 6-20) mg/dL, Cr- 0.6 (n 0.7-1.2) mg/dL, Na- 133 (n 136-145) mmol/L, K- 3.1(n 3.6-5.1) mmol/L, Cl- 84 (n 90-110) mmol/L, HCO3- 16 (n 22-28) mmol/L, AG- 34 (n 2.6-10.6) mmol/L, B-Hydroxy > 8 (n <0.3) mmol/L -, Lactic Acid- 1.3 (n 0.5-2.2) mmol/L, Serum Osm- 311 (n 280-290) mOsm/Kg . Urine was positive for ketones. PH- on ABG was 7.29 (n 7.350-7.450). Alcohol level was 211(n 0-10) mg/dL. Urine Drug Screen was negative for drugs. Since the patient was euglycemic, IV insulin drip was not initiated and he was presumably treated for starvation and alcohol ketoacidosis with multivitamins , thiamine and D5NS @ 150 mL/hour. Patient was kept NPO, finger sticks were followed hourly and coverage was established with Humalog sliding scale of 2 units per 50 for more than 150. Labs obtained 4 hours later showed no improvement with sustained Beta-Hydroxy > 8 (n <0.3) mmol/L, venous pH- 7.33(7.350-7.450), HCO3-10 (n 22-28) mmol/L, AG- 33 (n 2.6-10.6) mmol/L , blood glucose levels of 139 (n 70-115) mg/ dL, HBA1c- 8.3 (n 4.8-5.9) %, Fructosamine- 328 (n 0-285)umol/L. The patient was eventually started on insulin drip with close monitoring of serum electrolytes. Follow up labs showed gradual resolution of ketoacidosis .

Conclusion: This case demonstrates the diagnostic and therapeutic dilemma for treatment of euglycemic ketoacidosis. Literature elaborates that normal range blood sugar is the key factor in differentiating the diabetic ketoacidosis from starvation or alcoholic ketoacidosis, nevertheless multiple cases of euglycemic diabetic ketoacidosis have been reported[2]. Our patient had a classical overlapping picture of the common potential causes of metabolic ketoacidosis including alcohol, starvation and euglycemic diabetic ketoacidosis. Quandary remains, if insulin drip should be considered earlier in the course of treatment of " High Anion Gap Euglycemic Ketoacidosis " regardless of the cause!

 

Nothing to Disclose: NM, MI, RAP, AY

22366 5.0000 LBT-101 A Insulin Drip in Euglycemic Ketoacidosis - a Tough Nut to Crack! 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Sirimon Reutrakul*1, Hataikarn Nimitphong2, Nantaporn Siwarasanond1, Sunee Saetung3, Naricha Chirakalwasan4 and Boonsong Ongphiphadhanakul5
1Faculty of Medicine Ramahibodi Hospital, Bangkok, Thailand, 2Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 3Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 4Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 5Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

There is evidence that sleep and circadian system play a role in metabolism. Aside from physiological control, sleep is also affected by behaviors. In this study, we examined whether morning or evening preference, sleep timing and sleep duration are associated with glycemic control in patients with type 2 diabetes.

Two hundred and ten type 2 diabetes patients had an interview and completed questionnaires to collect information on diabetes history, habitual sleep duration and timing. Sleep debt was calculated as a difference between self-report sleep duration and the amount of sleep desired. Chronotype, an individual’s tendency for being a “morning” or “evening” person, was assessed using two methods; morningness-eveningness questionnaire (Smith) which reflects an individual’s preference, and mid-sleep time on weekends (MSF) which reflects their real life behavior. Shift workers were excluded. Most recent HbA1c values were retrieved from medical records.

Mean age is 58.6 ± 10.9 years with a mean BMI of 28.4 ± 4.8 kg/m2 and mean diabetes duration of 11.9± 10.0 years. Forty percent of the participants are male. More evening preference (as indicated by Smith score) and later bedtime on weekend, but not later MSF or wake up time, are correlated with higher HbA1c (correlation coefficient (r) 0.18, p=0.01, and r= 0.17, p =0.01, respectively). Comparing with earlier weekend bedtime (1st quartile of bedtime, mean 20:07± 0:21 PM), later weekend bedtime (4thquartile of bedtime, mean 23:42±0:44) is associated with more evening preference (Smith score 41.2±5.5 vs 49.3±3.5, p<0.001), higher HbA1c level (7.81±1.50 vs 6.95±0.92%, p=0.002), significantly shorter sleep duration (5.0±1.4 vs 6.4±1.6 h, p<0.001) and more sleep debt (1.7±1.6 vs 0.8±1.6 h, p=0.01).

Multiple regression analyses adjusting for age, sex, BMI, insulin use, and diabetes duration found that later bedtime on weekend is significantly associated with poorer glycemic control (B=0.018, p=0.02). This association is mediated by sleep duration.

Later bedtime on weekend is associated with shorter sleep duration and poor glycemic control in patients with type 2 diabetes. It is likely that patients with later weekend bedtime curtail their sleep by waking up earlier than desired. Exploring the reasons for this phenomenon, (i.e. culture, metropolitan lifestyle, environment, family and social obligations) may lead to behavioral modifications (i.e. earlier bedtime and/or sleep duration extension) and possibly improved glycemic control.

 

Nothing to Disclose: SR, HN, NS, SS, NC, BO

22358 6.0000 LBT-102 A Late Bedtime on Weekend Is Associated with Evening Preference, Shorter Sleep Duration and Poor Glycemic Control in Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Ibiye Owei*, Sotonte Ebenibo, Nkiru Umekwe, Ashley K Gilles and Samuel Dagogo-Jack
University of Tennessee, Memphis, TN

 

Background: Current definitions of “metabolically benign” or “insulin-sensitive” obesity (ISO), based on a body mass index (BMI) ≥ 30 kg/m2and indirect estimates of insulin sensitivity, are imprecise and insufficiently characterized in diverse populations. We, therefore, assessed obesity phenotypes, classified by directly measured insulin sensitivity in a biracial cohort.

Subjects and Methods: Study subjects are participants in the Pathobiology of Prediabetes in A Biracial Cohort study, a longitudinal study of normoglycemic African American and European American offspring of parents with type 2 Diabetes.  Assessments include OGTT, body composition(DEXA), insulin secretion (FSIVGTT), resting energy expenditure (REE, by indirect calorimetry), chemistries. Insulin sensitivity (Si-clamp) was measured by euglycemic clamp, and also estimated by HOMA-IR. Using the 25th percentile for Si-clamp (umol/kg fat free mass/min.pmol/L-1) and the 75th percentile for HOMA-IR values, we classified subjects as having insulin resistant obesity (IRO) (BMI ≥ 30 kg/m2, Si-clamp <0.1, HOMA-IR ≥2.5) or insulin sensitive obesity (ISO) (BMI ≥ 30 kg/m2, Si-clamp ≥0.1, HOMA-IR <2.5). A dichotomous comparison of cardiometabolic markers was then undertaken.

Results: 76 subjects (58 women, 18 men; 51 black, 25 white) met the criteria for IRO and 97 (71 women, 26 men; 59 black, 38 white) met criteria for ISO. The mean (± SD) values (IRO vs. ISO) were: age 44.0 ± 12.1 vs. 44.0 ± 10.6 yr (P>0.5), BMI 36.7 ± 6.86 vs. 34.1 ± 5.26 kg/m2(P= 0.005), Si-clamp 0.058 ± 0.025 vs. 0.138 ± 0.048 (P<0.0001), HOMA-IR 3.51± 1.60 vs. 1.49  ± 0.83(P<0.0001). Fasting (93.3 ± 6.47 vs. 92.7 ± 7.57 mg/dl) and 2-hr plasma glucose (128 ± 27.2 vs. 125 ±24.2 mg/dl) values were similar in IRO vs. ISO subjects. Compared to IRO subjects, individuals with ISO had lower values for waist circumference (107 ± 11.8 vs. 102 ± 11.6, P= 0.0065), total body fat (42.2 ± 12.9 vs. 37.6 ± 10.5 kg, P= 0.0148), trunk fat (21.6 ±6.46 vs. 18.7 ± 5.40 kg, P= 0.0032), serum triglycerides (115±57.7 vs. 89.7±47.4 mg/dl, P= 0.0019), fasting leptin (59.9 ± 45.0 vs. 48.1± 36.0 ng/ml, P=0.05), and insulin secretion (119 ± 91.9 vs. 84.4 ± 69.7 uU/ml, P=0.0061), and higher adiponectin levels (7.38±3.96 vs. 9.34±4.46, P=0.003). ISO subjects also had numerically higher HDL cholesterol and lower blood pressure and hsCRP levels. REE corrected for fat free mass was similar, but RQ was higher in ISO than IRO subjects (1.13±0.17 vs. 1.05±0.21, P=0.02). The data were consistent in African Americans and European Americans.

Conclusion: In our biracial cohort, insulin-sensitive obesity is associated with healthier body composition and cardiometabolic risk profile, decreased beta-cell stress, higher adiponectin levels, and enhanced carbohydrate oxidation, compared to insulin-resistant obesity. The mechanisms underlying the insulin-sensitive obesity phenotype remain to be elucidated.

 

Nothing to Disclose: IO, SE, NU, AKG, SD

22383 7.0000 LBT-103 A Phenotypic Characterization of Euglycemic Clamp-Defined Insulin-Sensitive Obesity in Non-Diabetic African-Americans and European-Americans 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Nilrat Wannasilp*, Ananya Kerdhangsoong, Sathien Sukpanichnant, Kosit Sribhen and Vip Viprakasit
Siriraj Hospital, Mahidol University

 

Objective
The objective of this study was to determine the possible interference from common abnormal hemoglobin (Hb) detected and known in Thailand on 7 hemoglogin A1c (HbA1c) analyzers.

Materials and Methods

177 EDTA blood samples were collected from healthy volunteers living in Chonburi Province, Thailand. HbA1c analysis was carried out on 7 instruments: Immunoassay chemistry analyzers - Integra 800 (Roche Diagnostics, Thailand) and ILab Taurus (SE Supply, Thailand), enzymatic assay analyzers-Architect C8000 (Abbott, Thailand) and Mindray BS-800 (SE Supply, Thailand), cat-ion exchange chromatography analyzers - Tosoh HCL -723 G8 (SE Supply, Thailand) and ADAMS A1c HA-8180V (Drew Bio, Thailand), and boronate affinity chromatography Premier Hb9210 (Helena Thai Laboratories, Thailand). All samples were additionally tested for Hb typing and DNA analysis to confirm and determine the abnormal hemoglobin variant pattern.
Results

This study found that the prevalence of abnormal Hb was 37.3% (66 of 177 volunteers). 2.8% (5 of 177) were alpha thalassemia 1 trait, and 9.6% (17 of 177) were alpha thalassemia 2 trait. For beta chain abnormalities, 17.6% (31 of 177) were heterozygous HbE, and 4.5% (8 of 177) were homozygous HbE. Finally, 2.8% (5 of 177) were combined alpha thalassemia trait with heterozygous HbE.

Although there were statistically significant differences in the mean HbA1c values in normal Hb typing amongst analyzers Premier, Integra, ILab Taurus, G8, HA8180-V, BS-800 and Architect. (5.36 ± 1.06, 5.58 ± 0.95, 5.23 ± 1.01, 5.51 ± 1.04, 5.43 ± 1.07, 5.05 ± 0.97, and 5.22 ± 1.12, respectively), there were no clinical significance due to the percentage of difference being less than 6%. The presence of homozygous HbE has proven to have a drastic clinical significance in interfering with the HbA1c values measured by all analyzers except the ILab Taurus analyzer. There was no HbA1c peak observed in 7 of 8 homozygous samples of HbE when analyzed on HA8180-V. All heterozygous and homozygous HbE pressence were picked up by chromatographic analysis from both cation exchange HPLC analyzers.

Conclusion

The presence of homozygous HbE does interfere and results in a much lower than actual HbA1c result on all instruments. It is recommended to use other tests such as glucose or fructosamine for monitoring diabetics patients with the pressence of homozygous HbE. 

 

Nothing to Disclose: NW, AK, SS, KS, VV

22866 8.0000 LBT-104 A Preliminary Data: Interference of Common Abnormal Hemoglobin (Hb) in Thailand on 7 Hemoglobin A1c (HbA1c) Analyzers  2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Carrie Elizabeth Casden*1 and Omolola Bolaji Olajide2
1Marshall University, Huntington, WV, 2Marshall University School of Medicine

 

Introduction:

Hypoglycemia is a serious condition with the potential for severe consequences. It is important to know and understand the etiology.  Nissan Fundoplication is a common treatment for reflux disease.  Dumping syndrome after the procedure can cause hypoglycemia.  Dumping syndrome has been described in up to 30% of children who had the procedure but few cases have been described in adults.  We present a 78 year old female who presented with hypoglycemia after a Nissen Fundoplication. 

Clinical Case:

The patient is a 78 year old female who presented for evaluation of hypoglycemia.  She had no past history of Diabetes or prediabetes.  She was having spells of sweats, feeling shaky and dizzy a few hours after she had eaten. These symptoms would resolve with orange juice.  The symptoms started soon after she had a Nissen Fundoplication for gastroesophageal reflux disease.  She had a long history of hypothyroidism and was on thyroid hormone therapy.

She had documented post prandial capillary glucose levels in the 50-60 range with the lowest value in the 40’s. She did not have fasting hypoglycemia at any time. 

It was felt her symptoms were likely secondary to the Nissen Fundoplication causing dumping syndrome.  She was encouraged to eat lower glycemic index foods and to keep a food diary to get a better understanding of what foods make her blood sugar go low. 

Her initial workup showed her A1C was 6.6%. Serum insulin level was normal at 5.5 µIU/ml (2.6-24.9) with a fasting venous glucose of 93 mg/dl. She reported a few hypoglycemic episodes on her follow-up visit but had not made the recommended changes to her diet.

Discussion: 

Dumping syndrome after a Nissen Fundiplication is divided into 2 stages.  The first is the early/osmotic stage which takes place around 45 minutes after intake and is due to accelerated gastric emptying of hyperosmolar and causes diarrhea.  The second stage is the late/hypoglycemic stage and takes place 2-4 hours after eating. This is secondary to hyperinsulinemic response to the initial hyperglycemia.  The glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide 1 (GLP-1) contribute to the development of this phase.  The treatment for hypoglycemia due to dumping syndrome is a diet free from rapidly absorbed sugars and divided into several small meals.

Conclusion: 

Although not reported as frequently in adults as children, hypoglycemia can occur after a Nissen Fundoplication.  This can often be treated by a change in diet.

 

Nothing to Disclose: CEC, OBO

22742 9.0000 LBT-105 A A Case of Hypoglycemia in an Adult after Nissen Fundoplication 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Ernesto Sola Sanchez*1, Jose Hernan Martinez2 and Carmen V Rivera2
1San Juan City Hospital, San Juan, 2San Juan City Hospital, San Juan, PR

 

Background:  DM has been identified as risk factor for developing TB infection, and relapse after therapy[i].  Strikingly, the risk (25.2%) of acquiring TB is described as comparable to that of HIV population (25.5%) in Hispanics.[ii]  Abnormal cytokine expression is proposed as underlying mechanism, yet to be fully understood.[iii]   Still, the fact that diabetics are 3 times more prone to develop pulmonary TB than non-diabetics, displaying atypical imaging features, irrespective of background incidence or geographic region, cannot be overlooked.2,[iv][v]  With DM recognized as global epidemic, and TB affecting one third of the world population, Physicians must remain vigilant.[vi],[vii]

Clinical Case:  A 45-year-old woman born in Dominican Republic (DR), with 10 year history of T2DM treated with metformin, arrived to our Urgency Room complaining of dry cough for the past 3 months.  Interview unveiled unintentional 15lb weight loss, night sweats, occasional unquantified fever, and general malaise.  Denied bloody sputum.  She traveled to DR 2 years previously, with no known tuberculous exposure.  Surgical history was remarkable for TAH due to pelvic cancer.  Physical examination showed a thin body habitus, otherwise well appearing woman with stable vital signs, presenting solely right middle lung field ronchi on auscultation.  Laboratories yielded no leukocytosis or monocytosis.  Blood cultures, HIV and PPD tests were negative.  However, LDH (997 units/L), ESR (80 mm/h),  hsCRP (71.2 mg/L), and HbA1C (12.4mg/dl corresponding to an average blood glucose of 309 mg/dl) were elevated.    X-rays imaging revealed a right middle lobe cavitation suspicious for malignancy versus infection.  Sputum for AFB disclosed active pulmonary TB, prompting therapy.  Marked hyperglycemia complicated hospital course in spite of raising dosages of insulin therapy, and this persisted even after clearance of AFB in the sputum. 

Conclusions:   Our experience attempts to emphasize that the consideration of TB, as differential diagnosis in diabetics, should be exercised with the same strength as it is undertaken during the evaluation of HIV patients.  Physicians should especially take into consideration that diabetic patients with TB may present atypical workup findings on imaging and laboratory tests, even mimicking other conditions, as in our case.    Inability to recognize TB will endanger the patient, hospital dwellers, and staff, as well as perpetuate this global public health menace.

 

Nothing to Disclose: ES, JHM, CVR

22912 10.0000 LBT-106 A Beware of This Hazardous Relationship:  Diabetes Mellitus Just As Worrisome for the Development of Tuberculosis As HIV 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Pakhadi H. Buddhadev*1, Mehul R Vora2 and Mihir Sanjay Shah1
1St Francis Hospital, Evanston, IL, 2None, Orland Park, IL

 

Introduction:

Uncontrolled hyperglycemia has been associated with poor outcomes in patients admitted to the Intensive Care Unit (ICU), but its impact on ventilator dependency in patients with exacerbation of chronic obstructive pulmonary disease (COPD) and/or congestive heart failure (CHF) is unknown. We conducted a retrospective study to determine whether an association exists between blood glucose levels and duration of mechanical ventilation in this population of patients.

Methods:

Patient charts were reviewed using Electronic Health Record (EHR) system. Subjects admitted at St Francis Hospital between January 2011 and December 2012 with a diagnosis of COPD and/or CHF exacerbation and were intubated within 48 hours of presentation were included in the study. Patients requiring vasopressors and/or tracheostomy, pregnant patients, patients younger than 18 years of age and patients who did not survive were excluded. Subjects were divided into three groups based on mean fasting glucose levels: 70-110 mg/dl (group 1), 111-150 mg/dl (group 2) and >150 mg/dl (group 3). Clinical data and laboratory parameters including steroid usage, history of smoking, BNP level at admission and therapy with bronchodilator and diuretic was recorded for all the patients. Hypoglycemic episodes were also noted if any. The primary end point was defined as successful extubation. Data analysis was performed using SPSS software with one-way ANOVA test, chi-square test, Spearman correlation and multinomial regression analysis.

Results:

Forty eligible patients were included in the study with six, fifteen and nineteen patients in groups 1, 2 and 3 respectively. ANOVA test showed statistically significant difference in mean duration of ventilation between the three groups (1.67±0.8 vs 2.87±1.8 vs 4.05±2.5; p=0.047), as well as significant difference in BNP level at admission (p=0.027). Multinomial regression analysis confirmed independent association between blood glucose level and duration of ventilation. Spearman test also showed positive correlation between duration of ventilation and mean fasting blood glucose (R=0.52, p=0.001).

Conclusion:

Blood glucose level is independently associated with duration of mechanical ventilation in patients with COPD and/or CHF exacerbation, with a positive correlation between rising blood glucose levels and prolonged need for ventilation. Hyperglycemia increases the chances of developing sepsis and critical illness neuropathy, which is related with increased duration of mechanical ventilation. Our study showed that blood glucose above 150 mg/dl was associated with an increased duration of mechanical ventilation.

 

Nothing to Disclose: PHB, MRV, MSS

22349 11.0000 LBT-107 A Correlation Between Blood Glucose Levels and Duration of Mechanical Ventilation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Shafaq Khairi*1, Babak Torabi Sagvand2 and Syed Kamal Nasser3
1Mercy Catholic Medical Center, Darby, PA, 2Massachusetts General Hospital, Boston, MA, 3Southeastern Regional Medical Centre

 

Metabolic syndrome is a pro-thrombotic and pro-inflammatory state which represents a constellation of risk factors for cardiovascular disease and type II Diabetes Mellitus. It is rapidly becoming a worldwide epidemic in association with central obesity and underlying insulin resistance. As cardiovascular disease is one of the leading causes of death, efforts are being made to aggressively identify the modifiable risk factors for CVD, so as to decrease the incidence of MS. Various studies have shown that smoking is a strong risk factor for Atherosclerosis and CVD. Moreover there is also some evidence that smokers are at greater risk than Non-Smokers for developing insulin resistance and hyper-insulinemea. Based on these findings smoking may be considered an important modifiable risk factor for metabolic syndrome and cardiovascular disease. However, studies looking at this relationship have been scarce.

Our study investigates the association between smoking and metabolic syndrome. The odds of tobacco smoking was compared between 150 patients with metabolic syndrome and 150 patients without metabolic syndrome. We have used the ATP III Guidelines which defines metabolic syndrome as any three of the following five criteria: waist circumference >40 inch for males and >35 inch for females, TGL >150 or Drug Rx, HDL <40 (M) or Drug Rx & <50 (F), BP > 130/80 or Drug Rx and FBG > 110 or Drug Rx. Patients who had not smoked for more than 3 months were excluded from the smoker group.

There was a significant association between smoking and metabolic syndrome (p value=0.02). The odds of smoking in patients with metabolic syndrome were 1.92. Furthermore there was an association between race and metabolic syndrome (p value=0.015). Contrary to previous studies, the prevalence of metabolic syndrome in African American patients was higher than Caucasians. The odds of metabolic syndrome in Caucasians was 0.54 times that of African Americans. Considering that smoking and obesity are the two leading causes of preventable death in the United States, the findings of an association between smoking and metabolic syndrome may have profound implication in reducing the incidence of cardiovascular disease and type 2 diabetes mellitus.

 

Nothing to Disclose: SK, BT, SKN

22495 12.0000 LBT-108 A Smoking and Metabolic Syndrome: A Case-Control Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Vincent Tok Fai Yeung*1, Jo Jo Y M Kwan2, Grace S P Yeung3 and Tak Cheung Wong3
1Our Lady of Maryknoll Hospital, Kowloon, Hong Kong, 2Our Lady of Maryknoll Hospital, Hong Kong, China, 3Our Lady of Maryknoll Hospital, Hong Kong

 

Background:

Modernization and improvement in living standard in Hong Kong has led to rising prevalence of non-communicable diseases that are closely related to lifestyle changes and increased cardiovascular (CV) risk, such as obesity (especially central obesity), hypertension (HT), and diabetes (DM). It is important to raise public awareness about the importance of healthy lifestyle, optimal body weight and waist circumference for prevention, and for early detection and treatment of CV risk factors and related diseases.  To this end, our Hospital and the local health promotion Board (Wong Tai Sin District Healthy & Safe City) jointly organized a “CV Risk Awareness Carnival for the local community in Oct 2014.

Methodology:

The Carnival consisted of a 12-hour program with physical checkup, educational health talks by health professionals, and Tai Chi exercise, etc.  We also set a target of performing the most waist circumference measurements and most vascular health screening within 12 hours in Hong Kong.

The participants attended voluntarily and had their demographics, including history of HT and/or DM recorded, and they had their body height, weight, blood pressure (BP), and waist circumference (WC) measured. Five Omron VP-1000 Plus Non-Invasive Vascular Screening Devices were employed to assess arteriosclerosis (arterial stiffness) through pulse wave velocity (PWV) determination.

Results:

There were a total of 509 participants (age 19-87), with 376 females (mean age: 57.3) and 133 males (mean age: 58.1). No significant difference exists between the ages.  However, compared to the women, men had significantly higher systolic BP (131 vs 127 mmHg), diastolic BP (79 vs 74 mmHg), and BMI (25.5 vs 23.8 Kg/m2).  In accordance to the ethnic specific values of WC for Chinese (male≥90 cm, female≥80 cm), 59.9% of men and 54.8% of women had central obesity. Also, 18% and 9.8% of males had history of HT and DM, respectively, whereas females had correspondingly lower figures of 15.3% and 6.7%.  Further, based on the IDF consensus worldwide definition, 6.8% of the men and 4.3% of the women had metabolic syndrome.   Subjects with history of HT had significantly greater arterial stiffness (estimated vascular age = 69.8 ± 10.6) than those without hypertension (60.6 ± 13.8), with age, male gender, HT, and WC being independent predictors of PWV.

Conclusions:

The Carnival revealed a high prevalence of cardiometabolic risk factors especially central obesity in our community, in particular in men, despite an underestimation of metabolic syndrome due to inadequate biochemical parameters.  On the other hand, males accounted for only 1/4 of the participants, in keeping with the notion that Chinese men have a misperception of their health status and are unaware of their high CV risk.  More health promotion activities, especially targeting men, are needed to enhance the community awareness of cardiometabolic risk in our population.

 

Nothing to Disclose: VTFY, JJYMK, GSPY, TCW

22679 13.0000 LBT-109 A An Assessment of Cardiometabolic Risk Amongst Community Chinese in Hong Kong 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Maha Abu Kishk*1 and Majdi Hamarshi2
1Solo Practitioner, Olathe, KS, 2Saint Lukes Health System

 

Introduction:

Pneumomediastinum is defined as the presence of air or other gas in the mediastinum, it occurs when air leaks through small alveolar ruptures and less commonly from the gastrointestinal tract. It can be spontaneous or related to processes that raise intrathoracic pressure. Common processes are mechanical ventilation or forceful vomiting as in this patient with diabetic ketoacidosis leading to alveolar rupture rather than esophageal tear.

Case report:

This is a 20 year old male who is not known to have diabetes before, presented to the emergency room with two days history of severe nausea and vomiting. He also reported polyuria and polydipsia for the past three weeks. Patient denied chest pain, dysphagia or odynophagia. Physical exam showed a well nourished male with moderate dehydration, he was hemodynamically stable with no signs of distress. Initial evaluation was consistent with Diabetic KetoAcidosis DKA. Chest X ray was part of initial evaluation and showed signs of Pneumomediastinum. Given concerns about effort rupture of the esophagus “Boerhaave's syndrome” a Computed tomography CT of the chest with intravenous and oral contrast was done, there was no evidence for extraluminal contrast or fluid to suggest perforated esophagus. Alveolar rupture was assumed as the etiology of the pneumomediastinum given the presence of pulmonary interstitial air. A decision was made to hold on doing Esophagram or Upper Endoscopy and to watch the patient closely in the ICU for 24 hours instead. Patient was then discharged out of the ICU the second day and out of the hospital the day after.

Discussion:

Spontaneous Pneumomediastinum has been reported in patient with DKA secondary to Boerhaave's syndrome and less likely secondary to alveolar rupture. The course of the later tends to be benign and observation management is often adequate. Either CT of the chest with oral contrast or Esophagram can be used to rule out esophageal rupture which can be a life threatening diagnosis. We recommend Chest X ray to be part of the work up in DKA patients to rule out infections precipitating DKA or less likely a potentially hidden complication from forceful vomiting or retching

 

Nothing to Disclose: MA, MH

22370 14.0000 LBT-110 A Spontaneous Pneumomediastinum in a Patient with Diabetic Ketoacidosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Elizabeth Hsu* and Dale J Hamilton
Houston Methodist Hospital, Houston, TX

 

It is published that more than a third of adults over the age of 20 in the United States are obese, defined as BMI >= 30kg/m2 (1).  The American Society for Metabolic and Bariatric Surgery reports that the number of bariatric surgeries performed annually is rising. In 2013 an estimated 179,000 weight loss surgeries were performed. Between 2011-2013, 34.2-37.5% of all bariatric surgeries were gastric bypass with Roux en Y (2). Although gastric sleeve is gaining popularity, gastric bypass is still the main stay of surgical treatment for obesity.

Nesidioblastosis or noninsulinoma pancreatogenous hypoglycemic syndrome (NIPHS) was first reported as a potential complication of gastric bypass in 2005 (3). With rising incidence of gastric bypass surgery an increasing number of case reports are being published. There is no consensus for diagnostic criteria or treatment. Here we described 9 patients at our medical center with a diagnosis of NIPHS after gastric bypass surgery.

In our cohort, 8 out of 9 patients were female and two patients had diabetes prior to bypass surgery with resolution after surgery. Time from surgery to the onset of hypoglycemia ranged from 6 to 108 months (mean 30 months). All had laboratory documented hypoglycemia with glucose less than 55mg/dL and symptoms that met Whipple’s triad. Insulin resistance was assessed by HOMR-IR in all patients when initially evaluated for hypoglycemia. None had HOMR-IR values >2 to suggest insulin resistance.

All underwent overnight fast and observed mixed meal challenge or oral glucose tolerance tests to establish hyperinsulinemic response followed by symptomatic hypoglycemia. Abdominal contrast imaging with either MRI or spiral CT with pancreatic protocol was done to assess for pancreatic mass. 7 out of the 9 patients underwent intra-arterial calcium stimulation test to identify the distribution of islet hyper function. Same protocol was performed for each by interventional radiology. A weight adjusted calcium gluconate dose (0.025 mEq Ca/kg) diluted with normal saline to 7 ml was injected into each of the three main arteries supplying the pancreas. Insulin concentrations were measured from right hepatic vein, before, 30, 60 and 120 seconds after the injection. A doubling or more of insulin level is consistent with hyperinsulinemia. A positive response seen in a single arterial distribution would suggest insulinoma[4].  Three patients underwent gradient guided partial pancreatectomy. The pathological interpretation revealed NIPHS rather than tumor.

NIPHS remains a rare disease, but it is increasingly recognized as a complication after gastric bypass. Individuals may present with a diagnosis of dumping syndrome or insulinoma. Definitive diagnosis requires synthesis and interpretation of baseline, dynamic and interventional data. To distinguish NIPHS from insulinoma requires an integration of clinical, laboratory and imaging data.

 

Nothing to Disclose: EH, DJH

22768 15.0000 LBT-111 A Limited Role of Selective Intra-Arterial Calcium Stimulation Testing in Distinguishing Insulinoma from Noninsulinoma Pancreatogenous Hypoglycemic Syndrome (NIPHS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Shahrad Taheri*1, Teresa Arora1, Ashley R Cooper2, Robert Charles Andrews3 and Mimi Z Chen4
1Weill Cornell Medical College in Qatar, Doha, Qatar, 2University of Bristol, Bristol, United Kingdom, 3University of Bristol, Taunton, United Kingdom, 4University of Bristol, Oxford, United Kingdom

 

Objective

To cross-sectionally and prospectively assess potential associations between baseline weekday sleep debt and obesity, as determined by body mass index (BMI), as well as HOMA-insulin resistance in a large sample of newly diagnosed type 2 diabetes mellitus patients.

Methods

Participants (n=522), recruited into the Early Activity in Diabetes trial, were randomized into one of three groups (usual care, physical activity intervention or diet and physical activity intervention). Information was obtained at baseline and then at six and 12 months post-intervention. Seven-day sleep diaries were completed and weekday sleep debt calculated. Objective height (cm) was obtained at baseline and weight (kg) ascertained at all visits to determine obesity status (BMI ≥30kg/m2), and fasting blood samples were drawn to determine insulin resistance using a standardized technique.

Results

At baseline, compared to those without weekday sleep debt, those with positive weekday sleep debt were 72% more likely to be obese (OR=1.72 [95% CI: 1.03-2.88]). At six months post-intervention, positive weekday sleep debt was significantly associated with obesity and insulin resistance after adjustment, where OR=1.80 (95% CI: 1.05-3.08) and OR=2.04 (95% CI: 1.01-4.11), respectively. A further increase was observed, 12 months post-intervention, for positive weekday sleep debt with obesity and insulin resistance OR=1.83 (95% CI: 1.01-3.29) and OR=2.96 (95% CI: 1.31-6.67), respectively. For every 30 minutes of positive weekday sleep debt at baseline, the risk of obesity and insulin resistance at 12 months post-intervention was significantly increased by 17% and 39%, respectively.

Conclusion

The long-term effects of weekday sleep debt may cause metabolic disruption, which may exacerbate the progression of type 2 diabetes mellitus. Future interventions designed to slow progression, or reverse metabolic disease, should consider all factors that impinge on metabolic function. Consistent optimum sleep hygiene/education may be a key component for driving successful future trials in metabolic disease control.

 

Nothing to Disclose: ST, TA, ARC, RCA, MZC

22422 16.0000 LBT-112 A The Impact of Sleep Debt on Adiposity and Insulin Sensitivity in Patients with Early Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Victoria Loseva*, Abosede Olatoyosi Adeoshun and Jon H Levine
Meharry Medical College, Nashville, TN

 

Introduction:  Hyperglycemia is a common side effect in patients on high dose steroid treatment, but diabetic ketoacidosis is observed rarely and is usually so mild that most patients do not require insulin therapy. We report a case of severe diabetic ketoacidosis requiring insulin therapy in a patient treated with high dose glucocorticoid therapy for Graves’ orbitopathy.

Clinical case:  A 54 year old woman presented with hyperthyroidism and exophthalmos. She was diagnosed with Graves’ disease and orbitopathy and treated with methimazole, metoprolol and Artificial Tears. Over the next few months her hyperthyroidism improved greatly; however thyroid orbitopathy got worse. She complained of dryness, grittiness and double vision on upward gaze of both eyes. Physical examination showed severe periorbital edema, worsening bilateral proptosis and lid retraction. She was referred to an ophthalmologist who started oral prednisone at dose of 80 mg/day. On day 5 of prednisone therapy she presented to an emergency department with two day history of nausea, vomiting and diffuse abdominal pain. There was no family history of diabetes mellitus. Blood glucose and urine examinations had been normal 4 weeks prior. On physical examination she was mildly tachycardic and markedly dehydrated. Laboratory results revealed serum glucose of glucose of 400 mg/dl, BUN of 15 mg/dl, creatinine of 1.28 mg/dl, sodium of 136 mEq/l, chloride of 110 mEq/l, CO2 of 12 mmol/l, and potassium of 5.2 mEq/l; room air arterial blood gas showed a pH of 7.10, pCO2 of 18 mmHg, and bicarbonate of 6.0 mEq/l.  Urinalysis revealed 4+ glucose and 3+ ketones. Hemoglobin A1C was found to be 5.6%. Urine and blood specimens were sterile. She was diagnosed with DKA and was managed with fluids, insulin and potassium supplementation and showed prompt recovery. She was maintained on insulin and followed by Endocrine and Ophthalmology. Prednisone dose was tapered and finally stopped following surgical decompression of the orbits ten days after the episode of DKA. The patient became normoglycemic and insulin was discontinued. Her hemoglobin A1C has remained normal during 2 years of follow up.

Conclusion: This case underscores the importance of recognition of DKA as a complication of steroid therapy in patients who are treated with high dose glucocorticoid therapy. Patients with autoimmune endocrine disease who are treated with high dose steroid therapy might be at higher risk for developing hyperglycemia and these patients should be carefully monitored for development of diabetes and DKA. It is possible that there might be incipient antibodies directed toward the islet cell which might be part of polyglandular failure syndrome which under usual circumstances cause no clinical problem, but when exacerbated by the insulin resistance produced by high dose steroids cause a temporary inhibition of insulin production, leading to diabetes and possible DKA.

 

Nothing to Disclose: VL, AOA, JHL

22638 17.0000 LBT-113 A Glucocorticoid-induced Diabetic Ketoacidosis in a Non-Diabetic Patient Treated for Graves' Orbitopathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Sira Korpaisarn* and Sneha Kirali
MetroWest Medical Center, FRAMINGHAM, MA

 

INTRODUCTION: Liraglutide is a long acting GLP-1 agonist. Though not first choice for treatment of type –II diabetes it is slowly growing in popularity due to its low risk for hypoglycemia, improved glycemic control and significant weight loss in patients using this drug. 

CASE PRESENTATION: 65-year-old Caucasian female with history of type-II diabetes on liraglutide for past 1 yr, no known alcohol use and prior cholecystectomy presented with intermittent epigastric pain, nausea, vomiting for 1 month with tenderness in the epigastric region. On Initial investigations CT Scan of the abdomen showed acute pancreatitis with areas of pancreatic necrosis, serum lipase (3000). Other work up includes serum CA 19.9 (45), serum triglycerides (188), mild anemia with normal iron studies, IgG, IgA, IgM are normal. We excluded most common etiologies for pancreatitis after a thorough workup. And we therefore concluded that liraglutide must have been attributing to acute necrotizing pancreatitis in this patient. Patient was managed conservatively with standard therapy for acute pancreatitis. She gradually improved over a course of several days and then discharged home with Insulin regimen and liraglutide was stopped indefinitely. 

DISCUSSION: Drug induced pancreatitis is a very rare cause of pancreatitis with a incidence of 1.4%-5%. Cases of acute and chronic pancreatitis have been reported although conclusive evidence linking pancreatitis to liraglutide therapy has not been established yet. Patients who are on liraglutide must be educated about the side effects and to call the physician at first signs of abdominal discomfort. And also clinicians must use caution in prescribing liraglutide particularly in those with one or more additional risk factors for pancreatitis. We also encourage reporting any life threatening drug reaction to FDA since drug induced pancreatitis is underreported due to low index of suspicion.

 

Nothing to Disclose: SK, SK

22649 18.0000 LBT-114 A Liraglutide Induced Life-Threatening Pancreatitis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Thursday, March 5th 3:00:00 PM LBT 097-116 6302 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism I Poster


Maria Annerbo*1, Lars Lind2, Peyman Bjorklund3 and Per Hellman3
1Center for Clinical Research Dalarna, Sweden, 2Department of Medical Sciences, Uppsala University, Uppsala, Sweden, 3Uppsala University, Sweden

 

Background

Calcium levels in serum is thoroughly regulated. The calcium-sensing receptor (CASR) has previously been demonstrated to be crucial in establishing the calcium level, by its associations between mutations and familial hypocalciuric hypercalcemia (FHH) and idiopathic hypoparathyroidism. Polymorphisms in the CASR gene have also been associated with serum calcium levels, also in large meta-analyses. We investigated a well-characterized Swedish cohort (PIVUS) for polymorphisms and calcium levels.

Material and Methods

We analyzed blood samples from 1016 healthy 70-year old individuals (501 women) of the PIVUS (Prospective Investigation of the Vasculature in Uppsala Seniors) cohort. Single Nucleotide Polymorphism (SNP) array was performed at the SNP&SEQ Technology Platform in Uppsala Sweden.

The SNPs rs1801725, rs1042636, rs1801726 corresponding to A986S, R990G and Q1011E, serum calcium and parathyroid hormone levels were analyzed. Students t-test, χ2 and ANOVA were performed for statistical analysis.

Results

Minor allele frequency (MAF) of these SNPs in our cohort were comparable to those reported by dbSNP. Carriers of the T allele in rs1801725 had significantly higher serum calcium levels (2.38 vs 2.36 mmol/l p=0.016). Of 27 theoretically possible haplotypes only nine were present. Carriers of T/G A/A G/C, present in 2% of the cohort, had significantly higher serum calcium, compared to the most common haplotype G/G A/A C/C present in 52.3% of the cohort (2.37 vs 2.36 mmol/l p<0.001).

Discussion

Small but still significant differences are demonstrated in the PIVUS cohort, supporting that CASR is involved in establishing the set-point of calcium regulation. Small changes in the amino acid conformation caused by polymorphisms cause changes in the sensing function of the receptor.

 

Nothing to Disclose: MA, LL, PB, PH

22816 1.0000 LBT-051 A Association Between Calcium Sensing Receptor Polymorphisms and Serum Calcium in a Swedish Well-Characterized Cohort 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Thursday, March 5th 3:00:00 PM LBT 051-055 6305 1:00:00 PM Late-breaking Membrane and Intracellular Signaling Poster


Alison M. Nagle*1, Cemal Erdem1, YuFen Wang2, Sergio Iadevaia3, Beate C. Litzenburger2, Angelo Casa2, Yiling Lu3, Gordon B. Mills4, Prahlad T. Ram3, Tim Lezon1, D. Lans Taylor1 and Adrian V. Lee1
1University of Pittsburgh, Pittsburgh, PA, 2Baylor College of Medicine, Houston, TX, 3UT MD Anderson Cancer Center, Houston, TX, 4The University of Texas MD Anderson Cancer Center, Houston, TX

 

Evidence indicates a role for insulin-like growth factor I (IGF-I) and insulin signaling in breast cancer initiation and progression.  IGF-I receptor (IGF-IR) and insulin receptor (InsR) overexpression has been noted in many breast tumors, and it is thought that high levels of circulating IGF-I in the plasma increases breast cancer risk. Signaling through IGF-IR and InsR drives tumor growth and proliferation mainly through the induction of the PI3K/Akt and MAPK pathways.  To better understand signaling downstream of IGF-IR and InsR in breast cancer, we performed a proteomic screen in a panel of twenty-one breast cancer cell lines.  Breast cancer cell lines of various histological subtypes were stimulated with 10nM of IGF-I or 10nM insulin over a time course (0, 5min, 10min, 30min, 6hr, 24hr, 48hr).  The expression levels of 128 protein markers were analyzed by reverse phase proteomics array (RPPA).  The protein markers analyzed were selected for their implication in growth factor signaling, cell cycle dynamics, or DNA repair pathways.  With the use of computational modeling we aim to understand the effect of individual protein expression profiles on the signaling network as a whole as a result of IGF-I/insulin stimulation.  Initial results of the analysis indicated that both IGF-I and insulin activated the IGF-IR/InsR and induced similar responses within the same cell line.  However, differential activation of Akt and MAPK occurred among the panel of cell lines in response to stimulation.  Interestingly, a cluster of cell lines exhibited a striking repression of p-MAPK expression upon IGF-I and insulin stimulation, a finding that opposes the consensus that IGF-I and insulin stimulate the MAPK pathway.  This result was mostly observed in Her2-amplified cell lines (AU565, BT20, BT474, MDA-MB-361, SKBR3, and UACC812) and one triple negative breast cancer cell line known to overexpress EGFR, MDA-MB-468.  AU565 cells also showed a repression in p-Akt signaling in response to IGF-I and insulin stimulation.  These findings have been validated independently by immunoblotting and studies to elucidate a mechanism for the IGF-I/insulin-induced repression of MAPK induction in ErbB2 overexpressing cell lines are underway.  Crosstalk between the IGF-I and ErbB2 signaling pathways has been shown previously, and competition for recruitment of modulators of the shared downstream signaling pathways may help to explain the finding.

 

Nothing to Disclose: AMN, CE, YW, SI, BCL, AC, YL, GBM, PTR, TL, DLT, AVL

22384 2.0000 LBT-052 A IGF-I and Insulin Repress MAPK Signaling in Her2-Amplified Breast Cancer Cell Lines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Thursday, March 5th 3:00:00 PM LBT 051-055 6305 1:00:00 PM Late-breaking Membrane and Intracellular Signaling Poster


Le Min*1, Huan Er Li2, Rona S. Carroll3 and Ursula B. Kaiser4
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 2Division of Endocrine, Brigham and Women's Hospital, Boston, 3Brigham and Women's Hospital/Harvard Med School, Boston, MA, 4Brigham and Women's Hospital/Harvard Medical School, Boston, MA

 

RF9 is known as an antagonist of RF amide-related peptide-3 (RFRP3). RFRP3, a counterpart of gonadotropin-inhibiting hormone (GnIH) in birds, has been implicated in the negative regulation of gonadotropin secretion in rodents, sheep, and cattle. Several recent studies have shown potent stimulation of gonadotropin secretion by RF9 in mammals. It has been proposed that the stimulatory effects of RF9 on gonadotropin secretion are through its antagonistic effects on RFRP3 receptors. However, a more recent mouse study has suggested that RF9 excitation of GnRH neurons is dependent upon Kiss1r. The underlying mechanism, however, remains to be elucidated.  To explore the mechanisms of RF9’s actions on KISS1R, we tested the effect of RF9 on KISS1R activation and intracellular signaling and on the binding affinity of RF9 for KISS1R using CHO-KISS1R cells, a cell line stably expressing of KISS1R. We first measured the intracellular calcium ([Ca2+]i) response to kisspeptin10 (KP10) and RF9. Both KP10 and RF9 stimulated an increase in [Ca2+]i in a dose dependent manner, with EC50 values of 9 x 10-9 M and 3 x 10-6 M, respectively. Co-administration of 10 nM KP10 with escalating doses of RF9 did not alter the KP10-stimulated [Ca2+]i response. Both KP10 and RF9 displaced 125I-KP10 binding to CHO-KISS1R cells in a dose dependent manner, with Kd values of 1.0 x 10-8 M and 1.6 x 10-5 M, respectively.  We next examined the effect of RF9 on inositol phosphate (IP) accumulation in CHO-KISS1R cells. Consistent with their effects on the [Ca2+]i response, both KP10 and RF9 stimulated IP accumulation in a dose-dependent manner, with EC50 values of 1 x 10-9 M and 2 x 10-7 M, respectively. RFRP3 did not stimulate IP accumulation and did not alter KP10- or RF9-stimulated IP accumulation. In conclusion, our study demonstrates that RF9 is a KISS1R agonist. The stimulatory effect observed on gonadotropin secretion in vivo may be mediated primarily through activating effects on KISS1R signaling, rather than through an inhibitory effect on the RFRP3 receptor. Our findings suggest a potential therapeutic role of RF9, a small molecule agonist of KISS1R, in the treatment of hypogonadotropic hypogonadism.

 

Nothing to Disclose: LM, HEL, RSC, UBK

22597 3.0000 LBT-053 A RF9 Activates KISS1R Signaling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Thursday, March 5th 3:00:00 PM LBT 051-055 6305 1:00:00 PM Late-breaking Membrane and Intracellular Signaling Poster


Seunghun Paul Lee*, Jianshen Qi, Shuyuan Zhao, Ivona Bakaj, Joseph W Gunnet, Hui Huang, Sanath Meegalla, Mark Player and Alessandro Pocai
Janssen Research and Development, Spring House, PA

 

GPR40 is a fatty acid receptor that mediates fatty acid-induced glucose-stimulated insulin secretion (GSIS) from pancreatic β-cells and incretin release from enteroendocrine cells. Numerous GPR40 ligands have been investigated for their anti-diabetic actions. We have previously demonstrated that there are at least 2 distinct ligand binding sites which show differing ligand specificities and degrees of intrinsic activity. Using two potent and selective GPR40 agonists JNJ-GPR40-A and JNJ-GPR40-B, we demonstrated that the endogenous ligand, α-linoleic acid, fully competed the binding of 3H-JNJ-GPR40-A with a  Ki value of 3.5 µM, but did not inhibit binding of 3H-JNJ-GPR40-B.  Furthermore, the two compounds did not compete with each other. In addition, JNJ-GPR40-B and α-linoleic acid were determined to be full agonists whereas JNJ-GPR40-A was a partial agonist as assessed by IPone. Recent evidence suggests that GPR40 is not only a Gq-coupled receptor, but also has the propensity to couple to Gs depending on the ligand. Here, we examined the ability of a full versus partial agonist to induce cAMP production in a low–expressing CH0-GPR40 human cell line and the rat insulinoma line INS 832/13. These compounds were also tested to assess their efficacy in inducing GSIS in INS 832/13 and human islets.

The full agonist was determined to promote both IPone and cAMP production in the CHO-GPR40 cell line and the INS 832/13 line whereas the partial agonist only induced IPone accumulation. Interestingly, the partial agonist was found to have only small enhancements in GSIS whereas the full agonist had robust GSIS in INS 832/13 and human islets. These data indicate that partial and full GPR40 agonists bind to unique sites on the receptor which lead to differences in their downstream receptor signaling and ultimately differences in glucose-stimulated insulin secretion. Differences in binding and signaling at the GPR40 receptor may lead to diverse therapeutic opportunities for the treatment of diabetes.

 

Disclosure: SPL: Employee, Jansen Pharmaceuticals. JQ: Employee, Jansen Pharmaceuticals. SZ: Employee, Jansen Pharmaceuticals. IB: Employee, Jansen Pharmaceuticals. JWG: Employee, Jansen Pharmaceuticals. HH: Employee, Jansen Pharmaceuticals. SM: Employee, Jansen Pharmaceuticals. MP: Employee, Jansen Pharmaceuticals. AP: Employee, Jansen Pharmaceuticals.

22922 4.0000 LBT-054 A Receptor Binding, Receptor Signaling and Glucose Stimulated Insulin Secretion By GPR40 Agonists 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Thursday, March 5th 3:00:00 PM LBT 051-055 6305 1:00:00 PM Late-breaking Membrane and Intracellular Signaling Poster


Subathra Poopalasundaram*1, Anthony Graham2 and Pierre-Marc Gilles Bouloux1
1UCL Medical School, London, United Kingdom, 2Kings College, London, United Kingdom

 

The hypothalamic gonadotrophin releasing hormone (GnRH) neurons are a small group of cells that regulate the reproductive axis.  These neurons are specified within the olfactory placode, delaminate from this structure and then migrate to enter the forebrain before populating the hypothalamus. 

Using the chick, we have studied the specification and development of GnRH neurons.  We have employed microarray technology to analyse the transcriptome of the olfactory placode at a number of key developmental time points which are important for GnRH ontogeny. This has resulted in the identification of a large number of genes which includes genes known to be important for GnRH neuronal development as well as many novel genes.  The novel candidate molecules are currently being characterised for their involvement in GnRH neuronal development.

One of the genes upregulated at the time when GnRH neurons are migrating from the olfactory placode to the forebrain is serotonin (5-HT) receptor 1A, HTR1A.  We have mapped the expression of HTR1A in chick embryos during GnRH neuronal ontogeny and used pharmacological agents to study the functional requirement for HTR1A. 

We find that HTR1A is expressed in the olfactory placodal region that gives rise to GnRH neurons.  When the receptor was inactivated using a selective antagonist to HTR1A, it delayed the migration of GnRH neurons into the forebrain, with the GnRH neurons accumulating just outside the forebrain.  These findings implicate HTR1A as being important for GnRH neuronal migration from the olfactory placode to the forebrain and the downstream molecules involved in this process are currently being characterised. 

Understanding the functional significance of the novel genes isolated will add to the repertoire of genes involved in GnRH neuron biology and help to identify new candidate molecules to screen patients who do not show any mutations in any of the thus identified HH/KS genes.

 

Nothing to Disclose: SP, AG, PMGB

PP16-2 19887 2.0000 FRI-418 A Specification and Migration of Gonadotrophin Releasing Hormone (GnRH) Neurons 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 11:30:00 AM PP16 5901 11:15:00 AM Kisspeptin-GnRH-Gonadotrope Axis Poster Preview


Sharon Lauretta Dubois*1, Andrew Wolfe2, Sally Radovick3, Ulrich Boehm4 and Jon E Levine1
1University of Wisconsin-Madison, Madison, WI, 2Johns Hopkins University School of Medicine, Baltimore, MD, 3Johns Hopkins School of Medicine, Baltimore, MD, 4University of Saarland School of Medicine, Homburg, Germany

 

Early activation of the kisspeptin receptors induces premature increases in GnRH and gonadotropin secretions, resulting in the early onset of puberty. In prepubertal female rodents, LH secretion, as well as kisspeptin (Kiss1) expression in the arcuate nucleus (ARC) of the hypothalamus, are inhibited by 17β-estradiol (E2). Therefore, it has been proposed that E2 limits the release of GnRH and the gonadotropins in prepubertal female rodents by suppressing kisspeptin expression and release from ARC neurons. Similar to its actions in adult rodents, E2 is thought to exert these effects by acting through estrogen receptor α (ERα). In accordance with this model, we recently reported that prepubertal female mice with ERα ablated in kisspeptin-expressing cells (KERαKO mice) exhibit significantly higher levels of circulating LH compared to their wild-type (WT) littermates, and an early onset of puberty. Here, we investigated the ERα-mediated negative feedback actions of E2 on GnRH and gonadotropin secretion in young WT and KERαKO female mice. Prepubertal (postnatal day 14; P14) and peri-pubertal (P34) female mice were sham-operated (sham), or ovariectomized (OVX) and treated with either vehicle- or E2-containing capsules. Two days after surgery, plasma was collected for LH and FSH measurements. As expected, WT mice of both ages exhibited a significant increase in circulating LH and FSH levels after OVX. At both ages, E2 suppressed LH to sham levels in WT mice. In addition, E2 fully suppressed FSH to sham levels at P14, but only partially suppressed FSH to sham levels at P34. In contrast, P14 sham KERαKO mice had high LH and FSH levels that were not further elevated by OVX or reduced by E2 treatment. In P34 KERαKO mice, LH levels were again unaffected by OVX and E2 treatment, while FSH levels were significantly increased after OVX and remained elevated after E2 treatment. Kiss1 mRNA levels in the medial basal hypothalamus (MBH), which includes the ARC, of P14 mice were measured using qPCR. Similar to LH and FSH results, Kiss1 mRNA expression was increased after OVX and fully suppressed with E2 treatment in WT mice, but remained unaffected by any treatment in KERαKO mice. These results show that E2-mediated suppression of GnRH and the gonadotropins, as well as Kiss1 mRNA expression in the MBH, are abrogated in prepubertal KERαKO female mice. Therefore, E2 acts through ERα in kisspeptin neurons to suppress the release of GnRH and the gonadotropins in prepubertal female mice. These findings contrast with our recent data from experiments in adult animals that showed E2-mediated suppression of LH secretion remains intact in adult KERαKO mice. Our observations suggest that E2-mediated suppression of GnRH secretion is exerted through different neural pathways in prepubertal versus adult female mice. The kisspeptin-independent negative feedback pathways that are engaged post-pubertally remain to be fully characterized.

 

Nothing to Disclose: SLD, AW, SR, UB, JEL

PP16-3 20009 3.0000 FRI-422 A Estradiol-Mediated Suppression of LH and FSH Secretion in Prepubertal Female Mice Requires Estrogen Receptor α Activation in Kisspeptin Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 11:30:00 AM PP16 5901 11:15:00 AM Kisspeptin-GnRH-Gonadotrope Axis Poster Preview


Elena Luo*1, Sharon Chaing2, Nagambika Munaganuru1, Alexander S Kauffman2 and Kellie M Breen1
1University of California San Diego, La Jolla, CA, 2University of California, San Diego, La Jolla, CA

 

Stress inhibits reproduction in multiple ways, including via glucocorticoids (GCs) released from the adrenal cortex. Although GCs disrupt neuroendocrine control of reproduction, where or how they act is not fully clear. Previous studies show that either restraint stress (1) or the synthetic GC dexamethasone (2) blocks the LH surge in female rats. Suppression of the LH surge by stress is associated with reduced expression of hypothalamic GnRH and pituitary GnRH receptor (Gnrhr), implying inhibitory actions at both these neuroendocrine sites. Here, we conducted two experiments to test the hypothesis that constant elevation of the natural GC corticosterone (cort) disrupts estrous cyclicity via the estradiol (E2)-induced LH surge. First, intact adult female mice in diestrus were implanted with either a 50mg cort or vehicle s.c. implant and monitored for cyclicity by vaginal smear. These implants increased serum cort three-fold similar to levels observed in response to restraint stress in female mice. Vehicle controls continued to cycle normally, but cort-treated mice stopped cycling and remained in diestrus for >10 days. Next, we tested whether disruption of the LH surge was involved with acyclicity. Adult female mice were ovariectomized and implanted with 0.625µg E2 to induce an LH surge, along with either a cort or vehicle implant. Mice were sacrificed 48 hours later at 10AM (time of negative feedback), or 56 hours later at 6PM (time of lights-off and expected LH surge). Serum LH and cort were measured by RIA and ELISA, respectively. AM mice of both treatment groups had undetectable serum LH levels, confirming negative feedback. All vehicle-treated PM mice showed clear LH surges. In contrast, mice treated with cort had no detectable serum LH at 6PM, indicating that stress levels of cort completely blocked the E2-induced LH surge. We next looked for gene expression changes in critical neural activators of the LH surge. Kisspeptin directly activates GnRH, and AVPV kisspeptin neurons are normally robustly activated at the time of the LH surge, as measured by cfos induction. Here, cort significantly decreased Kiss1-cfos colocalization in the AVPV, as measured by double-label ISH. The total number of Kiss1 cells in the AVPV and the amount of Kiss1 mRNA per cell were also significantly decreased in the PM cort group vs. vehicle PM controls. These data suggest that elevated cort inhibits activation of the kisspeptin neuron population. In addition, Gnrhr expression was significantly decreased, by more than half, in the pituitaries of cort-treated PM mice compared to PM controls, as measured by qPCR. Our data suggest that cort blockage of the LH surge in mice is at least in part mediated either directly by inhibition of Kiss1 neuron activation, or an upstream regulator. However, we cannot exclude the role of the pituitary as another possible site of cort inhibition of the LH surge.

 

Nothing to Disclose: EL, SC, NM, ASK, KMB

PP16-4 20214 4.0000 FRI-423 A Corticosterone Blocks Estrous Cyclicity and the LH Surge Via Decreased Kisspeptin Neuron Activation in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 11:30:00 AM PP16 5901 11:15:00 AM Kisspeptin-GnRH-Gonadotrope Axis Poster Preview


Mark Nixon*, Scott Douglas Mackenzie, Ash Taylor, Natalie Homer, Ruth Andrew and Brian R Walker
University of Edinburgh, Edinburgh, United Kingdom

 

The endogenous glucocorticoids cortisol and corticosterone circulate in human plasma at a ratio of approximately 10:1. In the CNS, where the ABC transporter ABCB1 exports cortisol but not corticosterone, this ratio is reduced to 3:1. Conversely, ABCC1 is an exclusive exporter of corticosterone but not cortisol in vitro. We have shown ABCC1 but not ABCB1 is expressed in human adipose tissue and in differentiated human SGBS adipocytes. Inhibition of ABCC1 in SGBS cells increases intracellular accumulation of corticosterone but not cortisol. Here we test in vivo whether ABCC1 allows preferential access for cortisol rather than corticosterone to adipose tissue.

Male mice lacking Abcc1 (Abcc1-/-; KO) and controls (FVB; WT) were adrenalectomized and infused with corticosterone or cortisol (250µg/day via subcutaneous osmotic minipump; N=8/group) for 7 days. Plasma and adipose tissue steroids were quantified by LC-MS/MS. Total corticosterone:cortisol ratio (0.9:1 vs 1.1:1, KO vs WT) was unchanged in plasma, but in Abcc1-/- mice corticosterone:cortisol ratio was higher in subcutaneous (3.7:1 vs 2.1:1, KO vs WT; p<0.05), but not mesenteric or epididymal adipose tissue. Brain corticosterone:cortisol ratios were unaffected by Abcc1 deletion.

10 patients with autoimmune Addison’s disease (3 male; age 53 ± 4 y) omitted steroid replacement therapy for 16 hours and were infused intravenously (on separate days in randomized crossover design) either corticosterone or cortisol for 4.5 hours in a ramped steady state infusion (33 – 423 nM) followed by subcutaneous adipose biopsy. Steady state plasma cortisol and corticosterone concentrations achieved were not significantly different, but adipose transcript levels of the glucocorticoid-responsive PER1 and LPL genes were higher following cortisol than corticosterone (2.2-fold and 1.3-fold respectively; p<0.05).

Thus, ABCC1 limits corticosterone accumulation in murine subcutaneous adipose tissue. This mechanism may explain greater sensitivity of adipose tissue to cortisol than corticosterone in humans in vivo. These data support a model of differential tissue-specific responsiveness to corticosterone (in CNS) and cortisol (in adipose).

 

Nothing to Disclose: MN, SDM, AT, NH, RA, BRW

PP17-1 19739 1.0000 FRI-354 A ABCC1 Export of Corticosterone from Adipose Tissue Renders Adipose More Sensitive to Cortisol in Vivo 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 11:30:00 AM PP17 5907 11:15:00 AM Novel Aspects of Adrenal Tumors and the HPA axis Poster Preview


Charlotte Steffensen*1, Olaf M Dekkers2, Jens Sandahl Christiansen3, Jørgen Rungby4, Johanne Lyhne5 and Jens Otto Jorgensen6
1Aarhus University Hospital, Aarhus, Denmark, 2Leiden University Medical Center, Netherlands, 3Aarhus University Hospital, Denmark, 4Rigshospitalet, Copenhagen, Denmark, 5Aarhus University Hospital, 6Aarhus Univ Hospital, Arhus C, Denmark

 

Cross-sectional studies in selected populations indicate that a relatively high number of patients with type 2 diabetes (T2D) have undiagnosed and/or subclinical Cushing syndrome (CS). This may have therapeutic implications, but it remains dubious if screening for CS in T2D is recommendable. The aim of our study was to investigate the prevalence of CS in a large, unselected cohort of newly diagnosed T2D patients and to identify any phenotypical features of hypercortisolism in T2D patients. A total of 505 consecutive out–patients with T2D diagnosed after 1 January 2009 were screened for hypercortisolism by means of 23:00 salivary cortisol (SC) as well as a 1 mg overnight dexamethasone suppression test (OD) Patients who did not suppress ≤ 50 nmol/l 12 hours after 1 mg OD were further examined with 48 h low-dose dexamethasone suppression test (LDDST) and 24-h urinary free cortisol (UFC). Of the 505 patients, 85 (16.8%) patients had elevated cortisol after screening with 23:00 SC and 1 mg OD. 20 (4%) of these patients failed to suppress serum cortisol after 48 h LDDST and/or had elevated UFC. 42 patients had normal cortisol after initial screening. Comparing these 42 patients with the 20 patients with subsequent hypercortisolism, we found no significant difference in age, BMI, HbA1c or blood pressure. Of the 20 patients (4 %) with manifest hypercortisolism, subsequent imaging with either pituitary MR or abdominal CT according to normal/elevated (n=12) or suppressed (n=8) ACTH levels revealed one pituitary macroadenoma and 9 adrenal adenomas. In conclusion, hypercortisolism without other phenotypical features of CS remains a problem with prevalence in this study reaching 4% of T2D patients. This prevalence compares with data obtained in more selected T2D populations and merits continued concern as these patients are potentially curable of CS and T2D. Large, randomized trials are warranted to investigate the overall effect of surgical removal of cortisol producing adenomas in T2D patients.

 

Nothing to Disclose: CS, OMD, JSC, JR, JL, JOJ

PP17-2 19791 2.0000 FRI-355 A Hypercortisolism Is Prevalent in Newly Diagnosed Type 2 Diabetes: A Prospective Study of 505 Consecutive Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 11:30:00 AM PP17 5907 11:15:00 AM Novel Aspects of Adrenal Tumors and the HPA axis Poster Preview


Anna J Anderson*1, Ruth Andrew1, Natalie Z Homer1, Gregory Jones2, Kenneth Smith1, Dawn EW Livingstone1, Brian R Walker1 and Roland H Stimson1
1University of Edinburgh, Edinburgh, United Kingdom, 2NHS Greater Glasgow and Clyde

 

Reducing cortisol regeneration using 11βHSD1 inhibitors in patients with type 2 diabetes (T2DM) improves glycaemic control, lipid profile, body weight and blood pressure, but these effects are of smaller magnitude than anticipated from pre-clinical studies. We hypothesized that metformin, which was administered to most participants in trials of 11βHSD1 inhibitors, causes down-regulation, limiting their efficacy. We tested this in obese men with and without T2DM.

8 obese non diabetic men (OND) and 8 obese men with type 2 diabetes (ODM) (BMI 37.4 ± 2.6 v 34.7 ± 1.1 kg/m2, respectively, p=ns) were recruited to a double-blind randomized crossover study. Subjects received 28 days of placebo or metformin, and the ODM group also received gliclazide in a third phase to control for effects mediated by glycaemic control. On day 28, participants attended after overnight fast for infusion of 9,11,12,12-[2H]4-cortisol (D4-cortisol)(20%) and unlabelled cortisol (80%) at 1.74mg/hr for 4 hours. Irreversible removal of 2H from the 11C by 11βHSD2 converts D4-cortisol to D3-cortisone, which then forms 9,12,12-[2H]3-cortisol (D3-cortisol) when regenerated by 11βHSD1. In steady state (t+150-180 mins), dilution of D4-cortisol by D3-cortisol is a specific measure of cortisol regeneration by 11βHSD1. In the ODM group, to assess hepatic 11βHSD1 activity oral cortisone (5mg) was administered at t+180 mins and rate of appearance (Ra) of cortisol quantified by dilution of D4-cortisol. Data are mean ± SEM.

Metformin reduced fasting plasma glucose in the ODM (metformin 7.4 ± 0.6 v placebo 9.6 ± 1.0 mmol/L, p=0.01) but not OND group (5.3 ± 0.2 v 5.6 ± 0.6 mmol/L); in ODM, metformin and gliclazide lowered fasting glucose similarly. Ra D3-cortisol was increased in ODM vs OND (p<0.05). Metformin increased steady state Ra D3-cortisol in both OND (12.9 ± 1.2 v 11.4 ± 1.4 nmol/min, p=0.01) and ODM (metformin 15.8 ± 0.6 v placebo 14.2 ± 0.6 v gliclazide 14.2 ± 0.6 nmol/min (metformin v placebo/gliclazide both p<0.05). In the ODM group, metformin tended to increase Ra cortisol following cortisone (peak Ra cortisol metformin 136 ± 17 v placebo 108 ± 15 v gliclazide 100 ± 20 nmol/min (both p<0.1)). Cortisol and D4-cortisol clearance were similar in all phases.

Amongst obese men, whole body 11βHSD1 activity is increased in those with T2DM. Metformin further increases whole body, and most likely liver, cortisol regeneration by 11βHSD1 in obese men with and without T2DM. This effect is independent of improved glycaemic control, as gliclazide reduced glucose levels comparably to metformin without altering 11βHSD1 activity. We conclude that any interaction between metformin and selective 11βHSD1 inhibitors in T2DM is likely to potentiate, rather than attenuate, efficacy of both agents.

 

Nothing to Disclose: AJA, RA, NZH, GJ, KS, DEL, BRW, RHS

PP17-3 20594 3.0000 FRI-356 A Metformin Increases in Vivo 11ßHSD1 Activity in Obese Men with and without Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 11:30:00 AM PP17 5907 11:15:00 AM Novel Aspects of Adrenal Tumors and the HPA axis Poster Preview


Andrea M Isidori*1, Mary A. Venneri1, Chiara Graziadio1, Chiara Simeoli2, Valeria Hasenmajer1, Daniela Fiore1, Annamaria Colao2, Rosario Pivonello3 and Andrea Lenzi1
1Sapienza University of Rome, Rome, Italy, 2Università Federico II, Naples, Italy, 3Federico II University, Naples, Italy

 

CONTEXT: Adrenal insufficient (AI) patients treated with conventional glucocorticoid therapies (CGC) have increased morbidity and mortality rate, with infections, cardiovascular disorders and malignancies reported as major causes of death. CGC fail to recapitulate cortisol circadian rhythm. We hypothesized that a defect in the immune system due to inappropriate CGC exposure-time might be a contributing factor. We carried out a multicenter trial (NCT02277587) to test the effect of shifting from CGC to once-daily oral hydrocortisone dual-release tablet (DR-HC) mimicking a more physiological cortisol profile.

AIM: To study the immune cell profile of conventionally treated primary and secondary AI patients and the changes induced by shifting to once daily DR-HC.

PATIENTS: The trial enrolled 58 adults: 43 (mean age 46.1±13.7; F=20) with AI due to primary (n= 21) or secondary (n=22) causes, and 15 controls (age 39.9±11.6; F=7). Duration of disease was 63±76 months. At baseline, all AI patients were on cortisone acetate (65%, mean equivalent HC dose 28±9 mg) or HC (35%, mean dose 21±3 mg) and, after providing informed consent, were randomly assigned to continue their own CGC (n=16) or shift to an equivalent dose of DR-HC (n=27, pAI=13) in an open label 6-month trial. At 0, 3 and 6 months all subjects had clinical, biochemical, hematological and metabolic assessment plus comprehensive immune cell flow cytometry analyses.

RESULTS: All 58 patients completed the first 3-month assessment. Compared to healthy controls, AIs exhibited a baseline marked reduction of NKs (10.9±4.2 vs 5.5±5.7 % of CD16+CD56+, p<0.01), and a tendency toward increased classical monocytes (21.2±3.5 vs 28.9±17.0  % of CD14++CD16-, p=0.08). No differences in T lymphocytes and granulocytes were found. After 3 months, a normalization of cytotoxic NK CD16+CD56+cells was observed in DR-HC shifted (D=5.2±7.4, P<0.01), but not in CGC treated patients (D=0.8±5.9, P=NS) or healthy controls (D=1.0±3.4, P=NS). DR-HC shift also produced a significant change in classical monocytes (P<0.01). The NKs and monocytes variation produced by DR-HC switch were similar between subjects previously on cortisone acetate or conventional hydrocortisone. NK changes did not correlate to disease duration or equivalent HC doses. Body weight (P<0.01) and systolic blood pressure (P<0.05) improved to a greater extent in DR-HC than CGC. A trend toward Hb1Ac reduction was also observed (p=0.07) in DR-HC shifted patients only.

CONCLUSION: Conventionally GC treated AI is associated with severely impaired NKs and classical monocytes cell profile, compromising early innate immune host defense against infections and malignancies. Switch to DR-HC was associated with a rapid recovery of NKs. Mimicking a more physiological circadian-based serum cortisol profile seems crucial to counteract the negative effects of glucocorticoids on the immune system.

 

Disclosure: AMI: Speaker, Menarini, Consultant, Besins, Consultant, Otsuka, Consultant, Novartis Pharmaceuticals, Consultant, Shire. CS: Consultant, Viropharma. AC: Principal Investigator, Novartis Pharmaceuticals, Principal Investigator, Ipsen, Principal Investigator, Pfizer, Inc., Principal Investigator, Lilly USA, LLC, Study Investigator, Merck & Co., Study Investigator, Novo Nordisk, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen, Consultant, Pfizer, Inc., Consultant, Italfarmaco, Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Pfizer, Inc.. RP: Principal Investigator, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Clinical Researcher, Viropharma, Consultant, Viropharma, Speaker, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Speaker, Shire, Principal Investigator, Hra pharma, Coinvestigator, Ipsen. Nothing to Disclose: MAV, CG, VH, DF, AL

PP17-4 20915 4.0000 FRI-357 A Impairment of Innate Immunity of Adrenal Insufficient Patients Treated with Conventional Glucocorticoid Therapy Is Restored By Switching to Once-Daily Dual Release Hydrocortisone: A Multicenter Controlled Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 11:30:00 AM PP17 5907 11:15:00 AM Novel Aspects of Adrenal Tumors and the HPA axis Poster Preview


Andrea Maria Mueller1, Kathrin A Schmohl2, Kerstin Knoop1, Nicole Salb1, Christina Schug1, Alexandra Wechselberger2, Nathalie Schwenk1, Peter J Nelson2 and Christine Spitzweg*1
1University Hospital of Munich, Germany, 2University Hospital of Munich, Munich, Germany

 

Mesenchymal stem cells (MSCs) are actively recruited into growing tumour stroma, where they support the tumour’s fibrovascular network. Thyroid hormones influence the hypoxia response network by stimulating hypoxia inducible factor- (HIF-) 1α expression through non-genomic mechanisms via integrin αvβ3. To improve our understanding of thyroid hormone action in the tumour microenvironment, we examined the effects of T3, T4 and the integrin-specific inhibitor tetrac on the hypoxia response of MSCs.

Immortalised MSCs stably transfected with a HIF-1α-specific sodium-iodide-symporter (NIS) reporter gene system (HIF-NIS-MSCs) were established and showed stimulation of NIS expression under hypoxic conditions in vitro. After injection of these cells into nude mice bearing hepatocellular carcinoma (HCC) xenografts, 123I-scintigraphy and 124I-/18F-tetrafluoroborate-PET-imaging revealed tumour hypoxia-induced radioiodide accumulation mediated by HIF-1α-driven NIS expression. Treatment with T3 or T4 in the presence of HCC cell-conditioned medium (HCC-CM) for 24 hours under normoxic conditions resulted in stimulation of HIF-1α-driven functional NIS expression in a concentration-dependent manner. In primary MSCs, the same treatment led to a tetrac-dependent increase in expression of HIF-1α and HIF-1α-responsive genes (CXCL12, IL-6, VEGF, TGF-b1) as determined by qPCR. No effects were observed in the absence of HCC-CM.

Our data suggest that in the presence of tumour signals thyroid hormones stimulate the hypoxia response of MSCs in a tetrac-dependent and therefore integrin αvβ3-mediated manner. The establishment of HIF-NIS-MSCs opens the prospect of investigating thyroid hormone action on the hypoxia response network in tumour stroma in vivo. These studies will increase our understanding of thyroid hormone action in hypoxia-induced angiogenesis in tumours.

 

Nothing to Disclose: AMM, KAS, KK, NS, CS, AW, NS, PJN, CS

PP23-2 21784 2.0000 FRI-058 A Analysis of the Effects of T3 and T4 on the Hypoxia Response Network of Mesenchymal Stem Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 11:30:00 AM PP23 5916 11:15:00 AM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster Preview


Ronny Lesmana*1, Rohit Anthony Sinha2, Brijesh Kumar Singh2, Zhou Jin3, Kenji Ohba2, Benjamin Livingston Farah3, Winifred WY Yau4, Ya Jun Wu5, Boon-Huat Bay6 and Paul Michael Yen2
1Duke-NUS, Singapore, 2Duke-NUS Graduate Medical School, Singapore, Singapore, 3Duke-NUS, Graduate Medical School, Singapore, Singapore, 4Duke-NUS, Graduate Medical School, Singapore, 5Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore, 6Yong Loo Lin School of Medicine, National University of Singapore, Singapore

 

Although thyroid hormone (TH) induces autophagy in liver, it is not known whether it occurs in skeletal muscle. To study whether TH induces autophagy in muscle cells, we treated differentiated L6 myoblast cells in the presence or absence of T3 (100 nM) for 24 hours, andobserved increased Lc3II and decreased p62 levels in time- and dose-dependent manners. We then treated mice with T3 (20 µg/100 gr b.w. i.p.) for 10 days, and found that TH also stimulated Lc3II and decreased p62 levels in soleus muscle. Electron micrographs also showed that TH induced autophagosome formation at intermyofibrillar and subsarcolemmal areas in soleus muscle. Additionally, the lysosomal inhibitor, chloroquine (CQ), further increased T3-stimulated Lc3II levelsin both L6 cells and soleus muscle, suggesting that TH increased autophagic flux. Interestingly, TH also reduced MHCI (oxidative fibers) protein levels, and CQ markedly inhibited TH-mediated MHCI downregulation in both L6 cells and soleus muscle in both systems. Similar findings also were observed in thigh muscle. These findings strongly suggest that alterations in serum TH levels can change the proportion of slow and fast twitch fiber type in skeletal muscle via autophagy. Since TH-stimulated mitochondrial oxidative phosphorylation generates ROS, we measured protein carbonyl levels in L6 cells and soleus muscle after TH treatment, and found that TH increased protein carbonyl levels. Moreover, autophagy was coupled with increased ROS production since the anti-oxidant, L-NAC, abrogated autophagy in L6 cells. We also observed that TH-mediated autophagy involved two major pathways: the activation of AMPK by CAMKK as well as the inhibition of mTOR and its downstream target proteins (4-EBP1 and p70-s6kinase), which in turn, activated ULK1 to initiate phagophore formation. Taken together, our data show that TH-induced autophagy participates in the down-regulation of MHCI, a process that enables a switch in the relative proportion of oxidative and glycolytic fibers in skeletal muscle. These findings also may help explain the symptoms of muscle weakness associated with hypothyroidism and aging.

 

Nothing to Disclose: RL, RAS, BKS, ZJ, KO, BLF, WWY, YJW, BHB, PMY

PP23-3 19536 3.0000 FRI-056 A Thyroid Hormone-Mediated Autophagy Regulates Oxidative Fiber Proportion in Skeletal Muscle 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 11:30:00 AM PP23 5916 11:15:00 AM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster Preview


Irene O Aninye*1, Vitor M S Pinto2, Shuiqing Qiu1, Shunichi Matsumoto1 and Fredric Edward Wondisford3
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Universidade Federal de Sao Paulo, Mogi Guacu, Brazil, 3Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

 

Thyroid hormone receptors are a member of the nuclear receptor superfamily of transcription factors important in the regulation of cellular metabolism and development. There are 3 principal isoforms of the thyroid receptor: THRA, THRB1, and THRB2. Although they share a strong homology in their DNA and ligand binding domains, each isoform varies in its ability to interact with thyroid hormone (TH) and bind DNA. The most common DNA binding sequences, known as thyroid response elements, are direct repeats (DR+4), palindromes, and inverted palindromes (LAP). Each receptor can bind as a homodimer and/or heterodimer (with retinoid X receptor) to DNA and is uniquely influenced by TH ligand. To date, however, no study has determined how natural THR isoforms exhibit binding specificity. Using tagged protein in equal amounts in vitro, we demonstrate that THRB1/2 binds as a homodimer to both the DR+4 and LAP elements, and that the liganded homodimer dissociates only from the DR+4 element. THRA, in contrast, shows a ligand-dependent homodimer release from the LAP element, but exhibits no homodimeric binding to DR+4 elements, in the presence or absence of hormone. We then synthesized chimeric receptors, targeting key regions of the DBD and LBD and studied DNA binding specificity. Switching the entire DBD of one isoform for the other surprisingly did not alter the binding of the chimeric receptor for DNA response elements. We show, however, that a three amino acid switch in helix 10 of THRB2 to amino acids found in THRA causes the chimeric THRB2 to mimic THRA binding to DNA. The complement experiment demonstrates that a chimeric THRA containing THRB amino acids no longer dissociates from the LAP element like wild-type THRA. Our data are the first to identify amino acids that confer isoform-specific DNA binding properties on natural THR isoforms. These results begin to elucidate the unique role of helix 10 of the LBD in dimerization, and perhaps thyroid hormone regulation of gene expression.

 

Nothing to Disclose: IOA, VMSP, SQ, SM, FEW

PP23-4 20563 4.0000 FRI-059 A Identification of Three Amino Acid Residues That Confer DNA-Binding Specificity of Thyroid Hormone Receptor Isoforms 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 11:30:00 AM PP23 5916 11:15:00 AM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster Preview


Ai Tamura*1, Yoko Matsuzawa1, Sachiko Suematsu1, Takumi Kitamoto2, Jun Saito1, Masao Omura1, Koshiro Nishimoto3, Kuniaki Mukai3, Hironobu Sasano4 and Tetsuo Nishikawa1
1Yokohama Rosai Hosp, Yokohama, Japan, 2Graduate School of Medicine, Chiba University, Chiba, Japan, 3School of Medicine, Keio University, Tokyo, Japan, 4Tohoku University Hospital, Sendai, Japan

 

Introduction: Germline mutations are generally observed in familial hyperaldosteronism with adrenal hyperplasia or adenoma. We had already reported high prevalence of somatic mutations of KCNJ5 gene (60~70%) in Japanese patients with APA. KCNJ5 mutations were reported to be associated with young age, female gender and a more severe hyperaldosteronism with higher preoperative aldosterone and/or lower plasma K levels. We had experienced a girl with primary aldosteronism (PA) due to bilateral adrenal hyperplasia (BAH) with somatic mutation of KCNJ5 gene.

Clinical case: Hypertension was first diagnosed at 8 years old, and transferred to our hospital when she was 16 years old. She had low-reninemic (PRA <0.1 ng/ml/hr, n 0.2 to 2.7 ng/ml/hr) and hyperaldosteronemic (PAC 603 pg/ml, n 30 to 159 pg/ml) hypertention and hypokalemia(K 2.8 mEq/L, n 3.6 to 4.7 mEq/l) in spite of spironolactone treatment. PA, 17-hydroxylase deficiency and GRA were suspected, and adrenal vein sampling (AVS) demonstrated bilateral hyperaldosteronemia. Then we started to treat her with eprelenone and CCB. The patient and her mother strongly wanted surgical treatment at 19 years old, and we reexamined her status after discontinuing eprelenone. PRA, PAC and cortisol were <0.1 ng/ml/hr, 565 pg/ml and 2.6 ug/dl (n 4.0 to 19.3 ug/dl), respectively. GRA gene mutation was not found, and PAC was not suppressed by dexamethasone administration. Then, we performed left total adrenalectomy and simultaneously right partial adrenalectomy. Pathological findings clearly demonstrated BAH, both of which could produce autonomous aldosterone, confirmed by immunohistochemistry. PRA was still less than 0.1 ng/ml/hr, but PAC decreased to 217 pg/ml at 3 days later after surgery. We analyzed germline mutations of KCNJ5 gene by using peripheral blood obtained from her mother and the patient. We found no germline mutation, while the same somatic KCNJ5 gene mutation (G151R) was detected in both adrenal glands.

Conclusion: The present case suffered from hypertension at 8 years old with strong autonomous aldosterone synthesis due to BAH. She was not diagnosed as FHIII because of no germline mutation, while removed samples clearly showed somatic mutation. This is the first case of BAH with somatic mutation of KCNJ5 gene. Thus we need to carefully examine adrenal functions with genetic analysis when we see this kind of young hypertensive case.

 

Nothing to Disclose: AT, YM, SS, TK, JS, MO, KN, KM, HS, TN

PP12-1 19700 1.0000 FRI-377 A Unique Case of Primary Aldosteronism Due to Bilateral Adrenal Hyperplasia with Somatic KCNJ5 Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 11:30:00 AM PP12 5990 11:15:00 AM Primary Aldosteronism and Pheochromocytoma Poster Preview


Joanna Klubo-Gwiezdzinska*1, Mihail Zilbermint2, Charalampos Lysikatos-Lyssikatos1, Elena Belyavskaya3, Constantine A Stratakis4, Anatoly N Tiulpakov5, Michael Allgaeuer6 and Chyi-Chia Richard Richard7
1National Institute of Health, Bethesda, MD, 2NIH/NICHD, Bethesda, MD, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 4National Institutes of Health (NIH), Bethesda, MD, 5Endocrinology Research Center, Moscow, Russia, 6National Cancer Institute/NIH, MD, 7National Cancer Institute/NIH, Bethesda, MD

 

Background

 Germ line KCNJ5 mutations affect ion selectivity of the potassium channels and are associated with familial hyperaldosteronism (FH) type III. We recently described a novel germ line KCNJ5 mutation (p.Glu145Gln) that resulted in abnormal depolarization of adrenal cells leading to continuous stimulation of aldosterone synthesis.

 Clinical case

            The patient was a 19 years old Caucasian female, who was diagnosed with primary hyperaldosteronism at the age of 2 years on the basis of extremely elevated serum aldosterone  5000 pmol/L (N 111–830 pmol/L), suppressed plasma renin activity (PRA) 0.2 ng/mL/h and nephrogenic diabetes insipidus due to hypokalemia. The etiology of hyperaldosteronism was established based on imaging studies and adrenal venous sampling consistent with bilateral adrenal hyperplasia. She was found to have novel germ line KCNJ5 mutation (p.Glu145Gln).

The patient was managed conservatively for several years with multiple anti-hypertensive medications (telmisartan, amlodipine and bisoprolol) and maximum doses of spironolactone. Medical management resulted in suboptimal blood pressure control (140-160/100-110mmHg) and persistent hypokalemia of 2.7-3.3 mmol/l. At the age of 16 years, the patient was offered bilateral adrenalectomy, but refused. At the age of 19 years, patient developed complications consisting of chronic kidney disease with basal creatinine ranging between 2.6 mg/dL to 2.7 mg/dL, proteinuria 1.9 g/24h, and aortic root dilatation. At that time, the patient underwent bilateral laparoscopic adrenalectomy. Apart from enlarged adrenal glands, there were three ectopic retroperitoneal adrenal glands identified and resected during the surgery. Pathology report confirmed bilateral multinodular adrenocortical hyperplasia and ectopic adrenocortical tissue. Subsequently, the patient was started on steroids replacement therapy.  Interestingly, the standard dose of fludrocortisone 100 mcg daily was not sufficient to control rising potassium. Fludrocortisone dose was escalated to 200 mcg daily which resulted in normalization of potassium with optimal PRA of 6.9 mg/ml/h.  The patient has biochemical evidence of remission with undetectable aldosterone levels, optimal BP control (120-130/80 mmHg) with one antihypertensive medication and stabilization of GFR at 30 ml/min/1.73m2.  

 Clinical Lesson

Surgical treatment of patients with severe FH type III should be implemented early in the course of disease to avoid complications of hyperaldosteronism and/or kidney disease. Ectopic adrenal tissue can complicate bilateral adrenalectomy for FH-III. Increased mineralocorticoid requirements post adrenalectomy could be attributed to the germ line KCNJ5 mutation affecting potassium channels in distal tubules of the kidneys leading to depolarization of the basolateral membrane and decreased driving force for Na reabsorption and K excretion.

 

Nothing to Disclose: JK, MZ, CL, EB, CAS, ANT, MA, CCRR

PP12-2 21569 2.0000 FRI-380 A Severe Hyperaldosteronism Leading to Multi-Organ Damage a Unique Case of Bilateral Adrenal Hyperplasia and Ectopic Adrenal Gland Associated with Germ Line De Novo KCNJ5 Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 11:30:00 AM PP12 5990 11:15:00 AM Primary Aldosteronism and Pheochromocytoma Poster Preview


Veljko Strajina*, Benzon Dy, Keith C Bible, Travis J. McKenzie, David Farley, Melanie Richards, Geoffrey B Thompson and Florencia G Que
Mayo Clinic, Rochester, MN

 

Introduction:  Pheochromocytoma and paraganglioma (PPGL) are rare neoplasms; about 10% of pheochromocytomas and about 30% of paragangliomas are malignant. There are no distinct histopathologic features of malignancy, and the diagnosis of malignancy is thus made by identifying local invasion or distant metastases.  Literature regarding possible benefit from resection is extremely limited.

Methods:  A 20-year review of all patients undergoing surgery for malignant pheochromocytoma or paraganglioma at Mayo Clinic. Rochester Campus between 1994 and June 2014 was performed.

Results:  We identified 34 patients undergoing surgery for malignant PPGL.  Metastases were present at the time of resection in regional lymph nodes (20), bone (12), liver (10), lung (5), peritoneum (2) and ovary (1).  Median follow up was 6 years, and 5-year survival was 93 % (median 11 years).  Complete resection (R0) was achieved in 16 patients (47 %).  Median disease-free survival was 4.5 years for patients with R0 resection (up to 12 years).  Overall survival was not significantly affected by completeness of resection (P = 0.43).  Only 8 patients (23%) were disease-free on last follow up.  Median disease-free survival was significantly shorter in patients with germline succinate dehydrogenase gene mutations (P<0.01).  Neither overall nor disease –free survival was significantly correlated with the location of primary tumor, or with number or site(s) of metastases.  Elevated preoperative fractionated metanephrines or catecholamines were documented in 22 patients (65%); these normalized in 11 of 22 patients (50%) postoperatively, with symptom relief in 15 of 19 preoperatively symptomatic patients (79%).  Among 22 patients with hormone-producing tumors, significant reduction in number of antihypertensive medications was also noted postoperatively; 11 patients have remained off all antihypertensives, 6 required one medication, 1 required two, while 4 required full blockade with phenoxybenzamine and a beta-adrenergic blocker.

Conclusion:  Surgery plays a significant role in the management of selected malignant PPGL. Resection can be effective in normalizing or significantly reducing levels of catecholamines and metanephrines and can improve hormone-related symptoms and hypertension.  Surgical resection, either complete or incomplete, is associated with durable survival despite a high rate of tumor recurrence.

 

Nothing to Disclose: VS, BD, KCB, TJM, DF, MR, GBT, FGQ

PP12-3 21047 3.0000 FRI-378 A Surgical Treatment of Malignant Pheochromocytoma and Paraganglioma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 11:30:00 AM PP12 5990 11:15:00 AM Primary Aldosteronism and Pheochromocytoma Poster Preview


Tamara Prodanov*1, Hana Turkova2, Maly Marek3, Victoria L Martucci4, Karen T Adams4, Jiri Widimsky5, Clara C Chen6, Alexander Ling7, Electron Kebebew8, Constantine A Stratakis9, Tito Fojo10 and Karel Pacak11
1NIH, Bethesda, 2Všeobecná Fakultní Nemocnice, Prague, Czech Republic, 3National Institute of Public Health, 4Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 5General Faculty Hospital and 1st Medical Faculty of Charles University in Prague, Czech Republic, 6National Institutes of Health Clinical Center, Bethesda, MD, 7NIH, Bethesda, MD, 8National Cancer Institute, NIH, Bethesda, MD, 9National Institutes of Health (NIH), Bethesda, MD, 10National Cancer Institute, National Institutes of Health, Bethesda, MD, 11National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD

 

Background: Overall about 10-20% of pheochromocytomas/paragangliomas (PHEOs/PGLs) are metastatic, with higher metastatic potential observed in SDHB/MAX-related tumors. Due to the improved availability of biochemical and genetic testing and the frequent use of anatomical/functional imaging, currently there is a higher detection rate of metastatic PHEO/PGL.

Methods: A retrospective analysis of 142 patients with metastatic PHEO/PGL seen from 2000-2013 was conducted.

Results: Eighty-two (58%) males and 60 (42%) females were included; 35 (25%) have died. Seventy-three (51%) patients had SDHB, 6 (4%) SDHD, 3 (2%) RET, and one VHL (1%) mutations; 59 (42%) patients had apparently sporadic tumors (AST). SDHx (SDHB/SDHD) patients had an average age at primary tumor diagnosis of 31 ± 16 years compared to 40 ± 15 years in AST patients (p<0.001). The proportion of patients with AST increased with age at initial diagnosis. The average metastatic interval (MI) decreased with increasing age in both SDHx and AST patients. Only 29% of all primary tumors were smaller than 6 cm. Twelve percent of patients had biochemically silent disease. Of SDHB patients, 19% had metastatic tumors at first diagnosis, compared to 15% of AST patients. Five- and 10-year survival rates were significantly better for metastatic AST than SDHxpatients (p=0.039).

Conclusions: Metastatic PHEOs/PGLs are equally distributed between SDHx and AST, with better 5- and 10-year survival rates for ASTs. The frequency of metastatic tumors from primary AST increases with age, including a decreased MI compared to SDHx tumors.

 

Nothing to Disclose: TP, HT, MM, VLM, KTA, JW, CCC, AL, EK, CAS, TF, KP

PP12-4 22037 4.0000 FRI-379 A Characteristics and Outcomes of Metastatic Pheochromocytoma/Paraganglioma: An NIH Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 11:30:00 AM PP12 5990 11:15:00 AM Primary Aldosteronism and Pheochromocytoma Poster Preview


Shakunthala Narayanaswamy*1, Channa N Jayasena2, Noel Ng1, Risheka Ratnasabapathy1, Julia K Prague1, Deborah A Papadopoulou1, Alexander N Comninos3, Ali Abbara3, Mohammad A Ghatei1, Stephen R Bloom2 and Waljit S Dhillo3
1Imperial College London, London, United Kingdom, 2Imperial College London, United Kingdom, 3Imperial College NHS Healthcare Trust, London, United Kingdom

 

Background: Kisspeptin is a recently identified hormone which potently stimulates hypothalamic gonadotropin releasing hormone secretion resulting in gonadotropin release. Women are markedly more responsive to exogenous kisspeptin during the pre-ovulatory phase when compared with the follicular phase of menstrual cycle. However, it is not known whether the effects of kisspeptin are related to circulating sex steroid levels in patients during the follicular phase of the menstrual cycle.  

Aim: To study the effects of baseline estradiol on gonadotropin secretion after intravenous kisspeptin-54 administration to healthy females in the early follicular phase of the menstrual cycle.

Study: This was a prospective, single-blinded placebo-controlled study. The effects of intravenous kisspeptin-54 on gonadotropin secretion were assessed over 8 hours in 4 healthy women at 0.1, 0.3 and 1.0nmol/kg/hr doses. Each participant received vehicle and all three doses of kisspeptin. Studies were performed during days 2-6 of the menstrual cycle, with one study visit scheduled each month per subject. Ten minutely blood sampling was conducted over the 8 hours to measure luteinising hormone (LH), follicle stimulating hormone (FSH) and estradiol.

Results: All doses of kisspeptin-54 increased LH release compared to vehicle (mean AUC LH in h/IU/L: 2470 ± 697.2, vehicle; 3214 ± 575.2, 0.1nmol/kg/hr; 6887 ± 1934, 0.3nmol/kg/hr, P<0.05 vs vehicle; 6252 ± 2146, 1.0nmol/kg/hr, P<0.05 vs vehicle). Baseline estradiol levels positively correlated with the LH response to the two highest doses of kisspeptin-54 (0.3 and 1.0nmol/kg), but did not with vehicle or the lowest dose 0.1nmol/kg kisspeptin-54 (correlation between mean AUC LH in h/IU/L and baseline E2 in pmol/L: vehicle, r2=0.62, P=0.42; 0.1nmol/kg/hr, r2=0.1, P=0.68; 0.3nmol/kg/hr, r2=0.90, P<0.05; 1.0nmol/kg/hr, r2=0.94, P<0.05).

Conclusion: Our data suggest that baseline estradiol levels may be an important determinant of the gonadotropin response to kisspeptin treatment in women in the follicular phase of the menstrual cycle. Further studies are required to determine if the modulatory effects of estradiol on gonadotropin response to kisspeptin occur at a hypothalamic or pituitary level.

 

Nothing to Disclose: SN, CNJ, NN, RR, JKP, DAP, ANC, AA, MAG, SRB, WSD

PP15-2 18807 2.0000 FRI-085 A Reproductive Endocrinology: the Gonadotrophin Response to Intravenous Kisspeptin Positively Correlates with Baseline Estradiol Levels in Healthy Women during the Early Follicular Phase of the Menstrual Cycle 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 11:30:00 AM PP15 6012 11:15:00 AM Female Reproduction - Interface with "Non-Reproductive" Systems Poster Preview


Ming Zhang*1 and Carole R Mendelson2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Med Ctr, Dallas, TX

 

Dysregulation of human trophoblast invasion and differentiation can result in a number of pregnancy-associated diseases, including preeclampsia (PE), a hypertensive disorder of pregnancy with significant morbidity and mortality for mother and offspring. To identify miRNAs involved in human trophoblast differentiation and the associated induction of aromatase/hCYP19A1, we performed miRNA microarray analysis of total RNA from freshly isolated human cytotrophoblasts, before and after differentiation to syncytiotrophoblast in primary culture. Members of miR-515 family, which belong to the placenta-specific chromosome 19 miRNA cluster (C19MC), were found to be significantly downregulated upon human syncytiotrophoblast differentiation. TaqMan-based RT-qPCR confirmed decreased expression of miR-515-5p, miR-519e*, miR-519c-3p and miR-518f during syncytiotrophoblast differentiation. Importantly, we also observed significantly higher expression levels of miR-515-5p and miR-519e* in placentas from women with PE than from gestationally-matched normotensive subjects. Using Targetscan software, we identified a number of predicted targets of miR-515-5p that are relevant to human trophoblast differentiation. These include: hCYP19A1/aromatase P450, glial cells missing 1 (GCM1), frizzled 5 (FZD5), and estrogen receptor α (ERα) mRNA. We observed that hCYP19A1, GCM1, FZD5, and ERα mRNA and protein were markedly upregulated during human trophoblast differentiation as miR-515-5p levels declined. hCYP19A1 catalyzes the biosynthesis of estrogens, which act via ERα in a positive feedback manner, to enhance human trophoblast differentiation and function [1]. GCM1 is a transcription factor critical for labyrinthine trophoblast development and hCYP19A1 expression [2]. FZD5, a component of WNT signaling pathway that is selectively expressed by the syncytiotrophoblast, forms a positive feedback loop with GCM1 and is critical for trophoblast differentiation [3]. Notably, overexpression of miR-515-5p in cultured primary human trophoblasts decreased the expression of all of these putative miR-515-5p targets and impaired the process of trophoblast syncytialization. Using luciferase reporter assays, hCYP19A1 and GCM1 mRNA were validated as direct targets of miR-515-5p. Interestingly, mRNA and protein levels of hCYP19A1, GCM1 and FZD5 were significantly decreased in PE placentas, while miR-515-5p levels were significantly increased compared to placentas of normotensive women. These intriguing findings suggest that miR-515-5p serves a key regulatory role in human trophoblast differentiation and that aberrant upregulation of this miRNA may be involved in the pathogenesis of PE. Further investigations are ongoing to define the mechanisms that underlie regulation of miR-515-5p expression during human trophoblast differentiation and in PE.

 

Nothing to Disclose: MZ, CRM

PP15-3 20643 3.0000 FRI-081 A Mir-515 Family Members Inhibit Expression of Key Genes Involved in Human Trophoblast Differentiation and Are Upregulated in Preeclampsia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 11:30:00 AM PP15 6012 11:15:00 AM Female Reproduction - Interface with "Non-Reproductive" Systems Poster Preview


Xing Xiuye1, Marcy Maguire1, Manousos Makridakis2, Shashi Shrivastav3, Hewang Lee3, Jeffrey B. Kopp3, Antonia Vlahou2, James H. Segars1 and Tomoshige Kino*1
1NICHD/NIH, Bethesda, MD, 2Biomedical Research Foundation of the Academy of Athens, Athens, Greece, 3NIDDK/NIH, Bethesda, MD

 

Ovarian aging is a major cause of menopause and is accompanied by oocyte and follicle depletion, but the biologic mechanism(s) underlying this process are incompletely understood. Ovarian granulosa cells are essential components of follicles investing oocytes and contributing to follicle survival, while microRNAs (miRNAs) are short hairpin-like RNAs with strong impact on reproduction by influencing proliferation, apoptosis and steroidogenesis. To explore molecular mechanisms underlying ovarian aging, we purified granulosa cells from young (6-week old: YOUNG) and old (2-year old: OLD) mice, and compared their expression profiles of ~600 miRNAs. We found that expression of 37 miRNAs were significantly up- or down-regulated in OLD granulosa cells; Among them, expression of miR-503 and -322, the most abundantly expressed miRNAs reported in the ovary, was significantly reduced (by ~10-fold) in OLD cells, while their gene cluster partner miR-351 was moderately downregulated (by ~2.5-fold). We confirmed that miR-503 and -322 were respectively reduced by 93.7% and 90.6% in OLD granulosa cells compared to YOUNG cells with reconstituted real-time PCR. To explore downstream molecules of these miRNAs, we performed differential protein expression analysis using 2-dimensional gel separation followed by mass-spectrometry, and found that 2 mitochondrial proteins, the ATP synthase subunit β and δ were significantly (~2-fold) downregulated in YOUNG granulosa cells in the presence of the miR-503 inhibitor compared to its absence. Since ATP synthases are components of the mitochondrial oxidative phosphorylation complex, we examined the mitochondrial oxygen consumption by using the XF24 Seahorse extracellular flux analyzer, and found that transfection of either miR-503 or -322 significantly reduced basal oxygen consumption rates in YOUNG granulosa cells. Indeed, several miRNA target-searching engines predicted that the autophagy/mitophagy-associated genes, such as garap12, atg4b, atg5g, bcl2 and bcl2l13, are common targets of miR-503, -322 and/or -322, whereas overexpression of the miRNA mimic for these miRNAs significantly reduced luciferase activity expressed from the reporter constructs harboring 3’ UTR of garap12, atg4b or bcl2. Collectively, these results indicate that expression of miR-503/322/351 gene cluster is downregulated in aged ovarian granulosa cells, which is associated with reduced mitochondrial activity by releasing the expression of autophagy/mitophagy-related genes. Since this miRNA gene cluster is located in the region of the human X-chromosome found to be deleted in patients with premature ovarian failure, it is possible that reduced expression of these miRNA may contribute to the reduced mitochondrial number, activity and steroidogenesis observed in the ovaries of aged women.

 

Nothing to Disclose: XX, MM, MM, SS, HL, JBK, AV, JHS, TK

PP15-4 18754 4.0000 FRI-082 A The miR-503/322/351 Cluster Mediates Aging-Dependent Reduction of Mitochondrial Activity by Targeting Autophagy/Mitophagy-Associated Genes in Mouse Ovarian Granulosa Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 11:30:00 AM PP15 6012 11:15:00 AM Female Reproduction - Interface with "Non-Reproductive" Systems Poster Preview


Lindsay M Thompson*, Jan A. Mennigen, Mandee Bell, Marlen Tellez and Andrea C Gore
University of Texas at Austin, Austin, TX

 

Polychlorinated biphenyls (PCBs) are organic pollutants and known endocrine disrupting chemicals that, although banned in 1979, still persist in the environment today. Aroclor 1221 (A1221) is a lightly chlorinated PCB mixture that was previously shown to cause altered reproductive phenotype in developing and adult rats when given during gestation. In this study we investigated the hypothesis that gestational PCB exposure results in transgenerational alterations of the reproductive and neuroendocrine phenotype in rats. Pregnant F0 rats were injected on embryonic days 16 and 18 with either DMSO (3% in sesame oil) vehicle control, A1221 (1 mg/kg), or the positive estrogenic control estradiol benzoate (EB, 50 ug/kg).  The F1 pups were allowed to mature and males and females were bred to the F3 generation to produce maternal and paternal lineages. Physiological data were obtained from each generation. After euthanasia, hypothalamic nuclei were dissected for real time PCR of 48 genes, assayed using low-density array card for the arcuate nucleus. Results: A1221 increased body weight in males and females descended from the maternal but not the paternal lineage. The effects of A1221 on endogenous hormones estradiol (E2), progesterone (P4), and corticosterone (Cort) were generation- and sex-specific. In females, A1221 decreased P4 levels in the F2 animals and increased E2 levels in F3 animals. In males, EB increased Cort levels in the paternal lineage in the F2 and F3 generations. Gene expression analysis of the arcuate nucleus identified 14 genes affected by A1221 in the F1 generation. Of those genes, Clock, Per2 and Dbp had effects that continued into the F2 and F3 generations. This latter result is interesting because these genes are involved in circadian rhythmicity.  Several genes also showed effects of treatment in a sex- and lineage -specific manner. Therefore, gestational exposure to PCBs has life-long and transgernational effects on body weight, hormones, and hypothalamic gene expression.

 

Nothing to Disclose: LMT, JAM, MB, MT, ACG

PP14-2 20014 2.0000 FRI-290 A Transgenerational Effects of Prenatal PCB Exposure on the Reproductive and Metabolic Phenotype, and Arcuate Nucleus Gene Expression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 11:30:00 AM PP14 6023 11:15:00 AM Endocrine Disruptors in Development and Gene Regulation Poster Preview


Christian Trolle*1, Morten Muhlig Nielsen2, Anne Skakkebæk Jensen2, Torben Falck Ørntoft1 and Claus H. Gravholt1
1Aarhus University Hospital, Aarhus, Denmark, 2Aarhus University Hospital, Aarhus N

 

The DNAmethylation landscape of Turner syndrome – a consequence of Epigenetic adaption?

 Background:  Women with Turner syndrome (TS) and 45,X monosomy suffer from considerable excess morbidity and mortality suggesting a causal role of sex chromosome haploinsufficiency. Despite decades of studies, only one gene (SHOX) has explained a phenotypic trait of TS and karyotype-phenotype studies suggest a surprisingly diverse clinical presentation of 45,X monosomy. We propose this diversity is partly due to high in utero lethality, driving a positive selection for fetuses with the appropriate constellation of transcribed and translated genes. We hypothesize, that this adaptation could be due to epigenetic regulation, partly compensating the sex chromosome haploinsufficiency. In support we provide evidence of global changes of the TS DNA methylation landscape.

Methods: A phenotypically well characterized cohort of adults with 45,X monosomy (n=33, 42.6±12.3 years) and age-matched female controls (n=33, 45.0±10.3 years) were recruited. The Illumina 450K methylation assay was applied to leukocyte DNA. Sex chromosomes were excluded from downstream analysis. Methylation values (M-values) were calculated following quality control procedures and normalization. Differentially-methylated-positions (DMPs) were identified by linear models (Limma) adjusting for the estimated relative cell proportions and age. Chromosomal and gene-centric-region enrichment analysis was done using hypergeometric test. Hierarchical cluster analysis was based on multi-scale bootstrap resampling. A Bonferroni corrected P-value<0.05 (FWER) was considered significant. To assign biological context, functional annotation clustering was performed using The Database for Annotation, Visualization and Integrated Discovery (DAVID).

Results: 10,687 DMPs (FWER<0.05) were identified. Chromosome 1, 9, 11, 17, 19 and 22 as well as the proximal promotor regions were enriched (FWER<0.05). Hierarchical cluster analysis distinctly clustered TS and controls. Gene set enrichment analysis identified pathways involved in congenital heart anomalies and coronary heart disease as well as enrichment for clusters of blood vessel development and transforming growth factor β.

Conclusion: We provide evidence of an altered DNA methylation landscape in TS affecting pathways related to congenital heart anomalies, blood vessel development and transforming-growth-factor β. Pathways that may account for the well described increased prevalence of congenital heart anomalies and increased incidence of aortic dissection seen in TS.

 

Nothing to Disclose: CT, MMN, ASJ, TFØ, CHG

PP14-3 21208 3.0000 FRI-294 A The Dnamethylation Landscape of Turner Syndrome – a Consequence of Epigenetic Adaption? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 11:30:00 AM PP14 6023 11:15:00 AM Endocrine Disruptors in Development and Gene Regulation Poster Preview


Amanda Shaine Janesick*1, Giorgio Dimastrogiovanni2, Sathya Balachander1, Christy Boulos1, Lenka Vanek1 and Bruce Blumberg1
1University of California, Irvine, Irvine, CA, 2IIQAB-CSIC, Barcelona, Spain

 

In Phase I of the ToxCast program, the Environmental Protection Agency commissioned the screening of 309 pesticides, herbicides, fungicides and other chemicals of interest in a series of high throughput assays.  One set of ToxCast assays concerned ligand binding to, and activation of PPARγ. We retested the top 21 chemicals identified in ToxCast Phase I as PPARγ activators using transient transfection assays in Cos-7 cells. Surprisingly, only 4 of the chemicals were bona fide PPARγ activators, another 3 were PPARγ antagonists, and the remainder were inactive.  The PPARγ activators induced adipogenesis in the 3T3-L1 cell model. We next evaluated the capability of a Toxicology Priority Index (ToxPi) based prediction of adipogenesis to identify chemicals that could activate PPARγ and/or induce adipogenesis.  We tested 19 chemicals predicted by the ToxPi as inducers of adipogenesis, and well as 7 predicted negatives.  Using transient transfection assays in Cos-7 cells, we found two weak PPARγ activators and one RXRα activator.  Further testing using 3T3-L1 preadipocyte and mesenchymal stem cell-based in vitro differentiation assays showed that 7/19 chemicals were adipogenic, and 2/7 negatives were also adipogenic.  We conclude that ToxCast assays for PPARγ activity are questionable and the utility of the ToxPi used as a predictor of adipogenesis filter is limited, at best. Overall, the results suggest that there is modest predictive value of ToxCast for PPARγ activation and adipogenesis and that there are probably a fair number of obesogenic chemicals remaining to be identified.

 

Nothing to Disclose: ASJ, GD, SB, CB, LV, BB

PP14-4 21545 4.0000 FRI-295 A Testing Toxcast Chemicals for PPARγ Activation and Adipogenesis Potential Reveals New Potential Obesogens 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 11:30:00 AM PP14 6023 11:15:00 AM Endocrine Disruptors in Development and Gene Regulation Poster Preview


Robert M Neer*
Mass Gen Hosp, Boston, MA

 

 

Disclosure: RMN: Consultant, Eli Lilly & Company.

AL22-1 22251 1.0000 A Advances in Osteoporosis Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 11:45:00 AM AL/OR22 6079 11:15:00 AM Gerald D. Aurbach Award for Outstanding Translational Research Lecture


Kristen A Ruka* and Suzanne M Moenter
University of Michigan, Ann Arbor, MI

 

Gonadotropin-releasing hormone (GnRH) is released in a pulsatile pattern that is essential for fertility.  Gonadal steroid feedback alters this pattern, but GnRH neurons themselves rarely express the necessary steroid receptors.  Therefore, feedback is likely mediated by steroid-sensitive afferents, such as arcuate neurons that coexpress kisspeptin, neurokinin B (NKB), and dynorphin, also known as KNDy neurons.  Kisspeptin stimulates GnRH neurons, and NKB stimulates KNDy neurons via NK3R, while dynorphin inhibits KNDy neurons via KOR.  In KNDy neurons from intact vs. gonadectomized (GDX) male mice, NK3R-mediated stimulation of action potential firing is attenuated, while KOR-mediated inhibition of firing is enhanced, supporting steroid negative feedback via both NK3R and KOR.  Testosterone can be metabolized to estradiol (E2) in the brain, and most KNDy neurons express both estrogen receptor alpha and androgen receptor.  Both steroid classes can suppress arcuate kisspeptin mRNA.  However, E2 but not dihydrotestosterone (DHT, an androgen that cannot be converted to E2) appears to be essential for negative feedback on GnRH neuron activity in mice.  Therefore, we hypothesized that estrogens, not androgens, modulate KNDy neuron firing responses to activation of NK3R or KOR in males.  To test this hypothesis, adult male Tac2 (NKB)-GFP mice were GDX and either untreated or implanted with Silastic capsules containing E2 or DHT.  Extracellular electrophysiological recordings were taken from KNDy neurons in acutely prepared coronal brain slices.  Frequency of action potential firing was averaged over the last 2 minutes of an untreated control period and compared with average frequency over the last 2 minutes of a 5 minute bath application of either the NK3R agonist senktide (SK) or dynorphin.  As in previous studies, preliminary data from GDX mice show a trend toward increased KNDy neuron firing frequency in response to SK (control 0.0±0.0 Hz, SK 8.9±2.7 Hz, p=0.063, n=5).  Consistent with our hypothesis, this effect is attenuated in cells from E2-implanted mice (control 0.0±0.0 Hz, SK 1.9±0.8 Hz, p=0.063, n=6; E2 SK vs. GDX SK p<0.05).  Interestingly, the response to SK treatment in KNDy neurons after DHT implantation is similar to that after E2 (control 0.0±0.0 Hz, SK 1.5±0.7 Hz, p<0.05, n=8; DHT SK vs. GDX SK p<0.05, DHT SK vs. E2 SK p>0.9).  Preliminary data also suggest that dynorphin reduces firing rate in all animal models tested and that this inhibition may be more effective in cells from either E2- or DHT-implanted mice.  These data are consistent with the action of estrogens and, in contrast to our hypothesis, also androgens in the alteration of NK3R- and KOR-mediated responses in KNDy neurons from GDX male mice.  Future studies will test through which receptors estradiol acts to mediate these changes and whether the effects are direct on KNDy neurons.

 

Nothing to Disclose: KAR, SMM

OR16-1 19844 1.0000 A Both Estrogens and Androgens Alter Neurokinin 3 Receptor (NK3R)- or Kappa-Opioid Receptor (KOR)-Modulated Activity in Arcuate Kisspeptin Neurons 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR16 5899 11:30:00 AM Kisspeptin-GnRH-Gonadotrope Axis Oral


Silvia Leon1, Alexia Barroso1, María J. Vázquez1, David Garcia Galiano1, Maria Manfredi-Lozano1, Francisco Ruiz-Pino1, Antonio Romero-Ruiz2, Juan Roa1, Gunther Schutz3, Milen Kirilov3, Leonor Pinilla1 and Manuel Tena-Sempere*1
1University of Cordoba, Cordoba, Spain, 2Department of Cell Biology, Physiology and Immunology, University of Córdoba; CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III; Instituto Maimónides de Investigación Biomédica de Córdoba/Hospital Universitario Reina Sofia, Cordoba, Spain, 3German Cancer Research Center, Heidelberg, Germany

 

Kisspeptins, ligands of the receptor, Gpr54, are essential regulators of puberty and fertility that act primarily on GnRH neurons to conduct their potent stimulatory actions on the reproductive axis. Yet, whether direct kisspeptin effects on GnRH can explain the whole repertoire of reproductive effects of kisspeptins is still matter of debate. Recent data using a Gpr54 null mouse model with selective rescue of Gpr54 expression in GnRH cells (Gpr54-/-Tg; rescued) suggest that such direct effects are sufficient to attain fertility in mice. However, indirect actions of kisspeptins via neuronal afferents to GnRH neurons and effects at other levels of the reproductive axis have been proposed also.

We report herein the detailed phenotypic characterization of male and female Gpr54-/-Tg rescued mice, assessing (i) reproductive hormone levels, gonadal histology and other indices of reproductive function; (ii) gonadotropin secretion after elimination of negative feedback by gonadectomy (GNX); and (iii) LH responses to different stimulators of the HPG axis, including kisspeptin-10, NMDA, the antagonist of GABA-A receptors, PHP, and agonists of the three tachykinin receptors (NKR).

The most salient findings of our study are: (a) Despite preserved fertility, adult Gpr54-/-Tg rescued females displayed subtle changes in estrous cycles and ovarian histology, reminiscent of precocious ageing; (b) Gpr54-/-Tg rescued males showed smaller testes and epididymis, overt histological abnormalities in the testis, and elevated LH levels without concomitant increases of testosterone secretion; (c) Feedback responses to GNX were clearly subnormal, for both gonadotropins in male and female Gpr54-/-Tg rescued mice; and (c) Although Gpr54-/-Tg rescued males displayed preserved absolute LH responses to various regulators of the gonadotropic axis, relative responses were variably affected, with fully conserved responses to PHP (GABA-A antagonist) and NK1R and NK3R agonists, and partially blunted responses to kisspeptin-10, NMDA and NK2R agonist.

In conclusion, our data confirm that direct effects of kisspeptins on GnRH cells are sufficient to attain fertility. Yet, such direct actions are not sufficient to allow complete preservation of proper functionality gonadotropic axis, as evidenced by altered gonadotropin secretion, perturbed negative feedback regulation, diminished relative responses to central transmitters and disrupted gonadal histology and possibly function, as revealed by our mouse model with elimination of kisspeptin signaling outside GnRH cells.

 

Nothing to Disclose: SL, AB, MJV, DG, MM, FR, AR, JR, GS, MK, LP, MT

OR16-2 21678 2.0000 A Direct Actions of Kisspeptins in GnRH Neurons Permit Attainment of Fertility but Are Insufficient to Preserve Full Activity of the Gonadotropic Axis in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR16 5899 11:30:00 AM Kisspeptin-GnRH-Gonadotrope Axis Oral


Buntaro Zempo*, Shinji Kanda, Yasuhisa Akazome and Yoshitaka Oka
The University of Tokyo, Bunkyo-Ku, Japan

 

Hypothalamic estrogen receptor (ER) α expressing neurons are considered to relay gonadal estrogen feedback signal to GnRH1 neurons, whose regulation on gonadotropin release is demonstrated to be widely conserved in vertebrates (1).

Recently, in mammals, Kiss1 neurons have been suggested to stimulate GnRH1 neurons in accordance with estrogen level. However, the essential role of Kisspeptin in reproductive regulation may not be common to all vertebrate species. For example, avian species do not possess kisspeptin gene, and kiss1 knockout medaka show normal fertility (2). In addition, even in mammals, some reports suggested that Kiss1 deficiency does not always cause infertility. Therefore, it may be suggested that, in addition to kiss1 neurons, some other neuronal systems may play important roles in the HPG axis regulation. To clarify the estrogen feedback pathway to the HPG axis, we have been using medaka as a model animal because of their easy access to molecular genetic tools and some of their characteristics of reproduction. We have already reported on their estrogen and testosterone receptor distribution (3).

In the present study, to clarify the estrogen feedback pathway to GnRH1 neurons, and to understand general feedback regulation system of the HPG axis in vertebrates, we generated transgenic (Tg) medaka line, which express EGFP in ERα-expressing neurons (ERα neurons).

First, we generated constructs for Tg medaka, by fusing medaka genomic DNA fragment containing the 5’-flanking region of the exon2 of erα gene with an EGFP. By injecting this construct, we established a Tg medaka line. EGFP positive cells were distributed in brain areas such as Vs, POA, NVT, which have been reported as main estrogen target regions. Then, we confirmed the specificity of EGFP labeling for ERα histologically, by double labeling for EGFP protein and erα mRNA. We analyzed the neural projection of ERα neurons. We found that the ERα neurons in POA projected to cell bodies of GnRH1 neurons. We also demonstrated, by double labeling with vglut2.1 or gad1.1 in situhybridization, that most of these ERα neurons were glutamatergic, while some POA-ERα neurons were GABAergic.

Thus, we suggest that POA glutamatergic and/or GABAergic ERa neurons relay estrogen signals to GnRH1 neurons in medaka. In this scenario, ERα neurons receive circulating estrogen and regulate GnRH1 neurons by glutamate and/or GABA in accordance with reproductive states, which is consistent with previous studies in mice demonstrating that glutamate/GABA synaptic input to GnRH1 neuron is altered by estrogen level (4, 5). Taken together, GnRH1 neuronal regulation mediated by glutamatergic and/or GABAergic POA ERα neurons is widely conserved among mammals and teleosts, and is possibly an original mechanism for HPG axis feedback regulation in vertebrates.

 

Nothing to Disclose: BZ, SK, YA, YO

OR16-3 19522 3.0000 A POA ER Alpha Neurons Transmit Estrogen Feedback Signal to GnRH1 Neurons for the Hypothalamo-Pituitary-Gonadal Axis Regulation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR16 5899 11:30:00 AM Kisspeptin-GnRH-Gonadotrope Axis Oral


Hanne Mette Hoffmann*1, Ikuo Kimura2, Ping Gong3, Crystal Trang1, Alexander S Kauffman3 and Pamela L Mellon1
1Center for Circadian Biology, University of California, San Diego, La Jolla, CA, 2Department of Applied Biological Science, Fuchu-shi, Japan, 3Univ of California San Diego, La Jolla, CA

 

Sexual maturation and fertility are regulated by the hypothalamic-pituitary-gonadal (HPG) axis. Improper development or disruption of this axis leads to reduced fertility or complete infertility. Infertility classed as idiopathic hypogonadotropic hypogonadism (IHH) is characterized by delayed or absent sexual development, and low gonadotropin and sex steroid levels. Approximately 60% of IHH patients present with defects in GnRH neuronal migration or maturation. Although mutations in various genes have been identified in IHH patients, the genetic causes of the majority of cases remain unknown. We recently determined that haploinsufficiency of the homeodomain transcription factor Ventral Anterior Homeobox 1 (Vax1) leads to subfertility due to a >60% reduction of GnRH neurons. Based on this finding, we hypothesized that Vax1 in GnRH neurons was required for GnRH neuron maturation. To test this, we generated the Vax1 flox mouse and crossed it with GnRHcre mice. Deletion of Vax1 in GnRH neurons produced a 99% reduction in GnRH expressing neurons, which led to a dramatic reduction in LH, FSH, hypogonadism, infertility, and absence of estrous cycling. To determine the role of Vax1 in GnRH neuron maturation, we investigated the developmental stage at which absence of Vax1 was important for GnRH neuron maturation. We counted GnRH neurons in Vax1 wild-type, heterozygote and knock-out (KO) embryos at e13.5, 2 days after the first GnRH neurons are detected in the mouse brain, and at e17.5, when the majority of GnRH neurons are found in the hypothalamus. At e13.5, Vax1KO mice had normal GnRH neuron numbers. In stark contrast, at e17.5, Vax1KO had no GnRH neurons in the brain, whereas Vax1 heterozygotes retained 50% of the neurons. This indicates that Vax1 is not required for GnRH neuron generation, but is necessary for GnRH neuron maturation/survival. The lack of GnRH staining could be due to absence of GnRH transcription. To identify a potential role of Vax1 as a regulator of the GnRH promoter, we first determined by in situ hybridization that GnRH neurons express Vax1 with an onset at the cribriform plate and maintain Vax1 expression hereafter. In agreement with this, the immature GnRH cell line, GN11, does not express Vax1, whereas the mature GnRH cell line, GT1-7, does. A detailed study of the GnRH promoter revealed that Vax1 is an activator of the proximal GnRH promoter in GN11 cells, whereas it represses GnRH transcription in GT1-7. The role as a transcriptional repressor of the GnRH promoter by Vax1 in mature GnRH neurons makes it unlikely that absence of Vax1 late in development would lead to absence of GnRH staining. In conclusion, during GnRH neuron migration, Vax1 is required for survival or maturation of GnRH-expressing neurons. Absence of Vax1 leads to absence of GnRH staining, hypogonadism and infertility. This work identified Vax1 as a key homeoprotein required for correct maturation of GnRH neurons.

 

Nothing to Disclose: HMH, IK, PG, CT, ASK, PLM

OR16-4 18606 4.0000 A Absence of Vax1 in GnRH Neurons Abolishes GnRH Expression and Leads to Hypogonadism: Investigating the Role of the Homeoproteins, Vax1, in GnRH Neuron Maturation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR16 5899 11:30:00 AM Kisspeptin-GnRH-Gonadotrope Axis Oral


Daniel J Bernard*1, Vikas Kumar2, Alexandre Boyer3, Ying Wang1, Romain Lambrot4, Xiang Zhou2, Charlene Rico3, Ulrich Boehm5, Marilene Paquet3, Christophe Celeste3, Sarah Kimmins6 and Derek T Boerboom7
1McGill University, Montreal, QC, Canada, 2McGill Univ., Montreal, QC, Canada, 3Université de Montréal, 4McGill Univ, QC, Canada, 5University of Saarland School of Medicine, Homburg, Germany, 6McGill Univ, Montreal, QC, Canada, 7University of Montreal, Saint-Hyacinthe, QC, Canada

 

Though classically considered a WNT signaling intermediary, CTNNB1 (β-catenin) can also mediate GnRH nduction of gonadotropin β subunit (Fshb and Lhb) transcription in the murine gonadotrope-like cell line LβT2. Here, we assessed CTNNB1’s role in gonadotropin synthesis in vivo. We used a Cre/lox approach to introduce both gain- and loss-of-function mutations in the murine Ctnnb1 gene in gonadotrope cells. Gonadotropin production and fertility were normal in Ctnnb1 knockout mice. Similarly, females harboring a deletion of exon 3 of Ctnnb1, which stabilizes the resulting CTNNB1 protein, showed normal fertility and gonadotropin synthesis. Interestingly, males with the activating CTNNB1-Δexon 3 mutation exhibited 50% reductions in FSH synthesis and secretion, without a corresponding change in LH.  This selective regulation of FSH suggested an alteration in the activin/inhibin/follistatin system.  Indeed, CTNNB1-Δexon 3 males showed a 60% increase in serum inhibin B levels and, in culture, their pituitaries exhibited a greater sensitivity to exogenous inhibin than controls.  At the same time, pituitary, but not testicular, follistatin (Fst) expression was increased significantly in these mice. Castration normalized FSH levels in CTNNB1-Δexon 3 males to those seen in castrated controls.  Paradoxically, pituitaries from CTNNB1-Δexon 3 males exhibited greater basal and activin-stimulated FSH synthesis in vitro. Similarly, CTNNB1-Δexon 3 overexpression potentiated activin A-induced murine Fshb promoter activity in LβT2 cells.  Together, these results indicate that CTNNB1 is dispensable for gonadotropin synthesis in vivo.  However, sustained CTNNB1 signaling potentiates activin-induced Fshb expression in gonadotropes, but this effect is overcome in vivo by enhanced inhibin feedback sensitivity and Fst expression.

 

Nothing to Disclose: DJB, VK, AB, YW, RL, XZ, CR, UB, MP, CC, SK, DTB

OR16-5 18260 5.0000 A Beta-Catenin Stabilization in Gonadotropes Impairs Follicle-Stimulating Hormone Synthesis in Male Mice in Vivo 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR16 5899 11:30:00 AM Kisspeptin-GnRH-Gonadotrope Axis Oral


Horacio Novaira*1, Momodou Sonko1, Kyle Brunner1 and Sally Radovick2
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Baltimore, MD

 

Introduction: Pubertal onset requires regulated changes in the expression and release of gonadotropin-releasing hormone (GnRH) from hypothalamic GnRH secretory neurons that involves the participation of multiple sets of genes within functionally connected networks. Thus, elucidating the molecular mechanisms of GnRH gene expression and regulation is vitally important for a complete understanding of mammalian reproduction. Synchronous activation of GnRH gene transcription and secretion by pulsatile kisspeptin stimulation has been demonstrated at time of puberty. Using mouse-derived immortalized GnRH-secreting neuronal cell lines (GT1-7 and GN11) and transgenic mouse models, we have shown that kisspeptin regulates GnRH gene expression as well as secretion. These studies provided in vitro and in vivo evidence that the region between -3446 to -2806 bp of the mGnRH gene is involved in the regulation of hypothalamic GnRH by kisspeptin, referred to as the kisspeptin response element (KsRE). The GnRH promoter has been characterized in several previous studies, including the role of GnRH neural-specific element (NSE, located at -1005 to +23bp), which contains the genetic information necessary and sufficient for appropriate expression of GnRH in the adult hypothalamus. Epigenetic changes controlling GnRH gene expression in culture cells and primates were also evaluated.

Aim: To identify the modulation of chromatin structure of the KsRE and the NSE on mGnRH promoter during pubertal onset.

Methods and results: In this study, we describe genomic isolation of active regulatory elements within the KsRE and the NSE on the GnRH promoter during pubertal onset. Using a novel strategy for genome isolation of active regulatory elements termed FAIRE (Formaldehyde Assisted Isolation of Regulatory Elements) followed by Real-Time PCR, nucleosome-depleted DNA in the KsRE and NSE during pubertal onset was detected. Evaluation of the KsRE demonstrated inactive chromatin conformation at post natal day (PND) 7 when compared to input DNA (n=3-5, p≤0.001), active chromatin conformation at PND 15 (n=3-5, p≤0.01) and 35 (n=3-5, p≤0.001) when compared to the nucleosome-depleted DNA at PND7. Evaluation of the NSE demonstrated inactive chromatin conformation at PND 7 when compared to the input DNA (n=3-5, p≤0.001), followed by an active chromatin conformation at PND 15 (n=3-5, p≤0.01) and PND 35 (n=3-5, p≤0.001) when compared to the nucleosome-depleted DNA at PND 7. The β-actin promoter gene was used as an active chromatin control and no changes were observed in all groups. An element located between -1858 bp and -1567 bp of the mGnRH promoter was used as a negative control of these experiments.

Conclusion: These studies suggest that epigenetic mechanisms may be involved in pubertal onset acting at different cis-regulatory elements on the mGnRH promoter.

 

Nothing to Disclose: HN, MS, KB, SR

OR16-6 19985 6.0000 A The Epigenetic Signature of Puberty in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR16 5899 11:30:00 AM Kisspeptin-GnRH-Gonadotrope Axis Oral


Tobias Else*1, Andrew S. McDaniel2, Debnita Talapatra1, Andi K. Cani1, Daniel H Hovelson1, Scott A Tomlins1, Thomas J Giordano1, William E. Rainey3 and Gary D Hammer1
1University of Michigan, Ann Arbor, MI, 2University of Michigan, MI, 3The University of Michigan, Ann Arbor, MI

 

Adrenocortical carcinoma (ACC) is a rare endocrine neoplasia. Aldosterone production can be observed in ~3-5% of all ACCs. Recently somatic mutations in KCNJ5, CACNA1D, ATP1A1, ATB2B3were identified as an underlying genetic cause of aldosterone producing adenomas. This study explores these mutations as well as a set of common cancer associated mutations in oncogenes and tumor suppressors.

A total of 13 aldosterone producing ACC (APACC) were identified in the Michigan Endocrine Oncology Repository either by documentation of aldosterone production in the physician’s note or full or partial biochemical evaluation.

DNA isolated from formalin fixed paraffin embedded (FFPE) samples was subjected to targeted multiplexed PCR based next generation sequencing using two custom panels. The first panel (APA_v1), contained 310 multiplexed amplicons targeting the coding sequences of somatic mutations in aldosterone producing adenomas, as well as genes shown to harbor variants associated with adrenal hyperplasia. The second panel (OCP), contained 2,462 amplicons interrogating oncogenic hotspots from 58 genes, coding sequences of 33 tumor suppressors, and amplicons to assess copy number status in 42 genes frequently lost/gained in cancer.

Across the 13 APACCs, we generated an average of 274x and 787x coverage using the APA_v1 and OCP panels, respectively. Using the APA_v1 panel, we identified a total of four high confidence prioritized variants. Only one APACC harbored a previously unreported ATP1A1 G547D somatic mutation and a PRKAR1A L379fs deleterious variant. Another APACC also harbored a deleterious PRKAR1A variant (A337fs), while a third ACC harbored a rare (0.1% allele frequency in healthy populations), homozygous PDE11A germ line variant (N298S). By the OCP, we identified a total of 18 high confidence prioritized variants across the 13 cases. One APACC harbored a high confidence germ line CHEK2 T338fs deleterious variant. In another APACC we observed a homozygous MSH2 nonsense variant (R389X) and eight additional prioritized mutations (from 73 total high confidence somatic mutations), consistent with a hypermutation phenotype. Known activating mutations were identified in CTNNB1 (n=3 cases) and GNAS (n=1 cases). Copy number analysis identified 109 high level autosomal somatic CNAs across the 13 samples, consistent with high levels of genomic instability.  The most frequent alterations include focal amplifications & broad gains of TERT and chr5, broad gains of chr12 (including KRAS, CDK4, and MDM2), focal loss of MTOR (on 1p), and focal loss of CDKN2A(on 9p).

We conclude that mutations in genes observed in aldosterone-producing adenomas are rare in APACC. The oncogenic mutational landscape of APACC is well in accordance with that previously reported for ACCs. These findings suggest that the mechanisms causing excess aldosterone production in APACC may vary from that observed in APA.

 

Disclosure: SAT: Researcher, Life Technologies Corporation. TJG: Consultant, Interpace Diagnostics, Clinical Advisory Board member, Asuragen. WER: Scientific Board Member, Atterocor. GDH: Consultant, Embara, Owner, Atterocor, Consultant, orphagen, Consultant, ISIS. Nothing to Disclose: TE, ASM, DT, AKC, DHH

OR17-1 20389 1.0000 A The Mutational Profile of Aldosterone-Producing Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR17 5903 11:30:00 AM Novel Aspects of Adrenal Tumors and the HPA Axis Oral


Guillaume Assie*1, Simon Faillot2, Windy Luscap3, Hortense Wilmot Roussel2, Delphine Vezzosi4, Olivia Barreau5, Rossella Libe1, Fernande rené-Corail6, Karine Perlemoine1, Stéphane Bonnet7, Bertrand Dousset8, Lionel Groussin2, Xavier Bertagna1, Aurélien de Reynies9, Felix Beuschlein10 and Jerome Yves Bertherat11
1INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 2INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, 3INSERM U1016, CNRS UMR 8104, Institut Cochin Université Paris Descartes, Paris, 4Hosp Rangueil, Toulouse Cedex, France, 5Inserm U1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, 6INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, Paris, 7Inserm U1016, CNRS 8104, Université Paris Descartes, Institut Cochin, 8Department of Digestive and Endocrine Surgery, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France, 9Ligue Contre Le Cancer, Paris, 10Klinikum der Universität München, Ludwig-Maximilian University, Munich, Germany, 11INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

Introduction

Cortisol secretion by the adrenocortical adenomas is variable. This variability may be related to differences in pathophysiology.

Transcriptome identifies two different groups of adrenocortical adenomas, with globally distinct cortisol secretion levels. 

Cortisol secretion is related to the Protein Kinase A (PKA) pathway, and activating mutations in the alpha catalytic subunit of PKA (PRKACA) have recently been identified.

Finally about one third of adrenocortical adenomas have an activating mutation of beta-catenin (CTNNB1). The aim is to clarify the relationship between the transcriptome, secretion, and mutation status of adenomas.

Methods

47 adrenocortical adenomas studied by transcriptome (Affymetrix) were included (24 Cushing, 12 subclinical Cushing and 11 non-secreting). PRKACA and beta-catenin were analyzed by Sanger sequencing.

Results

Unsupervised classification show two distinct groups of adenomas, with distinct cortisol secretion levels : a group of "overt Cushing” adenomas (18/19), and an "admixture” group of non-secreting (11/28), subclinical Cushing (11/28) and overt Cushing (6/28) (Fisher p <0.001).

PRKACA mutations are found exclusively in the “overt Cushing group” (9/19) and in none in 27/28 adenomas from the “admixture” group (Fisher p <0.001). PRKACA mutated adenomas are gathered into a specific subgroup among the "overt Cushing group".

CTNNB1 mutations are present in 10/27 adenomas from the “admixture” group, and are found in 2/19 adenomas from the “overt Cushing” group (Fisher p = 0.08). None of the tumors with a PRKACA mutated adenoma present any CTNNB1 mutation.

Conclusion:

These results suggest the existence of  two types of adrenocortical adenomas, one related to the activation of the PKA pathway and responsible for overt Cushing, the other linked to the activation of the Wnt-beta-catenin pathway and associated with globally low -but variable- cortisol secretion levels.

 

Disclosure: JYB: Advisory Group Member, atterocor, Investigator, Novartis Pharmaceuticals, Investigator, Ipsen. Nothing to Disclose: GA, SF, WL, HW, DV, OB, RL, FR, KP, SB, BD, LG, XB, AD, FB

OR17-2 21305 2.0000 A Transcriptome and Mutational Status of Adrenocortical Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR17 5903 11:30:00 AM Novel Aspects of Adrenal Tumors and the HPA Axis Oral


Julliana dos Santos Frassei*1, Larissa Garcia Gomes2, Ricardo Paranhos Moreira2, Guiomar Madureira1, Berenice B Mendonca2 and Tania A Bachega2
1Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2School of Medicine, Sao Paulo University, Sao Paulo, Brazil

 

Background: treatment of congenital adrenal hyperplasia (CAH) is mainly based on glucocorticoid (GC) replacement. The GC daily dose presents a great interindividual variability, therefore, fine adjustment in doses is needed to avoid side effects related to over or undertreatment. It is already shown that the GC receptor polymorphisms influence GC therapeutic doses in certain diseases, such as reumathoid arthiris. Objective: to analyze if GC receptor gene variants influence the dexamethasone (DEX) doses during GC replacement in CAH  adults. Pacients: 64 CAH adults followed in our Service, treated with DEX therapy and presenting good hormonal control were enrolled; the salt wasters (SW) also received fludrocortisone. Thirty one had the SW (23F) and 33 the simple virilizing (SV, 27F) forms. The mean age at the last evaluation was 31.6 (±9.4) yrs. Methods: good hormonal control was defined by normal androgen levels according to sex/age in the last 5 years and normal serum electrolytes. Exclusion criteria were Cushing signs and/or increased blood preassure. Mean DEX doses, adjusted by body surface, were assessed during the last 5 yrs. BMI and lipid levels were obtained in the last evaluation. NR3C1 gene polymorphisms were screened by restriction enzymes and/or Sanger sequencing. Association analyses between genotype-phenotype were performed using Chi-square and t-tests. Results: The BclI, A3669G, N363S and ER22/23EK alleles were found in 28%, 9.5%, 0.1% and 0.1% of alleles, respectively, and the two former variants were in Hardy Weinberg equillibrium. The durations of DEX therapy were not different among wild-type (wt), BclI and A3669G carriers. Mean DEX dose did not differ among wt, BclI and A3669G carriers, 0.19±0.1, 0.17±0.07 and 0.16±0.05 mg/m²/d, respectively (p>0.05). Frequency of obesity among wt, BclI and A3669G carriers were 25%, 33% and 16%, respectively (p<0.05). Only the LDL-cholesterol levels significantly differed between wt and A3669G carriers, 106±32.6 and 124.9±37mg/dL, respectively (p=0.02). Conclusions: In this CAH series, the presence of GC receptor variants did not explain the interindividual variability in the daily DEX doses. However, we did observe a relationship between NR3C1 gene variants and the frequency of dyslipidemia during GC replacement.

 

Nothing to Disclose: JDSF, LGG, RPM, GM, BBM, TAB

OR17-3 20318 3.0000 A Pharmacogenetic Analysis of Glucocorticoid Gene Polymorphisms and Prediction of Daily Dexamethasone Doses in Adults with Congenital Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR17 5903 11:30:00 AM Novel Aspects of Adrenal Tumors and the HPA Axis Oral


Camilla AM Glad*1, Johanna C Andersson-Assarsson2, Peter Berglund2, Ragnhildur Bergthorsdottir3, Oskar Ragnarsson2 and Gudmundur Johannsson1
1Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden, 2The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden, 3Sahlgrenska University Hospital, Gothenburg, Sweden

 

Background: Patients with Cushing’s syndrome (CS) commonly present with cognitive deficits, fatigue, anxiety and depression. Despite improvement with remission following treatment, the cognitive impairments are often persistent and troublesome. The aetiology of the persistent cognitive impairment is unknown. Aim: To test the hypothesis that patients with CS in remission show specific epigenetic alterations that are associated with persistent cognitive impairments, anxiety, fatigue and depression. Patients and Methods: Cross-sectional, case-controlled, single centre study including 48 women with CS in remission and 16 controls matched for age, gender and educational level. The mean age (±SD) in patients was 52.9±14 yrs and 53.6±16 yrs in controls. The mean age at diagnosis of CS was 37±14 yrs and the median (interquartile range) duration of remission was 13 (5-19) yrs. Thirty-seven patients had Cushing’s disease (CD) and 11 had a cortisol producing adrenal adenoma. Fatigue impact scale (FIS) was used for evaluation of fatigue and the comprehensive psychopathological rating scale was used to evaluate depression and anxiety. Cognitive function was assessed by standardized neuropsychological tests. DNA was isolated from whole blood, and DNA methylation was analysed on the Illumina Infinium HumanMethylation450K BeadChip, which simultaneously interrogates > 465,000 methylation sites per sample. Data quality control and analysis was performed using the ChAMP methylation analysis package in R. Correlation analyses were performed using Spearman’s rho. Results: Patients had higher median score for FIS, depression and anxiety. Methylation analysis identified 3,903 probes (in 340 genes) in regions that were differently methylated between CS patients and controls, 28% of these were significantly correlated to at least one of the clinical traits. Fatigue, depression and anxiety were the most commonly correlated traits. Two of the most highly correlated genes were RXRB and COL11A2. Gene ontology analysis revealed that these belong to the same GO-terms and that they are involved in retinoic acid receptor activity. Both genes were specifically hypomethylated in cases as compared to controls. Conclusion: In this preliminary report, we show that patients with CS in remission show specific DNA methylation that is different from that of healthy controls and is strongly correlated with clinical traits of anxiety, depression and fatigue. The results may suggest that an interaction between the glucocorticoid and the retinoic acid receptor is implicated in the long-term outcome of patients with CS in remission. Thus, the persistent cognitive impairment observed in patients with CS in remission may be due to epigenetic modulation of DNA.

 

Disclosure: PB: Speaker, Boehringer Ingelheim, Speaker, Lundbeck. GJ: Speaker, Novo Nordisk, Speaker, Pfizer, Inc., Speaker, Otsuka, Speaker, Shire, Consultant, Astra Zeneca, Consultant, Viropharma. Nothing to Disclose: CAG, JCA, RB, OR

OR17-4 21242 4.0000 A Epigenetic Modulation of DNA Is Associated with Fatigue, Depression and Anxiety in Patients with Cushing's Syndrome in Remission: A Genome-Wide Methylation Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR17 5903 11:30:00 AM Novel Aspects of Adrenal Tumors and the HPA Axis Oral


Kazutaka Nanba*, Andrew Chen and William E. Rainey
University of Michigan, Ann Arbor, MI

 

Context: The human adrenal cortex produces mineralocorticoids, glucocorticoids, and adrenal androgens. The disruption of adrenal steroid production results in various disorders. In vitro cell culture models provide important information for understanding molecular and cellular mechanisms controlling both the normal and pathologic function of the adrenal cortex. The H295R adrenocortical cell line is widely used but is known to have very little ACTH responsiveness. The lack of ACTH response was linked to low expression of its receptor, MC2R. We hypothesized that increasing MC2R accessory protein (MRAP), which is normally required to traffic MC2R to the cell surface, would increase ACTH responsiveness. Objective: To develop an ACTH-responsive human adrenocortical cell line. Methods: Lentiviral particles containing human MRAP-ORF were generated and transduced in H295R cells. Using antibiotic resistance, eighteen clones were isolated for characterization. The most ACTH-responsive steroidogenic clone, H295RA, was used for further experiments, including steroid assay, RT-qPCR, and protein analysis. Results: Successful induction of MRAP was confirmed by RT-qPCR. Treatment with ACTH (10 nM) for 24 h increased cortisol accumulation in H295RA cells (2.1-fold). ACTH also increased transcript levels for MC2R (12-fold), HSD3B2 (4-fold), and CYP11B1 (16-fold), while only small effects were observed in the parental cell model (less than 1.5-fold increase in cortisol, as well as in transcript levels for MC2R, HSD3B2, and CYP11B1). Treatment of H295RA cells with ACTH also acutely increased cellular protein levels for total StAR and phosphorylated StAR. Conclusion: Through genetic manipulation, we have developed an ACTH-responsive human adrenocortical cell line. This model will provide a powerful in vitro tool for molecular analysis of physiologic and pathologic conditions involving the HPA axis.

 

Disclosure: WER: Scientific Board Member, Atterocor. Nothing to Disclose: KN, AC

OR17-5 19109 5.0000 A Development of an ACTH-Responsive Human Adrenocortical Cell Line 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR17 5903 11:30:00 AM Novel Aspects of Adrenal Tumors and the HPA Axis Oral


Keiichi Itoi*1, Ashraf Hossain Talukder1, Toshimitsu Fuse1, Katsuya Uchida1, Junko Kono1, Kotaro Konno2, Maya Yamazaki3, Manabu Abe3, Masahiko Watanabe4 and Kenji Sakimura3
1Tohoku Univ, Sendai, Japan, 2Hokkaido Univ, Sapporo, Japan, 3Niigata Univ, Niigata, Japan, 4Hokkaido University School of Medicine Sapporo, Sapporo, Japan

 

Corticotropin-releaseing factor (CRF) plays a pivotal role in the regulation of hypothalamic-pituitary-adrenal stress axis. Developing animal models in which CRF neurons are visualized by fluorescent proteins is an imminent requirement for studying the structure and function of CRF neurons. Therefore, Venus (enhanced yellow fluorescent protein) gene was inserted into the CRF coding region in exon 2 in frame by homologous recombination, and CRF-Venus knock-in mouse was generated. Venus was expressed in the majoroty of CRF neurons in the paraventricular nucleus of the hypothalamus (PVH) of the CRF-Venus mouse as was shown by double immunofluorescence, but there were many CRF neurons that did not express Venus. Deletion of the pgk-Neo cassette from the CRF-Venus genome (CRF-VenusΔNeo) improved greatly the colocalization of Venus with CRF, and most Venus neurons expressed CRF and vice versa. Venus expression was dependent on the circulating glucocorticoid level in both CRF-Venus and CRF-VenusΔNeo, reflecting that the Venus gene was driven by CRF promoter. The EGFP/CRF-iCre mouse was generated by crossing a CAG-CAT-EGFP reporter with a CRF-iCre knock-in mouse. EGFP was expressed in most CRF neurons in the PVH of the EGFP/CRF-iCre. Venus or EGFP was expressed in most brain regions, in which CRF is reported to be expressed, in either CRF-Venus, CRF-VenusΔNeo, or EGFP/CRF-iCre mouse. In extrahypothalamic brain regions, Venus-expressing neurons overlapped with CRF mRNA-expressing neurons in a fairly good manner. These mouse lines will serve as useful tools for elucidating the neurobiology of CRF neurons in the brain.

 

Nothing to Disclose: KI, AHT, TF, KU, JK, KK, MY, MA, MW, KS

OR17-6 21835 6.0000 A Visualization of CRF Neurons in the Brain By Fluorescent Proteins: A Comparison Between CRF-Venus, CRF-Venus Delta Neo, and EGFP/CRF-Cre Mouse 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR17 5903 11:30:00 AM Novel Aspects of Adrenal Tumors and the HPA Axis Oral


Chaojie Wang*, Adlina Mohd-Yusof, Hiroshi Nakanishi, Motoyasu Saji and Matthew D Ringel
The Ohio State University, Columbus, OH

 

Metastasis suppressor proteins inhibit metastasis and secondary progression, and their loss can lead to metastatic progression. Their role in restraining progression may be magnified in tumors characterized by metastatic dormancy, such as differentiated thyroid cancer. Defining mechanisms of action may lead to translational opportunities to predict or treat progressive metastatic cancer. We recently identified RCAN1-4 (Regulator of Calcineurin 1-4) as a potential cell-autonomous metastasis regulator in thyroid cancer and other tumor types based on signaling properties of known metastasis suppressors in vitro and on subsequent in vitro studies that demonstrate RCAN1-4 dependence of cell migration. In the present study, we hypothesized that RCAN1-4 directly functions to inhibit thyroid cancer metastases in vivo. To test this hypothesis, thyroid cancer cell lines with high endogenous RCAN1-4 expression (Hth74 and FTC236) were utilized to create RCAN1-4 knockdown stable cells using RCAN1-4 specific shRNA. The knockdown was confirmed by quantitative PCR and Western blot. The cells were also engineered to stably express the firefly luciferase gene to enable in vivo imaging (IVIS). The RCAN1-4 knockdown cells demonstrated no significant difference in growth rate compared with the control cells measured by cell counting for both cell lines. However, the knockdown cells showed markedly increased invasion compared with control cells in in vitro invasion assays. 3D culture also showed increased migration in the knockdown cells. In xenograft models, mice inoculated with Hth74-shRCAN1-4 cells had faster tumor growth rate and significantly larger tumor size compared with control cell xenografts after 12 weeks (2450.2 mm3 vs 199.1 mm3, n = 4, p < 0.01). Metastatic modeling using tail vein injection showed mice injected with the knockdown cells developed lung metastases 3 weeks after injection while no lung metastases were observed in mice injected with control cells until 12 weeks. IVIS imaging of the mice showed RCAN1-4 knockdown cells maintained enhanced metastatic progression versus control cells at the 12 weeks (87.5% vs 33.3%, n ≥ 8, p < 0.01). The results were further confirmed by histological examination of the lungs. Our data indicates that RCAN1-4 has no effect on cancer cell growth in vitro but is a key regulator of both tumor growth and invasion in vivo. Further in vivo studies using additional cell lines, including those in which RCAN 1-4 is conditionally increased, are ongoing. In summary, RCAN 1-4 may represent a novel metastasis suppressor in thyroid cancer.

 

Nothing to Disclose: CW, AM, HN, MS, MDR

OR23-1 21085 1.0000 A RCAN1-4 Is a Novel Metastasis Suppressor Gene 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 1:00:00 PM OR23 5914 11:30:00 AM Thyroid Hormone Action, Cancer and Clinical Thyroid Oral


Jinyoung Choi*1, Ken-ichi T. Suzuki2 and Daniel R. Buchholz1
1University of Cincinnati, Cincinnati, OH, 2Hiroshima University, Hiroshima, Japan

 

Thyroid hormone (TH) receptors (TRs) play dual roles in TH-dependent development in vertebrates. TR acts to repress genes involved in developmental progression in the absence of TH, and in TH circulation, it binds TH, inducing the previously repressed genes to lead to developmental changes. TR expression occurs in the absence of or low circulating TH levels during development in all vertebrates, yet few developmental roles for unliganded TRs have been established. Unliganded TRs are expected to repress TH-response genes, increase tissue responsivity to TH, and regulate the timing of developmental events. Using TALENs (Transcription activator-like effector nucleases) technique, we disrupted TR alpha (TRα) in Xenopus tropicalis to examine the role of unliganded TRα in gene repression and development. By injecting TRα TALEN mRNA into one cell of two-cell stage embryos, half side mutant founder animals were generated. Offspring with a wild type phenotype had zero or one disrupted TRα alleles, and tadpoles with the mutant hind limb phenotype had two disrupted TRα alleles each causing a frame-shift between the two zinc fingers followed by 40-50 mutant amino acids and then an out-of-frame stop codon. We examined expression levels of TRβ, ST3 and KLF9, and early larval development with and without exogenous TH in F1 offspring. As hypothesized, we found increased expression of three TH-response genes in mutant phenotype tadpoles in the absence of TH. Similar results after the use of methimazole to block endogenous TH synthesis showed that increased TH-response gene expression and precocious development in mutant phenotype tadpoles was not due to early production of TH. Impaired induction of the three genes was observed in mutant phenotype tadpoles after exogenous TH treatment. Morphological analysis revealed reduced hind limb and gill responsivity to exogenous TH in mutant tadpoles when compared with wild type tadpoles at same age and stage. Growth rate profiling between NF stage 46 to 64 also supports our hypotheses that the lack of TRα causes early initiation and progression of metamorphosis showing difference in body size between wild type and mutant phenotype tadpoles. These results indicate that unliganded TRα regulates developmental timing by repressing TH-response genes to allow larval growth until TH is released into circulation.

 

Nothing to Disclose: JC, KITS, DRB

OR23-2 20968 2.0000 A Unliganded Thyroid Hormone Receptor Regulates Developmental Timing 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 1:00:00 PM OR23 5914 11:30:00 AM Thyroid Hormone Action, Cancer and Clinical Thyroid Oral


Hiroaki Shimizu*1, Inna Astapova1, Felix Ye1, Ronald N Cohen2 and Anthony Neil Hollenberg1
1Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 2University of Chicago, Chicago, IL

 

The nuclear receptor corepressors NCoR1 and SMRT play critical roles in mediating the action of nuclear receptors (NRs) in both metabolic disease and cancer. However, how the specificity of interactions with target NRs is mediated remains unclear. To further evaluate this we have used a variety of mouse models that target individual corepressors or both to specifically examine the role of NCoR1 and SMRT in thyroid hormone (TH) signaling. Despite being present in equal amounts in the liver at the protein level, the tissue-specific disruption of SMRT leads to no change in TH signaling in either the euthyroid or hypothyroid state in the liver. In contrast disruption of NCoR1 function in the liver alone leads to the increased expression of hepatic TH target genes despite similar levels of circulating T4 and T3 as controls. Thus, NCoR1 specifically targets TH signaling in the liver. To assess the role globally of SMRT in TH signaling we used a post-natal disruption strategy given that embryonic deletion of SMRT is lethal in mice. Similarly, post-natal disruption of SMRT in all tissues has no effect on the set point of the hypothalamic-pituitary thyroid axis while global disruption of NCoR1 leads to a re-setting of the axis such that circulating TH levels are low with a normal TSH. Taken together these data suggest that NCoR1 plays a specific role in TH action in the liver and in the regulation of the HPT axis while SMRT plays little role. In contrast, in the liver, in both tissue-specific and global mouse disruption models SMRT regulates the expression of the Cyp26a1 gene which is a key target of the retinoid acid receptor isoforms and regulates retinoic acid metabolism. Thus, these data suggest that corepressor specificity exists in vivo and that strategies that target individual corepressors could be developed to enhance or inhibit specific NR signaling pathways.

 

Nothing to Disclose: HS, IA, FY, RNC, ANH

OR23-3 21913 3.0000 A The Role of NCoR1 and SMRT in Nuclear Receptor Signaling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 1:00:00 PM OR23 5914 11:30:00 AM Thyroid Hormone Action, Cancer and Clinical Thyroid Oral


Kevin Phillips*
Houston Methodist Research Institute, Houston, TX

 

Mammals possess both white (WAT) and brown adipose tissue (BAT). WAT has low metabolic potential and is associated with obesity and the maladies of metabolic syndrome, while BAT has high metabolic potential and is associated with resistance to obesity. Functional conversion of WAT into a tissue with BAT-like activity, an action often referred to as “browning” has become an intriguing strategy to combat metabolic disease. Although, thyroid hormone receptors (TRs) have long been associated with metabolic regulation and adaptive thermogenesis, a full understanding of this relationship is lacking. Here, we report that pharmacological TR activation the synthetic agonist GC-1 evokes a profound functional conversion of WAT into a brown adipose-like tissue. TR agonist treatment of genetically obese (ob/ob) and diet induced obese (DIO) mice dramatically increases UCP-1 expression and upregulates the entire program of adaptive thermogenesis, uncoupled respiration, and mitochondrial biogenesis in WAT that is correspondent with an amelioration of obesity and insulin resistance. Consistent with the idea that metabolic increase is mediated principally by WAT, this effect does not require functional brown fat, yet all thermogenesis is lost in lean mice that possess little WAT. TR activation can also induce uncoupled respiration in white adipocytes in vitro demonstrating that browning is a cell autonomous effect of TR activation in WAT. This data demonstrates that TR activation can elicit a functional conversion of white to brown fat, a previously unrecognized component of TR-mediated thermogenesis, and suggests that WAT browning may have profound pharmacological potential.

 

Nothing to Disclose: KP

OR23-4 22175 4.0000 A Turning White Fat Brown - Can a Metabolic Villain be Reformed? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 1:00:00 PM OR23 5914 11:30:00 AM Thyroid Hormone Action, Cancer and Clinical Thyroid Oral


Eleanor M. Simonsick*1, Jennifer Sophie Mammen2, Chee W. Chia1 and Luigi Ferrucci1
1National Institute on Aging, Baltimore, MD, 2Johns Hopkins Medical Institutions, Baltimore, MD

 

Emerging evidence suggests that mildly down-regulated thyroid function with increasing age may be protective and/or indicative of maintained health in old age. To further address this hypothesis, we examined the concurrent relationship between free thyroxine (FT4) level in euthyroid men and women and functional mobility and fatigue, key indicators of health status, in older adults. Study participants are from the Baltimore Longitudinal Study of Aging, an ongoing prospective observational study of normative aging conducted by the National Institute on Aging (NIA) Intramural Research Program (IRP). This volunteer sample of 597 men (n=332) and women aged 68 to 97 years (mean (SD) =78.0(6.6)) with normal thyroid function (TSH level between 0.45-10.0 mU/L and taking no thyroid medications) were seen between January 2006 and March 2014 in the NIA IRP Clinical Research Unit at Harbor Hospital, Baltimore, Maryland. The main outcome measures included self-reported walking ability, usual and rapid gait speed over 6 meters, endurance walk performance over 400 meters, fatigability performance and reported energy level over the past month. These outcomes were examined with respect to FT4 level within the normal range (0.76-1.50 ng/dL) as a continuous variable and categorized as low (lower quartile: 0.76-0.89), medium (interquartile range: 0.90-1.09) or high (upper quartile: 1.10-1.50). In analyses adjusted for sex, age, race, height, weight, exercise and smoking, reported walking ability, usual and rapid gait speed, 400m time, fatigability and reported energy level were less favorable with increasing FT4 (p=.008 to <.001).  In sex-stratified analyses, the same associations were observed in men with the exception of reported walking ability and in women with the exception of reported energy level.  Categorical analyses revealed that persons with low FT4 exhibited better functional mobility on all measures and reported a higher mean frequency of a lot of energy than persons with intermediate or high FT4 (p<.05 for all).  Persons with high FT4 showed worse functioning than persons with intermediate FT4 for usual and rapid gait speed only.  In older adults with normal thyroid function, both men and women with FT4 levels at the lower end of normal exhibit better mobility functioning and more favorable fatigue profiles.  Findings add to evidence that mildly down-regulated thyroid function aligns with better health status in old age and thus may serve as a biomarker of healthy longevity.

 

Nothing to Disclose: EMS, JSM, CWC, LF

OR23-5 21944 5.0000 A Higher Free Thyroxine Level Is Associated with Worse Functional Mobility and Greater Fatigue in Euthyroid Men and Women from the Blsa 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 1:00:00 PM OR23 5914 11:30:00 AM Thyroid Hormone Action, Cancer and Clinical Thyroid Oral


Juliane Leger*1, Sophie Dos Santos2, Beatrice Larroque3 and Emmanuel Ecosse2
1Hopital Robert Debre, Université Paris Diderot, Paris, France, 2Hopital Robert Debre, Paris, France, 3Hopital Beaujon, Clichy, France

 

Background: Untreated hypothyroidism is associated with a higher risk of adverse obstetric and neonatal outcomes. Patients with congenital hypothyroidism (CH) born before the introduction of neonatal screening programmes, about 35 years ago in most industrialised countries, suffered from severe brain damage, and no cohort studies on pregnancy outcome in these individuals have been reported. The first patients treated since the introduction of screening are thus now young adults of reproductive age (1) and pregnancy complications have yet to be evaluated in patients treated early for CH. We recently showed that there was no evidence of generally lower fecundity in a cohort of patients treated early through the CH screening programme (2).

We aimed to investigate pregnancy outcomes and their determinants in these women.

Methods: In total, 1748 subjects were diagnosed with CH in the first 10 years after the introduction of neonatal screening in France; 1158 of these subjects completed a questionnaire on fecundity at a mean age of 25.3 years. We analyzed all declared singleton pregnancies ending after more than 22 weeks of gestation before the initial survey (n = 207 pregnancies) and in the three years following the initial survey (prospective study, n= 174 pregnancies). The reference group comprised 7245 subjects from the French National Perinatal Survey.

Results: In both the overall and prospective analyses, CH was associated with gestational hypertension, emergency cesarean delivery, induced labor for vaginal delivery, and prematurity. For the prospective population with CH, the adjusted odds ratios (95% CI) were 2.19 (1.26-3.81), 1.88 (1.17-3.02), 1.58 (1.12-2.24), and 1.85 (1.06-3.25), respectively. TSH concentrations ≥10 mIU/l during the first three or six months of pregnancy were associated with a higher risk of preterm delivery (aOR: 5.6, 95% CI 1.6 – 20.0) and fetal macrosomia (aOR: 4.5, 95% CI 1.03 – 20.1), respectively, whereas no such relationship was observed for TSH concentrations of 5.0-9.9 mIU/l. Patients with athyreosis required significantly higher levothyroxine doses than those with ectopic or eutopic thyroid glands (p<0.01). Disease etiology and severity were not associated with a higher risk of adverse outcomes.

Conclusion: CH may result in adverse pregnancy outcomes. These nationwide data suggest that better thyroid disease management is required, particularly during the first two trimesters of pregnancy, together with vigilant monitoring.

 

Nothing to Disclose: JL, SD, BL, EE

OR23-6 19337 6.0000 A Pregnancy Outcomes and Relationship to Treatment Adequacy in Women Treated Early for Congenital Hypothyroidism: A Longitudinal Population-Based Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 1:00:00 PM OR23 5914 11:30:00 AM Thyroid Hormone Action, Cancer and Clinical Thyroid Oral


Marissa Penna-Martinez1, Dimitra Bogdanou1, Claudia Döring2, Firouzeh Shoghi2, Yasmin Morán-Auth2, Nojan Nejatian2, Martin-Leo Hansmann2 and Klaus Badenhoop*3
1University Hospital, Goethe-University Frankfurt am Main, Germany, 2University Hospital Frankfurt am Main, Germany, 3Goethe-University Hospital, Frankfurt, Germany

 

Introduction: Dysregulated T helper cells are key factors in the pathogenesis of Type 1 diabetes mellitus (T1D) that may occur isolated or as part of an autoimmune polyendocrine syndrome (APS). The high prevalence of vitamin D (VD) deficiency in T1D patients prompted us to investigate clinical immune effects of high dose VD treatment and the gene expression pattern in T helper cells (Th) before and after therapy in patients with T1D stratified for the APS phenotype. Methods: Fourteen T1D patients (7 isolated-T1D and 7 T1D-APS) with 25(OH)D3 levels below 20ng/ml received three months 4000 IU/d Vigantol oil as part of the RCT VIDDA1. The 25(OH)D3 concentration and gene expression within Th cells were measured at baseline (V1) and after three months (V3). Mononuclear cells were isolated from freshly collected EDTA-blood and Th cells purified using magnetic sorting. The gene expression profile was investigated using GeneChip Human 1.0 ST (Affymetrix). 25(OH)D3 plasma concentrations were measured by radioimmunoassay. VD-therapy effects on the gene expression were evaluated by the differences between V1 and V3 (expressed in fold changes=FC) within the patient groups by  the statistical computing environment R version 3.0.2 [R Development Core Team, 2005]. Results: As expected the 25(OH)D3 concentrations rose significantly after high dose VD (median peaks: T1D 38 ng/mL, T1D-APS 37 ng/ml; p=0.01). In Th cells forty-four annotated genes changed significantly in patients with T1D and thirty-two in T1D-APS patients. Notably, in T1D patients a set of genes which code for zinc finger proteins (FC:-1.2 to -1.4;p=0.04-0.02) and chromosome open reading frame (FC:-1.4 to -1.2;p=0.004-0.03) showed a lower expression after treatment. Also the genes SNOD82 (FC:-1.8;p=0.01), interferon receptor-1 (FC:-1.3;p=0.02) and CD63-molecule (FC:-1.4;p=0.02) were down-regulated. In contrast, a set of genes which code for small nuclear RNA different families (SNORD FC:1.5-3.8;p=0.03-0.0008,SNORA FC:2.1-2.8;p=0.02-0.005,SCARNA FC:1.6-2.8;p=0.004), histone cluster 1/2 (FC:1.5-1.8;p=0.01-0.02) and Interleukin-32 (FC:1.6;p=0.02) showed a higher expression only in T1D-APS patients. Conclusion: VD therapy with 4000 IU/d affects gene expression profiles in T1D patients in a differential manner depending on the coexisting APS phenotype. These results reflect the heterogeneous pathogenic pathways leading to T1D and illustrate that any immune intervention will need to address this background. Our results demonstrate for the first time, that VD therapy in T1D patients regulates the gene expression patterns of Th cells in a disease specific manner.

 

Nothing to Disclose: MP, DB, CD, FS, YM, NN, MLH, KB

OR18-1 20870 1.0000 A High Dose Vitamin D Treatment Regulates Different Gene Expression Patterns in T Helper Cells of Type 1 Diabetes Patients with Autoimmune Polyendocrine Syndrome (APS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR18 5925 11:30:00 AM Novel Aspects of Insulin Sensitivity and Secretion Oral


Yang Shen* and Dorothy Santos Martinez
UCLA, Los Angeles, CA

 

Introduction: 

The prevalence of diabetes in China has increased significantly in the past 30 years. Recent national survey reported the prevalence of diabetes was more than 11% and the prevalence of pre-diabetes was 50% in 2010 (1). The prevalence of metabolic syndrome has not been assessed nationwide in recent years. 

Data and Methods:

China Health and Retirement Longitudinal Study (CHARLS) is a randomized and stratified national sample to collect information on the health and social economic status of adult Chinese. The survey focused on adults who were at least 45 year old. The baseline survey was completed in the 2011-2012 period, which included 17708 individuals (10257 households) from a total of 150 townships in 28 provinces of China. Logit transformation, Pearson’s chi-square test and logistic regression were used in statistical analyses. 

Results:

The overall prevalence of diabetes in this national sample was 13.2% (95% CI: 12.7% to 13.7%). The estimated prevalence of undiagnosed diabetes were 7.5% (95% CI: 7.2% to 7.9). The prevalence of pre-existing diabetes were 5.7% (95% CI: 5.4% - 5.9%). Using the definition of fasting glucose >=100mg/dL (ADA guideline 2014), we estimated the prevalence of impaired fasting glucose was 46.2% (95% CI: 45.3% - 47.1%).  The prevalence of diabetes was higher in older age groups: for adults >=55 year old, the prevalence was estimated to be 15.2%.  Using ATPIII definition of metabolic syndrome (2), the prevalence of Chinese adults with metabolic syndrome was estimated to be 19.7% (95% CI: 19.0% - 20.5%, unweighted). Metabolic syndrome was more prevalent among older respondents as well as among female respondents.  A significantly higher proportion of people with metabolic syndrome reported a history of heart disease (17.9% vs 11.1%, p<0.001) and a history of stroke (3.3% vs 2.1%, p=0.001), in comparison to people without metabolic syndrome. 

Conclusions: 

The overall prevalences of diabetes and impaired fasting glucose were comparable to the previously reported national estimates in China. Nearly 20% of Chinese adult population had metabolic syndrome, a condition associated with increased risks of cardiovascular diseases. This study provided additional evidence that diabetes and metabolic syndrome are emerging public health concerns in China. 

References:

  1. Xu Y, et al. Prevalence and control of diabetes in Chinese Adults. JAMA 2013: 310(9):948-958
  2. Grundy, S, etal. Definition of Metabolic Syndrome. Circulation 2004; 109: 433-438

 

Nothing to Disclose: YS, DSM

OR18-2 19507 2.0000 A The Prevalence of Impaired Fasting Glucose, Diabetes and Metabolic Syndrome in China 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR18 5925 11:30:00 AM Novel Aspects of Insulin Sensitivity and Secretion Oral


Yacir Benomar1, Hamza Amine2, Arieh Gertler3 and Mohammed Taouis*4
1University of Paris-Sud, France, 2University Paris-Sud, 3Hebrew Univ Inst of Biochemist, Rehovot, Israel, 4University of Paris XI, Chilly Mazarin, France

 

Central resitin infusion impairs FGF21/FGFR1/ β-Klotho hypothalamic expression and promotes peripheral FGF21 resistance: involvement of resistin/TLR4 signaling pathway.

Yacir Benomar, PhD 1, 2, Hamza Amine 1,2, Arieh Gertler, PhD3 and Mohammed Taouis, PhD 1,2

1Neuroendocrinologie Moléculaire de la Prise Alimentaire, University of Paris-Sud, UMR 8195, Orsay, F-91405, France.

2 Neuroendocrinologie Moléculaire de la Prise Alimentaire, CNRS, Centre de Neurosciences Paris-Sud UMR8195, Orsay, F-91405, France.

3The Institute of Biochemistry, Food Science, and Nutrition, Faculty of Agricultural, Food and Environmental Quality Sciences, The Hebrew University of Jerusalem, PO Box 12, 76100 Rehovot, Israel.

FGF21 is a pleiotropic hormone-like protein that has recently emerged as a major regulator of metabolism. FGF21 administration improves insulin sensitivit and leads to weight loss in obese mice. FGF21 is also a key regulator of adiponectin secretion. FGF21 acts through FGF receptors (FGFR 1, 2, 3 and 4). However, in contrast to the classic FGFs, a non-FGFR cofactor β-Klotho (KLB) is crucially required for FGF21 signaling and action. Although FGFRs are widely expressed, KLB is predominantly expressed in metabolically active organs such as adipose tissue, liver, and pancreas, but also in the hypothalamus making these as primary sites of FGF21 action. Recently, the notion of FGF21-resistance has been suggested in obese state.

In the present study, we aim to investigate whether central resistin/TLR4 pathways contribute to FGF21 resistance. To test this hypothesis, we assessed, in C57BL6 mice and Wistar rats, the impact of ICV resistin infusion on FGF21, FGFRs and KLB expression in the hypothalamus and key peripheral tissues: liver, muscle and white adipose tissue (WAT). Here we show that ICV resistin infusion significantly decreases hypothalamic FGF21 expression in both mice and wistar rats. The expression of FGFR1, the most abundant receptor in the hypothalamus, and KLB were also significantly reduced by resistin treatment. Similar results were obtained in resistin treated human neuronal cells SH-SY5Y. In peripheral tissue, ICV resistin increases the expression of FGF21 in both liver and WAT. In addition, this treatment reduces the expression levels of FGFR1 in both WAT and muscle.  Furthermore, ICV resistin treatment down-regulates KLB in WAT. Finally, the repression of TLR-4 using siRNA strategy in SH-SY5Y cells almost completely abolished resistin effect on FGFR1 and KLB expression.

In conclusion, we show 1/ central resistin down-regulates FGF21, FGFR1 and KLB in the hypopthalamus and promotes peripheral FGF21 resistance as mirrored by the overexpression of FGF21 in the liver and WAT with the down-regulation of FGFR1; 2/ resistin effects on FGF21 signaling are most likely mediated by TLR-4.

 

Nothing to Disclose: YB, HA, AG, MT

OR18-3 18978 3.0000 A Central Resitin Infusion Impairs FGF21/FGFR1/ Beta-Klotho Hypothalamic Expression and Promotes Peripheral FGF21 Resistance: Involvement of Resistin/TLR4 Signaling Pathway 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR18 5925 11:30:00 AM Novel Aspects of Insulin Sensitivity and Secretion Oral


Penny Ahlstrom*, Rengasamy Palanivel, Esther Rai, Ying Liu and Gary Sweeney
York University, Toronto, ON, Canada

 

Adiponectin levels decrease in obesity and diabetes and it is now well established that many metabolic abnormalities are improved upon adiponectin administration. Here we tested cellular mechanisms via which adiponectin improves insulin sensitivity using L6 skeletal muscle cells treated with high insulin and high glucose concentrations (HIHG) to induce insulin resistance. By examining changes in phospho-ULK1(Ser555), LC3-II formation and lysosomal enzyme activity we have demonstrated that adiponectin directly induced autophagic flux in cultured muscle cells in an AMPK-dependent manner. By generating an autophagy-deficient L6 cell line (stably overexpressing Atg5(K130R)) or using pharmacological inhibition of autophagy we have also shown that insulin sensitivity is reduced under these conditions. We have now observed that HIHG decreased levels of autophagy and induced insulin resistance which could be alleviated by adiponectin. Furthermore, to study endoplasmic reticulum (ER) stress we used Thioflavin T assay to show that protein aggregation increased after HIHG and was reduced by adiponectin. Elevated ER stress in response to HIHG was confirmed using transmission electron microscopy. As expected, the unfolded protein response (UPR) was also induced by HIHG. To demonstrate this we first generated L6 cells stably expressing a GRP78-mCherry reporter and second performed Western blotting which, interestingly, showed upregulation of the IRE1, but not the PERK/eIF2α, branch of the UPR. The IRE1 UPR axis has previously been implicated in developing insulin resistance while the PERK/eIF2α UPR axis is involved in the conversion of LC3I to II which is essential for autophagosome formation. We conclude that HIHG induced ER stress, with selective upregulation of UPR and decreased autophagy, and we propose that adiponectin stimulates autophagic flux and alleviates ER stress to contribute to increased insulin sensitivity in skeletal muscle cells. An improved understanding of primary cellular mechanisms involved in insulin resistance and their resolution by adiponectin will contribute to identifying potential therapeutic targets.

 

Nothing to Disclose: PA, RP, ER, YL, GS

OR18-4 21287 4.0000 A Adiponectin Alleviates Skeletal Muscle Insulin Resistance Induced By Hyperinsulinemia and Hyperglycemia Via Regulation of Endoplasmic Reticulum Stress and Autophagy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR18 5925 11:30:00 AM Novel Aspects of Insulin Sensitivity and Secretion Oral


Sushil K Mahata*1, Ennio Avolio2, Teresa Pasqua2 and Gautam Bandyopadhyay2
1VA San Diego Healthcare System & University of California, San Diego, La Jolla, CA, 2University of California, San Diego, La Jolla, CA

 

Obesity and diabetes, aggravated by hypertension, are global public health challenges. These calamities all arise from the development of insulin resistance in peripheral tissues. We have previously shown that peripheral administration of the Chromogranin A (CgA) peptide Catestatin (CST: human CgA352-372) (1) decreases blood pressure in polygenic (2, 3) and monogenic (4, 5) models of hypertension and acts as an anti-obesity peptide (6). Here, we show that central (intercerebroventricular) administration of CST (0.1 mM at 0.25 µl/hour) for 28 days via Alzet pump reduced systolic blood pressure (Saline: 138.91±3.07 vs CST: 102.55±7.93; p<0.003) in a monogenic (CgA knockout mice) model of hypertension. Peripheral administration of CST (5 µg/g BW, twice daily, IP) for 15 days improved insulin sensitivity in diet-induced obese (DIO) and in obese and diabetic db/db mice, as assessed by glucose and insulin tolerance tests (decreased area under the curve) and insulin signaling (increased phospho-AKT signaling). CST’s improvement of insulin sensitivity is comparable to that of Rosiglitazone (ROSI: 25 µg/g BW). Treatment of DIO mice with CST led to ~100% increase in 2-deoxyglucose uptake and glucose utilization in cardiac and skeletal muscle, which corroborate with the stimulatory role of CST in glucose disposal. Ultrastructural studies of DIO livers by Transmission Electron Microscopy (TEM) revealed dilation of endoplasmic reticulum (ER) lumen (61.65±3.17 nm) as compared to normal chow diet (NCD) fed mice (22.71±0.84 nm), suggesting ER stress. This stress was reversed by chronic treatments (15 days) with CST (ER lumen: DIO: 61.65+3.17 nm; DIO+CST: 16.12±1.66 nm; DIO+ROSI: 17.09±1.76 nm; one-way ANOVA: p<0.0001). DIO mice also showed fewer mitochondria, with broken cristae and decreased cristae surface area as compared to NCD fed mice. Chronic treatment of DIO mice with CST or ROSI reversed both mitochondrial numerical density (mitochondria number: DIO: 20.55±1.54; DIO+CST: 28.5±1.42; ROSI: 29.86±2.22; one-way ANOVA: p<0.006) and cristae surface area (cristae surface area: DIO: 1.65±0.12 µm; DIO+CST: 2.28±0.068 µm; DIO+ROSI: 2.84±0.186 µm; one-way ANOVA: p<0.0001). CST’s normalization of ultrastructural abnormalities caused by high fat diet is also comparable to that of ROSI. These results suggest a correlation between these stressful morphological features and hepatic insulin resistance in WT-DIO mice. Increased ER stress can lead to abnormal metabolic signaling as well as inflammatory response via cytokine production and excessive accumulation of lipids, ultimately compromising insulin action. We conclude that CST improves insulin sensitivity by reversing ER stress and mitochondrial dysfunction and offers a novel dual action therapeutic peptide, reducing hypertension and improving insulin sensitivity at the same time.

 

Nothing to Disclose: SKM, EA, TP, GB

OR18-5 22076 5.0000 A The Chromogranin a Peptide Catestatin Improves Insulin Sensitivity and Reduces Blood Pressure 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR18 5925 11:30:00 AM Novel Aspects of Insulin Sensitivity and Secretion Oral


Melanie Cree-Green*1, Ahbinav Gupta2, Gregory Coe3, Amy Baumgartner4, Laura Pyle5, Jane E Reusch6, Mark S. Brown7, Bradley R Newcomer8 and Kristen J Nadeau1
1University of Colorado School of Medicine, Aurora, CO, 2University of Colorado, Anschutz, Aurora, CO, 3University of Colorado, Anschutz Medical Campus, Auora, CO, 4University of Colorado, Anschutz, Auroa, CO, 5University of Colorado Anschutz Medical Campus, Aurora, CO, 6Denver Veterans Administration Medical Center, Denver, CO, 7University of Colorado, Anshutz, Aurora, CO, 8University of Alabama, Birmingham, AL

 

Type 2 diabetes (T2D) is increasingly prevalent in youth and forecasts early morbidity and mortality. Insulin resistance (IR) is associated with mitochondrial dysfunction, elevated free fatty acids (FFA) and intramyocellular lipid (IMCL) in adults with T2D. We hypothesized that muscle IR would be associated with similar factors in youth with T2D. Muscle IR and FFA suppression were assessed with a hyperinsulinemic euglycemic clamp (80 u/m2/min). Mitochondrial function was assessed by 31-phosphorus MR spectroscopy during  sub-maximal isometric calf exercise.  Mitochondrial function was modeled three ways: 1) ADP time constant (ADPTC) which includes muscle blood flow following exercise and mitochondrial function, 2) rate of oxidative phosphorylation (Oxphos) which reflects mitochondrial function and is relatively blood flow independent, and 3) QMAX which models maximal mitochondrial function and mitochondrial density and may be influenced by blood flow following exercise.  IMCL was measured with 1H MRS. Data are expressed as mean±SEM or median (25%ile, 75%ile) for non-normally distributed data. Groups were compared with ANOVA. Subjects included 17 youth with T2D (15.1 years (13.0, 16.5), 23 normal weight controls (LC) (15.1 years (12.3, 17.0)) and 26 obese controls (OB) (14.2 years (13.0, 16.0)) all matched for Tanner stage and activity level. T2D and OB were also matched for BMI. Youth with T2D were significantly more IR than both LC and OB (glucose infusion rate T2D 9.1±1.5 mg/leankg/min vs. OB 14.9±1.3 vs. LC 18.5±1.0 T2D; p<0.001).  For mitochondrial measures, ADPTC was longer in T2D vs. OB vs. LC (T2D 23.1(19.1, 27.0) seconds vs. OB 21.2 (18.1, 23.5) vs. LC 18.5(15.3, 22.6); p=0.03), OxPhos lower in T2D (T2D 0.11(0.06, 0.18) mM/sec vs. OB 0.18 (0.12, 0.23) vs. LC 0.18(0.13, 0.26); p=0.01) but there was no difference in  QMAX (T2D 0.34(0.18, 0.56) mM/s vs. OB 0.51 (0.38, 0.60) vs. LC 0.48(0.41, 0.64); p=0.18). FFA following hyperinsulinemia and IMCL were also significantly greater in T2D vs. OB vs. LC (FFA and IMCL both p<0.05). In a multiple linear regression model, lack of FFA suppression during hyperinsulinemia (R=0.58, p=0.002) and mitochondrial dysfunction (longer ADPTC) (R=0.56, p=0.01), but not IMCL or HbA1c, were independently associated with IR. Models with QMAX were similarly significant, but Oxphos did not relate to IR. In summary, youth with T2D had severe IR, mitochondrial dysfunction, lack of FFA suppression to hyperinsulinemia, and high IMCL.  However, IR in T2D youth was related to increased FFA and mitochondrial dysfunction, not IMCL or hyperglycemia. Further, post-exercise oxidative metabolism appears to be affected by limitations in blood flow following exercise and not solely an inherent mitochondrial defect.  In conclusion, our study suggests that elevated FFA’s and mitochondrial dysfunction are early abnormalities and potential treatment targets in youth with T2D.

 

Nothing to Disclose: MC, AG, GC, AB, LP, JER, MSB, BRN, KJN

OR18-6 19949 6.0000 A Insulin Resistance Is Related to Decreased Mitochondrial Function and Elevated Free Fatty Acids but Not Intramyocellular Lipid in Adolescents with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR18 5925 11:30:00 AM Novel Aspects of Insulin Sensitivity and Secretion Oral


Mark Daniel DeBoer*1, Matthew James Gurka2, Jessica G Woo3 and John A Morrison3
1Univ of Virginia, Charlottesville, VA, 2West Virginia University, Morgantown, WV, 3Cincinnati Children's Hospital Medical Center, Cincinnati, OH

 

Background and objective:  The value of the severity of metabolic syndrome (MetS) in the prediction of future type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) is not known.  For adolescents and adults we previously created MetS severity Z-scores that are sex- and race/ethnicity-specific.  Our goal was to determine the long-term associations of these scores from childhood and adulthood with future disease diagnosis.

Experimental Design and Methods:  We analyzed data from a cohort study in the Cincinnati, OH, metro-area with prospective evaluations from the Lipids Research Clinic (LRC, 1973-1976, Visit 1) and Princeton Follow-up Study (PFS, 2000-2004, Visit 2) and further disease status update on a subset of these participants from Princeton Health Update (PHU, 2010-2014, Visit 3).  The analytic cohort consisted of 649 individuals with mean (standard deviation) age 12.9 (3.3) years at baseline and 49.7 (3.5) years at most recent follow-up.  For both T2DM and CVD, participants were divided into three groups: 1) disease-free at all three time points, 2) diagnosed with disease between Visits 2 and 3 and 3) diagnosed with disease between Visits 1 and 2.  We additionally used linear and logistic regression to assess longitudinal relationships of childhood and adult MetS severity scores with incident T2DM and CVD.

Results:  Childhood MetS severity Z-scores were positively associated with adult MetS severity Z-scores (Pearson’s r=0.42, p<0.01).  Regarding eventual T2DM diagnosis, MetS severity Z-scores in childhood were: Group 1, -0.52 (CI -0.61,-0.42); Group 2, -0.08 (-0.48,0.33)(p<0.05 vs. Group 1); and Group 3, 0.09 (-0.21,0.40)(p<0.01 vs. Group 1).  Regarding eventual CVD diagnosis, MetS severity scores in childhood were: Group 1, -0.50 (-0.14,0.03); Group 2, -0.02 (-0.43,0.39)(p<0.05 vs. Group 1); and Group 3, 1.06 (0.39,1.73)(p<0.01 vs. Group 1).  In the case of both T2DM and CVD, these inter-Group differences in Mets Severity Z-scores widened by mid-adulthood (all p<0.01 comparing Groups 2 and 3 vs. Group 1).  For every 1-unit elevation in childhood MetS Z-score, the odds ratio (OR) of future T2DM and CVD was 2.6 and 10.3, respectively (both p<0.0001), for incident disease by Visit 2 and 1.9 and 2.2 (both p<0.05) for incident disease by Visit 3.  In assessing associations with the change in MetS severity Z-score from childhood to adulthood, for every 1-unit increase in MetS Z-score over time, the OR of incident T2DM and CVD between Visits 2 and 3 was 1.6 and 2.9, respectively (both p<0.01).

Conclusions and Relevance:  The severity of MetS in childhood was associated with incidence of adult T2DM and CVD and the degree of increase in this severity also predicted future disease.  This provides evidence of potential clinical utility in assessing MetS severity to detect risk and follow clinical progress over time.

 

Nothing to Disclose: MDD, MJG, JGW, JAM

OR13-1 18249 1.0000 A Severity of Metabolic Syndrome As a Predictor of Type 2 Diabetes and Cardiovascular Disease Between Childhood and Adulthood: The Princeton Lipid Research Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR13 5941 11:30:00 AM CV Risk - Drugs, Sex, and Rock and Roll Oral


Beatriz Schaan*1, Gustavo Waclawovsky2, Daniel Umpierre2, Franciele Ramos Figueira2, Eliandra Silveira Lima2, Ana Paula Alegretti2, Laiana Schneider2, Ursula da Silveira Matte2 and Ticiana Costa Rodrigues3
1Universidade Federal do Rio Grande do Sul/Hospital de Clinicas de Porto Alegre, Porto Alegre, 2Universidade Federal do Rio Grande do Sul/Hospital de Clinicas de Porto Alegre, 3Universidade Federal do Rio Grande do Sul/Hospital de Clinicas de Porto Alegre, Porto Alegre RS, Brazil

 

Endothelial progenitor cells (EPCs) derived from the bone marrow are essential to regenerate endothelial cells in the vascular system. In patients with type 1 diabetes (T1DM), EPCs are reduced when compared to healthy subjects, possibly accelerating endothelial dysfunction and atherosclerosis. Although exercise may mobilize EPCs from bone marrow in some populations, it is unknown whether patients with T1DM would show exercise-induced increases in EPCs. We evaluated the acute effect of aerobic (AE) and resistance (RE) exercise sessions on peripheral blood EPCs, blood flow, vascular resistance (VR) and reactive hyperemia (RH) in patients with T1DM. We conducted a crossover randomized clinical trial, in which 14 men with T1DM and 5 healthy controls were randomly assigned to a 40-min AE session (60% VO2peak) and a 40-min RE session (60% maximal load), one week apart. Venous blood was collected 10 min pre and post-exercise sessions to evaluate circulating EPCs (percentage of CD34+/KDR+/CD45dim of 200,000 mononuclear cells gated and analyzed by flow cytometry). Forearm blood flow and RH were evaluated by venous occlusion plethysmography before and after exercise sessions. Values are presented as means ± SEM; Generalized Estimation Equation (GEE) adjusted for baseline values (P<0.05) was used. Patients were 30.3 ± 1.6 yrs-old, HbA1c 7.7 ± 0.2%; controls were 26.8 ± 2.3 yrs-old. There were no differences in EPCs after AE (-5.075 ± 0.250 vs. -5.303 ± 0.250 Log (%), P= 0.102) or RE (-5.217 ± 0.250 vs. -5.056 ± 0.250 Log (%), P= 0.310) at baseline in patients with T1DM, but EPCs decreased after AE (-4.383 ± 0.353 vs. -4.854 ± 0.353 Log (%), P= 0.017) and increased after RE (-5.270 ± 0.353 vs. -4.629 ± 0.353 Log (%), P=0.004) as compared with baseline in controls. Blood flow did not change with AE neither in patients with T1DM nor in controls, but increased after RE in patients with T1DM (28.7 ± 11.4%, P= 0.009) and controls (41.7 ± 18.5%, P= 0.024). Vascular resistance decreased in AE (-8.6 ± 10.4%, P= 0.035) and RE (-21.5 ± 6.9%, P= 0.007) in patients with T1DM. In healthy controls VR was reduced after the RE session (-33.5 ± 9.8%, P< 0.001). Reactive hyperemia was increased after AE (36.5 ± 7.3%, P< 0.001), and RE (42.0 ± 10.0%, P< 0.001) in patients with T1DM and healthy controls (AE: 35.4 ± 11.0%, P= 0.001; RE: 74.3 ± 33.0%, P= 0.005). Conclusions: Despite the increases in RH in patients with T1DM and healthy controls after both exercise sessions, EPCs were only influenced by AE or RE sessions in controls. The unchanged number of EPCs in patients with T1DM after both exercise protocols might be indicating a blunted endothelium regenerating capacity, unraveling a very early deterioration of the functional arterial characteristics not disclosed by only evaluating vascular functional variables at this point of atherosclerosis evolution.

 

Nothing to Disclose: BS, GW, DU, FRF, ESL, APA, LS, UDSM, TCR

OR13-2 18983 2.0000 A Effect of a Single Session of Aerobic and Resistance Exercise in the Release of Circulating Endothelial Progenitor Cells in Patients with Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR13 5941 11:30:00 AM CV Risk - Drugs, Sex, and Rock and Roll Oral


Jennifer S. Lee*1, Elizabeth Ward2, Wesley Johnson2 and Ellen Gold3
1Stanford University Medical Center, Stanford, CA, 2University of California Irvine, Irvine, CA, 3University of California Davis, Davis, CA

 

The constellations of components of the Metabolic Syndrome (MetS) that occur during midlife in a woman offer a composite of her cardiovascular (CV) condition and risk of CV disease. We aimed to identify modifiable and non-modifiable factors associated with the common constellations of MetS components occurring at the time of new MetS diagnosis during the menopausal transition (MT). The Study of Women Across the Nation (SWAN) followed pre-/early peri-menopausal women as they underwent the MT. MetS diagnosis meant having at least 3 of 5 components: triglyceride >150mg/dL (hTG), HDL-cholesterol < 50mg/dL (lHDL), fasting glucose >=100mg/dL (hGluc), waist circumference > 88cm (80cm for Asians) (Obese), and blood pressure >130/85mmHg (HTN). We included 2,097 women who did not have MetS at baseline. In women who developed MetS during an observation period of up to 7 years, discrete time Cox regression models identified factors associated with risk of developing the most frequent constellations of components at MetS diagnosis. Models included age, education, alcohol use, MT stage (pre/early peri-menopause, late peri/post-menopause, or hormone therapy use), race/ethnicity (except Hispanics due to small sample size), physical activity (PA), smoking status, fiber intake, and Caloric intake. Study site did not influence the results and so were removed from the models. Of the 163 women who developed MetS during the MT, the 3 most common constellations at MetS diagnosis were:  Obese/hTG/lHDL, Obese/HTN/lHDL, and Obese/HTN/hGluc. In multivariable models, African Americans had a lower risk (HR 0.08, 0.01-0.61) of developing Obese/hTG/lHDL and a higher risk of Obese/HTN/lHDL (HR 3.75, 1.36-10.34) than non-Hispanic Whites. Physical activity was associated with a decreased risk of Obese/hTG/lHDL (HR 0.87, 0.69-1.11).  Conclusion: In women who developed MetS during the MT, their risk for specific constellations of MetS components was associated with race/ethnicity and a modifiable factor, physical activity.

 

Nothing to Disclose: JSL, EW, WJ, EG

OR13-3 22047 3.0000 A Metabolic Syndrome Constellations during the Menopausal Transition in the Study of Women's Health Across the Nation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR13 5941 11:30:00 AM CV Risk - Drugs, Sex, and Rock and Roll Oral


Jean N Cheong*1, Andrew J Jefferies1, Karen M Moritz2 and Mary E Wlodek1
1The University of Melbourne, Victoria, Australia, 2University of Queensland, Queensland, Australia

 

Intrauterine growth restriction increases the risk of adult metabolic diseases, with males exhibiting more severe phenotypes. These disease risks are not limited to the first, directly exposed generation (F1) but may be transmitted to the next generation (F2). Stress is increasingly prevalent in today’s society and mothers exposed to stress during pregnancy adversely impacts fetal development. However, the effects of a stressful pregnancy on the metabolic health of offspring of F1 mothers that were born small are not well understood. We characterised the metabolic phenotype of F2 male and female born to growth restricted F1 mothers and determined if maternal stress during late pregnancy exacerbated the phenotype.

Late gestation uteroplacental insufficiency was induced on embryonic day 18 by bilateral uterine vessel ligation (Restricted) or sham (Control) surgery in F0 Wistar Kyoto female rats. F1 females (Control, Restricted) were mated with a normal male rat and randomly allocated to Unstressed or Stressed groups. Physiological stressors (24h metabolic cage, tail cuff blood pressure, glucose tolerance test) were introduced during late pregnancy of F1 females in the Stressed group while their Unstressed counterparts were unhandled. F2 body weights were measured from birth and metabolic function characterised by fasting intraperitoneal glucose tolerance test (IPGTT) and insulin challenge at 6 and 12mo. Pancreatic β-cell and islet mass was quantified following post mortem.

F2 males and females from mothers exposed to maternal stress had reduced birth weight (-5%, p<0.05). Body weights were not different at subsequent ages. At 6mo, Control and Restricted F2 males from Stressed mothers had increased area under the glucose curve (AUGC) (+27%, p<0.05) during IPGTT. Compared to Control counterparts, Restricted males had reduced β-cell and islet mass (-30%, p<0.05) at 6mo. F2 Control and Restricted females from Stressed mothers had lower AUGC during IPGTT (-11%, p<0.05) at 12mo compared to their Unstressed counterparts. Insulin sensitivity and secretion were not altered at either ages in males or females.

Mothers exposed to modest stress during late pregnancy, independent of maternal birth weight, reduced F2 birth weight. We have demonstrated that there are sex specific effects of maternal stress on offspring metabolic health. F2 males that were born to Stressed mothers had impaired glucose tolerance while those born to Restricted mothers had reduced β-cell and islet mass, with both effects subsequently normalised. F2 females from mothers exposed to stress during pregnancy were protected and had better glucose tolerance compared to their Unstressed counterparts at 12mo. These effects were all independent of maternal birth weight and these offspring may be predisposed to differential responses when challenged with second-hits including unhealthy diets and sedentary lifestyles.

 

Nothing to Disclose: JNC, AJJ, KMM, MEW

OR13-4 19785 4.0000 A Female Rats Born Small That Experienced Stress during Pregnancy Led to Sex-Specific Metabolic Outcomes in the Offspring 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR13 5941 11:30:00 AM CV Risk - Drugs, Sex, and Rock and Roll Oral


Camila Manrique Acevedo*1, Guido Lastra1, Dominic Haertling1, Vincent G. DeMarco1, Annayya R. Aroor1, Guanghong Jia1, Francisco Ramirez1, Luis A. Martinez-Lemus2 and Iris Z Jaffe3
1University of Missouri, Columbia, MO, 2University of Missouri, 3Tufts Medical Center, Boston, MA

 

BACKGROUND: Women with obesity, insulin resistance and type 2 diabetes mellitus (T2D) lose the protection normally afforded by female sex hormones against cardiovascular disease (CVD), but the underlying mechanism(s) remain unknown. Vascular stiffness naturally occurs with aging, however conditions of insulin resistance such as obesity and T2D are characterized by accelerated development of this process.  Under physiological conditions, estrogen action via estrogen receptor alpha (ERα) increases bioavailable nitric oxide in the endothelium and decreases stiffness.  However, in conditions of insulin resistance, the effects of ERα signaling on the vasculature may be deleterious. METHODS: We used a novel rodent model lacking ERα in the endothelial cells (EC) (ECERαKO). The genomic region encompassing exon 3 of the ERα gene was flanked by loxP sites.  ECERαKO mice were generated by crossing ERα double floxed mice with Cad-Cre+ mice (VE-Cadherin promoter driving expression of Cre-recombinase). Female ECERαKO mice and littermates were fed a high fructose/high sucrose (HF/HS) diet for 8 weeks.  The HF/HS diet consisted of 60% fat and 20% sucrose. At the end of the intervention period, rodents underwent in vivo and ex vivo assessment of vascular stiffness.  Statistical significance was explored using 1-way ANOVA.

RESULTS: The absence of EC ERα did not impact whole-body insulin sensitivity (examined by HOMA-IR). Female rodents lacking the endothelial specific ERα had less vascular stiffness when assessed in vivo via aortic pulse wave velocity (p<0.05) than the littermates fed a HF/HS diet. Similarly, ex vivo evaluation of aortic EC stiffness using atomic force microscopy revealed increased stiffness in the female rodents with intact EC ERα when compared with ECERαKO mice (p<0.05). Resistant vessel (femoral artery) also revealed less stiffness (decreased modulus of elasticity) in ECERαKO mice fed a HF/HS.

CONCLUSION: Endothelial ERα does not protect females from vascular stiffness induced by exposure to a HF/HS diet. In addition, the present data suggests that the absence of endothelial ERα protects insulin resistant females from vascular stiffness.

 

Nothing to Disclose: CM, GL, DH, VGD, ARA, GJ, FR, LAM, IZJ

OR13-5 21925 5.0000 A Endothelial Estrogen Receptor Alpha Does Not Protect Female Mice Against High Fat/High Fructose Diet Induced Vascular Stiffness 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR13 5941 11:30:00 AM CV Risk - Drugs, Sex, and Rock and Roll Oral


Ren Zhang*
Wayne State Univ

 

Patients with metabolic syndrome are at high risk for developing atherosclerotic cardiovascular diseases and diabetes. Elevated plasma triglycerides are increasingly recognized as an independent risk factor for cardiovascular diseases. We recently identified a novel nutritionally- regulated circulating factor, lipasin, which mediates triglyceride metabolism by regulating activity of the lipoprotein lipase. The official symbol for lipasin in mice is Gm6484, which is also known as Angptl8 and betatrophin. Lipasin mRNA is enriched in liver and fat, and the expression level is reduced by fasting and markedly increased by feeding. In mice, adenovirus-mediated overexpression of lipasin dramatically increases serum triglycerides; conversely, lipasin deficiency reduces triglyceride levels. We showed that human circulating lipasin is increased in type 2 diabetes and obesity. To examine whether lipasin inhibition has therapeutic potential, we generated 5 monoclonal lipasin antibodies, and among which one significantly decreased serum triglyceride levels when injected intraperitoneally into wild type mice. We next performed epitope mapping, and determined that the antibody binds to the middle portion of lipasin protein. The lipid loading test showed that mice with the antibody injection cleared infused lipids more quickly than control mice. Therefore, lipasin is a promising new drug target for lowering plasma triglyceride levels, and the middle portion of lipasin is a critical domain in mediating the triglyceride-lowering effects.

 

Nothing to Disclose: RZ

OR13-6 19990 6.0000 A A Monoclonal Neutralizing Antibody Against Lipasin (Angptl8), a Novel Lipid Regulator, Reduces Serum Triglycerides in Mice By Enhancing Lipoprotein Lipase-Mediated Triglyceride Clearance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 1:00:00 PM OR13 5941 11:30:00 AM CV Risk - Drugs, Sex, and Rock and Roll Oral


Louise A Metherell*1, Angela Huebner2, Helen Spoudeas3, Tim D. Cheetham4, Tatiana V Novoselova5 and Li F Chan6
1William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom, 2Technical Univ Dresden, Dresden, Germany, 3Great Ormond Street Children's Hospital, London, United Kingdom, 4Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom, 5WHRI, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom, 6William Harvey Research Institute, John Vane Science Centre, Queen Mary, University of London, London, United Kingdom

 

Mutations in the side chain cleavage enzyme, (CYP11A1), like those in the steroidogenic acute regulatory protein, (STAR) cause lipoid congenital adrenal hyperplasia (CLAH) manifesting with adrenal and gonadal insufficiencies along with derangements of the renin/angiotensin system. Increased adrenal size is usually a feature of STAR but not of CYP11A1 mutation. Milder forms have also been described and the presentation can sometimes mimic that of isolated or Familial Glucocorticoid Deficiency (FGD). We present six patients, from four families with varying clinical pictures who have CYP11A1 mutations discovered by whole exome sequencing.

Patients 1 & 2 are sisters with ACTH resistance, having high ACTH levels, low glucocorticoids, no response to exogenous ACTH and no pigmentation. Patients 3 & 4 have FGD and subclinical hypothyroidism. The patients are adult now and female patient 4 has suffered 3 miscarriages. Patient 5, with a diagnosis of lipoid adrenal hyperplasia, presented with adrenal failure in early life with mineralocorticoid and glucocorticoid deficiency and had big adrenals in the neonatal period. Patient 6 had a salt wasting early neonatal history and was hyperpigmented in infancy. He was treated as a case of Addison’s disease despite normal renin and aldosterone levels.

Whole exome sequencing was undertaken on genomic DNA of the patients. Variants in the seven genes; MC2R, MRAP, STAR, CYP11A1, NNT, MCM4 and TXNRD2 were assessed for causality.

The mutations in CYP11A1 were as follows; patients 1&2 had a homozygous A359V mutation in exon 6, the parents and an unaffected sibling were heterozygous for the change. Patients 3&4 had compound heterozygous mutations I279Yfs*9 and *122Rext*68. Patient 5 was compound heterozygous for R120Q in exon 2 and Q395K in exon 7, the R120Q was inherited from her father, Q395K from her mother. Finally patient 6 was compound heterozygous for E314K and an exon5/intron5 splice site mutation, the E314K came from his mother and the splice mutation from his father, an unaffected sister inherited only the splice mutation. The A359V and I279Yfs*9 mutations have been previously reported and in homozygosity shown to cause severe cases of CLAH, all other variants were novel, with the exception of the E314K (aka rs6161 with a minor allele frequency 0.001).

The presentation varied between cases, ranging from a patient with neonatal salt wasting/adrenal crisis and large adrenals to a pair of non-pigmented sisters aged 2 and 4y on glucocorticoid replacement alone. Whole exome sequencing revealed the nature of the underlying defects in all patients to be mutation(s) in CYP11A1, the gene encoding the first enzyme in the steroidogenic pathway, converting cholesterol into pregnenolone. These cases emphasize the utility of whole exome sequencing as a tool for improved diagnosis and therefore patient management/genetic counselling in the endocrine clinic.

 

Nothing to Disclose: LAM, AH, HS, TDC, TVN, LFC

OR12-1 21952 1.0000 A Varied Presentation of Six Patients with CYP11A1 Mutations. 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR12 5983 11:30:00 AM Adrenal Steroids and Steroidogenesis: Novel Aspects Oral


Christa E. Fluck*1, Marie-Anne Burckhardt2, Nesa Marti3, Sameer Udhane4, Isabel Schnyder2, Coya Tapia5, Primus E Mullis4 and Ewa Rajpert-De Meyts6
1Univ Children's Hosp Inselspital, Berne, Switzerland, 2Univ Children's Hospital Bern, Bern, Switzerland, 3Pediatric Endocrinology and Diabetology of the Dept of Pediatrics, Univ of Bern, Bern, Switzerland, Bern, Switzerland, 4University Children's Hospital Bern, Bern, Switzerland, 5Univ of Bern, Bern, Switzerland, 6Department of Growth and Reproduction, Copenhagen University Hospital, Copenhagen

 

Background: Deficiency of 3β-hydroxysteroid dehydrogenase (3βHSD) is a rare disorder of sexual development (DSD) affecting both sexes and overall steroidogenesis. There are two isozymes of 3βHSD, encoded by separate genes HSD3B1 and HSD3B2. Human mutations are only known for the HSD3B2 gene which is expressed in the gonads and the adrenals. HSD3B1 is expressed in the placenta and peripheral tissues and shares the substrates with HSD3B2.

Aim: To describe the molecular genetics, the steroid biochemistry, the (immune-) histochemistry and the clinical implications in a patient harboring a severe, homozygote HSD3B2 mutation at birth and at puberty. 

Methods and Results: Genetic analysis of the HSD3B2 gene was performed by PCR and direct sequencing on blood leukocyte DNA. A homozygote c.687del27 deletion was identified. Further work-up by RT-PCR on RNA from testis tissue revealed a shorter cDNA product corresponding to the deletion while Western blot from testis protein extract showed no HSD3B2 protein expression. Urine steroid profiling revealed low overall steroid production for mineralocorticoids, glucocorticoids and sex steroids with typical precursor metabolites for HSD3B2 deficiency in early life and no alternate use of the backdoor pathway. However, at pubertal age, some sex steroid metabolites appeared likely through conversion of precursors by unaffected HSD3B1 enzyme activity in the peripheral tissues. Accordingly, the 46,XY boy presented at birth with severe undervilization of the genitalia but was able to virilize further at puberty. Remarkably, he developed enlarged breasts (Tanner 4) through production of estrogens in the peripheral tissues from androgen precursors through aromatase activity. At the age of 16 years, testis Sertoli cell function measured by serum inhibin B and AMH was normal. Serum free testosterone was in the low normal range and LH/FSH were low. Testis histology at late puberty revealed arrested spermiogenesis, presence of few Leydig cells in stroma, but no evidence of neoplastic changes (as seen in other types of 46,XY DSD).

Conclusion: This is the first longitudinal detail description of a patient with a severe human HSD3B2 mutation. Extensive laboratory studies on human biomaterials allowed obtaining further insight into the function of HSD3B2 and the bypass steroid pathways forced by its loss. This knowledge prompted us to offer the patient not only mineralocorticoid and glucocorticoid replacement therapy but also testosterone supplementation. It also opens the question whether aromatase inhibitor treatment should be installed. In addition, we found no (immune-)histological signs that the testis with HSD3B2 deficiency is at risk for malignancy.

 

Nothing to Disclose: CEF, MAB, NM, SU, IS, CT, PEM, ER

OR12-2 19528 2.0000 A Biochemical Bypass Steroidogenesis Pathways in HSD3B2 Deficiency: Lesions from an Experiment of Human Nature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR12 5983 11:30:00 AM Adrenal Steroids and Steroidogenesis: Novel Aspects Oral


Chiara Simeoli*1, Maria Cristina De Martino1, Teresa Mannarino1, Alessia Cozzolino1, Davide Iacuaniello1, Monica De Leo1, Annamaria Colao1 and Rosario Pivonello2
1Università Federico II, Naples, Italy, 2Università Federico II di Napoli, Naples, Italy

 

In patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency, life-long glucocorticoid (GC) treatment is often required to replace cortisol deficiency and to avoid the ACTH dependent increase of androgen levels. However, in these patients, the multiple daily doses required with conventional GCs can cause cortisol overexposure, leading to an increased risk of metabolic syndrome (MS), an impaired quality of life (QoL) and a poor treatment compliance (TC). The current study aimed at investigating the impact of the switch from twice or thrice daily conventional GCs to once daily dual release hydrocortisone formulation (DR-HC) on metabolic and hormonal profile, QoL, depression status (DS) and TC in a cohort of patients with CAH. Eighteen patients (14F, 4M, 20-29 years) with CAH, chronically treated with hydrocortisone (10-40 mg/day) or prednisone (6.25-10 mg/day) and switched to DR-HC (10-40 mg/day) entered the study and were evaluated before and after 6-12 months of DR-HC. Metabolic and hormonal parameters were measured using routine assays and the MS was evaluated according with IDF criteria. QoL, DS and TC were assessed using AddiQoL Questionnaire, Beck Depression Inventory II (BDI-II) and Morisky 8-items medication Adherence Questionnaire, respectively. At 6-month-follow-up fasting plasma glucose (p=0.01) was significantly reduced, whereas at 12 month-follow-up HDL (p=0.006) and LDL-cholesterol levels (p=0.039) were significantly improved as compared with baseline. A clear diagnosis of MS was performed in one patient at the baseline, but this was not confirmed after 6 and 12 months. No significant change in morning plasma ACTH, UFC, and serum aldosterone, 17-OH progesterone, testosterone, DHEA-S and androstenedione levels were observed and no clinical worsening of symptoms and signs related to hyperandrogenism were reported. Excluding from the analysis the two patients treated with prednisone at baseline, a significant increase in morning serum cortisol levels was registered after 6 months (p=0.039) but it was not confirmed after 12 months. Despite the unchanged fludrocortisone doses, both in the entire cohort (p=0.004) and in the subgroup of patients with salt wasting form (p=0.02) a significant decrease in renin levels was reported at 6-month-follow-up, but it was not confirmed at 12-month-follow-up. Additionally, DS improved both after 6 (p=0.045) and 12 months (p=0.079) whereas TC significantly, progressively, improved after 6 (p=0.013) and after 12 months (p=0.001). In conclusion, the switch from conventional GCs to DR-HC significantly improves MS, DS and TC, maintaining an optimal hormone control in patients with CAH due to 21-hydroxylase deficiency.

 

 

Disclosure: CS: Consultant, Viropharma. AC: Speaker, Novartis Pharmaceuticals. MD: Consultant, Viropharma. AC: Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Consultant, Italfarmaco, Consultant, Pfizer, Inc., Consultant, Ipsen, Consultant, Novartis Pharmaceuticals, Study Investigator, Novo Nordisk, Study Investigator, Merck & Co., Principal Investigator, Lilly USA, LLC, Principal Investigator, Pfizer, Inc., Principal Investigator, Ipsen, Principal Investigator, Novartis Pharmaceuticals, Speaker, Pfizer, Inc.. RP: Principal Investigator, Novartis Pharmaceuticals, Speaker, Shire, Speaker, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Consultant, Viropharma, Clinical Researcher, Viropharma, Coinvestigator, Novartis Pharmaceuticals, Principal Investigator, Hra pharma, Coinvestigator, Ipsen. Nothing to Disclose: MCD, TM, DI

OR12-3 19948 3.0000 A Treatment with "Dual Release" Hydrocortisone (DR-HC) in Congenital Adrenal Hyperplasia: Short-Term (6 months) and Long-Term (12 months) Follow-up after the Switch from Conventional Glucocorticoids to DR-HC 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR12 5983 11:30:00 AM Adrenal Steroids and Steroidogenesis: Novel Aspects Oral


Melanie Schorr*, Elizabeth A. Lawson, Anne Klibanski and Karen K. Miller
Massachusetts General Hospital/Harvard Medical School, Boston, MA

 

Context: There are conflicting reports of increased vs decreased HPA activation in obesity; the most consistent finding is an inverse relationship between BMI and morning serum cortisol. In anorexia nervosa (AN), a low-BMI state, cortisol measures, including 24-hour urine free cortisol (UFC), are known to be elevated.  However, a comprehensive assessment of cortisol measures across the weight spectrum has not been reported.

Methods:  We studied 60 women, 18-45 yo: AN (N=18), normal-weight controls (HC, N=21), and overweight/obese (OB, N=21).  Body composition was measured by DXA.  HPA dynamics were assessed by UFC, pooled overnight serum cortisol q20 min 8 PM - 8 AM, 8 AM serum cortisol, 8 AM CBG, 7 AM salivary cortisol, late-night salivary cortisol (LNSC), and dex-CRH testing.

Results:  Most HPA measures demonstrated a U-shaped relationship with BMI, including UFC/body surface area (BSA) (R=0.38, p=0.02; nadir BMI 29 kg/m2), but not uncorrected UFC;  overnight serum cortisol (R=0.66, p<0.0001; nadir BMI 32 kg/m2); 8 AM serum cortisol (R=0.45, p=0.003; nadir BMI 32 kg/m2); and 7 AM salivary cortisol (R=0.44, p=0.01; nadir BMI 33 kg/m2).  Mean levels of these cortisol measures were higher in AN vs OB (p<0.01).  UFC in 3 AN and 1 OB exceeded the upper limit of normal; 5 AN and 0 OB exceeded the mean + 2 SD for HCs when UFC was corrected for BSA.  There was a U-shaped association between visceral adipose tissue (VAT) and UFC (R=0.41, p=0.01), UFC/BSA (R=0.46, p=0.003), overnight serum cortisol (R=0.67, p<0.0001), 8 AM serum cortisol (R=0.37, p=0.03), and 7 AM salivary cortisol (R=0.51, p=0.002).  Associations with overnight serum cortisol remained significant using Coolen’s equation to estimate unbound cortisol.  Despite HPA activation in both AN and OB, there was a negative linear relationship between BMI and 8 AM serum cortisol after dex suppression (R= -0.36, p=0.009) and after subsequent CRH administration (R= -0.31, p=0.02); 4 women “failed” the dex-CRH test (3 AN, 1 HC) with a 15-min serum cortisol >1.4 mcg/dl. UFC was negatively associated with total hip (R= -0.33, p=0.02) and PA spine (R= -0.36, p=0.01) BMD, which remained significant after controlling for BMI.

Conclusion: Cortisol measures are lowest in overweight and mildly obese women, even lower than in lean women. With more significant obesity, cortisol levels rise, although levels are not as high as in very low BMI states.  VAT is generally more strongly associated than BMI with cortisol levels, also in a U-shaped pattern.  These data suggest that extreme underweight and overweight states may activate the HPA axis, and raise the question of whether hypercortisolemia may contribute to weight gain or VAT accumulation in the setting of caloric excess. The inverse association between UFC and BMD suggests that hypercortisolemia may contribute to decreased BMD in the setting of both caloric restriction and excess.

 

Nothing to Disclose: MS, EAL, AK, KKM

OR12-4 18661 4.0000 A Cortisol Measures Across the Weight Spectrum 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR12 5983 11:30:00 AM Adrenal Steroids and Steroidogenesis: Novel Aspects Oral


Scott D Mackenzie*1, Rebecca Reynolds1, David I W Philips2, Anna Jane Anderson1, Shaoyun Chen1, Geoffrey L Hammond3, Lesley Hill3, Catriona Kyle1, Natalie Z Homer1, Ruth Andrew1 and Brian R Walker1
1University of Edinburgh, Edinburgh, United Kingdom, 2Southampton General Hospital, United Kingdom, 3University of British Columbia, Vancouver, BC, Canada

 

Human plasma contains cortisol (F) and corticosterone (B), the major glucocorticoid in rats and mice, at a ratio of ~10: 1.  Although B is usually neglected in humans, previous reports suggest B responds more to ACTH than F, while differential transmembrane export of B and F by ATP-binding cassette (ABC) transporters may allow preferential sensitivity to B, eg in brain.  We aimed to characterise the physiology of B in humans.

We used a stable isotope tracer D8-corticosterone (D8-B) to assess B kinetics in vivo.  We developed LC-MS/MS assays.  In vitro validation studies excluded a kinetic isotope effect in metabolism of D8-B vs B by human 11β-HSD2 and 5β-reductase.  Intravenous D8-B administration in healthy men by bolus (n = 3) and primed steady-state infusion (n = 6) showed high volume of distribution (Vd 45.7 ± 5.3 L), short half-life (t ½ 28.5 ± 3.3 mins) and rapid clearance (Cl 1.11 ± 0.20 L/min) compared with F.  Rapid B clearance likely results from enhanced hepatic metabolism, since B and F were inactivated in vitro by human 11β-HSD2 at similar rates, but hepatic 5b-reductase inactivation of B exceeded that of F (by 4.3 fold, p<0.001).  Urinary metabolites of B and F by GC-MS/MS in healthy men (n = 24) showed the ratio of B: F metabolites was ~1: 10 (0.65 ± 0.06 vs 7.00 ± 0.43 mg/24 hr).  Regulation of plasma B and F by the HPA axis also appears distinct, since the response to ACTH1-24 stimulation (1 µg, 0830 hr) following dexamethasone suppression (0.25 mg) in a cross-sectional study of men (n = 279) was greater for B than F (6.2 ± 0.3 vs 3.9 ± 0.4 fold increase; p <0.001).  Finally, competitive binding studies indicated affinity of CBG was greater for F than B (IC-50 4.32 ± 0.10 vs 2.93 ± 0.09 nM; p <0.01), so we compared plasma total and free B and F by equilibrium dialysis in healthy volunteers (n = 3), total: free ratio was lower for B than F (4.9 ± 0.9 :1 vs 18.3 ± 2.1 :1; p < 0.05).

Conclusions: We have demonstrated important differences in the physiology of B and F in humans, challenging assumptions that B is negligible in humans or that B in mice/rats and F in humans are identical.  B is rapidly cleared by hepatic A-ring reductases and highly responsive to ACTH stimulation. In agreement with our finding that B binds less avidly to CBG than F, the free plasma B pool is disproportionately large.  These findings, together with the finding of differential transmembrane export of B and F, raise the possibility of distinct roles for B and F in humans.

 

Nothing to Disclose: SDM, RR, DIWP, AJA, SC, GLH, LH, CK, NZH, RA, BRW

OR12-5 20313 5.0000 A Rapid Turnover and High Free Plasma Concentrations of Corticosterone in Humans 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR12 5983 11:30:00 AM Adrenal Steroids and Steroidogenesis: Novel Aspects Oral


Michael J. McPhaul*1, Tobias Else2, Adina F. Turcu3, Richard E Reitz4 and Richard J. Auchus2
1Medical Director, Endocrinology, San Juan Capistrano, CA, 2University of Michigan, Ann Arbor, MI, 3The University of Michigan, Ann Arbor, MI, 4Quest Diagnosticis Nichols Institute, San Juan Capistrano, CA

 

Background: The differential diagnosis of adrenal neoplasms and the determination of hormone excess from these disorders can be difficult.  In particular, the distinction between adrenocortical carcinoma (ACC), nonfunctional adenoma (NFA), macronodular adrenal hyperplasia (MAH), and tumors causing mild or “subclinical” Cushing syndrome (SCS)—is clinically important.  We hypothesized that serum and urine steroid profiling using mass spectrometry can aid in distinguishing among these etiologies. 

Methods: We studied 35 patients with adrenal neoplasia: 4 ACC, 19 NFA, 5 MAH, and 7 SCS.  Steroids in random serum and urine samples were analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS, 13 analytes) and gas chromatography-mass spectrometry (GC/MS, 31 analytes).  Steroid patterns of each group were compared to identify characteristic patterns. 

Results: The most commonly elevated serum steroid biomarker in ACC was 17-hydroxypregnenolone (3 of 4 ACC), whereas 11-deoxycortisol was elevated in only 1 of 4 ACC patients.  Among urine steroid metabolites, tetrahydrocortisol (THF) and tetrahydro-11-deoxycortisol (THS) were elevated in 2 of 2 ACC patients for whom urine was available. The THF/THS ratio was <6 in both ACC patients but >6 in 30/31 of all other groups.  Pregnanediol was consistently elevated in ACC but also some SCS and MAH patients.

Conclusions: Comprehensive steroid profiling of both serum and urine steroids using mass spectrometry appears to have potential as a sensitive approach to distinguish ACC from other forms of adrenal neoplasia.  Urine THF might be the most sensitive marker to distinguish hypercortisolism from adrenal neoplasias.  Under basal conditions, urine steroids appear to be more discriminatory than serum steroids.  These data suggest there is value in better characterizing adrenal neoplasia profiles using mass spectrometry using a broader representative sample of patient specimens. These data will require confirmation in larger series.

 

Disclosure: MJM: Principal Investigator, Quest Diagnostics. RER: Coinvestigator, Quest Diagnostics. RJA: Consultant, Corcept, Investigator, Novartis Pharmaceuticals, Investigator, Quest Diagnostics, Advisory Group Member, Laboratory Corporation of America. Nothing to Disclose: TE, AFT

OR12-6 21609 6.0000 A Serum and Urine Steroid Profiling Patterns Using Mass Spectrometry in Adrenal Neoplasias 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 1:00:00 PM OR12 5983 11:30:00 AM Adrenal Steroids and Steroidogenesis: Novel Aspects Oral


Anthe S. Sterkenburg1, Anika Hoffmann2, Monika Warmuth-Metz3, Ursel Gebhardt4, Anna M.M. Daubenbüchel1 and Hermann L. Müller*4
1European Medical School Oldenburg-Groningen (EMS), Oldenburg, Germany, 2Klinikum Oldenburg AöR, Medical Campus University Oldenburg, Oldenburg, Germany, 3University Hospital Würzburg, Würzburg, Germany, 4Klinikum Oldenburg, Medical Campus University Oldenburg, Oldenburg, Germany

 

Background: Quality of life and prognosis are frequently impaired in childhood-onset craniopharyngioma (CP) patients. Knowledge of risk factors for long-term outcome and sequelae after 20 years follow-up could help to improve actual treatment.

Patients and methods: Cross-sectional study on overall (OS) and progression-free survival (PFS), body mass index (BMI) SDS, neuropsychological (EORTCQLQ-C30, MFI-20) and psychosocial status in 261 long-term survivors of CP recruited in the German CP registry (HIT Endo).

Results: 20-yrs OS in CP patients (n=261, 0.88±0.03) was lower (p=0.006) in CP patients with HI (n=132,0.84±0.04) when compared to CP patients without HI (n=82, 0.95±0.04). OS was not related to degree of resection, gender, age or year at diagnosis (before/after 1990). PFS (n=168, 0.58±0.05) was lower in younger CP (age <5 yrs at diagnosis) (n=30, 0.39±0.10) compared with patients of 5-10 yrs of age (n=66, 0.52±0.08), and >10 yrs of age (n=72, 0.77±0.06). No association of PFS was detectable with HI, degree of surgical resection and gender. CP with HI developed severe weight gain during the first 8-12 yrs of follow-up (median increase in BMI: +4.59 SD; range -0.40 to +11.15 SD) when compared to CP without HI (median increase in BMI: +1.20 SD; range -1.19 to +5.02 SD) (p=0.00). During follow-up of >12 yrs, patients with HI presented no further increase in BMI SDS. QoL in CP with HI was impaired due to physical fatigue, reduced motivation and diarrhea in comparison with CP without HI (p=0.024, p=0.042, and p=0.017, respectively).    

Conclusion: Not only OS but also neuropsychological and psychosocial status are impaired by HI in long-term survivors of childhood-onset CP. HI is associated with severe obesity, reaching a plateau after >10 years of follow-up. Fatigue, reduced motivation and diarrhea have major negative impact on QoL of long-term CP survivors. As OS and PFS were not associated with the surgical degree of resection, gross-total resection should be avoided in case of HI for prevention of further hypothalamic damage in CP.

 

Nothing to Disclose: ASS, AH, MW, UG, AMMD, HLM

OR20-1 19927 1.0000 A Survival, Hypothalamic Obesity and Neuropsychological / Psychosocial Status after Childhood-Onset Craniopharyngioma – Long-Term Results in 261 Patients Recruited in HIT Endo 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR20 5993 11:30:00 AM Pituitary Tumors-New Clinical Considerations Oral


Chloé Brunelle, Veronique Beauloye, Philippe A Lysy, Orsalia Alexopoulou and Dominique Maiter*
Université Catholique de Louvain, Brussels, Belgium

 

Prolactinomas are rare among children and adolescents. Some small cohort studies have shown a female predominance and a variable symptomatology, mainly related to gender and to the size of the adenoma. Long-term impacts on growth and endocrine functions (including fertility) have been however poorly studied.                            

Aims: To describe the characteristics and response to treatment of a new cohort of patients with a prolactinoma of peripubertal onset and to evaluate the impact on growth and endocrine functions.

Methods: This was a retrospective study of patients less than 21 year-old at the time of diagnosis, regularly followed between 1987 and 2013 at the Cliniques Universitaires Saint-Luc for a symptomatic prolactinoma.

Results: This study included 38 patients (29 females) with a median follow-up time of 5.8 years (0.5-24.0). Of them, 63% had a macroadenoma. The median age at onset of first symptoms was 15 years (8.0 -20.8). The period between first symptoms and diagnosis was longer in males and in subjects with macroprolactinomas. Macroprolactinomas were proportionally more frequent in males (89% vs 55% in women; P<0.05) and in patients younger than 15 years (79% vs 44% if symptoms after the age of 15; P<0.05). These two groups also had more frequently associated endocrine deficits. Median prolactin levels at diagnosis were 148 µg/L [28-10463] and were well correlated to the size of the adenoma (R=0.918). All our patients received dopamine agonists and 55% had also surgery. After treatment, prolactinemia was normalized in 32 patients (84%). Remission (normal prolactinemia without treatment) was obtained in 52% of patients who had surgery and in 13% for those with oral agents only (P<0.05). Final adult size was influenced by initial adenoma size, especially in boys, and the weight by concomitant hypogonadism at diagnosis. All women who wished to conceive (n=12) could become pregnant after medical and/or surgical treatment of their prolactinoma (total of 25 pregnancies, only one medically-assisted).

Conclusions: Prolactinomas occuring at an early age have a particular clinical, biological and radiological presentation. Male subjects or young patients who become symptomatic before the age of 15 have more aggressive tumors. This study also shows a negative impact of large macroprolactinomas on growth – especially in boys - but an excellent fertility rate in women.

 

Disclosure: DM: Speaker, Pfizer, Inc., Advisory Group Member, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Novo Nordisk, Speaker, Pfizer, Inc., Advisory Group Member, Novartis Pharmaceuticals. Nothing to Disclose: CB, VB, PAL, OA

OR20-2 20538 2.0000 A Prolactinomas in Pediatric Age: Characteristics and Long-Term Outcome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR20 5993 11:30:00 AM Pituitary Tumors-New Clinical Considerations Oral


Adrian F Daly*1, Maya Beth Lodish2, Giampaolo Trivellin2, Liliya Rostomyan1, Fabio R Faucz3, Bo Yuan4, Luciana Ansaneli Naves5, Catherine S. Choong6, Philippe A Lysy7, Nalini Samir Shah8, Elisa Verrua9, Jean-Hubert Caberg10, Emilie Castermans10, Maria Chiara Zatelli11, Marie Helene Schernthaner-Reiter12, Chiara Villa13, Daniel Metzger14, Natalia Strebkova15, Nadia Mazerkina16, Philippe Chanson17, Tim D. Cheetham18, Prashant Chittiboina19, Maria Rosaria Ambrosio11, Stephan Gaillard20, Gustavo Barcelos Barra21, Eva Szarek2, Leticia F. Leal2, Aggeliki Dimopoulos22, Paraskevi Xekouki2, Anelia Dafinova Horvath2, Rodrigo Bertollo de Alexandre12, Allison D Manning12, Isaac Levy2, Margaret Farmar Keil23, Maria De La Luz Sierra24, Leonor Palmeira1, Mauricette Jamar10, Vincent Bours10, Martha M Quezado25, Pengfei Liu4, James R Lupski4, Constantine A Stratakis2 and Albert Beckers1
1CHU de Liège-University of Liège, Liège, Belgium, 2National Institutes of Health (NIH), Bethesda, MD, 3National Institutes of Health, Bethesda, MD, 4Baylor College of Medicine, Houston, TX, 5University of Brasilia, Brasilia, Brazil, 6Princess Margaret Hospital for Children, Subiaco WA, Australia, 7Université Catholique de Louvain, Brussels, Belgium, 8KEM Hospital, Mumbai, India, 9University of Milan, Fondazione IRCCS Ca' Granda Policlinico, Milan, Italy, 10University of Liège, Liège, Belgium, 11University of Ferrara, Ferrara, Italy, 12Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 13Hopital Foch, Suresnes, France, 14BC Children's Hospital, Vancouver, BC, Canada, 15Institute of Pediatric Endocrinology, Moscow, Russia, 16Burdenko Neurosurgery Institute, Moscow, Russia, 17Univ Paris-Sud, UMR-S693, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France, 18Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom, 19National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD, 20Hôpital Foch, Suresnes, France, 21Laboratorio Sabin, Brasilia, Brazil, 22Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 23Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD, 24National Institute of Health, Bethesda, 25National Cancer Institute, Bethesda, MD

 

Background: Gigantism is a rare disorder usually due to pituitary adenomas. Despite recent genetic advances, most cases have an unknown etiology, including some of most severely affected historical cases in which gigantism occurred in early childhood.

Introduction: X-linked Acro-gigantism (X-LAG) is a new syndrome caused by microduplications of an approximately 500 kb region on chromosome Xq26. Individuals with XLAG have a remarkably consistent phenotype of early onset gigantism due to mixed GH/PRL secreting pituitary macroadenomas +/- hyperplasia.  The patients with X-LAG have a common shared region of overlap involving 4 coding genes, of which only one gene (an orphan G protein coupled receptor (GPCR)) is highly upregulated in tumor tissue

Methods: We performed a collaborative international study of all confirmed X-LAG syndrome cases to characterize the clinical phenotype and responses to therapy.

Results:  The study included 17 patients with X-LAG and a microduplication in chromosome Xq26, of whom 12 were sporadic.  Another 5 cases belonged to 2 families that originally presented with FIPA.  All sporadic cases had unique duplications, whereas the familial cases inherited identical duplications.  The inheritance pattern was dominant; there were no unaffected microduplication carriers .  Patients were born at full-term and were of normal length, weight and head circumference and apart from the familial cases generally had parents and siblings of normal height.  Patients with X-LAG syndrome began to grow rapidly during early childhood, in most cases rapid gain in length was noted between 6-18 months of age.  At diagnosis (median 36 months), patients had a median height SDS score of +3.9 and weight SDS score of +3.4.  On presentation apart from the increased overall body size, the children had some coarsening of facial features with broadening of the nose and marked enlargement of the feet and hands.  All patients had marked hypersecretion of GH, IGF-1 and prolactin.  All but one patient had a pituitary macroadenoma at diagnosis, the remaining patient only had marked hyperplasia. The pituitary tumors were  strongly positive for GHRH-R.  Primary neurosurgical control was not achieved except in cases where anterior hypophysectomy was performed.  Responses to medical therapy with somatostatin analogs and dopamine agonists were poor; 4 patients received radiotherapy.  Postoperative pegvisomant achieved control of IGF-1 in the 5 cases in which it was employed.  Final height has not been reached in 12 cases who are still in childhood/adolescence.

Conclusions: X-LAG is a new pediatric gigantism syndrome due to a microduplication in chromosome Xq26.  It is characterized by a severe clinical phenotype with disease onset usually at <3 years of age; the young age and the aggressive tumor behavior makes for very challenging disease management.

 

Disclosure: AFD: Ad Hoc Consultant, NPS, Clinical Researcher, Pfizer, Inc.. PC: Researcher, Novartis Pharmaceuticals, Researcher, Novo Nordisk, Researcher, Pfizer, Inc., Researcher, Ipsen, Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Viropharma, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc.. AB: Investigator, Ipsen, Medical Advisory Board Member, Novartis Pharmaceuticals, Clinical Researcher, Pfizer Global R&D. Nothing to Disclose: MBL, GT, LR, FRF, BY, LAN, CSC, PAL, NSS, EV, JHC, EC, MCZ, MHS, CV, DM, NS, NM, TDC, PC, MRA, SG, GBB, ES, LFL, AD, PX, ADH, RB, ADM, IL, MFK, MD, LP, MJ, VB, MMQ, PL, JRL, CAS

OR20-3 19447 3.0000 A Disease Characteristics of Patients with X-Linked Acro-Gigantism (X-LAG) Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR20 5993 11:30:00 AM Pituitary Tumors-New Clinical Considerations Oral


Tina Constantin*1, Vin Tangpricha2, Reshma Shah1, Octavian C Ioachimescu2, Nelson M Oyesiku1 and Adriana Gabriela Ioachimescu1
1Emory University School of Medicine, Atlanta, GA, 2Emory University School of Medicine, Atlanta VA Medical Center, Atlanta, GA

 

Patients with acromegaly may develop hypercalcemia in context of primary hyperparathyroidism or 1,25(OH)2 vitamin D excess. Acromegaly also increases the risk of vertebral fractures. We present a controlled prospective study on calcium homeostasis and bone turnover markers in acromegaly.

Patients with acromegaly (Group A) comprised 22 patients who underwent surgical or medical therapy. Controls (Group B) were 22 patients with nonfunctioning pituitary adenomas. Laboratory studies were done before and 3-6 months after treatment, including serum and 24-hour urine calcium, phosphorus, calciotropic hormones, C-terminal telopeptide of type 1 collagen (CTX) and Procollagen type 1 N-terminal propeptide (P1NP).

            Group A patients were younger (43±13 vs 54±9), but gender, weight, waist circumference, prevalence of hypogonadism and diabetes mellitus, tumor size, prolactin level and eGFR were similar to Group B. Calcium abnormalities consisted of hypercalcemia in 9% of Group A and 0% in Group B; hypercalciuria in 22% of Group A and  5.5% of Group B. Mean serum phosphorus was higher in Group A vs B (4.3±0.7 vs 3.5±0.5 mg/dL), and PTH was lower (Group A 36.3±13.9 vs Group B 56.0±19.9 pg/ml) (p<0.01), while mean serum and urine calcium, 25(OH) D and 1,25(OH)2D were similar. Some alterations correlated with disease activity; in group A, IGF-1 correlated with serum calcium (R2 0.41, p<0.01) and inversely correlated with PTH (R2 0.18, p<0.05). Conversely, following treatment of acromegaly, these parameters decreased: serum calcium (9.64±0.4 to 9.35±0.2 mg/dL), fractional excretion of calcium (1.02±0.24 to 0.75±0.37 mg/dL), and phosphorus (4.3±0.7 to 3.9±0.8 mg/dL), while PTH increased (36.3±13.9 to 48.9±16.7 pg/ml). Vitamin 25(OH)D and 1,25-(OH)2D were unaltered.

Markers of bone resorption and formation were higher in Group A: CTX 0.91±0.75 vs 0.35±0.27 ng/ml, and P1NP 78.4±87.3 vs 28.1±13.10 ng/ml (p<0.01 vs Group B). In uncontrolled acromegaly, CTX strongly correlated with P1NP (R2 0.82, p<0.001). After treatment, CTX decreased (0.91±0.75 to 0.63±0.68 ng/ml, p<0.01), while P1NP was unchanged. Stepwise regression analysis showed that baseline CTX was determined by age and disease group, while gender and hypogonadism were not significant. At 3-6 months after treatment, age was the only significant parameter to predict CTX.

In summary, patients with acromegaly exhibit PTH-independent calcium-phosphate homeostasis alterations even in absence of hypercalcemia. These correlate with disease activity and are reversible after treatment. Furthermore, patients with uncontrolled acromegaly have increased bone formation and resorption which appears to be coupled. At 3-6 months post-treatment, only bone resorption decreases. Further research to elucidate the effect of GH on osteoclasts and the mechanistic link between bone metabolism and calcium homeostasis is required.

 

Disclosure: OCI: Principal Investigator, Ipsen. AGI: Principal Investigator, Ipsen. Nothing to Disclose: TC, VT, RS, NMO

OR20-4 21347 4.0000 A Calcium and Bone Turnover Alterations in Patients with Acromegaly: A Prospective Controlled Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR20 5993 11:30:00 AM Pituitary Tumors-New Clinical Considerations Oral


Daniel S Olsson*1, Anna G Nilsson2, Penelope Trimpou3, Bengt-Ake Bengtsson3, Eva Andersson3 and Gudmundur Johannsson3
1Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden, 2Sahlgrenska University Hospital and Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 3Sahlgrenska University Hospital, Gothenburg, Sweden

 

The excess mortality seen in adults with hypopituitarism has been suggested to at least in part be explained by untreated growth hormone (GH) deficiency. We have therefore studied the mortality in patients with hypopituitarism with and without long-term GH replacement therapy (GHRT). In order to eliminate the influence of the etiology of hypopituitarism on mortality only patients with non-functioning pituitary adenoma (NFPA) were studied.

NFPA patients within the Sahlgrenska University Hospital’s catchment-area (1.5 million inhabitants) were identified through the Swedish National Patient Registry. The records of all identified NFPA patients were reviewed retrospectively. All patients were cross-referenced with the Swedish National Death Registry. The study period was between 1987 and 2011. Standardized mortality ratios (SMRs) with 95% confidence intervals (reference: Swedish population) were calculated and cox-regression analyses were used to identify predictors for mortality.

We identified 437 patients with NFPA, out of which 435 (99%) had complete records and were included in the study. GHRT had been used for at least one year by 188 patients (132 men, 56 women) and 247 patients had not been treated with GHRT (148 men, 99 women). Mean (±SD) age at diagnosis was lower (p<0.001) in the GHRT-group (54.2±11.7) compared to the non-GHRT-group (63.8±15.6). Mean duration of GHRT was 10.9 (6.7) years and mean follow-up time in the non-GHRT-group was 7.0 (5.4) years. ACTH deficiency, gonadotropic deficiency and thyrotrophic deficiency were more frequent in the GHRT-group (71%, 74% and 93%) than in the non-GHRT-group (38%, 34% and 50%). The total number of events/deaths in the study was 83. The SMR was 0.49 (0.27-0.80, p=0.002) for the GHRT group and 0.98 (0.76-1.24; p=0.94) for the non-GHRT-group. The SMR was lower in the GHRT-group compared to the non-GHRT-group (p=0.02). Cox-regression analyses identified GHRT (p=0.01) and younger age at diagnosis (p<0.0001) as predictors of decreased mortality. Cause specific mortality due to circulatory diseases was not increased (GHRT-group, SMR 0.62; 0.25-1.28; Non-GHRT-group, SMR 0.96; 0.65-1.36). SMR for malignant tumors was reduced in the GHRT-group (SMR 0.19; 0.02-0.68; p=0.003), and as expected in the non-GHRT-group (SMR 0.74; 0.37-1.31; p=0.37).

This is the first study to report a reduced mortality in NFPA patients with long-term GHRT both in comparison to the general population and to NFPA patients who have not received GHRT, despite a more severe hypopituitarism. The mortality due to circulatory diseases was not increased in NFPA patients regardless of GHRT. Furthermore, death due to malignant tumors was decreased in the GHRT-group.

 

Disclosure: DSO: Speaker, Pfizer, Inc., Consultant, Ipsen. AGN: Consultant, Viropharma. GJ: Speaker, Pfizer, Inc., Speaker, Novo Nordisk, Speaker, Otsuka, Consultant, Astra Zeneca, Consultant, Viropharma. Nothing to Disclose: PT, BAB, EA

OR20-5 19715 5.0000 A Reduced Mortality in Patients with GH Replacement Therapy – a Swedish Study Based on More Than 4 000 Patient-Years 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR20 5993 11:30:00 AM Pituitary Tumors-New Clinical Considerations Oral


Selcuk Dagdelen*1, Safak Akin1, Ekim Gumeler2, Burce Ozgen2, Tuncay Hazirolan2 and Tomris Erbas1
1Hacettepe University Medical School, Ankara, Turkey, 2Hacettepe University, Ankara, Turkey

 

Background: Leading cause of mortality in acromegaly is the cardiovascular events. GH-exces and GH deficiency are both cardiovascular risk factors for unknown reasons. Acromegaly is associated with both, micro- and macrovascular changes as well. Hence, the underlying mechanism of GH-related cardiovascular disease has not been clarified yet.

Aim:We aimed to investigate prevalance and distributin of aneursyms in cranium (with MR-angiography), thorax and abdomen (with CT-angiograhy) in acromegaly.

Materials and Methods: Fourty six (mean age:47±13.2 yrs, F/M:23/23) acromegalic patients were investigated with a case-control study. Thirty-six age-sex (mean age:48.5±11.9 yrs, F/M:19/17) matched non-acromegalic controls (selected from healthy donors for renal transplantation) and 32 age-sex matched non-acromegalic controls (selected from patients with thorax CT scan for probable diagnosis of pulmonary thromboembolism), (44.2±12.3 yrs, F/M:16/16) were used for abdominal and thoracic aneursyms, respectively. Nine (19.6%) of the acromegalic patients had cured disease, 18 (39.2%) had well controlled, 8 (17.4%) had partially controlled, and 11 (23.9%) had active disease.  

Results: The abdominal and thoracic arterial evaluation with CT-angioraphy revealed aneursyms in 8 of 46 (17.4 %) acromegalic patients. Three cases had splenic artery and five cases had aortic aneursyms. There was no aneursym in thoracic and abdominal control groups. Eleven (23.9%) acromegalic patients had other arterial anomalies. 3/11 cases had bilateral double renal arteries, 5/11 cases had polar left renal artery, 1/11 case had double right renal arteries, and 2/11 cases had polar celiac artery. Cranial aneursyms was detected in 7 (17.5%) of 40 acromegalic patients. A total of cranial arterial tortuosity identified in 15 (37.5%) of 40 acromegalic patients.

Conclusion: High prevalance of cranial aneursyms are previously published by other groups but our study firstly shows that acromegaly is associated with (-not only cranial) thoracic, abdominal aneursyms, as well. Additionally, arterial anomalies (-not only tortuosity) are also firstly shown to be significantly increased in our acromegalic patients. Clinical significance of these arterial abnormalites which were shown here in acromegaly, requires further investigations. Our findings raise new questions about the nature and the underlying mechanisms of cardiovascular events in GH excess and GH-deficient conditions, which might be substantially different, i.e. vascular wall abnormalites versus atherosclerosis?

 

Nothing to Disclose: SD, SA, EG, BO, TH, TE

OR20-6 21672 6.0000 A Abdominal, Thoracic and Cranial Aneursyms in Patients with Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 1:00:00 PM OR20 5993 11:30:00 AM Pituitary Tumors-New Clinical Considerations Oral


Kristen P Tolson*1, Christian J Garcia1, Iris S Delgado2, Jeremy Troy Smith3 and Alexander S Kauffman1
1University of California, San Diego, La Jolla, CA, 2University of California San Diego, La Jolla, CA, 3The University of Western Australia, Perth, Australia

 

Kisspeptin is primarily known for the regulation of puberty and reproduction via its signaling through the receptor, Kiss1r (also known as GPR54), in GnRH neurons. However, both kisspeptin and Kiss1r are produced in multiple tissues and cell-types, and several recent studies have highlighted a role for kisspeptin signaling in metabolism and glucose homeostasis. We previously reported that Kiss1r KO mice display a sexually dimorphic obese phenotype, with adult KO females displaying obesity and impaired glucose homeostasis, as well as impaired metabolism, while KO males have normal body weight and glucose tolerance. However, KO males do exhibit decreased lean mass and increased fat mass, suggesting some effect of impaired kisspeptin signaling, but their metabolism and energy expenditure were not previously assessed. Here, we first determined whether KO males demonstrate alterations in metabolism or locomotor activity, as do KO females. We found that, compared to littermate controls, KO males have decreased metabolism and locomotor activity, though not as robust as in KO females. Next, we tested whether the reductions in energy expenditure and locomotor activity in both sexes are dependent on their chronic lack of gonadal sex steroids. We previously found that much of the obesity phenotype in Kiss1r KO females is not due to their lack of gonadal sex steroids during puberty or adulthood, but metabolic and locomotor measures were not similarly assessed. Here, we found that long-term gonadectomized (GDX) KO females still displayed marked decreases in metabolism and locomotor activity compared to GDX control females. Interestingly, in contrast, GDX KO males no longer differed in these measures from GDX control males, suggesting that the metabolic differences seen in gonad intact males reflect genotypic differences in gonadal sex steroids, whereas the metabolic phenotype in KO females is sex steroid-independent. Lastly, we determined that KO females already exhibit altered adiposity, metabolism, and locomotor activity, but not food intake or glucose tolerance, at young adult ages, weeks before the eventual emergence of increased body weight. Thus, the altered feeding and glucose regulation may be secondary to changes in metabolism and adiposity. Collectively, these data highlight sexually dimorphic effects of disrupted kisspeptin signaling on body weight, glucose homeostasis, and metabolism, and further confirm that multiple aspects of the metabolic phenotype in KO females are gonadal steroid-independent. Alterations in kisspeptin signaling could be a novel and important factor contributing to some facets of female obesity and metabolic dysfunction.

 

Nothing to Disclose: KPT, CJG, ISD, JTS, ASK

OR15-1 20195 1.0000 A Assessment of Sex Differences, Sex Steroid Dependency, and Developmental Onset of Impaired Metabolism and Energy Balance in Mice Lacking Kisspeptin Signaling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR15 6007 11:30:00 AM Female Reproduction - Interface with "Non-Reproductive" Systems Oral


Cari Nicholas*1, Andrew Wolfe2, Yan Sun1 and Genevieve S. Neal-Perry3
1Albert Einstein College of Medicine, Bronx, NY, 2Johns Hopkins University School of Medicine, Baltimore, MD, 3University of Washington, Seattle, WA

 

Vitamin D deficiency (VD-) affects over one billion people worldwide. In the United States, more than 40% of pregnant women and nearly 20% of children are estimated to be vitamin D (vitD) deficient. The vitD receptor is expressed throughout the hypothalamic-pituitary-gonadal (HPG) axis raising the possibility that vitD signaling is important for normal HPG axis and reproductive function. We previously reported that in utero and lactational VD- results in programmed estrous cycle dysfunction. To determine the critical window of development when VD- programs reproductive dysfunction in adult females, we exposed female mice to dietary VD- at three specific developmental stages: 1) in utero, 2) lactation or 3) in utero and lactational (early life). We hypothesize that exposure to in utero VD- programs reproductive dysfunction in female mice through effects on the hypothalamus. We used vaginal opening and cytology to assess puberty and estrous cyclicity in females. Neither in utero, lactational nor early life VD- affected puberty. However, regardless of when in development female mice were exposed to VD-, they developed prolonged and irregular estrous cycles characterized by oligoovulation (P<0.05). These findings suggested that developmental vitD sufficiency is important for normal HPG axis function in adulthood. To determine how early life VD- disrupts HPG axis function, we collected serum samples during estrus, diestrus and proestrus and quantified serum LH. Females exposed to early life VD- released 40% less LH on the day of proestrus. To determine if the reduced LH surge amplitude in early life VD- resulted from abnormal hypothalamic responsiveness to excitatory input, we conducted kisspeptin (KISS; 10 pmol) challenges in ovariectomized and estradiol-benzoate and progesterone primed females. Briefly, control mice and mice exposed to early life VD- were infused intracerebroventricularly with KISS immediately after basal blood collection. Blood was collected 10 min after KISS infusion, and then at 20 min intervals for a total of 50 min. Despite similar gonadal steroid and baseline gonadotropin levels, peak LH release in females exposed to early life VD- was 31% less than controls infused with KISS (p <0.05). In contrast, FSH release was not affected. This study suggests that early life VD- resulting from maternal VD- may program estrous cycle dysfunction through effects on hypothalamic responsiveness to KISS excitatory input.

 

Nothing to Disclose: CN, AW, YS, GSN

OR15-2 18954 2.0000 A Maternal Vitamin D Deficiency: Defective Programming of Hypothalamic-Pituitary Function Causes Reproductive Dysfunction in Female Offspring 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR15 6007 11:30:00 AM Female Reproduction - Interface with "Non-Reproductive" Systems Oral


Justin Chosich*1, Andrew P Bradford1, Jane E Reusch2, Irene Elizabeth Schauer1 and Nanette Santoro3
1University of Colorado School of Medicine, Aurora, CO, 2Denver Veterans Administration Medical Center, Denver, CO, 3University of Colorado Anschutz Medical Campus, Aurora, CO

 

Introduction: Obesity is associated with high circulating free fatty acids and triglycerides, insulin resistance, and relative hypogonadotropic hypogonadism.  We hypothesized that these metabolic changes (elevated lipids and hyperinsulinemia) impact the hypothalamic-pituitary-ovarian axis, inducing the impaired gonadotropin secretion that is characteristically observed in obese women.  To address this, we investigated serum Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH) profiles in normal weight women, during a lipid or saline infusion in the presence or absence of a concurrent hyperinsulinemic, euglycemic clamp.

Methods: A follicular phase (cycle day 6-10), 6-hour infusion study was undertaken in 10 regularly cycling, normal weight women (mean BMI 22.8 ± 0.83) of reproductive age (mean 32.5 ± 1.89 years). A crossover design was employed such that patients received each of the following infusions: control (saline), 20% lipid emulsion/heparin (45ml/h), insulin (40 mU/m2/min) under euglycemic clamp conditions, and a combination of lipid plus insulin, over a series of 4 visits. Blood was collected every 2 hours and FSH and LH measured by a direct chemiluminescent assay (Perkin Elmer; Autodelfia). Transverse mean (±SEM) gonadotropin levels were compared between control and treatments for each patient using a paired t test.

Results: Lipid/heparin infusion elevated fatty acid and triglyceride levels to the high physiological levels typically observed in obesity and metabolic syndrome. Mean control FSH levels (4.06 ± 0.20 U/L) were increased by lipid infusion (4.55 ± 0.19 U/L, p<0.01) and a similar trend was observed in response to insulin (4.76 ± 0.35 U/L, p=0.056). In contrast, infusion of lipid plus insulin significantly suppressed FSH (3.47 ± 0.36 U/L), compared to saline (p<0.005), lipid alone (p<0.0001) or insulin alone (p<0.05).  Similarly, control LH levels (4.85 ± 0.38 U/L) were modestly increased by lipid infusion (5.33 ± 0.36 U/L, p=0.06) and not significantly changed in response to insulin (4.13 ± 0.43 U/L, p=0.51). Infusion of lipid plus insulin significantly decreased LH levels (3.63 ± 0.49 U/L) relative to lipid alone (p<0.0001).

Thus, infusion of insulin or lipid alone did not reduce serum levels of FSH or LH. However, the combination of insulin plus lipid significantly decreased levels of both gonadotropins. 

Conclusion: Hyperinsulinemia and elevated circulating lipids, comorbidities characteristic of metabolic syndrome, act to acutely and synergistically suppress endogenous FSH and LH in normal weight women. This combinatorial effect provides a possible mechanism underlying the relative hypogonadotropic hypogonadism of obesity and indicates that the effects of insulin on the hypothalamic-pituitary-ovarian axis may be dependent on the concomitant metabolic environment.

 

Nothing to Disclose: JC, APB, JER, IES, NS

OR15-3 20032 3.0000 A Mimicking Metabolic Syndrome Impairs the Hypothalamic-Pituitary-Ovarian Axis in Normal Weight Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR15 6007 11:30:00 AM Female Reproduction - Interface with "Non-Reproductive" Systems Oral


Mojca Jensterle*1, Vesna Salamun2, Tomaz Kocjan3, Eda Vrtacnik Bokal2 and Andrej Janez4
1University Medical Centre Ljubljana, Ljublijana, Slovenia, 2University Medical Centre Ljubljana, 3University Medical Centre Ljubljana, Ljubljana, Slovenia, 4University Medical Center Ljubljana, Ljubljana, Slovenia

 

Context: Weight management by lifestyle intervention and metformin often remains unsatisfactory in obese women with polycystic ovary syndrome (PCOS). New treatment options for weight reduction acting through glucagon-like peptide (GLP)-1 mediated effects could be considered in these patients.

GLP-1 receptor agonist liraglutide is now FDA approved anti- obesity agent, yet the experiences with its use in PCOS related obesity are still very limited. Phosphodiesterase enzymes (PDE) 4 inhibitor roflumilast is well recognized as efficient anti-inflammatory drug. However, its less known beneficial metabolic action based on the interplay between the inhibition of PDE4 and the regulation of GLP-1 release has never been directly compared to GLP-1 receptor agonist, either in PCOS or in any other obese population, yet. In addition, the expression of PDE4 enzymes in ovaries and the recognised involvement of PDEs in steroidogenesis do not exclude a potential role of roflumilast in direct regulation of ovarian steroidogenesis and in the pathophysiology of PCOS.

Objective: To compare the effects of liraglutide, roflumilast and metformin on body weight reduction, glucose homeostasis, androgen profile and menstrual frequencies in obese women with PCOS.

Design/Main Outcome Measure: A 12-week prospective randomized open-label study was conducted with 45 obese PCOS diagnosed by the ASRM-ESHRE Rotterdam criteria. They were randomized to metformin (MET) 1000 mg BID or liraglutide (LIRA) 1.2 mg QD s.c. or roflumilast (ROF) 500 mcg QD. The primary outcome was change in measures of obesity.

Results: 41 patients (aged 30.7 ± 7.9 years, BMI 38.6 ± 6.0 kg/m2, mean ± SD) completed the study. Subjects treated with LIRA lost on average 3.1±3.5 kg (p= 0.006), on ROF 2.1±2.0 kg (p= 0.002) vs 0.2±1.83 kg in MET group. BMI decreased for 1.1±1.26 kg/m2 in LIRA (p= 0.006), for 0.8±0.99 kg/m2 in ROF (p= 0.001) vs 0.1±0.67 kg/m2 in MET. LIRA was superior to MET in reducing weight (p= 0.022), BMI (p= 0.020) and waist circumference (p=0.007). LIRA also resulted in decrease in VAT area (p=0.015) and more favorable glucose homeostasis during OGTT. ROF resulted in reduction of waist circumference (p=0.023). In addition, ROF led to testosterone reduction (p=0.05) and increase in menstrual frequencies (p=0.009) when compared to baseline.

Conclusion: Short-term monotherapy with liraglutide or roflumilast was associated with significant weight loss in obese PCOS, liraglutide being superior to roflumilast. Reduction of body weight with liraglutide resulted in improvement of body composition. Despite the superiority of liraglutide in weight reduction and glucose homeostasis, roflumilast resulted in testosterone reduction and increase in menstrual frequencies not being demonstrated in liraglutide arm. Metformin did not significantly affect the body weight or other observed outcomes in this short-term period yet.

 

Nothing to Disclose: MJ, VS, TK, EV, AJ

OR15-4 18867 4.0000 A Short Term Monotherapy with GLP-1 Receptor Agonist Liraglutide or PDE 4 Inhibitor Roflumilast Is Superior to Metformin in Weight Loss in Obese PCOS Women: A Pilot Randomized Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR15 6007 11:30:00 AM Female Reproduction - Interface with "Non-Reproductive" Systems Oral


Rocio Ines Pereira*1, Beret Ann Casey2, Tracy Swibas1 and Rachael E Van Pelt1
1University of Colorado Anschutz Medical Campus, Aurora, CO, 2Essentia Health. Wisconsin-Minnesota., Ashland, WI

 

New incidence of Type 2 diabetes (T2D) is reduced by 30% in postmenopausal women randomized to estrogen-based hormone therapy (HT) compared with placebo. T2D risk reduction is particularly strong when women are treated with HT early after menopause (aged 50-59y, <10yrs past menopause), suggesting that timing of treatment may be important. Insulin action, specifically insulin-mediated glucose disposal rate (GDR), is a key determinant of T2D risk and overall cardiometabolic health, and well-controlled studies indicate that estrogens directly impact insulin action. Consistent with this, our previous studies showed that estradiol (E2) improved insulin action in postmenopausal women, but secondary analyses suggested E2 had the opposite effect (decreased insulin action) in those who were many years beyond menopause. Based on our previous observation we hypothesized that the timing of E2 administration after menopause is an important determinant of its effect on insulin action. To test this hypothesis we studied 42 women (n=21/group) who had never used HT and were either early postmenopausal (EPM; ≤6 yr of final menses) or late postmenopausal (LPM; ≥10 yr since last menses). We measured GDR via hyperinsulinemic-euglycemic clamp after 1 week of transdermal E2 and placebo in a randomized, cross-over design. Compared to EPM, LPM were older (mean±SD; 63±3 vs 56±4 yr, p<0.05) and more years past menopause (12±2 vs 3±2 yr, p<0.05). Body mass index (25±3 vs 24±3 kg/m2) and fat mass (24±6 vs 23±6 kg) did not differ between groups, but fat-free mass (FFM) was lower in LPM compared to EPM (41±4 vs 44±5 kg, p<0.05). Baseline GDR did not differ between groups (11.5±3.0 vs. 11.4±2.8 mg/kg FFM/min). In support of our hypothesis, 1 week of E2 increased GDR in EPM, but decreased GDR in LPM (+0.57±1.7 vs -0.58±1.8 mg/kg FFM/min, p<0.05). Taken together, our data demonstrated that there was not an inevitable decline in insulin action with age or time since menopause per se. However, E2 action on GDR was dependent on time since menopause, such that there was a benefit early (≤6 yr) in menopause but harm later (≥10 yr) in menopause. E2-mediated effects on insulin action may be one mechanism by which HT reduces the incidence of T2D in early postmenopausal women.

 

Nothing to Disclose: RIP, BAC, TS, REV

OR15-5 19943 5.0000 A Timing of Estradiol Treatment after Menopause Determines Benefit or Harm to Insulin Action 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR15 6007 11:30:00 AM Female Reproduction - Interface with "Non-Reproductive" Systems Oral


Janet E. Hall*1, Amanda R Arulpragasam1, Taylor Huhta1, Rachel Franklin1, Kathryn L Williams1, Alexandra M Rodman1, Darin D Dougherty2, Hadine Joffe3 and Thilo Deckersbach2
1Massachusetts General Hospital, Boston, MA, 2Massachusetts General Hospital & Harvard Medical School, Boston, MA, 3Brigham and Women's Hospital, Dana Farber Cancer Institute, & Harvard Medical School, Boston, MA

 

Background: Memory deficits have been observed in association with surgical and natural menopause while a therapeutic benefit of estrogen replacement on cognitive function has been demonstrated in some, but not, all studies. Recent evidence suggests that potential benefits of estrogen treatment (ET) may be confined to a critical window of age or years from menopause. Neuroimaging studies indicate that the dorsolateral prefrontal cortex (DLPFC) and hippocampus, key areas involved in working memory and executive function, are functionally altered by both estrogen and aging; however, how aging influences the effect of estrogen on these critical regions is not well understood. 

Methods: In a randomized, double-blinded, placebo-controlled study, younger (n=19; aged 52+/-2.7 yr [mean+/-SD], range 47-56;) and older (n=16; aged 70+/-4.1 yr, range 65-79) postmenopausal women (PMW) received placebo or low dose ET for one month. Subjects completed a working memory task (N-back) while undergoing functional magnetic resonance (fMRI) scans before (baseline), and at 2 days and one month after initiation of treatment. The N-back paradigm was used because it produces a reliable increase in blood-oxygen-level dependent (BOLD) signal in the DLPFC that is linearly related to working memory load. Depression and mild cognitive impairment were excluded and subjects were healthy, right handed, and on no-centrally acting or over-the-counter medications or supplements. 

Results: E2 was <10 pg/mL in all subjects at baseline and with placebo.  ET resulted in an increase in E2 (58.3+/-6.1 pg/mL) that was not different between groups. At baseline, there was greater activation in the left DLPFC in younger than in older PMW (p<0.02). In addition, there was a significant interaction between age group, treatment and time in the DLPFC. Specifically, the interaction between age and treatment (ET vs placebo) was influenced by the duration of treatment; at 2 days there was less activation in response to ET in the younger compared to the older PMW in specific DLPFC subregions, while at one month there was greater activation in response to ET in the younger compared to the older PMW in other DLPFC subregions bilaterally.

Conclusion: In the absence of treatment, activation of the DLPFC in response to a test of working memory is decreased as a function of age in postmenopausal women. Estrogen exposure is initially associated with greater activation in specific DLPFC subregions in older compared to younger postmenopausal women. However, with longer estrogen treatment, activation in other subregions is significantly greater in younger than in older postmenopausal women. The observation that activation of DLPFC subregions is differentially affected by age and duration of treatment suggests that estrogen treatment results in the use of unique processing strategies for working memory in older compared with younger postmenopausal women.

 

Disclosure: HJ: Clinical Researcher, Teva, Consultant, Merck & Co., Medical Advisory Board Member, Merck & Co., Consultant, Noven. Nothing to Disclose: JEH, ARA, TH, RF, KLW, AMR, DDD, TD

OR15-6 21501 6.0000 A Effect of Age and Estrogen on Cognitive Processing in Postmenopausal Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR15 6007 11:30:00 AM Female Reproduction - Interface with "Non-Reproductive" Systems Oral


Harry MacKay*, Zachary R Patterson and Alfonso Abizaid
Carleton University, Ottawa, ON, Canada

 

Bisphenol-A (BPA) is a component of polycarbonate and many other types of plastics.  BPA has been characterized as an endocrine disruptor, most famously due to observations of its estrogenic activity in various experimental models.  Because BPA is a common constituent of food and drink containers, and because it can leach out under certain conditions, human exposure is nearly ubiquitous.

Emerging evidence from our lab has shown that CD-1 mice exposed to low, environmentally relevant doses of BPA early in life exhibit an adult phenotype characterized by sex-specific metabolic disruptions.  Specifically, male mice exhibit impaired glucose tolerance, and females a propensity toward diet-induced obesity.  Given the sensitivity of the hypothalamus to the organizational effects of sex steroids, we explored the possibility that early-life BPA exposure adversely affects the development of hypothalamic feeding circuitry to bring about these effects.

To test this hypothesis, we used male and female CD-1 mice exposed pre- and post-natally to either a control diet, a diet containing BPA (appx. 13.5 µg/kg/day), or the estrogenic diethylstilbestrol (DES) as a positive control (appx. 3 µg/kg/day).  Serum from pups was collected on PND2, 8, 10, 12, 16, and 21 for analysis of circulating leptin. Results from this study show that BPA and DES exposed pups have respectively delayed and blunted postnatal leptin surges – a state of affairs that points to a role for leptin in the organizational effects of early-life xenoestrogen exposure.  qRT-PCR analysis of leptin mRNA expression in white adipose tissue collected at the same time suggests that BPA and DES act at the transcriptional level to bring about these effects.  Both male and female BPA-exposed mice showed a reduced density of POMC projections into the PVN.  Adult offspring from this experiment were resistant to leptin-induced suppression of food intake, body weight loss, and hypothalamic POMC upregulation.  Taken together, these data suggest that BPA, a known obesogen, may exert its effects through developmental programming of the hypothalamic melanocortin circuitry.

 

Nothing to Disclose: HM, ZRP, AA

OR14-1 20438 1.0000 A Bisphenol-a (BPA) As an Obesogen: Developmental Programming of Leptin Sensitivity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 1:00:00 PM OR14 6019 11:30:00 AM Endocrine Disruptors in Development and Gene Regulation Oral


Maria Ines Perez-Millan*1, Amanda Helen Mortensen1, Michelle L. Brinkmeier2 and Sally A Camper3
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI, 35704 Med. Sci II, 1241 Catherine St., Ann Arbor, MI

 

A critical issue for understanding pituitary organogenesis and maintenance is to determine how the balance of stem cell self-renewal and differentiation into hormone producing cells is regulated. We hypothesized that the transcription factors mutated in cases of Multiple Pituitary Hormone Deficiency (MPHD) in humans would provide an entrée to addressing this key question. The most commonly mutated gene in MPHD encodes the transcription factor PROP1, and two of its direct transcriptional target genes also cause MPHD: POU1F1 (PIT1) and HESX1. In mouse fetal development Prop1 expression coincides spatially and temporally with the delamination, migration, and differentiation of progenitor cells in Rathke's Pouch (RP) into hormone producing cells. These processes fail in Prop1 mutant mice, resulting in organ dysmorphology, poor vascularization, and postnatal pituitary hypoplasia (1).  The appearance of the dysmorphic organ in Prop1 mutants suggests that progenitors proliferate excessively and are unable to be released from the niche and differentiate. The cells of RP that normally undergo delamination exhibit a switch in expression of markers typical of the epithelial to mesenchymal transition (EMT), such as N-cadherin to E-cadherin (2). Prop1 mutants fail to make this shift in expression properly, suggesting that Prop1 regulates EMT.  To test this idea, we set out to identify additional downstream target genes of PROP1.  We chose an in vitro approach of identifying DNA sequences bound by PROP1 in an immortalized pituitary cell line by ChIP-Seq technology.  We identified enrichment of PROP1 binding at the known and novel sites near the Pou1f1 gene, and interestingly, in genes that encode components of the pathways of “Cell Junction Signaling” and “Regulation of EMT”. We examined expression of several candidate genes in Prop1 mutant mice and confirmed that their expression was altered. Prop1 mutants exhibit elevated expression of tight junction proteins like claudins and progenitor or stem cell markers including several SOX genes. In contrast, genes that are typically expressed after EMT showed reduced or undetectable expression in the mutants.  These data suggest that Prop1 is necessary for the transition of progenitors into differentiating cells by suppressing expression of progenitor markers and claudin genes, which releases the tight junctions between cells and drives EMT. This study establishes new mechanisms underlying PROP1’s role in pituitary progenitor cell regulation and offers new candidate genes for MPHD that remain unexplained.

 

Nothing to Disclose: MIP, AHM, MLB, SAC

OR14-2 21938 2.0000 A PROP1 Regulates the Epithelial to Mesenchymal Transition of Embryonic Pituitary Progenitor/Stem Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 1:00:00 PM OR14 6019 11:30:00 AM Endocrine Disruptors in Development and Gene Regulation Oral


Viktoria Y Topper*1, Deena M Walker2 and Andrea C Gore1
1University of Texas at Austin, Austin, TX, 2Univ of Texas - Austin, Austin, TX

 

MicroRNAs are small non-coding RNAs involved in post-transcriptional regulation of gene expression. Some microRNAs undergo developmental change and/or have sexually dimorphic expression in the brain, but this field is still in its infancy. In our study we aimed to accomplish two goals: 1) examine expression of microRNAs in two hypothalamic regions for developmental change and possible sexual dimorphisms, and 2) investigate whether low-level gestational exposures to environmental endocrine disruptors altered these microRNAs’ expression. To accomplish this, pregnant Sprague-Dawley rats were injected on gestational days 16 and 18 with one of three treatments: vehicle (DMSO), estradiol benzoate (EB, 50 ug/kg), or a weakly estrogenic mixture of PCBs (Aroclor 1221 (A1221), 1mg/kg). Pups were born and littermates were euthanized on postnatal days 15, 30, 45, or 90. The medial preoptic nucleus (MPN) and ventromedial nucleus (VMN) of the hypothalamus, regions important in regulating adult reproductive function and behaviors, were assayed for expression of targeted microRNAs. We found that neural microRNA expression is sexually dimorphic in the hypothalamus during development. In the MPN, but not VMN, mir-219, mir-7 (both significant), and mir-145 (trend) levels were sexually dimorphic during puberty (P30). In the MPN, EB treatment reversed (mir-145), abolished (mir-7, mir-219 at P30), and caused new dimorphisms to emerge (mir-7, mir-145 at P15 and P45). A1221 treatment abolished the sexual dimorphism of mir-145, mir-219, and mir-7 expression in the MPN. Additionally, in the MPN, two microRNAs (mir-7 and mir-145) were masculinized in A1221 and EB-treated females at P30. We then performed in silico target prediction analysis to identify the mRNA targets of the affected microRNAs. This revealed a list of gene targets, with most genes belonging to the neuronal system, neurodevelopmental, and synaptic transmission pathways. Selected mRNA targets (Ar, Pgr, Ppara in male MPN; Igf1r and Grin2a in female MPN; Ar and Clock in male VMN; Lin28b, Clock, Lepr, and Ppara in female VMN) were analyzed but showed few effects of treatment, suggesting that changes to these microRNAs had relatively little effect on the chosen mRNAs, although there may be other mRNA targets (not analyzed) that were affected. Bionetwork analysis was also conducted to identify relationships among microRNAs, genes, hormones, and physiological landmarks. In summary, this study showed, for the first time, that hypothalamic microRNAs are sexually dimorphic and regulated by EDCs.

 

Nothing to Disclose: VYT, DMW, ACG

OR14-3 20022 3.0000 A Hypothalamic microRNA Expression in Rats Is Sexually Dimorphic and Regulated By Endocrine Disruptors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 1:00:00 PM OR14 6019 11:30:00 AM Endocrine Disruptors in Development and Gene Regulation Oral


Lindsey S Treviño*1, Quan Wang1, Charles E Foulds2, Christopher B. Newgard3, Bert W O'Malley2 and Cheryl Lyn Walker1
1Texas A&M Health Science Center, Houston, TX, 2Baylor College of Medicine, Houston, TX, 3Duke University Medical Center, Durham, NC

 

Obesity is a major problem worldwide and little is known about how early-life exposures to endocrine-disrupting chemicals (EDCs) promote obesity in adulthood.  Most studies related to the “obesogen” hypothesis have thus far focused on EDC effects on adipocytes and pancreatic β-cells. The liver, however, plays a central role in whole body fat metabolism, energy conversion, and obesity, highlighting the need to determine EDC effects on liver function. EDCs have been shown to alter the epigenomic programming of developing tissues. We hypothesized that early-life EDC exposure could induce epigenomic alterations in the liver, altering gene expression and metabolism to increase susceptibility to obesity in adulthood. To test this hypothesis, we treated neonatal Sprague Dawley rats with low doses of several EDCs reported to have obesogenic activity: bisphenol A (BPA), genistein (GEN), diethylstilbestrol (DES), or tributyltin (TBT) on postnatal days 1, 3, and 5- a crucial developmental window for the liver. Liver tissue was examined in vehicle and EDC-exposed animals immediately after exposure (postnatal day 5) and in adult animals at postnatal day 70.  We found that BPA and TBT had a profound effect on liver morphology and histology in adult rats (consistent with hepatic steatosis), with the greatest effect seen with BPA.  In addition, metabolomic profiling of liver from adult rats treated neonatally with BPA revealed altered metabolite profiles consistent with altered energy metabolism.  Microarray analysis was performed to determine if hepatic gene expression patterns were also altered, and the orphan nuclear receptor small heterodimer partner (Shp), a master regulator of lipid metabolism, was identified as a target for reprogramming by BPA.  Real-time quantitative PCR analysis confirmed this result and revealed that Shp is also a target for reprogramming by TBT. The Shp gene promoter has binding sites for ERa and PPARg/RXRa (that bind BPA and TBT, respectively) and we are examining how these EDCs may induce genomic signaling by altering coregulator complexes at this promoter using cell-free DNA pulldown assays with hepatocyte nuclear extracts. We have previously shown that epigenetic reprogramming can occur via activation of nongenomic signaling in developing tissues by BPA and other EDCs.  We found that similar to developing tissues of the reproductive tract, BPA and TBT activated nongenomic signaling in the developing liver at postnatal day 5.  Collectively, these data suggest that acute, neonatal exposure to BPA or TBT during critical developmental periods can activate nongenomic signaling in the neonatal liver that is associated with reprogramming of the adult liver, altered liver metabolism, and function. Future studies will be aimed at identifying the pathways and epigenetic targets responsible for reprogramming of Shp and other genes that may contribute to the obesogenic activity of EDCs.

 

Nothing to Disclose: LST, QW, CEF, CBN, BWO, CLW

OR14-4 21942 4.0000 A Developmental Reprogramming in the Liver By Endocrine-Disrupting Chemicals 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 1:00:00 PM OR14 6019 11:30:00 AM Endocrine Disruptors in Development and Gene Regulation Oral


Shiuan Chen*1, Jui-Hua Hsieh2, Ruili Huang3, Srilatha Sakamuru3, Li-Yu Hsin1, Menghang Xia3, Keith Shockley2, Scott Auerback2, Noriko Kanaya1, Hannah Lu1, Daniel Svoboda2, Kristine L. Witt2, B. Alex Merrick2, Raymond R. Tice2 and Christina T Teng2
1Beckman Research Institute of the City of Hope, Duarte, CA, 2NIEHS, Research Triangle Park, NC, 3NIH, Rockville, MD

 

Aromatase is critical in maintaining normal androgen/estrogen balance.  Unexpected exposure of aromatase inhibitor (AI)–like chemicals may cause a variety of adverse health effects.  Through a team effort, the AroER tri-screen™ assay has been adapted to a 1536-well plate format for identifying potential AIs in the U.S. Tox21 10K compound library.  One goal of the Tox21 screening program is to cover a broad range of biological space by developing multiple cell-based assays targeting a variety of signaling pathways, including steroid hormone signaling pathways.  Many screens have been developed to identify compounds that interact with hormone receptors.  The development of screen methods targeting non-receptor-mediated mechanisms is an important need to broaden the identification of new classes of endocrine disrupting chemicals (EDCs).  This AroER tri-screen™ assay uses estrogen receptor (ER)-positive, aromatase-expressing MCF-7 breast cancer cells stably transfected with an estrogen-responsive element (ERE)-dependent luciferase reporter plasmid for screening in three formats yielding complementary information on three biological activities.  Screening with test compound alone identifies ERα agonists.  Screening in the presence of testosterone (T) identifies aromatase and/or ERα antagonists.  Screening in the presence of 17β-estradiol (E2) identifies ERα antagonists.  The initial screening of the Tox21 10K library in the presence of testosterone (T) identified 316 potential AIs.  These compounds, along with additional known actives and inactives, were rescreened in all 3-assay formats.  Of these selected compounds, 74 inhibited aromatase selectively.  Among the 74 positives, the two largest structural clusters (27 compounds total) were an imidazole class and a 1, 2, 4-triazole class (including two nonsteroidal AIs and antifungal agents).  Fourteen of the 74 compounds, that were newly identified and considered to be novel AIs, were further tested using a tritiated-water release aromatase enzyme assay.  Four compounds - amlodipine besylate, erlotinib, imazalil, travafloxacin – inhibited aromatase irreversibly.  Amlodipine besylate is a competitive inhibitor with respect to the androgen substrate, while the other 3 are noncompetitive inhibitors.  The current study also confirmed six additional AI-like chemicals (amoxapine; myclobutanil; Ro 22-9194; 4,4’-oxydianiline; 4,4’-propane-1,3-diyldipyridine; tetraconzaole) which inhibit aromatase in a reversible manner.  Therefore, the AroER tri-screen, in high throughput format, can accurately and efficiently identify chemicals selectively interacting with aromatase, but not ER, in large and diverse chemical libraries.  This work was supported by the Intramural Research Programs (Interagency agreement #Y2-ES-7020-1) of the National Toxicology Program, NIEHS and the CBCRP grant 17UB-8701 (SC).

 

Nothing to Disclose: SC, JHH, RH, SS, LYH, MX, KS, SA, NK, HL, DS, KLW, BAM, RRT, CTT

OR14-5 19977 5.0000 A Cell-Based High-Throughput Screening of Aromatase Inhibitors in Tox21 10K Library 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 1:00:00 PM OR14 6019 11:30:00 AM Endocrine Disruptors in Development and Gene Regulation Oral


Sylvie Babajko*1, Katia Jedeon1, Sophia Houari2, Sophia Loiodice2 and Ariane Berdal3
1INSERM, Paris, France, 2University Paris-Diderot, Paris, France, 3AP-HP, Paris, France

 

There has been increasing concerns over the last twenty years about the potential adverse effects of endocrine disruptors (EDs) especially Bisphenol A (BPA). It is commonly used in the plastics industry as the base compound for the manufacture of polycarbonates and epoxy resins and more than 95% of the population is contaminated by BPA. Anecdotally, molar incisor hypomineralization (MIH), an enamel pathology affecting 15 to 18% of 6-9 years old children, is increasing concurrently with ED related pathologies. Our previous data show that BPA impacts amelogenesis and enamel mineralization preferentially in male rats and generate similar enamel defects as those described for MIH.  The resulting irreversible enamel defects may provide an easily accessible marker for reporting early ED exposure in humans (1, 2).

The aim of the present study was to decipher the mechanism of action of low-dose BPA during amelogenesis.

First, the presence of putative BPA receptors has been investigated by RT-Q-PCR on microdissected rat ameloblasts at different stages of differentiation. ERRγ and ERα were expressed by pre-ameloblasts, the less differentiated cells whereas GPR30 and AR were expressed during the maturation stage corresponding to the final stage of ameloblast differentiation involved in enamel mineralization process. ERβ was not detected in dental epithelium whatever the stage of ameloblast differentiation considered.

Second, in vitro analysis carried out on the rat ameloblastic cell line HAT7 also showed the presence of ERα and AR (not ERβ). 10-9 M BPA as 10-9 M estrogen (E2) induced cell proliferation specifically via ERα. The ER antagonist ICI 182,780 used to inactivate ERα reduced the mitogenic effects of BPA and E2. In addition, ameloblast proliferation was greater in samples treated with the BPA and E2 combination than in samples treated with BPA or E2 alone.

On the other hand, functional response as nuclear translocation was recorded in HAT7 cells treated with steroid hormones, and modulated by BPA.

In conclusion, we report that BPA stimulates ameloblast proliferation and modulates differentiation. These data help to understand how enamel defects may be used as early marker of exposure to EDs. We also demonstrate, for the first time, that dental epithelial cells are estrogen and androgen targets and that an increase in pro-estrogenic activity has a greater effect on the enamel in male than in female rats. We thus provide evidence of hormonal influence on amelogenesis and probably on sexual differences of enamel quality.

 

Nothing to Disclose: SB, KJ, SH, SL, AB

OR14-6 20857 6.0000 A Bisphenol a Affects Amelogenesis through Steroid Hormone Receptors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 1:00:00 PM OR14 6019 11:30:00 AM Endocrine Disruptors in Development and Gene Regulation Oral


Marilena Nakaguma*, Tatiana S Pelaes, Christiane Gruetzmacher, Flávia Siqueira Cunha, Maria Helena Palma Sircili, Elaine M F Costa, Berenice B Mendonca and Sorahia Domenice
Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Background: Female-to-male transsexualism (FtMt) is a rare condition, with a prevalence of 1:30.000 to 1:400.000 females. Testosterone esters are used to induce virilization and menses cessation in these patients. The long-term effects of high doses of testosterone therapy in the female internal genital tract are not well known. Androgens involvement in the process of folliculogenesis has been demonstrated in vitro and in vivo experiments. This androgen effect has been correlated with the presence of enlarged ovaries and morphological features of polycystic ovary syndrome (PCOS) observed in some FtMt treated with androgens. Objective: To describe the histopathological effects in the internal genital tract of FtMt after long-term of androgen therapy. Patients and Methods: Histological findings of 26 FtMt submitted to hysterectomy, bilateral salpingo-oophorectomies in the sex reassignment surgery were retrospectively reviewed. The patients’ mean age at surgery was 36.5 + 8.1 yrs. The treatment with testosterone esters (200 to 250 mg, every 15 to 28 days) ranged from 1 to 18 yrs (6 ± 5.9 yrs). Two groups were established according to the interval of treatment: Group 1 (n=17) ≤ 5 years and Group 2 (n=9) > 5 years. 28% of the FTMt patients had irregular menstrual cycles before androgen treatment, and none was diagnosed with PCOS. The resected tissues were stained with HE using standard techniques. Results: Uterine’s volume and endometrial’s thickness in group 1 were: 121 ± 192 cm3 and 0.35 ± 0.5 cm and in group 2: 54 ± 24 cm3 (p= 0.17) and 0.28 ± 0.21cm (p=0.65), respectively. Proliferative (57.7%) and atrophic (42.3%) endometrial patterns were identified. Endometrial polyp was present in one patient and the prevalence of leiomyoma was 15.3%, which is not different from the prevalence in general population. Minimal changes in the cervical histology were observed: chronic cervicitis (38.4%) and cervical intraepithelial neoplasia (3.8%). Right and left ovarian mean size were 4.7 ± 1.9 cm3 and 5.7 ± 3.3cm3, respectively in group 1, and 2.8 ± 1.7cm3 and 3.0 ± 1.4 cm3 respectively in group 2. There was a significantly reduction of right (p=0.016) and left (p=0.008) ovarian volume in the FtMt of group 2. Multiple ovarian cysts were observed in 13 patients, the majority of them (69%) in group 1. Conclusion: An important reduction of ovarian volume was observed in the FtMt group with longer exposure to testosterone treatment. Despite the ovarian changes, the uterine histology does not seem to be significantly modified after long-term androgen exposure in this group of FtMt.

 

Nothing to Disclose: MN, TSP, CG, FSC, MHPS, EMFC, BBM, SD

OR21-1 21232 1.0000 A Histological Effects of Long-Term Androgen Therapy in Genital Tract of Female-to-Male Transsexual Subjects 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR21 6020 11:30:00 AM Basic and Clinical Aspects of Sexual Development Oral


Yardena Tenenbaum Rakover*1, Ariela Weinberg Shukron2, Paul Renbaum3, Dvir Dahary4, Ephrat Levy Lhahd2, Dani Bercovich5 and David Zangen6
1Ha'Emek Medical Center, Afula, Israel, 2Shaare Zedek Medical Center, Jerusalem, Israel, 3Shaare Zedek Medical Center, Israel, 4Toldot Genetics Ltd, Hod Hasharon, Israel, 5Tel Hai College, Tel Hai, Israel, 6Hadassah Hebrew Univ Med Ctr, Jerusalem, Israel

 

Primary gonadal failure is characterized by a lack of spontaneous pubertal development, primary amenorrhea or early menopause in females, and oligospermia or azoospermia in males. Variants of the minichromosome maintenance complex component 8 gene (MCM8) have been recently shown to be significantly associated with women's menopausal age in genome-wide association studies. Furthermore, MCM8-knockout mice are sterile. The objective of this study was to elucidate the genetic etiology of gonadal failure in two siblings from a consanguineous family presenting as primary amenorrhea in the female and as small testes and azoospermia in the male. Using whole exome sequencing, we identified a novel homozygous splice mutation (c.1954-1G>A) in the recently characterized MCM8 gene. The identified mutation segregated with the disease in the family and was absent in 100 ethnically matched control subjects. The splicing effects of the identified mutation were examined by cDNA sequencing and real-time polymerase chain reaction assays. MCM8 cDNA sequencing in the affected individuals revealed lack of the wild-type transcript and three different aberrant transcripts predicted to result in either truncated or significantly shorter proteins. Quantitative analysis of these aberrant transcripts showed a significant decrease in MCM8 message in affected siblings homozygous for the mutation, and an intermediate decrease in heterozygous family members.

Our study provides first evidence of MCM8 being crucial for gonadal development and maintenance in humans, while its disruption may lead to gonadal dysgenesis. These findings open new insights into the genetic disorders of infertility and premature menopause in women.

 

Nothing to Disclose: YTR, AWS, PR, DD, ELL, DB, DZ

OR21-2 18552 2.0000 A Minichromosome Maintenance Complex Component 8 (MCM8) Gene Mutation Results in Primary Gonadal Failure 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR21 6020 11:30:00 AM Basic and Clinical Aspects of Sexual Development Oral


Vasundhera Chauhan*1, Madan L Khurana1, Vandana Jain2, Rajesh Khadgawat1 and Rima Dada2
1All India Institute of Medical Sciences, New Delhi, India, 2All India Institute of Medical Sciences, Delhi, India

 

Background: 46, XY Gonadal Dysgenesis (GD) is often due to the disruption in genetic network that regulates the development of gonads. Causative mutations have only been explained in less than 20% of all cases of 46, XY GD. NR5A1, SRY, DAX1, SOX9, DHH genes play a crucial role in the cascade of events during sexual development. Mutations in these genes may be the cause of abnormal phenotype in our patients.

Objective: Molecular analysis of NR5A1, SRY, DAX1, SOX9, DHH genes in Indian patients with 46, XY GD attending a tertiary care hospital.

Methodology: Clinical examination, psychological assessment, cytogenetic evaluation, hormonal profile (LH, FSH, Testosterone) and molecular analysis of NR5A1, SRY, DAX1, SOX9, DHH genes was done.

Results: Eight patients were recruited in a period of 6 months. Age at intial presentation ranged from 6 days to 19 years (7.7±8.2). One patient had ambiguous genitalia, 3 presented with primary amennorhoea, 2 with unilateral undescended testis and 2 with bilateral undescended testis. Three patients were diagnosed with complete gonadal dysgenesis and five with partial gonadal dygenesis. On psychological assessment, sex of rearing in these patients was found to be concordant with their assigned sex. Cytogenetic analysis showed 46, XY karyotype in all the patients. The hormonal profile in these patients ranged from 0.24mIU/ml to 37.72mIU/ml for LH, 2.76mIU/ml to 111mIU/ml for FSH, 0.02ng/ml to 0.3ng/ml for Testosterone. On molecular analysis, heterozygous mutations were noted in five out of 8 patients. We found 3 novel (one heterozygous missense mutation V69E in high mobility group box of SRY gene, one heterozygous intronic change g.8079G>A and one heterozygous transversion c.2790T>A in the untranslated region of NR5A1 gene) and 4 previously reported genetic changes (rs1110061, rs1889311, rs10120967, rs10283445 ) in our patients.

Conclusion: We describe for the first time a missense mutation p.69V>E in SRY gene in three patients (one patient with unilateral and two patients with bilateral dysgenetic gonads). Two novel heterozygous changes were also found in NR5A1 gene in patients with bilateral dysgenetic gonads. These results reiterate the importance of NR5A1 and SRY genes in evaluation of patients with 46, XY GD.

 

 

Nothing to Disclose: VC, MLK, VJ, RK, RD

OR21-3 20896 3.0000 A Mutational Analysis of NR5A1,SRY, DAX1, SOX9, DHH Genes in Indian Patients with Gonadal Dysgenesis and 46, XY Karyotype 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR21 6020 11:30:00 AM Basic and Clinical Aspects of Sexual Development Oral


Manoj Prasad*1, Jasmeet Kaur1, Kevin J Pawlak1, Mahuya Bose2, Randy M Whittal3 and Himangshu S Bose1
1Mercer University, Savannah, GA, 2Florida Biologix, University of Florida, Gainesville, FL, 3University of Alberta, Canada, AB, Canada

 

Steroid hormones are essential for carbohydrate metabolism, stress management and reproduction, and are synthesized from cholesterol in adrenals and gonads/ovaries of mitochondria.  In acute stress or hormonal stimulation, steroidogenic acute regulatory protein (StAR) transports substrate cholesterol into the mitochondria for steroidogenesis in an unknown mechanism. We found that StAR interacts with VDAC2 at the mitochondria associated ER membrane (MAM) prior to its translocation to the mitochondrial matrix. In the MAM, StAR remains associated with several mitochondrial and ER proteins but directly interacts with VDAC2. In the absence of VDAC2, StAR expression is not altered but processing into the mitochondria as a mature 30 kDa protein is nearly ablated. VDAC2, interacts with StAR via its C-terminal 20 and N-terminal 221-229 amino acids. siRNA mediated VDAC2  knockdown MA-10 cells did not synthesise any pregnenolone. In the absence of VDAC2, StAR cannot enter the mitochondria or interact with MAM-associated proteins and, therefore, steroidogenesis is inhibited. Furthermore, the N-terminus is not essential for StAR activity, and the N-terminal deletion mutant continues to interact with VDAC2. Furthermore, the ER targeting prolactin signal sequence did not affect StAR association with the MAM and thus its mitochondrial targeting. So, VDAC2 controls StAR processing and activity, and thus MAM is a central location for initiating mitochondrial steroidogenesis.

 

Nothing to Disclose: MP, JK, KJP, MB, RMW, HSB

OR21-4 19351 4.0000 A Mitochondria Associated ER-Membrane (MAM) Associated VDAC2 Interacts STAR and Regulates Steroidogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR21 6020 11:30:00 AM Basic and Clinical Aspects of Sexual Development Oral


Giselle Neres Souza*1, Aline Zamboni Machado2, Maria Helena Palma Sircili2, Mirian Y Nishi2, Rosana Barbosa Silva2, Thatiana Evilen Silva2, Elaine M F Costa2 and Sorahia Domenice2
1Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/LIM42, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, São Paulo, Brazil, 2Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Background: The diagnosis of 46,XY disorder of sex development (DSD) due to 5-alpha reductase 2 (5α-RD2) deficiency has been based on testosterone:dihydrotestosterone (T:DHT) ratio, urinary steroid profiling and mutational analysis of SRD5A2 gene. The biochemical hallmarks of 5-alpha reductase 2 include increased T:DHT ratio. However, several difficulties are observed in the DHT measurement leading to misdiagnosis. The mutational analysis of the SRD5A2 has been proposed as the first line test in the investigation of 5α-RD2 deficiency. Objective: to screen the presence of SRD5A2 mutations in 21 patients with 46,XYDSD. Subjects and Methods -Twenty-one 46,XY DSD patients were studied. All the patients presented ambiguous genitalia at birth. The age at hormonal evaluation range from 11 months to 35 yrs of age. The 46,XY DSD patients was distributed in two groups: Group 1: 6 patients with known T∕DHT ratio (range from 11 to 129); Group 2: 15 patients with unknown T∕DHT ratio; 13 of them were previously orchiectomized and the hormonal profile was not available in the two other patients. The entire coding region of SRD5A2 gene was PCR amplified and directly sequenced using a BigDye Terminator in ABI PRISM 3130 DNA Sequencer. In silico secondary structure analysis of SRD5A2 variants were done in the prediction websites PolyPhen and SIFT. SRD5A2 CNVs was evaluated by MLPA technique. Results: Group 1: four allelic variants of SRD5A2 were identified in homozygous state and in one patient a compound heterozygous variant was found. In silico analysis of the two novel variants identified in this group, p.Trp140Glnfs*19 and p.Gly123Val, were predicted to be potentially damage. The variant p.Trp140Glnfs*19 was found in two unrelated patients with T∕DHT ratio of 11 and 43. The patients in whom the mutations previously described (p.Gly123Val, p.Arg227*, and p.Gln126Arg) were identified presented the T∕DHT ratio of 24, 46 and 129 respectively. The patient with a compound heterozygous allelic variants, p.Gly183Ser (damage) and p.Asp164Val (probably damage) presented T∕DHT ratio of 39. SRD5A2 sequencing identified mutations or potential deleterious allelic variants in 100% (5 of 5) of patients with hormonal profile of 5α-RD2 deficiency and in one patient without hormonal profile of 5α-RD2 deficiency (T/DHT=11). In the group 2, the p.Gly183Ser mutation, was identified in homozygous state in a 46,XY DSD patient without etiologic diagnosis that was submitted in the childhood to a genital feminization surgery with bilateral gonadectomy (Table 1; Fig 1). SRD5A2 CNV was not identified in these patients. Conclusion: Sequencing of SRD5A2 is a fast and effortless technique and should be used as the preferable approach for the diagnosis of 46,XY DSD due to 5α-RD2 deficiency

 

Nothing to Disclose: GNS, AZM, MHPS, MYN, RBS, TES, EMFC, SD

OR21-5 21737 5.0000 A Analysis of Steroid 5-Alpha Reductase 2 (SRD5A2) Gene in Patients with 46,XY Disorder of Sex Development 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR21 6020 11:30:00 AM Basic and Clinical Aspects of Sexual Development Oral


Ariel L. Negrón*1, Guiqin Yu2, Ulrich Boehm3 and Maricedes Acosta-Martínez4
1Stony Brook University, Stony Brook, NY, 2Stony Brook University Medical Center, 3University of Saarland School of Medicine, Homburg, Germany, 4Stony Brook University Medical Center, Stony Brook, NY

 

In mammals, the developmental and sex-specific changes in hypothalamic kisspeptin expression and release are critical for the maturation of the hypothalamic-pituitary-gonadal axis in both sexes, and the ability of females to show an ovulatory gonadotropin surge. However, the molecular mechanisms by which gonadal hormone-dependent and -independent pathways regulate kisspeptin development and function in both sexes are unknown. The signaling molecule phosphatase and tensin homolog (PTEN) is a dual protein and lipid phosphatase that plays an important role in neuronal development, regulating cell survival, neuronal size, and proliferation. To examine the importance of PTEN in the development and function of the hypothalamic kisspeptinergic system, we created a transgenic mouse with a kisspeptin cell-specific ablation of PTEN (Kiss-PTEN KO). Compared to wild-type (WT) littermates, Kiss-PTEN KO females showed kisspeptin neuron hypertrophy and notably increased peptide content in the anteroventral periventricular nucleus (AVPV) of the hypothalamus as observed by immunohistochemistry, however difference in mean optical density did not reach significance. This was accompanied by a significant decrease in the number of AVPV kisspeptin-immunoreactive (ir) cells (215.8 ± 26.92 vs. 120.0 ± 26.64 total # cells; P=0.033; n=5-6 per genotype). In contrast, Kiss-PTEN KO males had a significantly higher number of kisspeptin-ir cells compared to WT littermates (15.2 ± 1.45 vs. 21.7 ± 1.76 total # cells; P=0.017; n=6 per genotype) and more fiber staining in the AVPV but no effect on neuronal size was observed. Basal gonadotropin levels in adult intact Kiss-PTEN KO males were not significantly different from WT mice, however KO males exhibited a decreased gonadotropin response after gonadectomy. Serum testosterone levels in adult Kiss-PTEN KO males were notably decreased, though this did not reach significance. No genotype effects were observed on pubertal development in either sex; however, mating studies showed that Kiss-PTEN KO females had a 50% reduction in successful pregnancies compared to WT females (χ2=4.6, P=0.03, n=4 per genotype). Our findings on AVPV kisspeptin cell number bear resemblance to those observed in rodent models in which perinatal levels of steroid hormones, specifically estradiol (E2), are decreased. In several cell types, PTEN is a target of estrogen receptor alpha (ERα) signaling. We propose that E2-ERα regulates PTEN signaling in kisspeptin neurons and that E2-ERα-PTEN signaling participates in the E2-dependent organizational events leading to the sex-specific expression of hypothalamic kisspeptin neurons.

 

Nothing to Disclose: ALN, GY, UB, MA

OR21-6 21049 6.0000 A Targeted Deletion of PTEN in Kisspeptin Cells Results in Sex-Specific Trophic Effects and Disruptions in the Reproductive Axis of Male and Female Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 1:00:00 PM OR21 6020 11:30:00 AM Basic and Clinical Aspects of Sexual Development Oral


Jingjing Li1, Robert J Ferry Jr.*1, Shiyong Diao1, Bingzhong Xue2, Suleiman W Bahouth1 and Francesca-Fang Liao1
1University of Tennessee Health Science Center, Memphis, TN, 2Georgia State University, Atlanta, GA

 

Background: E3 ligases regulate substrate specificity for ubiquitin conjugation during protein degradation. The neural precursor cell expressed developmentally down-regulated gene 4 (Nedd4) is a HECT-type E3 ubiquitin ligase and represents the prototype of the Nedd4 protein family, who governs ubiquitin-dependent endocytosis and/or degradation of plasma membrane proteins. Many substrates of Nedd4 regulate metabolism, implying a potential metabolic role for Nedd4 itself. Loss of Nedd4 causes embryonic or neonatal lethality in mice and reduced insulin/IGF-1 signaling in murine embryonic fibroblasts (1).

Design: To investigate potential metabolic regulation by Nedd4 in vivo, we characterized the metabolic phenotypes of Nedd4+/– haplosufficient mice using a high-fat diet induced obesity (HFDIO) model.

Results: Nedd4+/- mice displayed moderately insulin resistant, but paradoxically protected against HFDIO. Total body weight gain were profoundly decreased by 30% in Nedd4+/– mice after 30 weeks of HFD (P<0.001 despite similar physical activity and food intake relative to wild-type controls). After HFD feeding, Nedd4+/- mice showed less fat mass and smaller adipocytes in epididymal white adipose tissue (WAT) than wild-type mice (P<0.05). Despite ameliorated HFDIO, the Nedd4+/- mice did not show manifest improvement in glucose tolerance vs. wild-type animals in both genders. Nedd4+/- male, but not female, mice displayed significantly lower fasting blood glucose levels and serum insulin levels. Furthermore, Nedd4+/- mice under obesogenic conditions were associated with elevated stimulated lipolytic activity through β-adrenergic receptor signaling, consistent with prior in vitro models in which Nedd4 severs as an E3 ligase for β2 adrenergic receptor (β2-AR) internalization and protein degradation (2,3). 

Conclusion: This is the first report of direct actions by Nedd4 itself in the molecular etiopathophysiology of obesity. Our data support novel complex roles for Nedd4 in metabolic regulation involving altered insulin and ß-adrenergic signaling pathways.

 

Disclosure: RJF Jr.: Principal Investigator, Bristol-Myers Squibb, Principal Investigator, Takeda, Principal Investigator, Novo Nordisk. Nothing to Disclose: JL, SD, BX, SWB, FFL

OR19-1 18218 1.0000 A Novel Metabolic Roles for the E3 Ubiquitin Ligase Nedd4 to Mobilize Fat and Protect from Obesity Induced By High-Fat Diet 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 1:00:00 PM OR19 6039 11:30:00 AM Obesity: Novel Basic Science Oral


David R Powell*1, Jean-Pierre Revelli2, Deon Doree2, Christopher M DaCosta2, Urvi Desai2, Dorit B Donoviel2, Melanie K Shadoan2, Lawrence Rodriguez2, Kenneth A Platt2, Gwenn M. Hansen1, Zhi-Ming Ding2, Brian Zambrowicz1, Peter Vogel2 and Robert Brommage2
1Lexicon Pharmaceuticals, The Woodlands, TX, 2Lexicon Pharmaceuticals, Inc., The Woodlands, TX

 

Screening mammalian gene function in vivo is a powerful way to identify potential drug targets. Because comparable genetic alterations in human and mouse genes encoding OB, DB, MC4R, POMC, SIM1, BDNF, SH2B1, MRAP2, KSR2 and TUB are associated with increased body fat (BF), screening gene function in mice should identify genes regulating human BF, including potentially druggable genes. We present high-throughput screening (HTS) data for 3734 distinct global gene knockout (KO) mouse lines with viable adult KO mice generated using either gene-trap or homologous recombination technologies. Body composition, presented as BF and lean body mass, was determined by: 1) DEXA scans (N = 3651 KO lines) at 14 weeks of age on male and female mice fed chow diet; and 2) QMR scans (N = 2463 KO lines) at 11 weeks of age on a separate cohort of male mice fed high fat diet; KO and wild-type littermate mice were examined for each KO line. Lethality was noted in another 850 distinct KO lines, with histopathology assessment finding BF phenotypes in some lines. Since primary HTS are susceptible to false positive findings, additional cohorts of mice were studied in the KO lines listed below to confirm either novel BF data or absence of a published BF phenotype in the HTS cohorts. Some KO lines with confirmed BF phenotypes underwent further studies, including measuring food consumption (FC), malabsorption, glucose and insulin levels during GTTs, metabolic rate (indirect calorimetry), physical activity (telemetry and beam break technologies) and circulating lipid levels in mice of different ages; also, for KOs of genes considered potential drug targets, phenotypes unrelated to body composition were studied. The HTS confirmed published high BF of Aqp7, Brs3, Igfbp2, Mc3r, Mc4r, Prlhr and Tsn KO mice but not Htr2c KO mice, and confirmed published low BF of Agpat2, Camkk2, Cnr1, Ctsl, Dgat2, Gpam, Gpr43, Lmtk3, Mapk8, Mchr1, Mest, Mstn, Pde4d, Plin1, Pip5k2b, Ptpn1, Scd1, Sglt1, Slc2a5, Slurp1 and Tph2 KO mice but not Acacb, Ghrl, Hsd11b1, Ppyr1 or Pyy KO mice. The HTS also identified novel high BF phenotypes in Ksr2, Asnsd1, Kiss1 and Kiss1r KO mice, along with novel low BF phenotypes in Dagla, Abcd3, Nlgn3, Tuft1, Ube2r2 and Wnt10a KO mice.  Also, 13 novel undisclosed genes coding for potential obesity drug targets (4 with high BF, 9 with low BF) were identified by HTS and confirmed with subsequent cohorts. Additional KO lines with low or high BF in the HTS await confirmatory studies. In summary, the HTS identified: 1) many KO lines with published high and low BF phenotypes; 2) the need to independently confirm published BF data from any KO line; 3) Ksr2, a novel gene that regulates BF and FC in mice and humans; and 4) low BF in mice lacking Dagla, a potential anti-obesity drug target.  We conclude that comprehensive screening of mouse KO lines identifies genes associated with human obesity, and may identify some that are targets for anti-obesity therapeutics.

 

Disclosure: DRP: Employee, Lexicon Pharmaceuticals, Inc., Employee, Lexicon Pharmaceuticals, Inc., Employee, Lexicon Pharmaceuticals, Inc.. Nothing to Disclose: JPR, DD, CMD, UD, DBD, MKS, LR, KAP, GMH, ZMD, BZ, PV, RB

OR19-2 18919 2.0000 A High-Throughput Screening of Mouse Gene Knockouts Identifies Established and Novel Obesity Phenotypes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 1:00:00 PM OR19 6039 11:30:00 AM Obesity: Novel Basic Science Oral


Dennis Löffler, Kathrin Landgraf, Denise Rockstroh, Julian Tristan Schwartze, Wieland Kiess and Antje Körner*
University of Leipzig, Dept. of Women´s & Child Health, Leipzig, Germany

 

Background: The new adipokine/myokine meteorin-like (Metrnl) has been proposed to be of interest for obesity and metabolic disease through its potential role for brown/beige fat thermogenesis and macrophage activation in mice. METRNLwas reported to be highly expressed in white adipose tissue (AT) and upregulated during 3T3 adipogenesis and by exercise and cold exposure in the skeletal muscle and adipose tissue1.

Aims: In this study we analysed the expression of METRNLduring human adipogenesis and its regulation by different metabolic regulators. Furthermore, we assessed its expression in AT, isolated adipocytes and cells of the stromal vascular fraction (SVF) from lean and obese children of our Leipzig Childhood Adipose Tissue cohort (n=103)2, and analysed associations with obesity and metabolic parameters.

Results: Metrnl was down-regulated during human adipogenesis of SGBS preadipocytes on mRNA (to 22.7±13%) and protein level. Dexamethasone inhibited METRNLmRNA expression to 65±6% in preadipocytes but not adipocytes, while insulin, IGF-1 and isoproterenol had no effect.

In human AT samples, METRNL expression was 5 fold higher in SVFs compared to adipocytes. However, only in adipocytes, but not in whole AT or SVF, obese children showed higher expression compared to lean children (7.1±4.0 versus 5.0±2.5; p=0.003). Furthermore both adipocyte and SVF METRNL expression correlated with BMI-SDS (r=0.33, p=0.001 and r=0.24, p=0.002) and adipocyte size (r=0.26, p=0.005 and r=0.28, p=0.03), but not with adipocyte number. METRNL expression in SVF was negatively related to experimental cell doubling time (r=-0.40, p=0.008). AT samples containing brown adipocytes, as indicated by histology and high UCP1 expression, did not show higher METRNLexpression compared to UCP1-negative samples.

METRNLexpression in adipocytes, but not in whole AT or SVF correlated with HOMA-IR as a marker of insulin resistance, macrophage number and CD68 expression, which was, however, not independent from BMI.

Conclusion: In AT of children, METRNL is expressed in adipocytes and SVF in relation with BMI-SDS but shows a fivefold higher expression in SVF. The down-regulation of METRNL during adipocyte differentiation, the negative association in SFV with proliferation potential, and the positive association with adipocyte size may indicate that METRNL is associated with hypertrophic AT and may explain the association with markers of insulin resistance and AT inflammation.

 

Nothing to Disclose: DL, KL, DR, JTS, WK, AK

OR19-3 20319 3.0000 A Meteorin-like (METRNL) Expression in Human Adipose Tissue Is Associated with Adipocyte Hypertrophy and Inflammation and Is Down-Regulated during Human Adipogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 1:00:00 PM OR19 6039 11:30:00 AM Obesity: Novel Basic Science Oral


Silvana Obici*1, Jack Magrisso1, Armen Ghazarian2, Alizera Shirazian2, Christine Loyd1, Denovan Begg1, Kimberly Krawczewski Carhuatanta1, Michael Haas1, Jon Davis1, Stephen Woods1, Darleen Sandoval3, Randy Seeley3, Laurie Goodyear4, Emmanuel Pothos2 and Joram Mul4
1Metabolic Diseases Institute, University of Cincinnati, Cincinnati, OH, 2Tufts University School of Medicine, Boston, MA, 3University of Michigan, Ann Arbor, MI, 4Joslin Diabetes Center, Boston, MA

 

Background.  Central melanocortin-4 receptors (MC4Rs) are critical for energy homeostasis regulation.  Their role in the mesolimbic dopaminergic system is however less completely understood.  Voluntary wheel running (VWR) is self-rewarding and triggers increased physical activity and metabolic improvements in rodents.

Methods.  Here we investigated if MC4Rs regulate VWR, and if VWR ameliorates MC4R-associated metabolic syndrome.  We measured VWR in obese MC4R-deficient rats and mice and wild-type (WT) littermates, in WT mice body weight-matched to MC4R-deficient mice, and in WT mice with intracerebroventricular administration of vehicle or SHU9119, an MC4R antagonist.  Mesolimbic dopaminergic system function was assessed in rats during sedentary and VWR conditions using amperometric recordings, and mRNA and protein expression, respectively.  Metabolic parameters were measured in wheel-running MC4R-deficient and control rats.

Results.  Chronic MC4R deficiency decreased VWR independent of body weight.  ICV SHU9119 also decreased VWR.  Wheel-running MC4R-deficient rats demonstrated markers of increased dopamine flux in the ventral tegmental area (increased tyrosine hydroxylase, presynaptic D2-type dopamine receptor, and dopamine transporter mRNA expression), as well as decreased intracellular D1-type dopamine receptor signaling in the nucleus accumbens (decreased ΔFosB and p(Thr34)-DARPP-32 protein levels) compared to WT and sedentary MC4R-deficient rats.  Under sedentary conditions, ex vivo electrically-evoked dopamine release was higher in nucleus accumbens shell, dorsal striatum, and medial prefrontal cortex acute coronal slices (383±30 vs. 213±33 pA, 405±53 vs. 243±28 pA, and 346±36 vs. 249±45 pA, mean ± s.e.m., respectively) from MC4R-deficient rats when compared to WT littermates.  VWR improved metabolic parameters in WT rats.  Despite relatively low amounts of VWR, many aspects of metabolic syndrome in MC4R-deficient rats were normalized to sedentary WT levels (body- and fat mass gain; food intake; HOMA-IR levels; plasma triglycerides; plasma cholesterol; and hepatic steatosis). 

Conclusion.  MC4R loss-of-function, predominantly on nucleus accumbens D1R medium spiny neurons, dysregulates molecular responses to VWR and attenuates behavioral responses to VWR.  The increase in evoked dopamine release in all projections of the midbrain dopaminergic system may be a compensatory mechanism following MC4R loss-of-function.  Our data suggest an important role for MC4Rs in modulating molecular and behavioral responses to natural rewards.  Although MC4R-haploinsufficient individuals may demonstrate reduced positive reinforcement during exercise, our data indicate that even small increases in physical activity can improve their metabolic outcome.

 

Nothing to Disclose: SO, JM, AG, AS, CL, DB, KK, MH, JD, SW, DS, RS, LG, EP, JM

OR19-4 21234 4.0000 A MC4R Loss-of-Function Attenuates Behavioral and Molecular but Not Metabolic Responding to Voluntary Wheel Running in Rodents 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 1:00:00 PM OR19 6039 11:30:00 AM Obesity: Novel Basic Science Oral


Dionysios V Chartoumpekis*, Dushani L Palliyaguru, Nobunao Wakabayashi, Nicholas KH Khoo, Gabriele Schoiswohl, Robert M O'Doherty and Thomas W Kensler
University of Pittsburgh, Pittsburgh, PA

 

Lipodystrophy is a pathological condition characterized by deficiency of adipose tissue together with ectopic lipid accumulation in liver, muscle, kidneys and pancreas, due to the limited storage capacity of residual adipose tissue. This manifestation leads to an insulin resistant, diabetic phenotype. The Notch family of intermembrane receptors is highly conserved across species and is involved in cell fate and lineage control. Thus, we hypothesized that Notch signaling can interfere with the development of adipose tissue. To this end, albino C57BL6J RosaNICD/NICD: AdipoqCre mice (NICD-mice), which overexpress NICD in adipose tissue, were generated. Male NICD-mice were compared to their control male littermates RosaNICD/NICD (control mice) for all the following measurements and metabolic tests at the ages of 1 and 3 months. T-test was employed for the statistical comparison of these 2 groups and p<0.05 was considered significant (n=8 per genotype). The 1-month old NICD-mice were heavier (26.5±0.5 g vs 23.8±0.2 g) with a lower body fat composition as assessed by EchoMRI (4.91±0.73% vs 9.29±0.56%). They also had higher serum glucose (GLU) levels    (288.2±14.7 mg/dl vs 231.5±11.6 mg/dl), higher serum triglyceride (TG) levels (69.35±7.07 mg/dl vs 41.66±5.45 mg/dl)  and were significantly more insulin resistant than the controls as assessed by an intraperitoneal insulin tolerance test (IPITT). However, the intraperitoneal glucose tolerance test (IPGTT) did not show any difference at this age. Interestingly, this insulin resistant phenotype deteriorated with age and the 3-month old NICD-mice were much heavier than the controls (41.3±0.5 g vs 34.6±1.7 g), their body fat percentage was 7.17±0.59% vs 16.52± 1.97% of the controls and both the IPITT and IPGTT revealed  more severe insulin resistant and glucose intolerant phenotypes. The much higher GLU levels (348±12.64 mg/dl vs 188±12 mg/dl), TG levels (161.5±23.6 mg/dl vs 46.96±3.81 mg/dl), non-esterified fatty acid levels (0.76±0.05 mEq/L vs 0.41±0.02 mEq/L) and the ~12 times lower serum leptin levels    (311.7±29.2 pg/ml vs 3664±110 pg/ml) along with the macroscopic and microscopic observation of the minute amounts of white adipose tissue (WAT) in the NICD-mice, are indicative of a lipodystrophic phenotype. In addition their increased liver to body weight ratio (10.3±0.6% vs 3.7±0.1%) and their highly steatotic liver reveals the increased ectopic lipid accumulation.   Initial gene expression analyses in adipose tissue depots showed that adipogenic and lipogenic pathways (SREBF-1, PPARγ, RXRα, ACC, FASN, GLUT-4) are downregulated in WAT of the RosaNICD/NICD: AdipoqCre mice. HES-1, a target of Notch pathway and a transcriptional repressor of some of these pathways, was significantly upregulated. In conclusion, Notch overexpression in the adipocytes in vivo led to the loss of WAT, resulting in a novel lipodystrophy model.

 

Nothing to Disclose: DVC, DLP, NW, NKK, GS, RMO, TWK

OR19-5 21280 5.0000 A Adipocyte-Specific Overexpression of Notch Intracellular Domain (NICD) Results in a Lipodystrophic Phenotype in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 1:00:00 PM OR19 6039 11:30:00 AM Obesity: Novel Basic Science Oral


Wan-Hui Liao*1, Claudia Suendermann1, Alex Odermatt2, Johannes Loffing1 and Nourdine Faresse1
1University of Zurich, Zurich, Switzerland, 2University of Basel, Basel, Switzerland

 

A tight link between plasma aldosterone levels and body weight has been clinically observed, where hyperaldosteronism is commonly seen in obesity and reversed by diet-induced weight loss [1-3]. Although studies have extensively characterized aldosterone as a factor promoting worsening obesity-related complications, like hypertension, the role of this steroid hormone in energy homeostasis per se has never been directly determined. Using aldosterone deficient mice (ASKO) resulting from whole-body deletion of cyp11b2 gene [4], we found that aldosterone had a critical role in limiting adipocytes from pathological expansion and diet-induced obesity. Despite being similar to matched controls in daily food intake and levels of activities, ASKO mice displayed a greater susceptibility to diet-induced weight gain and central adiposity. Mechanistically, we found that ASKO mice failed to counterbalance caloric overload by increasing the energy expenditure. This sympathetically mediated adaptive response to high fat diet-feeding [5], translated into increased expression of thermogenic and fatty acid oxidation genes, was absent in visceral adipose tissue of ASKO mice. Besides, these fat depots showed reduced lipolysis, correlating with reduction in hepatic steatosis and low serum free fatty acid levels. These in vivo observations were further confirmed in cultured human adipocytes, suggesting a cross-talk between aldosterone and the adrenergic pathways. Taken together, our data revealed a novel role for aldosterone in modulating diet-induced thermogenesis. Tracking body weight changes in patients on medications targeting aldosterone synthesis or release may be necessary.

 

Nothing to Disclose: WHL, CS, AO, JL, NF

OR19-6 21377 6.0000 A A Novel Role of Aldosterone in Energy Homeostasis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 1:00:00 PM OR19 6039 11:30:00 AM Obesity: Novel Basic Science Oral


John P Bilezikian*1, Claude Laurent Benhamou2, Celia JF Lin3, Jacques P Brown4, Nadia S Daizadeh3, Peter R Ebeling5, Astrid Fahrleitner-Pammer6, Edward Franek7, Nigel Gilchrist8, Paul D Miller9, James A Simon10, Ivo Valter11, Cristiano AF Zerbini12 and Cesar Libanati3
1College of Physicians and Surgeons, Columbia University, New York, NY, 2CHR d'Orléans, Orléans, France, 3Amgen Inc., Thousand Oaks, CA, 4Laval University and CHU de Québec (CHUL) Research Centre, Quebec City, QC, Canada, 5Monash University, Australia, 6Medical University, Graz, Austria, 7Medical Research Center, Polish Academy of Sciences, Warsaw, Poland, 8The Princess Margaret Hospital, Christchurch, New Zealand, 9Colorado Center for Bone Research, Lakewood, CO, 10George Washington University, DC, 11Center for Clinical and Basic Research, Tallinn, Estonia, 12Centro Paulista de Investigação Clinica, São Paulo, Brazil

 

The skeleton is 80% cortical bone, and cortical bone loss contributes importantly to increased fracture risk. Denosumab (DMAb) has been shown to increase BMD at sites of cortical bone, including the 1/3 radius, a skeletal site not responsive to most osteoporosis treatments. DXA measurements over time allow for tracking changes in BMD, a known predictor of fracture risk. Here, we examined changes over time in 1/3 radius BMD and wrist fracture incidence during 3 yrs of placebo (Pbo) in the FREEDOM trial and 6 subsequent yrs of DMAb therapy in the FREEDOM Extension (EXT).

We evaluated wrist fractures in 2207 women who enrolled in the EXT and had received Pbo during FREEDOM (3 yrs), and DMAb 60 mg Q6M during EXT (6 yrs) (cross-over group); all women received daily calcium and vitamin D. A subset of these women (n = 115) participated in a 1/3 radius DXA substudy and were evaluated at baseline, FREEDOM (yrs 1–3), and EXT (yrs 1–3 and 5). Analysis of mean percentage changes in BMD over time from FREEDOM and EXT baselines consisted of a repeated measures model. Wrist fracture rates (per 100 subject-yrs), rate ratios, and 95% confidence intervals (CI) were computed through EXT Yr 6.

At FREEDOM baseline, the mean (SD) 1/3 radius T-score was –2.53 (1.18). During FREEDOM, daily calcium and vitamin D alone resulted in a progressive and significant loss of BMD at the 1/3 radius over 3 yrs (–1.2%; p < 0.05 compared with FREEDOM baseline); on DMAb initiation during the EXT, this bone loss was reversed, resulting in BMD gains at the 1/3 radius of 1.5% at EXT Yr 5 (p < 0.05 compared with EXT baseline). During the FREEDOM Pbo period, the wrist fracture rate was 1.02 (95% CI = 0.80–1.29) per 100 subject-yrs. In the first 3 yrs of the EXT, during which time the BMD lost with Pbo recovered in response to DMAb and returned to original baseline levels, the subjects’ wrist fracture rate remained comparable to that observed during their FREEDOM Pbo period. With DMAb administration over the subsequent 2 yrs resulting in BMD increases above the original FREEDOM baseline, the number of wrist fractures was markedly reduced and the wrist fracture rate declined to levels significantly lower than the FREEDOM Pbo rate (rate ratio = 0.57, 95% CI = 0.34–0.95; p = 0.03). Further, the number of wrist fractures remained low through EXT Yr 6 and the wrist fracture rate continued to remain consistently lower than the Pbo rate observed during FREEDOM (rate ratio = 0.61, 95% CI = 0.39–0.94; p= 0.025 compared with FREEDOM).

In untreated women with postmenopausal osteoporosis, cortical bone density at the 1/3 radius declined despite calcium and vitamin D supplementation. DMAb treatment for 3 yrs halted and reversed this bone loss, and additional DMAb treatment resulted in further BMD gains that translated to significantly lower wrist fracture rates through EXT Yr 6. These data provide evidence of a relevant clinical endpoint of reversing cortical bone loss in patients with osteoporosis.

 

Disclosure: JPB: Consultant, Merck, Consultant, Johnson &Johnson, Consultant, NPS Pharma, Consultant, Amgen, Consultant, Asahi. CLB: Consultant, Amgen, Study Investigator, Amgen, Consultant, Roche, Consultant, Lilly, Consultant, MSD, Consultant, Servier, Study Investigator, Servier, Scientific Board Member, Rottapharm, Scientific Board Member, Pierre Fabre. CJL: Employee, Amgen, Employee, Amgen, Employee, Amgen. JPB: Advisory Group Member, Amgen, Clinical Researcher, Amgen, Advisory Group Member, Eli Lilly, Clinical Researcher, Eli Lilly, Ad Hoc Consultant, Radius. NSD: Employee, Amgen, Employee, Amgen, Employee, Amgen. PRE: Principal Investigator, Amgen, Advisory Group Member, Amgen, Principal Investigator, Merck, Principal Investigator, GlaxoSmithKline, Principal Investigator, Novartis, Principal Investigator, Eli Lilly, Advisory Group Member, Pfizer, Speaker, Takeda, Speaker, Novo Nordisk. AF: Speaker, Servier, Advisory Group Member, Servier, Speaker, Roche, Advisory Group Member, Roche, Advisory Group Member, Eli Lilly, Speaker, Pfizer, Speaker, Eli Lilly, Advisory Group Member, Amgen, Speaker, Amgen, Investigator, Roche, Investigator, Takeda, Investigator, Amgen , Investigator, Sanofi - Aventis , Investigator, Servier , Investigator, Merck . EF: Speaker, Amgen, Speaker, MSD, Speaker, Novartis, Speaker, Teva. NG: Investigator, Merck Sharp & Dohme, Investigator, Amgen, Investigator, Pfizer. PDM: Principal Investigator, Merck, Principal Investigator, Amgen, Principal Investigator, Novartis, Principal Investigator, Boehringer Ingelheim, Principal Investigator, Lilly, Principal Investigator, University of Alabama, Principal Investigator, Radius, Principal Investigator, Merck Serono, Principal Investigator, Takeda, Principal Investigator, National Bone Health Alliance, Medical Advisory Board Member, Amgen, Medical Advisory Board Member, Roche, Medical Advisory Board Member, AgNovos, Medical Advisory Board Member, Lilly. JAS: Ad Hoc Consultant, Sprout Pharmaceuticals, Ad Hoc Consultant, Shippan Point Advisors LLC, Speaker Bureau Member, Shionogi Inc., Ad Hoc Consultant, Shionogi Inc., Ad Hoc Consultant, Pfizer Inc., Clinical Researcher, Palatin Technologies, Clinical Researcher, Novo Nordisk, Ad Hoc Consultant, Novo Nordisk, Speaker Bureau Member, Noven Pharmaceuticals, Inc., Ad Hoc Consultant, Noven Pharmaceuticals, Inc., Ad Hoc Consultant, Novartis Pharmaceuticals Co, Ad Hoc Consultant, Merck & Co., Inc., Ad Hoc Consultant, Meda Pharmaceuticals Inc., Speaker Bureau Member, Eisai, Inc., Ad Hoc Consultant, Lupin Pharmaceuticals, Ad Hoc Consultant, Everett Laboratories, Inc, Clinical Researcher, EndoCeutics Inc., Ad Hoc Consultant, Eisai, Inc., Ad Hoc Consultant, Dr. Reddy Laboratories, Ltd, Ad Hoc Consultant, Depomed, Inc., Clinical Researcher, Bayer Healthcare LLC., Ad Hoc Consultant, Ascend Therapeutics, Ad Hoc Consultant, Apotex, Inc, Ad Hoc Consultant, Amneal Pharmaceuticals, Ad Hoc Consultant, Amgen, Clinical Researcher, Actavis, PLC., Ad Hoc Consultant, Actavis, PLC., Clinical Researcher, AbbVie, Inc., Ad Hoc Consultant, AbbVie, Inc., Ad Hoc Consultant, TherapeuticsMD, Clinical Researcher, TherapeuticsMD, Ad Hoc Consultant, Teva Pharmaceutical Industries Ltd, Clinical Researcher, Teva Pharmaceutical Industries Ltd. CAZ: Medical Advisory Board Member, Pfizer, Investigator, Pfizer, Medical Advisory Board Member, Lilly, Investigator, Lilly, Medical Advisory Board Member, Merck, Investigator, Merck, Investigator, Amgen, Investigator, Novartis, Investigator, Roche. CL: Employee, Amgen, Employee, Amgen, Employee, Amgen. Nothing to Disclose: IV

OR22-1 18766 1.0000 A Denosumab Restores Cortical Bone Loss at the 1/3 Radius Associated with Aging and Reduces Wrist Fracture Risk: Analyses from the Freedom Extension Cross-over Group 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 1:00:00 PM OR22 5966 11:45:00 AM Osteoporosis Oral


Steven Orlov*1, Rowena Ridout1, Lianne Tile1, Moira Kapral1, Savannah Cardew1, Marsha Ruth Werb2, Samantha D Sandler3, Jessica Chang1, Hanxian Hu1, Eva Szabo1, Christine Derzko4 and Angela M. Cheung1
1University Health Network / University of Toronto, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, Canada, 3LMC Diabetes & Endocrinology, Toronto, ON, Canada, 4St. Michael's Hospital, Toronto, ON, Canada

 

Background: 

Although teriparatide has been shown to increase bone mineral density (BMD) at the lumbar spine and hip, BMD at the radius has been shown to decreasewith therapy(1, 2). These observations raise the possibility that teriparatide may have  varying effects on  different peripheral sites, including the radius (non-weight-bearing) and tibia (weight-bearing). We aimed to examine the effects of teriparatide on bone microarchitecture at these peripheral sites in postmenopausal women with osteoporosis.  

Methods: 

We prospectively followed a cohort of 69 postmenopausal women (mean age 71.8 ±10.0 years) treated with teriparatide 20µg subcutaneously daily for 18 months. Bone microarchitecture was assessed using high-resolution peripheral quantitative computed tomography (HR-pQCT; Scanco Medical, Switzerland) at baseline, 6, 12 and 18 months of therapy. Measurements were obtained at both the distal radius and distal tibia. The primary outcome was cortical thickness. Secondary analyses examined cortical area and porosity, as well as trabecular thickness, number, separation and BV/TV. Bone strength (ultimate stress) was also estimated using finite element analysis.   Paired t-tests were used to compare 18-month outcomes to their baseline with statistical significance based on an α-level < 0.05.

Results: 

After 18 months of teriparatide therapy, there was a statistically significant decrease in the primary outcome of cortical thickness at the distal radius (0.55mm vs. 0.51mm, p <0.001) and distal tibia (0.74mm vs. 0.70mm, p<0.001). Secondary analyses at the distal radius revealed significant increases in trabecular area (195.0mm2 vs. 196.2 mm2, p=0.014), trabecular thickness (0.058 vs. 0.060, p=0.04) trabecular number (1.36mm-1 vs. 1.43mm-1, p=0.018) and BV/TV (0.079 vs. 0.085, p<0.001). These were accompanied by significant decreases in cortical area (35.9mm2 vs. 33.8mm2, p<0.001) and trabecular spacing (0.776mm vs. 0.74mm5, p=0.028).  Meanwhile, secondary analyses at the distal tibia revealed a significant decrease in cortical area (73.3mm2 vs. 69.4mm2, p<0.001) with a concurrent increase in cortical porosity (8.1% vs. 9.8%, p<0.001). Despite these changes in bone morphology, there were no significant decreases in estimated bone strength at either site over the duration of follow-up.

Conclusions: 

Teriparatide therapy significantly decreases cortical thickness at both the distal radius and distal tibia, while increasing trabecular area, thickness and number, at the distal radius.  These changes in bone microarchitecture did not result in decreases in estimated bone strength.  Further studies will be necessary to better understand the implications of these results on fracture risk at these peripheral sites.

 

Nothing to Disclose: SO, RR, LT, MK, SC, MRW, SDS, JC, HH, ES, CD, AMC

OR22-2 22064 2.0000 A Effects of Teriparatide on Bone Microarchitecture in Postmenopausal Women with Osteoporosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 1:00:00 PM OR22 5966 11:45:00 AM Osteoporosis Oral


Katherine Neubecker Bachmann*1, Alexander G. Bruno2, Miriam A. Bredella1, Elizabeth A. Lawson1, Corey M. Gill3, Erinne Meenaghan3, Anu V. Gerweck3, Mary Larsen Bouxsein4, Anne Klibanski5 and Karen K. Miller1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts Institute of Technology, MA, 3Massachusetts General Hospital, Boston, MA, 4Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 5Massachusetts General Hospital and Harvard Medical School, Boston, MA

 

The spectrum of anorexia nervosa (AN) includes women with very low weight (“typical” AN) and those with “atypical” AN, characterized by the same psychiatric phenotype including restrictive eating behaviors and body image issues, but with BMI ≥ 18.5 kg/m2. BMD assessed by DXA is impaired, particularly at the spine, in women with typical AN. However, little is known about vertebral strength or its relationship to weight and gonadal steroid status in women with both typical and atypical AN, i.e. across the AN weight spectrum. We hypothesized that women with AN, regardless of current weight, would have impaired vertebral strength due to both current and/or prior nutritional deprivation and gonadal steroid deficiency.

We estimated L4 strength in 154 women ages 18-45: 65 low-weight AN (BMI<18.5 kg/m2), 44 atypical AN (18.5≤BMI<23 kg/m2), and 45 controls (C) (18.5≤BMI<25 kg/m2). L4 strength was estimated by the linear combination of integral volumetric BMD (Int.vBMD) and L4 cross-sectional area (CSA) from QCT. All analyses were adjusted for age.  

Mean BMI was lowest in low-weight AN, intermediate in atypical AN, and highest in C (17.0±1.1, 19.6±1.0, 22.1±1.7 kg/m2, respectively; p<0.0001). Int.vBMD and L4 strength were lowest in low-weight AN, highest in C, and intermediate in atypical AN (p<0.0001); differences were not significant after controlling for BMI. CSA did not differ between groups. Among all AN (low-weight and atypical combined), Int.vBMD and L4 strength were positively associated with current BMI (R 0.27-0.30, p<0.005), as well as with lowest lifetime BMI (R 0.47-0.52, p<0.0001), which remained significant after adjusting for current BMI. AN with amenorrhea (N=50) had lower Int.vBMD (p≤0.0004) and L4 strength (p<0.02) compared to both AN with eumenorrhea (N=27) and AN taking gonadal steroids (N=32); differences in Int.vBMD, but not strength, remained significant after adjusting for BMI. Lifetime duration of amenorrhea was negatively associated with Int.vBMD and L4 strength (R -0.31 to -0.33, p<0.01) among all AN combined and remained significant after adjusting for BMI. Total and free testosterone (R 0.52-0.72), DHEAS (R 0.53-0.59), and BSAP (R 0.48-0.55) were positively associated with Int.vBMD and L4 strength (p<0.02) within all AN combined, including after adjusting for BMI. 

In conclusion, we are the first to report that vertebral Int.vBMD and strength are impaired in women with AN. Moreover, we are the first to show that these parameters are impaired in both typical and atypical AN. Vertebral Int.vBMD and strength are most severely impaired in women with AN who are currently low-weight, had the lowest BMIs in the past (even if currently normal weight), and have longer lifetime durations of amenorrhea. The extent of impairment of vertebral strength in AN across the weight spectrum is related to both current and prior nutritional deprivation and gonadal steroid deficiency.

 

Nothing to Disclose: KNB, AGB, MAB, EAL, CMG, EM, AVG, MLB, AK, KKM

OR22-3 18938 3.0000 A Determinants of Vertebral Strength in Anorexia Nervosa 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 1:00:00 PM OR22 5966 11:45:00 AM Osteoporosis Oral


Gianluca Toraldo*1, Thomas G Travison2, Xiaochun Zhang3, Kerry E Broe3, Shalender Bhasin4, Douglas P Kiel5 and Andrea D Coviello1
1Boston University School of Medicine, Boston, MA, 2Hebrew Senior Life - Harvard Medical School, Boston, MA, 3Hebrew Senior Life, Harvard Medical School, 4Brigham and Women's Hospital - Harvard Medical School, Boston, MA, 5Hebrew Senior Life, Harvard Medical Schiool, Boston, MA

 

Background: Estradiol (E2) and testosterone (T) have been associated with bone mineral density (BMD) in post-menopausal women. T effects may be independent of estrogen or may enhance estrogen effects on bone.  After-menopause, Estrone (E1) is more abundant than E2, but is considered less potent.  The role of endogenous estrone (E1) in bone health is unclear.  Objective:  To examine the associations between endogenous sex hormones T, E2, and E1 in women not using hormone replacement therapy and 1) bone mineral density (BMD), and 2) incident fracture risk.  Methods:  BMD and fracture risk were evaluated in 829 post-menopausal women in the FHS Offspring cohort.  BMD was determined by DXA in all women and by quantitative CT scan (QCT) of L3 in a subset of 304 women (total volumetric BMD, volumetric trabecular BMD, cross-sectional area).  T, E2 and E1 were measured by LC/MSMS. SHBG was measured by immunofluorometric assay.  Free T (FT), E2 (FE2) and E1 (FE1) were calculated using the law of mass action. Hormone values were log transformed prior to analysis to approximate the normal distribution. Associations between hormones and BMD by DXA and QCT were examined with linear regression.  Hormones were categorized by quartile and association of fracture risk by hormone quartile was examined with logistic regression.  Analyses were adjusted for age, BMI, physical activity, current smoking, and alcohol use.  Incident fracture risk was also assessed by logistic regression in the 556 post-menopausal women without prevalent fracture at baseline.  α= 0.05 (SASv9.1). Results:  Mean±SD age was 65±8 years (63±8 years in of women with QCT).  BMD by DXA: In fully adjusted models only logFE1 was associated with BMD of the hip (β=0.0019, 95%CI 0.0003-0.0034, p=0.02) and spine (β=0.003, 95%CI 0.0006-0.0054, p=0.001).  BMD by QCT (L3):  In fully adjusted models, only logFE1 (β=0.0008 g/cm3, 95%CI 0.0001-0.0014) was positively associated with total volumetric BMD but no hormones were significantly associated with trabecular BMD or cross-sectional area by QCT.  Fracture Risk:  One third of women (273/829, 33%) had a fracture at baseline.   In adjusted models, lower E2 (Q1 vs. Q4 OR 3.0, 95%CI 1.4, 6.7) and FE2 (Q1 vs. Q4 OR 2.5, 95%CI 1.1, 5.6) were associated with prevalent fracture but E1, FE1, TT, and FT were not associated with fracture.  Of the 556 women who did not have a fracture at baseline, 81 (15%) had an incident fracture over 12 years of follow up.  Only lower FE1 was associated with incident fracture risk (FE1 Q1 vs.Q4 OR 12.6, 95%CI 1.8, 86.6).  Conclusion:  Testosterone was not significantly associated with BMD or fracture risk. Estrone, the predominant estrogen in post-menopausal women, may have a role in bone health and fracture prevention in older women.  As a weaker estrogen than estradiol, estrone treatment may have a role in treatment of osteoporosis with less risk of tissue exposure in the breast seen with more potent estrogen formulations.

 

Disclosure: DPK: Principal Investigator, Amgen, Consultant, Amgen, Principal Investigator, Merck & Co., Consultant, Merck & Co., Consultant, Novartis Pharmaceuticals. Nothing to Disclose: GT, TGT, XZ, KEB, SB, ADC

OR22-4 19921 4.0000 A Estrone May be More Important Than Testosterone and Estradiol for Bone Health and Prevention of Fractures in Post-Menopausal Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 1:00:00 PM OR22 5966 11:45:00 AM Osteoporosis Oral


Elaine W. Yu*1, Marlene Wewalka2, Su Ann Ding2, Donald C Simonson3, Ashley Vernon3, Kathleen Foster2, Allison B Goldfine2 and Florencia Halperin3
1Massachusetts General Hospital, Boston, MA, 2Joslin Diabetes Center, Boston, MA, 3Brigham and Women's Hospital, Boston, MA

 

Background: Gastric bypass surgery leads to high-turnover bone loss over time.  Little is known about differential effects of various bariatric procedures or mechanisms underlying skeletal changes.  We tested the hypothesis that Roux-en-Y gastric bypass (RYGB) would be associated with greater skeletal changes than laparoscopic adjustable gastric banding (LAGB), and that RYGB has weight loss-independent effects on bone that can be observed even before significant weight loss occurs.

Methods: Participants had type 2 diabetes and underwent either RYGB (n=11) or LAGB (n=8); they were studied at baseline (pre-operatively), 10 days and 1 yr after surgery.  We examined fasting and postprandial changes in bone metabolic markers including serum C-terminal telopeptide (CTX), procollagen type 1 (P1NP), parathyroid hormone (PTH), and polypeptide YY (PYY, a potential gut-derived mediator of bone turnover that may negatively regulate osteoblast activity) during a mixed meal tolerance test (0, 30, 60, and 120 minutes).

Results:  Baseline weight (107 ± 4 kg), age (54 ± 2 yrs), and gender (48% female) were similar in RYGB and LAGB groups, and there were no differences in baseline fasting 25-hydroxyvitamin D (25 ± 3 ng/mL), PTH (42 ± 3 pg/mL), CTX (0.24 ± 0.03 ng/mL), P1NP (36 ± 3 ug/L), or PYY (32 ± 4 pg/mL).  Ten days after surgery, weight loss was equivalent after RYGB (-7 ± 1 kg) and LAGB (-6 ± 1 kg), but increase in fasting CTX was greater after RYGB than LAGB (69 ± 23% vs. 12 ± 12%, p<0.001).  P1NP was unchanged in both groups at 10 days post-operatively.  By 1 yr, weight loss after RYGB exceeded that of LAGB (-30 ± 3 kg vs. -8 ± 2 kg, p<0.001), and fasting CTX, P1NP, and PYY were significantly higher in the RYGB than the LAGB group (CTX 221 ± 60% vs. 15 ± 6%, p<0.001; P1NP 93 ± 25% vs. -9 ± 10%, p<0.001; PYY 38 ± 7% vs. 29 ± 8%, p<0.030). After RYGB, serum 25-hydroxyvitamin D levels were higher and PTH levels were unchanged, likely reflecting aggressive vitamin D supplementation.  Postprandial suppression of CTX and increase in PYY were more pronounced after RYGB than LAGB at 10 days and 1 yr (p<0.001 for all).  Postprandial PTH patterns did not change appreciably after RYGB or LAGB.  Changes in CTX were not significantly associated with changes in fasting or postprandial PYY.                          

Conclusions: Increased bone remodeling indexes occurred as early as 10 days after RYGB but not LAGB, despite comparable early weight loss.  Proportional increase of the resorptive marker CTX was greater than the formation marker P1NP. Together, these data suggest a RYGB-specific and weight loss-independent increase in bone resorption.  At 1 yr, both weight loss and increases in bone turnover are greater after RYGB than LAGB.  Although the mechanisms remain to be identified, the increased responsiveness of CTX to postprandial suppression after RYGB suggests that alterations in gut hormones may play a role in RYGB-specific skeletal changes.

 

Nothing to Disclose: EWY, MW, SAD, DCS, AV, KF, ABG, FH

OR22-5 19267 5.0000 A Bone Remodeling Increases after Bariatric Surgery: Early Changes Suggest Weight-Loss Independent Effects of Gastric Bypass but Not Gastric Banding 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 1:00:00 PM OR22 5966 11:45:00 AM Osteoporosis Oral


Yukitomo Arao*1, Katherine J Hamilton1, San-Pin Wu2, Ming-Jer Tsai2, Francesco J. DeMayo3 and Kenneth S Korach1
1National Institute of Environmental Health Sciences/NIH, Research Triangle Park, NC, 2Baylor College of Medicine, Houston, TX, 3Baylor College of Med, Houston, TX

 

The hypothalamus-pituitary-gonadal (HPG) axis regulates ovarian E2 synthesis and serum E2 levels through negative feedback of LH.  Estrogen receptor alpha (ERα) plays an important role in the HPG axis, supported by the phenotype of global ERα knock-out (αERKO) mice which have constitutively high serum E2 and LH levels, resulting in infertility due to cystic ovaries. Previously, floxed αERKO mice have been used to evaluate pituitary ERα functionality in a tissue specific manner using pituitary specific Cre expressing mouse lines. Several PitαERKO lines have been reported, but with inconsistent observations regarding regulation of serum hormone levels1, 2. Here we show a novel approach to test pituitary ERα function in the HPG axis by establishing negative feedback control of LH using a mouse line which re-expresses ERα only in the pituitary on a global ERα null background, thus expecting to eliminate the cystic ovarian phenotype associated with high persistent serum LH levels in this model. The ROSA-LSL-ERαLSL/+Ex3ERαKO-/-+αGSU-cre (termed PitERtgKO) mouse expresses the Cre-inducible human WT ERα in the anterior and intermediate lobes of the pituitary gland driven by aGSU-cre on the αERKO background. Western blot analysis detected ERα expression in the pituitary but no other tissues. The PitERtgKO females were phenotypically similar to αERKO and displayed abnormal cyclicity and hypoplastic uteri. Interestingly, at 3 months of age the hemorrhagic and cystic ovaries appeared to be more overt than age-matched αERKO littermates. The serum testosterone (T) level in PitERtgKO mice was significantly higher than WT, but slightly lower than αERKO. Surprisingly, serum E2 and LH levels in PitERtgKO were comparable to WT serum levels and significantly lower than αERKO indicating that negative feedback was corrected by pituitary ERα. We tested the negative feedback response using ovariectomized (OVX) PitERtgKO mice treated with E2. Our preliminary results show that the serum LH level does increase with OVX and subsequent E2 treatment results in reduction of the LH level to a comparable level as WT. These results suggest that pituitary ERα plays a role in estrogen negative feedback regulation without a major contribution from hypothalamic ERα. PitERtgKO mice develop the cystic ovarian phenotype in the absence of persistent elevated LH and E2, but in the presence of elevated T. Such a model is consistent with clinical cases of PCOS where the classical elevated serum LH levels are not present, but ovarian cystic morphology still persists. Through use of this genetic model we are trying to understand the etiology of the ovarian cysts in this hormonal environment of normal LH and the potential role of androgens in mediating the effects associated with PCOS.

 

Nothing to Disclose: YA, KJH, SPW, MJT, FJD, KSK

19484 2.0000 FRI-419 A Analysis of Estrogen Receptor Alpha Functionality in the Hpg Axis Using a Pituitary Estrogen Receptor Alpha Transgenic - Estrogen Receptor Alpha Null Mouse Line 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Nancy Lainez* and Djurdjica Coss
University of California, Riverside, Riverside, CA

 

The growing epidemic of obesity has far-reaching societal and economic consequences. Obese people are at high risk for numerous health complications including type II diabetes, cardiovascular disease and reproductive disorders. Reproductive problems rooted in obesity include early onset of puberty, menstrual irregularities, pregnancy complications, infertility due to anovulation, in women; and low testosterone and sperm count in men. Obesity is considered a chronic inflammatory state, and we are investigating molecular mechanisms by which inflammatory cytokines affect hypothalamic-pituitary-gonadal axis. Mice fed high fat diet display perturbed levels of gonadotropin hormones in the circulation and decreased reproductive fitness, similar to what is observed in obese humans. These mice express high levels of several inflammatory markers in the hypothalamus. In particular, IL-6 and LIF are increased following exposure to high fat diet, while IL-1b and TNF were not. Significantly, mice on high fat diet have lower levels of GnRH, and oxytocin gene expression, the same levels of vasopressin and increased POMC compared to their control diet mice. To analyze whether LIF or IL-6 have direct action on GnRH neurons, immortalized GnRH-producing hypothalamic neuronal cell line, GT1-7, was transfected with luciferase reporters containing the GnRH promoter region and treated with LIF or IL-6. Treatment with LIF significantly decreased GnRH promoter activity, while there was no effect with IL-6 treatment. LIF treatment normally activates gp130 following its dimerization with a specific LIF receptor that leads to activation of JAK/STAT pathway in several target cells. In GT1-7 cells, LIF causes phosphorylation of STAT3 after 15 minutes, indicating that this pathway is active in neuronal cells. Delineating the mechanisms by which inflammatory signals influence GnRH gene expression will provide insight into the physiology of the mammalian reproductive system and etiology of obesity-induced infertility.

 

Nothing to Disclose: NL, DC

PP16-1 21328 3.0000 FRI-420 A Obesity-Induced Cytokines Diminish Gonadotropin-Releasing Hormone Gene Expression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Nahoko Ieda*1, Shiori Minabe1, Kana Ikegami2, Yusuke Sugimoto1, Alisa Sugimoto2, Naoko Inoue2, Yoshihisa Uenoyama2, Kei-ichiro Maeda3 and Hiroko Tsukamura2
1Graduate School of Bioagricultural Sciences, Nagoya University, 2Graduate School of Bioagricultural Sciences, Nagoya University, Nagoya, Japan, 3Department of Veterinary Medical Sciences, The University of Tokyo, Tokyo, Japan

 

Kisspeptin is a strong secretagogues of luteinizing hormone (LH) and the effect is mediated by gonadotropin-releasing hormone (GnRH). One of the major populations of kisspeptin neurons in the hypothalamus is located in the arcuate nucleus (ARC). The population is characterized by co-expression of kisspeptin, neurokinin B and dynorphin and, therefore, is recently referred to as KNDy neurons. The ARC KNDy neurons are considered to be the center of GnRH/LH pulse generation while the other kisspeptin neuronal population in the AVPV is considered to be the surge generator. Contrary to the unambiguous roles of kisspeptin, its upstream regulatory mechanism of secretion is largely unknown. This study aims to identify the upstream regulator of kisspeptin neurons. From genetically modified rats in which kisspeptin neurons are visulalized by tdTomato, we collected the ARC KNDy neurons and the AVPV kisspeptin neurons. By transcriptome analysis, we identified Gpr101, a gene encoding a receptor of GnRH metabolite GnRH(1-5), was expressed in the KNDy neurons. The gene expression was not detected in the AVPV kisspeptin neurons. Next, we intracerebroventricularly injected GnRH(1-5) to ovariectomized or ovariectomized and estrogen implanted Wistar-Imamichi strain female rats. GnRH(1-5) was administered after the first blood sampling, and then blood samples were taken for 3 hours at 6-min intervals through the intravenous silicon cannula. The plasma LH concentrations were measured by radioimmunoassay. Immediately after the GnRH(1-5) injection, plasma LH concentration increased, resulting in the significant higher levels of mean, baseline and area under the curve of LH pulses compared to vehicle-treated controls. (p<0.05 by t-test compared to vehicle injection) in a estrogen-dependent manner. The central GnRH(1-5) administration failed to affect LH secretion in the kisspeptin deficient rats. Taken together, the present results suggest that GnRH(1-5) induces GnRH/LH secretion via direct stimulation of KNDy neurons in rats. This study implicates that a presence of ultra-shortloop positive feedback mechanism between GnRH and KNDy neurons in rats. This study was supported in part by Grant-in-Aid for the Japan Society for the Promotion of Sciences Fellows (No. 25-3767 to NI); the Research Program on Innovative Technologies for Animal Breeding, Reproduction, and Vaccine Development (REP2002); and Science and Technology Research Promotion Program for Agriculture, Forestry, Fisheries and Food Industry (to HT).

 

Nothing to Disclose: NI, SM, KI, YS, AS, NI, YU, KIM, HT

20783 4.0000 FRI-421 A Stimulation of LH Secretion By Ultra-Shortloop Positive Feedback Between GnRH and Kisspeptin Neurons 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Erica Christine Pandolfi*1, Jason D Meadows2 and Pamela L Mellon2
1UCSD, La Jolla, CA, 2Center for Circadian Biology, University of California, San Diego, La Jolla, CA

 

Gonadotropin-releasing hormone (GnRH) is produced by GnRH neurons, which originate in the olfactory placode and migrate to the hypothalamus.  GnRH is released from the median eminence, and acts at the pituitary gonadotrope to regulate the hypothalamic-pituitary-gonadal axis to control reproduction. We have studied two homeodomain genes of the sine oculus family, Six3 and Six6. Six3 and Six6 are homeodomain proteins and vertebrate homologues of Drosophila optix. They are crucial factors in forebrain development, and are expressed in the pituitary and hypothalamus. We previously described that female Six6KO mice had a striking decrease in fertility, fail to progress through the estrous cycle normally, show any signs of successful ovulation, or produce litters. Both male and female Six6KO mice displayed a remarkable decrease in the number of GnRH neurons. Interestingly, GnRH neuron numbers were normal at e13.5 in the embryo but decreased by 90% in the adult hypothalamus, showing Six6 was not involved in GnRH neuron generation but crucial in GnRH neuron survival/GnRH expression. Six6 is dramatically increased during GnRH neuronal maturation and its overexpression in the mature GnRH neuron cell line, GT1-7 induced GnRH transcription. In contrast, Six3, although also expressed in GT1-7, acts as a repressor of the GnRH promoter, and competes with Six6 for the binding to the GnRH promoter. Based on this, we hypothesized that Six3 and Six6 would be essential regulators of GnRH neuronal development, and be important in the migration, survival, and proliferation of GnRH neurons. To examine the role of Six3 in GnRH neuron migration, development, and maturation we studied mice with a specific deletion of Six3 from GnRH neurons by crossing Six3Flox mice with GnRHCre mice. We found that the adult mice showed a 30% increase in GnRH neurons numbers. This increase occurred during embryogenesis, as the Six3Flox:GnRHCre e15.5 embryo had a two-fold increase in GnRH neurons. Female Six3Flox:GnRHCre mice had normal estrous cycles, ovary and uterus weights. A 30% increase in GnRH neurons did thus not significantly impact female fertility. We propose that the balance of Six3 and Six6 in GnRH neurons is crucial for the correct maturation of GnRH neurons and determines the number of GnRH neurons in the mouse thus regulating fertility.

 

Nothing to Disclose: ECP, JDM, PLM

21367 7.0000 FRI-424 A The Homeodomain Protein, Six3 Is Important in the Development of GnRH Neurons in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Akiko Takahashi*1, Shinji Kanda1, Yasuhisa Akazome1 and Yoshitaka Oka2
1The University of Tokyo, Tokyo, Japan, 2The University of Tokyo, Bunkyo-Ku, Japan

 

Previous morphological and physiological studies suggest that kisspeptin neurons are the most probable candidate for the missing link in the sex steroid feedback system to mediate estrogen feedback signal for GnRH release in mammals. On the other hand, such studies have mostly been reported in mammals, and there has not been a clear evidence to suggest its important roles in reproduction in non-mammalian species. In addition, avian species have apparently lost kisspeptin genes during evolution. These findings suggest a possibility that HPG axis regulation mediated by kisspeptin neuron may be specific to some species, and there may be other essential kisspeptin functions common to vertebrates. For functional analysis of kisspeptin neuronal system in teleosts, we used a model animal medaka to generate kisspeptin gene (kiss1 or its paralog kiss2) knockout and kisspeptin receptor gene (gpr54-1 or gpr54-2) knockout animals, using novel genome editing tools, TALENs and CRISPR/Cas9 system.

We first analyzed phenotype of kiss1-/- medaka, because Kiss1 but not Kiss2 neurons have been proven to be estrogen sensitive in medaka. Surprisingly, unlike in mammals, they did not show significant changes in the pituitary lhb or fshb mRNA expression compared to that of wild type in both sexes. In addition, histological examination revealed normal maturation of ovary and testis in kiss1-/- medaka. Also, fertilized eggs from kiss1-/- medaka pairs developed normally. Furthermore, kiss1-/- male medaka showed normal courtship behavior toward female. These results clearly indicate that Kiss1 is not essential for reproduction or courtship behavior in medaka and suggest the existence of novel functions other than reproductive regulation in non-mammalian vertebrates. To assess other possible functions of kisspeptin neurons, we quantified the expression level of peptides and hormones in the brain and pituitary of kiss1-/- medaka. We detected significant difference between wild type and kiss1-/-medaka in expression level of several homeostatic genes.

Here, we clearly demonstrated that kiss1 gene is not necessary for reproduction in medaka unlike in mammals. Our results are consistent with previous reports on the lack of gpr54-1 and gpr54-2 expression in GnRH neurons in several teleosts (1) and of effects of kisspeptins and its agonists on LH release in goldfish (2). On the other hand, kisspeptin neurons are suggested to conserve estrogen sensitivity in a wide variety of vertebrates (3). This steroid-dependent expressional regulation may be related to the expressional changes in several homeostatic genes after kiss1 gene knockout. The present results and future analysis of kiss2, gpr54-1 and gpr54-2 knockout medaka are expected to reveal the general function of kisspeptin neurons in vertebrates.

 

Nothing to Disclose: AT, SK, YA, YO

19517 8.0000 FRI-425 A Functional Analysis of Kisspeptin Neuronal System in Teleosts Using Knockout Medaka 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Shaihla Amin Khan*1, Coleman Young2, Amy Marie Navratil1 and Brian D Cherrington1
1University of Wyoming, Laramie, WY, 2University of Wyoming

 

Peptidylarginine deiminases (PAD) are a family of Ca2+ dependent enzymes that post-translational convert positively charged arginine into the neutral non-coded amino acid citrulline. Citrullination of histone tail arginine residues results in an open chromatin state causing changes in gene expression. Estrogen simulates expression of PAD isoforms 2 and 4 in the mouse uterus and mammary gland suggesting a possible role for PADs in reproduction. Since gonadotropin releasing hormone (GnRH) receptor signaling is also critical for fertility, we were curious if PADs are expressed in anterior pituitary gonadotropes. Currently, PAD isoform expression and the functional role of PAD catalyzed histone citrullination within gonadotropes remains unknown. To address this gap in knowledge, we first examined the LβT2 gonadotrope derived cell line for expression of different PAD isoforms. PAD2 mRNA levels were over 600 fold higher compared to the other PADs. To confirm our results in vivo, we found strong PAD2 expression throughout the human pituitary by immunohistochemistry.  Next, we assessed the ability of the GnRH agonist Buseralin (GnRHa) to regulate PAD2 protein expression. LβT2 cells were treated with a time course of GnRH and western analysis of cellular lysates revealed that PAD2 levels increased rapidly with the highest expression seen at 30 minutes. Using an immunofluorescent approach, we observed punctate PAD2 staining in the nucleus of LβT2 cells after 30 minutes of GnRHa treatment. Given the upregulation and accumulation of PAD2 in the nucleus following GnRHa, we next examined if the functional consequence of this localization was to facilitate citrullination of histones. GnRHa treated LβT2 cells showed an increase in citrullination of histone H3 arginine residues 2, 8, and 17 in a time dependent manner. Collectively, we have found that GnRHa treatment of LβT2 cells results in increased PAD2 expression in the nucleus and citrullination of histones. We currently are identifying the genes that are regulated by PAD2 catalyzed histone citrullination in in gonadotropes in response to GnRH treatment.

 

Nothing to Disclose: SAK, CY, AMN, BDC

22083 9.0000 FRI-426 A Gonadotropin Releasing Hormone Stimulates Histone Citrullination in Gonadotrope Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


James P Garcia*1, Kim L Keen2, Brian P Kenealy1, Dustin Richter1 and Ei Terasawa1
1University of Wisconsin-Madison, Madison, WI, 2Univ of Wisconsin, Madison, WI

 

The gonadal steroid independent increase in GnRH release is essential for the onset of puberty. Although a significant contribution by kisspeptin and neurokinin B (NKB) signaling to the pubertal increase in GnRH has been extensively reported, it is still unknown whether the interaction between kisspeptin and NKB signaling undergoes a pubertal change. It is possible that the interaction between kisspeptin and NKB signaling may be important for the mechanism of puberty. In pubertal female monkeys we previously found that 1) both kisspeptin and the NKB agonist, senktide, respectively stimulate GnRH release in a dose responsive manner, 2) peptide 234, a kisspeptin antagonist, suppresses GnRH release, whereas SB222200, an NKB antagonist, does not cause any changes in GnRH release, and 3) there are reciprocal interactions between kisspeptin and NKB signaling to GnRH release, as stimulatory effects of kisspeptin and senktide are blocked by the presence of SB222200 or peptide 234, respectively. Therefore, to understand the developmental change in kisspeptin and NKB signaling, in this study we conducted parallel experiments in prepubertal female monkeys using the microdialysis method. Kisspeptin and NKB agonist were infused into the stalk-median eminence (S-ME) for 20 min, whereas kisspeptin and NKB antagonists were infused into the S-ME for 60 min starting 40 min before the agonist infusion. Dialysates were continuously collected in 20 min intervals and GnRH levels in dialysates were measured by RIA. Results are summarized as follows: 1) Both infusion of kisspeptin (0.1 and 10 µM) and the NKB agonist senktide (0.1 and 10 µM), respectively stimulated GnRH release in a dose responsive manner, although the GnRH responses to kisspeptin and senktide in prepubertal monkeys at the same doses were smaller than those in pubertal monkeys, 2) dissimilar to the suppression seen in pubertal monkeys, both infusion of P234 (0.1 µM) or SB222200 (1 µM) for 60 min did not induce consistent suppression of GnRH release in prepubertal monkeys, 3) in the presence of SB222200 (1 µM) the kisspeptin (0.1 µM)-induced GnRH increases remained unchanged, and 4) similarly, the senktide (0.1 µM)-induced GnRH increases did not appear to be blocked by P234 (0.1 µM). These results indicate that the contribution of kisspeptin and NKB signaling to GnRH release and the interaction between kisspeptin and NKB signaling in prepubertal female monkeys differ from those in pubertal female monkeys. The question of whether the developmental difference in kisspeptin and NKB signaling observed in the present study is due to the pubertal increase in circulating estradiol levels remains to be investigated.

 

Nothing to Disclose: JPG, KLK, BPK, DR, ET

21100 10.0000 FRI-427 A Pubertal Modification of the Interaction Between Kisspeptin and Neurokinin B Signaling in Female Rhesus Monkeys 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Lea Bäcker*1, Agnete Overgaard1, Nina Almegaard Frimer1, Sara Rubek Jorgensen1, Trudy Ana Kohout2 and Jens Damsgaard Mikkelsen1
1Neurobiology Research Unit, Copenhagen University Hospital Rigshospitalet, Denmark, 2Ferring Research Institute, San Diego, CA

 

Kisspeptin plays an essential role in the regulation of the hypothalamic-pituitary-gonadal (HPG) axis. The peptide modulates reproductive function by causing the release of gonadotropin-releasing hormone (GnRH), which in turn stimulates the secretion of gonadotropins. GnRH analogs are known to induce receptor desensitization at the level of the pituitary and they are therefore frequently used as drugs to inhibit sex steroid secretion in hormone-dependent diseases and to control fertility in animal production. However, it is not known if natural kisspeptin has a similar desensitizing effect and whether this effect would occur at the level of the kisspeptin receptor on the GnRH neurons, Kiss1R, or further downstream the HPG axis. To assess the effects of repeated treatment with kisspeptin and its site of action, we compared responses of luteinizing hormone (LH) and GnRH neuron activation to endogenous kisspeptin, the GnRH analog triptorelin and vehicle. First, we administered human kisspeptin-54 (hKp54; 80 nmol/kg, ip), triptorelin (240 μg/kg, im) or vehicle (1 ml/kg, ip) to adult male rats once-daily for four days. Second, a terminal cross-over injection of the two peptides was conducted on the fifth day, i.e. the hKp54 treatment group received a single injection of triptorelin, and the triptorelin and vehicle groups were injected with hKp54. We measured LH responses to the injections on days 1, 4 and 5. Furthermore, c-Fos induction in GnRH neurons and testes weight were determined after decapitation.

While triptorelin initially induced a strong LH response, this response was diminished to less than 25% of the original effect after repeated injections. The latter indication of desensitization was further supported by a decrease in testes weight. The terminal cross-over injection of hKp54 to the animals previously treated with triptorelin or vehicle caused similar c-Fos-induced GnRH neuron activation, whereas the LH response was significantly lower in the animals pretreated with triptorelin. These findings confirmed our hypothesis that kisspeptin can still stimulate GnRH neurons, if the GnRH receptors at the pituitary are desensitized. In contrast, hKp54 produced robust LH responses across the repeated injections that were half the size of the naive response to triptorelin, suggesting the absence of desensitization using this protocol of hKp54 administration and a lower potency of hKp54 compared to triptorelin. Furthermore, the responsiveness to the terminal injection of triptorelin was retained in this treatment group and caused no activation of GnRH neurons. We conclude that repeated peripheral administration of hKp54 over four days does not elicit desensitization at the level of the GnRH neurons or downstream, and that GnRH neurons remain sensitive to hKp54 after desensitization of the GnRH signal.

 

Nothing to Disclose: LB, AO, NAF, SRJ, TAK, JDM

19869 11.0000 FRI-428 A Effects of Repeated Peripheral Administration of Human Kisspeptin-54 and the GnRH Analog Triptorelin on the Hypothalamic-Pituitary-Gonadal Axis in Adult Male Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Brian S Edwards*1, An K Dang2, Gregory C Amberg2, Colin M Clay2 and Amy Marie Navratil1
1University of Wyoming, Laramie, WY, 2Colorado State University, Fort Collins, CO

 

We have shown that GnRH mediated engagement of the cytoskeleton induces cell movement and is necessary for GnRH signaling to ERK. It also has previously been established that a dominant negative form of the mechano-GTPase dynamin (K44A) attenuates GnRH activation of ERK. At present, it is not clear at what level these cellular events might be linked. To further explore this issue, we used a pharmacological inhibitor of dynamin GTPase activity, dynasore. Using the gonadotrope-derived αT3-1 cell line, we find that dynasore suppresses activation of ERK, but not JNK, following exposure to the GnRH agonist, buserelin (GnRHa). Live cell imaging displayed accumulation of dynamin-GFP in GnRH-induced lamellipodia and membrane protrusions. Coincident with translocation of dynamin-GFP to the plasma membrane, we demonstrated that dynamin colocalizes with the actin cytoskeleton and the actin binding protein, cortactin at the leading edge of the plasma membrane. Furthermore, exposure of αT3-1 cells to dynasore inhibited GnRH-induced cyto-architectural rearrangements. It has recently been discovered that Ca2+ influx via the L-type Ca2+ channels requires an intact cytoskeleton. Interestingly, not only does dynasore attenuate GnRH mediated actin reorganization, it also suppresses Ca2+ influx through L-type Ca2+ channels as visualized in living cells using total internal reflection fluorescence (TIRF) microscopy. Collectively, our data suggests that GnRH induced membrane remodeling events are mediated in part by the association of dynamin and cortactin engaging the actin cytoskeleton, that then regulates Ca2+ influx via L-type channels to facilitate ERK phosphorylation.

 

Nothing to Disclose: BSE, AKD, GCA, CMC, AMN

21075 12.0000 FRI-429 A Dynamin Is Required for GnRH Signaling to L-Type Calcium Channels and Activation of ERK 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Luhong Wang* and Suzanne M Moenter
University of Michigan, Ann Arbor, MI

 

Gonadotropin-releasing hormone (GnRH) neurons form the final common pathway for central control of reproduction, but lack estrogen receptor alpha (ERα). Estradiol, via ERα, provides both negative feedback to regulate pulsatile GnRH release and positive feedback to regulate preovulatory surge release. Kisspeptin cells in the arcuate nucleus (ARC) and anteroventral periventricular nucleus (AVPV) are estradiol-sensitive afferents postulated to mediate estradiol negative and positive feedback to GnRH neurons, respectively. Estrous cycle stage or estradiol can differentially alter ionotropic glutamate or GABA transmission to AVPV and ARC kisspeptin cells. Regulation may also occur through changes in the intrinsic properties of kisspeptin cells, such as membrane resistance Rm, or excitability measured as the effectiveness of a given stimulus to elicit action potential (AP) firing (input-output curve, I/O curve). We hypothesized the intrinsic properties of AVPV and ARC cells are differentially regulated by estrous cycle stage. Whole-cell recordings were made in brain slices obtained from kiss-GFP mice on the afternoon of diestrus 1 (D) or proestrus (P). Rm near the resting potential was increased in AVPV cells on P vs D (1392 ± 43 vs 824 ±16 MΩ, p < 0.01, n≥13). This change was not sufficient increase the excitability of AVPV cells, as the initial slope of I/O curve was steep with no difference observed between D and P. In ARC cells, Rm did not change with cycle stage, but these cells had a shallower I/O curve on P than D, resulting in fewer APs on P (p < 0.05, n≥13). Further, APs of ARC cells on P were irregular compared to those on D, demonstrated by increased variance of the interspike interval (ISI) on P vs D (F-test, p<0.01). Irregular APs can be due to interactions among intrinsic and synaptic properties. We thus blocked ionontropic glutamate and GABA receptors and again examined APs. Blockers did not alter Rm or I/O curve in AVPV cells (n=13). In ARC cells there was still no cycle stage-dependent change in Rm. Blockers did, however, eliminate the difference in ISI variance (n=13), and the cycle stage difference in AP response by increasing I/O curve slope on P (p < 0.01, n≥13). The same stimulus in the same ARC cells on P was tested before and after blockers; 3 of 4 changed from irregular to regular APs, and showed corresponding different variances of ISI (p < 0.001). These data imply different interactions between intrinsic and synaptic properties for ARC and AVPV kisspeptin cells. Decreased excitability in ARC cells on P may be due to synaptic transmission from GABA and glutamate afferents that are preserved in the slice generating interfering postsynaptic potentials, suppressing these cells. This suggests ARC afferents may also be under estrous cycle regulation. Previously we showed increased glutamate transmission on P in AVPV cells; coupled with increased Rm, AVPV cells are poised for increased activity on P.

 

Nothing to Disclose: LW, SMM

20475 13.0000 FRI-430 A Intrinsic Membrane Properties and Spontaneous Ionotropic Synaptic Transmission Interact in a Cycle-Dependent Manner in Arcuate but Not Avpv Kisspeptin Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Justin A. Lopez*, Richard B. McCosh, Gail Nesselrod, Michelle N. Bedenbaugh, Steven L. Hardy, Robert L. Goodman and Stanley M. Hileman
West Virginia University School of Medicine, Morgantown, WV

 

Neural mechanisms underlying the onset of puberty are not completely understood.  In sheep, this process involves an increase in GnRH release due to decreased sensitivity to estrogen (E2)-negative feedback. As GnRH neurons do not express the relevant E2 receptors, this pathway must involve interneurons. Recent data suggests that neurons in the arcuate nucleus of the hypothalamus that co-express kisspeptin, neurokinin B, and dynorphin (DYN), i.e. KNDy neurons, play a critical role. KNDy neurons express E2 receptors and previous work from our group showed DYN to be inhibitory to GnRH/LH secretion in progesterone-treated adults.  Thus, we hypothesized that DYN plays a role in the E2-induced suppression of LH secretion during the prepubertal period. To test this hypothesis, we compared the effects of nor-BNI, a κ-opioid receptor (DYN’s cognate receptor) antagonist in a single group of ovariectomized prepubertal ewes (n = 6) treated with either E2 (OVX+E; Study 1), E2 and progesterone (OVX+E+P; Study 2), or OVX+E at a postpubertal age (Study 3).  Ewes were ovariectomized, implanted sc with a small E2 implant (1cm), and a chronic guide cannula inserted into the lateral cerebroventricle. In Study 1, lambs were infused icv (60 ul/h) with aCSF or nor-BNI (60 nmol/h) for 3h. Blood samples were collected by jugular catheter at 12-min intervals and assessed for LH by RIA. Ewes received both treatments in a cross-over design. Infusion of nor-BNI produced a significant increase (p < 0.05) in mean LH compared to aCSF controls: 4.59 ± 0.84 ng/ml vs. 3.21 ± 0.66 ng/ ml. In Study 2, the effect of nor-BNI in OVX+E+P lambs was examined using a similar protocol, with the addition of an extra hour (4h) of blood sampling.  Infusion of nor-BNI significantly increased (p < 0.05) mean LH compared to aCSF controls: 3.08 ± 0.22 ng/ml vs. 1.77 ± 0.38 ng/ ml. In Study 3, nor-BNI or aCSF were infused for 4h in these same OVX+E ewes at a postpubertal age. Animals infused with nor-BNI did not exhibit a significant increase in mean LH compared to aCSF controls: 6.46 ± 0.93 ng/ml (nor-BNI) vs. 5.58 ± 1.54 ng/ml (aCSF) (p > 0.20). These data demonstrate that nor-BNI, a selective κ-opioid receptor antagonist, stimulates LH secretion in OVX+E ewes of a prepubertal, but not postpubertal, age. Based on these data, we suggest that DYN may mediate the inhibitory effects of estrogen on GnRH/LH secretion in prepubertal ewe lambs and a decrease in DYN inhibition plays an important role in the onset of puberty in female sheep.

 

Nothing to Disclose: JAL, RBM, GN, MNB, SLH, RLG, SMH

21866 14.0000 FRI-431 A Evidence that Alterations in Dynorphin Secretion Play an Important Role in Ovine Puberty 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Dean Tran*1 and Denise D Belsham2
1University of Toronto, Toronto, ON, 2Univ of Toronto, Toronto, ON, Canada

 

Fatty acids are bioactive signaling molecules that can regulate cellular processes such as gene expression and secretion. Although the links between nutrition and reproductive function are widely accepted, the specific effects of fatty acids on the reproductive axis are not well understood. The reproductive axis is coordinated by hypothalamic neurons expressing and secreting gonadotropin-releasing hormone (GnRH). The complex organization of the hypothalamus and the dispersed distribution of GnRH neurons make it difficult to study the molecular mechanisms regulating GnRH neuronal cell biology in vivo. To circumvent these issues, our lab has generated a novel, immortalized GnRH-synthesizing cell line. This line was generated from primary hypothalamic culture from a 2-month-old, female, transgenic GnRH-GFP mouse. The neurons were immortalized and then subsequently fluorescence-activated cell-sorted to obtain a non-clonal population of GnRH neurons, the mHypoA-GnRH/GFP cell line. Using this model, we studied the effects of docosahexaenoic acid (DHA), an omega-3, polyunsaturated fatty acid with well-documented health benefits, on GnRH neurons. We treated mHypoA-GnRH/GFP cells with 75 µM DHA for up to 24 hours. Total RNA was assessed for GnRH gene expression changes. Two hours of 75 µM DHA significantly increased GnRH gene expression (1.122±0.04526 vs. 0.7529±0.05388 Gnrh/histone mRNA for controls; P<0.01; n=4). To explore the potential molecular mechanisms through which DHA upregulated GnRH gene expression, we used western blot analysis to study the activation of intracellular signaling pathways. DHA can activate the G protein-coupled receptor 120 (GPR120), which is expressed by mHypoA-GnRH/GFP cells, and increase AKT phosphorylation. DHA increased levels of phosphorylated Akt (1.671±0.03733 vs. 0.7776±0.1240 pAkt/Akt for controls; P<0.05; n=3). Two hour treatment of the mHypoA-GnRH/GFP neurons with DHA in the presence of wortmannin, a PI3K/Akt pathway inhibitor, did not block the DHA-mediated increase in GnRH gene expression (1.420±0.072 vs. 0.856±0.111 GnRH/histone mRNA for controls; P<0.01; n=3), suggesting DHA may regulate GnRH gene expression through a PI3K/Akt-independent pathway. In addition, we identified a potential downstream transcriptional regulator of Gnrh. The mouse GnRH promoter contains response elements for the CCAAT-enhancer-binding protein beta (C/EBP-β), and we found that DHA significantly increased C/EBP-β gene expression (1.235±0.079 vs. 0.746±0.044 Cebpb/histone mRNA for controls; P<0.0001; n=4). These findings suggest that DHA may regulate GnRH mRNA levels directly at the transcriptional level via a C/EBP-β-mediated mechanism. The polyunsaturated, omega-3 fatty acid DHA may have direct regulatory effects on GnRH neurons, suggesting nutritional inputs may affect the reproductive axis at the level of the hypothalamus.

 

Nothing to Disclose: DT, DDB

21060 15.0000 FRI-432 A The Omega-3, Polyunsaturated Fatty Acid Docosahexaenoic Acid (DHA) Regulates GnRH Gene Expression in a Non-Clonal, GnRH-Synthesizing Neuronal Cell Model 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Angela K. Odle*, Melody Lyn Allensworth-James, Anessa C. Haney, Noor Akhter, Mohsin M Syed, Angus M. MacNicol, Melanie C. MacNicol and Gwen V. Childs
University of Arkansas for Medical Sciences, Little Rock, AR

 

The adipokine leptin is an important nutritional signal that informs the hypothalamus that energy stores are sufficient for reproduction.  Leptin receptors are found in many tissues, including the pituitary.  We have recently shown that deletion of the signaling portion of the long-form leptin receptor in gonadotropes using cre-lox recombination results in reduced GnRHr protein, but not mRNA, in male and female homozygous mutants (1).  We identified a consensus binding site within the murine GnRHrmRNA 3'-UTR for the mRNA-binding protein Musashi (MSI1).  We hypothesized that leptin stimulates GnRHr function through control of MSI1-mediated repression of translation in GnRHr mRNA.  

For these studies, deletion mutant animals had one allele of Cre-LH and two alleles of floxed leptin receptor exon 17.  Control animals are cre-negative with two alleles of LepR exon 17.  Pituitaries were collected, dispersed, and plated overnight.  Cultures received 0-100 nM leptin (3 hours) followed by 1 nM Bio-GnRH (10 minutes).  After fixation, the cells were dual-labeled for Bio-GnRH and LH-β or Musashi 1 (MSI1) (2). Additional pituitaries were collected and processed for mRNA (qPCR), or stimulated with leptin and processed for protein (ELISA).

Leptin treatment increased the percentages of pituitary cells labeled for Bio-GnRH in a dose-dependent manner, from 16.6±1% (0nM) to 24±1% (1 nM), 27±1% (10 nM) or 28.8±1% (100 nM) p<0.0001; 1nM<100 nM p=.03.  Leptin (10 nM) also increased pituitary GnRHr protein levels (CTL: 6.2±1 vs Leptin 14±1 ng/ml., p=0.03).  Immunolabeling of MSI1 protein in these same pituitary cell cultures showed a major increase in labeling density across the general population.  However, when we analyzed 300 Bio-GnRH bearing cells/group, leptin treatment decreased MSI1 expression selectively in these gonadotropes in a dose-dependent manner, from 48±3% of Bio-GnRH cells (0 nM), to 21±0.6% (1 nM), 10.6±3 (10nM) or 10.3±1% (100 nM) p<.0001, 1nM<10nM p=.03.  To determine the overall impact of deleting Lepr in gonadotropes, we also assayed control and Lepr-null male pituitaries for MSI mRNA. We found that deletion mutant males have significantly decreased MSI2 mRNA levels compared to control males (p<0.002) with no change in MSI1 mRNA. Thus, leptin downregulation of MSI1 may be post-transcriptional.

Our findings support our hypothesis that leptin is crucial for the stimulation of pituitary GnRH function through the suppression of the mRNA regulator MSI1.  Using both control and gonadotrope-specific leptin receptor-null animals, we determined that (1) leptin stimulates GnRH receptor protein levels, (2) leptin suppresses MSI1 levels in gonadotropes, and (3) this suppression of MSI1 is cell-type dependent.  These studies add mechanistic insight into the complex interplay of leptin and the hypothalamic-pituitary-gonadal axis.

 

Nothing to Disclose: AKO, MLA, ACH, NA, MMS, AMM, MCM, GVC

22098 16.0000 FRI-433 A Does Leptin Stimulation of Gonadotropes Involve the Translational Regulator, Musashi? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Stephen J Winters*, Robert Tyler Luckett and Joseph Patrick Moore Jr.
University of Louisville, Louisville, KY

 

Gonadotrophs are not a traditional target for dopamine signaling.  However, mouse gonadotroph cell lines and most human gonadotropin-producing pituitary tumors express the dopamine-2 receptor (Drd2), and while the function for Drd2 signaling in gonadotrophs is uncertain, Drd2 may regulate PACAP expression. Drd2 and PACAP are co-expressed in gonadotrophs in newborn rats.  Drd2 couples to Gαi to inhibit adenylate cyclase and reduce cAMP levels, and the Drd2 agonist bromocriptine (BC) suppressed PACAP-stimulated cAMP production and PACAP promoter activity in gonadotroph cells.  PACAP is expressed at a high level in the fetal pituitary, and declines rapidly and profoundly at the time of birth. Furthermore, this developmental decline is accompanied by a decrease in pituitary follistatin with a reciprocal rise in GnRH-R and FSH-β mRNAs suggesting a causal relationship.  While our previous studies suggest a cAMP-dependent feed-forward mechanism maintains the high level of PACAP in the fetal pituitary that is disrupted at birth by dopamine signaling, the effective BC dose for PACAP suppression exceeded the estimated Ki for the Drd2. The present experiments were designed to explore further the mechanism by which Drd2 signaling regulates PACAP expression.  We examined the effects of several dopamine agonists on PACAP promoter activity, cAMP signaling and MAPK activation in αT3-1 cells.  These cells, an established model for immature gonadotrophs, also express PACAP and produce cAMP in substantial excess when compared to the more mature LβT-2 gonadotroph cells, and express both the long and short forms of the Drd2. αT3-1 cells were transfected for 24h, replaced with serum-free media, treated for 6h with 10 nM PACAP or vehicle following 30 min pretreatment with the dopamine agonists (1 μM), lysed and assayed for luciferase activity.  The following dopamine agonists were studied: cabergoline, quinpirole, sumanirole, BC and BIM-53097 (Ipsen).  PACAP increased PACAP promoter activity 3.21±0.68 fold (p<0.01) which was partially blocked by BC (p<0.01) or quinpirole (p<0.025). cAMP signaling was increased  (p<0.01) by PACAP (17.3±1.16 fold) and repressed (p<0.01) by BC.  Both BC and BIM activated (p<0.01) MAPK signaling.  Experiments using deletion constructs indicate that the BC effect is maintained within the proximal PACAP promoter (-201/+36).   Thus various D2 agonists preferentially couple the Drd2 to different signal transduction pathways in gonadotrophs.  Of these, BC inhibits cAMP signaling and PACAP transcription whereas BIM-53097 and BC activate the MAPK signaling pathway perhaps explaining the high EC for BC inhibition of PACAP promoter activity.  There is a striking difference in the effects of various Drd2 agonists on gonadotrophs.  Understanding how PACAP and other targets are regulated by Drd2 signaling in αT3-1 cells provides new insight into how gonadotroph function is regulated by dopamine.

 

Nothing to Disclose: SJW, RTL, JPM Jr.

19077 17.0000 FRI-434 A Dopamine Agonists and PACAP Expression in Gonadotroph Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Michelle N. Bedenbaugh*1, Marcella Doliveira1, Rodolfo C. Cardoso1, Curtis Korthanke1, Sarah MV Sharpton1, Nancy Hughes Ing1, Alain Caraty2, Gary L Williams3 and Marcel Amstalden1
1Texas A&M University, College Station, TX, 2INRA/CNRS/Université de Tours/Haras Nationaux, Nouzilly, France, 3Texas A&M AgriLife Research, Beeville, TX

 

The pubertal initiation of a high-frequency, pulsatile release of gonadotropin-releasing hormone involves an escape from estradiol negative feedback. Kisspeptin neurons are proposed to mediate the effects of estradiol, and estrogen receptor alpha (ESR1) may play a role in this process. The present study investigated the hypothesis that reduced ESR1 expression in kisspeptin neurons is associated with decreased sensitivity to estradiol negative feedback that underlies reproductive maturation. Ewe lambs were ovariectomized at 24 wk of age and received no implant (OVX; n=7) or a subcutaneous implant containing estradiol (OVX+E; n=14). At 30 wk of age, blood samples were collected from these juvenile lambs to characterize the pattern of LH secretion. Lambs were then euthanized and a block of tissue containing the preoptic area (POA) and hypothalamus was collected. Detection of ESR1 mRNA and kisspeptin was performed by dual-label in situ hybridization/immunocytochemistry. In the mid arcuate nucleus (ARC), the abundance of ESR1 mRNA was greater in OVX than in OVX+E ewe lambs. Post hoc analysis of the LH data obtained from OVX+E lambs indicated three distinct patterns of LH release: low (1-2 pulses/12 h; n=3), intermediate (6-7 pulses/12 h; n=6) and high (>10 pulses/12 h; n=5) frequency of pulses. The proportion of kisspeptin cells containing ESR1 mRNA in the POA/periventricular area did not differ among OVX+E lambs exhibiting low, intermediate and high frequency of LH pulses. However, the percentage of kisspeptin cells containing ESR1 mRNA in the mid ARC was greater in OVX+E lambs exhibiting high frequency of LH pulses (57%) than in lambs exhibiting intermediate (36%) and low (27%) LH pulsatility and did not differ from OVX (50%) lambs. Although kisspeptin neurons are highly responsive to estradiol regulation, changes in ESR1 expression in kisspeptin neurons do not appear to drive the decrease in estradiol negative feedback observed during maturation of the reproductive neuroendocrine axis.

 

Nothing to Disclose: MNB, MD, RCC, CK, SMS, NHI, AC, GLW, MA

20553 18.0000 FRI-435 A ESR1 Expression in Kisspeptin Neurons during Reproductive Neuroendocrine Maturation in Female Sheep 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


David Garcia Galiano* and Carol F Elias
University of Michigan, Ann Arbor, MI

 

Kisspeptins, encoded by Kiss1 gene, are potent stimulators of GnRH release and are essential mediators of sex steroid feedback effects on GnRH neuronal activity. Within the hypothalamus, Kiss1 neurons are expressed in the anteroventral periventricular (AVPV), the anterior periventricular (PeN) and the arcuate (ARC) nuclei. Kiss1 mRNA and Kiss1-cre-mediated green fluorescence protein (GFP) expression have also been observed in other hypothalamic and extra-hypothalamic areas including the anterodorsal preoptic nucleus (ADP), the lateral septum (LS), the bed nucleus of the stria terminalis (BNST), the medial nucleus of the amygdala (MeA) and the cerebral cortex. However, it is not clear if Kiss1 neurons outside AVPV/PeN and ARC are developmentally regulated. In this study, we analyzed Kiss1 expression at different phases of postnatal development (prepubertal, pubertal and adult) and sex hormone milieu (gonadectomized/GNX) using our Kiss1-Cre transgenic reporter (Kiss1-eGFP) line. As expected, the detection of Kiss1-eGFP signal showed an increase of ARC Kiss1 neurons associated with reproductive development, with a significant increase at pubertal (P36) stage which remains elevated in adult and GNX compared to prepubertal (P23) male mice. In females, the number of ARC Kiss1 neurons was significantly higher in diestrus and GNX with respect to prepubertal (P15) and pubertal (P26) mice. In the AVPV Kiss1 population, we detected an increased number of positive neurons associated with the reproductive maturation in both sexes, with a lower number of labeled neurons in males. Moreover, we evaluated the estrogen sensitivity of AVPV Kiss1 neurons in females via co-localization analysis of ERα-positive AVPV Kiss1 neurons. We found a decreased rate during early reproductive development, between P15 and P26 (25-30% of AVPV Kiss1 neurons co-expressing ERα), and a significant increase during later stages of reproductive maturation in intact and GNX (75-80% of co-localization) mice. In our model, the absence of gonadal steroids did not affect the number of AVPV or ARC Kiss1 neurons or the percentage of ERα Kiss1-expressing neurons compared to adults. Finally, we analyzed Kiss1 mRNA expression and Kiss1-eGFP neurons in extra-hypothalamic sites (LS, BNST, MeA and cortex) in both sexes at different stages of the development, and we detected that Kiss1-eGFP expression in MeA and cerebral cortex was associated with acquisition of reproductive capacity. Then, our findings indicate that kisspeptins play a role in a variety of neuronal systems outside the neuroendocrine reproductive axis. Further studies will be necessary to assess the physiology relevance of Kiss1 expression is these additional sites.

 

Nothing to Disclose: DG, CFE

21365 19.0000 FRI-436 A Distribution of Hypothalamic and Extra-Hypothalamic Kiss1 Neurons during Postnatal Developmental 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Robert L. Goodman*, Leanne Mazzella, Richard B. McCosh, Pasha Grachev, John M Connors and Stanley M. Hileman
West Virginia University School of Medicine, Morgantown, WV

 

We have demonstrated that icv injection of 0.1 to 1.0 nmoles of NKB stimulates LH secretion in anestrous ewes. NKB is thought to act primarily via NK3R on KNDy neurons in the arcuate nucleus to increase kisspeptin release which then stimulates GnRH secretion.  However, recent evidence supports the proposal that neurokinin A (NKA) and substance P (SP) can also stimulate LH secretion in rodents via their receptors (NK2R and NK1R, respectively). Therefore we tested this hypothesis by determining the effects of different doses of NKA and SP on episodic LH secretion in ewes.   A chronic guide tube was implanted into the third ventricle of five anestrous ewes and they were allowed to recover for two weeks. In the initial study, jugular blood samples were collected every 12 min from 36 min before to 4 hrs after injection of either vehicle (0.1 mL), 2.0 nmoles NKA, or 2.0 nmoles SP.  This protocol was then repeated two times so that each ewe received all three treatments in randomized order. NKA produced an increase in LH secretion within 24 min of injection in all five ewes, and significantly increased mean LH concentrations  from 1.1 ± 0.2 to 2.0 ± 0.5 ng/mL, while vehicle had no effect (pre: 1.7 ± 0.3 ng/mL; post: 1.7 ± 0.2 ng/mL).  SP induced an increase in LH secretion in 80% of the ewes, but did not significantly increase LH concentrations (pre: 1.5 ± 0.1 ng/mL; post: 1.8 ± 0.2 ng/mL).  Based on these data, we next tested a lower dose of NKA (0.5 nmoles) and a higher dose of SP (10 nmoles) in these same ewes.  This dose of NKA induced an immediate increase in LH secretion in only two ewes and did not increase mean LH levels (pre: 1.8 ± 0.3 ng/mL; post: 2.4 ± 0.4 ng/mL).  Sixty percent of the ewes responded to the high dose of SP which also significantly increased mean LH concentrations from 1.6 ± 0.1 to 2.6 ± 0.2 ng/mL.  These data demonstrate that both NKA and SP can stimulate LH secretion in ewes, but that much higher doses of these two tachykinins are required than was previously observed with NKB injections. Moreover, the relative potency of these three tachykinins (NKB>NKA>SP) is consistent with that of the relative selectivity of NK3R. Thus these results, together with the observation that few KNDy neurons contain NK1R (Fergani et al., abstract ENDO2015), support the hypothesis that NK3R is the primary tachykinin receptor controlling LH secretion in ewes.

 

Nothing to Disclose: RLG, LM, RBM, PG, JMC, SMH

21289 20.0000 FRI-437 A High Doses of Neurokinin A and Substance P Stimulate LH Secretion in Ewes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Mitsumori Kawaminami*, Ryota Terashima and Shiro Kurusu
Kitasato University, Aomori, Japan

 

Annexin A5 (ANXA5) is a member of the annexin family of proteins. We have previously established that in the pituitary ANXA5 is found in gonadotropes (1), that GnRH stimulates ANXA5 synthesis and ANXA5 in turn facilitates gonadotropin secretion in primary cultures of pituitary cells (2, 3). We also found that ANXA5 moved into the nucleus of gonadotropes three weeks after the ovariectomy (OVX) (1). These data strongly suggest a physiological role for ANXA5 in mediating the actions of GnRH on gonadotropin secretion. In the present study, we further investigated changes in the expression and distribution of ANXA5 in pituitary gonadotropes under circumstances in which GnRH secretion is augmented, namely after OVX and during the LH surge. Adult female Wistar-Imamichi rats were used. Knockdown of ANXA5 with siRNA reduced GnRH-stimulated LH release in primary cultures of pituitary cells. This result demonstrates that ANXA5 synthesis is necessary at least for full GnRH stimulation of LH release in the pituitary. OVX increased mRNAs for the LHβ subunit and ANXA5. Increased expression of ANXA5 was also confirmed by Western blotting. Plasma concentrations of LH were augmented as well. OVX increased the number of gonadotropes two and four weeks after OVX, while in vitro LH responses to GnRH were retarded as time passed after OVX. Pituitary glands were harvested after one, two and four weeks after OVX and subjected to immunohistochemistry to localize LHβ and ANXA5. LH positive cells were larger than those from intact animals, appeared two and four weeks after OVX, and contained ANXA5. Furthermore, cytosolic ANXA5 redistributed to the nucleus and plasma membrane up until four weeks after OVX. Similar nuclear distribution of ANXA5 was observed in the pituitary gland of proestrous rats at 11:00 h and was reduced at 17:00 h, the time of LH surge. Together, these data suggest the synthesis of ANXA5 and its subcellular localization in gonadotropes are both regulated by GnRH. As relocation of ANXA5 into the nucleus was seen four weeks after OVX and was coincident with an increase in gonadotrope number and retardation of the LH response to GnRH stimulation, ANXA5 is postulated to be involved not only GnRH stimulation of LH secretion, but also in gonadotrope cell growth.

 

Nothing to Disclose: MK, RT, SK

20248 21.0000 FRI-438 A Involvement of Annexin A5 in GnRH-Stimulated Gonadotropin Secretion in Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Michael J Woller*1 and Deborah K Barnett2
1Univ of Wisconsin - Whitewater, Whitewater, WI, 2University of Alaska Southeast, Juneau, AK

 

Pulsatile release of GnRH drives pituitary release of gonadotropins in a wide range of animal species.   The vast majority of evolution of GnRH isoforms has occurred in fishes, specifically in salmonids.  We have collected Pink Salmon in the wild during their spawning migration, documented the physical condition of the fish as an indicator of development prior to spawning, and collected brain tissue explants to measure the release of both sGnRH and chGnRH-II isoforms over a 5-hour period in a tissue perifusion apparatus.  With this model, we have viewed developmental change in different stages of migration into freshwater as well as the morphological changes the fish undergo during migration.  Further, we are able to measure pulsatile release of both sGnRH and chGnRH-II from brain explants in culture.  Preliminary results indicate that: 1) There are differences in the pulsatile release of sGnRH in fish harvested early in migration (prior to morphological change associated with migration into freshwater) compared with fish that have completed the morphological change associated with spawning.  2) Changes in release parameters for chGhRH-II are less dramatic during the migration of the fish.  3) Release of both sGnRH and chGnRH-II are clearly pulsatile in fish at all developmental stages. 4) Pulsatile release of these two isoforms of GnRH are independent of each other in that there is a very low level of correlation between pulses of sGnRH and pulses of chGnRH-II from the same brain explants.

 

Nothing to Disclose: MJW, DKB

22112 22.0000 FRI-439 A Measurement of Sgnrh and Chgnrh-II  in Brain Explants from Pink Salmon Harvested in Alaska during Spawning Migration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Soo-Hyun Kim*1, Yeon Joo Kim1, Ji-Young Lee1, Paris Ataliotis1, Hyung-Goo Kim2 and Lawrence C Layman2
1St. George's Medical School, University of London, London, United Kingdom, 2Georgia Regents University, Augusta, GA

 

To ensure normal reproductive function, proper development and coordination of the hypothalamic-pituitary-gonadal (HPG) axis is essential. The key factor that regulates the HPG axis is gonadotrophin releasing hormone (GnRH). Timely release of GnRH is critical for the onset of puberty and subsequent sexual maturation. We have identified that a relatively unknown gene WDR11 is mutated in at least two forms of reproductive disorders, Kallmann Syndrome (KS) and normosmic hypogonadotrophic hypogonadism (nHH) (1). These are developmental genetic disorders defined by absent or delayed puberty and infertility, often accompanied by several other malformations such as anosmia, cleft palate, kidney anomalies, and neurological defects. More recently, a novel mutation of WDR11 was also identified in Combined Pituitary Hormone Deficiency (CPHD) (2). Although WDR11 has been shown to be expressed along the GnRH developmental niche in mouse and zebrafish embryos (1), how the mutation of WDR11causes these diseases is not known.

            In order to develop a full understanding of the role of WDR11 in vivo, and reveal the molecular pathogenesis of KS, nHH and potentially CPHD, we have generated a knockout mouse model.  Our preliminary data indicate that the homozygote null (Wdr11-/-) mice die postnatally within 2 days after birth. The heterozygote (Wdr11+/-) mice do survive and show a range of phenotypes with a different degree of penetrance. Both null and heterozygote mice have craniofacial defects. Further analyses of the phenotypes, particularly focusing on the puberty and reproductive competence are in progress.  Our studies will confirm the effects of WDR11 deficiency upon the establishment of GnRH neurones and gonadal function, supporting the notion that WDR11 is an underlying genetic cause of human reproductive neuroendocrine disorders.

 

Nothing to Disclose: SHK, YJK, JYL, PA, HGK, LCL

19797 23.0000 FRI-440 A The Role of WDR11 in Hypogonadotrophic Hypogoandism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Bill L Lasley*1, Alan James Conley1, Ch V Rao2, John H Morrison3 and Nancy A Gee1
1University of California, Davis, CA, 2Florida International University, Herbert Wertheim College of Medicine, Miami, FL, 3Icahn School of Medicine at Mount Sinai, New York, NY

 

Background:  In general, serum phosphate levels drop throughout life.  The exception to this general trend is a positive inflection in mid-aged women as they approach menopause.  The mechanism for this change in phosphate balance has not been explained, however it occurs at the same time that adrenal androgens increase, urinary free cortisol increases and aldosterone excretion rate decreases.  All three of these events have been related to increased luteinizing hormone (LH) concentrations that occur at the same time. 

Objective: The aim of this study was to determine if the presence of LH receptors (LHR) in the adrenal cortex of the laboratory macaque could provide a partial explanation for the gender and age-specific changes observed in cortisol, aldosterone and serum phosphate levels.

Methods: Adrenal tissues from intact, younger (7-13 y/o, n=7) and older (21-25, n=4) healthy, reproductively sound female laboratory macaques were fixed, sectioned and stained using a previously developed immunohistochemical technique to identify LHR in human adrenal cortices. Stained sections were evaluated by light microscopy.

Results:  LHRs were identified in all three zones of the adrenal cortex with no perceptible difference between the age groups in the zona reticularis (ZR) or the zona fasciculate(ZF).  Staining in the zona glomerulosa (ZG) however was markedly less in younger compared to older animals.

Conclusion: These observations reveal an age-specific increase in LHRs in the ZG of a nonhuman primate animal model.  These findings support a causal relationship between the decrease in aldosterone excretion with increasing circulating LH in women and the resultant increase in serum phosphate.  Further, this observation provides support for at least three potential LH-related mechanisms: 1) increased adrenal androgen driven by stimulated P450c17 activity; 2) increased cortisol by direct LH action; and 3) LH-mediated interference with the angiotensin II regulation of aldosterone secretion.

 

Nothing to Disclose: BLL, AJC, CVR, JHM, NAG

21420 24.0000 FRI-441 A Age-Specific Differences in Luteinizing Hormone Receptors in the Adrenal Cortex of Female Macaques 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 418-441 5900 1:00:00 PM Basic GnRH Poster


Samuel Backman*1, Joakim Crona1, Rajani Maharjan2, Peter Stålberg1, Per Hellman2 and Peyman Björklund1
1Uppsala University, Uppsala, Sweden, 2Uppsala University, Sweden

 

Pheochromocytomas are tumors derived from chromaffin cells in the adrenal medulla. Up to 60% of all pheochromocytomas harbor germline or somatic mutations in one of SDHA, SDHB, SDHC, SDHD, SDHAF2, VHL, EPAS1, RET, NF1, TMEM127, MAX or H-RAS genes. The role of epigenetic deregulation remains to be elucidated. Transcription silencing due to methylation of CpG-islands in the gene promoters is the most well understood epigenetic mechanism. We hypothesized that DNA methylation may play a role in tumor progression in pheochromocytoma. Bisulfite-treated DNA from 39 pheochromocytoma samples and 4 normal adrenal medullae were applied to the Illumina Infinium HumanMethylation27 microarray. Unsupervised clustering and principal components analysis (PCA) were performed in R. SNP array data was available for 31 of the tumor samples and the tumors had been previously analyzed for mutations in the known driver-genes. Unsupervised clustering of the tumor samples utilizing the 2757 (10% of total) most dissimilar probes resulted in two distinct clusters. Cluster A (n=28) contained all malignant pheochromocytomas (n=9, sensitivity=1, specificity=0.37) in the cohort, while Cluster B (n=11) consisted solely of benign tumors. PCA results were in concordance with the results from the clustering. Cluster B was enriched for VHL mutated tumors whereas Cluster A was enriched for NF1/RET/H-RAS mutated tumors and tumors without known driver mutation. The average methylation index (MI) was significantly lower in Cluster A than in Cluster B (0.2419 vs. 0.2765, p=1.54*10-8).  Normal adrenal medulla had an average MI of 0.2739 which was not significantly different from Cluster B. Cluster B was associated with less chromosomal aberrations (p=0.004) as detected by SNP array analysis. Pathway analysis of genes differentially methylated between normal tissue, benign tumors, and malignant tumors suggested that abnormal DNA methylation might affect genes involved in cell cycle regulation and tumor morphology. In conclusion, unsupervised clustering yielded two clusters of tumors that differed in driver mutation, methylation pattern, methylation index and malignancy while pathway analysis suggests that aberrant methylation may affect both tumorigenesis and malignant progression.

 

Nothing to Disclose: SB, JC, RM, PS, PH, PB

21158 5.0000 FRI-358 A Global Promoter Methylation Analysis Identifies Malignant Pheochromocytomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Anjana Radhakutty*1, Brenda L Mangelsdorf2, Sophie M Drake2, Dorit Samocha-Bonet3, Arthur Jenkins3, Leonie Heilbronn4, Arduino A Mangoni1, Andrew Rowland1, Malcolm D Smith1, Campbell H Thompson1 and Morton G Burt1
1Flinders University, Adelaide, Australia, 2Southern Adelaide Diabetes and Endocrine Services, Adelaide, Australia, 3Garvan Institute of Medical Research, Sydney, Australia, 4University of Adelaide, Adelaide, Australia

 

Low dose prednisolone (4-10 mg/day) can cause insulin resistance, but its effects on cardiovascular disease are uncertain. Arterial stiffness is a cardiovascular risk marker that is determined by vessel wall structure, autonomic tone and endothelial function. Insulin resistance can increase arterial stiffness acutely by reducing endothelial function and chronically by stimulating atherogenesis. We investigated whether prednisolone-induced insulin resistance is associated with increased arterial stiffness and mechanisms underlying changes in arterial stiffness.

Eighteen subjects with rheumatoid arthritis (6 males, age 64±7 years, BMI 28±5 kg/m2) who had not taken oral glucocorticoids for ≥6 months were studied before and after prednisolone 6 mg/day for 7 days to determine the acute effects of prednisolone. Pre-prednisolone data were compared to 18 subjects (6 males, age 66±7 years, BMI 28±6 kg/m2) with rheumatoid arthritis taking long-term (>6 months) prednisolone (6.5±1.8 mg/day) to assess the chronic effects of prednisolone. Augmentation index (marker of arterial stiffness) and reactive hyperaemia index (marker of endothelial function) were measured before and after a mixed meal (10 kcal/kg, 45% carbohydrate, 15% protein, 40% fat) by applanation tonometry and peripheral artery tonometry respectively. Insulin sensitivity was estimated by the Matsuda index. Sympathetic nervous system activity was estimated from urinary noradrenaline excretion and asymmetric dimethyl arginine (ADMA), an inhibitor of endothelial function, was quantified by liquid chromatography / mass spectrometry.

Matsuda index was lower after acute (3.6±1.1 vs 2.0±1.0, p=0.01) and chronic (3.6±1.1 vs 1.9±1.0, p=0.04) prednisolone. Postprandial augmentation index was lower after acute prednisolone (2962±865 vs 2552 ± 837 %*min, p≤0.001) indicating reduced arterial stiffness, but not in patients on chronic prednisolone (p=0.43). Urinary noradrenaline excretion was lower after acute (93±96 vs 54±34 nmol/6h, p=0.02), but not chronic (p=0.31) prednisolone. A fall in reactive hyperaemia index post-meal occurred in both groups suggesting postprandial endothelial dysfunction, with the fall tending to be lesser in patients on chronic prednisolone (-0.7±0.7 vs -0.4±0.6, p=0.09). The concentration of ADMA was lower in patients on chronic (0.59±0.15 vs 0.51±0.71 µM, p=0.03), but not acute (p=0.24) prednisolone.

In conclusion, acute and chronic low dose prednisolone both reduced insulin sensitivity. However, contrary to our hypothesis this was not associated with increased arterial stiffness. A prednisolone-induced reduction in sympathetic nervous system activity and ADMA (with consequent improvement in endothelial function) may contribute to reduced arterial stiffness in this patient group.

 

Nothing to Disclose: AR, BLM, SMD, DS, AJ, LH, AAM, AR, MDS, CHT, MGB

20792 6.0000 FRI-359 A Mechanistic Determinants of Arterial Stiffness in Patients with Inflammatory Arthritis Exposed to Mild Glucocorticoid Excess 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Daniel K. Langlois1, Michele C. Fritz1, Marc B Bailie2, William Schall1 and Stephen W Hunt III*3
1Michigan State University College of Veterinary Medicine, East Lansing, MI, 2INDS, Ann Arbor, MI, 3Atterocor, Inc., Ann Arbor, MI

 

ATR-101 is a novel small molecule therapeutic in clinical development for the treatment of adrenocortical carcinoma (ACC).  ATR-101 is a selective inhibitor of ACAT1 (acyl coenzyme A:cholesterol acyltransferase).  ACAT1 catalyzes cholesterol ester formation from cholesterol and long-chain fatty acyl-CoA and, in the adrenal cortex, is particularly important in creating a reservoir of substrate for steroid biosynthesis.  Previous studies in healthy dogs have shown that ATR-101 treatment led to rapid, dose-dependent decreases in ACTH-stimulated cortisol levels consistent with ATR-101-mediated inhibition of ACAT1 and disruption of substrate availability for steroid biosynthesis.  In this veterinary clinical study, we assessed ATR-101 activity in naturally-occurring Cushing’s syndrome in dogs.  Cushing’s syndrome in dogs has similarities to the disease in humans in both presentation and incidence (pituitary vs. adrenal causes).  However, diagnosis and treatment are markedly different.  Ten companion dogs with Cushing’s syndrome, due either to pituitary lesions (n=7) or adrenal tumors (n=3), were treated with ATR-101 for 2-4 weeks with each subject receiving 2 different dose levels.  ATR-101 exposure increased with increasing dose level in all subjects.  Exposures were equal to or above those associated with decreased steroidogenesis and other adrenal effects seen in previous studies with healthy animals.  ACTH-stimulated cortisol levels, the primary endpoint for the study, were decreased in 90% of the subjects.  The compound was well-tolerated and no drug-related AEs were reported.  The results of this study provide preclinical proof of concept for ATR-101 as a novel agent for the treatment of endocrine disorders like Cushing’s syndrome in humans.

 

Disclosure: MBB: Consultant, Atterocor, Inc.. SWH III: Chief Scientific Officer, Atterocor, Inc.. Nothing to Disclose: DKL, MCF, WS

21412 7.0000 FRI-360 A ATR-101, a Selective ACAT1 Inhibitor, Decreases ACTH-Stimulated Cortisol Levels in Naturally-Occurring Cushing's Syndrome in Dogs 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Sara G. Creemers*1, Peter M. Koetsveld1, Thomas Papathomas2, Fadime Dogan1, Wouter W. de Herder1, Joseph A M J L Janssen1, Richard A. Feelders1 and Leo J. Hofland1
1Erasmus Medical Center, Rotterdam, Netherlands, 2Department of Pathology, Josephine Nefkens Institute, Erasmus MC-University Medical Center, Rotterdam, Netherlands

 

Introduction
Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. Discrimination of ACCs from adrenocortical adenomas (ACAs) still remains challenging on both imaging and histopathological grounds. High IGF-II expression is associated with malignancy, but shows large variability. In this study, we used the sensitive method of pyrosequencing to investigate whether specific methylation patterns of IGF-II regulatory regions, alone or in combination, could serve as a valuable biomarker in distinguishing ACCs from ACAs.

Methods
Pyrosequencing was used to analyze methylation percentages of five different regulatory regions of IGF-II: the differentially methylated region-0 (DMR0), the differentially methylated region-2 (DMR2), the imprinting control region (ICR, consisting of CTCF3 and CTCF6) and the H19-promoter. Analyses were performed in three different adrenocortical cancer cell lines and in adrenocortical tissue obtained after adrenalectomy: 24 ACCs, 14 ACAs and 11 normal adrenals. Expression of IGF-II and H19 mRNA was assessed by real-time quantitative PCR in control cells, demethylating drug 5’-Aza-2’-deoxycytidine treated adrenocortical cancer cells, as well as in adrenocortical tissues. Methylation patterns in neoplasms were transformed into standard deviation scores based on methylation in normal adrenals. Using Receiver Operating curves, we evaluated which regions showed the best predictive value for ACC diagnosis and determined the diagnostic accuracy of these methylation patterns.

Results
In ACC cell lines, methylation of regulatory regions and IGF-II mRNA expression decreased after treatment with 5’-Aza-2’-deoxycytidine, while H19 mRNA expression increased. In adrenocortical neoplasms, methylation in the H19-promoter and the ICR was significantly higher in ACCs compared to ACAs (p=0.001, p=0.008 respectively). Methylation in the H19 promoter, CTCF3 and the DMR0 were positively correlated with IGF-II expression in ACCs (p<0.05). Methylation in the most discriminating regions distinguished ACCs from ACAs with a sensitivity of 100%, a specificity of 93% and an area under the curve of 0.997±0.005.

Conclusion
Methylation patterns of IGF-II regulatory regions appear to discriminate ACCs from ACAs with very high accuracy, and may therefore be of additional diagnostic value in the assessment of malignancy of adrenocortical tumors.

 

Nothing to Disclose: SGC, PMK, TP, FD, WWD, JAMJLJ, RAF, LJH

20254 8.0000 FRI-361 A The Methylation Pattern of IGF-II Regulatory Regions As a Novel Biomarker to Distinguish Adrenocortical Carcinomas from Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Edra London*1, Christopher Wassif2, Anelia Dafinova Horvath1, Christina Tatsi2, Anna Angelousi3, Alexander Karageorgiadis2, Forbes Porter2 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2NICHD, NIH, 3NICHD, NIH, Athens

 

Introduction: Cortisol producing adenomas (CPAs) and bilateral adrenocortical hyperplasias (BAHs) including primary pigmented nodular adrenocortical hyperplasia disease (PPNAD) and primary macronodular adrenocortical hyperplasia (PMAH) cause ACTH-independent Cushing syndrome (CS). The pathogenesis of these diseases, while not completely understood, shares a link to intracellular PKA signaling and cAMP levels. The concomitant association of cAMP levels with cholesterol and steroid biosynthesis led to the hypothesis that benign cortisol producing tumors display variable aberration of these pathways.

Objective: To identify possible differences in cholesterol biosynthesis among different CS-causing adrenocortical diseases.

Design: 23 patients with CPA, PPNAD or PMAH who underwent adrenalectomy surgery for CS were included in the study. Serum and urinary hormone levels, lipid profiles and anthropometric data were obtained preoperatively. Tumor tissues excised from patients were assayed for total protein, cholesterol and lathosterol content, and analyzed for expression of HMGCR, LDLR, ABCA1, DHCR24, and StARgenes.

Results: CPAs had higher cholesterol and lathosterol levels than PMAH and these levels tended to be higher than the corresponding levels in PPNAD. Lathosterol/cholesterol ratio, an index of cholesterol biosynthesis, was roughly 10-fold higher in CPAs compared to ratios in PMAH and PPNAD tissues. The mRNA expression of the LDLR and HMGCR genes also tended to be higher while ABCA1tended toward lower levels in the CPA compared to the PMAH group.

Conclusion: CPAs displayed characteristics of “cholesterol-starved tissues” when compared to tissues from patients with BAHs (PMAH and PPNAD). CPAs appeared to have increased intrinsic cholesterol production and uptake from the periphery, as well as decreased cholesterol efflux suggesting differences in cholesterol metabolism and trafficking that may underlie mechanistic differences in the source of excess glucocorticoids in these CS subgroups.

 

Nothing to Disclose: EL, CW, ADH, CT, AA, AK, FP, CAS

21899 9.0000 FRI-362 A Cholesterol Biosynthesis and Trafficking in Benign Cortisol-Producing Adenomas Is Enhanced Compared to Other Bilateral Adrenocortical Hyperplasias Causing Cushing Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Rajani Maharjan*, Tobias Akerstrom, Per Hellman and Peyman Bjorklund
Uppsala University, Sweden

 

Adrenocortical carcinoma (ACC) is rare and an aggressive disease with poor prognosis. Activation of the WNT signalling pathway, is the most common aberrance observed in non-syndromic ACC, although only a subgroup of these has been shown to be a consequence of a CTNNB1(encoding β-catenin) activating mutation. β-catenin activation has previously been associated with a decreased survival rate in ACC patients.

In this study 68 tumour DNA were subjected to high resolution SNP array and subsequent copy number variation analysis. The mutational status of ZNRF3 and CTNNB1 were analyzed by Sanger sequencing and cDNA was analyzed by q-PCR to determine expression levels of ZNRF3 and AXIN2. The hypodiploid and polyploid CNV pattern previously observed in ACC were also found in our cohort in a significant number of tumours. Most frequent homozygous deletions were found in ZNRF3 (n=14), LINC00290 (n=8), TENM3 (n=8), and CDKN2A (n=5). However we did not find any RB1deletions in our cohort. Recurrent deletion of locus chr4q34.3-q35.1 (including genes: LINC00290 and TENM3), chr3q13.31 (including genes: LSAMP/LSAMP-AS1, TUSC7, LINC00901) and chr1p36.21 (including genes: PRAMEF1, PRAMEF11, PRAMEF2) were also observed. TARP, SRA1, ABCA13 and PARP8 were the most significantly amplified genes. We found CTNNB1mutations in 9.6% of the tumours, which were mutually exclusive to ZNRF3 deletion. Expression of ZNRF3 in ZNRF3 deleted tumours were markedly reduced in comparison to β-catenin mutated and the tumours without both aberrations. AXIN2 expression was higher in ZNRF3 deleted tumours, but less in comparison to CTNNB1mutated tumours, still indicating activation of the WNT signalling pathway in tumours with ZNRF3 deletion. In conclusion, ZNRF3 homozygous deletions, but not point mutations are frequent genetic events in adrenocortical carcinomas. This can explain the activation of WNT signalling pathway observed in subgroup of ACCs without any CTNNB1 mutations.

 

Nothing to Disclose: RM, TA, PH, PB

21369 10.0000 FRI-363 A Frequent ZNRF3 homozygous Deletions in Adrenocortical Carcinomas with Activated WNT Signalling Pathway 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Nese Akcan*1, Oya Uyguner2, Guven Toksoy2, Firdevs Bas2, Umut Altunoglu2, Sukran Poyrazoglu2, Nurcin Saka2, Ruveyde Bundak2, Hulya Kayserili2 and Feyza Darendeliler2
1Near East University, Faculty of Medicine, Nicosia, Cyprus, 2Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

 

Nonclassical congenital adrenal hyperplasia (NCCAH), which  generally presents with symptoms of androgen excess, is inherited in autosomal recessive manner  with different kind of mutations majorly resulted by micro or macro conversions from pseudogene (CYP21A1P). Recently, predisposition of CYP21A2 gene duplication with p.Q319X for germ line de novo mutations in the next generation has been reported.

AIM: To underline the importance of evaluating complex structure of CYP21A2 in conjunction with sequencing and deletion / duplication analysis tests accompanied by parental investigations in cases with different molecular characteristics

METHODS: Five patients from unrelated families, diagnosed as NCCAH according to their clinical, hormonal or molecular (biallelic or monoallelic mutations) findings, were studied because of their remarkable moleculer analysis results. Sequencing and multiplex ligation-dependent probe amplification (MLPA) were used for deletion / duplication analysis.

RESULTS: Five patients with CYP21A1P and CYP21A2 gene duplications and microconversion are presented.  Although 3 of these patients  had moleculer analysis results  as carrier status; the hormonal  and clinical findings were  consistent with disease phenotype. Two unrelated patients had  CYP21A2 duplication and  point mutations (p.Q319X) similar to their mothers who had normal clinical and hormonal  findings.  The location of p.Q319X mutation is predicted to be on the duplicated allele of the another patient’s father who additionaly carried heterozygous p.V282L, since neither active gene duplication nor p.Q319X was present at his daughter. Heterozygous p.P454S mutation identified in this case was not found in either parent, so allele identity of this de novo occurrence could not be shown. Number of studies in the field addressed that CYP21A2 gene duplication in the presense of p.Q319X mutation predisposes de novo mutations in the offspring. Based on these reports, it could be predicted that p.P454S occurred on the paternal allele therefore at cis position with p.V282L. Another patient had conversion of exon 4 inherited from mother’s allel carrying heterozygous  p. I173N  mutation. This patient also carried  heterozygous p.V282L mutation inherited from father’s allel.

CONCLUSION: Complex structure of CYP21A2 locus requires that sequencing results of patients should be evaluated in conjunction with deletion / duplication analysis tests, further should be accompained  with parental investigations. Sequence analysis of CYP21A2 is complicated with various microconversion events from pseudogene. Therefore care must be taken to include sequencing from multiple sites and seek for agreements with MLPA results.

 

Nothing to Disclose: NA, OU, GT, FB, UA, SP, NS, RB, HK, FD

20867 11.0000 FRI-364 A CYP21A2 Gene Aberrations in Patients with Nonclassical Congenital Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Cornelie D. Andela*1, Janna Marie Hoogendam2, Steven J.A. Van der Werff3, J. Nienke Pannekoek3, Onno C. Meijer3, Mark A. Buchem3, Serge A.R.B. Rombouts3, Roos C. van der Mast3, Nienke R. Biermasz3, Nic J.A. van der Wee3 and Alberto M. Pereira1
1Leiden University Medical Center, Leiden, Netherlands, 2Leiden University, 3Leiden University Medical Center, Netherlands

 

Context: Patients with long-term remission of Cushing’s disease (CD) demonstrate residual psychological complaints. At present, it’s not known how previous exposure to high cortisol levels affects psychological well-being in the long-term, but it is likely that the brain, as a major target area for cortisol, is involved. In previous structural Magnetic Resonance Imaging (MRI) studies in patients with long-term remission of CD we demonstrated abnormalities of brain structure and connectivity, but limited data are available on functional brain abnormalities.

Objective: To examine abnormalities of activation patterns of emotion processing brain circuitry in patients with long-term remission of CD.

Design: A cross-sectional study with an emotional faces task to probe emotion processing circuitry.

Patients and Methods: Reactivity to emotional faces (angry, fearful, sad, happy, neutral) versus a non-emotional control condition (scrambled faces) was examined in 21 patients with long-term remission of CD and 21 healthy controls matched for age, gender and education. Our functional MRI analyses focused a priori on two regions of interest:  amygdala and medial prefrontal cortex (mPFC). Psychological and cognitive functioning and clinical severity were assessed using validated questionnaires.

Results: Patients with long-term remission of CD demonstrated hypoactivation in the mPFC in response to facial expressions relative to controls. No differences were found in the activation of the amygdala. There were no significant correlations between hypoactivation of the mPFC and reported psychopathology and clinical characteristics in the patient group.

Conclusion: We suggest that these findings indicate diminished top-down control of the mPFC over amygdala activation during processing  of emotional stimuli, which together with abnormalities in brain structure may (at least partly) explain the persisting psychological morbidity in patients with CD after long-term remission.

 

Nothing to Disclose: CDA, JMH, SJAV, JNP, OCM, MAB, SARBR, RCV, NRB, NJAV, AMP

19335 12.0000 FRI-365 A Hypoactivation in the Medial Prefrontal Cortex during Processing of Emotional Faces in Patients with Long-Term Remission of Cushing's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Brian G. Keevil*1, Dominic Foley2, Lisa Calton2, James Hawley3 and Laura Owen3
1Univ Hospital of South Manchester, Manchester, United Kingdom, 2Waters Corporation, Wilmslow, United Kingdom, 3University Hospital of South Manchester, Manchester, United Kingdom

 

Aldosterone is a mineralocorticoid steroid hormone which is monitored for the investigation of primary hyperaldosteronism.  Traditionally, aldosterone has been analysed by radioimmunoassay methods.  However, these methods can suffer from a lack of specificity due to the cross reactivity of structurally similar steroid hormones, which results in greater imprecision and inaccuracy.  LC-MS/MS provides a solution to this problem by providing three levels of selectivity; sample preparation, chromatography and MRM mass spectrometry detection. However, LC-MS/MS methods tend to be independently developed, using different calibration materials, extraction techniques and chromatographic conditions that can result in a lack of agreement between different laboratories.

 

Here we evaluate two independently developed LC-MS/MS methods for the quantification of plasma aldosterone.  Method 1 utilizes supported liquid extraction (SLE) with separation on a pentaflurophenyl (PFP) stationary phase, while Method 2 comprises of Waters® Oasis® MAX µElution with separation on a highly efficient C18 stationary phase.  Analysis was performed on a Waters ACQUITY® UPLC with a Waters Xevo® TQ-S mass spectrometer to obtain the optimal sensitivity for both methods.

Direct comparison between the two methods over the range 103 to 3006pmol/L (n = 59) yielded a Deming fit of Method 2 = 1.07(Method 1) - 22.94 with an Altman Bland agreement of -4.9%.  However, when examining low concentration samples over the range of 103 to 248pmol/L the resulting Altman Bland agreement of -16.7%, demonstrated increased negative bias at low concentrations for Method 2 compared to Method 1.  Comparison using Method 1 calibrators to determine samples extracted and analysed using Method 2 conditions (n = 20) yielded a Deming fit Method 2 = 1.02(Method 1) -18.03 and Altman agreement of -10.3%.  The negative bias of Method 2 observed at low concentrations (<250pmol/L) could be an indication of improved specificity of Method 2 at these concentrations through anion exchange SPE sample preparation.  This can be observed in low level sample chromatograms by a reduced background and improved signal to noise ratios.   It is also noted that Method 2 uses an aldosterone-2H4 internal standard, which has the benefit of aldosterone co-elution and reduced deuterium scattering over other commercially available internal standards but conversely increases the risk of isobaric interference i.e. 18-hydrocycorticosterone, therefore highlighting the need for chromatographic separation of these interferences. 

This study highlights the need for a specific aldosterone reference method to ensure that independently developed test procedures demonstrate accuracy and precision across the clinically relevant range.

 

Disclosure: DF: Employee, Waters corporation. LC: Employee, Waters corporation. Nothing to Disclose: BGK, JH, LO

19793 13.0000 FRI-366 A Let's be Specific: An Inter-Laboratory LC-MS/MS Study of Aldosterone in Plasma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Brian G. Keevil*1, James Hawley2, Dominic Foley3, Lisa Calton3 and Laura Owen2
1Univ Hospital of South Manchester, Manchester, United Kingdom, 2University Hospital of South Manchester, Manchester, United Kingdom, 3Waters Corporation, Wilmslow, United Kingdom

 

Measurement of aldosterone using liquid chromatography mass spectometry (LC-MS/MS)  is known to be difficult at concentrations less than 100 pmol/L (36 ng/L) due to non specific interference,  even after some thorough sample clean up procedures. To ensure that this wasn’t a concentration dependant phenomenon, because samples with a higher aldosterone concentration suffer less with this interference, we tested the use of a novel mass spectrometry ionisation source that improves sensitivity compared to the standard electrospray ionisation technique.  The Waters UnisprayTM source works by first spraying the column eluent from the liquid chromatography unit onto a charged pin which facilitates enhanced ion formation.

Serum samples for routine aldosterone analysis with results <100 pmol/L (36 ng/L) were extracted with either supported liquid extraction (SLE) or ion exchange solid phase extraction (IE-SPE).  Analysis was performed on a Waters ACQUITY® UPLC with a Waters Xevo® TQ-S mass spectrometer fitted with a UnisprayTM ionisation source to obtain the optimal sensitivity for both extraction methods.

The limit of quantitation using the UnisprayTM source was 10 pmol/L (3.6 ng/L). compared to 30 pmol/L ( 10.8 ng/L) using electrospray ionisation, thus showing a 3 fold increase in sensitivity over the routine method.  Extracted serum samples using SLE showed significant interfering peaks in the samples with aldosterone concentrations <100 pmol/L (36 ng/L) compared to the samples extracted with IE-SPE. This negated the accurate calculation of results in some samples.

Improving the sensitivity of the mass spectrometer did not improve the interference seen in many samples when SLE was used as the extraction technique. The only way to resolve the interference was to use IE-SPE. The UnisprayTM source did however give a much needed increase in sensitivity that will be useful to improve precision and accuracy in the lower concentration ranges of the assay. Analysis  of aldosterone using LC-MS/MS remains challenging, but sample clean up with IE-SPE before analysis using the UnisprayTM source is a powerful combination, and may prove to be a good approach for the development of a reference method procedure for the measurement of aldosterone

 

Disclosure: DF: Employee, Waters corporation. LC: Employee, Waters corporation. Nothing to Disclose: BGK, JH, LO

19842 14.0000 FRI-367 A A Highly Sensitive Method for Aldosterone Analysis Using LC-MS/MS 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Alaa Al Nofal*1, Irina Bancos1, Khalid Benkhadra1, Asma Javed1, Naykky Maruquel Singh Ospina1, Ekta Kapoor1, Kalpana Muthusamy2, Juan Pablo Brito1, Adina F. Turcu3, Dana Erickson1, Aida N Lteif1, Neena Natt1 and Mohammad Hassan Murad1
1Mayo Clinic, Rochester, MN, 2Olmsted Medical Center, Rochester, MN, 3University of Michigan, Ann Arbor, MI

 

Introduction: Multiple glucocorticoid regimens have been used in the treatment of patients with adrenal insufficiency, yet the effect of such regimens on patient health related outcomes is unknown.

Objective: We performed a systematic review and meta-analysis to study the effect of different glucocorticoid regimens on health related outcomes, including quality of life, in patients with adrenal insufficiency.

Methods: We searched multiple online databases for relevant abstracts and included those studies that evaluated outcomes of interest: quality of life, bone mineral density, number of adrenal crises, final adult height in children, and mortality rate. Risk of bias was assessed using the Cochrane tool for Randomized control trials and the Newcastle Ottawa scale for observational studies.

Results:  The search yielded 2726 references for abstract screening of which 24 studies met our pre-defined inclusion criteria. Of these, 15 assessed the effect of glucocorticoid regimens on patient quality of life; 8 assessed bone mineral density; 3 assessed the number of adrenal crises; none evaluated the effect on mortality or final adult height in children. We found no difference in quality of life scores between patients who received higher doses of glucocorticoid (30 mg/day of hydrocortisone equivalence or higher) and those who received a lower dose of daily replacement (<30 mg/day of hydrocortisone equivalence) (P=0.65). Extended and dual release forms of glucocorticoids appeared to have a more positive impact on quality of life compared to standard release glucocorticoid regimens (P=0.01). The included studies found no correlation between the dose or type of glucocorticoid and adrenal crises. Significant heterogeneity and conflicting results were found in regards to the effect of glucocorticoid regimens on bone mineral density.

Conclusion: The current available evidence suggests that extended release and dual release forms of glucocorticoid may lead to higher quality of life scores compared to once, twice and thrice daily dosing. However, this evidence is not sufficient for decision making and requires verification in a randomized trial.

 

Nothing to Disclose: AA, IB, KB, AJ, NMS, EK, KM, JPB, AFT, DE, ANL, NN, MHM

20457 15.0000 FRI-368 A The Effect of Various Glucocorticoid Replacement Regimens on Health Outcomes in Patients with Adrenal Insufficiency: A Systematic Review and Meta-Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Rafael Haikal Abduch*1, Ana Carolina Bueno1, Leticia F. Leal1, Marcelo M. Cavalcanti1, Silvia R. Brandalise2, Maria José Masterallo3, José A. Yunes2, Carlos Eduardo Martinelli Jr.1, Carlos A. Scrideli1, Luiz G. Tone1, Silvio Tucci1, Ayrton C. Moreira1, Margaret De Castro1 and Sonir Roberto Rauber Antonini1
1Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 2Boldrini Children's Center, Campinas, Brazil, 3Boldrini Children’s Center, Campinas, Brazil

 

Background: overexpression of the oncogene Yes-Associated-Protein-1 (YAP1), a Hippo pathway target, was recently associated with increased cell proliferation in some human cancers. However, its potential role on adrenal tumorigenesis is still unknown. YAP1is a potential target of Wnt/beta-catenin pathway, which play an important role in adrenocortical tumors.  

Objectives: to evaluate the role of YAP1in adrenal tumorigenesis and its potential interaction with the Wnt/beta-catenin pathway.

Patients and methods: 31 pediatric patients with adrenocortical tumors (77% females; median age: 23 months [5-185]), 10 normal adrenal cortices (controls) and the H295 tumor cell line were studied. Association between YAP1mRNA expression and clinical, biochemical,  pathological and patient’s outcome data were evaluated. To analyze the interaction between YAP1 and Wnt/beta-catenin pathway, H295 cell line, which harbors the beta-catenin p.Ser45Pro mutation, was treated with a TCF/beta-catenin complex antagonist (PNU-74654). YAP1 expression was evaluated by qPCR and Western blot. Statistics: Mann-Whitney test, Kaplan–Meier curves and log-rank test.

Results: YAP1 mRNA expression was detected both in normal adrenal as well as in adrenal tumors. A significant positive association was found between YAP1 mRNA overexpression and death (p=0.02), and tumor recurrence or metastasis (p=0.002). Kaplan-Meier curve and log-rank test showed that higher YAP1expression is associated with lower survival (p=0.02). In vitro, TCF/beta-catenin complex inhibition, induced by PNU-74654 treatment resulted in decreased cell viability along with decreased YAP1 protein expression of 56.2%, 42.1%, and 19.1% at 50µM, 100µM e 200µM, respectively, 48 hours after treatment. 

Conclusion: overexpression of the oncogene YAP1 appears to be a marker of poor prognosis of pediatric patients with adrenocortical tumors. Higher expression of YAP1 was associated with lower survival. In vitro, YAP1, a target of the Hippo pathway, is also a Wnt/beta-catenin target gene. Our results suggest that YAP1 may be an interesting target to treat invasive or recurrent adrenal tumors.

 

Nothing to Disclose: RHA, ACB, LFL, MMC, SRB, MJM, JAY, CEM Jr., CAS, LGT, ST, ACM, MD, SRR

20510 16.0000 FRI-369 A Unraveling the Expression of the Oncogene YAP1, a Wnt/Beta-Catenin Target, in Adrenal Tumors and Its Association with Poor Outcome in Pediatric Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Segolene Hescot*1, Maryse Guerin2, Severine Trabado3, Thierry Huby2, Eric Baudin4 and Marc Lombes5
1INSERM U693, Le Kremlin Bicetre, France, 2INSERM ICAN U1166, Paris, France, 3APHP CHU Bicêtre, Le Kremlin Bicetre, France, 4Institut Gustave-Roussy, Villejuif, France, 5Inserm U1185, Le Kremlin-Bicêtre, France

 

Mitotane (o,p’-DDD), the most effective treatment of advanced adrenocortical carcinoma (ACC), is a lipophilic drug that accumulates into circulating lipoprotein fractions and high lipid-containing tissues.

The aim of our study was to evaluate the impact of serum lipoproteins on mitotane efficiency in human adrenocortical H295R cells.

LDL, HDL and lipoproteins deficient sera (LPDS) were prepared from fetal calf serum (FCS) using separation by ultracentrifugation. H295R cells were then cultured in media containing either lipoproteins (FCS, LDL only or HDL only) or in lipid-free medium with LPDS, and treated with 50 µM o,p’DDD for 48h. Proliferation, apoptosis, expression of genes and proteins involved in steroidogenesis and mitochondrial respiratory chain were analyzed to evaluate o,p’DDD efficiency. Interestingly, as demonstrated by RTqPCR analysis, we showed that o,p’DDD drastically reduced by 15 fold factor StAR and CYP11A1 transcripts in LPDS grown H295R cells compared to other media (reduced by 3 fold factor) and also seriously compromised CYP11A1 protein expression whereas mitotane in all other media had no substantial effect. Dose-dependent curves demonstrated that mitotane in lipid-free medium exerts significant higher anti-proliferative effects than in the presence of lipoprotein fractions. Treatment with 50 µM Mitotane for 48h was unable to induce H295R cell apoptosis but led cell death when H295R cells were exposed to mitotane in the absence of lipoproteins as assessed by caspase 3/7 activation and anti-apoptotic BCl2 expression. In lipid-free medium, mitotane more efficiently reduced COX2 gene expression (encoding a subunit of respiratory chain complex IV) by 85% as compared to mitotane in the presence of lipoprotein fractions (-25%). Finally, relationship between pharmacological actions of mitotane and its intracellular contents is currently under investigation.

It is well established that mitotane impacts plasma lipoproteins composition. Our findings provide first evidence that, reciprocally, lipoproteins composition modulates cytotoxic and anti-steroidogenic properties of mitotane.

 

Nothing to Disclose: SH, MG, ST, TH, EB, ML

21086 17.0000 FRI-370 A Pharmacological Actions of Mitotane in H295R Cells Are Drastically Enhanced By Lipoproteins Deprivation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Yuto Yamazaki*1, Yasuhiro Nakamura1, Fumitoshi Satoh2, Yoichi Arai2, Sanae Midorikawa3, Yutaka Oki4, Satoshi Baba4 and Hironobu Sasano5
1Tohoku University Graduate School of Medicine, Sendai, Japan, 2Tohoku University Hospital, Sendai, Japan, 3Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan, 4Hamamatsu Univ Sch of Med, Hamamatsu, Japan, 5Took University School of Medicine, Sendai, Japan

 

Adrenocortical carcinoma (ACC) is a rare but highly malignant neoplasm with marked histological heterogeneity. Ki67 labeling index (Ki67 LI) is currently considered one of the most effective diagnostic markers in ACC not only in differential diagnosis from adenoma with 2.5-5% as cut off value but also in predicting postoperative clinical course. For instance Ki67 LI also is proposed as a prognostic marker by the European Network for the Study of Adrenal Tumors (ENSAT) with classifying post-operative ACC patients with complete resection into two groups; high risk (Ki67 LI>10%), and low/intermediate risk (Ki67 LI<10%). However, measurement of Ki67 LI has by no means standardized in ACC. Therefore In this study, we studied Ki67 LI in 17 ACC cases using both human eyeball and digital image analysis. We also compared Ki67 LI obtained by selecting "hot spot" and average of the whole tumor. Ki67 LI studied in hot spots was significantly higher than that in average by both eyeball (17.3% vs 6.3%; p<0.05) and digital image analysis (17.3% vs 5.3%; p<0.05). The value obtained by digital image analysis was significantly correlated with that obtained by human eyeball analysis in both hot spot (r=0.7397; p<0.0001) and average (r=0.6607; p<0.05). These results suggest that digital image analysis could be superior to eyeball in terms of time-cost performance in ACC with intratumoral heterogeneity, but it requires further improvement including its over-estimation of the value by counting mesenchymal cells and nuclear segmentation in high cell density area.

 

Nothing to Disclose: YY, YN, FS, YA, SM, YO, SB, HS

20378 18.0000 FRI-371 A Standardization of Ki67 Labeling Index in Adrenocortical Carcinoma; Eye Ball Versus Digital Image Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Yasuhiro Nakamura*1, Takashi Maekawa2, Saulo JA Felizola2, Kazue Ise2, Elise P Gomez-Sanchez3, Celso E. Gomez-Sanchez4, Fumitoshi Satoh1 and Hironobu Sasano2
1Tohoku University Hospital, Sendai, Japan, 2Tohoku University Graduate School of Medicine, Sendai, Japan, 3Univ of Mississippi Med Ctr, Jackson, MS, 4Univ of Mississippi Med Ctr, Madison, MS

 

Introduction

Cytochrome P450 11B2 (CYP11B2) plays a pivotal role in aldosterone synthesis in the zona glomerulosa (ZG) and cytochrome P450 11B1 (CYP11B1) and cytochrome P450 17A1 (CYP17) in cortisol synthesis in the zona fasciculata (ZF). However, CYP11B1 and CYP17 have been reported in aldosterone-producing adenoma (APA) but it has remained unclear whether aldosterone and cortisol are synthesized in the same APA tumor cells or not.

Materials and Methods

We examined the status of CYP11B1/CYP11B2 and CYP11B2/CYP17 in 27 APA cases using immunofluorescence staining and semi-quantitative evaluation of the results.

Results

Tumor cells negative for CYP11B1/B2 or negative for CYP11B2/ 17 were predominant in APA. In these double-negative tumor cells, the average size of each tumor cell was significantly greater than other cell types, suggestive of quiescent nature of these lipid rich cells. The tumor cells co-expressing CYP11B1/B2 (Hybrid cells type A) and CYP11B2/17 (Hybrid cells type B) were also identified. The area and size of the individual hybrid cell were significantly smaller than the other cell types. No significant correlations were detected between clinicopathological factors and the patterns of these positive cells in APA cases examined.

Conclusion

The presence of hybrid cells type A indicated that CYP11B1 is also involved in aldosterone biosynthesis in some APA cells, while hybrid cells type B indicated that cortisol, aldosterone and 18-oxocortisol are produced in the same tumor cells of APA.

 

Nothing to Disclose: YN, TM, SJF, KI, EPG, CEG, FS, HS

18671 19.0000 FRI-372 A CYP11B2/B1 and CYP11B2/CYP17 Double Positive Hybrid Cells in Adrenal Aldosterone-Producing Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Fatma Ela Keskin*, Hande Mefkure Ozkaya, Ozlem Haliloglu and Pinar Kadioglu
Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey

 

Objective: The aim of this study was to reveal the female sexual dysfunction, quality of life and depression status in female patients with Cushing Syndrome.

Materials and Methods: Twenty nine female patients with Cushing Syndrome followed in Cerrahpasa Medical School, Endocrinology and Metabolism out-patient clinic and age and body mass index-matched 30 healthy female subjects were included in the study. Sexual functions and status of depression in both patients and control groups were evaluated by using the Female Sexual Function Index Form (FSFI) and the Beck Depression Inventory (BDI). Quality of life was evaluated by using the Short Form Health Survey instrument (SF36). Blood was obtained to determine prolactin (PRL), luteinizing hormone (LH), follicle-stimulating hormone (FSH), progesterone, dehydroepiandrosterone-SO4 (DHEA-SO4), total testosterone, free testosterone, 17α hydroxyprogestrone (17-OH P), androstenedione, estradiol (E2), cortisol in the early follicular phase before 10:00 a.m. in subjects.

Results: The SF36 total score in female Cushing Syndrome and controls were 89.7 ± 13.4 and 89.6 ± 14.7, respectively (p=0.92). The FSFI total score and desire, arousal, orgasm, and satisfaction domains were not different between the groups (p=0.51, p=0.33, p=0.20, p=0.61, p=0.59, respectively). The pain domains of FSFI in patients were significantly lower than controls (p=0.05). There was no difference between biochemically controlled and uncontrolled patients with Cushing Syndrome with respect to FSFI and SF36 scores (p=0.48, p=0.1). BDI scores of patients were significantly higher than control subjects (p=0.007). LH, estradiol, DHEA-S04 levels were significantly lower than controls (p=0.03, p=0.03, p=0.05, respectively). Cortisol and 17-OH P levels were higher in patients than in controls (p=0.006, p=0.05). The levels of other hormones were not different between groups.

Conclusions: This study showed that SF36 and total FSFI scores are not decreased in Cushing Syndrome, except, pain domain of FSFI is lower than healthy subjects. Hormone levels that are related to sexual dysfunctions are lower in Cushing patients. High rates of pain associated with sexual intercourse in patients with Cushing Syndrome may be related with low sex hormone levels. Additionally, patients with Cushing Syndrome have higher depression rates.

 

Nothing to Disclose: FEK, HMO, OH, PK

21045 20.0000 FRI-373 A Is Cushing Syndrome Associated with Female Sexual Dysfunction? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Masako Hatano*1, Toshihide Mimura2, Takuya Awata2 and Shigehiro Katayama3
1Saitama Medical University, Saitama, Japan, 2Saitama Medical University, 3Saitama Med Univ, Saitama, Japan

 

Introduction

As all the details of hepatitis B virus (HBV) have been elucidated, reactivation of HBV and associated de novo hepatitishave been recently recognized in patients with a history of  HBs antigen (Ag)-negative and HBc or HBs antibody (Ab)-positive HBV infection who were treated by immunosuppressive or molecular targeting drugs.   So far, there were no reports demonstrating steroid-related HBV reactivation in patients with hypoadrenalism, who had corticosteroid-replacement therapy within the normal dosage.  In this study, we investigated the effect of corticosteroid replacement on HBV reactivation in patients with hypoadrenalism. 

Methods

A total of 72 patients (35 men and 37 women) were replaced with corticosteroid between January 2013 and June 2014 for hypopituitarism, primary and postoperative hypoadrenalism  were assigned to the replacement group.  As acontrol, 204 patients with rheumatic and connective tissue diseases (77 men and 197 women) treated with steroids were assigned to the treatment group. 

HBs Ag, HBs Ab, and HBc Ab were determined in all patients. In HBs Ag-negative and HBs or HBc Ab-positive patients, the amount of HBV DNA was measured using real-time PCR.  HBV DNA positive patients,  who were seroconverted to positive during steroid therapy, were defined as the HBV DNA positive seroconversion group. HBS DNA>2.5 log copies/ml was considered to be positive.

Results

Age was not different between two groups (54±18.3 years for the replacement group and 62±15.1 years for the treatment group).  Daily steroid dosage administered (equivqlent to prednisolone) differed significantly between two groups ( 4.2±1.8 mg vs.7.2 ± 6.3mg,p=0.0001).  

The HBs Ag-negative and HBs or HBc Ab-positive patients were11 in the replacement group (15.0%) and 47 patients in the treatment group (16.5%), with no difference in the percentage.  The HBV DNA positive seroconversion was identified in 5 patients of the treatment group (2.4%), while all of 11 patients with hypoadrenalism were negative in HBV-DNA. 

Discussion and Conclusions

HBV contains a glucocorticoid responsive element,  the same base sequence as glucocorticoid receptors, in the origin site of replication of viral genes.  This characteristically allows steroids to amplify HBV directly, raising concerns over HBV reactivation by steroidadministration.  In this study, we fortunately did not observe HBV-reactivated case by the corticosteroid replacement for hypoadrenarism.  The reactivation response of HBV may differe depending on whether serum levels of corticosteroid reach to an excessive pharmacological or optimal physiological level by the therapy.  These results suggest that corticosteroid replacement therapy for adrenocortical insufficiency might be safe in relation to HBV reactivation.  However, we should keep our mind on a subtle risk and check HBV reactivation if once patients’ liver function test shows any abnormalities.

 

Nothing to Disclose: MH, TM, TA, SK

19179 21.0000 FRI-374 A Is HBV Reactivated with Corticosteroid Replacement in Patients with Adrenocortical Insufficiency ? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Nina Kogekar1, Kenneth Haines1, Alexander Kirschenbaum2, Shen Yao3, Aarti Ravikumar4, William B Inabnet III4 and Alice C Levine*4
1Icahn School of Medicine at Mount Sinai, 2Mount Sinai School of Medicine, New York, 3Mount Sinai School of Medicine, 4Icahn School of Medicine at Mount Sinai, New York, NY

 

Background: Post-gonadectomy induced adrenal cortical neoplasia has been well described in neutered ferrets and certain mouse strains. The majority of these neoplasms demonstrate elevated expression of luteinizing hormone/human chorionic gonadotropin receptor (LH/hCGR), as well as GATA-4, a transcription factor involved in the differentiation of gonadal and other tissues.  Neutered ferrets can develop large adrenal tumors and even adrenal cortical carcinomas (ACC).  Interestingly, the ACCs completely regress with medical castration therapy using GnRH agonists. However, there are no known studies that have systematically examined LH/hCGR and GATA-4 expression in human adrenal cortical neoplasia using immunohistochemistry.

Hypothesis: Human adrenal neoplasms, including ACC, express LH/hCGR and GATA-4.

Materials & Methods: Archival adrenal tissues were obtained for immunohistochemical staining for LH/hCGR and GATA-4. Cases stained were: 4 primary ACC, 2 liver metastases of ACC (one from the same patient as one of the primary ACC), 5 adrenal adenomas, 2 bilateral macronodular adrenal hyperplasia (BMAH), 1 adrenal mass consisting of adrenal rest tissue in a patient with untreated congenital adrenal hyperplasia (CAH; 21 hydroxylase deficiency), and 1 normal testis tissue (positive control). Slides were reviewed in a blinded fashion by three independent observers.

Results: In the positive control normal testis tissues, cytoplasmic LH/hCGR expression was observed in the Leydig cells. Cytoplasmic LH/hCGR expression was also demonstrated in the hyperplastic tissue between nodules in BMAH. Cytoplasmic LH/hCGR expression was observed in all cases of adrenal cortical carcinomas, including metastases, though there was considerable variation between cases. All adrenal adenomas had cytoplasmic LH/hCGR expression with some adenomas also demonstrating membrane expression. Cytoplasmic LH/hCGR expression was also observed in the adrenal rest tissue from the patient with untreated CAH.  In all cases, negative internal controls for LH/hCGR expression included vascular smooth muscle tissue as well as the capsule of the adrenal gland. In general, GATA-4 had a similar cytoplasmic expression pattern to LH/hCGR in these tissues. A notable exception to this was seen in the positive control normal testis tissue, where nuclear GATA-4 expression was observed in the spermatids and Sertoli cells.

Conclusions:  Markers of gonadal differentiation including LH/hCGR and GATA-4 were expressed in adrenal cortical adenomas, BMAH, carcinomas and metastatic ACC lesions.  This may have potential therapeutic implications.

 

Nothing to Disclose: NK, KH, AK, SY, AR, WBI III, ACL

19998 22.0000 FRI-375 A Luteinizing Hormone/Human Chorionic Gonadotropin Receptor and GATA-4 Expression in Human Adrenal Cortical Neoplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Roberto Salvatori*1, Anthony DelConte2, Eliza B. Geer3, Ted Koziol4 and Diane Jorkasky5
1Johns Hopkins University, Baltimore, MD, 2Saint Joseph’s University, Philadelphia, PA, 3Icahn School of Medicine at Mount Sinai, New York, NY, 4Cortendo AB, Radnor, PA, 5University of California San Francisco, San Francisco, CA

 

Endogenous Cushing´s syndrome (CS) is a rare but serious and potentially lethal disorder with an estimated incidence of 2-3 cases per million population persons per year and a prevalence of 30-60 cases per million. Incompletely controlled disease results in ≥5-fold increased mortality, mainly due to metabolic and cardiovascular complications. Racemic ketoconazole, an antifungal agent that at higher dosages reduces adrenal steroid production, is a commonly used off-label drug for the treatment of CS. Toxicity can be significant at higher doses, including liver damage. Cortendo AB is developing levoketoconazole, the single 2S,4R enantiomer of ketoconazole, as an investigational new drug for the treatment of cortisol hypersecretion. Levoketoconazole is purified from racemic ketoconazole and is hypothesized to provide better safety and efficacy than racemic ketoconazole. This study is currently enrolling patients and is the first clinical trial investigating the safety and efficacy of levoketoconazole in patients with endogenous CS. This is a single-arm, open-label, dose titration study to assess efficacy, safety, tolerability, and pharmacokinetics, and to identify the minimally effective and maximally tolerated doses of levoketoconazole in patients with CS. The primary study objective is to evaluate ascending doses of levoketoconazole, in order to identify the range of effective and safe doses that reduce mean 24-hour-urinary free cortisol (UFC) levels to less than or equal to the upper limit of normal (ULN) range of the assay at month 6 of the maintenance phase (with no prior dose increase). Patients aged ≥18 years with confirmed persistent or recurrent CS (with or without previous therapy) or newly diagnosed disease, if they are not candidates for surgery, will be included. After screening, the 3 treatment phases are: Dose Titration; Maintenance (6 months at therapeutic dose); and Extended Evaluation (6 months of continued treatment after Maintenance). Once the therapeutic dose is achieved (as confirmed by UFC), patients will enter the Maintenance phase and return monthly for 6 months for evaluation of efficacy (by UFC measurements), and clinical, safety, metabolic, quality of life, and pharmacokinetic assessments. During the Extended Evaluation phase, patients will return every 3 months and have interim laboratory evaluations. The proportion of responders at 6 months in the Maintenance phase will be estimated along with corresponding 95% confidence intervals (CIs). If the lower bound of the 95% CI is ≥20% in the intent-to-treat population, levoketoconazole will be considered an effective new medical therapy for the treatment of CS.

 

Disclosure: AD: Consultant, Cortendo AB. TK: Employee, Cortendo AB. DJ: Consultant, Cortendo AB. Nothing to Disclose: RS, EBG

20580 23.0000 FRI-376 A An Open-Label Study to Assess the Safety and Efficacy of Levoketoconazole (COR-003) in the Treatment of Endogenous Cushing's Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 354-376 5905 1:00:00 PM Adrenal Tumors, Glucocorticoid Regulation and Action Poster


Chao Xu*1, Kexi Zha2, Furong Wang3, Xiaowen Zhen4, Ling Gao5 and Jiajun Zhao5
1Shandong Provincial Hospital affiliated to Shandong University, Department of Endocrinology and Metabolism, China ;, Jinan, Shandong, 2Shanghai Second People's Hospital, 3Shandong University of Traditional Chinese Medicine, 4Shandong Provincial Hospital affiliated to Shandong University, 5Shandong Provincial Hospital affiliated to Shandong University, Jinan, China

 

Background:Population-based studies have demonstrated that subclinical hypothyroidism (SCH) is an independent risk factor for atherosclerosis (OR=1.9). Although some studies have demonstrated that total cholesterol and LDL-C levels are elevated in patients with SCH, others have not shown any effect of SCH on these lipid measurements. Therefore, the association between SCH and atherosclerosis cannot be entirely explained by dyslipidemia accompanied with SCH. Lipid peroxidation also plays an important role in the development of atherosclerosis. In this study, we aimed to evaluate the oxidation stress in SCH patients.

Subjects and Methods: Hydroxy-octadecadienoic acids (HODEs) and hydroxyl-eicosatetraenoic acids (HETEs) are considered the most reliable oxidative biomarkers. The concentrations of HODEs and HETEs both in LDL and in plasma were examined in euthyroid (n=10), mild SCH (n=10), and significant SCH (n=10) subjects. Then, we analyzed the association among these biomarkers, extent of atherosclerosis as indicated by carotid intima-media thickness (IMT), and SCH. In addition, serum gp91phox, the catalytic core of NADPH oxidase, is a systematic oxidative stress biomarker. We further determined the concentration of gp91phoxwith ELISA in 13 newly diagnosed SCH patients with normal LDL-C (0.5-3.36 mmol/L) levels, 14 newly diagnosed SCH patients with high LDL-C(>3.36 mmol/L) levels and 12 healthy controls.

Results: Among all subjects, a linear and significant positive correlations were identified between TSH and mean-IMT after adjustment for confounding factors (r=0.480, P=0.018). The concentrations of HODEs (both 9-HODE and 13-HODE) in LDL increased in thickened IMT group than normal IMT group (p = 0.017 and 0.015, respectively). HODEs in LDL were also positively associated with mean-IMT. Moreover, the concentrations of HODEs and HETEs increased obviously in significant SCH patients compared to euthyroid subjects, while there was no difference between mild SCH and euthyroid group. Both 9-HODE (r=0.376, p=0.041) and 13-HODE (r=0.447, p=0.013) in LDL were linearly and positively correlated with TSH. Additionally, oxidative stress was also confirmed by the increased concentration of serum gp91phoxin SCH patients with high LDL-C levels. Gp91phox is positively correlated with LDL-C (r=0.57, P<0.05) and TSH (r=0.61, P<0.05) in SCH patients with high LDL-C levels. Notably, after adjustment for LDL-C levels, gp91phox is still positively correlated with TSH(r=0.57, P<0.05).

Conclusions: Our findings showed that lipid peroxidation was markedly enhanced in SCH patients, which might be associated with high level of oxidative stress. Our study suggested that qualitative as well as quantitative changes in serum lipids resulting from SCH may add to atherosclerosis risk. Therefore, we suggest monitoring of oxidant status and lipid levels besides TSH levels in SCH patients.

 

Nothing to Disclose: CX, KZ, FW, XZ, LG, JZ

PP23-1 21575 1.0000 FRI-055 A LDL from the Patients with Subclinical Hypothyroidism Show Increased Lipid Peroxidation and Oxidative Stress 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Wei-Ling Chiu*1, Elif Ilhan Ekinci1, Zhong Xian Lu2, Ken Sikaris2, Que Lam1, Intissar Bittar1, Karey Cheong1, Nick Crinis1 and Christine A Houlihan1
1Austin Health, Melbourne, Australia, 2Melbourne Pathology, Collingwood, Melbourne, Australia

 

Background:

The aim of antithyroid drug treatment of hyperthyroidism due to Graves’ disease in pregnancy is to control maternal hyperthyroidism while minimizing risk of fetal hypothyroidism.  In contrast to other common thyroid conditions in pregnancy where TSH is the treatment target, fT4 is the main target in Graves’ Disease (1, 2). Current guidelines recommend maintaining “free T4 (fT4) values at or just above the upper limit of normal” using trimester-specific fT4 values, or in their absence to use reference ranges for non-pregnant patients (1, 2). 

Aim:To determine trimester-specific fT4 reference intervals for common immunoassays used in Australia.

Method:

Healthy, thyroid-peroxidase antibody negative women with singleton pregnancy ≤13 weeks gestation were followed prospectively throughout pregnancy with samples collected at Trimester-1 (T1), Trimester-2 (T2), Trimester-3 (T3), and postpartum (PP).  Serum fT4 from the same group of women were measured by all four immunoassays: Beckman DXI800, Roche e602, Abbott Architect and Siemens Centaur. Reference intervals (RIs) were presented as 95% Confidence Intervals (calculated as mean±2SD).

Results: 

There were 118 women at T1 (11.8±0.2) (mean±SE weeks gestation), 78 at T2 (24.4±0.3), 63 at T3 (35.9±0.3) and 73 at PP (13±0.4 weeks postpartum).

Within each assay, there was a 15-20% decrease in fT4 at T2 and T3 compared to T1 (p<0.001). Between assays, significant differences were present at all time-points (ANOVA p<0.001).  At each time-point, the Beckman assay was approximately 30% lower than the Roche and Abbott assays, and 43% lower than the Siemens assay.  The Roche and Abbott assays gave similar results.

The RIs for the Beckman, Roche, Abbott and Siemens assays were:

5.9-15.4pmol/L, 9.6-20.6pmol/L, 10.3-18.7pmol/L and 12.7-21.2pmol/L, respectively, at T1;

4.9-11.3pmol/L, 8.6-16.2pmol/L, 9.4-14.8pmol/L and 11.5-17.7pmol/L, respectively, at T2;

4.5-11.1pmol/L, 8.2-15.6pmol/L, 9.1-14.8pmol/L and 11.8-18.0pmol/L, respectively, at T3; and

5.6-15.0pmol/L, 9.5-21.7pmol/L, 9.4-16.8pmol/L and 11.0-20.9pmol/L, respectively, at PP.

Conclusion:

Both gestation and assay method had a significant influence on fT4 results in pregnant women.  Knowledge of trimester and assay specific reference intervals assists in optimizing antithyroid drug therapy in pregnancies affected by Graves’ disease.

 

Nothing to Disclose: WLC, EIE, ZXL, KS, QL, IB, KC, NC, CAH

18399 3.0000 FRI-057 A Comparison of Four Immunoassays for Measurement of Free Thyroxine (fT4) Levels in Pregnancy: Which Assay Do You Use in Graves' Disease? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Ichiro Horie*, Takao Ando, Misa Imaizumi, Toshiro Usa and Atsushi Kawakami
Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan

 

Background

Hyponatremia is a well known electrolyte abnormality seen in hypothyroidism. In contrast it is not well known if hypothyroidism causes hyperkalemia.

Methods

We studied retrospectively 108 Japanese patients with thyroid carcinoma undergone radioiodine therapy by the standard protocol of levothyroxine withdrawal at Nagasaki University Hospital since 2009 to 2013. Blood samples analyzed were at euthyroid status just before levothyroxine withdrawal and at hypothyroid status a week prior to take I-131. Frequency of hyperkalemia (K ≥ 5 mEq/L) and its associations with patient’s age, serum levels of sodium (Na), creatinine (Cr), free T4 and TSH were studied.

Results

Five of 108 (4.6 %) patients developed hyperkalemia. Mean level of serum K (mEq/L) in acute hypothyroidism was significantly higher than those at euthyroid status (4.23 ± 0.50 vs. 4.09 ± 0.34, p < 0.001). At acute hypothyroid status, serum K values significantly correlated with age (r = 0.27, p = 0.004), serum levels of Na (r = -0.38, p < 0.001) and Cr (r = 0.26, p = 0.007), and estimated glomerular filtration rate (r = -0.34, p < 0.001), but did not correlated with free T4 (r = -0.004, p = 0.97) and TSH (r = -0.06, p = 0.56). Although the serum K levels in hypothyroid status (Hypo-K) showed a weak correlation with the serum K levels in euthyroid status (Eu-K) (r = 0.29, p = 0.003), the Hypo-K showed a strong correlation with the remainder after subtracting Eu-K from Hypo-K, which we defined as ΔK (r = 0.77, p < 0.001). Thus, ΔK seems to be a stronger contributing factor to the development of hyperkalemia in hypothyroid patients undergoing radioiodine therapy. Elevation of serum K > 0.5 mEq/L in hypothyroidism (ΔK > 0.5 mEq/L) was associated with patient’s age over 60 years (OR = 4.66, p = 0.026) and also associated with the use of angiotensin-II receptor blocker or angiotensin-converting enzyme inhibitor (OR = 3.53, p = 0.033) among patient’s age over 60 years in multivariate analysis.

Conclusions

Acutely hypothyroid patients undergoing withdrawal of a thyroxine replacement for radioiodine therapy may develop symptomatic hyperkalemia. Patients over 60 years old and/or under medical treatment with renin-angiotensin-aldosterone inhibitors in particular may have a greater risk of developing hyperkalemia, even if their serum K level is not high before levothyroxine withdrawal.

 

Nothing to Disclose: IH, TA, MI, TU, AK

18676 6.0000 FRI-060 A Risk Factors for Hyperkalemia in Acutely Hypothyroid Patients Undergoing Thyroxine Withdrawal before Radioiodine Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Ronny Lesmana*1, Toshiharu Iwasaki2, Yuki Lizuka3, Noriaki Shimokawa2 and Noriyuki Koibuchi4
1Universitas Padjadjaran, Bandung, Indonesia, 2Gunma Univ Grad Sch of Med, Maebashi, Japan, 3Gunma Univ Grad Sch of Med, Integrative Physiology, Japan, Maebashi, Japan, 4Gunma Univ Grad Sch of Med, Gunma, Japan

 

Aerobic training facilitates oxidative phosphorylation and glycolysis of skeletal muscle. Thyroid hormone (TH) also facilitates such metabolic events. However, TH involvement to regulate metabolic rate during aerobic training in skeletal muscle is remain unclear. Thus, we studied whether TH signaling pathway is activated and regulated by aerobic training. We have previously shown that both aerobic and anaerobic training groups suppressed TSH level during the exercise. Interestingly, only aerobic training group  increased significantly of TH receptor (TR)β1 mRNA expression, protein levels and improved responsiveness of several TH target genes to TH. Among several TH target genes examined, aerobic exercise potentiated significantly the responsesiveness of Na⁺/K⁺ATPaseβ1 gene to T3. In the present study, we want to identify novel of thyroid hormone response element (TRE) in Na⁺/K⁺-ATPaseβ1. To confirm predictive TRE in Na⁺/K⁺-ATPaseβ1 was recruited and bind to TR, HA-TRβ1 was transfected into L6 myoblast-derived clonal cells and treated with T3 (100 nM) for 10 min, then DNA extracts was used for chromatin immunoprecipitation assays (ChIP). To confirm whether predictive TRE of Na⁺/K⁺-ATPaseβ1 gene was a functional TRE, we generated Na⁺/K⁺-ATPaseβ1-LUC containing predicted TRE sequences, transfected into L6 cells and treated in the present or absent of T3 (100 nM, 16 h) then luciferase activity was measured by reporter gene assays. We observed that TRβ1 bound to the nucleotide sequence that is similar to typical TRE in promoter region of Na⁺/K⁺-ATPaseβ1 gene. Reporter gene assay also showed that the promoter region functions as a novel TRE in L6 cells. In conclusion, existence of functional TRE in Na⁺/K⁺ATPaseβ1 may partly explained underlying mechanism of aerobic exercise increased response and sensitivity Na⁺/K⁺ATPaseβ1 to T3. Such changes in TH homeostasis may contribute the metabolic adaptation in skeletal muscle and its performance during physical training.

 

Nothing to Disclose: RL, TI, YL, NS, NK

19327 7.0000 FRI-061 A Aerobic Training Increases Responsiveness of Na+/K+ATPaseB1 Gene to Thyroid Hormone in Rat Skeletal Muscle 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Gabor Wittmann*1, Petra Mohacsik2, Balazs Gereben2 and Ronald M Lechan1
1Tufts Medical Center, Boston, MA, 2Institute of Experimental Med, Budapest, Hungary

 

Thyroid hormone (TH) enters the brain across the blood-brain-barrier via TH transporters expressed in brain endothelial cells.  Two TH transporters, organic anion-transporting polypeptide 1c1 (OATP1c1) and monocarboxylate transporter 8 (MCT8), have been described to account for 90% of total TH uptake into the mouse brain (1).  Residual TH uptake may occur by means of lower affinity TH transporters present at the blood-brain or blood-cerebrospinal fluid barrier, such as L-type amino acid transporter 1 (LAT1).  We previously reported that bacterial endotoxin (LPS) administration robustly decreases OATP1c1 and MCT8 mRNAs in brain endothelial cells, whereas their expression increases markedly above control levels during the recovery phase from endotoxemia (2).  Here, we studied the effect of LPS (2.5µg/g body weight, ip) on LAT1 mRNA in the forebrain of male Sprague-Dawley rats using in situ hybridization.  LAT1 mRNA in blood vessels decreased at 2h, and was rarely detected in vessels by 9h after LPS injection.  LAT1 mRNA in vessels remained below control levels at 24h after LPS, but increased markedly above control levels by 48h.  LPS did not affect LAT1 mRNA in neurons and in the choroid plexus.  Preliminary results in male C57Bl/6 mice indicate that LPS affects vascular LAT1 mRNA the same way as in rats.  We conclude that LAT1 mRNA at the blood-brain barrier is regulated by LPS-induced inflammation in a similar manner as OATP1c1 and MCT8 mRNAs.  The downregulation of LAT1 mRNA further indicates that brain TH uptake is reduced during systemic inflammation, and also suggests a decrease in amino acid uptake.  Furthermore, the parallel decrease in OATP1c1, MCT8 and LAT1 expression raises the possibility that other transporter systems at the blood-brain barrier may be also downregulated during systemic inflammation, contributing to reduced cognitive function and consciousness.

 

Nothing to Disclose: GW, PM, BG, RML

18997 8.0000 FRI-062 A LAT1 mRNA in Brain Blood Vessels Is Regulated Similarly to Thyroid Hormone Transporters, OATP1c1 and MCT8, Following Lipopolysaccharide Administration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Poongkodi Karunakaran*1, Maharajan Chandrasekaran2, Sucharita V2, Kamaludeen Nainar Mohamed3 and Suresh Venkatesh Rachamadugu2
1Government Mohankumaramangalam Medical College and Hospital, Salem, India, 2Madras Medical College, Chennai, India, 3Madras Medical College

 

BACKGROUND: Hyperthyroidism is a known cause of high bone turnover osteopenia and osteoporosis. Although, bone mineral density (BMD) is known to improve following treatment of hyperthyroidism, the temporal timing of improvement and the extent of bone re-mineralization at cortical vs. trabecular sites remains controversial. In particular, the rate and extent of bone re-mineralization following surgical treatment of hyperthyroidism has not been fully assessed.  Therefore, we prospectively evaluated BMD, bone mineral content (BMC) and bone areal size in hyperthyroid patients before and after total thyroidectomy.  

MATERIALS AND METHODS: Overt hyperthyroid cases (n=40; 19M/ 21F -pre-menopausal; mean age: 36.4 ± 9.8y) and euthyroid controls (n=31; 8M/ 23F-premenopausal; mean age: 33.9 ± 9y) who were surgical candidates were studied. Bone indices were measured using dual energy X-ray Absorptiometry (DEXA) at femur, lumbar spine and forearm, initially at the time of diagnosis and six months after total thyroidectomy in both groups. Serum calcium, alkaline phosphatase and 25-OH-Vitamin D3 were also assessed serially.

RESULTS: Pre-treatment BMD Z-score at lumbar spine and femur were lower in cases than controls (-1.11+/-1.25 vs. -0.193+/-0.84; -0.85+/-1.19 vs. 0.28+/-0.99, p<0.001, respectively). Absolute BMD was also lower at all 3 sites in cases compared to controls (p=0.001). Serum alkaline phosphatase was elevated 2-3 fold in cases (143.18+/-72 vs. 71.9+/-23.1[reference range 32-90 IU/L]  p<0.001). At six months post surgery in hyperthyroid cases, BMD and bone area increased significantly at the hip (pre-treatment vs. post-treatment; 0.80 ± 0.12 vs. 0.87 ± -0.12 g/cm2, p<0.001; 259.1 ± 29.9 vs. 267.1 ± 26.2 cm2, p= 0.032, respectively) and spine (0.91 ± 0.14 vs. 0.97 ± 0.12 g/cm2 p<0.001; 162.4 ± 16.5 vs. 165.7+/-18.6 cm2, p=0.005, respectively) but not in the forearm (0.64+/-0.11 vs. 0.67+/-0.09 g/cm2, p=0.19; 403.63+/-76.6 vs. 397.2+/-82.3 cm2p=0.82, respectively). However, post-treatment BMC improved at all 3 sites (pre-treatment vs. post-treatment; spine: 149+/-33.7 vs. 161.6+/-32.3g, p<0.001; hip: 208.3+/-47.5 vs. 229.9+/-40.5g, p=0.003; forearm: 256.6+/-56.7 vs. 264.08+/-52.27g, p=0.001). Bone mass increased by 9.5%, 9.7% and 3.9% at spine, hip and forearm respectively. Despite hyperthyroidism, cases had normo/hypocalcemia(9.13+/-0.66 mg/dl[reference range: 8.4-10.2 mg/dl]) probably secondary to hypovitaminosis D( 25-OH vitaminD3: 24.3+/-10.6ng/ml[reference range for sufficiency: 30-100 ng/ml])

CONCLUSION: Definitive surgical management with total thyroidectomy restored the bone loss associated with hyperthyroidism as early as 6 months at both the spine and femur despite concomitant Vitamin D deficiency. Delayed recovery of bone indices at forearm, a cortical bone, needs further long-term evaluation.

 

Nothing to Disclose: PK, MC, SV, KNM, SVR

20477 9.0000 FRI-063 A Rapid Restoration of Bone Mass Following Surgical Management of Hyperthyroidism- a Prospective Case Control Study in India 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Hideyuki Iwayama*1, Xiao-Hui Liao1, Alfonso Massimiliano Ferrara1, Lyndsey Braun2, Brian Kaspar2, Roy E Weiss1, Alexandra M Dumitrescu1 and Samuel Refetoff1
1The University of Chicago, Chicago, IL, 2Nationwide Children's Hospital

 

Background: MCT8 is a specific T3 and T4 membrane transporter. MCT8 gene mutations produce thyroid hormone (TH) deficiency in brain, leading to a severe neuropsychiatric disorder that cannot be corrected with physiological doses of T3 or T4.

Aim: We examined the efficacy of the human MCT8 cDNA transferred by an AAV9 viral vector (AAV9-hMCT8) to increase brain T3 uptake and action on TH controlled genes (Hr, D3 and Cbr2) of Mct8 knockout (Mct8KO) mice.

Method: AAV9-hMCT8 or Empty Vector (EV) was injected into 1 day old (P1) mice intravenously (IV, 2x1011 particles/mouse) or intracerebroventricularly (ICV, 3x1010). T(5µg/100g body weight·day) was injected at P25-28 and tissues were obtained at P28.

Result: Human MCT8 mRNA content in brain was higher in ICV injected mice compared to IV injected mice. However the opposite profile was observed in liver where IV injected mice had a higher concentration of hMCT8 mRNA than ICV injected mice. Mice injected with AAV9-hMCT8 IV had higher brain T3 content than those injected IV with EV (23.6±2.1 vs 12.2±1.6 pg/mg·protein, p<0.01). This was not the case in ICV injected mice despite higher content in brain of hMCT8 mRNA (measured by qPCR) and protein (detected by Western blotting). IV but not ICV injected AAV9-hMCT8 significantly increased the TH-regulated genes in brain: Hr 2-fold (p<0.001), D3 5-fold (p<0.001) and Cbr2 2-fold (p<0.01). T3, T4 in serum before (P25) and after T3 injection (P28), and Tin liver were not significantly different in AAV9-hMCT8 and EV injected mice. The activity of AAV9-hMCT8 was confirmed in vitro by transient transfection in JEG3 cells.

Conclusion: These results indicate that intravascular injection of MCT8 is important in the delivery of T3 across the blood brain barrier (BBB) in Mct8 deficient mice. This suggests that localization of Mct8 in BBB cells achieved by IV injection is not accomplished by ICV injection. Furthermore, an increase of MCT8 expression in brain is insufficient to correct the defective gene expression in brain of Mct8KO mice without the provision of T3. Therefore, strategies that target the endothelial cells with MCT8 as delivered by intravascular administration of AAV9 are important for translational development.

 

Nothing to Disclose: HI, XHL, AMF, LB, BK, REW, AMD, SR

20412 10.0000 FRI-065 A Thyroid Hormone Transport Across the Blood Brain Barrier Is MCT8 Dependent 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Dong Yeob Shin*1, Kwang Joon Kim1, Jiyean An2, Byung-Wan Lee3 and Eun Jig Lee1
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Yonsei University College of Medicine, Seoul, 3Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Background: Type 2 deiodinase (D2) catalyzes intracellular T3 production in several human tissues including pituitary gland, hence occupying an important role in the feedback regulation of TSH secretion. Although several previous researches have shown that Thr92Ala D2 polymorphism with decreased D2 enzymatic activity influences the levothyroxine dose requirement and the set point of the hypothalamus-pituitary-thyroid axis for postoperative TSH suppressive therapy in thyroid cancer patients, the clinical implications of D2 polymorphism and liothyronine replacement in thyroid cancer patients are still unknown.

Methods: The effect of liothyronine combination on TSH suppression according to Thr92Ala D2 polymorphism in 40 papillary thyroid cancer patients (20 males and 20 females; age 46.6 ± 10.9 yr, range 20–66) who were persistently unable to repress the serum TSH levels to less than 0.1 μIU/mL for at least 3 months despite the daily 2.0 μg/kg intake of levothyroxine were analyzed. Total thyroidectomy with central compartment neck dissection and postoperative radioactive iodine ablation was performed in all patients at least a mean of 48.8 ± 35.8 months before this study.

Result: In these patients, a decreased of mean TSH level was observed in all patients after 3 months of 12.5 μg liothyronine add on with 50 μg reduction of levothyroxine (3.18 vs. 0.28 μIU/mL, P = 0.002). After liothyronine combination, serum T3 and free T4 levels became more comparable to preoperative levels. Of the 40 patients, Ala/Ala homozygous genotype was observed in 8 patients (20%), while wild-type and heterozygous type were observed in 15 (37.5%) and 17 (42.5%) patients, respectively. Preoperative serum free T4 level was lower in Ala/Ala homozygous patients (0.98 vs. 1.28 ng/dL, P = 0.006). Ala/Ala homozygous patients displayed higher ratio of TSH level before and after liothyronine combination compared with patients carrying the Thr92 variant (X/Thr patients) (133.9 ± 178.6 vs. 25.5 ± 41.5, P = 0.003).

Conclusion: Thr92Ala D2 polymorphism is associated with liothyronine-dependent TSH suppressive intensity in athyreotic individuals. Thr92Ala D2 polymorphism analysis will be beneficial in predicting the effect of T3 combination in thyroid cancer patients that are unable to achieve a full TSH suppression from levothyroxine mono-therapy.

 

Nothing to Disclose: DYS, KJK, JA, BWL, EJL

21584 11.0000 FRI-066 A Different TSH Suppressive Effects of Liothyronine Combination According to Thr92Ala Type 2 Deiodinase Polymorphism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Qiongjie Zhou*, Xiaotian Li and Chunfang Wang
Obstetrics and Gynecology Hospital of Fudan Unverisity

 

Preconception Thyroid Screening and Childhood Neurocognitive Function assessment at 1-year-old by Gesell scale

Qiongjie Zhou, MD.1,2, Chunfang Wang, MD, PhD1,2, Xiaotian Li, MD, PhD1,2,3

1 Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China; 2 the Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China; 3 Institute of Biomedical Sciences, Fudan University, China. 

The authors had no disclosure.

Introduction: Children born to women with low thyroid hormone levels were reported to have decreased cognitive function. It lacks evidence of universal pre-conception screening for childhood neurocognitive development.

Methods: Between September 2012 and August 2014, we conducted a prospective cohort study. Women were measured of thyrotropin and free thyroxine (T4) at first preconception or antenatal visit, and enrolled if their thyrotropin levels above the 97.5th percentile or/both free T4 levels below the 2.5th percentile. Gesell scale was used for the childhood neurocognitive assessment at 1-year-old as assessed by psychologists.

Results: Of 272 women who were enrolled in this study and completed childhood 1-year-old assessment, 102 were in the preconception group and 170 in the antenatal group. The maternal age, race, parity, obstetric and fetal complications had no difference (P>0.05). In the Gesell scale, the adaptive area and social area developmental quotations were better in preconception group compared with antenatal group (104.8 vs 100.0 and 104.0 vs 99.0, P<0.001); while fine motor developmental quotations were slightly lower in preconception group (101.3 vs 103.4, P>0.05). In addition, gross motor and language area developmental quotations were similar between the two groups (100.5 vs 99.7, 104.0 vs 105.4, P>0.05).

Conclusions: Preconception screening and maternal treatment for hypothyroidism possibly improved adaptive and social function in children at 1-year-old age. (ClinicalTrials number, NCT01744743.) 

Trial design and rationale: Epidemic evidence and animal studies suggested that hypothyroidism is related with maternal pregnancy outcome, offspring cognitive ability. Currently, it lacks evidence of universal pre-conception screening for maternal pregnancy outcome and offspring cognitive development, motivation ability and attention. China Governmental Health Department has included thyroid function screening into preconception in 2011. We hypothesize that pre-conception effective treatment may be helpful for decrease possible negative effects on maternal and offspring health, instead of early trimester.

Inclusion criteria: TSH ≥ 97.5%th and/or FT4 ≤ 2.5%th in preconception group; age between 18-55 years old; those who can obey the rules of this study and assign the consent.

Primary clinical endpoints: offspring neurocognitive assessment at 0-3 years old by Gesell scale.

 

Nothing to Disclose: QZ, XL, CW

18270 12.0000 FRI-067 A Preconception Thyroid Screening and Childhood Neurocognitive Function Assessment at 1-Year-Old By Gesell Scale 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Cristiane Jeyce Gomes Lima*1, Matheus de Oliveira Andrade2, Vinicius Santos da Cunha3, Andressa Aby Faraj Linhares Maciel3 and Adriana Lofrano-Porto4
1Molecular Pharmacology Laboratory, Faculty of Health Sciences, University of Brasilia, Brasilia, Brazil, 2Molecular Pharmacology Laboratory, Faculty of Health Sciences, University of Brasilia,, Brasília, Brazil, 3Molecular Pharmacology Laboratory, Faculty of Health Sciences, University of Brasilia,, Brasilia, Brazil, 4University of Brasilia, Brasilia DF, Brazil

 

Thyroxine-binding globulin (TBG) is the major human thyroid hormone transport protein. Inherited TBG abnormalities include partial and complete TBG deficiency (TBG-PD and TBG-CD, respectively). The gene encoding TBG is called SERPINA7 and it is located on the long arm of the X chromosome (Xq22.2). The purpose of this study was to perform the molecular analysis of this gene in a Brazilian family with TBG-PD. Genomic DNA was extracted from the female proband, her father, her dizygotic twin sister and her two brothers. The samples were subjected to polymerase chain reaction (PCR) for SERPINA7 amplification and automatically sequenced. The X-chromosome inactivation status was evaluated in the proband by the methylation pattern analysis of androgen receptor gene, which is located next to the TBG gene (Xq11.2). A novel single nucleotide substitution (C>T) at position 143 of exon 1 was found. This missense mutation resulted in the replacement of an arginine by a tryptophan in codon 35 (p.R35W). The proband was heterozygote and her brothers were hemizygotes. They presented low levels of TBG, compatible with TBG-PD; however, the proband had low FT4 levels and a very small thyroid volume on US examination. Central hypothyroidism was ruled out. She had a previous diagnosis of hypothyroidism and, when levothyroxine was withdrawn, she was severely symptomatic. Given the known X-linked inheritance of TBG deficiency, phenotypically affected women are rare. Therefore, analysis of the methylation pattern of the X-chromosome was performed. We found that the proband expressed an X-chromosome inactivation ratio of 20:80, which is still considered in the normal range, but suggests a tendency for a deviation of the inactivation pattern.We report, for the first time in Brazil, a new variant of the SERPINA7 gene associated with TBG-PD in three siblings: one woman and two men. TBG deficiency in women has been rarely described; some have been related to selective X-chromosome inactivation. We described a woman with TBG partial deficiency, who expressed a slightly deviated X-chromosome inactivation pattern, although a true selective inactivation could not be confirmed. We speculate that deviations from the X-chromosome inactivation pattern would account for genotype-phenotype variability in woman with heterozygous mutations in the SERPINA7 gene.

 

Nothing to Disclose: CJGL, MDOA, VSD, AAFLM, AL

20293 13.0000 FRI-068 A A Novel Variant in the SERPINA7 Gene Is Associated with TBG Partial Deficiency in a Woman and Her Two Male Siblings 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Anette Merke*1, Juergen Merke1, Winfried Maerz2 and Stefan Pilz3
1Thyroid Center Bergstrasse, Bensheim, Germany, 2Medical University of Graz, Graz, Austria, 3VU University Medical Center Amsterdam, Amsterdam, Netherlands

 

Background: The LURIC Study (LUdwigshafen RIsk and Cardiovascular Health Study) is a large prospective cohort study. 3316 patients were included between 1997 and 2001. Main inclusion criterium was clinical stability except for acute coronary syndrome. All patients were referred for angiography. Accumulating evidence suggests a complex interplay between thyroid hormone status and vitamin D. It is well known that thyroid hormone and vitamin D bind to similar nuclear receptors. Previous studies showed that thyroid hormone inhibits 25-hydroxyvitamin D (25[OH]D) 1-alpha hydroxylase and that vitamin D suppresses TSH secretion and exerts direct effects on thyroid follicular cells such as inhibition of iodine uptake. Clinical data on direct effects are however sparse and partially controversial.

Objective: We therefore aimed to evaluate whether 25(OH)D and 1,25-dihydroxyvitamin D (1,25[OH]2D) are associated with TSH, fT4 and fT3 levels in LURIC.

Methods: We examined 2804 participants with complete data on 25(OH)D, 1,25(OH)2D, TSH, fT4, and fT3. We performed linear regression analyses with TSH, fT4 and fT3 as outcome variables and carried out adjustments for age, sex, BMI, and active smokers.

 Results:Mean age was 62.8±10.6 years with 30% females. In linear regression analyses with thyroid hormones and TSH as the outcome variables and adjustments for age, sex, BMI, and active smokers, we found  no significant association of 25(OH)D or 1,25(OH)2D with TSH and fT4. However we observed a significant association of fT3 with 25(OH)D (beta coefficient 0.04; p=0.043) and 1,25(OH)2D (beta coefficient 0.12; p<0.001).

Conclusions: In patients referred for coronary angiography in LURIC there was no significant association between TSH, fT4 and vitamin D levels, but a significant association of 25(OH)D and especially with 1,25(OH)D and fT3. Further studies are required to elucidate the underlying pathophysiological mechanisms of the close relationship between the active metabolites and the clinical relevance of this finding.


 

Nothing to Disclose: AM, JM, WM, SP

19810 14.0000 FRI-069 A 25-Hydroxyvitamin D and 1,25-Dihydroxyvitamin D Are Significant Predictors of fT3 Concentrations in a Large Prospective, Hospital-Based Study: The Luric Study ( LUdwigshafen RIsk and Cardiovascular Health Study) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Nathalie Oliveira Santana*1, Debora Lucia Seguro Danilovic2, Lenine Garcia Brandao3, Vergilius Jose Furatdo Araujo Filho3 and Suemi Marui4
1School of Medicine, Sao Paulo University, Sao Paulo, Brazil, 2Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 3Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, 4Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

Thyroid lobectomy represents an option for the management of benign thyroid disease and might be considered as a curative approach for early differentiated thyroid carcinoma. Although this procedure is less morbid than total thyroidectomy, the possibility of post-operative hypothyroidism must be considered. In the literature, thyroid hormone supplementation is required in 10% to 50% of patients after thyroid lobectomy (1-3). In order to help to counsel the patients preoperatively regarding the probability of the need for postoperative levothyroxine (LT4) supplementation, we evaluated the prevalence of post-lobectomy hypothyroidism and the correlation of pre-operative data in our service. Material and Methods: From 2009 to 2014, we retrospectively reviewed medical records of patients, who underwent thyroid lobectomy at our Institution (Hospital das Clinicas-Sao Paulo-Brazil). Thyroid hormones, TSH, anti-thyroperoxidase antibodies (ATPO) and thyroid volume in ultrasound were determined preoperatively. Volume and histological type of resected thyroid and thyroid hormones and TSH in short, medium and long-term were analyzed after surgery. Results: From 24 patients, 20 were females, with mean age 44.7±13.9 years-old (23 to 65), had mean baseline TSH 1.8 ± 0.96 μIU/mL (normal range 0.4-4.5), free T4 (FT4) 1.08±0.16 (NR  0.7-1.5) and positive ATPO in 14%. Only 2 were on LT4 treatment pre-surgery. Total thyroid volume was 44±35 cm3 (16 to 158) and the remaining lobe 3.6± 1.7 cm3 (0.8 to 7). Pathologic reports revealed 19 goiter, 4 follicular adenomas and 1 papillary carcinoma. Only age and TSH preoperative were associated with post-operative TSH > 4.5 µIU/mL (r2 0.713, p=0.009 and p=0.002, respectively) along short and medium-term. We observed 46% of post-lobectomy hypothyroidism, but with a lower LT4 dosage (X=0.71 µg/kg). Conclusion: Age and baseline TSH must be considered to predict post-lobectomy hypothyroidism, helping to advice and choose the type of surgical approach.

 

Nothing to Disclose: NOS, DLSD, LGB, VJFA, SM

20926 15.0000 FRI-070 A Prediction of Hypothyroidism after Thyroid Lobectomy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Nathalie Oliveira Santana*1, Tatiana S Pelaes2, Christiane Gruetzmacher3, Romulo Hermeto Vale4, Heitor Naoki Sado4, Paulo Schiavom Duarte4, Marcelo Tatit Sapienza4, Carlos Alberto Buchpiguel5, Ana Oliveira Hoff6 and Debora Lucia Seguro Danilovic7
1University of São Paulo Medical School, Sao Paulo, Brazil, 2Hospital das Clínicas, Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/LIM42, FMUSP, SP, Brazil, Sao Paulo, Brazil, 3Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, São Paulo, Brazil, 4Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil, 5Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, 6ICESP/University of Sao Paulo, Sao Paulo, Brazil, 7Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil

 

Background: Simultaneous diagnosis of papillary thyroid carcinoma (PTC) and benign struma ovarii is rare, only three cases have been described to our knowledge (1, 2, 3). We report a case of struma ovarii detected through diagnostic I131 SPECT/CT prior to radioactive remnant ablation for PTC.

Clinical case: Female patient, 76-years-old, submitted to total thyroidectomy and central dissection due to PTC. Thyroid function before surgery: TSH=0.56 µIU/mL (normal 0.27-4.20), free T4 (FT4)=0.97ng/dL (normal 0.93-1.70). Pathology report described a 2.4 cm PTC, multifocal, classical variant, with extrathyroidal extension, vascular invasion and 3 out of 7 metastatic lymph nodes. After 19 weeks with levothyroxine 1 mcg/kg, her exams revealed suppressed TSH, FT4=2.21ng/dL, thyroglobulin (Tg)=176.7 ng/mL, and negative anti-Tg antibody. Diagnostic I131 whole body scan(WBS) prior to radioactive remnant ablation demonstrated cervical uptake < 1%, but increased focal activity in the pelvis and diffuse homogenous uptake in the liver, possibly as a result of increased metabolism of thyroid hormones. In order to improve anatomic diagnosis, SPECT/CT associated to the diagnostic WBS identified pronounced uptake in her left ovary, heterogeneous, with hypoattenuating cysts and coarse peripheral calcification, measuring 10.0 x 9.9 cm. MRI confirmed a 8.9 x 8.5 x 8.2 cm left ovary mass, containing solid areas with intense contrast enhancement, multilocular cysts and coarse calcification. The patient was submitted to bilateral oophorectomy, which disclosed mature teratoma filled with thyroid tissue (struma ovarii).After one month with the same dose of levothyroxine, her exams revealed TSH=54.3 µIU/mL, FT4=0.9 ng/dL and Tg=2.3 ng/mL. 

Conclusion: Differential diagnosis of pelvic iodine uptake in WBS includes metastasis of differentiated thyroid carcinoma, urinary retention, benign ovarian lesions, such as struma ovarii, or malignant ones, like metastasis of PTC to the ovaries or PTC in the thyroid tissue of struma ovarii (3). Although TSH suppression with low-dose levothyroxine and signs of hepatic thyroid hormone metabolism in diagnostic radioiodine whole body scan had suggested the presence of remnant thyroid tissue, SPECT/CT was crucial for anatomic diagnosis of the ovarian lesion, and surgical resection confirmed the mass benign origin.

 

Nothing to Disclose: NOS, TSP, CG, RHV, HNS, PSD, MTS, CAB, AOH, DLSD

20118 16.0000 FRI-071 A Benign Struma Ovarii: Incidental Finding in Diagnostic I131 Whole Body Scan for Papillary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 055-071 5915 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Mary Angelynne Esquivel*1, Chanika Phornphutkul2 and Geetha Gopalakrishnan3
1Alpert Medical School of Brown University/Rhode Island Hospital, East Providence, RI, 2Brown University Alpert Medical School, Providence, RI, 3Alpert Medical School of Brown University, East Providence, RI

 

Background:

Congenital disorder of glycosylation (CGD) type Ia, (aka PMM2-CDG, Carbohydrate-Deficient Glycoprotein Syndrome Ia and Jaeken Syndrome), is an autosomal recessive disease affecting 1:20,000 individuals worldwide. CDG commonly presents in childhood. However, the true spectrum of the disease remains unknown. The usual presentation is endocrine dysfunction (including hyperglycemia-induced growth hormone release, hyperprolactinemia, hypothyroidism, insulin resistance, and hyperinsulinemic hypoglycemia) with multisystem involvement. Diabetes mellitus has been reported in patients with CDG. 

Clinical Case: 

A 34 year-old Caucasian male with diabetes mellitus (DM) on insulin since 11 years old, presenting with peristent hypoglycemia. He had severe retinopathy resulting in blindness, gastroparesis and end stage renal disease, all of which were deemed DM complications in his case. However his hemoglobin A1c levels ranged between 6-8% which indicated reasonable control. Further history revealed developmental delay and ataxia since childhood. In addition, he also had short stature, sensorineural hearing loss, ptosis and cardiomyopathy suggestive of underlying genetic/metabolic/mitochondrial condition. Hepatic dysfunction was noted noted on routine labs.  During an episode of hypoglycemia, his laboratory results showed hyperinsulinemic hypoglycemia as follows: point of care blood glucose <30 mg/dL, serum glucose 27 mg/dL, serum insulin 29.8 mU/L (n: undetectable), C-peptide <0.10 ng/mL (n: 0.8-3.10), proinsulin <5.0 pmol/L (n:<18.8), B-hydroxybutyrate 0.03 mmol/L (n: 0.02-0.27), IGF-1 900 ng/mL (n 132-333), IGF-2 567 ng/mL (n: 288-736) and oral hypoglycemic agent screening panel negative. Other endocrine laboratory workup included TSH 7.2 uIU/mL (n:0.35-5.50), FT4 0.47 (n: 0.8-1.8) and serum AM cortisol 10.6 ug/dL (n:>7.0). The rest of his laboratory results were essentially unremarkable for other inherited errors of metabolism, including acylcarnitines, lactic acid and ammonia. Imaging studies of the abdomen including an MRI and a CT scan did not detect any GI or pancreatic lesions. Genetic testing revealed a heterozygous mutation in the PMM2 gene [c.470T>C (p.F157S), exon 6]. A follow up isoelectric focusing study revealed an abnormal pattern consistent with CGD.

Conclusion:

Congenital disorders of glycosylation are rare but fatal causes of hyperinsulinemic hypoglycemia amongst patients with longstanding diabetes mellitus and multisystem involvement. Proper biochemical, genetic workup are necessary for accurate diagnosis, which in turn will impact further management and care of patients and their relatives.

 

Disclosure: GG: Principal Investigator, Novo Nordisk, Principal Investigator, NPS, Principal Investigator, Novartis Pharmaceuticals. Nothing to Disclose: MAE, CP

22155 1.0000 FRI-618 A Congenital Disorder of Glycosylation Ia in a Diabetic Adult Patient with Hyperinsulinemic Hypoglycemia and Multisystem Involvement 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Mitsuru Nishiyama*, Yoshinori Taniguchi, Tomoaki Yatabe, Kosuke Inoue, Shuichi Nakayama, Takayuki Ikezoe, Shimpei Fujimoto and Yoshio Terada
Kochi Medical School, Nankoku, Japan

 

【Background】Malignant tumors rarely cause lactic acidosis and hypoglycemia. We experienced a case with severe lactic acidosis due to hidden malignant lymphoma.

【Clinical Case】A 67-year-old woman was urgently admitted for general malaise and urinary retention. Marked weight gain was observed (up to 101 kg from 88 kg) due to severe edema and bilateral hydronephrosis. Two days later, the patient was diagnosed with lactic acidosis (pH 7.3, HCO3 9 mmol/L, lactate 7.6 mmol/L) and moved to the intensive care unit (ICU). Computed tomography (CT) was performed, with results showing thickening of the rectus abdominis and iliopsoas muscles and subcutaneous abdominal edema. She was administered an infusion of 10% glucose, but a gradual decrease in plasma glucose (PG) levels to 60 mg/dL was noted. CT scan was repeated on ICU Day 5, revealing tumoral changes in the pelvis and at the rectus abdominis muscle wall as well as an increase in the number of subcutaneous nodules, which were subsequently biopsied. On ICU Day 8, the patient was started on total parenteral nutrition containing 17.5% glucose. Subsequently, PG levels dipped to 50-70 mg/dL, and lactic acid levels exceeded 20 mmol/L. On positron emission tomography using [18F]-fluorodeoxyglucose (FDG) performed on ICU Day 10, advanced accumulation of FDG was noted at the thickening rectus abdominis and iliopsoas muscles and abdominal subcutaneous. The biopsy results confirmed ultimately plasmablastic lymphoma, and the patient received cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP chemotherapy) on ICU Day 12. Her lactic acid levels began to fall from 20 mmol/L and improved to 5.7 mmol/L by 36 hours later, and PG levels held steady at approximately 110 mg/dL. She was transferred to hematology ward on chemotherapy Day 6, and following improvement of edema, a weight loss of 20 kg was seen over 3 weeks.

【Discussion】Lactic acidosis and hypoglycemia in malignant tumors believed to be caused by the Warburg effect. When glucose dosage was increased during therapy, lactic acid levels markedly increased as well due to further enhancement of the Warburg effect, as was previously reported. Treating the underlying cancer is the only way to treat lactic acidosis and hypoglycemia caused by malignant lymphoma. In the present case, start of CHOP therapy was followed by dramatic improvements in PG and lactic acid levels. While prior reports have been published on several type of B cell lymphoma, our case is the first to involve plasmablastic lymphoma causes lactic acidosis. Our findings suggest that malignant lymphoma might lead to lactic acidosis, regardless of tissue type.

【Conclusion】The potential involvement of lymphoma and other kinds of malignant tumors must be acknowledged in cases of advanced lactic acidosis and hypoglycemia of unknown etiology.

 

Nothing to Disclose: MN, YT, TY, KI, SN, TI, SF, YT

19514 2.0000 FRI-619 A A Case of Malignant Lactic Acidosis Due to Plasmablastic Lymphoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Marla Elaine Sevilla1, Natalia Chaar Tirado2 and Alejandra N Santiago*1
1Hospital Damas, Ponce, PR, 2Hospital Damas, Ponce

 

Glycogenic Hepatopathy: A rare cause of Hepatomegaly in a poorly controlled Diabetic Mellitus type 1 patient.

Alejandra Santiago, Marla Elaine Sevilla, Natalia Chaar

Internal Medicine, Hospital Damas, Ponce, Puerto Rico

Background: Glycogenic Hepatopathy (GH) is a rare condition of marked hepatomegaly, in some cases elevated liver enzymes and distinctive histopathological liver changes. It is related with poorly controlled glycemic levels in diabetic patients, especially diabetes type 1. The hallmark of GH is its reversibility with improved glycemic control.  The uncommonness of this condition makes GH a very interesting and challenging diagnostic.

Clinical Case: We presents a case of an 18 years old diabetic type 1 female patient with poorly glycemic control complicated by Diabetic Ketoacidosis who was admitted in February 2014 with symptoms of general weakness, nauseas, vomiting and epigastric pain. Her glucose control had been suboptimal for the last years (HbA1C= 10%) requiring four hospitalizations due to diabetic ketoacidosis. During the physical examination we found a non-tender hepatomegaly (liver span 14 cm) hardened to palpation. No previous history of underlying liver disease. Investigation revealed elevated ALP- 169 with normal AST and ALT. Abdominal ultrasound showed liver enlargement measuring 20.0 cm in craniocaudal dimension and the spleen is normal size. CT scan of the abdomen was performed who revealed hepatomegaly as well as diffuse increase liver attenuation with elevated Hounsfield Unit of 86. Liver pathologies related with this imaging findings are deposits of certain metals seen in Hemochromatosis, Hemosiderosis and Wilson disease, Glycogen storage disease, some medications and the previous use of Thoratrast administration (contrast agent used between 1930-1950). Workup for these conditions and others causes of liver injury were performed and all the results were negative. Patient recovered from DKA and was discharge home 3 days after admission. Follow up as OPD. Liver Biopsy was requested. Histopathological results showed Glycogenic Hepatopathy.

Conclusion: Glycogenic Hepatopathy is a rare disease. First described by Dr. Mauriac in 1930 as part of a syndrome including growth retardation, cushingoid phenotype and delayed puberty. Today is become clear that the liver defect observe in this condition can occur alone in the diabetic patients. Glycogenic Hepatopathy is caused by the pathologic accumulation of excess glycogen within the liver. It is most commonly associated with poorly controlled diabetes mellitus type 1. The clinical presentation typically includes hepatomegaly, abdominal pain and elevated transaminases. It is very important to distinguish this condition because it has the potential of reversibility after improved glycemic control.

 

Nothing to Disclose: MES, NC, ANS

20655 3.0000 FRI-620 A Glycogenic Hepatopathy: A Rare Cause of Hepatomegaly in a Poorly Controlled Diabetic Mellitus Type 1 Patient 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Henry G Fein*1, Artit Silpasuvan2 and Asha Thomas3
1Sinai Hospital and Johns Hopkins School of Medicine, Baltimore, MD, 2Sinai Hosptial of Baltimore, Baltimore, MD, 3Sinai Hospital, Baltimore, MD

 

Introduction

Since the initial US Food and Drug Administration approval of canagliflozin in 2013, subtype 2 sodium-glucose transport protein (SLGT-2) inhibitors have become increasingly utilized in the management of Type 2 Diabetes.  These agents can result in intravascular dehydration and increases in serum creatinine which usually respond to appropriate oral rehydration.  We present a patient who was briefly treated with dapagliflozin who developed acute renal failure while on this drug and who rapidly recovered when this agent was withdrawn.

Case Presentation:

We present a 60-year-old woman with a history of steroid-dependent rheumatoid arthritis, type 2  diabetes, and hypothyroidism who presented with symptoms of fatigue. She reported taking her medications as prescribed and no other recent illnesses. Over the last several months, she had noted increased fatigue, lethargy and a sense of being unwell. On followup bloodwork to assess her symptoms, she was found to have a blood urea nitrogen (BUN) of 33 mg/dl and a creatinine (Cr) of 3.49 mg/dl. Her baseline BUN was 11 mg/dl and Cr was 0.7 mg/dl.  The patient was assessed in the emergency department and admitted for dehydration. She was also noted to be profoundly hypomagnesemic (0.8 mg/dl) and hypokalemic (3.2 mmol/l). She was treated with normal saline intravenously. On further history, the patient noted that she had been started on dapagliflozin 5 mg daily by her physician several months previously. This medication was stopped and the patient had resolution of the acute renal failure with her creatinine returning to her baseline. The patient was subsequently seen in outpatient followup with resolution of symptoms and titration of her diabetic medications.

Discussion:

Dapagliflozin can be associated with significant acute renal failure.  Patients treated with this agent should be carefully monitored to ensure that they remain well hydrated and their renal function remains stable.  It should be considered in the differential diagnosis of patients with acute renal function changes on medical therapy.

 

Nothing to Disclose: HGF, AS, AT

22136 4.0000 FRI-621 A Acute Reversible Renal Failure Associated with Short-Term Treatment with an Sglt-2 Inhibitor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Rebecca M. Wood*1, Poonam Khadka1, Kathleen C BelBruno1 and Sushela S Chaidarun2
1Dartmouth Hitchcock Medical Center, Lebanon, NH, 2Dartmouth-Hitchcock Medical Center, Lebanon, NH

 

Myotonic Dystrophy is an autosomal dominant disorder, with two major
types that make up the most common forms of muscular dystrophy in
adulthood. Myotonic dystrophy affects several systems in the body
including the endocrine system.

We present a case of fasting hypoglycemia and marked insulin resistance
in a 49 year old female with Type 1 myotonic dystrophy. The patient was
transferred from an outside facility and admitted to the intensive care unit
for treatment of aspiration pneumonia with new ventilator dependence.
Her hospital course was complicated by cardiac arrest, pulmonary
embolus, methicillin resistant staphylococcus aureus pneumonia, and
cardiac arrhythmia. She initially displayed fasting hypoglycemia requiring
intravenous dextrose, that resolved with initiation of enteral nutrition. She
did not have a known diagnosis of diabetes or impaired fasting glucose,
and hemoglobin A1C was 5.5% on admission.

The patient's hospital course was complicated by inability to wean from
the ventilator and she required tracheostomy and feeding tube placement.
She then developed a new insulin requirement with severe hyperglycemia,
requiring 36-80 units daily of subcutaneous insulin over a 72 hour period,
therefore an insulin drip was initiated. She appeared to decline from a
mental status standpoint with increased somnolence and was
intermittently febrile. The insulin drip was titrated as high as 20 units per
hour with resulting blood sugars in the 200s-300s, despite minimal tube
feeds and absence of steroids. Infectious work up revealed evidence of a
urinary tract infection and the patient was treated with resolution of the
insulin requirement.

This case demonstrates severe insulin resistance that is reported in
literature of patients with myotonic dystrophy, which was thought to be
exacerbated by acute infection. Myotonic dystrophy is caused by
unstable nucleotide repeats within specific genes, which results in RNA
accumulation in the nucleus of cells and interferes with the activity of
binding proteins that regulate alternative splicing of developmentally
regulated genes. Affected proteins include the muscle chloride channels,
T tubules, troponin, as well as the insulin receptor, which is crucial to this
case. Insulin resistance in these patients is thought to be due to aberrant
expression of the insulin Type A receptor that is usually only seen in
embryonic insulin responsive tissue (skeletal muscle, liver, fat) rather than
expression of the Type B receptor, which is highly sensitive to insulin and
seen in healthy adults. We postulate fasting hypoglycemia in this patient
to be secondary to high levels of circulating insulin which is thought to be
the mechanism by which these patients overcome insulin resistance.

This case highlights the complexity of caring for patients with underlying
diseases that requires tailored insulin and blood glucose regulation,
specifically in the acute setting.

 

Nothing to Disclose: RMW, PK, KCB, SSC

18945 5.0000 FRI-622 A A Case of Marked Insulin Resistance with an Unusually High Insulin Requirement and Fasting Hypoglycemia in a Critically Ill Patient with Type 1 Myotonic Dystrophy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Rebecca Gupte*1, Tulip Sunil Nandu1 and W Lee Kraus2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Medical Center, Dallas, TX

 

Myeloid-derived cells, such as macrophages, are major components of the innate immune system involved in mounting an inflammatory response against infection or injury in the host. Macrophages activated by microbial agents, cytokines, and interferon-γ (IFNγ) generate high levels of pro-inflammatory cytokines, chemokines, and effector molecules such as TNFα, Interleukin (IL)1, IP10, inducible nitric oxide synthase (iNOS), and reactive oxygen species, making them highly effective in resolving the infection.  However, aberrant activation of macrophages results in excessive inflammation and can lead to various autoimmune diseases. Recently, the use of chemical inhibitors that target the intracellular signaling protein Poly(ADP-ribose) Polymerase-1 (PARP-1) have gained attention as potential therapeutics for treating autoimmune and inflammatory diseases.  Early studies showed that PARP-1 null mice are resistant to septic shock due to decreased serum levels of pro-inflammatory cytokines like TNFα and IL6.  Moreover, PARP-1 was shown to in modulate NF-κB activity via the coregulators p300 and CARM1. Although these studies implicate PARP-1 in the regulation of inflammation, its role in innate immune signaling is relatively unexplored. We hypothesize that PARP-1 potentiates pro-inflammatory responses by mediating signal-dependent transcriptional changes in macrophages. To test this hypothesis, we have identified the target genes of PARP-1 in primary bone marrow-derived macrophages using next-generation deep sequencing techniques, including RNA-Seq. Stimulation of macrophages with TNFα and IFNγ resulted in widespread transcriptional changes.  Moreover, in the presence of the PARP inhibitor, PJ34, these transcriptional profiles were significantly altered.  Strikingly, a number of the genes encoding TNFα- and IFNγ-stimulated pro-inflammatory cytokines and chemokines were down regulated upon PJ34 treatment.  This suggests that PARP-1 is an important component of the innate immune signaling pathways and inhibiting PARP-1 can lead to disruption of these pathways.  By elucidating the broad-spread effects of PARP inhibitors in innate immune signaling, this research has the potential to change the way PARP inhibitors are used in the clinic.  This work is supported by a grant (DK069710) from the NIH/NIDDK to WLK.

 

Nothing to Disclose: RG, TSN, WLK

22151 6.0000 FRI-624 A Role of PARP-1 in Modulating Pro-Inflammatory Signaling in Macrophages 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Monica Chiang*1 and Taniya Nayantara de Silva2
1LSU Health Sciences, New Orleans, 2LSU Health Sciences, New Orleans, LA

 

A 47 year-old man presents to his physician with fatigue, polyuria and mild numbness and tingling in his feet.  A diagnosis of diabetes mellitus (DM) is confirmed with laboratory studies.  HgA1c is not obtained. Sitagliptin and metformin are started.  Due to persistently elevated blood sugars, within 4 weeks, long acting insulin detemir is added to his regimen.  The patient self-initiates a very low calorie diet with a resultant rapid weight loss of 35 lbs. in three months.  After initiation of low calorie diet, he notes progression of paresthesias to his thighs and trunk.  Sensation is described as varying from a mild “goose bump” sensation to a severe burning sensation.  Patient also experiences myalgias without weakness.  One month later, insulin aspart is initiated prior to meals leading to worsening symptoms.  Pregabalin 50 mg each morning and 150 mg at night is started.  As there is little improvement in paresthesias patient is referred to Endocrinology.  Diabetic regimen at that time consists of detemir 25 units at bedtime, aspart 10-12 units prior to meals and metformin 500 mg twice daily.  Blood sugar log reveals an average blood sugar of 173 mg/dL (range 63-369 mg/dL).  Physical exam is significant for a weight of 176 lbs., BMI 24 kg/m2, blood pressure 172/106 mm Hg, heart rate 96 BPM, intact cranial nerves II-XII, 5/5 upper and lower extremity motor strength, 1+ deep tendon reflexes. No muscle atrophy or fasciculations are noted.  The patient reports a depressed mood.  Laboratory studies could not be obtained at the time of visit due to financial constraints of the patient.    He is given a presumptive diagnosis of insulin neuritis.  He is advised to follow a less restrictive diet.  Options for therapy including pregabalin, alpha lipoic acid and tricyclic antidepressant are discussed.  As retinopathy can accompany rapid improvement in glycemic control, patient is advised to obtain a dilated eye exam.  He is advised to seek care for worsening depression.  The patient liberalizes his diet but does not seek additional medications for his paresthesias or depression.  Within six months weight returns to baseline, paresthesias resolve and mood improves.  He is able to discontinue pregabalin.   Acute painful neuropathy also known as insulin neuritis can follow rapid glycemic improvement in patients with DM.  Symptoms of this disorder include paresthesias most notably burning of the hands and feet, weight loss and depression.  Paresthesias of the trunk are rare.  The precise etiology of insulin neuritis is unknown.  It is hypothesized that initiation of intense glycemic control can lead to axonal regeneration.  The neuropathic pain can be a result of hyperexcitability of these regenerated nerve fibers.   While this patient did not have any HgA1c levels documented, patients noted to have a rapid decline in HgA1c are at greater risk of developing insulin neuritis. As seen in this case most cases of insulin neuritis are self-limited.

 

Nothing to Disclose: MC, TND

20668 7.0000 FRI-625 A Every Silver Lining Has Its Cloud: A Case of Insulin Neuritis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Shaza Ahmed Samargandy* and Amani Alhozali
King Abdulaziz University, Jeddah, Saudi Arabia

 

Introduction:

   Diabetic muscle infarction (DMI) or diabetic myonecrosis is an uncommon musculoskeletal complication of poorly controlled diabetes mellitus. The underlying mechanism is thought to be arteriopathy. An association between DMI and cardiovascular mortality was proposed.

 Clinical Case:

    A 51-year- old female patient presented to the emergency department complaining of left thigh pain and swelling for 2 months. Patient’s complaint started 6 months ago when she noted a gradually increasing bilateral lower limb swelling. Two months prior to presentation, she noted pain and worsening of the swelling in the left thigh. The pain was progressive to the point where it started interfering with the patient’s sleep and mobility. There was no history of fever nor trauma. The patient was diagnosed with type 2 diabetes 20 years ago and is currently on insulin. Her blood sugar was poorly controlled. She was recently diagnosed with hypertension.

     Lower limb examination demonstrated bilateral pitting edema with a difference of 2 cm between the  two  limbs .There  was  tenderness upon  palpation  of  the  left  thigh, but  no  erythema, warmth  or  dilated  veins  were detected. Glove and stocking neuropathy was also evident. Fundoscpoic examination revealed severe non-proliferative diabetic retinopathy with bilateral macular edema. Investigations showed normal white cell count of 11000cell/μL (4.5-11.5) and creatinine phosphokinase of 41 IU/L (21-232). She had an impaired creatinine level of 124 μmol/L (53-115), and a high erythrocyte sedimentation rate of 100 mm/Hr (1-20). Her hemoglobin A1C was 11.2% and 24-hour urine protein was 4.5g/day. She was started on empirical antibiotic coverage for cellulitis and necrotizing fasciitis after a doppler ultrasound of the lower limb excluded deep venous thrombosis. Subsequently, an MRI of the left thigh showed myonecrosis . Bone scan and gallium scan ruled out infection at the left femur.

     Antibiotics were stopped and the patient was managed with aspirin and bed rest. She started to show improvement in the form of decreased  pain  during  her   hospital  stay. Her blood sugar was controlled upon discharge.

Conclusion:

Diabetic myonecrosis is a rare complication that has a presentation similar to a lot of common diseases. Recognition and cardiovascular risk adjustment are warranted as it is associated with poor outcome. Adding DMI to diabetes prognostic risk assessments is suggested.

 

Nothing to Disclose: SAS, AA

19435 8.0000 FRI-626 A Diabetic Muscle Infarction, a Rare Complication of a Common Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Wentong Pan*, Shwetha Thukuntla, Pavankumar Patel, BaoLan Pham and Nicola Abate
University of Texas Medical Branch, Galveston, TX

 

Background: Severe pancreatic atrophy is a rare cause of late onset insulin-dependent diabetes. In this case presentation we evaluated whether loss of both β and α-cell occurred in the pancreas of this patient with severe pancreatic atrophy and labile glycemic control.

Clinical case: a case of a 64-year-old female presented with late onset insulin-dependent diabetes associated with diabetic ketoacidosis and recurrent hypoglycemia. History was negative for pancreatitis and was characterized by overall poor glycemic control (HbA1c=11.8%). Initial work up revealed that both anti-glutamic acid decarboxylase (GAD)65 and anti-islet cell antibodies were undetectable. Computed tomography (CT) of the abdomen showed minimal pancreatic tissue within the head of the pancreas and proximal body, and no other pancreatic tissue was identified. There was no calcification or suspicion of malignancy in the pancreatic parenchyma. Magnetic resonance cholangiopancreatography (MRCP) visualized normal configuration in both the main and accessory pancreatic ducts, confirming the suspicion of severe pancreatic atrophy. Insulinopenia was confirmed as fasting C-peptide level was at 0.2 ng/mL with concurrent fasting glucose level at 213 mg/dL. Glucagon deficiency was also detected as a fasting glucagon less than 25 ng/L.

Conclusion: This is the first case reporting loss of both β and α- cell function in atrophic pancreas. Subsequent metabolic abnormalities are characterized by late onset insulin-dependent diabetes, labile glycemic control and excessive susceptibility to hypoglycemia.

 

Nothing to Disclose: WP, ST, PP, BP, NA

21537 9.0000 FRI-627 A Severe Pancreatic Atrophy- a Rare Cause of Late Onset Insulin-Dependent Diabetes Associated with Diabetic Ketoacidosis and Recurrent Hypoglycemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Faustyna Popkiewicz*
King's College Hospital London, London, United Kingdom

 

Background: Diabetic ketoacidosis (DKA) is a medical emergency where rapid and effective management is necessary to aid prompt recovery and to prevent life threatening complications such as: cerebral oedema, hypokalaemia, hypo/hyper-glycaemia and hypovolaemia. It requires effective co-operation between the emergency department (ED), general medical team and endocrinology team members.

Within the past 4 years, a new national guideline regarding the management of DKA has been used by the majority of hospitals in the United Kingdom (1). One of many points in these guidelines is that a fixed rate of iv insulin infusion with appropriate rate of iv fluids (normal saline and 10% of glucose) is preferable to variable insulin infusion. The new guidelines describe clearly each step of DKA management. This audit investigated the management of DKA at Medway Hospital to see if national and local hospital guidelines were being adhered to.     

Aims and Objectives:

Multiple steps of clinical management of DKA were examined, including: recognition of DKA, initiation of treatment, the occurrence of hypoglycaemia and hypokalaemia, blood glucose and ketones monitoring, venous blood gases monitoring and referral to endocrinology team. Results were presented to medical and ED doctors during a hospital audit meeting.

Methods: The search code in the hospital audit database was “diabetic ketoacidosis” and identified 34 cases between January and June 2014. The audit collection tool was a standard national DKA audit proforma. The national and local DKA guidelines were used as a standard.  

Results:

Thirty four patients were treated for DKA.

Only 82% of patients had treatment started within 1 hour of arrival in accordance with DKA guidelines.

The major challenges identified were:

  • Inadequate initial fluid resuscitation with normal saline in 88 % of patients.
  • Episodes of hypoglycaemia in 66 % of patients whilst on IV insulin.
  • Episodes of hypokalaemia in 82% of patients.
  • Long acting insulin was continued in only 40% of cases.
  • The endocrinology team review within 24 hr of admission was achieved in only 74% of patients.

The mean length of hospital stay was 4 days (no mortalities).

A variable rate of IV insulin infusion was still used at Medway Hospital which was not compliant with the national DKA guidelines.

Conclusions: The audit clarified and increased the awareness of DKA national guidelines amongst hospital staff.  The results were debated amongst ED, medical and endocrine doctors. Some doctors were not aware of fixed insulin infusion treatment in DKA.  It was emphasised to manage DKA appropriately from the beginning at ED, so that patients transferred to medical wards have a clear and correct plan that can be continued by nurses and non-endocrinology doctors. The endocrinology team should be informed about DKA admissions to review and guide management. The study is going to be re-audited to see the improvement in clinical practice.

 

Nothing to Disclose: FP

19963 10.0000 FRI-628 A Clinical Management of Diabetic Ketoacidosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Henrik Holm Thomsen*, Nikolaj Rittig, Ermina Bach, Jens Otto Lunde Jørgensen and Niels Møller
Aarhus University Hospital, Aarhus C, Denmark

 

Introduction

Widely applied for the study of metabolism and metabolic interventions,  administration of endotoxin is often employed as an operational model of acute inflammatory disease, e.g. sepsis. Studies have suggested development of tolerance to endotoxin, i.e. a reduced response to re-stimulation with endotoxin. However, the issue of whether true in vivo tolerance exist over longer lasting time spans in humans remains uncertain.

Aim

In order to assess the association between interval length and inflammatory responses to repeated administration of endotoxin, we administered endotoxin on two occasions with varying lengths of trial day intervals.

Methods

On two separate occasions, we exposed 18 healthy young men to E. Coli endotoxin (10,000 USP Endotoxin). Inflammatory responses to endotoxin were heart rate, mean arterial blood pressure and increments in temperature along with alterations in various cytokines and cortisol.

Results

Tolerance to endotoxin was confirmed by a reduced response to re-stimulation with endotoxin on the second trial day where the ratio between trial day 1 and 2 of 0.84 (95% CI 0.66-1.06, p=0.16), 0.93 (95% CI: 0.7-1.16, p=0.52) and 1.26 (95% CI 0.88-1.64, p=0.16) for TNF-alpha, IL-6 and IL-10. The ratio between cortisol levels was 0.91 (95% CI 0.81-1.00, p=0.052). Alterations in vital signs were not statistically significant between trial days. The median interval between exposures was 64 days (14-244).

Conclusion

Our results show a true in vivo tolerance to re-stimulation with endotoxin in The Human Endoxemia Model over a period of 14-244 days. This is a novel finding, which should be taken into consideration, when applying repeated endotoxin administration in humans, although the magnitude of weakening of responses is minor and wanes with increasing time spans between exposures.

 

Nothing to Disclose: HHT, NR, EB, JOLJ, NM

20264 11.0000 FRI-629 A Hormone and Cytokine Responses to Repeated Endotoxin Exposure – Evidence for Endotoxin Tolerance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Anya Tahani Weerasinghe*, Charu Kolekar, Sarosh Khan and Rhonda Kay Trousdale
Harlem Hospital, New York, NY

 

Introduction:

Diabetic Ketoacidosis (DKA) is a potentially life threatening complication of diabetes mellitus (DM). It is predominantly associated with Type 1 DM; however may occasionally be seen in Type 2 DM. Over the last few years, there have been case reports describing DKA, extreme hyperglycemic hyperosmolar state and even starvation ketosis associated with excessive soda consumption(1-4).  We present a case of a patient who had originally been diagnosed with type 1 DM but was later found to have type 2 DM with episodes of DKA when allowed unlimited access to soda.

Case:
A 38 year old African American female with a history of schizophrenia, bipolar disorder and type 1 DM was found unconscious at home and brought into the ED.  Blood Glucose was high at 1480mg/dl, pH 6.951, bicarbonate 6mmol/l, positive ketones. She was admitted to the ICU for treatment of DKA.  Work-up for infection was negative.  BMI of 27.  GAD antibodies were negative.  C-peptide level was 0.6ng/ml(0.9-7.1) when BG was 361mg/dl.  Presentation was consistent with Type 1 DM. 

When she awoke she reported being diagnosed with Type 1 DM 4 years ago in prison and given insulin. She had no family history of DM. She was released to a half-way house 3 months earlier and stopped taking her insulin.  She had a full recovery and was discharged on basal lantus and mealtime lispro. 
Less than 12 hours later she returned to the ED with acute psychosis.  Her case worker reported that in the half-way house she had been refusing to take her medications, including insulin and was only seen drinking soda - often more than 8 liters of soda per day in the week prior to admission.
On psychiatry ward, her BG was in 200-300mg/dl range.  The patient refused all insulin.  She agreed to oral Metformin and Januvia.  She did not have access to soda during admission.  7 days later, her random BG levels were all below 180mg/dl without insulin. 

Discussion:
Based on age, BMI, low c-peptide levels, and DKA, we originally agreed with the diagnosis of type 1 DM.  Her BG control with oral hypoglycemics alone on psychiatry ward clearly ruled out type 1 DM.  We considered A-β+ ketosis-prone T2 DM but this is more common in overweight African American and Latino men with a family history of diabetes,and is not usually associated with excessive hyperglycemia to her level of 1480. The ketoacidosis in these patients is generally spontaneous with no relation to infection, alcohol intake or stressors (5). Her fast recovery to normal BG without additional insulin after discharge suggests the excessive soda consumption created temporary acute beta cell dysfunction which contributed to the severe DKA on admission.  A better understanding of the effect of extreme soda intake on beta cell function in people without type 1 DM is needed.

 

Nothing to Disclose: ATW, CK, SK, RKT

21980 12.0000 FRI-630 A Diabetic Ketoacidosis Secondary to Excessive Soda Consumption in a Patient with Type 2 Diabetes. 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Mads Svart*1, Nikolaj Rittig1, Ulla Kampmann1, Niels Jessen1, Mogens Johannesen2, Per Løgstrup1 and Niels Møller1
1Aarhus University Hospital, Aarhus C, Denmark, 2Aarhus University Hospital, Aarhus N, Denmark

 

Background

Ketoacidosis is a life-threatening condition for patients with type 1 diabetes accounting for many hospitalizations every year. Ketoacidosis is often associated with infection/inflammation creating a vicious cycle. Inflammation decreases insulin sensitivity and causes food aversion and as a consequence some patients pause or reduce their insulin treatment. This, together with a stress metabolic response of inflammation stimulate release of free fatty acids and the formation of ketone bodies (in particular, beta-hydroxy-buturate, 3-OHB). The molecular mechanisms accountable for accelerated lipolysis and ketogenesis during ketoacidosis are poorly understood in humans.

The aim of our study is to create a new human model for mimicking ketoacidosis in patients with type 1 diabetes by combining infliction of relative hypoinsulinemia and exposure to lipopolysaccharide (LPS – endotoxin), and assessing regulation of lipolysis  in adipose tissue under these conditions.  

Design

We are currently conducting a randomized, cross over study including 9 patients with type 1 diabetes. All subjects are investigated on two occasions separated by at least 4 weeks. One day under euglycaemic control conditions (CTR) and one day under hyperglycaemic, ketotic conditions (KET). Subjects are hospitalized the evening prior to investigation and are treated with their normal dose of insulin (CTR) or a reduced dose of insulin (KET) throughout the night. In the KET morning, subjects are given an intravenous bolus of LPS.

Results

Preliminary results are available for N=3. Ketone levels measured as 3-OHB were higher during KET (2.0 mmol/l (SE ± 0.8)) than during CTR (0.1 mmol/l (SE ±0.03)). Furthermore, blood glucose levels were higher during KET (16.3 mmol/l (SE ± 0.5)) than during CTR (6.9 mmol/l (SE ± 0.7)). Indices of lipase activity are being processed.

Conclusion

We have established a new experimental human model of the initial steps of diabetic ketoacidosis allowing definition of the metabolic mechanisms inducing uncontrolled lipolysis in adipose tissue.

 

Nothing to Disclose: MS, NR, UK, NJ, MJ, PL, NM

19299 13.0000 FRI-631 A A New Human Model of Diabetic Ketoacidosis Combining Lipopolysaccharide Administration with Lack of Insulin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Nandita Sinha*, Halis Sonmez, Erwyn Chua Ong, Alberto Franco-Akel and Agustin Busta
Mount Sinai Beth Israel, New York, NY

 

Introduction: The effect of severe HTG in the pathophysiology of DKA has not been well studied. We report a rare case of a T2DM patient presenting with severe HTG associated with DKA and nonspecific lipase elevation, all of which resolved with insulin infusion. 

Clinical case: A 52-year old male with T2DM, combined hyperlipidemia, alcohol dependence presented with polyuria, polydipsia, weakness and sudden onset of shortness of breath. Examination showed BMI of 31 kg/m2, tachycardia, tachypnea and dehydration. Remainder of review of system and physical examination were unremarkable.

Laboratory: HbA1c: 9.8%, glucose: 324 mg/dL, venous blood gas: pH 6.92, bicarbonate 4.9 mEq/L, urine ketone bodies > 150 mg/dL, anion gap 27, triglyceride (TG) 6462 (n <151 mg/dL), total cholesterol (TC) 572 (n <200 mg /dL), HDL 31 (n >40 mg/dL), lipase 835 (n 23-300 U/L), C-peptide 0.35 (n 0.8-3.1 ng/mL). No evidence of infection, stroke or cardiac events.

Patient was given insulin infusion for 48 hours to treat both DKA and severe HTG. Acidosis, HTG (TG 1278) and pancreatic enzyme levels (Lipase 220) improved. Patient was discharged on multi-dose insulin therapy, dietary recommendation, gemfibrozil and atorvastatin.

Two weeks later, there was marked improvement in TG and metabolic markers: TG 146, LDL 226, TC 303, HDL 29, LPA cholesterol 2.0 (n <10 mg/dL), total VLDL 47, C-Peptide 1.53.

Discussion: It has been proposed that severe HTG causing pancreatitis/pancreatic cell dysfunction is due to the direct toxic effect of free fatty acid (FFA), ischemia and inflammation. Also, TG accumulation induces selective insulin resistance in liver and muscle.  In vitro studies have shown that chronic exposure of pancreatic β-cell to FFA inhibits the acute insulin response to glucose load. On the other hand, deficiency of insulin activates lipolysis in adipose tissue releasing FFA (accelerating formation of VLDL in the liver), and it also reduces activity of lipoprotein lipase (LPL) in peripheral tissues (decreasing removal of VLDL from plasma), both contributing to HTG. Thus, one can suggest that this might further perpetuate to DKA and pancreatitis/nonspecific elevation of pancreatic enzymes.

There is no consensus for treatment of severe HTG in this scenario. Clinical experience has shown that insulin treatment can correct severe HTG by activating LPL and breakdown of chylomicron, with subsequent improvement of insulin sensitivity. In our case, insulin infusion was successful in rapidly decreasing severe HTG and improving metabolic markers.

Conclusion: We propose that insulin infusion provides a simple, rapid, noninvasive, and safe treatment option for severe HTG associated with DKA and nonspecific pancreatic enzyme elevation in a patient with T2DM. Addition of anti-lipid agent(s) will hasten lowering of TG levels by mitigating its contribution to further insulin resistance and decreased insulin secretion.

 

Nothing to Disclose: NS, HS, ECO, AF, AB

20722 14.0000 FRI-632 A Severe Hypertriglyceridemia (HTG) As Proposed Culprit for Diabetic Ketoacidosis (DKA) in a Patient with Type 2 Diabetes Mellitus (T2DM) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Narmada Movva*1 and Janice L Gilden2
1Rosalind Franklin University of Medicine and Science/Chicago Medical School, North Chicago, 2Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL

 

 Background:

Insulin (INS)  resistance occurs when there is a subnormal glucose response to endogenous  or exogenous insulin.  Further,  INS  resistance is defined by a patient requiring  > 200 units of daily exogenous INS for treatment of hyperglycemia.   The rate-limiting step for INS activity is absorption after administration.  Most of the variability correlates with blood flow differences at injection sites and is also affected by volume of the injected liquid.  Larger doses can also cause a delay in the peak of action as well as changes in duration of action.  Prior studies have shown a mean glycosylated hemoglobin (A1c) improvement  of 2.8% from switching from U-100 NPH insulin to U-500 regular insulin in  uncontrolled  obese diabetic patients (requiring >200 units of insulin daily).

Clinical case:

Our patient is a 62 yr old, Puerto Rican non-obese female (BMI of 25.68) with 20 yrs of Diabetes Mellitus, chronic pancreatitis thought  secondary to  alcohol abuse ( >25yrs ago, with abstention since), diabetic retinopathy , peripheral and autonomic neuropathy (neurogenic orthostatic hypotension), necrobiosis , hyperlipidemia, gastroesophageal reflux disease, and depression.  There was no acanthosis nigicans.  Despite increasing doses of varying types of basal  and bolus insulin preparations, compliance with diet and medication, the blood glucose levels (BG) remained between 250-350 mg%  during the day.   Trials of other agents, such as metformin,  symlin,  and incretins improved her sugars,  but she was unable to tolerate any due to localized and  gastrointestinal  side effects.  A1c values ranged between 9-10.2%.  Due to lack of glycemic control despite increasing daily doses of insulin to 320 units, questionable absorption of high fluid volumes, and painful injection sites, a trial of U500 insulin was started at a dose of 25 units twice daily.  She returned 2 weeks later, and reported that due to lower sugars, she now required only 5 units of U500 twice daily.  Premeal  BG were  80-190 mg% and 2hr post prandial BG  were  130-200 mg%.  A1c  was 7.6 %.  She also reported decreased symptoms of hyperglycemia.

Discussion:

U-500 is a concentrated form of regular insulin that can be used to control hyperglycemia in severely insulin resistant patients (obesity, immune-mediated insulin resistance, and genetic abnormalities of the insulin receptor).  The pharmacologic profile of U-500 regular insulin is most similar to that of NPH, since there is delayed absorption and less variation.  Our non-obese INS resistant patient demonstrated rapid improvement in glycemic control following a switch to U500 insulin.

Conclusion:

This case highlights that switching from high dose insulin therapy  to U-500 regular insulin can be an effective strategy to improve  glycemic control in a non-obese  poorly controlled diabetic patient when no other insulin sensitizers can be used.

 

Disclosure: JLG: Speaker, Novo Nordisk. Nothing to Disclose: NM

20782 15.0000 FRI-633 A Successful Use of U-500 Insulin in a Patient with Insulin Resistance and Pancreatic Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Radhika Deshmukh*1, Bantwal Suresh Baliga2 and Lori Fuller1
1East Alabama Endrocrinology, Opelika, AL, 2East Alabama Endo, PC, Columbus, GA

 

Background:

We report a 22 year old male patient who  was referred for  evaluation of hypoglycemia and history of syncope since December 2013. He underwent thorough evaluation of hypoglyecemia including fasting insulin levels, 5 hour oral glucose tolerance test (OGTT) and ACTH stimulation test. Initial OGTT showed extremely low blood glucose (BG) levels of 14 mg /dl at 3 hours. However, 72 hour fasting at the hospital showed the lowest blood glucose reading to be 54 mg/dl only. 5 hour OGTT  immediately after 72 hour fasting showed BG in the diabetic range with maximum BG of 384 mg/dl at 2 hours. Few days later Glucose tolerance test in response to mixed meal showed features consistent with reactive hypoglycemia again!

Case Report:

We report a 22 year old male patient who was referred for the evaluation of hypoglycemia and recurrent episodes of recurrent. During the initial visit he complained of increased urinary frequency, increased thirst and an episode of syncope in December of 2013. The physical examination was unremarkable except for palpable left lymph node in the right superior neck. He was then followed up with fasting insulin levels, 5 hour OGTT, ACTH stimulation test and CT  scan of the neck. The fasting insulin level was low at 4, with corresponding BG of 77 . The 5 hour OGTT showed BG of 14 mg/dl at 3 hour suggestive of reactive hypoglycemia. Continuous glucose sensor (DEXCOM) showed lowest BG of 54 . The ACTH stimulation test showed robust response thus ruling out underlying adrenal insufficiency. Subsequently he was hospitalized for 72 hour fasting. BGs did not drop lower than 54 mg/dl throughout the fasting. At the end of the fasting, the insulin and the C peptide levels were appropriately low. However, 5 hour OGTT done soon after the fast was complete, showed BG to be in the diabetic range of 384 at 2 hr. Subsequently he underwent mixed meal tolerance test in the out- patient setting, the fasting BG was 63 mg/dl and 3 hr BG was 64 mg/dl again suggestive of reactive hypoglycemia. We advised the patient to continue with low carbohydrate, protein snacks at regular intervals and continue BG monitoring. CT scan of the pancreas did not show any abnormality.

Conclusion: Here we present a curious case of severe reactive hypoglycemia as suggested by symptomatology, OGTT, mixed meal tolerance test etc. Laboratory findings were not consistent with underlying insulinoma or Nesidioblastosis. OGTT at the end of the 72 hour fasting curiously showed glucose curve suggesting severe hypeglycemia. We do not have clear explanation for this anomaly. It is possible that Beta cells of the pancreas were in hibernation during fasting and failed to respond appropriately to the glucose load.

 

Nothing to Disclose: RD, BSB, LF

19625 16.0000 FRI-635 A A Curious Case of Severe Hypoglycemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 618-635 5930 1:00:00 PM Diabetes Case Reports Poster


Florencia Halperin*1, Su Ann Ding2, Donald C Simonson1, Marlene Wewalka2, Kathleen Foster2, Katherine Kelly2, Jennifer Panosian2, Ann Goebel-Fabbri2, Osama Hamdy2, Kerri Clancy3, David Lautz3, Ashley Vernon1 and Allison B Goldfine2
1Brigham and Women's Hospital, Boston, MA, 2Joslin Diabetes Center, Boston, MA, 3Emerson Hospital, Concord, MA

 

To compare effectiveness of bariatric surgery vs. intensive medical diabetes and weight management on cardiometabolic outcomes, we randomized 40 obese T2D (22 M / 18 F; age 51 ± 10 yrs; weight 109 ± 15 kg; BMI 36.5 ± 3.7 kg/m²; diabetes duration 9 ± 5 yrs; HbA1c 8.2 ± 1.2%; 40% on insulin) to laparoscopic adjustable gastric band (LAGB; n = 18) or intensive medical diabetes and weight management (IMWM; n = 22) with 12 months follow up. After 10% weight loss or 3 months (if 10% weight loss was not achieved), similar reductions in weight (-9.7 ± 0.8 vs. -9.2 ± 0.8 kg; LAGB vs IMWM) and fat mass by bioelectrical impedance (-8.0 ± 0.8 vs. -6.6 ± 0.8 kg) occurred. At 12 months, however, loss of weight (-13.5 ± 1.7 vs. -8.5 ± 1.6 kg, p < 0.05) and fat mass (-10.4 ± 1.3 vs. -6.7 ± 1.3 kg, p = 0.05) were greater post-LAGB. Total weight and fat mass loss were highly correlated in both groups (LAGB: r = 0.88, p < 0.001; IMWM: r = 0.73, p < 0.001). HbA1c reduction was similar post-LAGB vs. IMWM at both 3 months (-1.0 ± 0.3 vs. -1.7 ± 0.3%; p = 0.06) and 12 months (-1.2 ± 0.3 vs. -1.0 ± 0.3%). A pre-specified glycemic endpoint, defined as HbA1c < 6.5% and fasting glucose < 126 mg/dl at 12 months on or off medication, was achieved in 6 of 18 (33%) patients in the LAGB group and 5 of 19 (26%) in the IMWM group. At 12 months, reductions in systolic blood pressure (BP) were greater after IMWM vs LAGB (-5±2 vs 2±3, p = 0.05), with no differences in diastolic BP. Triglycerides decreased (-30 ± 16 vs. -43 ± 16 mg/dl) and HDL increased (8 ± 2 vs. 5 ± 2 mg/dl) in LAGB vs. IMWM, respectively, but without differences between groups. Change in LDL cholesterol trended lower in LAGB (-8 ± 6 vs. 5 ± 5 mg/dl; p = 0.09). Five-year risk of a coronary heart disease (CHD) event as determined by the UKPDS risk engine scores decreased from 10.5 ± 1.8% at baseline to 9.2 ± 2.1% at 12 months in the LAGB group (p < 0.05), and from 9.7 ± 1.7% to 9.0 ± 1.8% in the IMWM group (p = 0.11), with no significant difference between groups. Risk of a fatal CHD event also decreased from 6.5 ± 1.3% to 5.9 ± 1.5% in LAGB, and from 5.8 ± 1.1% to 5.5 ± 1.3% in IMWM, although these changes were not statistically significant. In summary, after 12 months of follow-up: 1) LAGB produces greater weight loss than an intensive diabetes and medical weight management program, 2) The total amount of weight loss is highly correlated with loss of fat mass in both groups, 3) Both LAGB and intensive medical management produce similar improvements in HbA1c and attainment of glycemic control, 4) Both groups had modest improvements in lipids and blood pressure, which were reflected in a moderate reduction in predicted CHD risk. These findings suggest that LAGB and an intensive diabetes and weight management program have many similar benefits on diabetes control and cardiometabolic risk factors, which should be discussed in the context of other factors such as personal preference or surgical eligibility when considering treatment options in obese type 2 diabetes patients.

 

Disclosure: OH: Research Funding, Metagenics, Research Funding, Neurometrix, Consultant, Abbott Laboratories, Consultant, Merck & Co.. ABG: Advisory Group Member, Novo Nordisk. Nothing to Disclose: FH, SAD, DCS, MW, KF, KK, JP, AG, KC, DL, AV

21843 1.0000 FRI-645 A Comparative Effectiveness of Cardiometabolic Outcomes after Laparoscopic Adjustable Gastric Banding Vs. Intensive Diabetes and Weight Management in Obese Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Shafaq Khairi*1, Babak Torabi Sagvand2 and Syed Kamal Nasser3
1Mercy Catholic Medical Center, Darby, PA, 2Massachusetts General Hospital, Boston, MA, 3Southeastern Regional Medical Centre

 

Many studies have shown that carbohydrate-restriction is a safe and effective intervention for weight loss and improvement in cardio metabolic risk. However, published data is limited regarding the use of carbohydrate-restriction in the treatment of Type 2 diabetes mellitus, especially in Native Americans in a real-world clinical practice setting.

We evaluated the efficacy of a carbohydrate-restricted diet on obese Type 2 diabetic subjects in a primary care/obesity medicine practice consisting mostly of Native Americans (Lumbee Indians).

The primary intervention was a carbohydrate-restricted diet defined as intake of <20 grams of carbohydrates/day. The intervention involved providing an educational handout and behavioral counseling assisted by a dedicated weight loss coordinator. We evaluated the effects of this intervention on body weight, blood pressure, lipid parameters and HbA1c. The patients were evaluated at baseline, 3 and 6-months. The patients underwent additional safety and counseling visits throughout the study. Patients were considered completers if they had baseline and 6 months data for weight and Hemoglobin A1c (HgbA1c).

Forty obese diabetic patients were studied. Thirty-eight were Native American. The mean age was 54.9±9.1 years and 60% were female. The baseline BMI was 38.4±6.6 kg/m2. Subjects lost an average of 10±4.0 kg in weight (9.1±3.2% total weight loss and 30.1±12.9% excess weight loss, p<.0001). Additionally, subjects had significant improvements in BMI (-3.5±1.4 kg/m2, p<.0001), HbA1C (-1.4±0.9%, p<.0001), systolic (-16±9 mm Hg, p<.0001), and diastolic blood pressure (-10±9 mmHg, p<.0001). Subjects also had significant improvement in total (-21.9±24.6 mg/dl, p<.0001) and LDL cholesterol (-41.5±19.2 mg/dl, p<.0001) and triglycerides (-43±45 mg/dl, p<.0001). Most patients had reduction or elimination of diabetes medications. In patients receiving insulin, the total required insulin dose was significantly decreased (-36±34 U/day, N=15, p=.0017) and one subject discontinued insulin entirely. The dose of metformin was also significantly reduced (-421±576, p=0.0005).

Carbohydrate-restricted diet led to clinically and statistically significant reductions in body weight, HbA1c and insulin requirement among patients with type 2 diabetes over a six month period. The results suggest carbohydrate restriction can be an effective real-world intervention in a primarily Native American clinical practice. However, further studies are needed to assess long term compliance and potential weight regain.

 

Nothing to Disclose: SK, BT, SKN

20604 2.0000 FRI-646 A Weighty Matters; The Impact of Low Carbohydrate Diet on Native American Diabetics 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Maysa Vieira Sousa*1, Ronaldo Cardoso2, Rosa Fukui2 and Maria Elizabeth Rossi da Silva2
1University of Sao Paulo, São Paulo, Brazil, 2University of Sao Paulo

 

Football training and caloric-restricted diet on biomarkers of insulin action in Brazilians patients with type 2 diabetes

High intensity interval training (~20-min bouts) performed by type 2 diabetic (T2D) patients over 2 weeks improved their metabolic health and glucose control (1). Similarly, football is a vigorous exercise interspersed with periods of rest (2, 3), and may be an attractive option to implement higher intensity training in patients. Then, it might be a good intervention strategy to prevent or treat diabetes, besides being very popular among Brazilians. Therefore, we aimed to compare acute and chronic football training with caloric-restricted diet versus diet alone on biomarkers of insulin action in patients with T2D. Fifty-one middle-aged (61.1±6.4 years) T2D patients (29 females and 22 males) were randomly allocated to the football+diet group (FDG; n= 22) or to the diet group (DG; n= 29). During 12 weeks, FDG performed 3x40 min/week of football training. After 40 min of the first football session, increases (P<0.05) were observed in blood lactate (from 1.4±0.1 to 6.0±0.7 mmol/L) and glucagon levels (from 112.1±6.2 to 142.9±8.0 pg/mL), and in glucagon/insulin ratio (from 6.8±0.5 to 8.7±0.8), whereas glucose and insulin levels remained similar. Further, FDG suppressed postprandial insulin response and determined higher free-fatty-acids, lactate levels, and glucagon/insulin ratio than DG (p<0.05). At 48 h of recovery a decrease was observed in leptin levels (p<0.05), however such difference was no longer evident at the last training session. After 12 weeks of treatment, fat mass decreased similarly in both groups by ~3.4 kg. VO2max increased by 11.4±0.2% in FDG and decreased by 5.7±0.1% in DG (p<0.05). Baseline reductions on fasting glucose and glucagon levels (p<0.05) were observed in FDG whereas lactate and leptin decreased in both FDG and DG groups (p<0.05). In conclusion, long term football training enhanced insulin sensitivity attested by lower glucose and glucagon levels, improved metabolic responses and VO2max in T2D patients, being a secure strategy to treat diabetes. Moreover, part of these improvements was observed after first acute training evidenced by lower insulin and leptin levels.

 

 

Nothing to Disclose: MVS, RC, RF, MER

20775 3.0000 FRI-647 A Football Training and Caloric-Restricted Diet on Biomarkers of Insulin Action in Brazilians Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Elamin Abdelgadir*1, Khadija Hafiz2, Alaaeldin Bashier3 and Mohamed Hassanein4
1Dubai Hospital, Dubai Health Authority, 2Rashid Hospital, Dubai Health Authority, 3Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates, 4Dubai Hospital, Dubai, United Arab Emirates

 

Ramadan is a lunar month in which more than 1.7 billion Muslims worldwide obey a religious command of  fasting for a month. The period of fasting varies between different countries with an average of 14-18 hours per day. This prolonged fasting may be associated with increased morbidity and admissions with complications in small number of people with diabetes  especially if they are not well controlled. Objective: We aimed to compare the rate of admissions with diabetic ketoacidosis during Ramadan and in the following month. We also aimed to assess the cause of admission and duration of acidosis as secondary end points. Methods: we prospectively assessed all adult Muslim patients who were admitted with DKA in two major hospitals in Dubai, we looked at many parameter including demographics, clinical, and laboratory indices of the patients. These data was later analyzed to assess for primary and secondary end points. Results: A total of 26 patients were admitted during the two months, 12 were admitted during Ramadan and 16 in the following month. All those admitted during Ramadan were type1 diabetes while 4 of those admitted in the following month were type2 diabetes. 91.7% of those admitted during Ramadan did not receive any education on management of diabetes during Ramadan. Urinary tract infections represented the most common cause for admission in both months. There was a significant difference in the duration of DKA due to more severe acidosis compared to the following month (P=0.02). Conclusion: Our study showed no higher rate of DKA admissions during Ramadan in comparison to the following month, nevertheless during Ramadan the duration of acidosis was longer (p0.02). The average Hba1c was significantly lower in Ramadan group (p0.041). Further larger studies are required to evaluate the rates of hospitalization during the month of Ramadan.

 

Nothing to Disclose: EA, KH, AB, MH

19563 4.0000 FRI-648 A Comparison of Incidences and Precipitating Factors of Diabetic Ketoacidosis in Ramadan and the Following Month in a Major Hospital in Dubai, United Arab Emirates. a Prospective Observational Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Sandeep Kumar Mathur*1, Poonam Punjabi2, Radhika Vaishnav3 and Prashant Mathur2
1SMS Medical College, Jaipur, India, 2SMS Medical College, Jaipur, Rajasthan, India, 3Vadodara stroke clinic, Vadodara, India

 

Background:T2DM  is associated with autonomic dysfunction measured as heart rate variability. Several studies have shown association of adipocytokines with an increased risk for the presence of autonomic dysregulation. In our previous study we found that autonomic dysfunction in Asian Indian diabetics is related to body weight instead of insulin resistance.

Aim:   To study the relationship between adiposity, HOMA-R, adipocytokines and autonomic dysfunction in Asian Indian T2DM patients.

Methods and Materials:90 T2DM patients (ages 30-66, mean 48)participated in the study. Following parameters were estimated in among diabetics: BMI,waist circumference, glucose, lipid profile, HOMA-R, HOMA-β, adipocytokines: leptin, adiponectin, hsCRP, TNF-alpha, and autonomic regulation  assessed in the form of  heart rate variability (HRV) parameters: Total Power, LF (nu), HF (nu), and LF/HF Ratio.15 patients weretreated with pioglitazone 30 mg PO once daily for at least 6 months and parameters were estimated among diabetics at baseline and 6 months.Pearson correlation test was used to study relationshipsamong the different parameters. Multivariate analysis and post-hoc t-tests were carried out to determine differences in means before and after treatment. P-values of 0.05 or less were considered as significant.

Results:Autonomic parameters did not show any correlation with adipocytokines.After 6 months treatment, as expected, glucose and lipid parameters showed statistically significant improvement. A significant 30% decrease was seen in hsCRP but no significant change in other adipocytokines. Various HRV parameters showed improvement.There was no association between change in BMI, adipocytokines,HOMA-R and HRV parameters. TNF-alpha, hsCRP and adiponectin showed a significant correlation with waist circumference and HOMA-R.

Conclusions:We did not find any association between adipocytokines and autonomic dysfunction. Although pioglitazone affects autonomic dysregulation, this is not related to change in adipocytokines

 

Nothing to Disclose: SKM, PP, RV, PM

21882 5.0000 FRI-649 A A Study of Relation Between Adipocytokines, Adipocity, HOMA-R and HRV Parameters of Autonomic Function in Asian Indian Diabetics 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Vaishnavi Amit Parnerkar*1, Jennifer Frances Iverson2, Mary Gannon3 and Frank Q Nuttall3
1University of Minnesota, MN, 2Park Nicollet health system, Eden Prairie, MN, 3VA Medical Center, Minneapolis, MN

 

Leucine (Leu) ingestion by normal individuals, only weakly stimulates an increase in insulin.  The glucose concentration remains unchanged.  However, we recently reported that if Leu is ingested with glucose (Glu) it further increased the insulin response (66% increase) when compared to when glucose was ingested alone.  This increase in insulin also resulted in a 50% smaller increase in glucose response.  That is, there was a synergistic effect on the insulin and glucose responses.

The objective in the present study was to determine whether similar responses would be obtained in patients with untreated Type 2 Diabetes Mellitus (T2D).  The glucagon response also was monitored.

Six subjects with type T2D (not on anti-diabetes oral agents ) were studied on 4 separate days.  On the first day they received water only (control).  Subjects then received either 1) 25 g Glu alone, 2) 1 mmol/kg lean body mass Leu, or 3) Leu+Glu, in random order.  After fasting for 12 hr, overnight 3 baseline blood samples were obtained on each occasion at ~ 0800 hr. Blood samples then were drawn every 15 min for 5 hr and analyzed for glucose, insulin and glucagon concentrations. Net areas under the curve were calculated using the mean fasting value as baseline.

When Leu was ingested alone, it modestly increased the insulin area response when compared to water alone, as expected (p=0.04). When glucose was ingested alone, the insulin area response also increased, as expected. However, when Leu+Glu was ingested together the insulin area response almost doubled (99% increase) compared to glucose alone (p=0.009).  The glucose area response following Leu+Glu ingestion was essentially the same as when only glucose was ingested.  The glucagon concentration did not change with Leu±Glu ingestion.  It modestly increased when Leu was ingested alone

In summary, in normal subjects Leu+Glu ingestion results in a strong synergistic effect on insulin area (66%) and a corresponding decrease in glucose area response (50%).  In patients with T2D addition of Leu to Glu strongly stimulated the insulin response, i.e. the insulin response doubled.  However it had no effect on the glucose response.  Why the glucose concentration did not respond to the addition of Leu in T2D remains to be determined.

 

Nothing to Disclose: VAP, JFI, MG, FQN

18504 6.0000 FRI-650 A Effect of Leucine on Glucose Metabolism in Individuals with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Heung-Yong Jin*1 and Kyung Ae Lee2
1Chonbuk National University School of Medicine, Jeonju, Korea, Republic of (South), 2Chonbuk National University Hospital, Jeonju, Korea, Republic of (South)

 

75g oral glucose tolerance test (OGTT) is helpful to diagnose diabetes, especially when patient shows impaired fasting plasma glucose (IFG) state although inter-or intra-individual variability and low reproducibility can be a pitfall. Moreover, this glucose loading can be non-physiological in the clinical practice. In this study, we investigated the relation among fasting plasma glucose (FPG), 2hr PLG, and HbA1c and clinical usefulness of 2 hr PLG in the decision of anti-diabetic medication initiation.

In method, 75g OGTT results of 1,754 patients from Jan.1995 to Dec. 2013 were analyzed. The relation and the degree of consistency among 2 hr PLG in OGTT, FPG, and HbA1c value were assessed according to the ADA diabetes criteria. Besides, the degree of contribution of 2 hr PLG in the prescription of anti-diabetic medication and average values of 2 hr PLG in normal and diabetic state based on FPG and HbA1c levels were calculated.

In result, among 1,754 patients, 596 patients (34,.0%) showed normal FPG (below 99mg/dL), however, they had family history of diabetes or random glucoses were within 140-200mg/dL, and so they wanted to test glucose loading evaluation. FPG of 704 patients (40.1%) were between 100 and 125mg/dL, hence OGTT was performed to determine disease state. 454 patients (25.9%) already showed FPG over 126mg/dL, however, OGTT also was performed to assess the degree of glucose tolerance. Among 596 patients of normal FPG, only 208 patients (34.9%) were normal glucose tolerance state in the respect of 2hr PLG (<140mg/dL) and HbA1c (5.7%). 321 patients (53.9%) were included in the impaired glucose tolerance (IGT) state. 67 patients (11.2%) showed 2hr PLG over 200mg/dL compatible to diabetes according to the ADA criteria, however, HbA1c of 21 patients (31.3%) was below 5.7%. Only 28 patients (42.0%) have been treated with anti-diabetic agents and others just have performed glucose monitoring because there random glucose values were not as high as 2hr PGL of OGTT based on the daily calori intake. Among 454 patients of diabetic patients based on the FPG, 409 patients (90.1%) also showed over 200mg/dL 2hr PLG and HbA1c of 347 patients (76.4%) was over 6.5%. However, 45 patients (9.9%) showed 2hr glucose level below 200mg/dL.

In conclusion, when we interpret OGTT result, it is necessary to keep in mind that around 10% patients are not adequate to diagnose diabetes based on the 2hr PGL value and we need to re-assess that the amount of loading glucose such as 75g and the cut off value of 2hr PGL in these patients. Moreover, the amount of loading glucose in tolerance test needs to be subdivided or categorized according to body weight, individual life pattern, or necessary calori to increase the usefulness of it in the clinical decision of diabetes management although our results did not show significant difference in BMI.

 

Nothing to Disclose: HYJ, KAL

18268 7.0000 FRI-651 A Reconsideration of the Usefulness of 2 Hr Glucose Value after 75g Glucose Loading in the Diagnosis of Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Peter Shane Hamblin*1, Michael Green1, Thien Tran2 and Christopher Preston2
1Western Health, Melbourne, Australia, 2University of Melbourne, Melbourne, Australia

 

Synthetic glucocorticoid administration decreases insulin secretion and sensitivity and is known to increase the risk of developing insulin resistance in patients without diabetes, and to exacerbate hyperglycemia in patients with diabetes. High dose glucocorticoid therapy is commonly used in oncology, either as part of cancer treatment or to reduce chemotherapy induced nausea and vomiting. This study aimed to (1) quantify the prevalence of diabetes amongst chemotherapy patients receiving glucocorticoid treatment at Western Health, Melbourne, Australia, (2) investigate the level of glycemic control in these patients, and (3) evaluate the current rate of blood glucose monitoring in all oncology patients receiving adjuvant treatment with glucocorticoids. Subjects were a subset of Day Oncology Unit patients (n=478) receiving concurrent treatment with glucocorticoids at the time of chemotherapy. Inclusion criteria comprised active treatment with chemotherapy during the period February 2012 to October 2014, as well as concurrent treatment with either dexamethasone or prednisolone. Diabetic status and glycemic control prior to glucocorticoid administration, and blood glucose monitoring on the day of chemotherapy were then recorded via a systematic search of both paper and electronic medical records, with diabetic status recorded according to patients’ three most recent discharge summaries, General Practitioner correspondences or pre-admission clinic notes. Glycemic control was assessed according to the most recent documented HbA1c up to 12 months prior to treatment with glucocorticoids. Of 478 patients identified through database searches, a total of 279 met the criteria for inclusion in this study. Of these, 18.2% (n=51) had a documented history of diabetes, one quarter of whom (n=13) were documented as requiring insulin. Of the patients with a recorded history of diabetes, only 23.5% (n=12) had a HbA1c result documented in hospital paper or electronic records within 12 months prior to their most recent treatment, with an average result of 7.5%. Of all patients receiving glucocorticoids with chemotherapy, only 1.4% (n=4) had a blood glucose level documented on the day of treatment. It is likely that the documentation of diabetes (18.2%)  underestimates the true rate, given the inpatient diabetes point prevalence at Western Health is 30%-35%(1). This study demonstrates significant under-assessment of the potential for hyperglycemia in glucocorticoid treated oncology patients.

 

Nothing to Disclose: PSH, MG, TT, CP

21097 8.0000 FRI-652 A Under-Assessment of Hyperglycemia in Glucocorticoid Treated Oncology Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Kristine Santos de Luna*1, Erick Sta. Rosa Mendoza2, Bien Jebunan Matawaran3 and Leilani Basa Mercado-Asis2
1University of Santo Tomas Hospital, Manila, Philippines, 2University of Santo Tomas, Manila City, Philippines, 3University of Santo Tomas Hospital, Quezon City, Philippines

 

INTRODUCTION: Before any impairment of glucose tolerance occurs, there is an early stage of compensated hyperinsulinemia or pre-impaired glucose tolerance (pre-IGT). This is a condition in which there is an abnormally high insulin secretion and concomitant insulin resistance. This condition is a forerunner of impaired glucose tolerance and itself a risk factor for cardiovascular diseases. The purpose of the study was to determine whether clinical scoring, plasma glucose level and glycosylated hemoglobin can identify those who are considered to have pre-impaired glucose tolerance state.

METHODOLOGY: This was a retrospective study which reviewed 174 patients who were high risk for diabetes mellitus. Risk factors identified were age, sex, body mass index, previous gestational diabetes mellitus, polycystic ovary syndrome, hypertension and first-degree family history of diabetes. They were screened using fasting plasma glucose, second-hour plasma glucose and plasma insulin after 75 gram glucose load and glycosylated hemoglobin. Multivariate regression analysis was used to establish clinical risk score and Student’s T-test was used to compare differences between pre-IGT group and normal glucose tolerance group (NGT).

RESULTS: In this high risk population, 85 (48.8%) have pre-IGT. There was a significant difference in the second-hour plasma glucose (128.60±18 vs. 90.68±26 g/dL, p-value <0.05), second-hour plasma insulin (86.29±68.82 vs. 17.40±8.15 uIU/mL, p<0.05) and HbA1C (6.09±0.55 vs. 5.15±0.25%, p-value <0.05) between pre-IGT group versus NGT group. The clinical risk score, derived using b-coefficient value of the risk factor, was not shown to be helpful in predicting pre-IGT.

CONCLUSION: Pre-IGT, the first stage of beta-cell dysfunction, can be identified with plasma insulin determination. HbA1C was significantly higher among patients with pre-IGT. Clinical risk scoring was not helpful in identification of pre-IGT reflecting the pre-clinical stage of the disease which may be the most appropriate time for intervention.

 

Nothing to Disclose: KSD, ESRM, BJM, LBM

21518 9.0000 FRI-653 A Elevated Glycosylated Hemoglobin but Not Clinical Risk Scoring Is Correlated with Compensated Hyperinsulinemia or Pre-Impaired Glucose Tolerance State 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Latha Dulipsingh*1, Wendy Spurrier2, Carole Demarest2, Margaret Whitaker2, Sally Cooney2, Diane Mulholland2 and Bernard Clark2
1Saint Francis Hospital and Medical Center, Hartford, CT, 2Saint Francis Hospital and Medical Center

 

Purpose:  To identify adults who are at risk for developing type 2 diabetes and provide an evidence-based lifestyle modification intervention program and evaluate their response to the program.  Methods:  The Center for Diabetes and Metabolic Care (CDMC) at Saint Francis Hospital and Medical Center (SFHMC) screened employees with a risk stratification questionnaire.  Individuals who screened positive were then offered a blood test to evaluate their blood glucose and a hemoglobin A1c (HbA1C).  Those who screened positive for prediabetes, were offered to participate in a lifestyle modification program. Participants worked with lifestyle coaches in a group-based model of 16 core sessions weekly and with monthly follow-up delivered by the same lifestyle coaches for another 6 months thereafter.  The CDMC adopted the lifestyle intervention program offered through the National Diabetes Prevention Program, led by the CDC (Center for Disease Control).  Results:  Of the 207 employees screened, 150 of them were normal.  Fifty seven (57) employees screened positive for prediabetes (28%).  25 individuals initially enrolled in program, 18 started the program and 10 completed program.  32 employees refused to participate in the program and were later referred to the health coaches at Saint Francis Hospital and Medical Center for follow-up.  Conclusion:  Prediabetes is very common and their risk of developing type 2 diabetes is 5-15 times higher than it is for people with normal glucose tolerance. We found that 28% of the subjects that we screened with blood work were found to have the diagnosis of prediabetes.  The 10 individuals who completed the program had a larger median weight loss (8 vs 3 lbs) than non-completers, the difference was not statistically significant (p=0.35).  Similarly, there was not a significant difference in BMI change (p=0.37).The next step is to evaluate the efficacy and sustainability of the lifestyle intervention program. These individuals will be followed over the next two years and to see if they continue to maintain the weight loss or have further weight loss and if this translates to a change in the HbA1c.

 

Nothing to Disclose: LD, WS, CD, MW, SC, DM, BC

18915 10.0000 FRI-654 A Preventing Type 2 Diabetes By Risk Stratification and Implementing Lifestyle Modifications: A Pilot Program at Saint Francis Hospital and Medical Center 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Fida Al-Atrash*1, Margaret Mersereau1, Mary Bierbrauer1, Nasir M. Khan1, Nitesh D Kuhadiya2, Husam Ghanim1, Ajay Chaudhuri1 and Paresh Dandona2
1State University of New York at Buffalo, Buffalo, NY, 2Diabetes and Endocrinology Center of Western New York, Buffalo, NY

 

Since the incidence of diabetes is increasing and the number of endocrinologists is limited, we hypothesized that certified diabetic educators (CDEs) trained and continuously guided by endocrinologists, called CDE-Ambassadors (CDE-A) could be used to instruct and guide patients’ treatment at the primary care level to induce  significant improvements in glycemia (A1c), body weight, blood pressure, lipid concentrations and albuminuria.

We, thus, conducted a retrospective review of one hundred type 2 diabetic patients managed by their primary care provider (PCP) and compared those referred by their PCP to consult with CDE-A with those who were not. The start date was the first visit with the CDE-A. The follow up visit date was the scheduled visit with their PCP following the intervention. Most patients met with the educator twice during that period and no patient consulted an endocrinologist.     

Over a mean duration of follow up of 4.6 months, the  mean A1c  dropped from 8.3 ±2 % to 6.8 ±1%;  weight by 2.8 Kg from 102 ± 22 to 99 ± 22 Kg; and BMI by 0.96 (p <0.0001 for all). Systolic blood pressure decreased from 134 ±17mm Hg to 128 ±13 mm Hg and the diastolic blood pressure dropped from 80±10 mm Hg to 77±9 mm Hg (p< 0.005 for both). LDL Cholesterol fell from 108±36 to 96± 36 mg/dl and triglycerides fell from 189 ±121 to 162±90 mg/dl (p< 0.005). The urine microalbumin/ creatinine ratio also dropped from 64±536 to 27± 153 mg/g (p=0.33). In contrast, in another group of forty five patients with diabetes from the same practice not referred to the CDE-A during the same timeframe, there was no significant change in any of the indices. The magnitude of improvement in HbA1c (1.5%) in our study is markedly greater than that observed in a published meta-analysis of data from trials with CDEs (1) not actively guided by endocrinologists (<0.5%).

Our data show clearly that the participation of the CDE-A, under the guidance of an endocrinologist at the primary care level led to a marked reduction in HbA1c, LDLc, triglycerides, blood pressure and body weight  within 5 months. These changes were dependent on changes in dietary habits and drug therapy including the addition or optimization in the doses of anti-diabetic drugs and insulin therapy. It is of interest that the changes in lipids occurred without any change in statin therapy, probably due to increased compliance.

The changes in glycemia, blood pressure, lipids and body weight would potentially result in a significant reduction in microvascular and macrovascular complications and improvement in the quality of life of these patients. In addition, it will reduce the magnitude of expenditure which currently occurs in the management of these complications. We are now contemplating prospectively randomized studies comparing centers which are supported with CDE-A with those that are not and to study the durability of and cost saving related to these effects.

 

Nothing to Disclose: FA, MM, MB, NMK, NDK, HG, AC, PD

19069 11.0000 FRI-655 A The CDE-Ambassador: A Novel Approach to Control Diabetes at the Primary Care Level Leads to Significant Improvement in Glycemic Control and Cardiovascular Risk Factors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Paola Luca*1, Bodiel Haugrad2, Jonathan M Dawrant1 and Daniele Pacaud1
1Alberta Children's Hospital, Calgary, AB, Canada, 2Alberta Children's Hospital

 

The management of Type 1 Diabetes (T1D) in children and youth is challenging, and can be affected by many psychosocial factors. These variables can be barriers for families to carry out regular diabetes care. During clinic visits, it can be difficult to identify each of the factors impacting a child’s glycemic control and engage families in making changes.

The objective of this quality assurance study was to evaluate the impact of the Diabetes Coach program on Hemoglobin A1C (HbA1C) levels in children and youth with T1D.

The Pediatric Diabetes team at Alberta Children’s Hospital developed an in-home support program for children and youth with T1D, called the Diabetes Coach program. Through this program, a nurse or “diabetes coach” visited families in their homes every 1-2 weeks. There, she had the opportunity to see first-hand diabetes routines, identify barriers for self-management, problem solve with families, and assist in goal-setting. The nurse also followed up with families by phone between visits. An electronic chart review was performed. Statistical analyses included the paired t-test.

Between November 2013-2014, 14 patients were referred to the Diabetes Coach program. Results were available for 8 patients as 6 patients were newly diagnosed at the time of the chart review. The average age of the patients was 12.1 years (range 9.7-15.4 years) and 63% were female. They had an average duration of T1D of 3.1 years (range 0.9-7 years). Prior to participating in the Diabetes Coach program, the average HbA1C was 11.3% (range 10.4-14.1%, reference range 4.3-6.1%). After a average duration of 0.8 years in the program, HbA1C decreased to 10.1% (range 8.9-12%), with an overall change in HbA1C of -1.2% (p=0.13). Feedback about the program from the diabetes clinic staff demonstrated that they felt patients were safer with visits from the diabetes coach.

For children and teens who are struggling to achieve glycemic targets, programs that provide in-home education and follow-up may be a valuable source of support for families and their health care team.

 

Nothing to Disclose: PL, BH, JMD, DP

19110 12.0000 FRI-656 A Evaluation of an in-Home Support Program for Children and Youth with Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Julia Beatrice Cartaya*, Gabriela Heiden Telo, Laurie A Higgins, Heidi M Quinn, Jessica T Markowitz and Lori M Laffel
Joslin Diabetes Center, Boston, MA

 

Successful type 1 diabetes (T1D) management requires a multidisciplinary approach. The American Diabetes Association (ADA) recommends yearly visits with a registered dietitian (RD); however, patients with established T1D often do not meet this recommendation. To evaluate attendance at RD visits, we examined RD visit frequency over a 2 year period and factors associated with RD visits in 1647 patients (50% male) with T1D ≥1 year. Mean age was 15.7±5.3 years (yrs) (range 2.7-30 yrs), T1D duration 8.8±5.0 yrs, and baseline A1C 8.7±1.4%. Of the sample, 108 (7%) had celiac disease and 157 (12%) had hyperlipidemia (LDL≥130mg/dL); 14 (1%) were underweight, 994 (60%) normal weight, 439 (27%) overweight, and 196 (12%) obese. Only 565 (34%) patients had ≥1 RD visit over the 2 years; 101 (6%) had 2 visits and 29 (2%) had ≥3 visits. Patients who had ≥1 RD visit versus those who had none were younger (14.8±4.8 yrs vs 16.1±5.4 yrs, p<0.0001), had shorter T1D duration (8.0±4.6 yrs vs 9.2±5.2 yrs, p<0.0001), and higher A1Cs (8.9±1.3% vs 8.7±1.5%, p=0.002). Patients with RD visits compared to those with none were more likely to have celiac disease (9% vs 5%, p=0.002) and to be overweight/obese (43% vs 37%, p=0.02). Hyperlipidemia status and sex were not associated with RD visits. In multivariable logistic regression, the odds of having an RD visit were reduced 4% per 1 year increase in age (confidence interval (CI) 0.93-0.98, p=0.001) and 3% per 1 year increase in T1D duration (CI 0.94-1, p=0.03), while the odds were increased 16% per 1% increase in A1C (CI 1.08-1.25, p<0.0001), 53% (CI 0.31-0.70, p=0.0002) with a diagnosis of celiac disease, and 30% (CI 0.56-0.87, p=0.001) with overweight/obesity. In summary, only ¨÷ of young patients with established T1D had an RD visit over 2 yrs. Those with visits were more likely to be younger, have shorter T1D duration, higher A1Cs, celiac disease, and elevated BMIs. It appears patients may be referred to see an RD as an intervention (e.g. to improve A1C, manage celiac disease or overweight/obesity) rather than as a preventive strategy to maintain health. To maximize the potential of RD expertise in managing T1D, qualitative investigation involving patients, families, and providers appears indicated to assess reasons behind the infrequent attendance and current referral practices.

 

Disclosure: LML: Consultant, Dexcom, Consultant, Menarini, Consultant, LifeScan/Animas, Consultant, Astra Zeneca, Consultant, Novo Nordisk, Research Funding, Bayer, Inc., Consultant, Eli Lilly & Company, Consultant, Johnson &Johnson, Advisory Group Member, Sanofi, Advisory Group Member, Bristol-Myers Squibb, Consultant, Boehringer Ingelheim. Nothing to Disclose: JBC, GHT, LAH, HMQ, JTM

21962 13.0000 FRI-657 A Predictors of Visits with a Registered Dietitian (RD) for Youth and Young Adults with Type 1 Diabetes (T1D) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Ruth S Weinstock*1, Ingrid Schütz-Fuhrmann2, Mohamed Mubasher3, Julia M Hermann4, David M Maahs5, Morten Schütt6, Sabine E Hofer7, Roy W Beck8 and Reinhard W. Holl9
1SUNY Upstate Med Univ/Syracuse, Syracuse, NY, 2Hospital Hietzing, Vienna, Austria, 3Jaeb Center for Health Research, 4University of Ulm, Ulm, Germany, 5Stanford University, Stanford, CA, 6Medical University of Lubeck, Lubeck, Germany, 7Medical University of Innsbruck, Innsbruck, Austria, 8Jaeb Center for Health Research Tampa FL, Tampa, FL, 9University of Ulm, German Center for Diabetes Research (DZD), Ulm, Germany

 

Type 1 diabetes (T1D) is becoming more common in older adults, but management approaches to reduce acute and chronic complications in this age group have not been well-studied.  Our objective was to compare patient characteristics and treatment-related factors associated with better clinical outcomes in older adults with T1D in the United States T1D Exchange (T1DX) and German/Austrian Diabetes Patienten Verlaufsdokumentation (DPV) registries.  

Both registries collect information from specialized diabetes centers.  We analyzed data from adults aged ≥60 years with T1D seen in 2011-2012 and enrolled in the T1DX (n=1285) and DPV (n=2014) registries.  Age, sex, duration of diabetes, therapies, smoking, HbA1c, lipid levels, and presence of acute and chronic complications were compared between the 2 registries using Wilcoxon rank-sum test for continuous variables and chi-square test for categorical variables.  Further adjusted analysis used Generalized Linear Models.  

Individuals in both registries had similar BMI (mean 27 kg/m2), percent obesity (25%), and percent male (48%).  Mean duration of diabetes was 32.8 years in the T1DX vs 28.8 years in the DPV.  In the T1DX compared with the DPV, mean HbA1c levels (7.5% vs 7.6%) and % HbA1c <7.5% (55% vs 57%) were similar; but more participants had HbA1c <8.5% (86% vs 81%, p=0.006) and there was more self-monitoring of blood glucose (5.7 vs 4.3 times daily; p<0.001), use of insulin pumps (58% vs 18%; p<0.001), and use of continuous glucose monitoring (15% vs. 11%, p=0.007); and fewer episodes of diabetic ketoacidosis (2.0% vs 5.5%; p<0.001).  There also were lower blood pressures (mean 128/68 mm Hg vs 136/74 mm Hg, p<0.001) and more use of antihypertensive medications including ACE-I and ARBs (p<0.001) as well as lower LDL-chol (2.17 mmol/L vs 2.82 mmol/L; p<0.001), more use of statin drugs (p<0.001) and aspirin (p<0.001), and less smoking (6.5% vs 9.7%; p<0.001) in the T1DX.  Notably, in the T1DX compared to the DPV there were fewer myocardial infarctions (6.0% vs 9.1%, p=0.02) and strokes (2.4% vs 8.1%, p<0.001), and fewer microvascular complications including microalbuminuria (17% vs 44%, p<0.001) and stages 4 and 5 chronic kidney disease (p<0.001). Depression was more common in the T1DX (16.0% vs 8.7%, p<0.001).  

A limitation was the cross-sectional study design.  Since data in the T1DX were collected from diabetes centers in the US, they may not be representative of older adults with T1D followed in other practice settings (e.g. primary care and nephrology)

Differences exist between the registries in certain aspects of diabetes management and diabetes complications.  Further assessments are needed to better understand the differences to determine if aspects of care can be modified to improve outcomes.

 

Nothing to Disclose: RSW, IS, MM, JMH, DMM, MS, SEH, RWB, RWH

19353 14.0000 FRI-658 A Type 1 Diabetes in Older Adults: Comparing Treatments and Complications in the United States T1D Exchange and the German/Austrian Dpv Registries 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Shivani Agarwal*1, Abbas F. Jawad2 and Victoria A. Miller2
1University of Pennsylvania Health System, Philadelphia, PA, 2The Children's Hospital of Philadelphia

 

Purpose: Psychosocial characteristics have been identified in prior studies as predictors of HbA1c in adolescents with Type 1 Diabetes (T1D).  However, when incorporated into multivariate models accounting for demographics, disease-related variables, and self-care behaviors, these factors have shown mixed results as they pertain to HbA1c.  This phenomenon may be due to mediation by BGM which continues to show a strong association with HbA1c.  The objective of this study was to add to this body of work, using a multivariate approach to examine correlates of HbA1c in a sample of adolescents with T1D, specifically paying attention to family and parenting variables.

Methods: Participants included 100 adolescents with T1D and their parents.  Questionnaires were administered to both adolescents and their parents to measure youth responsibility for T1D management, youth and parent behaviors during a recent discussion about T1D management, depressive symptoms, psychosocial maturity, treatment adherence, family communication, and parenting style.  Youth also were administered a measure of cognitive development. Bivariate associations with HbA1C were tested with Spearman correlations, independent sample t-tests, or ANOVA.  Hierarchical linear regression was used to inform the predictive model, utilizing variables associated with HbA1C at p < 0.10 in the bivariate analyses. 

Results: In the bivariate analysis, race, family structure, income, insulin regimen, cognitive development, youth responsibility for T1D management, and parent behaviors during the illness management discussion were associated with HbA1c.  Youth age, sex, duration of illness, family communication, parent coercion, psychosocial maturity, and adherence were not associated.  When incorporated into the multivariate model, the only significant predictors of HbA1c were race and insulin regimen, accounting for 17% of the variance in HbA1C values.  As expected, those who were Caucasian had lower HbA1c than their other racial counterparts (8.5% vs. 9.6%; β= -0.86, p=0.006).  Compared to those on insulin pumps, those using pre-mixed insulin (9.4% vs. 8.3%; β=0.85, p=0.036) or basal-bolus therapy (9.1% vs. 8.3%; β=0.75, p=0.019) had worse HbA1c. 

Conclusions: These findings highlight that although bivariate analyses initially show that psychosocial variables, such as parent behaviors related to illness management discussions and youth responsibility for illness management, are associated with HbA1c, in multivariate analyses they are not predictive of HbA1c.  Our study adds to the body of work which uses more complex statistical models of HbA1c to determine predictors.  Our findings suggest that there are most likely hidden mediators to the relationship between psychosocial variables and T1D metabolic control.

 

Nothing to Disclose: SA, AFJ, VAM

19373 15.0000 FRI-659 A A Multivariate Model of Demographic and Psychosocial Predictors of HbA1C in Adolescents with Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Geetha Mukerji*1, Cheryl Harris-Taylor2, Ana Cavacas2, Leah Drazek2, Idan Bergman2, Shilan Sedighi2 and Lorraine Lucille Lipscombe3
1Women’s College Hospital Institute for Health System Solutions and Virtual Care, Toronto, ON, Canada, 2Women's College Hospital, 3Women's College Hospital Research Institute, Toronto, ON, Canada

 

Background: The transition from pediatric to adult type 1 diabetes (T1DM) care represents a high-risk period for young adults (YA) between the ages of 18-30 years. Methods of transfer are variable with a high incidence of loss to follow up and complications. The needs of YA with T1DM are often poorly met by adult centers catering primarily to older adults with type 2 diabetes.

Objectives: To 1) understand current gaps in transitions of care 2) implement an innovative model of care (YA clinic) that improves the transition for YA with type 1 DM.

Methods:

Using a before and after study design, patients 18-30 years with T1DM were assessed at Women’s College Hospital, an academic ambulatory hospital in Toronto, Canada. Baseline chart review was conducted between July 2010-July 2012 to ascertain loss to follow-up, metabolic control (HbA1c) and frequency of admissions for diabetes-related complications. Using a Model for Improvement framework, iterative Plan-Do-Study-Act (PDSA) cycles were employed to design a multi-faceted transition model of care (YA clinic) that incorporated a patient navigator, attendance reminders, multi-disciplinary clinic visits and support groups from September 2012 to September 2013. Formal evaluation of the model was initiated between September 2013 and September 2014. Chi-Square test was used to determine differences in attendance pre and post model implementation. Satisfaction was assessed using a 5 point likert scale using surveys.

Results:

Baseline chart review demonstrated that 22.4% of YA with T1DM were lost to follow up, 12.2% were admitted with Diabetes Ketoacidosis and 20.4% had a HBA1c greater than 9% (n=49). Post-implementation of our model, there was a significant reduction in loss to follow up (4%, n=119, p<0.001). Median attendance rate in the YA clinic was 75%. Among new patients seen in our YA clinic, 26% (n=56) noted they did not feel prepared by their pediatric health care provider for transition to adult care. . Among follow up patients in the YA clinic, 96% reported being satisfied with their care (n=29). 

Discussion:

Young adults with T1DM are at increased risk of care fragmentation and many lack preparedness for transition. Tailoring a multi-faceted innovative model of care using PDSA cycles is feasible, can reduce loss to follow up and is associated with high satisfaction. Further evaluation is required to ascertain if the model translates into improvements in metabolic control and reductions in acute care visits.

 

Nothing to Disclose: GM, CH, AC, LD, IB, SS, LLL

20137 16.0000 FRI-660 A Improving Transitions of Care in Young Adults with Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Nithya Setty-Shah, Louise Maranda and Benjamin Udoka Nwosu Sr.*
University of Massachusetts Medical School, Worcester, MA

 

Background: It is unknown whether the coexistence of type 1 diabetes (T1D) and celiac disease (CD) increases the risk for vitamin D deficiency. 

Aims: To determine the vitamin D status and the risk for vitamin D deficiency in prepubertal children with T1D and CD compared to controls, TID, and CD.

Hypothesis: Subjects with CD+T1D will have significantly lower 25-hydroxyvitamin D [25(OH)D] concentration, and increased risk for vitamin D deficiency compared to controls, T1D, and CD groups.

Subjects and Methods: Characteristics of 62 prepubertal children of age 2-13y with either CD+T1D (n=22, 9.9 ± 3.1y), CD only (n=18, 8.9 ± 3.3y), or T1D only (n = 22, 10.1 ± 2.8y) were compared to 49 healthy control children of age 8.0 ± 2.6y. Vitamin D deficiency was defined as 25(OH)D <50 nmol/L, overweight as BMI of >85th but <95th percentile, and obesity as BMI >95th percentile.

Results: The four groups had no difference in 25(OH)D (ANOVA p=0.123) before stratification into normal-weight vs. overweight/obese subtypes. Following stratification, 25(OH)D differed significantly between the sub-groups [F(3, 98)=10.109 , ANOVA p<0.001], with post-hoc analysis showing a significantly lower 25(OH)D in the overweight/obese CD+T1D compared to the overweight/obese controls (p=0.039), and the overweight/obese CD (p=0.003). When compared to controls, subjects with CD+T1D were three times more likely to be vitamin D-deficient (OR=3.1[0.8-11.9], p=0.098), compared to 1.5 times for those with either TID or CD.

Conclusions: The coexistence of T1D and CD in overweight/obese prepubertal children may be associated with lower serum vitamin D concentration. Further research is needed to determine the exact mechanism of the combined impact of T1D, CD, and adiposity on vitamin D status.

 

Nothing to Disclose: NS, LM, BUN Sr.

20334 17.0000 FRI-661 A Increased Risk for Vitamin D Deficiency in Obese Children with Both Celiac Disease and Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Young-Jun Rhie*1, Joon Woo Baek2, Hyo-Kyoung Nam2 and Kee-Hyoung Lee2
1Korea University College of Medicine, Ansan City, Korea, Republic of (South), 2Korea University College of Medicine, Seoul, Korea, Republic of (South)

 

Objectives: There have been reports that patients with diabetes have hearing loss greater than those without. Suggested pathogenesis for diabetes-associated hearing loss has included cochlear microangiopathy, hyperglycemia of cerebrospinal fluid, auditory neuropathy and diabetic encephalopathy. This study is aimed to investigate hearing changes in children and adolescents with type 1 diabetes mellitus and to examine if hearing changes is associated with glycemic control..

Methods: Pure-tone thresholds were measured in both ears of children and adolescents with type 1 diabetes mellitus (T1DM) (n=53) and their sex and age-matched healthy controls (n=33) at frequencies from 125 Hz to 8,000 Hz.

Results: There was greater hearing loss in T1DM subjects compared to controls at 6,000 Hz. Significant greater hearing loss was also found in poorly-controlled T1DM subjects (HbA1c 9%) (n=25) compared to well-controlled subjects (HbA1c < 9%) (n=28) at 2000, 4000 and 6000 Hz.

Conclusions: T1DM is associated with an increased risk of hearing loss in children and adolescents and this difference seems to be related to blood glucose control states. Hearing evaluation and interventions are required in the management of T1DM in children and adolescents.

 

Nothing to Disclose: YJR, JWB, HKN, KHL

20950 18.0000 FRI-662 A Hearing Changes in Children and Adolescents with Type 1 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Latha Dulipsingh*1, Betsy Gaudian2, Susie Rychlewicz2, Kathleen D'Angelo2, Wendy Spurrier2, Linda Taylor2, Cynthia Eastman2, Leisa Moskowitz2, Rebecca Crowell2 and Kim Giwa3
1Saint Francis Hospital and Medical Center, Hartford, CT, 2Saint Francis Hospital and Medical Center, 3Saint Francis Health Care Partners

 

Purpose:  To pilot and evaluate the impact of standardized staff education and glucose management policies and protocols on total cost of care among hospitalized patients with a diagnosis of diabetes. Methods: The program was developed and piloted at a 617-bed, urban academic medical center. The program provided a standardized process of care for all admitted patients with a diagnosis of diabetes, including policies and procedures related to glucose management and staff education based on current clinical practice guidelines. The pilot was conducted on two medical units. Staff received mandatory education on diabetes and assessment of patient survival skills. An In-Patient Diabetes Guide was provided to patients admitted with a primary or secondary diagnosis of diabetes. Total costs and length of stay (LOS) were assessed 30 days prior to the intervention (n= 137) and 30 days post-intervention (n=126). Outcomes were analyzed using Chi-square, t-test, and univariate general linear modeling (GLM).  Results:   Length of stay (p <0.001) and total costs (p < 0.003) were significantly higher on unit 1, with patients more likely to have a primary diagnosis of diabetes (p < 0.03) prior to the start of the pilot program. Controlling for these variables in the analysis, a significant interaction effect was found between the two units and primary diagnosis pre-post relative to total cost (p < 0.001). Overall costs increased on Unit 2 and decreased among patients on Unit 1 following the pilot program. This decrease post intervention was attributed to lower costs for patients with a primary diagnosis of diabetes.  Conclusion:  Based on the pilot study, standardized intervention may reduce total cost of care and cost-efficiency, particularly among patients with a primary diagnosis of diabetes. This may be important, as total cost for these patients tends to be high. Additional analysis will assess intervening factors, including intervention components, adherence to policies and protocols, and overall reductions in hypoglycemic and hyperglycemic incidents.

 

Nothing to Disclose: LD, BG, SR, KD, WS, LT, CE, LM, RC, KG

21128 19.0000 FRI-663 A Effects of Standardization of Diabetes Care in Hospitalized Patients: A Pilot Program 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Jacqueline Velasco*1, David Fagan2, Joshua Fogel2, Robert L Levine3, Fernanda Kupferman2 and Renee Bargman4
1Winthrop University Hospital, MIneola, NY, 2Nassau University Medical Center, East meadow, NY, 3Winthrop University Hospital, Mineola, NY, 4Nassau University Medical Center, East Meadow, NY

 

Background: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM).  In the United States, DKA accounts for nearly 15% of all pediatric admissions each year.  It also accounts for approximately 20% of all mortality in children due to DM.  Management for DKA includes correcting hyperglycemia, dehydration, and electrolyte disturbances using intravenous (IV) fluids and insulin.  Frequent IV fluid modifications are necessary to adapt to ongoing changes in fluid balance, serum glucose and electrolytes.  Both one-bag and two-bag systems are used to treat pediatric diabetic ketoacidosis.  We compare these two systems with regard to hypoglycemia, serum bicarbonate correction, pH correction, and time to discharge from the pediatric intensive care unit (PICU).

Methods: This retrospective study of 61 patients had 38 treated with the one-bag system and 23 treated with the two-bag system.  The Fisher’s exact test compared bag type to percentage of hypoglycemia. Analysis of variance (ANOVA) compared bag type to the number of hours needed to raise  serum bicarbonate level to greater than 15 meqs/L and pH to greater than 7.3, and time to discharge from  PICU. 

Results: The two-bag system had a significantly (p=0.03) lower percentage of hypoglycemia (n=2, 8.7%) as compared to the one-bag system (n=13, 34.2%).  The two-bag system had significantly (p=0.001) shorter PICU stay (M=29.6 hours, SD=15.23) than the one-bag system (M=47.9 hours, SD=22.32). However, there were no significant differences between the bag systems for time to correction of  pH and bicarbonate level.

Conclusion: We found that the two-bag system is associated with fewer episodes of hypoglycemia and shorter PICU stay. We recommend that clinicians consider using the two-bag system for fluid management in pediatric patients with diabetic ketoacidosis.

 

Nothing to Disclose: JV, DF, JF, RLL, FK, RB

21173 20.0000 FRI-664 A Evaluation of the Potential Clinical Benefits of a Two-Bag System for Fluid Management in Pediatric Intensive Care Unit Patients with Diabetic Ketoacidosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Alisha Aggarwal*, Pascual Desantis, Jose M Cabral, Erlinda Rosenkranz, Vineeth Mohan, Tessey Chinna Jose, Sandra F Williams, Jessica Lee Betancourt, Dana Chanes Manuel and Carmen Vanessa Villabona
Cleveland Clinic Florida, Weston, FL

 

Introduction: Efficacy and safety of IV Insulin Infusion Protocol in Intensive Care Unit (ICU) to attain glycemic control has been actively pursued. Hyperglycemia and hypoglycemia in critically ill patients has been linked with increased morbidity and mortality. We aimed to have 95% of our patients achieve target blood glucose (BG) level of110-140 mg/dl within 8 hours of being on IV Insulin Infusion Protocol with 0% events of severe hypoglycemia (BG<50 mg/dl) and moderate hypoglycemia (BG<70 mg/dl). We report a single center standardized nurse driven IV Insulin Infusion Protocol in Medical ICU (MICU), Surgical ICU (SICU) and Intermediate Care Unit (IMCU) in a quality improvement study.

Method: We analyzed a cohort of 250 patients retrospectively from MICU, SICU and IMCU. All patients treated for DM on IV Insulin Infusion Protocol were included with regular glucose monitoring on hourly basis. The protocol was implemented in patients with BG>180 mg/dl. Median glucose concentration, frequency of moderate and severe hypoglycemic events and median time to achieve glycemic goal were calculated.

Result: IV Insulin Protocol in our hospital shows 0% events of severe hypoglycemia (BG<50 mg/dl). In MICU (n=50) the median glucose concentration was 136 mg/dl, with severe and moderate hypoglycemic rates of 0% (0/50) and 4% (2/50) respectively. In SICU (n=150) the median glucose concentration was 130 mg/dl, with severe and moderate hypoglycemic rates of 0% (0/150) and 0.6% (1/150) respectively. In IMCU the median glucose concentration (n=50) was 130 mg/dl, with severe and moderate hypoglycemic rates of 0% (0/50) and 6% (3/50) respectively. The median time (hh:mm) to achieve target BG concentration in MICU, SICU and IMCU was 01:10, 01:50 and 00:55 respectively.

Conclusion: At Cleveland Clinic Florida, our study demonstrates that IV Insulin Infusion Protocol with a glycemic target of 110-140 mg/dl is safe and has a 0% incidence of severe hypoglycemia. Prospective studies are needed to determine if this glycemic target has a significant impact on morbidity and mortality.

 

Nothing to Disclose: AA, PD, JMC, ER, VM, TCJ, SFW, JLB, DCM, CVV

21964 21.0000 FRI-665 A Glucose Control in Cleveland Clinic Florida Intensive Care Units 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Joanna Gotfrit*1, Amel Arnaout1 and Richard Davies2
1University of Ottawa, Ottawa, ON, Canada, 2University of Ottawa

 

It is well established that diabetes is independently associated with an increased risk of mortality after an acute cardiac event(1)(2)(3).  Despite the significant risk factor burden, among a sample of 7020 patients with diabetes seen at the University of Ottawa Heart Institute (UOHI) outpatient clinics from 2007-2009, only 13% had an HBA1C noted. This indicates a significant gap in the care of cardiac patients with diabetes. To facilitate the care of high risk cardiac patients with diabetes, the UOHI implemented a transitional diabetes management program that identifies patients with type II diabetes on admission for an acute cardiac event and provides intensive guideline-based outpatient diabetes follow-up for this high risk group.  The objective of this study was to assess the extent to which this transitional outpatient diabetes management program has improved diabetes care at the UOHI.  All patients admitted to the UOHI from October 2011 to November 2012 were systematically screened for diabetes with a mandatory HBA1C at admission.  All patients with an HBA1C greater than 6.5% were made aware of their diabetes diagnosis and control in hospital.  Referral to the integrated outpatient diabetes clinic was offered to all patients seen by the hospital-based endocrinology consult service or diabetes nurse educator, all newly diagnosed diabetics and all known diabetics who did not already have an endocrinologist.  These patients attended follow-up with an endocrinologist with visits at months 3 (baseline), 6, 9 and 12 or until their diabetes was deemed under good control according to published guidelines.  Patients referred comprised 40% of all inpatients with an HBA1C>6.5% at admission.  Of 358 consecutive patients referred to the diabetes clinic, 219 patients completed at least one clinic visit.  Of these, 65% completed the program (Completers), and 35% stopped attending the clinic before being discharged from the program (Non-completers).   At baseline, Completers had lower BMI (29.72 vs 31.94 kg/m2, p=0.012), lower HBA1C (8.15 vs 8.90%, p=0.0023) and were less likely to be smokers (5.71% vs 15.4%, p=0.018) compared to Non-Completers.  Overall oral hypoglycemic use at baseline was 66.1 % and by the fourth visit increased to 85.7%.  Insulin use at baseline was 29.7 % and by the fourth visit increased to 53.6%.  Between baseline and the final visit, in Completers HBA1C decreased from 8.12 to 7.00% (p <0.0001), LDL decreased from 2.03 to 1.70 mmol/L (p=0.015), HDL increased from 0.88 to 0.97 mmol/L (p=0.0007) and cholesterol-to-HDL ratio decreased from 4.27 to 3.57 (p=0.0004).  In non-completers, HBA1C decreased from 8.88 to 8.37% (p=0.0076) and the cholesterol-to-HDL ratio decreased from 3.89 to 3.59 (p=0.04).  These data show promising preliminary results for a transitional outpatient diabetes management program for high risk cardiac patients and highlight the need for an integrated approach to their care.

 

Nothing to Disclose: JG, AA, RD

20161 22.0000 FRI-666 A The Implementation of an Integrated Diabetes Management Program within a Cardiac Care Institution Improves Diabetes Care 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Jeffrey D Zajac*1, Natalie Nanayakkara2, Nyuk V Pang2, Hang d Nguyen2, Oliver Piercey2, Sarah Romero2, Matthew Stokes2, Danielle Richmond2, Michelle Lee2, Graeme K Hart2, Elizabeth Owen-Jones2, Jane Ross2, Victoia Stevenson2, Leonid Churilov3, Que Lam2, Nick Crinis4, Douglas Johnson2, Scott Baker2 and Elif Ilhan Ekinci4
1The University of Melbourne, Australia, 2Austin Health, 3The Florey Institute of Neuroscience & Mental Health, 4Austin Health, Melbourne, Australia

 

Background

While a high and rising prevalence of diabetes in acute inpatient settings is well recognised, many patients with diabetes remain undiagnosed1. In inpatients, including those admitted under general medicine, inpatient hyperglycaemia is associated with increased mortality and morbidity2,3.  HbA1c measurement is suited to diagnose diabetes in hospital inpatients as it is relatively unaffected by factors such as stress hyperglycaemia and recent glucocorticoid use. This study aims to determine the prevalence, characteristics and outcomes for patients with diagnosed and undiagnosed diabetes admitted under general internal medicine.

Methods

Under the Diabetes Discovery Initiative, using the Cerner MillenniumÒ Health IT Platform, HbA1c testing was performed automatically for all patients aged ≥54 years admitted between July 2013 and January 2014 to Austin Health, a tertiary metropolitan teaching hospital in Melbourne, Australia.  Diabetes was diagnosed in patients with an HbA1c ³6.5%4. Clinical and demographic information was collected by manual audit of the medical records.

Results

Patients admitted under general medicine (n=1072) were divided into three categories: those with previously diagnosed diabetes (33%), no prior history of diabetes and HbA1c <6.5% (61%), and no previously diagnosed diabetes and HbA1c ≥6.5%, ie undiagnosed diabetes (6%). Patients with diabetes, diagnosed and undiagnosed were younger compared to those with no diabetes (80 and 81 vs 83y respectively p<0.001). Median HbA1c was 7.2% and 6.7% vs 5.8% respectively (p<0.001). HbA1c was ≥8.5% in 7% of patients. Median HbA1c was higher, and median estimated Glomerular Filtration Rate (eGFR) was lower, in patients with diagnosed and undiagnosed diabetes compared to no diabetes (7.2% vs 6.7% vs 5.8% and 55 vs 48 vs 47 ml/min/1.73cm2, respectively, both p<0.001). Overall HbA1c did not correlate with length of stay, however, in patients with poorly controlled diabetes (HbA1c ≥8.5%, each 1% rise in HbA1c corresponded to a 0.75 day greater length of stay (r=0.23, p=0.04). Patients with diagnosed diabetes had a higher rate of readmission at 6 months compared to those with no diabetes and undiagnosed diabetes  (28%, 18% and 18% respectively p<0.001).There were no significant difference between the two groups in the rates of intensive care unit admission, mechanical ventilation and inpatient mortality. 

Conclusions

Almost 40% of all general medical inpatients over the age of 54 have diabetes. Previously undiagnosed diabetes affects 6% of all general medical inpatients over the age of 54.  Routine admission HbA1c measurement can identify patients with undiagnosed diabetes as well as patients with poor glycaemic control for review. Further study is required to determine if early identification and management of these patients improves patient outcomes.

 

Nothing to Disclose: JDZ, NN, NVP, HDN, OP, SR, MS, DR, ML, GKH, EO, JR, VS, LC, QL, NC, DJ, SB, EIE

19139 23.0000 FRI-667 A Diabetes Is Prevalent in up to 40% of General Medical Inpatients 54 Years and Older at a Tertiary Metropolitan Hospital 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Shinya Makino*1, Takeshi Uchihashi1, Yasuo Kataoka1, Mitsuru Nishiyama2, Yoshio Terada2 and Masayoshi Fujiwara1
1Osaka Gyomeikan Hospital, Osaka, Japan, 2Kochi Medical School, Nankoku, Japan

 

A growing body of evidence suggests that short and/or long nighttime sleep duration increase the risk of diabetes and deteriorate the glycemic control in diabetic patients. It is also reported that midday naps could modify the association between short nighttime sleep duration and higher risk of diabetes. However, there are no studies available showing the influence of nighttime sleep duration and midday naps on the glycemic control in diabetic patients. This study is designed to clarify the relationship between nighttime sleep duration, midday naps and the glycemic control in Japanese patients who are diagnosed as type 2 diabetes (n=393) or impaired glucose tolerance (n=66). A total of 459 patients were divided into 5 groups according to their self-reported nighttime sleep duration: less than 5h, 5-6h, 6-7h, 7-8h, and more than 8h. Each group was further divided into 2 subgroups according to the frequency of midday naps: regular (more than 3-4 days a week) or irregular (less than 2-3 days a week). Patients with short nighttime sleep duration (less than 5h) showed higher serum HbA1c levels compared with a sleep duration of 6-7h (P<0.01). Serum HbA1c level in a short nighttime sleep/irregular nap group was higher than that in other subgroups with different nighttime sleep duration (P<0.05-0.01), whereas a short nighttime sleep/regular nap group showed similar HbA1c levels to other subgroups. These results indicate that midday naps could mitigate the deteriorative effects of short nighttime sleep (less than 5h) on the glycemic control.

 

Nothing to Disclose: SM, TU, YK, MN, YT, MF

19325 24.0000 FRI-668 A Association Between Nighttime Sleep Duration, Midday Naps and the Glycemic Levels in Japanese Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Bu Beng Yeap*1, Kieran A McCaul1, Leon Flicker1, Graeme J Hankey1, Osvaldo P Almeida1, Jonathan Golledge2 and Paul E Norman1
1University of Western Australia, Perth, Australia, 2James Cook University, Townsville, Australia

 

Context

Demographic change is contributing to the rising prevalence of Type 2 diabetes as its incidence increases with age. However the interaction between older age and duration of diabetes and their impact on cardiovascular events and mortality remains unclear. The relative contributions of diabetes, prior myocardial infarction (MI) and prior stroke to risk of subsequent cardiovascular events in older adults is also uncertain.

Objective

We tested the hypothesis that in older men, diabetes duration predicts incident cardiovascular events and death, differently from prior MI or stroke.

Design, setting and participants

Longitudinal cohort study of 11,728 community-dwelling men aged ≥65 years in Perth, Western Australia, recruited in 1996-99.

Main outcome measures

We assessed all-cause mortality, and deaths or hospital admissions with MI or stroke between recruitment and December 2010. Age at risk was used as the analysis time, with age-specific hazard as the baseline in regression models. Hazard ratios for all-cause mortality, incident MI and incident stroke were analysed according to diabetes duration, interval since prior MI and interval since prior stroke using Cox and competing risks regression. Analyses were adjusted for smoking, alcohol, exercise, body mass index, hypertension and hypercholesterolemia.

Results

There were 1,433 (12.2%) men with diabetes, of whom 208 (14.5%) reported age of onset of diabetes <55 years, 451 (31.5%) 55-64 years, 679 (47.4%) 65-74 years with 95 (6.6%) >74 years. Diabetes duration was independently associated with increased all-cause mortality with hazard ratio (HR) of 1.37 (95% confidence interval [CI]=1.16-1.63) for duration 5-9 years, HR 1.35 (95% CI 1.18-1.55) for duration 10-14 years, HR 1.42 (95% CI 1.22-1.66) for duration 15-19 years and HR 1.74 (95% CI 1.45-2.10) for duration 20-24 years. Mortality from MI increased to a plateau with increasing diabetes duration, while stroke-specific mortality increased progressively with diabetes duration. The results were essentially unchanged after exclusion of 141 men with diabetes receiving insulin therapy. Prior MI was associated with increased risk of subsequent MI for a limited time window of 10-20 years, as was prior stroke with risk of subsequent stroke.

Conclusions

After accounting for age, increasing duration of diabetes predicts stable increases in all-cause and MI-related mortality and a progressively higher risk of stroke deaths in older men. Prior MI or stroke transiently increase risk of subsequent MI or stroke respectively. Diabetes is a duration-dependent risk factor for cardiovascular events which influences outcomes in older men differently from prior vascular disease. Additional studies are needed to clarify the role of improved glycemic control and intensified cardiovascular risk factor management in the increasing population of older adults with diabetes.

 

Nothing to Disclose: BBY, KAM, LF, GJH, OPA, JG, PEN

19662 25.0000 FRI-669 A Diabetes, Myocardial Infarction and Stroke Are Distinct and Duration-Dependent Predictors of Subsequent Cardiovascular Events and All-Cause Mortality in Older Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Inguna Leite1, Maija Mukane*2, Ingvars Rasa3 and Maksims Mukans4
1Pauls Stradins Clinical University Hospital, Riga, Latvia, 2Riga Stradins University, Riga East Clinical University Hospital, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 3Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 4Riga Stradins University, Riga East Clinical University Hospital, Riga, Latvia

 

Background: Diabetes mellitus (DM) is worldwide prevalent disease with known complications (most often – hypoglycaemia), and it is closely associated with cardiovascular diseases (CVD). Combination of these conditions impressively effects on the ability to drive and can be as a cause of road traffic accidents. The aim of the study was to analyse patients’ (pts) knowledge about DM and CVD impact on driving in one of the European Union countries – Latvia.

Materials and methods: Prospective study conducted in the time from August, 2014 till now. Anonymous questionnaire with 28 original questions (e.g., duration of DM, frequency of hypoglycaemia, knowledge about safe glucose level to drive and time after hypoglycaemia safe to continue driving and presence of a coronary type pain during driving) was given to DM patients with or without CVD. All scale data were presented in median values with the interquartile range.

Results: Totally 44 questionnaires were filled in. All pts were males with median age 64 years (yrs) (67–59 yrs). Mostly type 2 DM pts with the median duration of the disease 5 yrs (7–3 yrs) and treated with per orally medications (n=36, 81.8%). Data about glycated hemoglobin level was available in 18 pts, and median level was 6.2% (6.7–5.9 %). No pts had severe hypoglycemia in the last two yrs, and only two pts had asymptomatic hypoglycemia. CVD (e.g., coronary artery disease, myocardial infarction, percutaneous coronary intervention with angioplasty or aortocoronary bypass procedure) had 90.9% (n=40). Half of the all pts (n=22) agree that DM is a risk factor for driving and in this pts group duration of DM was shorter (3.7 yrs vs 5.5 yrs, p=0.04), but there were no difference in age comparison between pts who disagree (62 yrs vs 65 yrs, p=0.179). Half of those pts who agree (n=11) check their glucose level before starting to drive and 86.4% (n=19) of them had glucose containing products or glucagon in the car. Hypoglycaemia while driving was noted in three pts (6.8%). Most of the pts (n=42) mentioned save level to start driving and it was 3.8 mmol/L (4.0–3.5) and time after happened hypoglycemia to start driving was 60 minutes. Coronary type pain during driving had 7 pts and 3 of them stopped driving and used sublingual nitrates. Information about DM and associated risk with driving was given by health care practitioners to 59.1% (n=26) pts and information about CVD and associated risk with driving was given to 38.6% (n=17). More than a half of the pts (63.6%) mentioned necessity of more information available on the internet or from other sources.

Conclusions: Taking into account our present data we can conclude that patients with DM and CVD need more information from health care practitioners and from other sources (e.g., internet) about effects and risks of these conditions to ability to drive.

 

Nothing to Disclose: IL, MM, IR, MM

20088 26.0000 FRI-670 A Cardiovascular Diseases and Diabetes Mellitus Effects on the Ability to Drive (DriveLat) – What Do the Patients Know in Latvia? Part 2 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Abimbola Akintola*1, Raymond Noordam1, Steffy Wilhelmina Jansen1, Anton J. M. de Craen1, Simon P. Mooijaart1, Hanno Pijl2, Rudi G J Westendorp1 and Diana van Heemst1
1Leiden University Medical Center, Netherlands, 2Leiden University Medical Center, Leiden, Netherlands

 

There has been an astonishing increase in the incidence of diabetes in older adults, with glycemic variability being a possible risk factor for development of complications from diabetes. Thus, it becomes extremely important to validate a system for continuous measurement of glucose rhythms, that can reliably capture physiological fluctuations in glycemic variability. Here, we validated glucose recordings from the continuous glucose monitor (CGM) against frequent venous glucose measurements over 24 hours (gold standard). We aimed at determining the agreement and correlation (between and within-persons) between the methods with respect to overall mean (24-hour, daytime and nocturnal) glucose levels, mean glucose in response to meals and measures of glucose variability (overall standard deviation (SD), coefficient of variation (CV), and continuous overlapping net glycaemic action (CONGA)).

In total, 40 subjects (mean age 66 ± 4.8 years) underwent continuous 24- hour blood sampling with sampling frequency of every 10 minutes, while simultaneously wearing a continuous glucose monitoring system that was calibrated 4 times daily using a hand held glucose meter. The study was conducted under standardised environmental, sleeping and feeding conditions of 300kcal fluid meals thrice daily.


We found that mean 24-hour glucose levels from CGM and venous blood were in agreement (mean absolute difference 0.08 ±0.08 (P=0.346)), while mean levels during the day (mean absolute difference 0.22 ±0.09 (P=0.020)) and night (mean absolute difference -0.31 ±0.14 (P=0.029)) differed. Mean glucose levels in response to meals also differed between methods (mean absolute difference 0.41 ±0.13 (P=0.003)). Moreover, all estimates of mean glycemic variability differed between the two methods (all p<0.005). However, except for 24-hour mean glucose (Pearson correlation =0.336, p=0.052), nocturnal glucose (Pearson correlation=0.196, p=0.266), and mean glucose in response to meals (Pearson correlation= 0.255, p=0.145), other measures were significantly correlated, with Pearson correlations of 0.399 for day time glucose, 0.444 for overall SD, 0.449 for CV, and 0.489 for CONGA4 respectively. For mean glucose during the day, 74% of the subjects had within-person correlation of 0.5 compared to only 20% at night.

In conclusion, this study confirms that mean 24-hour glucose as measured by CGM and venous blood are comparable. A novel findings is that, despite the significant correlation between CGM and venous blood measures of glucose variability, CGM differs from venous glucose measures of glucose variability and response to physiological changes e.g. during meals. Furthermore, within- person correlations between the 2 methods is highly dependent on the time of day. This may have implications for treatment strategies involving the clinical use of the CGM, such as in diabetics on insulin pumps.

 

Nothing to Disclose: AA, RN, SWJ, AJMD, SPM, HP, RGJW, DV

21728 27.0000 FRI-671 A Measurements of Continuous Glucose Monitoring System Against Venous Blood: A Validation Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Tara Kim*1, Ann Marie Hasse2, Myriam Kline3 and Alyson K. Myers4
1Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, 2North Shore University Hospital, Manhasset, NY, 3Feinstein Research Institute North Shore LIJ, Manhasset, 4Hofstra University - School of Medicine, Great Neck, NY

 

Introduction: There are unique challenges in managing Continuous Subcutaneous Insulin Infusion (CSII) in the inpatient setting, but these challenges may be mitigated by institutional protocols and subsequent staff education.  North Shore University Hospital is an 803-bed quaternary medical center with Joint Commission Certification in Inpatient Diabetes, thus an insulin pump protocol was implemented in March 2013.  The primary purpose of our study was to determine the current level of patient satisfaction and to identify areas for improvement.  We hypothesize that patients will be satisfied with CSII management.  Methods: Adults (over age 18) with Type 1 or Type 2 diabetes utilizing outpatient CSII (n=30) were recruited.  A patient questionnaire was developed to determine patient satisfaction with staff adherence to inpatient CSII therapy policy and overall care.  The questionnaire was made up of 20 questions which asked patients to rate satisfaction on a five-level Likert scale (strongly disagree, disagree, neutral, agree, strongly agree).  The survey measured patient’s perception of care by emergency room staff, nursing, physicians, and diabetes educators as well as the convenience of CSII use in the hospital.   Data on 16 demographic parameters and associated diabetic complications were also collected. Fisher’s exact test was used to measure the association between categorical variables and patient satisfaction.  Results: 80% of patients responded “Agree” to “Strongly Agree” to the statement, “I am generally satisfied with my diabetes management in the hospital,” (7% disagreed, and the remaining 13% were neutral). No patients “Strongly Disagreed” with the statement.  When asked to respond to the statement, “I experienced no adverse events related to my insulin pump,” 90% agreed/strongly agreed, 7% disagreed, and 3% remained neutral.  Furthermore, 48% of patients agreed/strongly agreed to the statement, “The doctors on the floor understand how my pump works.” (30% disagreed, and 21% remained neutral). Conclusions: Overall, the care provided by hospital staff and use of CSII during hospital admission was rated as favorable, more often than not, on every measure of patient satisfaction. This favorable response could be attributed to selection bias of the participants. The fact that only half the patients were satisfied with their doctors’ understanding of how the pump works, demonstrates that more provider education is needed.  For further studies, it will be interesting to look at patient satisfaction over a longer period of time while working to establish the validity of our survey.

 

Nothing to Disclose: TK, AMH, MK, AKM

20423 28.0000 FRI-672 A Patient Satisfaction of Inpatient Management with Continuous Subcutaneous Insulin Infusion (CSII) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Anis Rehman*1, Mohamed Khayata2, Karla Cristina Borromeo Detoya1 and Christie Murphy2
1Akron General Medical Center, Cleveland Clinic Affiliate, Akron, OH, 2Akron General Medical Center

 

Background:

This study highlights the Point of Care Hemoglobin A1C Testing (POCT) in Diabetes Mellitus type 2 patients (DM2) in an underserved patient population at the medicine residents’ out-patient continuity clinics. Literature is scarce in terms of studying POCT in underserved DM2 patient population who are either Medicaid or uninsured, and face financial and logistic hurdles to test Hemoglobin A1C (HbA1C) every 3 months. This study aimed to intervene with  POCT to the DM2 patients and study the impact on HbA1C testing compliance and DM2 control. 

Methods:

This is a cohort study with POCT intervention for 16 months. All DM2 patients were included from Internal Medicine Clinic of Akron (IMCA), Akron OH, with a follow up of 10 ± 6 months for a primary end point of POCT value. Each patient with an established diagnosis of DM2 was scheduled a physician appointment and POCT at every 3 months. Patients with at least one follow up were included in the study. Primary outcomes included changes in baseline HbA1C values overtime from POCT (mean ± SD) and secondary outcomes included changes in HbA1C values with frequency of POCT (mean ± SD). The Siemens DCA Vantage was used for POCT. The data was analyzed using SPSS version 20. One Way ANOVA was used to analyze changes in HbA1C over time. Bivariate Pearson Correlation was performed to estimate correlation between HbA1C values and frequency of POCT.

Results: Our study enrolled 471 patients, however 263 subjects with a mean age of 59 ± 13 were followed up within the study period and were included.

The baseline HbA1C value of 7.89 ± 1.97 was reported at the first visit. Within the first five months of follow-up, 17 (6%) of patients showed HbA1C of 7.89±1.54. With 5-10 months of follow up, 100 patients (38%) had HgA1C of 7.40±1.54. With more than 10 months of follow up, 146 (55%) patients had HbA1C of 7.56±2.02. Repeated measures One Way ANOVA was used to analyze changes in HbA1C over time which showed statistically significant decrease in HbA1C values with p values (P=0.037), (P<0.0001), and (P<0.0001) during first 5 months, 5-10 months and after 10 months follow up respectively. The correlation between HgA1C values and frequency of POCT was found to be a weak positive correlation with correlation coefficient=0.043, however it was not statistically significant (P=0.512).

Conclusion: Intervention of POCT in the underserved DM2 patients at the internal medicine resident clinics show statistically significant decrease in the HbA1C values as compare to prior DM2 control. Further studies with a greater sample size are recommended.  

Funding: None

Conflict of Interest: None declared.

 

Nothing to Disclose: AR, MK, KCBD, CM

20714 29.0000 FRI-673 A Impact of Point-of-Care Hemoglobin A1C Testing on Diabetes Mellitus Type 2 Control in Internal Medicine Resident Continuity Practice Clinic 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Kyoung-Nyoun Kim*1, So-Young Park2, Sunghwan Suh3, Mi Kyoung Park1 and Duk Kyu Kim1
1Dong-A University Medical Center, Busan, Korea, Republic of (South), 2Dong-Eui Medical Center, Busan, Korea, Republic of (South), 3Dong-A University Medical Center, Seoul, Korea, Republic of (South)

 

High dose statin therapy increases the incidence of new onset diabetes but low dose statin therapy does not. Ezetimibe is known to improve insulin resistance in some studies. Therefore, we aimed to know whether the short-term therapy with ezetimibe and low dose statin might affect the levels of plasma glucose in prediabetic subjects.

Thirty-two prediabetic subjects (impaired fasting glucose, impaired glucose tolerance and HbA1c 5.7–6.4%) who have more than 130mg/dl of LDL-C level after 3 months of dietary and exercise therapy were studied. The treatment group (n=16) took ezetimibe 10mg and simvastatin 10mg daily to reduce LDL-C level below 100mg/dl. The control group (n=16) was followed with only dietary and exercise therapy. We measured the fasting plasma glucose (FPG), HbA1c, lipid profile before and after 6 months in both groups. We compared the changes of fasting plasma glucose levels, HbA1c and the remission rate of hypercholesterolemia (the rate of LDL-C decreased below 100mg/dl) induced by intervention between the two groups.

As result, FPG was not changed but HbA1c was increased in each group. The change of HbA1c was not significantly different between two groups. The remission rate of hypercholesterolemia was significantly higher in treatment group (81%) than that in control group (0%) (P<0.001).

We conclude that the short-term therapy with ezetimibe 10mg and simvastatin 10mg daily can effectively reduce LDL-C level without disturbing plasma glucose levels in prediabetic subjects with hypercholesterolemia.

 

Nothing to Disclose: KNK, SYP, SS, MKP, DKK

20830 30.0000 FRI-674 A The Effect of Ezetimibe and Low Dose Statin Therapy on Plasma Glucose Levels in Prediabetic Subjects with Hypercholesterolemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Pendar Farahani*1, Ana Johnson2, Marlo Whitehead3 and Susan Rohland4
1Queen's University, Kingston, ON, Canada, 2Queen's University, 3ICES - Queen's Univesity, 4ICES - Queen's University

 

Background: Statin therapy is very important in the management of diabetes in elderly patients for morbidity and mortality reduction.

Objective: The objective of this study was to assess the distribution of prescription/utilization of statins amongst elderly patients with diabetes according to age group and gender using the Institute of Clinical Evaluation Sciences databases in Ontario, Canada.

Methods: Using the Ontario Diabetes Database, a cohort of patients with diabetes aged 65 and older was constructed for a ten-year period between 2003 and 2013. The medication data for statin utilization was obtained from The Ontario Drug Benefit program for the same time period. The cohort was divided into four subgroups according to age and gender including women versus men between ages of 65 and 75 as well as beyond 75 years. Percentage of exposure to statin therapy was calculated as the sum of statin therapy days divided by number of eligible days for therapy in the database for each patient. 

Results: The total cohort included 231,824 patients. 113,515 were female and 118,309 were male.  For men (N=61,974) and women (N=43,746) aged between 65 and 75 years, the mean age ± SD was 69 ± 3 years and 69 ± 3 years, respectively.  For men (N=56,335) and women (N=69,769) older than 75 years, the mean age was 81 ± 4 years and 82± 5, respectively.  Duration of diabetes as mean ± SD (months) was the following: 69 ± 35 and 72 ± 36 for men and women aged between 65 and 75, and 61± 34 and 64± 35 for men and women older than 75, respectively. Charlson Comorbidity Index was comparable for men and women for all four subgroups. Percentage of exposure to statin therapy [mean % (median %)] was 69% (82%) and 67% (78%) for men and women aged between 65 and 75; and 67% (80%) and 65% (75%) for men and women older than 75, respectively.

Conclusion: This analysis demonstrated that in elderly patients with diabetes who are at high risk for cardiovascular events, exposure to statin therapy is significantly less than ideal situation both in men and women, regardless of their age (p-value = 0.001). On average, more than 30% of the time elderly patients with diabetes are not utilizing statins despite medical needs.

 

Nothing to Disclose: PF, AJ, MW, SR

18667 31.0000 FRI-675 A Clinical Gaps in Statin Therapy Amongst Elderly Patients with Diabetes According to Age and Gender 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Prasad Katulanda*1, Chinthana Dematapitiya2, Sisil Keerthisena2, Kavinga Gamage2, Jalitha Liyanage2 and Harsha Dissanayake2
1Diabetes Research Unit, Faculty of Medicine,University of Colombo, Sri Lanka, 2Faculty of Medicine, Sri Lanka

 

ABSTRACT

Hypoglycemia: Do we think enough of the cause?

 

INTRODUCTION

Hypoglycemia is a feared experience for diabetic patients due to the disturbing symptoms. It reduces treatment compliance and also contributes to the morbidity and mortality in diabetes. Identifying the cause of hypoglycemia is pivotal for optimal glycaemic control. We intended to describe the common causes and risk factors for hypoglycemia in Sri Lankan patients.

 

METHODS

An audit was conducted using a structured, interviewer administered questionnaire among 1000 diabetic patients attending a private sector clinic using consecutive sampling. Hypoglycaemic episodes within the preceding month were inquired and severity was graded on clinical features and capillary blood glucose levels.

 

RESULTS

 In 1000 patients (mean age 54.97 (+12.48) years, males 58.6%, mean duration of diabetes 10.61 years (+8.10) mean FBS and HbA1c were 134.55 mg/dL (+50.19) and 7.82% (+1.71) respectively. Prevalence of hypoglycemia was 26.1% (mild 20.7%, moderate 3.9%, and severe 1.5%). Sudden change in the diet (quantity, composition or timing) (41.5%), increased medicine dosage (15.2%) and unaccustomed exercise (13.9%) were the commonest causes. A cause was not recognized by 14.4%. Non-prescribed native food items were recognized by 15.0% of patients [Thebu(Costus speciosus)-  40.4%, Karawila(Momordica dioica)- 42.1%, Kothalahimbutu(Salacia reticulata)- 8.8%, Madatiya kola(Adenanthera  pavonina)- 3.4%, Kowakka(Coccinia grandis)- 5.2%] as the cause for the hypoglycemic episode.

CONCLUSION

 Hypoglycemia is common among diabetic patients. Patients need advice to maintain a regular routine of diet and exercise. Consumption of non-prescribed native food should be specifically looked into as a possible cause for hypoglycemia.

 

Nothing to Disclose: PK, CD, SK, KG, JL, HD

20847 32.0000 FRI-676 A Hypoglycaemia: Do We Think Enough of the Cause? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 645-676 5936 1:00:00 PM Epidemiology and Type 1 Diabetes Poster


Ziyad A. Alakkas*1, Khaled Abdullah Alswat2, Mohammed Al Otaibi1, Turki Althobaiti3, Nazih Alzaidi1, El- Shazly Abdul Khalek3 and Abdulaziz Alfifi3
1Taif University, 2Taif University, School of Medicine, Taif, Saudi Arabia, 3King Abdulaziz Specialist Hospital

 

Background:

Metabolic syndrome (MBS) is a group of multiple cardiovascular risk factors, dysglycemia, central obesity, high cholesterol and BP. Cardiovascular disease is one of the most common complications of MBS. Recent study showed high prevalence of MBS among patients admitted to the cardiology unit; reaches to as high as 46%.

Methods:

We conducted a cross-sectional study at the King Abdulaziz Specialist Hospital, Taif, Saudi Arabia, Division of Endocrinology and Cardiology. Patient’s age ≥ 18 years who were admitted to the CCU Aug2013-Jun2014 were asked to participate. Baseline characteristics and measurement were obtained by the participated physicians. The waist circumference was measured according to WHO STEPS protocol. MBS diagnosis was made based on the International Diabetes Federation (IDF) definition. Laboratory data was collected from the patient’s EMR. We excluded unconscious patients. The primary goal of this study is to evaluate the prevalence of MBS, its clinical characteristics and relationship with the cardiovascular markers.

Result:

Total of 203 patients participated, 120 (59.1%) were male and 83 (40.9%) were female with mean age 60.9 yrs old (SD 14.4 years), 53.7% were type 2 diabetics, mean BMI 28.97% (SD 5.4), mean waist circumference was 95.45 cm (SD 18.6), mean waist to hip ratio was 1.00 (SD 0.1), 41.4% reports sedentary lifestyle and 14.8% were smokers. Admission diagnosis was 26.1 % as unstable angina (UA), 21.7% as heart failure (HF), 18.2% as NSTEMI, 16.3% as STEMI, 7.4% as arrhythmia and 10.3% as other cardiac diagnosis. 

47.8% met the criteria for MBS. 60.2% of the female and 39.2% of the male included has MBS.  Compare to non-MBS patients, MBS mean age 62.5 yrs vs 59.4 yrs(p .12), mean BMI of 31.8 vs 26.4 (p<0.05), waist circumference of 106.4 vs 84.6 cm (p<0.05), SBP 138.4 vs 130.2 (p .07), DBP 75.8 vs 76.3 (p .8), sedentary lifestyle reported in 48.5% vs 34.9% (p<0.05), 97.9 % were overweight or obese vs 65% (p<0.05), active smoker 5.1% vs 23.4% (p<0.05), 68% were T2D vs 40.6% (p<0.05), A1c 8.3 vs 7.1 (p<0.05), total cholesterol 141.9 vs 151.3 (p .17),and LDL 84.8 vs 96 (p .04).

Compare to non-MBS patients, MBS were more likely to be admitted with the diagnosis of HF 28.9% vs 15.1% and UA 27.8% vs 24.5%; as likely to be admitted with NSTEMI 18.5% vs 17.9%, but less likely to be admitted with STEMI 13.4% vs 18.9% and arrhythmia 4.1% vs 10.4%.

Cardiac ECHO data were available for 33 patients (17 with MBS and 16 without MBS), mild LVH were diagnosed in 29.4% vs 56.3% , moderate-sever LVH 41.2% vs 6.3%(P<.05) respectively in the MBS vs the non-MBS patients. The mean ejection fraction (EF) was 33.9% in the MBS patients compare to 39.8% in those without it.

Conclusion:

47.8% of the patients admitted to the CCU have MBS, commonly among female. MBS patients are likely to be overweight/obese and T2D, more likely to be admitted with heart failure, and tend to suffer from moderate-sever LVH and tend to have lower EF.

 

Nothing to Disclose: ZAA, KAA, MA, TA, NA, ESA, AA

20665 1.0000 FRI-586 A Metabolic Syndrome in the Cardiac Care Unit (CCU) Patients: Prevalence, Clinical Characteristics and Relation to Cardiovascular Markers 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Jayesh J Sheth*1, Ankna Shah1, Frenny Sheth1, Sunil Trivedi2, Nutan Nabar3, Navneet N Shah4, Premal Thakor5 and Rama Vaidya6
1FRIGE’s Institute of Human Genetics, Ahmedabad, India, 2FRIGE's Institute of Human Genetics, Ahedabad, India, 3Kasturba Health Society Medical Research Centre,, Mumbai, 4Sterling hospital, Ahmedabad, India, 5Gujarat Diabetes Association, Ahmedabad, India, 6Medical Research Centre- Kasturba Health Society, Mumbai, India

 

Background: T2DM affects millions of people expose them to an increased risk of CAD. Among several biomarkers of CAD risk, LDL-C is an established risk marker. However, due to its limitations, non-HDL-C seems to be superior over LDL-C, calculating all bad cholesterol, for the risk assessment.

Hypothesis:Our study is aimed to identify, whether non-HDL-C can be used as a significant biomarker for CVD risk assessment and its association with HbA1c?

Materials & methods:Our study was carried out in 931 subjects from urban Western India. This includes 430 diabetics and 501 non-diabetics. Amongst the later, 248 subjects were prediabetics (49.5%; HbA1c >5.7 – ≤6.5%) and 253 were controls (50.5%; HbA1c ≤5.7%). They were investigated for an average glycemic index by HbA1c and lipid parameters like TC, TG, HDL-C, LDL-C and non-HDL-C ratio. Bivariate analysis for Pearson’s correlation was done.

Results:The mean age and WC of T2DM and controls were 56.57±10.52 yrs; 96.88±10.28 cm and 48.61±12.96 yrs; 92.11±10.72 cm respectively. Linear correlation of TC to HbA1c levels was observed to be significant in hyper-TC (≥220 mg/dl) T2DM and controls [r=0.312, p=0.004 and r=0.419, p=0.005 respectively]; while such significant linearity was absent in hyper-TC prediabetics. The correlation between hyper-TG (≥150 mg/dl) and hypo-HDL (≤40 mg/dl) with HbA1c was not significant in all the three groups. LDL levels were linearly correlated to HbA1c in hyper-LDL-C (≥130 mg/dl) T2DM and prediabetics, [r=0.317, p=0.001 and r=0.232, p=0.045 respectively]; same was not observed in controls. Moreover, non-HDL-C levels were linearly correlated to HbA1c in hyper-non-HDL-C (≥160 mg/dl) T2DM and controls [r=0.370, p=0.000 and r=0.275, p=0.000 respectively]; such linearity wasn’t observed in prediabetics. Centrally obese (Male WC>90cm & Female WC>80cm) hyper-TC subjects had significantly linear correlation to HbA1c in all the three groups [r=0.286, p=0.017; r=0.314, p=0.034 and r=0.576, p=0.002 respectively], whilst such correlation was not seen with hyper-TG and hypo-HDL-C with higher WC respectively. Hyper-LDL-C had significant linear correlation with HbA1c in centrally obese T2DM and prediabetics [r=0.274, p=0.016 and r=0.291, p=0.033 respectively] whereas similar observation was not detected in the controls. Furthermore, hyper-non-HDL-C and higher WC had significant linear correlation with HbA1c in T2DM and controls [r=0.336, p=0.002 and r=0.237, p=0.048 respectively] while it was absent in the prediabetics.

Conclusion: Current study demonstrate higher prevalence of hyper-non-HDL-C in T2DM (32.79%) and prediabetics (32.24%) followed by controls (26.73%) suggesting an increased risk of CVD compared to non-diabetic controls. Additionally   non-HDL-C, LDL-C, TC and central obesity has a significant influence on Hb glycation and suggest non-HDL-C as a better biomarker of glycemic index in addition to CAD.

 

Nothing to Disclose: JJS, AS, FS, ST, NN, NNS, PT, RV

20288 2.0000 FRI-587 A Non-HDL Cholesterol: An Emerging Biomarker for Coronary Artery Disease (CAD) in Patients with Type 2 Diabetes Mellitus and Prediabetics 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Beatriz Schaan*1, Sabrina Bernardez-Pereira2 and Otavio Berwanger2
1Universidade Federal do Rio Grande do Sul/Hospital de Clinicas de Porto Alegre, Porto Alegre, 2Research Institute of Heart Hospital (Hcor), Sao Paulo

 

Cardiovascular disease represents the main cause of morbidity and mortality in individuals with diabetes and the largest contributor to the direct and indirect costs of the disease, in high and middle-income countries. A broad range of cardiovascular risk was reported for people with type 2 diabetes in different countries, but large-scale and high-quality prospective data on populations from low/middle-income countries are lacking.

 Aim: To determine the rate of major clinical events and its determinants in patients with previous cardiovascular event or not, and with or without diabetes from a middle-income country.

Methods: REACT study is a multicenter registry conducted between July 2010 and May 2013 in 48 sites from Brazil. Patients were eligible if they were over 45 years and had high cardiovascular risk. We collected baseline clinical data, including pharmacological and nonpharmacological prescription and patients were followed up for 12 months. At 6 and 12 months after admission, patients completed a visit to assess data abouth adherence to evidence-based therapies and the occurrence of major clinical events (all-cause mortality, myocardial infarction, and stroke). Survival curves were constructed using the Kaplan-Meier method, according to the presence or not of diabetes and previous cardiovascular events at baseline, comparing the curves with the log-rank test.

Results: A total of 3599 subjects was included and analyzed in three groups: A, no diabetes and no previous cardiovascular event, n=316; B, diabetes and no previous cardiovascular event, n=868; and C, presence of previous cardiovascular event, n=2415. Mean age was 65.7 ± 10.3 years, most of them were male, Caucasian, and had an intermediary risk classification in Framingham score. Major clinical events in 1-year follow-up occurred in 222 patients. A previous cardiovascular event (Group C) determined a higher risk of having another event in the follow-up (RR 2.62 95% CI 1.36-5.20, p=0.0004) and higher mortality compared to groups A and B (p=0.0038). In patients with diabetes who had HbA1c at baseline (n=985), HbA1c targets not reached (HbA1c<8.5% for those with previous cardiovascular events, and HbA1c<7.5% for those without previous cardiovascular events) was related to poorer survival compared to patients with good metabolic control (p<0.001). After adjusting for possible confounders, the use of insulin was associated with higher rates of incident events (RR 1.79, CI 1.26-2.54, p<0.001). Sensitivity analyses considering cardiovascular mortality instead of all-cause mortality in combined events did not change the results.

Conclusions: Patients with previous cardiovascular events have shorter survival; diabetes did not confer this same risk. In patients with diabetes, not reaching HbA1c targets and use of insulin were independent factors for a worse prognosis.

 

 

Nothing to Disclose: BS, SB, OB

18223 3.0000 FRI-588 A Is Diabetes a Cardiovascular Risk Equivalent? Insights from a Multicenter Registry from a Middle-Income Country 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Vakkat Muraleedharan*1, Dheeraj Kapoor2, Hazel Marsh2 and Thomas Hugh Jones3
1Kings Mill Hospital, United Kingdom, 2Barnsley Hospital NHSFT, Barnsley, United Kingdom, 3Barnsley Hospital NHS Foundation Trust, Barnsley, United Kingdom

 

Testosterone (T) deficiency in men with type 2 diabetes (T2D) is associated with an adverse cardiovascular risk profile and increased cardiovascular and all-cause mortality. Cross-sectional studies have found that low T is associated with insulin resistance and poor glycemic control. Evidence suggests that testosterone replacement therapy (TRT) improves testosterone deficiency. It also suggested that physiological replacement (TRT) improves insulin resistance, may also benefit glycemic control and mortality. We report a 7-year follow up (mean 84+11 months)of a cohort 355 men (1) at baseline with T2D examining the effect of endogenous testosterone status on glycemic control. 192 men of the original cohort consented to follow up assessment. The remaining subjects were either lost to follow up, moved out of area, declined the invitation or had died (n=27).The re-assessment included measurement of total testosterone (TT), HbA1c, BMI and waist circumference (WC). All data was adjusted for co-variates (age, SHBG, BMI, duration of diabetes, use of metformin, insulin, sulphonylurea, statins, anti platelet agents ACE inhibitors and angiotensin II blockers). Mean age at baseline 56.6+8.7 yrs (range 34-75 yrs) At baseline TT was significantly associated with HbA1c (r=-0.16;p=0.04). At baseline for the total follow up Cohort A (n=192) TT <8nmol/l n=37;TT <12nmol/l n=103. Mean baseline TT 12.4 +5.1 nmol/l; follow up 11.6+5.4nmol/l (p=NS). After exclusion of subjects who received TRT after the initial screening or during the follow up period were excluded(n=37).This gives Cohort B (TRT naïve; n=155) which has baseline TT 13.3 +5 nmol/l; follow up 11.6 +5.4  nmol/l, p=0.001. A further 28 patients in  cohort B developed TT <8nmol/l during follow up. Cohort A. HbA1c increased over time (7.3%+1.2 to 7.7%+1.5 p=0.001) Subjects with TT <8nmol/l had a larger deterioration in HbA1c (7.3%+1.2 to 7.9%+1.5) vs. >8nmol/l (7.3% +1.3 to 7.6%+1.5 p=NS).Changes in diabetes medication: Metformin added in 51, stopped in 8, Sulphonylurea added in 18, stopped in 33, new Insulin started in 32 (16.7%).WC increased (109.7+ 13.4 to 113 +14.6 p=<0.001) but no significant difference between the baseline TT groups (TT<8nmol/l 114+ 12.7 to 118.8+ 12.5; T>8 nmol/l 108.7 +13.4 to 111.6+ 14.7 in T>8nmol/l; p=NS). No difference in BMI observed for the whole cohort or in the sub groups. Cohort B. HbA1c significantly more deteriorated in patients with low baseline TT at baseline (TT <8nmol/l; 7.1+1.7% to 8% +1.7 vs.TT>8nmol/l 7.3%+1.3 to 7.6%+1.5l p=0.024). There were no significant changes in WC or BMI. This study demonstrates that T2D men with low TT are associated with greater deterioration in long-term glycaemic control. It also shows that that TT levels fall significantly over time with some men developing hypogonadism.

 

Nothing to Disclose: VM, DK, HM, THJ

21224 4.0000 FRI-589 A Testosterone Deficiency Is Associated with Greater Deterioration of Glycemic Control during 7-Year Follow up in Men with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Xiaoyu Li*1, K Kover2, Mengwei Zang3, Dara J Watkins2, Daniel Heruth2, Kathryn Jackson2, Wayne V Moore2, Mark A Clements2 and Yun Yan2
1Children's Mercy Hospital and University of Missouri-Kansas City, Kansas city, MO, 2Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, MO, 3Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA

 

Background:Metformin is a first line therapy for type 2 diabetes and it has been shown positive impacts on improving insulin sensitivity in overweight youth with type 1 DM (1) and decreasing cardiovascular disease risk in patients with type 2 DM (2), while the machinery of metformin action in endothelial cells remains largely-unknown. In our previous studies, we discovered that the potential vascular-protective function of metformin was associated with its inhibitory effects on thioredoxin-interacting protein (TXNIP) over-expression induced by high glucose, and AMPK was involved in this process (3). However, the details of the metformin-AMPK-TXNIP pathway need to be defined.

Objective:To dissect the underlying mechanism of metformin-suppressed TXNIP over-expression induced by high glucose concentration in endothelial cells.

Materials and Methods: human (HAECs) and mouse (MAECs) aortic endothelial cells  were used. Metformin and compound C were from Sigma and Millipore.  Nuclear and cytoplasmic proteins were isolated with NE-PER Nuclear and Cytoplasmic reagents from Thermo Scientific. For the assay of TXNIP promoter activity, we transfected MAECs with a construct containing a TXNIP promoter-driven luciferase or the pGL3 basic vector with mouse-specific ChREBP siRNA, FoXO1siRNA or control siRNA, prior to the following treatments. Relative firefly luciferase activity was determined using the Dual Luciferase Assay Kit (Promega) after 24 h.

Results: The cells were divided into 4 groups: 1) normal glucose (5.5 mM), 2) high glucose (25 mM), 3) high glucose with metformin (2 mM), 4) high glucose with metformin (2 mM) and compound C (10 µM), and treated for 24 hours. Our ChIP-qPCR analysis confirmed that two transcription factors, ChREBP and FoXO1, specifically bound to TXNIP promoter in endothelial cells (n=3, p<0.05). Transient knockdown of ChREBP or FoXO1 significantly blunted high-glucose-induced TXNIP promoter activity (1.8 fold and 1.7 fold, respectively, p<0.05). High glucose stimulated 3-fold and 2.5-fold increase in the rate of ChREBP and FoXO1 nuclear entry, respectively, whilst metformin reduced these nuclear accumulations (1.5 fold and 2 fold, respectively, p<0.05). An AMPK inhibitor, compound C, reversed this metformin effect (1.9 fold and 3 fold, respectively, p<0.05).

Conclusion:  ChREBP and FoXO1 are two transcription factors which are responsible for high-glucose-induced TXNIP over-expression in endothelial cells. High glucose stimulates nuclear translocations of ChREBP and FoXO1 which are required for their activation. Metformin suppresses these high-glucose-induced nuclear translocations via AMPK activation. Further delineation of the mechanisms of metformin action on TXNIP overexpression induced by high glucose concentration will provide evidence for using metformin as a potential adjunctive therapy for treating the patients with type 1 diabetes.

 

Nothing to Disclose: XL, KK, MZ, DJW, DH, KJ, WVM, MAC, YY

PP13-4 22090 5.0000 FRI-590 A Metformin Suppresses High-Glucose-Induced Thioredoxin-Interacting Protein over-Expression in Endothelial Cells through the Impairment of Nuclear Translocation:  Carbohydrate-Responsive Element-Binding Protein and Forkhead boxO1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Jose Fernando Vilela-Martin Sr.*1, Luciana Neves Martin2, Luiz Tadeu Giollo-Junior Sr.3 and Flavia Mariana Valente3
1State Medical School at Sao Jose do Rio Preto (FAMERP)/Brazil, Sao Jose do Rio Preto, Brazil, 2State Medical School Sao Jose do Rio Preto, Sao Jose do Rio Preto, Brazil, 3State Medical School in Sao Jose do Rio Preto, Sao Jose do Rio Preto, Brazil

 

Hypertension presents multifactorial physiopathogenic characteristics, and some mechanisms may modify vascular structure. The vascular stiffness and enzymes, such as extracellular matrix metalloproteinases (MMP), may cause endothelial dysfunction, situation that increases the cardiovascular risk profile. Objective: This study aimed a) to correlate socio-demographic factors and biochemical levels of MMP-9; b) to evaluate the association between markers of vascular stiffness, represented by augmentation index (AI) and central blood pressure (BP), and levels of MMP-9 in hypertensive (HT), prehypertensive (PH) and normotensive (NT) individuals. Methods: We studied 40 healthy NT, 50 PH, and 44 HT (hypertensive individuals in outpatient treatment and with controlled blood pressure levels). Normotension was defined when systolic blood pressure (SBP) < 120 mmHg and/or diastolic blood pressure (DBP) < 80mmHg without antihypertensive treatment. Pre-hypertensive individuals were characterized when SBP was 120 to 139 mmHg and/or DBP 80 to 89 mmHg. Controlled hypertension was defined when SBP  < 140 mmHg and/or DBP < 90mmHg in antihypertensive treatment. Blood was collected for biochemical analysis and measurement of MMP-9. MMP-9 concentrations are given in ng/mL. Vascular stiffness was assessed by the applanation tonometry (OMRON HEM-9000AI). Comparison between groups was performed by Kruskal-Wallis and Dunn Tests. Value-p was considered p significant < 0.05. Results: Mean age was 56.6±7.4 for HT, 48.1±9.2 for PH and 40.4±7.9 years for NT (p<0.0001). There was difference of MMP-9 among the groups (p=0.04). The statistical difference occurred between PH and HT (125.6 x 95.4 ng/ml; p=0.03), but no difference between NT and PH (120.5 x 125.6 ng/ml; p=0.68), and between NT and HT (120.5 x 95.4 ng/ml; p=0.9). The systolic blood pressure (SBP) was higher in HT group in comparison to  prehypertensive group and it was also higher in the PH than normotensive group (p<0.05). The SBP correlated with values of MMP-9. MMP-9 presented association with vascular stiffness measures (central BP and AI) in the hypertensive group (univariate analysis). However, these data were not confirmed in multivariate analysis. Conclusions: SBP and central BP correlate to metalloproteinase 9 in hypertensive individuals, showing that this group evolves with greater arterial stiffness than the nomotensive group. This suggests the active participation of MMP-9 in vascular remodeling, in spite of lower MMP-9 level in the hypertensive group in comparison to prehypertensive group.

 

Nothing to Disclose: JFV Sr., LNM, LTG Sr., FMV

20721 6.0000 FRI-591 A Association Between Vascular Stiffness and Matrix Metalloproteinase 9 in Hypertensive and Prehypertensive Individuals 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Sarath Menon*
Amrita Institute of Medical Sciences & Research Centre,India, Ernakulam, India

 

A STUDY OF ENDOTHELIAL DYSFUNCTION BY FLOW MEDIATED DILATATION OF BRACHIAL ARTERY IN EUGLYCEMIC & HYPERGLYCEMIC INDIVIDUALS

                   Sarath Menon R1, .Girish.B.Ramteke1, Dharmendra Jhavar1,Manoj Gupta1

                (Department of Medicine,MGM Medical College & M.Y.Hospital,Indore ,M.P,India1)

                                                                

BACKGROUND: Endothelial dysfunction is regarded as an early marker for atherosclerosis & a precursor for future cardio vascular events.

OBJECTIVES :  This study was done to find out endothelial dysfunction in euglycemic & hyperglycemic individuals and also aimed at finding  any endothelial dysfunction in high risk euglycemic & pre-diabetic individuals .The study also compared degree of endothelial dysfunction with different types of hyperglycemia,various glycemic parameters & CV risk factors.

MATERIAL & METHODS :  A cross-sectional, prospective study was done in the subjects who were divided into two groups.First group included hyperglycemic individuals(80 subjects) comprised of Pre-diabetes(20),Type1DM(20),Type2 DM (34),clinically labeled MODY(06)subjects and second group included 40 euglycemic individuals.Body mass index,fasting lipid profile, FBS,PPBS,RBS,HbA1c were obtained.Endothelial dependent flow mediated dilatation was assessed with 7.5MHz high resolution ultrasound of brachial artery in all the above subjects.A p value of < 0.05 was considerd to be statistically significant.

RESULTS:   Flow mediated dilatation was impaired with increase in age,BMI,lipid profile(p=0.04,0.02,0.02 respectively).FMD was seen inversely related to all glycemic parameters like FBS(r=-.680,p=<0.001),PPBS(r=-.660,p=<0.001),RBS(r=.680,p=<0.001), HbA1c(r=-.820,p=<0.001).Flow mediated dilatation was impaired in Pre-diabetes,   Type 1 DM,Type2 DM, Clinical MODY,but did not show significant difference between each other (9.03+0.73% vs 8.21+1.18% vs 6.95+2.14% vs 9.4+0.45%,p=0.20) but had significant difference when compared to euglycemic individuals(14.01+3.06%,p=<0.001).FMD was also seen impaired even in high-risk euglycemic individuals(p=0.02)

CONCLUSION:  Results showed impaired endothelial function in hyperglycemic individuals and endothelial dysfunction was seen even in Pre-diabetes and in high risk euglycemic individuals, thus showing endothelial damage in these early stages.Endothelial function declined with increase in the severity of glycemic parameters and common CV risk factors.Our study showed FMD should be considered as a surrogate marker for future cardio-vascular events.

 

Nothing to Disclose: SM

19006 7.0000 FRI-592 A A Study of Endothelial Dysfunction By Flow Mediated Dilatation of Brachial Artery in Euglycemic & Hyperglycemic Individuals 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Pinar Karakaya*1, Meral Mert2, Yildiz Okuturlar2, Asuman Gedikbasi2, Filiz Islim2, Didem Acarer2, Nursel Kocamaz2, Ozlem Soyluk2, Teslime Ayaz3, Pinar Alarslan4, Ozlem Harmankaya2 and Abdulbaki Kumbasar2
1Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, 2Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, 3Recep Tayyip Erdogan University Training and Research Hospital, Rize, Turkey, 4Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey

 

Human paraoxonase 1/arylesterase (PON1) is a calcium dependent ester hydrolase with paraoxonase, arylesterase and diazoxonase activities along with antioxidant and anti-atherogenic properties (1-3). Decrease in PON1 activity was documented in states of high oxidative stress like metabolic syndrome, obesity, uncontrolled diabetes, and dyslipidemia and shown to be associated with susceptibility to coronary artery disease (1,4). This study was designed to evaluate the relation of serum paraoxonase and arylesterase activities with biochemical variables and brachial artery diameter (BAd) and intima media thickness (BA-IMT) in obese versus non-obese diabetic patients. A total of 201 diabetic patients were included in the present study as divided into two groups including obese (n=89, patients with BMI>30kg/m2, mean±SD age: 52.8(11.7) years, 83.1% were females) and non-obese (n=82, BMI<29.99 kg/m2, mean±SD age: 52.2(14.6) years, 65.5% were females) diabetic patients. Data on patient characteristics, blood biochemistry, HOMA-IR, BAd and BA-IMT were evaluated along with serum paraoxonase and arylesterase activities. No significant difference was noted in mean±SD paraoxonase (119.5±35.6 U/L in the obese group and 120±39.1 U/L in the non-obese group) and arylesterase values (150.4±39.0 U/L in the obese group and 147.9±40.7 U/L in the non-obese group) with respect to obesity. Paraoxonase and arylesterase activities were negatively correlated with HbA1c (r=-0.533, p=0.000 and r=-0.544, p=0.000, respectively) and plasma glucose (r=-0.457, p=0.000 and r=-0.584, p=0.000, respectively) in the overall study population as were in obese and non-obese groups. There was a negative correlation of HOMA-IR to paraoxonase (r=-0.263, p=0.039 in obese and r=-0.281, p=0.007 in non-obese patients) and arylesterase (r=-0.269, p=0.035 in obese and r=-0.334, p=0.001 in non-obese patients) levels in both obese and non-obese patients. Except for negative correlation of arylesterase (r=-0.303, p=0.048) and paraoxonase (r=-0.340, p=0.026) to left BA-IMT in obese patients, no correlation of paraoxonase and arylesterase values was noted to BAd and BA-IMT. In conclusion, our findings revealed no difference in serum paraoxonase and arylesterase activities with respect to obesity, gender and age along with a negative correlation of both serum paraoxonase and arylesterase activities to plasma glucose, HbA1c and HOMA-IR in both obese and non-obese patients, while to left BA-IMT only in obese diabetic patients. In this regard, our findings emphasize the possible role of low serum paraoxonase and arylesterase activities in predicting poor glycemic control among diabetics regardless of obesity, whereas early atherosclerosis only in obese diabetic patients.

 

Nothing to Disclose: PK, MM, YO, AG, FI, DA, NK, OS, TA, PA, OH, AK

18633 8.0000 FRI-593 A Relation of Serum Paraoxonase-1 Activity with Brachial Artery Intima Media Thickness in Obese Versus Non-Obese Diabetic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Hidetoshi Kawana*1, Daiji Nagayama1 and Ichiro Tatsuno2
1Toho University Sakura Medical Center, Sakura, Japan, 2Toho University Sakura Medical Center, Sakura-City, Japan

 

Increased serum uric acid (SUA) level is associated with glucose tolerance, dyslipidemia and hypertension, contributing to atherogenesis. However, the relationship between SUA level and arterial stiffness is not yet fully understood. The aim of this study was to investigate the association of SUA level with arterial stiffness assessed by cardio-ankle vascular index (CAVI).

Study subjects were 27,360 urban residents, 12,910 males and 14,450 females between 20 and 74 (47.6±12.0) years of age, who participated during 2004 to 2006 in Japan.

SUA levels (male: 6.0±1.3mg/dl, female: 4.3±1.5mg/dl) were divided into tertiles: T1 (n=8,462, ≤4.2mg/dl), T2 (n=9,909, 4.3-5.6mg/dl), T3 (n=8,989, ≥5.7mg/dl). The mean values of CAVI adjusted by age, gender, body mass index (BMI) and systolic blood pressure (SBP) increased gradually by SUA tertile (T1: 7.77±1.01, T2: 7.84±1.10, T3: 7.90±1.18). Moreover, CAVI adjusted by age, BMI and SBP significantly increased with elevated SUA levels especially in female.

Increased SUA level was associated with increased CAVI.

 

Nothing to Disclose: HK, DN, IT

19414 9.0000 FRI-594 A Serum Uric Acid Level and Cardio-Ankle Vascular Index (CAVI): A Cross-Sectional Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Irina Ciubotaru*1, Yuval Eisenberg2, Arfana Akbar3, Hassan Zaidi3, Fahad Zaidi4, Karthik Cherukupally3, Chizelle Onochie3, Subhash C Kukreja1 and Elena Barengolts3
1UIC Section of Endocrinology, Chicago, IL, 2University of Illinois at Chicago, Chicago, IL, 3Jesse Brown VAMC, Chicago, IL, 4Jesse Brown VA

 

While central obesity is known to play an important role in glucose tolerance (GT), there is still debate on the relative importance of central obesity markers as predictors for progression of glucose intolerance. It has been suggested that waist-to-hip ratio (WHR) is a stronger predictor than the body mass index (BMI) or visceral fat, that the distribution of adiposity may vary in different  stages of insulin resistance, and that smaller fat cell size is a worse prognostic factor than larger fat cell size. Controversy remains regarding markers of adiposity and data are scarce for some markers.

This study aimed to characterize the adipose tissue distribution and adipocyte size according to changes in glucose tolerance.

The study was ancillary to DIVA, a randomized controlled trial of vitamin D Intervention at VA in African American men (AAM) with dyscglycemia (HbA1C 5.7-6.9%, no anti-diabetes medications) and hypovitaminosis D [25(OH)D 5-29 ng/ml] (NCT01375660). Four groups were characterized based on changes in OGTT  between baseline (T0) and study completion at 12 months (T12): Group 1- stable normal glucose tolerance (n=55); Group 2- stable impaired fasting glucose or stable impaired GT (n=58); Group 3 - worsened GT (n=34); and Group 4- improved GT (n=31). WHR, body adiposity index [BAI, Hip/(Height1.5)-18], and DEXA (total fat % [TF], android fat% [AF], gynoid fat% [GF]) were used to investigate pattern of fat distribution. Abdominal fat biopsies were performed in a subgroup of subjects (n=10) and adipocytes were assessed for cell size under light microscopy.

The TF, AF, and GF were most represented in Group 2, and were significantly different compared to Group 1 (p=0.001 for all) and to Group 3 (p=0.001 for all). While WHR was concordant with the DEXA findings, BAI or A/G ratio did not identify any differences among the groups. Fat cell sizes varied by 10% among groups.

There was a trend for lower fat cell size in Group 1 vs Group 2 but the differences did not reach statistical significance. Interestingly, Group 2 subjects had the highest WHR, TF, AF, and GF among the four groups. These results are in contradiction with those reported in a cohort of Chinese, showing that abdominal/femoral fat by DEXA (similar to A/G ratio) was a better predictor of worsening glycemia than WHR, abdominal fat, and total fat. Our results are consistent with findings recently reported in Indian men, in whom anthropometric measurements were the best predictors of insulin resistance. Therefore, it is conceivable that race along with adiposity distribution play a role in defining certain insulin resistance phenotypes.

In AAM, anthropometric parameters were better predictors of changes in glycemic state over time compared to DEXA- defined parameters.  These findings suggest that fat distribution might impact changes in insulin resistance over a period of 12 month and therefore affect overall glycemic status in AAM.

 

Nothing to Disclose: IC, YE, AA, HZ, FZ, KC, CO, SCK, EB

21153 10.0000 FRI-596 A Adiposity Distribution May Affect Changes in Glucose Tolerance over 12 Months in African American Men with Dysglycemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Irina Ciubotaru*1, Stefan J Green2, Arfana Akbar3, Jose Cordoba4, Subhash C Kukreja1 and Elena Barengolts3
1UIC Section of Endocrinology, Chicago, IL, 2University of Illinois at Chicago, Chicago, IL, 3Jesse Brown VAMC, Chicago, IL, 4Jesse Brown VA, Chicago, IL

 

There is emerging evidence that intestinal microbiota is a contributor to the metabolic/glycemic phenotype. While changes in microbiota have been described in obesity and diabetes, little is known about microbiota composition in various dysglycemic states.

This study aimed to investigate the relationship between microbiota and changes in the glycemic control of prediabetic subjects.

Stool was collected from African American men participating in a randomized controlled trial of vitamin D Intervention at VA. Four groups (Gr) were characterized based on changes in OGTT between baseline (T0) and the study completion at 12 months (T12): Gr 1- stable normal glucose tolerance (GT); Gr 2- stable impaired fasting glucose or stable impaired GT; Gr 3 - worsened GT; and Gr 4 - improved GT. Microbiota DNA was extracted from stool collected at T12, analyzed using high-throughput next-generation sequencing of microbial rRNA genes and data processed using established bioinformatics pipelines. Microbiota (composition, alpha diversity, abundance) was analyzed in 116 subjects: Gr 1= 35, Gr 2 = 27, Gr 3 = 24, and Gr 4 = 29.

At Phylum level significant differences in bacterial composition were observed between Gr 1 and Gr 2 (p= 0.03) and a trend to significance for Gr1 vs Gr3 (p= 0.06), and Gr 1 vs Gr4 (p= 0.06). Bacteroidetes was higher, Firmicutes lower, and hence the Bacteroidetes/Firmicutes ratio (B/F) was lower with worsening glycemic control (B/F: Gr 1 vs Gr 2 = 1.9 vs 0.9, p= 0.01; and Gr 1 vs Gr 3 = 1.9 vs 1.1, p= 0.04). Proteobacteria decreased in Gr 2 and Gr 4 compared to Gr 1 (p=0.01 for both). Similarly, there were significant differences in microbiota at the Family and Genus levels. In Gr 2 vs  Gr1 there was less Prevotella (hence higher Bacteroides/Prevotella ratio, 5.6 vs 2.7, p= 0.05), less Enterobacteriacea (p=0.03), and more Ruminococcae (p= 0.01) and Veillonelacea (p= 0.02). Notably, Akkermansia was more abundant in Gr 4 vs Gr 1 (p=0.04).

We speculate that lower abundance of Prevotella may be associated with worsening glycemia, and conversely higher abundance of Akkermansia might be associated with improving glycemia, thus corroborating suggestions from previous studies. Ruminococcae might be associated with higher insulin level (seen in previous research), and therefore conducive to maintenance of stable glycemia. Observed association of Veillonelacea and glycemia was novel.

In conclusion, significant differences in microbiota (composition, alpha diversity, abundance) were observed in various GT states. Interesting most of the differences were seen between normoglycemic subjects and those who were remained prediabetics at the end of the study. These findings suggest that there may be a certain makeup of the gut microbiota associated with steady glycemic states. Further studies are needed to evaluate whether causative relationship exist between microbiota and changes in GT.

 

Nothing to Disclose: IC, SJG, AA, JC, SCK, EB

21179 11.0000 FRI-597 A Significant Differences in Fecal Microbiota Are Associated with Various Stages of Glucose Tolerance in African-American Male Veterans 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Riccardo Pofi*, Elisa Giannetta, Iacopo Carbone, Nicola Galea, Giacomo Frati, Marco Francone, Emilia Sbardella, Mary A. Venneri, Roberto Badagliacca, Andrea Lenzi and Andrea M Isidori
Sapienza University of Rome, Rome, Italy

 

Background and Objectives. Diabetic cardiomyopathy evolving into heart failure dramatically affects patient morbidity and mortality. Cardiac magnetic resonance (CMR) is the gold standard to assess cardiac remodeling. Aim of this study was to follow the long-term "natural" progression of diabetic cardiomyopathy by means of CMR with myocardial tagging.

Methods and Results. A longitudinal 4-year prospective study was undertaken for all subjects completing the CECSID trial (NCT00692237). CMR-tagging was performed at the baseline and after 4 years, with 51/59 of enrolled diabetic men (age 64.6 ± 8.15 years) completing the study. After 4 years there was an increase in ventricular mass (DLVMi= 13.47±29.66 g/m2; p=0.014) and a borderline increase in end-diastolic volume (DEDVi= 5.16±14.71 ml/m2; p=0.056). Circumferential strain worsened (Dσ=1.52 ± 3.85%; p=0.033) without significant changes in torsion (Dθ=0.24 ±4.04°; p=0.737). The adaptive uncoupling between strain and torsion observed at baseline was lost at follow-up. Contraction dynamics revealed a significant decrease in time to systolic peak (DTtP= -35.18±28.81 ms; p=0.000) and in early diastolic recoil rate (DRR=-20.01±19.07 s-1; p=0.000). Cardiac performance was preserved (DEF=0.00 ± 8.31%, p=0.998; Dstroke volume=4.42 ± 19.01 mL, p=0.172), without significant changes in HbA1c levels.

Conclusion. CMR-tagging allows morphofunctional monitoring of cardiac dysfunction in diabetes. Within a few years and independently of glycemic control, increasing cardiac hypertrophy is associated with a progressive impairment in strain, exhaustion of the compensatory role of torsion and changes in contraction dynamics that reflect alterations in the viscoelastic properties of the myocardium.

 

Nothing to Disclose: RP, EG, IC, NG, GF, MF, ES, MAV, RB, AL, AMI

PP13-1 21255 12.0000 FRI-598 A Diabetic Cardiac Hypertrophy Is Associated with Viscoelastic Changes in Myocardial Contraction Dynamics: A 4-Year Longitudinal Prospective Study Using Magnetic Resonance Imaging 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Mamta Sapra*1, Donna Marie Lawson2 and Ali Iranmanesh3
1Veteran Affairs Medical Center, 2Salem VA Medical Center, Roanoke, VA, 3VA Med Ctr, Salem, VA

 

Insulin resistance, altered adipokine physiology, and tendency towards increased inflammation reported in schizophrenic patients treated with atypical antipsychotic compounds are for the most part attributed to increased body fat. The purpose of this study was to explore body fat independent effect of therapy with atypical antipsychotics on various measures of glucose and adipokine homeostasis, and markers of inflammation. Eight non-diabetic schizophrenic men (age: 55 ± 3 years, BMI: 29.7 ± 1.2 kg/m2) on therapy with atypical antipsychotics were studied after an overnight fast. DXA and single-cut CT of abdomen were respectively used for the assessment of total body and abdominal fat. In addition, blood was collected in a fasting state for the measurements of glucose, insulin, leptin, adiponectin, high sensitive C-reactive protein (hsCRP), and TNF-α. Insulin resistance (HOMA-IR) was calculated using fasting serum glucose and insulin concentrations. Data in schizophrenic subjects were compared to the findings in eight age (55 ± 2.8 years) and BMI (29.6 ± 1.1 kg/m2) matched healthy men. The results were significant for markedly decreased serum adiponectin concentrations in schizophrenic patients (4.6 ± 0.9 vs 11.1 ± 1.5 ng/mL, P = 0.001). Lower levels of adiponetin in schizophrenic men were associated with significant increases in insulin resistance (4.2 ± 0.7 vs 1.7 ± 0.4, P = 0.004), and circulating hsCRP (3.5 ± 1.2 vs 1.2 ± 0.3 mg/L, P= 0.037) and leptin (12 ± 1.4 vs 8.5 ± 1.4 ng/mL, P = 0.05) concentrations. Various measures of adiposity, namely percentage and height adjusted total body fat (FMI: Fat Mass Index) and abdominal fat (total, subcutaneous, visceral) were not different in the 2 study groups. These findings in the context of comparable age and total body/abdominal fat mass are assumed to be either disease specific, and/or treatment inflicted. The definitive invoking etiology and a presumptive role of hypoadiponectemia in the development of insulin resistance and increased risk of inflammation warrant future investigation.

 

Nothing to Disclose: MS, DML, AI

19340 13.0000 FRI-599 A Adiposity-Independent Hypoadiponectemia As a Potential Marker of Insulin Resistance and Inflammation in Schizophrenic Patients Treated with Atypical Antipsychotics 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Ikuyo Kusaka*, Hodaka Yamada, Masashi Yoshida, Tomoko Asano, Atsushi Aoki, Aki Ikoma, Hideo Toyoshima, Masafumi Kakei and San-e Ishikawa
Jichi Medical University Saitama Medical Center, Saitama, Japan

 

Cathepsin K (CatK) belongs to a family of cysteine protease, and it is predominantly expressed in osteoclasts. Recent studies have shown that CatK may participate in development of atherosclerosis. The present study was undertaken to determine whether CatK is involved in atherosclerotic disorders and nephropathy in type 2 diabetes patients. Forty-five patients with type 2 diabetes mellitus were enrolled. They were 34 males and 11 females with the ages of 72±8 years. Their BMI was 23.5±3.1 and HbA1c, 7.1±1.0%. Serum levels of CatK, VEGF, HMGB-1 and CD146 were measured by ELISA. Vascular calcification, intima-media thickness (IMT) and flow-mediated dilation (FMD) were determined by ultrasound sonogram. The patients had been followed during 7 years period, and all the determinants were compared with initial serum CatK obtained 7 years ago. Serum CatK levels were 2.95±2.84 in 2007, and 3.56±2.29 ng/ml, respectively. In 2007 serum CatK levels had a negative correlation with FMD (r=-0.408, P=0.006) and a positive correlation with serum creatinine (r=0.408, P=0.005), but did not correlate with IMT and vascular calcification. Also, serum CatK levels positively correlated with serum VEGF (r=0.368, P=0.013) and CD146 (r=0.430, P=0.006). Next, we analyzed the 7 year clinical course of atherosclerotic changes. The change in IMT apparently correlated with initial serum CatK 7 years ago (r=0.381, P=0.060), and the change in serum creatinine significantly had a positive correlation with initial serum CatK (r=0.368, P=0.017). However, the clonological change of FMD did not associate with initial serum CatK. The present findings during the 7 years follow-up period indicate that serum CatK levels are, not only cross-sectionally but also clonologically, associated with vascular endothelial dysfunction and progression of renal impairment in type 2 diabetes patients.

 

Nothing to Disclose: IK, HY, MY, TA, AA, AI, HT, MK, SEI

19665 14.0000 FRI-600 A Cathepsin K Is Associated with Vascular Endothelial Dysfunction and Renal Impairment in Type 2 Diabetic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Anca Tomsa*1, Sara Klinepeter Bartz1, Rajesh Krishnamurthy1, Ramkumar Krishnamurthy1 and Fida F Bacha2
1Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 2Children's Nutrition Research Center, Baylor College of Medicine/Pediatric Endcorinology, Houston, TX

 

 

Endothelial dysfunction in youth is an early manifestation of subclinical atherosclerosis. There is increased controversy in regards to the effects of obesity related insulin resistance vs. hyperglycemia on endothelial function in youth. We investigated the physical and metabolic determinants of endothelial function determined by peripheral arterial tonometry (PAT) in overweight (OW) adolescents with and without dysglycemia compared with normal weight (NW) peers.

69 adolescents (all pubertal, non-smokers, mean age: 15.5±0.11 years), 13 NW with normal glucose tolerance (NW-NGT), 26 OW-NGT, 18 OW with impaired glucose regulation (OW-IGR) and 12 with type 2 diabetes (T2DM) underwent: oral glucose tolerance test (OGTT) with calculation of whole body insulin sensitivity index (WBISI); hyperinsulinemic-euglycemic clamp for measurement of insulin stimulated glucose disposal rate (Rd) and insulin sensitivity (IS); PAT with determination of reactive hyperemia index (RHI), body composition by DEXA and abdominal fat (AF) by MRI. T2DM adolescents had a mean HbA1c of 6.3±0.19 %, and were on metformin only therapy discontinued 48 hrs prior to clamp study. Results are mean ± SEM.

When evaluated across RHI tertiles (higher is better), the tertile groups did not differ with respect to race, gender, age, pubertal stage or glycemic status. The group in the highest RHI tertile had significantly lower BMI Z-score (p=0.001), fat mass (p=0.001), %body fat (%BF) (37.3±1.3, 33.3±1.6, 28.2±2.3%, p=0.002), AF (481.9±36.3, 418.6±38.5, 298.8±41.6, p=0.004) and higher IS (2.9±0.5, 3.4±0.6, 6.1±1.1 mg/kg/min per µu/ml, p=0.013). RHI was inversely related to BMI, fat mass (r=-0.37, p=0.002), % BF (r=-0.34, p=0.003) and AF (r=-0.4, p=0.006) and positively related to WBISI (r=0.3, p=0.03), Rd (r= 0.32, p=0.011) and IS (r= 0.25, p=0.06). RHI was inversely related to leptin (r=-0.36, p=0.003) and plasminogen activator inhibitor-1 (r=-0.3, p=0.05) levels with no significant correlation between RHI and HbA1c, lipids or BP. In a multiple regression analysis, % body fat independent of age, gender, race, IS or HbA1c was the significant contributor to the variance in RHI (R2=0.2, p=0.02)

Our findings demonstrate that adiposity-related insulin resistance and inflammation are associated with endothelial dysfunction, independent of traditional cardiovascular disease (CVD) risk markers and of dysglycemia. This supports the need for early intervention in obese children to prevent CVD.

 

Nothing to Disclose: AT, SKB, RK, RK, FFB

PP13-2 19853 15.0000 FRI-601 A Endothelial Function in Youth Is Modulated By Adiposity-Related Insulin Resistance and Inflammation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Reshma Esmail1 and Udaya Manohar Kabadi*2
1Mount Saint Mary College, Los Angeles, CA, Walnut, CA, 2University of Iowa, Clive, IA

 

Background

We recently documented better efficacy of Glimepiride in non obese subjects for delaying progression from prediabetes to type 2 diabetes as compared to Metformin in obese subjects over duration of 5-9 years (mean, 7.2 ± 0.2). No deaths or cardiovascular events occurred in either group. The effects of interventions on lipids and cardiovascular surrogate markers were not reported.

Objective

Serum Total cholesterol (TC), Triglyceride (TG), Low density Lipoprotein cholesterol (LDLC), High Density Lipoprotein Cholesterol (HDLC), Homocysteine (HomC),  highly sensitive C-Reactive Protein (CRP), Fibrinogen (FIBR) and Plasminogen Activator Inhibitor1 (PAI1)  were assessed prior to intervention and at interval of 6 months in  subjects with prediabetes.

Subjects and Methods

18 non obese subjects, 10 men and 8 women ages 27-78 years and 20 obese subjects, 10  men and 10 women with ages 32-81 years with prediabetes (fasting plasma glucose, 100 – 125 mg/dl and/or HbA1c, 5.7-6.4 %) participated in the study. Non obese subjects received Glimepiride and obese subjects were administered Metformin. Subjects were counseled with lifestyle intervention

 (appropriate diet and exercise ) at each visit. Comparisons were conducted between lipids and CV markers at entry, six months and last visit of the study for individual group as well as between groups for levels at baseline and at the end of the study.

Results

In Glimepiride  group, marked improvements occurred in all parameters by 6 months and  were sustained till the end of the study[ HbA1C(%): 6.2±0.2, 5.5±0.1*, 5.7±0.1*; TC (mg/dl): 212±15, 174±13*,178±14*; TG (mg/dl): 202±32, 162±28*,178±14*; LDLC (mg/dl): 130±12, 105±10*,109±9*; Non HDLC(mg/dl): 181±24, 130±14*,109±9*; HomC (µMol/l): 18±3, 11±2*, 12±2*; CRP(Units): 13±3, 6±2*,5±2*; FIBR (mg/dl): 403±41,296±32*,289±28*; PAI1  (ng/ml): 18±4, 13±3*,12±4*;*-p<.05 vs.Pre Rx for all values].HDLC was not significantly altered. Similar changes were also noted in obese subjects treated with Metformin. No significant differences were also noted between 2 groups at the entry, 6 months or the end of study.

 

Conclusion

In subjects with Prediabetes, Glimepiride is as effective in improving lipid profiles and cardiovascular surrogate markers in non obese when compared with Metformin in obese subjects thus explaining similar cardiovascular outcomes in both groups.   

 

Nothing to Disclose: RE, UMK

18330 16.0000 FRI-602 A Improvement in Cardiovascular Risk Markers with Glimepiride in Non Obese Subjects with Prediabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Naftali Stern*1, Julio Vainstein2, Tali Ganz3, Suzan Gilad1, Rona Limor4 and Mona Boaz3
1Tel Aviv Medical Center, Tel Aviv, Israel, 2Diabetes Service, Wolfson Medical Center, Holon, Isreak, 3E. Wolfson Medical Center. Tel Aviv University, Holon, Israel, 4Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

 

Rationale: L-Arginine (Arg) is the substrate for nitric oxide (NO) synthesis through nitric oxide synthase (NOS) whereas asymmetric dimethylarginine (ADMA) is an endogenous competitive inhibitor of endothelial NOS (eNOS). Increased oxidative stress in diabetes increases NO oxidation and low Arg could further reduce NO and impair vascular function, thus accelerating, in the long run, vascular complications.

Objectives: To study serum ADMA and Arg in subjects with type 2 diabetes and determine whether or not they are related to future maco-and microvascular complications.

Population:  A cohort of 107 type 2 diabetic and 137 weight- and age-matched non-diabetic subjects evaluated at baseline and 6-7 years later.

Baseline assessment: Arg was lower in type 2 diabetes compared to controls (64±3** vs.75±3µmol/l; p=0.009) and inversely related to HgbA1c (R=-0.2; p=0.002). Because Arg was affected by additional features, we used a principal component analysis to construct a factor which included age, gender, serum creatinine, the presence of diabetes and the diagnosis of hypertension. This factor was significantly associated with Arg levels at the lowest quartile (<44µmol/l) and was then entered into a logistic regression analysis. A 1 unit increase in this composite factor was associated with an odds ratio of 1.66 ( 95% CI= 1.22-2.25; p<0.001)  to have an Arg level at the lowest quartile. The model was valid (p<0.001) and included 73.5% of the patients.

Longitudinal follow up:   Arg levels at the lowest quartile were associated with increased risk for the subsequent evolution of nephropathy (OR=7.7; p<0.005), peripheral neuropathy (OR=3.9; p<0.03) and composite microvascular complications, (retinopathy, nephropathy and neuropathy; OR= 5.5 (95% CI-1.9-16; p=0.002). Compared with the three other quartiles, ADMA levels at the highest quartile was linked with increased risk for both microvascular (OR=4.5 [ 95% CI-1.4-14.1;p=0.009])) as well as 6.5 years incidence of macrovascular complications.

Conclusions: 1) L-arginine levels are lower in type 2 diabetes than in matched controls. 2)  In type 2 diabetes, both low Arg and high ADMA, independent of each other and adjusted for classical risk factors predicted the incidence of microvascular complications.

 

Nothing to Disclose: NS, JV, TG, SG, RL, MB

PP13-3 22088 17.0000 FRI-603 A Hypoargininemia Is an Unrecognized Feature of Type 2 Diabetes Mellitus and an Independent Predictor of Microvascular Complications 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Gonzalo Allo Miguel1, Elena Garcia Fernández2, Juan Carlos Romero Rodríguez2, David Lora Pablos2, Guillermo Martínez Díaz-Guerra2 and Federico G Hawkins*3
112 de Octubre Hospital, 212 de Octubre University Hospital, 3Hospital Universitario 12 de Octubre, Madrid, Spain

 

Introduction: It is well known that diabetes, especially type 2 (T2DM), confers a substantial burden of macrovascular disease. Previous studies suggest a link between nephropathy and retinopathy and macrovascular events in diabetes. However, no large-scale studies have investigated the association between peripheral diabetic neuropathy and cardiovascular disease. So, the purpose of this study is to investigate whether the presence of peripheral neuropathy is associated with macrovascular disease in diabetes patients.

Patients and Methods: 98 diabetic (48 male/50 female) patients were included in this single-center, cross-sectional study. Michigan Neuropathy Screening Instrument was used as the screening test to detect diabetic neuropathy, which was confirmed by electrodiagnostic testing. Adverse cardiovascular events were collected, including: cardiac events (like myocardial infarction, angina or revascularization), stroke and peripheral vascular disease (PVD) (confirmed by arteriography). Statistical analysis (SPSS-21): Chi-square test was used to compare the existence of macrovascular complications between the groups with and without peripheral neuropathy. Logistic regression was used to adjust the results. Significance level was 0.05.

Results: 68 patients with T2DM and 20 with type 1 diabetes (T1DM) with mean age (52.58±20.70) and mean HbA1c (11.21±2.33%) were included in the study. Neuropathy was diagnosed in 28 patients: 5 patients with T1DM and 23 with T2DM. Neuropathy was significantly correlated with the existence of, al least, one macrovascular complication (p<0.001). Also, significant differences between the groups of patients with o without neuropathy were found in the rate of PVD (39.29% and 5.17% respectively: p<0.001) and in the rate of cardiac events (35.71% and 6.78% respectively; p<0.001). These differences remained significant after adjusting for age, sex, hypertension, smoking habit, HbA1c, duration of diabetes, body mass index or waist circumference. There were no significant differences in the rate of strokes between the groups with and without neuropathy, but it was higher in the group with neuropathy (14.29% vs 8.20%).

Conclusions: Our results show significant correlation between diabetic neuropathy and the existence of one or more macrovascular complications. Moreover, we have found that diabetic patients with peripheral neuropathy present significant higher rates of cardiac events and PVD than diabetic patients without neuropathy. Also, the rate of strokes was higher in the group with neuropathy, but this was not significant. Despite the limitations of the study, our results suggest that early detection of neuropathy might be a valuable component of macrovascular risk assessment in diabetic patients.

 

Nothing to Disclose: GA, EG, JCR, DL, GM, FGH

21700 18.0000 FRI-604 A Association Between Peripheral Neuropathy and Macrovascular Disease in Diabetic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Antoine Lemaire*1 and Christine Lemaire2
1Cabinet Médical, Lille, France, 2Centre hospitalier de Germon Gauthier, Beuvry, France

 

Aim of the study

To detect with a noninvasive method (Advanced Glycated End products  Reader) a specific marker related to endothelial dysfunction and /or  neuropathy and verify any relation between this marker and other clinical data .

Material and methods

AGE levels were determined by a noninvasive skin autofluorescence method .Patients members of regional associations which goal is to manage patients withcardiovascular risk factors were proposed to enter the survey .  Sociodemographic and clinical data were collected by trained nurses . The relation with age  , waist circumference , HBA1C , blood pressure have been studied.In a small subgroup, of patients , erectile function was also evaluated .When erectile dysfunction was reported , specific treatment by type 5 phosphodiesterase (PDE5) inhibitor was proposed and its efficacy was evaluated.  

Results

The survey started in february 2010 . 740 diabetic persons have been enrolled in this study.AGE Reader values vary from 1,1 to 5,3 .

AGE Reader data (ARD)  and waist circumference correlates positively (p<.05) and also with blood pressure (p<.05) .

 No correlation was found with HbA1c  neither with BMI score .

150 patients complained of erectile dysfunction  . They all received a treatment by PDE5 inhibitor(PDE5 I) .No correlation was found with sexual function .When we consider the efficacy of PDE5 inhibitors among this group , we notice that men who were not improved by PDE5 I had a higher score with AGE reader : mean score of men who responded to treatment =2,1 vs mean score of men who did not respond =3,4 (p<.05).

 

Conclusion :

AGE reader is a very simple non invasive method which supports reliable data  about vascular risk factors among men with diabetes .

The fact ARD is higher in IPDE5 non responder men reinforce the hypothesis that both vascular and neurologic disease are main causes of erectile dysfunction for advanced glycated  end products (AGEs) are considered to be markers of
oxidative stress and are linked to development of atherosclerosis .

 

Nothing to Disclose: AL, CL

19874 19.0000 FRI-605 A Age Reader : A New Method to Detect Cardiovascular Damages ; Its Use Among Patients with Erectile Dysfunction 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Joel Estis, Heather Morrell, Jeff Bishop, Kevin Gunning, Peter Heseltine and Mark Stene*
Singulex, Alameda, CA

 

Background: Accurate laboratory reference ranges (RR) are essential for reliable interpretation of patient results.  RR are often determined from a small sampling of volunteers or by comparing an even smaller sampling to an already available reference range.   For Adiponectin, an anti-inflammatory and anti-atherogenic adipokine, we sought to establish healthy RR that are comprehensive enough to reliably classify all adult patients.  This was accomplished by retrospective data mining, a posteriori method, of selected laboratory patient data.  Data analysis revealed meaningful partitions based on gender and age.

Methods: De-identified circulating Adiponectin levels, measured by Enzyme Immunoassay (EIA)*, were mined from the Singulex patient database (n=66,121).  Apparently healthy patients were used as the final reference population (n=715), where healthy was defined as those patients having normal levels for 19 different biomarkers, including SMCTM hs-cTnI*, NTproBNP, SMCTM TNFα*, TSH, HbA1c, as well as standard liver and renal panels.  The data were partitioned by gender and age and then the central 95% was used to determine each RR.  *Singulex Laboratory-Developed Tests.  

Results:

Younger women (18-50 YO) had lower adiponectin levels than older women (>50 YO), 95% RR 5.7-38.7  µg /mL vs 7.0-56.3 µg /mL respectively, p<0.0001.  Likewise, younger men had lower Adiponectin levels than older men, 95% RR 4.3-19.7 µg /mL vs 4.4-28.8 µg/mL respectively, p=0.0043.  Adiponectin levels of female patients were elevated with respect to male patients,  both overall and within age groups, p <0.0001.  Patients were classified according to BMI as healthy (<25), overweight (25-30), or obese (>30).  With worsening BMI classification (healthy to overweight or overweight to obese), estimated adiponectin levels decrease by 4.3 ug/mL in women and 1.9 ug/mL in men, p-value for trend < 0.0001 and 0.0002 respectively. 

Conclusion:  RR should be derived from a significant sample size to accurately evaluate all patient groups submitted for clinical laboratory testing.  Using the a posteriori method on data from screened, apparently healthy individuals, we were able to derive meaningful RR, stratified by gender and age, that are appropriate for interpreting patient adiponectin data.  Normal adiponectin levels in adults correlated with BMI and were significantly grouped by gender and age (≤50 YO, >50).  Application of this EIA method with the matched RR should aid in risk classification and monitoring of patients with or at risk of metabolic syndrome and/or other related disorders.  

 

 

 

Disclosure: JE: , Singulex. JB: Vice President, Singulex. KG: Employee, Singulex Inc.. PH: Chief Medical Officer, Singulex, Chief Medical Officer, Singulex. MS: Vice President, Singulex, Vice President, Singulex. Nothing to Disclose: HM

19268 20.0000 FRI-606 A Comprehensive Adult Reference Ranges for Circulating Adiponectin By EIA 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Bengur Taskiran*, Eylem Bahadir, Guven BARIS Cansu and Ruya Mutluay
Yunus Emre State Hospital, Eskisehir, Turkey

 

RIncreased carotid intima media thickness (IMT) indicates subclinical atherosclerosis. IMT is related to cardiovascular events independent from conventional vascular risk factors.Vitamin D receptors are also expressed by endothelial cells and vascular smooth muscle cells.  We aimed to evaluate the relation between vitamin D level and IMT in patients with type 1 DM.

A1c was measured by HPLC and vitamin D by chemiluminiscence immunassay (Siemens, Advia 1800). IMT was measured and the presence of plaque was evaluated by real time B mode ultrasonography (MyLab 70 XVG, Esaote SpA, Genoa, Italy) using 4.0-13.0 MHz linear probe by the same experienced radiologist. The arithmetic mean value of right and left measurements was denoted as mean IMT. Atherosclerotic plaque was defined as intima-media thickening over 1 mm or double that of the adjacent vascular segment. We evaluated 54 patients (26 Female, 28 male) with type 1 DM. Mean age of patients was 33.3±12.6 years. Mean duration of diabetes was 9.6±7.5 years. Four had hypertension, one had coronary artery disease, and none of them had cerebrovascular disease. Nine were hypothyroid and on levothyroxine replacement therapy. Twenty four were current smokers. Nine had retinopathy and 12 had nephropathy.  Mean BMI was 22.35±3.50 kg/m2. Fat mass 11.89±.08 kg and fat mass percentage 18.23±9.89%. Laboratory data revealed mean A1c 9.55±2.31 %, LDL 115±37 mg/dl, TSH 2.43±4.17 mU/l, 25 OH vitamin D 18.97±4.17 ng/ml, creatinine 0.86±0.11 mg/dl. Mean IMT was 0.50±0.14 mm. Eleven had plaques there was no side predilection (4 right, 4 left, 3 bilateral). When the patients were evaluated according to 50th percentile for mean IMT (0.5 mm), duration of DM and age was  significantly different (p=0.013 and 0.0001>, respectively). Regression analysis revealed positive correlation between age and duration of DM (p=0.026, r=0.31), age and mean IMT (p=0.0001, r=0.635), duration of DM and mean IMT (p=0.002, r=0.417), BMI and mean IMT (p=0.028, r=0.300). Negative correlation was observed between TSH and vitamin D (p=0.011, r=-0.344), LDL and vitamin D (p=0.001, r=-0.457), age and vitamin D (p=0.00, r=-0.362).

We did not find relation between vitamin D level and IMT in type 1 diabetics. Conventional cardiovascular risk factors including increased BMI, age, and duration of DM play a role in subclinical atherosclerosis documented by increased IMT.

Sachs MC, Brunzell JD, Cleary PA, et al; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study Research Group. Circulating vitamin D metabolites and subclinical atherosclerosis in type 1 diabetes.Diabetes Care. 2013 Aug;36(8):2423-9.

 

 

Nothing to Disclose: BT, EB, GBC, RM

21296 21.0000 FRI-607 A Role of Vitamin D in Intima Media Thickness in Type 1 Diabetics 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Gonzalo Allo Miguel1, Elena Garcia Fernández2, Lucas Arroyave Villa2, David Lora Pablos2, Guillermo Martínez Díaz-Guerra2 and Federico G Hawkins*3
112 de Octubre Hospital, 212 de Octubre University Hospital, 3Hospital Universitario 12 de Octubre, Madrid, Spain

 

Introduction: Low vitamin D [25(OH)D] level is a common finding in patients with type 1 (T1DM) and type 2 diabetes (T2DM). Although emerging evidence indicates an association among vitamin D, serum lipids and adverse cardiovascular events in diabetic patients, the data are still inconsistent. So this study was designed to assess, in a group of diabetic patients, the association of low 25(OH)D level, metabolic profile and cardiovascular events.

Patients and Methods: 98 diabetic (48 male/50 female) patients were included in this single-center, cross-sectional study. Fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC) and 25(OH)D were measured. Also, past adverse cardiovascular events were collected. Statistical analysis: Data are presented as mean (std). Student t-test and chi-square test were used to compare lipid profile and number of cardiovascular events between the groups of 25(OH)D deficient (<20 ng/ml) and insufficient (≥20-<30 ng/ml) patients. Logistic regression was used to adjust the results. Significance level was 0.05.

Results: 68 T2DM and 20 T1DM patients were included in the study. Baseline characteristics: age (52.58±20.70), IMC (28.99±6.74 kg/m2), HbA1c (11.21±2.33%), TC (187.66±52.32 mg/dl), HDL-C (45.71±17.64 mg/dl), LDL-C (101.73±39.28 mg/dl), TG (192.67±134.28 mg/dl). 25(OH)D was low in all patients (14.81±4.87 ng/ml). Significant differences between 25(OH)D deficient and insufficient patients were found in TC (192.55±52.33 and 155.50±38.33 mg/dl respectively; p=0.05), TG (213.99±145.78 and 120.29±39.94 mg/dl respectively; p<0.01) and LDL-C (103.56±38.87 and 82.79±27.91 mg/dl respectively; p=0.05). HDL-C levels were lower in the 25(OH)D deficient group, but the difference was no significant (44.22±17.49 and 48.43±18.92 mg/dl; p=0.39) Those differences remained significant after adjusting for BMI: TC (p=0.04), TG (p=0.02), LDL-C (0.05). Differences between percentages of cardiovascular events collected (n=11) in both groups (25(OH)D deficiency and insufficiency) were significant (46.15% and 7.46% respectively; p<0.01). The difference remained significant after adjusting for IMC: p<0.01.

Conclusions: Our results show that 25(OH)D deficient diabetic patients present worse lipid profile and more cardiovascular events than diabetic patients with 25(OH)D insufficiency. We found significantly higher levels of TC, TG and LDL-C in the deficient group. Also, HDL-C level was lower in the deficient group, but this was not significant. Whether 25(OH)D supplementation will be beneficial among patients with diabetes is unknown and warrants further investigation. However, based on our results we recommend screening and avoiding 25(OH)D deficiency in diabetic patients with proper supplementation.

 

Nothing to Disclose: GA, EG, LA, DL, GM, FGH

21693 22.0000 FRI-608 A Diabetic Patients with Very Low Vitamin D Have Worse Lipid Profile and More Cardiovascular Events 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Kyung Ae Lee*1, Sun Hee Kim1, Yu Ji Kim1, Young Ha Baek2, Hong Sun Baek3, Tae Sun PARK3 and Heung-Yong Jin2
1Chonbuk National University Hospital, Jeonju, Korea, Republic of (South), 2Chonbuk National University School of Medicine, Jeonju, Korea, Republic of (South), 3Chonbuk National University Hospital, Chollabuk-Do, Korea, Republic of (South)

 

Disorders of the endocrine system including hormone hyperfunction and hypofunction have multiple effects on cardiovascular system. However, in clinical practice, there are many cases of delayed or overlooked diagnosis of underlying endocrine dysfunction in patients presenting chest pain or other cardiac symptoms.

(Case1) A 49-year-old female patient visited the emergency room (ER) with chief complaint of epigastric pain. At arrival, her electrocardiogram (EKG) showed sinus tachycardia (120 bpm/min) with ST segment depression in precordial lead. Troponin I (TnI) and creatine kinase muscle-brain fraction (CK-MB) were elevated. However, there was no occlusive lesion with relatively normal coronary artery in coronary artery angiography (CAG). Laboratory results were: free T4 at 143.6 [11.5-22.7] pmol/L, TSH < 0.01 [0.55-4.78] uU/mL, anti-TPO antibody titer at 215 [~34] IU/mL, and thyroid stimulating immunoglobulin at 26.19 [~1.75] IU/mL. After CAG, dyspnea and orthopnea were developed. Chest x-ray showed pulmonary edema with bilateral pleural effusion. The patient’s state was considered as impending thyroid storm precipitated by CAG.

(Case2) A 62-year-old male patient visited the ER with chief complaint of substernal chest pain. This was the third time he visited our ER with the same symptom for the past 10 years. At the present visit, the patient still felt chest pain despite of treatment with anti-spasm medications. EKG showed sinus tachycardia with ST segment depression and markedly elevated cardiac enzyme. However, CAG showed only non-significant stenosis. Biochemical study showed elevated plasma metanephrine at 1.47 [~0.50] nmol/L and normetanephrine at 6.00 [~0.90] nmol/L. Abdominal CT showed 4.6 cm sized strong enhanced adrenal mass in right adrenal gland that was compatible with pheochromocytoma.

(Case3) A 70-year-old female patient was referred to the Endocrinology Department because of incidentally detected hypercalcemia. Three years ago, the patient had an operation for ruptured aneurysm of cerebral artery in our Neurosurgery Department. During hospitalization at that time, the patient had complaint of sudden chest pain. EKG showed ST segment elevation. However, there was no significant occlusive lesion. Only moderate stenosis was observed. Medical treatment for spasm and coronary stenosis were maintained after that time. At the present visit, laboratory tests results were: total calcium at 11.6 [8.4-10.2] mg/dl, phosphorus at 2.3 [2.5-4.5] mg/dl, parathyroid hormone at 284.22 [11-62] pg/ml. Neck US showed about 2 cm sized well defined hypoechoic mass below inferior pole of right thyroid gland. Tc-MIBI showed strong uptake of sestamibi.

Endocrine hyperfunctions such as the three cases described above should be considered as possible diagnosis in patients with complaint of chest pain. High index of suspicion are needed.

 

Nothing to Disclose: KAL, SHK, YJK, YHB, HSB, TSP, HYJ

19427 23.0000 FRI-609 A Case Reports of Severe Coronary Artery Spasm Associated with Three Different Endocrine Hyperfunction: Hyperthyroidism, Pheochromocytoma, and Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Sarpreet Bindra*1 and Jazmin I Yepez-Kuri2
1Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX, 2Texas Tech University Health Sciences Center at the Permian Basin, Odessa

 

Introduction: We present an unusual case of severe symptomatic hyponatremia with Electrocardiogram (EKG) changes of ST elevation suggestive of acute myocardial infarction which normalized after improvement in the sodium levels.  

Clinical Case:  A 58 year -old woman with past medical history of hypertension, hypothyroidism, bipolar disorder and alcoholism was brought to the emergency room because of generalized tonic-clonic seizures. The patient was in altered mental status and was intubated for airway protection.   

The lab data revealed serum sodium of 97 meq/L (n 136-144), serum potassium 3.5 meq/L (n 3.6-5.1) and random glucose was 214 mg/dL.  TSH and random cortisol concentrations were normal. Troponin I was 0.01 ng/ml (n < 0.034) and increased to 0.7 ng/ml over 5 hours.  Her EKG showed ST segment elevation in leads II, III, avF as well as in lateral leads V4-6 suggestive of acute infero-lateral infarction.  Other labs included serum osmolarity 226 mosm/kg (n 280-300), urine osmolarity 326mosm/kg (n 250-1200) and random urine sodium of 16mmol/L.  Treatment was initiated with intravenous infusion of hypertonic saline 3% bolus of 75ml followed by 30ml/hour. She was immediately taken to cardiac catheterization laboratory and was found to have normal coronaries.  Her subsequent EKG showed normalization of the ST segment elevations and her sodium level by that time had increased to 105meq/L.  The hyponatremia was felt to be of multifactorial etiology including volume depletion superimposed on underlying beer potomania, psychogenic polydipsia and poor dietary solute intake.  The intravenous infusion was subsequently switched to 0.9% normal saline and then stopped within 24 hours. The sodium level gradually improved.  There was no recurrence of seizures and the patient was extubated successfully.  She had no neurological sequelae and 5 days later (on day of discharge) the sodium concentration was 131meq/L.

Conclusion: Severe hyponatremia may present with EKG changes of ST segment elevation mimicking acute myocardial infarction. Severe hyponatremia has been associated rarely with EKG findings of Brugada syndrome (1); However to our knowledge, this is the first observation of severe hyponatremia accompanied by an EKG pattern suggestive of acute myocardial infarction.

 

Nothing to Disclose: SB, JIY

19989 24.0000 FRI-610 A Severe Hyponatremia with Electrocardiogram Changes Mimicking ST Elevation Myocardial Infarction 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Jennifer Poste*1 and Harriette Rosen Mogul2
1Westchester Medical Center, Valhalla, NY, 2New York Med Coll, Valhalla, NY

 

Introduction:

Marfan Syndrome (MFS) is an autosomal dominant  disorder of connective tissue with a prevalence of 1 in 5,000. It is caused by a mutation in the fibrillin 1 gene and characterized by overexpression of Transforming Growth Factor β (TGF-β), as elucidated in studies of transgenic and knockout mice.  The syndrome affects cardiovascular, musculoskeletal, and ocular systems. By age 60 years, more than 95% of Marfan patients develop dilation of the ascending aorta, with dissection in approx. 75% in the absence of prophylactic surgery. (1) Proximal aortic diameter>5cm is strongly predictive of elevated risk of aortic dissection and rupture.  Prior studies have provided a rationale for therapies which reduce TGF-β in MFS, including losartan, an angiotensin receptor blocker, which reduces blood pressure, aortic dilatation, and stress. Losartan also lowers TGF-β signaling, which has been shown to reduce aortic root diameter(2)  Further pharmacological strategies targeting TGF-β signaling in MFS are being investigated. We present a case of MFS and hypothesize that metformin may be beneficial and should be evaluated in the future.

Case Report:

A 48 year old male with MFS was referred for management of metabolic syndrome. MFS was diagnosed at age 46, after presentation with a dilated ascending aortic aneurysm and a history of long standing hypertension.  Treatment with losartan (based on recent clinical trials(3) had resulted in notable decrease in fatigue and a dramatic improvement in general sense of well-being.   Impaired fasting glucose had also been noted and metformin 1000mg QD, diet, and exercise had been initiated culminating in 20 lb weight loss prior to presentation.  Other medications included ramipril and vitamin D.  Family history:  hypertension, hyperlipidemia, and obesity.  Physical exam: Wt 213 lbs, Ht 6’2”, BP 132/70, BMI 27.3kg/m2long arm span and limbs; chest, ocular exam unremarkable.  Labs: HA1c  5.7%, FBS 101 mg/dL.  Metformin was increased to 2000 mg OD with FBS normalization and additional 35 lb weight loss.  Recent DXA:  T-scores  -1.9, -2.2, -0.7, and 0.5 at total hip, femoral neck, total forearm, and proximal 1/3 forearm, respectively.  Subsequent cardiac scans have indicated no change in aortic diameter in the past 3 ½ years.

Conclusions:

Although, losartan has been shown to ameliorate vascular disease in mice with MFS, it has not been shown to address other manifestations of the disorder, including osteopenia.(4) Thus a multifaceted treatment strategy has been suggested. (2)Furthermore, therapies that attenuate TGF-β signaling have been beneficial in bone and joint disorders in which TGF-β is increased.(2)  Metformin is the best known clinical activator of AMP-activated protein kinase and via this pathway down regulates TGF-β.(5)In conclusion, this case suggests that metformin should be studied as an additional therapy in MFS, since it is a potent down regulator of TGF-β signaling.

 

Nothing to Disclose: JP, HRM

20494 25.0000 FRI-611 A Could Metformin Have a Role in Marfan Syndrome? a Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Ma. Conchitina Manas Fojas*1 and Kyaw Kyaw Soe2
1The Ohio State University Wexner Medical Center, Columbus, OH, 2The Ohio State Univ Med Ctr, Columbus, OH

 

Introduction:

Sarcoidosis is a granulomatous disease that can affect multiple organs. 5% of cases have myocardial involvement. 70% of autopsies in patients with history of non-cardiac Sarcoidosis reveal subclinical Cardiac Sarcoidosis. Early detection and treatment could prevent significant morbidity and mortality.

Case:

56 y/o F with CAD, MI s/p PCI, DM, HLD, CKD III, OSA, h/o Splenic Sarcoidosis s/p splenectomy, was admitted for recurrent syncope of one month duration. ACS and CVA work up were negative. Echocardiogram revealed septal hypertrophy and normal EF. Laboratory results: hypercalcemia (12.6 mg/dL, NL: 8.6-10.5 mg/dL; iCa 6.0 mg/dL, NL 4.6-5.3 mg/dL), kidney injury (BUN 41 mg/dL, NL: 7-22 mg/dL; creatinine 2.16 mg/dL [1.7 mg/dL baseline, NL:0.50 - 1.20 mg/dL]), and transaminitis (AST 59 U/L, NL:14 - 40U/L;  ALT 65 U/L, NL: 9 - 48 U/L). Treatment with IV hydration and diuretics did not improve hypercalcemia. Further work up showed low PTH  (PTH Intact 5.7 pg/mL, NL: 14.0 - 72.0 pg/mL). Monoclonal gammopathy work up was negative. She had normal 1,25(OH)2Vit D (59 pg/mL, NL: 18 - 72 pg/mL) and PTHrP (0.6 pmol/L, NL: <2.0 pmol/L ), an elevated ACE level (91 U/L, NL: 9 - 67 U/L). Cardiac MRI was contraindicated due to low GFR. PET showed focal uptake within the inferolateral portion of heart suggestive of Sarcoidosis. Empirical treatment with oral steroids improved lab parameters (calcium, creatinine, liver function test). She was discharged with cardiac event monitor. She was scheduled for an EP study. She followed up with Cardiology, Pulmonology, Endocrinology and Rheumatology.

Discussion:

Clinical manifestations of cardiac Sarcoidosis include conduction disease, arrhythmias, sudden death, heart failure, cardiomyopathy, and VHD; however the diagnosis is elusive due to latency of symptoms, insensitive screening tools and lack of definitive tests. Cardiac MRI and PET are superior imaging modalities. Cardiac biopsy is rarely required for diagnosis. No consensus exists regarding disease monitoring and treatment. The development of symptomatic hypercalcemia, renal insufficiency, and the presumptive diagnosis of Cardiac Sarcoidosis warrant prompt treatment given its disease-associated mortality of 25%. Further research is needed to fully elucidate the pathophysiology, progression, and optimal management of this disease.

Patients with histologic or clinical diagnosis of Sarcoidosis should be evaluated for subclinical Cardiac Sarcoidosis. Timely multi-disciplinary management coupled with surveillance for cardiac intervention, can decrease the morbidity and mortality.

 

Nothing to Disclose: MCMF, KKS

20068 26.0000 FRI-612 A Cardiac Sarcoidosis Presenting As Recurrent Syncope 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Sung Hoon Yu*, Dong Hyun Kang, Jae Myung Yu and Hyung Joon Yoo
College of Medicine, Hallym University, Seoul, Korea, Republic of (South)

 

Introduction

The proliferation of vascular smooth muscle cells (VSMCs) plays a crucial role in atherosclerosis. Fimasartan is a novel non-peptide angiotensin II receptor antagonist (ARB) used for the treatment of hypertension and heart failure. ARBs have a wide variety of pharmacological activities, however there are not sufficient data in vascular smooth muscle cells (VSMCs) proliferation and migration by intermittent hyperglycemia. In this study, we demonstrated that the effect of fimasartan on the proliferation and migration of VSMCs with glucose fluctuations .

Methods

Primary cultures of male Otsuka Long-Evans Tokushima fatty (OLETF) rat VSMCs were obtained from enzymatically dissociated rat thoracic aorta. VSMCs with fimasartan (10 μM) were incubated for 72 h with alternating normal (4.8 mmol/L) and high glucose (24.5 mmol/L) media every 12 h. The proliferation of VSMCs, proliferative molecular pathway (including p44/42 MAPK, MEK, PI3K, Akt) and apoptotic pathway were analyzed with fimasartan. And cell migration activity was assayed with using a Radius 24-well assay kit.

Results

We found enhanced proliferation of VSMCs incubated with intermittent high glucose medium compared to normal glucose media using the methylthiazoletetrazolium assay (relative ratio 1.95 ± 0.11 vs. 1.00 ± 0.08, p < 0.05). However, the proliferation of VSMCs with intermittent glucose was decreased with fimasartan treatment in dose dependent manners (p < 0.05). In Western blot analysis, treatment with intermittent high glucose for 72 h increases phospho-p44/42 MAPK(relative ratio 1.03 ± 0.03vs. 0.61 ± 0.02, p < 0.05), phospho MEK1/2(relative ratio 0.37 ± 0.02 vs. 0.24 ± 0.01, p < 0.05), PI3 kinase expression (relative ratio 1.83 ± 0.03 vs. 1.10 ± 0.04, p < 0.05) compared to treatment with normal glucose. These effects were suppressed with fimasartan. In the apoptotic pathway, Bcl-xl, Bcl-2, phospho-Bad, and caspase-3 were not affected by glucose fluctuations or fimasartan for 72 h. The effect on cell migration induced by glucose fluctuation was attenuated in cells pretreated with fimasartan (p < 0.05)

Conclusions

Fimasartan decreased the enhanced proliferation and migration of OLETF rat VSMCs by glucose fluctuations via the MAPK (ERK1/2) and PI3 kinase pathway.

 

Nothing to Disclose: SHY, DHK, JMY, HJY

19040 27.0000 FRI-613 A The Effect of Fimasartan on the Proliferation and Migration of Rat Aortic Vascular Smooth Muscle Cells with Glucose Fluctuations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Mark Falz*1, Victor Chalfant2, Isai Rea3, Desean L. Lee4, Indrani Sinha-Hikim5, Theodore C Friedman5 and Amiya P Sinha-Hikim4
1Charles R. Drew University, Los Angeles, CA, 2Charles R. Drew University of Medicine and Science, 3Charles R. Drew University, Endocrinology, 4Charles R Drew University of Medicine and Science, Los Angeles, CA, 5Charles R. Drew University of Medicine and Science, Los Angeles, CA

 

Nicotine plus a high-fat diet increases oxidative stress and triggers cardiomyocyte apoptosis in male mice

Mark Falz, Victor Chalfant, Isai Rea, Desean Lee, Indrani Sinha-Hikim, Theodore C. Friedman, Amiya P. Sinha-Hikim

Division of Endocrinology, Department of Internal Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA 90095

Background and objective: Cigarette smoking is an important risk factor for diabetes, cardiovascular disease, and nonalcoholic fatty liver disease. The health risk associated with smoking can be exaggerated by obesity. Smoking may also trigger cardiomyocyte (CM) apoptosis. Given that CM apoptosis has been implicated as a potential mechanism in the development of cardiomyopathy and heart failure, in this study, we characterized the key molecular component of the effector pathways in nicotine plus high-fat diet (HFD)-induced CM apoptosis. 

Experimental Design: Adult C57BL6 male mice were fed a normal chow diet (NCD) with 5% fat or HFD with 60% of calories derived from fat and received twice-daily IP injection of nicotine (0.75 mg/kg BW) or saline for 10 weeks. 

Results: HFD alone or in combination with nicotine led to ventricular accumulation of lipid compared with mice fed with NCD with or without nicotine. A very low incidence of CM apoptosis, expressed as the percentage of TUNEL-positive nuclei per total (apoptotic plus non-apoptotic) nuclei was noted in mice fed either NCD with (3.50 ± 1.75) or without nicotine (0.45 ± 0.22) or HFD alone (3.80 ± 0.26). However, combined with a HFD, nicotine led to a significant (P<0.05) increase in CM apoptosis (18.74 ± 6.90). Induction of CM apoptosis was accompanied by increased in vivo expression of 4-hydroxynonenal protein adducts (4-HNE), a biomarker of oxidative stress and inducible nitric oxide synthase (iNOS), which is critical for nitric oxide-mediated apoptosis.  Increased 4-HNE expression and iNOS induction was further associated with activation of caspase 2 (a key caspase working upstream of kinases activation, caspase 9 (a key initiator caspase in the intrinsic pathway), caspase 8 (a key initiator caspase in the death receptor pathway), and the downstream executioner caspase 3.

Conclusion: Nicotine when combined with a HFD triggers CM apoptosis and is mediated by both intrinsic and extrinsic apoptotic pathways. We surmise that nicotine, including e-cigarettes is likely to exacerbate HFD-induced cardiac abnormalities in obese patients.

 

Nothing to Disclose: MF, VC, IR, DLL, IS, TCF, APS

19108 28.0000 FRI-614 A Nicotine Plus a High-Fat Diet Increases Oxidative Stress and Triggers Cardiomyocyte Apoptosis in Male Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Jean N Cheong*1, James S M Cuffe2, Andrew J Jefferies1, Karen M Moritz2 and Mary E Wlodek1
1The University of Melbourne, Victoria, Australia, 2University of Queensland, Queensland, Australia

 

Being born small increases the risk of adult diseases. Pregnancy presents a great physiological challenge to females and females born small are known to have adverse pregnancy adaptations. Exposure to stress during pregnancy is common and negatively impacts fetal development. However, the effects of stress during pregnancy on long-term health of mothers are not well understood which may be exacerbated in females born small. We characterised the cardiovascular, metabolic and adrenal function later in life of females born small and exposed to stress in late pregnancy.

Late gestation uteroplacental insufficiency was induced on embryonic day 18 (E18) by bilateral uterine vessel ligation (Restricted) or sham (Control) surgery in F0 Wistar Kyoto female rats. F1 females (Control, Restricted) were mated with a normal male rat and randomly allocated to Unstressed or Stressed groups. Physiological stressors (24h metabolic cage, tail cuff blood pressure, glucose tolerance test) were introduced during late pregnancy of F1 females in the Stressed group while their Unstressed counterparts were unhandled. F1 females delivered naturally at term (E22). Tail cuff blood pressure was measured to 14mo and metabolic function characterised by fasting intraperitoneal glucose tolerance test (IPGTT) and insulin challenge. mRNA levels of adrenal genes (Mc2r, Star, Cyp21a1, Cyb11b1, Hsd11b2) responsible for steroidogenesis were measured following post mortem at 14mo.

Uteroplacental insufficiency reduced F1 female birth weight (-13%, p<0.05). Blood pressure was not different at all ages measured. At 14mo, Stressed Females had increased area under insulin curve: area under glucose curve (AUIC:AUGC) ratio (+40%, p<0.05) compared to Unstressed counterparts during IPGTT. HOMA-IR was increased in Unstressed Restricted Females compared to Control counterparts (+50%, p<0.05). There were no differences in HOMA-IR between Control and Restricted females that were Stressed. First phase insulin secretion was not different. Stress during pregnancy increased adrenal mRNA expression of Mc2r at 14mo (+22%, p<0.05).

Increased expression of the ACTH receptor (Mc2r) mRNA provided evidence of heightened HPA response in females that experienced stress during pregnancy earlier in life. Insulin secretory response to glucose, expressed as the ratio of AUIC to AUGC was increased in females exposed to stress during pregnancy regardless of birth weight. However, low birth weight was associated with evidence of insulin resistance (increased HOMA-IR) post-pregnancy in females born small but was not exacerbated by stress. This study indicates that stress during pregnancy and low birth weight can independently contribute to long-term health consequences of the mother in later life. These females may be predisposed to differential responses when challenged with further stress, unhealthy diets and sedentary lifestyles.

 

Nothing to Disclose: JNC, JSMC, AJJ, KMM, MEW

19795 29.0000 FRI-615 A Maternal Stress during Pregnancy and Uteroplacental Insufficiency Independently Programmed Long-Term Health Consequences in Female Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Charlotte Verroken*, Jean-Marc Kaufman, Stefan Goemaere, Kaatje Toye and Bruno Lapauw
Ghent University Hospital, Gent, Belgium

 

BACKGROUND: Although maternal age at childbirth tends to increase worldwide, studies investigating the effects of this trend on metabolic health in the offspring are scarce.

OBJECTIVE: We aimed to determine whether maternal age at childbirth is associated with adult body composition and parameters reflecting metabolic health in a cohort of young, healthy men.

METHODS: This study is part of a population-based sibling pair study in healthy men aged 25 to 45 years old. 689 subjects (mean age 33.9 +/- 5.4 years) for whom maternal data were available were included in the present analyses. Data collected in the study included birth weight, adult weight, height, DXA-derived body composition and blood pressure. Total cholesterol, glucose and insulin levels were determined in fasting serum samples. Insulin resistance was evaluated using the homeostasis model assessment of insulin resistance (HOMA-IR). Cross-sectional associations were investigated using linear mixed-effects modeling.

RESULTS: Maternal age at childbirth was 27.0+/-4.7 years (range 15-48) and was positively associated with birth weight (β=0.13; p=0.001). In their adult sons, maternal age at childbirth was inversely associated with fasting glucose levels (β=-0.12; p=0.001) and HOMA-IR values (β=-0.07; p=0.050) after adjustment for adult age and BMI. After further adjustment for birth weight, the associations between maternal age and glucose levels remained significant (β=-0.12; p=0.003), whereas the association between maternal age and HOMA-IR weakened (p = 0.092) and birth weight became an independent inverse predictor of HOMA-IR (β=-0.07; p=0.039). No associations were found between maternal age and body composition, blood pressure or cholesterol levels.

When subjects were divided into 4 groups according to maternal age at birth (<25, 25-29, 30-34 and ≥35 years), sons of mothers aged 30 to 34 at childbirth had significantly lower HOMA-IR values and fasting insulin levels compared to sons of mothers in the other age groups (p=0.007-0.015 for HOMA-IR, p=0.007-0.028 for insulin), whereas sons of mothers aged <25 had higher fasting glucose levels compared to sons of mothers aged 30-34 (p=0.010) and sons of mothers aged ≥35 (p=0.042). These associations were independent of adult age, BMI and birth weight.

CONCLUSION: Maternal age at childbirth is associated with birth weight and glucose metabolism in adulthood. Part of the association between maternal age and insulin resistance might be mediated through birth weight.

 

Nothing to Disclose: CV, JMK, SG, KT, BL

21018 30.0000 FRI-616 A Maternal Age at Childbirth Is Associated with Glucose Metabolism in Adult Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Annayya R. Aroor*1, Javad Habibi1, Vincent G. DeMarco1, Guanghong Jia1, Camila Manrique Acevedo1, Luis A. Martinez-Lemus2, Zhe Sun2, Mona Garro1, Gerald A. Meininger2 and James R. Sowers3
1University of Missouri, Columbia, MO, 2University of Missouri, 3Harry S Truman VA Hospital and University of Missouri, Columbia, MO

 

Background: We have previously shown that in female mice consuming a western diet (WD), high in refined sugars and fat, there is loss of estrogen mediated protection from development of systemic and cardiovascular insulin resistance. Consumption of this diet causes systemic insulin resistance and diastolic dysfunction at an earlier stage in females compared to males. Although arterial fibrosis/stiffness and cardiac fibrosis and diastolic dysfunction are often associated, sex differences in their progression have not been examined.

Methods:  Four week old male and female C57Bl6/J mice were fed a high fructose/high fat WD or control diet (CD) for 16 wks.  Echocardiograms were used to evaluate diastolic function. Aortic stiffness was evaluated by pulse wave velocity (PWV).  Atomic force microscopy (AFM) was used to evaluate endothelial stiffness ex vivo.

Results:  Cardiac diastolic dysfunction was evident but PWV was not increased in females after 8 wks of feeding of a WD. In contrast, at 8 wks, PWV was increased in males without impairment in diastolic dysfunction. At 16 wks of feeding, diastolic dysfunction persisted in female mice along with an increase in PWV.  Although males on WD also had diastolic dysfunction at 16 wks, PWV was not significantly different from that seen with a CD.  In contrast to the WD scenario, in mice fed a CD, PWV progressively increased in males but not in females.  The protection of age dependent increase in PWV was compromised with a WD in females. Endothelial stiffness, as determined by AFM of thoracic aorta, was also increased in females fed WD for 16 wks.  At 16 wks, cardiac hypertrophy and oxidative stress were most pronounced in females consuming a WD.

Conclusion: In the setting of a WD, diastolic dysfunction occurs earlier and aortic stiffness is promoted to a greater extent over time in females compared to males. The earlier presence of insulin resistance, cardiac oxidative stress/hypertrophy and diastolic dysfunction along with greater development of aortic stiffness in females suggests a greater adverse cardiovascular effect of consumption of a WD in females.

 

Nothing to Disclose: ARA, JH, VGD, GJ, CM, LAM, ZS, MG, GAM, JRS

21992 31.0000 FRI-617 A Sex Differences in Progression of Arterial Stiffness and Diastolic Dysfunction in Western Diet Fed Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 586-617 5943 1:00:00 PM Cardiovascular Risk Poster


Cecilia Ulrika Follin*1, Aki Johansson2, Kai Österberg1, Andrea Rovira3, Magdalena Jansson3, Thomas Wiebe4 and Eva Marie Erfurth5
1Institution of Clinical Sciences, Lund University, Lund, Sweden, 2Institution of Neuropsychology, Lund University, Lund, 3Department of Psychology, Lund University, Lund, Sweden, 4Instirurion of Clinical Sciences, lund University, Lund, Sweden, 5Skåne University Hospital, Malmo, Sweden

 

Background: Survivors of childhood leukemia (ALL) treated with cranial radiotherapy (CRT) are at risk for cognitive impairment. Whether the impairment progresses with aging and follow-up time and if survivors with cognitive impairment have an increased risk for overweight, is unknown. Previous studies lack information of hormone status and of matched population controls. Thus, we aimed to investigate the long-term cognitive functioning in ALL survivors treated with CRT and to compare them to matched controls.

Method: Cognitive functioning was investigated in 38 ALL survivors, treated with CRT of 24 Gy, at a median age of 5 years (1-17). Among the survivors 95% were treated with growth hormone, 16% were treated with Thyroxin and one survivor needed Cortisone. Median age at follow-up was 38 years (33-46) and the survivors were investigated 34 years (26-40) after diagnosis. Comparisons were made with 28 controls, matched for gender and age.

Results: After 34 years of treatment survivors demonstrated a lower performance in vocabulary, memory, learning capacity, spatial ability, executive functions and attention (all, P<0.001), compared to controls. Fifty-eight % of the survivors had moderate/severe impairment in visuo-spatial function and episodic memory, and had significantly higher BMI (28.4 vs 25.9), (P=0.01), compared to survivors with normal cognitive function. Furthermore, this group was treated at younger age (3; 1-9) compared to the survivors with normal cognition (6; 3-17). 

From the age of 26 yrs to the age of 38 yrs, and in comparison to the same matched controls 69%, of the survivors, demonstrated a decline in psychomotor speed tests of the reaction time (RT) (sustained attention)(P=0.02, P<0.001). A significantly higher BMI was recorded among 33% of the survivors who suffered from an increased RT of > 15%, compared to survivors with < 15% increased RT.

Conclusion: 34 years after ALL diagnosis, we report persistent cognitive impairment and a progressive decline in sustained attention in survivors on complete hormone replacement. The survivors with overweight had the most attenuated impairment in cognitive function.  Intervention strategies should be multidimensional and include tailored psychosocial and healthy life-style support and proper hormone replacement.

 

Nothing to Disclose: CUF, AJ, KÖ, AR, MJ, TW, EME

20315 1.0000 FRI-442 A Long-Term Follow-up of Cranially Irradiated Childhood Leukemia Survivors Show Cognitive Impairment and Progressive Decline in Sustained Attention, in Spite of on Complete Hormone Replacement 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Anne M Paulsen*1, Anne Bargiacchi1, Catherine Doyen1, Cecile Raverdy1, Jean-Claude Carel2, Marie-France Le Heuzey1 and Juliane Leger3
1Robert Debré Hospital,University Paris Diderot, Paris, France, 2Robert Debré Hospital, University Paris Diderot, Paris, France, 3Hopital Robert Debre, Université Paris Diderot, Paris, France

 

Background: Anorexia nervosa (AN), a state of chronic nutritional deprivation prevalent in children and young adolescents, is associated with major changes to the hypothalamic-pituitary axis including the GH-IGF-I axis, thyroid function, hypercortisolemia and hypogonadotropic-hypogonadism, with delayed puberty and a low height velocity (HV) at a time critical for the pubertal growth spurt, potentially affecting adult height. After nutritional and mental improvements, reports describing catch-up growth range from complete catch-up to less frequently failure to gain any height. Patients may take several years to recover, and physical and mental disorders may persist into early adulthood. Therefore these patients have limited time window for potentially effective treatment to improve HV. The effects of supraphysiological human GH on HV and improvement on adult height are currently unknown.

We aimed to investigate the effect of hGH on HV and until adult height in children with AN and profound growth impairment.

Patients and Methods: Ten girls diagnosed with AN (DSM IV) at a mean chronological age of 10.0 ± 1.9 years were treated for severe prolonged growth failure (HV< 2 cm/yr for at least 18 months) at a mean age of 13.3 ± 1.1 years and a bone age of 10.9 ± 1.7 years, Tanner stage I (n=7), II (n =1) or III (n =2), with open-label GH (0.040 mg/kg/day), until adult height was achieved.

Most of them (n=9) had associated comorbidity: depression(n=5), anxiety (n=7) and obsessive–compulsive disorder (n=3). The mean BMI SDS increased from -3.1 ± 1.1 at the time of lowest reached BMI to -0.8 ± 0.6 SDS at the beginning of the study and remained stable therafter.

Results: A significant increase in HV directly attributed to GH therapy was observed in all girls : baseline HV cm/y increased from 1.5 ± 1.2 to 7.8 ± 2.7 cm/y the first year and to 6.2 ± 3.1 cm/y the second year of treatment (p<0.001vs baseline). The mean height SDS increased from - 2.2 ± 1.3 at baseline to -1.6 ± 1.3 and -1.2 ± 1.6 after 1 and 2 years of GH treatment, respectively (p=0.002 vs baseline). Height SDS was at -0.2 ± 0.9 at the end of the treatment resulting in adult height close to target height after a mean duration of GH treatment of 3.9 ±1.9 years. Serum IGF-I levels normalized without exceeding the reference ranges (174 ± 66 vs 429 ± 134 ng/ml before and after one year of treatment p=0.002). Treatment was well tolerated with no adverse side effects.

Conclusions: Our pilot, proof of concept study provide a promising treatment to improve height velocity and adult height in severely growth affected children and adolescents with AN. A randomized controlled trial vs placebo is now required to determine the ultimate impact of GH treatment in this severe and rare condition.

 

Nothing to Disclose: AMP, AB, CD, CR, JCC, MFL, JL

21088 2.0000 FRI-443 A Successful Growth Hormone(GH)Treatment for Severe Growth Failure in Adolecents with Anorexia Nervosa until Adult Height 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Jahoon Kang*1, Pankyung Kim1, Eun Hwa Kwak1, Mei-Ying Xu1, OakPil Han1, Youngmin Kim1, Sung Youb Jung1, Se chang Kwon1, Yeamin Huh2 and Sunny Chapel2
1Hanmi Pharm. Co., Ltd., Seoul, Korea, Republic of (South), 2Ann Arbor Pharmacometrics Group (A2PG), Inc., MI, USA

 

HM10560A is a long acting recombinant growth hormone (synthesized from E. coli) chemically conjugated to N-terminus of recombinant immunoglobulin G4 Fc fragment (HMC001) by non-peptidyl linker. In non-clinical studies, the extended half-life and efficacy of HM10560A were successfully demonstrated.

This study is a dose block-randomized, double-blind, placebo-controlled, single dosing, dose-escalation phase I clinical trial to investigate the safety, tolerability and PK/PD of HM10560A after s.c. administration in Korean healthy male subjects. A total of 32 subjects were enrolled and randomized to one of the 4 dose cohorts according to dose of HM10560A by body weight (0.089 mg/kg, 0.179 mg/kg, 0.357 mg/kg, and 0.714 mg/kg). In each dose cohort, 6 subjects to the test group and 2 subjects to the placebo group were assigned, with the mean age of 29.84±5.46 years old and BMI of 22.88±1.67 kg/m2.

No serious adverse event related to the study drug occurred throughout the study and all of adverse events (47 cases out of 22 subjects) were mild, did not require any treatment, and spontaneously disappeared. There was no statistically significant difference between different dose groups in terms of the frequency of the number of subjects who experienced adverse events (p=0.767). Among total 32 cases of adverse events (68%) that were deemed possibly related to the study drug, the most frequent adverse events were headache (4 cases) and injection site tenderness (16 cases).

Population PK and PK/PD modeling was conducted; 1) to develop a PK model to describe the pharmacokinetic profiles of HM10560A; 2) to relate the IGF-I-time profile to the HM10560A exposure, where IGF-1 serves a PD marker; 3) to predict relevant HM10560A doses in adult growth hormone deficient(GHD) patients.

The mean duration of sustaining above the baseline IGF-1 values were longer than 1 week, and the mean serum elimination half-life of HM10560A were between 49.42 and 95.42 hr. HM10560A exhibited a higher exposure than the proportion of dose increase in studied dose range. A population PK model with a non-linear two compartmental disposition model with a dose-dependent dual absorption process successfully described the concentration-time profile of HM10560A. An indirect exposure-response model with a precursor transit compartment described the IGF-1-time profile as a function of HM10560A concentration. Using the exposure-IGF-1 model and based on the efficacy target that duration of IGF-1 SDS between 0 and +2 of at least 60% of the dosing interval, 0.03 mg/kg, 0.06 mg/kg and 0.09 mg/kg were recommended to explore for the next Phase II study in adult GHD.

In conclusion, a single dose of HM10560A administered subcutaneously to healthy male volunteers was well tolerated and safe. With current results, Phase II study has been initiated in adult GHD patients.

 

Nothing to Disclose: JK, PK, EHK, MYX, OH, YK, SYJ, SCK, YH, SC

20113 3.0000 FRI-444 A A Novel Long Acting Growth Hormone (HM10560A) Demonstrated Good Tolerability and Weekly Potential in Healthy Male Subjects after Single Administration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Cornelie D. Andela*1, Jitske Tiemensma2, Adrian A Kaptein1, Alberto M. Pereira1 and Nienke R. Biermasz1
1Leiden University Medical Center, Leiden, Netherlands, 2University of California Merced

 

Context:Quality of life improves with growth hormone (GH) replacement therapy in patient with growth hormone deficiency (GHD), but no normalization occurs. Illness perceptions have been found to contribute to QoL. At present, there are no studies available about illness perceptions of patients with GHD and/or beliefs about growth hormone replacement therapy.

Objective:To compare illness perceptions of patients with GHD with illness perceptions of patients with other endocrine disorders (acromegaly, Cushing’s syndrome, Addison’s disease). Furthermore, we aimed to examine possible associations between illness perceptions and beliefs about medication in patients with GHD.

Design and subjects:  Cross-sectional evaluation of illness perceptions and medication beliefs in 93 patients with GHD. The Illness Perception Questionnaire-Revised and the Beliefs about Medicines Questionnaire were used for the assessment. Illness perceptions data of patients with acromegaly, Cushing’s syndrome and Addison’s disease were derived from the literature.

Results: Patients with GHD attributed less symptoms to GHD compared to patients with other endocrine disorders (all P<.000). Patients with GHD perceive the timeline of the disease more chronic compared to patients with acromegaly (P=.001), but less chronic compared to patients with Addison’s disease (P<.000), and perceive a less cyclical timeline of the disease, compared to patients with Cushing’s syndrome (P<.000) or Addison’s disease (P=.004). Patients reported less negative consequences and less emotional representations compared to patients with Cushing’s syndrome (both P≤.001), but less personal control and less treatment control compared to patients with Addison’s disease (both P≤.003). Stronger beliefs about the necessity of GH replacement therapy and stronger concerns about the adverse effects were associated with attributing more symptoms to GHD, a stronger belief in a cyclical timeline, perceiving more negative consequences, more emotional representations having a stronger belief in a cyclical timeline (all P<0.05).

Conclusion:Patients with GHD reported different illness perceptions compared with patients with other endocrine diseases. Stronger medication beliefs in patients with GHD are related to more negative illness perceptions. These results need to be taken into account when developing/optimizing psychosocial care aiming to improve quality of life in patients with GHD.

 

Nothing to Disclose: CDA, JT, AAK, AMP, NRB

22130 4.0000 FRI-445 A Disease-Specific Illness Perceptions in Patients with Endocrine Diseases: More Concerns and Stronger Beliefs about the Necessity of Growth Hormone Replacement Therapy Are Related to More Negative Illness Perceptions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Viral P Chikani*1, Ross Collin Cuneo1, Ingrid Hickman1, Tracy Grierson2 and Ken Ho3
1Princess Alexandra Hospital, Brisbane, QLD, Australia, 2Princess Alexandra Hospital, Brisbane, Australia, 3Princess Alexandra Hospital, Brisbane QLD, Australia

 

Introduction Physical performance, function and quality of life (QoL) are influenced by GH. Sprinting is a performance measure of the anaerobic energy capacity (1). Sprint performance is reduced in GH deficient (GHD) adults in whom physical functioning such as climbing stairs, is also impaired (2).

Aim To investigate whether GH therapy improves anaerobic capacity, physical function and QoL in GHD adults.

Method 19 hypopituitary adults aged 46.3±10.4 years were randomized into a 2-month double-blind placebo-controlled GH replacement (0.5mg/day) study with a 1-month crossover followed by a 6-month open phase (n=16). Anaerobic capacity (watts) were assessed by a 30 sec Wingate test and aerobic capacity by the VO2max test. Physical function was assessed by the stair-climb test (duration to climb 4 flights of stairs), chair-stand test (repetitions over 30 sec) and 7-day pedometry count. QoL was assessed by the AGHDA questionnaire. Lean body mass (LBM) was quantified by DEXA. Repeated-measures ANOVA and paired t-test were used for between and within treatment comparisons respectively.

Results There were no statistically significant changes in LBM, anaerobic capacity, aerobic capacity and functional measures between placebo and GH treatments for 1 month. After 6 months of GH therapy, peak anaerobic power increased by 8.7 ± 3.1% (31.9 ± 10.8 watts, p = 0.01) with non-significant incremental trends in mean anaerobic power, VO2max and LBM. Stair climb duration fell (19.6 ± 0.7 vs. 18.8 ± 0.7 seconds, p = 0.02), chair stand repetitions increased (19.3 ± 1.1 vs. 25.6 ± 1.0, p < 0.0001) while pedometry count did not change significantly. QoL scores improved significantly (15.8 ± 1.6 vs. 8.6 ± 1.4, p = 0.004). There was an inverse correlation between anaerobic power and stair climb duration (r = -0.46, p = 0.069) that was stronger than between VO2max and stair climb duration (r = -0.27, p = 0.3).

Summary One month of GH replacement did not affect anaerobic power, VO2max and functional outcome measures. Six months of therapy significantly increased peak anaerobic power, stair-climb and chair-stand performance but not VO2 max or weekly step counts. The reduction in stair climb duration was related to improvement in mean anaerobic power.

Conclusion GH therapy improves anaerobic capacity and aspects of physical function dependent on the anaerobic energy system in a time-dependent manner over months. The improvement in QoL in the absence of a corresponding improvement in aerobic capacity, suggest that the anaerobic energy system regulates physical function that matter to the QoL in GHD adults

 

Nothing to Disclose: VPC, RCC, IH, TG, KH

21437 5.0000 FRI-446 A Growth Hormone Therapy Improves Anaerobic Exercise Capacity and Physical Function in Adults with Growth Hormone Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Jahoon Kang*1, Pankyung Kim1, Eun Hwa Kwak1, Mei-Ying Xu1, OakPil Han1, Youngmin Kim1, Sung Youb Jung1, Se chang Kwon1, Yeamin Huh2 and Sunny Chapel2
1Hanmi Pharm. Co., Ltd., Seoul, Korea, Republic of (South), 2Ann Arbor Pharmacometrics Group (A2PG), Inc., MI, USA

 

HM10560A is highly purified chemical conjugate of recombinant human growth hormone (hGH) and HMC001 (constant region of human immunoglobulin fragment) linked via a non-peptidyl 3.4 kDa PEG linker. The tolerability and extended half-life of HM10560A was well established in Phase I, single ascending dose study in healthy volunteers.

Current Phase II study was designed with three parts; Part 1, a pilot single dose PK/PD run-in period to bridge the IGF-1 level between healthy volunteers and AGHD patients: Part 2, 24 weeks fixed titration period to assess the safety, tolerability and PK/PD profile of HM10560A to select the optimal dose and dosing regimen; Part 3, 48 weeks individual titration period for safety follow up. In Part 2, IGF-1 SDS of HM10560A was compared with Genotropin and all patients were switched to HM10560A in Part 3 for long term follow up. Recommended doses for 24 weeks fixed titration period (Part 2) was obtained by population modeling and simulation, from 32 healthy volunteers received a single dose of HM10560A from Phase I and 9 AGHD patients received a single dose of HM10560A from Part 1 of current Phase II. Total 69 patients (29 males/40 females, 68 Caucasian/1 Asian) were randomized to 5 cohorts (0.03 mg/kg/week, 0.06 mg/kg/week, 0.10 mg/kg/week, 1.2 mg/kg/every other week, and Genotropin daily). Baseline demographic characteristics were similar between the groups with the mean age of 38.2 (±12) years old and had been 13.9 (±9.3) years since GHD diagnosis.

After 24 weeks treatment of HM10560A, 71% of patients in Cohort 2 (0.06 mg/kg/week), 79% of patients in Cohort 3 (0.10 mg/kg/week) and 86% of Cohort 5 (Genotropin daily) achieved the IGF-1 SDS between ±2. In Cohort 4, where HM10560A was administered in every other week, only 55% of patients achieved the IGF-1 SDS between ±2. Lean body mass was increased in all 4 cohorts treated with HM10560A, but the changes were marginal, due to a relative short treatment period. However, the exploratory exposure-response analysis suggested a strong relationship between HM10560A exposure and lean body mass. The most frequently reported AEs were headache, nasopharyngitis, oedema peripheral and injection site atrophy, as 7.2% respectively. An indirect exposure-response model with a precursor transit compartment described the IGF-1-time profile as a function of HM10560A concentration. Using the exposure-IGF-1 model and based on efficacy target to maintain IGF-1 SDS level between ±2, 0.1 mg/kg was predicted to an optimum in the next adult GHD patients study.

In conclusion, 24 weeks treatment with long acting HM10560A was safe, local tolerable and effective in AGHD. Dose for Phase III was selected as 0.1 mg/kg with weekly regimen from the PK/PD modeling. The results of current study warrants further development of HM10560A in adult GHD and pediatric GHD patients.

 

Nothing to Disclose: JK, PK, EHK, MYX, OH, YK, SYJ, SCK, YH, SC

19640 6.0000 FRI-447 A 6 Month Results of a Phase II, Randomized, Active Controlled, Open Label Study of Safety and Efficacy of HM10560A a Long Acting r-Hgh-HMC001 Conjugate in Adult Patients with Growth Hormone Deficiency (AGHD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Liou Y Sun*
SIUSOM, Chatham, IL

 

We examined the longevity of mice with targeted disruption of the hypothalamic hypophysiotropic peptide gene: Growth Hormone-releasing Hormone (GHRH). This gene is required for somatotroph cell proliferation and GH secretion. We provide a phenotypic, metabolic and molecular-level characterization of GHRH knockout (KO) mice and show that GHRH-KO mutants exhibit lifespan extension robustly in both sexes. In the present study we have shown that  deficiency in GHRH-GH signaling in mice leads to browning of WAT and elevated expression of uncoupling protein 1 (Ucp1), a key regulator of thermogenesis. Consequently, as compared to control mice, GHRH mutants exhibit elevated energy expenditure, improved insulin sensitivity and are more resistant to high fat diet–induced metabolic impairment.

 

Nothing to Disclose: LYS

18578 7.0000 FRI-448 A Growth Hormone-Releasing Hormone Disruption Extends Longevity, Regulates Response to Dietary Restriction, Promotes Browning of White Adipose Tissue and Ameliorates High Fat Diet-Induced Insulin Resistance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


David Maridas*1, Victoria Demambro1, Phuong T Le2, Casey R Doucette1 and Mohan Subburaman3
1Maine Medical Center Research Institute, Scarborough, ME, 2Maine Medical Center, Scarborough, ME, 3Loma Linda University, Loma Linda, CA

 

Insulin-like Growth Factor Binding Protein 4 (BP4) is expressed in high levels by human adipose tissue and is the most abundant IGF binding protein produced by osteoblasts.  In vitro, BP4 is known to inhibit IGF-I action on pre-osteoblasts. Previous reports showed that locally injected BP4 diminishes IGF-I effects on bone while systemic injection induces bone formation in mice; however, it is unclear whether BP4 enhances or inhibits IGF-I signaling in vivo. The purpose of this study was to determine how BP4 mediates adipose differentiation and if this impacts skeletal acquisition. Thus, we investigated the skeletal and adipose phenotypes of BP4 null (BP4-/-) mice at 8 and 16 wks of age using DXA, MicroCT, gene expression and protein analysis. Whole body DXA revealed a significant decrease in fat proportion and lean mass in 8- and 16-wk-old males and females (p<0.05). BP4-/- females had a reduction (p<0.04) of areal and femoral bone mineral density (BMD) and content (BMC) while males appeared unaffected by the loss of BP4. At 16 weeks, growth retardation of BP4-/- mice was characterized with reductions in femur length, inguinal (iWAT), gonadal white adipose tissues, and interscapular brown fat. Femurs of BP4-/- females had reduced BV/TV (p=0.06), trabecular and cortical thickness (p=0.05).  However, males had higher connectivity density (p=0.02) and trabecular number (p=0.005) with decreased trabecular spacing (p=0.02). Serum IGF-I and BP6 were both increased in BP4-/- females (p=0.03). However, in males, serum IGF-I was decreased (p=0.02) and BP6 was unchanged. Gene expression analysis showed that Sost expression was decreased in femurs of BP4-/- males but not females. Pparγ expression was reduced in iWAT of both genders. To measure adipogenesis in vitro, outer ear mesenchymal stem cells (eMSCs) were isolated from 3-wk-old mice and differentiated into adipocytes. BP4-/- eMSC showed a significant decrease in adipogenesis compared to BP4+/+ cells (p<0.001). In summary, our data suggest that BP4 is an important modulator of bone and fat development, but there is clear gender and tissue specificity. Indeed, males appeared to be protected against the reduction in bone parameters observed in females. Reduction of Sost expression in males but not in females may contribute to this gender-specific phenotype. Also, impaired adipocyte differentiation may partially explain the generalized reduction of adipose tissue. Taken together, our results support the hypothesis that BP4 likely mediates mesenchymal cell progression through several mechanisms, which may be linked to IGF-I and tissue specificity.

 

Nothing to Disclose: DM, VD, PTL, CRD, MS

22027 8.0000 FRI-449 A Gender-Specific Effects of Insulin-like Growth Factor Binding Protein 4 in the Development of Bone and Fat 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Ryan Berry*1, Yue Zhang2, Martin E. Young1 and Stuart J Frank1
1University of Alabama at Birmingham, Birmingham, AL, 2Univ of Alabama, Birmingham, AL

 

Cell autonomous circadian clocks synchronize physiological processes with the environmental light-dark cycle such that they occur at optimal times of day. When the clock mechanism is disrupted (e.g. through chronic jet lag or shift work) individuals are predisposed to health problems including cardiovascular disease, metabolic syndrome, diabetes, and cancer. Essentially all mammalian cells possess an intrinsic transcriptionally-regulated molecular clock that acts in concert with the suprachiasmatic nucleus central clock. A key component of both central and peripheral clocks is BMAL1, which also regulates expression of some non-circadian genes (1). Genetic silencing of BMAL1 in mouse cardiomyocytes (cardiomyocyte-specific BMAL1 knockout; CBK mouse) results in an age-onset hypertrophic cardiomyopathy in mice. Interestingly, a similar phenotype is observed in SIS2 transgenic mice, which over-express insulin-like growth factor (IGF) 1 (2). Cardiac dysfunction is also commonly observed in acromegalic individuals who have chronic growth hormone (GH) excess. We therefore hypothesized that aberrant GH/IGF-1 signaling in cardiac tissue of CBK mice may contribute to the observed cardiomyopathy. To test this hypothesis, gene expression analysis was initially performed in 12 week old ad libitum fed CBK and wild-type (WT; C57B6) mouse hearts isolated at three hour intervals over a 12hr:12hr light:dark cycle (n = 6 per time point). Interestingly, GH receptor (GHR) and IGF-1 mRNA levels were increased in CBK mouse hearts at all time-points by an average of 22% (p < 0.05) and 45% (p < 0.001), respectively, compared to WT mouse hearts. In a separate subset of mice, hearts were rapidly isolated during active phase to confirm increased levels of IGF-1 mRNA and for subsequent interrogation of GH/IGF-1 signaling axis via Western blot analysis.  In these samples IGF-1 mRNA levels were increased 80% in CBK hearts compared to WT controls (p < 0.05). Additionally, both Akt and ERK phosphorylation was increased in CBK mouse hearts, consistent with augmented GH/IGF-1 signaling. Further studies are underway to evaluate whether this pathway is activated in the CBK mouse hearts and, if so, the mechanism by which this dysregulation ensues.

 

Nothing to Disclose: RB, YZ, MEY, SJF

19859 9.0000 FRI-450 A Analysis of GH/IGF-1 Pathway Activation in Cardiac-Specific BMAL1 Knockout Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Yujun Gan*, Yue Zhang, Andrew J. Paterson, Jing Jiang and Stuart J Frank
University of Alabama at Birmingham, Birmingham, AL

 

Growth hormone (GH) signals through GH receptor (GHR), a cytokine receptor linked to the JAK2 tyrosine kinase that activates STAT5 to promote expression of genes including insulin-like growth factor-1 (IGF-1). IGF-1 binds IGF-1 receptor (IGF-1R), a tyrosine kinase growth factor receptor structurally related to insulin receptor (IR). We previously observed that GHR interacts with IGF-1R and that IGF-1R’s presence augments GH-induced STAT5 phosphorylation and IGF-1 gene expression. Pretreatment of human LNCaP prostate cancer cells, mouse 3T3-F442A preadipocytes, or primary mouse osteoblasts with a soluble fragment of IGF-1R extracellular domain’s L1CRL2 (sol IGF1R; residues 1-482), but not an analogous sol IR fragment, significantly blunted GH signaling (1). Notably, sol IGF-1R specifically co-immunoprecipitated with LNCaP GHR acutely upon GH treatment, mimicking the GH-induced co-immunoprecipitation of endogenous GHR and IGF-1R (2); this suggests that sol IGF-1R’s ability to inducibly interact with GHR underlies its dominant-negative effect on acute GH signaling and that sol IGF-1R competes with endogenous IGF-1R for interaction via its L1CRL2 region with GHR’s extracellular domain. In current work, we observe that sol IGF-1R pretreatment specifically blocks GH-induced GHR-IGF-1R co-immunoprecipitation. Thus, we hypothesize that sol IGF-1R’s ability to inhibit GH signaling relies on the presence of endogenous IGF-1R. To test this, we used H4IIE rat hepatoma cells, which like liver, are devoid of endogenous IGF-1R. We compared effects of pretreatment with sol IGF-1R or sol IR (control) on acute GH-induced STAT5 phosphorylation in H4IIE cells vs. H4IIE cells that adenovirally-expressed a human IGF-1R variant composed of extracellular and transmembrane domains, but devoid of the intracellular domain. We found that sol IGF-1R had no effect on GH-induced signaling in (IGF-1R-deficient) H4IIE cells. In contrast, sol IGF-1R specifically reduced GH-induced STAT5 phosphorylation by ~40% (n=4; p<0.02) compared to sol IR in H4IIE cells that express truncated membrane-anchored IGF-1R. These data suggest that sol IGF-1R exerts its dominant-negative inhibitory effect on GH signaling only when transmembrane IGF-1R is present. We hypothesize that IGF-1R contributes to proximal GH signaling by its GH-dependent interaction with a protein(s) associated with its extracellular domain below the L1CRL2 region or via its transmembrane domain. This protein(s) either enhances GH signaling or prevents its abatement. IGF-1R augmentation of GH action is most likely manifest in extra-hepatic and/or neoplastic tissue in which GHR and IGF-1R are both present. Further studies will explore physiologic consequences of this GHR-IGF-1R interaction.

 

Nothing to Disclose: YG, YZ, AJP, JJ, SJF

20533 10.0000 FRI-451 A Effects of a Soluble IGF-1R Extracellular Domain Fragment on GH Signaling in Liver Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Mathew James Buchman*, Edward Owen List, John J Kopchick, Darlene E Berryman, Katie Troike and Jonathan A Young
Ohio University, Athens, OH

 

Increases to the GH/IGF-1 axis have been shown to accelerate the aging process; however, the molecular mechanism(s) behind this remain unclear. The mammalian target of rapamycin (mTOR) is a potential target for the GH/IGF-1 axis. mTOR is a serine/threonine kinase involved in nutrient sensing, protein synthesis, cell proliferation and growth, and when inhibited, has been shown to extend the lifespan of several species. Recent evidence suggests that removal of GH action results in decreased mTOR activation. Thus, it would follow that elevation of GH should increase mTOR activation and partially explain how GH accelerates aging. Furthermore, since many of the actions of GH are due to IGF-1, differentiating the effects of GH versus that of IGF-1 is an important consideration. Thus, in the current study, we injected mice with GH or IGF-1 to determine whether these treatments affected mTOR activation. Three month old male C57BL/6J mice were injected with PBS (control group), 5 ug/g/day body weight recombinant bovine GH, or 10 ug/g/day body weight recombinant human IGF-1. After 2 weeks of treatment, body composition was measured prior to blood collection, dissection, and tissue collection. As expected, endogenous mouse IGF-1 levels were increased with GH treatment and decreased with human IGF-1 treatment. Body weight was increased in both treatment groups compared to controls. Analysis of body composition revealed that lean mass was increased in both GH and IGF-1 treatment groups, while fat mass was decreased in the GH treated group and unchanged in the IGF-1 treated group. Western blot analysis of mTOR and phosphorylated mTOR will be reported. In summary, both GH and IGF-1 significantly increased lean mass while only GH decreased fat mass. Results from Western blot analysis should shed light on the role mTOR in the GH/IGF-1 axis and should also be able to discriminate between the effects of GH versus that of IGF-1 on mTOR activation.

 

Nothing to Disclose: MJB, EOL, JJK, DEB, KT, JAY

22020 11.0000 FRI-452 A Analysis of mTOR in Mice Following Treatment with GH or IGF-1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Chiara Pascucci, Emilia Sbardella, Riccardo Valerio De Biase, Elisa Giannetta, Andrea Lenzi, Serena Quattrucci and Andrea M Isidori*
Sapienza University of Rome, Rome, Italy

 

Introduction: Cystic fibrosis (CF) is an autosomal recessive disorder caused by a variety of different mutations in the CFTR gene. Life expectancy has recently improved, however, patients (pts) with CF complain symptoms that overlap with the adult growth hormone deficiency syndrome (GHD): reduced muscle mass, bone fragility, cardiovascular complications and lower tolerance stress. The GH-IGF1 axis has been previously investigated only in small cohorts of children and adolescents with CF, while no large adult cohort studies are available. Aim: To investigate abnormalities of the GH-IGF-1 axis in adults with CF. Methods: From over 300 CF  adults followed-up in our referral center, we excluded pts with liver or lung transplantation, age<18years, subjects with FEV1(% predicted) <30% or on oxygen therapy. The remaining were consecutively enrolled in a prospective study with recording of anthropometric parameters, glyco-metabolic status, pituitary, thyroid, parathyroid, gonadal and adrenal function, arginine+GHRH stimulation test for GH, spirometry, dual-energy X-ray absorptiometry, thyroid and gonadal ultrasonography and questionnaires. BMI-adjusted criteria were used for the diagnosis of severe GHD (8 or 11.5 ng/ml) and partial GHD (16 ng/ml). Data are shown as mean±SD (range), if normally distributed, or median (interquartile). Results: The first 41 enrolled pts (30 men; age 36.9 ± 10.7 yrs) had the following  spirometric values: FEV1 %: 61.9 ± 18.3 (31-101), FVC%:78.7±19.5 (35-109),  FEF25-75 %:39±23.7 (24-53), confirming a good CF control. All pts had two severe (class 1 and 2) CTFR mutations. Testing of GH-IGF1 axis revealed a defective response in 34.2% (14/41): severe in 12.2% (5/41) and partial in 22% (9/41). In severe GHD, median GH peak was 8.5±1.3 (8.1-10.6) and IGF1 185.4±51.5 ng/ml (137-273); in partial GHD, GH peak was 12.8±1.5 (12.4-14.6) and IGF1 208±39.7 (146-283), the remaining had a GH peak of 38.9±38.6 (25.4-58.4). All pts with severe GHD had at least one ΔF508 mutation (100%, 5/5) [homozygous in 60%], compared to controls in whom ΔF508 was less frequent [(homozygous in 33.3% (9/27)]. Compared to non-GHD adults with CF, GHD pts had a worst fasting glucose (115.9±29.1 vs 87.7±13.7) and higher BMI (23.4±2.4vs 20.9±2.7) (both p<0.05) which were inversely correlated to GH peak (fasting glucose: r=-0.31, BMI: r= -0.33; both p<0.05). No significant differences were observed in spirometry, bone density and H-QLS questionnaire. Discussion: Very few data on GHD in CF are available. Our study is the first prospectively performed in well-controlled subjects aged 22 to 60 years showing a high GHD prevalence, a possible association with genetic background and an impact on metabolic status. Given these findings and the increased life expectancy of pts with CF, a larger screening and clinical follow-up of the impact of GHD in affected subjects is warranted.

 

Nothing to Disclose: CP, ES, RVD, EG, AL, SQ, AMI

19905 12.0000 FRI-454 A Growth Hormone and IGF1 in Adults with Cystic Fibrosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Kentaro Suda*1, Hidenori Fukuoka2, Genzo Iguchi2, Yushi Hirota2, Kenichi Yoshida1, Ryusaku Matsumoto1, Hironori Bando1, Hitoshi Nishizawa1, Michiko Takahashi1, Kazuhiko Sakaguchi2, Wataru Ogawa1 and Yutaka Takahashi1
1Kobe University Graduate School of Medicine, Kobe, Japan, 2Kobe University Hospital, Kobe, Japan

 

Background: Although recent evidences show that higher serum IGF-I levels are associated with a decreased risk of atherosclerosis in a general population, it is unclear in patients with type 2 diabetes (T2DM). The aim of this retrospective study was to examine the association of serum IGF-I levels and micro- and macro-angiopathies in patients with T2DM.

Subjects and Methods: A total of 327 hospitalized patients with T2DM (189 men and 138 women; age 60.5 ± 14.2; body mass index (BMI) 26.9 ± 5.9 kg/m2; HbA1c 9.1 ± 2.1 %) in Kobe University Hospital from 2011 to 2013 were enrolled. Patients with pituitary disease and pregnant women were excluded. Serum IGF-I levels were measured and analyzed the relationship between serum IGF-I levels and microangiopathies (retinopathy, nephropathy, and neuropathy) or macroangiopathies (cerebrovascular disease, cardiovascular disease, and peripheral arterial disease). We also analyzed the association of these angiopathies with atherosclerosis-related factors including BMI, smoking, hypertension, and dyslipidemia.

Results: The prevalence of retinopathy, nephropathy, neuropathy, cerebrovascular disease, cardiovascular disease, and peripheral arterial disease were 45%, 32%, 40%, 20%, 17%, and 13%, respectively. There were no associations between the serum IGF-I levels and presence or absence of these angiopathies. Then we divided these patients into 4 groups by presence or absence of microangiopathies (Mi) and macroangiopathies (Ma); (Mi(-)Ma(-), Mi(+)Ma(-), Mi(-)Ma(+), Mi(+)Ma(+)) and compared serum IGF-I levels. Intriguingly, serum IGF-I levels were significantly lower in the Mi(-)Ma(+) group (serum IGF-I 96.92 ± 15.26 ng/mL, IGF-I SD score (SDS) -0.97 ± 0.43, p = 0.030) compared with the Mi(-)Ma(-) group (serum IGF-I 138.33 ± 6.02 ng/mL, SDS -0.19 ± 0.15), Mi(+)Ma(-) group (serum IGF-I 140.08 ± 5.39 ng/mL, SDS -0.05 ± 0.14), and Mi(+)Ma(+) group (serum IGF-I 126.83 ± 6.15 ng/mL, SDS 0.10 ± 0.17). Multiple linear regression analyses revealed that the duration of diabetes was positively correlated with the presence of microangiopathies (p = 0.0007). Age, the duration of diabetes, hypertension, and dyslipidemia were positively correlated with the presence of macroangiopathies (p = 0.006, 0.001, 0.0001, and 0.042, respectively). Comparably, serum IGF-I levels were negatively correlated with the absence of microangiopathies and presence of macroangiopathies (p = 0.005).

Conclusion: Present data demonstrated that lower levels of IGF-I are associated with the presence of macroangiopathies and the absence of microangiopathies in patients with T2DM. The protective effect on atherosclerosis of IGF-I was comparable with the results of normal population in the previous reports. In addition, it is suggested that IGF-I may aggrevate microangiopathies in patients with T2DM.

 

Nothing to Disclose: KS, HF, GI, YH, KY, RM, HB, HN, MT, KS, WO, YT

20324 13.0000 FRI-455 A The Association of Serum IGF-I Levels Between Micro- and Macro-Angiopathies in Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Sunita MC De Sousa*1, Lynne Schofield2, Graham RD Jones2 and Ann I McCormack3
1St Vincent's Hospital, Sydney, Australia, 2St Vincent's Hospital, 3St. Vincent's Hospital, Sydney, Australia

 

Background: The insulin tolerance test (ITT), glucagon stimulation test (GST), and short Synacthen test (SST) are employed in the evaluation of suspected cortisol and/or GH deficiency, with ITT traditionally considered the gold standard.1 However, a recent study found lower peak cortisol on ITT compared to GST and 1mcg SST, and lower peak GH on ITT compared to GST.2We hypothesised that individual patients may have discordant results on dynamic testing with none of the stimuli being consistently more potent than the other.

Aims: We aimed to compare cortisol responses on ITT against GST and SST, and GH responses on ITT against GST, within individual patients.

Methods: We performed a retrospective audit of adults who had undergone ITT plus either GST and/or 250mcg SST for suspected hypopituitarism. As per local practice, cortisol adequacy was deemed by peak cortisol > 550 nmol/L at any time on ITT or GST, and at 30min on SST. GH adequacy was deemed by peak GH > 10 mU/L at any time on ITT or GST. The primary outcome was identification of discordant results for cortisol and/or GH responses between the different dynamic tests.

Results: Results were available for 13 patients: 6 had ITT + GST, and 8 had ITT + SST (including 1 patient who had all tests). All achieved symptomatic hypoglycaemia on ITT, with nadir BSL < 2.2 mmol/L except for 1 patient with nadir of 2.3 mmol/L. The mean peak cortisols from ITT and GST in subjects who underwent both tests were 468 and 507 nmol/L, respectively. In subjects who underwent ITT and SST, mean peak cortisols were 385 and 534 nmol/L, respectively. Mean peak GH from ITT and GST in subjects with both results were 7.2 and 18.1 mU/L, respectively.

In total, 5 of  the 13 patients had discordant results using the defined decision points. Of the 3 patients with cortisol discordance, 2 were cortisol-adequate on GST or SST and inadequate on ITT, whilst 1 was adequate on ITT and inadequate on GST. The 3 patients with GH discordance were all GH-adequate on GST and inadequate on ITT. One patient had discordant results in both cortisol and GH.

Conclusions: We found a 38% rate of cortisol and/or GH discordance amongst patients with multiple dynamic tests. Comparison of mean peak cortisol and GH suggested glucagon and Synacthen to be more potent stimuli of hormone secretion than hypoglycaemia, consistent with recent data.2 However, 1 subject showed cortisol adequacy on ITT and not on GST illustrating that results may vary by individual or possibly within an individual over time. The different cortisol responses also suggest that test-specific decision points may be indicated. Any of the three tests may thus be selected in the investigation of hypopitutarism, and the alternatives should be performed where clinical suspicion remains. We challenge the current notion of ITT as the first line investigation for hypopituitarism because of the false positives seen here and because of its seizure risk.

 

Nothing to Disclose: SMD, LS, GRJ, AIM

18963 14.0000 FRI-456 A Discordant Results in the Insulin Tolerance, Glucagon Stimulation and Short Synacthen Tests Amongst Adults with Suspected Hypopituitarism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Ayman A. Zayed1, Mohammad A. Zmaili*2, Marwa M. Sabha3, Mohannad M. Saleh2, Moaath K. Mustafa Ali4, Aref L. Zayed5, Suleiman I. Al Ashi6, Al-Motassem Yousef7 and Hussein D. Abdul-latif8
1The University of Jordan / Jordan University Hospital, Amman, Jordan, 2Faculty of Medicine - University of Jordan, Amman, Jordan, 3Jordan University Hospital, Amman, Jordan, 4King Hussein Cancer Center, Amman, Jordan, 5Faculty of Farmacy - Jordan University of Science and Technology, Irbid, Jordan, 6Gardens Hospital, Amman, Jordan, 7The University of Jordan, Amman, Jordan, 8Children Hostpital/ University of Alabama at Birmingham, Birmingham, AL

 

Abstract

 

Objective: Little is written about the utility of serum IGF-I/IGFBP-3 ratio in the diagnosis of growth hormone deficiency (GHD). This study aimed to investigate whether serum IGF-I/IGFBP-3 ratio might contribute to the diagnosis of GHD in a referred sample of short-statured children to a university hospital in Jordan.

Methods: A 25-month cross-sectional observational study was conducted at an outpatient university hospital in Amman, Jordan. We obtained a comprehensive medical and laboratory evaluation for 134 short-statured children (64 boys and 70 girls, aged 4-16 years). Complete and partial GHD were defined as peak GH response of 5 and 7 ng/ml [IRMA/ DiaSorin®], respectively in both clonidine stimulation and insulin tolerance tests. Serum IGF-I, IGFBP-3 and IGF-I/IGFBP-3 ratio were determined for all participants.

Results: GHD was diagnosed in 47.0% of the short children. The sensitivity of IGF-I, IGFBP-3, the combination of IGF-I and IGFBP-3 measurements and IGF-I/IGFBP-3 ratio in the diagnosis of complete GHD was 38.0%, 48.0%, 40.0% and 88.0% respectively, whereas their specificity was 90.1%, 71.8%, 90.7% and 76.1% respectively. In contrast, the sensitivity of the same parameters in partial GHD was 38.5%, 35.9%, 84.6% and 45.5% respectively, whereas the specificity was 90.1%, 71.8%, 76.1% and 90.7% respectively.

Conclusion: These results indicate that for the diagnosis of children with GHD, IGF-I/IGFBP-3 ratio performed better as a screening test (87.3% sensitivity) than IGF-I, IGFBP-3 and the combination of IGF-I and IGFBP-3 measurements. However, except for partial GHD, its specificity was inferior to IGF-I.

 

Nothing to Disclose: AAZ, MAZ, MMS, MMS, MKM, ALZ, SIA, AMY, HDA

21699 15.0000 FRI-457 A Emerging Role of Serum IGF-I/IGFBP-3 Ratio in the Diagnosis of Children with Growth Hormone Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Zhihong Liao*, Qiqi Yin, Wei He, Wen Ji, Luyao Zhang and Yanbing Li
1st Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China

 

Aims: To establish the normal range of serum Insulin-like growth factor -1 (IGF-1) level at local laboratory was crucial in evaluating of Growth Hormone-IGF axis function. This study investigated the IGF-1 distribution characteristics in healthy adult Chinese. 

Methods: The serum IGF-1 level was measured by automated chemiluminescence immunoassay(IMMULITE 2000,SIEMENS). 515 healthy adults (254 males and 261 females), without hepatic diseases, infection, cancer, obesity, or diabetes, aged 20 to 84 year-old (selected equally spaced of 5 year-old) were enrolled. 

Results: (1) From the beginning of adulthood (aged 20-24), IGF-1 reached the mean peak of 255.73ng/ml and decreased gradually with age (0.561ng/ml/age, P<0.001). (2) There was no significant difference statistically for the IGF-1 levels between men and women in the same age groups. (3) No impact of BMI on IGF-1was shown when it was in the range of 18.5-28Kg/M2. (4) Comparing the mean values of IGF-1 in Martin W. Elmlinger’s study[1], there was no statistical difference in the same age and gender groups. 

Conclusion: IGF-1 was declined with age in adults. The impacts of gender and BMI on IGF-1 levels were subtle when BMI was within the normal range. The normal reference ranges of IGF-1from Martin W. Elmlinger’s study was properly adaptable for Chinese adults.

 

Nothing to Disclose: ZL, QY, WH, WJ, LZ, YL

20972 16.0000 FRI-458 A Serum Insulin-like Growth Factor-1 Level of Healthy Adults in Southern China 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Vivien Bonert*1, John D. Carmichael2, Michael S. Broder3, Maureen P Neary4, Eunice Chang3, William H Ludlam4 and Dasha Cherepanov3
1Cedars-Sinai Medical Center, Los Angeles, CA, 2University of Southern California, Los Angeles, CA, 3Partnership for Health Analytic Research, LLC, Beverly Hills, CA, 4Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

OBJECTIVES:Control of acromegaly requires normalization of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). The primary objective of this study was to examine the relationship between achieving biochemical control and comorbidities.  Specifically, we compared the incidence of specific complications in patients who attained biochemical control compared with those who did not.

METHODS:An acromegaly registry at the Pituitary Center at Cedars-Sinai Medical Center (CSMC) was used to conduct this cohort study. We recorded data on demographics, radiologic findings, tumor characteristics, and comorbidities at baseline (first 6 months of data) and during follow-up. Follow-up was the period between the first IGF-I/GH test date and the last date of IGF-I/GH test date at the time of data collection. Patients were divided into cohorts based on biochemical control status using the most recent lab value at the time of analysis: controlled (only normal IGF-I and/or GH), uncontrolled (only abnormal IGF-I and/or GH values), and discordant (1 normal and 1 abnormal GH or IGF-1 within 7 days). Frequency of comorbid conditions was compared between groups.

RESULTS:The study group included 121 patients. Baseline age was 55.4 years mean (SD: 16.7), and 67 (55%) patients were female. At presentation to CSMC, 88% of patients had a macroadenoma. Treatment was initially surgical in 104 patients (86%), medication in 16 patients, and radiation in 1. At the initial visit, 8 (7%) patients were controlled, 7 (6%) had discordant laboratory values, and 106 (88%) patients were biochemically uncontrolled. Mean length of follow-up was 8.8 years (median: 5.5; SD: 7.2 years). By the end of follow-up 88 (73%) patients had required treatment with multiple modalities. At the last assessment, 70 (58%) were biochemically controlled, 16 (13%) were discordant, and 35 (29%) were uncontrolled. Several key comorbidities were seen less frequently in controlled compared to uncontrolled patients: diabetes 26% (n=18) vs. 43% (n=15), hypertension 43% (n=30) vs. 60% (n=21), sleep apnea 24% (n=17) vs. 29% (n=10), and cardiomyopathy 4% (n=3) vs. 9% (n=3).

CONCLUSIONS:This study confirms that biochemically uncontrolled patients with acromegaly appear to suffer common comorbidities more frequently than their controlled counterparts. Despite the use of multiple treatment modalities, almost a third of patients remain biochemically uncontrolled, demonstrating the difficulty of achieving biochemical control.

 

Disclosure: JDC: Ad Hoc Consultant, Genentech, Inc., Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Novartis Pharmaceuticals. MSB: Researcher, Novartis Pharmaceuticals. MPN: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. EC: Researcher, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. DC: Researcher, Novartis Pharmaceuticals. Nothing to Disclose: VB

21419 17.0000 FRI-459 A Biochemical Control and Comorbidities in a US Acromegaly Registry 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Cecilia Ulrika Follin*1, Sanaz Gabery2, Åsa Petersen2, Pia Maly sundgren1, Isabella Björkman Burtcher1, Jimmy Lätt1, Peter Mannfolk1 and Eva Marie Erfurth3
1Institution of Clinical Sciences, Lund University, Lund, Sweden, 2Translational Neuroendocrine Research Unit, Lund University, Lund, Sweden, 3Skåne University Hospital, Malmo, Sweden

 

Background: There is an increased risk for metabolic complications and cardiovascular disease after long-term follow-up in ALL survivors treated with cranial radiotherapy (CRT). These complications include obesity, lipid abnormalities, insulin resistance and physical inactivity. However, the etiology of these complications is not well understood. The hypothalamus (HT) is a small complex area of the brain involved in endocrine function and also energy expenditure and metabolic control. A greater vulnerability of the female brain to metabolic-related damage has also been reported. Neuro-radiological assessment of the volume of the HT in relation to metabolic parameters in ALL survivors has not been performed previously. Ghrelin levels are increased only in patients with Prader Willi Syndrome, but have not previously been reported in an ALL population. 

Method: Thirty-four (21 women) ALL survivors, on complete hormone supplementation, were investigated 34 years after ALL diagnosis. Their median-age was 38 (27-46) years and they had been treated with a CRT dose of 24 Gy. Comparison was made with 31 healthy matched controls. Assessments of BMI (kg/m2), waist (cm), fat mass (kg), Fat free mass (kg), plasma (p)-glucose (mmol/L), p-Insulin (mIE/L), Homa-Index, s-leptin (µg/L), Leptin/kg fat mass and s-Ghrelin (ng/L) was performed. A high-resolution structural magnetic resonance imaging (MRI) was performed with T1-weighted images (3Tesla) to conduct a structural volumetric analysis of the the volume of the HT.

Results: Significantly higher BMI (27.9 vs 22.6 kg/m2), waist (89 vs 79 cm), fat mass (29.9 vs 22.4 kg), p- insulin (10 vs 6 mIE/L), Homa-Index (0.15 vs 0.07), s-leptin (33 vs 13), leptin/kg fat mass (1.09 vs 0.6) and s-Ghrelin (1560 vs 993 ng/L) and significantly lower fat free mass (35.4 vs 41.6 kg) were recorded among the female ALL survivors compared to matched controls (all P<0.01). There was a trend of a smaller HT volume among the ALL women compared to gender matched controls (846 vs 869 mm3, P=0.06). In contrast this was not the case among the ALL men compared to controls. We also recorded a significantly smaller HT volume in ALL women compared to ALL men (846 vs 936 mm3, P=0.001). S-leptin levels were negatively correlated with the HT volume (r = - 0.4, P = 0.01) among the 34 ALL survivors, but not among the matched controls (P > 0.3).

Conclusion: Compared to CRT treated ALL men, ALL women treated with CRT, are at high risk of metabolic abnormalities and a smaller HT volume 34 years after ALL diagnosis. These findings suggest an association between reduced HT volume and metabolic risk after CRT. The significantly increased Ghrelin levels in ALL women are suggestive of a hypothalamic effect, but need further investigation.

 

Nothing to Disclose: CUF, SG, ÅP, PM, IB, JL, PM, EME

20345 18.0000 FRI-460 A High Metabolic Risk and a Smaller Hypothalamic Volume Are Recorded in Acute Lymphoblastic Leukemia (ALL) Women 34 Years after Cranial Radiotherapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Cindy B. Schmelkin*1, Kamryn T. Eddy1, Jennifer J. Thomas1, Emily K. Gray1, Dean A. Marengi2, Karen K. Miller1, Nouchine K. Hadjikhani1, Debra L. Franko3, Anne Klibanski1 and Elizabeth A. Lawson1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts General Hospital, Boston, MA, 3Northeastern University, Boston, MA

 

Anorexia nervosa (AN), a psychiatric disorder characterized by self-starvation, is associated with deficits in social emotional functioning, including increased social anxiety and alexithymia (difficulty recognizing and expressing one’s own emotions). Dysregulation of oxytocin, a neurohormone implicated in social behavior, is also observed in AN, even after weight recovery, and is associated with severity of disordered eating psychopathology, anxiety, and depressive symptoms. To further characterize the role of oxytocin in AN, we investigated the association between oxytocin levels and social emotional functioning deficits in women with DSM-5 AN. We examined 20 women with active AN, 27 weight-recovered AN (ANWR), and 34 healthy controls (HC), mean age 23.9±0.6 years. Fasting serum oxytocin levels were measured and social emotional functioning was assessed using the Dimensional Assessment of Personality Pathology–Basic Questionnaire: Suspiciousness and Inappropriate Attachment subscales, Leibowitz Social Adjustment Scale–Self Report, and, in 36 subjects, the Toronto Alexithymia Scale. BMI did not differ between HC and ANWR. We found that oxytocin levels were low in ANWR (p=0.0004) and AN (p=0.08) vs. HC. AN and ANWR did not differ in suspiciousness, difficulty identifying feelings, and overall alexithymia; both groups reported greater difficulties than HC (p<.01). ANWR reported social fear, social avoidance, and public fear intermediate between AN and HC (p<.05), whereas public avoidance was increased in AN (p<0.003), but did not differ between HC and ANWR. AN reported greater insecure attachment and difficulty describing feelings than HC (p<.007), and ANWR did not significantly differ from either group. Across all groups, lower oxytocin levels were associated with increased overall alexithymia (r=-0.39, p=.02), difficulty describing feelings (r=-0.33, p=.048), and difficulty identifying feelings (r=-0.38, p=.02). These relationships remained significant after controlling for BMI. Those subjects with alexithymia had lower mean oxytocin levels than those with possible/without alexithymia (757±148 vs. 1191±95 pg/ml, p=0.03). There were no associations between oxytocin and other social emotional measures.  These data suggest that abnormalities in oxytocin pathways and social emotional functioning may be “trait” characteristics of AN or scar from chronic starvation. Further investigation will be important to determine whether oxytocin deficiency contributes to symptoms of alexithymia in AN.

 

Nothing to Disclose: CBS, KTE, JJT, EKG, DAM, KKM, NKH, DLF, AK, EAL

19274 19.0000 FRI-461 A Oxytocin Levels Are Related to Alexithymia in Anorexia Nervosa 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Viveka P. Jyotsna*1, Ekta Malik1, Shweta Birla2 and Arundhati Sharma1
1All India Institute of Medical Scences, New Delhi, New Delhi, India, 2All India Institute of Medical Scences, New Delhi, New Delhi

 

Background: MEN1 gene variations are known in MEN1 syndrome (which comprises pituitary, parathyroid and pancreatic tumor). But not much is known about association of MEN 1 gene mutations with sporadic cases of pituitary adenoma. MEN1 is a tumor suppressor gene and its cytogenetic location is 11q13. MEN1 gene has 10 exons encoding a 610 amino acid protein menin. Menin is a nuclear protein with roles in transcriptional regulation, genome stability, cell division and proliferation.

Hypothesis:  MEN 1 gene variation are involved in the development of sporadic cases of anterior pituitary tumor.

Methodology: Twenty subjects diagnosed with different classes of anterior pituitary tumors were recruited from outpatient department. The number of tumors in each group was Cushing Syndrome (13), Acromegaly (6) and TSHoma (1). Genomic DNA isolated from peripheral blood sample by standard protocol and processed for PCR amplification followed by direct sequencing to screen for the presence of variations in MEN 1 gene. The results were compared with the reference sequences in the public databases.

Results: Novel Missense mutation Q260R was identified in 45% of all cases. Novel Missense mutation S219C was found in 23% of cases of Cushing syndrome only. Novel Intronic variation c.799-128T→A was present in one patient of Acromegaly. Reported polymorphism rs540012 was found to be present in all the patients representing a common polymorphism in our patient population. The reported benign polymorphism rs2071313 was present in 42% of tumors except TSHoma, suggesting its possible association with Cushing syndrome and Acromegaly. Intronic polymorphism rs669976 was found in 38% of cases except TSHoma.

Conclusion: Results revealed reported and novel MEN 1 gene variants both in exon and intron regions. Some variations are found to be restricted to specific tumor types and absent in others suggesting their probable role in the pathogenesis of the disease. Studies on a larger sample size needed to confirm this association.

 

Nothing to Disclose: VPJ, EM, SB, AS

19529 20.0000 FRI-462 A MEN1 Gene Variations in Sporadic Anterior Pituitary Tumors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Sayid Shafi Zuhur1, Hanife Ozkayalar2, Idris Kuzu3, Feyza Yener Ozturk3, Gulsah Elbuken1, Canan Tanik3 and Yuksel Altuntas*3
1Namik Kemal University, Faculty of Medicine, Tekirdag, Turkey, 2Near East University, Faculty of Medicine, 3Sisli Etfal Training and Research Hospital, Istanbul, Turkey

 

Purpose:  In recent studies, voltage gated potassium channel Eag1, a critical determinant of cell membrane potential, has been directly linked to cellular transformation, proliferation, invasion and survival of various types of tumors including colon, breast, prostate, lung, hepatocellular and gliomas. Eag1 expression is extremely limited in normal tissues except for the specific areas of the brain, but its overexpression has been determined in many different tumor cells, however, its expression has not been determined in growth hormone (GH) secreting pituitary adenomas. Therefore, the purpose of this study was to determine immunohistochemical expression of Eag1 in pituitary adenoma of patients with acromegaly and to compare its expression with age, gender, cavernous sinus invasion on magnetic resonance imaging and tumoral immunohistochemical expression of Ki-67 in those whose follow-up data were available (n = 20).

Methods:  The paraffin embedded pituitary adenoma tissue sections of 28 patients with acromegaly who were diagnosed as pure GH secreting adenomas were immunostained for Eag1 using avidin-biotin-peroxidase complex method. Eag1 immunoreactivity was scored according to the extensity of the cytoplasm and cell membran immunoreactivity for Eag1 (score 1 = <10%, score 2 = 10 - 25%, score 3 = 25-50% and score 4 = >50% of the adenoma cells showed immunoreactivity for Eag1, respectively).  

Results: Overall, all GH secreting pituitary adenomas displayed diverse levels of Eag1 immunoreactivity, however, 64% of the adenomas displayed extensive Eag1 immunoreactivity (score 3 and 4). Five of the tumors displayed Eag1 extensity score 1, 5 score 2, 10 score 3 and 8 score 4, respectively. No relationship was found between Eag1 extensity with age, gender, cavernous sinus invasion and Ki-67 LI of the patients (r = -0,002, p = 0,99; r = - 0,02, p = 0,99; r = - 0,13, p = 0,56 and r = 0,12, p = 0,61, respectively ).

Conclusions: Our results suggest extensive immunoexpression of Eag1 in the majority of GH secreting pituitary adenomas. As in other tumors, Eag1 may play a substantial role in tumorigenesis of these adenomas, however, we could not find any relationship between Eag1 extensity with cavernous sinus invasion, Ki-67 LI, age and gender of the patients. Further studies with larger sample sizes are required to demonstrate the role of Eag1 on tumorigenesis, angiogenesis, invasion, recurrence after surgery and response to the treatment in GH secreting pituitary adenomas.

 

Nothing to Disclose: SSZ, HO, IK, FY, GE, CT, YA

18362 21.0000 FRI-463 A Expression of Voltage Gated Potassium Channel Ether `a Go-Go in Pituitary Adenoma of Patients with Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Bibiana Moreno-Carranza*1, Juan Pablo Robles2, Martha Gabriela Ferrer-Rios3, Hugo Cruces-Solis3, Pamela Reyes-Ortega3, Gonzalo Martinez de la Escalera2 and Carmen Clapp4
1Universidad Nacional Autónoma de México (UNAM), Querétaro QRO, Mexico, 2Universidad Nacional Autónoma de México (UNAM), Querétaro, QRO, Mexico, 3Universidad Nacional Autónoma de México, Querétaro QRO, Mexico, 4National University of Mexico (UNAM), Queretaro, Mexico

 

Vasoinhibins are a family of N-terminal fragments of prolactin (PRL) with antiangiogenic properties. Some of these fragments have been extensively studied for their ability to inhibit angiogenesis during tumor growth, postpartum cardiomyopathy, and diabetic retinopathy. However, since natural proteolytic processing of PRL generates fragments containing a free cysteine in position 58 (C58), during recombinant production of vasoinhibins, the C58 has been commonly changed to serine (S58) to prevent the formation of anomalous intra- or inter-molecular disulfide bonds. Nevertheless, the functional implication of this mutation has not been well documented. Here, we compared the transcription, secretion, and biological activity of a recombinant vasoinhibin having 123 amino acids and produced in HEK293T/17 cells following: (i) improvement of the expression plasmid by codon optimization and b-globin intron incorporation, and (ii) mutation or not of C58 into S58. Optimization increased recombinant PRL mRNA and protein levels in cells and conditioned medium. The levels of vasoinhibin mRNA were also increased, but the protein levels were not. Additionally, the S58-mutated vasoinhibin associated with a bigger proportion of higher molecular weight isoforms due to glycosylation and with an elevated secretion rate. Nonetheless, the S58-vasoinhibin showed reduced antiangiogenic properties when compared to the wild-type vasoinhibin, as revealed by their inhibitory effect on the proliferation of endothelial cells in culture. In conclusion, an overproduction of vasoinhibin mRNA interferes with its translation and/or promotes the degradation of the protein. Moreover, C58 substitution for S58 increases vasoinhibin glycosylation, which may improve the secretion, but also interfere with the biological properties of the protein. This study has unveiled important aspects of the structure-function relationship of recombinant vasoinhibins relevant to their generation for basic and clinical studies.

 

Nothing to Disclose: BM, JPR, MGF, HC, PR, GM, CC

21495 22.0000 FRI-464 A Insights in the Production of Recombinant Vasoinhibins 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Melanie M. van der Klauw*, Anneke C. Muller Kobold, Janny H. Roffel-Hooijer, Eelco W. Hoving, Jos M.A. Kuijlen, Gerrit van den Berg and Bruce H.R. Wolffenbuttel
University Medical Center Groningen, Groningen, Netherlands

 

Introduction

Recently, an automated assay for CT-proAVP has become available. We examined whether this assay could be helpful in diagnosing central diabetes insipidus (DI) and syndrome of inappropriate ADH secretion (SIADH) after pituitary surgery.

Methods

From November 27, 2013 until September 10, 2014, 47 patients underwent pituitary surgery for non-functioning pituitary adenoma, Cushing’s disease, treatment resistant prolactinoma, meningeoma, acromegaly, pituitary cyst and hemangioma in the cavernous sinus in the University Medical Center Groningen. In all of these patients, IGF-1 was measured.  Serum from these measurements was stored at -20C for quality assurance purposes. We used the serum of those patients that was still available to measure CT-proAVP on the Kryptor Compact Plus (Brahms, Fischer Diagnostics, Germany). Furthermore, we collected retrospectively data on the development of DI and/or SIADH pre- or postoperatively on the days of measurement of IGF-1, and on the use of desmopressin on these days. Also, the sodium levels on the day of measurement of IGF-1 were collected.  The CT-proAVP levels of patients with and without DI and SIADH were then compared using an independent samples Mann-Whitney U test.

Results

Serum of 30 out of 47 operated patients was available for measurement of CT-proAVP, on several moments in time before and after pituitary surgery. In total, 90 measurements of CT-proAVP were available for analysis. Of those 30 patients, 5 developed a (transient or permanent) DI and 3 a transient SIADH. There were no patients with a consecutive DI and SIADH. There was one patient complaining 5 days after pituitary surgery of weight  changes, who clinically and based on a normal sodium level did not have a central DI. Her CT-proAVP levels were however undetectable in that period until 49 days after the surgery, and became detectable again later. The median CTproAVP levels in patients with a DI was: 1.744 pmol/l (range 1.354-2.491), in patients with a SIADH: 3.192 pmol/l (range 2.515-4.721), and in patients without DI or SIADH: 2.661 (range <0.900-14.970). Using the independent samples Mann-Whitney U test, we found that the difference in CT-proAVP levels in patients measured at time points with and without DI was significantly different (p-value 0.001).  Comparing patients with and without a SIADH we found no difference (p-value 0.583).

Conclusion

The CT-proAVP levels could help in distinguishing patients with and without central diabetes insipidus, but not in distinguishing between patients with and without SIADH after pituitary surgery. Currently, a prospective multicenter trial is ongoing, in order to further determine the predictive power of a single CT-proAVP measurement, and the optimal time point for sampling.

 

Nothing to Disclose: MMV, ACM, JHR, EWH, JMAK, GV, BHRW

21711 23.0000 FRI-465 A CT-Proavp Levels in Central Diabetes Insipidus and Syndrome of Inappropriate Adh Secretion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 442-465 5946 1:00:00 PM GH, IGF and Posterior Pituitary Poster


Dawn Phillips*1, Kimberly Hamilton2, Scott Moseley3, Tatjana Odrljin3, Kenji P Fujita3, Amy L Reeves4, Amy Yakimoski2, Cheryl Rockman-Greenberg2, Michael P. Whyte5 and Katherine L Madson4
1University of North Carolina, Chapel Hill, NC, 2University of Manitoba, Winnipeg, MB, Canada, 3Alexion Pharmaceuticals, Inc., Cheshire, CT, 4Shriners Hospital for Children, St. Louis, MO, 5Shriners Hospitals for Children, St. Louis, MO

 

Hypophosphatasia (HPP) is the rare inherited metabolic disorder resulting from loss-of-function mutation(s) in the tissue-nonspecific alkaline phosphatase (TNSALP) gene. TNSALP deficiency can cause a spectrum of sequelae in children including premature loss of primary teeth, rickets, poor growth, muscle weakness, compromised physical function, and pain. We preliminarily reported that 5‑12-yo children treated ≥3 yrs with asfotase alfa, a recombinant bone-targeted human TNSALP, improved skeletal mineralization, growth, physical function (Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition) and pain (Pediatric Outcomes Data Collection Instrument [PODCI]) (1,2). Now, we present additional assessments of activities of daily living (ADL), pain, and function that were performed in these children.

This Phase II open-label study began with a 6-mo treatment phase (≥6 mg/kg/wk asfotase alfa), followed by an ongoing extension phase (6 mg/kg/wk). ADL, physical function, and pain were assessed with the Childhood Health Assessment Questionnaire (CHAQ) and the PODCI. The CHAQ has 2 scales: a Disability Index with 30 age-appropriate items in 8 subscales of ADL, and a Discomfort (pain) Index (100 mm visual analog scale). CHAQ disability is scored from 0-3 (0=functional independence; 3=complete dependence on caregiver). A decrease of ≥0.13 is clinically meaningful in juvenile arthritis (3). The PODCI has 8 scales, including Upper Extremity and Physical Function, Transfer and Basic Mobility, Sports/Physical Functioning, and Global Functioning; each has a normative mean score of 50 (SD 10).

12/13 patients entered the extension study, receiving ≥3 yrs of treatment. Last assessment (LA) was at 3 yrs (n=8) or 3.5 yrs (n=4). The median (min, max) CHAQ disability score decreased from 1.0 (0.0, 2.3) at baseline (BL) to 0.4 (0.0, 1.9) at 3 mo (P=0.014), 0.3 (0.0, 0.5) at 6 mo (P=0.007), and 0.0 (0.0, 1.8) at 2 yrs (P=0.002). The median of 0 was sustained thereafter. Thus, most patients reported no disability by 2 yrs of treatment. CHAQ median pain scores decreased from 20.0 (0.0, 72.0) at BL to 0.0 (0.0, 42.0) at 3 mo (P=0.04), with most patients pain-free thereafter. Median parent-reported normative PODCI scores for global function (BL: 27 [-2, 55]), sports/physical function (BL: 20 [‑13, 53]), and transfer/basic mobility (BL: -7 [‑1, 53]) all improved, reaching normal values (≥44) at 6 mo (P<0.05) with additional or sustained gains through LA (P<0.01). Most patients improved in lifting of heavy books/half gallon of milk, running, climbing stairs, walking a mile, and outdoor recreational activities.

Children with HPP in this study had physical limitations compared with healthy peers. During treatment with asfotase alfa, they experienced rapid and sustained improvements in physical function and reduction in pain, and enhanced ability to participate in sports/recreation and activities of daily living.

 

Disclosure: DP: Researcher, Alexion. SM: Employee, Alexion. TO: Employee, Alexion. KPF: Employee, Alexion. CR: Principal Investigator, Alexion, Principal Investigator, Alexion, Principal Investigator, Alexion. MPW: Principal Investigator, Alexion, Principal Investigator, Alexion, Principal Investigator, Alexion. KLM: Coinvestigator, Alexion. Nothing to Disclose: KH, ALR, AY

21021 1.0000 FRI-224 A Improved Activities of Daily Living and Physical Function, with Decreased Pain, in Children with Hypophosphatasia Treated for Three Years with Asfotase Alfa: Results from the Childhood Health Assessment Questionnaire and the Pediatric Outcomes Data Collection Instrument 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Shervin Yousefian*1, J Chris Gallagher2 and Sri Harsha Tella3
1Creighton University, Omaha, NE, 2Creighton University Medical Center, Omaha, NE, 3National Institutes of Health, Bethesda, MD

 

Introduction Studies that looked at the effects of vitamin D on falls and on physical performance have shown conflicting results, some positive, others negative. Higher doses have actually increased the incidence of falls. We conducted a clinical trial of vitamin D supplementation in vitamin D deficient postmenopausal women with falls and physical performance as pre specified secondary outcomes. We hypothesized that vitamin D given to D-deficient women would improve physical performance and reduce falls.                      

Design: 163 free living women entered a 1-year double blind randomized dose ranging study of daily vitamin D 400,800,1600,2400,3200,4,000,4800 IU or placebo. The main inclusion criteria were serum 25OHD ≤ 20ng/ml and no known disease or drugs affecting calcium or bone metabolism. Serum 25-hydroxyvitamin D (25OHD), 1,25 dihydroxyvitamin D(1,25(OH)2D) and parathyroid hormone(PTH) were measured by Diasorin radioimmunoassays. Calcium intake was calculated from 7- day diaries. Daily total calcium intake was adjusted to 1200mg daily. Falls were recorded at 3-month visits. Standard physical performance tests performed were at baseline,6 and 12 months - Timed up and go (TUG), Timed walk (TW) , Chair rising -3 times(CR), Hand grip strength(GS). Statistical analysis was Intent to treat and ANOVA adjusting for significant covariates.                                                                             

Results. Age range 57-87 years, mean age 66.2 years (SD 7.3), mean BMI 30.3 kg/m2 (SD 5.9). Mean calcium intake 685mg/d (SD 235). Mean serum 25OHD showed a curvilinear dose response curve starting at 15ng/ml and reaching a plateau at 42ng/ml on the highest dose of 4800IU. Compliance, measured every 3 months, was 94% for vitamin D and 91% calcium. 147completed study. Falls : 71 (48.6%) women had total of 96 falls. There was no significant difference between Fallers or the incidence of falls with baseline serum 25OHD, 1,25(OH)2D and PTH levels. There was no difference between Fallers or the incidence of falls in the final 12-month levels of serum 25OHD, 1,25 (OH)2D and PTH: mean serum 25OHD was 35.3 (SD12.7) ng/ml in fallers versus 36.2(12) ng/ml in non-fallers (P>0.05). Mean serum 1,25 (OH)2D was 56 pg/ml (SD 20) in fallers and 59 pg/ml (SD17) in non-fallers (P>0.05). In subgroup analysis of doses, low(400, 800 IU), medium (1600-3200 IU), high (4000-4800 IU) fall rate was 52%, 30%, 68% respectively (p=0.001).  Physical performance tests; Timed up and Go, Timed walk, Chair rising test, grip strength, were not significantly different at baseline between Fallers and non-fallers. There was no significant change in any physical tests at 12-months in relation to the vitamin D dose or with serum 25OHD and 1,25(OH)2D levels.

Conclusions. In this elderly independent ambulatory population, vitamin D did not reduce falls or improve physical performance.  However a subgroup analysis suggests there may be an optimal dose for fall prevention and further studies are needed to confirm this finding.

 

Nothing to Disclose: SY, JCG, SHT

21639 2.0000 FRI-225 A The Effect of Vitamin D Supplementation on Falls and Physical Performance in Elderly Women. a Randomized Clinical Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Sara Anais Armaiz*1, Nichole R Kelly2, Ovidiu Anais Galescu3, Annie M Altschul4, Andrew Paul Demidowich1, Sheila M Brady1, Van S Hubbard5 and Jack Adam Yanovski1
1Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 2Eunice Kennedy Shriver National Institute of Child Health and Human Development Section on Growth and Obesity, Developmental Endocrinology Branch, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, 4National Institute of Diabeties and Digestive and Kidney Diseases Division of Nutrition Research Coordination, Bethesda, MD, 5National Institute of Diabetes and Digestive and Kidney Diseases/NIH, Bethesda, MD

 

Background: Childhood obesity is associated with higher peripheral concentrations of leptin in overweight compared to non-overweight children. Mouse models suggest a negative correlation between leptin and bone mineral density (BMD); this effect is mediated centrally by the activation of the sympathetic system, independent of fat mass. However, data are mixed regarding whether this association is also found in pediatric cohorts.

Objective: We examined if leptin is associated with BMD in non-overweight and overweight children and adolescents. We hypothesized that leptin would demonstrate a positive and independent association with BMD, after controlling for lean and fat mass, as well as other anthropometric and sociodemographic factors.

Design/Methods: A convenience sample was constructed from participants in three separate studies evaluating growth and development in obese and non-obese children. Measurements of BMD fat mass, and lean mass were obtained with dual energy x-ray absorptiometry using either the Hologic QDR 2000 or 4500A instrument. Fasting serum leptin concentrations were measured using ELISA. Pubertal development was determined by physical examination using Tanner staging. Height and weight were measured in triplicate using a stadiometer and calibrated digital scale, respectively. Our hypothesis was examined using hierarchical linear regression; covariates included age, sex (coded 0=female, 1=male), race (coded 0=non-Hispanic white, 1=non-Hispanic black, 2=Asian, 3=other), puberty (coded 0=Tanner stage 1, 1=Tanner stage 2 or 3, 2=Tanner stage 4 or 5), fat mass (kg), lean mass (kg) and height.

Results: Participants included 526 5-18 year old healthy volunteers (age=10.8±3.0; 75.0% female; 51.1% non-Hispanic white; BMI-z=1.43±1.23. After controlling for fat mass, lean mass and other covariates, there were significant and positive associations between log-leptin and BMD in two separate axial skeletal regions: head and pelvis (p<.05). There were, however no significant associations between leptin and femur, arm, or whole body BMD or BMDz score (ps=.09-.8), measures associated with the appendicular skeleton. Leptin was similarly not independently associated with radius, lumbar or thoracic spine BMD.

Conclusion: The positive association between BMD and leptin after adjustment for body composition in some regions of the axial skeleton may indicate that the peripheral anabolic effects of leptin on bone metabolism outweigh the central effects found in mouse models. The action of leptin may perhaps be more prominent in trabecular bone, or bone with a higher metabolic rate under less weight-related stress, or created by intramembranous ossification, such as the cranium and pelvis. The mechanism by which leptin may mediate its effects on bone metabolism at selective anatomic sites merits further study.

 

Disclosure: JAY: Principal Investigator, Zafgen. Nothing to Disclose: SAA, NRK, OAG, AMA, APD, SMB, VSH

19375 3.0000 FRI-226 A Association of Serum Leptin Concentrations with Axial and Appendicular Bone Mineral Density in Children and Adolescents 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Lisa A Owens*1, Oratile Kgosidialwa2, Audrey Melvin3 and Domhnall Jude O'Halloran2
1St James's Hospital, Limerick, Ireland, 2Cork University Hospital, Cork, Ireland, 3Cork University Hospital, Co. Sligo, Ireland

 

We present the case of a 41-year-old asymptomatic male found to have elevated calcium levels on routine blood testing. He had no medical history and was not taking any medications. His mother and one of his siblings had had normal calcium levels documented previously and his father had died many years previous. He had 11 other siblings who had not had their calcium levels tested and he did not have any children. His physical examination was unremarkable.

An uncuffed corrected serum sample was 2.91mmol/L. His phosphate level was normal (1.09mmol/L) and his magnesium was slightly above normal range (1.06mmol/L). His PTH was at the upper end of normal, 58ng/ml (range 10-65ng/ml).  His 24-hour urinary calcium was low on repeated testing (1.8 mmol/24 hours), as was his urinary calcium to creatinine clearance ratio (0.002). Other investigations including renal function, thyroid function and serum ACE were normal. His 25OH vitamin D level was low (13 nmol/L, range 75-200nmol/L). Dual Energy X-ray Absorptiometry scanning showed normal age and sex matched bone density.

 

Molecular analysis of the Calcium Sensing Receptor (CASR) was carried out. A C to T nucleotide substitution in exon 7 of the CASR (c.2254C>T) was discovered. This is predicted to result in replacement of the amino acid arginine with cysteine at residue 752 (p.Arg752Cys). The remainder of the CASR gene was screened and no other pathogenic variant has been detected. This has not been reported in the literature either as a pathogenic mutation or a neutral polymorphism. Whether this mutation is inherited or de novo currently remains unknown. Genetic counselling of possible heritability was offered to his family but they have as yet declined.

 

Familial Hypocalciuric Hypocalcaemia is a genetically heterogenous autosomal dominant disorder of the CASR. There are 3 described variants and over 200 genetic mutations. This case highlights some interesting and educational points; 1. There are still undiscovered mutations of the CASR gene; 2. Discovery of these mutations has led to increased knowledge of calcium metabolism and the functions of the CASR; 3. When the biochemistry fits with a particular condition it’s important to persevere to reach an accurate diagnosis.

 

Nothing to Disclose: LAO, OK, AM, DJO

18528 4.0000 FRI-227 A Identification of a Novel Mutation of Exon 7 of Casr Gene As the Cause of Familial Hypocalciuric Hypocalcaemia Type 1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Waleed Khan*1, Waleed Abdulgafour Hashem2, Angela M. Cheung3, Brian Lentle4, Ken Pritzker5 and Aliya Aziz Khan6
1Bone Research and Education Centre, ON, Canada, 2Mcmaster University, Hamilton, ON, Canada, 3University Health Network, Toronto, ON, Canada, 4University of British Columbia, 5University of Toronto, 6McMaster University, ON, Canada

 

Purpose: this study describes characteristics and histomorphometric and radiographic features of atypical femoral fractures (AFF) as seen in 19 cases referred for evaluation.

Methods:  All patients referred for evaluation of AFF were reviewed. Patients meeting the ASBMR criteria for AFF were further evaluated and tetracycline labeled bone biopsies was completed. Radiographs were reviewed by musculoskeletal radiologists.

Results: All fracture lines were transverse or short oblique and 15 of 19 patient’s had thickened cortices on x-ray. We report 19 cases of AFF in patients on long term bisphosphonate (BP) therapy. 14 of 19 fractures occurred without a fall or direct trauma to the femur with 5 cases occurring after a fall from standing height. All patients were female; average age was 65 years (range 23-80). 4 of the 19 cases were of chinese descent, 4 were East Indian, with 11 being Caucasian. Average BP duration of use was 9.8 years (range 6-15 years). 9 of 19 patients were on alendronate alone, 2 patients were on risedronate alone, 6 patients on a combination and 1 patient on a combination of pamidronate and alendronate. 1 patient was on a combination of alendronate and denosumab. Prodromal thigh or groin pain was seen in 12 of the 19 patients for 1 to 15 months prior to fracture. Proton pump inhibitor use was present in 6 patients. 2 patients were on prednisone for rheumatoid arthritis and 2 patients on prednisone for asthma. 1 patient had a diagnosis of osteogenesis imperfecta type IV with a family history of multiple fragility fractures and had experience a femoral fracture after 12 years of IV pamidronate with fractures consistent with an AFF. All patients had 25OH Vit D level > 50nmol/L. 18 of the patients with radiographic features of AFF had been on bisphosphonate for > than 6 years. 1 patient had been on alendronate for 5 months. 8 of 19 patients had bilateral femoral fractures. 

Summary: a large number of patients with radiographic features of an AFF had no evidence of mineralization abnormalities on tetracycline labeled bone biopsy. Decreased osteoid surface and mean mineralized trabecular width was seen in 6 of 11 biopsies. Diffuse label was noted in 5 of 11 biopsies. Mineralization abnormalities were noted in a significant number of patients with radiographic features of AFF. All of the women had normal or mildly reduced serum vitamin D levels

Conclusion: In our study we found evidence of tetracycline label in all of the biopsy specimens with the exception of one patient. This indicates that bone mineralization is not impaired. Bone remodeling was variable ranging from low, normal or high. Improved understanding of the pathophysiology leading to these fractures may be gained with further histomorphometric data in larger numbers of patients.

 

Disclosure: AMC: Researcher, Amgen, Researcher, Eli Lilly & Company, Researcher, Merck & Co.. AAK: Researcher, Merck & Co., Researcher, NPS, Researcher, Amgen. Nothing to Disclose: WK, WAH, BL, KP

18255 5.0000 FRI-228 A Atypical Femoral Features: Radiographic and Histomorphometric Features in 19 Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Javzandulam Natsag*1, Deborah Sellmeyer2, Sabina A Haberlen3, Joseph Margolick4, Lisa P Jacobson3, Frank J Palella5, Susan L Koletar6, Jordan E Lake7, Kristine M Erlandson8, Wendy Post9 and Todd Brown1
1Johns Hopkins University, Baltimore, MD, 2Johns Hopkins Bayview Medical Center, Baltimore, MD, 3Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 4Johns Hopkins Bloomberg School of Public Health, 5Northwestern University Feinberg School of Medicine, 6The Ohio State University, 7University of Texas Health Science Center at Houston, 8University of Colorado Denver - Anschutz Medical Campus, 9Johns Hopkins University

 

Background: Lower muscle attenuation on computed tomography (CT) is a surrogate measure of fatty infiltration of muscle, which has been associated with metabolic derangements, muscle dysfunction, decreased mobility, and increased fracture risk in the elderly general population. HIV-infected individuals may have abnormalities in fat distribution, but the association between HIV and thigh muscle attenuation has not been clearly established.

Methods: We evaluated the mean Hounsfield units of the lean tissue within the mid-thigh muscle bundle and its cross-sectional area (CSA), as well as grip strength in 368 HIV-infected (age 53.8±5.9 years) and 145 HIV-uninfected (age 56.5±6.39) men who participated in the Multicenter AIDS Cohort Study (MACS) Cardiovascular Substudy. Multivariable linear regression analysis was used to assess the relationship between HIV serostatus and 1) thigh muscle attenuation, 2) CSA, and 3) grip strength.

Results: HIV-infected men had higher thigh CSA (difference=10 cm2; 95% CI 5.4, 14.8; p <0.001) but lower muscle attenuation (difference=-1.4HU; 95% CI -2.2, -0.6; p< 0.001) compared to HIV-uninfected men, independent of age, race, and body mass index (BMI), cumulative total pack year cigarettes, alcohol use, insulin resistance, malignancy, and limitation in physical function. HIV-infected men had significantly higher abdominal visceral adiposity (difference=41.7cm2, 95% CI 27.2, 56.3; p<0.001) and lower thigh subcutaneous fat (difference=-18.2cm2, 95% CI -22.8, -13.6; p<0.001) compared to HIV-uninfected men independent of age, race and BMI. Muscle attenuation remained lower in HIV-infected men (difference=-1.3HU; 95% CI -2.2, -0.5; p 0.002) when abdominal visceral adiposity and mid-thigh subcutaneous adipose tissue were substituted for BMI in the multivariate model. Thigh muscle attenuation decreased by 0.16 HU per year (95% CI -0.23,-0.09; p<0.001) with increasing age among the HIV-infected men, but did not decline significantly with age in the HIV-uninfected men (0.02; 95% CI -0.08, 0.12; p=0.68) (HIV x age interaction -0.18HU; 95% CI -0.3; -0.06; p =0.003). Both thigh muscle attenuation and CSA were positively correlated with grip strength; however, no difference in grip strength by HIV serostatus was observed.

Conclusion: HIV-infected men had lower thigh muscle attenuation compared to HIV-uninfected men, and a more pronounced decline with increasing age. These findings suggest that muscle quality is lower in HIV-infected persons which may contribute to greater functional decline and increased fracture risk with aging.

 

Nothing to Disclose: JN, DS, SAH, JM, LPJ, FJP, SLK, JEL, KME, WP, TB

19699 6.0000 FRI-229 A HIV Infection Is Associated with Increased Thigh Muscle Cross Sectional Area and Lower Muscle Attenuation on CT in Men Age 40-70 Years 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Joseph Michael Shulan*1, Marla S Barkoff1 and Jennifer Anne Sipos2
1The University of Illinois-Chicago Medical Center, Chicago, IL, 2The Ohio State University Wexner Medical Center, Columbus, OH

 

Background: Primary hyperparathyroidism in pregnancy is a rare condition that can mimic symptoms of early pregnancy and can lead to significant maternal, fetal morbidity and mortality. Evidenced-based studies for management of severe hypercalcemia from primary hyperparathyroidism in pregnancy are limited to a few small retrospective studies and case reports. Currently, there are no formal guidelines for management of this condition. 

Case: A 22-year-old female presented to the emergency room at 12 weeks 3 days of pregnancy with a two-week history of worsening nausea, vomiting, and generalized weakness. In the emergency department, her albumin-corrected total calcium was found to be 15.3mg/dL, and intact PTH (iPTH) of 394pg/ml. She was started on aggressive intravenous hydration and admitted. An ultrasound of her neck revealed a 1.03cm by 2.09cm left inferior pole parathyroid adenoma. Consideration was given to administer Cinacalcet, Calcitonin, and/or Zoledronic acid to help normalize her serum calcium, however they were withheld given their risk to the developing fetus and lack of evidence-based studies supporting their use during pregnancy. Due to the persistent elevation of her serum calcium and her risk of pregnancy loss, she was taken for a parathyroidectomy. Post-operatively, her iPTH had dropped to 22.9 pg/ml, albumin-corrected total calcium to 9.0 mg/dL. The patient and fetus’s postoperative course remained uncomplicated with her presenting symptoms resolving. She delivered a liveborn male infant, weighing 3776g, APGARs of 8 and 8, at 38 weeks gestation complicated by fetal intolerance of labor and shoulder dystocia. Her post partum course and her newborn’s hospital course were uncomplicated.

Conculsion: Studies showing safety in pregnancy of traditional therapeutic agents for hypercalcemia are limited to case reports and animal studies, making  the decision to use in the clinical setting challenging; especially when weighing the risks and benefits to the mother and developing fetus. In addition, parathyroidectomy has been traditionally delayed until the mid second trimester to reduce the risk of complications to the developing fetus and the pregnancy during surgery. However, it has been suggested that intervention with parathyroidectomy in patients with severe hypercalcemia in the early second trimester may reduce complications from severe hypercalcemia and loss of the pregnancy (1).  This case highlights a successful intervention with parathyroidectomy in a patient in her early secondary trimester of pregnancy with severe hypercalcemia. The risks and benefits of pursuing medical versus surgical treatment during pregnancy should continue to be individualized to the patient.

 

Nothing to Disclose: JMS, MSB, JAS

18288 7.0000 FRI-230 A Severe Hypercalcemia from Primary Hyperparathyroidism in Pregnancy Treated with Parathyroidectomy during the Early Second Trimester of Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Radhika Chandramouli*
Temple University School of Medicine/ St. Lukes University Network, Bethlehem, PA

 

Bromocriptine is an ergot dopamine receptor agonist used to lower prolactin as standard therapy for suspected pituitary adenomas. The effects of bromocriptine on other organ systems have not been explored to a large extent in the literature. The potential effects of bromocriptine on diseases involving the pituitary, pancreas, and parathyroid, such as in MEN1 syndrome, could lead to a different therapeutic approach. The role of recently reported prolactin receptors on parathyroid gland might provide some insight into the observed effect of bromocriptine on hypercalcemia and hyperparathyroidism.

An 83 year-old woman presented to the hospital with a chief complaint of left-sided head pain. After admission to the hospital, she was worked up and treated for hypertensive emergency with an elevated prolactin. CT scan of the head obtained during hospitalization showed a sella turcica mass and possible pan-hypopituitarism. Diagnoses of acromegaly, hypercalcemia secondary to primary hyperparathyroidism, diabetes mellitus and pituitary adenoma were made. Bromocriptine was added in the hopes of treating the hyperprolactinemia. As expected, there was a decrease in prolactin. Interestingly, the levels of calcium also dropped dramatically within a few months of Bromocriptine administration.

Since this is unusual finding that has not been previously reported in the literature, it intrigued us as to whether there is a correlation between bromocriptine and calcium regulation. Some research has shown the possibility of PRL receptors on parathyroid tissue. If these receptors are inhibited by downregulation of PRL by bromocriptine, the secretion of PTH could subsequently decrease, with resulting calcium levels decreasing. Further studies could look at whether bromocriptine would make a difference in the regulation of high calcium and PTH, and thus provide a gateway into using bromocriptine as a single therapy to treat these different, but interconnected diseases.

 

Nothing to Disclose: RC

18254 8.0000 FRI-231 A The Effect of Bromocriptine on Primary Hyperparathyroidism: A Case Presentation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Chee Kian Chew*
Tan Tock Seng Hospital, Singapore, Singapore

 

Introduction

Primary hyperparathyroidism (PHPT) is mostly treated with minimally invasive parathyroidectomy following preoperative localization by imaging study. This is a case of PHPT successfully treated with neck exploration surgery after the failure of preoperative localization.

Case Report

This is a 75 years old gentleman referred for hypercalcemia found during the evaluation for renal calculi. He complained of polyuria, polydipsia and nocturia for 4 months. However, he denied abdominal pain, constipation, mood change, easy fatigability and sleep disturbance. There were no symptoms to suggest any malignancy and hyperthyroidism and no history of prolonged immobilization. He denied family history of hypercalcemia or taking any drug that can cause hypercalcemia such as thiazide diuretics or lithium. On examination, he was a medium built gentleman with BMI of 20.7 kg/m², blood pressure of 137/80 mmHg and heart rate of 62 beats per minute. He was euthyroid clinically. There was no pallor, lymphadenopathy and bony tenderness. There was also no pleural effusion or lung consolidation. Abdominal examination revealed no palpable mass, liver or spleen.  Examinations of cardiovascular and neurological systems were unremarkable. Biochemical tests: serum calcium 2.95 mmol/L (2.15-2.58), PTH 14.7 nmol/L (0.8-6.8), serum phosphate 0.8 mmol/L (0.8-1.6), 25-hydroxy vitamin D 13.4 ug/L (>20), serum creatinine 99 umol/L (60-105), ALP 106 U/L (38-126). He was diagnosed with PHPT. His calcium/creatinine clearance ratio of 0.03 (>0.02) excluded the diagnosis of familial hypocalciuric hypercalcemia. The low 25-hydroxy vitamin D is due to increased conversion to 1,25-dihydroxyvitamin D from the stimulation of PTH. He was treated with hydration and intravenous pamidronate for the hypercalcemia. He was planned for minimally invasive parathyroidectomy and preoperative sestamibi scan was done to localize the parathyroid lesion. However, the sestamibi scan failed to show any hyperfunctioning parathyroid lesion.  Merlino reported that sestamibi scan is less accurate for detecting abnormal parathyroid tissue in patients with small adenomas, multiglandular disease, superior adenomas or preoperative normocalcemia (1). Hence, neck exploration surgery was done and a left superior parathyroid adenoma was identified successfully intra operatively and was removed. Westerdahl hypothesized that superior adenomas are hidden behind the thickest part of thyroid gland and therefore disappear with computer subtraction of the thyroid image on anterior scintigraphic views causing false negative sestamibi scan (2). Post operatively, his serum calcium and PTH level normalized.

Conclusion

Neck exploration surgery should be offered to patient with PHPT if the imaging study fails to localize the parathyroid lesion. The success rate of neck exploration surgery was reported to be more than 95% (3).

 

Nothing to Disclose: CKC

18425 9.0000 FRI-232 A What to Do If Parathyroid Lesion Cannot be Localized in Patient with Primary Hyperparathyroidism? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


David Max Klachko*
Cosmopolitan International Diabetes Center, Columbia, MO

 

Introduction: Normocalcemic hyperparathyroidism (elevated intact parathyroid hormone with normal ionized calcium, vitamin D, magnesium, and renal function) usually is considered to be a precursor of primary hyperparathyroidism.  Secondary hyperparathyroidism and parathyroid hyperplasia induced by low calcium and/or high phosphate diets in animals can be reversed by restoring adequate dietary calcium. This is the first demonstration in a man of complete regression of hyperparathyroidism by sustained positive calcium balance.

Clinical case: A 64-year-old white man was referred to the Endocrinology Clinic for investigation of possible primary hyperparathyroidism.  His total calcium levels were elevated intermittently from April 2011 in the range of 10.0-10.7 mg/dL (normal range 8.4-10.2) although, corrected for albumin concentration, they were 9.8-10.3 mg/dL.  On March 19, 2013 his PTH level was 178.7 pg/mL (normal range: 8-74).

 When seen in the Endocrinology Clinic on April 24, 2013, his total calcium level was 10.9 mg/dL with an albumin of 4.0 g/dL, an ionized calcium of 1.28 mmol/L (normal range 1.09-1.30), and a random urine calcium concentration of 4.2 mg/dL.  Plasma magnesium was 2.4 mg/dL (normal range 1.6-2.6), 25-hydroxy-vitamin D 29.5 ng/mL (normal range 30-96) and estimated glomerular filtration rate 60.4 (normal >60), The interview revealed minimal calcium intake; no milk or yogurt, occasional cheese consumption and a multivitamin daily.  He was informed that his reported calcium intake was low and he was sent home with a container for a 24-hour urine collection for calcium and creatinine and a diet diary to record calcium intake for one week. 

 When he returned 2 weeks later, his diet diary revealed a dramatic increase in calcium intake.  He had started taking 1200 mg of calcium supplement daily as well as increasing his intake of dairy products.  He was drinking 3-4 glasses of milk and eating 2 ounces of cheese daily, 6 ounces of yogurt 3 times a week, and occasional ice cream  His estimated total daily intake of calcium was about 2600 mg.  His 24-hour urinary collection confirmed a low calcium output (113 mg/24 hours).

 Over the course of a year, his 24-hour urinary output of calcium increased to over 200 mg.  With the positive calcium balance, his PTH level gradually decreased into the normal range (48.0 pg/mL). Although total calcium levels did not change appreciably, there was a progressive decline in fasting ionized calcium from 1.28 to 1.24 mmol/L. 

Conclusion:  This is the first demonstration of complete regression of normocalcemic hyperparathyroidism by a sustained positive calcium balance.  This suggests that in patients with normocalcemic hyperparathyroidism and negative calcium balance, PTH levels may be normalized by calcium supplementation and thereby render parathyroid surgery unnecessary.

 

Nothing to Disclose: DMK

18656 10.0000 FRI-233 A Normocalcemic Hyperparathyroidism Cured By Calcium Repletion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Jessica Furst*1, Alice Abraham2, Ira Tabas2 and Mishaela Ruth Rubin1
1Columbia University College of Physicians and Surgeons, New York, NY, 2College of Physicians and Surgeons, Columbia University, New York, NY

 

Background:  Hypercalcemia from underlying neoplastic causes can be exacerbated by simultaneous ingestion of supplements containing high dose vitamin D.

Clinical Case:  A 70-year-old man with a history of six months of peripheral eosinophilia of unclear etiology and prostate cancer in remission presented with three weeks of malaise, cough, odynophagia and subjective fevers.  He noted six months of pruritus and a 15-pound weight-loss over the previous three weeks, coinciding with initiation of an unnamed herbal supplement to boost energy.  Endocrine was consulted for a serum calcium 17.3mg/dL (corrected 17.9mg/dL) [range 8.7-10.2] and ionized calcium >1.91mmol/L [range 1.12-1.32].  Serum creatinine was 2.30mg/dL [range 0.60-1.20].  Eight days prior to this presentation, serum calcium was 8.8mg/dL and serum creatinine was 1.1mg/dL.  Physical exam was notable for slowed mentation and diffuse lymphadenopathy.   Endocrine labs were notable for appropriately suppressed PTH at 4pg/mL [range 8-51]. PTHrP was 24pg/mL [range 14-27].  Both vitamin D metabolites were above the upper limits of the assays: 25-hydroxyvitamin D >96ng/mL [range 20-50] and 1,25-dihydroxyvitamin D  >190pg/mL [range 15-75].  Thyroid and adrenal function were normal, as were ACE and vitamin A levels; multiple myeloma screen and HTLV-1 antibodies were negative.  The patient was treated aggressively with 7 liters of normal saline, 2 doses of calcitonin, and 4mg of zoledronic acid.  Maintenance fluids with normal saline at 250cc/hr were subsequently initiated and his serum calcium dramatically decreased to 13mg/dL within 18 hours of initial presentation.   With continued IV hydration and discontinuation of the herbal supplement, the serum calcium level reached a nadir of 11.5mg/dL on hospital day 5.  However, by hospital day 6, the serum calcium rose to 12.9mg/dL with ionized calcium 1.70mmol/L.  He was treated with IV fluids, furosemide, calcitonin and a second dose of zoledronic acid 4mg on hospital day 9 with subsequent serum calcium in the 10.5-11.5mg/dL range.  PET scan revealed hypermetabolic lymphadenopathy in the neck, chest, abdomen and pelvis.  Bone marrow examination led to the diagnosis of angioimmunoblastic T-cell lymphoma, a rare lymphoproliferative disorder associated with hypercalcemia.  After initiation of treatment with steroids and chemotherapy on hospital day 17, serum calcium improved and remained in the 9.5-10.5mg/dl range through the next several months.

Conclusion:  This case demonstrates the combined effect of elevated 25(OH)D and 1,25(OH)D2 to cause a rapid rise in serum calcium to a life-threatening level.  Presumed high dose vitamin D intake through ingestion of the herbal supplement exacerbated an underlying malignancy-associated process.  When evaluating a patient with acute hypercalcemia, it may be prudent to perform full biochemical evaluation to assess for potential coexisting causes.

 

Nothing to Disclose: JF, AA, IT, MRR

18603 11.0000 FRI-234 A A Case of Combined 25-Hydroxyvitamin-D and 1,25-Dihydroxyvitamin-D Mediated Severe Hypercalcemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Fady Hannah-Shmouni*1 and Sandra Michelle Sirrs2
1Yale-New Haven Hospital, New Haven, CT, 2Vancouver General Hospital, UBC, Vancouver, BC, Canada

 

Unlocking Pandora's Box: Late-Onset Hypoparathyroidism and Mitochondrial Disease

Background: Pandora's box (all gifted box) is an artifact in Greek mythology, which contained all the evils of the world. Today, the phrase "to open Pandora's box" means to perform an action that may seem small or innocent, but that turns out to have severe and far-reaching consequences. In medicine, mitochondrial diseases behave as such, and are often missed by clinicians given their diagnostic challenge. We present a rare case of late-onset hypoparathyroidism from an inherited mitochondrial disorder.

Case presentation: A 59-year-old male from India with hypertension, diabetes and dyslipidemia presented to the Endocrine Clinic for evaluation of hypocalcemia, elevated CPK and myalgias. He noted 6 months of recurrent premature fatigue, generalized weakness, difficulty walking from diffuse muscle cramps, and polyuria. He had no history of neck surgery or head and neck irradiation. Family histroy was significant for maternal diabetes with no inherited disorders. Clinical examination showed power 5/5 in all muscle groups to confrontation and he was able to do repetitive knee bends without difficulty. Eye examination did not show any opacities, pigmentary retinopathy or opthalmoplegia, but revealed mild bilateral ptosis. There were no sensory deficits. Chvostek and Trousseau’s signs were negative. Labwork revealed hypocalcemia (Total 5.9 mg/dl, Free 2.8 mg/dl), hyperphosphatemia (4.4 mg/dl), and inappropriately normal levels of PTH, diabetes (A1C 8%), dyslipidemia and CPK of 500 IU/L. 24hr urine calcium, magnesium and lactate levels were normal. There was no evidence of AKI,  Celiac disease, vitD insufficiency, liver dysfunction, adrenal, pituitary or thyroid disease. Muscle biopsy showed focal increase in subsarcolemmal staining, modified Gomori trichome-stained sections associated with rare COX negative muscle fibres, and mild increase in lipid and glycogen staining, indicative of mitochondrial dysfunction. Electron microscopy confirms focal accumulation of mitochondrial within subsarcolemmal regions, which display an increase in variability in size and shape. Mitochondrial enzyme studies were negative. The patient received the diagnosis of late-onset mitochondrial disease in keeping with the Bernier Criteria (1) and on the basis of his muscular symptoms, associated endocrinopathies and muscle biopsy findings.
Discussion: This case illustrates the potential for an inherited disorder to present as late-onset. Mitochondrial disease is one of the most common genetic myopathies and the estimated prevalence (1/4,000) (2) is much higher than for autoimune hypoparathyroidism. The mitochondrial genome is considered the Pandora’s box, and clinicians should become aware of their potential to have far reaching consequences in clinical medicine.

 

Nothing to Disclose: FH, SMS

18531 12.0000 FRI-235 A Unlocking Pandora's Box: Late-Onset Hypoparathyroidism and Mitochondrial Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Huijuan Liao*, Daniel Louis Lorber and Ellen Cohen
Weill Cornell Medical College/New York Hospital Queens

 

Hypercalcemic crisis is a rare but life-threatening condition involving the decompensation of hypercalcemia (usually when serum calcium > 13-15 mg/dL) with significant disturbance to cardiac, renal, gastrointestinal and neurological function. Although major textbooks have thorough and detailed reviews of hypercalcemia, there are no articles elaborating specifically the etiology and pathophysiology of hypercalcemic crisis. The goal of this study was to identify the etiologies and risk factors of hypercalcemic crisis. We performed a retrospective review from 01/2012 to 05/2014 of patients with hypercalcemia at our tertiary care center and analyzed their characteristics. Sixty-two patients with severe hypercalcemia (adjusted serum calcium level by albumin ≥ 13.5 mg/dL) were identified from 262 of hypercalcemia. Demographic and clinical characteristics, such as age, gender, race, etiologies (e.g. primary hyperparathyroidism (pHPT), malignancy, or other causes), serum calcium level, clinical manifestations including gastroenterology, renal, cardiovascular, altered mental status, EKG changes, precipitating factors (dehydration, acute kidney injury (AKI), infection) were evaluated. Our study revealed that there were no differences in the etiologies between hypercalcemic crisis (pHPT/malignancy/others: 15%/60%/25%) and severe hypercalcemia without crisis (pHPT/malignancy/others: 7.1%/64.3%/28.6%, P = 0.617). Compared with severe hypercalcemia without crisis, the serum calcium level was significantly higher in hypercalcemic crisis (16.9±1.8 mg/dL vs 14.8±1.1 mg/dL, P < 0.001). However, no differences in serum calcium level were observed among the subgroups of different etiologies in hypercalcemic crisis (P = 0.662) or severe hypercalcemia without crisis (P = 0.423). The logistic regression analysis showed that serum calcium level and age were independent risk factors for hypercalcemic crisis. Specifically in our risk-prediction model, 1 mg/dL increase serum calcium concentration increases 2.7 times the odds of hypercalcemia crisis; one year increase in age increases the odds of hypercalcemic crisis by 61%. The multivariate linear regression analysis showed that significant predictors of serum calcium level in hypercalcemic crisis were age and AKI. To our knowledge, this is the first and most comprehensive study to investigate the etiology and risk factors of hypercalcemic crisis. Our constructed risk-prediction model makes possible the rapid and easy calculation of risk for hypercalcemic crisis. The accurate assessment of risk before investigating etiology has an important place in hypercalcemic crisis screening. The implementation of our risk-prediction model is expected to improve clinical and critical care practice in hypercalcemic crisis.

 

Nothing to Disclose: HL, DLL, EC

18796 13.0000 FRI-236 A The Etiology and Risk Factors Analysis in Hypercalcemic Crisis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Almoutaz Shakally*1 and Muhammad Abdullah2
1Mercy Medical Center, Des Moines, IA, 2Mercy Medical Center Des Moines, Des Moines, IA

 

Background: Milk-alkali syndrome as a result of ingestion of large amounts of calcium and absorbable alkali is a known but rare phenomenon. However, the association between this syndrome and cardiac arrhythmias is less documented. 

Clinical Case: A 67-Year-old male with history of Atrial Fibrillation and Non ischemic cardiomyopathy  with Ejection fraction of 30% presented to the ER for evaluation of Implantable Cardioverter Defibrillator (ICD) firing.

The patient recently returned from a week-long cruise where he had stomach upsets. He admitted to drinking more alcohol than water. He started taking Calcium carbonate (TUMS) for his gastric symptoms. He was taking up to 20 tablets a day for 14 days. He had generalized weakness and constipation. He denied bone pains or weight loss. His medication history was notable for furosemide 80 mg daily and metolazone 5 mg thrice a week.

On examination the patient had very dry mucous membranes. Lab data was significant for a markedly elevated calcium level of 17.3 mg/dl with ionized calcium level of 8.3 mg/dl. His creatinine was 1.9 mg/dl, Sodium of 128mEq/L and carbon dioxide of 41mEq/L.

EKG showed, biventricular paced rhythm with appropriate left-sided pre excitation. He had prolonged QTc  of 470 msec in the setting of BiV paced QRS complex. The device interrogation showed Ventricular Tachycardia with appropriate anti-tachycardia pacing as well as polymorphic Ventricular Tachycardia with shock delivery twice.

A work up for hypercalcemia showed an intact PTH of 5 pg/ml (normal 12-88), PTHrP of 16 pg/ml (Normal 14-27) and a Sedimentation rate of 4mm/hr (normal 0-20). A PSA was 0.6 ng/ml (normal up to 4).   A serum protein electrophoresis was negative for monoclonal band and a skeletal survey did not showed any lytic or blastic lesions.

The patient was diagnosed with Milk-Alkali syndrome based on the laboratory findings and clinical picture. Calcium carbonate was discontinued, and the patient was initiated on aggressive hydration with normal saline. He also received one dose of pamidronate 90 mg intravenously. At discharge his calcium was 10.3mg/dl and ionized calcium was 5.4 mg/dl while Creatinine was 1.4mg/dl.  At six month follow up, his calcium was 10 mg/dl with a creatinine of 1.4 mg/dl and he did not have any further AICD firing since initial hospitalization.

Conclusion

Milk Alkali Syndrome is third most common cause of in-hospital hypercalcemia following malignancy and primary hyperparathyroidism. It may cause cardiac arrhythmias due to renal failure, dehydration and hypercalcemia especially in patients with underlying cardiac disease. The recent surge in Milk alkali syndrome cases is due to increased osteoporosis awareness and use of calcium supplements. The public needs to be educated about calcium supplementation and the potential adverse effects if the recommended daily dosage is exceeded. Daily elemental calcium intake of no more than 2 g is considered safe.

 

Nothing to Disclose: AS, MA

21310 14.0000 FRI-237 A A Severe Case of MILK-Alkali Syndrome Presenting As Firing of Implantable Cardioverter Defibrilator (ICD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Jaisri Maharaj* and Robert Errol Jones
University of Utah, Salt Lake City, UT

 

Title: Increased intracranial pressure from Severe Hypocalcemia

Background: Hypocalcemia is a rarely reported but important cause of increased intracranial pressure, which if not quickly addressed, can lead to significant permanent morbidity. We report the cases of 2 patients who presented with increased intracranial pressure due to severe hypocalcemia from two different etiologies.

Case 1: A 65-year-old female with a history of primary hypothyroidism due to lymphocytic thyroiditis and hypertension presented with worsening vision, facial numbness and extremity tingling over 6 months. Blood pressure was uncontrolled on losartan 50 mg daily. Exam revealed bilateral papilledema.  

Diagnostic evaluation showed:

ionized calcium 0.59 mmol/L (n 1.11-1.30 mmol/L), magnesium 1.2 mmol/L (n 1.5-3.1 mmol/L), phosphorus 7.9 mg/dL (n 2.5-4.5 mg/dL), total serum calcium 4.1 mg/dL (n 8.4-10.5 mg/dL), intact parathyroid hormone 3 pg/ml (n 11-54 pg/ml), 25-hydroxyvitamin D 13 ng/ml (n 15-57 ng/ml).

Lumbar puncture was significant for elevated opening pressure of 380 mmH2O. She was started on oral calcium supplementation and calcitriol for management of presumed autoimmune hypoparathyroidism. Hypocalcemia corrected and vision improved over the next 8 weeks with resolution of increased intracranial pressure.

Case 2: A 47-year-old-female with a history of thyroidectomy for multi-nodular goiter 9 years ago, presented with a one month history of progressive vision loss, headaches, nausea, diplopia, dizziness and muscle twitching. Medications included calcium 1200 mg thrice daily and cholecalciferol 3000 IU daily. Exam noted bilateral papilledema and right optic neuritis. Lumbar puncture revealed elevated opening pressure of 360 mmH2O. Diagnostic evaluation showed:

Total serum calcium 4.9 mg/dL (n 8.4-10.5 mg/dL), intact parathyroid hormone 7 pg/ml 3 (n 11-54 pg/ml), magnesium 1.8 mg/dL (n 1.6-2.6 mg/dL).

She was started on oral calcitriol 0.5 mg orally twice daily and continued on calcium for management of postsurgical hypoparathyroidism. Hypocalcemia and increased intracranial pressure resolved with vision improvement over the next 3 months.

Conclusion: Both cases emphasize the importance of considering hypocalcemia in the differential diagnosis of increased intracranial pressure. They also highlight the need to understand and manage the underlying etiology of hypocalcemia. There should be high clinical suspicion for hypoparathyroidism in the settings of existing autoimmune disease and previous thyroid surgery.

 

Nothing to Disclose: JM, REJ

18682 15.0000 FRI-238 A Increased Intracranial Pressure from Severe Hypocalcemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Vibha Singhal*1, Natalia Cano Sokoloff2, Giovana De Nardo Maffazioli2, Kathryn E Ackerman3, Nupur Gupta4, Ryan M Woolley5, Meghan Slattery5, Miriam A. Bredella1, Anne Klibanski1 and Madhusmita Misra6
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusets General Hospital and Harvard Medical School, Boston, MA, 3Boston Children's Hospital/ Massachusetts General Hospital and Harvard Medical School, 4Massachusetts General Hospital and Harvard Medical School, 5Massachusetts General Hospital, Boston, MA, 6Massachusetts General Hospital and Harvard Medical School, Boston, MA

 

Visceral adipose tissue (VAT) is deleterious to bone, whereas subcutaneous adipose tissue (SAT) has positive effects. We have previously shown in young athletes that marrow adipose tissue (MAT), a relatively newly recognized fat depot shown to affect bone, is inversely associated with bone mineral density (BMD).  Bone mass in athletes depends on many factors including gonadal steroids and muscle mass. Exercise increases muscle mass and BMD, whereas, estrogen deficiency decreases BMD.  Thus, the beneficial effects of weight bearing exercise on areal and volumetric BMD (aBMD and vBMD) in regularly menstruating (eumenorrheic) athletes (EA), are attenuated in oligo-amenorrheic athletes (OA). Of note, data regarding VAT, SAT and regional muscle mass in OA compared with EA and non-athletes (C), and their impact on bone are currently lacking.

Our objective was to compare regional fat and muscle mass in normal-weight OA, EA and C in relation to bone. We hypothesized that even in normal-weight athletes, higher VAT/SAT would affect BMD negatively.

We used (i) MRI to assess VAT and SAT at the L4 vertebra level, and cross sectional muscle area (CSA) of the mid thigh, (ii) 1H-MRS to assess MAT at L4, the proximal femoral diaphysis and metaphysis, (iii) DXA to assess spine and hip aBMD, and (iv) HRpQCT to assess vBMD at the distal radius (non-weight bearing bone) and tibia (weight bearing bone) in 41 women (20 OA, 10 EA and 11 C 18-25 years). All athletes engaged in weight bearing sports for ≥4 hours/wk or ran ≥20 miles/wk.

Groups had comparable age, BMI, VAT, VAT/SAT and spine BMD Z-scores. EA had higher hip BMD Z than OA and C.  Fat mass was lowest and menarchal age highest in OA. SAT was lowest in OA (p= 0.05); L4 MAT was higher in OA than EA (p=0.03).  We found inverse associations of  (i) VAT/SAT with spine BMD Z (r=-0.43, p=0.01), (ii) L4-MAT with lumbar (r=-0.48, p=0.002) and hip BMD Z (r=-0.39, p=0.01), and vBMD of the radius and tibia (r=-0.37, p=0.02; r= -0.3, p=0.06), and (iii) diaphyseal-MAT with vBMD of the radius and tibia (r=-0.46, p=0.01; r=-0.36, p=0.03). In a multivariate model including VAT/SAT, L4-MAT and thigh CSA, spine BMD Z was predicted inversely by VAT/SAT and L4-MAT, and positively by thigh CSA (r2=0.36, p=0.0002); hip BMD Z was predicted inversely by L4-MAT and positively by thigh CSA (r2=0.34, p=0.0004). VAT/SAT did not predict radius and tibia total vBMD in this model. When L4-MAT was replaced with diaphyseal-MAT in the model, diaphyseal MAT did not predict aBMD Z, but inversely predicted vBMD of the radius and tibia. When we added % body fat to the model, metaphyseal MAT negatively predicted tibial trabecular vBMD, diaphyseal MAT negatively predicted tibial vBMD, and L4-MAT negatively predicted radial total and cortical vBMD.

Abdominal VAT/SAT and MAT are independent inverse predictors of spine BMD in athletes and non-athletes consistent with studies in obesity.  MAT also predicts other bone parameters.

 

Nothing to Disclose: VS, NC, GDNM, KEA, NG, RMW, MS, MAB, AK, MM

19655 16.0000 FRI-239 A Regional Fat Depots and Muscle Mass Are Determinants of Bone Density in Young Oligo-Amenorrheic and Eumenorrheic Athletes and Non-Athletes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Thomas J Weber*1, Eileen K Sawyer2, Scott Moseley2, Tatjana Odrljin2 and Priya S Kishnani1
1Duke University Medical Center, Durham, NC, 2Alexion Pharmaceuticals, Inc., Cheshire, CT

 

Hypophosphatasia (HPP) is a rare metabolic bone disease caused by loss-of-function mutation(s) in the tissue-nonspecific alkaline phosphatase gene. HPP is characterized by defective skeletal mineralization and diverse complications that may include proximal muscle weakness, pain, and fractures in adults, including multiple, recurrent, non-healing and non-traumatic fractures (1,2). Evidence of the morbidity and burden of HPP in adults has largely been gained from case reports and single-center retrospective chart reviews (2,3). Here, we describe the burden of HPP in patients ≥18 years old as assessed by 2 surveys specific to HPP symptomology.

The Hypophosphatasia Impact Patient Survey (HIPS, internet-based) and the Hypophosphatasia Outcomes Study Telephone interview (HOST) were made specifically to characterize the burden of disease in patients with HPP. Answers consisted of yes/no, “check all that apply,” and free text fields. Outreach from 2009-2011 by patient advocacy groups (HIPS, HOST) or physicians (HOST) provided survey awareness to patients with HPP of all ages, or their caregivers, and invited participation. Data from questions common to both surveys were pooled for analysis. Results are expressed as percentage of patients who responded to each item.

184 patients (125 adults, 59 children at time of survey) responded to the surveys. Reported here are data for the adult patients. Mean (SD) age at time of survey was 45 (14.3) years. 67% (n=84/125) reported their age as less than 18 years at onset of symptoms (pediatric onset; combined infantile- and juvenile-onset); mean (SD) time from first symptom was 33.5 (17.1) years. 66% (n=83/125) were female. Muscle weakness (62%; n=77/124) and unusual gait (52%; n=46/89, HIPS only) were common. 86% (n=108/125) of patients reported at least one fracture (mean number of fractures 12.9; min, max: 1, 100); 26% (n=32/125) reported >10 fractures. 69% (n=25/36, HOST only) of patients reported that their walking had worsened since HPP diagnosis; none reported improvement in walking. 60% (n=75/125) of patients had required an assistive device for mobility at some time; at the time of the survey, 34% (n=37/108) reported using an assistive device to walk, and 22% (n=23/107) required a wheelchair. 32% of patients (n=24/76, HIPS only) had modified their homes (mainly bathroom and entryway) due to HPP, and 14% (n=12/89, HIPS only) reported employing household assistance. Pain was prevalent: 95% (n=119/125) of patients reported pain; 90% (n=113/125) reported the pain as recent. 76% (n=68/89, HIPS only) had bone pain severe enough to limit activity.

Substantial morbidity can develop across the lifetime of patients with HPP, regardless of age of onset. As demonstrated by these patient-report surveys, HPP results in a high burden of disease in adults with pain and limited mobility that may impact quality of life.

 

Disclosure: TJW: Ad Hoc Consultant, Alexion. EKS: Employee, Alexion. SM: Employee, Alexion. TO: Employee, Alexion. PSK: Consultant, Alexion.

20871 17.0000 FRI-240 A Burden of Disease in Adult Patients with Hypophosphatasia: Results from Patient-Reported Outcome Surveys 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Natascia Di Iorgi*1, Nadia Vercellino2, Pietro Dal Monte2 and Mohamad Maghnie3
1Istituto G. Gaslini, University of Genova, Genova, Italy, 2Istituto G.Gaslini, Genova, Italy, 3University of Genova, Genova, Italy

 

Background. Gorham-Stout syndrome (GSD) is a rare disorder characterized by lymphangiomatosis, invasion of soft tissues, osteolysis associated with severe bone morbidity and potentially lethal in the presence of chilothorax. Although bone lesions are due to abnormal vessels proliferation, new lines of investigations point out the role of osteoclastogenic cytokines (1). As the management  of GSD is not univocal and outcomes are unpredictable we build a multifaced protocol in order to study its natural history, biomarkers of disease severity and to treat uniformly patients.

Methods. Seven patients (5M and 2F,  3 mts-26.0 yrs of age) with GSD diagnosed by biopsy underwent clinical, biochemical (Ctx, BAP, PTH, 25OHD, D-Dimer), karyotype, CGH-array and imaging  evaluations (Total Body -TB- and spine DXA and STIR Total Body MRI) at baseline, after 6 months and than yearly. All patients presented osteolysis at baseline (clavicle n=1, ribs n=2, femur n=1, sternum n=1, omerus n=1, scapula n=2, ulna n=1, cranial basis) and 1 lately (parietal bone), 3 reported pathological fractures (clavicle n=1F, femur n=1M, rib n=1M) and 4 chylothorax. Three M underwent INFα2b treatment (1500000UI/m2on alternate days), 2M pamidronate for 1 year and 2M and 1F zolendronate therapy due to severity of disease or recidivism.  

Results. Three out of 4 patients with a multifocal/extended GSD form presented low bone mineral density (BMD) for age and sex (Z-score): 1M and 1F at the TB scan and 2M and 1F at the spine (Z-scores between – 2.8 and –1.1) with mildly increased bone turnover markers and elevated D-Dimer at baseline and during disease recurrency of bone or pleura. TB Stir MRI revealed aspecific involvement (hyperintensity in STIR and hypointensity in T1) of multiple skeletal sites far from the primary localization in all, but also new foci of disease in 2 subjects. Five patients reached 4 years follow up; subjects on bisphosphonates showed acutely reduced bone pain, increased BMD of about 1 Z-score during follow up and significant reduction of D-Dimer. Karyotype and CGH were normal in all the patients tested. All patients are still alive.

Conclusion.As chilothorax or fragility fractures may be early complications of a massive osteolysis in GSD, a multidisciplinary team is warranted. Our preliminary findings suggest the potential usefulness of: 1) STIR TB MRI technique in detecting early skeletal foci of disease, although further evaluations are needed to support its sensitivity, 2) DXA scan in characterizing the severity of GSD and 3) anti-angiogenic and anti-reabsorption therapies in GSD control.

 

Nothing to Disclose: ND, NV, PD, MM

21989 18.0000 FRI-241 A Gorham-Stout Disease: A Diagnostic and Treatment Protocol 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Supna K Sandhu*1, Qun Yang2, Ramesh Saeedi2, Ali Mojibi2, JoAnn Ford2, Eric Yoshida2 and David L Kendler1
1University of British Columbia, Vancouver, BC, Canada, 2University of British Columbia

 

Introduction:

Patients with hepatitis B (HBV) may require chronic antiviral therapy, consequently, bone health is a concern. Fibroblast growth factor 23 (FGF23) decreases renal tubular phosphate resorption and may be a mediator of tenofovir(TDF)-induced hypophosphatemia.  TDF with low bone mineral density(BMD) has been reported in HIV patients but the mechanism is unclear. We investigated prospectively sampled HBV patients for calcium, phosphate, FGF23, and BMD abnormalities to elucidate factors relevant to bone health.

Methods:

Patients included were selected from 125 HBV adults seen at our outpatient Gastroenterology clinic in 2014. These patients were either on TDF (300mg/day), lamivudine(LVD)(100mg/day), or entacavir(ETV)(0.5mg/day) for at least one year, or  no therapy for the past 3 months. 17 patients had abnormalities in either calcium, phosphate, or FGF23 and 15 agreed to further evaluation with a BMD and bone biochemical markers.  We then conducted a retrospective chart and imaging review on these patients.  UBC Ethic’s Board approval was obtained.

Major Results:

13/125 (10.4%) patients had hypophosphatemia of whom 5 were on TDF, 4 were on LVD, 1 was on ETV, and 3 were on no treatment; 3 also had hypocalcemia. 4 patients on TDF had elevations in FGF23, one of whom also had low phosphate. One patient on no therapy had an isolated elevation in FGF23. 4 patients had hypocalcemia, 3 of whom were on TDF and 1 was on no treatment. For the 15 patients who had further bone evaluation, 10 were on TDF, 1 on LVD, 1 on ETV, and 3 on no therapy; no patient had stopped treatment at follow up. The mean age was 43 years (range 33 to 52 years). 13 patients had follow up blood work, no one had hypophosphatemia or hypocalcemia but 10 had low 25-hydroxyvitamin D and 1 had elevated PTH. 13 patients had 24 hour urines, 3 of whom had elevated calcium excretion and one with increased phosphate excretion. No patient with FGF23 abnormalities had urine abnormalities. The mean FRAX score for a major osteoporotic fracture was 2.33%(range 1.1-4.1) and 0.29%(range 0-0.8) for a hip fracture. 6 (40%) patients had Z-scores less than predicted for age matched control at the spine or hip. No differences in spine or hip Z-scores were found between the TDF (-1.18, -0.54) and other treatment groups (-1.56, -1).

Conclusions:

FGF23 abnormalities alone cannot predict low BMD or bone biochemical abnormalities in patients on anti-HBV therapy. It is possible that greater FGF23 abnormalities may lead to decreases in BMD with long term increases in fracture risk but we did not find consistent biochemical abnormalities in our patients with abnormal FGF23. A large subset of our patients did, however, have low BMD and low 25-hydroxyvitamin D levels. This abnormality may not be related to an underlying liver disease and instead may be a result of antiviral therapy. Future studies are needed to follow these patients in the long-term and better elucidate this finding.

 

Disclosure: EY: Speaker, Roche Pharmaceuticals, Speaker, Schering AG, Speaker, Merck & Co., Investigator, Novartis Pharmaceuticals, Investigator, Jansen Pharmaceuticals, Investigator, Pfizer, Inc.. DLK: Speaker, Eli Lilly & Company, Speaker, Amgen, Investigator, Merck & Co., Investigator, Novartis Pharmaceuticals, Speaker, Pfizer, Inc., Speaker, Astra Zeneca, Speaker, GlaxoSmithKline. Nothing to Disclose: SKS, QY, RS, AM, JF

18506 19.0000 FRI-242 A Abnormalities in Bone Density, Fibroblast Growth Factor 23, and Bone Turnover Markers Occur in Patients with Hepatitis B on Antiviral Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Sunil Gurung*1 and J. Bruce Redmon2
1University of Minnesota, Minneapolis, MN, 2Univ of MN Med Sch, Minneapolis, MN

 

Introduction:  

Hypercalcemia is a common clinical problem. Primary hyperparathyroidism and malignancy are the most common causes. Granulomatous disease like sarcoidosis can also cause hypercalcemia. We present a case of acute hypercalcemia with bilateral facial palsy.

Clinical case:   

A 34 year old African female presented to emergency department with cough and headache. CBC, basic metabolic panel and chest X ray were normal.  She was sent home on azithromycin.  She returned 2 days later with left facial palsy. CT head showed a saccular aneurysm at the left middle cerebral artery bifurcation without hemorrhage but was otherwise negative. She was discharged from ED on prednisone for Bell’s Palsy and 2 weeks of doxycycline to cover for Lyme’s disease. She returned again 2 weeks later with nausea, vomiting, headache and lethargy. She was now noted to be hypercalcemic (serum calcium 12.2 mg/dl) with facial diplegia and was admitted. She denied taking calcium supplements, vitamin D or antacids. There were no skin lesions or lymphadenopathy; palpable thyroid nodules were noted on exam. Hypercalcemia worsened to 14.5 mg/dl and was treated with iv fluids, calcitonin and zoledronic acid. Work up showed intact PTH <3 pg/ml (ref range 12-72 pg/ml). PTH related peptide was < 2.0 pmol/L (ref range < 3.4 pmol/L).  25-hydroxy vitamin D and vitamin A levels were normal.  Initial 1,25 vitamin D level was reported as 15 pg/ml, but a repeat sample was 58 pg/ml (ref range < 75 pg/ml).   CXR and CT scan of chest, abdomen, pelvis were unremarkable. Mycobacterium tuberculosis Quantiferon was negative. Serum angiotensin converting enzyme level was not elevated. Serum cortisol and serum protein electrophoresis were normal.  TSH was low (0.14 mU/L, ref range 0.4-4.0 mU/L) but free T4 was normal. Thyroid ultrasound showed multiple thyroid nodules. FNA of two largest nodules was benign. Lyme’s  and HIV serologies were negative. MRI brain showed abnormal enhancement of left facial nerve, bilateral trigeminal nerves, trigeminal ganglia and a focus of enhancement at the junction of right middle cerebellar peduncle and pons. CSF showed lymphocytic pleocytosis with elevated protein (118 mg/dl) but Gram stain, bacterial and fungal cultures were negative. CSF angiotensin converting enzyme level was normal. CSF VDRL, Cryptococcal antigen, HSV and Herpes Zoster PCR, Lyme’s ELISA were negative.  Based on patient’s clinical presentation with hypercalcemia, facial nerve palsy and the findings on MRI and CSF, a presumptive diagnosis of neurosarcoidosis was made and the patient was started on glucocorticoid therapy.

Conclusion:

Sarcoidosis, a multisystem granulomatous disorder, can cause hypercalcemia. Neurosarcoidosis is seen in 5 to 13 % of sarcoidosis patients. Cranial nerve involvement is the most common manifestation of neurosarcoidosis and facial nerve (unilateral or bilateral) is the most common cranial nerve affected. 

 

Nothing to Disclose: SG, JBR

19704 20.0000 FRI-243 A A Case of Hypercalcemia with Facial Diplegia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Hodaka Yamada*, Tomoyuki Saito, Tomoko Asano, Atsushi Aoki, Masashi Yoshida, Aki Ikoma, Ikuyo Kusaka, Hideo Toyoshima, Masafumi Kakei and San-e Ishikawa
Jichi Medical University Saitama Medical Center, Saitama, Japan

 

[Background]Fibroblast growth factor 23 (FGF23) regulates mineral homeostasis. In progressed renal dysfunction, FGF23 increases to maintain phosphate excretion capacity. However, in early stage of renal impairment with diabetes, FGF23 elevation is not sensitive. The breakdown of phosphate homeostasis constancy accompanying CKD brings about vascular calcification, and raises the risk of arteriosclerotic disease. The aim of this study was to determine a clinical indicator of phosphate metabolism at diabetic patients with early CKD.

[Methods]142 patients with diabetes mellitus were enrolled. Blood samples were collected at fasting state. FGF23 was measured by ELISA. 24 hour urinary excreted phosphate (UP) and albumin (UA) were measured. UP/FGF23 ratio was calculated by the formula: UP (mg/day)/FGF23 (pg/mL). The patients were categorized three eGFR (mL/min/1.73m²) groups; G1 (≥ 90), G2 (90>, ≥60), G3 (60>, ≥30).

[Results]There were 73 men and 69 women. The mean age, A1c and eGFR were 63 ± 11 years old, 9.3 ± 1.5% and 79.5 ± 25.4 ml/min. 37 patients had medical history of arteriosclerotic diseases (coronary heart disease, atherothrombotic brain infarction, peripheral artery disease). There were no differences of A1c, serum phosphate, calcium, 25-OH vitamin D in each G1-G3 group. Serum FGF23 was elevated and UP was decreased in G3 compared to G1. UP-FGF23 ratio was decreased significantly in G2 (p < 0.01, vs G1). UP/FGF23 ratio was only a variable correlated to eGFR in multiple linear regression analysis (r = 0.47, P < 0.001). Multivariate analysis of risk factors for the arteriosclerotic diseases revealed that duration of diabetes, eGFR and UP/FGF23 ratio were significantly associated with more frequent arteriosclerotic disease. However, in analysis of risk factors for retinopathy, a microangiopathy, significant variable was UA, but not the aforementioned factors.

[Conclusion]These findings suggest that an increase in UP-FGF23 ratio is associated with atherosclerosis, and reflects early stage renal impairment in patients with diabetes.

 

Nothing to Disclose: HY, TS, TA, AA, MY, AI, IK, HT, MK, SEI

18765 21.0000 FRI-244 A Urinary Phosphate-Serum FGF23 Ratio Is a Useful Marker for Atherosclerosis in Early Stage of Diabetic Nephropathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Seyfullah Kan1, Muhammed Kizilgul*1, Muyesser Sayki Arslan1, Mahmut Apaydin1, Mustafa Caliskan1, Taner Demirci1, Selvihan Beysel2, Ozgur Ozcelik2, Zeynep Giris3 and Tuncay Delibasi4
1Diskapi Training and Research Hospital, Ankara, Turkey, 2Diskapi Teaching and Research Hospital, Ankara, Turkey, 3Ankara Training and Research Hospital, Ankara, Turkey, 4Department of Internal Medicine, School of Medicine (Kastamonu), Hacettepe University, Ankara, Turkey

 

Background 

Women with polycystic ovary syndrome (PCOS) are at greater risk for glucose intolance including insulin resistance, type 2 diabetes mellitus, and complications including vascular diseases. Fibroblast growth factor 23 (FGF-23) is a biomarker for cardiovascular disease. This study was designed to compare the serum levels of FGF-23 between patients with PCOS and healthy subjects and to determine the possible association between the hormonal and metabolic parameters.

Material and Methods

A total of 80 women, aged 17–43 years, were consecutively enrolled in the study. Of them, 40 patients suffered from PCOS, and the remaining 40 PCOS-free patients served as controls in a cross-sectional study design. PCOS was diagnosed according to the Rotterdam ESHRE/ASRM-sponsored PCOS Consensus Workshop Group 2003 guideline. Groups were compared by demographic, anthropometric, biochemical data, and by serum FGF23 levels. Serum intact FGF23 levels were determined by enzyme-linked immunosorbent assay (ELISA).

Results

Mean serum FGF-23 levels were 19.73 ± 16.75 pg/ml in PCOS patients and 17.20 ± 9.26 pg/ml healthy control group. Although FGF23 levels were higher in PCOS patients, the difference did not reach statistically significant value (P > 0.05). BMI, waist circumference, hip circumference, total testosteron, FG score and hsCRP were significantly higher in women with PCOS (p<0.001). The levels of LH, DHEA-S, FSH, insulin, total cholesterol, triglyceride, HOMA-IR were significantly higher in the PCOS group than the control subjects (p<0.05). 25-OH vitamin D, estradiol and 17-OH progesteron levels significantly lower in PCOS patients (p<0.001). FGF23 levels did not correlate with BMI, fasting glucose and insulin, HOMA-IR and lipid parameters. 

Discussion and Conclusion

Serum FGF-23 levels were similar in women with PCOS compared with controls. The present findings may suggest that FGF23 is not a useful marker of metabolic abnormalities such as insulin resistance, dyslipidemia and obesity in PCOS however, comprehensive studies covering larger populations are needed to elucidate the relationship between FGF23 and PCOS. 

 

Nothing to Disclose: SK, MK, MSA, MA, MC, TD, SB, OO, ZG, TD

21701 22.0000 FRI-245 A Serum Levels of FGF-23 in Patients with Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Debra Maxine Gordon*1 and Lawrence A Distiller2
1instiitution, Johannesburg, South Africa, 2institution, Johannesburg, South Africa

 

A case of bone pain in a patient with previous thyroid cancer

 INTRODUCTION:

The presentation of a patient with lytic bone lesions raises suspicions of primary bone cancer, multiple myeloma or metastatic disease from underlying breast cancer or thyroid cancer. Other aetiologies such as parathyroid cancer remain an unlikely possibility.

CASE PRESENTATION:

A 77 year old Caucasian female presented with a history of worsening heartburn and back pain. Six years prior to this she underwent a total thyroidectomy for a thyroid malignancy. She also gave a history of previous “parathyroid adenoma” resection.

Clinical examination revealed epigastric tenderness abdominally and tenderness over her thoracic vertebrae. X-rays showed a lytic lesion in the thoracic spine (T10). Computerized tomography confirmed the lytic lesion and noted a 12x14mm mass in the right lower lobe of the lung.

Laboratory investigations revealed a low thyroglobulin. Serum adjusted-calcium 2,98mmol/L (2.20-2.50 mmol/L) and PTH 1589pg/ml (15-65pg/ml). Parathyroid 99Tc-sestaMIBI had no uptake. Venous sampling revealed elevated PTH in the azygous vein.

Partial pneumonectomy and T10 vertebral resection were performed and histology confirmed metastatic parathyroid carcinoma, although she was eucalcaemic immediately post-operatively, the PTH remained elevated (555pg/ml). Gallium 68 dotatate PET/CT failed to show any uptake post operatively.

Hypercalcaemia is currently managed with a calcium mimetic agent.

CONCLUSION:

The incidence and prevalence of parathyroid carcinoma remains low. It is responsible for less than 5% of all cases of primary hyperparathyroidism (1).

Parathyroid malignancy is difficult to differentiate from a benign adenoma, however, the degree of hypercalcaemia, the presence of brown tumours or the degree of elevation of parathyroid levels is suggestive. Definitive diagnosis is made histologically.

Parathyroid carcinoma usually occurs in primary hyperparathyroidism, but may occur in secondary or tertiary hyperparathyroidism. Similarly, parathyroid adenomas are associated with the development of thyroid cancers (2)

Cure is dependent on an “en bloc” resection of the entire tumour and restoration of eucalcaemia. Metastatic disease with resultant hypercalcaemia is difficult to manage. Chemotherapeutic agents lack efficacy. Bisphosphonates remain a treatment for hypercalcaemia. Calcium sensing receptor agonists, whilst efficacious remain costly. 

Despite medical treatment post-surgery long term survival remains 40-86% at 5 years and in the event of a recurrence, survival is 0% at 5 years (2-5)

 

Nothing to Disclose: DMG, LAD

19260 23.0000 FRI-246 A A Case of Bone Pain in a Patient with Previous Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Ji Young Seo*1, Min Jin Lee1, Sangchang Kwon1, Jong Ho Kim1, Su Bin Park1, Yoon Jeong Nam1, Kang Hee Ahn1, Sun Hye Shin2, Myung Jun Shin3, Yun Kyung Jeon1, Sang Soo Kim1, Bo Hyun Kim1 and In Joo Kim1
1School of Medicine, Pusan National University, Busan, Korea, Republic of (South), 2Bongseng Memorial hospital, Busan, Korea, Republic of (South), 3Pusan National Univerisy Hospital, Busan, Korea, Republic of (South)

 

Purpose: Lean body mass has been reported to be related to pulmonary function in patients with chronic obstructive pulmonary disease. However, the relationship between muscle mass and pulmonary function in healthy older adults has yet to be clarified. We investigated the associations of pulmonary function with muscle mass and sarcopenia in elderly community-dwelling Koreans.

Methods: The study subjects consisted of 463 people aged over 65 years without any diseases who underwent anthropometric measurements, laboratory tests, spirometry, and estimation of appendicular muscle mass in the 2008-2011 Korea National Health and Nutrition Examination Survey. Sarcopenia was defined as a value of appendicular skeletal muscle mass divided by height squared (ASM/height2) that was <2 standard deviations below the sex-specific mean of the young reference group.

Results: FEV1 and FVC were correlated positively with ASM/height2 in males (p<0.001 and P=0.001, respectively), but not in females (p=0.360 and p=0.779, respectively). In univariate logistic regression analysis, males with low FEV1 or FVC were more likely to have sarcopenia (OR=3.11, 95% CI 1.62-5.99 for FEV1; OR=1.99, 95% CI 1.13-3.53 for FVC); the significance was lower for females (OR=11.37, 95% CI 0.97-132.91 for FEV1; OR=7.31, 95% CI 1.25-42.74 for FVC). After adjustment for age, smoking, and moderate physical activity, low FEV1 was associated with a high risk of sarcopenia in both males (OR=2.90, 95% CI 1.50-5.63) and females (OR=9.15, 95% CI 1.53-54.77).

Conclusions: Low pulmonary function is associated with high risk of sarcopenia in community-dwelling older adults.

 

Nothing to Disclose: JYS, MJL, SK, JHK, SBP, YJN, KHA, SHS, MJS, YKJ, SSK, BHK, IJK

21593 24.0000 FRI-247 A Low Pulmonary Function Is Related to High Risk of Sarcopenia in Community-Dwelling Older Adults: The Korea National Healthand Nutrition Examination Survey (KNHANES) 2008-2011 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 224-247 5959 1:00:00 PM Metabolic and Genetic Bone Disorders Poster


Diana Ovejero-Crespo*1, Mary Scott Ramnitz1, Young Lim2, Nisan Bhattacharyya1, Rachel I Gafni1, Lori C. Guthrie3, Beth Brillante1, Edward W. Cowen1, Edward McCarthy4, Paul Stephen Thornton5, Julie Hoover-Fong6, Keith Choate2 and Michael T. Collins3
1National Institutes of Health, 2Yale University School of Medicine, 3Section on Skeletal Disorders and Mineral Homeostasis, Bethesda, MD, 4The Johns Hopkins Hospital, 5Cooks Children Medical Center, Fort Worth, TX, 6Johns Hopkins University School of Medicine

 

Background: Cutaneous-Skeletal Hypophosphatemia Syndrome (CSHS) is a newly described disorder characterized by congenital mosaic hamartomas of the skin, such as epidermal or melanocytic nevus, and FGF23-mediated hypophosphatemia that in the vast majority of cases occurs in the setting of a segmental skeletal dysplasia.  We previously described 5 such individuals in which somatic hyperactive RAS mutations were identified exclusively in affected tissues. To better define the natural history of CSHS, we describe the clinical course of one of these subjects and thoroughly reviewed the literature.  

Case report: A 15-year old boy with an extensive right-sided congenital epidermal nevus was evaluated for skeletal comorbidities. The patient had no history of pathological fractures and attained normal developmental milestones and height. Nevertheless, since age 12, he developed a leg length discrepancy and limp, bone pain and muscle weakness. Hypophosphatemia and renal phosphate wasting were detected. On admission, mild FGF23-mediated hypophosphatemia was confirmed. Other findings included: right hemihypoplasia, dysplastic segmental bone lesions in x-rays, colpocephaly in brain imaging, and BMD Z-scores of the affected left femur in the osteoporotic range. Whole exome sequencing of the nevus revealed a missense mutation in HRAS (G13R) absent in peripheral blood.  An iliac crest biopsy showed dysplastic bone and osteomalacia. Single cell-derived colonies of cultured bone marrow stromal cells demonstrated the presence of either WT or mutated HRAS G13R. Prior to this admission, the patient had been on oral phosphorus and vitamin D for one year. One year and a half later the patient was no longer on medication, showed symptomatic improvement, normalization of the biochemical parameters, and correction of altered BMD values.

Fifty-six additional CSHS cases were identified in the medical literature for comparison. Interpretation of these published data suggested that hypophosphatemia and signs of osteomalacia tend to resolve or improve during adulthood (8/12 patients >18 years).  

Conclusion:  Hypophosphatemia and osteomalacia in CSHS may resolve or improve as the skeleton matures. Further study is needed to understand the influence that somatic mutations in the RAS-family genes have on the skeleton.  

This research was supported (in part) by the Intramural Research Program of the NIH, NIDCR

 

Nothing to Disclose: DO, MSR, YL, NB, RIG, LCG, BB, EWC, EM, PST, JH, KC, MTC

20082 1.0000 FRI-200 A Hypophosphatemia Can Resolve in the Mature Skeleton in Cutaneous-Skeletal Hypophosphatemia Syndrome: Lessons from a Case and Review of the Literature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Aditi Kumar*, Peter J Tebben and Robert A Wermers
Mayo Clinic, Rochester, MN

 

Background: Autosomal dominant hypophosphatemic rickets (ADHR) is a rare disorder due to mutations in the FGF23 gene with impaired cleavage of intact FGF23 protein resulting in renal phosphate wasting, hypophosphatemia, inappropriately low/normal calcitriol concentrations, and rickets/osteomalacia. Prior work has suggested that iron deficiency may contribute to FGF23 dysregulation in ADHR. However, the clinical benefit of iron supplementation in iron deficient patients with renal phosphate wasting has not been demonstrated.

Clinical Case: A 41 year old female presented with progressively worsening muscle weakness and diffuse pain over the last 4 years. After approximately 3 years, her serum phosphorus was measured and found to be low at 1.0 mg/dl (nl 2.5-4.5 mg/dl).  She had evidence of renal phosphate wasting and a subsequent FGF23 level was 590 RU/mL (nl ≤ 180 RU/ml).  Despite phosphorus (250 mg QID) and calcitriol (0.5 mcg BID) therapy for several months, her phosphorus remained low and she had difficulty ambulating due to progressive weakness. Extensive imaging for tumor induced osteomalacia (OctreoScan & FDG PET/CT) was non-localizing. Family history was negative for bone disease.

At the time of referral, her exam was remarkable for severe proximal muscle weakness with urinary incontinence and wheel chair dependence. Lab tests were as follows: phosphorus (P) - 2.1 mg/dl; fractional excretion of P (FEP) - 23%; FGF 23 - 1905 RU/ml; PTH - 33 pg/mL (nl 15-65 pg/ml); Ca - 9.5 mg/dL (nl 8.9-10.1 mg/dl);  25-OH Vit D - 20 ng/dL (nl 20-50 ng/dl); 1,25-(OH)2 Vit D - 46 pg/mL (nl 18-78 pg/ml); alkaline phosphatase - 184 U/L (nl 37-98 U/L); hemoglobin - 9.4 g/dl (nl 12-15.5 g/dl); ferritin - 2 mcg/L (nl 11-307 mcg/l).  Diffuse demineralization and flattening of the femoral heads were seen on X-ray. Bone mineral density showed Z-scores of -3.7 and -3.0 at the lumbar spine & femoral neck respectively. Bone scan revealed widespread bony abnormalities consistent with osteomalacia. Sestamibi tumor scan was non-localizing.

Iron replacement with ferrous sulfate 325 mg TID was initiated. Hypophosphatemia resolved shortly thereafter allowing phosphorus supplements to be tapered off within 6 months, while maintaining calcitriol therapy. Within 5 weeks of iron supplementation progressive clinical improvement was noted such that at 6 months of starting iron, she was capable of ambulating for short distances unassisted. FGF23 levels decreased promptly at 6 weeks to 360 RU/ml and 270 RU/ml after 6 months of iron. The alkaline phosphatase reduced to 138 U/L and the FEP declined to 13% after 6 months of therapy.   

Conclusions: Iron replacement may be a potential treatment option for patients with renal phosphate wasting and iron deficiency. Further study of iron supplementation in such patients will be needed to confirm this clinical observation and determine its potential benefit.

 

Nothing to Disclose: AK, PJT, RAW

20762 2.0000 FRI-201 A Iron Replacement As a Therapeutic Approach for Renal Phosphate Wasting with Associated Iron Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Tzer Hwu Ting*1, Nurul Nadirah Razali2 and Karuppiah Thilakavathy2
1University Putra Malaysia, Kuala Lumpur, Malaysia, 2University Putra Malaysia

 

Introduction

Hypophosphatemic rickets (HR) is commonly inherited as X-linked or autosomal dominant manner due to mutations in phosphate-regulating gene with homologies to endopeptidases on the X-chromosome (PHEX) or fibroblast growth factor 23 (FGF23) genes, respectively. Sporadic cases of X-linked HR due to inactivating mutations of PHEX gene have been reported but little is known in South-East-Asian descent. We report a case and mutation analysis of a young Malaysian girl with sporadic HR.

Case

A 7-year-old Malay girl who presented at 2 years of age with frontal bossing, poor growth and mild leg bowing.  She was well otherwise. Her parents were non-consanguineous and she was the youngest of 3 children in the family.  There was no family history of skeletal deformity.  Examination at diagnosis showed a very short child with height 72.0 cm (-4.64 SD on WHO growth chart) and weight 8.4 kg (-2.95 SD on WHO growth chart). The midparental height was 146.9 cm (-2.48 SD). She had bilateral wrist swelling, mild ankle swelling & mild leg bowing.  Investigations revealed raised alkaline phosphatase 620 U/L (normal 100-350), low inorganic phosphate 0.64 mmol/L (normal 1.1-1.8); normal calcium 2.22 mmol/l (normal 2.10-2.55), PTH  4.9 pmol/L (normal 1.6-6.9) and 25-hydroxyvitamin-D 55 nmol/L  (normal > 50). Renal function test & venous blood gas were normal. Urine calcium/creatinine ratio was normal 0.22 (normal <0.7). Fractional excretion of phosphate was elevated 22.3% (normal <20%).  Wrist and ankle radiographs showed changes of rickets.  She was treated with oral alfacalcidol & phosphate salt.

Molecular genetic analysis

Blood samples were obtained from the patient and both her parents.  The extracted DNA were subjected to PCR and direct sequencing. Mutation analysis for PHEX & FGF23 genes were performed.  No FGF23 gene mutation was found. In PHEX gene analysis, the proband was found to be heterozygous for a previously reported missense mutation in exon 20 c.1970A>G (Y657C).  Her parents carried wild-type alleles. This mutation was previously reported by Gaucher et al., 2009 as sporadic in Europeans. The nonsynonymous changes were evaluated by amino acid substitution functional prediction tools, SIFT as damaging and PolyPhen as probably damaging.  This shows that the heterozygous mutation can give rise to clinical manifestations of HR.

Conclusion

The genetic study confirms the diagnosis of HR in this patient and contributes significantly to genetic counselling for the affected family.  This helps to improve patient clinical care & management.  


 

Nothing to Disclose: THT, NNR, KT

19752 3.0000 FRI-202 A Phex Gene Mutation in a Malaysian Girl with Sporadic Hypophosphatemic Rickets 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Bhargavi Patham*1, Ethan Miller2, William A Murphy Jr.3 and Mimi I-Nan Hu2
1Baylor College of Medicine, Houston, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3The University or Texas MD Anderson Cancer Center, Houston, TX

 

Introduction: Tenofovir (TEN) is a nucleotide reverse transcriptase inhibitor widely used in the management of hepatitis B virus (HBV).  TEN is excreted by the kidneys and may get concentrated in proximal renal tubular cells causing mitochondrial damage leading to Fanconi syndrome.  Acute tubular necrosis, progressive decline in renal function, and nephrogenic diabetes insipidus have all been reported with TEN, with risk correlating with duration of treatment.  Here we present a case of TEN-related Fanconi syndrome leading to hypophosphatemic osteomalacia and multiple insufficiency fractures initially presumed to be metastatic bone disease associated with hepatocellular carcinoma.

Case : A 76 y/o Vietnamese man was diagnosed with HBV at age 60.  He began treatment with TEN 4 years after diagnosis.  At age 72, he was diagnosed with hepatocellular carcinoma (HCC) and underwent transarterial chemoembolization with doxorubicin; he remains in remission at last follow-up this year.  During routine radiological surveillance for HCC, he was noted to have multiple insufficiency fractures in ribs, sacrum, and iliac crests, detected on bone scan and computed tomography.  The patient denied trauma, myalgias, or arthralgias.  Biopsy of the right iliac lesion was negative for malignancy.  DXA showed osteoporosis with the lowest T-score of -3.8 in bilateral femoral necks.  Review of routine labs showed chronic hypophosphatemia (phosphorus [phos] 1.6 – 2.3mg/dL, reference range [rr]: 2.5 – 4.5), progressive hyperchloremic metabolic acidosis with chloride of 110 mEq/L (rr: 98-108), carbon dioxide 21 mEq/L (rr: 23-30), and chronic renal insufficiency with an estimated GFR of 37mL/min/1.73m2.  Additional workup revealed elevated alkaline phosphatase (ALP), 25-hydroxyvitamin D 26 ng/mL (rr: 30-100), phosphaturia (urinary phos 700 mg/day, fractional excretion 95%), normoglycemic glycosuria, and aminoaciduria.  Gonadal and thyroid functions were normal.  Multiple myeloma was ruled out.  Fibroblast growth factor-23 (FGF-23) was not elevated.  Consequentially, TEN was replaced by entecavir.  Calcitriol and phosphorus replacement was initiated.  Within 1 month, the patient reported improved mobility due to resolution of joint stiffness.  Labs 3 months after initiation of replacement therapy demonstrated normal phos and ALP levels, and elevated but improving creatinine.

Conclusion: Although bone lesions and unexplained fractures in a patient with a known malignancy are suspicious for metastases, a thorough review of medications, laboratory and radiologic findings should be performed to evaluate for other potential reversible systemic causes.  Physicians must be aware of Fanconi syndrome and osteomalacia associated with TEN and should routinely assess for renal dysfunction and electrolyte and bone abnormalities.

 

Nothing to Disclose: BP, EM, WAM Jr., MINH

19971 4.0000 FRI-203 A Tenofovir-Related Hypophosphatemic Osteomalacia and Multiple Fractures Mimicking Metastatic Bone Disease in a Patient with Hepatocellular Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Nancy Fawzy Nakhoul*1, Ghada El-Hajj Fuleihan2, Mohammad Haidar1, Mahmoud Shoucair2, Mukbil Hourani1 and Asma Arabi2
1American University of Beirut, Beirut, Lebanon, 2American University of Beirut Medical Center, Beirut, Lebanon

 

Tumor induced osteomalacia (TIO) is a rare disease, associated with hyperphosphaturia, and hypophosphatemia. Tumors are usually difficult to localize. We present a case of TIO associated with a benign giant cell rich fibrohistiocytic tumor mimicking an inguinal lymphadenopathy.

A 47 year old man, presented for back pain, bilateral ankle pain with progressive muscle weakness of 2 years duration.

Initial work up revealed normal serum calcium (SCa)10 mg/dl (8.5-10.5) and ionized calcium 1.3 mmol/l (1.13-1.40), low serum phosphate (SP04) 1 mg/dl (2.7-4.8), high PTH 151 pg/ml (10-76), normal 25- hydroxyvitamin D (25OHD) 32 ng/ml, high 1-25 (OH)2vitamin D >100 pg/ml (20-46) and high Alk Ph 184 IU/L [35-120]. 24 hours urine phosphate excretion was 1.24 g/day. TSH and liver enzymes were normal.

BMD Z-Scores (by DXA) were -2 at the forearm, -1.5 at L1-L4, -0.5 at the femoral neck and -0.4 at the total hip.

On physical exam, there was tenderness with limited range of motion of both ankles but no detectable skin and mucosal tumors.

Additional follow-up studies revealed normal SCa 9.1 mg/dl and ionized calcium 1.3 mmol/l, normal Magnesium and creatinine, 25OHD level was 29 ng/ml, low SP04 1 mg/dl, high PTH 97 pg/ml and Alk Ph 253 IU/L, 24 hours urine calcium was 128 mg/day, and 24 hours urine phosphate 0.92 g/day. Repeated 1, 25 OH2D was 34 pg/ml.

FGF 23 level (EDTA Plasma) was elevated 556 kRU/l (26 – 110), thus confirming the diagnosis of TIO but a FDG PET scan failed to show the lesion.

Few months later, repeated PET/CT Whole body was performed using 6.17 mCuries of Gallium 68 DOTA-NOC. It showed: a 2.1 cm right inguinal lymph node with significant increased radiotracer uptake SUVmax=12.93, In retrospect this was present on the previous examination and has increased in size (previously 1.1 cm) however it showed no significant activity on the FDG PET . Excisional biopsy was performed. Pathology showed a 3x2x1.5 cm Lymph node with central necrotic and hemorrhagic cut surface. Microscopically it showed benign giant cell rich fibrohistiocytic tumor. One week after resection of the tumor, the patient reported marked improvement in his pain and weakness and the SP04 level returned to normal range.

our case is the first case of giant cell tumor, mimicking inguinal lymphadenopathy, associated with TIO. One case of TIO from nasal cavity giant cell tumor was previously reported but to our knowledge, this is the first case to present as a lymphadenopathy. TIO are difficult to diagnose by clinicians and no standard imaging techniques are available. the most frequently used are skeletal surveys MRI, FDG PET and octreotide scan. the role of Gallium DOTA-peptides scan is emerging in this field (1) and our case demonstrated its utility. Hence every case has its own teaching lesson and should be reported to finally come out with a consensus on the diagnostic modalities of these tumors in terms of markers, imaging, and histological features.

 

Nothing to Disclose: NFN, GE, MH, MS, MH, AA

21203 5.0000 FRI-204 A Tumor Induced Osteomalacia Associated with a Giant Cell Tumor Mimicking Inguinal Lymphnode, a Lesson to Learn from Each Case 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Muge Bilge*1, Mine Adas2, Ersin Kayalibag3 and Aysen Helvaci4
11SB Okmeydani Training Hospital, Istanbul, Turkey, 2Okmeydani Training Hospital, Istanbul, Turkey, 3Medipol University, Istanbul, Turkey, 4SB Okmeydani Training Hospital, Turkey

 

Aim

Hyperchloremic metabolic acidosis and osteomalacia are known as a late complication of urinary division with use of ileum or colon. Slowly progressive metabolic acidosis does not usually cause obvious symptoms; if asymptomatic acidosis persists for a long period, osteomalacia may occur many years after a urinary division. There are a few case reports in literature.

Case

A 54 year old man, with complaint of walking abnormality and general bone pain at last six months was admitted to our outpatient clinic. His complaints and walking abnormality gradually increased in last two months. The patient underwent cystectomy and urinary division surgery in 1983 because of  bladder cancer, and followed by chemotherapy.  In 1995, the patient underwent a second surgery because of perianal fissure; however, there was no oncological data. He was ex-smoker and using NSAID for bone pains. Waddling gait and thoracal kyphoscoliosis were observed during the physical examination. Sensibility was determined on the ribs with palpation. Arterial blood pressure was 120/70 mmHg, pulse per minute was 94/regular, and examination of the rest of the systems were normal. The laboratory tests determined an increased level of alkalinephosphatase (551 U/L), chloride (116 mEq/L) and  decreased level of calcium (7,96 mg/dL), phosphate (2,35 mg/dL). Parathyroid hormone was 36,6 pg/mL and 25-hydroxy-vitamin D was 8.7 μg/mL.  Arterial blood gas findings showed marked metabolic acidosis; pH 7,19, arterial oxygen tension 87,1, arterial carbon dioxide tension 41,9, and bicarbonate ion 15 mEq/L. Romatoid factor , anti SS-A/ SS-B, protein electrophoresis and anti nuclear antibody were identified as negative. Bone mineral analysis showed that the bone mineral content was lower than the standard value, and T score was -1,2 in the femoral neck and 0,2 in L1-L4. Bone scintigraphy revealed multiple signs of abnormal accumulation in the ribs and femoral heads suggesting metastatic disease. For differantial diagnosis PET-CT scan was performed wich showed hypermetabolic areas at rigt femur neck (suv max 4.02), right ribs (suv max 2.36) .

Based on these findings, the diagnosis was osteomalacia ; we reasoned that urinary division must have caused a marked  hyperchloremic metabolic acidosis. He was treated with oral calcitriol and sodium hydrogen carbonate.

Conclusion

Slowly progressive metabolic acidosis does not usually cause obvious symptoms; if asymptomatic acidosis persists for a long period, osteomalacis may ocur many years after an urinary division.

 

Nothing to Disclose: MB, MA, EK, AH

21207 6.0000 FRI-205 A Osteomalacia As a Result of Urinary Division 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Damien Gruson*, Michel Rousseau and Sylvie Ahn
Cliniques Universitaires Saint Luc, Brussels, Belgium

 

Background: Vitamin D deficiency and hyperparathyroidism are common in patients with heart failure (HF). There is a growing body of evidence supporting the role of vitamin D and parathyroid hormone (PTH) in cardiac remodeling and worsening of HF. Nevertheless, the prognosis value of the 1,25-dihydroxyvitamin D (1,25(OH)2D), the most potent biologically active metabolite of vitamin D, remains unclear. Therefore we examined the association of 1-25OHD levels and cardiovascular (CV) death in chronic HF.

Methods: The study included 170 chronic HF patients (females n=36; males n=134; NYHA II-IV; mean age: 67 years; etiology: ischemic n=119, dilated cardiomyopathy n=51; mean EF: 23 %). The primary outcome measured in this study was CV death. Levels of 1,25(OH)2D were determined at baseline with a fully automated and sensitive immunoassay that uses a specific recombinant fusion protein for the capture of 1,25(OH)2D (DiaSorin). Levels of 25-hydroxyvitamin D (25OHD), PTH(1-84), B-type natriuretic peptide (BNP), N-terminal proBNP (NT-proBNP) and Galectin-3 (Gal-3) were also measured.

Results: Serum levels of 1,25(OH)2D decreased markedly according to HF severity and were 30.9 pg/mL in NYHA class II, 22.0 pg/mL in NYHA class III, and 14.9 pg/mL in NYHA class IV (p<0.001). Decreased ratios of 1,25(OH)2D to PTH(1-84) were also significantly related to HF severity. In contrast, levels of 25OHD were not significantly different according to NYHA functional classes (p = 0.146). 1,25(OH)2D and its ratio to PTH(1-84) showed significant negative correlation with BNP, NT-proBNP and Gal-3. Levels of 25OHD were only related to BNP and NT-proBNP. After 8 years of follow-up, 106 patients reached the primary endpoint. Cox multiple variable analysis revealed 1,25(OH)2D and the ratio of 1,25(OH)2D to PTH(1-84) to be strongly predictive of the outcome. In receiver operating characteristic (ROC) analysis, the area under the curve (AUC) for 1,25(OH)2D and 1,25(OH)2D/PTH(1-84) ratio were 0.72 (95% CI: 0.64-0.78) and 0.74 (95% CI: 0.66-0.80), respectively, which was similar to BNP (AUC 0.72 [(95% CI: 0.64-0.79]) and to NT-proBNP (AUC 0.71 [(95% CI: 0.63-0.78]), but clearly higher than Gal-3 (AUC 0.65 [(95% CI: 0.57-0.73]) and 25OHD (AUC 0.53 [(95% CI: 0.45-0.61]).

Conclusions: 1,25-dihydroxyvitamin D and its ratio to PTH(1-84) are strong independent markers for cardiovascular death in chronic HF.

 

Nothing to Disclose: DG, MR, SA

20398 7.0000 FRI-206 A Serum Levels of 1, 25-Dihydroxyvitamin D and the Ratio to PTH(1-84) Are Strong Predictors of Cardiovascular Death in Heart Failure 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Shristi Neupane*1, Gregory A Clines2, Richard J. Auchus2 and Peter Arvan2
1University of Michigan, Ann Arbor,, MI, 2University of Michigan, Ann Arbor, MI

 

Background: The triad of hypercalcemia, osteolytic bone lesions with negative bone scintigraphy is typical of multiple myeloma. Here we present an unusual case of a young man presenting with the above features but discovered to have a different diagnosis.

Clinical case: A 23-year-old male college student with no prior medical problems presented with a 6 week history of intermittent fevers and night sweats that progressed to dyspnea on exertion, severe fatigue and constipation. He did not take medications, and he denied smoking, alcohol abuse, or use of illicit drugs, over the counter products and herbal supplements. Physical examination was unremarkable. Labs revealed hypercalcemia (14 mg/dl), hyperphosphatemia (5.9 mg/dl), anemia (Hb 12 g/dl) and acute kidney injury (Cr 1.8 mg/dl). Further investigation for hypercalcemia included low 25-OH vitamin D (6 ng/ml), low 1,25-OH vitamin D (6 pg/ml), suppressed PTH (<6 pg/ml) and low PTHrP (0.4 pmol/L, ref: <2.0). His peripheral smear and serum LDH were normal. A rheumatologic and infectious disease evaluation were unrevealing. Unexpectedly, a CT scan abdomen and pelvis reported multiple osteolytic lesions of the spine and pelvis; however, bone scintigraphy showed no abnormalities. Although suggestive of multiple myeloma, his UPEP and SPEP were normal. Finally, a bone marrow biopsy revealed acute precursor B-cell lymphoblastic leukemia (ALL). During the workup, the calcium and creatinine continued to increase despite hydration and calcitonin therapy. This worsening prompted treatment with IV zoledronic acid that led to a prompt resolution of both hypercalcemia and acute kidney injury.

Discussion: Hypercalcemia, osteolytic bone lesions and a negative bone scan are characteristic of multiple myeloma. Other malignancies associated with osteolytic bony metastasis commonly have increased uptake on bone scintigraphy. In multiple myeloma, osteoblast-inhibiting factors impair radiotracer incorporation by osteoblasts, leading to a negative bone scintigraphy. Hypercalcemia with osteolytic bony lesions is very rare in adults with ALL, and only few cases have been described. To our knowledge this is the first case describing normal bone scintigraphy in such a patient. The osteolytic bone lesions in ALL are thought to be due to infiltration of the red marrow areas or subperiosteal space by malignant blasts, causing a marked increase in osteoclastic bone resorption. The negative bone scan in our patient suggests the presence of an ALL-associated osteoblast-inhibiting factor.

 

Nothing to Disclose: SN, GAC, RJA, PA

19482 8.0000 FRI-207 A Hypercalcemia and Osteolytic Bone Lesions: A Surprising Etiology 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Elaine Cong*1, Thomas P. Jacobs2 and Shonni J. Silverberg3
1Division of Endocrinology, Columbia University, College of Physicians and Surgeons, New York, NY, 2Columbia University College of Physicians and Surgeons, New York, NY, 3Columbia University, College of Physicians and Surgeons, New York, NY

 

Background: Patients with osseous sarcoidosis are generally asymptomatic and have stable lesions localized to the hands and feet. Rarely, these lesions involve the axial skeleton and are destructive leading to fracture. Sarcoid therapy may improve bone pain, but often does not alter skeletal lesions.

Clinical Case: A 49 year old previously healthy perimenopausal Hispanic female presented with 1 year of weight loss, dyspnea on exertion and bone pain. Imaging revealed widespread lymphadenopathy and had lytic lesions of the occiput, humerus, scapula, clavicles, ribs, thoracolumbar spine, sacrum, ileum, acetabulum and proximal femurs. Hand X-rays were negative. No fractures were seen. An extensive workup was negative for infectious and malignant etiologies. Biopsy of a mediastinal lymph node and left iliac crest lesion revealed non-caseating granulomas consistent with sarcoid. ACE level was 14 U/L [9-67]. Laboratory values demonstrated profound vitamin D deficiency (25OHD <13 ng/ml [30-80]), low-normal calcium [8.8 mg/dl; 8.7-10.2] and very low 24 hour urine calcium [37 mg/24 hrs, urine creatinine 1320 mg/24 hrs], with normal levels of PTH (42 pg/ml; 8-51), 1,25(OH)2D (29 pg/ml; 15-75), ionized calcium (1.23 mmol/L; 1.12-1.32), phosphorous (3.6 mg/dl; 2.5-4.3), alkaline phosphatase (30 U/L; 33-96) and renal function. Bone turnover markers were not elevated (CTX 345 pg/ml [premenopausal range: 40-465], OCN 19 ng/ml [11-50], P1NP 35 ug/L [20-200], BSAP 4.6 ug/L [4.5-16.9]) and DXA BMD was normal (T-score: LS 0.9, FN 0.2, TH 0.5, RAD 1.4). However, HRpQCT showed markedly low cortical density at the distal tibia (T-Score -3.7) and bone scan showed multiple radiotracer avid lesions including those corresponding to her proximal femur lesions. All symptoms resolved with a prolonged high dose prednisone taper. Imaging at three months showed improved pulmonary nodules, but unchanged skeletal lesions. Given the highly avid lesions at sites at high risk for fracture, coupled with her underlying risk for progressive bone loss from incipient menopause and steroid therapy, we repleted her vitamin D and then treated with reclast 5mg IV. We will obtain six-month follow-up studies in February 2015.

Conclusion: Patients with sarcoidosis have lower BMD than controls and high fracture risk. In a study of sarcoid patients without osseous lesions, alendronate therapy prevented steroid-induced bone loss. There are, however, no data on the effect of bisphosphonates on the progression of lytic lesions due to osseous sarcoidosis. This case report describes a sarcoid patient with normal DXA BMD but widespread lytic lesions at weight bearing sites who was treated with reclast. It remains to be seen whether bisphosphonates affect the bone lesions of patients with extensive osseous sarcoidosis.

 

Nothing to Disclose: EC, TPJ, SJS

18912 9.0000 FRI-208 A A Case Report: Bisphosphonate Therapy in a Patient with Extensive Osseous Sarcoidosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Swathi Beeravolu*1, Deepika Nallala2, Carmel Maria Fratianni3 and Michael G Jakoby IV4
1Lexington Endocrinology, West Colombia, SC, 2Springfield Diabetes and Endocrine Center, Springfield, IL, 3Southern Illinois University School of Medicine, Springfield, IL, 4SIU School of Medicine, Springfield, IL

 

Background: Autoimmune polyglandular syndrome type 2 (APS2) includes primary adrenal insufficiency and at least one other autoimmune endocrinopathy, usually thyroid disease or Type 1 diabetes mellitus.  Although infrequent, hypercalcemia is a well-recognized complication of adrenal insufficiency and can be the initial presenting sign.  We present a case of APS2 in which adrenal insufficiency presented as hypercalcemia in the first trimester of pregnancy. 

Case: A 32 year-old female with Type 1 diabetes diagnosed at age 7 years and primary hypothyroidism diagnosed at age 20 years was admitted to hospital at 8 weeks gestation for management of nausea, vomiting, and dehydration.  Admission laboratories were notable for serum calcium 12.0 mg/dL (8.4-10.2) that remained persistently elevated after correction of the patient’s volume deficit and resolution of symptoms.  Parathyroid hormone was suppressed (< 6 pg/mL, 15-65), and measurements of parathyroid hormone related peptide (PTHrp, 0.4 pM, < 2.0), 25-hydroxyvitamin D (28 ng/mL, 24-80), and 1,25-dihydroxyvitamin D (< 8 pg/mL, 18-78) failed to identify an etiology for hypercalcemia.  TSH (0.46 mIU/L, 0.35-4.94) and free thyroxine (1.1 ng/dL, 0.9-1.5) confirmed biochemical euthyroidism.  Baseline 8 AM measurements of serum cortisol and adrenocorticotropic hormone (ACTH) were 0.6 μg/dL (4.0-22.0) and 2,609 pg/mL (6-50), respectively, and 30 minute stimulated cortisol after intravenous administration of 250 μg Cortrosyn™ was 0.8 μg/dL.  Autoimmune primary adrenal insufficiency was diagnosed, and treatment with hydrocortisone and fludrocortisone resulted in resolution of hypercalcemia and a successful pregnancy.

Conclusions: APS2 has a prevalence of approximately 1/20,000 and a 3:1 female predominance.  The diagnosis is usually made with the onset of Addison’s disease in the third or fourth decade, and Type 1 diabetes is the initial endocrinopathy in approximately 60% of cases.  This presentation of APS2 is unusual for three reasons.  First, the patient falls in the uncommon subset of APS2 patients with Carpenter’s syndrome by virtue of tri-glandular autoimmune endocrinopathies of the adrenal glands, thyroid, and pancreas.  Second, hypercalcemia, which is documented in only 5-6% of Addison’s disease cases, was the major initial biochemical abnormality of this patient’s primary adrenal insufficiency.  Third, adrenal insufficiency was diagnosed during pregnancy, and new onset of adrenal insufficiency in pregnancy appears to be rare, with an incidence of 1/3,000 in the only series published in the peer reviewed literature.  This case also illustrates the importance of distinguishing adrenal insufficiency from hyperemesis gravidarum so that appropriate treatment with glucocorticoids and mineralocorticoids can be initiated.

 

Disclosure: MGJ IV: Speaker, Sanofi. Nothing to Disclose: SB, DN, CMF

19370 10.0000 FRI-209 A An Unusual Case of Autoimmune Polyglandular Syndrome Type 2 Masquerading As Hyperemesis Gravidarum and Revealed By Persistent Hypercalcemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Swathi Beeravolu*1 and Michael G Jakoby IV2
1Lexington Endocrinology, West Colombia, SC, 2Southern Illinois University School of Medicine, Springfield, IL

 

Background: Hypercalcemia is a common clinical problem but may also be a clue to unsuspected illness.  Though primary hyperparathyroidism and malignancies account for the significant majority of hypercalcemia cases, granulomatous diseases are well established etiologies of hypercalcemia.  We present an unusual case of isolated extrapulmonary sarcoidosis confined to bone marrow manifesting as hypercalcemia and pancytopenia.

Case: A 64-year-old male was admitted to hospital with right flank pain and acute renal insufficiency.  Admission chemistries revealed severe hypercalcemia (15.5 mg/dL, 8.8-10.0), phosphorus 4.0 mg/dL (2.2-4.2), and serum creatinine (Cr) 2.7 mg/dL (baseline 0.8 mg/dL, 0.7-1.4).  No renal calculi or obstructive uropathy were apparent on abdominal computed tomography (CT), and no masses, infiltrates, or adenopathy were observed on chest CT.  Complete blood count showed pancytopenia with white blood cell count 3,100/mm3 (4,500-10,500), hemoglobin 8.8 g/dL (13.0-18.0), and platelet count 110,000/mm3 (150,000-350,000).  Parathyroid hormone (PTH) was suppressed (10 pg/mL, 10-65), indicating parathyroid independent hypercalcemia.  Pancytopenia prompted evaluation for multiple myeloma, but serum protein electrophoresis was unremarkable, urine electrophoresis showed minimally detectable gamma light chains, and no lytic or sclerotic lesions were visible on skeletal survey.  Iliac crest biopsy yielded hypocellular bone marrow with multiple, non-caseating granulomas.  Special stains for acid fast bacilli and fungi were negative, and flow cytometry did not show evidence of non-Hodgkin lymphoma or leukemia.  Angiotensin converting enzyme (ACE) level was elevated (145 U/L, 14-62) consistent with the histological diagnosis of sarcoidosis, and 1,25-dihydroxyvitamin D level was inappropriate for degree of PTH suppression (63 pg/mL, 18-64).  Calcium (10.2 mg/dL) and serum Cr (1.5 mg/dL) improved after treatment with isotonic fluids, calcitonin, and denosumab (120 mg).  Prednisone 20 mg daily was started for management of bone marrow sarcoidosis.

Conclusions: Sarcoidosis causes hypercalcemia through autonomous expression of 1-alpha-hydroxylase in granulomas and ectopic conversion of 25-hydroxyvitamin D to calcitriol.  In A Case Control Etiologic Study of Sarcoidosis (ACCESS), hypercalcemia and bone marrow involvement occurred in 3.7% and 3.9% of patients, respectively, with overlap between the two complications unspecified.    Only 14 of 736 patients had disease limited to extrapulmonary organs, and none were documented to have disease isolated to bone marrow, though sarcoidosis isolated to marrow is described in a few case reports.  This case illustrates that parathyroid independent hypercalcemia may be an indicator of granulomatous diseases, and bone marrow involvement should be considered in the setting of hematological abnormalities.

 

Disclosure: MGJ IV: Speaker, Sanofi. Nothing to Disclose: SB

20089 11.0000 FRI-210 A Hypercalcemia and Pancytopenia As the Presenting Signs of Bone Marrow Sarcoidosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Hiba Al-Zubeidi*1, Ron S Newfield2, Robert M Sheets3 and Carla Demeterco Berggren3
1UTHSC/Le Bonheur Children's Hospital, Memphis, TN, 2UCSD/Rady Children's Hospital, San Diego, California, 3UCSD/Rady Children's Hospital, San Diego, CA

 

Introduction: Sarcoidosis is a systemic inflammatory disease that can affect many organs. It is characterized by non-necrotizing granulomas. Pulmonary findings are found in more than 90% of patients and isolated extrapulmonary disease in less than10%. Hypercalcemia is found in 5% of cases and reflects activated T cells and macrophages expressing 25(OH)D-1-α hydroxylase activity, which converts vitamin D 25(OH) to calcitriol. We present a case of severe hypercalcemia in an adolescent who was later diagnosed with extrapulmonary sarcoidosis.

Methods: Chart review.

Case description:

A 16 year old male was initially admitted with fever, pancytopenia, and myositis and was found to be infected with influenza B virus. CT imaging was notable for hepatosplenomegaly, pericardial and pleural effusions. Muscle biopsy revealed myositis consistent with influenza infection, and bone marrow (BM) biopsy was negative for malignancy. He responded well to glucocorticoids (GC), which were weaned off over 4 weeks. Second hospitalization was eight months later with fever, pancytopenia, myositis, splenomegaly and an elevated serum Ca 11.3 mg/dl (8.5-10.4), Albumin 3 g/dL(3.5-5.1). Intact PTH <4pg/ml (8.5-72.5), Alkaline phosphatase 74 U/L(38-126), Phosphate 4 mg/dl (2.5-4.5),vitamin D25 (OH)9 ng/ml(30-100), vitamin D 1,25 (OH)2, 50 pg/ml (19-83,) and high urine Ca/Cr ratio of 0.56. BM biopsy was negative for malignancy. Chest MRI was negative. Hypercalcemia improved with calcitonin and GC, tapered over 6 months. Nine months later he presented with fever, pancytopenia and a higher calcium level of 15.8 mg/dl, appropriate PTH of 5.8 pg/ml (8.5-72.5) and PTHRP of 7 pg/ml (14-27). Vitamin D 25 (OH) was 13 ng/ml (30-100) but vitamin D 1,25 (OH)2, total was high at 94 pg/ml (19-83) with negative PPD and normal ACE. Muscle biopsy showed perimysial lymphohystiocytic infiltrates but no definitive granulomas. Eye exam was normal. Chest MRI was negative. One month later he developed erythematous plaques on the abdominal wall and a skin biopsy revealed non-necrotizing granulomatous inflammation. It was not until 30 months after his initial presentation, that a second skin biopsy, now from his left arm revealed nodular infiltrates consistent with cutaneous sarcoidosis. Patient has been managed with infliximab and prednisone with normal calcium levels, except for one relapse due to poor compliance to infliximab.

Conclusions: Severe hypercalcaemia can be the only initial symptom of sarcoidosis. Our case had an atypical presentation, and is a reminder of the broad and complex differential diagnosis of hypercalcemia. It was not until cutaneous signs were manifested that the diagnosis of sarcoidosis was confirmed, at a relatively late stage of the disease.

 

Nothing to Disclose: HA, RSN, RMS, CD

20135 12.0000 FRI-211 A Severe Hypercalcemia in a Young Adolescent Male Secondary to Extrapulmonary Sarcoidosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Olivia Papacostea* and Ugis Gruntmanis
UT Southwestern Medical Center, Dallas, TX

 

Pathological fractures are a known but rare complication of tophaceous gout. Since 1950 only 13 cases of severe gout resulting in non-traumatic fractures have been reported, only two of those in patients who are younger than 40. Tophi can cause development of bone erosions and subsequent increase in bone fragility as Monosodium urate crystals increase the activity of osteoclasts and decrease the activity of osteoblasts. Here we highlight the case of a young patient who presented with severe gout and extensive vertebral compression, rib and pelvic fractures.

A 38 year old Hispanic man with a 5 year history of gout, presented to our hospital with progressively worsening back, abdominal, and left hip pain. In the past he had been treated with allopurinol and most recently with a 6 month course of prednisone because of worsening joint pain and development of tophaceous deposits. 6 weeks prior to this admission patient underwent L3 and L5 kyphoplasty for newly diagnosed multiple vertebral compression fractures, of unknown etiology. 2 weeks prior to the admission he stopped taking prednisone at the advice of his primary care physician. He reported no history of trauma and no family history of gout, osteoporosis or fractures. Physical examination was remarkable for severe deformities of nearly every peripheral joint on his upper and lower extremities due to extensive tophaceous involvement, and innumerable tophi on the extensor surfaces of his body. Laboratory findings showed a normocytic anemia (hemoglobin = 7.9 g/dL n 13.2-16.9 g/dL), an elevated serum uric acid (9 mg/dL n 3.4-7 mg/dL), an elevated alkaline phosphatase (202 units/L n 40-129 units/L), an elevated C-reactive protein (5.6 mg/dL n < 0.5 mg/dL), a low total testosterone level (126 ng/dL n 249-836 ng/dL), an elevated  intact PTH (83.3 pg/mL n < 65 pg/mL) and a low 25-OH vitamin D (23 ng/mL, n > 30 ng/mL). Malignancy workup with 1, 25 (OH)2 vitamin D, PSA, SPEP, UPEP, CT chest/abdomen/pelvis was negative. MRI of the spine revealed multilevel compression fractures in the lower thoracic and lumbar spine, with severe hypertrophic and inflammatory changes noted in some of the lumbar spine vertebrae, likely related to tophi deposition. MRI of the left hip showed a stress fracture of the acetabulum and a CT of the chest showed multiple healing rib fractures. X-rays of hands and feet showed extensive bony destruction. Patient was started on allopurinol and colchicine, on calcium and vitamin D supplementation, and pain was adequately controlled. He will be followed in the endocrinology clinic for further treatment of his severe osteoporosis.

This patient had hypogonadism, vitamin D insufficiency with secondary hyperparathyroidism and a 6 month exposure to corticosteroids, yet at the age of 38, these would be an unlikely cause for so many non-traumatic fractures. This case illustrates the fact that in a young patient with multiple fractures, gout can be the main culprit.

 

Nothing to Disclose: OP, UG

19176 13.0000 FRI-212 A Severe Osteoporosis in a Young Patient with Tophaceous Gout 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Kajalben Buddhdev*1, Bhuvin Mukesh Buddhdev2, Rohan Mandaliya2 and Glenn Alan McGrath3
1University of Nebraska Medical Center, Omaha, NE, 2Abington Memorial Hospital, Abington, PA, 3Abington Memorial Hospital, Willow Grove, PA

 

Introduction

Humoral hypercalcemia of malignancy (HHM) associated with increased synthesis of parathyroid hormone-related peptide (PTHrP) is a relatively rare paraneoplastic disorder in ovarian malignancies. If present, HHM hardly ever involves increased circulating levels of active form of vitamin D, 1, 25-Dihydroxy Vitamin D3, except in ovarian dysgerminomas. We present an interesting case of ovarian clear cell carcinoma with resistant HHM secondary to elevated 1,25-Dihydroxy Vitamin D3.

Clinical Case

75 year female presented with weakness, nausea and vomiting for 1 day. On admission her temperature was 98.4 degree F, pulse 97/minute, blood pressure 104/61 mmHg, respiratory rate 16/minute and oxygen saturations 99% on room air. She was cachectic and very lethargic on examination.  Laboratory data was remarkable for corrected calcium level 15.2 mg/dl (n 8.5-10.7 mg/dl). Her past medical history was significant for stage IC clear cell ovarian carcinoma treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy one year ago. She refused subsequent chemotherapy at that point. 2 months ago, she presented with weakness and her calcium was elevated to 18 mg/dl, PTHrP 90 pg/ml (n 14-27 pg/ml) and intact PTH level was suppressed to 8.4 pg/ml (n 15-68 pg/ml). CA 125 increased from her baseline at 5.3 U/ml to 290 U/ml (n <35 U/ml). CT imaging showed ascites, carcinomatosis and new liver mass which was biopsied and recurrent clear cell ovarian carcinoma was diagnosed. HHM was then treated with zoledronic acid and upon discharge her serum calcium had improved to 11 mg/dl. Over the next 2 months, she had two more episodes of hypercalcemia which were treated with intravenous fluids, calcitonin and pamidronic acid. Also, chemotherapy with carboplatin and paclitaxel along with zoledronic acid was initiated. During this fourth hospitalization, further laboratory evaluation showed PTHrP level increased to 119 pg/ml. Serum 1,25-Dihydoxy Vitamin D3 levels were more than twice the upper range of normal at 157 pg/ml (n 18-72 pg/ml). Treatment was started with intravenous fluid hydration, calcitonin and prednisone was added to her regimen as hypercalcemia did not respond to bisphosphonates. Her calcium level normalized but patient refused further chemotherapy and chose hospice care.

Conclusion

Serum 1,25-Dihydroxy Vitamin D3 levels are usually low in patients with HHM. Our case demonstrates a novel mechanism of HHM likely secondary to extra renal production of 1,25-Dihydroxy Vitamin D3 as it responded to glucocorticoids. From the clinical point of view, separating HHM into Types I and II based on 1,25-Dihydroxy Vitamin D3 concentration can help understand tumor induced hypercalcemia and its management. HHM is associated with poor prognosis in cancer patients and future research to identify prognostic value of 1,25-Dihydroxy Vitamin D3 in these patients would be important.

 

Nothing to Disclose: KB, BMB, RM, GAM

20153 14.0000 FRI-213 A Paraneoplastic Hypercalcemia in Clear Cell Ovarian Carcinoma: An Unusual Mechanism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Hande Mefkure Ozkaya*, Fatma Ela Keskin, Ozlem Haliloglu, Tugba Elif Senel and Pinar Kadioglu
Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey

 

Background: Severe hypercalcemia is a life threatening condition which requires urgent medical treatment. Primary hyperparathyroidism and neoplastic diseases are frequent causes of hypercalcemia; however, some other rare causes do exist.

Clinical case: A 47-year-old woman was admitted to our clinic with the complaints of nausea, intermittent vomitting, constipation, fatigue, palpitation. She also had progressive weight loss of 10 kg. She had a history of bilateral surrenalectomy 3 years ago due to Cushing’s syndrome associated with ACTH independent macronodular adrenal hyperplasia. Her family history was significant for breast cancer in her mother, gastic cancer in her aunt and coronary artery disease in her uncle. Physical examination revealed tachycardia, presence of lid lag, warm skin, and orthostatic hypotension. The thyroid gland was enlarged and had a bruit. Pertinent laboratory values included a serum TSH value of 0.005 mIU/L  (normal, 0.4 to 4.2 ) with a fT4 value of 7.7 ng/dL (normal, 0.93 to 1.7). Thyroglobulin antibody and thyroid receptor antibody were elevated. Thyroid scan showed bilateral mildly increased, diffuse and homogenous uptake in the thyroid gland and radioactive iodine uptake was calculated to be 19% at two hours and 39 % at 24 hours. Thyroid ultrasonography revealed an enlarged and heterogenous thyroid gland.The patient’s serum calcium level was 16 mg/ dL (normal, 8.4 to 10.2), serum phosphorus  was 3.9 mg/ dL  (normal, 2,5  to 4,5 ), albumin level was in the normal range and iPTH was supressed to the level of 7.99 pg/ml (normal, 15 to 65). The 25-OH vitamin D was slightly decreased  [21 ng/dL (normal, 30 to 50)] and serum alkaline phosphatase was normal. Serum creatinine was in the normal range, serum sodium was 136 mmol/L (normal, 136 to 145) and potassium was 5.1 mmol/L (normal, 3.5 to 5.1 ). The electrocardiogram showed sinus tachycardia at a rate of 120 beat per minute and shortened QT interval. In the lights of these initial physical and laboratory investigations the diagnosis of thyrotoxicosis complicated by hypercalcemia and Addisonian crisis was suspected. As she had a family history of cancer and was in a debilitating clinical condition, a research to rule out a possible malignancy was started, but all of the investigations were negative. High dose steroid therapy together with zoledronic acid and antithyroid drugs prompted resolution of symptoms and her calcium levels were rapidly normalized. 

Conclusison: Although mild hypercalcemia is usually encountered in the context of thyrotoxicosis and adrenal failure, severe hypercalcemia may be seen especially if they occur concurrently. This case highligths the importance of recognizing these two entities as a possible cause of severe hypercalcemia.

 

Nothing to Disclose: HMO, FEK, OH, TES, PK

19880 15.0000 FRI-214 A An Unusual Cause of Life Threatening Hypercalcemia Due to the Grave's Disease and Concomitant Addisonian Crisis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Lindsay T. Fourman* and Pouneh K. Fazeli
Massachusetts General Hospital, Boston, MA

 

Background: Bone loss is an important complication of bone marrow transplantation (BMT) that warrants greater recognition given recent improvements in long-term survival.

Clinical case: A 72-year-old man with a history of B-cell chronic lymphocytic leukemia (CLL) transformed to B-cell non-Hodgkin lymphoma (NHL) status post autologous and then allogeneic BMT, graft versus host disease (GVHD), T2DM, and hypothyroidism was admitted to the hospital following a low-energy fall with fractures of the right femur and radius.  The patient was diagnosed with CLL ten years ago, which was treated with chemotherapy.  Three years prior to admission, he was found to have an aggressive B-cell NHL for which he received chemotherapy plus high-dose prednisone.  He subsequently underwent autologous followed by allogeneic BMT, each preceded by conditioning chemotherapy.  His post-transplant course was complicated by local recurrence in the pelvis that was treated with targeted radiotherapy, as well as GVHD involving the gut that was managed with a regimen including high-dose prednisone and tacrolimus.

On admission, labs were notable for mild hypocalcemia (8.1, n 8.5-10.5 mg/dL) with a normal albumin (3.9, n 3.3-5 g/dL) and phosphorus (3.3, n 2.6-4.5 mg/dL), low 25-OHD (12, n 20-100 ng/mL), and elevated PTH (66, n 10-60 pg/mL).  Morning testosterone was low (82, n 249-836 ng/dL) with normal SHBG (37, n 13-71 nmol/L) and elevated FSH (27.7, n 1-12 IU/L).  TSH was normal (1.04, n 0.4-5.0 μIU/mL), and HbA1c was elevated (8.5, n 4.3-6.4%).  The patient underwent open reduction and internal fixation of the right hip, and splinting of the right arm.  He was started on calcium and high-dose vitamin D repletion, and received a zolendronic acid infusion.  Testosterone replacement was deferred to the outpatient setting to allow for longitudinal surveillance.

Conclusions: Despite having had close follow-up, this patient developed multiple fragility fractures three years after BMT while his hematologic malignancies were in remission.  Factors predisposing BMT patients to bone loss include myeloablative chemotherapy and radiation leading to reduced osteoprogenitor number and function, post-transplant inflammatory cytokine release associated with increased bone resorption, endocrine complications of chemoradiation such as hypogonadism, poor nutritional status, and immobility.  Following allogeneic BMT, GVHD has deleterious effects on bone health through mechanisms including malabsorption and chronic use of supraphysiologic glucocorticoids.  This patient’s fracture risk may have been attenuated had he received aggressive calcium and vitamin D repletion to overcome malabsorption, screening for testicular failure after chemoradiation, and prophylactic bisphosphonates.  Our case underscores the importance of monitoring for osteoporosis risk factors and intervening early in the BMT population.

 

Nothing to Disclose: LTF, PKF

20168 16.0000 FRI-215 A Bone Health after Bone Marrow Transplantation: Unique Considerations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Walter N Le*1, Eva Y Wang1 and Charles F Sharp Jr.2
1Huntington Memorial Hospital, 2Huntington Memorial Hospital, Pasadena, CA

 

PTHrP-mediated hypercalcemia associated with benign uterine leiomyoma 

Walter N Le, Eva Y Wang, Charles F Sharp

Huntington Memorial Hospital, Internal Medicine, Pasadena, CA


Background:  PTHrP-mediated hypercalcemia in benign disease is rare, and has been estimated to account for less than 5% of cases. We present a patient with recurrent hypercalcemia that resolved with resection of uterine leiomyoma.

Clinical Case: A 37-year old female presented to the Emergency Department (ED) because of a frontal scalp abscess; however, she was found to have total serum calcium of 14.0 mg/dl (8.4-10.2) and ionized calcium of 2.04 mMol/L (1.10-1.32). The patient had experienced 4 previous admissions to 3 hospitals over the last 4 years for hypercalcemia, with typical symptoms consisting of fatigue, nausea, vomiting, mental torpor, polydipsia, and polyuria. Evaluation on each occasion revealed hypercalcemia, suppressed PTH and no elevation of 25(OH)D; on two previous occasions PTHrP levels were elevated.  She reported adhering to a “healthy diet” without exogenous supplementation, and she believed that exercising daily seemed to prevent “attacks” of hypercalcemic symptoms. Because she was a medical writer who occasionally sampled OTC products, she was, on each admission, thought to have a form of milk-alkali syndrome. Physical exam revealed no band keratopathy or lymphadenopathy; however, there was a firm lower abdominal mass.  CT abdomen/pelvis revealed a markedly enlarged heterogeneous uterus. Laboratory results on this admission were consistent with PTHrP-mediated hypercalcemia: low PTH <5.5 pg/mL (14.0-73.0), elevated PTHrP 18.0 pmol/L (0.0-3.4), normal 25(OH)D of 18 ng/mL (n 30-100), but elevated 1,25 (OH)2D of  93 pg/mL (n 15-75). On a 24 hour urine collection, calcium was 406 mg/24 (100-300). The patient also had moderate anemia. The patient was vigorously hydrated with normal saline and given one dose of calcitonin (240 IU subcutaneous). On the second hospital day, the patient underwent laparoscopic myomectomy. Pathological evaluation of the resected specimen revealed benign cellular leiomyoma. The following day, serum calcium dropped to 8.8 mg/dL.  By the 5th hospital day, total calcium, ionized calcium, and phosphorous levels had normalized, and PTH had risen into the normal range.

Conclusion: We present a case of a woman with recurrent PTHrP-mediated hypercalcemia which after successful surgical resection of benign uterine leiomyoma, normalized along with disappearance of serum PTHrP. Hypercalcemia in the setting of a uterine tumor should prompt investigation for a humoral cause.

 

Nothing to Disclose: WNL, EYW, CFS Jr.

20218 17.0000 FRI-216 A PTHrP-Mediated Hypercalcemia Associated with Benign Uterine Leiomyoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Maija Mukane*1 and Ingvars Rasa2
1Riga Stradins University, Riga East Clinical University Hospital, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia

 

X–linked hypophosphatemic rickets (XLH) is a dominant disorder with a prevalence of approximately one case per 20 000 live births. Latvia is one of the European Union countries, and there were approximately 2 million people living in 2011.Theoretically there should be diagnosed 100 cases of the XLH, but during the time from 2011 till 2014 no other cases were diagnosed or reported.

Although clinical features of the disease present soon after birth, case report shows patient with first diagnosed XLH at the age of 26 years in 2011. This young female sustained a muscle weakness in upper legs and upper arms, pain in left hip, left knee and back. Above–mentioned symptoms patient had from 2006, but the disease’s breakdown was in March, 2011 when she attended Hospital in the first time. There was no approved related congenital pathology in family history, however patient’s mother probably had 1.25(OH)2D vitamin resistance.

In–hospital laboratory findings were the following – serum calcium 2.24 mmol/L (reference range 2.10–2.60 mmol/L), parathyroid hormone 25.0 pg/mL (reference range 12.0–72.0 pg/mL) and serum phosphorus level was 0.51 mmol/L (reference range 0.80–1.60 mmol/L). CT and MRI scans of pelvic bones, knee and sacroiliac joints and whole body bone scintigraphy scan with technetium99m were made and multiple fractures were found (consolidated fractures of 7th and 8th ribs in the right side, 8thrib in the left side, multiple sacrum fractures and left hip fracture with pseudarthrosis). After hospitalization additional laboratory analyses showed low 25(OH)D level – 14.0 ng/mL (reference range 20.00–55.0 ng/mL), sufficient 1.25(OH)2D level – 51.20 pg/mL (reference range 19.60–54.30 pg/mL), high alkaline phosphatase level – 172.0 U/L (reference range <117.0 U/L) and high alkaline phosphatase bone fraction level – 51.2 μg/L (reference range 3.0–19.0 μg/L). Bone biopsy from crista iliacashowed thin cortical bone, trabecular bone atrophy and bone marrow fibrosis. Considering laboratory and instrumental findings XLH were suspected, but there was no possibility to make genetic analysis of the disease in Latvia.

Prescribed treatment was sodium phosphate 500 mg four times daily and 5000 international units of cholecalciferol daily per orally. In 2011 left hip replacement was made.

Till now patient’s follow–up continues, last laboratory findings in 2014 were the following – serum calcium 2.33 mmol/L (normal), phosphorus level 1.37 mmol/L (normal), 25(OH)D vitamin 49.9 ng/mL (normal), alkaline phosphatase 122.0 mmol/L (above reference range). In 2014 patient had first pregnancy and delivered healthy child.

Although not always there is a possibility to prove the diagnosis using genetic analysis, considering clinical, laboratory and instrumental findings it is possible to support patient and improve life quality.

 

Nothing to Disclose: MM, IR

20105 18.0000 FRI-217 A X–Linked Hypophosphatemic Rickets–Case Report from Latvia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Kaniksha Desai* and Ana Maria Chindris
Mayo Clinic Florida, Jacksonville, FL

 

Background: Hypercalcemia is often related to hyperparathyroidism, malignancy, and medications.  In up to 10% of cases, rarer causes of hypercalcemia need to be evaluated, including granulomatous diseases.  Silicone was first presented in 1984 as a rare cause of hypercalcemia and its mechanism of action is thought to be secondary to the formation of granulomas and the release of 1, 25 Vitamin D (1). Over the years, few case reports of silicone induced hypercalcemia due to cosmetic surgery have been published (2, 3). Here we present a case of symptomatic hypercalcemia from granulomas caused directly by silicone injected in the gluteal region for a buttocks augmentation cosmetic surgery.

Case: A 57 year old female with a history of Hepatitis C presented to our clinic with parathyroid (PTH) independent hypercalcemia of unknown origin that was refractory to treatment with bisphosphonates and cinacalcet. She initially presented with worsening body aches which resulted in a hospitalization for acute hypercalcemia with a calcium level of 18 mg/dl (normal < 10.1 mg/dl). She was treated with intravenous fluids and pamidronate and recommended for outpatient follow-up. Over the next few months she required 3 additional hospitalizations for acute hypercalcemia complicated by acute renal insufficiency. Laboratory workup included an elevated calcium level of 12.5 mg/dl with a suppressed PTH level and an elevated 1, 25 Vitamin D level. She was evaluated by multiple subspecialists including infectious disease, pulmonary, and oncology as there was concern that she may have a malignancy or granulomatous disease as the cause of her hypercalcemia.  She had a PET/CT scan for imaging and was noted to have the presence of multiple granulomas in the gluteal region, with otherwise normal imaging.  Upon review of her past medical history she was noted to have cosmetic buttocks augmentation surgery with multiple injections of silicone over the years. A CT guided biopsy of the granulomas in her buttocks was completed and the pathology was consistent with silicone induced granulomas. Due to the multiple injection sites, surgical resection could not be performed. Treatment consisted initially of prednisone 20mg orally daily, with a reduction but not normalization of the calcium levels.  The patient continued to be symptomatic so her prednisone dose was increased to 40mg daily. This resulted in the normalization of her calcium and 1, 25 Vitamin D levels, as well as the resolution of her symptoms. The prednisone was then slowly tapered over 4 months with continued stabilization of her calcium level and control of her symptoms.

Conclusions: Hypercalcemia can be caused by rare conditions including granulomatous disease of various etiologies.  A thorough past medical history including a history of cosmetic procedures should be obtained and a wide differential diagnosis should be considered when working up hypercalcemia of unknown origin.

 

Nothing to Disclose: KD, AMC

20741 19.0000 FRI-218 A A Case of Hypercalcemia from Elective Cosmetic Surgery 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Saranya Biswas*1, Katie L O'Sullivan2, Milad Abusag2, Anila Bindal2 and Louis H. Philipson2
1Mercy Hospital And Medical Center, Chicago, IL, 2University of Chicago, Chicago, IL

 

Background:While primary hyperparathyroidism (PHPT)-related hypercalcemia during pregnancy is a rare condition with less than 200 cases reported in the English literature, it is associated with maternal complications in 2/3 of cases and high risk fetal complications including intrauterine growth restriction and fetal demise. Parathyroidectomy remains the main treatment of PHPT during pregnancy, preferably performed during the second trimester. The optimal approach to treatment of PHPT during the first trimester remains uncertain.

Clinical Case: A31-year-old pregnant female with history of diabetes mellitus, hypertension and depression presented with progressive weakness, fatigue, polyuria and abdominal pain in the setting of untreated hypercalcemia, first noted 4 months prior to presentation. At 8 weeks gestation she was referred for further evaluation of severe hypercalcemia during pregnancy. Serum calcium was elevated to 13.7 mg/dL (n <10.2 mg/dL), PTH was elevated(284 pg/mL, n < 75 pg/mL), phosphate was low (2.3 mg/dL, n < 4.4 mg/dL), and Vitamin D 25-OH was low (11 ng/mL, n > 30 ng/mL). Ultrasound of the neck revealed a large, heterogeneous nodule measuring 2.8 x 1.7 x 2.6 cm posterior to the thyroid. Renal ultrasound revealed multiple bilateral kidney stones.

The patient was aggressively hydrated with intravenous normal saline with limited success. Medical therapy using bisphosphonates and calcimimetics was considered but these are pregnancy class C medications or lower and their use has not been well described during the first trimester. On the sixth day of hospitalization, she underwent surgical exploration of the neck and a large left superior parathyroid adenoma was removed. Intra-operative PTH level fell from a baseline of 430 pg/mL to normal levels (26 pg/mL) 5 minutes after resection. She was started on calcium and Vitamin D supplementation. Transvaginal ultrasound performed on post-operative day 1 revealed normal fetal heart tones. One week after surgery,she reported less fatigue and improved mood. Three weeks after surgery, her tests revealed normal calcium (8.9 mg/dL) and normal PTH (65 pg/mL). Prenatal ultrasound revealed normal heart tones.

Conclusion: We describe parathyroidectomy performed in the first trimester as successful treatment of a pregnant woman with uncontrolled hypercalcemia secondary to PHPT.This case emphasizes the importance of individualization of treatment of PHPT during pregnancy. Furthermore, it provides support for using surgery with positive outcomes as a treatment option for PHPT in the first trimester, which has been rarely reported.

 

Nothing to Disclose: SB, KLO, MA, AB, LHP

21090 20.0000 FRI-219 A Primary Hyperparathyroidism in Pregnancy Treated with Parathyroidectomy in the First Trimester 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Diane U Elegino-Steffens*1, George L Coppit2, Vinh Quang Mai1, Babette Carlson Glister3, Patrick W Clyde4 and Mohamed Shakir1
1Walter Reed National Military Medical Center, Bethesda, MD, 2Walter Reed National Military Medical Center, 3Walter Reed National Military Med, Silver Spring, MD, 4Walter Reed Bethesda National Mi, Silver Spring, MD

 

Introduction

Parathyroid cysts are rare clinical entities that often present as non-functional neck masses, but have been uncommonly reported as the etiology for primary hyperparathyroidism. It is invariably associated with aspiration of clear fluid from the lesion, so fine needle aspiration is a useful means to diagnose these cysts. However, these lesions may develop areas of hemorrhage that can be challenging to diagnose preoperatively and might be misinterpreted as a parathyroid carcinoma. Here we present a case of a functioning hemorrhagic parathyroid cyst.

Case Report

Patient is a 58yo male who presented with exacerbation of his underlying anxiety disorder and depression. His medical history is pertinent for nephrolithiasis and hypertension treated with hydrochlorothiazide. Corrected serum calcium was found to be12.1 mg/dl with an inappropriately elevated PTH level of 237pg/ml. Ionized calcium was elevated at 6.1 mg/dl, 25-Vitamin D level low at 16.8 ng/mL, and 24hr urine calcium high at 528 mg. A thyroid ultrasound showed a normal appearing thyroid gland and a 4.7 x 3.8 x 3.5 cm anechoic cystic structure posterior to the inferior left thyroid with few mural projections that was suggestive of parathyroid cyst. Magnetic resonance imaging with contrast was obtained for further characterization of this lesion and this demonstrated the oval mass along the inferior aspect of the left thyroid lobe with hyperintense T1 and T2 signaling, favoring a colloid cyst. Further imaging with a Sestamibi scan showed displacement of the left thyroid lobe anteriorly due to the cystic mass with no accumulation of radiotracer activity within or in the rim. Fine needle aspiration of the cyst was grossly hemorrhagic and the specimen did not contain any groups of follicular cells or colloid. A  PTH washout of this aspirate measured >5000 pg/mL. Patient underwent excision of the left parathyroid cyst. Intraoperative PTH dropped from a baseline of 258 to 57 pg/mL.  Post-operative calcium levels normalized and tissue pathology confirmed overall features of a parathyroid adenoma with marked cystic change and degeneration, but no features of malignancy.

Discussion

Up to 10% of parathyroid cysts are functionally active and may be clinically associated with primary hyperparathyroidism that occasionally present with calcium levels exceeding 13 mg/dL and hypercalcemic crisis. In addition, these parathyroid adenomas may develop areas of hemorrhage and cystic degeneration that can be misdiagnosed as malignant lesions preoperatively. This case illustrates the rare presentation of a parathyroid cyst with hyperparathyroidism and hemorrhage, mimicking a parathyroid carcinoma.

 

Nothing to Disclose: DUE, GLC, VQM, BCG, PWC, MS

21110 21.0000 FRI-220 A A Rare Case of a Functioning Hemorrhagic Parathyroid Cyst 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Uzma Mohammad Siddiqui*, Anupam Kotwal and Shirin Haddady
University of Massachusetts Medical School, Worcester, MA

 

Introduction:Primary hyperparathyroidism is a common endocrine disorder. For patients who need surgical intervention, minimally invasive surgery has replaced the traditional four gland exploration.  Preoperative parathyroid localization can be achieved by different techniques. 99mTc-sestamibi Single-photon emission computed tomography (SPECT) CT scans have been used widely with a false negative rate of 12 to 25%. More recently, ultrasound has gained popularity considering that it is inexpensive, noninvasive and reproducible in the operating room. Here we present a case of a patient with primary hyperparathyroidism with double adenomas on left side. Ultrasound successfully localized both adenomas before surgery, while only one was detected by the 99mTc-sestamibi SPECT CT.

Clinical case:A 55 year old female with no significant past medical history was referred to Endocrinology Clinic for evaluation of primary hyperparathyroidism. Earlier she had presented to her primary care physician because, like her brother, she had complaints of fatigue and constipation. Her brother had been diagnosed with hypercalcemia but had had no further workup because of lack of insurance.

She was found to be a candidate for parathyroid surgery as dual energy X-ray absorptiometry (DEXA) scan showed severe osteoporosis. Considering family history of hypercalcemia, evaluation for Multiple Endocrine Neoplasia (MEN) type I and II was offered, but patient refused genetic testing; though biochemical testing for medullary thyroid carcinoma and pheochromocytoma was negative. A 99mTc-sestamibi SPECT CT was ordered and it reported a possible parathyroid adenoma in left inferior position. Then, an ultrasound was performed to evaluate thyroid gland for nodules before surgery and that revealed a second possible parathyroid adenoma in the superior position on left side. Surgery confirmed the presence of double adenomas and serum calcium and parathyroid hormone levels returned to normal.

Conclusion: This case illustrates the value of ultrasound in pre-surgical evaluation of primary hyperparathyroidism, especially in experienced hands. As it has been reported before, parathyroid adenomas located in superior position may be missed by 99 mTC-sestamibi scans. In addition, special attention should be given to patients who have a family history of hypercalcemia. Double parathyroid adenomas happen in 2 to 5% cases of primary hyperparathyroidism but may be seen more frequently in familial forms of primary hyperparathyroidism.

 

Nothing to Disclose: UMS, AK, SH

20224 22.0000 FRI-221 A Primary Hyperparathyroidism: The Value of Ultrasound to Localize Double Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Sangeeta Chandramahanti*1 and Rodhan Abass Khthir2
1Marshall University - Joan C Edwards School of medicine, Huntington, WV, 2Marshall University School of Medicine

 

Recurrent Parathyroid Crisis from Primary hyperparathyroidism.

Sangeeta Chandramahanti MD, Rodhan Khthir MD

Department of Medicine, Section of Endocrinology, Joan C. Edwards School of Medicine, Huntington, WV.

Introduction:

Parathyroid Crisis is a rare and serious complication of primary hyperparathyroidism in which patients develop severe hypercalcemia with signs and symptoms of multiple organ dysfunction. Medical optimization is an important initial step providing an effective bridge to surgical treatment.

 Case Presentation:

45 y/o Caucasian female presented to ER for evaluation of fatigue, polyuria, polydipsia and mental status changes.  She denied headache, dizziness or focal neurological signs. Her Past medical history was notable for hypothyroidism on levothyroxine replacement, Type 2 Diabetes controlled on Glipizide and Metformin, Hypertension, CVA with residual left sided weakness and Multiple Sclerosis. She denied prior problems with calcium, kidney stones or fractures.

Physical Examination :

She was disoriented and had residual left sided weakness from prior CVA on exam.

Laboratory findings :

Upon evaluation was noted to have calcium 17.1mg/dl, low normal magnesium and phosphorus with normal kidney function. Vitamin D is 27.4ng/ml with an intact PTH 657pg/ml and TSH 70mu/l.

Imaging studies :

Neck ultrasound was noted to have a hypo echoic mass 3.5x3.1x4.5 cm posterior to left thyroid lobe, without thyroid abnormalities or lymphadenopathy. Sestamibi scan revealed increased uptake in left parathyroid lobe.

Management :

Her calcium has normalized with IV hydration and calcitonin and was discharged home.  She re-presented in 3 weeks with calcium level 17.4mg/dl. Her calcium levels have responded to IV hydration, calcitonin and cinacalcet; however use of cinacalcet was limited after her discharge as she could not afford the medicine. Surgery was delayed for few days on account of uncontrolled hypothyroidism. She finally underwent successful parathyroidectomy. Final pathology revealed 4.4 cm parathyroid adenoma measuring 15 gm. Her postoperative course is complicated by mild hypocalcaemia and left lower extremity DVT. She has stabilized calcium levels on calcium, Vitamin D and calcitriol supplementation.

Conclusion:

  1. Calcium is usually slightly elevated in primary hyperparathyroidism, and extreme elevations with 5-10 fold elevations in PTH, suggestive of parathyroid crisis is an unusual presentation of primary hyperparathyroidism.
  2. Emergent parathyroidectomy performed within 72 hours of presentation is the recommended management.
  3. Cinacalcet reduces serum calcium concentrations in patients with intractable primary hyperparathyroidism and can be either used in patients with persistent primary hyperparathyroidism after parathyroidectomy or with contraindications to parathyroidectomy.

 

Nothing to Disclose: SC, RAK

20761 23.0000 FRI-222 A Recurrent Parathyroid Crisis from Primary Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Heather Leigh Hofflich*1 and Taylor Coe2
1Univ of California, San Diego, La Jolla, CA, 2University of California, San Diego, San Diego, CA

 

Background:

Teriparatide, a recombinant PTH, is the only osteoporosis therapy that has osteoanabolic effects.  Teriparatide has been FDA approved since 2002 for patients with severe osteoporosis and glucocorticoid induced osteoporosis. Transient hypercalcemia was noted in clinical trials (up to 3% persistently) but was thought to be a rare side effect.  The FDA does not provide any specific guidelines about laboratory testing while on teriparatide therapy. We portray a case that exemplifies the need to perform routine lab testing in patients while on teriparatide therapy.

 Clinical Case Report:

A 69-year-old female was referred to our clinic for management of her osteoporosis. Patient sustained a right hip fracture in 2011 after falling from bed. She denied prior fractures or any family history of osteoporosis.  In addition, she denied history of rheumatoid arthritis, steroid use, thyroid disease, or eating disorders. Her menopause occured at age 51.

Patient’s past medical and surgical history were significant for DMII, HTN, paroxysmal atrial fibrillation, aortic stenosis with aortic valve replacement, and right hip replacement.

The patient was started on teriparatide therapy in June 2013 by an outside physician.  She presented to our institution after one year of teriparatide treatment.  6/2014 DEXA scan was obtained and showed:  left femur neck: T-score of -3.1 and Z-score of -1.5. Right distal radius: T-score of -2.2, Z-score of -0.4

Vitals were normal. BMI was 25. No abnormal physical exam findings were noted at our visit in 6/2014. Lab abnormalities: PTH of 77 pg/mL (15-65 pg/mL) and elevated serum calcium of 10.4 mg/dL (8.8-10.2 mg/dL). Repeat laboratory analysis showed similar elevations.  Teriparatide was discontinued at this time. Patient underwent sestamibi parathyroid imaging which showed persistent focal activity in the left inferior thyroid bed, consistent with a parathyroid adenoma.

Conclusions:

There are no epidemiologic or evidence-based studies assessing the frequency of primary hyperparathyroidism while on teriparatide therapy.  There are a limited number of studies in Canada and other countries that recommend the use of routine lab screening prior to teriparatide therapy and for the duration of therapy at specific intervals. 

 It is well known that teriparatide therapy can cause a transient elevation of serum calcium after dosing. However, to our knowledge, this is the second reported case of primary hyperparathyroidism while on teripiratide therapy.  This case highlights the need to routinely monitor serum calcium, and PTH (if calcium is elevated) while on teriparatide therapy.  We recommend that physicians check PTH, vitamin-D, phosphorus, creatinine, and calcium every 3-6 months while their patients are on teriparatide therapy to ensure that there are no contraindications, such as new onset primary hyperparathyroidism.

 

Nothing to Disclose: HLH, TC

19494 24.0000 FRI-223 A Teriparatide Use and Subsequent Development of Primary Hyperparathyroidism: The Importance of Monitoring Laboratory Data While on Teriparatide Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 200-223 5960 1:00:00 PM Bone Case Reports I Poster


Hanling Chang*1, Dimitry Petrenko1, Anne L. Schafer2 and Galateia Kazakia3
1San Francisco Veterans Affairs Medical Center, San Francisco, CA, 2Univ of California-San Francisco/San Francisco VA Med Ctr, San Francisco, CA, 3University of California, San Francisco, CA

 

With obesity a major health issue around the globe, methods of rapid weight loss, like bariatric surgery, are becoming increasingly popular for severely obese individuals. There is increasing interest in understanding how obesity and marked weight loss affect skeletal health, including bone mineral density (BMD). High-resolution peripheral quantitative computed tomography (HR-pQCT) is a powerful tool for the assessment of appendicular bone density, microstructure, and estimated strength, but its accuracy in the settings of obesity and weight loss is unknown. This study tested the accuracy of BMD measurements using a model of changing soft tissue mass.

Scans were taken of an idealized hydroxyapatite tibial phantom (1) with a trabecular insert with a density of 180 mg HA/cm3 and with a cortical shell of 1.5 mm thickness and a cortical density of 945.2 mg HA/cm3. To test the effect that various amounts of soft tissue have on HR-pQCT quantification of BMD, the phantom was wrapped with a purchased gel ice pack and sequentially thicker layers of fat. The layers of fat were constructed using an 8” (200 mm) Impulse Manual Bag Sealer, poly plastic bags, and Crisco vegetable shortening. Four models were constructed. Model 1 was the phantom wrapped with the gel pack, which was of similar density to human muscle (18 mg HA/cm3) and approximately 2 cm thick, and a fat layer (-50 mg HA/cm3) approximately 1 cm thick around the gel pack.  Model 2 included a fat layer approximately 1.5 cm thick around the gel pack, with the girth of this model remaining within the field of view of the scan. Model 3 added a fat layer approximately 2 cm thick around the gel pack, and extended outside the field of view. Model 4 added both the 1.5 and 2 cm thick fat layers around the gel pack. 

Model 1 yielded a measured cortical BMD of 930.9 mg HA/cm3. Cortical BMD decreased with successive soft tissue layers, with a total decrease of 4.1% (from 930.9 to 892.3 mg HA/cm3) between Model 1 and Model 4. Model 1 yielded a measured trabecular BMD of 174.0 mg HA/cm3. Trabecular BMD decreased by a total of 2.3% (from 174.0 to 170.0 mg HA/ccm) between model 1 and model 4, with the most substantial decline between Models 2 and 3.

Our findings indicate that successive amounts of soft tissue surrounding bone artificially decrease the apparent BMD assessed by HR-pQCT. This misrepresentation of BMD in the larger models results in an apparent increase in BMD when the apparent fat mass is reduced. An implication of these findings is that BMD could appear to increase in the setting of extensive weight loss, even if the true BMD does not change, or alternately, a measured decline in BMD by HR-pQCT could underestimate an actual decline in BMD.

 

Nothing to Disclose: HC, DP, ALS, GK

20229 1.0000 FRI-248 A Simulated Increases in Fat Mass Decrease Apparent Bone Mineral Density Measured By High-Resolution Peripheral Quantitative Computed Tomography (HR-pQCT) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Sol Epstein*1, Mary Ann Walter2, Margaret E. Hurley3 and Henry G Bone4
1Mt. Sinai School of Medicine, New York, NY, 2Mission Pharmacal Company, San Antonio, TX, 3Hurley Consulting Associates Ltd., Summit, NJ, 4Michigan Bone and Mineral Clinic, Detroit, MI

 

Approximately 20-30% of patients treated for osteoporosis require thyroid hormone for hypothyroidism. Alendronate (ALN) is a bisphosphonate that is extensively used for first-line treatment of osteoporosis. Binosto® is an unique widely approved ALN sodium formulation. The 70-mg buffered effervescent tablet is given once weekly in the morning following after an overnight fast, at least 30 minutes before the first food, beverage, or medication of the day. Levothyroxine (LT4) is administered after an overnight fast, 1/2 to 1 hr before breakfast and at least 4 hr apart from drugs known to interfere with its absorption. Separate administration of these drugs may be problematic for patients treated with both.   A randomized, single-center, open-label, 3-way crossover study in healthy subjects was conducted to evaluate potential pharmacokinetic interaction between ALN (Binosto, Mission) and LT4 (Synthroid, AbbVie), and to provide specific dosing instructions for their co‑administration.

A total of 30 subjects were randomized and received study drugs following a 12‑hour overnight fast. Each subject was dosed 3 times, separated by 35-day washout periods.  They received 1 dose of Binosto (1 × 70 mg), or 1 dose of Synthroid® (2 × 300 μg), or both 1 dose of Synthroid (2 × 300 μg) and 1 dose of Binosto (1 × 70 mg) in a randomized, crossover design, in compliance with FDA guidance. Blood samples were collected at pre-specified time points and analyzed using a validated LC-MS/MS method to determine plasma ALN and an electrochemiluminescence immunoassay for serum LT4 concentrations. Non‑compartmental pharmacokinetic analysis was performed. Analysis of variance was performed for log-transformed pharmacokinetic parameters. Geometric mean ratios and 90% CIs were used to assess pharmacokinetic interaction.

Median Tmax: for alendronate was 0.75 hours. The rate and extent of ALN absorption were similar for Binosto alone or with LT4. Geometric mean ratios (Binosto with levothyroxine/Binosto alone) were 0.927 (90% CI: 0.795-1.081) for AUC0-t and 0.912 (90% CI: 0.773-1.077) for Cmax, demonstrating that LT4 does not affect the pharmacokinetics of ALN. The pharmacokinetics of LT4 after co‑administration with Binosto were equivalent to LT4 alone. Geometric mean ratios (LT4 with Binosto/LT4 alone) were 1.049 (90% CI: 0.983-1.119) for AUC0-t and 1.075 (90% CI: 1.006-1.148) for Cmax, demonstrating that LT4 is bioequivalent between the two treatments. Co-administration of Binosto and LT4 was well tolerated in healthy subjects.

Conclusion: there is no significant pharmacokinetic interference between the Binosto formulation of ALN and LT4.  Levothyroxine can be co-administered with Binosto in the fasted state, which should increase compliance and confidence in patients being treated for both hypothyroidism and osteoporosis.

 

Disclosure: MAW: Protocol design and planning, Mission Pharmacal Company. MEH: Clinical Researcher, Mission Pharmacal Company. Nothing to Disclose: SE, HGB

20560 2.0000 FRI-249 A Successful Co-Administration of Levothyroxine and Binosto® (Alendronate Sodium) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Benjamin Zev Leder*1, Gary Hattersley2, Alan G Harris3, Kathleen Banks4 and Didier Hans5
1Harvard Medical School, Boston, MA, 2Radius Health, Inc, Waltham, MA, 3Radius Health, Inc., 4Radius Health, Inc., Waltham, MA, 5Lausanne University Hospital, Lausanne, Switzerland

 

Background:  Osteoporotic fracture is related to degradation of both bone mass (BMD) and alteration of bone microarchitecture. Abaloparatide-SC (ABL) is a novel synthetic peptide analog of parathyroid hormone-related protein (PTHrP) that is being developed as a potential anabolic agent in the treatment of osteoporosis and has been shown to significantly increase BMD at the hip and spine in postmenopausal women. The effects of ABL on bone quality or trabecular microarchitecture are unknown. Trabecular Bone Score (TBS) is a novel grey-scale textural analysis applied to spine DXA images that has been shown to be correlated with trabecular bone microarchitecture and bone strength. TBS is a predictor as well of fragility fractures of the spine and hip in postmenopausal women independently of BMD and other major clinical risk factors. As such it captures additional patients at risk of fracture missed by BMD alone1 and together with BMD reflects more closely bone strength

 Methods:  To assess the effects of ABL on trabecular microarchitecture as indirectly assessed by TBS, we retrospectively calculated the TBS (TBS Calculator v2.2, Medimaps group, Plan-les-Ouates, Geneva, Switzerland) in a blinded fashion at 0, 12, and 24-weeks in 222 postmenopausal osteoporotic women (age 55-85) who were randomized to receive 24-weeks of daily subcutaneous injections of placebo, ABL 20-µg, ABL 40-µg. ABL 80-µg, or teriparatide (TPTD) 20-µg. Between groups differences in the mean percent TBS changes were assessed by unpaired t-test.

 Results:  Out of 221 women treated, 77 women could not be assessed as the DXA scanner was not compatible with TBS software. Subjects (N= 145) in the 5 treatment groups were similar in regard to demographic and clinical characteristics, including baseline BMD measurements and levels of biochemical markers of bone turnover. After 12-weeks, TBS increased significantly by +1.2%, +1.7%, +1.9% and +1.5% in the ABL 20-µg, ABL 40-µg, ABL 80-µg and TPTD groups, respectively and decreased by -0.2% in the placebo group (PBO). The 12-week mean percent increases in TBS in the ABL 40-µg and ABL 80-µg treatment groups were significantly greater than in the placebo group (both p= 0.05). After 24-weeks, TBS increased by +2.4%, +2.7%, +3.6% and +2.6% in the ABL 20-µg, ABL 40-µg, ABL 80-µg and TPTD groups, and decreased by -1.1% in the placebo group (PBO). The 24-week increases in TBS were significantly greater in all treatment groups compared to the change in the placebo group (p<0.005).

Summary:  24-weeks of treatment with ABL significantly improves trabecular microarchitecture as indirectly assessed by TBS. Combined with the previously reported effects of ABL on BMD, these results support the further investigation of abaloparatide as an anabolic therapy in postmenopausal osteoporosis.

 

Disclosure: BZL: Consultant, Amgen, Consultant, Lilly USA, LLC, Consultant, Merck & Co., Consultant, Radius. GH: Employee, Nuvios, Inc., Employee, Nuvios, Inc.. AGH: Employee, Radius Health, Inc., Employee, Radius Health, Inc.. KB: Employee, Radius Health, Inc., Employee, Radius Health, Inc.. DH: Co-owner, TBS Patent, Employee, Medimaps Group.

21988 3.0000 FRI-250 A Twenty-Four Weeks of Treatment with Abaloparatide-SC Significantly Improves Trabecular Microarchitecture As Indirectly Assessed By Trabecular Bone Score (TBS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Ozgen Celer*1, Aysen Akalin2 and Cigdem Oztunali3
1Amasya Sabuncuoglu Serefeddin Training and Research Hospital, 2Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey, 3Eskisehir Osmangazi University, Eskisehir, Turkey

 

Context: Teriparatide, an anabolic agent used in the treatment of postmenopausal osteoporosis, can cause symptoms similar to primary hyperparathyroidism.

Objective: Our objective was to evaluate the effects of teriparatide on endothelial functions, insulin metabolism and inflammation markers.

Design and Setting: We conducted a 6-month prospective study in a single center.

Participants: Participants included 23 postmenopausal women over 65 years old with a lumbar spine or femoral neck T score of  -4.0 or lower and having at least two compression fractures in thoracic or lumbar spine.

Intervention: Low dose intermittent teriparatide (20 μg/day) was supplemented with calcium carbonate (1000 mg elemental calcium) and 880 IU cholecalciferol.

Main Outcome Measures: We determined biochemical parameters associated with bone turnover, glucose metabolism and inflammation. We also measured carotid intima-media thickness, brachial artery intima-media thickness, flow mediated dilation (FMD) and nitroglycerine induced dilation (NID).

Results: After 6 months of teriparatide treatment, glucose, HDL cholesterol, HOMA-IR, alkaline phosphatase, fibrinogen and homocysteine levels increased significantly (p<0.05 for all). 6th month HOMA-IR and 6th month C-peptide (r=0.863, p<0.001), baseline alkaline phosphatase and 3 month osteocalcin (r=0.550, p=0.007) and baseline homocysteine and 6thmonth creatinine levels (r=0.678, p<0.001) were significantly correlated. The percent change in brachial artery diameter before and after FMD and NID were statistically significant (p<0.01 for both). Osteocalcin and deoxypyridilonine levels significantly increased during the first 3 months of teriparatide administration (p<0.001 for both).

Conclusions: Intermittent teriparatide treatment, like hyperparathyroidism, negatively affects glucose metabolism and causes endothelial dysfunction and inflammation which can lead to atherosclerosis.

 

Nothing to Disclose: OC, AA, CO

18523 4.0000 FRI-251 A Effect of Teriparatide Treatment on Endothelial Function, Insulin Metabolism and Inflammation Markers in Patients with Postmenopausal Osteoporosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


SL Silverman*1, E Siris2, DL Kendler3, D Belazi4, JP Brown5, DT Gold6, EM Lewiecki7, A Papaioannou8, C Simonelli9, G Quinn10, A Balasubramanian11, FM Mirza11, B Stolshek11 and C Recknor12
1Cedars-Sinai Bone Center for Excellence, UCLA School of Medicine, and OMC Clinical Research Center, Los Angeles, CA, 2Columbia University Medical Center, New York, NY, 3University of British Columbia, Vancouver, BC, Canada, 4AlchemiPharma LLC, Wayne, PA, 5Laval University and CHU de Québec Research Centre, Quebec City, QC, Canada, 6Duke University Medical Center, Durham, NC, 7New Mexico Clinical Research & Osteoporosis Center and University of New Mexico School of Medicine, Albuquerque, NM, 8McMaster University, Hamilton, ON, Canada, 9Health East Osteoporosis Care, Woodbury, MN, 10Sarnia Statistics Ltd, Bishop, United Kingdom, 11Amgen Inc., Thousand Oaks, CA, 12United Osteoporosis Centers, Gainesville, GA

 

Background: Persistence with osteoporosis therapy is essential to achieve optimal fracture risk reduction. Persistence with denosumab in women with low bone mineral density has been investigated in a controlled clinical trial, but not in the community setting over the long term. A 2-year prospective, single-arm, observational study was undertaken to evaluate persistence with denosumab in routine clinical practice in the United States (US) and Canada (CAN). For the interim results at 1 year, 82% of patients were persistent with denosumab (1). Here we report the 2-year results.

Methods: Women were enrolled within 4 weeks after the first subcutaneous injection of denosumab, recommended for administration every 6 months for treatment of osteoporosis. No clinical procedures or changes to routine patient management were required. We assessed persistence with denosumab at 2 years (defined as receipt of ≥4 injections with no more than 6 months + 8 weeks between injections; with sensitivity analyses assessing 6 months + 4 or + 12 weeks between injections); number of injections; multivariate analysis of patient and physician attributes of persistence; and occurrence of serious adverse events (SAEs). Persistence rates were based on total patient count at enrollment.

Results: A total of 935 patients (US N=632; CAN N=303) were enrolled by 80 physicians (US n=54; CAN n=26). Mean (SD) age at baseline was 72 (10) years in the US and 69 (9) years in CAN; 42% of US patients and 28% of CAN patients were aged ≥75 years. Patients were followed for a median (Q1, Q3) of 24 (21, 25) months (US 25 [19, 26] months; CAN 24 [23, 25] months). At 24 months, 58% of patients were persistent with denosumab (US 50%; CAN 75%). In sensitivity analyses, persistence was lower with a shorter time period between injections (6 months + 4 weeks: US 37%; CAN 66%) and slightly higher with a longer time period (6 months + 12 weeks: US 55%; CAN 78%). Median number of denosumab injections was 4 in the US and 5 in CAN. Multivariate analysis identified the following determinants of persistence for both the US and CAN: geographic region, ethnicity, type of center, patient support program, and insurance prior authorization. SAEs were reported in 122 patients (13%); the most frequently reported was pneumonia (n=10 [1%]); no SAEs of osteonecrosis of the jaw, atypical femoral fracture, fracture healing complications, hypocalcemia, eczema, or SAEs potentially associated with hypersensitivity were reported. Clinical fractures were reported by 46 patients (5%); the most frequent were foot (n=14) and spine (n=10) fractures.

Conclusion: In this study of routine clinical practice, 58% of patients for whom denosumab was prescribed persisted on therapy at 2 years. Differences in persistence were observed between the US and CAN and some common determinants that potentially influence persistency, including the use of support programs, could be used to improve persistency.

 

Disclosure: SS: Consultant, Amgen, Consultant, Genentech, Inc., Consultant, Lilly USA, LLC, Consultant, Novartis Pharmaceuticals, Consultant, Pfizer, Inc., Investigator, Amgen, Investigator, Lilly USA, LLC, Investigator, Medtronic, Investigator, Pfizer, Inc., Speaker Bureau Member, Amgen, Speaker Bureau Member, Lilly USA, LLC, Speaker Bureau Member, Pfizer, Inc.. ES: Consultant, Amgen, Consultant, Lilly USA, LLC, Consultant, Merck & Co., Consultant, Novartis Pharmaceuticals, Consultant, Pfizer, Inc., Consultant, AgNovos, Speaker Bureau Member, Amgen, Speaker Bureau Member, Lilly USA, LLC. DK: Consultant, Amgen, Consultant, Eli Lilly & Company, Consultant, Pfizer, Inc., Principal Investigator, GlaxoSmithKline, Consultant, Merck & Co., Principal Investigator, Astalis, Principal Investigator, Astra Zeneca, Principal Investigator, Amgen, Principal Investigator, Eli Lilly & Company, Principal Investigator, Pfizer, Inc., Speaker, GlaxoSmithKline, Speaker, Amgen, Speaker, Eli Lilly & Company. JB: Advisory Group Member, Amgen, Advisory Group Member, Eli Lilly & Company, Ad Hoc Consultant, Radius, Clinical Researcher, Amgen, Clinical Researcher, Eli Lilly & Company. DG: Consultant, Eli Lilly & Company, Consultant, Amgen. EL: Advisory Group Member, Amgen, Advisory Group Member, Lilly USA, LLC, Advisory Group Member, Merck & Co., Advisory Group Member, Radius Health, Advisory Group Member, AgNovos, Research Funding, Amgen, Research Funding, Lilly USA, LLC, Research Funding, Merck & Co.. AP: Advisory Group Member, Amgen, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Merck Frosst, Clinical Researcher, Amgen, Clinical Researcher, Eli Lilly & Company, Clinical Researcher, Merck Frosst. CS: Speaker, Amgen, Advisory Group Member, Amgen. GQ: Independent Contractor (including contracted research), Amgen. AB: Employee, Amgen, Employee, Amgen, Employee, Amgen. FM: Employee, Amgen, Employee, Amgen, Employee, Amgen. BS: Employee, Amgen, Employee, Amgen, Employee, Amgen. Nothing to Disclose: DB, CR

18576 5.0000 FRI-252 A Persistence with Denosumab (Prolia®) in Postmenopausal Women with Osteoporosis: 24-Month Results from a Prospective Observational Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Dinesh Edem1, Shruti Bhandari2 and Esther Irina Krug*3
1Sinai Hospital of Baltimore, Baltimore, MD, 2Sinai Hospital of Baltimore, 3Johns Hopkins University/ Sinai Hosp of Baltimore, Baltimore, MD

 

Introduction: Osteoporosis (OP) is a systemic skeletal disease characterized by enhanced bone fragility leading to an increased risk of fractures. Roughly 10 million Americans over age of 50 have osteoporosis, and an additional 43.4 million suffering from osteopenia; with an incidence of 2 million fractures incurring a cost of $17 billion annually. History of prior osteoporotic fracture is an important risk factor for recurrent fragility fractures. Horizon recurrent fracture trial1 in 2007 demonstrated that, annual infusion of Zoledronic acid (ZA) showed a 28% relative reduction in mortality and 32% RR in clinical fractures in the ZA group2. This study evaluates current rate of recognition and management of underlying osteoporosis in patients presenting with fragility fractures to a large teaching hospital.

Methods: Adult patients between the age of 60-85, who were admitted with acute fragility fracture of humerus, femur/hip or vertebrae to a large teaching hospital between Jan 2010 and Jan 2013, were identified. Retrospective chart review was done to obtain information regarding calcium (Ca), albumin, Vitamin D (Vit D) levels at admission, discharge instructions, Ca and Vit D supplementation, prescription for anti-resorptive therapy, referral for DEXA scan and follow up of osteoporosis care. Patients with traumatic fractures, secondary causes of OP and those who were already on anti-resoptive therapy were excluded from the study.

Results:  462 patients had fractures and 201 patients were included in the study. There were 137 (68 %) women and 64 (32%) men. There were 87(43%) patients above age 80, 69 (35%) above age 70, and 45 (22%) below age 70. Among the fractures, 57 (28%) were vertebral, 26 (13%) humeral, and 118 (59%) were femoral. Only 24 (12%) of patients already had a diagnosis of OP. During their inpatient stay, Vit D levels were checked only in 21 (10%) of patients, 43 (22%) of patients were already on either Ca or Vit D supplementation prior to admission. All the patients received discharge instructions for PT, OT and weight bearing, but only 87(43%) were asked to follow up with their PCP. 89(45%) of these patients were given either Ca or Vit D recommendations on discharge, only 6 (3%) of patients were given instructions to start anti-resorptive medication, and 4 (2%) of patients received a specialty referral. None of the patients were scheduled for a DXA scan.

Discussion: Our findings confirm available data2 suggesting that patients with osteoporosis do not get adequate discharge instructions, BMD measurement, Ca and Vit D supplementation, recommendation for anti-resorptive therapy, or specialty referral. Considering a unique opportunity to improve long-term outcomes in patients with acute fragility fractures, introduction of a standardized electronic order set addressing post-fracture osteoporosis care could result in major improvements in outcomes locally and nationally.

 

Nothing to Disclose: DE, SB, EIK

21950 6.0000 FRI-253 A Recognition and Management of Osteoporosis in Patients Presenting with Acute Fragility Fractures 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Chaithra Prasad*1, Subashan Perera2 and Susan L Greenspan3
1University of Pittsburgh Medical Center, Pittsburgh, PA, 2University of Pittsburgh, 3Univ of Pittsburgh, Pittsburgh, PA

 

Background: Dual-energy X-ray absorptiometry (DXA) is currently the standard for diagnosis of osteoporosis and monitoring of bone mineral density (BMD). While BMD correlates strongly with hip fracture risk, there is considerable overlap in spine BMD values between those who develop vertebral fractures and those who do not. The quality of a patient’s trabecular microarchitecture, as estimated by the Trabecular Bone Score (TBS), predicts vertebral fracture risk as well as spine BMD but the combination of TBS and BMD is superior to either measurement alone. TBS is a computerized measurement obtained from the spine DXA image, which is cost-effective. We have previously shown that oral bisphosphonate therapy maintains or improves BMD at the spine and hip in postmenopausal women receiving aromatase inhibitors (AIs) for hormone receptor positive breast cancer. In this study, we examined whether bisphosphonate therapy also preserves bone microarchitecture, as measured by TBS.

Methods: This 2-year randomized, double-blind, placebo-controlled trial included postmenopausal women over age 55 with breast cancer on an AI who had low bone mass (T-score between -1.0 and -2.5 at the spine or hip), were not treated with a bisphosphonate in the previous year, and had no illness or were on no medications known to affect bone and mineral metabolism. Subjects were randomized to risedronate 35 mg once weekly or placebo. All received daily calcium (up to 1200 mg daily) and vitamin D (800 IU). In addition to BMD in the spine, total hip and femoral neck, we reviewed 12- and 24-month changes in spine TBS, analyzed using linear mixed models.    

Results: We randomized 109 patients whose mean age was 70.5 years. There were no baseline differences between the groups in age, BMI, calcium/vitamin D intake, BMD, or TBS. The TBS declined in the placebo group by -1.9% and -2.3% at 12 and 24 months, respectively (p<0.005). The 12 and 24 month TBS percent change in treated patients was not significant at -0.8% and -1.3% (p=0.34 and 0.14), respectively. The 12- and 24-month active vs placebo TBS differences were 1 (p=0.39) and 0.7 (p=0.49) percentage points. The medication was well tolerated and there were no significant differences in serious adverse events or deaths.

Conclusions: This study provides preliminary evidence that risedronate may preserve bone microarchitecture over 2 years during a time of accelerated bone loss in breast cancer survivors on AIs.

 

Nothing to Disclose: CP, SP, SLG

18826 7.0000 FRI-254 A Risedronate May Preserve Bone Microarchitecture in Breast Cancer Survivors on Aromatase Inhibitors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Noriko Ban*1, Yuta Sato2, Ayako Nagumo3, Sawako Suzuki4, Tomohiko Yoshida4, Tomoaki Tanaka4, Junichi Yamaguchi5, Takashi Terano6 and Ichiro Tatsuno7
1Toho University Sakura Medical Center, Sakura, Japan, 2Toho University Sakura Medical center, Chiba, Japan, 3Toho University Sakura Medical Center, 4Chiba University Graduate School of Medicine, Chiba, Japan, 5Chiba City Public Health Office, 6Chiba Aoba Municipal Hosp, Chiba, Japan, 7Toho University Sakura Medical Center, Sakura-City, Japan

 

Background: Osteoporosis causes an enormous health and economic impact with aging populations in the world. Since Japan is one of the longest countries for life expectancy in the world, Japanese government made a law to protect the women from the postmenopausal osteoporosis, in which the medical examination for osteoporosis was recommended to the local governments. Chiba City started the Chiba bone survey in cooperation with the Chiba City Medical Association from 2001.

Objective: We clarify the lifestyle-related risks for the postmenopausal osteoporosis, and make its diagnostic formula from the lifestyle-related risks in Japanese postmenopausal women.

Methods: We analyzed about 11932 Japanese postmenopausal women (mean age, 60.9 ± 6.7 years ; mean BMI, 22.5 ± 3.16) aged from 50 to 70 consisting of 15.7 % at 50 year, 16.5% at 55 year , 22.7% at 60 years, 22% at 65 year, and19.9% at 70 year. All participants underwent anthropometric measurements including bone mineral density (BMD) with dual-energy X-ray absorptiometry (DXA) at radius, and completed a structured, nurse-assisted, self-administered questionnaire also including patient lifestyle.

Results: Postmenopausal osteoporosis was observed in 19.1% (osteoporosis was defined with BMD less than -2.5 SD). Mean age of osteoporosis was 66.4 ± 5.7 years, which was older than that of non-osteoporosis group (60.0 ± 6.7 years). The rate of fracture in osteoporosis group was significantly higher than that in non-osteoporosis group, and the women with osteoporosis were thinner than those without non-osteoporosis. Logistic regression analysis revealed that age, fracture, thin, family history of kyphosis were the risk factors. Based on this analysis, we tried to make the diagnostic formula from the lifestyle-related risks for Japanese postmenopausal osteoporosis. Its sensitivity was 5%, the specificity 98.6%, predictive value 78.6%, respectively.

Conclusions: Our study indicated that various lifestyle factors were related to the onset of postmenopausal osteoporosis in Japanese women. Although we tried to make the diagnostic formula for osteoporosis from the lifestyle-related risks, it was insufficient to pick up the women with postmenopausal osteoporosis.

 

Nothing to Disclose: NB, YS, AN, SS, TY, TT, JY, TT, IT

19415 8.0000 FRI-255 A Characteristic Lifestyle As the Risk for Osteoporosis and Its Diagnostic Formula in Japanese Postmenopausal Women: Chiba Bone Survey 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Marissa Paige Grotzke*1, Phillip Lawrence2, Yanina Rosenblum2 and Grant Cannon2
1Veterans Health Administration Salt Lake City Health Care System, Salt Lake City, UT, 2Veterans Administration Salt Lake City Health Care System, Salt Lake City, UT

 

BACKGROUND: Improvements in secondary prevention of osteoporotic fractures have been widely reported with the creation and spread of Fracture Liaison Services, however few models for the primary prevention of such fractures have been described (1). Although the primary care setting seems to offer a clear opportunity for identifying at-risk patients, published reports continue to indicate screening and treatment rates in this setting remain low (2). We have previously presented a description of an interdisciplinary Bone Health Team (BHT) in the Veterans Affairs Salt Lake City Health Care System (VASLCHCS) comprised of a doctor of pharmacy, advanced practice nurse practitioner, and consultant endocrinologist designed to address these deficiencies in screening rates while addressing the need for primary osteoporotic fracture prevention. METHODS: Over the course of 12 months, the charts of 2,607 patients on six primary care providers’ (PCP) panels were reviewed for age-based screening criteria (aged 70 years or over in men, aged 65 or over in women) based upon current National Osteoporosis Foundation and Endocrine Society guidelines. RESULTS: Of the 2,607 patient charts initially reviewed, 61 were noted to be duplicates related to patients changing PCPs, leaving 2,546 patients on six PCP panels meeting absolute age-based indications for osteoporosis screening.  Of those, 72 (2.83%) had received a bisphosphonate prescription during the 12 months prior to BHT intervention. Seven hundred twenty-eight of the 2,546 age-eligible patients (28.6%) agreed to enrollment in the BHT.  Following twelve months of BHT intervention, 162 (6.36% of the 2,546 eligible, 22.3% of those enrolled in the BHT) had received a bisphosphonate prescription and 125 (4.9% of the 2,546 eligible, 17.2% of BHT enrollees) were referred to endocrinology for more aggressive therapy due to the severity of their osteoporosis. CONCLUSION:  When compared to current primary care practices, a dedicated BHT shows increased rates of bisphosphonate prescriptions for patients at risk for osteoporotic fracture.

 

Nothing to Disclose: MPG, PL, YR, GC

19972 9.0000 FRI-256 A A Dedicated Interdisciplinary Approach Improves Rates of Bisphosphonate Prescription Initiation in Primary Care Patients at Risk for Osteoporotic Fractures 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Joy Natalie Tsai*1 and Benjamin Zev Leder2
1Massachusetts General Hospital, Boston, MA, 2Harvard Medical School, Boston, MA

 

Background: The role parathyroid hormone (PTH) plays in the regulation of the osteocyte-derived Wnt signaling inhibitor, sclerostin, in vivo, has not been clearly defined. Sclerostin, a protein encoded by SOST and expressed by osteocytes, is an antagonist of the Wnt pathway and therefore a negative regulator of osteoblast differentiation and proliferation and hence bone formation.  SOST expression decreases in response to continuous or intermittent PTH in animal studies, suggesting that sclerostin may in part mediate the anabolic effect of PTH. Our group has previously reported that serum sclerostin levels decrease in men during an 18-hour PTH infusion, with effects seen as early as 6 hours. In a small study of postmenopausal women previously treated with bisphosphonates, there were no acute changes in serum sclerostin after intermittent PTH (1). We hypothesized that in postmenopausal women with osteoporosis, a single subcutaneous (SC) administration of PTH (1-34) (teriparatide) would suppress circulating serum sclerostin levels.

Methods: We measured serum sclerostin using an enzyme linked immunoassay (Biomedica Gruppe, Wien, Austria) in 25 postmenopausal osteoporotic women ages 52 to 81 immediately prior to and 4-hrs after a single 8 AM 40-mcg SC teriparatide injection. Subjects were excluded if they had been exposed to bisphosphonates during the preceding 12-months. Subjects remained fasting until all blood sampling was completed. The within-group change in serum sclerostin was assessed by paired t-test.

Results: Five of 25 subjects had been previously treated with at least one year of bisphosphonates. At baseline, the average sclerostin level was 894 ± 381 pg/mL. Four hours post-injection, sclerostin increased by 65 ± 147 pg/mL, or 7.4 ± 13.6 % (p=0.037, baseline versus hour 4).

Summary: In postmenopausal osteoporotic women, serum sclerostin increases significantly within 4-hours following a single 40-mcg SC injection of teriparatide. The unexpected increase in sclerostin levels contrasts with the observed decrease in serum sclerostin when PTH is administered by continuous infusion. Serum sclerostin is reported to have a nocturnal peak starting at 1 AM, so our observed increase in serum sclerostin in response to teriparatide is unlikely to be attributed to diurnal variation but this cannot be excluded in the current study (2).  The mechanisms by which PTH exerts immediate opposing influences on serum sclerostin when administered by bolus subcutaneous injection or continuous infusion remain to be defined.

 

Disclosure: BZL: Consultant, Amgen, Consultant, Lilly USA, LLC, Consultant, Merck & Co., Consultant, Radius. Nothing to Disclose: JNT

19992 10.0000 FRI-257 A Immediate Effects of Intermittent Parathyroid Hormone on Circulating Sclerostin Levels 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Marissa Paige Grotzke*1, Phillip Lawrence2, Yanina Rosenblum2 and Grant Cannon2
1Veterans Health Administration Salt Lake City Health Care System, Salt Lake City, UT, 2Veterans Administration Salt Lake City Health Care System, Salt Lake City, UT

 

BACKGROUND: Published reports continue to indicate osteoporosis is under-diagnosed in men, with published rates of screening in primary care settings repeatedly below 15% (1,2). We have previously presented a description of an interdisciplinary Bone Health Team (BHT) composed of a doctor of pharmacy, advanced practice nurse practitioner, and consultant endocrinologist developed to actively screen, evaluate, and treat primary care patients in the Veterans Affairs Salt Lake City Health Care System (VASLCHCS).  METHODS: Over the course of 12 months, the charts of 2,607 patients on six primary care providers’ (PCP) panels were reviewed for age-based screening criteria (aged 70 years or over in men, aged 65 or over in women) based upon current National Osteoporosis Foundation and Endocrine Society guidelines. RESULTS:  Of the 2,607 patient charts initially reviewed, 61 were noted to be duplicates related to patients changing PCPs, leaving 2,546 patients on six PCP panels meeting absolute age-based indications for osteoporosis screening.  Of those, 728 (28.6%) agreed to enrollment in the BHT with 12 (1.64%) women and 716 (98.4%) men. Prior to intervention by the BHT, 26 [0.10% of the 2,546 (total eligible), and 3.57% of the 728 (enrolled by BHT)] patients had had dual energy x-ray absorptiometry (DXA) studies performed. After 12 months of BHT intervention, 701 (27.5% of the (total eligible), and 96.3% of the 728 (enrolled in the BHT)] patients had received DXAs. CONCLUSION: When compared to primary care, a dedicated BHT demonstrates superior rates of osteoporosis screening for men meeting absolute age-based criteria.

 

Nothing to Disclose: MPG, PL, YR, GC

19994 11.0000 FRI-258 A A Dedicated Bone Health Team Improves Screening Rates for Osteoporosis When Compared to Primary Care 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Maija Mukane*1, Ingvars Rasa2 and Maksims Mukans3
1Riga Stradins University, Riga East Clinical University Hospital, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 3Riga Stradins University, Riga East Clinical University Hospital, Riga, Latvia

 

Background: Major health consequences of osteoporosis (OP) are fragility fractures, disablement, chronic pain, high morbidity and mortality risk. OP management may not be viewed as a high priority during in–hospital care, however it is obligatory in outpatient work–up. The aim of the study was to analyse reasons of OP care gap in hip fracture patients (pts) in one of the Northern Europe Union countries – Latvia.

Materials and methods: Retrospective quantitative medical record analysis included time period of three years (yrs), till 2012. In above–mentioned term totally 5050 pts with trauma admitted in the Riga 2nd Hospital. From them 888 pts had fragility hip fracture and were included in the study. Pts demographic characteristics, health status, OP risk factors (lifestyle factors, co–morbidities and used medications) and recommendations at discharge were analysed. All scale data were presented in median with the interquartile range.

Results: Mostly females (73.1%), older than males (80 (86–72) yrs vs 72 (80–61) yrs, p<0.001). Median hospital stay 15 (18–13) days. Most common hip fracture type was pertrochanteric fracture (41.8%) treated operatively (82.1% of all pts) using intramedullary hip screw (76.1%). Information about smoking and alcohol abuse was found in 20.4% pts medical records. Co–morbidities increasing risk of OP (e.g., diabetes mellitus, rheumatoid arthritis or sarcoidosis) had 24.4% (n=217) of all pts. Medications increasing risk of OP (e.g., proton pump inhibitors, anticonvulsants or loop diuretics) used 6.2% (n=55) of all pts. Glucocorticosteroids in the long term used 1.4% (n=12) of all pts. Previous fracture as a result of low energy trauma had 14.8% (n=131) of all pts and 9.2% of them had more than one fracture. Most of the pts had 1–2 OP risk factors (80.1% of all pts), more than 3 OP risk factors had 11.2% of all pts and six or more risk factors had 3% of them. Only 2.5% (n=22) of all pts received recommendations for further OP evaluation or treatment at discharge (e.g., perform osteodensitometry, calcium and vitamin D supplementation or specific OP treatment). More often recommendations received pts with 1–2 OP risk factors (77.3%, n=17). There was no difference in recommendations at discharge in comparison between pts with no risk factors and pts with 3–6 risk factors (p=0.662).

Conclusions: Although the study was retrospective medical record review and we were unable to recognize all OP risk factors and why target population did not received recommendations, reasons of OP care gap in hip fracture patients in Latvia could be omission of OP risk factors and lack of communication between specialists (e.g., traumatologist and general practitioner) involved in OP care.

 

Nothing to Disclose: MM, IR, MM

20067 12.0000 FRI-259 A Osteoporosis Care Gap in Hip Fracture Patients – First Data from Latvia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Heather Klingeman*1, Praveen Ramu2, Rajeev Chaudhry1, Robert A Wermers1 and Ann E Kearns1
1Mayo Clinic, Rochester, MN, 2Mayo Clinic

 

The recognition and treatment of osteoporosis lowers the susceptibility to fractures. The National Committee for Quality Assurance (NCQA) State of Health Care Quality Report for 2014 was recently released and shows improvements in Healthcare Effectiveness Data and Information Set (HEDIS) measures for osteoporosis testing/treatment.  However, the testing/treatment rate in women who had a fracture remains <30% and highlights the need for improvement. The Joint Commission has proposed facility based quality measures for osteoporosis testing/treatment of patients hospitalized with a fracture that may begin reporting in 2016.  The goal of our study was to develop a system to identify fracture patients and to assess the current rate of osteoporosis assessment and treatment in this group at the Mayo Clinic Rochester, MN. To accomplish this we utilized the Amalga Unified Intelligence system. Amalga is a data aggregator and viewer designed to retrieve and display near real-time clinical information from many unrelated medical systems, such as patient demographics, allergies, lab results, medications, history, and clinical procedure reports. The integration of data from multiple sites into a coordinated view thereby provides functionality for managing a cohort or population of patients. We used ICD9 codes encompassing fragility fractures, patient age >50, and exclusions of dialysis treated patients, severe trauma, and comfort care to generate a list of individual patients and their associated bone density testing results, osteoporosis medications and relevant demographic data. We then conducted electronic chart review of the 425 cases identified between October 1, 2013 and December 31, 2013.   The outcomes of interest were the ordering or performing a DXA scan or prescribing an FDA approved pharmacotherapy for osteoporosis:  1. Prior to discharge in the hospital setting (Joint Commission measure); 2. Within 3 months of the fragility fracture in the ambulatory setting.  Patients automatically met criteria if they were taking pharmacotherapy for osteoporosis at the time of fracture or had a DXA in the 12 months preceding the fracture.  Patients were censored for severe trauma, pathologic fracture, end stage renal disease, comfort care, and presentation greater than three months following fracture.  During the study period, 294 of 425 patients met inclusion criteria.  Among hospitalized patients, the rate of hospital measure attainment was 12% and the rate of ambulatory measure attainment was 24%.  For ambulatory patients, the rate of measure attainment was 45%.  Our system’s performance in the testing/treatment of osteoporosis following a fracture has room for improvement. The Amalga tool performed a complex task but has some limitations.

 

Nothing to Disclose: HK, PR, RC, RAW, AEK

20964 13.0000 FRI-260 A Osteoporosis Assessment and Treatment Following Fragility Fracture 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Maria Valeria Premrou1, Carolina Pelegrin1, Maria Jose Faraldo2, Laura Elena Maffei*1, Eugenia Segura1 and Maria Laura Eugenio3
1Centro Médico Dra Laura Maffei, Buenos Aires, Argentina, 2Centro Medico Dra. Laura Maffei, Buenos Aires, Argentina, 3Centro Medico Dra Laura Maffei, Buenos Aires

 

Introduction: Denosumab is a monoclonal antibody against RANKL, a potent inhibitor of bone resorption, effective in the treatment of postmenopausal osteoporosis, reducing the risk of vertebral and nonvertebral fractures and increasing BMD.

Objective: to evaluate the efficiency of Denosumab treatment in a group of patients with osteoporosis. Secondary objectives: to evaluate therapeutic response in relation to different variables: basal resorption markers, baseline BMD, history of prior fractures (FX), age of patients and history of prior osteoporosis treatment.

Methods: Retrospective study including all patients with osteoporosis who had reached followed 12 months of treatment with Denosumab. All received 60 mg Denosumab/ Sc every 6 months for 12 months. They received calcium and vitamin D (needed to maintain a level of 25OHD greater than 30 ng/ml) .They performed spine and femoral neck BMD at baseline and after 12 months of treatment.

Results: 42 patients (p), 41 female, 1 male, mean age 65.4 ± 10.7 years were included.  18 p (42.9%) had history of prior fractures (FX), (total events = 25), 18 p 1 FX, 5 p 2 FX and 1, 4 FX. The most frequent FX were vertebral (44%), hip (5%), wrist (4%), humerus (2%) and ribs, scapula and sternum (1% for every FX).

BMD results were expressed in g / cm2. Baseline spine 0,773 ± 0,092 vs 12 months 0,830 ± 0,102, % variation 6,5% (p: <0,001).  Baseline femoral neck 0,651 ± 0,087 vs 12 months 0,680 ± 0,087, % variation 4,2% (p: <0,001) t test.

When we having analyzed prior osteoporosis treatment, it was observed a slight increase in spine vs naïve treatment patients (6,1% vs 8%) p: NS, and in femoral neck 4,15 vs 4,42% (p: NS)

Other results of the variables analyzed showed that age at the beginning of treatment ,baseline BMD and level of serum cross laps, history of previous fractures; had no correlation with the rate of BMD change  with any of the variables were found. . There was also no correlation between the rate of change and urinary Ca and vitamin D at baseline (Spearman and Pearson correlation).

Conclusions: Denosumab was effective in this population with regard to increasing the BMD, both in naïve treatment and in patients with history of previous treatment. The occurrence of new fractures was low. The level of bone markers, urinary calcium, 25-OH vitamin D baseline, previous FX and patient age were not correlated with densitometric variation.

 

Nothing to Disclose: MVP, CP, MJF, LEM, ES, MLE

21497 14.0000 FRI-261 A Assessment of Therapeutic Response of Denosumab in Osteoporotic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Inese Pavlina*1, Ingvars Rasa2, Inara Adamsone3, Signe Zelca4, Ilze Daukste5, Ingrida Kaze4, Sandra Jaundzeikare4, Agita Medne6 and Dainis Kaneps7
1Medical Centre 55, Bruxelles, Belgium, 2Recuh, Riga, 3Pauls Stradins Clinical University Hospital, 4Recuh, 5Riga 2nd Hospital, 6Health Centre 4, 7Latvian Maritime Medicine Center

 

Objective(s): We aimed to assess  physical activities  and bone mineral density (BMD) correlation among postmenopausal women in Latvia.

Material & Methods: 1,598 women took part in a national cross-sectional study. All women filled out a questionnaire with multiple choice questions regarding to physical exercises. BMD was subsequently measured in all participants by DXA in lumbar spine (L1-4) and left total hip.

Results: Pts who had physical activities every day (regularly, at least 30 min) -  BMD in lumbar spine – osteoporotic values were 22.6% for pts, pts who had physical activities 2-3 times per week were 19.9% (p< 0.02), but those who have no physical activities were 24.0%. The BMD of left hip osteoporotic values were 9.0% pts who had physical activities every day, but 7.0% (p< 0.01) to pts who had  physical activities 2-3 times per week, and 11.3 % for pts who had no physical activities at all. BMD osteopenic values in lumbar spine were for 46.1% pts who had physical activities every day, those who had physical activities 2-3 times per week were 50.6% and 44.7% were osteopenic in the group with no physical activities at all. BMD in left hip osteopenic values physical activities every day were 60.8% pts, but physical activities 2-3 times per week were 63.0 % pts, and pts with no physical activities were 62.6%. BMD measurements in lumbar spine  and left hip positively correlated with physical activities 2-3 times per week

Conclusion(s): This survey suggests that physical activities 2-3 times per week regularly may improve BMD. We need to pay more attention to suggest to pts physical activities at least 2-3 times per week.

 

Nothing to Disclose: IP, IR, IA, SZ, ID, IK, SJ, AM, DK

21731 15.0000 FRI-262 A Physical Activities and BMD in Postmenopausal Women in Latvia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Smita Jha*1, Zhong Wang2, Nicholas Laucis2 and Timothy Bhattacharyya2
1National Institutes of Health, Derwood, MD, 2National Institutes of Health

 

Abstract

Background:

Bisphosphonates are effective for the treatment of osteoporosis despite recent reports of safety concerns (osteonecrosis jaw, atypical femur fracture, atrial fibrillation and esophageal cancer).  We conducted an epidemiological study in bisphosphonate use in the US and correlated to fracture outcomes and media reports.

Materials and Methods: We used the National Inpatient Sample (NIS) to estimate the incidence of fragility fractures and the Medical Expenditure Panel Survey (MEPS) to study the trends in bisphosphonate use.  We studied the female population from ages 55 and older, either with prescription for bisphosphonates (MEPS) or primary diagnosis of femoral fragility fractures – including inter-trochanteric, sub-trochanteric and shaft fractures (NIS). Trends in age-adjusted incident rate of fractures and prevalence of bisphosphonate use were studied from 1996-2011. We studied media reports of bisphosphonates using Google Correlate.

Results:

The use of bisphosphonates rose from 2.7% of the studied population in 1996 to 15.5% in 2008 then declined by 40% to 9.3% in 2011 (P< 0.001).  The decline was across all age groups, but more common in patients with lower incomes and lower education level.

Intertrochanteric hip fractures declined from 653.7 per 100,000 persons in 1996 to 476.9 per 100,000 persons in 2006 but showed a small but significant decline to 450.8 per 100,000 in 2011 (P < 0.001).  Sub-trochanteric and shaft fractures continued to show a steady and significant increase since 2002 – from 35.0 per 100,000 to 43.4 per 100,000 in 2011 (P < 0.05).

A series of spikes in internet searches for Fosamax occurred between 2006 and 2010 after media reports of safety concerns. 

Conclusion:

The plateauing and subsequent decline in bisphosphonate use since 2006 coincided with reports of safety concerns of alendronate (Fosamax).   Although this decline in bisphosphonate use may be associated with the flattening of the previous decline of the incidence of inter-trochanteric fractures, the continued increase in the incidence of sub-trochanteric and shaft fractures remains unexplained. Further studies are needed to define the susceptible population at risk of fragility fractures.

 

Nothing to Disclose: SJ, ZW, NL, TB

22081 16.0000 FRI-263 A Trends in the Prescription of Bisphosphonate and Incidence of Fragility Fractures in US: 1996-2011 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Helenius Jan Kloosterboer*1, Peter Schot2 and Marjanne Prins2
1KC2, Oss, Netherlands, 2OrgaNext Research

 

NDD, a fixed combination of a low dose of nandrolone decanoate (ND) and vitamin D3 (D3), is in development as Recovery Booster therapy for older women with vitamin D deficiency in order to mitigate disuse atrophy and loss of physical function after hip fracture surgery. After surgery the risk of muscle wasting is high and full recovery is hampered due to low muscle mass. The objective of NDD treatment is to reverse the post-operative catabolic state, activate muscle cells, increase muscle mass, improve functional outcome and restore vitamin D3 sufficiency. Studies with human skeletal satellite cells show that nandrolone and 1α,25-dihydroxyvitamin D3 have a synergistic effect on muscle cell proliferation. Receptor studies show that in muscle cells the two compounds increase the expression of their own and each other’s receptor, which may explain the synergistic effect on proliferation of muscle cells. Nandrolone inhibits the proliferation of human prostate LNCaP cells and this effect is enhanced by 1α,25-dihydroxyvitamin D3. In Phase I studies the safety, tolerability and kinetics of NDD were investigated in healthy women (65-79 years of age). Women received subcutaneously an injection of 0.5 ml sesame oil containing 25 mg ND and 14.000 IU D3 in a single dose study and 25 mg ND and 28.000 IU D3 in a multiple dose study (2 injections at day 1 followed by a single weekly injection for 3 weeks). In both studies NDD was safe and well tolerated. Both ND and D3 were released from the depots. Nandrolone shows first order kinetics. Mean serum D3 concentrations did not increase after the first dosing, but did after the 3 subsequent ones. Consequently, the mean AUC0-72h for D3 is higher after the fourth dosing than after the first dosing. Despite the increase in D3 levels, the mean 25(OH)D3 level and mean AUC0-72h hardly changed during treatment. However, mean screening corrected serum 25(OH)D3 levels in subjects with a low screening value (<30 ng/ml) increased, while the screening corrected mean level of 25(OH)D3 in subjects with high screening  levels (> 30 ng/ml) showed a decrease. This difference in effect may be explained by homeostatic regulation of D3 metabolites. The long-term effects on 25(OH)D3 levels 90 days after the last injection indicate that 28.000 IU D3 once a week are sufficient to restore 25(OH)D3 to adequate levels. Procollagen type III N-terminal peptide increased significantly (P<0.001) in the multiple dose study with NDD, which is indicative of an early anabolic response of NDD. A pivotal Phase IIb/III in which 3 low doses of nandrolone combined with 28.000 IU D3 will be investigated is in preparation. The duration of this study is 6 months and primary endpoints will be muscle mass, functional activity (gate speed) and 25(OH)D3 levels (>20 ng/ml). All subjects will participate in a physical rehabilitation program. So far, our studies indicate that NDD is a promising treatment for recovery after hip fracture.

 

Disclosure: HJK: Consultant, Roche Diagnostics, Consultant, PantarheiBio, Scientific Adviser, OrgaNext Research. PS: Employer, OrgaNext Research. MP: Owner, OrgNext Research .

19766 17.0000 FRI-264 A Preclinical and Clinical Development of a Novel Recovery Booster Therapy (NDD) for Hip Fracture in Older Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Kyung-jin Yun*1, Mee Kyung Kim1, Minhee Kim2, Dong Jun Lim2, Hyuk-Sang Kwon1, Ki Ho Song1, Moo-Il Kang2 and Ki-Hyun Baek1
1Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary’s Hospital, Seoul, Korea, Seoul, Korea, Republic of (South), 2Seoul St. Mary’s Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea, Republic of (South)

 

Studies on the effects of levothyroxine (LT4) therapy on bone and bone metabolism have yielded conflicting results. This 1-year prospective study examined whether LT4 in patients with well-differentiated thyroid carcinoma (DTC) is a risk factor for bone mass loss and the subsequent development of osteoporosis.

We examined 93 patients with DTC over 12 months after initiating LT4 therapy (early postoperative period). We examined another 33 patients on long-term LT4 therapy for DTC (late postoperative period). Dual energy X-ray absorptiometry was performed at baseline and after 1 year.

The mean bone losses during the early postoperative period in the lumbar spine, femoral neck, and total hip, calculated as the percentage change between levels at baseline and 12 months, were −0.88, −1.3 and −0.81%, respectively. Bone loss was more evident in postmenopausal women (lumbar spine −2.1%, femoral neck −2.2%, and hip −2.1%; all P < 0.05). We compared the changes in annual bone mineral density (BMD) in postmenopausal women according to calcium/vitamin D supplementation. Bone loss tended to be higher in the postmenopausal women receiving no supplementation. There was no decrease in BMD among patients during the late postoperative period. The mean bone loss was generally greater in the early than in the late postoperative group, and this was significant at the lumbar spine (P = 0.041) and femoral neck (P= 0.010).

TSH-suppressive levothyroxine therapy accelerates bone loss, predominantly in postmenopausal women and exclusively during the early post-thyroidectomy period.

 

Nothing to Disclose: KJY, MKK, MK, DJL, HSK, KHS, MIK, KHB

20155 18.0000 FRI-265 A The Effects of Thyrotropin-Suppressing Therapy on Bone Metabolism in Patients with Well-Differentiated Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Javier Mauricio Farias*1, Cesar Bogado2, Maria Belen Zanchetta2, Fabio Masari3, Mariana Papouchado4, Marcelo Criscuolo4, Roberto A Diez4 and Jose R Zanchetta2
1Sanatorio Güemes, Buenos Aires, Argentina, 2IDIM CR, Buenos Aires, Argentina, 3IDIM CR, Argentina, 4Biosidus SA

 

Teriparatide is an analogue of human parathyroid hormone, used to treat osteoporosis. To develop Osteofortil® (Biosidus S.A., Buenos Aires, Argentina) a new pharmaceutical product containing teriparatide, EMA guidelines for the development of medications were used. We report preliminary data corresponding to the comparison on efficacy and tolerability with the reference teriparatide product (Forteo®, Eli-Lilly, Indianapolis, IN, USA).Materials and methods:Randomized simple blind trial was designed in a single osteoporosis reference center. Teriparatide dose was 20 µg day by subcutaneous injection. Inclusion criteria: posmenopausal women between 50 and 81 years, with osteoporosis defined by mineral bone density (MBD) on lumbar spine (LS) < -2.5 (Tscore) or lumbar fracture with MBD <-2 on LS, femoral neck or total hip. The IRB, an ethical committee and the national drug regulatory agency of Argentina (ANMAT) approved the trial, also registered in clinicaltrials.gov (NCT 01945788). A comparative six-month initial phase was followed by an extension in which all patients were invited to receive Osteofortil® for 6 months. Data were analyzed using simple calculation, Mann Whitney U tests. Data were analyzed using the STATA 12 package (Stata Corp). A total of 182 patients were enrolled and 100 met inclusion and exclusion criteria, 95 and 72 completed the comparative  and the extension phase, respectively. Osteocalcin levels (O), N-terminal propeptide of procollagen type 1 (P1NP), C-terminal cross-linked telopeptide of type I collagen (CTX) were measured by Roche E411 ECLIA Electrochemi-luminescence, at baseline and months 1, 3,  6, 9 and 12. BMD was assessed after 6 and 12 months of treatment with DEXA (dual-energy x-ray absorptiometry) by Lunar Prodigy ™, GE Healthcare, Madison, WI, USA. The induction of anti-teriparatide antibodies was evaluated by ELISA. Results The mean age was 65.6 years, with no differences in age at menopause, previous use of bisphosphonates, vitamin D and the presence of fractures at baseline between both groups. At 6 months n = 48 Osteofortil® increased O levels 60.3 ± 30 mg/ml, P1NP 146.8 ± 98 mg/ml CTX 816.2 ± 467 pg/ml, whereas corresponding figures for Forteo were 67.8 ± 29.4 mg/ml, 179 ± 97 mg/ml and 1046 ± 656 pg/ml, (p 0.46, 0.56, 0.45) respectively. At 12 months the Ostefortil® values were O= 66.9 ± 36 mg/ml, CTX 727 ± 322 pg/ml P1NP 155 ± 100 mg/ml, vs Forteo® values of 62.6 ± 35.9 mg/ml, 786 ± 459 pg/ml and 166 ± 109 mg/ml, respectively. No differences between groups were found. The increase in mineral density in CL at 6 months was 5.46% with Forteo® and 5.43% with Osteofortil® (p 0.22). There was no induction of anti-PTH antibody with any product. Adverse events were similar between groups. Conclusions: Both products resulted in similar increase in bone markers and mineral bone density in the lumbar spine. Both depicted similar safety.

 

Nothing to Disclose: JMF, CB, MBZ, FM, MP, MC, RAD, JRZ

21336 19.0000 FRI-266 A Clinical Comparison of Efficacy and Safety of Two Teriparatide Formulations: Osteofortil® and Forteo® 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM FRI 248-266 5967 1:00:00 PM Osteoporosis Poster


Xiaokun Gang*1, Jian Zhong2, Guixia Wang1 and Haojie Huang2
1The First Hospital of Jilin University, Changchun, China, 2Mayo Clinic College of Medicine, Rochester, MN

 

Prostate cancer (PCa) exhibits a strong requirement of de novo fatty acid synthesis for growth and survival. Fatty acid metabolism has become a potential target for treatment of PCa. Fatty acid synthase (FASN), a key enzyme for fatty acid synthesis, is frequently overexpressed in human PCa, and its expression correlates with worse prognosis and poor survival. However, the regulatory mechanism of FASN expression in PCa remains poorly understood. P300 is a transcription co-activator. It has intrinsic acetyltransferase activity and functions as a strong PCa promoting factor. In this study, we analyzed p300 chromatin immunoprecipitation-sequencing (ChIP-Seq) data and detected an obvious p300 binding peak at the promoter of the FASN gene. This observation was further confirmed by ChIP-qPCR assays. Using both genetic (siRNA) and pharmacological (p300 inhibitors) approaches, we demonstrated that inactivation of p300 inhibited FASN expression, decreased lipid accumulation in both PCa cells cultured in vitro and Pten-knockout prostate tumors in mice. Immunohistochemistry (IHC) revealed that expression of p300 protein positively correlates with FASN protein levels in human PCa specimens. Together, our study identifies p300 as an important molecular determinant of regulation of FASN expression and lipid metabolism in PCa, suggesting that p300 is a key molecule for lipid metabolism-targeted therapy of PCa.

 

Nothing to Disclose: XG, JZ, GW, HH

20190 1.0000 FRI-330 A P300 Acetyltransferase Regulates Fatty Acid Synthase Expression and Lipid Metabolism in Prostate Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Gyhye Yoo* and Clinton Allred
Texas A&M university, College Station, TX

 

Inflammatory bowel disease (IBD) is a disease resulting from improper innate and adaptive immunity in the intestinal epithelial and mucosa [1]. It has been reported that IBD has shared characteristics with colorectal cancer and a positive correlation with colorectal cancer [2-4]. Though several cytokines are linked to IBD and inflammation-associated colon cancer, interleukin-6 (IL6) is positively correlated to occurrence and mortality from colorectal cancer [5]. Previous data from our laboratory have shown estrogen or phytoestrogen exposure to have protective effects against colon carcinogensis in vitro and in vivo. In this study, we evaluated how IL6 modulates cell physiology and gene expression in non-malignant colonocytes, and whether the treatment of estradiol (E2) and genistein (Gen) influence the effect of IL6 in vitro. IL6 treatment induced cell growth of Young Adult Mouse Colonocytes (YAMCs) significantly. The treatment of E2 or Gen suppressed the increase of cell growth by IL6. While IL6 reduced programmed cell death, E2 and Gen both increased it. IL6 elevated ERα, which is expressed in extremely low level in the colon epithelial, and CCND1 which is a target gene of ERα. These data indicate that IL6 could induce the shift of estrogen receptor expression from ERβ to ERα, resulting in an increase of cell growth. E2 or Gen suppressed the elevation of ERα and CCND1 expression induced by IL6. IL6 treatment increased gene expression of PCNA related to cell proliferation and E2 or Gen did not suppress the increase of PCNA expression. Interestingly, IL6 treatment suppressed IL6 expression though positive feedback of IL6 signaling has been reported. In conclusion, IL6 modulates cell physiology in YAMCs, and E2 and Gen suppressed the effect of IL6. These data suggest that elevation of IL6 could induce malignancy of colonocytes, and its ability to induce colon carcinogenesis could be suppressed by estrogen signaling.

 

Nothing to Disclose: GY, CA

22021 2.0000 FRI-331 A Estradiol and Genistein Modulate Cell Growth of Non-Malignant Colonocytes Induced By Interleukin-6 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Su-Jeong Kim*1, Richard Wong1, Kenneth A. Wilson1, Yan-He Lue2, Ronald S. Swerdloff2, Christina Wang2 and Pinchas Cohen1
1University of Southern California, Los Angeles, CA, 2Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA

 

The mitochondrial-derived peptide, humanin, is encoded within the mitochondrial DNA. Plasma and tissue humanin levels decreases with aging. Humanin is secreted in response to cellular stress and has broad neuroprotective and cytoprotective effects in various diseases. In addition, humanin has been shown to prevent chemotherapeutic drug-induced male germ cell loss.
Two cell surface receptors have been identified for humanin: humanin can interact with either FPRL1 or CNTFR/WSX-1/gp130 receptor complex and signal through the JAK/STAT and ERK1/2 signaling pathways that are well known to regulate autophagy in response to starvation. Based on the signaling pathway, here, we demonstrate that humanin induces autophagy in several cell types including HEK293 (normal embryonic kidney cells), SH-SY5Y (neuroblastoma), and B16 (melanoma). We observed an increased level of LC3-II, a marker of autophagosome by western blot and immunocytochemistry. We also observed an increase in the number of autophagosomes and autolysosomes in HEK293 cells stably expressing mRFP-GFP-LC3, a dual-tag reporter of autophagy, following humanin treatment. In addition, we investigated the signaling pathways activated by humanin using a phospho-antibody array in SH-SY5Y cells. This revealed several pathways known to regulate autophagy. Both activation and suppression of autophagy are involved in cancer pathogenesis and treatment, depending on the context. We recently demonstrated that humanin inhibits cancer progression and enhances the effects of chemotherapy treatments while reducing the side effects of such agents. However, the mechanisms of the anticancer action of humanin are still being unraveled.
This study was designed to determine the synergistic/additive effect of humanin on the efficacy of doxorubicin in B16 melanoma cells in vitro and more specifically, to reveal whether autophagy is involved in this combination strategy. The increased level of LC3-II found by western blot confirmed that the potent humanin analogue, HNG, increased autophagy in B16 cells. The combined treatment caused an additive effect on the cytotoxicity to the cancer cells versus doxorubicin treatment alone. In addition, inhibiting autophagy by treating cells with autophagy inhibitors, including 3-MA and chloroquine, diminished the additive effect of humanin in doxorubicin treated B16 cells. Taken together, the current study suggests that humanin has direct effects on tumor cells that involves induction of autophagy and thus humanin acts as a chemotherapeutic augmenter and synergistically enhances doxorubicin’s anticancer effects. Furthermore, the autophagy induction of humanin may be related to its apparent effects of enhancing longevity observed in other systems.

 

Disclosure: PC: Consultant, CohBar Inc.. Nothing to Disclose: SJK, RW, KAW, YHL, RSS, CW

22026 3.0000 FRI-332 A The Mitochondrial Peptide Humanin Is a Potent Inducer of Autophagy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Yan-He Lue*1, Ronald S. Swerdloff2, Junxiang Wan3, Vince Atienza2, Yue Jia2, Jenny Qian Dai-Ju2, Pinchas Cohen3 and Christina Wang2
1LABioMed at Harbor-UCLA Med Ctr., Torrance, CA, 2LABioMed at Harbor-UCLA Medical Center, Torrance, CA, 3University of Southern California, Los Angeles, CA

 

HNG, a synthetic potent Humanin analog, has cytoprotective activity in many organs and tissues. We have previously reported that HNG protects male germ cells from chemotherapy-induced apoptosis and at the same time suppresses metastatic lung melanoma formation. HNG reduces IGF-1 levels in the circulation, which has been shown by others to protect from chemotherapy side effects including neutropenia in the context of dietary interventions. Neutropenia is the most common adverse event after chemotherapy. We questioned whether HNG can prevent chemotherapy-induced neutropenia in melanoma-bearing mice. 25 adult male mice (C57BL/6J) were randomized into 5 groups. 5 mice were used as control. 20 mice were inoculated intravenously with B16 murine melanoma cells (100,000 cells/mouse). After 1 week,  the 4 groups of 5 tumor-bearing mice either received no further treatment or were treated with HNG daily intraperitoneal  (IP) injection (5mg/kg BW); a single cyclophosphamide (CP) IP injection (200mg/kg BW); or CP with HNG treatment for 2 weeks. All mice were sacrificed at 3 weeks. Blood was collected for complete blood cell count using an automated cell counter (VetScanHM2). Plasma HNG levels were measured by a sensitive and specific ELISA. Plasma HNG levels increased significantly (p<0.001) in HNG treated (86.2±13.3ng/ml), and HNG+CP treated (56.3±5.2ng/ml) mice compared to control (2.0±0.1ng/ml), non-treated tumor-bearing (5.9±1.3ng/ml), and CP treated mice (5.2±0.6ng/ml). HNG treatment alone had no effect on total white cell count (WBC:3.55±0.47x106/ml), granulocytes (GRA:1.13±0.31x106/ml), monocytes (MON:0.23±0.04x106/ml), and lymphocytes (LYM:2.2±0.36x106/ml) compared to control (WBC:2.61±0.48; GRA:0.26±0.04; MON:0.1±0.01; LYM:2.3±0.44x106/ml) and non-treated tumor-bearing mice (WBC:2.62±0.57; GRA:0.8±0.22; MON:0.17±0.04; LYM:1.65±0.46x106/ml). CP treatment significantly (p<0.05) decreased the number of WBC (0.99±0.04x106/ml), GRA (0.31±0.04x106/ml), MON (0.08±0.01x106/ml) and LYM (0.59±0.05x106/ml) as compared to non-treated tumor-bearing mice. Addition of HNG to CP significantly (p<0.05) rescued the CP induced neutropenia, WBC (2.33±0.3x106/ml), GRA (1.37±0.27x106/ml) and MON (0.23±0.03x106/ml), but not LYM (0.78±0.17x106/ml). There were no changes in red blood cell or platelet counts among groups. We conclude that 1) HNG prevents CP-induced suppression of granulocytes and monocytes; and 2) HNG may modulate hematologic/immune system acting as adjuvant to suppress tumor growth. Because HNG is a protective molecule in many normal cells, it is likely that HNG prevents the CP induced granulocyte and monocyte apoptosis. Our finding suggests that HNG is an ideal adjuvant to chemotherapy by reducing tumor growth while preventing neutropenia and onco-infertility.

 

Nothing to Disclose: YHL, RSS, JW, VA, YJ, JQD, PC, CW

20746 4.0000 FRI-333 A The Mitochondrial Peptide Analogue Hng Prevents Chemotherapy-Induced Suppression of Granulocytes and Monocytes in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Bo Mi Park*1, Eun Jin Kim2, Hee Jin Nam3, Dongdong Zhang3, Chu Hyun Bae1, Myeongmo Kang3, Bjarne Bogen4 and Sung-Kil Lim5
1Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul, Korea, Republic of (South), 2Institute of Biomedical Sciences, Yonsei University, Seoul, Korea, Republic of (South), 3Division of Endocrinology and Endocrine Research Institute, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 4University of Oslo and Oslo University Hospital, Norway, 5Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Currently, approved pharmaceutical approach to target bone metastases are limited to antiresorptive agents such as bisphosphonates or denosumab. DKK-1 has been extensively investigated in murine model of multiple myeloma where osteolytic lesions are a characteristic feature of advanced disease. The elevated DKK-1 levels in the bone marrow plasma and serum from myeloma patients were associated with the presence of focal bone lesions, and serum containing high levels of DKK-1 inhibited the differentiation of osteoblast precursors. Here, we developed the cyclized oligopeptide against DKK1 and tested the effects of the oligopeptide on tumor burden and osteolytic bony lesion. The oligopeptide based on the DKK1-LRP5/6 interaction was synthesized chemically, and the oligopeptide containing NXI motif bound to the E1 domain of LRP5/6 effectively on SPR analysis. The NMR structure and docking model between the oligopeptide and the first propeller domain of LRP5 were assessed. The inhibitor abrogated the Wnt-beta catenin signaling inhibited by DKK1 but not by sclerostin dose dependently (IC50: ~5X10-8 M). MOPC315.BM.Luc+ cells were injected into the tail vein and 5 days after injection, the inhibitor was injected subcutaneously every day 6 times per week for 4 weeks. It inhibited tumor burden and bone architecture assessed by uCT was relatively well preserved. More detailed results will be presented in the meeting.

 

Nothing to Disclose: BMP, EJK, HJN, DZ, CHB, MK, BB, SKL

19127 5.0000 FRI-334 A DKK1 Inhibiting Oligopeptide Reduces Tumor Burden and Bony Destruction in a Mouse Model for Multiple Myeloma (MOPC315.BM.Luc+) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Florencia Clément1, Marcela Venara1, Silvana Maglio2, Ayelen Martin1, Cecilia Matho1, César Petre3, Mercedes Garcia Lombardi3, Ignacio Bergada1 and Patricia Alejandra Pennisi*1
1Centro de Investigaciones Endocrinológicas Dr. César Bergadá, Buenos Aires, Argentina, 2Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina, 3Htal. de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina

 

Background: Central nervous system (CNS) tumors are the most frequent solid tumors in the pediatric population. Histologic grading is a mean of predicting the biological behavior of these tumors and survival is strongly correlated with tumor gradation. The insulin-like growth factor (IGF) system of ligands and receptors are known to play an important role in both normal and neoplastic growth. Recently, nuclear translocation of the type 1 insulin growth factor receptor (IGF-1R) has been demonstrated in tumor tissues. Although the IGF-1R expression has been described in CNS pediatric tumors, information about the intracellular localization and correlation with tumor grade is lacking. 

Objective: To characterize the expression and intracellular localization of the IGF-1R CNS tumors from pediatric patients according to WHO 2007 grading.

Patients and Methods: Thirty four patients (19 males/15 females), median aged 7.9 yrs, (range 0.9-18.3), with CNS tumors without previous medical treatment were included (23 gliomas, 5 medulloblastomas, 6 ependimomas). Formalin-fixed 5µm tumor tissue sections were immunostained for IGF-1Rβ. IGF-1R expression and intracellular localization were scored as positive or negative, nuclear or cytoplasmic respectively. Contingency tables were analyzed using Pearson's χ2 test to assess relationships between IGF-1R and tumor grade (Low grade I-II; High grade III-IV).

Results: IGF-1R staining was positive in 15/20 (75%) low grade tumors and in 14/14 (100%) high grade tumours (χ2 Test:p<0.05). Low grade tumors showed cytoplasmic localization of IGF-1R in 13/15 cases, while in high grade tumours IGF-1R localization was nuclear in 3/14 (χ2 Test:p<NS). Since gliomas are the most common subgroup of CNS tumors in children, we analyzed this subgroup of tumors separately. We observed that in low grade gliomas cytoplasmic localization of IGF-1R was present in 13/15 cases, while in high grade tumors IGF-1R localization was mainly nuclear (3/5) (χ2 Test:p<0.05).

Conclusions: Our results showed that IGF-1R expression is positive in most CNS tumors of the pediatric population, with a small but significant proportion of negative expression in tumors of low grade. Specifically in gliomas, ranging from grade I to grade IV, our results would indicate that both expression and intracellular localization of the IGF-1R are different in low vs high grade, suggesting a potential role for the IGF system in the biological behavior of this particular type of pediatric tumor. Further studies are necessary to confirm our results.

 

Nothing to Disclose: FC, MV, SM, AM, CM, CP, MG, IB, PAP

21051 6.0000 FRI-335 A Characterization of IGF-1 Receptor Expression and Localization in Pediatric Tumors of the Central Nervous System upon Diagnosis According to WHO 2007 Grading 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Albert P. Li*
In Vitro ADMET Laboratories LLC, Columbia, MD

 

The novel integrated discrete multiple organ co-culture (IdMOC) experimental system allows the co-culturing of multipe cell types as physically separated entities but interconnected by a common overlying medium.  The system employs a wells-in-a well concept, with multiple shallow wells inside a larger containing well.  The formats include 6, 48, and 96 inner wells within each containing well.  As the IdMOC plates have the same foot-print of regular 24- and 96-well plates, experiments can be performed with the plates without the need of special equipments as required for micro-fluidic co-culture systems.  The IdMOC system can be used with adherant cells as well as non-adherant cells as matrigel entrapped cultures. Proof of concept experiments were performed demonstrating endocrinal cell-cell interactions, with soluble factors produced by one cell type interacting with a different cell type in the co-culture. Primary human hepatocytes and primary human splenocytes were plated in IdMOC-96 plates (96-well palte format, with 16 containing wells each with 6 inner wells).  The co-cultures were treated with cyclophosphamide at 100, 200, 500, 1000 and 2000 uM.  In vitro immunotoxicity was quantified via ATP contents in the presence and absence of phytoagglutinant A (PHA), with PHA-induced cell proliferation as a measurement of immune function.  Cyclophosphamide induction of immunotoxicity was observed in splenocytes co-cultured with hepatocytes, but not in the absence of hepatocyte co-culture.  The results suggest that IdMOC system can be used for in vitro evaluation of cell-cell interactions via secreted soluble factors. Examples of applications include the evaluation of endocrinal interactions among cells of different organs, and paracrinal interactions among cells from the same organ.

 

Nothing to Disclose: APL

19960 7.0000 FRI-336 A The Novel Idmoc Experimental System for in Vitro Evaluation of Cell-Cell Interactions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Minqian Shen*
Miami University, Oxford, OH

 

Estrogen and its receptor agonists antagonize oncogenic actions of leptin in hepatocellular carcinogenesis

Minqian Shen, Haifei Shi

Department of Biology, Miami University, Oxford, OH

 

Abstract 

Objectives: Obesity is a significant risk for many types of cancer, including hepatocellular carcinoma (HCC). Leptin, a hormone secreted by adipose tissue, increases in obese individuals and precipitates HCC development. Epidemiology data suggest (Minqian: data is plural form for datus.) that men have higher incidence of HCC than women, indicating protective roles of estrogen against HCC development. However, whether estrogen antagonizes the oncogenic actions of leptin is unknown. 

Methods: Expression of estrogen receptors (ER) of human HCC cell line HepG2 was analyzed using quantitative real-time PCR. HepG2 cells were treated with leptin (100 ng/ml), 17β-estradiol (E2; 1-1000 nmol), ER-α agonist PPT (1 µmol), ER-β agonist DPN (1 µmol), or G-protein coupled estrogen receptor (GPER) agonist G-1 (1 µmol). Cell number, cell viability, cell proliferation, and cell apoptosis were determined respectively. Additionally leptin and estrogen signaling pathways were analyzed via western blot.

Results: E2 inhibited cell proliferation and promoted cell apoptosis in a dose-dependent manner mainly through ER-β and GPER activation. Although HepG2 expressed low level of ER-β, leptin treatment increased expression of ER-β.  E2 activated ERK and p38-MAPK signaling pathway in HepG2 cells. Additionally, both ER-α agonist PPT and ER-β agonist DPN reduced leptin-induced Stat3 signaling, but only ER-β agonist increased suppressor of cytokine signaling (SOCS3).

Conclusion: Estrogen antagonizes the oncogenic actions of leptin in HCC via multiple manners. Identifying the roles of different estrogen receptors would provide comprehensive understanding underlying protective effects of estrogen and gender disparity in HCC, thus would shed light on potential treatment for HCC.

 

Nothing to Disclose: MS

19361 8.0000 FRI-337 A Estrogen and Its Receptor Agonists Antagonize Oncogenic Actions of Leptin in Hepatocellular Carcinogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Tung-Yueh Chuang*1, Hsiao-Li Wu1, Michael P Diamond1, Ricardo Azziz2 and Yen-Hao Chen1
1Georgia Regents University, Augusta, GA, 2Augusta University, Augusta, GA

 

Hepatocellular carcinoma (HCC) is the fifth most common malignancy and the third leading cause of cancer-related death worldwide with an extremely grim prognosis. Berberine (BBR), a traditional Chinese herb, has been found to inhibit proliferation of human HepG2 HCC cells. This finding suggests that BBR may be a candidate for the treatment of HCC. However, more mechanistic studies are needed to affirm this concept before clinical trials are undertaken. In this study, we report that BBR treatment in HepG2 cells inhibits cell proliferation by modulating the expression of multiple tumorigenesis-related genes; including upregulating of kruppel-like factor 6 (KLF6), activating transcription factor 3 (ATF3), and p21, while downregulating the expression of oncogenes such as E2F transcription factor 1 (E2F1) and pituitary tumor transforming gene 1 (PTTG1). Previous studies and our results indicate that BBR induces phosphorylation of ERK1/2 in HepG2 cells. In the present study BBR-reduced cell proliferation and BBR’s upregulation of KLF6, ATF3, and p21 expressions was partially inhibited by the MEK kinase inhibitor, PD98059. PD98059, however, did not affect BBR’s downregulation of E2F1 and PTTG1 expression. In conclusion, BBR inhibits cell proliferation and regulates multiple tumorigenesis associated genes in HepG2 cells. MEK kinase inhibition was unable to completely block BBR’s effects in HepG2 cells suggesting that other pathways may also be involved in this regulation, and further studies are needed to identify these. Lastly, the results from our study further substantiate BBR’s potential role in the treatment of HCC.

 

Nothing to Disclose: TYC, HLW, MPD, RA, YHC

20981 9.0000 FRI-338 A Berberine Regulates Expression of Multiple Tumorigenesis Related Genes in HepG2 Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Leticia F. Leal*1, Ana Carolina Bueno1, Debora Cristiane Gomes2, Rafael Haikal Abduch1, Danila Akemi Arahata1, Rogério Lenotti Zuliani1, Margaret De Castro1 and Sonir Roberto Rauber Antonini1
1Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 2School of Medicine of Federal University of Uberlandia, Uberlandia MG, Brazil

 

Background: β-catenin mutations and/or Wnt/β-catenin pathway abnormal activation are common in adrenocortical tumors (ACTs). PNU-74654 is a non-FDA approved drug that can acts as Tcf/β-catenin complex antagonist.

Objective: to investigate the in vitro effects of PNU-74654 on β-catenin-dependent transcription, adrenal steroidogenesis and cell viability in adrenal (NCI-H295) and non-adrenal (HeLa) cell lines.

Methods: NCI-H295 and HeLa cell lines were treated with vehicle (DMSO) and PNU-74654 (5, 10, 50, 100 and 200μM) for 24-96h (NCI-H295) or 48h (HeLa) after treatment to evaluate cell viability (MTS-based proliferation assay), β-catenin expression and localization (western blot and immunofluorescence), mRNA expression of CTNNB1, AXIN2, TCF7, SF1 and CYP21A2(qPCR), and adrenal steroids production (radioimmunoassay).

Results: the inhibition of Tcf/β-catenin complex impaired cell proliferation in a dose-dependent manner. NCI-H295 cell viability decreased by 22%, 27%, 50 and 97% at 10, 50, 100 and 200μM PNU-74654 (p<0.0001), respectively, 96h after treatment. Instead, HeLa cell viability was not affected after treatment by PNU-74654, indicating that this drug-like acts specifically in cells/tissues in which Wnt pathway is activated. Immunofluorescence showed markedly cytotoxic effect as well as reduction of nuclear and cytoplasmic β-catenin expression 48h after treatment of PNU-74654 at 10, 50 and 100μM. β-catenin was also decreased 48 and 96h after PNU-74654 treatment as shown by western blot. In line, PNU-74654 treatment decreased CTNNB1 mRNA expression at 50 and 100μM (p=0.04 and p=0.0034, respectively), but did not affect TCF7 mRNA expression. β-catenin target genes, AXIN2 and CCND1, presented higher mRNA expression at 50μM 48h after treatment (p=0.01 and p=0.0048, respectively). Indeed, PNU-74654 treatment at 10, 50 and 100μM impaired steroidogenesis as shown by decrease in mRNA expression of CYP21A2 (12%, 63% and 88%, respectively; p<0.001) and SF1 (20%, 52% and 66%, respectively; p<0.001). In agreement, cortisol, testosterone, androstenedione and SDHEA secretion was reduced 24 and 48h after treatment with PNU-74654 at 50, 100 and 200μM. Interestingly, adrenal steroidogenesis was impaired already at 24h, before cell viability reduction, showing a potential direct effect on adrenal steroids secretion.

Conclusion: In NCI-H295 adrenal cell line, but not in HeLa cell line, PNU-74654, a TCF7/β-catenin inhibitor, impaired cell proliferation, β-catenin expression and nuclear localization, and adrenal steroids secretion. Thus, Tcf/β-catenin complex inhibitors might become a new target approach for ACTs showing Wnt pathway activation.

 

Nothing to Disclose: LFL, ACB, DCG, RHA, DAA, RLZ, MD, SRR

21190 10.0000 FRI-339 A Anti-Proliferative and Anti-Steroidogenic Effect of TCF7/Beta-Catenin Complex Inhibition in Adrenocortical Tumor Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Christopher Ryan LaPensee*1, Stephen W Hunt III2, Jacqueline E Mann3 and Gary D Hammer4
1University of Michigan, Ann Arbor, MI, 2Atterocor, Inc., Ann Arbor, MI, 3University of Michigan, 4Univ of Michigan, Ann Arbor, MI

 

Adrenocortical carcinoma (ACC) is a rare cancer of the adrenal cortex, with an estimated worldwide annual prevalence of 0.5 to 2 cases per million, accounting for 0.2% of cancer deaths annually. ACCs are highly aggressive with many patients presenting with metastases upon diagnosis due to difficulty of detection. Therapeutic options for the treatment of ACC are limited. While mitotane and cytotoxic chemotherapy are often used to treat metastatic ACC, the efficacy of most regimens is extremely toxic and poorly tolerated, leaving an unmet medical need for new treatments for ACC. ATR-101 is a novel, oral drug candidate currently in development for the treatment of ACC. ATR-101 is an inhibitor of acetyl-coenzyme A:cholesterol O-acetyltransferase 1 (ACAT1), an enzyme located in the endoplasmic reticulum (ER) membrane that catalyzes esterification of intracellular free cholesterol. Proper maintenance of cholesterol homeostasis in the adrenal cortex is essential, as cholesterol is the precursor of all steroid hormones. In preclinical studies, ATR-101 has been shown to have selective inhibitory effects on cells derived from the adrenal cortex in a number of species. We are investigating mechanisms by which ATR-101 specifically targets and induces apoptosis in cells of the adrenal cortex. In H295R human adrenocortical carcinoma cells, ATR-101 decreases the formation of cholesteryl esters and increases free cholesterol levels, demonstrating potent inhibition of ACAT1 activity. Caspase-3 levels are increased by ATR-101 treatment, indicating activation of apoptotic machinery. Exogenous cholesterol markedly potentiates the activity of ATR-101, suggesting that buildup of free cholesterol in response to inhibition of ACAT1 increases Caspase-3 activation and subsequent cell death. Inhibition of calcium release from the ER reverses apoptosis induced by ATR-101. ATR-101 also activates multiple components of the Unfolded Protein Response, an indicator of ER stress, as evidenced by XBP-1 splicing and induction of CHOP mRNA expression. Together, these studies indicate that ATR-101 increases intracellular free cholesterol, induces ER stress and causes apoptosis of H295R cells through a calcium-dependent mechanism.

 

Disclosure: SWH III: Employee, Atterocor Inc. GDH: Founder, Atterocor Inc. Nothing to Disclose: CRL, JEM

22080 11.0000 FRI-340 A ATR-101, a Selective and Potent Inhibitor of ACAT1, Increases Intracellular Free Cholesterol, ER Stress and Apoptosis in Adrenal Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Dorota Dworakowska*1, Paulina Szyszka2, Urszula Waszut3, Gregory Weitsman1, Melvyn Smith1, Salvador J Diaz-Cano4, Jane Moorhead5, Simon J B Aylwin4, Krzysztof Sworczak2, Stefan Richard Bornstein6 and Tony Ng1
1Kings College London, London, United Kingdom, 2Medical University of Gdansk, Gdansk, Poland, 3Medical University of Gdansk, 4King's College Hospital, London, United Kingdom, 5Kings College Hospital, 6University Hospital Carl Gustav Carus, Dresden, Germany

 

Mitotane acts specifically on adrenocortical tissue and is used as a standard treatment in adrenocortical cancer. The exact mechanism of its action remains unknown, despite its clinical use for more than 60 years. Recently it has been suggested that in human adrenocortical cancer cells, mitotane alters mitochondrial respiratory chain activity by inducing cytochrome c oxidase defect.

The aim of the study was to assess the effect of Mitotane on proliferation, apoptosis and mitochondrial metabolism in human breast (MCF7), lung (H1975) and colon (HKe-3) cancer cell lines and compare it with our previous results in human adrenocortical cancer (H295R).

The proliferation rate of cells was assessed by the resazurin assay. The apoptosis induction was determined by the caspase-3-like activity assay. Changes in expression of the 84 genes involved in mitochondrial metabolism (Complex I: NADH-Coenzyme Q Reductase; Complex II: Succinate-Coenzyme Q Reductase; Complex III: Coenzyme Q-Cytochrome c Reductase; Complex IV: Cytochrome c Oxidase; Complex V: ATP Synthase) were assessed using Mitochondrial Energy Metabolism Plus PCR Arrays, Qiagen.

Optimum cytotoxic effects of Mitotane were observed after 24 and 48 hours incubation for H295R cells and HKe-3, MCF7, H1975; respectively. In the H295R cell line a 10uM concentration of Mitotane resulted in 27.0±0.9% cytotoxicity, whereas in HKe-3, MCF7 and H1975 cell lines concentration of 40uM caused cytotoxicity of 48.5±5.2%; 40.2±2.5% and 28.6±2.1%, respectively. 100% cytotoxicity was achieved at a concentration of 20uM for H295R and 100uM for HKe-3, MCF7 and H1975. Cytotoxic effects were negatively influenced by the number of cells/well in H295R, HKe-3, and H1975 but not in MCF7. Although Mitotane had a strong cytotoxic effect on all tested cell lines, caspase-3 activity was induced only in H295R cell line. Expression levels of several genes involved in mitochondrial metabolism was changed by Mitotane, however different genes were affected in different cell lines. Of 84 genes investigated, mRNA levels were decreased/increased by >2 folds in 18/4; 10/29; 6/7 and 28/2 in H295R, HKe-3, MCF7 and H1975, respectively.

Mitotane exhibits anti-proliferative activity in breast, colon and lung cancer cell lines. It affects mitochondrial metabolism regardless from the type of cancer and hence his cytotoxic effect is not only specific to adrenal cortex.  

 

Nothing to Disclose: DD, PS, UW, GW, MS, SJD, JM, SJBA, KS, SRB, TN

21167 12.0000 FRI-341 A Mitotane Inhibits Proliferation and Affects Mitochondrial Metabolism in Human Breast, Lung and Colon Cancer Cell Lines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Ziying Liu*1 and W Lee Kraus2
1The Laboratory of Signaling and Gene Expression, Cecil H. and Ida Green Center for Reproductive Biology Sciences and The Division of Basic Research, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Medical Center, Dallas, TX

 

Triple-negative breast cancer (TNBC) is a subtype that imposes challenges for treatment, in part due to its lack of chemotherapeutic target proteins such as ER, PR, HER2.  Patients with TNBC frequently have poor prognoses and outcomes.  Therefore, identifying novel genes and pathways that cause the progression of TNBC will be of great help for designing therapies for treatment.  Sox2 is a transcription factor containing an HMG domain that plays important roles in maintaining Pluripotency and other stem cell features in embryonic stem cells.  Interestingly, recent studies have also identified Sox2 as a potential oncogene that drives the initiation and progression of multiple cancer types.  Importantly, Sox2 expression has been found to be positively associated with TNBC and metastatic breast cancers.  Higher Sox2 expression levels have also found to be correlated with poorer outcomes in TNBC patients.  These results suggest that Sox2 may be responsible for causing the aggressive growth phenotypes of TNBC, although the mechanism for this is largely unknown.  Poly(ADP-ribose) polymerase-1 (PARP-1) is a ubiquitous and abundant nuclear protein, which has been targeted therapeutically in cancers.  In addition to its role in regulating DNA damage response, PARP-1 also acts as a critical regulator of chromatin structure and gene transcription.  PARP inhibitors have been explored as a therapy for treating triple-negative breast cancers.  Our previous studies have shown that PARP-1 regulates Sox2 chromatin binding in embryonic stem cells.  Interestingly, this function of PARP-1 is independent of its PARylation activity.  We are currently testing whether the association between PARP-1 and Sox2 identified in ES cells also occurs in TNBC cells.  Our studies will shed light on understanding the mechanisms of Sox2-related TNBC tumor progression, and will provide further guidance in using PAR inhibitors as a therapeutic drug for treating TNBC patients.  This work is supported by a grant (DK069710) from the NIH/NIDDK to WLK.

 

Nothing to Disclose: ZL, WLK

22117 13.0000 FRI-342 A Functions of PARP-1 in Sox2-Positive Triple-Negative Breast Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Syreeta L Tilghman*1, Patrick Carriere1, Shawn Dion Llopis1, Jamal Pratt1, Anna Naiki1, Gina Nguyen1, Tina Phan1, Lynez Preyan1, Letitia Yearby1, Ian R Davenport2, KiTani Parker-Lemieux1, Florastina Payton-Stewart2 and Christopher C Williams1
1Xavier University of Louisiana, College of Pharmacy, New Orleans, LA, 2Xavier University of Louisiana, College of Arts and Sciences, New Orleans, LA

 

Although aromatase inhibitors, such as letrozole, are standard endocrine therapy for postmenopausal women with early-stage metastatic estrogen-dependent breast cancer, the major limitation in managing this disease is the development of drug resistance.  Therefore, a better understanding of this process is critical towards developing novel strategies and therapies for disease management.  Previously, we demonstrated a global proteomic signature of letrozole-resistance that was associated with hormone independence and enhanced cell motility implicating the involvement of epithelial mesenchymal transition (EMT).   Letrozole-resistant breast cancer cells (LTLT-Ca) were treated with a novel phytoalexin, glyceollin I, and a series of biological and functional studies were performed.  Glyceollin I-treated LTLT-Ca cells exhibited morphological characteristics synonymous with an epithelial phenotype, while vehicle-treated cells exhibited a mesenchymal-like morphology.  The glyceollin I induced reversion of LTLT-Ca cells to an epithelial phenotype did not restore ERα expression.  However, glyceollin I caused a 72.9% and 57.7% inhibition in LTLT-Ca cell viability and proliferation, respectively which were supported by a marked reduction in glyceollin I mediated Ki67 immunoflourescent staining.   Compared to letrozole sensitive AC-1 cells (ie., MCF-7 cells stably transfected with the human aromatase gene), letrozole resistance caused a 4.51-fold increase in ZEB1 expression, while glyceollin I treatment caused a -3.39-fold reduction.  Immunofluorescent analyses indicated that glyceollin I caused an 8.3-fold increase in E-cadherin protein staining intensity in LTLT-Ca cells compared to vehicle-treated cells.  In vivo studies were performed in ovariectomized postmenopausal, female nude mice and immunhistochemical tumor staining results indicated that glyceollin treated mouse tumors were weakly positive for ZEB1 (score 1) and N-cadherin (score 1) while very strongly positive for E-cadherin (score 3).  Similar immunohistochemistry results were also obtained in brain tissue.  When compared to letrozole sensitive cells, letrozole resistant cells displayed enhanced cell motility, however in the presence of glyceollin I, there was a 68% and 83% decrease in invasion and migration, respectively.   Here, we demonstrate for the first time, the potential of a novel phytoalexin, glyceollin I, to reverse EMT in letrozole resistant breast cancer cells, which may aid in the development of novel EMT inhibitors.

Sources of Research Support: NIH SCORE 2 Grant 1SC2GM099599-01A1 (PI: Tilghman); Xavier University of Louisiana RCMI Grant 3G12MD007595-05; Louisiana Cancer Research Consortium

 

Nothing to Disclose: SLT, PC, SDL, JP, AN, GN, TP, LP, LY, IRD, KP, FP, CCW

18546 14.0000 FRI-343 A Glyceollin I Reverses Epithelial to Mesenchymal Transistion in Letrozole Resistance through ZEB1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Erik Russell Nelson*1, Suzanne Elizabeth Wardell2 and Donald P McDonnell2
1University of Illinois at Urbana-Champaign, Urbana, IL, 2Duke University School of Medicine, Durham, NC

 

Breast cancer remains the most common cancer in women and is the second leading cause of cancer death in women. While frontline endocrine therapies have increased the survival rate of patients, relapse with resistant metastatic disease is common. It is important to note that the metastatic spread of the disease is the cause of mortality in the vast majority (>90%) of patients, not the primary tumor itself. The magnitude of this problem provides strong rationale for studies that may lead to the development of new chemopreventative strategies and/or lifestyle changes that reduce breast cancer metastasis. In this regard, both obesity and elevated cholesterol have been associated with a decreased relapse free survival. On the other hand, patients taking inhibitors of 2-hydroxy-3-methylglutaryl coenzyme A (statins) experience a significantly increased relapse free survival time. Therefore, using murine models, we tested the hypothesis that cholesterol promotes the metastasis of breast cancer. Since we have recently shown that a primary metabolite of cholesterol, 27-Hydroxycholesterol (27HC), exerts partial agonist activity on both the estrogen receptors (ERs) and liver X receptors (LXRs), we determined whether 27HC may mediate the potential pathogenic effects of cholesterol. We demonstrate that 27HC (1) increases metastasis to the lung, (2) promotes an epithelial to mesenchymal like transition, and (3) in a myeloid cell dependent manner, alters the metastatic microenvironment to promote cancer cell colonization. Our ongoing work is aimed at identifying the specific mechanisms by which 27HC induces these changes and thereby increases metastasis. In summary, our data strongly suggests that 27HC is the biochemical mediator of the effects of cholesterol on breast cancer metastasis. These results provide additional support for the exploration of potential chemopreventative benefits of lower cholesterol diets, pharmacological inhibitors of HMG-CoA reductase or the enzyme responsible for the synthesis of 27HC (CYP27A1), and macrophage ablative strategies.

 

Nothing to Disclose: ERN, SEW, DPM

19210 15.0000 FRI-344 A Mechanisms By Which Cholesterol Promotes Breast Cancer Metastasis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Teresa Gagliano*1, Federico Tagliati2, Eleonora Riva2, Sambugaro Silvia2, Erica Gentilin2, Simona Falletta1, Katiuscia Benfini1, Carmelina Di Pasquale1, Ettore Ciro degli Uberti2 and Maria Chiara Zatelli2
1University of Ferrara, Ferrara, Italy, 2University of Ferrara

 

TIM 16 is a protein of the traslocase complex TIM 23 situated in the mitochondrial inner membrane, encoded by the Magmas gene, that is overexpressed in human pituitary adenomas. Magmas silencing in ACTH-secreting rat pituitary adenoma cells leads to a greater sensitivity to apoptotic stimuli. We recently demonstrated that Magmas overexpression protects GH-secreting rat pituitary adenoma cell lines towards apoptosis. Moreover We found that compound 5, a Magmas protein inhibitor, is not cytotoxic but enhances the proapoptotic effects of staurosporine by reducing mitochondrial membrane potential (MMP) activation in a medullary thyroid carcinoma cell line, suggesting that compound 5 may be useful for cancer treatment in association with chemotherapeutic drugs, possibly allowing a reduction of the chemotherapeutic agent effective dose.

Since breast cancer (BC) display high chemoresistance the aim of our study was to investigate Magmas expression in human breast cancer cell lines and to verify if compound 5 could increase the effects of a chemotherapeutic agent, such as Doxorubicin in these cells.

We found that Magmas protein is overexpressed in the MCF7 cell lines as compared to MCF12A normal breast tissue cells. Our data show that treatment with compound 5 did not influences cell viability a while Doxorubicin inhibits cell viability by 20-30% in both cell lines.   Only in MCF7 co-treatment with compound 5 enhance by 15-20% the antiproliferative effects of Doxorubicin, Moreover MCF7 BAX levels are enhanced after treatment with compound 5 and Doxorubicin, while the same treatment did not affect BAX levels in MCF12A.

By a MitoTox Glo assay we determined that the enhancing effects of compound 5 on Doxorubicin effects are due to mitochondrial toxicity. In addition treatment with compound 5 strongly decreased MMP in MCF7 while had weaker effects on MCF12A. Finally we found that co-treatment with compound 5 and Doxorubicin leaded to a decreasing BrDu incorporation, suggesting antiproliferative effects of the combination of these drugs.

Taken together these data suggest a role for the use of compound 5 as a sensitizing agent for chemoresistant breast cancer treatment.

 

Nothing to Disclose: TG, FT, ER, SS, EG, SF, KB, CD, ECD, MCZ

19755 16.0000 FRI-345 A Inhibition of TIM 16 Leads to an Enhanced Sensitivity to Doxorubicin in Human Breast Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Nina Bickell1, Emily Jane Gallagher*1, Alison Estabrook2, Sheldon M Feldman3, Elisa Port1, Ayemoe Thu Ma4, Susan K Boolbol5, Kevin Clarke6, Rebeca Franco7, Kezhen Fei8 and Derek LeRoith1
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Mount Sinai Roosevelt, New York, NY, 3Columbia University Medical Center, New York, NY, 4Mount Sinai St. Luke's, New York, NY, 5Mount Sinai Beth Israel, New York, NY, 6Newark Beth Israel Medical Center, Newark, NJ, 7Icahn School of Medicine, New York, NY, 8Icahn School of Medicine at Mount Sinai, New York, NY

 

Background: White women are more likely to develop breast cancer than black women. However, black women are more likely to die of breast cancer and have more aggressive type cancers.  Black women are also more likely to have obesity and insulin resistance than white women.  Insulin resistance has been associated with faster tumor growth in mouse models of breast cancer, but has not been studied as a potential mediator of racial disparities in women with breast cancer. We hypothesized that black women would have more aggressive breast cancer at presentation and this would be associated with obesity and insulin resistance. We describe early findings of the association of insulin, insulin resistance and aggressive breast cancer among 74 white & 17 black women with newly diagnosed breast cancer.

Methods:  We recruited 91 (81% white, 19% black) women with a new primary breast cancer and measured pre-operative fasting blood glucose and insulin, measured BMI, the Nottingham prognostic index.  We classified aggressive breast cancer as a NPI >4.4. We calculated HOMA scores use fasting insulin and glucose and classified insulin resistance a HOMA >2.8, the upper quartile of insulin resistance in the US population. Patients self-identified race.

Results:  Of 91 women with new breast cancer, average age was 59.6 years (sd=12.3). 58 (64%) were stage I; 30 (33%) stage II; 3 (3%) stage III at time of diagnosis.  Twenty percent had a NPI >4.4 (2% >5.4 iNPI). There was no racial difference in stage or aggressive breast cancer: 24% of black women vs 19% of white women had aggressive breast cancer (p=0.74).  BMI ranged from 16.4 to 45.1 with a racial difference (25.5 in whites vs. 30.1 in blacks; p=0.001) and in insulin resistance (HOMA= 1.0 in whites v 2.1 blacks; p=0.01). Black women are more likely to be obese (47% vs. 10%, p=0.001) and be insulin resistant (24% vs. 7%, p=0.059).  HOMA scores were not significantly associated with NPI scores (r=-0.06, p=0.6).

Conclusions:  Even at this early stage in the study, we see that in women with newly diagnosed breast cancer, black women are more likely to be obese and insulin resistant than white women and with ongoing recruitment we will see if this correlates to significant differences in parameters of tumor aggression.

 

Nothing to Disclose: NB, EJG, AE, SMF, EP, ATM, SKB, KC, RF, KF, DL

21000 17.0000 FRI-346 A Are Racial Differences in Obesity and Insulin Resistance Related to Aggressive Breast Cancer? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Cinthia Gabriel Meireles*1, Francisco de Assis Rocha Neves2, Adriana Lofrano-Porto3 and Luiz Alberto Simeoni1
1University of Brasilia, Faculty of Health Sciences, Molecular Pharmacology Laboratory, Brasilia, Brazil, 2University of Brasilia, Brasilia, Brazil, 3University of Brasilia, Brasilia DF, Brazil

 

Pheochromocytomas are rare neuroendocrine tumors derived from chromaffin cells localized in the adrenal medulla. Malignant tumors still demand effective pharmacological treatment. The usefulness  of multitargeted tyrosine kinase inhibitors, specifically sunitinib, has shown conflicting results. On the other hand, metformin antitumoral effects have been demonstrated in various cancer cells lines in vitro and have been associated with AMPK activation, which ultimately result in growth and proliferation restrain, through mTORC1 inhibition. Despite its worldwide use in patients with type 2 diabetes, the antitumoral effect of metformin on pheochromocytoma has not been explored. Therefore, we aimed to investigate the effects of metformin alone and in combination with sunitinib on the viability of pheochromocytoma cells in vitro. We initially treated PC12 Adh rat pheochromocytoma cells with increasing concentrations of metformin and analysed cell viability by the MTT (Thiazolyl Blue Tetrazolium Bromide) assay after 24 and 48h, as compared to untreated cells (control). We showed that metformin induced a maximum inhibition of 40% of cell viability after 48h of treatment, with an IC50 of 20mM. Sunitinib induced a maximum inhibition of  60%, with an IC50 of 8uM. However, when the cells were treated with both sunitinib and metformin under varying concentrations, we observed that the maximum effect of sunitinib was not achieved, while inhibitory effect of metformin was apparently sustained. Moreover, western blot showed that metformin increased cleaved caspase 3, which was suggestive of apoptosis induction. Flow citometry was performed for cell cycle analysis. Our results suggest that metformin has a moderate inhibitory effect on the viability of pheochromocytoma cells in vitro, and that this effect may be associated with apoptosis induction. Moreover, the combination of metformin and the tyrosine kinase inhibitor sunitinib did not improve the antiproliferative potential of either drug. The cell viability inhibitory effect of metformin was apparently dominant when it was used in combination with sunitinib, which may suggest a possible interaction between these two drugs. Both metformin and sunitinib were previously shown to inhibit mTORC1 and reduced cell proliferation and survival. The hypothesis of  a possible inibitory modulation of metformin on sunitinib antiproliferative effect and the molecular mechanisms underlying this interaction deserve additional studies.

 

Nothing to Disclose: CGM, FDARN, AL, LAS

21926 18.0000 FRI-347 A Metformin Induces a Moderate Inhibitory Activity on Viability of PC12 Rat Pheochromocytoma Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Kate E Lines*1, Mark Stevenson1, Paul J Newey1, Sian E Piret1, Panagis Filippakopoulos1, Susanne Muller1, Simona Grozinsky-Glasberg2, Ashley B. Grossman1, Stefan Knapp1, Chas Bountra1 and Rajesh V Thakker1
1University of Oxford, Oxford, United Kingdom, 2Hadassah-Hebrew University Medical Center, Jerusalem, Israel

 

There are currently no curative treatments for metastatic pancreatic neuroendocrine tumors (PNETs), and the 5-year survival is less than 50%; such tumors frequently have mutations in chromatin remodeling genes and the protein encoded by the multiple endocrine neoplasia type 1 (MEN1) gene, menin, which is mutated in  up to 40% of sporadic PNETs, and binds the histone methyltransferase MLL1. Histone modifications, and specifically acetylated residues on histone tails, are recognized by members of the bromo and extra terminal (BET) protein family, via their bromodomains, causing alterations in the transcription of growth stimulating genes. We therefore assessed the efficacy of the pan-BET inhibitor, JQ1+, on proliferation (using the cell titre blue viability assay), apoptosis (using the CaspaseGlo, caspase 3/7 activity assay) and cell cycle progression (using propidium iodide staining and flow cytometry; and β-galactosidase (X-gal) staining) in three human NET cell lines (BON-1, derived from a PNET, and H727 and H270, both derived from lung NETs). All three of these cell lines were shown to express the BET genes bromodomain-containing (Brd) 2, Brd3 and Brd4, which are all inhibited by JQ1+, although the expression profiles of these BET genes differed among the cell lines such that in BON-1 cells the ratio of expression of Brd2:Brd3:Brd4 was 8:1:4, in H727 cells 6:1:5 and in H720 cells 4:1:1. However, in all NET cell lines JQ1+ was found, compared to the inactive stereoisomer control compound JQ1-, to significantly: reduce proliferation by up to 85% (p<0.001) with an average 50% inhibitor concentration (IC50) of 32nM, with H720 being the most sensitive cell line; increase apoptosis, with as little as 24 hour treatment, by up to 3-fold (p<0.0005), with the most sensitive cell line being H720; increase the percentage of cells in the G1 stage of the cell cycle by up to 10% (p<0.0001), with BON-1 cells being the most sensitive; and increase cellular senescence by up to 6-fold (p<0.0001), with equal sensitivity seen in BON-1 and H727 cells. Western Blot analysis revealed alterations in protein expression in JQ1+ treated NET cell lines when compared to JQ1- treated cell lines; thus, BET protein inhibition caused a significant decrease in expression of the oncogene c-myc, of up to 60% (p<0.005), in BON-1 and H727 cells; and a 50% decrease (p<0.01) in expression of the cell cycle regulator cyclin D1 in BON-1 cells. These results suggest that JQ1+ may elicit its effects via different mechanisms in each NET cell type. In summary, our data demonstrate that BET protein inhibitors may represent potential compounds for the treatment of NETs.

 

Disclosure: ABG: Ad Hoc Consultant, Lecture fees and Advisory Board, Ad Hoc Consultant, Lecture fees and Advisory Board. Nothing to Disclose: KEL, MS, PJN, SEP, PF, SM, SG, SK, CB, RVT

19192 19.0000 FRI-348 A An Epigenetic Modifier That Inhibits Bromo and Extra Terminal (BET) Protein Activity Reduces Proliferation, Prevents Cell Cycle Progression and Increases Apoptosis in Human Neuroendocrine Tumor (NET) Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Sita D Modali*, Vaishali I Parekh, Shruti S Desai and Sunita K Agarwal
National Institutes of Health, NIDDK, Bethesda, MD

 

Insulinomas are insulin secreting pancreatic neuroendocrine tumors (PETs/PNETs/PanNETs) that arise from the pancreatic islet β-cells. Understanding the molecular events associated with insulinoma pathogenesis can provide insights into β-cell function and proliferation pathways, and can also impact research about conditions that can benefit from β-cell replication and replacement strategies such as diabetes. Insulinomas occur sporadically or in the multiple endocrine neoplasia type 1 (MEN1) syndrome. In MEN1 patients, a germline inactivating mutation in MEN1 (1st hit) and subsequent somatic loss of the second copy of MEN1 (2nd hit) leads to tumor development in multiple endocrine glands, mainly the parathyroids, pituitary and pancreas. Germline homozygous Men1 loss in mice leads to early embryonic lethality (E10.5-E14.5), while Men1+/- mice mimic the human MEN1 syndrome with biallelic Men1 loss in the tumors. We found that the expression of the long non-coding RNA Meg3 was reduced in embryonic stem cells derived from Men1-null mouse embryos (microarray and RT-PCR), and in human insulinomas (RT-PCR). Meg3 (also known as Gtl2) acts as a tumor suppressor by affecting the Rb and p53 pathways, and it is also found in a chromatin modifying protein complex for transcriptional repression. In order to determine the role of Meg3 in insulinoma formation, we examined the level of Meg3 mRNA in pancreatic islets of the mouse model of MEN1 (Men1+/- mice). These mice develop insulinomas after age 15 months. Quantitative RT-PCR for Meg3 was performed using RNA from wildtype (WT) and Men1+/- mice: 5 mice each at age 6 weeks, 6 months, 15 months, and 18-22 months. For all mice at age 6 weeks, 6 months and 15 months, and for WT mice at age 18-22 months, RNA was prepared using islets isolated after intra-ductal collagenase perfusion of the pancreas. For older Men1+/- mice with visible insulinomas on the pancreas, the tumors were directly processed for RNA isolation. Tumor RNA from older mice (18-22 months) showed less Meg3 compared to RNA from islets of mice at a similar age (p < 0.005), but no significant difference in Meg3 was observed at the other time-points. Therefore, Meg3 deficiency may not be an early event in insulinoma formation. However, because not all islets would form a tumor, it would be useful to look at individual islets in the pancreas for Meg3 with in situ hybridization RNA probes or the targets of Meg3. Such studies will help to understand the early events in the pathogenesis of insulinomas and other tumors associated with the MEN1 syndrome and similar sporadic tumors, and could help to develop early detection and therapeutic options for the management of these tumors.

 

Nothing to Disclose: SDM, VIP, SSD, SKA

20973 20.0000 FRI-349 A Exploring the Deficiency of Long Non-Coding RNA Meg3 As an Early Event in the Pathogenesis of Insulinomas in the Mouse Model of MEN1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Renata Costa Camargo*, Clarissa Silva Martins, Fabiano Pinto Saggioro, Luciano Neder, Helio Rubens Machado, Ayrton C. Moreira and Margaret De Castro
Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil

 

Introduction: Genes involved in the process of proliferation and apoptosis might be involved in the pathogenesis of human pituitary tumors.

Objective: To evaluate the expression of genes encoding cell cycle regulators (RB1, TP53, MDM2, E2F, CDK4/6, and CCND1), RPS3 and RPL11 (ribosomal proteins involved in controlling cell cycle genes), and BTG2, a member of an anti-proliferative family in human non functioning pituitary tumors (NFPA) and in mouse cell lineage. In addition, we correlate gene expression with clinical findings, such as tumor diameter, immunohistochemistry, remission after surgery and hypopituitarism.

Methods: We studied normal pituitaries (n=7) and NFPA (n=21). Clinical data was collected. Non-functioning pituitary adenomas lineage (αT3-1) was compared to primary culture which was performed using anterior pituitary cells from mouse. RNA was isolated by TRIzol and gene expression assessed by qPCR (2 -ΔΔCT). Mann-Whitney and Kruskal-Wallis tests were used for continuous variables, when appropriated. Fisher Exact test was used for categorical data.

Results: We observed no differential expression of RPS3, TP53, MDM2, CDK4, CCND1, RB1, and E2F1. We observed underexpression of BTG2 (p=0.0007), CDK6 (p=0.02) and RPL11 (p=0.002) in NFPA compared to normal pituitaries. There was no association between the expression of any studied gene and any clinical findings, except by the association of RB1 underexpression with larger tumor size (p=0.03). The BTG2, RB1, CCND1, CDK4, CDK6, RSP3 and RPL11 genes were also analyzed in different tumoral cell line αT3-1 passages and in mouse pituitary primary culture. We observed no differential expression of BTG2 and RPS3 among the passages of αT3-1 lineage and primary culture. We observed overexpression of RB1 (p<0.001), CDK4 (p<0.001) and RPL11 (p<0.01) among the passages compared with primary culture and an underexpression of CCND1 (p<0.001) among the αT3-1 passages compared with primary culture. Interestingly CDK6 had no expression in the cell lineage.

Conclusion: Our data on gene expression in NFPA suggest a dysregulation of BTG2 and RPL11, both acting as tumor suppressor genes, which could underlie their pathogenesis and lead to deregulation of the cell cycle. Furthermore, this mechanism does not seem to be dependent neither of RB1 and P53 pathways. Finally, the differential gene expression pattern between NFPA and αT3-1 tumoral cell lineage may be ascribed to culture immortalization.

 

Nothing to Disclose: RCC, CSM, FPS, LN, HRM, ACM, MD

21116 21.0000 FRI-350 A Potential Role of BTG2 Gene in the Molecular Pathogenesis of the Non-Functioning Pituitary Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 330-350 5973 1:00:00 PM Tumorigenesis, Metastasis, and Therapies for Cancer Poster


Ataru Okumura*1, Hironobu Umakoshi2, Mayu Minamoto3 and Tomikazu Fukuoka3
1Tokai Central Hospital, Kakamigahara, Japan, 2National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 3Matsuyama Red Cross Hospital, Matsuyama, Japan

 

Although the aldosterone renin ratio (ARR) is a useful tool to screen for excess production of aldosterone, there is an increasing need to develop an efficient method detecting aldosterone producing adenomas (APAs) prior to their lateralization with an adrenal venous sampling (AVS). One study reported a higher plasma aldosterone concentration (PAC) at 90 min after cosyntropin administration (PAC90min) in patients with APAs than in those with bilateral idiopathic hyperaldosteronism (IHAs) under 1 mg dexamethasone suppression(1).

The aim of our retrospective study was to evaluate the diagnostic accuracy of novel indices (PAC60min, PAC60min/PAC30min) of aldosterone secretion in the diagnosis of an APA among patients suspected to have primary aldosteronism (PA).

Among the 45 consecutive patients who had an ARR > 20, 32 were examined with PA confirmatory tests including captopril challenge test, furosemide upright test, saline infusion test, oral sodium loading test and a cosyntropin stimulation test (iv. administration of 0.25 mg cosyntropin the morning after 1 mg dexamethasone at 11 pm). All PA cases, including pathologically confirmed APAs, were plotted on a 2D graph according to the novel indices. Detection rates for the pathologically confirmed APAs were compared using a receiver-operated characteristics (ROC) curve and the area under the ROC curve (AUC) among PA confirmatory tests.

APA was confirmed in 8 patients based on pathological findings and the postoperative clinical course. The remaining 24 patients were treated with medication. The ROC analysis showed a higher sensitivity, specificity and AUC of PAC60min (0.875, 0.958, 0.953) and a higher sensitivity and moderate specificity of PAC60min/PAC30min (1.000, 0.667, 0.818) compared to the other PA confirmatory tests. Most of APAs (7 out of 8 cases) had a value of PAC60min >46.6 ng/dL and in all 8 patients with APA the PAC60min/PAC30min was >103%.

Recently a higher mRNA expression of both CYP11B2 and corticotropin (ACTH) receptor has been reported in the specimens of APAs than in IHAs or nonfunctioning adenomas(2). Thus, a higher PAC value after cosyntropin stimulation could be attributable to the higher expression of CYP11B2 in APAs. In addition our finding of prolonged aldosterone secretion (PAC60min/PAC30min >103%) could be attributable to the higher expression of the ACTH receptor in APAs.

In summary, in our preliminary retrospective study we found that novel indices (PAC60min, PAC60min/PAC30min) following cosyntropin administration were highly predictive of APA as the cause of PA.

Acknowledgements

The authors thank Dr. William F. Young, Jr., MD, MSc (Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, MN) for his helpful advice and reviewing the manuscript.

 

Nothing to Disclose: AO, HU, MM, TF

19054 5.0000 FRI-381 A Prolonged Secretion of Aldosterone in the Dexamethasone-Suppressed Cosyntropin Stimulation Test—a Potential Marker of Aldosterone Producing Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Joanna Klubo-Gwiezdzinska*1, Mihail Zilbermint2, Andrew Paul Demidowich3, Joan Nambuba4, Joanne Glanville5, Electron Kebebew6, Susmeeta T. Sharma4, Lynnette K. Nieman5, Constantine A Stratakis2 and Karel Pacak7
1National Institute of Health, Bethesda, MD, 2National Institutes of Health (NIH), Bethesda, MD, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 4Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 5NIH, Bethesda, MD, 6National Cancer Institute, NIH, Bethesda, MD, 7National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD

 

Background

ACTH-secreting pheochromocytoma is an extremely rare cause of ectopic Cushing syndrome with only 25 cases reported in the literature since 1964.

Clinical case

A 70 year old Caucasian female presented with rapid weight loss, episodes of diaphoresis, progressive weakness, lower extremity edema and hirsutism. The patient was diagnosed with diabetes (HgbA1c 8%) and hypertension with systolic blood pressure range of 170-200 mmHg.

Diagnostic workup revealed elevated plasma norepinephrine 3228 pg/ml [N 112-750],  epinephrine 345 pg/ml [N 0-50], dopamine 203 pg/ml [N 0-29], fractionated normetanephrine 368 pg/ml [N 18-112], fractionated metanephrine 137 pg/ml [N 12-61] – highly suggestive of pheochromocytoma.

Additionally, the patient was found to have hypokalemia of 2.9 mmol/l [N 3.5-5.5] and severe hypercortisolemia with urine free cortisol of 6968.3 mcg/24h [N 3.5-45], morning cortisol levels of 94.7 mcg/dl [N 5.0-25.0] and ACTH 470 pg/ml [N 0.0-46.0] - all consistent with ACTH-dependent Cushing syndrome. Clinically evident hyperandrogenemia was confirmed biochemically by increased total testosterone of 151 ng/dl [N<63] and androstenedione 234 ng/dl [17-175] levels.

Upon admission, the patient developed respiratory failure due to Pneumocystis and Nocardia pneumonia, requiring intubation and mechanical ventilation for 5 days. The opportunistic infections were most likely secondary to immunosuppression caused by hypercortisolemia. Rapid normalization of serum cortisol levels was achieved with an etomidate drip. The patient was subsequently placed on “block and replace therapy” with ketoconazole, metyrapone, and physiologic hydrocortisone. The pheochromocytoma management consisted of alpha blockade with doxazosin and beta blockade with atenolol. Localization studies for pheochromocytoma and ACTH-dependent Cushing syndrome revealed a 4.3x2.9x3.3 cm left adrenal mass with central necrosis and marked right adrenal hyperplasia. Functional studies including 68Ga-DOTATATE PET and 18F-FDG-PET confirmed the adrenal tumor to be the sole source of excess hormone production. Therefore, the patient underwent laparoscopic left adrenalectomy which resulted in clinical and biochemical remission (fractionated normetanephrine 63 pg/ml, metanephephrine<12 pg/ml, cortisol <1.0 mcg/dL, ACTH 8.4 pg/ml).

The pathology report was consistent with 2.5 x 1.9 x 2.5 cm pheochromocytoma and additional 0.1 cm adenoma arising from adrenal cortex.

Clinical lesson

The following diagnostic criteria can be utilized for the diagnosis of ACTH-secreting pheochromocytoma:

(1) clinical and laboratory evidence of hypercortisolism,

(2) elevated plasma ACTH levels,

(3) biochemical evidence of a pheochromocytoma,

(4) resolution of symptoms of adrenocorticoid and catecholamine excess after adrenalectomy, 

(5) rapid normalization of plasma ACTH levels after adrenalectomy.

 

Disclosure: LKN: Editor, Up To Date, Clinical Researcher, HRA Pharma. Nothing to Disclose: JK, MZ, APD, JN, JG, EK, STS, CAS, KP

21533 6.0000 FRI-382 A ACTH-Secreting Pheochromocytoma Leading to Respiratory Failure Secondary to Multiple Opportunistic Infections - a Unique Presentation of Ectopic Cushing Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


A Ram Hong*1, Jung Hee Kim1, Yeong Shin Song1, Kyu Eun Lee1, Kyung Won Kim1, Hak Chul Jang2, Sang Wan Kim1, Chan Soo Shin1 and Seong Yeon Kim1
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seoul, Korea, Republic of (South)

 

Background: Recently identified KCNJ5 mutation, which encodes G-protein activated inward-rectifying K+ channel 4, is associated with the development of familial hyperaldosteronism III and sporadic aldosterone-producing adenoma (APA). The aim of the study was to investigate the prevalence of KCNJ5 mutation, and its correlates with clinical and biochemical characteristics in Korean APA patients.

Materials and methods: Mutation of the KCNJ5 gene was examined in 19 patients with APA who underwent adrenalectomy between August 2010 and October 2013 at Seoul National University Hospital. Mutations in KCNJ5 gene were detected by direct sequencing after extraction of DNA from surgically resected APAs.

Results: Somatic mutations of the KCNJ5 gene were found in 15 (78.9%) of the 19 patients with APA, 9 cases of p.G151R (eight with c.451G>A and one with c.415G>C), 5 cases of p.L168R (c.503T>G) and one case of p.E145Q (c.433G>C). There were no significant differences in age, gender distribution, tumor size, preoperative blood pressure (BP) and potassium levels according to mutational status. However, preoperative plasma aldosterone concentration (PAC) and aldosterone-renin ratio (ARR) were significantly higher in patients with KCNJ5 mutation compared with those without mutation (100.6 ± 142.0 vs. 24.7 ± 7.3 ng/dL and 1005.5 ± 1419.9 vs. 212.7 ± 139.3, All P = 0.037). Therapeutic outcomes after surgery including postoperative BP, potassium level, postoperative PAC and ARR did not differ between two groups.  

Conclusions: The present study demonstrated high prevalence of somatic KCNJ5 mutations in Korean patients with APA. KCNJ5 mutation carriers may harbor severe phenotypes of primary aldosteronism, but further studies with a large sample size are needed to evaluate characteristics of KCNJ5 mutation in APA.

 

Nothing to Disclose: ARH, JHK, YSS, KEL, KWK, HCJ, SWK, CSS, SYK

20910 7.0000 FRI-383 A High Prevalence of KCNJ5 Mutations in Korean Patients with Aldosterone-Producing Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Ryo Morimoto*, Masataka Kudo, Yoshitsugu Iwakura, Yoshikiyo Ono, Yasuhiro Nakamura, Yoichi Arai, Kazumasa Seiji, Kei Takase, Hironobu Sasano, Sadayoshi Ito and Fumitoshi Satoh
Tohoku University Hospital, Sendai, Japan

 

Primary aldosteronism due to bilateral aldosterone-producing adenomas is considered to be one of surgically curable subtypes. Bilateral adrenal tumors detected by computed tomography scan in patiens with primary aldosteronism should be functionally differentiated between 'aldosterone-producing adenoma' and clinically non-functioning adenoma with bilateral hyperplastic lesions. We therefore performed segmental adrenal venous sampling to show aldosterone hypersecretion from drainage veins of aldosterone-producing adenomas and suppressed secretion of aldosterone from non-tumor adrenal drainers, which makes it possible to preoperative diagnosis of bilateral aldosterone-producing adenomas, but not bilateral hyperplasia with clinically non-functioning bilateral adenomas. Five cases with mean age of 50 (four males) were enrolled to have segmental adrenal venous sampling for primary aldosteronism with bilateral adrenal tumors. Mean aldosterone and plasma renin activity levels were 32.7 ng/dL and 0.32 ng/mL/h, respetively. Low dose (1mg) dexamethasone suppression tests revealed mean cortisol level of 1.0 mcg/dL, suggesting that those were unlikely to have autonomous secretion of cortisol. Captopril challenge tests also showed that mean aldosterone-over-renin activity ratio of 124.9 ng/dL per ng/mL/h. Based upon findings obtained from segmental AVS, adrenal-sparing bilateral  adrenalectomy was performed without perioperative complication with appropriate and tentative replacement of glucocorticoid. After the surgery, mean aldosterone levels were decreased to 4.4 ng/dL with renin activity of 1.1 ng/mL/h at 7days after the adrenalectomy. Glucocorticoid replacement was withdrawn at mean of 155 days after the surgery without episodes of adrenal insufficiency. Bilateral aldosterone-producing adenomas could be preoperatively differentiated from bilateral hyperplasia with bilateral adrenal nodules by segmental adrenal venous sampling with specific sampling from drainers of both aldosterone-producing adenomas and non-tumor attached adrenal tissues.

 

Nothing to Disclose: RM, MK, YI, YO, YN, YA, KS, KT, HS, SI, FS

20928 8.0000 FRI-384 A Potential Indication of Segmental AVS for Bilateral APA 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Duan Lian, WANG Hui and Zheng Hongting*
Xinqiao Hospital, Third Military Medical University, Chongqing, China, ChongQing, China

 

Background: Corticomedullary mixed pathological changes originating from different germ layers rarely manifest as specific types of diabetes or hypertension in clinical settings. It’s mechanism is rarely reported.

Clinical case: A 58-year man, without the typical appearance of Cushing's syndrome, had the diagnosis of diabetes and hypertension for 3 years.He had elevated glycated hemoglobin a1c

(7.7%,n:4-6%).He were found the right adrenal incidentaloma. Functional assessment: 1.abnormal cortisol secretion rhythm (8Am 290 nmol/l,n: 176.6-579.4nmol/l;4Pm 510 nmol/l, n: 66-353

nmol/l; 0Am 635 nmol/l, n<220 nmol/l) ; abnormal 1 mg dexamethason overnight test (cortisol after 1 mg dex 232nmol/l, n<50 nmol/l); normal ACTH concentrations(21.2ng/l,n:4.8-48.8ng/l);

2.normal  VMA (6.44mg/24h,n<13.6 mg /24h); 3. slightly reduced Supine aldosterone concentration (42.65pg/ml,n:60-175pg/ml); Diagnosis: subclinical Cushing's syndrome.On gross observation after surgery, the tumour diameter was approximately 5 cm and consisted ofmainly the medullary substance; the remaining region revealed normal adrenal gland. Haematoxylin and eosin staining revealed the adrenal capsule, residual adrenal cortex, tumour capsule, cortical substance, and main medulla pheochromocytoma tumour with clear hierarchical structures. Immumohistochemical analysis showed that the tumour was positive for chromogranin A and S-100, with a Ki-67 index of <5%; therefore, the tumour was diagnosed as a corticomedullary

mixed tumour. The tumour was positive for subcapsular inhibin, calretinin, and

adrenocorticotropic hormone; staining for both CGA and steroidogenic factor-1 on the tumour surface indicated a double-mesodermaloriginated adrenal teratoma containing partial cortical structures composed of pheochromocytes; and it had a cortical component showing mainly medullary lesions.Acetaldehyde dehydrogenase 1,CD44,CD133, Nestin and Nerve Growth

Factor Receptor staining were positive, suggesting that the double-mesodermal-originated tumour might be related to tumour stem cells.Although administration of medications for diabetes and hypertension was stopped until surgery was performed, the blood sugar level and blood pressure were maintained at 2, 12, 24, and 48 weeks after surgery.Continuous glucose monitoring system results, cortisol rhythms, catecholamine metabolite levels, glycated haemoglobin A1c, C-peptide release, positron emission tomography-computed tomography results, and meto-iodobenzylguanidine scintigraphy results were normal.

Conclusions: This is the first report about possible mechanism of the Cancer Stem Cells induced Adrenal Corticomedullary Tumor.

 

Nothing to Disclose: DL, WH, ZH

19809 9.0000 FRI-385 A When Subclinical Cushing's Syndrome and Pheochromocytoma Meet-Cancer Stem Cells Induced Adrenal Corticomedullary Tumor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Masanori Fujimoto*, Tomoko Takiguchi, Eri Komai, Akina Shiga, Akitoshi Nakayama, Seiichirou Higuchi, Ikki Sakuma, Hidekazu Nagano, Naoko Hashimoto, Sawako Suzuki, Hisashi Koide, Tomohiko Yoshida, Tomoaki Tanaka and Koutaro Yokote
Chiba University Graduate School of Medicine, Chiba, Japan

 

Background

Pheochromocytomas (PCs) have varied clinical phenotypes with malignant PCs accounting for about 10%–30% of all cases. In some cases, the disease is highly progressive and metastatic lesions develop within few months or years after surgery. In other cases, recurrence may be delayed by 10 years or more after surgery. This variation makes is difficult to diagnose the degree of malignancy and to decide on a surveillance method or choose among therapeutic options. Here, we report two cases of malignant PCs. Both cases were initially difficult to diagnose as “malignant,” although a definitive diagnosis was reached after long-term periodic surveillance. We analyzed the expression profiles of malignancy/proliferation-related genes in tumor specimens. We report the results of our analysis and discuss the clinical courses of these cases. 

Clinical Cases

Case 1: A 51-year-old female presenting paroxysmal hypertension and constipation came to ourhospital. Laboratory tests showed elevated noradrenaline (NA) levels and a 10-cm right adrenal tumor was detected. We performed laparoscopic right adrenalectomy and made a diagnosis of PC. Four years after surgery, NA levels were again elevated and imaging (CT, MRI, and PET) showed local recurrence with peritoneal lymph node, lumbar-iliac, and liver metastases. We arrived at a diagnosis of malignant PC and performed surgical resection of the peritoneal lesion and additional metaiodobenzylguanidine internal radiation therapy. She is currently being followed-up as an outpatient.

Case 2: A 24-year-old female came to our hospital presenting with paroxysmal headache and vision loss, which started at the age of 17. Laboratory tests showed elevated NA levels and a 4-cm right adrenal tumor. We arrived at a diagnosis of PC and performed laparoscopic right adrenalectomy. Five years after surgery, her NA level was elevated, and a lung tumor was detected by CT six years after surgery. The lung tumor gradually increased in size. Positive FDG–PET accumulation and elevated NA levels lead us to perform thoracoscopic tumor resection because of suspected lung metastasis. We made the diagnosis of malignant PC. CVD adjuvant therapy is ongoing.

Results

We analyzed the expression profile of proliferation-related genes of these two and other PC cases by real-time PCR, which revealed a similar extent of IGF-2 and VEGF over-expression in PC samples and primary and metastatic lesions.

Conclusion

ki67 , p53 , and several other candidate genes are recognized as prognostic factors for malignant PC. In this study, IGF-2 and VEGF expression levels were high. These results suggest that the hypoxia-responsive pathway, which is crucial to the pathogenesis of PC, also plays a role in malignant formation in PC. Because the extent of marker genes over-expression was the same in the primary and metastatic lesions, analysis of primary lesions might be useful for prognosis.

 

Nothing to Disclose: MF, TT, EK, AS, AN, SH, IS, HN, NH, SS, HK, TY, TT, KY

18584 10.0000 FRI-386 A Expression Profile Analysis of Prognostic Factors for Malignancy: Two Cases of Malignant Pheochromocytoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Maria Batsis1, Tamara Prodanov2, Mihail Zilbermint1, Ricardo R Correa3, Constantine A Stratakis1, Maya Beth Lodish*4 and Karel Pacak2
1National Institutes of Health (NIH), Bethesda, MD, 2National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, 3National Institute of Health, Bethesda, MD, 4National Institutes of Health, Bethesda, MD

 

Behavioral symptoms related to catecholamine excess in the setting of pheochromocytoma/ paraganglioma (PHEO/PGL) may overlap with those seen in attention deficit hyperactivity disorder (ADHD); however, ADHD should be a diagnosis of exclusion. It is not known how frequently pediatric patients with PHEO/PGL report inability to concentrate, hyperactivity, or poor school performance; thus far only two cases have described PHEO/PGL presenting with ADHD-like symptoms. (1) We performed a retrospective review of patients < 18 year-old at the time of their diagnosis of PHEO/PGL with a documented prior diagnosis of ADHD. The chi-squared test was used to compare the observed prevalence of ADHD in the PHEO/PGL cohort compared to what would be expected given population estimates. Nine out of the 43 pediatric patients (21%) seen at the National Institutes of Health Clinical Center and diagnosed with PHEO/PGL between 2006-2014 had previously been diagnosed with ADHD. According to the National Survey of Children’s health, in 2011, 11% of children/adolescents aged 4 to 17 had ever received an ADHD diagnosis (1). Our prevalence of 21% is significantly higher than the expected 11% (p = 0.0356) These 9 individuals initially presented with behavioral symptoms including hyperactivity, difficulty concentrating, and poor school performance, and were diagnosed with ADHD. Four had been treated with amphetamine and dextroamphetamine or methylphenidate. One patient was admitted for a two-week behavior intervention for oppositional/defiant disorder. Median age at the time of diagnosis of PHEO/PGL was 14, range 6.6-15. Four patients were diagnosed with PHEO, 3 with extra adrenal PGL, and 2 with metastatic/multiple PGL. Seven patients were identified to have causative mutations for genetic syndromes associated with PHEO/PGL: SDHB, 5; SDHA, 1; MEN2A, 1; VHL, 1. Plasma norepinephrine was elevated in 3 out 7 patients, plasma dopamine was elevated in 1 out of 8, plasma metanephrine was elevated in 1 patient out of 8. Hypertension was a presenting symptom in 4 out of the 9 patients. All patients underwent surgical resection of their tumors. In 3 patients, behavioral abnormalities resolved following tumor resection. The misdiagnosis of ADHD in the setting of a PHEO/PGL is concerning for a number of reasons. Medications used in the treatment of ADHD are known to exacerbate hypertension and should be used in caution in individuals at risk for hypertensive crisis as they may potentiate the adrenergic effects of catecholamines. As there may be overlap in the presentation of these two disorders, children with ADHD-like symptoms who have signs and symptoms that could be compatible with PHEO/PGL such as headaches and hypertension and/or a family history of neuroendocrine tumors should be evaluated for the possibility of PHEO/PGL prior to initiating stimulant medications.

 

Nothing to Disclose: MB, TP, MZ, RRC, CAS, MBL, KP

19376 11.0000 FRI-387 A Critical Potential Misdiagnosis of Attention Deficit Hyperactivity Disorder (ADHD) in Children with Underlying Pheochromocytoma/Paraganglioma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Anastasia Mihailovna Lapshina*1, Eugenia Ivanovna Marova1, Iya Alexandrovna Voronkova2, Nicolay Sergeevich Kuznetsov1, Nona Vadimovna Latkina1, Lubov` Efimovna Kats1, Oleg Valer1evich Remisov1, Galina Sergeevna Kolesnikova1, Svetlana Dmitrievna Arapova1, Vadim Krylov1 and Ludmila Yakovlevna Rozhinskaya1
1Endocrinology Research Centre, Moscow, Russia, 2Endocrinology Rsearch Centre, Moscow, Russia

 

Pheochromocytomas are responsible for the development ACTH-ectopic syndrome in 5% of cases. Less than 1% pheochromocytoma accompanied by symptoms of ACTH-dependent hypercortisolism.

We observed 4 cases of ACTH-secreting pheochromocytoma in 2013-2014 years. Among these patients were all women from 50 to 63 years. The disease duration ranged from 6 months to 5 years. The clinical picture had symptoms associated with hypercortisolism (matronism, hyperpigmentation of the skin, the redistribution of fatty tissue on the central type, steroid myopathy, steroid diabetes, steroid osteoporosis, hypokalemia) and hypercatecholaminemia (arterial hypertension, tachycardia, shortness of breath, frequent urination). Hormonal study found increased levels of ACTH and cortisol with the disturbed rhythm of these hormones secretion in all patients: ACTH in the morning from 176,0 to 189,0 PG/ml (normal rate of 7.0-66,0), evening from 179,8 to 291,0 (normal rate of 0-30,0), cortisol in the morning from 962 to 4655 nmol/l (normal rate 123,0-626,0), in the evening from 1256 to 2460 (normal rate 46,0-270,0), free cortisol in 24-houres urine from 3726,0 to 9596,0 nmol/day (normal rate 60,0-413,0); increased metanephrine from 638,0 to 1481,0 µg/day (normal rate of 25.0-312,0) and normetanephrine from 545,6 to 1553 µg/day (normal rate of 35.0-445,0) daily urine in 3 of 4 patients (1 patient had normal catecholamine levels). Retroperitoneal space multislice spiral CT scan revealed tumors in the region of the left adrenal glands, sizes:  2,0x1,6x1,0 cm (density 27H),  2,7x3,0x4,6 cm (density 38 H) and  diameter 4,3 cm (density did not specified). In one case found 2 nodes: 1,8x2,3x2,5 cm and 2,0x2,3x2,5 cm (density 19H and 3H). Histological examination diagnosed 3 pheochromocytoma combined with diffuse-nodular hyperplasia of the adrenal cortex and 1 mixed tumor (pheochromocytoma and adenoma of the adrenal cortex). Immunohistochemical examination confirmed expression of ACTH in all cases. In all patients developed adrenal insufficiency and normalized levels of metanephrine and normetanephrine in daily urine after removal of adrenal tumors.

Conclusion:  the diagnosis of ACTH-secreting pheochromocytoma was established on the following criteria: symptoms of hypercortisolism and hypercatecholaminemia, increased levels of ACTH and cortisol in the blood, increased levels of free cortisol in the daily urine, excessive secretion of metanephrine and normetanephrine in the daily urine, the presence of a neoplasms in the adrenal glands produced by imagine technics, the normalization of ACTH, cortisol and catecholamines levels after removal of the tumor, histological confirmation of pheochromocytoma and immunoexpression of ACTH in the tumor cells.

 

Nothing to Disclose: AML, EIM, IAV, NSK, NVL, LEK, OVR, GSK, SDA, VK, LYR

19546 12.0000 FRI-388 A ACTH-Ectopic Syndrome in 4 Patients, Caused By Pheochromocytoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Ishita Prakash*1, Edina Paal2, Shruti Mahendra Gandhi3 and Eric S Nylen4
1Washington DC Department of Veterans Affairs, Washington, DC, 2Washington DC Department of Veterans Affairs, 3Washington DC VA Medical Center, DC, 4VA Medical Center, Washington, D.C.

 

Although an association of pheochromocytoma with brown fat proliferation was first described over 50 years ago, there has been a rediscovery of this phenomenon with the advent of FDG-PET imaging.  Our case is a 79 year old male with a history of a resected right adrenal pheochromocytoma.  The patient historically was asymptomatic and normotensive despite significantly elevated (> 5 fold) plasma metanephrines.  The tumor was successfully resected laparoscopically and showed invasion of the cortex with partial invasion of the capsule, without vascular invasion or necrosis and post-operative metanephrines normalized.  Six years later, the patient presented with weight loss and right flank pain. CT showed numerous soft tissue densities in the right adrenal bed with mild to moderate FDG-PET uptake (SUV 3.1) as well as an adjacent “lipoma”.  Iodine-123 MIBG scan showed a large area of focal, intense radiotracer activity in the right adrenal bed, corresponding to 18F-FDG-PET uptake and interpreted as recurrent pheochromocytoma.  Repeat plasma metanephrines showed a three-fold elevation from baseline but again patient was asymptomatic and normotensive. Histopathology after surgical removal showed a 6.2 cm hibernoma from the right adrenal bed with focal deposits of pheochromocytoma in the peritoneal tissue.

Hibernomas are rare brown fat tumors most often found in the thigh and shoulder region not previously described in association with a pheochromocytoma. However, several reports have documented brown fat staining positive for UCP-1 in the vicinity of pheochromocytomas.  The proposed mechanism suggests that the periadrenal fat appears to have two distinct and independent adipose lineages coexisting.  In the case of high catecholamine levels as demonstrated in our patient, there is an expansion of the inducible brown fat compartment, potentially giving rise to a hibernoma.

 

Nothing to Disclose: IP, EP, SMG, ESN

21585 13.0000 FRI-389 A Hibernoma and Recurrent Pheochromocytoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Veljko Strajina*, Benzon Dy, Keith C Bible, Travis J. McKenzie, David Farley, Melanie Richards, Geoffrey B Thompson and Florencia G Que
Mayo Clinic, Rochester, MN

 

Introduction:  Locally recurrent pheochromocytoma and paraganglioma is rare, and outcomes from surgical treatment are poorly defined in the literature.

Methods:  A review of all patients undergoing surgery for locally recurrent pheochromocytoma or paraganglioma between January 1, 1994, and June 30, 2012, at Mayo Clinic Rochester Campus was performed.  Patients with proven malignant disease at the time of resection (i.e. local invasion, distant or nodal metastases) were excluded from the analysis.

Results:  We identified 19 patients undergoing surgery for locally recurrent pheochromocytoma or paraganglioma.  This usually presented as multiple soft tissue nodules at and around the previous surgery bed.  Median follow up was 5.4 years (up to 15 years).  Five-year survival was 83% (median 13 years).  Complete (R0) resection was achieved in 17 patients (90%), with median disease-free survival of 5.3 years in response to R0 resection (up to 9 years). Completeness of resection did not affect overall survival (P=0.26).  Nine patients (47%) were free of disease at the time of last follow up, 4 patients developed local re-recurrence, 4 eventually developed metastatic disease, and 2 had persistent disease.  Preoperative catecholamine or metanephrine excess was documented in 10 patients (53%); these normalized in 8 (80%) postoperatively, with 8 of 9 patients with preoperative symptoms of hormone excess enjoying symptom relief postoperatively.

Conclusion:  Surgery plays an important role in management of selected patients with locally recurrent pheochromocytoma and paraganglioma.  Complete resection is possible in the majority of patients, with long overall and disease-free survival.  Surgery in this unique patient group offers normalization of catecholamines and metanephrines, improvement of hormone-related symptoms, and improved blood pressure control.  However, 53% of our patients developed later local re-recurrence, metastatic disease, or persistent disease.  Despite recurrence, prolonged survival can be achieved with surgery.

 

Nothing to Disclose: VS, BD, KCB, TJM, DF, MR, GBT, FGQ

20603 14.0000 FRI-390 A Surgical Treatment of Locally Recurrent Pheochromocytoma and Paraganglioma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Lucinda M Gruber*1, Irina Bancos2, Dana Erickson2 and William F. Young Jr.2
1Mayo Clinic School of Graduate Medical Education, Rochester, MN, 2Mayo Clinic, Rochester, MN

 

BACKGROUND: Individuals with neurofibromatosis type 1 (NF1) are at an increased risk of developing a pheochromocytoma or paraganglioma (PHEO/PGL), however little is known about the clinical presentation of such patients to guide screening recommendations.

METHODS: This is a retrospective review of 31 patients with NF1 and PHEO/PGL identified from 1960 to 2014 using the Mayo Clinic PHEO/PGL database (N=3125) and NF1 database (N=1158).

RESULTS: The prevalence of PHEO/PGL in our NF1 population was 2.7%. Patients included 14 women (45%) and 17 men; the mean age at diagnosis was 41.1 year, median 41.0 years (range, 14-67). Mean tumor size was 41.2 cm (range, 19-77) and was not significantly different in patients diagnosed before and 1990, 47.7 cm vs. 39.2 cm (P= .19). While most of the patients diagnosed prior to 1990 presented with symptoms of catecholamine excess, incidental imaging discovery led to the discovery of PHEO/PGL in a third of patients diagnosed after 1990. Two patients were diagnosed after developing severe hypertensive peri-operatively for unrelated surgeries. Only 2/31 (6.4%) patients were diagnosed with PHEO/PGL because of routine annual biochemistry screening. Bilateral disease occurred in 4 patients (12.9%) while metastatic or recurrent PHEO/PGL was present in 3 (9.7%) patients, all women. Since 2000, 3 patients were treated with cortical-sparing partial adrenalectomy. There is no evidence of recurrence 7 years after surgery in 2 of these patients, but the other patient is lost to follow-up.

CONCLUSION: Given the 10% rate of metastatic or recurrent PHEO/PGL in our NF1 population, we recommend yearly follow-up with 24-hr urine fractionated metanephrines in all NF1 patients with history of PHEO/PGL. In addition, biochemical screening for PHEO/PGL every 3 years and/or prior to a scheduled surgical procedure should be considered in all NF1 patients. Cortical sparing adrenalectomy may be a good option for NF1 patients, especially in the setting of bilateral PHEO/PGL.

 

Nothing to Disclose: LMG, IB, DE, WFY Jr.

22009 15.0000 FRI-391 A To Screen or Not to Screen:  Pheochromocytoma and NF1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Marie Freel*1, Patrick B Mark2, Robin Weir3, Eleanor Davies4 and John Muir Connell5
1University of Glasgow, Glasgow, 2University of Glasgow, 3NHS Lanarkshire, 4University of Glasgow, Glasgow, United Kingdom, 5University of Dundee, Dundee, United Kingdom

 

Primary Aldosteronism (PA) is common and associates with excess cardiac morbidity. Using contrast enhanced cardiac MRI, we have previously shown that PA patients are more likely to demonstrate non-ischaemic cardiac fibrosis (using late gadolinium enhancement, LGE, as a surrogate marker) than those with essential hypertension. Since previous studies have shown that aldosterone-induced end organ damage is reversible, the purpose of this study was to repeat CMR imaging of PA patients after treatment of aldosterone excess to demonstrate whether non-ischaemic fibrosis had resolved.

Patients with treated PA who had participated in the previous study underwent repeat CMR using 1.5T MRI (Siemens). Presence or absence of LGE as well as LGE pattern (non-infarct/infarct) was assessed by 2 expert independent observers who were blinded to the clinical scenario. Patients also underwent repeat assessment of blood pressure (mean of 3 office readings, seated) and plasma aldosterone.

Fifteen patients were recruited; 8 had undergone adrenalectomy and 7 were on medical therapy for PA. Mean (+/- SEM) days since treatment for PA had occurred was 1421 days (95.3). Treatment did result in a significant reduction in plasma aldosterone levels (p=0.003, in patients who had undergone surgical treatment) with reduction in blood pressure and myocardial mass that did not reach statistical significance. The prevalence of non-ischaemic cardiac fibrosis was significantly reduced after PA treatment and had resolved in 45% of patients (p=0.01). There was no difference in duration or mode of treatment between ‘resolved’ and ‘non-resolved’ cohort and no difference in plasma aldosterone levels in surgically managed patients, although there was a trend to lower blood pressure in the resolved cohort (median SBP 126 mm/Hg vs 152 mm/Hg; median DBP 79 mm/Hg vs 93 mm/Hg; p=0.06).

Cardiac fibrosis in PA is potentially reversible with treatment although this is not invariable. Factors that associate with increased likelihood of resolution of cardiac fibrosis in PA patients require further investigation in a larger cohort although current findings suggest that optimal blood pressure control is a key consideration.

 

Nothing to Disclose: MF, PBM, RW, ED, JMC

19834 16.0000 FRI-392 A Myocardial Fibrosis in Primary Aldosteronism Is Reversible with Treatment: A Cardiac MRI Pilot Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Avin P. Pothuloori*, Sreenija Suryadevara and William Bernard Kinlaw III
Dartmouth Hitchcock Medical Center, Lebanon, NH

 

No Catecholamines: An Unusual Case of Paraganglioma-Pheochromocytoma Syndrome

Background: Reported here is a case of a female with recurrent biopsy proven extra-adrenal catecholamine negative pheochromoctyoma and genetic testing that confirmed a succinate dehydrogenase beta subunit mutation. 

Clinical Case: A 34 y/o female first came to medical attention in 2005 with a two-week history of abdominal pain. Subsequent CT scan of the abdomen revealed a 6 cm right adrenal mass.  She had no palpitations, chest pain, weight loss, hypertension or diaphoresis.  Blood tests were negative for elevated cortisol, aldosterone or metanephrines.  However, her father had a paraganglioma removal in the past. She underwent right partial adrenalectomy and a 12 x 10 x 5 cm mass was removed with pathology consistent with pheochromocytoma with vascular invasion and positive margins.  From 2005 to 2009, she was followed yearly by surveillance CT chest/abd/pelvis that was negative as of 2009.  In 2010, a decision to stop imaging was made by the patient and she had an unremarkable pregnancy and delivery of a healthy boy.  She conceived again in 2014, but routine ultrasound for pregnancy found pelvic masses.  An MRI confirmed multifocal bilateral pelvic masses, para-aortic mass and left paraceliac mass.  24-hr urine catecholamines were again within normal limits [109 mcg/24h of normetanephrine (n: 111-419 mcg/24h) and 45 mcg/24h of fractionated metanephrine (n: 30-180 mcg/24h)].  A trans-abdominal biopsy FNA of one of the pelvic masses revealed pheochromocytoma.  A subsequent PET-CT Scan revealed extensive disease; intense hypermetabolic metastasis in the anterior arch of vertebra C2 adjacent to the odontoid process, bone lesions in the sacrum, T12 and L5, a mass at the right neuroforamina of T10, several hypermetabolic masses in the retroperitoneum at the level of the kidneys with the largest measuring 3.5 cm and a final mass adjacent to the aorta at the level of T12 vertebra.   Due to the past history of pheochromoctyoma and father’s history of paraganglioma, there was concern for paraganglioma-pheochromocytoma syndrome.  Genetic testing confirmed a succinate dehydrogenase beta subunit mutation, which is found in paraganglioma-pheochromocytoma syndrome type 4.  Presently, there is no mass effect of her extra-adrenal masses, though biopsy with possible surgical resection will be considered in the future.  She recently delivered her second child via normal spontaneous vaginal delivery without complications.  

Conclusion: This is a case of a catecholamine negative recurrent metastatic pheochromocytoma in a female with a succinate dehydrogenase beta subunit mutation (SDHB).

 

Nothing to Disclose: APP, SS, WBK III

20999 17.0000 FRI-393 A No Catecholamines: An Unusual Case of Paraganglioma-Pheochromocytoma Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


David Villafuerte*1, J Sonya Haw1, Saira Adeel1, Priyathama Vellanki2 and Francisco J Pasquel2
1Emory University, 2Emory University, Atlanta, GA

 

Introduction: A pheochromocytoma is a tumor arising from adrenomedullary chromaffin cells that commonly produces excessive catecholamines. Diagnosis is challenging in patients with end stage renal disease (ESRD) as there is no standardization of appropriate catecholamine levels. In such cases, use of radiotracer such as 123I-MIBG scanning could be helpful. Here we present a case of a Hispanic male with hypertension and ESRD on hemodialysis (HD) who was diagnosed with a clinical and biochemically silent incidentaloma with a negative 123I-MIBG scan with just CT and MRI findings.

 Case description: Patient is a 50-year old Hispanic male with a medical history significant for hypertension, ESRD secondary to focal segmental glomerulosclerosis on HD who had a large gallbladder mass on CT scan and an incidental finding of a right adrenal nodule, with pre-contrast and a delayed attenuation of 40 and 54 Hounsfield units, respectively, on further imaging. He had no prior history of tachycardia, headaches or sweating. Biochemical work-up did not show increased metanephrines or catecholamines even when tested multiple times.  Biochemical workup was also not consistent with hyperaldosteronism or hypercortisolism. However, MRI scan showed a markedly T2 hyperintense adrenal nodule and was consistent with a pheochromocytoma.  A 123I-MIBG scan was also negative.  Due to imaging characteristics, persistently elevated blood pressure, size and concern for possible metastatic gallbladder carcinoma, the decision was made to resect the right adrenal nodule.  Preoperatively, patient was prepared with alpha and beta blockade as imaging was suggestive of pheochromocytoma.  For preparation, the patient required high doses of phenoxybenzamine, amlodipine, and carvedilol, which did not control his blood pressure. Fluid removal was limited in preparation for surgery to prevent post-operative hypotension. Given the challenging management the patient was transferred to the ICU and was started on nitroprusside for optimal BP control prior to surgery,   Patient underwent resection of both the gallbladder mass and adrenal nodule. Histologic diagnosis showed a bening gallbladder mass, and the adrenal mass pathology was consistent with pheochromocytoma.  

Discussion:  This case illustrates that there should be a high index of suspicion for a pheochromocytoma if CT and MRI imaging are concerning even in a patient with negative biochemical or 123-MIBG imaging results for pheochromocytoma.  Further, our case illustrates that the management of hemodynamic instability associated with pheochromocytoma in patients on HD is still not well defined, but it requires a multidisciplinary approach for perioperative management.

 

Nothing to Disclose: DV, JSH, SA, PV, FJP

21830 18.0000 FRI-394 A Silent Pheochromocytoma and Resistant Hypertension in a Patient with End-Stage Renal Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Swarna Rai* and Amal A Shibli-Rahhal
University of Iowa Hospital and Clinics, Iowa City, IA

 

Background:Oral contraceptive pills (OCP) has been known to cause activation of the renin-angiotensin-aldosterone system (RAAS). This mechanism is considered to be one of the causes of hypertension in patients taking OCP with improvement upon discontinuation. We describe here a patient who developed hypertension with elevation in her pasma aldosterone and renin but remained hypertensive despite discontinuation and normalization of her RAAS. 

Clinical case:21-year-old female with a history of irregular menstrual cycles was found to have new onset hypertension on routine screening. Patient had been on OCP since the age of 18 and was taking Loestrin 24 fe. She had no past history of hypertension. She reported pheochromocytoma in her aunt and hypertension in her parents and brother. On examination, her blood pressure was 166/106 mmHg. Rest of her physical examination was normal. She had potassium of 3.3 mg/dl (3.5-5 mg/dl) with normal sodium, chloride, bicarbonate and creatinine. She was found to have an aldosterone level of 64 ng/dl (4-30 ng/dl) with a non-suppressed plasma renin activity (PRA) of 4.3 ng/ml/hr (0.5-4 ng/ml/hr). Pheochromocytoma work-up was negative. A CT scan of the abdomen was negative for adrenal mass. Renal artery stenosis was suspected due to to a non-suppressed PRA but ultrasound doppler was negative. Patient was taken off her OCP and a repeat aldosterone was 14.7 ng/dl with a PRA of 1.0 ng/ml/hr and potassium of 3.8 mg/dl. Patient continued to be hypertensive and was started on amlodipine. Patient was later restarted on progesterone only pill due to her menstrual symptoms. Her aldosterone increased to 20.1 ng/dl with a PRA of 4.1 ng/ml/hr and potassium of 3.5 mg/dl. Her blood pressure remained under good control.

Conclusion:Studies have shown OCP can cause elevated blood pressure in high-risk individuals due to activation of RAAS, which can be partially reversed by losartan. Estrogen induces angiotensinogen gene expression with a consequent increase in plasma angiotensinogen and aldosterone. Paradoxically, there is an elevation of PRA.  Our patient had persistent hypertension despite normalization of her aldosterone and renin levels, suggesting primary hypertension. The use of OCP should always be considered in evaluation of patients with elevated aldosterone and renin. The activation of RAAS could be contributing but may not always be the cause of hypertension suggesting continued blood pressure monitoring.  

Nothing to disclose: SR, ASR.

 

Nothing to Disclose: SR, AAS

21809 19.0000 FRI-395 A Activation of the Renin-Angiotensin-Aldosterone System Secondary to Oral Contraceptive Pills in a Patient with Newly Diagnosed Hypertension 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Fumitoshi Satoh*, Ryo Morimoto, Masataka Kudo, Yoshitsugu Iwakura, Yoshikiyo Ono, Kei Omata, Kei Takase, Kazumasa Seiji, Yoichi Arai, Yasuhiro Nakamura, Hironobu Sasano and Sadayoshi Ito
Tohoku University Hospital, Sendai, Japan

 

Adrenal venous sampling (AVS) is clinically critical to differentiate unilateral aldosterone producing adenoma (APA) from bilateral idiopathic hyperaldosteronism (BHA). However, it has been still almost impossible to discriminate bilateral APA from BHA according to a central vein AVS (C-AVS), which means a sampling blood from bilateral adrenal central veins. Though only very few case reports about bilateral APA were seen in the literature, there were no reports diagnozed differentially between bilateral APA from BHA complicating bilateral non-functioning adenomas (NFA) by AVS. To predict whether hyperaldosteronism can be cured or not after the sparing surgery for cases with bilateral APA, segmental AVS (S-AVS) has been developed in our institute and others. S-AVS was subsequently performed after finishing C-AVS, via the insertion of a microcatheter in up to three intra-adrenal first-degree tributary veins on bilateral adrenals. Among 270 primary aldosteronism (PA) patients who were admitted to our institute, bilateral adrenal tumors were detected by computed tomography (CT) in 24 patients consisting of five patients with bilateral APA, fifteen patients with unilateral APA plus contralateral NFA and four patients with BHA plus bilateral NFA, who were diagnozed differentially by S-AVS. S-AVS should be performed as an absolute indication for these PA patients who are highly suspected due to bilateral APA, or due to recurred APA after unilateral adrenalectomy, because of the necessity of sparing surgery, and furthermore, a very young patients highly suspected of APA or a case with concurrent PA and cortisol producing adenoma might be a candidate for this testing. Because S-AVS is a more time-consuming and labor-intensive testing compared to C-AVS, its adaptation should be confined. However, there have been innovative reports presenting clinical usefulness for laparoscopic simultaneous bilateral partial and total adrenalectomy (or bilateral partial adrenalectomy ) in our institute and other (1, 2). Therefore, S-AVS will be able to be considered depending on clinical indications, especially in the PA patients who can be expected to undergo bilateral partial and total adrenalectomy (or bilateral partial adrenalectomy ).

 

Nothing to Disclose: FS, RM, MK, YI, YO, KO, KT, KS, YA, YN, HS, SI

19986 20.0000 FRI-396 A What Is a Role for Super Selective Segmental Adrenal Venous Sampling and Adrenal Sparing Surgery in Primary Aldosteronism? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Yoshikiyo Ono*, Ryo Morimoto, Yoshitsugu Iwakura, Kei Omata, Masataka Kudo, Masahiro Nezu, Sadayoshi Ito and Fumitoshi Satoh
Tohoku University Hospital, Sendai, Japan

 

[Background] The plasma aldosterone-to-renin ratio (ARR) for the clinical diagnosis of primary aldosteronism(PA) is normally calculated with plasma renin activity (PRA) as denominator. However, in the Endocrine Society Clinical Practice Guideline for PA, they also recommended the use of active renin concentration(ARC) for diagnosing PA. Moreover, the rapid assay of ARC was recently developed.

[Objective] We examined the correlation of PRA and ARC in patients with hypertension including PA. Then, we investigated whether the calculation of ARR with ARC (ARR-Ac, ng/dl per pg/ml) instead of PRA (ARR-Pa, ng/dl per ng/ml/h) affects the diagnosing of the patients with aldosterone producing adenoma(APA). 

[Design and participants] PRA, ARC, and PAC were measured in 325 patients with hypertension, including the patients with APA(n=124),bilateral hyper aldosteronism (BHA, n=84), essential hypertension (EH, n=42), cushing syndrome (CS, n=27), subclinical cushing syndrome (SCS, n=19), palaganglioma (PGL, n=29). The ARR-Ac and ARR-Pa were calculated, and the receiver operating characteristic (ROC) curve analyses were performed.

[Results] ARC were significantly correlated with PRA (r=0.902, p<0.0001). ARR-Pa and ARR-Ac of APA patients were 107.2±4.6 and 8.7±0.3(Mean±SEM),respectively.Those of BHA were 42.8±2.2 and 4.3±0.1, EH 15.7±1.2 and 2.0±0.1, CS 8.4±1.2 and 1.2±0.1, SCS 10.6±1.4 and 1.4±0.9, and PGL 15.9±1.6 and 1.8±0.1, respectively. The ROC curve analyses confirmed the cut-off value of ARR-Pa of detecting APA was 32.0 (sensitivity: 69.8% and specificity:75.1%) and that of ARR-Ac was 4.68 (sensitivity: 67.3% and specificity:83.2%), respectively.

[Conclusion] ARC was significantly correlated with PRA. ARC is useful for detecting APA almost equally to PRA.

 

Nothing to Disclose: YO, RM, YI, KO, MK, MN, SI, FS

20325 21.0000 FRI-397 A Correlation of Plasma Renin Activity and Active Renin Concentration(ARC): ARC Is Effective for Diagnosing of Primary Aldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Nada El Ghorayeb*1, Isabelle Bourdeau2 and Andre Lacroix2
1Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC, Canada, 2Centre hospitalier de l’Université de Montréal (CHUM), Université de Montréal, Montreal, QC, Canada

 

Background: Primary bilateral macronodular adrenal hyperplasia (BMAH) is an uncommon cause (<2 %) of Cushing’s syndrome (CS). Bilateral adrenalectomy is the therapy of choice in patients with overt CS, but unilateral adrenalectomy can be efficient in patients with mild CS.

Clinical case: A 74 year-old woman with type 2 diabetes mellitus, hypertension, coronary artery disease and atrial fibrillation underwent distal pancreatectomy with splenectomy for intraductal papillary mucinous hyperplasia which was complicated by the recent presence of clinical signs and symptoms of CS. Her initial tests were consistent with ACTH‐independent CS: elevated 24hr urinary free cortisol (UFC) (531 and 560 nmol/24hr, n<220), abnormal 1 mg overnight dexamethasone test (cortisol 632 nmol/L, n<50), elevated midnight salivary cortisol (21.5 nmol/L, n<7), ACTH concentrations <1.4 pmol/L (n: 2-11). An abdominal CT scan showed bilateral adrenal nodules (2 on the right 2.5 cm and 3.6 cm in diameter; 2 on the left 1.9 cm and 1.5 cm). Screening for aberrant hormone receptors revealed no cortisol response to upright posture, meal, LHRH, TRH, metoclopramide or vasopressin. Ketoconazole was efficient to normalize UFC perioperatively, but UFC were 2 times above the normal range (458 and 400 nmoL/24hr) when it was stopped. Bilateral simultaneous adrenal vein sampling was performed to determine cortisol and aldosterone every 5 minutes, twice before (basal) and 3 times after 250 µg ACTH IV bolus. A Right/Left cortisol lateralization ratio was ≤2.0 in favor of bilateral source of cortisol, but a higher basal adrenal/peripheral vein ratio (3.01 vs 1.75) was present on the right side with a response to ACTH bilaterally (13.8 fold on the right vs 15.7 fold on the left). A right adrenalectomy was performed and pathology identified 2 adrenocortical nodules 3.5 and 1.9 cm in diameter with no hemorrhage, necrosis or malignant features, while the adjacent parenchyma contained multiple micronodules of variable sizes suggesting macronodular hyperplasia with 2 dominant adenomas. Four days post operatively her plasma cortisol level was 74 nmol/L, requiring hydrocortisone replacement at discharge from hospital.  Four months later an acute adrenal crisis occurred when hydrocortisone was inadvertently stopped by the pharmacist. An abdominal CT scan did not identify any signs of left adrenal hemorrhage or lesion following the contralateral adrenalectomy. Plasma morning ACTH was 4.2 pmol/L and plasma cortisol increased from 90 to 348 nmol/L following 250 mcg ACTH 1-24 suggesting incomplete recuperation of secondary adrenal insufficiency.

Conclusion: Despite AVS demonstration of bilateral source of cortisol in BMAH with overt CS, unilateral adrenalectomy can still result in adrenal insufficiency.

 

Nothing to Disclose: NE, IB, AL

19467 22.0000 FRI-398 A Adrenal Vein Sampling Does Not Always Predict Adrenal Insufficiency Following Unilateral Adrenalectomy for Bilateral Macronodular Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Colin Perry*1, E. Marie Freel2, Robert S Lindsay3 and Ross Jack4
1Western Infirmary, Glasgow, Glasgow, United Kingdom, 2Univ of Glasgow, Glasgow, United Kingdom, 3BHF Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom, 4University of Glasgow, Glasgow

 

Phaeochromocytomas (PHAEOs) and extra-adrenal paragangliomas (PGLs) are rare neuroendocrine tumours. As many as 35% may have an identifiable germline mutation, most commonly in the genes encoding RET, VHL or subunits of succinate dehydrogenase (SDHx).

  [123I]-labelled metaiodobenzylguanidine (123I-MIBG) scintigraphy is used to localise PHAEOs/PGLs, while 131I-MIBG is used as therapy in malignant disease. Uptake of radioisotope may vary with genotype; 18F-FDG-PET is more sensitive than MIBG in tumours associated with SDHB mutations. We compared MIBG avidity in genetically defined PHAEO/PGL patients with those without mutations in RET, VHL or SDHx.   

 We undertook a clinical record review of fifty five patients with histologically proven PHAEOs/PGLs attending the Endocrinology Unit at the Western Infirmary, Glasgow.

 Forty three of the 55 had genetic testing performed; in 31/43 (72%) a genetic mutation was identified. 18 (41.9%) had an SDHB mutation and four (9.3%) had an SDHD mutation; six (13.9%) had a mutation in VHL; three (7.0%) had a mutation in RET, and 12 (27.9%) had negative genetic testing.

 Pre-operative MIBG scans were performed in 39 of 55 patients. 33 patients (84.6%) had MIBG avid tumours. 11/13 (84.6%) patients with an SDHB mutation were MIBG avid; 1/2 (50%) SDHD mutations were MIBG avid (total SDHx mutation group 12/15 (80%) MIBG avid). The other populations were  as follows: RET 2/2 (100%); VHL 3/3 (100%); and sporadic 7/8 (87.5%) MIBG avid.

 We found a higher than anticipated proportion of PHAEOs/PGLs with an identifiable germline mutation (56.4%). This may reflect the clinical service and the population it serves. MIBG avidity was no different  in tumours associated with a genetic predisposition compared to those negative for RET, VHL and SDHx mutations. We suggest that MIBG uptake is measured pre-operatively in PHAEOs/PGLs where otherwise indicated, irrespective of genotype.

 

Nothing to Disclose: CP, EMF, RSL, RJ

21995 23.0000 FRI-399 A MIBG-Avidity in Genetically Distinct Phaeochromocytoma and Paraganglioma Populations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Akiyo Tanabe*
Tokyo Women's Med Univ, Tokyo, Japan

 

Objectives

It is recognized that the catecholamine (CA) biochemical phenotype in patients with pheochromocytoma/paraganglioma (PPGL) may correlate with malignant status, location of the primary tumor, and other clinical characteristics. In this study we classified our PPGL patients with by their biochemical phenotype of CA secretion and compared their clinical characteristics.

Subjects and methods

Plasma CAs levels from 61 patients with PPGL (male: n=26, female: n=35)aged 20 to 82 years (mean: 50±16 years). The plasma CAs were collected during times when the patients were asymptomatic. Reference ranges were: plasma epinephrine (E) <100 pg/ml and plasma norepinephrine (NE) <450 pg/ml. E and NE were defined as clinically significantly elevated when more than two-fold increase above the upper limit of reference ranges.

Results

1. Sixty one patients were divided into 4 groups according to the pattern of excess CA type: only E was elevated in 4 patients (7%, group E); both E and NE were elevated in 21 patients (34%, group E+NE); only NE was elevated in 27 patients (44%, group NE); and, both E and NE were not elevated in 9 patients (15%, group N).

2. There were no differences in age at the diagnosis of PPGL, sex, estimated duration of the disease, and tumor size between the 4 groups.

3. Percentage of the patients where the original tumor arose in an extra-adrenal location was 0% in the group E, 33% in the group E+NE, 52% in the group NE, and 22% in group N.

4. Percentage of patients with malignant PPGL was 0% in group E, 10% in group E+NE, 44% in group NE, and 56% in group N. In group NE, 33% of the cases of malignant PPGL arose in adrenal gland.

5. Percentage of patients with benign multiple tumors was 0% in group E, 19% in group E+NE, 0% in group NE and 11% in group N.

6. Patients showed the following patterns of hypertension (HT): sustained HT without spells; normotensive with paroxysmal HT; and, sustained HT with spells. The percentage of patients with sustained HT without spells was 50% in group E, 62% in group E+NE, 89% in group NE, and 22% in group N. Forty three percent of patients were normotensive with paroxysmal HT or sustained HT with spells in group N, in spite of normal plasma CAs levels when they did not have any spells.

Conclusions

Patients who had high E with normal NE and high E with high NE were characterized by high frequency of adrenal tumor location and low prevalence of malignancy. Patients who showed high NE with normal E tended to have sustained HT and higher prevalence of malignancy. Patients who showed normal plasma CAs levels were characterized by higher frequency of adrenal tumor location and higher prevalence of malignancy. Our findings suggest that careful follow-up is indicated in the patient CA phenotypes of NE with normal E and normal plasma CAs levels regardless of tumor localization.


 

Nothing to Disclose: AT

19294 24.0000 FRI-400 A Catecholamine Biochemical Phenotype Correlations Clinical Characteristics of Pheochromocytoma /Paraganglioma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Takashi Kono*, Hidekazu Nagano, Eri Komai, Akina Shiga, Akitoshi Nakayama, Tomoko Takiguchi, Ikki Sakuma, Naoko Hashimoto, Sawako Suzuki, Hisashi Koide, Tomohiko Yoshida, Koutaro Yokote and Tomoaki Tanaka
Chiba University Graduate School of Medicine, Chiba, Japan

 

Introduction

Aldosteron producing adenoma(APA) is one of the most cause of secondary hypertension,its rate is almost 10% of hypertension.Recently,the exome sequencing of  APAs is identified the genetic cause of APA generation,somatic mutations KCNJ5,ATP1A1,ATP2B3,CACNA1D,its tumorigenic mechanism is gradually cleared.But it has been still obscure.On the other hand, it have been reported which the GPCRs is related with the production of aldsteron in APAs.

Methods

So,we have performed direct sanger sequencing,real time PCR,RNA-sequencing analysis using the cDNA and mRNA of APA tissues for Japanese APAs in chiba University hospital, examined the relationship between the mutation.and the gene expression of steroidgenic enzyme, for example CYP11B2 and HSD3B2,and GPCRs.

Result

Tha rate of Gene mutation of 86 APA cDNA resulted that KCNJ5 mutations were present in 56 cases (65.1%), ATP1A1 in two cases (1.2%), ATP2B3 in one case (1.2%), CACNA1D in one case (1.2%) and WT in 26 cases (30.2%). Gene expression analysis using mRNA derived APAs showed that CYP11B2 expression was positive correlated to total urine aldosterone.And Serum aldosterone after adrenocorticotropic hormone load were  elevated in the mutations groups of APAs, but there was a many variation of serum aldosterone value in both mutation and wild type groups. For the regulator agents of aldosterone production in APA, we performed RNA-sequencing in mRNA derived 30 APAs. Total 11 GPCRs and are positive correlated to CYP11B2 expression and 7 of 11 factors are related to urine aldosteron,while 12 GPCRs  are negative correlated to CYP11B2 expression. PCP4, a Ca2+ signal transducer, was correlated to CYP11B2 expression.

Conclution

it is suggested that GPCRs is affected for the variation of aldosterone production in APAs

 

Nothing to Disclose: TK, HN, EK, AS, AN, TT, IS, NH, SS, HK, TY, KY, TT

21470 25.0000 FRI-401 A The Relationship Between Gene Expression Profile and Aldsteron Production of Somatic KCNJ5, ATP1A1, ATP2B3 and CACNA1D Mutations, Which Profiled By RNA-Sequence in Japanese Aldosterone Producing Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Hironobu Umakoshi*1, Tatsuki Ogasawara1, Keisho Hirota1, Miki Yokota1, Rieko Nakatani1, Maiko Kakita1, Mika Tsuiki1, Tetsuya Tagami1, Takeshi Usui1, Yusuke Hirokawa2, Akira Shimatsu1 and Mitsuhide Naruse2
1National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 2Kyoto Medical Center, Kyoto, Japan

 

Context: Adrenal vein sampling (AVS) is the reference standard test to distinguish unilateral from bilateral primary aldosteronism (PA). Since lateralization of aldosterone excess is determined by the ratio of aldosterone to cortisol (A/C), plasma cortisol concentration (PCC) has been indicated as a necessary marker to judge the catheter position appropriate in the adrenal vein. We demonstrated however that plasma aldosterone concentration (PAC) in the right adrenal vein showed a wide variation even when the AVS was judged successful from the PCC (Matsuo et al. ENDO2014). Whether the aldosterone variation is attributed to the assay method or to other unknown factors remain to be elucidated. Objective: Aim of the study was to evaluate the effects of a different assay method on PAC and PCC values. Methods: Six PA patients with blood samples obtained at least twice from the right adrenal vein during intraprocedural cortisol measurement were included. Blood samples were obtained from an approximately similar position in the right adrenal vein. Data of blood sample were used only when the selectivity index was ≧5. Of the adrenal blood sample, we selected two blood samples from each patient: one with the highest PAC (sample H) and the other with the lowest PAC (sample L). Both PAC and PCC were measured by LC-MS/MS in addition to RIA. We compared PAC, PCC, and A/C between the sample H and sample L. Results: Median percent difference of PAC and PCC between RIA and LC-MS/MS was 9% (IQR: -4 to 20) and 34.2% (IQR: 23 to 62), respectively. Median percent difference of A/C between RIA and LC-MS/MS was -20% (IQR: -43 to -3). Median percent difference of PAC and PCC between the sample H and sample L was 256% (IQR: 185 to 1665) and 18% (IQR: -20 to 55), respectively. Median percent difference of A/C between the sample H and L was 206% (IQR: 107 to 2518). PAC and A/C were significantly different between the sample H and L, while there was no significant difference of the date between RIA and LC-MS/MS. There was no significant difference of PCC between RIA and LC-MS/MS, and between the sample H and L. Conclusion: Even under similar PCC and similar position of the catheter, PAC and A/C showed a significant difference in some patients with PA. These results clearly demonstrated that PCC in the right adrenal vein is a necessary but not a sufficient condition to validate aldosterone excess and the subtype diagnosis of PA. Fluctuation of PAC in the right adrenal vein should be taken into account in the interpretation of the AVS results.

 

Nothing to Disclose: HU, TO, KH, MY, RN, MK, MT, TT, TU, YH, AS, MN

21745 26.0000 FRI-402 A Cortisol Concentration Is a Necessary but Not a Sufficient Reference Condition for Lateralizing Aldosterone Excess By Adrenal Venous Sampling in Primary Aldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Taweesak Wannachalee* and Rungpailin Buranagan
Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

 

Successful preoperative transcatheter arterial embolization of a large malignant pheochromocytoma to decrease intraoperative blood loss

Background:  Pheochromocytomas (PC) are rare hypervascular neuroendocrine tumors arising from chromaffin cells.   Preoperative transcatheter arterial embolization (TAE) of PC to decrease the significant risk of intraoperative bleeding has rarely been reported due to possible precipitation of a PC crisis.  We demonstrated the usefulness of arterial embolization before surgical resection of a large malignant PC.

Clinical case: A 57-year-old man was investigated for back pain and persistently elevated alkaline phosphatase.  Abdominal CT-scan revealed multiple liver nodules and a huge heterogeneous enhancing left adrenal mass (12x10x14 cm) with internal necrosis and calcification. Malignant PC was suspected.  An increase in 24- hour urine metanephrines and normetanephrines was detected (3,825 μg/day, normal 52–374 μg/day; 8,785 μg/day, normal 88–778 μg/day, respectively).  I131MIBG scan revealed a strongly-avid large left suprarenal mass and hepatic metastases. Surgical debulking of the primary tumor is the principal treatment for reduction of local symptoms and biochemical markers. Low dose prazosin (2 mg/day) was given to manage mild hypertension before surgery. Due to concern of massive hemorrhage from the large malignant tumor, preoperative TAE was performed using polyvinyl alcohol foam and gel foam via the left adrenal artery, the major vessel supplying the tumor.  There was no collateral feeding from renal or celiac arteries.  Two hours after TAE, the patient had tachycardia and blood pressure (BP) elevation, which was stabilized by low dose intravenous nicardipine and oral prazosin.  The following day, open adrenalectomy was successfully performed.  Operation time was 240 minutes with estimated blood loss of 700 mL.  BP was elevated during manipulation of the PC, requiring transient use of nitroprusside.  The patient was discharged on postoperative day 5 without complications.  His BP was well-controlled with prazosin 1 mg/day. 

Conclusion:  Preoperative TAE of large malignant PC can be a safe and effective procedure to reduce the risk of massive intraoperative blood loss.


 

Nothing to Disclose: TW, RB

20267 27.0000 FRI-403 A Successful Preoperative Transcatheter Arterial Embolization of a Large Malignant Pheochromocytoma to Decrease Intraoperative Blood Loss 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Adam C. Protain, Kevin C.J. Yuen*, Frederick S. Keller and Jose F Rueda
Oregon Health and Science University, Portland, OR

 

Background:Distinguishing unilateral aldosterone-producing adenomas (APAs) from bilateral idiopathic hyperplasia is mandatory for the correct management of primary aldosteronism (PA): 1) unilateral adrenalectomy for APA and unilateral adrenal hyperplasia, or 2) medical therapy for bilateral adrenal hyperplasia. Adrenal venous sampling (AVS) is considered the gold standard for identification and localization of the adrenal lesion responsible for PA. However, the success rate of this procedure is highly dependent on the expertise of the angiographer. With experience, and focusing the expertise to one or two angiographers at a referral center, the AVS success rate has been reported to be as high as 96% (1,2).

Methods:We conducted a retrospective analysis of all AVS procedures performed at Oregon Health and Science University (OHSU), Portland, Oregon for patients with biochemical confirmation of PA between June 1995 and June 2013 by the same angiographer (FSK). A ratio of adrenal vein to inferior vena cava cortisol concentration of 5:1 or greater was used to confirm the successful catheterization of the adrenal veins (SI: Sensitivity Index). Right and the left adrenal vein aldosterone concentrations were divided by their respective cortisol concentrations, and the ratio from high to low was calculated (LI: Lateralization index). A ratio of 4:1 or greater was used as the cutoff for diagnosing unilateral disease. Concurrently, CT/MRI reports, when performed, were extensively reviewed, and any complications were noted.

Results:AVS for PA was performed successfully in 105 of 126 (83.3%) procedures, and in 101 of 115 patients (87.8%). Repeat AVS was successfully performed in 10 of 11 attempts (90.9%). More than half [54/105 (51.4%)] of the successful AVS procedures had a LI ≥ 4:1, and 31/54 (57.4%) patients of this group underwent an adrenalectomy. Pathology reports yielded 23 APAs, with 6 glands being found to have adrenal hyperplasia, 1 normal adrenal gland, and 1 adrenal gland with hemorrhage. The CT/MRI and AVS concordance was 53%, whereas 5.8% of AVS lateralized to the opposite side of the mass seen on CT/MRI. Asymptomatic adrenal hemorrhage during adrenalectomy was the only noted complication (i.e., complication rate 0.8%).

Conclusions: In our institution, AVS was performed successfully in the majority (87.8%) of patients by the same angiographer with minimal complications. The high success rate of AVS at our institution is highly dependent on the proficiency and expertise of the angiographer.

 

Nothing to Disclose: ACP, KCJY, FSK, JFR

19282 28.0000 FRI-404 A Adrenal Vein Sampling for the Differential Diagnosis of Primary Aldosteronism: A Single-Center, Single Angiographer Experience from 1995 to 2013 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Dong-Hwa Lee*1, Jung Hee Kim1, Seo Young Lee1, Kyeong Seon Park1, Ji Won Yoon2, Hak Chul Jang3, Sang Wan Kim4, Chan Soo Shin1 and Seong Yeon Kim1
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Korea, Republic of (South), 3Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 4Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea, Republic of (South)

 

Context : Lateralization of aldosterone hypersecretion is crucial to determine the treatment in primary aldosteronism (PA). Adrenal venous sampling (AVS) is recommended as a gold standard to distinguish unilateral from bilateral PA. However, AVS is invasive, technically difficult and only available in several hospitals in Korea. Recently, clinical lateralization criteria to bypass AVS have been published. Another study suggested that patients with age below 40 years and adenoma on imaging can omit AVS.

Objective : The aim of study was to assess the applicability of recently suggested clinical predictors of unilateral PA in Korean patients under 40 years.

Design and Setting : Medical records were reviewed retrospectively from January 1994 to July 2014 at Seoul National University Hospital.

Patients : A total of 35 patients with PA below 40 years and an adenoma of at least 0.8cm on imaging were included if successful AVS or postoperative results were available.       

Main Outcome Measures : Unilateral aldosterone excess was determined based on the lateralization by AVS and clinical improvement after unilateral adrenalectomy. We applied a clinical prediction score system consisted of typical Conn’s adenoma imaging, serum potassium (<3.5 mmol/L), and estimated glomerular filtration rate (ml/min/1.73 m2) (Kupers et al.)

Results : A total of 31 patients (89%) had unilateral PA according to AVS or postoperative results. Patients with unilateral PA showed a shorter duration of hypertension at diagnosis than those with bilateral PA. Other parameters including serum potassium, glomerular filtration rate and baseline serum aldosterone level were no significantly different between two groups. The clinical prediction score ≥ 5 presented a sensitivity of 39% (12/31) and a specificity of 75% (3/4), and the score ≥ 6 had a sensitivity of 23% (7/31) and a specificity of 100% (4/4). The results suggested that in some patients who did not undergo AVS, we may be made a wrong diagnosis and treatment. 

Conclusions : The present study demonstrated that the proposed clinical prediction score cannot replace AVS even in Korean patients aged below 40.

 

Nothing to Disclose: DHL, JHK, SYL, KSP, JWY, HCJ, SWK, CSS, SYK

20860 29.0000 FRI-405 A Adrenal Venous Sampling Is Essential to Diagnose Unilateral Primary Aldosteronism Even in Korean Patients Under 40 Years 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Giovanna Mozardo Duarte*1, Victor Sousa da Silveira2, Christiane Andrade de Azevedo2, Vanessa Castro Ramos2, Ana Heloisa Correia Bresque3, Evandro S Portes4, Ricardo A Guerra5 and Marcio Faleiros Vendramini1
1Hospital do Servidor Público Estadual de São Paulo, 2Hospital do Servidor Público Estadual, 3Hospital do Servidor Público Estadual, Sao Paulo, Brazil, 4Hospital de Servidor, Sao Paulo, Brazil, 5Hospital do Servidor Publico Estadual de Sao Paulo

 

Obesity and Pheochromocytoma – Unusual Association: A Case Report

Background

Pheocromocytomas is a rare cathecolamine secreting tumor of cromaffin cells that causes both hypertension and hypermetabolism.

Clinical Case

A 60-year old man was referred to our department for the evaluation of hypertension that was difficult to control. The patient presented with a body mass index of 45.71 kg/m2 and reported several daily episodes of arterial hypertension, palpitations, sweating, chest pain, and headaches throughout 12 months of evolution. The patient reported an increase of 20 kg from the onset of the symptoms.

The patient’s comorbities included diabetes mellitus type 2 and hepatic steatosis (grade 2).

Endocrine studies showed urinary norepinephrine 114 µg/24h (n<97 µg/24h); urinary metanephrines 5177 µg/24h (VN <1000 µg/24h); urinary adrenaline 17 µg/24h (n <27). Other causes of secondary hypertension were discarded.

Computerized abdominal tomography indicated the presence of a tumor in right adrenal with a diameter of 3.0cm.

The patient underwent laparoscopic surgery with resolution of symptoms and weight loss of 15 kg after 4 months of follow up.

The adrenal tumor was diagnosed as a functioning pheochromocytoma through histological and immunohistochemical study.

Conclusion

Obesity has dramatically increased worldwide. Thus the increased  occurrence of obese patients with pheochromocytoma. However, due to hypermetabolism caused by catecholamine secretion, a significant weight loss is expected in the clinical manifestation. In the reported case the patient presented an unusual clinical course of the disease with significant weight gain and later weight loss subsequent to the definitive treatment.The justification found is based on the patient’s need for bed rest in order to minimize the adrenergic symptoms.

 

Nothing to Disclose: GMD, VSDS, CADA, VCR, AHCB, ESP, RAG, MFV

21371 30.0000 FRI-406 A Obesity and Pheochromocytoma Unusual Association: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Kristine Santos de Luna* and Leilani Mercado Asis
University of Santo Tomas Hospital, Manila, Philippines

 

BACKGROUND: Pheochromocytoma is a rare catecholamine-secreting neuroendocrine tumor from the chromaffin cells located in the adrenal medulla that can be hereditary or sporadic. This tumor usually occurs in the third to fifth decades. Hereditary tumors usually appear at a younger age. Larger-sized tumors are usually malignant. Pheochromocytoma can have different non-specific manifestations. However, the most common symptoms are headache, sweating, and palpitations. Hypertension can be persistently elevated or intermittent even in younger patients. The serious complications of pheochromocytoma are largely attributed to the effects of catecholamines. Cardiomyopathy which is secondary to excess catecholamines is relatively rare and is one of the challenging complications of pheochromocytoma. This condition is also usually overlooked by clinicians and if left untreated, can result in fatal cardiovascular outcomes. After removal of the tumor, the risk of cardiovascular morbidity and mortality becomes the similar to that of the general population.

CLINICAL CASE: We report a case of a 20 years old female with a 2 years history of headache, palpitations, and sweating. On her consultation, blood pressure was discovered to be greatly elevated (171/104 mmHg, n £ 110/70 mmHg). Upon further evaluation, twenty-four hour urine metanephrine level was more than 7 times elevated (7.46 mg/24 hour, n<1mg/24 hour). A CT scan of the abdomen showed a right suprarenal mass measuring 8 cm by 5 cm. Two-dimensional echocardiography showed an akinetic intraventricular septum. Patient subsequently underwent open complete right adrenalectomy. Histopathology findings showed malignant pheochromocytoma. During the post-operative period, the patient’s symptoms resolved. The blood pressure also normalized. Patient was discharged in a stable condition with low dose prednisone for 7 days and advised regarding careful follow-up of her condition.

CONCLUSION: Pheochromocytoma is a tumor of infrequent occurrence. Although rare, this condition should always be considered when entertaining secondary hypertension. One of its serious complications, especially if not recognized is cardiomyopathy due to the effects of chronic catecholamine excess. It is therefore important to perform cardiac imaging once pheochromocytoma is entertained even if the patient is young. In this case, we emphasize on the importance of early detection and removal of the tumor in order to reverse the effects of catecholamine excess and to prevent the onset of fatal cardiovascular and cerebrovascular complications. Genetic testing to determine whether pheochromocytoma is part of associated autosomal dominant conditions is indicated especially if the patient is young. Close and careful monitoring of the patient is also mandatory for tumors exhibiting malignant behavior.

 

Nothing to Disclose: KSD, LMA

21387 31.0000 FRI-407 A Malignant Pheochromocytoma-Induced Cardiomyopathy in a Young Adult 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Miguel Augusto OMeara*1, Carlos Tafur2 and Alejandro Garcia2
1Cardioinfantil Foundation Cardiology Institute, Bogota, Colombia, 2Del Rosario University, Bogota, Colombia

 

Background:

Primary aldosteronism (PA) is the most common cause of arterial hypertension among endocrine origin. There are different methods for detection and diagnosis confirmation of the PA, nevertheless in clinical settings of patients with severe hypertension and acute complications such as aortic dissection, perform a confirmatory test should be delayed to provide urgent treatment.

Clinical case:

A 45 Years old man was admitted to the emergency department complaining of acute chest pain; 10/10 of severity, radiates to the back, with no other mayor complains or a trigger circumstance. The past medical history was remarkable for a high blood pressure refractory to treatment, diagnosed about 10 years ago. He had three hospitalizations for hypertensive emergency, including a stroke. Patient's physical examination exhibited a severally hypertensive (160/87mmhg), distressed male, with no other remarkable findings. Initial laboratory tests evidenced a severe hypokalemia (2.5 mEq/L), with sodium, calcium, serum creatinine and troponin I levels within normal limits. EKG showed sinus rhythm with no other alterations, a chest CT scan confirmed the presence of aortic dissection with extension to the iliac arteries and an abdominal MRI was performed, which showed a focal lesion (15mm) in the left adrenal gland. After a carefully discussion the patient was taken to surgery for an ascending aortic replacement and a left laparoscopic adrenalectomy. The patient's blood pressure values were normalized gradually, as well as the levels of serum potassium, finally the patient was discharged ten days after with a half of the blood pressure medication.

Conclusion:

There are several clinical conditions in which perform biochemical studies for detection and confirmation of the primary aldosteronism involve modification or even interruption of antihypertensive medication for its proper analysis, in this case was impossible to confirm the diagnosis, therefore and considering the benefit of intervention (remove an unconfirmed hyperaldosteric tumor) against removing and incidental lesion led us to make a good decision.

In critical clinical situations like this, we must apply our clinical judgment as an only tool.

 

Nothing to Disclose: MAO, CT, AG

18683 32.0000 FRI-408 A Hyperaldosteronism: When the Urge for Treatment Cannot Wait the Diagnosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM FRI 377-408 5987 1:00:00 PM Pheochromocytomas and Aldosterone Producing Tumors Poster


Natalie Mora*1 and Louis F Amorosa2
1Rutgers Robert Wood Johnson, New Brunswick, NJ, 2Rutgers-RWJMS, New Brunswick, NJ

 

Background: Lymphocytic hypophysitis (LYH) primarily occurs in females, often during pregnancy or in   the postpartum period. This patient is atypical because of uncommon findings.

Clinical case: A 46-year-old female with no prior history of autoimmune disorders presented with headache, vertigo, and nausea. Laboratory studies were suggestive of SIADH: Na 121 mEq/L, urine sodium 52 mEq, and urine osmolarity 563 mOsm.  Cortisol studies were consistent with secondary adrenal insufficiency (corticotropin 10 pg/mL, AM cortisol 1.7 ug/dL, pre-stimulation cortisol level 4.6 ug/mL, 1-hour post-stimulation cortisol level 9.2 ug/mL). Hypothyroidism was indicated by inappropriately normal TSH (0.603 mcIU/mL) in context of low free T4 (0.66 ng/dL). Hyperprolactinemia (135 ng/dL) and decreased IGF-1 (50 ng/mL) were also detected. MRI imaging illustrated pituitary stalk enlargement (3mm) with no inflammatory changes in the hypothalamus.  Loss of the posterior pituitary “bright spot”, often found in LYH-induced diabetes insipidus, was also noted. The patient’s electrolyte imbalance readily corrected following hydrocortisone 20mg and levothyroxine 50mcg replacement.

            Findings in this patient indicate an atypical LYH presentation, not associated with pregnancy or the post-partum period. This patient raises the question of what mediated profound hyponatremia in the context of an absent pituitary bright spot. The patient’s decreased sodium level (121 mg/dL) is consistent with SIADH, as opposed to DI which is often associated with loss of bright spot. An absent bright spot does not account for the increased UrNa and Urosmand may be a nonspecific finding. However, hypothyroidism and hypoadrenalism can alter renal water clearance and therefore SIADH is excluded. Elevated prolactin levels in LYH are usually related to stalk involvement, which was observed in this patient as an enlarged stalk. However, LYH would be expected to demonstrate hypoprolactinemia as most patients with postpartum presentation commonly fail to lactate secondary to panhypopituitarism.

The diagnosis of LYH is ultimately confirmed on pituitary biopsy, however imaging has been increasingly used for detection. Specific features on imaging, including symmetric pituitary enlargement, a thickened, nondisplaced stalk, loss of bright spot, and intact sellar floor, strongly support a diagnosis of LYH.

Conclusion:

This case represents an atypical presentation of LYH not related to pregnancy or the post-partum state. The suggestion of a SIADH clinical picture with  loss of bright spot, no associated autoimmune disorders, and hyperprolactinemia define a unique constellation for this rare diagnosis.

 

Nothing to Disclose: NM, LFA

18865 1.0000 FRI-466 A Atypical Lymphocytic Hypophysitis Presenting As Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) with Loss of Posterior Pituitary Bright Spot and Hyperprolactinemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Peter Gergics*1, Michelle L. Brinkmeier2, Monica Seungah Choo1 and Sally A Camper3
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI, 35704 Med. Sci II, 1241 Catherine St., Ann Arbor, MI

 

Pituitary adenomas are generally benign and slow growing, but they can cause significant health problems and occasionally become invasive.  Genetically engineered mice make it possible to study the mechanisms that underlie the proliferative drive in adenomas.  Thyrotrope adenomas are rare, and some express growth hormone and prolactin, suggesting dysregulation of proliferation in a Pit1 lineage precursor.  The etiology of thyrotrope adenomas is not well understood.  To determine the mechanisms regulating proliferation of these adenomas, we used the chorionic gonadotropin alpha subunit (CGA) knockout mouse.  These mutants have profound thyrotrope hypertrophy and hyperplasia and reduced production of somatotropes and lactotropes (2).  Using an Illumina platform we compared the pituitary gene expression profiles of adult mutants and controls.  Cluster analysis identified multiple categories of molecular functions, including transcription factors (TF), mRNA processing, unfolded protein response, and vesicle trafficking.  Among the most highly elevated TF were two members of the family of transcription elongation factors.  These Zn-finger TF have RNA polymerase binding domains and are thought to regulate transcription by protein-protein interactions.  We investigated expression of these genes in the pituitary gland using in situ hybridization and immunohistochemical staining.  We found enrichment in the wedge area, which is thought to be a region rich in progenitor cells.  To assess the effect of elevated expression, we generated stable cell lines that express GFP-tagged TF or GFP alone.  We used the Pit1-triple cell line for the transfections because they represent the lineage of cells that differentiate into thyrotropes, somatotropes and lactotropes (3).  Our preliminary studies suggest that the TF accelerates proliferation of Pit1-triple cells.  A comparison of gene expression between these cell lines will be valuable for identifying target genes of this TF.  In summary, we have discovered altered expression of transcription elongation factors in a mouse model of thyrotrope adenoma and are assessing the effect on proliferation of a cell line that produces thyrotropin.  These studies may reveal drug targets to reduce the proliferation of adenomas and ultimately provide improved treatments for patients.

 

Nothing to Disclose: PG, MLB, MSC, SAC

22147 2.0000 FRI-467 A Thyrotrope Adenoma Mouse Model Exhibits Altered Expression of Transcription Elongation Factor Genes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Hanna Deguchi*1, Hisashi Koide2, Eri Komai2, Akina Shiga2, Tomoko Takiguchi2, Akitoshi Nakayama2, Seiichirou Higuchi2, Ikki Sakuma2, Hidekazu Nagano2, Naoko Hashimoto2, Sawako Suzuki2, Tomohiko Yoshida2, Koutaro Yokote2 and Tomoaki Tanaka2
1Graduate School of Medicine, Chiba University, Japan, 2Chiba University Graduate School of Medicine, Chiba, Japan

 

Background: Rathke’s cleft cysts (RCCs) are known as benign lesions that are remnants of the embryologic Rathke’s pouch. They are more frequently diagnosed these days, as imaging technology has become widely available and advanced. The various clinical features are caused by focal chronic inflammation and mass effect. However, their detailed pathological features and effectiveness of steroid treatment are still unknown. Here, we present two cases of hypophysitis, both treated with steroid. Both cases were first diagnosed as lymphocytic hypophysitis, which later turned out to be secondary hypophysitis caused by RCCs, based on their pathological findings of pituitary biopsies. Case 1 showed recovery of anterior pituitary function and decrease in cyst size in response to glucocorticoid administration. Case 2 showed a similar time course as case 1, which we expect recovery after steroid treatment. We will present these two cases focusing on pituitary function, pathological features, and radiographic features.

Case Reports: Case 1. A 62-year-old woman was admitted to our hospital complaining of polydipsia, polyuria, general fatigue, and asitia. The T1-weighted image of MRI showed swelling of the pituitary with a cystic lesion and disappearance of high intensity signal of posterior pituitary lobe. She was diagnosed as combined pituitary hormone deficiency and central diabetes insipidus due to hypophysitis. She was treated with 30 mg of hydrocortisone. The follow up MRI showed decrease in cyst size. The anterior pituitary function recovered and hydrocortisone was tapered off. However, cyst size increased after the treatment was terminated. Pituitary biopsy was performed to confirm diagnosis. The pathological findings demonstrated inflammation of the cyst capsule extending to the hypophyseal tissue. The infiltrate was mainly composed of lymphocytes and scattered IgG4-positive plasma cells.

Case 2. A 50-year-old woman had combined pituitary hormone deficiency. The MRI showed asymmetrical swelling of the pituitary, suggesting the possibility of RCC. She had visual defects and hyperprolactinemia due to mass effect. Moreover, she presented headache and diabetes insipidus. Her pathological diagnosed from pituitary biopsy was secondary hypophysitis caused by RCC. She was treated with prednisolone (PSL) for hypophysitis at the age of 35. PSL was gradually tapered off after confirming the decrease in cystic lesion size.

Conclusion: The inflammatory cell infiltration to the hypophyseal tissue after ruptures of RCCs and leakage of cyst contents leads to hypophysis causing pituitary impairment which could be irreversible in some cases. Both of our cases showed hypophyseal inflammation and mass effect. Case 1 showed that prompt steroid application could improve anterior pituitary function, suggesting that steroid may be useful in the treatment of the RCCs with hypophyseal inflammation.

 

Nothing to Disclose: HD, HK, EK, AS, TT, AN, SH, IS, HN, NH, SS, TY, KY, TT

19790 3.0000 FRI-468 A Two Cases of Steroid Responsive Hypophysitis Caused By Rathke's Cleft Cysts with Combined Pituitary Hormone Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Diana Denman*, Gino J Mongelluzzo, Joseph H Lock Jr., Rajiv Panikkar, Ying Zeng, Penny Gingrich and Ying Hu
Geisinger Medical Center, Danville, PA

 

Background:  Ipilimumab (IP), a human antibody against cytotoxic T-lymphocyte antigen 4 (anti-CTLA4), is FDA approved for the treatment of unresectable or metastatic malignant melanoma. Here we report two cases of patients treated with IP who developed hypopituitarism from autoimmune hypophysitis (AIH).   

Case reports:

Case 1 is a 52 year old male with stage IIIb malignant melanoma of perianal skin who was enrolled in a “phase III randomized study of adjuvant IP therapy versus high-dose Interferon α-2b for resected high-risk melanoma”.  After receiving four doses of IP (10 mg/kg), the patient presented with a severe headache and extreme fatigue.  Lab work revealed total testosterone 32.71 (193 - 740 ng/dL), TSH 0.17 (0.27 - 4.2 uIU/mL), free T4 0.40 (0.7 - 1.7 ng/dL), and cortisol 3.1 (6.2-19.4 ug/dL).  MRI showed a diffusely enlarged pituitary gland and infundibulum with homogenous enhancement.  Hypopituitarism due to AIH induced by IP was suspected.  IP was stopped and he was treated with prednisone 60 mg for five days followed by hydrocortisone, levothyroxine, and androgen replacement.  His symptoms were resolved rapidly.  At two months follow up, an MRI showed complete resolution of enlarged pituitary; lab results did not show signs of pituitary function recovery. 

Case 2 is a 56 year old female with stage IIIc metastatic melanoma of her left back who was enrolled in the same trial to receive IP (3 mg/kg).  After three doses of IP, she developed headache and mild fatigue.  Labs showed TSH 0.15 (0.27 - 4.2 uIU/mL), free T4 0.54 (0.7 - 1.7 ng/dL), cortisol 0.7 (6.2-19.4 ug/dL), and ACTH 5.9 (0-16 pg/ml).  MRI showed a diffusely enlarged pituitary gland consistent with hypophysitis.  IP was stopped and she was treated with prednisone 60 mg for five days, followed by levothyroxine and hydrocortisone replacement.  Her symptoms improved shortly after.  At one month follow up, an MRI showed improvement of pituitary size, but lab results did not show signs of pituitary function recovery.

Discussion:

Both patients developed hypopituitarism due to presumed AIH secondary to IP therapy. AIH is a rare endocrine disease, which has been reported in about 4% of patients involved in IP trials. Most patients developed AIH after receiving the third dose of treatment, which is similar to the cases reported here. Both cases presented with headache and fatigue. Treatments have corrected their clinical symptoms and radiographic abnormalities. However we haven’t seen the recovery of endogenous pituitary function several months after the events.

The mechanism of AIH induced by IP likely is related to its immunostimulation effect.  Whether large dose of steroids have helped their recovery process or not is unknown.

Conclusion:

AIH is a rare but significant complication from IP treatment. Endocrinologists and Oncologists need to be aware of this, as it can cause hypopituitarism, which could be life threatening if unrecognized.

 

Nothing to Disclose: DD, GJM, JHL Jr., RP, YZ, PG, YH

21334 4.0000 FRI-469 A The Growing Concern for Autoimmune Hypophysitis Due to Ipilimumab 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Preaw Hanseree*1 and Jennifer Lee Poehls2
1University of Wisconsin Hospital and Clinics, Madison, WI, 2University of Wisconsin, Madison, WI

 

Background:  Ipilimumab is a monoclonal antibody directed against cytotoxic T-lymphocyte antigen-4 that was approved by FDA as monotherapy for metastatic melanoma in March 2011.  There have been reports of immune-related adverse events affecting different organs.  The most common endocrinopathy is hypophysitis with the incidence of 1.8-17%(1).

Clinical case:  53 year old female with history of resected metastatic melanoma (N2b) of unknown primary site diagnosed by right inguinal lymph node biopsy.  She entered a clinical trial and was randomized to ipilimumab therapy.  After completing her fourth course of ipilimumab, she presented with headache that had progressively worsened over 2 weeks.  She also noted fatigue, dizziness, and weight gain.  She denied nausea, vomiting, visual symptoms, polydipsia or polyuria. Labs showed low TSH 0.23 uIU/mL(0.36-4.20 uIU/mL), low free T4 0.44 ng/dL(0.70-1.45 ng/dL), low free T3 2.0 pg/mL(2.2-4.0 pg/mL), low 8AM cortisol 3.3 mcg/dL(4.3-22.4 mcg/dL) with inappropriately normal ACTH 22 pg/mL(7-45 pg/mL).  Electrolytes were normal.  MRI of the brain demonstrated diffuse enlargement of the pituitary gland measuring 1.2 cm with mass effect on the optic chiasm and thickening of the pituitary infundibulum, suggestive of hypophysitis.  Visual field exam was normal.  Patient received high dose methylprednisolone infusions, about 2mg/kg on day 1, and about 1mg/kg on day 2 and 3.  Levothyroxine 50 mcg daily was also started.  Headache resolved 2 days after starting treatment and patient was discharged home with tapering course of prednisone.  Headache recurred during the 4th week as she was tapered to replacement dose of hydrocortisone.  Repeat MRI at that time showed pituitary gland had decreased to 1 cm with minimal residual inflammation.  Hydrocortisone was changed back to prednisone 20 mg daily for 3 days and headache improved.  Repeat TSH and free T4 were normal.  When prednisone taper tried again, the patient had recurrent headache.  Repeat MRI 8 weeks after initial presentation showed decrease in the size of pituitary now measuring 6 mm.  Patient was continued on prednisone 20 mg daily with plans to taper in 1-2 weeks if/when headache resolves.  

Clinical Lessons: The recommended treatment for immune-related adverse events secondary to ipilimumab, including hypophysitis, is high-dose glucocorticoids tapered down gradually over 1 month to replacement doses.  Ipilimumab should be held as well.  Most patients respond well  to this treatment with resolution of symptoms within a few days.  This report is to remind physicians to monitor for recurrence of symptoms while tapering steroids as some patients may require a longer tapering course.

 

Nothing to Disclose: PH, JLP

20802 5.0000 FRI-470 A Ipilimumab-Induced Hypophysitis – Recurrence of Symptoms during the Course of Steroid Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Priscila R M M Cardoso1, Marilia Almeida Cardoso*2, Raiane Pina Crespo3, Ane Caroline Freire1, Andrea Glezer4 and Marcello D Bronstein5
1USP, 2School of Medicine, Sao Paulo University, Sao Paulo, Brazil, 3Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil, 4Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 5University of São Paulo Medical School, São Paulo, Brazil

 

Background:Idiopathic Granulomatous Hypophysitis is a rare condition which diagnosis is frequently made after surgery.  Clinical picture usually comprehends headache and hypopituitarism. The most common treatments are excisional surgery alone or with corticosteroids as adjunvant treatment, less often with corticosteroids alone after biopsy.

Case report:

  A 52-yrs-old women, presenting with headache, nausea, postural hypotension, drowsiness and dry skin was referred to our hospital. Laboratory tests at admission pointed to panhypopituitarism: estradiol <15 pg/mL (up to 54 pg/mL), FSH 2,.1 IU/ L (1,5 to 12,4 IU/L), LH <0,1IU/L (1,7 to 8,6 IU/L) IGF-1 49 ng/mL (84 to 233 ng / ml), GH <0.1 ng / ml (up to 4,4 ng/mL), free thyroxine 0.36 ng/dL (0.93 to 1.7 ng /dl), TSH 0.36 μIU/ml (0.27 to 4.20 μIU / ml), cortisol 2.6 mg/dL (5 to 25 mg / dL) , ACTH 20 pg/mL (up to 46 pg / ml), except for normal PRL level. MRI showed a sellar mass abutting optical chiasm with 1.8 x 1.2 x 1.2 cm, homogeneous enhancement after gadolinium. Visual field perimetry was normal. Transsphenoidal biopsy was performed as the lesion aspect during de procedure was not as the expected for a pituitary adenoma. Hiistological diagnosis was granulomatous hypophysitis. Patient was further submitted to cutaneous, skeletal, visceral, and laboratory evaluation  to exclude systemic granulomatous disease such as tuberculosis, syphilis, sarcoidosis and histiocytosis X. Sequential  MRI scans in 3 and 7 months revealed lesion.progression and a clearly thickened pituitary stalk. Prednisone 60 mg/day (patient weight: 107kg - 0,5mg/kg/d) was started  and headache disappeared. Sellar MRI after 4 weeks showed significant lesion reduction. After 10 weeks, prednisone dose was gradually tapered. Pituitary function was not reestablished to date.

Conclusion: Even if clinical and radiological findings do not indicate the diagnosis of hypophysitis, it should be kept in mind that primary hypophysitis can mimic non-secretory pituitary. This case demonstrates a significant response of idiopathic granulomatous hypophysitis to non immunosuppressive doses of corticosteroids.

 

Nothing to Disclose: PRMMC, MAC, RPC, ACF, AG, MDB

20388 6.0000 FRI-471 A Idiopathic Granulomatous Hypophysitis Mimicking a Clinically Non-Functioning Pituitary Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Ngina Muigai*1, Daisy Acevedo1, Adriana Ricciuti2, Patrizio Caturegli3, Ronald J Benveniste4 and Atil Yilmaz Kargi5
1University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, 2Johnson Hopkins University, Baltimore, MD, 3Johns Hopkins University, Baltimore, MD, 4University of Miami Miller School of Medicine/Jackson Memorial Hospital, 5University of Miami Miller School of Medicine, Miami, FL

 

Introduction: Autoimmune Lymphocytic hypophysitis (LYH) is sometimes associated with visual disturbances, which are usually due to compression of the optic chiasm or oculomotor nerves manifesting as visual field defects or diplopia. Only 12 cases of either biopsy proven or clinically diagnosed autoimmune hypophysitis (AH) have been reported to be associated with optic neuritis (ON). Of these, none reported an association of LYH, with ON and anterior uveitis (AU).  We recently reported a case of LYH, ON and AU who was subsequently treated with sequential infliximab and rituximab. Here we report a second case and update a case reported previously with only LYH and ON which has since evolved and developed AU.

Clinical Case: 52-year-old woman presented for evaluation of hypopituitarism. History was significant for biopsy proven lymphocytic hypophysitis in the post-partum period 15 years prior. 9 years after the initial presentation she presented with bilateral ON and AU and was diagnosed with multiple sclerosis. 6 years after presenting with her ophthalmological symptoms, the patient presented with recurrent hypotension and endocrine testing revealed persistent secondary adrenal insufficiency and likely growth hormone deficiency but intact gonadotroph and thyrotroph function. Serum prolactin was low at <1ng/ml (n 2-18ng/ml). Pituitary autoantibody testing revealed cytostolic positivity in a perinuclear pattern.

The previously reported case of a 41-year old male who presented with sequential episodes of ON, then adrenal insufficiency and hypogonadism, who was later found to have biopsy proven LYH, has since developed AU 5 years after his initial diagnosis.  

Both patients were treated with glucocorticoids including intravitreal glucocorticoid implants and in the case of the woman presented above; treated with methotrexate, with some improvement in symptoms.

Conclusion: This is the second report of AH occurring as a triad of LYH, ON and AU and a third case of this autoimmune triad, previously reported with LYH and ON that has since developed AU. All three cases suggest a shared autoimmune entity with important underlying implications for pathogenesis and treatment with immunosuppressive agents.

 

Nothing to Disclose: NM, DA, AR, PC, RJB, AYK

21339 7.0000 FRI-472 A Triad of Lymphocytic Hypophysitis, Optic Neuritis and Uveitis: A New Autoimmune Syndrome? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Seher Tanrikulu*1, Gulsah Yenidunya Yalin2, Bilge Bilgic3, Savas Ceylan4 and Sema Yarman1
1Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey, 2Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey, 3Istanbul University, Istanbul Faculty of Medicine, 4Kocaeli University, Medical Faculty, Neurosurgery Department, Pituitary Research Centre,

 

Introduction: Lymphocytic hypophysitis is a rare inflammatory disease which is caused by autoimmune destruction of  the pituitary gland.  Patients present with expanding pituitary mass and/or  varying degrees of pituitary dysfunction.  It is rarely seen in men and is mimicking pituitary macroadenoma on magnetic resonance imaging (MRI). We, hereby report a unique presentation of  lymphocytic hypophysitis with  radiological features of an expanding pituitary mass and optic chiasma compression  which was diagnosed as an apparent pituitary macroadenoma in a man.

Case : A 57 year old man was admitted to the pituitary outpatient clinic with new onset visual disturbance. He had been experiencing symptoms of fatigue, malaise and loss of libido for 5 months without signs of  hypercortisolemia and growth hormone excess. His past medical history was not significant. He had pallor and his blood pressure was 100/70 mmHg. Physical examination was otherwise normal. Ophthalmologic examination revealed bitemporal hemianopsia. Diabetes insipidus was not present. Hormonal evaluation was compatible with secondary hypoadrenalism (basal cortisol: 0.1mcg/dl),  hypogonadism  (FSH: 0,8 mIU/ml , LH: 0,3 mIU/ml, Testosteron: 0,03 ng/ml), and hypothyroidism (TSH:0,028 mIU/L, sT4:8,4 pmol/L) with slightly elevated prolactine level (PRL: 22,8 ng/ml). There was no evidence of other autoimmune diseases.  MRI scan revealed a pituitary mass with suprasellar  extension which was mildly hyperintense and predominantly isointense on T1 and T2 images, respectively. Due to presence of visual  field defect the patient was referred to trans-sphenoidal surgery  after initiation of glucocorticoid  and thyroid hormone replacements.  Visual field defect resolved after surgery. Histopathological evaluation demonstrated  intensive infiltration of lymphoplasmocytic cells and fibrosis with preservation of the acinar structure which was consistent with lymphocytic hypophysitis.

Conclusion: This case illustrates the difficulty in differentiation of lymphocytic hypophysitis from pituitary macroadenoma, especially on the basis of radiological findings. Therefore, surgery is justified not only to establish the diagnosis, but also to restore vision by decompression of the optic nerves and the chiasm.

 

Nothing to Disclose: ST, GYY, BB, SC, SY

21064 8.0000 FRI-473 A Is It Easy to Differantiate Pituitary Macroadenoma from Lymphocytic Hypophysitis By MRI Findings ? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Maritza T. Farrant*1, Sasha Nair2 and Steven CM Miller1
1North Shore Hospital, Auckland, New Zealand, 2North Shore Hospital, Auckland

 

Background: Lymphocytic hypophysitis is a rare cause of pituitary dysfunction and is usually treated conservatively or with steroids.  Intracranial germinomas are also rare, occuring in 0.7 per million children, and may be benign or malignant. 

Clinical Case: A previously well 16 year old girl presented with rapid onset of polyuria and polydipsia, drinking up to 8 litres of water per day. Initial biochemistry showed normal anterior pituitary function and normal ACE, ESR and ferritin. A water deprivation test was consistent with central diabetes insipidus (DI). Desmopressin (DDAVP) nasal spray was commenced with immediate symptomatic improvement. MRI pituitary demonstrated thickening of the pituitary stalk, pituitary volume at the upper limit of normal and absence of the posterior bright spot.  CSF was obtained with normal white cell count, protein and glucose with no elevation in alpha fetoprotein (AFP) or beta HCG (HCG). Serum AFP, HCG and IgG4 levels were also normal. Measurement of pituitary autoantibodies was not available at our centre. She was commenced on 40mg oral prednisone reducing over four weeks. A pituitary MRI  one month after stopping prednisone demonstrated reduction in the size of the pituitary stalk with no change in pituitary gland size.

She became amenorrhoeic at four months and at six months after presentation reported mild galactorrhoea. Serum prolactin was elevated at 1084 mIU/l (10-650). A repeat prolactin level two weeks later was  984 mIU/l. Cabergoline 0.5mg weekly was commenced with suppression of prolactin the following month to 14 mIU/l. Cabergoline therapy was stopped after three months with no further recurrence of hyperprolactinaemia or galactorrhoea. However, she has remained amenorrhoeic for a total of eleven months to date despite normal gonadotrophins.

A third pituitary MRI seven months from the time of presentation demonstrated no significant interval growth but showed a new 5mm nodular enlargement of the superior aspect of the pituitary stalk presumed to be inflammatory in nature.  DDAVP has continued to be required. Biopsy of the pituitary stalk has not been done to date due to the invasive nature of this procedure and that results have been equivocal in case reports of mixed tumours (1). The radiological appearance of the pituitary and stalk, with persisting DI, is presumed due to lymphocytic hypophysitis. This is supported by negative tumour markers and radiological improvement with steroid therapy.  However initial shrinkage of germinomas have also been observed with steroid treatment (2). The transient hyperprolactinaemia is likely also due to hypophysitis.

Conclusion:  The initial appearance on MRI and change with corticosteroid treatment can be similar in lymphocytic hypophysitis and germinomas. Pituitary biopsy is invasive and not always conclusive. Thus if tumour markers are negative, serial imaging in the first instance may be appropriate.

 

Nothing to Disclose: MTF, SN, SCM

21446 9.0000 FRI-474 A Lymphocytic Hypophysitis Vs Germinoma in a 16 Year Old Girl Presenting with Central Diabetes Insipidus; A Diagnostic Challenge 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Jayme A. Aschemeyer* and Hussein Saad Elbadawi
Wayne State University, Detroit, MI

 

Background:  Primitive neuroectodermal tumors (PNET) belong to the Ewing family of tumor, deriving from the same neural crest stem cell.  PNET is an extremely rare and malignant tumor that typically occurs in children and young adults.  PNETs are considered high-grade tumors classified as WHO grade 4.  Adults have an overall 5-year survival rate of just 35%.

Clinical case: 48 year-old African American female who was referred to our consultation service for a pituitary mass and uncontrolled hyperglycemia.  Past medical history was relevant for diabetes mellitus type 2, hypothyroidism and a 6 mm pituitary microadenoma diagnosed in 2011 as an incidental finding on computed tomography (CT) imaging. We could not determine if any further work up was done.  She reported amenorrhea for the past four years. She had dizziness, for which a current CT of the head was done.

Physical examination at our hospital revealed an awake and alert female with morbid obesity and an otherwise normal exam.  Visual fields were normal to confrontation.

The brain CT scan with contrast revealed a large enhancing sellar/suprasellar mass extending into the third ventricle (2.4 x 3.4 x 1.9 cm) causing hydrocephalus with extensive bony remodeling of the sella (3.3 x 2.0 x 1.4cm) as well as a component in the suprasellar cistern (1.7 x 2.1 x 1.4cm).  Laboratory data prior to surgery showed a normal BMP, a TSH of 0.378 microIU/mL (Ref:  0.200-4.780 microIU/mL), subsequent free thyroxine on replacement levothyroxine was 1.1 ng/dL (Ref:  0.8-1.8 ng/dL), prolactin of 18.8 ng/mL (Ref:  2.8-29.2 ng/mL), IGF-1 of 79 ng/mL (Ref:  94-252 ng/mL), morning cortisol of 6.4 mcg/dL, ACTH of 50 pg/mL (Ref:  6-58 pg/mL), FSH of 0.3 mIU/mL (Ref:  1.5-33.4 mIU/mL) and LH of <0.1 mIU/mL (Ref: 0.5-76.3 mIU/mL).  The patient then underwent a transnasal transphenoidal biopsy on 8/26/2014 and pathology revealed a PNET WHO grade 4 with extensive fibrosis involving the adenohypophysis.

She had an elective midline frontal craniotomy for resection of the PNET sellar/suprasellar tumor.  Post-operative course has been complicated by change in mental status, decompression of ventricles with VP shunt and seizures. She needed fluid infusions, affecting DI management and causing sodium fluctuation for 3 weeks post surgery. She required a PEG tube and a tracheostomy placement. However, in spite of medical stabilization, she has remained with poor mental status 5 weeks post-operatively.

Conclusion:  This case highlights a rare, malignant PNET growing at an accelerated rate over three years at a very late age for this classification of tumor.  Although evidence suggests that survival has improved over the last 30 years with the advent of standardized treatment utilizing radiotherapy and chemotherapy, prognosis is still worse when diagnosed at a later age and further investigation is needed to determine this difference.

 

Nothing to Disclose: JAA, HSE

21080 10.0000 FRI-475 A Aggressive Progression of a Primitive Neuroectodermal Pituitary Tumor over Three Years in a 48 Year-Old Patient with a Poor Surgical Outcome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Henrique Vara Luiz*, Tiago Nunes Silva, Bernardo Dias Pereira, Isabel Manita and Jorge Ralha Portugal
Garcia de Orta Hospital, Almada, Portugal

 

Introduction: Intrasellar plasmacytoma is a rare disorder and about 30 cases have been reported in the literature. It is often misdiagnosed as a nonfunctioning pituitary adenoma because of clinical and radiological similarities, although it usually presents with intact anterior pituitary function. Multiple myeloma (MM) should be excluded. Radiotherapy is the treatment of choice, and the prognosis is variable.

Clinical case: A 68-year-old Portuguese male presented to the outpatient clinic, in November/2013, with a three-month history of gynecomastia, decreased libido and erectile dysfunction. He had hypertension treated with Lisinopril + Hydrochlorothiazide, a right ocular prosthesis following an accident and glaucoma of the left eye (LE). On physical examination, the patient had bilateral and painful gynecomastia, confirmed by ultrasound and mammography. Laboratory testing revealed secondary hypogonadism, hypothyroidism and adrenal insufficiency, with a slight increase in the prolactin level.  Hydrocortisone was started and subsequently Levothyroxine was added. Magnetic Resonance Imaging (January/2014) showed a 5.6 x 6.0 x 6.1 cm heterogeneous mass involving the clivus with intrasellar extension, infiltration of the sphenoid and cavernous sinuses and marked contrast enhancement.  No significant changes were identified in the visual fields of the LE. The diagnosis of invasive pituitary macroadenoma was considered and the patient was submitted to transsphenoidal surgery in June/2014, with partial removal of the lesion, complicated by tumor bleeding requiring blood transfusion. Histological examination was consistent with plasmacytoma. The patient had a monoclonal IgG kappa band on serum immunofixation, increased Kappa free light chains, with no clonal bone marrow plasma cells. MM was excluded and he underwent localized radiation therapy over 4 weeks (August-September/2014), at a dose of 50 Gy, with no complications. He is now waiting for the follow-up exams.

Conclusion: We present a case of a solitary intrasellar plasmacytoma, initially mistaken for a pituitary macroadenoma based on the clinical presentation, laboratory testing with panhypopituitarism and radiological features. Plasmacytoma should be considered in the differential diagnosis of a pituitary mass lesion, particularly in the case of invasive tumors.

 

Nothing to Disclose: HVL, TNS, BDP, IM, JRP

21411 11.0000 FRI-476 A Intrasellar Plasmacytoma: An Entity to be Considered in the Differential Diagnosis of a Pituitary Mass Lesion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Halis Kaan Akturk*1 and Shon Edward Meek2
1Mayo Clinic, Jacksonville, FL, 2Mayo Clinic-Jacksonville, Jacksonville, FL

 

Background: Majority of sella-suprasellar masses are pituitary adenomas. However, salivary gland-like tumors of the sella region are very rare.

Clinical Case: A 69-year-old male presented with sinus problems. Sinus CT showed a large sellar-suprasellar mass. MRI of the brain confirmed a 3.2 cm sellar-suprasellar mass causing elevation of the optic chiasm, greater on the right.  The mass was predominantly T1 hypointense and T2 hyperintense. He was referred to Endocrinology for further evaluation. He denied any pituitary related symptoms other than erectile dysfunction for a couple of years. He also denied any vision problems. Physical exam revealed normal blood pressure, testicular atrophy and scant body hair.  The rest of the physical exam was normal.

Lab evaluation revealed he had low am cortisol (4.8 mcg/dL, N>6 mcg/dL) with normal ACTH (14.9 pg/mL, 10-60 pg/mL) ; low free T4 (0.4 ng/dL, 0.9-2.4 ng/dL) with normal s-TSH (2.35 mIU/L, 0.3-5 mIU/L); low LH (0.3 IU/L, 1.8-8.6 IU/L) with low-normal FSH (1 IU/L, 1-18 IU/L ; low testosterone (<7 ng/dL, 240-950 ng/dL) and low free testosterone (<0.1 ng/dL, 9-30 ng/dL). He had also normal levels of IGF-1 and GH. His PSA was undetectable. Visual field testing revealed bilateral superior temporal visual field impairment, worse on the left side. Ophthalmologic exam suggested that the tumor was causing a predominantly bitemporal superior quadrantic visual field defect related to inferior optic chiasmal compression.

He was treated with levothyroxine and hydrocortisone for hypopituitarism. He underwent transsphenoidal resection of the sella mass. Pathology showed salivary gland tissue with well-differentiated mucous acini and scant moderately cellular fibrovascular stroma without any pituitary tissue, consistent with salivary gland-like tumor. At 6-month follow up, his visual field defect improved, pituitary MRI did not show any signs of recurrence of the tumor. He is on levothyroxine, hydrocortisone and testosterone replacement with normal hormone levels.

Conclusion:

Salivary gland-like tumors presumably derive from salivary gland rests. Salivary gland rests in the posterior pituitary gland have been reported in detailed pituitary autopsies. Some authors believe that salivary cells in the posterior pituitary originate from epithelium of Rathke’s pouch (1). Three cases of salivary gland tumors in the sella have been reported previously.  These patients presented with vision disturbances and increased thirst with urination (2). However, in our case, the patient denied any complaints other than sinus symptoms and the patient denied any visual disturbance despite objective evidence of visual field compromise.

 Salivary gland-like tumors need to be considered in differential diagnosis of sella-suprasellar masses. Secondary hypogonadism can be the first presentation of a sella-suprasellar mass.

 

Nothing to Disclose: HKA, SEM

21605 12.0000 FRI-477 A Mucous Salivary Gland Tissue in a Sella Mass 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Paul Jerome Custodio*1, David Jho1, Cunfeng Pu1, Murray B. Gordon2 and Ines Donangelo1
1Allegheny General Hospital, Pittsburgh, PA, 2Allegheny Neuroendocrinology Center, Allegheny General Hospital, Pittsburgh, PA

 

Background: Spindle cell oncocytoma (SCO) is a rare non-endocrine neoplasm of the anterior pituitary that is clinically and radiologically indistinguishable from non-functioning pituitary adenomas. The twenty one cases reported to date presented with symptoms of mass effect and chronic hypopituitarism. We describe a previously unreported presentation of SCO of the pituitary, with severe hyponatremia and adrenal crisis.

Case Report: A 60 year-old male presented with a 2-week history of nausea, vomiting, malaise, and syncopal episodes. On examination, he was hypotensive and dehydrated. He had normal visual fields, scant axillary and pubic hair, and small testicles. Initial laboratory showed serum sodium 112 mEq/L. Blood pressure normalized and hyponatremia partially improved to 128 mEq/L with intravenous saline hydration. Endocrine evaluation revealed panhypopituitarism, with hypocortisolism [8AM cortisol 6.6 mcg/dL (7-25), 8AM ACTH 2.0 pg/mL (10-48)], central hypothyroidism [TSH 1.63 mcU/mL (0.4-4.0), free T4 0.48 ng/dL (0.8-1.7)], central hypogonadism [total testosterone <3 ng/dL (240-950), LH 1.0 mIU/mL (2.0-12.0), FSH <0.1 mIU/mL (1.0-12.0)], growth hormone deficiency [IGF-1 <25 ng/mL (65-225)], and prolactin 9.2 ng/mL (1.6-18.7). Replacement with hydrocortisone and levothyroxine resulted in marked improvement of symptoms and normalization of serum sodium. Pituitary MRI showed a homogeneously enhancing bilobed 3.1 x 2.3 x 2.0 cm sellar mass with suprasellar extension and optic chiasm compression. Endoscopic endonasal transsphenoidal resection of the lesion, revealed a soft whitish-yellow mass that was very vascular (intra-operatively blood loss 1.25 L).  The mass was partly resected due to inability to remove the suprasellar component. Pathology of this tumor revealed fascicles of spindle cells with eosinophilic, granular cytoplasm with abundant mitochondria ultrastructurally. The tumor cells showed immunoreactivity for vimentin, S-100 protein, epithelial membrane antigen (EMA), and thyroid transcription factor (TTF-1).  Immunostaining was negative for pituitary hormones, CAM 5.2, cytokeratin AE1/AE3, synaptophysin, GFAP, neurofilament, and NEU-N. Ki-67 proliferative rate was 3%. These pathological findings are characteristic of SCO of the pituitary. The patient remained clinically stable on testosterone, hydrocortisone and levothyroxine replacement, and repeat MRI at 4 and 17 months showed no growth of the residual mass.

Conclusion:  Spindle cell oncocytoma of the pituitary should be considered as part of the differential diagnosis of a sellar mass with severe hyponatremia. Some cases of SCO may be markedly more vascular during surgery than non-functioning pituitary adenomas.

 

Nothing to Disclose: PJC, DJ, CP, MBG, ID

19614 13.0000 FRI-478 A Spindle Cell Oncocytoma of the Pituitary Presenting with Severe Hyponatremia and Adrenal Crisis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Radhika Chandramouli*
Temple University School of Medicine/ St. Lukes University Network, Bethlehem, PA

 

Craniopharyngioma is a rare, but potentially life threatening, intracranial tumor that can occur in children and adults. In evaluation of these patients, imaging studies are obtained that can confirm the diagnosis with notable calcifications in the sella and parasellar regions in brain scans.  Calcifications elsewhere in the body have been speculated to occur in these patients as well. In a case patient that presented with craniopharyngioma, there is an incidental finding of ear calcifications.

This is a 56-year-old man that has become increasing forgetful over the past few weeks. He was sleeping more during the day with occasional headaches, but no changes in vision, tinnitus, difficulty walking, or changes in speech. Past medical history is significant for hypertension, borderline diabetes mellitus, type 2 and low testosterone. During evaluation in the ED, a CAT scan showed a large calcified sellar mass measuring 3 x 2.8 cm. MRI results showed a heterogenous mass consistent with craniopharyngioma. When reviewing the MRI, also noted was some calcification in the ears. It was decided that the patient would undergo surgery to remove the tumor during the present hospitalization. 

Craniopharyngioma is a rare, slow-growing, benign primary intracranial tumor.  These tumors typically reside in the sellar or parasellar region. Adult patients will present with decreased visual acuity – bitemporal hemianopia and hypogonadism. An important clue to diagnosing craniopharyngioma is that there is almost always some calcification on imaging studies. Most commonly, within the tumor itself, it will present as a heterogeneous mass with points of calcification. Other points of calcifications can also occur, including in the ears. Often you will be able to palpate these crystals on physical exam. The implications and relevance of this finding have not been previously published, and further research could suggest ear calcifications as a pathognomonic finding in craniopharyngioma.

 

Nothing to Disclose: RC

18264 14.0000 FRI-479 A Incidental Finding of Ear Calcifications in Adult-Onset Craniopharyngioma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Joao L O Madeira*1, Isabela Peixoto Biscotto2, Aline P Otto3, Fernanda de Azevedo Correa4, Ivo J P Arnhold1, Berenice B Mendonca5 and Luciani R S Carvalho6
1University of Sao Paulo, São Paulo, Brazil, 2University of Sao Paulo, Hospital das Clinicas, São Paulo, Brazil, 3Univ of Sao Paulo, Sao Paulo, Brazil, 4Hospital das Clinical - FMUSP, Sao Paulo- SP, Brazil, 5Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil, 6University of São Paulo, Hospital das Clinicas, São Paulo, Brazil

 

Background: Craniopharyngiomas (CP) are benign tumors originated from embryonic remnants in sellar or parasellar regions. CPs are associated with high mortality and morbidity, and recurrence may occur even long periods after initial resection. Clinical Cases: Patient 1 was referred to our clinic with 15.2 years due to pubertal delay associated to headache, visual impairment, polyuria, polydipsia. He presented prepubertal genitalia, stature within normal range (158 cm, Z score = -1.73) and delayed bone age (10 y). Cranial CT-scan showed sellar tumor with suprasellar expansion, optic chiasm compression and left-lateral ventricule protrusion, harboring no calcifications. The tumor was totally resected by transehenoidal route. Hystological analysis diagnosed adamantinomatous CP. After surgery, he developed combined pituitary hormone deficiency (CPHD) and growth normally without GH replacement. He achieved a final height (182 cm, Z score = +1.1) with weight of 106 Kg and BMI = 32.0Kg/m2. At 24y he presented cortical glioma which was totally resected. GH was introduced with 33y08m to improve bone mass. Patient 2 was diagnosed as CP at 6y within a 5y onset history of headache, visual impairment, nausea  and vomiting. The child was referred to our clinic to perform hormonal replacement, after tumor partial resection by craniotomy, due to CPHD. He replaced GH since 10y and achieved final height (169cm, Z score = -0.86) within the normal range. The recurrent tumor was diagnosed in patient 1 at 37 yrs with headache while patient 2 presented acute visual loss at 27y. MRI revealed recurrence of CP in both patients with solid and cystic components and tumor dimensions of 3.0x2.0x2,8 and 3.3x2.1x2.0 cm, respectively, and an aneurysm of right carotid artery in patient 2. GH replacement was interrupted for both patients. Patient 1 was submitted to transspheinodal cyst drainage followed by conventional radiotherapy, whilst patient 2 was approached by surgery only 4 years after visual loss owing to the aneurysm. The surgery consisted of cyst fenestration and drainage by Ommaya reservoir. Both patients presented good local control and resolution to the symptoms. Clinical Lessons: These are the first reported cases of craniopharyngiomas whose recurrence occurred more than 20 yrs after initial resection. They reinforce the importance of keeping constant awareness of clinical symptoms even long periods after initial resection.

 

Nothing to Disclose: JLOM, IPB, APO, FDAC, IJPA, BBM, LRSC

20524 15.0000 FRI-480 A Recurrence of Craniopharyngioma More Than 20 Years after Initial Resection in Two Patients with GH Replacement 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Heidi Dutton*, Eric Belanger, Rafael S Glikstein, Amel Arnaout and Mary-Anne Doyle
University of Ottawa, Ottawa, ON, Canada

 

Background:  The intravascular variant of diffuse large B-cell lymphoma (IVBL) is a rare and often fatal hematologic malignancy characterized by neoplastic proliferation of lymphoid cells within capillaries and small vessels.  While dermatologic and neurologic manifestations are most commonly described, endocrine organs may be infiltrated, with resultant endocrine hypofunction.  In particular, hypopituitarism has been described.

 Clinical Case:  A 74-year-old male presented with a 2-month history of fatigue, weight loss, generalized weakness, nausea, and constipation.  His past medical history included hypertension, type 2 diabetes, psoriasis, and non-alcoholic fatty liver disease.  Laboratory investigations were consistent with central hypothyroidism, secondary adrenal insufficiency, and hypogonadotropic hypogonadism.  An MRI of the pituitary with gadolinium showed thickening of the pituitary stalk and an intrasellar lesion measuring 9.7 x 6.2 mm.  The lesion was isointense on T1 and T2 weighted images, and was not felt to be typical of a pituitary adenoma.  A CT-abdomen revealed an incidental left adrenal mass measuring 4.9 x 5.5 cm, with attenuation of 23 HU, and 8% post-contrast washout.  Pheochromocytoma was ruled out biochemically.  The patient was initiated on glucocorticoid, thyroid hormone and androgen replacement. 

 Although the patient was treated with appropriate hormone replacement, he continued to feel unwell and required hospital admission for hypotension.  Despite aggressive treatment including vasopressor therapy and stress dose corticosteroids, the hypotension was refractory to all therapies and he passed away.  An autopsy revealed IVBL with extensive systemic involvement, including the thyroid, right adrenal gland, kidneys, cerebral hemispheres, and meninges.   A histologic examination of the pituitary gland was not completed, but it is presumed that it was also infiltrated.  Interestingly, the left adrenal mass previously identified on CT-imaging was found to be a gastrointestinal stromal tumour arising from the stomach, and was also infiltrated by intravascular lymphoma.

 Clinical Lessons:  This case demonstrates the importance of considering infiltrative causes of hypopituitarism, particularly when pituitary stalk thickening is evident and when MRI findings are not typical of a pituitary adenoma.  Our case also highlights the rare involvement of the pituitary gland by disseminated IVBL, leading to hypopituitarism.  The diagnosis of IVBL can be difficult due to non-specific laboratory and imaging findings, and as a result is often made post-mortem.  When the diagnosis is made, a chemotherapy response rate of up to 55% has been reported(1).  Recognition of the potential for this malignancy to infiltrate endocrine glands and cause hormonal deficiencies may lead to earlier diagnosis and treatment.

 

Nothing to Disclose: HD, EB, RSG, AA, MAD

18959 16.0000 FRI-481 A The Importance of Recognizing Infiltrative Causes of Hypopituitarism: A Case of Lymphomatous Pituitary Infiltration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Aishah A Ekhzaimy*
King Saud university, Riyadh, Saudi Arabia

 

Primary intracranial germ cell tumor is a rare tumor affecting children more than adult. The clinical presentations are widely variable and can be misdiagnosed in children. We describe a case of mixed germ-cell tumor involving pituitary gland causing a panhypopituitarism and diabetes insipidus presented with common symptoms of headache, vomiting and progressive deterioration in school performance and misdiagnosed as a gastroenteritis in a-14 year old girl.

A-14-year old girl presented with a 9 month history of persistent vomiting, impaired short term memory with progressive deterioration of her school performance, secondary amenorrhoea with polyria and polydipsia.Her symptoms attributed to gastroenteritis and tension headache. While vising her hospitalized grandmother, she lost her consciousness and had generalized tonic-clonic seizure.Immediately, she was intubated and had an urgent plain CT-scan of the brain showing suprasellar mass extending superiorly and backward compressing the third ventricle causing acute hydrocephalus. She had had external ventricular drain (EVD) for the hydrocephalus and started on intravenous steroid with anti-epileptic medications. Urgent MRI of the brain showed large suprasellar mass ( 3.1 x3.1 cm) solid with cystic components with remarkable mass effect on the mid-brain causing acute hydrocephalus reported as a craniopharyngioma. Serum Na 167 mmol/L (135-145), urine osmolality 39 mosm/kg (50-1200), serum osmolality 332 MO/KG (278-305) with significant urine output of 6 L over 24 hour. She was started on desmopressin nasal spray to control her diabetes insipidus. Her hormonal evaluation showed LH <0.100 IU/L, FSH 0.12 IU/L, Estradiol 18.8 PM/L,TSH 0.216 MIU/L ( 0.25-5), Free T4 9.7 MIU/L (10.3-25.8), prolactin 1203 MIU/L (102- 496), IGF-I 132 ng/mL ( 188.4-509.9). She was started on corticosteroid, thyroxine preoperatively. She underwent transcranial resection of sellar and suprasellar mass and histopathology showed mixed germ cell tumor and negative Alpha fetoprotein immunostaining. Her post-operative MRI showed residual tumor tissues along the basilar artery and no evidence of CSF seeding of tumor in the cranial cavity or spinal canal.Serum tumor markers was negative. CSF was negative for tumor markers (HCG, LDH,α-fetoprotein)  and negative CSF cytology. CT –Scan of the whole body was negative for metastasis. She received chemotherapy with a plan to give her craniospinal irradiation (CSI) later to be treated as nongerminatous germ cell tumor ( aggressive form) despite negative tumor markers. She was discharged home on hormonal therapy for panhypopituitarism.  Conclusion: this is a rare case of a mixed germ-cell tumor involving sellar and suprasellar region mimicking craniopharyngioma appearance on MRI.

 

Nothing to Disclose: AAE

19942 17.0000 FRI-482 A Generalized Tonic-Clonic Seizure As a First Presentation of Sellar and Sumprasellar Mixed Germ-Cell Tumor Involving Pituitary Gland 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Hak Yeon Bae*, Jung Hae So, Jin Hwa Kim and Sang Yong Kim
Chosun University Hospital, Gwangju, Korea, Republic of (South)

 

Background

The primary intracranial development of neuroblastomas is rare and they generally arise in the supratentorial parenchyma, or the paraventricular region. Neuroblastomas originated in the sellar region are even rarer; only 10 cases have been reported previously. The effective management of these tumors is based on surgery. But adjuvant treatment is not consensual, largely depends on a patient’s conditions and aggressiveness of histopathological features. We are reporting a new case of primary sellar neuroblastoma presenting as a sellar mass lesion mimiking a pituitary macroadenoma.

Clinical case

A 36-year-old woman presented to our hospital with progressive headache without visual disturbance. The sellar MRI showed an intrasellar mass with suprasellar extension and left cavernous sinus invasion. It had a maximum diameter of 2.5cm and wall enhancement with cystic change, which mimicked pituitary macroadenoma. Laboratory findings revealed slightly increased polactin which is related to stalk compression, and the other endocrine evaluation showed no evidence of pituitary hypersecretion. The patient underwent transsphenoidal resection of the mass. Histological examination confirmed the diagnosis of neuroblastoma by numerous primitive blast cells with mature ganglion cells and positive immunohistochemistry stain of chromogranin and synaptophysin. Postoperatively, headache improved and prolactin level dropped to normal values. After the operation and histological confirmation, there was no significant abnormal uptake in 131I-MIBG scan, especially in the brain and abdomen. And then no other adjuvant therapy was done.

Conclusion

This is the first case of primary sellar neuroblastoma in Korea. Although, the primary sellar neuroblastomas are extremely rare, we should be considered in the differential diagnosis of patients with sellar lesions.

 

Nothing to Disclose: HYB, JHS, JHK, SYK

20187 18.0000 FRI-483 A A Case of Primary Sellar Neuroblastoma in Korea 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Elie Klam*, Heather Corn and Debra L. Simmons
University of Utah, Salt Lake City, UT

 

 

Objective:We present an unusual case of diffuse large B-cell lymphoma of the pituitary, masquerading as pituitary adenoma with apoplexy.

Case Presentation: 59 year old female presented with sudden headache for 4 weeks and 1 week of left sided ptosis. Exam showed left-sided third nerve palsy. Brain MRI showed 11 x 10 mm sellar mass with left cavernous invasion and abutting optic chiasm, noted to be concerning for pituitary apoplexy. Labs showed normal pituitary function except for prolactin of 28ng/mL. She was placed on stress dose steroids until she underwent transphenoidal resection of sellar mass. Pathology revealed diffuse large B-Cell Lymphoma. Initial staging workup included a negative bone marrow biopsy, and normal CSF analysis. PET/CT scan revealed widespread hypermetabolic lymphadenopathy (supraclavicular region, porta hepatis, and retroperitoneum) as well as hypermetabolic foci in the liver and spleen. Chemotherapy was started with rituximab, cyclophosphamide, doxorubicin, vincristine, methotrexate/ifosfamide, etoposide, and high dose cytarabine. The third nerve palsy persisted after surgery.

Discussion: Pituitary lymphomas are exceedingly rare in immunocompetent patients, exhibit variable clinical signs and symptoms, and carry poor prognosis. These tumors may represent metastasis of a systemic lymphoma, or a primary pituitary lymphoma.  Systemic lymphomas may cause secondary CNS involvement but there are only few reported cases of pituitary involvement as the first presentation of these tumors especially in the absence of hypopituitarism and negative CSF analysis.

Conclusion:  Diffuse large B cell lymphoma, although rare, can first manifest as a pituitary lesion. Our case demonstrates 3 major points: 1) Clinicians should consider pituitary lymphoma in differential diagnosis of any enhancing invasive pituitary lesion in the presence of neurologic manifestations, diabetes insipidus, or cranial nerves involvement. 2) Assumption of benign adenoma may lead to delay in staging and treatment of these malignant tumors. 3) Both primary and secondary pituitary lymphomas have been reported and thus a better understanding of the pathogenesis of these tumors is necessary.

 

Nothing to Disclose: EK, HC, DLS

20587 19.0000 FRI-484 A An Unusual Case of Diffuse Large B Cell Lymphoma Presenting As a Pituitary Mass and Review of Literature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Phatharaporn Kiatpanabhikul*1, Sarat Sunthornyothin2, Paisith Piriyawat3 and Thiti Snabboon4
1Charoenkrung Pracharak Hospital, Medical Service Department, Bangkok Metropolitan Administration, Bangkok, Thailand, 2Hormonal and Metabolic Disorders Research Unit, Excellence Center for Diabetes, Hormone, and Metabolism, and Division of Endocrinology and Metabolism, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand, 3Texas Tech University Health Sciences Center El Paso, El Paso, TX, 4Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

 

Background: Co-existence of growth hormone (GH) or thyrotropin (TSH)-producing pituitary adenoma with differentiated thyroid carcinoma (DTC) is exceedingly rare, with less than 10 cases having been reported. The simultaneous occurrence of GH/TSH/FSH-producing adenoma with DTC is even less common.

Clinical Case: A 44-year-old woman presented with palpitations and a 3-cm left thyroid nodule that was first noticed about one year earlier. She also complained of mild facial coarseness and acral enlargement. Endocrinological examination revealed elevated thyroid hormone levels (FT43.20 ng/dL, n: 0.8-1.8 ng/dL; FT3 5.6 pg/mL, n: 1.6-4.0 pg/mL) with inappropriate TSH secretion (TSH 1.4 mIU/ml, n: 0.3-4.1 mIU/ml) and elevated IGF-I levels (686.5 ng/ml, n: 32-238 ng/ml) with insuppressible GH after glucose loading test (nadir GH level 4.2 ng/ml). An unusually low level of gonadotropins was also noted (FSH 2.3 IU/L, n: 1.6-9.3 IU/L; LH 0.5 IU/L, n: 2.4-9.3 IU/L). Thyroid ultrasonography showed a well-defined heterogeneous hypo/hyperechoic lesion, measuring 2.4x2.3x3.9 cm, with internal cystic lesion and calcification involving almost entire left lobe and an adjacent 0.7-cm lymph node. Thyroid FNA revealed the presence of papillary thyroid carcinoma (PTC) with lymphatic infiltration. Pituitary MRI demonstrated a 1.6-cm sellar lesion with mild compression on the optic chiasm. Reversal of hyperthyroidism was, prior to pituitary tumor removal,  achieved through co-administration of octreotide (300 mcg/d) and methimazole (15 mg/d) and subsequently through total thyroidectomy and recombinant TSH-stimulated radioactive iodine remnant ablation with 150 mCi of 131-I.  Histological findings confirmed the lesion as a GH/TSH/FSH-producing pituitary adenoma and a PTC, columnar cell variant, with Hashimoto’s thyroiditis. She has remained asymptomatic with thyroxine suppressive treatment without biochemical or radiological evidence of pituitary dysfunction, pituitary residual tumor, or PTC recurrence.

Conclusion: To our knowledge, we presented the first case of a GH/TSH/FSH-producing pituitary adenoma co-existing with papillary thyroid carcinoma. Clinical implications, focusing on the strategy for proper management, were also discussed.

 

Nothing to Disclose: PK, SS, PP, TS

19416 20.0000 FRI-485 A A Case of Co-Existing of GH/TSH/FSH-Producing Pituitary Adenoma and Papillary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Chinenye Usoh*1, Niyati Chiniwala2, Laura Maria Calvi3, G Edward Vates4, Ismat Shafiq3 and Gabrielle Yeaney3
1University of Rochester School of Medicine and Dentistry, Rochester, NY, 2Rochester General Hospital, Rochester, NY, 3University of Rochester Medical Center, Rochester, NY, 4University of Rochester, Rochester, NY

 

Introduction: Hyperthyroidism is a common endocrine complaint, though etiology is typically primary.  TSH producing adenomas are rare and account for less than 2% of all functioning pituitary adenomas. We present two cases of TSH-producing adenomas causing hyperthyroidism.

Clinical Case 1: A 56 year old female with history of micropapillary thyroid carcinoma status post right lobectomy presented with tremors and palpitations.  She was being treated with levothyroxine after lobectomy.  Laboratory investigation revealed normal TSH of 3.22 µIU/mL (normal 0.27-4.20) and elevated free T4 of 1.9 ng/dL (normal 0.9-1.7 ng/dL).  Review of lab work over the last few years showed TSH in the mid-normal range with mildly elevated free T4.  Subsequent MRI head revealed a 1.9 x 1.9 x 1.3 cm pituitary macroadenoma.  She underwent endoscopic transphenoidal resection of pituitary tumor.   Histologic evaluation confirmed thyrotroph cell type.  Postoperatively, her symptoms improved and free T4 normalized to 1.6 ng/dL and TSH decreased to 0.08 µIU/mL.

Clinical Case 2: A 28 year old female with history of intellectual disability presented with longstanding tachycardia and anxiety.  She was placed on levothyroxine due to subclinical hypothyroidism.  Her symptoms worsened with thyroid hormone replacement and her levothyroxine was discontinued. She continued to have tachycardia and developed irregular menses.  Laboratory investigation showed elevated TSH of 4.91 µIU/mL (normal 0.27-4.20) and elevated free T4 of 2.2 ng/dL (normal 0.9-1.7 ng/dL). MRI head revealed 2.2 x 1.9 x 2.0 cm pituitary macroadenoma with displacement of the optic chiasm.  She underwent resection of pituitary tumor and immunohistochemical staining showed TSH positivity.  Postoperatively, her symptoms improved and free T4 normalized to 0.9 ng/dL and TSH decreased to 0.31 µIU/mL.

Clinical Lesson: TSH-producing pituitary adenomas are an infrequent cause of hyperthyroidism.   The above two cases explain the challenges with diagnosing TSH-producing adenomas especially in a patient taking thyroid hormone replacement or with an isolated elevated TSH.  Taking a thorough history, trusting patient symptoms, and following free T4 if elevated is critical for proper diagnosis and effective treatment.  Though rare, TSH-producing pituitary adenomas should be considered in patients with consistent biochemical and physical findings.  

 

Nothing to Disclose: CU, NC, LMC, GEV, IS, GY

21392 21.0000 FRI-486 A Two Cases of TSH-Producing Pituitary Adenomas Presenting with Symptoms of Hyperthyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Christopher W Rowe*1, Shaun A McGrath2 and Roger Smith3
1John Hunter Hospital, New Lambton Heights, NSW, Australia, 2John Hunter Hospital, New Lambton Heights, Australia, 3Hunter Medical Research Institute, Newcastle NSW, Australia

 

Background:

TSH secreting pituitary adenomas (TSHomas) are a rare cause of central hyperthyroidism, with information derived from large case series.  We retrospectively reviewed cases of TSHoma managed through a tertiary Endocrine centre in regional Australia over 20 years. 

Clinical cases: 

6 cases were identified in the study period, giving incidence of 0.35 cases.million-1.year-1, and prevalence of 7 cases.million-1.    Mean age at presentation was 51 years, with 2/6 female.  4/6 were referred for symptomatic hyperthyroidism, 1/6 with transient diabetes insipidus, and 1/6 discovered incidentally.  3/6 had clinically detected goitre, with one notable case having profound biochemical hyperthyroidism with no goitre on ultrasound.  2/6 had symptoms from pituitary enlargement.   1/6 had received inappropriate treatment with thionamides prior to referral. 

Mean TSH was 9.9mIU/L (0.5 – 4.5) with mean free T4 39pmol/L (10 – 20), All cases had elevations of alpha-subunit (range 2-30x upper limit normal), with 5/6 also having elevated alpha-subunit:TSH molar ratio.  SHBG was elevated in 4/6 of cases, and 5/5 cases demonstrated blunted response of TSH to TRH.  No tumour cosecreted additional hormones or caused other anterior pituitary hormonal insufficiency.  4/6 were invasive macroadenomas, with 2/6 microadenomas.

5/6 cases were treated pre-operatively with somatostatin analogues (SSA).  Duration of treatment ranged from 4 – 16 weeks.  Mean reduction in TSH and free T4 were 74% and 53% respectively with achievement of euthyroidism in all cases.  2 cases had tumour volume assessed following SSA, with 1 case demonstrating shrinkage of approximately 50% after 16 weeks SSA.  2/6 cases received directed pre-operative treatment with thionamides for duration of 6 months, with normalisation of fT4 and fT3 in both, and a rise in TSH of 33% and 1000% respectively.  

6/6 underwent trans-sphenoidal surgery, with post-operative follow up available for a median of 7 years (range 1 – 20).  Post operative TSH deficiency developed in 2/6 and FSH/LH deficiency in 2/6. 1/6 was treated with stereotactic radiosurgery, and has required maintenance 5mg carbimazole for 10 yrs with stable TFTs and no tumoural growth.  1/6 was treated with SSA commenced 18 months post surgery, with controlled TFTs for the subsequent 24 months. The remaining 4/6 maintained normal TFTs with no treatment for a median follow up of 3 years (range 1-20) No patient has demonstrated tumoral regrowth requiring re-operation.

Conclusions:

This series of TSHomas demonstrates both the effectiveness of SSA for pre-operative biochemical control of hyperthyroidism, and the efficacy of surgery for long term remission.  The absence of goitre despite marked hyperthyroidism in 3/6 cases remains poorly understood.

 

Nothing to Disclose: CWR, SAM, RS

19017 22.0000 FRI-487 A Response of TSH-Secreting Pituitary Tumours to Somatostatin Analogues in Five Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Noriaki Fukuhara*1, Mitsuo Okada2, Hiroshi Nishioka2 and Shozo Yamada1
1Toranomon Hosp, Tokyo, Japan, 2Toranomon Hospital, Tokyo, Japan

 

Introduction

FSH secreting pituitary adenoma (FSHoma) is usually diagnosed as nonfunctioning adenoma, because of lack of hormonal symptom. However, FSHoma rarely induced bilateral ovarian cysts in woman by the stimulation of FSH. We reports five cases of functioning FSHoma in this report.

Case report

The patients were 30 – 42 year-old women with bilateral giant ovarian cysts. Their pituitary tumor were 12 - 26 mm diameter, and two patients had visual disturbance. FSH was 9.5 - 15.9 IU/l (reference range: 1.7 - 8.3), LH was <0.1 - 0.8 IU/l (reference range: 1.2 - 12.1), E2 was 266.5 - 1791 pg/ml (reference range: 20 - 85). All patients had hyperprolactinemia, and their PRL was 31.6 - 76.9 ng/ml (reference range: 4.4 - 31.2). All tumors were totally removed by transsphenoidal surgery. Their FSH, LH and E2 were normalized and their ovarian cysts shrank.

Discussion

In these five case, FSH were slightly elevated, E2 were low, E2 were markedly elevated, PRL were high as with previous reports. Their tumor were relatively small and not invasive. Therefore, all tumors were totally resected. This is because the tumors were hormonally functioning and diagnosed early.

Conclusion

We reported five cases of functioning FSHoma in this report. The intractable ovarian cyst caused FSHoma was resolved after tumor resection.

 

Nothing to Disclose: NF, MO, HN, SY

21919 23.0000 FRI-488 A Five Cases of Functioning FSH Secreting Pituitary Adenoma with Bilateral Ovarian Cysts 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 466-488 6000 1:00:00 PM Hypophysitis, Sellar Masses, Craniopharyngioma, TSH and FSH Adenomas Poster


Aritro Sen*1, Emily Hayes1, Vitaly A. Kushnir2, Norbert Gleicher2 and Stephen R Hammes1
1University of Rochester, Rochester, NY, 2Center for Human Reproduction, New York, NY

 

The role of Anti-Müllerian hormone (AMH) across the female reproductive lifespan has only more recently come to light. Physiologically, AMH is a follicular gatekeeper limiting follicle growth initiation, and subsequently estradiol production from small antral follicles prior to selection. AMH is also considered an intra-ovarian regulator that inhibits follicular atresia. Here using a mouse model we try to further define the role of AMH in follicular development. We find that daily IP injection of AMH (120ng and 300ng) into pre-pubertal (21d old) mice (5 animals/treatment) for 4 weeks increases the percentage of primordial and primary follicles, decreases antral and artretic follicles, but does not change pre-antral follicle counts compared to vehicle treated mice. Moreover, irrespective of the AMH dose, treated animals have significantly fewer corpora lutea than controls. Similarly, AMH (300ng) injections to 8-9 week old mice disrupt cycling (measured by daily vaginal smears) and inhibit follicular development, with higher percentages of primordial, primary and pre-antral follicles, and lower atretic follicles and corpora lutea. These results suggest that AMH treatment impairs cycling and blocks follicular development. Since AMH receptors are expressed both in brain and ovaries, these AMH effects may be mediated either at the hypothalamus-pituitary axis or directly at the ovarian level. Studies are ongoing to differentiate the central and ovarian effects of AMH on follicular development. Intriguingly, we also find that in 8-9 week old mice, AMH treatment significantly lowers steroidogenic acute regulator protein, Cyp19 and luteinizing hormone receptor mRNA levels in the ovary compared to controls. Since these genes are all targets of FSH signaling, our results are consistent with other studies that suggest that AMH antagonizes FSH effects. Finally, given that AMH blocks complete follicular development, resulting in overall follicle accumulation, we examined whether stopping AMH treatment followed by superovulation would increase the number of ovulated oocytes. Pre-pubertal and 8-9 week old mice were treated with AMH (300ng) or vehicle for 4 weeks followed by 12 days of no treatment. Thereafter these animals were subjected to superovulation regime. Results show that irrespective of age, AMH treated animals super-ovulated more oocytes (pre-pubertal: 26 ± 1.5 vs 18.3 ± 0.9; 8-9 week: 15 ± 0.6 vs 20.3 ± 0.9). These studies may provide insights into AMH effects on pathophysiological conditions like premature ovarian insufficiency and/or PCOS.

 

Disclosure: NG: Owner, Fertility Neutraceuticals. Nothing to Disclose: AS, EH, VAK, SRH

19883 3.0000 FRI-083 A Regulation of Follicular Development By in-Vivo Anti-Müllerian Hormone (AMH) Administration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Alina Peraza Montalbano*1 and Carole R Mendelson2
1UT Southwestern Med Cntr, Dallas, TX, 2UT Southwestern Med Ctr, Dallas, TX

 

The initiation of labor at term and preterm is associated with an inflammatory response, with increased interleukins in amniotic fluid (AF) and infiltration of the myometrium by neutrophils and macrophages (Mφ). Whereas, in preterm labor, intra-amniotic infection may provide the stimulus for increased AF interleukins and inflammatory cell migration, the stimulus for these events at term appears to emanate from the fetus. In studies using pregnant mice, we previously observed that the Mφ that invade the maternal uterus near term arise, in part, from the fetal lung. We also obtained compelling evidence that surfactant protein-A (SP-A), a developmentally regulated C-type lectin secreted in increasing amounts by the fetal lung into AF near term, activates AF Mφ, inducing their migration to the uterus where they contribute to the inflammatory signaling leading to labor. More recently, we demonstrated that mice deficient in SP-A or doubly deficient in SP-A and the structurally related SP-D (SP-A/-D dKO), as well as those deficient in Toll-like Receptor 2 (TLR2), a putative receptor for SP-A, manifested delayed labor. Moreover, F4/80+ AF Mφ isolated from TLR2-/- and SP-A/D-dKO mice manifested significantly lower expression levels of both proinflammatory (M1) (i.e. IL-1β, IL-6) and anti-inflammatory (M2) (i.e. arginase 1 (ARG1), YM1, YM2) activation markers compared to those from gestation-matched wild-type mice (1). The objective of this study was to characterize AF Mφ phenotypic changes associated with developmental induction of SP-A and its secretion into AF. Using flow cytometry and  antibodies against Mφ specific markers, CD11b+F4/80+, we observed that the number of AF Mφ increased significantly between 15.5  and 18.5 days post-coitum (dpc) (19 dpc = term); this was due to an increase in the total number of F4/80+ cells in the AF population. Illumina whole-genome expression array, as well as RT-qPCR analysis of 15.5 dpc and 18.5 dpc F4/80+ sorted AF Mφ indicated that 15.5 dpc Mφ expressed predominately M2 markers, whereas 18.5 dpc Mφ expressed both M1 and M2 markers; a phenotype typically associated with tumor-associated Mφ (TAMs) populations. Ingenuity Pathway Analysis, indicated “cancer” and “inflammatory response” pathways as the two top biological functions associated with 18.5 dpc Mφ. To determine whether single, or multiple, Mφ populations are responsible for the mixed M1/M2 Mφ phenotype, we used flow cytometric analysis. At 15.5 dpc ~76% of CD11b+F4/80+ Mφ were ARG1+IL-1β-. However, at 18.5 dpc, 34% of the population expressed ARG1 and IL-1β (ARG1+IL-1β+), while ~62% of the AF Mφ expressed IL-1β+ alone. These findings confirm the existence of a M1/M2 TAM-like AF Mφ population during late gestation whose phenotypic changes are associated with the developmental induction of fetal lung SP-A and the initiation of labor.

 

Nothing to Disclose: APM, CRM

21171 4.0000 FRI-084 A Upregulation of Proinflammatory Relative to Antiinflammatory Markers in Murine Amniotic Fluid Macrophages during Late Gestation Heralds the Initiation of Labor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Karsten Koehler*1, Nancy I Williams2, Rebecca J Mallinson2, Emily A. Southmayd1 and Mary Jane De Souza1
1Pennsylvania State University, University Park, PA, 2Pennsylvania State University

 

Chronic energy deficiency in exercising women is associated with menstrual disturbances, such as functional hypothalamic amenorrhea (FHA), which is frequently associated with a suppression of resting metabolic rate (RMR). Previous investigators have normalized RMR to body size or lean mass and demonstrated lower RMR in exercising women with FHA. Whether this reduced RMR is explained by adaptations on a tissue level, or reflective of tissue loss in various body compartments is unknown. Whole-body dual-energy x-ray absorptiometry (DXA) can be used to assess the size of metabolic compartments and their contribution to whole body RMR. Thus, a reduced ratio of measured to DXA-predicted RMR may be a more sensitive indicator of RMR suppression. 

Purpose: To explore whether RMR suppression is associated with menstrual function in exercising women, and whether this suppression is due to the size of differences in the size of metabolically active tissue compartments.

Methods: A total of 16 exercising women with FHA (AMEN) and 15 exercising women with ovulatory menstrual cycles (OV), who served as controls, participated in this cross-sectional study. AMEN was defined as absence of menses for ≥90 days and chronically suppressed urinary estrogen and progesterone metabolites. Women with abnormal serum concentrations of prolactin, TSH, and androgens were excluded. OV women reported ≥9 menstrual periods in the last year and cycle lengths of 26-35 days. Ovulation was confirmed by daily urine samples. RMR was assessed using indirect calorimetry, and whole-body DXA was performed to assess the mass of brain, skeletal muscle, adipose tissue, bone, and residual tissue. DXA-predicted RMR was calculated from tissue mass using tissue-specific metabolic rates.

Results: In AMEN, measured RMR was significantly lower than DXA-predicted RMR (1087 ± 42 kcal/d vs. 1285 ± 26 kcal/d, p<0.001). In OV, measured and DXA-predicted RMR were not significantly different from each other (1173 ± 42 kcal/d vs. 1256 ± 43 kcal/d, p=0.14). Consequently, the ratio of measured to DXA-predicted RMR was significantly lower in AMEN when compared with OV (84±2% vs. 93±2%, p=0.010). When compared to OV, AMEN demonstrated a significantly greater residual mass (26.0 ± 0.9% vs. 22.5 ± 0.8% of total body mass, p<0.01) and a lower adipose mass (27.2 ± 1.5% vs. 31.8 ± 1.1, p<0.05). There were no significant differences in the relative size of brain, skeletal muscle, and bone mass between AMEN and OV.

Discussion: Our results demonstrate that the reduction in RMR in exercising women with FHA is not due to differences in the size of metabolically active tissue compartments, as AMEN did not exhibit a lower proportion of energetically expensive compartments (brain, residual tissue, skeletal muscle). The lower ratio of measured to DXA-predicted RMR in AMEN suggests that the suppression of RMR is caused by a reduced metabolic activity on the tissue level.

 

Nothing to Disclose: KK, NIW, RJM, EAS, MJD

22132 6.0000 FRI-086 A Is the Suppression of Resting Metabolic Rate in Exercise-Associated Amenorrhea Due to Differences in the Size of Metabolic Tissue Compartments? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Christine Lu*1, Eleanor G. Hutchens2, Heather G. Bonner2, Paul M. Suratt2 and Christopher R. McCartney3
1University of Virginia School of Medicine, Charlottesville, VA, 2University of Virginia Health System, Charlottesville, VA, 3University of Virginia, Charlottesville, VA

 

Sleep-related slowing of LH (GnRH) pulse frequency occurs in the early follicular phase (EFP) and, to a lesser degree, in the late follicular phase (LFP). Hall and colleagues reported that sleep-related LH pulses in the EFP were more likely to occur with wakefulness compared to REM and slow wave sleep; and wakefulness was more likely to precede LH pulses than to precede randomly selected, non-LH pulse-associated times (JCEM 2005; 90: 2050). Similar data have not been reported for the LFP. METHODS: Women participated in one of two overnight studies involving both polysomnography (PSG) and frequent (q 10 min) blood sampling for LH in the LFP; one study required transdermal estradiol (E2) pretreatment for 3 d to help standardize E2 levels. LH secretion from first to last sleep was analyzed using deconvolution procedures; to limit false positives, identified LH pulses with increments < 20% were excluded. Sleep stages were determined in 30 sec epochs, and temporal estimates of LH pulse initiation were aligned to PSG data. For each overnight study, additional non-LH pulse-associated time points (i.e., not occurring within 15 min of a pulse) were randomly determined. In an attempt to restrict analysis to sleep-associated time periods, LH pulses and random time points were excluded from analysis if no sleep epochs occurred in the preceding 15 min. SUBJECTS: To date we have analyzed 11 admissions—10 involving E2 pretreatment—from 6 women (5 normal, 1 PCOS): age 18.6 ± 0.9 y [mean ± SD], BMI 22.6 ± 2.3 kg/m2, E2 93 ± 55 pg/ml, testosterone 16 ± 13 ng/dl, progesterone 0.6 ± 0.4 ng/ml. A total of 41 LH pulses and 109 random time points from these 11 admissions were included in this preliminary analysis. RESULTS: Estimated LH pulse frequencies per sleep stage (i.e., number of pulses in a sleep stage divided by total time in that sleep stage) were 0.87 ± 1.4 (wake), 0.73 ± 0.61 (NREM 1+2), 0.65 ± 0.80 (NREM 3), and 0.23 ± 0.53 pulses/h (REM); no differences were demonstrable by Wilcoxon signed-rank tests. Compared to random time points, LH pulses were marginally more likely to be initiated during wake epochs (9 of 41 pulses vs. 10 of 109 random; p = 0.052 by Fisher’s exact test) and less likely to be initiated during REM epochs (2 of 41 pulses vs. 21 of 109 random; p = 0.040), with no differences for NREM 1+2 or NREM 3. Compared to the 5 min before random time points, the 5 min before LH pulses contained a higher percentage of wake epochs (mean 23 vs. 10%; p = 0.032 by Wilcoxon rank sum test) and a lower percentage of REM epochs (mean 7 vs. 20; p = 0.023), with no differences for NREM 1+2 or NREM 3. No sleep stage differences were demonstrable in the 5-10 min before (and in the 10-15 min before) LH pulses vs. random time points. CONCLUSION: In keeping with what has been described in the EFP, these preliminary data are consistent with the notion that sleep-related inhibition of GnRH pulse secretion during the LFP is weakened by brief awakenings and strengthened by REM sleep.

 

Nothing to Disclose: CL, EGH, HGB, PMS, CRM

20616 7.0000 FRI-087 A Sleep-Related Inhibition of LH (GnRH) Pulse Secretion during the Late Follicular Phase Is Weakened By Brief Awakenings and Strengthened By REM Sleep 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Timothy CR Prickett*1, Rennae S. Taylor2, Rosemary A. Reid1, Lesley M. McCowan2 and Eric A. Espiner1
1University of Otago, Christchurch, New Zealand, 2University of Auckland, Auckland, New Zealand

 

Background: C-type Natriuretic Peptide (CNP) is a paracrine growth factor widely expressed in tissues including the vasculature where vaso-protective actions have been identified(1). Initial studies of human pregnancy(2) show that maternal plasma concentrations of amino terminal proCNP (NTproCNP, a marker of CNP secretion) are raised in subjects with vascular complications but numbers of subjects with specific adverse events were insufficient to allow analysis of temporal changes in NTproCNP with blood pressure, or to determine causal mechanisms.
Objectives: Using the Screening for Pregnancy Endpoints (SCOPE) data and bio-bank(3), to examine associations of blood pressure and intra uterine fetal growth restriction with temporal changes in CNP secretion in women developing vascular complications during pregnancy.
Methods: Maternal plasma NTproCNP and blood pressure were measured in early (14-16, and again at 19-21 weeks) and late (34-36 weeks) gestation in two specific well documented groups of nulliparous women with vascular disorders: (i) preeclampsia (PET), and (ii) gestational hypertension (GHT) associated with impaired fetal growth (SGA) (n=20 per group). Plasma concentrations were related to concurrent blood pressure, time of onset and severity of complications, and birth weight.
Results: Compared to values in normal (uneventful) pregnancy (n=20), plasma NTproCNP did not differ in either group when sampled early in pregnancy. In uneventful pregnancy, plasma NTproCNP was significantly correlated at 34-36 weeks with both diastolic (r=0.56) and mean arterial pressure (r=0.54), p<0.05 for both. Late in pregnancy, levels in PET (28.8±2.3 pM) and GHT with SGA (28.6±4.8 pM) were significantly increased (p=0.01 and 0.027 respectively) compared to controls (21.3±1.0 pM) at the same gestational age. In subjects presenting with early PET (<34 weeks gestational age), plasma NTproCNP at 14-16 weeks (21.3±1.9 pM, n=6) was significantly higher than values in women with later presentations (17.0±0.9 pM, n=14, p=0.03). Combining data from all subjects at 34-36 weeks, strong associations of maternal NTproCNP were found with concurrent diastolic and mean arterial pressure (r=0.46, p<0.002 for both). No significant associations were identified with birth weight.
Conclusions:  These results are the first to show that CNP secretion is responsive to vascular stress. As well as applications in defining the different phenotypes associated with preeclampsia in late pregnancy, NTproCNP measurements early in gestation may assist in identifying the more serious forms of PET presenting prior to 34 weeks gestation.

 

Nothing to Disclose: TCP, RST, RAR, LMM, EAE

20148 8.0000 FRI-088 A Impact of Vascular Stress on C-Type Natriuretic Peptide in Nulliparous Women Developing Complications in Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Eun Kyung KO*1, Samuel D Quaynor1, Lawrence C Layman2, Lynn P Chorich1, Richard Cameron3 and Megan Sullivan3
1Georgia Regents University, Augusta, GA, 2Medical College of Georgia at Georgia Regents University, Augusta, GA, 3Georgia Regents University, Augusta, Georgia

 

The hypothalamic-pituitary-gonadal (H-P-G) axis plays a crucial role in pubertal development and is controlled by gonadotropin releasing hormone (GnRH). GnRH neurons originate from the olfactory bulb and migrate to the hypothalamus. Deficiency of neuron migration can cause Kallmann syndrome (KS), while impaired GnRH function may result in normosmic hypogonadotropic hypogonadism (nHH). Mutations in a number of genes have been identified in delayed puberty, but the function of many genes remains unclear. Mutations in Nasal embryonic LHRH factor (NELF), which is also known as NMDA receptor synaptonuclear signaling and neuronal migration factor (NSMF), have been reported in humans with KS. In addition, NELF is predominantly localized to the nucleus and contains putative zinc finger domains. We hypothesize that NELF is a transcription factor which regulates genes located downstream, but are unknown.  We performed microarrays after Nelf knock down (KD) in the immortalized, migratory NLT cell line derived from the olfactory placode of mice.  Nelf KD was achieved by using Nelf shRNA Lentiviral particles. Initial findings in cDNA arrays suggested genes of interest including Ccnt1, Rtp4, Olfr1392, and Chd7 which were altered by KD. Expression levels were quantitated in RNA extracted from NLT cells that underwent Nelf KD cells compared to a scrambled control.  STRING and DAVID were used to predict functional partners of Nelf and Ccnt1 that interact with NELF directly.  From our RT-qPCR and microarray results, Ccnt1, Rtp4, and Chd7 were all down regulated; however, Olfr1392 was upregulated in RT-qPCR but downregulated in microarrays. To confirm these findings, stably infected NLT clones were created with varying degrees of KD ranging from 40-90%. Findings from this study will further enhance our understanding of signaling, molecular interactions, and mechanisms by which NELF disrupts GnRH neuronal migration and function.

 

Nothing to Disclose: EKK, SDQ, LCL, LPC, RC, MS

20970 9.0000 FRI-089 A Identification of Candidate Which Interact with Nelf in Mouse Neuronal Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Polina Rovner*1, Nanette Santoro2, Justin Chosich3, Amanda Ashleigh Allshouse4, Julia Keltz5, Genevieve S. Neal-Perry6, Alex J. Polotsky7 and Barbara Isaac5
1University of Colorado, 2University of Colorado School of, Aurora, CO, 3University of Colorado School of Medicine, Aurora, CO, 4University of Colorado-Anschutz Medical Campus, Aurora, CO, 5Einstein, 6University of Washington, Seattle, WA, 7University of Colorado Denver, Aurora, CO

 

Estradiol positive feedback is mandatory for a normal luteinizing hormone (LH) surge and subsequent ovulation. It is widely believed that the ability to mount an LH surge is a late feature of pubertal maturation and does not consistently occur until well after menarche once the hypothalamic-pituitary-ovarian (HPO) axis has matured. We tested the long-standing clinical belief that premenarchal girls do not consistently respond to exogenous estradiol and would not mount an LH surge, as do normal, adult women. This was a cross-sectional prospective study comparing premenarchal girls to regularly cycling adult women. Girls were aged 8-15 years, premenarchal but at least Tanner Stage II, with a BMI >5th and <95th percentile, normal prolactin and thyroid stimulating hormone, and <4 hours of weekly exercise; women were aged 18-35 years, with a BMI >21 and <35 kg/m2, had no exogenous hormone use in the past 3 months, had monthly menses every 25-35 days, and met the same exercise and hormone criteria as the girls. Both groups received a 7-day course of transdermal estradiol (E2) targeted towards reproducing mid-cycle levels of E2, while collecting daily, first-morning voided urine. LH and follicle stimulating hormone (FSH) (DELFIA; Pharmacia, Gaithersburg, MD) as well as estradiol (E1c) and progesterone (Pdg) metabolites (in-house ELISA) were measured by immunoassay, which were corrected for creatinine excretion. Maximum LH was compared between groups with a two-tailed, two-sample t-test on the log-scale. LH and percent change in LH were compared between girls and women using linear mixed effects modeling on the log-scale. Logged values were back-transformed and reported as geometric mean and 95% confidence interval (GM, 95% CI). We enrolled nine girls and six women. Girls were all between Tanner Stages II to III. The absolute value of the LH surge in girls (GM=2.57 mLU/mgCr, 95% CI 0.53-12.49) trended lower than adult women (GM 9.50 mLU/mgCr, 95% CI 2.59-34.90), however this difference was not statistically significant (p=0.15). The difference in percent change from nadir to peak between girls (GM=497.9%, 95% CI 274.5-903.2) and women (GM=532.8%, 95% CI 253.7-1119) was minimal and not statistically significant (p=0.86). Centered at LH peak and analyzed over time with a mixed-effects model, both percent change in LH and absolute LH values demonstrated a similar pattern between girls and women. Pdg was <2 ug/mgCr in all girl participants, demonstrating the absence of spontaneous ovulation. Urinary E1c confirmed a robust rise in all women, with a range of peak E1c from 45-106 ng/mgCr, consistent with adequate E2 exposure.1 We conclude that premenarchal girls, when given exogenous estradiol, mount an LH surge proportionally similar in amplitude to regularly cycling adult women. These findings question the notion that a consistent positive HPO feedback mechanism only occurs after menarche.

 

Nothing to Disclose: PR, NS, JC, AAA, JK, GSN, AJP, BI

PP15-1 18508 10.0000 FRI-090 A Induction of an LH Surge in Premenarchal Girls: Early Maturation of the Hypothalamic-Pituitary-Ovarian Axis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Ying Wan*1, Johannes D Veldhuis2, Frederik Steyn1 and Chen Chen1
1The University of Queensland, Brisbane, Australia, 2Mayo Clinic, Rochester, MN

 

The hypothalamic-pituitary-gonadal (HPG) axis is the main pathway that modulates the release of pituitary hormones to drive reproductive function. In females, LH regulates ovarian steroid (estradiol) synthesis and secretion, as well as ovulation. Dynamic changes in LH release occur with age and reproductive status, and a greater understanding of the processes that contribute to matured LH output in females may provide critical information that define the development of optimal reproductive function. To this extent it remains unknown whether LH output in females is established during the first ovulatory cycle, or whether critical changes in LH output occur between pubertal maturation and adulthood to further prime ovarian function. To address this we monitored pulsatile LH release in female wild-type C57BL/6J mice over the estrous cycle, determining age-associated changes between the first ovulatory cycle (5 weeks old) and established adult cycle (10 weeks old). The timing of onset of the first ovulatory cycle was defined by vaginal opening, and the estrous cycle was monitored through assessment of vaginal cytology. Blood sampling and analysis was completed following established methodology[1]. Observations demonstrated significant changes in the pattern of LH release across the estrous cycle. We observed a significant rise in pulse number and approximate entropy (measure of irregularity) of LH pulses from estrus to diestrus. This coincided with a gradual rise in basal, total and pulsatile LH release. Altered pulse dynamics from estrus into diestrus were matched with a decrease in the mass of LH secretion per burst. The proestrus surge was defined by a peak in LH release occurring prior to the onset of the dark cycle. LH pulse dynamics between the first and adult ovulatory cycles were well conserved and differed only by a rise in pulse number and irregularity in diestrus. Of interest, the onset of the preovulatory LH surge between the first and adult ovulatory cycles varied only in the timing of onset. While the onset of the preovulatory LH surge occurred earlier in 5-week-old mice (by approximately 30 minutes), the amplitude of this was conserved when compared to older mice. This study provides critical data to further our understanding of dynamic changes in LH output that occurs during the transition from pubertal maturation into adulthood in female mice. We observed modest changes in LH output between the first ovulatory cycle and that observed in adulthood. Data suggest that LH output is established upon completion of pubertal maturation. While a refinement in LH output may occur between pubertal maturation and adulthood in mice, overall changes in LH release may not predict increased reproductive capacity.

 

Nothing to Disclose: YW, JDV, FS, CC

21506 11.0000 FRI-091 A Pulsatile Luteinizing Hormone (LH) Secretion in Female Mice throughout the Estrous Cycle Is Established By the Onset of the First Ovulatory Cycle 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Jessica Frances Hoffman*1, Neelima Dubey1, Kornel Schuebel2, Cheryl Marietta2, Qiaoping Yuan2, Pedro E Martinez1, Lynnette K. Nieman3, David R Rubinow4, Peter John Schmidt1 and David Goldman2
1National Institute of Mental Health, Bethesda, MD, 2National Institute on Alcohol Abuse and Alcoholism, Rockville, MD, 3National Institutes of Health, Bethesda, MD, 4Univ of North Carolina at Chapel Hill, Chapel Hill, NC

 

Premenstrual dysphoric disorder (PMDD) is a mood disorder linked with the menstrual cycle.  A lack of consistent diagnosis-related differences in reproductive hormones, remission of symptoms during suppression of ovarian steroid secretion, and recurrence after re-exposure to physiologic levels of steroids in women with PMDD suggests the behavioral differences reflect an abnormal cellular response to ovarian steroids.  We used lymphoblastoid cell cultures from women who underwent a hormonal intervention paradigm and confirmed presence (PMDD) or absence (asymptomatic controls) of an ovarian-triggered mood disorder.  Cells were exposed to vehicle or steroids (estradiol or progesterone) and examined for changes in gene expression and protein levels.  Whole transcriptome RNA analysis revealed genome-wide RNA expression changes between women with PMDD and asymptomatic controls, as well as several molecular pathways that appear to be altered in women with PMDD.   We found significant effects of diagnosis (MTF2, PHF19, SIRT1, p<0.05) and diagnosis x treatment interactions (EED, EZH2, MTF2, p<0.05) in several genes from the ESC/E(z) complex, which is a known modulator of steroid signaling and involved in gene silencing. These data could identify the cellular basis for the differential behavioral sensitivity observed in PMDD and other reproductive endocrine-related depressions.

 

Disclosure: LKN: Editor, Up To Date, Clinical Researcher, HRA Pharma. Nothing to Disclose: JFH, ND, KS, CM, QY, PEM, DRR, PJS, DG

19233 12.0000 FRI-092 A Whole Transcriptome Expression Profiles in Lymphoblastoid Cells from Women with Pmdd and Controls: Diagnostic Differences and Differential Response to Ovarian Steroids 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Marissa L Steinberg*, Peter de Chavez, Mercedes Carnethon and Erica Elizabeth Marsh
Northwestern University, Chicago, IL

 

While a number of studies have suggested HC use results in lower AMH levels, others have found no effect. Few studies have looked at the effect of specific types of HC on AMH level and, to our knowledge, no studies have investigated the effect of long-term HC use on AMH. Our objective was to determine the impact of type and duration of HC use on AMH level among young AAW. 1696 women were enrolled in the Study of Environment, Lifestyle & Fibroids (SELF). Eligibility criteria included AA race, age 23-34 years at recruitment, and no history of chemotherapy or radiation for cancer or autoimmune disorders. Blood samples were run on an ultrasensitive AMH ELISA assay (CV<10%). Log AMH was used for the linear regression model, as AMH was not normally distributed. The mean age of the subjects was 28.7±3.5 years (mean±SD). The mean AMH level (ng/mL) was 3.99±3.48. 27.4% of the subjects were currently using some form of HC. Mean AMH level among current HC users (3.31±2.56) was significantly lower than those who had previously used HC (4.25±3.90, p<.001), and those who had never used HC (4.26±3.02, p<.001). Among current HC users, the most commonly used types of HC were oral contraceptive pills (OCPs) (44%), hormonal shot (23%), and levonorgestrel IUD (22%). With the exception of the hormonal patch, all types of HC (OCPs, hormonal implant, vaginal ring, hormonal shot, and levonorgestrel IUD) were associated with significantly lower mean AMH levels, when compared to those not currently using HC. After controlling for age and BMI, OCPs (β=-.25; SE=.080; p=.002), vaginal ring (β=-1.15; SE=.21; p<.0001), and hormonal shot (β=-.37; SE=.011; p=.001) remained associated with lower log AMH values in the multivariate analysis. To further determine the role of duration of HC use on AMH, we restricted our analysis to those subjects who were either currently using HC for at least one month (n=430) or had never used HC (n=233). The mean duration of HC use among current HC users was 75.9±58.2 months (range 1-252 months). When duration of HC use was divided into quartiles, all quartiles of current users had significantly lower AMH levels than never users. When duration of use was considered in tertiles by HC type, lower AMH levels were observed with longer duration of use among subjects using OCPs (T1 [12-96 months] 3.83±2.71, p=.28; T2 [108-132 months] 3.57±2.38, p=.13; T3 [144-252 months] 2.98±3.36, p<.01) and hormonal shots (T1 [1-42 months] 3.57±2.68, p=.20; T2 [48-84 months] 3.47±2.36, p=.14; T3 [93-180 months] 2.36±1.88, p<.001). This study supports an association between current HC use and lower AMH levels, and suggests a differential impact of various types of HC. The mean AMH of previous HC users was not significantly different from those who had never used HC, suggesting that the suppressive effect of HC on AMH is temporary. Further, we found that for OCPs and hormonal shots, increasing duration of use is associated with reductions in AMH levels.

 

Nothing to Disclose: MLS, PD, MC, EEM

20702 13.0000 FRI-093 A Type of Hormonal Contraception (HC) and Duration of Use Are Associated with Lower Anti-Mullerian Hormone (AMH) Levels in Young African American Women (AAW) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Geraldine Skurnik*1, Lawrence C. Tsen2, Aditi Saxena2, Lucia A. Joseph2, Thomas F. McElrath2 and Ellen W. Seely3
1Brigham and Women's Hospital, Boston, MA, 2Brigham & Women's Hospital, Boston, MA, 3Brigham & Women's Hospital, Harvard Medical School, Boston, MA

 

Background: Preeclampsia (hypertension and proteinuria after 20 weeks (w) gestation) occurs in 3-5% of pregnancies. Linked etiologically to the presence of the fetal placenta unit (FPU), the only cure is the delivery of pregnancy. However women can develop postpartum preeclampsia (PPPE), onset of hypertension with or without proteinuria, 48h to 6w postpartum (PP), even after a normotensive pregnancy (NTP) (de novo PPPE). Pathophysiology of de novo PPPE is poorly understood and its prevalence unknown.

Hypothesis: To determine prevalence and clinical characteristics of de novo PPPE and to test the hypothesis that retained placenta, as measured by postpartum (PP) need for dilation and curettage (D&C), is more common than in the general BWH obstetrics population.

Methods: Using a centralized clinical data registry at Brigham and Women’s Hospital (BWH, Boston; > 7,000 deliveries/year), we searched for deliveries from 2009-11 with ICD-9 codes of postpartum preeclampsia (642.XX).  De novo PPPE, confirmed by physician chart review, was defined as SBP and/or DBP ≥ 140/90mm Hg on 2 occasions, > 4h apart, 48h - 6w PP in women with NTP (defined as SBP<140 and DBP<90mm Hg during pregnancy through 48h PP). Deliveries <37w were excluded. Clinical characteristics of de novo PPPE were extracted from medical records, including age, race, mode of delivery and compared to BWH obstetric overall. BMI, anesthesia and lab tests were extracted. Means, SDs and percentages are given and Chi2and Cochran-Armitage test were done.

Results: In 2009-11, 296 of 21,034 total deliveries had PPPE ICD9 codes, of which 44 had de novo PPPE (0.2% of total deliveries). Others had PPPE following pregnancies with antepartum preeclampsia, gestational or chronic hypertension or unrelated diagnoses.  Women with de novo PPPE were 32±7 yrs with BMI of 30±6 (pre-pregnancy or 1st trimester) and 34±6 kg/m2(delivery); 98% had singleton pregnancies. Delivery was at 39.1±1 w, with 41% occurring by cesarean delivery (CD). Neuraxial anesthesia was used in 91%. None had D&C PP. Symptoms were diverse: headaches (70%), abdominal/chest pain (23%) or shortness of breath (16%). Six (14%) were asymptomatic (high BP at routine check). Two (5%) had eclampsia. Each had determination of serum creatinine (all <1.1mg/dl), platelet count (all>100K/uL), and serum transaminases (7% (3/44) had ALT and/or AST at twice normal).  Spot urine was done in 68% (30/44) with 4 positive (urine protein/creatinine > 0.3). De novo PPPE group was significantly higher in younger (p<0.01) and African-American (p<0.01) women than the BWH overall.  CD rates were not significantly different (de novo PPPE: 41% and BWH overall: 33%).

Conclusion: In our population, de novo PPPE is a rare condition that occurred in younger, more often African-American women without relation to CD or D&C. The need for PP D&C may not be a sensitive enough measure of retained placenta and further studies are needed.

 

Nothing to Disclose: GS, LCT, AS, LAJ, TFM, EWS

21159 14.0000 FRI-094 A Placental Retention As a Risk Factor of De Novo Postpartum Preeclampsia and Clinical Characterization of This Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Daniella Sabino Batagello1, Renata Juliana da Silva2, Joelcimar Martins da Silva3, Helder Cravo Costa2, Giovanne Baroni Diniz2, Claudimara Ferini Pacicco Lotfi4, Luciane Valéria Sita2, Estela Bevilacqua2 and Jackson Cioni Bittencourt*2
1Institute of Psychology - University of Sao Paulo, Sao Paulo, Brazil, 2Institute of Biomedical Sciences - University of Sao Paulo, Sao Paulo, Brazil, 3Institute of Biomedical Sciences - University of Sao Paulo, São Paulo, Brazil, 4Institute of Biomedical Sciences - University of Sao Paulo, Sao Paulo SP, Brazil

 

Introduction: The melanin-concentrating hormone (MCH) mRNA, as well as the MCH, are located predominantly in hypothalamic nuclei. Novel sites of MCH mRNA expression and immunoreactivity have been identified in other hypothalamic nuclei only during the final period of lactation, such as the ventral part of medial preoptic area (MPOAv). The MCH receptor 1 (MCHR1) is an orphan G protein-coupled receptor detected in many regions of the rat brain, but there are no descriptions of MCHR1 expression in the mammary glands of non-lactating or lactating dams. Objective: this project was designed to detect MCHR1 mRNA expression and immunorreactivity in the mammary glands of lactating and non-lactating rats, correlating MCH mRNA expression in the MPOAv with the consequent MCHR1 mRNA expression in the mammary gland, thereby, increasing the knowledge regarding the control of maternal behavior (MB). Material and methods: We used in situ hybridization, immunohistochemistry and RT-PCR protocols to detect MCHR1 in mammary gland tissue from three groups of Long-evans rats: virgins; dams of lactation day 12 and dams of lactation day 19. Results: We detected MCHR1 mRNA expression in mammary glands of dams in lactation days 12 and 19. In the skin (epidermis and dermis) we found a comparable expression in the virgin group when compared to lactating dams, while a differential expression was found in the surrounding glandular tissue's ducts of dams in lactation days 12 and 19. We also found MCHR1-ir cells bordering the acini and ducts as well as in the epidermis and dermis of lactating dams (19th day) by immunohistochemistry. This immunoreactivity pattern was fully compatible with mRNA expression of MCHR1 seen in lactation day 19 using in situ hybridization. MCHR1 mRNA was detected in mammary gland tissue (with and without skin) and hippocampus (as control) of dams in lactation day 19 by RT-PCR. Conclusion: This study described the presence of mRNA MCHR1 expression and MCHR1-ir cells in mammary gland tissue during the lactation and non-lactation days, suggesting that MCHR1 is expressed and possibly involved at the end of the lactation process.

 

Nothing to Disclose: DSB, RJD, JMD, HCC, GBD, CFPL, LVS, EB, JCB

20309 15.0000 FRI-095 A Expression and Immunoreactivity of MCHR1 in Mammary Gland of Lactating and Non-Lactating Long-Evans Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Deborah E Ikhena*, Lia A Bernardi, Peter de Chavez, Randall B Barnes, Mercedes Carnethon and Erica Elizabeth Marsh
Northwestern University, Chicago, IL

 

Obesity is at epidemic proportions in the United States with AAW having the highest rates of obesity in the country.  While there are known negative repercussions of obesity on reproduction, the data are conflicting on its effects on ovarian reserve. Obesity is clinically defined as a BMI ≥ 30 kg/m2, and while BMI is helpful for clinical categorization of individuals, it is too broad a label to provide insight into the mechanisms by which obesity causes pathology. Adipokines are a family of adipose tissue secreted hormones/cytokines with biological effects beyond energy metabolism. Leptin is an adipokine with serum levels directly correlated with obesity while adiponectin is an adipokine whose levels are inversely correlated with obesity. The objective of this study was to determine if there is a relationship between obesity and ovarian reserve, using BMI as a marker of obesity and using AMH as a marker of ovarian reserve. To gain insight into the mechanisms by which obesity exerted its impact on AMH,  we also examined the relationship between AMH and leptin and adiponectin levels.  This was an epidemiological,  cross sectional study of 1696 AAW recruited to the Study of Environment, Lifestyle and Fibroids (SELF). Inclusion criteria for participation in SELF included AA race, age 23-34 at enrollment, and no prior radiation/chemotherapy or current medication for cancer or autoimmune disease. Serum AMH, leptin and adiponectin levels were obtained using ELISA assays (CV <10%). As AMH was not normally distributed, log-transformed AMH was used as the outcome in simple and multiple linear regression models. The mean subject age was 28.7 ± 3.5 years (mean ±SD) and the mean AMH was 4.00 ± 3.49 ng/ml (range <0.002 -39.4). The mean BMI was 33.6 ± 9.4 (range 15.9 -79.4), with 59.5% of the subjects being obese. There was a significant inverse relationship between log-AMH and BMI (β=-0.012, SE =0.003, P<.0001). The mean leptin level was 16.11 ± 9.68 ng/ml and the mean adiponectin level was 5.287 ± 2.69 μg/m. There was no significant association between log-AMH and adiponectin levels (β= <0.001, SE = <0.001, p=0.963). There was a significant association between leptin and log-AMH levels (β= -0.017, SE = 0.004, p=<0.001). In multivariate analysis adjusting for age, BMI and current contraception use, this relationship is no longer significant, but approaches significance (p=0.088). Our findings indicate that for this population of young AAW, higher BMI and serum leptin levels were associated with a lower AMH level. Although the association between serum leptin and AMH levels was no longer significant on adjusted analysis, there is a trend towards significance which suggests that the negative effects of obesity on ovarian reserve are at least in part mediated by leptin. For this population of young, largely obese AAW, ovarian reserve is inversely correlated with BMI and this may contribute to disparities seen in infertility.

 

Nothing to Disclose: DEI, LAB, PD, RBB, MC, EEM

20681 16.0000 FRI-096 A The Relationship Between Obesity and Ovarian Reserve in a Population of Young African American Women (AAW) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Rui Chen*1, Fatemeh Bejaei2, Shan Yi3, Tabassum Vali2 and Jerilynn C Prior4
1University of British Columbia, BC, Canada, 2Centre for Menstrual Cycle and Ovulation Research, Vancouver, BC, Canada, 3Healthlink BC, BC, Canada, 4Vancouver Coastal Health Research Institute, Vancouver, BC, Canada

 

Background

Low-dose combined hormonal contraceptives (CHC) have commonly been recommended for “non-contraceptive benefits” in treating menstrual cycle-related problems. There is no consensus, however, about therapeutic choices in current guidelines. Also, evidence supporting CHC effectiveness for these problems remains sparse. Our purpose was to assess the hormone-based clinical choices of pharmacists, physicians and nurse-clinicians (health care providers, HCP) to realistic clinical cycle problem-related scenarios. 

Methods

We created a 1-page questionnaire with four common clinical scenarios each involving a different menstrual cycle-related problem: menorrhagia and anemia in a young teen, worsening acne and heavy flow in a CHC-using 35 year old smoker with PCOS, a 26 year old with irregular cycles and a fragility wrist fracture and a 42 year old with regular cycles and premenstrual night sweats. These vignettes were provided to continuing professional education attendees at events across Canada (2007-2014). Each case was followed by five to six choices and all included CHC and cyclic progesterone or medroxyprogesterone (P4/MPA); HCP could choose multiple options.

Results

A total of 315 responses were collected. For at least one of four scenarios, CHC was recommended by 84% of HCPs and cyclic P4 or MPA were recommended by 64%. For teenage menorrhagia, 63% chose CHC and 67% iron supplements but only 31% chose ibuprofen (evidence-based flow-decreasing) and less than 17% chose cyclic P4/MPA. For the 35 year-old smoker with PCOS, over half recommended she discontinue CHC (55%) but 22% suggested switching to 35 µg EE/cyproterone CHC; in total, 47% opted for CHC. Less than a quarter (23%) suggested cyclic MPA, 32% spironolactone and 14% metformin. For the premenopausal fragility  fracture, 34% recommended CHC, 17% a contraindicated aminobisphosphonate,12% menopausal type bio-identical hormone therapy and only 12% cyclic P4  or 5% cyclic MPA. For perimenopausal vasomotor symptoms, 14% of HCP recommended CHC, 34% cyclic P4, 10% cyclic MPA, 28% compounded progesterone cream and 21% menopausal-type hormone therapy (MHT).  

Conclusion

Hormone-based therapy in some form was recommended for all problems—the most frequent hormone-based treatment was CHC. CHC-specific evidence of Level I effectiveness for each of these indications is universally lacking. Few recommended evidence-based ibuprofen for teen menorrhagia; RCTs document its 25-50% flow reduction. Few suggested likely effective non-CHC treatments for PCOS. Cyclic P4/MPA was rarely chosen for irregular cycles and fracture although an RCT showed significantly increased spine BMD (Prior, Am J. Med 2004). Cyclic P4/MPA was chosen by 44%, CHC by 14% and MHT by 21% for cyclic night sweats in early perimenopause. We need to translate research-based, physiological menstrual cycle treatments into safe and effective clinical practice.

 

Nothing to Disclose: RC, FB, SY, TV, JCP

19239 17.0000 FRI-097 A Treatment of Menstrual Cycle-Related Problems from Adolescence to Perimenopause—a Vignette-Based Multi-Professional Health Care Provider Survey 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Saleh Ahmad AlAsiri*1 and Areej A. Al Fattani2
1King Saud University, Riyadh, Saudi Arabia, 2King Faisal Specialist Hospital and Reserach Center, Riyadh, Saudi Arabia

 

Predictive value of anti-müllerian hormone, follicle-stimulating hormone and antral follicle count on the outcome of IVF/ICSI treatment cycles in Saudi Women

Objective: To determine the predictive value of serum levels of anti-müllerian hormone (AMH), basal levels of follicle-stimulating hormone (FSH) and the antral follicle count (AFC) on biochemical pregnancy rate after IVF/ICSI.

Design: Retrospective cohort study

Setting: University-affiliated IVF Unit

 

Patient(s): Infertile women undergoing in vitro fertilization/intracytoplasmic sperm injection

 

Intervention(s): Controlled ovarian hyperstimulation and ICSI

 

Main outcome Measure(s): The primary outcome was biochemical pregnancy which was defined as the detection of a positive β-hCG concentration 2 weeks after the embryo transfer. Secondary outcomes were number of retrieved oocytes, and the number and quality of generated embryos by ICSI.

Results: A total of 118 women receiving IVF/ICSI treatment were enrolled. Thirty women tested positive (25.42%) for biochemical pregnancy. Mean BMI, AMH level and FSH of pregnant women were higher than in non-pregnant cohort. Testing for BMI, basal FSH, AFC, and AMH for their performance to predict the probability of positive biochemical pregnancy after age adjustment, only AMH and BMI were significant with AUC = 0.648 , p value 0.017 and AUC = 0.635 , p value 0.028, respectively. Using the cutoff of 3.37 ng /mL for AMH levels, the sensitivity was 76% and specificity was 51%. On multivariate logistic regression analysis and after controlling for other independent variables e.g., age, BMI, PCOS, basal FSH and AFC, the significant association between AMH and biochemical pregnancy rate remained robust  ( OR 1.155, 95% CI: 1.029 to 1.297, p value 0.015). The number of retrieved oocytes was significantly negatively correlated with age and basal FSH and positively correlated with baseline AMH and AFC. Only AMH (t= 7.94, 95%CI: 0.44 to 0.739, p-value <0.01), and FSH (t= -2.25, 95%CI: -0.339 to -0.026, p-value <0.01) were significant factors on the prediction model. Age was significantly positively associated with the number of embryos generated (t: 2.585, 95% CI: 0.007 to 0.051, p-value 0.011). None of the predictive parameters studied was significantly associated with embryo quality.

Conclusion(s): BMI, baseline AMH, basal AFC and FSH are good predictors for biochemical pregnancy. However, AMH appears to have the best predictive value. After controlling for confounders, AMH had the best performance to predict the number of oocyte retrieved. However, age only was positively associated with the number of embryos generated.

 

Nothing to Disclose: SAA, AAA

19702 18.0000 FRI-098 A Predictive Value of Anti-Müllerian Hormone, Follicle-Stimulating Hormone and Antral Follicle Count on the Outcome of IVF/Icsi Treatment Cycles in Saudi Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Zhihong Liao*, Wei He, Qiqi Yin, Wen Ji, Luyao Zhang and Yanbing Li
1st Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China

 

Objective: There were several methods to measure Anti-mullerian hormone (AMH) levels. Ultrasensitive assay of Ansh lab was lately developed with advantage at the very low level detecting. There has been limited data using this assay. We investigated the distribution feature of the AMH in healthy adult women using the ultrasensitive assay and analysis the convertibility among the three assays, the ultrasensitive assay, DSL and IOT.

Design: This is a cross-sectional study of serum AMH level. 217 healthy adult women, 20 to 84 year-old (YO), without diabetes, hypertension, dislipidemia, or menstrual cycle disturbance, fasting blood sample were taken on a random day in the menstrual cycle. The volunteers were selected equally spaced of 5 YO. 

Results: The big variation range of AMH was seen among the reproductive age. It declined dramatically along with age. The median value was 6.977 (95% CI: 6.190, 9.098) ng/ml for 20-24 YO; 7.494(95% CI: 6.100,10.033) ng/ml for 25-29YO; 4.272 (95% CI: 3.614,6.162) ng/ml for 30-34 YO; 2.566 (95% CI: 2.164,5.350) ng/ml for 35-39 YO; 0.384 (95% CI: 0.705,2.101) ng/ml for 40-44YO; 0.083 (95% CI: 0.250,1.331) ng/ml for 45-49YO. The median level of 0.084ng/ml was measured for 58 menopausal women aged from 44 to 84YO. AMH value of 0.13-0.75ng/m were detected in seven menopausal women. Comparison with previous studies, AMH values were higher for the ultrasensitive assay than DSL or IOT among those under forty YO.

Conclusions: We contributed a percentile form describing the AMH level from 20 to 84YO of healthy adult women, valuable normative data for older ages. It provided a reference for determining the normal range. It might be unconvertible of AMH from the value of ultrasensitive assay to DSL or IOT because of the relative higher levels using the ultrasensitive assay.

 

Nothing to Disclose: ZL, WH, QY, WJ, LZ, YL

20358 19.0000 FRI-099 A Anti-Mullerian Hormone Level in Healthy Adult Women Using the Ultrasensitive Assay 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Lindsey Jayne Anderson*1, Lucinda L Baker2 and E Todd Schroeder3
1University of Southern California, Los Angeles, CA, 2University of Southern California, 3Univ of Southern CA, South Pasadena, CA

 

Methods: 100 contractions of maximally tolerated neuromuscular electrical stimulation (NMES) were performed on one quadriceps.  The oral contraceptive (OC) group, consuming an exogenous estrogen source, performed NMES between days 8-11 of pill consumption. The high (HI) and low (LO) endogenous estrogen groups performed NMES between days 19-21 or 1-3 of the menstrual cycle, respectively; day 1 was menses onset. HI and LO did not take OC. Maximal voluntary isometric contraction (MVIC) was assessed before, 0, and 48 hours post. Soreness was measured before and 48 hours post with a 7-point and 10-point Likert Scale of Muscle Soreness for Lower Limb (LSMSLL) and a 100 mm visual analog scale (VAS). Maximum and average Rating of Perceived Exertion (RPE) and Pain were reported for the NMES bout.

Results: Age and BMI were similar across groups; lean mass was higher in OC and fat mass was higher in LO. LO (N=2) performed NMES at a mean force of 43.3±26.0% MVIC. MVIC was 71.4±3.2% and 91.1±40.4% of baseline immediately and 48 hours post, respectively. Soreness increased by 375.0±176.8mm (VAS), 3.8±1.1 points (7-pt LSMSLL), and 6.0±2.8 (10-pt LSMSLL), at 48 hours. HI (N=3) performed NMES at a mean force of 37.9±12.4% MVIC. MVIC was 86.6±7.5% and 87.7±8.1% of baseline immediately and 48 hours post, respectively. Soreness increased by 491.5±185.4mm (VAS), 3.2±1.5 points (7-pt LSMSLL), and 4.7±2.3 (10-pt LSMSLL), at 48 hours. OC (N=6) performed NMES at a mean force of 33.2±7.3% MVIC. MVIC was 85.2±16.6% and 96.7±7.1% of baseline immediately and 48 hours post, respectively. Soreness increased by 403.3±185.7mm (VAS), 2.9±0.8 points (7-pt LSMSLL), and 4.7±2.1 (10-pt LSMSLL), at 48 hours. Mean maximum (16.3) and average (14.2) RPE were similar across groups while mean maximum and average pain was consistently 1-2 points less for HI than OC or LO.

Conclusions: All three groups likely did similar work; however, LO experienced greater immediate strength loss and delayed soreness than OC or HI despite having less lean mass and all groups reporting similar RPE during NMES. In addition, OC reported higher pain perception during NMES than HI or LO but recovered strength at 48 hours while HI and LO still displayed significant strength loss. Future analyses may require covarying for absolute force and lean mass. Given the small sample and large variability, there may be a trend for estrogen to reduce immediate strength loss and for estrogen source to differentially influence pain perception and delayed muscle soreness.

 

Nothing to Disclose: LJA, LLB, ETS

21581 20.0000 FRI-100 A Estrogen Source Influences Skeletal Muscle Soreness and Recovery in Young Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Natalya Volkova*1, Maria Antonenko2, Ilia Davidenko3, Igor Reshetnikov4, Irina Dzherieva5, Aida Gulmagomedova5 and Lilia Ganenko5
1The Rostov State Medical University, Rostov-on-Don, Russia, 2Rostov State Med Univ, Rostov-on-don, Russia, 3Rostov State Medical University, Rostov-on-Don, Russia, 4Rostov State Medical University, Rostov-on-Don, Russia, 5Rostov State Medical University, Rostov on Don, Russia

 

The enormous progress has been made in infertility treatment, first of all, due to emerging of available and effective assisted reproductive technologies. However, there is a great problem of late usage of modern achievements of reproductive endocrinology because of delayed and postponed diagnosis of infertility, which is result of extended investigation. Since gynecologists, urologists and endocrinologists are the first specialists in primary care setting for infertile couple, they play the greatest role of early establishment of infertility.
The aim of the study was to inquire about adherence to diagnostic protocol for primary investigation of fertility problems by gynecologists, urologists and endocrinologists.
There was performed a retrospective analysis of 19 case reports of couples diagnosed with unexplained infertility. The following parameters were analyzed: reporting general information about factors decreasing infertility, invitation other partner to discuss decisions surrounding investigation and treatment, primary appointed investigations, time of complete census.
Among 19 couples, 10 were initially consulted by gynecologists, 6 - by endocrinologists, and 3 – by urologists. In all cases noone specialist gave general information about factors decreasing infertility and asked to come other partner to discuss decisions surrounding investigation and treatment. Primary investigations by gynecologists were complete hormonal investigations (10 of 10), postcoital testing (3 of 10), screening for chlamydia trachomatis, ureaplasma and micoplasma (10 of 10 in all cases), cervical cancer screening (10 of 10), laparoscopy and hysterosalpingography 
to screen for tubal occlusion (7 of 10, 4 of 10, respectively). Primary appointed investigations by urologists were semen analysis (3 of 3), screening for antisperm antibodies (2 of 3), hormonal assesment (1 of 3). Primary investigations by endocrinologists were assesment of only TSH (1 of 6) and complete hormonal investigations (5 of 6), screening for chlamydia trachomatis, ureaplasma and micoplasma (6 of 6 in all cases). The average time of complete census was 4,5 years (SD±2,2).
In accordance with results received, firstly, there is complete absence of perception of infertility as couple pathology. Secondly, there is an extended and unreasonable investigations. Since these specialists play the greatest role in initial management of infertility couples, it might be useful to create united and interdisciplinary clinical guidelines for primary investigation of couple fertility problems.

 

Nothing to Disclose: NV, MA, ID, IR, ID, AG, LG

20827 21.0000 FRI-101 A Diagnostics of Couple Infertility in Primary Care Setting 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 081-101 6010 1:00:00 PM General Female Reproductive Endocrinology Poster


Kirsty A Walters*, Stephanie Eid, Aimee Caldwell, Linda Middleton, Charles M Allan and David J Handelsman
ANZAC Research Institute, University of Sydney, Sydney, Australia

 

Polycystic ovary syndrome (PCOS) is associated with a host of reproductive, endocrine and metabolic abnormalities, and affects 5-10% of women of reproductive age. Despite substantial research the etiology of PCOS remains unknown, although a fetal origin has been proposed. Androgens have been implicated as playing an important role in PCOS, with hyperandrogenism the most consistent PCOS feature. A prenatal increase in androgen exposure during foetal life in primate, sheep and rodent models of PCOS is reported to induce reproductive, endocrine and metabolic features of PCOS. Therefore, using wildtype and androgen receptor (AR) knockout mice (ARKO), created by in-frame deletion of an AR zinc finger which disrupts DNA binding, together with a mouse model of PCOS based on prenatal DHT administration, we have examined the potential contribution of genomic AR-mediated actions in the development of PCOS traits later in life. Wildtype, AR heterozygote and homozygote ARKO mice were subcutaneously injected with DHT (250µg) or oil (controls) daily on days 16-18 of gestation. Compared to wildtype controls, wildtype mice prenatally exposed to DHT displayed disrupted estrous cycles (DHT 42% cycled vs. oil 100% cycled), fewer corpora lutea, indicative of reduced ovulation, (DHT 5.0 ± 0.4 vs. oil 9.8 ± 1.8), and all had ovarian cysts. DHT treated wildtype mice had no significant changes in body weight or body fat, but exhibited an increase in parametrial adipocyte area (DHT 1778.9 ± 88.6 μm2 vs. oil 1130.6 ± 83.6.4 μm2) compared to control wildtype females. In contrast, compared to oil treated AR heterozygote and ARKO mice, AR heterozygote and ARKO females exposed to DHT prenatally maintained comparable estrous cycles and corpora lutea numbers, displayed no ovarian cysts, and no increase in adipocyte size. These findings provide strong evidence that genomic AR signaling is an important mediator in the development of these PCOS traits, and indicate that AR-dependent prenatal hyperandrogenism may induce PCOS traits in adult life.

 

Nothing to Disclose: KAW, SE, AC, LM, CMA, DJH

18226 1.0000 FRI-102 A Loss of Genomic Androgen Receptor Signaling Protects Female Mice from Induction of Polycystic Ovary Syndrome Features By Prenatal Hyperandrogenization 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Min Hu*1, Jennifer Richard2, Manuel Maliqueo3, Milana Kokosar2, Romina Fornes1, Anna Benrick2, Xiaoke Wu4, Karolina Patrycja Skibicka2 and Elisabet Stener-Victorin1
1Karolinska Institutet, Stockholm, Sweden, 2Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 3University of Chile, Santiago, Chile, 4First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China

 

Women with polycystic ovary syndrome (PCOS) are at an increased risk of developing symptoms of anxiety and depression. During pregnancy women with PCOS display high circulating androgens which may affect the fetus and increase the risk of mood disorders in offspring. To test the hypothesis that maternal androgen excess causes anxiety-like behavior in adult offspring we used the prenatally androgenized (PNA) model. To elucidate whether altered behavior is mediated via activation of androgen receptor (AR) and/or estrogen receptor (ER), their blockers were administrated. Pregnant Wistar rats received a daily injection (sc) from gestational day 15 to 19 of 1) Vehicle; 2) Testosterone Propionate (TP) 0.5mg/kg/day; 3) TP + Flutamide (T+Flut): TP 0.5 mg/kg/day with flutamide 7.5 mg/kg/day; and 4) TP + Tamoxifen (T+Tam): TP 0.5 mg/kg/day with tamoxifen 10 µg/kg/day.

Anxiety-like behavior was tested by the elevated plus maze (EPM) in female and male offspring. Female PNA rats spent longer time in the closed arm (P = 0.003) and less time in the open arm (P = 0.047) compared with vehicle-treated offspring indicating increased anxiety-like behavior. This behavior was attenuated by the AR and ER blockade since time spent in closed and open arms in T+Flut and T+Tam-treated rats did not differ from vehicle-treated rats. These effects were observed without changes in total locomotor activity in the open field test. There was no significant effect on anxiety like behavior in male PNA rats.

Next, in order to understand the neurobiological underpinnings of the increased anxiety-like behavior observed in female PNA offspring we determined the expression of genes associated with steroid receptors and emotional regulation in three areas of the brain key to regulating anxiety responses, the amygdala, the hippocampus and the hypothalamus.

In the amygdala PNA rats had a 50% reduction in Ar, but no changes in the expression of estrogen receptors (Erα, Erβ, Gper) compared with vehicle treated rats. There was a twofold increase in the expression of serotonin receptor 2C (5-ht2c) without any significant changes in 5-ht1a, changes highly consistent with the increased anxiety-like behavior. The mRNA expression of GABAB receptor Gbbr1 was increased in PNA-rats, with no changes in the enzyme glutamic acid decarboxylase 65 (Gad65) and Gad67. In the hippocampus PNA rats displayed a 50% reduction in Erα, and a trend to reduced Gper without any changes in Ar and Erβ. In contrast to results obtained in the amygdala, 5-ht2c expression was not changed but there was a potent reduction in the expression of 5-ht1a in the hippocampus. In the hypothalamus Ar, Erα and Gperwere not altered in PNA rats.

The results suggest that maternal testosterone exposure causes anxiety-like behavior in female offspring, an effect that at least in part seems to be mediated via AR and ERα, with changes in serotonergic and GABAergic pathways in amygdala and hippocampus.

 

Nothing to Disclose: MH, JR, MM, MK, RF, AB, XW, KPS, ES

20290 2.0000 FRI-103 A Maternal Testosterone Exposure Cause Anxiety Behavior in Female but Not Male Offspring: Neuroanatomical and Behavioral Evidence 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Romina Fornes*1, Min Hu1, Manuel Maliqueo2, Anna Benrick3, Milana Kokosar3 and Elisabet Stener-Victorin1
1Karolinska Institutet, Stockholm, Sweden, 2University of Chile, Santiago, Chile, 3Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

 

Women with polycystic ovary syndrome (PCOS) exhibit high circulating androgen levels during pregnancy. This may be a cause of their increased risk of gestational complications including aberrant uterine artery blood flow resulting in an altered nutrient exchange in placenta. It has been demonstrated prenatal androgenization (PNA) by testosterone injections (5mg/Kg) at gestational day (GD) 16 to 19 reduce fetal and placental weight compared to control rats. This is a high dose and we therefore decided to repeat with a more physiological dose which is 10 times lower; 0.5mg/kg. Further, we aimed to elucidate if PNA cause a sex dependent development of the placenta. We hypothesized that PNA during late pregnancy in rats decrease the weight of fetuses and their placentas in a sex dependent manner. Further we aim to explore expression of molecules involved in placenta tissue homeostasis.

Time-pregnant female Wistar rats were given subcutaneous injection of vehicle or testosterone proprionate (0.5 mg/kg) at GD 15 – 19 and divided into two groups: Control (C; n=9) and Testosterone (T; n=9). On GD 21, blood pressure was measured and thereafter the dams were euthanized and maternal blood were collected and fetuses and placentas dissected. To investigate placenta pathways affected by PNA, western blot analysis of pooled placental tissues from each litter was performed for downstream adrenergic pathway molecules; GRK2/3 and CamKKIIα, and energy sensor markers; p-STAT3 and LKB1.

The systolic pressure in pregnant dams increased by 8% in T group compared with C. Plasma levels of noradrenaline did not differ between C and T (15.4 ± 3.1 vs 13.6 ±3.7,ns = non-significant). There was no difference in litter size between the groups (C = 11.1; T = 11.3, ns) or in the number of female and male fetuses.

Fetal and placenta weight was lower in the T treated group compared with the C group (fetal weight: 4.04 gr ± 0.05 vs 4.20 gr ± 0.05, P < 0.05; placenta weight: 0.54 ± 0.09 vs 0.57 ± 0.10, P < 0.05). When separating according to sex, there was no difference in fetal weight (males or females) between T and C group. The placenta weight, on the other hand, was lower in females exposed to testosterone compared with C (0.53 ± 0.01 vs 0.58 ± 0.01, P < 0.05). In T group, the female fetuses weighed less than the male fetuses (P< 0.05), with no difference in placenta weight between female and males.

Placental expression of molecules studied did not differ between the T and C groups in the pooled placenta samples of each litter when they were normalized to C value (GRK 2/3: 0.943 ± 0.18, ns; CamKKIIα: 1.051 ± 0.22, ns; p-STAT3: 0.937 ± 0.25, ns; LKB1: 1.193 ± 0.32, ns)

In conclusion, lower fetal weight in androgenized dams is not gender dependent in the PNA model. The lower placenta weight, on the other hand, seems to be sex-dependent as only female placentas weight less. None of the molecules studied were altered by androgens in placental tissues.

 

Nothing to Disclose: RF, MH, MM, AB, MK, ES

20965 3.0000 FRI-104 A Prenatal Androgenization in Rats during Late Pregnancy – Is There a Sex Difference in Fetal and Placenta Development? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Rodolfo C. Cardoso* and Vasantha Padmanabhan
University of Michigan, Ann Arbor, MI

 

Prenatal treatment with testosterone (T) leads to progressive reproductive and metabolic dysfunction in rodents, sheep, and monkeys. At the neuroendocrine level, prenatal T-excess is associated with disrupted steroid feedback and elevated luteinizing hormone (LH) levels, suggesting that the reproductive neuroendocrine axis is activated, leading to ovarian dysfunction. Our studies in sheep have demonstrated that gestational T-excess results in maternal hyperinsulinemia and impaired insulin signaling in a tissue-specific manner in the adult offspring. In addition, T-treated females present increased pituitary responsiveness to gonadotropin-releasing hormone (GnRH) and LH hypersecretion as early as 5 wk of age, when reduced peripheral insulin sensitivity is also observed. However, insulin sensitivity normalizes as puberty approaches.  Because insulin can augment the effects of GnRH on LH expression and secretion, we hypothesized that increased insulin signaling in the pituitary in the absence of peripheral insulin resistance is involved in the LH hypersecretion observed during pubertal development in T-treated females. Pregnant sheep were injected im with 100 mg of T-propionate twice weekly from d 30-90 of gestation. Pituitary, liver, skeletal muscle and visceral fat were harvested from control (n = 8) and prenatal T-treated (n = 6) female offspring at 20 wk of age (puberty: ~28 wk of age). Changes in phospho and total protein levels of components of the insulin signaling pathway (protein kinase B, AKT; and mammalian target of rapamycin, mTOR) were analyzed by western blot. Student’s T test was used to compare treatment groups. Results revealed that p-AKT-Ser (473), p-AKT-Thr (308), total AKT, p-mTOR-Ser (2448), and total mTOR levels in the pituitary, liver, and skeletal muscle did not differ between controls and prenatal T-treated females. However, prenatal T-treatment increased (P = 0.05) p-AKT-Ser (473) in the visceral fat when compared to control group. No changes in p-AKT-Thr (308) or total AKT were observed in the visceral fat. In conclusion, these findings reject the hypothesis that increased pituitary insulin sensitivity compared to classical insulin target tissues mediates the augmented pituitary responsiveness to GnRH in prepubertal, T-treated sheep. Moreover, the lack of peripheral insulin resistance reinforces the idea of a period of developmental adaptation. Because prenatal T-excess leads to progressive exacerbation of LH hypersecretion, additional studies are currently underway to investigate insulin sensitivity in the gonadotroph in adult females. Considering that prenatal T-treated sheep present reproductive and metabolic phenotypes that closely resemble those of women with polycystic ovarian syndrome (PCOS), a better understanding of the mechanisms underlying these neuroendocrine dysfunctions may be of translational relevance to human PCOS.

 

Nothing to Disclose: RCC, VP

21177 4.0000 FRI-105 A Developmental Programming: Increased Pituitary Responsiveness to GnRH during the Prepubertal Period Is Not Associated with Increased Pituitary Insulin Signaling in Prenatal Testosterone-Treated Sheep 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Muraly Puttabyatappa*1, Almudena Veiga-Lopez2 and Vasantha Padmanabhan3
1University of Michigan Med Schl, Ann Arbor, MI, 2Univ of Michigan Med Schl, Ann Arbor, MI, 3University of Michigan, Ann Arbor, MI

 

Prenatal exposure to excess testosterone (T) induces reproductive defects that include multifollicular ovarian phenotype in the sheep stemming from enhanced recruitment and follicular persistence, features characteristic of women with polycystic ovarian syndrome (PCOS). The follicular persistence in PCOS and prenatally T-treated ewes could be due to defect in follicular development that prevents follicles from undergoing ovulation or atresia. Matrix metalloproteinase (MMP) 2 and 9, proteases belonging to the MMP family, are expressed in the ovary of many species including sheep. These participate in tissue remodeling by regulating the extracellular matrix turnover. Interestingly, women with PCOS have higher levels of MMP2 and 9 proteins in the granulosa cells, follicular fluid and circulation. Because prenatal T-treated sheep mimic characteristics of women with PCOS, we hypothesized that prenatal T treatment would increase MMP2 and 9 proteins in the granulosa cells similar to that observed in the PCOS ovary. To address this, female offspring born to sheep treated with vehicle or T propionate from days 30 to 90 of gestation were studied. As T can be aromatized, we also studied animals treated prenatally with dihydrotestosterone (DHT), a non-aromatizable form of T, to address the androgenic contribution of T. Ovaries were collected from 1-year-old females following synchronization with PGF2α, during their follicular phase and MMP2 and 9 protein levels quantified using a immunoperoxidase based histochemical method. MMP2 and 9 protein levels in the granulosa cells of the primordial, primary, and small pre-antral follicles and granulosa/theca cells of the large pre-antral and antral follicles were imaged and quantified using Image Pro Plus software. At least 5-10 of each follicular type were imaged and quantified from each animal. Both MMP2 and 9 were detectable in granulosa cells of all follicle classes and theca cells of large pre-antral and antral follicles. In control animals, granulosa cells of antral follicles had significantly higher amount of MMP2 compared to primordial follicles (p<0.05; n=4 per treatment), but not other follicle classes.  MMP9 protein expression was similar across follicular classes in both granulosa and theca cells. In contrast to findings from women with PCOS, prenatal treatment with either T or DHT did not induce any changes in the MMP2 and 9 protein levels in the granulosa and theca cells of pre-antral and antral follicles. These results indicate that changes in the expression level of MMP2 and 9 during the follicular phase are not contributing factors in the development of multifollicular ovaries. However, because the function of the MMPs depends on their inhibitors, a role for MMPs cannot be excluded until changes in expression levels of tissue inhibitors of MMPs (TIMP) together with the ovarian stromal expression of these proteins are determined.

 

Nothing to Disclose: MP, AV, VP

21841 5.0000 FRI-106 A Developmental Programming: Prenatal Exposure to Excess Testosterone Does Not Alter Granulosa or Theca Cell Expression of Matrix Metalloproteinase 2 and 9 in the Sheep 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Shameka Childress*1, Stanley Andrisse1, Yi Chen1, Andrew Wolfe1, Sally Radovick2 and Sheng Wu1
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Baltimore, MD

 

Polycystic Ovary Syndrome (PCOS) is a common endocrine system disorder among women of reproductive age and one of the leading causes of female infertility. The main focus of this project is to determine whether hyperandrogenism (at doses in the female physiological range) can induce PCOS and the underlying physiological mechanisms that contribute to the reproductive and metabolic dysfunction. To replicate the androgen levels found in women with PCOS, adult female mice were given low doses of DHT (2 fold higher than control (receiving cholesterol)) for 3 months. This dose of DHT  was chosen since during the preovulatory surge, female mice exhibit a 2 fold increase in DHT levels compared to  basal level, which is similar to the elevation of DHT (2-3 fold) seen in women with PCOS. Our preliminary data demonstrated that DHT receiving female mice become acyclic after one week of DHT.  Additionally, they had few corpora lutea, and a significant increase in the number of follicular cysts after two months of receiving DHT compared to controls. Mice receiving DHT were also less responsive to GnRH or kisspeptin stimulation as assessed by LH secretion. Mice receiving DHT had reduced pituitary LHβ mRNA expression without lowering serum LH levels. In addition, the LH receptor mRNA levels were significantly lower in the ovary while FSH receptor mRNA levels were higher in mice receiving DHT compared to control littermates. mRNA levels of genes controlling steroidogenesis (cyp17 (rate limiting enzyme for androgen synthesis) and cyp19 (aromatase)) were significantly lower in mice receiving DHT compared to control littermates.  Insulin sensitivity was not altered by glucose and insulin tolerance test following two weeks of DHT implantation.  In conclusion, mice receiving low dose DHT closely mimicked the reproductive phenotype of PCOS women (hyperandrogenism, polycystic ovaries and anovulation), which will provide a very valuable model to study the mechanism of hyperandrogenism induced PCOS.

 

Nothing to Disclose: SC, SA, YC, AW, SR, SW

21023 6.0000 FRI-107 A Low Doses of DHT Treatment Induce Female Reproductive Dysfunction before Metabolic Impairment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Yi Chen*1, Shameka Childress1, Stanley Andrisse1, Andrew Wolfe1, Sally Radovick2 and Sheng Wu1
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Baltimore, MD

 

Women with polycystic ovary syndrome (PCOS) exhibit symptoms of hyperandrogenism, oligo/amenorrhea and polycystic ovaries.  PCOS is also commonly associated with metabolic syndrome, hyperinsulinemia, and insulin resistance in metabolic tissues. It has been reported that elevated androgen levels in women can lead to infertility; however the target organs impacted by the elevated androgen levels are not yet fully known. The aims of the study were to determine the role of androgen signaling in the ovary on the development and function of reproduction. Our model system used the cre-lox system to generate ovarian theca specific androgen receptor knockout (ThARKO) mice. This study examined puberty, estrous cyclicity and fertility in female mice. There was no difference in the age of puberty between control and ThARKO littermates, assessed by the age of vaginal opening and first estrus. Cyclicity and fertility were also studied, and there were no significant differences between control and ThARKO mice. Ovarian gene expression and fertility were compared between 3 month old mice and 8 month old mice. We observed lower cyp19 (aromatase) mRNA levels in both 3 and 8 moths old groups of the ThARKO compared to control littermates. However, cyp17 (rate limiting enzyme for androgen synthesis) mRNA levels were only significantly reduced (P<0.05) in 8 month old ThARKO mice compared to control littermates. Although fertility was not altered in ThARKO mice, the AR in theca cells may play a role in steroidogenesis of aged mice.

 

Nothing to Disclose: YC, SC, SA, AW, SR, SW

20595 7.0000 FRI-108 A Conditional Knockout of the Androgen Receptor in Ovarian Theca Cells Reveals Altered Steroidogenesis in Aged Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Wassim Y Almawi*1, Fabiola Lisa Saldanha1, Amina M Al-Awadi2 and Naeema A. Mahmoud3
1Arabian Gulf University, Manama, Bahrain, 2Arabian Gulf University, Manama, 3Salmaniya Medical Complex, Manama, Bahrain

 

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy among women of reproductive age. Insofar as vascular endothelial growth factor A (VEGF-A) regulates angiogenesis and vascular permeability, previous studies demonstrated that VEGF plays an important role in the pathogenesis of PCOS, highlighted by the elevation in the levels of VEGF in serum and follicular fluid of women with PCOS. VEGF production is genetically determined, and several single nucleotide polymorphisms (SNPs) in VEGFA gene were related to VEGF production. This study examined the possible association of nine common polymorphisms of VEGFA gene comprising -2578C/A (rs699947), -460T/C (rs833061), -1154G/A (rs15703060), -634G/C (rs2010963), 398G/A (rs833068), 497G/A (rs833070), -583T/C (rs3025020), 936C/T (rs3025039), and 534C>T (rs25648), with PCOS. We analyzed genotype and allele distributions of these SNPs in 196 women with PCOS and 206 healthy women. VEGFA genotyping was done by real-time PCR, and differences in genotype distributions and allele frequencies in the cases and controls were compared using c2-test. Haplotype frequencies were constructed using Haploview 4.2 software. Higher minor allele frequency (MAF) and genotype distribution of rs302502 (-583T/C) (Pc = 0.010) were seen in PCOS cases than control women.  Increased PCOS risk was seen with rs302502 in the heterozygous and more in the homozygous states. Serum VEGF levels were significantly increased in PCOS cases compared to control women (P = 0.016), and correlated with rs3025020 genotypes. Haploview analysis revealed high LD between rs699947, rs833061, rs1570360, rs2010963, rs833068, rs833070, and rs25648, but weak or no LD between rs3025020, rs3025039.  Seven-locus (rs699947/rs833061/rs1570360/ rs2010963/rs833068/rs833070/rs25648) VEGFA haplotype analysis identified haplotypes CCAGGGC (P   = 0.025;  Χ2 = 5.043) and CCGGGAC (P   = 0.012;  Χ2 = 6.347)  be negatively, and haplotype ACAGGAC (P   = 0.020;  Χ2 = 5.382)  to be positively associated with PCOS, after controlling for key covariates. Our results suggest that elevated VEGF levels resulting in part from VEGFA rs3025020 variant, as well as specific VEGFA haplotypes contribute to the pathogenesis of PCOS.

 

Nothing to Disclose: WYA, FLS, AMA, NAM

21597 8.0000 FRI-109 A Analysis of VEGFA Single Nucleotide Polymorphisms and Changes in VEGF Serum Levels Underscores the Involvement of VEGF in Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Sameh Sarray1, Layal Saleh2, Fabiola Lisa Saldanha1, Naeema A. Mahmoud3 and Wassim Y Almawi*1
1Arabian Gulf University, Manama, Bahrain, 2Pennsylvania State University, State College, PA, 3Salmaniya Medical Complex, Manama, Bahrain

 

Central adiposity plays an important role in the pathophysiology of insulin resistance (IR) linked with polycystic ovary syndrome (PCOS), principally through altered production of various adipokines. Adiponectin (A), leptin (L), and resistin (R) are key adipokine hormones secreted by adipose tissue, and were proposed to play a role in the pathogenesis of PCOS. Of these, adiponectin exists as three distinct isoforms, of which the high molecular weight isoform (HMW-A), is the most significant biologically. Growing evidence suggested that altered A/L, and A/R ratios constitute biomarker of IR and low-grade inflammation in PCOS.

This was a cross-sectional case–control study that evaluated the potential role of the Total-A/L, HMW-A/L and Total-A/R, and HMW-A/R ratios in the manifestation of PCOS and related features.

Total-A, HMW-A, L, and R serum levels were evaluated in 204 untreated women with PCOS and 186 healthy age- and BMI-matched control women. Bioactive (BT) and free (FT) testosterone, and the homeostasis model assessment of insulin resistance (HOMA-IR) index were determined for all study participants.

Significant differences in Total-A (P <0.001), HMW-A (P <0.001), but not leptin (P = 0.308) and resistin (P = 0.122) serum levels were seen between women with PCOS and control women. However, Total-A/L ratio (P = 0.002), HMW-A/L (P <0.001), Total-A/R ratio (P = 0.002), and HMW-A/R ratio (P <0.001) were significantly different between PCOS cases and control subjects. Receiver operated characteristics (ROC) area-under-the-curve demonstrated high sensitivity and specificity for Total-A/L ratio (0.620±0.037; P =0.002), HMW-A/L (0.642±0.036; P <0.001), Total-A/R ratio (0.629±0.037; P =0.001), and HMW-A/R ratio (0.645±0.036; P <0.001) as predictors of PCOS. Total-A/L, HMW-A/L, Total-A/R, and HMW-A/R ratios negatively correlated with BMI (r = -0.395 to -0.465), HOMA-IR (r = -0.138 to -0.216), P <0.001), and free insulin (r = -0.149 to -0.195). In addition, only HMW-A/R ratio negatively correlated with BT (r = -0.151).

In conclusion, Total-A/L, HMW-A/L, Total-A/R, and HMW-A/R ratios may serve as reliable biomarkers of insulin resistance and adiposity in women with PCOS.

 

Nothing to Disclose: SS, LS, FLS, NAM, WYA

21647 9.0000 FRI-110 A Validity of Adiponectin-to-Leptin and Adiponectin-to-Resistin Ratios As Predictors of Insulin Resistance and Adiposity in Women with Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Ana Hrovat*1, Nika Aleksanda Kravos2, Katja Goricar1, Mojca Jensterle2, Andrej Janez3 and Vita Dolzan1
1Faculty of Medicine, University of Ljubljana, Ljubljana, 2University Medical Center Ljubljana, Ljubljana, 3University Medical Centre Ljubljana, Ljubljana, Slovenia

 

Objectives:

Sortilin-related VPS10 domain containing receptor 1 (SORCS1) polymorphisms may influence insulin release. We investigated the influence of SORCS1 polymorphisms on insulin secretion in obese women with PCOS.

Methods: Metabolic status was recorded in 50 clinically well characterized PCOS patients.  Oral glucose tolerance test was performed and laboratory parameters of insulin resistance measured. Real-time PCR based methods were used to genotype for SORCS1 rs1358030, rs1416406 and rs11192966 polymorphisms. Statistical analysis was performed using Mann-Whitney test.

Results: SORCS1 rs1416406 significantly influenced glucose concentration at 30 minutes (p = 0.027), 60 minutes (p = 0.006) and 90 minutes (p = 0.044) of OGTT, AUC for glucose (p = 0.013) and insulin concentration at 60 minutes (p = 0.034) and 120 minutes (p = 0.029) of OGTT. Patients with at least one rs1416406 polymorphic allele had higher stimulated levels of both glucose and insulin. None of the polymorphisms influenced insulin resistance as measured by homeostatic model assessment.

Conclusion: Our study provides novel insight into the influence of SORCS1 polymorphisms on glucose stimulated insulin secretion in obese women with PCOS.

 

Nothing to Disclose: AH, NAK, KG, MJ, AJ, VD

20606 10.0000 FRI-111 A Impact of SORCS1 Polymorphisms on Insulin Secretion in Obese Women with Polycystic Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Sebastiano Raimondo*1, Chantal Di Segni1, Francesco Leo2, Valentina Fuoco2, Francesco Guidi3, Christian Bergamini4, Francesco Volta5, Romana Fato4, Daniela Romualdi1, Rosanna Apa2, Antonio Lanzone1 and Antonio Mancini1
1Catholic University of the Sacred Heart, Rome, Italy, 2Catholic University of The Sacred Heart, Rome, Italy, 3Catholic University of The sacred Heart, Rome, Italy, 4University of Bologna, Bologna, Italy, 5University of Bologna, Rome, Italy

 

It is well known that insulin resistance (IR) is associated with polycystic ovary syndrome (PCOS). Oxidative stress (OS) is, in turn, related to IR, with a vicious cycle, but mechanisms underlying reciprocal influences between IR and OS are still poorly understood. The physiopathology of normal weight PCOS is more complex even if IR is reported in such situation.

OS and PCOS are likely associated but the small number of studies does not permit to establish any definitive conclusion. Various studies on patients with PCOS have remarked the abnormal level of OS markers (augmented MDA and homocysteine, augmented SOD, decreased glutathione and paraoxonase-1) Most studies however are performed in obese patients. In order to investigate parameters of OS in normal weight PCOS and the relationships with hormonal and metabolic parameters, we have evaluated the concentrations of malondialdheyde (MDA) in plasma and lymphocytes of a group of normal weight PCOS and controls. We have studied a group of PCOS patients (n=21, age 18-25 ys, mean BMI 21.6 ± 2.5 kg/m2) and normal menstruating women (n=10, age 19-23 ys, mean BMI  20.7 ± 1.1 kg/m2). A blood sample was collected after an overnight fast, in follicular phase of the cycle; after centrifugation, plasma aliquots were stored at -80° until assayed. We determined metabolic and hormonal parameters. HOMA (Homeostasis Model of Insulin Resistance) index  is a good parameter to evaluate IR. Testosterone, DHEAS and Insulin were assayed using the CMIA method (Chemiluminescent Microparticle ImmunoAssay). A sample collected in EDTA tubes was collected to obtain blood peripheral mononuclear cells (BPMC: 80% CD3+ cells, 5% CD19+ cells, 10% CD16+ cells, 5% monocytes) by density-gradient  centrifugation on Lympholyte (Lympholyte, Cederlane) and washing twice with medium (RPMI 1640, Gibco, Grand Island NY). Then cells were pelletted and stored at -20°C until analysis. MDA levels were determined spectrophotometrically at 535nm by TBARS assay. As expected, PCO patients exhibited higher testosterone levels (mean 1.14 ± 0.41 vs 0.55 ± 0.1 ng/ml). No difference was present in HOMA index. Despite plasma MDA levels were not significantly different between PCO and controls (3380 ± 1589 vs 7120 ± 1430 pmol/ml), intracellular MDA levels were significantly higher than controls (mean 3259 ± 1330 vs 458 ± 114 pmol/106). These data show that oxidative stress could be present in tissue even if not revealed in plasma in normal weight PCO patients. The relationship of this datum with metabolic status remain to be estabilished but they could be a physiopathological basis for antioxidant treatment in such patients.

 

Nothing to Disclose: SR, CD, FL, VF, FG, CB, FV, RF, DR, RA, AL, AM

19876 11.0000 FRI-112 A Intracellular Markers of Oxidative Stress in Normal Weight Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Zeliha Keles1, Fatih Kilicli*2, Ahmet Altun2 and Sebila Dokmetas3
1Cumhuriyet Universy, 2Cumhuriyet University, Sivas, Turkey, 3Medipol University, Istanbul, Turkey

 

AIM: PCOS is a heterogeneous syndrome with a broad spectrum of reproductive, and metabolic manifestation including anovulation, hyperandrogenemia, polycystic ovaries, hirsutism and insulin resistance. We aimed to investigate some of the important metabolic conditions and hormones including Total antioxidant status (TAS), Total oxidant status (TOS), neopterin and resistin in patients with different components of PCOS including PCOS+Anovulation (PCOS+AN), Hyperandrogenism+PCOS+ Anovulation (HA+PCOS+AN), Hyperandrogenism+Anovulation (HA+AN) and Hyperandrogenism+PCOS (HA+PCOS).

METHODS: Eighty patients who admitted Cumhuriyet University Endocrinology Clinic have been divided into 4 different phenotypic groups (PCOS+AN), (HA+PCOS+AN), (HA+AN) and (HA+PCOS) according components of PCOS they have. Venous blood samples have been collected and Total antioxidant status (TAS), Total oxidant status (TOS), neopterin and resistin leves have been evaluated by enzyme-linked immunosorbent assay (ELISA).

FINDINGS: When the total oxidant status (TOS) has been evaluated, it has been observed that TOS was increased significantly in all groups. The highest value was in HA+PCOS+AN group (22.3±2.7 µmol/L). The lowest value was in PCOS+AN group (10.1±1.1 µmol/L). There was statistically significant difference between all groups (p<0.05). When the total antioxidant status (TAS) has been evaluated, it has been observed that TOS was decreased significantly in all groups. The lowest value was in HA+PCOS+AN group (0.2±0.08 mmol/L). The highest value was in PCOS+AN group (1.2±0.1 mmol/L). There was statistically significant difference between all groups (p<0.05). Plasma resistin levels were significantly high in all groups. In (PCOS+AN), (HA+PCOS+AN), (HA+AN) and (HA+PCOS) groups, resistin levels were 2.46±0.4, 2.52±0.8, 2.50±0.9 and 2.62±1.0 mg/mL, respectively. Plasma neopterin levels were also high in all study groups. But there were significant differences in between groups. Plasma neopterin levels of (HA+PCOS+AN) (14.04±0.42 nmol/L) and (HA+PCOS) (13.94±0.25 nmol/L) groups were similarly high and significantly different than other two groups. Neopterin levels of (PCOS+AN) group (12.67±0.62 nmol/L) was the lowest and significantly different than other groups (p<0.05).

CONCLUSION: Our results revealed that oxidative stress plays important role in patients with PCOS. Especially in groups containing patients with hyperandrogenism TOS values was significantly higher and TAS values significantly lower. Similarly neopterin levels were significantly high in groups containing patients with hyperandrogenism. These findings may show that different metabolic manifestations of PCOS may not contributing the pathogenesis and prognosis equaly and hyperandrogenism may be more important than the others in terms of prognosis and pathophysiology. 

 

Nothing to Disclose: ZK, FK, AA, SD

20372 12.0000 FRI-113 A Levels of Inflammatory Markers in Four Different Phenotypes of PCOS 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Manuel Doblado*1, Kevin Maas2, Sandy Shuai-Ju Chuan2, Jingwen Hou3, Antoni J Duleba3 and R Jeffrey Chang3
1UCSD, 2Univeristy of California, San Diego, La Jolla, CA, 3University of California, San Diego, La Jolla, CA

 

Objective:  We have previously shown that women with PCOS may exhibit high 17-OHP

responses (HR-PCOS) or normal responses (NR-PCOS) to hCG stimulation compared to that of

normal women. Notably, in the NR-PCOS subgroup, basal serum LH and AMH levels were

markedly elevated, whereas in HR-PCOS women, these levels were similar to normal controls.

It has previously been shown in human granulosa cells (GC) that LH stimulates AMH

production. To address whether differences of serum AMH in PCOS subgroups may be

facilitated by LH, we investigated AMH responses to hCG in women with PCOS and normal

women.

Design:  Prospective study in an academic center.

Materials and Methods:  Eighteen women with PCOS (19-34 yr) and 15 normal women (19-35

yr) were studied. Each subject was administered hCG, 25 micrograms iv, and blood samples

were obtained before and 24 hours after stimulation. Normal women were tested during the mid-

follicular phase of the menstrual cycle. Serum AMH, Inh B and 17-OHP levels were assayed by

RIA. Student's T-test or ANOVA followed by post-hoc analysis with the Tukey-Kramer test were

used to establish statistical significance between control, NR-PCOS, and HR-PCOS groups.  

Results:  As previously reported baseline serum levels of AMH, LH, and Inh B in NR-PCOS

were significantly higher compared to those observed for HR-PCOS and normal control

women (p <.005). Following hCG injection, serum AMH levels were minimally changed and

not statistically different among groups. By comparison Inh B responses to hCG were

characterized by a significant reduction observed in NR-PCOS and normal controls while in

HR-PCOS Inh B levels were unaltered.

Conclusions: Our findings show that AMH levels in PCOS subgroups as well as normal women

are not influenced by hCG administration and suggests that LH has minimal, if any, effect on

AMH production. In contrast, in NR-PCOS and normal women Inh B levels declined after hCG

administration whereas there was a lack of Inh B response in HR-PCOS. Thus, in HR-PCOS the

absence of elevated AMH levels and lack of Inh B responses to hCG may reflect a more severe

impairment of GC function compared to NR-PCOS women.

 

Nothing to Disclose: MD, KM, SSJC, JH, AJD, RJC

21642 13.0000 FRI-114 A SERUM AMH and Inhibin B Responses to Gonadotropin Adminstration in Women with Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Damien Gruson*
Cliniques Universitaires Saint Luc, Brussels, Belgium

 

Background: Anti-müllerian hormone (AMH), a member of the transforming growth factors-β family, is produced by the granulosa cells of the growing ovarian follicles. Measurement of circulating levels of AMH is relevant for the evaluation of primary ovarian insufficiency, success of assisted reproductive therapies, and for the diagnosis of polycystic ovary syndrome (PCOS). However, until now only a limited number of AMH assays are available. We therefore examined the performances of a new enzyme linked immunosorbent assay (ELISA) for AMH measurement. Methods: The evaluation of the analytical performances of the new ultrasensitive AMH ELISA (Ansh Laboratories, Inc, Webster, TX, USA) included the limit of detection and the method imprecision. Furthermore, method comparison was performed with the AMH Gen II® (Beckman Coulter) ELISA assay in 80 patient’s samples. The levels of AMH were also determined with the ultrasensitive assay in 25 women suspected of PCOS. Results: The limit of detection of the Ansh AMH assay was 0.10 ng/mL (n=10). The within-run coefficients of variation (CV) were 5.8% at 0.2 ng/mL (n=10), 3.0% at 0.5 ng/mL (n=10) and 4.1% at 0.9 ng/mL (n=10) and 2.6% at 6.5 ng/mL (n=10). For the same AMH concentrations, the between-run CVs (n=20) of the Ansh AMH assay were 5.8, 4.6, 3.4 and 2.4%, respectively. In the 80 patients, the median AMH levels were 3.7 ng/mL (range: 0.17 – 130 ng/mL) with Ansh assay and 3.8 ng/mL (0.15 – 115) with the AMH Gen II®. A positive and significant correlation was observed between the two methods (r = 0.96, p<0.001). Passing and Bablock regression analysis provides a slope of 1.08 and an intercept of 0.014, without significant deviation of linearity. The mean difference between the two AMH assays and observed on Bland an Altman plot was 0.2 ng/mL. Our results also showed that women with PCOS have significantly higher AMH levels (median: 7.4 ng/mL, n=10) than those not diagnosed with PCOS (3.0 ng/mL; p<0.05). Conclusions: Our study demonstrated the reliability of the Ansh Laboratories ultrasentsitive AMH immunoassay as well as its potential added value for the diagnosis of polycystic ovary syndrome

 

Nothing to Disclose: DG

19523 14.0000 FRI-115 A Performances of a New Ultrasensitive Immunoassay for Measurement of Anti-Mullerian Hormone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Alexandra N Garcia*1, Christina K Depena2, Weiling Yin3, Kelsey Bezner2, Mercedes Munselle4 and Andrea C Gore3
1The University of Texas at Austin, Austin, TX, 2University of Texas at Austin, 3University of Texas at Austin, Austin, TX, 4The University of Texas at Austin, TX

 

Menopause is associated with neurobehavioral changes including those related to social behaviors. These behaviors are strongly influenced by oxytocin (OXT) and vasopressin (AVP) neurons in the hypothalamus, which are highly sensitive to the ovarian hormones. We developed a rat model to test the “critical window” hypothesis that the timing/duration of estradiol (E2) treatment relative to deprivation influences the neurobehavioral and underlying neurobiological phenotype of social behavior. Here, we tested effects of aging, and different timing/durations of E2 treatment, on gene expression of Avp, Avpr1a, Oxt, Oxtr, Esr1 and Esr2 in the paraventricular nucleus (PVN) and medial preoptic area (mPOA). We used 8 groups of ovariectomized (OVX) Sprague-Dawley rats that were young (~4 mo) or middle-aged (MA, ~11 mo) at the time of OVX given E2 or vehicle. Groups were: 1) young vehicle (3 mo), 2) young E2 (3 mo) 3) MA vehicle (3 mo), 4) MA E2 (3 mo), 5) MA vehicle (6 mo), 6) MA E2 (6 mo), 7) MA vehicle (3 mo, then switched to E2 3 mo), and 8) MA (E2 3 mo, then switched to vehicle 3 mo). After euthanasia, micropunches taken from the PVN, mPOA of the hypothalamus were used for mRNA extraction and qPCR. Gene expression results showed: 1) In the PVN, E2 did not affect the Avp and Oxt genes but rather had substantial effects on their receptors. Avp1ra was greater in MA than young rats  Oxtr was up-regulated by E2  2) In the mPOA, Avp was down-regulated by E2. For Oxtr, rats with E2 at euthanasia, irrespective of age/duration/timing, had greater expression than vehicle groups. The young vehicle (3 mo) rats had greater Esr2 expression than corresponding young E2 (3 mo) or MA vehicle (3 mo) rats.  Our data suggest that age and E2 treatment had effects on the receptors for OXT and AVP, but not on the neuropeptide genes themselves, with region specific differences in responses to age, timing, and duration of E2 treatment. Therefore, the “critical window” hypothesis of E2 treatment holds up for some genes, but not others.

 

Nothing to Disclose: ANG, CKD, WY, KB, MM, ACG

19866 15.0000 FRI-116 A Testing the “Critical Window” of Estradiol Replacement on Hypothalamic Gene Expression in Aging Female Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Xutong Wang*1, Weiling Yin1, Kelsey Bezner2, Mercedes Munselle3, Alexandra N Garcia4 and Andrea C Gore1
1University of Texas at Austin, Austin, TX, 2University of Texas at Austin, 3The University of Texas at Austin, TX, 4The University of Texas at Austin, Austin, TX

 

One striking physiological outcome in perimenopausal women and ovariectomized (OVX) animal models is body weight gain due to estradiol (E2) deprivation. Our lab has developed a rat model to test the “critical window” hypothesis of different timing and duration of E2 treatment at menopause. Here, we used this model to determine effects on body weight, food intake, and circadian activity and body temperature. Middle-aged (MA; 11 months) Sprague-Dawley female rats were OVX and subcutaneously implanted with a Silastic capsule containing vehicle (VEH) or estradiol (E2) during surgery. A telemetry device (E-mitter) was implanted in the abdominal cavity during OVX to remotely collect locomotor activity and core temperature data. Rats were longitudinally monitored 10 days per month over a 6-month period, enabling us to test effects of the duration of E2 treatment or deprivation (VEH). At the 3-month period, half of the rats had their capsules switched (E2 to VEH, or VEH to E2) and monitoring continued for the next 3-months to assess how a delay in E2, or termination of E2, affected our physiological measures. Results: 1) E2 rats had higher activity during the lights-out period for the first 2 months after OVX compared to their VEH counterparts (p<0.05, p<0.05 for months 1 and 2 respectively). 2) Average core temperature showed no statistical difference between VEH and E2 rats. However, the distribution of core temperature was significantly different with larger variance in VEH compared to E2 rats. 3) OVX significantly increased food intake in both E2 and VEH (p<0.0001) rats; for the first 2 months after OVX, VEH rats showed higher food intake compared to their E2 treated counterparts (p<0.0001). 4) Switching treatment from VEH to E2 significantly lowered food intake (p<0.0001), elevated activity level (p<0.0001), and resulted reduced body weight. Our data suggests the sensitivity and plasticity of these physiological parameters in response to timing and duration of E2 treatment.

 

Nothing to Disclose: XW, WY, KB, MM, ANG, ACG

20034 16.0000 FRI-117 A Timing and Duration of Estradiol Treatment Affects Circadian Activity, Temperature, and Food Intake in a Rat Model of Menopause 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Chrisandra Shufelt*1, Doris A. Taylor2, Sarah L. Berga3, Margareta Pisarska1, Moshe Arditi1, Prediman K Shah4 and Cathleen Noel Bairey Merz1
1Cedars-Sinai Medical Center, Los Angeles, CA, 2Texas Heart Institute, Houston, TX, 3Wake Forest School of Medicine, Winston Salem, NC, 4Cedars-Sinai Medical Center

 

Background: Premature cardiovascular disease (CVD) is the leading cause of death in premenopausal women yet traditional risk factors underestimate this risk. Inflammation plays a key role in the development of pre-clinical CVD and estrogen has anti-inflammatory effects. We hypothesized that premenopausal women with secondary amenorrhea due to hypoestrogenemia (HypoE) will have relatively more immune-mediate inflammation and sub-clinical CVD as compared to premenopausal eumenorrheic women (controls).

Methods:  We studied 18 premenopausal women with no CVD risk factors aged 18-40 years old, 8 with HypoE compared to 10 controls. HypoE was defined as amenorrhea for at least 3 consecutive months, estradiol <50 pg/ml, FSH <10 mIU/l, and LH <10 mIU/l.  Controls self-reported monthly menstrual cycles, not on hormones, with a day 22-24 progesterone level > 3 ng/ml to confirm ovulation. Endothelial function was measured as PAT Index using Endo PAT 2000 (Itamar® Medical Ltd). Cytokines were measured using standard ELISA methods. Statistical analysis included standard t test for normally distributed variables and Wilcoxon rank sum for nonparametric testing.

Results: The mean age and BMI of HypoE vs controls was 25.6 ± 7.5 vs 30.7 ± 6.6 and 22.4 ± 6.5 kg/m2 vs. 23.4 ± 3.4 kg/m2, respectively, both p=NS. HypoE had a significantly lower PAT index than controls (1.75 + 0.35 and 2.32 + 0.44, p=0.009, respectively). Median IP-10 chemokines were statistically higher in HypoE compared to controls (588.1 vs. 327.4, p=0.04). Pro-inflammatory cytokines trended towards higher levels in HypoE compared to controls (median, pg/ml): IL-6 (38.9 vs. 21.4, p=0.28, respectively); IL-8 (40.5 vs. 9.5, p=0.25); IL-12 (74.3 vs 37.7, p=0.43), IL-17A (142.7 vs 67.0, p=0.17); and MCP-1 (116.0 vs 94.1, p=0.20).

Conclusion: Initial results demonstrate lower endothelial function and higher pro-inflammatory IP-10 cytokine with trends of higher other cytokines. Future studies expand this work on estrogen and immune-mediated inflammatory and pre-clinical CVD.

 

Disclosure: CNB: Speaker, Victor Change Cardiac Research Institute (Australia), Speaker, University of New Mexico, Researcher, NIH-SEP (grant review study section). Nothing to Disclose: CS, DAT, SLB, MP, MA, PKS

18738 17.0000 FRI-118 A Endothelial Function, Immune-Mediated Inflammation and Hypoestrogenemia in Young Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Cemal Ozemek*, Kerry L Hildreth, Wendy M Kohrt and Kerrie L Moreau
University of Colorado, Anschutz Medical Campus, Aurora, CO

 

Risk of developing cardiovascular disease (CVD) in women increases after menopause. Brachial artery flow mediated dilation (FMD), a measure of conduit artery endothelial function, is a predictor of CVD events in women and declines across the stages of the menopause transition. Hyperemic velocity, the stimulus for FMD and a newly described measure of microvascular function, was a predictor of CVD events in men, whereas FMD was not. Whether microvascular function is impaired across the stages of the menopause transition is unclear. Accordingly, we determined whether microvascular function and conduit artery endothelial function decline similarly across the stages of the menopausal transition in healthy women. Endothelial function (brachial artery FMD) and microvascular function (hyperemic velocity time integral [VTI]) were assessed using ultrasound in 107 healthy, non-smoking women (22-66 y) free of overt CVD, classified as pre- (n = 25, 33±7 y), peri- (n=30, 49±3 y), or postmenopausal (n=52, 57±5 y). FMD was found to be significantly different (P<0.001) among menopausal groups (Pre: 10.3±2.2%, Peri: 7.1±2.2%, Post: 4.8±1.9%). VTI was reduced in postmenopausal women (81.3±18.7 cm) when compared to pre- or perimenopausal women (95.0±18.1 cm, 95.2±25.7 cm, respectively, both P<0.05). In conclusion, conduit artery endothelial and microvascular function were impaired in postmenopausal women. In contrast, perimenopausal women had impaired conduit artery endothelial function, but preserved microvascular function. These findings suggest that conduit artery endothelial dysfunction precedes microvascular dysfunction in women during the menopause transition. Whether microvascular dysfunction is a significant predictor of CV events in postmenopausal women warrants further study.

 

Nothing to Disclose: CO, KLH, WMK, KLM

21469 18.0000 FRI-119 A Conduit Artery Endothelial Dysfunction Precedes Microvascular Dysfunction Across the Menopause Transition 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Ashley Lynn Russell*1, Darwin Omar Larco2, Danette F Cruthirds1, Jamie Moran3, Margaret Farmar Keil4, Michael James Weiser5, Robert J Handa6 and Tao-Yiao J Wu2
1Uniformed Services University of the Health Sciences, Bethesda, MD, 2Uniformed Services University, Bethesda, MD, 3Uniformed Services University of the Health Sciences, Bethesda, 4Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD, 5University of Colorado, Boulder, CO, 6University of Arizona College of Medicine, Phoenix, AZ

 

Obesity and anxiety related disorders are primary comorbidities of menopause. Hormone replacement therapy is a common treatment that counteracts the symptoms that result from the deficiency in estrogen during menopause. In the literature there are conflicting results of the effects of estrogen on anxiety-like behaviors in rodents, which could be in part attributed to the presence of phytoestrogens present in the rodent chow.  This study examined the effects of hormone treatment, with and without soy-products present in the diet.  Estradiol treatment alone decreased body weight in ovariectomized rats (n=10, p<0.05).  The presence of soy based products in the diet led to an exacerbated reduction in weight (p<0.05).  However, the soy-free fed rats consumed less food than the regular diet fed rats, a result unexpected after the observed body weight changes (p<0.05).  To further investigate this discrepancy, we examined the signaling pathway mediating the alterations in the metabolic pathway in response to phytoestrogens.  Previous studies have reported, when fed a soy-free diet, there are increases (p<0.05) in Ob-R and SOCS3 with E2 treatment but no significant changes within the JAK-STAT pathways.  Interestingly, a decrease (p<0.05) is seen in components of the AMPK pathway, a molecule involved in energy homeostasis.  A 2-fold decrease is seen in pACC after E2 administration in when animals are fed a soy-based diet.   Utilizing the elevated plus maze as a measure of anxiety, OVX rats fed a soy-based diet and administered E2 demonstrated an increase in anxiety-like behaviors ( p<0.05).  On the other hand, rats fed a soy-free diet and administered E2 treatment showed a decrease in anxiety-like behaviors (p<0.05).  Nearly a 2.5-fold decrease in BDNF expression is seen in animals fed soy-free diet compared to animals fed a soy-based diet (p<0.10).  No significant differences are yet observed in the PFC (p>0.10).  Overall, the conclusions of this study are that, like E2 treatment, soy-derived phytoestrogens naturally found in food can have physiological, biochemical and psychological alterations and the interactions between E2 treatment and phytoestrogens can be the result of the conflicting literature.

 

Nothing to Disclose: ALR, DOL, DFC, JM, MFK, MJW, RJH, TYJW

21816 19.0000 FRI-120 A The Effect of Soy on Body Weight and Anxiety-like Behaviors in the Ovx Rat 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Hadine Joffe*1, Sybil Crawford2, Marlene Freeman3, Geena Athappilly4, David Wolfe4, Semmie Kim4, Thania Galvan4, Julia Camuso4, Janet E. Hall5 and Lee Cohen3
1Brigham and Women's Hospital, Dana Farber Cancer Institute, & Harvard Medical School, Boston, MA, 2University of Massachusetts Medical School, Worcester, MA, 3Massachusetts General Hospital, Boston, MA, 4Brigham and Women's Hospital, Boston, MA, 5Massachusetts General Hosp, Boston, MA

 

BACKGROUND

The menopause transition is a period of risk for depression.  Epidemiologic studies report that greater variability in serum estradiol (E2) correlates with greater likelihood of depression, suggesting that changing levels of E2 on mood-regulating neurotransmitters may cause depression.  Fluctuations in E2 may also indirectly affect mood, mediated through hot flashes, an important correlate of depressive symptoms. To test these pathways, we measured depressive symptoms, serum E2, and hot flash frequency weekly in a 2-month observational study of depressed perimenopausal women.  We hypothesized that variability in E2 would predict worse mood independent of hot flashes.

METHODS

Women in the menopause transition (STRAW stage -2/skipped ≥2 but <12 consecutive cycles or STRAW stage -1/irregularity > 7 days, excluding other causes of oligo-amenorrhea) with untreated depressive symptoms (Montgomery-Asberg Depression Rating Scale [MADRS] score 10–24, higher score worse) completed 9 weekly assessments (minimum 4) of mood (MADRS), hot flashes (daily diary), and blood draws for serum E2 (LC/MS method) and progesterone (P4).  MADRS scores were correlated with coefficient of variability (cv) in logE2 (cvE2) and hot flashes, and with the number of episodes in which P4 exceeded 6 ng/dl (test of trend). Repeated measure linear regression was used to examine the independent associations of cvE2 and the episodes of P4 elevation with depressive symptoms scores, and to test for mediation by hot flashes. 

RESULTS

Of 51 women enrolled (mean age 48.2 + 4.1 yrs; 35% African-American; 50% STRAW stage -2), 44 (86%) completed 9 assessments.  Baseline mean MADRS score was 15.4 + 5.3. Hot flashes were present in 84% of women, with symptomatic women reporting an average of 3.3 + 3.0 per 24 hours.   Higher MADRS scores correlated positively with cvE2 (r=0.16, p<0.001) and nighttime (but not daytime) hot flashes (r=0.12, p=0.02) while MADRS scores were negatively correlated with the number of P4 elevation episodes (z=-4.81, p<0.001).   In adjusted models, MADRS scores were lower in women with episodic P4 elevation (p<0.001);  greater cvE2 increased MADRS scores in the absence (p<0.001) but not in the presence (p=0.80) of episodic P4 elevation.  There was no association of nighttime hot flashes with MADRS scores in adjusted models, nor did nighttime hot flashes explain the positive association of cvE2 and depressive symptoms.

DISCUSSION

Among perimenopausal women with depressive symptoms, mood symptoms were less severe in association with episodic progesterone elevation. In contrast, variability in E2 in the absence of progesterone worsened mood.  This association of variability in E2 with worse mood did not appear to be mediated by hot flashes.  These results indicate that increasing dysregulation of menstrual cycle hormone dynamics with loss of ovulation and marked variability in E2 is associated with worsening of mood.

 

Disclosure: HJ: Clinical Researcher, Teva, Consultant, Merck & Co., Medical Advisory Board Member, Merck & Co., Consultant, Noven. MF: Medical Advisory Board Member, Takeda, Medical Advisory Board Member, Otsuka, Medical Advisory Board Member, Lundbeck, Medical Advisory Board Member, Genentech, Inc., Medical Advisory Board Member, JDS Therapeutics, Researcher, Takeda, Editor, DSM Nutritionals, Editor, Global Organization for EPA and DHA (GOED). LC: Researcher, Astra Zeneca, Researcher, Bristol-Myers Squibb, Researcher, Cephalon, Inc., Researcher, National Institute on Aging, Researcher, National Institute of Health, Researcher, National Institute of Mental Health, Researcher, Ortho McNeil, Researcher, Sunovion Pharmaceuticals, Inc., Researcher, Takeda. Nothing to Disclose: SC, GA, DW, SK, TG, JC, JEH

19884 20.0000 FRI-121 A Influence of Perimenopausal Hormone Dynamics on Mood 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Bill L Lasley*1, Daniel S. McConnell2, Sybil Crawford3, John H Morrison4, Ellen Gold5 and Nancy A Gee1
1University of California, Davis, CA, 2University of Michigan Department of Epidemiology School of Public Health, 3University of Massachusetts Medical School, Worcester, MA, 4Icahn School of Medicine at Mount Sinai, New York, NY, 5University of California Davis, Davis, CA

 

Background:  Hormone replacement therapy (HT) consisting of estrogen plus progesterone (E+P) has benefit when administered in close proximity to the last menstrual period (LMP).  This benefit decreases and can turn to increased risk when initiated six to ten years following the LMP.  This concept has been suggested to explain discrepant results across randomized clinical trials assessing HT for the prevention of cardiovascular disease (CVD).  Similarly, postmenopausal estrogen therapy alone (E) is associated with a slight decrease in breast cancer (BrCA) but this decrease is not found with E+P. No mechanism for this time-related change in benefit/risk has been suggested.

Objective: To compare the effects of estrogen alone (E) or estrogen plus progesterone (E+P) HT regimens on adrenal steroid production in ovariectomized (OVX) laboratory macaques and compare the response to these treatments on the induction of increased adrenal androgens during the menopausal transition (MT) of women.

Methods:  Laboratory macaques were OVX prior to treatment with different HT regimens for several months.  Both younger (7-13 y/o) intact control (n=7) and OVX treated (n=6) as well as older (21-25 y/o) intact control (n=4) and treated animals (n=5) received either vehicle (n=3, in both younger and older), estrogen alone (n=3, in both younger and older) or estrogen and cyclic progesterone (n=3 and n=2, respectively).  Estradiol and cyclic progesterone were delivered to simulate normal ovarian cycles. Circulating estradiol and progesterone was monitored during treatment at quarterly intervals (every 3 months) to document the successful administration of the treatments. At necropsy, blood and adrenal tissues were collected and evaluated for adrenal androgens.

Results: Circulating dehydroepiandrosterone sulfate (DHEAS) was measured prior to and following treatment.  E+P but not E alone increased adrenal cortex width and significantly increased circulating DHEAS in OVX macaques.  This increase in DHEAS was similar to the increase in DHEAS observed in most women during the MT when endogenous E+P dominates the circulating sex steroid profile. 

Conclusion:  The result of E+P treatment in the OVX macaque model is consistent with the rise in adrenal androgens in mid-aged women associated with increased incidence of CVD.  Estrogen alone had no effect.  These data support the concept that E+P HT, when initiated in the late postmenopause, reiterates the rise in adrenal androgens during the MT and perhaps provides a mechanism for the accompanying increased incidence of CVD in late postmenopausal women, but not in early postmenopause and never with estrogen alone.

 

Nothing to Disclose: BLL, DSM, SC, JHM, EG, NAG

21471 21.0000 FRI-122 A Estrogen Plus Progesterone but Not Estrogen Alone Mimics the Induction of Increased Adrenal Androgen Production Observed during the Menopausal Transition of Mid-Aged Women Using the Ovariectomized Macaque Model 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Roisin Worsley1, Pragya Gartoulla1, Robin Bell1 and Susan Ruth Davis*2
1Monash University, Melbourne, Australia, 2Monash University, Melbourne VIC, Australia

 

Prior to the publication of the findings of the Women’s Health Initiative (WHI)1, menopausal hormone therapy (MHT) was the mainstay of treatment for menopausal symptoms, used by approximately 30% of postmenopausal Australian women2. Following the WHI findings, the use of MHT declined dramatically2. Conversely, there has been the emergence of compounded ‘bioidentical’ hormone therapies which are promoted as natural but do not have established efficacy or safety. To determine the current prevalence of use in Australia of conventional and compounded menopausal hormone therapy (MHT) we conducted a cross-sectional questionnaire-based study between October 2013-March 2014. Participants were provided with a tick-box list of all MHT available in Australia as of October 2013, and a list of compounded hormones and androgen therapies.

2020 women, aged 40-65, able to complete an English questionnaire were recruited from a large, dynamic database derived from the electoral roll. 5850 women were invited to participate by telephone, 2911 questionnaires were posted, and 2020 completed questionnaires were returned (response rate 35%). Demographic characteristics of the participants are representative of all Australian women aged 40-65. For this analysis, only the 1491 perimenopausal and postmenopausal women were included.

The main outcome measures were use of MHT and menopausal symptoms measured by the Menopause-specific Quality Of Life questionnaire.

Moderate-severe vasomotor symptoms (VMS) were reported by 17% of women, (7.85% extreme VMS) and 18.3% reported moderate-severe sexual symptoms. 11.3% were using MHT, with a predominance of oral estrogen (68.5%). 1.1% of women used compounded estrogen and/or progesterone, 0.9% used androgen therapies (DHEA or testosterone), 0.9% used tibolone, and 4.5% used vaginal estrogen. MHT use was associated with surgical menopause (adjusted odds ratio [AOR], 4.44; 95% CI, 2.68-7.38), hysterectomy only (AOR, 1.81; 95% CI, 1.16-2.82) (Table 5), moderate-severe VMS (AOR, 1.83; 95% CI, 1.20-2.79), and moderate-severe psychological symptoms (AOR, 1.67; 95% CI, 1.09-2.54. Current smoking (AOR, 0.50; 95% CI, 0.28-0.90) and a BMI ≥ 40 (AOR, 0.36; 95% CI, 0.15-0.88) were inversely associated with MHT use.

Translating our findings to the 3.7 million Australian women aged 40-64 years, 2.66 million are peri or postmenopausal, and 308, 000 are using MHT, mostly oral estrogen (185, 000). 455, 000 would have moderate-severe VMS, yet most of these women would be untreated (385, 000).

Conclusion: The use of MHT by highly symptomatic perimenopausal and postmenopausal Australian women aged 40-64 is low. The use of safer therapies (non-oral estrogen, tibolone) and vaginal estrogen is strikingly low, especially in comparison to the use of unregulated compounded hormone therapies.

 

Disclosure: SRD: Investigator, Bayer, Inc., Investigator, Lawley Pharmaceuticals, Ad Hoc Consultant, Trimel Pharmaceuticals, Investigator, Trimel Pharmaceuticals. Nothing to Disclose: RW, PG, RB

20894 22.0000 FRI-123 A Use of Conventional and Compounded Menopausal Hormone Therapy in Perimenopausal and Postmenopausal Australian Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


JoAnn V Pinkerton*1 and Ginger D Constantine2
1University of Virginia, Charlottesville, VA, 2EndoRheum Consultants LLC, Malvern, PA

 

In 2002, 93 million total prescriptions were filled for FDA-approved MHT.  From 2002 – 2012, there was a 61% decrease to 36 million FDA-approved MHT prescriptions.  Recent survey data from consumers suggests a sharp increase in the use of custom compounded MHT and lack of awareness that these products are not approved by the FDA (1).   A separate review of compounding websites reported that almost half of the websites contained claims that compounded MHT was generally safer than FDA-approved MHT and had less side effects (2).

A survey of a representative sample of pharmacists that provide compounding services in the US was conducted in October 2014 by Rose Research on behalf of inThought Research and the International Journal of Pharmaceutical Compounding (IJPC).  The survey provided data to estimate the number of prescriptions filled of compounded MHT in the US and assess the potential trend over the next two years.  Email invitations to participate in the survey were sent to 12,250 potential participants.  As a reward for completing the survey, panel members received an equivalent of up to approximately $17-35 in cash or merchandise.  Twenty-four percent (24%) answered screening questions. 904 responders met the initial screening criteria of pharmacists representing either independent community pharmacies, defined as less than 50 stores, (ICP; n=717) or independent compounding pharmacies (CP; n=187).  685 respondents indicated that their pharmacy performed compounding services (70% ICP & 96% CP).  483 completed the full survey related to compounding – 365 ICP and 118 CP. 

Based on the survey response, the numbers of independent community and compounding pharmacies in the US and the reported average percentage of compounding from the National Community Pharmacists Association (NCPA) and IBISWorld, an estimated 26 to 36 million total prescriptions may be filled annually for custom compounded MHT.  Majority of respondents from community pharmacies (52%) and compounding pharmacies (75%) reported that they expected the compounding business to grow over the next 2 years with the overwhelming majority predicting between 5% to 25% growth. 

The estimated compounded MHT prescriptions that may be filled annually from this pharmacist survey (26 to 36 million) confirms the results found in the aforementioned consumer survey (21-39 million) and approaches FDA-approved prescriptions (36 million).

Given that non-FDA approved MHT prescriptions now approximate the number of FDA-approved MHT, clinicians may want to familiarize themselves with the differences in unregulated and FDA-approved MHT and help their patients to understand the potential risk-benefit ratio of unregulated custom compounding.

 

Disclosure: JVP: Consultant, Pfizer, Inc., Consultant, TherapeuticsMD, Consultant, Noven, Consultant, Shionogi. GDC: Consultant, TXMD.

21460 23.0000 FRI-124 A Menopausal Hormone Therapy (MHT) Usage: FDA-Approved Mht Has Decreased While Compounded Non-FDA Approved Mht Has Increased 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Khalid Benkhadra*, Khaled Mohammed, Alaa Al Nofal, Barbara Gisella Carranza Leon, Fares Alahdab, Abd Moain Abu Dabrh, Jorge Zuniga and Mohammad Murad
Mayo Clinic, Rochester, MN

 

Objectives: To assess all-cause and cause specific mortality (myocardial infarction, stroke and cancer) associated with Menopausal hormone therapy (MHT) in postmenopausal women.

Methods: A comprehensive search of several online databases from each database’s earliest inception to August 2013. The databases included Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Randomized trials of follow up ≥ 6 month were included if they compared MHT with placebo or no treatment and reported an effect size for outcomes.

Results: Meta-analysis from 43 randomized controlled trials showed no association between all cause-mortality was and MHT [risk ratio (RR) 0.99 (95% confidence interval 0.94-1.05)] with no significant interaction based on hormone type or pre-existing heart disease. No association was found between MHT use and mortality due to myocardial infarction (RR 1.04, 95%CI 0.87-1.23), breast cancer (RR 0.93, 95%CI 0.26-3.32) or stroke (RR 1.49, 95%CI 0.95-2.31). Postmenopausal women taking MHT with cancer other than breast cancer had increased cancer mortality (RR 1.34 95%CI 1.09-1.67) compared to placebo   

Conclusion: Moderate to high quality evidence from randomized controlled trials suggests that MHT use is not associated with a significant effect on all-cause mortality, cardiovascular death or breast cancer death; but may increase the risk of other types of cancer death. 

 

Nothing to Disclose: KB, KM, AA, BGC, FA, AMA, JZ, MM

20414 24.0000 FRI-125 A Menopausal Hormone Therapy and Mortality: A Systematic Review and Meta-Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Ginger D Constantine*1, Harvey Kushner2, Brian Bernick3, Shelli Graham3 and Sebastian Mirkin3
1EndoRheum Consultants LLC, Malvern, PA, 2BioMedical Computer Research Institute, Inc., 3TherapeuticsMD, Boca Raton, FL

 

Vulvar and vaginal atrophy (VVA) is a common, chronic condition in postmenopausal women, assessed by objective (vaginal cells and vaginal pH) and subjective measures (symptom severity).  In clinical practice, healthcare providers (HCPs) utilize vaginal visual assessment to diagnose VVA and address a patient’s need for treatment.  However, for a product to be approved for the indication of VVA, significant improvements in change from baseline to Week 12 must be shown for all co-primary endpoints: superficial cells, parabasal cells, vaginal pH and improvement in the most bothersome moderate to severe symptom. 

To assess the relationship between the HCP visual assessment on physical exam and objective measures. 

Fifty healthy postmenopausal women (aged 40-75 yrs) with moderate to severe VVA symptoms, superficial cells ≤5% and a vaginal pH >5 were randomized to a new investigational gelcap (VagiCap™) containing 10 µg of solubilized estradiol (n=24) or Placebo (n=26) daily for 14 days.  Efficacy endpoints were change from baseline in the maturation index, vaginal pH, severity of the most bothersome VVA symptom, and Investigator assessment of vaginal mucosa. Physician visual assessment for vaginal criteria (secretions, epithelial integrity, epithelial thickness and color) were each graded on a four point scale (0=no atrophy to 3=severe) and totaled.   Visual assessments at both visits were performed by the same gynecologist, blinded to previous assessments.  Spearman rank-order correlation coefficient was used. Categorical changes between treated and placebo were compared using Fisher’s test. 

At baseline, there was a statistically significant correlation between parabasal cells (p<0.05) and the sum of the four visual assessments.  Because baseline values of superficial cells were very low, analysis with physical exam was not statistically significant.  At end of study, there were significant correlations between change in the sum of visual assessment ratings and change in percentage of parabasal cells (p=0.008) and vaginal pH (p=0.02).  After 15 days of treatment with VagiCap™ 10 µg, there were significant improvements in vaginal color (p=0.001), epithelial thickness (p=0.004) and epithelial integrity (p=0.001) in treated versus placebo subjects.  There was no statistical improvement in vaginal secretions.

Visual exam at baseline significantly correlates with vaginal epithelial cells; at Day 15 there was a significant correlation between visual findings and vaginal cells and vaginal pH.  Treatment with VagiCap™ was associated with a significant increase in superficial cells and significant decreases in parabasal cells and pH.  These findings correlated with improvement in the visual examination, including vaginal color, epithelial thickness and epithelial integrity. In conclusion, physical examinations are valid and reliable measures to assess VVA as well as the response to treatment.

 

Disclosure: GDC: Consultant, TXMD. BB: Employee, TherapeuticsMD. SG: Employee, TXMD. SM: Chief Scientific Officer, TherapeuticsMD. Nothing to Disclose: HK

20534 25.0000 FRI-126 A Vaginal Physical Examination Correlates with Vaginal Epithelial Cells and pH and Can be Used to Assess Treatment Efficacy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 102-126 6011 1:00:00 PM Hyperandrogenic Disorders and Menopause Poster


Karen Michele Tordjman*1, Laura Grinshpan2, Lena Novack3, Dar Segev4, Naftali Stern5, Thomas Goen6 and Tamar Berman7
1Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 2Hebrew University of Jerusalem, Rechovot, Israel, 3Ben Gurion University in the Negev, Faculty of Health Sciences, Beer-Sheva, Israel, 4ORT Braude College, Karmiel, Israel, 5Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 6University of Erlangen-Nuremberg, Erlangen, Germany, 7Ministry of Health, Jerusalem, Israel

 

Background: Unknown just a century ago,  endocrine disruptors chemicals (EDCs) are now ubiquitous.  Epidemiological data combined with biomonitoring studies have raised the possibility they may play a role in a variety of human diseases, among which obesity and diabetes. Recently, the first Israeli  human biomonitoring study (IBMS) demonstrated an excess  burden for a number of EDCs in the Israeli population compared with that of the US and Canada.

Aim of study: As the concentration of EDCs tends to go up the food chain,  we tested the hypothesis that a vegetarian/vegan diet is associated with a lower burden of exposure to man-made EDCs.

Methods: Fourty-two residents  of the vegetarian village of Amirim, 29 vegetarians and 13 vegans, took part in this study. Participants responded to a lifestyle/food frequency questionnaire and  underwent  a detailed 24 h dietary recall interview. They provided a morning urine sample, on which the concentrations of 11 phthtalate metabolites were determined by tandem LC-MS/MS, while that of bisphenol A (BPA),  and that of the phytoestrogens genistein and daidzein were measured by  by GC-MS/MS.  Geometric means of creatinine-adjusted concentrations were used to compare the results with those of the Jewish population from the IBMS.

Results: The sample consisted of  24 women and 18 men aged 50.7±13.7 y. There were no differences in gender distribution or in BMI among the 2 samples, but the Amirim  subjects were older, more educated than in the IBMS, and they also hardly smoked. 

Urinary BPA  was no different in the Amirim sample than in the general population. In contrast,  5OHMHEP, and 7oxoMiNP, metabolites of the high molecular weight phthalates DHEP and DiNP were 30-35% lower in the Amirim residents (P=0.001 and P<0.001, respectively). The parent compounds are mostly used in PVC manufacturing, flooring, toys and food packaging. Likewise, metabolites of  the low molecular weight phthalates DnBP  and DiBP, used in cosmetics, medications, and the food industry, were  17% to 35% lower in  Amirim women than in the general female Israeli population (P=0.07, and P<0.0005, respectively). While, MBzP, metabolite of the low molecular weight phthalate BzBP used in PVC, was 36% lower in Amirim men than in among the general IBMS male population (P=0.03).

As expected from a diet high in soy and legumes,  phytoestrogens were an order of magnitude higher in the Amirim residents.  Genistein was 338.2 μg/g in Amirim vs. only 24.5 μg/g in the IBMS, while daidzein was found at a concentration of 363.1 μg/g among Amirim residents, compared to 61.7 μg/g in the IBMS, P<0.0001 for both. Finally, high molecular weight phthalate metabolites were, or tended to be, lower among vegans than among vegetarians.

Conclusions: Taken together these data suggest that even in a country whose population faces a high burden of  EDCs, diet, and specifically a vegan diet, can result in lower levels of exposure to EDCs, particularly to phthalates.

 

Nothing to Disclose: KMT, LG, LN, DS, NS, TG, TB

PP14-1 19452 2.0000 FRI-291 A Endocrine Disruptors Burden in Vegetarians/Vegans Is  Characterized By a Lower Exposure  to Phthalates 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Elina Karimullina*1, Margareta Halin Lejonklou2, Hannah Chung1, Monica Rönn2, P. Monica Lind2 and Bruce Blumberg1
1University of California, Irvine, Irvine, CA, 2Uppsala University, Uppsala, Sweden

 

It is now well documented that exposure to environmental xenobiotic chemicals in early embryonic development alters gene expression patterns that can lead to altered health later in life. In particular, obesogens can alter the epigenome of bone marrow mesenchymal stem cells (BMMSCs), biasing them toward the adipocyte lineage at the expense of bone (1). It is unknown whether BPA, a high volume production chemical, alters BMMSC lineage allocation and if there is sex-specific effect. To study possible shifts in BMMSCs adipogenesis due to developmental BPA exposure, we performed differentiation assays, exposing cells from perinatally BPA (or vehicle) treated 5 week old F344 rats to standard adipocyte induction cocktail (MDI) or MDI plus the PPARγ activator, rosiglitazone (ROSI). Pregnant rats were exposed, via drinking water (to mimic the route of human exposure), to 0.5 and 50 µg/kg/day BPA or ethanol vehicle from gestation day 3.5 throughout the end of lactation. Endpoints were levels of lipid accumulation (Nile Red staining) and the expression of mRNAs encoding the adipogenic markers (FABP4, FSP27) using QRT-PCR.

BMMSCs derived from animals exposed to 0.5 µg/kg/day BPA showed increased lipid accumulation in the presence of ROSI added ex vivo compared to controls (0.177±0.0104 vs. 0.212±0.0105 relative units; P=0.027; n 16-20 per group). Treatment with 50 µg/kg/day BPA had no effect on lipid levels vs. controls (0.177±0.0104 vs. 0.184±0.0119 relative units; P=0.704; n 13-20 per group), which is in agreement with a prior report (2). QRT-PCR analysis of BMMSCs demonstrated that gestational BPA exposure (0.5 µg/kg/day) significantly increased expression of FABP4 not only in MDI+ROSI cocktail (6.58±1.37 vs. 12.76±3.12 fold induction; P=0.025; n 13-20 per group) but also in cells induced with MDI alone, which was used as the baseline for BMMSC differentiation capacity (1.0±0.225 vs. 2.3±0.698 fold induction; P=0.023; n 13-20 per group). FSP27 expression was also increased after MDI induction in 0.5 µg/kg/day BPA exposure group compared to untreated control (1.0±0.222 vs. 2.17±0.620 fold induction; P=0.026; n 13-20 per group). Analysis of gene expression revealed sex-specific effects: increased levels of FABP4 and FSP27 resulting from exposure to 0.5 µg/kg/day BPA were observed in cells from female offspring (P=0.016-0.034; n 7-10 per group), whereas cells from male offspring showed no effect (P=0.176-0.485; n 5-10 per group). Treatment with BPA at 50 µg/kg/day also induced FSP27 expression (2.3±0.698 fold induction; P=0.023; n 7-10 per group) in BMMSCs harvested from female offspring.

We conclude that chronic perinatal BPA exposure at environmentally relevant levels may predispose BMMSCs toward the adipogenic pathway.

 

Nothing to Disclose: EK, MH, HC, MR, PML, BB

20174 3.0000 FRI-292 A Perinatal Low-Level BPA Exposure May Predispose Adipogenesis in Bone Marrow Mesenchymal Stem Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Jan A. Mennigen*, Lindsay M Thompson and Andrea C Gore
University of Texas at Austin, Austin, TX

 

Endocrine-disrupting chemicals (EDCs) such as PCBs are organic pollutants that are routinely detected in human and wildlife tissues despite their ban decades ago. We previously showed that gestational exposure of Sprague-Dawley (SD) rats to Aroclor 1221 (A1221) resulted in altered reproductive behavior and physiology, and changes gene expression of key hypothalamic nuclei implicated in the regulation of both. One such area is the anteroventral periventricular nucleus (AVPV), a sexually dimorphic brain area that is responsive to organizational effects of sex steroids. In the current study we addressed the hypothesis that developmental A1221 exposure regulates gene expression in the AVPV not only in the exposed F1 animals but also in their descendants without any further EDC treatment. We injected pregnant SD rats with DMSO, A1221 (1 mg/kg bw), or estradiol benzoate (EB; 50 μg/kg bw) on gestational days 16 and 18. The F1 female and male offspring served to generate maternal and paternal lineages of F2 and F3 generations. We profiled the expression of 46 selected genes in the AVPV using low-density qPCR array cards. Results: Within the F1 generation, the mRNA expression of 11 genes was regulated by treatment, and 9 genes were sexually dimorphic. Among the genes whose expression was regulated by treatment, Esr1Esr2Pgr, Gal, andMc3r were decreased by A1221 and EB treatment, while the expression of Per2 was decreased by A1221. Within-sex analysis of sexually dimorphic genes revealed that A1221 and EB treatment increased the expression of Ahr and Srd5a1 and decreased the expression of Ar and Oxt genes in males, but not females. Within the F2 generation, we found no treatment effects for the expression of any AVPV gene studied. 5 genes were sex-dependent and 1 gene was lineage-dependent. Within the F3 generation, the expression of 1 gene (Lepr) was decreased with A1221 treatment. Ten genes were sexually dimorphic, with no effect of lineage or treatment.  Overall, this study indicates that developmental PCB exposure exerts strong effects on AVPV gene expression in the F1 generation and lesser effects in subsequent generations. This study provides a framework for future investigation of transgenerational effects of PCBs, which will provide important information on novel modes of action of these endocrine disrupting chemicals that will contribute to our understanding of PCB effects on reproductive phenotypes.

 

Nothing to Disclose: JAM, LMT, ACG

20013 4.0000 FRI-293 A Transgenerational Effects of Prenatal PCB Exposure on Gene Expression in the Avpv of Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Noriko Kanaya*1, Duc Nguyen1, Hannah Lu1, Li-Yu Hsin1, Myrto Petreas2, David Nelson3, Weihong Guo2, Peggy Reynolds3, Tim Synold4, Przemyslaw Twardowski5 and Shiuan Chen1
1Beckman Research Institute of the City of Hope, Duarte, CA, 2California Department of Toxic Substances Control, 3The Cancer Prevention Institute of California, 4Beckman Research Institute of the City of Hope, 5City of Hope National Medical Center

 

AroER tri-screen assay was developed by stable transfection of estrogen receptor (ER)-positive, aromatase-expressing MCF-7 breast cancer cells with an estrogen responsive element (ERE)-driven luciferase reporter plasmid.  It has been validated to be a biologically relevant high-throughput screening assay to identify endocrine-disrupting chemicals (EDCs) targeting aromatase and ER [Chen et al., Toxicological Sciences, 139: 198-209, 2014].  Because the cell line overexpresses the aromatase enzyme, this novel assay can evaluate four different types of EDCs: estrogenic EDCs, antiestrogenic EDCs, aromatase inhibitor (AI)-like EDCs, and indirect estrogenic EDCs which are converted by aromatase.  Results from screening the 446 drugs in the National Institutes of Health Clinical Collection revealed 106 compounds that modulated ER and/or aromatase activities.  In this study, we confirmed that 4 compounds exhibit estrogenic activity, including cortodoxone which is estrogenic through a two-step conversion in this aromatase-positive cell line.  The additive effect of natural and synthetic EDCs could be demonstrated when they were tested in combination.  Furthermore, we have established a biological function assessment, using AroER tri-screen, to determine estrogenic or aromatizable androgenic activity in biospecimens or water samples.  Steroid hormones and EDCs are extracted using a C-18 Solid-Phase Extraction (SPE) column.  Recovery rate of SPE column extraction is over 98%.  As a proof-of-principle study, the estrogenic activities in the extracts of 11 human serum samples were found to correlate well to their ability to promote the proliferation of estrogen-responsive cells.  Most of the activities were blocked by ICI 182780 or letrozole treatment, indicating that aromatizable androgens are present at significant levels in human serum samples.  In another experiment using serum samples from prostate cancer patients, the aromatizable androgenic activity was positively correlated to the PSA values of tested samples.  Aromatase expresses at higher levels in breast tumors than normal tissue, resulting in increased local estrogen production to drive tumor progression.  Natural estrogen and androgen are important factors to increase breast cancer risk, as well as EDCs.  In addition, androgen plays critical roles in the development of prostate cancer.  Therefore, it is critical to estimate overall estrogenic and androgenic activities from biological samples to assess the risk of breast cancer or prostate cancer.  In summary, the presence of functionally active aromatase makes AroER tri-screen a powerful and unique tool to identify novel EDCs binding to aromatase and/or ER, as well as to estimate male and female hormonal activities in biological samples.

 

Nothing to Disclose: NK, DN, HL, LYH, MP, DN, WG, PR, TS, PT, SC

19975 7.0000 FRI-296 A AroER Tri-Screen™ Is a Novel Functional Assay for Both Estrogenic and Androgenic Activity in Environmental Specimen 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Michael P Reilly*1, Connor D Weeks1, Viktoria Y Topper1, Lindsay M Thompson1, David Crews2 and Andrea C Gore1
1University of Texas at Austin, Austin, TX, 2Univ of Texas, Austin, TX

 

Endocrine disrupting chemical (EDC) exposures during critical periods of development influence neuronal development and the manifestation of sexually dimorphic behaviors that emerge in adulthood. Among these behaviors, social information processing is sexually dimorphic and regulated by sex steroids. Oxytocin and vasopressin serve as primary neurotransmitters mediating these behaviors; these neuroendocrine circuits are hormone sensitive and potential targets of prenatal EDC exposures. In this study, we assessed the effects of gestational exposure to PCBs on the social behavior of males and females later in adulthood. A weakly estrogenic PCB mixture, Aroclor 1221 (A1221, 0.5 or 1.0 mg/kg) was administered to pregnant Sprague-Dawley rat dams during the last trimester, when the hypothalamus undergoes sexual differentiation. Both a positive control (estradiol benzoate, EB) and negative control (3% DMSO in sesame oil vehicle) were administered similarly to separate sets of dams. The sexes responded differently in two tasks essential to sociality. In the first task we investigated the experimental animal’s social activity using a three-chamber apparatus which contained a caged, same-sex, gonadectomized stimulus animal and an empty stimulus cage. While both sexes showed a strong preference for affiliating with a stimulus animal (vs. an empty cage), males associated more than females with the conspecific. In the second task, we tested novelty preference by introducing a new stimulus animal and observing how the experimental animal behaved in the presence of the novel conspecific compared to the now-familiar stimulus animal. When presented with a familiar vs. novel animal, the females displayed a higher degree of novelty preference than the males. However, there was a sex- and dose-specific reduction in the novelty preference seen in the A1221 (1.0mg/kg) female and A1221 (0.5 mg/kg) male groups. Of particular interest, A1221 (0.5mg/kg) males had an overall decrease in nose-to-nose investigations. These behavioral data suggest that the males are more sensitive to A1221 treatment than the females. Ongoing work is focusing on sex differences and EDC effects on hypothalamic oxytocin and vasopressin neurons to investigate the possible neurobiological bases underlying the observed behavioral changes.

 

Nothing to Disclose: MPR, CDW, VYT, LMT, DC, ACG

20016 8.0000 FRI-297 A Gestational Exposure to PCBs Leads to Changes in Adult Social Behaviors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Viktoria Mladenovik*, Meghan Quigley, Kelly Marie Hallman, Julieta Saluzzo and Sumi Dinda
Oakland University, Rochester, MI

 

The North American plant Cimicifuga racemosa, also known as black cohosh, is an herb that has been used for centuries by numerous cultures for its wide range of health benefits. Recently, black cohosh has gained attention for its hormonal effects which have the potential to alleviate female medical conditions including menopause.  Black cohosh has been used in menopausal women to relieve hot flashes, profuse sweating, and sleep disturbances.  As the usage of hormone replacement therapy is declining due to its adverse affects in women with cancer, many are turning to herbal remedies like black cohosh (BC) to treat menopausal symptoms.  Studies indicate that this flavonoid may act as a SERM, thus inducing inhibitory growth effects on hormone dependent cancer cells. Therefore, it is crucial to determine whether the effects of black cohosh involve ER-alpha.  Previous studies from our lab have shown the estrogen receptor (ER-alpha) to be a possible molecular target for BC.  In this study, the effects of black cohosh alone and in combination with hormones and anti-hormones were examined with cellular viability and expression and cytolocalization of ER-alpha in ER (+) T-47D breast cancer cells.  In order to deplete any endogenous steroids or effectors, breast cancer cells were cultured in medium containing 5% charcoal-stripped fetal bovine serum for six days.  Western blot analysis revealed alterations in the expression of ER-alpha after 24 hours of treatment with varying concentrations of BC (5 – 100 µM).  BC induced a concentration-dependent decrease in ER-alpha protein levels, with a 57% reduction occurring with 100 µM BC when compared to DMSO.  In order to determine the influence of BC on the growth of breast cancer cells, image cytometric analysis with propidium iodide staining was utilized to quantify alterations in T-47D cell number and viability.  After six days of treatment, a 23 – 61% decrease in T-47D cell viability was observed upon treatment with 5 – 100 µM BC.  The ideal concentration of black cohosh (100 μM) was used in combination with hormones and anti-hormones in an effort to further understand the possible similarities between this compound and other known effectors of ER-alpha.  After a 24-hour concomitant treatment of 100 µM BC and 10 nM E2 on T-47D cells, down-regulation of ER-alpha protein levels was observed.  When BC was used in combination with the pure ER-alpha antagonist ICI (1 µM), similar effects were detected.  The proliferative effect of estrogen (E2) was reduced when treated in the presence of BC.  Delineating the role of BC in the regulation of ER-alpha and its mechanisms of action may be important in understanding the influence of BC and hormone receptors in breast cancer.

 

Nothing to Disclose: VM, MQ, KMH, JS, SD

20489 9.0000 FRI-298 A The Effects of Black Cohosh on the Regulation of Estrogen Receptor Alpha in Breast Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Matthew Eric Johnson*1, Ursula W Parlin1, Kevin J Basile1, Brian T Johnston1, Qianghua Xia1, Vanessa Guy1, Jesus Sainz2, Andrew D. Wells1 and Struan F.A. Grant3
1Children's Hospital of Philadelphia, Philadelphia, PA, 2Institute of Biomedicine and Biotechnology of Cantabria, Santander, Spain, 3The University of Pennsylvania

 

Background: Bisphenol A (BPA) and phthalates are common chemical components of plastics and have been implicated as endocrine disruptors. Exposure to diethylhexyl phthalate (DEHP) or BPA has been widely reported to correlate with obesity and type 2 diabetes (T2D) risk. Despite these observations, little is known about the molecular mechanisms involved.

 

Objective: Through the application of ChIP-seq, we elected to analyze the influence of BPA and DEHP administration on the genomic occupancy behavior of TCF7L2. This transcription factor is both widely regarded as a master regulator of key pathways related to metabolic traits and is encoded by the locus most strongly associated with T2D reported to date.

 

Design/Methods: Drawing on our laboratory and bioinformatic experience with ChIP-seq, we analyzed TCF7L2 ChIP-seq data generated in DEHP and BPA treated HCT116 cells. We used the algorithm HOMER to gain insight into DEHP and BPA disruption of global genomic binding patterns and the corresponding downstream molecular pathways.

 

Results: We observed that treatment with either BPA or DEHP resulted in fewer TCF7L2 occupancy sites when contrasted with data generated in the controls. Using the software package, Ingenuity, we explored which pathways occupied were most perturbed by these treatments. Strikingly, the annotated ‘Type II Diabetes Mellitus Signaling’ pathway, which was extremely strongly enriched in the controls, was not even nominally significantly enriched in the treatment groups. We observed that strength of occupancy was highly perturbed for Wnt signaling, showing greater than 1.5 fold increased or decreased occupancy for multiple individual pathway members. Apart from occupancy sites that were exclusive to a particular setting, the greatest changes for occupancy with BPA treatment was with sites near FOXL1 (Fold Change (FC):22x, P=6.8x10-4), PCDH18 (FC:19x, P=6.8x10-4), ARHGAP12 (FC: -6.9x, P=1.6x10-4) and C1orf95 (FC:-5.2x, P=3.6x10-4) while with DEHP is TCF7L2 itself (FC:15x, P=1.0x10-5), NKD1 (FC:15x, P=4.4x10-4), MKL1 (FC:-6.7x, P=2.8x10-3) and ABLIM1 (FC:-6.2x, P=1.9x10-5). Finally, using the Ingenuity “Disease and bio functions pathway” prediction tool, it is predicted that DEHP plays a role in down-regulating genes that inhibit the release of fatty acids (Activation Z-score (AZ)=-2.2, P=7.9x10-3) while BPA is predicted to regulate genes that activate increases in both lipid (AZ=2.2, P=5.4x10-4) and progesterone concentrations (AZ=2.4, P=1.3x10-3).

 

Conclusions: Leveraging TCF7L2 genomic occupancy pattern information, we observe that exposure to BPA and DEHP perturbs important metabolic pathways, principally related to T2D. Wnt signaling is particularly disrupted by these approaches and that the knock-on effects could primarily mediate changes in fatty acid, lipid and progesterone levels.

 

Nothing to Disclose: MEJ, UWP, KJB, BTJ, QX, VG, JS, ADW, SFAG

21078 10.0000 FRI-299 A The Endocrine Disruptors, Bisphenol A and Diethylhexyl Phthalate, Perturb Key Molecular Pathways Based on Analyses of TCF7L2 Genomic Occupancy Patterns 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Satoshi Takahashi*, Kaori Nemoto, Takuya Uchino, Yuki Ozawa, Yamato Mashimo, Koji Morita, Hiroko Okinaga, Makoto Kinoshita, Shin Fujimori and Toshio Ishikawa
Teikyo University School of Medicine, Tokyo, Japan

 

Background

Aryl hydrocarbon receptor (AhR), also known as the dioxin receptor, is a ligand-activated transcription factor that functions as a receptor for various substances, including xenobiotics such as dioxins, polychlorinated biphenyls, and polyaromatic hydrocarbons (PAHs). Although AhR is also activated by some dietary constituents, it is unclear how regularly AhR stimulators are ingested into the human body in our daily life. It is known that PAHs are formed by the incomplete combustion of organic materials, and in fact, we have recently shown that coffee beverages made from roasted coffee beans upregulate AhR-mediated gene expression when added directly to cultured cells (PLoS ONE 9: e102152, 2014). Thus, we were interested in whether scorched foods could also release AhR ligands, to the extent that would affect cellular AhR-dependent gene transcription.

Methods

Water was mixed with various scorched foods (e.g. bread, cheese, almonds, etc.), and the supernatants were retrieved as samples. The samples (10% (v/v)) were added to HepG2 cells stably expressing an AhR-responsive firefly luciferase gene, and the luciferase activity was measured. Also, expression of CYP1A1, a representative endogenous AhR-responsive gene, was analyzed using real-time quantitative RT-PCR in HepG2, Caco-2, MCF-7, and HeLa cells treated with the samples. We further tested whether pretreatment of the samples with activated charcoal would alter their AhR-stimulating activity.

Results

All the supernatant samples obtained from scorched foods, but not from non-scorched foods, robustly induced AhR-mediated luciferase expression in the reporter gene assay and strongly enhanced CYP1A1 mRNA expression in all the cell lines tested. In some samples, these inductions were clearly diminished by pretreatment with activated charcoal.

Conclusions

We have revealed that AhR-mediated gene transcription is elicited in cultured cells by the leachate samples of scorched foods and that the AhR ligands in some samples are adsorbed by activated charcoal. Although it has not yet been confirmed that burnt foods actually enhance AhR-mediated gene transcription in vivo, there is a possibility that those who habitually eat scorched foods are exposed to AhR ligands on a regular basis, even if they do not drink coffee. Our observation may help elucidate as-yet-unknown effects of scorched foods on our health.

 

Nothing to Disclose: ST, KN, TU, YO, YM, KM, HO, MK, SF, TI

19051 11.0000 FRI-300 A Scorched Foods Leach AhR Ligands That Can be Adsorbed By Activated Charcoal 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Flora Aparecida Milton*1, Angelica Amorim Amato2, Mariella Guimaraes Lacerda1, Dileesh Prakasan1, Pedro Góes Mesquita1, Simone Batista Sinoti1 and Francisco de Assis Rocha Neves1
1University of Brasilia, Brasilia, Brazil, 2University of Brasilia, Brasilia-DF, Brazil

 

The association between the use of chemical compounds and obesity has been discussed in the last 15 years. Several studies have shown that environmental contaminants act as endocrine disruptors with obesogenic properties. One of the most well studied obesogenic environmental contaminant is tributyltin chlorate (TBTC), an organotin compound mostly used in the manufacture of PVC. TBTC induces the activation of nuclear receptors RXRα and PPARγ and is related to the development of obesity and diabetes. Another group of organotin compounds, dibutyltins (DBTs), that is also used in the PVC, polyurethane and silicone manufacturing as well as biocidal in residential and farming products is poorly studied. So far, the effects of DBTs on PPARs and RXR transcriptional activity and in adipocytes differentiation process were not investigated. In this report, we describe the effect of four DBTs in transactivation assays using HeLa cells treated with rosiglitazone, DBT diacetate, diclorate, dilaurate or maleate for 24 hours. Our results demonstrated that all these DBTs compounds are partial agonists for PPARγ, inducing transcription activation similar to TBTC. Moreover, two of them, DBT diclorate and dilaurate also show a partial agonist effect on RXRα. In adipogenic differentiation assays with 3T3-L1 preadipocytes, the treatment with rosiglitazone, TBTC or DBTs for 12 days induced adipogenesis, as was evidenced by oil Red O staining. In protease digestion assay, DBT diacetate and dilaurate diminished the digestion of PPARγ by trypsin, suggesting binding properties of these compounds with PPARγ. Studies are being carried out to investigate the effect of these compounds in vivo. Additionally, we are working in the crystal structure of these compounds with PPARγ. These results may provide a better understanding of how these pollutants can affect human health.

 

Nothing to Disclose: FAM, AAA, MGL, DP, PGM, SBS, FDARN

21118 12.0000 FRI-301 A Adipogenic Effect of DBT Compounds 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Pani Fabiana*1, Germana Baghino1, Francesco Atzori2, Clelia Madeddu2, Maria Teresa Ionta2 and Stefano Mariotti1
1Dipartimento di Scienze Mediche Unità di Endocrinologia Policlinico Universitario Monserrato (Cagliari) Di, Italy, 2Dipartimento di Scienze Mediche Oncologia Medica Policlinico Universitario Monserrato (Cagliari) Di, Italy

 

Background: Tyrosine kinase inhibitors (TKIs) may induce thyroid dysfunction, while endocrine dysfunctions have not been systematically studied.

Objective: Prospective evaluation of thyroid and gonadal function. 18 patients (16 men and 2 post-menopausal women [median age 57.7, range 51-77]) with metastatic carcinoma (17 renal cell and 1 GIST) with comparable tumor staging, normal thyroid function and no evidence of thyroid autoimmunity, were studied before and at monthly intervals after beginning TKI: Pazopanib (Votrient®) in 1, Sunitinib (Sutent®) in 14, and Axitinib (Inlyta®) in 3 patients. Sunitinib was given at a daily oral dose of 50 mg 4 weeks on, 2 weeks off, Pazopanib daily oral dose of 800 mg and Axitinib daily oral dose of 5 mg. In all cases TSH, FT3, FT4, thyroid antibodies (TgAb and TPOAb), morphological evaluation with color doppler ultrasound, LH, FSH, Prolactin (PRL) were measured up to 6 months, associated to total testosterone (TT) in male patients.

Results. During 6 months of treatment 14 (78%) patients developed primary hypothyroidism (TSH increased from 1.31±0.7 to 15.74±25.73 mUI/L, [normal range 0.4-4 mUI/L]). This was associated to a decrease of thyroid volume (12.5±11.6 ml to 6.2±4.2 ml [p<0.001]) in 17 (95%) patients and to de novo appearance of TPOAb (84-3000 IU/ml) in 5 hypothyroid patients, who had the highest TSH values (25-114 mUI/ml). Twelve (75%) men developed TT <3 ng/ml, (from 4.4±1.35 ng/ml to 3.11±2.46 ng/mL, [p<0.001]), while LH decreased (from 4.44±2.92 mUI/ml to 2.02±1.03 mUI/mL [normal range: 1.5-10] and FSH from 6.82±4.24 to 3.32±2.5mUI/ml [normal range: 1-12 mUI/ml]). LH (from 4.5 and 16 mUI/ml to 2.9 and 0.96 mUI/mL [normal range 15.2-62 mUI/ml]) and FSH (from 0.4 and 88 to 0.1 and 2.27 [normal range 16.7-134.8 mUI/ml]) also decreased in 2 women. Finally, high serum PRL (35-68 ng/dl [normal range <20 ng/dl]) were observed in the 5 patients with severe hypothyroidism and positive TPOAb.

Conclusions. TKI interfere with the endocrine system at different levels: primary hypothyroidism (with possible involvement of autoimmune mechanisms) and central hypogonadism. Hyperprolactinemia (possibly contributing to central hypogonadism) was also observed in patients with more severe hypothyroidism and positive TPOAb. Further longitudinal studies involving other endocrine axes are needed to precisely characterize TKI as endocrine disruptors.

 

Nothing to Disclose: PF, GB, FA, CM, MTI, SM

19742 13.0000 FRI-302 A Thyroid and Gonadal Dysfunction in Patients with Metastatic Carcinoma Trated with Tyrosine Kinase Inhibitors. Results from a Prospective Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Enrico Campioli*, Tam B Duong and Vassilios Papadopoulos
The Research Institute of the McGill University Health Centre, Montreal, QC, Canada

 

Plastics are generally mixed with additives like plasticizers to enhance their flexibility, pliability, and elasticity proprieties. Plasticizers are easily released into the environment and absorbed mainly through ingestion, dermal contact, and inhalation. The two main classes of plasticizers, bisphenol A and phthalates, have been associated with endocrine and reproductive diseases (i.e. prostate disease, changes in testicular testosterone and Leydig cell homeostasis and decreased anogenital distance in males; promotion of early puberty, development of different types of cancers and mid-pregnancy abortions in females). In 2002, 1,2-cyclohexane dicarboxylic acid diisononyl ester (DINCH) was introduced in the market for use in plastic materials and articles intended to come into contact with food, and it received final approval from the European Food Safety Authority in 2006. At present, there is limited knowledge about the safety and potential endocrine-disrupting properties of DINCH and its metabolites. No evidence of developmental or reproductive toxicity was observed prenatally in two-generation toxicity studies in Wistar rats and rabbits at doses of up to 1,000 mg/kg body weight/day. Studies from our group and other researchers showed that the di-2-ethylhexyl phthalate (DEHP) bioactive metabolite, mono-2-ethylhexyl phthalate (MEHP), is able to affect the differentiation of preadipocyte cell lines, as well as primary human preadipocytes. Due to the similar structure of DEHP and DINCH, the purpose of this study was to evaluate the effect of DINCH and its active metabolites, cyclohexane-1,2-dicarboxylic acid (CHDA) and cyclohexane-1,2-dicarboxylic acid mono isononyl ester (MINCH), on rat primary stromal vascular fraction (SVF) of adipose tissue. DINCH and its metabolite, CHDA, were not able to directly affect SVF differentiation. However, exposure of SVF to 50 μM and 100 μM concentrations of MINCH affected the expression of Cebpa and Fabp4, thus inducing SVF preadipocytes to accumulate lipids and fully differentiate into mature adipocytes. The effects of MINCH on SVF were similar to those obtained using MEHP, a molecule shown to act as an agonist of peroxisome proliferator-activated receptors (PPARs). Indeed, the effect of MINCH was blocked by the PPAR-α antagonist, GW6471 at both mRNA and lipid accumulation levels. Taken together, these results suggest that MINCH is a PPAR-α agonist capable of inducing SVF preadipocyte differentiation, and that DINCH/MINCH are potential metabolic/endocrine disruptors.

 

Nothing to Disclose: EC, TBD, VP

19074 14.0000 FRI-303 A Cyclohexane-1, 2-Dicarboxylic Acid Diisononyl Ester (DINCH) and Metabolite Effects on Rat Epididymal Stromal Vascular Fraction Differentiation of Adipose Tissue 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Disruptors Friday, March 6th 3:00:00 PM FRI 290-303 6021 1:00:00 PM Developmental Regulation of Gene Expression and Its Susceptibility to Endocrine Disruptors Poster


Regan Michelle Memmott* and Vijayaratna Chockalingam
Banner Good Samaritan Medical Center (University of Arizona - Phoenix), Phoenix, AZ

 

Background:  Multiple thyroid and parathyroid pathologies can occur in the same patient.  However, the development of papillary thyroid cancer (PTC) in patients with thyrotoxicosis is rare and typically occurs in the setting of prior radioactive iodine treatment. We present a case of new onset thyrotoxicosis, papillary thyroid cancer, and PTH-mediated hypercalcemia in a patient treated with lithium.

Clinical Case: A 61 year-old female with a history of bipolar disorder and breast cancer presented for management of lithium overdose. On examination, she was hypoxic, tachypneic and tachycardic, and had a single hard, fixed right thyroid nodule in a normal-sized thyroid gland. Laboratory studies showed an elevated free T4 of 2.5 ng/dL (0.8 - 1.8), TSH of 0.04 uIU/mL (0.45-4.5), corrected serum calcium of 13.1 mg/dL (8.6-10.2), PTH of 264 pg/mL (15-65),  Vit D 25-hydroxy of 5.1 ng/mL (35-100), absent TPO and TSI antibodies, and a lithium level of 1.8 mEq/L, (0.8-1.2). Ultrasound showed multiple thyroid nodules, including a dominant exophytic nodule with internal calcifications and a hypoechoic mass inferolateral to the thyroid with internal blood flow. She was diagnosed with thyrotoxicosis, PTH-mediated hypercalcemia, and vitamin D deficiency. A diagnostic challenge in this patient was to determine if the etiology of her PTH-mediated hypercalcemia was due to lithium or a parathyroid adenoma. A 24-hour urine calcium of 270 mg/day indicated that this patient’s hypercalcemia was likely due to a parathyroid adenoma.  Emergent total thyroidectomy and resection of her suspected parathyroid adenoma was scheduled because of the presence of psychiatric comorbidities and concern that the patient would be lost to follow-up. The patient was at high risk for thyroid storm and hungry bone syndrome.  Pre-operatively, she was treated with methimazole, Lugol’s solution, propranolol, prednisone, and high-dose vitamin D. Total thyroidectomy and subtotal parathyroidectomy were performed successfully without any post-operative complications.  Pathology showed bilateral, multifocal PTC, 1.2 cm at the greatest dimension, nodular chronic lymphocytic thyroiditis, and bilateral inferior parathyroid adenomas.

Conclusion: This case shows that PTC can develop in the context of thyrotoxicosis independently of prior radioactive iodine exposure.  A unique challenge in our case was to identify the etiology of PTH-mediated hypercalcemia: lithium vs parathyroid adenoma. This was clinically important because lithium-mediated hypercalcemia with associated hypocalciuria does not require parathyroidectomy.  This patient also had a significant deficiency in vitamin D that predisposed her to hungry bone syndrome. Our case demonstrates the efficacy of emergent medical management with high-dose vitamin D repletion in preventing hungry bone syndrome following resection of multiple parathyroid adenomas.

 

Nothing to Disclose: RMM, VC

21421 1.0000 FRI-020 A Presentation, Diagnosis, and Emergent Management of a Patient with Thyrotoxicosis, Papillary Thyroid Carcinoma, and Primary and Secondary Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Mizuho Ando*, Mitsuyasu Itoh, Izumi Hiratsuka, Takeshi Takayanagi, Megumi Shibata, Sahoko Ueda, Eisuke Tomatsu, Yasumasa Yoshino, Ayako Kakita and Atsushi Suzuki
Fujita Health University, School of Medicine, Toyoake, Japan

 

【Background】The fine needle aspiration biopsy (FNAB) is useful tool for the diagnosis of thyroid tumor. Therefore, FNAB plays a crucial role in the diagnosis of thyroid nodules in the field of clinical endocrinology, and it enables the number of surgical operations to be reduced. The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) has recently been developed and improved the clinical management. Among the introduction of BSRTC, atypia/follicular lesion of undetermined significance is expected to repeat FNAB.

【Aim】We retrospectively reviewed cases with FNAB to investigate the accuracy and effectiveness of repeated FNAB.

【Subjects】The records from 1068 patients who were subjected to FNAB under the guidance with ultrasonography at our department since March 2003 to August 2014 were reviewed. The mean age was 53.5 year-old (11~90 year-old), and the patients were composed of 906 women and 162 men.

【Results】 Total number of 1994 FNAB had been performed. The patients who had repeated FNAB were 402 patients (37.6%), while 666 patients (42.4%) received only one. The cytology report claimed that 1402 samples (70.4%) were normal or benign, 169 samples were follicular neoplasm. Three hundred and seventeen samples (15.9%) were reported as non-diagnostic. Seventy-five samples (3.8%) were malignant (one sample was a metastatic cancer of lung small cell carcinoma), and 31 samples (1.7%) were suspicious for malignancy. All patients who diagnosed as malignancy or suspicious malignancy by FNAB except a case with metastatic cancer of lung small cell carcinoma were subjected to surgical operations. Eighty-three patients were histologically confirmed their papillary thyroid carcinoma (PTC), one patient had medullary carcinoma, and two patients had no cancer. The ratio of male to female with PTC was 15 (18.1%) to 68 (81.9%). The mean age was 56.8 year-old (20~86 years-old). The patients were classified into (A) 66 patients with only one, and (B) 17 patients with repeated FNAB ranged twice to eight times. We compared the difference between two groups about age, the ratio of male to female, the size of the tumor, and serum values of thyroglobulin. There was no difference between two groups about these indicators. The average duration required to be diagnosed as PTC by FNAB was 26 months (6~54 months).

【Conclusion】In most cases of PTC, only one FNAB was enough. However, it is sometimes required to repeat FNAB to obtain the definitive diagnosis for PTC. Our most difficult case was obtained a final diagnosis for PTC after the eighth FNAB following previous reports for benign tumor. Unfortunately we could not reveal the characteristics of the tumor in such a patient. Further improvement and refined techniques of FNAB are required in combination with the progress in the field of ultrasonography.

 

Nothing to Disclose: MA, MI, IH, TT, MS, SU, ET, YY, AK, AS

20257 2.0000 FRI-021 A The Accuracy and Effectiveness of Repeated Fine Needle Aspiration Biopsy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Jacob P Christ*1 and Eren Berber2
1Cleveland Clinic Foundation, 2Cleveland Clinic, Cleveland, OH

 

Background: Body weight has been found to associate with higher incidence of thyroid malignancy, as well as more advanced stages of disease. Whether this represents a true biological association, or is indicative of delays in detection of thyroid neoplasms remains unclear. Furthermore, the safety of thyroidectomy procedures among obese and overweight remains uncertain.

Objective: To determine the impact of body weight on the detection of thyroid nodules, prevalence and staging of thyroid malignancies, and surgical outcomes.

Methods: A retrospective chart review was completed consisting of patients undergoing primary thyroidectomy procedures at the Cleveland Clinic Foundation from 2004-2009.  Exclusion criteria included a history of previous thyroid procedures and concomitant procedures during thyroidectomy. Data on age, gender, BMI, mode of nodule detection, diameter of nodule, nodule symptoms, substernal extension of thyroid, surgery type, surgery time, incision size, duration of hospital stay, post-operative complications, surgical pathology, cancer staging, cancer extension and cancer recurrence was collected on 155 patients. Patients were classified based on BMI into normal weight (<25), overweight (25-30), obese (30-35) and severely obese (>35) as well as stratified by gender when assessing prevalence of malignancy. Analyses included univariable and multivariable linear regression, one-way analysis of variance, chi-squared, and Fisher’s exact tests. 

Results: Increased BMI associated with nodule diameter (β=.05, p=.007), incision size (β=.12, p<.0001), surgery time (β=.02, p=.002) and duration of hospital stay (β=2.24, p=.002). BMI was associated with presence of nodule symptomology (χ2=9.1, p=.03) and gender (χ2=14.9, p=.002) but did not associate with perioperative complications or type of pathology (p>.05). Among men alone, lower BMI category associated with increased prevalence of malignancy (p=.045). Furthermore, compared to those with thyroid growths detected during routine physical exam, BMI was higher among those with detection by self-exam (p=.045) and trended towards being increased among those with detection incidentally found on imaging (p=.064). Increased BMI and female gender independently predicted longer surgery time in our model (p<.05).

Conclusions:  Thyroid nodules are less amenable to detection by physical exam in obese patients, and hence these patients present more frequently with symptomatic large nodules.  Thyroidectomy is more challenging in this patient population, requiring larger incisions, longer operative time and hospital stay.  Nevertheless, the perioperative morbidity and rate of thyroid malignancy is similar to non-obese patients.  These results demonstrate that thyroid nodules in obese patients require increased attention from physicians for both screening of thyroid disease and perioperative management.

 

Nothing to Disclose: JPC, EB

21910 3.0000 FRI-022 A The Impact of Obesity on the Management of Thyroid Nodules 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Athanasios Bikas*1, Kenneth Burman2, Sameer Desale3, Mihriye Mete4, Leonard Wartofsky2 and Douglas Van Nostrand2
1MedStar Georgetown University Hospital, Washington, DC, 2MedStar Washington Hospital Center, Washington, DC, 3Medstar Health Research Institute, Hyattsville, MD, 4MedStar Health Research Institute, Hyattsville, MD

 

Introduction: Dosimetry is used to determine the maximum tolerated activity (MTA) of 131I for the treatment (tx) of metastatic differentiated thyroid cancer (DTC). It is well established that 131I tx can result in hematopoietic toxicity. The natural course of the effects of 131I on bone marrow over time has not been extensively studied.

Objective: To evaluate the frequency and severity of bone marrow suppression after administration of dosages of 131I based on MTA calculated by dosimetry.

Methods: 
A retrospective analysis was performed on 152 patients with DTC who had 185 dosimetry-guided 131I tx. Repeated measure ANOVA was used for the analysis of the differences in the averages of complete blood counts (CBC) that were documented at baseline, 1, 6, 12, 24-36 and 48-60 months (mo) post-131I tx. Univariate and multivariate analyses of the relationships of the differences with multiple factors were performed.

Results: 
All parameters demonstrated the same time pattern of response to 131I tx: they decreased to a minimum value at 1mo and then they gradually returned towards baseline values. White blood cells (WBC) and platelets (PLT) were the most significantly affected cells. At 1mo the decrease was 29.6% (p<0.0001) for WBC and 25% (p<0.0001) for PLT, while at 12mo the decrease was 15.6% (p<0.0001) for WBC and 13% for PLT (p<0.0001). The decrease remained significant even at 24-36 mo post tx [5.6% (p=0.017) for WBC and 9.5% (p<0.0001) for PLT], but it was not clinically significant. Lymphocytes appeared to be more susceptible to 131I effects than neutrophils as the decrease was 46.6% (p<0.0001) vs. 23.6% (p<0.001) at 1mo, and 19.7% (p<0.0001) vs. 14.4% (p<0.0001) at 12mo. Despite reaching statistical significance at all time points up to 24-36 mo, the decrease was rather small in absolute numbers for red blood cells (RBC), hematocrit (Hct) and hemoglobin (Hb) not surpassing 10%. The multivariate analysis demonstrated no association between the differences from baseline as noted above and the dosage of 131I or the cumulative dosage of 131I. However, the decrease at 1mo was significantly associated with an increase in the ratio of dosage-to-MTA for WBC (p=0.0016), Hb (p<0.0001), Hct (p<0.0001), and RBC (p<0.0001). The ratio dosage-to-MTA also correlated with the decrease at 12mo in WBC (p=0.001) and ANC (p=0.0063).

Conclusion: 
This study extensively evaluated the effects of dosimetry-guided 131I treatment on bone marrow at multiple time points over 4-5 years. The results demonstrated that a statistically significant decrease in CBC (especially WBC and PLT) after 131I tx occurred, and followed a distinct time-pattern.  These observations may help identify potential risks to the bone marrow when subsequent 131I treatments are given at closer intervals.  Future study is warranted to evaluate the utility of the ratio of dosage-to-MTA in predicting decreases in CBC parameters from dosimetry-guided 131I treatments.

 

Nothing to Disclose: AB, KB, SD, MM, LW, DV

21946 4.0000 FRI-023 A Effects of Dosimetry-Guided 131I Therapy for Metastatic Differentiated Thyroid Cancer on Complete Blood Counts 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Debora Lucia Seguro Danilovic*1, Gilberto Castro Jr2, Marco Aurelio Kulcsar2, Manuel Caetano Ferreira Maia2, Fernanda Amarante Bonani2, Suemi Marui3 and Ana O Hoff1
1Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 2Instituto do Cancer do Estado de Sao Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 3Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

Introduction: Total thyroidectomy, radioactive iodine and TSH suppression are the mainstay treatment of differentiated thyroid carcinomas (DTC). Treatment of metastatic DTC is complex and can include surgery when feasible, 131I therapy and external beam radiotherapy. However, a few cases of metastatic carcinomas progress despite 131I treatment and therapy with tyrosine-kinase inhibitors has been studied with promising results. Tyrosine-kinase inhibitors block molecular targets involved in the pathogenesis of thyroid cancer. Locally aggressive initial presentation of DTC is rare;, however, when neck disease is unresectable, traditional therapy, especially radioiodine treatment, becomes unfeasible. We report a case of unresectable papillary thyroid carcinoma at presentation treated with sorafenib.

Clinical case: A 20 yr-old male presented with an increasing cervical mass for 4 years and dyspnea for 6 months. CT scans revealed nodular heterogeneous hypo-attenuating thyroid enlargement with calcifications causing severe tracheal stenosis and  compression of internal jugular veins, besides conglomerates of metastatic cervical lymph nodes and  multiple pulmonary nodules, up to 1 cm. Although unresectable thyroid disease, tracheostomy and left neck dissection were performed and intraoperative thyroid biopsy confirmed papillary thyroid carcinoma. Sorafenib was introduced and permitted considerable neck disease reduction for 1 year. Total thyroidectomy and bilateral neck dissection became feasible. Pathology report was diffuse sclerosing papillary carcinoma, multifocal, with gross extra-thyroidal invasion and 13 out of 38 metastatic lymph nodes (T4N1bM1). External beam radiotherapy was indicated due to residual tracheal lesion and Radioiodine therapy will complete the traditional DTC therapy.

Conclusions: Sorafenib has been recently approved by the FDA for the treatment of progressive radioiodine refractory metastatic DTC. We described a case of an unique use of sorafenib in an unresectable locally advanced DTC, which provided neck disease reduction not only improving obstructive symptoms but also making surgical and posterior radioiodine treatments feasible. Sorafenib represents a potential neoadjuvant therapy in aggressive DTC.

 

Nothing to Disclose: DLSD, GC, MAK, MCFM, FAB, SM, AOH

21468 5.0000 FRI-024 A Potential Role of Sorafenib As Neoadjuvant Therapy in Unresectable Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Inderpreet K Dardi*1, Lindsay Ann Bischoff1, Colette Hyatt2, David Cognetti1, Madalina Tuluc1, Charalambos C Solomides1, Edmund Pribitkin1 and Jeffrey L Miller1
1Thomas Jefferson Medical College & University Hospitals, Philadelphia, PA, 2Crozer Regional Cancer Center, Upland, PA

 

Anaplastic Thyroid Cancer in the setting of Lynch Syndrome with MSH-6 gene mutation: A case report of an unusual association

Introduction: Lynch Syndrome (also known as Hereditary Nonpolyposis Colorectal Cancer) is an autosomal dominant inherited disorder caused by germline mutation in one of the several DNA mismatch repair (MMR) genes, commonly MLH1 & MSH2, less frequently MSH6 & PMS2. A mutation in the MMR gene results in a defective DNA mismatch repair. Lynch syndrome is characterized by a high risk of developing colorectal cancer and multiple extra-colonic malignancies, typically neoplasms of endometrium, ovary, upper urinary tract, stomach, pancreas & small intestine. Multiple cancers arising at an early age are hallmarks of Lynch syndrome. Thyroid cancer is not considered to be a part of the traditional Lynch syndrome tumor spectrum.

 Clinical Case: We describe an unusual case of a 54 year old male diagnosed with Lynch syndrome who developed anaplastic thyroid cancer. Routine colonoscopy at age 54 revealed two separate loci of colon cancer, one in the cecum and the other in the proximal transverse colon. Within a month of diagnosis of colon carcinoma, he noticed a rapidly growing neck mass with FNAB findings concerning for poorly differentiated thyroid cancer. He underwent total thyroidectomy which revealed 8.2 cm undifferentiated (anaplastic) thyroid cancer. Patient had significant family history of Lynch syndrome associated cancers on his maternal side. His mother was diagnosed with endometrial cancer at the age of 40. The proband in the family was patient’s eldest sister who died from complications of inoperable adrenal cancer at age 56. Patient’s other older sister was treated for both thyroid and colon cancer in the past. On genetic testing, our patient was found to be heterozygous for the c.3312dupT pathogenic mutation (also known as c.3312insT) in the MSH6 gene which was previously identified in the patient’s affected family members. Immunohistochemical staining of thyroid carcinoma showed lack of expression of MSH6 protein suggestive of a deficient DNA mismatch repair function. This immunoprofile is consistent with a Lynch syndrome related malignancy.

 Conclusions: MSH6 gene mutations tend to result in an attenuated Lynch syndrome, which has an older age of onset. Although the risk of certain cancers including thyroid cancer is not significantly increased in Lynch syndrome, incidental cases of a growing range of tumor types have occasionally been reported in literature. Our patient with Lynch syndrome had colon cancer and anaplastic thyroid cancer and both carcinomas showed absent MSH-6 mismatch repair gene, thus suggesting that thyroid neoplasm in this patient was not coincidental but developed as a result of a germline defect in MSH6 gene.

 

Nothing to Disclose: IKD, LAB, CH, DC, MT, CCS, EP, JLM

18626 6.0000 FRI-025 A Anaplastic Thyroid Cancer in the Setting of Lynch Syndrome with MSH-6 Gene Mutation: A Case Report of an Unusual Association 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Frances E Carr*1, John P. Hanley2, Erin Jackson3, Leslie A Morrissey2, Donna M Rizzo2, Brian L Sprague4 and I. Neil Sarkar4
1University of Vermont College of Medicine, Burlington, VT, 2University of Vermont School of Engineering, 3University of Vermont, 4University of Vermont College of Medicine

 

The incidence of thyroid cancer has been increasing at an annual rate of 3-5% resulting in a near doubling in the past 30 years making thyroid cancer the most rapidly increasing endocrine malignancy. Reasons for this increase have not been established. With the capability to visualize, analyze, interpret and map geo-located data, geostatistics and the GIS tool have emerged as a powerful geospatial technology gaining prominence in healthcare applications including GIS-based cancer mortality maps. Spatial statistical analyses have recently been used to identify spatial disease clusters, map disease patterns and trends, and assess the impact of ecological and socioeconomic factors on the spatial distribution of diseases to identify new drivers of public health concerns. In the present study, we used geospatial and temporal analysis as well as logistic regression to analyze thyroid cancer incidence in a rural population. We found that thyroid cancer incidence rates increased significantly in Vermont (8.0 per 100,000) comparable to the national rate (8.4 per 100,000) however with a higher estimated annual percentage change (APC) of 8.3 compared with 5.7 for the U.S. The ratio of incidence was 3.1:1 females to males and mortality rate at 0.5 per 100,000 cases, similar to national estimates. The highest age-adjusted incidence for females peaked at 30-59 reflecting a significant rise from 2001 to 2007, while the incidence for males did not vary significantly by age. Distribution of tumors by size for both females and males did not vary over time; <1.0, 1.1-2.0, >2.0 cm represented 38%, 22%, 40%, respectively. Papillary thyroid cancer (PTC) accounted for 89% of the incidence for females followed by follicular (FTC) 8%, medullary (MTC) 2% and anaplastic (ATC) 0.6% while PTC represented 77%, FTC 15%, MTC 1% and ATC 3% in males.  A significant negative correlation was found for the county age-adjusted rates and the number of physician practices who participate in the Vermont Department of Health’s Vaccines for Children program per 100,000 people, although no significant relationship was observed for the age adjusted rate per county for the number of primary care physicians per 100,000 people nor the percent of people with health insurance. Thyroid cancer incidence Hot Spots did not correlate with urban centers or health care centers. The geospatial analysis revealed locations and spatial patterns, that when combined with multivariate incidence analyses, indicated that factors other than increased surveillance and access to health care contribute to the increased thyroid cancer incidence.  These data provide evidence of an increase in thyroid cancer incidence in a rural population likely due to environmental drivers and socioeconomic factors. The geospatial modeling provides a method for identifying cancer Hot Spots provides an important framework for evaluation of additional associative risk factors.

 

Nothing to Disclose: FEC, JPH, EJ, LAM, DMR, BLS, INS

21262 7.0000 FRI-026 A Geospatial and Temporal Analysis of Thyroid Cancer Incidence in a Rural Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Shilpa Deshmukh*1, Vinuta Mohan2 and Tasneem Zahra3
1Lincoln Medical Center, New York, NY, 2Lincoln Medical Center, 3Lincoln Medical Center, Roslyn Heights, NY

 

INTRODUCTION: Sertoli leydig cell tumors (SLCT) are extremely rare tumors which account for about 1% of sex cord stromal tumors and less than 0.2% of all primary ovarian neoplasms. A few cases in literature describe the occurrence of SLCT along with thyroid adenoma. There is one case reported about SLCT occurring with papillary thyroid cancer. We here describe the second case where SLCT was found in a woman with history of papillary thyroid cancer.

CASE: 41 year old female was seen in endocrine clinic for hirsutism.  Patient complained of having excess facial hair requiring her to shave every day, excess body hair, balding, facial acne and hoarseness of voice. She had noticed these changes over the last 1-2 years. She had normal menstrual cycles. Past medical history was significant for papillary thyroid cancer treated with total thyroidectomy and I131 more than 10 years ago. Patient was taking 200 mcg of levothyroxine daily and denied using any other prescription or over the counter drugs.  On physical exam vitals were stable, BMI-34. Excess facial hair and male pattern baldness were noted. Cardiorespiratory and abdominal exam were normal. Pelvic exam showed clitoromegaly. Laboratory tests showed TSH- 2.56, total testosterone level of 543 ng/dl and free testosterone level of 129 pg/ml. DHEA- sulfate level was 189 microgram/dl. These values were repeated and confirmed. A pelvic ultrasound showed the right ovary measuring 4.3x2.9x4.5 cm. A solid vascular echogenic structure 3x3 cm with vascularity was noted in the right ovary. Abdominal CT scan was normal and adrenal tumor was ruled out. Our probable diagnosis was an androgen producing ovarian tumor most likely a Leydig cell tumor. Patient was referred to onco-gynecology and Laparoscopic right salpingo-oophorectomy and left salpingectomy were performed. Pathology report showed a well differentiated sertoli leydig cell tumor. Three months later the patient was seen in clinic. Her acne was clearing and repeat testosterone level was 21 ng/dl.

DISCUSSION: SLCT are usually seen in women in the age group of 30-50 years. They are unilateral in 98% of patients and associated with hyper androgenic symptoms. SLCT have a good prognosis and 5 year survival is 70-90%. Poorly differentiated tumors are associated with a worse prognosis. Surgical excision is the gold standard of treatment. It is generally believed that unilateral salpingo-oophorectomy is the treatment of choice in young women who wish to have children. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is considered for women who do not wish to preserve their fertility.

CONCLUSION: To our knowledge this is the second report of SLCT occurring in a woman with history of papillary thyroid cancer. This may suggest common etiology. Further studies are needed to find if any association exists between these 2 endocrine tumors.

 

Nothing to Disclose: SD, VM, TZ

18321 8.0000 FRI-027 A A RARE Case of Sertoli Leydig CELL Tumor Occurring in a Patient Treated for Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Patricia Papendieck*1, Ana Chiesa1, Marcela Venara2, Oscar Acha3, Hugo Cozzani4, Fernanda Matteos4, Silvana Maglio4, Maria del Lujan Calcagno5, Laura Gruñeiro-Papendieck4 and Ignacio Bergadá6
1Centro de Investigaciones Endocrinológicas Dr. César Bergadá - CONICET – ,, Buenos Aires, Argentina, 2Centro de Investigaciones Endocrinológicas Dr. César Bergadá, Buenos Aires, Argentina, 3Centro de Investigaciones Endocrinológicas Dr. César Bergadá - CONICET –,, 4Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina, 5University of Buenos Aires,, 6Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina

 

Introduction: Pediatric retrospective reported series of thyroid nodules (TN) are small and scarce.  In addition it is well known that malignancy risk of pediatric   TN is greater than in adults. Therefore, with the widely current diagnostic methods together with a good clinical perception as predictors of malignancy are needed.

Objective: to report a single center experience in the characterization and management of a prospectively and uniformly followed cohort of pediatric TN and to analyze the findings likely to differentiate malignancy prior to surgery.

Material and methods: We prospectively enrolled 75 patients <19 years referred to our Division (2008-2013). Initial evaluation included  clinical data, thyroid function, Doppler US, Tc99scan and US guided-FNAB cytology categorized with the Bethesda System for Reporting Thyroid Cytopathology. Surgery was indicated (n: 62) in those patients with one of the following:  a) FNAB results BIII-VI (n 26), b) FNAB BII, persistent or growing TN and predisposing risk factors or suspicious US findings of malignancy (n 23) c) non diagnostic FNAB (BI) and predisposing risk factors and/or suspicious US findings of malignancy and/or persistent or growing TN on follow up (n13).  Histology was evaluated. 13 patients did not fulfill surgical criteria and were followed every 3 months for a minimum of 2 years.  In these group if persistent, growing or changing lesions occurred US-FNAB was repeated. Retrospectively, the differences between benign and malignant TN were evaluated

Simple descriptive statistics, chi-squared test, univariate and multiple binary logistic regression analyses and ji-squared test for trend.of assesed variables were applied for analysis. Malignancy rate (MR) was calculated for each cytological B category in the operated group as well as  the Positive and Negative Predicted Values (PPV /NPV) for  BV-VI.

Results: Upon referral mean age was 14 years, 80% females, 87% pubertal and 86% were euthyroid. US showed a solitary nodule in 75%. Within operated patients (n 62)  papillary DTC was found as the only malignant lesion (22.6%) (18.5% of the whole cohort).TSH >2.5mUI/L (p<0.04), Multinodularity (MNG) (p<0.01), solid nodules, irregular margins and pathologic lymphadenopathies (p<0.01) were significantly associated with cancer. MR for each B category was in BI: 15.4%, BII: 4.3%, BIII: 14.3%, BIV: 0%, BV: 50% and BVI:100%.  PPV and NPV of BV-VI for cancer were 75% and 92% respectively.

Conclusions: With the complete assessment of 75 pediatric patients with TN our results confirm the elevated prevalence of thyroid cancer. TSH >2.5mUI/L, MNG, solid nature, irregular margins and pathologic lymphadenopathies as well as  BV-VI FNAB results were predictors of malignancy. Therefore, the collection of all the data, and not just one or a few, is important to establish the malignancy risk and choose the best therapeutic strategy for each patient.

 

Nothing to Disclose: PP, AC, MV, OA, HC, FM, SM, MDLC, LG, IB

18785 9.0000 FRI-028 A Prospective Evaluation of Pediatric Thyroid Nodules: Searching for Cancer Predictors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Shira B Eytan*1 and David Bleich2
1Rutgers University New Jersey Medical School, Newark, NJ, 2UMDNJ-NJ Med School, Newark, NJ

 

Introduction

Follicular thyroid cancer is the second most common thyroid cancer, and is a well differentiated malignancy. It is usually slow growing, with distant metastasis occuring via hematogenous route. Bone and lung are the two most common locations of distant metastasis. However, there have been very few reported cases of occult malignancy presenting as a massive metastatic lesion to the calvarium. We report an interesting case of follicular thyroid carcinoma first presenting as a massive skull mass.

Case Presentation

A 79 year old woman presented to her primary physician with a rapidly enlarging right frontoparietal skull mass. CT scant of the head showed a 13.6cm x 13cm soft tissue mass replacing both frontal bones, the anterior right parietal bone, and anterior right temporal bone, causing mild mass effect on both frontal lobes. She then underwent a CT angiogram and venogram of the head, which showed large arteriovenous feeder vessels to the mass and significant hypervascularity. Metastatic workup revealed a 1.4cm right calcified thyroid nodule. She underwent preoperative embolization of the feeder vessels and then had a staged bilateral bifrontal craniectomy to resect the tumor. The first surgery resulted in hemodynamic instability requiring 10 units of packed RBC transfusion and 8 units of fresh frozen plasma. The second craniectomy was successfully completed two days later. Pathology revealed typical appearance of a follicular carcinoma of the thyroid, including positive immunostaining for TTF-1 (thyroid transcription factor 1) and thyroglobulin.

A week later, she underwent total thyroidectomy, with pathology showing a unifocal right 1.5cm follicular thyroid carcinoma, with vascular invasion and no lymph node involvement (pT1b N0 M1).  Six weeks later, she  received adjuvant therapy with 195 mCi I-131, and her post therapy scan showed multiple areas of uptake in the skull and a small focus of uptake in the left lower frontal region. Thyroglobulin level was 893 ng/mL with negative thyroglobulin Ab at this time. She is currently on levothyroxine suppressive therapy and feels well. 

Conclusions

Skull metastasis occurs in only 2.5% of cases of follicular thyroid cancer. It is even more rare for the lesion to be of such a large size, and to be the first presentation of thyroid cancer. It is important for clinicians to recognize that even a small primary thyroid cancer can present with massive distant metastasis.

 

Nothing to Disclose: SBE, DB

21517 10.0000 FRI-029 A Follicular Thyroid Cancer Presenting As Massive Skull Metastasis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Juan Carlo Pascual Dayrit*1, Elaine Cheeay Cunanan2 and Sjoberg Ang Kho3
1University of Sto. Tomas Hospital, Manila, Philippines, 2University of Sto. Tomas Hospital, Quezon City, Philippines, 3University of Santo Tomas Hospital, Manila, Philippines

 

Hyponatremia in hypothyroidism has been encountered in clinical practice, seen either symptomatically or incidentally among hypothyroid patients. Severe hyponatremia in hypothyroid patients have been noted after withdrawal of thyroid hormones together with low iodine diet. The prevalence of hyponatremia (serum Na <135mEq/L) on short-term uncomplicated hypothyroidism has been noted at 3.9%.1 In patients with thyroid cancer, 6 to 8 cases of symptomatic hyponatremia were associated with 131Iodine preparation-induced hypothyroidism.2 Case reports of life-threatening hyponatremia developing in hypothyroid patients have been reported, either due to post-surgical hypothyroidism or levothyroxine withdrawal; however, its prevalence has not been well established in this population. Routine serum Na levels are not done in these patients prior to RAI therapy. With several reports of unforeseen life-threatening neurological complications in this population, the need to investigate degree of hyponatremia in relation to duration of hypothyroidism and TSH level is realized.  This study aimed to determine the prevalence of hyponatremia in hypothyroid and salt-deprived patients with well differentiated thyroid cancers.

This cross-sectional study included 59 patients diagnosed with well-differentiated thyroid cancer, rendered hypothyroid after surgery and levothyroxine withdrawal, and who are for RAI ablation. Serum sodium (Na) was extracted on 3 occasions: when the patient was euthyroid and before salt deprivation (baseline); after RAI ablation; and after hydration with 3- 4 liters of water. TSH levels was determined to assess adequate levels prior to RAI and to document elevated TSH >25uIU/L (N: 0.27 – 4.2 uIU/L). The degree of hyponatremia (serum Na <135mmol/L) was correlated with the clinical symptoms of the patient. The outcome measures were to determine the prevalence of hyponatremia among patients on low iodine diet, after RAI ablation and after oral hydration post-RAI. 

Preliminary results included 9 patients, with ages from 23 to 56 years old (mean: 39 ± 11), with female preponderance (7:2). TSH values at baseline were 36.7 - 100 uIU/L; mean 56.7 ± 20.9. Serum Na levels at baseline (1), after RAI (2), and after hydration (3) were as follows: (1) 135-143 mmol/L, mean 138 ± 3; (2) 136-142 mmol/L, mean 138 ± 2; and (3) 135-141 mmol/L, mean 138 ± 2. Only 1 patient (11.1%) had mild hyponatremia (135mmol/L) at baseline, before salt deprivation; no patient was hyponatremic after RAI ablation; and 1 patient (11.1%) had mild hyponatremia (135mmol/L) after hydration. No hypnatremic symptoms were observed. There was no correlation between TSH levels and serum Na levels at baseline (r = -0.001).

In this study, the prevalence of hyponatremia in hypothyroid, salt-deprived patients is low at 11.1%. No patient developed hyponatremia after RAI ablation.

 

Nothing to Disclose: JCPD, ECC, SAK

21829 11.0000 FRI-030 A The Prevalence of Hyponatremia in Hypothyroid, Salt-Deprived Patients during Radioactive 131IODINE Ablation for Well-Differentiated Thyroid Cancer: A Cross-Sectional Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Ma. Conchitina Manas Fojas*1, Ming Jin2 and Fadi Nabhan1
1The Ohio State University, Columbus, OH, 2The Ohio State Univeristy

 

Introduction

Anaplastic Thyroid Carcinoma (ATC), seen in about 3.8% of thyroid malignancies, carries the worst prognosis. Despite advances, the median survival of 3-5 months following diagnosis, has not improved in over 50 years.  The diagnosis is based on clinical presentation, suspicious USG findings and FNAB. Some studies have suggested cytological accuracy for diagnosing anaplastic carcinoma, to be as low as 50%. Timing and type of treatment varies tremendously, should the diagnosis be made. 

Case

A 60-year-old male presented with dysphagia of 6 months duration and a rapidly enlarging neck mass for the past 2 month.  Work up revealed normal TSH and ultrasound revealed a 5.3 cm left solid heterogeneous, hypoechoic mass with irregular border.  US-guided FNAB was suspicious but not diagnostic of Anaplastic Thyroid Carcinoma. CT of neck/chest/abdomen and pelvis was negative for conclusive evidence of metastases.  He then underwent total thyroidectomy and the histopathological diagnosis was consistent with Hurthle Cell carcinoma.

Discussion:

ATC has a rapidly fatal course. Patients commonly present with enlarging neck mass, often manifesting with signs of airway compression. It usually presents later in life and is more common in women. Cytologically, these tumors have pleomorphic giant or spindle cells with multilobulated, single or multiple nuclei. Findings of clumped chromatin pattern and prominent parachromatin clearing, multiple prominent nucleoli, and hyperchromasia enhance sensitivity.   The differential diagnosis includes metastatic poorly differentiated carcinoma, melanoma, Hurtle cell carcinoma, insular carcinoma, and medullary carcinoma. In our patient, while the cytological findings were suspicious for ATC, there were other clues against this diagnosis such as the clinical course, which was not as rapid as expected in patients with ATC. Furthermore, while the thyroid mass was significantly large, there were no obvious nodal involvement or distant metastases, and the patient did not fit the age group of ATC.  The final pathological diagnosis was Hurthle Cell Carcinoma. This case highlights the challenge diagnosing ATC cytologically and the importance of integrating the other clinical and imaging findings in making the diagnosis.

 

Nothing to Disclose: MCMF, MJ, FN

19988 12.0000 FRI-031 A A Case of Cytological Uncertainty in the Diagnosis of Anaplastic Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Laura Banks1, Patricia Liu2, Victor Tsirline1, Vanessa Williams1, Elise Saddleton1, Erin Neuschler1, Anthony Yang1, Cord Sturgeon1 and Dina M Elaraj*1
1Northwestern University Feinberg School of Medicine, 2University of Wisconsin Madison

 

Background Thyroid nodules 4 cm or greater in diameter have been associated with a higher false negative rate on fine needle aspiration (FNA) biopsy than smaller thyroid nodules. Thyroidectomy has been recommended for definitive diagnosis on the basis of size alone. We hypothesized that FNA is reliable for nodules ≥ 4 cm in diameter. Methods We retrospectively reviewed the clinical data of patients who underwent thyroidectomy for the indication of a thyroid nodule ≥ 4 cm from 2007-2012 at a single institution. All patients underwent FNA biopsy of the nodule under ultrasound guidance. Patients with an insufficient FNA biopsy specimen or clearly malignant lesion by FNA biopsy were excluded from analysis. A thyroid nodule with an FNA result that was negative for malignancy but a final pathology of follicular or H¨¹rthle cell adenoma was considered to be a "false negative/missed follicular neoplasm" result. Sensitivity and specificity of FNA for the detection of neoplastic or malignant lesions was determined. Results 393 patients (292 female) with 403 nodules met our inclusion criteria. Preoperative FNA biopsies were categorized as negative for malignancy (n=256; 63.5%), indeterminate (n=144; 35.7%), 54 of which were neoplasms, and suspicious for malignancy (n=3; 0.8%). Final pathology of the index nodule was benign in 384 patients (95.3%), 139 of which were follicular/H¨¹rthle cell adenomas and malignant in 19 patients (4.7%). FNA performance: true negative n=199 (77.7%), false negative/papillary thyroid cancer n=1 (0.4%), false negative/missed follicular neoplasm n=56 (21.9%), true positive n=101 (68.7%), false positive n=46 (31.3%), sensitivity 63.9%, specificity 81.2%, PPV 68.7%, and NPV 77.7%. All of the missed follicular neoplasms on FNA were benign on final pathology. Conclusions The malignancy rate of thyroid nodules ≥ 4 cm is not different than the accepted malignancy rate for smaller thyroid nodules. Missed thyroid cancers on FNA biopsy were rare, but the rate of missed follicular neoplasms in this study was high (21.9%). Although all of the missed follicular neoplasms in this study were benign on final pathology, the high rate of missed follicular neoplasms on FNA biopsy of thyroid nodules ≥ 4 cm supports the current practice of recommending thyroidectomy for these nodules.

 

Nothing to Disclose: LB, PL, VT, VW, ES, EN, AY, CS, DME

21400 13.0000 FRI-032 A False Negative Cytology in Thyroid Nodules Greater Than 4 Cm Is Due to Missed Follicular Neoplasms 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Pablo F Florenzano*1, Francisco J Guarda2, Rodrigo Jaimovich3, Antonieta Solar3, Lorena M Mosso2, Claudia Campusano2 and Jose Miguel Dominguez1
1Pontificia Universidad Católica de Chile, Santiago, Chile, 2Pontificia Universidad Catolica de Chile, Santiago, Chile, 3Pontificia Universidad Católica de Chile, Chile

 

Introduction:The initial treatment of Differentiated Thyroid Cancer (DTC) includes surgery and selective use of radio-iodine therapy (RAI). There have been several reports on adverse effects associated with RAI, affecting up to 30% of patients, especially in higher dosages.

Patients and Methods: We designed an observational study to evaluate and compare the frequency of adverse effects of RAI after 6 months of administration in patients with DTC treated with total thyroidectomy, with or without different doses of RAI. All patients ≥18 years old with DTC treated in our institution in 2013 were invited to answer a survey on 13 adverse effects associated with RAI administration after 6 months of intervention. Intensity of symptoms was evaluated with a Likert scale. Statistical analysis was performed with SPSS 15® and Stata12®. Sixty patients (47%) of a total of 128 answered the survey 12±3.6 months after initial treatment.

Results: Mean age was  41.7±14.4 years  and 58 (96.7%) were women. Forty eight (80%) received RAI (median 75 mCi range 30-150mCi), 54.2% of patients were classified as low risk and 45.8% as intermediate risk of recurrence according to ATA risk classification. When we compared the presence of side effects between patients who received RAI and those who did not, periorbitary edema (35 vs 0%, p=0.015), sialadenitis (48 vs. 17%, p=0.04) and xerostomy (71 vs. 33%, p= 0.01) were different. These differences persisted when comparing patients who received less than 50 mCi with those who did not receive RAI. Frequency and intensity of adverse effects were not different between high and low doses of RAI (≤50 vs. ≥100mCi).

Conclusion: RAI administration was frequently associated with adverse effects that persisted after 6 months of administration, even when low doses were administered. This finding must be taken into account when deciding RAI administration, especially in patients with low risk stratification, in whom benefit is controversial.

 

Nothing to Disclose: PFF, FJG, RJ, AS, LMM, CC, JMD

21416 14.0000 FRI-033 A Radioiodine Administration Is Associated with Persistent Adverse Effects in Patients with Differentiated Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Barbara Gredysa* and Marie Catherine Gelato
Stony Brook University Medical Center, Stony Brook, NY

 

Introduction:

Papillary thyroid cancer is the most common type of differentiated thyroid cancer. It is usually diagnosed via fine needle aspiration of a thyroid nodule. Presence of distant metastases at the time of diagnosis is rare, ranging from 3-15%. The most common site of metastasis is cervical lymph nodes, lung and bones.

We are presenting an interesting case of a patient whose first manifestation of papillary thyroid cancer was metastatic disease in the spine.

Clinical case:

 A 63 year old female was initially referred to us in 1997 for evaluation of hyperthyroidism. She had anxiety, weight loss and night sweats. Her TSH was low, but T4 and T3 were in the normal range. On initial exam blood pressure was normal and pulse was 92 beats per minute. She had diffuse thyromegaly without palpable nodules and only small submandibular nodes were palpated. Her DTRs were brisk and she had fine tremor in upper extremities. She was restless. Propranolol and methimazole were started. I-123 thyroid uptake was 25 % at 24 hours. There was no evidence of cold or hot nodules.

Over years she developed osteoporosis which was treated with bisphosphonates. In October 2013 she presented to her PCP with new onset lower back pain. It radiated to right buttock and down the right leg. X ray was negative, but MRI showed compression fracture of L3 with expansive lesion at that level. Bone scan showed uptake at the level of L3, consistent with compression fracture of unknown etiology. She underwent spine surgery; pathology was consistent with papillary thyroid cancer, follicular type. Soon after that total thyroidectomy was performed and revealed multifocal bilateral papillary thyroid cancer, follicular variant. Three lymph nodes were removed from central compartment and they were negative for malignancy. External beam radiation was administered to the lesion in the lumbar spine followed by treatment with Xgeva with significant improvement in symptoms. Radioactive iodine ablation was followed by marked decrease in serum thyroglobulin level.

Conclusion:

This patient’s papillary thyroid cancer presented with distant metastasis – a spine lesion. It is an unusual presentation for this type of cancer, which most commonly is confined to the neck. It is also rare to see distant metastases without presence of lymph node involvement in papillary thyroid cancer. Early intervention and multidisciplinary approach resulted in excellent outcome in this patient. This case serves as a reminder that, although most often indolent in nature, papillary thyroid cancer can metastasize to distant organs and present in an unusual way.

 

Nothing to Disclose: BG, MCG

21565 15.0000 FRI-034 A Unusual Presentation of Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Pallavi Heda*1, Leo Tchong1 and Joel Oster2
1Lahey Hospital and Medical Center, Burlington, MA, 2Lahey Hospital and Medical Center

 

Background - Carcinoid tumours are neuroendocrine tumours derived from enterochromaffin cells. They typically arise from gastrointestinal tract and the bronchus, but can involve any organ. Neuroendocrine tumour metastasis to the thyroid gland is rare and metastasis to bones is even rarer. Metastasis to the thyroid gland may be difficult to differentiate from primary neuroendocrine tumours like medullary thyroid carcinoma. We report a rare case of pulmonary carcinoid metastatic to the posterior chest wall, bones, breasts, pancreas and thyroid.

Clinical Case - A 63 year old female presents with a history of pulmonary carcinoid status post left pneumonectomy and proton beam radiation to the eyes secondary to metastatic disease. She presented to our hospital with CT scans showing multiple metastatic lesions to the pancreas, breasts, chest wall and enlarged thyroid but with no significant symptoms. She presented to the Endocrinology department with a thyroid ultrasound showing non toxic multinodular goitre. Subsequent Fine needle aspiration biopsy was done which showed a low grade neoplasm with neuroendocrine features. The cells stained negative for calcitonin and positive for chromogranin. The staining profile confirmed the diagnosis of neuroendocrine tumour favouring a diagnosis of carcinoid tumour. The negative calcitonin stain made the diagnosis of medullary thyroid cancer less likely. Therefore, thyroidectomy was not performed. Serum chromogranin A levels in the blood were in the range of 98-185 NG/ML. Subsequent octreotide scans showed uptake in breasts, calvarium, pancreas, thyroid and chest wall. Despite significant metastasis, she remains asymptomatic.  She is currently on observation and is followed by regular octreotide scans and is doing well.

Conclusion: Thyroid nodules detected during follow-up of neuroendocrine tumour patients should be thoroughly investigated. A fine needle aspiration biopsy of the thyroid confirms the diagnosis in most cases and leads to appropriate management of those patients and may prevent unnecessary treatment approaches like thyroidectomy. The distinction between medullary thyroid cancer and calcitonin negative neuroendocrine tumour is important as treatment and prognosis differ.

 

Nothing to Disclose: PH, LT, JO

18439 16.0000 FRI-035 A A Rare Journey of Pulmonary Carcinoid Metastasizing to the Thyroid Gland 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Andrew M. Hinson*1, Arny A. Ferrando2, Bekka Wilkerson2, Brendan C. Stack Jr.1 and Donald L. Bodenner1
1UAMS, Little Rock, AR, 2University of Arkansas for Medical Sciences, Little Rock, AR

 

In a prior study, we demonstrated that canines could reliably discriminate between urine samples obtained from subjects previously diagnosed with either metastatic thyroid carcinoma (PTC) or benign thyroid disease1. In order to test the ability of canines to prospectively detect thyroid cancer in undiagnosed subjects, urine was collected (February 2014 to November 2014) from 59 subjects who presented to our thyroid clinic with > 1 thyroid nodule(s) suspicious for thyroid cancer. Prior to testing, a canine was imprinted with urine, blood and thyroid tissue obtained from multiple patients with PTC, and trained over 6 months to discriminate between PTC and benign urine samples. In the lab, a gloved handler, blinded to the sample status, presented each unknown sample in a 3-mL cryotube to the canine. The handler verbally communicated the canine’s alert (if PTC, the canine laid down) to a blinded study coordinator who recorded the response. Known control samples (both cancer and benign) were interspersed with the unknown samples and correct answers were rewarded with positive reinforcement. Only PTC (conventional type) (n=14) and benign thyroid disease (n=13) confirmed by final surgical pathology were included in the final analysis. The canine’s alert matched the final surgical pathology diagnosis in 24 out of 27 cases (92.3% correct, 2 false negatives and 1 indeterminate), yielding a sensitivity of 83.0% (10/12) and specificity of 100% (14/14).  Based on preliminary data, scent detection by trained canines serves as a noninvasive, inexpensive and highly specific adjunct to current diagnostic practices.

 

Nothing to Disclose: AMH, AAF, BW, BCS Jr., DLB

21210 17.0000 FRI-036 A Scent-Trained Canine Prospectively Detects Thyroid Cancer in Human Urine Samples 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Lakshmi Kannan*1, Young Nam Kim1 and Frederick Kim2
1Einstein Medical Center, Philadelphia, PA, 2Phillip Jaisohn Medical Center, Philadelphia, PA

 

A 76 year old female was found to have an incidental density in her lung on x-ray during routine preoperative evaluation for knee replacement. Bronchial brushing and endobronchial biopsy showed no evidence of malignancy and was read as inconclusive. She had a ten year history of hypothyroidism but was euthyroid with treatment. Thyroid peroxidase (TPO) antibodies were negative. Patient had a CT scan of the chest that confirmed the lung mass and also revealed enlargement of the left thyroid lobe. Fine Needle Aspiration Biospy (FNAB) of the thyroid showed diffuse large B cell lymphoma. FDG-PET CT scan was performed and it showed an enlarged, metabolically active thyroid gland with avid FDG uptake and bilateral cervical lymphadenopathy. The lung nodule was FDG-avid too. Patient was diagnosed with Stage IIE primary thyroid lymphoma and started on RCHOP chemotherapy. After four cycles of treatment a follow up PET-CT scan showed near complete response of the thyroid gland to treatment, with return to normal size and minimal residual disease in the left thyroid lobe. The lung nodule remained unchanged, indicating a possibly chronic, benign, lesion.

Primary thyroid lymphoma (PTL) is a rare, extranodal Non-Hodgkin Lymphoma (NHL) constituting less than 5% of thyroid malignancies and less than 2% of extranodal NHL (1). Chronic lymphocytic thyroiditis, also known as Hashimoto’s thyroiditis, is the only well known precursor of PTL. Here we describe a patient with autoimmune thyroiditis found to have primary thyroid lymphoma and a concurrent lung nodule. Patients with Hashimoto’s thyroiditis are at increased risk, about 60 times, as compared to the general population. Diffuse large B cell lymphoma is the most common subtype. FDG-PET scanning has been used recently in the differential diagnosis, including differentiating chronic thyroiditis from lymphoma (2);  staging of thyroid lymphomas and also to monitor response to treatment.  It plays a key role in detecting disease recurrence and restaging the disease and can help identify treatment resistance early on (3). In our patient PET-CT has been very helpful in staging the disease and monitoring treatment response. Further it has indicated that the lung nodule is possibly distinct from the thyroid pathology due to the differential response to treatment as compared to the primary thyroid lymphoma.

 

Nothing to Disclose: LK, YNK, FK

21025 18.0000 FRI-037 A Primary Thyroid Lymphoma and PET-CT- Role in Diagnosis and Management 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Tasha Kouvatsos*1, Mary Kate McCullen1, Adam Luginbuhl1, Nathaniel R Evans III1, Madalina Tuluc2, Edmund Pribitkin2 and Jeffrey L Miller2
1Thomas Jefferson University Hospital, Philadelphia, PA, 2Thomas Jefferson Medical College & University Hospitals, Philadelphia, PA

 

Introduction:

Thymic metastasis from any malignant carcinoma is rare. There have been approximately 6 cases of papillary thyroid carcinoma with thymic metastasis reported.  Here we describe an unusual case of a young female who underwent total thyroidectomy with pathology consistent with micropapillary thyroid carcinoma. In follow-up, the patient experienced rising thyroglobulin levels prompting further evaluation and was found to have metastatic papillary thyroid carcinoma in the thymus.

Case:

A 26 year old female without significant past medical history, family history, or exposure to radiation underwent total thyroidectomy at an outside hospital in November 2013. The pathology revealed a 0.7cm follicular variant papillary thyroid carcinoma of the left lobe without vascular or capsular invasion, two psammoma bodies in the lower right pole, two benign lymph nodes, and unremarkable thymus tissue. The patient was started on levothyroxine and referred to our institution in February 2014 with complaints of weight gain, fatigue, intermittent paresthesias and a newly diagnosed seizure disorder. Pertinent medications included levothyroxine 125mcg daily. Physical examination was unrevealing. Laboratory studies were remarkable for a TSH of 12 uIU/mL (n 0.450-4.500uIU/mL), anti-thyroglobulin antibodies (AbTgs) of <1.0 IU/mL (n <1.0 IU/mL) and a thyroglobulin (Tg) level of 121ng/mL (n 1.5-38.5 ng/mL).  Neck ultrasound demonstrated no identifiable thyroid tissue or adenopathy. Levothyroxine was titrated accordingly.   

In June 2014, repeat laboratory testing showed an increasing TG level to 416.7 ng/mL with negative AbTgs and TSH of 5.497 uIU/mL. Because of rising Tg, in August 2014, following thyroid hormone withdrawal, a whole body scan demonstrated two areas of radiotracer activity in the thyroid bed and mediastinum. Labs at that time were TSH of 42.71 uIU/mL, Tg 19,784 ng/mL and negative AbTgs. The patient received 100 mCi of I-131. A subsequent PET scan showed mild uptake (SUV max 2.14) within the anterior mediastinum corresponding to a 1.2 x 2.5 cm soft tissue density previously identified on the I-131 scan. Cardiothoracic surgery was consulted and the patient opted to proceed with anterior mediastinal mass resection which was completed in October 2014. The pathology was consistent with BRAF-negative intrathymic metastatic papillary thyroid carcinoma.

Conclusion:

This is an unusual case of a young female with micropapillary thyroid carcinoma who developed rising TG post-operatively and was found to have metastatic papillary thyroid carcinoma to the thymus.

 

Nothing to Disclose: TK, MKM, AL, NRE III, MT, EP, JLM

20758 19.0000 FRI-039 A Intrathymic Papillary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Karen T. Le*1, Mark W. Sawicki2, Marilene B. Wang3, Jerome M. Hershman4 and Angela M. Leung2
1VA Greater Los Angeles Healthcare System, Los Angeles, 2VA Greater Los Angeles Healthcare System, Los Angeles, CA, 3VA Greater Los Angeles Healthcare System, 4VA Greater LA Healthcare System, Los Angeles, CA

 

BACKGROUND:

Thyroid cancer is the most common endocrine malignancy and the most rapidly increasing cancer in the U.S.  Recent U.S data showed that the incidence of thyroid cancer increased by nearly threefold (from 4.9 to 14.3 per 100,000) between 1975 to 2009, in part due to improved methods of detection in the past few decades (1).  Thyroid cancer is more prevalent in women and in individuals with a history of ionizing radiation exposure and/or family history of thyroid cancer.  Little is known regarding the epidemiology and characteristics of patients with thyroid cancer within the national Veterans Health Administration (VHA) integrated healthcare system.  Agent Orange was a mixture of two herbicides (2,4,5-trichlorophenoxyacetic acid and 2,4-dichlorophenoxyacetic acid) used during the Vietnam War and contaminated by the toxin 2,3,7,8-tetrachlorodibenzodioxin (TCDD).  The aim of this study is to further understand the characteristics of thyroid cancer patients in the VHA population, particularly in relation to Agent Orange exposure. 

METHODS:

This is a descriptive analysis of the VA Corporate Data Warehouse database from all U.S. VHA healthcare sites from October1, 1999 to December 31, 2013.  Information was extracted for all thyroid cancer patients based on ICD-9 193 diagnosis codes; histological subtypes of thyroid cancer were not available.

RESULTS:

There were 19,592 patients (86% men, 76% White, 58% married, 42% Vietnam Era Veteran) in the VHA system with a diagnosis of thyroid cancer within this 14-year study period.  The gender-stratified prevalence rates of thyroid cancer among the Veteran population during the study period were 1:1,114 (women) and 1:1,023 (men), which are lower for women but similar for men, when compared to the U.S. general population in 2011 (1:350 for women and 1:1,219 for men) (2,3).  There was a significantly higher proportion of self-reported Agent Orange exposure among thyroid cancer patients (10.0%), compared to the general VHA population (6.2%) (p<0.0001).  Only 0.54% reported a history of ionizing radiation exposure.  The states with the highest number of thyroid cancer cases were Florida (n=1,694), California (n=1,684), and Texas (n=1,512).

CONCLUSIONS:

Thyroid cancer patients, in this sample, have a higher prevalence of self-reported Agent Orange exposure compared to the overall national VA healthcare patient population.  Additional research regarding the strength and consistency of this association may lead to a better understanding of the link between Agent Orange exposure and thyroid cancer within this group.

 

Nothing to Disclose: KTL, MWS, MBW, JMH, AML

19254 20.0000 FRI-040 A High Prevalence of Agent Orange Exposure Among Thyroid Cancer Patients in the National VA Healthcare System 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Jung Ah Lim*1, Young Shin Song2, Min Joo Kim3, Hoonsung Choi2, Tae Hyuk Kim2, Hye Sook Min2, Kyung Won Kim2, Young A Kim2, Ka Hee Yi2, Do Joon Park2 and Young Joo Park2
1School of Medicine, Eulji University, Seoul, Korea, Republic of (South), 2Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 3Korea Cancer Center Hospital, Seoul, Korea, Republic of (South)

 

In papillary thyroid cancer (PTC), the reported incidence of BRAF mutations is around 70~80% in Korea showing the highest rate all over the world. However, the frequency of RAS mutation or RET rearrangement, which is supposed as the next frequent mutation, is still not known exactly. The purpose of this study was to elucidate the prevalence of RET rearrangement or RAS mutation in PTC in this BRAF-V600E-prevalent area and its clinical implication.

We reviewed 413 PTC cases who underwent total thyroidectomy at Seoul National University Hospital between 2009 and 2012. RAS point mutations or RET rearrangements in the postoperative FFPE (formalin-fixed, paraffin-embedded) samples were assessed by using direct sequencing or FISH (fluorescent in situ hybridization) respectively.

RAS point mutations were shown in  6.2% of PTCs, consisting of 16 N-RAS 61 (73%), 3 N-RAS 12/13(14%), 2 K-RAS 12/13 (9%) and 1 H-RAS 61 mutations (4.5%). RET rearrangements were investigated only in BRAF wild-type cases (n=171), and its prevalence was 8.8% of BRAF wild-type PTC, and the predictive prevalence among all PTC was 2.6%. RAS mutations and RET rearrangements were mutually exclusive. RAS mutation was significantly more common in follicular variant PTC than in conventional type (29.2% vs 2.8%, p<0.001). Among all type of PTC, the prevalence of conventional type was 80.1% and that of follicular variant type was only 14.8%. On the contrary, from the recent reports in United States, classic PTC was 36.3% and follicular variant type was 56.6% respectively. Compared with the recent reports of US, low frequency of RAS mutation in our study is primarily due to low prevalence of follicular variant type in Korea. However, the low prevalence of RET rearrangement in our study (2.6%) was similar to that of recent US data (2%), irrespective of thyroid cancer type. Mean tumor size is significantly larger (1.9±1.5cm vs 1.2±0.8cm, p=0.027), but LN metastases and extrathyroidal extensions are less common in RAS mutant cancer (4.5% vs 40.2%, p=0.001; 27.3% vs 57.2%, p=0.006, respectively). There are no significant differences of clinicopathologic characteristics in RET rearranged cases compared with RET wild type cases.

The prevalence of RAS mutation in Korea was relatively low, due primarily to low proportion of follicular variant in all PTCs. The percentage of RET rearrangements also showed low, suggesting different etiologic factors in Korea, compared with other countries.

 

Nothing to Disclose: JAL, YSS, MJK, HC, THK, HSM, KWK, YAK, KHY, DJP, YJP

21666 21.0000 FRI-041 A Frequency of RET-Rearrangement and RAS Point Mutation of Papillary Thyroid Cancer and Its Clinical Significance in BRAF V600E-Prevalent Area 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Catherine Jameson1, Charalampos Lyssikatos2, Thomas H Shawker3, Maya Beth Lodish*4 and Constantine A Stratakis5
1NICHD, 2Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 3National Institutes of Health, 4National Institutes of Health, Bethesda, MD, 5National Institutes of Health (NIH), Bethesda, MD

 

Peutz-Jeghers Syndrome (PJS) is an autosomal dominant intestinal polyposis syndrome associated with an increased risk of developing malignancies in the breast, colon, pancreas, stomach, and ovary. Little research has been done into the relationship between thyroid abnormalities, thyroid cancer, and PJS; as of 2011, six cases of thyroid cancer had been reported in individuals with PJS (1). While a definitive connection between thyroid cancer and PJS has not yet been found, DTC is known to occur with a higher incidence in patients with other intestinal polyposis syndromes, including familial adenomatous polyposis and Cowden’s Syndrome. We retrospectively reviewed the medical records of 19 patients with confirmed PJS who had been seen at the National Institutes of Health (NIH), 3 F, 16 M, mean age at first evaluation 19.3 ± 13.3 years. A single radiologist reviewed all thyroid ultrasounds. The chi-squared test was used to compare the observed prevalence of thyroid abnormalities in the PJS cohort compared to what would be expected given population estimates. Six patients had multiple ultrasounds performed, median length of follow up was 7 years, range 2-9. Twelve had a confirmed STK11/LKB1 mutation. Fourteen out of 19 individuals with PJS had a thyroid abnormality on at least one ultrasound. Thyroid abnormalities included hypoechoic regions (7), nodules (5), cysts (4), regions of inhomogenous tissue (1), hyperechoic regions (1), and calcifications (1). In comparison to a generous population estimate of the prevalence of incidental ultrasonographic thyroid findings of 35.6% (2), the prevalence of 73.7% among our cohort is significantly higher (p=0.0006). Current screening recommendations for PJS do not include thyroid surveillance, although thyroid carcinoma is sometimes part of the clinical picture of intestinal polyposis syndromes. If thyroid abnormalities are, in fact, more prevalent in individuals with PJS than in the healthy population, appropriate screening and management could prevent progression to overt disease in affected patients.

 

Nothing to Disclose: CJ, CL, THS, MBL, CAS

19383 22.0000 FRI-042 A Incidence of Thyroid Abnormalities in Peutz-Jeghers Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Kristen Kobaly*1, Lawrence Q Wong2, Zubair Wahld Baloch2, Jill E Langer2 and Susan J Mandel3
1University of Pennsylvania, Philadelphia, PA, 2University of Pennsylvania School of Medicine, Philadelphia, PA, 3Perelman School of Medicine, University of Pennsylvania, Ardmore, PA

 

The ideal management of atypical/follicular lesion of undetermined significance (FLUS) thyroid cytology, which comprises up to 18% of FNAs (1), remains uncertain. FLUS is cytologically heterogeneous (2).  Studies demonstrate subsequent FNA may be benign. We sought to determine predictors of benign cytology on repeat FNA.

Retrospective review (2008-2012) identified 410 nodules with FLUS cytology and repeat ultrasound guided-FNA within 3.71 ± 1.26 months. Sonographic features including nodule size, echogenicity, composition, calcifications, presence of halo and border type were assessed. Based on cytomorphology, FLUS cytology was divided into subgroups: 1= follicular cell groups with increased cellularity, crowding and overlapping in a benign-appearing background (n=200), 2= follicular cell groups with crowding and overlapping in a scant specimen (n=106), 3= follicular cell groups with crowding and overlapping in a background of lymphocytic thyroiditis (n=56), 4=other (included focally present nuclear atypia, grooves and elongation in too small a quantity for a diagnosis of “suspicious for malignancy/malignancy” (n=48)).  Multivariable regression analysis evaluated predictors of benign cytology on repeat FNA. 

Repeat cytology was: benign 50%, follicular neoplasm 21%, FLUS 15%, suspicious for malignancy 7%, malignant 2%, nondiagnostic 5%.  In multivariable analysis of FLUS subgroups using group 2 as the reference, group 1 had a 71% higher odds of benign repeat cytology (OR 1.71,95% CI 1.04-2.82, p=0.04), whereas the other subgroups were not statistically different. Female sex (OR 1.62 95% CI 1.01-2.60, p<0.05) and absence of a halo (OR 1.63 95% CI 1.08-2.48, p=0.02) had increased odds of benign repeat cytology. Microcalcifications (OR 0.38, 95% CI 0.14-1.05, p=0.06) and nodule hypoechogenicity (OR 0.65, 95% CI 0.41-1.05, p=0.08) were less likely to be associated with benign repeat cytology. Nodule composition (solid v. other) and border (lobulated/irregular v. other) did not predict benign repeat cytology.  33 subjects had surgery following a second FLUS; 36% had thyroid cancer. Of these, 83% were PTC follicular variant and 17% were minimally invasive follicular carcinoma.

50% of repeat FNAs yielded a benign cytology diagnosis, allowing for nonoperative surveillance.  FLUS specimens with increased cellularity and focal nuclear overlapping and crowding in a benign appearing background were more likely to yield benign cytology on re-aspirate, perhaps reflecting the architectural heterogeneity of hyperplastic nodules. Microcalcifications and hypoechogenicity were less likely to be associated with benign repeat cytology. Absence of a halo predicted benign repeat cytology, which corresponds to the finding that malignant FLUS lesions were encapsulated tumors. Repeat FNA should be considered part of the management strategy of FLUS nodules.

 

Nothing to Disclose: KK, LQW, ZWB, JEL, SJM

21313 23.0000 FRI-043 A Predicting Benign Cytology on Repeat Fine Needle Aspirate of an Aus/Flus Thyroid Nodule 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Satoshi Ogasawara*1, Chihaya Maesawa2, Masahide Yamamoto3, Yutaka Usuki1 and Tomoyuki Masuda2
1Kojin Hospital, Morioka, Japan, 2Iwate Medical University, Yahaba, Japan, 3Yamamoto Clinic, Japan

 

Background; Anaplastic thyroid cancer (ATC) is one of the most aggressive neoplasms in humans, being rapidly fatal with a mean survival of 6 months after diagnosis. Generally, ATC is thought that the transformed form from differentiated thyroid cancer (DTC) or long-standing goiter (LSG).  This phenomenon is called “anaplastic transformation”. However, little is identified about the mechanisms of the transformation of DTC/LSG to ATC.
We have focused on calcified lesions observed often associated with ATC.  Although the relationship between DTC and calcified lesions are reported in detail on many articles, there is no study of the relationships between ATC and calcified lesions in detail.

Aim;We confirmed the relationship between ATC and calcified pattern, further clarify the importance of calcified lesions in anaplastic transformation by examining their pathology in detail.

Materials & Methods; A search for primary-ATC (no history of any treatment for thyroid neoplasm) over an 24-year period (1990-2013) from the surgical pathology files of our institution and affiliate hospitals yielded 42 cases.  Among them, 34 cases were confirmed the CT image.  A novel classification for calcifications in ATC on CT images was applied. The prevalence and patterns of calcification were classified, analyzed, and correlated with clinical and histopathologic findings. Furthermore, ATC patients undergoing thyroid operations or autopsy were reevaluated to identify the tumor tissue within the calcified lesion.

Result; Of the 34 patients, 30 (88%) had intrathyroidal calcifications identified on CT.  The calcified patterns observed with these 30 cases were as follows;Two (7%) of 30 were punctate calcification. Four (13%) of 30 were amorphous calcification. It was the calcification that 24 (80%) of 30 were peripheral calcification.
Among these 30 patients, we were able to check 24 (79.4%) about histopathology using a past fixed sample.  The microscopic views around the calcified lesion were observed and the existence of tumor thought to be the histology of the precedent lesion was confirmed with 13 of 24 cases. As for the contents, 5 cases were papillary thyroid cancer (PTC), and 8 cases were follicular tumor (FT).

Conclusion; These results suggest that a subset of ATCs is associated with  the lesion with calcification. When the pattern shows solitary Peripheral-calcification within the primary lesion, the risk of anaplastic transformation is high in this study.   The patients having Peripheral-calcification should be recommended carefully follow-up regardless of the result of cytologic findings.

 

Nothing to Disclose: SO, CM, MY, YU, TM

21751 24.0000 FRI-044 A Calcification within the Primary Lesion Should be Considered As an Origin of the Anaplastic Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Christian Helmut Pfob*1, Martina Erika Pfob2, Klemens Scheidhauer1, Markus Schwaiger1 and Gregor Weirich3
1TU München, Munich, Germany, 2Ludwig-Maximilians-Universität München, Munich, Germany, 3TU München, Munich

 

Objectives: PTC (papillary thyroid cancer), especially when associated with Hashimoto’s thyroiditis, exhibits activating point mutations of the BRAF–gene in most cases (70%), among which BRAF V600E is predominant (90%). In cases of advanced disease, mutation carriers may profit from targeted therapy by BRAF inhibitors, e.g. Vemurafenib. As the BRAF V600E mutation is not a feature of other thyroid neoplasia than PTC, mutation detection can be used as a diagnostic tool to define PTC on a molecular basis. Thyroid nodules with equivocal iodine uptake and ultrasound morphology are usually subjected to fine needle aspiration cytology (FNAC), which may encounter unresolved differentials, as well. To address this diagnostic dilemma with respect to PTC, we subjected stained smears or cell blocks to microdissection and allele-specific PCR for the detection of the BRAF V600Emutation. 

Methods: We performed 220 FNAC in 2013 in patients with hypofunctional or indifferent thyroid nodules with malignant aspects by thyroid image reporting and data system (TIRADS). One patient with known PTC was subjected to FNAC of a suspicious lymph node (LN). Among these 221 aspirates, cytology detected 38 samples with malignant or equivocal morphology. Of these, 16 samples with enough cell counts were subjected to molecular analysis using microdissection and PCR.

Results: The BRAF V600E mutation was detected in 5/16 samples (31 %). On a cytologic basis four mutation positive samples were suspicious for PTC (confirmed by surgery), one suspicious for a follicular neoplasia. The remainder 11 mutation-negative samples consisted of one PTC, four samples suspicious of follicular neoplasia, three samples suspicious of undetermined thyroid proliferation, accompanied by regressive changes in one sample. There was no BRAF V600Emutation in the LN aspirate with a suspicious cytomorphology.

Conclusion: The BRAF V600E mutation was detected in 5 of 6 PTC cytology samples. This high detection rate is probably due to the use of microdissection prior to PCR. This preliminary data shows, that the BRAF V600E PCR approach may therefore be helpful in the diagnostic workup of FNAC aspirates with questionable PTC cytomorphology. This method may also help to stratify PTC patients for a putative BRAF inhibitor therapy.

 

Nothing to Disclose: CHP, MEP, KS, MS, GW

22058 25.0000 FRI-045 A BRAF V600E Specific PCR in Aspiration Cytology of Thyroid Nodules 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Maria Joana Santos*1 and Maria João Bugalho2
1Hospital de Braga, Braga, Braga, Portugal, 2Portuguese Institute of Oncology, Lisbon, Portugal

 

INTRODUCTION: The 7th edition of the UICC TNM staging system defines papillary thyroid carcinoma (PTC) pT3 as a tumor >4 cm or a tumor with any size and minimal extra thyroidal extension (ETE). Thus, it includes 3 subgroups: A:>4cm, no ETE; B:≤4cm, with ETE; C:>4cm with ETE. Do these subgroups carry the same prognosis?

METHODS: Retrospective analysis of clinicopathological data of patients with PTC pT3, treated at IPOLFG between 2003-2008, identified through ROR-SUL and with a minimum follow-up of 2 years. Statistical analysis was performed using Excel and SPSS.

RESULTS: 282 patients were identified, 215 included. The distribution among the groups was: A (N=91), B (N=101), C (N=23). Most patients were female (80,0%); mean age at diagnosis was 49,9±16,5 years. All but one patient underwent total thyroidectomy; central and unilateral lymphnode dissections were more frequently performed in groups B and C (p<0,001). The classic variant of PTC was more frequent in groups B and C, whereas the follicular variant was more frequent in group A (p<0,001). Angioinvasion and lymphnode metastases were more frequent in groups B and C (p<0,001). 208 patients had at least 1 treatment with 131I (183 in adequate conditions). Mean follow-up duration was 6,2±2,1 years. At 2 and 5 years of follow-up, patients were classified according to evidence of disease: NED (no evidence); BED (biochemical evidence); SED-L and SED-D (structural evidence: locoregional/at distance).  After 2 and 5 years, the best outcome was observed in group A (NED:89%/87%) and the worst outcome in group C (NED:47,8%/45%) (p<0,001), having group B an intermediate outcome (NED 77%/64,9%) (p<0,001).

 CONCLUSIONS: pT3 papillary thyroid carcinomas constitute a heterogeneous group. Independently of tumor size, ETE is associated with a worse prognosis. The association of ETE and size >4cm seems to predict the worst outcome at 2 and 5 years of follow-up.

 

Nothing to Disclose: MJS, MJB

20286 26.0000 FRI-046 A Papillary Thyroid Carcinoma: One or Multiple Prognoses for pT3 Tumors? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Ana Mari­a Sequera*1, Marta Torres2, Patricia Otero1, Graciela Astarita2, Maria Paula Esteban2, Viviana Mesch3, Andrea Kozak2, Natalia Blanco2, Graciela Mosquera Filoso2, Isabel Teres2, María José Iparraguirre2, Mirta Gurfinkiel2, Patricia Pagano2, Monica Saavedra2 and Patricia Glikman2
1Argentine Society for Endocrinology and Metabolism, CABA, Argentina, 2Argentine Society for Endocrinology and Metabolism, Caba, Argentina, 3School of Pharmacy and Biochemistry, University of Buenos Aires, Argentina

 

Thyroglobulin (Tg) is a well recognized marker in the follow up of Differentiated Thyroid Cancer (DCT) patients for persistent disease, distant metastasis, or disease recurrence after thyroidectomy. Different clinical guidelines or consensus have set cut off levels for Tg without taking into account method-related differences.  Clinical utility of Tg is linked to the specificity (Sp), functional sensitivity (FS) and reproducibility of measurement method.

Aim: To compare 5 immunoassays for Tg in samples from DTC patients and quantify the differences between methods at clinical decision levels, analyzing their concordance and assessing their correlation with disease status.

Materials and methods: 136 samples from DTC patients (P) with negative thyroglobulin antibodies under follow-up after thyroidectomy were included. Recurrence or absence of disease was determined by TBS, Positron Emission Tomography (PET), Tg in fine needle aspirates, cytology or any complementary studies. We defined 4 groups (G) according to Tg (ng/ml), values obtained with Access method (lower FS): G1 (n=68): patients (P) with Tg: 0.30 -1.0, G2 (n= 20): Tg:1.1-2.0, G3 (n=29): Tg: 2.1-10.0 and G4 (n=18): Tg > 10.0.  Serum Tg was measured in aliquots from all samples by 5 immunoassays (methodology/FS): Access (ACC)/0.30, Cobas-Elecsys (CEl)/1.0; Immulite 1000 (IM1)/0.90; Immulite 2000 (IM2)/ 0.60 and RSR/1.0. For G2, G3 and G4, between-method differences were calculated as (Xi – M) *100/ M (M: mean of five methods, Xi: each method value). 

Results: Tg ranges (ng/ml) were: G1: ACC: 0.3-1.0; CEI:1.0-2.0; IM1:0.9-5.9; IM2: 0.6-6.9; RSR: 1.0-2.7. Patients (n=44) in G1 were categorized as disease-free according to studies already mentioned (37/44 P with Tg= FS value in all methods); G2=ACC: 1.1-2.0; CEI: 1.2-4.1; IM1:0.9-2.6; IM2: 0.6-3.4; RSR: 1.0-4.2; G3= ACC: 2.1-9.4; CEI:2.8-14.7; IM1:1.2-8.9; IM2: 1.6-11.0; RSR: 1.8-11.0. G4= ACC: 11.1-186; CEI: 15.1-290; IM1:7.9-174; IM2: 8.9-205; RSR: 10.5-190. The range of differences expressed in % were: G2=ACC: -49 to 18.3; CEI:-6.5 to 105; IM1:-61 to 35; IM2:-70 to 30; RSR: -18 to 52; G3= ACC:-32 to 3.0; CEI:-20 to 74; IM1: -58 to 3.0; IM2: -64 to 31; RSR: -27 to 126; G4= ACC:-33 to 14; CEI:-4.5 to 52; IM1: -30 to 3.1; IM2: -23 to 30; RSR: -19 to 22. Significant differences between methods were found in all groups (p< 0.01, Friedman, Dunn test). ACC showed a tendency to lower values of Tg, and levels reported by CEI were the highest in all groups.

Conclusions: The 5 immunoassays evaluated showed broad between-method differences of Tg level in the same patient’s sample, regardless of their disease status, both for low Tg values higher than method FS or Tg values over 1 ng/ml. 

We consider that the use of a unique cut off for Tg in DTC should be reviewed, as between-method differences could lead to different therapeutic approaches.

 

Nothing to Disclose: AMS, MT, PO, GA, MPE, VM, AK, NB, GM, IT, MJI, MG, PP, MS, PG

21026 27.0000 FRI-047 A Differences Between Five Assays for Thyroglobulin in Patients with Differentiated Thyroid Cancer: Is It Right to Use an Unique Cut Off? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Nini Thomas*, Michael L Gent and Mark Tulchinsky
Penn State Milton S Hershey Medical Center, Hershey, PA

 

Objectives: To determine the expected maximum thyroglobulin (Tg) levels at initial post-thyroidectomy evaluation in relationship with corresponding 24 hour Iodine-131 uptake (24HrIU) measurement in differentiated thyroid cancer (DTC) patients who had no evidence of residual disease (NERD) before ablation or on follow-up at one year.

Methods: All DTC patients referred for ablation on hormone withdrawal stimulation protocol in the past 3 years were reviewed. Excluded were patients with: 1) positive regional metastatic disease at surgery, 2) positive scan or thyroglobulin at one year follow-up, 3) suspicious ultrasound findings or any other indication for residual disease at one year follow-up evaluation, and 4) abnormal Tg antibody titer. Linear regression analysis of Tg (ng/mL) versus 24HrIU (% points) was performed.

Results: 43 patients (30 females) were included. The patients’ data (mean ± standard deviation) included age of 50.0±15.0 years (21-88), 24HrIU of 7.12±7.51 % (0.1-32.7), and Tg of 5.87±8.43 ng/mL (0.2-47.8). TSH ranged from 6.58 to >100 mcIU/mL (<35 in 6 pts, ≥35 to 100 in 19 pts, and >100 in 18 pts). The linear regression equation was Tg = 0.87(24HrIU) – 0.32 with r=0.776 and p < 0.0001. Two test equations ((24HrIU x 2) – Tg) < 1 or < 2 were analyzed for specificity (requires only cases without disease) of detecting remnant DTC. The 2 proposed equations rendered specificities (true negative cases) of 95.3% (41) or 97.7% (42), respectively.

Conclusion: There is a strong linear relationship between 24HrIU and Tg in DTC patients with NERD. Two simple equations were developed based on our cohort that should determine remnant cancer with specificity of over 95.3% or 97.7%. The sensitivity of these equations can now be tested in a different cohort of DTC patients with probability of residual tumor.

 

Nothing to Disclose: NT, MLG, MT

21538 28.0000 FRI-048 A Thyroglobulin Levels Relative to the 24 Hour Radioiodine Uptake in the Thyroid Bed May Help Identify Residual Disease Post-Thyroidectomy in Differentiated Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Yasemin Tutuncu*1, Nurdan Barca2, Bercem Aycicek Dogan3, Tuba Eyüpkoca4, Mazhar Muslum Tuna3, Dilek Berker3 and Serdar Guler5
1Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey, 2Ankara Numune Training and Research Hospital, Ankara, Turkey, 3Ankara Numune Education and Research Hospital, Ankara, Turkey, 4Ankara NumuneTraining and Research Hospital, Ankara, Turkey, 5Ministry of Health, Ankara Numune Training and Research Hospital, Turkey

 

Introduction:

                Breast growth and development require the coordinated action of many hormones, such as prolactin, estrogen, progesterone, adrenal steroids, insulin, growth hormone, and Thyroid hormones.THs are not essential for the development of the breast ducts; however, they appear to stimulate the development of the lobules of these glands. It is also thought that, in states of excess or lack of this hormone, the process may be negatively affected. For this reason we aimed to investigate the effect of made hypothyroidism for assessment of stimulated thyroglobulin in thyroid cancer patients on benign and malignant lesions of breast. 

Method:

                26 female patients with the diagnosis of thyroid cancer were included into the study between January 2013 and June 2013 in Ankara Numune Training and Research Hospital, Department of Endocrinology and Metabolism, Turkey.  Patients were assessed in terms of mastalgia, galactorrhea, benign and malignant lesions via ultrasonography after TSH values reached >30µIU/ml  and suppressed <0,1 µIU/ml  after L-thyroxin treatment. During ultrasonography BI-RADS scoring was used.

Results:

                Patients ages were between 26-66 years, and their average was 44.84±10.19 years. There was no difference in terms of galactorrhea and mastalgia between two groups (TSH>30 µIU/ml  and TSH<0,1 µIU/ml  ). No breast cancer was found in any patient. Three patients' (%11,53) BI-RADS scores were improved when TSH levels were lower than 0,1 µIU/ml  .

Discussion:

                The relationship between thyroid hormones and breast cancer  is a controversial topic. The topic was first addressed in 1896 when Beatson used thyroid extract as a treatment for breast cancer; however, some studies reported that thyroid hormones increased the risk of breast cancer. But further studies are needed with large sample size.  

 

Nothing to Disclose: YT, NB, BAD, TE, MMT, DB, SG

22166 29.0000 FRI-049 A The Relation Ship Between TSH Levels and Breast Lesions in Thyroid Cancer Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Pablo Valderrabano*1, Jeffrey Russell2, Kristen J Otto2, Domenico Coppola2, Judith McCaffrey2 and Bryan McIver1
1H. Lee Moffitt Cancer Center, Tampa, FL, 2H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL

 

Background: The 2009 ATA medullary thyroid carcinoma (MTC) guidelines(1) recommend a “preoperative neck ultrasound for all patients when an FNA or calcitonin (Ct) level is diagnostic or suspicious for MTC” and a search for distant metastases if serum Ct is >400 pg/ml or local lymph nodes (LN) are detected. The recommended treatment for MTC “with suspected limited local metastatic disease to regional LN in the central compartment in the setting of no distant metastases or limited distant metastases is total thyroidectomy and level VI compartmental dissection”, although some guideline authors “favored prophylactic lateral neck dissection when lymph node metastases (LNM) were present in the adjacent paratracheal central compartment”.

Objective: The aim of this study was to evaluate the impact of presurgical serum Ct levels and primary tumor size (measured by ultrasound) in predicting the presence of lateral LNM in the absence of suspicious lateral cervical lymph nodes in preoperative imaging (either US or CT scan).

Methods:In this IRB-approved retrospective study, we reviewed the charts of all patients with MTC evaluated at our institution between 1998 and 2014. Comparisons were made between patients with negative imaging and presurgical Ct level <400 and >400 and those with MTC <2 cm and ≥2 cm in size.

Results:A total of 93 patients with MTC were evaluated at our institution during the study time. Serum Ct before initial surgery was available for review in 51 (54.8%) patients. Presurgical lateral neck imaging (either US or CT scan) was available for review in 46 of these patients, and suspicious LN were present in 23 (50%). In the other 23 patients with negative imaging, Ct level was <400 in 13 (low-Ct group), and >400 in 10 (high-Ct group). Lateral LNM were found in 5 of 10 in the high-Ct group but in none of the low-Ct group. Sensitivity (Sn) and specificity (Sp) were 100% and 72% yielding a Negative and positive predictive values (NPV and PPV) of 100% and 50%, respectively. Presurgical thyroid US scan and lateral neck imaging were available for review in 29 of the 93 patients (31.2%). Suspicious LN were present in 10 (34.5%) of them. In the 19 patients with negative imaging, tumor size was <2 cm in 9 patients and ≥2 cm in 10. Lateral LNM were found in 6 of 10 in the ≥2 cm tumors but in none of the <2 cm tumors. Sn and Sp were 100% and 60% yielding a NPV and PPV of 100% and 60%, respectively.

Among the patients with negative lateral neck imaging, a prophylactic lateral neck dissection was performed in 3 of 13 patients (23%) with Ct <400 and in 1 of 9 (11%) with a tumor <2 cm (this patient also had a Ct <400). If the proposed Ct and size thresholds were used to determine the extent of surgery, 3 lateral neck dissections could have been safely avoided. 

Conclusion: Presurgical Ct levels and size of the primary tumor can safely identify patients at low-risk for lateral LNM of MTC, who can then be spared a prophylactic lateral lymph node dissection.

 

Nothing to Disclose: PV, JR, KJO, DC, JM, BM

21807 30.0000 FRI-050 A Presurgical Calcitonin and Tumor Size As Predictors for Lateral Lymph Node Metastases in Medullary Thyroid Carcinoma with Negative Imaging 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Ronen Gurfinkel*1, Stephanie Siu2, James Ted McDonald3, Terri Louise Paul4, Irina Rachinsky5, Deric James Morrison4, Sarah Nixey4, Mahmoud Badreddine4, John Yoo4 and Stan Van Uum6
1Schulich School of Medicine and Dentistry, Western University, Canada, London, ON, Canada, 2University of Toronto, Toronto, ON, Canada, 3University of New Brunswick, Fredericton, NB, Canada, 4Schulich School of Medicine and Dentistry, Western University, London, ON, Canada, 5Schulich School of Medicine and Dentistry, Western University, London, ON, 6Western University, London, ON, Canada

 

Background: Several studies have shown an inverse relationship between smoking and the incidence of thyroid cancer.  Lower socioeconomic status (SES) is associated with a decreased incidence of thyroid cancer but an increased American Joint Committee on Cancer (AJCC) stage at presentation. However, as lower SES is associated with increased smoking, it is not clear if the effect of smoking on thyroid cancer incidence and stage is independent of SES.  We examined the association between thyroid cancer diagnosis, stage at presentation, smoking history, and SES.

Methods: We analyzed patient data from our tertiary thyroid cancer clinic in London, Ontario. We included patients who presented with thyroid cancer between 1998 and 2011. We determined age at presentation, sex, and AJCC stage. Individuals’ postal codes at the time of diagnosis were used to retrieve data from the Canadian census for the years 1996, 2001, and 2006 to approximate household income. Smoking history at time of diagnosis was obtained retrospectively in 2014 using a questionnaire mailed to 937 eligible patients in our registry.  Ordered logistic regression was used to determine odds ratios of presenting with more advanced stage of thyroid cancer as they relate to smoking status, income, age, and sex.

Results:  We included 586 patients who responded to our questionnaire. 58 patients indicated that they were smokers at time of diagnosis. Compared to patients who have never smoked, patients smoking ½-1 pack/day at the time of diagnosis had a trend towards higher thyroid cancer stage (OR 2.53, 95% CI 0.97-6.57, p = 0.059). A similar relationship was not seen in patients smoking > 1 pack/day or in former smokers (OR 0.76, p = 0.644; OR 1.08, p = 0.813 respectively). After adjusting for smoking status, lower SES was still associated with a higher stage of thyroid cancer at diagnosis.

Conclusion: Our study suggests that moderate smoking at the time of thyroid cancer diagnosis may be associated with a higher stage of disease at diagnosis, and that this effect is not fully explained by SES. Further studies are needed to better understand this relationship.

 

Nothing to Disclose: RG, SS, JTM, TLP, IR, DJM, SN, MB, JY, SV

19663 31.0000 FRI-051 A Association Between Smoking, Socioeconomic Status, and Thyroid Cancer Stage at Presentation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Dana Chanes Manuel*, Jessica Lee Betancourt, Tessey Chinna Jose, Sandra F Williams, Vineeth Mohan, Jose M Cabral, Pascual Desantis, Diane Carlson, Sergey Kachur, Patricia Kachur, Alisha Aggarwal and Carmen Vanessa Villabona
Cleveland Clinic Florida, Weston, FL

 

Background: There have been several recommendations on when to perform Fine Needle Aspirations (FNA) for thyroid nodules. These recommendations have been based on size, thyroid function studies, clinical symptoms, risk factors for malignancy, and ultrasound characteristics. For patients requiring surgery for symptomatic nodular goiter, there is no consensus on the utility of preoperative FNA. It has been proposed that preoperative FNA could influence the extent of surgery. In this study, we aim to determine whether FNA will influence the extent of the thyroid surgery, the incidence of recurrent thyroid cancer, and the need for subsequent surgery.

Methods: We retrospectively reviewed the charts of 431 patients who underwent thyroidectomy at our institution from 2008 to 2011. Patients who presented with compressive symptoms and no prior FNA at initial presentation to our clinic were included in this study. Information about FNA, extent of surgeries, and other pertinent variables were collected.

Results: Eighty patients met the criteria for our study, of which, 57.5%(n=46)  were sent to have FNA prior to surgery and 42.5% (n=34) were referred to surgery without FNA. In the FNA group, 50%(n=23) were benign , 17% (n=7) were suspicious , 13% (n=6) were AUS , 6.5% (n=3) were malignant , 4% (n=3) were follicular , and 8.6% (n=4) were non-diagnostic. The prevalence of malignancy (thyroid cancer >1 cm) on surgical pathology in the FNA group and non FNA group, were 41% (n=19) and 38% (n = 13) respectively. There was not a statistically significant difference between the rate of total thyroidectomies (69.5%  in FNA vs 79.4% in non FNA,  P = 0.31.) or lobectomy (28.2% in FNA vs 20.5% in non FNA, P = 0.43.) between the FNA and non FNA group.  There was not a significant association between the number of lymph node dissections and FNA (P= 0.89). No statistically significant relationship was observed between the rate of follow up surgery and FNA (P = 0.72). There was zero recurrence or mortality recorded in both groups (median follow up time: 113 weeks). No statistically significant differences were found in mean nodules size (3.27 cm in FNA vs 4.10 cm in non FNA group, P = 0.08) or age (49 y in FNA vs 47 y in non FNA, P = 0.52) between the 2 groups.

Conclusion: Patients presenting with compressive symptoms and nodular goiters have high prevalence of malignancy. In our study, FNA did not influence the extent of surgery. In addition, the majority of patients with benign FNAs ultimately had total thyroidectomies. More studies are needed to assess the cost and benefit ratio of performing FNA or other diagnostic modalities in this specific population.

 

Nothing to Disclose: DCM, JLB, TCJ, SFW, VM, JMC, PD, DC, SK, PK, AA, CVV

22025 32.0000 FRI-052 A Should FNA be Performed in All Patients Undergoing Thyroidectomy for Symptomatic Nodular Goiter? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Steven Orlov*, Farnaz Salari, Jeremy L Freeman, Allan Vescan, Ian J Witterick and Paul G Walfish
University of Toronto / Mount Sinai Hospital, Toronto, ON, Canada

 

Background: 

Low post-operative stimulated thyroglobulin (sTg) has been shown to have a high negative predictive value (NPV) for future disease-free status (DFS) in differentiated thyroid cancer (DTC)(1). However, the level of sTg is also dependent on the degree of thyroid stimulation, quantified by the serum thyrotrophin (TSH) level.  We aimed to evaluate the utility of the sTg/TSH ratio in predicting long-term DFS in patients with DTC.

Methods

We retrospectively analyzed a cohort of 433 DTC patients (77% female) followed for a median of 4.1 years [IQR  = 1.7-7.6 years]. All patients underwent total/completion thyroidectomy and selective therapeutic central compartment neck dissection.  sTg and TSH measurements were performed at a median 3.6 months [IQR = 2.7-6.1 months] post-operatively and prior to any radioactive iodine (RAI) administration. TSH stimulation to achieve a level >20mIU/L was achieved by 1 of 3 protocols: recombinant human thyroid stimulating hormone (rhTSH; Thyrogen), 9-day withdrawal from tri-iodothyronine or 22-day withdrawal from L-thyroxine. Patients were selectively treated with RAI when clinically indicated. All patients were anti-Tg antibody negative. Long-term DFS was assessed using a repeat sTg measurement, with an undetectable level (<1µg/L) indicating the absence of disease.  Logistic regression analyses were used to examine the association of sTg and the sTg/TSH ratio with long-term DFS. The results were expressed as odds ratios (OR) with 95% confidence intervals (CI) and associated p-values. Receiver-operator characteristic (ROC) curves with area under the curve (AUC) calculations were used to evaluate all regression models.

Results: 

A total of 106 (24.5%) patients had a detectable sTg (≥1µg/L) on long-term follow-up. Both sTg and the sTg/TSH ratio independently predicted long-term DFS (sTg OR 1.011, 95% CI [1.002, 1.020], p = 0.013; sTg/TSH OR 2.938, 95% CI [1.537, 5.615], p = 0.0011). The optimal threshold values for identifying long-term DFS were sTg <1µg/L (sensitivity 91%, specificity 48%) and sTg/TSH <0.07µg/L/mIU/L (sensitivity 68%, specificity 71%). In ROC curve analyses, the regression model using sTg/TSH ratio had greater accuracy in predicting long-term DFS, compared to a standard model using sTg alone (AUC 0.752 and 0.719, respectively).

Conclusions: 

The post-operative sTg/TSH ratio is an independent predictor of long-term DFS in patients with DTC.  Logistic regression using the sTg/TSH ratio was more accurate than a standard model using sTg alone in predicting DFS after a median of 4.1 years of follow-up.

 

Nothing to Disclose: SO, FS, JLF, AV, IJW, PGW

20610 33.0000 FRI-053 A Using Post-Operative Stimulated Thyroglobulin/TSH Ratio to Predict Long-Term Disease-Free Status in Differentiated Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Jaime L Wiebel*, Nazanene H Esfandiari, Maria Papaleontiou, Francis P Worden and Megan R Haymart
University of Michigan, Ann Arbor, MI

 

Background: Using the SEER-Medicare database, we previously reported a large increase in the use of positron emission tomography (PET) scans after 2004 in patients with differentiated thyroid cancer (DTC). The cause of the increased utilization of PET scans was not clear based on available data. Therefore, in this study, we evaluated the indications and results of PET scans performed at a single academic institution.

Methods: We performed a retrospective cohort study of DTC patients who underwent surgery at the University of Michigan Health System from 2006-2011. We identified patients with a PET scan performed at the University of Michigan or who had outside images reviewed by our radiology department. We evaluated the indications for PET scan, method of stimulation utilized, the percent of positive PET scans and whether PET scan changed management.  For positive PET scans, we characterized the location of the disease and determined if it could be identified with other imaging techniques.

Results: Of the 585 patients in the cohort, 111 (19%) patients had 200 PET scans performed for evaluation of DTC. Indications for PET scan included: elevated thyroglobulin and negative radioiodine scan in 52 scans (26.0%), positive thyroglobulin antibodies in 13 scans (6.5%), rising thyroglobulin in 18 scans (9.0%), evaluation of an abnormality on other imaging tests in 22 scans (11.0%), evaluation of extent of disease in 33 scans (16.5%), follow up of a previous scan in 57 scans (28.5%), other indications in 2 scans (1.0%), and unclear indications in 3 scans (1.5%). The method of stimulation was Thyrogen in 97 (48.5%) of scans, thyroid hormone withdrawal in 21 (10.5%) scans, 64 (32.0%) scans were performed without stimulation and the method of stimulation was unknown in 18 (9.0%) scans. Any disease was present on 124 of the scans (62.0%) and absent on 76 (38.0%) of scans. Disease was present in the thyroid bed on 25 scans, in the cervical or mediastinal lymph nodes on 105 scans, in the lung on 28 scans, in the bone on 4 scans and in other areas on 14 scans. Therapy after PET scan was surgery in 66 cases (33.0%), chemotherapy (including tyrosine kinase inhibitors) or radiation in 23 cases (11.5%), observation in 110 cases (55.0%) and palliative care in one case (0.5%). Disease was identifiable on other imaging studies in 66% of cases. PET changed management in 59 cases (29.5%).

Conclusions: In this tertiary-care academic medical center, PET scans were utilized in 19% of patients.  Indications for PET scans included well accepted applications, such as evaluation of elevated thyroglobulin with non-iodine avid disease, and more controversial uses, such as evaluation of extent of disease or abnormalities on other imaging tests. PET scans mainly identified local disease in the neck that was visible on other imaging tests, including ultrasound. PET scans changed management in about 30% of cases.

 

Nothing to Disclose: JLW, NHE, MP, FPW, MRH

19063 34.0000 FRI-054 A Evaluating PET Scan Use in Differentiated Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 020-054 6027 1:00:00 PM Thyroid Cancer Poster


Alejandro Velez-Hoyos*1, Claudia Monsalve2, Alex Ramirez2 and Natalia Aguirre3
1Dinamica IPS, Medellin, Colombia, 2Universidad Pontificia Bolivariana, Medellin, Colombia, 3Universidad de Antioquia, Medellin, Colombia

 

Introduction: Rosai defined two types of pathologists, the clinical one and the surgical-morphological one, but recently appeared the interventionist pathologist as a modern and global figure with a more active role in the process of diagnosis (1). Thyroid Fine Needle Aspiration Cytology (FNAC) is considered the test of choice for studying thyroid nodules (2). In 2007, Bethesda recommended the use of ultrasonography by pathologists as a guide for FNAC in thyroid lesions (3).

Objective: To evaluate the technique of FNAC guided by ultrasonography performed by an interventionist pathologist in a reference center in Medellin.

Materials and methods: 1000 thyroid FNAC procedures were performed guided by ultrasonography by a trained interventionist pathologist in a reference center in the city of Medellin from 2012 until 2013 using the conventional technique, capillary technique, TIRADS radiological classification and Bethesda’s 2007 cytology report. 

Results: Cytological samples of excellent quality prepared using conventional technique and capillary technique were obtained.

  1. Immediate evaluation of the samples prepared using Diff Quick technique.
  2. Insufficient material in 4% of the procedures compared to 20 – 40% found in other operators of other specialties in the city of Medellin.
  3. Results based on Bethesda’s classification: I-No diagnosis: 4&; II-Benign: 75%; III-:2%; IV-Follicular neoplasm:4%; V-Doubtful for malignity: 7%; VI-Malignity: 8%
  4. First experience in Colombia of the application of Bethesda’s recommendations regarding the use of ultrasonography by other specialists.
  5. Clinical experience, which has allowed training in FNAC technique guided by ultrasonography by surgeons, pathologist, endocrinologist and radiologists in Colombia.

Conclusion: FNAC guided by ultrasonography performed by an interventionist pathologist; the technique allows for a better clinical pathological correlation and decreases the diagnostic material, it also allows for a better association between the clinical, imaging and cytological aspects of diagnosis.

 

Nothing to Disclose: AV, CM, AR, NA

21435 1.0000 FRI-001 A Results of Interventonalist Pathology: Clinical Experience in Progress of a Thousand FNAC Guided By Ultrasonography in Medellin, Colombia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Satoshi Suzuki*1, Satoru Suzuki2, Sanae Midorikawa3, Toshihiko Fukushima1, Hiroki Shimura3, Tetsuya Ohira3, Akira Ohtsuru3, Masafumi Abe1, Izumi Nakamura1, Shunichi Yamashita3 and Shinichi Suzuki1
1Fukushima Medical University, Fukushima-shi, Japan, 2Fukushima Medical University, Fukushima, Japan, 3Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan

 

Thyroid hemiagenesis is a rare congenital abnormality in which one thyroid lobe lacks the ability to develop, without any clinical manifestations. We aimed to determine the prevalence of asymptomatic thyroid hemiagenesis and hypoplasia in a normal population. This study was a cross-sectional study from October 9, 2011 to March 31, 2012. The subjects included 37,818 children who were examined after the accidents at the Fukushima Daiichi Nuclear Power Plant in an initial preliminary survey undertaken by the Fukushima Health Management Survey from October 9, 2011 to March 31, 2012. Screened between October 2011 and March 2012, 15 cases had developed hemiagenesis and either lateral or bilateral hypoplasia (0.03%). The female-to-male ratio was 1.8:1, although there were no statistical differences. Three out of 15 cases revealed the hypoplastic thyroid in the left lobe. In addition, two cases showed atrophy or absence of both lobes of the thyroid gland. In the two cases, one subject afflicted with cretinism was treated with levothyroxine at the time of examination. Although the other subject showed asymptomatic conditions, subclinical hypothyroidism was present. 0.026% (10 cases) of ages 0–19 showed a prevalence of thyroid hemiagenesis. The female-to-male ratio was 1.01:1. Four cases showed a defect of the thyroid lobe but also of the isthmus. The results obtained from the exhaustive survey by ultrasound suggested that the prevalence of thyroid hemiagenesis or hypoplasia was in agreement with results reported in other countries.

 

Nothing to Disclose: SS, SS, SM, TF, HS, TO, AO, MA, IN, SY, SS

18876 2.0000 FRI-002 A Preliminary Results in Prevalence of Thyroid Hemiagenesis and Hypoplasia: The Fukushima Health Management Survey 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Spyridoula Maraka*, M. Regina Castro, Diana S. Dean, Vahab Fatourechi, Pravin Thapa, Rebecca S Bahn and Marius N Stan
Mayo Clinic, Rochester, MN

 

Background: Radioactive iodine (RAI) therapy is the most common method of treating Graves’ disease (GD) in the United States.  The current practice is to reevaluate these patients 2-3 months after RAI.  The majority are hypothyroid by that time with some experiencing related troublesome symptoms and possible development or worsening of Graves’ orbitopathy.  We initiated this randomized controlled trial (RCT) to determine whether early treatment with levothyroxine after RAI therapy for GD will prevent overt hypothyroidism (OH).

Hypothesis: The aim of this interim analysis of our RCT is to test the safety of early levothyroxine therapy following RAI therapy using our study protocol.

Design and Methods: Patients (ages 18-70 yr) with GD treated with RAI were randomized 4 weeks later, in double-blinded manner, to start levothyroxine 25 mcg/day or placebo.  The levothyroxine dose was increased to 50 mcg/day, 2 weeks later.  At 8 weeks post RAI, all patients had a face-to-face clinical evaluation.  Patients in both groups had blood drawn for measurement of TSH and free thyroxine (fT4) at 4, 6, and 8 weeks.  Incidence of OH at 8 weeks, defined as TSH > 4.5 mIU/L or fT4 < 0.8 ng/dL, was the primary endpoint.  Hyperthyroidism was defined as fT4 > 1.8 ng/dL.  The hypothyroid-Health Related Quality of Life (H-HRQL) and the Thyroid Specific Questionnaire (TSQ) were completed at 4, 6, and 8 weeks by both groups to assess quality of life.  Data is reported as median and interquartile range.

Results: This analysis reports on the initial 17 patients enrolled in our trial, in which 60 patients will ultimately be enrolled.  Eleven patients were randomized to levothyroxine and 6 patients to placebo.  There was no difference at baseline between patients in the levothyroxine and placebo arm regarding age (52.7, 27.6-60.6 vs. 55.3, 46.7-66.2 yr), gender (female 72.7 vs. 66.7%), thyroid size (30, 25-40 vs. 30, 15-35 g), and fT4 (2.7, 2.4-4.8 vs. 1.9, 1.3-2.6 ng/dL).  Only one adverse event was reported; a patient in the levothyroxine arm discontinued the study drug due to palpitations.  At 8 weeks, OH was found in 54.5% of patients on levothyroxine compared to 66.7% of patients on placebo.  The levothyroxine group had lower rate of hyperthyroidism (18.2%) than the placebo group (33.3%).  The levothyroxine group had similar TSQ score with the placebo group (12, 12-22 vs. 12, 11-13) but somewhat worse H-HRQL score (46, 39-67 vs. 36, 31.5-42.5).  As expected none of the analyses reached statistical significance given that the sample size is 25% of the planned population.

Conclusions: It is reassuring that initiating low dose levothyroxine 4 weeks after RAI appears safe, without increased prevalence of hyperthyroidism.  There is an encouraging trend for prevention of OH.  In this small sample we do not see yet congruent improvement in the quality of life.  Accordingly, we plan to continue the trial to completion without protocol modifications.

 

Disclosure: RSB: Consultant, Merck & Co., Consultant, GlaxoSmithKline, Consultant, Genentech, Inc.. Nothing to Disclose: SM, MRC, DSD, VF, PT, MNS

18941 3.0000 FRI-003 A Prevention of Overt Hypothyroidism Following Radioactive Iodine Therapy for Graves' Disease By Early Initiation of Levothyroxine Therapy: Interim Analysis of a Randomized Control Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Gitadokht Majdi*1, Rommel G Tirona1, Alyse Goldberg2 and Stan Van Uum3
1University of Western Ontario, London, ON, Canada, 2University of Toronto, Toronto, ON, Canada, 3Department of Medicine, Western University, London, ON, Canada

 

HIGH DOSE LEVOTHYROXINE ABSORPTION TEST TO DIFFERENTIATE BETWEEN MALABSORPTION AND NON-ADHERENCE: 5 CASES AND DISCUSSION

       Majdi G¹, Tirona RG², Goldberg A³, Van Uum SH¹

Divisions of ¹Endocrinology and Metabolism and ²Clinical Pharmacology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada

Division of ³Endocrinology and Metabolism, Depatment of Medicine, University of Toronto, Toronto, Ontario, Canada

Abstract

Background:Consistent gastrointestinal absorption of levothyroxine (LT4) is essential for proper thyroid hormone replacement. Increase in LT4 dose requirements can be caused by non-adherence or by impaired absorption, e.g. due to gastrointestinal disorders or interaction with other drugs. In practice, it can be challenging to differentiate between malabsorption and non-adherence.

Objective:We evaluated the ability of a high dose LT4 absorption test to differentiate between non-adherence and malabsorption of LT4 in 5 patients with therapy resistant hypothyroidism.

Methods: We evaluated patients whose TSH did not normalize with prescribed doses of LT4 or required an LT4 dose over 3 microgram/kg . Patients underwent an absorption test involving an oral dose of 1000 mcg LT4 given under supervision. Plasma total T4, free T4, free T3 and TSH were determined at 0, 30, 60, 90, 120, 180 and 240 minutes after LT4 intake. Total T4 was quantified using LC-MS/MS and the pre-dose level corrected Area Under the Curve (AUC) was calculated as the % of standard AUC previously determined in healthy subjects1.

Results: We included 5 female patients age 45 ± 11.5 years (mean ± SD), weight 85 ± 27 kg, prescribed a median LT4 dose of 370 (range 200 to 1000) microgram/day. The AUC in the patients was 140%, 20%, -9%, 15% and -7% of healthy subjects, suggesting non-adherence in 1 patient, decreased absorption in 1 patient and no absorption in the other 3 patients. The changes in free T4 following LT4 dose paralleled those for total T4, and for all patients, no change in free T3 or total T3 were observed. 

CONCLUSIONS: The oral LT4 absorption test can be used to differentiate between non-adherence and impaired LT4 absorption. The results can inform clinical decision making focused on improved adherence, increase of oral LT4 dose, or even consideration of parenteral LT4 administration.

 

Nothing to Disclose: GM, RGT, AG, SV

19280 4.0000 FRI-004 A High Dose Levothyroxine Absorption Test to Differentiate Between Malabsorption and NON-Adherence: 5 CASES and Discussion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Sena Hwang*1, Dong Yeob Shin2, Wonjin Kim1, Jin Sook Yoon1 and Eun Jig Lee1
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Yonsei University College of Med, Seoul, Korea, Republic of (South)

 

Alpha-lipoic acid (ALA) (1,2-dithiolane-3-pentanoic acid) is a powerful antioxidant, helping to protect against oxidative stress and inflammatory damage. Considering GO is a disorder associated between increased oxidative stress and inflammation, leading to hyaluronan (HA) production and adipogenesis, ALA is a good candidate agent for GO treatment.

To determine the effect of ALA on oxidative stress and inflammation, intracellular reactive oxygen species (ROS) and proniflammatory cytokine and chemokine mRNA expression were measured in primary cultured orbital fibroblasts from GO patients. Also, HA production and adipogenesis were examined. The expressions of proteins peroxisome proliferator-activated receptor (PPAR)γ, CCAAT-enhancer-binding proteins (C/EBP)α and β, and heme oxygenase-1 (HO-1) were measured after adipogenesis of GO cells.

In results, ALA strongly suppressed intracellular ROS generation, and increased HO-1 expression in GO cells. HO-1 pathway was involved in the protective effect of ALA against oxidative damage in GO cells. Also, ALA significantly attenuated TNFα-induced intercellular adhesion molecule-1 (ICAM-1), interleukin (IL) -6, IL-8, and chemokine (C-C motif) ligand 2 (CCL2) and CCL5 mRNA expression through suppression of nuclear factor kappa B (NFkB). Oxidative stress and inflammatory cytokine simulated HA production and adipogenesis in GO cells. However, ALA inhibited HA production and accumulation of intracytoplasmic lipid droplets, and resulted in a dose-dependent decrease in expression of PPAR γ, C/EBPα and β, and HO-1 proteins.

Taken together, these results show that ALA represents an important mechanism for protection of GO cells against oxidative stress and inflammatory responses, reading to prevention for aberrant accumulation of extracellular matrix macromolecules and adipose tissue expansion.

 

Nothing to Disclose: SH, DYS, WK, JSY, EJL

20175 5.0000 FRI-005 A The Effect of á-Lipoic Acid on Oxidative Stress and Inflammation in Orbital Fibroblasts from Graves' Orbitopathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Huai-Dong Song*
Shanghai Ninth People’s Hospital Affiliated to Shanghai Jiaotong University (SJTU) School of Medicine, Shanghai, China

 

Thyrotoxic periodic paralysis is a novel subtype of Graves’ disease and caused by some molecualr pathways differenting from that underlying Graves’ disease

Huai-Dong Song1,2, Shuang-Xia Zhao2, Chun-Ming Pan2, Wei Liu1, Hai-Ning Wang2, Fei-Fei Yuan2, Zhao-Hui Gu2, Zi-Guan Zhang2, Guan-Qi Gao3, Jun Liang4, Xiao-Mei Zhang5

1 Center of Clinical Medical Research, Center of Thyroid Disease, Shanghai Ninth People’s Hospital Affiliated to Shanghai Jiaotong University (SJTU) School of Medicine, Shanghai 200025, China  

2State Key Laboratory of Medical Genomics, Ruijin Hospital Affiliated to SJTU School of Medicine, Shanghai 200025, China

3 Department of Endocrinology, The People’s Hospital of Linyi, 27 Liberation Road, Linyi, Shandong Province 276003, China

4 Department of Endocrinology, The Central Hospital of Xuzhou Affiliated to Xuzhou Medical College, Xuzhou, Jiangsu Province 221009, China

5 Department of Endocrinology, The First Hospital Affiliated to Bengbu Medical College, 287 Changhuai Road, Bengbu, Anhui Province 233004, China

Abstract

Thyrotoxic Periodic Paralysis (TPP), characterized by muscle paralysis and hypokalemia due to a massive intracellular shift of potassium, is a potentially lethal complication of hyperthyroidism.  In the Chinese, TPP occurs in 13% of male and 0.17% of female thyrotoxic patients, however, TPP rarely occurs in caucasians.  To investigate the genetic architecture of TPP, we carried out a two-stage genome-wide association study in a total of 533 patients with TPP and 3,249 healthy controls.  We identified a new TPP susceptibility loci on chromosome 4q31.3 in DCHS2 (rs1352714: odds ratio (OR) = 1.60; Pmeta-analysis = 1.51 x 10-8) and confirmed a previously reported locus on chromosome 17q24.3 near KCNJ2 (rs312729: OR = 2.10; Pmeta-analysis = 4.12 x 10-28), both of the two loci were associated with TPP, but not with Graves’ disease.  Given all TPP patients also had Graves’ disease in our cohort, we further evaluated the association between the 34 SNPs in 22 Graves’ disease susceptibility loci and TPP in the total populations.  Fortunately, we found 13 SNPs in 10 Graves’ disease susceptiblity loci were also associated with TPP at the P<0.014 (0.05/34). Among them, 4 SNPs in MHC loci and one SNP in BACH2 were associated with TPP at the GWAS significant level (5 x 10-8), indicating that the TPP is a novel subtype of Graves’ disease and caused by some molecualr pathways differenting from that underlying Graves’ disease.

 

Nothing to Disclose: HDS

20271 6.0000 FRI-006 A Thyrotoxic Periodic Paralysis Is a Novel Subtype of Graves' Disease and Caused By Some Molecualr Pathways Differenting from That Underlying Graves' Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Masakazu Notsu*1, Mika Yamauchi1, Toru Yamaguchi2 and Toshitsugu Sugimoto1
1Shimane University Faculty of Medicine, Izumo, Japan, 2Shimane university, Izumo, Japan

 

The treatment of benign cystic thyroid nodules is a common clinical problem. Ethanol injection therapy has proven effective in the treatment of recurrent thyroid cyst, but not all facilities perform this procedure. Simple aspiration is also the treatment of choice for therapeutic purposes with benign cystic thyroid nodules and is the simplest and most cost-effective first-line method. Various studies have reported a success rate for simple aspiration of 8–45%. However, few reports have examined factors affecting the efficacy of cyst reduction by needle aspiration, particularly in terms of ultrasound (US) characteristics. The aim of this study was to evaluate US characteristics affecting cyst size reduction. We reviewed the medical records and US images of the 54 patients (age, 62±14 years; nodule diameter, 3.0±1.3 cm; mean follow-up period 20±17 months) who underwent simple aspiration for a benign cystic thyroid nodule in our institution from January 2009 to March 2014. We defined effective reduction of the cyst size as a ≥30% decrease in long diameter of the initial nodule at the end of follow-up US. The following variables were measured: age, gender, US characteristics (initial diameter, presence of septum or multilobular septum, Comet-tail sign, solid component, and vascularity) and biochemical parameters (serum levels of free T3, TSH, and thyroglobulin). Cystic nodules with and without size reduction were found in 21 patients (mean diameter reduction, 62.0±15.3%) and 33 patients (mean diameter reduction, −7.7±23.7%), respectively. We compared US characteristics and biochemical parameters between subjects with and without reduction. Initial diameter (mm)(3.3±1.5 vs. 2.9±1.1, P=0.32), serum levels of free T3 (pg/mL)(2.8±0.4 vs. 2.6±0.3, P=0.12), TSH (μU/mL) (1.8±2.3 vs. 2.1±1.4, P=0.62), and thyroglobulin (ng/mL) (770±1741 vs 121±292, P=0.12) were not significantly associated with size reduction. Presence of single or multilobular septum, Comet-tail sign, solid component, and vascularity were found in 7 (31.8%), 3 (13.6%), 13 (59.1%), and 6 (23.7%) nodules with size reduction, respectively. Subjects without reduction showed vascularity significantly more often than those with reduction (72% vs. 27%, P<0.01). Multivariate logistic regression analyses adjusted for age, gender, and initial diameter revealed that absence of vascularity was significantly associated with successful reduction (odds ratio 7.4; 95%CI: 2.0-26.8, p<0.01). Our findings suggest that simple aspiration is effective in cystic nodules showing no vascularity on ultrasound examination.

 

Nothing to Disclose: MN, MY, TY, TS

20335 7.0000 FRI-007 A Ultrasound Characteristics Affecting Efficacy of Cyst Size Reduction By Simple Aspiration in Benign Cystic Thyroid Nodules 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Banu Sarer Yurekli1, Serkan Yildirim2, Gokcen Unal Kocabas3, Nilufer Ozdemir Kutbay*4, Asli Suner5, Murat Aksit6, Giray Bozkaya6 and Ahmet Gokhan Ozgen1
1Ege University Faculty of Medicine, Izmir, Turkey, 2Izmir Bozyaka Education and Research Hospital, 3Bozyaka Education and Research Hospital, 4Ege University Faculty Of Medicine, 5Ege University Faculty of Medicine, 6Bozyaka Training and Research Hospital, Izmir, Turkey

 

Introduction

Hashimoto’s thyroiditis (HT), also known as chronic lymphocytic thyroiditis, is an organ-specific autoimmune disease characterized by the presence of goitre, lymphocytic infiltration and serum thyroid autoantibodies. HT is a complex disease caused by overt autoimmune response, multiple gene susceptibility and environmental factors. Leptin is involved in pathogenesis of several autoimmune diseases. Leptin can modulate T cell function. Accumulating evidence suggests that leptin acts as a proinflammatory cytokine in immune responses, which is involved in the pathogenesis of various autoimmune diseases. In this study, we investigated leptin levels in premenouposal women with Hashimato’s thyroiditis.

Material and Method

We enrolled 80 premenopousal women with BMI level of 20-25 kg/m2. Out of 40 were patients with HT. They had AntiTg and/or AntiTPO positivity called as antibody positive group. Control group was antibody negative one without HT. All patients were euthyroid and had normal BMI values. They had regular menstrual periods and were not taking oral contraceptive pills. Groups were age, sex and BMI matched.

Results

Mean level of leptin in antibody positive group was 8.50±3.79 ng/ml and was 8.80±4.49 ng/ml in antibody negative group (p=0.81). When correlation analysis was performed, there were no correlation of leptin with antiTg (p=0.36) and with antiTPO (p=0.81). No correlation was observed between leptin and TSH level (p=0.76).

Conclusion

There was no significant difference in leptin levels between HT and control group. It is suggested that leptin can take a role in immune responses. But in this study, there were no correlation between leptin and antiTPO levels. So, further investigations are needed to elucidate the role of leptin in HT.

 

Nothing to Disclose: BS, SY, GU, NO, AS, MA, GB, AGO

20384 8.0000 FRI-008 A Leptin Levels in Premenouposal Women with Hashimato's Thyroiditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Liege Tambelini Gomes1, Isabel Cristina de Mello Guazzelli1, Gabriela Hae Oh1, Tomoco Watanabe1, Nicolau Lima2 and Suemi Marui*3
1Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

Graves´ disease (GD) is usually characterized by thyrotoxicosis, goiter and ophtalmopathy. Genetic background has important role in thyroid autoimmune tolerance and consequently may influence clinical presentation. Several polymorphisms, especially in CTLA4 gene, PTPN22, IFIH1, TSH receptor and recently NRXN3 and ARID5B were associated with GD (1,2). To study the frequencies and the potential impact on clinical picture, we retrospectively evaluated 172 patients (125 females) with GD diagnosed at our Institution. Patients and methods: Clinical, hormonal and treatment data were obtained from medical records from 2006 to 06/2014. DNA of all patients and 173 normal controls were extracted from peripheral leukocytes. The polymorphisms rs2476601 (PTPN22-R620W), rs1990760 (IFIH1-A946T), rs179247, rs2284720 and rs12101255 localized in TSHR and also rs12147587 (NRXN3) and rs6479778 (ARID5B) were genotyped by Real-time PCR (Taqman®). The mean age of GD diagnosis was 41.6 ± 13.2 years-old (from 18 to 77), ophthalmopathy was clinical diagnosed in 42.4%, smoking was referred in 28% and only 9.4% had negative TSH receptor antibody (TRAb). Anti-thyroperoxidase antibodies (ATPO) were also positive in 71% of TRAb positive patients. Remission was reported in only 22% after drug treatment (mean duration of treatment = 24 months) and mostly received radioiodine therapy. All polymorphisms were in Hardy-Weinberg equilibrium in control group. No differences, but PTPN22-R620W (p=0.024) were found according to polymorphism genotypes and risk allele between GD and control group.  No associations of risk alleles or risk genotypes were found according to age at GD diagnosis, presence of ophthalmopathy, TRAb and ATPO positivity. We conclude that only the PTPN22-R620W polymorphism was associated with GD in our cohort and all polymorphisms here studied had no impact on GD clinical presentation.

 

Nothing to Disclose: LTG, ICDMG, GHO, TW, NL, SM

20614 9.0000 FRI-009 A Analysis of PTPN22, IFIH1, TSH Receptor (TSHR), NRXN3 and ARID5B Gene Polymorphisms in Patients with Graves Disease: Association with Clinical Presentation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Maria Papaleontiou*1, Nazanene H Esfandiari1, Sarah T Hawley2 and Megan R Haymart1
1University of Michigan, Ann Arbor, MI, 2University of Michigan

 

Background: Thyroid hormone replacement use is widespread. Despite published guidelines, there is still a debate about appropriate thyroid hormone preparations and indications for use. Moreover, little is known about factors that influence providers’ decision-making regarding thyroid hormone use and target thyroid stimulating hormone (TSH).                                                                                                

Methods: Members of the American College of Physicians, the American Academy of Family Physicians and the Endocrine Society were randomly selected and surveyed at a national level. A modified Dillman method was used, consisting of three waves of mailings with a gift included in the first mailing. All surveys were de-identified prior to data analysis.

Results: Out of 453 respondents, 378 physicians who managed thyroid hormone replacement therapy over the past 5 years completed the survey, 19 refused to complete the survey, 19 were unreachable, deceased or retired, and 38 stated that they did not treat patients with thyroid disease. Family practitioners (35.1%) were the largest physician group represented, followed by endocrinologists (31.4%), internists (25.5%) and other (8%). Most physicians were in private practice (48.9%), 20.2% worked at an academic setting, 13.6% at a community-based academic affiliate and 17.3% practiced in other settings. The majority of physicians (68.3%) stated that >25% of their patients on thyroid hormone replacement were aged >65. Synthetic thyroid hormone preparations (T4) were used by 100%, desiccated thyroid preparations by 31%, T3 preparations alone by 26.8%, combination therapy with T3 and T4 by 16.1% and over-the-counter nutraceuticals by 1.1% of physicians. Indications for thyroid hormone replacement initiation included hypothyroidism (99.4%), thyroid cancer (58.3%), thyroid nodule growth suppression (26.2%), fatigue (4.5%), depression (3.4%), and weight gain (2%). Forty-seven percent of physicians aimed for a higher TSH range (3.1-5.0 mIU/L) in patients aged ≥85, regardless of gender. Factors influencing physicians’ decision-making regarding goal TSH included patient symptoms (68.6%), cardiac arrhythmias (65.8%), age (53.7%), fatigue (49.7%), heart disease (44.9%), osteoporosis (43.8%), pregnancy (40.4%), weight (31.1%), fractures (27.4%), patient preference (27.4%), interest in conception (27.1%), and multiple falls (7.6%).

Conclusion: In this diverse provider group caring for patients on thyroid hormone replacement, there was variation of thyroid hormone preparations used. Thyroid hormone replacement was initiated for appropriate indications such as hypothyroidism and thyroid cancer, and for controversial indications such as thyroid nodule growth suppression and fatigue. Physicians aimed for a higher TSH range in older adults. Subjective factors such as patient symptoms and preference also influenced physicians’ decision making in the management of these patients.

 

Nothing to Disclose: MP, NHE, STH, MRH

20634 10.0000 FRI-010 A Thyroid Hormone Replacement Administered By a Diverse Cohort of Providers 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Jung Hwan Park* and Dong-Sun Kim
College of Medicine, Hanyang University, Seoul, Korea, Republic of (South)

 

Breech presentation is the most common abnormal presentation. Factors to encourage a breech presentation are premature birth, mulifetal pregnancy, abnormal volume of amniotic fluid, fetal anomalies, uterine abnormalities, piror Caesarean sections (C-sec), contracted pelvis, placenta praevia or multiparae. The relationship between thyroid dysfunction during gestation and impaired obstetrical outcome is well-known. Therefore, we examined any relationship between breech presentation and thyroid dysfunction during gestation. We selected patients who underwent C-sec due to breech presentation or other causes in vertex presentation for 2 years in our hospital. We examined the history of fertility, prior C-sec, prior breech presentation, abortion, and thyroid disease, age, gestational age, thyroid function test at birth, and the presence of abnormal volume of amniotic fluid, uterine abnormalities, placenta praevia and multifetal pregnancy. There were 20 patients (Group1) who underwent C-sec due to breech presentation and 20 patients (Group2) with vertex presentation who underwent C-sec due to other causes. Mean age of Group1 was 32.8 ± 5.5 years and Gruop2 was 33.4 ± 3.5 years. When compared with abnormal higher TSH levels during end gestation, there was no statistical significance. However, when compared  with known hypothyroidism and subclinical hypothyroidism which were treated by levothyroxine (Group1, n=6, Group2, n=1), there was statistical significance. When compared with other factors except history of fertility and C-sec, there were no statistical significance. In fertility and C-sec, numbers of patients in Group 2 were higher than those in Group1 and there were statistical significances. Unlike previous studies, abnormal higher TSH levels at birth did not show any positive relationship with breech presentation. However, patients with known hypothyroidism and subclinical hypothyroidism are statistically related to breech presentation.

 

Nothing to Disclose: JHP, DSK

20737 11.0000 FRI-011 A The Relationship Between Breech Presentation and Thyroid Dysfunction during Gestation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Hiroki Shimura*1, Satoru Suzuki2, Toshihiko Fukushima2, Sanae Midorikawa1, Keiichi Nakano2, Yuko Ito1, Tetsuya Ohira2, Shunichi Yamashita1 and Shinichi Suzuki2
1Fukushima Medical University, Fukushima-shi, Japan, 2Fukushima Medical University, Fukushima, Japan

 

Context: Fukushima prefecture has started Thyroid Ultrasound Examination Program as a part of Fukushima Health Management Survey after the accident of the Fukushima Dai-ichi Nuclear Power Plant. The thyroid function tests were performed in the confirmatory examinations of this program. In order to interpret the results precisely and to assess the prevalence of thyroid dysfunctions in children and adolescents in Fukushima, it is quite important to elucidate the reference intervals in the children and adolescent in Fukushima prefecture.

Objective: The aim of this study was to assess the reference intervals of thyroid function tests and the prevalence of thyroid function disorders in children and adolescents in Fukushima.

Design: This study was a cross-sectional study between October 2011 and March 2014.

Setting and Participants: 1747 children and adolescents were subjected to this study. The median age of subjects was16 years (interquartile range, 13 - 19 years).

Main Outcome Measures: Serum TSH, FT3, and FT4 levels were measured by a chemiluminescence immunoassays, and serum anti-thyroglobulin (TgAb) and anti-thyroid peroxidase (TPOAb) antibodies were determined by electro-chemiluminescence immunoassays. The reference intervals were assumed between the mean±2SD.

Results: The TSH, FT3, and FT4 levels in female were significantly higher than those in male. FT3 and FT4 levels in subjects with diffuse sonographic findings were also significantly higher than those in subjects with no findings. However, comparisons between subjects positive and negative for either TgAb or TPOAb showed no significant differences in TSH, FT3, and FT4 levels. In the reference population after exclusion of subjects with a defect of thyroid lobe, diffuse sonographic finding, or thyroid antibodies, the reference intervals of TSH, FT3, and FT4 were established. Investigation of the prevalence rate of thyroid dysfunctions based on the reference intervals of TSH and FT4 showed that the prevalence of overt and subclinical thyrotoxicosis were 1.1% and 2.6% of the subjects, respectively. Overt and subclinical hypothyroidism were also observed in 0.6% and 3.1% of the subjects, respectively.

Conclusions: The present study provided the reference intervals of thyroid function tests, which will be able to assist the managements of diffuse thyroid diseases in children and adolescents under the radiation hazard in Fukushima prefecture.

 

Nothing to Disclose: HS, SS, TF, SM, KN, YI, TO, SY, SS

20805 12.0000 FRI-012 A Reference Intervals of Thyroid Function Tests and Prevalence of Thyroid Function Disorders in Children and Adolescents with Thyroid Nodules: The Fukushima Health Management Survey 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Hee Kyung Kim*1, Jee Hee Yoon2, Soo Jeong Kim2 and Ho-Cheol Kang2
1Chonnam National University College of Medicine, Gwangju, Korea, Republic of (South), 2Chonnam National University Medical School, Gwangju, Korea, Republic of (South)

 

Background: Antithyroid drugs (ATD) for treatment of Graves’ disease could lead to the development of agranulocytosis which is the most serious adverse effect. Characteristics of ATD-induced agranulocytosis (AIA) have been reported sparsely because of its rarity. The aim of this study was to describe the clinical features of ATD-induced agranulocytosis in Korean patients.

Method: We retrospectively reviewed data on 52 patients with AIA diagnosed between 1997 and 2013 at four tertiary hospitals. Agranulocytosis was defined as a granulocyte count less than 500/mm3. We analyzed the data to determine the risk factors for AIA, according to the drug and recovery time (shorter than 5 days and longer than 6 days).

Results: 86.5% of patients with AIA had fever and sore throat on initial presentation, and 73.1% of patients suffered AIA within 3 months after initiation of ATD. The patients taking methimazole (MMI) showed lower level of ANC and more frequent use of GM-CSF than propylthiouracil (PTU) users. Patients with long recovery time showed lower levels of initial ANC and more frequent MMI use than those of patients with short recovery time. We observed no differences between two groups as regards to age, sex and duration of ATD medication. We could not find any risk factors for AIA. Four patients (7.7%) who had been taking ATD less than two months died of sepsis on the 1st and 2nd hospital day.

Conclusions: Most AIA occurs abruptly in early treatment period and MMI is associated with more severe form of AIA. Considering the high fatality rate of AIA, early aggressive therapeutic approach is critical and patients should be well informed about warning symptoms of AIA.

 

Nothing to Disclose: HKK, JHY, SJK, HCK

20832 13.0000 FRI-013 A Methimazole Is Associated with More Severe Agranulocytosis: Multicenter Study in Korea 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Sanjay Gawade*1, Katrin Hafen1, Urs Zumsteg2, Werner Krenger1 and Gabor Szinnai2
1Pediatric Immunology, Basel, Switzerland, 2University Children's Hospital Basel, Basel, Switzerland

 

The thyroid is composed of endocrine epithelial cells, blood vessels and mesenchyme. Fluorescence-activated cell sorting (FACS) provides a tool for quantification of distinct cell populations. However, in the absence of an established tissue-specific protocol, no data exist on absolute cell numbers, relative distribution, and proliferation of the different cell populations in the developing and mature thyroid.

The aim of this study was to establish a FACS protocol allowing quantification of cell populations in murine embryonic (E13.5, E15.5, and E17.5) and adult thyroid tissues. Specificity of antibodies was validated whenever available by a second cell type specific marker: erythroblasts (TER119), lymphoblasts (CD45), epithelial cells (EpCAM, E-cadherin), thyrocytes (NKX2-1), endothelial cells (CD31, CD34, ICAM-1), fibroblasts (PDGFRalpha), proliferating cells (BrdU). For analyses, micro-dissected embryonic thyroids were pooled (E13.5 n=25, E15.5 n=15, E17.5 n=15) in one sample.

The absolute parenchymal cell number per thyroid (mean±SD) excluding the large number of hematopoietic cells (TER119+ erythroblasts and CD45+ lymphocytes) increased from 7300±1300 at E13.5 to 190000±20000 in adult tissues. As expected, NKX2-1+ cells represented the largest cell population in adult tissues (87±2%). Surprisingly, at all three embryonic stages thyrocytes accounted only for a small percentage of the total thyroid cell mass (6±0.4% to 11±2%). In contrast, the largest cell population at all three embryonic stages were PDGFRalpha+ fibroblasts (79±1% to 85±1%), while representing the smallest cell population in adult tissues (5±0.5%). CD31+ endothelial cells increased significantly from E13.5 to E15.5 from 4±1% to 12±4%, and remained stable in E17.5 and adult tissues.  Proliferation rate was significantly different between embryonic cell populations with distinct proliferative peaks at E13.5 in epithelial cells (33±0.6% BrdU+), and at E15.5 in endothelial cells (22±2% BrdU+), while fibroblasts showed a constant proliferation rate in embryonic tissues. In adult tissues, BrdU+ cells were below 1% in all cell types.

We established a FACS protocol for quantification of developmental dynamics in thyroid cell populations providing a new tool for functional analysis in murine thyroid disease models.

 

Nothing to Disclose: SG, KH, UZ, WK, GS

21191 14.0000 FRI-014 A A Fluorescence-Activated Cell Sorting (FACS) Protocol for Quantification of Cell Populations and Their Growth Dynamics in Embryonic and Adult Mouse Thyroid 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Celestino Neves*1, César Esteves1, Helena Greenfield2, Miguel Pereira1, Oksana Sokhatska1, Carmo Palmares3, Davide Carvalho4, Luís Delgado1 and José Luís Medina2
1São João Hospital, Faculty of Medicine, University of Porto, Porto, Portugal, 2Faculty of Medicine, University of Porto, Porto, Portugal, 3São João Hospital, Faculty of Medicine, University of Porto, Portugal, 4Endocrinology Service, São João Hospital. i3S - Instituto de Investigação e Inovação em Saúde, Faculty of Medicine, University of Porto, Porto, Portugal

 

Introduction and objective: Evidence has been emerging that normal-high levels of TSH are related to an increased cardiovascular risk. The objective of our study is to evaluate the relationship between the TSH levels and cardiovascular risk factors in patients with autoimmune thyroiditis and with normal thyroid function.

Methods: We analyzed the thyroid function, autoimmunity and total cholesterol, HDL, LDL, triglycerides, apolipoprotein B, apolipoproteinA1, lipoprotein (a), homocysteine, hs-CRP, folic acid, vitamin B12, HOMA-IR, HOMA-β, QUICKI, HISI, WBISI and IGI levels in 186 patients with autoimmune thyroiditis.

We defined two groups of patients to compare; in one group we included patients with TSH levels within 0.35 and 2.5 µUI/ml and normal levels of FT4 and FT3 (between 0.70 and 1.48 ng/dl  and between 1.71 and 3.71 pg/ml, respectively). In the second group we included patients with TSH levels superior to 2.5 µUI/ml and normal levels of FT4 and FT3. For the statistical analysis we used the Mann-Whitney test, logistic regression and the Spearman correlations. The results were adjusted for age and body mass index and are expressed in median±percentiles 25 and 75. A bilateral value of p <0.05 was considered statistically significant.

Results: 94% of individuals were females. The median age was significantly superior in the group with TSH between 0.35 and 2.5µUI/ml. The patients with higher total cholesterol (OR=1.008;p=0.03), CRP (OR=1.684;p=0.04) or antithyroglobulin antibodies(OR=1.002;p=0.02) presented with an increased risk of developing TSH values higher than 2.5 µUI/ml.

The CRP values were significantly raised in the group with TSH higher than 2.5µUI/ml [0.335 (0.115-0.620) vs 0.180 (0.080-0.380) mg/dl; p=0.030].

In the total group of individuals with found statistically significant correlations between the levels of FT3 and of HDL-cholesterol (r=0.163;p=0.009) and between the levels of TSH and CRP (r=0.132; p=0.043). We also found significant correlations between the HOMA-IR and the TSH levels. (r=0.158; p=0.029) and between the IGI and FT4 levels. (r=0.224; p=0.002) in the total group of individuals. In the patients with TSH> 2.5 µUI/ml we found statistically significant correlations between the levels of homocysteine and FT3 (r=-0.357; p=0.011) and between the levels of anti-TPO antibodies and FT4 (r=-0.281; p=0.020).

Conclusions: In autoimmune thyroiditis there is an association between TSH values > 2.5 µUI/ml and the levels of total cholesterol, CRP and antithyroglobulin antibodies.  The relationship between the markers of insulin resistance, thyroid hormones and CRP seem to indicate that there is an increased cardiovascular risk in patients with autoimmune thyroiditis and normal-high TSH levels.

 

Nothing to Disclose: CN, CE, HG, MP, OS, CP, DC, LD, JLM

21349 15.0000 FRI-015 A Cardiovascular Risk in Patients with Autoimmune Thyroiditis and Normal-High Levels of TSH 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Celestino Neves*1, César Esteves1, Helena Greenfield2, Miguel Pereira1, Oksana Sokhatska1, Carmo Palmares3, Davide Carvalho4, Luís Delgado1 and José Luís Medina2
1São João Hospital, Faculty of Medicine, University of Porto, Porto, Portugal, 2Faculty of Medicine, University of Porto, Porto, Portugal, 3São João Hospital, Faculty of Medicine, University of Porto, Portugal, 4Endocrinology Service, São João Hospital. i3S - Instituto de Investigação e Inovação em Saúde, Faculty of Medicine, University of Porto, Porto, Portugal

 

Introduction: it is possible that the higher cardiovascular risk in Graves’ disease (GD) may be due not only to hemodynamic changes induced by the hyperthyroid state, but also to alterations in the cardiovascular risk factor profile.

Aim: The aim of our study is to evaluate the association between thyroid function in GD and lipoprotein profile, homocysteine, folate, vitamin B12, high-sensitivity C-reactive protein (hs-CRP) and insulin resistance.

Patients and Methods: We studied 104 subjects with Graves’ disease (GD) (55 with euthyroidism and 49 with hyperthyroidism). Hyperthyroidism was defined as increased levels of serum fT3 (>3.71pg/mL) and/or fT4 (>1.48ng/dL) in the presence of low TSH levels (<0.35mUI/mL). Euthyroidism was defined as levels of TSH, fT3 and fT4 within the normal range (0.35-4.94mUI/mL, 1.71-3.71pg/mL and 0.70-1.48ng/dL, respectively).

The laboratory data obtained included thyroid function tests [TSH, free T3 (fT3) and free T4 (fT4)] and levels of antithyroid antibodies (TRAb, anti-TPO and anti-Tg), total cholesterol (total-C), LDL-Cholesterol (LDL-C), HDL-Cholesterol (HDL-C), triglycerides (TG), apolipoprotein B (apoB), apolipoprotein A1 (apoA1), lipoprotein(a) [Lp(a)], hs-CRP, homocysteine, folate and vitamin B12. We also determined the Homeostasis Model Assessment for insulin resistance (HOMA-IR) and beta-cell function (HOMA-b), the Quantitative Insulin Sensitivity Check Index (QUICKI), the Hepatic Insulin Sensitivity Index (HISI), the Whole-Body Insulin Sensitivity Index (WBISI) and the Insulinogenic Index (IGI), in order to evaluate insulin resistance. For this purpose, a 75 g OGTT was performed, and venous blood samples were obtained every 30 minutes, for 120 minutes, for measurements of plasma glucose, insulin and C-peptide.

Results: Significantly higher median levels of TRAb were found in the hyperthyroid patients. On the other hand, levels of folate [5.1 (3.6-6.5) vs 6.9 (5.1-9.4), p=0.001] and WBISI [4.39 (2.49-6.15) vs 5.50 (4.08-7.79), p=0.015)] were significantly lower in the hyperthyroid group. It was observed that patients with higher levels of TRAb (OR=1.166; p=0.004) or hs-CRP (OR=3.064; p=0.042) had a higher risk of being hyperthyroid. The same observation was established for subjects with higher values of HOMA-IR (OR= 1.613; p=0.025) or IGI (OR=2.933; p=0.046). On the other hand, patients with higher levels of folate had a lower risk of being hyperthyroid. In the euthyroid group, TSH levels were positively correlated with WBISI values (r=0.291; p=0.047) and the levels of fT3 and vitamin B12 were negatively correlated (r=-0.358; p=0.01).

Conclusions: The hyperthyroidism in Graves’ disease is associated with insulin resistance and diminished levels of folate.

 

Nothing to Disclose: CN, CE, HG, MP, OS, CP, DC, LD, JLM

21770 16.0000 FRI-016 A Insulin Resistance, Lipoprotein Profile, Homocysteine, Folate, Vitamin B12, High-Sensitivity C-Reactive Protein and Insulin Resistance in Graves' Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Alejandro Velez-Hoyos*1, Claudia Monsalve2, Alex Ramirez2 and Natalia Aguirre3
1Dinamica IPS, Medellin, Colombia, 2Universidad Pontificia Bolivariana, Medellin, Colombia, 3Universidad de Antioquia, Medellin, Colombia

 

Introduction: The cutaneous manifestations of hypothyroidism are characterized by changes such as dermis atrophy and occasional hyperkeratosis due to glycosaminoglycan accumulation in interstitial spaces (1,2). Other manifestations include coldness, pallor, dryness, decreased sweating and association with vitiligo (3-5). The description of the dermatological findings in the context of specific causes of hypothyroidism is rare in medical literature (1-5). Since 1997 there has been a semeiological phenomenon, which occurs after performing fine needle aspiration cytology (FNAC) not described before in medical literature until now.

Objective: To describe de semeiological findings of a series of a thousand FNAC performed between 2011-2012 in a reference center in the city of Medellin.

Materials and methods: 1000 thyroid FNAC procedures were performed by specialist in pathology in a reference center in the city of Medellin between 2011-2012 with 400 patients characterized as benign category 2 by Bethesda who were evaluated for the appearance of skin lesions during the procedure.

Results: Amongst 400 patients diagnosed using FNAC in Bethesda’s category 2 benign, 38% presented a semeiological sign characterized by erythema in the neck area, sometimes in the shape of the thyroid or a butterfly, during approximately 10-20 minutes with complete disappearance afterwards.

  1. All the patients who presented this sign were diagnosed, histopathologically, with lymphocytic thyroiditis; the sign was not observed in patients with hypothyroidism of different etiologies, goiter or neoplasm.
  2. The patients who presented this semeiological sign did not report history of dermographism or hives.
  3. The patients who presented this semeiological sign did not present cutaneous reactions in other parts of the body simultaneously or after a similar stimulus.
  4. In all the patients differential diagnosis and alternative causes of the local redness were ruled out.
  5. All the patients who presented this sign had normal thyroid function or had hypothyroidism; none of the patients had hyperthyroidism.

Conclusion: A new semeiological sign is described in patients with lymphocytic thyroiditis during the performance of FNAC due to unknown causes, which could be explained by the release of histamine or unknown molecules, which could have triggered the local dermatological reaction. The transitory nature and described duration are in accordance with the physiological response of histamine and the local release of mastocytes. Given the context of autoimmunity, it is considered a local immune response in patients with lymphocytic thyroiditis.

 

Nothing to Disclose: AV, CM, AR, NA

21393 17.0000 FRI-017 A Clinical Experience of FNAC: Description of a New Semeiological SIGN in Limphocytic Thyroiditis in Medellin, Colombia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Juan Pablo Brito*1, Ana Castaneda-Guarderas2, Michael R. Gionfriddo1, Spyridoula Maraka1, Naykky Maruquel Singh Ospina1 and Victor M Montori1
1Mayo Clinic, Rochester, MN, 2Mayo Clinic

 

There are three effective treatments for Graves Disease (GD): thyroidectomy, radioactive iodine, and antithyroid drugs. These options differ in their efficacy, safety, convenience, and costs; none is clearly superior to the others for all patients. Practice patterns, however, suggest that patients are more likely to receive a particular mode of therapy depending on where they receive care. This inconsistency of practice suggests that GD patients are not receiving evidence-based patient-centered care. The overall goal of this study was to develop a decision aid for the treatment of GD

Methods

To develop the decision aid, we used a framework consisting of appraisal of existing evidence, prototypes development, field-testing and training. To test its impact, we designed and conducted a quasirandomized trial. We recruited patients referred to the Division of Endocrinology at Mayo Clinic in Rochester, MN for the management of GD during the period from April 2013 to December 2013 to and allocated them to usual care (UC); patients referred in the period January 2014 to September 2014 received care with GD choice. The primary outcomes were patient knowledge, patient involvement in decision-making and treatment choice. 
 Results

We engaged patients, clinicians, health service researchers and designers to develop a decision aid for use during the clinical encounter, which we dubbed GD Choice. This is an interim report: of the 52 patients evaluable for analysis, 33 were in the UC arm and 19 in the decision aid arm.  Baseline characteristics were found to not differ between arms.  Compared to UC, patients receiving GD Choice had greater involvement in decision making, as measured by the OPTION scale (mean OPTION score, 38.5 vs. 30.8 out of 100 points, difference 7.6 (95% CI 1.9, 13.4). p=0.01). We also found a large but imprecise improvements in decisional uncertainty among patients using GD choice compared to patients in the UC arm (31/100 points vs. 19/100 points, p=0.19). There were no differences in participant reported measures of shared decision making (SDMQ9). While imprecise, there was evidence of more knowledge about side effects in the GD Choice arm and evidence of difference in uptake of RAI across arms. Finally, the length of discussion was similar in both arms (37 minutes using the decision aid, 95% CI 31, 42 vs. 39 minutes, 95% CI 31.9, 46.5

 Conclusions

We were able to develop GD Choice, a feasible, acceptable, efficient, and effective encounter decision aid to promote shared decision making about treatment options for Graves Disease. GD Choice improves patient involvement in decision making about treatment options without increasing the length of the consultation. However, knowledge transfer, decisional uncertainty, and effect on treatment choice yielded imprecise results suggesting no difference across both groups.

 

Nothing to Disclose: JPB, AC, MRG, SM, NMS, VMM

21902 18.0000 FRI-018 A Decision Aid for Patients with Graves Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Serkan Yildirim1, Banu Sarer Yurekli2, Gokcen Unal Kocabas3, Ilker Altun*2, Ilgin Yildirim Simsir4, Murat Aksit5, Giray Bozkaya5 and Mehmet Erdogan6
1Izmir Bozyaka Education and Research Hospital, 2Ege University Faculty of Medicine, Izmir, Turkey, 3Bozyaka Education and Research Hospital, 4Ege University School of Medicine, Izmir, Turkey, 5Bozyaka Training and Research Hospital, Izmir, Turkey, 6Ege University Hospital

 

Aim

Vitamin D is a steroid hormone which has a well known role in maintaining bone health. Besides, vitamin D receptors have also been identified in different immune cell types. There are studies in the literature investigating the role of vitamin D in autoimmune diseases. We evaluated 25 hydroxy vitamin D level (25OHD) in subjects with Hashimato’s thyroiditis (HT) and healthy controls.

Material and Methods

We included 80 premenopousal women for this cross-sectional study. We recruited 40 patients with HT as study group. Patients with HT were seropositive for thyroglobulin autoantibodies (AntiTg) and/or thyroperoxidase autoantibodies (AntiTPO). Forty subjects who had seronegative for AntiTg and AntiTPO autoantibodies were accepted as control group. HT and control group were age and BMI matched. All patients were euthyroid and had normal body mass index (BMI). None of the subjects were taking oral contraceptives.

Results

Mean age of HT group was 33.0±8.0 and of control group was 30.3±7.9 (p=0.12). BMI was 24±3.1 kg/m2and 23.4±3.0 kg/m2 in HT and control group, respectively (p=0.31). All patients were euthyroid. There was no statistical difference in TSH levels between HT and control group (2.4±1.2 μIU/ml 1.9±0.9, p=0.07, respectively). The level of vitamin D in HT group was 16.1±7.6 ng/ml and in control group was 18.0±3.0 ng/ml. Although vitamin D was lower in HT group, the difference was not significant (p=0.30). There was not significant correlation between vitamin D and antibody levels (AntiTg and AntiTPO)  (p=0.85 and p=0.97 respectively).

Conclusion

There was no significant difference in vitamin D levels between HT and control group. In the literature there was one study that shows vitamin D level was lower in HT patients significantly. D vitamin could have role in immunity. Further studies are needed to evaluate the effect of vitamin D on autoantibody levels and autoimmunity. 

 

 

 

 

Nothing to Disclose: SY, BS, GU, IA, IY, MA, GB, ME

21906 19.0000 FRI-019 A Vitamin D Levels in Premenouposal Women with Hashimatos Thyroiditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM FRI 001-019 6033 1:00:00 PM Clinical and Translational Thyroid and Thyroid Autoimmunity Poster


Banu Kucukemre Aydin*1, Esra Devecioglu1, Sezin Kisabacak1, Gulbin Gokcay1, Firdevs Bas1, Sukran Poyrazoglu1, Ruveyde Bundak1 and Feyza Darendeliler2
1Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey, 2Istanbul University, Istanbul, Turkey

 

Introduction: Increased risks of obesity and metabolic syndrome have been shown in small for gestational age babies with accelerated weight gain. Our aim was to investigate the effects of growth rate during the first years of life on the rate of obesity and the other parameters of metabolic syndrome in children born appropriate for gestational age (AGA).

Methods: 141 AGA children aged between 6-9 years who were attending the Well Child Clinic between the ages of 1 month and 5 years were included in the study. Anthropometric measurements during the follow up were obtained from children’s files. Weight, height, waist circumference (WC) and blood pressure (BP) were measured at the time of investigation at a mean age of 7.6±0.9 years. Clinically significant accelerated weight gain was defined as a gain in weight z-score 0.67 SDS. Early adiposity rebound (EAR) was defined as the 2nd rise in body mass index (BMI) before 5 years of age. Fasting blood samples for insulin, glucose, total cholesterol, HDL, LDL and VLDL cholesterol, triglyceride, leptin and adiponectin were collected.

Results: 17% of girls were overweight, 10% obese and 5.6% were morbidly obese. 13% of boys were overweight, 17% obese and 10% morbidly obese. Overweight and obese girls had a significantly higher BMI SDS starting from 9th month and this difference became more evident with time and was preserved until 60th months of age. BMI SDS was significantly higher in obese and overweight boys starting from 18th month and this difference became more evident with time and was preserved until 60th months of age.

Girls having an accelerated weight gain between 6 -15 months of age were more likely to be obese or overweight (p=0.007) and their systolic BP SDS values were significantly higher at the ages of 6-9 years (p=0.006).  The exclusive and total breastfeeding times were shorter in girls with accelerated weight gain (p=0.006 and p=0.006).

Girls with EAR had higher BMI and WC SDS at the ages of 6-9 years (p=0.001and p=0.001). Boys with EAR had higher height, BMI and WC SDS (p=0.02, p<0.001 and p=0.002, respectively). Height SDS target height SDS difference and insulin levels were higher in boys with EAR (p=0.04 and 0.03, respectively).

Overweight and obese boys had higher systolic and diastolic BP SDS and higher insulin, HOMA-IR, total cholesterol levels (p=0.01, p=0.01, p<0.001, p=0.002 and p=0.04, respectively). Overweight and obese girls had higher insulin, HOMA-IR and triglyceride levels, higher leptin/BMI and leptin/adiponectin ratios (p=0.006, p=0.007, p=0.005, p=0.002 and p=0.002, respectively).

Conclusions: Early growth parameters could help to identify the children with the risk of obesity. 

 

Nothing to Disclose: BK, ED, SK, GG, FB, SP, RB, FD

20024 1.0000 FRI-552 A At What Age Does Obesity -the Disease of the 21st Century- Starts? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 552-561 6042 1:00:00 PM Obesity: Pediatric and Surgery Poster


Sani M. Roy*1, Jordan G. Spivack2, Myles S. Faith3, Alessandra Chesi1, Jonathan A. Mitchell4, Struan F.A. Grant2, Babette S. Zemel1 and Shana E. McCormack1
1The Children's Hospital of Philadelphia, Philadelphia, PA, 2The Children's Hospital of Philadelphia, 3University of North Carolina, 4The University of Pennsylvania

 

Background: There is no consensus on how to measure adiposity in children under age 2 years. Weight-for-length (WFL) percentile curves are often used but do not reflect age-dependent patterns of infant growth. No studies have compared WFL and Body Mass Index (BMI) Z-scores in infancy.

Objective: To compare WFL and BMI Z-scores in infancy and identify characteristics associated with discordance between these measures.

Design/Methods: Growth data were extracted from electronic medical records for 73,949 healthy, full-term infants, ages 0 to 24 months, from the CHOP pediatric care network. WHO WFL and BMI Z-scores were calculated at 0, 0.5, 1, 2, 4, 6, 9, 12, 15, 18, and 24 months (corresponding to usual well-child checks), and correlation analysis was performed for each age group. WFL and BMI percentiles were classified as: underweight (<5%ile), normal weight (5-85%ile), overweight (85-97.7%ile), and obese (>97.7%ile); measurements were considered “concordant” if the percentile category was the same and “discordant” if different. Bivariate analyses were performed to assess effects of age category (> or <6 months), sex, population ancestry, Medicaid status, length and weight Z-score categories (by chi-square) on discordance status. T-tests assessed difference in BMI Z-score at age 2 years by concordance status at age 2 months.

Results: Using 346,939 simultaneous length and weight measurements, correlations between WFL Z-scores and BMI Z-scores increased from r=0.88 at birth (p<0.001) to r=1.0 at age 6 months (p<0.001) and remained strong (r=0.98-0.99) from ages 6 to 24 months (p<0.001). Overall, 10% of WFL and BMI measurements were discordant; 14% were discordant below and 6% discordant above age 6 months. Bivariate analysis demonstrated more discordance than expected in males (p<0.001), non-Hispanic Blacks (p<0.001), age <6 months (p<0.001), Medicaid status (p<0.001), and extremes of length or weight Z-scores at >97.7%ile or <5%ile (p<0.001 for both). Those discordant at age 2 months had significantly higher BMI Z-score at age 2 years than subjects with concordant measures (Z=0.65 vs. Z=0.45, p<0.001).

Conclusions: Concordance between WFL and BMI Z-score increased from birth to 6 months and remained consistently high thereafter. Discordance of WFL and BMI Z-score was associated with clinical factors by bivariate analysis (male sex, non-Hispanic Black ancestry, age <6 months, Medicaid status, and extreme weight or length measurements of <5%ile or >97.7%ile) and, in early infancy, was related to higher risk of obesity in early childhood. Multivariate analyses are ongoing with a view to developing evidence-based guidance for clinicians on how best to use anthropometrics to counsel regarding infants' future risk for obesity.

 

Nothing to Disclose: SMR, JGS, MSF, AC, JAM, SFAG, BSZ, SEM

19216 2.0000 FRI-554 A Concordance Between Weight-for-Length and BMI Under Age 2 Years in a Large, Longitudinal, Multi-Ethnic Cohort 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 552-561 6042 1:00:00 PM Obesity: Pediatric and Surgery Poster


Rogerio Friedman*1, Natalia Luiza Kops2, Jaqueline Driemeyer Correia Horvath2, Fabiana S Costa2 and Mariana Laitano Dias de Castro2
1Hospital de Clinicas de Porto Alegre / UFRGS, Porto Alegre, Brazil, 2Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

 

Eating disorders are highly prevalent in severely obese subjects. The possibility of a genetic predisposition has been considered, but, so far, not confirmed. We analyzed a possible relationship between the occurrence of Binge Eating Disorder (BED) and mutations in Fat mass and obesity associated (FTO) gene in patients with severe obesity.  Patients referred to the Endocrine clinic of Hospital de Clinicas de Porto Alegre (HCPA), with morbid obesity for evaluation towards bariatric surgery, according to the Brazilian guidelines, between January 2010 and December 2013 were studied. The patients answered a structured questionnaire (Binge Eating Scale) for diagnosis of BED. A blood sample was drawn within 7 days of the interview for analysis of the candidate gene polymorphism. One-hundred and sixty patients were sequentially studied. The subjects were 44.5 ± 11.5 (mean ± SD) years old, 78.8% female, 56.7% without BED, 22.3% with severe compulsion and 21.0% with moderate compulsion. The frequencies of the rs9939609 polymorphism were 21.9% (TT), 41.9% (AT), and 36.3% (AA). The body mass index (BMI) was 47.8 ± 7.3kg/m², weight was 126.8 ± 24.1 kg, arm circumference was 42.6 ± 5.8cm, waist circumference was 135.2 ± 15.3cm, hip circumference was 138.3 ± 14.7cm. Total Cholesterol was 187.8  ±  36.6 mg/dL, HDL cholesterol 40.7 ± 9.5 mg/dL, LDL cholesterol 113.8 ± 31.8mg/dL, triglycerides 167.9 ± 94.7mg/dL, fasting glucose 122.3 ± 38mg/dL, glycated hemoglobin 6.84 ± 1.68%, and insulin 31.1 ± 19.9 µU/ml. Waist circumference and fasting glucose were significantly different between the three genotypes. Nevertheless, the frequency of BED was not different between the groups. The connection between FTO and satiety appears in studies in rodents where the mRNA of FTO is highly expressed in brain regions important for energy regulation. The possible association of specific polymorphisms with BED in the setting of severe obesity remains open for future studies.

 

Nothing to Disclose: RF, NLK, JDCH, FSC, MLD

21241 3.0000 FRI-555 A The Association of Fto Polymorphism rs9939609 with Binge Eating Disorder in Morbidly Obese Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 552-561 6042 1:00:00 PM Obesity: Pediatric and Surgery Poster


Rogerio Friedman*1, Natalia Luiza Kops2, Jaqueline Driemeyer Correia Horvath2 and Mariana Laitano Dias de Castro2
1Hospital de Clinicas de Porto Alegre / UFRGS, Porto Alegre, Brazil, 2Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

 

Genetic factors may play a significant role in the pathogenesis of overweight and obesity, contributing with of to 40% of the variability of body mass índex (BMI). The Ala54Thr polymorphism of the Fatty Acid Binding Protein-2 (FABP-2) gene confers a higher affinity for long chain fatty acids than the Ala54Ala genotype. Hence, various studies have associated the presence of the Thr54 allelle with the serum levels of lipids. Nevertheless, these findings have not been controlled for the patients’ food intake, which could be the factor responsible for this difference.

Objective: To evaluate the anthropometric and lipid profiles of patients with grade III obesity, with or without the Thr allele of the Fatty Acid Binding Protein 2 gene (FABP-2), taking into account the patients' food consumption.

Methods: 89 patients sequentially referred for bariatric surgery were submitted to nutritional, laboratory (lipids) and genetic assessments.  Nutritional evaluation included anthropometry (height on a wall mounted stadiometer - Sany, Brazil - and weight on a digital scale - Filizolla, Brazil), and 3-day weighed food records (using a digital kitchen scale - Plenna, Brazil - and a measuring cup). Laboratory assessment included total cholesterol (enzymatic colorimetric, Hitachi 917, Roche, Brazil), HDL cholesterol (homogeneous, enzymatic colorimetric, Hitachi 917, Roche, Brazil) and triglycerides (enzymatic colorimetric, Hitachi 917, Roche, Brazil). LDL cholesterol was calculated from the Friedewald equation. The genetic assessment consisted of the genotyping of the FABP-2 gene by a  Real-Time DNA amplification technique (ID C_30090620_10 assay, Applied Biosystems, Foster City, CA; TaqMan® SNP genotyping Assay, Applied Biosystems, CA, USA).We excluded those subjects with triglycerides> 400mg/dl. 

Results: Among the patients, 33.3% had the Ala54Thr genotype and 7.1% had the Thr54Thr genotype. No significant differences were found between these 2 groups in terms of anthropometric parameters. Total cholesterol (179.273 ± 33.1 vs 196.77 + 34.34; p=0,009) was lower in the carriers of the Thr allele. The only significant difference in dietary intake was the omega 6/omega 3 ratio, which was found to be lower in the carriers of the Ala allele (8.15 + 3.08 vs 9.06 + 2.66, p=0.017). When adjusted for dietary intake, serum total cholesterol was no longer different (p=0,754) between patients with and without the Thr allele. 

Conclusions: When the dietary intake of Polyunsaturated fatty acids was controlled for,  no difference in blood lipids was found between carriers and non-carriers of the Thr54 FABP-2 allelle. This finding, though preliminary due to sample size, suggests that future studies analyzing FABP-2 polymorphisms and serum lipid levels should always take into account the dietary fat intake.

 

Nothing to Disclose: RF, NLK, JDCH, MLD

21877 4.0000 FRI-556 A Ala54Thr Polymorphism of Fatty Acid Binding Protein-2 and Blood Lipids of Morbidly Obese Patients Controlled By Food Intake 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 552-561 6042 1:00:00 PM Obesity: Pediatric and Surgery Poster


Christian Ludwig Roth*1, Clinton Elfers2 and Thomas Reinehr3
1Seattle Children's Rsrch Inst, Seattle, WA, 2Seattle Children's Research Institute, Seattle, WA, 3University of Witten-Herdecke, Datteln, Germany

 

Background: Irisin is a recently identified myokine responsible for browning of adipocytes and thereby affecting thermogenesis and metabolic homeostasis. However, previous studies showed that white adipose tissue also secretes irisin and that circulating irisin is elevated in obesity but decreased in type 2 diabetes subjects. The aim of this study was to test the hypothesis that serum irisin levels are associated with metabolic outcomes in children participating in obesity intervention.

Design: The relationships between fasting irisin levels and parameters of the metabolic syndrome and response to  oral glucose tolerance test were studied in 40 obese children (mean age 12.7±1.6 years; 50% male; 30% prepubertal; mean BMI 28.9±3.8; 50% with normal and 50% with impaired glucose tolerance at baseline) participating in a 1-year lifestyle intervention.

Results: In cross-sectional data analyses, baseline irisin was significantly associated with parameters of the metabolic syndrome such as insulin (r=0.29, p=0.033), 2h glucose in OGTT (r=0.33, p=0.020), HOMA (r=0.30, p=0.031), HDL-cholesterol (r=-0.28, p=0.039), AST (r=0.41, p=0.004), and ALT (r=0.40, p=0.005). In multiple linear regression analysis (r²=0.18) adjusted for age and gender, irisin was significantly associated with pubertal stage (β-coefficient 2.5±1.1, p=0.04), HDL-cholesterol (β-coefficient -0.09 ±0.04, p=0.036), and HOMA (β-coefficient 0.31±0.12, p=0.019). Serum irisin concentrations differed significantly (p=0.010) between 12 prepubertal (median irisin concentration 7.5 (IQR 5.8-11.5) ng/ml) and 28 pubertal children (median irisin concentrations 10.9 (IQR 9.4-12.8) ng/ml). After 1 year intervention, 50% of children had substantial weight loss (ΔBMI-SDS>0.3). In longitudinal analyses, baseline irisin levels were significantly negatively related to changes of BMI-SDS (r=-0.31, p=0.025), and changes of different metabolic parameters including HOMA (r=-0.31, p=0.025), ALT (r=-0.42, p=0.004), and insulin (r=-0.41, p=0.004), while positively related to changes of HDL-cholesterol (r=0.31, p=0.026), using partial regression analyses adjusted to changes of puberty. In multiple linear regression analysis (r²=0.40), changes of irisin levels were significantly associated with entry into puberty (β-coefficient 5.2 ±1.4, p<0.001), change of glucose (β-coefficient 0.17 ±0.06, p=0.008), and 2h glucose in OGTT (β-coefficient 0.03 ±0.01, p=0.023).

Conclusion: Irisin increased strongly at entrance into puberty which could be related to the greater susceptibility for insulin resistance in this age group. Higher serum irisin at baseline was associated with more severe metabolic syndrome and less favorable changes (BMI, cardiovascular risk factors) in response to lifestyle intervention.

 

Nothing to Disclose: CLR, CE, TR

20144 5.0000 FRI-557 A Relationship Between Irisin, Pubertal Stage, and Metabolic Syndrome in Obese Children Participating in a Lifestyle Intervention 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 552-561 6042 1:00:00 PM Obesity: Pediatric and Surgery Poster


George Paltoglou*1, Maria Schoina2, George Valsamakis1, Alexandra Avloniti2, Athanasios Chatzinikolaou2, Athanasios Jamurtas3, Dimitris Draganidis2, Ioannis Papassotiriou4, Alexandra Margeli5, Christina Kanaka-Gantenbein6, Maria Papagianni7, Nicolaos Salakos8, George P Chrousos8, Ioannis G Fatouros9 and George Mastorakos1
1Athens University Medical School, Athens, Greece, 2Democritus University of Thrace, 3University of Thessaly, 4“Aghia Sophia” Children’s Hospital, Athens, Greece, 5"Aghia Sofia" Children’s Hospital, Athens, Greece, 61st Dept. of Pediatrics, National and Kapodistrian University of Athens, Medical School, Athens, Greece, 7Aristotle University of Thessaloniki, Thessaloniki, Greece, 8Athens University Medical School, 9Democritus University of Thrace, Athens, Greece

 

Oxidative stress and adipocytokines in humans have been associated with obesity and resulting co-morbidities even in childhood. To investigate the association of adipocytokines with markers of pro- and anti- oxidation at baseline and post acute aerobic exercise we studied 76 healthy pre- and early pubertal, normal weight and obese boys. At baseline they underwent a baseline blood sampling followed by an aerobic exercise bout until exhaustion at 70% VO2max and a subsequent (post-exercise) sampling for the measurement of pro-oxidation markers (TBARS, PCs); anti-oxidation markers (GSH, GSSG, GPX, Catalase, TAC), adipocytokines (adiponectin, leptin, NGAL and RBP4) and inflammatory markers (hsCRP and hsIL6).

Baseline and post-exercise concentrations of leptin and hsCRP were greater in obese than normal weight pre- and pubertal boys. Baseline and post-exercise concentrations of adiponectin were lower in obese than normal weight pre- and pubertal boys. Baseline and post-exercise concentrations of hsIL-6 were greater in obese than normal weight pre- pubertal boys. RBP4 concentrations significantly increased during exercise in normal weight pubertal boys.

In pre- and pubertal normal weight subjects, baseline concentrations of hsCRP correlated positively with NGAL concentrations. In pre-pubertal obese subjects baseline concentrations of hsCRP and hsIL-6 correlated negatively with Catalase and positively with PCs, respectively; ΔNGAL correlated positively with ΔhsCRP. In pre- and pubertal obese subjects, ΔhsIL-6 correlated positively with ΔPCs and negatively with ΔGSSG, respectively. In all subjects taken as a single group, baseline adiponectin and leptin were the best positive predictors for post-exercise concentrations of Catalase and of TBARS respectively. Baseline hsIL-6 was the best positive and negative predictor for post-exercise PCs and GSH/GSSG respectively.

In conclusion, in boys obesity in pre- and early puberty is associated with increased pro-oxidation, inflammation and leptin concentrations while normal weight at the same period of life is associated with increased anti-oxidation and adiponectin concentrations.  Puberty seems to attenuate the inflammatory response in obese boys while only RBP4, a presumed myokine, increases post-exercise in normal weight pubertal boys. These findings indicate the deleterious association of pro-oxidation, low-grade inflammation and induction of insulin resistance in presence of increased adipose tissue mass in pre- and early- pubertal boys. The possible role of RBP4 as an adipo-myokine emerges.

 

Nothing to Disclose: GP, MS, GV, AA, AC, AJ, DD, IP, AM, CK, MP, NS, GPC, IGF, GM

21669 6.0000 FRI-558 A The Morbid Connection Among Obesity, Aseptic Inflammation, Pro-Oxidation and Markers of Insulin Resistance in Pre- and Early- Pubertal Boys before and after an Acute Bout of Treadmill Exercise 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 552-561 6042 1:00:00 PM Obesity: Pediatric and Surgery Poster


Man-Ho Choi*1, Hyun-Hwa Son1, Shin Hye Kim2, Ju-Yeon Moon1, Bong Chul Chung1 and Mi-Jung Park2
1KIST, Seoul, Korea, Republic of (South), 2Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea, Republic of (South)

 

Quantitative sterol signatures in obese children and their clinical implications have not been fully investigated. To evaluate the metabolic changes of cholesterol and its precursors/metabolites in serum of childhood obesity, a total of 253 children (72 obese, 39 overweight and 72 normal controls aged 6 to 14 yr; 147 girls and 106 boys) were recruited. Anthropometric indices, body composition and fasting total lipid profiles were determined. Serum concentrations of 20 sterols, as their free fraction, were analyzed by gas chromatography-mass spectrometry (GC-MS)-based metabolite profiling. Although no significant differences of Total- and LDL-cholesterols between groups were found, the serum levels of main cholesterol precursors, lanosterol (p < 0.02) and lathosterol (p < 0.0001), were remarkably increased with obesity, and they showed positive correlations with waist to hip ratio, body fat percent and body fat mass. The metabolic ratios of lanosterol and lathosterol to cholesterol were also elevated (p < 0.01 both), which indicate up-regulation of cholesterol biosynthesis in childhood obesity. In contrast, the absorption of plant sterols was tended to compensatory decrease in obese children. The strong correlations of free cholesterol with Total- and LDL-cholesterols were also observed (r > 0.760, p < 0.001), while high-density lipoprotein cholesterol had no correlation. The level of total cholesteryl ester was closely associated with triglyceride (r = 0.763, p < 0.001). The results indicate that the childhood obesity can maintain cholesterol homeostasis, but increased cholesterol synthesis might be a major risk factor in cardiometabolic conditions. The findings reported here provide insight into GC-MS-based quantitative sterol signatures as a complementary assay for understanding cholesterol metabolism in obesity, while individual sterols changed are closely associated with body compositions and lipid profiles. The association of higher levels of serum lanosterol, lathosterol and cholesteryl esters correlated with cardiometabolic risk factors will be further investigated.

 

Nothing to Disclose: MHC, HHS, SHK, JYM, BCC, MJP

19839 7.0000 FRI-559 A Altered Serum Sterol Signatures Reveal an Increased Cholesterol Biosynthesis in Childhood Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 552-561 6042 1:00:00 PM Obesity: Pediatric and Surgery Poster


Nicte Figueroa-Vega*1, Lissette López2, Ma Eugenia Garay-Sevilla3 and Juan M Malacara4
1University of Guanajuato, Leon, 2University of Guanajuato, 3Univ de Guanajuato, Leon GTO, Mexico, 4University of Guanajuato, Leon Campus, Leon, Guanajuato, Mexico

 

Glycosylation is an ubiquitous post-translational protein modification that modulates the structure and function of polypeptides. It may has two variants, N- and O-linked. O-GlcNAc (O-GlcNAcylation) involves the reversible addition of a single O-GlcNAc moiety to Ser/Thr residues, by two enzymes: O-GlcNAc transferase (OGT), and β-N-acetylglucosaminidase (OGA). Variation in protein glycosylation has physiological significance. Obesity is strongly associated with low-grade inflammation, and O-GlcNAc protein sites are found in leukocytes, therefore, we hypothesized that leukocyte proteins from obese children may have increased O-GlcNAc, and that glycan changes may be related to metabolic status. We compared O-GlcNAc in several leukocytes from obese and normal weight children in order to identify the factors associated that may contribute to O-GlcNAc in obesity. We recruited thirty-two obese children and thirty normal weight age-matched children, and collected clinical data including BMI, waist girth, fasting plasma glucose, lipid profile, insulin, and RBP4. O-GlcNAcylation expression was determined in T lymphocytes, T CD4+, T CD8+, B lymphocytes, CD14+CD11c+ monocytes and CD64+ neutrophils populations by FACS. After comparing obese with normal weight children, we found that obese children had enhanced O-GlcNAcylation by 22.9±6.2% in the total leukocyte population. O- GlcNAc modification was augmented in both T and B lymphocytes, and T lymphocytes also showed a robust increase in O-GlcNAc intensity. By multivariate analyses, we found that O-GlcNAc expression on T lymphocytes and T CD4+ cells correlated positively with triglycerides but negatively with glucose levels. O-GlcNAcylation expression on B lymphocytes was related to waist girth. Finally, we found an inverse relationship between O-GlcNAc expression on granulocytes and RBP4 levels. Abnormalities in lipid profile and glucose levels alter the amount of O- GlcNAc in lymphocytes, suggesting a role of this process in recruitment and activation of T lymphocyte. Insulin resistance decreases O-GlcNAc in neutrophils, contributing to susceptibility to infections. In summary, these data support that O-GlcNAc is actively involved in the appropriate function of immune cells and that obesity may impair glycosylation.

 

Nothing to Disclose: NF, LL, MEG, JMM

19362 8.0000 FRI-560 A Altered Leukocyte O-Glcnacylation Expression Suggests an Impairment of Immune Cells Function in Obese Children 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 552-561 6042 1:00:00 PM Obesity: Pediatric and Surgery Poster


Francesco Leo*1, Chantal Di Segni2, Sebastiano Raimondo2, Jacopo Pareo1, Maria Cristina Mele2, Andrea Silvestrini2, Elisabetta Meucci2, Aurora Natalia Rossodivita2 and Antonio Mancini2
1Catholic University of The Sacred Heart, Rome, Italy, 2Catholic University of the Sacred Heart, Rome, Italy

 

Kisspeptin is a neuropeptide secreted in the anteroventral periventricular and arcuate hypothalamic nuclei involved in starting of pubertal development and also in other functions typical of adult life. Its blood value varies according with sex so they are higher in prepubertal girls and in adult women compared to age-matched male. Recently it has been proposed a possible role in the stimulation of antioxidant defenses in murine models. We studied Kisspeptin plasma levels in a population of 27 prepubertal (stage 1 of Tanner) children (13 males and 14 females) aged 5-12 years, classified on the bases of Cole’s criteria into 3 overweight and 24 obese. 8 normal weight children, aged 6-12 years, were studied as controls. We evaluated metabolic parameters: glucose and insulin levels after oral glucose load, total- LDL- and HDL-cholesterol, triglycerides, uric acid, total proteins, C Reactive Protein.  In order to evaluate kisspeptin levels, morning blood sample was immediately centrifuged for 11 minutes at 2700 rpm and 4°C to obtain plasma, that was stocked at a temperature of -80°C. Plasma was then acidified to extract peptides in a C-18 SEP-Column (Phenomenex Inc, Torrance, CA, USA) containing 200 mg of C18. The eluted samples were evaporated to dry and finally stored at -80°C until the time of assay. The concentration of Kisspeptin (expressed in pg/ml) was measured using the kit KISS1 (61-121) Amide-Metastin (1-54)-NH2 (Rk-048-59, Phoenix Pharmaceuticals, Inc., Burlingame, CA, USA) based on Radio Immuno Assay. We did not find significant differences between obese and normal weight children (mean ±SEM: 20.1±1.96  and 20.7±0.68 pg/ml, respectively) and between males and females obese children (mean±SEM 19.05±3.39  and 20.9±2.49 pg/ml,  respectively). Kisspeptin levels did not correlate with BMI,  HOMA index and Insulin peak levels after glucose load. On the contrary a significant correlation was found between Kisspeptin and uric acid (Spearman correlation test=0,455; p-value=0,059). These preliminary data suggest that Kisspeptin could play a role in antioxidant status and could be regarded as metabolic modulator and not only a regulator of pituitary gonadal axis. Further studies can clarify the complex interrelationship between central and peripheral Kisspeptin secretion and oxidative stress in children obesity.

 

Nothing to Disclose: FL, CD, SR, JP, MCM, AS, EM, ANR, AM

19332 9.0000 FRI-561 A Frailty of Obese Children: Evaluation of Antioxidant Systems 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 552-561 6042 1:00:00 PM Obesity: Pediatric and Surgery Poster


Guanghong Jia*1, Javad Habibi1, Annayya R. Aroor1, Zhe Sun2, Lixin Ma3, Vincent G. DeMarco1, Brian P Bostick1, Melvin R Hayden4, Adam T Whaley-Connell1, Gerald A. Meininger2 and James R. Sowers5
1University of Missouri, Columbia, MO, 2University of Missouri, 3University of Missouri - School of Medicine, 4Univ of Missouri Columbia, Camdenton, MO, 5Harry S Truman VA Hospital and University of Missouri, Columbia, MO

 

The rising obesity rates parallel increased consumption of a western diet (WD), high in fat and fructose, which is associated with increased liver production of uric acid.  Population based data support the notion that elevated serum uric acid levels are associated with aortic stiffness, left ventricular hypertrophy and diastolic dysfunction.  However, the mechanism by which excess uric acid promotes these maladaptive cardiovascular effects has not been explored.  In assessing the adverse cardiovascular effects of elevated levels of uric acid accompanying consumption of a WD, we hypothesized that reductions in serum levels of uric acid and tissue xanthine oxidase (XO) activity would prevent WD-induced development of aortic and cardiac stiffness, cardiomyocyte hypertrophy, and impaired diastolic relaxation by reducing growth and pro-fibrotic signaling pathways.  Four wk-old male C57BL6/J mice were fed a WD consisting of excess fat (46%) and fructose (17.5%) or a mouse chow (CD) with or without allopurinol (125 mg/L), a XO inhibitor, for 16 wks. The WD induced increases in serum uric acid along with increases in aortic and cardiac tissue XO activity that was temporally related to increases in body weight, fat mass, and insulin resistance (HOMA-IR) without changes in blood pressure. The WD increased endothelial cell and vascular smooth muscles cell stiffness as determined by ex vivo an atomic force microscopy technique. The elevated aortic stiffness was accompanied by increased expression of inflammatory cytokines IL-1 and MCP-1 and pro-inflammatory M1 markers CD 86 and CD11b. High resolution cardiac MRI revealed that WD caused diastolic dysfunction (LV diastolic relaxation time 35.3 ms for WD versus 25.4 ms for CD, p<0.01; Initial filling rate 0. 28 µl/ms for WD, 0.43 µl/ms for CD, p<0.05). Also, the WD induced cardiomyocte hypertrophy, myocardial oxidative stress, and interstitial fibrosis. Transmission electron microscopy examination of myocardial ultrastructure revealed that WD induced remodeling was associated with large mitochondria with disordered cristae and increased lysosomes. Further, in cardiac tissue the WD enhanced activation of the S6 kinase-1 growth pathway, increased reactive oxygen species and MMP-9 activity, and the pro-fibrotic transforming growth factor (TGF)-β1/Smad2/3 signaling pathway, and macrophage pro-inflammatory polarization. All of the WD abnormalities were improved with allopurinol treatment, which lowered aortic and cardiac XO as well as serum uric acid levels. These findings support the hypothesis that WD induced  increases in  production of uric acid and cardiac and aortic  XO activity and resultant oxidative stress and inflammation and fibrosis  a promotes aortic and cardiac  stiffness, cardiomyocyte hypertrophy, and associated impaired diastolic relaxation.

 

Nothing to Disclose: GJ, JH, ARA, ZS, LM, VGD, BPB, MRH, ATW, GAM, JRS

PP19-1 20495 1.0000 FRI-562 A Uric Acid Promotes Aortic Stiffness and Left Ventricular Diastolic Dysfunction in Mice Fed a Western Diet 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Jianqiang Mao*, San-Pin Wu, Chad J. Creighton, Sophia Y Tsai, Ming-Jer Tsai and Francesco J. DeMayo
Baylor College of Medicine, Houston, TX

 

Steroid receptor coactivator 2 (SRC-2, TIF2, GRIP1, or NCOA2) plays an important role in lipid metabolism and energy homeostasis. Global ablation of SRC-2 protects the mice against high-fat diet induced obesity and liver-specific knockout impairs hepatic glucose production. To investigate the role of SRC-2 in adipogenesis, we inserted a CAG-LSL-hSRC-2 (hSRC-2LSL/+) minigene in the ROSA26 locus by homologous recombination.  In the presence of Cre recombinase, the loxP-STOP-loxP (LSL) cassette will be removed to allow expression of human SRC-2 in mice. To study the role of SRC-2 in adipose tissues, we bred the hSRC-2LSL/+ allele into the aP2-cre background and the resulting mice (SRC-2:OE) produced elevated levels of hSRC-2 in both white adipose tissue (WAT) and brown adipose tissue (BAT). Consequently, these mice exhibited obesity as manifested by the significant increase of fat mass and hepatic steatosis. The brown adipocyte cell size was significantly larger in hSRC-2 overexpressing mice compared to that in control mice.  Blood glucose level and cholesterol including both HDL and LDL were significantly increased in SRC-2:OE mice; while serum triglyceride level was not affected by high levels of hSRC-2. The overexpression of hSRC2 did not affect energy expenditure, but it led to decreased lipolysis in adipose tissue, decreased insulin sensitivity and impaired glucose tolerance. Hyperinsulinemic-euglycemic clamp further exhibited that insulin insensitivity occurred only in white and brown adipose tissues but not in soleus muscle. ChIP-seq analysis reveals that SRC-2 binding regions and motifs are overlapped in WAT and BAT, but unique binding regions and motifs exist in either of adipose tissues. Gene expression profiling suggests that inflammation, instead of endoplasmic reticulum stress, might cause the obesity phenotype. Since aP2-Cre is also active in macrophage, to exclude the influence of hSRC-2 overexpressed in macrophage on observed phenotype, we generated macrophage-specific Lyz2-Cre-driven hSRC-2 overexpressing mice; however, overexpression of hSRC-2 in macrophage did not affect the body weight, blood glucose and cholesterol, as well as the weight of adipose tissues. These data suggests a mechanism through which SRC-2 differentially regulates the gene expression in these two types of adipose tissues.

 

Nothing to Disclose: JM, SPW, CJC, SYT, MJT, FJD

20199 2.0000 FRI-563 A Overexpression of Steroid Receptor Coactivator 2 (SRC-2) in Adipose Tissue Leads to Hepatic Steatosis, Obesity and Insulin Resistance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Kanakadurga Singer*1, Nidhi Maley2, Taleen Mergian3, Jennifer DelProposto3, Kae Won Cho4, Gabriel Martinez-Santibanez2, Brian Zamarron3 and Carey N. Lumeng1
1University of Michigan, Ann Arbor, MI, 2University of MIchigan, 3University of Michigan, 4Soonchunhyang University

 

Background: Inflammation is a recognized link between obesity and metabolic disease.  Women of reproductive age are protected from metabolic disease compared to post-menopausal women and males.  Most murine studies are skewed towards the use of male mice to study obesity-induced metabolic dysfunction because of a similar protection in female mice. The contribution of sex differences in inflammatory responses has not been assessed as a mechanism of these differences.

 

Objective: The objective of this study was to understand if sex differences in obesity-induced inflammation contribute to differences in metabolic disease risk between males and females.

 

Design/Methods: Male and female C57Bl/6J mice were fed a high-fat diet (HFD) for 6 or 16 weeks, and glucose metabolism and leukocyte activation in bone marrow, blood, and adipose tissue were assessed.  Competitive bone marrow transplant experiments using mixtures of male and female bone marrow as donors were performed to assess differences between sexes in myeloid responses to obesity.  Colony forming unit (CFU) assays were used to assess progenitor capacity to produce myeloid leukocytes from male and female bone marrow.

 

Results: Males and females gained weight and adiposity with short- and long-term HFD; however, male mice demonstrated more weight gain and increased CD11c+ adipose tissue macrophage content compared to female mice.  Adipocyte hypertrophy was similar between sexes suggesting that the male immune response to an increase in adiposity is different.

Male mice were noted to have worse glucose tolerance compared to females on the same diet regimen. Competitive bone marrow transplant studies demonstrated that obesity induced a preferential contribution of male hematopoietic cells to circulating leukocytes and adipose tissue macrophages compared to female cells independent of the sex of the recipient.  CFU assays showed that ex vivo male bone marrow was able to generate more granulocyte and macrophage colonies after fatty acid stimulation and after HFD exposure compared to female marrow.

Conclusion: Sex differences in obesity-induced leukocyte activation are due to cell intrinsic differences in hematopoietic cell activation in response to obesogenic cues.  This may contribute to sexually dimorphic responses to HFD induced metabolic dysfunction.

 

Nothing to Disclose: KS, NM, TM, JD, KWC, GM, BZ, CNL

PP19-2 18284 3.0000 FRI-564 A Hematopoietic Stem Cells Contribute to Sexually Dimorphic Inflammatory Responses to Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Alev Cagla Ozdemir*, Grace M Wynn and Mary K Rudd
Emory University, Atlanta, GA

 

Duplication of the guanine nucleotide-binding protein beta subunit 3 (GNB3) gene is associated with early-onset obesity. Children with an unbalanced chromosome translocation that includes GNB3 have BMI values above the 95th percentile. A cytosine to thymine (C825T) polymorphism in GNB3 is also associated with hypertension, obesity and metabolic syndrome; however the mechanism of GNB3-related obesity is unknown. We created BAC-transgenic mice that carry the human risk-allele (T) of GNB3. Heterozygous mice express transgenic GNB3 in whole brain, hypothalamus, olfactory bulb, and cerebellum at levels significantly greater than endogenous Gnb3. These GNB3-T mice weigh significantly more than their wild-type littermates starting at age 6-7 weeks (p=0.002). At 20 weeks, GNB3-T mice have greater subcutaneous and visceral white adipose tissue (WAT) and brown adipose tissue (BAT) depots, larger white adipocytes, and larger livers compared to wild-type littermates. Lean mass is the same between GNB3-T and wild-type mice, indicating that the difference in weight is strictly due to an increase in fat mass. Even though GNB3-T mice have greater adiposity, they have similar food intake compared to their wild-type littermates at age 5, 10, 15, 20 and 25 weeks. Fasting plasma ghrelin and PYY levels are similar to wild-types, while amylin is elevated in GNB3-T mice at 20 weeks, suggesting proper satiety. GNB3-T mice have glucose intolerance and higher fasting plasma glucose, insulin, C-peptide at 20 weeks, consistent with type 2 diabetes. GNB3-T mice also have higher fasting plasma leptin, triglycerides, total cholesterol and phospholipids at 20 weeks compared to wild-type littermates. At 20 weeks, GNB3-T mice have difficulty maintaining core body temperature during acute cold stress compared to wild-type littermates. Lep expression is increased in subcutaneous and visceral WAT and BAT in GNB3-T mice, while Ucp1 expression is decreased in subcutaneous WAT. Taken together, these data suggest that GNB3-T mice exhibit obesity and metabolic syndrome. Future experiments will test whether GNB3-T overexpression is associated with changes in activity and heat production.

 

Nothing to Disclose: ACO, GMW, MKR

PP19-3 21195 4.0000 FRI-565 A GNB3 Overexpression Causes Obesity and Metabolic Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Meghan Lynne Ruebel*1, Kartik Shankar2, Dana Gaddy3, Horacio Gomez-Acevedo4, Forrest Lindsey1 and Aline Andres4
1Arkansas Children's Nutrition Center, Little Rock, AR, 2University of Arkansas for Medical Sciences, Little Rock, AR, 3Texas A&M University, College Station, TX, 4Arkansas Children's Nutrition Center/ UAMS, Little Rock, AR

 

Exposure to maternal obesity during development leads to increased risk of obesity in adult-life. However, whether programming is initiated in utero or during the peri-conception period is yet unknown. Obesity is associated with infertility, impaired oocyte quality, and delayed embryo development, suggesting a potentially detrimental effect of obesity on ovarian function. We hypothesize that maternal obesity is associated with ovarian inflammation and decreased AKT signaling. Lean ([LN], n=10) and obese ([OB], n=7) female Sprague-Dawley rats were examined during the peri-implantation period at dpc 4.5. Obesity was induced prior to conception by controlled overfeeding (40% excess calories for 28 d) via total enteral nutrition. OB dams had higher body weight (p<0.001), greater fat mass (p<0.001), reduced lean mass (p<0.05), and developed metabolic dysfunction with elevated serum lipids (triglyceride, total cholesterol, NEFA), insulin, leptin, and chemokine CCL2 (p<0.05) compared to LN dams. Microarray analyses yielded 284 genes that were differentially expressed between ovaries from LN vs. OB dams (±1.3 fold, p<0.05). RT-qPCR confirmed a decrease in expression of glucose transporters (GLUT)4 and GLUT9 (p<0.05) and an elevation of pro-inflammatory gene expression including CCL2, CXCL10, CXCL11, CCR2, CXCR1, and TNF-α; p<0.05 in ovaries from OB compared to LN dams. Protein levels of PI3K and AKT were significantly decreased (p<0.05) while nuclear levels of Egr-1(p<0.05) and FOXO3a (p=0.09) were increased in whole ovary lysates from OB compared to LN dams. Immunohistochemistry revealed Egr-1 localization to the granulosa cells, with the highest expression in cumulus cells of pre-ovulatory follicles. Egr-1 is an important regulator of acute-phase response and inflammatory signals, and has also been shown to be important for ovarian functions. Maternal obesity led to an increase in VCAN (a marker of follicular development) and a decrease in AURKB (a marker of oocyte development) and PLAT (a marker of ovulation) mRNA expression (p<0.05), suggesting changes in ovarian function. VCAN, AURKB and PLAT expression were also significantly correlated with % visceral fat (r= 0.51, r = -0.56, r = -0.57, p<0.05, respectively). In summary, maternal obesity lead to an upregulation of inflammation, an increase in Egr-1 protein levels and a decrease in AKT and PI3K protein levels.

 

Nothing to Disclose: MLR, KS, DG, HG, FL, AA

21105 5.0000 FRI-566 A Maternal Obesity Leads to Ovarian Inflammation and Upregulation of Early Growth Response Factor (Egr)-1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


David Tyson, Xin Wu, Gunes Uzer, Janet E Rubin and Maya Styner*
University of North Carolina Chapel Hill

 

In rodents and humans, intramyocellular lipid (IMCL) increases during conditions associated with insulin resistance (IR). In trained athletes, IMCL increases in a phenomenon known as “athlete’s paradox”, which, rather than contributing to IR, may supply energy needs for long distance running. We and others have demonstrated an increase in IMCL in running rodents. Here we asked whether exercise could alter the phenotype of fat deposits in muscle due to diet-induced obesity (DIO). We hypothesized that IMCL would further increase with running exercise in obesity but that this depot would be altered toward the brown phenotype associated with exercise.  Four week old, female C57BL/6 mice were provided low fat diet (LFD) or high fat diet. After 12 weeks, mice were further divided into control (LFD, DIO) or exercise groups (LFD-E, DIO-E) with voluntary running wheels (4 groups, n=7/group). LFD mice ran a similar distance to DIO mice. After 3 weeks of running, body composition via MRI and calorimetry testing was performed. Fat mass was double in DIO (4.8±0.4g) compared to DIO-E 2.1±0.3g (p<0.05). Lean mass was higher in DIO relative to LFD (p<0.01) but was not altered by exercise. Respiratory quotient was significantly lower in DIO (0.94 vs 0.79 p<0.01), without an exercise effect.  Harvest weights, after 6 weeks of running, were 22.8 ±0.6 g (LFD), 22.8 ± 0.5g (LFD-E), 27.2 ± 0.8g (DIO), and 25 ± 1.0g (DIO-E) (p<0.05 DIO vs. LFD). Quadriceps muscle gene expression was assessed by qPCR. DIO muscle expressed similar levels of fat markers compared to LFD, (markers analyzed: FASN, Perilipin, aP2, FSP27). Brown fat regulators/markers were also similar between DIO and LFD groups (markers: Irisin, UCP1, Cytochrome C, PGC1α). In contrast, exercise changed fat phenotype significantly. Comparing LFD-E vs. LFD, fat markers trended upward: FASN, Perilipin, and FSP27 increased 5.4 (p=0.40), 5.1 (p=0.35), and 4.9 (p=0.14) fold. LFD-E muscle had increased brown fat regulators/markers vs. LFD: Irisin, UCP-1, CytC, and PGC1α were 1.4 (p=0.99), 15 (p=0.99), 1.2 (p=0.99), and 2 (p=0.42) fold higher. Exercise also increased fat markers in DIO: FASN, perilipin, aP2, and FSP27 increased 21 (p=0.03), 20 (p=0.04), 10 (p=0.03), and 6.8 (p=0.15) fold. The brown fat specific UCP1 expression was significantly higher in DIO-E vs. DIO at 3800-fold (p=0.02). Irisin, CytC and PGC1α trended up in DIO-E vs. DIO. We found that running increased fat markers in murine skeletal muscle, consistent with an athlete’s paradox in both control and obese animals. Increased UCP-1 in the muscle of exercising mice suggests that exercise induces a brown fat phenotype, more significantly in the setting of high fat diet. Our data suggests that exercise effectively induces brown/favorable phenotypic changes in IMCL and that this effect may be stronger in IMCL of obese mice. This may imply that exercise is even of greater metabolic importance in the setting of obesity.

 

Nothing to Disclose: DT, XW, GU, JER, MS

22084 7.0000 FRI-568 A Exercise Browns Intramyocellular Lipid in Diet-Induced Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Yan Ding*1, Eugenia Morselli2, Aaron Frank1 and Deborah J Clegg1
1Cedars-Sinai Medical Center, Los Angeles, CA, 2University of Texas Southwestern Medical Center, Dallas, TX

 

Lipophagy is an autophagic process of intracellular lipid breakdown through lysosomal degradation. The hypothalamus regulates energy homeostasis and food intake and hypothalamic lipophagy has been shown to play an important role in maintaining lipid metabolism and normal hypothalamic function. A previous study from our laboratory shows that chronic high-fat diet (HFD) feeding induces inflammatory responses in male but not in female hypothalamic tissues. Since excessive lipid accumulation can result in inflammation, we hypothesize that there is a sexual dimorphism in hypothalamic lipophagic flux following chronic HFD exposure. Both male and female C57BL/6 mice were fed a 42% HFD for 16 weeks. Weight gain was comparable between males and females. Male hypothalami after HFD feeding had a significantly higher content of palmitic acid than chow-fed males (5642±393μg vs. 4101±302μg) while HFD female hypothalamic palmitic acid content had a tendency of decreasing compared to that of chow-fed group (7499±868μg vs. 4821±906μg). Results also suggest that a lipid droplet marker, perilipin 2, had a 3-fold increase in the hypothalamus of males compared to male chow group while such induction was not observed in female counterparts. Microtubule-associated protein 1A/1B-light chain 3 (LC3) is commonly used as a marker of autophagosomes. The number of LC3 and co-localization of LC3 and perilipin 2 were quantified after both male and female GFP-LC3vac mice were put on HFD for 16 weeks. HFD males had higher numbers of GFP-LC3vac and significantly lower co-localization of perilipin 2 and GFP-LC3vac than chow-fed males, suggesting increased number of autophagosomes but the loss of lipophagy machinery in male mice. But no such change occurred in female hypothalami. In addition, p62, a protein that recognizes toxic cellular waste, was increased in the ventromedial hypothalamus and arcuate nucleus in male HFD mice compared to chow-fed males. In summary, our data suggest that there is a sexual dimorphism in hypothalamic lipophagy following HFD exposure.

 

Nothing to Disclose: YD, EM, AF, DJC

21258 8.0000 FRI-569 A Chronic High-Fat Diet Exposure Inhibits Hypothalamic Lipophagy in Male Mice, but Not in Females 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Amy Christensen* and Christian J Pike
University of Southern California, Los Angeles, CA

 

The gradual loss of sex steroid hormones at menopause appears to increase the risk of women for Alzheimer’s disease (AD). The menopause transition is also associated with weight gain, which increases central adiposity and metabolic dysfunction including type 2 diabetes (T2D). Interestingly, obesity and T2D are independent risk factors for AD. Evidence that these are sex steroid-regulated health issues suggests the possibility that estrogen-based hormone therapy (HT) may have the dual effect of decreasing adiposity and T2D-related symptoms as well as AD neuropathology. Recent clinical evidence suggests that although the use of HT several years after the onset of menopause can increase rather than reduce AD risk, initiation of HT nearer to perimenopause may be protective. The potential protective effects of HT against AD have not previously been explored in human or animal models of perimenopause. To begin evaluating this possibility, we compared the effects of HT under normal weight and obese conditions in female 3xTg-AD undergoing reproductive senescence, which shares key similarities with human perimenopause. Early middle-aged (7-9 month old) female 3xTg-AD mice were maintained on either a normal (10% calories from fat) or high fat (60% calories from fat) diet and in the presence or absence of HT (continuous E2 with 10 days/month progesterone) for a period of four months. The increase in body weight caused by high fat diet over the course of the experiment was reduced in animals treated with HT. HT treatment in both normal and high fat fed animals improved working memory, as tested by spontaneous alternation behavior test. Finally, HT was associated with reduced AD neuropathology, as measured by b-amyloid accumulation in the hippocampus.  When HT was administered in late middle-age (16-17 month old), adiposity was decreased in high fat fed females, but there was no effect on behavior or AD neuropathology.  One mechanism that may contribute to these interactive relationships is inflammation, which is increased by obesity, reduced by ovarian hormones, and contributes to AD and related diseases. Here, we observed that HT administered during early middle age was effective in significantly reducing microglial activation. Late middle-aged mice showed greater levels of microglial activation and no significant effect of HT. These results show that HT consisting of continuous E2 and cyclic progesterone initiated during perimenopause has positive metabolic and neuroprotective effects in a mouse model of AD. These findings support a window of opportunity for HT use in women near the onset of menopause.

 

Nothing to Disclose: AC, CJP

21062 9.0000 FRI-570 A Diet-Induced Obesity in Middle-Aged Female 3xTg-AD Mice: Protective Effects of Estradiol and Progesterone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Licy L. Yanes Cardozo*1, Rodrigo Maranon2, Jana Ball2, Jane F. Reckelhoff1 and Damian G. Romero3
1Univ. of Mississippi Med. Ctr., Jackson, MS, 2University of Mississippi Medical Center, 3Univ of Mississippi Med Ctr, Jackson, MS

 

Obesity is often associated with low levels of plasma testosterone in men. It has been shown that testosterone replacement in men can ameliorate adiposity and insulin resistance, hallmarks of the metabolic syndrome. However, the safety of testosterone replacement in patients with metabolic syndrome is unknown. We have recently reported that in a model of metabolic syndrome, the obese male Zucker rat (OZ), testosterone levels are reduced and blood pressure is elevated compared to their lean counterparts. Interestingly, testosterone replacement in this model caused a further elevation of blood pressure, despite the fact that insulin resistance, obesity and dyslipidemia were significantly improved. The kidney is a key organ for long term blood pressure control. It had been previously shown that testosterone can regulate the expression of preproendothelin-1, a potent vasoconstrictor. The aim of the present study was to determine whether renal inflammation and/or changes in the renal endothelin system are associated with increases in blood pressure in OZ rats. Male obese (OZ) and lean (LZ) Zucker rats were treated with testosterone (8 mg/10 mm silastic tube; OZT and LZT) or placebo (empty tube; OZP and LZP), beginning at 10 weeks of age for 16 weeks. Plasma testosterone was reduced by 50% in OZP compared to LZP (2.7±0.6 vs. 1.3±0.3 ng/ml, p<0.05), and testosterone replacement increased plasma levels by ~10-fold in OZT and LZTs (24.3±11.6 vs. 9.9±1.7 ng/ml, p<0.05). Blood pressure, determined by radiotelemetry in freely moving conscious animals, was higher in OZT than in LZT (115±12 vs. 100±8, p<0.05).  Renal expression of preproendothelin-1, endothelin type A receptor, osteopontin, TGF-β and MCP-1 mRNAs, measured by RT-PCR, were significantly higher in OZP compared to LZP but were not affected by testosterone replacement in either OZ or LZ. In conclusion, our data shows that the effects of testosterone replacement upon different parameters of metabolic syndrome are dual. Testosterone replacement improves some parameters of the metabolic syndrome but fails to ameliorate renal inflammation. Blood pressure increase by testosterone is independent of changes in renal preproendothelin or its receptors. Further studies are needed to elucidate the mechanism(s) by which testosterone replacement can be beneficial for metabolic syndrome parameters but detrimental for cardiovascular risk factors.

 

Nothing to Disclose: LLY, RM, JB, JFR, DGR

21248 10.0000 FRI-571 A Two Sides of the Same Coin: Consequences of Testosterone Replacement in a Rat Model of Metabolic Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Juan Du*1, Amy Leung1, Candi Trac1, Liang Zhou1, Brian W. Parks2, Aldons J Lusis2, Rama Natarajan3 and Dustin E. Schones1
1City of Hope, Duarte, CA, 2University of California Los Angeles, Los Angeles, CA, 3Beckman Research Institute of City of Hope, Duarte, CA

 

Obesity is a highly heritable complex disease that results from multiple genetic and environmental factors. Even though the genetics of obesity has been extensively studied, we still can only explain very little of the estimated heritability of this disease. One reason for this is the lack of approaches to account for the interaction of environmental and genetic factors. We hypothesized that chromatin remodeling can mediate the interaction between genetics and environment. Our lab has shown that environmental factors, such as diet, can alter chromatin accessibility, thereby contributing to disease progression (1). We have now further investigated the interaction between chromatin variation, genetics and high-fat diet.

We investigated chromatin variation in two parental (C57BL/6J and DBA2/J) and four recombinant inbred (BXD) strains of mice that were fed with a high-fat/high-sucrose (HF/HS) diet. We performed genome-wide chromatin accessibility profiling in liver tissue from these mice and identified both common and strain-specific open chromatin sites in response to diet. Interestingly, 90% of the most variable open chromatin sites cannot be predicted simply from the underlying DNA sequence, suggesting that environmental factors are involved as well. Among the six strains under study, BXD15 is the most resistant to HF/HS diet, in terms of the body fat percentage and liver triglyceride levels. We identified open chromatin regions that are specific to BXD15 across the genome. Surprisingly, several of these regions are clustered together (within 500kb) on chromosome 12. We also performed strand-specific RNA-seq in BXD15 and two parental strains, and found that this region contains transcripts that are specifically expressed in the strain resistant to high-fat diet.  These results illustrate a powerful systems approach to identify novel genes and regulatory loci involved in complex diseases.

 

Nothing to Disclose: JD, AL, CT, LZ, BWP, AJL, RN, DES

20652 11.0000 FRI-572 A Using Systems Approach to Identify Novel Genes Involved in High-Fat Diet Response in Mice Liver 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Poonamjot Deol*1, Johannes F Fahrmann2, Dmitry Grapov2, Jun Yang2, Jane R Evans1, Antonia Rizo1, Cynthia Perea1, Oliver Fiehn2 and Frances M. Sladek1
1University of California, Riverside, Riverside, CA, 2UC, Davis, Davis, CA

 

Vegetable oils, which are naturally high in unsaturated fats, were initially thought to be healthier than saturated fats and were hydrogenated in order to increase their shelf-life and temperature stability. The process of hydrogenation, however, generated trans fats, which are now widely recognized as being unhealthy. Soybean oil is the most common vegetable oil used in the U.S. and contains ~55% linoleic acid (LA), a polyunsaturated fat (PUFA, C18:2). In order to reduce the production of trans fats, increase shelf life and create a generally healthier cooking oil, genetically modified (GM) soybean plants that contain seed oils with a fatty acid composition similar to that of olive oil – low LA and high oleic acid (OA, C18:1) – have recently been developed. Our previous results showed that replacing some of the fat in a diet high in saturated fats (40%kcal total fat, HFD) with soybean oil to achieve 10%kcal LA (LA-HFD), a level common in the American diet, causes significantly more weight gain, adiposity, diabetes and insulin resistance (IR) than the HFD in C57/BL6 mice. The LA-HFD mice also had fatty livers with ballooning injury and fibrosis. To determine whether LA was responsible for the metabolic effects of soybean oil, we designed a parallel diet in which the regular soybean oil was replaced, on a per gram basis, with GM high oleic acid soybean oil (Plenish). Surprisingly this diet (PL-HFD) induced weight gain and fatty liver essentially identical to that of LA-HFD but the mice remained insulin sensitive and had less adipose tissue. These results indicate that LA may contribute to IR and adiposity but that another as yet unidentified component of the soybean oil affects the liver and overall weight gain. Using an integrated multi-omics approach, liver and plasma samples from HFD, LA-HFD and PL-HFD fed mice were analyzed at the NIH West Coast Metabolomics Center at UC Davis to determine alterations in primary metabolites, complex lipids, lipid signaling mediators (oxylipins) and protein expression induced by the different diets. We will present a meta analysis of these data with the goal of identifying metabolites derived from traditional and GM soybean oil that drive various aspects of the metabolic phenotype. To our knowledge this is the first in-depth analysis of the metabolic effects of GM high oleic acid soybean oil. The overall impact of our results is potentially tremendous as soybean oil accounts for >90% of all the seed oil production in the U.S. and its increased consumption parallels that of the obesity epidemic.  A thorough understanding of the metabolic effects of the GM soybean oil, such as we provide here, is essential before the adoption of yet another dietary trend that could have long lasting and impactful health consequences.

 

Nothing to Disclose: PD, JFF, DG, JY, JRE, AR, CP, OF, FMS

PP19-4 21828 12.0000 FRI-573 A Metabolic Effects of Genetically Modified High Oleic Soybean Oil in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Geetanjali Sharma*1, Chelin Hu1, Nicholas P Gannon1, Roger A Vaughan2, Kristina A Trujillo1, Helen J Hathaway1 and Eric R Prossnitz1
1University of New Mexico, 2College of Human Sciences, Texas Tech University

 

Estrogen (E2) affects adiposity in part by regulating fat content and the site of fat deposition. In females, E2 protects against visceral adiposity by preferential fat deposition in subcutaneous depots. Multiple receptors mediate the effects of E2, including Estrogen Receptor α and β as well as the G protein-coupled estrogen receptor (GPER/GPR30). Loss of E2 or its receptors can lead to obesity that increases the risk of diabetes and cardiovascular disease. Our study focused on examining the effect of GPER on adiposity and associated metabolic dysfunction. To this end we utilized the GPER-selective agonist G-1. Treatment of 3T3-L1 cells with G-1 inhibited triglyceride accumulation and increased mitochondrial biogenesis and metabolism. Furthermore, in ovariectomized mice, G-1 treatment attenuated weight gain and visceral adiposity as revealed by smaller perigonadal fat pads compared to the vehicle-treated mice. Ovariectomized mice treated with G-1 also exhibited improved glucose tolerance and lower fasting glucose levels compared to the control animals. To summarize, we show here for the first time that the GPER selective agonist G-1 attenuates adiposity and metabolic dysfunction in ovariectomized mice and may have a therapeutic potential in treating obesity.

 

Nothing to Disclose: GS, CH, NPG, RAV, KAT, HJH, ERP

22052 13.0000 FRI-574 A Gper/GPR30 Agonist G-1 Increases Mitochondrial Biogenesis in Adipocytes, Attenuates Adiposity and Improves Glucose Intolerance in Ovariectomized Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Belinda A Henry*1, John-Paul Fuller-Jackson2 and Iain J. Clarke3
1Monash University, Victoria, Australia, 2Monash University, Clayton, Australia, 3Monash University, Melbourne, Australia

 

Food restriction causes a homeostatic reduction in thermogenesis, preventing weight loss (1). On the other hand, exercise may increase thermogenesis (2, 3). We aimed to determine whether exercise counteracts the decrease in thermogenesis caused by dieting. Ewes were assigned to 4 groups (n=5);  1) sedentary, ad lib diet, 2) exercise, ad lib diet, 3) sedentary, diet (30% food restriction) and 4) exercise, diet. Exercise involved running at 8km/ h for 30 minutes/ day, 5 days/ week. Interventions were maintained for 4 weeks. Body composition was assessed with dual-energy x-ray absorptiometry before and after intervention and temperature probes were inserted into sternal fat, retroperitoneal fat and skeletal muscle. Tissue heat production was recorded during non-exercise periods. Neither diet nor exercise altered body weight or food intake, but body fat content was reduced (P<0.05) in the diet/exercise group (ad lib, sedentary animals gained 1.48±0.48 kg whereas diet/exercise group lost 0.26±0.21 kg). Food restriction lowered (P<0.05) night time thermogenesis in sternal and retroperitoneal fat (Sternal fat ad lib: 38±0.2 ⁰C vs diet: 36.7±0.7 ⁰C; Retroperitoneal fat ad lib: 39.5±0.1 ⁰C vs diet: 39.0±0.2 ⁰C). There was no effect of exercise in ad lib fed animals. Diet-induced reduction in thermogenesis was partially reversed by exercise in sternal fat (37.3±0.1 ⁰C). Skeletal muscle heat production was not affected by diet or exercise. We conclude that dieting reduces  thermogenesis, especially in sternal fat (which is a brown adipose tissue bed (4)), particularly at night. This adaptive response is partially reversed by exercise. Thus, the homeostatic diet-induced reduction in thermogenesis may be counteracted by increased exercise.

 

Nothing to Disclose: BAH, JPF, IJC

21430 14.0000 FRI-575 A Exercise Counteracts Diet-Induced Inhibition of Thermogenesis in Female Sheep 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Mariana Peduti Halah*1, Paula Beatriz Marangon2, Jose Antunes-Rodrigues3 and Lucila Elias3
1University of Sao Paulo, Ribeirao Preto Medical School, Ribeirao Preto, Brazil, 2Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil, 3Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil

 

Background: Exposure to changes in nutritional conditions during prenatal or neonatal life induces long-lasting metabolic effects in adult life.  Adiponectin influences food intake and body weight.  Thus, the aim of this work was to investigate the effects of neonatal nutritional programming on the responsiveness to adiponectin in adult life. Methods: Male Wistar rats were subdivided, just right after birth, in litters of different size: 3 rats (Small litters, SL), 10 rats (Normal litters, NL) or 16 rats (Large litters, LL). After weaning animals received regular diet ad libitum. Pre- and post- weaning body weight gain was evaluated for 60 days. Another set of rats, 53 days after birth, was subjected to cannula implantation into the lateral ventricle. 7 days after surgery, diet was removed at 4pm and rats received icv injection of adiponectin (1μg/rat) or saline at 5pm. Diet was presented 60 min after the injections and food intake and body weight were determined 12h and 24h after. Results: SL rats showed higher  body gained (g) at weaning (day 21: NL: 52.9g ± 1.25; SL: 72.5 ± 2.96; LL: 37.9 ± 2.8) and also thereafter (day 60: NL: 409.4 ± 13.7, SL: 442.2 ± 19.4 and LL: 369.1 ± 11.6, while LL rats remained smaller than control rats during the evaluated periods (p<0.05). Central adiponectin stimulation decreased body weight gain (g) (Vehicle 12h: 18 ± 1.8 and 24h: 7.1 ± 2.1; Adiponectin 12h -3.7 ± 3.8 and 24h: -11.5  ± 6.1) and food intake (g/100g bw) (Vehicle 12h: 9.5± 0.7  and 24h: 12.2± 1.7; Adiponectin 12h: 5.07 ± 0.87 and 24h: 7.7 ± 1.7) in NL rats. However, adiponectin had no effect on SL rats (Food intake: Vehicle 12h: 7.44 ± 1.51 and 24h: 12.8 ± 1.32; Adiponectin 12h: 8.46  ± 0.6 and 24h: 7.68 ± 0.51; Weight gain: Vehicle 12h: 14.75 ± 8.6 and 24h: 4 ± 2; Adiponectin 12h: 13.5 ± 4.28 and 24h: 7.83 ± 1.22) and LL (Food intake: Vehicle 12h: 9.16 ± 1.32 and 24h: 12.32 ± 1.15; Adiponectin 12h: 8.18  ± 1.13 and 24h: 6.8 ± 1.57 ; Weight gain: Vehicle 12h: 17.2 ± 3.34 and 24h: 6.8 ± 2; Adiponectin 12h: 23.8 ± 6.3 and 24h: 13 ± 5.6), compared to the respective vehicle. Conclusion: In conclusion, neonatal over- and undernutrition induces changes in feeding behavior and body weight and impair the responsiveness to central stimulation with adiponectin in adulthood.

 

Nothing to Disclose: MPH, PBM, JA, LE

21839 15.0000 FRI-576 A Neonatal Nutritional Programming Impairs Hypothalamic Responsiveness to Adiponectin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Yan Guo, Ruo-Han Hao, Shan-Shan Dong and Tielin Yang*
Xi'an Jiaotong University, Xi'an, China

 

Obesity is a major worldwide health problem. It is a common complex disease with strong genetic control. Obesity phenotypes, including body mass index (BMI) and body fat mass, are high heritable, but the specific genes influencing these phenotypes, are largely unknown. Fibroblast growth factor 2 (FGF-2), secreted by adipocytes, has been found to influence adipocyte differentiation. To date, there is no information on whether FGF-2 relates to obesity phenotypes in Chinese population. Therefore, the aims of this study were to investigate: 1) the correlation of plasma FGF-2 level with BMI and body fat mass and 2) the association of SNPs within the FGF-2 gene with BMI and body fat mass in Chinese Han populations. The BMI was calculated by standard formula and body fat mass was detected by dual-energy X-ray absorptiometry. Plasma FGF-2 concentration was measured through enzyme-linked immunosorbent assay (ELISA). Eleven SNPs in FGF-2 were genotyped and tested for associations with BMI and body fat mass in a discovery sample of 1,300 unrelated Chinese Han subject. Significant results were further subjected to replication in another Chinese sample of 1,035 subjects. We found that plasma FGF-2 level was positively correlated with fat mass (P = 0.01, r2 = 0.104). Association study in the discovery sample recognized three SNPs (rs1449683, rs167428, rs308442) in FGF-2 significantly associated with body fat mass. Subsequent study in the replication sample validated one SNP (rs167428, combined P = 8.23×10-5) associated with body fat mass successfully. Our study indicated that higher plasma FGF-2 level was correlated with larger body fat mass. The genetic variants of the FGF-2 gene could result in individual variances of being obese. Therefore, this gene could be recognized as a new susceptibility gene for obesity.

 

Nothing to Disclose: YG, RHH, SSD, TY

20940 16.0000 FRI-577 A Plasma FGF-2 Level and FGF-2 Polymorphisms Are Associated with Obesity Phenotypes in Chinese Han Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Bruna Kelly Sousa Hirata, Ana Paula Segantine Dornellas, Luciana Chagas Caperuto, Lila Missae Oyama, Eliane Beraldi Ribeiro and Monica Marques Telles*
Universidade Federal de São Paulo

 

Obesity is recognized as a low-grade chronic and systemic inflammatory disease. Such inflammation is associated to the development of important comorbidities, such as insulin resistance, dyslipidemia and hypertension. Ginkgo biloba extract (GbE) is described as a potent anti-inflammatory plant extract and it was demonstrated that its beneficial effects could be, at least in part, due to the down-regulation of Toll-Like Receptor 4 signaling pathway. In this context, we evaluated the effect of GbE on TLR4 inflammatory cascade in retroperitoneal white adipose tissue depot of diet-induced obese rats. Male Wistar rats were fed from 2 to 4-mo-old with high fat diet and thereafter treated for 14 days with 500mg/kg of GbE. After euthanasia, retroperitoneal fat depot was removed and processed for the analysis of protein total levels of TLR4, MyD88 and NF-κB p-65 and phosphorylation levels of NF-κB p-65 by Western blotting. It was also evaluated the levels of IL-10, TNF-α and IL-6 and the gene expression of IL-10 in retroperitoneal fat depot. The prolonged treatment with GbE significantly increased IL-10 gene expression (33%, p=0.013) whilst it significantly reduced NF-κB p65 phosphorylation (60%, p=0.004) and TNF-α levels (36%, p=0.014) in retroperitoneal fat depot. The beneficial anti-inflammatory effects of GbE herein demonstrated may encourage further studies of this potential new line of therapy, especially for the treatment of individuals with severe obesity and metabolic syndrome.

 

Nothing to Disclose: BKSH, APSD, LCC, LMO, EBR, MMT

21217 17.0000 FRI-578 A Ginkgo Biloba Extract Attenuates Inflammation in Retroperitoneal Adipose Tissue Depot of Obese Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Risa M Wolf*, Kimberley E Steele, Leigh Peterson, Thomas H Magnuson, Michael A Schweitzer and G. William Wong
The Johns Hopkins University School of Medicine, Baltimore, MD

 

C1q/TNF-related protein3 (CTRP3), also known as CORS26, is a novel adipokine that lowers blood glucose levels, reduces triglyceride synthesis, and is protective against liver steatosis in diet-induced obese mice. We hypothesized that higher levels of serum CTRP3 expression would be associated with a lean body mass index (BMI) and a more favorable metabolic profile in humans.

Fasting serum samples were obtained from 60 healthy patients (BMI<26), and from 44 obese patients (BMI>35). Serum was analyzed in the core laboratory for the following parameters: A1C, glucose, AST, ALT and lipid panel (Cholesterol, HDL, triglyceride and LDL). Serum CTRP3, insulin and leptin levels were measured by ELISA. Results were analyzed using the Student’s t-test and Pearson correlation testing.   

Our cohort included 27 men and 77 women with a mean age of 38 ± 11 years (range 23-66). BMI of the lean group was 21.9 ± 2 kg/m2 (range 17.6-25.8) and the obese group was 45.2 ± 7.3 kg/m2 (range 35.6-68.6). Baseline metabolic parameters were normal for the lean group. Mean fasting glucose was significantly higher in the obese group 111mg/dL v 74 (p<0.001), A1C 6.4% v 4.9 (p<0.001), ALT 23 v 16 (p<0.001), triglycerides 143 v 73mg/dL (p<0.001), compared to the lean group. HDL was lower in the obese group compared to the lean group (47 v 66 mg/dL (p<0.001). CTRP3 was inversely correlated with BMI (p=0.001). We found significantly lower levels of CTRP3 in obese individuals (405 ± 55 vs. 436± 55ng/mL, p<0.01), and significantly higher levels of leptin in the obese group compared to the lean group (77467 v 8343pg/mL, p<0.001).  There was no difference in CTRP3 levels by ethnicity or age, but men had significantly lower CTRP3 levels compared to women (397.7 v 432ng/mL, p<0.01). In obese individuals, CTRP3 was inversely correlated with triglyceride levels (p=0.02). 

CTRP3 is an anti-inflammatory adipokine whose circulating levels are significantly lower in human obesity. Obesity causes dysregulation in adipokine production, and the down-regulation of anti-inflammatory adipokines such as CTRP3.  Lower CTRP3 levels may contribute to the pathophysiology of metabolic disorders associated with obesity.  Optimizing CTRP3 levels through novel therapies may improve obesity and its comorbidities.

 

Nothing to Disclose: RMW, KES, LP, THM, MAS, GWW

20642 18.0000 FRI-579 A C1q/TNF-Related protein3 (CTRP3) Levels Are Significantly Decreased in Human Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Hui Huang*, Fan Yang and Ya-Xiong Tao
Auburn University, Auburn, AL

 

Melanocortin-3 receptor (MC3R) is a G protein-coupled receptor (GPCR) primarily expressed in the hypothalamus. MC3R plays an important role in the regulation of energy homeostasis and several other physiological functions. In addition to the conventional Gs-cAMP signaling pathway, MC3R activation also induces the phosphorylation of MAPKs, especially ERK1/2. Biased mutants have already been reported in several GPCRs. In the present study, we investigated the ERK1/2 signaling of 22 naturally occurring human MC3R mutations and analyzed the signaling differences of Gs-cAMP and ERK1/2 pathways of these mutants. We showed that two mutants (S17T and D158Y) had significantly decreased basal pERK1/2 level. One mutant (I183N) had increased basal pERK1/2 level by approximately 2-fold and therefore is a constitutively active mutant in ERK1/2 pathway. Nine mutants (S69C, I87T, N128S, M134I, D158Y, M275T, T280S, A293T, and X361S) were defective in activating ERK1/2 upon a-MSH stimulation. By comparing the Gs-cAMP and ERK1/2 signaling of the 22 mutants stimulated by a-MSH, we showed that 10 mutants were biased to either one of the signaling pathways, including 6 mutants (S69C, N128S, M134I, M275T, A293T, and X361S) that had Gs-cAMP signaling bias and 4 mutants (F82S, I183N, L285V, and I335S) that had ERK1/2 signaling bias. In summary, we reported the first constitutively active MC3R mutant with increased pERK1/2 level and biased signaling of naturally occurring human MC3R mutants. Our current findings added a new layer of understanding of MC3R pharmacology. However, the in vivo relevance of the ERK1/2 signaling and biased signaling of MC3R still needs further investigation.

 

Nothing to Disclose: HH, FY, YXT

21126 19.0000 FRI-580 A Biased Signaling in Naturally Occurring Mutations in Human Melanocortin-3 Receptor Gene 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Zhao Yang*, Zhi-Li Huang and Ya-Xiong Tao
Auburn University, Auburn, AL

 

The melanocortin-3 receptor (MC3R) is a member of family A G protein-coupled receptors (GPCRs). The MC3R remains the most enigmatic of the melanocortin receptors with regard to its physiological functions, especially the role in energy homeostasis. The N/DPxxY motif and the eighth helix (Helix 8) in the carboxyl terminus of GPCRs have been identified to be important for receptor expression, ligand binding, signal transduction and internalization. To gain a better understanding of the structure-function relationship of MC3R, we have performed systematic study of all the 20 residues in this domain using alanine-scanning mutagenesis. The cell surface expression, ligand binding and signaling properties were studied. We showed that although all mutants were expressed normally on cell surface, eleven residues were important for ligand binding and one was indispensable for downstream cAMP generation. F347A showed constitutive activity in cAMP signaling while all the other mutants had normal basal activities. We also studied the signaling capacity of nine mutants in the extracellular signal-regulated kinases 1 and 2 (ERK1/2) signaling pathway. All mutants had normal basal ERK1/2 phosphorylation levels. The pERK1/2 levels of six binding- or signaling-defective mutants were increased by NDP-MSH stimulation, suggesting the existence of biased signaling in these MC3R mutants. In summary, we highlighted the importance of the DPLIY motif and Helix 8 for MC3R binding and activation, including biased signaling. Our data led to a better understanding of the structure-function relationship of MC3R.

 

Nothing to Disclose: ZY, ZLH, YXT

21058 20.0000 FRI-581 A Biased Signaling in Human Melanocortin-3 Receptors: Alanine Scanning Mutants in Dpliy Motif and Helix 8 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Anshu Gupta*, Edmond P. Wickham III, Adam P Sima and Daniel H Conrad
Virginia Commonwealth University, Richmond, VA

 

Introduction: Obesity in childhood is associated with an increased prevalence of diabetes and other traditional cardiometabolic risk factors, suggesting an epidemic of premature cardiovascular disease among today’s youth. Glycotoxins, known as advanced glycation end products (AGE’s), activating via the membrane-bound receptors (mRAGE), have been implicated in the pathophysiology of insulin resistance and vascular dysfunction in adults, but the role of RAGE in the early stages of metabolic disorders is unknown. As a result, we investigated the relation between AGEs, mRAGE and cardiometabolic risk factors (RF's) in a cohort of obese adolescents.

Methods: Twenty seven adolescents,11-16 years of age, with body mass index (BMI) Z-score≥2 were admitted following a 12-hour overnight fast for anthropometrics, fasting peripheral blood sample collection, and a 2-hour 75 gm, oral glucose tolerance test (OGTT). The following additional RF's were determined:  fasting triglyceride (TG), HDL-cholesterol, fasting and 2-hour glucose/insulin during OGTT. Peripheral blood mononuclear cells (PBMNC) isolated from blood were analyzed by flow cytometry to quantify the proportion of CD14+monocytes positive for mRAGE (%mRAGE, from Abcam ). Also, N-ε carboxymethyl lysine (CML, ng/ml), the dominant ligand for mRAGE, was determined by competitive AGE-ELISA (Microcoat, Germany). Pearson's coefficients were calculated to assess the associations between %mRAGE and CML and RF's . A multivariate linear regression model was used to assess relationship of BMI Z-score, insulin level at 120 (Ins120) and TG with %mRAGE and CML as joint outcome variables.

Results: The participants had a mean age 12.7±1.41 years and BMI-z score 2.37±0.37 SD with 70% participants being female; 51% were Black, 40.7% Caucasian, 7.4% were Hispanic. The %mRAGE had a significant negative association with CML (r=-0.63, p<0.05). In a joint multivariate model for RAGE and CML, TG and Ins120 were significant predictors for both outcomes (model p<0.05).

Conclusion: We show a significant inverse relationship between %mRAGE and CML in adolescents with obesity. Moreover, both %mRAGE and CML were significantly associated with TG and  Ins-120. Others have reported an inverse correlation of CML with adiposity and of soluble RAGE with metabolic risk factors in similar cohorts of children; however, %mRAGE was not specifically examined. These findings are novel and suggest that in obese children, monocyte mRAGE may be a marker of insulin resistance and TG levels. While speculative, it is also possible that mRAGE removes CML from circulation and these CML-laden monocytes get trapped in adipose tissue, mediating adipose tissue inflammation and adipogenesis causing high TG levels. Future studies involving healthy age- and sex- matched children as well as adipose tissue sampling from children with obesity are needed to evaluate the role of AGE-RAGE axis.

 

Nothing to Disclose: AG, EPW III, APS, DHC

20045 21.0000 FRI-582 A Advanced Glycation Endproduct Ligand and It's Membrane-Bound Receptor (RAGE) Are Inversely Associated in Obese Adolescents 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 562-582 6043 1:00:00 PM Obesity: Basic Science Poster


Christine Ibrahim*1, Jeffrey L Mahon1, Lisa-Ann Fraser1 and Stan Van Uum2
1Division of Endocrinology and Metabolism, Department of Medicine, Western University, London, Canada, 2Division of Endocrinology and Metabolism, Department of Medicine, Western University, London, ON, Canada

 

Background:Adrenal insufficiency (AI) is chronic disease requiring on-going glucocorticoid, and often mineralocorticoid, replacement. The management of AI involves patient education on dose adjustments during stress and illness. At times, patients may not be able to self-treat, or they may develop an adrenal crisis, and require an emergency room (ER) visit to receive parenteral stress-dose glucocorticoids.

Objective:  We developed a survey in order to better understand the experiences and challenges of patients with AI surrounding the use of stress-dose glucocorticoids, both self-administered, and in the ER.  

Methods: In early 2014, an invitation to participate was mailed to all patients with AI in our outpatient endocrinology clinic. An electronic invitation was also sent to all members of the Addison’s Society of Canada. This survey specifically assessed patients’ knowledge of their illness, disease stability, individual glucocorticoid stress dosing, their experience with stress dosing in the ER, and the utility of medical alert identifiers for AI.

Results:Of the 304 patients invited to participate, 134 patients with AI completed the survey. Ninety-six (71.6%) were female. Mean current age (range) was 56 (18-89) years, with a mean age at diagnosis of 47 (1-88) years, and a mean duration of AI of 14 (0-54) years. Most participants (82.7%) had been on a stable glucocorticoid dose for the past 6 months. Patients most commonly stress-dosed for illness, life stressors (eg. tests, divorce, funerals), and surgical procedures. Stress-dose duration varied from one day to four weeks. Of the respondents who presented to hospital, 25 (37.9%) received stress dosing in less than 1 hour after arrival, 31 (47.0%) within the first 1-6 hours, and 10 (15.1%) within 6-12 hours. A medical alert identifier (eg. MedicAlert bracelet) was carried by 85% of patients, but checked by only 32% of paramedics and 60% of ER personnel. Patients equally reported confidence versus anxiety surrounding disease management. A large number of participants expressed frustration at the medical system for its lack of awareness, lack of patient attentiveness, and delay in triaging—making some patients averse to seeking medical help.

Conclusion: This study shows that most AI patients are aware of the need for stress dosing, but many lack confidence on how, when, and for how long to do this. When visiting ERs, it may take up to 12 hours before stress doses are given, which may result in subsequent adrenal crisis, and risk of death. The current utility of medical alert identifiers to assist emergency medical providers in rapidly treating adrenal crisis appears questionable and requires improvement.

 

Nothing to Disclose: CI, JLM, LAF, SV

19573 1.0000 FRI-184 A Adrenal Insufficiency, Quality of Life, and Treatment in the Emergency Room [Adequate Study] 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Ramon Espaillat*, Michael F. Jarvis, Cory Torkelson and Brent D. Sinclair
AbbVie, Inc., North Chicago, IL

 

Background: Concerns regarding certain excipients in pharmaceutical products and their potential impact on general health have increased as patients and consumers become more exposed to medical information. AbbVie specifically has experienced an increase in inquiries from heath care providers as well as patients regarding gluten and aluminum content in Synthroid®.   The objective of this study was to review and quantify levels of gluten and aluminum in Synthroid® tablets.

Methods: Gluten content was determined in multiple lots of drug substance and excipients used in the manufacture of Synthroid tablets using the US-RIDASCREEEN Gliadin Test Kit at a third party laboratory.  Aluminum level estimations were based on the information from the raw material suppliers, raw material specifications, information from the literature, and scientific judgment using worst case assumptions.

Results: All lots evaluated had gluten concentrations of less than 3.0 ppm, which is the lowest detectable limit of the method and below the < 20 ppm threshold the FDA is tentatively considering for defining “gluten-free” in foods. The estimated maximum aluminum levels across the various tablet strengths, ranged from 19 to 137 micrograms per tablet. This is an order of magnitude lower than the ATSDR1chronic-duration oral minimal risk level of 1 mg Al/kg/day for aluminum(1).

Conclusions: Synthroid® tablets do not contain gluten or gluten derivatives. Across the various tablet strengths, the estimated maximum aluminum levels were far below the expert determined minimal risk level of exposure to aluminum.

 

Disclosure: RE: Employee, AbbVie, Inc.. MFJ: Employee, AbbVie, Inc.. CT: Employee, AbbVie, Inc.. BDS: Employee, AbbVie, Inc..

20436 2.0000 FRI-185 A Gluten and Aluminum Content in Synthroid® (levothyroxine sodium tablets) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Elif A Oral*1, David Araujo-Vilar2, Kyle Brown3, Rebecca J. Brown4, Abhimanyu Garg5, Taisia Isupov6, Deborah HP Jae3, Vanessa Rangel Miller7, David B Savage8 and Andra Stratton9
1University of Michigan, Ann Arbor, MI, 2Biomedical Research Institute-CIMUS, University of Santiago de Compostela, Spain, Spain, 3PatientCrossroads, CA, CA, 4National Institute of Health, Bethesda, MD, 5University of Texas Southwestern Medical Center, Dallas, TX, 6AstraZeneca, Fort Washington, PA, 7PatientCrossroads, CA, 8University of Cambridge Metabolic Research Laboratories, Cambridge, United Kingdom, 9Lipodystrophy United, NM

 

Background:  Natural history data for lipodystrophy (LD) have not been systematically collected. With an approved treatment (Myalept, by AstraZeneca) and multiple potential novel treatment targets, this becomes even more important and can help determine impacts of new therapies. A patient-entered registry was therefore developed through a unified global effort and launched in January 2014. 

Registry Development and Launch:  The Lipodystrophy Connect patient registry was developed using PatientCrossroads’ HIPAA-compliant program with oversight by Chesapeake IRB and a Governance Board.  Each user has a password-protected account. Family members can be linked via a unique family code.  The registry collects longitudinal patient-reported data via 6 survey tools, and submitted test reports and photos.  Surveys were developed in partnership with global disease experts, patient and industry representatives, and epidemiologists.  Surveys were designed to collect information needed to characterize and classify individuals with diagnosed or suspected LD while not being overly burdensome. In addition, surveys ask sufficient questions to trigger supplemental surveys. Deidentified data can be viewed by participants and professionals on the registry website. Data can be exported to statistical programs using Excel or CSV format. Outreach is provided by Lipodystrophy United advocacy organization, by awareness among physicians and physician networks, by industry, and by participants.

Registry Participation and Data Collected: As of 10/10/14, there are 110 participants (56% female) from 22 US states and 13 countries in this constantly updating registry.  Fifty-one % have Familial Partial LD, 9% have Congenital Generalized LD; with smaller percentages of other LD subtypes. Data are collected on medical history, quality of life, lifestyle, and feedback. To date, 77% of participants report a history of fat loss.  Fifty-four % report current diabetes, 3.6% had diabetes in the past but not currently, and 39% never had diabetes.  Fifty-five% report current high cholesterol or triglycerides, 19% had high cholesterol or triglycerides in the past but not currently, and 18% never had high cholesterol or triglycerides. This is in contrast to patients who have participated in the reported clinical trials or case experiences where almost all of the patients appear to display metabolic derangements.

Future Plans: Next steps for the registry include translation into additional languages, verifying patient-entered data through the development of an algorithm designed by disease experts, Governance Board expert review of patient-uploaded photographs and test results, and adding additional surveys. In the future, registry data can be used to better understand LD natural history, and patient needs. In addition, the registry can be leveraged to design and support recruitment for clinical trials.

 

Disclosure: EAO: Principal Investigator, Eli Lilly & Company, Investigator, GI DYNAMICS, Principal Investigator, Bristol-Myers Squibb, Advisory Group Member, Astra Zeneca, Principal Investigator, Astra Zeneca, Principal Investigator, Amylin Pharmaceuticals. DA: Advisory Group Member, Astra Zeneca, Advisory Group Member, Amylin Pharmaceuticals. KB: Research Funding, Astra Zeneca. AG: Principal Investigator, Bristol-Myers Squibb, Principal Investigator, Amylin Pharmaceuticals, Ad Hoc Consultant, Eli Lilly & Company, Ad Hoc Consultant, GERSON LEHMAN GROUP, Ad Hoc Consultant, ENGAGE HEALTH, Ad Hoc Consultant, MEDA CORP, Ad Hoc Consultant, BACKBAY LIFE SCIENCES, Ad Hoc Consultant, HYPERION THERAPEUTICS, Ad Hoc Consultant, BIOMARIN, Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Amgen, Principal Investigator, Pfizer, Inc., Principal Investigator, Astra Zeneca. TI: Employee, Astra Zeneca. DHJ: Employee, Astra Zeneca. VRM: Employee, Astra Zeneca. AS: Advisory Group Member, Amylin Pharmaceuticals, Advisory Group Member, Astra Zeneca. Nothing to Disclose: RJB, DBS

20191 3.0000 FRI-186 A Lipodystrophy Connect: The Global Registry 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Kendra Morotti1, Julio Lopez1, Michael Harvey2, Vanessa Vaupel1, Arthur Swislocki*1 and David Siegel3
1VA Northern California Health Care System, Martinez, CA, 2VA Sierra Pacific Network, Reno, NV, 3VA Northern California Health Care System, Matther, CA

 

Background:  A relative cardiovascular risk reduction of 25-35% has been reported in patients that have started statins for elevated cholesterol; yet many patients fail to consistently take these medications as directed.  Our study evaluated factors that impact adherence to and persistence with statin therapy.

Methods:  This retrospective study analyzed data extracted from a VA database encompassing  facilities  west of the Rocky Mountains (California, Nevada, Hawaii, Colorado, Idaho, Oregon, Washington, Alaska, Arizona, New Mexico, Montana, Wyoming, Utah, and parts of Texas) for patients newly prescribed statin medication between July 1, 2007 and December 31, 2012.  Patient demographics, co-morbidities, prescription record information, and time on therapy were collected.  Adherence to statin therapy was determined using the medication possession ratio (MPR), calculated as the total days’ supply of medication dispensed divided by the total number of days in the intended treatment period. Persistence was defined as whether a patient continued to refill their statin prescription, with non-persistence occurring when a given patient did not refill their statin for a period of > 135 days. 

Results:  Of 173,025 patients, overall adherence to statins was reflected by a mean MPR of 0.842.  Approximately 61% of patients continued to be persistent on statin therapy after 675 days.  Patients prescribed pravastatin, lovastatin, rosuvastatin, and those who took more than 1 different statin during the follow-up period had statistically significant higher rates of adherence than those prescribed simvastatin.  Patients aged 18 - 50 had an overall mean MPR < 0.8, considered non-adherent (MPR for 18-30:  0.752, 31-40:  0.78; 41-50:  0.799); those older than 71 years of age were adherent with an overall mean MPR > 0.8 (P<0.001).  The overall mean MPR progressively increased with age groups from age 18-30 to 71-80 years of age. 

Conclusions:  In Veterans, statin adherence was excellent.  Certain populations may benefit from interventions targeted at improving statin adherence including younger Veterans (age 18-50).

 

Nothing to Disclose: KM, JL, MH, VV, AS, DS

21620 4.0000 FRI-187 A Adherence and Persistence to Statin Therapy in a Large Population of Veterans 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Teresa McHugh*, Ashley F. Perritt, Meredith Elman, Ashwini Mallappa and Deborah P. Merke
National Institutes of Health, Bethesda, MD

 

Background Precise measurement of height is essential for accurate growth assessment, especially in clinical trials. Over the years, at the National Institutes of Health (NIH) Clinical Center we have had several clinical trials in the area of pediatric endocrinology where growth and/or height is a major outcome of interest. In these studies, height is carefully measured in a standard manner to optimize accuracy.  Here we report, the difference between admission height (mostly late afternoon) and early morning height (upon awakening) obtained as part of a long-term study of children with classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency.

Methods:  Children enrolled in a long-term clinical trial (ClinicalTrials.gov Identifier: NCT00001521) visited the NIH Clinical Center every 6 months for an inpatient hospital stay of two days duration.  Vital signs were obtained on hospital admission (afternoon) and upon awakening in a fasted state at approximately 0800h on the first day of the admission.  Height was measured as the average of three heights with a calibrated stadiometer (Holtain), and weight was measured with a digital scale (Scaletronix). We retrospectively examined height discrepancies between admission afternoon and early morning heights for the patients’ first hospital visit.

Results:  60 children aged 2 to 11 years (mean ± s.d.: 5.9 ± 2.3) participated in the study. Admission afternoon heights were measured at approximately 1600h (16:12 ± 2h 42min.) and early morning heights were measured upon awakening (9:32 ± 1h 27min).  Ninety-three percent (56 of 60) of heights were greater when measured in the morning.  Early morning heights upon awakening were approximately 1 cm greater than heights obtained in the afternoon (range: -0.4 to 2.0; Δ height ± s.d.: 0.8 ± 0.5 cm). This difference was independent of the child’s age, sex and height.

Conclusions: Prepubertal children have heights approximately 1 cm shorter in the afternoon compared to the morning representing a significant height discrepancy.  Time of day should be considered when assessing growth in children.

 

Disclosure: DPM: Principal Investigator, Diurnal, Principal Investigator, Medtronic Minimed. Nothing to Disclose: TM, AFP, ME, AM

21005 5.0000 FRI-188 A Time of Day Influences Height Meausrement in Pediatric Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Renee E Amori*, Allison Ferris, Richard Paluzzi and Barbara Simon
Drexel University College of Medicine, Philadelphia, PA

 

Implementation of Computer Based Learning Modules in Diabetes for First Year Internal Medicine Residents: a review of the first year of use

Introduction: Internal medicine (IM) residents have variable exposure to diabetes care during their education in inpatient and outpatient settings, based on current literature.  Residents also have time constraints, needing to balance education and service within duty hour limits.  While traditional daytime lectures remain a primary teaching modality, technology can increase access to learning activities. 

Methods: The Drexel IM Residency program began the online “Diabetes for Residents” curriculum using the Learn Blackboard software during academic year 2013-14.  The Learn software is accessible from most internet connections, eliminating the barrier of attending a traditional lecture at a specified time.  The curriculum includes eight PowerPoint modules based on current literature and best practices; hyperglycemic emergencies (DKA and HHNK) were excluded.  Modules were designed to be freestanding, foundational in content area, and could be accessed multiple times.  Our target learners are first year residents in the categorical IM program (N=40 ).  The Drexel University College of Medicine IRB approved the protocol to study our outcomes.

Results: In our first year of implementation, first year categorical IM residents were enrolled, the course director reported regularly to the program directors on the progress of the class, and regular reminders were sent to the class until all residents completed it.  Residents accessed the material on each day of the week with Thursday and Wednesday being the popular days.  They also accessed the modules at a variety of times of the day, with the most accesses from 6pm to midnight, but over 8% occurred in the overnight hours from midnight to 5am.   At the end of the academic year, we conducted a voluntary survey for feedback to the residents, and 30% responded.  The majority of survey respondents found that the amount of content was relevant to their needs, and it enhanced their understanding of diabetes and medical care.  Survey respondents felt most confident in their abilities to manage insulin in the inpatient setting, but less confident in outpatient settings based on a modified Likert scale. 

Conclusion: Implementing a computer based diabetes curriculum decreased time barriers to learning activities, and allowed 100% participation in a learning activity.  A self-reported sampling of residents generally felt that the content was relevant.  Significant support from the course director and the program directors is needed to ensure completion.


 

 

Nothing to Disclose: REA, AF, RP, BS

18560 6.0000 FRI-189 A Implementation of Computer Based Learning Modules in Diabetes for First Year Internal Medicine Residents: A Review of the First Year of Use 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Shipra Bansal*1, Kannan Kasturi2 and Sheila Perez-Colon1
1SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, 2SUNY Downstate Medical Center, Brooklyn, NY

 

Background: Over the years, Insulin pump use has increased due to significant improvement of glycemic control in diabetics. Since these patients present to different medical care settings (inpatient, outpatient and ER) for treatment, hospital staff needs basic knowledge of Insulin pump. Residents serve as the point of contact for Endocrine subspecialists and may need to look up or change settings on Insulin pump. Also, as primary care providers after completing their training, they may encounter patient on the Insulin pump at their offices.

Hypothesis: US pediatric and Internal medicine residents are not comfortable with handling the insulin pump although have knowledge of the basics and advantages and risks of insulin pump therapy.

Design/Methods: Cross-sectional study. After IRB approval, we sent emails to all Pediatrics and Internal Medicine Program Directors or Coordinators in USA which was then forwarded to their residents with the link to an online anonymous questionnaire via surveymonkey.com. Reminder email was sent after 2 weeks. Frequency tables, ANOVA, t-test (p< 0.05 significant) were used for statistical analysis.

Results: Out of 314 responders, 93 - PGY1, 102- PGY2, 106- PGY3 and 10 -PGY4 while 3 did not answer this question. Specialty wise, 182 were Pediatrics RES, 91 Internal Medicine and 21 were combined Medicine-Pediatrics RES while 20 chose not to reply. 42% had done at least one endocrine rotation. When asked about the number of diabetics encountered per month on Insulin pump, most of the residents (194) saw 1-2 per month, fewer (15) saw >3 while 100 of them, saw none.

The mean knowledge scores (KS) across PGY level significantly improved (p=0.005) with the training level, PGY4 scoring the highest. Having completed an Endocrine rotation also increased the KS by 0.75(95% Cl: 0.51-1.0). No significant differences in KS were noted based on the specialty or number of diabetics encountered each month. 40% of 292 believe that Insulin pump use does not increase the risk of DKA from pump malfunction. Also, only 60% agree that Insulin pump use allowed precise insulin delivery compared to a syringe. Of the 284 residents who answered, <50% felt comfortable in looking up or changing Insulin pump settings. 70% RES feel that they do not have enough exposure during their training for Insulin pump and would welcome an educational session to learn more about it.

Conclusions: Despite adequate knowledge among some RES about IP, there is a need for improvement in their attitudes and practices. It is imperative that all residents get at least a training session regarding IP for basic knowledge since it is commonly used as an effective form of insulin delivery.

 

Nothing to Disclose: SB, KK, SP

20472 7.0000 FRI-190 A Knowledge, Attitudes and Practices of US Residents Regarding Insulin Pump in Diabetics 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Gloria Wu*1, Byongdo Kim2, Victor Chen3 and Victoria Phan4
1UC San Francisco School of Medicine, San Francisco, CA, 2University of California, Berkeley, 3UC San Diego, 4UC Berkeley, Berkeley, CA

 

Background: There have been more than 1000 diabetes related apps in 2013.  56% of adult Americans have a smartphone.  However, only 1.2% of diabetic patients with a smartphone have downloaded such apps. By 2018, there are predictions that 24 million people will be using such diabetes apps.

Purpose: Assessing smartphone apps from both the physician’s viewpoint and the patient’s viewpoint.

Methods: Using Google Analytics from Google Trends, we downloaded the 7 most popular apps which capture 65% of the market: Glucose Buddy, Go Meals, On Track, Diabetes Log (iPhone only), Diabetes Buddy, Diabetes Pal, and Carb Counting with Lenny.

Results: Of the 7 most popular, one of them, Diabetes Buddy, is no longer active as of this writing. Data is on the remaining 6.

Glucose Buddy (Azumio): 4.4 stars; 7756 raters
Must register with email
Diary format
100,000 downloads

Go Meals (Sonofi-Aventis): 3.9 stars; 1497 raters
Must register with email
Diary format
Problems: food lists are vague, activity drop down menu options range from overly specific to vague
100,000 downloads

On Track (Medivo): 4.4 stars; 5296 raters
Must register with email
Diary with graphing capabilities
wt in kg or lbs
500,000 downloads at least

Diabetes Log (Distal Thoughts - individual developer): 3.0 stars, 1544 raters
Does not require registration with email
iPhone only
Diary format with no graphics capabilities
Problems: under Medications, Humalog is listed as the only insulin type
No information about number of downloads

Diabetes Pal (Telecare): 4.0 stars; 71 raters
Must register with email
Diary format with graphing capabilities. input data, Generates a report and emailing report, only one connected to their glucose meter.
10,000 downloads

Carb Counting with Lenny (Medtronic): 3.4 stars; 146 raters
Must register with email
Meant for children, All pictorial
50,000 downloads

Avg downloads per app: 150,000, number of downloads per app range = 10,000 - 500,000. avg star rating 3.85, range=3.0 to 4.4. Avg number of people who rated the apps= 2,718. Range =71-7,756, Email registration 5/6. Fitness capability 2/6, Graphing capability 2/6. Diary 5/6. Industry sponsors and downloads: Medtronic (50,000), Sanofi-Aventis (100,000), Telecare (10,000)

Discussion: As smartphone apps become more popular, patients will be presenting these types of data to physicians.  On behalf of our patients and medical associations, we may be able offer helpful input to app developers so that future apps can record our patients’ data in a medically accurate and relevant manner.

 

Nothing to Disclose: GW, BK, VC, VP

22063 8.0000 FRI-191 A Smartphone Apps and Diabetes Outreach 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Addie L Fortmann*1, Maria Isabel Garcia1, Monica Ruiz1, Linda C Gallo2, James Schultz3, Austin Carlson1, Mayra Hernandez1 and Athena Philis-Tsimikas1
1Scripps Health, San Diego, CA, 2San Diego State University, San Diego, CA, 3Neighborhood Healthcare, San Diego, CA

 

Mobile health (mHealth) technology has emerged as an effective method for providing self-management education and support, and improving clinical control in diabetes. Notably, mHealth circumvents many of the common barriers to participation in traditional self-management programs (e.g., schedule conflicts, lack of transportation). However, little research has examined the feasibility or acceptability of mHealth in underserved, ethnic/racial minority populations. Dulce Digital, a diabetes self-management intervention delivered via mobile text messaging, achieved clinically and statistically significant improvements in blood glucose control over 6 months in a 2012-2014 randomized controlled trial of N=126 low-income Hispanics with type 2 diabetes and HbA1c >7.5% recruited from a San Diego FQHC.  Dulce Digital participants (n=63) received 3 types of text messages: educational/motivational, medication reminders, and blood glucose monitoring (BGM) prompts; 2-3 messages/day were sent at study start, with frequency tapering over 6 months. Study staff monitored blood glucose responses, assessed possible reasons for hyper/hypoglycemia, and encouraged as needed provider follow up. The present study examined the feasibility and acceptability of Dulce Digital via 2 focus groups conducted with ~20% of the intervention group (n=12).  Consistent with published standards for qualitative methods, focus groups were 120 minutes in duration and conducted in participants’ preferred language (Spanish) by a bilingual moderator; proceedings were audio-recorded and transcribed verbatim for analysis. Focus group findings indicated high acceptability; the majority reported text messages to be helpful for managing their diabetes (100%), sufficient in frequency (100%), and easy to understand (92%). In terms of barriers/feasibility, 33% endorsed at least minor difficulty carrying their phone consistently, 42% reported work-related obstacles to reading/responding to some text messages, and 17% indicated that receiving messages on their personal phone was expensive. Data on phone ownership, patient responsiveness to BGM prompts, and attrition are presented for the overall sample (N=126) as indirect indicators of feasibility and acceptability. Approximately one-third (37%) did not own a cell phone with texting capabilities, and were provided with one for study purposes. On average, participants responded to 70% of BGM prompts; one-third of participants responded to all prompts.  Attrition was slightly higher in the Dulce Digital (n=8; 13%) versus Control group (n=3; 5%), but still comparable to, or lower than rates for non-mHealth studies in this population. This study provides preliminary evidence of the acceptability of an mHealth intervention in an underserved, Hispanic sample, and offers valuable information about barriers to enhance feasibility in future studies.

 

Nothing to Disclose: ALF, MIG, MR, LCG, JS, AC, MH, AP

21577 9.0000 FRI-192 A Acceptability and Feasibility of an Mhealth Self-Management Intervention in Underserved Hispanics with Poorly Controlled Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Amy Larkin*, Colleen Healy and Karen Badal
Medscape Education

 

Introduction: Despite widespread dissemination of the evidence for better outcomes with improved glycemic control, a significant proportion of patients with type 2 diabetes (T2D) do not achieve A1c goals. Adherence to treatment is a persistent barrier in T2D management, and patient education/engagement could address this challenge. We studied the effect of education designed to help clinicians implement strategies for more successful patient interactions related to T2D management. We measured the impact of the education on self-reported patient communication strategies via a follow-up Planned Change Assessment® (PCA) of performance outcomes.

Methods: Educational need and clinical performance gaps related to T2D management were identified and used in developing content. An online, video-based educational activity was designed with a focus on developing successful patient-clinician interactions and featured 2 experts in the field of T2D management. Faculty discussion on real world adherence challenges was accompanied by synchronized slides presenting supportive data.  Video-based patient vignettes also served to demonstrate successful patient-clinician shared decision-making interaction.  The activity was targeted to primary care physicians (PCPs), endocrinologists, and other clinicians who treat patients with T2D. A PCA survey was utilized immediately post-education to assess planned changes and 8 weeks later to measure self-reported changes in practice.

 

Results: A total of 840 clinicians completed the initial survey, with 93% indicating an average of 2.8 intended changes in practice. When re-engaged with the follow-up survey, 98% of those who responded reported having made an average of 5.3 changes in practice as a result of this activity. The percentage of those making changes and the number of changes is high compared to similar activities, which averaged 86% of respondents in. Changes in practice were reported in the following areas: engaging patients in discussing concerns about insulin (97%-100% of respondents), directly engaging patients in shared decision making (84%-92%), discussing insulin as a possible treatment option earlier in management (94%-100%), involving the patient in determining short-term goals (87%-92%), identifying and facilitating access to patient education for all patients with T2D (74%-81%), and spending more time educating patients on available treatment options (71%-85%). The most commonly reported barriers included insufficient time, insufficient office staff, and low patient health literacy.

 

Conclusion: The metrics gathered in this assessment are a strong indicator that the educational activity prompted changes in clinical performance, showing that appropriately designed, practical education on developing successful patient-clinician interactions is a useful way to effect changes in practice.

 

Nothing to Disclose: AL, CH, KB

18734 10.0000 FRI-193 A Success of CME at Improving Patient-Clinician Interactions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Amy Larkin*, Colleen Healy and Martin Warters
Medscape Education

 

Introduction

Despite major advances in the management of type 2 diabetes (T2D), nearly half of patients (47.5%) are failing to achieve treatment goals of HbA1c <7% with current therapies. In updated recommendations, organizations advocate the use of a wider range of treatments, including incretins, to help patients achieve glycemic control. A study was conducted to determine if online, simulation-based educational interventions could improve competence and performance of endocrinologists and primary care physicians (PCPS) in managing patients with T2D.

 

Methods

A cohort of US-practicing endocrinologists and PCPS who participated in simulation-based educational interventions was evaluated. The Virtual Patient Simulation episodes provided a real world intervention consisting of two distinct patient cases presented in a platform that allowed physician learners to choose from numerous lab tests, diagnoses, pharmacologic options, and procedures. The clinical decisions made by the participants were analyzed using an artificial intelligence technology and clinical guidance was provided. The outcomes survey method used by CE Outcomes, previously validated to measure performance-level outcomes, included multiple-choice questions focused on current evidence-based recommendations for the management of T2D. Results were compared with responses from demographically similar control groups (nonparticipants) to determine the educational impact.

 

Major Results

Endocrinologists and PCPs (n = 100) who participated in these simulation-based educational interventions were 56.5% (actual effect size of 1.03) more likely to make evidence-based practice choices than were a demographically matched group of nonparticipant physicians, specifically in:

  • Selecting an appropriate therapy to best benefit a patient’s weight loss and glucose control (PCPs 41% vs. 9%, P < .001)
  • Determining appropriate use of GLP-1 receptor agonist therapy in a patient who is obese and not at A1c goal (PCPs 34% vs. 11%, P = .001)
  • Avoiding inappropriate use of GLP-1 receptor agonists in patients with comorbidities (Endocrinologists 67% vs. 37%, P = .02; PCPs 66% vs. 46%, P = .02)
  • Determining a non-pharmacologic approach for managing a patient’s weight (PCPs 86% vs. 61%, P = .001)

The 3,000 physician participants of this activity see, on average, 33 patients per week with T2D. Therefore, some 99,000 patients seen each week by participating physicians may benefit from improved care.

 

Conclusions

This study demonstrated the success of simulation-based educational interventions on improving the evidence-based practice patterns of endocrinologists and PCPS in the management of patients with T2D. Simulation-based instructions that lead to improvement in physician performance in a consequence-free environment can result in more evidence-based clinical decisions for T2D and improvement in patient outcomes.

 

Nothing to Disclose: AL, CH, MW

18736 11.0000 FRI-194 A Simulation-Based Medical Education: Strategy to Improve T2D Management? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Amy Larkin*1, Anne Le1, Stacey Hughes1 and Anne Wolf2
1Medscape Education, 2University of Virginia

 

Introduction

Obesity is a major public health crisis. In the past 10 years, prevalence in the United States has increased from 20.0% to 35.7%. Despite recognition as a disease, obesity remains undertreated. We sought to determine if participating in a case-based online educational intervention related to obesity management improves the knowledge, competence, and clinical decision-making of internists in the United States (US).

Methods

The online continuing medical education (CME) activity used a case-based, text format wherein clinicians were given 2 case scenarios and asked to address and treat obesity with respect to lifestyle and pharmacologic changes. The activity was directed to internists who see patients with obesity and focused on developing effective, appropriate, and comprehensive treatment plans. The effects of education were assessed using a linked pre-assessment/post-assessment study design that separated learners into 3 categories: improved (incorrect pre-, correct post-education), reinforced (correct pre- and post-education), and unaffected (incorrect post-education). For all questions combined, the effect size was calculated by comparing pre-assessment means and post-assessment means of linked learners to show the size of the effect of the educational intervention. Effect sizes > 0.8 are large, between 0.8 and 0.4 are medium, and < 0.4 are small. A paired 2-tailed t-test was used to assess whether the mean pre-assessment score was different from the mean post-assessment score. P values < .05 indicate a statistically significant result.

Major Results

584 internists completed both the pre- and post-assessment survey, with a large overall effect size of 1.594 (P <.05). Correct responses on post-assessment questions ranged between 10% and 246% higher after CME completion. A comparison of pre- and post-assessment scoring indicates that the scoring distribution curve shifted to the right. While only 9% of participants answered all 4 questions correctly on the pre-assessment, 78% answered them all correctly on the post-assessment. Between 11% and 65% of participants showed improvement in understanding key concepts in the management of obesity by correctly answering case-based questions. Key learning concepts included effective communication techniques, effect of dietary and exercise recommendations on weight loss, and the mechanism of action and risk vs benefit of currently available anti-obesity agents.

Conclusions

An online case-based CME activity improved the knowledge and skills of participants, showing that when appropriately constructed, online CME is an effective tool to improve clinical decision-making in the area of obesity treatment.

 

Disclosure: AW: Consultant, GlaxoSmithKline. Nothing to Disclose: AL, AL, SH

18729 12.0000 FRI-195 A Effectiveness of Case-Based Education on Clinical Decision-Making in Obesity Management 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Gloria Wu*1, Victor Chen2, Aarushi Banerjee3, Agastya Gupta4, Byongdo Kim5 and Kimberly D. Pham6
1UC San Francisco School of Medicine, San Francisco, CA, 2UC San Diego, 3Homestead High School, 4Saratoga High School, Saratoga, CA, 5University of California, Berkeley, 6University of California, Berkeley, Berkeley, CA

 

Diabetes affects 26 million in the US, 96 million in China, and 65 million in India.  Prediabetes affects approximately 80 million in the US.1,2 Asians are particularly at risk for Metabolic Syndrome, which is associated with higher risk of diabetes. Last year we created a free Android app, Asian Diet Watch (ADW). This year, to address the needs of South Asians globally, we created a similar app to assess the response to this dietary educational tool.

Purpose: To create a mobile app about the calorie count and glycemic index for South Asian foods.  

Methods: Google search was used to identify the 150 most commonly queried South Asian foods.  We used average serving size, 8 oz., to determine calories per serving. Glycemic index was determined for each of the foods via Google search. Body Mass Index (BMI) calculator was included in the app for the individual user. The data were coded into an Android app using the Java programming language and uploaded for free download on Google Play. No paid advertising was used.

Results: Asian Diet Watch  (ADW) and South Asian Diet Watch (SADW) were uploaded on August 7, 2013 and October 28, 2014, respectively. At two weeks, ADW had 20 downloads and SADW has 11 downloads, 10 from US, 1 from India. ADW has been in use for a year and it has 130 current downloads and reached 985 individuals in Indonesia, Malaysia, Singapore and the US. Google Trend Analytics shows that the search term “Diabetes” has the approximately the same number of queries as the term “Chinese food.” However, “Indian food” generates only 10% of the number of searches compared to “Diabetes” or “Chinese food.”

Discussion: To our knowledge, these are the first mobile apps which focus on the glycemic indices and nutritional information for Asian and South Asian foods available free on Google Play. The apps may educate people about BMI and glycemic indices of Asian foods, as  Asian food becomes more popular in US and abroad. As physicians, the app may enable us to reach out to diverse patient populations with diabetes risk factors.

 

Nothing to Disclose: GW, VC, AB, AG, BK, KDP

20498 13.0000 FRI-196 A South Asian Diet Watch 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Samantha Madala*1, Victor Chen2, Andrew Nam3, Kimberly D. Pham4 and Gloria Wu5
1Healthy Scholars Foundation, Monte Sereno, CA, 2UC San Diego, 3Santa Clara University, San Jose, CA, 4University of California, Berkeley, Berkeley, CA, 5UC San Francisco School of Medicine, San Francisco, CA

 

Hypothyroidism Screening in School-Aged Children in Rural Southern India

Background: The incidence of hypothyroidism in India is between 4-9%1, and most of the screenings have been directed at congentital hypothyroidism in a healthcare setting. School children have been examined in Northern India in Delhi but not in rural Southern India.2,3

Purpose: To determine if school health screening can assess the incidence of subclinical hypothyroidism in school-aged children in rural Southern India.

Method: Data were obtained from two health screenings done at the Center for Community Development in Varni, a mandal in Telegana, India with a population of 72 thousand people. The two health screenings occurred in December 2013 and August 2014 with students government-run schools and private schools.

The students were questioned about hypothyroid disease symptoms, and based on their self reporting and physical examination by a physician, they were referred for blood tests. Institutional informed consent was obtained.

Results: 1413 total screenings were performed. 50 of the screening data were excluded from the analysis due to incomplete records. Of the analyzed 1363 screenings: 814 are male and 549 are female. Age range = 6 to 26 yrs, avg= 12.8 ± 1.8 yrs. Avg BMI = 16.7 ± 3.2 kg/m2, ranging from 9.6 kg/m2 to 38.1 kg/m2.

Of the 1363, 162 (11.9%) were directed towards thyroid screening and had TSH levels tested.  73 of the 162 ( 45.1%) also had T3 and T4 levels tested. Of the 162, 8 (4.9%) were diagnosed by the physician with “thyroid disease:” 2 of these 8 were obese (defined by comparing their BMI to the 95th percentile data from the Center for Disease Control for BMI, gender, and age).4 Of the total population, 32 of 1363 (2.3%) were considered obese, suggesting that these children may need followup for possible future development of hypothyroidism.

Of the 8 individuals who were diagnosed with thyroid disease, 3 were from government-run school screening, and 5 were from private schools. The incidence of thyroid disease in these two groups were 0.51% and 0.65%, respectively. However, the difference is not significant.

Conclusion: To our knowledge, this is the first study that assessed a screening of school aged children in rural Southern India for subclinical hypothyroidism . In comparison to the incidence for hypothyroidism in India (4 - 9%), our study’s incidence is low. We hope this small study will highlight hypothyroidism in health screening fairs in school children in India.

 

Nothing to Disclose: SM, VC, AN, KDP, GW

18758 14.0000 FRI-197 A Hypothyroidism Screening in School-Aged Children in Rural Southern India 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Friday, March 6th 3:00:00 PM FRI 184-197 6049 1:00:00 PM Endocrine Healthcare Delivery & Education II Poster


Lisa Kenigsberg*, Chhavi Agarwal, Raanan Arens and Rubina Heptulla
Children's Hospital at Montefiore, Bronx, NY

 

Polycystic Ovary Syndrome (PCOS) is associated with obesity and many metabolic abnormalities, including insulin resistance (IR) and obstructive sleep apnea (OSA). Studies examining the prevalence of OSA in PCOS adolescents and the effects of OSA on IR are lacking. Our aim was to evaluate the prevalence of OSA in obese and lean PCOS adolescents. We hypothesized that obesity will be associated with a higher prevalence of OSA and increased IR.

This was a cross-sectional study comparing obese (BMI >95%) and lean (BMI <85%) females aged 13-21 years diagnosed with PCOS (without diabetes) by Rotterdam criteria. They underwent a 180 minute hyperinsulinemic euglycemic clamp (HEC) to determine IR. Glucose Infusion Rate (GIR) was calculated during the last 60 minutes of the HEC. OSA was determined based on an apnea-hypopnea index (AHI) of > 2.0 events per hour during an overnight polysomnography. Nonparametric tests (Spearman’s rho and Kruskal-Wallis Test) were used to compare age, BMI z-score, free testosterone (FT), total testosterone (TT), GIR, and AHI.

We studied 22 obese and 9 lean PCOS subjects. Age was similar between the lean and obese groups (17.3 (16.4, 18.5) vs. 16.4 (15.3, 17.9), p=0.14), respectively. Prevalence of OSA was significantly higher in obese subjects compared with lean subjects (41% vs. 0%, p<0.001). GIR in the obese PCOS group was significantly lower compared to the lean group (2.16 (1.62, 3.30) vs. 7.36 (4.75, 11.10) mg/kg/min, p<0.001). The significant correlation between GIR and AHI (r=-0.50, p<0.01) was related to BMI z-score and this co-relation diminished and was non-significant with the exclusion of lean subjects (r=-0.16, p>0.05).  There was a significant correlation between GIR and FT (r=-0.40, p=0.03), which was not found between GIR and TT (r=0.03, p=0.86). This association appears to be driven by the lean group as lean subjects showed a strong but not significant correlation between GIR and FT (r=-0.57, p=0.11), which did not hold true for the obese group alone (r=-0.10, p=0.66).

A subgroup comparison was performed between obese PCOS subjects with and without OSA. BMI z-score was similar between groups (2.39 (2.30, 2.60) vs 2.20 (1.65, 2.55), p=0.13). No differences in GIR were seen (2.24 (1.59, 2.88) vs 2.06 (1.48, 3.83) mg/kg/min, p=1.0).

A high prevalence of OSA was seen in obese PCOS adolescents, which was absent in lean PCOS adolescents. The severity of OSA is driven by BMI, as opposed to IR. Differences in the strength of association of IR and FT concentrations between groups suggest that there may be different factors influencing insulin sensitivity in obese versus lean adolescents with PCOS. In this study, OSA did not add to the burden of IR in PCOS, however future studies are needed to evaluate this association further. In agreement with Endocrine Society guidelines, we recommend that all obese PCOS adolescents undergo screening for OSA.

 

Nothing to Disclose: LK, CA, RA, RH

18778 1.0000 FRI-144 A Is Insulin Resistance and Obstructive Sleep Apnea Present in Obese and Lean Adolescents with PCOS? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Nelly Mauras*1, Richard J Santen2 and Ian A. Blair3
1Nemours Children's Clinic, Jacksonville, FL, 2University of Virginia, Charlottesville, VA, 3University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

 

Background:  Estrogen levels and their metabolites are higher in obese vs. lean postmenopausal women as a result of extra-glandular steroid production, and estrogens increase  breast cancer risk through  both ER-dependent and independent mechanisms. The quinone derivatives of 4-hydroxylated estrogen metabolites bind to DNA independently of ER, and cause depurination resulting in impaired DNA repair. 16α-OH-E1, e.g.,  has been shown to be involved in tumor promotion and proliferation.  Ever being overweight in childhood also increases the risk of all-cause and breast cancer death in women compared to lean subjects, but the levels of estrogen derivatives had not been previously studied in young obese children.

Specific Aim: We designed this study to investigate if total and genotoxic estrogens are increased in obese girls compared to lean controls prior to the onset of puberty.

Methods: Stored sera from 15 lean and 23 obese (BMI>95th%) well characterized  pre-pubertal girls studied previously   were assayed for  parent estrogens, estrone (E1) and   estradiol (E2),  and their multiple metabolites (12 steroids total). New state-of-the-art methodology, which  made   this study feasible,  enabled 50-fold higher sensitivity than with standard LC-MS/MS-based methods.

Results:  All girls were Tanner Stage I for breast and pubic hair development, well-matched for age but with  markedly different BMIs   (obese: 9.0 ± 0.2 (SE) yrs, BMI: 33.8 ± 0.9 kg/m2; lean: 9.5 ± 0.3yrs, BMI: 16.2 ± 0.3).  E2 concentrations were three fold  higher in obese vs. lean girls (3.4 ± 0.8 pg/ml vs. 1.2 ± 0.4 pg/ml,  p=0.06) with 32% of obese girls having values >1SD of lean controls. Theoretically, only non-methylated metabolites are active whereas the methylated cannot bind to DNA. Accordingly, we calculated the ratio  of 4-OH-E2 to 4-methoxy-E2 and found a statistically significantly  higher ratio in obese girls  (0.946 ± 0.044 vs. 0.701 ± 0.098, p=0.01). Concentrations of 16α-OH-E1 were also significantly higher in the obese group (7.1 ± 1.5 pg/ml) vs. lean girls (1.7 pg/ml ± 0.9, p=0.02), with 50% of obese girls having values >1SD of lean controls. Levels of 16α-OH-E1were positively correlated with BMI (r=0.55, p <0.0001).

Conclusions: Parent estrogens and genotoxic metabolites were higher in obese vs. lean pre-pubertal girls. These data suggest  that obesity is associated with increased extra-glandular estrogen production  and metabolism  well before the onset of puberty  in girls. Long-term epidemiologic studies will now be required to assess any potential increase  in breast cancer risk.

 

Disclosure: NM: Researcher, Pfizer, Inc., Researcher, Medtronic Minimed, Researcher, Quest Diagnostics, Researcher, Astra Zeneca, Researcher, Genentech, Inc., Consultant, GlaxoSmithKline, Researcher, Novartis Pharmaceuticals. RJS: Principal Investigator, Pfizer, Inc.. Nothing to Disclose: IAB

21270 2.0000 FRI-145 A Estrogens and Their Genotoxic Metabolites Are Increased in Prepubertal Obese Girls 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Roy Kim*1 and David Leonard2
1UT Southwestern Medical Center, Dallas, TX, 2Children's Medical Center, Dallas, TX

 

Background

In adolescents, metabolic syndrome is associated with inflammation and an unfavorable cardiovascular risk profile. Promotion of a healthy diet is a management mainstay. Intake of nuts (tree nuts and peanuts) lowers the risk of cardiovascular morbidity in adults. Whether a relationship between nut intake and cardiovascular risk factors is present during adolescence is not known.

Objective

To examine the association between nut intake and prevalence of metabolic syndrome in US adolescents, and determine if this relationship varies by gender or race/ethnicity.

Methods

This is a cross sectional analysis of a national sample of adolescents. We used data from the National Health and Nutrition Examination Survey (NHANES), years 2003-2010. Data from 24-hour diet recall surveys, fasting blood tests, and anthropometric measurements were retrieved from NHANES participants, age 12 to 19 years (n=2,233). A threshold of 12.9 grams of nut intake per day was used to define significant nut intake, based on clinical trial literature (1). Metabolic syndrome was defined according to published pediatric criteria (2). Descriptive results for nut intake in the entire cohort, and gender and race/ethnic group-specific strata were generated. Crude and adjusted odds ratios (OR) and 95% confidence intervals for metabolic syndrome were estimated using nut intake as the exposure. Regression splines were used to examine the non-linear relationships between nut intake as a continuous variable and components of the metabolic syndrome.

Results

Average nut intake was low (4.1g/d), and the median intake during the sampling periods was zero.  Caucasians had higher nut intake than non-Hispanic blacks and Latinos (6.1 g vs 3.1 g vs 3.0 g, respectively; ANOVA p < 0.001). Only 8.9% of all subjects had nut intake of more than 12.9 grams per day. The overall prevalence of metabolic syndrome was 7.4%. Higher nut intake was associated with a lower odds ratio for metabolic syndrome compared to low intake (crude OR=0.43; 95%CI 0.20 to 0.93). Controlling for age, gender, race/ethnic category, and household income resulted in an adjusted OR of 0.43 (95%CI 0.20 to 0.92).

In a regression model that included a term for total calories and a spline to capture nonlinear effects of continuous nut intake, each g/day of nut intake above zero was associated with lower odds of metabolic syndrome up to an intake of approximately 50g/d at which point the odds rose above 1. Nut consumption was directly associated with high density lipoprotein cholesterol (0.04 mg/dL/(g/d), p=0.032).

Summary

Modest intake of nuts was associated with a lower odds for having the metabolic syndrome in this cohort of adolescents.

 

Nothing to Disclose: RK, DL

18918 3.0000 FRI-146 A Nut Intake Is Associated with Lower Odds of Metabolic Syndrome in Adolescents 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


David R Weber*1, Jennifer Kelley2, Tammy B Mawson3, Steven Matthew Willi2, Mary B Leonard4 and Babette S. Zemel5
1University of Rochester, Rochester, NY, 2Children's Hospital of Philadelphia, Philadelphia, PA, 3The Children's Hospital of Philadelphia, 4Stanford University, Palo Alto, CA, 5The Children's Hospital of Philadelphia, Philadelphia, PA

 

Type 1 diabetes (T1DM) is associated with an increased risk of fracture. Preclinical models suggest that impaired bone formation may contribute to skeletal fragility in T1DM. Because most patients with T1DM present prior to the attainment of peak bone mass, impaired bone formation early in the disease may have lifelong implications on bone health. We sought to determine if deficits in bone density and structure were present at the time of T1DM diagnosis. Participants included 24 children (16 males, 79% white) presenting with new onset T1DM. Children with a history of chronic disease, corticosteroid exposure, or obesity were excluded. Whole body and regional DXA and tibia peripheral quantitative computed tomography (pQCT) scans were obtained within 30 days of diagnosis. Bone mineral density (BMD), body composition, and bone structural outcomes were converted into age, sex, and race (bone outcomes) specific Z-scores using existing pediatric reference data, and were adjusted for height (DXA) and tibia length (pQCT). Means were expressed (± SD) and compared using t-tests; medians as (interquartile range) and compared using Wilcoxon rank sum tests. At diagnosis, participants had median age of 14 yrs (11-16), hemoglobin A1c of 12% (11-14), and 25OH vitamin D of 26 ng/mL (16-35). Median bicarbonate was 19 mEq/L (11-22) in females vs 24 (18-26) in males, p=0.1.  Mean BMD Z-scores were lower in females compared to males for whole body less head (-0.7 ± 1.1 vs 0.4 ± 1.1), lumbar spine (-0.8 ± 0.8 vs 0.1 ± 0.7), femoral neck (-0.8 ±0.8 vs 0.3 ± 0.9) and radius (-0.4 ± 0.8 vs 0.8 ±1.2); p≤0.04. Lumbar spine and femoral neck BMD in females were also lower compared to the reference population; p=0.03. Mean pQCT bone and DXA body composition Z-scores appeared lower in females compared to males for trabecular density (-1 ± 1.2 vs 0.1 ± 1.3), cortical area (-0.2 ± 0.5 vs 0.3 ± 0.9), cortical thickness (-0.1 ± 0.7 vs 0.6 ± 1.3), periosteal circumference (-0.3 ± 1.3 vs 0.1 ± 0.7), fat mass index (fat mass/ht2, -0.9 ± 0.9 vs -0.4 ± 0.6), and lean body mass index [LBMI (lean mass/ht2), -0.9 ± 1 vs -0.2 ± 0.9], but did not reach statistical significance. Linear regression found female sex to be a significant negative predictor of all BMD outcomes (β coefficients ranged from -0.9 for spine to -1.1 for femoral neck, p<0.04). Adjustment by LBMI-Z (β coefficients ranged from 0.4 for spine to 0.7 for femoral neck, p<0.04) resulted in an average attenuation of β coefficients for sex of 34%; p-values retained borderline significance for spine BMD only, p=0.05.  Our preliminary results found that females but not males had significant deficits in trabecular bone density at the diagnosis of T1DM. Based on the associations between LBMI, sex and bone outcomes, we speculate that the sex differences in bone outcomes may be attributable to more severe and long-standing disease at presentation in the females. A larger study to confirm and extend these findings is ongoing.

 

Nothing to Disclose: DRW, JK, TBM, SMW, MBL, BSZ

18690 4.0000 FRI-147 A Sex Differences in Bone Density and Body Composition in Children Newly Diagnosed with Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Kelsee Leisner*1, Ryan McDonough1 and Yun Yan2
1Children's Mercy Hospital, Kansas City, MO, 2Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, MO

 

Background:

Chronic hypoglycemia due to an insulinoma often presents with neurolgycopenic symptoms that can easily be overlooked, especially in adolescents where nonspecific complaints are common. The vagueness of symptoms, the rareness of the condition, and challenge of tumor localization make insulinoma a true diagnostic quandary for clinicians.

Clinical Case:

A 15-year-old girl presented to her PCP with episodes of altered mental status. She reported a thirty minute period of fatigue, confusion, poor concentration, irritability, and “staring off” which was noted by parents while the patient was getting ready for school. They had witnessed several similar events, always in the morning, over the past 5 months. The patient herself did not recall the episodes. She had not sought medical care previously assuming her behavior was related to early morning drowsiness. She was scheduled for an outpatient EEG after a basic metabolic profile, thyroid studies, and urine drug screen were normal. The patient became unresponsive during the study and was referred to the local hospital with the following lab results: serum glucose 28 mg/dL (65-110mg/dL), pro-insulin 85.1pmol/L (0-10pmol/L), and C-peptide 4.6ng/mL (1.1-4.4ng/mL). In search of an insulin-producing mass, she underwent abdominal CT and endoscopic ultrasound which were negative. She was started on valproic acid for potential seizure activity and discharged home with a glucometer. Two months later she was admitted to a tertiary care pediatric center for uncontrolled hypoglycemia. The patient became hypoglycemic overnight and a critical sample confirmed hyperinsulinemic hypoglycemia. An MRI of the abdomen revealed a 0.9 x 1.1 x 1.3cm pancreatic mass. Valproic acid was stopped and her hypoglycemia medically managed with diazoxide until she underwent laparoscopic distal pancreatectomy. Pathologic examination of the mass confirmed a benign insulinoma. She had mild hyperglycemia post-operatively which resolved within 48 hours without insulin therapy. Gene sequencing for multiple endocrine neoplasia was negative. The patient has been euglycemic since discharge. She lost 15 kilograms and is considered cured. The time from onset of symptoms to correct diagnosis and appropriate treatment was approximately eight months.

Conclusion:

Despite its rarity, clinicians must consider hypoglycemia secondary to insulinoma when addressing nonspecific concerns such has fatigue, irritability, or problems with concentration. This is particularly true if symptoms occur in the morning and are accompanied by weight gain. If these neurolgycopenic complaints are unnoticed or misdiagnosed, patients with a potentially curable disease are put at risk of neurologic injury, or even death, due to untreated hypoglycemia.

 

Nothing to Disclose: KL, RM, YY

18304 5.0000 FRI-148 A Hidden Hypoglycemia: Vague Neuroglycopenic Complaints Camouflage Diagnosis of Adolescent Insulinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Liana Senaldi*1, Resmy Palliyil Gopi2 and Bina Shah2
1NYU School of Medicine, 2New York University School of Medicine, New York, NY

 

Background: Transient hyperinsulinism and thrombocytopenia can occur in neonates following exposure to perinatal stress and birth asphyxia. However, little is known about whether there is a direct association between neonatal hyperinsulinism and thrombocytopenia. In-vitro studies suggest that platelets express the insulin and insulin-like growth factor-1 (IGF-1) receptors, but there are conflicting reports about the effects of insulin on platelet function. We report a neonatal case of transient hyperinsulinism and thrombocytopenia, both of which resolved after administration of diazoxide.

Case report: Patient is a full term boy, twin, with a birth weight of 2.5kg, conceived by in-vitro fertilization. There was no significant perinatal history and pregnancy was uncomplicated. Baby was delivered by emergency caesarean section for fetal bradycardia and APGAR scores were 4 and 9 at 1 and 5 minutes, respectively.

Baby had hypoglycemia with blood glucose levels < 30mg/dl at 8 hours of life. Multiple dextrose boluses were given followed by intravenous dextrose at glucose infusion rate (GIR) of 6 mg/kg/min. GIR was titrated to a maximum of 19mg/kg/min on 3rdday of life (DOL). As blood glucose levels stabilized, GIR was reduced to 7mg/kg/min, but patient had intermittent hypoglycemia. On DOL 7, at a blood glucose level of 29mg/dl, glucagon stimulation was positive and insulin level was 5microIU/ml suggestive of hyperinsulinism. Other metabolic tests for hypoglycemia were negative and baby was started on diazoxide at 10mg/kg/day on DOL 8.

Concomitantly, baby also had thrombocytopenia (platelet count less than 30,000/mm3) on DOL 1 and required four platelet transfusions in the first 8 days. Despite multiple transfusions, platelet counts remained mostly below 100,000/mm3. Neonatal alloimmune thrombocytopenia and other infectious etiology work up were negative.

Results: Within 24hours after starting diazoxide (DOL 8), both blood glucose and platelet counts improved. Platelet counts increased to 200,000/mm3 on DOL 10 and patient did not require further transfusions.  As blood glucose improved, diazoxide was gradually weaned and stopped on DOL 18. Baby continued to have normal blood glucose levels and platelet counts after discontinuation of diazoxide.

Conclusion: We report a coexistence of hyperinsulinemia and thrombocytopenia, although the cause of association remains unknown. Improvement of thrombocytopenia in this newborn may have occurred due to resolution of the perinatal stress period, hypoglycemia, and/or hyperinsulinemia following administration of diazoxide treatment. We speculate a possible association of hyperinsulinism with thrombocytopenia at the cellular level.

 

Nothing to Disclose: LS, RP, BS

18960 6.0000 FRI-149 A Impact of Perinatal Stress Related Hyperinsulinemic Hypoglycemia on Thrombocytopenia: A Case Report and Review of Literature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Yuezhen Lin*1, Meenal Shewale Mendiratta1, Lefkothea P Karaviti2 and Colleen Buggs-Saxton3
1Baylor College of Medicine, Houston, TX, 2Baylor College of Medicine, Texas Children's Hospital, Houston, TX, 3Children’s Hospital of Michigan

 

Background: Hypoglycemia is a very common presentation in the pediatric population and the differential diagnoses are very broad. We reported here a case of severe hypoglycemia caused by familial glucocorticoid deficiency (FGD).

Case: Patient was a 12-month-old boy with a 3-day history of an upper respiratory infection and decreased oral intake who presented with septic shock and hypoglycemia (serum glucose < 20mg/d). He was stabilized with fluid resuscitation, vasopressors and steroids. Past medical history was remarkable for several visits to his pediatrician office for jitteriness and lethargy which resolved without special intervention. Physical examination was remarkable for tall stature (height was above 95th percentile) and generalized skin hyperpigmentation.

Workup and clinical course: Biochemical evaluation revealed low cortisol (2.1 mcg/dL) and markedly elevated ACTH (3070 pg/ml). Serum electrolytes, aldosterone, and plasma renin activity were normal. Common causes for primary adrenal insufficiency were ruled out including negative 21 hydroxylase antibody and normal very long chain fatty acid. The diagnosis of FGD was confirmed by genetic testing that revealed compound heterozygous mutations in the MC2R gene.  One of the mutations was S74I which has been previously associated with type I FGD, and the other MC2R mutation, R137P, was novel.  The patient was treated with hydrocortisone (HC) and 6 years later he continues to do well on maintenance HC (10-12 mg/m2/day) with height tracking at 50th percentile, consistent with his genetic potential.

Literature review: FGD is a rare autosomal recessive disorder characterized by normal mineralocorticoid production and primary hypocortisolism.  To date FGD has been associated with mutations in the following genes:  MC2R, MRAP, STAR, MCM4, and NNT.  Mutations in the ACTH receptor gene (MC2R) and the MRAP genes account for about 45% of cases with FGD.  Patients with FGD typically present with severe neonatal hypoglycemia, frequent childhood infection, and excessive skin pigmentation. Tall stature with FGD is frequently associated with MC2R mutations, and normal stature is found in patients with FGD associated with mutations in other genes.  Although the exact mechanism of excessive growth in FGD is unknown, it is speculated that excessive growth may be secondary to ACTH receptor mutation and markedly elevated levels of plasma ACTH.

Conclusion: This case serves as a reminder to have a high index of suspicion for FGD as a rare cause of hypoglycemia in a patient who presents with hyperpigmentation and tall stature.  Prompt initiation of steroids along with a thorough diagnostic evaluation is important to avoid unnecessary lifelong mineralocorticoid replacement and recurrent illnesses secondary to life-threatening adrenal insufficiency in patients with FGD.

 

Nothing to Disclose: YL, MSM, LPK, CB

19141 7.0000 FRI-150 A Familial Glucocorticoid Deficiency: A Rare Cause of Hypoglycemia in Children 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Angela S. Lennon*1, Mitzi Go2, Chaitali Mahajan2 and Prabhu Parimi3
1University of Kansas Medical Center, Kansas City, KS, 2University of Kansas Medical Center, 3Univeristy of Kansas Medical Center

 

Background

Hyperglycemia is common issue seen in extremely premature infants especially in the first week of life, brought about by a combination of insulin resistance and relative insulin deficiency.  Typical neonatal issues such as sepsis, intracranial hemorrhage, necrotizing enterocolitis, respiratory distress syndrome, and interventions such as steroids, inotropes, and TPN, contribute to the hyperglycemia as well.  When the hyperglycemia persists beyond 2 -3 weeks of life, despite controlling contributing factors, then neonatal diabetes needs to be considered. 

Objective: Examine the etiology of persistent neonatal hyperglycemia in extremely low birth weight premature infant.

Case Study: A 26 5/7 week, 910 gram, appropriate for gestational age African American male infant was delivered to a 21 year old G3P3 mother with sickle cell trait and thalassemia via classical cesarean section due to cord prolapse.  Pregnancy was complicated by a positive GBS screen, preeclampsia and premature prolonged rupture of membranes. Family history was notable for Type 2 diabetes, asthma and sickle cell trait.  Baby was placed on non-invasive ventilator support in the delivery room due to poor respiratory effort. The Apgar score was 8 and 9 at 1 and 5 minutes, respectively.  Placental pathology was significant for chorioamnionitis and funisitis.  Neonatal course was complicated by respiratory distress syndrome managed by non-invasive ventilation, hyperbilirubinemia and anemia.  Hyperglycemia developed at 46 hours after birth, managed initially by decreasing the glucose infusion rate and intralipids. Persistent hyperglycemia prompted investigations, including evaluation for genetic mutations of insulin secretion, and initiation of insulin.

Results: The POC glucose at 32 min after birth was 105 mg/dl and it remained less than 150 mg/dl until 46h after birth, at which time the POC glucose was 173 mg/dl. The mean POC glucose in the first 72h was 175 ± 68 mg/dl, and increased to 192 ± 40 mg/dl between 96-168h post-birth. Despite decreasing the rate of glucose infusion and intralipids, and initiation of insulin, the mean POC glucose continued to be at 191 ±52 mg/dl. POC glucose began to normalize 32 days after birth with sporadic transient hyperglycemia.  Insulin levels and c-peptide drawn during hyperglycemia were mildly elevated, showing some endogenous production. KCNJ11 gene analysis showed a pathogenic sequence change in c.685G>A, p.Glu229Lys. Baby was discharged home at age 61 days with normal POC glucose. He was seen 2, 4, and 6 months later in the medical home with normal POC glucose and normal growth parameters.

Conclusions: KCN J11 gene mutation ought to be considered in preterm infants with persistent hyperglycemia refractory to medical management. A close follow-up of these babies is necessary as a sub-set may develop diabetes at a later stage during childhood.

 

Nothing to Disclose: ASL, MG, CM, PP

19255 8.0000 FRI-151 A KCNJ11 Gene Mutation As a Cause of Neonatal Hyperglycemia in an Extremely Low Birth Weight Premature Infant 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Joshua Tarkoff*1, Eric Bomberg1, Grace E Kim2, Luc Baeyens1, Michael Scott German1 and Roger K Long1
1University of California - San Francisco, San Francisco, CA, 2University of California - San Francisco

 

Title: Asymptomatic hyperinsulinemic hypoglycemia secondary to a mediastinal teratoma with fetal pancreatic features

Background: Mediastinal teratomas with clinically functional neuroendocrine tissue are rare clinical entities with only scattered reports in the literature. We report a case of asymptomatic hypoglycemia from a mediastinal teratoma containing fetal pancreatic features.

Clinical Case: A healthy 5-year old male presented with a several month history of progressive exercise intolerance. An x-ray showed near total opacification of the left hemithorax, and chest CT highlighted a 15.2 x 10.8 x 9 cm heterogenous, solid and cystic mass extending from the left anterior mediastinum and compressing the left lung. Serum chemistries revealed hypoglycemia. He was asymptomatic at serum glucose levels as low as 34 mg/dL and had no history of seizure or loss of consciousness. Maintenance of euglycemia required a glucose infusion rate up to 7 mg/kg/min. After several hours of fasting off glucose, serum glucose fell to 40 mg/dL, and labs were obtained: Beta-hydroxybutyrate 0.32 mmol/L (0.02 – 0.27), insulin 4.9 mU/L (3.3 – 22.1). Glucose rose 50 mg/dL within 30 minutes in response to glucagon. These findings confirmed hyperinsulinism (HI). His hypoglycemia resolved after resection of the mass. Pathology confirmed the diagnosis of a teratoma composed predominantly of pancreatic tissue with both exocrine and endocrine components. The nests of endocrine cells stained for synaptophysin and chromogranin and included cells expressing insulin (39.2±2.6%), somatostatin (18.0±1.5%), and PP (30.4±3.1%), but only rare cells expressing glucagon (0.09±0.04%). The branching ductal cells stained for pancreatic ductal markers E-Cadherin, Cytokeratin19, Sox9, and Onecut1, and also for fetal markers Pdx1 and Neurogenin3. When grown in culture and treated with increasing concentrations of glucose (0-25 mM), insulin secretion from the tumor cells was left shifted relative to cultured adult human islets (max secretion at 5mM vs. 25mM), consistent with the secretory pattern of fetal beta cells.

Conclusion: Few case reports document teratomas containing pancreatic tissue, and even fewer report associated hypoglycemia. Our case report describes a teratoma with immunohistochemical and structural features of the fetal pancreas. Furthermore, persistent insulin secretion at low glucose concentrations provides a potential mechanistic explanation for this patient’s hypoglycemia. Hypoglycemia should be considered in patients with teratomas, and teratomas considered in cases of HI. The apparent arrest of the pancreatic tissue from this teratoma at the fetal stage potentially provides a valuable tool to expand our understanding of human pancreas development.

 

Nothing to Disclose: JT, EB, GEK, LB, MSG, RKL

19278 9.0000 FRI-152 A Asymptomatic Hyperinsulinemic Hypoglycemia Secondary to a Mediastinal Teratoma with Fetal Pancreatic Features 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Tara Sutherland*1, Neda Zadeh2 and Christina M Southern Reh3
1University of California Irvine/Children's Hospital Orange County, CA, 2Children's Hospital Orange County, CA, 3Children's Hospital Orange County, Orange, CA

 

Background:Type 1 diabetes mellitus (T1DM) and congenital adrenal hyperplasia (CAH) are relatively common conditions, but there are only a few reported cases in the literature of T1DM in association with 21-hydroxylase deficiency CAH, providing a unique opportunity to evaluate the underlying genetic abnormalities for the presence or absence of overlapping genetic risk factors in these distinct conditions.

Case Description: An 11 year old female with CAH due to 21-hydroxylase deficiency diagnosed prenatally due to a positive family history of an older brother that was diagnosed with CAH at age 5 after presenting with precocious puberty. Our subject was prenatally diagnosed by genetic screening on amniocentesis and was treated via the mother with dexamethasone during pregnancy to prevent virilization. The patient was delivered full term without complications and physical exam was normal with no evidence of virilization. She has been treated with cortef and florinef from birth to current. At age 11 years old she was found to have significant hyperglycemia on routine follow up labs with serum glucose of 597 mg/dL (n 65-99 mg/dL). At that time patient endorsed 3-4 weeks of fatigue, polyuria, polydipsia, and polyphagia.  Physical exam was unremarkable. Initial laboratory evaluation revealed Hemoglobin A1c (A1c) 14.6% (n<6%), HCo3- 20 mMol/L (n 17-26 mMol/L), and large urine ketones (n=none). Diabetes autoantibodies are positive for islet cell antigen 512 and anti-GAD 65, but normal for insulin antibody, consistent with T1DM. Subject was started on insulin and A1c levels have been in target range. Subsequently, genetic testing was done to confirm the genes associated with CAH and HLA-DR typing performed to assess genetic risk of T1DM.

Results: The subject is compound heterozygous for mutations (p.I172N and p.Q318X) in the CYP21A2 gene (MIM 613815) confirming the diagnosis of CAH.  Parental testing identified that the p.Q318X mutation was maternally inherited, and the p.I172N mutation was paternally inherited and that these findings exist in a trans configuration in the patient. Furthermore, HLA genotyping revealed multiple alleles that are high risk for T1DM including DQA1-B-0201, DQB1-B-0202, and DQB1-A-0302.  In addition, she has DQA1-A-0301 and DRB1-A 0401 that was paternally inherited, which in combination predisposes her to T1DM. Unfortunately, she does not have any protective alleles for T1DM.

Discussion: The HLA DR locus is found on chromosome 6p21.32 and determines a group of cell membrane alloantigens expressed on B-cells increasing the risk of autoimmune diseases.  Some HLA typing has been associated with high risk of developing T1DM. The CYP21A2 gene is located on 6p21.33 and there may be an association between the genetic mutations allowing CAH and T1DM to occur together in at risk individuals.

 

Nothing to Disclose: TS, NZ, CMSR

19585 10.0000 FRI-153 A Genetic Findings in a Subject with Type 1 Diabetes Mellitus and Congenital Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Mahmuda M Ahmed*1, Luisa Aguiar2, Mary Alice Abbott2 and Chelsea Gordner3
1Baystate Children's Hospital, Springfield, MA, 2Baystate Medical Center, Springfield, MA, 3Baystate Medical Center- University of Massachusetts Medical School, Springfield, MA

 

Background: Martinez-Frias et al reported an autosomal recessive condition in 2 siblings of consanguineous Gypsy parents with prenatal growth deficiency, TE fistula, duodenal atresia, extrahepatic biliary atresia, hypoplastic pancreas, and hypospadias. A variant of this syndrome without TE fistula, Mitchell-Riley syndrome, has also been described. Autosomal recessive mutations in the RFX6 gene have been linked to these syndromes.  Most patients expire within the 1styear of life with multiorgan failure.  We describe a patient with Mitchell-Riley syndrome who suffered a fatal brainstem stroke on DOL 2.

Objective: To report a case of Mitchell-Riley syndrome, a variant of Martinez-Frias syndrome, highlighting the importance of genetic testing for patients with IUGR, neonatal diabetes and GI malformations.

Design/Methods:  We describe a case of a neonate born at FT with BW of 1400g to a 28yo G8P3-4 female. Pregnancy was uncomplicated, with normal prenatal US at 18 weeks, but significant polyhydramnios and IUGR were diagnosed on the day of birth. She had severe asymmetric SGA and nonspecific facial dysmorphology, with small face, narrow chin, short nose with anteverted nares, periorbital edema with down slanting palpebral fissures.  Within 18 hours of life, she developed marked hyperglycemia (> 400 mg/dL) and required IV insulin (0.005-0.01 U/kg/hr) to maintain euglycemia. Duodenal atresia was identified and on DOL 2, she underwent repair with additional findings of intestinal malrotation and a Meckel’s diverticulum.  Post-operatively, she was noted to be flaccid, and MRI confirmed multiple areas of brainstem ischemia with infarction of thalamus, brainstem and cerebellum.  MRA and coagulation studies were normal. Given the severity and irreversibility of her condition, the family opted to withdraw life support, and the baby expired on DOL 10. 

Results: Postmortem examination showed pancreatic hypoplasia (reduced beta cell mass and no alpha or delta cells), intestinal atresia, gallbladder hypoplasia and hepatic hemochromatosis.  Chromosome microarray identified a region of homozygosity encompassing chromosomal band 6q15 to 6q22.33, a region including the RFX6 gene. Molecular analysis of the RFX6 gene confirmed that both parents carried a disease-causing mutation.

Conclusions:   The constellation of clinical findings, associated with autopsy and genetic testing results, were consistent with the diagnosis of Mitchell-Riley syndrome. This case reminds clinicians to consider syndromic causes of neonatal diabetes when evaluating newborns with history of GI malformations and IUGR.

 

Nothing to Disclose: MMA, LA, MAA, CG

19861 11.0000 FRI-154 A A Case of Fatal Neonatal Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Rajan Senguttuvan*, Mark Wheeler, Salaheddin Elrokshi and Cindy Chin
University of Arizona, Tucson, AZ

 

Background:
Neonatal diabetes mellitus (NDM) is a rare condition with a reported incidence of 1 in 100,000 to 400,000 live births.1 NDM can be permanent or transient. Most TNDM cases result from abnormality of the imprinted region on chromosome 6q24.2  We present a case of TNDM most likely caused by triplication of the 6q23.3 - 24.3 region.  

Clinical Course:
CA is a preterm male infant born at 34 weeks estimated gestational age with prenatally diagnosed triplication at chromosome 6q23.3 - 24.3. Fetal ultrasound showed bilateral pyelectasis, left hydronephrosis, prominent umbilical vein and echogenic intracardiac focus. Vaginal delivery was induced for decreased fetal movement and oligohydramnios. Birth parameters included weight of 1745 g (10-25%), head circumference 31 cm (50%), and length 44.5 cm (25-50%). Physical exam showed macroglossia, epispadias, umbilical, and bilateral inguinal hernias. Hyperglycemia (200-400 mg/dL) was noted on day of life (DOL) 2 and managed via insulin drip. A trial of glyburide was initiated without improvement in insulin needs. He eventually transitioned to subcutaneous insulin, including diluted lispro insulin (U-1, 1 unit lispro /1 mL) and glargine. His insulin was decreased gradually and eventually discontinued on DOL 76. The baby was discharged home on DOL 80 and was euglycemic without insulin therapy. 

Discussion:
Genetic aberrations at the TNDM locus on chromosome 6q24 causes overexpression of two imprinted genes, PLAGL1 and HYMAI.2,3 The three reported causes of this overexpression are: paternal uniparental disomy of chromosome 6, paternally inherited duplication of 6q24 and maternal hypomethylation at 6q24.3 Our patient‘s TNDM resolved on DOL 76. His physical findings of macroglossia and umbilical hernia are seen in genetic aberrations in the 6q24 region.3 Uniquely, our patient had a triplication of the 6q23.3 - 24.3 region. A PubMed search did not reveal any reported cases of TNDM with this mutation. It is important that physicians are aware of this mutation and its association with TNDM.

 

Nothing to Disclose: RS, MW, SE, CC

19912 12.0000 FRI-155 A Transient Neonatal Diabetes Mellitus (TNDM) Associated with Triplication of Chromosome 6q23.3 - 24.3 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Deepa Suresh*
Texas Children's Hospital, Houston, TX

 

Background: Uncontrolled maternal diabetes is associated with a high incidence of major congenital malformations in the fetus. The spectrum of malformations often overlaps with several other syndromes like DiGeorge syndrome, CHARGE, and caudal dysgenesis. This overlap frequently leads to masking of additional involvement of other organs unless a more extensive work-up is undertaken. Several of these infants are misdiagnosed.  We present a case of a 16 y.o. female who presented with hypocalcemia at birth and was diagnosed with DiGeorge syndrome. She presented later with delayed puberty and further work-up identified an alternative diagnosis.

Case:  A 16 y.o. female presented to the Endocrine clinic with delayed menarche. She had a previous diagnosis of DiGeorge syndrome at birth when she presented with hypocalcemia, VSD and facial dysmorphic features like low set ears. Her mother had uncontrolled diabetes during pregnancy. She was diagnosed with DiGeorge syndrome based on the presentation. The hypocalcemia resolved when she was about 1 year old. She had surgical correction of VSD. At the age of 16 yrs she presented with primary amenorrhea and no breast development. Further workup done for primary amenorrhea revealed agenesis of the uterus and ovaries and ectopic kidneys. Genetic testing was negative for DiGeorge and a comprehensive CMA did not identify any genetic defect.

Conclusion:  Hyperglycemic embryopathy seen in infants of mothers with uncontrolled diabetes can present with multiple organ defects. The spectrum of pleomorphic birth defects includes cardiac defects, genitourinary malformations, musculoskeletal defects, central nervous defects, craniofacial dysmorphism, hypocalcemia and hypoglycemia. Some of these features may not be evident at birth and may manifest later in life like in our patient who had uterine aplasia that was not detected until she presented with delayed puberty. Given the frequent co-occurrence of malformations of multiple organs, identification of features that match a single syndrome should not preclude more extensive evaluation for concurrent defects in other organs.

 

Nothing to Disclose: DS

20466 13.0000 FRI-156 A Late Recognition of Syndrome-like Manifestations in Hyperglycemic Embryopathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Min-Jye Chen*1, George Said Jeha2 and Katherine Hwu3
1Baylor College of Medicine, Texas Children's Hospital, Houston, TX, 2Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 3Baylor College of Medicine / Texas Children's Hospital, Houston, TX

 

Background

Transient neonatal diabetes mellitus (TNDM) is rare, occurring in approximately 1 in 400,000 worldwide, though this may be an underestimation as expression is variable and patients may be misdiagnosed. 6q24 abnormalities, including uniparental disomy, are the most common cause of TNDM. Approximately 50% of patients with TNDM will relapse, usually in adolescence.  We report a case of an adolescent with clinical diagnosis of relapsed TNDM, successfully treated with sulfonylurea, in a family with strong history of Type 1 or Type 2 diabetes in young males.

Clinical Case

A 16-year-old male presented for evaluation of diabetes, with polyphagia, polydipsia, and elevated blood glucose. He had a history of neonatal diabetes requiring insulin, which resolved by 2 months of age, and umbilical hernia, surgically repaired at age 9. Prenatal and birth history were notable for oligohydramnios, and birth weight of less than 5th percentile for gestational age. There was a strong family history of diabetes, including reported Type 1 diabetes in paternal half-brother, on insulin therapy; young onset Type 2 diabetes in father, treated with sulfonylurea; and Type 1 diabetes in paternal grandfather and multiple great-uncles. Physical exam revealed a thin male without acanthosis nigricans. Initial labs included glucose 318 mg/dL (reference range 70-100 mg/dL), with corresponding insulin of 10.1 mU/L (reference range 2-105 mU/L), and c-peptide 2.51 ng/mL (reference range 0.8-5.2 ng/mL) and hemoglobin A1C (HbA1C) of 9.7% (reference range <6%). There was no acidosis or ketosis. There was no evidence of autoimmunity. He did not have mutations in common genes for mature onset diabetes of the young (MODY), including HNF4a, GCK, HNF1a, PDX1, and HNF1b. He was started initially on insulin, and later was successfully transitioned to glyburide with subsequent HbA1C levels of less than 6%.

Clinical Lesson

This is a case of relapsed TNDM in a family with a dominant inheritance pattern of diabetes in young males, though none others in the neonatal period. It is possible that the family members that were previously diagnosed with Type 1 or Type 2 diabetes may actually have the same underlying cause, as variable expression of TNDM could include absence of the neonatal form. This case emphasizes the importance of considering inherited forms of diabetes in patients, such as TNDM and MODY, with strong family history of diabetes and without evidence of autoimmunity and insulin resistance.

 

Nothing to Disclose: MJC, GSJ, KH

20578 14.0000 FRI-157 A Relapsed Neonatal Diabetes in a Family of Male Dominant Diabetes: Coincidence or Genetics? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Marwan Bakhach*1, Sara Akhtar1 and Anzar Haider2
1Cleveland Clinic Children's, Cleveland, 2Cleveland Clinic Children's, Cleveland, OH

 

Autoimmune Polyglandular Syndrome (APS)-3 is characterized by autoimmune thyroid disease associated with another autoimmune condition such as alopecia areata, vitiligo, other than autoimmune adrenal insufficiency. Type 1 Diabetes Mellitus (DM) being an autoimmune disease may be associated with APS and classified as APS-3 variant. We describe a case of APS-3 associated with Type 2 DM which has not been previously reported in the pediatric population.

A 13 year old African American female with past medical history of alopecia areata and Hashimotos thyroiditis was admitted to the hospital with polyuria, polydipsia and nocturia of 3 weeks duration.  She was diagnosed with alopecia areata by the dermatologist at age 5 years. She had a thyroid function test at that time with elevated microsomal antibody titer of 399 (<5 IU/ml) and slightly elevated TSH of 6.4 (0.4-5.5 uU/ml) but normal free T4 of 1.2 (0.7-1.8 ng/dl). Around the same time she started gaining weight and was started on 50 mcg thyroxine supplement when her repeat TSH remained elevated at age 6 years. Family history was significant for Type 1 Diabetes in mother since age 9 year and Graves disease in maternal grandmother.

Physical exam at the time of admission revealed an obese adolescent with height at 85th%, weight at 99th% and BMI at 99 %. Her pulse rate was 87 and BP was 119/67mmHg. She was mildly dehydrated with no Kussmaul breathing. She also had mild acanthosis nigricans and a small goiter. She had significant alopecia areata involving almost 90% of her scalp. Lab tests revealed a blood glucose of 277 (65-100 mg/dl), bicarbonate of 21 (23-32 mmol/L) and ß-hydroxybutyrate of 1.04 (0.00-0.30 mmol/L). Her HbA1C was 10 (4-6%). Except for low HDL of 33 (>55 mg/dl), her lipid profile was normal with triglyceride of 95 (25-125 mg/dl) and LDL of 55(50-109 mg/dl).  Her C-peptide was 1.0 (0.8-3.2 ng/ml) and insulin level was 4.2 (1-24 uU/ml). She was hydrated with IVF and started on long acting insulin at bed time and short acting analog insulin at meal times. Because of her APS-3, it was felt that she probably had Type 1 DM. However; serological antibody titers obtained were not elevated  against pancreas GAD 65, Insulinoma associated antibody and Islet cell antibody.  Metformin was added in 2 weeks and insulin was weaned off over 4 weeks. Blood glucoses have remained in 70's-190's over the past 6 months.

Conclusion:  Presence of 2 autoimmune disorders such as thyroid disease and alopecia areata in a patient does not necessarily mean DM must be due to an autoimmune process. Serological markers should be obtained to help characterize the type of DM. It is conceivable that autoimmunity may play a role in the development of insulin resistance and beta cell damage leading to pathogenesis of Type 2 DM; however, these putative markers are not yet established in Type 2 DM.

 

Nothing to Disclose: MB, SA, AH

21632 15.0000 FRI-158 A Autoimmune Polyglandular Syndrome Type 3 Associated with  Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Nader Kasim*1, Robert Wilroy Jr.2, Eniko Pivnick3, Roya Mostafavi4 and Sunil Kumar Sinha5
1University of Tennessee Health Science Center, Memphis, TN, 2The University of Tennessee Health Science Center, 3University of Tennessee Health Science Center, 4Le Bonheur Children's Hospital, Memphis, TN, 5University of Tennesee Health Science Center, Memphis, TN

 

Introduction: Trisomy 13 has a wide array of phenotypic variability, usually with a very short lifespan rarely extending beyond infancy. The association of hyperinsulinemic hypoglycemia (HIH) and trisomy 13 has been described in four published case reports. Molecular basis of approximately 50% of HIH still remains to be identified; association with chromosome 13 is not well studied.

Case: AA female was born at term to a 24 year old G2P1 mother. The pregnancy was complicated by preeclampsia, oligohydramnios, and congenital heart defect. Maternal history was negative for gestational diabetes. Birth weight, length and OFC were 2.87 kg (23%), 50 cm (64%), and 30.5 cm (<3%) respectively. Physical exam was significant for large fontanelles, all sutures widely open, microphthalmia, micrognathia, synophrys, lowset ears, narrow high-arched palate, notched upper alveolar ridge, deep pilonidal dimple, hirsutism, dimpling of the lateral aspects of both knees, and left hand postaxial hexadactyly. Echocardiograms revealed a variant of hypoplastic  left heart; CT scan of the head showed an occipital encephalocele. Spinal ultrasound revealed a tethered cord with a distal filar cyst. Due to the multiple congenital anomalies blood for chromosomal study was obtained.

At delivery, she was intubated and was hypotensive requiring a prostaglandin drip, dopamine infusion, and hydrocortisone.  She was also started on TPN at a GIR 6.98 mg/kg/min. She was immediately found to be persistently hypoglycemic. On day of life 1, her glucoses ranged from 35 mg/dL to 56 mg/dL. Next two days she required approximately 20-25 mg/kg/min to maintain euglycemia. Critical samples at serum blood glucose of 47mg/dL were strongly suggestive of HIH: β-hydroxybutyrate 0.07 mmol (N: 0.00 - 0.29), insulin 96.7 mIU/mL (N: <=17.0), cortisol 13.80 mcg/dL, growth hormone 2.6 ng/mL, FFA 0.27 mmol/L (N: 0 - 2.30). With the diagnosis of HIH, she was started on diazoxide at 15mg/kg/day. On day of life 3, the cytogenetic study confirmed trisomy 13. Due to the condition’s poor prognosis all interventions were discontinued per the parents’ wishes. 

Discussion: Severe non-ketotic hypoglycemia with concomitant presence of markedly elevated serum insulin, and low free fatty acid concentration clinically confirms the diagnosis of hyperinsulinism. Low growth hormone can lead to hypoglycemia but this is unlikely to require this degree of GIR to maintain euglycemia. Two candidate genes, IPF1 and CDX2, located on 13.q12.2 and 13q12.3, respectively, have been associated with HIH. However, the precise mechanism of HIH in relation to trisomy 13 remains unknown.

 

Nothing to Disclose: NK, RW Jr., EP, RM, SKS

22133 16.0000 FRI-159 A Hyperinsulinemic Hypoglycemia and Trisomy 13: Are They Related? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Eiichiro Satake*1, Rie Matsushita2, Kohnosuke Ohtaka2, Kazuteru Kitsuda3, Eiko Nagata2, Rie Yamaguchi2, Yasuko Fujisawa2, Toshiki Nakanishi2, Yuichi Nakagawa4 and Takehiko Ohzeki5
1Joslin Diabetes Center, Boston, MA, 2Hamamatsu University School of Medicine, Hamamatsu, Japan, 3Sagamihara Kyodo Hospital, Sagamihara, Kanagawa, Japan, 4Shiraume Toyooka Hospital, Iwata, Shizouka, Japan, 5Kyoritsu Women's University, Tokyo, Japan

 

Background and Aim:Myo-inositol is a form of inositol that is widely available in organisms. In adult diabetic patients, urinary myo-inositol (UMI) levels are elevated and increase after glucose loading. However, the relationship between UMI and plasma glucose levels in children is unknown. The aim our study was to assess whether UMI is a practical marker for glucose intolerance in children.

Subjects and methods: In Study1, a cross-sectional study of 328 school children (167 boys and 161 girls; age, 9–12 years) was performed. UMI was enzymatically measured before and 2 h after lunch. The ΔUMI was defined as the difference between pre- and postprandial UMI levels. In Study 2, 18 participants (13 boys and 5 girls) suspected of having diabetes mellitus (DM) were enrolled. Oral glucose tolerance tests and UMI measurements before and 2 h after glucose ingestion were performed. In Study 2, the ΔUMI was defined as the difference between UMI levels of pre- and post glucose ingestion.

Results: For Study 1, ΔUMI was negative in both males and females. UMI levels were not significantly correlated with age and sex. Of the 18 participants in Study 2, 2 were newly diagnosed with DM, 4 had impaired glucose tolerance (IGT) and 12 were normal glucose tolerance (NGT). Children with non-NGT (DM and IGT) had a significantly higher ΔUMI than children with NGT. There was a positive correlation between ΔUMI and glucose level and negative correlation between ΔUMI and serum insulin level or insulinogenic index.

Conclusion: We conclude that ΔUMI can be a practical marker for the early detection of glucose intolerance in children.

 

Nothing to Disclose: ES, RM, KO, KK, EN, RY, YF, TN, YN, TO

18215 17.0000 FRI-160 A Utility of Urinary Myo-Inositol in Children with Glucose Intolerance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Kate Millington*1 and Andrew Anthony Palladino2
1Boston Children's Hospital, Boston, MA, 2The Childrens Hospital of Philadelphia, PA

 

Glycogen storage diseases (GSDs) are a group of rare inherited disorders of glycogen metabolism. Morbidity and mortality has declined since the introduction of continuous feeding and uncooked cornstarch as therapies to maintain normoglycemia. Little is known about the factors that increase the risk of death in a patient with a GSD. Out of a group of 69 GSD patients, we have identified and describe 8 patients (11.6%) that died within an 18 year period. Patients who died in childhood were more likely to die as a direct result of their GSD, while patients who died as adults succumbed as a result of other medical conditions. There was no difference in disease severity or degree of disease control between those patients who died and those who survived as demonstrated by triglyceride levels. Mean number of admissions (±SD) within the preceding 12 months was greater in patients that died (2.5±2.1) compared to patients who survived (0.48±1.2). Additionally, the mean number of comorbidities (±SD) was higher in patients that died (4.4±3.3) compared to survivors (1.3±1.7). We recommend closer monitoring and follow up for patients with GSD that have comorbid conditions and any unplanned hospitalizations.

 

Nothing to Disclose: KM, AAP

18510 18.0000 FRI-161 A Mortality in Glycogen Storage Disease: The CHOP Experience 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Antonio Mancini*1, Francesco Leo2, Sebastiano Raimondo1, Chantal Di Segni1, Francesco Guidi3, Diego Currò1 and Aurora Natalia Rossodivita1
1Catholic University of the Sacred Heart, Rome, Italy, 2Catholic University of The Sacred Heart, Rome, Italy, 3Catholic University of The sacred Heart, Rome, Italy

 

Kisspeptin is a neuropeptide secreted in the anteroventral periventricular and arcuate hypothalamic nuclei involved in starting of pubertal development and also in other functions typical of adult life. Its blood value varies according with sex so they are higher in prepubertal girls and in adult women compared to age-matched male. Recently it has been proposed a possible role in the stimulation of antioxidant defenses in murine models. We studied Kisspeptin plasma levels in a population of 27 prepubertal (stage 1 of Tanner) children (13 males and 14 females) aged 5-12 years, classified on the bases of Cole’s criteria into 3 overweight and 24 obese. 8 normal weight children, aged 6-12 years, were studied as controls. We evaluated metabolic parameters: glucose and insulin levels after oral glucose load, total- LDL- and HDL-cholesterol, triglycerides, uric acid, total proteins, C Reactive Protein.  In order to evaluate kisspeptin levels, morning blood sample was immediately centrifugated for 11 minutes at 2700 rmp and 4°C to obtain plasma, that was stocked at a temperature of -80°C. Plasma was then acidified to extract peptides in a C-18 SEP-Column (Phenomenex Inc, Torrance, CA, USA) containing 200 mg of C18. The eluted samples were evaporated to dry and finally stored at -80°C until the time of assay. The concentration of kisspeptin (expressed in pg/ml) was measured using the kit KISS1 (61-121) Amide-Metastin (1-54)-NH2 (Rk-048-59, Phoenix Pharmaceuticals, Inc., Burlingame, CA, USA) based on Radio Immuno Assay. We did not find significant differences between obese and normal weight children (mean ±SEM: 20.1±1.96  and 20.7±0.68 pg/ml, respectively) and between males and females obese children (mean±SEM 19.05±3.39  and 20.9±2.49 pg/ml,  respectively). Kisspeptin levels did not correlate with BMI,  HOMA index and Insulin peak levels after glucose load. On the contrary a significant correlation was found between Kisspeptin and uric acid (Spearman correlation test=0,455; p-value=0,059).  Theese preliminary data suggest that Kisspeptin could play a role in antioxidant status and could be regarded as metabolic modulator and not only a regulator of pituitary gonadal axis. Further studies can clarify the complex interrelationship between central and peripheral Kisspeptin secretion and oxidative stress in children obesity.

 

Nothing to Disclose: AM, FL, SR, CD, FG, DC, ANR

19326 19.0000 FRI-162 A Kisspeptin Evaluation in Children Obesity: A Metabolic Role? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Won Kyoung Cho*1, Hyo Jin Kim1, Yeon Jin Jeon1, In Ah Jung2, Shin Hee Kim1, Kyoung Soon Cho1, So Hyun Park1, Min-Ho Jung1 and Byung-Kyu Suh1
1College of Medicine, The Catholic University of Korea, Seoul, Korea, Republic of (South), 2College of Medicine, The Catholic University of Korea, seoul, Korea, Republic of (South)

 

Aims: Body mass index (BMI) is not a complete tool of the distribution of body fat. The world health organization (WHO) recommends using waist to height ratio (WHtR) to screen children obesity. We try to evaluate the metabolic syndrome components of normal weight (NW) and overweight (OW) children stratified by WHtR.

Methods: This is a cross-sectional study. Data were obtained from the Korean National Health and Nutrition Examination Survey (K-NHANES) conducted during 2008-2010 by the Korean Ministry of Health and Welfare. A total of 1741 subjects aged 13 - 18 years were estimated. Based on the age and sex specific BMI, the children were grouped as NW (5th-85th percentile) and as OW (≥ 85th percentile). These groups were stratified by the age and sex specific WHtR over top quartile (central obesity) and below (no central obesity).

Results: In male, the weighted prevalence of NW was 79.3% (723/909) [central obesity NW was 7.0% (61/909)] and OW was 20.7% (186/909) [no central obesity OW was 2.2% (21/909)]. In female, the weighted prevalence of NW was 82.3% (604/832) [central obesity NW was 9.6% (83/832)] and OW was 17.5% (145/832) [no central obesity OW was 2.5% (20/832)].

In male NW, WHtR showed significant positive correlations with insulin (r=0.27), HOMA-IR (r=0.25), TG/HDL ratio (r=0.14), ALT (r=0.32), WBC (r=0.15) and negative correlation with HDL (r=-0.17). In male OW, WHtR showed significant positive correlations with insulin(r=0.26), HOMA-IR(r=0.24), TG(r=0.23), TG/HDL ratio (r=0.23), ALT(r=0.33), AST(r=0.27), WBC(r=0.17) and negative correlation with HDL(r=-0.17).

In female NW, WHtR showed significant positive correlations with insulin (r=0.10), HOMA-IR (r=0.08), TG(r=0.07), TG/HDL ratio (r=0.10), ALT (r=0.23) and negative correlation with HDL (r=-0.10). In female OW, WHtR showed significant positive correlations with insulin (r=0.24), HOMA-IR (r=0.26), TG/HDL ratio (r=0.13), ALT (r=0.19).

In male adolescents, the central obesity NW was 2.5 times (95% confidence interval [CI], 1.21-5.00) more likely to have top quartiles of HOMA-IR than no central obesity NW (control group) after adjusting for age, weight, ALT. However, no central obesity OW showed non-significant odds ratio of having top quartiles of HOMA-IR than no central obesity NW (control group).

Conclusion: WHtR can discover central obesity in NW classified by BMI and may suggest relationships with metabolic syndrome components in not only OW but also NW group in Korean adolescents.

 

Nothing to Disclose: WKC, HJK, YJJ, IAJ, SHK, KSC, SHP, MHJ, BKS

20159 20.0000 FRI-163 A Metabolic Syndrome Components of Normal and Overweight 13-18 Children Stratified By Waist to Height Ratio: Results from K-Nhanes 2008-2010 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Christopher Prestel*1, Remberto C. Paulo1, Ibrahim Shatat2, Deborah A. Bowlby1 and Katherine A. Lewis1
1Medical University of South Carolina, Charleston, SC, 2Medical University of South Carolina

 

Purpose of Study: Hypertension (HT) during adolescence tracks into adulthood. As cardiovascular disease is
the leading cause of death in adults, it is important to diagnose and treat at early stages. The diagnosis of
elevated blood pressure (BP) in children is weight, height and sex specific which requires provider to check
both growth charts and BP tables to identify elevated measurements. Frequently, in a busy clinical setting
elevated BP goes unrecognized. In this study, we examine the impact of electronic medical record (EMR)
smartphrase that calculates height, age and sex specific BP percentile (BP%).

Methods Used: BP of children with T2DM followed at our outpatient Pediatric Diabetes clinic for 6 months
before and 6 months after implementing the BP % smartphrase were analyzed. Elevated BP in the
hypertensive range was defined as ≥95% systolic/diastolic. Chi square was used to analyze difference in
detection rate of elevated BP before vs after implementation.

Summary of Results: 118 patients with T2DM were analyzed. Average age was 14.3yo, with 65% females
and 86% African­Americans. All were obese (BMI (≥95%). 54% have Medicaid. 7 (6%) have been diagnosed
with HT and on antihypertensive medications prior to the start of the study.

Of the 69 patients seen before implementation of the EMR smartphrase, 30 (44%) had BP ≥ 95% but only 6
(20%) were recognized. After implementation, 68 patients were seen, 24 (35%) had BP ≥ 95% and
significantly more patients [15 (62%)] were recognized (P<0.001). This led to higher frequency of counseling,
instruction to monitor BP at PCP’s office, or referral to the hypertension clinic.

Conclusions: There is a high prevalence of elevated BP among children with T2DM. Implementing an EMR
smartphrase increased the rate of elevated BP detection, and thus improved care. Utilizing features in EMRs
that facilitate detection of children at higher risk of cardiovascular morbidities should be encouraged and
systematized.

 

Nothing to Disclose: CP, RCP, IS, DAB, KAL

21507 21.0000 FRI-164 A Improved Detection of Elevated Blood Pressure in Children with Type 2 Diabetes Mellitus after Implementation of Electronic Medical Record 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Lina Huerta Saenz*1, Yun Yan2 and Carol J. Saunders3
1The Children's Mercy Hospital - Wichita Specialty Clinic, Wichita, KS, 2Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, MO, 3Children's Mercy Hospital, Kansas City, MO

 

Background: Congenital hyperinsulinism (CHI) is the leading cause of severe hypoglycemia in neonates, causing severe developmental and cognitive delays if not recognized and treated appropriately. The infant of a diabetic mother (IDM) typically presents with transient hyperinsulinism; however CHI needs to be considered if hypoglycemia persists. The most common form of CHI is caused by loss-of-function mutations in the ABCC8 and the KCNJ11 genes, together associated with 90% of CHI cases. Here, we report a case of an IDM with CHI caused by a novel KCNJ11 variant.

Clinical case: A Hispanic male infant was born large for gestational age at 34 weeks to a 17-year old mother who had uncontrolled gestational diabetes and pre-eclampsia.  Infant was born by emergent C-section after concerning fetal monitor strip during prenatal visit. At delivery, he was floppy, cyanotic and required positive pressure ventilation. His initial blood glucose level was 7mg/dL. He was diagnosed with hypoplastic aortic arch and developed severe hypoglycemia, respiratory distress syndrome, and supra-ventricular tachycardia on day 2 of life (DOL #2). The infant received an initial intravenous (IV) bolus of dextrose 12.5%, then IV fluids were started with a glucose infusion rate (GIR) of 6.9 mg/kg/min due to persistent hypoglycemia; then the GIR was gradually increased to 16 mg/kg/min and polycose supplementation was started with the goal of maintaining glucose levels above 70 mg/dL.  The patient subsequently developed hypoglycemia (glucose < 50 mg/dL) after IV dextrose was weaned off on DOL# 21 despite consuming a 26 calorie/oz of formula supplemented with polycose.

Extensive work-up for CHI was performed on DOL# 25, revealing an insulin level of 16.3 uU/mL [normal < 2] and a glucose level of 48mg/dL. Betahydroxybutyrate was <100 mcmol/L. Ammonia, pyruvic acid, cortisol, free fatty acid, serum amino acids, acylcarnitine profile, and urine organic acids levels were all in normal range. Genetic testing for ABCC8 and KCNJ11 revealed a maternally inherited heterozygous sequence variant in the KCNJ11 gene, c.616C>T (p.Arg206Cys). This novel missense variant results in the substitution of a highly conserved amino acid and is predicted by multiple in silico programs to be pathogenic. It is absent in approximately 6,500 individuals in the NHLBI Exome Sequencing Project database as well as our internal database of 2,500 samples. Diazoxide treatment was started immediately and glucose levels stabilized above 60mg/dL at a dose of 15 mg/kg/day on DOL#30. Patient was discharged home on DOL# 71 with diazoxide dose at 10mg/kg/day and remains stable on diazoxide therapeutic dose.

Conclusion: CHI should be considered as the presumed etiology in an IDM with prolonged and refractory hypoglycemia. Appropriate work-up, including genetic testing for ABCC8 and KCNJ11 mutations should be pursued immediately if hypoglycemia persists.

 

Nothing to Disclose: LH, YY, CJS

18812 22.0000 FRI-165 A Severe Persistent Hypoglycemia in an Infant of a Diabetic Mother Secondary to a Novel KCNJ11 Variant-Related Congenital Hyperinsulinism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Marie Helene Schernthaner-Reiter*1, David Adams1, Giampaolo Trivellin1, Mary Scott Ramnitz1, Margarita Raygada1, Gretchen Golas1, Fabio R Faucz2, Kavitha Dileepan3, Maya Beth Lodish1, Paul R. Lee1, Thomas C. Markello1, Cynthia J. Tifft1, William A Gahl1 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3Children’s Mercy Hospital, Kansas City, MO

 

M.H.S.-R. and D.A. contributed equally to this work.


Background

Congenital diabetes insipidus (DI) can be due to mutations in the arginine vasopressin (AVP) gene (familial neurohypophyseal DI) or due to mutations in the arginine vasopressin receptor type 2 (AVPR2) or aquaporin 2 (AQP2) genes (congenital nephrogenic DI, NDI). The clinical manifestation of congenital NDI, especially the response to arginine vasopressin (AVP), can vary greatly depending on the functional effect of the AVPR2 mutation. Here we present two male siblings with an identical, novel splice site mutation in AVPR2 leading to NDI. 


Clinical case

A 20-month old boy presented with failure to thrive, polyuria and polydipsia. Laboratory evaluation showed hypernatremia with elevated serum osmolality and inappropriately low urine osmolality. AVP levels were elevated at 6.4 pg/mL (0.7-3.8 pg/mL). A water deprivation test led to a further increase in the basally high AVP levels with no adequate improvement of urine osmolality. However, DDAVP administration increased urine osmolality slightly to 347 mOsm/kg, consistent with partial NDI. The patient’s older brother (8 years) also presented with polyuria, polydipsia and failure to thrive and was subsequently diagnosed with DI, while the two parents, a sister and a brother did not have DI.

Initial Sanger Sequencing reported no strongly pathogenic variants in AVPR2 or AQP2, with mention made of one possible splice site effect of a synonymous change.  We performed exome sequencing and found the same variant. In fact, we confirmed that both the patient and brother were hemizygous for two AVPR2 variants with in silico predicted effects on mRNA splicing, which were subsequently tested in vitro. A minigene assay revealed that only one, the novel AVPR2 c.276 A>G mutation created a cryptic splice acceptor site that led to 5’ truncation of AVPR2 exon 2 when tested in HEK293 cells. This truncation corresponds to AVPR2 transmembrane helix II, which is involved in AVP binding, and is likely to be the cause for these familial cases of NDI with partial responsiveness to AVP. Of note, the patients’ mother and sister are both heterozygous (carriers) for this mutation; the mother developed polyhydramnios during the pregnancies with her two affected sons and also with her healthy son. Both patients were treated with high dose DDAVP and showed improvement of DI symptoms as well as improved growth and weight gain.

Conclusion

We detected a novel AVPR2 splice site mutation as a cause of X-linked NDI in two patients. Patients with DI of unknown etiology can harbor splice site mutations whose pathogenicity may initially be underestimated on routine sequence analysis.

 

Nothing to Disclose: MHS, DA, GT, MSR, MR, GG, FRF, KD, MBL, PRL, TCM, CJT, WAG, CAS

20650 23.0000 FRI-166 A Nephrogenic Diabetes Insipidus Due to a Novel AVPR2 Splice Site Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 144-166 6050 1:00:00 PM Pediatric Diabetes, Obesity & Metabolic Disorders Poster


Christopher Prestel*1, Deborah A. Bowlby1, Katherine A. Lewis1, Murray Passo2, Natasha Ruth2, Laura Parks2 and Remberto C. Paulo1
1Medical University of South Carolina, Charleston, SC, 2Medical University of South Carolina

 

Introduction

Antithyroid drugs (ATD) are reported to cause a wide range of adverse events including drug rash, pancytopenia, agranulocytosis, and liver dysfunction. Uncommonly, ATDs may also cause systemic vasculitis, including microscopic polyangiitis. We report a pediatric patient with Graves’ disease (GD) treated with Methimazole (MMI), who presented with acute blindness and found to have microscopic polyangiits (MPA) involving multiple organs, including retinal vasculitis. The need to explore other treatment options for GD with patient and family in this scenario is highlighted.

History

15yo F with one year history of GD on MMI 5mg BID was transferred for further management of acute right sided visual loss. She has a 1.5 month history of blurry vision preceding acute blindness of the right eye on the day of admission. She also had bilateral lower extremity weakness, paresthesias, and ulcerations. Ophthalmologic evaluation showed bilateral, severe, retinal vasculitis and papillitis, R>L, with no light perception on right. She was ANA and APA negative and her complements were normal. She had a positive p-ANCA at 1:80 with a myeloperoxidase IgG elevated at 3.6 (nml <0.9). Proteinase 3 IgG and c-ANCA were neg, Her ESR was 97and CRP 34. Infectious workup was normal. Free T4 and TSH were normal at 1.22 and 1.4. MMI was stopped. Skin biopsy revealed diffuse vasculitis affecting small and medium-sized vessels in dermis and subcutaneous tissue, suggestive of MPA vs MMI-induced ANCA vasculitis . Kidney biopsy was normal (no crescents, necrosis, or vasculitis), except for 1 red cell cast. She was given pulse dose IV methylprednisolone and then BID IV solumedrol at 0.6mg/kg/day. Rituximab was started at 375mg/m2 two days after completion of steroids. At discharge, her vision improved in left eye, but only minimally in the right. Her leg pain attributed to neuropathy improved. Other treatment options for GD were discussed with patient and family, and they are considering radioactive ablation (RAI).

Discussion

ATD-induced MPO-ANCA vasculitis is well established1,2, specifically microscopic polyangiitis1, 3. To our knowledge, this is the first case of sudden visual loss in a pediatric patient with MPO-ANCA vasculitis/MPA in the setting of MMI treatment for GD. In adults, there are few case reports of the same1, and in patients with systemic necrotizing vasculitides in general6. Multi-organ involvement as in our patient’s case is not uncommon1. Case reports have also described some patients initially thought to have idiopathic systemic vasculitis but later developed ATD-induced MPA during GD relapse5. Discontinuation of ATD is prudent after vasculitis diagnosis, and alternate treatment for GD is needed, including RAI treatment or surgical excision4. Clinicians should maintain a high index of suspicion for ANCA vasculitides in patients with GD treated with ATD to mitigate serious complications.

 

Nothing to Disclose: CP, DAB, KAL, MP, NR, LP, RCP

21311 1.0000 FRI-167 A Sudden Blindness in a Pediatric Patient with Graves' Disease on Methimazole 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 167-173 6052 1:00:00 PM Pediatric Thyroid & Growth Disorders Poster


Vidit Bhargava*, Fadeke Adewole, Sally Robinson and Phillip D K Lee
University of Texas Medical Branch, Galveston, TX

 

Abstract PWS/AS

Introduction: Del 15q11-13 is associated with 2 distinctive genetic syndromes depending on the parent of origin: Angelman Syndrome (AS), characterized by developmental delay, seizures, microcephaly, movement or balance disorder, speech disorder and happy demeanor and Prader Willi Syndrome (PWS), characterized by hypotonia, hyperphagia and developmental delays. We report an unusual case of PWS presenting with clinical signs and symptoms suggestive of AS, without typical features of PWS.

Case:  A 12.3 year old female was evaluated for developmental delay with cognitive disabilities, minimal speech, echolalia and continuous hand motions; and a pleasant but minimally interactive demeanor. Chromosomal microarray analysis revealed a 5.02 MB interstitial del of 15q11.2>q13.1 (21,192,943-26,213,571), consistent with PWS or AS, and a 604 KB interstitial duplication of 16p11.2 (29,530,197-30,134,432). Past medical history revealed prolonged hospitalization for prematurity, specific details were unavailable but no unusual feeding or weight gain problems were recalled. On examination, height was 0.61 percentile, weight 66th percentile, head circumference and hand length 25thpercentile; the patient had a stocky build, mild generalized hypotonia without apparent decrease in muscle mass, broad nasal bridge and no specific features suggestive of PWS; Tanner stage B2P3. Based on her presentation, AS was suspected, however methylation analysis confirmed the diagnosis of PWS, with presence of only the maternal copy of 15q11.2q13.1. Lab testing showed isolated growth hormone deficiency (peak growth hormone level 3.23 ng/ml). She sunsequently had a good response to growth hormone treatment, with height increasing from 136.1 cm (0.40 percentile) at age 12.6 years to 147.3 cm (1.29th percentile) at age 14.9 years. Her BMI decreased from 94th percentile to 79th percentile during the same time. Menarche had not occurred as of 14.9 years old (Tanner stage B2P3); speech and behavior had remained essentially unchanged.

Conclusion:  Although variable phenotypic  presentation of PWS has been reported, this case is particularly unusual in having virtually no typical features of PWS; but rather presenting as possible AS. We postulate that the 16p11.2 duplication, involving an autism susceptibility region, may have attenuated some features of PWS. This case emphasizes the importance of defining parent-of-origin for deletions or mutations of the PWS/AS region of 15q in patients clinically suspected of having PWS or AS. In addition, evaluation for other chromosomal abnormalities, e.g., by chromosomal microarray analysis, may be useful in patients with atypical presentation.

 

Nothing to Disclose: VB, FA, SR, PDKL

18801 2.0000 FRI-168 A Attenuated Phenotype in a Patient with Prader Willi Syndrome and 16p Duplication 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 167-173 6052 1:00:00 PM Pediatric Thyroid & Growth Disorders Poster


Jessica A. Ferris* and Mitchell E. Geffner
Children's Hospital Los Angeles, Los Angeles, CA

 

Background: Aromatase inhibitors (AIs) are frequently used off-label, alone or with other growth-promoting agents, to increase adult height in boys with short stature (SS) and/or rapid-tempo puberty (RTP) despite minimal efficacy and safety data.

Methods: Charts of 24 boys with SS and/or RTP treated with AIs were retrospectively reviewed (8 were excluded due to incomplete data). Subjects were divided as Tanner stage (TS) I-III (Group or G1, n=7) and TS IV-V (Group or G2, n=9), with outcomes of interest including Bayeley-Pinneau predicted adult height (PAH), clinical data, and biochemical analytes. Differences in baseline characteristics between groups were assessed by unpaired t-test. Paired t-tests were used to compare baseline pre-AI and on-treatment clinical and biochemical data. Severity of acne was scored from 0-3. Data are presented as mean±SD (range).

Results: Baseline characteristics for G1: chronologic age (CA) 9.08-15.92 y, bone age (BA):CA 0.88-1.23, PAH 64.3-70.1 in, and target height (TH) 61.1-71.5 in; for G2: CA 11.25-15.5 y, BA:CA 0.94-1.24, PAH 63.3-67.2 in, and TH 65-71 in. AIs included letrazole (n=15), and anastrozole for 1 y followed by a switch to letrazole (n=1). Duration of treatment: 0.33-5.83 y (G1) and 0.5-1.98 y (G2). PAH went from 66.9±1.8 (64.3-70.1) to 66.5±3.1 (63.3-70.8) in G1 and from 65.3±1.6 (63.3-67.4) to 65.4±2.1 (62.5-68.6) in G2, (both p=NS). In G1, testosterone (T) increased from 155±189 (13-435) to 728±401 (99-1178) ng/dL (TS I-III, <5-719 ng/dL), p=0.0071; in G2, T increased from 417±295 (219-1045) to 1192±342 (803-1642) ng/dL (TS IV-V, 25-975 ng/dL), p=0.0004. In G1, estradiol (E2) went from 6.4±4.1 (2-10) to 6.72±5.39 (2-17.5) pg/mL (12-14 y, <24 pg/mL), p=0.77; in G2, E2 went from 9.13±6.27 (4-23) to 13.4±9.1 (2.5-28) pg/mL (15-17 y, <31), p=0.06. FSH, LH, and Hematocrit (Hct) levels did not significantly increase in G1. In G2, FSH increased from 2.95±2.93 (0.29-9.12) to 8.96±5.62 (4.16-22.2) mIU/mL (14-17 yr, 0.85-8.74 mIU/mL), p = 0.0016; LH increased from 2.3±1.54 (0.62-5.84) to 9.15±5.95 (3.14-22.2) mIU/mL (TS IV-V, 0.06-4.77 mIU/mL), p=0.009; Hct increased from 43±2.5 (37.7-46.4) to 47.5±1.5 (44.8-49.5) % (35-45%), p=0.0001. Acne and BMI did not significantly increase in G1, whereas in G2, acne increased from none-mild (0.44±0.53) to mild-moderate (1.44±1.01), p=0.017, and BMI increased from 19.6±2 (17.8-23) to 22±2.4 (18-26.9) kg/m2, p=0.0006.

Conclusions: Short-term AIs were not effective in increasing PAH, regardless of early vs late TS, but the latter group, had significant increases in T, FSH, LH, Hct, acne, and BMI, but no reduction in E2. Potential consequences of these findings are of concern and require careful long-term study, especially when AIs are started in late puberty.

 

Disclosure: MEG: Consultant, Daiichi Sankyo, Principal Investigator, Eli Lilly & Company, Principal Investigator, Endo Pharmaceuticals, Principal Investigator, Ipsen, Principal Investigator, Novo Nordisk, Principal Investigator, Versartis, Advisory Group Member, Endo Pharmaceuticals, Advisory Group Member, Ipsen, Advisory Group Member, Pfizer, Inc., Advisory Group Member, Sandoz, Principal Investigator, Genentech, Inc., Principal Investigator, Novo Nordisk, Editor, Up To Date, Editor, McGraw Hill. Nothing to Disclose: JAF

20122 3.0000 FRI-169 A Are Aromatase Inhibitors in Boys with Short Stature and/or Rapid-Tempo Puberty Effective and Safe? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 167-173 6052 1:00:00 PM Pediatric Thyroid & Growth Disorders Poster


Jane Loftus*1, Anders Lindberg2, Ferah Aydin2 and Nina Camacho-Hubner3
1Pfizer Ltd, Tadworth, United Kingdom, 2Pfizer Health AB, Sollentuna, Sweden, 3Pfizer Inc, New York, NY

 

Background: The aims of growth hormone (GH) treatment in patients with growth disorders, including Idiopathic growth hormone deficiency (IGHD), born small for gestational age (SGA) and Turner Syndrome (TS), are to achieve  optimal height outcome in an individual with the lowest possible risks and costs. This led to the development and validation of growth prediction algorithms (GPAs) using data from the KIGS database (Pfizer International Growth Database) pharmaco-epidemiological survey.  The utility and application of such algorithms in clinical practice presupposes its accessibility via an accurate and easy to use web-based tool.

Objective: To develop an independent web-based, accessible, easy to use growth prediction system applicable for all brands of GH. This tool was developed as ‘iGRO’.

Method: All appropriate validated and published KIGS GPAs were incorporated into iGRO, as were specific country reference charts for height, height velocity (HV) and weight. Rigorous testing was undertaken to ensure iGRO was clinically validated and fit for purpose.  A “Patient Summary Document” was also developed. Achieving technical compatibility with most platforms and web browsers was a major requirement. A Technical File was developed to meet the appropriate regulatory standards for a Class I software medical device complying with the EU Medical Device Directive.

Result: The final version of iGRO included 17 unique GPAs; 9 for IGHD (including 2 pubertal GPAs), 5 for TS (including 1 pubertal GPA) and 3 for SGA. They were checked and validated by a paediatric endocrinologist. All GPAs demonstrated accurate prediction following rigorous testing. User acceptance testing confirmed that iGRO was easy and intuitive to use. The clinical variables required for the GPAs include: birth date, gender, primary diagnosis, mother’s/ father’s height, age at treatment start, height, weight and GH dose (presented as µg/kg/day, mg/kg/day, mg/kg/week, mg/injection). Additional variables included are desirable for IGHD GPAs (maximum GH peak and gestational age) and for TS GPAs (oxandrolone treatment status and number of injections). Bone age is required for pubertal GPAs. After one year on GH therapy, a comparison between actual HV and  predicted HV can be used for calculating the individual ‘index of responsiveness’. Approximately 90 country reference charts were included. The “Patient Summary Document” met clinicians’ needs; it provides a summary of the patient characteristics, a graphical output and a summary of the patient’s visits which includes additional information i.e. SDS calculations, BMI and BSA values.

Conclusion: This approved Class I software medical device provides accurate growth prediction via the application of validated and published GPAs and country reference charts. Navigation and data entry into iGRO was intuitive and user friendly. It is compatible with most platforms and browsers.

 

Disclosure: JL: Employee, Pfizer, Inc.. AL: Employee, Pfizer, Inc.. FA: Employee, Pfizer, Inc.. NC: Employee, Pfizer, Inc..

20920 4.0000 FRI-170 A Individualised Growth Response Optimisation (iGRO): A Clinically Validated and User Friendly Multi-Language Software Medical Device (Class I) to Predict Growth Response in Children Treated with Growth Hormone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 167-173 6052 1:00:00 PM Pediatric Thyroid & Growth Disorders Poster


Hernan Garcia Bruce*1, Daniela Quiroga2, Jaime Cerda2 and Andreina Cattani2
1Pontificia Universidad Católica de Chile, Santiago, Chile, 2Pontificia Universidad Catolica de Chile, Santiago, Chile

 

Introduction: Precocious puberty (PP) exhibits a premature activation of the hypothalamic-pituitary-gonadal axis which leads to faster growth and premature fusion of the epiphys. Some of them reach a smaller height  than genetic target. Height prognosis (HP) is critical in the decision of treatment in these cases. Aim: To compare the accuracy of three different methods for predicting final height in girls with PP who have completed their growth. Patientes and Methods:  We Invited to participate 143  girls who consulted for PP in our institution at 8.3±1.2 years old (6,4-10.5) and bone age 9.9±1.7  years, wich had reached their final height  without being treated with been treated with LHRH analogues. Final height was considered with  bone age> 15 years. Of those invited, 93  agreed to participate, and attended to measure their current height and weight carefully. Previously all parents were measured by one of the authors. We compared the HP, made at the beginning by one of the authors, by 3 different methods, with the final attained height. Bone age was reported by the same observers. HP was calculated by:  Bayley-Pinneau, Roche-Wainer-Thissen and midparental height (mother height +father height/2  ± 13 cm). Correlation between HP and final height was evaluated with Bland and Altman a method of data plotting used in analyzing the agreement between two different assays. Results: Bayley-Pinneau method vs. final height showed -1.01 cm difference, but with great interindividual variation (+ 8.87cm: and -10.89 cm, ± 2DS respectively). Similarly Roche-Wainer-Thissen method showed +0.96 cm difference (+9.65 and -7.72± 2DS respectively). In contrast midparental height a simple and easy method that calculates the height of both  parents, was that showed less dispersion and variación over the other : (+0.05cm difference with + 6.19 and -6.10cm, ± 2DS respectively). Conclusions: 1). While all methods for predicting final height in girls with PP show good results on average, there is a considerable individual variation in the responses. 2). The  greater variability observed in methods that require determination of bone age is probably due to the subjectivity of the carpus radiological report. 3. Therefore midparenal height, a simple method that does  not consider bone age like others do, demonstrated superior ability to predict final height in girls with PP

 

Nothing to Disclose: HG, DQ, JC, AC

21155 5.0000 FRI-171 A Determine the Most Accurate Method of Estimating Final Height in Girls with Precocious Puberty 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 167-173 6052 1:00:00 PM Pediatric Thyroid & Growth Disorders Poster


Anne-Marie Dore Kaulfers* and Nat Nasomyont
University of South Alabama, Mobile, AL

 

Background: The association between low serum IGF-1 level and various types of cerebellar ataxia has been proposed in literature. However, the concurrence of IGF-1 deficiency and idiopathic episodic ataxia and its response to IGF-1 treatment has never been reported.   

 

Clinical case: A previously healthy 10.8-year-old female patient presented with new-onset paroxysmal attacks of vertigo, ataxia, and nystagmus lasting minutes to hours in duration, 8-12 attacks per day. Attacks were not associated with focal neurological deficit but were so debilitating that the patient was unable to walk and had to stop going to school. Comprehensive work up including EKG, Holter monitoring, EEG and MRI of the brain with contrast x 2 were normal. On examination, however, she was in -2.05 SD height for age, despite midparental height in the 50th percentile. Her height velocity was low at 3.6 cm/year. Further evaluation was consistent with IGF-1 deficiency: serum IGF-1 of 71 ng/mL (88 – 452 ng/mL), peak GH levels of 45.1 ng/mL with clonidine stimulation and 34.7 ng/ml with L-Dopa stimulation, and delayed bone age to 8.5 years. Acetazolamide was initially started due to concern for episodic ataxia type 2, however, the patient reported no improvement in symptoms. Subcutaneous recombinant IGF-1 treatment (Increlex) was initiated at age of 12.3 years, when her height for age was -2.89 SD.  She had dramatic improvement in her height velocity. Unexpectedly, her ataxic spells completely stopped after 2 months of treatment and did not recur.  When she was 13.5 years old, she had to   discontinue IGF-1 treatment due to financial problems.  Within a few months, she had recurrence of vertigo and ataxia, and the episodes were so severe that she became home-bound again.  When she was 14 years old, she was able to restart IGF-1 treatment. Her ataxic spells, again, completely resolved within the first month after IGF-1 treatment was reintroduced.  The patient is now 15.8 years old and remains on IGF-1 therapy.  Her height has improved to -1.16 SD for age.  She has not experienced any ataxic spells since restarting therapy almost 2 years ago. She has returned to school and regained her normal life.

 

Conclusion: This is the first case report of idiopathic episodic ataxia in a patient with IGF-1 deficiency that responds to subcutaneous recombinant IGF-1 treatment (Increlex). This report may extend the repertoire of conditions that respond to IGF-1, and establish a link between IGF-1 function and ataxia.

 

Nothing to Disclose: AMDK, NN

21481 6.0000 FRI-172 A Improvement of Episodic Ataxia in a Patient with IGF-1 Deficiency, during Treatment with Increlex (IGF-1) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 167-173 6052 1:00:00 PM Pediatric Thyroid & Growth Disorders Poster


Jonathan Christian Howell*1, Kasiani Myers2, Gregpry Wallace2, Christopher Dandoy2, Javier El-Bietar2, Adam Lane1, Stella M Davies2, Sonata Jodele2 and Susan R Rose1
1Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 2Cincinnati Children's Hospital Medical Center

 

Background:  Myeloablative conditioning regimens used for hematopoietic stem cell transplant (HSCT) are known to affect endocrine function, most commonly causing poor growth, hypothyroidism, and hypogonadism. Little is known regarding these late effects after newer reduced intensity conditioning (RIC) regimens without irradiation. Our study goal was to evaluate late endocrine effects after RIC HSCT in pediatric and young adult patients. 

Methods:  An IRB approved retrospective chart review was performed of 120 children and young adults at our center, who received a single RIC without radiation for HSCT between 2004 and 2012 and survived at least 1 year.  Analysis was grouped by age (<2 years and ≥ 2 years), and diagnosis (HLH/XLP, other immune disorders, and metabolic or genetic disorders).  Steroid therapy was defined as glucocorticoids administered either before HSCT or beyond 2 months following HSCT. Height for age z-score (HAZ) and BMI z-scores (BMI-Z) were examined separately using linear mixed effects models.

Results:  Subjects age 2-17y with height (n=103) and weight (n=120) data both prior to and at least 1 year following HSCT were analysed for growth.  The mean follow-up was 3.2 years. All groups displayed short stature before (HAZ = -1.33) and after HSCT (HAZ = -1.35) (p=0.66). After HSCT, younger children with HLH/XLP grew better (HAZ =-3.36 vs -1.35, p= 0.002), while older subjects had worsening (HAZ =-.61 vs -.99, p= 0.004), although all remained short.  Overall, subjects receiving steroid therapy were shorter than untreated patients (p = 0.02). After HSCT, older subjects with HLH/XLP became thinner (BMI-Z= 1.29 vs. 0.61, p=0.003), and similarly in metabolic or genetic disorders (BMI-Z=  0.56 vs. -0.77, p<0.001). There was a trend toward increased BMI-Z among younger children in these same groups. Thyroid function testing was performed on 77 subjects following HSCT.  Eleven (14%) had evidence of primary hypothyroidism, 5 (7%) had central hypothyroidism, and 2 (3%) had evidence of primary hyperthyroidism. Of the 66 subjects with 25-OH vitamin D levels, 46 (70%) were low (<30 ng/mL).  Bone densitometry by DXA scan was below -1 SD in 16 of 21 evaluable subjects with an average Z-score of -1.8 SD (0.7 to -4.9 SD) at median duration after HSCT of 2.2 years.

Conclusions:  Despite using RIC, children and young adults still have significant late endocrine effects following transplant. Algorithms for early detection of endocrine late effects should be implemented for RIC transplant survivors. Further research is required in order to compare post-transplant endocrine effects after RIC to those after standard chemotherapy protocols.

 

Nothing to Disclose: JCH, KM, GW, CD, JE, AL, SMD, SJ, SRR

19231 7.0000 FRI-173 A Late Endocrine Effects Remain Prevalent Despite Reduced Intensity Chemotherapy for Hematopoietic Stem Cell Transplantation in Children and Young Adults 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 167-173 6052 1:00:00 PM Pediatric Thyroid & Growth Disorders Poster


Tripti Joshi*1, Mark Formby2 and Shaun A McGrath3
1John Hunter Hospital, New Lambton, Australia, 2John Hunter Hopsital, New Lambton, 3John Hunter Hospital, New Lambton Heights, Australia

 

Background: Myoepithelial tumors involving adrenal glands are extremely rare.

Clinical Case:  A 73-year-old lady unwell for a year with 20 kg weight loss associated with nausea, vomiting was referred to the surgeons for investigations of weight loss. The gastroscopy and colonoscopy were essentially normal. She also had mildy suppressed TSH 0.08mU/L (0.40-5.00), FT4 13.7pmol/L (RR 10-20), FT3 4.3pmol/L (RR 2.3-5.7), which did not explain her symptoms. She recalled having consulted an endocrinologist many years ago for an incidentally found adrenal lesion measuring 3 cm in 2001.

A repeat non-contrast CT scan showed the left adrenal lesion measuring 5 cm. Her hormonal profile was suggestive of a non-secretory lesion; 24hr Urine Free cortisol was <28nmol/L, 24 hr. urine catecholamine’s were negative; dopamine 1.02(0.20-3.00) umol/d, Noradrenalin0.105 (<0.600) umol/d, adrenalin 0.008(<0.100) umol/d, DHEAS 0.3umol/L, testosterone <0.4nmol/L (0.4-2.0)

.

The PET scan showed a 51 ×73×81 mm, hypermetabolic lesion in left adrenal suggestive of malignancy.

After discussion in the gastrointestinal multi-disciplinary meeting, in view of the large size of the tumor and being FDG avid on PET, It was surgically resected. The tumor was found to be densely adherent to surrounding structures; adherent to left renal vein and enmeshing the anterior surface of renal artery .The histology surprisingly came back as inflammatory myofibroblastic tumor of adrenal gland. It showed positive staining for smooth muscle actin but was ALK negative.

Conclusion: Myoepithelial tumor is a mesenchymal tumor composed of spindle cells, fibrosis, and inflammatory cells. Most present s an incidentally discovered mass, about 15-30% present with constitutional symptoms, weight loss. They can be found at any site most common is lung. Most common extra pulmonary site is liver, however, involvement of adrenal gland is rare (1). The etiology remains unknown. 36-61.8% have rearrangement of Anaplastic Lymphoma Kinase (ALK) on Ch. 2p23. ALK is a member of a receptor tyrosine kinase. It has a role in normal development and oncogenesis; associated with c-myc expression (2).

8.2%(2001) -56% (2007) ALK positivity rate. ALK negativity is associated with older age, metastases. ALK positivity is associated with younger age and no metastases. Recurrences are more common in ALK positive compared to ALK negative tumors (4).

They are non responsive to chemotherapy and radiotherapy.

Surgery is the treatment of choice. They are prone for recurrences and thus long-term follow up is necessary. Crizotinib, an ALK 1 inhibitor is in phase 1 trials and hold promise for unresectable tumors, local recurrences, or metastases (5).

 

Nothing to Disclose: TJ, MF, SAM

20575 1.0000 FRI-312 A Adrenal Myoepithelial Tumour- a Rare Tumor Involving the Adrenal Gland 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Vibushitha Narendra*1 and Surender Kumar Arora2
1Louisiana State University Shreveport, Shreveport, LA, 2Overton Brooks VA Medical Center & Louisiana State University at Shreveport, Shreveport, LA

 

INTRODUCTION

Primary adrenal cancers are very rare and may present with symptoms related to the size and hormonal nature of the tumor. Diagnosis is frequently delayed and early identification and management is critical. We present an interesting case of a symptomatic and rapidly progressive adrenal mass which proved to be a rare and invasive adrenal malignancy with very poor prognosis.

CLINICAL CASE   

A 63 year old White male presented with abdominal pain, anorexia and 20 lbs weight loss. His symptoms started 3 months ago and a CT study showed a 3.5 cm left adrenal mass. Due to persistent pain and leukocytosis (14000/ mcL), repeat CT done a month ago showed a larger 4.4 cm left adrenal mass. Due to increasing size of the left adrenal mass, FNA was done and was reported negative for malignancy. Current CT abdomen revealed an enlarging 6 cm lobulated left adrenal mass abutting tail of pancreas. Endocrinology consult confirmed an undernourished man without any signs or symptoms of catecholamine, cortisol, aldosterone or androgen excess. Biochemical evaluation showed normal plasma and urinary Metanephrines, Plasma Renin, Aldosterone, DHEAS levels and normal Dexamethsone Suppression Test. Infectious work up for persistent leukocytosis (21,000/ mcL) was noncontributory. CT adrenal protocol confirmed a heterogeneous, rapidly enlarging 10 cm left adrenal mass with unenhanced attenuation of 38 HU and <50% washout after contrast, encasing left renal vein with extension into left psoas muscle. PET scan showed a larger 11.7 cm highly FDG avid left adrenal mass without any metastasis. A very aggressive and invasive primary adrenal malignancy was suspected and endocrine surgery was consulted for prompt surgical management. A CT-guided core adrenal biopsy identified a High Grade Adrenal Sarcoma. Patient was deemed inoperable due to size, invasion and encasement of vessels and treated with chemotherapy with poor response. Subsequent PET scan showed a 2.5 cm lung metastasis and patient opted for palliative care.  

DISCUSSION:

Primary adrenal sarcomas are very rare and aggressive tumors associated with early metastasis and poor prognosis. Tumor morphology may be pleomorphic with epithelial and spindle cells, and areas of necrosis, hemorrhage and inflammation. This case illustrates the significance of high index of suspicion in the evaluation of adrenal nodules, especially symptomatic adrenal masses with atypical features such as large size, rapid growth, heterogeneity, abnormal contrast characteristics, unexplained leukocytosis and weight loss, as seen in this case. It should be recognized that the role of FNA in diagnosis of primary adrenal tumors is controversial and a negative FNA cannot exclude a primary adrenal malignancy with any degree of certainty. A core biopsy of the adrenal gland may have better diagnostic yield and early surgical excision could be a key to diagnosis, management and survival.

 

Nothing to Disclose: VN, SKA

21346 2.0000 FRI-313 A Primary Adrenal Sarcoma: A Case of Misleading FNA and Unexplained Leukocytosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Kadapalakere Reddy*1, Kaushik Chatterjee2, Sartaj Sandhu3, Nitesh D Kuhadiya4 and Paresh Dandona5
1State University of New York at Buffalo, Amherst, NY, 2Suny At Buffalo, Buffalo, NY, 3University at Buffalo, williamsville, NY, 4University at Buffalo, Buffalo, NY, 5Diabetes and Endocrinology Center of Western New York, Buffalo, NY

 

Metastatic Germ cell Testicular Tumor With High Testosterone levels. Is that true?

Introduction:

Germ cell tumors are commonly associated with normal testosterone levels. We hereby report a case of metastatic germ cell testicular tumor with high testosterone levels.

 Case:

23-year-old young Caucasian gentleman seen for evaluation of type 1 diabetes diagnosed at 12 years of age He reported low sexual drive and inadequate beard growth. His physical exam showed thin eyebrows bilaterally.  His body mass index (BMI) was 23.05kg/m2. His labs revealed elevated free and total testosterone levels on two separate occasions (Total testosterone: 2069 and 1718; N: 250-1100 ng/dl), free testosterone 420 and 417.5 N: 35-155 pg/ml respectively. He had suppressed LH (Luteinizing Hormone: <0.2) andFSH (Follicle Stimulating Hormone: <0.7) and elevated hemoglobin (16.2 g/dl and hematocrit  (51.4 %). He denied being on over the counter or prescription testosterone supplementation. Ultrasound of the testes reveled 10x8x10mm heavily calcified coarse conglomerate mass with no internal vascularity. He had elevated alpha protein levels AFP (31.3), HCG (4867.6) and LDH (3151).   Enhanced whole body CAT scan of the showed extensive metastatic cancer involving axillary, supraclavicular, mediastinal, and retroperitoneal, pelvic lymph adenopathy.  A supraclavicular lymph node biopsy confirmed metastatic germ cell tumor consistent with embryonal carcinoma. He received preoperative chemotherapy with bleomycin, etoposide, and cisplatin 4 cycles. Following which his AFP, HCG decreased to 2.1, <2 respectively. LH and FSH levels were FSH 36.3 and DHEA level 183, total testosterone 441 ng/dl. He underwent left radical orchiectomy and retroperitoneal dissection followed by axillary, supraclavicular and mediastinal mass resection with histopathology confirming embryonal carcinoma.

Discussion:

Fung et al reported a case of high testosterone with acne, increase muscular mass with evident leydig cell hyperplasia associated with HCG producing synctiotrophoblast mass stimulating leydig cells. Djaladet et al described two cases of seminoma and nonseminoma with androgen excess where both patients presented with gynecomastia and elevated testosterone level.

Conclusion:

Uniqueness to our case is incidental finding of elevated testosterone level with coincident association with type 1 diabetes mellitus with leydig cell hyperplasia with no symptoms of hyperandrogenism and paradoxically low sexual drive, poor beard and average built.

1. Fung LC, Honey RJ, Gardiner GW (1994) Testicular seminoma presenting with features of androgen excess. Urology 44:927–929.

2. Djaladat HNichols CDaneshmand S. Androgen-producing testicular germ cell tumors. J Clin Oncol. 2011 Jul 20;29(21):e634-5. doi: 10.1200/JCO.2011.35.1965. Epub 2011 May 23.

 

Nothing to Disclose: KR, KC, SS, NDK, PD

20086 3.0000 FRI-314 A Metastatic Germ Cell Testicular Tumor with High Testosterone Levels. Is That True? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Ramy Sedhom*1, Sophia Hu1, Anupam Ohri1 and Sara E Lubitz2
1Rutgers - RWJMS, New Brunswick, NJ, 2Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

 

Introduction: Ectopic Cushing’s is rarely seen with ovarian tumors. Steroid cell tumors account for <0.1% of ovarian tumors. These tumors are associated with androgenic changes in 56-77% and Cushing’s syndrome in 6-10%. Due to the rarity of available data, little is known about their malignant potential and treatment. We report a patient with a malignant steroid secreting sex cell tumor causing rapid onset of virilization and Cushing’s syndrome.

Case: A 67-year-old nulliparous female presented with new onset hypertension and diabetes mellitus. She reported four months of worsening hirsutism, deepening voice, weight gain, edema and easy bruising. Labs revealed testosterone 826ng/dl (8-60), DHEA 243ng/ml (0.4-4), LH <0.2IU/L (16-54) and FSH <0.7IU/L (16-136). 24hr free urine cortisol was 273mcg (<45). 1mg dexamethasone testing failed to suppress AM cortisol 33mg/dL (<5). Hypokalemia 2.6mEq/l and metabolic alkalosis CO2 44.8mEq/l were noted; however, serum aldosterone was <4ng/dl (0-21) and renin 1.2ng/mL (0.6-3). MRI abdomen and pelvis showed a 9.4x5.8x7.9cm ovarian mass with ascites and diffuse abdominal metastasis.

Tumor debulking was performed. Histologically, brisk mitotic activity (22 mitoses/10 HPF) was seen. Tumor stained positive for Inhibin and Calretinin. A diagnosis of ovarian steroid cell tumor was made.  Post-operatively, testosterone 90ng/dl and urine cortisol 656mcg/24hr were still elevated with suppressed ACTH 12pg/mL (10-60).

Spironolactone was titrated up to 400mg and Ketoconazole to 1200mg daily with persistent hypokalemia. Post-operative complications included wound dehiscence with MRSA infection requiring surgical debridement and ICU admission for pneumonia. Mitotane 1500mg daily and mifepristone 300mg daily were added but urine cortisol remained elevated 1056mcg/24hr with refractory hypokalemia. She developed delirium, depression and malnutrition. Poor functional status prohibited traditional Platinum and Taxane based chemotherapy. The decision was made for comfort care and she subsequently expired under hospice.

Conclusion: We present a rare coexistence of Cushing’s syndrome and hyperandrogenemia due to a malignant steroid cell neoplasm of the ovary. Most steroid tumors behave in a benign fashion, although malignancy has been reported in 43% of cases. The patient’s rapid clinical deterioration and the aggressive nature of the tumor present a unique diagnostic and therapeutic challenge. Surgery is the mainstay of therapy in this rare ovarian neoplasm. An optimal adjuvant chemotherapeutic regimen has not been developed.  Our patient was refractory to treatment with Mitotane, Mifepristone and Ketoconazole. Poor functional status secondary to hypercortisolism prevented the use of traditional chemotherapy.  This case underscores the need for further research into the biology of this tumor to aid in the development of novel treatments.

 

Nothing to Disclose: RS, SH, AO, SEL

19083 4.0000 FRI-315 A Symptomatic Cushing's Syndrome and Hyperandrogenemia in a Steroid Cell Ovarian Neoplasm: A Unique Therapeutic Challenge 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Morgana L Maia*1, Fernanda Cavalieri Costa2, Carmen L G F Alves1, Rafaela D Severino3, Augusto Cezar Santomauro Jr.4, Priscila Sales Barroso5, Daniel Soares Freire6 and Maria Adelaide Albergaria Pereira7
1USP, Brazil, 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Hosp.Servidor Municipal (HSPM), 4Hospital das Clinicas FMUSP, Sao Paulo, Brazil, 5USP, Sao Paulo, 6Instituto do Cancer do Estado de Sao Paulo, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil, 7Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Background: Cushing's syndrome is associated with multiple electrolyte disturbances (ED), including hypocalcemia, most often observed in severe hipercortisolism.

Clinical Case: Female, 58 years, with abdominal pain, chronic diarrhea, weight gain, hyperpigmentation, moon face 10 months ago. Laboratory tests: ACTH 423 pg/mL (n < 46 pg/mL), serum cortisol 68 mg/dL (n 5 to 25 mg/dL) after 1 mg dexamethasone 55 mg/dL, midnight serum cortisol 65 ug/dL (n <1.8 ug/dL), urinary cortisol 22,124 mg/24h (n 300mg/24 h), DHEA(S) 2,750 ng/mL (n 189-2,050 ng/mL) and gastrin 37,244 pg/mL (n 13 to 115 pg/mL). CT abdomen: neoplastic lesion in the pancreas of 9.0 cm. Biopsy: well-differentiated neuroendocrine neoplasia grade 2 with lymph node metastasis. Other tests: K 2.8 mEq/L (n 3.5 to 5 mEq/L), total Ca 7.1 mg/dL (n 8.6 to 10.2 mg/dL), ionic Ca 3.3 mg/dL (n 4.6 to 5.3 mg/dL), P 2.1 mg /dL (n 2.7 to 4.5 mg/dL), Mg 1.4 mg/dL (n 1.58 to 2.55 mg/dL), pH 7.58 (n 7.35 to 7.45), bicarbonate 37.6 mmol/L (n 23 to 27 mmol/L), PTH 122 pg/mL (n 15 to 65 pg/ml) vitamin D 9.0 ng/mL (n < 30 ng/mL). Urinary: FEPi 23.4% (n < 5%), Ca 628 (n 100 to 320 mg/vol 24h), Mg 152 (n 60 to 210 mg/vol 24h). Exams six weeks after bilateral adrenalectomy: K 4.7 mEq/L, total Ca 9,1 mg/dL, ionic Ca 4.82 mg/dL, P 3.2 mg/dL, Mg 1.3 mg/dL, pH 7,39, bicarbonate 22 mmol/L, ACTH 404 pg/mL, serum cortisol 4,8 mg/dL, DHEA(S) < 80 ng/mL.

Discussion: This case illustrates the association between hypercortisolism and severe electrolyte and acid-base disturbances, requiring intravenous and oral replacement, with improving after adrenalectomy. The cortisol and aldosterone have similar affinity for non-selective mineralocorticoid (MR) receptors. In cases of severe hypercortisolism, as described above, there is a greater activation of the MR by cortisol excess with hypokalemia and hypervolemia consequently hypercalciuria and hypocalcemia due to reduced renal reabsorption of calcium.

Conclusion: This case illustrates the ED in patients with severe hypercortisolism, with resolution after bilateral adrenalectomy.

 

Nothing to Disclose: MLM, FCC, CLGFA, RDS, ACS Jr., PSB, DSF, MAAP

21214 5.0000 FRI-316 A Electrolity Disturbances Associated with Severe Cushing's Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Supna K Sandhu*1, Sara Gail Stafford2, Naomi Elisabeth Severin3, Ben Schroeder3 and Reena Khurana3
1University of British Columbia, Vancouver, BC, Canada, 2University of British Columbia, North Vancouver, BC, Canada, 3University of British Columbia, Surrey, BC, Canada

 

Background: Severe hypokalemia and hypertension are usually thought to be secondary to primary hyperaldosteronism.  However, less common causes need to be considered in the differential diagnosis.  We present a case of severe hypokalemia due to ectopic ACTH secondary to a pulmonary carcinoid tumor.

Clinical Case: A 61 year old female with a history of type 2 diabetes mellitus and hypertension was admitted to hospital after a 10 day history of fatigue and headache. On admission she was found to have hypokalemia (1.7mmol/L, N3.5-5mmol/L) and upon further review, she had at least a one year history of hypokalemia. The preliminary diagnosis was primary hyperaldosteronism exacerbated by her hydrochlorothiazide medication. Investigations for her hypokalemia revealed suppressed aldosterone <50pmol/L (N 30-415pmol/L) and renin <0.12 ng/L/s, N <0.45ng/L/s).  Primary aldosteronism was ruled out. Given the above findings, a 24-hour urine collection was ordered to investigate for the more rare diagnosis of Cushing’s syndrome. This showed significantly elevated cortisol (27056nmol/d, N 10-166nmol/d) and 5-HIAA (81umol/d, normal 10-40umol/d). An AM cortisol (2102 nmol/L) post 1mg dexamethasone failed to suppress.  An 8mg dexamethasone suppression test revealed an AM cortisol of 2770nmol/L.  She had an elevated ACTH (188pmol/L, N<11), and an MRI of the pituitary was unremarkable. This prompted a search for an ectopic ACTH source. CT chest revealed a few small lung nodules.  The largest was a 13mm nodule on the superior segment of the right lower lobe which was unchanged from a previous CT scan last year. To evaluate for a functioning mass, multiple imaging modalities were performed but none revealed a definitive source of the ACTH. Imaging modalities were as follows: (1) 18F-FDG-PET which showed a well-defined 1.2cm nodular opacity in the superior segment of the RLL with minimal FDG uptake (SUV maximum 1.5) with low grade activity within bilateral hilar and subcarinal lymph nodes but no definite FDG avid neoplasm, (2) an unremarkable octreotide scan and (3) 235 MBq F-DOPA scan which showed a 12mm mixed attenuation density within the RLL with low grade F-DOPA activity.  As no definitive source was confirmed, wedge resection of the RLL of the lung was performed for a presumed diagnosis of an ACTH producing pulmonary tumor. AM cortisol on post-operatively day 1 had normalized to 302 nmol/L. The final pathology report revealed a typical carcinoid tumor of 1.3cm in the right lung lobe with no lymphovascular invasion which stained strongly for ACTH. Her potassium normalized and her 24 hour urine cortisol 1 month post-resection was 42 nmol (N 28-276nmol/d).

Conclusion: This is a rare case of severe hypokalemia as a result of a pulmonary carcinoid tumor that was not easily diagnosed via PET, F-DOPA, or octreotide imaging.

 

Disclosure: BS: Speaker, Abbott Laboratories, Speaker, Eli Lilly & Company, Speaker, Jansen Pharmaceuticals, Speaker, Merck & Co., Speaker, Novo Nordisk, Speaker, Sanofi. Nothing to Disclose: SKS, SGS, NES, RK

18551 6.0000 FRI-317 A An Ectopic ACTH Pulmonary Carcinoid Tumor Presenting As Severe Hypokalemia: The Challenges in Imaging 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Rosana J Ayoub*1, Peter Y Liu1 and Marelle Yehuda2
1Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 2Harbor-UCLA Medical Center, Torrance, CA

 

Background: EAS can be difficult to diagnose and the clinical course can rapidly deteriorate.

Clinical Case: A 73 year old man presented to the ER complaining of lower extremity edema for 3 days. He had a past medical history of hypertension, chronic liver disease, hyperlipidemia and a 120 pack year tobacco smoking history. He was hypertensive to 210/97, with physical exam findings of clubbing, peripheral stigmata of chronic liver disease, decreased breath sounds, hepatomegaly and pitting lower limb edema to the mid-shin. Hypokalemia (initially, 2.7 mmol/L) was noted. Chest and abdomen CT identified a left upper lung mass with nodular liver lesions concerning for metastatic disease. Morning ACTH, cortisol, renin and aldosterone were 348 pg/mL, 182 mcg/dL, 0.28 ng/mL/h and <0.1 ng/dL, respectively. He did not have common manifestations of hypercortisolism, such as abdominal striae, moon facies, central obesity, easy bruising, or a buffalo hump. A liver biopsy was performed with pathology revealing small cell carcinoma, which was metastatic from the lung. Post biopsy complications include intra-abdominal bleeding, worsening liver dysfunction, and renal failure. Significant liver disease and other comorbidities precluded surgical resection or chemotherapy. Blood pressure and hypokalemia were adequately controlled with antihypertensives and potassium replacement and he was discharged to hospice care.

EAS represents 9-18% of cases of endogenous Cushing Syndrome, and small cell lung carcinoma constitutes 8-20% of these cases. The most frequent physical exam findings include lower extremity edema and proximal myopathy, with hypokalemia and metabolic alkalosis characterizing the metabolic disturbances.  Once suspected, diagnosis can be made on laboratory evidence of elevated ACTH and cortisol. In some instances, differentiation between Cushing’s disease and ectopic ACTH secretion needs to be resolved by through bilateral petrosal sinus sampling, although this may not be necessary in  the context of biopsy-proven small cell lung cancer and a typical clinical course. Optimal treatment includes surgical resection of the primary ACTH producing tumor, cytotoxic agents targeting the primary tumor, and/or adrenal enzyme inhibitors. However, as in our patient, diagnosis is often made as the patient deteriorates rapidly, and treatment cannot be administered due to comorbidities.

EAS is often overlooked as a diagnosis, since hypercortisolism is often severe and rapidly progressive. Thus, delays in treatment occur, and decline of health typically ensues. For this reason, high clinical suspicion is required in order to swiftly diagnose and aggressively treat Ectopic ACTH Syndrome, prior to severe complications of hypercortisolism. In an individual with proven small cell lung cancer, the utility of further investigation of pituitary ACTH dependent hypercortisolism may not be necessary.

 

Disclosure: PYL: Investigator, Clarus. Nothing to Disclose: RJA, MY

19686 7.0000 FRI-318 A Ectopic ACTH Syndrome (EAS) Presenting with a 3 Day History of Lower Extremity Edema and Weakness 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Adem Gungor1, Naile Gokkaya1, Selin Merih Urlu2, Arzu Bilen3, Murat emin Akbas4 and Habib Bilen*5
1University of Ataturk, 2University of Ataturk,Faculty of Medicine, 3University of Ataturk, Faculty of Medicine, Erzurum, Turkey, 4University of Erzincan, Faculty of Medicine, 5University of Ataturk, Faculty of Medicine, Erzurum, Turkey

 

Introduction: Doege-Potter syndrome (DPS) is a paraneoplastic syndrome which causes hypoinsulinemic hypoglycemia secondary to solitary fibrous tumor (SFT) originating from submesothelial mesenchymal cells (1). We present the case of a 61-years old man who have DPS that is very rare complication (%4) of SFT.

Case Report: 61 years old man who have diagnosed with malign solitary fibrous tumor of the pleura was admitted to hospital with symptoms of hypoglycemia. He was operated 4 years ago but  6 months ago the recurrence was detected and considered inoperable. The physical examination showed that temperature was 36.7° C, pulse 112/mn, and tension arterial 110 /70 mmHg. Hypoglycemia was confirmed biochemically (glucose 30 mg/dl, n: 70-100 mg/dl). He had no other history of a known systemic disease. On further workup; the other causes of hypoglycemia (insulinoma, exogen insulin use, adrenal insufficiency, hypopituitarism) was excluded. He was found to have hypoinsulinemic hypoglycemia with a glucose level; 50mg/dl, insulin: 0.43 µIU/ml (n:1.9-23), C-peptide: 0.27 ng/ml (n:1.1-4.4), Hba1c: 6%, TSH: 0.3 µIU/ml (n:0.34-5.60), FT4: 1.38 ng/dl (n:0.61-1.12), cortisol: 13 ug/dl (n:6.7-22.6), ACTH: 16.3 pg/ml (n:15-60), IGF-1:33 ng/ml (n:55-225), IGF-2: 1233 ng/ml (n:521-873), IGF-2/IGF-1: 37 (n:<10). Thorax Computed Tomography (CT) showed a 172x102x140-mm-sized solid mass with heterogeneous contrast involvement on the right mediastinal pleural surface and spreading to diaphragmatic pleural surface. Follow-up of the patient, because of hypoglycemic attacks continued despite of the intravenous infusion of glucose, high-calorie diet and parenteral nutrition treatment, octreotide LAR 10 mg/month theraphy was applied. Since the follow-up examination showed that there were hypoglycemic attacks imatinib mesylate was started to treatment of the SFT. After imatinib mesylate treatment hypoglycemia attacks were not occurred and blood glucose level was 150-200 mg/dl.

Discussion: A decreased insulin, c-peptide and growth hormone levels and increased Big-IGF-II levels with hypoglycemia are diagnostic criteria for DPS. In DPS, cause of hypoglycemia is the secretion of a prohormone form of IGF-II, often called ‘big IGF-II’ which has insulin like effects. In our case, IGF-II/IGF-I ratio was attained 37(> 10). When IGF-II / IGF-I ratio exceeds 10 in tumors causing non-islet-cell hypoglycemia is considered pathognomonic.

 

Nothing to Disclose: AG, NG, SMU, AB, MEA, HB

19472 8.0000 FRI-319 A Hypoinsulinemic Hypoglycemia Secondary to Solitary Fibrous Tumor of the Pleura: Doege-Potter Syndrome; A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


John Mihailidis*1, Vitaly Kantorovich2, Harold Yamase2 and Pamela Taxel3
1University of Connecticut, Farmington, CT, 2University of Connecticut Health Center, Farmington, CT, 3Univ of Connecticut Hlth Ctr, Farmington, CT

 

Background: Insulinomas are rare neuroendocrine tumors that are typically less than 2 cm at the time of diagnosis.  However, only a few cases report giant insulinomas.

Clinical Case:  A 30-year-old African-American man was transferred from an outside hospital following a second episode of severe hypoglycemia brought on in both instances by vigorous exercise.  He also complained of persistent right upper quadrant abdominal pain for 2 months.  Physical exam revealed a well-developed male with a hard, tender right upper quadrant mass approximately 4-5 cm in size.  Initial CT scan revealed innumerable hypodense lesions within the liver; the largest was located in the right hepatic lobe and measured 6.8 cm in diameter.  Another mass measuring 6.8 cm in the vicinity of the pancreatic head, was confirmed to be a large retroperitoneal lymph node on subsequent MRI. No pancreatic masses were visualized on MRI.

Biochemical testing, when blood glucose was 60mg/dL (nl 70-110mg/dL), revealed an inappropriately elevated insulin level of 49 uIU/ml (nl 3-19 uIU/mL), elevated proinsulin of 65.7pmol/L (nl <8.0 pmol/L), and elevated chromogranin A of 2531ng/ml (nl 0-95 ng/mL).  Gastrin level was also elevated 588 pg/mL(nl 0-100 pg/mL). 

The large right hepatic lesion was biopsied and immunohistochemical staining was positive for chromogranin, synaptophysin and insulin.  Ki-67 index was approximately 20%.  The pathological diagnosis was consistent with an insulin-secreting neuroendocrine tumor.

An octreotide scan revealed increased uptake throughout the entire liver.  The patient was treated with Diazoxide and then transitioned to Octreotide three times daily, which improved his hypoglycemia.  Since the patient was not considered a good surgical candidate due to extensive disease, he underwent chemoembolization of his large hepatic lesion in an attempt to alleviate his abdominal discomfort.

Conclusion:  This is a rare case of giant metastatic neuroendocrine tumors with hypersecretion of insulin.

 

Nothing to Disclose: JM, VK, HY, PT

21166 9.0000 FRI-320 A Abrupt Onset of Severe Hypoglycemia in a Patient with Metastatic Giant Neuroendocrine Tumor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Christine Rae Cox*
University of California-Davis, Sacramento, CA

 

Background: Hypoglycemia induced by a tumor-related mechanism is a rare phenomenon and requires methodical interpretation of laboratory data and treatment aimed at alleviating intractable hypoglycemia.

Clinical case: A 33yr old woman with metastatic (lung, liver) adrenal cortical carcinoma status post mitotane therapy and left adrenalectomy was admitted for hypoglycemia and further evaluation of metastatic lesions. Initial workup revealed low insulin <1 uU/mL (2-22.1 uU/mL), low proinsulin <1.5 pmol/L (<= 8.0 pmol/L), low c-peptide level <0.1 ng/mL (0.8-3.5 ng/mL), and low beta-hydroxybutyrate 0.05 mmol/L (0.02-0.27 mmol/L) in the setting of symptomatic hypoglycemia (BG 55), improved after glucose therapy. The etiology of hypoglycemia was not due to surreptitious use of diabetes medications as sulfonylurea panel was negative, nor was it due to insulin autoimmunity as anti-insulin antibody was negative. Hypopituitarism was considered as a cause but unlikely given that GH level was appropriately elevated at 4 am to 6.10 ng/mL (0.05-8.0 ng/mL). Hypoglycemia was not from cortisol suppression due to mitotane given that patient continued to have hypoglycemia on supraphysiologic doses of steroids (dexamethasone 5 mg BID). This revealed that the cause of hypoglycemia was IGF mediated. IGF-1 level was low at 47ng/mL (115-307 ng/mL), making IGF1-oma unlikely. Non-islet cell tumor hypoglycemia (NICTH) due to IGF2 was considered. The main mechanism in IGF2-induced NICTH is the overexpression of the IGF2 gene (structurally homologous to the insulin gene) by tumor secretion of incompletely processed precursors of IGF2 (pro-IGF2 or big IGF2) with a persistent insulin like activity. IGF2 suppresses both GH and insulin at pituitary and pancreas levels respectively. Owing to the suppression of GH secretion, synthesis and secretion of IGF1 and IGF-binding protein 3 (IGFBP3) are also decreased. IGF3 BP was low at 2450 ng/mL (2878-6650 ng/mL). Although the serum level of total IGF2 may be normal, the ratio of IGF2:IGF1 may be elevated. The normal molar ratio of IGF2:IGF1 is 3:1. The IGF2:IGF1 (551:47), in this patient exceeded 10:1. With this data, the diagnosis of NICTH was made. Treatment is stepwise and includes immediate correction of hypoglycemia, treatment directed at the underlying tumor and prevention of recurrent hypoglycemia if  tumor is incurable.

Conclusion: NICTH is a rare cause of hypoglycemia requiring methodical interpretation of laboratory data shown in this case with elevated IGF2:IGF1 ratio, low insulin, proinsulin, c-peptide and beta-hydroxybutyrate, negative antibodies and sulfonylurea panel. Long-term management with glucocorticoid therapy reverses the biochemical abnormalities caused by tumor-derived IGF2 and this therapy alone or with human growth hormone, with or without long-acting glucagon is the most effective therapy in alleviating intractable hypoglycemia.

 

Nothing to Disclose: CRC

18916 10.0000 FRI-321 A Non-Islet Cell Tumor Causing Hypoglycemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Lima Lawrence*1, Aleida Rodriguez1, Erin Dana Drever2, Tahira Yasmeen3 and Armand A Krikorian4
1UIC/Advocate Christ Medical Center, Oak Lawn, IL, 2University of Illinois at Chicago, Advocate Christ Medical Center, Oak Lawn, IL, 3The University of Illinois/Advocate Christ Medical Center, 4University of Illinois/Advocate Christ Medical Center, Oak Lawn, IL

 

Introduction: In the presence of hypoglycemia, a diagnosis of insulinoma is established with elevated serum insulin, proinsulin and C-peptide levels. The established values for diagnosis depend on normal renal function. We present a case of insulinoma in a patient with end-stage renal disease (ESRD) to demonstrate the challenges that exist in diagnosis.

Clinical Case: A 52 year old male presented to the ER unconscious due to a suspected seizure. His history was significant for coronary artery disease, ESRD on hemodialysis, epilepsy, and hypothyroidism. He had missed 3 dialysis sessions and was noncompliant with his seizure medications. He had no history of diabetes and denied using insulin or oral hypoglycemics. On admission, blood glucose was normal (112 mg/dL). He received calcium gluconate, 10 units of Insulin R with dextrose, and emergent dialysis for hyperkalemia. He then developed hypoglycemia (23 to 80 mg/dL) refractory to D10W infusion. This was attributed to poor insulin clearance in renal failure; however he continued to have hypoglycemic episodes. During hypoglycemia (33 mg/dL), his labs demonstrated free insulin 141.0 (1-24 pmol/L), C-peptide 12.3 (0.8-3.9 ng/mL) and intact proinsulin 13.8 (<8.0 pmol/L). His sulfonylurea level was negative, beta-hydroxybutyrate level 0.2 (0-0.3 mmol) and insulin antibody level <0.4 U/mL. HbA1C was 3.9 (4.5-5.9%), TSH 1.55 (0.35-5.0 mcunit/mL) and  8 AM cortisol level 20.6 (3.0-23.0 mcg/dL). CT of the chest, abdomen and pelvis revealed no acute pathology. An EUS guided FNA of the pancreas showed cystic lesions at the pancreatic head and body. Cytology revealed glandular cells negative for malignancy. A somatostatin receptor scan showed increased abnormal uptake at the level of the pancreatic tail. A review of the CT revealed a 2.5 cm pancreatic tail mass. Diazoxide was initiated and blood glucose levels normalized. Due to his poor cardiac status, he was deemed a poor surgical candidate for pancreatectomy.

Conclusion: We present a patient with ESRD and insulinoma detected after recurrent, severe hypoglycemic episodes. Hypoglycemia in renal failure can be due to decreased clearance of insulin, malnutrition, reduced renal gluconeogenesis, impaired counter-regulatory hormone response and the use of high glucose containing dialysate. Our patient fulfilled standard criteria for diagnosis of insulinoma. In this case, the marked degree of peptide elevation was helpful in establishing the diagnosis of insulinoma instead of hypoglycemia related to renal failure. The literature suggests that patients with renal disease have higher circulating levels of insulin and C-peptide during hypoglycemia and thus evaluation of hypoglycemia in patients with renal disease must be done with caution. Guidelines for establishing insulin-mediated hypoglycemia and insulinoma in the setting of advanced renal failure should be revisited to take this into account.

 

Nothing to Disclose: LL, AR, EDD, TY, AAK

20692 11.0000 FRI-322 A Challenges in the Diagnosis of Insulinoma with Advanced Renal Failure 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Melek Eda Ertorer*, Filiz Eksi Haydardedeoglu, Aysenur Izol Torun, Cagatay Andic, Okan S Bakiner, Emre Bozkirli and Fazilet Kayaselcuk
Baskent University, Faculty of Medicine, Adana, Turkey

 

BACKGROUND: Fasting hypoglycemia is the typical presentation of insulinoma, although cases with postprandial hypoglycemia have been reported rarely. In a retrospective analysis of insulinoma cases, the incidence of postprandial symptoms has been reported to be 6% and 25% had negative 72-hour fasting test. Only 10% of insulinomas are malignant and the only criterion for malignancy is detection of metastases.

CLINICAL CASE: A 48-year-old woman was admitted for the evaluation of her symptoms highly suggestive for hypoglycemia that had been told to start four years before admission. Her complaints were reported to begin 1-2 hours after meals and improve following carbohydrate ingestion. She had many previous investigations for insulinoma and all were inconclusive. She denied insulin secretagogue use, and had no history for gastrointestinal surgery. Her family history was uneventful.

Neither her physical examination nor laboratory analysis demonstrated abnormality. A 72-hour fasting test was unable to induce hypoglycemia, however a mixed-meal tolerance test resulted in symptomatic hypoglycemia; serum glucose level; 19mg/dl starting one hour following food ingestion with simultaneous high insulin and c-peptide levels; 66.3 uIU/mL (2.6-25.0) and 2.68 pmol/ml (0.37-1.47), respectively. These data suggested a state of endogenous hyperinsulinemic hypoglycemia presenting postprandially. 

An abdominal computerized tomography (CT) revealed a 20 mm sized mass lesion at distal pancreas. As she exhibited postprandial hypoglycemia which was not typical for insulinoma, a decision was made to perform an arterial stimulation venous sampling test with calcium (ASVS). During ASVS, insulin level was found to increase 33-fold after calcium stimulation in the sample collected from proximal splenic artery (PSA) suggesting that the mass detected at pancreatic tail on abdominal CT was the source of hyperinsulinemia. Distal pancreatectomy and splenectomy was performed with lymph node dissection of the splenic hilus.

The patient was symptom free after surgery. Pathological examination was compatible with a low grade well-differentiated neuroendocrine tumor with regional lymph node metastasis. The tumor cells and one of the four resected lymph nodes of splenic hilus exhibited uniform atypical cell proliferation with positive immunostaining for chromogranin and synaptophysin with Ki-67 index below<2%, necrosis and mitosis were not detected.

CONCLUSION: Our findings clearly underline the fact that a negative 72 hours fasting test does not exclude endogenous hyperinsulinism, even in a patient harboring a metastatic insulinoma. Postprandial hypoglycemia in this case may be either due to the presence of glucose transporter-2 (Glut-2) on tumor cells or aberrant expression of glucagon like peptide-1 receptor (GLP-1R), which induced the secretion of insulin from abnormal insulinoma cells.

 

Nothing to Disclose: MEE, FEH, AIT, CA, OSB, EB, FK

20511 12.0000 FRI-323 A Postprandial Hypoglycemia: An Unusual Presentation for Insulinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Vijaya Surampudi*1 and Ronald S. Swerdloff2
1Harbor-UCLA Medical Center, Los Angeles, CA, 2Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA

 

Background:

Paragangliomas are rare neuroendocrine tumors and are commonly described together with pheochromocytomas. The incidence of paragangliomas is unknown but there are approximately 500 to 1600 cases of pheochromocytomas and paragangliomas in the United States per year (1). For patients with a catecholamine-secreting paraganglioma, localization of the tumor can be challenging.

Clinical Case:

The patient is a 32 y/o F who was referred for evaluation of hypertension and elevated catecholamines.  The patient was first diagnosed with hypertension by four years prior and recently presented to the emergency room in hypertensive urgency. She was discharged home with oral anti-hypertensive medication and referred for evaluation secondary causes of hypertension. The work up revealed elevated normetanephrines [plasma: 10,886 (nl <148 pg/ml); urine: 18,041 (nl 35-482 mcg/24 hr)], and norepinephrine [urine: 4,013 (nl 15-100 mcg/24hr)] with relatively normal metanephrines [plasma: 84 (nl  <57 pg/ml); urine: 79 (nl 36-190 mcg/24hr)] and epinephrine [urine: 6 (nl <2-24 mcg/24hr)]. Patient was referred to Endocrinology for localization of the lesion.

The prior laboratory evaluation work up was suggestive of a paraganglioma as extra-adrenal catecholamine secreting tumors are unlikely to secrete epinephrine, because phenylethanolamine N-methyltransferase, which converts norepinephrine to epinephrine, requires high levels of cortisol as a cofactor. A prior abdominal MRI did not show any lesions in the adrenal glands.

On questioning, the patient complained of palpitations, headaches and diaphoresis after urination.

MIBG scan revealed a filling defect projecting over the bladder. Given the post-micturition clinical symptoms and the results of the MIBG scan it was felt that lesion was located in the pelvis. An MRI pelvis revealed a 4.7 x 5.4 x 5.3 cm well-circumscribed mass lesion between the anterior wall of the vagina and the posterior bladder wall. Following treatment with α and β blockade the patient was referred to Urology for surgical intervention.

Conclusion:

Catecholamine secreting tumors can be found in the adrenals or can be in extra-adrenal ganglionic sites. A clinical history may suggest the extra-adrenal location, but MRI or CT scans are usually required for localization. MIBG imaging, while helpful when positive, is associated with a higher false-negative rate for localizing a paraganglioma (2). Once there is evidence of a non-adrenal source for elevated catecholamine levels, a paraganglioma can be found with a thorough clinical history and cross-sectional imaging studies.

 

Disclosure: VS: Clinical Researcher, Novartis Pharmaceuticals. RSS: Consultant, Quest Diagnostics, Investigator, Novartis Pharmaceuticals, Investigator, Lipocine, Principal Investigator, Aptys, Investigator, Antares, Investigator, Antares, Investigator, AbbVie, Investigator, Endo Pharmaceuticals, Principal Investigator, Clarus, Consultant, Clarus, Medical Advisory Board Member, Clarus.

20516 13.0000 FRI-324 A Localization Strategy of Paragangliomas Based on Clinical History and Imaging 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Victoria Rollins Hudspeth*, Ellen Shannon Story and Kelli Coop Dunn
Carolinas Medical Center, Charlotte, NC

 

Pheochromocytomas are bilateral in 10% of adults and in 30% of patients with MEN2 syndrome. Treatment with bilateral adrenalectomy is a morbid procedure requiring lifelong steroid replacement.

A 37 year old healthy man was seen by his internist for three months of intermittent right sided abdominal pain. He denied headaches, but reported weekly 5 minute episodes of sweating and severe fatigue. A CT abdomen/pelvis revealed a 5.4cm right adrenal mass with peripheral enhancement and hypodense center. The left adrenal was normal. 24 hour urine had significantly elevated normetanephrine (NM) of 4414ug/24hour (82-500). Plasma NM was also elevated at 2008 pg/mL (0-145). He was referred to surgery and PET/CT showed a 4.4cm by 5.8cm cystic necrotic right adrenal nodular mass with maximal SUV 13.3, as well as a hypermetabolic 1.5cm nodular thickening of the left adrenal gland with maximal SUV 5.5.

Surgery made plans for bilateral adrenalectomy for presumed bilateral pheochromocytoma and referred the patient to endocrinology for pre-operative evaluation. With no underlying left adrenal mass on initial CT and only mildly increased uptake on PET, we advocated for right adrenalectomy only. Genetic testing showed no mutations. We started pre-operative phenoxybenzamine followed by atenolol and a high sodium diet.

Pathology from right adrenalectomy confirmed pheochromocytoma with negative margins. The patient was seen in surgery clinic on post-operative day 13 with normal vitals but ongoing post-operative pain requiring oxycodone-acetaminophen four times a day. His surgeon obtained labs that showed elevated plasma NM of 229 pg/mL (0-145) and elevated urine NM of 551ug/24hour (82-500). We were called with concern that a contralateral pheochromocytoma was still present. We felt these elevations were more likely a false positive from his ongoing pain and acetaminophen use. We recommended waiting to repeat labs until after he was off pain medicines. His surgeon obtained an MRI abdomen that showed a resolving hematoma in the right adrenal bed and no abnormalities of the left adrenal. Six weeks later, plasma NM was normal, and has remained that way on two subsequent checks. The patient is now 15 months out from surgery and we plan to check yearly labs.

This case highlights that PET scans are sensitive but not specific for tumor and that adrenal glands can be hypermetabolic at baseline. In addition, it highlights that false positive NM testing can occur when a patient is still recovering from surgery. 2014 Endocrine Society guidelines based on expert opinion recommend biochemical testing 2-4 weeks after surgery. We feel this may often be too soon, resulting in a higher false positive rate. Further studies need to be done to evaluate the optimal time for retesting. Lastly, this case highlights the importance of critical evaluation prior to committing a patient to bilateral adrenalectomy and lifelong steroid dependence.

 

Nothing to Disclose: VRH, ESS, KCD

20703 14.0000 FRI-325 A “Bilateral” Pheochromocytoma: A Case of Right-Sided Pheochromocytoma with Double False Positive on Left 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Iqra Javeed*, Arthur S Tischler, Michael E Tarnoff and Ronald M Lechan
Tufts Medical Center, Boston, MA

 

Most pheochromocytomas are composed of only chromaffin cells.   In rare cases, pheochromocytomas (PCCs) are associated with other tumors.  These tumors are termed “composite” if they show the same embryologic origin as pheochromocytoma (the neural crest) or “mixed” if the associated tumor has a different embryologic origin from pheochromocytoma.  Non-pheochromocytoma components found in the composite pheochromocytoma include ganglioneuroma, ganglioneuroblastoma, neuroblastoma, and malignant schwannoma.  The frequency of composite adrenal tumors has been reported as ranging between 1% and 9% of pheochromocytomas.  The biologic behavior of these tumors may be as difficult to predict as the more traditional pheochromocytomas.

Here we present the case of a 64 year old woman with hypertrophic cardiomyopathy and frequent episodes of headaches, palpitations, and diaphoresis who was admitted to the hospital with hypertensive urgency.  Work up for severe hypertension and her symptoms revealed markedly elevated 24 hour urine epinephrine, norepinephrine, metanephrines, and normetanephrines.  Computed tomography (CT) imaging of the abdomen revealed a 6.5 cm x 7.8 cm x 6.0 cm left adrenal mass.  I-123-metaiodobenzylguanidine (MIBG) scan showed uptake of the radiotracer in the left upper quadrant of the abdomen corresponding to the large, left, adrenal mass seen on CT imaging.  Following pretreatment with an alpha blocker and metyrosine, she underwent left adrenalectomy.  Histologically, approximately 80% of the tumor consisted of typical PCC and 20% was comprised of neurons and neuropil in a Schwann cell-poor stroma consistent with ganglioneuroblastoma (GNB).  However, the tumor was unusual in that the neurons were almost all cytologically mature and Ki-67 immunostaining showed extremely low labeling (<1%) in both the neural and endocrine components.  Staining for S100 showed extremely sparse sustentacular cells in the PCC as well as sparse Schwann cells in the GNB.  The tumor was immunopositive for succinate dehydrogenase subunit B (SDHB).

There have been only few reported cases of composite PCC+GNB, occurring in patients with ages ranging from 5 to 73 years.  The GNB component usually shows a typical diagnostic mixture of Schwann cell-rich and Schwann cell-poor stroma containing mature and immature neurons.  Most have been benign, but two cases were malignant.  The overall rarity of composite pheochromocytoma and the paucity of information about the histologenesis and biologic potential of neuroblastic elements make it difficult to predict clinical outcomes.  It was of interest that in this particularly unusual composite tumor, both Schwann cells and sustentacular cells were sparse, supporting a possible histogenetic relationship between these cell types.

 

Disclosure: MET: Chief Medical Officer and full time employee, Covidien. Nothing to Disclose: IJ, AST, RML

19946 15.0000 FRI-326 A Presentation of a Patient with an Unusual Composite Pheochromocytoma-Ganglioneuroblastoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Edward R Maharam* and Sathya G Jyothinagaram
Banner Good Samaritan Medical Center, Phoenix, AZ

 

Purpose: Pheochromocytomas are rare catecholamine secreting adrenal tumors often detected incidentally. Prior to removal, these lesions require preoperative alpha blockade to prevent life-threatening hypertensive events. Here, we present a case of missed pheochromocytoma, leading to hypertensive crisis.

Case: A 40 year old female initially presented with chest pain to an outside hospital. CT scan demonstrated a mid-sized right adrenal incidental adenoma (4.5 x 2.5cm). ROS was positive for episodic headaches, palpitations, and sweating. Further evaluation at that hospital included normal 24hr urine norepinephrine and epinephrine with elevated urine dopamine at 406 mcg/24h [normal range 65 - 400 mcg/24h] at a time of normotension. Metanephrines were not tested. Patient underwent biopsy of this mass without peri-procedural alpha blockade resulting in hypertensive crisis with reported blood pressure of 188/53, palpitations and tachycardia. Our evaluation revealed elevated urinary fractionated metanephrines on two separate occasions.  Urine metanephrines were 419 and 289 mcg/24h [NR 58 – 203] and normetanephrines were 1611 and 1144 mcg/24h [NR 88-649]. Patient underwent laparoscopic adrenalectomy after pre and perioperative alpha and beta-blockade. Her course was uneventful without further tachycardia or hypertensive episodes.  Pathology report was consistent with pheochromocytoma.

Discussion: Pheochromocytomas are rare, reported at an incidence of 0.05-0.2% of hypertensive patients. Many go undiagnosed, and 10% of cases are discovered incidentally, as in our patient. Diagnostic testing includes urine and plasma metanephrine testing. 24 hour urine testing has superior specificity (99.7%) at the cost of sensitivity (87%) when compared to serum testing (96% sensitive). Another study reports 100% serum sensitivity for metanephrines. Catecholamine studies, urine and serum, are reported to have inferior (79%) sensitivity. Collections done during a symptomatic episode increases test sensitivity.

In our case, pheochromocytoma was incorrectly excluded since her urine epinephrine and norepinephrine levels were normal and elevated dopamine level was not further investigated. Uncertainty regarding the type of mass, as well as its size, led to a biopsy prior to operation for removal. Failure to prophylactically institute alpha-blockade contributed to her peri-procedural hypertension. The diagnosis was missed due to use of a lower sensitivity test in an asymptomatic moment. With this case we emphasize the importance in choosing the correct diagnostic modality to evaluate for pheochromocytoma and to consider repeat testing while the patient is symptomatic if possible. In times of uncertainty, it is safer to initiate treatment prior to intervention.

 

Nothing to Disclose: ERM, SGJ

21908 16.0000 FRI-327 A The Right Test at the Right Time. a Missed Case of Pheochromocytoma. 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Regina Belokovskaya*1, Ana M. Kausel2, Francisco Perez Mata2 and Gregory B. Dodell2
1Mt. Sinai St. Luke's Roosevelt Hospital, New York, NY, 2Mount Sinai St. Luke's and Mount Sinai Roosevelt Hospitals, New York, NY

 

Introduction:

Pheochromocytomas, tumors arising from chromaffin cells, are rare catecholamine-secreting neuroendocrine tumors. Approximately 90% of all pheochromocytomas are benign. However, malignant forms do exist. The disease has a well-documented high recurrence rate in both benign and malignant forms. Patients usually present with episodic palpitations, headache, sweating and hypertension. Mood changes are usually not described. We present a rare follow-up case of a man whose recurrence of pheochromocytoma coincided with a return in violent and aggressive behavior.

Clinical Case:

A 37-year-old male with a past medical history of pheochromocytoma, status post successful right adrenalectomy four years prior, presented with a week long history of persistent daily headaches, intermittent episodes of diaphoresis, diarrhea, night sweats and palpitations. The patient had not followed up since his surgery. The patient stated that his aggressive and violent behavior had returned in the last two months. During his initial presentation, similar psychological symptoms were thoroughly documented, which were attributed to his primarily norepinephrine-producing pheochromocytoma. Normetanephrine was 12010 (<=148 pg/mL) and total metanephrines were 12995 (<205 pg/mL). Metanephrines of 25 (<=57 pg/mL), 24hr urine epinephrine of 16 (2-24 mcg/24h), 24 h urine norepinephrine > 2000 mcg/24h, 24hr urine dopamine 416 (52-480 mcg/24h).

A follow-up CT of the abdomen demonstrated multiple masses in the right adrenal bed indicative of recurrence. The largest mass was 60 x 66 mm and was heterogeneous and necrotic extending into the posterior right lobe of the liver. In addition, there were masses identified adjacent to the right kidney, abutting the suprarenal IVC and several superior to the proximal transverse colon. I 123MIBG scan showed increased radiopharmaceutical uptake in the surgical bed of the previous right adrenalectomy and inferior aspect of right hepatic lobe corresponding to the masses seen on CT. A PET scan showed metastatic lung nodules. The patient underwent a lung biopsy which was positive for neuroendocrine carcinoma.

The patient was initially started on phenoxybenzamine. His vitals and symptoms have remained stable throughout his follow up. Given the patient’s financial limitations, he is being treated with Doxazosin 6mg/day. The treatment plan is under multi-disciplinary discussion.

Conclusion:

We present a rare follow-up case of a 37-year-old male who developed metastatic pheochromocytoma four years post resection. The concurrence of the patient’s aggression, which had diminished, and the return of the tumor further demonstrates that there is a strong correlation between a catecholamine producing pheochromocytoma and violent tendencies.

 

Nothing to Disclose: RB, AMK, FP, GBD

19045 17.0000 FRI-328 A Metastatic Pheochromocytoma with Recurrent Aggression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Farhad Hasan*
University of Virginia, Charlottesville, VA

 

A 65 year-old white male with past history of well-controlled Type-2 diabetes and hypertension was referred for evaluation and management of a pituitary macroadenoma. This was discovered during workup for loss of peripheral vision, headache, and erectile dysfunction. Evaluation revealed Hyperprolactinemia (serum prolactin 610 ng/ml; ref. value <18 ng/ml), hypogonadotrophic hypogonadism, and hypercalcemia (serum calcium 11.5 mg/dl).  Further workup for hypercalcemia revealed hyperparathyroidism (serum iPTH 272 pg/ml; ref. range 10-70 pg/ml) and abnormal Tc-99m Sestamibi scan with persistent uptake in both inferior parathyroid glands.  Given an increased pre-test probability of multiple endocrine neoplasia (MEN) syndromes, he was referred for genetic testing, which returned positive for MEN-1 germline mutation.  He had no family history of MEN-1, pituitary adenomas, or hypercalcemia. He has one son in good health.  Testing for gastrointestinal neuroendocrine tumors revealed high chromogranin-A (128 ng/ml; ref. range 2.3-14.3), and pancreatic polypeptide (1066 pg/ml; ref. range <312).  Abdominal and pelvic imaging (using computed tomography and magnetic resonance imaging) showed three 2-3 mm pancreatic lesions, but Octreotide scan was negative.  Computed tomography also discovered a left adrenal mass (3x2.2 cm) with a density of 29 HU pre-contrast, 95 HU during the arterial phase, and 65 HU during the venous phase, suggesting that the lesion is less likely to be benign (e.g. adrenal adenoma or myolipoma).  Subsequent testing for pheochromocytoma returned positive with elevated 24-hour urine collection for norepinephrine on two separate occasions (118 and 119 repectively; ref. values <100).  Following proper preoperative management, he underwent uneventful laparoscopic left adrenalectomy, and histologic exam confirmed pheochromocytoma. He subsequently required two parathyroid surgeries to correct hypercalcemia and hyperparathyroidism. His prolactin-secreting macroadenoma was treated medically with cabergoline, resulting in near normal values of prolactin (30-50s ng/ml), and in reduction of tumor size by ~70%. His peripheral vision loss is virtually resolved. We perform annual serveillance for gastrointestinal neuroendocrine tumors. Chromogranin-A and pancreatic polypeptide remain elevated, but his small pancreatic lesions had changed minimally in 8 years since initial discovery. His diabetes and hypertension are well controlled.  His persistent hypogonadism is treated with topical testosterone.  His only complaints during his latest visit were arthritic pain related to obesity and neuropathic feet pain related to his diabetes.

The occurrence of pheochromocytoma as part of the MEN-1 syndrome is rare, ranging between 0-3%. We briefly discuss our literature review of the prevalence, genotypic and phenotypic patterns of pheochromocytoma in MEN-1 syndrome. 

 

Nothing to Disclose: FH

21941 18.0000 FRI-329 A Pheochromocytoma in Multiple Endocrine Neoplasia Type-1: A Case Report and Literature Review 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM FRI 312-329 6092 1:00:00 PM Neoplasia Case Reports Poster


Anne R Cappola*1, Margaret C Garin2, Theresa Scattergood2, Domenick Salvatore2, Sarah J Ratcliffe2 and Kathryn Schmitz2
1University of Pennsylvania, Philadelphia, PA, 2Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA

 

Background:  Frailty is a common geriatric syndrome with no approved therapies. Key components of frailty include unintentional weight loss and loss of muscle mass and quality (sarcopenia). We hypothesized that a joint intervention of ghrelin plus home-based progressive resistance training would improve strength and lower extremity function in frail older individuals.

 

Study design: 12 week randomized, double-blind, placebo-controlled pilot study

 

Methods:  Fifteen men and women aged 70 years or older who were frail by the Fried criteria were enrolled. Data from a previous dose finding study showed a 30% increase in food intake with a 7.5 mcg/kg ghrelin dose. Five participants were randomized to 7.5 mcg/kg/day of subcutaneous ghrelin dosed 30 minutes prior to breakfast and ten to placebo. All participants completed twice weekly, home-based one hour resistance training sessions supervised by a nationally certified exercise professional. The primary outcome was change in performance of the Short Physical Performance Battery (SPPB), which includes balance, walking speed, and chair rise tests. The SPPB is scored out of a possible 12 points; higher score is better and 0.5 points represents a clinically significant difference. Additional outcomes included assessment of food intake by three-day diary, weight, body composition by DXA, upper and lower body strength testing (bench and leg press 1 repetition maximum), and the SF-36 quality of life measure. Outcomes were assessed at baseline, 6 and 12 weeks, except the DXA scan, which was assessed at baseline and 12 weeks. Data are reported as mean (SD). Longitudinal analyses were performed using generalized estimating equations (GEE).

Results: Five men and 10 women enrolled with a mean age of 81.5 years (range 70-90 years). Participants who received ghrelin ate more than placebo group participants (mean 12 week between-group difference 350 kcal/day, longitudinal p-value p<0.05), but there were no clinically or statistically significant between-group differences in change in weight, muscle mass, fat mass, muscle strength, SF-36 domains, or SPPB. Adverse events and safety parameters did not differ between groups. When data were analyzed without respect to ghrelin arm, comparing outcomes pre and post 12 weeks of resistance training, there was a 1.8 (2.0) point increase in SPPB (p<0.001) from a baseline of 7.7 (1.8) points. There were corresponding statistically and clinically significant gains in lean body mass, upper and lower body strength, and the physical function, role limitation, energy, and general health domains of the SF-36.

Conclusions: A home-based resistance training protocol was highly effective at improving strength and physical function in frail older participants, with no additional benefit from ghrelin administration.

 

Nothing to Disclose: ARC, MCG, TS, DS, SJR, KS

19900 1.0000 FRI-542 A Effects of Ghrelin Administration Plus Resistance Training in Frail Elderly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Leon S Farhy*, Jianhua Liu, Suzan S Pezzoli, Bruce D Gaylinn and Ralf Manfred Nass
University of Virginia Health System, Charlottesville, VA

 

Background. Ghrelin, a hormone released predominantly from cells lining the stomach, circulates in acylated (acyl ghrelin, AG) and non-acylated (desacyl ghrelin, DG) forms. Ghrelin acylation is performed by the enzyme ghrelin-O-acyltransferase, which uses medium chain fatty acids (MCFA) to octanoylate serine-3 of the peptide. The mechanisms for in vivo regulation of ghrelin acylation however are unknown. Circulating AG stimulates growth hormone (GH) release and has orexigenic, adipogenic and diabetogenic effects. In contrast, recent data suggest that AG and DG have independent and opposite effects. It is generally assumed that in obesity circulating ghrelin levels are low and as a result endogenous ghrelin is not actively targeted to treat this condition. However, this concept is mainly based on assay techniques that measure only total ghrelin (TG=AG+DG) and cannot distinguish between AG, DG and ghrelin fragments. In addition, recent reports (e.g., see [1]) suggest that in the obese, DG levels are reduced, while AG levels are actually elevated. Here, we use a frequent 26 hour sampling and specific assays for AG and DG to determine the differences between lean and obese with respect to their ghrelin levels.

Methods. We studied 7 lean (Age=21 ± 2.9, BMI=21.8 ± 2.9 kg/m2) and 6 obese (Age=23 ± 4, BMI=34.6 ± 2.1kg/m2) individuals. After an overnight fast 10-min blood sampling for AG and DG started at 0800 and continued for 26 h. Meals were served at 0800, 1300, 1800, and 0800 h (next morning). AG and DG were measured using an in-house two-site sandwich assay. Circulating ghrelin acylation (GA) was defined as GA=% AG to TG. A mathematical model of AG and DG secretion, acylation, clearance and AG de-acylation was used to analyze the potential changes in ghrelin acylation in the obese.

Results. We detected: (i) no difference between lean and obese in circulating AG levels; (ii) higher DG and TG during the day and first part of the night (8:00-24:00) in lean vs. obese (p<0.05); (iii) tendency for GA to be higher (p=0.13) in the obese, (iv) 1.24-fold overnight GA decline in the lean (p<0.05), but only 1.18-fold in the obese (p<0.05); (v) GA tended to be 3-fold higher around breakfast (0800-1000; after 13.5 hours of overnight fasting) in the obese (p=0.07). Our model-based analysis indicates that ghrelin acylation in the obese is about 22% higher as compared to the lean.

Conclusion. The results of this work indicate that, as reported by many other investigators, total ghrelin is indeed reduced in obese as compared to lean individuals. However, based on our data, circulating desacyl but not acyl ghrelin levels are lower in the obese suggesting an increase in ghrelin acylation in this population. Given recent reports of opposing actions of AG and DG on appetite, adipogenesis, and glucose metabolism, increased ghrelin acylation may contribute to the obesity phenotype by promoting overeating and insulin resistance.

 

Nothing to Disclose: LSF, JL, SSP, BDG, RMN

20969 2.0000 FRI-543 A Circulating Levels of Acyl Ghrelin and Desacyl Ghrelin in Obese Individuals 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Kim Thien Nguyen*1, Deniz Atalyer1, Gabrielle Page-Wilson1, Kana Meece1, Heather A Bainbridge1, Rebecca J Gordon1, Anne White2, Richard M. Smiley1, Judith Korner1 and Sharon L. Wardlaw1
1Columbia University College of Physicians & Surgeons, New York, NY, 2University of Manchester, Manchester, United Kingdom

 

The melanocortin neuronal system, consisting of the proopiomelanocortin (POMC)-derived MSH peptides, the MSH antagonist, agouti-related protein (AgRP) and the brain melanocortin receptors, plays a critical role in regulating energy balance. Physiological studies in animals show that this system responds to calorie restriction and to leptin but such studies have been limited in humans by the lack of reliable biomarkers for brain melanocortin activity. We have therefore measured POMC and AgRP in cerebrospinal fluid (CSF) collected by lumbar puncture (LP) after acute and chronic calorie restriction.  We have previously shown that high levels of intact POMC are present in human CSF and may be a useful biomarker of hypothalamic POMC activity. AgRP was also measured in plasma as we have found a correlation between plasma and hypothalamic AgRP in the rat.  In the first study 8 healthy subjects (5 lean; 3 obese) had an LP after a 40h fast and were then re-fed over the next 24h at 200% of their calculated calorie requirement and had a second LP.  Plasma leptin decreased to 34% of baseline during the fast; this was paralleled by a 155% increase in plasma AgRP (p=0.004). During refeeding there was an increase in leptin with a reciprocal decrease in plasma AgRP.  No significant changes in CSF POMC or AgRP were found. Of note the percent changes in plasma and CSF leptin were much greater in the lean vs obese subjects.  In the second study 7 healthy obese subjects (BMI 31-38) were studied before and after 6 weeks of an 800 kcal/day liquid diet (OPTIFAST). Mean weight loss was 9.1%. Fasting insulin and HOMA decreased and ghrelin increased significantly after weight loss. Mean plasma leptin decreased to 45% of baseline and CSF leptin to 71% of baseline (p<0.01). CSF POMC decreased consistently (p=0.007) and CSF AgRP increased (p=0.08) after weight loss. Plasma AgRP levels also increased (p=0.02). The biggest change was in the CSF POMC to AgRP ratio which fell by 30% (p<0.005). In conclusion plasma and CSF leptin decreased substantially following both an acute fast and a 6-week diet but a significant fall in CSF POMC was only seen after the diet.  However plasma AgRP levels increased in both settings consistent with the more acute changes in brain AgRP noted in rodents. This study provides further evidence for the use of CSF POMC measurements as biomarker of hypothalamic melanocortin activity and suggests that plasma AgRP may also be useful in this respect.

 

Nothing to Disclose: KTN, DA, GP, KM, HAB, RJG, AW, RMS, JK, SLW

20172 3.0000 FRI-544 A Effects of Acute and Chronic Calorie Restriction on Plasma and CSF Leptin and Melanocortin Neuropeptide Levels in Human Subjects 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Charu Baskaran*1, Kamryn T. Eddy1, Karen K. Miller2, Erinne Neubecker Meenaghan1, Anne Klibanski1, Madhusmita Misra3 and Elizabeth A. Lawson1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts Gen Hosp, Boston, MA, 3Massachusetts General Hospital and Harvard Medical School, Boston, MA

 

Levels of the anorexigenic hormone leptin are low in anorexia nervosa (AN) and high in overweight/obesity (OB). However, leptin secretory dynamics across the weight spectrum and the relationship with disordered eating psychopathology have not been studied. We hypothesized that women with lower leptin secretory parameters would have more severe disordered eating psychopathology.

We compared leptin secretory dynamics in 37 women; 13 AN, 12 OB and 12 normal-weight controls (C).

Serum leptin levels were obtained every 20’ from 2000- 0800 h. Basal secretion, half-life, number of pulses, mean pulse height, mean pulse mass, total pulsatile secretion, and area under the curve (AUC) were calculated using deconvolution analysis. Dual energy X-ray absorptiometry was used to measure % body fat. Disordered eating psychopathology was assessed by the Eating Disorders Examination-Questionnaire (EDE-Q) and Eating Disorders Inventory-2 (EDI-2).   

BMI and % body fat were lower in AN (18.5±0.9 kg/m2, 18±4%), and higher in OB (31.3±4.1 kg/m2, 37±4%) than C (22.0±1.5 kg/m2, 26±5%, p<0.001). The groups differed for basal secretion (AN: 0.08 ±0.09, OB: 0.13±0.08, C: 0.07±0.03 ng/ml.12hr, p=0.02). Mean pulse height (AN: 0.18±0.12, OB: 1.40±0.72, C: 0.58±0.29 ng/ml), mean pulse mass (AN: 4.8±3.1, OB: 38.2±18.5, C: 14.3±5.6 ng/ml), total pulsatile secretion (AN: 87.9±56.0, OB: 709.8±382.4, C: 263.6±110.7 ng/ml.12hr) and leptin AUC (AN: 3,011±1,986, OB: 24,062±10,359, C: 8,897±3,385 ng/ml.12hr) were significantly different between groups before and after adjustment for basal secretion (p<0.0001 for all). Leptin AUC correlated strongly with total pulsatile secretion (r=0.97, p<0.0001) and less with basal secretion (r=0.35, p=0.03). On multivariate analysis, only total pulsatile secretion was a significant predictor of leptin AUC (p<0.0001). Total pulsatile secretion was inversely associated with most EDE-Q and EDI-2 parameters and the associations remained significant for EDE-Q Eating Concern (p=0.01), and EDI-2 Asceticism, Ineffectiveness and Social Insecurity (p<0.05) after adjusting for basal secretion. The relationships between total pulsatile secretion and disordered eating psychopathology were no longer significant after controlling for % body fat.

Secretory dynamics of leptin differ greatly across the weight spectrum, with mean pulse height, mean pulse mass and total pulsatile secretion being low in AN and high in OB. Pulsatile, rather than basal secretion, is the major contributor to leptin AUC. Decreased pulsatile leptin is associated with disordered eating psychopathology, possibly reflecting low % body fat in AN.

 

Nothing to Disclose: CB, KTE, KKM, ENM, AK, MM, EAL

19253 4.0000 FRI-545 A Leptin Secretory Dynamics and Associated Disordered Eating Psychopathology Across the Weight Spectrum 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Samineh Madani*, Rogelio Almario and Sidika Emine Karakas
University of California at Davis Medical Center, Sacramento, CA

 

Obesity is a risk factor for metabolic syndrome (METS).  White adipocytes have low mitochondrial content and uncoupling protein (UCP1).  Brown adipocytes are rich in mitochondria and UCP1; dissipate energy as heat.  Recent research has shown that exercise may reduce obesity and diabetes by converting white adipocytes to beige adipocytes, which are similar to the brown adipocytes. This is mediated by irisin, a protein secreted by exercising muscle.  Administration of irisin to mice improves glucose tolerance (1).  We investigated the role of irisin during weight loss in women with METS.  Twenty-nine women with METS underwent a 2 month weight loss program.  Fasting blood samples were obtained at baseline and at the end of the study.  At the end of the intervention, weight, fat mass, and lean mass measured by dual-energy X-ray absorptiometry decreased (all p < 0.000).  Resting energy expenditure (REE) decreased by 92±10 kcal/day (p = 0.01).  Insulin resistance parameters (homeostatic model assessment, adiponectin, and triglyceride) and inflammatory markers (high sensitivity c-reactive protein and fatty acid-binding protein 4) improved.  Serum irisin increased from 209±47 to 258±107 ng/mL (p = 0.02).  Baseline irisin correlated (p < 0.05) directly with triglyceride (r = 0.419), and inversely with adiponectin (r = -0.316) and interleukin-1 beta (r = -0.331). The change (Δ) in irisin correlated inversely with ΔBMI (r = -0.460, p = 0.012) and Δlean mass (r = -0.359, p = 0.056).

In summary, although serum irisin increased during weight loss, baseline irisin correlated with the variables associated with METS (directly with triglyceride and inversely with adiponectin).  Therefore, the role of irisin in regulation of insulin resistance, hyperlipidemia and other components of METS is not yet clear in humans.

 

Nothing to Disclose: SM, RA, SEK

20069 5.0000 FRI-546 A Effect of Weight Loss on Serum Irisin in Women with Metabolic Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Christian Muschitz*1, Roland Kocijan1, Christina Marterer1, Arastoo Rahbar Nia1, Gabriela Katharina Muschitz2, Heinrich Resch1 and Peter Pietschmann3
1St. Vincent Hospital Vienna, Vienna, Austria, 2Department of Surgery, Medical University of Vienna, Vienna, Austria, 3Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria

 

Context: The role of sclerostin as a key regulator of bone formation remains unknown after Roux-en-Y gastric bypass (RYGB) or laparoscopic sleeve gastrectomy (SG).

Objectives: Evaluation of sclerostin and Dickkopf-1 (DKK-1) serum levels after surgery and correlations with bone turnover markers (P1NP, CTX), parathyroid hormone (iPTH) and areal bone mineral density (BMD) changes at total body, lumbar spine and total hip.

Design and Setting: A prospective observational single-center two-arm study in premenopausal women with acute adipositas over 24 months.

Participants: 52 premenopausal women (40 ±8 years, BMI 43.4) after RYGB and 38 premenopausal women (41±7 years, BMI 45.7) after SG.

Main Outcome Measures: Prior to surgery and 1, 3, 6, 9, 12, 18 and 24 months after surgery sclerostin, DKK-1, CTX, P1NP and BMD levels were measured.

Results: Sclerostin, CTX and (to a lesser extent) P1NP increased after surgery and remained elevated during the entire study period (p<0.001).  DKK-1 declined during months 3 – 9 (p<0.005) and then remained unchanged, serum phosphate continuously increased (p<0.001), iPTH remained within the upper normal limit. Sclerostin increases were significantly positively correlated with CTX and P1NP increases and negatively correlated with BMD loss. BMD independently declined regardless of RYGB and SG. Elevations of sclerostin, CTX, P1NP and phosphate but not DKK-1 and iPTH, were significant discriminating factors for BMD loss (AUC 0.920).

Conclusion: Rapid and sustained increases of sclerostin, CTX and - to a lesser extent - P1NP cause an increase in bone metabolism and result in BMD loss at all skeletal sites.

 

Nothing to Disclose: CM, RK, CM, AR, GKM, HR, PP

19851 6.0000 FRI-547 A Sclerostin Levels and Changes in Bone Metabolism after Bariatric Surgery 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Naji Torbay*1 and Rita Nawar2
1The Weight Care Clinic, Beirut, Lebanon, 2The Weight Care Clinic, Dubai, United Arab Emirates

 

Despite the fact that low-carbohydrate diets are still controversial, they continue to demonstrate effectiveness with little risk and good compliance in the treatment of diabetes and metabolic syndrome [1]. Low-carbohydrate diets that restrict carbohydrates to 20-60 g/d have been found to cause superior weight loss, and significant improvements in glycemic control and lipid profile as compared with low-fat diets [2]. In addition, the continuous reports of diabetes medication side effects, indicates a need to re-evaluate the role of dietary carbohydrate reduction [1].

 We had previously reported on the long-term effects of an ad-lib low-carbohydrate non-ketogenic high-protein diet [3]. The aim of the present retrospective study is to investigate the effects of such a diet on glycemic control, weight loss, lipid profile and kidney function over the short-term in patients with uncontrolled diabetes. 

 We reviewed the medical charts of all patients with diabetes that attended our clinic in the years 2011-2013. We selected only those with uncontrolled diabetes (HbA1c ≥7 %) who came back for a follow-up visit within 1-4 month with lab results. 76 patients were found to meet these criteria: 45 males and 31 females (59.2% and 40.8% respectively). Mean age was 53.8±11.0 years, and mean BMI was 34.7±7.8 kg/m2, mean duration of diabetes was 5.8±6.6years. Patients were instructed on an ad-libitum low-carbohydrate non-ketogenic high-protein diet and were encouraged to exercise and maintain a healthy lifestyle. No restrictions on use, amount, or type of fat were made, although the use of canola and olive oils was recommended. The diets provided 130-150g of carbohydrate per day to prevent ketosis. All patients were on metformin, some in combination with sulfonylureas or a DPPIV inhibitor, and few were on a combination of all three. Data was analyzed using paired-sample t-tests, and mean±SD is reported.

 Patients came for follow-up within an average of 2 months, and our findings revealed a significant decrease from baseline in BMI (34.8±7.8 vs. 33.2±7.4 kg/m2; p<0.001); fasting blood sugar (179.0±63.3 vs. 129.7±39.6 mg/dl; p<0.001); HbA1c (8.53±1.56 vs. 6.83±1.12 %; p<0.001); total cholesterol (199.4±39.1 vs. 184.9±35.7 mg/dl; p=0.002); triglycerides (220.1±177.7 vs. 174.2±95.9 mg/dl; p=0.009); and SGOT (28.7±17.9 vs. 21.2±7.7 IU/L; p<0.001). No significant changes were observed in LDL, HDL, SGPT or creatinine. In 6.4% of patients, reduction in medication dose was also observed.

 We conclude that decreasing carbohydrate intake over a short period of time significantly lowers the HbA1C level without the need of increasing the doses of oral hypoglycemic medication or introducing new ones; a strategy that could be successfully introduced, even if intermittently, in order to bring diabetes to control, and should be discussed as part of diabetes management with patients.

 

Nothing to Disclose: NT, RN

20253 7.0000 FRI-548 A An Ad-Libitum Low-Carbohydrate Non-Ketogenic High-Protein Diet Improves Diabetes Control over the Short-Term 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Sumudu Nimali Seneviratne*, Yannan Jiang, Lesley M. McCowan, Graham Parry, Silmara Gusso, Raquel Rodrigues, Wayne Stephen Cutfield and Paul Leslie Hofman
University of Auckland, Auckland, New Zealand

 

Background-Obesity rates in women of child bearing age have increased dramatically over the last three decades. This poses risks in pregnancy for both mother and baby, including  higher  birth weight and increased risk of obesity in the offspring (1).  There is an interest whether antenatal exercise can improve these outcomes (2).  While  antenatal exercise in lean women has  been associated with  a reduction in offspring birth weight and childhood adiposity (3) , the  effects on offspring of overweight/ obese women are not well established.

Objectives- To compare offspring and maternal health outcomes in overweight / obese women undergoing an antenatal exercise programme, to a control group. We hypothesized that antenatal exercise would reduce offspring birth weight and neonatal adiposity, which would be protective against  future  obesity (4).

Methods-This parallel two- arm trial was prospectively registered with the Australian New Zealand Clinical Trial Registry (ACTRN12612000932864). Overweight/ obese (BMI> 25) non-smoking pregnant women from Auckland were randomised to a 16 week home-based moderate-intensity stationary cycling programme or control group with no intervention, at 20 weeks of gestation.  The primary outcome was birth weight.  Maternal weight, fitness (submaximal exercise test on a cycle ergometer, resting blood pressure and heart rate), blood metabolic markers and quality of life (WHO- BREF) were assessed at baseline and end of intervention.  Fetal growth, maternal diet and exercise were monitored over the intervention period.  Pregnancy and delivery outcomes were obtained from medical records. Neonatal and maternal body composition was assessed by DEXA scanning 14 days after delivery. Analysis was by intention to treat.

Results- 75 participants were recruited (intervention n =38; control n = 37) between March 2013- April 2014. Mean pre-pregnancy BMI was 31.5 kg/m2.  While birth weight was unaltered by the intervention (3634 vs 3594 g, p=0.8), offspring in the intervention group showed an unanticipated increase in body fat (8.4% vs 7.2%, p< 0.05). There were no group differences in customised birth weight centiles, birth length, head circumference, lean mass and perinatal complication rates.

Maternal fitness improved (improvement in test time (sec) + 32 vs – 15, p<0.05), with a trend towards reduced systolic blood pressure (113 vs 118 mmHg, p = 0.06) and reduced post- partum body fat (45% vs 47% p=0.09) in the intervention group.  Maternal weight gain, quality of life, pregnancy and delivery outcomes, dietary intake, HbA1c, metabolic markers and placental weights were similar between groups.

Conclusions- While this non-weight bearing antenatal exercise intervention improved maternal outcomes; it increased neonatal adiposity in the offspring. We propose that this effect may be specific to overweight and obese pregnancies, and may adversely increase offspring obesity risk.

 

Nothing to Disclose: SNS, YJ, LMM, GP, SG, RR, WSC, PLH

20183 8.0000 FRI-549 A The Improve Randomised Controlled Trial: Non-Weight Bearing Antenatal Exercise in Overweight and Obese Women Increases Neonatal Adiposity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Nazia Raja-Khan*1, Katrina Agito1, Julie Shah1, Christy M. Stetter1, Theresa S Gustafson1, Holly Socolow1, Allen R Kunselman1, Diane K Reibel2 and Richard S Legro1
1Penn State Univ Coll of Med, Hershey, PA, 2Thomas Jefferson University, Philadelphia, PA

 

Stress may contribute to increased diabetes and cardiovascular disease in women who are overweight or obese. Our objective was to conduct a pilot randomized controlled trial to determine the feasibility and effects of Mindfulness-Based Stress Reduction (MBSR) in overweight/obese women. We randomized 86 women with body mass index (BMI) ≥25 kg/m2 to 8 weeks of MBSR or health education control (HEC). At baseline, 8 weeks and 16 weeks fasting blood work and questionnaires were administered. Our overall hypothesis was that MBSR would increase mindfulness, reduce stress and ultimately lead to favorable changes in blood glucose, blood pressure, psychological distress and quality of life. Fifty three women completed the study. Results were analyzed by intention-to-treat. The two groups were similar in age and BMI (mean ± SD in MBSR group 47.0 ± 11.5 years and 39.0 ± 7.7 kg/m2; HEC 42.2 ± 13.1 years and 38.8 ± 9.7 kg/m2). Compared to HEC, MBSR significantly increased the primary outcome mindfulness assessed with the Toronto Mindfulness Scale total score at 8 weeks [mean change from baseline (95% CI) in MBSR was 4.5 (1.2 to 7.7) (18.5% change from baseline) vs. HEC -1.0 (-4.4 to 2.5), P = 0.03]. Compared to HEC, MBSR significantly reduced stress assessed with the Perceived Stress Scale-10 at 16 weeks [MBSR -3.6 (-4.7 to -2.5) (-15.8% change from baseline) vs. HEC -1.3 (-2.6 to -0.002), P = 0.01]. There was a borderline statistically significant increase in salivary cortisol levels at waking with MBSR at 16 weeks (MBSR vs. HEC, P = 0.09). In the MBSR group there were significant reductions in fasting glucose [at 8 weeks -8.9 (-16.5 to -1.3) mg/dl, P = 0.02; at 16 weeks -9.3 (-17.1 to -1.5) mg/dl, P = 0.02]. Fasting glucose did not significantly improve in the HEC group. However, the between group difference did not reach statistical significance likely because this pilot study was not powered to detect a difference in glucose. The MBSR group also demonstrated significant increases in the quality of life SF-36 mental component summary [at 8 weeks 8.0 (4.9 to 11.1), P <0.001; at 16 weeks 5.3 (1.8 to 8.8), P = 0.003]. Both MBSR and HEC demonstrated reductions in PROMIS Sleep Related Impairment, and depression, anxiety and overall psychological distress assessed with the Brief Symptom Inventory-18. There were no significant changes in weight, BMI, blood pressure, lipid profile, hemoglobin A1c, fasting insulin, HOMA-IR or hsCRP with MBSR. In conclusion, MBSR significantly reduces fasting glucose and improves quality of life without changing body weight or insulin resistance in overweight/obese women. This may be due to increased mindfulness and reduced stress leading to physiological changes in the HPA axis and cortisol secretion. Our findings support the integration of MBSR with conventional medical approaches to overweight/obesity and diabetes prevention and treatment. ClinicalTrials.gov Identifier: NCT01464398.

 

Nothing to Disclose: NR, KA, JS, CMS, TSG, HS, ARK, DKR, RSL

18783 9.0000 FRI-550 A Mindfulness-Based Stress Reduction Decreases Fasting Glucose in Overweight and Obese Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Harold Edward Bays*1, F Xavier Pi-Sunyer2, Joanna Uddén Hemmingsson3, Christine Bjørn Jensen4, Birgitte Claudius4 and Luc F Van Gaal5
1L-MARC Research Center, Louisville, KY, 2St Luke's Roosevelt Hosp, New York, NY, 3Capio St Goran´s Hospital / Karolinska institutet, Stockholm, Sweden, 4Novo Nordisk A/S, Søborg, Denmark, 5Faculty of Medicine, Antwerp University Hospital, Edegem, Belgium

 

Adipose tissue is an active endocrine and immune organ; obesity often results in metabolic (fat dysfunction) and biomechanical (fat mass) adverse health consequences. Liraglutide 3.0 mg may benefit individuals with obesity via weight-loss dependent and weight-loss independent effects. The SCALE trials examined the efficacy and safety of liraglutide 3.0 mg in overweight or obese individuals (n=5,358) with or without prediabetes (Clinicaltrials.gov ID NCT01272219); type 2 diabetes (NCT01272232); or obstructive sleep apnea (NCT01557166).1-4Across Phase 3 trials, liraglutide 3.0 mg vs placebo reduced mean body weight by 5.7-8.0% vs 0.2-2.6% and waist circumference by 4.7-8.2 cm vs 1.2-4.0 cm, respectively (all p<0.0001). Liraglutide 3.0 mg also significantly improved secondary endpoints such as A1c, fasting plasma glucose (FPG), blood pressure, lipid profile, and reduced concomitant use of glucose-lowering, lipid-lowering and antihypertensive medications. Health-related quality of life (QoL) scores and the apnea hypopnea index (AHI) also improved. This post hoc analysis examined the relative contribution of weight loss to the treatment effect on key secondary efficacy endpoints.

Data in this analysis were primarily derived from the largest trial (SCALE Obesity and Prediabetes). A1c, FPG, and use of oral antidiabetes drugs (OADs) were also included from the SCALE Diabetes and Sleep Apnea trials, and AHI from the SCALE Sleep Apnea trial. A mediation model was applied, which is a statistical method intended to explain the dependent and independent relationship between a studied variable (in this case, weight loss), and an observed outcome (in this case, secondary efficacy outcomes). While this analysis cannot be conclusive with respect to a causal relationship between weight loss and effects on secondary endpoints, its assumptions rely on such a relationship. The analysis has its limitations, including that weight loss is a post-randomization observation. The degree to which liraglutide-induced weight loss mediated its effects on key secondary endpoints at end of treatment was ranked in the range of 0-100%; 100% indicates that the effects may all be mediated by weight loss. Endpoints predominantly driven by weight loss with liraglutide included waist circumference, diastolic blood pressure, triglycerides and HDL cholesterol levels, as well as AHI and IWQoL-Lite total and physical function scores [ranked 88-100%]. Endpoints predominantly independent of weight loss included glycaemic endpoints and use of OADs [ranked 18-32%]. Importantly, for each endpoint, including those predominantly driven by weight-loss independent mechanisms, weight loss was a significant contributor to the treatment effect. In conclusion, in individuals with overweight or obesity, liraglutide 3.0 mg mediates its effects through both weight-loss dependent and weight loss-independent effects.

 

Disclosure: HEB: Investigator, Alere, Investigator, Amarin, Investigator, Amgen, Investigator, Ardea, Investigator, Arisaph, Investigator, Astra Zeneca, Investigator, Boehringer Ingelheim, Investigator, Bristol-Myers Squibb, Investigator, California Rasin Board, Investigator, Catabasis, Investigator, Cymabay, Investigator, Eisai, Investigator, Elcalyx, Investigator, Eli Lilly & Company, Investigator, Esperion, Investigator, Forrest, Investigator, Gilead, Investigator, Given, Investigator, GlaxoSmithKline, Investigator, Hanmi, Investigator, Hisun, Investigator, High Point Pharmaceuticals LLC, Investigator, Hoffmann-La Roche, Investigator, Home Access, Investigator, Janssen, Investigator, Merck & Co., Investigator, Metabolex, Investigator, Necktar, Investigator, Novartis Pharmaceuticals, Investigator, Novo Nordisk, Investigator, Omthera, Investigator, Orexigen, Investigator, Pfizer, Inc., Investigator, Pronova, Investigator, Regeneron, Investigator, Sanofi, Investigator, Takeda, Investigator, TIMI, Investigator, Transtech Pharma, Investigator, Trygg, Investigator, Vivus USA, Investigator, WPU Pharma, Speaker Bureau Member, Amarin, Speaker Bureau Member, Amgen, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Catabasis, Speaker Bureau Member, Daiichi Sankyo, Speaker Bureau Member, Eisai, Speaker Bureau Member, Isis, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Novartis Pharmaceuticals, Speaker Bureau Member, Omthera, Speaker Bureau Member, Vivus USA, Speaker Bureau Member, WPU Pharma. FXP: Advisory Group Member, Novo Nordisk, Advisory Group Member, Weight Watchers International, Advisory Group Member, Johnson &Johnson, Advisory Group Member, Vivus USA, Advisory Group Member, Eisai, Advisory Group Member, Zafgen. JU: Advisory Group Member, Sanofi, Advisory Group Member, Novo Nordisk, Investigator, InfuCare, Speaker, Novo Nordisk, Speaker, Sanofi. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. BC: Employee, Novo Nordisk, Employee, Novo Nordisk. LFV: Advisory Group Member, Astra Zeneca, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Janssen, Advisory Group Member, Johnson &Johnson, Advisory Group Member, Merck & Co., Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Novo Nordisk, Advisory Group Member, Sanofi, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Janssen, Speaker Bureau Member, Johnson &Johnson, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Novartis Pharmaceuticals, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Sanofi.

19533 10.0000 FRI-551 A Liraglutide 3.0 Mg: Weight-Loss Dependent and Independent Effects 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM FRI 542-551 6094 1:00:00 PM Obesity - Clinical Trials II Poster


Ritu Madan*1, Ranganath Muniyappa2, Radwa Noureldin3, Ronald Ouwerkerk4, Elizabeth Liu5, Katherine Mullins4, Ahmed M. Gharib4 and Monica C. Skarulis6
1National Institutes of Health, Bethesda, MD, 2Diabetes Endocrinology and Obesity Branch, NIDDK, NIH, 3NIDDK/NIH, 4NIH, Bethesda, MD, 5NIDDK, 6DEOB, NIDDK, NIH

 

Background: Myocardial steatosis, an independent predictor of diastolic dysfunction is frequently present in type 2 diabetes mellitus. Increased free fatty acid (FFA) delivery and uptake in excess of oxidative capacity leads to the accumulation of triglycerides (TG) in the myocardium. High FFA flux secondary to reduced suppression of lipolysis in adipose tissue, hyperglycemia, and hyperinsulinemia are characteristic of insulin resistance. There are no prior studies examining the relationship between anti-lipolytic actions of insulin and cardiac steatosis.

Objective: Using a cross-sectional study design of individuals with and without metabolic syndrome (MetSyn), we examined the relationships between cardiac steatosis and insulin sensitivity of the anti-lipolytic and glucose disposal actions of insulin.

Methods: Pericardial fat volume (PF, by cardiac MRI), intramyocardial and hepatic fat content (MF and HF, respectively, by MR spectroscopy), visceral and subcutaneous fat content (VF and SF, by abdominal MRI) were assessed in 77 subjects (49 without MetSyn and 28 with MetSyn). In a subset of the larger cohort (n=52), peripheral insulin sensitivity index (SI) was determined from Insulin Modified Frequently sampled intravenous glucose tolerance test (IM-FSIVGTT). Quantitative Insulin Sensitivity Check Index (QUICKI) was used as a surrogate for hepatic insulin sensitivity. Adipo-SI, expressed as the decay rate of plasma FFA concentrations divided by the increment in insulin concentration was used as a surrogate of adipocyte insulin sensitivity. Univariate regression followed by stepwise multiple regression analyses was used to identify independent predictors of tissue-specific fat content.

Results: Individuals with the MetSyn had significantly higher BMI, total body fat, MF, PF, HF and VF content. HF was negatively correlated with QUICKI (r= -0.46, p=0.0009), Adipo-SI (r= -0.48, p=0.0008) and SI (r=.-0.36, p= 0.0132). VF was similarly related to QUICKI, Adipo-SI, and SI. However, MF was not significantly associated with QUICKI (r= -0.20), Adipo-SI (r= -0.07) and SI (r=-0.06). In contrast, PF tended to be negatively related to insulin sensitivity (QUICKI, r= -0.23, p=0.18; Adipo-SI, r= -0.26, p=0.08; SI r=-0.27, p=0.07). Stepwise regression revealed that waist circumference and serum TG levels independently predicted MFC and PF, respectively. Adipo-SI and serum TG levels independently predict HF.

Conclusion: Myocardial steatosis is unrelated to hepatic, adipocyte, or peripheral insulin sensitivity.  In contrast, pericardial fat depot similar to fat content in liver and visceral adipose tissue is negatively related to insulin sensitivity. Although frequently observed in insulin-resistant subjects, further studies are necessary to identify and delineate pathogenic mechanisms that differentially affect cardiac and hepatic steatosis.

 

Nothing to Disclose: RM, RM, RN, RO, EL, KM, AMG, MCS

PP18-1 21716 1.0000 FRI-636 A Hepatic but Not Myocardial Steatosis Is Associated with Anti-Lipolytic and Glucose Disposal Actions of Insulin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 636-644 6097 1:00:00 PM Diabetes Genetics and Epidemiology Poster


David Carmody*1, Lukas Szczerbinski2, Agata Minor3, Carrie Fitzpatrick3, Siri Atma W Greeley4 and Louis H. Philipson1
1University of Chicago, Chicago, IL, 2University of Chicago, 3The University of Chicago, 4Univ of Chicago, Chicago, IL

 

Introduction

Russell Silver syndrome (RSS) is characterized by intrauterine growth retardation accompanied by postnatal growth deficiency. Affected individuals are short and may have distinctive facial features including a small triangular shaped face due to a prominent forehead and small jaw. Here we report the first case of a patient with a H19 duplication resulting in RSS and atypical diabetes mellitus.

Case

A 19 years old Caucasian man was referred with atypical diabetes mellitus. His birth weight was 2 lbs following induction at 33 weeks gestation for intrauterine growth retardation. Pre and post-natal growth retardation coupled with a triangular facies, frontal bossing and crowded teeth prompted the clinical diagnosis of RSS. His height has remained below the 3rd centile despite a three year course of human growth hormone from 11 years of age. He presented with diabetic ketoacidosis at 12 years of age. His initial HbA1c was 108 mmol/mol (12%) and he was commenced on mixed insulin twice daily and has maintained a HbA1c of less than 64 mmol/mol (8%) since. C-peptide has been detectable since diagnosis with a level of 0.57 pmol/ml at 19 years of age (serum glucose was 10.3mmol/l (185mg/dl)). No detectable anti GAD, ICA or insulin antibodies have been noted at any stage, he has remained euthyroid and he has a non DR3/4 HLA status. There is no history of autoimmune disease or diabetes in his family.

Genetic testing

The genetic causes of Russell-Silver syndrome are varied, most frequently involving abnormalities in the region 11p15 of chromosome 11 containing genes such as H19 and IGF2 having great significance in the control of fetal growth. Using a SNP array, we identified small cryptic gains at both breakpoints of the translocation between chromosomes 3 and 11. A 1.8MB gain in Chromosome 3p14.1 (65448161bp - 67287434bp) and 84KB gain in Chromosome 11p15.5 (1965047bp – 2049484bp which includes H19).

Discussion

Mutations giving rise to RSS are typically spontaneous with only few reports of familial inheritance. The human 11p15 chromosome contains the H19/IGF2 domain which is regulated by Imprinting Control Region 1 (ICR1). H19 has no identifiable protein product but is thought to modulate the expression of other genes including IGF2 through a noncoding transcript. Beta cell apoptosis has been associated with reduced IGF2 expression, while IGF2 supplementation in animal models with reduced IGF2 expression may promote expansion of beta cells mass. In adult mice, IGF2 expression in intimately tied to beta cell regeneration.

Conclusions

While duplications in IGF2 have been reported to cause RSS, we report the first patient with a H19 duplication resulting in RSS. This is the second case of antibody negative, c-peptide positive diabetes in a patient with disruption of the 11p15.5 locus.

 

Nothing to Disclose: DC, LS, AM, CF, SAWG, LHP

22079 2.0000 FRI-638 A H19 Duplication Resulting in Russell Silver Syndrome (RSS) and Atypical Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 636-644 6097 1:00:00 PM Diabetes Genetics and Epidemiology Poster


Jenna L Cowan*, Elaine W Butterly, James G Boyle, Robert S Lindsay and Russell S Drummond
NHS Greater Glasgow and Clyde, Glasgow, United Kingdom

 

Background

Glucokinase (GCK) catalyses the conversion of glucose to glucose-6-phosphate and is postulated to function as the glucose sensor for beta cells. Heterozygous mutations in the GCK gene result in a higher threshold for glucose stimulated insulin secretion. This form of monogenic diabetes characteristically encompasses stable, mild hyperglycaemia not associated with typical vascular complications.

Clinical Case

A 35 year old female presented with glycosuria at 31 weeks gestation in her first pregnancy. BMI was 21.2 and there was no significant past medical history. A 75g OGTT confirmed gestational diabetes in keeping with IADPSG guidelines; fasting glucose 5.6 mmol/l (NR<5.1), 2 hour glucose 9.5 mmol/l (NR<8.5). HbA1c was 44 mmol/mol (NR 20-42). She was treated with metformin and insulin and had an uncomplicated vaginal delivery of a healthy baby boy, weighing 3.05kg, at 38 weeks.6 weeks post partum OGTT indicated impaired glucose tolerance with fasting glucose 6.0 mmol/l and 2 hour level 8.4 mmol/l, HbA1c was 49 mmol/mol.

There was a family history of type 2 diabetes affecting her paternal grandmother and father. Her father (70) was diagnosed incidentally aged 47, BMI was <25. He has hypertension and ischaemic heart disease. HbA1c varies between 40-56 mmol/mol since 1997 and he has been treated with gliclazide and pioglitazone. He recently developed unilateral mild background retinopathy but has no other microvascular complications. Her sister age 33 years, BMI 23, was also found to have a raised HbA1c of 44 mmol/mol. Given the clinical phenotype, family history and in particular the glycaemic profile, a diagnosis of GCK MODY was made clinically and genetic testing was performed by direct Sanger sequencing.

A novel heterozygous nucleotide substitution c.751A>G was detected in the GCK gene. The substitution is predicted to result in a missense amino acid change from the highly conserved methlonine residue to valine at codon 251, p.(Met251Val). Three out of four in silico protein prediction algorithms predict the p.(Met251Val) to be deleterious to protein function and hence associated with the observed clinical phenotype with stable, mild hyperglycaemia. DNA was subsequently analysed from her sister and father who were both heterozygous for the same mutation.

 

Conclusion

 

The clinical presentations in 2 generations of this family are in keeping with a Glucokinase MODY clinical phenotype. On examination of the Leiden Open Variation Database and the Single Nucleotide Polymorphism Database [1,2], the c.751A>G substitution has not been previously described in the literature as pathogenic. Other missense mutations in the same domain have been reported as pathogenic. We conclude that this c.751A>G mutation in the GCK gene is pathogenic and consistent with the clinical diagnosis of MODY subtype GCK.

 

Nothing to Disclose: JLC, EWB, JGB, RSL, RSD

19379 3.0000 FRI-639 A A Novel Heterozygous Nucleotide Substitution (c.751A>G) in the Glucokinase Gene Causing Maturity Onset Diabetes of the Young in a Scottish Family 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 636-644 6097 1:00:00 PM Diabetes Genetics and Epidemiology Poster


Zhixiao Wang*1 and Shaloo Gupta2
1Eisai Inc, Woodcliff Lake, NJ, 2Kantar Health, Princeton, NJ

 

Background: Sleep status is associated with poor glycemic control and increased risk of type 2 diabetes mellitus (T2DM). This study examined the prevalence of sleep disorders and self-reported sleep symptoms and risk factors (including but not limited to obesity) among adult patients diagnosed with T2DM.

Methods: Data were obtained from the 2012 National Health and Wellness Survey (NHWS), an annual Internet-based survey demographically representative of the US adult population (N=71,157). A total of 7,239 participants reported a diagnosis of T2DM. Patients also provided information on a diagnosis of sleep disorders (e.g., insomnia, sleep breathing disorder, other sleep conditions, etc.) and regularly experienced sleep symptoms (e.g., difficulty falling asleep, sleep apnea, daytime sleepiness, difficulty staying awake, etc.). Logistic regressions were used to examine factors associated with sleep disorders and symptoms, including demographics, health insurance, smoking, exercise, alcohol use, body mass index, and modified Charlson comorbidity index (CCI).

Results:  Among patients with T2DM, the average age was 59.9 (SD=12.2), 59.5% were male, 24.4% were diagnosed with a sleep disorder, 76.8% reported experiencing any sleep symptom regularly (difficulty falling asleep, 30.5%; sleep apnea, 17.4%;  daytime sleepiness, 26.8%; difficulty staying awake, 10.1%) . Multivariable logistic regression models showed the strongest predictors of diagnosed sleep disorders were obesity class (OC) III (OR=2.20), Caucasians (vs. black, OR=1.92), OC II (OR=1.57), smoking (OR=1.57), unemployment (OR=1.38), and the CCI (OR=1.35), all p<0.05. The strongest predictors of any sleep symptom were OC III (OR=2.22), OC II (OR=1.78), female gender (OR=1.72), OC I (OR=1.60), Caucasians (vs. black, OR=1.54), and smoking (OR=1.47), all p<0.05. Difficulty falling asleep was associated with Caucasians (vs. black), female gender, smoking, unemployment and OC III, all p<0.05. Sleep apnea was associated with all three obesity classes, overweight, male gender, smoking, and Caucasians (vs. black), all p<0.05. Strong predictors of daytime sleepiness were all three obesity classes, Caucasians (vs. black), low income, female gender, and smoking, all p<0.05. Difficulty staying awake was associated with Caucasians (vs. black), all three obesity classes, low income, and smoking, all p<0.05.

Conclusions: Almost 25% of patients withT2DM were diagnosed with a sleep disorder and over 75% reported experiencing at least one sleep symptom regularly. Sleep disorders and symptoms were strongly associated with obesity, Caucasians, gender, low income, and smoking. Interventions focusing on modifiable risk factors, including weight management and smoking cessation, have been shown to improve T2DM and may also potentially improve sleep disorders in those patients.

 

Disclosure: ZW: Employee, Eisai. SG: Principal Investigator, Eisai.

PP18-3 19915 4.0000 FRI-640 A Predictors of Sleep Disorders Among Patients with Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 636-644 6097 1:00:00 PM Diabetes Genetics and Epidemiology Poster


Gulsah Yenidunya Yalin*1, Sebahat Akgul2, Mustafa Sevinc3, Seher Tanrikulu4, Selda Celik5, Ayse Kubat Uzum1, Nurdan Gul6, Fatma o. Sarvan3, Mehmet sukru Sever3 and Ilhan Satman4
1Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey, 2Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey., Istanbul, Turkey, 3Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey., 4Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey, 5Istanbul University Istanbul Medical Faculty, Istanbul, Turkey, 6Istanbul Faculty of Medicine, Istanbul, Turkey

 

Background: New onset diabetes after renal transplantation (NODAT), is a serious complication which has gained significance as the rates of survival after renal transplantation have increased in the recent years. In addition to traditional risk factors, some genetic mutations have recently been proposed in the etiopathogenesis of this disorder. We aimed to examine the association of polymorphisms in the glutathion peroxidase (GPX1) and KCNJ11 genes in patients with NODAT.

Material-Method: Patients who had been followed up after renal transplantation between 1980-2014 in Istanbul Medical Faculty, in Departments of Nephrology and Endocrinology, Metabolism Disorders were included in the study (n:118). Patients were divided into two groups: NODAT (group-1, n:58, F:18, M:40  ) and non-NODAT (group-2, n:60, F:22, M:38). The patients’ data were evaluated retrospectively. Genomic DNA was extracted with a DNA Mini Kit (Invitrogen). PCR-RFLP method was used for genotyping of polymorphisms in the GPX1 (rs1050450) and KCNJ11 (rs1805127) genes. Two alleles were visualized for each gene (C/T for GPX1 and A/G for KCNJ11).

Results:  Analyzing the C599T polymorphism in GPX1 gene, TT allele was significantly more frequent in patients with NODAT compared to patients without NODAT (p<0.0001). KCNJ11 polymorphisms were not significantly associated with NODAT. However, GG allele of KCNJ11 gene showed negative correlation with the age at onset of diabetes. NODAT was positively corelated with age at transplantation (p<0.0001), presence of pretransplant hypertension (p=0.028), postransplant systolic blood pressure (p=0.020), dyslipidemia (p<0.0001), BK virus infection (p=0.047), type of immune supressive therapies (p=0.047) and medications other than immune supressive agents (beta blockers, p=0.045; thiazid diuretics and statin, p<0.0001). TT allele of GPX1 gene was more frequent in  current/ex smoker diabetic patients. There was no significant association between HCV infection, type and duration of renal replacement therapy and cadaveric transplantation.

Conclusion: C599T polymorphism in GPX1 gene may be associated with an increased risk of NODAT. However, other possible diabetogenic factors (i.e. immunosupressive regimens, accompanying comorbidities and concomitant medications) might also contribute to development of NODAT.

 

Nothing to Disclose: GYY, SA, MS, ST, SC, AKU, NG, FOS, MSS, IS

PP18-4 20525 5.0000 FRI-641 A Glutathion Peroxidase and KCNJ11 Gene Polymorphisms in Patients with New Onset Diabetes after Renal Transplantation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 636-644 6097 1:00:00 PM Diabetes Genetics and Epidemiology Poster


Colleen Buggs-Saxton*
Wayne State University School of Medicine, Detriot, MI

 

Background:  Mutations in the ß-cell sulfonylurea receptor (ABCC8) gene have been associated with both transient and permanent neonatal diabetes (PNDM) (1).  This report describes a novel homozygous missense mutation in the ABCC8gene that was detected in two siblings, one with transient and the other with permanent neonatal diabetes (PNDM). 

Clinical case:  A 6-month old female presented with vomiting, fatigue, and increased urination.  Since an older sibling was diagnosed with diabetes during infancy, her blood glucose was checked and was elevated (430 mg/dL).  In the hospital she was diagnosed with mild diabetic ketoacidosis (serum glucose 408 mg/dL, C-peptide 0.2 ng/ml, insulin <1 mIU/mL, ß-hydroxybutyrate 33.6 mg/dL with reference range 0.2-2.8, carbon dioxide 16 mMol/L).  She had an elevated glycosylated hemoglobin A1c (HgbA1c) 11.6% and negative autoimmune antibodies for human insulin, islet cell, and glutamic acid decarboxylase (GAD).  She was treated with insulin (0.3 units/kg/day) for only 8 months.   Her older sibling was diagnosed with PNDM at age 3.5-months of age when she presented with diabetic ketoacidosis (serum glucose 792 mg/dL, positive acetone, carbon dioxide 15 mMol/L) with an elevated HgbA1c 17.9% and has been treated with insulin (0.7 unit/kg/day) for over 14 years with no recurrent DKA but with variable levels of HgbA1c (8.3-11.7%).  Recent testing revealed the presence of human insulin autoantibodies but no GAD or islet cell antibodies.  Both siblings were found to have a new homozygous missense mutation in a highly conserved region of the ABCC8 gene, but no mutations in the KCJN11 gene.  The sibling with PNDM also had no mutations in other genes associated with neonatal diabetes (e.g., glucokinase, insulin, and the pancreatic and duodenal homeobox 1 gene).  Family history revealed consanguinity and both parents and one of three other siblings were heterozygous for the new ABCC8mutation but had no clinical history of abnormal glucose levels.   The sibling with PNDM was transitioned off insulin to glyburide as an outpatient (2,3) along with using the Dexcom continuous glucose monitor.  Prior to glyburide therapy, she had a suppressed C-peptide level (0.1 ng/ml, reference range 0.8-3.9).  Four weeks after stopping insulin, she was maintained on glyburide (1.8 mg/kg/day) with an increased postprandial C-peptide level (2.1 ng/ml) and a decreased HgbA1c (7%).

Conclusion:  This new homozygous missense mutation in the ABCC8 gene is associated with both transient and permanent diabetes and responds to sulfonylurea therapy.  Therefore, genetic testing of all individuals with a history of neonatal diabetes can identify potential patients who can be transitioned off subcutaneous insulin injections to oral therapy with a sulfonylurea, which can improve glycemic control.

 

Nothing to Disclose: CB

21634 6.0000 FRI-642 A A Novel Homozygous Mutation in the ABCC8 Gene Is Associated with Both Transient and Permanent Neonatal Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 636-644 6097 1:00:00 PM Diabetes Genetics and Epidemiology Poster


Mustafa Unubol*1, Zeliha Cansel Ozmen2, Muzaffer Katar3, Bilal Acar4 and Volkan Yazak5
1Adnan Menderes University Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology, Aydın, Turkey, Turkey, 2Gaziosmanpasa University, Faculty of Medicine-Clinical Biochemistry, Turkey, 3Tokat State Hospital, Clinical Biochemistry, 4Cankiri State Hospital, Internal Medicine, Turkey, 5Nazilli State Hospital, Internal Medicine, Turkey

 

Intro: Type 1 Diabetes Mellitus (DM)  is a chronic auto-immune disease characterized by distruction of pankreatik β cells by T cells resulting in lack of insüline and hyperglycemia.The aim of this study was to evaluate the relationship between Type 1 DM and the antiapoptotic gene Bcl2

Materials and Method: Patients diagnotised with Type 1 DM  visiting Tokat Public Hospital Clinic of Endrochrinology and Metabolic Diseases  between December 2013 and February 2014 and a Control Group of Healthy individuals were enrolled in this study. The study was designed as a cross-over: observational study. Enrolled patients’  on-going drug regiments comorbid diseases, micro and macro vascular  complications and laboratory data were  recorded. Elissa method  was used to analyse Bcl-2 levels. All statistical analyses were performed using SPSS v.16.0. Student T test was used to analyze inter-group difference. Correlation estimations of groups were performed using Pearson correlation analysis. The chi-square test was used to compare rates between groups. Statistical significance was set at P < 0.05

Results:Twenty-five Type 1 DM patients and 24 Healthy individuals were included in the study. The average age of Type 1 DM patients was 27.84±7.28 while that of the Control group was 24.75±5.77 and was no significant statistical difference between the two groups (p>0.05). The average duration of illness for Type-1 DM patients  was 8±5.52 years. The Bcl-2 level of Type-1 DM patients was 0.138 while that of the Control group 0.155 ng/dl and there was no significant difference between the two groups (p>0.05).Correlation between Bcl-2 levels and HbA1c in all the groups was not established (r=0.123, p=0.381). There was no correlation between the level of Bcl-2 and HbA1c within the Type 1 DM patients’ group. There was no correlation between the duration of illness and the levels of Bcl-2  in Type 1 DM patients (r=-0.144, p=0.492).

Discussion:Literature search  reveals there are contrasting results regarding the  relationship between Type 1 DM and Bcl-2. In our study, significant differences between the Type 1 patient s and the Healthy Control group wee not observed. With this study, we observed that there is no relationship between Type 1 DM and the antiapoptotic Bcl-2 gene.

 

Nothing to Disclose: MU, ZCO, MK, BA, VY

21154 7.0000 FRI-643 A Relationship Between Type-1 Diabetes Mellitus and Antiapoptotic Gene BCL-2 Expression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 636-644 6097 1:00:00 PM Diabetes Genetics and Epidemiology Poster


Mustafa Unubol*1, Muzaffer Katar2, Zeliha Cansel Ozmen3, Volkan Yazak4 and Bilal Acar5
1Adnan Menderes University Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology, Aydın, Turkey, Turkey, 2Tokat State Hospital, Clinical Biochemistry, 3Gaziosmanpasa University, Faculty of Medicine-Clinical Biochemistry, Turkey, 4Nazilli State Hospital, Internal Medicine, Turkey, 5Cankiri State Hospital, Internal Medicine, Turkey

 

Objective:Type 1 diabetes mellitus (T1DM) is associated with a high risk of cardiovascular (CV) events irrespective of the presence of other traditional risk factors. Myeloperoxidase (MPO) has an important role in both processes of inflammation and oxidative stress. Myeloperoxidase is secreted by activated neutrophils and macrophages, and has been known as an inflammatory biomarker. MPO has been identified as a noticeable contributor to the process of progress, propagation and complication of atherosclerosis. Myeloperoxidase (MPO) is a predominantly leukocyte-derived enzyme, involved in the initiation, destabilization of atherosclerotic plaque and genesis of acute coronary syndromes. Plasma MPO levels have been positively associated with coronary artery disease (CAD) and risk of a subsequent cardiac event. In this study, we aimed to evaluate plasma myeloperoxidase  Level in non-complicated T1DM.

Method:Twenty-four patients with T1DM and 29 healthy controls were involved in the study. Type 1 Diabetic Patients whose confirmed diagnosis was less than 5 years and without any identifiable micro and macro-vascular complications were included in the study. Fasting venous blood samples were collected from all participants. Serum myeloperoxidase, HbA1c, and fasting glucose  levels were measured.

Results:There was no significant difference in plasma myeloperoxydase levels between healty control groups and patients with T1DM: 7.85 ± 3.92 ng/mL and 8.03 ± 1.84 ng/mL, respectively. No correlation was noted between HbA1c and plasma myeloperoxidase levels (p=0.596, r=0.074).

Conclusion: In conclusion, plasma MPO levels were similar in healty control groups and in patients with T1DM. MPO levels in T1DM Patients without any complications were found to be normal. Plasma MPO level can be used as an independent prognostic predictor for long term incident major adverse cardiovascular event in stable CAD patients medically followed.When several biomarkers were compared to each other, elevated MPO concentration were found to be highly sensitive predictors of future cardiovascular events. It is a known fact that complications develop in patients who have been diagnotised with T1DM for more than 5 years. Our failure to identify increase in MPO levels in the patients group in comparison to the healthy group was thought to be compatible to the absence of  atherosclerotic cardiovascular complications. We think that future studies should aim at evaluating the relationship between development of complications in T1DM patients and MPO.

 

Nothing to Disclose: MU, MK, ZCO, VY, BA

21194 8.0000 FRI-644 A Myeloperoxidase Plasma Level in Type-1 Diabetic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM FRI 636-644 6097 1:00:00 PM Diabetes Genetics and Epidemiology Poster


Yoshiyu Takeda*1, Yoshimichi Takeda2, Takashi Yoneda2, Mitsuhiro Kometani2, Shigehiro Karashima2 and Atsushi Hashimoto2
1Kanazawa Univ Sch of Med, Ishikawa, Japan, 2Kanazawa University, Kanazawa, Japan

 

Objective: We have reported that angiotensinogen gene expression was increased in the hypertrophic hearts of salt-sensitive hypertensive (SSH) rats. The methylated status of the promoter region of angiotensinogen gene influences its gene expression (1). In order to clarify the relationships between the methylation status of angiotensinogen gene and high salt diet, we examined the three parts of CpG islands of angiotensinogen gene in the hearts of SSH rats.

Methods: Five male SSH rats were fed with high salt diet (8% NaCl) or normal salt diet (0.45%) for 8 weeks. Plasma aldosterone and PRA were measured at 8 weeks. The DNA and RNA were extracted from the hearts of each experimental group. Histological analysis of the hearts was done. The methylation status was estimated by bisulfite sequencing. The expression levels of mRNA of angiotensinogen were measured by quantitative real time PCR

Results: High salt diet significantly increased blood pressure and heart weight compared with normal salt diet (p<0.05). Plasma aldosterone and PRA were decreased. The mRNA levels of angiotensinogen in the hearts were significantly increased (p<0.05) in the high-salt diet group. Hypomethylated status of the angiotensinogen gene was seen in the hearts of SSH rats fed with high salt diet.

Conclusion: Epigenetic influence of high salt diet may affect gene expression of angiotensinogen and partly induced hypertrophy of the hearts of SSH rats.

(1) Feng et al. Hypertension 2014; 63:281-288

Nothing to disclose: YT, YT, TY, SK, MK, AH

 

Nothing to Disclose: YT, YT, TY, MK, SK, AH

21486 1.0000 FRI-522 A Epigenetic Effect of High Salt Diet on Angiotensinogen Gene in Salt-Sensitive Hypertensive Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Yasufumi Seki*, Satoshi Morimoto, Masaki Ryuzaki, Yuki Mizuguchi, Michita Niiyama, Naohiro Yoshida, Kanako Bokuda, Daisuke Watanabe, Takashi Ando and Atsuhiro Ichihara
Tokyo Women's Medical University, Tokyo, Japan

 

(Pro)renin receptor [(P)RR] regulates tissue renin-angiotensin system, which is involved in end-organ damages in diabetes and hypertension. Its extracellular domain, called as soluble (P)RR [s(P)RR], is shedded by furin and is secreted into the bloodstreem. We previously reported that in adult growth hormone (GH) deficiency (GHD) patients, serum s(P)RR concentration was elevated and positively correlated with body weight (1). Because GHD causes visceral obesity, we hypothesized that GHD state elevates expression of (P)RR in adipose tissue to increase serum s(P)RR level. Thus, we investigated whether (P)RR expression is increased in adipose tissue in a GHD mouse model induced by GH receptor blockade. We subcutaneously injected 40 mg/kg of pegvisomant, a GH receptor antagonist, (Peg group, n=6) and saline (Saline group, n=6) into 9 week-old C57BL/6 mice for 5 days.  After the treatments, body weight and serum concentrations of s(P)RR and IGF-1 measured by ELISA were compared between the two groups. In addition, mRNA expression levels of (P)RR and furin in liver, kidney, white adipose tissue (WAT), and brown adipose tissue (BAT) were determined by RT-PCR and were compared between the groups. Body weight was not significantly different between Peg and Saline groups. Serum IGF-1 concentration was significantly lower in Peg group than Saline group (100.5±8.0 vs 364.4±248.9 ng/mL, P=0.04). Serum s(P)RR concentration was significantly higher in Peg group than Saline group (6.18±2.26 vs 3.87±1.47 ng/mL, P=0.04). The (P)RR mRNA expression level in WAT was significantly higher in Peg group than Saline group (1.65±0.15 vs 1.13±0.21, P=0.03),  while its level was not significantly different between the groups in BAT, liver, or kidney. The furin mRNA expression level was not significantly different between two groups in all obtained organs. In conclusion, we showed that GH receptor blockade increased (P)RR mRNA expression in WAT. These results suggested that the increase in serum s(P)RR level might be, at least in part, due to elevated expression of (P)RR in adipose tissue in GHD patients.

 

Nothing to Disclose: YS, SM, MR, YM, MN, NY, KB, DW, TA, AI

18975 2.0000 FRI-523 A Growth Hormone Receptor Blockade Increases Expression of (Pro)renin Receptor in Adipose Tissue 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Maheshinie Rajapaksha*1, Jasmeet Kaur1, Kevin J Pawlak1, Veena Thapliyal1, Randy M Whittal2 and Himangshu S Bose1
1Mercer University, Savannah, GA, 2University of Alberta, Canada, AB, Canada

 

The Outer Mitochondrial membrane Translocase 40 (TOM40) complex functions as an entry gate for most mitochondrial proteins. TOM40 complex is composed of core complex consists of Tom40, Tom22, Tom5 and Tom7, and peripheral receptor subunits Tom20 and Tom70. Tom22 spans the outer membrane by its central TM segment with its N- terminal and C- terminal domains exposed to the cytosolic and IMS respectively. In the present study we describe the interactions of Tom22 with the IMM resident 3β-hydroxysteroid dehydrogenase 2 (3βHSD2), which is responsible for catalyzing two key steps in steroid metabolism: the conversion of Pregnenolone (Preg) to progesterone (Prog) and dehydroepiandrosterone to androstenedione. Chemical crosslinking experiments with mitochondria isolated from both steroidogenic MA-10 cells and mouse adrenal tissues showed that Tom22 is interacting with 3βHSD2. We also observed that the degree of interaction of the two proteins was elevated when mice were injected with chemical chaperone Lauryl maltoside (LM). Native page followed by mass spectrometric analysis reviled that 3βHSD2 and Tom22 formed tighter complexes when chaperones are present. These observations were further confirmed by Co-IP and sucrose density gradient experiments. Pregnenolone to progesterone synthesis of mouse adrenal mitochondria was enhanced in the presence of chemical chaperones, which may attribute to the increased interactions between 3βHSD2 and Tom22. In summery we have shown that Tom22 and 3βHSD2 interactions play a major role in inner mitochondrial steroidogenesis.

 

Nothing to Disclose: MR, JK, KJP, VT, RMW, HSB

19371 3.0000 FRI-524 A Tom22 Is the Crucial Regulator to Initiate Inner Mitochondrial Steroidogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Jasmin Kristianto*1, Michael Gilbert Johnson2, Abigail Radcliff2, Forum Patel2, Ryley Zastrow2, Baozhi Yuan2, Xiaohu Wang3 and Robert Daniel Blank3
1University of Wisconsin-Madison, Madison, WI, 2University of Wisconsin Madison, Madison, WI, 3Medical College of Wisconsin, Milwaukee, WI

 

Endothelin converting enzyme-1 (ECE1) catalyzes the conversion of inactive big endothelin 1 (ET1) to active ET1. Ece1 is essential in development, as homozygous Ece1 knock out (KO) mice die in utero or at birth, displaying multiple abnormalities including mandibular hypoplasia, cardiac outflow tract malformations, and enteric aganglionosis, in spite of the presence of ample tissue ET1. In contrast, increased ECE1 activity and increased circulating and/or tissue ET1 are associated with many disease states in adults, including idiopathic pulmonary fibrosis (IPF), a chronic and fatal lung disease. Treatments targeting ET1 receptors in patients with IPF have proven to be unsuccessful. Similar associations exist between elevated ET1 and disease in multiple other conditions, including pulmonary hypertension, renal hypertension and congestive heart failure. There is thus an apparent paradox between the need for ET1 in development and its harmful effects in adult disease. The lethal phenotype of Ece1 KO mice has hampered systematic study of ECE1 biology in post-natal mice. In order to address this gap, our lab developed a conditional Ece1 KO mouse, in which the gene is ablated following tamoxifen (tam) treatment. We hypothesized that ECE1 serves to localize ET1 signals to specific cell populations and is essential in adult normal physiology. We included the following control groups in our study: mice given vehicle rather than tam (group A), mice lacking the tam-inducible Cre recombinase (group B), mice harboring a normal rather than a conditional Ece1 allele (group C), and the experimental animals (group D). Animals were treated with vehicle or tam at 8-9 weeks of age. Group D showed 85-100% knock-down efficiency at mRNA level 8 weeks after tam treatment (p=0.023, n=3/group). Two weeks after treatment, group D mice had lower blood pressure compared to controls, which persisted until euthanasia at 17-20 weeks (p=0.004). By 17 weeks of age, group D mice have significantly reduced body weight compared to controls (p=0.005). Between 17-20 weeks of age, 50% of the ECE1-/- mice have impaired breathing, pectus excavatum, cardiac arrhythmia, reduced cardiac output, and depleted adipose tissue mass. Histological examination revealed eosinophilic crystalline pneumonia in the group D mice. This constellation of findings is consistent with development of IPF in the experimental mice, and we are presently analyzing collagen content and cross-linking. Our findings demonstrate that Ece1 ablation in post-natal animal results in a lethal phenotype, suggesting that ectopic activation of ET1 by other tissue proteases, rather than ET1 activation by ECE1, is the primary mechanism underlying the association of increased ET1 signaling in disease states.

 

Nothing to Disclose: JK, MGJ, AR, FP, RZ, BY, XW, RDB

21931 4.0000 FRI-525 A Ece1 is Essential in Normal Adult Physiology 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Brian P Bostick1, Javad Habibi1, Guanghong Jia1, Timothy L Domeier1, Michelle D Lambert1, Annayya R. Aroor1, Ravi Nistala1, Shawn B Bender1, Mona Garro1, Melvin R Hayden2, Lixin Ma3, Camila Manrique Acevedo1 and Vincent G. DeMarco*1
1University of Missouri, Columbia, MO, 2Univ of Missouri Columbia, Camdenton, MO, 3University of Missouri - School of Medicine

 

Background: Overnutrition/obesity predisposes individuals, particularly women, to cardiac diastolic dysfunction (DD), an independent predictor of future cardiovascular disease. Evidence-based therapies for treatment of obesity-related DD are lacking but previous evidence demonstrated that low dose mineralocorticoid receptor (MR) antagonism with spironolactone (Spiro) improved DD in a model of renin-angiotensin-aldosterone system (RAAS)-dependent hypertension. Since obesity may be associated with increased aldosterone levels, especially in females, we examined whether low dose Spiro treatment could be used to prevent DD associated with overnutrition/obesity in female mice. 

Methods and Results:  We examined the impact of MR blockade in female C57BL6J mice fed a high-fat, high-sugar Western Diet (WD) known to induce weight gain, insulin resistance and DD for 16 weeks with or without Spiro.  WD-fed mice exhibited increased body weight, body/visceral fat weight, and insulin resistance but similar blood pressures compared to mice fed a control diet (CD). Compared to untreated WD fed mice, WD fed mice administered Spiro (1 mg•kg-1•day-1) prevented the development of diastolic function as indicated by decreased isovolumic relaxation time and improvement in the myocardial performance (<Tei index) and the septal annular velocity (<E’/A’ ratio), assessed by echocardiography, as well as decreased diastolic relaxation time and increased diastolic initial filling rate assessed by magnetic resonance imaging.  Spiro also prevented left ventricular hypertrophy, interstitial fibrosis (collagen 1: collagen 3 ratio), and oxidative stress (myocardial 3-nitrotyrosine staining). Immune markers of cardiac macrophage polarization indicated increased pro-inflammatory M1 polarization with consumption of a WD and a shift to increased M2 polarization with Spiro. Spiro did not improve systemic insulin resistance or reduce blood pressure.

Conclusions: Consumption of WD-induced DD by increasing oxidant stress, M1 macrophage polarization and myocardial fibrosis. MR antagonism with Spiro reduced myocardial M1 polarization/increased M2 polarization and reduced oxidative stress and fibrosis. This work supports a novel BP-independent mechanism for Spiro treatment of WD-induced DD in females.

 

Nothing to Disclose: BPB, JH, GJ, TLD, MDL, ARA, RN, SBB, MG, MRH, LM, CM, VGD

21288 5.0000 FRI-526 A Mineralocorticoid Receptor Blockade Prevents Diastolic Dysfunction in Western Diet Fed Female Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Namita G. Hattangady*1, Lucy Yuan1, Celso E. Gomez-Sanchez2 and William E. Rainey1
1University of Michigan, Ann Arbor, MI, 2University of Mississippi Medical Center, Jackson, MS

 

Background: Primary aldosteronism (PA), characterized by renin-independent aldosterone production, has recently been shown to be caused by mutations in the inward rectifying K+ channel (KCNJ5). A role for calcium signaling has been determined in mutated KCNJ5 (mKCNJ5)-mediated elevations in aldosterone synthase (CYP11B2) gene expression and aldosterone production. However, very few studies have demonstrated the effects of mKCNJ5on acute events and chronic mechanisms of aldosterone production.

Hypothesis: Mutated KCNJ5 stimulates acute and chronic rate-limiting steps of aldosterone production, including the activation of steroidogenic acute regulatory protein (StAR) protein, as well as transcription factors, NURR1 and ATF2, that regulate the expression of CYP11B2

Methods: The human adrenocortical cell line with doxycycline (doxy)-inducible mKCNJ5, harboring the T158A mutation (HAC15-doxy-mKCNJ5), was generated and utilized for this study. Gene expression and protein levels were investigated by real-time qPCR expression and western blotting, followed by semi-quantitative densitometry.

Results: Doxy incubation caused a dose- and time-dependent increase in mKCNJ5 and CYP11B2 mRNA and protein levels. Transcript levels peaked at 36 h for mKCNJ5, and at 60 h for CYP11B2. A corresponding increase in aldosterone production was seen at 60 h of doxy treatment. Mutated KCNJ5 also increased the expression of NURR1 mRNA (in a time-dependent manner) and nuclear protein (at 48 h doxy incubation). Doxy incubation also increased the phosphorylation/activation of nuclear-localized ATF2 protein after 18 h doxy treatment. These stimulatory effects of mKCNJ5 were inhibited by L-type Ca2+channel blocker, verapamil. Acute events regulating aldosterone production, including increase in 30 kDa total StAR and phosphorylated StAR protein, were also stimulated by mKCNJ5.

Conclusion: Overall, mKCNJ5 increases CYP11B2 expression and aldosterone production by up-regulating acute and chronic regulatory events in the adrenocortical carcinoma cell line.  This study also bolsters the use of verapamil as an efficient therapy in abrogating mKCNJ5-mediated aldosterone excess in PA.

 

Disclosure: WER: Scientific Board Member, Atterocor. Nothing to Disclose: NGH, LY, CEG

20654 6.0000 FRI-527 A Effects of Mutated KCNJ5 on Acute and Chronic Regulation of Aldosterone Synthase (CYP11B2) Expression and Aldosterone Production 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Urs Daniel Lichtenauer1, Phillip Schmid2, Andrea Osswald3, Ingrid Renner-Mueller4, Martin Reincke5, Richard Warth6, Eckhard Wolf4 and Felix Beuschlein*5
1Med. Klinik IV, Munich, Germany, 2Med. Klinik IV, 3Medizinische Klinik und Poliklinik IV, 4Institute of Molecular Animal Breeding and Biotechnology, 5Klinikum der Universität München, Ludwig-Maximilian University, Munich, Germany, 6Universitat Regensburg, Regensburg, Germany

 

Hypertension is a major cardiovascular risk factor that affects large proportions of the general population. Primary aldosteronism (PA) is considered the most common form of secondary hypertension. Recently, a number of genetic alterations have been identified as causative events for sporadic and familial cases of PA including mutations in KCNJ5, ATPA1A/ATPA2B and CACNA1D. While these findings highlight pathophysiological mechanisms that result in excessive aldosterone secretion appropriate in vivo models are missing.

Three different vectors containing the full length human KCNJ5 gene as the wild-type sequence as well as the KCNJ5G451A and the KCNJ5T503G mutants, respectively, were obtained. The expression vectors included a 0.5 Mb fragment of the promoter region of the Akr1b7 gene, which had been demonstrated to be active specifically in the adrenal cortex of transgenic animals. Following this approach transgenic animals were generated that express human wild-type (KCNJ5wt) and mutated KCNJ5 (KCNJ5G451A and KCNJ5T503G), respectively, in the adrenal cortex. Upon genotyping animals (n=49 females and n=41 males with minimum n=8 per genotype) were euthanized at 8 weeks of age and subjected to initial morphological and phenotypical characterization. There were no significant differences in body weight and kidney weight between genotypes within female and male animals. Interestingly in female animals combined adrenal weight was significantly lower in KCNJ5G451A (4.59±0.18mg) in comparison to KCNJ5wt (5.27±0.22mg, p=0.03) while in male animals a tendency towards higher adrenal weight was evident (4.37±0.19 vs. 3.72, p=0.05). Adrenal weight of KCNJ5T503G was not different to that of KCNJ5wt animals in either gender group. Within this age group, no gross morphological alterations in transgenic animals were observed. On a functional level in female mice adrenal expression levels of Cyp11b2 – as the rate limiting step for aldosterone synthesis – was significantly higher in KCNJ5T503G mice (150.8±5.8%, p=0.005) and showed a tendency for higher expression in KCNJ5G451A animals (172.6±38.3%, p=0.12) in comparison to KCNJ5wt (100.0±13.0%). No differences in adrenal Cyp11b2 expression was observable in male animals.

These preliminary data demonstrate a likely adrenal phenotype induced by transgenic expression of mutated KCNJ5 as commonly identified in patients with sporadic PA. Upon further phenotypic characterization these models have the potential to provide functional insights into the development of aldosterone excess and could be utilized as a humanized disease model for specific pharmacological intervention.

 

Nothing to Disclose: UDL, PS, AO, IR, MR, RW, EW, FB

20903 7.0000 FRI-528 A Characterization of in Vivo Models of KCNJ5 Dependent Hyperaldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Mitsuhiro Kometani*, Takashi Yoneda, Shigehiro Karashima, Masashi Demura and Yoshiyu Takeda
Kanazawa University, Kanazawa, Japan

 

Background: KCNJ5 gene mutation has been identified frequent mutations of aldosterone producing adenoma, especially in Japanese patients with aldosterone producing macroadenoma. However, the frequency of the KCNJ5 gene mutation in aldosterone producing microadenoma (micro APA) and the difference of the clinical characteristics between micro- and macro APA with the KCNJ5 gene mutation is still unknown.

Objection: To investigate the mutations of the KCNJ5 gene in Japanese patients with micro APA and the comparison of the clinical characteristics between micro- and macro APA with the KCNJ5 gene mutation.

Subjects: 24 patients, 9 of micro APA (4male, 5female) and 15 of macro APA (8male, 7female).

Results: Of the 9 patients with micro APA, 7(77.8%) had the somatic mutations of KCNJ5 gene. Contrastively, of 15 patients with macro APA, 13(86.7%) had the somatic mutations of KCNJ5 gene. The serum potassium level in the patients of macro APA with KCNJ5 gene mutation (3.2±0.8mEq/L, n=13) was lower than that of micro APA (4.0±0.6mEq/L, n=7) (p<0.05). There are no significant differences of age (54±13 vs 49±14yo), blood pressure (156±16/91±14 vs 156±36/96±20mmHg), plasma aldosterone concentration (164±73 vs 259±141pg/mL) and plasma renin activity (0.3±0.2 vs 0.3±0.2ng/mL/h) between micro- and macro APA with KCNJ5 gene mutation(n=7 vs 13).

Conclusion: The tumor size influenced only the serum potassium level of APA with the KCNJ5 mutation. Further studies are necessary to clarify the micro-APA.

 

Nothing to Disclose: MK, TY, SK, MD, YT

20346 8.0000 FRI-529 A Analysis of the Clinical Characteristics of Primary Aldosteronism Due to Aldosterone Producing Microadenoma with KCNJ5 Gene Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Jamie Laura Benham*1, Maysoon Eldoma2, Derek J Roberts2, Doreen Rabi2 and Gregory A Kline2
1University of Calgary Department of Medicine, Calgary, AB, 2University of Calgary, Calgary, AB, Canada

 

Background: Primary aldosteronism (PA) is the leading cause of secondary hypertension. While unilateral primary aldosterone excess (a.k.a., aldosterone-producing adenoma) is often treated with adrenalectomy, variable hypertension cure rates following this procedure have been reported. 

Aim: The objective of this systematic review and meta-analysis was to determine the prevalence of cure of hypertension (i.e., hypertension resolution without the aid of antihypertensive medications) after adrenalectomy for patients with PA.

Methods: We searched Medline, Embase, and the Cochrane Library without restrictions. Two investigators independently reviewed all identified abstracts and potentially relevant full-text articles and extracted data. We included cohort studies that enrolled adults and reported the proportion of cure of hypertension following adrenalectomy. We calculated the pooled prevalence of cure using DerSimonian and Laird random-effects models. Heterogeneity was examined using stratified meta-analyses.

Results: Among 1928 abstracts identified during the search, we included 23 articles in the systematic review. The overall pooled prevalence of cure following adrenalectomy reported was 50% (CI = 0.48 to 0.53).  The data were very heterogeneous (I2 = 90.6%), with reported cure rates varying from 0 to 81%. The pooled prevalence of cure following adrenalectomy for aldosterone producing adenomas was 48% (CI = 0.43 to 0.53) compared with 27% (CI = 0.10 to 0.44) for pathology that included adrenal hyperplasia. When analyzed by geographical location, the prevalence of cure ranged from 24% in Switzerland (CI = 0.14 to 0.35) and Poland (CI = 0.06 to 0.42) to 66% in the Czech Republic (CI = 0.52 to 0.79).

Conclusion: This study suggests that adrenalectomy for unilateral forms of PA results in highly variable rates of hypertension resolution, with an overall prevalence of hypertension resolution of approximately 50%. The high rate of hypertension resolution supports surgical therapy as a valuable primary therapy for PA.

 

Nothing to Disclose: JLB, ME, DJR, DR, GAK

19487 9.0000 FRI-530 A The Prevalence of Hypertension Resolution Following Adrenalectomy for Primary Aldosteronism: A Systematic Review and Meta-Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Gerard A Browne*1, Tomas Griffin2, Paula OShea3 and Michael Conall Dennedy1
1National University of Ireland, Galway, Galway, Ireland, 2South Infirmary Victoria University Hospital, Cork, Ireland, 3Galway University Hospital, Galway

 

Context: Primary hyperaldosteronism (PHA) prevails in up to 20% of individuals with essential hypertension, but often presents a diagnostic challenge due to difficulty in interpreting the aldosterone renin ratio (ARR) largely due to anti-hypertensive medication interference. Interpretation of the ARR in the context of beta blockers presents a particular challenge and may produce false positive results due to renin suppression.

Design: We investigated the effects of beta blocker withdrawal on ARR in a cohort taking long term beta blocker therapy for blood pressure (BP) control. Hypertensive individuals with suboptimally controlled blood pressure on a combination of beta blockers, thiazide diuretics and ACEi/ARB were recruited and followed over 8 weeks. Beta blockers were withdrawn at the first visit. Serial measurements of BP were performed and patients had blood drawn serially for measurement of plasma renin activity (PRA), renin mass, aldosterone and electrolytes. BP was optimised at each visit by maximising non-renin-suppressing antihypertensive agents. Main outcome measures were ARR, renin and aldosterone concentrations following beta-blocker withdrawal. 50 individuals were enrolled under informed consent and ethical approval.

Results: Interpretation of ARR on beta-blockade gave a false positive diagnosis of PHA in 22%. Beta blocker withdrawal produced a rapid (>50%) recovery of PRA (F=28.6; p<0.0001) and renin mass (F=18.4; p=0.0007) which reached significance within 2 weeks of withdrawal and return of the ARR to normal range in all individuals (F=29.3; p=0.0003). Aldosterone remained unchanged throughout the duration of the study (F=2.5; p=0.1). BP remained unchanged throughout the duration of the study (F=1.0; p=0.4). Both renin mass (r2=0.67; p<0.05) and PRA (r2=0.69; p<0.05) were inversely correlated with beta blocker dose.

Conclusion: While "clean screens" using the ARR are seldom possible, our results demonstrate a high false positive rate for PHA in those taking beta blockers. Beta blocker withdrawal was well tolerated, blood pressure control easily optimised and the ARR more accurate within 2 weeks of withdrawal. We provide convincing data to support beta blocker withdrawal, 2 weeks in advance of screening for PHA.

1. Ahmed AH, Gordon RD, Taylor P, Ward G, Pimenta E, Stowasser M. J Clin Endocrinol Metab. 2010 Jul;95(7):3201–6.

 

Nothing to Disclose: GAB, TG, PO, MCD

19561 10.0000 FRI-531 A Rnaldo: The Effects of Blocker Withdrawal on Renin and Aldosterone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Nada El Ghorayeb*, Ping Shi Zhu, Isabelle Bourdeau and Andre Lacroix
Centre hospitalier de l’Université de Montréal (CHUM), Université de Montréal, Montreal, QC, Canada

 

Background: Confirmation of adequate adrenal vein catheterization (selectivity) is essential before assessment of lateralization to differentiate unilateral from bilateral etiologies of primary aldosteronism (PA). Selectivity has been based on the ratio between the cortisol concentrations in each adrenal vein sample in comparison to a peripheral vein sample (Ca/Cp).  However, in certain centers, only basal samples are obtained without ACTH stimulation, and the various Ca/Cp ratios utilised have provided limited sensitivities of adequate selective sampling.

Objectives: To assess sensitivity and specificity of basal adrenal to peripheral ratio for aldosterone (Aa/Ap), cortisol (Ca/Cp), and combination of cortisol or aldosterone (combined ratio) to detect catheter selectivity in adrenal venous samplings (AVS) at different cut-offs.

Methods: 158 AVS obtained in 160 consecutive patients with confirmed PA (49 women and 111 men, mean age 53.6 years) were included in this analysis. Cortisol and aldosterone levels were measured simultaneously from both adrenal veins as well as from the left iliac vein every 5 minutes, 2 times before (basal) and 3 times after 250 µg ACTH 1-24 IV bolus. Selectivity was defined by a Ca/Cp or Aa/Ap ≥ 5 in at least one sampling after ACTH.  Sensitivity and specificity to detect AVS selectivity were calculated for basal Ca/Cp, Aa/Ap, and combined ratios for 3 most common cut-offs reported in the literature; all sensitivity and specificity were calculated for the mean value of the 2 basal samplings. A subgroup analysis was realized in 80 patients who underwent unilateral adrenalectomy based on lateralization criteria.

Results: Sensitivity and specificity for ≥ 3, ≥ 2, and ≥ 1.1 cut-offs ratios to detect AVS selectivity were respectively 50,3% and 100%, 71,0% and 100%, 98,6% and 76.9% for Ca/Cp; 60,0% and 100%, 70,3% and 100%, 94,0% and 54% for Aa/Ap; 75,2% and 100%, 88,3% and 100%, 99,3% and 46,2% for combined ratio. In a subgroup analysis done on patients with PA who underwent unilateral adrenalectomy, sensitivity and specificity for ≥ 3, ≥ 2, and ≥ 1.1 cut-offs to detect AVS selectivity were respectively 50,7% and 100%, 70.7% and 100%, 96% and 80% for Ca/Cp; 52% and 100%, 60% and 100%, 90.7% and 80% for Aa/Ap; 66.7% and 100%, 81,3% and 100%, 97.3% and 60% for combined ratio.

Conclusion:  The basal combined ratio has the best sensitivity to detect AVS selectivity at all cut-offs and the ≥ 2 cut-off has the best sensitivity for a specificity of 100% for all ratios even in the patients who underwent unilateral adrenalectomy. Examining the aldosterone ratio in addition to the cortisol ratio in basal samples obtained without ACTH stimulation can improve the determination of adequate selectivity of adrenal vein sampling.

 

Nothing to Disclose: NE, PSZ, IB, AL

19492 11.0000 FRI-532 A The Adrenal to Peripheral Aldosterone Ratio Can Also be Useful in Addition to the Cortisol Ratio to Determine Selectivity during Adrenal Vein Sampling for Primary Aldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM FRI 522-532 6100 1:00:00 PM Renin-Angiotensin-System Poster


Maria Kristina Parr*1, Gerhard Wolber1, Alexandra Naß1, Gabriella Ambrosio1, Francesco Botrè2 and Patrick Rene Diel3
1Freie Universität Berlin, Berlin, Germany, 2Laboratorio Antidoping FMSI, Rome, Italy, 3German Sports University Cologne, Cologne, Germany

 

Dietary supplements (DS) containing ecdysterone (ECDY) are widely marketed as legal alternative to anabolic steroids. As often seen for DS insufficient quality control results in substandard quality of these products (1). In our study also products labelled to contain ECDY were found to contain no ECDY at all.

Anabolic effects of ECDY are reported; however, in receptor-binding assays, no significant binding affinity of ECDY to the androgen receptor (AR) could be detected (2). Recently the involvement of Estrogen Receptor (ER)β in ECDY mediated skeletal muscle hypertrophy was shown by our group (3).

To confirm these findings ECDY was docked into crystal structures of the ERα, ERβ and AR (PDB entries 3UUD (4), 3OLL (5) and 2AM9 (6), respectively). These structures represent complexes with Estradiol for the ERs and Testosterone for AR to make sure they represent the protein conformation relevant for agonism. The docking experiment was performed using the software GOLD (7) allowing side chain flexibility in the binding regions to allow adaptions to the significantly larger ligand ECDY. Binding poses were analyzed using LigandScout (8,9).

The docking pose for ECDY in AR shows a crowded binding site compared to the Testosterone complex. At those positions where methyl groups are found in the natural ligand Testosterone, hydroxyl groups sterically interfere with the receptor in case of ECDY. In addition, a water molecule mediating important interactions in the testosterone complex is replaced by a methyl group for the ECDY docking pose resulting in an unfavorable interactions pattern.

Both estrogen receptor isoforms offer a binding side shape more suitable to accommodate ECDY. Docking poses in both subtypes share several interactions. Three additional hydrogen bonds are exclusively formed in the docking pose of ECDY in ERβ, which can explain the experimentally observed isoform preference (3): In ERβ the ligand can adapt a conformation close enough to Met343 and form a hydrogen bond with the hydroxyl group in position 2 of ECDY. Additionally, two more hydrogen bonds with the terminal hydroxyl group to the backbone of the beta subtype (Leu346, Phe404 and Leu387, respectively) could be observed.

 

Nothing to Disclose: MKP, GW, AN, GA, FB, PRD

21233 1.0000 FRI-270 A ER-Beta Mediated Action of Dietary Supplement Ingredient Edcysterone Confirmed By Docking Experiments 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Shigeru Suzuki1, Darrell E. Hurt2 and Tomoshige Kino*1
1NICHD/NIH, Bethesda, MD, 2NIAID/NIH, Bethesda, MD

 

Familial or sporadic generalized glucocorticoid resistance syndrome is a rare, genetic condition characterized by partial end-organ insensitivity to glucocorticoids. Most of the cases with this syndrome are caused by inactivating mutations in the human glucocorticoid receptor (GR) gene, which generate mutant receptors harboring single amino acid replacement in the ligand-binding domain. The amino acid replacements then impair molecular actions of GR, such as the ability to bind glucocorticoids and to activate transcription of glucocorticoid-responsive genes. We performed molecular dynamics simulations to 10 known pathologic GR mutants with single point mutations and reported in the previous meeting (SUN-339, the 95th Annual Meeting and EXPO) that reduced affinity to ligand is a primary character of these mutant receptors, and their defect in dexamethasone (DEX)-binding (ligand-binding pocket: LBP) activity is driven primarily by conformational mismatches and subsequent reduction/loss of ionic interaction between their arginine (R) 611 and the carbonyl oxygen at carbon-3 of DEX. Since reduced sensitivity to glucocorticoids in some patients with this syndrome is not completely resolved even with the use of high doses of strong glucocorticoids such as DEX (SUN-459, the 94th Annual Meeting and EXPO), we explored potential therapeutic ligands that could fit more tightly to deformed LBP of mutant GRs and strongly activate their transcriptional activity. Structural simulation indicated among some candidate compounds that deacylcortivazol (DAC), a pyrazilosteroid with potent GR agonistic activity harboring the large phenylpyrazole group on its steroid A-ring instead of the carbonyl oxygen (at carbon-3), fit tightly to LBP of pathologic GR mutants, because this structural moiety filled a large space formed by deviated R611 of mutant receptors. In agreement with above structural results, DAC strongly activated the transcriptional activity of some pathologic GR mutants (D641V, R714Q and V729I) on a glucocorticoid-responsive synthetic GRE-driven luciferase reporter construct in GR-defective human colon cancer HCT116 cells, to the degree equivalent to its effect on the wild type GR. Taken together, these results indicate that DAC is a promising compound for resolving reduced glucocorticoid actions observed in patients with familial/sporadic generalized glucocorticoid resistant syndrome due to its better fit to deformed LBP of pathologic mutant receptors with its large phenylpyrazole group, compared to known glucocorticoids, such as DEX and cortisol, which have a small carbonyl oxygen at their carbon-3 position. Further, computer-based structural simulation is useful for sorting out potential ligands that could adjust molecular defects of pathologic GR mutants.

 

Nothing to Disclose: SS, DEH, TK

18753 2.0000 FRI-271 A Deacylcortivazol Is a Potential Therapeutic Compound for Patients with Familial/Sporadic Generalized Glucocorticoid Resistance Syndrome with Its Property to Activate Strongly Their Mutated Glucocorticoid Receptors: Usefulness of Computer-Based Structural Simulation for Identifying Chemical Compounds That Fit to Deformed Ligand-Binding Pocket 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


J Dinny Graham1, Audrey Silvestri1, Tram B Doan1, Britta M Jacobsen2, Kathryn B Horwitz3 and Christine L Clarke*1
1University of Sydney, Westmead Millennium Institute, Westmead NSW, Australia, 2University of Colorado Denver, Aurora, CO, 3University of Colorado, Anschutz Medical Campus, Aurora, CO

 

The ovarian hormone progesterone is a critical regulator of normal female reproductive physiology and is essential for normal breast function. However, exposure to progesterone analogues in hormone replacement therapy confers an increased risk of breast cancer. Progesterone effects are mediated by its nuclear receptor (PR), which is expressed as two isoforms, PRA and PRB. Binding to hormone elicits receptor dimerization and binding to genomic DNA to regulate transcription of target genes. PR forms both homodimers and heterodimers and all three dimer species are transcriptionally active. There is considerable in vitro evidence that PRA and PRB have distinct transcriptional activities. In vivo, they have been shown to play different tissue-specific roles, with PRB driving progesterone-dependent mammary ductal development in the mouse. They are equivalently expressed in the normal human breast; however that balance is often disrupted in cancer resulting in a predominance of one isoform, most often PRA, resulting in an altered transcriptional response to progestins. To understand the effects of shifting PR expression towards a single isoform we conducted ChIP-seq in breast cancer cells expressing PRA, PRB, PRA+PRB, and in cells where PRA was induced to become predominant. Shifting from PRB only or equivalent PRA and PRB expression to PRA predominant or exclusive expression resulted in a 2-3 fold increase in the number of sites bound by PR in response to progestin. The majority of sites bound by the PRB homodimer were also bound by PRA, however many additional sites were bound only by the PRA homodimer or when PRA was predominant. Examination of the different classes of binding sites revealed a conserved progesterone response element that was similar regardless of the PR dimer bound. Paradoxically, transcriptional profiling revealed that PRA did not regulate more transcriptional targets than PRB in response to progestin. At 6h treatment PRB regulated 4 fold more unique targets than PRA, however more transcripts were uniquely regulated by PRA at 24h, suggesting altered kinetics of PRA regulation. Enrichment of transcriptional cofactor motifs, such as the known partner FOXA1, was stronger in PRB unique sites than in those unique to PRA. Our data suggest that predominance of PRA in breast cancer may result in reduced fidelity of progestin response, ultimately leading to aberrant regulation at weak, non-traditional PR target sites.

 

Nothing to Disclose: JDG, AS, TBD, BMJ, KBH, CLC

21459 3.0000 FRI-272 A Progesterone Receptor B Isoform Drives Binding Fidelity and Transcriptional Efficacy in the Human Breast 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Jessica Phan* and Kevin Sinchak
California State University, Long Beach, Long Beach, CA

 

Progesterone infused into the arcuate nucleus of the hypothalamus (ARH) facilitates sexual receptivity (lordosis) within 30 minutes in ovariectomized (OVX) rats primed with 2 μg of estradiol benzoate (EB).  These rapid actions indicate that progesterone is signaling through extranuclear receptors to induce lordosis.  Estradiol upregulation of classical progesterone receptor-B (PR-B) is necessary for progesterone facilitation of sexual receptivity.  Although PR-B is a classified as a nuclear transcription factor, it is also found in the cytoplasm and plasma membrane.  Further, PR-B forms complexes with and signals through Src family kinase (Src) in peripheral tissue (1).  Progesterone facilitation of sexual receptivity is also mediated through dopamine D1 receptor (D1; 2, 3) that can signal through multiple G protein signaling cascades including Src.  We have shown that in the ARH neurons that PR and D1 are coexpressed and coexpression is increased by EB priming.  Further, we observed that Src activation in the ARH facilitates sexual receptivity that can be blocked by inhibition of either PR or D1.  Conversely, inhibition of Src in the ARH blocks both PR and D1 facilitation of lordosis, indicating that PR, D1, and Src signaling converge and are interdependent.  Therefore, we tested the hypothesis that PR-D1 and PR-Src directly interact through the formation of complexes in plasma membrane and cytoplasm of neurons in the ARH.  OVX rats were treated with either oil, 2 μg EB, or 2 μg EB + progesterone (500 μg) and proteins from plasma membrane and cytosolic fractions were extracted from ARH block dissections.  Western blot analysis revealed Src, D1 and PR-B present in the plasma membrane and cytosol.  However, co-immunoprecipitation indicates PR-B complexes with Src in plasma membrane and cytosol, but does not complex with D1.  This indicates the potential for direct PR-B signaling through Src at multiple subcellular compartments in the ARH to facilitate lordosis.  Levels of Src stay constant in whole tissue, cytoplasm, and plasma membrane ARH for oil, EB, and EB+P treated rats.  Our results suggests that the formation of PR-Src complexes can mediate rapid progesterone facilitation of sexual receptivity.  Although colocalized, D1 and PR do not form complexes.  Therefore, D1 and Src may directly interact providing the potential for a PR-Src-D1 signaling complex that would explain the interdependence of PR, D1 and Src signaling that regulates sexual receptivity.

 

Nothing to Disclose: JP, KS

21606 4.0000 FRI-273 A Progesterone Receptor-B Complexes with Src Family Kinase but Not Dopamine D1 Receptor in the Arcuate Nucleus of the Hypothalamus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Yefei Pang*, Jing Dong and Peter Thomas
University of Texas at Austin, Port Aransas, TX

 

Progesterone (P4) exerts beneficial effects on the human cardiovascular system by inducing rapid increases in nitric oxide (NO) production in vascular endothelial cells, but the receptors mediating these nongenomic P4 actions remain unclear. Using human umbilical vein endothelial cells (HUVECs) as a model, we show that P4 and the selective membrane progesterone receptor (mPR) agonist, Org OD 02-0 (02-0) bind to plasma membranes of HUVECs with high affinities, whereas the nuclear PR (nPR) agonists R5020 and medroxyprogesterone acetate (MPA) display low binding affinities. Immunocytochemical and Western blot analyses showed that mPRs (mPRα, β, γ) and PGRMC1 are expressed in HUVECs and localized on their plasma membranes. In contrast, minor expression of nPR was detected in HUVECs and was present only in the cytosolic fraction. NO levels increased rapidly in a time- and dose-dependent manner after treatment with 20 nM P4, 02-0, and a P4-BSA conjugate, but not with 100 nM R5020 and MPA, which suggests this P4 action is initiated at the cell surface and mediated by mPRα. These effects of P4 and 02-0 were abolished by treatment of cells with 0.5 µg/ml pertussis toxin, an inhibitor of inhibitory G protein (Gi) activation, which suggests this P4 action involves activation of an inhibitory G protein. P4 and 02-0 also significantly increased endothelial nitric oxide synthase (eNOS) activity, and phosphorylation of eNOS, Akt and ERK. Knockdown of mPRα expression by treatment with small interfering RNA (siRNA) blocked the stimulatory effects of P4 on NO production and eNOS phosphorylation, whereas knockdown of nPR did not alter these P4 effects, which suggests that P4 upregulation of NO synthesis in HUVEcs is solely mediated through mPRα. Treatment with PI3k/Akt inhibitors (Ly294002 and ML-9) and MAP kinase inhibitors (PD98059 and AZD6244) prevented P4- and 02-0-induced increases in Akt and ERK phosphorylation, and also blocked the stimulatory effects of P4 and 02-0 on NO production and eNOS phosphorylation. Treatment of HUVECs with wortmannin, a PI3k inhibitor, completely abolished P4-induced phosphorylation of ERK, suggesting PI3k is upstream of ERK. On the other hand AZD6244, a MEK inhibitor, significantly enhanced basal and P4-stimulated Akt phosphorylation, suggesting that ERK exerts a negative feedback action on PI3k. The results suggest that progesterone stimulation of NO production in HUVECs is mediated by mPRα and involves signaling through PI3k/Akt and MAP kinase and interactions between these two pathways.

 

Nothing to Disclose: YP, JD, PT

20625 5.0000 FRI-274 A Progesterone Increases Nitric Oxide Synthesis in Human Vascular Endothelial Cells through Activation of Membrane Progesterone Receptor Alpha (mPRalpha) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Won Chung Lim1, Moung-Kuk Shim1, Sikwan Kim2 and Young Joo Lee*1
1Sejong University, Seoul, Korea, Republic of (South), 2Konkuk University, Chungju, Korea, Republic of (South)

 

Korean Red Ginseng (KRG) is a traditional herbal medicine made by steaming and drying the fresh ginseng, leading to chemical transformation of some components by heat. It ameliorates various inflammatory diseases and strengthens the endocrine, immune, and central nervous systems. The cyclooxygenase-2 (COX-2)/prostaglandin E2 pathway in hypoxic cancer cells has important implications for stimulation of inflammation and tumorigenesis. In this study we examined the effects and the mechanism underlying KRG inhibition of hypoxia-induced COX-2 in human distal lung epithelial A549 cells. The effect of the KRG on suppression of hypoxia-induced COX-2 in A549 cells were determined by Western blot and/or qRT-PCR. The anti-invasive effect of KRG was evaluated on A549 cells using matrigel invasion assay. The activation of glucocorticoid receptor (GR) and Sirtuin1 (Sirt1) was examined by using specific inhibitors. We first observed that hypoxia induced COX-2 protein and mRNA levels and promoter activity were suppressed by KRG. Second, we observed that hypoxia-induced cell migration is dramatically reduced by KRG.  Third, we found that the effect of KRG was not antagonized by the GR antagonist RU486 implying that the effect is mediated other than GR pathway. Finally, we demonstrated that inhibition of Sirt1 abolished the effect of KRG on hypoxia-induced COX-2 suppression and cell-invasion indicating that the suppression is mediated by Sirt1. Taken together, KRG inhibits the hypoxic induction of COX-2 expression and cell invasion through Sirt1 activation. Our results imply that KRG could be effective for suppression of inflammation under hypoxia.

 

Nothing to Disclose: WCL, MKS, SK, YJL

19696 6.0000 FRI-275 A Repression of Hypoxia-Induced Cyclooxygenase-2 By Korean Red Ginseng 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Young Joo Lee* and Joon Woo Park
Sejong University, Seoul, Korea, Republic of (South)

 

The estrogen receptors plays an important role in breast cancer development and progression. Hypoxia has been shown induce ligand-independent transcriptional activation of ERa which may be intimately associated with the biology of breast carcinomas. Since phosphorylation itself affects the transcriptional activity and stabilization of ERa, we have examined the change on phosphorylation of ERa upon hypoxia treatment. Hypoxia induced phosphorylation of ERa at serine 118 residue and tyrosine 537 residue in the absence of estrogen. Phosphorylation defective ERa mutant with tyrosine-to-phenylalanine replacements at 537 residue impaired hypoxia induced ERa transcriptional activation and hypoxia-mediated ERa protein degradation showing that, phosphorylation of tyrosine 537 is involved in hypoxia induced ERa transcriptional activation and protein degradation. In addition to, the hypoxia-induced ERa-mediated transcriptional response and ERa protein degradation was dependent on Src kinase, as assessed using chemical Src inhibitor. Our study implies that hypoxia-mediated ERa transcriptional activation and ERa protein degradation via phosphorylation of ERa tyrosine 537 through Src kinase action.

 

Nothing to Disclose: YJL, JWP

19042 7.0000 FRI-276 A Estrogen Receptor Alpha Phosphorylation Under Hypoxia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Anusha Nagari*1, Shino Murakami1 and W Lee Kraus2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Medical Center, Dallas, TX

 

Estrogen receptor alpha (ERa) is a ligand-regulated, DNA-binding transcription factor that nucleates the de novo formation of enhancers across the genome in response to estrogen signaling.  ERa enhancers have all of the features that are associated with active enhancers (e.g., H3K4me1, H3K27ac, enrichment of p300/CBP and Mediator, and the eRNA production), although the roles these features play in ERa enhancer function are not well understood.  p300 and CBP are bromodomain-containing protein acetyltransferases that are recruited to liganded ERa at enhancers through the steroid receptor coactivators (SRCs; a.k.a. p160 coregulators), which interact directly with ERa.  Mediator, a multisubunit coregulator complex that is thought to bridge enhancers and the core transcription machinery, also interacts directly with ERa through the Med1 subunit.  Interestingly, the SRC proteins and Med1 interact in a mutually exclusive manner with the same ligand-induced hydrophobic cleft on ERa.  We are using a combination of biochemical, molecular, genomic, genetic, and chemical approaches to dissect the distinct functions of SRC-p300/CBP and Mediator at ERa enhancers.  A mutant ERa that selectively binds Mediator versus SRCs is providing insights into the specific mechanistic roles of SRC-p300/CBP and Mediator in ERa activity at enhancers.  Genomic and molecular approaches are providing insights into ERa enhancer complex assembly, chromatin regulation, enhancer-promoter looping, and transcription activation.  Collectively, these studies will allow a greater understanding of the different functions of p300/CBP and Mediator at ERa enhancers, as well as their downstream effects.

 

Nothing to Disclose: AN, SM, WLK

21312 8.0000 FRI-277 A Dissecting the Distinct Roles of p300/CBP and Mediator in Estrogen Receptor Enhancer Function 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Christopher C Williams*1, Marlon D Williams2, Syreeta L Tilghman1, Jamal Pratt1 and Shawn Dion Llopis1
1Xavier University of Louisiana, College of Pharmacy, New Orleans, LA, 2Xavier University of Louisiana, New Orleans, LA

 

De novo or acquired resistance to anti-estrogens in estrogen receptor α (ERα)+ breast cancer has been attributed to ligand independent activation of the ER. Cross-talk with kinase signaling pathways may mediate ligand-independent activation of the ERα, resulting in tumor progression despite anti-estrogen therapy. Protein kinase CK2, a ubiquitously expressed serine threonine kinase, has been shown to impact the transcriptional activity of nuclear receptors and can directly phosphorylate ERα. In this study, we sought to ascertain the impact of CK2 inhibition on ER-dependent gene expression and breast cancer cell proliferation. In order to ascertain the impact of CK2 on estrogen dependent gene expression, T47D breast cancer cells were cultured in the presence of tetrabromocinnamic acid (TBCA), a selective inhibitor of CK2.  Estrogen responsive gene expression was measured by RT-PCR array analysis and ERE-driven luciferase activity. Additionally, the proliferative capacity of breast carcinoma cells was determined after exposure to TBCA in the presence or absence of fulvestrant by cell cycle progression and cellular senescence flow cytometric assays. To determine if CK2α can physically interact with ERα at estrogen responsive element of target gene promoters, we performed chromatin immunoprecipitation (ChIP) assays to determine the CK2 using α CK2α antibodies before and after ERα depletion. Our studies suggest that CK2 inhibition results in modulation of basal and estrogen-induced transcription from canonical estrogen response elements in luciferase assays. Among endogenous estrogen-regulated genes, CK2 inhibition resulted in a differential expression signature, with gene specific induction or repression upon exposure to TBCA. Interestingly, CK2 formed stable complexes with ER as determined by ChIP assay, suggesting that CK2 may interact with ERα at the gene promoter level. Furthermore, TBCA potentiated/induced cell cycle arrest and senescence of breast cancer cells, highlighting the potential efficacy of CK2 inhibition in prohibiting ER-dependent cell proliferation. These studies suggest a role for CK2 as central regulator of nuclear receptor function, and that CK2 inhibition may be a viable adjunct to anti-estrogen therapy in the treatment of breast cancer.


 

Nothing to Disclose: CCW, MDW, SLT, JP, SDL

21269 9.0000 FRI-278 A CK2-Mediated Modulation of ER Alpha Transcritional Activity in Breast Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Mohammed El Ezzy*1, Tatiana Traboulsi2, David Cotnoir-White1 and Sylvie Mader2
1Universite de Montreal, Montreal, QC, Canada, 2Université de Montréal, Montréal, QC, Canada

 

About 70% of breast tumours express the estrogen receptor ERα and their growth is regulated by estrogens. Antiestrogens (AEs) are used to treat all stages of ER+ breast cancers. Selective Estrogen Receptor modulators such as Tamoxifen have tissue-specific partial agonist activity, while full antiestrogens, also called Selective Estrogen Receptor Downregulators, display a higher degree of antiestrogenicity in experimental systems. Full AEs increase ubiquitination levels of ERα (1), and we have recently observed that they also induce its SUMOylation (2). Using BRET assays for either type of modification, we observed that SUMOylation and ubiquitination occur with similar kinetics, characterized by gradual increases in signal intensity over several hours. Both types of modifications are affected by mutations in helix 12 of the ERα ligand binding domain and by mutations in the dimerization interface. Induction of SUMOylation and ubiquitination by full antiestrogens is specific to ERα versus ERβ, but use of a three-partner BRET assay demonstrates that full antiestrogens also induce SUMOylation of ERα-ERβ heterodimers. Finally, while removal of ubiquitination marks by overexpression of a deubiquitinase did not prevent SUMOylation, overexpression of a deSUMOylase markedly reduced ubiquitination levels of ERα in the presence of full antiestrogens, suggesting a directional cross-talk between these modification marks.

 

Nothing to Disclose: ME, TT, DC, SM

21583 10.0000 FRI-279 A Mechanisms of Action of Full Antiestrogens: Crosstalk Between Sumoylation and Ubiquitination of Estrogen Receptor Alpha 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Marine Adlanmerini1, Anne Abot2, Aurélie Fabre3, Romain Solinhac3, Isabelle Raymond-letron4, Frederic Boudou3, Sung-Hoon KIM5, Coralie Fontaine3, Andrée Krust6, Pierre Chambon7, Philip W Shaul8, Pierre Gourdy9, Gilles Flouriot10, John A Katzenellenbogen11, Daniel Henrion12, Jean-Francois Arnal13 and Francoise Lenfant*1
1INSERM U1048, Toulouse, France, 2INSERM U1048, 3INSERM U1048, France, 4Ecole Vetérinaire Nationale de Toulouse, France, 5Department of Chemistry, University of Illinois, 6IGBMC, France, 7IGBMC, Illkirch, France, 8University of Texas Southwestern Med. Ctr, Dallas, TX, 9INSERM, France, 10INSERM U1085,, Rennes, France, 11University of Illinois at Urbana-Champaign, Urbana, IL, 12CNRS UMR 6214, Université d’Angers, France, 13INSERM

 

Estrogen Receptor alpha (ERα) classically mediates gene transcription in response to estradiol (E2).  A fraction of ERa is targeted to plasma membrane and elicits membrane-initiated steroid signaling (MISS).

To investigate the importance of the membrane effects of E2, we recently generated a mouse mutated for the palmitoylation site (C451A-ERα) by homologous recombination, leading to an abrogation of membrane localization of ERα. A complementary mutant mouse lacking the transactivation function AF-2 of ERα (ERα-AF2°) provided selective loss-of-function of nuclear ERα actions. These mice models indicate that membrane and nuclear actions of ERα in vivo are highly tissue-specific in some key targets and functions. Membrane actions of ERa are involved in vascular actions of E2 (such as rapid dilatation, acceleration of endothelial healing and endothelial NO synthase phosphorylation), whereas E2 proliferative action was completely preserved in the uterus of C451A-ERa mutant mice. In striking contrast, in mice inactivated for genomic effects (ERa-AF2°), vascular effects were preserved while uterine proliferation was completely lost.

These concepts were extended through to pharmacological tools, such as the Estrogen-Dendrimer Conjugate (EDC), which cannot enter the nucleus,  and Esterol (E4), a natural estrogen produced only by the human fetal liver during pregnancy. In contrast to EDC, which only activates membrane ERa actions, E4 activates preferentially the nuclear ERa actions but failed to promote endothelial NO synthase activation and acceleration of endothelial healing, two processes clearly dependent on membrane-initiated steroid signaling (MISS), thereby uncoupling membrane versus nuclear actions of E2.  

These models and tools should now allow us to optimize the selective ERa modulation according to the pathophysiological objectives and context.

 

Nothing to Disclose: MA, AA, AF, RS, IR, FB, SHK, CF, AK, PC, PWS, PG, GF, JAK, DH, JFA, FL

21896 11.0000 FRI-280 A The Mouse Mutated for Palmitoylation Site of Estrogen Receptor Eralpha Provides a Selective Loss of Function of Membrane Effects of Estradiol, Revealing Tissue-Specific Role for Membrane Versus Genomic Effects of Estrogens 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Peter Thomas* and Yefei Pang
University of Texas at Austin, Port Aransas, TX

 

A membrane androgen receptor was recently discovered in Atlantic croaker granulosa cells and shown to be a member of the ZIP  zinc transporter ZIP9 (SLC39A) subfamily, the first androgen receptor unrelated to nuclear steroid receptors identified in any vertebrate species (1). Human ZIP9 was also shown to function as a membrane androgen receptor and zinc transporter in human prostate and breast cancer cells (2). ZIP9 mediates testosterone (T) induction of apoptosis in cancer cells through activation of the intrinsic apoptotic pathway.  Additional receptor and signaling characteristics of human ZIP9 were investigated in the present study in PC-3 cells transfected with ZIP9 (PC3-ZIP9). Pretreatment with GTPγS decreased [3H]-T binding to PC3-ZIP9 cell membranes, consistent with an association of ZIP9 with G proteins.  ZIP9 was coimmunoprecipitated with an inhibitory G protein (Gi), suggesting ZIP9 is coupled to Gi. Ligand blot analysis of solubilized PC3-ZIP9 cell membranes showed [3H]-T binding was associated with a 40kDa band corresponding to the position of ZIP9 on Western blots. These results suggest the ZIP9 protein can bind [3H]-T alone, in the absence of other protein partners. Progesterone displayed high relative binding affinity for ZIP9 but did not mimic the stimulatory androgenic effects of T on intracellular zinc levels and apoptosis. Instead 20 nM progesterone antagonized the stimulatory action of 20 nM T on Erk1/2 phosphorylation which suggests progesterone exerts an antiandrogenic action through ZIP9. The zinc status also influenced ZIP9 functions. Expression of ZIP9 mRNA was inversely proportional to the external zinc concentration. No T-induced increase in intracellular zinc concentrations was observed in PC3- ZIP9 cells cultured in zinc-free media, indicating  that in response to T treatment ZIP9 transports extracellular zinc across the cell membrane to increase intracellular zinc concentrations and zinc signaling.

 

Nothing to Disclose: PT, YP

20076 12.0000 FRI-281 A Membrane Androgen Receptor Characteristics of Human ZIP9 (SLC39A9) Zinc Transporter 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Zhong-Sheng Wu1, Yu-Tzu Chang2, Chia-Shan Yeh1, Chia-Yun Lu1, Yu-Chun Lin2 and Juu-Chin Lu*2
1Chang Gung University, 2Chang Gung University, Tao-yuan, Taiwan

 

Peroxisome proliferator activated receptor γ (PPARγ) is an important transcription factor regulating the function of adipocytes. It is also the cellular target of anti-diabetic drug thiazolidinediones (TZDs), including rosiglitazone (Rosi) and pioglitazone. Through PPARγ, TZD treatment increases insulin sensitivity and reduces inflammation in the patients. However, the side effects, mostly coming from their agonistic effects, largely limit the effectiveness of TZDs. Recent studies have shown that Serine 273 (S273) phosphorylation of PPARγ by cyclin-dependent kinase 5 is elevated in obesity, which correlates with dysregulation of gene expression in obesity. TZD treatment suppresses PPARγ S273 phosphorylation, which may account for its anti-diabetic effects. Moreover, a novel PPARγ ligand SR1664, which does not contain agonistic activity, also suppresses S273 phosphorylation of PPARγ. Therefore, we mutated S273 into alanine (PPARγ-S273A) or glutamate (PPARγ-S273D) to mimic hypo- or hyper- phosphorylation of PPARγ. We also compared the effects of Rosi and SR1664 on expression of genes that was activated or suppressed by PPARγ in 3T3-L1 adipocytes. As expected, S273 mutations of PPARγ did not affect basal and TZD-induced promoter activity in a PPARγ target gene reporter system. Rosi, but not SR1664, was able to activate PPARγ target gene expression in 3T3-L1 adipocytes. Both Rosi and SR1664 suppressed proinflammatory gene expression in differentiated adipocytes. However, unlike Rosi, SR1664 was unable to suppress tumor necrosis factor α (TNFα)-induced expression of proinflammatory genes such as monocyte chemoattractant protein-1 in adipocytes. Overexpression of PPARγ-S273D in adipocytes increased basal and TNFα-induced inflammatory gene expression and extracellular signal-related kinase (ERK) phosphorylation. However, S273D mutation did not affect Rosi-mediated suppression of TNFα-induced gene expression or ERK phosphorylation. Further studies will be required to elucidate the mechanism by which ligands and S273 phosphorylation modulate the function of PPARγ in adipocytes.

 

Nothing to Disclose: ZSW, YTC, CSY, CYL, YCL, JCL

18973 13.0000 FRI-282 A Modulation of Peroxisome Proliferator Activated Receptor-Gamma (PPARg) Function By Ligands and Phosphorylation in 3T3-L1 Adipocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Y. Peng Loh*
NICHD, National Institutes of Health, Bethesda, MD

 

Rosiglitazone-activated PPARg induces Neurotrophic Factor-a1 Transcription to mediate Neuroprotection

Y. Peng Loh, Erwan Thouennon, Yong Cheng, Vida Falahatian,  Niamh X. Cawley

Section on Cellular Neurobiology, Program on Developmental Neuroscience, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA

Rosiglitazone is a drug used to treat type 2 diabetes through activation of peroxisome proliferator-activated receptor gamma (PPARg) resulting in increased insulin sensitivity leading to reduced blood glucose. In the brain, rosiglitazone activates PPARg and is involved in neuroprotection and in the amelioration of depression in humans and animal models. The mechanism of its role in neuroprotection is unknown although an increase in expression of BCL-2, a pro-survival protein, has been reported. The newly identified neuroprotection protein, neurotrophic factor-a1 (NF-a1, previously known as carboxypeptidase E) also induces the expression of BCL-2 and suggests a hypothesis that rosiglitazone activates PPARg to induce expression of NF-a1 leading to increased BCL-2 and neuroprotection. To this end, luciferase reporter assays with the mouse NF-a1 promoter demonstrated active PPARg binding sites capable of binding activated PPARg. Treatment of neuro2a cells, a neuro-endocrine cell line, and primary hippocampal and cortical neurons with rosiglitazone increased the expression of endogenous NF-a1 and prevented cell cytotoxicity induced by hydrogen peroxide. Concomitant with the increase of NF-a1, BCL-2 was also increased in these cells. When siRNA against NF-a1 was used, the BCL-2 levels induced by rosiglitazone, were reduced and the neuroprotective effect of rosiglitazone was prevented. These results demonstrate that rosiglitazone can induce the expression of NF-a1 in neurons which leads to increased BCL-2 and neuroprotection. Additionally, its effect on induction of NF-a1 in neurons has previously been shown to stimulate fibroblast growth factor 2 expression and neurogenesis in the hippocampus to alleviate depression. We also found that mice fed rosiglitazone showed increased hippocampal NF-a1 levels. Taken together, PPARg agonists, such as rosiglitazone may be a useful approach to treating or preventing degenerative disorders and depression often found in diabetic patients, while also treating the diabetes.

 

Nothing to Disclose: YPL

20854 14.0000 FRI-283 A Rosiglitazone-Activated Ppargamma Induces Neurotrophic Factor-alpha1 Transcription to Mediate Neuroprotection 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Rohit Anthony Sinha*1, Brijesh Kumar Singh2, Jin Zhou1, Benjamin Livingston Farah3, Ronny Lesmana4 and Paul Michael Yen2
1Duke-NUS Graduate Medical School, Singapore, Singapore, Singapore, 2Duke-NUS Graduate Medical School, Singapore, Singapore, 3Duke-NUS, Graduate Medical School, Singapore, Singapore, 4Duke-NUS, Singapore

 

Liver X receptors (LXRs) are important regulators of cholesterol, fatty acid, and glucose homeostasis. LXR agonists have shown efficacy for treatment of lipid and cholesterol derangements in mouse model systems. In this study, we show that ULK1 (unc-51 like kinase-1) an autophagy regulator is critical for LXR’s transcriptional and biological activity in hepatic cells. Using mouse primary hepatocytes and the mouse hepatic cell line AML-12 we show that LXR ligand GW3965 protects against palmitate induced lipotoxicity via increased Stearoyl-CoA desaturase-1 (SCD-1) transcription and SCD-1 mediated partitioning of free fatty acids into triglycerides. Knockdown (KD) of Ulk1 abolished GW3965 induced SCD-1 transcription and protection against lipotoxicity. Mechanistically, this loss of LXR induced SCD-1 transcription by Ulk1 KD involved selective reduction of a LXR interacting co-activator protein levels in an autophagy dependent manner. Since autophagy is known to be impaired in several metabolic diseases, we believe that therapies involving LXR agonists in metabolic disorders may benefit from stimulation of autophagy.

 

Nothing to Disclose: RAS, BKS, JZ, BLF, RL, PMY

20751 15.0000 FRI-284 A Autophagic Protein Ulk1 Regulates Liver X Receptor (LXR) Transcriptional Activity and Protection from Lipotoxicity in Liver Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Maxwell P Rego, Yana B Feygin, Guy N Brock and James L Wittliff*
University of Louisville, Louisville, KY

 

Forecasting clinical behavior and therapeutic response of breast carcinoma currently utilizes a few tumor markers (e.g., ER, PR and HER-2) and disease characteristics. Our goal is to identify a subset of clinically relevant genes that improves prediction of recurrence and identifies new molecular targets compared to those derived from ER and PR protein. Using an IRB-approved biorepository and database, total RNA was extracted from carcinoma cells procured by laser capture microdissection (LCM) of 247 de-identified tissue biopsies to perform microarray analyses of 22,000 genes. Nuclear Receptor Superfamily genes were investigated using microarray data. Univariate analyses, with Cox Regression and Kaplan-Meier plots, indicated that expression of AR, ESR1, NR4A2, NR5A1, RARA, RARG and RORC independently predicted either disease-free survival (DFS) or overall survival (OS) whereas ESRRA, NR2E3, NR3C2 (MCR), PGR, PGR-3’UTR1, PGR-3’UTR2 and THRB predicted both DFS and OS. L1-penalized multivariable Cox regression models of these candidates were fit to predict DFS and OS, with 1000 splits of the data into training (70%) and test (30%) sets to determine predictive accuracy based on the C-Index (measure of predictive value of a model). LASSO penalty was used to perform variable selection in each training set, and a permutation procedure determined a significance threshold for frequency that a variable was retained in a model. The highest count for any gene under this null distribution after 1000 iterations was 176 and 178 for DFS and OS, respectively. Using this as a cutoff, only NR4A2, PGR-3’UTR2, PPARA and THRB were necessary to predict DFS while NR3C2, PGR-3’UTR2, PGR-3’UTR1 and THRB were necessary to predict OS. Using various combinations, the highest C-Index was expressed by the two gene model of PGR-3’UTR2 and THRB for both DFS and OS. THRB expression was statistically significant (in multiple models) for predicting DFS and OS, regardless of ER/PR status. To ascertain additional genes in ER/PR regulated networks, expression of 87 genes, measured by qPCR in 579 cases, was evaluated based on ER/PR protein status (e.g., ER+/PR+; ER-/PR-) of the tissue biopsy. Of these, 22 genes exhibited statistically significant differences (by ANOVA with Benjamini-Yekutieli FDR adjusted p-values < 0.05) among categories of ER/PR status. Noteworthy, ERBB4, CAXII and SLC39A6 (LIV-1) were significantly over-expressed in ER+ breast cancers compared to ER- biopsies. Collectively, expression of PGR-3’UTR2 and THRB genes had slightly higher predictive power for assessing risk of breast carcinoma recurrence (median C-index of 0.629) and overall survival (median C-index of 0.635) than previously reported using a combination of ER and PR protein expression. New molecular targets for design and development of diagnostics and therapeutics were identified with our novel approach using LCM procured cancer cells.

 

Nothing to Disclose: MPR, YBF, GNB, JLW

21176 16.0000 FRI-285 A Assessing Risk of Breast Cancer Recurrence Using Expression of Nuclear Receptor Superfamily Genes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM FRI 270-285 6101 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Enver Simsek*1, Makbule Eren2, Meliha Demiral1, Cigdem Binay1, Tulay Simsek1 and Baran Tokar1
1Eskisehir Osmangazi University School of Medicine, Eskisehir, Turkey, 2Eskisehir Osmangazi University School of Medicine, Eskişehir, Turkey

 

Neurofibromatosis type 1 (NF1), an autosomal dominantly inherited condition with complete penetrance but extremely variable phenotypic presentation, is caused by mutation in the NF1 gene. The patients are diagnosed on the basis clinical findings, such as cutaneous (cafe-au-lait macules, inguinal and axillary freckles), and neural (neurofibromas, plexiform neurofibromas, Lisch spots, optic nerve gliomas) signs. However, it can involve many other systems including the gastrointestinal, endocrine, vascular, and skeletal systems. We present a 15-year-old girl  with a 14-month history of secondary amenorrhea, wasting syndrome (cachexia), short stature (Figure 1), and relapsing episodes of gastrointestinal complaints (pain and diarrhoea) for six months. Physical examination revealed wasting syndrome (cachexia) with extremely generalised loss of subcutaneous fat and muscle tissues (Figure 1). She weighed 35 kg (-3.1 SDS), her height was 146 cm (-2.6 SDS), and body-mass index was 16.4 (-1.7 SDS). Clinically the patient had café-au-lait spots on her skin, axillary and groin freckling, and pigmented hamartomas of the iris. Laboratuar tests revealed that total haemoglobin was 9.9 g/dl, total protein 3.4 g/dl, albumin 1.7 g/dl, albumin/globulin ratio < 1, alanine amino transferase and aspartate aminotrasferase were 9 and 15 IU/L, respectively; calcium 7.7 mg/dl, phosphorus 3.7 mg/dl, alkalen phosphatase 290 U/l, and serum 25-OH vitamin D level 5.0 ng/ml. Follicle stimulating hormone, luteinising hormone, and estradiol levels were 0.8 IU/L, 0.1 U/L, and 5.0 pg/ml. Bone age was compatible with her chronological age. Abdominal ultrasound examination revealed extensive increasing thickness of intestinal wall measured 10 mm and plenty of fluid accumulation in the abdominal cavity. Histopathological investigation of intestinal wall and mesenteric lymph nodes biopsies by laparoscopic method revealed neurofibromas. She has been followed by pediatric endocrinologist, gastroenterologist, neurologist and dietician. Unfortunately, we could not make a progress on malabsorbtion. She had to take an enteral or parenteral nutrition supports intermittently.  Conclusion, NF1 may present with extremely large clinical spectrum, such as precocious puberty or secondary amenorrhea.

 

Nothing to Disclose: ES, ME, MD, CB, TS, BT

18430 1.0000 FRI-174 A Neurofibromatosis Type 1 Presenting with Secondary Amenorrhea and Wasting Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 174-182 6102 1:00:00 PM Puberty Disorders Poster


Maria F Contreras*1, Manish Raisingani2, Bonita H Franklin1, Kris Prasad1 and Bina Shah2
1NYU School of Medicine, NY, 2New York University School of Medicine, New York, NY

 

Background:

Treatment for induction of puberty in boys is indicated in those who do not undergo spontaneous development. Stimulating development of the secondary sex characteristics are possible using gradually increasing doses of testosterone (T) derivatives.  The most widely used T substitution  is intramuscular(IM) injection of T esters. While free unesterified T has a half-life (<2hrs), T esters have a prolonged half-life (8 days). It is an effective, cheap treatment that results in adequate virilization. However, serum T exhibit large fluctuations with supraphysiologic levels immediately after the injection followed by a decrease into the low range. Also, inactivation of T occurs primarily in the liver, which can be a problem in cases with hepatic dysfunction. Transdermal testosterone (TT) gels are available to deliver T at a controlled rate into the systemic circulation (over 24 hrs) avoiding hepatic first pass, which can be beneficial in patients with hepatic dysfunction. However, the clinical experience of TT gel in adolescent boys is sparse.

Objective:

To report 3 adolescent boys with delayed puberty who were treated with TT gel for pubertal induction/continuation. This route was chosen as an alternative therapy due to hepatic dysfunction.

Cases Report

1. A 16 yr old obese boy with delayed puberty due to testicular atrophy had elevated liver enzymes (2.5 X normal).  He was started on TT (Fortesta gel 10 mg daily) for induction of puberty. Follow up at 3 and 6 months liver enzymes were trending down, while serum T levels were early pubertal (90ng/dl at 3 month, 65 ng/dl at 6 months).

2. A 14.25 yr old non obese boy with panhypopituitarism and delayed puberty was initiated on IM T (50mg) and was gradually increased. After 1 yrs of IM T, he was switched to TT gel for continuation of puberty because of rising liver enzymes. Follow up at 3 and 8 months liver enzymes were trending down, while serum T levels were mid pubertal (137ng/dl at 3 month, 118 ng/dl at 8 months).

3. A 14 yr old obese boy with panhypopituitarism and delayed puberty, was initiated IM T (50mg) and discontinued after the first dose. He was switched to TT gel (12.5mg/day) because of elevated liver enzymes. Follow up at 5 and 9 months liver enzymes were trending down, while serum T levels were mid pubertal (114 ng/dl at 5 month, 137 ng/dl at 9 months).

Conclusion:

Transdermal T gel has been widely used in adults, but the recommended dose is too high to be used to induce puberty in adolescents. However, the new preparations (TT gel), lower doses can be used for induction of puberty in adolescents. Transdermal T gel is a promising alternative agent for the treatment of pubertal induction/continuation, specifically in cases with hepatic dysfunction. We recommended that long term randomized controlled studies should be performed in this population.

 

Nothing to Disclose: MFC, MR, BHF, KP, BS

18744 2.0000 FRI-175 A Induction and Continuation of Puberty in Adolescent Boys with Transdermal Testosterone Gel 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 174-182 6102 1:00:00 PM Puberty Disorders Poster


Edward John Bellfield*
University of Illinois College of Medicine, Chicago, IL

 

Background: Sertoli-Leydig cell tumors (SLCT) are sex-cord neoplasms that can occur in Peutz-Jegher syndrome (PJS). Recurrent ovarian SLCT in a pediatric-aged patient has yet to be documented.

Clinical Case: A 3.3 year-old African-American female with a strong paternal history of PJS and associated polyposis presented with gonadotropin-independent isosexual precocious puberty and vaginal bleeding. Her laboratory studies revealed undetectable serum LH and FSH, elevated testosterone 78 ng/dL (0-9.9), estradiol 210 pg/mL (0-55), and CA-125 54 U/mL (0-35). AFP and β-HCG tumor markers were negative. Abdominal CT demonstrated a large pelvic mass involving the right ovary and a prominent thick-walled uterus. She underwent mass resection with right salpingo-oophorectomy. Pathology results demonstrated a SLCT limited to the ovary with positive cytokeratin, vimentin and inhibin staining. Uterine bleeding ceased 6 days after surgery, with decrease in breast size and pubic hair over the following months. Her bone age was 8 years at chronological age of 4 years at follow-up. She underwent menarche at 11.5 years of age with a bone age concordant with her chronological age at that time. Although she had been followed until 13 years of age without tumor recurrence, she was lost to follow-up until age 17.4 years when she presented with one year of intermittent stabbing abdominal pain, daytime fatigue and irregular menses. She had no clinical signs of hyperandrogenemia. Laboratory studies revealed normal serum FSH 1.9 IU/L (3.4-10), testosterone 53 ng/dL (11-62), and estradiol 201 pg/mL (2-259), but a highly elevated serum LH 164.1 IU/L (2.1-10.9). Abdominal CT demonstrated a left adnexal complex cystic mass extending to the midline. She underwent mass excision with left salpingo-oophorectomy and cervical biopsy. Pathology results again demonstrated a SLCT limited to the ovary. Immunohistochemical stains were positive for vimentin, inhibin, as well as WT1, calretinin, CAM 5.2 and estrogen receptors.  

Conclusion: This is the first known documented case demonstrating a recurrent ovarian Sertoli-Leydig cell tumor in a pediatric patient with PJS. This case emphasizes the importance of regular surveillance for neoplasm, as the possibility of syndrome-related morbidity exists even in young children with this disorder.

 

Nothing to Disclose: EJB

18755 3.0000 FRI-176 A Perils of Peutz-Jegher Syndrome: Recurrent Ovarian Sertoli-Leydig Cell Tumor in a Pediatric Patient 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 174-182 6102 1:00:00 PM Puberty Disorders Poster


Joao L O Madeira*1, Caroline Caetano da Silva2, Aline P Otto3, Ericka Barbosa Trarbach4, Mirian Y Nishi5, Rodrigo Itocazo Rocha6, Berenice B Mendonca7 and Luciani R S Carvalho8
1University of Sao Paulo, São Paulo, Brazil, 2University of Sao Paulo, 3Univ of Sao Paulo, Sao Paulo, Brazil, 4Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 5Hosp das Clinicas de FMUSP, Sao Paulo, Brazil, 6University of Sao Paulo, Hospital das Clinicas, 7Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil, 8University of São Paulo, Hospital das Clinicas, São Paulo, Brazil

 

Background: Aromatase excess syndrome (AEXS) is a rare genetic disease characterized by pre or peripubertal gynecomastia owing to increased peripheral expression of aromatase, which converts testosterone (T) to estradiol (E2) and anstrostenedione to estrone (E1). Only 8 female cases of AEXS have been reported, whose clinical features ranged from asymptomatic to one or more of macromastia, advanced bone age, premature thelarche, early menarche, short adult stature, irregular uterine bleeding, enlarged uterus and endometriosis. Clinical Case: A 10-year and 11-months (10y11m) girl was referred to our clinic due to gigantomastia with an onset history of only 7 months. The patient presented at first evaluation, besides important bilateral gigantomastia, advanced bone age (13 years), enlarged uterus (4.8x2.0x3.0 cm) and ovaries (7.3 and 10.9cc) for age, detected by pelvic US. There was no familial history of gigantomastia. Patient developed menarche at 11y01m. In order to evaluate the hypothalamic-pituitary-gonadal axis, serum hormone levels were measured in different phases of menstrual cycle. Although integrity of the axis was preserved with normal E2 levels and slightly increased E1 levels, E2/T ratio was increased, ranging from 365 (follicular phase) to more than 1800 times (luteal phase). The patient underwent bilateral mastectomy and the histopathology analysis showed Pseudoangiomatous Stromal Hyperplasia (PASH) with positive expression for estrogen and progesterone receptors. To investigate aromatase excess, CYP19 gene expression was analyzed by RT-qPCR using 0,6 ug total RNA from skin, adipose tissue, mammary gland and fibroblast cell culture for cDNA synthesis from patient and normal female control. Relative expressions were calculated by the 2-ΔΔCT method and showed 2-3 times fold in the patient´s skin and 20-40 times fold in patient´s fibroblast cell culture compared to normal. Patient maintained advanced bone age (14 y with chronological age of 12 y). Although the initial height is within the normal range (145,5cm at 11y9m, Z score = 0.0), the prediction for final height is poor owing to acceleration of bone age. Patient refers normal menstrual cycles and denies any symptom of endometriosis, so aromatase inhibitor was not introduced. Clinical Lessons: This case reinforces the importance of endocrinological evaluation of patients harboring gigantomastia and spread the clinical presentation of female cases of AESX.

 

Nothing to Disclose: JLOM, CCD, APO, EBT, MYN, RIR, BBM, LRSC

19558 4.0000 FRI-177 A Aromatase Excess Syndrome in a 10-Year Old Girl with Gigantomastia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 174-182 6102 1:00:00 PM Puberty Disorders Poster


Hironori Shibata*, Tomohiro Ishii, Naoaki Hori, Goro Sasaki, Tsutomu Kamimaki, Makoto Anzo, Shinya Tamai, Seiji Sato, Nobutake Matsuo and Tomonobu Hasegawa
School of Medicine, Keio University, Tokyo, Japan

 

Background: Testosterone enanthate (TE) therapy was established for children and adolescents with male hypogonadotropic hypogonadism (c/a MHH). However, the effect of TE therapy on adult height (AH), genital maturation, and bone mineral density (BMD) in c/a MHH has not been described well.

Objective: The objective of this investigation was to assess the effect of TE therapy in c/a MHH on final growth status, pubertal development, bone acquisition, and the possible adverse effect on spermatogenesis by subsequent gonadotropin therapy.

Design and Participants: This was a retrospective evaluation of c/a MHH patients who were treated with TE to develop secondary sexual characteristics and attained AH at Department of Pediatrics at Keio University between April 1984 and June 2014. We excluded patients with history of gonadotropin therapy before TE therapy or those with DAX1 (NROB1) mutation.

Methods: We reviewed medical records of c/a MHH followed at the institution. Variables analyzed included AH, target range (TR), pubic hair Tanner stage, stretched penile length (SPL), and lumbar BMD by DXA before TE therapy and at the attainment of AH, as well as sperm concentration by subsequent gonadotropin therapy.

Results: The present study included 14 c/a MHH, 6 of whom had isolated hypogonadotropic hypogonadism, 3 had Kallmann syndrome, 3 had hypopituitalism due to brain tumors, and 2 had idiopathic hypopituitalism. One had untreated bilateral cryptorchidism at the first visit. The median age at the first visit was 14.4 (range: 0.8 – 22.8) years. The median age at the start of TE therapy was 15.2 (range: 13.3 – 22.9) years. The median age at the attainment of AH was 19.3 (range: 17.4 – 25.9) years. The median duration of TE therapy until the attainment of AH was 3.6 (range: 1.8 – 6.3) years. The median age at the last visit was 27.0 (range: 18.4 – 47.3) years.

The median AH (N=14) was 175.7 (range: 162.3 – 184.2) cm. All of AH were greater than the lower limit of TR. Pubic hair Tanner stage (N=13) remained 1 or 2 before treatment, reached 4 or 5 at the attainment of AH. The median SPL Z-score (N=12) was -3.8 (range: -7.3 – -1.5) before treatment and -1.5 (range: -4.6 – 1.7) at the attainment of AH (P=0.01).The median of lumbar BMD Z-score (N=9) was -3.13 (range: -3.89 – -0.64) before treatment and -1.70 (range: -3.11 – 0.00) after the attainment of AH (P=0.02). Sperm concentration (N=3) by subsequent gonadotropin therapy was 18*106/mL in 2 and 0 *106/mL in 1. A patient with azoospermia had untreated bilateral cryptorchidism at 22 years old.

Conclusion: These data indicate that TE therapy in c/a MHH is effective in achievement of appropriate AH for genetic potential, maturation of genitalia, and improvement of BMD and also suggest that subsequent gonadotropin therapy can induce spermatogenesis.

 

Nothing to Disclose: HS, TI, NH, GS, TK, MA, ST, SS, NM, TH

19667 5.0000 FRI-178 A Effect of Testosterone Enanthate Therapy on Adult Height, Genital Maturation, and Bone Mineral Density in Children and Adolescents with Male Hypogonadotropic Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 174-182 6102 1:00:00 PM Puberty Disorders Poster


Mouhammad Rateb Alwazeer*1, Min-Jye Chen2, Jason Au3, Yunru (Kathy) Shao4, Patricio C Gargollo3, Vernon R Sutton4, Sheila K Gunn2 and Lefkothea P Karaviti2
1Pediatric Endocrinology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, 2Baylor College of Medicine, Texas Children's Hospital, Houston, TX, 3Pediatric Urology, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 4Molecular and Human Genetics, Baylor College of Medicine, Texas Children's Hospital

 

Background

Mutations in SRD5A2, a gene responsible for the coding for 5-alpha reductase 2 enzyme, result in various 5-alpha reductase 2 deficiencies. Presentations of 5-alpha reductase 2 deficiency, apart from the full phenotype, create uncertainty for the physician and may prevent recognition of the diagnosis. Only one case has been reported previously of 5-alpha reductase 2 deficiency in a patient with normal SRD5A2 gene with heterozygous V89L polymorphism. We report herein a second case of 5-alpha reductase 2 deficiency with a normal SRD5A2 gene with homozygous V89L polymorphism.

Case

A 17 year old male presented for evaluation of hypogonadism. The initial physical exam revealed a small phallus with no hypospadias and otherwise normal male genitalia. He had history of anosmia, but evaluation for suspected Kallmann syndrome was negative, leading to a later diagnosis of congenital anosmia. Prior to our evaluation, he received monthly IM testosterone 500 mg injections for two years, with only mild improvement of the phallus size (6.5 cm, - 2 SD below the mean). Labs revealed baseline testosterone (T) level of 259 ng/dl (normal range = 148-794 ng/dl) and dihydrotestosterone (DHT) of 13 ng/dl (normal range = 24-65 ng/dl) (T/DHT ratio of 20:1). After LHRH stimulation test, T was 457 ng/dl and DHT was 15 ng/dl (T/DHT ratio = 30:1), consistent with a diagnosis of 5-alpha reductase deficiency.

SRD5A2 gene sequencing showed no mutation but V89L polymorphism (homozygous for leucine) was present. Array comparative genomic hybridization for the androgen receptor (AR) gene was normal.

Conclusions

The final diagnosis, based on the high T:DHT ratio and requirement of high dose T, is 5-alpha reductase 2 deficiency. 5 alpha reductase 2 is a key enzyme for androgenic function. The V89L polymorphism in the SRD5A2 gene has been found to be of functional importance in that the homozygous leucine substitution has been shown to result in almost 30% reduction in 5 alpha reductase enzyme activity (1).

Our case raises awareness that isolated V89L polymorphism possibly associated with other environmental factors may affect the 5-alpha reductase enzyme activity in the absence of a SRD5A2 gene mutation.

Raised awareness of this condition may lead to recognition of more cases with similar genetic phenotypes, which in turn may lead to a personalized, more effective management approach, as well as insights into the importance of polymorphisms associated with 5-alpha reductase 2 deficiency.

Early recognition is critical to avoid losing the testosterone priming effect early in treatment course.

Since DHT cream/gel is not available in the U.S., a trial of T replacement with HCG supplementation in regards to preservation of fertility and promoting phallic growth may be considered (2).

 

Nothing to Disclose: MRA, MJC, JA, YS, PCG, VRS, SKG, LPK

20136 6.0000 FRI-179 A Challenges Associated with V89L Polymorphism in 5-Alpha Reductase Deficiency and Normal srd5A2 Gene: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 174-182 6102 1:00:00 PM Puberty Disorders Poster


Eun Young Kim*1, Shin-Eui Park2, Il Tae Hwang3 and Kyunghee Yi4
1Chosun University, College of Medicine, Gwangju, Korea, Republic of (South), 2Chonnam National University, Gwangju, Korea, Republic of (South), 3Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea, Republic of (South), 4Wonkwang University Sanbon Medical Center, Gunpo, Korea, Republic of (South)

 

Purpose: Puberty is the important period during development in which major physical, psychological and complex social skills occur. It has been suggested that pubertal hormones may induce some neuroanatomical changes during adolescence. Central precocious puberty (CPP) is caused by premature activation of the hypothalamic-pituitary-gonadal axis in inappropriately early age (before 8 ages in girls and 9 ages in boys). In adolescents with early pubertal timing, there is a tendency of severe emotional problems and antisocial behaviors. Psychosocial changes may be related to cerebral development, including widespread changes in brain morphology. However, little is known about brain structure (especially brain volume) in idiopathic CPP. Therefore, this study aimed to evaluate the difference of brain structure between idiopathic CPP and age-matched healthy control, and the correlation between brain volume difference and luteinizing hormone (LH).

Subjects and Methods: Fifteen girls with idiopathic CPP and 15 age-matched healthy girls as controls were enrolled. The subjects underwent on a 1.5 Tesla Avanto MR Scanner (Siemens Medical Solutions, Erlangen, Germany). Anatomical T1-weighted images were acquired with a T1 spin echo sequence. MR image data were processed by using SPM8 software (Statistical Parametric Mapping 8, The Welcome Department of Cognitive Neurology, University College London, U.K.) with Diffeomorphic Anatomical Registration through Exponentiated Lie Algebra (DARTEL) algorithm.

Results: In our findings, the regional cerebral volumes in CPP were different from those of the controls. Compared with controls, CPP showed a significant increase in gray matter (GM) volumes; the orbitofrontal gyrus, superior parietal gyrus, supramarginal gyrus, angular gyrus, postcentral gyrus, superior occipital gyrus, cuneus, hippocampus, parahippocampal gyrus, posterior cingulate gyrus (PCgG), cerebellar cortex (Cb), and in white matter (WM) volumes; the lnsular, caudate, posterior corpus callosum  (P<0.001). Especially, the GM volumes of the PCgG (r=0.57, p=0.03) and Cb (r=0.53, p=0.04) were correlated positively with LH concentrations.

Conclusion: Localized GM and WM volume was increased in girls with idiopathic CPP compared with age-matched controls. The GM growth might be directly or indirectly mediated by LH production. These data suggest that the presence of early sexual maturation is related to variations in structure of developing brain of girls with idiopathic CPP.

 

Nothing to Disclose: EYK, SEP, ITH, KY

20312 7.0000 FRI-180 A The Influence of Luteinizing Hormone on Brain Structure in Girls with Idiopathic Central Precocious Puberty 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 174-182 6102 1:00:00 PM Puberty Disorders Poster


Sejal Patel Kadakia*1, Michael Everett Gottschalk2 and Maja Marinkovic3
1University of California, San Diego, San Diego, CA, 2University of California San Diego, San Diego, CA, 3University of California San Diego, La Jolla, CA, USA/Rady Children's Hospital, USA, San Diego, CA

 

While early pubertal development in girls is mostly idiopathic, precocious puberty (PP) in boys is always concerning for CNS pathology. We present the rare case of central PP in a male caused by a LH secreting adenoma.  

An 8 year 8 month Hispanic male was referred for evaluation of precocious puberty (testicular and penile enlargement) that started around 7.5 years. At presentation he had tall stature, acne, Tanner 3-4 pubic hair and enlarged testes (6ml on left; 10ml on right). Laboratory testing revealed pubertal levels of testosterone (T) 442 ng/dl (<42) and LH 5 mIU/ml (<0.49), but suppressed FSH <0.05 mIU/ml (0.87-9.16 mIU/mL for bone age). Tumor markers (HCG, AFP) were normal, as was testicular ultrasound. Androstenedione, 17 OH-P and DHEAS were slightly elevated, but normal for his Tanner stage. The bone age was markedly advanced to 12.5 years. As studies indicated central cause of PP a brain MRI was done showing diffusely enlarged anterior pituitary (without a discrete tumor) thought to be related to his mid-pubertal stage of development. Leuprolide 30mg injection was given at 8 years 11 months and 2 months later histrelin implant was placed, however without achieving pubertal suppression. Leuprolide stimulation test showed LH 5.84 mIU/ml, FSH 0.14 mIU/ml, and testosterone 576 ng/dl.  Lack of pubertal suppression raised a concern for a LH secreting tumor. A MRI at 9 years 7 months showed progressive diffuse enlargement of the pituitary gland now with heterogeneous enhancement, deviation and mass effect over the pituitary stalk consistent with a macroadenoma. At that time alpha subunit and prolactin were elevated. Trans-sphenoidal resection of pituitary adenoma was performed at 9 years 8 month. Afterwards LH and T levels remained elevated. Interestingly, the tumor stained for both LH and prolactin, but not FSH. Repeat brain MRI at 9 years 11 months redemonstrated the heterogeneously enhancing pituitary mass, increased in size that necessitated second trans-sphenoidal resection. Postoperatively, LH and T decreased slightly, but did not normalize. Therapy with cabergoline 0.5 mg weekly was initiated at 10 years 6 months in an attempt to suppress LH secretion similar to the effect seen with co-localizing prolactin/growth hormone adenomas. Although prolactin normalized, LH and T levels remained elevated. Dose was recently increased to 0.5mg twice weekly and we are awaiting repeat evaluation.

This case demonstrates an exceedingly rare cause of central PP. Review of the literature reveals only a handful of gonadotropin secreting adenomas and even fewer that are purely LH secreting. Lack of pubertal suppression with potent GnRH agonists, persistent LH and T elevation with suppressed FSH raised our concern for LH secreting adenoma. We hope that higher dose of cabergoline will be effective in controlling growth of macroadenoma and its secretory function otherwise the patient may need additional surgery.

 

Nothing to Disclose: SPK, MEG, MM

20814 8.0000 FRI-181 A LH Secreting Adenoma: An Unusual Cause of Precocious Puberty 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 174-182 6102 1:00:00 PM Puberty Disorders Poster


Penny Meryl Feldman* and Mary Min-Chin Lee
University of Massachusetts Medical School, Worcester, MA

 

Background: Thyroid hormone is vital for normal brain development in utero and in the first three years of life in all infants. Therefore, prompt diagnosis and treatment of hypothyroidism is crucial for optimizing brain development (1).  Infants with Down syndrome (DS) have global developmental delay and an increased frequency of hypothyroidism. Therefore, timely institution of thyroid hormone replacement therapy is even more critical for brain development. Currently, the American Academy of Pediatrics screening guidelines recommend that infants with DS be screened at birth and at 6 and 12 months of age for thyroid dysfunction (2). Several publications have reported the diagnosis of hypothyroidism in infants with DS between these wide screening points (3-5). Frequently, the hypothyroidism in infants and children with DS is mild, which is difficult to diagnose clinically, but is easily detected with screening thyroid function studies (TFT).

Objective: To assess the timing of thyroid dysfunction in infants with DS to determine the optimum intervals to screen these infants for thyroid dysfunction. Also, to determine whether there is an autoimmune etiology for the thyroid dysfunction in these infants.

Methods: Infants with a confirmed diagnosis of DS who are <5 months of age and born after a 30 week gestation are eligible. Informed consent was obtained from the parents.  TFTs are measured with a capillary blood sample collected on a newborn filter paper screening card at birth, 2 and 4 weeks of age and then monthly thereafter until age 12 months. Samples are analyzed at the New England Newborn Screening Program, Jamaica Plain, Massachusetts. Study subjects with abnormal TSH and T4 have a confirmatory venous sample for TSH and free T4. Infants with confirmed hypothyroidism (TSH > normal for age and/or free T4 < normal value for age) promptly start treatment with daily thyroid hormone replacement, and are managed as per the standard of care for infants with congenital hypothyroidism. Thyroid antibodies are measured at 12 months of age in study subjects diagnosed with hypothyroidism.

Results: 4 of the 15 enrolled study subjects were diagnosed with hypothyroidism on day of life (DOL) 7, 20, 21 and at 7 months of age and started on thyroid hormone replacement therapy.  One of the study subjects had a lingual thyroid (diagnosed on DOL 21) and another tested positive for the TSH receptor antibody (diagnosed on DOL 20). The etiology for the hypothyroidism in the remaining two subjects is unknown. The incidence of congenital hypothyroidism in this study is 26.7%.

Conclusion: Preliminary data from this study indicates that TFTs may need to be repeated sooner than current recommendations.  Our data suggests that repeat screening is recommended in the first month of life in infants with DS for early detection and prompt institution of thyroid hormone replacement therapy to optimize neurodevelopmental outcomes.

 

Nothing to Disclose: PMF, MMCL

20739 9.0000 FRI-182 A Should Infants with Down Syndrome be Screened More Frequently for Thyroid Dysfunction? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM FRI 174-182 6102 1:00:00 PM Puberty Disorders Poster


Tanya Burton*1, Elisabeth LeNestour2, Maureen P Neary3 and William H Ludlam3
1Optum, Waltham, MA, 2inVentiv Health Clinical, France, 3Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

OBJECTIVE: Prevalence estimates of acromegaly in the United States (US) are limited.  Most existing reports are based on European data sources (1). The objective of this study was to estimate the annual prevalence of acromegaly in a large US managed care population, overall and stratified by age, sex, and geographic region, using data from 2008 to 2012.

METHODS:Using administrative claims data, commercial health plan enrollees were identified with acromegaly if they had 2 or more medical claims with an acromegaly diagnosis code (ICD-9-CM: 253.0x) or one medical claim with an acromegaly diagnosis code in combination with one other claim for a pituitary tumor (ICD-9-CM: 237.0x), hypophysectomy, or cranial stereotactic radiosurgery. The first date for an acromegaly-related claim set the index year. The denominator for each annual prevalence estimate was the total number of health plan enrollees enrolled for at least one day during each calendar year.  Estimates were stratified by age (0-17, 18-44, 45-64, 65+ years), sex (male, female), and US geographic region of the health plan (Northeast, Midwest, South, West).

RESULTS: The overall annual prevalence of acromegaly was relatively constant across the five years from 2008 to 2012 with approximately 74 cases per million per year (PY). Prevalence estimates increased with age, ranging from 27-35 cases per million PY among children aged 0-17 years old to 148-179 cases per million PY among adults aged 65 years old or older. Males and females were similarly affected; each sex had approximately 74 cases per million PY. The South and Northeast had the highest prevalence estimates (85 and 88 cases per million PY, respectively); while the estimates for the Midwest and West were lower (54 and 62 cases per million PY, respectively).

CONCLUSION: This study examined five years of recent data to estimate the prevalence of acromegaly in a large geographically-diverse managed care population. Results suggest that the overall prevalence is stable and similar to estimates reported by studies outside of the US. Prevalence increased by age, did not differ for males and females, and varied by geographic region.  Using a claims-based approach, this analysis only captured acromegaly patients with an acromegaly-related medical claim. As a result, these estimates may underestimate the prevalence of acromegaly in the US as they do not include individuals who were undiagnosed, in remission, undertreated, not monitored, or uninsured during the study period. Additional evaluations are needed to identify the full extent of acromegaly in the US.

 

Disclosure: MPN: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. Nothing to Disclose: TB, EL

19895 1.0000 FRI-489 A Prevalence of Acromegaly in a Large US Managed Care Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Michael Howard Shanik*1, Paul Cao2 and William H Ludlam3
1Endocrine Associates of Long Island, Smithtown, NY, 2Medthink SciCom, Raleigh, NC, 3Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

Somatostatin analogs (SSAs) are considered to be the mainstay of medical therapy for patients with acromegaly. Variable rates of biochemical control (decrease in insulin-like growth factor-1 [IGF-1] and/or growth hormone [GH] levels) with SSAs have been reported in the literature, with prior treatment history being one important determinant of treatment effectiveness. In a recently completed phase 3 study (ClinicalTrials.gov NCT00600886), rates of biochemical control with pasireotide long-acting release (LAR) and octreotide LAR in medically-naive patients were 31.3% and 19.2%, respectively (1). This reported rate of biochemical control with octreotide LAR is in contrast to higher rates of control (~60%) observed among patients who were pretreated and/or selected for response with SSA therapy (2,3).

To assess whether study design played an important role in the low octreotide LAR efficacy rate reported in the above study, we performed a systematic literature review to identify studies in acromegaly with similar characteristics: i) English language, ii) medically naive patients, iii) enrollment of ≥20 patients, iv) treatment with SSAs, v) treatment duration of ≤1 year, vi) prospective collection of data, and vii) use of composite efficacy endpoint (GH levels <2.5 ng/mL and normalized IGF-1 levels). Studies that assessed changes in GH levels after SSA treatment only by OGTT were excluded.

An initial analysis on PubMed identified 8831 published articles on acromegaly through May 2014. A total of 1242 articles were related to treatment with SSAs. Of these, a total of 90 articles reported on GH and IGF-1 control, and GH levels <2.5 ng/mL. Each of these 90 studies was reviewed by two independent authors to confirm compliance with all criteria and only those meeting all inclusion criteria were included. As a last step, references cited within the identified articles, as well as meta-analyses and systematic reviews of trials in acromegaly published in the past 10 years, were examined to identify additional relevant trials.

A total of 10 studies (N=421 patients) were identified that met all inclusion criteria. Among these studies, reported rates of biochemical control averaged 34% (range: 20%-57%). Of note, beyond inclusion of medically naïve patients, studies that enrolled completely treatment-naïve patients generally reported the lowest efficacy rates.

We demonstrate that the interpretation of biochemical response rates in patients with acromegaly is critically dependent on the context of the study and should be evaluated across clinical trials with similar study design characteristics.


 

Disclosure: MHS: Clinical Researcher, Novartis Pharmaceuticals. PC: Employed by MedThink SciCom, a medical communication company that provides publication support to pharmaceutical companies, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals.

19911 2.0000 FRI-490 A Historical Response Rates of Somatostatin Analogs in the Treatment of Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Kenichi Yoshida*1, Hidenori Fukuoka2, Ryusaku Matsumoto1, Hironori Bando1, Kentaro Suda1, Hitoshi Nishizawa2, Genzo Iguchi2, Wataru Ogawa1, Susan M. Webb3 and Yutaka Takahashi1
1Kobe University Graduate School of Medicine, Kobe, Japan, 2Kobe University Hospital, Kobe, Japan, 3Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain

 

Background Acromegaly is caused by an excess secretion of growth hormone (GH) and insulin-like growth factor- I (IGF-I) and associated with increased mortality and morbidity. Quality of life (QoL) is reportedly impaired in patients with acromegaly but factors that could affect the QoL have not fully been elucidated.

Objective To investigate the factors associated with impaired QoL in Japanese patients with acromegaly.

Patients and Methods We developed a Japanese version of the acromegaly QoL questionnaire (AcroQoL) and evaluated 38 patients with acromegaly (19 men and 19 women, mean age 56.1 ± 12.6 years, mean duration of disease 17.4 ± 9.0 years) who had been followed up at an outpatient clinic at Kobe University Hospital. The mean GH level and IGF-I SD score were 2.08 ± 3.59 ng/mL and 0.80 ± 1.50, respectively. Among those patients, 26 patients were biochemically-controlled, seven patients showed discordant status of GH and IGF-I levels, and five patients were active according to random serum GH levels, IGF-I SD score, and the related symptoms.

Results The median total score of the AcroQoL in all 38 patients was 67.0% (range; 31.8–96.6) with the appearance score showing the lowest values (median; 57.1%, range; 21.4–92.9) compared to the physical and personal relationship scores (67.2%; 18.8–100, 78.6%; 32.1–100, respectively). Age was positively correlated with the total score (r = 0.380, p = 0.019). In the subanalysis, the physical (r = 0.345, p = 0.034) and psychological (r = 0.336, p = 0.039) scale correlated with age. Patients who had been treated with radiotherapy (n = 4) showed lower total score compared to those who had not received radiotherapy (48.9 vs. 68.2, p = 0.052). Sex, duration of the disease, serum GH levels, IGF-I SD score, and presence of hypopituitarism did not show any correlations with the total score. Although there was no difference in the total scores between the three groups according to status of disease activity, the physical score in the active group tended to be lower (controlled 68.8% vs. active 43.6%, p = 0.461). Intriguingly, in the biochemically-controlled group after the exclusion of patients who received radiotherapy, patients who received surgery alone exhibited a higher psychological (75.0% vs. 65.7%, p = 0.036) and appearance (64.3% vs. 53.6%, p= 0.036) score than those who received medical therapy.

Conclusions Younger age was associated with lower QoL in patients with acromegaly. In patients with biochemically-controlled acromegaly, patients who received surgery alone exhibited better QoL than those treated with medical therapy. These results strengthen the importance of biochemical remission by surgery rather than with medical therapy in the treatment of acromegaly.

 

Nothing to Disclose: KY, HF, RM, HB, KS, HN, GI, WO, SMW, YT

20255 3.0000 FRI-491 A Factors Associated with Quality of Life in Japanese Patients with Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Gonca Oruk*, Husnu Yılmaz and Baris Onder Pamuk
Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey

 

Acromegaly is a quite rare chronic disease, the frequency of which is estimated at about 50–70/ million. Untreated, acromegaly shortens life expectancy by about 10 years, leading to a number of complications. Although cardiovascular disease remains the most common cause of mortality among acromegalic patients, increased prevalance of malignant and benign neoplasms remains a matter of debate. Neoplasms constitute the cause of 15-24% of deaths in acromegalic patients. Tumors also continue to be an increasing problem for this group, as with improved patient care, their lifespan has increased. As a result, this has extended the patients’ exposure to elevated levels of IGF-1, consequently creating a higher risk of carcinoma.The aim of this study to evaluate the types and risk of malignancy in patients being followed with the diagnosis of acromegaly. Data of 135 patients (77 female, 58 male) were evaluated retrospectively. Number, age and sex of the patients, duration of the disease, age at diagnosis of malignancy, growth hormone and insulin-like growth factor-1 levels were recorded. 10 patients (6 female, 4 male) had been diagnosed with malignant tumours: 1 lung adenocarcinoma, 1 pancreas adenocarcinoma, 1 breast ductal carcinoma, 1 urothelial neoplasm, 1 thyroid follicular carcinoma part of MEN 1 syndrome, 3 thyroid papillary carcinoma, 1 colon adenocarcinoma, 1 patient both thyroid papillary and colon adenocarcinoma. 3 patients (2 male, 1 female) had died because of reasons related with carcinoma (lung, colon and pancreas adenocarcinoma). Ages of the patients at diagnosis were 68, 56 and 76 respectively. In all of the 3 patients who had died the duration of the disease was long (> 10 years) and the disease was uncontrolled for a long time. None of our patients were lost because of cardiovascular reasons, neoplasia was the only factor responsible for mortality. Hence, monitoring patients for early detection of potential neoplasms remains a vital part of the treatment. Some patients might have multiple neoplasia at the same time. Although thyroid and colorectal neoplasia are the most reported malignancies in the literature, different types of malignancies can also be observed. It can be concluded that systematic screening of patients for neoplastic lesions should constitute an indispensable element of managing acromegalic patients. Also it is needed to diagnose acromegaly as early as possible, implement appropriate treatment quickly, and continually monitor its effectiveness.

 

Nothing to Disclose: GO, HY, BOP

20310 4.0000 FRI-492 A Different Kinds of Neoplasia Can Increase the Risk of Mortality in Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Annamaria Colao*1, Alberto M Pedroncelli2, Albert Kandra2, Karina Hermosillo Reséndiz3 and Mônica R. Gadelha4
1Università Federico II di Napoli, Naples, Italy, 2Novartis Pharma AG, Basel, Switzerland, 3Novartis Pharmaceuticals Corporation, East Hanover, NJ, 4Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil

 

Background: Pasireotide LAR (40 / 60 mg) was shown to provide superior efficacy over continued treatment with first-generation SSAs (octreotide LAR 30 mg / lanreotide Autogel [ATG] 120 mg) in patients with inadequately controlled acromegaly despite ≥ 6 mo treatment with first-generation SSAs (PAOLA study). An earlier treatment change (at least >3 mo treatment) to pasireotide LAR might be beneficial for inadequately controlled patients with acromegaly.

We aim to assess efficacy and safety of pasireotide LAR in patients with acromegaly inadequately controlled (as per new criteria for biochemical control: GH <1.0 μg/L associated with normalized IGF-1 level) after ≥ 3 mo treatment with the maximal approved doses of first-generation SSAs.

Methods: Phase IIIb, multicenter, single-arm study consisting of a core phase (wk 0 to 36) and optional extension phase (wk 36 to 72). Adults with inadequately controlled acromegaly despite receiving octreotide LAR (30 mg / 40 mg depending on the country) or lanreotide ATG (120 mg) for ≥ 3 mo will be enrolled (target [N] ~112). Patients receiving octreotide LAR 30 mg will enter a run-in phase to receive octreotide LAR 40 mg/28d (3 injections), if 40 mg dose is approved in their country by the time of screening. All patients who enter the study will receive open-label pasireotide LAR 40 mg/28d. GH and IGF-1 will be assessed every 12 wk; dose will be increased to 60 mg/28d 4 wk after the assessment in uncontrolled patients (mean GH level >1.0 μg/L and/or IGF-1 >ULN) without tolerability issues. Patients with biochemical control will continue receiving the same dose of pasireotide LAR. Dose decrease is allowed for safety reasons. During the extension phase, patients uncontrolled with pasireotide 60 mg/28d are allowed to receive concomitant medications (as per investigator’s judgment) used to treat acromegaly. Safety and tolerability will be assessed throughout the study.

Endpoints: Primary: proportion of patients with GH < 1 μg/L and IGF-1 < ULN at wk 36; Supporting analysis for primary endpoint by GH level at screening (patients with GH between 1 μg/L to 2.5 μg/L and GH > 2.5 μg/L) will be performed. Secondary: Change in mean GH (5-point profile over a 2-h period), IGF-1xULN from study baseline to wk 36; proportion of patients with a) GH < 1 μg/L and IGF-1 < ULN alone at wk 12 and 24, b) GH < 1 μg/L at wk 12, 24 and 36, c) IGF-1 < ULN at wk 12, 24 and 36 overall and by GH level at screening, safety and health-related quality of life.

Conclusions: This study will provide data on efficacy and safety of pasireotide LAR in patients with inadequately controlled acromegaly after at least 3 mo treatment with maximal approved doses of first-generation SSAs. Based on the new criteria for biochemical control, patients with GH between 1 μg/L to 2.5 μg/L will also be analyzed; a new patient population not studied in PAOLA.

 

Disclosure: AC: Advisory Group Member, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals. AMP: Employee, Novartis Pharmaceuticals. AK: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. KH: Employee, Novartis Pharmaceuticals. MRG: Consultant, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Principal Investigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Researcher, Pfizer, Inc., Principal Investigator, Ipsen, Speaker, Ipsen.

20341 5.0000 FRI-493 A Efficacy and Safety of Pasireotide Long-Acting Release (LAR) in Patients with Inadequately-Controlled Acromegaly Treated with First-Generation Somatostatin Analogues (SSA): A Study Design of a Phase IIIb Open-Label, Single Arm Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Roberto Salvatori*1, Whitney W Woodmansee2, Mark E Molitch3 and David Cox4
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 3Northwestern University Feinberg School of Medicine, Chicago, IL, 4Ipsen Biopharmaceuticals, Inc.

 

Multicenter, observational study of lanreotide depot for treatment of patients with acromegaly in the United States: an update from the SODA registry 

Introduction: The Somatuline® Depot (lanreotide) Injection for Acromegaly (SODA) study is an ongoing, multi-center, observational, post-marketing study of lanreotide-treated patients (pts) with acromegaly, reflecting the “real world” lanreotide experience. Here, we present an update on the efficacy and safety of the drug according to the SODA registry.

Methods: Acromegalic patients enrolled in SODA if they are treated with lanreotide (newly prescribed patients or switched from other agents), and give informed consent. Demographics, efficacy data, targeted adverse events (TAE), and serious adverse events (SAE) were collected.

Results: By September 9, 2014, 243 patients were enrolled in SODA (52% female; age was 49.8 ± 14.5 years). 80% and 59% of patients have been in the study for at least 1 year and 2 years, respectively. 5% received self-injections only, 10% received partner injections only, 21% received injections only from a health care provider (HCP), and 63% received both self-injections as well as administrations by a HCP. The initial lanreotide dose for most patients (70%) was 90 mg; 77% had undergone pituitary surgery, 30% were previously naïve and 52% were previously treated with another somatostatin analogue. Of the patients with IGF-1 levels measured at diagnosis, 1 year and 2 years after enrollment, mean IGF-I (SD) levels were 804 (±381) ng/mL (n=165),  348 (±140) ng/mL (n=118) and 232 (±146) ng/mL (n=86), respectively. The percentages of patients with IGF-1 below the age-adjusted upper limit of normal were 71% at 1 year and 74% at 2 years. The percentages of patients with fasting GH level ≤ 2.5 ng/mL were 83% (n=65) and 79% (n=48) for the patients with GH measured at 1 year and 2 years after enrollment, respectively. Lanreotide was well tolerated. 44 (18%) patients reported SAEs; a majority were deemed unrelated (35 unrelated; 7 possibly related; 2 probable). The 3 most commonly reported targeted AEs (TAEs) were arthralgia, headache, and diarrhea.

 Conclusions: In this open-label, observational study, nearly three-quarters of patients treated with lanreotide depot had IGF-1 levels within the age-adjusted normal range, reflecting biochemical control of acromegaly for patients remaining in the registry, with safety consistent with the known profile of lanreotide.

 

Disclosure: RS: Investigator, Pfizer, Inc., Investigator, Ipsen, Investigator, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals. WWW: Investigator, Ipsen, Investigator, Novo Nordisk, Investigator, Pfizer, Inc.. MEM: Investigator, Ipsen, Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Pfizer, Inc., Ad Hoc Consultant, Genentech, Inc.. DC: Vice President, Ipsen.

20354 6.0000 FRI-494 A Multicenter, Observational Study of Lanreotide Depot for Treatment of Patients with Acromegaly in the United States: An Update from the Soda Registry 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


John S Bevan1, Stephan Petersenn2, Pascal Maisonobe3 and Philippe Caron*4
1JJR Macleod Centre for Diabetes, Endocrinology & Metabolism (Mac-DEM), Aberdeen, Scotland, United Kingdom, 2ENDOC Center for Endocrine Tumors, Hamburg, Germany, 3Ipsen Pharma, Boulogne-Billancourt, France, 4CHU Larrey, Toulouse, France

 

Introduction: The prevalence of glucose and lipid abnormalities is increased in acromegalic patients. As somatostatin analogs also vary in their impact on glucose metabolism, it is important to investigate glucose and lipid changes for individual analogs, particularly high doses, across treatment settings. Here, we present glycemic and lipid data from PRIMARYS, a 48-wk study of primary treatment with the highest available LAN dose in patients with GH-secreting macroadenomas.

Methods: Treatment-naïve patients received primary LAN 120 mg/4 wk for 48 wks (NCT00690898). A priori analyses of A1C, FPG, and lipids during the study for the safety population were supplemented with post hoc analyses comparing FPG and lipids for patients with hormonal control (GH ≤2.5 µg/L with normal IGF-1) and without hormonal control at last post-baseline visit available [LVA]), and analyses examining correlations between IGF-1 changes vs. glycemic and lipid changes for safety population.

Results: 90 patients were treated (mean [SD] age, 49.5 [12.4] yrs, GH 15.0 [18.8] µg/L, IGF-1 810 [300] µg/L); 19 (21.1%) had a history of diabetes mellitus and 16 (17.8%) were using previous/concomitant antidiabetes medications. Mean (SD) A1C (%) and FPG levels (mmol/L) were stable during the study (A1C: baseline, 6.3 [1.5]; 12 wks, 6.2 [1.2]; 24 wks, 6.2 [1.2]; 48 wks, 6.1 [0.7]; FPG: baseline, 6.5 [2.8]; 12 wks, 6.5 [2.1]; 24 wks, 6.4 [2.2]; 48 wks, 6.2 [1.3]). There was no evidence of deterioration for patients with a history of diabetes (A1C: baseline, 8.0 [2.0]; 12 wks, 7.4 [2.3]; 24 wks, 7.4 [2.3]; 48 wks, 6.8 [1.3]; FPG: 9.1 [4.4]; 8.8 [3.7]; 8.5 [4.1]; 7.3 [1.9], respectively) or those without diabetes (A1C: baseline, 5.9 [0.9], 12 wks, 5.9 [0.4], 24 wks, 5.9 [0.4], 48 wks, 5.9 [0.4]; FPG: 5.8 [1.6], 5.9 [0.7], 5.9 [0.6], 5.9 [1.0], respectively).  Deterioration of glycemic control to levels considered diabetic occurred infrequently (A1C ≥6.5% for 1/63, 2/56, 0/47 patients with data at 3, 6, and 12 mo, respectively; FPG ≥7.0 mmol/L [126 mg/dL], for 9/63, 3/62, 5/56 patients with data). Mean (SD) baseline triglycerides, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol levels were 1.39 (0.68), 5.05 (0.98), 3.13 (0.90), and 1.30 (0.31) mmol/L, respectively. Mean (SD) lipid levels improved slightly after 12 mo (–0.20 [0.46], –0.02 [0.88], –0.12 [0.80], +0.20 [0.27] mmol/L). Hormonal control was achieved by 30/88 patients at LVA. There was no clear association between achievement of hormonal control and glucose and lipid levels (at baseline or changes from baseline to 12 mo). There were no correlations between IGF-1 changes vs. glycemic or lipid changes.

Conclusions: In treatment-naive acromegalic patients with macroadenomas, 1-yr treatment with the highest available LAN dose (120 mg/4 wks) had no overall adverse impact on glucose homeostasis and a modest positive impact on lipid levels.

 

Disclosure: JSB: Consultant, Ipsen, Study Investigator, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, ViroPharma. SP: Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc., Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer Global R&D. PM: Employee, Ipsen. PC: Consultant, Ipsen, Consultant, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Ipsen.

20426 7.0000 FRI-495 A Glucose and Lipid Levels after Lanreotide Autogel/Depot (LAN) 120 Mg in Treatment-Naïve Patients with Acromegaly: Data from the Primarys Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Aart J. van der Lely*1, Andreas M. Pleil2, Xavier Badia3, Thierry Brue4, Michael Buchfelder5, Pia Burman6, Ezio Ghigo7, Roy Gomez8, Jens Otto Lunde Jørgensen9, Anton Luger10, Joli van der Lans8, Susan M. Webb11 and Christian J Strasburger12
1Erasmus University Medical Center Rotterdam, Netherlands, 2Pfizer Inc., San Diego, CA, 3University of Barcelona, Spain, 4Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, France, 5Neurochirurgische Klinik, Universitatsklinikum Erlangen, Germany, 6Skane University Hospital, University of Lund, Malmö, Sweden, 7University Hospital Città Salute e Scienza, Turin, Italy, 8Pfizer Medical Affairs, United Kingdom, 9Aarhus University Hospital, Aarhus C, Denmark, 10Medizinische Universität Wien, Austria, 11Hospital Sant Pau Barcelona, UAB and CIBERER unit 747, Spain, 12Charité-Universitätsmedizin, Berlin, Germany

 

Introduction: Acromegaly is a rare progressive condition characterized by elevated growth hormone secretion due to a pituitary tumor. Treatment goals are to reduce/control tumor size, achieve biochemical control through normalization of biochemical parameters (GH & IGF-I) as well as improving signs and symptoms. To enable a holistic evaluation of disease activity, a disease specific tool named ACRODAT (ACROmegaly Disease Activity Tool) is in development. We hereby report on the first developmental steps of this multi-dimensional support tool, which aggregates patient-level outcome data to allow the treating endocrinologist to evaluate the patient’s health status. 

Methods: A panel of Key Opinion Leaders in the field of endocrinology, neurosurgery and acromegaly management was convened to develop ACRODAT and determine the appropriate health status parameters and scoring algorithm for this support tool.

Results: Five parameters were selected as key aspects of the patient’s condition; 1) IGF-I level; 2) tumor status; 3) comorbidities; 4) signs and symptoms; and 5) health-related quality of life (HRQoL). Each parameter was defined at three levels of severity.  The IGF-I parameter is assay-based and level is assigned using deviations from normal values. Tumor status is based on MRI and level is assigned based on change in size and invasiveness over time. The comorbidities parameter is assigned a level based on the presence or absence and severity of diabetes, sleep apnea and cardiac disease; comorbidities known to be directly related to acromegaly. The symptoms parameter is based on the self-reported presence and severity of symptoms on the PASQ (Patient Acromegaly Symptom Questionnaire). The HRQoL Impairment parameter is based on the standardized total score from a validated measure of health related quality of life. Each parameter will be scored individually, weighted by its importance to overall health status, and combined into a composite score. The result will be used to characterize the health status of the patient.  The final linear model to determine overall health status will be developed and validated by a multinational panel of expert endocrinologists based on their clinical assessment of a set of hypothetical patient cases, each described by the five clinical parameters at varying levels.

Conclusion: The value of ACRODAT is in its potential ability to provide a holistic view of disease activity at any stage of the disease independent of the therapeutic interventions received supporting the treating physicians to take appropriate actions in managing  patients with acromegaly.

 

Disclosure: AJV: Consultant, Pfizer, Inc.. AMP: Employee, Pfizer, Inc.. XB: Consultant, Pfizer, Inc.. TB: Consultant, Pfizer, Inc.. MB: Investigator, Pfizer, Inc., Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Novo Nordisk. PB: Consultant, Pfizer, Inc.. EG: Consultant, Pfizer, Inc.. RG: Employee, Pfizer, Inc.. JOLJ: Consultant, Pfizer, Inc.. AL: Speaker, Pfizer, Inc., Consultant, Pfizer, Inc., Speaker, Novo Nordisk, Consultant, Novo Nordisk, Speaker, Ipsen, Consultant, Ipsen, Speaker, Serono, Consultant, Serono. JVDL: Employee, Pfizer, Inc.. SMW: Speaker, Pfizer, Inc., Consultant, Pfizer, Inc.. CJS: Advisory Group Member, Chiasma, Advisory Group Member, Ipsen, Advisory Group Member, Pfizer, Inc..

20452 8.0000 FRI-496 A Acrodat: Identification of Disease Activity in Patients with Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Maria Mercedes Pineyro*, Ramiro Lima, Saul Wajskopf and Raul Pisabarro
Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay

 

Acromegaly (ACR) is a rare disorder with significant morbidity and mortality.  Epidemiological data are quite scant over de Latin American area. We retrospectively evaluated clinical presentation, morbidity and treatment outcomes in 31 acromegalic patients followed at our center.

Thirty-two patients (16 women, 15 men) with a mean age at diagnosis of 46 (20-76) years where followed a mean of 6.5 years. Remission was defined as age-normalized IGF-1 and, if available, a nadir GH level during OGTT <1μ/l without medical treatment, and an age-normalized IGF-1 in those on medical treatment.

Most usual presenting symptoms included acral enlargement in all, macroglossia in 80%, skin tags in 80%, sweating in 70%, headaches in 64%, symptoms of hormone deficiencies in 38% and visual field defects in 12%. The mean time among the onset of ACR-specific symptoms and diagnosis was 7.7 years (range 1,30). Etiology in all cases was pituitary tumors, with 65% presenting with macroadenomas which 30% where invasive. The most frequent co-morbidities at diagnosis where HTN (58%), diabetes and carbohydrate intolerance (45%) and dyslipemia (41%). At least one hormone deficiency was present at diagnosis in 45% of cases. Transphenoidal surgery (TSS) was the first line treatment in 25 patients (80%), with 3 patients having a second TSS and one patient a 3rd operation. Six patients did not have surgery: 2 have been recently diagnosed and are awaiting TSS, 1 had radiotherapy (RT), 1 went to live abroad and was lost to follow-up and 2 are on primary medical therapy (PMT). Twelve patients (38%) where treated by TSS alone. Seventeen patients (68%) went on to have medical treatment, with somatostatin analogs (SA) in 44 %, dopamine agonists in 36% and 3 patients received both. In some cases patients received SA intermittently due to availability issues. Seven patients (28%) went on to have RT.  One patient (0.02%) received TSS combined with RT, 6 patients (19%) TSS combined with medical treatment and 8 patients (25%) a combination of the 3 treatment modalities.  Six patients where lost to follow-up, and 1 patient died. Outcomes in 21 out of 29 patients revealed 12 patients in remission (57%). Of these, six had only 1 TSS, 1 had 3 TSS, 3 received RT after TSS, 1 received SA after TSS and 1 patient is on PMT. Mean size of tumor of patients in remission was 11 vs. 16 mm on those with active disease. Appraisal of co-morbidities showed 91% (11/12) of patients with colonic polyps, 56%(14/25) with myocardial hypertrophy, 100% (16/16) with sleep apnea, and 47% (10/21) with goiter or MNG. One patient presented with a meningioma 18 years after RT.

In conclusion, patients presented with marked signs of ACR and substantial morbidity. Patients in remission presented with smaller tumors, and a multimodal approach was necessary to achieve control in half of them.  Treatment outcomes could be improved by earlier diagnosis, focused care and exploiting medical treatment options.

 

Nothing to Disclose: MMP, RL, SW, RP

20456 9.0000 FRI-497 A Clinical Presentation and Outcomes in 31 Patients with Acromegaly Followed at the University Hospital in Uruguay 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Jeremy Richard Anthony*1, Daniel Brat1, Octavian C Ioachimescu2, Nelson M Oyesiku1 and Adriana Gabriela Ioachimescu1
1Emory University School of Medicine, Atlanta, GA, 2Emory University School of Medicine, Atlanta VA Medical Center, Atlanta, GA

 

Atypical adenomas are defined by Ki-67 (MIB-1) proliferative index >3%, p53 immunoreactivity, and increased mitotic activity. The predictive value of these markers has not been established as correlative data with clinical course is sparse. Our aim is to evaluate their impact on long-term outcomes in acromegaly.

We reviewed data on 106 patients who underwent their first transsphenoidal adenectomy (TSA) by a single neurosurgeon between January 1994 and October 2013. Of them, 79 had histologically-confirmed GH adenomas and follow up >3 months. We performed atypia marker evaluation is 39 patients in whom tumor sample was available.

The cohort included 25 women/14 men of age 43.8±13.1 followed for a median of 43.5 months (24.6-101.7).  Mean tumor diameter was 2.1±1.1 cm. Nine patients (23%) had Ki-67>3% (range: 4-10%); they were younger (36.3±11.6 vs 47.1±11.7) but had similar preoperative IGF-1, GH, prolactin, tumor diameter and similar proportion of patients with cavernous sinus invasion as those with normal Ki-67. The group with abnormal Ki-67 included more patients with tumors exhibiting increased mitoses (33% vs 0%) and p53 immunopositivity (66.6% vs 23.3%). There was no difference in CAM5.2 immunoreactivity, postoperative biochemical remission (44.4 vs 36.6%) or time to biochemical control with medical therapy between groups. Univariate analysis showed that none of the atypia markers were associated with postoperative remission. Predictors of remission included cavernous sinus invasion, diameter, preoperative GH and IGF-1 in the univariate analysis, and cavernous sinus invasion in multivariate analysis.

Two patients fulfilled all 3 criteria of atypical adenoma (5.1%).  Of them, one had an aggressive postoperative course. This is a 28 year old man with a 4.1cm adenoma, Ki-67 of 10% and tumor residual in the cavernous sinus, pterygopalatine fossa, foramen ovale, and medial aspect of the right temporal lobe. He had sudden increase in tumor size causing mass symptoms despite normalized IGF-1 after 5 months of octreotide LAR treatment. After repeat debulking surgery, fractionated radiation therapy and while taking lanreotide depot, he remained in biochemical control with a significant decrease of tumor residual. After 2 more years, he suddenly developed eye proptosis due to contiguous extension of pituitary adenoma into his right orbit; repeat Ki-67 was 25%.

In summary, atypical pituitary adenomas are rare in acromegaly - 5.1% in our series. Atypia makers do not seem to predict postoperative outcome in acromegaly. Further research is needed to identify specific histological markers to predict tumor behavior.

 

Nothing to Disclose: JRA, DB, OCI, NMO, AGI

20738 10.0000 FRI-498 A Prognostic Significance of Markers of Histological Atypia in Acromegaly: An Emory University Extended Cohort Series 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Christian J Strasburger*1, Judith Hey-Hadavi2, Ann-Charlotte Akerblad3, Anders F. Mattsson4, Maria Koltowska-Haggstrom5, Patrick Wilton6 and Beverly M.K. Biller7
1Charite Universitätsmedizin, Berlin, Germany, 2Pfizer Inc, New York, NY, 3Endocrine Care, Pfizer Health AB, Sollentuna, Sweden, 4Pfizer Health AB, Sollentuna, Sweden, 5Uppsala University, Uppsala, Sweden, 6Stockholm, Sweden, 7Massachusetts General Hospital/Harvard Medical School, Boston, MA

 

Introduction & Methods

Medical treatment options for acromegaly include somatostatin analogues (SSAs), dopamine agonists (DA), and pegvisomant (peg); they can be used alone or in combination.  The global ACROSTUDY database was interrogated to characterize the cohorts of patients receiving pegvisomant in combination with long acting SSA (Combo-SA) or with DA (Combo-DA) versus those receiving pegvisomant alone (Peg-only). The current analysis included data from 1715 patients enrolled between June 2004- September 2012. 

Results

At pegvisomant treatment start there were 971 Peg-only patients, 604 in the Combo-SA and 100 in the Combo-DA groups, with 40 patients receiving other combinations such as short-acting SSA. Between 2004 and 2011, the proportion of Combo-SA patients steadily increased from 31 to 54% while concomitantly the proportion of Peg-only patients declined from 58 to 35%. The frequency of Combo-SA differed between countries and was most common in the Netherlands and in Italy, with 60 and 55% of patients in those countries treated with both medications, whereas in Germany and the USA, Combo-SA was only used in 26 and 19% of patients, respectively. The average dose per day of peg given in the different treatment groups was 16.5mg for Combo-SA, 18.3mg for Combo-DA and 17.2mg for Peg-only.

At 1, 2 and 5 years into treatment with pegvisomant, the rates of patients with normal IGF-I levels for age in the Combo-SA group were 61.7, 59.1 and 63.4% as compared to 61.2, 64.7 and 69.1% in the Peg-only group and 47.0, 60.8 and 58.3% in the Combo-DA groups, respectively. Overall adverse event (AE) / serious adverse event (SAE) rates in the different groups were 577/97,  728/104  and 410/88 AE/SAEs per 1000 treatment exposure years in the Combo-SA, Combo-DA and Peg-only groups, respectively. The most commonly reported adverse events in all groups were injection site reactions and increased hepatic enzymes. 

Conclusion

Whereas pegvisomant monotherapy was the most common treatment regimen in ACROSTUDY, many patients were treated with pegvisomant in combination with SSA-LA and/or DA.  The use of combination therapy was not associated with different doses of pegvisomant, and appeared to produce similar rates of normal IGF-I levels and adverse events.  Combination therapy use has increased over time and there are significant regional differences in treatment patterns.

 

Disclosure: CJS: Advisory Group Member, Pfizer, Inc., Advisory Group Member, Ipsen, Advisory Group Member, Chiasma. JH: Employee, Pfizer, Inc.. ACA: Employee, Pfizer, Inc.. AFM: Employee, Pfizer, Inc.. MK: Employee, Pfizer, Inc.. PW: Consultant, Pfizer, Inc.. BMKB: Consultant, Pfizer, Inc., Consultant, Novartis Pharmaceuticals, Principal Investigator, Novartis Pharmaceuticals.

20876 11.0000 FRI-499 A Use of Combination Medical Therapy Is Common in Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Andrea Giustina*1, John S Bevan2, Marcello D Bronstein3, Felipe F Casanueva4, Philippe Chanson5, Stephan Petersenn6, Xuan-Mai Truong Thanh7, Christine Massien7, Carla Dias-Barbosa8, Isabelle Guillemin8, Benoit Arnould8 and Shlomo Melmed9
1University of Brescia, Italy, 2JJR Macleod Centre for Diabetes, Endocrinology & Metabolism (Mac-DEM), Aberdeen, Scotland, United Kingdom, 3Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil, 4Universidad de Santiago de Compostela, Santiago de Compostela, Spain, 5Hôpital Bicêtre, Kremlin-Bicêtre, France, 6ENDOC Center for Endocrine Tumors, Hamburg, Germany, 7Ipsen Pharma, Boulogne Billancourt, France, 8Mapi, Lyon, France, 9Cedars-Sinai Medical Center, Los Angeles, CA

 

Introduction: The SAGIT tool has been developed to help endocrinologists accurately stage and classify patients with acromegaly in everyday clinical practice. It records five elements of the disease: signs and symptoms (S), associated comorbidities (A), growth hormone (GH) concentration (G - assessed as GH nadir after oral glucose tolerance test or GH random/series), insulin-like growth factor-1 concentration (I), and tumor (T). In the first phase of pilot testing, the tool was assessed by practicing endocrinologists to identify potential areas for improvement; endocrinologists exclusively used patients’ medical records in this phase. The tool was then revised. In the second stage of pilot testing reported here, practicing endocrinologists without prior knowledge of the SAGIT tool assessed acceptability, understanding, and possible uses of the tool, with the majority (9/13) completing the tool in clinical-practice conditions.

Methods: Endocrinologists from France (n=2), Germany (n=1), Italy (n=2), Spain (n=2), and the USA (n=2) completed the SAGIT tool for patients in real time. Endocrinologists from Brazil (n=2) and the UK (n=2) used medical records. Nine patients had active acromegaly and 10 had controlled/stable acromegaly; a further seven patients were treatment-naïve. Endocrinologists then reported their perceptions and opinions of the tool using the PRAC Test® (PRAgmatic Content and face validity Test) (or cognitive debriefing interview for endocrinologists from Brazil and the UK).

Results: Endocrinologists had no difficulties completing the S, A, I, and T elements of the tool and reporting respective scores based on patients’ data. Endocrinologists reported that GH tests are not undertaken in some countries or in some specific situations (e.g. patient with diabetes). Accordingly, the GH element of the tool had missing data (n=2). Four endocrinologists provided both GH nadir after oral glucose load and GH random/series for patients rather than just one of these items. The large majority of endocrinologists found the tool both concise (n=12) and easy to understand, simple and quick to complete (n=11); 10 found the tool informative. Endocrinologists most commonly reported that the tool information would be useful for research purposes (n=8), decision-making (n=8), and assessing the response to therapy (n=7). Implications for decision making in clinical practice was a key aspect needing improvement. Scores for the elements of the SAGIT tool were sensitive to patients’ acromegaly status.

Conclusions: Face and content validity of the SAGIT tool have been demonstrated, as was its applicability in clinical practice and research. The planned validation study will define scoring rules, and also provide interpretations and recommendations for managing patients in clinical practice.

 

Disclosure: AG: Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Pfizer, Inc.. JSB: Consultant, Ipsen, Study Investigator, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, ViroPharma. MDB: Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc., Advisory Group Member, Chiasma, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Principal Investigator, Ipsen, Principal Investigator, Novartis Pharmaceuticals. PC: Researcher, Ipsen, Researcher, Novartis Pharmaceuticals, Researcher, Novo Nordisk, Researcher, Pfizer, Inc., Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Viropharma, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc.. SP: Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc., Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer Global R&D. XMT: Employee, Ipsen. CM: Employee, Ipsen. CD: Consultant, Ipsen. IG: Consultant, Ipsen. BA: Consultant, Ipsen. SM: Planning Group Member, Ipsen, Ad Hoc Consultant, Genentech, Inc.. Nothing to Disclose: FFC

20914 12.0000 FRI-500 A Sagit©: A Novel Clinician-Reported Outcome Tool for Managing Acromegaly in Clinical Practice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Iulia Potorac1, Patrick Petrossians1, Adrian F Daly1, Liliya Rostomyan1, Mona Sahnoun-Fathallah2, Frederic Castinetti3, Thierry Brue4, Orsalia Alexopoulou5, Dominique Maiter5, Franck Schillo6, France Devuyst7, Bernard Corvilain7, Ammar Muhammad8, Sebastian J.C.M.M. Neggers8, Fahrettin Kelestimur9, Christof Schofl10, Flavius Zoicas10, Michael Buchfelder11, Elena Nazzari12, Laura Roffredo12, Diego Ferone12, Florina Luca13, Bernard Goichot13, Gerald Raverot14, Veronique Lapras15, Sophie Kalfon15, Susan M. Webb16, Analia Emilce Ramos17, Frederic Illouz18, Vincent Rohmer18, Patrice Rodien19, Rogelio Garcia Centeno20, Vaclav Hana21, Farida Nasybullina22, Gulnar Vagapova22, Jean-François Bonneville*1 and Albert Beckers1
1CHU de Liège-University of Liège, Liège, Belgium, 2La Timone Hospital, Marseille, France, 3La Conception Hospital, Marseille, France, 4Hopital de la Conception, Marseille, France, 5Université Catholique de Louvain, Brussels, Belgium, 6CHU Besancon, Besancon, France, 7Universite Libre de Bruxelles, Bruxelles, Belgium, 8Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands, 9Faculty of Medicine, Erciyes University, Kayseri, Turkey, 10Universitätsklinikum Erlangen, Erlangen, Germany, 11University Hospital Erlangen, Erlangen, Germany, 12University of Genova, Genova, Italy, 13CHU Strasbourg, Strasbourg, France, 14Hospices Civils de Lyon, Lyon Cedex 03, France, 15CHU Lyon, Lyon, France, 16Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain, 17Universitat Autonoma de Barcelona, Barcelona, Spain, 18CHU Angers, Angers, France, 19CHU Angers - Centre Hospitalier Universitaire, Angers, France, 20Hospital Univesitario Gregorio Maranon, Madrid, Spain, 21Charles University, Prague, Czech Republic, 22Kazan State Medical Academy, Kazan, Russia

 

Introduction: Several predictive factors of response to treatment in acromegaly are currently used. Imaging criteria include pituitary adenoma size and cavernous sinus invasion which may impede surgical cure. However, there are no official imaging prognostic criteria of somatotropinoma response to somatostatin analogue (SSA) therapy. It is known that somatotropinomas are more frequently hypointense on T2-weighted MRI sequences than other types of pituitary adenomas. These T2-hypointense adenomas are usually smaller and therefore, more rarely invasive, and correspond to higher IGF1 levels. However, an evaluation of the response, both anti-secretory, as well as anti-proliferative, of somatotropinomas to primary therapy with SSA has not been comprehensively studied and constitutes the purpose of our work.

Materials and methods: Acromegalic patients treated with SSA as primary therapy were included in this multicentric, international study, both prospectively and retrospectively. The duration of therapy varied from 3 to 12 months. The results of biological and MRI evaluations at baseline and after treatment were recorded and statistically analysed. T2-weighted signal of the adenoma was classified as hypointense, isointense or hyperintense compared to the normal pituitary tissue or when the latter was not visualized, to the grey matter of the temporal lobe.

Results: 105 patients were included in the study (51 male, 54 female). These patients were diagnosed at 54 years (male 47 vs female 59). GH nadir levels during OGTT were 5.3 ng/ml (2.7-17.4), while IGF1% was 316% (229-385). T2-weighted signal was hypointense for 69 adenomas (65.7%), isointense for 21 adenomas (20%) and hyperintense for 15 adenomas (14.3%). T2-hypointense adenomas were smaller, had higher GH nadir and IGF1% levels and presented an invasion of the cavernous sinus or compression of the optic chiasm more rarely than the iso- or hyperintense groups. Treatment duration did not vary significantly between the T2-hypo-, iso- or hyperintense groups. However, T2-hypointense adenomas had a better biological response to SSA with a decrease in GH of 84.6% (vs 20.9% for T2-isointense and 38.4% for T2-hyperintense, p=0.002) and IGF1% of 59.3% (vs 23.9% for T2-isointense and 41.8% for T2-hyperintense, p=0.003). The anti-proliferative response was also better for T2-hypointense adenomas with a decrease of the vertical diameter of 22% (vs 1.9% for T2-isointense and 11.8% for T2-hyperintense adenomas, p=0.0006).

Conclusions: T2-weighted signal of the pituitary adenoma on the diagnostic MRI of acromegalic patients allows the classification of somatotropinomas into different categories. The T2-hypointense adenomas, smaller and with a higher GH secretion, also present a better response to primary therapy with SSA, both anti-secretory and anti-proliferative.

 

Nothing to Disclose: IP, PP, AFD, LR, MS, FC, TB, OA, DM, FS, FD, BC, AM, SJCMMN, FK, CS, FZ, MB, EN, LR, DF, FL, BG, GR, VL, SK, SMW, AER, FI, VR, PR, RG, VH, FN, GV, JFB, AB

21144 13.0000 FRI-501 A Do T2-Hypointense GH-Secreting Pituitary Adenomas Behave Differently Under Somatostatin Analogues As Primary Therapy in Acromegaly? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Antonio Bianchi*1, Sabrina Chiloiro2, Antonella Giampietro3, Linda Tartaglione4, Marilda Mormando2, Francesca Lugli5, Serena Piacentini2, Francesco Doglietto6, Carmelo Anile7, Giulio Maira7, Libero Lauriola7, Guido Rindi7, Alfredo Pontecorvi3 and Laura De Marinis5
1Catholic University, School of Medicine,, Rome, Italy, 2Catholic University of the Sacred Heart, Rome, Italy, 3Catholic University, Rome, Italy, 4Catholic Univ Sch of Medicine, Rome, Italy, 5Catholic University, School of Medicine, Rome, Italy, 6University of Brescia, Brescia, Italy, 7Università Cattolica del Sacro Cuore, Rome, Italy

 

Previous studies showed that Ki-67 labeling may predict clinical outcome and somatostatin analogs (SSA) response in acromegaly. No data are available about pegvisomant (PEGV) treatment and proliferative markers. Therefore, we evaluate whether Ki-67 is a predictor of pegvisomant response in somatotropinomas resistant to SSA

We selected 27 consecutive acromegalic patients referred to our hospital during a 7-yr period. The Ki-67 index was determined by immunohistochemistry on tissue samples obtained from each adenoma after surgery. All patients, who were not completely cured after surgery and after at least 1 year of SSA, began medical therapy with PEGV. Periodical pituitary magnetic resonance imaging and hormonal evaluation were performed during the follow-up.

No correlation was found between Ki-67 index and age, tumor size and extension, GH, or IGF-I plasma levels. There was no difference in Ki-67 levels between patients controlled and not controlled with PEGV, but in not controlled IGF-I levels before PEGV were higher than in controlled one. Final daily PEGV dose was significantly increased in not controlled patients.

In conclusion, in acromegalic patients resistent to SSA, Ki-67 not appear to be a predictor of response to Pegvisomant.

 

Nothing to Disclose: AB, SC, AG, LT, MM, FL, SP, FD, CA, GM, LL, GR, AP, LD

21957 14.0000 FRI-502 A Ki-67 Is Not a Predictor of Acromegaly Response to Pegvisomant 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Cornelie D. Andela1, Nienke R. Biermasz2, Adrian A Kaptein1, Alberto M. Pereira1 and Jitske Tiemensma*3
1Leiden University Medical Center, Leiden, Netherlands, 2Leiden University Medical Center, Netherlands, 3University of California Merced

 

Context: Patients with acromegaly can be treated with surgery, radiotherapy and/or medically with somatostatin analogs (SA). In general, beliefs about medication are associated with illness perceptions, a contributory factor of Quality of Life (QoL). At present, there are no studies available about medication beliefs in patients with acromegaly.

Objective: To compare illness perceptions of patients with and without medical treatment, and examine possible associations between medication beliefs and illness perceptions and QoL in patients with acromegaly.

Design and subjects:  Cross-sectional evaluation in 75 patients in long-term remission of acromegaly (n=28 with medication, n=47 without mediation). The Beliefs about Medicines Questionnaire, Illness Perception Questionnaire-Revised, EuroQoL-5D, and AcroQoL were used for the assessment.

Results: Patients with medical treatment perceive a more chronic timeline of acromegaly, compared with patients without medication (P=0.002). Stronger beliefs about the necessity of SA and stronger concerns about the adverse effects were associated with attributing more symptoms to acromegaly, perceiving more negative consequences, and having a stronger belief in a cyclical timeline (all P<0.05). Stronger beliefs about the necessity of SA were associated with a worse disease-specific QoL (P<0.01).

Conclusion: Patients in long-term remission of acromegaly who receive SA treatment perceive a more chronic timeline of their disease, compared with patients without medication. Negative medication beliefs in patients after long-term remission of acromegaly are related to more negative illness perceptions and worse disease-specific QoL. These results need to be taken into account when developing a psychosocial education program/self-management program aiming to improve QoL in these patients.

 

Disclosure: NRB: Coinvestigator, chiasma. Nothing to Disclose: CDA, AAK, AMP, JT

22013 15.0000 FRI-503 A No Medication Means No Chronic Illness to Patients with Acromegaly: Negative Medication Beliefs Are Related to More Negative Illness Perceptions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM FRI 489-503 6105 1:00:00 PM Pituitary Tumors-Acromegaly Poster


Farid Saad*1, Mahmoud Nasser2, Ahmad Haider3, Aksam A Yassin4, Winfried Kurtz5, Gheorghe Doros6, Monika Fijak7, Linda Vignozzi8 and Louis J Gooren9
1Bayer Pharma AG, Berlin, Germany, 2University of Aleppo, Aleppo, Syria, 3Private Urology Practice, Bremerhaven, Germany, 4Segeberger Kliniken, Norderstedt, Germany, 5Klinikum Bremerhaven, Bremerhaven, Germany, 6Boston University School of Public Health, Boston, MA, 7Justus-Liebig University, Giessen, Germany, 8University of Florence, Florence, Italy, 9VU University Medical Center, Amsterdam, Netherlands

 

Introduction:

Anti-inflammatory effects of testosterone (T) have been demonstrated in numerous studies. Effects of T in auto-immune models have been studied experimentally (Fijak M et al., J Immunol 2011, 186: 5162-5172). We previously reported effects of two years of T treatment in a small group of hypogonadal men with Crohn’s disease (Haider A et al., Horm Mol Biol Clin Invest 2010; 2(3): 287–292). We report now further results in this group grown to 92 subjects.

Methods:

In a prospective, cumulative, observational registry study, 92 hypogonadal men with Crohn’s disease and with T 12.1 nmol/L from 2 centers in Germany and 1 in Aleppo, Syria received treatment with parenteral testosterone undecanoate every 12 weeks following an initial 6-week interval for up to 84 months. 12 hypogonadal men of similar age with Crohn’s disease did not receive T and served as control group (CTRL). The Crohn's Disease Activity Index (CDAI) was assessed every 3 months. Highly sensitive C-reactive protein (hsCRP), leukocyte count and liver transaminases (AST and ALT) were measured. The Aging Males’ Symptoms Scale (AMS) was used as a quality of life (QoL) instrument. 5 patients in the T group had osteoporosis.

Results:

T levels at baseline were 9.68 ± 1.09 nmol/L in the T group and 9.57 ± 2.96 in CTRL. During treatment, T increased to 17.5 ± 8.39 and slightly declined in CTRL. The CDAI decreased from 241.15 ± 39.97 to 71.54 ± 3.15 in the T group and increased from 207.14 ± 24.24 to 227.27 ± 24.43 in CTRL. hsCRP (mg/dl) levels at baseline were 12.63 ± 8.73 in the T group vs 8.11 ± 2.29 in CTRL. They decreased to 1.54 ± 1.41 after 84 months in the T group and increased to 10.41 ± 2.76 in CTRL. Leukocyte count decreased from 11.8 ± 2.95 to 6.23 ± 0.97 x 109/l in the T group and remained unchanged in CTRL (11.71 ± 1.1 at baseline to 11.63 ± 1.49 at 18 months, NS). AST declined from 42.91 ± 17.97 to 19.77 ± 3.61 U/l, ALT from 45.9 ± 17.17 to 20.15 ± 4 U/l in the T group. Changes for both were statistically significant vs. baseline (p<0.0001) each year and vs. previous year for the first three years. Both enzymes showed a tendency to increase in the comparison group. AMS improved from 49.47 ± 8.11 in the T group to 17.33 ± 0.58. In CTRL, AMS remained unchanged from 47.17 ± 1.03 at baseline to 48 at the end of the observation period. 5 patients in the T group had osteoporosis. T-scores in these patients improved from approximately -2.9 to approximately -1.8.

Conclusion:

Normalisation of T in hypogonadal men with Crohn’s disease led to improvements of the CDAI, hsCRP, a reduction of leukocytes, liver transaminases (AST and ALT), and an improvement of QoL. The mechanism of this improvement may be through anti-inflammatory and immunosuppressive effects of testosterone, reducing chronic inflammation of the intestinal wall in Crohn’s Disease. In (elderly) men with Crohn’s Disease, serum T should be measured.

 

Disclosure: FS: Employee, Bayer Schering Pharma. MN: Coinvestigator, Bayer Schering Pharma. AH: Investigator, Bayer Schering Pharma. AAY: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. Nothing to Disclose: WK, MF, LV, LJG

19448 1.0000 FRI-127 A Hypogonadal Patients with Crohn's Disease Benefit from Treatment with Testosterone – Further Data from an Ongoing, Long-Term, Observational Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 127-134 6119 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Ahmad Haider*1, Karim Sultan Haider1, Gheorghe Doros2, Abdulmaged M Traish3 and Farid Saad4
1Private Urology Practice, Bremerhaven, Germany, 2Boston University School of Public Health, Boston, MA, 3Boston University School of Medicine, Boston, MA, 4Bayer Pharma AG, Berlin, Germany

 

Objective:

Testosterone replacement therapy (TRT) in hypogonadal men is still controversial. This registry was established to assess long-term effectiveness and safety of TU in a urological setting.

Material and Methods:

Observational, prospective, cumulative registry study in 347 men (age: 57.32 ± 7.12 years) with total testosterone (T) levels below 12.1 nmol/L and symptoms of hypogonadism. They received parenteral TU 1000 mg/12 weeks following an initial 6-week interval for up to 7 years. Patients were entered into the registry after receiving at least 4 injections of TU. A variety of parameters were measured every 3 or 6 months.

Results:

This cohort represented a mixed population with a variety of comorbidities: type 2 diabetes mellitus (n=126, 36.3%), cardiovascular disease (n=68, 19.6%), inflammatory bowel diseases (IBD; n=61, 17.6%), osteoporosis (n=61, 17.6%), Klinefelter’s syndrome (n=36, 10.4%), psoriasis (n=15, 4.3%).

Mean total T at baseline was 9.84 nmol/L (283.8 ng/dl). It increased to trough levels of 17 nmol/L (490 ng/dl) within the first year and remained stable thereafter.

Anthropometry: Waist circumference progressively decreased from 105.77 to 97.74 cm, weight from 103.87 to 87.82 kg with statistical significance vs previous year for both measures over the entire observation period. Weight loss was 16.67% at 7 years.

Lipids: Total cholesterol (TC) decreased from 278.55 to 186.77, LDL from 162.09 to 109.64, triglycerides (TG) from 271.8 to 188.01 mg/dl. HDL increased from 55.05 to 66.26 mg/dl (p< 0.0001 vs baseline for all). TC:HDL ratio declined from 5.79 to 3.12, TG:HDL from 5.38 to 3.05.

Blood pressure (BP): Systolic BP dropped from 151.35 to 135.34, diastolic BP from 90.73 to 76.18 mmHg. Heart rate decreased from 77.54 to 73.94 bpm (p< 0.0001 vs baseline for all).

Glycemic control: Fasting glucose declined from 102.68 to 96.3 mg/dl, reaching a plateau after 2 years. HbA1c decreased from 6.88 to 5.67% with statistical significance vs previous year over the entire observation period

Liver transaminases: AST dropped from 39.85 to 18.99, ALT from 41.9 to 19.33 U/L with a plateau after 3 years.

Inflammation: CRP decreased from 5.42 to 0.51 mg/dl with a plateau after 4 years. The high baseline level could be attributed to the fact that 61 patients had IBD.

During the first treatment year and before joining the registry, an estimated 5-10% of patients decided to not continue TRT. Once in the registry, no further dropouts were recorded suggesting an excellent adherence. During the entire observation time, no major adverse cardiovascular event occurred.

Conclusions:

Long-term TRT with TU in an unselected cohort of hypogonadal men resulted in improvements in a variety of anthropometric and metabolic parameters. Long-term TU was well tolerated and excellent adherence suggested a high level of patient satisfaction.

 

Disclosure: AH: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: KSH, AMT

19433 2.0000 FRI-128 A Long-Term Experience of 21.678 Patient-Months with Testosterone Undecanoate (TU) Injections from a Single Urologist's Office: Observational Effectiveness Data from a Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 127-134 6119 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Ahmad Haider*1, Karim Sultan Haider1, Gheorghe Doros2, Abdulmaged M Traish3 and Farid Saad4
1Private Urology Practice, Bremerhaven, Germany, 2Boston University School of Public Health, Boston, MA, 3Boston University School of Medicine, Boston, MA, 4Bayer Pharma AG, Berlin, Germany

 

Objective:

The safety of testosterone replacement therapy (TRT) in hypogonadal men is still questioned. This registry was established to assess long-term effectiveness and safety of TU in a urological setting.

Material and Methods:

Observational, prospective, cumulative registry study in 347 men (age: 57.32 ± 7.12 years) with total testosterone (T) levels below 12.1 nmol/L and symptoms of hypogonadism. They received parenteral TU 1000 mg/12 weeks following an initial 6-week interval for up to 7 years. Patients were entered into the registry after receiving at least 4 injections of TU. A variety of parameters were measured every 3 or 6 months.

Results:

This cohort represented a mixed population with a variety of comorbidities: type 2 diabetes mellitus (n=126, 36.3%), cardiovascular disease (n=68, 19.6%), inflammatory bowel diseases (IBD; n=61, 17.6%), osteoporosis (n=61, 17.6%), Klinefelter’s syndrome (n=36, 10.4%), psoriasis (n=15, 4.3%).

Mean total T at baseline was 9.84 nmol/L (283.8 ng/dl). It increased to trough levels of 17 nmol/L (490 ng/dl) within the first year and remained stable thereafter.

Prostate: Prostate volume increased from 28.98 (max.: 56) to 30.87 (max.: 59) ml. This increase was statistically significant vs baseline and vs previous year for the first 3 years. Prostate volume was stable thereafter. Prostate specific antigen (PSA) increased slightly from 1.73 to 1.79 ng/ml (p=0.0151 vs baseline). Biopsies were performed if PSA increased to >4 ng/ml or by >0.75 ng/ml within 12 months, or if there were suspicious findings upon digital rectal examination (DRE) or transrectal ultrasound (TRUS). 6 patients (1.7%) were diagnosed with low-grade prostate cancer (PCa) corresponding to an incidence per 10,000 years of 27.7 (95% confidence interval 11.5-66.5). All patients were successfully treated by radical prostatectomy.

Erythropoiesis: Haemoglobin rose from 14.47 to 15.09 g/dl, reaching a plateau after 2 years. Haematocrit increased from 43.7 to 48.59% with the highest single measurement of 56%. Changes were statistically significant vs previous year for the first 2 years.

Liver function: Aspartate transaminase decreased from 39.85 to 18.99 U/L, alanine transaminase from 41.9 to 19.33 U/L. Both transaminases reached a plateau after 3 years.

Kidney function: Creatinine remained stable throughout the entire observation time at values between 0.77 and 0.82 mg/dl.

During the first treatment year and before joining the registry, an estimated 5-10% of patients decided to not continue TRT. Once in the registry, no further dropouts were recorded suggesting excellent adherence. During the entire observation time, no major adverse cardiovascular event occurred. No acute urinary retention was reported.

Conclusions:

Long-term TRT with TU was well tolerated. 6 patients were diagnosed with low-grade PCa and successfully treated. Otherwise, no major adverse events were reported.

 

Disclosure: AH: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: KSH, AMT

19436 3.0000 FRI-129 A Long-Term Experience of 21.678 Patient-Months with Testosterone Undecanoate (TU) Injections from a Single Urologist's Office: Observational Safety Data from a Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 127-134 6119 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Ahmad Haider*1, Karim Sultan Haider1, Gheorghe Doros2, Farid Saad3 and Abdulmaged M Traish4
1Private Urology Practice, Bremerhaven, Germany, 2Boston University School of Public Health, Boston, MA, 3Bayer Pharma AG, Berlin, Germany, 4Boston University School of Medicine, Boston, MA

 

Introduction and Objective:

Concerns regarding the safety of testosterone treatment, particularly regarding PCa in middle-aged and elderly men, still hamper the use of testosterone in hypogonadal men. In this study, we investigated prostate parameters incl. incidence of PCa in hypogonadal patients on long-term treatment with TU.                                                   

Methods:

In a prospective, cumulative registry study, 340 men (age: 57.37 ± 7.03 years) with testosterone ≤12.1 nmol/L received TU 1000 mg every 12 weeks following an initial interval of 6 weeks for up to 7 years. Prostate volume (PV) and PSA were measured and digital rectal examination (DRE)/ transrectal ultrasound (TRUS) performed before treatment initiation and then regularly every 3-6 months. In case of suspected PCa, biopsies were performed.

Results:

PV increased from 28.96 ± 10.41 to 29.88 ± 13.85 ml by model-adjusted 2.59 ± 0.2 ml (p<0.0001). This increase was statistically significant compared to the previous year for the first four years.

PSA increased from 1.74 ± 0.94 to 1.96 ± 1.03 ng/ml by model-adjusted 0.23 ± 0.52 ng/ml (p<0.0001). 

53 biopsies were performed in testosterone-treated patients. Of these, 5 (9.4%) were positive and 48 (90.6%) negative. The proportion of PCa in testosterone-treated patients in our registry study was 1.5% with an incidence of 30.7 per 10,000 patient years.

In hypogonadal patients without testosterone treatment, 314 biopsies were performed. Of these, 111 (35.4%) were positive and 203 (64.6%) negative.

In eugonadal patients, 584 biopsies were performed. Of these, 263 (40.4%) were positive and 321 (55%) negative.

In total, 951 prostate biopsies were performed in our practice from 2004 through 2013, of which 379 (42.2%) were positive and 519 (57.8%) negative.

Conclusions:

Long-term treatment with TU in hypogonadal men undergoing regular monitoring according to EAU guidelines does not increase the incidence of PCa.

 

Disclosure: AH: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: KSH, AMT

19438 4.0000 FRI-130 A Incidence of Prostate Cancer (Pca) in 340 Hypogonadal Men Treated with Testosterone Undecanoate Injections (TU) for up to 7 Years: Observational Data from a Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 127-134 6119 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Ahmad Haider*1, Aksam A Yassin2, Gheorghe Doros3, Abdulmaged M Traish4 and Farid Saad5
1Private Urology Practice, Bremerhaven, Germany, 2Segeberger Kliniken, Norderstedt, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA, 5Bayer Pharma AG, Berlin, Germany

 

Background:

Obesity can cause hypogonadism, and hypogonadism promotes further accumulation of fat mass in a vicious cycle. In excessively obese men (defined by BMI 40 kg/m2) awaiting bariatric surgery, a 75% prevalence of hypogonadism was found [1]. Testosterone (T) treatment has been shown to improve body composition and reduce weight [2-5]. We studied the effects of normalising testosterone in hypogonadal men with excessive obesity.

Methods:

Cumulative, prospective, observational registry studies of 609 men from two cohorts with total T levels ≤12.1 nmol/L receiving TU for up to 11 years. A subgroup of 39 men with excessive obesity (BMI minimum: 40.1; maximum: 46.5 kg/m2) had received uninterrupted treatment for up to 114 months (9.5 years). Minimum treatment duration was 42 months, maximum 114 months.

Results:

Average weight decreased from 128.7 kg to 101.5 kg. The average weight loss was 27.2 kg. The magnitude of weight loss was dependent on treatment duration, i.e. the longer the treatment, the greater the weight loss. Minimum weight loss was 18 kg in a subject who had received 42 months of treatment, maximum weight loss of 39 kg was observed in a man who had been treated for 87 months. No subject gained weight, and the weight loss was progressive over time.

Average waist circumference decreased from 118.0 cm to 104.9 cm. The average reduction was 13.1 cm. The smallest reduction of 6 cm was seen in a man who had been treated for 57 months, the greatest reduction of 25 cm was observed in a man who had been treated for 114 months.

20 of the 39 men (51%) had type 2 diabetes mellitus (T2DM), 1 had type 1 diabetes mellitus (T1DM). Average HbA1c in the T2DM patients was 8.25% (minimum: 6.7; maximum: 9.1%). The T1DM patient had an HbA1c of 8.8%. At the end of the observation period, average HbA1c of the T2DM patients had dropped to 6.7% (minimum: 5; maximum: 7.1%). The average reduction was 2.1% (minimum: 0.8; maximum: 3.2%). HbA1c in the T1DM patient dropped from 8.8 to 5.8 by 3.0%.

Conclusions:

Treating hypogonadism by TU in hypogonadal men with excessive obesity resulted in sustained improvements in weight and waist circumference in all subjects. The magnitude depended on treatment duration. In patients with T2DM or T1DM, long-term T therapy resulted in marked and sustained improvements in glycaemic control.

 

Disclosure: AH: Investigator, Bayer Schering Pharma. AAY: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: AMT

21815 5.0000 FRI-131 A Effects of Long-Term Treatment with Testosterone Undecanoate Injections (TU) on Excessively Obese, Hypogonadal Men – Experience from an Observational Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 127-134 6119 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Aksam A Yassin*1, Dany-Jan Yassin2, Gheorghe Doros3, Abdulmaged M Traish4 and Farid Saad5
1Segeberger Kliniken, Norderstedt, Germany, 2Klinikum Braunschweig, Braunschweig, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA, 5Bayer Pharma AG, Berlin, Germany

 

Introduction:

The longest-term follow-up on testosterone replacement therapy (TRT) in hypogonadal men in the literature is 6 years. In this registry study, we assessed effects of TRT beyond this period.

Methods:

Single-center, cumulative, prospective, registry study of 262 hypogonadal men receiving TU for up to 11 years. Cut-off for total testosterone (T): 12 nmol/L (~350 ng/dl). In 147 men, TRT had been temporarily discontinued due to reimbursement issues or diagnosis of prostate cancer. In 115 men reported here, TRT was never interrupted for up to 11 years. 115 men were treated for a minimum of 4 years, 114 for 5, 97 for 6, 70 for 7, 57 for 8, 48 for 9, and 23 for 10 years. 4 patients dropped out, 2 due to relocation, 2 were lost to follow-up for unknown reasons. Measures were taken at every other visit. Results at the end of 10 years follow-up are reported.

Results:

Mean age was 59.05 ± 9.36 years (min.: 19; max.: 80).

Total T increased from 7.84 ± 2.34 nmol/L to trough levels (measured prior to the following injection) between 17 and 20 nmol/L, free T from 150.31 ± 65.24 to 400-500 pmol/L, and SHBG decreased from 40.12 ± 20.73 to 33.11 ± 22.14 nmol/L (p<0.0001).

Mean waist circumference decreased from 106.47 ± 8.72 to 92.33 ± 5.32 cm. The decrease was statistically significant vs baseline (p<0.0001) and significant vs previous year for the first 7 years. Mean weight decreased from 97.3 ± 12.88 to 84.65 ± 7.04 kg. The decrease was statistically significant vs baseline (p<0.0001) and significant vs previous year for the first 8 years. Mean BMI decreased from 30.81 ± 4.33 to 27.06 ± 2.49 kg/m2 The decrease was statistically significant vs baseline (p<0.0001) and significant vs previous year for the first 8 years. Weight reduction was progressive and accumulated to 18.51 ± 6.46% after 10 years. The reduction of waist circumference was 11.98 ± 5.03%.

Total cholesterol (TC) decreased from 251.15 ± 46.77 to 172.02 ± 12.09 mg/dl (p<0.0001 vs baseline, statistical significance vs previous year for the first 7 years), LDL from 156.9 ± 25.43 to 98.09 ± 17.62 (p<0.0001 vs baseline, statistical significance vs previous year for the first 3 years), triglycerides (TG) from 235.72 ± 89.26 to 158.04 ± 20.99 (p<0.0001 vs baseline, statistical significance vs previous year for the first 4 years). HDL increased from 42.41 ± 12.61 to 56.52 ± 6.34 mg/dl (p<0.0001 vs baseline, statistical significance vs previous year for the first 3 years).

TC:HDL ratio improved from 6.59 ± 2.82 to 3.08 ± 0.33 (p<0.0001). Non-HDL cholesterol decreased from 208.74 ± 52.35 to 115.5 ± 11.31 mg/dl (p<0.0001, statistical significance vs previous year for the first 7 years). TG:HDL ratio improved from 6.24 ± 3.53 to 2.82 ± 0.38  (p<0.0001).

No major adverse cardiovascular event (MACE) occurred during the entire observation time.

Conclusions:

Long-term TRT improved anthropometric and lipid parameters in hypogonadal men in a meaningful and sustained fashion.

 

Disclosure: AAY: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: DJY, AMT

20889 6.0000 FRI-132 A Effects of Continuous Treatment up to 11 Years with Testosterone Undecanoate Injections (TU) in 115 Hypogonadal Men on Hormonal, Anthropometric and Lipid Parameters: Real-Life Data from an Observational Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 127-134 6119 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Aksam A Yassin*1, Yousef Al Mehmadi2, Gheorghe Doros3, Abdulmaged M Traish4 and Farid Saad5
1Segeberger Kliniken, Norderstedt, Germany, 2Institute for Urology and Andrology, Norderstedt, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA, 5Bayer Pharma AG, Berlin, Germany

 

Objective:

This study investigated effects of long-term TRT, its withdrawal and re-treatment on metabolic parameters in hypogonadal men.

Material and methods:

Prospective, cumulative, registry study. 262 hypogonadal patients (mean age 59 years) received testosterone undecanoate (TU) 1000 mg injections in 12-week intervals for a maximum of 11 years. After having been on TRT for a median duration of 5 years, 147 men interrupted TRT for 2 years, mainly due to cost reimbursement issues, and resumed TRT thereafter (Group A; A). 115 men were treated continuously (Group B; B). To compare on-treatment to off-treatment periods, three periods of equal duration were defined: pre-interruption (on TRT), during interruption (off TRT) and post interruption (on TRT after resumption of TRT). For comparison, the same periods were analysed for those patients who continued TRT throughout.

Anthropometric and metabolic parameters were measured at every other visit.

Results:

A: Total testosterone was 16.54 pre, dropped to 7.48 and increased to 18.5 nmol/L post interruption. B: Total testosterone was stable at 19.61, 19.76 and 19.65 nmol/L.

A: Waist circumference was 100.16 pre, increased to 105.44 during and decreased to 102.29 cm post interruption. B: Waist circumference declined progressively from 98.4 to 97.2 and 95.7 cm.

A: Weight was 92.1 pre, increased to 97.1 during and decreased to 94.4 kg post interruption. B: Weight declined progressively from 87.7 to 86.2 and 84.4 kg.

A: Fasting glucose (mg/dl) was 104.2 pre, increased to 116.8 during and dropped to 89.2 post TRT interruption. B: fasting glucose decreased progressively from 92.6 to 88.3 and 80.2.

A: HbA1c (%) was 5.9 pre, rose to 6.7 during and decreased to 6.0 post interruption. B: HbA1c decreased continuously from 5.8 to 5.7 and 5.6.

A: Total cholesterol (mg/dl) was 224 pre, increased to 284 during and dropped to 201 post. B: total cholesterol decreased progressively from 197 to 186 and 174.

A: HDL (mg/dl) was 51 pre, decreased to 38 during and rose to 58 post. B: HDL increased continuously from 54 to 55 and 58.

A: LDL (mg/dl) was 131 pre, increased to 163 during and dropped to 116 post. B: LDL decreased progressively from 120 to 111 and 102.

A: Triglycerides (mg/dl) were 223 pre, increased to 289 during and dropped to 192 post. B: triglycerides showed fluctuations from 177 to 203 and 148.

A: Systolic blood pressure (SBP; mmHg) was 125 pre, increased to 137 during and dropped to 121 post TRT interruption. B: SBP remained stable at 119,117 and 116.

A: Diastolic blood pressure (DBP; mmHg) was 77 pre and remained stable at 77 during and 74 post TRT interruption. B: DBP remained stable at 75, 73 and 72.

In Group A, 6 patients had major adverse cardiovascular events (MACE) while off TRT. There were no MACEs in Group B or in Group A while patients were on TRT.

Conclusions:

Interruption of TRT resulted in worsening of symptoms. Hypogonadism may require lifelong TRT.

 

Disclosure: AAY: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: YA, AMT

19430 7.0000 FRI-133 A Effects of Interrupting and Resuming Long-Term Testosterone Replacement Therapy (TRT) on Anthropometric and Metabolic Parameters in Hypogonadal Elderly Men. How Long Should Hypogonadal Subjects be Treated? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 127-134 6119 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Aksam A Yassin*1, Yousef Al Mehmadi2, Gheorghe Doros3, Abdulmaged M Traish4 and Farid Saad5
1Segeberger Kliniken, Norderstedt, Germany, 2Institute for Urology and Andrology, Norderstedt, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA, 5Bayer Pharma AG, Berlin, Germany

 

Objective:

This study investigates effects of long-term TRT, its withdrawal and re-treatment on prostate, urinary parameters, erectile function and quality of life in hypogonadal men.

Material and methods:

Prospective, cumulative, observational registry study. 262 hypogonadal patients (mean age 59 years) received testosterone undecanoate (TU) 1000 mg injections in 12-week intervals for a maximum of 11 years. After having been on TRT for a median duration of 5 years, 147 men interrupted TRT for 2 years, mainly due to cost reimbursement issues, and resumed TRT thereafter (Group A; A). 115 men were treated continuously (Group B; B). To compare on-treatment to off-treatment periods, three periods of equal duration were defined: pre-interruption (on TRT), during interruption (off TRT) and post interruption (on TRT after resumption of TRT). For comparison, the same periods were analysed for those patients who continued TRT throughout.

Prostate volume and residual voiding volume were measured by ultrasound at every other visit. International prostate symptoms score (IPSS), International Index of Erectile Function-erectile function domain (IIEF-EF) and Aging Males’ Symptoms questionnaire (AMS) were filled in and blood samples taken. Because lower urinary tract symptoms are associated with inflammation, C-reactive protein (CRP) was also determined.

Results:

A: Total testosterone was 16.54 pre, dropped to 7.48 during and increased again to 18.5 nmol/L post TRT interruption. Group B: testosterone remained stable at 19.61, 19.76 and 19.65 nmol/L.

A: Prostate volume was 33.8 pre, 33.8 during and increased to 35.3 ml post interruption. B: prostate volume increased slightly from 33 to 33.7 and 34 ml.

A: PSA was 1.9 pre, decreased to 1.4 during and increased again to 1.6 ng/ml post. B: PSA remained stable at 1.3, 1.4 and 1.4 ng/ml.

A: Post voiding urine volume was 16.9 pre, increased to 26.5 during and decreased again to 16.5 ml post interruption. B: post voiding urine volume decreased from 14.5 to 13.7 and 13.3 ml.

A: IPSS was 7.7 pre, increased to 11.2 during and decreased again to 7.6 post TRT interruption. B: IPSS decreased slightly from 6.1 to 5.8 and 5.7.

A: IIEF-EF was 17.8 pre, decreased to 12.5 during and increased to 18.2 post TRT interruption. B: IIEF-EF increased from 18.9 to 19.4 and 19.9.

A: AMS was 36.5 pre, 57.7 during and 31.9 post TRT interruption. B: AMS improved from 30.3. to 27.8 and 25.5.

A: CRP was 1.02 pre, increased to 1.05 during and decreased to 0.99 mg/dl post. B: CRP continuously decreased from 1.07 to 0.88 and 0.87 mg/dl.

While off TRT, 4 patients had acute urinary retention. 2 underwent transurethral resection of the prostate (TURP), 1 patient underwent TURP due to persistent severe obstructive symptoms.

Conclusion:

Interruption of TRT resulted in worsening of symptoms. Hypogonadism may require lifelong TRT.

 

Disclosure: AAY: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: YA, AMT

19431 8.0000 FRI-134 A Long-Term Testosterone Treatment: Effects of Therapy Withdrawal and Re-Treatment in Hypogonadal Elderly Men on Prostate, Sexual and Voiding Functions, and Quality of Life 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM FRI 127-134 6119 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Anna Nordenstrom*1, Agnieszka Butwicka2, Henrik Falhammar1, Angelica Lindén Hirschberg3, Catarina Almqvist4, Agneta Nordenskjöld5 and Louise Frisen1
1Karolinska Institutet, Stockholm, Sweden, 2Karolinska Instituet, Stockholm, Sweden, 3Dept. of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden, 4Karolinska Instiutet, Stockholm, Sweden, 5Karolinska Institutet, Sockholm, Sweden

 

Congenital adrenal hyperplasia (CAH) is one of the most common monogenic autosomal recessive disorders with an incidence of 1 in 15000. About 1 in 70 individuals in the population are carriers of a classic CYP21A2 mutation. It has been questioned whether that confers a survival advantage. The HPA axis has been reported to be more active in CYP21A2 carriers. This prompted us to investigate the vulnerability to psychological stress in obligate carriers of classic mutations.

Methods

The Swedish CAH registry comprises more than 600 patients. Through the multigenerational registry parents to patients with classical CAH, SW or SV form, were identified (n=395). We used the diagnosis of the child as the psychological stressor. Psychiatric diagnoses, in the national diagnosis registry, before and after the birth of a child with CAH were investigated. Parents of children in the general population, with hypospadias or with diabetes type 1 (T1DM) were used as controls.

Results

Parents of children with CAH had less risk of receiving a psychiatric diagnosis of affective disorder or substance miss-use after the diagnosis of the child, compared to the general population, Odds Ratio (OR) 0.3 (95%CI 0.2-0.7) and 0.3 (0.1-0.8) respectively after the child’s birth. Compared to parents with a child with hypospadias OR was 0.5 (0.2-0.9) and 0.3 (0.1-0.7), and compared to parents of a child with T1DM OR was 0.4 (0.2-0.9) and 0.2 (0.1-0.6) respectively.

Discussion

CAH and T1DM are both potentially life threatening diseases that requires daily treatment and extra attention from the parents. Hypospadias and CAH affect genital development that may lead to uncertainty of gender assignment at birth, known as a stressful event for the parents. Obligate CYP21A2 carriers seemed to be less vulnerable to these psychologically stressful situations, at least with respect to psychiatric diagnosis. The results indicate a better ability to cope with psychological stress among heterozygous carriers of severe CYP21A2 mutations.

 

Nothing to Disclose: AN, AB, HF, ALH, CA, AN, LF

22416 1.0000 LBF-064 A Are Heterozygous Carriers of CYP21A2 Less Vulnerable to Psychological Stress? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Emilia Modolo Pinto*1, Xiang Chen2, John Easton2, David Finkelstein2, Zhifa Liu2, Stanley Pounds2, Carlos Rodrigues Galindo2, Bonald Cavalcante Figueiredo3, Jinghui Zhang2, James R Downing2, Raul C Ribeiro2 and Gerard P Zambetti2
1St. Jude Children's Research Hospital, Memphis, TN, 2St. Jude Children's Research Hospital, 3Instituto de Pesquisa Pele Pequeno Principe, Curitiba PR, Brazil

 

Pediatric adrenocortical tumor is a rare malignancy with poor prognosis and frequently arise in the context of Li-Fraumeni and others constitutive genetic syndromes. We performed a comprehensive genomic analysis using whole genome sequencing, whole exome sequencing and transcriptome profiling in a total of 37 cases representing the spectrum of ACT in the pediatric age group including those with Beckwith-Wiedemann and Li-Fraumeni syndrome associated, wild-type TP53 and cases with the founder R337H TP53 mutation. The tumors were clonally heterogeneous and chromosomal instability was a hallmark. Most cases (91%) show loss of heterozygosity (LOH) of chromosome 11p, with uniform selection against the maternal chromosome. IGF2 on chromosome 11p is overexpressed in 100% of the tumors. TP53 mutations and chromosome 17 LOH with selection against wild-type TP53 are observed in 28 ACTs (76%). Copy-neutral loss of heterozygosity for chromosomes 11 and 17 was prevalent and observed during early tumorigenesis, indicating likely driver events. ACTs associated with germline TP53 mutations showed a complex spectrum of genomic alterations whereas those with wild-type TP53 were more stable. Recurrent somatic mutations were rare, and additional acquired mutation was observed in ATRXCTNNB1 and integration of human herpesvirus-6 in chromosome 11p. A dismal outcome is predicted by concomitant TP53 and ATRX mutations and associated genomic abnormalities, including massive structural variations and a high background mutation rate. Collectively, these findings demonstrate the nature, timing and potential prognostic significance of key genetic alterations in pediatric ACT and outline a hypothetical model of adrenocortical tumorigenesis and potentially other embryonal tumors.

 

Nothing to Disclose: EMP, XC, JE, DF, ZL, SP, CRG, BCF, JZ, JRD, RCR, GPZ

22483 2.0000 LBF-065 A Genomic Landscape of Pediatric Adrenocortical Tumors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Sandhya Khurana*1, Julie Grandbois2, Phong Nguyen2, Heather Peltsch2, Suet Lo2, Krishnan Venkataraman1 and T.C. Tai1
1Northern Ontario School of Medicine, Sudbury, ON, Canada, 2Laurentian University, Sudbury, ON, Canada

 

Human health and disease are influenced not only by the genetic make up of an individual, but also to a great degree by environmental factors. The prenatal environment can be a significant determinant of long-term health outcomes. An adverse fetal milieu such as undernourishment or exposure to environmental insults can have long-term developmental consequences impacting adult health, a phenomenon known as fetal programming. Epidemiological data suggests that conditions in utero can be linked to the development of diseases such as hypertension, diabetes and other pathophysiological conditions in adulthood. Studies suggest that fetal programming of adult diseases is mediated by glucocorticoids (GCs); either endogenous (ex. maternal stress), or exogenous (ex. synthetic GCs administered to aid in the development of the premature babies). Indeed, prenatal exposure to high levels of GCs can predispose the offspring to hypertension. Glucocorticoids regulate catecholamine biosynthesis and are critical for blood pressure homeostasis, with elevated levels leading to hypertension. The purpose of this study was to examine whether prenatal exposure to elevated GC levels influences the development of adult hypertension via alternations in adrenaline synthesis. We investigated the impact of prenatal GC exposure on the post-natal regulation of the gene encoding for phenylethanolamine N-methyltransferase (PNMT), the enzyme involved in the biosynthesis of the catecholamine, adrenaline. PNMT has been linked to hypertension and is elevated in animal models of hypertension. Pregnant Wistar-Kyoto dams were injected with either 100 μg/kg/day of the synthetic glucocorticoid dexamethasone (DEX) or saline in the third trimester of pregnancy. Blood pressure and weights of the offspring were measured (3 to 17 weeks of age), at which point the animals were sacrificed and tissues collected. The results show that systolic, diastolic and mean arterial blood pressures were elevated in WKY rat offspring born to DEX injected dams, with males showing a more pronounced increase as compared to females. Adrenal PNMT mRNA was elevated in prenatally DEX-exposed rats at 17 weeks.  Additionally, analyses of the transcriptional regulators of the PNMT gene show that prenatal GC exposure increased mRNA levels of Egr-1, AP-2, Sp-1 and GR with differences in both males and females. These results suggest that prenatal GC exposure increases adrenal PNMT gene expression via altered transcriptional regulation. The study exemplifies the influence of in utero stress on PNMT and thereby adrenaline biosynthesis as a potential mechanism by which elevated prenatal GC levels may program for hypertension later in life.

 

Nothing to Disclose: SK, JG, PN, HP, SL, KV, TCT

22862 3.0000 LBF-066 A Role of Adrenal Phenylethanolamine N-Methyltransferase in a Fetal Programming Model of Hypertension 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Maha Elhassan*1, Susan McDonough2, Delia M Vazquez1, Charles R Neal Jr2, Juan F Lopez2 and Niko R Kaciroti2
1University Of Michigan, Ann Arbor, MI, 2University of Michigan, Ann Arbor,, MI

 

Background: Women at risk for depression (HR) have altered Hypothalamic Pituitary Adrenal (HPA) axis during pregnancy without clinical signs of depression. Offspring of women with frank depression during pregnancy have early evidence of behavior difficulties in infancy when exposed to the Still Face experiment; a controlled situation in which mothers briefly refrain from interacting with their infants. The observed behavior difficulties are associated to cognitive and behavioral dysfunction in childhood.

Objective:We hypothesized that infants born to HR mothers have an altered HPA axis. We, thus, examined infants’ cortisol reactivity to The Still Face paradigm.

Study Design: Pregnant women between 8 and 28 weeks of gestation were recruited between 2003-2006 from 3 obstetrics clinics in Michigan. Women were screened using The Edinburgh Postpartum Depression Scale and the Beck Depression Inventory followed by Structural Clinical Interview for DSM IVto confirm absence of clinical depression. Mothers were divided into two groups; women with high risk, but currently not depressed (HR) and women with no psychopathology or low risk (LR). Women and offspring were followed longitudinally. At 3 and 7 months, the mother and infant dyads participated in a Still Face experiment [3 months n= 75 (HR=56, LR=19), 7 months n=43 (HR=36, LR = 7)]. Saliva were collected from both infants and mothers on arrival to the procedure room (basal T0, during free play prior to the Still Face (T1), 10 minutes (T2) and 30 minutes (T3) after Still Face. Salivary cortisol levels were quantified with ELISA (™Salimetrics). Statistical analysis was done using STATA 13.0. Significance was defined with a p value <0.05.

Results:  Compared to infants born to LR mothers: 1.Three months old infants born to HR mothers had higher cortisol levels at T2 (p= 0.013); 2. Infants born to HR mothers had higher cortisol at 7 months of age at T0 (p= 0.0001), T1 (p= 0.0005) and T2 (p= 0.0024); 3. At 7 months of age, infants born to HR mothers exhibited significantly higher total cortisol levels (p= 0.0006;  4. There was a significant change in overall infants' total cortisol secretion during Still Face from 3 months to 7 months (p= 0.0446) for both groups. 

Conclusion: Infants born to HR mothers have high cortisol response during Still Face at age 3 and 7 months when compared to infants born to mothers with low risk for depression. High allosteric load imposed by activation of the HPA axis is associated with poor health outcomes (e.g. obesity, diabetes and hypertension). Future studies will be designed to explore early interventions in this at risk population

 

Nothing to Disclose: ME, SM, DMV, CRN, JFL, NRK

22432 4.0000 LBF-067 A Cortisol Reactivity during Still Face in Infants Born to Mothers at Risk of Depression during Pregnancy and Post-Partum Period 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Ali Saeed Alzahrani*1, Mai Almohanna2, Hindi Al-Hindi3, Ebtesam Qasem1 and Mohammed Almehthel4
1King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia, 2King Faisal Specialist Hospital & research center, 3King Faisal Specialist Hospital & research center, Riyadh, Saudi Arabia, 4King Faisal Specialist Hosp & Research Centre, Riyadh, Saudi Arabia

 

Background

BRAFV600E mutation (BRAF) occurs commonly in melanoma and papillary thyroid cancer (PTC). TERT promotor mutations (C228T and C250T) occur in gliomas and were found recently to occur in PTC with more aggressive histopathological features1.  Similarly, a fibroblast growth factor receptor 4 (FGFR4) single nucleotide polymorphism (SNP) at codon 388 (G388R) has been found to be associated with more aggressive histopathogical features and higher risk of recurrence in a number of cancers including pancreatic neuroendocrine tumors2.  In this study, we investigated the frequency of these genetic mutations/SNP and their association with histopathological scores in a large sample of adrenocortical tumors.

Patients and Methods

We extracted DNA from formalin embedded paraffin blocks of 66 adrenocortical tumors operated at our hospital during the period 1990-2012.  Twenty nine tumors (44%) were adrenocortical cancer (ACC) and 37 tumors were benign non-functioning adrenocortical adenomas (ACA).  The median (range) Weiss score in ACA and ACC were 1 (0-2) and 6 (2-9), respectively (P <000.1).  The patients were 36 females and 30 males and their median age was 45.5 years (range 3-85). Amplifications of DNA fragments that contained the mutations/SNP were performed using primers and PCR conditions described previously1,2. Successfully amplified fragments were resolved on a 2% agarose gel electrophoresis and directly sequenced using dideoxy termination method (Applied Biosystems, 3730XL)

Results

BRAF mutation was detected in only 3 cases out of 60 tumors (5%) successfully amplified.  Two cases were ACC (2/26, 7.7%) while 1 case was benign ACA (1/34, 2.9%). The benign ACA was 5 cm in size with a Weiss score of 1 and an Aubert score of zero.  The two ACC cases with BRAF positive mutation were 6 cm each and had a Weiss score of 4 and 5 and Aubert scores of 5 and 6, respectively.  TERT promotor mutations were absent in all but one tumor (1of 60 successfully amplified fragments, 1.7%) which had a C228T TERT promotor mutation. The patient was a 24-year old lady with a 16-cm ACC with Weiss score of 9 and Aubert score of 7. The distribution of FGFR4 G388R polymorphism was similar in ACA {GG (48.6%), GA (51.4%) and AA (0%)} compared with ACC {GG (39.3%), GA (57.1%) and AA (3.6%)}, P=0.42.  In cases of ACC, Weiss score and Aubert score were not different between GG genotype and GA/AA genotype.  Similarly, they were no significant differences between G and A alleles.  These results suggest that FGFR4 G388R polymorphism is not associated with an increased risk of malignancy or a higher grade in adrenocortical tumors.

Conclusions

BRAF and TERT promotor mutations occur at a low frequency in benign and malignant adrenocortical tumors.  BRAF occurs not only in ACC but also in benign ACA.  FGFR4 G388R polymorphism has a similar distribution between ACA and ACC and is not associated with more aggressive features or a higher histopathological score of ACC.

 

Nothing to Disclose: ASA, MA, HA, EQ, MA

22568 5.0000 LBF-068 A Low Frequency of BRAFV600E and TERT Promotor Mutations in Adrenocortical Tumors and Lack of Association of FGFR4 G388R Polymorphism with Adrenocortical Cancer Occurrence and Histopathological Score 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Shao Ling Zhang*1, Hailun Lin2, Huisheng Xiao2 and Li Yan3
1Sun Yat-sen University, Sun Yat-sen Memorial Hospital, Guangzhou, China, 2SUN YAT-SEN MEMORIAL HOSPITAL, 3Sun Yat-sen University, Sun Yat-sen Memorial Hospital

 

Menstrual disturbance due to hypercortisolism in Cushing’s syndrome(CS) often leads to infertility so that pregnancy during CS is extremely rare with only a few cases reported. Notably, cortisol producing adenoma (CPA) are more commonly found in pregnant CS cases. Once diagnosed, treatment could be consisted of conservative therapy, surgical treatment and medical treatment, depending on the plasma cortisol level, severity of complications, gestational weeks and the patient’s general state. There is still no confirmative evidence to ascertain the optimal approach with maternal and fetal morbidity reduction. Here, we report a case of a gravida with CPA , who was conservatively treated during the third trimester of pregnancy until delivery. Unilateral adrenalectomy was performed postpartum.

Clinical case:

A 27-year-old gravida (G2P0A1) woman was referred to our hospital at 28 week 2 day weeks of pregnancy for mild hypertension, gestational diabetes mellitus, hypokalemia and mild edema of lower legs. Physical examination revealed cushingoid features-moon face, buffalo hump, striaes in abdominal and lower limb. Her blood pressure was 146/84 mmHg and body mass index was 26.8kg/m2. Endocrinological tests revealed exceeding cortisol production and abnormalities in circadian rhythm of cortisol: 8am 924nmol/L(118nmol/L<n<618nmol/L), 4pm 733.26nmol/L, 12mn 959.39nmol/L; mid-night salivary cortisol were 61.95 nmol/L and 48.89 nmol/L(0 pmo/L<n<10.4 pmo/L); basal urinary free cortisol were 2611 nmol/24h, 2590 nmol/24h and 2554 nmol/24h (153 nmol/24h <n<789 nmol/24h); plasma ACTH was consistently suppressed below detection limit (5 pg/mL). There was no suppression of cortisol with both 1mg and 8mg overnight dexamethasone test. Serum potassium level was 3.12mmol/L. Obstetrical laboratory tests were normal except 75g oral glucose screening test (FPG 4.4mmol/L, 1h PG 12.0mmol/L, 2h PG 9.5mmol/L).Abdominal ultrasound demonstrated a left adrenal mass measuring 2.0cm in diameter, which was confirmed by MRI scanning of the adrenal glands while pituitary MRI scanning was normal. Respecting the patient’s wishes, conservative therapy was applied to carry her pregnancy to full-term (38 weeks): blood pressure was strictly monitored and blood glucose was well controlled by insulin. No maternal and fetal complications occurred during gestation and delivery. As scheduled, left adrenalectomy was conducted 2 months after delivery. Shortly after operation, she was asymptomatic and achieved the normalization of blood pressure, blood glucose,serum potassium and cortisol level.

Conclusion:

In pregnant CS cases with mild hypercortisolism and mild complication, conservative symptomatic therapy and postpartum surgery may avoid unnecessary adverse effect and contribute to uneventful gestation and delivery.

 

Nothing to Disclose: SLZ, HL, HX, LY

22665 6.0000 LBF-069 A A Case of Mild Cushing’s Syndrome during Pregnancy with Conservatively Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Andrea Paissan*, Valeria de Miguel, Maria Belen Bosco, Andrea Kozak, Patricio Garcia Marchiñena, Rodrigo Castro Azcurra and Patricia Fainstein Day
Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

 

Background: Ectopic Cushing´s Syndrome is associated with markedly raised of

ACTH and cortisol levels that leads to impaired the immune response, increasing the

occurrence of opportunistic infections. Severe hypercortisolism increases morbidity and

mortality

Clinical case:

A 49 year-old man with a history of obesity and hypertension experienced progressive

muscle weakness, polyuria, polydipsia and weight loss during the last two months. He

was admitted to his community hospital for atrial fibrillation due to severe hypokalemia

and for uncontrolled hyperglycemia.

He was referred to our hospital with a presumptive diagnosis of Cushing´s Syndrome

(CS). He had clinical features of CS, severe hypertension, proximal muscle atrophy

and skin hyperpigmentation. Biochemical studies revealed high levels of 24-hour

urinary free cortisol (UFC): 3855 mcg (up to 100 mcg) and late-night free salivary cortisol:

55 nm/L (0.7-5 nm/L), serum cortisol after 1 mg-overnight dexamethasone suppression test (DXM): 73.7 mcg/dl (<1.8 mcg/dl) and plasma ACTH: 189 pg/dl (10-46 pg/dl), serum cortisol after 8-mg-DXM: 32 mcg/dl. Pituitary MRI was

normal. CT scan of the chest showed multiple lung opacities, a 27 mm mediastinal

nodule and diffuse adrenals enlargement. A CT guided biopsy of the lung was

performed which showed acute inflammatory cells, predominantly neutrophils and

gram-positive filamentous rods suggestive of Nocardia. Empirical antibiotic

therapy with trimethropin-sulfamethoxazole and ketoconazole were started. Cushing`s-

related symptoms worsen and 24 UFC levels increased up to 15.500 mcg in spite of

the maximum dose of ketoconazole (1600 mg/day). An octreotide challenge test was

also ineffective. He underwent a successfully bilateral laparoscopic adrenalectomy

(BLA) with rapid improvement of the clinical status. A follow-up CT scan of the chest

revealed resolution of the pulmonary infiltrates. Several months later the mediastinal

nodule was resected and the histology reported adipose tissue without neoplastic cells.

One year later he is asymptomatic, on hydrocortisone and fludrocortisone therapy, and

the ACTH source remains occult.

Conclusions:

Establishing the source of ACTH may be difficult and opportunistic infections must be

considered in patients with ectopic CS. BLA is a safe and effective treatment for

patients with occult ectopic CS resistant to medical therapy.

 

Nothing to Disclose: AP, VD, MBB, AK, PG, RC, PF

22688 7.0000 LBF-070 A Ectopic Cushing´s Syndrome Associated to Pulmonary Nocardiosis Treated with Bilateral Adrenalectomy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Hans Kumar Ghayee*1, Vikash Bhagwandin2, Juilee Rege3, Victor Stastny4, Fiemu Nwariaku4, Adi Gazdar4, Jerry Shay5, William E. Rainey3 and Richard J. Auchus3
1University of Florida College of Medicine, FL, 2University of California San Francisco, 3University of Michigan, Ann Arbor, MI, 4University of Texas Southwestern Medical Center, 5University of Texas Southwestern Medical Center, Dallas, TX

 

Background: Adrenal cortical tumors are commonly found in 1 to 9% of adults.  Most of these tumors do not cause a hormone excess syndrome, but others are functional.  Adrenal tumor formation and behavior are difficult to study because limited cell line models are available. The NCI-H295 human adrenal cortical carcinoma cell line and its substrains are the only models commonly in use, but these cells have limitations in their ability to model adrenal adenomas and normal adrenal cells. We thus sought to establish human adrenal cortical cell lines from benign neoplasms. 

Methods:  Tissues from an aldosterone-producing adenoma (APA, line 1) and a DHEAS-producing macronodular hyperplasia (line 2) were excised surgically, minced, dispersed with collagenase & DNAse 1, and passaged in ACL-4 medium. Primary APA cells were infected with lenti-virus containing human telomerase reverse transcriptase (hTERT) and selected with blastocidin. Primary hyperplasia cells were infected with lenti-viruses containing hTERT and the human papilloma virus early genes E6/E7 and selected with G418. The resultant lines were characterized with phase-contrast microscopy.  RNA was isolated and used in quantitative polymerase chain reaction (qRT-PCR) to assess the expression of steroidogenic factor-1 (SF1, NR5A1), steroidogenic enzymes (CYP11A1, CYP11B2, CYP17A1, SULT2A1, 3BHSD2, and AKR1C3), and cofactor proteins (StAR, CYB5A) relative to cyclophin A (PPIA) and compared to the H295R and the non-steroidogenic SW13 adrenal-derived cell lines.

Results:  The 2 cell lines have been in culture for 6 years and propagated for over 800 passage doublings. The cells have an epithelial and cuboidal appearance with variably granular cytoplasm. The expression of SF1 in the 2 lines was 580 to 840-fold higher than in the non-steroidogenic SW13 line and only 2 to 3-fold lower than the control H295R human adrenal cortical carcinoma cell line. In contrast to the steroidogenic H295R cells, however, both of these new cell lines showed low expression of several steroidogenic enzymes.

Conclusions:  We have established 2 new, SF1-positive human adrenal cortical cell lines from benign neoplasias.  These cell lines appear to mimic non-functional adrenal adenomas and might have de-differentiated from their steroidogenic phenotypes during passaging.

 

Disclosure: WER: Scientific Board Member, Atterocor. Nothing to Disclose: HKG, VB, JR, VS, FN, AG, JS, RJA

22900 8.0000 LBF-071 A Preliminary Characterization of Two New Human Adrenal Cortical Cell Lines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Stephaine Curry* and Julie R. Chan
Lahey Hospital & Medical Center, Burlington, MA

 

A 45-year-old female with a past medical history of Hepatitis B and hypertension was referred to hematology for evaluation of polycythemia, discovered by a dermatologist she had seen for hair loss.  The hair loss began approximately 8 months earlier and had gradually worsened.  She denied any acne, but had always bruised easily; no hirsutism or deepening of her voice.  She had noticed overall fatigue and increasing leg weakness, especially with climbing stairs.

She had recently been diagnosed with hypertension, and her blood pressure remained difficult to control even with two antihypertensive medications.  She denied any headaches or palpitations, but reported occasional dizziness.  She would periodically experience hot flashes of her face.   No history of pulmonary disease.  She was a non-smoker. 

Exam revealed temporal recession of the hairline with thinning of hair at the vertex, mildly erythematous conjunctiva with flushing of her cheeks, and thin skin with several bruises on the lower extremities as well as trace edema; the remainder of her physical examination was unremarkable.  On laboratory evaluation she was found to have elevated hemoglobin and hematocrit values of 16.6 g/dL and 48.5% respectively.  Further investigation revealed an inappropriately normal erythropoietin level, consistent with secondary polycythemia rather than polycythemia vera.  Thus, the patient was sent for CT scan to rule out a renal mass. 

CT scan revealed a 2 cm left adrenal nodule, in addition to uterine fibroids and liver hemangiomas.  Both adrenal tumors and uterine fibroids have been associated with polycythemia, but given the patient’s other symptoms the decision was made to first proceed with hormonal assessment of the adrenal nodule since the fibroids were otherwise asymptomatic.  Hyperaldosteronism, pheochromocytoma, and adrenal hyperandrogenism were ruled out, but there was evidence of hypercortisolism based on late-night salivary cortisol and 24-hour urine cortisol testing, with suppressed ACTH, consistent with ACTH-independent Cushing’s syndrome.  The patient underwent laparoscopic left adrenalectomy, and her hematocrit normalized to 37.8 % by one month postoperatively.

This case was presented to increase awareness of the potential occurence of polycythemia secondary to a cortisol-producing adrenal adenoma.  The polycythemia seen in Cushing’s is usually mild; the underlying mechanism remains unclear, but may involve the myelostimulatory effect of glucocorticoids.  There have been case reports of polycythemia resolving after a pituitary adenomectomy for Cushing’s disease.  Secondary polycythemia, however, may be due to increased production of erythropoietin secondary to a tumor; the inappropriately normal erythropoietin level in our patient suggests that the polycythemia may have in part been mediated by erythropoietin produced by the adrenal adenoma.

 

Nothing to Disclose: SC, JRC

22691 9.0000 LBF-072 A Cortisol-Producing Adrenal Adenoma Presenting with Polycythemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Antonio M Lerario*1, Tobias Else1, William E. Rainey1, Siyuan Zheng2, Roel Verhaak2, Thomas J Giordano1 and Gary D Hammer1
1University of Michigan, Ann Arbor, MI, 2The University of Texas MD Anderson Cancer Center, Houston, TX

 

Background: Adrenocortical carcinoma (ACC) is a rare cancer with a dismal prognosis. In terms of clinical phenotypes and outcomes, ACC is a heterogeneous disease. Recent work has suggested that distinct molecular subtypes may explain the observed heterogeneity. However, important aspects of the molecular pathogenesis of ACC remain unknown. A broad characterization of the molecular alterations in a representative cohort is essential for understanding the pathogenic mechanisms that drive ACC. Here, we present the genomic, epigenomic and proteomic profiling of 91 ACCs as a part of The Cancer Genome Atlas (TCGA). Patients and methods: Ninety-one samples of primary tumors from patients with chemo and radiotherapy naïve ACC from 6 different countries were included. Somatic mutations, copy-number variation (CNV), mRNA and microRNA expression, methylation and proteomic profiling were studied by whole-exome sequencing (WES), SNP-arrays, RNA sequencing, microRNA sequencing, array-based methylation profiling and RPPA, respectively. Results: Whole-exome sequencing identified recurrent somatic mutations in 5 genes (RPL22, TP53, CTNNB1, PRKAR1A and MEN1). CNV analysis identified widespread arm-level chromosomal events and whole genome doubling in a large proportion of cases. Recurrent focal amplifications (TERT, TERF2 and CDK4) and deletions (ZNRF3, RB1 and CDKN2A) were also observed. Unsupervised analysis of the combined data from RNA sequencing, microRNA sequencing, CNV and methylation profiling identified 3 different groups of tumors with distinct clinical features and outcomes. Conclusions: Our results present a comprehensive genomic landscape of ACC that significantly improves our understanding of the molecular pathogenesis the disease, which may ultimately improve the care of patients.

 

Disclosure: WER: Scientific Board Member, Atterocor. TJG: Consultant, Interpace Diagnostics, Other activities, please specify:, Asuragen. GDH: Owner, Atterocor, Consultant, Embara, Consultant, orphagen, Consultant, ISIS. Nothing to Disclose: AML, TE, SZ, RV

22908 10.0000 LBF-073 A Integrated Genomic Characterization of Adrenocortical Carcinoma (ACC) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Rupendra T Shrestha1, Maria Batool1, Sunil Gurung2 and Tasma Harindhanavudhi*3
1University of Minnesota Medical Center, Minneapolis, MN, 2University of Minnesota, Minneapolis, MN, 3Univ of Minnesota, St. Paul, MN

 

Pheochromocytoma could precipitate life-threatening cardiovascular dysfunction. Despite best efforts to optimize blood pressure control, the predictors for complications are largely unknown. We present 3 cases of pheochromocytoma and discuss predictors of perioperative complications.

Case 1: 45 year old previously healthy male presented with mild HTN, frequent bilateral headache and right-sided abdominal pain. CT abdomen showed a right non-obstructed inguinal hernia and 4 cm right adrenal mass. 24 hour Normetanephrine (NME) was elevated at 904 (normal 50-650) ug/day and normal Metanephrine (ME)  cortisol and plasma DHEAS. He underwent right laparascopic adrenalectomy. Pathology was consistent with 3 cm pheochromocytoma with no atypical features. He developed transient hypotension required inotropes that was discontinued shortly after the surgery.

Case 2: 30 year old male with two years of intermittent headache, palpitation and sweating transferred from an outside facility for severe hypertension, chest pain precipitated by beta blocker. CT chest revealed a right adrenal mass with hemorrhage. Cardiac function worsened resulting in PEA arrest twice requiring ECMO for hemodynamic support. He was started on continuous phentolamine infusion, oral phenoxybenzamine, metyrosine and IV Hydrocortisone with subsequent improvement in the blood pressure. Labs revealed serum epinephrine of 31,285 pg/ml (0-20) and norepinephrine of 69,115 pg/ml (80-250). Elective adrenalectomy was performed after optimization of blood pressure with high doses of clonidine, Isosorbide dinitrate, hydralazine, metoprolol and phenoxybenzamine 2 weeks after cardiac arrest. Surgery was uneventful and a 10.5 cm right-sided pheochromocytoma was resected.

Case 3: 44 year old Afroamerican man with HTN, left parietal headache, episodic palpitation, blurred vision and chest pain presented with severe epigastric pain and found to be hypertensive and reverse Takotsubo cardiomyopathy. CT abdomen/pelvis showed a left 5.7 cm adrenal mass. 24 hour NME was 7465 ug/d and ME was 1781 ug/d (normal 30-350) He was planned for elective adrenalectomy and started on prazosin and metoprolol preoperatively. The operation aborted twice due to PEA arrest during anesthetic induction and accelerated hypertension. He was eventually operated successfully after preoperative optimization with higher dose of phenoxybenzamine and metyrosine. Pathology revealed pheochromocytoma with atypical features but lacked distant metastasis.

These cases highlight the fact that complications could still occur despite optimal management. Predictors that associated with increased risk of hemodynamic instability include high plasma catecholamine level, tumor size larger than 4 cm and postural hypotension following α–receptors blockade. Pre and perioperative management of pheochromocytoma is crucial.

 

Nothing to Disclose: RTS, MB, SG, TH

22712 11.0000 LBF-074 A Pheochromocytoma: How to Predict the Perioperative Outcome: A Review of Literature 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Friday, March 6th 3:00:00 PM LBF 064-076 6272 1:00:00 PM Late-Breaking Adrenal/HPA Axis II Poster


Elamin Abdelgadir*1, Alaaeldin Bashier2, Safiya Bashiri3, S Raja4, Fatheya Fardallah Alawadi5, Suada Makeen4 and Mohamed Abdelatif Elsayed6
1Dubai Hospital, Dubai Health Authority, 2Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates, 3endocrine division, Dubai Hospital, 4Dubai Hospital, 5Dubai Hospital, Dubai Health Authority, Ash Shariqah, United Arab Emirates, 6Dubai Hospital, Endocrine Division

 

Background:

Vitamin D deficiency is a very common medical problem, especially in the gulf region of the Middle East where prevalence rates exceeded 50% in many studies. This is probably related to the lack of sun exposure in a huge number of the population, rarity of vitamin D in the commonly taken foods. The prevalence was even higher among females, given the trend of wearing long dresses and veils based to cultural and religious concepts.

Vitamin D deficiency has been found to be associated not only with Rickets, but also with many other serious medical problems, almost affecting all the organs of the human body. This multi-organ involvement is explained by presence of Vitamin D Receptors (VDR) in almost all body tissues.

Objectives:

Primary objective:

To assess the overall prevalence of vitamin D deficiency and association between the low vitamin D and different medical illnesses in patients attending endocrine clinic of Dubai hospital.

Patients and methods: 

The studied group was the patients attending endocrine clinic, Dubai hospital over a period 2008-2012. We included patients who are Vitamin D naïve.   Retrospectively, we collected demographic, clinical and laboratory data. Later we conducted simple descriptive analysis using SPSS program analysis. 

Results:

Total number of patients included was 2836, 76.3% were females. The mean 25(OH) D was 18.6ng/ml and 20.6ng/ml for males and females, respectively. The overall prevalence of vitamin D (25 (OH) D3 <30ng/ml) is 81%. Vitamin D deficiency was <30ng/ml in 82% of diabetes mellitus, 80.6% of patients with hypertension, 79.7% of patients with hypothyroidism, 76.8% of patients with thyroid cancer (figure 1). The overall prevalence of 25(OH) D <30ng/ml among diabetic patients was found 82% while in patients with other endocrine comorbidities found to be 77.9%, (P=0.033) which was statistically significant. 

Conclusion:

Vitamin D deficiency is a very prevalent medical problem in Dubai, the over all prevalence was 81%, 63.6% had levels below 20ng/ml. Male are substantially affected more than females. There is statistically significant difference between diabetic and non-diabetic patients in of vitamin D deficiency. The second most common association was hypertension, hypothyroidism, thyroid cancer, and thyroiditis.

 

Nothing to Disclose: EA, AB, SB, SR, FFA, SM, MAE

22379 1.0000 LBF-033 A Association Between Common Medical Diseases and Vitamin D Deficiency. Retrospective Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Jorge Alejandro Velez Garza1 and Jan M Bruder*2
1UTHSCSA, San Antonio, TX, 2University of Texas Health Science Center at San Antonio, San Antonio, TX

 

Background

Atypical fracture of the femur is a well describe complication on patients on long term bisphosphonate therapy but there are no reports after a long drug holiday

Clinical Case

A 72 year old postmenopausal woman with a history of osteoporosis was referred to the Endocrine Clinic after suffering an atypical fracture of the right femur (AFF). In March 2014, the patient described discomfort and weakness in the right leg a few days prior to falling from a standing height.  Imaging studies revealed a right mid shaft femoral fracture and localized periosteal reaction of the lateral cortex (beaking) of the shaft in the contralateral femur. She underwent open reduction and internal fixation of the right femur. Three months later, 60 mg of denosumab was administered.   Extensive callus formation was noted on x-ray 6 weeks after the injection; there was no change in the left femur shaft beaking. We first saw the patient in October 2014. On history, osteoporosis was diagnosed at age 50 by BMD and she was treated with alendronate for 10 years. Alendronate was stopped around the age of 60, ten years prior to the AFF.  Additional past medical history was significant for COPD, coronary artery disease and hypertension. Medications included metoprolol, benazepril, aspirin, atorvastatin and 600 mg of elemental calcium two times daily. Risk factors for osteoporosis included a remote history of heavy smoking, poor dietary calcium intake and a family history of hip fracture (mother). On physical examination, vital signs were normal and BMI was 29.  She had poor balance with a negative Romberg sign and significant thoracic kyphosis. Laboratories were normal including serum levels of calcium, phosphate, creatinine, alkaline phosphatase, TSH, vitamin D 25, PTH, sedimentation rate and SPEP. Bone mineral density in 2014 showed a lumbar spine T score of -3.2 with a 8% loss, femoral neck T score of -2.2 with a 6% loss and total hip T-score of -1.4 with a loss of 7% from last BMD in 2010.  Denosumab, which has been associated with AFF, was discontinued and teriparatide 20 ugm daily was started, along with adequate calcium and vitamin d intake and limited weight bearing.  A left femoral shaft MRI was ordered. If an incomplete AFF is diagnosed, depending on the severity, the patient could be referred to orthopedics to undergo prophylactic nail fixation or assess fracture healing with radiological monitoring while on teriparatide.

Conclusion

The patient presented with bilateral atypical fractures of the femur after a prolong exposure to bisphosphonates ten years earlier. Contrary to our case, recent epidemiological studies and the majority of case reports have shown that the highest risk for AFFs is current bisphosphonate therapy or shortly after discontinuation1,2.  As the cohort of patients on long term bisphosphonate therapy ages and exponentially grows, we must be aware of potential complications that might still be forthcoming.

 

Nothing to Disclose: JAV, JMB

22608 2.0000 LBF-034 A Bilateral Atypical Fractures of the Femur: Ten Years after Ten Years of Bisphosphonate Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Ke Ke*1 and Hye Seon Choi2
1University of Ulsan, Ulsan, 2University of Ulsan

 

Cilostazol Attenuates Ovariectomy-Induced Bone Loss by Inhibiting Osteoclastogenesis

 

Ke Ke, and Hye-Seon Choi

Department of Biological Sciences, University of Ulsan, Ulsan 680-749, Korea

Postmenopausal osteoporosis is a bone disorder characterized by a progressive loss of bone tissue after menopause, which leads to fracture primarily due to loss of the ovarian function. Cilostazol, an inhibitor of cyclic AMP-dependent phosphodiesterases(PDE), has been reported to alleviate the metabolic syndrome induced by increased intracellular adenosine 3’, 5’-cyclic monophosphate (cAMP) levels. cAMP signaling has been also associated with osteoclast (OC) differentiation and function. We hypothesized that bone loss might be attenuated via an action on OC by cilostazol. To test this idea, we investigated the effect of cilostazol on ovariectomy (OVX)-induced bone loss in mice and on OC differentiation ex vivo, using μCT and tartrate-resistant acid phosphatase staining, respectively. Cilostazol prevented from OVX-induced bone loss in vivo. It also reduced the increase of OC number induced by OVX. Therefore, our data highlight the therapeutic potential of cilostazol for alleviating bone loss caused by loss of ovarian function.

The authors have declared that no competing interests exist.

This work was supported by the Korea Healthcare Technology R&D Project, Ministry of Health, Welfare & Family Affairs, Republic of Korea (A111295) funded by the Korean government. #These researchers were supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2014R1A6A1030318; NRF-2014R1A1A2008740).

 

Nothing to Disclose: KK, HSC

22621 3.0000 LBF-035 A Cilostazol Attenuates Ovariectomy-Induced Bone Loss By Inhibiting Osteoclastogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Fergus E McKiernan*1, Stuart M Sprague2, Neil C Binkley3, Sailaja Dharmanolla4, Jay White5, Martin Petkovich6, Amy Seidel7, Stephen Strugnell5, Charles W Bishop5 and Joel Z Melnick5
1Marshfield Clinic, Marshfield, WI, 2NorthShore University Health System-University of Chicago, Pritzker School of Medicine, Evanston, IL, 3University of Wisconsin, Madison, WI, 4OPKO, Miami, FL, 5OPKO Renal, Miami, FL, 6Queens University, Kingston, ON, 7OPKO

 

Vitamin D (ergocalciferol or cholecalciferol) repletion therapy is the current standard of care for correcting vitamin D insufficiency (VDI), controlling secondary hyperparathyroidism (SHPT) and improving skeletal health in patients with chronic kidney disease (CKD) but is unreliable and generally ineffective. We evaluated whether an oral modified-release calcifediol (MRC) could provide reliable and effective therapy with acceptable safety.

   Two identical, randomized, double-blind, placebo-controlled trials were conducted in 429 patients with SHPT (plasma iPTH>85 pg/mL), stage 3 or 4 CKD and VDI (serum 25(OH)D of 10-29 ng/mL) randomized 2:1 to daily MRC (30-60 µg) or placebo for 6 months. Efficacy endpoints included a mean ≥30% decrease in iPTH and a mean 25(OH)D ≥30 ng/mL at 6 months, as well as changes in markers of bone turnover including total alkaline phosphatase (AlkP), bone specific alkaline phosphatase (BAP), procollagen type 1 N-terminal propeptide (P1NP) and type I collagen C-telopeptide (CTX1). Safety endpoints included adverse events (AEs), serum Ca and P, urine Ca/Cr and tubular reabsorption of phosphate (TRP). Patients could continue to receive MRC for an additional 6 months during an ongoing open-label extension study.

   At 6 months, iPTH response rates for MRC treatment were 40% and 39% in stage 3 and 4 CKD, respectively, vs. 11% and 5% for placebo (p<0.001), rising to 50% and 58% at 52 weeks. iPTH progressively declined during treatment, often to normal levels. There were no differences between CKD stages in baseline serum 25(OH)D. Mean levels increased from 19 to 67 ng/mL in stage 3 subjects and from 19 to 68 ng/mL in stage 4 subjects. VDI was corrected in 97% (226 of 234) of patients independent of CKD stage. Baseline serum 1,25(OH)2D levels were slightly higher in CKD stage 3 subjects with significant (p <0.001) mean increases observed regardless of stage (39 to 54 and 29 to 39 pg/mL in stages 3 and 4, respectively). Significant (p <0.001) mean decreases in markers of bone turnover also were observed for MRC treated subjects, regardless of CKD stage: AlkP decreased from 93 to 87 U/L; BAP decreased from 38 to 27 U/L; P1NP decreased from 99 to 89 ng/mL; CTX1 decreased from 734 to 612 pg/mL. Mean serum Ca and P were slightly increased at some time points but remained within the normal range; urine Ca/Cr and TRP were unchanged. Rates of AEs, confirmed hypercalcemia (>10.3 mg/dL) and hyperphosphatemia (>5.5 mg/dL), and overall safety and tolerability data were comparable between treatment groups and CKD stages.

   In conclusion, MRC was reliable, effective and safe in controlling SHPT, correcting VDI and reducing markers of bone turnover in patients with stage 3 or 4 CKD with vitamin D insufficiency.

 

Disclosure: FEM: Principal Investigator, OPKO Health, Principal Investigator, Alexion. SMS: Investigator, OPKO Pharm, Consultant, Opko. SD: Employee, OPKO Health. JW: Employee, OPKO Health. MP: Consultant, OPKO Health, Renal Division. AS: Employee, OPKO. SS: Employee, OPKO Health, Inc.. CWB: Employee, OPKO. JZM: Employee, OPKO. Nothing to Disclose: NCB

22539 4.0000 LBF-036 A Modified-Release Calcifediol Controls Elevated iPTH, Corrects 25(OH)D Levels and Reduces Bone Markers in CKD Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Kharis Burns*, Teresa Lam and David Ronald Chipps
Westmead Hospital, Sydney, Australia

 

Background:

Bone disease in the HIV population is common and causes are multifactorial. Hyphosphosphataemic osteomalacia may present with characteristic symmetrical bilateral pseudofractures, while bisphosphonates for treating osteoporosis have been associated with atypical femoral fractures. The coexistence of these two fracture aetiologies has not previously been reported.

Clinical Case:

A 51 year old man presented with newly diagnosed HIV/AIDS, and Hepatitis B.  Highly Active Antiretroviral Therapy (HAART) was commenced; zidovudine, lamivudine and efavirenz, with adefovir for Hepatitis B.  The HAART regimen was changed nine years later to tenofovir, emtricitabine and efavirenz due to evidence of viral resistance, and adefovir ceased. Two months later, the patient suffered a minimal trauma metatarsal fracture. BMD Lumbar Spine T-Score was -1.1, and total proximal femur T-score -1.7. Total testosterone was 9.6nmol/L (ref 9.5-28), free testosterone 181nmol/L (ref 80-370), LH 15U/L (ref <9.0), FSH 21U/L (ref <9.0), and SHBG 74nmol/L (ref 10.0-57.0). Risedronate 35mg weekly, and testosterone replacement were commenced. Three years later the patient developed acute onset left thigh pain in the absence of trauma. CT imaging confirmed an incomplete subtrochanteric femoral fracture. Bone scan demonstrated corresponding uptake in the femur and multiple symmetrical focal areas of uptake in ribs and the first metatarsal bilaterally. Retrospective review identified a steady decline in serum phosphate since shortly after initial HIV presentation with rapid decline following the introduction of tenofovir to a nadir of 0.45mmol/L (ref 0.75-1.5). Serum corrected calcium was normal (2.10-2.60) with replete serum 25(OH) Vitamin D 96nmol/L, and 1,25(OH)2Vitamin D 157pmol/L (ref 60-158). Alkaline phosphatase had been stable at 75-100U/L (ref 30-110) apart from a single rise to 220U/L. 24-hour urine investigations found elevated fractional excretion of phosphate 46% (ref range 5-20%), proteinuria 0.83g/L and aminoaciduria. Urinalysis revealed glucose 1+. Investigations were indicative of tenofovir-induced hypophosphataemic osteomalacia secondary to phosphate wasting and Fanconi Syndrome. However, the femoral shaft fracture showed characteristic features of an atypical fracture possibly related to bisphosphonates. Such atypical fractures have also been reported in osteomalacia, though more commonly in a medial femoral location. Treatment involved cessation of the bisphosphonate and tenofovir, phosphate and calcitriol therapy with orthopaedic fracture management.

Conclusions:

The risk of atypical fracture may be amplified by the combination of osteomalacia and bisphosphonate therapy.  In the HIV population, at high risk of bone disease, multiple contributory factors need to be considered with appropriate monitoring and treatment.

 

Nothing to Disclose: KB, TL, DRC

22623 5.0000 LBF-037 A 'HAART Break' an Unusual Case of HIV Related Bone Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Ningjian Wang*1, Qin Li2, Bing Han2, Yi Chen1, Chunfang Zhu2, Yingchao Chen2, Fangzhen Xia2, Xiaoqi Pu2, Zhen Cang2, Chaoxia Zhu3, Meng Lu2, Ying Meng2, Hui Guo2, Chi Chen2, Dongping Lin2, Weiping Tu4, Bin Li5, Ling Hu6 and Yingli Lu1
1Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 2Shanghai Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 3The First Affiliated Hospital of Henan University of Science and Technology, 4Shangyu People's Hospital, 5Fengcheng Hospital, 6the Third Affiliated Hospital of Nanchang University

 

Several studies suggested that androgen levels and 25-hydroxyvitamin D (25(OH)D) levels were associated in European men. No study has explored this association in Chinese men, the largest population in the world. We aimed to investigate the relationship of 25(OH)D levels with total and free testosterone (T), sex hormone binding globulin (SHBG) and estradiol, and further with hypogonadism in Chinese men. Our data were from population-based Survey on Prevalence in East China for Metabolic Diseases and Risk Factors (SPECT-China) in 2014. 2854 men were enrolled with a mean±SD age of 53.0±13.5 years. Hypogonadism was defined as total T <11.3nmol/L or free T <22.56pmol/L. 25(OH)D (normal range ≥50.00nmol/L), FSH, LH, total T, estradiol and SHBG were measured by chemiluminescence and free T was detected by ELISA. The associations of 25(OH)D with reproductive hormones and hypogonadism were analyzed by linear regression and binary logistic regression analyses, respectively. Among participants, 713 (25.0%) had hypogonadism, who had significantly lower 25(OH)D than men without hypogonadism (42.6±11.8 vs.  43.7±11.7nmol/L). These men also had higher fasting insulin, HOMA-IR, BMI and systolic blood pressure as well as higher prevalence of diabetes. The quartile ranges of 25(OH)D were ≤35.36, 35.37-41.32, 41.33-48.81 and ≥48.82nmol/L. Compared with men in the highest quartile, men in the lowest quartile were younger and more likely to live in urban area and rapid economic development area, but had higher prevalence of hypogonadism and diabetes. These men also had significantly lower total T, E2, SHBG, FSH and LH but higher free T. In linear regression, after fully adjustment for age, residence area, economic status, smoking, BMI, HOMA-IR, diabetes and systolic pressure, total T (β=0.023) and E2 (β=0.238) were still associated with 25(OH)D (both P<0.05). In logistic regression analyses, increased quartiles of 25(OH)D were associated with significantly decreased odds ratios of hypogonadism (P for trend <0.01). This association was greatly attenuated by BMI and HOMA-IR but persisted in fully adjusted model (P for trend <0.01) in which for the lowest compared with the highest quartile of 25(OH)D, the odds ratio of hypogonadism was 1.50 (95%IC 1.14-1.97). Lower vitamin D was associated with higher prevalence of hypogonadism in Chinese men. This association was partially explained by adiposity and insulin resistance, which warrants further investigation.

 

Nothing to Disclose: NW, QL, BH, YC, CZ, YC, FX, XP, ZC, CZ, ML, YM, HG, CC, DL, WT, BL, LH, YL

22431 6.0000 LBF-038 A Vitamin D Associates with Hypogonadism in Chinese Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Serife Nur Boysan*1, Yusuf Selcuk Yildiz1, Nagihan Bilal1, Eylem Sahin1, Serdal Citil1, Serkan Caglar2 and Pinar Kadioglu3
1Kahramanmaras Necip Fazil City Hospital, Kahramanmaras, Turkey, 2Kahramanmaras Necip Fazil CityHospital, Kahramanmaras, Turkey, 3Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey

 

Background: Hypoparathyroidism, sensorineural deafness, and renal dysplasia(HDR syndrome) is caused from GATA3 haploinsufficiency on chromosome 10p. GATA3 expression has been found in the parathyroid glands, inner ears, and kidneys with the thymus and central nervous system.

Clinical Case: A 43-year old man was admitted to hospital for the third time. Chovestek's sign was positive and he had a hearing loss. Biochemical tests showed hypocalcemia: 4.2 mg/dl(8.8-10.2), hyperphosphatemia: 6.4mg/dl(2.7-4.5), hypoparathyroidism: 6.64 pg/dl(15-65), high CK level: 1246U/L(39-308), and proteinuria 157 mg/day.

Arrhythmia and ST changes were detected on electrocardiogram. Echocardiogram revealed heart failure with % 30 EF and global hypokinesia. Because he had mental retardation, he could not incorpotared with audio and we planned for auditory brain stem applicatoin with sedation. Cranial CT showed dense calcifications in the basal ganglions and cerebellum. Cranial MR revealed diffuse T2 hyperintense signalization in the periventricular white matter. Abdominal CT showed left renal rotation anomaly. Electroencephalogram detected slow wave characterized pathology. 

Initial urgent treatment was parenteral calcium gluconate infusion  until serum calcium level reached to 7mg/dl and  also peroral calcitriol and calcium supplementation began. For cardiac failure the treatment was the combination of beta blocker, ACE inhibitor and ASA. For seizures the treatment was valproic acid.

Conclusion:HDR syndrome is a developmental disorder. The haploinsufficiency of the GATA3 genes causes phenotypic variability as a result of penetrance and expressivity of related genes. The wide range of renal involvement from proteinuria to renal failure on dialysis can be seen.

 

Nothing to Disclose: SNB, YSY, NB, ES, SC, SC, PK

22748 7.0000 LBF-039 A Barakat Syndrome: A Case Report of Hypoparathyroidism, Deafness and Renal Dysplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Muhammad Amer, Ankit Mahajan*, Sujay Madduri, Julius Ngwa and Bryan H Curry
Howard University Hospital, Washington, DC

 

Background: Observational studies suggest an independent association between 25(OH)D and maximal oxygen consumption (VO2max); measure of cardiovascular (CV) fitness in select populations. However, little is known about this relationship in general population. We have examined the association between 25(OH)D and VO2max and explored the impact of body mass index (BMI) on this relationship in a large cohort of asymptomatic adults living in United States.

 Methods: Utilizing data from the National Health and Nutrition Examination Survey (2001-04), analysis was conducted on adults (age ≥18-49 years, free of CV disease). Sub-maximal exercise treadmill protocol (based on age, gender, BMI and self-reported physical activity) was used to elicit 75% of age-predicted (220-age) maximum  heart rate and VO2max (ml/kg/min) for each participant. Linear regression models adjusted for demographic variables, systolic blood pressure, glomerular filtration rate, and glycohemglobin were used to estimate mean change (β-coefficients and p values) in VO2max.

Results: The mean (SD) age, VO2max and BMI of 2,759 participants (47% females) was 30 (10) years, 40(9)ml/kg/min, and 27(6)kg/m2, respectively. A total of 1189 (41%)participants were normal (BMI: 18.5-24.9), 867(30%) overweight (BMI: 25-29.9), while 703(24%) were obese (BMI>30). For each 10 ng/mL change in 25(OH)D, significant change in VO2max noted in simple (β:0.96, p=0.003) regression analysis until model was adjusted for BMI (β:0.60, p=0.08). Significant improvement observed in VO2max with increasing 25(OH)D among obese participants was neutralized once models was adjusted for relevant predictors.

Conclusions: We observed that BMI neutralized the linear association between 25(OH)D with VO2max in a national cohort of asymptomatic adults. In addition, obese participants with elevated 25(OH)D showed no improvement in VO2max in adjusted models.

 

Nothing to Disclose: MA, AM, SM, JN, BHC

22611 8.0000 LBF-040 A Body Mass Index and the Association of Serum 25(OH)D with Maximal Oxygen Consumption in Asymptomatic Adults (Findings from the Continuous National Health and Nutrition Examination Survey, 2001-2004) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Nidhi Agrawal*1, Maureen Miller1, Angela Arbach1, Jonathan Melamed1, Jennifer Adams2, Jennifer B Ogilvie3 and Gillian Katz1
1New York University Langone Medical Center, New York, NY, 2New York University Langone Medical Center, New York, 3New York University School of Medicine, New York, NY

 

Background

Parathyromatosis, described as hyperfunctioning, benign parathyroid tissue scattered throughout the soft tissues of the neck, is a rare cause of recurrent hyperparathyroidism. Fewer than 40 cases have been described in the literature. We describe a case of a woman with recurrent hypercalcemia secondary to parathyromatosis; additionally this is the first reported case of a papillary pattern in parathyromatosis.

Clinical Case

 A 45 year old woman with a history of a left parathyroid adenoma, status post focused parathyroidectomy 10 years ago, presented with constipation, polyuria and abdominal pain. Initial examination demonstrated a well healed cervical scar with no palpable neck masses.  Admission laboratory findings were significant for a calcium level of 13.6 mg/dL (n 8-10.4 mg/dL) , ionized calcium 7.7 mg/dL (n 4.6-5.2 mg/dL), phosphorus 2.2 mg/dL (n 2.7-4.5 mg/dL), 25 OH-vitamin D 9.6 ng/mL (n 30-100 ng/mL), PTH 395 pg/mL (n 14-72 pg/mL), PTHrP <0.7 pmol/L (n <2.0 pmol/L) and urine calcium 484 mg/24 hr (n 50-250 mg/24hr). No obvious enlarged parathyroid was localized on neck ultrasound or sestamibi scan. Neck CT showed two 6 mm nodular lesions in the upper mediastinum. The patient had refractory hypercalcemia despite maximal medical therapy.  She was taken to the operating room for reoperative neck exploration. She was noted to have diffuse exophytic fronds of tissue covering her left thyroid lobe, which prompted removal of the lobe. Intraoperative PTH decreased from 454 pg/mL to 39 pg/mL. Microsopic examination demonstrated multifocal hypercellular parathyroid nodules in skeletal muscle and perithyroid adipose tissue consistent with parathyromatosis. An unusual pathologic finding was its unique papillary configuration, raising consideration for a parathyroid carcinoma on frozen section. Final pathology confirmed parathyromatosis with no features of carcinoma (vascular invasion, fibrosis or high mitotic activity) with diffuse immunohistochemical reactivity for PTH and non-reactivity for Thyroid Transcription Factor-1. The patient’s calcium level was normal post operatively (9.2 mg/dL) with resolution of symptoms.

Conclusion

Parathyromatosis is a rare disease that raises challenges in diagnosis and management. Preoperative localization of parathyromatosis is difficult, leading to a high surgical failure rate. Scarring and fibrosis from previous neck exploration leads to technical difficulty, since the most common cause for parathyromatosis is seeding of hypercellular parathyroid tissue during previous parathyroidectomy. Medical management is essential during the post-operative period to maintain a normocalcemic state. Our case presents with a pathologic finding of papillary pattern in parathyromatosis, which has not been previously described and can pose a diagnostic challenge in separation from papillary carcinoma on frozen section examination.

 

Nothing to Disclose: NA, MM, AA, JM, JA, JBO, GK

22750 9.0000 LBF-041 A Parathyromatosis: A Rare Cause of Recurrent Hypercalcemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Brenda Dorcely*1, Shira B Eytan1 and John Junghoon Shin2
1Rutgers University New Jersey Medical School, Newark, NJ, 2Veterans Affairs Med Ctr, East Orange, NJ

 

Background: Hypocalcemia is sometimes seen in the setting of post-surgical hypoparathyroidism.  It is usually easily managed with combinations of calcium, vitamin D, and thiazide diuretics. Recently, recombinant PTH (1-34 & 1-84) has been investigated as another option for these patients. There have been case reports showing success with this therapy.  However, this is the first case of severe symptomatic post-surgical hypocalcemia resistant to conventional therapy possibly related to poor absorption ultimately responding to teriperatide therapy.

Clinical Case: A 53 year old man with laryngeal squamous cell carcinoma and a percutaneous endoscopic gastrostomy tube (GT) underwent total laryngectomy, partial pharyngectomy, and left neck dissection.  Prior to surgery, his calcium was 9.1 mg/dl [n 8.0-10.2mg/dl]. After surgery his calcium was noted to be 7.18 mg/dl.  Despite 1 gm of IV calcium gluconate, a repeat calcium was 6.2 mg/dl. Calcium carbonate 6 gms daily, calcitriol 1 mcg daily, and calcium gluconate 51 meq were added to his regimen.  The calcium improved initially to 7.5mg/dl, but repeat levels declined. The patient had perioral and facial numbness. Other pertinent labs included 25-OH D of 9.12 ng/ml [n 30-100 ng/ml], PTH level was 0.80 pg/ml [n 14-72 pg/ml], and urinary calcium level was 249 gms/24 hrs [n 100-300 gms/24 hrs]. At this point the patient was diagnosed as having post-surgical hypoparathyroidism.  Since his calcium levels were not at goal, his treatment was adjusted. Over the following few days, calcium gluconate was titrated up to 4 gms daily, calcium carbonate was titrated up to 5 gms daily, and calcitriol was increased to 2 mcgs daily.  Further, ergocalciferol 50,000 IU was increased from three times a week to daily.

Despite changes to his regimen, his calcium remained between 6.88 mg/dl and 7.98 mg/dl. The assumption was that vomiting and possible poor absorption of medications may have been contributing factors for declining calcium levels.  Teriparatide 20 mcg daily was started and increased to twice daily.  Over several days, his corrected calcium improved to 10.6 mg/dl.  Calcitriol and calcium gluconate were eventually discontinued, and calcium carbonate dosages were decreased by 50%. Ergocalciferol was also decreased to twice weekly dosing.   His urinary calcium level decreased to 133 gms/24hrs. The patient’s symptoms of perioral numbness and finger tingling resolved.  Subsequently calcium levels were maintained in the 8.5-10 mg/dl range.

Conclusion: This is a case of difficult post-surgical hypoparathyroidism which responded to teriparatide therapy.  Poor absorption of oral medications may have contributed to the difficulty in management.  Teriparatide provides a more physiologic therapy for these post-surgical patients and allows for a decreased need for oral supplementation. Recombinant PTH may prove to be a superior therapy in the future for patients such as ours.

 

Nothing to Disclose: BD, SBE, JJS

22756 10.0000 LBF-042 A Resistant Case of Hypocalcemia Treated with Teriparatide in Post-Surgical Hypoparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Alejandro Roman-Gonzalez*1, Natalia Aristizabal2, Carolina Aguilar1, Karen Palacios3, Juan Camilo Perez4, Carlos Simon Duque5, Alejandro Velez-Hoyos6 and Alvaro Sanabria7
1Universidad de Antioquia, Medellin, Colombia, 2Universidad Pontificia Bolivariana, Medellin, Colombia, 3Universidad de Antioquia, 4Hospital Pablo Tobon Uribe, Dinamica IPS, 5Hospital Pablo Tobon Uribe, 6Hospital Pablo Tobon Uribe, Dinamica IPS, Colombia, 7Hospital Pablo Tobon Uribe, Universidad de Antioquia, Colombia

 

Introduction: Parathyroid cyst is an infrequent and commonly unsuspected disease. There are more than 300 hundred cases reported in the literature and few of them are from Latin America. The experience of our center and a review of the cases from Latin America are presented. Methods: Review of the database of patients with parathyroid cyst from our institutions and report of the cases according to the CARE guidelines for case reports. A search of Medline, Embase, BIREME, LILACS, Google Scholar and Scielo databases was performed. Also a review of the references of all original articles and telephonic or email communications with other experts in the field from Latin America was done. Results: During the last 9 years (2005-2014) 7 patients with parathyroid cyst have been diagnosed and treated. One of the cases is excluded from this report due to incomplete clinical data. Our first patient was a 44 years-old male who presents with an anterior neck mass of 1 year of evolution. Computed tomography showed a cystic mass of 10 cms largest diameter, extension to superior mediastinum and displacement of common carotid artery and trachea. The patient underwent surgical resection and a parathyroid cyst was confirmed. The second case was a healthy 25 years-old woman who presents with a 15 month history of a left paratracheal mass. The ultrasonography showed a simple cystic lesion in the left thyroid lobule. A fine needle aspiration was performed with the finding of clear fluid with high PTH level. The third case was a 56 years old female who presents with anterior neck mass. The ultrasonography showed a cystic lesion. The fine needle aspiration was acellular with crystal-clear fluid. The PTH level in the fluid was elevated (119.90 pg/ml). The fourth case was a 37 years old female who presents for a fine needle aspiration of the thyroid. The ultrasonography disclosed a cystic lesion of 4 x 4 cms. A clear fluid was found after aspiration of the cyst with a PTH level of 44 pg/mL. The fifth case was a 24 years old woman who presents for a fine needle aspiration of a cystic lesion of 4 x 3 cm. A clear fluid was aspirated with a PTH level of 66 pg/mL. The sixth case was a 53 years old woman with diagnosis of symptomatic primary hyperparathyroidism. On surgical examination a parathyroid cyst was found with an adenoma inside the cyst. The search of the literature retrieves 11 references of reported cases from countries of Latin America (Argentina, Brazil, Chile, Cuba and Venezuela) for a total of 19 cases from our region. The diagnosis was done postoperative in almost all cases. Conclusion:  Parathyroid cysts are uncommonly reported in Latin America. Most of them are diagnosed postoperatively. This lesion can be confounded with thyroid diseases. The diagnosis of parathyroid cyst may be easily done if PTH level is measured in the cyst fluid preventing surgery. Also, parathyroid cyst can be functional.

 

Nothing to Disclose: AR, NA, CA, KP, JCP, CSD, AV, AS

22837 11.0000 LBF-043 A Parathyroid Cysts: The Latin America Experience 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Friday, March 6th 3:00:00 PM LBF 033-047 6275 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D II Poster


Lawrence Lee1, Evangelia Theodosopoulos2, Elliot Jonathan Mitmaker3, James A Lee4, John Chabot4 and Jennifer Hong Kuo*4
1McGill University Health Centre, Montreal, QC, Canada, 2McGill University Health Centre, Montreal, QC, 3McGill University Health Center, Montreal, QC, Canada, 4Columbia University Medical Center, New York, NY

 

Introduction: The management of thyroid nodules >4 cm with benign cytology after fine-needle aspiration (FNA) is controversial. FNA is associated with a high false-negative rate and may result in a delayed diagnosis and management of thyroid cancer. On the other hand, the majority of these nodules are still benign, and routine thyroid lobectomy may accrue unnecessary costs and put the patient at risk for permanent complications. Therefore, the objective of this study is to determine the cost-utility of observation versus surgical management for thyroid nodules >4 cm with benign cytology after FNA.

Methods: A microsimulation model (1 million simulations) was constructed to compare expectant and surgical strategies for >4cm thyroid nodules with benign cytology after a FNA over a lifetime horizon (3% discount rate) from the US Medicare perspective. In the observation strategy, nodules were observed according to American Thyroid Association guidelines, including a 5% yearly probability of growth >50% requiring repeat FNA with appropriate subsequent management. In the surgical strategy, all nodules underwent diagnostic lobectomy, with completion thyroidectomy if malignant. Probabilities for all outcomes were identified from specific literature reviews. The probability of malignancy for thyroid nodules >4cm was simulated at 23% and the sensitivity of FNA at 66%. A delayed diagnosis was modeled with a higher risk of recurrence and mortality (relative risk 2.3 and 2.2, respectively). Main outcome measures were cost, quality-adjusted life years (QALYs), and life expectancy. Costs were obtained form US national sources and expressed in 2013 US dollars. Probabilistic sensitivity analyses were performed.

Results: The mean age of the simulated patients was 54.6 years (SD 21.1). The proportion of patients undergoing thyroid lobectomy for benign final pathology was 40% in the observation strategy versus 66% in the surgical strategy (p<0.001). Overall, the surgical strategy was associated with higher lifetime costs compared to the observation strategy (incremental difference: +13850 US$; 95% CI 13228, 14508), but also more QALYs (+0.26 QALYs; 95% CI 0.18, 0.34) and longer life expectancy (+2.94 years; 95% CI 2.67, 3.21). Incremental lifetime costs were lower for patients <55 years versus those >=55 years (+11604 vs +16132, p<0.001). The probability of cost-effectiveness of the surgical strategy was 63% at a $100k/QALY threshold or 74% at a $100k/life-year gained threshold.

Conclusions: Routine thyroid lobectomy is associated with improved outcomes at an acceptable cost compared to observation for thyroid nodules >4cm with benign cytology after FNA. Surgical resection may be a cost-effective strategy to rule out malignancy in these nodules.

 

Nothing to Disclose: LL, ET, EJM, JAL, JC, JHK

22395 1.0000 LBF-001 A Diagnostic Lobectomy for Thyroid Nodules >4cm with Benign Cytology after Fine-Needle Aspiration Is Associated with Improved Outcomes at an Acceptable Cost Compared to Observation: A Cost-Effectiveness Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Nikita Pozdeyev*1, Qiong Zhou2, Laura A Pike1, Aik Choon Tan1, Jennifer Anne Morrison1, Rebecca E Schweppe3 and Bryan R Haugen1
1University of Colorado Medical School, Aurora, CO, 2University of Colorado Anschutz Medical Campus, Aurora, CO, 3University of Colorado, Aurora, CO

 

Cell lines are widely used for in vitro and in vivo xenograft studies of cancer. Progress has been hampered by misidentification of cell lines, and concerns that cultured cells may not accurately represent tumor biology. We sought to address these issues and gain insight into thyroid cancer biology through systematic analysis of transcriptome wide gene expression profiles of 40 commonly used and newly derived thyroid cancer cell lines. Gene expressions of these thyroid cancer cell lines were compared to 1036 cancer cell lines from the Cancer Cell Line Encyclopedia and 12 thyroid cancer cell lines from the GlaxoSmithKline database. On hierarchical clustering, the majority of the thyroid cell lines formed a sole cluster distinct from the clusters of tumor cells derived from cancers of other histologic origins. This indicates that thyroid cancer cell lines retain their cell-type specific features in vitro, and supports the use of these cells as models of thyroid malignancy. The medullary thyroid cancer cell line, TT, clustered with small cell lung cancer cell lines, consistent with their neuroendocrine origin. ARO-81 and DRO-90 cell lines clustered with gastrointestinal and skin cancer clusters, respectively, confirming our published short tandem repeat analysis data of their likely colon cancer and melanoma origins. Surprisingly, HTh74 cells clustered together with central nervous system tumor cell lines. Supervised analysis of differential gene expression of papillary (PTC) versus anaplastic thyroid cancer (ATC) cell lines, as well as functional annotation and gene set enrichment analysis, did not identify clear pathways/gene sets that are overrepresented in ATC cell lines. In contrast, similar analysis of gene expression profiles of PTC and ATC tumor specimens obtained from Gene Expression Omnibus indicated highly significant upregulation of cell cycle pathways in anaplastic tumors. Thus, these cell lines may not be as useful for studying differences between ATC and PTC. Finally, we compared gene expression of cell lines that form tumors in an intracardiac metastasis model in nude mice (CUTC-5, 8505C, Cal62, HTh7, THJ16T), with those that do not (K1, TPC1, C643, SW1736). Of particular interest is a 4.2-fold increase in the expression of the CD59 gene in metastasis-forming cells that may protect thyroid cancer cells from being destroyed in the bloodstream by complement, a part of the innate immune system that functions normally in otherwise immunodeficient nude mice.  In summary, we have used a bioinformatics approach to show that the majority of thyroid cancer cell lines cluster together, that there are fewer pathway differences between ATC and PTC cell lines compared with tissues, and have identified potential molecules/pathways that may explain metastatic potential in thyroid cancer cell lines.

 

Disclosure: BRH: , Veracyte, Inc.. Nothing to Disclose: NP, QZ, LAP, ACT, JAM, RES

22872 2.0000 LBF-002 A Thyroid Cancer Cell Lines Gene Expression Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Alisha Aggarwal, Jessica Lee Betancourt*, Hassan Amer, Vineeth Mohan, Jose M Cabral, Julia Diacovo, Pascual Desantis, Tessey Chinna Jose, Sandra F Williams and Carmen Vanessa Villabona
Cleveland Clinic Florida, Weston, FL

 

Introduction: Atypia of Undetermined Significance often undergoes diagnostic analysis with the Afirma Gene Expression Classifier (GEC) which classifies it as either high probability of being benign or suspicious for malignancy. At Cleveland Clinic Florida, our goal was to assess the clinical validity and utility of GEC in the evaluation of AUS cytology. Also, we aimed to evaluate the performance of ultrasound for predicting malignancy.

Methods:We conducted a study with a retrospective cohort of patients from January 2012- January 2014 who had FNA of thyroid nodules >1 cm in size with AUS cytology and underwent GEC testing. Information regarding patient demographics, USG characteristics, FNA and GEC results, final recommendations by our endocrinologists and subsequent clinical and surgical follow up were collected.

Results:Cleveland Clinic Florida has an overall incidence of AUs at 5%. 119 cases with nodules >1cm in size were reported as AUS-1 (AUS on 1st FNA). Of these 119 AUS-1, 48 (40.3%) were sent for GEC with 27 classified as suspicious. Only 21 went for surgery and 14 (66.6%) had thyroid cancer on histopathology. The remaining 71 AUS-1 were sent for a 2nd FNA: 19 (26.7%) were benign and 52 were reported as AUS-2 (AUS on 2nd FNA). 38 (73.1%) cases of these 52 were reported suspicious after GEC. 35 went for surgery and 32 (91.4%) confirmed malignancy on histopathology. Nodules that were AUS-2, solid and hypo echoic on ultrasound had a 92% positive predictive value for being malignant. 

Conclusion: In our practice, the nodules that were AUS-2, had solid and hypo echoic features on ultrasound have a high chance to be malignant. The performance of GEC after 1st biopsy showing AUS was associated with low level of diagnostic accuracy (66.6% likelihood of malignancy). The diagnostic accuracy of GEC testing was markedly higher at 91.4% when it was done after 2 consecutive AUS cytologies. We recommend to send the patients for surgery rather than molecular testing if they have AUS-2 and worrisome features on USG. Prospective studies with long term follow up are required to evaluate the efficacy of this protocol for detection and appropriate management of thyroid malignancy.

 

Nothing to Disclose: AA, JLB, HA, VM, JMC, JD, PD, TCJ, SFW, CVV

22890 3.0000 LBF-003 A Utility and Validity of the Novel Gene Expression Classifier and Correlation with Ultrasound Features in Thyroid Nodules at Cleveland Clinic Florida 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Amena Iqbal*, Andrew Workman and David Bowen-Jones
Wirral University Teaching Hospital, Wirral, United Kingdom

 

ABSTRACT

Introduction

The treatment of Alemtuzumab in Relapsing Remitting Multiple Sclerosis is associated with the development of other autoimmune diseases. We report a case of severe treatment resistant Graves Disease following Alemtuzumab treatment.

Case Report

44 year old Caucasian female with history of Diet controlled Diabetes Mellitus, Hypothyroidism, Thymic hyperplasia and Relapsing-Remitting Multiple Sclerosis, presented with symptoms of overt hyperthyroidism. 3 years ago she had received 3 cycles of Alemtuzumab consecutively each year as she had aggressive onset RRMS. She was diagnosed hyperthyroidism secondary to Grave’s disease. Biochemically she was thyrotoxic with suppressed TSH at <0.1 (0.3-5.5 mU/l), Free T4 >100 (11.5-22.7 pmol/l), Free T3 31.6 (0-7pmol/l). Thyroid receptor antibodies (TRAB) were strongly positive at 282(Normal <10). Imaging revealed large thyroid gland. Levothyroxine was stopped and commenced on Carbimazole and propranolol. Carbimazole was titrated up to 80mg once a day due to lack of response and Propylthiouracil 200mg twice a day was added. Despite high doses she remained resistant to treatment with Free T4 levels at 93.2pmol/l and Free T3 of 22.1pmol/l. At this stage, 1 drop potassium iodide 950mg/1ml twice a day was added to her regimen and prednisolone 30mg commenced but had no improvement. She underwent total thyroidectomy for her resistant thyrotoxicosis and remains biochemically improved with TSH suppressed and FT4 of 15.5pmol/l. Histology revealed Adenomatous goitre.

Discussion

Alemtuzumab, an anti-CD52 Monoclonal antibody has been licensed to treat Relapsing- remitting Multiple Sclerosis. Thyroid autoimmunity including TSH receptor-antibody positive Graves Disease, hypothyroidism and thyroiditis has been reported in about 30 % of the cases. Time to presentation has been reported as 9 – 30 months. The mechanism of autoimmunity has been postulated to be due to loss of self tolerance due to immune reconstitution that occurs after profound lymphopenia. It has been observed that higher IL21 levels prior to treatment predispose development of autoimmunity. In the CAMMS223 trail, 14.8% of patients in the test arm developed hyperthyroidism of which about 11.5% developed sustained hyperthyroidism. Routine testing of IL21 levels pre-treatment and obtaining tissue levels of medications can give direction on the mechanism of delayed development and resistance to treatment.                                                                                                                              

Our patient had developed hypothyroidism after 12 months of treatment and sustained hyperthyroidism 36 months after her last dose and did not respond well to high dose of anti-thyroid medication, prednisolone and Potassium Iodide. She underwent total thyroidectomy and her thyroid levels are now normal. Blood levels of anti-thyroid medications were not available. This case illustrates delayed severe and resistant thyrotoxicosis following Alemtuzumab therapy.

 

Nothing to Disclose: AI, AW, DB

22405 4.0000 LBF-004 A Delayed Onset Resistant Thyrotoxicosis in Patient Treated with Alemtuzumab ( Campath-1H) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Kelsey Wuensch*1, Thomas C Beadnell1, Qiong Zhou1, Katie M Mishall1 and Rebecca E Schweppe2
1University of Colorado Anschutz Medical Campus, Aurora, CO, 2University of Colorado, Aurora, CO

 

Targeted therapies represent a promising new strategy for the treatment of advanced cancers; however the emergence of resistance mechanisms remains a major clinical problem. In thyroid cancer, the MAPK pathway is a promising therapeutic target due to activating mutations in BRAF and RAS, however, the efficacy of MAPK pathway inhibition has thus far been limited.  Heat shock protein 90 (Hsp90) is a molecular chaperone for many oncogenic proteins, including Raf, ALK, Akt, p53, FAK, and Src, all of which play key roles in thyroid cancer pathogenesis. Thus, Hsp90 inhibition represents a promising clinical target due to the potential to simultaneously destabilize multiple pro-tumorigenic proteins. Furthermore, the ability of Hsp90 inhibition to destabilize Raf and Akt represents an alternative strategy to target oncogenic RAS signaling, which has thus far been ‘undruggable’. We therefore hypothesized that Hsp90 inhibition would effectively inhibit the pro-tumorigenic functions of BRAF- and RAS-mutant thyroid cancer cells. First, we studied the effects of the novel Hsp90 inhibitor, ganetespib (Synta Pharmaceuticals), on thyroid cancer cell growth, and showed that Hsp90 inhibition potently inhibits the growth of both BRAF-mutant (BCPAP and SW1736) and RAS-mutant (C643 and Cal62) cells with low nanomolar IC50 values (4 – 20 nM). Inhibition of Hsp90 induced apoptosis in the SW1736, C643, and Cal62 cell lines (1.3 – 2.2 fold), along with a significant arrest at G2-M (p < 0.004) and a decrease in S-phase (p < 0.02) of the cell cycle. To examine mechanisms of response, Western blot analysis showed that Hsp90 inhibition results in reduced c-Raf and Akt expression in both BRAF- and RAS-mutant cells, whereas B-Raf expression was differentially regulated. Consistent with destabilization of Raf and Akt, we observed a reduction in phospho-ERK1/2 and phospho-Akt. We next tested the ability of Hsp90 inhibition to overcome resistance to the clinically relevant Src inhibitor, dasatinib, in an acquired resistance model, where we have shown that reactivation of the MAPK pathway through increased B-Raf and c-Raf dimerization is a key mechanism of resistance. Notably, the dasatinib resistant (DasRes) cells exhibit high IC50 values to dasatinib (>1 µM), whereas Hsp90 inhibition overcame resistance to dasatinib, with low nanomolar IC50 values of 4 – 33 nM. Hsp90 inhibition induced apoptosis in the DasRes BCPAP and C643 cells, and cell cycle arrest at G2-M in the DasRes BCPAP, C643, and Cal62 cells, and at G1-S in the SW1736 cells. Similar to Hsp90 inhibition in the parental cells, components of the MAPK and Akt pathways were destabilized (c-Raf, B-Raf, Akt), resulting in inhibition of the pathways. Overall, these results indicate that Hsp90 inhibition represents a promising, single-agent therapeutic strategy for BRAF- and RAS-mutant thyroid cancer, as well as a potential therapy to overcome resistance to Src inhibition.

 

Nothing to Disclose: KW, TCB, QZ, KMM, RES

22919 5.0000 LBF-005 A Targeting Hsp90 in Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Mustafa Kulaksizoglu*1, Huseyin Kacmaz2 and Ahmet Kaya1
1Necmettin Erbakan University, Konya, Turkey, 2Necmettin Erbakan University, Meram Medical Faculty, KOnya, Turkey

 

Vitamin D regulates calcium homeostasis in the human body by acting on intestinal system, kidney and bone. Vitamin D also acts in cell differentiation and has antiproliferative effects. Vitamin D deficiency can be a risk factor for some cancers including thyroid cancer(1). Differentiated thyroid cancers are seen in 5-15% of thyroid nodules. So we aimed to evaluate that if vitamin D deficiency plays a role in nodule formation.

Study was done in a prospective manner in the summer time. One hundred consecutive euthyroid patients with thyroid nodules and 100 euthyroid healthy subjects without thyroid nodules were recuireted in the study. Samples were centrifuged and preserved in -80 C until the day of study. 25(OH)D3 were studied with liquid chromatography mass spectrometry analyzer. Thyroid fine needle aspiration biopsies were done in patients with thyroid nodules when indicated. . We compared the groups according to demographic datas, serum sT3, sT4, TSH, TMAB, AntiTG, Ca, P, ALP, PTH, Vit D levels, thyroid volumes and nodule characteristics.

Thyroid nodule group consisted of 88 female and 12 male patients where as control group’s female to male ratio was 86/14. Mean ages were 44,4±10,9 ( 20-65) years in the nodule group which was similar in the control group (43,3 ±10,05, 18-61years). The mean levels of 25(OH)D3 were 15.39 ± 9.1 ng/ml in thyroid nodule group and 13.33 ± 7.1 ng / ml in the control group. 25(OH)D3 levels were lower in control group, but it did not reach statistical significance. Thyroid volume was 17,8 ± 15,7 cm3 in the thyroid nodule group where as, it was 8,4 ± 3,7 cm3 in the control group and reached statistical significance(p<0,001). Three patients were diagnosed as papillary throid cancer which was confirmed postoperatively. Vit D levels were 12,2 ng/ml, 13,5 ng/ml, 14,2 ng/ml in these patients. There was no significant correlation between 25 (OH)D3 levels and the presence of thyroid nodules, nodule number, nodule volume and thyroid gland volume.

This is the first study that aimed to investigate the relationship between Vit D levels and thyroid nodules. Vit D levels were prominently lower in both groups which were lower than the other parts of the country. The study was done in a moderate iodine sufficient area. This study did not find any correlation between Vit D deficiency and thyroid nodule formation but further studies are needed in iodine and Vit D repleted areas to confirm these results.

 

Nothing to Disclose: MK, HK, AK

22443 6.0000 LBF-006 A Comparison of 25(OH)D3 Levels in Patients with Thyroid Nodule and in Healthy Subjects without Thyroid Nodule 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Rebekah Mara Gospin*
Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY

 

Introduction:  Riedel’s thyroiditis is a rare form of thyroiditis that often presents with compressive symptoms and vocal cord paralysis and is associated with a systemic fibrosclerotic process. 

Clinical Case:  A 65 year old Jamaican lady presented to the hospital with complaints of neck enlargement, dyspnea, and headache.  Additionally, she reported symptoms of hypothyroidism including dry skin, myalgias, cold intolerance, constipation, depressed mood.  Physical exam notable for enlarged thyroid with hard texture and decreased movement with swallowing.  Workup revealed elevated TSH (64.5 uU/mL), and low fT4 (0.12 ng/dL), negative anti-TPO, mildly positive anti-thyroglobulin of 6.5 IU/mL (< 4.0 IU/mL).  Thyroid U/S showed diffusely enlarged heterogeneous, hypoechoic thyroid tissue bilaterally, with a 3.1 cm echogenic nodule within the left lobe.  FNA of this nodule revealed rare clusters of oncocytic follicular cells, abundant lymphoid cells and some colloid, suggestive of chronic lymphocytic thyroiditis.  Core biopsy of the thyroid showed sclerotic fibroconnective tissue infiltrated by chronic inflammatory cells with no thyroid tissue present.  After the patient developed dysphagia and right vocal cord paralysis a neck CT showed diffusely enlarged thyroid gland with soft tissue extending from the right thyroid lobe to completely encase the right common carotid artery and tracking superiorly along the carotid sheath to the level of the carotid bifurcation, infiltrating fat planes, resulting in parapharyngeal and retropharyngeal edema and narrowing of the trachea. Incisional biopsy of both thyroid lobes revealed dense fibrous tissue with chronic inflammation, no thyroid tissue identified, immunostain negative for IgG4+ plasma cells.  CRP mildly elevated (6.3 mg/L, range 0.0 – 2.9 mg/L), ESR normal, serum IgG normal.  She was started on treatment for Riedel thyroiditis and hypothyroidism with prednisone 60mg daily and levothyroxine 125 mcg daily with continued improvement.  Head CT to evaluate headache revealed expansion and bony abnormality of the left frontal, parietal, sphenoid and ethmoid bones and right temporal bone with a mixed lytic/sclerotic matrix, areas of cortical thickening, increased sclerosis with ground glass opacity consistent with isolated fibrous dysplasia as there was no evidence of café au lait spots or endocrine hyperfunction.   

 Conclusion: Although the exact etiology of Riedel’s thyroiditis remains unclear there are several histologic and serologic features that support an autoimmune mechanism.  This may be mediated in part by IgG4+ plasmocytes, however as with this patient, it is not always correlated.  Further, it has been suggested that it is a manifestation of a systemic fibrosclerotic process involving other organs.  While an association with fibrous dysplasia has not yet been described, this may be an additional component of the disease to further evaluate.

 

Nothing to Disclose: RMG

22558 7.0000 LBF-007 A Riedel's Thyroiditis with Isolated Fibrous Dysplasia Causing Hypothyroidism and Compressive Symptoms 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Ian D Hay*1, Tammi A Johnson1, Geoffrey B Thompson2, Thomas J Sebo2 and Megan S Reinalda2
1Mayo Clinic, Rochester, MN, 2Mayo Clinic College of Medicine, Rochester, MN

 

BACKGROUND. Gross extrathyroid extension (GEE), reported intra-operatively in pT4 tumors, is a major prognostic factor in papillary thyroid carcinoma (PTC). However, the recognition by pathologists of minimal extrathyroid extension (MEE) without concomitant GEE is of uncertain significance. Recent studies suggest that MEE may not lead to increased tumor recurrence (TR); only two studies to date have analyzed the influence of MEE on cause-specific mortality (CSM).The present study assessed the prognostic impact of GEE and MEE on CSM and TR in patients treated with curative intent for localized PTC during seven decades (1940-2009).

METHODS. From a computerized PTC database, we studied outcome in a cohort of 3524 patients without distant metastases (WDM) at diagnosis, who had their primary surgery at our institution. Endpoints studied included CSM and TR at local, regional and distant sites. For TR analyses, we studied only 3433 patients with complete surgical resection. The medical histories of all patients with GEE on surgical reports or MEE on pathology reports were carefully re-evaluated. Follow-up was updated to 10/2014. Kaplan-Meier curves were constructed; differences between groups were evaluated by log-rank testing.   

RESULTS. 30-year CSM rate for GEE of 25.1% was eleven-fold higher (p<0.001) than the 2.3% seen with surgically intra-thyroid tumors (SIT). By contrast, none of 120 MEE patients died of PTC. No significant difference (p=0.37) existed in CSM rates between 120 MEE and 3109 microscopically intra-thyroid tumors (MIT). Twenty-year TR (all sites) rate for GEE was 42.9%, as against 11.4% with SIT (p<0.001).  By twenty years, 23/119(19%) MEE and 269/3102(9%) MIT tumors had recurred. Analyzing only 2067 pNO tumors, GEE patients had higher TR rates at regional, local and distant sites, when compared to either SIT or MEE (p<0.001).However, when 40 MEE were compared to 1949 MIT cases, the TR (all sites) rates were insignificantly different at 5.3 and 5.1% (p=0.43); twenty-year regional recurrence rates were 2.7% for MEE and 3.0% for MIT (p=0.64). These insignificant differences were also seen with 1253 patients older than 45 years (p=0.42 and p=0.18).

CONCLUSION. In our study, MEE did not increase rates of either CSM or TR in PTC. It would therefore seem unjustifiable to consider postoperative radioactive iodine therapy as a mandatory component of the initial management plan. These results may also have implications for proposed pTNM staging modifications and future treatment guidelines for PTC patients whose tumors only exhibit minimal extrathyroid invasion.

 

Nothing to Disclose: IDH, TAJ, GBT, TJS, MSR

22498 8.0000 LBF-008 A When a Papillary Thyroid Carcinoma Exhibits Minimal (pT3), but Not Gross (pT4), Extrathyroid Extension into Adjacent Neck Tissues, Does This Result in a Worsened Prognosis Justifying a More Aggressive Approach to Initial Management? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Jessica Rose Wilson*1, Howard B A Baum2 and Andrea Lynn Utz3
1Vanderbilt University Medical Center, Nashville, TN, 2Vanderbilt University Medical Ce, Nashville, TN, 3Vanderbilt University, TN

 

Background: Fewer than 1% of cases of medullary thyroid cancer are associated with ACTH production. Among these, it is exceedingly rare for an initial diagnosis of hypercortisolism to lead to discovery of underlying medullary thyroid carcinoma (1).

Clinical case: A 67 year old man presented with four months of progressive diarrhea and weakness. Medical history was remarkable for hypertension, mycosis fungoides, diverticular disease, and history of colonic surgery for polyp removal. Initial laboratory evaluation revealed hypokalemia to 2.8 mmol/L (3.3-4.8), new diagnosis of diabetes (hemoglobin A1C 6.8%), elevated hepatic enzymes (AST 66 unit/L (5-40), ALT 137 unit/L (0-55)), and abnormal thyroid testing (TSH 0.144 mcunit/mL (0.35-3.60), FT4 0.63 ng/dL (0.70-1.37)). Follow up tests showed elevated ACTH 314 pg/mL (7-51), cortisol 52.7 mcg/dL (3.7-19.4), serum sodium 151 mmol/L (136-144), and potassium 2.6 mmol/L, prompting hospitalization. 24 hour urine free cortisol was 4028.8 mcg/day (<60). Serum cortisol did not suppress to low and high dose dexamethasone. Pituitary MRI revealed a 4mm lesion. Aldosterone and renin levels were normal. Due to severity of cortisol excess and hypokalemia, further evaluation for ectopic Cushing’s was performed: VIP and 5HIAA testing were normal, calcitonin >20,000 pg/mL (0-11.5), and chromogranin A 1089 ng/mL (<96). IPSS was considered not necessary. Thyroid imaging revealed an irregular 2cm left thyroid mass and lymphadenopathy. CT of chest and abdomen with contrast showed new adrenal hypertrophy and low density liver lesions not seen 3 months prior. Left neck lymph node and liver biopsies confirmed the diagnosis of metastatic medullary thyroid carcinoma.

Initial therapy for hypercortisolism included ketoconazole and spironolactone which normalized his potassium, although cortisol remained >50 mcg/dL. Ketoconazole was discontinued due to hepatic enzyme elevation and mifepristone was initiated. He developed progressive weakness, abdominal pain, and a perforated diverticulum with an associated intra-abdominal abscess for which he received percutaneous drainage and antibiotics. Mifepristone therapy was stopped, and he was treated with “block and replace” (2) therapy with etomidate (starting dose 2.5mg/hr) and hydrocortisone. Serum cortisol levels with this therapy improved to goal of 20s-30s mcg/dL, in the setting of acute illness. He was administered vandetanib therapy for metastatic medullary thyroid carcinoma. He underwent bilateral adrenalectomy. Adrenal pathology was negative for malignancy. He died 6 days later due to respiratory complications.

Conclusion: In this unique case, a patient was diagnosed first with ectopic ACTH production prior to diagnosis of underlying metastatic medullary thyroid carcinoma. Therapy included etomidate for severe hypercortisolism and vandetanib for metastatic medullary thyroid carcinoma.

 

Disclosure: ALU: Principal Investigator, Novartis Pharmaceuticals, Principal Investigator, Ipsen. Nothing to Disclose: JRW, HBAB

22610 9.0000 LBF-009 A Ectopic Adrenocorticotropic Hormone (ACTH) Production and Diarrhea Leading to the Diagnosis of Metastatic Medullary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Wenyi Zhang*1 and Kevin Anthony Codorniz2
1Loma Linda University Medical Center, loma linda, CA, 2Loma Linda University Medical Center, Loma Linda, CA

 

Müllerian cyst usually locates in the pelvis of females and the prostate utricles in males (1,2). Cases of mediastinal cysts with similar pathological and ICH characters were reported in the past and they were named as mediastinal cyst of Müllerian origin (3). In most cases, patients were asymptomatic and cysts were revealed during regular medical check up (3,4,5).

We present a case of mediastinal cyst of Müllerian origin with I131 uptake activity in a patient with stage 1 papillary thyroid carcinoma.

A 35 year old obese Hispanic female was diagnosed with stage I thyroid papillary carcinoma and underwent total thyroidectomy and radioactive iodine ablation therapy. Pre and post radiation whole body iodine scan both indicated focal increased activity in the left lower chest. A CT scan showed a mass in the left parastinal region at the level of T5 vertebral body. A video assisted thoracoscope was done, which exposed a cystic mass adjacent to the aorta in the left mediastinum. Cyst was removed intact.  Pathology of the cyst revealed benign ciliated epithelial-lined cyst, most consistent with mediastinal cyst of Müllerian origin.

To our knowledge, this is the first case of mediastinal cyst of Müllerian origin that also has I131 uptake activity in the setting of thyroid carcinoma. There are other case reports for false-positive I131 uptake in bronchogenic cysts in the setting of thyroid carcinoma in remission (6,7). However, these 2 kinds of cysts can be differentiated by pathology and ICH staining.

 

Nothing to Disclose: WZ, KAC

22618 10.0000 LBF-010 A Radioactive I131 Uptake in  Posterior Mediastinal Cyst of Müllerian Origin in a Patient with Papillary Thyroid  Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Sean J Iwamoto*1, Richard Shaw1 and Anthony York Yul Yin2
1California Pacific Medical Center, San Francisco, CA, 2Sutter Pacific Medical Foundation, San Francisco, CA

 

Background:Several guidelines have been proposed to identify thyroid nodules that should be assessed with fine needle aspiration biopsy (FNAB) based on various characteristics.  We compared the accuracy of three sets of such guidelines:  the Kim criteria, the Society of Radiologists in Ultrasound (SRU), and the American Association of Clinical Endocrinologists (AACE).

Hypothesis and questions: We investigated the diagnostic accuracy of the aforementioned criteria at an urban, referral-based endocrinology clinic.  Based on findings by Ahn, et al, (1) we hypothesized that the AACE guidelines would have the highest specificity, and the Kim criteria would be most sensitive.

Experimental design/methodology: 199 thyroid nodules biopsied between December 2011 and December 2013 were analyzed.  The Kim criteria recommends FNAB of a nodule with at least one of the following characteristics: marked hypoechogenicity, irregular or microlobulated margins, microcalcifications, or length greater than width.  The SRU recommends FNAB of nodules 1 cm or larger in diameter with microcalcifications; 1.5 cm or larger in diameter and solid nodules or with coarse calcifications; 2 cm or larger in diameter and mixed solid/cystic; and nodules that have undergone substantial growth or those associated with abnormal cervical lymph nodes. The AACE recommends FNAB of hypoechoic nodules with at least one additional feature including: irregular margins, length greater than width, or microcalcifications.  All malignant nodules were confirmed with post-operative pathology.

Results:  In this series there were a total of seven surgically proven cases of thyroid carcinoma, for a malignancy rate of 3.5%.  Of the sonographic features examined, the presence of microcalcifications had the greatest positive predictive value (5.8%; OR = 2.2), and hypoechogenicity the highest accuracy (Az = 0.620).  Sensitivities were 71.4%, 57.1% and 14.3%, and specificities 22.9%, 56.8% and 70.8%, for Kim, SRU and AACE guidelines, respectively.   Accuracy of the guidelines calculated by area under the ROC (Az) were 0.528, 0.570, 0.574, for Kim, SRU and AACE guidelines, respectively (p > 0.05).  

Conclusion: There was no significant difference in accuracy among the three guidelines.  Consistent with prior reports, the Kim criteria have the highest sensitivity and AACE guidelines the highest specificity.

 

Nothing to Disclose: SJI, RS, AYYY

22736 11.0000 LBF-011 A A Comparison of Three Sets of Guidelines for Ultrasound-Guided Fine-Needle Aspiration Biopsy of Thyroid Nodules at an Urban Endocrinology Clinic 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Mohammed Zafer Ansari*1, Jiaqiong Xu2, Jett Brady3, Jawairia Shakil4 and Richard J Robbins4
1Houston Methodist Sugar Land Hospital, Houston, TX, 2Houston Methodist Research Institute, Houston, TX, 3Houston Methodist Hospital, 4Houston Methodist Hospital, Houston, TX

 

Background:

Thyroid cancers are now frequently found incidentally during imaging of the neck or following thyroidectomy for benign thyroid disease. It is unclear if these tumors have different clinical behavior and outcomes than those that are discovered by signs or symptoms.

Methods:

129 patients with differentiated thyroid cancer (DTC) seen at one institution over the past 20 years were retrospectively analyzed. Incidental thyroid cancer (ITC) was detected on radiological examination done for non-thyroid disease or following a thyroidectomy which was done for benign thyroid disease. Clinically apparent (CA) thyroid cancer cases presented with clinical signs or symptoms of thyroid cancer. Patients were considered to have a recurrent/residual (R/R) cancer if there was evidence of abnormal regional lymph nodes (LN) on thyroid ultrasound (US) or if the unstimulated serum thyroglobulin (Tg) was ≥5 ng/ml on follow up. The demographics, pathological features, treatment and long-term outcomes of the two groups were compared.

Results:

89% of all tumors were papillary thyroid carcinomas (PTC). There were no significant differences between ITC (n=32) and CA (n=97) in tumor size, AJCC Stage, lymph node positivity, anti-Tg antibodies, or multicentricity. The ITC group had a higher percentage of men (34.4% vs 21.7% in CA, p=0.16). Mean age at diagnosis was 53.6±15.6 in the ITC group and 46.7±13.8 in the CA group (p=0.02). Stage I cancer was more frequent in the ITC group (79.3% vs 65.9%, p=0.25). Patients with ITC were less likely to receive adjuvant radioiodine (48.3% vs 70.2% in CA, p=0.04). R/R disease tended to be less common in the ITC group (9.4%) than the CA group (21.6%, p=0.19). ITC patients had a better, but not significantly different disease-free survival than CA (p=0.21) over a median follow-up of 24 months (Interquartile range 6-48 months). R/R disease for the entire cohort was significantly more likely in those with positive anti-Tg antibodies (8/23, 34.8% vs 9/79, 11.4%; p=0.02), larger tumor size (>4cm vs ≤2 cm; p=0.04), and positive lymph nodes at initial surgery (p=0.009). Recurrence rates were higher in patients who received adjuvant radioiodine therapy (86.4% vs 60.4%, p=0.03).

Conclusion:

Our ITC patients had slightly better outcomes with trends toward lower recurrence rates and longer disease-free survival, compared with CA patients. However these differences did not meet statistical significance with our current cohort size. Therefore, we suggest that the clinical management of ITC patients should not differ from patients whose tumors are found by standard signs or symptoms.

 

 

 

Nothing to Disclose: MZA, JX, JB, JS, RJR

22739 12.0000 LBF-012 A Recurrence Rates and Disease-Free Survival in Incidentally Discovered Thyroid Carcinoma: A Retrospective Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Marcel E. Sambo1, María Luisa Prieto Martín2, Luis Ocaña Wilhelmi3, Jorge L Reverter Calatayud4, Cristina Familiar Casado5, Maria Concepcion Sanabria6, Tomas Martin Hernandez7, Alberto Torres Cuadro7, Xavier Serres Créixams8, Guillem Cuatrecasas9, Jordi Mesa10, Jose Luis del Cura Rodriguez11, Javier Larrache Latasa12 and Juan C Galofre Ferrater*13
1Hospital General Universitario Gregorio Marañón, Madrid, Spain, 2Hospital General Universitario Gregorio Marañón, Madrid, 3Hospital Universitario Virgen de la Victoria de Málaga, 4Hospital Germans Trias i Pujol, Badalona, 5Hospital Universitario Clínico San Carlos, Madrid, 6Clinical Hospital San Carlos, Madrid, Spain, 7Hospital Virgen Macarena, Sevilla, 8Hospital Vall d'Hebron, Barcelona, 9Centro Médico Teknon, Barcelona, Spain, 10Hospital Vall d'Hebron, Barcelona, Spain, 11Hospital de Basurto, Bilbao, 12Clínica Universidad de Navarra, Pámplona, 13Clínica Universidad de Navarra, Pamplona

 

T

Furthermore, about 5-10% of the solid benign TN are hyperfunctioning and cause subclinical hyperthyroidism up to 75% of cases that can be symptomatic and associated increased cardiac, bone and / or perinatal morbidity, not forgetting the 4% year rate of conversion to hyperthyroidism. Radioiodine (RI) is considered the treatment of choice in most of these patients. Surgery is when compressive symptoms are associated or when the RI is not effective or can’t be used. However, with the RI the risk of permanent clinical or subclinical hypothyroidism ranges from 11-58% .It’s also contraindicated in pregnancy, lactation or fertility plans in the subsequent 6-12 months and can’t be used in patients who recently received iodinated contrasts.

Radiofrequency ablation (RFA) using “moving shot” technique is a radioguided minimally invasive percutaneous thermal ablation alternative to be performed under local anesthesia (+/- conscious sedation) and outpatient. It has been associated with a mean volume reduction from 80 to 93.5% at 4-12 months and decrease of symptomatology in all cases, almost always with unique treatments. Complication rate is lower than 3,3,% (major complications less than 1.5% of cases, all reversible and mostly conservatively treatable), with low recurrence rate and remaining euthyroid  in virtually all cases.

Nevertheless, the experience to date is primarily from Korea and some groups in Italy. We don't have multicenter clinical trials or studies with combined endpoints, neither demonstrated reproducibility in large volume TN.

This is a 6 month follow-up Spanish multicenter prospective study involving 9 hospitals. It's aimed to determine the effect of RFA in the clinical, morphological and functional control of solids, symptomatic benign large TN in patients not candidates for surgery or RI.

The project is still ongoing, so we will present preliminary data.

To date 25 TN have been ablated, with a mean volumen of 155,31 mL ± 119 (range, 29.54– 439,6) to 24 patients (20 euthyroid and 4 with subclinical hyperthyroidism). No major complications have been report during the procedure, only 6 patients with mild transient pain, 2 with slight edema in soft tissues and 1 with vasovagal symptoms. After 48 h. no serious side effects were reported, just 1 patient with slight bruising on the skin, 2 with mild pain and 1 with cough

 

Nothing to Disclose: MES, MLP, LO, JLR, CF, MCS, TM, AT, XS, GC, JM, JLD, JL, JCG

22871 13.0000 LBF-013 A Radiofrequency Ablation (RFA) in the Clinical, Morphological and Functional Control  of  Large, Solids, Symptomatic and Benign Thyroid Nodules: Justification and Preliminary Safety Outcomes of a Multicenter Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Friday, March 6th 3:00:00 PM LBF 001-014 6278 1:00:00 PM Late-breaking Thyroid/HPT Axis II Poster


Emily Jaye Gianatti1, Rudolf Hoermann2, Que Lam3, Philippe Dupuis4, Jeffrey D Zajac5 and Mathis Grossmann*6
1University of Melbourne Austin Health, Melbourne VIC, Australia, 2The University of Melbourne, Heidelberg, Australia, 3Austin Health, Heidelberg, Australia, 4Department of Medicine Austin Health, University of Melbourne, Sainte-Foy, QC, Canada, 5The University of Melbourne, Australia, 6Univ of Melbourne/Austin Health, Heidelberg, VIC, Australia

 

Objective: To assess the effect of testosterone treatment on cardiac biomarkers in men with type 2 diabetes (T2D).

Design: Randomized double-blind, parallel, placebo-controlled trial. The primary outcome of this trial, effects of testosterone treatment on glucose metabolism, has been reported previously (1).

Setting: Tertiary referral center.

Patients: Men aged 35-70 years with T2D and a total testosterone level < 12.0 nmol/L (346 ng/dl) at high risk of cardiovascular events, median 10-year United Kingdom Prospective Diabetes Study (UKPDS) coronary heart disease (CHD) risk 21% (IQR 16%, 27%).

Intervention: 88 participants were randomly assigned to 40 weeks of intramuscular testosterone undecanoate (n= 45) or matching placebo (n= 43).

Main Outcome Measures: N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT).

Results: Testosterone treatment reduced NT-proBNP (mean adjusted difference (MAD) in change over 40 weeks across the testosterone and placebo groups, -17.9 ng/L [95% CI -32.4, -3.5], p=0.047), but did not change hs-cTnT (MAD, 0.41 ng/L [95% CI -0.56, 1.39], p=0.62). Six men, three in the testosterone, and three in the placebo group experienced an adverse cardiac event (p=1.00). Testosterone-treated men who experienced a cardiovascular event had higher baseline NT-proBNP (p=0.004) and hs-cTnT levels (p=0.01) as compared to men who did not. At baseline, 10-year UKPDS CHD risk was associated positively with NT-proBNP (tau=0.21, p=0.004) and hs-cTnT (tau=0.23, p=0.003), and inversely with testosterone (total testosterone tau=-0.18, p=0.02, calculated free testosterone tau=-0.19, p=0.01), but there was no significant association between testosterone and cardiac biomarkers (p>0.05).

Conclusions: In this trial of men with T2D and high cardiovascular risk, testosterone treatment reduced NT-proBNP, but did not change hs-cTnT. Further studies should determine whether men with increased cardiac biomarkers prior to testosterone therapy are at higher risk of testosterone-treatment associated adverse cardiac events.

 

Disclosure: MG: Clinical Researcher, Bayer Schering Pharma. Nothing to Disclose: EJG, RH, QL, PD, JDZ

22352 1.0000 LBF-015 A Effect of Testosterone Treatment on Cardiac Biomarkers in a Randomised Controlled Trial of Men with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM LBF 015-023 6281 1:00:00 PM Late-breaking Reproductive Endocrinology II Poster


Caroline A. Maguire*1, Serap Simavli2, Rona S. Carroll1, Ursula B. Kaiser3 and Victor M. Navarro4
1Brigham and Women's Hospital/Harvard Med School, Boston, MA, 2Brigham and Women's Hospital and Harvard Medical School, Division of Endocrinology/Diabetes, Boston, MA, 3Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 4Harvard Medical School and Brigham and Women's Hospital, Boston, MA

 

Sexual differentiation of the brain occurs during a critical window, from embryonic day E17.5 to postnatal day (p) 10 in rodents, when changes in the levels of sex hormones may permanently alter the wiring of a number of neuronal circuits. During this period, high levels of centrally aromatized estradiol present in the male have been associated with masculinization of the brain. Estradiol also induces an increase in enzymes involved in the synthesis of the pro-inflammatory molecule prostaglandin E2 (PGE2) from the microglia, leading to higher levels of this molecule in the male than in the female brain. Importantly, perinatal PGE2 participates in the establishment of the neuronal networks that lead to the manifestations of male sexual behavior in adulthood.  In this study, we aimed to characterize the action of perinatal PGE2 in the maturation of the gonadotropic axis and the shaping of the populations of Kiss1 neurons in the anteroventral/periventricular (AVPV/PeN) and the arcuate (ARC) nuclei in the mouse. Female mice were injected icv (intracerebroventricular) bilaterally on p1 with 1 μl of PGE2 (2 μg/μl) or vehicle (saline). Male counterparts were injected subcutaneously with an inhibitor of the PGE2 synthesizing enzymes (COX-1 and COX-2), indomethacin (50 μg/50 μl sesame oil). The timing of puberty onset, as indicated by the age of vaginal opening (VO) in the female and preputial separation (PS) in the male, was delayed in both sexes. Of note, before puberty, PGE2–treated females showed significantly higher body weight (BW), while this was significantly lower in indomethacin-treated males, but subsequently normalized to control levels in both cases during adulthood. Adult females that were neonatally injected with PGE2 had irregular estrous cycles and significantly fewer corpora lutea, indicating decreased ovulation, compared to controls. These females displayed significantly lower post-gonadectomy (1 week) plasma LH levels than controls and correlated with a lower number of Kiss1 neurons in the ARC. Males, in contrast, responded normally to gonadectomy (LH levels and Kiss1 cell count were similar to controls). Overall, these data offer compelling evidence for a disruptive effect of central PGE2 on the maturation of Kiss1 neurons and control of BW prepubertally in the female; in the male, higher levels of PGE2 may play a role in puberty onset and metabolism. These results also indicate the possibility of permanent developmental impairment in reproductive function, at least in females, suffering inflammatory processes during perinatal ages.

 

Nothing to Disclose: CAM, SS, RSC, UBK, VMN

22442 2.0000 LBF-016 A Central Prostaglandin E2 (PGE2) Levels during the Perinatal Period Participate in the Permanent Shaping of the Hypothalamic Kiss1 System 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM LBF 015-023 6281 1:00:00 PM Late-breaking Reproductive Endocrinology II Poster


Reshmi Srinath*1, Kathryn A Carson2, Sherita Hill Golden1 and Adrian Sandra Dobs3
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 3Johns Hopkins School of Medicine

 

Introduction: Epidemiologic studies suggest that men with low testosterone (T) are more likely to have diabetes, due to changes in body composition, adiposity and increased inflammatory mediators.  It is not known if diabetic men with low T have greater risk of complications. We hypothesized that low T was associated cross-sectionally with the presence of diabetes and diabetic complications including retinopathy and albuminuria.

Methods:  The Atherosclerosis Risk in Communities (ARIC) study is a large prospective multicenter cohort study of individuals followed since 1987 to evaluate risk factors associated with incident cardiovascular disease.  In a sample of male participants at visit 4 (1996-1998) without prior T therapy, we measured plasma total T by liquid chromatography mass spectrometry using samples obtained prior to 10:30 AM. Cochran-Armitage test for trend and general linear models regression was used to assess the cross-sectional association of quartile of T with demographic parameters and with presence of diabetes at visit 4. Logistic regression analysis was used to assess the relationship between T and presence of diabetes and, in those with diabetes, presence of diabetic retinopathy (Early Treatment Diabetic Retinopathy Study(ETDRS) score≥20) and presence of albuminuria (albumin/creatinine ratio>30 mg/g). Models were adjusted for age, race and center, body mass index (BMI), waist circumference, smoking status, hypertension, LDL and HDL.

Results:  In 1923 males (mean (SD) age=63.4 (5.6) years, BMI=28.2 (4.3) kg/m2), median (interquartile range) plasma T was 371.9 (285.7-475.6) ng/dL. Lower T was significantly associated with higher BMI, greater waist circumference, lower HDL, never smoking, and presence of hypertension. Lower T quartile (Q) was significantly associated with prevalent diabetes (odds ratios (95% CIs) for Q1-Q3 vs. Q4: 3.28 (2.27-4.75), 2.10 (1.43-3.09), 1.35 (0.90-2.04), respectively; p-for-trend<0.001).  Following multivariable adjustment, Q of T remained significant for prevalent diabetes (p-for-trend=0.02). However, only Q1 was significantly different than Q4 (1.53 (1.01-2.32)). For the 312 diabetic men, there was no association between T and presence of retinopathy (p-for-trend=0.81) or albuminuria (p-for-trend=0.94).

Summary/Conclusions: In a sample of males from ARIC low T was significantly associated with increased prevalence of diabetes before and after multivariable adjustment.  No relationship was seen between T and the presence of diabetic complications, however this was limited by a small sample size of diabetics. Further investigation is necessary regarding the role of endogenous testosterone in diabetes risk.

 

Nothing to Disclose: RS, KAC, SHG, ASD

22545 3.0000 LBF-017 A Association Between Endogenous Plasma Testosterone and Prevalent Diabetes and Diabetic Complications in Males in the Atherosclerosis Risk in Communities (ARIC) Cohort Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM LBF 015-023 6281 1:00:00 PM Late-breaking Reproductive Endocrinology II Poster


Om P Dhingra* and James S Bernstein
SOV Therapeutics, Inc., Morrisville, NC

 

Background:  Oral dosing for testosterone (T) replacement is likely a preferred option for many hypogonadal men. One of the major challenges encountered is selection of an appropriate starting dose and dose titration algorithm to minimize Cmax excursions above 1800 ng/dL and optimize Cavg. An adaptive design was successfully used to determine a starting dose for Phase III requiring minimal or no dose titration.  For testosterone replacement therapy, the US FDA has set Cmax and Cavg criteria.  The Cmax criteria restrict the patient population percentages experiencing T concentrations above certain thresholds:  ≤ 15% above 1500 ng/dL, ≤ 5% above 1800 ng/dL, and 0 % above 2500 ng/dL.  The Cavg0-24 criterion is that ≥ 75% of subjects achieve an average T concentration (Cavg0-24) in the normal range.

Method:  This was a single center; open-label, 4-part (n=36; Cohort 1: n=21 & Cohort 2: n=15), multiple-dose, safety, tolerability, and PK study in hypogonadal men. The study was divided in four parts as follow: Part 1 included 7-day repeat bid dosing with 200 mg TU bid or 400 mg TU bid doses in a 2-period randomized crossover design, for 14 consecutive days, with 24 hours PK on Day 7 and Day 14, respectively. Part 2 started on Day 15 and included 400 mg TU bid dosing for 21 consecutive days, with 8 hours PK on Day 28. Data from Part 2 were analyzed to select a dose for Part 3, using the dose response obtained from Part 1. Part 3 started on Day 35 and included repeat bid dosing for 21 consecutive days with 24 hours PK on Day 49 and 12 hours PK on Day 56. Part 4 started on Day 56 and included repeat bid dosing for 28 consecutive days, with 24 hours PK on Day 84. Based on results from Cohort 1 using titration and three dose levels in Parts 3 and 4, all subjects in Cohort 2 for Parts 3 and 4 received a dose of 400 mg TU in the morning and 200 mg TU in the evening.

Results:  Following administration of TU twice daily to hypogonadal men for 84 days, the mean Cmax 0-24 was 1239 ng/dL for Cohort 1 and 1079 ng/dL for Cohort 2. The median peak T levels (Tmax) were reached between 3 and 5 hours after dosing, returning to basal levels after about 10 hours. Cohort 2 (n=15) successfully achieved with no titration the FDA Cavg and Cmax TRT criteria: 86.7% of the subjects had Cavg in the normal range of 300-1000 ng/dL; 86.7% of the subjects had Cmax < 1500 ng/dL, and 13.3% of subjects had Cmax > 1500 ng/dL with no subject’s Cmax > 1800 ng/dL or > 2500 ng/dL. The mean ratio of AUCDHT/AUCT ranged between 0.16 and 0.26 independent of the dose or the fat content in meal ingested.

Conclusion:  The SOV2012-F1 formulation, in a dose regimen of of 400 mg TU in the morning and 200 mg TU in the evening, has high probability to meet FDA criteria for testosterone replacement therapy with minimal down titration.  The use of testosterone concentrations obtained between 3 and 5 hours after the morning dose correlates well with the Cmax observed in this dose regimen, allowing for effective titration.

 

Nothing to Disclose: OPD, JSB

22591 4.0000 LBF-018 A Use of an Adaptive Design in a Phase IIb Study of SOV2012-F1, an Oral Testosterone Undecanoate (TU) Formulation to Minimize Cmax Excursions Above 1800 Ng/Dl in Hypogonadal Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM LBF 015-023 6281 1:00:00 PM Late-breaking Reproductive Endocrinology II Poster


Om P Dhingra*1, James S Bernstein1, Sylvain Lachance2, Stephanie Gagnon2, Caroline Savard2, Nathalie Pelletier2, Nadine Boudreau2 and Ann Levesque2
1SOV Therapeutics, Inc., Morrisville, NC, 2inVentiv Health clinical, Québec, Canada, Quebec, QC, Canada

 

Background: Testosterone undecanoate (TU), a pro-drug of testosterone, is metabolized by non-specific esterases in blood to testosterone1-2. Two intramuscular (IM) and one oral testosterone replacement therapy products using TU have been approved in US (IM;Aveed®), Europe (Oral; Andriol® or Restandol® TestocapsTM; IM, Nebido®), Canada (Oral; Andriol®) and many other countries. It is well established in the bioanalytical industry that testosterone (T) and dihydrotestosterone (DHT) are analyzed in human serum4-8.  To minimize conversion of TU to testosterone during the serum preparation from blood, published literature in pre-clinical studies of TU has used potassium fluoride (KF) as an esterase inhibitor in sample collection tubes3. However, published clinical data on TU have used standard serum tubes without an esterase inhibitor2,4-8. One publication on the validation of a bioanalytical method for testosterone analysis concluded that TU is stable in blood12.

Method: The possible degradation of TU and dihydrotestosterone undecanoate (DHTU) into T and DHT was evaluated by collecting fresh human whole blood and spiking the blood with known concentrations of TU and DHTU.  The whole blood samples were subjected to conditions typical of those encountered during the course of a clinical study.  The harvested serum or plasma was analyzed for T and DHT by liquid-liquid extraction and tandem mass spectrometry.

 

Results: It was observed that TU and DHTU degrade extensively to T and DHT in human whole blood, including those conditions typical of harvesting serum.  Blood fortified with 600ng/mL TU after processing to harvest serum (30 min. at RT) resulted in 343% increase in T level compared to the T level in serum harvested from un-spiked blood sample. Further storage of serum for 30 min. at RT results in additional 55% increase in T level. It was found that the use of an enzyme inhibitor (sodium fluoride) to yield a plasma sample, combined with low temperature during sample collection and handling, minimizes degradation during sample processing.  These results were confirmed with a clinical study in which serum and NaF-Na2EDTA plasma samples were collected and analyzed for T and DHT. The serum/plasma ratio observed in the clinical study for T and DHT was 130% and 122%, respectively.

 

Conclusions:  The analysis of T and DHT in human serum from individuals orally dosed with TU will deliver overestimated concentrations of these analytes due to the degradation of TU and DHTU during typical sample collection and handling procedures. To report reliable and accurate concentrations of circulating T and DHT, NaF-Na2EDTA plasma samples (with low-temperature collection and handling) should be used when TU is the administered medication.

 

Nothing to Disclose: OPD, JSB, SL, SG, CS, NP, NB, AL

22902 5.0000 LBF-019 A The Importance of Using Plasma Rather Than Serum to Measure Blood Testosterone Levels in Men Receiving Testosterone Undeconoate for Androgen Replacement Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM LBF 015-023 6281 1:00:00 PM Late-breaking Reproductive Endocrinology II Poster


Reshmi Srinath*1, Kathryn A Carson2, Sherita Hill Golden1 and Adrian Sandra Dobs3
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 3Johns Hopkins School of Medicine

 

Introduction: Prior longitudinal studies suggest that low testosterone is associated with increased risk of diabetes, but little is known about the long term risk of low testosterone (T) in predicting both incident diabetes and diabetic complications.  We hypothesize that low T is independently associated with incident diabetes and the presence of diabetic albuminuria.

Methods:  The Atherosclerosis Risk in Communities study is a large prospective multicenter cohort of individuals followed since 1987 to evaluate risk factors associated with incident cardiovascular disease. Using visit 4 (1996-1998) as baseline, we measured plasma total T by liquid chromatography mass spectrometry in a sample of male participants without prior T therapy, using samples obtained prior to 10:30 AM. Cochran-Armitage test for trend and general linear models regression was used to assess the cross-sectional association of T quartile with demographic parameters. Participants were followed annually through visit 5 (2011-2013). Proportional hazards regression analysis was performed to assess the association of T quartiles with incident diabetes as defined by self-reported physician diagnosis, use of oral antihyperglycemic medications or insulin, or by elevated fasting (≥126 mg/dL) or random (≥200 mg/dL) glucose measurement at visit 5. Ordinal logistic regression analysis was used to assess the association of T quartile with incidence of albuminuria (microalbumin/creatinine ratio≥30 mg/g) at visit 5.  Models were adjusted for age, race and center, body mass index (BMI), waist circumference, smoking status, hypertension, LDL and HDL.

Results: In 1923 males (mean (SD) age=63.4 (5.6) years, BMI=28.2 (4.3) kg/m2), median (interquartile range) plasma T was 371.9 (285.7-475.6) ng/dL. Lower T was significantly associated with higher BMI, greater waist circumference, lower HDL, never smoking, and presence of hypertension. Median follow-up was 12.8 years. There was a significant association of lower T at baseline with incident diabetes (hazard ratios (95% CI)=2.30 (1.62-3.27), 1.92 (1.34-2.74), 1.49 (1.03-2.15) for Q1-Q3 compared to Q4, respectively( p-for-trend<0.001); however following multivariable adjustment, there was no association of T with incident diabetes (p-for-trend=0.13). Data on albuminuria at follow-up was available for 284 (63.8%) of 445 participants with microalbumin/creatinine ratio< 30 mg/g at baseline and diabetes at baseline or follow-up. There was no association between T and incident albuminuria (p-for-trend=0.56).

Summary/Conclusions: After multivariable adjustment no association was seen between T and incident diabetes or with the diabetic complication of albuminuria, although limited by a small sample of diabetics. Thus emphasis should be placed on treating other risk factors and comorbidities associated with diabetes.

 

Nothing to Disclose: RS, KAC, SHG, ASD

22546 6.0000 LBF-020 A Association Between Endogenous Plasma Testosterone and Incident Diabetes and Diabetic Complications in Males in the Atherosclerosis Risk in Communities (ARIC) Cohort Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM LBF 015-023 6281 1:00:00 PM Late-breaking Reproductive Endocrinology II Poster


Yuyong Ke*1, Renaud Gonthier1 and Fernand Labrie2
1EndoCeutics Inc., Quebec City, QC, Canada, 2EndoCeutics Inc, Quebec, QC, Canada

 

The accurate measurement of total serum testosterone is very important, especially in women and children for proper diagnosis. In the reference LC-MS/MS method [1], the removal of protein binding is carried out in acidic buffer (pH = 5.5) while the removal of lipids is performed in basic buffer (pH = 9.8) during the second extraction using hexanes. In the sample preparation process, the first extraction solvent is a mixture of ethyl acetate and hexanes (3:2 in volume). In the present study, a simple approach of liquid-liquid extraction is examined against the reference procedure, where the extraction was done in the buffer ammonium acetate using chlorobutane as extraction solvent. For comparison, QCs and unknown samples were processed using both procedures. The difference of accuracies of QCs and values of unknown samples between the simple procedure and the reference one is less than 5% for both QCs and unknown samples, where the calibration curve was prepared by the reference procedure. This comparison shows that the protein binding was removed efficiently in the simple sample preparation procedure.

In addition, baseline comparison of LC-MS/MS chromatograms from stripped and unstripped serum for both procedures indicates that the sample prepared by the reference procedure is not cleaner than that by the simple procedure. Recovery using the simple procedure is higher than that using the reference one by 10 ~ 15%. Furthermore, recovery using the simple procedure is more consistent in stripped and unstripped serum. By contrast, the recovery in stripped serum is lower than that of unstripped serum in the reference procedure.

Lipids were removed efficiently in the reference procedure and verified by mornitoring the MRM transition of m/z 496 - > 184, which is a typical phospholipid transition. In the current assay, the retention time of testosterone is 3.6 minutes with isocratic elution of 55% methanol while lipids can be removed using 95% methanol. For every injection, there is one minute of online column wash with 95% methanol. This online wash can effectively remove the lipids on the column, therefore maintaining the column life time comparable to the reference procedure.  As conclusion, this simple procedure could replace the reference procedure for the accurate measurement of testosterone in human serum.

(1)   Wang et al. Clinica. Chimica. Acta. 2014; 436 : 263–67

 

Nothing to Disclose: YK, RG, FL

22588 7.0000 LBF-021 A Comparison of Total Serum Testosterone Measurements By LC-MS/MS Using Different Liquid-Liquid Sample Preparations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM LBF 015-023 6281 1:00:00 PM Late-breaking Reproductive Endocrinology II Poster


Narender Kumar*, Nishant K Gupta, William De Jesus, Lisa Mamkina and Regine Sitruk-Ware
Population Council, New York, NY

 

Hormonal male contraceptive regimens, currently in clinical development, include exogenous androgen treatment either alone or in combination with progestins. These regimens are effective in suppressing spermatogenesis in a significant number of men, even though 10 - 30% of men do not respond because of ethnicity or other unknown reasons. The selected dose of exogenous androgen is critical to effectively suppress gonadotropins and endogenous testosterone (T) production while supporting peripheral androgenic/anabolic actions. The androgen dose must also be below the threshold for maintaining spermatogenesis since low intra-testicular androgen levels are capable of maintaining spermatogenesis. A regimen that can block testicular T production completely while maintaining optimal androgen replacement is ideal. Synthesis of T in testis requires a series of steroidogenic enzymes, some of which can be blocked by specific enzyme inhibitors. Orally active Abiraterone acetate (ABX), was recently approved for the treatment of Castration Resistant Prostate Cancer.  It inhibits CYP450 17A1 (17 hydroxylase/17, 20 lyase) activity in testis and adrenals and suppresses T and cortisol synthesis.

Here, we tested this approach by using a CYP450 17A1 enzyme inhibitor (ABX) in combination with synthetic androgen 7α-methyl-19-nortestosterone acetate (MENT) for male contraception. Male rats were treated with ABX (50 mg/day/ip) in combination with MENT at a dose of 5, 10 or 30 µg/day delivered via Alzet osmotic pumps for 6 weeks. Treatment with MENT at 5 or 10 µg/day and ABX was highly effective in decreasing testis weights and spermatogenesis. Intra-testicular and serum T levels were significantly inhibited by ABX treatment while MENT maintained sex accessory glands and muscle growth without initiating spermatogenesis. In contrast, with the high dose MENT replacement (30 µg/day), testicular weights and normal spermatogenesis was maintained even in the presence of the inhibitor, indicating that enough MENT entered the testes to maintain normal spermatogenesis. The effectiveness of ABX and low dose MENT in inhibiting spermatogenesis demonstrated that this regimen could be a highly effective male contraceptive in men. However, ABX cannot be used for male contraception as it inhibits glucocorticoid synthesis as well leading to adverse effects. ABX is the FDA approved treatment for prostate cancer but must be administered with a replacement dose of glucocorticoid. Therefore, to pursue this new regimen of CYP450 17A1 inhibitor and exogenous androgen for male contraception, it will be necessary to design and develop safe and effective CYP 450 17A1 inhibitor(s) that will selectively inhibit 17, 20 lyase activity in testis without affecting 17-hydroxylase activity in adrenals which is required for corticosteroid synthesis.

 

Nothing to Disclose: NK, NKG, WD, LM, RS

22920 8.0000 LBF-022 A Promising Approach for Male Contraception Using Testicular Enzyme Inhibitor with Low Dose Androgen Replacement: Proof of Concept Study in Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM LBF 015-023 6281 1:00:00 PM Late-breaking Reproductive Endocrinology II Poster


Dat Ha*1, Garineh Ovanessoff2, Gaja Andzel3 and John Matchette1
1Phoenix VA Health Care System, Phoenix, AZ, 2St Joseph's, Scottsdale, AZ, 3Banner Good Samaritan, Phoenix, AZ

 

Background:  Hypothalamic hypogonadism (HH) is common in VA patients. Usual treatment is intramuscular or transdermal testosterone (T), modalities both inconvenient and expensive. In young patients, fertility and testicular atrophy are of concern, since T suppresses the hypothalamic-pituitary-gonadal (HPG) axis. Recently, clomiphene, a partial estrogen agonist/antagonist used in female infertility, has been shown to increase LH and T production in male HH. We are examining clomiphene citrate as a treatment for HH in men, some with concomitant conditions that suppress the HPG axis.

Methods:  Subjects were recruited from endocrinology clinics at our facility. Inclusion criteria were:  diagnosis of HH (T level < 250 ng/dl, no LH elevation, no significant pituitary abnormality on MRI or CT), age 30-70 y, and ability to provide informed consent. Exclusion criteria were pituitary tumor >5mm, chronic renal, liver or heart disease, chronic non-compliance, PSA ≥ 4.0 ng/ml, history of prostate, testicular or breast cancer, or cataracts limiting vision. Subjects were treated with oral clomiphene for 7 weeks, initially at 25 mg/d.  Dose was increased to 50 mg/d if T was <450 ng/dl after week 3.  Primary endpoint was total T by immunometric assay. Values were compared to week 0 by repeated measures analysis of variance (rmANOVA) and by simple T test.  Physical exam was performed at weeks 0 and 7; laboratory tests were drawn at weeks 0, 3, and 7. We called subjects at weeks 2, 4, and 6 to assess adverse effects.

Results: Of 20 men recruited, 17 completed, 1 is active, and 2 withdrew.  Mean age was 51±12 y (mean ± SE). At week 3 only 5/17 men were at T goal of 450 ng/dl, which increased to 11/16 at week 7.  Subjects were divided in two groups: naïve to T treatment (n=12), and previously treated with T for >12 weeks with discontinuation of T at least 4 weeks prior to clomiphene treatment (n=8). At week 0, T was 187±28 ng/dl in men with prior T treatment, and 203±21 ng/dl in men naïve to T (NS).  Means at week 7 were 401±53 ng/dl and 526±59 ng/dl, respectively (p=0.069 by T test, but p=0.19 for week 0 to week 7 change by rmANOVA).  At week 0, LH was 3.7±0.4 mIU/ml and at week 7, 10.9±1.3 mIU/ml, p<0.001. Week 0 PSA was 0.9±0.2 ng/dl, and at week 7, 1.3±0.3 ng/dl (p = 0.18). Week 0 Hct was 43.6%, and at week 7, 43.9% (NS).  One patient had Hct >52% at week 3 (withdrawn) and no subjects had Hct >52% at week 7. Adverse events were transient hot flashes (4), headache (3), and nausea (1).

Discussion: Clomiphene was well-tolerated and raised T levels to goal in most men, making it a promising alternative to T treatment.  Men naïve to T treatment showed a trend towards a more robust response to clomiphene than men previously treated with T, but this difference was not statistically significant. More subjects are needed to clarify this finding. The study is ongoing.

 

Nothing to Disclose: DH, GO, GA, JM

22650 9.0000 LBF-023 A Testosterone Response to Clomiphene Citrate in Veterans with Hypothalamic Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Friday, March 6th 3:00:00 PM LBF 015-023 6281 1:00:00 PM Late-breaking Reproductive Endocrinology II Poster


Christiaan de Bruin*1, Maria Mericq2, Shayne F. Andrew1, Hermine A. van Duyvenvoorde3, Nicole S. Verkaik4, Monique Losekoot3, Aleksey Porollo5, Hernan Garcia6, Yi Kuang5, Dan Hanson7, Peter Clayton7, Dik C. van Gent4, Jan Maarten Wit8, Vivian Hwa1 and Andrew Dauber1
1Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 2Institute of Maternal and Child Research, Santiago, Chile, 3Laboratory for Diagnostic Genome Analysis, Leiden, Netherlands, 4Erasmus MC, Rotterdam, Netherlands, 5Cincinnati Children's Hospital Medical Center, Cincinnati, 6Pontificia Universidad Catolica de Chile, Santiago, Chile, 7University of Manchester & Manchester Academic Health Sciences Centre, Manchester, United Kingdom, 8Leiden University Medical Center, Leiden, Netherlands

 

Severe short stature can be caused by defects in numerous biological processes including defects in IGF-1 signaling, centromere function, cell cycle control and DNA damage repair. Many syndromic causes of short stature are associated with medical co-morbidities including hypogonadism, microcephaly or tumor predisposition. In this study, we describe two adult siblings (male P1 and female P2) from a rural Chilean family who presented with a history of severe postnatal growth failure (adult heights of -6.8 SDS in P1 and -4 SDS in P2) and microcephaly (adult occipital frontal circumference -3.3 and -2.9 SDS, respectively). Both siblings had absent pubertal development due to hypergonadotropic hypogonadism (peak levels: LH 45 and 57 mIU/ml, FSH 62 and 117 mIU/ml) requiring lifelong sex hormone replacement therapy. Moreover, severe insulin resistance without concurrent obesity developed by late adolescence in both siblings (peak insulin levels on oral glucose tolerance tests of 218 and 180 μIU/ml) eventually resulting in clinical diabetes. Additionally, they developed dyslipidemia, requiring statin treatment. In addition, P2 developed a malignant gastrointestinal stromal tumor at age 28, which was resistant to standard tyrosine-kinase inhibitor therapy, leading to her demise at age 36. Combined microarray analysis and whole exome sequencing of the two affected (P1 and P2) and one unaffected sibling (S1) identified a homozygous single nucleotide variant in XRCC4 as the probable candidate variant. XRCC4 is a key enzyme in the process of non-homologous end-joining (NHEJ), which is involved in DNA repair after double stranded DNA breaks. Mutations in functionally related proteins in the NHEJ process, including Ligase IV and NHEJ1, can cause primordial dwarfism, as well as increased tumor susceptibility and varying degrees of immunodeficiency. Murine models of homozygous XRCC-4 -/- display severe growth retardation, tumor predisposition and testicular atrophy. Sanger sequencing and mRNA studies in our patients revealed a splice variant resulting in an in-frame deletion of 23 amino acids, which was predicted to interfere with the NHEJ1-binding domain of XRCC4. Cultured patient fibroblasts (P1) showed significantly reduced ability for DNA damage repair in a specific non-homologous end-joining assay in vitro. In conclusion, we have identified a novel pathogenic variant in XRCC4, a gene which is known to play a critical role in non-homologous end-joining DNA repair. This finding expands the spectrum of DNA damage repair syndromes to include XRCC4 deficiency as a cause of severe postnatal growth failure, microcephaly, gonadal failure, metabolic syndrome and possibly tumor predisposition.

 

Nothing to Disclose: CD, MM, SFA, HAV, NSV, ML, AP, HG, YK, DH, PC, DCV, JMW, VH, AD

22491 1.0000 LBF-024 A An XRCC4 Splice-Site Mutation Is Associated with Severe Short Stature, Microcephaly, Primary Gonadal Failure, and Early-Onset Metabolic Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM LBF 024-030 6284 1:00:00 PM Late-breaking Pediatric Endocrinology II Poster


Rabab Zehra Jafri*1, Rasha Al-Radadi1 and Claudia Cheryl Boucher-Berry2
1University of Illinois, Chicago, IL, 2University of Illinois College of Medicine, Chicago, IL

 

Background: Literature concerning the adverse effects of maternal Graves’ disease on the pituitary function leading to the development of central congenital hypothyroidism (CCH) in the offspring of these mothers is limited.  Fetal and neonatal risks associated with Graves' disease are related either to the disease itself or to treatment of the disease.

We describe the case of a 35 year old Hispanic female with a history of Graves’ disease who delivered a female infant with primary hypothyroidism and then 11 months later delivered a male infant with central hypothyroidism. Graves’ disease was diagnosed in the last trimester of her first pregnancy (TSH 0.06mcIU/ml and FT4 3.1ng/dl) and she was placed on Methimazole (MMI) with poor compliance. Maternal TSH receptor antibody was elevated (8.66IU/L). The infant’s thyroid panel done at birth was within normal limits but at 1 week of age her TSH trended up with a normal FT4. At 1 month of age TSH was found to be further elevated (11.98mcIU/ml) with a normal FT4 and a diagnosis of subclinical hypothyroidism was made. She was started on Levothyroxine 37.5 mcg (9 mcg/kg/day) with normalization of her TSH. Anti-TPO measured at birth was elevated at 60.9 and normalized to 4.6 by 8 months. Her treatment was continued until the age of 6 months at which point Levothyroxine was discontinued. TSH and FT4 remained normal and stable at 1 and 3 months post discontinuation of levothyroxine.

Mother conceived again 3 months after her last delivery. She restarted therapy with Propylthiouracil (PTU) in the first trimester and then switched to MMI at the second trimester. TSH remained persistently low (range 0.01-0.03) with a high FT4 (range 2.5-3.1) throughout pregnancy. The infant was born full term and thyroid labs obtained at birth, day 1 and day 3 of life showed persistently low TSH (0.16), FT4 (1.1) and total T3 (57). Central hypothyroidism was suspected and after a normal brain MRI, he was started on Levothyroxine 25mcg (8.3mcg/kg/day). His dose of Levothyroxine was not adjusted for weight as he aged and he remained euthyroid. He was given a trial off Levothyroxine at 6 months and then was lost to follow up until 10 months of age when repeat labs showed a normal thyroid profile.

Conclusion: The etiology and clinical presentation of maternal Graves’ can cause different presentations of hypothyroidism in the offspring. We have described an infant born with transient primary hypothyroidism, presumably due to maternal antibodies suppressing the baby’s thyroid gland and a second infant delivered with transient central hypothyroidism, presumably due to suppression of the fetal pituitary-thyroid axis from placental transfer of maternal thyroid hormone. Both conditions may persist for months after birth, requiring close monitoring and treatment for optimal neurodevelopmental outcome.

 

Nothing to Disclose: RZJ, RA, CCB

22513 2.0000 LBF-025 A Relationship Between Maternal Graves Disease and Two Different Presentations of Congenital Hypothyroidism at Birth 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM LBF 024-030 6284 1:00:00 PM Late-breaking Pediatric Endocrinology II Poster


George M Bright*1, Wayne V Moore2, H. Q. Nguyen3, Gad B. Kletter4, Bradley Miller5, Douglas G. Rogers6, David Ng7, Eric Humphriss8 and Jeffrey L Cleland9
1Versartis, Inc., Menlo Park, CA, 2Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, MO, 3Sierra Medical Research, Clovis, CA, 4Swedish Medical Center, Seattle, WA, 5Univ of Minnesota Amplatz Childr, Minneapolis, MN, 6Cleveland Clin Fndn, Cleveland, OH, 7ResearchPoint Global, Inc., Austin, TX, 8Versartis, Inc, Menlo Park, CA, 9Versartis Inc., Menlo Park, CA

 

VRS-317 is an rhGH fusion protein with delayed clearance and extended half-life capable of eliciting IGF-I responses for up to one month following a single SC dose.  In a Phase 1b/2a trial, the degree of GHD was moderate for the 64 pre-pubertal children who enrolled and completed 6 months of treatment: mean age = 7.47 years, mean HT-SDS = -2.60, mean IGF-I SDS = -1.75, and mean stimulated GH = 5.4 ng/mL.  Patients were randomized into three VRS-317 dosing regimens of 1.15 mg/kg weekly, 2.5 mg/kg semi-monthly and 5.0 mg/kg monthly.  After 6 months of treatment, the observed safety profile was benign when compared to daily rhGH and annualized height velocities were comparable to annual height velocities with daily rhGH at 34 µg/kg/d.  Patients were offered the opportunity to continue in the long-term Extension Study; 60 patients were enrolled and 57 subjects completed 12 months of treatment.  After 12 months, adverse events continued to be benign when compared to daily rhGH and no new safety signal has been observed. Importantly, a subset of 20 patients had VRS-317 dose adjustments from 1.15 mg/kg weekly to 3.5 mg/kg semi-monthly in the Extension Study. As compared to subjects maintained at a VRS-317 dose of 2.5 mg/kg semi-monthly, the subjects with an increased dose of 3.5 mg/kg semimonthly had a higher peak IGF-I SDS (-0.4 for the 2.5 mg/kg semimonthly vs. +0.5 for the 3.5 mg/kg semi-monthly). Patients who completed 6 months at the increased VRS-317 dose of 3.5 mg/kg semi-monthly had an increase in their mean 6 month annualized height velocity from 7.5 cm/yr (0-6 months) to 9.3cm/yr (6-12 months). Patients in the Extension study remaining on their Phase 1b/2a regimen of 2.5 mg/kg semi-monthly dose or 5 mg/kg monthly dose had mean height velocities of 8.5 and 7.9 cm/yr, respectively, at 12 months, not significantly different from their mean 3 month annualized height velocities of 8.9 cm/yr and 8.4 cm/yr, respectively. This is in contrast to the decrease in annualized height velocity usually observed between 3 and 12 months with daily rhGH.  Overall, an increase in peak IGF-I SDS within the normal range and an increase in height velocity were noted when the VRS-317 dose was increased.

 

Disclosure: GMB: Vice President, Versartis, Inc.. WVM: Principal Investigator, Versartis, Inc. HQN: Principal Investigator, Versartis, Inc. GBK: Principal Investigator, Versartis, Inc. BM: Principal Investigator, Versartis, Inc. DGR: Principal Investigator, Versartis, Inc. DN: Independent Contractor (including contracted research), Versartis, Inc.. EH: Vice President, Versartis, Inc. JLC: , Versartis, Inc.

22525 3.0000 LBF-026 A Dose Response and 12 Month Safety and Efficacy of VRS-317 in Pre-Pubertal Children with Moderate Growth Hormone Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM LBF 024-030 6284 1:00:00 PM Late-breaking Pediatric Endocrinology II Poster


Ronadip R Banerjee*1, Neyssa Marina2, Laurence Katznelson1 and Brian Jay Feldman3
1Stanford University School of Medicine, Stanford, CA, 2Lucile Salter Packard Children's Hospital, Palo Alto, CA, 3Stanford University, Stanford, CA

 

Background:

Treatment of ACTH-dependent Cushing’s syndrome (CS) caused by surgically unresectable disease is highly challenging and requires a multidisciplinary approach.   Ectopic CS due to a neuroendocrine tumor is an uncommon cause of hypercortisolism.  This case describes the first reported use of mifepristone for the treatment of CS in a pediatric patient.

Clinical Case:

A 14-year-old girl with an 18 month history of metastatic neuroendocrine carcinoma presented to our hospital for a second opinion.   Prior management included chemotherapy, though tumors had grown despite therapy.  She complained of fatigue, profound weakness, irritability, depression, and was found to have hypertension, hypokalemia, and worsening control of her preexisting type-1 diabetes.   Her examination revealed a cushingoid habitus.  Laboratory studies revealed severe hypercortisolemia that was ACTH-dependent, consistent with ectopic CS.  Surgical and radiation therapies were not pursued because of poor functional status and life expectancy, and medical treatment of CS was indicated for symptom relief.  Mifepristone (300 mg daily) was administered orally and provided rapid improvement in glycemic control, insulin resistance, and hypertension as well as significant diminishment of her myopathy and fatigue.  Hypokalemia was managed with introduction of potassium replacement; no other significant adverse effects were observed.  Despite successful palliation of Cushing’s symptoms, the patient died from progression of her neuroendocrine carcinoma.

Conclusion:

This case demonstrates the safety and efficacy of mifepristone treatment in an adolescent with symptomatic and ectopic CS.  In appropriate pediatric patients with CS, glucocorticoid receptor antagonism with mifepristone should be considered to control the effects of hypercortisolism and improve quality of life.

 

Disclosure: LK: Advisory Group Member, Pfizer, Inc., Investigator, Novartis Pharmaceuticals, Advisory Group Member, Genentech, Inc., Advisory Group Member, Novartis Pharmaceuticals. Nothing to Disclose: RRB, NM, BJF

22754 4.0000 LBF-027 A Mifepristone Treatment of a Pediatric Patient with Ectopic Cushing's Syndrome Caused By a Metastatic Neuroendocrine Tumor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM LBF 024-030 6284 1:00:00 PM Late-breaking Pediatric Endocrinology II Poster


Monica E Bianco* and Himala Kashmiri
Loyola University Medical Center, Maywood, IL

 

Tuberous Sclerosis (TS) is an autosomal dominant neurocutaneous disorder due to a mutation in tumor suppressor genes TSC1 or TSC2. TS has rarely been associated with endocrine disorders. Our literature review produced only a few cases of TS with congenital or acquired hypothyroidism. However, no cases have been reported of TS and hypopituitarism. Here we present a 12 year old female initially diagnosed with TS who subsequently developed multiple pituitary hormone deficiencies including central hypothyroidism, adrenal insufficiency, and diabetes insipidus. She was initially diagnosed with central hypothyroidism with a TSH of 4.49 uIU/ml (0.4-4.4) and free T4 of 0.7 ng/dl (0.8-1.7) during a state of normal health. As part of her other pituitary evaluation, she was later evaluated for adrenal insufficiency with a high dose ACTH stimulation test that showed a baseline cortisol of 1.0 ug/dl and 1 hour peak cortisol of 11.1 ug/dl suggestive of adrenal insufficiency. She was also diagnosed with diabetes insipidus based on an elevated serum osmolality of 307 mOsm/kg and serum sodium of 150 mEq/L. Subsequently, she is currently being treated with levothyroxine, hydrocortisone, and desmopressin for hypothyroidism, adrenal insufficiency, and diabetes insipidus respectively. Evaluation for other pituitary hormone deficiencies has been thus far been normal including normal IGF studies and gonadotropins. Her serial MRI’s have been remarkable for numerous subependymal nodules, a giant cell astrocytoma, and glioneuronal hamartomas.  To our knowledge, this is the first case of TS associated with hypopituitarism emphasizing the importance of maintaining an index of suspicion for hypopituitarism in patients with TS when managing these patients.

 

Nothing to Disclose: MEB, HK

22785 5.0000 LBF-028 A Tuberous Sclerosis: An Unusual Presentation with Hypopituitarism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Friday, March 6th 3:00:00 PM LBF 024-030 6284 1:00:00 PM Late-breaking Pediatric Endocrinology II Poster


Matthew D Taves*1, Adam W Plumb1, Benjamin A Sandkam2, Ninan Abraham1 and Kiran K Soma1
1University of British Columbia, 2Simon Fraser University

 

Glucocorticoids are synthesized in the adrenal glands and circulate through the blood to coordinate organismal physiology. In early life, glucocorticoids can suppress growth and neural development, and neonates avoid these deleterious effects by undergoing a stress hyporesponsive period (SHRP) during which circulating glucocorticoids are minimal (1). The SHRP deprives other organs of blood-borne glucocorticoids where they are needed, but this apparent conflict could be resolved by tissue-specific glucocorticoid production. Glucocorticoids are produced in extra-adrenal tissues such as the thymus (2), where they are critical for the production of immunocompetent T cells (3) responsible for cell-mediated adaptive immunity. We found that in neonatal mice, endogenous glucocorticoids and their upstream precursors were much higher in lymphoid organs (thymus, bone marrow, spleen) than in circulating blood (4). To determine if this local elevation is due to local glucocorticoid synthesis, here we cultured lymphoid organs in the presence of metyrapone, which blocks conversion of upstream precursors and downstream metabolites into active glucocorticoids. Metyrapone inhibited in vitro corticosterone production in neonates and adults, indicating local synthesis in all thymus, bone marrow, and spleen. Neonatal lymphoid organs expressed mRNAs for the full suite of glucocorticoid-synthetic enzymes, while adult bone marrow and spleen did not express mRNA for Cyp11b1, which is needed for upstream precursor conversion into glucocorticoids. The age-related decrease in Cyp11b1 mRNA, together with an increase in mRNA for Hsd11b1 (required for reactivation of downstream glucocorticoid metabolites), indicates that lymphoid glucocorticoid production occurs from precursors in neonates, and from metabolites in adults. Consistent with this, corticosterone production was much higher in adult tissues incubated with metabolites, rather than precursors. These findings show that lymphoid organs locally synthesize glucocorticoids, and suggest that local enzymatic machinery changes with age. Furthermore, glucocorticoid production occurs not only in the thymus, where glucocorticoids are necessary for T cell development, but also in bone marrow and spleen, the sites of B cell development. Developing B cells have especially high levels of glucocorticoid receptors (5), indicating that these are likely targets of locally-produced glucocorticoids. Together, these results suggest that locally-produced glucocorticoids may play a critical role in production of T and B cells, and resultant cell-mediated and humoral immunity.

 

Nothing to Disclose: MDT, AWP, BAS, NA, KKS

22804 1.0000 LBF-048 A Local Glucocorticoid Synthesis and Reactivation in Lymphoid Organs: Neonatal Versus Adult Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM LBF 048-050 6288 1:00:00 PM Late-breaking Nuclear Receptors and Steroid Hormone Action II Poster


Martin C Sadowski*, Anja Rockstroh, Carolina Soekmadji, Stephen John McPherson, Gregor Tevz, Jennifer H Gunter, Varinder Jeet and Colleen C. Nelson
Queensland University of Technology - Translational Research Institute, Brisbane, Australia

 

There is a general consensus that the androgen receptor (AR) is one of the key factors driving the progression of prostate cancer. This is highlighted by the focus of clinical therapies based on either antagonism of AR action or suppression of androgenic ligand production. Furthermore, mounting evidence shows that the development into treatment resistant PCa evolves from adaptive changes to AR activity and AR-regulated pathways, emphasizing the need for in vitro models systems to study AR function. Currently there are a limited number of PCa cell lines available that share the traits of being androgen-dependent and express wild-type AR, thereby understating the clinical heterogeneity of this malignancy. In this work, we compared by phenotypic and molecular analysis the classic LNCaP cell line originating from a lymph node metastasis to DuCaP cells, which are derived through xenografting of a metastasis to the dura mater of a PCa patient. We analyzed the expression of a panel of nuclear steroid receptors, including AR and its splice variants ARV1 and ARV7 in a series of malignant and non-malignant prostate cell lines. We studied phenotypic and molecular changes to cell morphology, proliferation, cell viability, oxidative metabolism, mitochondrial bio-energetic capacity, lipid content and sensitivity to de novo lipogenesis antagonists, cell cycle progression, global gene expression, and AR activity in the presence of androgens as well as conditions simulating AR-targeted therapies. Our comparative analysis of LNCaP and DuCaP cells revealed the commonalities and dissimilarities in androgen-regulated pathways and demonstrated that DuCaP cell are highly dependent, sensitive and reactive to androgens, yet distinctive in critical metabolic pathways, thereby providing a valuable complementary PCa cell line model to study AR signaling in this heterogeneous disease.

 

Nothing to Disclose: MCS, AR, CS, SJM, GT, JHG, VJ, CCN

22777 2.0000 LBF-049 A Phenotypic and Molecular Analysis of Androgen Receptor Signaling in the Ducap Prostate Cancer Cell Line 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Friday, March 6th 3:00:00 PM LBF 048-050 6288 1:00:00 PM Late-breaking Nuclear Receptors and Steroid Hormone Action II Poster


Alicja Hubalewska-D*1, Paola Anna Erba2, Clemens Decristoforo3, Renata Mikolajczak4, Helmut Maecke5, Katja Zaletel6, Petra Kolenc-Peitl6, Thea Maina-Nock7, Irene Virgollini3, Agata Jabrocka-Hybel1 and Monika Tomaszuk8
1Jagiellonian University Medical College, Krakow, Poland, 2Azienda Ospedaliero-Universitaria Pisana, 3Innsbruck Medical University, Austria, 4Radioisotope Center POLATOM, NCBJ, Poland, 5University Hospital Freiburg, Germany, 6University Medical Centre Ljubljana, Slovenia, 7Molecular Radiopharmacy, INRASTES, NCSR Demokritos, Athens, Greece, 8University Hospital in Krakow, Krakow, Poland

 

Introduction: Medullary thyroid cancer still remains one of the most challenging cancers for both: early detection of postsurgical remnant cancer tissue and metastases/tu recurrence as well as for therapy. Therefore, it is necessary to develop alternative therapeutic strategies to control tumour growth, possibly through the use of new biomarkers. The cholecystokinin 2 (CCK2) receptor is overexpressed in MTC with very high density and >90% incidence. From the late 1990’s, a variety of CCK2 receptor related peptides were studied as the targets for radionuclide scintigraphy and therapy. The DOTA-DGlu-DGlu-DGlu-DGlu-DGlu-DGlu-Ala-Tyr-Gly-Trp-Met-Asp-Phe-NH2 (CP04) showed the most promising characteristics (high receptor affinity, high stability and low kidney retention) and it was selected for further clinical evaluation (COST BM0607). 

Methods: In a multicentre the first phase randomised study of the hypothesis that labelled CPO4 may become a viable target for radionuclide scintigraphy and radionuclide therapy in MTC patients, is tested.
The main objective of the project is to establish the safety of i.v. administration of a therapeutic amount of 111In-CP04 and to assess the tracer biodistribution and dosimetry in MTC and normal tissues and to determine critical organs. The evaluation of the potential of CCK2 receptor scintigraphy to detect cancer lesions for both diagnostic (10ug) and therapeutic peptide (50ug) amount and the decrease of kidney dose after co-administration of gelofusine as a nephroprotective agent are also planned. The study consists of preclinical (to establish a clinically useful formulation for the radiolabelled peptide CP04), and a clinical step.
Inclusion criteria: patients with progressive or metastatic nonoperable histologically proved MTC with positive 18F-FDG PET-CT/CT/MRI or elevated Ct (Ct DT) will be enrolled to the study.
Study Design: The first 4 pts will receive 2 doses of CP04: low-dose (diagnostic) and high-dose (therapeutic) of 111In-CP04. If no SAE is present, the remaining pts will be randomized for 2 arms: high-dose of 111In-CP04 with and without gelofusine infusion. Safety of 111In-CP04 i.v. administration, biodistribution, pharmacokinetics, and diagnostic sensitivity/specificity will be assessed. At present the preclinical part of the study is finalized and it was proved that radiolabelling of CP04 with 111In could be effectively translated into a clinically useful formulation. 
Conclusions: The project may become the first step to establish a new, more selective and efficient strategy for the diagnosis, early detection and therapy of recurrent and metastatic MTC patients leading to reduction of mortality as well as improvement of the life quality. 

Acknowledgements: GRAN-T-MTC is part of the ERA-NET on Translational Cancer Research (TRANSCAN) funded by the European Commission under the Seventh Framework Programme (FP7).

 

Nothing to Disclose: AH, PAE, CD, RM, HM, KZ, PK, TM, IV, AJ, MT

22718 1.0000 LBF-056 A A Novel CCK2/Gastrin Receptor-Localizing Radiolabelled Peptide Probe for Personalized Diagnosis and Therapy of Patients with Progressive or Metastatic Medullary Thyroid Carcinoma - Grant-MCT:  Study Design of a Multicentre First Phase Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM LBF 056-063 6291 1:00:00 PM Late-breaking Tumor Biology II Poster


Maria Theresa E Montales*, Frank A Simmen, Stepan B Melnyk, Shi Liu, Yunying L Liu and Rosalia CM Simmen
University of Arkansas for Medical Sciences, Little Rock, AR

 

Breast cancer is increasingly considered to be a metabolic disease; thus, improving metabolic status of breast cancer patients is an attractive therapeutic strategy. Our laboratory has recently used the Wnt1-transgenic mouse model to investigate the long-term linkages between metabolic dysfunction and mammary tumor risk. We found that female Wnt1-Tg offspring exposed to high fat diet (HFD; 45% fat) only through their dams [pregnancy+lactation; control diet (CD, 17% fat) after weaning] had higher mammary tumor incidence, shorter tumor latency, and more invasive tumor pathology than CD-exposed offspring (1). The inferior tumor outcomes with maternal HFD exposure were associated with dysregulated metabolism (lower insulin sensitivity, higher oxidative status) of HFD-dams and their offspring. Herein, we evaluated the treatment response to doxorubicin (Dox) of adult mammary tumor-bearing Wnt-Tg offspring with distinct metabolic status. One week after initial tumor detection (by palpation), mice were injected intraperitoneal with Dox (8 mg/kg body weight) once-weekly for two weeks and mammary tumors were collected one week post-treatment. HFD and CD offspring had similar reductions in mammary tumor volume and comparable mammary tumor Pten, Bcl2, Il6 and Stat1 gene expression, upon DOX injection. However, HFD tumors showed higher Egr1 and lower Notch 2 transcript levels and increased numbers of Egr1- and Ki67-immunostaining cells. Analyses by FACS of mammary tumor cells prior to Dox treatment showed that HFD offspring had higher % of CD29highCD24+ (basal-like) epithelial sub-population (9.03±3.61 vs. 2.85±0.81), but comparable frequencies of CD29lowCD24+ (luminal progenitor-like) (35.44±9.00 vs. 41.88±4.99) and of Thy1+CD29highCD24+ (4.61±2.23 vs. 7.63±3.61) epithelial sub-populations, when compared to CD offspring. After Dox treatment, the % of basal-like cells were comparably decreased in tumors of both diet groups (by 80%), but that of CD29lowCD24+ was modestly decreased for HFD (by 20%) in contrast to that for CD (by 80%) offspring. Moreover, the % of Thy1+CD29highCD24+ cells increased (to 21%) in the HFD group but was undetectable in the CD group, after Dox. Isolated epithelial cells from mammary tumors of CD offspring prior to Dox were plated under non-adherent conditions for mammosphere formation assays and then treated with Dox (100 nM) for 24 h. Dox decreased the numbers of mammosphere-forming units (MFU) under these plating conditions. When treated with sera (5% v/v final dose) from HFD offspring, tumor cells showed an increase in % MFUs relative to untreated cells in the presence of Dox; this was not found for cells treated with CD offspring sera. Results suggest that early metabolic history can influence response to therapeutic treatment in part, by altering the growth and survival of specific epithelial subpopulations with distinct tumor potential.

 

Nothing to Disclose: MTEM, FAS, SBM, SL, YLL, RCS

22454 2.0000 LBF-057 A Early Metabolic History Influences Treatment Response to Doxorubicin of Mammary Tumor-Bearing Adult Female Wnt1-Tg Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM LBF 056-063 6291 1:00:00 PM Late-breaking Tumor Biology II Poster


Sarika Rao*1, Jennifer Chu2 and Mira Sofia Tiglao Torres2
1University of Massachusetts Medical School, Worcester, MA, 2University of Massachusetts, Worcester, MA

 

Background:

Ectopic ACTH syndrome (EAS) is rare and its presentation is often difficult to recognize.  A systematic approach to diagnosis is time consuming, consequently delaying treatment. Additionally, results need to be interpreted in light of the clinical picture to arrive at the correct diagnosis. We describe an unfortunate patient where timing was critical, and the diagnostic workup was not immediately conclusive.

Clinical Case:

A 74 year-old thin female was admitted with 6 weeks of progressive cognitive impairment, muscle weakness, and hypokalemia. She had a mastectomy in the past for breast cancer. She was admitted to two institutions previously where neurologic and infectious work-up was pursued.  We suspected hypercortisolism and found her AM cortisol elevated to 107.6 mcg/dL (7-22.6 mcg/dL) and urine free cortisol was > 5600 mcg/24h (4-50mcg/24h).  ACTH was 221 pg/mL (6-50 pg/mL). High-dose dexamethasone failed to suppress AM cortisol. CRH stimulation showed over two fold increase in cortisol (77 to 165 mcg/dL) and ACTH (243 to 510 pg/mL) at 30 minutes, and remained elevated. Pituitary MRI was negative for focal lesions and pan-CT did not show an obvious lesion. PET revealed FDG-avid pancreatic head mass, measuring 3.6x1.6 cm. Endoscopic ultrasound biopsy identified the mass as a neuroendocrine tumor, with low mitotic index, that stained positive for ACTH.  Ketoconazole was started after the CRH test, with dose adjusted based on serum and urine cortisol.  Due to her rapidly declining performance status, including progression to profound muscle weakness and development respiratory distress and pneumonia, she was not considered a surgical candidate for a Whipple’s procedure. Her condition worsened from her now systemic infection and she elected not to pursue resuscitative measures and passed away.

Conclusion:

Our case illustrates the need for early recognition and rapid completion of diagnostic workup for EAS in order to hasten definitive treatment. The suspicion of an ectopic ACTH source was high once hypercortisolism was apparent, given the rapidity of her symptoms and degree of hypercortisolism and ACTH elevation. However, initial testing seemed contradictory (lack of suppression with dexamethasone suggested an ectopic, but the CRH test pointed to a pituitary source of ACTH). This suggests the CRH test should be interpreted with caution in patients with suspected ectopic Cushing’s due to variable results. There are few reported cases describing ectopic tumors responsive to CRH stimulation (primarily limited to the lung), but to our knowledge, this is the first example in a pancreatic neuroendocrine tumor. The need for expedited testing is imperative to diagnose EAS, especially in those with poor functional status, as rapid deterioration in muscle function and respiratory status can occur with exposure to the high cortisol concentrations.

 

Nothing to Disclose: SR, JC, MSTT

22338 3.0000 LBF-058 A Ectopic Cushing Syndrome: A Diagnostic Dilemma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM LBF 056-063 6291 1:00:00 PM Late-breaking Tumor Biology II Poster


Kerry L Burnstein*1, Stephanie O. Peacock2, Ning Zhao1, Meghan A. Rice2, Ann M. Greene1, Phillip C. Miller2 and Jonathan R. Weitz3
1University of Miami Miller School of Medicine, Miami, FL, 2University of Miami Miller School of Medicine, 3University of Miami Miller School of Medicine, Miami

 

The clinical success of both a new androgen receptor (AR) antagonist and an androgen synthesis inhibitor in castration-resistant prostate cancer (CRPC) underscores the essential nature of AR signaling in this incurable stage of the disease. Nevertheless, these drugs prolong survival for only a limited number of months due to development of resistance. Expression of constitutively active AR variants such as AR-V7 (AR3), which lack the AR ligand binding domain, is linked to poor clinical prognosis and failure of second line AR-directed therapies.  AR and AR variant signaling is potently enhanced by the coactivator Vav3, a guanine nucleotide exchange factor. Vav3 levels increase during progression to CRPC and Vav3 confers castration resistance in vivo. Vav3 is elevated in patient metastatic specimens and is often co-expressed with AR-V7. While Vav3 promotes full length AR amino-carboxyl terminal (N-C) interaction, AR variants typically lack the C-terminal region. Mutational and biochemical analyses demonstrated that Vav3 interacts with AR-V7 and increases nuclear levels of AR-V7. Selective disruption of the Vav3-AR-V7 interaction decreased AR-V7 transcriptional activity as well as the proliferation and anchorage-independent growth of CRPC cells that co-express Vav3 and AR-V7.  An AR-V7 and Vav3 coregulated target gene was identified. Preclinical studies revealed that pharmacologic inhibition of this new candidate drug target decreased CRPC growth in vivo. Together, these data indicate that Vav3 enhancement of AR variant signaling promotes CRPC and reveals new therapeutic strategies.

 

Nothing to Disclose: KLB, SOP, NZ, MAR, AMG, PCM, JRW

22772 4.0000 LBF-059 A Interaction Between the Androgen Receptor Variant AR-V7 and Vav3, a Unique Coactivator of Androgen Receptor Signaling, Reveals Novel Therapeutic Approaches for Castration-Resistant Prostate Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM LBF 056-063 6291 1:00:00 PM Late-breaking Tumor Biology II Poster


Joanne M de Laat*1, Rob B van der Luijt2, Carolina R.C. Pieterman1, Maria P Oostveen2, Ad RMM Hermus3, Olaf M Dekkers4, Wouter W. de Herder5, Anouk N A Van der Horst-Schrivers6, Madeleine L. Drent7, Peter H Bisschop8, Bastiaan Havekes9, Menno R Vriens1 and Gerlof D Valk1
1University Medical Center Utrecht, Netherlands, 2University Medical Center Utrecht, Utrecht, Netherlands, 3Radboud University Medical Center Nijmegen, Nijmegen, Netherlands, 4Leiden University Medical Center, Netherlands, 5Erasmus Medical Center, Rotterdam, Netherlands, 6University of Groningen, University Medical Center Groningen, Groningen, Netherlands, 7VU University Medical Center, Netherlands, 8Academic Medical Center, Netherlands, 9Maastricht University Medical Centre, Netherlands

 

Multiple endocrine neoplasia type 1 (MEN1) is diagnosed if at least two out of three main MEN1 manifestations hyperparathyroidism (pHPT), duodenopancreatic neuroendocrine tumors (dpNET) and pituitary tumors (PIT) occur in a patient. However, in up to 10% of patients with MEN1 phenotype no mutation is found in the MEN1 gene.(1) It is unclear if the clinical course of the disease of  mutation negative patients is comparable with mutation positive patients. Some recent studies suggest that some mutation negative patients with MEN1-like phenotype might have a distinct syndrome such as MEN4 (caused by mutation in the CDKN1B gene). (2)
 The aim of our study was to compare age-related penetrance of MEN1 related manifestations and age of death between mutation positive and mutation negative MEN1 patients. In addition, mutation negative patients were asked to participate in a genetic screening program for familial neuroendocrine tumors (including CDKN1B and AIP).
 A cohort study was performed using the Dutch MEN1 database, including >90% of the Dutch MEN1 population >16 years (n=323).(3) Two-hundred-ninety-three (91 %) mutation positive and 30 (9 %) mutation negative MEN1 patients were identified. Median follow-up from moment of MEN1 diagnosis was 8 years (range 0 –  44 years). The median age for developing the first main MEN1 manifestation was 14 years lower in mutation positive patients (34 vs. 48 years) (P = 0.010). In mutation negative patients, a third main MEN1 manifestation did not occur in the course of follow-up compared to the occurrence in 42% in mutation positive patients (P = 0.001). Only one non-main MEN1 associated manifestation developed in a mutation negative patient (an adrenal tumor; 3%), while mutation positive patients developed such manifestations in 57.0% at a median age of 58 years (54 –  62). Mean age of death was 60 years in mutation positive patients (SD 13 years). Only two mutation negative patients died, due to non-MEN1-related causes at the age of 64 and 84 years. Genetic analysis did not reveal additional mutations in mutation negative patients.
In conclusion, our data suggest that mutation positive and mutation negative MEN1 patients have a different clinical course. Mutation negative MEN1 patients develop MEN1 manifestations at higher age and the age of death was higher compared with mutation positive patients. Mutations in CDKN1B and AIP did not explain the MEN1 phenotype in the MEN1 mutation negative patients in our cohort. The apparent differences in clinical course suggest that MEN1 mutation negative patients do not have true MEN1, but co-incidence of two neuroendocrine tumors or other unidentified distinct syndrome.

 

Nothing to Disclose: JMD, RBV, CRCP, MPO, ARH, OMD, WWD, ANAV, MLD, PHB, BH, MRV, GDV

22315 5.0000 LBF-060 A MEN1 Redefined: A Clinical Comparison of Mutation- Positive and Mutation- Negative Patients with MEN1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM LBF 056-063 6291 1:00:00 PM Late-breaking Tumor Biology II Poster


Ling Zhang*1, Qing-hai Ji1, Yong-xue Zhu1, Zhuo-ying Wang2, Yu Wang1 and Cai-ping Huang1
1Fudan University Shanghai Cancer Center, Shanghai, China, 2Fudan University Shanghai Cancer Center, Shanghai

 

GWAS may be appropriate strategies to define genetic risk factors for cancer. The GWAS studies performed in papillary thyroid cancer shows FOXE1 may be the potential risk gene for papillary thyroid cancer(PTC), which is a transcription factor of thyroid development regulated by TSH. Recently, the endogenous TSH level is described as a predictor of a subsequent thyroid cancer diagnosis. The mechanism of the elevated serum TSH level remains unknown. A genotyping study for FOXE1 was perfomed in a Chinese series of 647 PTC cases, 527 benign thyroid disease cases, and 677 community-based normal controls. The FOXE1 genetic region and its flanking sequences (approximately from 1,100 bp upstream to 500 bp downstream of this gene) were directly sequenced to identify polymorphic sites in 48 samples including 24 unrelated sporadic PTC cases and 24 controls. Considering 48 samples may have insufficient representativeness to construct precise haplotypes of the whole population, all of the identified common SNPs (minor allele frequency (MAF>10%) were further genotyped. Genotyping work was performed using the Taqman 5’-nuclease assays for 10 SNPs in FOXE1 gene region. All the PTC and benign thyroid disease cases had a serum TSH measurement by a chemiluminescent microparticle immunoassays with interassay coefficients of variation of less than 10% over the ranges 0.35–4.94 uIU/mliter. In PTC versus normal, the strongest association results were observed for rs3758248 C>T (OR= 2.01; 95%CI = 1.20–3.55; P=1.035E-8), rs907577 A>G (OR = 1.98; 95%CI = 1.57–2.50; P=1.7388E-11) and rs1867277 G>A (OR= 3.52; 95%CI = 2.91–4.24; P =1.9628E-31); in benign disease versus normal, the strongest association results were observed for rs3758248 C>T (OR= 2.19; 95%CI = 1.08–4.45; P=6.8563E-19), rs907577 A>G (OR = 1.59; 95%CI = 1.20–2.11; P=6.8563E-19) and rs1867277 G>A (OR= 1.72; 95%CI = 1.39–2.12; P =6.8563E-19); in PTC versus benign, the strongest association results were observed for rs3758248 C>T (OR= 1.48; 95%CI = 1.20–1.82; P=1.0E-4) and rs1867277 G>A (OR= 1.81; 95%CI = 1.51–2.17; P =5.2789E-11). Combing with serum TSH in PTC and benign group, the risk of PTC went higher in patients with allele C of rs3758248 and G of rs1867277 when the serum TSH elevated. In summary, FOXE1 may be a genetic risk gene for PTC in Chinese patients. The special genotype of FOEX1 may be more susceptible by the affect of TSH.

 

Nothing to Disclose: LZ, QHJ, YXZ, ZYW, YW, CPH

22701 6.0000 LBF-062 A The Affection of TSH on the Papillary Thyroid Cancer Susceptibility of the Variant rs1867277 and rs3758248 in FOXE1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM LBF 056-063 6291 1:00:00 PM Late-breaking Tumor Biology II Poster


Lonnele J Ball*1, Sheng Zhao2, Veronica Kim1 and Lance J Kriegsfeld1
1University of California, Berkeley, CA, 2Southeast University Medical School, Nanjing, China

 

Historically, reproductive endocrinologists and cancer biologists considered the impact of reproductive axis activity (e.g., estrogen) on breast tumorigenesis to be mediated through hypothalamic gonadotropin-releasing hormone (GnRH) control of ovarian sex steroids that, in turn, influence breast cancer biology.  It is becoming increasing clear, however, that neuropeptides that regulate the reproductive axis by acting at the hypothalamic and/or pituitary levels are also expressed, and act, locally to regulate breast cancer progression and metastasis. The RFamide (Arg-Phe-NH2) peptide, gonadotropin inhibitory hormone (GnIH) (also known as RFamide-related peptide-3 (RFRP)), has recently emerged as a major hypothalamic inhibitor of reproductive axis functioning.  The current studies asked whether or not GnIH and its receptor, like several other reproductive neuropeptides, are expressed in human breast cancer cells and function locally to mediate breast tumorigenesis.  We found that GnIH receptor (G-protein-coupled receptor 147 (GPR147)) is endogenously expressed in two highly metastatic ER negative human breast cancer cell lines, MDA-MB-453 and MDA-MB-231, as well as in the U2OS osteocarcinoma cell line and the WAR5 prostate cancer cell line.  Furthermore, GnIH peptide was expressed in the MDA-MB-231 breast cancer cell line as well as in the HeLa cervical cancer cell line.  Given this finding, we hypothesized that GnIH and GPR-147 overexpression will impact tumor growth in human and mouse models of breast cancer.  To characterize the effects of GnIH peptide and receptor overexpression on mammary tumorigenesis, MDA-MB-453 cells stably expressing luciferase were engineered allowing for longitudinal analysis of tumorigenesis and metastasis using non-invasive in vivo imaging.  When GnIH and GPR-147 were overexpressed in the MDA-MB-453 luc human breast cancer xenografts, tumor burden increased 4.3 fold over intact controls.  These results were further repeated and validated in the DB-7 luc mouse model of breast cancer where overexpression of GnIH and GPR-147 in syngeneic tumor transplants increased tumor volume by over two-fold compared to intact controls. Together, these studies are the first to examine the tissue specific regulation of breast tumorigenesis by GnIH and demonstrate the tumor promoting activity of this RF-amide neuropeptide in human and mouse models of breast cancer.

 

Nothing to Disclose: LJB, SZ, VK, LJK

22787 7.0000 LBF-063 A Tissue Specific Overexpression of Gonadotropin-Inhibitory Hormone (GnIH) Accelerates Breast Tumorigenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Friday, March 6th 3:00:00 PM LBF 056-063 6291 1:00:00 PM Late-breaking Tumor Biology II Poster


Julie M Carroll, Ashley White and Charles T Roberts Jr.*
Oregon National Primate Research Center, Beaverton, OR

 

The incretin hormone GLP-1 is secreted by intestinal L cells and exhibits insulinotropic effects on the pancreatic beta cell through the adenylyl cylase-linked, G protein-coupled GLP-1 receptor to facilitate glucose disposal.  Full-length (7-37)GLP-1 is rapidly converted to the more biologically active 7-36amide form, which is subsequently processed to the major (9-36amide) metabolite by dipeptidyl peptidase (DPP)-4, particularly in the hepato-portal bed (1).  Injectable GLP-1 analogs resistant to DPP-4 and orally available small-molecule DPP-4 inhibitors are important classes of current type-2 diabetes therapies.  The DPP-4-generated metabolite, originally considered inactive, has recently been shown to exert insulin-mimetic and cardioprotective effects that are not clearly ascribable to the classical GLP-1 receptor (2,3).  The nature of the metabolite’s receptor and related signaling pathways represents a significant gap in our understanding of overall GLP-1 biology.  It has been recently reported that nM concentrations of the GLP-1 metabolite bind to and to activate the IGF-I receptor, but not the insulin receptor, in cardiac fibroblasts (4).  If firmly established, this would have important ramifications for both GLP-1 and IGF biology, in that some biological effects previously attributed to IGF-I could conceivably be the result of GLP-1 metabolite action in vivo.  However, maximal postprandial concentrations of the GLP-1 metabolite in human circulation are in the low pM range (1,5), and the sequence homology between GLP-1 and IGF-I proposed in support of IGF-I receptor cross-activation primarily involved the signal peptide of IGF-I, which is not present in the mature hormone, with the remaining homology between the N-terminus of mature IGF-I and GLP-1 being shared with insulin.  We therefore evaluated the ability of intact GLP-1 and its metabolite to activate the IGF-I and insulin receptors in engineered mouse embryo fibroblast cell lines expressing high levels of one receptor or the other, a well-established model of IGF/insulin signaling.  Receptor autophosphorylation as well as phosphorylation of the downstream targets Erk and Akt were determined using sensitive and specific ELISAs.  While IGF-I and insulin exhibited robust, dose-dependent activation of their cognate receptors and signaling pathways over a 0.1 to 10-nM dose range, neither GLP-1 nor its metabolite exhibited activation of any parameter at the concentrations tested.  These data suggest that direct activation of the IGF-I receptor by GLP-1 or its metabolite is unlikely to occur in vivo and that any apparent crosstalk seen at pharmacological doses may be cell type-specific or reflect indirect post-receptor signaling pathway interactions.

 

Nothing to Disclose: JMC, AW, CTR Jr.

22560 1.0000 LBF-077 A GLP-1 Metabolite Does Not Signal through the IGF-I Receptor in Mouse Embryo Fibroblasts 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Paolo Beck-Peccoz*1, Charlotte Höybye2, Robert D Murray3, Suat Simsek4, Alfonso Leal-Cerro5, Markus Zabransky6 and Günter K. Stalla7
1Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, Milan, Italy, 2Karolinska University Hospital, Stockholm, Sweden, 3Leeds Centre for Diabetes and Endocrinology, St James’s University Hospital, Leeds, United Kingdom, 4Medisch Centrum Alkmaar, Alkmaar, Netherlands, 5Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío Seville, Sevilla, Spain, 6Sandoz International GmbH, Holzkirchen, Germany, 7Max Planck Institute of Psychiatry, Munich, Germany

 

Introduction: PATRO Adults is an ongoing, international, open, longitudinal, non-interventional study of the long-term safety and efficacy of Omnitrope® (Sandoz), a recombinant human growth hormone (rhGH). This study will provide additional data on the long-term safety of rhGH in adult patients with severe GH deficiency (GHD). Here we present safety data from an interim analysis.

Methods: Eligible patients are male or female adults who are receiving treatment with Omnitrope® and who have provided informed consent. Patients treated with another rhGH before starting Omnitrope® therapy are eligible for inclusion. The primary objective of the study is to assess the safety and efficacy of Omnitrope® in adults treated in routine clinical practice. Particular emphasis is placed on the risk of glucose intolerance or diabetes and normalisation of IGF-1 levels.  

Results: To date (November 2014), 800 patients have been enrolled in the study; 414 (52%) have received previous GH treatment. Mean (SD) age of enrolled patients is 50.4 (15.5) years, and mean (SD) body mass index is 29.7 (6.5) kg/m2. So far, 1033 adverse events (AEs) have been reported in 321 (40%) patients, with 92 (8.9%, in 59 [7.4%] patients) regarded as serious. Eighty-nine AEs (8.6%) in 58 (7.3%) patients were suspected as drug-related. These included 17 nervous system disorders, 17 general disorders/administration site conditions, 11 musculoskeletal/connective tissue disorders and 11 investigations (increased IGF levels). One serious AE (dyspnoea) in 1 (0.2%) patient was suspected as drug-related. Of the 76 patients who have discontinued treatment, 17 did so due to an AE.

Conclusions: On the basis of this interim analysis, Omnitrope® treatment in adults with GHD is well tolerated in a real-life clinical practice setting, both in rhGH-naïve and previously treated patients. The ongoing PATRO Adults study will provide important data on the diabetogenic potential and overall safety of long-term GH treatment in this population.

 

Disclosure: PB: Speaker, Sandoz, Speaker, Eli Lilly & Company, Clinician, Pfizer, Inc.. CH: Advisory Group Member, Sandoz. RDM: Advisory Group Member, Sandoz. SS: Advisory Group Member, Sandoz. MZ: Employee, Sandoz. GKS: Advisory Group Member, Sandoz. Nothing to Disclose: AL

22477 2.0000 LBF-078 A Latest Results from the Patro Adults Study of Omnitrope® for the Treatment of Adult Patients with Growth Hormone Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Alfonso Humberto Paredes*1, Hernan E Lara2 and Daniela Fernandois3
1Universidad de Chile, Santiago, Chile, Chile, 2University of Chile, Santiago, Chile, 3University of Chile, Santiago

 

Kisspeptin, Neurokin B and Dynorphin (KNDy) are peptides involved in GnRH neurons regulation and in the ovulatory process through its action in the central nervous system.  At the peripheral nervous system, Kisspeptin colocalize with tyrosine hydroxylase in sympathetic neurons of the celiac ganglion (CG) projecting its axons into the rat ovary to locally regulates ovary function opening the interesting possibility that Kiss and noradrenaline (NA) could interact in a cooperative fashion to regulates ovary function.

Considering that ageing of the ovary is characterized by increased NA concentration and in the activity of sympathetic nerves (originated at CG), it is possible that these peptides which are closely related to central regulation of reproduction, could also increases during development and participate in the neurogenic-dependent increase in ovarian follicular cysts-accompanying the ageing of the ovary.

The main purpose of this work was to determine the changes in Kisspeptin Neurokinin B and KNDy mRNA levels during reproductive ageing to relate these changes to ovary function.

Ovary and CG were collected from Sprague-Dawley rat of different age, fertile (6 month old), subfertile (8 to 10 month old) and infertile (12 month old). The mRNA content for KNDy were determined by RT-qPCR, using a IQ5 Biorad Real time PCR in CG and ovary, The protein level was determinated in the rata ovary (by western blot analysis). Rats from 6 to 12 months old showed increased of mRNA and peptide for Kisspeptin at subfertile period, followed by a decrease at 12-month old. In the CG, Kisspeptin mRNA decreased during subfertile period. However, Dy and NKB receptor mRNA levels did not change during reproductive aging but Neurokinin B increased at 8 month old followed by a decrease at 10 month old

In conclusion, we demonstrated for the first time that celiac ganglion cells express KNDy system, Neurokinin and dynorphin being potential local regulators of ovary function and thus in follicular ageing.

Supported by Grant Fondecyt 1120147

 

Nothing to Disclose: AHP, HEL, DF

22364 3.0000 LBF-079 A mRNA Expression of Kisspeptin, Neurokinin B and Dynorphin in the Celiac Ganglion during Reproductive Ageing 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Leonardo Tadeu Araújo1, Ericka Barbosa Trarbach2, Marcio Carlos Machado3, Marcello D Bronstein4, Antonio M Lerario5 and Maria Candida B V Fragoso*3
1Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil, 2Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 3Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 4University of São Paulo Medical School, São Paulo, Brazil, 5Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Background: Corticotropinomas (ACTH-omas) are monoclonal tumors and represent around 10% of diagnosed intracranial tumors. Although considered benign, their biological behaviour is quite variable, ranging from indolent with an extremely slow growing potential, to recurrent, aggressive, and exceptionally malignant tumors, accounting 0.1-0.2% of all pituitary tumors. In some of these invasive adenomas, an effective surgical treatment is very difficult and neither remission nor recurrence are remarkable. Early prediction of invasiveness could be helpful for patients management, however, despite of the extensive tissue-based study on molecular markers for invasiveness and recurrence, it still remains challenging.

Objective: To determine the genome-wide transcriptional status of non-invasive versus invasive corticotrophinomas tumors in order to identify new potential marker for aggressiveness.

Methods: We evaluated mRNA extracted from frozen samples of corticotrophinomas: 4 microadenomas (mean tumor size, 7.5±1.29 mm, Grade I according to Hardy Classification); 5 macroadenomas (mean tumor size, 13.4±3.65 mm, Grade II according to Hardy Classification) and 3 invasive macroademonas (mean tumor size, 27.7±11.2 mm, Grade III and IV according to Hardy Classification). Imunohistochemistry was positive for ACTH stain for all tumor samples. Patients were female (mean age at diagnosis, 39.4 years; range, 14-70). All mRNA was processed on Affymetrix Exon 1.0 ST microarrays protocols and array data analysis was performed using pre-defined Exon expression workflow in Partek® Genomics Suite™ software 6.4. The Robust Multiarray Analysis (RMA) algorithm was used for global normalization and probe set summarization. Differentially expressed genes were determined using Student’s t test and DAVID Functional Gene Classification Tool was used for pathway analysis.

Results and Conclusion: We identified 236 genes that were differentially expressed between non-invasive and invasive corticotrophinomas. Of these, 111 were over-expressed and 120 were under-expressed in the invasive group compared to the noninvasive group. Hierarchical clustering demonstrated a strong tendency to categorize samples in two main classes according to their invasiveness, and the heat map clearly displays a different group of over- and under-expressed genes between them. DAVID pathway analysis of over-expressed gene showed enrichment of categories involved in cell proliferation and adhesion functions, response to hormonal stimulus and apoptosis. When samples were categorized only as macro or microadenomas, no statistical difference was observed.  In conclusion, our findings suggested a distinct transcriptional signature in invasive versus non-invasive corticotrophinomas. Ongoing bioinformatics analysis will possibly reveal candidate genes linked to aggressive behavior on ACTH-oma.

 

Disclosure: MDB: Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc., Advisory Group Member, Chiasma, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Principal Investigator, Ipsen, Principal Investigator, Novartis Pharmaceuticals. Nothing to Disclose: LTA, EBT, MCM, AML, MCBVF

22514 4.0000 LBF-080 A Microarray Analysis in Cushing's Disease Reveals Differential Gene Expression Between Invasive and Non-Invasive Pituitary Corticotropinomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Orit Cohen-Barak*1, Anat Sakov2, Michelle Rasamoelisolo3, Merav Bassan1, Kurt Brown1, Kathleen Butler4, Ofer Spiegelstein1 and Nurit Ashkenazi1
1Teva Pharmaceuticals Research and Development, 2Teva Pharmaceuticals Research and Development, Israel, 3Teva Biopharmaceuticals, 4Teva Pharmaceuticals, Frazer, PA

 

Background: TV-1106 (Teva Pharmaceuticals Inc) is a genetically fused recombinant protein of human growth hormone and human serum albumin, in development for the treatment of growth hormone deficiency (GHD). For patients with GHD, deficiency of growth hormone reduces production and release of insulin-like growth factor (IGF-I) with recognized clinical sequelae.  IGF‑I is accepted as the PD marker of GH activity. TV-1106 has an extended duration of action compared to daily GH treatment and thus can reduce the frequency of injections and improve compliance and quality of life for adults and children requiring growth hormone replacement therapy. 

Objective: To assess IGF-I and IGFBP-3 concentrations after administration of TV-1106 in cynomolgus monkeys and healthy human volunteers.  

Methods: In the multiple dose preclinical assessment, 32 mature treatment-naïve monkeys (16 males and 16 females) were assigned to 4 groups (n = 8 per group) and received four once weekly injections of 0, 5, 10, or 20mg/kg. Serum IGF-I levels were determined using a validated ELISA method. In the single dose assessment, healthy male human subjects (N=56) were assigned to 1 of 7 ascending dose groups (3-100mg) and received either a single dose of TV-1106 (n=6) or placebo (n=2) by SC injection. Serum IGF-I and IGFBP-3 levels were determined using a validated Liquid Chromatography/Mass Spectrometry – Mass Spectrometry (LC/MS-MS) and immunochemiluminescence assays, respectively.

Results: Following repeated administration of TV-1106 at 5, 10 or 20mg/kg, there was a linear dose-related increase in IGF-I levels for male and female animals (r = .9735 and r=0.8242, respectively) compared with the control group. Following single dose administration of TV-1106 in human subjects, IGF-I levels rose rapidly above baseline levels within 12 to 24 hours, peaking at 48-72 hours post dosing, and remained elevated for one week following dosing. IGF-I was presented in SDS units by taking into account the age of the subject. The Emax (maximum observed effect) in IGF-I SDS appeared to increase in an approximately linear fashion from 10 mg up to 50 mg, where it reached a plateau. IGFBP-3 showed a small increase above baseline within 24 hours following TV-1106 doses at equal to or higher than 10 mg dosages compared to placebo and peaked at 48-96 hours. IGFBP-3 slowly declined toward baseline values around 168 hours; however, concentration values above baseline were still observed in the higher dose groups (35 to 100 mg). A clear pharmacokinetic/pharmacodynamic correlation was noted between IGF-I levels and TV-1106 dose in both human subjects and monkeys.

Conclusions: Elevation of IGF-I levels above baseline levels following single and multiple once weekly doses of TV-1106 suggests that TV-1106 can alleviate the low IGF-I concentrations observed in GHD, despite reduced dosing frequency compared to daily GHD treatment regimens.

 

Disclosure: OC: Researcher, Teva. AS: Researcher, Teva. MR: Researcher, Teva. MB: Researcher, Teva. KB: Researcher, Teva. KB: Researcher, Teva. OS: Researcher, Teva. NA: Researcher, Teva.

22526 5.0000 LBF-081 A The Effects of TV-1106, a Once-Weekly Treatment for Growth Hormone Deficiency on IGF-1 Concentrations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Kellie M Breen*, Michael J Kreisman, Christopher I Song and Kathleen Yip
University of California, San Diego, La Jolla, CA

 

The anterior pituitary gland produces hormones that are responsible for regulating a variety of body functions, including growth, metabolism and reproduction.  Improper hormone production can lead to deficiencies in normal physiologic function.  For example, the primary cause of infertility in men and women is insufficient hormone production by the anterior pituitary gonadotrope cell.  It is well known that the brain undergoes changes in a sexually dimorphic manner during fetal development.  Here, we postulate that sex differences are present in another neuroendocrine tissue, the pituitary gland.  The present study tested the hypothesis that androgens mediate sex differences in gene expression during fetal development of the anterior pituitary gland.  Female C57Bl6 mice were mated and checked daily for the presence of a vaginal plug, indicating embryonic day (e) 0.5.  Gestational length for this strain in our colony is 19 days.  During late gestation (e15.5-17.5), the pregnant females were treated daily with a subcutaneous injection of the androgen receptor antagonist flutamide (150 µg/animal) or sesame oil vehicle.  The timing of treatment corresponds to late development of the anterior pituitary gland, when gonadotropin gene expression is first detected, and a period in which fetal testosterone is present and elevated in males.  On e18.5 the pregnant females were sacrificed and the fetuses extracted.  Tail DNA was analyzed by SRY genotyping to distinguish males from females.  The pituitary from each fetus was collected and RNA was isolated and processed for gene expression using quantitative PCR.  We assessed expression of key genes from the five endocrine cell types within the pituitary of the female and male fetuses treated in utero with flutamide or vehicle.  In vehicle-treated fetuses, multiple gonadotrope-derived genes were expressed at significantly higher levels in females compared to males, such as luteinizing hormone beta (Lhb), follicle-stimulating hormone beta (Fshb) and gonadotropin-releasing hormone receptor (Gnrhr).  In addition, the gonadotrope- and thyrotrope-derived gene, alpha glycoprotein subunit (Cga), was expressed in a sex-dependent manner, yet thyrotropin-stimulating hormone beta (Tshb) was not.  Lactotrope-derived prolactin (Prl) was also more highly expressed in females.  Expression of proopiomelanocortin (Pomc) and growth hormone (Gh) were not significantly different between male and females.  Treatment with flutamide eliminated the difference in Lhb, Fshb, Gnrhr, Cga and Prl gene expression in male and female fetuses.  Specifically, treatment with flutamide relieved the suppression of gene expression in males to the level observed in vehicle-treated females.  These data demonstrate robust sex differences in gene expression in the fetal mouse pituitary and suggest that the suppression of gene expression in males is dependent on circulating androgens.

 

Nothing to Disclose: KMB, MJK, CIS, KY

22594 6.0000 LBF-082 A Androgens Mediate Sex-Differences in Gene Expression within the Fetal Anterior Pituitary Gland 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Robert Formosa*1, Joseph Borg2 and Josanne Vassallo1
1University of Malta, Msida, Malta, 2University of Malta, Mater Dei Hospital, Msida, Malta

 

Research to elucidate molecular mechanisms driving pituitary tumour formation and progression is essential given the dearth of data regarding pathways involved. In order to identify novel mechanisms driving pituitary adenomas (PA) growth, RNA profiling microarray analysis was carried out on locally resected PAs (5 non-functioning, 2 growth hormone secreting and one prolactin-secreting PA). Ingenuity pathway analysis identified the aryl hydrocarbon receptor signaling pathway as a key canonical pathway deregulated in all PA types. A general down – regulation of AHR downstream targets and co-regulators was observed in all tumours as compared to pooled control RNA and confirmed by quantitative PCR in a total of 31 tumours.  Proliferation analysis using MTT assays and a number of functional analyses were then used to validate the role of the AHR in PA using the GH3 sommatotroph/lactotroph cell line. GH3 cells were transfected with AHR expression vector and activated using benzo α-pyrene (BαP) ligand. AHR over-expression alone reduced GH3 cell proliferation significantly in the presence and absence of exogenous ligand, indicating a possible tumour suppressive role. However, over-expressed AHR induced a xenobiotic response only in the presence of BαP, indicating that an exogenous agent activating the canonical xenobiotic signaling pathway may not be required for AHR to carry out its anti-proliferative behavior in GH3 cells. Cell cycle analysis and quantitative PCR of cell cycle regulator genes revealed that both unstimulated and BαP-stimulated AHR  alters specific non-xenobiotic pathways shifting the percentage of cells in G0/G1 phase and thereby slowing the proliferation rate of GH3 cells. The evidence provided corroborates a role for the AHR as a putative suppressor of pituitary tumour formation, possibly through its role as an indirect cell cycle co-regulator.

 

Nothing to Disclose: RF, JB, JV

22697 7.0000 LBF-083 A The Aryl Hydrocarbon Receptor (AHR) May Act As a Tumour Suppressor in Pituitary Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Hataiwan Chokechuwattanalert1, Carina Lund1, Kristiina Pulli1, Venkatram Yellapragada1, Paolo Giacobini2, Karolina Lundin1, Sanna Vuoristo1, Timo Tuuri3, Parinya Noisa1 and Taneli Raivio*1
1University of Helsinki, Helsinki, Finland, 2INSERM U1172, University of Lille 2, France, Lille, France, 3Helsinki University Central Hospital, Helsinki, Finland

 

Hypothalamic gonadotropin-releasing hormone (GnRH) secretion is essential for puberty and reproductive function. We have developed a 27-day, two-step protocol to differentiate human pluripotent stem cells (hPSCs; human embryonic stem cells and induced pluripotent stem cells) into GnRH-secreting neurons. First, hPSCs were differentiated toward neuroectodermal lineage by using 10 days of dual SMAD inhibition, which led to forebrain-specific neural progenitor cell (F-NPC) identity, as shown by robust upregulation of PAX6, EMX2, FOXG1, and GSX2. Second, GnRH neuron fate specification was achieved by exposing F-NPCs to FGF8, a key ligand implicated in GnRH ontogeny. The ensuing GnRH-expressing cells were TUJ1-positive, bipolar-shaped neurons that also expressed DCC and NRP-1, similar to human fetal GnRH neurons. Importantly, hPSC-derived GnRH neurons secreted GnRH into the culture medium, a feature suggesting their neuroendocrine maturity. Taken together, our results provide a new translational tool for investigating the mechanisms of human puberty and its disorders.

 

Nothing to Disclose: HC, CL, KP, VY, PG, KL, SV, TT, PN, TR

22841 8.0000 LBF-084 A Generation of GnRH-Secreting Neurons from Human Pluripotent Stem Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Brittany Davis*1 and Erica Crespi2
1Hofstra North Shore-LIJ, Westbury, NY, 2Washington State University, Pullman, WA

 

Objective: Functional hypothalamic amenorrhea commonly afflicts endurance runners and may impact cardiovascular responses to exercise and endurance performance. The objective of this study was to examine the relationships among menstrual status, circulating levels of steroid hormones, cardiovascular function, and endurance performance in a group of female endurance athletes.

Design: Observational Study.

Methods: Collegiate female distance runners(18-22 yrs)  reporting a history of eumenorrhea (EAs, n=11) or menstrual dysfunction (MDAs, n=9) performed a modified Bruce Protocol Treadmill Test. Salivary estradiol, testosterone, and cortisol levels, circulating lactic acid levels, and ECG data were collected pre- and post-run. Heart rate, VO2max, time to exhaustion, and rate of perceived exhaustion were measured pre-, during, and post-run.

Results: MDAs had significantly lower estradiol levels and higher testosterone levels than EAs, despite no significant differences in training volume, BMI, or body fat %. MDAs had significantly lower heart rates from prolonged ST intervals before, during and after the treadmill test. There were no differences in time to exhaustion, rate of perceived effort or VO2max between groups. 

Conclusion: Lower estradiol levels link neuroendocrine reproductive dysfunction with altered cardiovascular responses to training in female endurance athletes, though do not appear to influence submaximal performance. We propose that depressed heart rate and hypoestrogenism heart rates in young female athletes could aid in the early identification of the “athlete triad” and may indicated heightened risk for cardiovascular abnormalities.

 

Nothing to Disclose: BD, EC

22977 9.0000 LBF-085 A Menstrual Dysfunction, Hypoestrogenism, and Cardiac Abnormalities in Young Endurance Runners 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Andrew James Lessey*1, Samantha Mary Mirczuk1, Jordan Elise Read1, Stijn J Niessen2, Imelda Mary McGonnell1 and Robert C Fowkes1
1The Royal Veterinary College, London, United Kingdom, 2The Royal Veterinary College, North Mymms, United Kingdom

 

Human patients with mutations within NPPC or NPR2 genes (encoding C-type natriuretic peptide (CNP) and guanylyl cyclase-B (GC-B), respectively) display clinical signs associated with skeletal abnormalities, such as overgrowth or short stature. In mice, spontaneously occurring, as well as induced models of Nppc or Npr2 deletion result in profound achondroplasia, dwarfism and early death, with growth hormone deficiency present in some instances; thus, current pharmacological therapies to treat short stature have included long-acting CNP analogues. We have demonstrated the presence of NPPC and NPR2 transcripts in normal human fetal pituitaries, as well as human pituitary adenomas of differing origins, suggesting potential roles for CNP during development. Using the versatile Danio rerio (Zebrafish) as a model for vertebrate development, we previously reported that exposure of Zebrafish larvae to excessive exogenous CNP leads to altered pituitary gene expression and stunted growth. In the current study, we have used a reverse genetics approach to alter expression of two of the four genes that encode CNP in the Zebrafish (nppcl and nppc4). Here we employed the clustered regularly interspaced short palindromic repeats (CRISPR)/Cas 9 system to efficiently facilitate genome editing of Zebrafish embryos in vivo. RNA-guided Cas9 endonuclease targeting nppcl or nppc4 was injected into wild type Zebrafish embryos at the one-cell stage. Mutant embryos were subsequently reared to either 24, 48 or 72 hours post fertilization (hpf) alongside uninjected controls and gDNA extracted. A T7 endonuclease I assay was used to demonstrate the induction of indels in the nppcl and nppc4 loci in Zebrafish. Gross morphological and biometric analyses of these mutants showed that disruption of either nppcl or nppc4 transcripts in vivo severely impaired embryonic development. Body length was significantly reduced in comparison to wild type controls (nppcl: p<0.01, nppc4: p<0.01) and eye diameter was significantly smaller (nppcl: p<0.05, nppc4: p<0.01). Mutant embryos also display impaired forebrain development, impaired locomotion and substantial cardiac oedema in comparison to wild type controls. Collectively, these data suggest that CNP in Zebrafish is crucial for normal embryonic development, specifically with regards to  skeletal growth, brain development and fluid homeostasis. Furthermore, the phenotypic similarity of nppcl and nppc4 mutants, without apparent compensation, requires further elucidation as to their specific developmental functions.

 

Nothing to Disclose: AJL, SMM, JER, SJN, IMM, RCF

22852 10.0000 LBF-086 A Crispr-Induced Genetic Manipulations to C-Type Natriuretic Peptide Transcripts in Danio Rerio (Zebrafish) Larvae Results in Impaired Growth and Development 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Joe Kurian*
Southern Illinois University School of Medicine, Springfield, IL

 

Late onset hypogonadism (LOH) is characterized by sexual dysfunction, muscle weakness, and/or depression in ageing men. Testosterone replacement has become an increasingly popular request of men suffering these symptoms; though the true impact and long-term safety of this treatment is not well defined. Defining the root cause of LOH is consequently critical to determining the most efficacious and safe treatment of the syndrome. LOH can be caused by a primary failure of testicular function or secondary disruptions of hypothalamic-pituitary function with reduced or abnormally stable plasma luteinizing hormone (LH) levels. Secondary LOH is related to lifestyle factors (e.g., diet and obesity) or coexisting conditions (e.g., diabetes, COPD, cardiovascular disease). We hypothesize that these environmental factors have an epigenetic impact on hypothalamic function that consequently interfere with the regulation of pituitary release of LH. We previously found that gonadotropin releasing hormone (GnRH) neuron activity coincides with the level of DNA methylation in the primate GnRH gene. We subsequently discovered that a mature GnRH cell line (GT1-7) expressed significantly higher levels an enzyme that regulates active DNA demethylation (Tet2) when compared to the immature GnRH cell line (GN11). Remarkably, GnRH neuron specific disruption of Tet2 led to an age dependent decrease of male plasma LH in mice. Whether disruption of Tet2 leads to epigenetic changes in mature GnRH neurons remained unclear. Using Chromatin immune-precipitation, we evaluated Tet2 binding and an activating histone modification (H3K4me3) across the mouse GnRH gene 5’ region in four conditions: 1) GN11, 2) GT1-7, 3) GN11 cells overexpressing Tet2, and 4) GT1-7 cells with Tet2 eliminated by CRISPR/cas9 mediated gene disruption. Tet2 binding was low in GN11 cells across the entire 5’ region, but significantly elevated in GT1-7 cells at the promoter and neuron specific enhancer region. The activating H3K4me3 modification largely mirrored Tet2 binding patterns, with significantly higher abundance in GT1-7 compared to GN11 cells. Overexpression of Tet2 in GN11 cells significantly increased Tet2 binding of the promoter and to a lesser extent the neuron specific enhancer; H3K4me3 levels were also significantly higher at the promoter compared to non-transfected GN11 cells. Disruption of Tet2 in GT1-7 cells decreased Tet2 binding across the entire region; remarkably, H3K4me3 levels significantly dropped at the neuron specific enhancer after Tet2 disruption in GT1-7 cells. They further suggest the novel concept that Tet2 mediated epigenetic patterns must be actively maintained, as opposed to established solely as a developmental process. Future studies will evaluate how the environment influences Tet2 activity in the hypothalamus and how this relates to the etiology of LOH.

 

Nothing to Disclose: JK

22905 11.0000 LBF-087 A Tet2 Enables Elevated GnRH Neuron Activity and Maintains Activating Histone Modifications within the GnRH Gene 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Ryan J Tomm1, Cathy Q Ma1, Maric T Tse1, Maddie M Grist1, Katelyn L Low1, Daniel J Tobiansky*1, Stan B Floresco1 and Kiran K Soma2
1The University of British Columbia, Vancouver, BC, Canada, 2University of British Columbia

 

Circulating levels of testosterone (T) decline in males during the aging process. Furthermore, aging is characterized by changes in decision making and executive function. T modulates signaling in the mesocorticolimbic dopamine (DA) system, a circuit that is critical for decision making and executive function. Thus, changes in circulating T levels during aging might affect cognition via this DA system.  Here, we measured T in serum and microdissected brain regions of young adult (5 months) and aged (22 months) male rats. As expected, serum T levels were lower in aged rats than young rats. Compared to young rats, aged rats had lower levels of T in the ventral tegmental area (VTA), which is the origin of DA projections to forebrain structures, and also in the nucleus accumbens (NAc), which receives DA projections from the VTA. Both young and aged rats displayed higher levels of T in microdissected brain regions than in serum, suggesting that T might be locally synthesized in the brain. Interestingly, the DA-synthesizing enzyme tyrosine hydroxylase (TH) was also reduced in the NAc of aged rats. Aged rats also showed deficits in some behavioral measures of cognitive flexibility and working memory. Interestingly, individual performance on the behavioral tasks was correlated with levels of TH in the NAc. These data suggest that T modulates DA signaling in the NAc and that the decline in T levels during male aging might affect cognition via this critical brain region.

 

Nothing to Disclose: RJT, CQM, MTT, MMG, KLL, DJT, SBF, KKS

22933 12.0000 LBF-088 A Effects of Aging on Cognition, Mesocorticolimbic Dopamine System, and Testosterone in Male Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Haluk Kelestimur*, Zafer Sahin, Sinan Canpolat and Mete Ozcan
Firat University Medical School, Elazig, Turkey

 

There is growing evidence that RFamide-related peptides (RFRPs) show their effects on reproductive functions by modulating kisspeptin/GPR54 signaling system. Our previous experiment (1) shows that GnIH treatment attenuates kisspeptin-10-induced GnRH release in GT1-7 cells. Combined injection of kisspeptin-10 and the antagonist of RFRP receptor, RF9, modestly increased the responses to kisspeptin alone (2). The above data strongly suggest the possibility of interactions between kisspeptins and RFRPs in the control of the HPG axis. Therefore, it is proposed that it is the dynamic balance and interplay between these two sets of factors that drives the function of the reproductive system. The aim of this study was to determine the modulatory effects of peptide 234 (p234) (an antagonist of GPR54 receptors) on kisspeptin and RF9 (an RFamide-related peptide antagonist) - induced changes in reproductive functions and energy balance in female rats.  Female Sprague-Dawley rats were weaned on post natal day (pnd) 21. The animals were intracerebroventricularly cannulated under general anesthesia on pnd 23. Groups of female rats were injected with kisspeptin, RF9, p234, kisspeptin plus p234 or RF9 plus p234, daily. Kisspeptin and RF9 elicited significant elevations of circulating LH levels. Coadministrations of kisspeptin or RF9 with p234 decreased LH levels significantly. The use of p234 alone did not cause any significant change in LH secretion. Kisspeptin or  RF9 alone advanced vaginal opening (VO), which was delayed by administration of kisspeptin antagonist alone. In the rats given kisspeptin plus p234 or RF9 plus peptide 234, VO was not different from control rats.   Kisspeptin decreased both food intake and body weight while RF9 decreased only food intake without affecting body weight. The effects of both kisspeptin and RF9 on energy balance were also reversed by central administration of p234. In conclusion, kisspeptin antagonist, p234, modulates the effects of not only kisspeptin but also RF9 on reproductive functions and energy balance, and therefore RF9 seems to exert its effects on reproductive functions and energy balance by means of GPR54 signaling the same as kisspeptin in the female rats. The understanding of the effects of kisspeptin and RFRP-3 antagonists will provide new therapeutic approaches to treat some hormone-dependent reproductive and metabolic disorders such as precocious puberty and obesity, respectively.

 

Nothing to Disclose: HK, ZS, SC, MO

22310 13.0000 LBF-089 A the Kisspeptin Antagonist, Peptide 234, Reveales Regulatory Mechanisms of Reproductive Functions and Energy Balance By Kisspeptin and RF9, a Selective Antagonist of RF-Amide Related Peptide Receptors, in Female Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Friday, March 6th 3:00:00 PM LBF 077-089 6294 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary II Poster


Andrea Kassai*1, Mary F. Walter2, Brent S. Abel3, Michael Ring3, Simeon Taylor3, Monica C. Skarulis4, Phillip Gorden2 and Rebecca J. Brown5
1National Institutes of Health, Bethesda, MD, 2NIDDK, NIH, 3NIDDK, Bethesda, MD, 4DEOB, NIDDK, NIH, 5National Institute of Health, Bethesda, MD

 

Background: Apolipoprotein CIII (apoCIII) regulates triglyceride metabolism, and apoCIII levels strongly correlate with serum triglycerides in a variety of patient populations. Lipodystrophy is a rare disease of deficient adipose mass, characterized by severe hypertriglyceridemia as well as insulin resistance, diabetes mellitus, fatty liver disease, acute pancreatitis, and early cardiovascular events. The metabolic complications of lipodystrophy are related to leptin deficiency, and can be ameliorated by leptin replacement. However, leptin deficiency alone may not entirely explain the severity of metabolic disease, particularly in patients with partial lipodystrophy who have variable leptin deficiency. We hypothesized that elevated apoCIII plays a role in the hypertriglyceridemia seen in lipodystrophy and might therefore represent a therapeutic target in these patients.

Methods: Apo CIII levels were measured on stored serum samples from 60 lipodystrophy patients and 54 healthy volunteers. The lipodystrophy cohort included patients with both generalized and partial lipodystrophy who were not leptin-treated. Healthy volunteers were chosen from a large database by matching to lipodystrophy patients based on age, gender, race, and ethnicity. We also attempted to match by triglyceride levels. ApoCIII level was measured by ELISA (Abcam).

Results: ApoCIII level was significantly elevated in lipodystrophy patients (30.4 ± 22.7 mg/dL) compared to healthy controls (16.1 ± 6.9 mg/dL) (p< 0.0001). Despite the attempt at matching, triglyceride levels were significantly higher in lipodystrophic patients versus controls (881.4 ± 1320 versus 152.5 ± 74.7, p< 0.0001). ApoCIII and triglyceride levels were positively correlated with one another in both lipodystrophy patients (R2= 0.521, p< 0.0001) and healthy volunteers (R2= 0.3608, p< 0.0001). The relationship between triglyceride and apoCIII was not different in lipodystrophy versus healthy controls (95%CI of slope 0.79 – 1.3 in lipodystrophy; 0.5 – 1.1 in controls). There was no correlation between ApoCIII and hemoglobin A1c in patients with lipodystrophy (p= 0.842).

Conclusion: Hypertriglyceridemia is one of the hallmark metabolic abnormalities of lipodystrophy. We have shown that lipodystrophy patients have elevated apoCIII levels compared to healthy volunteers, and that the relationship between apoCIII and triglycerides is the same in lipodystrophy as in other populations. These findings suggest that apoCIII may play a role in the abnormal triglyceride metabolism seen in lipodystrophy, and that apoCIII lowering may lower triglycerides in these patients.

 

Nothing to Disclose: AK, MFW, BSA, MR, ST, MCS, PG, RJB

22544 1.0000 LBF-090 A Apolipoprotein Ciii Levels Are Elevated in Lipodystrophy Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM LBF 090-092 6297 1:00:00 PM Late-breaking Cardiovascular Endocrinology II Poster


Asha Asthana*1, Brent S. Abel2, Monica C. Skarulis1, Phillip Gorden2, Rebecca J. Brown3 and Ranganath Muniyappa4
1DEOB, NIDDK, NIH, 2NIDDK, NIH, 3National Institute of Health, Bethesda, MD, 4Diabetes Endocrinology and Obesity Branch, NIDDK, NIH

 

Background: Lipodystrophy (LD), characterized by selective deficiency of adipose tissue, is a hypoleptinemic state associated with severe insulin resistance, diabetes, and hypertriglyceridemia. Some studies suggest that reduced triglyceride (TG) clearance due to impaired lipoprotein lipase (LPL)-mediated lipolysis contribute to severe hypertriglyceridemia. Angiopoietin-like protein 3 (ANGPTL3) and 4 (ANGPTL4) play important roles in lipid metabolism by impairing clearance of TG by inhibiting LPL. Whether circulating ANGPTL3/4 levels are altered in LD and the effects of leptin therapy on these ANGPTLs are unknown.

Objectives: In this study we: a) compared plasma ANGPTL3 and 4 in patients with LD and healthy controls and b) examined effects (16–32 weeks) of leptin replacement on ANGPTL 3 and 4.

Methods: In a prospective, open-label, ongoing study, we studied effects of leptin replacement (once or twice daily self-administered metreleptin) on plasma ANGPTL3 and 4 in 17 patients with generalized (n=9) or partial LD (n=8). Pre-leptin treatment levels of ANGPTLs (measured by ELISA) were compared with healthy, lean controls (n=15, BMI, 22.4±1.4 kg/m2). Patients were on stable doses of glucose and lipid-lowering medications prior to and at the end of 16–32 weeks of metreleptin. Data are compared by paired or unpaired t-tests and are presented as mean ± SD or median (interquartile range, IQR).

Results: The median baseline age of LD patients was 31 years (range of 7–68). Prior to metreleptin, median serum leptin levels were 1.8 ng/mL (IQR 5.7). Patients with partial LD had higher levels of leptin compared with generalized LD [6.86 (1.98) vs. 0.90 (0.70), P = 0.03]. At baseline, patients with LD compared with lean controls had higher ANGPTL3 (275 ± 106 vs. 197 ± 54 ng/mL) and 4 (95 ± 64 vs. 42 ± 14 ng/mL) (p<0.05). ANGPTL4, but not ANGPTL3 was positively related with baseline leptin (r=0.46, p=0.06) and TG (r=0.45, p=0.07) levels. Neither of the ANGPTLs were significantly related with fasting glucose, total cholesterol, or A1c. After metreleptin therapy, A1C (7.1 ± 1.6 vs. 7.9 ± 1.9 %) and fasting glucose (133 ± 60 vs. 157 ± 79 mg/dL) were lower but not significantly different than baseline. Metreleptin was associated with a significant decrease in TG levels (247 ± 135 vs. 476 ± 421 mg/dL, p=0.04), with no change in total cholesterol or HDL. However, metreleptin was not associated with a significant change in plasma ANGPTL3 (259 ± 94 vs. 275 ± 106 ng/mL) or ANGPTL4 (105 ± 71 vs. 95 ± 64 ng/mL).

Discussion: LD is associated with elevated plasma ANGPTL 3 and 4. Elevated ANGPTL4 levels are associated with higher TG levels, suggesting that ANGPTL4 may play a role in hypertriglyceridemia in these patients. However, metreleptin decreases TG levels independent of changes in circulating ANGPTL3 or 4. These novel findings suggest that elevated ANGPTLs may be therapeutic targets to modulate lipid metabolism in patients with LD.

 

Nothing to Disclose: AA, BSA, MCS, PG, RJB, RM

22854 2.0000 LBF-091 A Effects of Recombinant Human Leptin (Metreleptin) Therapy on Plasma Angiopoietin-like Proteins 3 and 4 in Lipodystrophy Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Friday, March 6th 3:00:00 PM LBF 090-092 6297 1:00:00 PM Late-breaking Cardiovascular Endocrinology II Poster


Anne E Bantle*, Qi Wang and John P Bantle
University of Minnesota, Minneapolis, MN

 

Postprandial hypoglycemia after gastric bypass surgery is a serious problem.  Its pathogenesis is not established, but might be due to rapid absorption of ingested nutrients or an increase in beta cell mass and hyperinsulinism.  Available treatments are often ineffective.  Accordingly, we tested the hypotheses that injection of rapid acting insulin before a high carbohydrate meal would prevent postprandial hyperglycemia with subsequent hypoglycemia and that replacement of glucose with fructose in the meal would prevent hypoglycemia.  Ten patients with post-gastric bypass hypoglycemia were studied on three occasions in random order.  The conditions were 1) a high carbohydrate meal with pre-meal saline injection (control), 2) a high carbohydrate meal with pre-meal rapid acting insulin injection, and 3) a high fructose meal with carbohydrate content similar to the control meal.  Plasma glucose and serum insulin were sampled before and frequently for four hours after the meals.  After the control meal, mean peak plasma glucose and serum insulin were 173±47 mg/dL and 134±55 mU/L, respectively, mean plasma glucose nadir was 44±15 mg/dL, and 8 of 10 subjects demonstrated plasma glucose < 60 mg/dL.  Five subjects demonstrated a plasma glucose nadir < 40 mg/dL, and the lowest plasma glucose observed was 22 mg/dL.  There were no significant differences in the corresponding values after pre-meal insulin treatment except that the mean plasma glucose nadir of 34±10 mg/dL was lower (p<0.05).  After the fructose meal, mean peak postprandial plasma glucose and serum insulin were 117±20 mg/dl and 45±31 mU/L, respectively (both p<0.001 for comparison with control), mean plasma glucose nadir was 67±10 mg/dL (p<0.001 for comparison with control) and 2 of 10 subjects demonstrated glucose < 60 mg/dL (p<0.05 for comparison with control).  In summary, people with post-gastric bypass hypoglycemia can consume fructose with little risk of subsequent hypoglycemia.  Treatment with rapid acting insulin before a carbohydrate containing meal did not prevent hypoglycemia.

 

Nothing to Disclose: AEB, QW, JPB

22452 1.0000 LBF-093 A Prevention of Hypoglycemia in Patients with Post-Gastric Bypass Hyperinsulinemic Hypoglycemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM LBF 093-096 6300 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite II Poster


Christopher J Loftus*, Michael D Byrne and Sri Sivalingam
Cleveland Clinic, Cleveland, OH

 

INTRODUCTION: Bariatric surgery is accompanied by a number of beneficial effects such as weight loss and decreases in rates of diabetes, hypertension and mortality. Conversely, this surgery raises the risk for kidney stone formation. The effect of calcium supplementation on lithogenic risk in non-bariatric populations remains unclear, though it has been shown to increase risk in post-menopausal women. Our objective was to determine whether calcium supplementation increases the risk of nephrolithiasis in gastric bypass patients.

METHODS: We conducted a retrospective analysis of patients at our institution with a history of bariatric surgery. Patients with nephrolithiasis as confirmed by post-bariatric procedure CT were included in the study. CT scans were reviewed by a urologist blinded to outcomes. Stone burden was calculated as the sum of the max diameters of all stones on CT, and rate of stone growth was calculated by the change in consecutive stone burden divided by the elapsed time between scans.

RESULTS: We identified 43 patients with a history of bariatric surgery and documented kidney stones. Twenty-nine patients were prescribed calcium supplementation after bariatric surgery while 14 patients were not. The two groups were similar in age, gender, stone composition, number of procedures for stones, and number of ED visits for renal colic. All patients with documented stone compositions had calcium oxalate based stones. Stone growth rate was significantly higher in the supplemented group compared to the unsupplemented group (15.9±3.3 mm/year vs. 3.1±4.8 mm/year; p=0.034). 

CONCLUSIONS: Our study suggests that calcium supplementation for post-gastric bypass patients may increase the rate of stone growth. These patients are already at higher risk for stone disease and therefore, further studies are needed to elucidate the exact role of calcium supplementation on stone disease in this patient population.

 

Nothing to Disclose: CJL, MDB, SS

22729 2.0000 LBF-094 A Increased Rate of Kidney Stone Formation with Calcium Supplementation after Bariatric Surgery 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM LBF 093-096 6300 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite II Poster


Janiel L Pimentel*1, Muhammad Waseem2 and Swati Dave-Sharma3
1Lincoln Medical and Mental Health Center, Bronx, NY, 2Lincoln Medical and Mental Health Center, Bronx, 3Lincoln Med & Mental Hlth Ctr, Bronx, NY

 

Background: Obesity is a major health concern across the world including USA. In New York City (NYC) it is a problem that crosses generations. Childhood obesity is linked to many morbidities including but not restricted to diabetes, high cholesterol, hypertension and psychological issues. South Bronx is an underserved area of NYC representing minority population with poor socioeconomic background. Childhood obesity prevalence is 30% in south Bronx. It is a known fact that nutrition in early life might influence the risk of subsequent obesity. We wanted to study the effect of early ablactation on childhood obesity in our patient population of south Bronx.

Objective:  To determine protective effect of breastfeeding on obesity and effect of high risk feeding behavior such as early introduction of solid food on childhood obesity.

Methods:   Study population included 392 overweight or obese subjects between 2-8 years of age in our pediatric outpatient practice at Lincoln Medical and Mental Health Center in south Bronx; patients with chronic illnesses were excluded. A survey was conducted through a questionnaire to the parents or legal guardian of subjects. Questions included duration of breastfeeding versus formula feeding in first year of life, age of solid food introduction, parental education and access to WIC program. We used standard definition of obesity; a child with a BMI > 85th and < 95th percentile for age and gender is considered overweight and BMI > 95th percentile for age and gender is considered obese.

Results: Only 11.7% of our overweight/obese patients were exclusively breastfed for 6 months, 48% subjects were exclusively formula fed and 40.3% of subjects were fed with both. 88.3 % were introduced to solid food before 6 months of age. 86% of parents did not have any college education; 69.6% of our patients had WIC access.

Conclusion: Breastfeeding is a protective factor for prevention of overweight and obesity; early ablactation and introduction of solid food increase risk for obesity. Further controlled based prospective studies are needed.

 

Nothing to Disclose: JLP, MW, SD

22894 3.0000 LBF-095 A Association of Childhood Obesity with Time of Ablactation and Early Feeding Practices 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM LBF 093-096 6300 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite II Poster


Amy Miskimon Goss*1, Brooks C Wingo2, Jamy Ard3, Julie Locher2 and Barbara Ann Gower4
1University of Alabama at Birmingham, Birmingham, AL, 2University of Alabama at Birmingham, 3Wake Forest, 4Univ of AL at Birmingham, Birmingham, AL

 

Depression is common in older adults, particularly among women and individuals who are obese.   The physiological mechanisms underlying these associations are not clear, but inflammation has been implicated.  High levels of visceral fat, a depot associated with elevated inflammation, have been associated with depression onset.   In addition, circulating concentrations of the adipocyte-derived hormone leptin have been positively associated with depressive symptoms.  Leptin production is greater in women than men, and is increased by obesity.  Leptin facilitates the secretion of proinflammatory cytokines, which in turn may increase risk for depression.  The objective of this study was to investigate the independent relationships among depressive symptoms, total fat mass, intra-abdominal adipose tissue (IAAT), markers of inflammation, and leptin in aging men and women with obesity.  Participants were 164 obese (BMI 30-40 kg/m2) men and women over 65 years of age.  Body composition was assessed by DXA, fat distribution by MRI, and leptin, hsCRP, IL-6, and TNF-α from a fasting blood sample.   Depressive symptoms were assessed by the Center for Epidemiologic Studies-Depression (CES-D) 20-item scale.  Results indicate that women had significantly greater leptin (+110%, p<0.001), hsCRP (+63.9%, p<0.01), and CES-D scores (+52.7%, p<0.001) compared to men.  Men had significantly greater IAAT (+82%, p<0.001) and lean mass (+42.0%, p<0.001) compared to women.  In a multiple linear regression model, leptin was positively associated with CES-D scores (Std β=0.37, p<0.05) independent of hsCRP, total fat, IAAT, and sex.  No independent associations were observed for markers of inflammation with CES-D score.  In conclusion, elevated leptin may, in part, mediate the observed relationship between excess adiposity and onset of depressive symptoms in aging, obese adults. Higher leptin and hsCRP concentration in women compared to men may indicate greater proinflammatory state and explain sex differences in depressive symptoms in this population.  Further studies are needed to determine the precise mechanisms linking leptin and inflammation with depression.

 

Nothing to Disclose: AMG, BCW, JA, JL, BAG

22907 4.0000 LBF-096 A Leptin Is Independently Associated with Depressive Symptoms in Older Adults with Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Friday, March 6th 3:00:00 PM LBF 093-096 6300 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite II Poster


Robert V Brockway*, Kimberly L Holliday-White, Heather M Bogie, Kathryn E Lillegard and Justin Van Hee
Data Sciences International, St. Paul, MN

 

A fully implantable telemetry device is evaluated for continuous monitoring of blood glucose, temperature and locomotor activity in C57BL/6 male mice.  A surgical procedure has been established based on previous success with continuous blood pressure monitoring in mice.  The sensor is surgically placed through the carotid artery to the aortic arch with the device housing placed sub-cutaneously on the side.  A calibration method is established using an intraperitoneal glucose tolerance test (IPGTT) with reference samples collected from the tail.  Sensors were evaluated by observing the continuous signal for expected variations with feeding, activity and circadian variations.  IPGTT was also used periodically to assess sensor response over a range of glucose.  Using this device we recorded 10-second averages in over 25 mice for durations ranging from a few days to 37 days.  The chronic data demonstrates a high degree of physiologic variability both during light and dark periods, with minimal overall circadian baseline variations.  These patterns are distinctly different from previous experience with continuous glucose measurements in rats.  The sensors respond as expected to IPGTT with peak amplitudes approaching 500mg/dL and time from dose to peak of 11-15 minutes.  The IPGTT also provides highly detailed morphology, low sample variability (noise), and a good basis for calculating parameters such as AUC.  These new telemetry sensors will provide a basis for enhanced understanding of glucose metabolism in mice and will contribute to advancements in therapies for diabetes in humans.

 

Nothing to Disclose: RVB, KLH, HMB, KEL, JV

22893 1.0000 LBF-097 A 28-Day Continuous Glucose Profiles Via Implantable Telemetry in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Gokcen Kocabas*1, Mehmet Yavuz2, Mehmet Calan2, Belma Gokcen3, Murat Aksit1, Giray Bozkaya1 and Oktay Bilgir2
1Bozyaka Training and Research Hospital, Izmir, Turkey, 2bozyaka training and research hospital, 3bozyaka training and research hospital, Izmir

 

Abstract

Background: Insulin resistance plays a crucial role in the development of glucose homeostasis disturbance. It has been demonstrated that increased expression of nuclear factor- κβ ligand (RANKL) in the liver causes development of insulin resistance.

Aims: To investigate soluble receptor activator of RANKL and osteoprotegerin (OPG) levels in prediabetic subjects.

Materials & Methods:  Forty prediabetic subjects and 40 age- and BMI-matched subjects with normal glucose tolerance in this cross-sectional study were conducted. Serum OPG and RANKL levels were measured using ELISA.

Results:  Serum OPG (261.54 ± 74.55 vs. 159.23 ± 52.91 pg/mL, P=0.020) and RANKL (97.74 ± 17.67 vs. 55.00 ± 11.19 pg/mL, P=0.010) levels were significantly elevated in prediabetic subjects compared with control subjects. There was a positive correlation between RANKL and age, OPG, HOMA-IR, hs-CRP, HbA1C and BMI. Multiple linear regression analysis showed that BMI, HOMA-IR and hs-CRP were independently related factors influencing serum RANKL levels. Furthermore multivariable logistic regression analysis model showed that elevated serum RANKL levels were independently associated with increased odds of prevalent prediabetes. Subjects with the highest quartile RANKL levels were 2.743 times more likely to develop prediabetes compared with subjects with the lowest quartile RANKL after adjustment for age, BMI, hs-CRP and HOMA-IR (OR=2.743, 95% CI=1.216-6.187, P=0.007).

Conclusions: Prediabetic subject have significantly higher serum RANKL and OPG levels compared with having NGT subjects. Moreover, higher serum RANKL levels were independently associated with increased the development of prediabetes risk. Our results suggest that RANKL may contribute to the underlying pathogenesis of prediabetes.

 

Nothing to Disclose: GK, MY, MC, BG, MA, GB, OB

22361 2.0000 LBF-098 A Association Between Increased Soluble Receptor Activator of Nuclear Factor- Κβ Ligand in Subjects with Prediabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Eun Kyung Koh* and Dace Trence
University of Washington, Seattle, WA

 

Objective:

Continuous glucose monitoring (CGM) has been shown to improve glycemic control in patients with type 1 diabetes mellitus (T1DM) in multiple study populations. Willingly embracing CGM after attending a required informational session pre-sensor use, which fully outlined CGM advantages and limitations, how to use data seen, then being instructed in sensor set-up and timely follow-up after initiation on sensor to help with data analysis, patients still discontinued use of CGM.  We sought to understand why this technology was abandoned.

Methods:

We present a retrospective chart review of  patients seen at an academic diabetes clinic at the University of Washington, who abandoned their CGM.

Results:

17 subjects, 8 men and 9 women, with average duration of T1DM of 19.9 +/- 9 years   (range 1 to 35 years), were identified. Average age at initiation of CGM was 40 +/- 12 yrs. All subjects used insulin pump therapy. Medtronic Sof-sensor was most commonly used CGM device (n= 12). Others included Medtronic Enlite (n= 7), Dexcom G4 Platinum (n= 1) and Abbott Freestyle (n= 1). Duration of CGM use averaged 11-12 months, but ranged 1 to 53 months.

Patients reported multiple reasons for abandoning their CGM use. Most reasons related to technical issues, including reported discomfort at the sensor insertion site (n=7), frequent alarming (n=3), inability to attach the sensor consistently (n=3) , bleeding (n=2) and incompatibility with active lifestyle (n=1). Data collection issues were second most common- 6 patients reported feeling overwhelmed in processing the amount of data seen and 6 patients reported frustration with the lack of correlation between CGM and glucose meter data.  One patient reported problems with medical insurance not consistently providing coverage for the sensors.

15 patients had documented severe hypoglycemic episodes before CGM use, which either resolved or significantly diminished after CGM initiated. Use of CGM significantly improved overall glycemic control. Average hemoglobin A1c level was 7.85 +/- 1% before CGM and 7.48 +/- 1% during CGM (p= 0.045), while from downloaded glucose meter data, average glucose levels were 180 +/- 37.5 mg/dl before CGM and 180 +/- 31.2 mg/dl during CGM (p > 0.05). Glucose variability as defined through mean standard deviation, averaged 85mg/dl before CGM and 78 mg/dl during CGM (p = 0.04).

Conclusion:

Although technological advances in the treatment of T1DM have provided exciting tools for self- management of diabetes mellitus, these tools can only be effective as long as the patient is willing to use them. Neither preparation before, nor close follow-up after CGM initiation was effective in prevention of CGM being abandoned, yet glycemic control and glycemic variability improved with CGM use.

 

Disclosure: DT: Other activities, please specify:, Sanofi, Other activities, please specify:, Medtronic Minimed. Nothing to Disclose: EKK

22457 3.0000 LBF-099 A Why Technology Use Fades in a Real World Setting 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Wendela de Ranitz-Greven*1, Joline Beulens1, Douwe Biesma1, Bianca Silvius1, Marloes Bons1 and Harold Wessel De Valk2
1University Medical Center Utrecht, Netherlands, 2University Medical Center Utrecht, Utrecht, Netherlands

 

Background: Patients with diabetes have a reduced quality of life, especially those with high Hba1c. This study hypothesizes that high glycemic variability also negatively influences quality of life.

Methods:

In this cross-sectional observational study glycemic variability was measured in 124 patients with type 2 diabetes by standard deviation of glucose data from 48 hours continuous glucose monitoring. Quality of life was assessed with different questionnaires: Problem Areas in Diabetes Scale (PAID), 12-item short form general health survey (SF-12) and EuroQaulity of life -5 dimensions visual analogue scale (EQ5D VAS). Association of glycemic variability and quality of life was analysed in the entire study population, and in pre-defined subgroups (insulin treatment (n=68); other treatment (n=56)).

Results:

A higher glycemic variability tended to be associated (p=0.07) with a worse PAID score in the entire study population (β 0.20(95%CI -0-01-0.42)), but this attenuated when adjusted for confounders. Higher glycemic variability was associated with worse PAID scores in insulin-treated patients (0.33(0.01-0.65)), especially  in the domains of the PAID questionnaire “treatment-related problems” (0.29(0.09-0.50)) and “diabetes-related emotional problems” (0.32(0.03-0.61)). The associations for these specific domains attenuated (0.24 (0.04-0.44); 0.24(-0.06-0.54)) after correction for confounders and after correction for HbA1c (0.15(-0.07-0.38); 0.17(-0.17-0.52)). Glycemic variability was not consistently associated with parameters from other questionnaires.

Conclusions:

High glycemic variability was associated with reduced quality of life, albeit not independent of HbA1c. Since this association was found in insulin-treated type 2 diabetes patients only; glycemic variability could be a potential treatment goal for this particular group.

 

Nothing to Disclose: WD, JB, DB, BS, MB, HWD

22549 4.0000 LBF-100 A Is Higher Glycemic Variability in Type 2 Diabetes Patients Associated with Reduced Quality of Life? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Gloria Ortiz*1, Sanjay Navin Mediwala2 and Marco Marcelli2
1Baylor College of Medicine, Houston, TX, 2Baylor College of Medicine VAMC, Houston, TX

 

Our objective is to show the changes in HBA1c when a large patient population is switched from insulin glargine to insulin detemir. Observe additional DM end points: frequency of PCP or ER visits, inpatient hospitalization and mortality in these patients.

This is a retrospective cohort study. We will obtain data from all patients switched from glargine to determir between February and October 2014. Data will be collected at two time points: 1) between 0 and 180 days prior to the time of the switch 2) between day +120 to + 180 after the switch. The first time point is representative of DM control before the switch, the second time point is representative of the DM control after it has stabilized following the change in insulin. We will collect: Hb1Ac, FBG, frequency and dose of basal and bolus insulin per patient, insulin related cost of care. We will also determine DM-related events occurring during the six months prior to and subsequent to the switch date. Demographic and baseline characteristics will be summarized descriptively. The effect of changing insulin will be studied by comparing HbA1c obtained at time point 1 to time point 2 using the Wilcoxon signed ranks tests. Other characteristics will be compared with the paired t-test, the Wilcoxon signed ranks test and Fisher’s Exact test as deemed necessary. All statistical tests will be performed as 2‑tailed tests, and all effects will be considered to be statistically significant if p < 0.05. Our study will reveal differences in primary and secondary endpoints in patients switched from glargine to detemir. We expect to see similar DM control, but with significant decrease in cost. We anticipate no difference in DM related end points.

Prior studies have shown that the efficacy of both glargine and determir is similar, however the perception by healthcare providers remains divided with a group favoring one over the other. With this study, we aim to show what happens to HbA1c when a large cohort of patients is changed from glargine to determir, and the costs associated with each. By completing this study, we are able to observe the response of HbA1c in patients on either insulin glargine or insulin detemir and see the associated expenses coupled with the patient's clinical response.

 

Nothing to Disclose: GO, SNM, MM

22490 5.0000 LBF-101 A Medical and Financial Consequences of Changing a Large Cohort of Patients from Insulin Glargine to Insulin Detemir 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Ioannis Ilias*1, Sofia Apollonatou2, Nikitas Nikitas3, Maria Theodorakopoulou3, Frantzeska Frantzeskaki2, Dimitra Vasiliadi2 and Ioanna Dimopoulou3
1E Venizelou Hosp, Athens, Greece, 2Univ of Athens Medical School, Attikon Hosp, Athens, Greece, 3University of Athens Medical School, Athens, Greece

 

In the metabolic pathway of glycolysis, glucose is converted into pyruvate. Sepsis leads to numerous metabolic alterations, including changes in carbohydrate metabolism. In sepsis, entry of glucose carbon into the tricarboxylic acid cycle may be limiting for glucose oxidation, possibly from inhibition of the pyruvate dehydrogenase complex. To assess early onset differences in glucose metabolism in septic patients vis-à-vis shock resolution we studied 10 patients with septic shock during the first day of ICU hospitalization, measuring every 2 hours blood glucose and tissue pyruvate with microdialysis (MD). We excluded patients with diabetes. In six patients shock resolution was noted. Analysis was done with a cross-correlation matrix for 2-hours’ increments with blood glucose and MD pyruvate data expressed on a heat map, separately for patients with shock resolution and no shock resolution. Differences were noted in patients with shock resolution vs no shock resolution: in the former significant correlations were noted between blood glucose and MD pyruvate (the highest being r:+0.96, p:0.004 with pyruvate lagging by 12 hours), whereas no significant correlations between blood glucose and tissue pyruvate were noted in the latter group. Septic shock patients who eventually resolved their shock status showed active glycolysis during the first day of ICU hospitalization, while patients who remained in shock had early on no appreciable glycolysis.

 

Nothing to Disclose: II, SA, NN, MT, FF, DV, ID

22512 6.0000 LBF-102 A Differences of Glycolysis in Septic Patients According to Shock Resolution Status 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Brindha Gopala Krishnan*, Kay Khine Win, Anya Tahani Weerasinghe, Olubunmi Anibaba and Rhonda Kay Trousdale
Harlem Hospital, New York, NY

 

Background:  The rate of diabetes (DM) in the US is estimated at 8% of the general population and 13% for minorities1.  The estimated rate of pre-diabetes (PDM) is even higher at 39% for minorities.  The Diabetes Prevention Study (DPP) showed early intervention at PDM stage can slow or prevent progression to DM2.  At Harlem Hospital Center (HHC) 87% of patients are non-Hispanic black or Hispanic white, 2 high risk populations for DM.  In the outpatient Medicine Clinic at HHC the prevalence of DM is very high at over 50%.  However, the rate of PDM was lower than the national average at 26.9%. We hypothesized the reason for the low rate of PDMs is delayed screening for DM in this high risk population.   

Purpose: To monitor the rate of conversion from NDM to PDM and PDM to DM amongst patients in the HHC Medicine Clinic over the course of 24 months

Methods:  Retrospective chart review.  Patients in Medicine clinic in July 2012 were reviewed for recent diabetes screening with A1C.  NDM was defined as A1C<5.7.  PDM was defined as a single A1C ≥5.7.  DM was defined as 2 A1C measurements ≥ 6.5.  Patients with at least one follow-up A1C between July 2012 and July 2014 were followed.  The timing of the follow up A1C was grouped into 1-12 and 13-24 months.  Due to the time limitations of the study, progression to PDM was reported if A1C ≥5.7 and progression to DM was defined at least one reading A1C ≥6.5. 

Results:  1993 patients were seen in the outpatient Medicine Clinic at HHC in July 2012.  1323 patients, 66.3%, were either PDM or met criteria for diabetes screening.  616 of these patients, 46.5%, had a recent A1C:  92 new onset DM, 310 PDM and 214 NDM.  We screened the NDM and PDM patients for at least one follow up A1C within the next 24 months and identified 259 people: 135 NDM and 224 PDM. 

Of the 135 NDM pts 53(40%) converted to PDM within 24 months. The ADA recommends NDM patients undergo repeat testing within 3 years.  In the HHC medicine clinic, 35 of the 53 NDM pts (66%) converted to PDM within the first 12 months.

In the PDM group, 45 out of 224 pts (20%) converted to DM over 2 years.  The DPP reported approximately 11% of PDM convert to DM every year in the placebo group.

Conclusion:  The DPP reported a reduction of progression to DM with aggressive intervention in the PDM patients.  At Harlem Hospital, the percentage of PDM patients was lower than expected.  In this study, patients with PDM progressed to DM at a rate similar to the DPP placebo group.  The problem we identified is two-fold.  First, we have a high risk population and only 46.5% of patients eligible for screening are being screened.  Second, the patients who were screened and had a normal A1C converted to PDM at a rate of 66% within 12 months.  We conclude, in this high risk population patients who have never been screened and patients with normal A1C in the past should be screened at least once a year for progression to PDM.  Identifying patients at the PDM stage can prompt interventions effective in delaying or preventing progression to DM.

 

Nothing to Disclose: BG, KKW, ATW, OA, RKT

22589 7.0000 LBF-103 A Aggressive Screening Is Necessary for Early Identification of Conversion from Non-Diabetic to Pre-Diabetic in Medical Clinic of a Predominatly Minority Patient Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Michelle T Duong1, Caroline K Thoreson1, Stephanie T Chung1, Paola C Aldana1, Madia Ricks1, Lilian Mabundo1, David Barry Sacks2 and Anne E Sumner*1
1NIDDK, NIH, Bethesda, MD, 2NIH, Bethesda, MD

 

Introduction:

The value of A1C as a diagnostic test for abnormal glucose tolerance is that A1C can be drawn without consideration of the time of day or fasting status. However, the interpretation of A1C may be compromised by iron deficiency, anemia and certain hemoglobinpathies common in Africa. Alternatives include glycated proteins such as fructosamine and glycated albumin (GA).  Fructosamine is a measure of circulating glycated protein. GA is a subfraction of fructosamine. Our goal was to determine if fructosamine and GA were as effective as A1C in detecting abnormal glucose tolerance.

 

Methods:

For diagnostic purposes, OGTT were performed in 189 African immigrants from the Africans in America study (68% male, age 39±10y (mean±SD), BMI 27.8±4.6 kg/m2). Abnormal glucose tolerance was defined as the presence of either pre-diabetes or diabetes using fasting glucose ≥ 100 dL and/or a 2h glucose ≥ 140 mg/dL.  The area under the receiver operator characteristic (AUC-ROC) curves were calculated to determine the ability of A1C, fructosamine and GA to predict abnormal glucose tolerance. Then, using A1C as the standard, chi-square comparison of the area under the receiver operator characteristic (AUC-ROC) curves for fructosamine and GA was performed.

 

Results:

Abnormal glucose tolerance was identified in 33% (63/189); pre-diabetes occurred in 27% (51/189) and diabetes in 6% (12/189). For the prediction of abnormal glucose tolerance, AUC-ROC curves were not significantly different for A1C, GA, and fructosamine: A1C, 0.66±0.05 (ROC area±SE); GA, 0.57±0.04; fructosamine, 0.54±0.05 (P=0.202). When GA and fructosamine were directly compared to A1C, there was no significant difference between A1C and GA (P=0.195) or A1C and fructosamine (P=0.075).

 

Conclusion:

The AUC-ROC curve analysis suggests that GA and fructosamine are as effective as A1C in detecting abnormal glucose tolerance.

 

Nothing to Disclose: MTD, CKT, STC, PCA, MR, LM, DBS, AES

22613 8.0000 LBF-104 A Assessing the Efficacy of A1C, Fructosamine and Glycated Albumin in Detecting Abnormal Glucose Tolerance: The Africans in America Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Kristina Djekic*1, Yang Lu2, Pauline Genter2, Yii-Der Ida Chen2, Jerome Rotter2 and Eli Ipp2
1Western University of Health Sciences, 2Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA

 

Patients with autoimmune diabetes with onset later in life may be misinterpreted as having type 2 diabetes especially in busy primary care practices. Routine serological screening, a test with high specificity to identify type 1 diabetes is expensive and not performed routinely in primary care. Thus, patients with type 1 diabetes/Latent Autoimmune Diabetes of Adults (LADA) may go unrecognized in primary care practices. We tested whether demographic and laboratory data could be used to optimize the screening for autoimmune diabetes in large populations with diabetes. We studied a predominantly minority diabetic population with GAD-positive type 1 diabetes (DM1; n=94) or with type 2 diabetes on oral antidiabetic agents (DM2: n=415).  We evaluated the following routine clinical measures in all patients: BMI, serum HDL cholesterol (HDL), and triglyceride (TG), adjusted for age of diabetes onset and gender, to develop a prediction model for autoimmune diabetes, in this case GAD positivity. Percentage female was similar in both groups, 60% and 63%. Median [IQR] age of onset and BMI was predictably lower in DM1, 28 [18-39]yrs vs 45 [38-51] yrs; and 25.6 [22.7-28.9] Kg/m2 vs 30.6 [27.0-34.6] Kg/m2 (both p<0.0001). Median HDL and TG were also different, 53 [42-64] mg/dl vs 40 [33-48] mg/dl; and 78 [53-116] mg/dl vs 144 [102-205] mg/dl (both p<0.0001). Area under the curve for ROC using BMI, HDL and TG adjusted for age of onset and gender was 0.92. Sensitivity and specificity were 88.1% and 84.3%, respectively. Latino patients comprised the majority of those studied. When ROC curves were estimated for Latinos only, the results were similar. AUC for ROC was 0.93, sensitivity 81.8% and specificity 92.5%. This predictive model allows estimation of personalized threshold values for HDL, BMI, and TG, by taking into account a person’s demographic background and laboratory data. For example, for a typical Latino male in this population with age of onset of 41 yrs, a BMI of 30 Kg/m2and triglycerides levels of 168 mg/dl (all sample mean values for the DM2 group), the cutoff value of HDL that would predict GAD positivity would be >59.4 mg/dl.  A HDL result greater than this value would justify GAD antibody screening, despite what appears to be typical DM2. In conclusion, these data suggest that using a combination of simple and routinely obtained demographic and laboratory data it is possible to predict GAD positive autoimmune diabetes with a high sensitivity and specificity.  This may be applicable for cost efficient serological screening in large populations of diabetic patients in primary care settings.

 

Nothing to Disclose: KD, YL, PG, YDIC, JR, EI

22615 9.0000 LBF-106 A Predicting Autoimmune Diabetes in Minority Diabetic Populations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Sihua Gao*1, Dandan Zhao2, Xiaoke Li3, Xin Fang4, Qianqian Mu5, Fangfang Mo2 and Dongwei Zhang2
1Beijing university of Chinese medicine, Bejing, China, 2Beijing university of Chinese medicine, Beijing, China, 3Beijing university of Chinese medicine, Beijing, 4Beijing university of Chinese medicine, Montreal, QC, 5beijing university of Chinese medicine, Beijing

 

Given the substantial morbidity and mortality associated with type 2 diabetes (T2DM) and the fact that increasingly more young people are suffering from T2DM and the associated disorders, there is much more pressure on clinical physicians and basic researchers seeking ways to prevent and treat T2DM, in which traditional Chinese medicine (TCM) plays a crucial role. Professor Sihua Gao’s diabetes research group have engaged in exploring pathogenesis, pattern differentiation, treating principles and methods of using TCM to treat T2DM, and lots of clinical experiences have been accumulated. Thus, we proposed a novel treating method for T2DM, which is characterized by regulating the function of liver, spleen and kidney, together with paying attention to treat the accompanying syndromes, which rationality and safety were confirmed by the clinical trials, and the mechanism has been explained and verified in the recorded documents. Here, the basic theory, the scientific basis, the characteristics and the advantages of this method are fully discussed and analyzed. This novel idea of treating T2DM not only accords with two main features of Chinese medicine theory, holistic concept and syndrome differentiation, but also bases on understanding of diabetes from modern medicine perspective. 

Diabetes is a complex disease of systemic metabolic disorders, of which pathogenesis involves three dominant organs (liver, spleen and kidney), even though in the late stage when complications occur, many other organs maybe dysfunction as well. It is found in most cases that T2DM is characterized by whichever organ (liver, spleen or kidney) is injured initially, the other two are inevitably affected, leading to deficiency of protective qi and generation of phlegm, blood stasis, and excessive heat, then T2DM occurs gradually in consequence. Based on overall cognition, we constructed a new zang-fu organs differentiation model, in which affected organs of diabetes are firstly characterized; then nature of the disease such as qi, blood, yin and yang, cold, heat, deficiency, excess, phlegm, dampness, blood stasis or toxin is diagnosed; finally, treating principles and drugs are selected after carefully analyzing the basic causes and symptoms, progress of the disease, priority of the affected organs and the accompanied syndrome of T2DM. In regards with the prescription, the components are used according to which direction they will go inside the body, their four flavors and five tastes, the belonging meridians and their action in TCM, as well as results of pharmacology studies in modern medicine of the selecting drugs. Therefore, the theory of treating T2DM by regulating the function of these three dominants, together with treating the accompanying syndrome will broaden the treatment methods for T2DM to some extent.

 

Nothing to Disclose: SG, DZ, XL, XF, QM, FM, DZ

22662 10.0000 LBF-107 A A Novel Treatment of Type 2 Diabetes By Regulating Liver, Spleen and Kidney Together 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Catherine Pihoker*1, Dana M Dabelea2, Daniel P Beavers3, Jean M Lawrence4, Thomas Meissner5, Thomas Michael Kapellen6, Thomas Reinehr7, Edith Schober8, Susanna Wiegand9, Maria Fritsch10 and Reinhard W. Holl11
1Department of Pediatrics, University of Washington, Seattle, WA, 2University of Colorado, Denver, CO, 3Wake Forest University School of Medicine, 4Kaiser Permanente Southern California, Pasadena, CA, 5University Children's Hospital, Heinrich Heine University Düsseldorf, German Center for Diabetes Research (DZD), Düsseldorf, Germany, 6University of Leipzig, Leipzig, Germany, 7University of Witten-Herdecke, Datteln, Germany, 8University of Vienna, Vienna, Austria, 9Charite University Medicine, Berlin, Germany, 10Medical University of Vienna, Vienna, Austria, 11University of Ulm, German Center for Diabetes Research (DZD), Ulm, Germany

 

Objectives: To assess changes in glycemic control over time in two population-based cohorts of youth with T2DM, SEARCH (USA) and DPV (Germany and Austria). 

Methods: This analysis included 323 youth from SEARCH and 239 from the DPV who were diagnosed with T2DM at < 20 years of age between 2002 and 2008, were negative for both glutamic acid decarboxylase and insulinoma-associated protein-2 autoantibodies, and had ≥ 3 study visits over a mean period of 1.6 years.  Measures collected at each visit included T2DM treatment regimens, BMI, fasting C-peptide (FCP) and A1c. SEARCH participants self-reported race/ethnicity while DPV participants reported country of birth, designated as native born if both participant and parents were born in Germany or Austria. Mean A1c levels, adjusted for age at diagnosis, T2DM duration, FCP, and BMI were compared across the 2 populations overall, as well as by race/ethnicity (non-Hispanic white (NHW) vs "Other") or country of origin (native vs non-native) and sex.  P-values were derived from mixed model analyses.     

Results:  SEARCH and DPV participants were similar at baseline in terms of age at diagnosis (14.3 vs 14.4 years), sex (63.1% vs 63.6% female) and mean A1C 7.22 vs 7.40%.  However, race/ethnicity and nativity differed: 22% of the SEARCH youth were NHW and 76% from other racial/ethnic groups, while in DPV, 79% were native and 22% were not.  In addition, SEARCH youth were heavier than DPV youth (WHO BMI Z-score 2.92 ± 0.99 vs 2.46 ± 0.94, p<0.0001).  Over the follow up period, mean A1C tended to rise in the SEARCH participants (5.1% relative increase, p=0.22), but was stable in the DPV cohort (1.2% relative decrease, P=0.38), though differences in these trends across the 2 studies were not significant after adjusting for age, duration, FCP and BMI (p=0.12). Among SEARCH participants, a higher A1c at last visit was associated with minority race/ethnicity (7.74% in NHW vs 8.40% in "other", p< 0.001) and sex (males 8.52% vs females 7.67%, p=0.041). There were no significant differences in A1c by nativity status or sex for DPV youth. At last visit, mean A1C was similar in SEARCH and DPV youth managed with lifestyle and oral agents, but SEARCH participants on insulin-containing regimens had higher A1C than DPV youth [9.88% vs 7.97% (p<0.0001)]. 

Conclusions:  While SEARCH and DPV cohorts of youth with T2DM were similar at baseline in many respects, and A1C and BMI overall were stable during the follow up period, SEARCH youth who were male, minority race/ethnicity, and on insulin-containing regimens had significantly poorer glycemic control over time.    Possible explanations include psychosocial or genetic factors, adherence, or health care delivery. Further exploration may reveal management strategies that are effective globally.

 

Nothing to Disclose: CP, DMD, DPB, JML, TM, TMK, TR, ES, SW, MF, RWH

22733 12.0000 LBF-109 A Change in Glycemic Control in Youth with Type 2 Diabetes (T2DM):  Search for Diabetes in Youth and Prospective Diabetes Follow-up Registry (DPV) Cohorts 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Anthony L. McCall*1, E. Andy Ortiz2, Jennifer Mason Lobo2, Leon S Farhy1, Jennifer L. Kirby2, James M. Isbell2 and Stephen D. Patek2
1University of Virginia Health System, Charlottesville, VA, 2University of Virginia, Charlottesville, VA

 

Background: Stress hyperglycemia is common in critically ill ICU patients and can contribute to infection risk, retard wound healing, and increase short-term morbidity and mortality. While early studies of tight glycemic control demonstrated reductions in mortality and morbidity in the ICU, later studies found mixed results and resulted in a view that the risk of hypoglycemia may overshadow the benefits of tight glycemic control. None of these studies, however, clarifies whether the harm is due to the tight glycemic targets themselves or to the inability of protocols used to achieve and maintain these targets. We have developed a procedure for characterization of the variability in patients’ parameters in a simulation model of glucose metabolism that allows the creation of a computer-based blood glucose (BG) ICU simulator. The simulator is centered around a virtual subject population (in silico “clones"), which replicates the responses of the real population to insulin therapies. The simulator can be used for in silico design and optimization of glycemic control algorithms. Here, we report our initial efforts to develop in silico “clones” representative for the University of Virginia Thoracic and Cardiovascular Post-Operative (TCVPO) unit. Methods: Based on BG, insulin delivery, and nutrition data from electronic medical records, patients recovering from valve replacement and/or coronary artery bypass surgery in the TCVPO unit are cloned by (i) identification of a closest match among a set of normal and type 2 diabetic in silico subjects in an established metabolic simulator and (ii) computing an additional time-evolving “stress action” curve that reflects the increased hepatic glucose production and impaired peripheral glucose uptake characteristic of stress hyperglycemia. The deviation between the original BG data and the in silico replay of the carried out real insulin treatment was evaluated to confirm the ability of the clones to replicate the responses of the real population to insulin treatment. Results: An initial set of 72 TCVPO patient clones has been developed. The mean average relative deviation (MARD) between the original BG data and the in silico replay of the corresponding real insulin treatment for 3,761 hours within the cloned population is 1.03% (sd 0.98), suggesting that the sources of stress hyperglycemia and BG variability in this cloned population are closely captured within the associated stress action curves. Discussion: Since the in silico clones can be replayed with alternative insulin infusions, they provide a convenient means of using simulation to evaluate the safety and efficacy of alternative insulin protocols prior to deployment within a specific patient population. This capability is central to an envisioned simulation-based methodology for insulin protocol optimization and simulated case-based training.

 

Nothing to Disclose: ALM, EAO, JML, LSF, JLK, JMI, SDP

22830 13.0000 LBF-110 A In silico Clones of Cardiovascular Surgical Patients: A First Step Toward Simulation-Based Insulin Protocol Optimization for This Patient Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Harold Wessel De Valk*
University Medical Center Utrecht, Utrecht, Netherlands

 

Background
Real time continuous glucose monitoring (rtCGM) was introduced as innovation in glucose monitoring leading to improvement in glycemic control in type 1 diabetes. Randomized clinical trials in type 1 diabetes showed that there was a statistical significant decrease in HbA1c in patients with type 1 diabetes compared to conventional monitoring without an excess of hypoglycemia.
 In the Netherlands, rtCGM was endorsed for use in type 1 diabetes in adults on insulin pump and HbA1c ≥ 64 mmol/mol ), during pregnancy and in children with the objective to limit the use of and expenditure on those patients proven to benefit or most likely to benefit from rtCGM. Following the same reasoning, both patients and clinical centers have to meet certain requirements to qualify for rtCGM. Patients must be on insulin pump, practice adequate self-management and self-measurement of blood glucose levels and there may not be other reasons for the inadequacy of glycemic control. Hospitals needs to have sufficient experience with insulin pumps and CGM and must have electronic patient records and agree provide data on the treatment results.
To evaluate  the real-life use of rtCGM, a  multicenter registry was set up using a new nationwide hospital-based diabetes research consortium (TRACING (regisTRAtion of ContINuous Glucose monitoring).
Methods
Patients were recruited in various hospital around the country; centers participated voluntarily. Patient data were transferred electronically to the coordinating center and entered with a unique personal code in the registration database.
Results
Sixty of the potential of 90 hospitals participate in this ongoing study and 784 adult patients are recruited: 86 (11.0%) ex-users, 473 (60.3%) current users, 225 (28.7%) new users. We report here on the latter group.  RtCGM was given for inadequate control  in 52.1%, pregnancy in 18.2% and other indications (not formally endorsed)  in 29.8%, mostly in patients with severe hypoglycemia and/or hypoglycemia unawareness, high glucose variability, pregnancy wish or glycemic control interfering with professional life.  Baseline: mean age 39 years (range 18-69), 72.4% males, type 1 diabetes 94,4%, insulin pump 90,7%, Hba1c 61.1 mmol/mmol (range 36-116). In patients treated for poor glycemic control, HbA1c fell in 6 months from 71.3 to 62.8 mmol/mmol (p<0.001) without increase in hypoglycemia.
Conclusion
This first observational study of this publicly funded nationwide research consortium in diabetes research has shown that real time continuous glucose monitoring in inadequately controlled type 1 diabetes in real-life setting has an efficacy in inadequately controlled type 1 diabetes comparable to landmark studies and that rtCGM is used for a wide scope of indications,  indicating targets for research . This study also indicates the potential value of such real life implementation assessments. The study is ongoing.

 

Nothing to Disclose: HWD

22832 14.0000 LBF-111 A First Nationwide REAL-Life Results on the Efficacy of REAL-Time Continuous Glucose Monitoring in the Netherlands: The Tracing Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Conor Best*1, Heidi Struthers2, Erin Laciny2, Paige Kuhlman3, Mark A Ziegler2, Michael Royal2, Dominic Nicholas Reeds1 and Kevin Edward Yarasheski1
1Washington University in St. Louis, Saint Louis, MO, 2Washington University in St. Louis, 3University of Missouri Medical School, MO

 

People living with chronic human immunodeficiency virus (HIV) infection are known to have up to a 2 fold increased risk of vascular disease, myocardial infarction, or stroke as well as a 2-4 fold increased incidence of elevated fasting glucose or hyperinsulinemia.  The precise underlying mechanisms driving this risk remain unclear, but may be related to chronic low-grade systemic inflammation as evidenced by higher levels of circulating inflammatory markers. Dipeptidyl peptidase-4 inhibitors (DPP-4i) such as sitagliptin indirectly enhance insulin secretion through inhibiting breakdown of incretins, however, DPP-4 is also expressed as CD26 on leukocyte membranes and is thought to play a role in inflammatory signaling. The effects of DPP-4 inhibitors on the HIV associated pro-inflammatory state are unclear.

We designed a prospective, randomized, placebo-controlled, double-blind trial of sitagliptin given to HIV+ men and women with glucose intolerance to evaluate its effects on both glucose tolerance and markers of inflammation. 36 HIV+ people with stable immune and virologic status on HAART and impaired glucose tolerance were enrolled and randomized to an 8 week treatment course with either sitagliptin 100mg daily or placebo. Serum was drawn at baseline and week 8 for markers of inflammation and oral glucose tolerance tests and abdominal fat biopsies were performed before and after treatment. Extracted fat RNA was purified and qRT-PCR for M1 macrophage gene transcripts was performed on pre and post-treatment samples.

During oral glucose tolerance test, the treated group showed significant decline in glucose AUC (p=0.002) and improvement in oral glucose insulin sensitivity index (p = 0.04). Plasma hsCRP and CXCL10 levels declined in the treatment group (p < 0.009). Adipose CCL2 mRNA abundance declined in the treated group (p=0.01) with a non-significant trend towards lower abundance of EMR1 RNA.

Treatment with sitagliptin in HIV+ patients with glucose intolerance improved both response to oral glucose tolerance testing and several serum markers of inflammation. Changes in adipose tissue mRNA suggest that there may be a shift in the inflammatory state of adipose-resident macrophages. This suggests that sitagliptin may have beneficial anti-inflammatory effects in individuals with HIV.


 

Nothing to Disclose: CB, HS, EL, PK, MAZ, MR, DNR, KEY

22967 15.0000 LBF-112 A Sitagliptin Reduces Markers of Inflammation and Chronic Immune Cell Activation in HIV+ Adults with Glucose Intolerance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Veronica VilasBoas Freitas* and Maria de Lourdes Lima
Escola Bahiana de Medicina e Saude Publica, Salvador, Brazil

 

Introductions: Diabetes Mellitus type 1 is a group of metabolic disorders characterized by hyperglycemic and associated a complications, dysfunction and insufficiency of many organs. The Diabetes Mellitus is the results of pancreatic beta cell destruction by the immune system causing a chronic hyperglycemic, characteristic of the disease. The adequate control glycemic reduces these complications and the treatment intensification is a procedure that occasions a better clinic control of the disease, in addition to improve survival of patients. The Knowledge of metabolic profile of patients with DM type 1 in our country is the beginning for better control glycemic and prevents future complications. Objective: To describe the metabolic profile of patients with DM type 1 from an outpatients clinic of Sistema Único de Saúde (SUS) and test the association between demographic, clinical and laboratory and the nice and bad control of Diabetes. Methodology: It is a describe study of morbidity in patients with DM type 1 diabetes treatment in ambulatory of SUS at the General Hospital Roberto Santos in Salvador ,Bahia , Brasil. Data collection was performed by a questionnaire applied by the researchers during the medical treatment and all the patients signed and informed the consent form (ICF). Been evaluated demographic, anthropometric, socioeconomic, comorbidities, complications of type 1 diabetes, drug treatment and adequacy glycemic control or not. Results: Of 21 patients, 57, 1 % were female and 42, 9% were male with a mean age of 9,6+ 50 years. In relation to comorbidities dyslipidemia was observed in 14, 3%, hypertension in 9,5%, overweight in 10%. Ophthalmology complications was observed in 23, 8%, peripheral neuropathy in 19% and renal complications in 14,3%. Finally, satisfactory glycemic control glycated hemoglobin was observed in 5,6% , fasting plasma glucose in 15,8% and postprandial glycemic in 35,3%. Conclusion: This study shows that only a minority of patients achieved satisfactory glycemic control. Therefore it´s necessary investments in the care of diabetic patients by multidisciplinary team .

 

Nothing to Disclose: VVF, MDLL

22985 16.0000 LBF-113 A The Metabolic Profile of Patients with DM Type 1 from an Outpatients Clinic of Sistema Único De Saúde (SUS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Friday, March 6th 3:00:00 PM LBF 097-116 6303 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism II Poster


Scott M Belcher*1, Eric L. Kendig1 and Robin Gear2
1University of Cincinnati, Cincinnati, OH, 2Universiity of Cincinnati, Cincinnati, OH

 

This study has determined the consequences of life-long dietary exposure to BPA on cardiovascular functions, and defines the sex-specific modes of BPA action in the heart of male and female CD-1 mice. Using an established exposure paradigm that mimics human routes of exposure (1). Dams and analyzed progeny were maintained on defined diet containing BPA (0.03, 0.3, 3, 30, or 300 ppm) that resulted in BPA exposures from 4-5 to 5000 mg/kg/day, or diet containing 17α-ethinyl estradiol (EE; ~0.02, 0.2 and 0.15 mg/kg/day) as an estrogen-effect control. Assessment of electrocardiogram parameters using noninvasive methods found that ventricular functions in both male and female mice were not altered by either BPA or EE. However exposure-related changes in rates of ventricular contraction, suggestive of a shift in sympathovagal balance of heart rate control toward increased parasympathetic activity, were detected in males. Decreased systolic blood pressure was observed in males exposed to BPA above 5 mg/kg/day in males, and in females from the highest BPA exposure group. Quantitative histopathological analysis revealed sexually dimorphic changes in the cardiac collagen extracellular matrix in each sex, and increases in fibrosis and evidence of modest exposure-related remodeling in males. Experiments using the a-selective adrenergic agonist phenylephrine found that BPA enhanced reflex bradycardia in females, but not males, revealed that BPA and EE exposure sex-specifically altered sympathetic regulation of the baroreflex circuits. Increased sensitivity to the cardiotoxic effects of the β-adrenergic agonist isoproterenol was observed in BPA‑ and EE-exposed females.  This effect was not observed in males, where BPA or EE exposures were protective of isoproterenol-induced ischemic damage and hypertrophy. Results of RNAseq analysis identified significant sex-specific changes in gene expression in response to BPA that were consistent with the observed exposure-related phenotypic changes in the collagenous and non-collagenous extracellular matrix, cardiac remodeling, altered autonomic responses, changes in ion channel and transporter functions, and altered glycolytic and lipid metabolism.

 

Nothing to Disclose: SMB, ELK, RG

22848 1.0000 LBF-051 A Effects of Life-Long BPA Exposure on the Heart of Male and Female CD-1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Friday, March 6th 3:00:00 PM LBF 051-055 6306 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals Poster


Shuk-Mei Ho1, Ana Cheong*1, Hung-ming Lam1, Wen Yang Hu2, Guang Bin Shi2, Xuegong Zhu3, Jing Chen1, Xiang Zhang4, Mario Medvedovic1, Yuet-Kin Leung1 and Gail S. Prins2
1University of Cincinnati College of Medicine, Cincinnati, OH, 2University of Illinois at Chicago, Chicago, IL, 3University of Cincinnati College of Medicine, Cincinnati,, OH, 4University of Cincinnati, Cincinnati, OH

 

Bisphenol-A (BPA) is a ubiquitous endocrine disruptor known to induce malignant transformation of the normal human prostate epithelial cells to cause prostate cancer (PCa). We recently reported that neonatal exposure of rats to BPA reprograms the prostate methylome and increases their susceptibility to estrogen-driven prostate neoplasia with aging. Since the adult prostate is resided with a population of stem and progenitor cells that possess self-renewal capacity and differentiation plasticity, we enriched these cells from primary prostate epithelial cells to form three-dimensional prostaspheres and derived an in vivo humanized model which showed that low-dose BPA increased the propensity of these prostate grafts to develop PCa. Yet, the mechanism of the cancer-priming action of BPA is still unclear. We hypothesize that BPA reprograms the human prostate epithelium through epigenetic changes and in turn increases hormone-dependent PCa risk. To test this hypothesis, we performed genome-wide transcriptome and methylome analyses on the prostaspheres treated with BPA (10 nM, 200 nM, and 1000 nM) or estradiol-17β (E2; 0.1 nM) for 7 days and applied qPCR, bisulfite sequencing, and chromatin immunoprecipitation for validating changes in the expression, methylation, and histone marks, respectively. BPA/E2 treatment altered the expression of 91 genes but did not significantly affect the methylation status of 485,000 CpG sites in the treated prostaspheres. There were 26 repressed genes and 15 of them were SNORDs, which are non-coding, small nucleolar RNAs known to regulate ribosomal RNA assembly and function. We selected ten most downregulated SNORDs for further studies and confirmed all ten SNORDs were repressed by BPA and only three were confirmed to be repressed by E2. Furthermore, SNORD suppression was not associated with CpG methylation status in gene regulatory regions. Instead, specific histone modifications (H3K9me3, H3K4me3, and H3K27me3) was associated with the silencing of six BPA-repressed SNORDs. There were yet no correlation between these histone modifications and E2-repressed SNORDs. This study reveals the suppression of noncoding RNA as the novel and unique action of BPA, which is associated with histone modification and serves to initiate the reprogramming of prostasphere epigenome.

 

Nothing to Disclose: SMH, AC, HML, WYH, GBS, XZ, JC, XZ, MM, YKL, GSP

22851 2.0000 LBF-052 A Bisphenol-a Suppresses the Expression of Snords in the Prostaspheres Via Histone Modification 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Friday, March 6th 3:00:00 PM LBF 051-055 6306 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals Poster


Heather B Patisaul*1, Jinyan Cao1, Roger Echelberger1, Min Liu2, Emily Sluzas1, Katherine McCaffrey1 and Brian Buckley2
1North Carolina State University, Raleigh, NC, 2Rutgers University, Piscataway, NJ

 

Human exposure to endocrine disrupting compounds (EDCs) is ubiquitous, and it has recently been hypothesized that some EDCs can act as “obsogens;” promoting persistent weight gain and consequently heightening risk of related metabolic co-morbidities.  Because it has been shown in prior studies to interact with bisphenol a (BPA), we assessed the influence of soy diet and GEN itself (administered as the aglycone genistin GIN) on body weight, ingestive behavior, reproductive maturation (females) and growth parameters in orally BPA-exposed Wistar rats.  Serum levels of BPA, GEN and their primary conjugates were monitored throughout the study.  One group was developmentally exposed to BPA through weaning then switched to a soy diet.  Soy enhanced food intake, weight gain and early puberty (females) in the offspring.  In contrast, GIN (metabolized to GEN) exposed offspring were ultimately lighter as adults, and BPA had no meaningful effect on any outcome.  Soy diet accelerated female puberty, even in the group switched to the diet at weaning.  Soy-fed dams gained less weight during pregnancy but their offspring (both sexes) were significantly heavier; an effect which persisted through weaning and was more pronounced in males.  Lactating dams on the soy diet consumed more than dams on the casein diet but dam body weight did not appreciably differ; suggesting soy-fed dams disproportionally shifted resources to their offspring resulting in higher pup weight.  Collectively, these data are consistent with the “thrifty phenotype” concept which posits that environmental factors can induce fetal reprogramming to make offspring more efficient at scavenging calories and nutrients but also, consequently, put them at higher risk for adult obesity, diabetes, metabolic syndrome, and cardiovascular disease.

 

Nothing to Disclose: HBP, JC, RE, ML, ES, KM, BB

22863 3.0000 LBF-053 A Soy but Not Bisphenol a (BPA) or Genistin Alters Developmental Weight Gain and Food Intake in Pregnant Rats and Their Offspring 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Friday, March 6th 3:00:00 PM LBF 051-055 6306 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals Poster


Joe Kurian* and Somaja Louis
Southern Illinois University School of Medicine, Springfield, IL

 

People suffering from type 2 diabetes mellitus (T2DM) are more likely to carry higher levels of bisphenol A (BPA) than non-diabetics. T2DM is characterized by hyperinsulinemia leading to insulin resistance and glucose intolerance. BPA potentiates glucose stimulated insulin secretion (GSIS) from pancreatic beta cells; this could subsequently trigger or worsen diabetic symptoms. However the mechanisms responsible for BPA control over GSIS remain unclear. Importantly, kisspeptin, a potent gonadotropin releasing hormone (GnRH) secretatogue, also suppresses GSIS. We recently observed that BPA interferes with kisspeptin mediated GnRH release. Because GnRH neurons and beta cells share several functional similarities, we hypothesized that BPA would influence kisspeptin regulation of GSIS and beta cells in general. We evaluated the impact of kisspeptin-10 and BPA in vitro on beta cell 1) GSIS, 2) proliferation, and 3) apoptosis. Using MIN6 cells, we found that kisspeptin significantly reduced GSIS. This effect was dose dependent with the lowest observable effect at 10nM. GSIS was stimulated in the presence of BPA, though this effect was not significant at any dose evaluated (1-100 nM). Remarkably, kisspeptin (10 nM) suppression of GSIS was eliminated by co-incubation with BPA (10 nM). Using RINm5F cells, we found that kisspeptin significantly reduced cell proliferation over a 48-hour period; again, the lowest observable effect dose was 10nM. Both BPA and estradiol (1nM-1 µM) had subtle but non-significant stimulatory impacts on proliferation. However, when co-incubated over 48 hours, BPA (10 nM) eliminated the kisspeptin (10 nM) suppression of cell proliferation. Surprisingly, estradiol did not influence kisspeptin effects on proliferation. To determine whether reduced proliferation could be explained by increased cell death, we performed apoptosis assays with RINm5F cells. Again, after 48 hours of kisspeptin (10 nM) exposure, the proportion of proliferating cells was decreased; however, this was not explained by an elevation of cell death. Rather, after kisspeptin exposure, cells were alive but non-proliferative. Both BPA and estradiol increased the proportion of cells proliferating and dying, while decreasing the number of live, non-proliferative cells. Co-incubation of cells with kisspeptin (10 nM) and BPA (1-10 nM) or estradiol (0.1-10 nM) significantly increased the number of proliferating cells with no potentiating effect on apoptosis. Altogether, our results suggest that BPA interferes with kisspeptin regulation of GSIS and beta cell viability. The impact of BPA on GSIS does not appear to be estrogenic whereas BPA and estradiol have similar influence over kisspeptin regulation of beta cell viability.

 

Nothing to Disclose: JK, SL

22910 4.0000 LBF-054 A Bisphenol a Interferes with Kisspeptin Regulation of Glucose Stimulated Insulin Secretion and Beta Cell Viability 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Friday, March 6th 3:00:00 PM LBF 051-055 6306 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals Poster


Steven Jones*1, Annie Boisvert2, Sade Francois2, Liandong Zhang3 and Martine G Culty4
1McGill University, Montreal, QC, Canada, 2McGill University, 3Xi'an Jiaotong University, 4The Research Institute of the McGill University Health Centre, Montreal, QC, Canada

 

Perinatal exposure to endocrine disruptors (EDs) is believed to predispose males to reproductive abnormalities. Although males are exposed to ED combinations from conception to adulthood, few studies have evaluated the effects of ED mixtures. Our previous work demonstrated that fetal exposure to a mixture of Genistein (GEN) and DEHP at 10mg/kg/day induced short and long term alterations in rat testis gene expression and histology different from single EDs. In these studies, pregnant dams were fed a soy-based rat chow optimal for reproductive functions and paralleling a phytoestrogen-rich human diet.

The present follow up study was conducted using a casein-based diet devoid of phytoestrogens. Casein-fed pregnant dams were gavaged from GD14-parturition with control corn oil, 0.1 or 10 mg/kg GEN, DEHP alone or combined. Male offspring reproductive functions were assessed at different ages.

While casein diet alone did not alter any of the end-points examined compared to regular soy diet, analysis of 10mg/kg/day treated PND6 rats revealed significant alterations in testis histology, somatic and germ cell markers and inflammatory status. Testes from all treatment groups displayed impaired germ cell migration, with higher proportion of gonocytes remaining in the center of seminiferous tubules. In parallel, qPCR analysis of early germ cell markers revealed a significant reduction of Plzf, Oct4 and Gfra1 mRNA. Interestingly, mRNA of steroidogenic mediators P450scc and 3bhsd1 were decreased in treated rats, most significantly in combined GEN + DEHP, indicating the possible targeting of fetal Leydig cells or adult Leydig cell progenitors. REDOX mediators, Nr2f2 and Cat, were significantly upregulated in DEHP and combined GEN + DEHP, suggesting the involvement of DEHP-induced cellular stress. Lastly, CD68+ inflammatory macrophages numbers, as determined by IHC, were significantly increased in DEHP, but not GEN or combined GEN + DEHP, possibly indicating a protective role of GEN.

Adult male offspring revealed high cases of infertility, abnormal tubule histology and extensive germ cell loss, in treatment groups compared to control. Serum estradiol levels measured by radioimmunoassay were reduced in all treatment groups at PND90, remaining depressed at PND120 for GEN0.1 and DEHP10, but resolved in the mixture. Testosterone was decreased in DEHP0.1 PND120 rats, an effect rescued by GEN.

This study unveiled more severe reproductive toxicity of GEN, DEHP and their combination in comparison to soy-based maternal diet. Further research is underway to characterize and elucidate the cellular and molecular events driving the observed phenotypes. Treated animals did not follow classical dose−response effects, at perinatal and adult ages, highlighting the importance of assessing a range of doses during appropriate windows of exposure and under varying baseline dietary conditions.

 

Nothing to Disclose: SJ, AB, SF, LZ, MGC

22916 5.0000 LBF-055 A Maternal Casein-Based Diet Sensitizes Male Offspring to in-Utero Endocrine Disruptor (ED) Induced Reproductive Toxicity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Friday, March 6th 3:00:00 PM LBF 051-055 6306 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals Poster


Manu Verma*1, Tiina Kipari2, Chris Kenyon2, Jonathan Seckl2, Megan Holmes2 and Karen Elizabeth Chapman1
1University of Edinburgh, Edinburgh, United Kingdom, 2University of Edinburgh, UK, Edinburgh, United Kingdom

 

Background: Chronically elevated glucocorticoid (GC) levels in the brain impair cognition in humans and rodents1,2. In rodents, raised GC levels prior to lipopolyaccharide (LPS) administration potentiate neuroinflammation although GC suppresses neuroinflammation if administered after LPS3. Intracellular GC can be increased, without alteration in circulating levels, by the activity of 11β-hydroxysteroid dehydrogenase type1 (11β-HSD1)4. 11β-HSD1 is widely expressed in the brain including the hippocampus and the hypothalamus4  and its deficiency/inhibition is protective against age related cognitive impairment in rodents4 and improves cognitive function in elderly men4. However the underlying mechanism remains unclear. 11β-HSD1 activity depends on NADPH (co-factor) provided by hexose-6-phosphate dehydrogenase activity, itself dependent on cellular energy status4. Processes affected by deficiency/inhibition of 11β-HSD1 (eg. increased acute inflammation, angiogenesis) are associated with altered metabolic state particularly increased glycolysis4. Lactate is able to preserve neuronal metabolism and function during elevated brain activity/stress by acting as emergency/buffer fuel5,6,7.  

Hypothesis:11β-HSD1 deficient mice will show enhanced glycolysis and/or lactate uptake in the hippocampus following inflammation.    

Method: Levels of mRNA encoding inflammatory cytokines, Hsd11b1 and metabolic transporter and enzymes were quantified by qPCR in adult male C57BL6 (control) and Hsd11b1-/-(KO) mice basally or following inflammation (n=5-10/group). Inflammation was induced in an experimental model of arthritis (i.p. injection of arthritogenic K/BxN serum) or sterile peritonitis (i.p. injection of 100µg/kg LPS). Plasma corticosterone and inflammatory cytokines levels were measured by RIA and ELISA respectively. A test of burrowing activity8 was carried out to assess sickness behavior following sterile peritonitis.       

Results: Hippocampal levels of mRNA encoding lactate transporter, Mct1, were increased (1.2 fold, p<0.05) and glucose transporter, Glut1, reduced (0.7 fold, p<0.001) in naïve KO compared to controls. Arthritis (15d) increased hippocampal Tnfa mRNA levels (3.1 fold, p<0.05) and reduced Hsd11b1 mRNA levels (0.48 fold, p<0.001) in controls. In arthritis (7d) hippocampal levels of mRNA encoding Tnfa were indifferent between groups but lactate, glucose transporters and glycolytic enzymes and plasma corticosterone levels were increased (p<0.05) in KO compared to controls. In sterile peritonitis (3h) hippocampal levels of mRNA encoding Tnfa, Il-1b and Il-6 were reduced (0.33-0.47 fold, p<0.05) in KO compared to controls.        

Conclusion: These results suggest that deficiency of 11β-HSD1 leads to increased glycolysis and/or energy substrate (lactate) availability in the hippocampus and altered inflammatory response following inflammation.

 

Disclosure: JS: Other activities, please specify:, I have co-developed & patented in the University a molecule entering clinical phase I that inhibits 11β-HSD1. Its now owned by a public company. If it succeeds (<10% chance, I stand to gain royalties). In the past (>2 years ago) I have consulted for. Nothing to Disclose: MV, TK, CK, MH, KEC

PP30-1 20317 1.0000 SAT-464 A Role of 11ß-HSD1 in Regulating Brain Energy Homeostasis and Hypothalamic–Pituitary–Adrenal Axis Activity Following Inflammation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 11:30:00 AM PP30 5913 11:15:00 AM Neuroendocrinology Poster Preview


Simone Ferreira Lemes*1, Milena Diorio Versutti2, Tanyara da Silva Baliani2, Anelise Parras Souza2, Cristiano Mendes-da-Silva3, Marciane Milanski2, Adriana Souza Torsoni2 and Marcio Alberto Torsoni2
1Institute of Biology, Campinas, Brazil, 2Faculty of Applied Sciences, University of Campinas, Limeira, Brazil, 3Federal University of Sao Paulo, Santos, Brazil

 

Studies show that hypothalamic neural stem cells (htNSCs) play an important role in the energetic homeostasis, since they are essential for hypothalamic neurogenesis. Inflammation triggered by high-fat diet-induced (HFD) obesity seems to impair hypothalamic neurogenesis mainly through of NOTCH1 signaling. In addition, maternal consumption of HFD during the pregnancy cause metabolic disturbs in adult offspring. The aim of this study was to evaluate the effects of the maternal HFD consumption on the NOTCH1 signaling in the hypothalamus of mice offspring. Females mice (Swiss) were maintained in individual cages, with water and diet ad libitum, in a room with controlled temperature (22-24°C) and a light/dark cycle (12h). Females mice were randomly divided into two groups: one was fed with HFD and the other, with standard chow diet (SC), during pregnancy and lactation. After delivery the litter size (SC offspring, SC-O; HFD offspring, HFD-O) was reduced to 8 animals per dams. A group of dams was euthanized at the 12th day of gestation, the hypothalamus was collected to evaluate gene expression and content of TNF-alpha (by qPCR and Western Blot - WB). The offspring was evaluated in different ages (neonates – P0 and 28 days old – P28). Pups were weighed, euthanized and the hypothalamus was collected to evaluate gene expression and content of NOTCH1, MASH1 and HES5 proteins by qPCR and WB. Data are expressed as means ± SD, the groups were compared with the Student’s t-test. Statistical significance for all analysis was set at p<0.05. Hypothalamic Tnf gene expression (HFD=246.91±87.13, n=4 vs. SC=100±6.35%, n=3; p<0.05) and the protein level of TNF-a (HFD=1.51±0.15, n=4 vs. SC=1.00±0.10 arbitrary units, n=3; p<0.05) were higher in the HFD than SC dams mice. Notch1 (HFD-O=78.91±21.75, n=7 vs. SC-O=100±11.09%, n=7; p<0.05), Hes5 (HFD-O=47.27±22.68, n=5 vs. SC-O=100±31.45%, n=5; p<0.05) and Ascl1 (HFD-O=71.44±10.59, n=6 vs. SC-O=100±22.22%, n=7; p<0.05) gene expression was lower in the HFD-O compared to SC-O P0 mice. MASH1 protein content (HFD-O=0.21±0.14, n=3 vs. SC-O=0.99±0.03 arbitrary units, n=3; p<0.001) was lower in the HFD-O than SC-O P0 mice, but NOTCH1 and HES5 protein levels were not different between groups. Hes5 gene expression (HFD-O=226.21±57.61, n=7 vs. SC-O=100±34.63%, n=6; p<0.001) was higher in the HFD-O compared to SC-O P28 mice. However, Ascl1 gene expression (HFD-O=71.44±10.59, n=7 vs. SC-O=100±22.22%, n=6; p<0.05) was lower in the HFD-O than SC-O P28 mice and the gene expression of Notch1 was not different between groups. However, no difference was observed in the protein level of NOTCH1, HES5 and MASH1. This study suggests that maternal HFD consumption influences NOTCH1 signaling, can lead to alterations on the cellular differentiation and maintenance of neural progenitors. These events can be related to metabolic disorders that are associated to obesity development in adulthood.

 

Nothing to Disclose: SFL, MDV, TDSB, APS, CM, MM, AST, MAT

PP30-2 20328 2.0000 SAT-465 A High-Fat Diet Consumption during Pregnancy and Lactation Alters NOTCH1 Signaling Pathway in Mice Offspring 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 11:30:00 AM PP30 5913 11:15:00 AM Neuroendocrinology Poster Preview


Holly K Rau1, Elizabeth A Colasurdo1, Carl Sikkema1, Sean P Meichle1, Madeleine L Werhane2, Kathleen F Pagulayan1, Elaine R Peskind1 and Charles W Wilkinson*1
1VA Puget Sound Health Care System, Seattle, WA, 2University of California, San Diego/San Diego State University, San Diego, CA

 

Concussion (or mild traumatic brain injury (mTBI)) resulting from explosive blasts is the most common injury sustained by U.S. troops in Iraq and Afghanistan conflicts. Blast-related concussions represent an estimated 30% of all diagnosed injuries and are considered to be underreported. Two recent studies have found a prevalence of chronic hypopituitarism after blast-related concussion of over 30% (1,2). We are screening two groups of male U.S. Veterans of deployed to Iraq or Afghanistan for pituitary dysfunction: Veterans who have experienced at least one blast-related concussion (mTBI group), and a non-blast-exposed deployment control (DC) group. Screening consists of measurement of basal morning concentrations of 11 anterior pituitary, posterior pituitary, and target-organ hormones together with administration of the glucagon stimulation test (GST) to evaluate capability for growth hormone and ACTH secretion. Several neuropsychological tests of cognitive function and behavioral self-report questionnaires are administered to (1) assess cognitive and behavioral correlates of specific hormonal deficits after blast concussion, and (2) develop a screening algorithm based on these characteristics to identify those patients most likely to benefit from provocative testing. In a preliminary investigation of 7 mTBI and 5 DC Veterans, we found one member of the mTBI group with basal TSH and thyroxine levels and an abnormally high percentage of body fat consistent with hypothyroidism, and one each with GHD and sAI as indicated by GST. Two members of the DC group – one with a history of non-blast concussion – were found with basal LH and testosterone levels indicative of hypogonadism. Veterans with blast-related concussions with and without posttraumatic hypopituitarism (PTHP) reported similar clinically elevated levels of depressed mood, sleep disturbance, and traumatic symptoms. However, one example of a distinctive difference between the mTBI subgroups was observed with item-level analysis of responses on the PTSD Checklist - Military Version (PCL-M). Veterans with PTHP endorsed decreased severity on the subset related to emotional and physiological reactivity to reminders of trauma, suggesting that certain characteristic features of PTSD may be less prevalent in Veterans with PTHP. This finding may explain why none of the participants with PTHP, but 75% with mTBI and no pituitary dysfunction, met clinical criteria for PTSD on the Clinician–Administered PTSD Scale (CAPS), and may aid in the clinical differentiation of PTSD from posttraumatic hypopituitarism (PTHP). Screening for hypopituitarism after blast concussion, together with evaluation of select cognitive and behavioral parameters, shows promise for appropriately directing diagnostic and therapeutic decisions that may otherwise remain unconsidered and for markedly facilitating recovery and rehabilitation.

 

Nothing to Disclose: HKR, EAC, CS, SPM, MLW, KFP, ERP, CWW

PP30-3 21338 3.0000 SAT-478 A High Prevalence of Chronic Hypopituitarism after Blast Concussion: Cognitive and Behavioral Associations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 11:30:00 AM PP30 5913 11:15:00 AM Neuroendocrinology Poster Preview


Anna M.M. Daubenbüchel1, Anika Hoffmann2, Ursel Gebhardt3, Monika Warmuth-Metz4, Anthe S. Sterkenburg1 and Hermann L. Müller*3
1European Medical School Oldenburg-Groningen (EMS), Oldenburg, Germany, 2Klinikum Oldenburg AöR, Medical Campus University Oldenburg, Oldenburg, Germany, 3Klinikum Oldenburg, Medical Campus University Oldenburg, Oldenburg, Germany, 4University Hospital Würzburg, Würzburg, Germany

 

Background: Pediatric patients with sellar masses (craniopharyngioma, cyst of Rathke´s poch) frequently suffer from impaired quality of life (QoL) due to disease and treatment-related sequelae. The prognostic relevance of hydrocephalus as an initial risk factor for long-term outcome is controversial. We analyzed the impact of hydrocephalus (HY) and hypothalamic involvement (HI) at the time of diagnosis on long-term survival and QoL in children with sellar masses.

Patients and methods: In 177 pediatric patients (163 craniopharyngioma, 14 cysts of Rathke´s pouch) diagnosed before the year 2000 and recruited in HIT Endo, the presence of HY at primary diagnosis could be assessed based on neuroradiological imaging. 20-years overall survival (OS) and progression-free survival (PFS), QoL (functional capacity, FMH ability scale), and body mass index (BMI) SDS were analyzed for this cohort of 177 long-term survivors in regard to initial HY and HI.

Results: 105/177 patients (103/163 craniopharyngioma, 2/14 cysts of Rathke´s pouch) presented with HY at initial diagnosis (median age at diagnosis: 7.2 yrs; range: 1.5-25.2 yrs). HY at diagnosis was associated with papilledema (p=0.000), neurological deficits (p=0.000), higher BMI SDS at diagnosis (p=0.001) and during follow-up (p=0.000), and the later insertion of a VP-shunt (p=0.000). OS, PFS, and long-term functional capacity (FMH ability scale) were not related to HY at initial diagnosis. On the other hand, HI at diagnosis (96/177) had major negative impact on long-term prognosis. Sellar masses with HI were associated with lower OS (0.84±0.04;p=0.021), lower functional capacity (FMH percentile: median 47; range: 5-97, p=0.003), and higher BMI SDS at diagnosis (median +1.08 SD; range: -2.2 to +7.6; p=0.000) and at last follow-up visit (+4.0 SD; -1.9 to +13.6 SD) when compared with sellar masses without HI (OS: 0.94±0.05; FMH percentile: median 50 , range: 6-95; median BMI at diagnosis: -0.28 SD, range: -3.7 to +5.3 SD; median BMI at last follow-up: +0.83 SD, range: -1.6 to +9.2 SD). PFS was similar in relation to HI.      

Conclusions: Initial HY at the time of diagnosis has no impact on survival and QoL in long-term survivors of sellar masses. Overall survival and QoL are significantly impaired in survivors presenting with HI at diagnosis. PFS is not related to HY and HI. Accordingly, gross-total resection as treatment strategy is not recommended in pediatric patients with sellar masses presenting with HI at initial diagnosis in order to prevent further hypothalamic damage and thereby hopefully increase long-term OS and QoL.

 

Nothing to Disclose: AMMD, AH, UG, MW, ASS, HLM

PP30-4 20381 4.0000 SAT-487 A Hydrocephalus and Hypothalamic Involvement at the Time of Initial Diagnosis - Impact on Long-Term Prognosis in 177 Pediatric Patients with Craniopharyngioma and Cysts of Rathkexs Pouch Recruited in HIT Endo 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 11:30:00 AM PP30 5913 11:15:00 AM Neuroendocrinology Poster Preview


Shrikanth S Gadad*1, Minho Chae2, Kristine M Hussey3, Xin Luo1, Rosemary Conry1 and W Lee Kraus1
1UT Southwestern Medical Center, Dallas, TX, 2University of Texas Southwestern Medical Center, Dallas, TX, 3Children's Hospital Boston

 

Poly(ADP-ribose) polymerase-1 (PARP-1), a multifunctional chromatin-regulating protein, has gained recent attention as a target for therapeutic inhibitors in breast cancers.  Accumulating evidence supports a role for PARP-1 in breast cancer through its effects on the transcription of tumor-related genes.  Recent genomic analyses in MCF-7 human breast cancer cells from our lab have shown that PARP-1 localizes to active gene promoters and modulates the modification state of histones (PARP-1 promotes H3K4 trimethylation, an activating mark, and inhibits H3K27 trimethylation, a repressive mark), altering the expression of various tumor-related genes.  In our current study, we have explored the role of PARP-1 in estrogen-dependent gene regulation in estrogen receptor alpha (ERα)-positive breast cancers.  We find that PARP-1 knockdown affects estrogen-dependent gene expression and proliferation of MCF-7 cells.  We hypothesized that PARP-1 controls chromatin dynamics and regulates estrogen-regulated transcription.  In order to address this hypothesis, we performed Global nuclear Run-On and Sequencing (GRO-Seq) performed in estrogen-treated MCF-7 cells with or without PARP-1 knockdown.  GRO-Seq is a genomic assay that measures both annotated and unannotated transcription by RNA polymerases I, II, and III.  Systematic analysis of GRO-Seq data generated a comprehensive transcriptional profile of protein-coding and non-coding genes co-regulated by estrogen and PARP-1 in the MCF-7 cells.  Subsequent ChIP-Seq analyses revealed that PARP-1 directly regulates the ligand-dependent binding of ERa to a subset of its genomic binding sites.  Finally, we found that the expression levels of the PARP-1- and estrogen-regulated gene set correlate with the expression of PARP-1 in different grades of ER-positive breast cancer tumors.  Taken together, the current study suggests that PARP-1 regulates critical molecular pathways that underlie proliferation of breast cancer cells.

This work is supported by a postdoctoral fellowship from the Susan G. Komen for the Cure Foundation to S.S.G. and a grant from the NIH/NIDDK (DK069710) to W.L.K.

 

Nothing to Disclose: SSG, MC, KMH, XL, RC, WLK

PP31-1 22122 1.0000 SAT-270 A The Role of PARP-1 in Estrogen-Regulated Transcription 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 11:30:00 AM PP31 5922 11:15:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Poster Preview


Neal D Andruska*, Xiaobin Zheng, Xujuan Yang, William Helferich and David J Shapiro
University of Illinois, Urbana, IL

 

Estrogens, such as 17β-estradiol (E2), acting via estrogen receptor α (ERα), were known to regulate gene expression, activate signal transduction pathways, induce cell proliferation and protect cells against stress. We describe a new pathway that represents the initial cell response to estrogens and is required for subsequent E2-ERα induced gene expression and cell proliferation. In less than 1 minute, E2 elicits ERα-dependent activation of phospholipase C γ (PLCγ), producing inositol triphosphate (IP3), which opens the endoplasmic reticulum (EnR) IP3R calcium channels, resulting in activation of the EnR stress sensor, the unfolded protein response (UPR) and increased intracellular calcium. Consistent with the view that the elevated calcium level authorizes subsequent nuclear and extranuclear actions of E2-ERα, inhibition or siRNA knockdown of ERα, PLCγ, or IP3R blocks the increase in intracellular Ca2+ and strongly inhibits E2 stimulated cell proliferation. Furthermore, closing the EnR Ca2+ channels with inhibitors abolishes the increase in intracellular Ca2+ and inhibits E2-ERα regulated gene expression. Moreover, this mild and transient E2-ERα activation of the UPR protects cells against otherwise lethal stress. Demonstrating biological relevance, analysis of data from about 1,000 ERα positive breast cancers shows that elevated expression of a UPR gene signature is a powerful new prognostic marker tightly correlated with subsequent resistance to tamoxifen therapy, reduced time to recurrence and poor survival.

    This anticipatory E2-ERα-dependent pathway activates the UPR prior to endoplasmic reticulum stress and readies the cell for the increased protein folding load that will accompany subsequent cell proliferation. Anticipatory UPR activation is distinct from the well-studied reactive mode of UPR activation in which the UPR is activated in response to unfolded protein or stress. Anticipatory activation of the UPR is a newly identified common pathway of mitogenic hormones, conserved between insects and humans and from steroid hormones to peptide hormones.

    Using unbiased high throughout screening we identified a non-competitive small molecule ERα biomodulator, BHPI, which targets this pathway and hyperactivates the UPR, converting it from protective to lethal. BHPI is effective in diverse ERα positive cancer cells resistant to current therapies. In a mouse xenograft, BHPI induces rapid and substantial regression of large pre-existing tumors. BHPI’s novel mode of action, high potency, and effectiveness in therapy-resistant tumor cells, make it an exceptional candidate for further mechanistic and therapeutic exploration. Thus, anticipatory activation of the UPR generates targetable authorizing signals that initiate the estrogen cascade.

 

Nothing to Disclose: NDA, XZ, XY, WH, DJS

PP31-2 21284 2.0000 SAT-283 A An Authorizing Signal Required for Estrogen Receptor Action 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 11:30:00 AM PP31 5922 11:15:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Poster Preview


Franco Izzo*1, Florencia Mercogliano2, Leandro Venturutti3, Mercedes Tkach2, Mauro Ezequiel Cenciarini3, Roxana Schillaci1, Leandro Cerchietti4, Patricia Virginia Elizalde1 and Cecilia Jazmín Proietti2
1Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina, 2Instituto de Biología y Medicina Experimental, CONICET, Buenos Aires, Argentina, 3Instituto de Biología y Medicina Experimental (IBYME) CONICET, Buenos Aires, Argentina, 4Weill Cornell Medical College, New York

 

The Progesterone Receptor (PR) exerts its functions through diverse molecular mechanisms, either rapid activation of signaling pathways or direct transcriptional regulation after binding to progesterone response elements (PREs) or tethering to other transcription factors. Although PR-mediated transcriptional activation has been extensively studied, the mechanisms and co-regulators through which PR represses transcription of target genes remain to be fully elucidated.

On the other hand, the histone methyltransferase enhancer of zeste homolog 2 (EZH2) is the catalytic subunit of the Polycomb Repressor Complex 2 (PRC2), and mediates the tri-methylation of lysine 27 of histone H3 (H3K27me3) a modification associated with chromatin compaction and transcriptional repression. One of the key aspects of PRC2 function that remains to be determined is how PRC2 is directed to its target genes in mammalian cells. Since most PRC2 target genes are involved in cell differentiation, we studied the effect of progestin on the transcription factor GATA3, which is involved in mammary gland development and the maintenance of the differentiated status of luminal epithelial cells. The role of GATA3 in breast cancer as a tumor suppressor has been widely established, although insights into the mechanisms of GATA3 expression loss are still required. Our hypothesis is that PR activation promotes GATA3 downregulation through EZH2 recruitment.

In the present work, we demonstrate by chromatin immunoprecipitation and DNAse sensitivity experiments that progestin-activated PR binds and co-recruits EZH2 to a potential PRE upstream of the GATA3 gene, increasing H3K27me3 and inducing chromatin compaction. These modifications result in decreased GATA3 mRNA levels as measured by q-PCR. We also show that PR ability to bind DNA is required in order to target EZH2 upstream of GATA3, and that PR and EZH2 co-immunoprecipitate upon progestin stimulation.

We also show the existence of a post-translational mechanism in which progestin treatment increases the activity of cAMP-dependent Protein Kinase A which phosphorylates GATA3 at serine 308, as demonstrated by in vitro kinase phosphorylation assays. Through site-directed mutagenesis we generated a GATA3 mutant carrying a substitution of alanine instead of serine in residue 308 and showed that impeded phosphorylation of serine 308 increases the stability of GATA3 and prevents its post-translational regulation by PR activation.

Finally, we demonstrate that GATA3 downregulation is required for progestin-induced upregulation of cyclin A2 and breast cancer cell in vitro proliferation and in vivo tumor growth. The results presented here address EZH2 as a player in PR-mediated transcriptional repression. In addition these findings provide insight into the molecular mechanisms of loss of GATA3 expression in breast cancer.

 

Nothing to Disclose: FI, FM, LV, MT, MEC, RS, LC, PVE, CJP

PP31-3 18653 3.0000 SAT-284 A Progesterone Receptor Activation Downregulates GATA3 By Transcriptional Repression and Increased Protein Turnover Promoting Breast Tumor Growth 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 11:30:00 AM PP31 5922 11:15:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Poster Preview


Elizabeth Ann Wellberg*1, Erin Danielle Giles1, Sonali Jindal2, Laura A Checkley1, Ann D Thor1, Susan M Edgerton1, Pepper Schedin3, Steven Mathias Anderson1 and Paul S MacLean1
1University of Colorado Denver, Aurora, CO, 2Oregon Health and Science University, Portland, OR, 3Oregon Health Sciences University, Portland, OR

 

Obesity increases the risk for and mortality associated with breast cancer, particularly after menopause and tumors from obese postmenopausal women are frequently estrogen (ER), androgen (AR), and progesterone (PR) receptor positive.  Obese women with hormone-dependent breast cancer are more likely to experience tumor recurrence after taking aromatase inhibitors (AIs) compared to lean women, indicating that estrogen may not be completely suppressed; however, there is evidence that AIs effectively reduce circulating estrogens at currently prescribed doses.  Two recent reports have confirmed a role for AR in driving cancer progression after AI treatment.  This suggests that androgens, which accumulate following aromatase inhibition, may support tumor growth in a subset of women.  We hypothesized that AR mediates tumor progression in obese, postmenopausal women.  The purpose of this study was to investigate the link between AR and tumor growth in obesity-associated postmenopausal breast cancer.  To accomplish this, we measured AR expression in tumors from a rodent model of postmenopausal obesity.  Lean and obese tumor-bearing (MNU-induced) rats were ovariectomized (OVX) and tumors were monitored for 25 weeks.  All rats experienced a 3-4 week period of weight gain associated with OVX. At the end of this study, obese rats had more tumors that progressed, fewer tumors that regressed, and developed more new tumors, compared to lean rats.  The adverse effects of obesity manifested primarily during the period of OVX-induced weight gain. In another cohort of obese rats, we collected tumors at the end of a 24 hour tracer study (3H-deoxyglucose, glucose uptake; 14C-palmitate, dietary fat trafficking), performed during the period of rapid OVX-induced weight gain.  As expected, progressing tumors had higher glucose uptake and Ki67 indices.  In obese rats, progressing tumors exhibited higher levels of PR (indicating activated ER) and nuclear-localized AR (indicating activated receptor) when compared to regressing tumors, suggesting that estrogens and androgens play a role in driving tumor growth. Gene expression studies in normal mammary tissue from these same animals showed that 17βHSD and Srd5a1 mRNA levels were elevated with overfeeding in the obese rats.  These data suggest a scenario in which obesity and the OVX-induced positive energy imbalance work in concert to support the production of estrogens and androgens by mammary adipose tissue, and these hormone ligands can activate their cognate receptors in adjacent tumors to drive tumor growth. Together, these data suggest that AR may substitute for or cooperate with ER to drive tumor progression in a subset of postmenopausal breast tumors, and may uncover a widow during which therapies aimed at improving energy homeostasis can effectively treat hormone-dependent postmenopausal breast cancer.

 

Nothing to Disclose: EAW, EDG, SJ, LAC, ADT, SME, PS, SMA, PSM

PP31-4 22149 4.0000 SAT-278 A A Link Between Androgen Receptor Activation and Tumor Progression in Obesity-Associated Postmenopausal Breast Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 11:30:00 AM PP31 5922 11:15:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Poster Preview


Tatyana Gurlo*1, Safia Costes1 and Peter Cawood Butler2
1UCLA, Los Angeles, CA, 2University of California Los Angeles, Los Angeles, CA

 

Type 2 diabetes (T2D) is characterized by a progressive defect in insulin secretion in the setting of insulin resistance. Beta cell failure in T2D shares much in common with neurodegenerative diseases including impaired cell function, endoplasmic reticulum (ER) stress, increased reactive oxygen species (ROS) formation, disruption of cellular Ca2+compartmentalization leading to calpain hyperactivation and an impaired autophagy lysosomal pathway that collectively renders cells vulnerable to apoptosis.  The effected cell types in these diseases share in common expression of amyloidogenic proteins that form soluble membrane permeant toxic oligomers in diseases states. Islet amyloid polypeptide, co-expressed and secreted with insulin by beta-cells (with increased expression due to insulin resistance), forms toxic oligomers in beta-cells in T2D. Islet pathology in T2D is reproduced in mice transgenic for human IAPP (hIAPP) when expressed at levels that induce toxic oligomer formation. While the pattern of beta-cell dysfunction in T2D is increasingly well characterized, there remains a lack of disease modifying therapies to intervene in this adverse cycle of dysfunction. We hypothesized that calpain hyperactivation propagates cellular dysfunction initiated by hIAPP membrane permeant oligomers and that suppression of this calpain hyperactivation might offer a disease modifying therapy in T2D. 

We tested this by backcrossing mice expressing the endogenous calpain inhibitor human calpastatin (hCAST) in beta-cells to hIAPP transgenic mice (hTG), or wild type (WT) mice for control. Four groups of mice were generated: hTG; hTG,hCAST; WT and WT,hCAST. Calpain hyperactivation in hTG mice (assessed by cleavage of the calpain target alpha-spectrin) was attenuated in hTG,hCAST mice. Suppressed calpain hyperactivation markedly delayed diabetes onset. Ninety percent of hTG mice developed diabetes by 12 wk of age (fasting blood glucose 245±32 mg/dl) while hTG,hCAST mice remained normoglycemic (69±6 mg/dl). Two thirds of hTG,hCAST mice stayed diabetes-free up to 24 wk of age. The delay in diabetes development in hTG,hCAST mice was associated with the inhibition of beta-cell apoptosis and preservation of beta-cell mass. The levels of ER stress (measured by nuclear CHOP) and oxidative stress (assessed by nitrotyrosine) were decreased in hTG,hCAST relative to hTG mice.  The defect in lysosomal degradation characteristic of beta-cells in hTG mice was also attenuated by overexpression of calpastatin.

The profound protective effect of calpain inhibition on diabetes development in hTG mice is consistent with the hypothesis that calpain mediated pathways may propagate beta-cell dysfunction initiated by hIAPP toxic oligomers, and invites consideration of calpain inhibition as a potential disease modifying therapeutic approach in T2D.

 

Disclosure: PCB: Speaker, Genentech, Inc.. Nothing to Disclose: TG, SC

PP26-1 21298 1.0000 SAT-657 A Calpain Hyperactivation, a Novel Therapeutic Target to Preserve Beta-Cell Mass and Function in Type 2 Diabetes? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 11:30:00 AM PP26 5944 11:15:00 AM Fundamental Islet Cell Biology Poster Preview


Jin Li*1, Kilian Huber2, Thomas Frogne3, Charles-Hugues Lardeau2, Giulio Superti-Furga2, Jacob Hecksher-Sorensen3 and Stefan Kubicek1
1CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria, 2CEMM, Vienna, 3Novo Nordisk

 

The destruction of pancreatic beta cells by auto-immune response was believed as the major reason of Type I diabetes and to generate insulin-producing cells from other cell types within pancreas showed great potential to provide new beta cells for Type I diabetes patients. Recent research suggested that the loss of the master regulatory transcription factor Arx or overexpression of its counter-player Pax4 are able to induce the conversion of mature alpha to functional beta-like cells(Al-Hasani et al., 2013; Collombat et al., 2003; Collombat et al., 2009). In order to build up a high through put screening for small molecular affecting the function of Pax4 and Arx, inducible overexpression cell culture models were established in Min6 cells. The overexpression of GFP, PAX4 and ARX could be induced by doxycycline treatment in these models. Transcriptome-wide changes by transcription factors overexpression after 24, 72 and 144 hours using RNA-seq was investigated on these cells. Importantly, alpha-cell characteristics were induced by transient overexpression of ARX in beta cells. Therefore, an image-based high content screening for functional inhibitor of Arx was processed on the ARX-overexpressed beta cells. Following 72 hours ARX induction, 50% reduction of Insulin level was detected by immunofluorescence in Min6 cells. The significant hits from the screening were defined as compounds which could reverse this phenotype and maintain high insulin level in the presence of ARX. A natural product, which was a clinical approved drug used in infectious diseases was identified to repress ARX function in beta cells and induced beta-cell characteristics in alpha cells. Chemical proteomics assay was applied to search for the binding partners of this drug and a group of membrane-receptor related proteins were fished out as potential targets of it. The physical interactions between the drug and targets were validated by cellular thermo-shift assay. Ex vivo treatment on primary human islets three days treatment significantly decreased the transcription of ARX, increased the amount of double positive cells expressing both insulin and glucagon and the secretion of Insulin after glucose stimulation. These results should induce the clinical investigation of these drugs for the regeneration of beta cell mass in C-peptide negative T1D.

 

Nothing to Disclose: JL, KH, TF, CHL, GS, JH, SK

PP26-2 20884 2.0000 SAT-658 A An Approved Drug Induces a Beta-like Phenotype in Alpha Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 11:30:00 AM PP26 5944 11:15:00 AM Fundamental Islet Cell Biology Poster Preview


Alena Welters*1, Jan Marquard1, Silke Otter1, Alin Stirban2, Jan Eglinger1, Diran Herebian3, Olaf Kletke1, Masa Skelin Klemen4, Andraz Stozer4, Stephan Wnendt5, Lorenzo Piemonti6, Martin Köhler7, Jorge Ferrer8, Bernard Thorens9, Freimut Schliess2, Marjan Slak Rupnik10, Tim Heise11, Per-Olof Berggren12, Nikolaj Klöcker1, Thomas Meissner13, Ertan Mayatepek14, Daniel Eberhard1, Martin Kragl1 and Eckhard Lammert1
1Heinrich Heine University Düsseldorf, Germany, 2Profil Institute for Metabolic Research, 3University Children's Hospital Düsseldorf, Germany, 4University of Maribor, 5MLM Medical Labs GmbH, 6San Raffaele Scientific Institute, Milan, Italy, 7Karolinska Institutet, Stockholm, Sweden, 8Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Barcelona, Spain, 9University of Lausanne, Center for Integrative Genomics, Lausanne, Switzerland, 10Institute of Physiology, Center for Physiology and Pharmacology, Medical University of Vienna, 11Profil, Neuss, Germany, 12The Rolf Luft Research Center for Diabetes and Endocrinology, Karolinska Institutet, Stockholm, Sweden, 13University Children's Hospital, Heinrich Heine University Düsseldorf, German Center for Diabetes Research (DZD), Düsseldorf, Germany, 14University Children's Hospital, Heinrich Heine University Düsseldorf, Düsseldorf, Germany

 

Characterization of pancreatic N-Methyl-D-Aspartate receptors as novel drug targets for the treatment of diabetes mellitus

N-Methyl-D-Aspartate receptors (NMDARs) are ionotropic glutamate receptors that are widely expressed within the central nervous system where they are involved in neurotransmission, cell viability and serve as drug target for the treatment of neurodegenerative disorders. By contrast, only little is known about pancreatic NMDARs. We therefore aimed to investigate the role of pancreatic NMDARs in insulin secretion, glucose tolerance and islet cell viability.

Both, genetic deletion of pancreatic NMDARs and pharmacologic inhibition of NMDARs with the over-the-counter drug dextromethorphan (DXM) and its metabolite dextrorphan selectively increase glucose-stimulated insulin secretion from rat insulinoma cells, mouse and human pancreatic islets and improve glucose tolerance in mice without affecting insulin secretion under low glucose conditions. Furthermore, in db/db mice long-term DXM treatment lowers fasting blood glucose levels, improves glucose tolerance and promotes islet cell survival. In isolated mouse and human pancreatic islets NMDAR antagonists protect against cytokine-induced cell death, further suggesting beta cell protective properties of NMDAR blockade. Finally, in a phase IIa clinical trial a single dose of DXM increased postprandial plasma insulin concentration and improved glucose tolerance in type 2 diabetic patients.

In summary, our data demonstrate a regulatory role of NMDARs in insulin secretion, glucose tolerance and islet cell survival and propose NMDARs as novel drug targets for the treatment of diabetes mellitus.

 

 

Nothing to Disclose: AW, JM, SO, AS, JE, DH, OK, MS, AS, SW, LP, MK, JF, BT, FS, MSR, TH, POB, NK, TM, EM, DE, MK, EL

PP26-3 21024 3.0000 SAT-661 A Characterization of Pancreatic N-Methyl-D-Aspartate Receptors As Novel Drug Targets for the Treatment of Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 11:30:00 AM PP26 5944 11:15:00 AM Fundamental Islet Cell Biology Poster Preview


E. Danielle Dean*1, Mingyu Li1, Nripesh Prasad2, Anastasia G Coldren1, Scott N Wisniewski1, Greg Poffenberger1, Nadia Bozadjieva3, Olga Ilkayeva4, Ernesto Bernal-Mizrachi3, Shawn Levy2, Chunhua Dai1, Christopher B. Newgard4, Wenbiao Chen1 and Alvin Powers5
1Vanderbilt University Medical Center, Nashville, TN, 2Hudson Alpha Institute of Biotechnology, Huntsville, AL, 3University of Michigan Comprehensive Diabetes Center, Ann Arbor, MI, 4Duke University Medical Center, Durham, NC, 5Vanderbilt University, Nashville, TN

 

Interventions to decrease glucagon action could be a useful therapeutic approach to treat diabetes.  However, interrupting glucagon action by several mechanisms [glucagon receptor (Gcgr) knockout, antibodies, and antagonists] promotes hyperglucagonemia and alpha cell hyperplasia. The responsible mechanism not known. Using islet transplantation, we recently demonstrated that a signal(s) originating from liver of mice with interrupted glucagon signaling stimulates alpha cell proliferation independent of the pancreatic environment, suggesting a circulating hepatic factor. Using a newly developed in vitro, alpha cell proliferation assay, serum from mice with interrupted glucagon signaling (Gcgr-/-) stimulate alpha cell proliferation in cultured mouse islets within 72 hours (media – 0.870±0.14%***, media + 10% Gcgr+/+ serum – 1.72±0.31%*, media + 10% Gcgr-/- serum – 5.09±0.74%; n=3-12, *p<0.05, ***p<0.001 vs media + 10% Gcgr-/- serum-treated). Using a combination of serum fractionation, proteomics, metabolomics, liver transcriptomics, a zebrafish model, and the in vitro assay, we tested both candidate serum factors and inhibitors for the alpha cell proliferation response. Rapamycin co-treatment blocked Gcgr-/- serum-stimulated alpha cell proliferation suggesting that mTOR signaling is required for this increase in alpha cell proliferation (DMSO – 0.483±0.10%**, DMSO + 10% Gcgr-/- serum – 3.96±0.03%; 10nM rapamycin 36hrs + 10% Gcgr-/- serum – 1.37±0.71%*; 30nM rapamycin 36hrs + 10% Gcgr-/- serum – 0.611±0.13%**; 10nM rapamycin 72hrs + 10% Gcgr-/- serum – 1.89±0.75%**; 30nM rapamycin 72hrs + 10% Gcgr-/- serum – 0.469±0.34%**; n=2-3, *p<0.05, **p<0.01 vs DMSO + 10% Gcgr-/- serum-treated). Since mTOR is responsible for integrating multiple mitogenic signals (e.g. nutrient signals, growth factors) in other cell types and glucagon regulates gluconeogenesis in the liver, we quantified amino acid levels in the serum of Gcgr-/- mice. Serum levels of most amino acids were 2-3 fold higher in Gcgr-/- mice than Gcgr+/+ mice. To determine if the elevated levels of the amino acids were responsible for the alpha cell proliferation, we cultured islets in media with similar levels of all 20 major amino acids plus hydroxyproline, citrulline, and ornithine found in either Gcgr-/- or Gcgr+/+ mouse serum. These results indicate that another factor, but not the elevated amino acids,  mediates the increased alpha cell proliferation. These results suggest a hepatic-alpha islet cell axis regulating alpha cell mass and possibly glucagon levels.

 

Disclosure: AP: Speaker, Boehringer Mannheim. Nothing to Disclose: EDD, ML, NP, AGC, SNW, GP, NB, OI, EB, SL, CD, CBN, WC

PP26-4 21914 4.0000 SAT-659 A Hepatic-Derived Factor Stimulates Alpha Cell Proliferation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 11:30:00 AM PP26 5944 11:15:00 AM Fundamental Islet Cell Biology Poster Preview


Michael A Gordon*1, Nicholas D'Amato2, Haihua Gu1, Bolin Liu1, Anthony Elias3 and Jennifer K Richer2
1Dept. of Pathology, University of Colorado Anschutz Medical Campus, Aurora, CO, 2University of Colorado Anschutz Medical Campus, Aurora, CO, 3Univ of Colorado Anschutz Medical Campus, Aurora, CO

 

Background: The androgen receptor (AR) is expressed in ~60% of HER2+ (HER2amplified) breast cancer (BC) and up to 1/3rd of triple negative BC (TNBC), and evidence indicates that some BC critically depend on AR signaling for growth and survival. AR affects numerous cellular functions and signaling cascades, including the HER2/PI3K/mTOR pathway. Conversely, the HER2/PI3K/mTOR pathway regulates steroid hormone receptor activity and expression, including AR. Therapeutics targeting this pathway such as the anti-HER2 agent trastuzumab (TRAS) and the anti-mTOR drug everolimus (EVER) have shown significant clinical benefit; however de novo and acquired resistance to these agents remains a critical problem.

Hypothesis: Because AR signaling intersects with the HER2/3 and mTOR signaling pathways, we postulate that targeting AR in combination with growth factor targeted therapies will provide synergy to reduce risk of recurrence in subsets of BC. The AR inhibitor enzalutamide (ENZ) prevents nuclear entry of AR, is clinically effective in castrate-resistant prostate cancer, and is being tested in BC clinical trials.

Methods: HER2+ and TNBC cell lines were treated with ENZ, TRAS, and EVER, alone or in combination, at three clinically relevant doses per drug. Cell proliferation was measured on an IncuCyte live cell imager. Drug synergy and dose reduction index were calculated from proliferation data using Calcusyn software by comparing combinations of multiple drug concentrations. Pathway component proteins were measured by western blot and gene expression by qRT-PCR.

Results: Dihydrotestosterone (DHT)-mediated nuclear localization of AR was inhibited by ENZ in 3 HER2+ BC cell lines tested (MDAMB453, BT474, SKBR3). ENZ inhibited proliferation of HER2+ BC cells, and a combination of ENZ + TRAS inhibited proliferation more effectively than either agent alone. The effect was synergistic in SKBR3 (HER2+/ER-) cells, and additive in BT474 (HER2+/ER+) cells and TRAS-resistant SKBR3-Pool2 cells. Treatment of BT474, ZR7530 (HER2+/ER+), and MDA-MB-453 (HER2+ non-amplified/ER-) cells with DHT caused increased expression of pHER3 and total HER3 protein, which was attenuated by addition of ENZ. However, pHER3 and total HER3 levels did not change in SKBR3, SUM225 (HER2+/ER-), and ZR7530 (HER2+/ER+) cells; instead pHER2 levels increased in response to DHT and were attenuated with ENZ. ENZ + EVER treatment synergistically inhibited proliferation in three HER2+ cell lines (SKBR3, SKBR3-Pool2, BT474) as well as one TNBC cell line tested (BT549). Treatment with EVER caused a compensatory increase in AR protein in some cell lines. This increase was attenuated with ENZ + EVER combination treatment.

Conclusion: ENZ synergizes in vitro with FDA-approved BC therapies, TRAS and EVER, through distinct mechanisms. Combination therapies containing ENZ may provide benefit for BC subtypes including HER2+ and TNBC.

 

Nothing to Disclose: MAG, ND, HG, BL, AE, JKR

PP25-1 20612 1.0000 SAT-312 A The Anti-Androgen Enzalutamide Synergizes with Trastuzumab and Everolimus to Inhibit Breast Cancer Growth Via Distinct Mechanisms 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 11:30:00 AM PP25 5954 11:15:00 AM Biomarkers and Hormone-Dependent Cancers Poster Preview


Hong Zhao*1, Vamsi Parini2, Demirkan B Gursel2, Robert T Chatterton Jr.1, John S Coon V1, Yelda C Orhan1, Irene Moy1 and Serdar Ekrem Bulun1
1Northwestern University, Chicago, IL, 2Northwestern University

 

It has recently been reported that SUSD3 expression is related to aromatase inhibitor (AI) response in estrogen receptor positive (ER+) breast cancer patients (1), and that it together with FGD3  is prognostic of length of survival (2).  However, SUSD3 facilitates estrogen/ERα-dependent MCF-7 breast cancer cell proliferation and is associated with loss of cell adhesion and increased cell migration (1).  To determine the integral function of ERα and SUSD3 in breast cancer, we analyzed 30 tumors from cancer patients for expression of SUSD3 using an in situ hybridization technique (RNAscope, Advanced Cell Diagnostics) with high sensitivity and specificity.  ERα and progesterone receptor (PR) were analyzed by immunohistochemistry.  Normal breast tissue from breast reduction mammoplasties served as controls.  The SUSD3 mRNA was found in epithelial cells but not in stromal cells.  Within epithelial cells, SUSD3 expression is lowest in the normal breast, slightly increased in ERα- tumor epithelium, intermediate in benign epithelium within the ERα+ ductal carcinoma in situ (DCIS) and invasive breast cancer (IBC) specimens, and highest in ERα+ DCIS and IBC tumor epithelium.  Thus, SUSD3 was limited to ERα+ epithelium with a significant bystander effect.  Further investigation in six breast cancer cell lines confirmed the association with ERα positivity.  However, SUSD3 was not significantly correlated with the expression level of ERα but was correlated with PR, suggesting that the activity rather than the level of ERα is critical. Overexpression of SUSD3 in MCF-7 cells (SUSD3+, ERα+++, PR+) led to a suppression of ERα and a large increase in expression of PR.  Knockdown of SUSD3 in T47D (SUSD3+++, ERα+, PR+++) cells resulted in an increase in ERα and a suppression of PR expression. Thus, SUSD3 mediates estrogen/ERα function and increases its target gene PR expression.  We conclude that ERα/SUSD3 is an integral component of the response to estradiol in ERα+ cells, and that loss of SUSD3 severely impairs the activity of the estradiol-ERα complex, resulting in non-functional ERα, non-responsiveness to AI in ERα+ breast cancer, and a more aggressive tumor.  In contrast, higher expression of SUSD3 is associated with more differentiated tumors and longer survival.

 

Disclosure: SEB: Ad Hoc Consultant, Bayer, Inc., Ad Hoc Consultant, Merck BV. Nothing to Disclose: HZ, VP, DBG, RTC Jr., JSC V, YCO, IM

PP25-2 21985 2.0000 SAT-313 A Relation of Sushi Domain-Containing Protein 3 (SUSD3) to Estrogenic Effects and Breast Tumor Development 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 11:30:00 AM PP25 5954 11:15:00 AM Biomarkers and Hormone-Dependent Cancers Poster Preview


Sandra L. Grimm*, Adriana P Visbal, Chelsea Alyssa Kimiko Saito-Reis, Sean Michael Hartig, Celetta G. Callaway, Shixia Huang, David G. Edwards, Daniel Medina and Dean P. Edwards
Baylor College of Medicine, Houston, TX

 

Progesterone (P4) stimulates proliferation of breast epithelium during the luteal phase of the cycle and clinical and epidemiological data indicate that P4 is a risk factor for breast cancer.  P4 has been proposed to have a role in tumorigenesis by expanding cells that have undergone transformation to promote progression of non-invasive lesions to invasive breast cancer (IBC).  Ductal carcinoma in situ (DCIS) is a non-obligate precursor to most types of IBC, yet little is known about mechanisms underlying transition to IBC including the potential role of P4 and progesterone receptor (PR).  Human DCIS cell lines are PR negative, therefore lentiviral vectors were used to stably express PR-A, PR-B or both PR isoforms in DCIS.COM (comedo) cells.  Cells expressing PR-A underwent changes with passage that did not occur with PR-B or parental cells including loss of adhesion, growth as large spheroids without central necrosis and hyper-proliferation.  Also, PR-A spheroids in Matrigel grew faster as larger colonies, but did not acquire invasive properties.  This cell phenotype occurred in the absence of hormone; however, continuous exposure to the progestin R5020 prevented spheroid development and inhibited enhanced growth in Matrigel.  Proteomic analysis by reverse phase protein array (RPPA) revealed that PR-A spheroids exhibited up-regulation of cell stress pathways (p38 and p53), and proliferation (c-myc and ERK1/2), down-regulation of proteins associated with differentiation, extra-cellular matrix signaling and attachment, and other changes consistent with suppression of autophagy.  RPPA data were confirmed by immunoblotting and qPCR for gene expression.  Up-regulated p53 is functional as indicated by induced expression of p53 target genes and a physical interaction between PR and p53 was detected suggesting a potential functional cooperation between the two proteins.  To determine the influence of PR on DCIS.COM in vivo, cells were injected in the primary mammary duct of intact immune-compromised SCID/Beige mice and tumor formation was monitored for 10 weeks.  This intra-ductal xenotransplantation system mimics DCIS in its natural microenvironment requiring cells to grow as DCIS inside ducts and eventually invade into the surrounding stroma.  Parental DCIS.COM and PR-B cells formed a mixture of DCIS lesions and invasive tumors.  PR-A spheroids failed to form DCIS or invasive tumors and no viable cells were detectable at any time between 3-10 weeks.  When transplanted into the mammary gland fat pad, essentially by-passing the ductal environment and need to invade, PR-A spheroids grew as tumors with a similar rate and frequency as parental cells; albeit, PR-B cells formed larger tumors under these conditions.  These data suggest that overexpression of PR-A in the absence of P4 acts to suppress survival and progression of DCIS through inhibition of autophagy, an effect that may be abrogated by hormone.

 

Nothing to Disclose: SLG, APV, CAKS, SMH, CGC, SH, DGE, DM, DPE

PP25-3 22059 3.0000 SAT-314 A The Role of Progesterone Receptor in the Biology and Progression of Breast Ductal Carcinoma in Situ 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 11:30:00 AM PP25 5954 11:15:00 AM Biomarkers and Hormone-Dependent Cancers Poster Preview


Salma Khan*1, Tessarae Stiff2, James c Lynch2, Patrick Leaf2, Carlos a Casiano1 and Nathan R Wall2
1Loma Linda University, Loma Linda, CA, 2Loma Linda University

 

Prostate cancer is the most commonly diagnosed cancer in American men.  Studies have shown that African American men are about 1.5 times more likely to develop prostate cancer and about 2.5 times more likely to die from prostate cancer. However, there’s no known cause of increased rate of morbidity and mortality in these population. Stress is well known factor for the causation of health disparities. Stress is a known inducer of post-transcriptional modification in cellular levels. Survivin, a member of the inhibitor of apoptosis family can get alternatively spliced both transcriptionally and post-transcriptionally. Alternative splicing of survivin has resulted in many splice variants, the most interesting of which have proved to be survivin-2B and survivin-DEx3. Survivn-2B contains an additional exon (exon 2B) while survivin-DEx3 lacks exon 3. Recent studies have shown that like survivin, survivin splice variants are differentially expressed in cancer cells. Recent studies have shown that survivin and its splice variants are secreted from cells via exosomes, or small membrane-bound vesicles used in cell-cell and cell-extracellular communication (1,2). The overall objective of our study is to identify any differences in survivin splice variant expression in prostate cancer patients for non-invasive early detection establishing interventions that can be tailored to Americans of different ethnicities. In this study, exosomes were collected from the serum of 78 randomized Caucasian and African American men using the commercially available ExoQuick kit. Along with protein, microRNA and mRNA were extracted from the exosomes and analyzed using RT-PCR and Western blotting. Survivin splice variants mRNA and proteins are found in the exosomes of prostate cancer patients’ sera. Survivin-2B and DEx-3 are differentially expressed in prostate cancer. Specifically, DEx-3 are expressed more in African American patients whereas Survivin-2B  is expressed highly in Caucasian samples. We found that this observation will ultimately pave the way for future studies focused on analyzing these biomarkers in larger cohorts of ethnically diverse cancer patients.

1. Khan et al, PLOS ONE 2012, 7: e46737. doi:10.1371.  2. Khan et al, BMC Cancer 2014, 14:176  doi:10.1186/1471-2407-14-176

Disclosure: nothing to disclose: SK, TS, JCL, PL, AG, CAC, NRW

Sources of Research support: Research was supported by the National Institute of General Medical Sciences of the National Institutes of Health under award number 2R25 GM060507 and the National Institute of Health Disparities and Minority Health of the National Institutes of Health under award number P20MD006988.

 

Nothing to Disclose: SK, TS, JCL, PL, CAC, NRW

PP25-4 22141 4.0000 SAT-315 A Survivin Splice Variants in Prostate Cancer Health Disparities 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 11:30:00 AM PP25 5954 11:15:00 AM Biomarkers and Hormone-Dependent Cancers Poster Preview


Katherine Thuy Trang Tonks*1, Christopher White2, Jacqueline R Center1, Donald John Chisholm1, Jerry R Greenfield3 and Dorit Samocha-Bonet1
1Garvan Institute of Medical Research, Sydney, Australia, 2Prince of Wales Hospital, Randwick, Australia, 3Garvan Institute of Medical Research, Darlinghurst, Australia

 

Background: In humans, the relative contribution of insulin resistance vs. adiposity in determining bone mineral density (BMD) and fracture risk is unknown. Obesity is associated with higher BMD, yet type 2 diabetes (T2D) is associated with increased non-vertebral fracture risk for similar BMD.

Aim:To determine if there is an effect of insulin resistance on bone turnover markers (BTM), independent of obesity.

Methods:We studied lean (n=19), overweight/obese insulin-sensitive (Ob-IS, n=15), overweight/obese insulin-resistant (Ob-IR, n=20) and T2D volunteers (n=17). Insulin sensitivity was assessed by hyperinsulinemic-euglycemic clamp (glucose infusion rate/fat free mass [GIR/FFM]). Non-diabetic overweight/obese volunteers were stratified to Ob-IS and Ob-IR based on HOMA-IR (<1.5 and >3, respectively). Total BMD and body fat mass (FM) were assessed by DXA. Subcutaneous (SCF), visceral (VF) and liver fat were assessed by CT. BTM (osteocalcin [OC], procollagen type 1 propeptide [P1NP] and collagen type 1 cross-linked C-telopeptide [CTx]) were measured fasting and during clamp hyperinsulinemia.

Results:Groups were age-matched (57±9 years). Ob-IS, Ob-IR and T2D were matched for SCF and VF, and Ob-IR and T2D had more liver fat than lean (p<0.001). GIR/FFM was similar between lean and Ob-IS (P=1) and 2-fold higher than GIR/FFM in Ob-IR and T2D (all p≤0.01; Ob-IR vs. T2D P=0.09). Similarly, fasting insulin levels did not differ between lean and Ob-IS individuals (p=1) and were 2-fold lower than Ob-IR and T2D (all p<0.0001; Ob-IR vs T2D p=1).

BMD correlated with fat mass (P=0.006). There were no significant differences between groups’ BMD z-scores.

Fasting BTM concentrations correlated inversely with fasting insulin (P≤0.04) and positively with GIR/FFM (P≤0.02). Change in CTx and OC with hyperinsulinemia correlated inversely with GIR/FFM (P≤0.01).

Ob-IR (p=0.0005) and T2D (p=0.016) individuals had significantly lower fasting CTx levels than lean. Similarly, fasting OC was lower in Ob-IR compared to lean (p=0.003) and Ob-IS (p=0.003). There was a trend to lower fasting P1NP in Ob-IR compared to Ob-IS (PANOVA=0.02, adjusted p=0.06). In response to hyperinsulinemia, insulin-sensitive volunteers suppressed both CTx (lean p=0.0008, Ob-IS p=0.03) and OC (lean P=0.003, Ob-IS P=0.03) to a greater extent than the suppression seen in Ob-IR. In addition, lean volunteers also suppressed CTx more than T2D (p=0.04). P1NP levels were unaffected by hyperinsulinemia (p=0.5).

Conclusions: BMD correlates with FM. BTM correlate inversely with insulin levels, are suppressed in insulin resistance, and do not suppress further with clamp hyperinsulinemia. These findings suggest that CTx and OC remain insulin-responsive, even in insulin-resistant states. This effect is independent of adiposity. This may explain increased fracture risk in insulin-resistant individuals with apparently normal BMD.

 

Nothing to Disclose: KTTT, CW, JRC, DJC, JRG, DS

PP29-1 21655 1.0000 SAT-246 A Bone Turnover Markers Are Suppressed in Insulin Resistant Humans, Independent of Adiposity, Suggesting Bone Remains Insulin Responsive in Insulin Resistant States 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 11:30:00 AM PP29 5962 11:15:00 AM Metabolic Bone Disease - Pathophysiology and Treatment Poster Preview


Amy M DeGueme*, Alex Tessnow and Naim M Maalouf
UT Southwestern Medical Center, Dallas, TX

 

Objective: To illustrate an alternative treatment method for recurrent bisphosphonate-resistant hypercalcemia of malignancy.

Case Presentation: This is a 40 year old woman with metastatic poorly differentiated adenocarcinoma who initially was admitted with chest, rib, and back pain, nausea/vomiting, and constipation. Physical exam was remarkable for ill-appearing woman in distress from minimal movement, tachycardia, and dry mucous membranes. Her calcium on admission was 17.4 mg/dL (8.4-10.2), albumin 4.4 g/dL (3.5-5.2), PTH 9.0 pg/mL (15-65), PTHrP 2.7 pmol/L (<2.0), and eGFR > 60. She was found to have metastatic lesions throughout the skull, spine, sternum, manubrium and ribs as well as liver. She was treated with intravenous fluids, furosemide, calcitonin, and zoledronic acid, resulting in correction of calcium to 9.4 and she was discharged shortly thereafter.

She had three subsequent admissions for hypercalcemia over the next three months, with each calcium level higher than prior nadir (18.5 mg/dL, 20.0 mg/dL, 21.7 mg/dL) and decreasing albumin (3.6 down to 2.3 g/dL). During each admission she was treated with intravenous fluids, furosemide, and pamidronate, with improvement in calcium levels lasting about one month until the last hospitalization where calcium levels started to increase after 7 days. Another dose of pamidronate was given however a similar calcium increase was seen to 13.2 mg/dL. Due to increasing calcium levels despite bisphosphonate, denosumab 120mg subcutaneous was given. Her calcium dropped to 9.2 mg/dL 7 days after receiving dose. She had continued relative control of calcium of 11.1 mg/dL 5 weeks later.

Discussion: Denosumab is a human monoclonal antibody that inhibits bone resorption by binding to and inhibiting receptor activator of nuclear factor κ-B ligand (RANKL), with resultant reduced osteoclast activation. It is currently approved for treatment of postmenopausal osteoporosis, hormone ablation-induced bone loss, unresectable giant cell tumor of bone, and for the prevention of skeleton-related events (SRE) in patients with bone metastases from solid tumors. In several clinical trials, profound hypocalcemia was seen in normocalcemic patients. This side effect has been used as a novel treatment for bisphosphonate-resistant hypercalcemia of malignancy, with improved calcium levels seen within days of treatment and sustained response for several weeks reported. With improved calcium levels, the complications, hospital admissions and length of stay related to hypercalcemia can be reduced, leading to improved quality of life. In a recently completed clinical trial addressing this specific indication, an interim analysis report showed an 80% response rate with median 26 days maintained calcium of lower than 11.5 mg/dL, in 15 patients enrolled. Further trials are needed to determine safety and efficacy in this specific patient population.

 

Nothing to Disclose: AMD, AT, NMM

PP29-2 19076 2.0000 SAT-247 A Bisphosphonate-Resistant Hypercalcemia of Malignancy: A Therapeutic Dilemma with an Emerging Treatment Option 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 11:30:00 AM PP29 5962 11:15:00 AM Metabolic Bone Disease - Pathophysiology and Treatment Poster Preview


Alison Skrinar*, Ayla Marshall, Javier San Martin and Melita Dvorak-Ewell
Ultragenyx Pharmaceutical Inc., Novato, CA

 

Background: X-linked Hypophosphatemia (XLH) is a disorder of renal phosphate wasting caused by high circulating levels of fibroblast growth factor 23 that impairs normal phosphate reabsorption in the kidney. The disorder presents in childhood with hypophosphatemia that causes rickets, bowing of the legs and diminished height.  Despite treatment with oral phosphate and vitamin D metabolites in childhood, skeletal defects remain unresolved and lead to significant complications in adulthood.  Progressive osteomalacia with associated pseudofractures and bone pain, and osteoarthritis with joint pain and stiffness in the lower extremities are common complications. Objective: The primary objective of the study was to characterize the clinical presentation and disease course in adults with XLH and assess pain, mobility and quality of life.  Methods: An IRB-approved, web-based questionnaire with patient reported outcome measures [Brief Pain Inventory (BPI), Western Ontario and McMaster osteoarthritis index (WOMAC), and SF-36v2 Health Survey] was completed by adults with XLH. Results: 150 adult surveys were completed by affected adults from 18-73 years of age with a median age of 45.5 years.  Current phosphate/vitamin D therapy was reported by 93/150 (62%) with associated complications of hyperparathyroidism 49/150 (33%) and nephrocalcinosis 38/150 (25%). The most commonly reported skeletal complications were short stature [130/150 (87%)], bowing of the tibia/fibula [117/150 (78%)] bowing of the femur [101/150 (67%)] and osteoarthritis [90/150 (60%)]. A history of fractures was reported by 70/150 (47%) responders with a mean of 3 fractures per subject and a mean age at first fracture of 25.4 years (4-63 years).  97/150 reported at least one orthopedic surgery including osteotomy [95/150 (63%)], knee replacement [18/150 (12%)] and hip replacement [12/150 (8%)]. The majority of subjects complained of joint and bone pain [145/150 (97%)], restricted range of motion [139/150 (93%)] and gait disturbance [125/150 (83%)].  Significant pain was reported on all 3 outcome measures, [Mean SF-36 Bodily Pain score = 39.2), BPI (Mean Pain Severity Score = 3.6), and WOMAC (Mean Pain Severity Score = 7.9)] and led to pain medication use by 105/150 (70%), including 27/150 (18%) taking narcotics.  Limitations in physical functioning were also reported on the 3 outcome measures, [Mean SF-36 Physical Functioning = 35.7), Mean BPI (Mean Pain Interference Score = 4.2), and WOMAC (Mean Physical Function Score = 27.4). Conclusions:  Adults with XLH experience significant progressive skeletal complications that impair mobility and quality of life highlighting the need for safer and more efficacious therapies.  

 

Disclosure: AS: Employee, Ultragenyx Pharmaceutical Inc., Employee, Ultragenyx Pharmaceutical Inc.. AM: Employee, Ultragenyx Pharmaceutical Inc., Employee, Ultragenyx Pharmaceutical Inc.. JS: Employee, Ultragenyx Pharmaceutical Inc., Employee, Ultragenyx Pharmaceutical Inc.. MD: Employee, Ultragenyx Pharmaceutical Inc., Employee, Ultragenyx Pharmaceutical Inc..

PP29-3 20717 3.0000 SAT-244 A X-Linked Hypophosphatemia (XLH) Impairs Skeletal Health Outcomes and Physical Function in Affected Adults 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 11:30:00 AM PP29 5962 11:15:00 AM Metabolic Bone Disease - Pathophysiology and Treatment Poster Preview


Anand Vaidya*1, Julie Paik2, Gary Curhan3 and Eric Taylor3
1Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, 2Brigham and Women's Hospital, Harvard Medical School, Brookline, MA, 3Brigham and Women's Hospital, Harvard Medical School

 

Context:  Hypertension associates with higher parathyroid hormone (PTH) levels, and the use of certain anti-hypertensive medications have been observed to modulate PTH levels.  For example, furosemide has been associated with higher PTH levels, whereas thiazides and renin-angiotensin-aldosterone system inhibitors have been associated with lower PTH levels.  We hypothesized that a history of hypertension would increase the risk of developing incident primary hyperparathyroidism (P-HPTH), and that the use of specific anti-hypertensive medications may also influence this risk.

Objective: To determine whether history of hypertension and the use of specific anti-hypertensive medications associate with risk for incident P-HPTH in a prospective analysis in the Nurses’ Health Study (NHS).

Methods: 75,600 female nurses enrolled in the NHS in 1986 with no history of P-HPTH were followed for 24 years (1986-2010) with detailed biennial questionnaires that assessed lifestyle factors, dietary intake, and medical history. Cases of incident P-HPTH were confirmed after review of medical records including laboratory results, surgical and pathology reports. Cox proportional hazards models were used to evaluate whether history of hypertension and types of anti-hypertensive medications (thiazide, furosemide, angiotensin coverting enzyme inhibitor, calcium channel blocker, beta-blocker, other) were associated with incident P-HPTH after adjusting for potential confounders including age, BMI, race, smoking, menopausal status, physical activity, diabetes status, and dietary factors (intake of calcium, vitamin D, vitamin A, magnesium, protein, and alcohol). 

Results: We documented 361 incident cases of P-HPTH during 1,867,561 person-years of follow-up.  The age-adjusted relative risk for incident P-HPTH associated with hypertension was 1.73 (95% CI: 1.39, 2.17) and multivariate adjusted relative risk was 1.39 (1.06, 1.82). Among participants with a history of hypertension, the use of furosemide was associated with an increased risk for developing P-HPTH (RR=1.72 (1.10, 2.70)). Additional adjustments for concomitant heart failure or chronic kidney disease did not change these results.  No other anti-hypertensive medication class exhibited significant associations with incident P-HPTH.  When compared with participants without a history of hypertension, those with hypertension who did not use furosemide had a multivariable adjusted RR=1.45 (1.09, 1.94) for incident P-HPTH, whereas participants with hypertension who did use furosemide had an adjusted RR=2.55 (1.53, 4.26).

Conclusions: In a large longitudinal prospective cohort study, history of hypertension and use of furosemide were both independently associated with an increased risk of developing P-HPTH in women.

 

Nothing to Disclose: AV, JP, GC, ET

PP29-4 18501 4.0000 SAT-245 A Hypertension, Anti-Hypertensive Medications, and Risk of Incident Primary Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 11:30:00 AM PP29 5962 11:15:00 AM Metabolic Bone Disease - Pathophysiology and Treatment Poster Preview


Yongfeng Song*1, Chao Xu2, Shanshan Shao3, Ling Gao4 and Jiajun Zhao4
1Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, 2Shandong Provincial Hospital affiliated to Shandong University, Department of Endocrinology and Metabolism, China ;, Jinan, Shandong, 3Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, Shandong, 4Shandong Provincial Hospital affiliated to Shandong University, Jinan, China

 

Bile acids (BAs) play a crucial role in dietary fat digestion and in the regulation of lipid, glucose, and energy metabolism. Thyroid-stimulating hormone (TSH) is a hormone produced by anterior pituitary gland, whose direct regulation on metabolic pathways has begun to emerge from recent studies. However, the impact of TSH on BA homeostasis remained largely unknown.

Methods: We analyzed serum BAs and TSH levels in healthy volunteers under strict control of caloric intake. Thyroidectomised rats were injected with different dose of TSH in the presence of given thyroxine, Tshr(-/-) mice were supplemented with thyroxine and C57BL/6 mice were injected with Tshr-siRNA via tail vein. Serum BA levels, BA pool size, and fecal BA excretion rate were measured, respectively. The regulation of SREBP-2, HNF-4α and CYP7A1 by TSH were analyzed using luciferase reporter, RNAi, EMSA and CHIP assays.

Results:Serum TSH and BA levels showed a negative relationship in healthy volunteers. Following TSH administration, BA contents and CYP7A1 activity decreased in thyroidectomised rats supplemented with thyroxine. When Tshr was silenced in mice, the BA pool size, fecal BA excretion rate and serum BA levels increased. We identified HNF-4α acts as a critical molecule by which TSH represses CYP7A1 activity. And we further confirmed that mature SREBP-2 protein accumulation can impair the capacity of nuclear HNF-4α binding to CYP7A1 promoter, which mediated the effects of TSH.

Conclusions: TSH represses hepatic BA synthesis via SREBP-2/HNF-4α/CYP7A1 axis which strongly supports that TSH is an important physio-pathological regulator of BA homeostasis in liver independently of thyroid hormones.

 

Nothing to Disclose: YS, CX, SS, LG, JZ

PP28-1 19058 1.0000 SAT-525 A Thyroid-Stimulating Hormone (TSH) Regulates Hepatic Bile Acid Homeostasis Via Srebp-2/Hnf-4α/CYP7A1 Axis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 11:30:00 AM PP28 5982 11:15:00 AM Lipids - Liver, Muscle, and Patient Poster Preview


Alper Sonmez*, Teoman Dogru, Cemal Nuri Ercin, Halil Genc, Gurkan Celebi, Hasan Gurel, Serkan Tapan, Ali Fuat Cicek, Cem Barcin, Cem Haymana, Omer Azal and Sait Bagci
Gulhane School of Medicine, Ankara, Turkey

 

Aims

Betatrophin, the novel liver derived hormone, regulates glucose and lipid metabolism. No data is present about the effect of liver diseases on betatrophin levels. We measured betatrophin levels in biopsy-proven nonalcoholic fatty liver disease (NAFLD) and compared to those of the healthy controls. The relationship of betatrophin to the liver histology, liver enzymes and other metabolic parameters were also investigated.

Methods

Fifty males with NAFLD and 30 healthy controls were included. Betatrophin concentrations were measured by ELISA kit. Insulin sensitivity was assessed by homeostasis model assessment of insulin resistance (HOMA-IR) index. Histological features; steatosis, lobular inflammation, and hepatocyte ballooning were scored by the semi quantitative classification and combined as the NAFLD activity score (NAS).

 

Results

Betatrophin levels in the NAFLD group were not significantly different from the healthy subjects, but positively correlated to the age, waist circumference, total cholesterol, triglycerides (TG), LDL cholesterol, fasting glucose, insulin, HOMA-IR index and gamma glutamyl transpeptidase levels and negatively correlated to the steatosis and NAS. In the stepwise linear regression analysis, the TG (β=0.457, p<0.001), glucose (β=0.281, p=0.02) and NAS (β=-0.260, p=0.03) were the independent determinants of betatrophin.

 

Conclusion

The results imply that the liver injury in the early stages of NAFLD, may decrease the betatrophin levels. This could be an important preliminary mechanistic finding to explain the increased frequency of glucose intolerance during the course of NAFLD. Whether the possible association of the betatrophin levels to the well-established cardiovascular risk factors is a liver defense warrants further studies.

 

Nothing to Disclose: AS, TD, CNE, HG, GC, HG, ST, AFC, CB, CH, OA, SB

PP28-2 19910 2.0000 SAT-528 A Betatrophin Levels Are Related to the Early Histological Findings in Nonalcoholic Fatty Liver Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 11:30:00 AM PP28 5982 11:15:00 AM Lipids - Liver, Muscle, and Patient Poster Preview


Paresh Dandona*1, Husam Ghanim2, Kelly Green3, Sanaa Abuaysheh4, Antoine Makdissi2 and Ajay Chaudhuri1
1Diabetes and Endocrinology Center of Western New York, Buffalo, NY, 2State University of New York at Buffalo, Buffalo, NY, 3SUNY at Buffalo, 4Suny at Buffalo

 

Our previous work has shown that the ingestion of cream induces an increase in reactive oxygen species (ROS) generation and other cellular and molecular indices of inflammation by peripheral blood mononuclear cells (MNC). Similar increases are observed after the intake of a high fat high carbohydrate meal. Since vytorin, containing the combination of simvastatin and ezetamibe, has a profound effect on lowering plasma concentrations of LDLc, which exerts a pro-inflammatory effect, we hypothesized that vytorin intake in type 2 diabetic patients may exert an anti-inflammatory effect and also inhibit the pro-inflammatory effect of cream. Twenty type 2 diabetic patients were randomized to either vytorin or placebo treatment for 6 weeks. Patients in both groups were asked to ingest 33g of cream (= 300 Calories) containing a large amount of saturated fat and fasting and post-cream challenge blood samples were obtained at baseline and at 6 weeks. The two treatment arms had comparable, age, BMI, HbA1c and gender distribution at baseline. Total cholesterol and LDLc concentrations were lowered significantly at 6 weeks following vytorin (P<0.05). Cream induced significant increases in MNC expression of IL-1β (by 105±18%), TNFα (by 97±12%), CD68 (by 48±8%), PECAM (by 66±10 %), TLR-4 (by 84±11%) and TLR-2 (by 67±9%) at 0 week. The MNC expression of IL-1β and CD68 expression both fell in the fasting state (by 21±7 and 24±10, P<0.05) compared to baseline at 0 week and following cream (by 74±15% and 68±13%, respectively, compared to increase at 0 week, P<0.05) in the vytorin group. The increase in expression of TNFα and PECAM following cream was also suppressed significantly (by 67±14% and 45±9%, respectively, compared to the increase at 0 week) in the vytorin group. In addition, there was a paradoxical suppression of the expression of Cream induced increases in expression of TLR-2 and TLR-4 (by 21±8% and 18±7%, respectively, compared to baseline) following cream at 6 weeks in vytorin group.  Vytorin treatment also suppressed fasting and cream induced increase in LPS concentrations in plasma (by 24% and 26%, P<0.05, compared to baseline at 0 week). Fasting concentrations of CRP, FFA and IL-18 also fell by 32±11%, 19±8% 15±4%, respectively, (p<0.05) following vytorin treatment. We conclude that vytorin exerts a powerful anti-inflammatory effect and reduces expression of pro-inflammatory mediators following cream challenge. Finally, it also reverses the action of cream from one of induction of TLR-4 and TLR-2 to one of paradoxical suppression of the expression of these receptors. Our data do not indicate whether it is the simvastatin or ezetamibe which is responsible for these intriguing and potent effects.  This issue will need further investigation.

 

Nothing to Disclose: PD, HG, KG, SA, AM, AC

PP28-3 22087 3.0000 SAT-530 A Vytorin Inhibits and Reverses the Pro-Inflammatory Effects of Cream on Peripheral Blood Mononuclear Cells in Type 2 Diabetic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 11:30:00 AM PP28 5982 11:15:00 AM Lipids - Liver, Muscle, and Patient Poster Preview


Haeri Baek*1, Sohee Kim1, Jisun Nam2, Chul Woo Ahn1, Min Seon Kim3, IE Byung PARK4 and Jae Myung Yu5
1Gangnam Severance Hospital, Seoul, Korea, Republic of (South), 2College of Medicine, Yonsei University, Gangnam Severance Hospital, 3Division of Endocrinology and Metabolism, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South), 4Division of Endocrinology and Metabolism, Dept. of Internal Medicine., Incheon, Korea, Republic of (South), 5College of Medicine, Hallym University, Seoul, Korea, Republic of (South)

 

BACKGROUND

Dyslipidemia is known as major risk factor of cardiovascular disease. Generally, the main therapeutic target of dyslipidemia is lowering low-density lipid cholesterol level. However, serum triglyceride level and high density lipid cholesterol level are also important to those patients with type 2 diabetes. 

The aim of this study was to evaluate the effect of omega-3 fatty acids supplementation on lipid metabolism, inflammatory marker, metabolic profile, body mass index and the changes of appetite in patients with type 2 diabetes.

METHODS

This study was conducted as multicenter prospective trial. Thirty type 2 diabetic patients who visited 4 Korean tertiary medical centers, from April 2012 to August 2014, received omega-3 fatty acid concentration 2.0 mg per day for first 2 weeks, and then 4.0mg per day for following 8 weeks. Lipid profile, inflammatory marker, metabolic profile including body mass index, plasma fasting glucose and HbA1c, serum insulin, appetite questionnaire including G-FCQ-T(General Trait of Food Craving Questionnaires) and G-FCQ-S (Food Craving Questionnaires with Visual Stimulation of High Carbohydrate and Low Fat foods and Low Carbohydrates and High Fat foods) were measured before and after omega-3 fatty acids supplementation.

RESULTS

There were significant decreases in total cholesterol (183.37±33.58 vs. 175.60±36.29, p=0.009), triglyceride (245.00 ± 53.56 vs. 205.93 ± 103.28, p=0.023), non-high density lipid cholesterol (139.93±29.88 vs. 131.40 ± 33.74, p=0.007), low density lipid cholesterol (110.57±32.85 vs. 95.80±31.15, p=0.001), APO A1 (137.76±16.63 vs. 131.40±33.74, p=0.004) in total study population after 10 weeks of omega-3 supplementation. Body weight (71.69±11.39 vs. 71.06±11.64, p=0.095), body mass index (26.73±1.79 vs. 26.45±2.07, p=0.059), waist circumference (92.16±7.55 vs. 89.08±15.31, p=0.157), HOMA-IR (4.49±3.67 vs. 3.99±2.84, p=0.423) decreased, but was not statistically significant.  The markers of appetite assessed from FCQ-T (50.28±15.93 vs. 42.14±13.06, p<0.001) and FCQ-S (36.45±11.51 vs. 31.66±11.48, p=0.008) were also decreased. The changes of FCQ-T value over 10 weeks significantly correlated with the changes of serum fasting glucose (γ=-0.374, p=0.045).

CONCLUSIONS

In patients with type 2 diabetes, supplementation of omega-3 fatty acids had favorable effects on metabolic parameters as well as reducing appetite which related with the decrease of waist circumference and HOMA-IR.

 

Nothing to Disclose: HB, SK, JN, CWA, MSK, IBP, JMY

PP28-4 19705 4.0000 SAT-522 A The Prospective Multicenter Study to Assess the Metabolic and Endocrine Changes of Omega-3 Polyunsaturated Fatty Acids in Type 2 Diabetic Patients with Dyslipidemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 11:30:00 AM PP28 5982 11:15:00 AM Lipids - Liver, Muscle, and Patient Poster Preview


Pia Burman*1, Britt Eden Engström2, Bertil Ekman3, F Anders Karlsson2, Erik Schwarcz4 and Jeanette Wahlberg3
1Skane University Hospital, University of Lund, Malmö, Sweden, 2University Hospital, Uppsala, Sweden, 3Linköping University, Linköping, Sweden, 4University Hospital, Örebro, Sweden

 

Background Cabergoline has been used as monotherapy for treatment of ACTH-dependent Cushing’s syndrome. The experience is limited to case reports and a few open studies in selected patients. Varying results have been presented.

 Objective To document salivary, serum, and urinary free cortisol (UFC) during a six-week trial with cabergoline in treatment-naive patients with Cushing’s disease, subsequently subjected to pituitary surgery.

 Study Design 20 patients were given increasing doses of cabergoline, 0.5-5 mg/week over 6 weeks. 24h UFC, morning cortisol and ACTH, and salivary cortisol at 08, 16, and 23h were monitored once weekly throughout the study. Diurnal curves of six samples of serum cortisol were measured at start and end. Response to treatment was defined as >50% decrease in UFC between the start and stop of treatment. Prolactin serum levels served as markers of compliance.

 Results The median cabergoline dose reached at the end of study was 5 mg, range 3-5 mg/week. Prolactin levels were suppressed in all patients during treatment. Five patients had a >50% reduction of UFC between start and stop, another patient had a normalization of UFC, three patients had a >50% rise of UFC. Salivary cortisol at 23h showed a congruent >50% change with UFC in 2 of 6 ’responders’, and in 1 of 3 ’progressors’. Morning ACTH determined throughout the study did not correlate with the UFC levels. In the 2 ’responders’ who had consistent biochemical changes over the 6-week treatment period, including a lowering of mean diurnal cortisol, the amelioration of hypercortisolism occurred within the first 2-4 weeks.

 Conclusions Cabergoline seems to be of limited value in treatment of Cushing’s disease. Given the variability of the course of hypercortisolism characteristic of the disease, the two responders (10%) might represent a chance finding, or a genuine effect of cabergoline on corticotrophic tumors with exceptional dopamine sensitivity

 

Nothing to Disclose: PB, BE, BE, FAK, ES, JW

PP24-1 19889 1.0000 SAT-385 A Limited Value of Cabergoline in Cushing's Disease - a Prospective Six-Week Pre-Operative Study in 20 Newly Diagnosed Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 11:30:00 AM PP24 5991 11:15:00 AM Cushing's Disease Poster Preview


Fatemeh G.Amlashi*1, Brooke Swearingen2, Alexander Terence Faje3, Lisa B Nachtigall3, Karen K. Miller3, Anne Klibanski3, Beverly M.K. Biller4 and Nicholas A Tritos3
1Massachusetts General Hospital, Boston, MA, 2Massachusetts General Hospital and Harvard Medical School, Boston, MA, 3Massachusetts General Hospital/Harvard Medical School, Boston, MA, 4Neuroendocrine Unit, Boston, MA

 

Late-night salivary cortisol (LNSC) is an established test in the diagnosis of Cushing’s disease (CD). However, the accuracy of LNSC during follow up in patients undergoing transsphenoidal surgery (TSS) has not been well-characterized. We therefore examined the role of LNSC in establishing remission and predicting recurrence after TSS.

Medical records of all 165 patients with CD who underwent TSS in our Institution between 2005-2014 were analyzed. Data extracted include demographic and clinical characteristics, am serum cortisol, 24 hr urine free cortisol (UFC) and LNSC levels, obtained before and after TSS and at the most recent follow-up visit. LNSC levels were measured (normal range ≤4.3 nmol/l) with a single immunoassay (ACL, West Allis, WI). Remission was defined as am serum cortisol <5 mcg/dl and 24 hr UFC<23 mcg within 3 months after TSS; in addition, five patients were considered in remission based only on low 24 hr UFC. Recurrence was defined based on clinical diagnosis and considered definite if confirmed surgically. Non-parametric statistical techniques and receiver operating characteristic (ROC) curve analysis were performed.

There were 85 patients [71 women, 14 men, median age 43.2 yr (range: 17.8-84.2 yr)], including 76 (89%) with microadenomas and 9 (11%) patients with macroadenomas, who underwent their first TSS and had all three evaluated tests available. Overall early remission rate was 89% after first TSS (88% in microadenomas and 100% in macroadenomas). The median nadir early postoperative LNSC (obtained within 3 months after TSS) was 0.6 nmol/l (range: 0.3-29.9). Lower nadir early (within 3 months) postoperative LNSC were associated with higher likelihood of remission (P<0.0001). A LNSC cutpoint of 1.9 nmol/l established remission with 93% sensitivity and 89% specificity [area under the curve (AUC): 0.96 on ROC analysis].

Recurrence (definite in 14 and probable in 4) developed in 27% of 65 patients with available follow-up data after first TSS (including 25% of 56 patients with microadenomas and 44% of 9 patients with macroadenomas). Neither nadir nor maximal early postoperative LNSC (obtained within 3 months after first TSS) predicted recurrence. Among 34 patients with available long-term LNSC data (obtained within 12 months from date of last visit) and a follow-up median interval of 53.4 months (range: 5.8-155 months), a LNSC cutpoint of 7.4 nmol/l predicted recurrence with 75% sensitivity and 95% specificity (AUC: 0.87, P<0.0001). Regarding 24 hr UFC, a cutpoint of 1.6 times the upper limit of normal range predicted recurrence with 68% sensitivity and 95% specificity (AUC: 0.77, P=0.003).

In summary, nadir levels of early postoperative LNSC may accurately establish remission of CD. The maximal LNSC level (measured during the last 12 months of follow up) may predict recurrence more accurately than the corresponding 24 hr UFC levels.

 

Disclosure: LBN: Advisory Group Member, Genentech, Inc., Study Investigator, Ipsen. BMKB: Clinical Researcher, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Clinical Researcher, Cortendo AB, Consultant, Cortendo AB. Nothing to Disclose: FG, BS, ATF, KKM, AK, NAT

PP24-2 20676 2.0000 SAT-386 A Accuracy of Late Night Salivary Cortisol in the Evaluation of Remission and Recurrence in Patients with Cushing's Disease Undergoing Pituitary Surgery 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 11:30:00 AM PP24 5991 11:15:00 AM Cushing's Disease Poster Preview


Susmeeta T. Sharma*1 and Lynnette K. Nieman2
1Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2National Institutes of Health, Bethesda, MD

 

Background: Magnetic Resonance Imaging (MRI) of the pituitary gland is an integral part of the diagnostic testing to differentiate between a pituitary and ectopic source in ACTH-dependent Cushing’s syndrome (CS). However, 10% of the normal adult population can have pituitary abnormalities on MRI scans suggestive of an adenoma (3-6mm) without any overt hormonal dysfunction (1). Many patients with ectopic ACTH syndrome (EAS) undergo unnecessary transsphenoidal pituitary surgery based on a possible lesion visualized on MRI of the pituitary gland (2). Our aim here is to determine the prevalence of incidental pituitary abnormalities suggestive of a possible microadenoma on MRI scans in patients with EAS.

Methods: We conducted a retrospective study of all CS patients diagnosed with EAS at the National Institutes of Health from 1993 to 2014. Patients were classified as EAS or Cushing’s disease (CD) based on pathology, or as ‘occult’ if testing including inferior petrosal sinus sampling (IPSS) suggested EAS but no tumor was found. MRI with and without gadolinium contrast enhancement with standard spin echo sequences was used in all cases and spoiled gradient recalled acquisition sequences were added starting in 1997.

Results: Eighty-five patients (46 females, 39 males) with ACTH-dependent CS were diagnosed with EAS (proven = 60, occult = 25). Ten (11.8%) patients had undergone unsuccessful transsphenoidal surgery prior to definitive diagnosis of EAS, two of them with more than one unsuccessful attempt. MRI Pituitary was not performed in five patients (contraindications or obvious metastatic disease) and imaging data was not available in four patients with EAS. Of the 76 patients (54 proven EAS, 22 occult) where MRI pituitary data was available, 16 (29.6%) patients with proven EAS and 5 (22%) patients with occult EAS were found to have a hypointense lesion suggestive of a pituitary adenoma on MRI scan, size ranging from 3 to 7.5 mm. None of the patients with incidental pituitary abnormalities had signs or symptoms suggestive of hypersecretion of other pituitary hormones or a personal or family history indicative of genetic syndromes like multiple endocrine neoplasia, McCune Albright syndrome, Carney complex or familial isolated pituitary adenoma. 

Conclusion: Incidental pituitary abnormalities suggestive of a microadenoma (as large as 7mm) can be seen in a significant proportion of patients with EAS. Undue reliance on pituitary MRI findings without clear biochemical diagnosis can lead to unnecessary surgery and delay in diagnosis. Biochemical testing including IPSS performed in the setting of hypercortisolemia remains essential for proper diagnosis of EAS or CD.

 

Disclosure: LKN: Editor, Up To Date, Clinical Researcher, HRA Pharma. Nothing to Disclose: STS

PP24-3 21315 3.0000 SAT-387 A MRI Pituitary Findings in Ectopic Cushing's Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 11:30:00 AM PP24 5991 11:15:00 AM Cushing's Disease Poster Preview


Ricardo R Correa*1, Maria Batsis2, Prashant Chittiboina3, Pooja Raghavan4, Elena Belyavskaya5, Charalampos Lyssikatos6, Maya Beth Lodish2 and Constantine A Stratakis2
1National Institutes of Health, Bethesda, MD, 2National Institutes of Health (NIH), Bethesda, MD, 3National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD, 4National Institutes of Health, North Bethesda, MD, 5Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD, 6Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD

 

Introduction: Cushing disease (CD) is a rare condition in children. It is defined as hypercortisolism due to overproduction of ACTH by a pituitary adenoma. Most of these are microadenomas defined as being less than 1 cm. However, there are a small percentage of CD patients with pituitary macroadenomas (>=1cm). In adult patients with CD, it has been documented that macroadenomas behave differently biochemicaly and clinically than microadenomas. Our objective was to see whether this was also true in children (<18 years): are macroadenomas causing CD in children different than microadenomas?

Methods:A retrospective review of all patients <18 years of age admitted to the National Institute of Health (NIH), with the diagnosis of CD confirmed by pathology between 1997-2014 was performed.

Results: Of 87 patients identified, 13 were determined to have pituitary macroadenoma and 74 microadenoma based on imaging; 9/13 (69%) in the macroadenoma group and 43/74 (58%) in the microadenoma group were females. The mean age±SD in both groups were similar (14±6.4 vs 14±5.4yr). The mean BMI±SD was also similar in both groups (31.8±7.5 kg/m2 for macroadenoma and 30.2±15.4 kg/m2 for microadenoma group). The median (25%-75%) baseline 24-hr urine UFC was 263.60 mcg/24hr (170.7-528.0) for macroadenomas and 371.6 mcg/24hr (244.2-625.3) for microadenomas (P=0.47). The baseline median 24-hr urinary 17-hydroxysteroid excretion was 12.6 mg/24 hr (range 8.9-42.5) and 31.6 mg/24 hr (range 4.3-39.9) for macroadenomas and microadenomas, respectively. Mean 0800-0900 hr serum cortisol was 38.9±40.4 mcg/dl in macroadenomas compared to 20.2±15.8 mcg/dl in microadenomas (P=0.16). Basal plasma ACTH 0800-0900 hr (mean±SD) was 106.3±112.3 pg/ml for macroadenomas vs 49.9±44.3 pg/ml for microadenomas (P=0.11). In the ACTH responses to ovine CRH test there were also no statistically significant differences. Using the high dose dexamethasone suppression test, 58% (7/12) suppressed more than 69% in the macroadenoma group compared to 69% (44/64) in the microadenoma group (P=0.51).

Discussion: Studies in adult patients have demonstrated that macroadenomas have less glucocorticoid suppressibility after the high-dose dexamethasone suppression test and attenuated ACTH response to CRH compared to pituitary microadenomas. However, the present study shows that this is not true in children; although patients with macroadenomas had a tendency for higher baseline serum ACTH and cortisol levels, their responses to dynamic testing were similar to those with microadenomas.

 

Nothing to Disclose: RRC, MB, PC, PR, EB, CL, MBL, CAS

PP24-4 21587 4.0000 SAT-389 A Cushing Disease Due to Pituitary Macroadenoma:  Biochemical Characteristics in a Pediatric Cohort 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 11:30:00 AM PP24 5991 11:15:00 AM Cushing's Disease Poster Preview


Elena Daniela Aflorei*1, Serban Radian1, Chenghao Chen2, Benjamin Klapholz3, Nick Brown3, Ralf Stanewsky2 and Márta Korbonits1
1William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 2Cell & Developmental Biology, London, 3The Gurdon Institute, Cambridge

 

Introduction: Twenty percent of Familial Isolated Pituitary Adenoma families harbor a heterozygous germline loss-of-function mutation in the aryl hydrocarbon receptor interacting protein (AIP) gene. While protein-truncating mutations of this highly conserved tumour-suppressor gene are likely to be disease causing, the pathogenic role of some of the missense mutations is more difficult to characterise. Consequently, these missense mutations pose challenging genetic counselling issues.

Aim: We propose to utilise the fruitfly to create a model of AIP orthologue knockout and rescue this model with human AIP. We also proposed to use the Drosophila AIP knockout as a functional in vivo assay to test the disease capacity and to characterise the putative disease-causing human variants.

Methods: The Drosophila melanogaster AIP orthologue is the CG1847 gene located on the X chromosome. CG1847 knock-out was generated by deleting two of the three exons (CG1847exon1_2). To functionally test the homology between human AIP and CG1847, a UAS::humanAIPwt construct was made. We also generated five UAS::humanAIP constructs carrying either a truncated human AIP variant or four missense mutations identified in FIPA families: p.R16H, p.C238Y, p.A299V, and p.304Q. Microinjection of these constructs into fruitfly embryos enabled us to obtain transgenic fruitflies carrying wild-type or mutant human AIP sequences.

Results: The CG1847 knockout mutant is lethal in males. A construct containing wild-type fruitfly CG1847 was able to rescue the lethality of the CG1847exon1_2 male mutants. Strikingly, the wild-type human AIP gene can also rescue the lethality of the Drosophila melanogaster CG1847 knockout model, demonstrating that CG1847 is a true functional homologue of AIP. Conversely, a C-terminus truncated human AIP mutant transgene did not rescue the lethality. The fruitfly lethality was also rescued by 3 missense variants: p.R16H, p.A299V, and p.304Q. The p.C238Y missense variant (known to disrupt the TPR domain of AIP), however, was unable to rescue the lethality of the CG1847 knockout.

Conclusions: We were able to rescue the lethality of fruitfly CG1847exon1_2 mutant with human AIP, confirming that AIP is a highly conserved gene throughout evolution. Based on our rescue experiment results with missense AIP variants, we propose that this system could be used as a functional test for human AIP variants with unknown pathogenicity.

Acknowledgments: This work was supported by the William Harvey Research Foundation (grant number #2011-5).

 

Nothing to Disclose: EDA, SR, CC, BK, NB, RS, MK

PP35-1 19547 1.0000 SAT-440 A Functional Homology Between Human and Fruitfly AIP Protein - an in Vivo assay System to Test the Pathogenicity of AIP Mutations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 11:30:00 AM PP35 6003 11:15:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Poster Preview


Tatiana Fiordelisio*1, Karine Rizzoti2, Patrick Samper3, Chrystel Lafont4, Shannon William Davis5 and Patrice E Mollard4
1Facultad de Ciencias, Universidad Nacional Autonoma de México, México, Mexico, 2NIMR/MRC, LONDON, United Kingdom, 3Institute of Functional Genomics, Montpellier, France, 4IGF-CNRS, Montpellier, France, 5University of South Carolina, Columbia, SC

 

During the past 20 years, the developmental program of pituitary endocrine cells has been extensively described. However, practically nothing is known about the origin of the pituitary portal system, which mainly consists of fenestrated capillaries formed by endothelial cells covered by pericytes and extracellular matrix. Since a defective portal system is a signature of numerous pituitary pathologies, elucidation of its embryonic development  is important. Moreover, mutations in HESX1, LHX4, OTX2, SOX3, PROKR2, and GPR161 have been associated with some cases of pituitary stalk interruption syndrome (PSIS) albeit the roles of these genes in the development and function of the portal system remain largely unknown. This prompted us to perform lineage tracing studies of the portal system and pituitary using mouse models. Using Mesp1Cre; Rosa26ReYFP mice we observed that endothelial cells have a mesodermal origin in both compartments. At 14.5dpc, these form a vascular network at the base of the third ventricle, around the infundibulum and in the developing gland. Using both Wnt1-cre, Sox10-Cre and Mesp1-cre mouse, we unveiled that portal pericytes form two distinct populations, with a dual developmental origin, namely from the neuroectoderm and the mesoderm. In the embryo, NG2-ve;PDGFRβ+ve pericytes are observed in the progeny of Wnt1 or Sox10+ve cells, while Mesp1+ve cells give rise to NG2+ve;PDGFRβ+ve pericytes. The identification of portal system origin described here will allow future investigation of how the pituitary portal vessels function, not only during periods of normal physiological demand (e.g., the preovulatory LH surge) but also when the microvasculature is altered (e.g., hypopituitarism with PSIS).

 

Nothing to Disclose: TF, KR, PS, CL, SWD, PEM

PP35-2 20364 2.0000 SAT-443 A Developmental Program of the Pituitary Portal System 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 11:30:00 AM PP35 6003 11:15:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Poster Preview


Louise Cheryl Gregory*1, Robert Hufnagel2, Juan Pedro Martinez-Barbera1, Mehul Tulsidas Dattani3, Gavin Arno4, Nichole D Hein5, Joshua Hersheson6, Megana Prasad7, Yvonne Anderson8, Laura A Krueger9, Corinne Stoetzel7, Thomas J Jaworek9, Sarah Hull4, Abi Li6, Vincent Plagnol10, Christi M Willen11, Thomas M Morgan12, Cynthia A Prows9, Rashmi S Hedge9, Saima Riazuddin13, Gregory A Grabowski2, Gregory A Grabowski2, Rudy J Richardson5, Klaus Dieterich14, Taosheng Huang9, Tamas Revesz6, Robert A Sisk9, Craig Alan Jefferies15, Henry Houlden6, John K Fink5, Helene Dollfus7, Anthony T Moore4 and Zubair M Ahmed2
1UCL Institute of Child Health, London, United Kingdom, 2Cincinnati Children's Hospital, Cincinnati, OH, 3UCL GOS Institute of Child Health, London, United Kingdom, 4UCL Institute of Ophthalmology and Moorfields Eye Hospital, London, United Kingdom, 5University of Michigan, Ann Arbor, MI, 6UCL Institute of Neurology, London, United Kingdom, 7Laboratoire de génétique Médicale, IGMA, INSERM U1112, Université de Strasbourg, FMTS, Strasbourg, France, 8Taranaki Base Hospital, New Plymouth, New Zealand, 9Cincinnati Children’s Hospital, Cincinnati, OH, 10University College London, London, United Kingdom, 11University of Kentucky, Lexington, KY, 12Vanderbilt University, Nashville, TN, 13University of Maryland, Baltimore, MD, 14Hôpital Couple Enfant, CHU Grenoble and Grenoble Institut des Neurosciences, Equipe Muscle et Pathologie, Inserm U836, Grenoble, France, 15Starship Children’s Hospital, Auckland, New Zealand

 

Introduction: Oliver-McFarlane and Laurence-Moon syndromes are rare recessively inherited disorders of unknown etiology. The first is characterized by trichomegaly, congenital hypopituitarism, with the vast majority having hypogonadotropic hypogonadism, and retinal degeneration with choroidal atrophy. The latter is similar to the former, but presents with spastic paraplegia without trichomegaly. Results: Through exome sequencing, we have identified compound heterozygote mutations in the PNPLA6 gene incorporating eight different mutations, six of which are novel, in six patients with Oliver-McFarlane syndrome and four previously reported patients with Laurence-Moon syndrome. Here we focus on two out of the ten patients: patient 1 was a 27 year old male with micropenis and cryptorchidism, short stature (height 148 cm; -4SDS), dysmorphic features including a triangular shaped face, pointed chin, deviated nasal bridge, prominent and cupped ears, deep set eyes, and brachycephaly. This patient also had GH (peak 0.7μg/L) deficiency (GHD), complete gonadotrophin deficiency (absent LH, FSH responses on a GnRH test) and a small anterior pituitary (AP) on MRI. Patient 2 was an 8 year old male who presented with micropenis with normal testes, short stature (height 117.5cm, -1.6SDS; mid-parental height +1 SDS), GHD (peak 2.8 μg/L), probable hypogonadotropic hypogonadism and a small AP with a normal posterior pituitary on MRI. Intriguingly, these syndromes appear to be progressively degenerative with a gradual reduction in the size of the pituitary. PNPLA6 encodes neuropathy target esterase (NTE), a phospholipase that hydrolyzes phosphatidylcholine and maintains axonal integrity. PNPLA6 expression in human embryonic tissue was established in the developing human eye, pituitary and brain, which is consistent with the clinical phenotype seen in the patients. In zebrafish, the pnpla6 curly-tailed morphant phenotype was fully rescued by the wild type human PNPLA6 mRNA, though not with mutation-harbouring mRNAs. Consistent with molecular modelling predictions, NTE enzymatic activity was significantly reduced in all fibroblast cells derived from affected individuals. Conclusions: Biallelic mutations are required for the development of PNPLA6-associated diseases. Disease severity and congenital onset of Oliver-McFarlane and Laurence-Moon syndromes correlates with a more drastic reduction in NTE activity compared to the adult-onset spastic paraplegia type 39 (SPG39) disorder (75-80% compared to 25% reduction), suggesting that disease phenotypes correlate with NTE activity in a tissue-specific and dose-dependent manner. Expression and functional studies reveal a wider spectrum of neurodevelopmental and neurodegenerative conditions caused by NTE impairments, adding congenital pituitary disorders and trichologic involvement to the PNPLA6 spectrum.

 

Nothing to Disclose: LCG, RH, JPM, MTD, GA, NDH, JH, MP, YA, LAK, CS, TJJ, SH, AL, VP, CMW, TMM, CAP, RSH, SR, GAG, GAG, RJR, KD, TH, TR, RAS, CAJ, HH, JKF, HD, ATM, ZMA

PP35-3 19203 3.0000 SAT-441 A Neuropathy Target Esterase Impairments Cause Oliver-Mcfarlane and Laurence-Moon Syndromes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 11:30:00 AM PP35 6003 11:15:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Poster Preview


Surya Panicker Rajeev*1, C Steele2, Sumudu Bujawansa2, David Husband3, Atik Baborie4, Ksv Das4, C Gilkes5 and Christina Daousi2
1Aintree University Hospital, Liverpool, 2Aintree University Hospital, 3Clatterbridge Centre for Oncology, 4The Walton Centre for Neurology and Neurosurgery, Liverpool, 5The Walton Centre for Neurology and Neurosurgery, Liverpool,

 

Background

Temozolomide has proven useful in the management of pituitary carcinomas and aggressive pituitary adenomas. Most of the literature comprises of prolactin and ACTH secreting adenomas with relative scarcity of GH secreting tumors. We report two cases of aggressive somatotroph adenomas treated with Temozolomide (TMZ).

Clinical Cases

Patient 1

A 30-year-old female with acromegaly presented in 1997 with pituitary apoplexy and underwent emergency transsphenoidal surgery (TSS). Post-operatively she received radiotherapy and subsequently remained radiologically and biochemically stable on somatostatin analogue (SSA).Between 2006-2009 she underwent repeat TSS followed by three craniotomies for massive, symptomatic recurrences. Her MRI scan showed a large, invasive residual adenoma. She deteriorated clinically and biochemically.

In 2009 she was started on oral TMZ 150 mg/m2 for 5 days in 28-day cycles. After 12 months of treatment more than 80 % reduction in the size of the tumor had been achieved and temozolomide was discontinued. Ten months later there were signs of clinical and radiological progression and she was re-commenced on a higher dose of TMZ (300 mg/m2) for six months with no effect.Alternative chemotherapy in the form of etoposide (50 mg twice daily for 10 days of 28-day cycle) was trialled, well tolerated and the patient attained clinical and radiological stability which continues to date.

 Patient 2

 A 40-year-old female with acromegaly underwent emergency TSS in 1996 for pituitary apoplexy. Biochemistry and post-operative histology confirmed a somatotroph adenoma. She had fractionated radiotherapy in 1997, stereotactic radiosurgery in 2003, and craniotomy in 2008 for tumor regrowth and remained stable on SSA till 2011 when rapid increase in the size of the residual tumor occurred with visual compromise and seizures. She was started on oral TMZ (150mg/m2 every 5 days of a 28-day cycle) but this was discontinued after 5 cycles due to clinical, radiological and biochemical deterioration. Alternative chemotherapy in the form of Lomustine (CCNU) was administered orally for 4 days every 4 weeks. Within 6 months of treatment radiological and clinical response was observed which continues to date (24 months after start of treatment).

 Clinical Lesson

Our two cases add to the very limited body of literature available to date on the treatment response to TMZ of aggressive somatotroph adenomas. Similar to the other 3 cases reported so far on the use of TMZ in the management of aggressive, GH only secreting adenomas, treatment outcome in our patients was also negative, which strengthens the postulation from available evidence that this group of patients might be intrinsically less responsive to TMZ. We also report our experience with the use of other conventional, chemotherapeutic agents and if tolerated, these may need to be used to manage tumor progression and clinical deterioration.

 

Nothing to Disclose: SPR, CS, SB, DH, AB, KD, CG, CD

PP35-4 19815 4.0000 SAT-442 A Temozolomide in the Management of Aggressive, Somatotroph Pituitary Adenomas- a Single Centre Experience from the United Kingdom 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 11:30:00 AM PP35 6003 11:15:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Poster Preview


Sara Klinepeter Bartz*1, Maria Claudia Caldas2, Rajesh Krishnamurthy1, Ramkumar Krishnamurthy1 and Fida F Bacha3
1Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 2Baylor College of Medicine, Houston, TX, 3Children's Nutrition Research Center, Houston, TX

 

Background: Polycystic Ovary Syndrome (PCOS) has been associated with increased cardiovascular disease (CVD) risk in adult women.  We tested the hypothesis that girls with PCOS have evidence of endothelial dysfunction, a marker of subclinical atherosclerosis, and this was related to insulin resistance in girls with PCOS compared with non-PCOS controls. 

Methods: 14 adolescents with PCOS (on no pharmacotherapy) and 7 non-PCOS (NIH criteria) controls underwent oral glucose tolerance testing, fasting lipids, body composition (DXA scan), abdominal fat distribution (MRI), hyperinsulinemic-euglycemic clamp with [6,6-2H2] glucose stable isotope infusion with determination of hepatic insulin sensitivity (HIS), insulin stimulated glucose disposal rate (Rd),  and peripheral IS expressed per fat free mass (ISFFM), endothelial function by peripheral arterial tonometry with determination of reactive hyperemia index (RHI), and circulating  inflammatory markers. Results are presented as mean ± SEM.

Results: The PCOS and non-PCOS groups had similar age, tanner stage, race, glucose tolerance status, BMI (34.1 ± 1.1 vs. 30.4 ± 1.6 kg/m²), % body fat (38.2±1.1 vs. 38.4±1.7%), and total abdominal and visceral fat (94.3±10.8 vs. 63.2±9.0 cm2).  Girls with PCOS had higher free testosterone (FT) levels (9.8±2.4 vs. 3.8±0.5 pg/mL, p=0.031) lower peripheral ISFFM (3.1±0.4 vs. 5.2±0.6 mg/kgFFM/min per µu/ml, p=0.01), and lower hepatic IS (20.1±4.1 vs. 44.4±8.3mg/kg/min per µu/ml-1, p=0.008). There was no significant difference in HbA1C, BP, lipids, hs-CRP or RHI between the 2 groups; adiponectin was lower (9.8±1.9 vs 21.2±6.4 ug/ml, p=0.03), and adhesion molecules [s-ICAM (164.1±11.5 vs. 88.1±8.9 ng/ml, p<0.001), and s-VCAM (706.5±84.1 vs 412.0±43.3 ng/ml, p=0.028)] were higher in PCOS vs. non-PCOS.  The FT level was inversely related to RdFFM (r=-0.52, p=0.02), ISFFM(r=-0.42, p=0.06) and positively related to s-ICAM (r=0.55, p=0.01), s-VCAM (r=0.58, p=0.006) and e-selectin (r=0.5, p=0.02) but not to RHI.  

Conclusion: Despite higher peripheral and hepatic insulin resistance in adolescents with PCOS, endothelial function as reflected by RHI is not significantly lower when compared with controls of similar total body and abdominal adiposity. However, there is evidence of increased vascular inflammation in the girls with PCOS. Hyperandrogenemia, in addition to insulin resistance, may play an important role in modulating vascular inflammation. Overall, these findings are consistent with increased CVD risk in adolescent girls with PCOS.


 

Nothing to Disclose: SKB, MCC, RK, RK, FFB

PP27-1 19856 1.0000 SAT-092 A Role of Insulin Resistance and Hyperandrogenemia in Early Vascular Dysfunction in Adolescents with PCOS 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 11:30:00 AM PP27 6006 11:15:00 AM Hyperandrogenic Ovarian Dysfunction Poster Preview


Frank Gonzalez*, Robert V. Considine, Sarah L. Pardue and Anthony J. Acton Jr.
Indiana University School of Medicine, Indianapolis, IN

 

We have shown that in Polycystic Ovary Syndrome (PCOS), saturated fat ingestion increases reactive oxygen species generation, NFκB activation and cytokine secretion from mononuclear cells (MNC) (1-3). We examined the effect of this same dietary maneuver on the MNC expression of p47phox, the NFκB subunits, p65 and p105, TNFα and IL-6 mRNA; and its relation to insulin sensitivity and the ovarian androgen response to HCG administration.  We studied 16 women with PCOS (8 lean, 8 obese) between ages 18-40, diagnosed on the basis of oligomenorrhea and hyperandrogenemia, and 16 ovulatory controls (8 lean, 8 obese) of similar age.  The mRNA content of p47phox, NFκB subunits, TNFα and IL-6 was determined by real-time quantitative PCR from MNC isolated from blood samples drawn while fasting and 2 hours after dairy cream ingestion.  Insulin sensitivity was derived using the Matsuda Index (ISOGTT). Androgens were measured by RIA from blood samples drawn at 0, 24, 48 and 96 hours after administration of a 5000 IU IM HCG injection.  Compared with lean controls, lean and obese women with PCOS and obese controls exhibited a greater change from baseline (%) in the mRNA content of p47phox (-35.3±15.8 vs. 24.8±16.7, 28.1±15.7, 16.0±14.3, p<0.03), p65 (-33.7±11.6 vs. 9.6±4.7, 23.4±13.4, 7.9±11.0, p<0.006), p105 (-28.7±12.9 vs. 14.9±13.2, 22.1±15.9, 12.2±12.2, p<0.05), TNFα (-37.8±15.0 vs. 20.2±5.5, 31.4±27.2, 19.2±14.7, p<0.04) and IL-6 (-40.6±12.8 vs. 24.8±14.1, 57.6±29.5, 21.0±18.9, p<0.02). Compared with weight-matched controls, women with PCOS exhibited greater area under the curve (AUC) following HCG administration for testosterone (T) (lean: 6305±873 vs. 3651±427, p<0.02; obese: 7668±1229 vs. 3644±247, p<0.002), and androstenedione (A) (lean: 532±35 vs. 299±29, p<0.002; obese: 590±80 vs. 324±48, p<0.001). ISOGTT was negatively correlated with change from baseline (%) in mRNA content of p47phox (r=-0.44, p<0.02), TNFα (r=0.49, p<0.005) and IL-6 (r=-0.53; p<0.002).  Androgen AUC was positively correlated with the change from baseline (%) in mRNA content of p47phox (A: r=0.44, p<0.02), p65 (A: r=0.44, p<0.02), p105 (T: r=0.43, p<0.02; A: r=0.42, p<0.02), TNFα (T: r=0.37, p<0.04; A: r=0.63, p<0.0002) and IL-6 (T: r=0.49, p<0.005; A: r=0.46, p<0.009). These data suggest that in PCOS, the prooxidant, proinflammatory response to saturated fat ingestion begins at the level of MNC gene expression and is independent of obesity. This phenomenon may promote insulin resistance and excess ovarian androgen production.

 

Nothing to Disclose: FG, RVC, SLP, AJA Jr.

PP27-2 19588 2.0000 SAT-091 A Hyperandrogenism Is Linked to Prooxidant, Proinflammatory Gene Expression in Response to Saturated Fat Ingestion in Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 11:30:00 AM PP27 6006 11:15:00 AM Hyperandrogenic Ovarian Dysfunction Poster Preview


Anshu Gupta*1, Daniela Jakubowicz2 and John E Nestler1
1Virginia Commonwealth University, Richmond, VA, 2Tel Aviv University, Tel Aviv, Israel

 

Introduction: Insulin resistance in women with polycystic ovary syndrome (PCOS) is thought to be mediated in part by a deficiency in the insulin-stimulated release of a D-chiro-inositol-inositolphosphoglycan (DCI-IPG) mediator of insulin action. Supporting this idea, several studies have reported improved insulin sensitivity in both lean and obese women with PCOS after oral administration of DCI.  Pioglitazone is an insulin-sensitizing drug that improves insulin sensitivity in women with PCOS, but it is unknown whether this may be in part due to enhanced insulin-stimulated release of the DCI-IPG second messenger.

Objective: To determine if pioglitazone increases the release of biologically active DCI-IPG per unit insulin released during oral glucose tolerance test (OGTT).

Design: Thirty two obese women with PCOS were randomized in a double-blind placebo-controlled trial  for treatment with either  pioglitazone 45 mg daily or matched placebo for six months.

Outcome measure(s): AUC of DCI-IPG (AUCDCI-IPG), AUC of insulin (AUCinsulin), and the ratio of AUCDCI-IPG to AUCinsulinduring a 2-hour 75 g oral glucose challenge.

Results: After treatment with pioglitazone, mean AUCinsulin during the OGTT decreased significantly from baseline within both the pioglitazone (6649.39±236.67 to 3634.58±152.74 μIU.min/ml  p<0.0001) and placebo groups (7595.57±269.11 to 6560.63±189.22 μIU.min/ml, p=0.0013), however  the decrease in the pioglitazone group was three- fold greater than that in the placebo group (-3014.8±273.78 vs. -1034.9±263.30 μIU.min/ml , respectively, p<0.001). Whole body insulin sensitivity, as determined by the Matsuda index, increased significantly in the pioglitazone group, but did not change in the placebo group.  The change in Matsuda index after treatment with pioglitazone differed significantly from that in the placebo group (4.29±0.36 versus 0.29±0.16, respectively, p<0.0001). After treatment, the ratio of AUC DCI-IPG /AUCinsulin increased in the pioglitazone group by 1.85 fold (from 2.01 to 3.60 %/μIU/ml; p<0.0001) but did not change in the placebo group. The fold-increase in the ratio of AUCDCI-IPG/ AUCinsulin  from baseline to end-of-treatment differed significantly between the two groups (pioglitazone group: 1.85±0.17 vs. placebo group:1.2±0.15, p=.0083).

Conclusion: In obese women with PCOS, pioglitazone increased insulin-stimulated release of the DCI-IPG second messenger of insulin action, which may contribute to its insulin-sensitizing effect in these women. Potential mechanisms include enhanced coupling between insulin and DCI-IPG release, increased intracellular production of the DCI-IPG messenger, improved incorporation of the substrate DCI with membrane phosphoglycans to generate and release DCI-IPG mediator, or a combination of such actions which need to be further investigated.

Support: R01HD035629 (J.E.N.) KL2TR000057 (A.G.)

 

Nothing to Disclose: AG, DJ, JEN

PP27-3 20049 3.0000 SAT-093 A Pioglitazone Therapy Increases Insulin-Stimulated Release of D-Chiro-Inositol-Containing Inositolphosphoglycan Mediator in Women with Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 11:30:00 AM PP27 6006 11:15:00 AM Hyperandrogenic Ovarian Dysfunction Poster Preview


Thozhukat Sathyapalan*1, Rhiannon David2, Nigel J Gooderham3 and Stephen L Atkin4
1Hull York Medical School, Hull, United Kingdom, 2Faculty of Medicine, Department of Surgery & Cancer, Imperial College, London, UK, United Kingdom, 3Imperial College, London, UK, United Kingdom, 4Weill Cornell Medical College Qatar, Doha, Qatar

 

Introduction. MicroRNAs (miRNA) are a novel class of small noncoding single-stranded RNA molecules 18-24 nucleotides long that regulate gene expression at the post-transcriptional level. There is increasing evidence of their importance in polycystic ovary syndrome (PCOS), with their differential expression depending on obesity. There is recent evidence that miRNA-93 and mi-RNA-223 may have a role to play in the modulation of insulin resistance, through GLUT4 modulation in adipose tissue, that is inherent in this condition.

Objective: To determine if miRNA-93 and miRNA-223 are differentially expressed in the circulation of women with PCOS compared to age matched women without PCOS and to correlate these miRNAs to the metabolic indices found in PCOS.

Design: A case–control study comparing women with PCOS (n = 25) to age (32.8 ± 7.7 vs. 32.1 ± 9.0 years) and weight (76.0 ± 18.8 vs. 77.4 ± 16.3 kg) matched controls (n = 24) without PCOS. MiRNA-93 and miRNA-223 were determined by total RNA reverse transcription.

Results: Women with PCOS had significantly higher insulin, HOMA-β and testosterone levels compared to control subjects. Both miRNA-93 and miRNA-223 were significantly increased relative to the control group (p <0.016 and p <0.019, respectively).  In both the control group and the PCOS group there was no correlation of either miRNA-93 or miRNA-223 with any of the parameters including insulin, HOMA-IR, HOMA-β or testosterone levels. The area under the receiver operator characteristic (ROC) curve (AUC) for miR-223 and miR-93 was 0.66 and 0.72 respectively, suggesting miR-93 is a more efficient biomarker than miR-223 for the diagnosis of PCOS. The combination of the two miRNAs together, tested using multiple logistic regression analysis, did not improve the diagnostic potential of miR-93 alone (AIC miR-93+miR-223, 64.868; AIC miR-93, 63.51).

Conclusions: Circulating miRNA-93 and miRNA-223 were higher in women with PCOS compared to age and weight matched controls independent of insulin resistance and testosterone levels, and miR-93 may represent a novel diagnostic biomarker for PCOS.

 

Nothing to Disclose: TS, RD, NJG, SLA

PP27-4 18866 4.0000 SAT-089 A Increased Expression of Circulating miRNA-93 in Women with Polycystic Ovary Syndrome May Represent a Novel, Non-Invasive Biomarker for Diagnosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 11:30:00 AM PP27 6006 11:15:00 AM Hyperandrogenic Ovarian Dysfunction Poster Preview


Erica L Schoeller*1, Daniel D Clark2, Sandeepa Dey3, Lisa Stowers3 and Pamela L Mellon1
1University of California, San Diego, La Jolla, CA, 2University of California, San Diego, CA, 3Scripps Research Institute

 

Circadian rhythms serve to synchronize a variety of physiological processes with the earth’s day/night cycle. The mammalian circadian rhythms are organized by a hierarchical system involving the suprachiasmatic nucleus (SCN) in the hypothalamus, which drives central rhythms and synchronizes the endogenous rhythms in peripheral tissues. The Bmal1 knockout (KO) mouse lacks a functional molecular clock. Thus, its peripheral organs lack circadian rhythms, leading to a desynchronization of peripheral tissues from the central timing system, resulting in a variety of metabolic and hormonal disturbances. Notably, circadian rhythms significantly affect fertility parameters. The link between circadian rhythms and reproduction has long been established, though the role of the molecular clock machinery in regulating male sexual behavior is not well defined. We show that male Bmal KO mice are completely infertile, due to a failure to mount female mice (15 mounts/30 min for WT versus 0 mounts for Bmal KO). Though Bmal KO males have decreased testosterone levels, gonadectomy with testosterone replacement does not rescue copulatory behavior. Since sexual behaviors and aggressive behaviors are tightly linked, we also examined aggressive behavior and determined that the Bmal KO males did not engage in aggressive behaviors compared to WT (57.8 sec/15 minutes vs. 0). Given that both aggressive and copulatory behaviors are initiated by pheromone signals, we analyzed both pheromone production and pheromone detection in Bmal KO males by analysis of one of the primary pheromonal detection systems in mice, the vomeronasal organ (VNO).  Bmal KO males had a functional VNO, with 10.2 (+/- 0.9) percent of neurons responding to stimulus compared to 9.3 (+/- 1.2) percent for WT. Conversely, urine from Bmal KO males activated fewer WT neurons compared to WT urine (0.7% +/- 0.18 for KO vs 2.9% +/- 0.75 for WT). We also found that Bmal KO males have decreased production of major urinary protein pheromones expressed in their urine, potentially explaining the failure of Bmal KO males to elicit an aggressive response from intruders. To characterize whether Bmal KO males could respond to estrus female scent, we analyzed whether Bmal KO males performed territorial marking in response to estrus female scent. We found that Bmal KO males could detect estrus urine scent and perform the characteristic urine marking behavior, indicating that some of the manifestations of sex behavior are intact in Bmal KO males. Future studies will address the neurological circuit involved in male mating to understand how loss of the circadian clock gene, Bmal1, results in male infertility.

Supported by R01 HD072754, T32 HD007203, and the Lalor Foundation

 

Nothing to Disclose: ELS, DDC, SD, LS, PLM

PP34-1 20636 1.0000 SAT-116 A The Role of the Circadian Clock Gene, Bmal1, in Male Copulatory Behavior 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 11:30:00 AM PP34 6016 11:15:00 AM Novel Developments in Male Reproduction Poster Preview


Yasaman Aghazadeh*1, Barry R Zirkin2 and Vassilios Papadopoulos3
1McGill University, Montreal, QC, Canada, 2Johns Hopkins Univ/Pub Hlth, Baltimore, MD, 3The Research Institute of the McGill University Health Centre, Montreal, QC, Canada

 

Translocator protein (TSPO) drug ligands induce testosterone formation in GnRH antagonist castrated rats

Low testosterone (T) is a major cause of male hypogonadism and infertility and is linked to osteoporosis, reduced bone-mass index and aging. The treatment of choice, T-replacement therapy, has been linked to increased risk of prostate cancer, LH suppression, cardiovascular problems, increased mortality rates and skin irritation. The principal site of regulation of steroid hormone biosynthesis is at the mitochondria where the lipophilic cholesterol moves across the aqueous intramembranous space of this organelle. This transport is hormone-dependent and mediated through a multi-protein complex, the transduceosome. This complex is assembled from proteins that include the steroidogenic acute regulatory (STAR) protein, translocator protein (TSPO) and voltage-dependent anion channel 1 (VDAC1). We recently reported that a synthetic peptide targeting 14-3-3ε-VDAC1 increases VDAC1-TSPO interactions through which cholesterol enters mitochondria, resulting in increased T production by the testis (Mol Therapy 2014; 22:1779). Further studies showed that TSPO and the hormone-induced STAR interact directly only after 15 min of treatment with 8-Br-cAMP, likely due to the assembly of transduceosome. The STAR-TSPO interaction was lost over time. However, VDAC1-TSPO interaction was sustained up to 120 min after 8-Br-cAMP treatment, suggesting that pharmacological activation of these proteins could potentially induce T formation. We tested drug candidates that target TSPO in vivo on T formation. To this end, the GnRH antagonist Cetrorelix was injected intraperitoneally  into adult rats for 4 days, which resulted in complete suppression of T in the testes and serum. Various classes of well-characterized high affinity TSPO drug ligands, including PK 11195, FGIN-1-27 and XBD173 were administered by intratesticular injection to one testis per animal on day 4. To assess the acute effect of TSPO drug ligands on steroidogenesis, intratesticular T levels were measured after 2 hrs.  The results obtained showed a significant increase in intratesticular T levels in Cetrorelix-treated rats by all TSPO drug ligands.  The order of efficacy of the compounds used were XBD173 > FGIN-1-27 > PK 11195. These results suggest that the mitochondrial transduceosome is a viable pharmacological target for treating primary hypogonadism and for maintaining physiological T levels without the exogenous administration of T.

 

Nothing to Disclose: YA, BRZ, VP

PP34-2 19234 2.0000 SAT-117 A Translocator Protein (TSPO) Drug Ligands Induce Testosterone Formation in GnRH Antagonist Castrated Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 11:30:00 AM PP34 6016 11:15:00 AM Novel Developments in Male Reproduction Poster Preview


Yue Jia*1, Aikoui Ohanyan2, Yan-He Lue3, Peter Y Liu2, Ronald S. Swerdloff3, Pinchas Cohen4 and Christina Wang3
1LABioMed at Harbor-UCLA Medical Center, Torrance, CA, 2Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 3Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 4University of Southern California, Los Angeles, CA

 

Humanin (HN) is a mitochondrial derived small peptide that prevents stress-induced apoptosis in many cells and tissues. We have previously demonstrated that exogenous HN reduces GnRH-antagonist (GnRH-A), heat, or cyclophosphamide (CP) induced male germ cell apoptosis in rodents. HN binds to IGFBP-3, a putative IL-6 like trimeric membrane receptor, or intracellularly with Bax to exert its anti-apoptotic effect. Several HN analogues that differ from HN by one or two amino acids have been synthesized and shown to possess different biochemical and biophysical properties in cell cultures. To understand the effects of HN analogues on male germ cell apoptosis, we studied five HN analogues including: 1) HN-S14G a potent analog (substituting serine at position 14 to glycine, HNG); 2) HNG-F6A with loss of binding to IGFBP-3 (HNG phenylalanine 6 to alanine); 3) HN-S7A with failure to dimerize and binding to membrane receptor (serine 7 to alanine); 4) HN-C8P with no binding to BAX (cysteine 8 to proline); and 5) HN-L12A, an antagonist that dimerizes and inactivates HN (leucine 12 to alanine) on CP induced male germ cell apoptosis in mice. Adult male mice were divided into seven groups (n=4-5 per group) and received one of the following treatments and sacrificed after 24 hours: 1) vehicle (control); 2) a single intra-peritoneal (IP) injection of HN peptide (HN, 40mg/Kg); 3) a single IP injection of CP (CP, 200mg/Kg); 4) IP injection of CP and HN (CP+HN); 5) a single IP injection of one of the HN analogues (HNG 5mg/Kg, HNG-F6A 5mg/Kg, HN-S7A 40mg/Kg, HN-C8P 40mg/Kg, or HN-L12A 40mg/Kg) ; 6) IP injection of CP together with one of the HN analogues as listed above; and 7) IP injection of CP+HN+one of the HN analogues. Germ cell apoptosis was detected by TUNEL assay, and quantified by numerical count. The results showed that CP-induced germ cell apoptosis was inhibited by HN, HNG, HNG-F6A, and HN-S7A; HN-C8P was the less effective; only HN-L12A was ineffective at the dose level examined. When HN was administered with HN-L12A, this analogue acting like an antagonist blocked the protective effect of HN against CP-induced male germ cell apoptosis; HN-S7A and HN-C8P were not antagonistic. Immunoblotting showed that HN, HN-S7A, and HN-C8P restored CP-suppressed STAT3 phosphorylation in testes. These results suggest that: 1) HN suppresses CP-induced male germ cell apoptosis in vivo; 2) the cytoprotective action of HN on male germ cells is mediated by binding of HN to the putative membrane receptor activating STAT3 pathway and/or BAX-binding pathway in mice; 3) molecular self-dimerization of HN or its binding to IGFBP-3 is not essential for HN’s cytoprotective effect. Understanding the mechanism of action of HN expands our knowledge of germ cell homeostasis and its abnormalities that lead to infertility and testicular diseases including germ cell tumors. These insights may also provide new approaches to male contraception.

 

Nothing to Disclose: YJ, AO, YHL, PYL, RSS, PC, CW

PP34-3 20126 3.0000 SAT-118 A The Effects of Humanin and Its Analogues on Cyclophosphamide-Induced Male Germ Cell Apoptosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 11:30:00 AM PP34 6016 11:15:00 AM Novel Developments in Male Reproduction Poster Preview


Katarina T Borer*1, Maureen Devlin2, Karl John Jepsen1, Lingjie Li3 and Yueqin Yang4
1The University of Michigan, Ann Arbor, MI, 2The University of Michigan, School of LS&A, Ann Arbor, MI, 3East China Normal University, Shanghai, China, 4Beijing Sport University, Beijing, China

 

Leptin involvement in body weight regulation is demonstrated in its capacity to suppress hunger when its blood concentration is experimentally increased during weight-loss maintenance (1). It is not known whether the inappropriate raising of leptin concentration during the hypoleptinemic underweight state permanently alters the proportion of body fat during recovery from weight loss. To examine this question, we administered a supra-physiological dose of murine leptin at 2.8 µg/h during the last 4 weeks of a 42-day period of food restriction (FR) that produced a 21% weight loss in non-growing mature hamsters and in hamsters stimulated to display rapid catch-up growth by exposure to voluntary exercise (2). Body composition by NMR and body length were measured at the start and the end of FR, and after 60 days of ad-libitum re-alimentation (REAL). Blood for the measurement of serum leptin by ELISA was collected at the same times.  Femoral length, mineral density, and robusticity (area/length) were measured by µCT at the end of REAL. Serum leptin concentrations during leptin infusion and FR were 15.9 ± 3.7 and 17.5 ± 4.8 ng/ml in sedentary (LEPSED) and exercising (LEPEX) groups and less that 1 ng/ml at the other two times. At the end of FR, sedentary groups lost about 10% of lean body mass (LBM) and 69% of body fat, and the exercising groups 6.5% and 79%, respectively. Body weight increased significantly more after day 11 of REAL in the LEPEX and buffer-treated (CONEX) exercising hamsters and stabilized at a significantly higher plateau than in the corresponding sedentary groups (LEPSED and CONSED) (p<0.001).  Relative FI increased during the first 10 days of REAL and was unaffected by leptin. Leptin administration facilitated lean body mass (LBM) and body length accretion in growing (30.4% LBM increase in LEPEX , 3.9% more than in controls, 1.3 cm elongation, 3% more than in controls) compared to non-growing animals (10.1% LBM increase in LEPSED, 2% < than controls, 0.6 cm elongation, 40% < than controls) animals. Femora grew 1 mm longer in exercising than in sedentary animals (p<0.0003), but LEPEX femora had highest robusticity. Leptin reduced the recovery body fat by 13% in both exercising and sedentary hamsters with 86.8 % recovery in LEPSED versus 100% recovery in CONSED, and 93.3% recovery in LEPEX versus 106% recovery in CONEX (p<0.044). Therefore, the supra-physiological leptin exposure during weight-loss maintenance re-partitions final recovery body composition in favor of lean body mass and bone during rapid growth and against body fat component in both growing and non-growing state.

(1)    Rosenbaum M et al. 2005, J Clin Invest 115:525-539. (2) Borer KT & Kelch RP. 1978, Am J Physiol 234: E611-E616.

 

Nothing to Disclose: KTB, MD, KJJ, LL, YY

PP32-1 18300 1.0000 SAT-542 A Leptin RE-Partitions Body Composition during Growth and Recovery from Weight Loss 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 11:30:00 AM PP32 6037 11:15:00 AM Obesity: Regulation of Feeding and Fat Poster Preview


Sebastian D Parlee*, Becky R Simon, Xiaomin Ning, Corinne Weinsheit and Ormond A MacDougald
University of Michigan, Ann Arbor, MI

 

Diminished adipogenesis under states of energy excess is hypothesized to contribute to the development of co-morbidities associated with obesity. In a recent study from our laboratory the novel extra-gustatory expression of the sweet taste receptor in preadipocytes was characterized and subsequently hypothesized to function as a nutrient sensor to regulate adipogenesis [1]. Indeed the sweet taste receptor ligand saccharin enhanced adipogenesis of murine and human preadipocytes by rapidly stimulating phosphorylation of Akt leading to increased expression of downstream targets CCAAT/enhancer-response element-binding protein-α (C/EBPα) and peroxisome proliferator-activated receptor-γ (PPARγ). The heightened adipogenesis was, however, independent of the sweet taste receptor. Despite saccharin preferentially binding the sweet taste receptor, it also binds bitter taste receptors. Accordingly, in the current study preadipocyte bitter taste receptors were explored as sensors for adipogenesis. In line with this hypothesis, the bitter taste receptor agonist quinine enhanced 3T3-L1 differentiation in a concentration dependent manner marked by elevated neutral lipids and expression of C/EBPα, adiponectin and fatty acid binding protein-4 (FABP4). Maximal effects on adipogenesis were achieved with 50-100 μM quinine. 3T3-L1 preadipocytes treated with quinine alone exhibited this enhanced adipogenesis. Additionally, when combined with individual components of the induction hormonal cocktail MDI (methylisobutylxanthine, dexamethasone, and insulin) quinine displayed synergistic stimulatory effects on differentiation thereby supporting an independent pathway for quinine signaling. Accordingly, 3T3-L1 adipocytes treated with quinine manifest a rapid phosphorylation ERK1/2 that remained elevated compared to controls between 30 and 60 minutes. Equally, quinine enhanced expression of adipogenic genes C/EBPβ at 12-36 hours and C/EBPα and PPARγ at days 5-8. Overall, like saccharin, quinine robustly enhanced adipogenesis. Thus bitter taste receptors may act as preadipocyte sensors to regulate and enhance adipogenesis.

 

Nothing to Disclose: SDP, BRS, XN, CW, OAM

PP32-2 20042 2.0000 SAT-554 A Quinine Induces Adipogenesis in 3T3-L1 Preadipocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 11:30:00 AM PP32 6037 11:15:00 AM Obesity: Regulation of Feeding and Fat Poster Preview


Sabyasachi Sen*1, Carol Rouphael2, Sara Houston2, Allison Sylvetsky (Meni)2 and Kristina I Rother3
1The George Washington University, Washington, DC, 2George Washington University, Washington, DC, 3National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD

 

Background: Artificial sweeteners are extensively used as alternatives for caloric sugars. Given their sweet taste profile and lack of calories, diet sodas and other foods and beverages containing artificial sweeteners are often promoted as replacements for high sugar items for weight loss and/or maintenance. However, recent studies demonstrate that saccharin and acesulfame-potassium may actually increase adipogenesis1. Here we aimed to determine whether sucralose promotes adipogenesis in human mesenchymal stem cells (MSCs). MSCs are multipotent cells which differentiate to adipocytes, myoblasts, osteoblasts or chondroblasts2.

Methods: We cultured MSCs in Normal Glucose DMEM medium (5.5mM glucose) or in adipogenic medium (Lonza Inc., 5.5mM) with or without sucralose (0, 0.45mM or 4.5mM) for 6 days. At the end of day 6, cells were stained with Oil Red O stain (lipogenesis). Cells were lysed post staining and absorbance of the assimilated dye was measured using a plate reader (520 nm).  Non-stained cells from each medium and each sucralose concentration were also lysed as control and RNA was collected for RT-PCR to measure oxidation, inflammation and adipogenesis related gene expression.

Results: Before lysing the cells for absorbance readings, cells were observed under the microscope for phase contrast image. With increasing sucralose concentrations, more fat droplets were observed.. Moreover, absorbance measurements showed that adipogenesis increased by 1.8 fold with addition of low dose sucralose (0 vs. 0.45mM) and further increased by 2.85 fold with the 10 fold higher sucralose concentration in cells cultured in both normal glucose and adipogenic media.

We also conducted a 12 day experiment, where MSCs were cultured in adipogenic medium for 12 days. In this experiment cytotoxic effects of 4.5 mM sucralose were noted along with increased intracellular fat droplet accumulation observed by microscopy. RT-PCR showed increased gene expression with increasing sucralose concentration from 0 to 0.45mM forPPARG (2.28 fold), C/EBPb (1.14), C/EBPa (1.42), ADIPOQ (2.16) and leptin (1.55 fold). We also noted increased superoxide dismutase (SOD) 1 and 2 gene expression by 1.59 fold and 1.39 fold respectively with increase in TNF alpha expression (1.36 fold).

In summary, sucralose appears to promote fat accumulation by Oil Red O stain quantification. It also appears to upregulate expression of genes involved in adipogenesis,inflammation  (TNFα) and anti-oxidant pathways(SOD). Increase in SOD expression may be a cellular adaptive response to increased intracellular super-oxide. Conclusion: Our studies indicate that sucralose may promote intracellular fat accumulation with upregulation of key genes in adipogenesis and inflammation. This finding may have important public health implications and warrants further cellular, animal model, and human studies.

 

Nothing to Disclose: SS, CR, SH, AS, KIR

PP32-3 20488 3.0000 SAT-556 A Sucralose Promotes Increased Fat Accumulation in Cultured Human Adipose Tissue Derived Mesenchymal Stem Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 11:30:00 AM PP32 6037 11:15:00 AM Obesity: Regulation of Feeding and Fat Poster Preview


Michael C. Rudolph*, Julie A Houck, Rebecca M Aikens, Christopher B Erickson, Andrew S Lewis, Jacob E Friedman and Paul S MacLean
University of Colorado Denver, Aurora, CO

 

After birth, rapid weight gain and fat accretion in the first 3-6 months of life is a powerful predictor of later obesity and metabolic risk.  The prevalence of n-6 maternal dietary fatty acids transmitted to the infant via human milk (HM) has increased from 6% to 15% over the decades, while n-3 fatty acids remain unchanged, thus increasing the n-6 to n-3 milk fatty acid ratio.  These observations suggest that raising the n-6 to n-3 fatty acids ratio (n6/n3) in HM has on infant adipogenesis and risk of obesity later in life.  In rodents, increasing the n-6 fatty acids through the perinatal maternal diet increased the n6/n3 ratio delivered to neonates and elevated offspring adipogenesis. We hypothesized that reducing the n6/n3 milk fatty acid ratio through genetic manipulation would reduce adipogenesis and lipid deposition in offspring. We tested this hypothesis using the FAT1 mouse that expresses the C. elegans n-3 fatty acid desaturase (not present in mammals).  As expected, fatty acid composition analysis by mass spectrometry revealed the 20:4 n-6/(20:5 n-3 + 22:6 n-3) ratio was significantly reduced (p=0.02), while the milk fat % by volume and total milk protein from FAT1 dams was unchanged at lactation day 14.  Unexpectedly, FAT1 milk had significantly greater triglyceride (p = 0.045), lower lactose (p = 0.005), and reduced medium chain fatty acids (p=0.01). Total MUFA, PUFA and the ratio of 18:2 n-6/18:3 n-3 were unchanged in FAT1 milk.  At day 14, offspring of FAT1 dams had no differences in weight or % fat mass.  However, subcutaneous adipose tissue mass was significantly higher (p = 0.02) in FAT1 offspring, despite having smaller adipocytes when compared to wildtype offspring consuming milk with a high n6/n3 milk fatty acid ratio.  These data suggest that FAT1 reduction of the n6/n3 milk fatty acid ratio alters adipogenesis and lipid deposition in offspring by day 14 post partum.  Future studies should examine if the n6/n3 fatty acid ratio in milk plays a role in programming a predisposition for obesity and metabolic disease later in life.

 

Nothing to Disclose: MCR, JAH, RMA, CBE, ASL, JEF, PSM

PP32-4 22153 4.0000 SAT-555 A Neonates Consuming Milk with a High n-6 to n-3 Fatty Acid Ratio Have Larger Adipocytes but Smaller Subcutaneous Adipose Depot By 14 Days of Life 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 11:30:00 AM PP32 6037 11:15:00 AM Obesity: Regulation of Feeding and Fat Poster Preview


Gokhan Hotamisligil*
Harvard Sch of Public Health, Boston, MA

 

 

Disclosure: GH: Principal Investigator, UCB Pharmaceuticals, Principal Investigator, Servier.

AL33-1 22252 1.0000 A Regulation and Dysregulation of Signaling Networks 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 11:45:00 AM AL/OR33 6080 11:15:00 AM Roy O. Greep Award for Outstanding Research Lecture


Arian F. Baquero*1, Melissa A. Kirigiti2, Camdin M Bennet2, M. Susan Smith3 and Kevin L. Grove1
1Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, 2Oregon National Primate Research Center, Beaverton, OR, 3OR National Primate Rsrch Ctr, Beaverton, OR

 

NPY/AgRP/GABA (NAG) neurons play an important role in the control of food intake and are located in the arcuate nucleus of the hypothalamus (ARH). During early postnatal development in the rodent, immature ARH neurons are extending their axonal projections to other important metabolic hypothalamic nuclei, such as the dorsomedial hypothalamus (DMH), and paraventricular nucleus (PVH). Although there is strong neuroanatomical evidence in the development of efferent neuronal projections from the ARH, there is a lack of knowledge regarding the formation of functional synapses onto NAG neurons, especially during early postnatal development. Using electrophysiology and transgenic mouse models, we have examined the ontogeny of excitatory inputs onto ARH-NPY-GFP+ neurons during the first four weeks of life. We observed that throughout postnatal days (P) 3 to 7, the number of excitatory inputs onto NAG neurons were relative low. By the middle of the second week (P9-11), there was a marked increase in the frequency of excitatory currents onto NAG neurons, suggesting that ARH may receive afferent neuronal projections from other hypothalamic nuclei. In order to explore the potential source of these inputs, we performed Dil implants in the PVH of P7, P10, and P15 mice. Our results revealed that projection pathways from the PVH to the ARH are developed during the second week of postnatal development, from P10 to P15. Furthermore, excitatory currents onto NAG neurons continue to rise throughout the third week, and by P21, the frequency of EPSCs in NAG neurons resembles the young adult phenotype (9-10 weeks of age). These findings could provide evidence of a potent orexigenic stimulus in pups during this critical growth period through the activation of NAG neurons by glutamate release from presynaptic terminals. Furthermore, these developmental changes coincide with the period in which pups initiate independent consumption of solid food.

 

Disclosure: KLG: Consultant, Ember, Principal Investigator, Novo Nordisk, Advisory Group Member, Novo Nordisk, Consultant, Sanofi, Principal Investigator, ERX, Employee, Novo Nordisk. Nothing to Disclose: AFB, MAK, CMB, MSS

OR30-1 21010 1.0000 A Developmental Changes in Excitatory Postsynaptic Currents (EPSCs) in Npy/Agrp/GABA (NAG) Neurons 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR30 5909 11:30:00 AM Neuroendocrinology Oral


Rebecca Lynn Cunningham*1, Brina Snyder2, Monica Bullock2, Silahis Hontiveros2 and Derek A Schreihofer3
1UNTHSC, Fort Worth, TX, 2University of North Texas Health Science Center, 3University of North Texas Health, Fort Worth, TX

 

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of complete or partial airway obstruction during sleep.  Obstruction lasting 10 seconds or greater and leading to at least 4% oxygen desaturation is highly associated with cardiovascular disease (CVD) and is an independent risk factor for ischemic stroke.  In addition to the effects on CVD risk, OSA leads to memory deficits and impaired executive function.  Age, male gender, and obesity are major risk factors for OSA.  Coincidently, these same risk factors are associated with lower levels of circulating testosterone (T) and OSA itself can lead to low T.  Prescriptions for testosterone replacement therapy (TRT) have increased three-fold in the last decade, and it is now estimated that >3% of men over 40 have been prescribed some type of TRT.  Severe OSA (Apnea-hypoxia index >30) is contraindicated for men seeking TRT.  However, the role of mild or moderate OSA has not been examined.  We hypothesized that mild sleep apnea (Apnea-hypoxia index of ≤ 10) would have similar detrimental effects on the brain and increase susceptibility to stroke injury.  Male Sprague-Dawley rats were exposed to 2 weeks of chronic intermittent hypoxia (CIH; 10% O2) for 8 hours a day at AHI=10 as a model of moderate OSA.  CIH significantly reduced serum total T (1.7±0.4 vs 3.4±1 ng/ml; n=6; p<0.05) and free T (37±2 vs 43±1 pg/ml; n=6; p<0.05) and increased peripheral oxidative stress (advanced oxidation protein products 501±8 vs 411±10 μM; n=5; p<0.05).  CIH also significantly increased peripheral inflammation evidenced by a 4-fold rise in IL6 and 75% increased in IL10 (n=4; p<0.05).  This increase in oxidative stress was also reflected in the cerebral cortex by an increase in immunoreactivity for 8-OHdG.  The CIH-induced increase in oxidative stress and inflammation resulted in a significant increase in infarct size 3 days after stroke in rats subjected to middle cerebral artery occlusion using endothelin-1 (28±5 vs 13±7% infarct; n=5; p<0.05).  These data suggest that even mild/moderate OSA can lead to decreased T, increased oxidative stress and inflammation and increase neurological risk and injury.  Future studies will determine whether TRT exacerbates or mitigates these changes.

 

Nothing to Disclose: RLC, BS, MB, SH, DAS

OR30-2 22078 2.0000 A Moderate Chronic Intermittent Hypoxia Reduces Testosterone and Increases Neurodegeneration in Male Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR30 5909 11:30:00 AM Neuroendocrinology Oral


Shyuan Ngo*1, Teresa Xie1, Sarah Chapman2, Chen Chen3, Matthew Leevy2, Robert Henderson4, Pamela McCombe5 and Frederik Steyn3
1University of Queensland, Brisbane, Australia, 2University of Notre Dame, 3The University of Queensland, Brisbane, Australia, 4Royal Brisbane and Women's Hospital, 5University of Queensland

 

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease for which there is no cure. For patients, death usually occurs within 2-5 years of diagnosis. While the primary pathology in ALS is the death of motor neurones, there is increasing evidence to suggest that altered metabolic flux contributes to disease pathogenesis. Increased body mass index and supplementation with high calorie/high carbohydrate diets is associated with improved prognosis in ALS patients. Thus, we hypothesize that decreased fat mass or decreased availability of fat as an energy substrate will predict disease outcome. To understand the impact of altered fatty acid flux in ALS pathogenesis, we used a pre-clinical mouse model and human subjects to assess fatty acid metabolism and metabolic profile in ALS.

Analysis in ALS mice was conducted at well-defined stages of disease progression; pre-symptomatic (no symptoms), onset (onset of muscle weakness), mid-stage (more severe muscle weakness), and end-stage (loss of the righting reflex). ALS mice were observed to have a significant reduction in total body weight and fat mass at the mid-stage of disease. This occurred in parallel with an increase in the expression of genes that encode for proteins and enzymes that regulate fatty acid catabolism and mobilization, the maintenance of lipolytic rate (assessed in ex vivo white adipose explants), and an increase in the expression of circulating b-hydroxybutyrate. Our data in mice suggests that fat is released from (or not deposited into) white adipose stores at latter stages of disease, presumably for use as an energy substrate. This requirement for energy does not occur as a consequence of increased non-shivering thermogenesis as assessed by PET/CT analysis of 18F-fluorodeoxyglucose uptake.

To translate observations in mice to humans, we studied subjects who were defined as having probable or definite ALS according to the El Escorial criteria. Analysis of plasma samples from ALS patients and BMI-, gender-, and age-matched controls demonstrate a decrease in the expression of active ghrelin, gastric inhibitory peptide, and pancreatic polypeptide. Moreover, we observed an increase in the expression of adipokines lipocalin-2 and plasminogen activator inhibitor-1, and the adipocytokines tumor necrosis factor alpha and interleukin-8. This data demonstrates specific endocrine responses to match altered demand on adipose.

Collectively, our data suggests that altered fatty acid metabolism occurs throughout the course of disease, presumably to accommodate for the hypermetabolism that is observed in ALS. We are now assessing the neuroendocrine mechanisms that underpin these changes in energy utilization. We propose that major derangements in endocrine function that accompany altered metabolic flux may predict the severity of the neurodegenerative process in ALS.

 

Nothing to Disclose: SN, TX, SC, CC, ML, RH, PM, FS

OR30-3 21462 3.0000 A Altered Fatty Acid Metabolism in Neurodegeneration: Studies in Amyotrophic Lateral Sclerosis (ALS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR30 5909 11:30:00 AM Neuroendocrinology Oral


Christopher J Child*1, Alan G Zimmermann2, Nan Jia3, Leslie L Robison4, Jurgen H Bramswig5 and Werner F Blum6
1Eli Lilly and Company, Windlesham, United Kingdom, 2Eli Lilly and Company, Indianapolis, IN, 3Eli Lilly and Company, Indianapolis, 4St. Jude Children's Research Hospital, Memphis, TN, 5University of Muenster, Muenster, Germany, 6University of Giessen, Giessen, Germany

 

Because of the general growth-inducing effect of GH, concern remains regarding the potential influence of GH treatment on neoplastic cell growth.  Many studies that evaluated the risk for primary cancer in patients (pts) without previous malignancy who received childhood treatment with GH have found no increased rates of primary neoplasia (1-3).  One study indicated increased risk for colorectal cancer, based on 2 cases, in a single-country cohort of pts treated with cadaveric pituitary GH (4). In addition, epidemiologic data have reported associations between high serum IGF-I concentrations and certain cancer types in adulthood (5).

Therefore, we assessed the reported primary cancer occurrence in the prospective, multinational GeNeSIS observational study of pediatric GH use and compared the observed cases with expected cases using SEER for the USA (6) and GLOBOCAN (7) for all other countries.

Study data and serious adverse event reports from 30 countries for pts with ≥1 follow-up visit available were examined to identify those with no history of previous malignancy.  Pts with uncertain historical malignancy status were also excluded.  A cohort of 19,054 pts was identified (40% were female; 63% were diagnosed with growth hormone deficiency, 13% with idiopathic short stature, 9% with Turner syndrome, 6% born small for gestational age, and 9% with other diagnoses).  The mean±SD baseline age for this cohort was 9.5±4.0 years (y), period on GH per patient was 4.2±3.1 y, and follow-up time in study was 3.4±2.5 y).  Pts with incident cases of primary malignancy were ascertained using the same data sources.

In the cohort of GH-treated pts with no recorded previous malignancy, 13 potentially malignant primary neoplasms were identified, with crude incidence of 16.2 cases per 100,000 person-years.  The 13 cases were from Canada, France, Germany, Japan and USA.  Mean age at reported onset of cancer was 13.5±2.7 y.  The standardized incidence ratio (SIR) 95% CI) for primary cancers in GH-treated pts was 0.86 (0.46-1.47) for all countries combined; no individual country had a significantly elevated SIR.  10 of the affected pts (4 cases of lymphoma, 3 germ cell tumors, and one case each of Ewing sarcoma, osteosarcoma and skin cancer) had no recorded history of neoplastic disease.  The remaining 3 pts had neoplastic history/predisposing conditions (rectal adenocarcinoma in a pt with recurrent neurofibromatosis (NF) and Gardner syndrome, pancreatic neuroendocrine tumor with “possible malignant behaviour” in a pt with NF, and malignant schwannoma in a pt with history of pilocytic astrocytoma).

In summary, in this analysis of GeNeSIS with an average follow-up of 3.4 y, we did not find an increased risk for primary cancers in GH-treated pts with no previous cancer history than in general population cancer registries.

 

Disclosure: CJC: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. AGZ: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. NJ: Employee, Eli Lilly & Company. WFB: Retiree, Eli Lilly & Company, Retiree, Eli Lilly & Company. Nothing to Disclose: LLR, JHB

OR30-4 18271 4.0000 A Assessment of Primary Cancers in Growth Hormone (GH)-Treated Pediatric Patients Compared to Population Databases: An Epidemiological Analysis of a Large, Multinational, Prospective Observational Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR30 5909 11:30:00 AM Neuroendocrinology Oral


Marie Joelle Pitteloud*, Ramona Dadu, Maria E Cabanillas, Komal Shah, Mimi I-Nan Hu, Mouhammed Amir Habra and Steven G Waguespack
The University of Texas MD Anderson Cancer Center, Houston, TX

 

Background

Novel immunotherapies are currently being used to treat melanoma and are being studied in the treatment (tx) of other solid tumors. The use of drugs, such as anti-CTLA4 agents (ipilimumab [ipi] and tremelimumab [treme]) and anti-PD1 agents (nivolumab [nivo]), are associated with autoimmune hypophysitis, an adverse event that is poorly understood. Using a strict definition, we sought to study our own experience with immunotherapy-induced hypophysitis (IH).

Methods

This is a retrospective analysis of 968 patients (pts) treated with immunotherapy since 2005 at MD Anderson Cancer Center. We defined IH as (1) ≥1 pituitary hormonal deficiencies (either ACTH or TSH) plus MRI abnormality OR (2) ≥2 pituitary hormonal deficiencies plus headache or MRI abnormality.  IH was confirmed by independent review by 2 endocrinologists, and a radiologist reviewed all MRIs. 

Results

Of 968 pts, 51 were referred to Endocrinology as possible IH. 27 pts met our definition of IH. The median age at diagnosis was 60 yrs (r: 31-75); 19 (70%) were men. Cancer diagnosis included melanoma 21/27 (78%), prostate 5/27 (18%) and renal cell 1/27 (4%). Immunotherapy included ipi in 24/27(89%), treme in 2/27 (7%) and nivo in 1/27 (4%). 20/27 (74%) were on clinical trial. Pts developed IH early with the anti-CTLA-4 agents. Median time from tx start to IH diagnosis was 2.4 months (mos) (r: 1.8-4.3) and median number of cycles was 4 (r: 2-5) in ipi pts. The treme pts had a median time to IH diagnosis of 2.9 mos (r: 2.6-3.2) and median number of cycles was 1.5 (r: 1-2). The single nivo pt received 19 cycles in a period of 9 mos before developing IH.  In evaluable patients, central adrenal insufficiency was diagnosed in 17/22 (77%) pts; central hypothyroidism in 24/27 (89%) pts and central hypogonadism in 15/19 (79%) pts. 23/27 (85%) pts had pituitary gland abnormality on MRI, and 4/27 (15%) had no abnormalities but had headache as a presenting symptom. In the acute phase of IH, the majority of pts (18/27) received high dose steroids whereas the others were started on routine physiologic replacement and did well with resolution of symptoms.  After a median follow up (f/u) of 17 mos (r: 1-76), no pts recovered normal adrenal function, while 3/24 (12.5%) and 2/15 (13%) recovered thyroid and gonadal function, respectively.

Conclusions

The diagnosis of IH remains a challenge to endocrinologists and oncologists. In this large series of IH using strict clinical definitions, we confirmed 27 cases of IH from 51 referred for possible IH, suggesting IH remains a disease that may be overdiagnosed based on symptoms alone. In our experience, all pts with IH had chronic ACTH deficiency, underscoring the need for long-term tx and f/u. Given that many pts did well with physiologic doses of glucocorticoid replacement at diagnosis, the current recommendation to treat all IH pts with high dose steroids should be re-evaluated through further studies.

 

Nothing to Disclose: MJP, RD, MEC, KS, MINH, MAH, SGW

OR30-5 21626 5.0000 A Hypophysitis in the Age of Cancer Immunotherapy: Experience in a Large Cancer Center 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR30 5909 11:30:00 AM Neuroendocrinology Oral


Emanuel R Christ*1, Kwadwo Antwi2, Tobias Heye2, Melpomeni Fani2, Guillaume P Nicolas3, Elmar Merkle4, Beat Gloor5, Jean Claude Reubi6 and Damian Wild2
1University Hospital of Berne, Berne, Switzerland, 2University Hospital of Basel, Basel, Switzerland, 3UniversityHospital of Basel, Basel, Switzerland, 4University of Basel Hospital, Basel, Switzerland, 5University Hospital of Bern, Inselspital, Bern, Switzerland, 6Univ-Bern/ Inst of Pathology, Bern, Switzerland

 

Background

Insulinoma are small insulin secreting pancreatic neuroendocrine tumors. They overexpress in nearly 100% of the cases GLP-1R. The only curative approach is the surgical excision but the preoperative detection remains a challenge due to the small size of these tumours. We have previously shown, that GLP-R targeting using 111In-DOTA-exendin-4 SPECT/CT is a non-invasive and useful tool for the preoperative localisation of insulinomas. Positron emission tomography (PET) is a more sensitive imaging modality than SPECT. Due to the shorter half-life of 68Ga compared with 111In, the radiation exposure is lower (3-5x) and the scanning time after injection is much shorter (2h with PET vs 24-90h using SPECT) and, therefore, more convenient for patients. We aimed at prospectively comparing the detection rate of PET/CT vs SPECT/CT vs standardized contrast enhanced 3T MRI in patients with hyperinsulinemic hypoglycemia.

Methods

Preliminary results of an ongoing study are reported. Eleven consecutive Patients (9 female and 2 male patients, age range 39-81 yrs.) with neuroglycopenic symptoms due to endogenous hyperinsulinemic hypoglycemia were enrolled. A standardized contrast media enhanced 3T abdominal MRI was performed. Afterwards, on 2 or 3 consecutive days the patients received abdominal imaging via SPECT/CT after injection of 90 MBq 111In-DOTA-exendin-4 and PET/CT after injection of 70 MBq 68Ga-DOTA-exendin-4 in a randomized order. Gold standard was the histological diagnosis after surgery.

Results

In 9 patients histological diagnosis confirmed benign insuIinoma, one patient had adult nesidioblastosis. One patient refused surgery. In 8 of 11 patients previously performed conventional imaging (CT/MRI) including ASVS was not able to localize the insulinoma. Standardized contrast media enhanced 3T MRI was able to predict the exact localisation of the insulinoma in 6 of 11 patients. PET/CT correctly identified the insulinoma or nesidioblastosis in all 10 operated patients whereas SPECT/CT correctly identified the insulinoma in 7 of 10 patients. PET/CT was the only modality which correctly identified the region of islet cell hyperplasia (adult nesidioblastosis) within the pancreas. In one patient none of the imaging modalities including the previously performed imaging was able to find any lesion

Conclusion

1)    These preliminary data suggest that GLP1-R PET/CT performs better as standardized MRI imaging and GLP1-R SPECT/CT.

2)    Due to the lower irradiation dose and the more convient scanning time it is conceivable that GLP-1R PET/CT will be proposed as the gold standard in the preoperative localization of benign insulinoma.

3)    Further studies will have to confirm whether GLP1-R PET/CT is able to localize adult nesidiblastosis, a rare clinical condition in adults

 

Nothing to Disclose: ERC, KA, TH, MF, GPN, EM, BG, JCR, DW

OR30-6 19152 6.0000 A Novel Imaging Procedure for the Localisation of Insulinoma Using Glucagon-like Peptide-1 Receptor (GLP-1) PET/CT 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR30 5909 11:30:00 AM Neuroendocrinology Oral


Katarzyna Anna Ludwik*, Lejla Pasic, Miranda Elise Sowder and Deborah Ann Lannigan
Vanderbilt University, Nashville, TN

 

For unknown reasons, high levels of active RSK in estrogen receptor α (ERα)-positive (ER+) breast cancer patients correlate with better responsiveness to anti-estrogen therapies.  Investigation of these surprising observations led us to discover an unanticipated mechanism in which ERα controls RSK2 nuclear accumulation. RSK2 is retained in the nucleus by physical association with ERα and this interaction is disrupted by anti-estrogen treatment.  Consistent with these findings, in primary human ER+ breast tissue organoids, 4-hydroxy-tamoxifen (4-OHT) drove export of RSK2 to the cytoplasm. Importantly, RSK2 nuclear accumulation is critical for the expression of the oncogene, cyclin D1.  This conclusion is supported by the observation that a RSK2 mutant, which cannot accumulate in the nucleus, does not rescue cyclin D1 in cells silenced for endogenous RSK2.  Analysis of RNAseq data shows that ERα and RSK2 cooperatively regulate a transcriptional program, which includes cyclin D1.  The physiological relevance of these conclusions is supported by our observations that in ~60% of ER+ breast cancer patients, active nuclear RSK correlates with ERα and cyclin D1 levels.  Taken together, these findings suggest that responsiveness to endocrine-based therapy is driven by reduced RSK2 nuclear accumulation, which in turn reduces expression of cyclin D1 and of other tumor-promoting effectors.  Based on these observations we hypothesized that nuclear RSK2 cooperates with ERα and is a physiologically relevant driver of ER+ breast cancer.  To test this hypothesis we generated a transgenic mouse model in which the MMTV promoter controls expression of RSK2 fused with the nuclear localization signal (NLS) of SV40.  Strikingly, in ~50% of transgenic mice forced nuclear accumulation of RSK2 in the mammary gland caused hyperplasia and ductal carcinoma in situ (DCIS).  These results are the first demonstration that RSK2 can drive proliferation and transformation in vivo.  Transgenic animals had a 4-fold increase in the number of cyclin D1 expressing cells and a 6-fold increase in Ki67 levels.  Surprisingly, in vivo expression of nuclear RSK2 increased the number of ERα-expressing cells by ~40%.  The expansion of ER+ cells in the transgenic mice demonstrates, for the first time, that nuclear RSK2 drives the amplification of the cell population relevant to ER+ breast cancer.  These results further support our hypothesis that RSK2 cooperates with ERα and is an important drug target for ER+ breast cancer.

 

Nothing to Disclose: KAL, LP, MES, DAL

OR31-1 21156 1.0000 A The Complex, RSK2/ERα, Drives Proliferation and Transformation in ER+ Breast Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 1:00:00 PM OR31 5920 11:30:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Oral


Zeynep Madak Erdogan* and Benita S Katzenellenbogen
University of Illinois at Urbana-Champaign, Urbana, IL

 

ERα, a member of the large superfamily of nuclear receptors, exerts profound effects on gene expression, cellular response programs, and phenotypic properties of estrogen target cells. Because of these broad and important actions, ERα is considered the single most important predictor of breast cancer prognosis and is the target of endocrine therapies. The importance of kinases in cancer biology is well known, as increased kinase activity through phosphorylation, mutations or increased expression is often observed in clinical samples and is associated with a poorer prognosis. It is believed that, in therapy-resistant breast cancers, control of cellular physiology switches from ERα nuclear-initiated pathways to extranuclear-activated protein kinase pathways, which enable these cells to adopt a more aggressive phenotype.  However, the mechanisms underlying the interplay between ERα and protein kinase pathways in cancer, and the processes by which ERα influences these pathways are poorly understood.

Our aim is to elucidate the crosstalk and interrelationships between ERα and extranuclear- initiated and direct nuclear pathways which impinge on gene transcription via chromatin-associated protein kinases. We have previously shown that ERK5, a member of the typical MAPK family, works together with ERα and Cofilin to regulate gene expression (PMID: 24505128).  In order to further understand the role that ERK5 plays in endocrine resistance and breast cancer aggressiveness, we analyzed its genome-wide DNA binding and effects on gene expression using integrative systems biology approaches, where we employed computational analyses of RNA-Seq data and ChIP-Seq data from breast cancer cells as well as gene expression data from publicly available tumor databases.  This comprehensive analysis indicated a role for ERα- mediated ERK5 activity in regulating angiogenesis and natural killer cell mediated toxicity. Cell studies further supported ERK5 collaboration with ERα to regulate genes important for breast cancer cell interactions with endothelial and natural killer cells present in the tumor microenvironment. ChIP studies showed that activated ERK5 was recruited to the transcription start site of genes promoting angiogenesis and modulating viability of natural killer cells.  Depletion of ERK5 in breast cancer cells prevented release of factors that increase endothelial cell motility or decrease natural killer cell viability.  The findings provide insight into how activation of ERK5 by estrogens regulates signaling and gene expression in breast cancer. They also suggest that therapeutic targeting of ERK5 activity may decrease aggressiveness of breast cancers and increase the efficiency of endocrine therapies by impacting interrelationships of cancer cells with other cells in the tumor microenvironment.

 

Disclosure: ZM: Investigator, Pfizer, Inc.. Nothing to Disclose: BSK

OR31-2 18741 2.0000 A Systems Biology of Gene Regulation By Estrogen Receptors and Kinases in Breast Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 1:00:00 PM OR31 5920 11:30:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Oral


Ali A Pedram*1, Mahnaz Razandi2, Bruce Blumberg3 and Ellis R Levin4
1Univ of CA-Irvine, Long Beach, CA, 2Long Beach VAMC, Long Beach, CA, 3University of California, Irvine, Irvine, CA, 4University of California-Irvine and the Long Beach VAMC, Long Beach, CA

 

After menopause, women develop increased visceral fat deposition that predisposes them to metabolic diseases. Estrogen suppresses increased fat deposition in animal and human studies by limiting food intake and aspects of fat metabolism. We recently published that membrane ERa-only (MOER) and nuclear ERa-only (NOER) female mice each develop significant fat deposition in multiple visceral compartments, accelerated with aging. These studies indicate that both ERa pools must work together to suppress fat differentiation and deposition. To investigate how both pools contribute to suppressing adipogenesis, we isolated mesenchymal stem cells from the bone marrow (BMSC) of mature wild type (WT), MOER, and NOER mice. The stem cells showed endogenous ERa and ERb proteins that were mainly nuclear but also cytoplasmic-membrane. Estradiol (E2) suppressed both proliferation and commitment to adipocyte lineage differentiation of the cultured multi-potent BMSC but only in WT cells. In WT cells, estrogen action was mediated exclusively through ERa, based upon siRNA(s) knockdown and specific ER isoform agonists where only PPT and not DPN showed similar effects to E2. Pre-adipocytes (3T3L1 cells) responded to differentiation media or rosiglitazone (PPARg agonist) by maturing into adipocytes synthesizing triglyceride, deposited in intracellular vesicles determined by Oil Red O staining and cell morphology. This was suppressed by E2. Known genes that are essential to the adipocyte differentiation process or reflect differentiation include aP2, PPARg, IRX3,C/EBPb, and adiponectin. Rosiglitazone induced differentiation of BMSC and pre-adipocytes and caused the stimulation of all mentioned genes that was suppressed by E2 via ERa only in WT cells. Cultured BMSC fully differentiated in 8 days to mature adipocytes that produce triglyceride but this was only suppressed by E2 in WT cells. However, we measured triglyceride synthesis in differentiated adipocytes and either E2 or an estrogenic compound that only binds membrane ER (EDC) each comparably suppressed this. In addition, rosiglitazone stimulated the sequential production of the transcription factors that are required for triglyceride synthesis in adipocytes, ChREBPa and b. This was comparably inhibited by either E2 or EDC, indicating a novel and exclusive role for membrane ERa. In summary, estrogen suppresses the commitment and maturation of multi-potent stem cells to the adipocyte lineage and pre-adipocytes to mature, lipid-synthesizing white fat cells. This mainly occurred through collaboration of membrane and nuclear ERa but lipid synthesis suppression only required membrane ERa signaling in the mature adipocyte. This was reflected in adipose phenotypes in our transgenic mouse models, MOER and NOER, that showed extensive visceral fat while eating normal chow.

 

Nothing to Disclose: AAP, MR, BB, ERL

OR31-3 18521 3.0000 A Estrogen Via Extra-Nuclear and Nuclear Estrogen Receptor Alpha Suppresses Adipogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 1:00:00 PM OR31 5920 11:30:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Oral


Joshua D Stender*1, Irida Kastrati2, Maayan Yakir3, Jonna Frasor2 and Christopher Kevin Glass3
1University of California San Diego, La Jolla, CA, 2University of Illinois at Chicago, Chicago, IL, 3Univ of CA - San Diego, La Jolla, CA

 

The infiltration of macrophages into breast tumors establishes a microenvironment that promotes tumor progression and metastasis. Inflammatory macrophages produce cytokines that can alter estrogen receptor α (ERα) transcriptional activity and drive an endocrine-resistant state in cell-based model systems. However, the underlying molecular mechanisms of this activation potential remain poorly understood. We sought to identify the global impact that IL1β and TNFα have on ERα-dependent transcription and the ERα cistrome in breast cancer cells. We discovered that these pro-inflammatory cytokines promote binding of ERα to a large fraction of the genomic sites that are observed following stimulation of cells with estradiol. These binding events are correlated with the expression of ERα-dependent target genes and knockdown of ERα using specific siRNA oligos or pharmacological degradation of the ERα reduces cytokine-dependent gene activation. This cytokine-dependent activation of ERα requires IKKβ-dependent phosphorylation of S305 on ERα and mutation of S305 abolishes the ability of Il1β and TNFα to activate ERα-dependent transcription. In addition, phosphorylation of ERα at S305 renders tamoxifen ineffective at inhibiting the expression of 90% of tamoxifen sensitive, E2-dependent target genes. Furthermore, pharmacological inhibition of IKKβ restores the ability of tamoxifen to repress E2-dependent gene activation. Collectively these results provide molecular details dictating how inflammatory cytokines activate the transcriptional potential of the ERα, how they may contribute to endocrine-resistant breast cancers, and suggest alternative treatment strategies for tamoxifen resistant breast tumors.

 

Nothing to Disclose: JDS, IK, MY, JF, CKG

OR31-4 22048 4.0000 A Inflammatory Cytokines Activate Unliganded Estrogen Receptor and Alter the Sensitivity of Breast Cancer Cells to Tamoxifen Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 1:00:00 PM OR31 5920 11:30:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Oral


Myles Cameron Hodgson1, Egla Suarez1, Lubov Nathanson2 and Irina U Agoulnik*3
1Herbert Wertheim College of Medicine, Miami, FL, 2Nova Southeastern University, Fort Lauderdale, FL, 3Baylor College of Medicine, Houston, TX

 

Castration therapy, the primary treatment option for patients with metastatic prostate cancer, frequently fails and patients recur with castration-resistant metastatic disease. This suggests that castration itself activates pathways that lead to prostate cancer recurrence and metastases. We have shown that castration conditions in androgen receptor (AR) dependent cell lines and human in mouse xenografts lead to a decline in INPP4B expression. During progress to metastases, the tumor suppressor INPP4B is lost in nearly half of prostate tumors. Similar to PTEN, INPP4B is a dual specificity phosphatase, which dephosphorylates phosphatidylinositol polyphosphates on the 4th position of the inositol ring and has phosphotyrosine phosphatase activity. INPP4B is highly expressed in the luminal epithelium of normal prostate and displays mostly membrane and cytoplasmic localization in both prostate cancer cell lines and human prostate. Unlike PTEN, INPP4B is a direct AR target. Since loss of PTEN causes significant changes in the AR transcriptional output, we tested whether loss of INPP4B affects AR transcriptional activity. The prostate cancer cell line LNCaP expresses high levels of both AR and INPP4B but not PTEN. Knockdown of INPP4B in LNCaP cells significantly activated proliferation, Akt, and PKC signaling without altering AR protein levels. Using global gene expression analysis, we tested the effect of INPP4B loss on AR transcriptional activity in these cells. Changes in gene expression caused by INPP4B loss had a highly significant impact on the AR transcriptional signature as determined using GSEA. We determined that INPP4B stimulated some and inhibited other AR target genes in a promoter dependent manner. Distinct subsets of transcriptional changes were mediated by either PKB, PKC activity, or neither. Independently derived prostate cancer cell line VCaP has high levels of AR, INPP4B and PTEN expression. Using this cell line, we compared AR transcriptional changes caused by loss of either INPP4B or PTEN. This analysis revealed that these tumor suppressors have distinct effects on AR transcriptional activity. We show that there is a feedback loop between AR and INPP4B: AR induces INPP4B expression and INPP4B, in turn reprograms AR transcriptional activity.  Therefore androgen inhibiting therapies in prostate cancer patients would cause a decline in tumor suppressor INPP4B expression, activating some cell signaling pathways and reprogramming the AR transcriptome. Our data also suggests that loss of PTEN and INPP4B in prostate cancer would have different consequences for prostate cancer prognosis and sensitivity to therapies.

 

Nothing to Disclose: MCH, ES, LN, IUA

OR31-5 22099 5.0000 A Modulation of Androgen Receptor Action By Tumor Suppressor Inositol Polyphosphate 4-Phosphatase Type II (INPP4B) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 1:00:00 PM OR31 5920 11:30:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Oral


Larry Denner*1, Jordan Jahrling2 and Kelly T Dineley2
1University of Texas Medical Branch, Galveston, TX, 2University of Texas Medical Branch

 

The systems biology of cognitive impairment is an unexplored approach to understanding cognitive function. Learning and memory deficits are quintessential features of Alzheimer’s disease (AD) and some AD mouse models. We previously reported that the peroxisome proliferator-activated receptor gamma (PPARγ) agonist rosiglitazone (RSG) improves hippocampus-dependent cognitive deficits in some AD patients and ameliorates deficits in the Tg2576 transgenic AD mouse model. We have used a systems biology approach to build a knowledge base of normal and pathophysiological cognitive performance in this model. Using targeted qPCR, unbiased RNA-Seq, and the bioinformatics tool Ingenuity Pathway Analysis, we discovered that the gene expression profile of RSG-mediated cognitive enhancement is mediated through many genes containing PPREs and CREs that provide a convergence of signaling through PPARγ and ERK. In fact, dysfunctional ERK phosphorylation is normalized by recruitment of PPARγ into a multiprotein complex with pERK that is required for consolidation-dependent learning and memory. Using multiplex kinase inhibitor bead-mass spectrometry, we found several additional kinase signaling pathways that are dysregulated in Tg2576 and normalized by RSG that signal to ERK and PPARγ. Consistent with this, using quantitative mass spectrometry-based phosphoproteomics, we identified hundreds of phosphorylation sites differentially regulated in Tg2576 that were normalized by RSG. Many of these were also in pathways converging on ERK and PPARγ. Furthermore, unbiased mass spectrometry revealed altered expression of hundreds of proteins that are normalized by RSG. These were mostly in the domains of mitochondrial energy production and synaptic plasticity. Several proteins seminal to presynaptic SNARE function that regulate vesicular neurotransmitter release were critical to restoration of normal cognition. Using patch clamp electrophysiology of dentate gyrus granule cells, the gateway to the hippocampus, we found hyperactivity and compromised probability of neurotransmitter release in the Tg2576, both of which were normalized by RSG. Our findings provide a comprehensive understanding of the systems biology of normal cognition, its dysregulation in an animal model of AD, and normalization with PPARγ agonism. These molecular mechanisms offer new targets for therapeutic development in AD.

 

Nothing to Disclose: LD, JJ, KTD

OR31-6 22054 6.0000 A The Systems Biology of PPAR Gamma-Mediated Cognitive Enhancement in Alzheimer's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 1:00:00 PM OR31 5920 11:30:00 AM Nuclear Receptors and Kinases: Intertwined in Cancer, Obesity and Brain Disorders Oral


Mark P Keller*1, Pradyut K Paul1, Mary E Rabaglia1, Donnie S Stapleton1, Jose Rodriguez-Martinez1, Ning Leng1, Christopher L Plaisier2, Melkam A Kabede1, Mark A Klein1, Nitin S Baliga2, Brian S Yandell1, Christina Kendziorski1, Aseem Z Ansari1 and Alan D Attie1
1University of Wisconsin, Madison, WI, 2Institute for Systems Biology, Seattle, WA

 

Type-1 diabetes (T1D) is caused by an autoimmune destruction of pancreatic β-cells, resulting in severe insulin deficiency. In Type-2 diabetes (T2D), there is relative insulin deficiency; insulin is produced in insufficient amounts to satisfy the increased demand evoked by obesity-induced insulin resistance. Insulin insufficiency in T2D can be the result of loss of β-cell mass or defects that affect β-cell function. Development of therapies to restore β-cell mass and/or improve β-cell function may offset the insulin deficiency in patients with T1D or T2D. We have shown that two members of the Nuclear Factor of Activated T-cells (NFAT) family of transcription factors offer clues for the development of these therapies. To study the effects of NFAT on β-cells, we overexpressed constitutively active (ca) NFAT, with N-terminal regulatory serines mutated to alanines, in mouse and human islets. The overexpression of ca-Nfatc1 and ca-Nfatc2 induced human β-cell proliferation ~2 and 4-fold respectively. In mouse islets, ca-Nfatc2 induced β-cell proliferation ~20-fold; ca-Nfatc1 had no effect. To evaluate the influence of NFAT on β-cell function, we monitored insulin secretion in response to several insulin secretagogues. Both NFAT isoforms augmented insulin secretion from human and mouse islets. To identify transcriptional targets of NFAT, we used whole-islet RNA-sequencing of mouse islets 48hr after overexpression of ca-Nfatc2 or ca-Nfatc1. Two sets of genes were enriched for Cell Cycle: genes induced exclusively by ca-Nfatc2; and genes induced by ca-Nfatc2 and suppressed by ca-Nfatc1. The suppression of one or more of these cell cycle genes may explain why ca-Nfatc1 was unable to induce β-cell proliferation in mouse islets; many of these genes in human islets were induced by ca-Nfatc1, in parallel with increased β-cell proliferation. NFAT has several binding partners that mediate transcriptional regulation of specific target genes. We experimentally determined the preferred DNA binding sites for human NFATc2, alone and in complex with one of its binding partners, Jun/Fos (AP1). Proteins were incubated with >1012 distinct DNA segments that represented all possible sequence permutations. Whereas NFATc2 alone preferred the canonical motif GGAAA, the motifs recognized by the NFATc2-AP1 complex were distinct; with AP1, GGAAA can be reduced to a minimal GG dinucleotide if positioned next to the high affinity AP1 site, TGA(C/G)TCA. In addition to AP1, the FOXP family has been shown to complex with NFAT. We showed that FOXP1 and FOXP4 are abundantly expressed in mouse and human islets, suggesting that NFAT/FOXP complexes may mediate effects on β-cell proliferation and function. We hypothesize that distinct nuclear binding partners determine preferred DNA binding motifs, which underlie the differential effects of NFAT on β-cell proliferation and insulin secretion in human vs. mouse islets.

 

Nothing to Disclose: MPK, PKP, MER, DSS, JR, NL, CLP, MAK, MAK, NSB, BSY, CK, AZA, ADA

OR26-1 19962 1.0000 A NFAT Stimulates Beta-Cell Proliferation and Insulin Secretion in Human and Mouse Islets 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 1:00:00 PM OR26 5940 11:30:00 AM Fundamental Islet Cell Biology Oral


Guadalupe Navarro*1, Zhengshan Zhao2, Neali Armstrong2, Robert Nichols2 and Justin P Annes2
1Stanford University, Stanford, CA, 2Stanford University

 

The Role of Adenosine Kinase in pancreatic b-cell regeneration

 Diabetes is a disease state characterized by the inability to maintain normal blood glucose levels. Although several pathophysiologic mechanisms lead to glucose dysregulation, loss of insulin-producing beta-cells is a shared pathologic finding among most forms of diabetes. While a variety of therapeutic strategies are used to maintain normal glucose levels, none of these restores β-cell mass, achieves the exquisite glucose control realized by endogenous hormone production or consistently prevents disease-related complications. We hypothesize that the development of a novel therapeutic class of compounds that stimulates β-cell regeneration will effectively restore glucose homeostasis and prevent diabetic sequelae. Consequently, we developed a primary islet-cell-based screening platform to identify small molecules that promote β-cell replication. Use of this screen has identified adenosine kinase inhibitors (ADKi) as novel in vitro and in vivo inducers of b-cell replication. These findings raise the possibility that inhibition of ADK may be used to stimulate β-cell regeneration.

To further assess the in vivo function of ADK in β-cells we generated mice conditionally targeted at the ADK locus and selectively disrupted ADK expression within β-cells using the Rip-Cre driver mouse strain (βADKO mice). Successful disruption of ADK expression was confirmed in islets isolated from βADKO mice. On a normal chow (NC), βADKO and control RIP-Cre mice display similar glucose tolerance at 12 weeks of age; however, by 25 weeks, βADKO mice have improved glucose tolerance. Additionally, βADKO mice challenged with a high fat diet (HFD) exhibit improved glucose tolerance with 6 weeks, decreased fasting blood glucose and reduced random fed glucose levels. Importantly, both NC- and HFD-fed βADKO mice display increased glucose-stimulated insulin secretion capacity. Consistent with this phenotype, HFD-fed βADKO mice (18 weeks) have increased β-cell area compared to Rip-Cre control animals. These findings demonstrate an important role for ADK in modulating β-cell function in vivo.

 

Nothing to Disclose: GN, ZZ, NA, RN, JPA

OR26-2 21272 2.0000 A The Role of Adenosine Kinase in Pancreatic β-Cell Regeneration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 1:00:00 PM OR26 5940 11:30:00 AM Fundamental Islet Cell Biology Oral


Alan Schneyer*1, Danielle Andrzejewski2, Amy S Burnside3 and Melissa L Brown4
1University of Massachusetts Amherst and Fairbanks Pharmaceuticals, Springfield, MA, 2UMass-Amherst, Springfield, MA, 3UMass-Amherst, Amherst, MA, 4UMass Amherst, Springfield, MA

 

Both type 1 and type 2 diabetes involve loss of functional pancreatic β-cells which is driving research into potential replacement sources.  Expansion of functional β-cell mass, such as through induction of β-cell neogenesis or through transdifferentiation of α-cells into functional β-cells represent appealing therapeutic solutions to restoring glucose control.  To date, however, these processes have been induced through genetic misexpression of cell fate determining transcription factors such as Arx or Pax4 or following severe pancreatic injury or β-cell destruction.  It remains to be determined whether transdifferentiation or neogenesis contribute to maintaining and/or expanding functional β-cell mass under normal physiological conditions and how these processes are regulated.

 We have previously reported that inactivation of the activin antagonist follistatin like-3 (FSTL3) resulted in a 2-fold increase in mean islet size and expansion of the β-cell compliment.  We hypothesized that the β-cell expansion resulted from accelerated α- to β-cell transdifferentiation that was induced by enhanced activin bioavailability of the FSTL3 KO mouse.  In support of this hypothesis, we found that activin, acting via phosphorylation of Smad2 but not Smad3, suppressed expression of Arx and other α-cell genes while it promoted β-cell gene expression in cell lines.    We then used cell sorting based on natural fluorescence of α- and β-cells to achieve >95% enrichment of these cell populations.  Activin treatment of enriched primary α-cells also suppressed α-cell gene expression including Arx.  To explore whether activin had this effect in vivo, we used Gluc-Cre/YFP lineage tracing to label α-cells with YFP and crossed these mice with our FSTL3 KO mice.  Cell sorting identified 2 additional populations, YFP labeled α-cells (YFP+gluc+) and YFP labeled β-cells (YFP+Ins+), the identities of which were confirmed by fluorescence immunohistochemistry on frozen pancreas sections.   Interestingly, the number of YFP+Ins+ cells was significantly increased (2-fold) in 3 month old FSTL3 KO islets compared to WT.  Moreover, the number of total YFP+ cells, as well as YFP+Ins+ cells increased significantly with age in FSTL3 KO mice but not in WT littermates. These results support the hypothesis that β-cell expansion observed in FSTL3 KO mice results, at least in part, from increased α- to β-cell transdifferentiation.  This in turn suggests that activin signaling directly or indirectly regulates α- to β-cell transdifferentiation and that transdifferentiation may occur in the absence of injury or genetic overexpression of cell fate drivers.  These results also suggest that modulation of FSTL3 activity may be a potential therapeutic pathway for alleviating diabetes.

 

Nothing to Disclose: AS, DA, ASB, MLB

OR26-3 19953 3.0000 A Lineage Tracing Indicates That a- to b-Cell Transdifferentiation Is Enhanced in FSTL3 KO Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 1:00:00 PM OR26 5940 11:30:00 AM Fundamental Islet Cell Biology Oral


Safia Costes*1, Tatyana Gurlo1, Alexandra E Butler1, Sam Sereda2, Orian Shirihai2 and Peter Cawood Butler3
1UCLA, Los Angeles, CA, 2Boston University, 3University of California Los Angeles, Los Angeles, CA

 

Type 2 diabetes (T2D) is characterized by a deficit in beta-cell mass and function, and islet amyloid derived from islet amyloid polypeptide (IAPP), a protein co-expressed with insulin by beta-cells. Intracellular membrane-permeant toxic oligomers of amyloidogenic proteins mediate cell dysfunction in protein misfolding diseases such as Alzheimer’s disease. These diseases share in common progressive attrition of cells that express the amyloidogenic protein with a pattern of cell dysfunction that includes endoplasmic reticulum (ER) stress, dysregulation of Ca2+ signaling and mitochondrial dysfunction. We previously reported that toxic IAPP oligomers are present in both ER and mitochondrial membranes in beta-cells of humans with T2D and rodents transgenic for human-IAPP (h-IAPP). We hypothesized that the pattern of cellular dysfunction induced by h-IAPP toxic oligomers may be mediated by disruption of the ER-mitochondria interface, “mitochondria-associated ER membranes” (MAMs), crucial for lipid synthesis, ER to mitochondria Ca2+exchange required for oxidative phosphorylation, mitochondrial fission and fusion required for mitochondrial network repair.

To test this hypothesis, we used models of beta-cells with h-IAPP expression sufficient to induce toxic oligomers; INS 832/13 cells transduced with adenovirus expressing h-IAPP (or the non-amyloidogenic r-IAPP as control), and isolated islets from h-IAPP transgenic rodents. We established that high expression of h-IAPP induced fragmentation of the mitochondrial network (visualized using mitochondrial targeting of fluorescent DsRed) and loss of cristae (by electron microscopy), with impaired mitochondrial function (mitochondrial respiration evaluated by Seahorse technology) and increased oxidative stress (levels of carbonyl-modified proteins and reactive oxygen species). As Mitofusin-2 (Mfn-2) tethers ER and mitochondria in MAM and mediates mitochondrial network repair by fusion, it was notable that high expression of h-IAPP induced a marked decrease in beta-cell Mfn-2 expression (by Western blotting). We further evaluated the integrity of the MAM interface in beta-cells using a specific MAM-associated marker, phophofurin acidic cluster sorting protein-2 (PACS-2). Immunofluorescence revealed marked up-regulation of PACS-2 protein in beta-cells of h-IAPP transgenic mice in comparison to controls, and notably this finding was reproduced in beta-cells of human subjects with T2D.

We conclude that h-IAPP expression sufficient to induce toxic oligomers leads to disruption of the mitochondrial network and function, with subsequent oxidative stress in beta-cells. Our data support the hypothesis that the pattern of cellular dysfunction induced by formation of toxic h-IAPP oligomers may be mediated at least in part by disruption of the fidelity of the ER-mitochondria cross-talk.

 

Disclosure: PCB: Speaker, Genentech, Inc.. Nothing to Disclose: SC, TG, AEB, SS, OS

OR26-4 20109 4.0000 A Disruption of the Endoplasmic Reticulum-Mitochondria Interface By Toxic IAPP Oligomers May Compromise Beta-Cell Mitochondrial Network Integrity and Function in Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 1:00:00 PM OR26 5940 11:30:00 AM Fundamental Islet Cell Biology Oral


Talitha van der Meulen1, Cynthia J. Donaldson2, Anna Hunter3, Elena L. Caceres4 and Mark O Huising*1
1University of California, Davis, Davis, CA, 2The Salk Institute for Biological Studies, 3University of California, Davis, 4The Salk Institute for Biological Studies, CA

 

The peptide hormone Urocortin3 (Ucn3) is the third-most abundantly expressed hormone by beta cells after insulin and amylin, yet its physiological role remains unknown. Here we resolve this enigma by demonstrating that Ucn3 acts on delta cells to promote somatostatin release. Ucn3 is required for the development and maintenance of a normal complement of delta cells, as mice lacking Ucn3 demonstrate fewer delta cells, reduced somatostatin content and lower expression of delta cell markers. Ucn3 null islets display impaired basal and glucose-stimulated somatostatin secretion, which is rescued by synthetic Ucn3 peptide, demonstrating that endogenous Ucn3 is required for normal somatostatin release. While Ucn3 is highly selective for mature mouse beta cells, human Ucn3 is expressed in alpha cells as well. Indeed, we demonstrate that Ucn3 in human islets not only induces somatostatin release under medium and high glucose conditions, but is required for normal somatostatin release under low glucose conditions associated with alpha cell activity. Our findings revise the dogma that somatostatin secretion is mediated by delta cell-autonomous stimulus-secretion coupling analogous to the mechanism of insulin release by the beta cell. Instead, we demonstrate that Ucn3 acts as a paracrine signal from beta cells and human alpha cells that promotes somatostatin release to ensure normalization of insulin and glucagon secretion in a classical negative feedback loop. Furthermore, Ucn3 is markedly reduced in residual beta cells in both major forms of diabetes, which we show by continuous glucose monitoring in mice to be associated with dramatic increases in the volatility of plasma glucose levels. It follows that Ucn3 is a key contributor to life-long maintenance of stable glycemic control whose loss aggravates glycemic volatility during diabetes.

 

Nothing to Disclose: TV, CJD, AH, ELC, MOH

OR26-5 21370 5.0000 A Urocortin3 Triggers Somatostatin-Mediated Negative Feedback to Control Insulin Secretion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 1:00:00 PM OR26 5940 11:30:00 AM Fundamental Islet Cell Biology Oral


Hen Prizant*1, Soumya Mitra1, Allison Light2 and Stephen R Hammes2
1University of Rochester Medical Center, Rochester, NY, 2University of Rochester, Rochester, NY

 

Lymphangioleiomyomatosis (LAM) is a devastating rare lung disease in which adenomas consisting of abnormal smooth muscle cells grow within the lungs and progressively lead to loss of pulmonary function. The true origin of the LAM cell is unknown, however, important features of LAM provide us with clues. First, LAM cells contain inactivating mutations in genes encoding Tsc1 or Tsc2, proteins that limit cell growth through mTORC1 activity. Second, LAM cells appear to be metastatic. Third, LAM cells express estrogen and progesterone receptors as well as melanocytic-differentiation markers. Finally, LAM is found almost exclusively in women. Interestingly, LAM shares many features with uterine leiomyomas, benign tumors of myometrial cells, and a recent study demonstrates that the majority of patients with lung LAM also have uterine LAM lesions (1). To test the hypothesis that LAM cells originate from uterine leiomyomas containing Tsc mutations, we developed a mouse model for leiomyoma and LAM by targeting uterine-specific Tsc2 deletion. 100% of uteri from uterine-specific Tsc2 knockout mice develop LAM-like leiomyomas by 18-24 weeks and approximately 50% of 28-34 weeks old mice develop smooth-muscle Tsc2-null tumors in the lungs. Uniquely, uterine Tsc2-null cells express melanocytic-differentiation markers pMEL and MLANA, both considered hallmarks of LAM. 10-weeks after ovariectomy or treatment with the aromatase inhibitor letrozole, knockout uteri contain reduced mTORC1 activity as well as decreased myometrial proliferation, resulting in reversal of the uterine phenotype. Thus, loss of Tsc2 is not sufficient to promote mTORC1-mediated leiomyoma growth without a continuous positive proliferative signal from estradiol. Mechanistically, uterine gene profiling data demonstrate an up-regulation of matrix metalloproteinase (MMP) expression, as well as other markers of inflammation, by estrogen in the absence of Tsc2. In-vivo and ex-vivo fluorescent imaging using an MMP-sensitive optical biomarker show higher signal specifically in leiomyomas, suggesting that MMP activity is primarily in Tsc2-null myometrial cells. In addition, using gelatin zymography and qPCR, we find that MMP2 activity and MMP9 expression are dependent on estrogen in the absence of Tsc2. Together, these data indicate that myometrial proliferation in uterine-specific Tsc2 null mice is exquisitely dependent on estradiol, and that estrogen regulates mTORC1 and MMP2/9 activity in these LAM-like cells. We therefore suggest that anti-estrogen therapy may be an effective means of treating not only leiomyoma, but LAM as well.

 

Nothing to Disclose: HP, SM, AL, SRH

OR25-1 20046 1.0000 A Leiomyoma Proliferation in Uterine-Specific Tsc2 Null Mice Is Exquisitely Dependent of Estradiol Signaling - Implications in the Treatment of Lymphangioleiomyomatosis (LAM) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 1:00:00 PM OR25 5952 11:30:00 AM Biomarkers and Hormone-Dependent Cancers Oral


Sumanta Chatterjee1, Wenyi Yang2, Arun Seth2 and Afshin K Raouf*1
1University of Manitoba, Winnipeg, MB, Canada, 2University of Toronto, Toronto, ON, Canada

 

Insulin-like growth factors (IGFs) and their binding proteins (Igfbps) play essential roles in the normal development of mammary gland as well as the development of many malignancies including breast cancer. Interestingly, the Igfbp-related protein, Igfbp7, has been shown to act as a potential tumor suppressor. To investigate the role of Igfbp7 in the normal mammary gland development and breast cancer, we recently generated and characterized Igfbp7-null mice. While these mice did not develop any detectable malignancies, the normal maturation of mammary glands was severely diminished in these mice. As well, the Igfbp7-null mice featured a precocious involution phenotype. In this report we show that loss of Igfbp7 disrupts the normal differentiation of luminal progenitors into mature luminal cells while enhancing the proliferation potential of these progenitors. To this end, we used isolated luminal progenitors from the Igfbp7-null (KO) or the Wild Type (WT) glands and used matrigle assays in combination with the colony forming cell  (CFC) assay to measure the proliferation and differentiation potentials of these luminal progenitors. Surprisingly we found that the KO glands contained 3 fold more luminal progenitors. Where as the WT luminal progenitors only expanded by 3 folds in matrigels, the KO progenitors showed an 8-fold expansion in the same assay. The enhanced proliferation potential of the KO progenitors was further corroborated by Ki67 staining and cell cycle analysis. These studies suggested that the KO glands contain and expanded pool of luminal progenitors that are capable of producing differentiated cells. Yet in vivo, the Igfbp7-null glands contain fewer mature cells. To reconcile these seemingly divergent phenotypes, we examined the ability of KO stromal fibroblasts to support the differentiation of luminal progenitors.  Interestingly, we found that the Igfbp7-null fibroblasts are unable to support the differentiation of luminal progenitors in the CFC assays. Our secretome analysis revealed that the KO fibroblasts show decreased secretion of IGFs and that addition of recombinant IGF1 or IGF2 partially recovers KO fibroblasts’ ability to support luminal progenitor cell differentiation. Our data therefore, shows that loss of Igfbp7, a potential tumor suppressor, can lead to an abnormally expanded luminal progenitor pool which has been previously reported in BRCA1 mutant breast tumours. The acquisition of further mutation(s) by this expanded pool of luminal progenitors could confer a cancer stem cell phenotype on these highly proliferative cells.

 

Nothing to Disclose: SC, WY, AS, AKR

OR25-2 22004 2.0000 A Loss of Igf Binding Protein 7 Enhances Proliferation Potential of Luminal Progenitors While Diminishing Thier Differentiation Potential 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 1:00:00 PM OR25 5952 11:30:00 AM Biomarkers and Hormone-Dependent Cancers Oral


Ayesha A Shafi*, James Michael Arnold, William E Bingman III, Vasanta Putluri, William Charles Krause, Zheng Xia, Wei Li, Nagireddy Putluri, Arun Sreekumar and Nancy L Weigel
Baylor College of Medicine, Houston, TX

 

Prostate cancer (PCa) is an androgen-dependent disease. Metastatic disease is treated with androgen deprivation therapy (ADT). The tumors respond initially, but usually become resistant and are termed castration-resistant PCa (CRPC). However, they remain androgen receptor (AR) dependent. Numerous mechanisms for AR-dependent resistance have been proposed including local synthesis of androgens and expression of constitutively active AR splice variants lacking a hormone binding domain. The best characterized AR splice variant is AR-V7 (AR3), which contains exons 1-3 (amino-terminus and DNA binding domain) of AR and 16 unique amino acids. Recent clinical studies show that AR-V7 expression correlates with resistance to ADT and poor outcome. This raises the question whether variants simply substitute for AR or have novel activities that contribute to resistance. Using our previously generated LNCaP cell lines that express AR-V7 in response to doxycycline (Dox) and transcriptomes for AR and AR-V7 derived using RNA-Seq, we have now asked whether the differences in gene expression translate into unique biological responses. AR-V7 preferentially induces several genes in the cholesterol/steroid synthesis (including androgen) pathway. To test if these changes can induce conversion of adrenal androgens to an AR agonist, LNCaP or LNCaP AR-V7 cells were treated with androstenedione (AD) and AR activation monitored using SGK1, an AR specific target. AR-V7 caused a time dependent activation of AR in response to AD, suggesting conversion of AD to an AR agonist. This finding is paradigm shifting. Aberrant steroid metabolism and variants are considered alternate means of resistance, but this suggests that variants contribute to aberrant synthesis. AR is also important for cell metabolism. We previously found via Seahorse assay that both AR and AR-V7 increase glycolysis. However, our new studies have revealed unique actions of the isoforms. Using liquid chromatography-mass spectrometry (LC-MS), the effects of AR or AR-V7 activation on the levels of metabolites involved in energy metabolism and proliferation were examined. Metabolic flux analysis (MFA) using [U-13C]-glucose, [U-13C]-glutamine, [5-13C]-glutamine, and [1-13C]-glutamine showed that AR-V7 accelerated glycolysis more effectively than AR. AR has been reported to induce CAMKKβ expression resulting in activation (phosphorylation) of AMPK and our data confirmed this. However, AR-V7 did not induce CAMKKβ to activate AMPK. MFA showed AR induced flux through both the canonical TCA (Kreb cycle) and reductive carboxylation for glutamine metabolism. In contrast, AR-V7 preferentially stimulated glutamine metabolism through reductive carboxylation suggesting an increased dependence on this pathway. Overall these studies suggest that AR-V7 has unique functions that may be therapeutic targets to counteract resistance to therapy.

 

Nothing to Disclose: AAS, JMA, WEB III, VP, WCK, ZX, WL, NP, AS, NLW

OR25-3 20561 3.0000 A Androgen Receptor (AR) Isoform-Specific Effects on Cell Metabolism in Prostate Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 1:00:00 PM OR25 5952 11:30:00 AM Biomarkers and Hormone-Dependent Cancers Oral


Mitchell G Lawrence*1, Ruth Pidsley2, Stuart J Ellem3, Luc Furic4, Shalima Nair2, Hugh French2, Aaron Statham2, Ola Larsson5, Mark Frydenberg3, John Pedersen6, Australian Prostate Cancer Bioresource3, Grant Buchanan7, Renea A Taylor3, Susan Clark2 and Gail P Risbridger3
1Monash University, Clayton, Australia, 2Garvan Institute of Medical Research, 3Monash University, Melbourne, Australia, 4Monash University, Clayton/VIC, Australia, 5Karolinska Institutet, 6Tissupath Pathology Services, Melbourne, Australia, 7University of Adelaide

 

Reciprocal interactions between prostate epithelium and stroma are regulated by the actions of steroid hormone receptors, including estrogen receptor α (ERα). This cross-talk is essential for prostate development and homeostasis, but is perturbed in prostate cancer. It was once often assumed that the corresponding changes in tumor stroma are a transient reaction to dysregulated signalling in adjacent cancer cells. Yet, the phenotypic differences between normal prostate fibroblasts (NPFs) and cancer-associated fibroblasts (CAFs) are maintained in the absence of epithelium, implying that tumor stroma undergoes more permanent changes.

Therefore, we hypothesised that tumor stroma acquires epigenetic modifications that fundamentally alter the balance of steroid hormone action and confer tumorigenicity.

Cultures of matched NPFs and CAFs were established from benign and malignant regions of radical prostatectomy specimens. In vivotissue recombination assays were used to confirm that BPH-1 prostate epithelial cells formed tumors in the presence of CAFs, but not NPFs. We also compiled the first complete epigenome map of human tumor stroma using whole genome bisulphite sequencing (WGBS), which covers 95% of all CpG sites. RNAseq and Affymetrix arrays were used to compare mRNA abundance.

Our data revealed that NPFs and CAFs have distinct epigenome profiles. CAFs exhibited global hypomethylation and focal hypermethylation compared to NPFs. There were more than 300 differentialy methylated regions between CAFs and NPFs. These changes were highly reproducible and were validated using targeted bisulfite sequencing of DNA from an independent cohort of 10 patient-matched sets of NPFs and CAFs. In many instances, differential DNA methylation correlated with differences in mRNA levels between CAFs and NPFs. One notable example was the ESR1 gene encoding estrogen receptor α (ERα). Hypomethylation of the ESR1 promoter was associated with higher mRNA abundance in CAFs. Concomitantly, there was a significant increase in the ratio of ERa staining within tumor stroma of patient tissue specimens. Up-regulation of ERα in CAFs was associated with the enrichment of an estrogen-regulated gene signature, of which CXCL12 was the most highly over-expressed gene. Functional assays showed that CXCL12 secreted by CAFs recruited CXCR4+mast cells. The mast cells in turn secereted pro-tumorigenic cytokines in response to estrogen.

Collectively, these data demonstrate that epigenomic changes are an underlying mechanism for the enduring functional differences between NPFs and CAFs. Key epigenetically-regulated genes, such as ESR1, also have the ability to actively promote the progression of prostate cancer.

 

Nothing to Disclose: MGL, RP, SJE, LF, SN, HF, AS, OL, MF, JP, APCB, GB, RAT, SC, GPR

OR25-4 20821 4.0000 A Estrogen Receptor α Is Epigenetically Regulated in Human Prostate Cancer-Associated Fibroblasts and Drives a Pro-Tumorigenic Loop at the Tumor Interface 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 1:00:00 PM OR25 5952 11:30:00 AM Biomarkers and Hormone-Dependent Cancers Oral


Renea A Taylor*1, Mitchell G Lawrence1, Kohei Hashimoto1, Hong Wang1, Melissa Papargiris1, Heather Thorne2, , kConFab2, Mark Frydenberg3, Declan Murphy2, Andrew Ryan4, David Clouston4, Damien Bolton5 and Gail P Risbridger3
1Monash University, Clayton, Australia, 2Peter MacCallum Cancer Centre, Melbourne, Australia, 3Monash University, Melbourne, Australia, 4TissuPath, Melbourne, Australia, 5University of Melbourne, Melbourne, Australia

 

Men with localised prostate cancer are stratified into risk categories for disease progression using D’Amico criteria. Men with high risk disease are more likely to show rapid biochemical relapse after curative local therapy and for these men, androgen deprivation therapy (ADT) is standard of care. Men with familial prostate cancer, including BRCA2 mutation carriers, also have a high risk of recurrence. Our recent retrospective analysis of tumors from men with BRCA2 mutations, linked the pathological feature of intraductal carcinoma of the prostate (IDC-P), with poor prognosis and reduced overall survival.

We recently showed that castrate-tolerant cells pre-exist in localised prostatic adenocarcinoma specimens, and that these cells are stem-like and tumor regenerating. The aim of this study was to examine whether lethal castrate-tolerant cells are detectable in IDC-P in all men with high risk prostate cancer. To do this, we used patient derived xenografts (PDXs) of localised prostate cancer from men with high risk sporadic and familial disease.

To investigate the putative response of IDC-P to ADT, we established and used PDXs from n=8 patients at high risk of disease recurrence (5 sporadic and 3 familial cases). The pathology of all radical prostatectomy specimens was reviewed to confirm the presence of IDC-P and adenocarcinoma. PDXs were established as sub-renal grafts in host mice that were castrated for 4-8 weeks and then re-administered with testosterone for a further 4 weeks.

Consistent with the original specimens, IDC-P pathology was detected together with adenocarcinoma in PDXs from all 8 cases. IDC-P foci in PDXs displayed classical histopathology with dense cribriform tumor foci within benign glands lined by p63+ basal cells. Of the 6 cases treated with castration, castrate-tolerant cells were identified within IDC-P and adenocarcinoma foci in 5 patients, suggesting incomplete regression of IDC-P in response to androgen withdrawal. After testosterone was re-administered, 5/6 cases regenerated with adenocarcinoma and 4/6 cases with IDC-P, confirming the tumor regenerating potential of castrate-tolerant IDC-P cells.

This study demonstrates that castrate-tolerant cancer cells reside in IDC-P of PDXs from men with high risk prostate cancer, indicating that the endocrine response within IDC-P may be as important as adenocarcinoma and supports the assignment of IDC-P as a high risk feature. Importantly, patients with IDC-P may benefit from additional therapy at the time of ADT. Our current preclinical studies using aggressive localised tumors will demonstrate if adjuvant therapies can completely regress both adenocarcinoma and IDC-P.

 

Nothing to Disclose: RAT, MGL, KH, HW, MP, HT, K, MF, DM, AR, DC, DB, GPR

OR25-5 21480 5.0000 A Prostate Cancers with Intraductal Carcinoma (IDC-P) Pathology Harbor Castrate-Tolerant Regenerating Cells: Implications for Response to Endocrine Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 1:00:00 PM OR25 5952 11:30:00 AM Biomarkers and Hormone-Dependent Cancers Oral


Vijay Pandey*1, Min Zhang2, Mingliang You1, Tao Zhu2, Xiu Qin Xu3 and Peter E Lobie4
1NUS, Singapore, 2University of Science and Technology of China, China, 3Medical College, Xiamen University, China, 4National University of Singapore, Singapore, Singapore

 

Cell proliferation and survival have been postulated to provide a platform for oncogenic transformation of normal cells and which may occur through the constitutive activation of growth promoting factors and their downstream effectors (1, 2). It was previously demonstrated that oncogenic transformation of human mammary epithelial cells (HMECs) requires the expression of at least three genetic elements, including hTERT (catalytic subunit of human telomerase), SV40 large T, and H-Ras oncoprotein (3).

Trefoil factor 3 (TFF3), is an oestrogen-responsive secreted protein, absent or expressed at relatively low levels in normal tissues but significantly elevated in numerous human malignancies, including mammary carcinoma (MC) (4, 5). TFF3 protein expression was observed to be associated with advanced clinicopathological features of malignant disease (4, 6, 7). TFF3 has been reported to stimulate tumor progression and metastatic seeding of ER+ MC cells (5, 6). However, the functional role of TFF3 in oncogenic transformation largely unknown.

We observed that simple forced expression of TFF3 efficaciously stimulated oncogenic transformation of immortalized but otherwise normal human mammary epithelial cells (HMECs). Forced expression of TFF3 in immortalized-HMECs enhanced cell proliferation, cell survival, anchorage independent growth and produced highly disorganized three-dimensional (3D) acinar structures; and importantly generated tumours in nude mice. Forced expression of TFF3 in immortalized-HMECs stimulated STAT3 activity that was required for TFF3-stimulated cell proliferation and survival, and anchorage independent growth. TFF3 specifically utilized STAT3 activity to govern a transcriptional program, which was required for TFF3-stimulated oncogenic transformation of immortalized-HMECs including transcriptional up-regulation of proto-oncogenes, CCND1 and BCL2. siRNA-mediated depletion or functional inhibition of STAT3 significantly inhibited the TFF3-stimulated transcription of CCND1 and BCL2 , and oncogenicity in immortalized-HMECs.

Furthermore, inducible expression of TFF3 in HMEC-hTERT cells resulted in increased protein levels of TFF3, increased pSTAT3, and increased CCND1, and BCL2. Furthermore, DOX-induced expression of TFF3 in HMEC-hTERT cells also exhibited enhanced anchorage independent growth and produced highly disorganized 3D acinar structures in 3D Matrigel. Removal of DOX-induced expression of TFF3 in HMEC-hTERT cells, previously grown with DOX resulted in efficient normalization of the disorganized 3D acinar architecture in Matrigel.

Thus, TFF3 is potent oncogene and utilizes STAT3 signaling to execute its oncogenic transforming activity in immortalized-HMECs. This study therefore provides evidence that the expression of two non-mutated genetic elements is sufficient to produce oncogenic transformation in HMECs.

 

Nothing to Disclose: VP, MZ, MY, TZ, XQX, PEL

OR25-6 21615 6.0000 A Expression of Two Genetic Elements Is Sufficient to Stimulate Oncogenic Transformation of Human Mammary Epithelial Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 1:00:00 PM OR25 5952 11:30:00 AM Biomarkers and Hormone-Dependent Cancers Oral


Mahmoud Habibullah*1, Nicolas Kluger2, Annamari Ranki2, Kai Krohn3, Anthony Peter Weetman1 and Elizabeth Helen Kemp1
1University of Sheffield, Sheffield, United Kingdom, 2Institute of Clinical Medicine, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland, 3Clinical Research Institute HUCH Ltd, Helsinki, Finland

 

Autoimmune polyendocrine syndrome type 1 (APS1) is a rare autosomal recessive disease characterised by chronic mucocutaneous candidiasis and multiple autoimmune endocrinopathies and which results from mutations in the autoimmune regulator (AIRE) gene. Approximately 80% of patients present with hypoparathyroidism which is suggested to result from autoimmune responses against the parathyroid glands. The calcium-sensing receptor (CaSR), which plays a pivotal role in maintaining calcium homeostasis by sensing blood calcium levels and regulating release of PTH, has been identified as a parathyroid autoantibody target in APS1. The aim of the study was to characterise CaSR autoantibodies detected in 16 APS1 patients in relation to their epitopes, IgG subclass and functional effects. Autoantibody reactivity against CaSR peptides 41–69, 114–126, 171–195 and 260-340 was identified by phage-display and subsequently confirmed by ELISAs in 16 (100%), five (31%), six (38%), and seven (44%) of the 16 APS1 patients, respectively. Absorption experiments using CaSR peptides also confirmed the specificity of all patient CaSR autoantibodies in recognising their respective epitopes. The data verify previous findings that amino acid residues 41-69 in the CaSR extracellular domain contain the major autoantibody binding site, and also indicate a new CaSR epitope at residues 260-340. To investigate functional effects, CaSR autoantibodies were analysed for their ability to increase both Ca2+-dependent extracellular signal-regulated kinase phosphorylation and inositol phosphate accumulation in HEK293 cells expressing the CaSR. The results indicated that only two of 12 APS1 patients tested had CaSR-activating autoantibodies and suggest that although the majority of APS1 patients do not have CaSR-stimulating autoantibodies, there may be a small minority of patients in whom the hypoparathyroid state is the result of functional suppression of the parathyroid glands rather than their irreversible destruction. Finally, ELISAs were used to determine CaSR autoantibody IgG subclasses: autoantibodies against CaSR epitopes 41–69, 171-195 and 260-340 were exclusively of the IgG1 subclass. Autoantibody responses against CaSR epitope 114-126 were also predominantly of the IgG1 with a minority of autoantibodies of the IgG3 subclass. The data suggest a Th1-type immune response to the CaSR. It is also interesting to note that IgG1 subclass autoantibodies have the capacity to activate complement and induce cellular effector mechanisms and so these need to be analysed in the context of CaSR autoantibodies. The study provides a detailed analysis of the characteristics of CaSR autoantibodies in APS1 patients, although further investigations are required to determine the exact role played by the autoimmune response against the CaSR in the pathogenesis of APS1.

 

Disclosure: AR: Scientific Board Member, ImmunoQure AG. KK: Scientific Board Member, ImmuoQure AG. Nothing to Disclose: MH, NK, APW, EHK

OR29-2 20895 1.0000 A Epitopes, Specificity, Functional Effects and Immunoglobulin G Subclasses of Calcium-Sensing Receptor Autoantibodies in Patients with Autoimmune Polyendocrine Syndrome Type 1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 1:00:00 PM OR29 5955 11:30:00 AM Metabolic Bone Disease - Pathophysiology and Treatment Oral


Deborah M Mitchell*1, Padrig Tuck1, Kathryn E Ackerman1, Ryan M Woolley1, Natalia Cano Sokoloff1, Meghan Slattery1 and Madhusmita Misra2
1Massachusetts General Hospital, Boston, MA, 2Massachusetts General Hospital and Harvard Medical School, Boston, MA

 

While athletic activity is associated with increased bone density and favorable microarchitecture, young oligo-amenorrheic athletes (AA) have lower bone density and decreased estimated bone strength than eumenorrheic athletes (EA) and non-athletic controls (NAC). To better understand the effect of hypogonadism on trabecular microarchitecture, we used the emerging technology of individual trabecula segmentation (ITS). This technology enables non-invasive classification of trabeculae as plate-like or rod-like, with plate-like trabeculae conferring greater bone strength. We hypothesized that AA would have decreased plate-like bone volume as a percentage of total medullary bone volume (pBV/TV) compared to EA and NAC, which could confer increased risk of fracture. We enrolled 161 young women (97 AA, 32 EA, and 32 NAC) ages 14-26 years. The groups were of similar age, but varied by race, with more white subjects in the AA (90%) vs. EA (69%) and NAC (44%) groups (p<0.001). The mean BMI was lower in the AA vs. the EA group (20.6 ± 2.3 and 22.4 ± 2.3 kg/m2 respectively, p=0.001), but not significantly different from NAC (21.6 ± 2.5 kg/m2). At the weight-bearing distal tibia, trabecular density as measured by standard high-resolution peripheral quantitative computed tomography (HR-pQCT) was significantly lower in NAC (p=0.004 vs. EA and p=0.03 vs AA after adjusting for race, age, and height), associated with a significant decrease in trabecular thickness. Plate-like trabeculae were similarly lower among non-athletes, with pBV/TV of 16.7 ± 5.3% in NAC, 20.1 ± 5.2% in EA, and 18.6 ± 4.6% in AA (adjusted p=0.002 for NAC vs. EA and p=0.02 for NAC vs. AA). At the non weight-bearing distal radius, standard HR-pQCT trabecular parameters did not differ significantly among the 3 groups. However, pBV/TV was significantly lower in AA vs. EA (10.2 ± 3.8 vs 12.6 ± 4.4%, adjusted p=0.04) with a non-significant intermediate value in NAC (11.4 ± 4.9%). In univariate correlations, pBV/TV at the radius correlated positively with BMI (R=0.28, p<0.001), and negatively with age at menarche (R=-0.24, p=0.003), and height (R=-0.23, p=0.005). Tibia pBV/TV correlated positively with serum parathyroid hormone (PTH) (R=0.27, p=0.03). As compared with non-black subjects, black subjects had significantly higher mean pBV/TV at the radius (10.7 ± 4.2 vs. 14.5 ± 4.1%, p=0.04) and a trend towards higher mean at the tibia (18.4 ± 5.0 vs. 20.5 ± 3.0%, p=0.06) after adjustment for group. In multivariate analysis, radius pBV/TV was independently associated with height, BMI, and race, while tibia pBV/TV was independently associated with height, BMI, athlete status, and PTH. These results suggest that hypogonadism has a negative impact on trabecular microarchitecture which is more sensitively distinguished by ITS vs. standard HR-pQCT. In addition, PTH may help mediate the positive effect of weight-bearing on trabecular microarchitecture.

 

Nothing to Disclose: DMM, PT, KEA, RMW, NC, MS, MM

OR29-3 21960 2.0000 A Individual Trabecula Segmentation Reveals Impaired Microarchitecture in Oligo-Amenorrheic Athletes Compared with Eumenorrheic Athletes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 1:00:00 PM OR29 5955 11:30:00 AM Metabolic Bone Disease - Pathophysiology and Treatment Oral


Dawn Phillips*1, Kimberly Hamilton2, Scott Moseley3, Tatjana Odrljin3, Kenji P Fujita3, Amy L Reeves4, Amy Yakimoski2, Katherine L Madson4, Cheryl Rockman-Greenberg2 and Michael P. Whyte5
1University of North Carolina, Chapel Hill, NC, 2University of Manitoba, Winnipeg, MB, Canada, 3Alexion Pharmaceuticals, Inc., Cheshire, CT, 4Shriners Hospital for Children, St. Louis, MO, 5Shriners Hospitals for Children, St. Louis, MO

 

Hypophosphatasia (HPP) is the rare inherited metabolic disorder resulting from loss-of-function mutation(s) in the tissue-nonspecific alkaline phosphatase (TNSALP) gene. TNSALP deficiency can cause a spectrum of sequelae in children including premature loss of primary teeth, rickets, poor growth, muscle weakness, compromised physical function, and pain. We preliminarily reported that 5‑12-yo children treated ≥3 yrs with asfotase alfa, a recombinant bone-targeted human TNSALP, had improved skeletal mineralization, growth, and physical function (Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition [BOT-2] composite score) (1,2). Here, we report changes in muscle strength with Hand Held Dynamometry (HHD) and individual subtests of the BOT-2 including Strength and Running Speed/Agility.

This Phase II open-label study began with a 6-mo treatment phase (≥6 mg/kg/wk asfotase alfa), followed by an ongoing extension phase (6 mg/kg/wk). Bilateral hip and knee extension and flexion, hip abduction, and grip strength were assessed by HHD, and reported here in torque for the right side (dominant side in the general population) as percent predicted for age- and weight-matched healthy peers. Physical function was evaluated using the BOT-2 Strength subtest (standing long jump, push-ups, sit-ups, wall sit, and V-ups), and Running Speed/Agility subtest (50 ft shuttle run, sideways steps over balance beam, and 1- and 2‑legged hops).

12/13 patients entered the extension and received ≥3 yrs of treatment. Last assessment (LA) was at 3 yrs (n=8) or 3.5 yrs (n=4); 1 patient with Asperger’s syndrome was unable to complete testing. Across muscle groups tested, strength (percent predicted) ranged from median (min, max) 32 (9, 53; right hip extensor) to 60 (21, 149; right grip) at baseline (BL). Strength in all muscle groups improved at 3 mo (P<0.05) except grip, and continued to improve to LA (median 59-98 percent predicted, right hip and knee extensor, respectively) (P<0.05). Consistent with HHD, BOT-2 Strength scaled score (mean [SD] for healthy peers: 15 [5]) improved from a median (min, max) of 4 (1, 13) at BL to 15 (10, 24) at LA (P<0.0001). Similarly, median Running Speed/Agility scaled score was 2 SDs below the mean at BL (3 [1, 9]) and improved to 12 (7, 19) at LA (P<0.0001). Notably, the shuttle run, which requires grading ambulation speed during a functional task and reflects skills for navigating the environment, improved from a median of 21.6 sec (12.4, 33.1) at BL to 9.1 sec (8.1, 10.6) at LA. Performance on all other BOT-2 subscale items also improved significantly (data to be presented).

Children with HPP in this study had substantial muscle weakness, as measured by two methods, and impaired function at BL. With asfotase alfa treatment, rapid and continued improvements in muscle strength contributed to significant gains in physical function which impact ability to perform activities of daily living.

 

Disclosure: DP: Researcher, Alexion. SM: Employee, Alexion. TO: Employee, Alexion. KPF: Employee, Alexion. KLM: Coinvestigator, Alexion. CR: Principal Investigator, Alexion, Principal Investigator, Alexion, Principal Investigator, Alexion. MPW: Principal Investigator, Alexion, Principal Investigator, Alexion, Principal Investigator, Alexion. Nothing to Disclose: KH, ALR, AY

OR29-4 20906 3.0000 A Significantly Improved Muscle Strength, Running Speed, and Agility in Children with Hypophosphatasia Treated with Asfotase Alfa 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 1:00:00 PM OR29 5955 11:30:00 AM Metabolic Bone Disease - Pathophysiology and Treatment Oral


Line Hartvig Cleemann*1, Kirsten Holm1, Hanne Kobbernagel1, Bent Kristensen1, Sven Oluf Skouby2, Andreas Emil Kryger Jensen1 and Claus H. Gravholt3
1Nordsjællands Hospital Hillerød, Hillerød, Denmark, 2Herlev University Hospital, Herlev, Denmark, 3Aarhus University Hospital, Aarhus, Denmark

 

Reduced bone mineral density (BMD) is seen in Turner syndrome (TS) and it has been linked to an increased risk of fractures and osteoporosis. Due to hypogonadism estrogen replacement therapy is necessary to induce and maintain feminization and for attaining and preserving normal bone mass in most girls with TS. Age-appropriate timing of pubertal induction is important in optimizing BMD, and there is a potential role of age-specific estrogen doses, with lower doses being used in early puberty and higher doses at the end of adolescence and at the beginning of adult life. However, there are little data to support a standard estrogen dosing regimen in TS. We aimed to evaluate the effects of 2 different dosing regimens of oral 17ß estradiol in young women with TS on the BMD and its association to bone markers and hormones related to bone metabolism. We performed a double-blind 5 year randomized controlled clinical trial. The lower-dose group (LD group) took 2 mg 17ß-estradiol/day orally and placebo. The higher-dose group (HD group) took 2+2 mg 17ß-estradiol/day orally. 20 young TS women (19.2±2.5 years, range 16.0-24.9) participated. All but one participant had been treated with GH earlier. We used DXA scan (whole body, spine, hip and forearm), bone resorption marker (CTX), bone formation markers (PINP, bone specific alkaline phosphatase (BSAP)) and hormones (PTH, IGF1, and IGFBP3) to assess bone metabolism. DXA scan and blood test were performed at baseline and yearly thereafter. BMD (whole body and regional) increased over time with a tendency of an attenuated increase towards the end of the study. There were no significant differences in any BMD measurement between the HD group and the LD group at any of the yearly visits. CTX and PINP decreased significantly over time. BSAP increased during the first 2 years hereafter it decreased. There were no significant differences between the treatment groups except for BSAP, where the HD group had a significant higher level throughout the study period compared to the LD group. IGF1 and IGFBP3 also declined in both groups where as PTH remained unchanged. No differences between the treatment groups were found. The pattern of changes in BMD over time in this group of young women with TS were expectable and in accordance with the pattern observed in the general population of healthy young women. A selective positive effect of the higher estrogen dose on bone formation was found. However, this did not translate into higher BMD suggesting that a treatment regimen in TS using the lower estrogen dose seems to be sufficient in terms of accumulating bone mass even in the late adolescence and early adult years. Whether higher estrogen dose in the early adult years will have a positive effect in older TS women in terms of reduced risk of fractures and osteoporosis is speculative at present but could be evaluated in a future follow up study.

 

Nothing to Disclose: LHC, KH, HK, BK, SOS, AEKJ, CHG

OR29-5 20556 4.0000 A The Effect of High Dose Oral 17ß Estradiol on Bone Mineralization in Young Women with Turner Syndrome - a 5 Year Randomized Controlled Clinical Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 1:00:00 PM OR29 5955 11:30:00 AM Metabolic Bone Disease - Pathophysiology and Treatment Oral


Imranul Alam*1, Amie K Gray2, Dena Acton2, Rita L. Gerard-O'Riley2 and Michael John Econs3
1Indiana University School of Medicine, Indianapolis, IN, 2Indiana University School of Medicine, 3Indiana Univ Med Ctr, Indianapolis, IN

 

ADO2 is a heritable osteosclerotic disorder that usually results from heterozygous missense mutations in the chloride channel 7 (CLCN7) gene, and is characterized by a wide range of symptoms and severity including multiple fractures, impaired vision and hearing, and osteomyelitis. ADO2 is presently incurable, although anecdotal evidence suggests that interferon gamma-1b (INF-G) and calcitriol may have some beneficial effects. To identify the role of these drugs for the treatment of ADO2, we utilized ADO2 knock-in (G213R mutation in Clcn7) mice recently developed in our laboratory (1). The G213R mutation leads to severe osteopetrosis and lethality in homozygous mice but produces a moderately severe form of osteopetrosis in heterozygous mice on 129Sv background that phenocopy human ADO2 (1). Six-week-old ADO2 heterozygous mice (n=10/group) were administered either vehicle (PBS) or INF-G (low 22.5 ug/kg, medium 37.5 ug/kg and high 100 ug/kg) or calcitriol (low 0.1 ug/kg, medium 0.5 ug/kg and high 1 ug/kg) 5 times per week for 8 weeks. We analyzed the serum biochemistry and determined the bone phenotypes at the baseline and the end of treatment using dual X-ray absorptiometry (DXA) and micro-computed tomography (µCT). Mice treated with INF-G significantly (p<0.005) attenuated the increase of whole body aBMD in both male (low dose 88%, medium dose 83% and high dose 68%) and female (low dose 94%, medium dose 45% and high dose 54%) ADO2 mice as compared to the vehicle group. Similarly, µCT analyses of trabecular bone at distal femur revealed that INF-G treatment significantly reduced (p<0.05) the bone volume over tissue volume (BV/TV) gain in both male (low dose 52%, medium dose 66% and high dose 39%) and female (low dose 62%, medium dose 43% and high dose 58%) ADO2 mice as compared to the vehicle group. In contrast, mice treated with low and medium doses of calcitriol showed a trend of higher bone mass including whole body aBMD and BV/TV whereas high dose calcitriol group significantly increased aBMD (male 5%; female 4%) and BV/TV (male 40%; female 20%) compared to the vehicle group. Serum biochemistry analysis revealed that calcium and phosphorus did not differ between vehicle and INF-G or calcitriol treated mice. Also, we detected significantly (p<0.05) higher CTX/TRAP5b ratio in INF-G treated mice whereas no change in this ratio was observed among different groups of calcitriol treated mice compared to the vehicle group. Our findings indicate that while INF-G at all doses markedly improve the osteopetrotic phenotypes in both male and female ADO2 heterozygous mice, calcitriol treatment at any dose did not improve the phenotype and at high dose further increased the bone mass. Thus, anecdotal use of high dose of calcitriol therapy in ADO2 patient deserves serious reconsideration for further use. Also, our data justifies a clinical trial of INF-G in ADO2 patients. 

 

Disclosure: MJE: Investigator, Horizon (Vidara). Nothing to Disclose: IA, AKG, DA, RLG

OR29-6 20514 5.0000 A Successful Treatment of a Mouse Model of Autosomal Dominant Osteopetrosis Type II (ADO2) with Interferon Gamma, but Not Cacitriol 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 1:00:00 PM OR29 5955 11:30:00 AM Metabolic Bone Disease - Pathophysiology and Treatment Oral


Jose Cordoba-Chacon*1, Neena Majumdar2, Michelle Puchowicz3, Stuart J Frank4, Edward O List5, John J Kopchick5 and Rhonda D. Kineman1
1& Medicine, Section of Endocrinology, Diabetes and Metabolism, University of Illinois at Chicago, Chicago, IL, 2Jesse Brown VA Medical Center/University of Illinois at Chicago, Chicago, IL, 3Case Western Reserve University, Cleveland, 4University of Alabama at Birmingham, Birmingham, AL, 5Ohio University, Athens, OH

 

Enhanced de novo lipogenesis (DNL) is thought to contribute to non-alcoholic fatty liver disease (NAFLD). Progression of NAFLD is also associated with low IGF-I suggesting hepatic GH resistance. Developmental, liver-specific GH resistance, in mice, promotes hepatic lipid accumulation.  This is due in part to low IGF-I and high GH levels that favor insulin resistance and white adipose tissue (WAT) lipolysis, leading to hepatic fatty acid reesterification. By contrast, GH overexpression in diet-induced obese rats, or GH replacement in GH-deficient patients, resolves fatty liver. This positive action of GH could be due to direct antagonism of insulin-mediated hepatic lipogenesis and triglyceride (TG) storage or to indirect mechanisms (ex: IGF-I dependent promotion of peripheral insulin sensitivity). To determine whether GH directly regulates hepatic lipid metabolism in adults, hepatic GH receptor (GHR) expression was knocked-down in 10wk-old GHR floxed mice by iv injection of an adeno-associated virus bearing a hepatocyte-specific promoter driven Cre recombinase. This resulted in adult-onset hepatocyte-specific knockdown of the GHR (aLivGHRkd). Just 7 days after aLivGHRkd, the rate of hepatic DNL, measured by heavy-water labeling, was more than doubled, in both male and female mice fed a standard chow diet. As previously reported, hepatic TG content doubled in male, but not female, aLivGHRkd mice, likely due to an estrogen-dependent mechanism. In male aLivGHRkd mice, the increase in DNL and hepatic TG content could not be attributed to changes in hepatic proximal insulin signaling, fatty acid mobilization due to WAT lipolysis, secretion rate of hepatic VLDL, or clearance of postprandial lipoproteins/chylomicrons. In addition, no consistent changes were observed in the expression of lipogenic genes (ACC1, FASN and ELOV6) or maturation of SREBP1c. These results suggest that aLivGHRkd does not alter the classic pathway used by insulin to promote hepatic TG synthesis/accumulation. Interestingly, PPARγ and glucokinase (Gck, a PPARγ target gene) mRNA and protein levels were consistently increased in aLivGHRkd livers. In fact, cytosolic/active Gck was increased which suggests an enhanced glycolytic flux to provide energy and substrates to sustain an enhanced rate of DNL.  The increase in DNL was associated with a decrease in fatty acid oxidation (β-hydroxybutyryl-CoA levels were low), while acetyl-CoA levels were maintained and malonyl-CoA levels tended to be increased as supported by a reduction in the P-ACC/ACC ratio. Taken together, these data demonstrate GH normally suppresses hepatic DNL, in part by controlling substrate availability by regulating Gck/glycolytic flux. These novel findings raise the possibility that hepatic GH resistance or reduced hepatic GH input could contribute to the progression of NAFLD by maintaining inappropriate DNL.

 

Disclosure: JC: Recipient Award, Genentech, Inc.. RDK: Jose Cordoba-Chacon, PhD was intergral in performing and interpretin many of the studies to be discussed. He has recieved a post-doctoral research award (Endocrine Scholar Award for GH Research 2014) from Genetech, Genentech, Inc.. Nothing to Disclose: NM, MP, SJF, EOL, JJK

OR28-1 19390 1.0000 A Hepatic GH Resistance Increases De Novo Lipogenesis Independent of Sex, but Only Leads to Fatty Liver in Males 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 1:00:00 PM OR28 5980 11:30:00 AM Lipids - Liver, Muscle, and Patient Oral


Desean L. Lee*1, Adaku Ume2, Indrani Sinha-Hikim2, Wai-Nang Paul Lee3, Theodore C Friedman2 and Amiya P Sinha-Hikim1
1Charles R Drew University of Medicine and Science, Los Angeles, CA, 2Charles R. Drew University of Medicine and Science, Los Angeles, CA, 3Los Angeles Biomedical Research Institute

 

Nicotine stimulates muscle de novo lipogenesis in mice but causes intramyocellular lipid accumulation and mitochondrial abnormalities only when combined with a high-fat diet

Desean Lee, Adaku Ume, Indrani Sinha-Hikim, W. N. Paul Lee, Theodore C. Friedman, Amiya P. Sinha-Hikim

Division of Endocrinology, Department of Internal Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA 90059, Los Angeles Biomedical Research Institue, Torrance, CA 90509, and David Geffen School of Medicine at University of California, Los Angeles, CA 90095.

Background and Objective: Smoking is a major risk factor for diabetes, cardiovascular disease and non-alcoholic fatty liver disease. The health risk associated with smoking can be exaggerated by obesity. We recently demonstrated that combined treatment with nicotine and a HFD but not normal chow diet (NCD) for 10 weeks, causes intramyocellular lipid (IMCL) accumulation  in close association with intramyofibrillar (IMF) mitochondria along with IMF mitochondrial swelling and vacuolization (Endocrinology 155: 865-872, 2014). The detrimental effects of combined treatment of nicotine and HFD on muscle abnormalities were associated with increased oxidative stress and inactivation of AMP-activated protein kinase (AMPK) and activation of its downstream target, acetyl-coenzyme A-carboxylase (ACC). Here, we examined the role of de novo lipogenesis (DNL) in the development of skeletal muscle abnormalities in nicotine-treated mice on a HFD.

Experimental Design: Adult C57BL6 male mice were fed a NCD or HFD with 60% of calories derived from fat and received twice daily IP injections of 0.75 mg/kg BW of nicotine or saline for 10 weeks. To measure DNL, animals in each group at the beginning of 8th week of treatment were given an IP injection of deuterated water (D2O) approximately 2% of body weight. Animals on both diets had free access to drinking water containing 6% D2O in drinking water for two weeks.

Results: Nicotine significantly (P<0.05) increased muscle DNL, determined by de novo synthesis of palmitate, in mice fed either a NCD or HFD. There were no significant dietary effects on muscle DNL. As expected, nicotine-treated mice fed a HFD exhibited IMCL accumulation juxtaposed with IMF mitochondria and IMF mitochondrial damage. Increased muscle DNL in nicotine- treated mice on a HFD, as opposed to nicotine-treated mice on a NCD, was further associated with inactivation of AMPK and activation of its downstream target ACC.  

Conclusions: We conclude that nicotine stimulates muscle DNL in mice that consumed both diets, thus suggesting that muscle DNL has little or no contribution to IMCL accumulation in response to nicotine plus HFD treatment. These results, however, underscore the importance of AMPK and its downstream target ACC in mediating the effect of nicotine on skeletal muscle abnormalities in diet-induced obesity.

 

Nothing to Disclose: DLL, AU, IS, WNP, TCF, APS

OR28-2 19004 2.0000 A Nicotine Stimulates Muscle De Novo Lipogenesis in Mice but Causes Intramyocellular Lipid Accumulation and Mitochondrial Abnormalities Only When Combined with a High-Fat Diet 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 1:00:00 PM OR28 5980 11:30:00 AM Lipids - Liver, Muscle, and Patient Oral


Anda Raluca Gonciulea*1 and Deborah Sellmeyer2
1Johns Hopkins School of Medicine, Baltimore, MD, 2Johns Hopkins Bayview Medical Center, Baltimore, MD

 

Hypercholesterolemia and elevated LDL-C are leading risk factors for cardiovascular disease. Vegetable based diets can improve serum cholesterol profiles with specific beneficial effects attributed to soy foods.  However, there are limited data comparing the effects of soy based and non-soy based vegetable diets on lipids, particularly using whole food diets. We conducted a secondary data analysis using data from a randomized trial that evaluated the effect of dietary protein source on calcium metabolism.  Postmenopausal women without renal, GI, or bone disease, or insulin requiring DM (n=176, age = 63 ± 7 years) were randomized to one of four weighed metabolic diets for eight weeks. Diets were equivalent in energy (2149 ± 157 kcals/d), protein (73 ± 4 g/d), and fat (73 ± 20 g/d) with >80% of the protein coming from either non-dairy animal, non-soy vegetable, dairy or soy sources.  Total cholesterol content was 0 mg/d in vegetable and soy diets and 238 ± 87 mg/day in animal and dairy diets.  Saturated fat was 12 ± 5, 8 ± 1, 29 ± 4, 9 ± 4 g/d in the animal, vegetable, dairy, and soy diets respectively (p<0.05 for dairy vs. other groups).  Polyunsaturated fat was 9 ± 4, 27 ± 6, 5 ± 2, 23 ± 3 g/d in the animal, vegetable, dairy, and soy diets respectively (p<0.05 for each of animal and dairy vs. each of vegetable and soy).  Fasting blood samples, obtained at baseline and week 8 were assayed for total cholesterol, LDL-C, HDL-C, triglycerides, glucose and insulin.  Change in each variable was calculated by subtracting the baseline value from the week 8 value.  Parameters were compared across diet groups using ANOVA.  Baseline lipid concentrations were not different among diet groups.  Total cholesterol decreased by 39 ± 3 mg/d in the soy group (p<0.001 vs. dairy, p=0.002 vs. animal) and 31 ± 5 in the vegetable group (p=0.004 vs. dairy, 0.15 vs. animal).  LDL-C decreased by 28 ± 3 mg/d in the soy group (p<0.001 vs. dairy, p=0.01 vs. animal) and 21 ± 4 in the vegetable group (p=0.006 vs. dairy, 0.38 vs. animal).  There were no significant differences in lipid effects between the soy and vegetable diets.  There were no significant differences among the groups in change in triglyceride, VLDL, HOMA-IR, fasting glucose, or insulin.  HDL-C decreased by 12 ± 1 mg/d in the soy group (p<0.008 vs. dairy, p=0.02 vs. animal) although there were no significant differences in change in total cholesterol:HDL ratio.  There were no significant changes in HDL-C in any other diet group.  In conclusion, both the soy and vegetable diets resulted in significant reductions in total cholesterol and LDL although the reductions in the vegetable group, while significant compared to the dairy group, were not statistically significant compared to the animal group.  Given that there were no significant differences between the soy and vegetable groups, these data do not support a specific lipid lowering component in soy foods, but suggest a beneficial effect of plant based diets in general.

 

Nothing to Disclose: ARG, DS

OR28-3 19081 3.0000 A The Effect of Dietary Protein Source on Serum Lipids 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 1:00:00 PM OR28 5980 11:30:00 AM Lipids - Liver, Muscle, and Patient Oral


Zahid Ahmad*1, Connie Newman2, Emily O'Brien3, Peter Shrader3, Emil M deGoma4, Catherine D Ahmed5, Patrick M Moriarty6, Mac Rae F Linton7, Michael D Shapiro8, P. Barton Duell9, Christie M Ballantyne10, William A Neal11, Danielle Duffy12, Lisa Hudgins13, Linda C Hemphill14, James A Underberg15, Karol E Watson16, Samuel S Gidding17, Seth Baum18, Katherine Wilemon5, Dave Pickhardt19, Iris Kindt5, Daniel J. Rader20, Matthew Roe3 and Joshua W Knowles21
1UT Southwestern Medical Center, Dallas, TX, 2NYU School of Medicine, New York, NY, 3Duke University School of Medicine, 4Perelman School of Medicine at the University of Pennsylvania, 5FH Foundation, 6University of Kansas Medical Center, Kansas City, KS, 7Vanderbilt University School of Medicine, Nashville, TN, 8Oregon Health and Science University, 9Oregon Health and Science University, Portland, OR, 10Baylor College of Medicine, Houston, TX, 11West Virginia University, 12Jefferson University Hospitals, 13NewYork-Presbyterian/Weill Cornell, 14Massachusetts General Hospital, 15NYU Langone Medical Center, New York, NY, 16Ronald Reagan UCLA Medical Center, Redondo Beach, CA, 17AIfred I duPont Hospital for Children, Wilmington, DE, 18Preventive Cardiology, Inc., 19Archimedes Group, 20University of Pennsylvania School of Medicine, 21Stanford University School of Medicine

 

Introduction:  Familial hypercholesterolemia (FH) is an autosomal dominant disorder with a prevalence of 1:300 to 1:500 worldwide. FH patients have 20-fold increased risk for premature coronary heart disease (CHD) due to lifelong extreme elevations in LDL-C. 

Three criteria can be used to diagnose FH: Simon-Broome, Dutch Lipid Clinic Network (DLCN) or United States (US) Make Early Diagnosis to Prevent Early Deaths (MEDPED).

In the Netherlands the DLCN criteria was a critical component of a public health strategy to identify FH patients for genetic testing, early treatment, and CHD prevention. The consistent application of these criteria resulted in identification of 71% of estimated cases (1).

In the US, however, < 10% of FH patients are identified, perhaps due to a lack of a nationwide consensus on diagnostic criteria. We lack contemporary data regarding diagnostic strategies and patient outcomes in the US.

Objectives:  To characterize the FH diagnostic criteria applied by US lipid specialists participating in the FH Foundation’s CASCADE FH (CAscade SCreening for Awareness and DEtection of Familial Hypercholesterolemia) patient registry - a US registry that became active in September 2013 and currently has data on FH patients treated at 11 specialty lipid clinics (2).

Methods:  We queried the CASCADE FH database for the diagnostic criteria chosen for each patient and baseline patient characteristics. Diagnostic criteria were divided into 5 non-exclusive categories: “clinical diagnosis,” MEDPED, Simon-Broome, DLCN, and/or other. Only adults (age >18) were included since the diagnostic criteria cannot be applied to pediatric populations.

Results: 876 FH adults had available data entered from clinical sites. 57% were female; mean (SD) age 53 (17) yrs; and BMI 28 (6) kg/m2. Ethnicity/race was 78% white, 6% African American, 3% Hispanic, 12% other. Mean age at FH diagnosis was 43 (19) yrs. 38% had prior CHD, 16% had tendon xanthomas, and 45% had a family history of myocardial infarction. Mean pre-treatment LDL-C was 269 (87) mg/dL.

Most adults enrolled in CASCADE FH received a “clinical diagnosis” of FH: 64% “clinical diagnosis” (n = 560) vs. 11 % MEDPED (n = 105) vs. 4% Simon-Broome (n = 32) vs. 1% DLCN (n = 7) vs. 1% other (n = 9) vs. 19% “multiple diagnostic criteria” (n = 163), p = 0.01.   For patients with “multiple diagnostic criteria”, 57% were diagnosed using two or more of the established criteria (Simon-Broome, MEDPED, DLCN); the remainder had one of the established criteria and “clinical diagnosis.”

Summary: Among US lipid clinics participating in the CASCADE FH registry, most did not report utilizing one of the existing diagnostic tools.

Conclusions:  Our findings imply that established FH criteria are not regularly utilized to diagnose FH in the US. A need exists to develop a nationwide consensus, which will lead to better identification, earlier treatment, and ultimately prevention of CHD events.

 

Disclosure: ZA: Speaker, Sanofi, Speaker, Genzyme Corporation. EMD: Clinical Researcher, Amgen, Clinical Researcher, Pfizer, Inc.. PMM: Consultant, Genzyme Corporation, Consultant, Amarin. MRFL: Consultant, Merck & Co., Consultant, Amgen. MDS: Consultant, Aegerion. PBD: Consultant, Genzyme Corporation, Consultant, Pfizer, Inc., Consultant, Sanofi. CMB: Consultant, Abbott Laboratories, Consultant, Amarin, Consultant, Genentech, Inc., Consultant, Genzyme Corporation. SSG: Principal Investigator, GlaxoSmithKline. DJR: Consultant, Aegerion. MR: Consultant, Bristol-Myers Squibb, Consultant, Eli Lilly & Company, Consultant, Merck & Co., Consultant, Novartis Pharmaceuticals, Consultant, Sanofi. Nothing to Disclose: CN, EO, PS, CDA, WAN, DD, LH, LCH, JAU, KEW, SB, KW, DP, IK, JWK

OR28-4 21140 4.0000 A Diagnosing Familial Hypercholesterolemia (FH) in the United States: Results from the Cascade FH Patient Registry 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 1:00:00 PM OR28 5980 11:30:00 AM Lipids - Liver, Muscle, and Patient Oral


William I Sivitz*1, Manish Suneja2, Daniel K Fox2, Brian D Fink3, Judith A Herlein3 and Christopher M Adams4
1Univ of Iowa and the Iowa City VAMC, Iowa City, IA, 2University of Iowa, Iowa City, IA, 3Iowa City VAMC, Iowa City, IA, 4University of Iowa and the Iowa City VAMC, Iowa City, IA

 

HMG-CoA reductase inhibitors (statins) prevent vascular events and are widely prescribed, particularly in persons with type 2 diabetes.  However, intolerability due to myopathic symptoms often limits their use. We investigated the effects of simvastatin on parameters of mitochondrial function and muscle gene expression in 11 subjects with type 2 diabetes; none of whom had statin intolerance.  After withdrawal of statins for two months, we obtained blood samples, performed vastus lateralis muscle biopsies, and assessed whole body resting energy expenditure (REE).  We then re-initiated therapy using simvastatin, 20 mg/day, for one month before repeating these studies.  As expected, simvastatin lowered LDL, but did not induce myalgias or significant elevations in serum creatine kinase.  However, we found subtle but significant reductions in muscle citrate synthase activity and REE.  In addition, gene set enrichment analysis of muscle samples significantly repressed gene sets involved in mitochondrial function, and significantly induced gene sets involved in inflammation and remodeling of the extracellular matrix.  Further, the effects of simvastatin on muscle gene sets showed some similarities to previously described changes that occur in Duchenne muscular dystrophy, polymyositis, and dermatomyositis.  Although statins inhibit an early step in coenzyme Q (CoQ) biosynthesis, we observed no differences in CoQ content within skeletal muscle mitochondria, muscle tissue, or circulating platelets.  In summary, we report subtle changes in whole body energetics, mitochondrial citrate synthase activity, and microarray data consistent with subclinical myopathy. Although the benefits of statin therapy are clear, further understanding of muscular perturbations should help guide safety and tolerability.

 

Nothing to Disclose: WIS, MS, DKF, BDF, JAH, CMA

OR28-5 21037 5.0000 A Evidence for Subclinical Myopathy in Asymptomatic Persons with Type 2 Diabetes after Initiation of Simvastatin Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 1:00:00 PM OR28 5980 11:30:00 AM Lipids - Liver, Muscle, and Patient Oral


Sheetal Malhotra*1, Michael F Lafountaine2, Christopher Cirnigliaro3, Donald R Dengel4, Steven C. Kirschblum5 and William A Bauman6
1JJ Peters VA Medical Center, Bronx, NY, 2Icahn School of Medicine at Mount Sinai, New York, NY, 3James J. Peters VA Medical Center, Bronx, NY, 4University of Minnesota Medical School, Minneapolis, MN, 5Kessler Institute for Rehabilitation, West Orange, NJ, 6James J. Peters VA Medical Cente, Bronx, NY

 

Background:  Visceral fat cells secrete or produce unfavorable cytokines and inflammatory markers, such as interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and C-reactive protein (hsCRP). IL-6 is a pleiotropic cytokine that inhibits insulin action by disrupting insulin signal transduction, and it has been associated with ischemic vascular disease. Immobility from spinal cord injury (SCI) results in a higher percent of total body adiposity and a greater absolute visceral adiposity. This study determined the relationships between DXA-derived visceral adipose tissue volume (VATvol) and levels of  serum IL-6, hsCRP, and TNF-α, as well as their relationship with insulin resistance by HOMA-IR in individuals with SCI and in able-bodied (AB) controls. 

Methods:  The measurements of DXA-derived VATvol, serum IL-6, TNF-α, and  hsCRP were determined in 65 male subjects with SCI and in 37 age- and gender-matched AB controls. VATvol was acquired by iDXA scan in the lumbar region (L1-L4) using enCoreTM CoreScan software. Fasting blood samples were collected for analysis of serum cytokines and hsCRP. HOMA-IR scores were calculated by standard equations using fasting plasma glucose and insulin levels. T-tests and ANOVAs were performed to compare VATvol and values of IL-6, TNF-α, and  hsCRP between the SCI and AB groups, as well as for sub-group analysis of paraplegics vs. tetraplegics vs. AB subjects. Pearson correlation coefficients and regression analyses were used to test relationships between VATvol and HOMA-IR with values of IL-6, TNF-α, and  hsCRP.

Results: Compared to the AB group, the SCI group had significantly greater VATvol (1,040 vs. 1,840 cm3, p ≤0.001) and levels of serum IL-6 (0.81 vs. 2.66 pg/ml, p ≤0.001) and hsCRP (3.48 vs.12.11 mg/ml, p ≤0.001), but not levels of serum TNF-α pg/ml (p >0.05).  In sub-group analyses of AB vs. paraplegics vs. tetraplegics, significant differences were seen for VATvol (F=5.38; df 2,78; P<0.01) and serum hsCRP (F=7.21; df 2,70; P<0.01) and IL6 (F= 7.70; df 2,65; P<0.001), but not for serum TNF-α (P=0.20). In regression analyses of subjects with SCI, VATvol had a significant correlation with serum IL-6 (R=0.36, P<0.01), but not with serum hsCRP and TNF-α. In subjects with SCI, HOMA-IR was significantly related to VATvol (R=0.49, P=0.002), hsCRP (R=0.57, P=0.001), and IL-6 (R=0.35, P=0.043). In AB subjects, HOMA-IR was not related to levels of serum hsCRP, IL-6, or TNF-α.

Conclusions:  Persons with SCI have a greater VATvol than that of able-bodied controls. VATvol in SCI subjects correlates well with levels of IL-6. Insulin resistance is related to VATvol, and levels of IL-6 and hsCRP. Increased stores of visceral fat appear to be a source of inflammatory mediators, specifically IL-6 that may directly contribute to insulin resistance and abnormalities of carbohydrate metabolism, which may predispose those with SCI to premature atherosclerotic vascular disease.

 

Nothing to Disclose: SM, MFL, CC, DRD, SCK, WAB

OR28-6 20921 6.0000 A Relationships Among Visceral Fat, Inflammatory Mediators, and Insulin Resistance By HOMA-IR in Persons with Spinal Cord Injury 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 1:00:00 PM OR28 5980 11:30:00 AM Lipids - Liver, Muscle, and Patient Oral


Mihail Zilbermint*1, Paraskevi Xekouki1, Fabio R Faucz2, Alexandra Gkourogianni1, Annabel Sophie Berthon1, Marie Helene Schernthaner-Reiter1, Maria Batsis1, Stéphanie Espiard1, Ninet Sinaii2, Martha M Quezado3, Aaron Hodes4, Smita Baid Abraham1, Rossella Libe5, Guillaume Assie5, Ludivine Drougat5, Bruno Ragazzon5, Adam Davis6, Samson Gebreab6, Ryan Neff6, Jerome Yves Bertherat7, Maya Beth Lodish1 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3National Cancer Institute, Bethesda, MD, 4Rainbow Babies & Children's Hospital, University Hospitals Case Medical Center, 5INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 6National Institutes of Health (NIH), 7INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

Context: Primary aldosteronism (PA) is one of the leading causes of secondary hypertension, causing significant morbidity and mortality. A number of genetic defects have recently been identified in PA, whereas we identified mutations in ARMC5, a tumor-suppressor gene, in cortisol-producing primary macronodular adrenal hyperplasia (PMAH).

Objective: We investigated a cohort of 56 patients who were referred to the National Institutes of Health for evaluation of PA.

Methods: Patients underwent step-wise diagnosis, with measurement of serum aldosterone and plasma renin activity followed by imaging, saline suppression and/or oral salt loading tests plus adrenal venous sampling. Cortisol secretion was also evaluated and adrenalectomy was performed, if indicated. Blood DNA from 56 subjects were genotyped by Sanger sequencing.

Results: We identified 12 ARMC5 genetic alterations in 20 unrelated and 2 related individuals in our cohort (39.3%). ARMC5 mutations in six patients (10.7%) were predicted to be damaging by in silico analysis. All affected patients were African-Americans (p=0.0023). Subjects with pathogenic ARMC5 mutations had higher urinary 17OHS/Cr levels during dexamethasone testing (p=0.0331) and half of the cohort (48.21%) had impaired fasting glucose or diabetes mellitus.

Conclusions: Germline ARMC5 mutations may cause PA with glucocorticoid co-secretion, not necessarily in the context of PMAH. We suggest that patients with PA and metabolic syndrome, particularly African-Americans, should be screened for cortisol co-secretion and ARMC5 mutations. ARMC5 defects may underlie part of the known increased predisposition of African-Americans to low renin hypertension.

 

Disclosure: JYB: Investigator, Ipsen, Investigator, Novartis Pharmaceuticals, Advisory Group Member, atterocor. Nothing to Disclose: MZ, PX, FRF, AG, ASB, MHS, MB, SE, NS, MMQ, AH, SBA, RL, GA, LD, BR, AD, SG, RN, MBL, CAS

OR24-1 18697 1.0000 A Primary Aldosteronism Due to Germline ARMC5 Mutations: Common in African-American Hypertensive Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 1:00:00 PM OR24 5984 11:30:00 AM Adrenal Tumors: Clinical Implications of the Recent Molecular and Genetic Findings Oral


Eri Komai*, Akina Shiga, Tomoko Takiguchi, Takashi Kohno, Akitoshi Nakayama, Seiichirou Higuchi, Ikki Sakuma, Hidekazu Nagano, Naoko Hashimoto, Sawako Suzuki, Hisashi Koide, Tomohiko Yoshida, Koutaro Yokote and Tomoaki Tanaka
Chiba University Graduate School of Medicine, Chiba, Japan

 

Cushing’s syndrome (CS) and subclinical Cushing’s syndrome (SCS) are however different in clinical symptoms, both sometimes lead to metabolic disorders such as hypertention, dyslipidemia and glucose intolerance caused by excessive glucocorticoid production. Genome wide exome sequencing of cortisol producing adenoma in CS identified somatic mutations in cAMP-dependent protein kinase catalytic subunit alpha PRKACA, and in the stimulatory G-protein alpha subunit GNAS. However, a little is known about the frequency of these mutations as well as endocrinological pathogenesis in cortisol producing adenoma of Japanese CS and SCS patients. We performed direct sequencing, and RT-qPCR analysis using post-operated adrenal tumor tissues and examined the relationship between types of mutation, clinical features and molecular biological characteristics including gene expression in steroid hormone synthetic pathways, GPCR ,cancer and WNT pathways. Gene mutation analysis of 37 CS cDNA samples and 40 SCS cDNA samples revealed that PRKACA mutations were present in CS 20 cases (54.1%), SCS 8 cases (20.0%), GNAS mutations in CS 5 cases SCS 6 cases (15%). Consistent with previous reports busy count of digressers were statistically lower in post operation than in pre operaion in both CSs and SCSs. Gene expression analysis using tumor-derived mRNA showed that HSDβ2 ,CYP17 & Ki 67  expression were statistically higher in CSs and SCAs in PRKACA mutations than in wild type. Furthermore, HSDβ2 & CYP 21 expression were moderately positive correlated to PRKACA expression. Taken together, our results suggest activation of PKA signaling pathway in CSs and SCSs plays a key role in autonomous cortisol production and tumorgenesis.

 

Nothing to Disclose: EK, AS, TT, TK, AN, SH, IS, HN, NH, SS, HK, TY, KY, TT

OR24-2 19805 2.0000 A Analysis of Somatic Prkaca and GNAS Mutations, Its Clinical Features and Gene Expression Profile in Japanese Cortisol Producing Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 1:00:00 PM OR24 5984 11:30:00 AM Adrenal Tumors: Clinical Implications of the Recent Molecular and Genetic Findings Oral


Masanori Murakami*1, Takanobu Yoshimoto1, Nana Komatsu1, Yujiro Nakano1, Isao Minami1, Masatomo Mihara1, Hajime Izumiyama2, Koshi Hashimoto1, Daisuke Ban2, Takanori Ochiai2, Akira Takemoto2, Akane Yukimori1, Hiroshi Nakajima2, Takumi Akashi2, Keiko Homma3, Koshiro Nishimoto4, Kuniaki Mukai5, Tomonobu Hasegawa5, Minoru Tanabe2 and Yoshihiro Ogawa6
1Tokyo Medical and Dental University, Tokyo, Japan, 2Tokyo Medical and Dental University, 3Keio University Hospital, Japan, 4Tachikawa Hospital, Tokyo, Japan, 5School of Medicine, Keio University, Tokyo, Japan, 6Tokyo Medical and Dental University and AMED, CREST, Tokyo, Japan

 

Background: Adrenocortical carcinoma (ACC) is a malignant tumor that can secrete a variety of steroid hormones. Hormone-producing ACC most often secretes cortisol, while the co-secretion of cortisol and aldosterone in ACC is quite rare. How the two steroid hormones are produced in ACC has not been fully understood.

Clinical case: A 78-year-old woman with a history of hypertension was admitted to our hospital for examination of right adrenal tumor. She presented hypokalemia (2.7 mEq/L, 3.7<n<5.0 mEq/L) and Cushingoid appearance. A CT scan showed a heterogeneous 90 x 84 mm right adrenal mass accompanied with 50 x 37 mm mass directly invading the posterior right robe of liver with tumor emboli in the inferior vena cava. Endocrinorogical examination revealed high PFC (19.9 μg/dL, 4.0<n<19.3 μg/dL) with suppressed ACTH concentration (2.2 pg/mL, 7.2<n<63.3 pg/mL), low PRA (0.8 ng/mL/hr, 0.2<n<2.7 ng/mL/hr), high PAC (283 pg/mL, 30<n<159 pg/mL), and high DHEA-S concentration (3663 ng/mL, 130<n<1540 ng/mL). Diurnal cortisol rhythm was not observed and one milligram dexamethasone tests showed no cortisol suppression (22.6 μg/dL, n<1.8 μg/dL). In addition, urinary steroid profile analysis showed increased secretion of aldosterone and androgen. With a diagnosis of aldosterone, cortisol, and androgen secreting ACC, the patient underwent right adrenalectomy with segmentectomy of the right posterior liver and IVC. Her potassium level was normalized (3.8 mEq/L) and PAC was decreased (100 pg/mL) two months after surgery. However, 6 months later, her potassium level was decreased (2.6 mEq/L) and PAC was increased (303 pg/mL) with multiple liver metastasis detected by abdominal CT. Despite the treatment by spironolactone, trilostane, and mitotane, her PAC has reached 32000 pg/mL levels. The palliative care was initiated and she expired 12 months after the surgery.

Pathophysiological findings: The histopathological findings in her resected specimen of adrenal tumor fulfilled at least eight of the Weiss’s criteria for the diagnosis of ACC. Immunohistochemical analysis detected immunoreactivities of steroidogenic enzymes in the tumor cells to a varying degree; diffuse and intense distribution of CYP11B1, focal and intense distribution of CYP17 and HSD3B, and intense but scattered distribution of CYP11B2 at high magnification. Noteworthy, two distinct areas were observed. One consisted of cells positive for CYP17, HSD3B, and CYP11B1, which is compatible with cortisol production, and the other consisted of those positive for HSD3B and CYP11B2 but negative for CYP17, which is compatible with aldosterone production.

Conclusion: This report is the first immunohistochemical analysis of cortisol and aldosterone biosynthetic enzymes in ACC. This study provides further insight into the pathophysiology of ACC.

 

Nothing to Disclose: MM, TY, NK, YN, IM, MM, HI, KH, DB, TO, AT, AY, HN, TA, KH, KN, KM, TH, MT, YO

OR24-3 18956 3.0000 A Immunohistochemical Analysis of Cortisol and Aldosterone Secreting Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 1:00:00 PM OR24 5984 11:30:00 AM Adrenal Tumors: Clinical Implications of the Recent Molecular and Genetic Findings Oral


Tomoko Takiguchi*, Ikki Sakuma, Eri Komai, Akina Shiga, Takashi Kohno, Akitoshi Nakayama, Seiichirou Higuchi, Hidekazu Nagano, Naoko Hashimoto, Takafumi Mayama, Sawako Suzuki, Hisashi Koide, Tomohiko Yoshida, Koutaro Yokote and Tomoaki Tanaka
Chiba University Graduate School of Medicine, Chiba, Japan

 

Introductions:

Palagangliomas/Pheochromocytomas(PGLs/PCCs) are rare neuroendocrine tumors that develops in the extra-adrenal sympathetic or parasympathetic paraganglia or the adrenal medulla. As PGLs/PCCs carry the highest degree of heritability (Germline mutations are found in approximately 25% of individuals with PGLs/PCCs), knowledge concerning the familial forms of them has greatly improved in recent years. However, we have still limited and incomplete knowledge on the factors predicting PGLs/PCCs patients’ outcome and the effects of targeting agents which are expected to have a treating effect for refractory PGLs/PCCs. Here, we report 70 cases of PGLs/PCCs with addressing clinical and endocrinologic features as well as a molecular network relating with the tumorigenesis and the metabolic disturbance present in PGLs/PCCs determined using tumor tissue samples.

Methods:

This cohort consisted of 70 patients with a histopathological diagnosis of PGLs/PCCs which were removed by operations. 6 cases of them were malignant PGLs/PCCs, and 10 cases have some genetic mutations. Endocrinological findings; urinary metanephrine excretion (UMN) and urinary normetanephrine excretion (UNMN) and functional imaging; MIBG scintigraphy and FDG-PET scan were collected for all subjects. Resected tumors were examined by real time PCR for gene expressions of catecholamine-biosynthesis enzymes, some transporters and molecular pathway related to tumorigenesis of PGLs/PCCs.

Major results:

The expression of tyrosine hydroxylase (TH), which is the rate determining enzymes functioning in the catecholamine-biosynthesis correlated with UMN+UNMN. And the ratio of UMN/UNMN was determined by the expression of phosphatidylethanolamine N-methyltransferase (PNMT). MIBG scintigraphy yielded a sensitivity of 92%, and the expression of norepinephrine transporter (NET) is important for that. The average FDG-PET uptake by PGLs/PCCs was correlated with the expression or GLUT-1 and IGF-2. Regarding to the signaling pathway of oncogenesis in PGLs/PCCs, the expression of HIF-1a, VEGF and MAX was interacted by themselves. Hypoxia induced factor signaling, such as HIF-1a, VEGF and MAX, interconnects kinase downstream signaling (IGF-2) and hypoxia regulation.

Conclusions:

PGLs/PCCs are the result of a combination of the genetic mutation as the upstream driver and epigenetic changes. This result causes the heterogeneity of the cellular and clinical outcome. At the moment there is no treatment for metastatic PGLs/PCCs that is either curative of capable of inducing durable responses. And then, our knowledge about the oncogenic signals is helping in charting a new era of diagnostic and therapeutic strategies for these diseases.

 

Nothing to Disclose: TT, IS, EK, AS, TK, AN, SH, HN, NH, TM, SS, HK, TY, KY, TT

OR24-4 21706 4.0000 A Clinical Features and the Molecular Network Related with the Tumorigenesis and the Metabolic Disturbance Present in Palaganglioma/Pheochromocytoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 1:00:00 PM OR24 5984 11:30:00 AM Adrenal Tumors: Clinical Implications of the Recent Molecular and Genetic Findings Oral


Ingo Janssen*1, Elise M Blanchet2, Karen T Adams3, Clara C Chen4, Corina M Millo5, Peter Herscovitch5, David Taieb6, Electron Kebebew7, Hendrik Lehnert8, Tito Fojo9 and Karel Pacak10
1National Institutes of Health, Bethesda, MD, 2Bichat Hospital, Paris, France, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 4National Institutes of Health Clinical Center, Bethesda, MD, 5NIH -Clinical Center, Bethesda, MD, 6CHU de la Timone, Marseille Cedex 05, France, 7National Cancer Institute, NIH, Bethesda, MD, 8Klinikum der Univ zu Lubeck, Lubeck, Germany, 9National Cancer Institute, National Institutes of Health, Bethesda, MD, 10National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD

 

Purpose: Patients with SDHB mutation-related pheochromocytoma/paraganglioma (PHEO/PGL) are at a high risk for metastatic disease and show worse outcomes compared to other hereditary PHEOs/PGLs. Current therapeutic approaches are limited but the best outcomes are based on the early and proper detection of as many lesions as possible. Because PHEOs/PGLs are especially known to overexpress somatostatin receptor 2 (SSTR2), the goal of our study was to assess the clinical utility of [(68Ga)-DOTA0,Tyr3]Octreotate ([68Ga]-DOTATATE) positron emission tomography/computed tomography (PET/CT) and to evaluate its diagnostic utility in comparison to [18F]-fluorodopamine ([18F]-FDA)-, [18F]-L-dihydroxyphenylalanine ([18F]-FDOPA)-, [18F]-fluoro-2-deoxy-D-glucose ([18F]-FDG) PET/CT and [123I]-metaiodobenzylguanidine ([123I]-MIBG)-scintigraphy, which are the currently recommended imaging modalities in these patients.

Patients and Methods: [68Ga]-DOTATATE PET/CT was prospectively performed in 15 patients with SDHB-related metastatic PHEOs/PGLs. All patients also underwent [18F]-FDG, with 14 of the 15 patients receiving [18F]-DOPA and [18F]-FDA PET/CT.  6 patients underwent [123I]-MIBG-scintigraphy. Sensitivities in the detection of metastatic lesions were compared between all these functional imaging studies. Magnetic resonance (MR) and computed tomography (CT) were used as the gold standard.

Results: On CT and MR 245 metastatic lesions were identified. [68Ga]-DOTATATE PET/CT demonstrated a lesion-based sensitivity of 98.0%, detecting 240 lesions. Lesion-based sensitivities for [18F]-FDG, [18F]-FDOPA, [18F]-FDA PET/CT and [123I]-MIBG-scintigraphy were 84.5% (p<0.01), 60.6% (p<0.01), 51.9% (p<0.01), and 18.7% (p<0.01), respectively.

Conclusions: [68Ga]-DOTATATE PET/CT showed a significantly superior sensitivity compared to all other functional imaging modalities and may replace the currently recommended [18F]-FDG PET/CT as the preferred imaging modality in the evaluation of SDHB-related metastatic PHEO/PGL.

 

Nothing to Disclose: IJ, EMB, KTA, CCC, CMM, PH, DT, EK, HL, TF, KP

OR24-5 19088 5.0000 A Superiority of 68Ga-Dotatate PET-CT to Other Functional Imaging Studies in the Localization of SDHB-Related Pheochromocytoma and Paraganglioma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 1:00:00 PM OR24 5984 11:30:00 AM Adrenal Tumors: Clinical Implications of the Recent Molecular and Genetic Findings Oral


Camilo Jimenez*1, Daniel A. Pryma2, Daniel C. Sullivan3, Julie K. Schwarz4, Richard B. Noto5, Nancy Stambler6, Tom Armor6, Jessica D. Jensen6 and Robert J. Israel6
1The University of Texas MD Anderson Cancer Center, Houston, TX, 2Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 3Duke University Medical Center, 4Washington University School of Medicine, 5Rhode Island Hospital, 6Progenics Pharmaceuticals, Inc.

 

Background:  Azedra is a radiopharmaceutical under development for the treatment of patients (pts) with iobenguane-avid relapsed/refractory malignant pheo/para. Produced using the proprietary Ultratrace® platform, Azedra is designed to minimize unlabeled iobenguane being carried through from production reaction to final formulation resulting in higher specific activity. This may result in increased cellular uptake of radioactivity and hence greater tumor uptake and reduced toxicity. The purpose of this analysis is to assess long term follow-up in pts treated with Azedra in a phase 2 study in malignant pheo/para.

Methods:  Eligible pts were ≥12 years old with a confirmed diagnosis of malignant pheo/para, ineligible for curative surgery, and on stable antihypertensive medication for tumor-related hypertension for at least 30 days prior to first dose. Pts initially received 3 to 6 mCi (imaging dose) followed by 3 whole body scans to confirm tumor uptake of study agent, assess biodistribution, and determine whole body and organ dosimetry. Pts then received up to 2 therapeutic administrations of 8 mCi/kg up to a maximum of 500 mCi each given 3 to 6 months apart. The primary endpoint was the proportion of pts with at least a 50% reduction of all antihypertensive medications lasting at least 6 months. Antihypertensives were titrated according to standard algorithms.

Results:  49 pts were enrolled; 41 received at least one therapeutic administration (full analysis; FA), and 34 received two therapeutic administrations (per protocol; PP). The primary endpoint was met by 13 pts (32%; FA), (95% CI 16%-47%).  Best overall tumor partial response (RECIST) was seen in 35% and 32% of evaluable PP (n=34) and FA (n=38) populations, respectively.  All 41 pts who received at least 1 therapeutic administration experienced at least 1 treatment-emergent adverse event (TEAE), most frequently gastrointestinal and hematologic disorders. 29% of subjects experienced an SAE ≥Grade 3. At a median follow-up of 32 months, there have been 25 deaths, 19 due to disease progression. Median survival is 36 months; five subjects remain in long term follow-up. Overall survival was 93% and 67% at 12 and 24 months respectively.

Conclusions: Long term follow-up of pts treated with Azedra shows significant activity as measured by reduction in antihypertensives, tumor reductions (RECIST), and median survival of 3 years.  In this study, Azedra was an effective and well tolerated treatment for pts with iobenguane-avid metastatic and/or recurrent pheo/para, an orphan disease with no approved therapies.

 

Disclosure: DAP: Investigator, Progenics Pharmaceuticals, Inc.. NS: Employee, Progenics Pharmaceuticals, Inc.. TA: Employee, Progenics Pharmaceuticals, Inc.. JDJ: Employee, Progenics Pharmaceuticals, Inc.. RJI: Management Position, Progenics Pharmaceuticals, Inc.. Nothing to Disclose: CJ, DCS, JKS, RBN

OR24-6 21041 6.0000 A Long Term Follow-up of a Pivotal Phase 2 Study of Ultratrace® Iobenguane I-131 (AZEDRATM) in Patients with Malignant Relapsed/Refractory Pheochromocytoma (Pheo)/Paraganglioma (Para) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 1:00:00 PM OR24 5984 11:30:00 AM Adrenal Tumors: Clinical Implications of the Recent Molecular and Genetic Findings Oral


Juan Pedro Martinez-Barbera*
UCL Institute of Child Health, London, United Kingdom

 

Adamantinomatous craniopharyngioma (ACP) is a paediatric pituitary tumour that is associated with high morbidity due to the tendency of the tumour to infiltrate locally into surrounding brain structures such as the hypothalamus and visual tracts. We have developed and validated two mouse models for human ACP, which have provided original insights into the aetiology and pathogenesis of these human tumours. Recently, we revealed a novel and intriguing mechanism by which Sox2+ve pituitary stem cells contribute to oncogenesis, which is fundamentally different to the classical cancer stem cell paradigm. When targeted to express oncogenic β-catenin, mutant Sox2+ve stem cells do not give rise to the progeny populating the tumour, instead these oncogenic stem cells induce tumorigenesis in a paracrine manner. To provide insights into this novel mechanism, we have revealed that in these models, senescence and the senescence-associated secretory phenotype are critical players for tumour progression. Specifically, we show that following a short burst of proliferation, oncogenic Sox2+ve cells stop dividing to form β-catenin-accumulating cell clusters that become senescent. These clusters show senescence-associated β-galactosidase activity, p53 pathway activation and up-regulate the expression of the cell cycle inhibitors p21 and p16. Additionally, cluster cells show elevated expression of lysosomal components and activate the autophagy pathway. Oncogenic β-catenin also causes DNA damage as evidenced by an increase in H2A.X phosphorylation, triggering the DNA damage response. As a consequence, NF-κΒ signalling is elevated resulting in the expression of activation a Senescence-Associated Secretory Phenotype (SASP) with expression of multiple secreted factors including pro-inflammatory cytokines such as IL1, IL6 and IL8. Of translational significance, we show that this mechanism is relevant in human ACP tumorigenesis. β-catenin-accumulating cell clusters in human ACP express several senescence markers such as p21, p16 and lysosomal enzymes, exhibit DNA damage and activate P53, NF-κΒ  and autophagy pathways, resulting in SASP activation. Together, the mouse and human data suggest that senescence and SASP are likely to modify the tumour microenvironment resulting in cell transformation, tumour growth and survival.

 

Nothing to Disclose: JPM

OR35-1 19532 1.0000 A Adamantinomatous Craniopharyngioma Contains Senescent Cells with Tumour-Inducing Potential 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR35 5997 11:30:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Oral


Laura C. Hernández Ramírez*1, Federico Martucci2, Francesco Ferraù1, Rhodri M.L. Morgan3, Giampaolo Trivellin4, Fauzia Begum1, Daniel Tilley1, Nancy Ramos-Guajardo1, Donato Iacovazzo1, Chrisostomos Prodromou3 and Márta Korbonits1
1Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 2Policlinico di Monza, Monza, Italy, 3Genome Damage and Stability Centre, University of Sussex, Brighton, United Kingdom, 4National Institute of Health, Bethesda, MD

 

Introduction: A subset of familial isolated pituitary adenomas (FIPA) and sporadic pituitary adenomas are due to mutations in AIP, a novel tumor-suppressor gene. Although the Knudson’s “two-hit” hypothesis is fulfilled in most of the AIP mutation (AIPmut)-associated adenomas, not all of them display loss of heterozygosity at the AIP locus. As for other non-imprinted genes, the AIP protein level in the cells should depend on the translation of both alleles, and rapid degradation of AIP mutants with insufficient compensation from the normal allele could account for reduced AIP levels.

Methods: We performed a screening for AIP-interacting partners using pull-down assay (GST-tagged wild-type [WT] and p.R304* AIP as baits) and quantitative mass spectrometry (qMS); results were confirmed by co-immunoprecipitation (co-IP). AIP half-life was assessed by Western blot (WB) in cyclohexamide-treated EBV-transformed lymphoblastoid cells (EBV-LC) from healthy control (HC) and AIPmut positive (heterozygous p.R304* or c.100-18>T) individuals, untransfected GH3 cells and HEK293 cells untransfected and transfected with plasmids encoding Myc-tagged WT-AIP and eight AIP variants. The response of AIP to treatment with octreotide was studied in EBV-LC.

Results: The SCF1 complex members FBXO3 and SKP1 were identified by qMS screening, and binding to p.R304* AIP was 1.5 times higher for FBOX3 and 3.3 more for SKP1 than for WT-AIP; WT-AIP/FBXO3 interaction was confirmed by co-IP. Half-life of endogenous WT-AIP was 25.1, 38.9 and 36.6 hours in EBV-LC, HEK293 and GH3 cells, respectively. In AIP c.100-18>T EBV-LC, the degradation rate constant (k) of endogenous AIP was slightly, though not significantly higher than in HC EBV-LC (k=0.040 vs. k=0.028, P=0.068), while in AIP p.R304* EBV-LC the endogenous mutant AIP was only detected after MG-132 proteasome inhibitor treatment. In transfected HEK293 cells, a significantly higher k, and therefore, shorter half-life, was found for the AIP variants p.C238Y (k=0.117), p.I257V (k=0.033), p.R271W (k=0.115), p.A276V (k=0.082), p.V291M (k=0.104) and p.R304* (k=0.156), but not for p.M170T (k=0.011) and p.R325Q (k=0.010) compared to WT-AIP (k=0.012, P<0.001 for all the comparisons). In heterozygous AIP p.R304* EBV-LC, WT-AIP showed impaired response to treatment with 10nM octreotide (fold change at 48 hours post-treatment 0.01 [±0.04 SEM] vs. time 0) compared to homozygous WT EBV-LC (3.6 [±0.2], P <0.01).

Conclusions: AIP is processed via ubiquitination and proteasomal degradation, mediated by the SCF1 E3 ubiquitin ligase complex containing FBXO3 and SKP1. Enhanced proteasomal degradation conferred shorter half-life to most of the AIP mutant proteins tested. In AIP p.R304* EBV-LC, biallelic expression of AIP is necessary for the cell to achieve a normal response to octreotide, which could be important for the physiological role of AIP in the pituitary gland.

 

Nothing to Disclose: LCH, FM, FF, RMLM, GT, FB, DT, NR, DI, CP, MK

OR35-2 21181 2.0000 A The Enhanced Proteasomal Degradation of AIP Mutant Proteins Is a Mechanism for AIP Deficiency in AIP mutation-Associated Pituitary Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR35 5997 11:30:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Oral


Donato Iacovazzo*1, Eivind Carlsen2, Francesca Lugli3, Sabrina Chiloiro4, Serena Piacentini3, Antonio Bianchi3, Antonella Giampietro3, Marilda Mormando4, Andrew J Clear5, Carmelo Anile3, Giulio Maira3, Libero Lauriola3, Guido Rindi3, Maurizio Spinello6, Márta Korbonits5 and Laura De Marinis3
1Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 2STHF, Skien, Norway, 3Università Cattolica del Sacro Cuore, Rome, Italy, 4Catholic University of the Sacred Heart, Rome, Italy, 5Barts and The London School of Medicine, London, United Kingdom, 6Novartis Pharma, Origgio, Italy

 

Introduction: the expression of somatostatin receptor 2 (SSTR2) in somatotropinomas positively correlates with response to octreotide. Low AIP expression has been found to be associated with resistance to somatostatin analogs (SSA). No data are available regarding the expression of SSTRs and AIP and its correlation to pasireotide treatment.

Methods: 39 samples were collected from a single center series of acromegaly patients requiring post-operative SSA. The expression of SSTR2, SSTR5 and AIP has been evaluated via immunohistochemistry (IHC). SSTRs expression was scored according to a standardized scoring system (Volante, Mod Pathol 2007) (score 0: negative; score 1: cytoplasmic staining; score 2: incomplete membranous staining or membranous staining in less than 50% of cells; score 3: circumferential membranous staining in more than 50% of cells). AIP expression was scored using a semi-quantitative method (staining intensity, range 0-3 x percentage of positive cells; range 0-300). Responsiveness to SSA has been defined as a greater than 50% reduction of IGF-1 levels compared to baseline. All patients have been treated post-operatively with SSA (octreotide LAR or lanreotide ATG), and 11 resistant patients have been subsequently treated with pasireotide LAR.

Results: SSTR2 and SSTR5 were both highly expressed (score 3) in 31% of samples, SSTR5 was preferentially expressed in 26%, SSTR2 in 26% of cases, while 8% of samples were negative for both SSTRs. The expression of SSTR2 correlates with responsiveness to conventional SSA (responsive patients, score 0-1: 0%, score 2: 40%, score 3: 72%; p<0.05). The expression of both SSTR2 and SSTR5 (score 3) is associated with a higher rate of responsiveness to octreotide or lanreotide (83%) compared to tumors preferentially expressing SSTR2 (30%) (p<0.005). The expression of SSTR5 correlates with responsiveness to pasireotide (responsive patients, score 0-1: 0%, score 2-3: 86%; p<0.05). AIP deficient tumors (IHC score <50), accounting for 23% of all samples, are highly resistant to conventional SSA compared to AIP proficient tumors (83% vs 43%, p<0.05), while no significant difference is seen in patients treated with pasireotide (responsive patients, AIP deficient tumors: 50%, AIP proficient tumors: 60%). AIP deficient tumors present lower SSTR2 expression (p<0.05) compared with AIP proficient ones, while no difference is observed for SSTR5.

Conclusions: this scoring system for SSTRs immunostaining represents a useful tool to predict responsiveness to SSA. SSTR2 expression is associated with a positive response to octreotide and lanreotide treatment, mainly when co-expressed with SSTR5. Adenomas preferentially expressing SSTR5 tend to better respond to pasireotide. AIP deficient adenomas are highly resistant to conventional SSA, express lower levels of SSTR2 but not SSTR5, and might benefit from pasireotide treatment.

 

Disclosure: MS: Medical adviser, Novartis Pharmaceuticals. MK: Research Funding, Novartis Pharmaceuticals. LD: Research Funding, Novartis Pharmaceuticals. Nothing to Disclose: DI, EC, FL, SC, SP, AB, AG, MM, AJC, CA, GM, LL, GR

OR35-3 21229 3.0000 A Expression of Somatostatin Receptor 2 & 5 and AIP: Useful Tools to Predict Responsiveness to Conventional Somatostatin Analogs and Pasireotide Treatment in Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR35 5997 11:30:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Oral


Katja Kiseljak-Vassiliades*1, Katherine Gowan2, Mei Xu2, Taylor S Mills2, BK Kleinschmidt-Demasters3, Kevin Lillehei2, Kenneth Jones2 and Margaret E Wierman1
1University of Colorado School of Medicine and Research Service VAMC, Aurora, CO, 2University of Colorado School of Medicine, Aurora, CO, 3University of Colorado, Aurora, CO

 

Growth hormone pituitary (GH) tumors represent an aggressive type of pituitary tumors, causing acromegaly, associated with increased morbidity and shortened lifespan in patients with uncontrolled disease.  Differing clinical behavior between two GH tumor histological subtypes (densely (DG) and sparsely (SG) granulated), have been reported, but is not used routinely in clinical management. We hypothesized that a differential molecular signature may play a critical role in their behavior.  Genetic and genomic analysis of human samples from DG and SG tumors was performed to identify novel differential pathways and targets in GH tumorigenesis and progression, with the ultimate goal of identifying new therapeutic targets. Affymetrix exon expression microarray was performed on 21 GH tumors (11 DG and 10 SG) to characterize the tumor transcriptome. An ANOVA model was used to examine differentially expressed transcripts with FDR<1% and fold change >2 identified 860 dysregulated genes (391 upregulated and 469 downregulated in SG vs DG).  Downstream pathway analysis of gene expression using GSEA identified 5 enriched gene sets with FDR (false discovery rate) < 25% and nominal p < 0.01. The top enriched pathways in DG samples were Cell Cycle (p< 0.001; FDR=5%) and NFAT pathway in SG (p=0.004, FDR=18%). The genetic landscape of 11 GH tumors (5 DG, 6 SG) was analyzed using whole exomic sequencing with Illumina HiSeq 2000.   The exomic sequences were aligned to human reference genome (hg19) and mutations were identified using GATK. ANNOVAR was used to annotate and subsequently filter the variants, e.g., removal of common polymorphic variants utilizing data from 1000 genome project. Database of nonsynonymous functional prediction (dbNSFP) was then used to model the mutational effect on the protein.  The results show 547 mutated genes in DG and 624 in SG, with the criteria of at least 1 mutation per tumor. The most frequently mutated genes in SG compared to DG tumors include TPR (translocated promoter region), NEB (nebulin), SLK (STE20-like kinase) and CENPJ (centromere protein J). Bioinformatic GSEA pathway analysis of exomic sequencing data identified dysregulation of Focal Adhesion in DG (p=1.31e-13, FDR=1.73e-10) and the GPCR pathway in SG tumors (p=6.26e-5, FDR=7.79e-3) as the top cellular pathways affected.  Analysis that combines gene expression (dysregulated genes with fold change > 2) and exomic sequencing from SG tumors (damaging mutation in at least 1 tumor) identified 35 common genes (22 downregulated and 13 upregulated). In summary, genomic and genetic profiling of GH tumor subtypes suggests differential molecular signatures between DG and SG tumors. Future studies are underway to define the functional significance of identified novel targets in patients with acromegaly.

 

Nothing to Disclose: KK, KG, MX, TSM, BK, KL, KJ, MEW

OR35-4 21625 4.0000 A Genomic and Genetic Analysis of Growth Hormone Pituitary Tumor Subtypes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR35 5997 11:30:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Oral


Matthew J Biehl* and Lori T Raetzman
University of Illinois at Urbana-Champaign, Urbana, IL

 

The mammalian arcuate nucleus (ARC) houses neurons critical for energy homeostasis and sexual maturation. Antagonistic Proopiomelanocortin (Pomc) and Neuropeptide Y (NPY) neurons function to balance energy intake versus satiety, whereas Kisspeptin neurons are involved in onset of puberty and reproductive function. While the function of these neurons has been well established, their development, especially with respect to each other, remains elusive. We have previously shown that Notch signaling directs cell fate within the ARC of mice. Active Notch signaling prevented neural progenitors within the ARC from differentiating into feeding circuit neurons, whereas conditional loss of Notch signaling lead to a premature differentiation of these neurons within the ARC. Presently, we hypothesized that Kisspeptin neurons of the ARC would similarly be affected by Notch manipulation. To address this, we utilized mice with a conditional deletion of Rbpj-κ, an essential co-factor of active Notch signaling (Rbpj cKO), or mice persistently expressing the Notch1 intracellular domain within Nkx2.1 expressing cells of the developing ventral hypothalamus. Interestingly, we have found that in both mouse models, a lack of Kisspeptin/Kiss1 expression is observed. This would indicate that Notch signaling represses differentiation of all ARC neurons. However, Notch signaling also instructs formation of Kisspeptin neurons. The observed loss of Kisspeptin neurons in Rbpj cKO mice could be due to depletion of a common progenitor for all ARC neurons prior to Kisspeptin formation or a direct role for Notch in Kisspeptin fate choice. To address this, we characterized the timing of Kisspeptin neuron formation and lineage from which they arose. Using a BrdU birthdating paradigm, we determined the percentage of NPY and Kisspeptin neurons born on embryonic days 11.5, 12.5, and 13.5. We found no difference in the timing of differentiation of either neuronal subtype, with a majority occurring at e11.5. To determine if Kisspeptin neurons of the ARC differentiate through a Pomc intermediate similar to many NPY neurons, we utilized a genetic lineage tracing model expressing the tdTomato fluorescent protein in all cells that have ever expressed Pomc. We observed some Kisspeptin expressing neurons labeled with our reporter, suggesting that a subset arose from a common progenitor. Taken together, our findings suggest that active Notch signaling is an important molecular switch involved in instructing subpopulations of progenitor cells to differentiate into Kisspeptin neurons. Loss of Kisspeptin persists into adulthood in Rbpj cKO mice within the ARC, thus we hypothesized that mice would show reproductive phenotypes. After 8 weeks, Rbpj cKO mice had smaller gonads and showed striking reproductive deficits. These findings support the importance of Notch signaling in the ARC for reproductive function.

 

Nothing to Disclose: MJB, LTR

OR35-5 22073 5.0000 A Rbpj-κ dependent Notch Signaling Regulates Development of the Arcuate Kisspeptin Neurons 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR35 5997 11:30:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Oral


Carles Gaston-Massuet*1, Mark J McCabe2, Valeria Scagliotti3, Louise Cheryl Gregory4, Sujata Jayakody5, Juan Pedro Martinez-Barbera4 and Mehul Tulsidas Dattani4
1William Harvey Research Institute, London, United Kingdom, 2Garvan Institute of Medical Research, Sydney, Australia, 3William Harvey Research Institue, Barts & The London, London, United Kingdom, 4UCL Institute of Child Health, London, United Kingdom, 5UCL, Institute of Ophtalmology, London

 

Congenital hypopituitarism usually results from disordered hypothalamic-pituitary (HP) axis development. Previously we have shown that the Wnt/β-Catenin pathway is important not only in the causation of paediatric pituitary tumours, but is also required for the normal morphogenesis and development of the HP-axis. Here we show that the repressor activity of the Wnt effector Tcf3/TCF7L1 is required for brain and pituitary gland development. Conditional deletion of Tcf3/TCF7L1 (Tcf3Fl/-;Hesx1Cre/+) results in a phenotype that is highly reminiscent of Septo-Optic Dysplasia (SOD), a form of congenital hypopituitarism combined with eye abnormalities and central nervous system defects. In order to assess the clinical relevance of our murine studies we screened a cohort of patients with SOD; we identified two novel mutations in hTcf3/TCF7L1 in two unrelated SOD patients. Functional characterization of these using Top-Flash reporter assays show that these mutations compromise the repressor activity of hTcf3/TCF7L1 suggesting for the first time a critical role for the Wnt/β-catenin effector Tcf3/TCF7L1 for development of the hypothalamic-pituitary axis in humans.  To understand the role of Tcf3 during HP development,  we examined the integrity of the HP-axis during pituitary gland development in conditionally deleted Tcf3 mice (Tcf3Fl/-;Hesx1Cre/+); these embryos show an anterior expansion of the ventral diencephalic signals (Fgf10 and BPM4) leading to more oral ectoderm being specified into pituitary tissue. Moreover, we observe a higher mitotic index of the periluminal progenitors which results in hyperplasia of the gland. To determine if TCF3 is required to mediate transcriptional activation or repression of the Wnt/β-catenin pathway, we studied a murine mutant (Tcf3DN/DN) expressing a mutant TCF3 lacking the β-catenin interacting domain. Unlike Tcf3Fl/-;Hesx1Cre/+ mice, Tcf3DN/DN mutant embryos exhibit normal development of both the prospective hypothalamus and the pituitary gland at all developmental stages, indicating that TCF3-repressing activity is essential for hypothalamic-pituitary development. Taken together these results indicate for the first time a novel role for Tcf3/TCF7L1 in hypothalamic-pituitary axis development and associates mutations in Tcf3/TCF7L1 with SOD clinical phenotype. 

 

Nothing to Disclose: CG, MJM, VS, LCG, SJ, JPM, MTD

OR35-6 20509 6.0000 A Mutations in the Wnt/b-Catenin Effector Tcf3/TCF7L1 Are Associated with Septa-Optic Dysplasia in Mouse and Humans 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 1:00:00 PM OR35 5997 11:30:00 AM Tumorigenesis and Development of the Pituitary and Hypothalamus Oral


Laura Torchen*1 and Andrea Dunaif2
1Feinberg School of Medicine, Northwestern University, Chicago, IL, 2Northwestern University Feinberg School of Medicine, Chicago, IL

 

Recent studies have found that morbidly obese peripubertal girls (OB-G) have increased testosterone (T) levels compared to lean girls (L-G).  This observation has led to the proposal that OB-G are at increased risk to develop polycystic ovary syndrome (PCOS), a common, highly heritable complex genetic disease.  Consistent with a genetic contribution to PCOS, female first-degree relatives of affected women are at increased risk for the syndrome.  Further, reproductive and metabolic features of PCOS are present in the daughters of affected women (PCOS-D) in childhood.  We performed this study to test the hypothesis that PCOS-D have a distinctive reproductive phenotype compared to OB-G. 

Thirteen PCOS-D (94.5±3.1 BMI percentile), 15 OB-G (98.7±0.5 BMI percentile) and 18 L-G (50.0±18.9 BMI percentile), aged 8-12 years with breast Tanner stage I-III were studied.   AMH, total T and sex hormone binding globulin (SHBG) levels were measured.  Free T levels were calculated from total T and SHBG levels.  One-way ANOVA with Tukey post-hoc testing was applied (mean ± SD, α=0.05).  The association between AMH levels and BMI z-scores was assessed by linear regression.  By design, age and breast Tanner stage were similar but BMI z-scores differed among the groups (p<0.0001, ANOVA, 1.7±0.3 PCOS-D vs 0.0±0.5 L-G, p<0.0001; 2.4±0.2 OB-G, p<0.0001; PCOS-D vs L-G p<0.0001).  Total T levels did not differ significantly but SHBG levels were lower (p<0.0001, ANOVA) in PCOS-D and OB-G (33±15 PCOS-D vs 70±23 L-G, p<0.0001; 24±11 OB-G vs L-G, p<0.0001; PCOS-D vs OB-G p=0.17, nmol/L).  As a result, free T levels were significantly higher (p=0.002, ANOVA) in PCOS-D and OB-G (0.7±0.6 PCOS-D vs 0.3±0.2 L-G, p=0.005; 0.6±0.4 OB-G vs L-G, p=0.006; PCOS-D vs OB-G p=0.99, pmol/L).  In contrast, AMH levels were similar and significantly higher (p=0.0006, ANOVA) in PCOS-D and L-G (19.3±11.2 PCOS-D vs 8.6±5.6 OB-G, p=0.0007; 14.7±6.7 L-G vs OB-G, p=0.009; PCOS-D vs L-G p=0.46, pmol/L). The relationship between AMH levels and BMI z-score differed significantly among the groups (z test p=0.01).  There was a significant positive association between AMH levels and BMI z-score in PCOS-D (R2=0.43, p=0.02), whereas there was a trend towards a significant negative association between these parameters in OB-G (R2=0.21, p=0.09); there was no association in L-G (R2=0.01, p=0.65).

Although OB-G and PCOS-D had comparable elevations in free T levels, their AMH levels differed.  The low AMH levels in OB-G suggest that they do not have an increase in ovarian follicles, a key feature of PCOS.  Further, the relationship between AMH levels and BMI z-score differed in OB-G compared to PCOS-D.  Our findings suggest that 1) the etiology of hyperandrogenemia differs in OB-G compared to PCOS-D, and 2) OB-G may not be at increased risk for PCOS, despite having hyperandrogenemia.

 

Nothing to Disclose: LT, AD

OR27-1 20015 1.0000 A Distinctive Reproductive Phenotypes in Peripubertal Daughters of Women with Polycystic Ovary Syndrome Compared to Morbidly Obese Girls 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR27 6004 11:30:00 AM Hyperandrogenic Ovarian Dysfunction Oral


Christine M. Burt Solorzano*1, Eleanor G. Hutchens2, R Jeffrey Chang3, Christopher R. McCartney1 and John C. Marshall2
1University of Virginia, Charlottesville, VA, 2University of Virginia Health System, Charlottesville, VA, 3University of California, San Diego, La Jolla, CA

 

Our previous studies suggest that ~ 60% of obese peripubertal girls have hyperandrogenemia (HA), which can be a precursor to adult polycystic ovary syndrome (PCOS). However, the sources of HA (e.g., ovarian vs. adrenal) in such girls remain unclear. We aimed to determine the source of androgen excess in some overweight pubertal girls by assessing differences in androgen levels after adrenal and ovarian stimulatory tests. We also assessed changes in anti-mullerian hormone (AMH) since AMH correlates with HA in adult women and is elevated in daughters of PCOS women.

We expanded our previous studies to examine girls Tanner stages 3-5 for breast development who were normal weight ([NW] BMI %-ile-for-age <85; n=9) and overweight ([OW] BMI %-ile-for-age ≥85; n=12). We gave dexamethasone (DEX) 1 mg po for two nights prior to morning sampling. Baseline hormone levels were drawn at 7 am. Girls underwent a cosyntropin (ACTH; 250 mcg IV) stimulation test with blood draws at 30, 60, and 90 min after administration. Levels at 90 min are reported as they correlated with maximal levels in most subjects. Recombinant human chorionic gonadotropin (r-hCG; 25 mcg IV) was given and hormone levels drawn 24 h later. Results were compared using Student’s t-tests (unequal variances).

OW girls had elevated androstenedione ([Δ4A] NW 1.09±0.21 ng/dL [mean±SEM]; OW 2.10±0.37 ng/dL; p=0.03) and free T (NW 6.0±1.2 pmol/L; OW 17.5±1.5 pmol/L; p=0.04) levels after DEX suppression. ACTH significantly increased adrenal androgen levels (p≤0.05 compared to baseline). Absolute levels of free T were increased higher in OW girls after ACTH (NW 11.6±2.6 pmol/L; OW 28.0±4.9 pmol/L; p=0.01), but increases from baseline were not different between groups (Δ4A [ΔNW 1.18±0.28 ng/dL; ΔOW 2.30±0.98 ng/dL; p=0.29]; free T [ΔNW 5.6±1.8 pmol/L; ΔOW 10.5±2.9 pmol/L; p=0.17]). Similarly, after r-hCG, absolute values of Δ4A (NW 1.76±0.32 ng/dL; OW 3.06±0.52 ng/dL; p=0.05) and free T (NW 9.7±1.9 pmol/L; OW 24.5±5.5 pmol/L; p=0.02) were higher in OW girls at 24 h, but there were no significant differences in changes from baseline between groups (Δ4A [ΔNW 0.67±0.14 ng/dL; ΔOW 0.96±0.32 ng/dL; p=0.41]; free T [ΔNW 3.7±1.1 ng/dL; ΔOW 7.0±2.0 ng/dL; p=0.17]; 17OH progesterone [ΔNW 1.92±0.46 ng/mL; ΔOW 2.88±0.76 ng/mL; p=0.30]).

AMH levels were the same in OW girls at baseline (NW 2.57±0.76 ng/mL; OW 4.09±0.80 ng/mL, p=0.12). AMH levels did not change after r-hCG in either NW or OW group.

Higher androgen levels after DEX in OW girls suggest an ovarian origin of HA. However, similar rises in levels after r-hCG administration suggest that ovarian responsiveness to acute gonadotropin stimulation is not exaggerated. Differences in basal androgen levels may be related to chronically increased gonadotropin exposure, instead of acute ovarian hyper-responsiveness. AMH does not seem to acutely rise after gonadotropin exposure in most pubertal girls, even those with HA.

 

Nothing to Disclose: CMB, EGH, RJC, CRM, JCM

OR27-2 21917 2.0000 A Sources of Androgen Excess in Pubertal Girls--Acute Androgen Responses Are Not Increased in Overweight Girls 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR27 6004 11:30:00 AM Hyperandrogenic Ovarian Dysfunction Oral


Jyothis T George*1, Rahul Kakkar2, Jayne Marshall2, Martin L Scott2, Richard Finkelman3, Tony Ho2, Stuart McIntosh3, Johannes D Veldhuis4, Richard Alexander Anderson5 and Lorraine Webber6
1University of Oxford, Oxford, United Kingdom, 2AstraZeneca, 3Former AstraZeneca employee, 4Mayo Clinic, Rochester, MN, 5University of Edinburgh, Edinburgh, United Kingdom, 6Astrazeneca

 

Background: Polycystic Ovary Syndrome (PCOS) is characterized by elevated serum testosterone (T) concentrations, and associated with accelerated luteinizing hormone (LH) pulse frequency. Recent elucidation of the kisspeptin-neurokinin B (NKB)-dynorphin system as the pivotal modulator of GnRH, and gonadotropin secretion presents a therapeutic target to address this pathophysiology.

Hypothesis: That NKB receptor antagonism will reduce LH secretion and thereby decrease T in women with PCOS. 

Design: We undertook a randomized, double-blind, placebo-controlled trial with total daily oral dosing of 20, 40 and 80mg of AZD4901 (a selective NKB receptor antagonist) or placebo for 28 days conducted at 9 sites in the UK, US and Germany.

Primary Objective: To determine change in 8-hour LH area-under-curve (AUC) between baseline (day -1) and day 7 vs. placebo. 

Secondary objectives included quantifying changes from baseline in total testosterone (days 7 and 28) and in LH pulsatility (frequency and mass-per-pulse) at day 7 vs. placebo.

Key eligibility criteria: Diagnosis of PCOS (≤ 6 menstrual cycles/year, hyperandrogenemia (Free T>0.85 Upper Limit of Normal) and polycystic ovarian morphology).

Statistical Analyses: LH AUC was calculated by trapezoid summation of 10-min values over 8 hours. Blinded deconvolution analysis was used to characterize LH pulsatility. LH and T endpoints are presented as change from baseline; comparisons between groups were performed using mixed effects models for repeated measures with baseline as a covariate. 

Results: 65 women were randomized (27±5 years, BMI 31.5±6.0 kg/m2, Mean ±SD), 59 of whom provided day -1 LH samples that were evaluable per protocol, with 13 to 16 patients contributing to the primary endpoint in each of the four arms.

At day 7, LH AUC reduced by 52% (95% CI 30-67%) in the 80mg group (from 67.4±1.6 to 36±2.3 IU/L*hr) compared to placebo (from 61.1±1.9 to 69.8± 1.7 IU/L*hr); p=0.0003. LH pulse frequency also reduced from 5.8±2.1 to 3.7±2.1 pulses/8hr in this group compared to placebo (from 7.2±2.3 to 6.8±2.6); p<0.0001. LH mass-per-pulse remained unchanged.

Concurrently, T decreased by 29% (95% CI 14-41%) at day 7 in the 80mg group (from 2.2±1.3 nmol/L at baseline to 1.6±1.5) compared to placebo (from 1.5±1.7 to 1.6±1.9 nmol/L); p=0.0006. Average T reduction was maintained in this group over the remaining study period (17% decrease from baseline vs. placebo at day 28).

No significant LH or T changes were observed with lower doses. No drug-emergent serious adverse events were recorded.

Conclusions: Consistent with decreased LH secretion observed in patients with NKB signaling defects (1, 2), the NKB receptor antagonist AZD4901 reduced LH secretion and pulse frequency in this first randomised trial to assess LH pulsatility in PCOS. These effects were associated with a significant and sustained fall in serum testosterone.

Clinicaltrials.gov, NCT01872078

 

Disclosure: JTG: Clinical Researcher, Takeda, Advisory Group Member, Novo Nordisk, Advisory Group Member, Bristol-Myers Squibb, Clinician, Astra Zeneca, Clinician, Sanofi, Clinician, Eli Lilly & Company, Clinical Researcher, Astra Zeneca. RK: Employee, Astra Zeneca. JM: Employee, Astra Zeneca. MLS: Employee, Astra Zeneca. RF: Employee, Astra Zeneca, Employee, Astra Zeneca. TH: Employee, Astra Zeneca. SM: Employee, Astra Zeneca. JDV: Consultant, Astra Zeneca. RAA: Consultant, Astra Zeneca. LW: Employee, Astra Zeneca, Employee, Astra Zeneca.

OR27-3 18514 3.0000 A The Neurokinin B Receptor Antagonist AZD4901 Decreases LH and Testosterone Secretion in Women with PCOS: A Randomised, Double-Blind, Placebo-Controlled Clinical Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR27 6004 11:30:00 AM Hyperandrogenic Ovarian Dysfunction Oral


Michael T Sellix*, Amanda L Mereness and Zachary C Murphy
University of Rochester School of Medicine and Dentistry, Rochester, NY

 

The circadian timing system plays a critical role in female reproductive physiology, implicated in the timing of ovulation, steroid hormone synthesis and parturition. Initially localized to neurons in the central clock or suprachiasmatic nucleus (SCN), the molecular clock has now been detected in each tissue of the hypothalamo-pituitary-ovarian (HPO) axis. Synchronization between the SCN, peripheral oscillators and the environment, referred to as circadian organization, is a fundamental property of physiological homeostasis. We have determined that excess androgen exposure during gestation, known to produce features of polycystic ovarian syndrome (PCOS) in offspring, affects the timing of clock gene expression and disturbs circadian organization. Thus, we have categorized fetal androgenization as a novel form of environmental circadian disruption and hypothesize that the influence of excess androgen on fertility and metabolism are due, in part, to the impact of developmental programing on the timing system. Further, we predict that treatments known to stabilize reproductive cycles and improve glucose metabolism in PCOS may do so indirectly through their effects on clock function.

To examine the functional relationship between circadian organization, infertility and metabolic function in PCOS we measured clock gene expression, reproductive cycles, body weight and glucose tolerance in adult prenatally androgenized (PNA) female PERIOD2::luciferase transgenic mice exposed to one of 4 treatments: (Group 1) was given access to a running wheel (voluntary exercise; VE; n=8), (Group 2) was placed on caloric restriction (60% of normal food intake; CR, n=4), (Group 3) was exposed to both CR and VE (n=3) and (Group 4) was treated with Metformin (n=4,; MET; 100-500mg/Kg/d in drinking water). After 3-5 weeks animals were sacrificed and tissues, including the SCN, liver, pituitary, oviduct, adipose tissue and isolated ovarian follicles were cultured and luminescence was recorded.  The distribution within and among tissues of peak PER2::LUC expression was analyzed as a function of treatment. Mice treated with MET had more consistent estrous cycles and a substantial increase in phase alignment among central and peripheral oscillators. Animals given access to VE, CR or VE+CR failed to cycle normally and continued to show circadian disorganization. This effect was independent of metabolic dysfunction, as none of the treatments groups showed a significant improvement in glucose tolerance after 3-5 weeks of treatment. These data reveal that, in stark contrast with Metformin, lifestyle changes (diet and exercise) are unable to improve reproductive function and internal circadian organization in PNA mice. They support a functional relationship between circadian alignment, metabolism and fertility, particularly as it relates to the impact of androgen-dependent developmental programming. 

 

Nothing to Disclose: MTS, ALM, ZCM

OR27-4 21282 4.0000 A Differential Effects of Voluntary Exercise, Diet and Metformin on Internal Circadian Organization and Reproductive Function in Prenatally Androgenized Female Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR27 6004 11:30:00 AM Hyperandrogenic Ovarian Dysfunction Oral


Stanley Andrisse*1, Shameka Childress1, Yi Chen1, Andrew Wolfe1, Sally Radovick2 and Sheng Wu1
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Baltimore, MD

 

Polycystic ovarian syndrome (PCOS), the leading cause of female infertility, occurs in 5-10% of reproductive-aged women and is characterized by hyperandrogenism, oligo- or anovulation, and polycystic ovaries. Hyperandrogenemia and hyperinsulinemia are believed to play prominent roles in the genesis and progression of PCOS. In the following studies, we explored the effects of low dose dehydrotestosterone (DHT, a non-amortizable androgen) on tissues that mediate metabolic and reproductive function in a mouse model. We hypothesized that low dose DHT will differentially alter insulin signaling and glucose metabolism resulting in peripheral tissue insulin resistance but increased insulin sensitivity in reproductive tissues. Although many DHT-induced PCOS-like mouse models use DHT concentrations 8-fold that of normal female mice, we used a continuous release10 mm DHT pellet achieving serum DHT levels 3-fold (330 pg/ml) higher than controls (110 pg/ml, inserted with cholesterol pellets), similar to the elevation of DHT seen in women with PCOS.  We performed reproductive testing (estrous cycling), metabolic tests (GTT, ITT), and blood sampling (hormonal assays: LH, FSH). After 90 days, energy storage (skeletal muscle, liver, and abdominal fat) and reproductive (pituitary and ovaries) tissues were isolated and histological H&E staining (ovary and liver), quantitative real-time PCR (qRT-PCR), Luminex multiple ligand assay, and western blot analysis were performed. Mice receiving DHT demonstrated impaired glucose tolerance and were less insulin sensitive than controls. Livers from mice receiving DHT were found to have lower mRNA expression measured by qRT-PCR of insulin signaling intermediates (insulin receptor substrate 1, phosphoinositide-3-kinase), the glucose transporter (GLUT1/2), enzymes used in glycolysis (hexokinase, phosphofructokinase), and glycogen synthesis (glycogen synthase) when compared to controls. Unlike in energy storage tissues, ovaries of mice receiving DHT exhibited higher expression levels of insulin signaling genes measured by qRT-PCR compared to controls. Interestingly, ovarian inflammatory cytokine mRNA expression levels were lower than controls, which may play a role in maintaining insulin sensitivity of the ovaries. In addition, we assessed protein expression levels with the Luminex Multi-Pathway 9-plex assay and subsequent western blot analysis of intermediates in the insulin signaling pathways, and observed that the protein expression levels correlated with the mRNA levels. These findings characterize a low dose DHT induced PCOS mouse model, demonstrating a differential effect of DHT on insulin signaling pathways in energy storage versus reproductive tissues resulting in metabolic and reproductive dysfunction, and identifies mechanistic pathways that may serve as potential therapeutic targets for PCOS intervention.

 

Nothing to Disclose: SA, SC, YC, AW, SR, SW

OR27-5 18608 5.0000 A Differential Tissue Specific Effects of Low Dose DHT Defining Metabolic and Reproductive Dysfunction 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR27 6004 11:30:00 AM Hyperandrogenic Ovarian Dysfunction Oral


Alexander S Kauffman*1, Varykina G. Thackray1, Genevieve E Ryan1, Matthew C Poling1, Navi Chahal1, Danalea V. Skarra1, Kristen P Tolson1, Sheila J Semaan1, Christine A Glidewell-Kenney1, Nahoko Iwata1, Kellie M Breen1, Antoni J Duleba1, Elisabet Stenor-Victorin2, Shunichi Shimasaki1, Nicholas J Webster3 and Pamela L Mellon1
1University of California, San Diego, La Jolla, CA, 2Karolinska Institute, 3Univ of California San Diego, La Jolla, CA

 

Polycystic ovary syndrome (PCOS) is one of the most common reproductive endocrine disorders in women and is characterized by androgen excess, polycystic ovaries and chronic anovulation. Additional hallmarks of PCOS include elevated luteinizing hormone (LH) secretion and increased ovarian steroidogenic enzyme production. The pathophysiology of PCOS is not completely understood, due in part to lack of appropriate PCOS animal models that fully recapitulate the many facets of this complex disorder. Recently, a novel rat model of PCOS using letrozole (LET), a nonsteroidal aromatase inhibitor, was shown to encompass multiple aspects of PCOS, including some metabolic features absent in other models. Given the technical advantages of using genetic and transgenic mouse models, we investigated whether LET produces a similar PCOS phenotype in mice. At 4 weeks of age, female C57BL6 mice were exposed to continuous vehicle or LET treatment, which lowers but does not fully deplete estradiol levels. After 5 weeks of treatment, we examined multiple endocrine and metabolic parameters. As in PCOS women, ovaries from LET, but not control (CON), mice were polycystic, lacked corpora lutea, and were larger. Moreover, the majority of LET females were acyclic. LET females displayed elevated serum LH levels and markedly higher Lhb mRNA in the pituitary. In contrast, serum FSH and Fshb were significantly reduced in LET females, demonstrating differential effects on the two gonadotropins, as in PCOS. Matching the elevated LH, serum testosterone was also markedly increased by LET, recapitulating the hyperandrogenemia of PCOS. Within the ovary, LET females had higher expression of Cyp17 (androgen synthesis), which is elevated in PCOS women, as well as increased FSH receptor and Cyp19 (aromatase) mRNA levels, with normal levels of LH receptor. In the hypothalamus, LET females had higher kisspeptin receptor levels but lower progesterone receptor expression. In addition to the reproductive endocrine phenotype, LET females also gained more weight than CON females and had markedly increased abdominal adiposity, increased adipocyte cell size, and impaired glucose tolerance, mirroring the metabolic phenotype in many PCOS women. Lastly, demonstrating a functional effect on reproduction, fertility was completely blocked in LET-treated females paired with breeder males, though this deficit was later restored to full fertility after LET treatment was discontinued. In summary, we report a new LET mouse model that impressively recapitulates the PCOS phenotype, including endocrine, ovarian, and metabolic aspects. This paradigm may be a useful tool in future studies to genetically probe the etoliogy and mechanisms of PCOS.

 

Nothing to Disclose: ASK, VGT, GER, MCP, NC, DVS, KPT, SJS, CAG, NI, KMB, AJD, ES, SS, NJW, PLM

OR27-6 20593 6.0000 A Letrozole, an Aromatase Inhibitor, Recapitulates Both the Reproductive and Metabolic Phenotypes of Polycystic Ovarian Syndrome in Female Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR27 6004 11:30:00 AM Hyperandrogenic Ovarian Dysfunction Oral


Elaine W. Yu*1, Hang Lee1, Sherri-Ann M Burnett-Bowie1, Sarah C Hirsch1, Gabriela Abrishamian-Garcia2, Lawrence F Borges2, David W. Goldstein2, Alex P Taylor2, Kendra Elizabeth Wulczyn3, Allan F Moore4 and Joel S Finkelstein1
1Massachusetts General Hospital, Boston, MA, 2Massachusetts General Hospital, 3Massachusetts General Hospital, Philadelphia, PA, 4Massachusetts General Hospital, PA

 

Background: The higher prevalence of cardiovascular disease in men than in premenopausal women suggests that testosterone may promote and/or that estradiol may protect against CVD.  Existing studies of the roles of androgens vs estrogens on known CVD risk factors and other potentially–related metabolic factors have produced highly variable results.

Methods: We recruited 2 cohorts of healthy men aged 20-50. All men received goserelin acetate (Zoladex®, AstraZeneca LP, 3.6 mg q4wk) to suppress endogenous testosterone (T) and estradiol (E). Men in Cohort 1 (n=198) were randomized to receive a placebo gel or 1.25 g, 2.5 g, 5 g, or 10 g of testosterone gel (AndroGel®, Abbvie) daily for 16 weeks.  Men in Cohort 2 (n=202) received the same regimen plus all men received anastrozole (Arimidex®, AstraZeneca LP, 1 mg/d) to block conversion of T to E. Fasting serum leptin, lipids, glucose, and HOMA-IR were measured every 4 weeks. Intramuscular (IM) fat was measured at the thigh by quantitative computed tomography at 0 and 16 weeks.  Changes were assessed between T dose groups within Cohort 2 to assess T effects, and between Cohorts 1 and 2 to assess E effects.

Results: By design, mean serum T levels ranged from prepubertal to high-normal and were similar in both cohorts (mean T=44, 191, 337, 470, and 805 ng/dL in Cohort 1 vs. 41, 231, 367, 485, and 924 ng/dL in Cohort 2 at T doses of 0, 1.25, 2.5, 5, and 10 gm of T/day; P=NS at each dose). Mean serum E levels increased progressively with T dose escalation in Cohort 1 (3.6, 7.9, 11.9, 18.2, and 33.3 pg/mL) but remained <3 pg/mL in all dose groups in Cohort 2 (P<0.001 between cohorts).  Serum HDL and leptin levels were inversely associated with T dose in both cohorts (P<0.001 for all). This relationship was not altered by suppressing estrogen production, indicating that T alone regulates these measures.  In contrast, fasting glucose, HOMA-IR, and IM fat increased similarly in all men in Cohort 2 regardless of T dose group, and were significantly higher than in Cohort 1 (P<0.05 for all), indicating that E primarily regulates these measures. Changes in blood pressure, LDL, and body weight were not significantly associated with T or E.

Conclusions: Whereas worsening of insulin resistance and accumulation of body fat due to low estrogen levels are consistent with the known male predominance in CVD, changes in LDL and blood pressure, the parameters most consistently related to cardiovascular risk, do not appear to be regulated by gonadal steroids. Even though leptin is made by adipocytes, it’s circulating level is regulated exclusively by androgens in men. These findings may contribute to a better understanding of the roles of androgens and estrogens in gender differences in CVD.

 

Nothing to Disclose: EWY, HL, SAMB, SCH, GA, LFB, DWG, APT, KEW, AFM, JSF

OR34-1 20646 1.0000 A Effects of Androgens and Estrogens on Cardiometabolic Parameters in Young Adult Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR34 6013 11:30:00 AM Testosterone Replacement Therapy: Risks and Benefits Oral


Hu Li*, Nancy L Ostrowski, Karin Benoit, Wei Wang and Stephen P Motsko
Eli Lilly and Company, Indianapolis, IN

 

Background: To date, no studies have assessed whether an association exists between testosterone replacement therapy (TRT) and venous thrombotic events (VTE).

Purpose: Investigate whether an association exists between TRT use and VTE in hypogonadal men via retrospective cohort and nested‑case‑control analyses.

Methods: Truven Databases were reviewed to obtain data from men with a hypogonadal condition (either treated with an approved TRT product or untreated but with a hypogonadal diagnosis meeting prespecified International Classification of Diseases [ICD‑9] criteria) who were ≥18 years old, continuously enrolled (≥12 months) in a healthcare plan, and did not have a VTE diagnosis during baseline. Propensity‑score (PS) 1:1 matching was used in the cohort analysis to ensure comparability between TRT‑treated and untreated patients (pts) at baseline. In nested‑case‑control analyses, TRT‑treated pts were matched to untreated pts in a 1:4 ratio based on age and calendar year. Among TRT-treated pts, index date was defined as the first TRT prescription date; among untreated pts, index date was assigned at random according to the distribution observed for treated pts. The outcome was defined as incident VTE, primarily Idiopathic VTE; exposure was assessed as primarily any TRT use and by different TRT administration routes. Cox regression and conditional logistic regression models were used in cohort and nested‑case‑control analyses, respectively, to assess hazard ratios (HRs) and odds ratios (ORs) for TRT/VTE associations. Sensitivity analyses were also performed using different TRT exposure and VTE parameters.  

Results: 533,223 hypogonadal men met study inclusion criteria. After PS 1:1 matching, 102,650 TRT-treated pts and 102,650 untreated pts with Idiopathic VTE were included in the analysis.

Retrospective cohort analysis revealed an HR for Idiopathic VTE that was 1.08 for all TRT-treated pts (95% CI: 0.91, 1.27; p=0.378), 1.07 for topical/gel TRT‑treated pts (95% CI: 0.88, 1.29; p=0.496), and 1.32 for injectable TRT‑treated pts (95% CI: 0.89, 1.96; p=0.164). Stratification of pts by age (≤65 vs >65 years old) revealed similar, statistically non‑significant results.

Nested‑case‑control analyses of 2,785 TRT-treated cases and 11,119 untreated controls revealed similar, non‑significant findings. The OR for current TRT was 1.02 (95% CI: 0.92, 1.13; p=0.702), while the OR for past TRT was 0.92 (95% CI: 0.82, 1.03; p=0.145). Similar, non-significant findings were observed with age and TRT administration-route stratification.

Results from most sensitivity analyses supported those observed from the cohort and nested‑case‑control analyses.  

Conclusion: The results from this study do not support an association between exogenous testosterone replacement therapy in hypogonadal men and an increased risk of venous thrombotic events.

 

Disclosure: HL: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. NLO: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. KB: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. WW: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. SPM: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company.

OR34-2 19410 2.0000 A Assessment of the Association Between the Use of Testosterone Replacement Therapy (TRT) and the Risk of Venous Thrombotic Events Among TRT-Treated and Untreated Hypogonadal Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR34 6013 11:30:00 AM Testosterone Replacement Therapy: Risks and Benefits Oral


Reshmi Srinath*1, Rebecca Gottesman2, Kathryn A Carson3, Sherita Hill Golden1 and Adrian S Dobs1
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Baltimore, MD, 3Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

 

Introduction: Epidemiologic studies in men suggest both low and high testosterone (T) are associated with atherosclerosis and contribute to clinical cardiac and cerebrovascular events.  We hypothesize that low T is independently associated with incident cerebrovascular events and the presence of ischemic changes on brain MRI.

Methods:  The Atherosclerosis Risk in Communities (ARIC) study is a large prospective multicenter cohort of people aged 45-64 years at baseline followed since 1987 to evaluate risk factors associated with incident cardiovascular disease (CVD). In a sample of male participants at visit 4(1996-1998) who were free of CVD (including stroke) and without prior T therapy, we measured plasma total T by liquid chromatography mass spectrometry using samples obtained prior to 10:30 AM.  Cochran-Armitage test for trend and general linear regression models were used to assess the cross-sectional association of T quartile with demographic characteristics and cardiovascular risk factors. Proportional hazard regression analysis was performed to assess the association of T quartiles with incident stroke through 2011. A subset of participants underwent brain MRI at visit 5 (2011-2013) with semiquantitative evaluation of white matter hyperintensities (WMH) as well as infarcts (cortical or subcortical).  Linear and logistic regression models were used to assess the association of T quartiles with these ischemic changes. Multivariable regression analysis was adjusted for age, race and ARIC center, body mass index (BMI), waist circumference, smoking status, diabetes, hypertension, LDL and HDL.

Results:  In 1558 males (mean (SD) age= 63.1 (5.6) years, BMI=28.2 (4.27) kg/m2) the median (interquartile range) plasma T was 377.6 (288.4-480.1) ng/dL.  Lower T was significantly associated with higher BMI, greater waist circumference, presence of diabetes, hypertension, lower HDL, and never smoking.  Median follow-up for incident stroke was 14.1 years. Following multivariable adjustment, there was no association of T quartile (Q) with incident stroke (hazard ratios (95% CIs) for Q1-Q3, each vs. Q4: 1.08 (0.56-2.08), 0.85 (0.44-1.66), 0.65 (0.33-1.30)]. Similarly there was no association of T quartile with WMH (results not shown), or with cortical and subcortical infarcts on brain imaging (odds ratios (95% CIs) for Q1-Q3, each vs. Q4: 0.65 (0.28-1.49), 0.65 (0.29-1.45), 0.54 (0.26-1.16)).

Conclusions:  After controlling for key CVD risk factors, there was no association between endogenous T and incident stroke or ischemic changes on brain MRI imaging in men within the ARIC cohort.

 

Disclosure: ASD: Clinical Researcher, Endo Pharmaceuticals, Advisory Group Member, Lipocine, Inc., Advisory Group Member, Endo Pharmaceuticals, Advisory Group Member, AbbVie, Consultant, AbbVie, Clinical Researcher, Clarus. Nothing to Disclose: RS, RG, KAC, SHG

OR34-3 21030 3.0000 A Association Between Endogenous Testosterone and Incident Stroke and Ischemic Changes on Brain MRI in Men in the Atherosclerosis Risk in Communities (ARIC) Cohort 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR34 6013 11:30:00 AM Testosterone Replacement Therapy: Risks and Benefits Oral


Salim Janmohamed*1, Greg Cicconetti2, Carol E Koro3, Richard V Clark4 and Elizabeth Tarka2
1GSK R&D Ltd, Uxbridge, United Kingdom, 2GSK R&D Ltd, King of Prussia, PA, 3GSK R&D Ltd, Collegeville, PA, 4GSK R&D Ltd, Research Triangle Pk, NC

 

Background:  The cardiovascular (CV) safety profile of testosterone replacement therapy (TRT) in men is uncertain, particularly in older individuals with pre-existing coronary heart disease (CHD), and has been heightened by recent retrospective analyses of observational data.1  Prior studies, including relatively small prospective clinical trials of hypogonadal men, have yielded conflicting results.  Additional data are required to address this safety concern.

Objectives and Methods:  We utilized data from two large, international, double blind, placebo-controlled randomised clinical trials evaluating the potential effect of darapladib, a lipoprotein phospholipase A2 inhibitor, on ischemic events.  Subjects were men and women with documented stable coronary heart disease (N=15,828; STABILITY2) or recent acute coronary syndrome (N=13,026; SOLID3).  Cardiovascular risk factors were managed according to ‘standard of care’, and major adverse cardiovascular events (MACE - CV death, non-fatal MI, and non-fatal stroke) were prospectively ascertained and adjudicated.  These trials were recently completed and had median follow-up periods of 3.7 and 2.5 years, respectively.  Darapladib did not significantly reduce the risk of CV events.  Cox proportional hazards modelling was used to assess the risk of MACE in men who were exposed to testosterone (< 12 months and > 12 months) compared to those not exposed to testosterone using data from both trials combined.  The models were adjusted for treatment group, age, BMI, HDL/Total cholesterol ratio, Systolic BP, GFR, diabetes, aspirin use, statin use and smoking status. 

Results: TRT use amongst male trial subjects was low (N=217, 1%) and most (83%) was by US men.  The majority of MACE events (N=1412, 57%) were myocardial infarctions.  Men exposed to TRT for less than or equal to 12 months had a hazard ratio of 0.48 (95% CI: (0.15, 1.49), p=0.21) compared to those not exposed to TRT.  Men exposed to TRT for greater than 12 months had a hazard ratio of 0.47 (95% CI: (0.25, 0.87), p=0.02) compared to those not exposed to TRT.

Conclusions:  Pooled analyses of both studies, including adjustment for potential confounders, suggest that TRT is not associated with an increased risk of MACE in men with well characterised coronary heart disease.  Despite the limitations of this retrospective analysis, including small numbers of TRT exposed men and lack of ascertainment of gonadal status, these data do not corroborate recent observational reports that testosterone therapy is associated with increased CV risk.

 

Disclosure: SJ: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. GC: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. CEK: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. RVC: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline, Employee, GlaxoSmithKline. ET: Employee, GlaxoSmithKline, Employee, GlaxoSmithKline, Employee, GlaxoSmithKline.

OR34-4 19549 4.0000 A The Association Between Testosterone Use and Major Adverse Cardiovascular Events (MACE): An Exploratory Retrospective Cohort Analysis of Two Large, Contemporary, Coronary Heart Disease Clinical Trials 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR34 6013 11:30:00 AM Testosterone Replacement Therapy: Risks and Benefits Oral


Christina Wang*1, Anthony DelConte2, Jed C. Kaminetsky3, Martin M. Miner4, Pavan Rajendra Yadav1, Srinivasan Venkateshwaran5, Nachiappan Chidambaram5, Satish Nachaegari5, Mahesh Patel5 and Adrian S Dobs6
1Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 2Saint Joseph’s University, Philadelphia, PA, 3Manhattan Medical Research, New York, NY, 4Brown University and the Miriam Hospital, Providence, RI, 5Lipocine, Inc., Salt Lake City, UT, 6Johns Hopkins University School of Medicine, Baltimore, MD

 

Introduction: TRT is indicated for treating hypogonadal men with low serum testosterone (T) levels and related symptoms. However, T products administered as topical or depot formulations are associated with inadvertent T transfer, messy application, poor retention rates, and superphysiologic T levels in some patients. There is a need for T formulations that are more user friendly, limit blood level dose excursions, and avoid T transdermal transfer. LPCN 1021 is a novel oral T undecanoate formulation being assessed in a Phase 3 trial that may avoid some of the undesirable attributes of non-oral T formulations.

Methods: SOAR is a randomized, active-controlled, 2-arm, 12-month, open-label, multicenter, dose-titration trial that included 18- to 80-year-old hypogonadal (T <300 ng/dL on 2 separate days) men. Participants were randomized to either oral LPCN 1021 (n=210) or Androgel® 1.62% (n=105). The starting dose was 225 mg LPCN 1021 BID taken with a meal. The dose could be titrated up (eg, if T Cave,24h <300 mg/dL) or down (eg, if T Cmax was >1500 mg/dL) at weeks 4 and 8 based on 24 h PK. Efficacy was assessed on week 13 based on T Cave,24h from serum samples collected over 24 h for T assayed by LC-MS/MS. Analysis was conducted using the Efficacy Population Set (subjects with ≥1 PK profile and no significant protocol deviations; N=152 LPCN 1021).

Results: LPCN 1021 reliably restored and maintained T levels in the eugonadal range (300-1140 ng/dL) in 88% of hypogonadal men (lower bound 95% CI=81.9%). Mean T Cave,24h value was 447±166 ng/dL, consistent with other non-oral TRT therapies. There was no significant dose timing effect (eg, AM vs PM), suggesting consistent intra-day performance. Overall variability was low (37% CV for Cave,24h). 82.9% of subjects had serum T peak (Cmax) <1500 ng/dL, <5% had Cmax 1800-2500 ng/dL, and only 2% had serum T levels >2500 ng/dL, and those cases were sporadic, transient, and isolated, with no associated clinical events. 85% of subjects required ≤1 dose adjustment, suggesting a safe and effective titration algorithm. 

Conclusions: LPCN 1021 is an orally administered TRT product with acceptable Cave and Cmax excursions, consistent with US FDA targets met by other non-oral TRT products. LPCN 1021 may improve patient adherence as a generally safe, effective, and more convenient option compared to topical, transdermal, injectable, or implanted TRT products.

 

Disclosure: CW: Clinical Researcher, Clarus, Consultant, Clarus, Clinical Researcher, Lipocine, Inc., Clinical Researcher, Antares, Clinical Researcher, Prolor, Consultant, Lipocine, Advisory Group Member, TesoRx. AD: Consultant, Lipocine, Inc.. JCK: Principal Investigator, AbbVie, Principal Investigator, Lipocine, Inc., Principal Investigator, Ferring Pharmaceuticals, Principal Investigator, Clarus, Principal Investigator, Antares, Consultant, Antares, Principal Investigator, Auxillium, Consultant, Auxillium, Speaker, Auxillium. MMM: Clinical Researcher, NERI, Clinical Researcher, Forest, Consultant, AbbVie, Consultant, Lipocine, Inc., Consultant, Repros. SV: Employee, Lipocine, Inc.. NC: Employee, Lipocine, Inc.. SN: Employee, Lipocine, Inc.. MP: Employee, Lipocine, Inc.. ASD: Consultant, AbbVie, Advisory Group Member, AbbVie, Advisory Group Member, Endo Pharmaceuticals, Advisory Group Member, Lipocine, Inc., Clinical Researcher, Endo Pharmaceuticals, Clinical Researcher, Clarus. Nothing to Disclose: PRY

OR34-5 20400 5.0000 A Efficacy and Pharmacokinetics of LPCN 1021, a Novel Oral Testosterone Replacement Therapy (TRT), in Hypogonadal Men: Study of Androgen Replacement (SOAR) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR34 6013 11:30:00 AM Testosterone Replacement Therapy: Risks and Benefits Oral


Arthi Thirumalai*1, Lori Cooper2, John K. Amory3, Jonathan L Wright1, Alvin M. Matsumoto4, Daniel W Lin1, Brett Marck5 and Stephanie T. Page6
1University of Washington, Seattle, WA, 2The Polyclinic, Seattle, WA, 3Univ Washington, Seattle, WA, 4VA Puget Sound Health Care System, Seattle, WA, 5VA Puget Sound, Seattle, WA, 6University of Washington and Harborview Medical Center, Seattle, WA

 

There is concern that testosterone replacement therapy (TRT) might increase the risk of prostate disease as the prostate highly expresses 5 alpha-reductase, which converts testosterone (T) to the more potent androgen dihydrotestosterone (DHT). In order to determine the effect of TRT on the intraprostatic androgen concentrations, a 12-week, randomized, placebo-controlled trial was conducted in 53 healthy men aged 25-55 years. Subjects were randomly assigned to receive placebo injections every 2 weeks and placebo transdermal gel (Control), or injections of acyline (300μg/kg every 2 weeks), a potent and rapidly acting GnRH antagonist to produce medical castration, plus testosterone gel in one of five doses: 1.25 g, 2.5 g, 5.0 g, 10 g or 15 g daily, to produce serum T levels ranging from the hypogonadal to supraphysiologic range, with 8-10 men/group. Serum T and DHT levels measured at baseline and then every 2 weeks and intraprostatic T and DHT concentrations in ultrasound-guided prostate needle biopsies at week 12 were quantified by LC/MS/MS. Comparisons between groups were performed using a Kruskal-Wallis ANOVA with Wilcoxon rank-sum post-hoc tests. Data are expressed as medians and interquartile ranges (median (25th percentile, 75th percentile)). 

There were no significant adverse events.  As expected, serum T and DHT concentrations increased with increasing doses of exogenous T (p=0.003)(range of median serum T 1.9-7.7 ng/ml, range of median serum DHT 0.6-1.8 ng/mL). In contrast, intraprostatic DHT concentrations did not significantly differ between groups (median intraprostatic DHT for all men: 4.03 ng/g (2.8, 5.34)). Interestingly, intraprostatic T concentrations, which were 5-10% of intraprostatic DHT concentrations, did differ between groups (p=0.008). Men receiving acyline and 1.25 or 2.5 grams daily of T gel had median intraprostatic T concentrations of 0.13 ng/g (0.11, 0.24) and 0.12 ng/g (0.09, 0.19) respectively vs. men receiving 15 grams of T had median intraprostatic T of 0.3 ng/g (0.22, 1.7) (p<0.01 for both comparisons). 

In summary, in healthy, medically-castrate men, intraprostatic DHT concentrations were 10-20 times higher than intraprostatic T and were relatively stable across a wide range of serum T concentrations achieved by exogenous T. Although intraprostatic T concentrations were higher with increasing doses of TRT, our results suggest that TRT within the mid-normal range of serum T concentrations does not substantially affect the intraprostatic androgen milieu, which is predominantly determined by intraprostatic DHT. These findings may have implications for the safety of treating male hypogonadism with regards to prostate health.

 

Disclosure: JKA: Investigator, Clarus, Investigator, Clarus. AMM: Principal Investigator, Abbott Laboratories, Principal Investigator, GlaxoSmithKline, Consultant, Abbott Laboratories, Consultant, Lilly USA, LLC, Consultant, Endo Pharmaceuticals, Consultant, Clarus, Editor, Up To Date. STP: Investigator, Abvie, Investigator, Besins. Nothing to Disclose: AT, LC, JLW, DWL, BM

OR34-6 19495 6.0000 A Stable Intraprostatic Dihydrotestosterone (DHT) Levels in Healthy Medically Castrate Men Treated with Increasing Doses of Testosterone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 1:00:00 PM OR34 6013 11:30:00 AM Testosterone Replacement Therapy: Risks and Benefits Oral


Casey C Nestor*1, Jian Qiu1, Stephanie L. Padilla2, Martha A. Bosch1, Wei Fan1, Richard D Palmiter2, Oline K. Ronnekleiv3 and Martin J Kelly4
1Oregon Health & Science University, Portland, OR, 2Howard Hughes Medical Institute, Seattle, WA, 3Oregon Health & Science University/Oregon National Primate Research Center, Portland/Beaverton, OR, 4Oregon Health & Science University/Oregon National Primate Research Center, Portland, OR

 

The anorexigenic pro-opiomelanocortin (POMC) and orexigenic neuropeptide Y/agouti-related peptide (NPY/AgRP) neurons in the ARC are essential for the control of energy homeostasis.   These ARC POMC and NPY/AgRP neurons receive glutamatergic input from interneurons, but the specific neuronal origins of these afferents have not been elucidated.   Interestingly, kisspeptin (Kiss1) neurons, which are essential for reproductive function, may be a source of some of the excitatory synaptic input given that the majority of ARC Kiss1 neurons co-express the vesicular glutamate transporter-2 (vGlut2).  Therefore, we hypothesized that ARC Kiss1 neurons make excitatory synaptic connections with ARC POMC and NPY/AgRP neurons.  Together with single cell RT-PCR and whole-cell electrophysiology we used an optogenetic approach, which allowed for Cre-mediated expression of a light sensitive ion channel (channelrhodopsin 2; ChR2) and fluorophore (yellow fluorescent protein; YFP) exclusively in ARC Kiss1 neurons.  Male Kiss1-Cre-GFP mice (n=16) received bilateral ARC injections of an adeno-associated viral (AAV) vector containing ChR2 (AAV-DIO-ChR2-YFP).  Initially in a subset of these mice (n = 5), we dispersed ARC cells (see Bosch et al., Mol Cell Endocrinol 2013) and harvested individual ChR2-YFP expressing cells (~30-35 cells/mouse).  Single cell RT-PCR analysis revealed that 100% of YFP neurons harvested expressed Kiss1 mRNA.  Furthermore, similar to what others have shown using dual in situ/immunocytochemistry, the majority (86%) of ARC Kiss1-YFP neurons expressed vGlut2 mRNA.  In addition,  whole-cell recordings in hypothalamic slices from AAV-DIO-ChR2-YFP ARC injected mice (n=11) revealed that optogenetic activation of ChR2-YFP cells (n = 16) with 470 nm blue light LED stimulation generated graded inward currents in voltage-clamp and depolarizations in current-clamp.  Post-hoc RT-PCR analysis revealed that 100% of YFP recorded cells expressed Kiss1 mRNA.  Subsequently, we examined post-synaptic responses in targeted non-fluorescent neurons in the ARC that were juxtaposed to Kiss1-ChR2-YFP fibers.  With optogenetic stimulation (0.5 Hz), twenty four of forty two cells (57%) showed a fast inward current (mean amplitude = 27.7 + 6 pA), which was abrogated by the AMPA and NMDA receptor blockers CNQX and AP-5 (n=5), indicative of ionotropic glutamate signaling.   Finally using RT-PCR, seven of 24 responsive neurons were identified as POMC, while six of 24 were identified as NPY neurons.    In summary, this data indicates that in adult male mice POMC and NPY/AgRP neurons receive glutamatergic afferents from ARC Kiss1 neurons, which may be a critical synaptic pathway for kisspeptin neurons to coordinate energy homeostasis and reproduction.

 

Nothing to Disclose: CCN, JQ, SLP, MAB, WF, RDP, OKR, MJK

OR32-1 20667 1.0000 A Optogenetic Stimulation of Hypothalamic Arcuate (ARC) Kiss1 Neurons Reveals Glutamatergic Input to ARC Pomc and Npy/Agrp Neurons in Male Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 1:00:00 PM OR32 6035 11:30:00 AM Obesity: Regulation of Feeding and Fat Oral


Brandon Podyma*, Min Chen, Yogendra Bhakta Shrestha, Hui Sun, Benedetta Naglieri, Yong-Qi Li, Oksana Gavrilova and Lee S. Weinstein
NIDDK, NIH, Bethesda, MD

 

The ubiquitously expressed G protein α-subunit (Gsα) mediates receptor-stimulated cAMP generation. Heterozygous inactivating Gsα mutations in Albright hereditary osteodystrophy (AHO) patients lead to early-onset obesity and insulin resistance, but only when the Gsα mutation occurs on the maternal allele (a condition referred to as pseudohypoparathyroidism type 1A, PHP1A). A similar parent-of-origin effect of Gsα mutations on obesity also occurs in mice, and we have shown that this effect is due to Gsα imprinting, with preferential expression from the maternal allele in one or more areas within the central nervous system (1). However, the brain sites at which Gsα imprinting plays an important role in the control of energy homeostasis remains undefined. We now examined the effect of loss of Gsα in the dorsomedial nucleus of the hypothalamus (DMH) on energy metabolism and glucose homeostasis by injecting AAV-Cre or AAV-GFP (negative control) virus into the DMH of male Gsα-floxed mice. Similar to what we previously observed in maternal whole-brain Gsα knockouts (mBrGsKO), heterozygotes with DMH-specific deletion of the maternal Gsα allele (AAV-Cre-injected Gsαfl/+ mice; mDMHGsKO) developed severe obesity and insulin resistant-diabetes, associated with reduced energy expenditure and impaired brown adipose tissue (BAT) activation based upon histological appearance and Ucp1 expression after cold exposure, but without increased food intake. In contrast, all metabolic parameters were normal in heterozygotes with deletion of the Gsα paternal allele (AAV-Cre-injected Gsα+/fl mice; pDMHGsKO). Homozygotes (AAV-Cre-injected Gsαfl/fl) also developed a similar phenotype, and in addition showed increased food intake during the first two weeks after injection. Whether this latter effect is secondary to complete absence of Gsα in DMH neurons or loss of Gsα in surrounding glia with secondary global effects on DMH neurons is unclear. These results provide evidence that Gsα/cAMP signaling in the DMH plays a critical role in the regulation of energy balance, primarily through the control of energy expenditure and BAT activation, as well as peripheral glucose metabolism. Our findings also suggest that Gsα is imprinted in the DMH, although this needs to be confirmed by molecular genetic studies, and that maternal Gsα deficiency in the DMH may contribute to the early-onset obesity in PHP1A patients.

 

Nothing to Disclose: BP, MC, YBS, HS, BN, YQL, OG, LSW

OR32-3 19933 2.0000 A Gs-Alpha Deficiency in the Dorsomedial Nucleus of the Hypothalamus Plays a Key Role in Obesity Associated with Gs-Alpha Mutations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 1:00:00 PM OR32 6035 11:30:00 AM Obesity: Regulation of Feeding and Fat Oral


Mark Nixon1, Kavitha Rajendran2, Nicholas John Justice1 and Rebecca Lynne Berdeaux*1
1University of Texas Health Science Center at Houston, Houston, TX, 2University of Texas Health Science Center at Houston, TX

 

The ability of brown fat to dissipate energy as heat is important not only for maintenance of body temperature but also for maintenance of metabolic homeostasis. During acute cold exposure, catecholamines signal via cAMP-mediated pathways to stimulate brown fat activity. The transcription factor CREB has been implicated positively in regulation of brown adipose tissue activity via stimulation of Ucp1 mRNA transcription. Salt inducible kinases are cAMP-regulated AMPK family kinases that are known to inhibit CREB activity through inhibition of CREB co-activators (CRTCs) in several cell types, including liver and brown adipose tissue. Among salt inducible kinases, SIK1 is unique in that it is a CREB target gene and is thought to serve as part of a feedback circuit to inhibit CREB/CRTC activity after acute activation by extracellular signals. Indeed, we found that Sik1 mRNA is strongly induced in primary brown adipocytes treated with cAMP-inducing drugs. We generated mice lacking the kinase domain of Sik1 (SIK1-KO) to test the hypothesis that Sik1 normally represses thermogenesis in brown fat via repression of CREB/CRTC activity. We found that Sik1 deletion results in markedly elevated core body temperature, coupled with reduced lipid accumulation and elevated thermogenic gene expression (Ucp1, Pgc1-alpha) in brown adipose tissue. SIK1-KO mice maintain a higher core body temperature during cold challenge, alongside a striking potentiation of the thermogenic program in brown adipose. Primary brown adipocytes isolated from SIK1-KO mice exhibited enhanced thermogenic gene expression responses to cAMP-inducing agents, suggesting that SIK1 action in brown fat is at least partially responsible for the elevated body temperature observed in knockout mice. Importantly, loss of Sik1 did not result in elevated hepatic glucose production, which is also stimulated by CREB/ CRTC2. Our data indicate that SIK1 contributes to maintenance of temperature homeostasis by restricting the thermogenic program. We propose that this may occur via a CREB/ CRTC2-dependent mechanism in the brown adipose tissue. As transplantation of brown fat has been shown to improve glucose homeostasis in mice, we suggest that SIK1 could serve as a therapeutic target to promote brown fat activity without affecting hepatic glucose synthesis.

 

Nothing to Disclose: MN, KR, NJJ, RLB

OR32-4 20527 3.0000 A Salt Inducible Kinase 1 (SIK1) Suppresses Brown Fat Thermogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 1:00:00 PM OR32 6035 11:30:00 AM Obesity: Regulation of Feeding and Fat Oral


Dana C Glicksberg, Pradip K Saha, Kimal Rajapakshe, Cristian Coarfa, Mandeep Bajaj, Lawrence C Chan, David D Moore and Sean Michael Hartig*
Baylor College of Medicine, Houston, TX

 

Subcutaneous adipose tissue can burn energy in brown-like (‘beige’) adipocytes that express Uncoupling Protein 1 (UCP1) to allow inducible thermogenesis.  These beige adipocytes exhibit increased mitochondrial function and greater oxygen consumption for fatty acid catabolism.  The enhancement of thermogenic gene programs in subcutaneous adipose tissue by beige adipocytes protects against type 2 diabetes mellitus (T2DM) and associated comorbidities, including hepatic steatosis, in rodents and likely in humans. We discovered that expression of the microRNA miR-30a is reduced in subcutaneous adipose tissue from diabetic mice and humans when compared to normal controls.  To establish the role of miR-30a in vitro, we manipulated miR-30a expression using microRNA mimics and inhibitors in human subcutaneous adipocytes.  We found that miR-30a mimics are sufficient to drive enhanced oxygen consumption and markedly stimulate the thermogenic gene program.  In contrast, inhibition of miR-30a disrupted UCP1 expression and reduced respiration.  To test the hypothesis that restoration of miR-30a expression in white adipose tissue would improve peripheral insulin insensitivity, we injected adenovirus (Adv) expressing either miR-30a or GFP directly into the subcutaneous fat pad of high fat fed insulin resistant mice.  Unilateral Adv-miR-30a overexpression did not change body weight, but modestly improved whole body glucose tolerance and markedly enhanced peripheral insulin sensitivity as assessed by insulin tolerance.  Adv-miR-30a treatment reduced serum insulin, free fatty acids, triglycerides, and increased adiponectin.  Peripheral insulin sensitivity improvements correlated with reduced hepatic steatosis, increased energy expenditure, and enhanced hepatic insulin signaling. In agreement with our in vitro findings, miR-30a supports the activation of the beige fat program in vivo as evidenced by enhanced mitochondrial biogenesis and induction of UCP1 expression.  Additional transcriptome profiling by RNA-seq indicates that the metabolic effects of miR-30a overexpression in subctaneous adipose tissue are associated with increased recruitment of T regulatory cells, which suppress local inflammation.  We conclude that miR-30a drives white to beige fat conversion, leading to improved insulin sensitivity. Increasing miR-30a action represents a novel therapeutic avenue for treating insulin resistance and T2DM.

 

Nothing to Disclose: DCG, PKS, KR, CC, MB, LCC, DDM, SMH

OR32-5 22113 4.0000 A Micro-30a Remodels Adipose Tissue Energy Metabolism to Improve Peripheral Insulin Sensitivity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 1:00:00 PM OR32 6035 11:30:00 AM Obesity: Regulation of Feeding and Fat Oral


Tuo Deng*1, Laurie J Minze1, Joey Liu2, Christopher J Lyon1 and Willa Ann Hsueh3
1The Methodist Hospital Research Institute, Houston, TX, 2Wexner Medical Center, The Ohio State University, 3The Ohio State University Wexner Medical Center, Columbus, OH

 

The adipocyte is a novel instigator of adipose inflammation during high fat diet (HFD), activating CD4+ T cells through enhanced antigen presentation (Deng, Cell Metab, 2013).  Major histocompatibility complex II (MHCII) and co-activator proteins (CD80/86) are up-regulated in both subcutaneous and visceral adipocytes of obese humans and mice. To determine the role of adipocyte MHCII in obesity-induced adipose inflammation and insulin resistance, we crossed adiponectin-cre and H2Ab1flox/flox mice to generate adipocyte-specific MHCII knockout (aMHCII-/-) mice.  At 6wks and 12wks HFD, WT and aMHCII-/-  mice gained similar weight and body fat, but aMHCII-/- mice had markedly enhanced insulin sensitivity. Adipocytes from HFD-fed aMHCII-/- mice expressed less inflammatory factors (MHCII, CD80/86, IL1b, and TNFa) and more adiponectin. WT adipocyte cultures stimulated 3-fold more CD4+ T cell activation than aMHCII-/-adipocytes. Adipose T cells of aMHCII-/- mice expressed less IFNγ and Tbet (pro-inflammatory CD4+ Th1 cell marker), but 3-fold more Foxp3, a lineage marker for anti-inflammatory regulatory T cells (Tregs).  Decreased IFNγ likely contributed to aMHCII-/- mouse Treg increases, since IFNγ dose-dependently suppressed Treg differentiation and IFNγ-blocking antibodies enhanced Treg differentiation in cultures treated with conditioned media from WT adipocyte/T cell co-cultures. We conclude that 1) adipocyte MHCII plays a major role in adipose inflammation during HFD, 2) increased adipose Treg abundance improves insulin sensitivity in aMHCII-/- mice, and 3) reduced IFNγ expression contributes to the Treg increase in aMHCII-/- mice. Thus, inhibition of the adipocyte/T cell dialogue during HFD improves insulin sensitivity and may be a therapeutic strategy in obesity-related metabolic diseases.

 

Nothing to Disclose: TD, LJM, JL, CJL, WAH

OR32-6 22110 5.0000 A An Adipocyte/T Cell Dialogue Is a Determinant of Systemic Insulin Sensitivity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 1:00:00 PM OR32 6035 11:30:00 AM Obesity: Regulation of Feeding and Fat Oral


Gang Xi*1, Xinchun Shen2, Christine Wai1, Caroline Vilas1 and David R Clemmons1
1University of North Carolina at Chapel Hill, Chapel Hill, NC, 2Nanjing University of Finance and Economics, Nanjing, China

 

Hyperglycemia leads to vascular smooth muscle cell (VSMC) dedifferentiation and enhances their response to insulin like growth factor (IGF-I). Hyperglycemia stimulated NADPH oxdiase 4 (Nox4) synthesis and its recruitment to a signaling complex that contains Src kinase. Nox4 acts locally to activate Src leading to AKT and MAP kinase pathway activation thereby enhancing IGF-I functions. To determine the mechanism by which hyperglycemia induced these changes, we analyzed the roles of p62 (sequestrosome1) and PKCζ. Hyperglycemia stimulated a 2.2 ± 0.4 fold increase (p<0.01) in p62 and a 4.9 ± 1.0 fold increase (p<0.01) in p62/PKCζ association. This resulted in an increase of PKCζ enzymatic activity and activation of PKCζ could only be detected if it was associated with p62. Disruption of PKCζ/p62 association using a competitive peptide inhibitor or p62 knockdown inhibited PKCζ activation. The kinase responsible for PKCζ activation was determined to be PDK1. As for PKCζ, PDK1 was recruited to the p62 complex in response to hyperglycemia and directly phosphorylated PKCζ leading to its activation. Pre-incubation with a PDK1 inhibitor prevented high glucose-induced PKCζ activation. Subsequently activated PKCζ phosphorylated the signaling protein p65rel (serine 311) which led to NF-kappaB activation and Nox4 synthesis. Disruption of PKCζ/p62 complex formation either via a disrupting peptide or p62 silencing significantly impaired NF-kappaB pathway activation. In vivo studies confirmed these findings and showed that disruption of PKCζ/p62 attenuated the ability of hyperglycemia to stimulate PKCζ activation, p65rel Ser 311 phosphorylation and Nox4 synthesis in diabetic mice. These results define the molecular mechanism by which PKCζ is activated in response to hyperglycemia and suggest that this could be a mechanism by which other stimuli such as cytokine activation or high fat diets function to stimulate NF-kappaB activation thereby altering cellular sensitivity to peptide growth factors.

 

Nothing to Disclose: GX, XS, CW, CV, DRC

OR33-1 21260 1.0000 A Hyperglycemia Stimulates p62/Pkcζ Interaction Which Mediates NF-Kappab Activation and Nox4 Expression in Vascular Smooth Muscle 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 1:00:00 PM OR33 5949 11:45:00 AM Regulation and Dysregulation of Signaling Networks Oral


David N Boone*1 and Adrian V. Lee2
1University of Pittsburgh, 2University of Pittsburgh, Pittsburgh, PA

 

Evidence suggests that insulin-like growth factor 1 (IGF1) signaling is involved in the initiation and progression of a subset of human breast cancers by inducing cell proliferation and survival. Although the signaling cascade following IGF1 receptor activation has been well studied, the key elements of the transcriptional response and the molecular mechanisms governing IGF1’s actions are not well understood. ENCODE and other ‘omics’ studies recently revealed that the majority of the genome is transcribed. In fact, there are more long non-coding RNAs (lncRNAs) than protein coding genes and several of these are deregulated in human cancer. However, the studies to determine the mechanisms of how these lncRNAs are regulated and function are in their infancy. Here we show through RNAseq following IGF1 stimulation of serum starved MCF7 breast cancer cells that IGF1 signaling significantly (FDR<0.05) regulates the expression of 181 and 241 putative lncRNAs at 3 and 8hrs respectively, with 94 being regulated at both times.  Two of the top five most highly expressed and consistently regulated lncRNAs are SNHG7 and SNHG15, which are members of the small nucleolar host gene family. Interestingly, while we show that SNHG15 expression is induced by IGF1 signaling, we demonstrate that IGF1 signaling decreases SNHG7 expression by a post-transcriptional mechanism through the MAPK pathway. We further demonstrate with four independent siRNA duplexes that SNHG7 is necessary for proliferation of breast cancer cell lines in a dose-dependent manner. We observed that silencing SNHG7 expression stimulates cell cycle arrest in G0/G1 without a significant change in cell death by preventing the upregulation of IGF1 transcriptional targets without altering the IGF1 signaling cascade or the downregulation of transcriptional targets. Moreover, constitutive overexpression of either of the two dominant isoforms of SNHG7 enhanced proliferation. Finally, we show with TCGA data that SNHG7 is overexpressed in the tumor cells of a subset of breast cancer patients and that these patients have lower overall survival than patients without elevated SNHG7 expression. Therefore, we propose that SNHG7 is a putative lncRNA oncogene that is controlled by growth factor signaling in a feedback mechanism to prevent hyperproliferation, and that this regulation can be lost in the development or progression of breast cancer.

 

Nothing to Disclose: DNB, AVL

OR33-2 21152 2.0000 A SNHG7 Is an Insulin-like Growth Factor (IGF1) Regulated Long Non-Coding RNA Necessary for Proliferation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 1:00:00 PM OR33 5949 11:45:00 AM Regulation and Dysregulation of Signaling Networks Oral


Da Young OH*, Evelyn Walenta, Vivian A Paschoal and Armen Abagyan
University of California San Diego, La Jolla, CA

 

We previously reported that the G protein-coupled receptor 120 (GPR120) functions as a receptor for the omega-3 fatty acids (FAs), DHA and EPA. Stimulation of GPR120 with omega-3 FAs or a recently published small molecule agonist (compound A; cpdA), causes inhibition of TNF-α and lipopolysaccharides (LPS)-induced inflammatory signaling responses in primary macrophages. In addition to direct anti-inflammatory effects in macrophages, we have found that inflammatory macrophage infiltration into adipose tissue is significantly reduced in wild type (WT) mice on omega-3 FAs or cpdA-admixed diet compared with GPR120 knockout (KO) mice. DHA/cpdA treatment inhibited the ability of primary WT macrophages to migrate towards adipocyte condition medium as well as specific chemoattractant, monocyte chemotactic protein-1 (MCP-1). Activation of GPR120 causes blunted MCP-1-induced actin reorganization in macrophages which is necessary step for macrophage chemotaxis. These effects proceed through heterologous desensitization of CCR2, MCP-1 receptor by GPR120 stimulation in response to DHA or cpdA. GPR120 and CCR2 interact with each other after DHA or cpdA stimulation and then inhibits CCR2-mediated signaling pathway which can lead to inflammatory response. All of these effects are abrogated by GPR120 KO. To dissect more in detail about GPR120 signaling pathway in these effects, we have used G protein-coupled receptor kinase 5 (GRK5) KO mice and beta-arrestin 2 KO mice which are upstream molecules of GPR120 signaling pathways. Both of knockout animals show phenocopy of GPR120 KO mouse that blunted GPR120-mediated anti-inflammatory/insulin sensitizing effects upon GPR120 stimulation. In conclusion, GPR120 activation by omega-3 FAs or cpdA causes decreased macrophage chemotaxis, contributing to the drastic decreases in adipose tissue macrophage content and mediates potent anti-inflammatory/insulin sensitizing effects.

 

Nothing to Disclose: DYO, EW, VAP, AA

OR33-3 18944 3.0000 A Mechanism of Omega-3 Fatty Acid Receptor, GPR120 Signaling in Insulin Resistance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 1:00:00 PM OR33 5949 11:45:00 AM Regulation and Dysregulation of Signaling Networks Oral


Sarah A Howles1, M Andrew Nesbit2, Fadil M Hannan1, Angela Rogers1, Sian E Piret1, Treena Cranston3, Mushtaqur Rahman4 and Rajesh V Thakker*1
1University of Oxford, Oxford, United Kingdom, 2Ulster University, Ulster, United Kingdom, 3Oxford Molecular Genetics Laboratory, Churchill Hospital, Oxford, United Kingdom, 4London North West Healthcare NHS Trust, United Kingdom

 

The calcium-sensing receptor (CaSR) is a guanine-nucleotide-binding protein (G-protein)-coupled receptor (GPCR) that has a central role in calcium homeostasis. Loss-of-function mutations of the CaSR result in familial hypocalciuric hypercalcemia type 1 (FHH1) and loss-of-function mutations in the CaSR-associated G-protein subunit Gα11 cause FHH2; however, only two coding mutations in GNA11 have been reported to date. Therefore, the aim of our study was therefore to ascertain if mutations of the non-coding regions of GNA11 also cause FHH2. DNA sequence analysis of the 12 exon-intron boundaries and 5’ untranslated region (UTR) of GNA11 was undertaken in a cohort of 25 unrelated hypercalcemic patients who had neither CaSR mutations nor coding-region mutations of GNA11. This identified a 40-basepair deletion in the 5’UTR in one patient, encompassing positions -43 to -4 with respect to the translation-initiation codon (ATG), of GNA11. To investigate the effect of this mutation on translation, luciferase (luc) reporter expression vectors were constructed containing luc under the control of either the wild-type (WT) GNA11 promoter and 5’UTR or the WT GNA11 promoter and mutant 5’UTR. Transient transfection of HEK293 cells stably expressing the CaSR with these constructs demonstrated that the mutant 5’UTR sequence resulted in >85% reduction in luciferase activity from the mutant-5’UTR construct when compared to the WT-5’UTR construct (luciferase activity fold-change WT=219.5±19.06, mutant-5’UTR=29.95±7.14; p<0.0001, n=6 experiments). Furthermore, Western blotting and densitometry of cell lysates using protein extracted from patient and normal (control, WT) lymphoblastoid cells transformed by Epstein-Barr virus (EBV) demonstrated a >50% reduction in Gα11 protein expression in the affected patient cells when compared to WT cells (relative density WT=1.25±0.40, mutant-5’UTR deletion=0.54±0.27; p<0.005, n=5 experiments). Quantitative polymerase chain reaction, using RNA extracted from the patient and normal (control, WT) EBV-transformed lymphoblastoid cells, demonstrated that the deletion-mutation had no effect on GNA11 transcription. In summary, the FHH2-associated 40bp deletion in the 5’UTR of GNA11 does not effect transcription but significantly decreases the translational efficiency of Gα11. Threrfore, these findings indicate that FHH2 may be due to haploinsufficiency as a reduction in Gα11 expression is sufficient to cause a hypercalcemic phenotype. These studies of the first non-coding FHH2-causing mutation in GNA11, provide new insights into the role of Gα11 in CaSR signalling and the mechanisms causing FHH2.

 

Nothing to Disclose: SAH, MAN, FMH, AR, SEP, TC, MR, RVT

OR33-4 19756 4.0000 A A Mutation in the 5'UTR of GNA11 Causes Familial Hypocalciuric Hypercalcemia Type 2 (FHH2) Due to Reduced Translational Efficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 1:00:00 PM OR33 5949 11:45:00 AM Regulation and Dysregulation of Signaling Networks Oral


Francesca Marta Elli*1, Valentina Boldrin2, Lorenza Lazzari3, Valentina Parazzi3, Paolo Bordogna4, Anna Spada5 and Giovanna Mantovani6
1University of Milan; Fond IRCCS Ca' Granda Policlinico, Milano, Italy, 2IRRCS Cà Granda H Maggiore Policlinico, 32Cell Factory, Unit for Cellular Therapy and Cryobiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, 4IRCCS Cà Granda H Maggiore Policlinico, Milano, Italy, 5IRCCS Cà Granda H Maggiore Policlinico, Milan, Italy, 6Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy

 

The GNAS locus is a complex imprinted transcriptional unit, encoding different transcripts including the α subunit of the stimulatory G protein (Gsα), a key element of the cAMP-mediated signal transduction pathway. GNAS defects (epi/genetic) have been associated with a heterogeneous group of rare and highly desabling metabolic diseases, collectively termed as Pseudohypoparathyroidism.

Most GNAS-based disorders have the common feature of episodic de novo formation of heterotopic ossifications (HO) in skin and subcutaneous fat. The mosaic  tissue distribution of HO suggests that pathogenesis involves an abnormal differentiation of mesenchymal stem cells (MSCs) and/or more committed precursor cells, and that GNAS defects provide a sensitized background, but the molecular mechanism is still under investigation.

To date, investigations have been mainly conducted in mouse models, thus this project aims to develop an in vitro human model to study the determinants underlying HO formation in GNAS-related diseases.

We set up our in vitro model of hMSCs from surgically removed samples of subcutaneous fat (adipose-derived MSCs, ADMSCs). Flow cytometric analysis showed a cell surface antigen profile characteristic of mesenchyme-derived adult stem cells. The multilineage in vitro differentiation ability of ADMSCs was confirmed via biochemical assays, specific stainings and the expression analysis of specific markers. We also determined by MS-MLPA the preservation of GNAS imprinting profile during cell culture and handling.

Then, ADMSCs were treated with siRNAs against Gsα –specific or non-specific GNAS transcripts, and harvested at specific time points to evaluate the efficiency of transfection (ranging from about 75% at day 4, up to about 50% at day 21) and the effect on cell differentiation toward osteoblasts (OB). No significant differences due to different siRNA target sequences were observed. The increase of phosphatase alkaline activity reflects cell maturation and non-induced silenced cells displayed an intermediate phenotype between cells grown in control and inducing medium (Abs 405nm at day 14: silenced=0.507±0.16, control=0.076±0.01, induced=0.861±0.13, p<0.05). Moreover, Gsα-deficient cells, although not able to completely differentiate and depose mineralized matrix, began to lay down few, interspersed and very small calcium deposits.  

Future experiments will connect HO formation with aberrant modulation of osteogenic/adipogenic stimuli in hMSCs by large scale genes expression analysis. Moreover, the ability of hMSCs to produce microvesicles, a preferential route to modulate cellular crosstalk, and their content, cytokines and microRNAs, will be tested, in the attempt to expand our knowledge in molecular mechanisms underlying HO formation in GNAS-related disorders and to test pharmacological treatments against HO formation and progression.

 

Nothing to Disclose: FME, VB, LL, VP, PB, AS, GM

OR33-5 21898 5.0000 A Ectopic Ossification in GNAS-Related Disorders: Effect of GNAS Transcript Manipulation on Human Mesenchimal Stem Cells Differentiation Towards Osteocyte Cell Lineage 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 1:00:00 PM OR33 5949 11:45:00 AM Regulation and Dysregulation of Signaling Networks Oral


Jianmei Yang*1, Wenbin Chen2, Xu Zhang2 and Jiajun Zhao2
1Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, Shandong, 2Shandong Provincial Hospital affiliated to Shandong University, Jinan, China

 

Previous studies shows that elevated serum triglycerides levels are detrimental to health. However, it is unclear whether there is an association between elevated serum triglycerides levels and pituitary hormones, and whether cholesterol has a synergistic interaction with triglycerides. We here investigated the effect of triglycerides accumulation on pituitary hormones using in vivo animal and epidemiological studies. In animal experiment, we assigned Sprague-Dawley rats to three diets for 28 weeks: control (6% fat and 0% cholesterol); high-fat (HF; 21% fat and 0% cholesterol) and high-fat, high-cholesterol (HFHC; 21% fat and 1% cholesterol). Serum levels of thyrotropin (TSH), luteinizing hormone (LH) and follicle- stimulating hormone (FSH), which are produced by the basophilic cells of anterior pituitary, were elevated in a time-dependent manner in rats fed with HF or HFHC diet, but there was no any difference between HF and HFHC diet. TSH levels seemed sensitive to excess lipid exposure and exhibited the first to undergo a significant change, while adrenocorticotropin (ACTH), another hormone of basophilic cells, was bluntness and only a mild decrease. Following fed time longer, the triglycerides deposition increased gradually in the pituitary, meanwhile, those basophilic cells became hyperplasia. A corresponding increase in the protein levels of β-subunit controlling the hormone specificity and activity, especially TSHβ, FSHβ and LHβ. Strangely, there was also no any difference between HF and HFHC diet in these protein levels. In our epidemiological study, we tested the similar elevation of serum TSH, LH and FSH, and the decrease in ACTH in the patients with isolated hypertriglyceridemia and combine hypertriglyceride-hypercholesterolemia together, as the similar as the animal study, there was no any difference between these two hyperlipidemia groups in these hormone levels. Taken together, these results indicated that hypertriglyceridemia affected the levels of hormones derived from anterior pituitary basophilic cells, and cholesterol has no synergistic interaction with triglycerides.

 

Nothing to Disclose: JY, WC, XZ, JZ

19725 1.0000 SAT-463 A Hypertriglyceridemia Affects the Levels of Hormones Derived from Anterior Pituitary Basophilic Cells, Cholesterol Has No Synergistic Interaction with Triglycerides 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Nidhi Bansal*1, Prashant V Nadkarni2 and Ruban Dhaliwal1
1SUNY Upstate Medical University, Syracuse, NY, 2SUNY Upstate Medical University, Manlius, NY

 

Introduction:  Empty Sella Syndrome occurs when subarachnoid space herniates into the sella turcica, filling it with cerebrospinal fluid and causing enlargement of sella turcica and flattening of pituitary gland. It can be classified into primary and secondary empty sella. Primary Empty Sella results from congenital incompetence of diaphragmatic sella. Secondary Empty Sella can be caused by trauma, surgery for pituitary pathologies, radiotherapy or infections. Literature suggests that endocrine dysfunction associated with this condition varies widely.

Objective:  To assess the prevalence and etiology of Empty Sella and associated hormonal abnormalities at a tertiary care center.

Methods: Medical chart review of patients admitted at SUNY Upstate Medical University and affiliated outpatient centers from 1998 to 2013. We collected demographic, clinical, laboratory and imaging data.

Results: A total of 15 patients had diagnosis of Empty Sella documented in medical records and all diagnoses were confirmed by reviewing corresponding radiological studies (CT/MRI). 73% (11 out of 15) patients had Primary Empty Sella and 26% (4 patients) had secondary etiology. 33% (5) of these patients had a partial Empty Sella. Hormonal abnormalities associated with Empty Sella were seen in 47% (7) patients, out of which 4 patients had primary etiology.  Most common hormonal dysfunction was hypogonadotropic hypogonadism in 26.6% (4) patients, followed by central hypothyroidism in 20% (3), central adrenal insufficiency in 20% (3) and central diabetes insipidus in 13.3 % (2) cases. 13.3% (2) patients had panhypopituitarism (> 3 hormone deficiencies) and both of these patients had diabetes insipidus. None of these patients had low IGF-1 level.

Conclusion: Empty Sella Syndrome, itself as a diagnosis, is a rare entity. However, the incidence of endocrine dysfunction associated with the Empty Sella is high. Clinicians should have high index of suspicion for hormonal evaluation and subsequent adequate treatment of symptomatic patients with the diagnosis of Empty Sella

 

Nothing to Disclose: NB, PVN, RD

19276 4.0000 SAT-466 A Clinical Importance of Being “Empty” 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Pinar Kadioglu1, Asli Sezgin Caglar1, Aysegul Kapucu2, Kadriye Akgun Dar2, Hande Mefkure Ozkaya*1, Erkan Caglar1 and Haluk Ince3
1Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey, 2Faculty of Science, University of Istanbul, Istanbul, Turkey, 3Council of Forensic Medicine, Istanbul, Turkey

 

Aromatase is a key enzyme in estrogen synthesis from androgens. Although aromatase expression has been demonstrated in animal and human pituitary gland, few data exist about its cellular localization and function. İn this study we aimed to evaluate aromatase expression on PRL, TSH and GH secreting cells and elucidate its possible indirect role on the regulation of these hormones. Non tumoral human pituitary specimens (15 females; 35 males, mean age: 38.9 ± 14.0 years) were obtained from autopsy samples of 50 patients dead from non endocrine causes. Aromatase co-expression on PRL, GH, TSH producing cells was determined by double immunostaining and assessed semi-quantitatively by H score. H scores for GH-aromatase co-expression (GH-aromatase), PRL-aromatase co-expression (PRL-aromatase), and TSH -aromatase co-expression (TSH-aromatase) were calculated as 83.1±13.1, 95.6±16.1, and 83.7±14.5, respectively. Of three cell types studied TSH  producing cells exhibited the highest H score for co-expression of aromatase (p <0.0001). There was no gender difference in terms of H scores for  aromatase expression and double immunostaining results (p> 0.05 for all, Data not shown). There was a negative correlation between the H scores for aromatase and PRL-aromatase, GH-aromatase, TSH -aromatase respectively (r=-0.592, p<0.001; r=-0.593, p<0.001; r=-0.650, p<0.001 respectively). Also H scores for aromatase co-expression of each hormone were negatively correlated with the H scores for the corresponding hormone (r= - 0.503, p<0.001 for PRL-aromatase and PRL; r= -0.470, p<0.001 for GH-aromatase and GH; r= -0.641, p<0.001 for TSH-aromatase and TSH). H scores for mean aromatase, GH-aromatase, TSH-aromatase were invariant of age  (p> 0.05 for all , Data not shown). The age was negatively correlated with PRL-aromatase H score (r= -0.373, p=0.008). In conclusion, our study demonstrates, for the first time, via immunohistochemical double staining, significant aromatase co-expression in PRL, GH, TSH secreting cells of the human anterior pituitary gland. The mutual paracrinal regulation  between aromatase and three adenohypophyseal hormones studied indicates that aromatase may have a regulatory role on the synthesis and secretion of these hormones.

 

Nothing to Disclose: PK, AS, AK, KA, HMO, EC, HI

19315 5.0000 SAT-467 A Localization of the Aromatase Enzyme Expression in Human Pituitary Gland and Its Effect on Ghrowth Hormone, Prolactin, Thyroid Stimulating Hormone Axis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Milena Caccelli*1, Andrea Glezer2, Marcello D Bronstein3 and Thais P Sickler4
1Unidade de Neuroendocrinologia da Disciplina de Endocrinologia e Metabologia, HC-FMUSP, Sao Caetano do Sul -SP, Brazil, 2Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School., Sao Paulo, Brazil,, Sao Paulo, Brazil, 3University of São Paulo Medical School, São Paulo, Brazil, 4Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School., Sao Paulo, Brazil

 

Prolactinoma, which incidence is higher in young women, is an important cause of hypogonadism and infertility. Medical treatment, meaning dopamine agonist (DA), promotes hormonal control and tumor volume decrease in more than 80% of the cases. As there more data on bromocriptine inducing pregnancy is available as compared to cabergoline , this is still the DA of choice for women desiring pregnancy. Most cases concern patients harboring micro and intrasselar macroprolactinomas, in whom DA frequently is withdrawal after pregnancy confirmation. Nevertheless, data regarding pregnancy induced by cabergoline is increasing. We described 20 pregnancies induced by cabergoline in 19 women harboring prolactinomas (8 micro and 11 macro). Mean age at pregnancy diagnosis was 33 yrs and mean time of previous CAB use was 46.8 months. CAB mean dose at pregnancy was 1 mg/w and drug was withdrawal at 6 to 40 (mean 6) weeks of pregnancy. Three patients used the drug during all pregnancy.  Three preterm and 14 births at term were observed. Children age currently varied between 4 months and 15 yrs. After delivery, serum PRL levels varied from 15.5 to 167 ng/mL. All patients except three had to return to CAB after stop nursing, nevertheless a lower dose was introduced in three. Sellar imaging pointed to tumoral disappearance (36%) or significant reduction (27%). Our data confirmed previous studies pointed to a safety profile of cabergoline in inducing pregnancy. However, more data are necessary to counterpart cabergoline to bromocriptine in this field

 

Nothing to Disclose: MC, AG, MDB, TPS

21798 6.0000 SAT-469 A Pregnancies in Women Harboring Prolactinoma Treated with Cabergoline :Experience from One Single Center 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Larisa Suturina*1, Ludmila Lazareva1, Alina Atalyan1, Leonid Sholohov1 and Daria Lizneva2
1The Scientific Center for Family Health and Human Reproduction Problems, Irkutsk, Russian Federation, 2Scientific Center of Family Health and Human Reproduction, Irkustk, Russia

 

Evidence of the effects of modern low dose oral contraceptives (OCs) on prolactin levels in normoprolactinemic and hyperprolactinemic patients, and data regarding the prevalence of hyperprolactinemia in young users of hormonal contraception, is limited. The objective of this study was to determine the prevalence of hyperprolactinemia and its subtypes in young starters of OCs and investigate the changes in serum prolactin levels with its use. We performed a cross-sectional study in a group of students identified via a public campaign that offered free contraceptive advice, with a subsequent one-year follow-up. Three major Eastern Siberia Universities participated in the current study. Clinical assessment and serum prolactin assays were performed at 0, 3, 6, and 12 months (normal value ≤ 490 mIU/ml). A total of 305 young women (mean age 21.5±2.9 years, BMI 20.5±2.7 kg/m2) were enrolled for a cross-sectional study. The prevalence of hyperprolactinemia was 22 % (n=66) in the whole study group: 1.9% (n=6) had prolactinomas (2342.3±745 mIU/ml), 16.1 % (n=49) had idiopathic hyperprolactinemia (773.1±358.4 mIU/ml), 3.6 % (n=11) had secondary causes of hyperprolactinemia (977.5± 465.8 mIU/ml): in 2.0% (n=6) hyperprolactinemia was associated with an isolated TSH elevation, in 1.7 % (n=5) associated with PCOS.  A total of 270 of women: 18.5 % with hyperprolactinemia (n=50) and 81.5 % - normoprolactinemic (n=220) who agreed to use oral contraception and had no contraindications were enrolled in the follow-up study. Patients with prolactinoma were excluded.  By the 6 and 12 month in the group with hyperprolactinemia there were  21 (42% of included) and 9 (18%) women, in the group of normoprolactinemic women -   66 (30%) and 34 (15.5%), respectively. There was no significant change in prolactin level in normoprolactinemic patients at 3, 6, and 12 months; 22 hyperprolactinemic women (71%) had a decrease in serum prolactin  by the 3rd month  compare to baseline (756.9±364.9 vs 471.2 ±156.6, pW=0.0001). In contrast, 29 % (n=9) of women with an initially elevated prolactin demonstrated an increase in prolactin with OC use compare to pretreatment levels (753.1±277.8 vs 955.8±357.2, pW=0.01, 0-3 month). We conclude that elevated serum prolactin is a common finding in young adults seeking contraceptive advice; and the use of OCs is not associated with an increase in prolactin levels in normoprolactinemic and majority of hyperprolactinemic patients.

 

Disclosure: LS: Advisory Group Member, Pfizer, Inc., Advisory Group Member, Bayer Schering Pharma, Advisory Group Member, Abbott Laboratories. LL: Independent Contractor (including contracted research), Bayer Schering Pharma, Independent Contractor (including contracted research), Abbott Laboratories. DL: Advisory Group Member, Dr Reddis. Nothing to Disclose: AA, LS

21977 7.0000 SAT-470 A Hyperprolactinemia in Combined Oral Contraception Users: The Prevalence and Follow-up Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Han-Hyuk Lim*
Chungnam National University School of Medicine, Daejeon, Korea, Republic of (South)

 

Aims: To determine the serum concentrations of anti-Müllerian hormone (AMH) and inhibin B in girls with and without early sexual maturation, and investigate possible changes of AMH and inhibin B release after treatment with a gonadotropin releasing hormone agonist (GnRHa) in normal weight or overweight girls with central precocious puberty (CPP).

Methods: Seventy-nine girls with CPP and 15 bone age-matched controls without signs of puberty were recruited for this study. We obtained their age, height, parental height, bone age, and pubertal status from their medical records. All participants underwent a GnRH stimulation test. Venous fasting blood samples before and after 6 months of treatment with a GnRHa were collected to measure serum levels of luteinizing hormone (LH), follicle stimulation hormone (FSH), estradiol, progesterone, AMH, and inhibin B.

Results No significant difference in serum levels of AMH was found between the two groups (CPP vs Controls; 6.0 ± 3.7 vs 6.6 ± 2.2 ng/mL, P = 0.266). In girls with CPP, peak LH levels (r2 = 0.070, P = 0.029) and peak FSH (r2 = 0.168, P = 0.001) were inversely correlated with serum levels of AMH. Peak FSH levels (r2 = 0.145, P = 0.042) were negatively correlated and serum estradiol levels (r2 = 0.191, P = 0.016) were positively correlated with serum levels of inhibin B. In girls with CPP, serum levels of AMH (P = 0.003), inhibin B (P < 0.001), basal FSH (P < 0.001), and estradiol (P = 0.001) were significantly reduced after 6 months of treatment with GnRHa. Serum levels of AMH (P = 0.003) and inhibin B (P = 0.001) were reduced by GnRHa treatment in girls with normal-weight CPP, not in over-weight and obese.

Conclusions: AMH concentrations were not association with early sexual maturation. Our results suggests a direct or indirect link between gonadotropin, AMH and inhibin B, and adiposity in girls with CPP..

 

Nothing to Disclose: HHL

19132 8.0000 SAT-471 A Serum Anti-Müllerian Hormone and Inhibin B in Normal Weight and Overweight Girls with Central Precocious Puberty after GnRH Agonist Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Shintaro Iwama*1, Naoko Iwata2, Yoshihisa Sugimura2, Kohtaro Nakashima2, Seiji Takeuchi2, Hiroshi Takagi2, Hiroshi Arima2, Teruhiko Koike1, Yoshiharu Oshida1, Patrizio Caturegli3 and Yutaka Oiso2
1Nagoya University, Nagoya, Japan, 2Nagoya Univ Grad Schl of Med, Nagoya, Japan, 3Johns Hopkins University, Baltimore, MD

 

Pituitary antibodies are measured in patients to estimate the presence of autoimmune reactions against the pituitary gland. Several methods have been used to detect serum pituitary antibodies, but most commonly indirect immunofluorescence (IIF). This method has yielded variable results, in part explainable by the use of pituitary gland substrates from different species. Recently, we reported that pituitary gland substrates from humans offer greater sensitivity and specificity than Rhesus monkey, dog, or mouse substrates (1). Rat pituitary, naturally easier to obtain than human pituitary, is the substrate most widely used in Japan for the detection of pituitary antibodies. We tested the serum from six patients with biopsy-proven lymphocytic hypophysitis (lymphocytic adenohypophysitis [n = 3], lymphocytic panhypophysitis [n = 3]) on both human and rat pituitary substrates. Fresh frozen sections were prepared from autopsy human pituitaries or male Sprague-Dawley rat pituitaries, and then fixed in acetone. Autofluorescence from human pituitary sections were suppressed by Sudan black b staining, as we previously reported (1-3). All six sera were shown to contain pituitary antibodies when tested on human pituitary sections, but were negative on rat pituitary sections. These results indicate that the human pituitary gland is a better substrate than the rat pitutiary gland for the detection of pituitary antibodies, suggesting the existence of species-specific antigenic epitopes. The results also suggest that the use of rat pitutiary substrates underestimates the prevalence of pituitary autoimmunity, highlighting the need for the development of new detection methods.

 

Nothing to Disclose: SI, NI, YS, KN, ST, HT, HA, TK, YO, PC, YO

18976 9.0000 SAT-472 A Comparison of Human and Rat Pituitary Gland Substrates for the Detection of Serum Pituitary Antibodies in Patients with Biopsy-Proven Lymphocytic Hypophysitis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


YangJong Lee*1, Jin Mo Cho2, Cheol Ryong Ku3, Wonjin Kim3, Sun Ho Kim3 and Eun Jig Lee4
1Yonsei University, Seoul, Korea, Republic of (South), 2Ajou University School of Medicine, Korea, Republic of (South), 3Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 4Yonsei University College of Medicine, Korea, Republic of (South)

 

Recent studies suggest that aberrant microRNA expression is common in numerous malignancies. Although miR-338-3phas been implicated in several gastrointestinal cancers, its role in pituitary adenoma is unknown. In this study, we evaluated the role of miR-338-3p on GH secreting pituitary adenoma. Prolactin and growth hormone level in rat pituitary GH-producing (GH3) cells were markedly down-regulated after inhibition of miR-338-3p, however, miR-338-3p and prolactin level was highly up-regulated after estrogen (E2) treatment. These results demonstrate that miR-338-3p affects hormonal system of GH3 cells and compensate for the tumorigenic condition. Same pattern of these results is also shown in human pituitary adenoma tissue. miR-338 targeted pituitary tumor transforming gene (Pttg), which is an important paracrine growth factor involved in early lactotrope transformation and early onset of angiogenesis in pituitary hyperplasia. Our findings provide the evidence of tumor suppressor function of miR-338-3p in pituitary adenoma in acromegalic patients and highlight the concurrent effect of compensation in the pathogenesis of pituitary adenoma.

 

Nothing to Disclose: YL, JMC, CRK, WK, SHK, EJL

21671 10.0000 SAT-473 A MiR-338-3p As a Tumor Suppressor through Pttg Modulation in GH3 Cell Lines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Kamal A S Al-Shoumer*1, Vasanthy S Nair2 and Aida H Ali2
1Kuwait University/Faculty of Medicine, Division of Endocrinology, Safat, Kuwait, 2Faculty of Medicine, Kuwait University, Safat, Kuwait

 

INTRODUCTION:  Age-related changes and anthropometric relations of chromogranin A (CgA) levels in normal female subjects are unknown. This study aimed to investigate the changes of chromogranin A with advances in age in normal female subjects.

SUBJECTS & METHODS: A random sample of 140 normal female subjects, aged between 20-69 years, was studied. Subjects were included into the study if they were not taking any medication and were not known to have any illness for at least 12 months. After taking baseline anthropometry, an overnight fasting blood was collected for the measurement of CgA (by ELISA). Body composition was then assessed using dual-energy X-ray absorptiometry (DXA) machine (lunar prodigy). From the DXA, we calculated % body fat (BF), % lean body mass (LBM) and % bone mineral content (BMC).

RESULTS: The (mean±SEM) age and BMI of the studied females were 44±1 years and 28.8±0.5 kg/m2, respectively. Subjects were stratified based on age-decades into 5 groups (group 1, n=29, aged 20-29 years; group 2, n=19, aged 30-39; group 3, n=42, aged 40-49; group 4, n=35, aged 50-59; and group 5, n=15, aged 60-69). As age advanced from group 1 to group 5, BMI (p=0.0001), waist (p=0.0001) and % BF (p=0.0008) demonstrated significant positive trends, whereas height (p=0.0117), % LBM (p=0.0052), and % BMC (p=0.0001) demonstrated significant negative trends. The mean CgA level for the whole groups was 4.83±0.63 ng/ml. CgA demonstrated a non-significant negative trend as age advanced (group 1: 6.02±2.10, group 2: 5.99±2.30, group 3: 4.87±0.85, group 4: 3.77±0.89, group 5: 3.62±1.26ng/ml). However, log transformation of CgA demonstrated a significant negative correlation with % BF (Rho= -0.22, p= 0.029), and a significant positive correlation with % LBM (Rho= 0.20, p= 0.029). It demonstrated no relation with waist, weight, BMI, BMC, nor with age.

CONCLUSION: Age-related changes in serum CgA concentration are determined by changes in components of body composition, namely % LBM and % BF.

 

Nothing to Disclose: KASA, VSN, AHA

19092 11.0000 SAT-474 A Relationship of Serum Chromogranin (A) Level with Age and Anthropometric Parameters in Normal Female Subjects 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Bruno Ramos-Molina* and Iris Lindberg
University of Maryland-Baltimore (UMB), Baltimore, MD

 

FAM20C is a secretory kinase responsible for the phosphorylation of multiple secreted proteins in mammalian cells; it has been shown to phosphorylate serine residues within many different bone proteins. In this work we demonstrate that FAM20C phosphorylates threonines within the N-terminal domain of the neuroendocrine chaperone 7B2. Analysis of the primary sequence of 7B2 revealed that three threonine residues in its N-terminal domain are located within FAM20C consensus motifs: Thr73, Thr99 and Thr111. The individual substitution of Thr73 and Thr111 residues by neutral alanines caused a marked decrease in the total phosphorylation levels of 7B2. Furthermore, the phosphomimetic substitution of Thr111 by Glu clearly reduced the ability of 7B2 to activate proPC2 in 7B2-lacking SK-N-MC neuroblastoma cells, suggesting that the phosphorylation of this residue critically impacts the 7B2-proPC2 interaction. However, the phosphomimetic mutation did not alter 7B2’s ability to function as an anti-aggregant for human islet amyloid polypeptide. FAM20C-mediated phosphorylation of a common alternatively-spliced variant of human 7B2 that lacks Ala100 (thus removing the Thr99 phosphorylation consensus site) was similar to the Ala-containing protein, but this variant did not activate proPC2 as efficiently as the Ala-containing protein. While threonines within 7B2 were phosphorylated efficiently, FAM20C was incapable of performing the well-known regulatory threonine phosphorylation of BiP, suggesting that the FAM20C kinase is not responsible for this modification. Taken together, these results indicate that FAM20C plays a role in 7B2-mediated proPC2 activation by phosphorylating residue Thr111; and that 7B2 function is regulated by alternative splicing.

 

Nothing to Disclose: BR, IL

19102 12.0000 SAT-475 A Phosphorylation of the Neuroendocrine Chaperone 7B2 By the Secretory Kinase FAM20C As a Novel Mechanism of Regulation for Prohormone Convertase 2 Activation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Alan Scott Sacerdote*1, Gul Bahtiyar2, Grazyna Kaluta3, Judith Giunta4, Taiga Inoue5, George Ezeji6 and Annpia Baby6
1Woodhull Med & Mental Hlth Ctr, Brooklyn, NY, 2NYU School of Medicine, New York, NY, New York, NY, 3Woodhull Medical and Mental Health Center, Brooklyn, NY, 4SUNY Downstate Medical Center, Brooklyn, NY, 5St. George's University, St. George, Grenada, 6Woodhull Medical & Mental Health Center, Brooklyn, NY

 

Background: Hyperammonemia is a prognostic factor in ornithine transcarbamylase deficiency (OTCD), often resulting in severe and long term neurological impairment. Biotin deficiency has been shown to cause hyperammonemia (OTCD) in rats and yeast. We present a case of misdiagnosed OTCD with amelioration in ammonia levels and neuropsychiatric condition following biotin supplementation.

Clinical case: Our patient is a 48 year old man with a long history of psychiatric disorder who was brought in by ambulance to the emergency department from a nursing home on account of altered mental status, resulting in abusive behavior and visual hallucinations. Physical examination showed mild icterus, and impaired vision. He was being managed for dementia, seizure disorder, bipolar disorder, schizoaffective disorder and catatonia. He also has benign prostatic hypertrophy, T2DM, and hypertension on treatment. Further investigation revealed hyperammonemia by spectrophotometry (120mg/dl, reference range 12 – 47mg/dl) with normal routine liver function tests, raising the suspicion of a urea cycle disorder. Allopurinol challenge test was positive. Treatment was instituted with low protein diet, l-arginine, citrulline, lactulose, rifaximin and the nitrogen scavenger, sodium phenylacetate. However, his plasma ammonia level fluctuated between 120mg/dl and 226mg/dl. Biotin 800 mcg daily was introduced, which was associated with a fall in the level of ammonia to 69mg/dl with a remarkable improvement of the patient’s neuropsychiatric condition. Subsequently, the patient was discharged to a rehabilitation center.

Conclusions: OTCD is a rare inborn error of metabolism of the urea cycle. Improper diagnosis can result in late presentation cum long term neuropsychiatric sequelae. Biotin therapy may be effective in reducing hyperammonemia while improving neuropsychiatric derangement.  This is the first reported use of biotin supplementation in human OTCD. Randomized clinical trials are needed to confirm the effects of biotin in OTCD.

 

Nothing to Disclose: ASS, GB, GK, JG, TI, GE, AB

18548 13.0000 SAT-476 A The Effect of Biotin on Human Ornithine Transcarbamylase Deficiency Diagnosed in Late Adulthood 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Godwin Chuks Ojieh*1, Osaretin A.T. Ebuehi2 and Friday Kenneth Iweka3
1Ambrose Alli University, Ekpoma, Ekpoma, Nigeria, 2University of Lagos, Surulere, Nigeria, 3Ambrose Alli University, Ekpoma., Ekpoma, Nigeria

 

BACKGROUND: Traumatic Brain Injury (TBI) is the most common cause of death and disability in young adults.  A major challenge of endocrine complications of TBI is the time course, early recognition and diagnosis of the subtle problems after trauma.

OBJECTIVE:  To determine serum Oestrogen and prolactin levels in the acute, subacute and chronic phases of TBI and target when hormone replacement therapy may be required.

METHOD:  Fifty seven female adults excluding pregnan,  lactating,  postmenopausal and moribund patients without history of chronic ailments were enrolled in the study. Endocrine function was assessed by basal hormonal concentrations.  In each case, blood was collected within 24h in the 1st instance, and subsequently at first week and sixth week of trauma.  The blood samples were collected by standard venopuncture procedure in plain bottles and allowed to clot by leaving it undisturbed at room temperature for about 30 minutes and centrifuged. Serum was extracted from the resulting supernatant and stored frozen at -20oc until the samples were analyzed consecutively for oestrogen and prolactin by ELISA method.  The results obtained were compared with reference values of normal healthy adults. Severity of TBI was determined by Glasgow Coma Scale (GCS).

RESULTS: Forty five of the patients with moderate to severe TBI had low mean Oestrogen level of 9.9± 0.40 pg/ml.  The oestrogen level became lower after first week and remained lower in the sixth week.  Twelve of the patients with mild TBI had minimal lowering of Oestrogen level in 24h and one week but the level regained normalcy in the sixth week.  Hyperprolactinemia of 30± 0.35 ng/ml mean level was prevent in the moderate to severe TBI patients while those with mild TBI had normal mean level of 7.9±  0.42ng/ml

CONCLUSION:  Moderate – Severe TBI was associated with abnormalities of Oestrogen and prolactin secretion in the acute, sub acute and chronic phases of injury. Routine and comprehensive assessment, identification and appropriate timely management of endocrine functions may be required in order to optimize patient recovery, improve quality of life and avoid the long-term adverse consequence of untreated hypopituitarism.

 

Nothing to Disclose: GCO, OATE, FKI

19914 14.0000 SAT-477 A Evaluation of Changes in Pituitary Hormone Secretion on the Acute, Subacute and Chronic Phases of Traumatic Brain Injury 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Hiromi Nakamura*1, Yung-Ping Chin2, Vladislava Paharkova1 and Kuk-Wha Lee3
1UCLA, Los Angeles, CA, 2UCLA School Of Medicine, Los Angeles, CA, 3Mattel Children's Hosp - UCLA, Los Angeles, CA

 

Humanin (HN) is a 24-amino acid putative mitochondrial-derived peptide that has been shown to have cytoprotective properties in various cells, especially in neuronal cells. The mechanism of cytoprotection by HN in neurons has been shown to be via activation of a trimeric cell surface receptor and phosphorylation of STAT3 at Tyr705.  We hypothesized that exogenous humanin would accelerate neuronal differentiation, and maintain differentiation status under nerve growth factor (NGF) withdrawal.

Rat PC12 cells are a well characterized in vitro model of neuronal differentiation and NGF was used to induce differentiation into neuronal-like cells, or withdrawn to induce de-differentiation. Cells were treated with HNG (a potent analogue of HN), and western blotting was performed to assess the effects of humanin on differentiation and de-differentiation status.

HN treatment potentiated differentiation in a dose- and time-dependent manner and maintained differentiation upon NGF withdrawal. Neuronal differentiation marker synapsin-1 expression increased during differentiation conditions and under humanin treatment, the expression of synapsin-1 was accelerated and neurite extension increased compared to non-treated cells.  This was not related to any effect of HN on cell proliferation or apoptosis.  Neurite extensions disappeared on the second day of de-differentiation after NGF withdrawal, however, treatment with HN maintained cells in the differentiated state. Whereas phosphorylation of STAT3 at Tyr705 had previously been reported as important to the cytoprotective effects of HN, we found that HN treatment induced the phosphorylation of Ser727 in our model as had been previously described for NGF treatment and differentiation.   In addition, the endogenous rat HN homologue is induced acutely by HN treatment.

In summary, we report a novel pro-differentiation effect of HN on neuronal-like cells that is related to phosphorylation of STAT3 on a different amino acid that reported for cytoprotective effects in neuronal cells.

 

Nothing to Disclose: HN, YPC, VP, KWL

20035 16.0000 SAT-479 A Novel Pro-Differentiation Effects of Humanin in Rat Neuronal-like Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Irina Dzherieva*1, Natalya Volkova1, Ilia Davidenko1, Maria Antonenko1, Igor Reshetnikov2 and Aida Gyulmagomedova1
1Rostov state medial university, Rostov on Don, Russia, 2Rostov State Medial University, Rostov on Don, Russia

 

The pineal gland produces melatonin which relays information regarding the environmental light–dark cycle. In addition this hormone regulates vascular reactivity. Melatonin deficiency is associated with increased vascular disorders. The pineal calcification can lead to the low level of melatonin and developing cerebral infarctions. There are limited clinical data on the association of pineal calcification and stroke. Computed tomographic (CT) scans of the brains of 701 patients >35 years old were reviewed in retrospect. Patients with embolic or hemorrhagic stroke were excluded. The prevalence of pineal calcification was 41% [95% CI:38% – 45%]. Symptomatic cerebral infarction was found in 34% [95% CI:31% – 38%] patients. The risk of stroke in patients with pineal calcification was 31.4%, and in group without calcification - 15.9%. Thus, the risk of stroke in patients with calcification was 15.4% [95% CI:9.3% - 21.6%] or 1.96 times more compared with the group without calcification [95% CI:1.47 - 2.62]. Both coefficients are highly significant (p <0.0001). To assess the possibility of predicting the likelihood of symptomatic cerebral infarction in patients with a diagnosis of calcification was built a logistic regression model. The calcification and age were significant predictors in the model. The interpretation of the model coefficients for the prediction of symptomatic cerebral infarction suggests that calcification is associated with increased in 1.23 [95% CI:1.02-1.49, p=0.03] times the odds of cerebral infarction developing. Increasing age of the patient by a year is associated with increased chances of stroke at 1.02 [95% CI :1.01 - 1.03, p=0.0005]. Pineal calcification may be a potential new risk factor of cerebral infarction.

 

Nothing to Disclose: ID, NV, ID, MA, IR, AG

21127 17.0000 SAT-480 A Pineal Calcification Is a Potential New Risk Factor of Cerebral Infarction 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Ian Worden*1, Carlo A Prades1, Janice L Gilden2, Rohan Bhattaram1 and Boby G Theckedath3
1Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A. Lovell Federal Health Care Center, North Chicago, IL, 2Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL, 3Rosalind Franklin University of Medicine and Science/ Chicago Medical School, and Captain James A. Lovell Federal Health Care Center, North Chicago, IL

 

Neurogenic orthostatic hypotension (NOH) is known to develop as a result of autonomic dysfunction.  NOH is defined by a decrease of 20 mmHg systolic and/or 10mmHg diastolic blood pressure with an inappropriate heart rate (HR) response, and  symptoms of cerebral hypoperfusion (dizziness, lightheadedness, visual changes, presyncope, or even syncope).  Secondary autonomic neuropathies, like those arising in diabetes mellitus, often result in NOH.  Previous studies in diabetics have confirmed the use of prolonged QT intervals, corrected for heart rate (QTc) on electrocardiograms (EKG), as a surrogate marker for cardiac autonomic neuropathy.  However, they have not evaluated progressive changes over time in non-diabetic patients.  The goal of the present study was to characterize the change in autonomic function over time in patients with NOH. A retrospective chart review was performed in 25 patients with NOH of various etiologies [(Age=66±16yrs)(Male 18: Female 7)(BMI= 26.47 ± 2.76 kg/m2 )  (duration of disease= 5.5±3.4 yrs) (HR= 71.2 ± 5.42 beats/min)].  QTc intervals on EKG, as calculated by Bazett’s formula, were obtained over time from the earliest to the latest available electronic medical record.  QTc values ≥440 msec were considered to be prolonged.  Patient characteristics (age, sex, BMI, duration of disease, lipid profiles) were also assessed.  The rate of QTc prolongation over time was measured by the slope (m) of the linear regression analysis.  Results show that prior to diagnosis (Pre-Dx), NOH patients displayed a modest rate of progressive QTc prolongation over an average of 7.2 ± 5.42 yrs (m=1.6197, R2=0.29).  Following the diagnosis of NOH (Post-Dx), there was a 2.7-fold increase over time in the rate of QTc prolongation for 5.5 ± 3.4 yrs (m=4.3334, R2=0.50).  Additionally, the percent of patients with clinically prolonged average QTc intervals (≥440 msec) increased from Pre-Dx to Post-Dx (16.67% vs 41.18%; p<0.05). In conclusion, our results indicate that autonomic dysfunction may be predicted at an early stage by progression of QTc prolongation, which increases post diagnosis, and that a chronological association may exist between the extent of QTc prolongation and the duration of NOH.  This is also supported by our findings indicating a 2.7-fold increase in the rate of QTc prolongation following the diagnosis of NOH.  However, it remains unclear whether this association is a direct result of the pathologic progression of NOH.  It is known that prolongation of the QTc ≥440 msec predisposes patients to the development of potentially fatal ventricular arrhythmias.  This trend may predict the potential risk for sudden death, which is often observed in patients with autonomic dysfunction.

 

Nothing to Disclose: IW, CAP, JLG, RB, BGT

21136 18.0000 SAT-481 A Progression of Autonomic Dysfunction in Patients with Neurogenic Orthostatic Hypotension 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Friedhelm Sayk*1, Jacqueline Reiter1, Alexander Krapalis1, Felix Machleidt1 and Manfred Hallschmid2
1University hospital Schleswig-Holstein, University of Luebeck, Luebeck, Germany, 2University of Tuebingen

 

Background:Orexin A is a hypothalamic hormone crucially involved in the regulation of sleep/wake states. Orexinergic neurons project to blood pressure (BP) regulating brain networks, and orexin A was previously reported to induce BP-relevant sympathetic activation in animals (1). In humans, intranasal (i.n.) administration effectively delivers neuropeptides directly to the central nervous system, as evidenced by functional effects of i.n. orexin A on sleep architecture in orexin-deficient narcoleptic patients (2). However, sympathetic blood pressure effects of orexin A remain to be elucidated. Using highly specific microneurographic techniques, we therefore investigated whether i.n. orexin A alters sympathetic baroreflex function in healthy humans.

Methods:In a double-blind cross-over study orexin A (500 nmol) and placebo (sterile water), respectively, was i.n. administered to 12 awake normotensive male subjects. Muscle sympathetic nerve activity (MSNA) was assessed microneurographically and correlated with oscillometric BP and heart rate assessed during supine rest and a pharmacologic baroreceptor challenge before (pre-substance period) and from 30-60 minutes after orexin A administration (post-substance period).

Results:Orexin A did not induce any changes of BP or heart rate with regard to pre- vs. post-substance as well as orexin vs. placebo comparisons. Moreover, resting MSNA was not increased and sympathetic baroreflex sensitivity was not altered during baroreceptor testing with vasoactive drugs at the respective periods.

Conclusion:In this pilot study we found that i.n. orexin A at doses previously shown to induce central nervous effects in humans (2) does not alter sympathetic baroreflex function in healthy male subjects. However, protocols with higher doses of Orexin A warrant further investigation.

 

Nothing to Disclose: FS, JR, AK, FM, MH

20638 19.0000 SAT-482 A Intranasally Administered Orexin a Does Not Activate Sympathetic Baroreflex Function in Healthy Humans 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Ling Zhu* and Joan J C Khoo
Changi General Hospital, Singapore, Singapore

 

Background

Lithium is widely used as a mood-stabilising drug in the treatment of bipolar disorder. One of the side-effects of lithium is nephrogenic diabetes insipidus (NDI), via downregulation of aquaporin-2 channels in collecting duct. We report a patient on lithium who developed recurrent hypernatraemia in consecutive hospital admissions.

Case Report

A 52 year old male with a history of bipolar disorder presented with two weeks of generalised weakness, tremors and falls. His regular medications included haloperidol and lithium. Initial investigations revealed: serum sodium 136 mmol/L [NR 135-145 mmol/L], potassium 6.2 mmol/L [NR 3.5-5.3 mmol/L], creatinine 156 umol/L [NR 65-125 umol/L]. Lithium was discontinued as serum level was 2.28 mmol/L [NR 0.60-1.20 mmol/L]. He was hydrated with 3 L of intravenous 0.9% sodium chloride daily. Three days later, he was only rousable with sternal rub and tests showed serum sodium of 172 mmol/L, increased from last measured level of 141 mmol/L a day after admission. Brain imaging, serum glucose, renal function, liver enzymes and inflammatory markers were normal. He was retrospectively noted to have high urine output, up to 8.6 L/day for the past three days, resulting in a negative balance of up to 4 L/day. Serum osmolality was 359 mOsm/kg [NR 275-300 mOsm/kg], with paired urine osmolality of 130 mOsm/kg. There was no significant response to 1 mcg of intravenous desmopressin, in keeping with NDI due to lithium. Hypotonic fluids in the form of dextrose 5% was administered to match the water deficit, with oral water when his conscious level improved in tandem with gradual reduction of sodium over the next six days. Lithium was removed from his medication list following discussion with his psychiatrist. A month later, he was readmitted with fever and cough to another discipline. Serum sodium on admission was 134 mmol/L. He was given antibiotics and hydrated with 2 L of 0.9% sodium chloride a day. He required restraints and sedative medications for agitated and disinhibited behaviour, which was likely due to his underlying psychiatric condition, exacerbated by sepsis. Three days later, his serum sodium was 169 mmol/L, with a serum osmolality of 340 mOsm/kg, and urine osmolality of 125 mOsm/kg, prompting a review of the events of his previous admission. In response to this, free water was administered, and hydrochlorothiazide 25mg twice daily was started. He made a good recovery biochemically and clinically.

Conclusions

Severe acute hypernatraemia can occur in patients with lithium-induced NDI with limited access to hypotonic fluids, even after discontinuing lithium. Contributory factors include the use of 0.9% saline, mood instability, and lack of free access to water. Recurrent hypernatraemia could be prevented by vigilance in monitoring fluid and electrolyte balance in patients with prior history of lithium-induced NDI, even with normal serum sodium at presentation.

 

Nothing to Disclose: LZ, JJCK

19463 20.0000 SAT-483 A Failing to Learn from History: Recurrent Iatrogenic Hypernatraemia in a Patient with Bipolar Disorder 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Samaneh Yazdanikivi*1, Atsuko Kasajima2, Saulo JA Felizola1, Yoshiaki Onodera1, Yasuhiro Nakamura2 and Hironobu Sasano2
1Tohoku University Graduate School of Medicine, Sendai, Japan, 2Tohoku University Hospital, Sendai, Japan

 

Progesterone receptor (PR) expression has been reported as a favorable prognostic factor in pancreatic neuroendocrine tumor (PNET), suggesting an anti-proliferative role of progesterone in these patients. However, its details have remained largely unknown. PR isoforms, PRA and PRB, has been reported to have a distinctive set of target genes, which could influence the invasiveness and metastatic potential of PNET tumor cells, but the details of PR isoforms have not been reported at all in PNET. Therefore in this study, we investigated the status of PRA and PRB in a human PNET cell line and their association with cell proliferation of the tumor cells. Quantitative RT-PCR and cell proliferation assay were performed in PNET cell line, QGP-1, following the treatment with progesterone and RU486 as PR antagonist. QGP-1 only expressed PRB in its native status. Therefore PRA transfection was performed in the same cell line. PRA, PRB and cyclin D1 (CCND1) were immunohistochemically evaluated in 90 human PNET cases and the results were correlated with clinicopathological parameters of the patients. mRNA expression level of CCND1, c-Fos and c-Jun were significantly decreased following progesterone treatment in QGP-1 cell line with PRA transfection than those without PRA transfection (P= 0.02, P= 0.007, P= 0.001; respectively). Cell proliferation of QGP-1 was also significantly decreased following the treatment of progesterone in QGP-1 with PRA transfection compared to those without PRA transfection (P= 0.006). PRA immunoreactivity was significantly decreased in PNET with higher grade (P= 0.04) but CCND1 significantly increased in higher grade PNET (P= 0.035). Results of our present study demonstrated that PRA could serve as an inhibitory regulator of cell proliferation of PNET through inhibiting PRB mediated signals in presence of progesterone, subsequently resulting in the decreased CCND1 expression. The status of PRA in tumor cells could also serve as the prognostic factor in PNET.

 

Nothing to Disclose: SY, AK, SJF, YO, YN, HS

19646 21.0000 SAT-484 A Progesterone Receptor Isoforms in Pancreatic Neuroendocrine Tumor: Potential Regulators of Cell Cycle 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Vadim Krylov*1, Ekaterina Dobreva2, Nikolay Kuznetsov2, Eugenia Marova2, Leonid Ippolitov3 and Nona Vadimovna Latkina2
1University Clinical Hospital – 1, I.M. Sechenov First Moscow State Medical University, Moscow, Russia, 2Endocrinology Research Centre, Moscow, Russia, 3First Moscow State Medical University, Moscow, Russia

 

Introduction: Ectopic adrenocorticotropic hormone (ACTH-ectopic) syndrome (EAS) is a rare

cause of ACTH-dependent endogenous hypercortisolism.

Objective: The objective of this study was to analyze the clinical, biochemical, and radiological

features, management, and treatment outcome of patients with EAS.

Design: It was a retrospective case-record study of 52 patients with EAS.

Materials and Methods: Clinical, biochemical, and radiological features and response to

therapy and survival were measured.

Results: The median follow-up was 7 yr (range, 1–13 yr). None of the dynamic tests achieved

100% accuracy. Imaging correctly identified the lesion at first investigation in 83% of cases.

Bronchial carcinoid tumors were the most common cause of EAS (n = 34; 65,4%), followed by

other neuroendocrine tumors (n = 13, 25 %). In 9.6 % (5) of patients, the source of EAS was

never found. Octreotide scintigraphy and whole-body venous sampling were of limited value.

Surgical attempt at curative resection was successful in 83% (43 of 52) of all patients; 9 (19.1%)

responded generally well to bilateral adrenalectomy by vital necessity. Tumor histology and the

presence of distant metastases were the main predictors of overall survival (P < 0.05).

Conclusions: No single test provides to find the source of EAS correctly. Despite a variety of

tests and imaging studies for the correct diagnosis of the EAS, up to 10% of cases present an

occult EAS syndrome. These cases require a prolonged follow-up, review, and repetition of

diagnostic tests and scans, but, if it is necessary, do bilateral adrenalectomy.

 

Nothing to Disclose: VK, ED, NK, EM, LI, NVL

18319 22.0000 SAT-485 A Ectopic ACTH Syndrome: Clinical Features, Diagnosis, Treatment and Observation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Raiane Pina Crespo*1, Morgana L Maia2, Nina de Castro Musolino3, Valter Angelo Sperling Cescato4, Maria Candida B V Fragoso5, Marcio Carlos Machado6 and Marcello D Bronstein7
1Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil, 2USP, Brazil, 3Hospital das Clínicas, FMUSP, São Paulo, Brazil, 4Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 5Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 6University of Sao Paulo Medical School, Sao Paulo, Brazil, 7University of São Paulo Medical School, São Paulo, Brazil

 

Background: There is no overall consensus about the post surgical criteria of remission on Cushing’s disease (CD) patients, but low serum cortisol (<2 to 5 μg/dL) is frequently used. Additionally, the risk of recurrence can be assessed by several methods such as serum cortisol, duration of glucocorticoid replacement, return of circadian rhythm of cortisol secretion and response of ACTH and cortisol to secretagogues such as CRH or desmopressin (early post operative days or reappearance in follow-up). There is little information about the use of ACTH to predict recurrence risk in patients with initial remission at pituitary surgery.

Objective: The aim of this study is to assess the predictive value of plasma ACTH measured in early post-operative days to evaluate the recurrence risk in patients who reach remission criteria based on clinical picture and low cortisol measurements.  

Patients and methods: Between 2007 and 2014, 95 CD patients with clinical, biochemical and histological confirmation of ACTH-secreting pituitary adenomas were evaluated after first pituitary surgery. Were included patients with assessment of serum cortisol and plasma ACTH simultaneously collected up to 30 days after surgery (median of five days) and with at least six months of follow-up. Remission was defined as a low (≤5 µg/dL) or undetectable serum cortisol levels (Fs) (18-24h after last dose of cortisone acetate), clinical symptoms and signs of adrenal failure, need for glucocorticoid replacement, disappearance of clinical signs of hypercortisolism and normal urinary cortisol levels for as a minimum of 6 months. Recurrence was defined as reappearance of clinical symptoms and signs of hypercortisolism and at least two first line methods pointing to CD´s activity after more than six months of pituitary surgery.

Results: Remission occurred in 60 patients. Of them, 53 remained in prolonged remission during a follow-up of 40 months (6-133). In this group, the serum cortisol and plasma ACTH were 1.7 ± 2.3 µg/dL and 8.9 ± 12.2 pg/mL respectively. The seven patients who recurred presented with serum cortisol of 2.6 ± 1.3 µg/dL and plasma ACTH of 18.0 ± 7.1 pg/mL in a follow up of 57 months (14-86). It was noted that a plasma ACTH cut-off of 17 pg/mL could separate the patients regarding the recurrence risk, once 71.4% (5/7) in the group of recurrence, had ACTH ≥17 pg/mL, compared to 13.2% (2/53) in the group with persistent remission. On the other hand, recurrence occurred in 4.2% (2/48) in patients with ACTH <17 pg/mL and 41.7% (5/12) in those patients with ACTH ≥17 pg/mL.

Conclusions: Plasma ACTH assessment may be another indicator of recurrence risk. Even with low serum cortisol levels, patients with higher ACTH should be more closely monitored for early detection of recurrence. More studies are necessary to confirm the best predictive cut-off value of plasma ACTH.

 

Nothing to Disclose: RPC, MLM, NDCM, VASC, MCBVF, MCM, MDB

21755 23.0000 SAT-486 A Post Surgical ACTH Levels in Cushing's Disease Patients: Is There a Difference Between Persistent Remission and Recurrence Groups? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Suresh Kumar Athiappan Palanisamy*1, Thirumalaisamy P Velavan2, Muren Herrid3 and James Robert McFarlane4
1Centre for Bioactive Discovery in Health and Ageing, Collaborative Network Research, University of New England, Armidale, 2Universität Tübingen, Tuebingen, Germany, 3University of New England, Armidale NSW, Australia, 4University of New England, Australia

 

In recent years, there has been an increased focus on studying the positive psychological traits (eg. optimism and resilience) rather than just the negative ones (eg. depression and anxiety). Recent investigations have shown that psychological resilience is heritable factor and can act as a buffer between depression and stress. However to date, there are no recognized biomarkers that can measure resilience. Oxytocin, a neuropeptide secreted in the hypothalamus has been reported to play a role in the development of a range of social behaviours such as trust, positive communication, and group favouritism. Recently genetic polymorphisms in the coding region of the oxytocin receptor (OXTR) gene have been reported which are associated with depression. OXTR is located on chromosome 3q25 and an intronic variant rs53576 (G/C) was demonstrated to associate with human social behaviours. In addition, Reelin (RELN), a gene that spans over 500 kb positioned on chromosome 7q22  encoding at least two alternatively spliced glycosylated isoforms which are important proteins for brain development particularly with synaptic plasticity and learning. It has also been found in various tissues and body fluids including brain, blood, spinal cord, and liver. Several genome wide association studies (GWAs), candidate gene and protein measurement studies have shown a strong association of reelin protein levels and its polymorphisms with schizophrenia, bipolar disorder, depression, Alzheimer’s disease, lissencephaly and other brain disorders.

We hypothesised that OXTR rs53576 variant and RELN polymorphisms may possibly play a role in human psychological resilience as it has been shown that SNP rs53576 is associated with positive traits and mice overexpressing RELN are resistant to depressive symptoms with increased resilience in stressful environments. We extracted DNA samples from study subjects (n=101) from buccal cells. Psychological measurements were performed using Zung self-rating depressive scale and Conner-Davidson resilience scale scores. The OXTR rs53576, the RELN rs362719 and RELN rs72753 variants were subsequently genotyped by RFLP-PCR, direct sequencing and qPCR-HRM methods.

Our results showed a trend, although not significant that OXTR rs53576 wild type alleles G/G subjects had higher resilient scores compared to C/C homozygous mutants. RELN rs362719 had no association with resilience (P=0.73), while homozygous mutant for RELN rs727531 had significantly higher (P=0.025) resilience scores than wild type or heterozygous mutant carriers. These preliminary results are encouraging and suggest that Reelin genetic variants may possibly considered as an important genetic biomarker for psychological resilience.

 

Nothing to Disclose: SKA, TPV, MH, JRM

21811 25.0000 SAT-488 A OXTR rs53576 and Reln rs727531 gene Variants: Promising Predictive Biomarkers for Psychological Resilience in a Rural Australian Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Suresh Kumar Athiappan Palanisamy*1, Muren Herrid2, Thirumalaisamy P Velavan3 and James Robert McFarlane4
1Centre for Bioactive Discovery in Health and Ageing, Collaborative Network Research, University of New England, Armidale, 2University of New England, Armidale NSW, Australia, 3Universität Tübingen, Tuebingen, Germany, 4University of New England, Australia

 

Chronic stress is clearly associated with the quality of life resulting in various illnesses and diseases. Salivary cortisol (sC) has been used as a reliable biomarker for acute stress and stress related illnesses. Cortisol, a major glucocorticoid plays various roles in the human body such as; anti-inflammatory mechanisms and in glucose homeostasis, immunosuppressive disorders. Recent studies show depression cases are on the rise increase particularly in developed countries and that a third of the population will be affected by depression within their life time. Family history can be used as an effective predictor of depression, which has led to investigations of heritability of depression. Twin studies show that genes alone do not play a direct role in the development of depression, however when combined with major life stressors can lead to depression. The serotonin transporter (SLC6A4) protein and its genetic variants in the promoter region (5-HTTLPR) have been a recent focus. Although there has been more than 90 studies investigating the role of 5-HTTLPR the findings are contradictory with some studies showing the presence of the short alleles predicts the susceptibility to depression while other demonstrate that long alleles predict depression in some populations.  However, the mechanism underlying this process remains yet to be elucidated. Thus we proposed to study the relationship between waking sC levels, 5-HTTLPR, depression and resilience in a rural community population.

Genomic DNA was extracted from study subjects (n=91) from the buccal cells. The genetic locus 5-HTTLPR was genotyped by RFLP-PCR and by direct sequencing. Waking saliva samples were collected using salivates and the sC levels were quantified using ELISA. In addition, the depression and resilience were measured using Zung self-rating depressive scale and Connor-Davidson resilience scale respectively.

Subjects carrying the alleles long/short (l/s) had significantly (P=0.025) higher depressive scores compared to long/long (l/l) and short/short (s/s) allele carriers. The subjects carrying l/s had lower resilience scores compared to l/l and s/s. However, there was no significant association (P>0.5) in sC levels between the 5-HTTLPR genotypes. Our data confront the idea that the s/s allele carriers are more susceptible to depression and suggests that the waking sC levels may not be particularly useful as a biomarker for depression.

 

Nothing to Disclose: SKA, MH, TPV, JRM

21855 26.0000 SAT-489 A The L/L and L/S Alleles of 5-Httlpr, the Polymorphic Promoter Region of Serotonin Transporter Is a Predictor of Depression, but Not Waking Salivary Cortisol 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 463-489 5911 1:00:00 PM Neuroendocrinology Poster


Neil McKenna*, Lauren Becnel, Yolanda Darlington and Scott Andrew Ochsner
Baylor College of Medicine, Houston, TX

 

Nuclear receptors (NRs), their ligands and coregulators play key roles in the development of diabetes and obesity and other metabolic conditions. Effective management of the increasing volumes of data in this field requires the development and maintenance of curated web-based resources. We describe here the new version of the Nuclear Receptor Signaling Atlas (NURSA) website at www.nursa.org. The user interface has been completely redesigned to provide for more rapid and intuitive navigation. In addition, we have expanded the number of external data resources in our Molecule Pages, a comprehensive compendium of information on nuclear receptors (NRs), their physiological and synthetic ligands, their coregulators and target genes. Moreover, we have added a number of new features to the Transcriptomine NR target gene analysis tool, including the ability to mine datasets in specific articles, and to readily discover related data points. Transcriptomine is being integrated with a number of external small molecule resources, including PubChem, ChEBI and IUPHARDB, allowing users of those resources to link directly from those resources to genes regulated by specific NR ligands. Using supplemental funds from the NIH Big Data To Knowledge (BD2K) initiative, we are collaborating with publishers to enhance the reuse of global differential gene expression datasets in papers published by journals in the field. We are also collaborating with Thomson Reuters to deposit DOI-tagged datasets in their Data Citation Index to maximize the visibility of these datasets. The NURSA website affords an entirely new paradigm for leveraging transcriptomic, eipgenomic and other datasets in the NR signaling field, empowering users to query across diverse regulatory molecules, tissues & cell lines, target genes, biological functions and associations with diabetes, obesity and other metabolic diseases.

 

Nothing to Disclose: NM, LB, YD, SAO

21967 2.0000 SAT-271 A The Nuclear Receptor Signaling Atlas (NURSA): A Web Resource for the Nuclear Receptor Signaling Community 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Jonathan Robert Deans*1, Nina V. Titova1, Anushka Wickramaratne2 and Frances M. Sladek1
1University of California, Riverside, CA, 2University Of California Riverside, Riverside, CA

 

Next generation sequencing (NGS) technologies have brought the prospect of personalized medicine from the realm of science fiction to scientific reality. But while single-nucleotide polymorphisms (SNPs) are increasingly being associated with various phenotypes and diseases in genome-wide associate studies (GWAS), the vast majority of SNPs are found in intergenic regions making it difficult to predict their effect on gene function, if any. One possible mechanism by which these SNPs could act is by disrupting or enhancing the interaction of transcription factors with specific DNA response elements. To investigate this possibility, in the Nuclear Receptor DNA Binding Project (http://nrdbs.ucr.edu) we previously employed a high-throughput in vitro DNA binding assay, termed Protein Binding Microarrays (PBMs), to explore differences in DNA binding of nuclear receptors (NRs) to SNP alleles. We used custom-designed PBMs to examine 125,000 SNPs extracted from published HNF4α ChIPseq peaks from human liver (HepG2) and colon cancer (CaCo2) cell lines and identified 1,700 affinity altering SNPS (aaSNPs) in vitro. Now, for a proof of principle, we utilized the CRISPR/Cas system to edit the genome of HepG2 cells for nine of the aaSNPs that also showed a decreased expression of a nearby gene in an HNF4α knockdown (KD). We will present the results from our genome editing experiments in HepG2 cells and the effect of the aaSNP on in vivoHNF4α chromatin binding and mRNA expression. While editing all 1700 aaSNPs identified in vitro is not an option, these experiments will validate the PBM approach for the identification of aaSNPs and allow for a rapid screening method to identify aaSNPs for other NRs.

 

Nothing to Disclose: JRD, NVT, AW, FMS

21651 3.0000 SAT-272 A Verifying Affinity Altering SNPs with Crispr/Cas System in HepG2 Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Linh M. Vuong*1, Joseph Dhahbi2 and Frances M. Sladek3
1University of California, Riverside, CA, CA, 2University of California, Riverside, CA, Riverside, CA, 3University of California, Riverside, CA

 

The ability of the cells in the liver to transdifferentiate into pancreatic cells, and vice versa, has been known for some time1. The switch is facilitated by the fact that the liver and pancreas originate from the same precursor, the endodermal germ layer; both organs bud outward from the ventral foregut. Hepatocyte nuclear factor 4 alpha (HNF4a), a highly conserved member of the nuclear receptor superfamily, plays an important role in the development of the endodermal lineage. There are two promoters (P1 and P2) in the HNF4A gene that give rise to splice variants that differ in their N-terminal region and that drive expression in different tissues. P1-HNF4a is expressed in the fetal and adult liver, whereas the P2-HNF4a is expressed in the fetal, but not the adult, liver and in the adult pancreas. It is not clear which HNF4a variant(s) are expressed in the early formation of the ventral foregut, before cells bifurcate into hepatic and pancreatic buds. Here, using mouse embryonic stem cells (mESCs) we show that P1-HNF4a is expressed first at day five of embryoid body (EB) development, and that P2-HNF4a expression appears to follow shortly thereafter. To determine the role of the HNF4a isoforms in early endodermal development, we generated Tet-On inducible mES cell lines that express either HNF4a2 (P1) or HNF4a8 (P2) under control of doxycycline (DOX). When either the a2 or a8 line was induced with 0.3 μg/mL of DOX, the cells changed morphology into a more differentiated state and expressed the early endodermal marker HNF3a/β (Foxa1,2). Both HNF4a isoforms also decreased cell proliferation and Oct4 expression, although P2-HNF4a inhibited proliferation less well than P1-HNF4a. Despite continued induction with DOX, HNF4a protein expression was lost over time but the morphology change and decreased cell proliferation persisted, indicating that the HNF4a isoforms can have an ephemeral yet irreversible effect on ESC proliferation and differentiation. Finally, in order to determine what type of cells are induced by the HNF4a isoforms, we performed RNAseq at 24 and 72 hours post DOX induction. Our results show that expression of a single nuclear receptor, HNF4a, is sufficient to induce a new developmental program in ESCs, even in the absence of added growth factors. They also show that P1- and P2-driven HNF4a isoforms display subtle yet distinct differences during differentiation. Finally, these inducible ESC lines will be useful tools for understanding the role of the HNF4a isoforms in early hepatic and pancreatic development and could provide insight into the development of diabetes as HNF4A is mutated in an inherited form of type 2 diabetes (MODY1).

 

Nothing to Disclose: LMV, JD, FMS

22103 4.0000 SAT-273 A Expression of Nuclear Receptor HNF4a in Mouse Embryonic Stem Cells Is Sufficient to Inhibit Cell Proliferation and Drive Differentiation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Aleksandra Cvoro*1, Liani Devito2, Flora Aparecida Milton3, Douglas Harold Sieglaff1, Dusko Ilic2 and Paul Webb1
1Houston Methodist Research Institute, Houston, TX, 2King’s College London, London, United Kingdom, 3University of Brasilia, Brasilia, Brazil

 

Thyroid hormone receptors (TRs) mediate the majority of thyroid hormone (THs) actions and play crucial roles in embryonic development. Expression and functional studies have revealed that several members of the nuclear receptor (NR) family are required for embryonic stem cells (ESC) maintenance, self-renewal and differentiation. However, it is very little known about the role of TRs despite the fact that at least one form, TRα, is expressed in stem cells (SC). To gain insight into TR/TH regulated biological processes in SC we performed microarray analysis on human ESC (hESC) KCL034 and human induced pluripotent stem cells (hiPSC) iKCL004, treated with triiodothyronine (T3) for 6h or 18h. The analysis revealed 820 and 826 genes changed in KCL034 and iKCL004 respectively after 6h T3 treatment. Thus, SC display rapid and large responses to TH treatment, with dramatic changes in SC gene expression profiles. After prolonged, 18h treatment, the number of regulated genes was increased to 1824 in KCL034 but only 576 genes show significant change in iKCL004. Furthermore, there was only partial overlap in profile of T3-regulated genes after 6 vs 18h of treatment in both SC suggesting time-dependent dynamics of T3 response. Overall 307 and 133 transcriptional factors, cofactors and chromatin remodeling factors were T3-regulated in KCL034 and iKCL004 respectively suggesting, again, that TRs control change of transcriptional programs. Analysis of T3 target genes using GeneCodis and Ingenuity Pathway Analysis (IPA) revealed that T3 target genes clustered into categories related to embryonic development and differentiation as well as cell-cell signaling. Further, analysis of 18h T3-targets flagged processes that were not targeted during first 6h of treatment, including genes involved in mitosis, cell cycle, cell division and cytoskeleton organization. These studies implicate TRα as a fundamental regulator of stem cell state. Modulating TR activity in pluripotent cells with TH may prove to be effective at driving pluripotency or direct differentiation toward specific cell lineages that could be relevant for therapeutic applications.

 

Nothing to Disclose: AC, LD, FAM, DHS, DI, PW

21193 5.0000 SAT-274 A A Role for Thyroid Hormone Receptors in Stem Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Yewei Xing*, Isabella Finco and Gary D Hammer
University of Michigan, Ann Arbor, MI

 

Background: Sf1 (Nr5a1) is a nuclear receptor that is essential for both steroidogenesis and cell proliferation during development and homeostasis of adrenocortical cells.  In mouse models, complete loss of Sf1 causes adrenal aplasia with haploinsufficiency decreases cortical responses to stress(1). On the other hand, transgenic mice bearing multiple copies of Sf1 develop adrenocortical nodular hyperplasia(2). In addition to gene dosage, post-translational modifications of Sf1 regulate DNA binding, cofactor recruitment and activation of target genes(3). The in vivo role of Sf1 phosphorylation in adrenal development and homeostasis however has not been explored.

 

Methods: In the current study, we generated two knock-in mouse models bearing mutations of the major serine residue (S203) in the hinge region that is phosphorylated in response to CDK7 and Erk1/2.  Both non-phosphorylate-able (Sf1 S203A) and phosphorylate-mimic (Sf1 S203D) mutants were created.

 

Results: Preliminary results reveal defects in the adrenal glands of both the Sf1 S203A and Sf1 S203D mutant mice. Heterozygote and homozygote Sf1 S203A mice exhibit significantly smaller adrenal glands at 6 weeks of age when compared to wild type littermates (het 0.7±0.1 mg, homo 0.8±0.3 mg Vs. wt 2.1±0.3 mg). Furthermore, the medulla is disorganized, with chromaffin cells localized directly under the adrenal capsule (similar to Sf1 haplo-insufficient mice), suggesting that Sf1 phosphorylation (or Sf1 effective dosage) is critical for neural crest cell infiltration and/or medullary organization in the adrenal gland.  The fetal/X-zone has a normal histological appearance at birth but regresses prematurely in females, suggesting that phosphorylation of Sf1 is required for maintenance of postnatal fetal/X zone cells and/or the timing of fetal/X zone regression.  Sf1 S203D mice, while having no significant changes in body or adrenal weight at 6 week of age, do exhibit marked disorganization of the cortex with frequent nodule formation in homozygote males.

Current studies aim to further define the homeostatic defects in the Sf1 S203A and Sf1 S203D mice. Phenotypic analysis of stem cell function, proliferation and differentiation will determine the molecular, cellular and organo-typic roles of Sf1 phosphorylation in adrenal health and disease.

 

Disclosure: GDH: Owner, Atterocor, Consultant, Embara, Consultant, orphagen, Consultant, ISIS. Nothing to Disclose: YX, IF

22070 6.0000 SAT-275 A Phosphorylation of Nr5a1 (Sf1) Regulates Mouse Adrenal Development 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Alicia Belgorosky*1, Maria Sonia Baquedano2, Mercedes Maceiras3, Nora Isabel Saraco2, Paula Aliberti4, Esperanza Beatriz Berensztein3 and Marco A. Rivarola2
1Hospital de Pediatría Garrahan, Buenos Aires, Argentina, 2Hospital de Pediatria Garrahan, Argentina, 3Hospital de Pediatria Garrahan, Buenos Aires, Argentina, 4Garrahan Pediatric Hospital, Buenos Aires, Argentina

 

17-Hydroxyprogesterone (17OHP) can be converted to DHT via the backdoor pathway without the intermediacy of DHEA, androstenedione and testosterone (T). Liquid Chromatography–Tandem Mass Spectrometry analysis of urinary steroids showed this pathway is a major route to DHT in pathological states in which 17OHP accumulates, including 21-hydroxylase (21OH) and POR deficiencies. However, the relevance of the backdoor pathway to human adrenal physiology is unknown. We have previously described that the postnatal human adrenal gland expresses androgen receptor and the enzymes to complete all the steps in the backdoor pathway to DHT without a clear age and zone-specific pattern(1). Aim: The aim of the study was to evaluate the role of DHT on human adrenal steroidogenesis. Material and Methods: The effects of DHT upon steroid production in human adrenal NCI-H295R cells were measured by immunoassay. Results: 17OHP incubation (300nM, 24h) of H295R cells caused an increment in DHT/T ratio, showing the integrity of the backdoor pathway in H295R cells. DHT significantly decreased cortisol and stimulated progesterone and aldosterone basal (-1.3, +1.8 and +4 fold, respectively) and 8-bromo-cAMP-induced (-1.6, +2,2 and +2 fold, respectively) production from NCI-H295R cells in a dose-dependent manner at concentrations ≥ 100nM (p<0.05). The effect of DHT on cortisol, progesterone and aldosterone secretion was not blocked by the classical androgen receptor antagonist hydroxyflutamide. In a time-course study (30min to 24 hours), we detected stimulation of Progesterone secretion soon after the addition of DHT, with a significant rise by 30 min. Treatment with DHT did not affect expression of CYP17A1 mRNA (quantitative real-time RT-PCR analysis).

Conclusions: Our results suggested that DHT may participate in the regulation of adrenal cortisol and aldosterone secretion through inhibition of P450 CYP17A1 by a post-transcriptional mechanism.

Finally, intraadrenal DHT might have physiological and/or pathophysiological significance as a paracrine/autocrine regulator of adrenocortical function.

 

Nothing to Disclose: AB, MSB, MM, NIS, PA, EBB, MAR

20395 7.0000 SAT-276 A Dihydrotestosterone (DHT) Stimulates Progesterone Secretion and Decreases Cortisol Production By H295R Human Adrenocortical Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Nicholas A Sanek*1, Sharon Lauretta Dubois2, Gloria E Hoffman3, Sally Radovick4, Ulrich Boehm5, Andrew Wolfe6 and Jon E Levine1
1University of Wisconsin-Madison, Madison, WI, 2University of Wisconsin-Madison, WI, 3Morgan State University, Baltimore, MD, 4Johns Hopkins School of Medicine, Baltimore, MD, 5University of Saarland School of Medicine, Homburg, Germany, 6Johns Hopkins University School of Medicine, Baltimore, MD

 

Pulsatile neurosecretion of gonadotropin-releasing hormone (GnRH) maintains the activity of hypothalamic-pituitary-gonadal axes of both sexes. In males, homeostatic negative feedback regulation within the axis is conveyed by testosterone (T), which suppresses GnRH pulsatility and thereby restrains luteinizing hormone (LH) secretion.  These effects are mediated by activation of the androgen receptor (AR) by T and/or estrogen receptor alpha (ERα) by estrogens derived from aromatization of T.  Since GnRH neurons do not express appreciable AR or ERa, both actions are likely exerted in first- or multi-order neuronal afferents controlling pulsatile GnRH neurosecretion.  Kisspeptin (Kiss1) neurons have been implicated in the transmission of gonadal steroid feedback, as they innervate GnRH neurons, stimulate GnRH release, and express ERα and AR. Moreover, Kiss1 expression in the arcuate nucleus (ARC) of the hypothalamus is increased following castration and suppressed by T replacement.  We tested the hypothesis that negative feedback in the male mouse reproductive axis is dependent upon activation of either AR or ERα in kisspeptin neurons. Male kisspeptin cell-specific AR knockout (KARKO) mice, kisspeptin cell-specific ERα knockout (KERKO) mice, and control Cre- wild-type (WT) mice were generated and their hormone responses to sham surgery (SS), castration (Cx) + vehicle (V), Cx + T, Cx + 17b-estradiol (E2), or Cx + dihydrotestosterone (non-aromatizable androgen; DHT) were compared.  Results: Serum LH levels were low following SS, and elevated in all genotypes following Cx + V, although the post-Cx rise in LH was moderately attenuated in KARKO mice.  T was fully effective in suppressing LH in all genotypes. However, E2 exerted full feedback suppression in WT and KARKO, but was only partially suppressive in KERKO mice; by contrast DHT exerted full feedback suppression in WT and KERKO mice, but was only partially effective in KARKO mice. Measurement of Kiss1 mRNA in the ARC by qPCR revealed differences in Kiss1 expression among groups and treatments that were strikingly similar to those observed for effects on serum LH. Conclusions: These results demonstrate that ERα in kisspeptin neurons mediates negative feedback elicited by E2, while AR in kisspeptin neurons is required for a portion of the negative feedback actions exerted by androgens.  Our observations are consistent with the idea that ERa and AR in kisspeptin neurons convey parallel and mutually compensatory feedback actions of T in the male reproductive axis.

 

Nothing to Disclose: NAS, SLD, GEH, SR, UB, AW, JEL

20017 8.0000 SAT-277 A Kisspeptin Neurons Mediate Negative Feedback in the Male Reproductive Axis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Kyohei Horie*, Masanobu Kanou, Ken-ichiro Takagi, Etsuko Fujita, Shinnosuke Hosoda, Kousuke Sasaki, Hidekazu Watanabe, Motoko Hamada, Hiroyuki Sugiyama, Naoki Hase, Yoshiaki Azuma, Tsuyoshi Kimura and Kei Yamana
Teijin Pharma Limited, Hino Tokyo, Japan

 

Decreased muscle mass and strength result in reduced mobility and quality of life, leading to increased nursing care and mortality which constitute a big impact in increase of healthcare costs. Therefore, varieties of pharmacological approach have been tried to treat muscle atrophy conditions such as sarcopenia, disuse and cachexia. Androgens are well-known to have beneficial anabolic effects on muscle. However, the clinical use of androgens has been limited because of unfavorable side effects in liver and reproductive tissues. SARMs, selective androgen receptor modulators are thought to have anabolic activity in muscle while reduced effects in reproductive tissues. Although several SARMs have been tested in clinical studies, no SARM is currently available in clinical use because of the limited efficacy with narrow therapeutic window.

Recently, we identified a novel non-steroidal orally available SARM, TEI-SARM2 which induces strong muscle anabolism with reduced effects in prostate and testis. In vitro characterization of TEI-SARM2 revealed that this compound exhibited strong AR affinity and transcription activity comparable with ostarine, the most advanced SARM in clinical studies. Interestingly, TEI-SARM2 showed strong N/C interaction same as androgens while ostarine does not have it. Moreover, TEI-SARM2 has longer half-life and higher AUC in blood than ostarine in pharmacokinetic study in rats. In orchidectomized (ORX) rats, once treatment of TEI-SARM2 increased muscle (levator ani) weight dose dependently at 1 week after treatment and notably the anabolic effect continued over 2 weeks after treatment whereas prostate weight was increased at 1 week but progressively reduced after 2 weeks. This result suggested that TEI-SARM2 may function as SARM where it induces strong muscle anabolism and less effect in prostate by once-weekly regimen. As we expected once-weekly treatment of TEI-SARM2 in normal male rats for 6 weeks resulted in dose dependent increase of muscle weight similar to that of nandrolone, a clinically available androgen while no significant change was observed in prostate and testis weights which significantly affected by nandrolone treatment.

Thus, TEI-SARM2 is a novel SARM which induces strong anabolism in muscle with minimal effects in reproductive tissues by once-weekly regimen. Notably, the in vivo muscle anabolic activity of TEI-SARM2 is comparable with nandrolone which is stronger than ostarine. In addition, TEI-SARM2 has long half-life in blood and can be administered once-weekly. Moreover, TEI-SARM2 is non-steroidal structure and orally available which lead to reduced side effects in liver and improved drug compliance. Taken together our results suggest that TEI-SARM2 is a promising therapeutic candidate for muscle wasting diseases such as sarcopenia and cachexia.

 

Nothing to Disclose: KH, MK, KIT, EF, SH, KS, HW, MH, HS, NH, YA, TK, KY

19734 10.0000 SAT-279 A Tei-SARM2: Once-Weekly Oral SARM with Robust Muscle Anabolism and Minimal Androgenic Effects in Reproductive Tissues 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Thomas Ullrich1, Sanjita Sasmal2, Chetan Pandit2, Sven Weiler1, Sujatha Rajagopalan2, Shekar Chelur2, Paulo G Santos3, Bharat Lagu4, Mark Perrone4, Mark Bock4 and Hansjoerg Keller*1
1Novartis Institutes for BioMedical Research (NIBR), Basel, Switzerland, 2Aurigene Discovery Technologies Ltd., Bangalore, India, 3Novartis Pharma, Basel, Switzerland, 4NIBR, Cambridge, MA

 

Selective androgen receptor modulators (SARMs) are promising drug candidates for the treatment of muscle wasting diseases. SARMs are tissue-selective androgen receptor (AR) ligands stimulating muscle anabolism while showing minimal androgenic activity such as prostate stimulation. Recently, we have reported the identification of an alkoxy-pyrrolo-pyrazoline SARM (AUSRM-057) with ideal physicochemical properties for transdermal administration. Here, we describe the identification of a different chemical class of spiro hydantoin SARMs using a further improved screening strategy with an additional novel in vitro prostate tissue-selectivity assay. Compounds showing potent AR activation in a C2C12 muscle cell reporter gene assay (RGA) were subsequently screened for AR activation in a RGA using immortalized human RWPE-1 prostate cells transiently transfected with AR and MMTV luciferase reporter plasmid. RWPE-1 cells are non-tumorigenic in mice and can undergo acinar differentiation in 3D cell cultures. Testosterone (T) dose-dependently activated AR with an EC50 of 4 nM and dihydrotestosterone was slightly more potent with an EC50 of 2 nM as expected. We identified a spiro hydantoin SARM, AUSRM-0178, that potently activated AR in the muscle cell assay (EC50 = 0.6 nM), but showed much lower potency in the prostate cell RGA (EC50 = 17.5 nM) with significantly reduced maximal efficacy (79%) compared to T (100%). AUSRM-0178 also showed good in vivo tissue-selectivity in a two week Hershberger assay with castrated immature rats showing dose-dependent recovery of levator ani (LA) muscle with full recovery at 10 mg/kg s.c. daily treatment, while prostate weight was only partially recovered. Muscle-specific in vivo anabolism was further confirmed in a two week study using intact young rats treated with 10, 30 and 60 mg/kg s.c. daily where no significant prostate weight stimulation was observed. As AUSRM-0178 showed low solubility of 0.1 mg/mL and limited human skin flux of 0.08 µg.cm-2.h-1 we developed a related compound AUSRM-0470 with much improved solubility of 0.7 mg/mL and human skin flux of 0.5 µg.cm-2.h-1 for potential transdermal application. AUSRM-0470 was less potent in the muscle RGA (26.9 nM), but also showed selectivity in the prostate RGA (EC50 = 44.8 nM and Emax = 77%) and in the Hershberger assay in vivo with an even improved selectivity profile compared to AUSRM-0178. In the two week intact rat assay, AUSRM-0470 led to specific full LA muscle recovery at 100 mg/kg without significantly affecting prostate weight. In conclusion, we have identified spiro hydantoin SARMs as prostate-sparing muscle-specific anabolic drug candidates for the treatment of muscle-wasting conditions.

 

Nothing to Disclose: TU, SS, CP, SW, SR, SC, PGS, BL, MP, MB, HK

19854 11.0000 SAT-280 A Identification and Pharmacological Characterization of Novel Spiro Hydantoins As Selective Androgen Receptor Modulators 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Scott A. Lawrence*1, Eric Schreiter2, Ching-Yi Chang1, Mary Ann Dwyer1, Robert Baldi1, Loren Looger2 and Donald P McDonnell1
1Duke University School of Medicine, Durham, NC, 2Howard Hughes Medical Institute, Ashburn, VA

 

Estrogen-related receptor alpha (ERRα) is an orphan member of the nuclear receptor superfamily of transcription factors involved in the regulation of cellular energy and metabolism. Of interest is the observation that elevated expression and activity of this receptor is associated with poor clinical outcomes in several cancer types. Furthermore, pharmacological inhibition of ERRα was demonstrated to have significant antitumor activity in preclinical models of breast and prostate cancer. However, further optimization of existing small molecule inhibitors of ERRα is needed to advance this class of drugs for clinical use. Given what has been learned from studies targeting the estrogen and androgen receptors in breast and prostate cancers, there is a consensus that “receptor degraders” may provide better clinical efficacy than compounds exhibiting pure competitive antagonist activity alone. One ERRα antagonist, XCT790 (XCT), has been shown to induce ERRα protein degradation. To gain insight into the mechanism of XCT-induced degradation of ERRα, we solved the crystal structure of the ERRα ligand-binding domain in complex with XCT.  Analysis of this structure showed that helix 12 (H12) was repositioned from its agonist location to occupy the AF2 co-activator groove. Interestingly, XCT occupancy of ERRα promoted the formation of an apparent salt bridge between helix 3 (H3) and H12, resulting in significant rotation of H12 and exposure of hydrophobic residues to the protein exterior.  Disruption of the H3-H12 salt bridge pair by mutagenesis resulted in functional ERRα proteins that were less susceptible to degradation by XCT. Despite the lack of degradation by XCT, we confirmed that these mutant proteins retained their ability to bind XCT, suggesting that the H3-H12 salt bridge is required for XCT-mediated degradation of ERRα.   By identifying this important salt bridge interaction, we now have a better understanding of the mechanism behind the unique molecular pharmacology of XCT790. Using this information, we are now developing ERRα ligands that regulate the H3-H12 interaction with a view to (a) define the importance of this interaction in antagonist/degrader action, (b) identify the precise mechanism of ERRα degradation, and (c) develop ERRα antagonists/degraders with clinically useful pharmaceutical properties.

 

Nothing to Disclose: SAL, ES, CYC, MAD, RB, LL, DPM

22016 12.0000 SAT-281 A Structural Insights into Ligand-Induced Degradation of Estrogen Related Receptor Alpha 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Shagufta H Khan*, Elizabeth L Helwig and Raj Kumar
The Commonwealth Medical College, Scranton, PA

 

The treatment of endocrine-based pathologies with steroid hormone ligands is complicated by the current inability to restrict steroid hormone receptor (SR) actions to specific organ/gene targets. Due to available ligand binding domain (LBD) structures and the intrinsically disordered (ID) nature of the N-terminal (NTD) AF1 domain, rational structure-based design of small molecule SR modulators (SRMs) has been limited by necessity to how these compounds modulate coregulatory protein (CoR) interactions with LBD/AF2, thereby missing signaling mediated by AF1. It is known that tissue-specific residual SR activity in the presence of SRMs may mainly be mediated via AF1 and that the relative functional importance of AF1 may be decided by conformational dynamics of the highly flexible NTD/AF1 coupled with allosteric regulations. Thus, binding proteins that induce coupled folding of active NTD/AF1 conformations may either function directly as a CoR or reorganize structure of AF1 for binding of other CoRs. Molecules that can interfere with AF1-CoR interaction surfaces provide an attractive opportunity for novel therapeutic targeting of SRs. Because TATA box binding protein (TBP) is a common binding partner for AF1/NTD of all SRs and does not bind to the AF2/LBD, yet leads to conformational changes, we hypothesize that TBP-induced disorder-order transition opens AF1 surfaces for its interactions with specific coactivators. Consistent with this concept, we recently reported that structural reorganization of AF1/NTD induced by TBP, enhanced binding of SRC-1 to AF1, and TBP and steroid receptor coactivators-1 (SRC-1) acted synergistically to stimulate AF1-dependent activity. Thus, small molecules that could modify AF1/NTD-TBP binding may provide the additional selectivity needed to target SR-selective genes in current endocrine-based therapies. In this study, using immunoprecipitation assay, we identified a small peptide that is capable of blocking the glucocorticoid receptor’s (GR’s) AF1-TBP interaction. The binding kinetics of AF1-TBP interaction as assessed by surface plasmon resonance method showed that both TBP and the peptide bind to AF1 with a KD of low µM range. On the other hand, when AF1 is pre-incubated with the peptide, TBP fails to bind AF1. The kinetic patterns showed that binding of both peptide and TBP to AF1 result in conformational changes in the complex. Our biophysical analyses showed that upon either peptide or TBP binding, AF1 adopts a compact/stable structure. A comparison of TBP- and peptide-induced structural changes in AF1 indicates differential rearrangements of AF1 surfaces. In this peptide-induced AF1 conformation, TBP and SRC-1 fail to synergize. Our studies have identified a small peptide that may synergistically act to block CoR-mediated AF1 activity of SRs and thereby could open unique opportunities for cell/tissue-specific endocrine-based therapies.

 

Nothing to Disclose: SHK, ELH, RK

20406 13.0000 SAT-282 A A Novel Mechanism to Therapeutic Targeting of AF1 Surfaces to Achieve Tissue-Restricted Activities of Steroid Hormone Receptors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM SAT 270-284 5921 1:00:00 PM Nuclear Receptors, Ligands and Co-Regulators Poster


Nitesh D Kuhadiya*1, Sandeep S Dhindsa2, Husam Ghanim3, Manav Batra4, Kelly Green5, Robin Girdhar6, Antoine Makdissi3, Ajay Chaudhuri1 and Paresh Dandona1
1Diabetes and Endocrinology Center of Western New York, Buffalo, NY, 2Texas Tech University Health Sciences Center, Odessa, TX, 3State University of New York at Buffalo, Buffalo, NY, 4University at Buffalo, Buffalo, NY, 5SUNY at Buffalo, 6Suny at Buffalo, Williamsville

 

We have recently shown that liraglutide, a GLP-1 receptor agonist, improves diabetic control in patients with type 1 diabetes through reduction in glycemic levels and glycemic excursions. Since these patients have no β-cell reserve, the mechanism underlying these effects is not clear. We hypothesized that liraglutide suppresses post prandial glucagon increase and the intake of carbohydrates. Thirty two patients were randomized into two groups, one of whom was treated with liraglutide 1.8 mg daily and the other with placebo for 12 weeks. HbA1c fell by 0.43% in the liraglutide group with a reduction in the insulin dose by 20% while it was reduced by 0.3% in the placebo group without any change in insulin dose. C-peptide concentrations were non-detectable both at the beginning and at the end. There was no significant change in fasting levels of glucagon following 12 weeks of treatment while there was a significant increase in fasting GLP-1 and GIP concentrations in the liraglutide group by 19±6% and 15±6% (P<0.05). Before start of interventions, the consumption of a high fat and high carbohydrates (HFHC) meal, induced a significant increase in plasma glucagon levels in both study groups. At the end of 12 weeks, there was in increase by 35±7% (P=0.018) in the liraglutide group compared to baseline. This was associated with lower glucose excursion by 21±8% (P=0.017) at 12 weeks while there was no significant change in glucose excursions in the placebo group. In addition, carbohydrate intake fell, both as total quantity by 30±5% (from 153±18 grams to 107±15 grams, p<0.05) and as the number of daily helpings (from 3.5 to 3 /day). Liraglutide treatment for 12 weeks induced a significant reduction in basal plasma concentration of CRP, FFA and endotoxin by 19±8, 21±5% and 24±6%, respectively (P<0.05) and in basal mRNA expression of IL-1β, JNK-1, and SOCS-3 in peripheral blood mononuclear cells (MNC) by 22±7%, 19±6% and 23±6%, respectively (p<0.05) as reported. There was no change in these parameters in the placebo group. We conclude that the beneficial effects of liraglutide on glycemia in patients with type 1 diabetes are due to marked reductions in post prandial concentrations of glucagon and carbohydrate intake. In addition, the anti-inflammatory actions may also contribute to insulin sensitivity and glucose disposal.

 

Nothing to Disclose: NDK, SSD, HG, MB, KG, RG, AM, AC, PD

21107 1.0000 SAT-625 A Effect of Liraglutide on Post Prandial Glucagon, Carbohydrate Intake and on Inflammation in Patients with Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Steven E Thiessen*1, Ilse Vanhorebeek1, Inge Derese1, Jan Gunst1 and Greet Van den Berghe2
1KU Leuven, Leuven, Belgium, 2Katholieke Universiteit Leuven, Leuven, Belgium

 

Aims: Fibroblast growth factor 21 (FGF21) is a hormone that regulates metabolism (1). FGF21 is elevated in diabetes mellitus and is induced by mitochondrial damage, controlled by mediators of the integrated stress response (ISR) (2-3). Targeting normoglycemia (80-110 mg/dl) during critical illness has shown to attenuate mitochondrial damage and may improve survival as compared with tolerating hyperglycemia up to 215 mg/dl (4-5). We hypothesized that critical illness elevates serum concentrations of FGF21, possibly evoked by mitochondrial damage in vital organs, brought about by ISR mediators. We also hypothesized that targeting normoglycemia during critical illness suppresses FGF21 gene expression and FGF21 serum concentrations, which could relate to its outcome benefit.

Methods: We quantified FGF21 serum concentrations on admission, day 3, day 7 and last day in ICU in 405 patients requiring intensive care for at least 7 days, who were randomized to normoglycemia or tolerating hyperglycemia, and in 20 matched controls. In 39 critically ill rabbits randomly assigned to normoglycemia or hyperglycemia, FGF21 gene expression was quantified on day 3 or day 7 in liver, kidney, muscle and adipose tissue and compared with healthy controls. Correlations between FGF21 expression and mitochondrial complex activities and ISR mediators were analyzed.

Results: In patients, median serum FGF21 concentrations were 8-fold higher than normal upon ICU admission (p<0.0001), decreased with time and were always higher in non-survivors than survivors (p≤0.006). Maintaining normoglycemia lowered serum FGF21 (AUC) by a median 36% (p=0.01). In multivariate logistic regression analysis, this FGF21 effect statistically explained the mortality benefit of the intervention. In critically ill hyperglycemic rabbits, FGF21 expression in liver on day 3 was >300-fold higher than normal (p<0.0001) which was lowered by maintaining normoglycemia (p<0.0001). On day 7, the FGF21 rise in hyperglycemic animals was less pronounced than on day 3 (p=0.01) but normoglycemia again lowered FGF21 expression (p=0.01). In kidney, muscle and adipose tissue, FGF21 expression was undetectable. In liver, FGF21 expression correlated inversely with mitochondrial function on both days (all R2≥0.49, all p≤0.0006 for complex I and V) and positively with ISR mediators on day 3 (R2≥0.73, p≤0.0001).

Conclusions: In human patients, serum FGF21 was found to be immediately and markedly increased by critical illness, possibly driven by the ISR in the liver. Targeting normoglycemia lowered circulating FGF21 in patients, likely by suppressing liver FGF21 expression as shown in the experimental model. This FGF21 effect explained at least part of the mortality benefit of glycemic control in ICU patients. Whether the FGF21 rise in ICU patients is an adaptive response to mitochondrial damage should be further investigated.

 

Nothing to Disclose: SET, IV, ID, JG, GV

20292 2.0000 SAT-626 A Fibroblast Growth Factor 21 and the Integrated Stress Response to Critical Illness 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Pooja Raghavan*1, Elizabeth Liu2, Andrea Mari3, Monica C. Skarulis4 and Ranganath Muniyappa5
1National Institutes of Health, North Bethesda, MD, 2NIDDK, 3Institute of Biomedical Engineering, National Research Council, Padova, Italy, 4DEOB, NIDDK, NIH, 5Diabetes Endocrinology and Obesity Branch, NIDDK, NIH

 

Background: African Americans (AA) are more prone to developing diabetes and are less insulin-sensitive compared to Caucasians (C). Few studies, mainly in women, have examined differences in β-cell function following an intravenous glucose challenge. β-cell glucose sensitivity for insulin secretion in these studies was found to be higher in AA. However, there are no studies examining the ethnic differences in β-cell responsivity using a more physiologic stimulus such as a mixed-meal.

Objective: Using a cross-sectional study design, we sought to compare model-assessed β-cell function and insulin clearance in non-diabetic, overweight/obese AA (n=36) and C (n=47) after a mixed meal test (MMT).

Methods: Insulin secretion rate (ISR) was calculated by C-peptide deconvolution. ISR as a function of plasma glucose levels (glucose sensitivity), rate of glucose changes (rate sensitivity), and potentiation factor was derived from a mathematical model. Insulin sensitivity was measured by frequently sampled intravenous glucose tolerance test (FSIVGTT). In a separate cohort, levels of insulin degrading enzyme (IDE) and carcinoembryonic antigen-related cell adhesion molecule-1 (CEACAM1), key players in insulin clearance, were measured (by ELISA) in hepatic membrane fractions from age-, gender-, and BMI-matched AA and C cadaveric liver donors (n=6). Hepatic IDE activity was measured by fluorescence assay. Data are expressed as mean ± SEM.

Results: AA were less insulin sensitive (insulin sensitivity index: 3.6 ± 0.5 vs. 6.5 ± 0.6, p<0.05). Fasting and mean postprandial plasma glucose levels were similar in both ethnic groups. AA had higher fasting (61 ± 7 vs. 38 ± 5 pmol/L, p<0.05) and mean postprandial plasma insulin levels (259 ± 23 vs. 195 ± 21 pmol/L, p<0.05). However, fasting insulin secretory rate and total insulin output during MMT were not different between the groups. Fasting and meal plasma insulin clearance was lower in AA (fasting: 1.96 ± 0.20 vs. 2.90 ± 0.16 L/min/m2; meal: 1.09 ± 0.06 vs. 1.49 ± 0.06 L/min/m2, p<0.05). Glucose sensitivity was similar but rate sensitivity was higher in AA (2677 ± 255 vs. 1750 ± 216 pmol/m2/mmol, p<0.05). Hepatic levels of IDE and CEACAM1 were similar in AA and C. However, hepatic IDE activity tended to be lower in AA (2.21 ± 0.19 vs. 3.21 ± 0.59 RFU/µg/30 min, p=0.07).

Conclusions: In this study, there were no ethnic differences in β-cell glucose sensitivity or insulin secretory rates (fasting or during MMT). Thus, it is likely that lower insulin clearance contributes to higher plasma insulin levels in AA. Discrepancies in insulin clearance may be explained by lower IDE activity levels in AA. However, further studies with a larger cohort are needed to investigate diminished insulin clearance in AA as a result of lower IDE activity levels.

 

Nothing to Disclose: PR, EL, AM, MCS, RM

21892 3.0000 SAT-627 A Ethnic Differences in Pancreatic ß-Cell Glucose Sensitivity, Insulin Clearance, and Hepatic Insulin Degrading Enzyme (IDE) Activity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Malini S Iyer*1, Orison O Woolcott1, Viorica Ionut2, Morvarid Kabir1, Richard N Bergman3 and Cathryn Kolka1
1Cedars Sinai Medical Center, Los Angeles, CA, 2Cedars Sinai Medical Center, LA, CA, 3Cedars-Sinai Medical Center, CA

 

Over-activation of sympathetic nervous system has been linked to obesity-related metabolic dysfunction. Renal sympathetic denervation (RDN) is a clinical technique recently developed to treat patients with drug-resistant hypertension. The recent Symplicity-3 clinical trial showed that RDN reduced fasting plasma glucose and insulin levels in hypertensive patients, although the mechanism is unknown. To study the mechanism by which RDN improves the metabolic profile of glucose and insulin, we performed RDN bilaterally in obese normotensive dogs.  Protocol:  Dogs were put on 6 weeks of high fat diet (HFD, 52% fat, n=4) to induce insulin resistance. Frequently sampled intravenous glucose tolerance tests (FSIGT) were performed before fat-feeding (w0) and after the 6 weeks of HFD (w6-HFD); Insulin sensitivity (SI) decreased with 6 weeks of HFD, as expected (4.9±1.01 µU/mL-1.min-1 at w0 vs 2.26±0.4 µU/mL-1.min-1 at w6-HFD, P=0.05).  Then, after 6 weeks, RDN surgery was performed under anesthesia:  In both kidneys we stripped all the adventitia and visible nerves around the renal arteries and then painted with 10% phenol. Successful denervation of the kidneys was confirmed by measuring noradrenaline in the renal cortex. Despite continuation of the HFD, SI was restored to baseline by RDN (3.9±1.1 µU/mL-1.min-1 at HFD+RDN vs 2.26±0.4 µU/mL-1.min-1 at w6-HFD, P=0.1 and 4.9±1.01 µU/mL-1.min-1 at w0, P=NS).  In addition RDN improved the acute insulin response to glucose (AIRg) compared to either w6-HFD (615.4±38 µU/mL.min vs 436.4±27.5 µU/mL.min, P=0.02) as well as w0 (426.3±45.4 µU/mL.min at w0, P=0.03). This improvement in insulin response was also reflected in normalization of the disposition index (DI, 2363.4±848.6 at HFD+RDN vs 1178.9±140.0 at w6-HFD and 1948.0±604.0 at w0, P=NS).  Renal denervation normalizes glucose utilization despite a high fat diet due to improvements in insulin action as well as insulin release.  The role of the SNS in these improvements remains to be clarified but it may indicate that denervation may result in a treatment for obesity-related metabolic dysfunction.

 

Nothing to Disclose: MSI, OOW, VI, MK, RNB, CK

20115 4.0000 SAT-628 A Renal Sympathetic Denervation Improves Metabolic Function in Obese Insulin Resistant Canines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Rebecca J. Brown*1, Ranganath Muniyappa2, Peter J Walter2, Ahmed M. Gharib2, Ronald Ouwerkerk2, Megan Mattingly2, Elaine Cochran2 and Phillip Gorden2
1National Institute of Health, Bethesda, MD, 2NIH, Bethesda, MD

 

Leptin is an adipokine secreted in proportion to fat mass that regulates energy balance.  Patients with lipodystrophy (LD) have leptin deficiency due to lack of adipose tissue, and are a natural model to study effects of leptin deficiency and replacement in humans.  Leptin replacement in LD reduces food intake, improves insulin resistance/diabetes, and lowers triglycerides (TG).  Pair-feeding studies in rodents have shown that leptin, independent of changes in food intake, decreases insulin resistance and blood glucose, but not TG.  This has not been explored in humans. We aimed to determine if leptin improves glucose and lipid metabolism in LD, independent of its effects on food intake.

This was a 2 period non-randomized crossover study, including previously leptin-treated (N=5, all generalized LD, treatment duration 1-12y) and leptin-naïve (N=10, 9 partial LD) subjects.  Subjects were hospitalized for 19d on a weight-maintenance diet.   In period 1 (5d) the leptin-treated group continued leptin; leptin was withdrawn for the next 14d (Period 2).  Leptin-naïve subjects were studied without leptin in Period 1, and with leptin replacement in Period 2. At the end of each period, outcomes included: insulin sensitivity (M, mg/kgFFM/min) via hyperinsulinemic euglycemic clamp, hepatic insulin sensitivity (HIS) as % suppression of endogenous glucose production during the clamp using isotopic tracers, lipolysis as glycerol turnover using tracers (mg/kgFFM/min), % TG in liver and muscle using magnetic resonance spectroscopy, and fasting glucose (mg/dL) and TG (mg/dL).

In leptin-treated subjects transitioning from the leptin replete to deficient state, muscle and liver insulin sensitivity worsened in all subjects (M from 5.7±1.7 to 10.5±4.6 [P=0.06]; HIS from 55±23 to 109±26% [N=3]); glucose was unchanged from 92±15 to 111±40 (P=0.6).  TG and lipolysis trended up (TG from 146±83 to 246±163 [P=0.18]; lipolysis from 0.2±0.1 to 0.4±0.1 [N=2]), and ectopic TG increased in liver and muscle in a single subject.  In leptin-naïve subjects transitioning from the leptin deficient to replete state, glycemic parameters were unchanged (M from 4.2±2.4 to 5.0±2.4 [P=0.10]; HIS from 62±23 to 57±21 [P=0.8; N=5]; glucose from 153±45 to 144±43 [P=.25]). In this group, serum and ectopic TG trended down with leptin treatment (serum TG from 1017±1366 to 442±378 [P=0.08], liver TG from 27.5±8.6 to 16.7 ±17.9 [N=3], intramyocellular TG from 11.0±3.4 to 9.1±0.7 [N=2], and extramyocellular TG from 21.6±8.5 to 14.4±4.7 [N=2]); lipolysis did not change (0.8±0.1 to 0.8±0.2 [P=0.6; N=4]).

In generalized LD, leptin withdrawal worsened glucose and lipid metabolism during constant food intake, strongly suggesting that leptin has effects independent of energy balance.  In subjects starting leptin (mostly partial LD), effects of leptin independent of food intake were less marked, possibly due to less severe leptin deficiency.

 

Nothing to Disclose: RJB, RM, PJW, AMG, RO, MM, EC, PG

18718 5.0000 SAT-629 A Effects of Leptin on Glucose and Lipid Metabolism during Constant Food Intake 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Ali Iranmanesh*1, Donna Marie Lawson1 and Johannes D Veldhuis2
1VA Medical Center, Salem, VA, 2Mayo Clinic, Rochester, MN

 

Insulin role in glucose homeostasis in fed and fating states is believed to be modulated by the incretins, GLP-1 and GIP. Such associations, and the pulsatile nature of insulin and GLP-1 secretion are highly suggestive of rhythmic GIP release. In this study, GIP secretory properties were assessed in 19 normal men (age: 18-60 years, BMI: 21-39 Kg/m2) after water and dextrose intake. Each subject was studied on 2 randomly assigned separate occasions after an overnight fast, consisting of ingestion of either 75 grams of dextrose solution or equal volume of water. All sessions started between the hours of 0800-0900 and continued for 6.5 hours, with blood collected at 10-min intervals for GIP measurements. The secretory pattern of GIP was assessed by deconvolution analysis. ApEn was used to assess regularity of serial GIP release. Results are reported as mean ± SD, unless indicated otherwise. Oral dextrose ingestion resulted in a marked increase in mean (± SE) 6.5 hour circulating GIP concentrations (94 ± 7.3 vs 31 ± 4.4 vs pg/mL: P<0.0001). Deconvolution analysis of GIP time series identified basal and pulsatile secretory events contributing to total GIP secretion, both on water and dextrose days. Dextrose ingestion induced significant increases in total GIP release from 527 ± 428 to 1,313 ± 484 (P < 0.001), primarily due to augmented pulsatile component (994 ± 363 vs199 ± 137: P<0.001). Post-dextrose increases in pulsatile GIP release was attributed to jointly amplified burst mass (181 ± 63 vs 60 ± 46: P<0.001) and increased secretory burst frequency (5.7 ± 1.4 vs 3.6 ± 1.3: P <0.001). ApEn of GIP concentration time series decreased after dextrose intake (0.392 ± 0.112 vs 0.678 ± 0.206: P<0.0001). In conclusion, the present study demonstrated a strong pulsatile pattern in GIP release both in the fasted and fed states. Oral nutrient intake improved regularity of GIP patterns, and amplified the pulsatile component by increasing burst mass and burst frequency. Potential effect of age and adiposity on GIP secretory properties warrant future investigation.

 

Disclosure: JDV: Consultant, Astra Zeneca. Nothing to Disclose: AI, DML

19855 6.0000 SAT-630 A Fasting and Post Oral Dextrose Gip Secretory Dynamics in Healthy Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Hyo Kyun Chung*1, Koon Soon Kim2, Bon Jeong Ku3 and Minho Shong4
1Chungnam National University School of Medicine, Daejeon, Korea, Republic of (South), 2Chungnam National University College of Medicine, Daejeon, Korea, Republic of (South), 3Chungnam National University Hospital, Daejeon, Korea, Republic of (South), 4Chungnam Natl Univ Hopsital, Daejeon, Korea, Republic of (South)

 

Human mitochondrial disease is manifest as a various clinical outcomes largely dependent on the magnitude and tissue distribution of the impairment. In the clinical studies, mitochondrial dysfunction of skeletal muscle is suggested as an etiology of insulin resistance and contributes to development of diabetes. However, the metabolic phenotype of abnormal OXPHOS in skeletal muscle remains to be identified. Here, we generated skeletal muscle specific Crif1 knockout mice, crossing the Crif1f/f mice to myosin light chain (MLC)-cre mice. Muscle specific Crif1 knockout pups were born healthy, viable, but adult mouse showed progressive loss of body weight, skeletal muscle and fat mass. Furthermore, increased mortality and decreased physical performance were observed in this model. Ultra-structural examination showed increased abnormal mitochondria and also, decreased OXPHOS complex was confirmed in skeletal muscle. Interestingly, these mice had improved glucose disposal compared to control mice. We report here that OXPHOS defect of skeletal muscle induce muscle atrophy and enhance glucose disposal. Therefore, we suggest that Crif1 is a critical factor for OXPHOS complex and mitochondrial OXPHOS determines the regulation of skeletal muscle mass, functions, and may be insulin resistance.

 

Nothing to Disclose: HKC, KSK, BJK, MS

20278 7.0000 SAT-631 A Skeletal Muscle Specific Oxphos Defect Mice Exhibit Muscle Atrophy and Enhanced Glucose Disposal 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Yani Chen*1, Rebecca Woelfle2, Andrea D'Aquila3, Mei Xu1, Christopher Bull4, Dhan Chand1, Claudio Casatti5 and David A Lovejoy1
1University of Toronto, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, 3University of Toronto, Oakville, ON, 4Molecular Imaging, Inc., 5Sao Paulo State University

 

A hallmark feature of type-2 diabetes is insulin resistance. Thus, treatments of type-2 diabetes include those that act independent of insulin-sensitive pathways. New discoveries indicate that the Teneurin C-terminal Associated Peptide (TCAP)-1 is intrinsically associated with glucose metabolism, and appears to be the natural endogenous ligand of the black widow spider toxin receptor, latrophilin. In normal and Goto-Kakizaki rats, nanomolar concentrations of TCAP-1 decreases plasma glucose levels 15-20% one week after a single subcutaneous (SC) injection. Similarly, positron emission tomography (PET) studies show a significant uptake of glucose in the rat brain after a single SC injection after 3 days. In vitro, TCAP-1 administration results in increased ATP production, decreased lactate accumulation and increased glucose transporter relocation to the plasma membrane of neurons. TCAP-1 also induces 3H-deoxyglucose transport into neurons in an insulin-independent manner. These findings indicate that the primary role of TCAP may be to regulate metabolic optimization in the brain by increasing the efficiency of glucose transport and energy utilization. To understand the mechanism by which this occurs, we used a previously established pathway by which TCAP-1 signals in vitro to establish a link between the MEK-ERK1/2 pathway and glucose uptake as well as a connection between the MEK-ERK1/2 and AMPK pathways. TCAP-1 administration results in increased AMPK phosphorylation associated with the longer residency time of glucose transporters in the plasma membrane. The structure and expression of TCAP-1 in primates is almost identical to that in rats, therefore, we suggest that the role of TCAP-1 in regulating glucose metabolism could be useful in management of hyperglycemia in humans.

 

Disclosure: DAL: Chief Scientific Officer, Protagenic Therapeutics, Inc.. Nothing to Disclose: YC, RW, AD, MX, CB, DC, CC

21039 8.0000 SAT-632 A Insulin-Independant Transport of Glucose into the Brain with Prolonged Reduction of Plasma Glucose By Teneurin C-Terminal Associated Peptide (TCAP)-1: A Potential New Approach to the Treatment of Type II Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Carina Preskill*, Pankaj Shah and Adrian Vella
Mayo Clinic, Rochester, MN

 

Background: The rates of obesity, and subsequently Roux-en-Y gastric bypass (RYGB), continue to rise worldwide.  At the same time, there is a corresponding rise in the number of associated complications.  Postprandial hypoglycemia is an increasingly recognized complication of RYGB, typically presenting one to three years following RYGB and is characterized by both vasomotor and neuroglycopenic symptoms that occur one to two hours after food intake.  The pathophysiology of postprandial hypoglycemia after RYGB remains unclear.  Methods: To better understand the underlying etiology of this syndrome, we retrospectively reviewed mixed meal data from a group of 31 RYGB patients with symptomatic postprandial hypoglycemia who were evaluated at our institution for this diagnosis from 2009-2013.  These were compared to data from a group of asymptomatic subjects who had previously undergone RYGB.  All of these patients underwent a mixed meal test in which they ate a standardized meal containing carbohydrate, fat, and protein (in solid form). Glucose, insulin, and glucagon concentrations were then measured at 30 minute intervals for the following 300 minutes.  Results:  In asymptomatic RYGB subjects, glucagon rose within 30 minutes of meal ingestion.  This did not occur among the symptomatic RYGB patients (ratio of glucagon at 30 minutes compared to baseline levels was 1.34±0.14 vs. 0.96±0.17, p=0.005).   The asymptomatic patients also had corresponding higher glucose levels at 30 minutes (205±12.1 mg/dL vs. 127±4.5 mg/dL, p<0.001) and at 60 minutes (152±14.6 mg/dL vs. 111±5.2 mg/dL, p=0.002), but did not have significantly different glucose levels after 90 minutes.  Only two of the 31 patients with post-RYGB hypoglycemia experienced glucose < 55mg/dL during the mixed meal test.  Conclusion: The postprandial rise in glucagon concentrations observed in post-RYGB patients may be necessary to maintain endogenous glucose production in the presence of rapid meal appearance post-RYGB.  It is possible that in the absence of appropriate glucagon secretion in symptomatic post-RYGB patients, other counterregulatory responses to prevent hypoglycemia account for the symptoms experienced even in the absence of hypoglycemia.

 

Nothing to Disclose: CP, PS, AV

19648 9.0000 SAT-634 A Abnormal Postprandial Glucagon Responses in Roux-En-Y Gastric Bypass Patients with Symptoms of Postprandial Hypoglycemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Chikako Fujii*1, Kazutoshi Miyashita2, Masanori Tamaki2, Kentaro Fujii2, HIroyuki Inoue2, Aika Hagiwara2, Hidetoshi Kawai3 and Hiroshi Itoh2
1School of Medicien, Keio University, Tokyo, Japan, 2School of Medicine, Keio University, Tokyo, Japan, 3School of Medicine, Keio university, Tokyo, Japan

 

 Sarcopenia affects not only physical performance, but also increases the risk for metabolic diseases and cardiovascular diseases. Treatment for sarcopenia so far has been aimed to increase muscle mass, and activation of muscle mitochondria was placed in secondary importance. Aminolevulinic acid (ALA) is a precursor of mitochondrial electron carrier, which is synthesized to heme or cytochrome C. In the present study, physical performance, glucose tolerance and body weight of ALA-treated mice (0.03%-ALA/ chow weight) were examined to elucidate the usefulness of ALA for the treatment of sarcopenia. Harvested skeletal muscle was examined for factors related to mitochondrial amount and function. Expressions of PGC1a and UCP3 were up-regulated, and mitochondrial amount were increased in the skeletal muscle of ALA-treated mice. Decreased muscle strength, exercise endurance and glucose tolerance of aging mice and 5/6 nephrectomized mice, which were sarcopenic with reduced amount of muscle mitochondria, were improved by the ALA-feeding for 8weeks. Food intake, body weight and muscle volume were also increased. In the experiments using cultured myocytes treated with ALA, expressions of PGC1a and UCP3, and mitochondrial amount were increased, associated with augmented oxygen utilization. Suppression of electron transport by antimycin A attenuated the increases in oxygen utilization, PGC1a expression and mitochondrial amount in ALA-treated myocytes. In summary, ALA improved exercise endurance and glucose intolerance of sarcopenic mice through increases in muscle PGC1a expression and mitochondrial amount. These results indicated the usefulness of ALA for improvement of physical performance and glucose tolerance in sarcopenic patients through activation of muscle mitochondria.

 

Nothing to Disclose: CF, KM, MT, KF, HI, AH, HK, HI

19279 10.0000 SAT-635 A 5-Aminolevulinic Acid, Aprecusor of Mitocondrial Electron Carrier, Improves Exercise Endurance and Glucose Tolerance through Activation of Muscle Mitochondrial Biogenesis in Saropenic Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Maria Chondronikola*1, Robert A Rodriguez2, Sylvia Ojeda3, David N. Herndon4 and Walter J. Meyer III4
1University of Texas Medical Branch at Galveston, Galveston, TX, 2Shriners Hospital for Children-Galveston, 3Shriners Hospital for Children, Galveston, TX, 4University of Texas Medical Branch, Galveston, TX

 

Although advances in the treatment of severely burned patients have improved the reported survival rates, pediatric burn injury survivors continue to experience numerous metabolic perturbations, which may persist up to three years post burn. The purpose of this study was to determine the prevalence of pre-diabetes in post acute pediatric burn injury survivors and detect potential predictors on impaired glucose metabolism.

The study sample consisted of 83 pediatric patients (age 6.9 ± 0.6 years old, 65% male, 47.6 ± 1.5% total body surface area burn). A 2hr oral glucose tolerance test (OGTT) was performed 22±2 days post burn and participants’ glycemic status was defined according to the Diagnostic Criteria of the American Diabetes Association 2014. The ratio of the 2hr OGTT area under the curve for glucose and insulin was used as an index of insulin sensitivity. Family history of diabetes, anthropometric, and socio-demographic information were also obtained from participants’ medical record.

According to the study results, the prevalence of pre-diabetes and diabetes was 30.1% and 2.1%, respectively. Patients with pre-diabetes or pre-diabetes were significantly older than patients with a normal OGTT (8.7±2.0 years vs. 6.0 ± 0.7 years, p<0.05). Moreover, they had a higher fasting insulin (19.3±6.7µIU/mLvs.8.9 ± 0.9µIU/mL, p<0.05), fasting glucose (107.0 ±9.8 mg/dLvs.91.3±3.1mg/dL, p<0.001) and 2hr OGTT glucose (130 ± 7.4mg/dL vs.103 ±2.5mg/dL, p<0.001) indicating an abnormal fasting and postprandial glucose metabolism. According to the results of the multiple linear regression analysis, age and burn size were independent predictors of insulin sensitivity (P<0.05 for both).

These results indicate that the prevalence of pre-diabetes is high among post-acute pediatric burn injury survivors. Patients with large burns and of older age appear are more probable to manifest abnormal glucose metabolism in the post-acute phase of the injury. Future studies are needed to investigate the effect of pharmacological and lifestyle interventions to improve glucose metabolism in pediatric burn injury survivors.

 

Nothing to Disclose: MC, RAR, SO, DNH, WJM III

21119 11.0000 SAT-636 A Prevalence of Pre-Diabetes and Predictors of Insulin Resistance in Post-Acute Pediatric Burn Injury Survivors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Anna Benrick*1, Milana Kokosar1, Martin Larsson2, Manuel Maliqueo3, Min Hu4, Peter Thorén5 and Elisabet Stener-Victorin4
1Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2University of Gothenburg, Institute of Neuroscience and Physiology, 3University of Chile, Santiago, Chile, 4Karolinska Institutet, Stockholm, Sweden, 5University of Gothenburg, Institute of Neuroscience and Physiology, Gothenburg, Sweden

 

Acupuncture for 4-5 weeks with low-frequency (2 Hz) electrical stimulation, improves insulin sensitivity, lipid profile and modulates skeletal muscle and adipose tissue gene expression. And, a single acupuncture treatment with electrical stimulation improves insulin sensitivity, though the mechanism of action is not yet elucidated. This study aims to investigate the mechanism linking acupuncture and insulin sensitivity by administering blocking agents for sympathetic and opioid receptors. We also determined gene expression of key regulatory molecules in skeletal muscle.

Fourteen weeks old female rats were each randomly divided into two experimental groups; 1) no-stimulation or 2) electrical stimulation acupuncture in combination with the following blocking agents; A bolus of naltrexone (10 mg/kg), phentolamine (5 mg/kg), propranolol (1 mg/kg), phentolamine and propranolol, or saline. Followed by a continuous infusion of phentolamine (7mg/kg/h) and propranolol (0.5mg/kg/h) throughout the experiment.

Insulin sensitivity was measured by euglycemic-hyperinsulinemic clamp and glucose infusion rate (GIR) was monitored at steady state, during treatment and a 45-minute follow up period. Electrical stimulation groups were given 2 Hz stimulation with an intensity evoking muscle twitches while no-stimulation controls were kept at steady state without receiving acupuncture treatment. Blocking agent was given after 30 minutes into acupuncture treatment during steady state.

Acupuncture with electrical stimulation, increased GIR by 25% during and after stimulation compared to steady state (p<0.01). Naltrexone, an opioid receptor antagonist, did not affect GIR in rats receiving electrical stimulation. After administration of phentolamine and propranolol, unselective α- and β-adrenergic receptor antagonists, the blocking effect was immediate and GIR did not differ from steady state. Blocking either α- adrenergic or β-adrenergic receptors partially blocked the GIR. Phosphorylated ERK expression was increased in skeletal muscle by electrical stimulation and decreased by blocking of α- and β-adrenergic receptors (1±0.15 vs. 0.5±0.06). Blocking of sympathetic nerves did not alter upstream targets of ERK including GRK2/3, LKB1 and CaMKKIIα. Serum interleukin (IL)-6 levels increased during clamp (514±353 vs. 5305±551, p<0.05), and this increase was gone with phentolamine and propranolol infusion (1215±509 vs. 2229±914, ns).

The insulin sensitizing effect of a single acupuncture treatment is at least in part mediated via the sympathetic nervous system and does not seem to involve β-endorphins. The mechanism involves phosphorylation of ERK in skeletal muscle.

 

Nothing to Disclose: AB, MK, ML, MM, MH, PT, ES

20376 12.0000 SAT-637 A Sympathetic Nerve Antagonists Can Block the Increase in Glucose Uptake after One Electrical Stimulation Acupuncture Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Amrita Kamat*1, Yun Shi2, Zhen-Ju Shu2 and Quynh Ngo2
1South Texas Veterans Health Care System, San Antonio, TX, 2University of Texas Health Science Center at San Antonio, San Antonio, TX

 

Aging and obesity pose increased risks for the development of metabolic syndrome which manifest as impaired glucose tolerance, hepatic steatosis and dyslipidemia. Studies from our laboratory and others have demonstrated that obesity and aging increase beta adrenergic receptor (β-AR) membrane content and associated adenylyl cyclase responsiveness in liver. Furthermore, we have shown that β-AR activation acutely induces hepatic insulin resistance in rats. The β-AR subtype, β2-AR, is ubiquitously expressed and increasingly being recognized as an important mediator for insulin secretion and glucose metabolism. In the current study, we evaluated the effects of β2-AR deficiency and the impact of aging or high-fat diet (HFD) challenge on the metabolic profile. We found that in young animals (~5 months), β2-AR disruption did not alter glucose or insulin action, whereas in aged animals (>20 months), loss of β2-AR function significantly improved glucose tolerance (p=0.01) while showing a trend for greater insulin sensitivity (p=0.09). The plasma levels of cholesterol, free fatty acids, triglycerides and insulin were not altered in old knockout (KO) mice when compared to age-matched wild-type (WT) animals. When young KO and WT mice were challenged with a high-fat diet (60% calorie from dietary fat) for 6 months, both groups showed similar weight gain, body composition, resting metabolic rate, glomerular filtration rate and blood pressure. No significant difference was found in glucose tolerance test or insulin tolerance test. In summary, data from these studies suggest that loss of β2-AR does not alter glucose/insulin metabolism at a young age. However it improves glucose tolerance in aged animals. On the other hand, β2-AR deficiency does not protect against HFD-induced metabolic alterations in young animals. Studies are on-going to investigate the insulin signaling pathways in liver, skeletal muscle, and adipose tissues, and compare the responses between KO and WT mice with aging and HFD.

 

Nothing to Disclose: AK, YS, ZJS, QN

19387 13.0000 SAT-638 A Loss of Beta2-Adrenergic Receptor (β2-AR) Function Improves Glucose Tolerance in Aged Animals but Does Not Protect Against Diet-Induced Metabolic Alterations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Ikki Sakuma*, Akitoshi Nakayama, Hidekazu Nagano, Naoko Hashimoto, Sawako Suzuki, Takafumi Mayama, Hisashi Koide, Koutaro Yokote and Tomoaki Tanaka
Chiba University Graduate School of Medicine, Chiba, Japan

 

Background

Iron is an essential cofactor for many proteins that function in electron transport or oxygen transport as iron-sulfur cluster or heme. However, excess ferrous iron cause oxidative damage, leading to cytotoxity. Increased body iron stores have been shown to be characteristics of NAFLD and Type 2 diabetes. Iron metabolism has recently been noted association with life-related disease. On the other hands, hepatic p53 expression is elevated in patients with NAFLD.  p53 regulates hepatic fat accumulation. Iron metabolism and p53 also has been shown to associate with pathogenesis of NAFLD and diabetes. But relationships between iron metabolism and p53 metabolism has not been sufficiently examined. We have identified ferredoxin reductase (FDXR) as p53 inducible gene concerned iron metabolism using RNA-sequencing. In the present study, we examined the role of FDXR  during NAFLD through iron metabolism using in vitro and in vivo analysis.

Results

        p53 and FDXR expression levels in the liver of C57BL6 mouse after High fat diet (HFD). We also confirmed that p53 induced FDXR expression in SKHEP1, HCT116 and adipocyte. In vitro analysis, immunohistochemistry showed that FDXR colocalized with each complex of respiratory chain. FLAG-IPs and Complex2-IPs on H1299 cells transiently expressing FLAG-tagged FDXR suggested that FDXR interacted with complex 2 and 3 of respiratory chain, indicating that FDXR regulates respiratory chain. FDXR knockdown in SKHEP1 upregulated IRP2, leading to increase of cellular ferrous iron. In vivo analysis, treatment with the FDXR adenovirus significantly improved glucose intolerance mediated by HFD and decrease ferrous iron content in the liver, whereas FDXR knockdown exacerbate glucose intolerance and increase ferrous iron content. Gene expression analysis in the liver suggested that FDXR knockdown activated PGC1α, a key transcription factor that mediates upregulation of PCK1 and G6PC, with consequent hepatic gluconeogenesis activation.

Conclusion

       p53 inducible FDXR downregulated cellular ferrous iron, through inhibition of IRP. Moreover, FDXR inhibits ferrous iron accumulation in liver and links to hepatic gluconeogenesis regulation through PGC1α activation.

 

Nothing to Disclose: IS, AN, HN, NH, SS, TM, HK, KY, TT

20391 14.0000 SAT-639 A p53 Inducible Fdxr Regulates Iron Metabolism and Links to Hepatic Gluconeogenesis Regulation through PGC1a Activation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Naresh Ramesh*1, Sima Mortazavi2 and Suraj Unniappan3
1Laboratory of Intergrative Neuroendocrinology, Saskatoon, SK, Canada, 2Laboratory of Integrative Neuroendocrinology, Saskatoon, SK, Canada, 3University of Saskatchewan, Saskatoon, SK, Canada

 

The hormones secreted by intestinal mucosal enteroendocrine cells regulate insulin secretion. These include glucagon-like peptide-1 (GLP-1) and peptide YY (PYY), glucose-dependent insulinotropic polypeptide (GIP), and cholecystokinin (CCK). While GLP-1, GIP and CCK are insulinotropic, PYY is insulinostatic. Nesfatin-1 is an anorexigenic and insulinotropic peptide (82 amino acids) found abundantly in the gastric oxyntic mucosa, brain and pancreas. Exogenous nesfatin-1 decreases food intake, and stimulates insulin secretion. The main objectives of this research are to determine whether nesfatin-1 is in the intestine of mice, and it regulates enteric hormone secretion. Immunofluorescence microscopy detected NUCB2/nesfatin-1 immunoreactivity in STC-1 cells, and in the mucosal cells of small and large intestines of male C57BL/6J mice. NUCB2/nesfatin-1 is co-localized with CCK, GLP-1 and PYY immunoreactive cells in the intestine, indicating that enteroendocrine cells are a source of endogenous nesfatin-1. In order to assess the effects of nesfatin-1 on intestinal hormones, STC-1 cells (2X106 cells/well, n=8 wells/treatment; 2 separate studies) were incubated for 1 hour with synthetic rat nesfatin-1. At 1 hour post-incubation, secretion (ELISA/RIA) of GLP-1, GIP, CCK and PYY into the culture media, and the expression of mRNAs (qPCR) encoding these peptides were measured. Nesfatin-1 upregulated preproglucagon (GLP-1 precursor) mRNA at 0.01 nM (~1.2 fold), 0.1 nM (~1.2 fold), 1 nM (~2 fold) and 10 nM (~1.3 fold). Concurrently, total GLP-1 levels were augmented at 0.1 nM (10.9±0.8 pM), 1 nM (10.5±0.8 pM) and 10 nM (9.98±0.8 pM) nesfatin-1 compared to untreated controls (6.6±0.9 pM, p<0.01). Nesfatin-1 increased GIP mRNA expression at 0.1 nM (~2.3 fold), 1 nM (~2.8 fold) and 10 nM (~2 fold). Total GIP levels were also elevated at 0.1 nM (7.7±0.4 pg/mL), 1 nM (9.4±0.3 pg/mL) and 10 nM (8.2±0.4 pg/mL) when compared to controls (5.8±0.1 pg/mL, p<0.1). Nesfatin-1 enhanced CCK mRNA expression at 1 nM (~2 fold) and 10 nM (~2.6 fold), while PYY mRNA was decreased at all doses tested (0.001 nM – 0.7 fold, 0.01 nM – 0.2 fold, 0.1 nM – 0.4 fold, 1 nM – 0.5 fold, 10 nM – 0.3 fold). A corresponding stimulation in CCK secretion was found in 0.1 nM (36.28±2.9 pg/mL), 1 nM (40.14±1.94 pg/mL) and 10 nM (41.50±1.7 pg/mL) doses compared to controls (23±1.06 pg/mL, p<0.01). Similarly, nesfatin-1 attenuated PYY secretion at 0.01 nM (3.95±0.55 pg/mL) and 0.1 nM (5.33±2.35 pg/mL) doses compared to controls (18.45±2.74 pg/mL, p<0.001). These results, for the first time, demonstrate that nesfatin-1 has a direct action on enteroendocrine cells in regulating hormone secretion in vitro. While nesfatin-1 stimulates GLP-1, GIP and CCK, it inhibits PYY secretion. Whether intestinal metabolic hormones modulated by nesfatin-1 mediate its role in the regulation of energy balance remains to be elucidated.

 

Nothing to Disclose: NR, SM, SU

18828 15.0000 SAT-640 A Nesfatin-1 Is Present in Mouse Intestinal Enteroendocrine Cells and Regulates Enteric Hormone Secretion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Mariella Guimaraes Lacerda*1, Michella Soares Coelho2, Ivan da Rocha Pitta3, Angelica Amorim Amato2, Francisco de Assis Rocha Neves2 and Marie Togashi2
1University of Brasilia, Brasilia DF, Brazil, 2University of Brasilia, Brasilia, Brazil, 3Federal University of Pernambuco, Pernambuco-PE, Brazil

 

Anti-hyperglycemic drugs belonging to the class of thiazolidinediones (TZDs), which act as full peroxisome proliferator-activated receptor gamma (PPARγ) agonists, have been widely used in the treatment of type 2 diabetes. Known for their clinical effectiveness in increasing insulin sensitivity, their use is limited by side effects such as cardiovascular mortality, weight gain, and bone loss. Since partial PPARγ agonists are devoid of many unfavorable effects of TZDs, there is an increasing interest in describing and understanding their effects on cardiovascular risk. GQ-16 is a partial PPARγ agonist previously shown to increase insulin sensitivity without promoting weight gain. These promising results raise the question whether other undesirable effects caused by TZDs, specifically cardiovascular toxicity, could be minimized by this ligand. The purpose of this study is to evaluate the effects of different doses of GQ-16 and rosiglitazone (RSG) on gene expression in the heart of mice with diet-induced obesity and insulin resistance. Male Swiss mice were fed from weaning (3 weeks of age) to adulthood (18 weeks of age) with a normal-fat (NFD, 10% kcal fat) or high-fat (HFD, 60% kcal fat, Harlan Teklad) diet. At 16 weeks of age, they were assigned into treatment with vehicle (NFD and one group of HFD-fed mice), GQ-16 (5, 10 or 20 mg/kg/day), and RSG (4 mg/kg/day) by gavage for two weeks. All animals were weighed weekly and fasting blood glucose was measured once a week. At week 18, animals were euthanized and their hearts were weighed. Total RNA was extracted for heart tissue for determination of mRNA levels (RT-qPCR) of adipocyte protein 2 (aP2) gene, a marker of adipogenesis. (p < 0.05, ~ 4 mice/group): At the end of week 16, body weight and mean fasting blood glucose levels of HFD-fed mice was higher compared to NFD-fed mice (58.44 ± 2.40 vs 50.96 ± 2.38 g; and 120.10 ± 3.85 vs 71.25 ± 2.68 mg/dL). Total cardiac mass was higher in HFD + vehicle group compared to NFD + vehicle (0.297 ± 0.029 vs 0.207 ± 0.005 g). Total cardiac mass (0.197 ± 0.026 g) was reduced by RSG treatment in HFD-fed mice whereas there was no change in response to the three different doses of GQ-16 (0.227 ± 0.024; 0.247 ± 0.008; 0.257 ± 0.021 g, respectively). GQ-16 treatment at 20 mg/kg/day dose increased the relative gene expression of aP2 compared to vehicle-treated mice fed with HFD. No differences in the expression of aP2 were observed in the other groups. Our findings indicate different effects of full and partial PPARγ on cardiac mass and expression of aP2 mRNA levels in the heart tissues. Further studies are warranted to clarify the effect of PPARγ ligands with different pharmacological properties in heart tissue and determine the implications of these potential differences.

 

Nothing to Disclose: MGL, MSC, IDRP, AAA, FDARN, MT

21117 16.0000 SAT-641 A Comparison of GQ-16 and Rosiglitazone Effects on Gene Expression in the Heart of Obese and Insulin Resistant Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


In-seung Lee*, Ki-Suk Kim, Eun-Kyeong Choi, Kang-Hoon Kim, Jiyoung Park, Hyeon-Soo Jeong, Yumi Kim, Sung-Ki Jung and Hyeung-Jin Jang
Kyung Hee University, Seoul, Korea, Republic of (South)

 

Glucagon-like peptide-1 (GLP-1) has been the subject of much research as a potential treatment for T2DM in recent year due to its glucose-dependent insulin secreting stimulation effect. In this study, we investigated the blood lowering effect of rutin in db/db mice which is a T2DM animal model and determined that this hypoglycemic effect resulted from the GLP-1 secreting effect of rutin. In addition, we used Gα-gust knock out (KO) mice to determine whether rutin stimulates GLP-1 secretion via the bitter or sweet taste receptor. To study the effect of rutin in the cellular mechanism, a GLP-1 ELISA assay with signaling inhibitors such as lactisole, H-89, gallein, 2-aminoethoxydiphenyl borate (2-APB) and bis-indolylmaleimide (BIM) was performed on human enteroendocrine L cell line, NCI-H716 which expresses taste receptors and related signaling elements. A cAMP assay, phospho-PKA western blotting, and calcium imaging were additionally performed to establish our hypothesis. The results of our study shows, rutin activated the Gα-gust of the taste receptor and increased the production of cAMP, as well as the phosphorylation of PKA. These results of this study not only provide scientific evidence for the usage of rutin on T2DM but also suggest a potential T2DM treatment of rutin given its GLP-1 stimulation effect through the T1R3-mediated signaling pathway.

 

Nothing to Disclose: ISL, KSK, EKC, KHK, JP, HSJ, YK, SKJ, HJJ

20790 17.0000 SAT-642 A Short-Term Treatment with Rutin Stimulates Secretion of the Intestinal Sweet Taste Receptor-Mediated Glucagon-like Peptide-1 GLP-1 on Enteroendocrine L Cells and Has Anti-Hyperglycemic Effect on Db/Db Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Qing Cai, Edmond P. Wickham III*, Trang N. Le and Youngman Oh
Virginia Commonwealth University, Richmond, VA

 

INTRODUCTION: Intact IGFBP-3 improves insulin signaling through activation of a specific IGFBP-3 receptor; however, recent findings demonstrate that obesity-activated neutrophil serine proteases (NSPs) reduce circulating intact IGF-BP3.  Therefore, we propose that inhibition of IGFBP-3 proteolysis by the NSP inhibitor alpha-1-antitrypsin (AAT) can improve obesity-associated insulin resistance. To this end, we investigated the relationships between AAT, IGFBP-3 proteolysis, and insulin sensitivity in a murine model of diet-induced obesity.

METHODS: To examine the effect of AAT treatment on pre-existing obesity-associated insulin resistance, mice fed a high fat diet (HFD) for 8 weeks, n=3 per group, were treated with or without AAT (60mg/kg body weight) for an additional 7 weeks. Insulin tolerance tests (ITT, 0.75U insulin/kg body weight) were performed at 15 weeks. Serum IGFBP-3 proteolysis, quantified as the ratio of IGFBP-3 fragments to total IGFBP-3, was determined by Western immunoblot (IGFBP-3 Antibody, Santa Cruz Biotech).  To further assess the ability of AAT to prevent obesity-associated insulin resistance, mice (n=6-7 per group) were fed either a control diet (CD) or HFD, and concurrently treated with or without AAT. Assessment by intraperitoneal glucose tolerance tests (GTT, 1mg/g body weight) was performed at 8 weeks of AAT treatment, and by ITT at 10 weeks of AAT treatment. For both GTT and ITT, blood glucose was measured at 0, 15, 30, 60, 90, and 120 minutes. Insulin sensitivity was assessed by the area under the curve for glucose [Glucose AUC0-120].

RESULTS: AAT treatment reduced IGFBP-3 proteolysis by 37% (p=0.04) in HFD-fed mice (AAT+/HFD) when compared with untreated HFD-fed (ATT-/HFD) mice. In the pre-existing obesity model, AAT+/HFD mice showed improved insulin sensitivity and lower glucose values at all ITT time points when compared with AAT-/HFD mice (P<0.05).

When AAT was assessed for ability to prevent obesity-associated insulin resistance, mice treated with AAT at HFD initiation demonstrated comparable insulin sensitivity to CD-fed mice. All HFD mice were more insulin resistant (lower glucose AUC0-120) than CD mice (P<0.01); however, treatment with ATT appeared to partially ameliorate HFD-induced glucose intolerance and insulin resistance. Specifically, AAT+/HFD mice had lower blood glucose values than AAT-/HFD mice at 60, 90, and 120 minutes by GTT (P<0.05) and at 90 and120 minutes by ITT (P<0.05). The glucose AUC0-120 for the GTT was significantly lower in AAT+/HFD mice (P<0.05)

CONCLUSIONS:  Treatment with AAT improves existing obesity-induced insulin resistance and can prevent HFD-induced insulin resistance in vivo; these effects may be mediated via reductions in IGFBP-3.

 

Nothing to Disclose: QC, EPW III, TNL, YO

21774 18.0000 SAT-643 A Alpha-1 Antitrypsin Treatment Decreases IGFBP-3 Proteolysis and Ameliorates High-Fat Diet-Induced Insulin Resistance in Vivo 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Luciana Pavan Antoniolli*, Bárbara Limberger Nedel, Vanessa Piccoli, Tássia Cividanes Pazinato, Mayara Abichequer Beer, Lucas Eduardo Gatelli, Anize Delfino von Frankenberg and Fernando Gerchman
Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil

 

Insulin resistance has been associated with the development of metabolic syndrome (MS), which is an interrelated cluster of risk factors for cardiovascular disease and type 2 diabetes (T2DM). The most precise method for measuring insulin resistance is the euglycemic hyperinsulinemic clamp technique, which may be cumbersome for clinical and epidemiological studies. Consequently, several equations derived from the oral glucose tolerance test (OGTT) have been developed to estimate insulin resistance and insulin sensitivity. In a cross sectional study, we aimed to determine the accuracy of insulin resistance (IRI) and the reciprocal of insulin sensitivity (ISI) indices to identify MS in a sample of 178 subjects (females 72.5%; white color 82%; age 52.4±11.9; mean±SD). Subjects were submitted to a 2-h 75g OGTT (41 with normal glucose tolerance, 80 with prediabetes, 57 with T2DM; ADA criteria) and MS was classified by the presence of 3 out of 5 of the following according to IDF: hypertension, low HDL-cholesterol, high triglycerides levels, hyperglycemia and high waist circumference (MS n=135, 75.8%). Glycosylated hemoglobin (HbA1c) and lipid profile were tested. IRI was estimated by HOMA-IR, HOMA-2-IR, and by the reciprocal of QUICKI, HOMA-2-S, Matsuda, Stumvoll and OGIS ISI. The accuracy of IRI to identify MS was determined by ROC curve analysis and the identification of an optimal cut point was based on Youden index and distance to (0,1). It was considered p<0.05 for significant statistical differences. QUICKI, Matsuda and OGIS ISI were inversely related with fasting and 2-h plasma glucose, HbA1c, triglycerides levels, systolic and diastolic blood pressure (BP), waist circumference and body mass index, but they were directly related with HDL-cholesterol. Stumvoll ISI was also related with these variables, but not with diastolic blood pressure, while HOMA-IR presented the opposite direction. ROC analysis showed that the area under the curve was greater for 1/Stumvoll (0.882) than for 1/OGIS (0.828), 1/Matsuda (0.792), 1/QUICKI (0.777), HOMA-IR (0.776), 1/HOMA-2-S (0.747) and HOMA-2-R (0.710) to identify subjects with MS. By using an optimal cut point of 0.0915, 1/Stumvoll presented 77% sensitivity, 86% specificity, and a respective positive and negative likelihood ratio of 5.52 and 0.27 for MS. The reciprocal of the Stumvoll ISI was the most accurate method for assessing insulin resistance in a sample with a significant prevalence of MS and may be the preferred equation to be used in studies which is necessary to estimate insulin sensitivity in subjects with MS.

 

Nothing to Disclose: LPA, BLN, VP, TCP, MAB, LEG, ADV, FG

21168 19.0000 SAT-644 A Accuracy of Insulin Resistance Indices for Metabolic Syndrome in a Population with Different Degrees of Glucose Tolerance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Elena Barengolts*1, Irina Ciubotaru2 and Hajwa Kim3
1University of Illinois at Chicago, Chicago, IL, 2UIC Section of Endocrinology, Chicago, IL, 3UIC Medical Center, Chicago, IL

 

BACKGROUND: The hyperbolic relationship between insulin sensitivity and secretion reflects physiologic mechanisms underlying glucose homeostasis. The product of sensitivity and secretion is recognized as useful measure of in vivo β-cell function, i.e. disposition index. Two established oral disposition indices calculated from the oral glucose tolerance test (OGTT) include the insulin secretion-sensitivity index-2 (ISSI-2) and Insulinogenic Index at 30 min (Insulinogenic index-30) multiplied by 1/fasting insulin. The ISSI-2 is defined as Matsuda composite index multiplied by ratio of total area-under-the-insulin-curve to area-under-the-glucose-curve [AUC(insulin/glucose)]. The hyperbolic model has not been tested in a population of African American men with dysglycemia.

OBJECTIVE: We investigated whether hyperbolic law applies to several indices of insulin sensitivity and secretion derived from OGTT.

METHODS: This analysis used data from a randomized controlled trial of vitamin D Intervention at VA (DIVA, NCT01375660). African American men with dysglycemia (HbA1C 5.7-6.9%, no anti-diabetes medications) completed OGTT at baseline (T0, n = 205) and at 12 month (T12, n = 173) yielding data from T0 + T12 = 378 OGTTs. Based on OGTT we calculated five insulin sensitivity indices: Oral Glucose Insulin Sensitivity (OGIS), OGIS/(Insulin peak), Matsuda composite index, 1/fasting insulin, and HOMA-S. Four insulin secretion indices were calculated as follows: Insulinogenic index-30, AUC(insulin/glucose), C-peptide-based index-30, and AUC(C-peptide/glucose). Hyperbolic law was established using a model of log (secretion measure) = constant + β × log (sensitivity measure), if β approximately equaled to −1, and 95% confidence interval (CI) excluded 0. β was calculated from Perpendicular Least Squares Properly Weighted regression and the standard error of β was derived from the bootstrap method with 1,000 sets of data randomly selected from the original data set for each analysis (1).

RESULTS: Four combinations of insulin sensitivity and secretion indices satisfied the criteria of hyperbolic law: OGIS/(Insulin peak) and Insulinogenic index-30: β = −1.00, 95% CI (−1.006, −1.001); OGIS/(Insulin peak) and AUC(Insulin/Glucose): β = −0.75, 95% CI (−0.752, −0.750); Matsuda composite index and AUC(insulin/glucose): β = −0.96, 95% CI (−0.958, −0.956); 1/fasting insulin and AUC(insulin/glucose): β = −0.91, 95% CI (−0.916, −0.912). Similar results were seen after subjects with diabetes (HbA1C 6.5-6.9%) were excluded.

CONCLUSION: Our data show that hyperbolic law is applicable to multiple oral indices of insulin sensitivity and secretion in African American men providing insight into pathophysiological dynamics of glucose control.

 

Nothing to Disclose: EB, IC, HK

21556 20.0000 SAT-645 A Hyperbolic Relationship Exists Between Several Insulin Secretion and Sensitivity Indices Derived from Oral Glucose Tolerance Test 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Baris Akinci1, Fatos Koseoglu2, Huseyin Onay3, Sevgi Yavuz4, Canan Altay5, Ilgin Simsir6, Secil Ozisik*7, Leyla Demir8, Meltem Korkut9, Nusret Yilmaz10, Samim Ozen11, Gulcin Akinci12, Tahir Atik13, Mehmet Calan7, Mustafa Secil7, Abdurrahman Comlekci7 and Tevfik Demir5
1Dokuz Eylül University Medical School, Izmir, Turkey, 2Tepecik Training Hospital, İzmir, Turkey, 3Ege University Medical School, İzmir, Turkey, 4Kanuni Sultan Suleyman Training Hospital, İstanbul, Turkey, 5Dokuz Eylul University Medical School, İzmir, Turkey, 6Ege University School of Medicine, Izmir, Turkey, 7Dokuz Eylul University Medical School, Izmir, Turkey, 8Ataturk Training Hospital, Izmir, Turkey, 9Yeditepe University, İstanbul, Turkey, 10Akdeniz University, School of Medicine, Antalya, Turkey, 11Ege University Medical School, Izmir, Turkey, 12Dr.Behcet Uz Training Hospital, İzmir, Turkey, 13Ege University School of Medicine, İzmir, Turkey

 

Abstract

Acquired partial lipodystrophy (APL) is a rare disorder characterized by fat loss starting at childhood or early adulthood which first affects the face, and then progresses to the neck, upper extremities, and trunk, sparing some fat on the lower extremities. In previous case studies, metabolic complications were reported to be relatively rare in APL, while they were quite common in other types of lipodystrophy syndromes. However, so far, there has been no systematic study on metabolic complications in APL.

In this work, we systematically evaluated APL patients in the Turkish Lipodystrophy Study Group (TuLip) registry who were enrolled in a prospective follow-up protocol for metabolic complications.

Of 21 APL patients, 15 individuals (71.4%) had at least one metabolic abnormality. Six patients (28.6%) had diabetes, 12 (57.1%) hypertrigylceridemia (hyperTg), 10 (47.6%) low HDL cholesterol, and 11 (52.4%) hepatic steatosis. Steatohepatitis was further confirmed in 2 patients with liver biopsy. Two patients with severe hyperTg (9.5%) had recovered from several acute pancreatitis episodes. The median age at onset of diabetes was 21. Anti GAD was negative in all. Leptin levels were slightly decreased compared to patients with type 2 diabetes and healthy controls, however, consistently very low leptin as detected in patients with congenital generalized lipodystrophy (CGL), was not the case. Basal and mix meal stimulated insulin/C-peptide levels suggested that APL patients with diabetes had a significant amount of pancreatic beta cells functioning, and their diabetes was apparently associated with insulin resistance.

Our results reveal that a significant number of patients with APL develop metabolic complications associated with insulin resistance. Therefore, we recommend clinicians to screen their patients with APL for diabetes and other metabolic parameters at a regular basis. Further research is needed to clarify if APL patients with metabolic complications would benefit from metreleptin treatment.

 

Nothing to Disclose: BA, FK, HO, SY, CA, IS, SO, LD, MK, NY, SO, GA, TA, MC, MS, AC, TD

21670 21.0000 SAT-646 A Acquired Partial Lipodystrophy Is Associated with Increased Risk for Metabolic Complications 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Madison Spier*1, Isabel U Lambertz1, Clayton Cruthirds2, J. Timothy Lightfoot2 and Robin S L Fuchs-Young1
1Texas A&M University Health Science Center, College Station, TX, 2Texas A&M University, College Station, TX

 

In animal studies involving exercise, dietary manipulations (peer feeding/calorie restriction) and carcinogenesis, we have observed that results can be strongly impacted by housing density. Our data demonstrate that singly housed mice have reduced incidence of carcinogen-induced mammary cancers compared to those who are group caged. To optimize studies on the effects of voluntary physical activity (vPA) and diet on glucose metabolism, body weight and disease risk, we evaluated the effects of co-caging to better recapitulate natural conditions and allow socialization. We have developed a 2-mouse/2-wheel system (2/2), in which mice are implanted with microchips and are provided with running wheels fitted with individual electronic monitors. This design allows mice to have free and continuous access to running wheels and for the speed and distance to be individually recorded per mouse and per wheel. Interestingly, animals in the 2/2 setting ran at significantly greater speed than those in either the 1 wheel/1mouse (1/1), or 1 wheel/2 mice (2/1) situation, but co-caging reduced the running distance, regardless of the number of wheels.  Average distance run by mice in the 2/2 housing was 3.8 - 6.4 km/day. We used the 2/2 system to assess the impact of voluntary wheel running on body weight and glucose and insulin tolerance in mice exposed to either high fat/high sugar (HF/HS) or control, low fat/low (LF/LS) sugar, post-weaning diets.  Voluntary PA significantly reduced body weight in mice on the HF/HS diet, but did not signficiantly affect body weights of mice fed the LF/LS diet. Glucose tolerance tests (GTTs) revealed that vPA improved glucose tolerance by 23.5% (measured as area under the curve, AUC) in the HF/HS group, and recovery serum glucose levels at 120 minutes post glucose injection were significantly lower in the + vPA compared to ­the – vPA group. In animals on the LF/LS diet, PA improved glucose tolerance by 21% (AUC), but serum glucose levels at baseline (fasting) or at 120 minutes post injection were not affected by vPA. LF/LS animals were insulin sensitive and all HF/HS animals were insulin resistant, and vPA did not affect these responses in either group. These results indicate that caging parameters can affect exercise/activity behavior and that voluntary wheel running experiments can be conducted with co-caged animals. Further, vPA had its greatest effect on BWs and GTTs in the HF/HS-fed animals. Glucose tolerance was only modestly improved by vPA in the LF/LS group.

 

Nothing to Disclose: MS, IUL, CC, JTL, RSLF

21426 22.0000 SAT-647 A A New Approach to Assessing the Effects of Voluntary Physical Activity on Body Weight, Glucose Metabolism and Carcinogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Manoj Kumar*1, Samim Ali Mondal2, Deep Dutta3, Parna Choudhury4, Subhankar Chowdhury2 and Satinath Mukhopadhyay5
1Institute of Post Graduate Medical Education And Research and SSKM Hospital, Kolkata, India, 2Institute of Post Graduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, India, 3Post Graduate Institute of Medical Education & Research & Dr. Ram Manohar Lohia Hospital, delhi, India, 4Institute of Post Graduate Medical Education & Research and Seth Sukhlal Karnani Memorial Hospital, Kolkata, 5Institute of Postgraduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, India

 

Background:

Initial reports have suggested selenprotein-P (SeP), a novel hepatokine, to modulate insulin resistance (IR) and energy metabolism in animals and humans. This study evaluated the relation between SeP, anthropometric parameters, IR, systemic inflammation and vitamin-D across the spectrum of glycemia, viz. normoglycemia (NGT), prediabetes (preDM) and newly diagnosed treatment naïve type-2 diabetes  (T2DM) patients.

Methods:

Anthropometric parameters (waist circumference, hip circumference, neck circumference (NC)], serum selenoprotein, fasting blood glucose (FBG), 2h post 75gram glucose blood glucose (2hPGBG), HbA1c, fasting insulin, lipids, high sensitivity c-reactive protein (hsCRP), inflammatory cytokines [interleukin (IL)-6, IL1β, soluble tumor necrosis factor receptor (sTNFR)-1, sTNFR2] and 25-hydroxy-vitamin-D (25OHD) were evaluated in 34 HGT, 64 preDM and 38 T2DM patients, selected from the eastern India vitamin-D in prediabetes study (CTRI/2011/091/000192). Serum insulin was estimated using CLIA (Immunite-1000, Gwynedd, UK). Human SeP was estimated using sandwich ELISA, (Cat No. MBS2515309, MyBioSource, USA), detection range 0.156-10ng/ml, sensitivity 0.094ng/ml with intra and interassay coefficient of variation of <10%. 25OHD was measured using 125I radioimmunoassay kit (REF 68100E, Diasorin, USA). IL6, IL1b, sTNFR1 and sTNFR2 were estimated using sELISA. Insulin sensitivity was estimated using QUICKI (Quantitative Insulin Sensitivity Check Index).

Results:

NGT (age: 50.29±13.2 years), prediabetes (age: 46.9±12.3 years) and T2DM (age: 49.73±13.4 years) had significantly different BMI (24.7±2.75, 24.6±4.28, 27.29±5.08kg/m2, P=0.035), waist-height ratio (0.55±0.04,        0.55±0.06, 0.59±0.07, P=0.009), NC (34.72±3.19, 35.33±2.9, 37.3±2.68cm, P=0.003), triglycerides (126.7±60.1, 115.9±63, 200.9±62.6mg/dl, P=0.031), IL6 (4.93±0.44, 4.74±2.65, 5.7±1.6pg/ml, P=0.08), sTNFR1 (2863.77±1106.72, 3371.89±1102.4, 3830.41±1529.65 pg/ml, P=0.021), 25OHD (30.50±18.37, 31.95±23.25, 42.07±20.23ng/ml, P=0.075) and SeP (848.35±220.21, 1002.93±279.50, 826±240.59ng/ml, P=0.011). SeP had very strong inverse correlation with insulin sensitivity (QUICKI) in NGT (r=-0.94, P<0.001), prediabetes (r=-0.92, P<0.001) and diabetes (r=-0.96, P<0.001). SeP was persistently the strongest predictor of QUICKI in NGT, prediabetes and T2DM at baseline (β=-1.124, P<0.001; β=-1.003, P<0.001; β=-0.957, P<0.001, respectively) and after adjusting for age, BMI and waist circumference (Model-1) (β=-1.11, P<0.001; β=-1.006; P<0.001; β=-0.942, P<0.001, respectively).

Conclusion:

SeP is elevated across the spectrum of dysglycemia with lowest in normoglycemia. SeP is a very good predictor of insulin sensitivity across the spectrum of dysglycemia. SeP may be considered as a biomarker of insulin resistance.

 

Nothing to Disclose: MK, SAM, DD, PC, SC, SM

20682 23.0000 SAT-648 A Selenoprotein-P Is Predictive of Insulin Resistance and Systemic Inflammation in Individuals with Prediabetes and Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Katherine Beckwith-Fickas*1, Sara M McMillin2, Amanda Nwaopara1, Sally Radovick2 and Fredric Edward Wondisford3
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Baltimore, MD, 3Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

 

Type 2 diabetes mellitus (T2D) typically arises in obese individuals and is characterized by systemic insulin resistance, impaired pancreatic insulin secretion, and inappropriate gluconeogenesis. Diet Induced Obesity (DIO) mouse models using a 60% high fat diet (HFD) are often used to mimic the T2D phenotype in humans.  Studies in this model and in patients with T2D and obesity, however, do not consistently show an increase in hepatic gluconeogenic enzyme gene expression.  Since a combination of fat and carbohydrate intake is known to contribute to human obesity, we hypothesize that a high fat, high sucrose diet in mice would more closely mimic human T2D and obesity.  For this purpose, we generated DIO mice using male C57BL/6J mice fed a 45% fat, high sucrose diet or 60% fat, low sucrose diet; control mice were fed a nutrient matched 10% fat, no sucrose diet (Research DietsTM). Metabolic testing was completed at 1 week and 4 weeks after diet initiation using 6 mice per group. Glucose intolerance was present in both the 45% and 60% HFD groups at 1 and 4 weeks. There was an increase in glucose production in response to pyruvate challenge in both the 45% and 60% HFD groups at 4 weeks.  Insulin tolerance, measured by the insulin tolerance test, did not change significantly between groups at 1 or 4 weeks. However, a decrease in hepatic phospho-AKT protein expression in response to insulin injection after 4 weeks was seen in the 60% but not the 45% HFD group, indicating insulin resistance in the 60% group. Liver Pck1 mRNA expression increased significantly compared to controls at both 1 and 4 weeks in the 45% HFD group with no change between the control and 60% HFD group.  G6Pc mRNA expression in liver did not differ from control in the 45% HFD group after 4 weeks and decreased significantly in the 60% HFD group at both 1 and 4 weeks.  These results suggest that the metabolic parameters, measured as glucose intolerance and increased Pck1 expression, after a 4 week 45% fat, high sucrose diet more closely resemble those that result in development of human T2D and can not be explained by hepatic insulin resistance.  Addition of carbohydrates to a HFD appears to cause differential induction of gluconeogenesis based perhaps on altered substrate utilization in the pathway.

 

Nothing to Disclose: KB, SMM, AN, SR, FEW

21028 24.0000 SAT-649 A Modeling Human Type 2 Diabetes and Obesity in Mice: A Look at Different Diets 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Nan Zhang, Di Gao, Qian Shen and Lei Sha*
China Medical University School of Pharmacy, Shenyang, China

 

Background: Substance P (SP) is a neuropeptide contained in primary sensory afferent nerves and nerves from intrinsic ganglia in pancreas. SP released from nerves innervates endocrine (β cells and α cells) and exocrine (ductal and acinar cells) activities. Pancreatic ductal cells are a part of exocrine component of pancreas and have been considered as the progenitor cells of islet β cells in recent studies. Ductal cells can differentiate into insulin-producing β-like cells in vivo and in vitro. SP has been shown to play an important role in the development of diabetes. SP was found to express in single nerve fibers of the duct system, indicating that SP mediate ductal cell activity. The aim of this study was to investigate the effects of SP on the proliferation and differentiation of fibroblast-like cells derived from rat pancreatic duct.

Methods and Results: Pancreases were dissected from Adult Sprague Dawley rats and then digested with IV collagenase. Primary ductal cells were collected using 600μm cell strainer and then cultured for 7days. Cells were then expanded at the third passage (P3) for purification. The P3 cells were immunostained by CK19 (the ductal cell marker) to confirm the identification. P3 ductal cells were divided into different groups and treated with serial concentrations of SP (10-4, 5×10-5, 10-5, 5×10-6 and 10-6 μM) for 3 days. Cell viability was measured by CCK-8 test. Results showed that SP promoted proliferation of ductal cells in a non-dose dependent manner (P<0.05, n = 6 wells for each group compared to the controls; P>0.05, among groups treated with different dose, One-way ANOVA).  P3 ductal cells were also treated with SP (10-4, 10-5 and 10-6 μM) for 7 and 14 days and immunostained with Pdx-1 and insulin antibodies. Results showed that those cells all expressed Pdx-1 but not insulin, indicating that SP did not induce β cell differentiation from ductal cells.

Conclusion: Our results suggested that SP released in pancreas from intrinsic or extrinsic fibers promotes proliferation of adult pancreatic ductal cells but not differentiation into β-cells.

 

Nothing to Disclose: NZ, DG, QS, LS

21623 25.0000 SAT-650 A Substance P Promotes Proliferation of Adult Pancreatic Ductal Cells but Not Differentiation into Beta-Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Tooru Mizuno*, Pei San Lew, Arnold Leckstrom and Yanming Luo
University of Manitoba, Winnipeg, MB, Canada

 

Hepatic glucose production is critical for maintaining normal glucose homeostasis. Excessive hepatic glucose production contributes to fasting hyperglycemia in diabetes. Common genetic variants of the fat mass and obesity associated (FTO) gene are strongly associated with obesity and type 2 diabetes. Although FTO is expressed in the liver, little is known about the role of hepatic FTO in the regulation of glucose homeostasis. We have demonstrated that hepatic FTO mRNA levels were increased by fasting and reduced by glucose treatment in mice (1). Levels of gluconeogenic genes, glucose-6-phosphatase (G6Pase) and phosphoenolpyruvate carboxykinase (PEPCK) mRNA behaved in a similar manner to FTO mRNA in response to changes in metabolic states. There was a significant inverse correlation between hepatic FTO mRNA levels and blood glucose levels. Hepatic FTO mRNA levels were positively correlated with hepatic G6Pase mRNA and PEPCK mRNA levels. Fasting also reduces circulating insulin levels and insulin inhibits gluconeogenesis by suppressing the expression of gluconeogenic genes. These findings led us to hypothesize that hepatic FTO participates in the regulation of glucose homeostasis by modulating hepatic gluconeogeneisis. We also hypothesized that hepatic FTO may mediate the inhibitory effect of insulin on gluconeogenesis. To address these hypotheses, we examined the effect of enhanced FTO expression on G6Pase mRNA levels and the effect of insulin on FTO and G6Pase mRNA levels in alpha mouse liver 12 (AML12) immortalized hepatic cell line. To extend our in vivo finding that fasting reduces FTO mRNA levels in mouse liver, we eamined the effect of starvation on FTO and G6Pase mRNA levels in AML12 cells. Starvation for 24 h caused significant increases in FTO and G6Pase mRNA levels in AML12 cells. To determine the effect of increased FTO levels on G6Pase mRNA expression, AML12 cells were transfected with a FTO-expressing vector. Levels of FTO mRNA and protein were significantly higher in FTO-transfected cells compared to mock-transfected control cells. G6Pase mRNA levels were increased in FTO-transfected cells compared with mock transfected control cells. To determine the direct effect of insulin on FTO expression, AML12 cells were starved for 24 h and treated with insulin (1 μM) for 6 h. Insulin treatment significantly reduced levels of FTO and G6Pase mRNA compared to control vehicle treatment. These findings support the hypothesis that hepatic FTO participates in the regulation of gluconeogenesis by stimulating gluconeogenic gene expression and by mediating the inhibitory effect of insulin on gluconeogenic gene expression in liver. These findings further suggest that reducing hepatic FTO levels may be beneficial in reversing abnormally increased hepatic glucose production and hyperglycemia in diabetic patients.

 

Nothing to Disclose: TM, PSL, AL, YL

21999 26.0000 SAT-651 A Hepatic Fat Mass and Obesity Associated (FTO) and Gluconeogenic Gene Expression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Ji Young Kim*, Sang Ah Lee, Sang Ouk Chin, Gwanpyo Koh and Soyeon Yoo
Jeju National University Hospital, Jeju, Korea, Republic of (South)

 

Background and aims:

Monnier et al. showed greater contributions of postprandial (PHG) and fasting (FHG) hyperglycemiae to overall hyperglycaemia at lower and higher HbA1c, respectively. However, it has never been studied in Korean diabetic patients. In addition, there have been few studies about determinant factors in postprandial and fasting glucose levels. Therefore, we assessed the relative contributions of PHG and FHG to the overall hyperglycemia and the influencing factors on PHG and FHG in Korean patients with type 2 diabetes.

Material and methods:

We enrolled 195 Korean type 2 diabetic patients which did not take insulin or α-glucosidase inhibitor. They performed a seven-point self-monitoring of blood glucose (7-point SMBG) more than once during each month for 3 consecutive months. Glucose area under the curve (AUC) above 100 mg/dL (5.5 mmol/L) was defined as AUC(total) to represent the overall hyperglycemia. The area under the curve above fasting glucose level was considered the postprandial hyperglycemia (AUC(PHG)). The fasting hyperglycemia (AUC(FHG)) was calculated as [(AUC(total) - AUC(PHG)]. The relative contributions of PHG and FHG to overall hyperglycaemia were respectively defined as the proportions of AUC(PHG) and AUC(FHG) to AUC(TOTAL).

Results:

The relative contribution of PHG showed a significant difference and gradual decrement according to increasing quartiles of HbA1c (66.9±6.0, 36.1±6.0, 40.3±3.2, 32.3±3.8%; P(ANOVA)<0.001, P(TREND)<0.001). And the contribution of FHG was increased progressively with increasing quartiles of HbA1c (33.0±9.5, 63.8±6.0, 59.6±3.2, 67.6±3.8%; P(ANOVA)<0.001, P(TREND)<0.001). AUC(PHG) was positively correlated to age (r=0.191; p<0.01), systolic blood pressure (r=0.185; p<0.01), duration of diabetes age (r=0.185; p<0.01), C-peptide (r=0.198; p<0.01), HbA1c (r=0.282; p<0.01), and hsCRP (r=0.145; p<0.05). AUC(FHG) was positively correlated to body weight (r=0.190; p<0.01), waist circumference (r=0.185; p<0.01), C-peptide (r=0.217; p<0.01), HbA1c (r=0.658; p<0.01), alanine aminotransferase (r=0.228; p<0.01), and triglyceride (r=0.278; p<0.01) but negatively correlated to age (r=-0.146; p<0.05). Using multiple linear regression to adjust for age, sex and other covariates, only age (β=0.181; p<0.05) and triglyceride (β=0.150; p<0.01) remained significant variables of the AUC(PHG) and AUC(FHG), respectively.

Conclusions:

In Korean type 2 diabetic patients, postprandial hyperglycemia predominantly contribute to overall hyperglycemia at lower HbA1c level, whereas fasting hyperglycemia is a predominant contributor to it at higher HbA1c level. And age and plasma triglyceride are independent predictors of postprandial and fasting hyperglycemia, respectively.

 

Nothing to Disclose: JYK, SAL, SOC, GK, SY

18874 27.0000 SAT-652 A Fasting and Postprandial Hyperglycemia: Their Relative Contributions to the Overall Hyperglycemia and Their Determinants in Korean Patients with Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Joshua Lowndes*, Stephanie Sinnett and James Marshall Rippe
Rippe Lifestyle Institution, Celebration, FL

 

High levels of fructose consumption have been shown to promote changes in insulin resistance and associated parameters.  Debate continues over the effects of sugars at more typically consumed levels and whether the identity of the sugar consumed is important.

All Participants were apparently healthy and weight stable (no change in weight greater than 3% over the past three months) prior to enrollment.  Participants were randomly assigned to one of five groups, four that contained low fat milk with added sugar in amounts equivalent to the 50th percentile of fructose consumption in the US, and one unsweetened low-fat milk control group.  Milk was consumed in amounts so that the added sugar contributed a target percentage of the calories required for weight maintenance. The groups were as follows: Fructose 9%, Glucose 9%, High fructose corn syrup 18%, sucrose 18% and an unsweetened milk control consumed so milk contributed 18% of the weight-maintenance calories.  The energy intake required for weight maintenance was estimated for each participant using the MIflin St Joer equation and using an appropriate activity factor determined by responses to a physical activity questionnaire.  The intervention lasted ten weeks.  This study is a preliminary analysis on the one hundred fifty two participants (M=65, F=87) who had completed the intervention at the time of submission.

In the entire study population there was a 1.8lbs increase in weight (161.4 ± 27.8 vs 163.2 ± 28.7lbs), which was statistically significant (p<0.001), but the change in weight was comparable among groups (interaction p<0.001).   There were no changes in fasting glucose (88.8 ± 7.0 vs 90.5 ± 9.6mg/dl), insulin (8.5 ± 5.8 vs 8.9 ± 7.3µIU/ml), insulin resistance as measured by HOMA (1.9 ± 1.3 vs 2.0 ± 1.5), or glucose AUC in response to a standard 2 hour OGTT (13.7 ± 3.1 vs 14.0 ± 3.0mg.min/dl, p>0.05 for all).  In all cases the response among groups was comparable (interaction p>0.05).

These data suggest that, when consumed at the median American intake for added sugar, added sugar does not produce changes in measures of insulin sensitivity or glucose tolerance.  Furthermore, at this level of consumption, the identity of the added sugar is not important.

 

Nothing to Disclose: JL, SS, JMR

19122 28.0000 SAT-653 A No Effect of Added Sugar Consumed at the Median American Intake Level on Glucose Tolerance or Insulin Resistance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Melanie N Kuehl*1, Amy Alman1, Henry Rodriguez2 and Brant R Burkhardt1
1University of South Florida, Tampa, FL, 2University of South Florida Coll, Tampa, FL

 

Studies have shown that there is a strong, bi-directional, relationship between diabetes and periodontal disease in which glycemic control is a major determinant. Our previous analysis of T1D subjects, revealed a significant association between glycemic control and levels of specific cytokines and periodontal markers (ie. Matrix-metalloproteinases) within the saliva. To further investigate this, our goal was to offer first clues characterize the source of this oral inflammation as to whether local cells of the oral cavity are producing these cytokines or the source was systemic. However, the precise impact of hyperglycemia on the inflammatory profile of the oral cavity is yet to be fully elucidated. Our previous analysis of T1D subjects revealed a significant association between glycemic control and specific cytokines within the saliva (Diabetes; 2014; 63 (suppl 1): A1577).  As follow-up to this previous study, our goal was to characterize the source of this inflammation and determine whether local cells of the oral cavity are potentially producing these cytokines under hyperglycemic conditions. To determine this, cytokine production from a Human Submandibular gland (HSG) cell line at basal and glucose-stimulatory conditions was measured. Cytokine secretion and intracellular levels of interleukin (IL)-1β, IL-6, IL-8, IL-10, TNF-α, and IFN-γ were simultaneously measured from the identical sample at 24/48/72- hours post-exposure to increased glucose concentrations (5 mM (basal), 11 mM, and 22 mM) using a multiplexed bead immunoassay via the Luminex MAGPIX. IL-1β and IFN-γ were minimally detected in the media with no appreciable increase upon glucose induction. With respect to the other cytokines, at 24 hours of exposure following increased glucose concentrations, secreted levels of IL-8 are relatively increased in a dose-dependent manner as compared to measure IL-8 levels at the 5 mM condition. An approximate 32% and 40% increase of IL-8 were observed at the 11 and 22 mM conditions, respectively.  In contrast, levels of TNF-α and IL-6 do not appear to appreciably increase upon glucose stimulation. Taken together, our results suggest that oral-induced IL-8 levels within the saliva are sensitive to glucose conditions and indicates that the HSG is a potential source of glucose-dependent inflammation and IL-8 may provide a potential oral biomarker for non-invasive evaluation of hyperglycemia but much validation for this purpose remains to be performed.

 

Nothing to Disclose: MNK, AA, HR, BRB

20635 29.0000 SAT-654 A Glucose Induced Interleukin-8 Secretion from Human Submandibular Gland Cell Line 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Younes Anini*1 and Kyungsoo Shin2
1Dalhousie University, Halifax, NS, Canada, 2Dalhousie University

 

Role of TNF-α in the altered Ghrelin Secretion in Obesity

Shin K and Anini Y

Departments of Obstetrics & Gynecology, Physiology & Biophysics, and Biochemistry & Molecular Biology. IWK health centre, Dalhousie University.

The stomach derived hormone, ghrelin, has emerged as a key player in the neuro-endocrine regulation of appetite and energy storage. Ghrelin increases food intake and adiposity through its action on the ghrelin receptor in appetite-regulating neurons of the hypothalamus.  Ghrelin levels increase during periods of fasting and decrease after a meal is consumed. Although obesity is commonly associated with increases in food intake, basal concentration of ghrelin was found to be decreased in obese individuals. We hypothesized that circulating ghrelin levels are altered in obesity. The goal of the present study was to investigate the mechanisms leading to the dysregulation of ghrelin secretion in obesity.

We used the mouse model of high fat-diet induced obesity (DIO) to investigate the postprandial suppression of ghrelin secretion in normal weight and obese mice. We further delineated the intracellular pathways involved using rat primary culture of ghrelin cells. Since increased adipose tissue-derived inflammatory cytokines was linked with insulin resistance, we investigated the role of TNF-α in ghrelin secretion.

We confirmed lower fasting ghrelin level in DIO mice. Interestingly, the postprandial suppression of ghrelin secretion was found to be significantly higher in normal weight compared to obese mice (p<0.01).

Using primary culture of ghrelin cells, we demonstrated that Insulin (10 nM) significantly suppressed ghrelin secretion (by 60%, P<0.05, n=6). Pre-treatment of ghrelin cells with TNF-α (10ng/mL) abolished the inhibitory effect of insulin (10 nM) on ghrelin secretion.

We demonstrate that ghrelin secretion is altered in DIO mice and that the suppression effect of insulin on ghrelin secretion is lost when ghrelin cells were pre-incubated with TNF-α.

 

Nothing to Disclose: YA, KS

19075 30.0000 SAT-655 A Role of TNF-Alpha in the Altered Ghrelin Secretion in Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


Jorge David Rogel*1 and Diego Espinoza-Peralta2
1ISSSTESON, Hermosillo, Sonora, 2ISSSTESON, Hermosillo, Sonora, Mexico

 

INTRODUCTION

Association between metabolic disruption and sleep deprivation has been known for several years. Short periods of sleep, disrupt insulin sensitivity and glucose homeostasis in non diabetic patients. In Mexico, Medical Training consists of 8 to 9 semesters of which are merely college assistance, another 2 semesters are the pre grade internship, which consists one year Hospital Stay, with 9 hours-work day from Monday to Friday, and night wards every 3 called ABC shifts (Established as Law by the Mexican Oficial Norm NOM-234-SSA1-2003), that means 33 straight hours on duty, this intermittent sleep deprivation routine continues in all specialty training programs. We decided to explore if this intermittent type of sleep deprivation routine, affects glucose metabolism in young medical students. 

DESIGN

A prospective and comparative study designed to identify if there's glucose changes after ward in subjects with intermittent sleep deprivation.

RESULTS

34 subjects were screened, 29 of them met all inclusion criteria (no prior diabetes or lipid abnormalities, taking medication that affected glucose or lipids metabolism and that had sleep deprivation during wards), 6 (28.57%) were males, mean age 23.03±0.75 years, BMI mean 24.83±2.67. When compared before ward and after ward, there was only statistically significant difference on glycaemia with concentrations being greater in the group after ward (Student’s T-Test 86.47±4.7 vs 89.06±6.5 mg/dL, p=0.005). Only 6 (28.57%) presented insulin resistance before ward without changes after. There was no statistically significant difference with cholesterol, triglyceride, HDL o LDL. Sleep hours median before ward was higher than after ward (Wilcoxon 6.5 (6,0 - 7.0) and 3.5 p<.001). The We also measured Sleep Quality with the Pittsburgh Sleep Quality Index, 83.3% reported low sleep quality. 

CONCLUSIONS

Early intermittent sleep deprivation alters glucose metabolism even in young medical students, without insulin changes, probably because of the lost in dopaminergic pathway resultant of intermittent sleep deprivation, Of our knowledge, this is the first study that proves glucose changes after a 33 hours ward on health young subjects. This could lead to a higher insulin resistance/Diabetes risk seen in health professionals in a future. One of the limitations of the present study was that we did not make glucose tolerance tests or other test for insulin resistance.. This early data requires further investigation with a greater number of subjects and with more specific tests with nutritional evaluation and sleep hours questionnaire in a longitudinal study design.

DISCUSION

There’s an important number of health care professional in Mexico with metabolic syndrome, but there’s no single study that describes when the metabolic disruption begins. The Internship is the first stage were all the physicians get a drastic change in their circadian cycle.

 

Nothing to Disclose: JDR, DE

21653 31.0000 SAT-656 A Ward Roles during Medical Training Is Associated with Glucose and Insulin Changes in Young Medical Students 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 625-656 5928 1:00:00 PM GI Regulatory Peptides; Glucose Metabolism Poster


April M. Teague*, Christopher E. Aston, Kevin R. Short, David A. Fields and Steven D. Chernausek
OU Health Sciences Center, Oklahoma City, OK

 

Fetal exposure to maternal diabetes mellitus (DM) increases the risk of developing type 2 DM later in life and is due, in part, to the impact of the intrauterine environment. As alterations in circulating concentrations of specific adipokines may be involved, we measured leptin and pigment epithelium-derived factor (PEDF) in cord serum from infants of DM mothers (IDM) and non-diabetic controls. These adipokines were selected because of their putative effects on appetite, metabolic rate, β-cell function, insulin sensitivity and angiogenesis.

Pregnant women with DM (type 2 or gestational; n=44, average HgbA1c = 5.6 ± 0.7%) and normoglycemic women (n=79) were invited to participate. At delivery umbilical cord blood was collected and adipokines were measured by ELISA. Anthropometric measures were obtained at birth. Differences between groups were assessed using the Generalized Linear Model procedure or the Mann-Whitney U test. Significance was set at p<0.05.

IDM were slightly heavier than controls (3.6 ± 0.6 vs 3.4 ± 0.4 kg, p = 0.036).  However, sum of skinfolds (SSF) was similar between groups, indicating no difference in adiposity. Cord leptin was nearly 2-fold higher in IDM than control (18.7 ± 13.5 ng/ml vs. 10.2 ± 11.5 ng/ml; p<0.001). Birth weight (r = 0.345, p = 0.002) and SSF (r = 0.367, p = 0.0014) correlated with leptin in controls but not IDM. Maternal hemoglobin A1c correlated with cord leptin level in IDM (r = 0.399, p = 0.032) and fasting maternal glucose with leptin in controls (r = 0.605, p <0.001). PEDF did not differ between groups but correlated with leptin in both groups (control, p = 0.012; IDM, p <0.001).  Furthermore, the relationship was significantly stronger in the IDM (p = 0.008). The PEDF level explained 30% of the variation in leptin level in IDM, but only 8% in controls.   

We found that maternal DM produces fetal hyperleptinemia and disrupts the normal relationship between infant adiposity and leptin concentration. The increased leptin in IDM is not due to increased fat mass, but reflects maternal/fetal hyperglycemia. Similarly, cord leptin correlated with glycemic measures in controls as well, suggesting that maternal glycemia is the common denominator. 

The strong correlation between PEDF and leptin concentrations in fetal circulation was unexpected. Although, the explanation for this relationship is unknown at this time, it could reflect the need for the angiogenic properties of leptin to be balanced by the anti-angiogenic effects of PEDF in the placenta, a source of both adipokines.

The long term effects of prenatal leptin exposure and the significance of the leptin-PEDF interaction, especially in the IDM, remain to be determined. This study provides further evidence that infants born to mothers with near-optimal management of maternal dysglycemia manifest hormonal changes that may impact their future health.

 

Nothing to Disclose: AMT, CEA, KRS, DAF, SDC

22042 1.0000 SAT-605 A Cord Blood Leptin Concentrations Are Dependent on Maternal Glycemia and Correlate with Fetal PEDF 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Somvang Amnakkittikul1, Naricha Chirakalwasan2, Sunee Saetung3, Punyu Panburana1, Sommart Bumrungpeutch1 and Sirimon Reutrakul*1
1Faculty of Medicine Ramahibodi Hospital, Bangkok, Thailand, 2Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 3Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Obstructive sleep apnea (OSA) is prevalent in type 2 diabetes patients, between 58-86% from several studies, with its severity associated with glycemic control. The data in pregnant women with gestational diabetes (GDM) are lacking. We hypothesized that OSA is prevalent and has an impact on glucose metabolism in women with GDM.

We conducted a cross sectional study in obese pregnant women with diet-controlled GDM [pre-pregnancy BMI ≥25 kg/m2 (cutoff in Asians)] between gestational age of 24 and 34 weeks. Sleep quality and daytime sleepiness were assessed by sleep questionnaires [Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS)]. OSA was diagnosed using an overnight, in-home monitoring device, Watch-PAT200, which detects changes in peripheral arterial tone in response to changes in oxygen saturation levels. Fasting plasma glucose (FPG) and hemoglobinA1c (HbA1c) were collected.

Of the 25 participants (mean gestational age 27.9±3.4 weeks), 14 or 52% had OSA (Apnea-hypopnea index (AHI) ≥5); with 85.7% had mild (5≤ AHI <15) and 14.2% had moderate OSA (15≤ AHI <30), respectively. Those with OSA tended to have a higher pre-pregnancy BMI than those in the No-OSA group, but this difference was not statistically significant (31.2±4.1 vs 29.0±2.6 kg/m2, p=0.14), while there were no differences in age, neck circumference, gestational age, PSQI score, ESS score, FPG or HbA1c between groups. As expected, those in the OSA group had a significantly higher median(IQR) AHI, oxygen desaturation index (ODI) and median percent of sleep time spent under oxygen saturation of 90% (T90) than those in the No-OSA group; 9.9(8.4-13.0) vs.1.4(0.4-3.4) events/hour (p<0.001), 4.7(3.5-6.9) vs. 0.5(0.2-1.0) (p<0.001), and 0.1(0.0-0.3) vs. 0.0(0.0-0.0) (p=0.012), respectively. Median minimum oxygen saturation (MinO2) was significantly lower in the OSA group than in the No-OSA group [87.0% (84.7-89.0) vs. 92.0% (91.0-94.0), p<0.001].

Analyses revealed that indices of OSA severity tended to correlated with pre-pregnancy BMI [AHI correlation coefficient(r)=0.34 (p=0.09); ODI r=0.36 (p=0.08); T90 r=0.38 (p=0.06) and MinO2 r= -0.37 (p=0.06)]. For glycemic parameters, MinO2negatively correlated with FPG, even after adjusting for pre-pregnancy BMI (r= -0.42, p=0.04), and ODI tended to correlate with FPG (r=0.35, p=0.09). There were no correlations between sleep parameters and HbA1c.   

There was no relationship between subjective sleep quality (as measured by PSQI) and objectively measured sleep parameters. However, daytime sleepiness (ESS) significantly correlated with T90 (r=0.49, p=0.01) while it was negatively correlated with MinO2 (r= -0.43, p=0.03).

In conclusion, OSA is prevalent in obese GDM women, similarly to those with type 2 diabetes. Lower oxygen saturation is associated with more daytime sleepiness and higher fasting plasma glucose levels in these women.

 

Nothing to Disclose: SA, NC, SS, PP, SB, SR

18641 2.0000 SAT-606 A Obstructive Sleep Apnea and Gestational Diabetes Mellitus: Prevalence and Relationship with Glycemic Control 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Michele La Merrill*1, Piera Cirrillo2, Nickilou Krigbaum2 and Barbara A Cohn3
1University of California, Davis, CA, 2Public Health Institute, 3Public Health Institute, Berkeley, CA

 

Growing evidence implicates prenatal tobacco smoke as a risk factor for obesity. The purpose of this study was to identify whether parental tobacco smoking during gestation influences risk of diabetes mellitus. This is a prospective study of 44 to 54 year old daughters (N = 1,801) born in the Child Health and Development Studies pregnancy cohort between 1959 and 1967. Their mothers resided near Oakland California, were members of the Kaiser Foundation Health Plan, and reported parental tobacco smoking during an early pregnancy interview.  Daughters reported physician diagnoses of diabetes mellitus and provided blood for hemoglobin A1C measurement. Prenatal maternal smoking had a stronger effect than prenatal paternal smoking on daughters’ diabetes mellitus risk, and the former persisted after adjustment for parental race, diabetes, and employment (aRR = 2.4 [95% confidence 1.4 - 4.1] p < 0.01 and aRR = 1.7 [95% confidence 1.0 – 3.0] p = 0.05, respectively]. Estimates of the effect of parental smoking were unchanged when further adjusted by daughters’ birth weight or current BMI. Maternal smoking was also a significant predictor of self-reported of type 2 diabetes diagnosis (2.3 [95% confidence 1.0 - 5.0] p < 0.05). Women with parents who smoked during pregnancy had increased risk of diabetes mellitus independent of known risk factors, providing further evidence that prenatal environmental chemical exposures independent of birth weight and current BMI can contribute to adult diabetes mellitus. While other studies seek to confirm our results, caution toward tobacco smoking by or proximal to pregnant women is warranted in diabetes mellitus prevention efforts.

 

Nothing to Disclose: ML, PC, NK, BAC

20084 3.0000 SAT-607 A The Impact of Prenatal Parental Tobacco Smoking on Risk of Diabetes Mellitus in Middle-Aged Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Natthinee Charatcharoenwitthaya*1, Charintip Somprasit1, Athita Chanthasenanont2, La-or Chailurkit3 and Boonsong Ongphiphadhanakul4
1Thammasat University, Pathumthani, Thailand, 2Faculty of Medicine, Thammasat University, Pathumthani, Thailand, 3Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 4Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Background: Bisphenol A (BPA) is an industrial chemical widely used in the manufacture of polycarbonate plastics and epoxy resin. Several studies have suggested that BPA exposure may be associated with the increased risk of type 2 diabetes. However, data are limited for an association between BPA exposure and the risk of gestational diabetes mellitus (GDM).

Objectives: The objectives were to examine the differences in urinary total- and free BPA levels between women with GDM and normal pregnant women, and to examine the relationships between BPA levels and glucose parameters including plasma glucose levels, fasting insulin levels, HOMA-IR, and HOMA-B.

Methods: A nested case-control study was conducted. One hundred women with GDM were matched with 100 normal pregnant women for age and body mass index (BMI) range. Clinical data, blood samples and spotted urine samples were obtained during the first trimester of pregnancy and during 24-28 weeks’ gestation. Urinary BPA levels were measured by an online solid-phase extraction high performance liquid chromatography tandem mass spectrometry.

Results: Urinary free BPA levels were detectable in 166 women (83 women with GDM and 83 controls) during the first trimester, and 159 women (77 women with GDM and 82 controls) during the second trimester. Urinary total BPA levels were detectable in all women during the first trimester and 196 women during the second trimester (99 women with GDM and 97 controls). Levels of free BPA were not significantly different between women with GDM and normal controls both during the first trimester [median 0.12 ng/ml (IQR 0.03-0.25 ng/ml) vs. median 0.19 ng/ml (IQR 0.02-0.35 ng/ml); P = 0.11] and during 24-28 weeks’ gestation [median 0.12 ng/ml (IQR 0.003-0.24 ng/ml) vs. median 0.14 ng/ml (IQR 0.02-0.25 ng/ml); P = 0.53]. Levels of total BPA were not significantly different between women with GDM and controls both during the first trimester [median 1.0 ng/ml (IQR 0.55-1.8 ng/ml) vs. median 1.11 ng/ml (IQR 0.67-1.81 ng/ml; P = 0.46] and during 24-28 weeks’ gestation [median 0.81 (IQR 0.37-1.25 ng/ml) vs. 0.80 (IQR 0.35-1.27 ng/ml); P = 0.98]. There were no significant correlations between BPA levels (both free and total forms) and glucose parameters (glucose levels, insulin levels, HOMA-IR, and HOMA-B) both during the first trimester and during 24-28 weeks’ gestation. In multivariate analyses adjusting for age, log BMI, and a family history of diabetes, BPA levels were not associated with GDM both during the first trimester of pregnancy and during 24-28 weeks’ gestation.

Conclusions: BPA exposure during pregnancy was not associated with the risk of GDM.

 

Nothing to Disclose: NC, CS, AC, LOC, BO

20961 4.0000 SAT-608 A Bisphenol a Exposure and the Risk of Gestational Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Sally K. Abell*1, Helena J. Teede1, Sophia Zoungas2, Sanjeeva Ranasinha1 and Jacqueline Boyle1
1Monash University, Melbourne, Australia, 2Monash University, Clayton VIC, Australia

 

Aim
To examine the relationship between Gestational Diabetes Mellitus (GDM), obesity, and adverse pregnancy outcomes.

Methods
A large scale retrospective observational study was conducted of all births >20 weeks gestation in an ethnically diverse population at Monash Health from 2009 to 2013 (n=38374) recorded in the longitudinal Birthing Outcomes System database. Antenatal characteristics, maternal and neonatal outcomes were compared for those with GDM (n=3018) and those without GDM (n=35356) [diagnosis based on 75g OGTT at 26-28weeks with fasting plasma glucose level ≥5.5mmol/L and/or 2-h level ≥8.0mmol/L]. Multivariable regression analysis was used to detect associations between GDM, obesity and adverse pregnancy outcomes, adjusting for potential confounders including maternal age, parity, baseline body mass index (BMI), country of birth and smoking status.

Results
Age, country of birth (Asian, African/Middle Eastern and Polynesian regions), BMI, past history of GDM, family history of diabetes, presence of hypertension and polycystic ovarian syndrome were associated with an increased risk of GDM. Smoking was associated with a decreased risk of GDM. 

GDM was an independent risk factor for pre-eclampsia, induction of labour (IOL) and C-section. Neonates of women with GDM had increased risk of macrosomia, hypoglycaemia, hyperbilirubinaemia, and special care nursery (SCN) admission compared to those without GDM (p<0.05). Women with GDM had significantly reduced risk of a composite neonatal outcome including death, stillbirth, shoulder dystocia and birth trauma compared to those without GDM (p<0.05).  Women with insulin treated GDM (30%) were more likely to require IOL and C-section and their neonates had increased risk of macrosomia, hypoglycaemia and SCN admission compared to diet controlled GDM (p<0.05). 

Women with GDM who were overweight and obese had increasing risk of gestational hypertension, obstetric intervention, and neonatal morbidity (hypoglycaemia and macrosomia) compared to those with normal BMI after adjustment for confounders (p<0.05). A BMI of 30-35kg/m2 conferred an additional risk of pre-eclampsia and BMI>35 kg/m2 was associated with stillbirth and low birth weight. The impact of obesity on pregnancy outcomes across different ethnicities was also determined.

Conclusions
Women with GDM have a greater risk of pre-eclampsia, higher rates of obstetric intervention, and adverse neonatal outcomes. However, pregnancies with GDM have lower rates of stillbirth and neonatal death.  Excess risks of IOL, C-section, SCN admission, macrosomia and neonatal hypoglycaemia persisted despite insulin therapy.  Pre-existing obesity enhances maternal and neonatal risks in women with GDM across BMI categories when compared to normal weight women with GDM.

 

Nothing to Disclose: SKA, HJT, SZ, SR, JB

20247 5.0000 SAT-609 A Gestational Diabetes Mellitus and Adverse Pregnancy Outcomes: Experience from Australia's Largest Healthcare Service 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Aoife M Egan*1, Andriy Danyliv2, Louise Carmody3 and Fidelma P Dunne3
1National University of Ireland Galway, Ireland, 2National University of Ireland Galway, Galway, Ireland, 3National University of Ireland Galway

 

Background:

Rates of pregnancy complications are significantly elevated among women with pregestational diabetes mellitus.  It is well established that for women with type 1 diabetes, prepregnancy care (PPC) reduces adverse pregnancy outcomes.   Many studies however, predate the era of modern diabetes care in pregnancy, contain small selected groups of women, and do not include women with type 2 diabetes. 

Aims:

Our aims were to evaluate the effectiveness of a regional PPC program for women with pregestational diabetes mellitus, type 1 and type 2. 

Methods:

This prospective cohort study included women with type 1 and type 2 diabetes attending five antenatal centres in the West of Ireland between January 2006 and December 2013.  PPC was offered to all women age 18-40 years with type 1 or type 2 diabetes via a diabetes register.  Primary outcomes included adverse neonatal outcome (shoulder dystocia, congenital malformation, stillbirth or neonatal death), delivery by cesarean section, admission to the neonatal intensive care unit, use of prepregnancy folic acid, and first trimester HbA1c.  Comparisons were made between those that did and did not attend the PPC program. Statistical analysis was completed using IBM SPSS Version 20.   

Results:

In total 452 women were included, 275 (60.8%) with type 1 diabetes and 177 (39.2%) with type 2 diabetes.  PPC was attended by 148 (32.7%) women, 109 (39.6%) of those with type 1 and 39 (22.0%) of those with type 2 diabetes.  Women who attended PPC were older on average than those who did not (33.8 versus 31.8 years, p< 0.001) and more likely to be of Caucasian ethnicity (95.9% versus 81.9%, p<0.001). Rates of adverse neonatal outcomes were higher in those that did not attend PPC (9.5% versus 4.1%, p= 0.04).  A higher proportion of infants born to women who attended PPC required neonatal unit admission (37.2% versus 48.7%, p=0.02).  Prepregnancy folic acid use was greater (96.6% versus 54.9%, p<0.001) and mean first trimester HbA1c was lower (6.9% versus 7.8%, p=0.003) among those who attended PPC.  There was no difference in rates of cesarean delivery between groups. 

Conclusion:

Women who attend PPC are more prepared for pregnancy as demonstrated by higher rates of preconceptual folic acid use and lower 1st trimester HbA1c.  Despite the provision of high quality diabetes care with tight glycemic control during pregnancy for all women, there was a lower rate of major adverse neonatal outcomes and less admissions to the neonatal care unit among infants born to women who attended PPC.  This study supports the ongoing provision of PPC to all women planning pregnancy with pregestational diabetes, type 1 and type 2.

 

Nothing to Disclose: AME, AD, LC, FPD

22003 6.0000 SAT-610 A A Regional Prepregnancy Care Program for Women with Pregestational Diabetes: Is It Worthwhile? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Bharat Rakesh Sharma1, Roza Bardeskar2, Ameya S Joshi3, Premlata Krishnamoorthy Varthakavi3, ASHA Dalal2, Manoj Dharam Chadha4 and Nikhil Madhusudan Bhagwat*5
1Currently working at BYL Nair hospital and Topiwala National medical college, Mumbai, Mumbai, India, 2BYL Nair hospital and Topiwala National Medical College, 3BYL Nair hospital and Topiwala National Medical College, Mumbai, 4BYL Nair hospital and Topiwala National Medical College, Navi Mumbai, India, 5BYL Nair hospital and Topiwala National Medical College, Mumbai Maharashira, India

 

CONTEXT: Both pregnancy induced hypertension(PIH) and gestational diabetes mellitus(GDM) being manifestations of insulin resistance in pregnant women, we looked at serum markers of insulin resistance in first half of pregnancy (when patho-physiological changes start) for prediction of PIH and GDM (increasingly prevalent complications) in second half of pregnancy.

AIMS: To study markers of insulin resistance in the first twenty weeks of pregnancy as predictors of PIH and GDM

METHODS: 300 consecutive pregnant women attending the ante-natal care clinic of a tertiary care hospital before 20 weeks of gestation were registered for a prospective study. At the first visit, maternal clinical characteristics (age, body weight, blood pressure(BP), signs of insulin resistance) and biochemical markers [leptin, adiponectin, high sensitivity C reactive protein (hsCRP), sex hormone binding globulin (SHBG), insulin and tumour necrotic factor alpha] were studied. 75 gm oral glucose tolerance test (OGTT) was performed between 26-32 weeks. BP was measured on each visit and PIH was defined as BP>140/90mm Hg after 20 weeks of gestation. GDM and gestational glucose intolerance (GGI) were defined as fasting blood sugar > 92 mg/dl or 2 hour post glucose blood sugar > 140 mg/dl; and > 120 mg/dl respectively, using the Diabetes in Pregnancy study group of India (DIPSI) criteria1.

RESULTS: In the PIH arm, out of 300, 24 patients (8%) were diagnosed with PIH. On statistical analysis, mean serum leptin levels were significantly different in patients with PIH (32.74 + 14.11 ng/ml, n=24) and controls (21.75 + 7.09 ng/ml, n=276) (p<0.01).

In the GDM/GGI arm, out of 167 patients, 18 had GDM(10.7%) and 38(22.7%) had GGI. Age(p=0.011) and weight(p=0.004) had significant positive correlation with 2 hour OGTT values. Mean serum leptin(p<0.001), SHBG(p=0.017) and serum insulin(p=0.020) levels were significantly different between GDM/GGI and control group. On linear regression analysis, first trimester serum leptin levels had a positive correlation and SHBG and adiponectin had a negative correlation with 1 and 2 hour OGTT values in the third trimester. On multiple regression analysis, only leptin had strong correlation with the 2 hour OGTT values (p=0.021).

          The AUC/ROC curve for correlation of leptin levels and GDM/GGI in the third trimester showed an area under the curve of 0.752 m2. Serum leptin>16.46 ng/ml in first trimester had 70% sensitivity and 74% specificity for predicting GDM/GGI.

CONCLUSION/ DISCUSSION: Age,body weight and leptin had significant positive correlation while adiponectin and SHBG correlated negatively with occurrence of GDM/GGI. Serum leptin, SHBG and insulin were significantly different between PIH/GDM and control arms. In a multiple regression model, leptin had significant correlation with occurrence of GDM/GGI, allowing use of AUC-ROC curve to establish leptin cut-off for prediction of latter.

 

Nothing to Disclose: BRS, RB, ASJ, PKV, AD, MDC, NMB

20801 7.0000 SAT-611 A Pregnancy Induced Hypertension and Gestational Diabetes Mellitus: Search for an Optimal Predictive Marker before the 20th Week of Gestation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Suleyman Hilmi Ipekci*1, Ayse Gul Kebapcilar2, Setenay Arzu Yilmaz2, Tolgay Tuyan Ilhan2, Aybike Tazegul Pekin2, Sedat Abusoglu2, Ali Unlu2, Ali Annagur2 and Cetin Celik2
1Selcuk University Med Faculty, Konya, Turkey, 2Selcuk University Faculty of Medicine, Konya, Turkey

 

The pathophysiologic mechanisms responsible for GDM are not as yet completely understood, there are two main pathways leading to GDM, insulin resistance and chronic subclinical inflammation. Neopterin is a pteridine that is produced as a catabolic product of guanosine triphosphate metabolism. It is synthesized and released by activated monocytes or macrophages upon stimulation with gamma-interferon. Increased neopterin levels indicate endogenous formation of gamma-interferon produced by activated T cells and suggest cell-mediated immune activation. High neopterin level is associated with increased production of reactive oxygen species suggesting oxidative stress elicited by the immune system. In neonates, non-infection associated elevation of proinflammatory cytokines was described by several authors in conditions of maternal and perinatal distress, neonatal hypoxia, and tissue damage. In previous studies have been shown that placental inflammation and GDM was independently associated with low Apgar score in neonates.  To our knowledge there is no available data with regard to the alteration of neopterin levels in maternal and cord serum in women with GDM and compared with a matched nondiabetic control group. In the present study, we hypothesized that serum neopterin concentrations are elevated in patients with GDM when compared with pregnant women with normal glucose tolerance and to evaluate neopterin levels that could be potential predictors of low Apgar score in patients with GDM. We carried out a prospective case-control study by enrolling 81 women with GDM and 38 pregnant women without GDM. Between the 24th and 28th weeks after gestation, the 50-g glucose challenge test (GCT) was applied and among pregnant women, those who showed GCT over or equal to 140 mg/dl were given a 3-h diagnostic 100-g oral glucose tolerance test (OGTT) the next week. Maternal blood samples were obtained from an antecubital vein before cesarean delivery. During delivery, the umbilical cord was double clamped. Just after delivery of the placenta, umbilical whole blood was collected into tubes without anticoagulant Maternal and cord neopterin levels were higher in women with GDM. There was a significant positive association between fasting blood glucose levels and maternal serum neopterin levels. 50 g oral glucose challenge test results correlated to maternal and cord neopterin levels. Pregnancies complicated by GDM exhibited lower Apgar score than those of control subjects. A level of cord neopterin level was inversely correlated with Apgar score in patients with GDM. Patients with GDM had higher maternal and cord neopterin levels and also cord neopterin level is inversely associated with lower Apgar scores in women with GDM. Increased neopterin levels suggest that neopterin level could be potentially used as indicators of risk factor for assessing low Apgar score in women with GDM.

 

Nothing to Disclose: SHI, AGK, SAY, TTI, AT, SA, AU, AA, CC

21263 8.0000 SAT-612 A Serum Levels of Neopterin in Gestational Diabetes Mellitus: Relationship with Apgar Scores 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Eon Ju Jeon*, Chulyun Park, Eui Dal Jung Sr., Ho Sang Shon Sr. and Ji Hyun Lee
Catholic University of Daegu School of Medicine, Korea, Republic of (South)

 

Aim: Pregnancy in women aged 35 years or older is becoming increasingly prevalent. Age and body mass index(BMI) are important risk factors for gestational diabetes mellitus(GDM). The aim of this study was to evaluate adipokines concentration and insulin resistance according to age and pre-pregnancy BMI in GDM.

Method: We enrolled total 54 pregnant women with GDM. All subjects underwent a 100g oral glucose tolerance test (OGTT) during the 24th-28th weeks of gestation. The subjects were classified into two groups: (1) pregnancy before the age of 35 (n=31), (2) pregnancy after the age of 35 (n=23).

Results: GDM with pregnancy in women aged 35 years or older was decreased adiponectin levels, elevated resistin levels, decreased leptin levels compared with GDM with pregnancy before the age of 35 (p=0.349, p=0.747 and p=0.311). In GDM with advanced maternal age, leptin was not correlated HOMA-IR and pre-pregnancy BMI. However, in GDM with before the age of 35, leptin was significantly correlated with HOMA-IR and pre-pregnancy BMI (p=0.043 and p=0.14). In GDM with pregnancy before the age of 35, HOMA-IR was significantly higher in pre-pregnancy BMI 25 kg/m2 group compared with pre-pregnancy BMI < 25 kg/m2 group (p=0.032).

Conclusion: This study showed that adipokines might be correlated with age of pregnant women with GDM. Leptin was correlated with insulin resistance and pre-pregnancy BMI in GDM with before the age of 35. Insulin resistance was correlated with pre-pregnancy BMI in young aged pregnant women with GDM.

 

Nothing to Disclose: EJJ, CP, EDJ Sr., HSS Sr., JHL

20724 9.0000 SAT-613 A Correlation of Adipokines and Insulin Resistance According to Age and Pre-Pregnancy Body Mass Index in Gestational Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Panudda Srichomkwun*1, Natnicha Houngngam2, Sophitsachi Pasatrat3, Thipaporn Tharavanij4 and Weerapan Khovidhunkit5
1Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 2Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand, Bangkok, Thailand, 3Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, Bangkok, Thailand, 4Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand, Pathumthani, Thailand, 5Division of Endocrinology and Metabolism, Department of Medicine, and Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

 

Osteocalcin (OC) is an osteoblast-derived protein which locally acts on the bone. Recent studies in animals have discovered that OC plays an unexpected role in glucose homeostasis. An undercarboxylated form of OC (ucOC) has been shown to stimulate beta cell proliferation and increase insulin sensitivity in animals. In humans, both total OC and ucOC levels have been reported to be decreased in patients with type 2 diabetes and have negative correlation with insulin resistance indices. Pregnancy is a physiological state of insulin resistance and gestational diabetes mellitus (GDM) can serve as a model of insulin resistance during pregnancy. The aim of this study was to investigate an association between OC levels and insulin resistance indices during pregnancy. We measured serum levels of OC, ucOC, glucose, lipid, and insulin and assessed insulin resistance indices using homeostasis model assessment (HOMA-1IR and HOMA-2IR) among 138 pregnant women with varying degrees of IR (GDM=78, non-GDM=60), all of whom were positive for glucose challenge tests (GCT). Samples were obtained during an oral glucose tolerance test (OGTT). We found that total OC and ucOC levels were positively correlated with HOMA1-IR (r=0.23, P<0.001 and r=0.30, P<0.001, respectively) and HOMA-2IR (r=0.22, P<0.001 and r=0.24, P<0.001, respectively). Although both total OC and ucOC levels were not significantly different between women with and without GDM, the levels were significantly higher in non-GDM women who had 1 abnormal OGTT value than those who had all normal OGTT values (expressed as median (interquartile range): 14.57 (9.71-18.09) vs. 8.85 (6.79-11.57) ng/mL for total OC, P<0.01 and 6.75 (2.75-10.08) vs. 2.53 (1.07-6.14) ng/mL for ucOC, P<0.01). Total OC and ucOC levels in women who had completely normal OGTT values after a positive GCT were also not significant different from those in women with negative GCT. We concluded that, during pregnancy, serum total OC and ucOC levels were positively correlated with IR indices, unlike what has been observed in non-pregnant subjects. Our results suggested that changes in total OC and ucOC levels in pregnancy women may be secondary to increased IR during pregnancy and that total OC and ucOC do not play a major role in the pathogenesis of increased IR during pregnancy.

 

Nothing to Disclose: PS, NH, SP, TT, WK

18431 10.0000 SAT-614 A Total and Undercarboxylated Osteocalcin Are Associated with Insulin Resistance during Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Edesiri Akajagbor*1, Gregory Grimberg2, Mudar Dalloul2, John Kral3 and Vijaya Lakshmi Nacharaju3
1Downstate Medical Center, Brooklyn, NY, 2Downstate Medical Center, 3Downstate medical center, Brooklyn, NY

 

 

Placental 11β-hydroxysteroid dehydrogenase activity and cord serum cortisol levels in obesity.

Objective: Maternal diabesity and stress and excess fetal glucocorticoid exposure are associated with increased risk of obesity and diabetes in later life. Previously we found attenuated placental conversion of estradiol to estrone related to lower 17betaHSD activity, resulting in fetal exposure to high levels of estradiol in obese women. Placental 11β-hydroxysteroid dehydrogenase (11β-HSD) activity regulates fetal exposure to maternal cortisol. We study cord cortisol and placental 11β-HSD activity in obese parturients.

Design: Pilot study in prospectively collected cord blood and placental tissue in a convenience sample of full-term Caribbean Black women in an inner-city academic medical center.

Methods: Placental samples of central villous tissue and cord blood were obtained from 19 patients, ages 20-35 years with BMI ranging 24-49. Serum was separated and stored and placenta was immediately frozen and stored at -800 C.  Placental homogenates were incubated with tritium labeled cortisol and NAD for 60 minutes at 370 C and cortisol and cortisone were separated by TLC, counted with a beta counter for calculation of % conversions. 11β-HSD activity is expressed as nM cortisone formed/min/mg placental tissue. Cord serum cortisol levels were determined by ELISA.

Results: Cord serum cortisol levels were high, mean 41.05 ± 11.08 µg/dl compared to our earlier published data showing less than 10 µg/dl  in normal pregnant women, and inversely correlated with placental 11β-HSD activity (r= - 0.48, p=0.04).  Birthweight was inversely related to 11β-HSD activity (r= - 0.52, p=0.02) but there were no associations between 11β-HSD activity and maternal BMI or gestational age (mean 38 weeks, range 35-42).

Conclusions: Lower 11β-HSD activity in obesity is associated with increased fetal weight and higher cord serum cortisol as a potential mechanism for maternal-fetal transmission of the dysmetabolic diathesis.

 

Nothing to Disclose: EA, GG, MD, JK, VLN

21911 11.0000 SAT-615 A Placental 11β-Hydroxysteroid Dehydrogenase Activity and Cord Serum Cortisol Levels in Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Changhwan Ahn*1, Kipung Kim2, Myoungho Lee2 and Eui-Bae Jeung1
1Chungbuk National University, Cheongju, Korea, Republic of (South), 2Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South)

 

Introduction: The endoplasmic reticulum (ER) is designed in an interconnected tubular network involved in metabolic mechanisms such as carbohydrate and steroid metabolism. Especially in the smooth endoplasmic reticulum, ER regulates calcium ion concentration as a reservoir in the cell, and it has a crucial role in the apoptosis and autophagy pathway. ER stress, also known as unfolded protein response, is a cellular stress response related to the endoplasmic reticulum. ER stress is activated in response to accumulation of unfolded or misfolded proteins in the lumen of endoplasmic reticulum. At the initial stage of ER stress, ER tries to restore normal function by halting protein translation, degrading misfolded proteins, and increasing production of chaperones involved in protein folding. If ER fails to restore ER stress, ER stress can lead to apoptosis. Methods: To study the signaling between ER stress and calcium channels under ER-stressed circumstances, we designed a hypoxia induced diabetic model. Nine-week-old female pregnant mice were chosen, maintained under hypoxic condition under 10% O2, 5% CO2 from 6.5 days of gestation (GD 6.5) to GD16.5, and the expression of ER stress markers and calcium channel gene expression were examined by real-time PCR. Results: By maintaining hypoxic condition, the pregnant mice showed high glucose level. Under this diabetic condition, in pancreatic beta cells, ER stress markers, XBP1s, ASK1, CHOP, and ERO1a were elevated by hypoxic condition. This tendency showed an increase in calbindin-D9k KO mice. Chaperones such as calreticulin and calnexin were decreased, but in Calbindin-D9K KO mice chaperone calnexin was not decreased. Conclusion: We examined the relationship between calbindin D9k and ER stress using a hypoxia-induced diabetes mellitus model. The blood glucose level was increased by hypoxia. Interestingly, the calbindin-D9k KO normnoxia mice showed increased glucose level compared with wildtype normoxia mice. Also, calnexin expression of pancreas was decreased in calbindin-D9k KO normoxia mice. This result indicates that pancreas cells were under endoplasmic reticulum stress. Taken together, calbindin may play an important role in endoplasmic reticulum stress in pancreas. Further study on expression of Ryr2, Serca2a, NCX, and Pmca1 is being conducted.

 

Nothing to Disclose: CA, KK, ML, EBJ

20496 12.0000 SAT-616 A Calbindin-D9k and ER Stress in Hypoxia-Induced Diabetes Mellitus Model 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Jean Huang*1, Horng-Yih Ou2, James Lin1, Rudruidee Karnchanasorn3, Wei Feng1, Raynald Samoa1, Lee-Ming Chuang4 and Ken C Chiu1
1City of Hope National Medical Center, Duarte, CA, 2National Cheng-Kung University Medical College and Hospital, Tainan, Taiwan, 3The University of Kansas Medical Center, Kansas City, KS, 4National Taiwan Univesity Hospital, Taipei, Taiwan

 

The relationship of metabolic profile with hepatitis B virus infection have been evaluated by many but remained unclear. We used a U.S. population study to investigate metabolic profile in glucose tolerant subjects that were successfully vaccinated for Hepatitis B.

We included adult subjects (≥20 y/o) with hepatitis B serology and body mass index (BMI) available from the NHANES 1999-2010.  Subjects with either diabetes or impaired glucose tolerance were excluded based on established diabetes, fasting plasma glucose (FPG) ≥100 mg/dL, 2-hour plasma glucose (2hPG) >140 mg/dLor HbA1c 5.6%. Successful vaccination for Hepatitis B was defined by positive Hepatitis B surface antibody, negative Hepatitis B core antibody, and negative Hepatitis B surface antigen. The total sample size was 15,481 with variation between different metabolic profile based on the data availability (n= 5,671–15,481). The subjects received pharmacological interventions for blood pressure (BP) and lipid were excluded from the analyses of BP and lipid, respectively. Metabolic profile of successful vaccinated subjects was compared with others considering the following covariates: age, gender, BMI, ethnic/racial group, current smoker, active alcohol consumption, family history of diabetes, poverty index, and education. BMI was not used as a covariate for the analysis of BMI and waist.

The successful vaccinated subjects were associated with lower BMI, smaller waist, lower HbA1c, lower FPG, lower systolic and diastolic BP, lower total cholesterol, higher HDL and lower LDL cholesterol (all P values < 0.00005). After adjusted for above covariates, BMI (P= 0.000002), waist (P<0.000001), diastolic BP (p=0.002), total cholesterol (P=0.00003) and LDL cholesterol (P=0.01) still differed significantly between two groups. Although HOMA-IR did not show a difference in the unadjusted model (P=0.16), lower HOMA-IR was noted in the successful vaccinated subjects when compared to others (P=0.006) after adjusting covariates. There was no difference observed between the two groups for HOMA-B.

 

Our study shows that successful immunization after Hepatitis B vaccination is associated with a favorable metabolic profile in glucose tolerant population. It suggests hepatitis B immunization could potentially prevent future development of metabolic syndrome and lower risks for diabetes. A prospective study is needed to validate our observation.

 

Nothing to Disclose: JH, HYO, JL, RK, WF, RS, LMC, KCC

18601 13.0000 SAT-617 A Successful Vaccination of Hepatitis B Is Associated with a Better Metabolic Profile 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Ji Youl Yang1, Jun Ho Yun2, Heun-Sik Lee2, Suyeon Park2, Hyun Jeong Jeon3, Taekeun Oh3, Bong-Jo Kim2, Jeong-Min Kim2, Hyung Jin Choi*4 and Sihoon Lee5
1Department of Internal Medicine, Chungbuk National University College of Medicine, Korea, Republic of (South), 2Center for Genome Science, Korea National Institute of Health, Korea, Republic of (South), 3Chungbuk National University College of Medicine, Cheongju, Korea, Republic of (South), 4Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 5Gachon University School of Medicine, Incheon, Korea, Republic of (South)

 

Background: Metabolomics profiling is a rapidly evolving method of comprehensive measurement of numerous endogenous metabolites in a biological fluid, such as blood, and can be used to investigate novel effect of certain drug on metabolites.

Methods: AbsoluteIDQ p180 kit was used to quantify 186 metabolites. To investigate metabolites profiles associated with diabetes drugs, serum of diabetes patients was divided by metformin-alone group, metformin+thiazolidinedione group, or metformin+sulfonylurea group. T-test and partial least-squares discriminant analysis (PLS-DA), were performed to identify significant metabolites.

Results: PLS-DA plot showed significant differences in metabolites profiles between metformin-alone group and metformin-based combination groups. Eighteen metabolites were significantly different between groups based on t-test (P<0.05). Ten metabolites were chosen to be different between groups based on PLS-DA analysis (VIP>1.5). Thiazolidinedione with metformin group showed increased level of phosphatidylcholine and lyso-phosphatidylcholine metabolites and decreased level of biogenic amine metabolites such as knyurenine and taurine when compared with metformin alone group. Sulfonylurea with metformin group showed decreased level of phosphatidycholinemetabolites and sphingomyelin metabolites when compared with metformin alone group.

Conclusion: These comprehensive metabolic profiling revealed novel effects of thiazolidinedione and sulfonylurea on blood metabolites. These results could suggest novel clinical implications or plausible unwanted side effects of these drugs.

 

Nothing to Disclose: JYY, JHY, HSL, SP, HJJ, TO, BJK, JMK, HJC Disclosure Not Provided: SL

21488 14.0000 SAT-618 A Metabolomics Profiling of Patient Blood Reveals Novel Effects of Thiazolidinedione and Sulfonylurea 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Ping Yu* and Richard B Meagher
University of Georgia, Athens, GA

 

Multipotent cell types commonly have enlarged nuclei with decondensed chromatin. Decondensed chromatin is associated with increased rates of transcription, increased expression of chromatin modifying machinery, and increased expression of markers of cell cycle activity and multipotency. We recently reported that a large fraction of mouse brain cell nuclei (NeuN-High nuclei) have decondensed chromatin relative to most NeuN-Low neuronal cell nuclei or NeuN-Neg (negative) non-neuronal brain cell nuclei from glia, astrocytes, endothelial cells, and leukocytes. Sorted NeuN-High nuclei do indeed express significantly higher levels of transcripts encoding chromatin modifying machinery (SIRT1, HDAC1, HDAC2, HDAC11, KAT2B, KAT3A, KAT3B, KAT5, DMNT1, DNMT3A, Gadd45a, Gadd45b) and markers of neural progenitor cells and elevated cell cycle activity (BRN2, FOXG1, KLF4, c-MYC, OCT4, PCNA, SHH, Sox2) relative to other brain cell nuclei. NeuN-High nuclei also express higher levels of transcripts encoding markers of neurogenesis, neuroplasticity, and learning and memory (ARC, BDNF, ERG1, HOMER1, NFL/NEF1, SYT1) as might be expected for the most active neurons. Regions of the brain most active in neurogenesis contain the highest levels of NeuN-High decondensed nuclei (cortex, hippocampus, hypothalamus, thalamus, nucleus accumbens), while there were very few in the cerebellum and pons.

Intrigued by the increase in complementary factors directing both increased and decreased DNA methylation, DNMTs and GADDs, respectively, we began to test the hypothesis that NeuN-High decondensed nuclei are from cells with elevated turnover rates for DNA5´-methylcytosine (5meC). This idea follows directly from Sir Francis Crick’s original 1984 (Nature) proposal linking learning and memory with molecular turnover.The machinery responsible for the decay of 5meC has been somewhat enigmatic. 5meC may be lost (1) during normal excision repair and DNA replication if DNMTs fail to replace C with 5meC in hemimethylated 5meCG/GC dinucleotides and (2) through an active DNA demethylation pathway, when 5meC is oxidized to 5hmC by the Ten-Eleven Translocation family of enzymes (TET1, TET2, TET3). 5hmC is then further be oxidized and repaired by base excision repair (BER) system to regenerate unmodified cytosine replacing 5meC. We found the DNA of NeuN-High mouse brain nuclei contained exceptionally high levels of 5hmC relative to NeuN-Low and NeuN-Neg non-neuronal cell nuclei.  NeuN-High decondensed nuclei also expressed higher levels of TET enzymes responsible for generating 5meC.Examining the turnover of epigenetic marks among neuronal cell nuclei may provide novel insights into learning and memory and neurodegenerative disease.

 

Nothing to Disclose: PY, RBM

20531 16.0000 SAT-620 A 5-Hydroxymethylcytosine (5hmC) Levels Are Exceptionally High in Decondensed Neun-High Neuronal Cell Nuclei 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Richard B Meagher*1, Suresh Ambati1, Elizabeth Cohen McKinney1, Diane L Hartzell2, Lexiang Ji1 and Robert Schmitz1
1University of Georgia, Athens, GA, 2Univ of Georgia, Athens, GA

 

Obesity is characterized by increased adipocyte development in muscle and bone marrow as well as an expansion of subcutaneous and visceral adipose tissue (SAT & VAT) depots. It is widely speculated that harmful differences in obese adipokine expression are under epigenetic control. Considering that epigenetics is the study of cell-type-specific differences in a developmental context, it is important to examine isolated adipocytes. However, adipocytes represent only a subset of cells in adipose tissues. For example, VAT and SAT also containsvarious leukocytes and endothelial cells. Leukocyte cell types increase in relative concentrations in obese adipose tissue. Adipocytes are large, sticky, fragile and difficult to manipulate or sort in large numbers. We propose that by working with adipocyte nuclei we can simplify and advance the epigenetic analysis of obesity and descending diseases such as CVD, cancers, and diabetes.

First, we developed protocols that allowed adipocyte cellular nuclei to be isolated with relative ease and manipulated by fluorescent nuclear cytometry (FNC) and sorting (FANS). Second, we implemented an innovative technology, INTACT (Isolation of Nuclei TAgged in Specific Cell Types), in transgenic mice which enables the rapid affinity isolation of a specific of adipocyte nuclei.In our construct the nuclear trans-membrane proteinSUN1was fused via its extracellular to a red fluorescence protein (mRFP1) reporter and an immunoepitope tag (3xFlag).The construct ADNp:SUN1RFPFlag was expressed under control of a modified mouse adipocyte-specific adiponectin promoter (ADNp).

TheADNp::SUN1RFPFlag construct was strongly expressed in 3T3L1 cells, once they were differentiated into mature adipocytes. Furthermore, a paramagnetic bead basedimmunoaffinity purification of SUN1RFPFlag-tagged adipocyte nuclei using anti-RFP and anti-FLAG antibodies was simple to execute.

We constructed mice expressing ADNp:SUN1RFPFlag. Twomouse lines expressing the transgene strongly expressed the SUN1RFPFlag transcript and protein in mature white adipose tissue. Nuclei were affinity captured from SAT and VAT tissues and DNA and RNA were prepared. We are in the process of comparing the adipocyte cell-type specific methylome and transcriptome of SAT and VAT.

INTACT technology will enable adipocyte-specific analysis of nuclei from different adipose tissue depots of normal and environmentally compromised mice, lean and obese mice, drugged mice, and mice on different diets in VAT, SAT, muscle. INTACT technology will allow the adipocyte specific analysis of their epigenomes, transcriptomes, and proteomes to be compared.

 

Nothing to Disclose: RBM, SA, ECM, DLH, LJ, RS

20542 17.0000 SAT-621 A A Mouse with Affinity Taggedadipocyte Nucleiforepigenetic Studies 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Natalie M Hohos*, Muthugapatti M Kandasamy, Bradley P Phillips and Richard B Meagher
University of Georgia, Athens, GA

 

Blood leukocytes are a convenient source of DNA to study the epigenomic reprogramming which results from physiological stress and disease. The majority of published studies on reprogramming DNA methylation utilize mixed white blood cell types. However, each of the major seven-leukocyte cell types in blood are functionally distinct and havehighlydivergent DNA 5´-methyldeoxycytosine (5meC) profilesfor cytosinesin the CG dinucleotide context. Therefore, mixing cell types in assays of the whole blood methylome can lead to un-interpretable data. Significant findings are lost due to the mixing of site-specific hypermethylated and hypomethylatedepitypes. We have developed a simplified protocol to successively isolate the major seven leukocyte types from one or two 5 ml blood samples, yielding relatively pure cell populations for epigenomic analyses.We developed qRT PCR assays to rapidly assess cell type purity as a supplement to current approaches (e.g., cytometry, nuclear morphology). While global increases and decreases in promoter proximal 5mCG levels often reflect gene silencing and activation, respectively, total5meCG levels are relatively constant across most human cell types (~4.3% of all Cs). By contrast recent evidence suggests total andintragenic hydroxymethylcytosine (5hmCG) levels may be to be more directly related to the turnover of DNA methylation, to changes in gene expression and to cell type specificgene expression. In particular, leukocytes express moderate 5hmCG levels (0.12% of all Cs). 5hmCG appears to be important to early leukocyte development and to naïve T cellsin activating T cell development.We are examining the role of DNA hydroxymethylation andrelated pathways of 5meCG turnover in subsetsof leukocytes. Our hypothesis is that the leukocyte types with the highest levels of 5hmC and thosegenes tagged with 5hmC will be more likely to respond epigenetically to a disease state or related stress. Understanding the mechanisms of 5meCG turnover in these cell types may help identify not only the DNA methylation changes associated with disease, but also the leukocyte types most valuable to use as surrogate markers of different diseases(i.e., those leukocytes that respond to particular signaling molecules in the blood released in relation to specific disease states).  We not only examined cell type specific 5hmC levels, but enzymes and factors relevant to its turnover rate (DNMTs, GADD45s, TETs). This knowledge will better identify the leukocyte types best applicable to be utilized as surrogate cells to study epigeneome induced pathologies and disease risk.

 

Nothing to Disclose: NMH, MMK, BPP, RBM

20562 18.0000 SAT-622 A Variations in 5-Hydroxymethylcytosine-Related Activities Among the Seven Classes of Peripheral Leukocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Nojan Nejatian1, Marissa Penna-Martinez2, Dieter Steinhilber3 and Klaus Badenhoop*4
1University Hospital Frankfurt am Main, Germany, 2University Hospital, Goethe-University Frankfurt am Main, Germany, 3Goethe University Frankfurt, 4Goethe-University Hospital, Frankfurt, Germany

 

Introduction: Arachidonate 5-lipoxygenase (ALOX-5) metabolizes the two initial steps in the biosynthesis of leukotrienes (LT), a group of inflammatory lipid mediators derived from arachidonic acid. The role of ALOX-5 in Type 2 Diabetes (T2D) is not well known but a vitamin D (VD) regulation is postulated due to a vitamin D response element upstream The aim of the present study was to investigate a single nucleotide polymorphism (SNP) rs4987105, located in a regulatory region of ALOX-5 nearby a VD response element, in T2D patients and in healthy controls (HC) as well as its interaction with the vitamin D pathway. Methods: German T2D patients (n=533) and HC (n=473) were genotyped for the ALOX-5 SNP by a Taqman assay. In addition, the 25(OH)D3 and 1,25(OH)2D3 plasma levels were measured by radioimmunoassay in a subgroup of patients (n=76) and controls (n=271). Statistical analyses were performed using allele-wise and genotype-wise Chi(x2)-tests. The genotype associations of both metabolites levels were analyzed by Kruskal-Wallis-tests. Results: Significant differences in the genotype analysis of ALOX-5 polymorphism were found between T2D and HC (CC: 76.4 vs. 68.7 %, CT: 22 vs. 28.1 %, TT: 1.7 vs.3.2 %; p = 0.017 corrected (c) p = 0.05). In addition allele C was more frequent (87.3 vs. 82.8% p = 0.0048 pc = 0.01 OR=1.44; 95% CI: 1.12-1.84) and allele T was less frequent (12.7 vs. 17.2% p = 0.0048 pc = 0.01 OR=0.7; 95% CI: 0.54-0.89) in T2D in comparison to HC respectively. In the subgroup with vitamin D metabolites available a significantly lower 25(OH)D3 level was observed in CC and TT homozygous T2D patients (n=62) compared to genotype matched HC (n=268) ( CC: median in ng/ml: 12.6 vs. 19.8, p = 1.0 x 10-7 pc = 9.0 x 10-7 and TT: 7.8 vs. 19.8, p = 0.0047 pc = 0.04) respectively. In addition significantly lower 1,25(OH)2D3 levels were only observed in the CC genotyped T2D patients (n=55)  compared to CC genotyped HC (n=184) (median in pg/ml: 44 vs. 52.4, p = 5.0 x 10-7 pc = 4.5 x 10-6). Conclusion: Our results reveal an association of the ALOX-5 SNP rs4987105 with T2D. Allele C appears to be a moderate risk factor for the development of T2D. Both homozygote genotypes (CC and TT) are associated with low 25(OH)D3 levels but only CC is associated with low 1,25(OH)2D3. In conclusion, our results indicate an interaction of the VD status with the ALOX-5 pathway in T2D. These preliminary results need to be confirmed in a separate cohort and larger number of vitamin D measures. Whether and by which mechanisms vitamin D may regulate anti-inflammatory actions of ALOX-5 in T2D is subject of further studies.

 

Nothing to Disclose: NN, MP, DS, KB

21743 19.0000 SAT-623 A The Association Between Vitamin D and the Arachidonate 5-Lipoxygenase (ALOX-5) Gene Polymorphism in Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Sanghamitra Singh*1, Saurabh Trikha2 and Aleksandar Jeremic1
1The George Washington University, Washington, DC, 2GWU, Washington, DC

 

Lysosomes Regulate Turnover and Toxicity of Human Amylin in Pancreatic Cells

Pancreatic hormone human amylin derived oligomers and aggregates are implicated in the pathogenesis of type 2 diabetes mellitus (TTDM). These oligomers and aggregates, which accumulate both intracellularly and extracellularly in the pancreas of diabetics, are linked to loss in islet beta-cell mass and progressive insulin deficiency, hallmarks of TTDM. Recent studies using the intracellular model of islet amyloidosis demonstrated that human amylin is degraded by autophagosomes and lysosomes, thereby preventing its intracellular accumulation and toxicity. However, the biological significance of this event, its relevance for internalized human amylin (extracellular model) and cellular compartments involved in this process remain to be clarified and is the goal of this study.

Using pancreatic rat insulinoma (RINm5F) beta-cells and human islets of Langerhans as model systems, we showed that human amylin monomers and its toxic oligomers, following their internalization, primarily accumulated in the nucleus. Using confocal microscopy, we showed that while majority of amylin accumulated in the nucleus, some amylin accumulation was detected in the lysosomes and the cytosol.  Amylin was largely absent from mitochondria, golgi complex and did not co-localize with aggresomal markers, heat shock proteins (HSP) 70 and 90, and tubulin. To reconfirm these findings biochemically, enriched nuclear and cytosolic fractions were obtained by cell fractionation, followed by human amylin specific ELISA. ELISA results also showed that majority of amylin accumulation was in the nucleus. Our results also suggested a pivotal role of lysosomes in amylin’s detoxification in pancreatic cells. Inhibition of lysosomal proteolytic activity by NH4Cl increased both monomeric and oligomeric intracellular content in cells leading to increased toxicity of amylin, the effect of which was reversed by the oligomeric inhibitor, methylene blue (MB). In summary, our results indicated that degradation of internalized human amylin encompassed two major branches in pancreatic cells: one that involved cytoplasmic lysosomes-mediated pathway and the other being the nuclear pathway. The significant increase in amylin-induced beta-cell death in lysosome impaired cells suggested a cyto-protective role of this proteolytic compartment against amylin’s toxicity in pancreatic cells.

 

Nothing to Disclose: SS, ST, AJ

20554 20.0000 SAT-624 A Lysosomes Regulate Turnover and Toxicity of Human Amylin in Pancreatic Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 605-624 5937 1:00:00 PM Genes, Metabolism, and Gestational Diabetes Poster


Chad Hunter* and Jamie Galloway
University of Alabama at Birmingham, Birmingham, AL

 

Transcription factors are critical for regulating genes involved in pancreatic endocrine cell fate determination and mature beta-cell function. Islet biologists are closer than ever to producing transplantable insulin-producing beta-cells de novo that improve diabetes outcomes. Success will require a clear understanding of endogenous gene regulatory mechanisms driving functional beta-cell development. The LIM-homeodomain transcription factor Islet-1 (Isl1) is required for late islet endocrine cell development and survival, which largely requires interaction with the LIM domain binding protein 1 coregulator (Ldb1). In other tissues, Ldb1 and Isl1 interact with additional factors to impact target gene transcription, yet few binding partners have been described in beta-cells. We hypothesize that Ldb1 and Isl1 participate in various complexes that include other transcription factors and coregulators to impact beta-cell gene expression. To test this, we utilized a crosslinked-immunoprecipitation/mass spectrometry approach, termed ReCLIP, to enrich and identify proteins directly interacting with Ldb1 and Isl1 in mouse beta-cells. Mass spectrometry datasets revealed numerous interacting candidates that may participate in Ldb1::Isl1 complexes, including a class of Single-Stranded DNA Binding Proteins (e.g. SSBP2-4). SSBPs are coregulators that potentiate LIM transcription factor target gene trans-activation and complex stability in other tissues. However, nothing is known of SSBP expression or activity in pancreatic beta cells. Notably, SSBP3 was the most abundant SSBP coregulator in the mass spectrometry data sets, which we confirmed to interact with Ldb1 and Isl1 by co-immunoprecipitation. Western blotting and immunofluorescence analyses demonstrated that SSBP3 was expressed in beta-cell lines, embryonic mouse endocrine cells and in adult islets, along with Ldb1 and Isl1. Furthermore, beta cell line siRNA-mediated SSBP3 knockdown mirrored mRNA deficiencies observed upon Ldb1 or Isl1 reduction in vitro or in vivo. This appears to be (at least) due to SSBP3 occupancy of known Ldb1:Isl1 target promoters including MafA and Glp1r, as tested by chromatin immunoprecipitation in beta-cell lines. Our results suggest that SSBP3 interacts with Ldb1 and Isl1 in complex and is required for expression of critical beta-cell target genes. This project will further elucidate the components and activity of Ldb1::Isl1 complexes, which are required for beta-cell development, maturation and function.

 

Nothing to Disclose: CH, JG

21396 4.0000 SAT-660 A Single-Stranded DNA Binding Protein 3 (SSBP3) Participates in Ldb1 and Islet-1 Mediated Transcriptional Complexes in Pancreatic Beta Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Katarzyna Malenczyk*1, Vincenzo Di Marzo2, Agnieszka Dobrzyn3 and Tibor Harkany1
1Center for Brain Research, Medical University of Vienna, Vienna, Austria, 2Istituto di Chimica Biomolecolare, Pozzuoli, Italy, 3Nencki Institute of Experimental Biology, Warsaw, Poland

 

Endocannabinoid (eCB) signaling was implicated in regulating insulin and glucagon release from mature pancreatic islets. Yet the presence and function of eCB signals during endocrine pancreas development remains unknown.

In the present study, we showed the cell-type-specific expression of CB1 cannabinoid receptors (CB1R), transient receptor potential vanilloid 1 channels (TRPV1) and the enzymatic machinery producing 2-arachidonoylglycerol (2-AG) in the mouse endocrine pancreas as early as embryonic day (E)16.5. The organization of a 2-AG signaling axis is such that α cells serve as a cellular origin for 2-AG (that is, they express diacylglycerol lipases), while CB1Rs are exclusively present on β cells otherwise co-expressing monoacylglycerol lipase (MAGL) for 2-AG degradation. Therefore, we hypothesized that paracrine 2-AG signaling regulates pancreatic islet development. We combined the genetic ablation of CB1R, MAGL or TRPV1 in mouse models with pharmacological disruption of eCB signaling in ‘pseudoislets’, α/β cell aggregates that model cell sorting in pancreatic islets in vitro. Here, we demonstrate that 2-AG metabolism and action via CB1R signaling regulate α/β cell sorting, whereas TRPV1, endogenously activated by anandamide, an alternative endocannabinoid, controls the size of pancreatic islets. Accordingly, reducing the intake of eCB precursors by dietary enrichment in ω3 fatty acids during pregnancy led to the disruption of prototypic core-mantle morphology of pancreatic islets in adult mouse offspring, with a cells scattered within the islet core. We associate this ‘mixed’ islet phenotype, which was also observed in pancreata of CB1R-/- and MAGL-/- adult mice, with improved glucose clearing, as well as an increase in the ratio of insulin/glucagon secretion from isolated pancreatic islets.

The core-mantle configuration of pancreatic islets composed of β and α cells, respectively, is physiologically preferred in many mammalian species. However, in humans, and upon increased bodily energy demand in rodents, an intermixed configuration of pancreatic islets is favored. Our data suggest that eCBs can mobilize cell contingents to adopt alternative distribution patterns in the endocrine pancreas and thereby increase the efficacy of the hormonal regulation of glucose homeostasis.

 

Nothing to Disclose: KM, VD, AD, TH

18770 6.0000 SAT-662 A Endocannabinoid Signaling Controls Islet Size and Cellular Topology in the Developing Endocrine Pancreas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Angela Lombardi1 and Yaron Tomer*2
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Icahn School of Medicine at Mount Sinai and James J. Peters VA Medical Center, New York, NY

 

Type 1 Diabetes (T1D) is an autoimmune disease characterized by pancreatic beta cell destruction, whose incidence has been rapidly rising in the past several decades (1). Environmental factors such as viruses have been implicated as possible triggers accounting for this rise and emerging evidence suggests that the virus-induced cytokine interferon alpha (IFNα) has a key role in the pathophysiology of T1D (2). All the major beta-cell autoantigens, including insulin, traffic through the endoplasmic reticulum (ER), an essential organelle specialized in a number of important cellular tasks including protein folding, calcium regulation, redox regulation and activation of survival or death pathways. Several factors, including cytokines, can disrupt ER homeostasis and lead to the development of ER stress. Our hypothesis is that local production of IFNα in the pancreas (e.g. during viral infections) can trigger ER stress leading to beta-cell dysfunction with or without beta-cell death. Preliminary results obtained in our laboratory have shown that both in a human beta-cell line (ENDOC-BH1) and in human islets from cadaveric donors, IFNα treatment (1000 units/ml, 48 hr) induced upregulation of ER stress markers including BiP, calnexin, phospo-eIF2α, Chop, and spliced-Xbp1, similar to classical ER stress-inducers tunicamycin and thapsigargin. Moreover, in both experimental systems IFNα also downregulated the sarco-endoplasmic reticulum pump SERCA2b suggesting a new mechanism through which IFNα might induce ER stress in pancreatic human beta-cells. Interestingly, IFNα treatment impaired insulin production in both ENDOC-BH1 cells and human islets, as revealed by significantly lower insulin content when compared with vehicle treated samples. Furthermore, IFNα decreased the expression of PC1 and PC2 convertases, suggesting an altered functional state of the beta cells characterized by a slower proinsulin/insulin conversion. Corroborating our findings, pretreatment of both ENDOC-BH1 cells and human islets with chemical chaperones 4-phenylbutyric acid (PBA) and tauroursodeoxycholic acid (TUDCA) completely prevented IFNα effects, indicating an ER stress-mediated impairment of insulin production. In conclusion, we demonstrated for the first time that IFNα elicits ER stress in human beta-cells and human islets providing a novel mechanistic role for this virus-induced cytokine in the development of T1D. We hypothesize that compounds targeting molecular processes altered in ER-stressed beta-cells could represent a potential therapeutic strategy to prevent IFNα-induced beta-cell dysfunction.

 

Nothing to Disclose: AL, YT

20996 7.0000 SAT-663 A Interferon-Alpha Impairs Insulin Production in Human Beta Cells Via Endoplasmic Reticulum Stress 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Feng Wu*1, Souriya Vang2, Johnny Luo2 and LuGuang Luo2
1Center for Stem Cell Biology, Roger Williams Medical Center, Boston University School of Medicine, Providence, RI, 2Roger Williams Medical Center, Providence, RI

 

Background

Islets transplantation holds promise as a long term treatment to Type I diabetes. We have previously reported that bone marrow (BM) cells co-cultured with human islets generate a microenvironment suitable for repairing islets and promoting longevity.  However, overcoming immunorejection is still a great challenge. We hypothesize that encapsulated islet/BM enhances human islet function while preventing immunorejection.

Experimental design and methodology

APA encapsulation was established by coating gel beads with additional layers of poly-L-ornithine and alginate to create a 4-layered immunoisolatory membrane. Fresh human islets were co-encapsulated with or without fresh human BM (1, 5 and 10 x 106) in APA microcapsules and the optimal ratio of BM to islets was studied based on insulin secretion using ELISA.

Results

No labeled peripheral blood cells (PBCs) were observed inside the capsule with human islets, indicating the APA encapsulation isolated human islets from PBCs to create a unique microenvironment free from potential interaction with host immune responses. Human islets (2500 IEQ) co-encapsulated with 5 x 106 BM generated the most optimal results over a 5 week culture period. After 4 weeks of culture, encapsulated human islets with BM formed a 3D structure while groups without encapsulation formed a 2D structure.  Encapsulated human islets with 5 x 106 BM released more insulin when stimulated than groups without encapsulation under otherwise the same conditions.

Conclusions

Our results show encapsulated human islets with 5 x 106 BM can create a microenvironment benefitting human islet function/longevity while preventing immunorejection.  Further developing this approach will create optimized human islets to enhance islet transplantation.

 

Nothing to Disclose: FW, SV, JL, LL

18646 8.0000 SAT-664 A Bone Marrow Stem Cells Support Human Islet Beta-Cell Function in an Encapsulated Microenvironment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Vladislava Paharkova*1, Julian Whitelegge2, Joseph Capri2, Simon Hui3 and Kuk-Wha Lee4
1Mattel Children's Hospital, UC, Los Angeles, CA, 2David Geffen School of Medicine, UCLA, Los Angeles, CA, 3David Geffen School of Medicine, University of California, Los Angeles, CA, 4Mattel Children's Hosp - UCLA, Los Angeles, CA

 

Despite the multifactorial etiology of type 2 diabetes, the common hallmarks are hyperglycemia, insulin resistance and beta cell dysfunction.  Recent evidences show that activation of common stress signaling pathways due to increased oxidative stress in hyperglycemia and mitochondrial dysfunction lead to insulin resistance and pancreatic β cells apoptosis.  Oxidative stress occurs by mitochondrial overproduction of H2O2 and superoxide ion.  Thus, control of oxidative stress may prevent or delay the onset and progression of diabetes.  Humanin (HN) is a 24 amino acid putative mitochondria-derived peptide (MDP) encoded within the open reading frame of mitochondrial 16S ribosomal RNA.  HN’s cytoprotective effects against cellular stressors have been suggested to be via antagonism of oxidative stress. To investigate HN’s potential to attenuate mitochondrial ROS production, HNG, an ultra potent analogue of HN, was incubated with isolated mitochondria from INS-1 cells.  A 55% reduction (p < 0.013) in H2O2 production compared to untreated controls was demonstrated.  This is the first direct evidence for a MDP functioning as a local antioxidant.  Analysis with MS/MS of immunoprecipitation products with an anti-rat HN antibody revealed thioredoxin (Trx), and peroxiredoxin (Prx), as  potential HN binding partners.  The former two observations were tested and supported by Western blot (WB). Trx2, Prx3 and Prx5—nascent to mitochondria, are induced and function protectively under conditions of oxidant-induced stress and ischemia. HN expression was not detectable on WB in thioredoxin binding protein (Txnip—an inhibitor of Trx) knockout mouse (TKO) embryonal fibroblasts (MEF), demonstrating that HN and the Trx systems modulate each other.  In summary, we have demonstrated that HN decreases mitochondrial H2O2 output and directly interacts with peroxiredoxin and thioredoxin 1 and 2. HN’s expression data in TKO MEFs suggest that HN acts as a functional modulator of Txnip.  As Prxs have particular cellular localization  and are considered the cellular switch between H2O2, acting as an oxidative stressor or a second messenger in signal transduction,  we propose that HN may differentially affect the redox state in various cell compartments, thus affecting beta cell function.

 

Nothing to Disclose: VP, JW, JC, SH, KWL

19913 9.0000 SAT-665 A HN Decreases ROS Release from Mitochondria, Functioning As a Local Antioxidant, and Interacts with the Cellular Redox Modulators Peroxiredoxin and Thioredoxin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Tamara Casteels*, Jin Li and Stefan Kubicek
CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria

 

Within the pancreatic islets of Langerhans, α- and β-cells tightly maintain glucose homeostasis via the controlled release of the hormones glucagon and insulin. During Type I Diabetes (T1D), this tight interaction is deregulated with the targeted destruction of β-cells, resulting in severe hyperglycemia. The loss of secreted insulin and β-cell mass underscore the need for a new insulin source in T1D patients. The close developmental relationship between α- and β-cells, evident via their common Ngn3progenitor, make α-cells an effective candidate. What’s more, previous studies have revealed the ability of α-cells to adopt functional characteristics of β-cells upon epigenetic manipulation. In effect, previous work from our laboratory has shown that most HDAC inhibitors contribute to α-cell adoption of β-cell specific markers, including insulin secretion. Hence, further epigenetic manipulation of this α-β-cell relationship could aid in understanding their transdifferentiation capacities and allow for potential β-cell mass replenishment.

Consequently, we set out to uncover new proteins that induce β-cell properties in α cells. We constructed an epigenetically focused RNAi library, encompassing approximately 300 gene knockdowns. We applied this library to αTC1 cells, via viral delivery of short hairpin RNA (shRNA) sequences. We monitored the cells’ transcription profiles for any increase in insulin expression and isolated the causative shRNA. In fact, this large-scale silencing screen also provided us with novel information regarding the expression patterns of these genes. The screen identified three targets, including one gene involved in post-translational modifications. Focus was placed on this third gene, as it had a good knockdown efficiency and had never been studied in this context before. We are now in the process of validating it as an effective α-to-β cell transdifferentiation factor, as well as running proteomics experiments to identify mode of action of the protein and to further characterize the resulting β-like cells. Initial RNAseq data revealed an upregulation in β-cell markers, including Iapp, Gck, Pax4 and Ins2, upon knockdown in αTC1 cells. Overall, α-cell-targeted loss of this gene might provide us with a new insulin cell source.

 

Nothing to Disclose: TC, JL, SK

21715 10.0000 SAT-666 A Epigenome-Wide Screen for Alpha to Beta Cell Transdifferentiation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Jyothi Vijayaraghavan*1, Eugene Blanchard IV1, Jimena Trillo-Tinoco2, Elaine Carol Maggi1, Jone Garai3, Jovanny Zabaleta3, Christopher M Taylor2, Luis Del Valle2 and Judy S Crabtree2
1Louisiana State University Health Sciences Center, New Orleans, LA, 2Louisiana State Univeristy Health Sciences Center, New Orleans, LA, 3Louisiana State Univeristy Health Sciences Center

 

The adult pancreatic beta cell mass, although long considered static, is now known to dramatically expand its functional mass to compensate for systemic increases in insulin demand such as during pregnancy, non-diabetic obesity and aging. It is now well-established that defects in this compensatory mechanism result in gestational diabetes and Type 2 diabetes (T2D). With T2D and obesity at epidemic levels, a better understanding of this adaptive property of beta cells will provide a basis to develop novel therapies to treat these chronic metabolic conditions.

MicroRNAs (miRNAs) have emerged as vital players in most biological processes. As a result, miRNA profiling studies are gaining importance with a view towards understanding miRNA expression patterns of diseases and applying this knowledge to miRNA-based therapies. Not new to the field of diabetes, miRNAs have been shown to be involved in several key processes that help maintain normal glucose homeostasis, including compensatory beta cell mass expansion. However, information regarding global miRNA expression profiles of islet expansion under different physiological stimuli is lacking. Therefore, we set out to establish the miRNA signature associated with adaptive beta cell mass expansion during three metabolic stress conditions - pregnancy, genetic and diet-induced obesity (DIO).

Using Illumina small RNA sequencing, we determined the miRNA profiles of expanded islets of C57BL/6 mice on High Fat Diet (HFD), C57BL/6 timed pregnant mice, and leptin deficient, genetically obese ob/ob mice. We found that among the three metabolic states studied, the islets of the genetically obese group displayed a large number of differentially expressed miRNAs. We also observed a high commonality among the downregulated miRNAs across the three metabolic groups suggesting an upregulation of similar proteins and thereby activation of similar signaling cascades. Altogether, our data show that all of the three physiological stimuli resulting in adaptive islet expansion share some common miRNAs, but also display certain miRNAs exclusive to their state, highlighting the unique underlying etiology of each metabolic condition.

These data provide an enhanced view of beta cell plasticity and the adaptation of the pancreatic islet to increased insulin demand. Future work correlating the dysregulated miRNAs with their predicted mRNA targets will reveal the different pathways that control adaptive islet expansion and may provide a basis for diabetes therapy.

 

Nothing to Disclose: JV, EB IV, JT, ECM, JG, JZ, CMT, LD, JSC

18652 11.0000 SAT-667 A Microrna Expression Profiling in Mouse Models of Compensatory Beta Cell Mass Expansion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Sana Hasan*1, Courtney Smith2, Ronda White2, Frederick G Hamel3, Cyrus V Desouza1 and Robert G. Bennett4
1University of Nebraska Medical Center, Omaha, NE, 2University of Nebraska Medical Center, 3Omaha VA Med Ctr, Omaha, NE, 4VA Nebraska-Western Iowa Health Care System, Omaha, NE

 

Type 1 diabetes (T1D) is characterized by lymphocytic infiltration of the pancreatic islets, resulting in the inflammation and progressive destruction of the β cells. All-trans retinoic acid (ATRA) is a vitamin A metabolite which has been recognized as important immune-potentiating agent due to its modulatory effects on both T and B lymphocytes.  But the effect of ATRA on T1D with established insulitis is unclear.

We previously showed that treatment (tx) of prediabetic NOD mice with ATRA decreased fasting blood glucose and improved glucose tolerance, with no significant changes in body weight. The objective of this study was to determine the effects of ATRA on insulitis/apoptosis, α and β cell masses, and insulin content in a prediabetic NOD model.  The NOD mice typically begin to exhibit decreased insulin content at 12 weeks of age, therefore, we started tx at 10 weeks of age.   Female NOD mice (10 per group) were treated with vehicle (corn oil) or ATRA at 0.6 mg/mouse, 5 days/week for 20 weeks by voluntary oral feeding.  The overall incidence of diabetes was lower than expected in both groups, likely due to the influence of nonsterile housing or other environmental factors that affect penetrance in this model, and therefore in this study most mice remained prediabetic. No significant changes were observed in the insulin levels and HOMA-IR between the control and ATRA group during the course of the study. The oral dose of ATRA was well tolerated and no adverse effects of hepatotoxicity, alopecia or pruritus were noted during the study duration. This suggests that the improvements in fasting blood glucose and glucose intolerance were not due to weight loss or vitamin A toxicity.  However, the NOD mice developed insulitis, which was markedly reduced with ATRA as reflected in the pancreatic hematoxylin and eosin sections. Immunohistochemistry of the pancreas revealed that ATRA treatment improved the islet integrity. This change was reflected in the total islet number per pancreatic section which was higher in the ATRA group (2.11±0.5 control vs 5.30±1.9 ATRA, p <0.05). There were no significant changes in α- and β-cell masses between the control and ATRA group. The number of apoptotic cells identified within the infiltrating immune cells were markedly increased with ATRA, which is reflective of its immunomodulatory effects on insulitis. The number of apoptotic insulin positive cells identified in islets were not statistically significantly (1.70±1control vs 1.40±1 ATRA). 

We have shown that ATRA tx improved glucose tolerance and fasting glucose. Further, ATRA attenuates inflammation by inducing apoptosis of lymphocyte infiltration, while simultaneously improving islet integrity. Our preliminary findings demonstrate its prospective use for the tx of T1D.  Future studies will focus on investigating the immunoregulatory effect of ATRA on the expression of Th 1 and Th 2 cytokines.

 

Nothing to Disclose: SH, CS, RW, FGH, CVD, RGB

20048 12.0000 SAT-669 A The Effect of All Trans Retinoic Acid on Insulitis and Beta Cell Apoptosis in NOD Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Lena Wedeken*1, Tao Feng1, Ismail H. Al-Abdullah1, Fouad R Kandeel2 and Hsun Teresa Ku1
1Beckman Research Institute of City of Hope, Duarte, CA, 2Diabetes & Metabolic Research Institute, Beckman Research Institute of City of Hope, Duarte, CA

 

Adult pancreatic stem and progenitor cells are a potential source of insulin-producing beta cells for cell replacement therapy of type 1 diabetes. However, it has proved difficult to identify these progenitor cells and analyze their properties, in part due to a lack of an analytical tool. We recently developed a colony assay that allows quantitative and functional analysis of adult murine pancreatic progenitor-like cells in culture. Now, we have established serum-free culture conditions that allow the growth of progenitor-like cells from adult human pancreas. In this assay, human exocrine tissues remaining from islet isolation were dissociated into single cell suspension and plated into a semisolid medium containing methylcellulose (a viscous material), Matrigel (for extracellular matrix components), Serum Replacement and various growth factors. The semisolid medium restricts cell movement yet permits a cell to self-renew, proliferate, differentiate and form a colony of cells. This assay allows us to quantify colony-forming cells and directly analyze their differentiation potential. We found that the adult human pancreas contains colony-forming progenitor cells, which were able to give rise to cystic colonies containing ductal-, acinar- and endocrine-like cells. These colony-forming cells were present in the normal donor tissues of various ages and in type 2 diabetes patients. To enrich the colony-forming progenitors, we investigated the use of cell surface markers and fluorescence-activated cell sorting (FACS). CD133+CD49f+ cell population was found to be enriched for colony-forming progenitor cells. Further characterization of growth factor requirement revealed that a transforming growth factor-beta (Tgf-β)/Activin-receptor inhibitor had a positive effect on colony size and number. Moreover, the concentration of Matrigel in the culture affected colony number, morphology and expression level of endocrine progenitor markers. Finally, adult human colony-forming cells were able to survive freezing and thawing and retained their abilities to form colonies, which will be an important factor for a potential clinical application. In conclusion, our methylcellulose-based pancreatic colony assay will be valuable for future mechanistic studies to generate large number of beta-like cells for transplantation from adult human pancreas.

 

Nothing to Disclose: LW, TF, IHA, FRK, HTK

21133 13.0000 SAT-668 A Adult Human Exocrine Pancreas Contains Multi-Potent Progenitor-like Cells That Form Colonies in a 3D Culture 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Alexander J. Ryan*1, Theodore P. Ciaraldi2 and Robert R. Henry2
1University of California San Diego, San Diego, CA, 2VA San Diego Health Care System, San Diego, CA

 

Recent studies have shown that increased inflammation plays a role in the pathogenesis of Type 2 Diabetes (T2D).  Circulating levels of pro-inflammatory cytokines are increased in patients suffering from T2D, and metabolic tissues including skeletal muscle and adipose tissue display increased infiltration by inflammatory cells. T2D is characterised by insulin resistance, coupled with decreased insulin secretion, and inflammation is thought to play a role in regulating both. We set out to investigate the effects of inflammation on the possible role of factors secreted from skeletal muscle (myokines) on influencing pancreatic cell function. Skeletal muscle biopsies were taken from T2D and non-diabetic (ND) patients, satellite cells were isolated, propagated, and differentiated into myotubes (SMCs). After differentiation, conditioned media (CM) was collected. The rodent pancreatic β cell line, INS-1 was exposed to this media (25% (v/v); 2x concentrated) for 24 hours prior to determination of cell viability, insulin content and glucose-stimulated insulin secretion (GSIS). GSIS was similarly unaffected by CM from ND and T2D SMCs; treatment with 16.5mM glucose consistently increased insulin secretion by 130-150% over 2.5mM glucose treatment. Seeing that inflammation is increased in T2D, we attempted to create the same state in SMCs using lipopolysacharide (LPS), a bacterial endotoxin capable of inducing pro-inflammatory pathways. SMCs were also treated with a combination of insulin, palmitate and glucose at levels observed in the circulation of T2D subjects, to mimic the “metaflammation” seen in T2D. We have previously shown that infectious (LPS) and metaflammation result in different profiles of myokine secretion. After LPS treatment (1 mg/mL, 24 hr), the secretion of multiple pro-inflammatory myokines (including IL-6, IL-8, TNFα, GRO) were increased from both T2D and ND SMCs. Surprisingly, treatment of INS-1 cells with CM from LPS-exposed SMCs had no effect on GSIS. However, while CM collected from ND SMCs after metaflammation also had no effect on GSIS, INS-1 cells treated with CM from T2D SMCs undergoing metaflammation displayed severely impaired GSIS (65.59 ± 5.6% of control; p<0.001) suggesting that T2D muscle plays a role in impairing β cell function. INS-1 cell viability, total insulin levels and IBMX-stimulated insulin secretion were all unaffected by treatment with ND or T2D CM. The identity of specific factor(s) unique to T2D SMCs capable of causing the decrease in GSIS seen here has yet to be determined, while potential roles for several factors often linked to pancreatic dysfunction (e.g. TNFα and IL-1β) have been ruled out. In conclusion, our results suggest a specific dysfunction in the pathway to GSIS that was induced by the myokine response of T2D muscle cells to a metabolic environment characteristic of T2D.

 

Nothing to Disclose: AJR, TPC, RRH

20093 14.0000 SAT-670 A Human Skeletal Muscle Cells Exposed to Infectious and Metabolic Inflammation Produce Differing Effects on Insulin Secretion: Impact of Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Julie Donaldson*, Nirja Patel, Seamus Webb, Elizabeth Weiss, Julie Melito, Timothy McKendry, Chris Wisherd, Tal Murthy, Stacy Dion and Martin Blankfard
ALPCO, Salem, NH

 

Quantification of insulin, C-peptide, intact and total proinsulin is vital in furthering diabetes research.

Many commercial human ELISAs require extra sample dilution steps to ensure concentrations fall

within a limited standard curve range. This results in increased sample preparation time as well

as potential re-dilution and re-testing of samples. Furthermore, sensitivity is limited when using

standard colorimetric detection methods in ELISA, whereas chemiluminescence platforms offer

vast improvements. Many of the improvements in sensitivity and dynamic range by luminescence

are limited due to many being read on expensive flash chemiluminescence readers or using

proprietary instrumentation.

A new set of STELLUX™ chemiluminescent assays have been developed at ALPCO to address these

needs specifically for beta cell profiling in human samples. The STELLUX™ insulin, C-peptide, intact

proinsulin and total proinsulin ELISAs offer a broad range, high sensitivity, and utilize small sample

volumes. These assays were designed for the end user to have the capability of running multiple

sample types, disease states, and treatment states in one assay without the uncertainty of the

sample being the correct dilution. All of these assays are highly characterized for accuracy, precision,

sensitivity and specificity. Additionally, each production lot contains a complete validation package.

In this poster we present the performance and the experimental data that supports the detection of

these 4 analytes in serum, plasma, and tissue culture supernatants. Differences in beta cell outputs

are seen when evaluating serum from normal, Type 1 Diabetic, and Type 2 Diabetic fasted or fed

samples. All samples were detected without performing upfront dilutions and use a standard glow

chemiluminescence plate reader that is available in most laboratories.

 

Nothing to Disclose: JD, NP, SW, EW, JM, TM, CW, TM, SD, MB

22131 15.0000 SAT-671 A Stelluxâ„¢ Chemiluminescent Elisas: Novel Tools for Beta Cell Profiling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Shuntaro Morikawa*1, Akie Nakamura2, Katsura Ishizu1 and Toshihiro Tajima1
1Hokkaido University Graduate School of Medicine, Sapporo, Japan, 2National Research Institute for Child Health and Development, Tokyo, Japan

 

Introduction: Wolfram syndrome (WS) is a disorder characterized by the association of early-onset, insulin-dependent diabetes mellitus (DM), diabetes insipidus, deafness, and progressive optic atrophy. The disease is caused by mutations of WFS1 located on 4p16 encoding protein that is called wolframin. This protein is expressed in various tissues such as the pancreas, brain, bone, muscles, lungs, liver, kidneys, and the resident component of the endoplasmic reticulum (ER) membrane. Pancreatic islet β-cells are the major site of WFS1 expression. When abnormal WFS1 caused by mutation of WFS1 results in ER dysfunction, misfolded and unfolded proteins accumulate in the ER which leads to cell apoptosis (known as ER stress). This is considered to be the major mechanism underlying the development of symptoms in WS. Here, we report a Japanese female patient with WS and a novel heterozygous mutation.

Case report: The 10-month-old patient was admitted to our hospital for poor weight gain and DM. Her growth failure was evident at 3 months old and congenital cataract was noticed at 7 months old. When she was admitted, her height was 66.8 cm (-1.8 SD for a normal Japanese girl) and body weight was 6,050 g (-2.8 SD for a normal Japanese girl). The auditory brainstem response (ABR) test revealed severe bilateral hearing loss. Brain magnetic resonance imaging (MRI) showed a normal optic nerve and hypothalamic-pituitary region. Her psychomotor development was delayed. Based on early onset of DM, deafness, cataract and developmental delay, a diagnosis of Wolfram syndrome (WS) was suspected.

Methods: The WFS1 exon was amplified by PCR and direct sequencing was performed. The functional consequence of the mutant WFS1 identified in this study and previously reported (p.H313Y, p.W314R, p.Q194X, p.L543R) were analysed using GPR78-luciferase vector in vitro.

Results: Sequence analysis showed a heterozygous twelve bases deletion in exon 8, resulting in 3 amino acid in-frame deletion (c.973_984del12, p.N325_M328del). As her parents did not have the deletion, the mutation presumably occurred de novo. In vitroanalysis revealed that the mutant WFS1 lost the suppression activity of ER stress response compared with the wild type WFS1, resulting in the increase of ER stress.

Conclusion: We identified a novel mutation of WFS1 in a Japanese patient with WS. While most WFS1 mutations in WS patients are detected on both alleles and the inheritance of WS is considered to be autosomal recessive, we detected novel heterozygous WFS1 mutation as a cause of WS. Since WS is characterized by a wide spectrum of clinical features, it should be considered in the differential diagnosis of a toddler with DM and accompanying features such as hearing impairment, growth failure and cataracts.

 

Nothing to Disclose: SM, AN, KI, TT

19541 16.0000 SAT-672 A A Novel Heterozygous Mutation of WFS1 Gene in a Japanese Infant of Wolfram Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Ashley N Ogawa-Wong*, Ann C Hashimoto, Marla J Berry and Lucia A Seale
University of Hawaii, Honolulu, HI

 

Selenium is an essential trace element recognized for its properties curbing oxidative stress in cells. Selenium is incorporated into the amino acid selenocysteine (Sec), which is at the core of selenoproteins, effectors of cellular redox regulation. Sec is decomposed by Sec lyase (Scly) into alanine and selenide, allowing for recycling of selenium. Alternatively, Sec can undergo degradation via a transsulfuration pathway. Longitudinal clinical trials demonstrated that selenium supplementation in Americans, a population who generally receives an adequate selenium supply, is associated with higher incidence of type 2 diabetes. Thus, it is concerning that 19% of Americans report consuming selenium supplements, justifying a need to better understand the interaction between selenium and glucose homeostasis. We previously reported that Scly deficiency results in increased adiposity and hyperinsulinemia in mice. Because selenium supplementation induces hyperinsulinemia, and Scly is highly expressed in the pancreatic β-cells, we hypothesized that Scly is involved in pancreatic insulin production and/or secretion. Our investigation of the effects of treatment with 30 and 100 nM sodium selenite on a mouse pancreatic cell line, MIN6, determined that insulin secretion was not altered by different selenium levels. However, β-cells expression of Scly was regulated under the same conditions, and also regulated by glucose treatment. Comparison of pancreatic gene expression from wild-type vs Scly-/- mice revealed significant alterations in enzymes involved in selenium recycling and transsulfuration pathway, as well as selenoproteins with antioxidant function, such as glutathione peroxidase 4, thioredoxin reductase 1 and selenoprotein S. These results suggest a possible role for Sec degradation on insulin secretion in mouse pancreatic β-cells.

 

Nothing to Disclose: ANO, ACH, MJB, LAS

21598 17.0000 SAT-673 A Selenium Metabolism in Mouse Pancreatic β-Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Eriko Nara*1, Takumi Kitamoto2, Yoko Matsuzawa1, Jun Saito1, Masao Omura1 and Tetsuo Nishikawa1
1Yokohama Rosai Hosp, Yokohama, Japan, 2Graduate School of Medicine, Chiba University, Chiba, Japan

 

Background: Evaluating  the pancreatic β-cell function helps us to decide type 2 diabetes medication,especially, in incretin-based therapies enhancing insulin seceretion, including glucagon-like peptide-1 agonists (GLP-1RAs) and dipeptidyl peptidase-4 inhibitors (DPP-4i). Although incretin-based drugs secrete insulin through a common GLP-1 pathway, they varies in effectiveness:One is more effective treatment with DPP-4i more than GLP-1RAs,the other isn’t good with DPP-4i.

Thus, we aimed to clarify that comparison of responsiveness of c-peptide (CPR) to the mixed meal tolerance test (MMTT) and the glucagon loading test (GLT) can predict the effectiveness of incretin-related drugs.

 Method: Patients with type 2 diabetes (n=214) hospitalized from May 2011 to October 2013 in our hospital were enrolled in this study. All of them had been evaluated their ability examined by MMTT and GLT on admission. After 6 months treatment, we divided the patients into well-controlled group (HbA1c<8.0%) and poor-controlled group (HbA1c≥8.0%). Then the responsiveness to MMTT and GLT was compared according to the drug prescribed ;Insulin group, GLP-1RAs group,DPP-4i group, and the other group.

 Result: The subjects were 58±13 years old, BMI was 27.0±5.3, and HbA1c was 10.2±2.2% (average±SD). Serum CPR response to GLT was significantly higher in well-controlled patients (n=37) than poor-controlled patients (n=17) among 54 patients treated with GLP-1RAs (2.37±1.41vs. 1.57±0.88 (ng/ml); p=0.035). CPR response to MMTT was significantly higher in 55 well-controlled patients than 8 poor-controlled patients among 63 patients treated with DPP-4i (3.27±1.7 vs. 1.88±1.18 (ng/ml); p=0.003).The cut-off points for estimating efficacy of incretin-based therapies were decided by the receiver–operating characteristic analysis. It was shown that the best cut-off point for HbA1c<8.0% in GLP-1RAs therapy was ΔCPR over 2.0 ng/ml on GLT (Sensitivity: 0.622, Specificity: 0.765). On the other hand, ΔCPR over 2.0 ng/ml on MMTT was the best cut-off point for HbA1c<8.0% in DPP-4i therapy (Sensitivity:0.818, Specificity:0.625).

 Conclusion: ΔCPR over 2.0 ng/ml on GLT suggests the effectiveness of GLP-1RAs ,and ΔCPR over 2.0 ng/ml on MMTT predicts the effectiveness of DPP4i. GLT shows the total capacity of cyclic AMP-mediated insulin secretion, that is, endogenous insulin secretion. MMTT may reflect the postprandial responsiveness of insulin secretion, which is regulated by the interactions among incretin, insulin, and glucagon. Therefore , MMTT and GLT are useful for assessment of pancreatic β-cell function, although those tests are acting on different mechanisms for insulin secretion.

 

Nothing to Disclose: EN, TK, YM, JS, MO, TN

19708 19.0000 SAT-675 A Difference in Endogenous Insulin Secretion Between Glucagon and Meal Loading Tests in Japanese Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Juan C Diaz-Zagoya*1, Isela E Juarez-Rojop2, Andrés E Castell-Rodríguez3, Pedro H Miranda-Osorio4, Jorge L Ble-Castillo5 and Rodrigo Miranda-Zamora6
1Univ Nacional Autonoma de Mexico, Mexico D.F., Mexico, 2Univ Juarez Autonoma de Tabasco, Villahermosa, Tabasco, Mexico, 3Universidad Nacional Autónoma de México, Mexico City, Mexico, 4División Académica de Ciencias de la Salud, Universidad Juárez Autónoma de Tabasco, Villahermosa, Mexico, 5Centro de Investigación, DACS, Universidad Juárez Autónoma de Tabasco, Villahermosa, Mexico, 6Faculty of Medicine, National University of Mexico, Mexico City, Mexico

 

Several plant-derived drugs have become therapeutic alternatives for blood glucose control in diabetes.

The aim of this work was to study the hypoglycemic action of the leaf extract of Carica papaya on streptozotocin (STZ)-induced diabetic rats, focusing on the pancreatic cells structure and function.

Male Wistar rats, 280-300 g, received a single injection of STZ 60 mg/Kg to induce experimental diabetes. The experiment design included six groups of 8 rats: 1) Control normal (CN), 2) CN+Carica papaya extract (CPE) 62/mg/Kg, 3)Diabetic (D), 4) D+CPE31mg/kg, 5) D+CPE62mg/Kg, 6) D+CPE125mg/Kg. Animals were sacrificed after 3 weeks of treatment. Blood, liver and pancreas were obtained. Pancreas was studied by microscopy and also by immunocytochemistry using insulin antibodies. Pancreas islets of each group were analyzed by the Image Pro Plus 7.0 program.

Average results ± std error for N group were: islet area 2283±263.2 μm2; islet diameter 2283±263.2 μm; labeled area 1690±286.4 μm2; integrated optical density (IOD) 1386.8±231.1; for D group: islet area 1971±964.9 μm; islet diameter 84.6±18.5  μm; labeled area 225.4±107.2 μm2; IOD 164.9±94.     

Islet area and diameter were bigger in CPE-treated groups than in N. The insulin-positive area and the integrated optical density were also higher in CPE-treated rats than in D group except in D+CPE125. These results are in accordance with previous reports of CPE action on rat serum glucose and insulin production by cultured pancreatic cells in the presence of either or both STZ and CPE.

 

Nothing to Disclose: JCD, IEJ, AEC, PHM, JLB, RM

21151 20.0000 SAT-676 A Carica Papaya Extract Preserves Pancreatic Cells in Streptozotocin-Induced Diabetic Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 657-676 5942 1:00:00 PM Islet Biology Poster


Caroline M Gorvin*1, Benoît Hastoy1, Gerda E Breitwieser2, Patrik Rorsman1 and Rajesh V Thakker1
1University of Oxford, Oxford, United Kingdom, 2Weis Center for Research, Danville, PA

 

The calcium-sensing receptor (CaSR), a class C G-protein coupled receptor (GPCR) that is expressed at the cell surface of a number of cells including those of the parathyroid and renal tubule, plays a critical role in calcium homeostasis. Calcium binding to CaSR initiates activation of its associated G-proteins, leading to elevated phospholipase levels, activation of the mitogen-activated protein kinase signalling pathway, and release of calcium from intracellular stores. The presence of CaSR at the plasma membrane surface is regulated by a balance between internalisation via clathrin-mediated endocytosis, and agonist-induced plasma membrane insertion from intracellular receptor pools, in a mechanism known as agonist-driven insertional signalling (ADIS). Recently, mutations of the sigma subunit of the clathrin-mediated endocytic adaptor protein-2, AP2σ, have been identified in patients with familial hypocalciuric hypercalcaemia type-3 (FHH3). To date, mutations in AP2σ have only been identified at one residue, Arg15 (R15), and consist of substitutions to Cys (C), His (H) or Leu (L). We investigated the effect of AP2σ mutations on plasma membrane expression of CaSR using total internal reflection fluorescence microscopy (TIRFM). Imaging was performed in HEK293 cells stably expressing either AP2σ-wild-type (WT) or FHH3-associated AP2σ-mutants R15C, R15H or R15L (N=33-48 cells), and transiently transfected with a construct of CaSR with an N-terminal tag containing: a binding site for fluorescent bungarotoxin (BTx-594) for monitoring endocytosis; and a pH-sensitive superecliptic pHluorin to simultaneously measure total plasma membrane CaSR. Cells were exposed to 0.1mM basal Ca2+ for 1 minute, followed by exposure to 10mM Ca2+. We observed an increase in net plasma membrane abundance in all AP2σ-expressing cells on exposure to 10mM Ca2+, confirming agonist-induced insertion of CaSR following receptor stimulation. The levels of BTx-594 at the cell surface reduced rapidly in AP2σ-WT expressing cells consistent with constitutive internalisation of CaSR. However, cells expressing AP2σ-mutants R15H and R15L were observed to have significantly longer cell surface expression of BTx-594, indicative of delayed internalisation of the receptor in these cells (p<0.02). Furthermore, investigation of the CaSR internalisation rate revealed that all cells harbouring AP2σ mutations required significantly longer to reach 25% internalisation of CaSR than AP2σ-WT expressing cells (WT – 392.3±130.5s, R15H – 1114.3±120.6s (p<0.02), R15L – 745.5±125.5s, (p<0.02), R15C – 650.2±116.1s (p<0.05)). In summary, our results show that FHH3-associated AP2σ-mutations (R15H, R15L and R15C) cause delays in internalisation of CaSR, thereby indicating a likely important role for CaSR endocytosis in regulating CaSR cell surface expression and signalling.

 

Nothing to Disclose: CMG, BH, GEB, PR, RVT

19714 1.0000 SAT-290 A Familial Hypocalciuric Hypercalcaemia Type 3 (FHH3)-Associated Adaptor Protein-2 Sigma Subunit Mutations Impair Calcium-Sensing Receptor Internalisation Pathways 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Valerie N Babinsky*1, Fadil M Hannan1, Sarah A Howles1, M Andrew Nesbit2, Nigel Rust1, Jianxin Hu3, Allen M Spiegel4 and Rajesh V Thakker1
1University of Oxford, Oxford, United Kingdom, 2Ulster University, Ulster, United Kingdom, 3National Institutes of Health, Bethesda, MD, 4Yeshiva University, Bronx, NY

 

Germline mutations of G-protein alpha-11 (Gα11), a guanine nucleotide-binding protein, which couples the calcium-sensing receptor (CaSR) to parathyroid and kidney signaling pathways involving intracellular calcium (Cai2+), lead to disorders of extracellular calcium (Cao2+) homeostasis. Indeed, loss- and gain-of-function Gα11 mutations that affect guanine nucleotide binding, or the interface at which Gα11 is predicted to bind to the CaSR transmembrane domain (TMD), give rise to familial hypocalciuric hypercalcemia type 2 (FHH2) and autosomal dominant hypocalcemia type 2 (ADH2), respectively. Cinacalcet and NPS-2143 are TMD-binding allosteric CaSR activators and inactivators, respectively, that ameliorate signaling disturbances associated with CaSR mutations. However, the potential for these CaSR-targeted drugs to treat FHH2 and ADH2 caused by Gα11 mutations is unknown. We therefore investigated the effectiveness of Cinacalcet and NPS-2143 in rectifying alterations in Cai2+ responses associated with FHH2 and ADH2-causing Gα11 mutations, respectively. Wild-type and mutant Gα11 proteins associated with FHH2 (L135Q and I200del) and ADH2 (R181Q and F341L) were expressed by transient transfection in HEK293 cells stably expressing the CaSR. Alterations in Cai2+ responses were measured by flow cytometry following exposure to varying concentrations of Cao2+ and allosteric CaSR modulators, and the half-maximal (EC50) values (mean ± SEM of n = 6 experiments) determined. This revealed that FHH2-causing Gα11 mutations led to ~30% increases in EC50 values (L135Q EC50 = 3.54 ± 0.07 mM, I200del EC50 = 3.49 ± 0.04 mM), whereas the ADH2-causing Gα11 mutations led to ~10% decreases in EC50 values (R181Q EC50 = 2.32 ± 0.05 mM, F341L EC50 = 2.29 ± 0.04 mM), when compared to wild type Gα11 (EC50 = 2.64 ± 0.02 mM, p<0.0001). A dose-titration of Cinacalcet in cells expressing FHH2-causing Gα11 mutants revealed 20 nM to significantly lower the EC50 of the L135Q mutation to 2.61 ± 0.08 mM (p<0.0001), whereas 40 nM was required to decrease the EC50 of the I200del mutation, which is located at the CaSR-Gα11 interface, to 2.68 ± 0.04 mM (p<0.0001). Similarly, addition of NPS-2143 to cells expressing ADH2-causing Gα11 mutants revealed 20 nM to increase the R181Q mutant EC50 to 2.75 ± 0.05 mM (p<0.0001), whilst 40 nM was required to elevate the EC50 of the F341L mutation, located at the CaSR-Gα11 interface, to 2.81 ± 0.04 mM (p<0.0001). These findings demonstrate that CaSR allosteric modulators can correct the loss- and gain-of-functions associated with FHH2 and ADH2-causing Gα11 mutations, respectively. Moreover, Gα11 mutations located at the CaSR-Gα11 interface impaired drug efficacy, thus highlighting the importance of this region for mediating the effects of allosteric receptor modulators.

 

Nothing to Disclose: VNB, FMH, SAH, MAN, NR, JH, AMS, RVT

19718 2.0000 SAT-291 A Calcium-Sensing Receptor (CaSR) Allosteric Modulators Rectify Signal Transduction Abnormalities Associated with G-Protein Alpha-11 (GNA11) Mutations Causing Familial Hypocalciuric Hypercalcemia Type 2 (FHH2) and Autosomal Dominant Hypocalcemia Type 2 (ADH2) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Angela Rogers*, Caroline M Gorvin and Rajesh V Thakker
University of Oxford, Oxford, United Kingdom

 

Familial hypocalciuric hypercalcemia type 3 (FHH3) is caused by loss-of-function mutations of the σ subunit of adaptor protein-2 (AP-2), encoded by AP2S1. AP-2 is a ubiquitously expressed tetrameric protein, with a central role in clathrin-mediated endocytosis of transmembrane proteins, such as G-protein coupled receptors (GPCRs), and thus their cellular signal transduction. Calcium binding to the calcium sensing receptor (CaSR), a multiligand GPCR, activates its associated G-proteins, with multiple downstream signalling pathways that include induction of phospholipase C, release of calcium from intracellular stores, and stimulation of the mitogen-activated protein kinase (MAPK) pathway. The FHH3-associated AP2σ mutations identified to date affect only the Arg15 residue, and comprise the following heterozygous missense mutations: Arg15Cys, Arg15Leu, and Arg15His. These FHH3-associated AP2σ mutations have been shown to decrease activity of the intracellular calcium signalling pathways in response to increases in extracellular calcium concentration. We therefore hypothesised that AP2σ mutations may also disturb MAPK signalling, and focused our studies on the extracellular signal-regulated kinase 1/2 (ERK1/2) pathway, which was examined using an amplified luminescence proximity homogenous (AlphaScreen) assay that measured phosphorylated ERK1/2 (pERK1/2). AlphaScreen assays were performed in HEK293 cells stably expressing C-terminal tagged His-V5-AP2σ proteins, that comprised either the wild type (WT) AP2σ-Arg15, or mutants AP2σ-Cys15 or AP2σ-Leu15 proteins. All cells were transiently transfected with CaSR-WT, and equal transfection verified by Western blot analysis using the anti-CaSR ADD antibody. Levels of pERK1/2 were elevated on exposure to increasing concentrations of extracellular calcium (0-10mM) in a dose-dependent manner in AP2σ-WT and AP2σ-Arg15Cys expressing cells. However, pERK1/2 responses were significantly reduced in AP2σ-Arg15Cys cells between 5-10mM extracellular calcium concentrations compared to AP2σ-WT (p<0.05, N=4) and in AP2σ-Arg15Leu cells at 10mM extracellular calcium concentration compared to AP2σ-WT (p<0.02, N=4), consistent with a loss-of-function. Thus, our results demonstrate that FHH3-associated AP2σ mutations disrupt MAPK signalling, thereby indicating a likely role for AP2σ in potential regulation of cell proliferation via CaSR signalling.

 

Nothing to Disclose: AR, CMG, RVT

19738 3.0000 SAT-292 A Familial Hypocalciuric Hypercalcemia Type 3 (FHH3) Associated Mutations in the Adaptor Protein-2 Sigma Subunit (AP2 sigma) Cause Disturbances in MAPK Signalling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Sarah A Howles1, Fadil M Hannan*1, Valerie N Babinsky1, Angela Rogers1, Nigel Rust1, Tristan Richardson2, Malachi J McKenna3, M Andrew Nesbit4 and Rajesh V Thakker1
1University of Oxford, Oxford, United Kingdom, 2Royall Bournemouth Hospital, Bournemouth, United Kingdom, 3St Vincent's University Hospital, Dublin 4, Ireland, 4Ulster University, Ulster, United Kingdom

 

Familial hypocalciuric hypercalcemia type 3 (FHH3) is a recently identified disorder of extracellular calcium homeostasis caused by Arg15Cys, Arg15His and Arg15Leu mutations affecting the adaptor protein-2 σ2-subunit (AP2S1), which lead to diminished calcium-sensing receptor (CaSR) function. In the majority of cases, FHH3 is asymptomatic but in some patients, it may present with symptoms of hypercalcemia such as fatigue and bone pain. To assess the potential of the allosteric CaSR activator cinacalcet to ameliorate the loss of CaSR function associated with AP2S1 mutations we initially undertook in vitro studies in HEK293 cells stably expressing the CaSR and measured alterations in intracellular calcium concentrations in response to changes in extracellular calcium after transient transfection with FHH3-associated AP2S1 mutants with and without the addition of cinacalcet. This demonstrated that the FHH3-associated Arg15Cys, Arg15His and Arg15Leu AP2S1 mutants caused a rightward shift in the concentration-response curves with significantly higher half-maximal (EC50) values (Arg15Cys EC50=3.12, 95% confidence interval (CI)=3.07-3.17; Arg15His EC50=3.27, 95% CI=3.20-3.35; Arg15Leu EC50=3.22, 95% CI=3.18-3.26) when compared to wild-type (EC50=3.01, 95% CI=2.98-3.04; p<0.001). A dose-titration of cinacalcet in cells expressing the Arg15Cys AP2S1 mutant revealed that 10 to 30nM of cinacalcet progressively lowered the Arg15Cys mutant EC50 (10nM EC50=2.95, 95% CI=2.91-3.00; 20nM EC50=2.83, 95% CI=2.77-2.89; 30nM EC50=2.70, 95% CI=2.65-2.76). The addition of 10 nM of cinacalcet to cells expressing Arg15Cys, Arg15His or Arg15Leu mutants restored their raised EC50 values to those that were indistinguishable from cells expressing wild-type AP2S1 (p>0.05). Cinacalcet was therefore used to treat three unrelated symptomatic FHH3 individuals, each with an Arg15Cys, Arg15His or Arg15Leu mutation, who had plasma ionized or serum adjusted-calcium concentrations of >1.5mmol/L (probands 1 and 2) or >3.0mmol/L (proband 3), (normal range 1.1-1.3mmol/L or 2.2-2.6mmol/L) respectively. Cinacalcet given at a dose of 30mg or 60mg daily for >6 months was well tolerated, reduced symptoms, led to >20% reductions in circulating calcium concentrations, and lowered serum PTH concentrations, which remained within the normal range in all three FHH3 probands. In summary, our findings demonstrate that cinacalcet rectified the reduced sensitivity to extracellular calcium of cells expressing FHH3-causing AP2S1 mutants, and lowered circulating calcium concentrations in three symptomatic FHH3 probands, each with an Arg15Cys, Arg15His or Arg15Leu AP2S1 mutation. Thus, cinacalcet represents an effective therapy for the hypercalcaemia associated with FHH3.

 

Nothing to Disclose: SAH, FMH, VNB, AR, NR, TR, MJM, MAN, RVT

19737 4.0000 SAT-293 A Cinacalcet Is an Effective Therapy for Familial Hypocalciuric Hypercalcemia Type 3 (FHH3) Caused By AP2S1 Mutations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Caroline M Gorvin*, Andrei I Tarasov, Patrik Rorsman and Rajesh V Thakker
University of Oxford, Oxford, United Kingdom

 

Calcium binding to the calcium-sensing receptor (CaSR), a G-protein coupled receptor (GPCR), initiates activation of its associated G-proteins, leading to calcium release from intracellular stores, that is observed as oscillations at low extracellular calcium [Ca2+]o concentrations (maximally between 2-4mM), and elevated steady-state responses at higher [Ca2+]o concentrations (above 7.5mM). These oscillations are hypothesised to be an adaptive response to allow receptors to continue to respond to small calcium fluctuations during prolonged ligand exposure, without deleterious consequences to the cell. Recently, loss-of-function mutations of the sigma subunit of the clathrin-mediated endocytic adaptor protein-2, AP2σ, which affect CaSR function and signalling, have been identified in familial hypocalciuric hypercalcaemia type 3 (FHH3) patients. To date, all FHH3-associated mutations have been reported to involve Arg15 (R15) and to lead to one of three missense mutations: Arg15Cys (R15C), Arg15His (R15H) and Arg15Leu (R15L). We sought to investigate the effect of these FHH3-associated AP2σ mutations on CaSR signalling pathways by measuring intracellular calcium responses. Imaging was performed in Fura-2 loaded HEK293 cells stably expressing wild-type CaSR, and transiently transfected with red fluorescent protein (RFP)-tagged AP2σ-wild-type (WT) or FHH3-associated AP2σ-mutants R15C, R15H and R15L (n=30-35). AP2σ expressing cells were selected based on RFP expression, alternately illuminated with 340 and 380nm light, and 510nm emission wavelengths recorded in real-time in the presence of increasing concentrations of [Ca2+]o. Peak responses of 340/380nm ratios were used to plot dose-response curves. Intracellular calcium responses increased in all AP2σ-expressing cells in response to the elevation of [Ca2+]o in a dose-dependent manner. However, responses in cells expressing AP2σ mutant proteins were significantly (p<0.05) reduced compared to AP2σ-WT expressing cells (EC50 (95% CI) –WT - 2.33 (1.91-2.63), R15C – 3.36 (2.94-3.78), R15H – 3.21 (2.89-3.69), R15L – 3.14 (2.72-3.72)). Further examination of calcium oscillations revealed that AP2σ mutations lead to three types of responses when compared to AP2σ-WT which were: 1) a reduction in total number of oscillating cells observed with mutants R15C and R15H; 2) similar distribution in responses to [Ca2+]o observed with the mutant R15H; and 3) altered distribution to WT that required a higher [Ca2+]o ­to result in maximal oscillations observed with the mutants R15C and R15L. This impairment in the intracellular calcium signalling events in cells expressing AP2σ-mutant proteins are consistent with a loss-of-function within the CaSR signalling pathway, and reflect the altered phenotypes observed in FHH3 patients.

 

Nothing to Disclose: CMG, AIT, PR, RVT

19719 5.0000 SAT-294 A Familial Hypocalciuric Hypercalcaemia Type 3 (FHH3)-Associated Mutations in Adaptor Protein-2 Sigma Subunit Cause Reduced Intracellular Calcium Signalling and Delayed Oscillation Events 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Kyle W Sloop*1, Wenzhen Ma1, Aaron D Showalter2, Joseph D Ho1, Anna M Russell1, J Michael Sauder1, Tamika D Meredith1 and Francis S Willard2
1Eli Lilly and Company, 2Eli Lilly and Company, Indianapolis, IN

 

The glucagon-like peptide-1 receptor (GLP-1R) belongs to the structurally complex family of class B peptide-binding seven transmembrane spanning, heterotrimeric G protein-coupled receptors (GPCRs). Activation of the GLP-1R stimulates membrane-associated adenylyl cyclase and cAMP production which enhances glucose-dependent insulin secretion. To establish new systems for studying structure-function properties of the GLP-1R, we generated and optimized receptor-ligand fusion proteins that are specifically activated by exogenous enzyme application. Chimeric GLP-1R constructs were designed to express fusions of the GLP-1R with its native ligand, GLP-1(7-36), or the mimetic agonist, exendin-4. To control receptor activation, the receptor-ligand fusions were uniquely engineered to include an enterokinase-cleavable signal peptide that provides a neo-epitope identical to the N-termini of the soluble ligands. This system was validated by measuring enterokinase-dependent GLP-1R mediated cAMP accumulation, and a structure-activity relationship for both linker length and peptide sequence was determined. Moreover, the results show this approach can be used in physiologically relevant cell systems, as the GLP-1R-ligand chimeras induce glucose-dependent insulin secretion in INS1 insulinoma cells upon exposure to enterokinase. Based on the functional data showing the chimeras increase cAMP signaling, and the design strategy whereby an agonist is tethered to the receptor to ensure each receptor is occupied by ligand, these new tools may aide biophysical pursuits aimed at stabilizing the GLP-1R in the agonist-bound conformation. Further, data generated using this expression system may provide new strategies for designing approaches to better understand structure-function relationships of other peptide-binding GPCRs.

 

Nothing to Disclose: KWS, WM, ADS, JDH, AMR, JMS, TDM, FSW

21383 6.0000 SAT-295 A Probing Structure-Function Characteristics of the Glucagon-like Peptide-1 Receptor Using Novel Protease-Activated Chimeras 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Vanni Caruso*1, Madeleine Le Grevés2, Shahrzad Shirazi Fard2, Tatiana Haitina2, Pawel K. Olszewski3, Johan Alsiö2, Helgi B. Schioth4 and Robert Fredriksson2
1Uppsala University, Uppsala, 2Uppsala University, 3Waikato University, 4Uppsala University, Uppsala, Sweden

 

G protein-coupled receptors (GPCRs) are a class of integral membrane proteins mediating physiological functions fundamental for survival, including energy homeostasis. A few years ago, an amino acid sequence of a novel GPCR gene was identified and named Gpr178. In this study, we provide new insights regarding the biological significance of GPR178 protein investigating its evolutionary history, tissue distribution as well as examining the relationship between its expression level and feeding status. Our phylogenetic analysis indicated that GPR178 is highly conserved among all animal species investigated, and that GPR178 is not a member of a protein family. Real-time PCR and in situ hybridization revealed wide expression of Gpr178 mRNA in both the brain and periphery, with high expression density in the hypothalamus and brainstem, areas involved in the regulation of food intake. Hence, several feeding paradigms including starvation and overfeeding were assessed to investigate the functional involvement of the gene in  food intake. Short-term starvation (12-48h) or food restriction resulted in upregulation of Gpr178 mRNA expression in the brainstem, hypothalamus and prefrontal cortex. Conversely, short-term (48h) exposure to sucrose or Intralipid solutions downregulated Gpr178 mRNA in the brainstem; and long-term exposure (10 days) to a palatable high-fat and high-sugar diet resulted in a downregulation of Gpr178 in the amygdala but not in the hypothalamus. Our results indicate that hypothalamic Gpr178 gene expression is altered during acute exposure to starvation or acute exposure to palatable food. Changes in gene expression following palatable diet consumption suggest a possible involvement of GPR178 in the complex mechanisms of feeding reward.

 

Nothing to Disclose: VC, ML, SS, TH, PKO, JA, HBS, RF

21202 7.0000 SAT-296 A The Orphan G Protein-Coupled Receptor Gene Gpr178 Is Evolutionary Conserved and Altered in Response to Acute Changes in Food Intake 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Burcu Hasdemir*1, Juan A Oses-Prieto2, Alma L Burlingame2 and Aditi Bhargava3
1University of California, San Francisco, San Francisco, CA, 2University of California San Francisco, 3University of California San Francisco, San Francisco, CA

 

Women are twice as likely as men to suffer from stress-related disorders, but the cellular basis for these gender differences are not understood. The CRF family of neuropeptides that includes CRF and urocortins and their receptors, CRF1 and CRF2, mediate neuroendocrine stress responses. Using an acute model of pancreatic stress, we recently demonstrated that Ucn1 rescued stress-induced endoplasmic reticulum and unfolded protein response in wild type (WT) and Crh2-/- (KO) male mice alone; it exacerbated cellular stress responses in female WT and Crh2-/- mice. The mechanism by which Ucn1 mediates its sex-specific stress coping effects remains unknown. Ca2+ release from Ca2+ stores in acinar cells regulates many secretory processes including amylase release, thus, [Ca2+]i is tightly regulated in acinar cells. Primary pancreatic acinar cells from male and female mice were loaded with Fura-2 AM and Ca2+ release in response to various agonist stimulations was measured. We found that baseline Ca2+ release in acinar cells was similar in WT male and female cells in response to caerulein-stimulation. Acinar cells from WT male mice pre-treated with caerulein and subsequently challenged with Ucn1 continued to show a normal rise in [Ca2+]i; in contrast, acinar cells from female mice showed decreased peak as well as total Ca2+ release. Importantly, CRF2 protein expression in acinar cell lysates was similar in both genders. Thus, given that there was no inherent difference in the amount of CRF2 protein expression, we reasoned that association of the CRF2 with ancillary proteins must confer this gender-specific function. We used mass spectrometry to identify CRF2-interacting proteins in co-immunoprecipitated lysates after CRF or Ucn1 stimulation. Scaffold proteins such as F-actin and vimentin and heat shock proteins were identified. Redistribution of F-actin is a crucial event responsible for inhibition of Ca2+-mediated secretion in acinar cells. Western blot analysis of co-immunoprecipitated lysates showed that F-actin association with CRF2 was increased in male mice after Ucn1 treatment. Reverse phase LC-MS/MS analysis of iTRAQ-labeled peptides was used to identify specific phospho-species in pancreatic lysates from male and female mice. After acute pancreatic stress, MAPK1 was significantly more phosphorylated at the tyrosine residue in WT male, whereas in the WT female the same kinase was phosphorylated at two distinct residues (tyrosine and threonine) compared to controls or Crh2-/- mice. Similar differences in phosphorylation levels at distinct residues were present in other MAPK and Ser/Thr kinases. Western blots confirmed increased phosphorylation of p38 MAPK in male mice after Ucn1 treatment. To conclude, our results demonstrate a novel mechanism by which CRF2 interacts with cellular proteins in a context-specific manner to mediate gender-specific stress coping cellular responses.

 

Nothing to Disclose: BH, JAO, ALB, AB

21130 8.0000 SAT-297 A Differential Interaction of Corticotropin-Releasing Factor Receptor 2 (CRF2) with Ancillary Proteins to Mediate Gender-Specific Stress Coping Responses in Pancreatic Acinar Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Yasuhisa Akazome*1, Eri Yamamoto2 and Yoshitaka Oka3
1The University of Tokyo, Tokyo, Japan, 2The University of Tokyo, Japan, 3The University of Tokyo, Bunkyo-Ku, Japan

 

Neuroeptide FF (NPFF) and RFamide related peptide (RFRP) are members of vertebrate Arg-Phe-amide peptides. NPFF and RFRP specifically bind and activate membrane receptors NPFFR1 (GPR147) and NPFFR2 (GPR74), and NPFF shows higher affinity to GPR74 than GPR147, while RFRP prefers GPR147. GPR147 and GPR74 have been regarded to couple to Gi protein, and NPFF and RFRP have been considered to possess inhibitory effects on GPR147 or GPR74 expressing cells.

In the medaka (Oryzias latipes) brain, we previously demonstrated that terminal nerve (TN) GnRH3 neurons express both NPFF and GPR74-1 mRNAs (Akazome et al., 2012).  NPFF (dwarf gourami (Trichogaster lalius)) or RFRP (medaka) application to the TN GnRH neurons evoke hyperpolarizing response (Saito et al., (2010); Umatani et al., (2013)). Therefore, in the medaka TN GnRH neurons, we assumed that GPR74 might function as an autoreceptor in combination with NPFF released from TN GnRH neurons themselves, and we expected NPFF-GPR74 system in the TN GnRH neurons should be a suitable model for studying the autoinhibitory mechanism of peptidergic neurons. On the other hand, the signal transduction of neither GPR147 nor GPR74 has been characterized in teleosts.

Through a medaka genome database mining, we identified partial sequences of one GPR147 and two GPR74 gene candidates. By performing 5’- and 3’ RACE using medaka brain cDNA, we determined full length nucleic acid sequences of these receptor cDNAs. We subcloned these cDNAs into expression vector pcDNA3.1+ and transfected into HE293-T cells in combination with CRE-luciferase reporter gene plasmids. We measured PKA activation by applying NPFF or RFRP at various concentrations ranging from 0 to 10-5 M with or without forskolin to assess the ligand-induced receptor coupling with Gi- or Gs proteins.

When RFRP was applied at lower concentration (from 10-13 M to 10-9 M) in combination with forskolin to GPR147 expressing HEK-293-T cells, RFRP showed PKA inhibition in a dose-dependent manner, suggesting the coupling of Gi to GPR147. Surprisingly, at higher concentrations ranging from 10-9 to 10-5 M, RFRP-induced PKA inhibition diminished in a dose-dependent manner. The similar feature was also observed when NPFF was applied to HEK293-T cells expressing GPR74-1 or GPR74-2. Next, we assessed PKA activation by NPFF or RFRP application without forskolin, and we found dose dependent PKA-stimulating activity, suggesting coupling of Gs to these receptors at concentrations of 10-8 M and higher. Based on these findings, we propose a possible switch of coupling of GPR147/GPR74 to Gi- and Gs-proteins in the medaka, potentially providing a basis for exquisite neuronal tuning dependent on a single ligand-single receptor combination.

 

Nothing to Disclose: YA, EY, YO

20838 9.0000 SAT-298 A Ligand Dose-Dependent Switch in G-Protein Coupling (Gi and Gs) of Medaka (Oryzias latipes) Neuropeptide FF Receptors, NPFFR1 (GPR147) and NPFFR2 (GPR74) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Robert G. Bennett*1, Ronda L Simpson2 and Alexander I Agoulnik3
1VA Nebraska-Western Iowa Health Care System, Omaha, NE, 2University of Nebraska Medical Center, Omaha, NE, 3Herbert Wertheim College of Medicine, Florida International University, Miami, FL

 

The polypeptide hormone relaxin has potent antifibrotic effects in a number of organs, including the liver. Our previous data showed that relaxin improved established hepatic fibrosis and reduced markers of myofibroblast activation in experimental models of liver injury.  Therefore, we hypothesized that impaired relaxin signaling would cause increased susceptibility to carbon tetrachloride (CCl4) induced liver damage. To investigate this possibility, male mice lacking the relaxin receptor RXFP1 (RXFP1-/-) or age-matched wild-type mice were challenged with a single intraperitoneal injection of CCl4, and the degree of hepatic damage was assessed after 24, 48 and 72 hours.  Wild-type mice developed marked necrosis at 24 hours, which improved steadily from 48 to 72 hours.  The RXFP1-/- mice had greater areas of necrosis at each time point, suggesting that the susceptibility to damage was greater, and the rate of recovery was markedly slowed. The serum levels of liver transaminases were modestly elevated in the RXFP1-/- mice compared to wild-type mice, but RXFP1-/- mice had significantly higher interleukin-6 (IL-6) levels at 48 hours.  The degrees of myofibroblast activation and hepatocyte proliferation were monitored by immunohistochemistry for smooth muscle α-actin (SMA) or Ki-67, respectively.  While wild-type livers were characterized by moderate SMA content at 48 which almost completely resolved by 72 hours, the RXFP1-/- mice had markedly increased SMA staining at both time points. Conversely, wild-type mice had a large induction of hepatocyte proliferation from 48 hours as determined by Ki-67 staining, while the RXFP1-/- had dramatically lower levels.  This effect was significant at both 48 and 72 hours after CCl4 injection.  The differences in proliferation were reflected in the expression levels of genes critical for efficient regeneration, such as cyclin-D1, hepatocyte growth factor, and its receptor c-Met, all of which were significantly lower in RXFP1-/- mice.  A second study was performed to determine the effects of chronic CCl4 treatment over a 2 week period.  Similar results were obtained, in which the RXFP1-/- mice had elevated SMA content, along with reduced Ki-67-positive hepatocytes, consistent with increased myofibroblast activation and decreased hepatocyte proliferation. In summary, mice deficient in relaxin signaling had increased susceptibility to liver injury, and impaired hepatocyte regeneration.  These results suggest that endogenous relaxin-RXFP1 signaling plays a role not only in the onset of liver injury, but also in the rate of repair after injury.

 

Nothing to Disclose: RGB, RLS, AIA

21881 10.0000 SAT-299 A Disruption of Relaxin Signaling Causes Increased Susceptibility to Liver Injury and Impaired Heptatocyte Regeneration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Alicia Christine Weeks*1, Melanie Dart2, Xhanhai Li2, Dawn Belt Davis1 and Michelle E. Kimple1
1University of Wisconsin, Madison, WI, 2University of Wisconsin, Madison

 

The varied response of patients with type 2 diabetes mellitus (T2DM) to therapeutic agents is well known, but the underlying etiology remains unclear.  Considering the morbidity associated with hyperglycemia and the cost of pharmacotherapy, elucidating causal factors is of great significance.  As incretin mimetics function in part by directly stimulating the insulin-producing β-cells, factors down-regulating β-cell function are of particular interest.  Using islets isolated from diabetic mice and humans, we showed prostaglandin E2 (PGE2) acts through a specific β-cell receptor to reduce insulin secretion, directly competing with incretin signaling[i].  We hypothesized (1) individuals with high PGE2 production have poorer glycemic control and a weaker response to incretin-based therapeutics than those with low PGE2 production and (2) plasma PGE2 level can be a biomarker of T2DM status and therapeutic response.  In a preliminary study using 75 anonymized patient samples, individuals with T2DM (n=65) had significantly elevated plasma PGE2 levels (18.0 ± 22.4 pg/ml) as compared to non-diabetics (ND) (11.0 ± 7.3 pg/ml, n=10).  Subjects with diabetic nephropathy, indicating poorer glycemic control, had the most elevated levels (19.9 ± 11.6 pg/ml, n=16, p=0.04 vs. ND).  This data gave support to a new cohort study of T2DM and ND subjects recruited from the UW Endocrinology and Diabetes Clinic.  Exclusion criteria included age <18 or>70, chronic or recent use of most COX inhibitors or oral steroids, active infection, and most autoimmune diseases.  A power analysis with α=0.05 and β=0.08 indicated 35 ND and 137 T2DM subjects (with 20-30% on incretin therapy) needed.  PGE2 levels are correlated with (1) donor demographics and measures of (2) diabetes/obesity status, (3) glycemic control, and (4) inflammation.  Chart review is performed at 6 and 12 months to record diabetes status, glycemic control and medication failure.  We performed an interim analysis of 62 subjects (14 ND and 47 T2DM, with 19 T2DM subjects on incretin–based therapy).  Multivariable analysis of all subjects adjusted for covariates demonstrated no significant effects on PGE2 levels with respect to age, BMI, triglycerides, HgA1c, ESR, or aspirin use; however, age (p=0.0795) and TG (p=0.0588) demonstrated a strong trend.  Within the T2DM group alone, triglycerides again showed a strong trend (p=0.0678), as did ESR (p=0.1363) and age (p=0.18).  The correlation of ESR with PGE2 levels in the T2DM group appeared to be more relevant with incretin therapy (p=0.2398) than without (p=0.9732), whereas the opposite was true for triglyceride levels (p=0.3262 with incretin therapy vs. 0.0489 without).  Although results did not show a significant correlation between PGEM levels and T2DM status, this may reflect additional unidentified covariates rather than a true rejection of our hypothesis, providing guidance for the full analysis. 

 

 

 

Nothing to Disclose: ACW, MD, XL, DBD, MEK

21635 11.0000 SAT-300 A Prostaglandin E2 Levels As a Predictor of Disease Status in Human Subjects with Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Nikolaj Rittig*1, Ermina Bach1, Henrik Holm Thomsen1, Mogens F Johannsen2, Jens Otto Lunde Jørgensen1, Bjorn Richelsen1, Niels Jessen1 and Niels Møller1
1Aarhus University Hospital, Aarhus C, Denmark, 2Aarhus University, Aarhus N, Denmark

 

Background: Inflammation is catabolic and causes muscle loss. It is unknown if amino acid supplementation reverses these effects during the acute phase of inflammation.

Objective: To test whether amino acid supplementation counteracts endotoxin-induced catabolism.

Design: Eight young, healthy, lean males were investigated three times: (i) normal conditions (Placebo), (ii) endotoxemia (LPS), and (iii) endotoxemia with amino acid supplementation (LPS+A). Protein kinetics were determined using phenylalanine, tyrosine, and urea tracers. Each study day consisted of a four-hour non-insulin stimulated period and a two-hour hyperinsulinemic euglycemic clamp period. Muscle biopsies were collected once each period.

Results: Endotoxin administration created a significant inflammatory response (cytokines, hormones, and vital parameters) without significant differences between LPS and LPS+A. Whole body protein breakdown was elevated during LPS compared with Placebo and LPS+A (p<0.05). Whole body protein synthesis was higher during LPS+A than both Placebo and LPS (p<0.003). Furthermore, protein synthesis was higher during LPS than during Placebo (p<0.02). Net muscle phenylalanine release was markedly decreased during LPS+A (p<0.004), even though muscle protein synthesis and breakdown rates did not differ significantly among interventions. LPS+A increased mammalian target of rapamycin (mTOR) phosphorylation (p<0.05) and eukaryotic translation factor 4E-binding protein 1 (4EBP1) phosphorylation (p=0.007) without activating AMPK or affecting insulin signaling through Akt. During insulin stimulation net muscle phenylalanine release and protein degradation were further reduced.

Conclusions: Amino acid supplementation in the acute phase of inflammation counteracts whole body and muscle protein loss, and this effect is associated with activation of mTOR and downstream signaling to protein synthesis through mTORC1, suggesting a therapeutic role for intravenous amino acids in inflammatory states.

 

Nothing to Disclose: NR, EB, HHT, MFJ, JOLJ, BR, NJ, NM

18897 12.0000 SAT-301 A Protein Supplementation Is Anabolic during the Acute Phase of Inflammation: A Human Randomized Crossover Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Xin-Hua Liu*1, Christopher Pratt Cardozo2 and William A Bauman3
1J.J. Peter VA Medical Center, Bronx, NY, 2James J. Peters Veteran Affairs Medical Center, Bronx, NY, 3James J. Peters VA Medical Center, Bronx, NY

 

Nuclear factor-kappa B (NF-κB) is a transcription factor that regulates the expression of more than 150 genes related to inflammation and cell survival responses. Recent studies revealed that NF-κB plays important roles in muscle atrophy associated with aging, disuse, denervation, muscular dystrophy, and cachexia due to cancer (1). NF-κB activity is regulated by various factors, including ankyrin repeat domain (AnkrD) proteins, which belong to the muscle ankyrin repeat protein family, whose members are involved in muscle responses to stresses such as acute resistance exercise, congenital myopathy, and Duchenne muscular dystrophy (2, 3). In addition, our preliminary data showed a significant up-regulation of AnkrD1 in mouse gastrocnemius after denervation, suggesting an involvement of AnkrD1 in NF-κB mediated cellular responses to paralysis. With these considerations in mind, we examined the effect of AnkrD1 on NF-κB activity and determined the interactions between AnkrD1 expression and NF-κB signaling induced by TNFα in differentiating C2C12 myoblasts. Real time PCR revealed a significant increase in AnkrD1 mRNA levels within 2d after adding TNFa (5 ng/ml). Western blotting showed an upregulation in AnkrD1 protein 3d after TNFα addition, which predominantly occurred in the nuclei of the cells. To determine whether elevated AnkrD1 expression influenced NF-κB transcriptional activity, AnkrD1-siRNA was employed to inhibit the expression of AnkrD1. Gene knockdown with AnkrD1-siRNA did not alter basal levels of NF-κB transcriptional activity, detected by NF-κB-luciferase reporter assay, but significantly increased TNFα-induced activation of NF-kB compared to the cells treated with non-silencing random siRNA. Conversely, overexpression of AnkrD1 inhibited TNFa-induced NF-κB activity. To determine whether AnkrD1 directly interacted with NF-κB, we performed co-immunoprecipitation studies; anti-AnkrD1 antibodies pulled down NFκB-p50 protein and vice versa, indicating that these two proteins formed complexes. Finally, we performed a chromatin immunoprecipitation (CHIP) assay to examine whether exposure of C2C12 cells to TNFα induced recruitment of AnkrD1 to the NF-κB binding site in its promoter region. PCR amplification of the DNA fragments immunoprecipitated with AnkrD1 antibodies gave a single band of 500 bp; and overexpression of AnkrD1 caused a reduced density of this band, suggesting that AnkrD1 was able to bind with DNA-bound NF-κB, and the binding capacity was modulated by the levels of AnkrD1 in response to inflammation. These results provide a molecular mechanism for signaling integration between AnkrD1 and NF-κB pathways, and suggest a novel anti-inflammatory role of AnkrD1 through feedback inhibition of NF-κB transcriptional activity by which Ankrd1 modulates the balance between physiological and pathological inflammatory responses in skeletal muscle.

 

Nothing to Disclose: XHL, CPC, WAB

18434 13.0000 SAT-302 A AnkrD1 Modulates the Balance Between Physiological and Pathological Inflammation Responses through Feedback Inhibition of NF-Kb Signaling Activity in C2C12 Myoblasts 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Kelvin Yen*, Hemal H Mehta and Pinchas Cohen
University of Southern California, Los Angeles, CA

 

Humanin is the first member of a new class of mitochondrial-derived peptides (MDPs) that are encoded in the mitochondrial genome from small, alternative open reading frames (ORFs) and humanin’s ORF is located within the 16S rRNA gene.  Administering humanin in vivo or in vitro protects both cells and animals from amyloid-beta toxicity, oxidized lipid toxicity, and prevents the development of both diabetes and atherosclerosis.  Humanin is found in tissue samples as well as in plasma and because of the central role of mitochondria in aging and age-related diseases, we hypothesized that signaling from the mitochondria through MDPs plays a key role in aging and age-related diseases.

            In addition, humanin is a conserved peptide and the ORF can be found in animals as distant as jellyfish.  Because of the benefits of working with simpler model organisms, we examined whether humanin had any biological effects in C. elegans by creating a transgenic worm model.  Both genomic PCR and QPCR of the humanin transcript indicated that these transgenic worms were overexpressing humanin and we found that similar to our in vitro work, humanin expression significantly decreases the overall oxygen consumption rate of whole worms as measured by the Seahorse XF96 Bioanalyzer.  This decrease in oxygen consumption rate was similar to that described in the long-lived insulin/IGF receptor mutant worms (daf-2-/-). We also observed a decrease in pharyngeal pump-rate and egg-laying rate of the humanin-transgenic worms similar to daf-2 worms.  Lifespan studies of the transgenic worms at both 15°C and 20°C demonstrated a dramatic increase in lifespan compared to wild-type or the parental strain.  Our findings suggest that in addition to its cytoprotective effects, humanin plays a role in aging.  Using the powerful genetic tools of C. elegans, future studies will elucidate the pathway by which humanin achieves the lifespan effects.

 

Disclosure: PC: Founder, Cohbar. Nothing to Disclose: KY, HHM

22065 14.0000 SAT-303 A Humanin, a Mitochondrial-Derived, Cytoprotective Peptide That Modulates Aging-Related Phenotypes and Increases Lifespan in Worms 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Susanne Schuster*1, Melanie Penke1, Theresa Gorski1, Sandy Richter1, Tommaso deGiorgis2, Wieland Kiess3 and Antje Garten1
1University of Leipzig, Faculty of Medicine, Leipzig, Germany, 2University of Chieti, Chieti, Italy, 3University of Leipzig, Dept. of Women´s & Child Health, Leipzig, Germany

 

Background and Hypothesis: Animal and human studies have shown that nicotinamide phosphoribosyltransferase (NAMPT), a key enzyme of mammalian NAD salvage, is modified in chronic liver diseases. Here, we investigated the effects of NAMPT inhibition by its specific inhibitor FK866 on different human hepatocyte models to elucidate its effects on the nutrient sensing metabolic regulator AMP-activated protein kinase (AMPK) and downstream targets and asked whether administration of nicotinamide mononucleotide (NMN), the enzyme product of NAMPT, is able to rescue FK866-induced effects. We hypothesized that intracellular NAD depletion affects AMPK and mammalian target of rapamycin (mTOR) signalling.

Methods: Human hepatocyte models (HepG2 cells, Huh7 cells, Hep3B cells) were used. Cell viability and apoptosis were measured by WST-1 assay and AnnexinV/PI staining, respectively. NAMPT enzymatic activity was quantified using 14C-labeled nicotinamide.  Intracellular NAD levels were measured by HPLC analysis. Expression and phosphorylation of AMPKα, mTOR and p70S6 kinase was analyzed by western blot.

Results: NAMPT activity was significantly decreased by -71.0% in HepG2 cells, by -38.1% in Hep3B cells and by -74.9% in Huh7 cells after treatment with FK866 [10nM] for 24h which caused a sharp decline of NAD levels (3.3±1.1 vs. 0.3±0.1 µmol/g protein in Huh7 cells; 2.2±0.7 vs. 0.3±0.08 µmol/g protein in Hep3B cells). Already after 24h of FK866 treatment, a decreased activity of mitochondrial dehydrogenases was noted (HepG2 cells -29.3%, Huh7 cells -49.4%, Hep3B cells -20.6%). A significantly increased phosphorylation of AMPKα (Thr172) (+3.3-fold) was found in cells treated with FK866 [10nM] for 48h. This was associated with a significant decrease of phosphorylation of mTOR (Ser2448) by -50.7% and its down-stream target p70S6 kinase (by -94.7% in Huh7 cells). The administration of NMN [500µM] was able to completely reverse the FK866-induced effects on AMPK activation and mTOR signalling. We also found that hepatocytes treated with FK866 showed significantly increased mRNA expression of PGC1α (+1.9-fold in Huh7 and Hep3B cells; +2.7-fold in HepG2 cells), a major integrator of transcriptional responses to nutrient stress.

 Conclusion: NAMPT inhibition by FK866 induces energy stress in hepatocytes by depleting intracellular NAD levels which leads to growth inhibition and the activation of the metabolic sensor AMPK.

 

Nothing to Disclose: SS, MP, TG, SR, TD, WK, AG

20291 15.0000 SAT-304 A FK866-Induced NAD Depletion Leads to AMPK Activation and Inhibition of mTOR Signalling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Awat N Yousif1, Yong S. Kim1, Douglas L Vincent2 and Jinzeng Yang*2
1University of Hawaii at Manoa, Honolulu, 2University of Hawaii at Manoa, Honolulu, HI

 

A better understanding of skeletal muscle growth and regulation can contribute to human health and well-being. Skeletal muscle responds to physiological changes such as growth, physical activities and aging by changing its size and composition. Physical activity plays a significant role in promoting muscle mass. As skeletal muscle serves as a pool of amino acids and energy sources in times of dietary limitation, loss of skeletal muscle mass caused by inadequate energy intake, cachexia, and age-associated sarcopenia has a major impact on disease progression and recovery. Myostatin, one of the transforming growth factors-β superfamily, is a negative regulator of muscle growth.  Myostatin-knockout mice showed a significant increase in individual muscle mass and suppression of body fat accumulation. Myostatin propeptide is a ligand that enhances muscle growth by suppressing myostatin function. We previously demonstrated that transgenic over-expression of myostatin propeptide cDNA led to significant muscle growth. We hypothesized that transgenic mice over-expressing myostatin propeptide can continue keeping their muscle mass in old age. Samples were collected at three different ages of the myostatin propeptide (MLC-pro) transgenic and wild type littermate mice: 6 month (adult), 12 month (middle- aged), and 18 month (aged mice). The results showed that liveweight and muscle weight of transgenic mice remained heavier than those of wild type during the experimental periodduringThe adipose tissue mass increased during aging in both genotypes, but the extent of increase was much greater (P<0.05) in wild type as compared to the transgenic mice, reaching 80% reduction at  at 18 months of age. The qPCR results for gene expression showed that myostatin mRNA level was higher in transgenic mice and its level fluctuated during different time points of age. Both MyoD and Myf5 mRNA levels were higher in transgenic mice during the experimental periodas compared to wild-type mice, while their levels reduced gradually with advancing in age. Pax7 gene showed higher expression in transgenic mice compared to wild-type groups during the experimental periodtwith its level being highest at 18 months of age in transgenic mice. This finding provides support for the role of myostatin in skeletal muscle maintenance in old animals, and the prospect of targeting myostatin to prevent or reverse progressive muscle wasting that occurs in aging and certain degenerated diseases.

 

Nothing to Disclose: ANY, YSK, DLV, JY

21079 16.0000 SAT-305 A Transgenic Expression of Myostatin Propeptide Prevents Muscle Loss and Fat Accumulation in Old Ages 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Olivia Morris-Barry1, Christopher Nichols2, Nigel Goode1 and Abir Mukherjee*1
1Royal Veterinary College, London, United Kingdom, 2Forest Research, Surrey, United Kingdom

 

Transforming growth factor β (TGFβ) ligands play important roles in testicular development and function. Appropriate regulation of TGFβ ligand action is necessary to maintain normal testicular function. Follistatin-like 3 (FSTL3), an endogenous inhibitor of TGFβ ligands, including activin, is strongly expressed in the testis. FSTL3 gene deleted (FSTL3 KO) mice develop significantly enlarged testes that do not regress with age, unlike their WT counterparts. This phenotype suggests that one of the roles of FSTL3 is to limit testis size and function. Ageing and seasonal changes are two common signals that reduce testis size, spermatogenesis and function. We have reported a series of candidate proteins identified by quantitative mass spectrometry that might be important in preventing age-related testicular size regression. Here, we hypothesize that alteration of testis size and function requires the activity of a common set of proteins and cell biological pathways, at least some involving the action of FSTL3. A significant variation of testicular size and function occurs in seasonal breeders where testis size directly corresponds to reproductive status. This is seen in the common grey squirrel (Sciurus carolinensis) and we have begun to investigate FSTL3 dependent effects using this model. Seven grey squirrels trapped during summer and seven trapped during autumn are used in this study. Growth plate closure, as visualized by x-ray imaging of wrists, is used to confirm that only adult squirrels are selected. One of the two testicles dissected is fixed in Bouin’s fixative and the other weighed and frozen for later use. To date we have investigated the summer samples and have found that the immunohistochemical staining pattern for testicular PCNA, phospho-histoneH3 and phospho-SMAD2 in squirrel mimics that observed in mice. Moreover, signalling pathways implicated in the maintenance of a functional testis in FSTL3 KO mice, including AKT and SMAD2 activation, are also active in the summer squirrel, as observed by western blotting. This suggests that the squirrel is likely to be a valid model for the investigation of the role of FSTL3 in testis size and function determination. Our data suggests that the mechanisms of age-related testicular regression in mice are, at least in part, similar to the mechanisms of seasonal testis size reduction in the wild. Hence, it seems that the squirrel will not only be an invaluable model in which to dissect FSTL3 associated pathways pertaining to seasonal structural and functional change in a seasonal breeder and but will also enable us to compare these to the mechanisms observed in age-related testicular regression. We are currently investigating the autumn samples to compare FSTL3 and activin dependent signalling pathways that we have demonstrated are induced in FSTL3 KO mouse testes and are likely to be important in maintaining testicular size.

 

Nothing to Disclose: OM, CN, NG, AM

22062 17.0000 SAT-306 A Role of Activin Signalling and FSTL3 in Seasonal Changes in Testicular Size in Grey Squirrels 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Candela Rocío Gonzalez1, Susana Beatriz Rulli2, Ilpo T. Huhtaniemi3, Alfredo Daniel Vitullo1, Ricardo S Calandra*4 and Silvia Inés Gonzalez-Calvar5
1Universidad Maimónides, 2Institute of Biology and Experimental Medicine, Buenos Aires, Argentina, 3Imperial College London, London, United Kingdom, 4Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina, 5Instituto de Biología y Medicina Experimental, CONICET

 

Transforming growth factor beta 1 (TGFB1) is involved in the modulation of testicular function. We have previously described a proliferative effect on Leydig cells (LC) induced by TGFB1 through its co-receptor endoglin (EDG) which is induced by progesterone (Pg) via the transcription factor KLF14 (1). The aim of this work was to study in infertile mice (strain FVB/n) over- expressing alpha and beta subunits of hCG (hCG+) and show an increase in testicular steroidogenesis with high levels of Pg, testosterone and a marked hyperplasia of LC: 1) the protein expression of EDG and Pg receptor (PgR) by immunohistochemistry; 2) the gene expression of PgR A (PgRA), PgR B (PgRB) and KLF14 by Real time PCR on purified LC; 3) the in vitro effect of TGFB1 expression on PgRA and PgRB by Real time PCR in purified LC and 4) the in vitro effect of Pg on KLF14 by Real time PCR in purified LC. The PgR and EDG were immunolocalized in LC. The expression of both PgRA and PgRB was increased in hCG+ respect to WT mice (p< 0.05). Gene expression of PgRA, PgRB and KLF14 was significantly higher in LC from hCG+ respect to WT mice (p<0.05). The expression of PgRA was significantly higher than PgRB in LC from hCG+ mice (p<0.05). In vitro incubation of WT LC with TGFB1 (1 ng/ml) increased the gene expression of PgRA and PgRB after 30 min of incubation (p< 0.05). In vitro incubation of WT LC with Pg (10-6M) significantly increased KLF14 gene expression after 60 min (p<0.05). The effect of Pg was abolished in the presence of RU486 (antiprogestogen). These results show that TGFB1 stimulates differentially the gene expression of PgR subtypes. The increased of PgRA expression induced by TGFB1 along with the increased of KLF14 induce by Pg migth stimulate the expression of EDG leading to a proliferative effect of TGFB1 in LC.

 

Nothing to Disclose: CRG, SBR, ITH, ADV, RSC, SIG

20520 18.0000 SAT-307 A Involvement of Progesterone Receptor Type a and B on Leydig Cell Proliferation Induced By TGFB1 in Transgenic Mice over-Expressing Hcg 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Celine Sallon*1, Ida Boulay1, Joel Fontaine1, Delphine Logeart-Avramoglou2, Xavier Cayla1, Gregoire Harichaux1, Valérie Labas1, Sylvie Canepa1 and Catherine Taragnat1
1INRA, Nouzilly, France, 2Université Paris Diderot, Paris, France

 

At the pituitary level, the bone morphogenetic proteins (BMPs), members of the TGFb superfamily govern organogenesis but also play roles in different differentiated cell types. For instance, in gonadotrope cells, the regulation of FSH synthesis is affected by BMPs. Several BMP ligand mRNAs, as well as BMP receptors, are present in sheep pituitary suggesting that BMPs can exert paracrine/autocrine actions on FSH synthesis (Faure et al. 2005; Sallon et al. 2010).

The first aim of the study was to determine whether ovine pituitary cells produced BMPs. The potential presence of BMPs in conditioned medium (CM) from ovine pituitary cells cultured for 48h, as well as in ovine serum, was investigated by using a bioactivity test based on embryonic mesenchymal cells (C3H10T1/2 cells) transfected with a BMP-responsive element fused to firefly luciferase reporter gene. The results showed that pituitary CM, in contrast to ovine serum, did not exhibit BMP activity whatever the treatment (GnRH, estradiol or activin) or the incubation period (6h-48h) applied to the pituitary cells. Surprisingly, this assay demonstrated that pituitary CM contained factor(s) able to inhibit BMP-4 action. Moreover, GnRH increased this inhibitory activity.

In the second part of the work, we conducted the identification of the putative factor(s) responsible for the inhibition of BMP action. To explore the hypothesis that the factor(s) can be BMP-4 binding protein, BMP-4 was immobilized on a BIACORE sensorchip and pituitary CM were injected on the chip for analysis by surface plasmon resonance. The result demonstrated that pituitary CM contain factor(s) able to bind BMP-4. The bound factor was then recovered from the chip and analysed by nanoLC-MS/MS allowing for identification of one molecule, the thrombospondin-1 (TSP-1).

Subsequent analyses confirm that TSP-1 is produced by pituitary cells. Moreover, rhTSP-1 or TSP-1 enriched CM are capable to bind BMP-4 immobilized on BIACORE sensorchip and to antagonize BMP4 effect as evaluated in the bioassay. 

In conclusion, our study identifies a novel role for TSP-1 as a BMP4 antagonist acting through BMP4 binding. The ability of TSP-1 to antagonize BMP4 action suggests that TSP-1 might be important in pituitary processes where BMP4 is involved. We hypothesize that this factor could regulate the bioavailability of BMPs reaching the pituitary by the blood way.

 

Nothing to Disclose: CS, IB, JF, DL, XC, GH, VL, SC, CT

21011 19.0000 SAT-308 A A Novel BMP4 Binding Protein Synthetized By Pituitary Cells: Thrombospondin-1 Acting As BMP4 Antagonist 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Courtney Elizabeth Stewart*1, Kristina M Corella2, Brittany D Samberg2 and Wilson C J Chung1
1Kent State University, Kent, OH, 2Kent State University

 

Loss-of-function mutations in the Fgf8 gene has been causally linked to Kallmann Syndrome (KS), a form of hypogonadotropic hypogonadism that results in the absence of pubertal onset and anosmia. Interestingly, recent clinical studies showed that KS patients also exhibit abnormal corpus callosum formation, including agenesis of the corpus callosum (ACC). These data are in line with our results from studies showing that newborn homozygous (neo/neo) Fgf8 hypomorphic mice also harbor ACC. Our initial studies led us to further study the role of FGF8 signaling during the formation of the corpus callosum in Fgf8 hypomorphic mice as a model system to better understand the underlying cellular and molecular mechanism of abnormal corpus callosum formation found in KS patients. In our first studies, we used GFAP immunohistochemistry to examine the midline glial cells, which have been shown to be critical for the interhemispheric crossing of callosal fibers. These initial studies showed that the number of GFAP+ glial cells was reduced by about 50% in the newborn indusium griseum of heterozygous (+/neo) Fgf8 hypomorphic mice, whereas GFAP+ glial cells were virtually eliminated in Fgf8neo/neo mice as compared to wildtype (WT) mice. These data indicate that the formation of the corpus callosum is dependent on midline glial cells, whose development requires FGF8 signaling. Furthermore, we found that cell proliferation in the subventricular zone (SVZ), the birth place of indusium griseum glial cells, was significantly lower in the newborn Fgf8neo/neo mice compared to WT mice. Together, these data indicate that FGF8 signaling is required for perinatal midline glial guidepost cell development, which in turn enables normal formation of the corpus callosum. Therefore, based on the animal studies, we infer that the abnormal development of the corpus callosum in KS patients may be the result of reduced GFAP+ midline glial cell proliferation. Future studies will address if FGF8-dependent disruption of midline GFAP+ glial cell development may also have functional consequences on the ability of midline glial cells to guide extending callosal fibers.

 

Nothing to Disclose: CES, KMC, BDS, WCJC

21928 20.0000 SAT-309 A The Agenesis of the Corpus Callosum in Fibroblast Growth Factor 8 Hypomorphic Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM SAT 290-309 5950 1:00:00 PM Signaling Poster


Irina Lerman*1, Aritro Sen2, Soumya Mitra1 and Stephen R Hammes2
1University of Rochester Medical Center, Rochester, NY, 2University of Rochester, Rochester, NY

 

Inflammation has been implicated in the initiation and progression of many cancers. While there is growing evidence that prostatic inflammation is associated with prostate cancer, the contribution of inflammation to carcinogenesis is poorly understood, with no causal relationship established to date. Here we sought to define the role of infiltrating immune cells in sensitizing prostatic epithelium to more robustly respond to signaling molecules such as androgens and growth factors present within the tumor microenvironment. Our lab has shown that androgens trigger epidermal growth factor (EGF) receptor signaling via protease-mediated release of EGF receptor ligands. Others have reported that immune cell derived proteases can similarly cleave membrane bound EGF receptor ligands to activate the EGF receptor. Finally, we have shown that the scaffolding protein paxillin extranuclear-signal-regulated (Erk) kinase signaling downstream of EGF receptor signaling in response to both androgens and EGF. Erk then mediates paxillin phosphorylation and translocation to the nucleus, where phospho-paxillin mediates transcription of proliferative genes. Here we show that neutrophil elastase (NE), a serine protease found primarily in neutrophil granules, is able to transactivate the EGF receptor in two prostate cancer cell lines, PC3 and LnCAP, which then results in serine phosphorylation and nuclear localization of paxillin. Thus, neutrophil elastase may activate similar proliferative pathways as EGF and androgens in prostate cancer cells. To study the role of neutrophil elastase in prostate cancer in vivo, we established PC3 xenografts in athymic nude mice. After 4 weeks growth, xenographs contain significant infiltration of neutrophils.  Importantly, daily administration of a clinically relevant dose of Sivelestat, an FDA approved NE inhibitor, results in a two-fold decrease in tumor burden. Moreover, we successfully use a protease sensitive biomarker probe specific for NE to visualize activity using an in vivo imaging system (IVIS). NE activity localizes to xenograft tumors and is reduced two-fold in Sivelestat treated animals. Since NE is not expressed by prostate cancer cells using RT-PCR analysis, we hypothesize that the aforementioned infiltrating neutrophils are the main source of NE, and play a critical role in tumor progression. Experiments are underway to expand our in vivo xenograft findings to other prostate cancer cell lines and identify whether neutrophil elastase is present in human prostate cancer samples. Our findings could establish neutrophil elastase as a potential biomarker and/or therapeutic target for prostate cancer.

 

Nothing to Disclose: IL, AS, SM, SRH

18492 5.0000 SAT-316 A Neutrophil Elastase Potentiates Human Prostate Cancer Growth in Mouse Models 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Hui Wang*, Hongting Zheng, Xiufei Liu, Linlin Zhang, Rui Zhang, Lingzhi Guan, Jing Xu and Qiang Tong
Department of Endocrinology, Xinqiao Hospital, Third Military Medical University

 

Type 2 diabetes (T2DM) has been shown to be associated with cancer. Some of the medications used to treat hyperglycemia are associated with an increased or a decreased risk of cancer. The present study shows the effects of DPP-4 inhibitors (DPP-4i) on migration and invasion in cancer cells and examines possible mechanisms underlying these effects. Here, 5 types of cancer cells were examined, all of them closely related to T2DM: colon cancer cells (SW480, HCT116), hepatocellular carcinoma cells (HuH7), lung cancer cells (A549), melanoma cells (A375), and glioma cells (CHG5). Each type of cells was divided into 2 groups, a control group and a treatment group. The control group was treated with saline and the treatment group was treated with saxagliptin (0.1 μM) and sitagliptin (0.6 μM). In the Transwell experiments, DPP-4i was found to promote the migration and invasion of cancer cells considerably (P<0.05). The effect of DPP-4i may have been induced by the increase in the persistence of cancer cell migration, as indicated by time-lapse microscopy and Trank-plot analysis. It was even found to promote pseudopod formation in cells, as observed under the microscope. ELISA analyses showed DPP-4 to be inhibited in cancer cells (P<0.05). ROS levels were significantly lower after DPP-4i treatment (P<0.05). The intracellular oxidative states were also decreased, as indicated by the ratio of GSH to GSSG. DPP-4i treatment significantly reduced oxidative damage in cancer cells, as indicated by 8-oxo-dG staining. Treatment with DPP-4i markedly increased protein levels of Nrf2, NQO1, HIF-1, Cox-2, APRIL, and Cortactin. The effects of short-term DPP-4i treatment were tested in models of experimental metastasis. Human metastatic hepatocellular carcinoma HuH 7 Luc+ cells and colon cancer HCT 116 Luc+ cells expressing luciferase were injected into the tail veins and paw pads, respectively, of nude mice. These mice then received either vehicle treatment or a short-term DPP-4i (saxagliptin 15mg/kg/day, sitagliptin 120mg/kg/day) therapy regimen administered by gavage after tumor cell inoculation. Short-term DPP-4i treatment resulted in accelerated experimental metastasis as measured by bioluminescence. Kaplan-Meier survival curves showed significantly less median survival than vehicle-treated controls. Micrometastases were confirmed by immunostaining for human vimentin in organs of the HuH 7 Luc+ model, HCT 116 Luc+ model, and in vehicle-treated nu/nu mice. More importantly, the Nrf2/ROS-related pathway (Nrf2, NQO1, and GCS) and metastasis-related genes, such as HIF-1 and Cox-2 et al. showed more activation in HuH 7 Luc+ and HCT 116 Luc+ models treated with DPP-4i than in those that only received vehicle. It is here speculated treatment with DPP-4i significantly promotes the migration and invasion of cancer cells and these effects may take place through the Nrf2/ROS pathway.

 

Nothing to Disclose: HW, HZ, XL, LZ, RZ, LG, JX, QT

19807 6.0000 SAT-317 A Role and Mechanism of DPP-4 Inhibitors in the Promotion of Migration and Invasion in Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Raghuveer Kavarthapu*1 and Maria L Dufau2
1National Institutes of Health, Bethesda, MD, 2NIH-NICHD, Bethesda, MD

 

Prolactin receptor (PRLR) and epidermal growth factor receptor (EGFR/ERBB1) play important roles in normal physiology of breast and in human breast cancer. Clinical studies indicate an increased expression of EGFR and its family member ERBB2 in breast cancers which are associated with tumor etiology and progression. Most of the breast cancers that become resistant to endocrine therapy have an increased activation of EGFR and their downstream MEK/MAPK and PI3K/AKT signaling pathways. Our present studies in MCF-7 breast cancer cells revealed that EGF induces up-regulation of PRLR via activation of EGFR downstream signaling pathway leading to the activation of estrogen receptor (ER) α. EGF treatments in MCF7 cells cultured in serum starved conditions induced significant increase in expression of PRLR in a time dependent manner which is consistent with increased activation of PRLR generic promoter (hPIII) and was abolished by ERa antagonist ICI 182,780 and ERa siRNA. This indicated involvement of ERα in EGF induced hPIII promoter activity. We further investigated the involvement of MEK/MAPK and PI3K/AKT downstream signaling pathways in the phosphorylation of ERα through EGFR/ERBB1 using U0126 (MEK inhibitor) and Wortmannin (PI3K inhibitor). PI3K inhibitor significantly abolished the PRLR promoter activity induced by EGF while the MEK inhibitor did not show significant effect. Our previous studies have demonstrated a central role for ERα on transcriptional activation of the PRLR gene induced by endogenous PRL in MCF-7 cells. In the present study, ChIP assay revealed increased recruitment of non-DNA bound ERα to Sp1 and C/EBPβ complex bound to their respective sites at the PRLR hPIII promoter induced by EGF which was abrogated by ERα siRNA, demonstrating the requisite role of ERα in the PRLR up-regulation. Our studies clearly indicate a role for paracrine EGF on EGFR in the transcriptional activation of PRLR gene expression and explain its contribution to high levels of PRLR receptors in breast cancer tissues. This regulation independent of estrogen in concert with endogenous prolactin/PRLR could play a role in cancer progression and resistance to endocrine therapy.

 

Nothing to Disclose: RK, MLD

20432 7.0000 SAT-318 A The role of EGF/EGFR in transcriptional activation of prolactin receptor (PRLR) gene expression: The EGF/EGFR - PRL/PRLR breast cancer connection 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Justin Michael Roberts*1, James Gordon MacKrell2, Guilherme Rocha3, Venkatesh Gary Krishnan2 and Nancy L Weigel1
1Baylor College of Medicine, Houston, TX, 2Lilly Research Laboratories, Indianapolis, IN, 3Lilly Research Laboratories, Indianapolis, IL

 

The role of vitamin D signaling in prostate cancer (PCa) is controversial. Some studies find an inverse correlation between levels of vitamin D metabolites and PCa risk, but others do not. The active metabolite 1α,25-dihydroxyvitamin D3 (1,25D), a ligand for the vitamin D receptor (VDR), inhibits the growth of PCa cells in vitro; 1,25D or less calcemic analogs also inhibit growth in some pre-clinical models, but clinical trials have been disappointing. A majority of PCas contain a genomic rearrangement that links the androgen and 1,25D regulated TMPRSS2 promoter to the coding region of an ETS transcription factor, typically ERG. VCaP cells are the only commonly used cell line that contains the T/E fusion. We have shown previously that VDR agonists inhibit VCaP cell growth in vitro despite inducing T/E. However, EB1089, a 1,25D analog, which inhibited growth of LNCaP xenografts, had no effect on VCaP xenografts. VDR and ERG cooperate to hyper-induce the vitamin D metabolizing enzyme, CYP24A1. Thus, T/E may limit VDR signaling through inactivation of 1,25D. To counteract the induction of CYP24A1 in VCaP cells, we are testing a novel non-secosteroidal VDR agonist, VDRM2, developed by Eli Lilly & Co, which should be resistant to CYP24A1. The window between the dose required to prevent bone loss in rats and the induction of hypercalcemia is 50-fold, but its effects in PCa cells are unknown. We find that it inhibits LNCaP and VCaP cell growth and is resistant to metabolism by CYP24A1. Previous microarray studies identified a small number of 1,25D regulated genes in LNCaP cells. To gain a better understanding of the differences in biology of 1,25D and VDRM2 as well as VDR actions in T/E and non-T/E expressing cells, we used next generation sequencing (RNA-Seq).  We compared gene expression in proliferating LNCaP and VCaP cells treated with concentrations of 1,25D and VDRM2 that resulted in similar levels of CYP24A1 gene induction. Within each gene, the sequence data were summarized to the level of data-defined exon groups; for each exon group, a two-way ANOVA model on treatment was used to identify statistically significant differences in expression across cell line, treatment and differential response to the two treatments. Most well-known VDR targets are regulated in both cell lines and by both agonists.  Interestingly, there are many cell line specific targets, and more overall targets in VCaPs. This may in part be secondary to VDR mediated induction of T/E.  There also are differences in regulation of sub-sets of genes suggesting that VDRM2 may act as a selective VDR modulator. CDK2 activity and c-Myc are major targets of VDR in PCa.  Our data suggest that other targets can lead to activation of p73, inhibition of CDK4/6, and inhibition of NFKB signaling. Thus, VDR ligands have the capacity to act though multiple pathways to inhibit PCa growth.

 

Nothing to Disclose: JMR, JGM, GR, VGK, NLW

20569 8.0000 SAT-319 A Prostate Cancer Cell and Ligand Specific Actions of 1 Alpha, 25-Dihydroxyvitamin D3 and a Novel Non-Secosteroidal VDR Agonist, VDRM2 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Raul M. Luque*1, Laura López-Sánchez2, Alicia Villa-Osaba2, Marina Álvarez-Benito3, Francisco Gracia-Navarro2, José López-Miranda4, Manuel D. Gahete2 and Justo Pastor Castano5
1Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain, 2University of Córdoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, and CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain, 3Hospital Universitario Reina Sofía, IMIBIC and CIBERobn, Córdoba, Spain, 4Hospital Universitario Reina Sofía, IMIBIC and CIBERObn, Córdoba, Spain, 5University of Cordoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain

 

Breast cancer (BC) is the most frequent malignant tumor and the leading cause of cancer-related death in female population. BC exhibits a profound hormonal/metabolic component, and its development and progression are tightly linked to both endocrine environment and diet. Hence, design of more specific and effective antitumoral treatments requires a better understanding of this pathology and its endocrine-metabolic environment. Specifically, BC risk is directly associated to all the components of the metabolic syndrome, including visceral adiposity, insulin resistance, hyperglycemia/hyperinsulinemia, low HDL-cholesterol and hypertension. However, metabolic syndrome is tightly associated with obesity, which is also an independent risk factor in BC and, therefore, the complex association between metabolic syndrome, obesity and BC hampers to determine which factors are relevant for BC development and progression. In this work, we aimed to analyze the putative relationship between the components of metabolic syndrome (insulin resistance, impaired glucose metabolism, hyperglycemia, hyperinsulinemia, etc.) and the presence of BC in patients with different body mass index (BMI). Specifically, in this prospective study, 148 women were recruited (77 patients with BC and 71 control patients without BC), classified in 3 groups attending to their BMI: normoweight (<25), overweight (25-30), or obese (>30), and subjected to an oral glucose tolerance test (OGTT). Glucose and insulin were determined in fasting conditions (time 0) and during the OGTT (30, 60, 90, 120 min). Fasting glucose levels were elevated in patients with higher BMI (p=0.002) and also were positively associated with tumor presence (p=0.019) in overweight or obese but not in normoweight patients. Interestingly, whereas in normoweight women a similar response in OGTT was observed between controls and BC patients, overweight and obese BC women presented impaired OGTT compared to controls, suggesting an association between BC and impaired glucose metabolism. Moreover, fasting insulin levels were elevated in women with higher BMI (p=0.001), but BC presence did not seem to influence insulin levels per se. However, insulin levels during the OGTT remained higher in overweight and obese BC patients compared to their controls, while no such differences were found in normoweight groups, suggesting an elevated insulin resistance in overweight and obese BC patients. Altogether, our data indicate that key components of the metabolic syndrome such as hyperglycemia, hyperinsulinemia or insulin resistance are associated to BC presence in overweight or obese patients but not in normoweight patients, thus suggesting that an exacerbated dysregulation of metabolic homeostasis is linked to BC.

 

Nothing to Disclose: RML, LL, AV, MÁ, FG, JL, MDG, JPC

19955 9.0000 SAT-320 A Breast Cancer Is Associated to Enhanced Insulin Resistance, Hyperglicemia and Hyperinsulinemia in Overweight and Obese, but NOT in Normoweight Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Carolyn M Klinge*1, Brandie N. Radde2, Bradford G. Hill2 and David J Schultz3
1University of Louisville School of Medicine, 2University of Louisville School of Medicine, Louisville, KY, 3University of Louisville, Louisville, KY

 

Tumor cells have increased glucose uptake and glycolysis.  Estrogen receptor α (ERα+) breast tumors rely on mitochondria (mt) to generate ATP and biosynthetic intermediates for nucleic acid and amino acid metabolism. Here we examined if there are differences in cellular bioenergetics between MCF-7 and T47D endocrine-sensitive versus ERα+ tamoxifen and fulvestrant resistant LCC9 human breast cancer cells that might be exploited therapeutically.  Oxygen consumption rate (OCR) and extracellular acidification rate (ECAR, an index of glycolysis) were measured using an XF24 Extracellular Flux Analyzer (Seahorse Biosciences). Estradiol (E2,10 nM) increased and 4-hydroxytamoxifen (4-OHT, 100 nM ) reduced basal and ATP-linked OCR in MCF-7 and T47D cells.  E2 increased ECAR in both cell lines.  Despite having a higher mt DNA: nuclear DNA ratio than MCF-7 cells, T47D cells have a lower basal OCR and ATP levels and higher proton leak, reflecting lower efficiency of coupling.  Mitochondrial reserve capacity, reflecting tolerance to cellular stress, was higher in T47D cells and was further increased by 4-OHT, but was decreased by 4-OHT in MCF-7 cells, suggesting T47D are more ‘stress-resistant’ than MCF-7 cells.  LCC9 cells had lower basal OCR, ATP-linked OCR, and reserve capacity compared to MCF-7 or T47D cells. Anacardic acid, 2-hydroxy-6-alkylbenzoic acid a dietary and medicinal phytochemical that inhibits breast cancer cell proliferation, was reported to be an uncoupler of oxidative phosphorylation in isolated rat liver mt.  However, anacardic acid (0.1-25 µM) showed no uncoupling activity in either MCF-7 or LCC9 cells, but increased basal OCR and stimulated reserve capacity in MCF-7 cells, while 25 µM anacardic acid acted as a mt toxicant.  LCC9 cells were more sensitive to inhibition of OCR  by anacardic acid.  Oleic acid (25 µM) inhibited ATP-linked OCR and increased proton leak in MCF-7 cells while stimulating ATP-linked OCR and inhibiting non-mt. oxygen consumption in LCC9 cells.  Salicyclic acid did not affect OCR or ECAR.  These data demonstrate critical differences in cellular energetics among these ERα+ breast cell lines, likely reflecting cancer cell avoidance of apoptosis.

 

Nothing to Disclose: CMK, BNR, BGH, DJS

20519 10.0000 SAT-321 A Regulation of Bioenergetic Function in Endocrine- Sensitive Versus Resistant Breast Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Josefa Andrade*1, Younhee Choi2, William Baker3, Cherie Paquette4, Jill Slack-Davis2, Frances Byrne1, Kyle Hoehn2, Susan C Modesitt2 and Margaret A. Shupnik1
1University of Virginia, Charlottesville, VA, 2University of Virginia, 3University of Virginia School of Medicine, 4Unviersity of Virginia School of Medicine

 

Endometrial cancer is the most common gynecological cancer in the US, with 50,000 new cases yearly; of these, over 40% are directly attributable to obesity. Type I endometrial cancer accounts for more than 85% of cases and is considered obesity related; these cancers are most often low grade and stage and generally estrogen (ER) and progesterone receptor (PR) positive. Exposure to estrogen unopposed by progesterone is proposed as a leading cause of endometrial cancer.   To understand how obesity may contribute to malignant transformation, we conducted studies comparing normal and cancerous endometrial tissue from obese women (1).   Gene set enrichment analysis demonstrated 40 alternatively regulated gene sets in endometrium.  In cancerour endometrium, genes were significantly upregulated in pathways related to androgen and estrogen metabolism, fructose and mannose metabolism, PPAR signaling, glycolysis, and gluconeogenesis.  Among these genes, Glucose Transporter 6 (GLUT6) was among the most highly overexpressed (37-fold) in endometrial cancer.  GLUT6 protein was overexpressed in endometrial tumors compared to non-cancerous adjacent tissue, and was upregulated in  human endometrial cancer cell lines, but not normal stromal or endometrial cells (2).  Decreasing GLUT6 by siRNA inhibited glycolysis, proliferation, and survival in endometrial cancer cells.

Obesity may be associated with decreased progesterone and SHBG, and increased estrogens, leading to increased bioavailable estrogen.  We thus evaluated GLUT6 expression in tumors of obese pre- and post-menopausal women, and found equivalent expression in cancerous glands of pre- and post-menopausal (33% vs 29% tumors), but greater expression in stroma of pre-(27%) vs post-menopausal (6% tumors) women.  We next examined regulation of GLUT 6 in type I endometrial cancer cells (MFE 296 and Ishikawa), which express ER and PR.  Treatment of cells with estradiol (E2, 1 nM) rapidly and transiently increased GLUT6 protein 3- to 5-fold between 1-3 h, which declined slowly after 4 h to control levels.  Treatment with estrone, which is secreted by ovarian and adipose tissue and is the most abundant estrogen in post-menopausal women, stimulated GLUT6 as well as E2.   In contrast, tamoxifen, raloxifene and androgens had minimal effects and the anti-estrogen ICI had no effect on GLUT 6 expression.  E2 treatment also increased proliferation in both cell lines, correlating with increased G1 to S phase transition in the cell cycle. Proliferation correlated with rapid and transient (1 h) stimulation of GLUT6 mRNA (14-to 30-fold); E2 treatment amplified GLUT6 mRNA expression and shortened the time between peaks of expression.  Thus, E2 stimulates expression of GLUT6 mRNA and protein, and is correlated with increased proliferatio.  The role of GLUT6 in E2-induced proliferation is under investigation.

 

Nothing to Disclose: JA, YC, WB, CP, JS, FB, KH, SCM, MAS

18543 11.0000 SAT-322 A Estrogens Rapidly Stimulate Expression of GLUT6, a Glucose Transporter Overexpressed in Obesity-Linked Endometrial Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Tianzhu Zang*, Daniel Tamae, Clementina Mesaros, Ian A. Blair and Trevor M Penning
University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

 

Prostate cancer (CaP) is the most commonly diagnosed cancer and the second leading cause of cancer death among North American men.  The development of CaP is androgen-dependent and advanced localized disease can be treated by surgical or chemical castration.  However, the recurrence of prostate cancer, also called castration resistant prostate cancer (CRPC), occurs despite castrate levels of circulating testosterone (T) and dihydrotesterone (DHT) and has the potential to become more metastatic.  CRPC remains hormonally driven and new drugs such as abiraterone acetate (a P450c 17 inhibitor) or enzalutamide (an AR antagonist) have been approved by FDA for the treatment of CRPC, but resistance to both drugs eventually occurs.  In order to better understand the response to hormonal therapy and mechanisms of drug resistance, a comprehensive investigation of how androgen levels change in serum and prostate cancer tumors is imperative.  So far, traditional immunoassays cannot give an accurate quantitation of circulating or tumor androgens because of the lack of specificity.  Our group has developed a stable isotope dilution liquid chromatography electrospray ionization tandem mass spectrometric (SID-LC-ESI-MS/MS) method to quantify human keto-androgens with the requisite specifcity and sensitivity for T, DHT, androsterone, Δ4-androstene-3,17-dione, 5α-androstanedione, DHEA and their sulfated and glucuronidated conjugates.  This method has been applied to the neoadjuvant TAPS and Abiraterone acetate/Leupron clinical trials which revealed that a large reservoir of DHEA-SO4 remains.  We have commenced cell culture studies using our SID-LC/ESI/SRM/MS to investigate whether the DHEA-SO4 that remains after drug treatment is sufficient to support androgen biosynthesis.  We have also expanded our method to quantify hydroxy-androgens, using picolinic acid derivatization so that the entire androgen metabolome can be displayed.  So far, nine derivatized hydroxy-androgens including T and DHT can be separated by RP-HPLC.  The LLOQ of six derivatized hydroxy-androgens with a mono-hydroxyl group is between 1.56 pg and 0.78 pg.  Dihydroxy-androgens e.g. 5-androstene-3β, 17β-diol, 5α-androstane-3α, 17β-diol and 5α-androstane-3β, 17β-diol cannot be accurately quantified as bis-picolinates using stable isotopically labeled monohydroxy-androgens.  We are using enzymatic methods to synthesize stable isotopically labeled dihydroxy-androgens for derivatization as internal standards.  The new method when combined with the keto-androgen quantitation would permit further interrogation of mechanisms of drug resistance to hormone ablative therapy.

 

Disclosure: TMP: Consultant, Tokai Pharmaceuticals, Owner, Penzymes, LLC. Nothing to Disclose: TZ, DT, CM, IAB

20101 12.0000 SAT-323 A Quantitation of Human Androgens By Stable Isotope Dilution LC-ESI-MS/MS Method and Its Application in Clinical Samples 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Adina F. Turcu*1, Robert Chomic2, David Anthony Madrigal2, William E. Rainey1 and Richard J. Auchus2
1The University of Michigan, Ann Arbor, MI, 2University of Michigan, Ann Arbor, MI

 

Background: 21-hydroxylase deficiency (21OHD) is an autosomal recessive disease, characterized by deficient cortisol synthesis and excessive adrenal androgen production. The diagnosis of 21OHD relies on measurement of 17α-hydroprogesterone (17OHP), a substrate of the defective enzyme. Serum 17OHP has also been used to monitor treatment of CAH, along with the traditional androgen precursors of adrenal origin: dehydroepiandrosterone (DHEA), its sulfate (DHEAS) and androstenedione (AD).  Currently, laboratory testing for both diagnosis and disease monitoring suffers from several pitfalls: false positive and false negative results of 17OHP, the need for dynamic confirmatory testing following cosyntropin stimulation when 17OHP values are indeterminate, and poor correlation of 17OHP with DHEA, AD or clinical evidence of androgen excess. Furthermore, AD and testosterone do not always reflect adrenal androgen production, as these steroids also derive from the gonads.

Objective: To compare 17OHP and AD with other steroid biomarkers for improved diagnosis and treatment monitoring of 21OHD.

Methods: Peripheral sera were obtained from 13 adults (9 women) with classic 21OHD and 8 controls (4 women). Sixteen unconjugated steroids were quantified by LC-MS/MS. The groups were compared by unpaired t-test with Welch's correction.

Results: Four 21-carbon steroids were significantly higher in 21OHD patients: 21-deoxycortisol (21dF, 157-fold, p=0.008); 16α-hydroxyprogesterone (16OHP, 35-fold, p=0.0073); 17OHP (28-fold, p=0.001) and 11β-hydroxyprogesterone (11OHP, 7-fold, p=0.0014). Of the 19-carbon steroids, four 11-oxygenated steroids were significantly higher in 21OHD patients: 11β-hydroxyandrostenedione (11OHA, 9-fold, p=0.0019); 11-ketotestosterone (11KT, 6-fold, p=0.005); 11β-hydroxytestosterone (11OHT, 4-fold, p=0.0001) and 11-ketoandrostenedione (11KA, 3.8-fold, p=0.0247).

Conclusions: Along with 17OHP, the 21-carbon steroids 21dF, 16OHP and 11OHP might comprise a useful biomarker panel for increased sensitivity and specificity of 21OHD diagnosis. The 19-carbon steroids 11OHA, 11OHT and their 11-keto metabolites might serve as biomarkers of adrenal-derived androgen excess, because their synthesis requires 11β-hydroxylase (CYP11B1), an enzyme expressed in the adrenal but not in the gonads.

 

Disclosure: WER: Scientific Board Member, Atterocor. RJA: Consultant, Corcept, Investigator, Novartis Pharmaceuticals, Investigator, Quest Diagnostics, Advisory Group Member, Laboratory Corporation of America, Investigator, Neurocrine Biosciences. Nothing to Disclose: AFT, RC, DAM

20545 13.0000 SAT-324 A Serum Steroid Profiles in Classic 21-Hydroxylase Deficiency Using Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Mark M Kushnir1, Alan L Rockwood2, Frederick G Strathmann3, Joely A. Straseski*4 and A Wayne Meikle5
1ARUP Laboratories, Salt Lake City, UT, 2University of Utah, Salt Lake City, UT, 3University of Utah, 4University of Utah & ARUP Laboratories, Salt Lake City, UT, 5Univ of UT Med Sch, Salt Lake City, UT

 

Parathyroid hormone related protein (PTHrP) has close homology with parathyroid hormone (PTH), and some of the physiological functions of PTHrP are similar to the functions of PTH. In health, circulating concentrations of PTHrP are very low and commercial assays are often unable to detect endogenous concentrations.  PTHrP is known to activate pathways that promote formation of bone metastasis from tumor cells and cause hypercalcemia of malignancy.  PTHrP can be present in elevated concentrations in blood of patients diagnosed with squamous cell lung cancer, squamous cell head and neck cancers, breast, uterus, and skin cancers.

We developed a liquid chromatography tandem mass spectrometry (LC-MS/MS) method for the measurement of PTHrP. Sample preparation was performed as follows: stable isotope labeled internal standard was added to samples and PTHrP was enriched using anti-PTHrP antibody conjugated to magnetic beads.  After incubation, the beads were washed, PTHrP was digested with trypsin and samples were analyzed by LC-MS/MS. The ratio of mass transitions was used to assess the specificity of analysis in every sample.

The lower limit of quantification and upper limit of linearity were 0.6 and 580 pmol/L, respectively. Total imprecision of triplicate measurements in serum samples over seven days was < 9.4%. Analytical sensitivity of the method was sufficient for measuring PTHrP in the blood of healthy individuals. No interferences were observed in over 2000 samples analyzed by the method. Poor agreement was observed with a commercial RIA (Immunotech), which is likely explained by low sensitivity and nonlinearity of the RIA. As an alternative to the regression analysis, we assessed agreement of the quantitative measurements using the LC-MS/MS with qualitative results of the RIA using logistic regression analysis (results by RIA were considered positive at concentrations above 4 pmol/L).  Area under ROC curve for the logistic regression analysis was 0.82.  Reference intervals of PTHrP in healthy adults (n=238) established with this method were 0.6-3.3 pmol/L in women, and 0.6-2.2 pmol/L in men; measurable concentrations of PTHrP were observed in all analyzed samples.  In order to assess performance of the assay we analyzed PTHrP in a set of plasma samples from patients with unexplained hypercalcemia (calcium >10.5 mg/dL, and PTH <15 pg/mL; n=88); 42% of these samples had concentration of PTHrP above the reference interval, suggesting that PTHrP was the cause of hypercalcemia.

This method is highly specific for PTHrP and has acceptable performance characteristics for use in clinical diagnostic applications. Sensitivity of the method is sufficient for quantitative measurements of PTHrP in samples of healthy and pathologic individuals.

 

Nothing to Disclose: MMK, ALR, FGS, JAS, AWM

20598 14.0000 SAT-325 A High Sensitivity Measurement of Parathyroid Hormone-Related Protein in Plasma Using LC-MS/MS 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Liqun Yu*, Neal D Andruska, Xiaobin Zheng and David J Shapiro
University of Illinois, Urbana, IL

 

Epidermal Growth Factor (EGF) activates a well-studied signaling cascade that stimulates tumor cell proliferation and rapidly alters gene expression. We describe an extremely rapid EGF-activated signaling pathway that strongly influences EGF-regulated gene expression and cell proliferation. EGF elicits rapid and moderate anticipatory activation of the endoplasmic reticulum (EnR) stress sensor, the unfolded protein response (UPR). In contrast to the classical reactive pathway of UPR activation in which the UPR is activated in response to EnR stress, or accumulation of unfolded protein, EGF elicits anticipatory activation of the UPR in the absence of EnR stress. This prepares cells for the increased protein folding load that accompanies EGF:EGFR-induced cell proliferation. EGF acts through EGFR to elicit phospholipase C γ (PLCγ)-mediated opening of the endoplasmic reticulum inositol triphosphate receptor (IP3R) calcium channel, leading to efflux of calcium from the lumen of the EnR into the cytosol. This results in moderate and transient activation of all three arms of the UPR. Since an EGFR inhibitor blocked UPR activation, EGF is activating the UPR pathway through EGFR.  EGF:EGFR activation of the IRE1α and ATF6α arms of the UPR leads to induction of the antiapoptotic chaperone BiP/GRP78/HSPA5. Inhibition or knockdown of PLCγ, or of IP3R, strongly inhibited EGF:EGFR-induced UPR activation and calcium release. Blocking EGF:EGFR-mediated UPR activation or chelating intracellular calcium inhibited EGF-induced gene expression and cell proliferation.

This work describes a new EGF signaling pathway that promotes cell proliferation through UPR activation and chaperone production. Together with other very recent studies, our work supports the view that protein and steroid mitogens pre-activate the UPR in a conserved pathway that readies cancer cells for subsequent cell proliferation.

 

Nothing to Disclose: LY, NDA, XZ, DJS

21373 15.0000 SAT-326 A Rapid Anticipatory Epidermal Growth Factor Activation of the Unfolded Protein Response Is Linked to EGF-Stimulated Cell Proliferation and Gene Expression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Wei Yue*, Jiping Wang and Richard J Santen
University of Virginia, Charlottesville, VA

 

Menopausal hormone therapy (MHT) with conjugated equine estrogens (CEE), when administered alone for 6 years, did not increase the risk of breast cancer in the Women’s Health Initiative Study. In contrast, estradiol (E2) alone appeared to enhance breast cancer risk, as reported in the Million Women, EPIC-E3N, Multi-ethnic, NIH-AARP, Schairer, and Reeves Studies (Scientific Statement Endocrine Society, Santen RJ et al JCEM 2010). These data suggested the possibility that CEE and E2 might act differently on breast cancer. To address this question, we compared the effects of CEE and E2 in the carcinogen, nitrosomethylurea (NMU), induced breast cancer model. Female Sprague-Dawley rats received NMU intraperitoneally at 50 mg/kg on day 50 of age. Twenty days later, the rats were divided into 5 groups with 10 animals per group. Four ovariectomized (ovx) groups were given either vehicle; E2 to achieve mid-luteal levels with silastic implants; CEE by gavage at 3 mg/kg and 10 mg/kg. To serve as untreated controls, rats in the 5th group retained their ovaries. We observed that mammary tumors developed in 100% of control rats.  As evidence of hormone dependence, ovx reduced this incidence to 40%. We then compared the effects of E2 and CEE in the ovx rats. Tumor incidence was 90% in E2 treated rats, but in striking contrast, only 30-40% in rats receiving 3 mg/kg or 10 mg/kg of CEE. Notably, the 30-40% incidence of tumors in the CEE treated ovx rats did not differ from the 40% in ovx rats with vehicle. Demonstration that the amounts of CEE and E2 were biologically equivalent in these rats was critical to interpretation of our data. Accordingly, we compared the effects of these two estrogens on uterine weight. Both CEE and E2 stimulated uterine weight to a similar degree indicating estrogenic equivalence. As we had previously demonstrated that E2 and CEE caused similar effects on benign breast tissue in immature mice, we then examined the effects of CEE and E2 on rat mammary gland whole mounts.   In contrast to the divergent effects on breast cancer, we found that both E2 and CEE stimulated growth of mammary gland end-buds in a similar fashion. As ancillary support for these findings, these rat data are nearly identical to our prior observations regarding E2 and CEE on human MCF-7 tumor xenografts and benign mammary tissue in nude mice (Endocrinology 153: 5706–5715, 2012).  To summarize, we have now shown in two models that CEE does not stimulate breast tumor growth while E2 does. We speculate that one or more of the 207 components of CEE might have SERM-like properties on breast cancer but not benign mammary tissue.  Our findings could partially explain the WHI results demonstrating that CEE alone is not associated with an increased risk of breast cancer. These results, while unexpected and not explained mechanistically, could have major clinical implications regarding use of E2 as MHT and breast cancer risk in women.

 

Disclosure: WY: Coinvestigator, Pfizer, Inc.. RJS: Principal Investigator, Pfizer, Inc.. Nothing to Disclose: JW

19909 16.0000 SAT-327 A Differential Effects of Conjugated Equine Estrogens and Estradiol on Breast Cancer: Implications for Menopausal Hormone Therapy in Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Elena Barengolts*1, Yuval Eisenberg1, Irina Ciubotaru2 and Arfana Akbar3
1University of Illinois at Chicago, Chicago, IL, 2UIC Section of Endocrinology, Chicago, IL, 3Jesse Brown VAMC, Chicago, IL

 

Cytokines, adipokines and vitamin D are the putative regulators of insulin secretion and function and play an important role in the pathogenesis and complications of type 2 diabetes (T2D). Dynamic changes of these biomarkers in response to glucose challenge have not been extensively evaluated in human subjects. We hypothesized that response of circulating cytokines, adipokines and other biomarkers to glucose load would vary and that circulating 25(OH)D might interact with this response. Methods: African American male (AAM) veterans with prediabetes (HbA1C 5.7-6.4%) and hypovitaminosis D [25(OH)D 5-29 ng/ml] enrolled in a randomized controlled trial of vitamin D Intervention at VA (DIVA, NCT01375660) completed 75g 3-hour OGTT at baseline of enrollment. Multiplex (Millipore, USA) immunoassays were used to measure samples from 0 and 60 min post-glucose load. Statistical analysis was done using paired T-test and Pearson correlation. Results: Data for 19 men were analyzed. Circulating levels (Mean [SD]) in pg/ml (unless specified) increased from 0 to 60 min for GIP 12.5 [5.2] vs 59.8 [13.2] (p<0.01) and pancreatic polypeptide (PP) 82.2 [48.8] vs 131.2 [42], p=0.012. Similarly increased were peptide YY (PYY) 49.6 [25.7] vs 82 [43.9], p=0.023; vascular endothelial growth factor (VEGF) 275.2 [177.9] vs 333.6 [223.2], p=0.05; and adiponectin (ng/ml) 21.9 [9] vs 30.2 [13.8], p=0.026. Conversely, there was a decrease from 0 to 60 min in interferon-γ-inducible protein-10 (IP-10) 658.2 [466.7] vs 560.1 [384.2], p=0.008 and complement-C3 (C3) 465 [224] vs 350 [198], p=0.037. There were no differences in other 28 measured biomarkers. Serum 25(OH)D correlated positively with GIP (r=0.51) and adipsin (r=0.54) but negatively with IL-13 (r=-0.89, p<0.05 for all) when biomarker levels were measured at 60 min post-glucose-load, while at fasting only IL-13 correlated with 25(OH)D (r=-0.75, p<0.01). These pilot data suggested that variable biomarkers responded differently to hyperglycemia, corresponding to their variable roles in pathogenesis of diabetes as suggested by published studies. IP-10 appeared to be specifically involved in beta cell apoptosis. C3 was strongly associated with insulin resistance mediated by hepatic fat accumulation. IP-10 and C3 decline during OGTT might be facilitated by reduced free fatty acid levels in response to a rise in insulin. GIP, an incretin insulin secretagogue, acted via specific GIP receptor on b-cell and activated cAMP. Adipsin, an adipokine insulin secretagogue acted via protein C3a that increased ATP in b-cells. Vitamin D decreased infection-induced inflammatory cytokine IL-13 in cell culture. Also, vitamin D inhibited VEGF-induced angiogenesis in retinas of diabetic rats. We speculated that interactions between vitamin D and cytokines and adipokines might influence the latter response to hyperglycemia and thus affect the pathogenesis of diabetes.

 

Nothing to Disclose: EB, YE, IC, AA

19515 17.0000 SAT-328 A Circulating IP-10 and C3 Declined, and Pancreatic Polypeptide, Peptide YY, VEGF and Adiponectin Increased in Response to Oral Glucose Tolerance Test While 25(OH)D Strongly Correlated with Post-Glucose-Load Adipsin and IL-13 in African American Men with Prediabetes and Hypovitaminosis D 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Matthew Thomas Cook1, Benford Mafuvadze1, Cynthia Besch-Williford2, Mark Ellersieck3, Sandy Goyette1 and Salman M Hyder*1
1University of Missouri, Columbia, MO, 2IDEXX BioResearch, 3University of MIssouri

 

Post-menopausal women undergoing hormone replacement therapy (HRT) containing both progestins (P) and estrogens (E) are at an increased risk of developing breast cancer compared with those taking E alone. We have shown that the commonly used P, medroxyprogesterone acetate (MPA) increases production of the potent angiogenic growth factor VEGF in breast cancer cells (Int J Cancer, 2001, 92:469). This led to our hypothesis that P increases the angiogenic potential of latent tumorigenic cells in the breast, leading to development of tumors. We demonstrated that MPA exerts similar effects in a DMBA-induced mammary tumor model in rats (Clin Can Res, 2006, 12:4062). Since synthetic anti-progestins are frequently associated with undesirable side-effects which limit their clinical use, we undertook studies to identify less toxic naturally-occurring compounds that might prevent P-dependent VEGF induction and tumor development. We identified luteolin (LU), a low molecular weight flavonoid commonly found in fruits and vegetables, as an in vitro inhibitor of MPA-induced VEGF secretion from human breast cancer cells. Using the DMBA-induced rat mammary tumor model, we conducted a study to determine whether LU prevented the development of P-accelerated tumors in vivo. Female Sprague-Dawley rats (n=10) were treated with DMBA by oral gavage (Day 0) and preneoplastic lesions were given time to form. Afterwards, daily treatments of LU were given between Days 21 and 31 (1-25 mg/kg/day ip), followed by every second day for two weeks (to Day 46).  In order to determine whether LU suppresses early tumorigenic events, the flavonoid was given prior to implantation of the MPA pellet (25 mg/60 day release), which occurred on Day 28.  Animals were palpated from day 30 to 60, at which point the experiment was terminated. Tumors and contralateral mammary glands were collected. Treatment with LU at both 1 and 25 mg/kg suppressed MPA-driven tumor incidence [67% vs 20%; p<0.05, SAS (Proc GenMOD)], and delayed the appearance of the first tumor compared with MPA alone (p<0.05, SAS Proc LIFETEST).  In contrast, 10 mg/kg LU failed to reduce tumor incidence but reduced the number of large tumors [>300 mm3; p<0.1, SAS (Proc GenMOD)].  Importantly, tumor incidence did not increase in the absence of MPA in response to treatment with 10 mg/kg LU.  Immunohistochemcial analysis (IHC) of mammary tumor tissue revealed that all concentrations of LU tested reduced VEGF levels. With the exception of animals given 25 mg/kg, LU did not suppress levels of progesterone receptors.  IHC of contralateral mammary glands showed that LU did not block or reverse DMBA-induced mammary tissue hyperplasia, suggesting that the effects of the flavonoid are exerted beyond formation of DMBA-induced hyperplasia. We conclude that LU appears to be a compound with useful anti-tumor properties which might be used clinically to prevent the development of P-accelerated tumors.

 

Nothing to Disclose: MTC, BM, CB, ME, SG, SMH

19466 18.0000 SAT-329 A Luteolin Prevents Development of Progestin-Accelerated 7,12- Dimethylbenz(a)Anthracene (DMBA)-Induced Mammary Tumors in Sprague-Dawley Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Shuang Liu*1, Anna Tsimelzon2, Yuanxin Xi2, Wei Li2 and Carolyn L Smith1
1Baylor College of Medicine, Houston, TX, 2Baylor College of Medicine

 

Estrogen receptors (ER) belong to a superfamily of ligand-regulated transcription factors. Antiestrogens, typically used at high concentrations, block estradiol (E2) from binding to ERα and thereby effectively inhibit estrogen-stimulated gene expression. However, it is not clear if all E2-induced ER target genes are equally sensitive to the inhibitory effects of antiestrogens, and we therefore assessed the ability of an equal concentration of an ER agonist (conjugated estrogens, CE) and antagonist (bazedoxifene, BAZ) to impact gene expression in MCF-7 breast cancer cells. Microarray analyses revealed three categories of E2-regulated genes: 1) BAZ antagonized, 2) BAZ non-antagonized and 3) BAZ enhanced. This latter gene expression profile is most readily apparent with equal concentrations of CE and BAZ, since higher concentrations of BAZ blocked BAZ non-antagonized as well as BAZ enhanced genes, likely through competitive inhibition of CE binding to ER. Genes cooperatively induced by combined CE/BAZ treatment include IGFBP4, KCNK6 and SDK2, the latter of which was selected for further analysis. Cooperative induction of SDK2 mRNA expression was not specific to CE/BAZ treatment as combinations of the agonists E2 or CE with the selective estrogen receptor modulators (SERMs) tamoxifen, raloxifene or bazedoxifene yielded similar results. However, neither E2 nor CE in combination with the pure antiestrogen, fulvestrant recapitulated this response. Knock-down of ERα by siRNA prevented the CE/BAZ cooperative effect indicating its ERα-dependence. A time course experiment revealed that cooperative induction of SDK2 mRNA levels required at least 24 hr of CE/BAZ treatment; prior to that time point the relative levels of SDK2 mRNA were CE ≈ CE/BAZ > BAZ. Nonetheless, RT-qPCR analyses of primary gene transcripts demonstrated that CE/BAZ cooperative induction of SDK2 mRNA is a direct transcriptional effect. ChIP-seq analyses of MCF-7 cells treated with vehicle, CE, BAZ or CE/BAZ indicated that the majority of ERα DNA binding sites in BAZ and CE/BAZ treated cells overlapped with the CE treatment group; only ~1% of BAZ- or CE/BAZ-induced ERα binding sites are unique. More specifically, the profile of ERα binding to the SDK2 gene was similar for the 3 treatment groups, demonstrating that the cooperative induction of SDK2 by CE/BAZ represents a gene regulatory step subsequent to ERα binding to DNA, most likely through the role of a novel coregulator induced by BAZ treatment that ultimately supports the greater expression of SDK2 mRNA in CE/BAZ treated cells. Overall, these finds indicate that differential sensitivity of ERα target genes to the antagonist effects of SERMs is mediated via transcriptional events subsequent to ERα binding to DNA, and further our understanding of the mechanisms by which the selective effects of a combined ER agonist and antagonist therapy used in the clinic may be achieved.

 

Nothing to Disclose: SL, AT, YX, WL, CLS

21321 19.0000 SAT-330 A Cooperative Activation of Gene Expression By Conjugated Estrogens and Bazedoxifene in Human Breast Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Tomomi Yoda*1, Keely M McNamara2, Yasuhiro Miki3, Kiyoshi Takagi4, Takashi Suzuki4 and Hironobu Sasano5
1Tohoku Univ Sch of Med, Sendai, Japan, 2Tohoku University, Sendai, Japan, 3International Research Institute of Disaster Science, Tohoku University, Sendai, Japan, 4Tohoku University Graduate School of Medicine, Sendai, Japan, 5Tohoku Univ Sch of Med, Miyagi, Japan

 

Aldo-keto reductase family 1 member C3 (AKR1C3), also known as 17β-hydroxysteroid dehydrogenase type 5 (17βHSD5) or Prostaglandin F synthase, is a multi-functional enzyme responsible for the metabolism of androgens, estrogens, progesterone as well as prostaglandin. As a prostaglandin F synthase, AKR1C3 contributes to the production of 11β-Prostaglandin F2α (11β-PGF2α), a bioactive prostanoid which influences intracellular signaling via an activation of its cognate G-protein coupled receptor (GPCR), Prostaglandin F receptor (FP receptor). In breast carcinoma cells, AKR1C3 is reported to be highly expressed compared with normal ductal cells and correlates with adverse clinical outcome of the patients. We previously reported that endogenous expression of AKR1C3 in breast carcinoma cell lines contributed to 11β-PGF2α production, and FP receptor expression trended to be associated with poor prognosis in AKR1C3-positive breast cancer cases (ENDO 2014, Chicago). However, biological role of 11β-PGF2α through the FP receptor remains unclear in breast cancer. Therefore we evaluated the biological function of this prostaglandin using FP receptor stably expressed MCF-7 (MCF-FP) cells with an empty vector-transfected MCF-7 (MCF-empty) cells as a negative control.

We first identified the signaling pathway activated by 11β-PGF2α using phospho-kinase array. In this assay we detected the phosphorylation of ERK and CREB, and also confirmed FP receptor-mediated activation of these signaling by 11β-PGF2α treatment with immunoblotting. Then we evaluated an alteration of epithelial-to-mesenchymal transition (EMT) markers following a long exposure (96 hours) to 11β-PGF2α because induction of EMT by GPCR-dependent ERK phosphorylation has been reported in some carcinoma cells. Interestingly, in a panel of EMT related genes Slug expression was markedly increased at both mRNA and protein levels in MCF-FP cells. In line with a role for FP receptor signaling inducing Slug expression MCF-FP cells exhibited higher levels of Slug expression compared with parental MCF-7 or MCF-empty cells under normal cultural condition. Furthermore, 11β-PGF2α-dependent Slug induction was partially suppressed by upstream suppression of ERK signaling. In addition to its role as an EMT marker Slug has also been shown to contribute to drug resistance in various cancers. Therefore we examined sensitivity against anti-cancer agent Epirubicin in MCF-7, MCF-empty and MCF-FP cells. In MCF-FP cells, Epirubicin sensitivity was significantly lower than that in MCF-7 or MCF-empty cells.

These results suggested that activation of FP receptor-ERK-slug pathway induced by 11β-PGF2α treatment could contribute to the acquisition of malignant phenotype in breast carcinoma cells. The present study might contribute to the understanding of clinical and biological significance of AKR1C3 in breast cancer.

 

Nothing to Disclose: TY, KMM, YM, KT, TS, HS

19664 20.0000 SAT-331 A 11beta-Prostaglandin F2alpha, a Bioactive Prostanoid Synthesized By AKR1C3, Stimulates FP Receptor and up-Regulates Slug (SNAI2) Expression in Breast Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Xiaoting Ma*1, Anindita Biswas1 and Stephen R Hammes2
1University of Rochester Medical Center, Rochester, NY, 2University of Rochester, Rochester, NY

 

Paxillin regulates cell proliferation and apoptosis in prostate cancer

Abstract: Paxillin is well known as a cytoplasmic scaffold protein that, among its many functions, mediates cytoplasmic Erk1/2 signaling. However, recent studies have shown that paxillin also plays a critical role in nuclear Erk1/2 signaling, as well as in the regulation of both genomic and nongenomic steroid signaling. In prostate cancer cells, paxillin serves as a critical liaison between cytoplasmic and nuclear signaling, mediating not only androgen or growth factor induced extranuclear Erk1/2 signaling, but also Erk1/2 or Androgen Receptor(AR)-induced intranuclear gene transcription. After serving as scaffold to regulate androgen or growth factor-induced Erk1/2 signaling, activated Erk1/2 then mediates phosphorylation of serine residues on paxillin, leading to nuclear translocation of phosphoserine-paxillin. Once in the nucleus, phosphoserine-paxillin mediates several AR and Erk1/2-dependent genes expression, including PSA and cyclinD1. In fact, paxillin expression is upregulated in prostate cancer tumor microarrays, suggesting that it may be an important mediator of prostate cancer progression. Here, we use an RNA-Seq strategy to take a global look at paxillin regulated gene expression in prostate cancer cell lines. Decreased proliferation rates are observed in multiple cell lines in which paxillin expression is reduced by siRNA. RNA-seq data from paxillin knockdown PC3 cells reveals that paxillin significantly upregulates pro-proliferation pathways and downregulates pro-apoptotic pathways. For example, expression of cell proliferative genes such as E2F transcription factor 1(E2F1) and cyclin D1(CCND1), are significantly induced by paxillin, whereas pro-apoptotic genes such as caspase1(CASP1) and tumor necrosis factor (ligand) superfamily, member 10 (TNFSF10), are reduced by paxillin. In addition, DNA repair genes such as thyrmidylate synthase(TYMS) are upregulated by paxillin. Finally, paxillin mediates expression of Erk1/2-responsive metabolic genes such as pyruvate dehydrogenase kinase, isozyme 4(PDK4), which may also contribute to cell survival and proliferation. Similar results are observed in LNCaP cells, where several androgen regulated genes also demonstrate paxillin dependent pattern. Thus we propose that paxillin is a master regulator of proliferative and anti-apoptotic gene expression in prostate cancer, perhaps in both castration sensitive and resistant states, suggesting that paxillin might serve as a potentially common therapeutic target for prostate cancer.

 

Nothing to Disclose: XM, AB, SRH

20079 21.0000 SAT-332 A Paxillin Regulates Cell Proliferation and Apoptosis in Prostate Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Christian Selmer*1, Jesper Clausager Madsen2, Christian Torp-Pedersen3, Gunnar Hilmar Gislason4 and Jens Faber5
1Amager University Hospital, Copenhagen, Denmark, 2Copenhagen General Practitioners Laboratory, Copenhagen, Denmark, 3Aalborg University, Aalborg, 4Gentofte University Hospital, Hellerup, Denmark, 5Herlev University Hospital, Herlev, Denmark

 

Context: Hyponatremia has been associated with increased all-cause mortality in individuals admitted to hospital, but limited data is available on the importance of hyponatremia in the primary care setting.

Objective: To examine the risk of all-cause mortality in subjects with hyponatremia in the primary care setting.

Design: Retrospective cohort study.

Setting and participants: Subjects consulting their general practitioner 2000–2011 in Copenhagen, Denmark who underwent blood tests including serum sodium measurements. The normal reference range for serum sodium was 135–145 mmol/L, and mild, moderate and severe hyponatremia was defined as 130–135, 125–129 and < 125 mmol/L, respectively.

Main Outcome Measure: All-cause mortality events identified in nationwide registries.

Results: 105,748 (15.5%) deaths occurred among 682,125 included subjects (mean age 51.4 [SD ±18.7] years; 43.1% males). All-cause mortality was increased in all levels of hyponatremia including mild, moderate and severe hyponatremia (age-adjusted mortality rates [IRs] 27, 33, and 15 per 1000 person-years (py); incidence rate ratios [IRRs] 1.81 [95% CI: 1.77–1.86], 2.15 [2.05–2.25]), and 2.73 [2.48–3.02], respectively, compared to individuals with normal serum sodium (IR 14 per 1000 py). Main models were adjusted for age, sex and calendar-year. Further adjustment for comorbidity and prescription medication did not change the overall findings.

Conclusions: All levels of hyponatremia seem to be an independent risk factor for all-cause mortality in primary care patients. Even mild hyponatremia detected in primary care could be caused by serious underlying conditions associated with increased risk of all-cause mortality.

 

Nothing to Disclose: CS, JCM, CT, GHG, JF

22085 22.0000 SAT-333 A Hyponatremia and Risk of All-Cause Mortality in the Primary Care Setting: A Large Population Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Caroline Chong and Vuong N Trieu*
Autotelic Inc, Fountain Valley, CA

 

Background: Brain natriuretic peptide (BNP) is a substance secreted from the ventricles of the heart in response to changes in pressure that occur when heart failure develops and worsens.  The BNP level in a person with heart failure – even someone whose condition is stable – is higher than in a person with normal heart function.  Methods: BNP levels were determined for 55 donors and 79 ovarian cancer patients.  Serum samples collected at time of diagnosis of ovarian cancer were tested using rapid and quantitative point-of-care (POC) devices for blood biomarkers (CA125, FSH, and BNP) and the data was evaluated using JMP9 statistical analysis software.  Results: The donors and ovarian cancer patients were matched for age (donor 50 years; patient 51 years), height (donor 166cm; patient 165cm), weight (donor 70kg; patient 72kg) and BMI (donor 25; patient 27).  The donor average BNP was 126.36 ng/mL, whereas the average BNP level for the patients was 55.34 ng/mL.  As the ovarian cancer population was imbalanced for hypertension, a subgroup analysis was performed.  Of the 55 donors one had hypertension and in the patient group 30 had hypertension and 49 were normotensive.  The hypertensive and normotensive patients were compared and the mean BNP level for the hypertensive patients was 68.9423 ng/mL and the mean BNP level for the normotensive patients was 64.0855 ng/mL.  The mean BNP level for the normotensive patients was 68.881 ng/mL and the mean BNP level for the normotensive donors was 171.066 ng/mL. Conclusions: BNP level is depressed in ovarian cancer patients and there appears to be little to no differences between hypertensive patients versus normotensive patients with respect to BNP levels of those with ovarian cancer.  BNP level remained depressed when normotensive patients were compared to normotensive donors.  This is the first demonstration of a linkage between ovarian cancer and the cardiovascular system.

 

Nothing to Disclose: CC, VNT

21046 23.0000 SAT-334 A Brain Natriuretic Peptide and Ovarian Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Takao Susa*, Masayoshi Iizuka, Mimi Adachi-Tamamori and Tomoki Okazaki
Teikyo Univ Schl of Med, Tokyo, Japan

 

Androgen is a key regulator of prostate carcinogenesis. Most prostate cancers (PC) depend on androgen and androgen receptor (AR) signaling for their development and proliferation, which underlies the efficacy of antiandrogens as powerful therapeutic agents for PC. On the other hand, many reports suggest that 1,25(OH)2vitamin D3 (D3) is also crucially involved in the pathogenesis of prostate cancer (Wang et al., Front. Physiol. 2014), anticipating the crosstalk of D3 and androgen via their cognate nuclear receptors (NRs). Here, we investigated the intracellular behavior of D3 in dihydrotestosterone (DHT)-AR signaling in prostate cancer LNCaP cells.

At first, we demonstrated that LNCaP cells expressed appreciable amounts of vitamin D3 receptor (VDR) along with abundant AR by real-time PCR and western blotting, reconfirming that LNCaP cells possessed both of functional DHT-AR and D3-VDR signaling systems. The AR in LNCaP cells has a point mutation (Thr-Ala877) in its ligand-binding domain, resulting in the partial loss of the AR’s ligand specificity and cross-reaction with several steroidal ligands, although no reports have ever demonstrated its reactivity with D3. Immunocytochemistry and western blotting using fractionated protein revealed ligand- independent nuclear localization of the mutated AR (Thr-Ala877) and its enhanced nuclear accumulation after DHT treatment. Interestingly, D3 also potentiated nuclear accumulation of AR (Thr-Ala877) while its magnitude was several-fold lower than that seen in DHT-treated cells. Then, we performed knockdown of either AR or VDR with the respective siRNA before treating LNCaP cells with either DHT or D3 for 24h. By using whole genome microarray from LNCaP cell RNA, we observed D3 and DHT regulated comparable numbers of their target genes, respectively. Of interest, nearly half of the genes whose transcripts were up- or down-regulated by D3 were found to lose D3 response after introduction of siRNA for AR, but not for VDR. These results imply the presence of skewed cross-talk signaling referred to as D3-AR system in LNCaP cells.

We postulate an entangled intracellular interaction between D3 and the AR in LNCaP cells. Deeper characterization of the D3 role in DHT-AR signaling may offer insights into the novel therapeutic approach to prostate cancer management.

 

Nothing to Disclose: TS, MI, MA, TO

21522 24.0000 SAT-335 A Involvement of Vitamin D3 in Intracellular Signaling Between Dihydrotestosterone and Androgen Receptor in Prostate Cancer LNCaP Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Yasuhiro Miki*1, Misaki Fue1, Mizuki Hasegawa1, Kiyoshi Takagi2, Takashi Suzuki2, Hironobu Sasano3 and Kiyoshi Ito1
1International Research Institute of Disaster Science, Tohoku University, Sendai, Japan, 2Tohoku University Graduate School of Medicine, Sendai, Japan, 3Took University School of Medicine, Sendai, Japan

 

Cancer patients are under a lot of stress; they are faced with the fear of death, stress of high medical costs, and the stress associated with being informed that their life is going to be drastically changing. In breast cancer patients, it is reported that metastatic patients had significantly higher baseline levels of cortisol, the stress hormone, than early stage patients, and both groups of breast cancer patients showed higher cortisol levels than healthy women. Cortisol is a hormone that regulates blood pressure and the immune responses to physical or emotional stress. Several investigators have suggested that glucocorticoids such as cortisol may also play a role in reproductive physiology. However, the direct effects of cortisol on the activity of cancer cells remain largely unclear. Previously, we have reported that the production of cortisol and cortisone may be regulated in endometrial cancer tissues via an intracrine pathway (ENDO2014, Chicago). In this study, we examined the expression of cortisol receptors [glucocorticoid receptor (GR)] and their downstream targets in endometrial cancer. Informed consent was obtained from all the patients. The research protocol for this study was approved by the Ethics Committee at the Tohoku University School of Medicine. In the immunohistochemical analysis of GR expression, GR immunoreactivity was detected in both endometrial carcinoma cells and its surrounding stromal cells such as fibroblast-like cells and inflammatory cells (87 cases of endometrial tissues). However, the expression level of GR in endometrial carcinoma cells was lower than that in stromal cells. In this study, we focused on the expression of S100 calcium-binding protein P (S100P), whose expression is known to be induced by cortisol. S100P immunoreactivity in endometrial carcinoma cells was significantly correlated with GR immunoreactivity in stromal cells but not with that in carcinoma cells. This finding suggests that GR-dependent soluble factors, such as interleukin-6, derived from intratumoral stromal cells, may elevate the expression of S100P in endometrial carcinoma cells. We then examined the proliferative effects of cortisol on endometrial carcinoma tissues (40 cases). In this study, intratumoral cortisol level was significantly higher in the group that showed immunoreactivity to the proliferation marker Ki-67 than in the group that was not immunoreactive. It is well known that S100P stimulates cell proliferation via the receptor for activated glycation end products (RAGE). We have previously confirmed the expression of RAGE immunoreactivity in endometrial carcinoma cells. Therefore, the results of this study suggest that intratumoral cortisol may induce cell proliferation through the stromal GR signal in endometrial cancer. In addition, the S100P-RAGE pathway may play a central role in these proliferative signals.

 

Nothing to Disclose: YM, MF, MH, KT, TS, HS, KI

20978 25.0000 SAT-336 A Cortisol and S100P in Human Endometrial Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Hirotoshi Kawata* and Akira Tanaka
Jichi Medical University, Shimotsuke Tochigi, Japan

 

Prostate and breast cancers have prominent potential to promote cell survival under hormone ablation. In our earlier studies, RhoC-mediated EMT plays a key role in the cell survival after hormone ablation [1, 2]. Still, other pathways are likely to be involved in the cell survival of these cancers. Cellular senescence is known as a phenomenon to induce permanent cell-cycle-arrest under various biological stresses. Recent advance on this field has shown that senescence-associated secretory phenotypes (SASPs) are tightly linked with cellular senescence. Here we presented that cellular senescence and SASPs are induced under hormone ablation in human prostate cancer specimens, hormone-responsive cancer cells as well as epithelial cells of murine prostate and breast tissues.

[Materials and Methods] Ten-week-old male and female ICR mice were either castrated or sham-treated. After one week, prostate and breast tissues were resected. Cellular senescence was evaluated with SA-β-Gal staining using senescence detection kit (BioVision, Mountainview, CA). SA-β-Gal staining was also performed in androgen-sensitive mouse mammary carcinoma SC-3, androgen-sensitive human prostate cancer LNCaP and estrogen-sensitive human breast cancer MCF-7 cells. Human prostate cancer specimens, 30 cases resected after endocrine therapy and control 30 cases resected without any treatment, were retrieved from Jichi Medical University Hospital Records. Expressions of p16INK4a, p21Cip1 and p53 were immunohistochemically analyzed, as cellular senescence markers, in mice castrated and sham-operated specimens as well as in human prostate cancer specimens. IL6, IL8, MMP2, and MMP9 were also analyzed, as SASP markers, in these specimens.

[Results] Ratios of positive cells in SA-β-Gal staining were significantly more increased in castrated mice than sham-operated ones (p<0.002). Cancer cells cultured for 5 days in the absence of hormone showed significantly higher ratios of positive cells than hormone-treated cells in SA-β-Gal staining (p<0.05). Although levels of p16INK4a, p21Cip1 and p53 were immunohistochemically unchanged, SASP markers of IL6 and MMP2 were significantly more immunostained in prostate and breast tissues of castrated mice than those of the sham-operated ones. In addition, IL6 expression was significantly more enhanced in human prostate cancer specimens with endocrine therapy than the untreated tumors (p<0.05).

[Conclusions] Cellular senescence is induced after hormone ablation in human prostate cancer, hormone-responsive cancer cells, and murine models. The cellular senescence induced by hormone ablation appears to be premature, based on the findings of p16INK4a, p21Cip1 and p53 immunostainings. Still, the secretory phenotypes were associated in this process.

 

Nothing to Disclose: HK, AT

21485 26.0000 SAT-337 A Induction of Premature Cellular Senescence and Senescence-Associated Secretory Phenotypes after Hormone Ablation in Human Prostate Cancer, Hormone-Responsive Cancer Cells, and Murine Prostate and Breast Tissues 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Maria Cuevas*1, Morgan Gallo2, Kelsey Rice2, Taylor Vickers2, Jonathan King3, Rebecca Sheller2 and Maria Todd2
1Southwestern University, Georgetown, TX, 2Southwestern University, Georgetown, 3Trinity University, San Antonio, TX

 

According to the American Cancer Society, endometrial cancer is the most common female reproductive cancer in the United States with an incidence of 1 in 37 women. Alterations of tight junction (TJs) proteins have been reported in a number of endometrial and other human cancers. Occludin is one of several TJ proteins that contributes both to the correct assembly and function of TJs. While disruption of TJs has been associated with tumorigenesis, very few studies have investigated the role of occludin in the development and progression of endometrial cancer. In this study we evaluated the possible effects of estradiol (E2) and 4-hydroxytamoxifen (4-OHT) treatments on occludin expression and the invasive capabilities of HEC-1A and HEC-1B adenocarcinoma cell lines. Our results show that HEC-1A cells overexpressed two low molecular weight (46, 58 kDa) and the expected 65 kDa isoforms of occludin, whereas HEC-1B expressed only the 46 kDa isoform. After treatment with 0-100 nM E2, we observed a biphasic effect on occludin expression in both cell lines with the lowest levels of occludin expression at 50 nM E2 for all isoforms. In contrast, when cells were treated with 4-OHT, we observed only the 46 kDa isoform in both HEC-1A and HEC-1B cancer cell lines. In addition, treatment with 4-OHT resulted in a dose-dependent inhibition on the expression of the 46 kDa occludin isoform. We also investigated the effect of E2 treatment on the invasive capability of both cell lines.   We observed a decrease in the invasive capability of HEC-1A and HEC-1B with increased E2 concentration. Both cell lines appeared to exhibit the highest invasive potential when treated with 10 nM E2 concentration. Furthermore, the inhibitory effect seems to be more pronounced in the HEC-1B cell line. These data suggests that changes in occludin expression may be involved in the invasive potential of both HEC-1A and HECC-1B endometrial cancer cell lines.

 

Nothing to Disclose: MC, MG, KR, TV, JK, RS, MT

18301 27.0000 SAT-338 A Hormonal Effect on Occludin Expression in the Endometrial Adenocarcinoma HEC-1A and HEC-1B Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Catarina Segreti Porto*, Maria Fatima Magalhaes Lazari and Thais FG Lucas
Escola Paulista de Medicina-UNIFESP, Sao Paulo, Brazil

 

Aim: Testicular germ cell tumors (TGCC), seminoma and non-seminoma (including embryonal cell carcinoma) have been identified to arise from a precursor lesion carcinoma in situ (CIS), identified as a dysfunctional gonocyte. However, the precise mechanisms that trigger CIS development are currently unknown (McIver SC et al., F1000Res. 2013, 2:55). Recently, it has been reported that polymorphisms of genes encoding the classic estrogen receptors, ESR1 and ESR2, and the luteinizing-hormone-releasing hormone (LHRH) were linked to a higher risk of TGCC and metastasis occurrence (Brokken LJ et al., Mol Cell Endocrinol 2012, 351:279). Genomic and rapid actions of estrogens on spermatogenesis appear to influence, in a cell-specific manner, proliferation, differentiation, as well as survival and apoptosis. Moreover, several evidences suggest that estrogen signaling is involved in testicular tumorigenesis (Lucas TFG et al., Spermatogenesis 2011, 1:4, 318; Chimento A et al., Front Endocrinol 2014, 5:30). Thus, the aim of this study was to identify the expression, the cellular localization and the function of the classic estrogen receptors, ESR1 and ESR2, and the isoform ER-alpha36, in the testicular embryonal carcinoma cells NT2/D1. Methods and Results: The three estrogen receptors were detected by Western Blot assays. Immunofluorescence assays showed a nuclear localization of ESR1 and ESR2, and a preferentially extranuclear localization of ER-alpha36. The effects of the 17beta-estradiol (E2), ESR1-selective agonist PPT and ESR2-selective agonist DPN on the expression of proteins involved with cell cycle regulation were determined by Western Blot assays. Treatment with E2, PPT and DPN did not affect the expression of Cyclin D1. E2 and PPT, but not DPN, increased the expression of Cyclin D2. E2 and DPN, but not PPT, increased the expression of Cyclin E and cyclin dependent kinase inhibitor p27kip1. Discussion and Conclusion: In testicular tumor extracts and NT2/D1 cells, cyclinD2/cyclin-dependent kinase complex was previously shown to bind and sequester p27kip1 and allow the expression and activation of the Cyclin E and cellular proliferation (Kuboski R et al., Appl Immunohistochem Mol Morphol 2003, 11:138). These data together with the present results suggest that the activation of both receptors ESR1 and ESR2 play a role in the testicular embryonal carcinoma cell proliferation. Further experimental approaches, using shRNAs for both receptors and ER-alpha36 and proliferation assays, are necessary to address this issue. The better understanding of the molecular mechanisms involved in the development and maintenance of these tumors may reveal new therapeutic targets for the treatment.

 

Nothing to Disclose: CSP, MFML, TFL

19802 28.0000 SAT-339 A Estrogen Receptors Play a Role in Testicular Embryonal Carcinoma Cells NT2/D1 Proliferation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Dongoh Lee*1, Ji-Sun Lee1, Changhwan Ahn2, Kipung Kim1 and Eui-Bae Jeung1
1Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South), 2Chungbuk National University, Cheongju, Korea, Republic of (South)

 

Introduction : 2-Methoxyestradiol (2-ME) is an endogenous metabolite of 17β-estradiol (E2), and has affinity for estrogen receptors. It was reported as a promising antitumor drug due to antiproliferative activity on a wide range of tumor cell types with antiangionenic actions. It has also been used in a number of preclinical and clinical studies for treatment of solid tumors. Thus, several studies have been conducted to investigate the cytotoxic effect of 2-ME on tumor cell lines in which it induced G2/M cell cycle arrest and subsequent apoptosis. Uterine leiomyomas (fibroids) are the most frequently occurring tumor of the female reproductive tract. These benign uterine smooth muscle tumors rarely progress to malignancy, but they are associated with a number of reproductive problems, including infertility, lost pregnancy, and pelvic pain. This tumor is also influenced by estrogen, which acts as a promoter. The purpose of this study was to examine the anti-proliferative effect of 2-ME in vitro and in vivo, in a mouse xenograft model using human leiomyosarcoma SK-LMS-1 cell line. Method : To performed in vitro experiment, we evaluated anti-proliferative effect of 2-ME on SK-LMS-1 cells using MTT assay and western blot. In vivo experiment also investigated effect of 2-ME on uterine leiomyoma by measured tumor size and western blot. Result : In vitro condition, we confirm that 2-ME at high concentration (10-5M) and flavopiridol have anti-proliferative influence on SK-LMS-1 cell line, but 10-7M, 10-6M dose of 2-ME were not detected, rather these two doses showed little proliferative response through the MTT assay. Also, BAX/Bcl-2 and LC3 expression was increased by the 2-ME (10-5M)-treatment in western blot analysis. Conclusion: In a previous study, we found that 2-ME has two faces in an in vitro and an in vivo model. The 2-ME, which is used as a therapeutic agent for solid cancers, has not only apoptotic but also has proliferative effect, depends on its doses. We expect that 2-ME may be a potential therapeutic reagent for human uterine leiomyoma, but the appropriate dose of 2-ME should be used for estrogen-response tumor treatment

 

Nothing to Disclose: DL, JSL, CA, KK, EBJ

19759 29.0000 SAT-340 A Effect of 2-Methoxyestradiol (2-ME) Induced Uterine Leiomyoma on Mouse Xenograft Model 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Irvin M Modlin*1, Mark Kidd1, Harry Aslanian2, Lisa Bodei3 and Ignat Drozdov3
1Wren Laboratories, Branford, CT, 2Yale University School of Medicine, New Haven, CT, 3Wren Laboratories, Brandord, CT

 

Background: The management of gastroenteropancreatic (GEP) neuroendocrine tumors (NETs) are characterized by diagnostic delay and inability to define treatment efficacy. This reflects the lack of sensitive/specific blood biomarkers for tumor detection or measurements of treatment responses as well as the limitations of imaging. We report a 51 marker peripheral blood signature, the NETest, and describe its utility in comparison to the standard ELISA-based Chromogranin A (CgA) measurement during treatment and surgery.

Methods: The candidate signature was validated using qPCR in four separate, prospectively collected (blinded samples) datasets. Set 1 comprising 150 NETs (gastric: n=12, pancreatic: n=41, small intestinal: n=80, appendiceal: n=10, rectal: n=7); 50 controls were included. Set 2 comprised 53 samples collected at ERCP (assessment of benign or malignant disease) at a pancreatic neoplasia clinic and Set 3, all comers (n=63) undergoing phlebotomy at a general cancer clinic. Set 4 was included to measure the relationship between the NETest and treatment responses (n=62: surgical resections: n=27; somatostatin analog (SSA) (n=35)). Marker gene expression (qPCR) and CgA (DAKO) were compared (χ2, non-parametric, ROC curves) in Set 1. For Sets 2 and 3, selectivity was assessed; sensitivity and specificity metrics were calculated for the entire cohort.

Results: Set 1: PCR was positive (disease activity index >20% [0-100 score]) in 145 (97%) compared to CgA (elevated [>19U/L] in 77: 51%, Chi2=77.8, p<10- 19). The ROC-derived AUC for the NETest was 0.998, significantly better than CgA (AUC = 0.64, z-statistic 7.21, p<0.0001). When CgA was normal (32%), PCR was elevated (94%).

Set 2: PCR was positive in 6 (9.5%), 4 were subsequently identified as true positives (pancreatic NETs); false positive rate = 3.8%.

Set 3: PCR was positive in 4 (6.5%), 3 were identified as tumors with neuroendocrine features (gastric neuroendocrine carcinoma, goblet and mucinous appendiceal tumors); false positive rate = 1.6%.

For the entire cohort, the overall sensitivity was 96.8%, specificity 98.1%, PPV 98.1% and NPV 96.9%.

Set 4: PCR score was significantly reduced by surgery (28.9±5.5% vs. 80±6.4%, p<0.0001) and identified residual activity in 73% considered to be R0. In SSA-treated patients, levels were significantly higher in progressive disease compared to stable disease (82.7±3.6% vs. 32±3.7%, p<0.0001).

Conclusions: The NETest is both specific and selective for GEP-NET detection. Levels differentiate clinically stable from progressive disease and correlate with effectiveness of surgical resection. The test is robust and significantly more sensitive and accurate than CgA measurement. Application of this PCR- based blood test will permit accurate disease detection, and facilitate identification of disease progress thereby enabling assessment of treatment efficacy.

 

Nothing to Disclose: IMM, MK, HA, LB, ID

21912 30.0000 SAT-341 A A Multi-Gene Transcript Blood Molecular Signature with Algorithmic Analysis Identifies Gut Neuroendocrine Tumors and Defines Treatment Efficacy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Amir H Sam*1, Michelle Louise Sleeth2, E. Louise Thomas3, Nurhafzan Ismail4, Norlida Mat Daud4, Edward Chambers4, Fariba Shojaee-Moradie5, A. Margot Umpleby5, Anthony P. Goldstone6, Carel W Le Roux7, Paul Bech2, Mark Busbridge8, Rosemary Laurie4, Daniel Cuthbertson9, Adam John Buckley4, Mohammad A Ghatei10, Stephen R Bloom11, Gary Frost2, Jimmy D Bell12 and Kevin G. Murphy2
1Imperial College NHS Healthcare Trust, London, United Kingdom, 2Imperial College London, London, United Kingdom, 3University of Westminster, 4Imperial College London, 5University of Surrey, 6Imperial College, London, 7University College Dublin, 8Imperial College Healthcare NHS Trust, London, United Kingdom, 9University of Liverpool, Liverpool, United Kingdom, 10Imperial College of Medicine, London, United Kingdom, 11Imperial College London, United Kingdom, 12University of Westminster, London, United Kingdom

 

 

Background: No current biomarker can reliably predict visceral and liver fat content, both of which are risk factors for cardiovascular disease. Vagal tone has been suggested to influence regional fat deposition. Pancreatic polypeptide (PP) is secreted from the endocrine pancreas under vagal control. We investigated the utility of PP in predicting visceral and liver fat.

Methods: Fasting plasma PP concentrations were measured in 104 overweight and obese subjects (46 men and 58 women). In the same subjects, total and regional adipose tissue, including total visceral adipose tissue (VAT) and total subcutaneous adipose tissue (TSAT), were measured using whole body magnetic resonance imaging (MRI). Intrahepatocellular lipid content (IHCL) was quantified by proton magnetic resonance spectroscopy.

Results: Fasting plasma PP concentrations positively and significantly correlated with both VAT (r=0.57, p<0.001) and IHCL (r=0.51, p <0.001), but not with TSAT (r=0.02, p=0.88). Fasting PP concentrations independently predicted VAT after controlling for age and gender. Fasting PP concentrations independently predicted IHCL after controlling for age, gender, BMI, WHR, HOMA2-IR and serum concentrations of triglyceride (TG), total cholesterol (TC) and alanine aminotransferase (ALT). Fasting PP concentrations were associated with serum ALT, TG, TC, LDL and HDL cholesterol and blood pressure (p<0.05). These associations were mediated by IHCL and/or VAT. Fasting PP and HOMA2-IR were independently significantly associated with hepatic steatosis (p<0.01).

 Conclusions: Pancreatic polypeptide is a novel predictor of visceral and liver fat content, and thus a potential biomarker for cardiovascular risk stratification and targeted treatment of patients with ectopic fat deposition.

 

Nothing to Disclose: AHS, MLS, ELT, NI, NM, EC, FS, AMU, APG, CWL, PB, MB, RL, DC, AJB, MAG, SRB, GF, JDB, KGM

18834 31.0000 SAT-342 A Circulating Pancreatic Polypeptide Concentrations Predict Visceral and Liver Fat Content 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Thamara E Osinga*1, Anouk NA Van der Horst-Schrivers2, Martijn van Faassen3, Michiel N Kerstens2, Robin PF Dullaart2, Marloes AM Peters3, Bernard FAM van der Laan2, Geertruida H de Bock2, Thera P Links2 and Ido P Kema2
1University of Groningen, University Medical Center Groningen, Groningen, Bethesda, MD, 2University of Groningen, University Medical Center Groningen, Groningen, Netherlands, 3University of Groningen, University Medical Center Groningen, Groningen, Groningen, Netherlands

 

Background and Purpose: Head and Neck paragangliomas (HNPGL) rarely secrete catecholamines. Therefore, a biochemical marker for the presence of these tumors is lacking, advocating frequent imaging in patients at risk of developing these tumors. Dopamine secretion measured as plasma 3-methyoxytyramine (3-MT) has been found in up to 28% of patients. Free dopamine is rapidly incorporated in circulating platelets through the dopamine transporter (DAT). In this study we determined the diagnostic accuracy of the dopamine concentration in platelets and plasma 3-MT in patients with HNPGL.

Patients, Controls and Methods: A single center cohort study was performed between 2012-2014. Thirty-six patients with HNPGL were compared to 68 healthy controls for dopamine in platelets and 120 healthy controls for plasma 3-MT.

Reference intervals for platelet dopamine concentrations were calculated using EP EvaluationTM software as recommended by the Clinical and Laboratory Standards Institute. For 3-MT the upper reference limit (URL) based on 120 healthy controls was (<0.17 nmol/L).

The discriminating capacity of dopamine levels in platelets and plasma 3-MT was calculated with receiver operating characteristic (ROC) curves using Analyse-it Software Ltd. Since we wanted to investigate whether dopamine in platelets could be useful to exclude the presence of a HNPGL we calculated the cutoff value for dopamine in platelets and the concurrent specificity closest to 90% sensitivity.

Results:  Dopamine concentration in blood platelets was elevated in HNPGL patients compared to healthy controls (median and interquartile ranges 0.48 [0.32-0.82] pmol/109 platelets vs. 0.31 [0.24-0.47] pmol/109 platelets; P<.05). Plasma 3-MT concentration did not differ between patients with HNPGL and healthy controls (0.06 [0.06-0.08] nmol/l vs. 0.06 [0.06-0.06] nmol/l; P =.119). The reference interval for dopamine in platelets was 0.12-0.97 pmol/109 platelets. Using this URL for dopamine concentration in platelets, 6 patients (16.7%) with HNPGL were biochemically detected instead of 3 patients (8.3%) when using the URL for plasma 3-MT (P=.053). The areas under the curve (AUC)s of dopamine concentration in platelets and plasma 3-MT were not significantly different (0.678 (95% CI 0.564-0.792) vs. 0.570 (95% CI 0.457-0.683); P=0.19). When selecting 91.7% sensitivity, platelet dopamine concentration had 13.9% specificity for detecting HNPGL with a cutoff level of 0.208 pmol/109 platelets. For plasma 3-MT, no sensitivity of 90% could be reached.

Conclusion: Platelet dopamine levels are increased in patients with HNPGL compared to healthy controls, although in the present study the discriminating capacity was not significantly different from plasma 3MT measurements. Future studies are warranted to investigate whether platelet dopamine concentration might have a role in the screening of germline mutation carriers.

 

Nothing to Disclose: TEO, ANV, MV, MNK, RPD, MAP, BFV, GHD, TPL, IPK

19934 32.0000 SAT-343 A Dopamine in Blood Platelets As a Diagnostic Marker in Head and Neck Paraganglioma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Emmanuel Labourier*1, Sylvie Beaudenon2, Dennis Wylie3 and Thomas J Giordano4
1Interspace Diagnostics and Asuragen, 2Interpace Diagnostics and Asuragen, 3Asuragen, 4University of Michigan Health System

 

Background: Current clinical management of thyroid cancer entails the cytopathological evaluation of ultrasound-guided fine needle aspirations (FNAs) from solid thyroid nodules larger than 1 cm. For nodules with indeterminate cytology, approximately 60% of malignant cases (1,2) or 50% of benign cases (3) can be identified using independent molecular tests with high positive or negative predictive value (PPV or NPV). We investigated the potential utility of miRNA biomarkers to overcome current limitations and further increase the preoperative diagnostic yield of molecular cytology. Methods: miRNA expression was measured in surgically resected thyroid lesions and preoperative FNAs by reverse transcription-quantitative PCR using the miRCURY LNA Universal RT microRNA PCR system. Qualitative analyses for 17 distinct oncogenic gene alterations in the BRAF, HRAS, KRAS, NRAS, PAX8 and RET genes were performed with the miRInform Thyroid testing service. Results: A comprehensive set of 254 unique thyroid lesions was used to 1/ identify the most significant miRNA candidates differentially expressed between various papillary or follicular carcinomas and benign conditions such as adenoma, diffuse hyperplasia or chronic thyroiditis, and 2/ develop robust linear classification models that could discriminate between benign and malignant lesions with a sensitivity or specificity >90%. A multi-step, 10-miRNA algorithm was further optimized in the surgical training set and in 235 preoperative FNAs by targeting a type I error <5% compatible with high sensitivity/specificity and actionable PPV/NPV when added to gene mutation testing (mutation- or miRNA-positive results both scored as positive). In an independent cross-sectional cohort study on 109 nodules with AUS/FLUS or FN/SFN cytology collected at 12 distinct endocrinology practices across the United States, mutations were detected in 68.6% of nodules with a malignant histology outcome. Among mutation-negative specimens, the optimal miRNA classifier identified 63.6% of the malignant cases and 98.4% of the benign cases. The diagnostic sensitivity and specificity of the combined algorithm was 88.6% (95% confidence intervals: 73.3-96.8%) and 85.1% (95% confidence intervals: 75.0-92.3%), respectively. Importantly, the NPV (95.6% at 24% prevalence) was similar to the NPV previously reported for the Afirma gene expression classifier (94.3% at 24% prevalence) (3) with a 65% increase in true benign call rate. Conclusions: Multicategorical testing for DNA, mRNA and miRNA in preoperative thyroid nodule FNAs has high PPV/NPV and improves the diagnostic yield of molecular cytology. Independently of variations in cancer prevalence in distinct pathology practices, this novel testing algorithm can identify more benign or malignant nodules and may further decrease the number of unnecessary surgeries and 2-step total thyroidectomies.

 

Disclosure: EL: Consultant, Interpace Diagnostics, Former employee, Asuragen. SB: Consultant, Interpace Diagnostics, Former employee, Asuragen. DW: Employee, Asuragen. TJG: Consultant, Interpace Diagnostics, Clinical Advisory Board member, Asuragen.

18782 33.0000 SAT-344 A Multicategorical Testing for miRNA, mRNA and DNA on Fine Needle Aspiration Improves the Preoperative Diagnosis of Thyroid Nodules with Indeterminate Cytology 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Nathalie Lobo Figueiredo-Feitosa*1, Patrícia Kunzle Ribeiro Magalhães1, Janaina Cristiana de Oliveira Crispim2, Daiani Cristina Silião-Alves3, Gustavo Martelli-Palomino4, Celso Teixeira Mendes-Junior4, Luciano Neder5, Edson Garcia Soares3, Eduardo Antonio Donadi4 and Lea Maria Zanini Maciel6
1Ribeirão Preto School of Medicine, Ribeirão Preto, Brazil, 2Federal University of Rio Grande do Norte, 3Ribeirão Preto School of Medicine, Brazil, 4Ribeirão Preto School of Medicine, 5Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 6Ribeirão Preto School of Medicine, Ribeirao Preto, Brazil

 

Human leukocyte antigen G (HLA-G) is a non-classical class I histocompatibility molecule with restricted tissues distribution and immunoregulatory properties. Tumor cell expression has been considered detrimental and related to disease progression. In previous study we demonstrated a gradual increase of HLA-G expression from thyroid hyperplasia to carcinomas and a higher frequency of 3`untranslated region (UTR) polymorphisms associated with a grater magnitude of HLA-G production in thyroid malignant neoplasms. Additionally we observed that HLA-G protein expression and its polymorphisms were associated with some variables implicated in poor prognosis in thyroid cancer. Objectives: To associate alleles, genotypes and haplotypes of 3`UTR with the magnitude of HLA-G protein expression in follicular adenoma (FA), papillary (PTC) and follicular thyroid carcinomas (FTC). Methods: HLA-G expression was studied by immunohistochemical reactions. The percentage of stained cells was graded from 0 to 3+. Polymorphic sites from 3UTR region (14bpIN/DEL, +3003C/T, +3010C/G, +3027A/C, +3035C/T, +3142C/G, +3187A/G, +3196C/G) were characterized by sequencing. We studied 14 patients with FA, 16 with FTC and 63 with PTC. Fisher’s exact test was used to compare groups. Results: +3196C allele (P = 0.04; OR = 0.093; 95%CI = 0.005-1.7584) and +3196CC genotype were associated with lower HLA-G protein expression, immunoreactivity represented by 1+ compared to 2+ (P = 0.02; OR = 0.048; 95% CI = 0.0022-1.0734) and to 3+ (P = 0.04; OR = 0.082; 95%CI = 0.0044-1.6247). The UTR-2 haplotype were associated with moderate (P = 0.04; OR = 0.093; 95%CI = 0.0049-1760) and strong (P = 0.05; OR = 0.1170, 95%CI = 0.0066-2.072) HLA-G protein expression. Conclusion: Only one polymorphic site was associated with HLA-G protein expression, supporting the hypothesis of HLA-G involvement in thyroid carcinogenesis. However more data are needed to confirm the influence of 3`UTR diversity as a mechanism by wich this gene can be ectopic expressed in thyroid tissue, inhibiting the immunoinflamatory response against tumor cells. 

FAPESP # 10/51649-9, CNPq Project announcement 31/2013 - Metabolic and Endocrine Diseases - Process 457231/2013-0

 

Nothing to Disclose: NLF, PKRM, JCDOC, DCS, GM, CTM, LN, EGS, EAD, LMZM

19999 34.0000 SAT-345 A HLA-G Expression and 3` Untranslated Region Polymorphisms of the Corresponding Gene in Patients with Thyroid Tumors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM SAT 312-345 5953 1:00:00 PM Biomarkers and Hormone-Dependent Cancers Poster


Sarah Zaheer*1, Jenifer Michelle Brown2, Matthew Allison3, David Siscovick4, Joachim Ix3, Bryan Kestenbaum5, Ian de Boer6 and Anand Vaidya7
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 2Brigham and Women's Hospital, Harvard Medical School, MA, 3University of California, San Diego, 4The New York Academy of Medicine, 5University of Washington, 6University of Washington, Seattle, WA, 7Brigham and Women’s Hospital/Harvard Medical School, Boston, MA

 

CONTEXT: The use of diuretics has been associated with bone-mineral density and incident fracture. Dihydropyridine sensitive calcium channels have been detected on parathyroid cells. The potential for these anti-hypertensive medications to modulate calcium-homeostasis and parathyroid hormone (PTH) levels may represent a mechanism to explain their associations with skeletal outcomes.

HYPOTHESIS:  In a large community-based cohort without chronic kidney disease, thiazide diuretic (TZ) use associates with lower PTH, whereas use of loop diuretics (LD) or calcium-channel blockers (CCB) of the dihydropyridine class associates with higher PTH.

METHODS: We conducted cross-sectional analyses of participants using anti-hypertensive medications in the Multi-Ethnic Study of Atherosclerosis after excluding those with primary hyperparathyroidism and chronic kidney disease (n=1888).  We compared PTH levels between users and non-users of TZ, LD, and CCB using t-tests.  We conducted further comparisons within users of CCB to evaluate PTH levels between dihydropyridine and non-dihydropyridine users.  Multivariable linear regression was performed to evaluate the independent association between each anti-hypertensive medication and PTH after adjustment for age, gender, race, BMI, glomerular filtration rate, education level, cigarette smoking, physical activity, 25-hydroxyvitamin D, serum calcium and phosphate, urinary calcium- and phosphate-to-creatinine ratio, FGF-23, and individual anti-hypertensive medications (TZ, LD, CCB, renin-angiotensin-aldosterone system inhibitors, beta blockers, alpha blockers).

RESULTS: The use of TZ was associated with lower PTH when compared to non-TZ use (44.4 vs 46.8 pg/mL, P=0.02), whereas the use of LD and CCB were associated with higher PTH (LD: 60.7 vs 45.5 pg/mL, P<0.0001; CCB: 49.5 vs. 44.4 pg/mL, P<0.0001).  Multivariable modeling confirmed independent associations between TZ use and lower PTH (β = -3.5 pg/mL, P=0.0003), and LD and CCB use and higher PTH (LD: β = +11.8 pg/mL, P<0.0001; CCB: +3.4 pg/mL, P=0.0003).  Among CCB users, the use of dihydropyridines was independently associated with higher PTH (β= +4.5 pg/mL, P<0.0001) whereas non-dihydropyridine was not (β=0.58 pg/mL, P=0.68). When compared to a reference of TZ use, LD use was associated with a +11.2 pg/mL higher PTH (p=0.004), dihydropyridine CCB with a +9.9 pg/mL higher PTH (<0.0001), and non-dihydropyridine CCB did not significantly differ (β= +2.3 pg/mL PTH, p=0.29).

CONCLUSIONS: In a large community-based cohort without chronic kidney disease, we observed independent associations between the use of TZ with lower PTH, and the use of LD and dihydropyridine CCB with higher PTH.  Whether these associations provide a mechanistic explanation for the use of these anti-hypertensives and the development of primary hyperparathyroidism or skeletal outcomes warrants further study.

 

Nothing to Disclose: SZ, JMB, MA, DS, JI, BK, ID, AV

18864 5.0000 SAT-248 A Diuretic and Calcium-Channel Blocker Use and Parathyroid Hormone Levels: The Multi-Ethnic Study of Atherosclerosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Beom-Jun Kim*, Seong Hee Ahn, Hyeon Mok Kim, Seung Hun Lee and Jung-Min Koh
Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South)

 

Purpose: Skeletal muscle and bone interact mechanically and functionally. The present study was performed to investigate the association between muscle mass and femoral neck composite strength indices using a nationally representative cohort.

Methods: This is a population-based, cross-sectional study from Korea National Health and Nutrition Examination Surveys, including 1,275 Koreans (674 women and 601 men) aged 50 years or older. Femoral neck axis length and width were measured by hip DXA scans and were combined with BMD, body weight, and height to create composite indices of femoral neck strength relative to load in three different failure modes: compression, bending, and impact. Presarcopenia was defined as an appendicular skeletal muscle mass (ASM) divided by body weight that was less than 1 SD below the sex-specific mean for young adults.

Results: After adjusting for confounders, women with presarcopenia had consistently lower indices for compression strength (CSI), bending strength (BSI), and impact strength (ISI) than women without this condition. Men with presarcopenia had a lower ISI value than men without presarcopenia. Multiple regression analyses revealed that lower relative skeletal muscle mass (ASM/weight) associated significantly with lower values for all three femoral neck composite indices in women and with lower CSI and ISI in men.

Conclusions: These findings provide the first clinical evidence for the notion that age-related low muscle mass may increase the risk of osteoporotic hip fractures by decreasing femoral neck strength relative to load, especially in older women, and support the highly-integrated nature of skeletal muscle and bone.

 

Nothing to Disclose: BJK, SHA, HMK, SHL, JMK

18609 6.0000 SAT-249 A Low Skeletal Muscle Mass Associates with Low Femoral Neck Strength, Especially in Older Korean Women: The Fourth Korea National Health and Nutrition Examination Survey (KNHANES IV) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Mamata Ojha*1, George Hebdon1, Saleh Aldasouqi2 and Ved V Gossain3
1Michigan State University, East Lansing, MI, 2Michigan State University, East lansing, MI, 3Michigan State Univ, East Lansing, MI

 

The prevalence and the natural history of normocalcemic hyperparathyroidism (NCHPT) are not well known.

Therefore the aim of the study was to determine the prevalence and natural history of (NCHPT).

We reviewed the electronic medical records of patients with normal serum calcium level (8-10.5 mg/dl) and elevated serum parathyroid hormone (PTH) level (>72 pg/ml) over a period of 10 years (2003 to 2013) seen at Michigan State University outpatient clinics. We excluded patients with chronic liver disease, kidney disease and previous parathyroid surgery. 

50 patients were identified with NCHPT, while 282 were diagnosed with primary hyperparathyroidism during the same time period. Thus, the prevalence of NCHPT is approximately 50/332 (15%).  Among all patients with NCHPT, 43 were female and 7 were male. The mean age was 59.1, SD ± 13.94 years (range 33-92). Although the total serum calcium level was normal in all patients, 5 (10%) had elevated ionized calcium, and 14 (28%) had normal ionized calcium.  Ionized calcium was not measured in 31 (62%) patients. Serum albumin was normal in all.  Twenty seven (54%) patients were found to have vitamin D deficiency (25 Hydroxy vitamin D level< 30ng/ml), which was thought to be the etiology of elevated PTH levels. In the remainder 23 (46%), no cause for elevated PTH level was found.  Among those with Vitamin D deficiency PTH level returned to normal only in 7 patients over a period of 3 months to 4 years after the correction of the deficiency.  In two patients, PTH levels gradually declined but did not reach normal levels despite having normal vitamin D level, for a period of 3 and 7 years.  In 18 patients, PTH remained elevated throughout the follow up ranging from 2 months to 5 years. Bone mineral density had been determined in 29 patients. 10/29 (34.5%) showed osteoporosis and 13/29 (44.8%) had osteopenia. Out of 10 with osteoporosis, 8 (80%) had vitamin D deficiency. Out of 13 with osteopenia, 10 (76.9%) had vitamin D deficiency.  Two patients (4%) had history of recurrent fractures, and 7 (14%) had recurrent kidney stones. Out of the 7 patients with recurrent stones only one had BMD checked which showed osteopenia. Only 2 out of 7 (28.5%) patients with recurrent kidney stones had vitamin D deficiency. Vitamin D levels in others were within the normal range.

This retrospective analysis shows that among all patients with hyperparathyroidism about 15 % may have NCHPT. Vitamin D deficiency is frequently associated with NCHPT.  When vitamin D deficiency is the putative cause of elevated PTH levels, it may take several months for PTH levels to return to normal, even after the vitamin D levels have been normalized.  Our data also shows that NCHPT is not a benign entity and may be associated with increased risk of osteopenia, osteoporosis and kidney stones.

 

Nothing to Disclose: MO, GH, SA, VVG

19029 7.0000 SAT-250 A Normocalcemic Hyperparathyroidism: Prevalence and Natural History 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Muhammad S. Khan*, Sajini Wijetilleka, Aung Mon, William D. Fraser and Jiten Vora
The Royal Liverpool University Hospital, Liverpool, United Kingdom

 

Background: Adult Growth Hormone Deficiency (AGHD) is associated with reductions in both bone turnover and bone mineral density; factors improved by growth hormone replacement (GHR). Limited data exists on the link between BMI and GHR replacement on osteotrophic factors and bone metabolsim in AGHD patients.

Objective: Investigate effects of GHR on parathyroid hormone (PTH), phospho-calcium metabolism and bone metabolism in obese (O) and non-obese (N-O) AGHD patients 

Method: 16 O (BMI>30kg/m2) and 16 N-O (BMI≤30kg/m2) AGHD patients matched for age, sex and baseline pituitary hormonal replacement therapy were recruited. Calcium, phosphate, PTH and nephrogenous cyclic AMP (NcAMP) were measured half-hourly for 24h prior to (baseline) and post-GHR. Levels of type-I collagen C-telopeptide (CTX), marker of bone resorption, pro-collage type-I amino-terminal pro-peptide (PINP), marker of bone formation, and the PINP/CTX bone remodeling balance ratios were recorded to assess bone metabolism.

Results: Baseline: N-O group had significantly lower 24h mean values of calcium (2.30±0.003 mmol/L vs. 2.53±0.01 mmol/L, p<0.001) and NcAMP (9.34±1.08 nmol/L/GFR vs. 15.44±0.88 nmol/L/GFR, p=0.007), with higher 24h mean levels of PTH (4.19±0.09 pmol/L vs. 3.88±0.07 pmol/L, p<0.0001), phosphate (1.20±0.07 mmol/L vs. 1.03±0.01 mmol/L, p=0.02), bone resorption (CTX: 0.21±0.01 ng/L vs. 0.13±0.01 ng/L, p<0.001) and bone formation (PINP: 44.8±0.35 µg/L vs. 32.3±0.37 µ/L, p<0.001) than the O group. The bone remodeling balance was significantly worse in the N-O group than the O group (p<0.001).

Post-GHR: N-O group had a significant percentage reduction in PTH (15.6% vs. 11.1%, p<0.001) and calcium (0.53±0.12% vs. 10.1±0.39%, p<0.001) compared to the O group. Percentage increase in phosphate levels was comparable (18.3±2.8% vs. 15.5±0.7%, p=0.3).  Percentage increase in NcAMP was significantly higher in N-O than O patients (78.6±17.7% vs. 38.2%±9.7%, p=0.02). The O group had a greater percentage increase in bone resorption (CTX: 141±5.2% vs. 87.5±4.5%, p<0.001) and formation (PINP: 81.4±1.9% vs. 65±1%, p<0.001) than the N-O group, yet the boneremodeling balance was comparable (p>0.05).

Conclusions: N-O patients showed relative PTH resistance at baseline with increased 24h mean PTH and phosphate but reduced 24h mean calcium and NcAMP levels. Bone remodeling balance was less favorable in the N-O group reflecting a negative association between BMI and bone turnover rate. Post-GHR, both groups showed increasing sensitivity to PTH, yet target organ response to PTH differed with BMI. With GHR, N-O patients had greater improvement in renal PTH sensitivity, whilst bone PTH sensitivity was greater in O patients. However, the bone re-modeling balance was comparable between groups indicating that GHR may yield a more beneficial bone remodeling balance in patients with lower BMI.

 

Nothing to Disclose: MSK, SW, AM, WDF, JV

19615 8.0000 SAT-251 A Impact of Body Mass Index (BMI) on Parathyroid Hormone (PTH), Phospho-Calcium Metabolism and Bone Metabolism in Adult Growth Hormone Deficient (AGHD) Patients before and after Growth Hormone Replacement (GHR) Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Mariana Tenorio Antunes Reis*, Diogo Toledo Matias, Maria Estela Justamante de Faria and Regina M Martin
Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), Sao Paulo, Brazil

 

Background: Pseudohypoparathyroidism (PHP) is a rare heterogeneous genetic disorder characterized by resistance to the peripheral action of PTH due to maternally inherited heterozygous inactivating mutations in the coding sequence of Gsα (PHP1A) or methylation defects at GNAS (PHP1B), which results in hypocalcemia and hyperphosphatemia with elevated PTH levels. The dental manifestations include: failure of tooth eruption, enamel aplasia or hypoplasia, hypodontia, retarded root development with short blunted roots, larger root canals, distorted and thick dentin at the apex, and widened pulp chambers, often nearly occluded by calcified deposits. Primary failure of tooth eruption (PFE) is related to some syndromes involving skeletal development, but it is also known as a nonsyndromic autosomal-dominant condition. Studies already showed that familial nonsyndromic PFE is caused by heterozygous mutations in the gene encoding the G protein-coupled receptor (PTH1R) for PTH and PTH-related protein (PTHrP). Thus, we hypothesized that PFE in PHP could be due to elevated PTHrP levels.

Objective: To investigate failure of tooth eruption in 18 patients with PHP and to correlate with plasmatic PTHrP levels.

Subjects and methods: 18 patients with ages between 10 and 48 years, 9 females and 9 males. All of them had molecular diagnosis of PHP (5 with PHP1A and 13 with PHP1B). All patients had undergone dental panoramic radiography (DPR) and had PTHrP levels measured by immunoassay. Patients with alterations at DPR were submitted to clinical dental evaluation.

Results: Four patients had normal DPR for age and no need for further dental evaluation. 13 patients were clinically evaluated and one patient missed her clinical evaluation. 8/18 patients exhibited unerupted teeth (without considering third molars). The normal range for plasmatic PTHrP levels was between 14 – 27 pg/mL. 13 patients had PTHrP levels within the normal range, including three patients with normal DPR. Only one patient had PTHrP levels slightly elevated (32 pg/mL), but she had no dental alterations. Four patients had PTHrP levels slightly low (ranging from 12 to 13 pg/mL), but we did not find this meaningful. Additional dental manifestations detected were: enamel hypoplasia (11/13), short blunted roots (12/13), widened pulp chambers and/or calcified intrapulpal deposits (4/13) and hypodontia (1/13).

Conclusion: we described the dental abnormalities in a large series of PHP patients. Contrary to what we expected, no relation between plasmatic PTHrP levels and failure of tooth eruption or dental manifestations of PHP was found. It is important that doctors pay attention to dental manifestations of the disease in order to refer patients to a proper care with dentists. On the order hand, dentists should be aware of the disease as they could be the first contact of the patients with health care.

 

Nothing to Disclose: MTAR, DTM, MEJDF, RMM

21746 9.0000 SAT-252 A Failure of Tooth Eruption in Pseudohypoparathyroidism Is Not Related to Parathyroid Hormone-Related Protein (PTHrP) Plasma Levels 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Yasaman Mohtasebi*1, Manige Konig2, Lisa Davidoff3 and Elizabeth A. Streeten4
1Univ of Maryland Med Ctr, Baltimore, MD, 2UMMC, MD, 3University of Maryland Medical Center, 4University of Maryland Medical Center, Baltimore, MD

 

Hypoparathyroidism: Less morbidity from acute hypocalcemia with chronic Vitamin D2 treatment compared to calcitriol

 

Yasaman Mohtasebi, Manige Konig, Lisa Davidoff, Elizabeth A. Streeten

 

 

Background: Ergocalciferol (D2) was the first treatment used for hypoparathyroidism, but is now used in <20% of patients due to concern for potential renal toxicity because of its long half–life.  High doses of D2 are needed to promote production of 1,25(OH)2D and maintain eucalcemia, in the absence of PTH, but in our experience, toxicity from D2 occurs far less often than with calcitriol. The purpose of this retrospective study was to compare number of hospitalizations and emergency department visits for hyper and hypocalcemia and incidence of kidney stones in hypoparathyroid patients chronically treated with D2vs calcitriol. We have previously presented data showing no difference between serum calcium and creatinine between the groups.

Methods:After IRB approval, billing records containing ICD9 codes for hypoparathyroidism were used to identify patients treated for hypoparathyroidism at the University of Maryland over the past 10 years. After review of electronic medical records, 30 patients with confirmed hypoparathyroidism were identified, 16 treated chronically with D2 and 14 with calcitriol. We compared number of hospitalizations and ED visits for hypo/hypercalcemia and incidence of kidney stone between the 2 groups.

Results: Four of 14 patients in the calcitriol group required emergency treatment (hospitalization or ED visit) for hypocalcemia vs zero of 16 in the D2 group (p=0.03), and 3 patients in calcitriol group required multiple (4-6) hospital visits. There were no differences between calcitriol and D2 groups in number of hospitalizations for hypercalcemia (4 vs 3, p=0.67), ED visits for hypercalcemia (1 in each group) or for the combination (p=0.67). There was no difference between incidence of kidney stones passed between the 2 groups (p=0.32). There were no differences between calcitriol and D2 groups in: age (50.9±22.6 vs 58±16 yrs, p=0.28), duration of hypoparathyroidism (8.8±4.4 vs 17.8±14.2 yrs, p=0.08), cause of hypoparathyroidism (p=0.98), mean serum Cr (0.98±0.26 vs 0.92±0.33mg/dl, p=0.71) or mean serum Ca (8.4±0.7 vs 8.6±0.6mg/dl, p=0.37). The mean doses were: 0.58±0.31 ug/day in calcitriol group and 41,326±30,198 units/day in the D2group.

Conclusion: We found significantly less morbidity from hypocalcemia in patients with hypoparathyroidism treated with Vit D2 compared to calcitriol and found no difference in renal function or morbidity from hypercalcemia on chronic treatment. Treatment with vitamin D2 should be considered  in patients with hypoparathyroidism, particularly in those requiring acute treatment for hypocalcemia.

 

Nothing to Disclose: YM, MK, LD, EAS

19620 10.0000 SAT-253 A Hypoparathyroidism: Less Morbidity from Acute Hypocalcemia with Chronic Vitamin D2 Treatment Compared to Calcitriol 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


David Peter Macfarlane*1, Ning Yu2, Peter T Donnan2 and Graham Leese2
1University of Dundee, Dundee, United Kingdom, 2University of Dundee

 

Previous epidemiological studies from Scandinavia and the USA have produced conflicting estimates as to whether the incidence of primary hyperparathyroidism (PHPT) is rising or falling, also producing significantly differing prevalence results. Here we extend the population based Parathyroid Epidemiology and Audit Research Study (PEARS) to span 20 years, from 1993-2012, and calculate the annual incidence density (ID) and period prevalence (PP) of PHPT in adults in Tayside, Scotland through extensive linkage of electronic health records.

44,908 individuals were identified with at least one elevated corrected serum calcium >2.55mmol/L (reference range 2.10-2.55mmol/L) from a population of ~400,000. Using a pre-defined biochemical screening algorithm we identified 2933 cases of probable (almost definite) and 3170 cases of possible(very likely) PHPT. Over 2/3 of cases were female, in both groups. Possible cases were slightly older 69±13.6 vs 66±14.7 years (mean±SD, P<0.001). The prevalence of PHPT increased with age (P<0.001), but hypercalcaemia was generally mild in both probable (mean Ca 2.63 mmol/L, range 2.55-5.49) and possible groups (mean Ca 2.60; range 2.55-4.31). The age and sex adjusted ID of probable PHPT ranged from 1.62-9.10 cases per 10,000 patient years. Considering possible and probable PHPT together the ID ranged from 2.11-20.50 per 10,000 patient years in the general population. There was also an initial cyclicity to the ID with peaks in 1996, 2000 and 2004 followed by a steady decline in both groups, and males and females. The adjusted PP of probable PHPT increased year on year to a peak of 6.18 per 1000 of the general population in 2007, before falling to 4.98 per 1000 in 2012. Combining all probable and possible PHPT the PP increased significantly and rose from 1.01 per 1000 in 1993 to 12.34 per 1000 of the general population in 2006 before falling to 8.33 per 1000 by the end of the study period. This trend was similar in both probable and possible cases, and in both sexes.

In summary, using population level data we demonstrate a recent fall in both the incidence and prevalence of diagnosed PHPT, also confirming that there is likely to be a large burden of undiagnosed cases within the community, with a likely prevalence of greater than 1%. There was an apparent cyclicity in the ID which is unexplained.

 

Nothing to Disclose: DPM, NY, PTD, GL

20336 11.0000 SAT-254 A The Changing Epidemiology of Primary Hyperparathyroidism over 20 Years in Tayside, Scotland: A Significant Burden of Undiagnosed Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Udaya Manohar Kabadi*
University of Iowa, Clive, IA

 

Background:  Elevated PTH in subjects with normal serum calcium and sub normal 25 OH Vit D concentration may be due to either Vit D deficiency with secondary hyperparathyroidism or normocalcemic primary hyperparathyroidism with low 25 OH Vit D due to enhanced conversion to 125 OH Vit D.

Objective: To assess the effect of Vit D supplementation on serum  PTH, calcium and 25 OH Vit D concentration in subjects manifesting  subnormal Vit D, normal serum calcium and elevated PTH levels.

Subjects: 20 subjects, 12 women and 8 men with ages 31-64 years referred to

Endocrinology clinic between 01/01/2014 and 06/30/2014 for evaluation and management of Vit D deficiency.

Methods: Serum calcium, albumin , other chemistries, 25 OH Vit D and PTH concentrations were determined prior to administration of Ergocalciferol  50000 units twice a week and again at 3-4 months on normalization of 25 OH Vit D levels.

Results: In all subjects, serum albumin and other chemistries were within normal range. In 14 subjects, elevated serum PTH (95±12 pg/ml) normalized (48±6 pg/ml; normal range 15-65pg/ml, p<0.01) on attaining normal Vit D level (44±8 ng/ml; Normal >30 ng/ml) on Vit D supplementation. Serum calcium (9.4 ±0.3mg/dl) was not significantly altered (9.3±0.3mg/dl) and remained within normal range (8.5 -10.5 mg/dl).  Among the remaining 6 subjects, elevated serum PTH (98±14 pg/ml) persisted in 4 or rose paradoxically in 2 subjects (mean for the group,100±14 pg/ml) despite attaining normal 25 OH Vit D concentrations (44±7 ng/ml) following Vit D supplementation. Serum calcium rose significantly in these subjects and attained supernormal levels (11.1±0.4 mg/dl. Serum concentrations of PTH, calcium and 25 OH Vit D were not significantly different between 2 groups prior to Vit D supplementation (p>0.05 for all comparisons.

Conclusion: Subjects manifesting low 25 OH Vit D, normal calcium and elevated PTH concentrations belong  to 2 groups; 1)Vit D deficiency with secondary hyperparathyroidism and 2)Normocalcemic hyperparathyroidism with low 25 OH Vit D levels secondary to enhanced conversion to 125 OH Vit D documented previously in hypercalcemic primary hyperparathyroidism.

 

Nothing to Disclose: UMK

20781 12.0000 SAT-255 A Non Suppressible PTH with Vitamin D Supplementation in Normocalcemic Primary Hyperparathyroidism and Low 25 OH Vitamin D 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Christopher W Rowe*1 and Shaun A McGrath2
1John Hunter Hospital, New Lambton Heights, NSW, Australia, 2John Hunter Hospital, New Lambton Heights, Australia

 

Background

Familial hypocalciuric hypercalcemia (FHH) is a rare genetic cause of hypercalcemia due to mutations in the calcium-sensing receptor apparatus.  It does not cause parathyroid gland enlargement (1) and patients do not benefit from surgical resection.  Current screening tests lack specificity for differentiating  FHH from primary hyperparathyroidism (HPT) .  We evaluated the sensitivity and specificity of parathyroid ultrasound (PUS) to detect parathyroid adenomas, to assess the theoretical effectiveness of a negative PUS as screening for FHH.    

Methods

We retrospectively reviewed 139 patients with biochemically proven primary hyperparathyroidism without risk factors for multigland disease who underwent localisation PUS by a single practitioner prior to surgical excision.   122 patients met strict criteria for post-operative cure (normal calcium and PTH).  As they were cured, we applied the assumption that all abnormal parathyroid tissue was detected and removed at operation.  This data was used to assess prevalence (0.289), sensitivity (0.716) and specificity (0.974) for PUS detection of parathyroid enlargement, with a prevalence-adjusted positive likelihood ratio (LR) of 11.1 and a negative LR of 0.11.  

Analysis

Urine calcium:creatinine clearance ratio (CCCR) is the best current screening test for FHH, with sensitivity 0.95 and specificity 0.79 at cutoff <0.013 (2).  With FHH prevalence estimated at 2 per 100 hypercalcemic patients (2), a low CCCR yields a positive predictive value (PPV) for FHH of 0.08.  In a hypercalcemic patient with a pretest probability of HPT of 0.98, a negative PUS gives a post-test probability of HPT of 0.78.  If clinical suspicion of FHH could reduce pretest probability of HPT to 0.9, a negative PUS would give a post-test probability of 0.49 for HPT.  Applying CCCR to this select population would give a PPV of 0.81, making the diagnosis of FHH considerably more likely, and further diagnostic testing of considerable benefit.  

Discussion

Diagnosis of FHH is hampered by limited specificity of current screening tests, resulting in investgiation of a large number of patients with HPT to detect the few with FHH.  This data suggests that clinical assessment, combined with PUS, could be a useful tool to stratify patients for further testing for FHH.  PUS is inexpensive, simple to administer, and has no side effects, but utility is limited by the subjective, operator dependent nature of PUS.  Prospective studies are required to validate this tool in clinical practice.

 

Nothing to Disclose: CWR, SAM

19025 13.0000 SAT-256 A Parathyroid Ultrasound As Screening Tool for Familial Hypocalciuric Hypercalcemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Jee Hee Yoon*1, Soo Jeong Kim1, Jung Min Kim2, Min Gui Han1 and Ho-Cheol Kang1
1Chonnam National University Medical School, Gwangju, Korea, Republic of (South), 2St. Carollo Hospital, Suncheon, Korea, Republic of (South)

 

Background: Primary hyperparathyroidism can be cured by minimal invasive surgery (MIS) with optimized preoperative localization. Ultrasonography (US) and scintigraphy are the imaging modalities most widely used for localization of the affected glands. The aim of this study was to define the roles of US and scintigraphy.

Method: We retrospectively reviewed 40 patients who had undergone parathyroidectomy for single adenoma between 2004 and 2013. US and scintigraphic findings were compared to operative findings to determine the diagnostic values of localization.

Results: Accurate localization of US and scintigraphy occurred 38 patients (95%) and 37 patients (92.5%), respectively. The patients without localization on US had higher frequency of superior location and lower levels of preoperative iPTH. Twenty nine patients (76.3%) showed typical extrathyroidal hypoechoic nodule with central or peripheral vascularity, and they all were confirmed to be single parathyroid adenoma after MIS. Eight patients with atypical US findings (extrathyroidal cystic nodule 1, intrathyroidal adenoma 7) and 2 patients with undetectable lesion on US underwent MIS after localization by scintigraphy and CT. Four gland exploration was needed in only 1 patient with an extrathyroidal cystic nodule on US and negative scintigraphic study.

Conclusions: US is a sensitive and accurate method for preoperative localization of parathyroid adenoma, especially if the lesion has typical US features and is located inferiorly. We suggest that US is the first localization modality and scintigraphy or CT can be used in limited cases with negative US study.

 

Nothing to Disclose: JHY, SJK, JMK, MGH, HCK

20839 14.0000 SAT-257 A Ultrasonography Is the Localization Method of Choice in Primary Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Sujin Lee*1, Soo Hyun Lee2, Jong Ju Jeong2 and Yumie Rhee3
1Yonsei University College of Medicine, Seoul, 2Yonsei University College of Medicine, 3Yonsei Univ College of Medicine, Seoul, Korea, Republic of (South)

 

Objective: Most of the secondary hyperparathyroidism are corrected by successful renal transplantation. However, over-secretion of parathyroid hormone (PTH) with hypercalcemia, tertiary hyperparathyroidism (THPT), occurs in approximately 5% of the recipients of the renal transplantation. In THPT patients, parathyroidectomy is recommended when PTH fails to be normalized within 1 year after the transplantation. In order to predict exactly which patients would develop THPT, we retrospectively analyzed patients with or without THPT regarding the clinical parameters.

Methods: A total of 751 kidney transplantation recipients, transplanted during 2009 to 2013, were evaluated and the recipients were followed up for fully 2 years. Twenty eight patients with a functioning graft and diagnosed as THPT were selected with age, sex and renal function-matched controls. Seventy eight patients without THPT were selected as control group.

Results : Among all the biochemical parameters analyzed, significantly different factors were serum calcium, PTH, and alkaline phosphatase before renal transplantation and after 1-year renal transplantation (p < 0.05, respectively). Among the clinical factors, the duration of dialysis before the renal transplantation was significantly longer in THPT group compared to that of non-THPT group (p = 0.001). Moreover, patients with THPT received significantly more from the deceased donors while control group received from the living donors (p = 0.001). The rejection of the transplants was also significantly higher in THPT group by 2.89 folds (p = 0.025). By multiple logistic regression, significant risk factors for THPT were longer duration of dialysis (Odds ratio (OR) 1.02, p = 0.045), normocalcemia or hypercalcemia at the time of renal transplantation (OR 14, p = 0.035), and high log(PTH) (OR 5.12, p= 0.01).

Conclusion : We concluded that the renal transplant recipients with longer previous dialysis period and higher level of calcium and PTH before renal transplantation had significantly higher risk of developing THPT. Identifying significant risk factors for persistent tertiary hyperparathyroidism after renal transplantation will guide us to recognize earlier and make appropriate management plan for these patients.

 

Nothing to Disclose: SL, SHL, JJJ, YR

20855 15.0000 SAT-258 A Clinical Risk Factors of Persistent Hyperparathyroidism in Renal Transplant Recipients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Carles Villabona1, Manuel Munoz-Torres2, Xavier Badia3, Susan M. Webb*4 and Manuel Puig-Domingo5
1Hospital Universitario Bellvitge, L'Hospitalet de Llobregat, Spain, 2H. Universitario San Cecilio- Granada, Spain, Granada, Spain, 3IMS Health S.A-Barcelona, Spain, 4Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain, 5H.Universitari Germans Trias i Pujol-Badalona, Universitat Autònoma de Barcelona, Spain, Badalona, Spain

 

INTRODUCTION: A specific Health Related Quality of Life (HRQoL) questionnaire (PHPQoL questionnaire) was developed to assess the impact of primary hyperparathyroidism (PHPT) on patients HRQoL and its treatment. AIM: Validate PHPQoL questionnaire in clinical practice. MATERIAL AND METHODS: Observational, prospective, multi-centre study including 10 reference centers in Spain; 182 adult patients with active PHPT were included. Group A (patients initiating medical therapy or undergoing surgery) was evaluated at baseline, 3, 6 and 12 months after treatment to assess the ability of PHPQoL to detect changes related to treatment effect; Group B included clinically stable patients in which active treatment was not performed according to clinical guidelines, who were evaluated at baseline and 1 month to assess the reliability of the questionnaire. Sociodemographic (age, gender) and clinical variables (calcium, iPTH, treatments received) were collected at each study visit; patients also filled in several HRQoL questionnaires: SF-36, Psychological Well-Being Index (PWBI), a question on self-perceived health status and the disease-specific PHPQoL. PHPQoL is a unidimensional 16-item questionnaire, with a 5-point Likert scale for each answer and a recall period of the prior 4 weeks. Score ranges from 0 (worst HRQoL) to 64 (best HRQoL), which is transformed to a scale ranging from 0 to 100. RESULTS: Of the total sample, 79.7% were women; mean age (SD) was 60.3 (11.7) years (Group A: 104 patients; Group B: 78 patients). In Group A, 73.5% underwent surgery, after which circulating Ca (mg/dl) and iPTH (pg/ml) levels as well as the number of symptoms fell (<0.001) at 3, 6 and 12 months. In these patients a better HRQoL was observed than in those that did not show any decrease (p<0.001). In Group A, PHPQoL scores improved significantly 3 months after baseline (p< 0.001), and persisted at 6 and 12 months (p<0.001)  A parallel improvement was also seen for SF-36, PWBI and self-perceived health status scores (p< 0.001) at each follow-up visit in Group A. In terms of sensitivity to change, the PHPQoL score showed moderate changes (effect size > 0.4) at 6 months in patients who scored slightly better on their self-perceived health (Group A) (effect size=0.48). A difference of 9 points in PHPQoL score between two administrations of the questionnaire was found to be the minimum important difference perceived by patient, in terms of HRQoL, to be considered meaningful. No change in PHPQoL scores was observed in Group B at reevaluation after 1 month, demonstrating that the questionnaire has good test-retest reliability (intraclass correlation coefficient (ICC)= 0.839). PHPQoL showed good reliability in terms of internal consistency (α-Cronbach= 0.931) CONCLUSIONS: The PHPQoL questionnaire is a valid tool to be used in clinical studies in PHPT and to assess the patient’s health perception in usual clinical practice conditions.

 

Disclosure: CV: Investigator, Amgen. MM: Investigator, Amgen. XB: Consultant, Amgen. SMW: Advisory Group Member, Amgen. MP: Investigator, Amgen.

20932 16.0000 SAT-259 A Evaluation of Health Related Quality of Life in Patients with Primary Hyperparathyroidism with a New Tool: The Phpqol Questionnaire 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Serena Palmieri*1, Cristina Eller-Vainicher1, Elisa Cairoli1, Valentina Morelli1, Volha V. Zhukouskaya1, Anna Spada2 and Iacopo Chiodini1
1University of Milan, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Milan, Italy, 2Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy

 

CONTEXT: Hypercalciuria, frequently found in primary hyperparathyroidism (PHPT), generally normalizes after successful parathyroidectomy. However, hypercalciuria may persist in some patients. Currently, the factors related to this phenomenon have not been clarified. OBJECTIVE: To determine the prevalence of persistent hypercalciuria (PH) in our PHPT population and to establish factors related to this phenomenon. DESIGN: Retrospective longitudinal study. SETTING: Tertiary care center. PATIENTS/INTERVENTION: 95 PHPT patients successfully operated between 2008 and 2012 without renal dysfunction. MAIN OUTCOME MEASURE: Biochemical parameters of calcium metabolism before and 24 months after surgery were assessed. All histological findings were recorded. RESULTS: Before surgery 70/95 patients (73.7%) showed hypercalciuria, after surgery 30/95 patients (31.6%) had PH. At baseline PH patients showed lower calcium levels than patients without PH (10.9±0.6 vs 11.4±0.8, P=0.01) while the other parameters, in particular urinary calcium levels and prevalence of PHPT complications (osteoporosis, renal stones, hypertension), were comparable. After surgery serum calcium, phosphate and PTH levels were comparable between the two groups but only patients without PH improved BMD Z-score at spine and femur. The prevalence of the histological finding of parathyroid hyperplasia was significantly higher in PH patients (50%), as compared with controls (21.5%, P=0.01). The PH was positively associated with basal hypercalciuria (OR 4.71, 95% CI 1.18–18.8, P=0.03) and histological examination (OR 3.52, 95% CI 1.31–9.43, P=0.01). CONCLUSIONS: PH in present in 30% of surgically treated PHPT patients, the absence of BMD improvement is associated with PH. The parathyroid hyperplasia is associated with PH. Therefore it remains to be clarified the possible causative role of a pre-existent hypercalciuria in PHPT.

 

Nothing to Disclose: SP, CE, EC, VM, VVZ, AS, IC

21007 17.0000 SAT-260 A The Persistence of Hypercalciuria after the Recovery from Primary Hyperparathyroidism Is Associated with Parathyroid Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Barbara Lucchini*1, Stefan Bilz2 and Michael Brändle3
1Kantonsspital St. Gallen, St. Gallen, Switzerland, St. Gallen, Switzerland, 2Cantonal Hospital Saint gallen, St. Gallen, Switzerland, 3Cantonal Hospital St. Gallen, Switzerland

 

Background/Introduction:

Familial hypocalciuric hypercalcemia (FHH) due to loss of function mutations in the calcium sensing receptor gene (CaSR) is a rare but important differential diagnosis of primary hyperparathyroidism (pHPT) since it is not amenable to surgical cure. In addition to familiy history and genetic testing, assessment of renal calcium handling by measurement of the urinary calcium/creatinine ratio or fractional excretion of calcium (FE Ca) from both 24-hour urine collections and spot urins is considered an important diagnostic tool. A threshold of 0.01 has been reported to distinguish pHPT from FHH with a sensitivity of 85% and a specificity of 88%. Values > 0.01 are considered a diagnostic hallmark of pHPT whereas values below the cut-off require further diagnostic steps to rule out FHH. We assessed the accuracy of this threshold in a population of 40 patients with surgically proven pHPT.

Methods:

Preoperative FE Ca from simultaneously obtained early morning plasma and urine samples was assessed in 40 subsequent patients with surgically proven pHPT due to uninodular disease and related to various clinical and biochemical parameters. Surgical cure was defined as normocalcemia 6 weeks and/or 6 months after parathyroid surgery.

Results:

40 subjects (34 females, 6 males) with a mean age of 58 years were included in the study. Mean total and ionized calcium at referral were 2.71 ± 0.03 and 1.44 ± 0.02 mmol/l. Mean plasma PTH was 114 ng/l. All patients had preserved renal function (eGFR > 70 ml/min, CKD-EPI) and the majority (75%) was mildly vitamin D deficient (25-OH-Vitamin D3 20-75 nmol/l). FE Ca was below 0.01 in 27% of the patients. Patients with a FE Ca below 0.01 were younger (50 vs. 61 years, p=0.01), had lower total and ionized calcium concentrations (2.62±0.02 vs. 2.77±0.04 and 1.39±0.02 vs.1.47±0.02 mmol/l, p=0.04) and higher urinary creatinine concentrations (15±1.6 vs. 6±0.7 mmol/l, p=0.0001). All patients with a FE Ca below but only 14% with a FE Ca above the threshold had a creatinine concentration > 10 mmol/l in their spot urine samples.

Conclusion:

A FE Ca < 0.01 is present in 27% of patients with pHPT and application of this threshold to distinguish pHPT from FHH will result in unneccessary diagnostic tests to rule out FHH. A low FE Ca in subjects with pHPT is associated with younger patient age and borderline to mild hypercalcemia and is likely if the creatinine concentration in the spot urine sample to derive FE Ca is > 10 mmol/l.

 

Nothing to Disclose: BL, SB, MB

20246 18.0000 SAT-261 A A Low Fractional Urinary Excretion of Calcium Is Not Indicative of Familial Hypocaluric Hypercalcemia in Patients with Biochemically Mild Primary Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Carolina Aguiar Kulak*1, Victoria Zeghbi Borba2, Larrisa Savi3, Maicon P Lopes3, Ileana Bini3, Victor B Cury3, Rodrigo Kulchetscki3, Marco Assad3 and Breno Kliemann3
1Federal University of Parana, Curitiba, Brazil, 2Federal University of Parana, Curitiba-PR, Brazil, 3Federal University of Parana

 

Hypoparathyroidism (HP) is a metabolic disorder characterized by low serum levels of parathyroid hormone (PTH) or by resistance to its actions (pseudohypoparathyroidism); causing hypocalcemia and hyperphosphatemia. The treatment consists in calcium and vitamin D supplementation. Renal complications such nephrocalcinosis and nephrolitiasis have been valued by recent literature. The aim of this study was to evaluate the clinical profile and the prevalence of renal complications in patients with HP followed at the Bone Unit of a tertiary hospital (1990-2014).

Data related to age, gender, weight, HP etiology, age at the diagnosis, disease length, treatment doses of calcium carbonate, calcitriol and cholecalciferol were collected and analysed. Results from laboratorial exams of serum calcium, phosphate, serum levels of creatinine and PTH and urinary calcium were collected. The presence of renal disturbances was investigated through ultrasonography of urinary tract.

A total of 55 patients were identified, 76,3% were women; the median current age was 44,1 years old and the median duration of disease was 11,5 years. The most frequent etiology was the post-surgical, corresponding 74,5% of the cases, followed by primary HP with 16,3% and pseudo-HP with 9% of the cases. The serum calcium and creatinine levels significantly increased between the first and the last appointment (p<0,001 and p<0,05; respectively), and the phosphate serum levels decreased significantly in this period (p<0,001).  Mean (±SD) of 24 hour urinary calcium excretion was 173,5±117,3mg.  Forty out of 55 patients analysed, had ultrasonography of the urinary tract, and from these, 25% showed renal calcifications. There was no significant difference in the of urinary calcium excretion, dose of calcium and vitamin D between patients with renal disturbances compared to the others. The reduction of hypocalcemia and hyperphosphatemia suggests that the treatment was effective and the increase on serum creatinine indicate an impairment of the renal function.

In conclusion, the prevalence of renal complications was high, and similar to the literature, even in this group of young patients without a long history of the disease. None correlation between the renal calcifications and laboratorial findings or doses of calcium and vitamin D was found.

 

Nothing to Disclose: CAK, VZB, LS, MPL, IB, VBC, RK, MA, BK

21414 19.0000 SAT-262 A Prevalence of Renal Calcifications in Hypoparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Sara J. Healy*1 and Kyaw Kyaw Soe2
1The Ohio State Univ Wexner Med Ctr, Columbus, OH, 2The Ohio State Univ Med Ctr, Columbus, OH

 

Parathyroid carcinoma is a rare endocrine malignancy associated with a high rate of recurrence but prolonged survival. The goal of the study was to review cases of parathyroid carcinoma treated at our institution in the last 30 years. We reviewed clinical and pathological characteristics; treatments including surgery, radiation, and or chemotherapy; disease burden and metastasis; calcium and PTH levels; and complications and mortality.

We retrospectively identified patients who were treated for parathyroid carcinoma at our institution by searching for ICD-9 code for parathyroid carcinoma in the information warehouse. The study was approved by our institution’s IRB. After verifying the diagnosis in the patient’s chart, we identified seven patients, five men and two women, who were seen at our institution for parathyroid carcinoma. Age at diagnosis was 28-78 years and years of diagnosis were 1971-2014. One patient was African American and the rest were Caucasian. All patients were past or present smokers. The mean peak calcium was 14.9 mg/dl and peak PTH was 528 pg/ml. Original pathology was available for four of the patients, and all four had capsular invasion. Size of initial tumor was greater than 3 cm in three patients. Five of the seven patients are known to have recurrence and metastatic disease. Most had metastatic disease in the neck. One patient had spinal metastasis and two had lung metastasis. Time to treatment of first recurrence ranged from 3 to 28 years. All were treated with more than one surgery and one was treated with adjuvant radiation. Six out of seven patients had postoperative hypocalcemia requiring calcium supplements, and four patients required calcitriol. Four patients were treated with bisphosphonates and two were treated with cinacalcet. Two patients had a history of other malignancies including small cell lung cancer in one patient and squamous cell lung cancer, prostate cancer, and colon cancer in another patient. Two patients are known to be still alive, and two of the patients are known to have survived over 25 years after the initial diagnosis.

Parathyroid carcinoma is a slow growing neoplasm with a high rate of recurrence. Our cohort included a wide range of ages at diagnosis, and common presentations included the incidental finding of hypercalcemia or thyroid nodule. Most of our patients were Caucasian males and all were smokers. One of our patients may have had familial disease but genetic testing is not available. Parathyroid cancer may be initially misdiagnosed as benign parathyroid adenoma. Capsular invasion and metastasis is strong pathological evidence of carcinoma, and significant hyperparathyroidism and hypercalcemia and recurrence may help the clinician suspect parathyroid carcinoma. Surgery is the mainstay of treatment and postoperative hypocalcemia is common. Recurrence can occur many years later and long-term follow up is mandatory.

 

Nothing to Disclose: SJH, KKS

19848 20.0000 SAT-263 A Parathyroid Cancer Cases: A Single Center Experience 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Gita Avotina*1 and Ingvars Rasa2
1Riga East Clinical University Hospital, The University of Latvia, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia

 

Background: PHPT characterises with uncontrolled parathyroid hormone (PTH) secretion resulting in hypercalcemia. This condition can occur at any age, more commonly affects those older than 50 years (yrs) of age. Patients (pts) may have bone disease, renal manifestations, gastrointestinal symptoms, neuropsychiatric and cardiovascular manifestations. Aim of this study was to determine pts demographics, laboratory data, diagnostics and treatment methods of PHPT. Hypothesis of this study was that the patient profile in Riga East Clinical University Hospital is similar to describe in the medical literature.

Materials and methods: This hospital-based case-control and retrospective study analyzes 205 medical records of PHPT occurring in 163 pts admitted 01.01.2009 – 06.30. 2014 (5.5 yrs) to a tertiary care, multi-profile, Clinical University Hospital. The statistical data were processed using SPSS 16.0.

Results:87.1 % (n=142) of pts were female, 12.9 % (n=21) were male. Mean age was 60.8 ± 13.1 yrs. Mean calcium level was 2.81 ± 0.36 mmol/l (n=156). Mean PTH level was 248.17 ± 298.72 pg/mL (n=150). Mean phosphorus level was 0.90 ± 0.26 mmol/L (n=122). Mean alkaline phosphatase level was 87.46 ± 36.08 U/L (n=77). Mean vitamin D3 level was asessed for 30.7% of pts and it was 15.47 ± 0.09 ng/mL. Mean vitamin total vitamin D2,D3 level was asessed for 23.9% of pts and it was 23.55 ± 12.59 ng/mL. Using ultasonography, parathyroid adenoma was verified in 41.7 % (n=68) and suspected in 28.8 % (n=47). In 32.6 % (n=43) parathyroid adenoma was localised in right side, in 50.0 % (n=66) – in left side, in 3.8 % (n=5) – in both sides. Using CT, parathyroid adenoma was verified in 54.7 % (n=29), suspected in 20.8 % (n=11). In 30.2 % (n=16) parathyroid adenoma was localised in right side, in 35.8 % (n=19) – in left side, in 3.8 % (n=2) – in both sides, in 5.7 % (n=3) it was atipically localised. Using scintigraphy, parathyroid adenoma was verified in 52.9 % (n=27), suspected in 19.6 % (n=10). In 35.2 % (n=18) parathyroid adenoma was localised in right side, in 31.4 % (n=16) – in left side, in 5.9 % (n=3) – in both sides. Using SPECT/CT, parathyroid adenoma was verified in 66.7 % (n=6), suspected in 30.0 % (n=3). In 11.1 % (n=1) parathyroid adenomawas localised in right side, in 55.6 % (n=5) – in left side, in 22.2 % (n=2) – in both sides. DXA revealed osteoporosis for 80.5 % (n=33) and osteopenia for 24.4 % (n=10). Parathyroidectomy was treatment of choice for 46.0 % (n=75) pts.

Conclusions: Pts with PHPT in tertiary care multi-profile Riga East Clinical University Hospital is more often female, and the mean age is older than described in the literature. More often parathyroid adenoma is localised in the left side. Parathyroidectomy is treatment of choice for only 46.0% of pts.

 

Nothing to Disclose: GA, IR

20110 21.0000 SAT-264 A Primary Hyperparathyroidism (PHPT) Patient Profile in Tertiary Care Multi-Profile Riga East Clinical University Hospital–5.5 Years Data 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Ross Molinaro*, Cheryl Krumm, Harry Leipold, Mariah Arcuri, Jessica Sica and Eddine Merabet
Siemens Healthcare Diagnostics, Inc., Tarrytown, NY

 

INTRODUCTION: Parathyroid hormone (PTH) is the primary endocrine regulator of calcium metabolism and plays a major role in the regulation of mineral metabolism and skeletal physiology. The continuous advancement of Acridinium Ester (AE) chemiluminescence technology by Siemens Healthcare Diagnostics has led to the development of significantly improved commonly used clinical assays with higher performance and reliability.  Recent developments have established the groundwork for assays with even better low-end precision and sensitivity, enhanced reagent stability, higher throughput, wider measuring range, and smaller sample volumes. The latest application using this technology is an improved intact Parathyroid Hormone (iPTH) assay on the Siemens ADVIA Centaur® systems. 

OBJECTIVE: To present the performance of the new ADVIA Centaur iPTH assay and compare it to a previous iPTH assay generation.

MATERIALS & METHODS: The ADVIA Centaur Intact PTH assay is a two-site sandwich immunoassay using the most advanced chemiluminometric technology.  The reagent uses two anti-human PTH antibodies specific to the intact polypeptide parathyroid hormone (1-84 amino acids). The first antibody in the Lite Reagent is a monoclonal mouse anti-human PTH (N-terminal) antibody labeled with acridinium ester. The second antibody is a biotinylated monoclonal mouse anti-human PTH (C‑terminal) antibody that is preformed to streptavidin coated paramagnetic latex particles in the Solid Phase.   The replacement of polyclonal antibodies with monoclonal antibodies makes this assay more reliable and reduces lot to lot variability.

RESULTS: The ADVIA Centaur iPTH assay under development has a measuring range of up to 2,900 pg/mL.  Limit of Blank (LoB), measured according to CLSI EP17-A, is found to be 1.0 pg/mL.  A precision study based on CLSI EP-05 was conducted over 20 days.  Between run imprecision at 10, 40, and 400 pg/mL was less than 6%.  Within run imprecision at the 3 levels was less than 1.5%.   Method comparison against the previous PTH generation was evaluated according to CLSI EP-09 and found to be in good agreement across the measuring range ( r=0.99, slope= 1.04, and y intercept< 5 pg/mL).  No high dose hook effect was present in PTH concentrations up to 100,000 pg/mL.   Cross reactivity to common PTH fragments was less than 0.01%.  Sample volumes have been reduced to 50 uL of serum, EDTA, Li-Heparin, or Na-Heparin plasma.

CONCLUSION: The new ADVIA Centaur iPTH assay under development combines a strong analytical performance, a fast turnaround time, and smaller sample volumes, with the advantage of rapid automated ADVIA Centaur immunoassay systems.  These factors should benefit both the clinician and laboratorian using PTH tests for the management of patients with different disease states.

Under development. Not available for sale.

 

Disclosure: RM: Employee, Siemens Healthcare Diagnostics, Inc.. CK: Employee, Siemens Healthcare Diagnostics, Inc.. HL: Employee, Siemens Healthcare Diagnostics, Inc.. MA: Employee, Siemens Healthcare Diagnostics, Inc.. JS: Employee, SIemens Healthcare Diagnostics, Inc.. EM: Employee, SIemens Healthcare Diagnostics, Inc..

19976 22.0000 SAT-265 A Meeting Evolving Clinical Demands for Assay Performance: Development of an Intact PTH Assay on the Siemens ADVIA Centaur Systems Using an Advanced Acridinium Ester Technology 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Guillermo Martinez Diaz-Guerra1, Sonsoles Guadalix2, Florencio Garcia1, Natalia Melon3, Jose Ignacio Martinez-Pueyo1, Eduardo Ferrero4 and Federico G Hawkins*2
112 Octubre University Hospital, 2Hospital Universitario 12 de Octubre, Madrid, Spain, 312 Ocubre University Hospital, 412 de Octubre University Hospital

 

Introduction: Surgery indications for PHPT are currently being reviewed.

Objective:  The aim of our work was to analyze clinical and biological characteristics of the patients who underwent surgical intervention for PHPT in our hospital between January 1997 and June 2014.

Patients and methods:  A review of medical records of 272 patients with PHPT was carried out.

Results: Mean age was 59.6 ± 14 years, 82% were women and 55% of patients were asymptomatic. Parathyroidectomy indications were: renal stones in 32%, hypercalcemia (>11.2 mg/dl) in 38.6%, low bone mass in 30% and glomerular filtrate <60 ml/min in 2.6%. The sensitivity for preoperative localization of sestamibi-scan was 92% and 69% for cervical ultrasonographyHistopathology of parathyroid glands showed that adenomas accounted for 94.5% of cases and hyperplasia in 5.5% of cases. Patients with adenomas were older than patients with hyperplasia (61 ± 13 vs 41 ± 19 yearsp<0.001) and had higher serum Ca2+ levels (11.5 ± 0.9 vs 10.9 ± 1 mg/dL; p<0.05). Nine patients showed MEN-1; seven of them had parathyroid hyperplasia. The percentage of patients who were cured was 95% within 1 year.

Conclusions: Asymptomatic disease was slightly more frequent in our study. The most frequent indication of parathyroidectomy was hypercalcemia and renal stones. Sestamibi-scan showed a high accuracy rate for preoperative parathyroid localization.PHPT is a treatable disorder with a high chance of success through surgery.

 

Nothing to Disclose: GM, SG, FG, NM, JIM, EF, FGH

19445 23.0000 SAT-266 A Parathyroidectomy in Primary Hyperparathyroidism (PHPT): Retrospective Study of 272 Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 244-266 5958 1:00:00 PM Parathyroid Disorders Poster


Maria Javaid, Jennifer Auer Sutter, Beatriz E Ramirez and Fiona J Cook*
Brody School of Medicine, Greenville, NC

 

Introduction: Autosomal dominant hypocalcemia (ADH) is a rare disorder associated with variable clinical severity. This disorder is caused by activating mutations in the calcium sensing receptor (CaSR) gene. ADH has also been associated with premature osteoarthritis of the knees and short stature.(1) We present a kindred with ADH in which the index case has a CaSR mutation previously reported in one other family.(2) In our kindred, premature small joint osteoarthritis is also noted in multiple generations.

Clinical Cases: Our index case (generation IV), a 15 year old female followed in pediatric endocrinology clinic, presented in her neonatal period with severe hypocalcemia resulting in seizures and tetany. She took calcium and calcitriol until age 3. She remained asymptomatic off these medications until age 11, when calcium and calcitriol were resumed due to moderate hypocalcemia. Her CaSR gene analysis revealed a missense mutation causing the amino acid change p.Glu767Lys at position 2299 in Exon 7. This mutation co-segregates with hypocalcemia in a previously reported kindred (2) and has been associated with an increase in calcium affinity of the mutant CaSR.(3) In the adult endocrinology clinic, the 66 year old grandmother of the index patient (generation II) presented for continued treatment of hypocalcemia, hyperphosphatemia, hypoparathyroidism, and hypercalciuria. She was diagnosed with mildly symptomatic hypocalcemia in her fourth decade, treated with calcium and calcitriol. She has short stature (1.47 meters) and striking deformities consistent with osteoarthritis of the small joints of both hands with onset in the fourth decade. Three members of generation I and at least one member of generation III (also seen in our clinic) also suffer from hypocalcemia and early onset osteoarthritis in the hands.

Conclusion: More than 70 activating mutations in the CaSR have been previously reported in the literature, with clinical features ranging from asymptomatic to severe hypocalcemia with or without Bartter’s syndrome (4). The kindred we describe adds to this body of literature, and demonstrates an apparent association of a CaSR gene mutation with premature osteoarthritis of the small joints in the hands. As the CaSR is expressed widely in various organs of the body, including cartilage and bone, more studies in patients with ADH may elucidate the role of the CaSR in the health of the skeleton and joints. (5,6)

 

Disclosure: FJC: Investigator, (spouse), Speaker Bureau Member, (spouse), Speaker Bureau Member, Forrest (spouse), Investigator, Gilead (spouse) . Nothing to Disclose: MJ, JAS, BER

21441 1.0000 SAT-200 A Early Onset Osteoarthritis in a Novel Kindred with Autosomal Dominant Hypocalcemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Sahar M Hindi*1, Yongmei Wang2, Kirk D. Jones1, Jesse C. Nussbaum1, Yongen Chang1, Umesh Masharani3, Daniel D Bikle4, Dolores M. Shoback4 and Edward C. Hsiao5
1University of California, San Francisco, San Francisco, CA, 2Veterans Affairs Medical Center and University of California, San Francisco, San Francisco, CA, 3Unversity of California, San Francisco, San Francisco, CA, 4University of California San Francisco, San Francisco, CA, 5University of California-San Francisco, San Francisco, CA

 

Introduction:  Foreign body-induced granulomas are a rare cause of hypercalcemia.  The molecular mechanisms are uncertain, although extrarenal 1,25(OH)2D production has been suggested.  We evaluated a man with severe hypercalcemia who received poly(methyl methacrylate) (PMMA) injections for cosmetic purposes.  To determine the mechanism, we performed muscle biopsy and immunohistochemical staining to localize expression of CYP27B1.

Clinical Case:  A 52 year-old man with well-controlled HIV/HBV co-infection for 25 years reported a 3-month history of fatigue, polyuria, and weight loss.  Physical exam was notable for prominent muscles and diffuse tenderness.  Review of systems was negative except for myalgia.  Labs showed elevated corrected serum calcium [14.6 mg/dl (nl, 8.8-10.3)], creatinine [2.02 mg/dL (nl, 0.77-1.22)], and 1,25-dihydroxyvitamin D [1,25-D, 128 pg/ml (nl, 18-72)].  Parathyroid hormone [PTH, < 3 pg/ml (nl, 12-65)], PTH-related protein [0.2 pmol/L (nl < 2.0)], and 25-OH vitamin D [17 ng/ml (nl, 30-100)] were low.  Serum phosphate, TSH, and morning cortisol levels were within normal limits.  CD4 was 378 [nl, 410 - 1590 x10E6/L], and there were no signs of opportunistic infection.

Work-up for 1,25-D-mediated hypercalcemia was pursued.  Serum angiotensin converting enzyme was elevated [ACE, 200 U/L (nl, 9-67)].  A non-contrast CT showed no evidence of sarcoid but nodular soft-tissue densities in both buttocks.  FDG-PET scan showed uptake in the subcutaneous tissue of the proximal thighs and buttocks, without tracer-avid lymphadenopathy or masses.  Malignancy work-up, including bone marrow biopsy and serum/urine protein electrophoresis with immunofixation, was negative. 

The patient later revealed a history of cosmetic injections with PMMA to treat HIV lipodystrophy, first in his buttocks in 2008 and then his deltoids in 2013, one month prior to symptom onset.  Biopsies from both sites showed florid giant cell reaction with histiocytic infiltration surrounding globules of amorphous material (PMMA).  Muscle samples stained with antibody to CYP27B1 (25-OH vitamin D3 1-alpha-hydroxylase) revealed strong histiocytic expression of CYP27B1. 

The patient was treated for acute hypercalcemia with intravenous (IV) fluids and pamidronate.  After 5 weeks, he received IV zoledronic acid for persistent hypercalcemia, followed by a 1-week course of methylprednisolone.  His serum calcium subsequently normalized.  Three months later, he had a relapse of severe hypercalcemia, which resolved after a second dose of IV zoledronic acid and a short course of methylprednisolone.

Conclusion:  Although uncommon, substantial activation of granulomatous reaction to foreign substances is an important cause of hypercalcemia in clinical practice.  Here, we show the mechanism of calcitriol-mediated hypercalcemia with elevated CYP27B1 in the rare setting of foreign body reaction to PMMA injections.

 

Disclosure: ECH: Researcher, Clementia Pharmaceuticals, Researcher, March of Dimes, Researcher, Doris Duke Charitable Foundation. Nothing to Disclose: SMH, YW, KDJ, JCN, YC, UM, DDB, DMS

21454 2.0000 SAT-201 A Hypercalcemia and Overexpression of CYP27B1 in Muscle Lesions in a Patient with HIV Infection after Poly (methyl methacrylate) Injections for Wasting 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Ritu Madan*1, Joanna Klubo-Gwiezdzinska2, Michael T. Collins3, Stephen J Marx4 and William F Simonds5
1National Institutes of Health, Bethesda, MD, 2National Institute of Health, Arlington, VA, 3National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 4National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, 5NIH

 

Severe hypercalcemia in parathyroid cancer patients is associated with a high morbidity and mortality. The standard management of parathyroid cancer consists of surgical resection of the tumor, chemotherapy, and alleviation of hypercalcemia with bisphosphonates and cinacalcet. We present the clinical course of PTH-mediated hypercalcemia in a parathyroid cancer patient successfully treated with anti-RANK ligand monoclonal antibody denosumab.

Clinical Case

A  65 yo Caucasian male presented with primary hyperparathyroidism in 2002 with calcium of 12 mg/dl  Pathology report after excision of left lower parathyroid tumor was consistent with parathyroid cancer . Follow up studies 2 years after the initial surgery revealed persistent/recurrent disease in the neck, rising serum ionized calcium (iCa) 1.51-2.29 mmol/l (normal N 1.12-1.32 mmol/l) and PTH 970-1900 pg/ml (N10-65 pg/ml), requiring four additional neck explorations between 2005 and 2011 for locally invasive disease. After the last surgery PTH levels decreased to 122 pg/ml and iCa normalized for 3 months. Subsequently, therapy with cinacalcet was not effective in controlling hypercalcemia as dosage maximization was not possible due to significant gastrointestinal side effects. Bisphosphonates could not be used due to the presence of kidney disease (CrCl 14 ml/min/m2). Therefore, therapy with Denosumab 60 mg s.c. was initiated when the patient presented with symptomatic hypercalcemia of 13.6 mg/dl(N 8.2-10 mg/dl) . This resulted in a dramatic response  with total calcium nadir of 6.24 mg/dl and phosphorous levels dropped to 1.6 mg/dl (N 2.5-4.5 mg/dl) The response was transient and the patient subsequently required denosumab dose increase viz. monthly injections of 120 mg for next 13 months. With this treatment, the patient remained normocalcemic to mildly hypercalcemic with calcium levels in the range of 8.28-11 mg/dl with normal albumin levels and stable renal function (CrCl 14-34 ml/min/m2).  Nevertheless, during this period of time the patient gradually developed structural and biochemical disease progression with neck mass growth from 1.5 cm to 5 cm and PTH increase from 1519 pg/ml to >5000 pg/ml. Therefore, the patient underwent another palliative tumor debulking, resulting in PTH decrease to 2270 pg/ml. Interestingly, the patient developed significant postoperative hypocalcemia, which was attributed to pre-treatment with denosumab possibly complicating postoperative hungry bone syndrome. 

Conclusion:

 Prolonged use of denosumab was highly effective in controlling parathyroid cancer related hypercalcemia  resistant to standard treatment  in this patient. There are 6 case reports of use of denosumab in parathyroid cancer related hypercalcemia but in only one case was denosumab given long term i.e. for 16 months. It is unknown if patients develop resistance to the drug’s effect in the long term

 

Nothing to Disclose: RM, JK, MTC, SJM, WFS

21308 3.0000 SAT-202 A Denosumab Is Effective in Long Term Control of Hypercalcemia from Parathyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Saraswathi Saiprasad*1, J Chris Gallagher2 and Robert J Anderson3
1VA - Nebraska Western Iowa Healthcare System / Creighton University Medical Center, Omaha, NE, 2Creighton University Medical Center, Omaha, NE, 3VA - Nebraska Western Iowa Healthcare System / Creighton University Medical Center, Omaha, NE

 

Introduction: This is a case of magnesium deficiency causing hypocalcemia as a result of functional hypoparathyroidism (FH). Regular intravenous (IV) magnesium has to be given to maintain magnesium and calcium levels in normal range.

Clinical Case: A 61 year old male presented with chronic malabsorption secondary to “short gut” syndrome. He had about 3 feet of his small intestine (ileum) in addition to right hemicolon removed 5 years previously for pneumotosis intestinalis and ileal-cecal volvulus.

He presented with cramps in his hands, neck and legs. Serum results: calcium 7.0 mg/dl (normal 8.4-10.2), ionized calcium 3.92 mg/dl (4.48-5.20), magnesium 0.4 mg/dl (0.6-2.3), phosphate 4.7 mg/dl (2.6-4.9), PTH 18 pg/ml (8-53), albumin 4.2 g/dl (3.5-5), 25OH D 20 ng/ml (27-100) and creatinine 0.8 mg/dl (0.7-1.5). Hypocalcemia due to magnesium deficiency was diagnosed. Due to intestinal malabsorption he was started on intravenous magnesium sulfate 5 grams intravenously twice a week. (1gm MgSO4=8.12 mEq of magnesium). After 3 hours, serum levels were: calcium 7.1 mg/dl; magnesium 2.3 mg/dl; PTH 88pg/ml. Two days later, serum values were: calcium 10.1 mg/dl; magnesium 1.4 mg/dl; PTH 40 ng/ml. After 7 days, the serum calcium was 9.9 mg/dl, and magnesium was 1.3 mg/dl. The magnesium sulfate dose was increased to 6gm three times a week. This was later switched to 8gm twice a week for the sake of patient’s convenience. He requires this dose long-term via a port to maintain his serum calcium in the normal range. He is now asymptomatic. His most recent labs: calcium 9.9 mg/dl; ionized calcium 1.3 mg/dl, magnesium 1.4 mg/dl; PTH 70pg/ml, 25OH D 29 ng/ml.

Conclusion: Hypomagnesemia should be suspected in cases of hypocalcemia associated with chronic intestinal malabsorption. The main cause of hypocalcemia is “functional hypoparathyroidism.” Long-term intravenous magnesium may be needed if the hypocalcemia is chronic and severe. Magnesium is required for conversion of ATP to cAMP by the enzyme adenylate cyclase. cAMP is a mediator of peripheral actions of PTH and regulates PTH secretion by the parathyroid gland. Defective production of cAMP in the parathyroid gland causes failure to secrete parathyroid hormone by exocytosis. Magnesium replacement increases serum PTH within minutes, whereas hypocalcemia takes 24-48 hours to normalize. This may be due to a delayed responsiveness of kidney and bone to parathyroid hormone.

 

Nothing to Disclose: SS, JCG, RJA

21505 4.0000 SAT-203 A Chronic Functional Hypoparathyroidism Due to Magnesium Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Ana Heloisa Correia Bresque*1, Ricardo A Guerra2, Magnus R Dias da Silva3, Christiane Andrade de Azevedo4, Giovanna Mozardo Duarte5, Victor Sousa da Silveira4, Vanessa Castro Ramos6, Climerio Pereira do Nascimento Jr.7 and Livia Marcela Santos8
1Hospital do Servidor Público Estadual, Sao Paulo, Brazil, 2Hospital do Servidor Publico Estadual de Sao Paulo, 3UNIFESP, Sao Paulo, 4Hospital do Servidor Público Estadual, 5Hospital do Servidor Público Estadual de São Paulo, 6Hospital do Servidor Público Estadual de São Paulo, Brasil, Sao Paulo, Brazil, 7Hospital do Servidor Público Esatdual de Sao Paulo, 8UNIFESP, Sao Paulo, Brazil

 

Introdution

MEN1 is a syndrome diagnosed when two of the following three tumors present in a patient: parathyroid, duodeno-pancreatic or pituitary. It’s a rare disease that can cause morbidity and shortening of life expectancy. Mutations in MEN gene, localized in cromossomo 11, are usually the main cause of MEN1. This gene doesn’t have hot spots and more than 1000 Mutations have been described but despite that, we report a patient diagnosed with the syndrome carring a mutation never described until now.

Clinical Case

A 66 year-old woman with previous partial grastrectomy because of an ulcer 39 years ago presents with friable lesion of 6,4x5,7 cm in the fundus. A total gastrectomy was perfomed and the immunohistochemistry showed a  neuroendocrine tumor.  Her gastrin was > 1000 pg/ml (13 – 115 pg/ml), total calcium was 11,0 mg/dl (8,7 – 10,0) and the ionic calcium was 1,37 mg/dl (1,21 – 1,31 mg/dl).

The MEN1 diagnosis was suspected and the patient underwent a MR, wich showed a slight pituitary asymmetry. Her prolactin levels were 197 (0-25 ng/ml) and she didn’t have any symptoms. A CT scan of abdomem was also performed and a lesion on the left adrenal was found, with 3,7 cm of diameter, with irregular edges, punctate calcifications and enhancement to the contrast. A laboratory investigation showed that this was a non-functional lesion.  A biopsy guided by CT scan wasn’t possible because of anatomic reasons and so she was subjected to a left adrenalectomy. The pathological analysis and immunohistochemistry confirmed that it was a simple adenoma and it is known that adrenal tumors can occur in patients with MEN1. The US of the cervical region demonstrated 2 lesions well delimitated in the inferiors right and left region of thyroid, measuring 18x7 mm and 15x6 mm, respectively. The scintigraphy confirmed abnormal captation in these sites. Her bone densitometry showed T-scores of -5,4 in the spine, -3,9 in the neck , -4,2 in the total femur and -5,4 in the radius 33%.

She was subjected to a total parathyroidectomy with reimplantation of a part of a parathyroid in the forearm. After the surgery the PTH levels, that was 414 pg/ml (12-72 pg/ml) just before, decreased to 37,3 pg/ml, with total calcium 8,5 mg/dl (8,8-10,6 mg/dl) and ionic calcium 1,17 mmol/L (1,17-1,43 mmol/L).  She didn’t developed hypocalcemia.

The genetic testing revealed a novel mutation in the MEN1 gene: p.Pro12delCfs (c.35delC) and p.Asn189Ser (c.567A>g). This mutation causes a deletion in 1bp in the exon 2, codon 12, causing a frameshift and a stop in codon 118.

She didn’t report any case in the family and her sons didn’t have any abnormality in the laboratory test and in the genetic test.

Conclusion

We report a novel mutation, based in the data available in the NHLBI Exome Sequencing Project and in The Human Gene Mutation Database, of the MEN1 gene what can be associated with the clinical manifestations of MEN1 in this patient.

 

Nothing to Disclose: AHCB, RAG, MRDD, CADA, GMD, VSDS, VCR, CPD Jr., LMS

21540 5.0000 SAT-204 A A Novel Mutation in MEN1 Gene in a 66 Year-Old Female: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Nathalia Lisboa Rosa Almeida Gomes*1, Bruno Muzzi Camargos2, Fabiano Franco Monteiro Prado1, Delaine Cleuber Silva1, Maria Regina Calsolari1, Alan Brett3, Keenan Brown3, Angelica Maria Franca Paiva Tiburcio1 and Barbara Campolina Carvalho Silva1
1Santa Casa de Belo Horizonte, Brazil, 2Hospital Mater Dei, Brazil, 3Mindways Software

 

Background: Measurement of areal bone mineral density (BMD) by dual X-ray absorptiometry (DXA) is considered the gold standard for diagnosis of osteoporosis and fracture risk assessment. Despite its widespread use and clinical utility, DXA has a number of limitations. Areal BMD (aBMD) is influenced by bone size such that true BMD is underestimated in those with smaller bones and overestimated in those with larger bones. To this end, quantitative computed tomography (QCT) measurement of volumetric BMD (vBMD), which is not affected by bone size, may offer advantages over DXA in individuals whose lower aBMD seems to reflect their smaller bone geometry rather than reduced bone strength. We report a case of a man with SHORT syndrome (an acronym for Short stature, Hyperextensibility of joints and/or inguinal Hernia, Ocular depression, Rieger anomaly, and Teething delay), who was found to have very low aBMD by DXA, despite the absence of previous fragility fractures.

Case report: A 50-yr-old man with SHORT syndrome was referred to our Metabolic Bone Diseases unit for evaluation of severe osteoporosis. Further history revealed type 2 diabetes, hypertension, and glaucoma. His medications included insulin, enalapril, amlodipine, aspirin, simvastatin, and calcium supplements. Physical examination was remarkable for his short stature, 129 cm in height, distinctive facial features (facial gestalt), and low visual acuity. His body mass index (BMI) was normal at 21.9Kg/m2. BMD by DXA showed T- and Z-scores of -3.6 and -1.9 at the lumbar spine, -4.1 and -2.5 at the femoral neck, and -3.1 and -1.9 at the total hip, respectively. Lateral spine radiographs did not show vertebral fractures, and his medical history was negative for fragility fractures. Extensive evaluation for secondary causes of osteoporosis, including hyperthyroidism, hyperparathyroidism, hypogonadism, Cushing’s syndrome, calcium and vitamin D deficiency, celiac disease, alcoholism, renal and liver disease, and growth hormone deficiency, was performed and ruled out any condition related to bone loss. QCT at L1-L2 and femur was then performed using QCT Pro 5.1 (Mindways, Austin, TX) according to manufacturer’s instructions. Remarkably, QCT results showed normal vBMD at the lumbar spine (L1-L2: 148 mg/cm3) and low, but not indicative of osteoporosis, vBMD at the femur (total hip: 112 mg/cm3; femoral neck: 117 mg/cm3).

Conclusion: We report a case of a 50-yr-old man, with short stature, whose true BMD was clearly underestimated by DXA, as shown by the finding of a normal vBMD assessed by QCT at the spine, and a low-normal vBMD at the femur. While QCT is not widely available and offers a relatively high radiation exposure, our results suggest that it may be helpful in selecting individuals whose aBMD measured by DXA does not reflect bone strength and fracture risk.

 

Disclosure: AB: Employee, Mindways Software, USA. KB: Employee, Mindways Software, USA. Nothing to Disclose: NLRAG, BMC, FFMP, DCS, MRC, AMFPT, BCC

21543 6.0000 SAT-205 A Clinical Applicability of Quantitative Computed Tomography (QCT) in Individuals with Small Bone Sizes and Low Bone Mineral Density By DXA 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Geoffrey Chu Chin* and Babette Carlson Glister
Walter Reed National Military Medical Center, Bethesda, MD

 

Background: Teriparatide is the first anabolic agent approved for osteoporosis.  Side effects range from common (arthralgia, pain, nausea) to rare (osteosarcoma).  We present two cases of significant liver associated enzyme (LAE) elevations after starting Teriparatide.  To our knowledge this has not been previously reported.  In rat hepatocytes, PTH was associated with decreased cytochrome P450 levels (1) and may be a potential mechanism for drug-induced hepatotoxicity.

Case #1: 68 yo Asian woman with osteoporosis was switched to Teriparatide due to worsening femoral neck T-score (-2.6) on Alendronate.  Other medications included Atorvastatin, Gabapentin, Fexofenadine, Esomeprazole, Calcium/Cholecalciferol, Ibuprofen, Pseudoephedrine, and an herbal tea.  Baseline LAE were Alkaline phosphatase (AP) 68 U/L (35-105), Bilirubin (TB) 0.5 mg/dL (0-1), AST 17 U/L (0-32), ALT 6 U/L (0-33).  TSH, 25-OH Vitamin D, Calcium, and PTH were normal.  Routine labs 9 months later showed AP 428 U/L with Gamma-glutamyl transpeptidase (GGT) 481 U/L (6-42).  All medications were held, but LAE peaked 4 months (AP 937 U/L, GGT 822 U/L, TB 1.2 mg/dL, AST 290 U/L, ALT 116 U/L) and normalized 14 months after discontinuation.  Workup showed negative titers for ANA, Liver Kidney Microsomal Ab, Smooth Muscle Ab, Mitochondria Ab; negative serologies for HBV, HCV; and normal levels of Ceruloplasmin, Iron, A1AT, CEA, CA 19-9, AFP, ACE.  Liver Ultrasound and MRI showed mild steatosis.  She was asymptomatic and synthetic liver function was unaffected. 

Case #2: 59 yo Caucasian woman with osteoporosis (femoral neck T-score -3.1) and cervical radiculopathy was referred for Teriparatide therapy ahead of Anterior Cervical Discectomy and Fusion.  Other medications included Diazepam, Alprazolam, Zolpidem, Venlafaxine, Butalbital/Acetaminophen/Caffeine, Esomeprazole, Cholecalciferol, and Conjugated Equine Estrogens/Medroxyprogesterone.  Baseline LAE were AP 56 U/L, TB 0.2 mg/dL, AST 24 U/L, ALT 38 U/L.  TSH, 25-OH Vitamin D, Calcium, and PTH were normal.  She suffered a self-limited flu-like illness (nausea, myalgias, mild fever, chills) after starting Teriparatide.  Routine LAE 2 months later showed AP 362 U/L, TB 0.5 mg/dL, AST 634 U/L, ALT 1088 U/L, GGT 512 U/L.  Workup showed: negative titers for ANA, Smooth Muscle Ab, Mitochondrial Ab; negative serologies for HAV, HBV, HCV; and normal levels of Acetaminophen, Ceruloplasmin, Iron.  Ferritin was 3654 ng/mL (13-150) but Hemochromatosis DNA panel was negative.  Liver Ultrasound was normal.  Teriparatide was discontinued and LAE normalized in 1 month.  She had slight nausea but synthetic liver function was unaffected.

Conclusion: Although the mechanism for hepatotoxicity and causality are unclear, clinicians should consider checking LAE on patients taking Teriparatide.  PTH-mediated pathways may lead to hepatotoxicity via protein kinase A, protein kinase C, or NF-κB (1).

 

Nothing to Disclose: GCC, BCG

21549 7.0000 SAT-206 A Case Reports: Teriparatide and Hepatotoxicity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Thanh Duc Hoang* and Alfred Francis Shwayhat
Naval Medical Center San Diego, San Diego, CA

 

Background:  Ultrasound-guided (US) fine-needle aspiration (FNA) of the parathyroid gland is infrequently performed.  We report a case in which FNA of an intrathyroidal parathyroid adenoma confirmed abnormal parathyroid tissue in a patient who underwent previous bilateral neck exploration which failed to correct her hyperparathyroidism. 

Case Presentation: A 44 year-old female presented with increased fatigue, forgetfulness, and esophageal reflux.  The patient was taking an ace inhibitor for hypertension and a statin for hyperlipidemia.  The patient had no pertinent family medical history.  Physical examination was normal.  Laboratory data: serum calcium 11.0 (8.9-10.3 mg/dL), albumin 3.8 (3.5-5.0 mg/dL), PTH intact 167 (ref 10-65 pg/mL), phosphate 2.1(2.5-4.6 mg/dL), 25-hydroxy-Vitamin D 11 (30-100 ng/mL). Parathyroid sestamibi scan suggested a right inferior parathyroid adenoma.  Patient underwent bilateral neck exploration without identified parathyroid adenoma.  Postoperatively PTH 184 pg/mL, phosphate 2.2 mg/dL, calcium 11.1 mg/dL. Bedside thyroid ultrasound showed a 9mm hypoechoic lesion with increased vascularity within the inferior portion of the right thyroid lobe.   Repeat sestamibi scan showed a focus of increased accumulation of radiotracer in the inferior pole of the right thyroid lobe, suspicious for intrathyroidal parathyroid adenoma.  FNA of this lesion showed lymphocytic thyroiditis with cystic degenerative changes; however, PTH measurement from FNA was 4737 pg/mL, confirming a parathyroid adenoma. The patient then underwent right thyroid lobectomy with without complications. Postoperative PTH 14.9 pg/mL, calcium 9.4.  Pathology showed a right inferior intrathyroidal parathyroid adenoma 0.6 cm (0.334 g) with benign thyroid tissue.

Discussion:   FNA of a parathyroid adenoma can mimic cytological features of lymphocytic thyroiditis; however, aspirates of parathyroid adenoma show elevated intact parathyroid hormone measurements (1,2).  It has been reported that cytology and immunocytochemistry may play an important role in the interpretation of US-guided FNA for preoperative localization of parathyroid tissue (3). If an intrathyroidal parathyroid gland is suspected in a patient with primary hyperparathyroidism, an FNA can distinguish adenoma from a thyroid nodule.

Conclusion:  This case demonstrated the usefulness of FNA of parathyroid lesion in a patient with primary hyperparathyroidism and an intrathyroidal parathyroid adenoma who had failed prior bilateral neck exploration. It may be important to perform a combined approach of cytology and PTH measurement (immunochemistry) in diagnosing and localizing parathyroid tissue.

 

Nothing to Disclose: TDH, AFS

21564 8.0000 SAT-207 A The Usefulness of Fine Needle Aspiration in Hyperparathyroid Patients with Intrathyroidal Parathyroid Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Anshu Alok*1, Kadapalakere Reddy2, Nitesh D Kuhadiya3, Antoine Makdissi4 and Manav Batra5
1State University of New York at Buffalo, 2State University of New York at Buffalo, Amherst, NY, 3University at Buffalo, Buffalo, NY, 4State University of New York at Buffalo, Buffalo, NY, 5SUNY at Buffalo, Buffalo, NY

 

INTRODUCTION:

Denosumab is a human monoclonal anti RANKL antibody (receptor activator of NFκB ligand), which inhibits activation of the RANK receptor and reduces osteoclast activity and bone resorption. We report a case of life threatening hypocalcemia in a patient with vitamin D deficiency caused after administration of Denosumab.

CASE:

32-year-old African-American lady with past medical history of rickets secondary to vitamin D deficiency presented to ER with severe carpo-pedal spasms. Her past history included a fracture at age 3 and left femur traumatic fracture at age 29, which required intramedullary rod placement. Based on DEXA scan, she was diagnosed with osteoporosis and received 60mg denosumab subcutaneously. Within 24 hours of administration she developed, numbness and tingling along with spasms in all extremities and presented to the ER. She was found to be severely hypocalcemic with ionized calcium of 2.2mg/dL(4.7-5.3) and total calcium of 4.7 mg/dL(8.5-10.5). She had magnesium of 1.1 mg/dL(1.7-2.7),  phosphate of 2.7 mg/dL(2.5-4.8), 25 OH Vitamin D of 17 ng/mL(30-100) and elevated intact PTH levels of 428 pg/ml(12-72).

On examination she had positive Chvostek’s and Trousseau signs with skeletal exam showing frontal bossing, scoliosis and bowed legs. Skeletal survey revealed looser’s zone and arrest lines.

Her hypocalcemia was very resistant to treatment and required aggressive replacement of calcium, magnesium, Vitamin D and calcitriol.  She received intravenous(IV) calcium of 25 g over a period of 10 days and oral calcium carbonate at 1300 mg TID which was further increased to 5000mg TID. She received 50,000 Units of vitamin D daily along with Calcitriol of 1mcg daily. In addition, she received 24 g of magnesium over 10 days with oral replacement of 1000 mg TID. With aggressive calcium, magnesium and vitamin D replacement as above her total calcium , magnesium  and phosphorous levels were 8.8 mg/dL, 2.8 mg/dL and 2.7 mg/dL respectively.

Patient was discharged after stabilization of calcium levels and is lost to follow up.

DISCUSSION:

Denosumab is a human monoclonal antibody that inhibits osteoclastic bone resorption via inhibition of RANKL.Hypocalcaemia is a known risk of denosumab use, especially in patients with severe renal impairment. Its use in patients with hypocalcemia is contraindicated and preexisting hypocalcemia must be corrected before initiating therapy. Patients must also be adequately supplemented with vitamin D.

CONCLUSION: 

The case emphasizes thorough evaluation for secondary causes of low bone density to decide the best therapeutic intervention prior to administering antiresorptive agent and T-scores should not be used solely to diagnose osteoporosis especially in pre-menopausal women. It also highlights the fact that hypocalcemia could be extremely resistant to treatment with concomitant magnesium deficiency and should be replaced aggressively.

 

Nothing to Disclose: AA, KR, NDK, AM, MB

21578 9.0000 SAT-208 A Severe Hypocalcemia after Single Dose of Denosumab in a Patient with Osteomalacia Secondary to Long Standing Vitamin D Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


roselyn Cristelle isidro Mateo* and Jill Apel
Rush University Medical Center, Chicago, IL

 

We describe the case of a 29/F with alcohol hepatitis and cirrhosis who was initially admitted for BLE pain and weakness and urinary incontinence and was found to have epidural hematoma at L2-L3 which was a complication of lumbar puncture in the setting of coagulopathy. She was also found to be anemic to 5.3g/dL. Her hospital course was complicated by expanding L2/L3 epidural hematoma needing repeat evacuation of hematoma, anemia, thrombocytopenia, worsening transaminitis and hyperbilirubinemia. She received multiple units of pRBCs, FFP and platelets and also developed TACO needing diuretics. After about a week, patient’s counts subsequently stabilized and she was subsequently transferred to the acute rehabilitation center.

5 days later, patient was observed to have intermittent  lethargy. Drug toxicity from medications was excluded due to her low doses, encephlopathy was excluded because of regular bowel movements and regular lactulose. CT head ruled out intracranial process and infectious work up was negative.  A BMP showed new elevation in her calcium to 13.5 mg/dL.

Over the next few days, despite IV fluids, calcium levels fluctuated but remained elevated, ranging from 11.6-13.5. Decreased PTH levels ruled out primary hyperparathyroidism and decreased PTHrp and negative CTs and MRI ruled out humoral hypercalcemia of malignancy. Low 25 OH and 1,25 OH vitamin D ruled out a calcitriol driven process, normal TSH and cortisol ruled out hyperthryoidism and adrenal insufficiency. She had normal UPEP and SPEP, no evidence of TB, sarcoidosis, Wegener’s granulomatosis or Crohn’s disease. She was not taking VitD , VitA, antacids, milk, lithium, HCTZ, theophylline. She had no family history of FHH. She did not have a prolonged period of immobilization and participated in PT and OT sessions despite her complicated hospitalization. A citrate-induced transient hypocalcemia causing a paradoxical increase in her PTH as a result of massive blood transfusion was also excluded. Our patient’s liver disease is the most likely cause of her elevated calcium levels. Liver disease causes increased bone resorption, the pathogenesis of which is not yet fully understood but resorptive factors such as OAF TNF interleukin 1, prostagalndin TGF may play a role. The catabolism of metabolites stimulating bone resorption is decreased with the subsequent stimulation of osteoclastic activity in liver failure. Renal failure also contributes by decreasing the renal ability to excrete Calcium.

Hypercalcemia is a great mimic that can manifest in so many different ways. Although infrequently described in literature, hypercalcemia induced by advanced chronic liver disease, should be recognized as it is readily treatable and could prevent further debility in patients who are otherwise already chronically ill. It is an area that should spur research interest in order to gain a better understanding of its mechanism

 

Nothing to Disclose: RCIM, JA

21567 10.0000 SAT-209 A Hypercalcemia Induced By Advanced Chronic Liver Disease without Malignancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Edwin Antonio Wandurraga*1, Juan Carlos Rojas1 and Johana Villamizar2
1Universidad Autonoma de Bucaramanga (UNAB), Bucaramanga, Colombia, 2Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia

 

Osteogenesis imperfecta is an inherited connective tissue disorder clinically heterogeneous that is mainly characterized by weakness and bone fragility leading to minimal trauma fractures ("the brittle bone disease"), blue sclerae and hearing impairment. The pathogenesis is a defect in the synthesis of collagen type I either by direct mutation of the COL1A1 and COL1A2 genes encoding the α1 and α2 chains (the most common form) or by protein point mutation responsible for collagen synthesis and assembly. The prognosis varies depending on the type of OI, however overall is serious, with some types incompatible with life that lead to early death.

We report the case of a 26 years old Latin woman with a history of long bone fractures in the first year of life with recurrent fractures on 7 different occasions, in the left femur, right elbow, right radius and ulna, left foot metatarsal and first and fifth metatarsal in right foot. Physical examination revealed blue sclera, clinodactyly in hands, brachydactyly in feet, and no evident bone deformity, without alteration of teething or auditory function. The bone densitometry showed lumbar Z score:-3,9 SD (BMD 0,705g/cm²) and left femoral neck Z Score:-1,6 SD (BMD 0,830 g/cm²), 25 hydroxyvitamin D3: 29 ng/ml, Calcium: 9,3 mg/dl, phosphorus: 3,2 mg/dl. Genetic study showed COL1A1 gene mutation and the diagnosis was confirmed for Osteogenesis Imperfecta type I. Treatment was initiated with Zoledronic acid, 12 months ago without new episodes of fractures. Although genetic counseling was performed, the patient became pregnant. Currently, she has a two years old daughter with blue sclerae, without alteration of teething or auditory acuity, who had fractured left fibula and left humerus at 12 and 16 months of age respectively, by fall from their own height while it was in the early development of ambulation. Genetic study was performed, which confirmed the same gene mutation in heterozygous state in exon 19: c.1299+1G>A in splicing site.

Despite being rare and with clinically variable presentations, we should suspect Osteogenesis Imperfecta in young adult patients with severe osteoporosis, history of multiple fractures and blue sclera finding.

 

Nothing to Disclose: EAW, JCR, JV

21627 11.0000 SAT-210 A Osteogenesis Imperfecta in an Adult Woman and Her Daughter: Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Anh Hoang Pham* and Charles F Sharp Jr.
Huntington Memorial Hospital, Pasadena, CA

 

Background: Primary hyperparathyroidism (PHPT) is a common endocrine disorder often diagnosed in asymptomatic individuals on routine biochemical screening.  Osteitis fibrosa cystica with pathological fractures and brown tumors has become an increasingly rare manifestation of PHPT.

Clinical case:  A 65 year old woman who had avoided seeing physicians for more than a decade presented with progressive hip pain and generalized weakness for the past eight months.  She had developed worsening fatigue and confusion.  Initial laboratory studies showed a calcium level of 14.6 mg/dL (N: 8.4 – 10.2), phosphorus level of 1.6 mg/dL (N: 2.4 – 5.1), magnesium level of 1.1 mg/dL (N: 1.8 – 2.5), and elevated alkaline phosphatase of 471 IU/L (N: 45 – 129).  Intact parathyroid hormone was 1,533 pg/mL (N: 14 – 73).  The 25 (OH)D level was 6.5 ng/ml (30-100), while 1, 25 (OH)2D was 44 pg/mL (N: 15 – 75).  Radiograph studies of the hip revealed radiographic osteopenia with multiple lytic lesions in the pelvis and femur.  There was significant cortical thinning of the proximal femurs and pathological fractures in the pelvis.  Radiographs of both hands were significant for subchondral cysts and subperiosteal bone resorption in the digits.  A skeletal survey showed mottled lucencies throughout the arms, ribs, and lower legs.  A large right side paratracheal solid mass measuring 3.3 cm was identified on a chest CT scan. 

A radionuclide Sestamibi parathyroid scan demonstrated prominent uptake in the right superior mediastinum corresponding to a large parathyroid adenoma in the area identified on CT imaging.  Bone marrow biopsy of the iliac spine was performed to rule out malignant causes of the lytic lesions and demonstrated normal multilineage cells without plasma cell dyscrasias.  Treatment was initiated with intravenous saline, magnesium, and potassium.  Parenteral salmon calcitonin, oral phosphate, cholecalciferol, and cinacalcet were added.  Serum calcium decreased towards normal levels, and the patient experienced symptomatic improvement in bone pain, confusion, and fatigue.  Because of the profound deconditioning and severe bone pain, the patient was transferred to a rehabilitation facility on oral cinacalcet, oral phosphate, cholecalciferol, and vigorous ambulation in preparation for definitive parathyroidectomy.  On follow up, the patient had a calcium level of 8.1 mg/dL (albumin 3.2 gm/dL) and intact PTH levels decreased to 959 pg/mL. Hungry bone syndrome is anticipated as a consequence of successful surgery.

Conclusion:  Osteitis fibrosa cystica currently represents an extremely rare complication of severe hyperparathyroidism.  This case validates the utility of screening for bone involvement in PHPT and should remind clinicians of the devastating consequences of advance parathyroid bone disease.

 

Nothing to Disclose: AHP, CFS Jr.

21640 12.0000 SAT-211 A Primary Hyperparathyroidism Presenting As Diffuse Osteolytic Lesions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Nimalie Jacintha Perera*1, Francesca Valpoto2, Elizabeth Lian Chua3 and Arthur David Conigrave4
1Royal Prince Alfred Hospital, Camperdown NSW, Australia, 2Royal Prince Alfred Hospital, 3Royal Prince Alfred Hospital, Sydney, Australia, 4University of Sydney, University of Sydney, Australia

 

Background:  Alkaline phosphatase (ALP) is commonly measured after organ transplant as marked increase of ALP levels can suggest Infection, Liver or bone disease.  Transient Hyperphosphatasemia (TH) is commonly reported in infancy or early childhood characterised by a marked elevation of serum AP in the absence of detectable liver or bone disease, which commonly return to normal ranges within 6 months.  

Clinical Case : A 49 year old woman  4 1/2 months post liver transplant for Hepatitis B/ HCC  was noted to have a rapid rise of the ALP levels to 1065 U/L (n < 130 U/L).  The ALP isoenzyme fractionation by electrophoresis indicates it is of bony origin. Other liver function tests ALT, AST, GGT, Albumin, Bilirubin and viral serology for EBV, CMV were normal. Initial tests  include Vitamin D  65 nmol/L ( n> 60 nmol/L) , 1- 25 D(OH) Vitamin D 106 pmol/L (n 36-120 pmol/L), PTH 3.8 pmol/L (n 2-6 pmol/L). Corrected Calcium 2.26 mmol/L (n 2.15- 2.55 mmol/L), Magnesium 0.60 mmol/L (n 0.75- 0.95mmol/L), Phosphate 0.83 mmol/L ( n 0.8-1.5 mmol/L). TSH 3.920 mIU/L (n 0.27-4.2 mIU/ L), Serum EPG and IEPG  showed a low unquantifiable Kappa paraprotein which is probably insignificant. Pre transplant Bone Density was normal.  Bone scan showed some localised uptake in the skull and a rib (she did not report any focal pain or deformity in these areas of increased uptake) and the corresponding X-rays were normal suggesting a non-Paget’s pathology. She continued with immunosuppressive therapy Prednisone 2.5mg, Mycophenolate, Tacrolimus and  Trimethorpim/Sulphamethoxazole antibiotic prophylaxis, antiviral Tenofovir as well as vitamin D, Calcitriol, Magnesium  supplementation with progress pathology showing a gradual decline in the ALP level  to the normal range.

Clinical Lesson and Conclusion : TH is a diagnosis of exclusion. Usually it is called benign TH of infancy or childhood (< 5years), but have been reported after paediatric liver or kidney transplant and  rare in adults post transplant. It has been suggested that the most likely aetiology is transient increased production of ALP during periods of catch-up-growth after weight loss or vitamin D insufficiency , at a rate that overwhelms the mechanisms that normally desialytate the enzyme resulting decreased clearance. Recognition of this benign condition is crucial to avoid unnecessary and invasive investigations.

 

Nothing to Disclose: NJP, FV, ELC, ADC

21656 13.0000 SAT-212 A Transient Massive Hyperphosphatasemia in an Adult Patient after Liver Transplant 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Madhukar Mittal*1, Neha Jain2, Anupam Wakhlu2 and Sanjay Gambhir3
1King George's Medical University, Lucknow, India, 2King George's Medical University, 3Sanjay Gandhi Postgraduate Institute of Medical Sciences

 

Background: Tumor induced osteomalacia (TIO) or Oncogenic Osteomalcia is a rare disorder presenting with hypophosphatemia, progressive bony deformities and with debilitatiing consequences. Patients usually are detected late.

Clinical Case: A 55 year male presented with gradually progressive bilateral lower limb pain for 15 years. Patient was bedridden for past 5-6 years. He had been evaluated over the years before being referred to Endocrinology. He had bilateral lower limb deformities and had sustained multiple low trauma fractures. He had swellings around right knee joint, scalp and left side of thorax. There was no history of malabsorption, chronic renal failure. He had received calcium and vitamin D supplementation several times but with no improvement. Prior investigations revealed normal USG neck, and FNA from left knee swelling showed only chronic inflammation. Current investigations showed normal CBC, liver and renal functions tests (serum creatinine 0.6 mg/dl). Fasting serum calcium was 8.8, 8.3 mg/dl and serum phosphorus 2.6 and 1.6 mg/dl. SALP was 714 IU/L with low 25(OH)D (14ng/ml) and elevated iPTH (291pg/ml). Thyroid functions were normal. BMD by DXA was low (Left hip T -5.9, Z -4.9, Left radius distal 33% T -8.3, Z -8.3). Spine BMD could not be assessed because of severe deformity. Serum FGF-23 levels (C-Terminal) were very high 4641.7 RU/ml (Range 0-150). 1,25(OH)D values were low normal 43.84 pmol/l (39-193). MRI showed multiple well defined lesions involving right lower femur, vertebral column, left thoracic wall and scalp. The same four swellings also showed an increased uptake on whole body MIBI scan. The largest lesion measured approximately 12.5x12.8x12 cm involving lower meta-diaphyseal region of right femur and was infiltrating adjacent muscles, vessels and eroding bone. The patient was treated with oral phosphate solution along with calcium and vitamin D. The phosphate dose was gradually uptitrated and serum phosphate values normalized. The patient regained strength and was able to sit up with support.

Conclusion: Metabolic bone disease presenting with bony pains and deformities is commonly treated as vitamin D deficiency. Diseases not responding to calcium and vitamin D are generically labelled as resistant rickets/osteomalacia. TIO in our patient was due to multiple soft tissue tumors which showed high uptake on whole body MIBI scan corresponding anatomically to the soft tissue tumors seen clinically and on MRI. Surgery could not be done for the soft tissue tumors as they were multiple and spinal tumor was non-resectable. Histopathology and antibodies to FGF-23 may provide immunopathological correlation which we were unable to do. Both anatomical and functional correlation is a must for confirming the soft tissue tumors. Previous reported cases have been due to single lesions. This is the first such reported case of Oncogenic Osteomalaica due to multiple tumors.

 

Nothing to Disclose: MM, NJ, AW, SG

21788 14.0000 SAT-213 A Oncogenic Osteomalacia Caused By Multiple Soft Tissue Tumors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Isabel R Hsu*1, Elaine S Kamil2 and Pisit Pitukcheewanont1
1Children's Hospital Los Angeles, Los Angeles, CA, 2Cedars-Sinai Medical Center, Los Angeles, CA

 

Background:  Type I Antenatal Bartter Syndrome (BS) is caused by mutations in the SLC12A1 gene leading to loss of function in the Na-K-2Cl cotransporter in the renal tubule.  These patients can present with polyhydramnios in utero and prematurity with postnatal hypokalemia, hyponatremia, polyuria, hypercalciuria and nephrocalcinosis. However, hyperparathyroidism with hypercalcemia have not been previously reported. We report two Hispanic male siblings with a novel compound heterozygous variant in the SLC12A1 gene with Antenatal BS, hyperparathyroidism and hypercalcemia.

Case presentation:  Sibling 1 (1) was referred at 23 mo for evaluation of hypercalcemia. He was born at 27 wk with history of polyhydramnios. Medullary nephrocalcinosis was seen on renal ultrasound postnatally. He developed polyuria, hyponatremia, and hypokalemia at 15 mo, and was diagnosed with suspected Antenatal BS and started on NaCl and KCl supplementation. He was also found to be hypercalcemic at that time.  Sibling 2 (2) was referred at 11 mo for evaluation of hypercalcemia. He was born at 33 weeks with history of polyhydramnios. Laboratory evaluation at birth showed hypokalemia and hyponatremia and medullary nephrocalcinosis on ultrasound. He was diagnosed with suspected Antenatal BS and started on KCl supplementation.  He developed polyuria and hypercalcemia at 10 mo. Evaluation of hypercalcemia (1: 11.4 mg/dL, 2: 11.1 mg/dL; normal 8.3-10.7 mg/dL) demonstrated inappropriately elevated intact PTH level (1: 62.8 pg/mL, 2: 83.5 pg/mL; normal 10-65 pg/mL).  In addition, 25(OH) Vitamin D levels were within normal limits but 1,25(OH)2 Vitamin D levels were elevated inappropriately for hypercalcemia, suggesting primary hyperparathyroidism. Treatment with Cinacalcet normalized intact PTH and calcium levels and improved but did not resolve polyuria. Whole exome sequencing showed compound heterozygous variants, c.735C>G (p.Typ245) and c.1522G>A (p.Ala508Thr), in the SLC12A1 gene.  The c.735C>G variant was inherited from the mother and has not been previously reported, while the c.1522G>A variant was inherited from the father and has been previously reported in patients with Antenatal BS without hyperparathyroidism and hypercalcemia. Other genes associated with Antenatal BS (KCNJ1, CLCNKB, BSND) and hyperparathyroidism (CDC73, MEN1, RET, CASR) did not reveal any variations. The mechanism of the link between the SLC12A1 gene and hyperparathyroidism and hypercalcemia is unclear.

Conclusion:  We report a new syndrome of Antenatal BS with hypercalcemia and hyperparathyroidism due to a novel compound heterozygous variant in the SLC12A1 gene, the mechanism of which should be further explored.  Patients with suspected Antenatal BS should be evaluated for hyperparathyroidism and hypercalcemia and have molecular gene analysis in order to promptly initiate the appropriate treatment as well as genetic counseling.

 

Nothing to Disclose: IRH, ESK, PP

21904 15.0000 SAT-214 A a Syndrome of Antenatal Bartter Syndrome, Nephrogenic Diabetes Insipidus, Nephrocalcinosis, Hypercalciuria, Hypercalcemia, and Hyperparathyroidism in Two Hispanic Male Siblings Due to a Novel Compound Heterozygous Variant in the SLC12A1 Gene (c.735C>G/c.1522G>A) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Ieva Ruza*1, Inta Leitane2, Alvils Krams1 and Aivars Lejnieks3
1Riga Eastern Clinical University Hospital, Riga, Latvia, 2Riga Health Center, Clinic Tornakalns, Riga, Latvia, 3Riga Stradins University, Riga, Latvia

 

Introduction: Neurosarcoidosis is a possible manifestation of a systemic disease, seen in ~5% of cases, with involvement of different central nervous system (CNS) structures and variable presentation of hypothalamic-pituitary axis impairment. We would like to report a case of neurosarcoidosis which initially manifested with unclear complex CNS damage, later uncovering mild secondary hypothyroidism and severe hypercalcemia.

Report: A 33 years old white male was initially hospitalized in neurology ward due to progressing general muscle weakness, inability to perform simple daily activities, dyspnoe, subfebrility over last 3 months. First investigations were done to exclude different autoimmune or infective causes of neuropathy. Only limited biochemical testing was done. Brain MRI was consistent with possible CNS granulomatous process. Additional tests followed showing marked hypercalcemia (3.7 mM/l [2.1-2.6]) and kidney impairment (creatinine- 196 mkM/l [30-106], GFR-36 ml/min). PTH <3 pg/ml [12-72] and calcitriol – 101.6 pg/ml [19.6-54.3]. Phosphorus, Alat, Asat, LDH, ACE was within normal range. TSH 0.9 mIU/ml [0.39-4.94], FT4 9 pM/l [10-22]. There were no signs of hyperprolactinemia, diabetes insipidus and other pituitary involvement. Bilateral hilar lymphadenopathy was seen in chest X-ray. Sarcoidosis was proven by salivary gland and transbronchial lung biopsy. Treatment with glucocorticoids and levothyroxine was started, and improvement of all symptoms was seen in follow-up.

Conclusion: The case showed a diagnostic challenge to differentiate sarcoidosis as a possible cause of CNS damage and subsequent reason of metabolic changes. There is too little awareness of hypercalcemia as a manifestation of sarcoidosis.

 

Nothing to Disclose: IR, IL, AK, AL

21780 16.0000 SAT-215 A Hidden Clues: A Case Report of Neurosarcoidosis Uncovering Mild Secondary Hypothyroidism and Severe Hypercalcemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Ifechukwude Ebenuwa* and Ricardo R Correa
National Institutes of Health, Bethesda, MD

 

Patient is a 66-year-old male with no significant past medical history who presented to the ER from a holiday cruise ship with acute respiratory insufficiency. Four days earlier, he was evaluated by the cruise ship medical service for vomiting, flank pain and unsteady gait. He was treated for presumed gastroenteritis with ciprofloxacin, discharged back to his cabin. He returned to the medical service the next day appearing confused, complaining of left frontal headache, lower extremity weakness causing gait instability. While obtaining patient’s history, he had a seizure episode, developed respiratory arrest. He was subsequently intubated and mechanical ventilated and transferred to the emergency department.

On initial evaluation, vitals were stable, physical exam was unremarkable. Laboratory data revealed serum calcium of 19mg/dL [8.1-10.4], ionized calcium of 3.6 mmol/L [1.10-1.35], intact parathyroid hormone level of 831 pg/mL [15 - 65]. Hypercalcemia was treated with aggressive IV fluids, high doses of cinacalcet and pamidronate. Thyroid ultrasound revealed a 3.8 x 2.8 x 4.1 cm spiculated cystic structure in the inferior and mid aspect of the right lobe of the thyroid, with thickening of the walls, findings concerning for parathyroid carcinoma.

Following resolution of acute hypercalcemia, patient was discharged home with the diagnosis of primary hyperparathyroidism due to parathyroid carcinoma. He later underwent en bloc resection right inferior parathyroid gland, right thyroid lobectomy and right lower parathyroidectomy. Histology revealed a 4cm parathyroid carcinoma within the cyst which was fully excised. After surgery , parathyroid level decreased to 10pg/ml [15 - 65]. 6 months later no complications or recurrence disease

 Hypercalcemic crisis or parathyroid storm is a rare but life-threatening complication of primary hyperparathyroidism. Most cases are caused by a parathyroid adenoma and parathyroid gland hyperplasia, with parathyroid carcinoma being a very uncommon case.

 Acute severe hypercalcemia should be suspected in acutely ill patients with altered mental status, muscular weakness, gastrointestinal and/or urinary symptoms. To reduce mortality, it is essential to provide appropriate emergency management correcting hypercalcemia and dehydration and at the same time, make an accurate diagnosis without delays to treat the patient with a possible curative procedure (i.e.  parathyroidectomy).

 

Nothing to Disclose: IE, RRC

21580 17.0000 SAT-217 A A Little Too Much Calcium in My Vacation: Acute Severe Hypercalcemia in a Previous Asymptomatic Man 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Tossaporn Seeherunvong1 and Gary David Berkovitz*2
1University of Miami Miller School of Medicine, Miami, FL, 2University of Miami, Miller School of Medicine, Miami, FL

 

Background: Hypocalciuric hypercalcemia is a condition characterized by mild elevation in serum calcium, high normal to slightly elevated serum PTH, but normal urinary calcium excretion.   The condition typically results from heterozygous mutation of the Calcium Sensing Receptor (CASR) gene, and is usually recognized when asymptomatic hypercalcemia is identified on a routine blood test.  By contrast, homozygous mutation of the CASR is associated with severe hyperparathyroidism usually presenting in the newborn period.  Rare cases of neonatal hyperparathyroidism have also been associated with heterozygous mutation of CASR.  We report a boy with a heterozygous mutation of CASR who presented with hyperparathyroidism later in childhood. 

Clinical case: The patient was referred to Endocrine Clinic when he was 9 and 7/12 years old because mild hypercalcemia (serum calcium 12.4 mg/dL) had been identified on routine screening. Urinary Ca/Cr ratio (0.02) was low, and serum intact PTH (59 pg/mL) was inappropriately elevated.. Parents had normal serum calcium levels. The patient’s condition was considered benign hypocalciuric hypercalcemia. However in follow up 14 months later, the serum calcium (13.4 mg/dL) and PTH (132 pg/mL) were significantly higher than on the initial evaluation. An MIBI scan was suggested a parathyroid adenoma in the left inferior parathyroid gland. Mutational analysis of the RET proto-oncogene was negative. Surgical removal of two and one half parathyroid glands was performed. Pathological analysis indicated hyperplastic parathyroid tissue in the left inferior and superior parathyroid gland. Serum calcium and intact PTH levels normalized shortly after surgery, but two months later, the serum levels of calcium (11.7 mg/dL) was again above normal.  Serum PTH was 42 mg/dL. Treatment with Cinacalcet resulted in a decline in serum to Ca 10.7 mg/dL, but treatment was subsequently discontinued. Mutational analysis of CASR indicated a heterozygous mutation (cCASR c.554G>A) that predicted an amino acid change p.Arg185Gln. This heterozygous mutation in CASR has also been reported in a patient with neonatal hyperparathyroidism as well as in hypocalciuric hypercalcemia. Although gene testing could not be done in the parents, their lack of hypercalcemia suggests that the patient had a de novo mutation or that the mutation had incomplete penetrance.

Conclusion: This report indicates the variability in the clinical presentation of CASR mutation. It also highlights the importance of careful follow up of patients with hypocalciuric hypercalcemia and consideration of hyperparathyroidism if the serum calcium levels increase markedly over time.

 

Nothing to Disclose: TS, GDB

21971 18.0000 SAT-218 A Heterozygous Mutation of Calcium Sensing Receptor Gene in a Child with Primary Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Min Wong*
Etobicoke Endocrine Clinic, Toronto, ON, Canada

 

Hypercalcemia in Systemic Lupus Erythematosis (SLE): Lessons from a Rare Case

Background: Hypercalcemia associated with SLE is rare, with about 12 cases described in the literature. The mechanism is unknown, with PTH- related peptide (PTHrP) being one of those proposed. PTHrP was elevated in the serum of one case and in the lymph node biopsy in another but negative in the rest. In general, SLE was active at the time of hypercalcemia. Many cases were associated with lymphadenopathy and serositis.

Clinical Case: A 31 year old woman had a total thyroidectomy in 1996 for papillary carcinoma. She developed permanent hypoparathyroidism and required calcium 4 gms/d and calcitriol 0.5 mcg/d to maintain normocalcemia. Attempts to wean these doses were unsuccessful. In 2010, ionized calcium (ICA) was 1.20 mmol/l (1.15-1.35), and serum calcium 2.17 mmol/l (2.15-2.60). In 2011, she developed anemia, polyarthritis, Raynaud’s, serositis (pleuritis), alopecia, photosensitivity and a low C3 complement. Serology was positive for ANA 1:640, Ro, La, RNP, Smith, chromatin but negative for APLA, dsDNA, ANKA, anti Jo, and SCL-70. She had enlarged cervical lymph nodes, benign on biopsies. A diagnosis of SLE was made. She was started on prednisone and hydroxychloroquine. SLE remained active. She was hospitalized for pleuritis. CT chest and bronchoscopy showed inflammatory changes. On her usual calcium and calcitriol doses, ICA rose to 1.40 mmol/l (1.15-1.35), serum calcium 2.77 mmol/l (2.15-2.60), PTH <0.1 pmol/l (1.3- 8.2), 25 hydroxyvitamin D 43 nmol/l, creatinine 66 umol/l (44-88), TSH 0.22 mIU/l (0.3-4.0), free T4 19 pmol/l (9-23), thyroglobulin <0.1 ug/l, angiotensin converting enzyme (ACE) 104 u/l (60-85), and 24 h urine calcium 3.6 mmol/d (1.2-6.2). When calcium and calcitriol were stopped, serum PTH and 1,25 dihydroxyvitamin D (1,25(OH)2 D) levels were undetectable while serum PTHrP was 8.5 pg/ml (1-15). Serum calcium remained at 2.14 mmol/l (2.15-2.60), and ICA 1.12 mmol/l (1.15-1.35). Bone scan and skeletal survey showed no active bone lesions. In 2012, azathioprine was added to prednisone. SLE improved. ICA fell to 0.93 mmol/l. She was put on calcium 2 gms/d and calcitriol 0.5 mcg/d to reach normocalcemia.

Conclusion: This case is unique with hypercalcemia and SLE occurring in a patient with hypoparathyroidism. While the mechanism of hypercalcemia is uncertain, it is not mediated by PTH.  ACE elevation is nonspecific, but can be found in sarcoidosis in which hypercalcemia is mediated by calcitriol production in alveolar macrophages and less commonly by PTHrP. In this patient, the level of 1,25 (OH)2 D was undetectable when calcitriol was stopped. The lack of elevation of PTHrP after calcitriol discontinuation does not exclude the possibility that PTHrP could have played a role in the elevation of calcium. PTHrP levels will be monitored and tissue expression of PTHrP examined to further understand the mechanism.

 

Nothing to Disclose: MW

22102 19.0000 SAT-219 A Hypercalcemia in Systemic Lupus Erythematosis (SLE): Lessons Learned from a Rare Case 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Niko Broodie-Murray*1 and Pamela Taxel2
1University of Connecticut Health Center, Farmington, CT, 2Univ of Connecticut Hlth Ctr, Farmington, CT

 

Background As more older patients with osteoporosis (OP) are seeking chiropractic care, it is important to understand the risks and dangers of spinal manipulations, particularly in patients with known history of OP. We report the case of an 80-year old woman with unrecognized vertebral fracture severely worsened by spinal manipulation.

 Clinical Case A very active and otherwise healthy 80-year old woman with 12-year history of OP on bisphosphonate (BP) therapy and no history of prior fracture, presented to our OP clinic for recommendations after she was diagnosed with a T6 vertebral fracture two weeks prior.  

 The patient had experienced 3-4 days of bilateral mid-thoracic aching pains and a friend recommended that she see a chiropractor. An AP X-ray of her spine obtained by the chiropractor prior to manipulation was read as negative for any pathology, though it did show a T6 fracture. However, this was not appreciated and the patient underwent two sessions of spinal manipulation on two sequential days.  The manipulations included the patient lying prone with the application of pressure to her mid and upper back.  After the second session, the soreness in her back acutely transformed to a sharp, debilitating pain and she was taken immediately to the ED by a family member.

 At a local ED, X-rays revealed a T6 compression fracture and a MRI showed marrow edema and abutting of the fracture on the spinal cord; however, the patient showed no clinical or radiological evidence of cord compression. She was hospitalized and successfully underwent kyphoplasty, after which she developed new onset atrial fibrillation. Bone biopsy was negative for any malignancy. She was discharged on opiate therapy for pain.

 Lab results 2 weeks after fracture and BP discontinuation: Vit D 61 ng/ml, NTX 11 nmol BCE/mmol Cr (Nl 26-124) and Bone-specific Alkaline Phos 6.2 ug/L (Nl 7-22.4).

 Clinical Lesson This is a case of a healthy, active elderly woman with OP who was treated for back pain with spinal manipulation and experienced severe, debilitating back pain requiring hospitalization and kyphoplasty. In addition, she developed a second comorbidity, atrial fibrillation, after kyphoplasty. This case is relevant as older patients are frequently seeking chiropractic care to manage their back pains.  Vertebral fractures are frequently not identified initially on plain film radiographs, placing patients at risk for poor outcomes. According to the WHO guidelines, OP remains a relative contraindication for chiropractic medicine and should be avoided, unless treatment is modified accordingly1.  There is limited evidence to suggest its safety in patients with osteoporosis.  Acute fracture is an absolute contraindication for spinal manipulative therapy per these guidelines.  It is critical that a complete and adequate assessment be done to avoid unnecessary comorbidities in patients with known OP.

 

Nothing to Disclose: NB, PT

22123 20.0000 SAT-220 A Unrecognized Vertebral Fracture Worsened By Spinal Manipulation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Racha Dermesropian*1, John Mihailidis2, Kourosh Parham3 and Vitaly Kantorovich3
1University of Connecticut Health Center, 2Univeristy of Connecticut, Farmington, CT, 3University of Connecticut Health Center, Farmington, CT

 

Background: Primary hyperparathyroidism is a common endocrine disorder resulting in hypercalcemia (1).  Parathyroid adenomas account for 85% of all cases of hyperparathyroidism.  Other less common causes include four gland hyperplasia and parathyroid carcinoma.  Also, particlarly in the younger population or those with similar family history, familial syndromes including Multiple Endocrine Neoplasia (MEN) and Jaw Tumor Syndrome need to be considered.  Interestingly, rarely do parathyroid adenomas attain dimensions large enough to be considered giant adenomas.

Clinical Case: A 29 year old female presented for evaluation of persistent, asymptomatic hypercalcemia.  Biochemical tests were consistent with primary hyperparathyroidism: elevated total calcium (11.8, n 8.9-10.4 mg/dL), elevated ionized calcium (1.59, n 1.14-1.33 mmol/L), elevated intact PTH (100 n 15-88 pg/dL), elevated 1, 25-dihydroxyvitamin D (94 n 15-75 pg/mL) and normal 25-hydroxyvitamin D (42, n 30-74ng/dL ).

A parathyroid scan revealed a large sestamibi avid mass with possible central necrosis extending inferiorly, laterally and posteriorly from the lower pole of the right thyroid lobe.  CT scan of the neck identified a right thoracic inlet/paratracheal oval circumscribed mass with central area of nonenhancement measuring 5.2 x 2.0 x 2.2 cm suspicious for a parathyroid mass.  The patient underwent surgical removal of the right inferior parathyroid mass weighing 37 g with concurrent improvement of intraoperative PTH levels falling from 167 pg/mL to 29 pg/mL.  Final surgical pathology was consistent with a parathyroid adenoma.

Conclusion:  This case is a rare presentation of primary hyperpararthyroidism in a young woman with a giant parathyroid adenoma.

 

Nothing to Disclose: RD, JM, KP, VK

21391 21.0000 SAT-221 A Primary Hyperparathyroidism Presenting with a Giant Parathyroid Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Vanessa Castro Ramos*1, Ricardo A Guerra2, Michele Molina Mari Salvariego3, Ana Heloisa Correia Bresque4, Christiane Andrade de Azevedo3, Giovanna Mozardo Duarte5, Victor Sousa da Silveira3, Marcio Faleiros Vendramini5 and Evandro S Portes6
1Hospital do Servidor Público Estadual de São Paulo, Brasil, Sao Paulo, Brazil, 2Hospital do Servidor Público Estadual, São Paulo, Brazil, 3Hospital do Servidor Público Estadual, 4Hospital do Servidor Público Estadual, Sao Paulo, Brazil, 5Hospital do Servidor Público Estadual de São Paulo, 6Hospital de Servidor, Sao Paulo, Brazil

 

Background: Pseudohypoparathyroidism corresponds to a group of genetic disorders defined by target organs non-responsiveness to PTH. Biochemically characterized by hypocalcemia, hyperphosphatemia and high concentrations of PTH, it is classified in types IA, IB, IC, II and pseudopseudohypoparathyroidism according to the etiology and phenotype.  

Clinical case: A fifteen years old female patient with systemic lupus erythematosus (SLE) diagnosed in November 2012, and a history of seizures since 2011, controled with Fenobarbital 100mg/day, being recently hospitalized for SLE activity was referred to our service due to severe hypocalcemia diagnosed in routine laboratory tests but without symptomatic correlation. On physical examination, there weren’t Chvostek and Trosseau signs. Complementary tests: EKG QT widening; Head - TC (2011) with calcification of the basal ganglia, but disturbances of calcium uninvestigated. Laboratory tests: Cai 0.99 mmol/L; P 5.2 mg/dL; 25(OH) vitaminaD3 26 ng/mL; PTH 1148 pg/mL . Using Calcitriol 0,75μg/day; Colcecalciferol 30000UI/week, Calcium Carbonate supplements in divided doses of  600mg, we obtained normalization of serum calcium (Ca 8,8 mg/dL; Cai 1,27 mmol/L) and decrease PTH levels (PTH 188 pg/mL). Patient didn’t present new seizures even without anticonvulsivant drug for the last three months.  No similar changes were found in family members. Based on clinical tests and phenotype, we made the hypothesis of Pseudohypoparathyroidism type 1B but we are proceeding genetic investigation.

Conclusion: We present this case to demonstrate the importance of thinking about pseudo hypoparatiroidism in differential diagnosis of hypocalcemia and the possibility to improve the neurological signs through institution of adequate treatment.

 

Nothing to Disclose: VCR, RAG, MMMS, AHCB, CADA, GMD, VSDS, MFV, ESP

21504 22.0000 SAT-222 A Improvement of Seizures in a 15-Years Old Patient Female with Pseudohypoparathyroidism  2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Nada Ayedh Bin Hareez*
University of Ottawa, Ottawa, ON, Canada

 

Aim---

To describe our experience with the use of a subcutaneous infusion of recombinant human PTH 1 -34 (Teriparatide) in a patient with Vitamin D nonresponsive hypoparathyroidism.

Methods ---

 Chart review, blood works, 24-hour urine collection and comparison before and after PTH-RP pump use.

Case report

A 38-year-old woman developed severe hypoparathyroidism after thyroidectomy for thyroid cancer. Minimal therapeutic response was obtained with oral and iv. calcium ,magnesium, calcitriol, Amiloride and Hydrochlorothiazide. Digestive disorders were excluded by endoscopy and biopsy of the duodenum. The serum ionized calcium remained in the 0.7 - 0.9 range (normal 1.15-1.32 mmol/L) despite Teriparatide injections 20 ug sc t.i.d., Calcium citrate 12 g po over the day, Magnesium oxide 10 g over the day, Calcitriol 2 ug po t.i.d.,Amiloride/ Hydrochlorothiazide 5 mg/50 mg po od and occasional infusions of intravenous calcium in the Emergency Department. We administered Teriparitide 30 ug/day (1.25 ug/hour). Teriparitide is provided as 20 ug/80ul (0.25 ug/ul) so we needed to infuse 5 ul/hour. The insulin pump is designed for delivering Insulin U100 (100 units/ml or 0.1 unit/ ul). The desired rate was accomplished by setting the pump to administer a continuous basal rate of 0.5 units of insulin/hour. Infusing Teriparatide with a pump was very successful. With the infusion of 30 ug over the day, the ionized calcium rose above 1.0 on the first day. A few days later, we stopped the bolus injections of Teriparatide, decreased the oral Calcium citrate from 12 g/day to 6 g/day, the Magnesium oxide from 12 g/day to 6 g/day, the Calcitriol from 2 ug po t.i.d. to 1 ug po t.i.d. and stopped the Amiloride/ Hydrochlorothiazide 5/50 po od. A week later the ionized calcium increased to 1.08 and we will further decreased the oral Calcium citrate to 3 g/day, the Magnesium oxide to 3 g/day and the Calcitriol to 0.5 ug po t.i.d.

Results. –

Conclusions. –PTH-RP pump use in sever resistance hypocalcaemia was confirmed to improve patient calcium level in this patient

 

Nothing to Disclose: NAB

21858 23.0000 SAT-223 A Use of a Subcutaneous Infusion of Recombinant Human PTH 1 -34 (Teriparatide) in a Patient with Vitamin D Nonresponsive Hypoparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 200-223 5961 1:00:00 PM Bone Case Reports II Poster


Patrick Ammann* and Rene Rizzoli
Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland

 

Bone strength, hence fracture risk, is dependent on bone geometry, microstructure and bone material level properties. Alendronate treatment maintains bone mass and prevents further microarchitecture deterioration. Indeed only an improvement of bone material level properties, could explain the decrease in fracture risk. We investigated the effects of alendronate treatment on bone material level properties and bone microarchitecture of transiliac bone biopsies from postmenopausal osteoporotic patients. In a longitudinal study, 76 paired biopsies in 38 patients were obtained at baseline and after 6 or 12 months of treatment with alendronate 70 mg once weekly. Elastic modulus, hardness and working energy were blindly analyzed by nanoindentation at the level of the interstitial and haversian bone of the cortex and of trabecular nodes and remodeling units under humid conditions. Parameters of microarchitecture were evaluated by microCT (Scanco Medical). Values are mean±SEM, significance of differences are evaluated by Student’s unpaired t-test, **p<0.01, ***p<0.001. Bone microarchitecture was not influenced by alendronate treatment. At the level of the interstitial cortical bone, changes in bone material level properties were observed; modulus was at base line 13.31±0.18 gPa and after 6 months of treatment 14.46±0.20 *** and hardness 3189±37pJ at base line and 3372±43 ** after 6 months of treatment. In summary, changes in bone material level properties were observed at the level of the interstitial cortical bone at the two time points and only by 12 months in haversian bone, but not at the level of the trabecular bone. Thus a prevention of deterioration cannot be excluded at the level of the trabecular bone since a progressive alteration was observed after the menopause. The positive effect on bone material level properties of alendronate could be partially explained by the known increase of mean degree of mineralization and could contribute to the known improvement of bone strength since no modification of bone mass was observed. Interestingly this study indicates that bone material level properties which represents a target for anti-osteoporotic treatment, could be selectively improved by alendronate.

 

Disclosure: PA: Investigator, Servier. Nothing to Disclose: RR

21939 1.0000 SAT-224 A Alendronate Improves Bone Material Level Properties in Paired Human Transiliac Bone Biopsy Specimens 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Gherardo Mazziotti*1, Chiara Dordoni2, Filippo Maffezzoni2, Feliciano Galderisi1, Mauro Doga2, Stefano Frara2, Vincenza Serra1, Marina Venturini1, Piergiacomo Calzavara-Pinton2, Roberto Maroldi1, Andrea Giustina2 and Marina Colombi2
1University of Brescia, Brescia, Italy, 2University of Brescia, Italy

 

Context. Ehlers-Danlos syndrome (EDS) refers to a group of heritable connective tissue disorders that may affect the skin, joints and multiple organs. Previous studies have reported an increased prevalence of osteoporosis in EDS, but these studies were limited by small number of patients and lack of information on fragility fractures.

Objective. To evaluate the prevalence and determinants of radiological vertebral fractures in patients with EDS.

Design. Cross-sectional study.

Setting. Referral centers.

Subjects and Methods. Fifty-two consecutive patients with EDS (10 males, 42 females; mean age 41 years, range: 21-71; 12 with EDS classic type, 37 with EDS hypermobility type, and 3 without specific classification) and 256 control subjects (175 females and 81 males; mean age 54 years, range: 26-83) attending an outpatient bone clinic were evaluated for prevalence of vertebral fractures using a quantitative morphometric evaluation of spine X-ray and bone mineral density (BMD) with DXA scan at lumbar spine, total hip and femoral neck. EDS patients were also evaluated for serum osteocalcin, parathyroid hormone (PTH), calcium and 25-hydroxyvitamin D values.

Results. Vertebral fractures were significantly more prevalent in EDS as compared to the control subjects (38.5% vs. 14.4%; p<0.001). In EDS patients, vertebral fractures were not significantly (p=0.72) different between classic and hypermobility types. Severe back pain (≥ 7 VAS) was more frequent in EDS patients with vertebral fractures as compared to those without fractures (60% vs. 28%; p=0.04). EDS patients with vertebral fractures showed significantly lower serum osteocalcin values (14±6 ng/ml vs. 20±8  ng/ml; p=0.04) as compared to those who did not fracture, without any significant difference in serum 25-hydroxyvitamin D (p=0.23), PTH (p=0.57), serum (p=0.99) and urinary (p=0.34) calcium values. Moreover, BMD was not significantly different between fractured and non-fractured EDS patients either at lumbar spine (p=0.14), total hip (p=0.08) or femoral neck (p=0.21). Among 50 years aged or older patients (17 cases), 6 patients (35.3%) fractured, but only one of them showed osteoporosis at DXA scans. Among patients younger than 50 years (35 cases), vertebral fractures occurred in 17 patients (40%) and only 5 of them showed BMD Z-score below -2 SD at either site.

Conclusions. This is the first study showing high prevalence of vertebral fractures in a relatively large population of EDS patients. Vertebral fractures were associated with more severe back pain suggesting a potential involvement of skeletal fragility in determining poor quality of life in this clinical context. The occurrence of vertebral fractures in patients with normal or low-normal BMD is consistent with the hypothesis that bone quality more than bone quantity may be impaired in EDS.

 

Disclosure: GM: Consultant, Novartis Pharmaceuticals, Board Member, Ipsen. AG: Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Pfizer, Inc.. Nothing to Disclose: CD, FM, FG, MD, SF, VS, MV, PC, RM, MC

20351 2.0000 SAT-225 A High Prevalence of Vertebral Fractures in Patients with Ehlers-Danlos Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Katherine Neubecker Bachmann*1, Alexander G. Bruno2, Miriam A. Bredella1, Elizabeth A. Lawson1, Corey M. Gill3, Erinne Meenaghan3, Anu V. Gerweck3, Mary Larsen Bouxsein4, Anne Klibanski5 and Karen K. Miller1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts Institute of Technology, MA, 3Massachusetts General Hospital, Boston, MA, 4Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 5Massachusetts General Hospital and Harvard Medical School, Boston, MA

 

Somewhat paradoxically, fracture risk, which depends on loads applied to bone and its strength, is elevated in both obesity and anorexia nervosa (AN). The factor-of-risk (Φ), defined as the ratio of applied load to bone strength, is a biomechanically-based method to estimate fracture risk; higher Φ values are associated with increased fracture risk. We hypothesized that higher vertebral fracture risk (estimated by Φ) would be driven by higher applied loads in obesity, whereas reduced vertebral strength would predominate in AN. We also posited that lean body mass (LBM) would be a positive, but visceral adipose tissue (VAT) a negative, determinant of vertebral strength.

We estimated L4 strength, applied load, and Φ in 176 women (18-45y): 65 AN (BMI<18.5 kg/m2), 45 controls (C) (18.5≤BMI<25 kg/m2), and 66 obese (OB) (BMI>30 kg/m2). L4 strength was estimated by the linear combination of integral volumetric BMD (Int.vBMD) and L4 cross-sectional area (CSA) from QCT. Loads applied in vivo to L4 were estimated with a biomechanical model for 4 activities: 1) standing; 2) standing with 5 kg in each hand, elbows flexed 90° (holding); 3) 45° trunk flexion, 5 kg in each hand (lifting); 4) 20° trunk right lateral bend, 10 kg in right hand (bending). For each activity we calculated Φ. Body composition was measured by DXA and CT. All analyses were controlled for age.

AN had lower L4 strength and Int.vBMD than C and OB, and lower CSA than OB (p<0.004). OB had similar L4 strength, Int.vBMD, and CSA as C. Across all groups combined, LBM was positively associated with L4 strength (R 0.45), Int.vBMD (R 0.27), and CSA (R 0.41) (all p≤0.0004); LBM was associated positively with L4 strength within AN (R 0.32, p<0.01) and with CSA within each group (R 0.26-0.56, p<0.04). Across all groups VAT demonstrated an inverted U-shaped relationship with L4 strength and Int.vBMD; VAT was negatively associated with L4 strength and Int.vBMD within OB (R -0.36, p<0.003). All associations remained significant after controlling for BMI except LBM vs Int.vBMD. Applied load was highest in OB and lowest in AN for standing, holding, and lifting (p<0.0001). In contrast applied load for bending was higher in AN than C and OB (p<0.03) due to recruitment of additional muscles in AN. OB had higher Φ for standing and lifting vs C and AN (p<0.0001) whereas AN had higher Φ for bending than C and OB (p<0.0001). OB and AN had higher Φ for holding than C (p<0.03).

In conclusion, women with AN had lower vertebral strength than lean and OB women. Strength was associated positively with LBM and negatively, in OB, with VAT. AN had higher estimated vertebral fracture risk (Φ) for holding and bending, predominantly driven by inferior strength. Despite normal L4 strength, OB had higher Φ than C for standing, holding, and lifting, due to higher applied loads from higher weight. Examining the load-to-strength ratio provides an explanation for increased fracture risk in both low-weight and OB women.

 

Nothing to Disclose: KNB, AGB, MAB, EAL, CMG, EM, AVG, MLB, AK, KKM

18216 3.0000 SAT-226 A Vertebral Strength and Estimated Fracture Risk Across the BMI Spectrum from Anorexia Nervosa to Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Sikarin Upala*1 and Anawin Sanguankeo2
1Bassett Medical Center, Cooperstown, NY, 2Bassett Medical Center, United States, NY

 

Background: Obstructive sleep apnea (OSA) is thought to be a systemic disease and has been associated with many disorders such as metabolic, endocrine, and especially cardiovascular diseases. One of the consequences of OSA is hypoxia, which can lead to reducing growth of osteoblast and stimulating osteoclast. Our meta-analysis was conducted to determine the risk of osteoporosis in patients with OSA compared to controls.

Methods: Eligible studies assessing the effects of obstructive sleep apnea on incidence of osteoporosis were comprehensively searched in PubMed/MEDLINE, EMBASE, and CENTRAL from their inception to September 2014. Two authors independently assessed article quality and extracted the data. Primary outcome was number of participants, prevalence, or risk ratio of osteoporosis in OSA and controls.

Results: From 40 full-text articles, 3 observational (retrospective and prospective cohort) studies involving 113,090 participants were included in the meta-analysis that were based on the random effects model. Compared with controls, participants who were diagnosed with obstructive sleep apnea had increased risk of osteoporosis with a pooled risks ratio of 1.85(95% CI: 1.34- 2.56). 

Conclusions: Patients with OSA had a higher risk of developing osteoporosis. Further study is needed to evaluate the possible mechanisms between these two conditions and to find potential treatment for OSA that could be used to prevent osteoporosis.

 

Nothing to Disclose: SU, AS

18610 4.0000 SAT-227 A Obstructive Sleep Apnea Is Associated with an Increase Risk of Osteoporosis: A Systematic Review and Meta-Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Hyeon Mok Kim*, Seong Hee Ahn, Beom-Jun Kim, Seung Hun Lee and Jung-Min Koh
Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South)

 

Purpose: Many lines of evidence indicate that dehydroepiandrosterone (DHEA) plays a distinct role in bone metabolism, and that its sulfated form (DHEA-S), which is easily measured in blood, may be a potential biomarker of osteoporosis-related phenotypes. However, most previous epidemiologic studies focused on postmenopausal women and reported conflicting results. In our present study, we investigated the association between the serum DHEA-S level and bone mass in men.

Methods: This large cross-sectional study included 1,089 healthy Korean men who participated in a routine health screening examination. Bone mineral density (BMD) at the lumbar spine, total femur, femur neck, and trochanter and serum DHEA-S level were obtained in all subjects.

Results: After adjustment for age, body mass index, lifestyle factors, and serum levels of calcium, phosphorus, testosterone, 25-OH-vitamin D3, and cortisol, higher serum DHEA-S concentrations were associated with higher BMD values at all skeletal sites. Consistently, compared to the subjects in the highest DHEA-S quartile (Q4), those in the lowest DHEA-S quartile (Q1) showed significantly lower BMD values. Multiple logistic regression analyses revealed that the odds ratios for the risk of lower BMD (T-score <−1) increased in a dose-dependent manner across decreasing DHEA-S quartiles, and the odds for the risk of lower BMD was 2.59-fold higher in Q1 than in Q4.

Conclusion: These findings support previous evidences that DHEA-S has favorable effects on bone mass in men and suggest that a low serum DHEA-S level may be a potential risk factor for male osteoporosis.

 

Nothing to Disclose: HMK, SHA, BJK, SHL, JMK

18621 5.0000 SAT-228 A The Association Between Serum Dehydroepiandrosterone Sulfate (DHEA-S) Level and Bone Mineral Density in Korean Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Melissa Orlandin Premaor*, Felipe Welter Langer, Antonio Aurelio da Silveira Codevilla, Léo Canterle Dal Osto, Giovani Ricardo Ruviaro Sartori, Adhan Rizzi de Vieira and Fabio Vasconcellos Comim
Federal University of Santa Maria, Santa Maria, Brazil

 

Bone fractures and obesity are a well-known cause of morbidity and poor health-related quality of life. Furthermore, studies that assess the recovery of obese subjects after a fracture have described the risk of fracture non-union, post-operative complications, and longer time for recovery (1). In this study, we aimed to evaluate the health-related quality of life in obese post-menopausal women with fractures. With this purpose, we carried out a cross-sectional study from March 1st to August 31st, 2013. Post-menopausal women aged 55 years or older who had at least one appointment at the basic health units of the municipality of Santa Maria, Brazil in the two years prior the study were recruited. Women with cognitive impairment were excluded. The GLOW study questionnaire (2) and the Short-Form Health Survey (SF-36) were applied with permission of The Center for Outcomes Research, University of Massachusetts of Medical School and QualityMetric Incorporate (QM0 16471). Height and weight were measured according the WHO protocol. Bone fractures (excluding hand, feet, and head) which occur after age 45 years were considered as the study factor. Overall, 1301 women were invited to participate of the study; of whom, 1057 women filled the survey. Information about the SF-36 was available in 990 women. The mean [mean (SD)] age, SF-36 physical component summary (PCS), and, SF-36 mental component summary (MCS) were 67.2(7.6) years, 47,1 (9.3) and, 50,1 (11.4), respectively. The prevalence of fractures and obesity (BMI ≥ 30 kg/m2) were: 17% and 39.6%.  Both obesity and fractures were independently associated with a worse PCS in the general linear model.  Obese post-menopausal women with fractures had the lowest PCS when compared with obese women without fractures, lean women with fractures and lean women without fractures (P <0.0001, ANOVA test). There was no association between MCS and obesity or fractures. In conclusion, both obesity and fracture had a negative influence in the physical component of the health-related quality of life. Moreover, obese women with fracture had the worst physical health-related quality of life.

 

Nothing to Disclose: MOP, FWL, AADSC, LCD, GRRS, ARD, FVC

18659 6.0000 SAT-229 A Health-Related Quality of Life in Obese Women with Bone Fractures: A Cross-Sectional Study at Santa Maria, Brazil 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Jo Eun Kim*1, Curie Kim1, Yumie Rhee2 and Sung-Kil Lim3
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Yonsei Univ College of Medicine, Seoul, Korea, Republic of (South), 3Yonsei Univ. College of Med, Seoul, Korea, Republic of (South)

 

Objective: The Relationship between bone mineral density (BMD) and liver disease such as liver steatosis and/or liver fibrosis assessed by liver fibroscan has not been studied yet. We hypothesized that patients with liver steatosis and/or fibrosis may have lower BMD than normal people.

Methods: We performed a retrospective chart review of subjects who underwent evaluation of BMD study with liver fibroscan at Severance Hospital for regular health check-up between November 2005 and March 2014. Patients with chronic liver disease such as autoimmune hepatitis, hepatitis B viral carrier, hepatitis C viral carrier, alcoholic hepatitis, and drug induced hepatitis were excluded. The BMD was measured at the lumbar spine, femur neck and total hip using dual-energy x-ray absorptiometry. Liver steatosis and liver fibrosis were defined as 238 dB/m controlled attenuated parameter (CAP) or higher, and 5.5 kPa or higher, respectively using liver transient elastography (Fibroscan®).

Results: A total of 74 male and 151 female older than 50 subjects were enrolled in this study (mean age ± SD; male 59.6 ± 7.6; female 60.2 ± 6.7 years). Of the 74 male subjects, 73.0 % and 24.3 % had liver steatosis and liver fibrosis, while of the 151 female subjects, 64.9 % and 40.4 % showed liver steatosis and liver fibrosis, respectively. The presence of liver steatosis was not associated with low BMD in both male and female subjects. In female subjects, liver fibrosis showed negative correlation with BMD in femur neck and total hip showed (β -0.313, P-value 0.011; β -0.251, P-value 0.046) after adjustment of age, body mass index (BMI), history of diabetes, fasting plasma glucose, ALT, triglyceride, HDL (high-density lipoprotein)-cholesterol, and 25-hydroxy vitamin D, but the significance disappeared after further adjustment with liver  steatosis. In male subjects, liver fibrosis was significantly associated with low BMD in lumbar spine, femur neck, and total hip after adjustment of age, body mass index (BMI), history of diabetes, fasting plasma glucose, ALT, triglyceride, HDL (high-density lipoprotein)-cholesterol, 25-hydroxy vitamin D, and liver steatosis (β -0.983, P-value < 0.001; β -0.840, P-value < 0.001; β -0.940, P-value < 0.001).

Conclusions: The presence of liver fibrosis was associated with low BMD in Korean men.

 

Nothing to Disclose: JEK, CK, YR, SKL

19298 7.0000 SAT-230 A Liver Fibrosis Assessed By Liver Transient Elastography (Fibroscan®) Is Associated with Low Bone Mineral Density in Korean Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Graziano Onder1, Angelo Carfì1, Emanuele Rocco Villani1, Chantal Di Segni1, Andrea Silvestrini1, Elisabetta Meucci1, Alfredo Pontecorvi2 and Antonio Mancini*1
1Catholic University of the Sacred Heart, Rome, Italy, 2Catholic University, School of Medicine, Rome, Italy

 

Thyroid disorders such as hypothyroidism and autoimmune thyroiditis are common in individuals of all ages with Down’ syndrome (DS). People with DS show lower bone mass density (BMD) values compared to those of the general population. Hence, DS is considered to be an independent risk factor for osteoporosis and the most significant predictor of lower BMD among people with intellectual disabilities. Several studies identify hypothyroidism as a condition with a higher incidence of both osteoporosis and osteoporotic fractures. A higher oxidative stress appears to lead to an important reduction in BMD. Thyroid function is involved in oxidative stress mechanisms. DS is a well-known high oxidative stress condition and a study has shown that CoQ10 (lipophilic antioxidant) is more correlated with hypothyroidism than TSH itself in individuals with DS. In order to find relationships among thyroid function, BMD and oxidative stress, we enrolled 26 adults with DS (10 males) between 18 and 64 yr of age and BMI between 18.33 and 43.28 Kg/m2. 14 of them were under thyroid replacement therapy with levotiroxine. We evaluated TSH, fT3, fT4 and total antioxidant capacity (TAC) in blood plasma. Total antioxidant capacity (TAC) was evaluated with a colorimetric method, using the system metamyoglobin-H2O2 and the chromogen ABTS; the latency time (LAG, sec) in the appearance of ABTS radical species is proportional to antioxidant content of the system. BMD was evaluated with a DEXA scan performed with a Hologic machine. Patients were classified by TSH levels (n.r. 0.30-2,80 uUI/l). 16 patients showed TSH levels > 2.80 uUI/l. We performed a linear regression analisys and we found a significant correlation between Lag phase and BMD taken at the lumbar spine (r2 = 0,33) among 16 patients with TSH levels >2.80 uUI/l, while no correlation was found among the 10 euthytoid patients (r2 = 0,003). These data suggest that lower blood plasma antioxidant capacity could be associated with reduced BMD values. Further studies will be necessary to evaluate whether oxidative stress should be considered as a pathogenic factor for osteopenia in hypothyroid patients with DS.

 

Nothing to Disclose: GO, AC, ERV, CD, AS, EM, AP, AM

19858 8.0000 SAT-232 A Relationships Between Antioxidant Systems and Bone Mass Density in Down' Syndrome Patients with Hypothyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Sunil Raj Thomas*1, Lisa Allenspach2, Lisa Stagner2 and D. Sudhaker D. Rao1
1Henry Ford Health System, Detroit, MI, 2Henry Ford Health System

 

Background: Osteoporosis can be debilitating in patients with chronic lung disease and lung transplant recipients. Advanced age, female sex, poor nutrition and conditioning, steroid use and immunosuppressive therapy negatively impact bone health. Based on previous studies, the prevalence and incidence of fragility fractures in lung transplant patients is estimated to be 10-15% and 15-50%, respectively. (1,2)

Objective: To ascertain the prevalence and incidence of vertebral fractures in recipients of lung transplantation at a university-affiliated tertiary medical center in Southeast Michigan.

Study population: 157 recipients of single or bilateral lung transplants from 1993 to 2013.

Design and Methods: As part of a quality improvement project, we reviewed the patients' medical records and radiographs. Data collected included age, sex, race and ethnicity, prevalence and incidence of vertebral fractures prior to and post-lung transplantation, underlying diagnoses, DEXA results and the treatment of bone loss.

Results: There were 83 men and 74 women with a mean age of 61± 9.9 years (range: 28 to 78). The prevalence of patients with vertebral fractures in our lung transplant recipients was 10 (6.4%) with a total of 25 fractures in the 10 patients. The number of patients with incident vertebral fractures was 19 (12.1%), with 45 new compression deformities. 5 patients with prevalent fractures developed new fractures after transplant, whereas 14 patients without prevalent fracture developed incident fractures after lung transplant.

88 patients had bone densitometry prior to transplant compared to 32 after surgery. The lowest T-score among all patients was -4.0 SD at the lumbar spine. All patients were on treatment with calcium and vitamin D supplements prior to transplant and after regardless of the severity of bone loss. Of the 42 patients on additional therapy, 35 were on bisphosphonates. The others were treated with hormone replacement, raloxifene, teriparatide and calcitonin.

Limitations: The foremost limitation is that this is an observational study. As a convenience sample, the study population could not be controlled with regards to the number or the gender of patients selected. By excluding those with severe osteoporosis from receiving transplants, the most vulnerable group is removed. (3) Variations in immunosuppressive regiments also affect the results.

Conclusions: In summary, the prevalence and incidence of vertebral fractures in our study population was lower than the published data. Early interventions including vitamin D supplementation and anti-resorptive therapy may have improved baseline bone quality in lung transplant candidates. A multidisciplinary approach to improve physical conditioning and nutrition of prospective transplant candidates may improve the outcomes further.

 

Nothing to Disclose: SRT, LA, LS, DSDR

20075 9.0000 SAT-233 A Prevalence and Incidence of Vertebral Fractures in Lung Transplant Recipients- a Retrospective Review 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Gherardo Mazziotti*1, Michele Maddalo1, Filippo Maffezzoni2, Stefano Frara2, Vincenza Serra1, Ivan Zorza1, Pier Antonio Soldini1, Luigi Cerri1, Francesco Doglietto1, Andrea Giustina2 and Roberto Maroldi1
1University of Brescia, Brescia, Italy, 2University of Brescia, Italy

 

Context. Over the last years, there has been convincing evidence that acromegaly may cause skeletal fragility with high risk of vertebral fractures (VF). However, the skeletal determinants of VF in this clinical setting are still unknown, since VF were shown to occur even in patients with normal or low-normal bone mineral density (BMD).

Objective. To investigate whether VF are associated with abnormalities of trabecular bone structure in patients with acromegaly.

Design.Cross-sectional study.

Setting. Referral centre.

Subjects. 19 patients with acromegaly (11 females, 8 males; mean age 56 years, range 25-72). 9 patients had active acromegaly, while the disease was controlled/cured in the remaining 10 patients.

Main Measures. Patients were evaluated for VF using a quantitative morphometric evaluation of spine X-ray. Geometric trabecular parameters were measured at the distal radius using a high resolution Cone Beam computed tomography (CBCT) system (Newtom 5G; QR, Verona, Italy) with an isotropic voxel size of 75 microns.  For each patient a volume of 120 slices was obtained, corresponding approximately to a section of 9 mm in the axial plane. The first CBCT slice was obtained 9.5 mm proximal to the endplate of the radius. An irregular volume of interest (VOI) containing only trabecular bone was defined through segmentation and exclusion in every slice of the cortical cross-sectional area. A fixed threshold value equal for every patient was applied in order to separate trabeculae from bone marrow in the VOI. Bone volume fraction (BV/TV), mean trabecular thickness (Th.mean) and mean trabecular separation (Sp.mean) were measured  by means of BoneJ plugin for ImageJ software version 1.47v (Rasband, W.S., ImageJ, U.S. National Institutes of Health, Bethesda, MD, USA). All patients were also evaluated for DXA BMD at lumbar spine, total hip, femoral neck and distal radius.

Results. VF were found in 10 patients with acromegaly (5 with active and 5 with controlled/cured disease). Patients with VF had significantly lower BV/TV (0.72±0.13% vs. 0.86±0.08%; p=0.023) and greater Sp.mean (0.44±0.11 mm vs. 0.34±0.07 mm; p=0.037) as compared with non fractured patients, without statistically significant differences (p=0.068) in Th. mean. Moreover, patients with VF had longer duration of active disease (p=0.0.07) and were significantly older (p=0.002) than patients who did not fracture, without significant differences in sex and DXA BMD at either sites between the groups.

Conclusions. This study shows for the first time that abnormalities of bone trabecular structure, as assessed by high resolution CBCT, are associated with morphometric VF in acromegaly.  Our data, which need to be confirmed in larger populations, open an avenue that could finally lead to an accurate prediction of the risk of fracture in acromegaly and potentially in other secondary forms of osteoporosis in which DXA poorly predicts this risk.

 

Disclosure: GM: Consultant, Novartis Pharmaceuticals, Board Member, Ipsen. AG: Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Pfizer, Inc.. Nothing to Disclose: MM, FM, SF, VS, IZ, PAS, LC, FD, RM

20338 10.0000 SAT-234 A Cone BEAM Computed Tomography Analysis of Trabecular Bone Structure in Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Ohk Hyun Ryu*1, Moon Gi Choi2, Seong Jin Lee2, Jae Myung Yu2, Hyung Joon Yoo2, Doo-Man Kim2, Sung-Hee Ihm2 and Eun Gyung Hong2
1Division of Endocrinology and Metabolism, Hallym University College of Medicine, Seoul, Korea, Republic of (South), 2College of Medicine, Hallym University, Seoul, Korea, Republic of (South)

 

Background: Higher body weight is associated with greater bone mineral density (BMD) in adults. However, a number of controversial studies have suggested that obesity has a detrimental effect on bone mass accrual and fractures in adolescence. The differential effect of obesity might be affected by hormonal changes during puberty.

Objective: We evaluated the effect of body mass index (BMI), surrogate measures for obesity, on bone, and examined whether the effect of obesity changed with pubertal status in adolescent girls.

Methods: We analyzed the data of  946 Korean girls (aged 10-19 year) from the Korea National Health and Nutrition Examination Survey (2008-2011).The whole body bone mineral content (BMC), bone area, and soft tissue composition (lean mass and fat mass) excluding head (total body less head, TBLH) were measured by dual-energy X-ray absorptiometry (DXA). Pubertal stage was assessed by menarcheal status and the age of menarche. The effect of obesity on bone was evaluated by multiple regression model, including the interaction effects of pubertal stage. Obesity was defined by 95 or more BMI percentiles within the same age group.

Results: One-quarter (n=213) were in the state of pre-menarche. The age of menarche in post-menarcheal adolescents (n=733) were 12.23±1.33. Only in the obesity group of adolescent girls, fat mass was negatively related to BMD. The negative effect on BMD was alleviated by the menarche.  In a multiple regression model with second-order polynomial terms, BMI was in an inverted U-shaped relationship with BMD, especially in pre-menarche. As the BMI was higher, estimated BMD in pre-menarcheal girls at a specific age declined more rapidly than that of post-menarcheal subjects.

Conclusions: Our study shows that the relationship between BMD and obesity is represented by an inverted U-shaped curve in Korean adolescent girls. Furthermore, the negative effect of excess fat on BMD may be attenuated during the post-menarcheal period. Hormonal changes during puberty might contribute to the differential curvilinear effect of obesity.

 

 

Nothing to Disclose: OHR, MGC, SJL, JMY, HJY, DMK, SHI, EGH

20918 11.0000 SAT-235 A Inverted U-Shaped Relationship Between Obesity and Bone Mineral Density in Adolescent Girls: Differential Curvilinear Effect By Pubertal Stage 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Nadine M Vaninetti*1, Susan Kirkland2, Jerilynn C Prior3, Christopher Simon Kovacs4, Sophie Jamal5, Jonathan Adachi6, Tanveer Towheed7, William D Leslie8, K Shawn Davison9, Suzanne Morin10, David Goltzman10 and Stephanie M Kaiser1
1Dalhousie University, Halifax, NS, Canada, 2Dalhousie University, Halifax, NS, 3University of British Columbia, Vancouver, BC, Canada, 4Mem Univ of Newfoundland, St John's, NF, Canada, 5University of Toronto, Toronto, Canada, 6McMaster University, Hamilton, ON, Canada, 7Queen's University, Kingston, ON, 8University of Manitoba, Winnipeg, MB, Canada, 9University of Saskatchewan, Saskatoon, SK, 10McGill University, Montreal, QC, Canada

 

Background: Warfarin, a vitamin K antagonist exerts its anticoagulation effects through interference with post-translational carboxylation of glutamic acid residues on clotting factors II, VII, IX and X. Osteocalcin a bone-specific protein secreted by osteoblasts, has an important role in bone metabolism and mineralization. Uncarboxylated osteocalcin has been shown to predict risk for hip fracture and lower bone mineral density (BMD) of the femoral neck. Warfarin is proven to inhibit carboxylation of osteocalcin in a similar fashion in in vitrostudies, animal models and in warfarin-treated patients, thus providing a plausible mechanistic link between warfarin use and impaired bone metabolism. To date, studies looking at the relationship between warfarin use, bone density and fracture risk have been inconsistent with an association reported in some studies but not others. Given the conflicting evidence regarding warfarin use, BMD and fracture risk, further studies are required to characterize a relationship.

Study population: The Canadian Multicenter Osteoporosis Study (CaMos) is a population-based, prospective cohort of the Canadian population consisting of 9423 adults 25-80+ recruited between 1995 and 1997. Participants underwent BMD testing, using DXA L-spine (L1-4), total hip (TH) and femoral neck (FN) at years 0, 5 and 10. A comprehensive interviewer-administered questionnaire at 0, 5 and 10 years included medical/reproductive history, medications, osteoporosis risk factors and family history.

 Methodology: All adults 50 years and older at the time 0 were included. Primary outcomes were L1-4, TH and FN BMD. Warfarin use, as reported in the interview-administered questionnaire, was the independent predictor of interest. Baseline group differences between those taking and those not taking warfarin were compared using t-tests for continuous variables and chi-square tests for categorical variables.

Results: In total, 7753 participants with complete data were included, with 162 on warfarin at the time 0. At baseline, there was a statistically significant difference in diuretic use (22% vs 46%; p <0.0001) and chronic kidney disease (2% vs 4%; p=0.02) between warfarin non-users vs users. There was a statistically significant difference in the mean baseline TH BMD in warfarin users vs non-users (0.8482 vs. 0.8839; p=0.03), but not L1-4 or FN. Analysis of warfarin use and longitudinal changes in BMD at L1-4, TH and FN at years 0, 5 and 10 and 10-y incident fracture risk is ongoing.

Conclusions: Warfarin users had lower baseline TH BMD compared to non-warfarin users, but similar L1-4 and FN BMD. Warfarin is a commonly prescribed anticoagulant, particularly among elderly patient populations who may benefit from additional lifestyle of pharmacological interventions to optimize BMD.

 

Nothing to Disclose: NMV, SK, JCP, CSK, SJ, JA, TT, WDL, KSD, SM, DG, SMK

20963 12.0000 SAT-236 A Warfarin Use and Baseline Bone Mineral Density in the Population-Based Canadian Multicentre Osteoporosis Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Lina E Aguirre*1, Georgia Colleluori2, Kenneth E Fowler1, Irum Z Jan3, Kenneth Villareal4, Clifford R. Qualls5, David N Robbins6, Dennis Tan Villareal2 and Reina Condevillamar Villareal2
1New Mexico VA Health Care System, Albuquerque, NM, 2Michael E. DeBakey VA Medical Center, Houston, TX, 3University of New Mexico Health Care Sciences, 4New Mexico Health Care System, Albuquerque, NM, 5University of New Mexico Health Sciences Center, Albuquerque, NM, 6New Mexico VA Medical Center, Albuquerque, NM

 

Background: Because the aromatase enzyme catalyzes the conversion of testosterone to estradiol, the activity of this enzyme could be important in the musculoskeletal health of men with low testosterone.

Objective: To determine the influence of aromatase activity on the bone mineral density (BMD) and body composition of patients with low testosterone.

Methods: The baseline data of ninety patients, between 40 to 74 years old, participating in a genetic study of response to testosterone therapy in men with low testosterone (i.e. <300 ng/dl) were analyzed.  BMD and body composition were measured by dual energy x-ray absorptiometry. Serum testosterone was measured by automated immunoassay, estradiol by ultrasensitive enzyme immunoassay, and sex hormone binding globulin by enzyme immunoassay.

Results: Men in the highest tertile of estradiol to testosterone ratio (E2/T) had the highest spine BMD (p=<0.048), highest truncal fat (p=0.046) and lowest total lean body mass (p=0.045). A similar pattern was observed in the upper extremities, i.e. fat mass significantly increased (p=0.047) while lean mass significantly decreased (p=0.034) with increasing E2/T tertiles. 

Conclusions: Our findings suggest that in men with low testosterone, aromatase activity could be an important determinant of musculoskeletal health. Men with high aromatase activity are able to maintain a higher BMD despite low circulating testosterone, but have lower lean and higher truncal fat mass compared to those with lower aromatase activity. 

Values are Means±SD, E2/T: estradiol to testosterone ratio, FEI: free estradiol index, FAI: free androgen index

*p<0.05 tertile 1 vs. tertile 3. 

**p<0.05 tertile 2 vs.  tertile 3.

 

Nothing to Disclose: LEA, GC, KEF, IZJ, KV, CRQ, DNR, DTV, RCV

21375 13.0000 SAT-237 A High Aromatase Activity in Men with Low Testosterone Is Associated with Higher Spine BMD, Increased Truncal Fat Mass and Reduced Lean Mass 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Rani Kulkarni*1, Pamela Rose Schroeder1 and Sonia Hans2
1Medstar Union Memorial Hospital, Baltimore, MD, 2Medstar Union Memorial Hospital

 

Objective: To identify the rates of screening for male osteoporosis in a medicine resident primary care clinic. Compare with the rate of screening in post-menopausal women.

Background: Primary care physicians have a lower threshold to screen postmenopausal women compared to men with risk factors.  There is a dearth of evidence on male osteoporosis screening and recommendations are not uniform among different societies. DXA scan is currently the best non-invasive method to screen for osteoporosis.

Method: We conducted a chart review of patients seen in an urban primary care clinic in a community teaching hospital in Baltimore, MD over the past three years. We looked at the DXA screening rates and presence of Vitamin D and calcium supplements in the medication profile. The target population included charts with ICD-9 codes for males between 50 – 69 years with osteoporosis risk factors, males aged 70 years or more and post-menopausal women. ICD-9 codes for risk factors that were reimbursable by Medicare were used. We performed an educational intervention via handouts and short lectures to the medical staff on the current guidelines of osteoporosis screening followed by prospective chart review.

Results:  Less than 5% of high-risk males were screened for osteoporosis and less than 30% advised calcium and vitamin D supplementation compared to females.  Physician education on current screening guidelines may improve the rate of screening for osteoporosis in males with risk factors.

Conclusion: Males at significant risk for osteoporotic fractures do not get adequately screened at primary care clinics. There is a lack of consensus among medical societies.

 

Nothing to Disclose: RK, PRS, SH

21528 14.0000 SAT-238 A Male Osteoporosis and Screening Rates 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


A Ram Hong*, Jung Hee Kim, Kyung Won Kim, Ji Won Yoon, Sang Wan Kim, Seong Yeon Kim and Chan Soo Shin
Seoul National University College of Medicine, Seoul, Korea, Republic of (South)

 

Background: Type 2 diabetes mellitus (T2DM) is associated with increased fracture risk despite normal or higher bone mineral density (BMD). Osteocalcin is a bone formation marker and plays a role in glucose metabolism. We investigated lumbar spine trabecular bone score (TBS), a novel texture index to evaluate bone microarchitecture, BMD and serum osteocalcin in postmenopausal women with T2DM. 

Materials and methods:We examined 1095 postmenopausal women who visited the Seoul National University Healthcare System Gangnam Center for routine checkup from January 2008 to February 2011. Biochemical parameters related to glucose metabolism, lumbar spine TBS, lumbar spine (LS) BMD, femur neck (FN) BMD, total hip (TH) BMD and serum osteocalcin were evaluated.

Results: Prevalence of T2DM was 12.4% (135/1095). TBS was significantly lower in T2DM patients than non-DM subjects (1.364 ± 0.006 and 1.386 ± 0.002, P <0.001) after adjusting for age and body mass index (BMI). However, BMD was not significantly different between T2DM and non-DM subjects. Serum osteocalcin levels were also significantly lower in T2DM patients than non-DM subjects (17.9 ± 10.4 vs. 20.0 ± 8.9 ng/mL P=0.009). TBS showed significantly negative correlation with serum osteocalcin, HbA1c and fasting plasma glucose (r=-0.156, -0.098, and -0.115, respectively, all P <0.001), whereas positive correlation with LS, FN and TH BMD (r=0.531, 0.467, 0.503, respectively, all P<0.001) after adjusting for age and BMI.

Conclusions: The current study demonstrated lumbar spine TBS and serum osteocalcin level were decreased in postmenopausal women with T2DM independent of BMD. This finding suggests that low osteocalcin level in T2DM may be attributed to deterioration of bone microarchitecture in T2DM.

 

Nothing to Disclose: ARH, JHK, KWK, JWY, SWK, SYK, CSS

21591 15.0000 SAT-239 A Association of Osteocalcin with Trabecular Bone Score in Postmenopausal Women According to Glycemic Status 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Tatiana Munhoz da Rocha Lemos Costa1, Talita da Silva2, Tatyane Calegari2, Fabio Costa2, Carolina Aguiar Kulak*1, Leda Rabelo2, Cesar Boguzszewski3 and Victoria Zeghbi Borba4
1Federal University of Parana, Curitiba, Brazil, 2UFPR, 3Federal University of Parana, 4Federal University of Parana, Curitiba-PR, Brazil

 

Chronic obstructive pulmonary disease (COPD) is associated with many extra-pulmonary disorders. Body composition changes, especially loss of fat free-mass (sarcopenia), is associated with reduced exercise capacity and poor quality of life in these patients. Besides, in conjunction with the bone loss, contributes to the bone fragility and increased fractures prevalence.

The objective was to evaluate the relationship between the severity and prognosis of COPD with the prevalence of morphometric vertebral fractures (MVF), bone mineral density (BMD) and body composition data.          

We conducted a retrospective study with COPD patients at the Hospital de Clínicas (HC)/UFPR, patients underwent a body composition, VFA (Vertebral Fracture Assessment) and BMD evaluation at SEMPR (Serviço de Endocrinologia e Metabologia do HC/UFPR) in a dual energy X-ray absorptiometry (DXA). Patients were classified by BODE prognosis index (B - body mass index, O - airway obstruction, D - dyspnea and E - exercise capacity) in four quartiles, being 4 the most severe; the clinical stage GOLD (A, B, C and D) and the degree of obstruction (FEV1) in  groups 1 to 4. The diagnosis criteria of densitometric sarcopenia (DS) was based, for low weight patients, on the study of Baumgartner et al and for normal or overweight patients was adjusted for fat mass based on Newman et al.  

Ninety-one patients (50 females and 41 males) with a mean of 67,4±8,7 years were evaluated. A reduction in the BMD of all sites: lumbar (LS), total femur (TF) and femoral neck (FN) was related to an increase in the disease severity and prognosis, p<0,05. A correlation between lower lean mass and lower BMD was found in all bone sites p<0,001 (LS r=0,339, TF r=0,465 and FN r=0,459). MVF were seen in 62,6% of the patients (42% with two or more) and was associated with the FN BMD (p=0,022). The diagnosis of DS was done in 40,6% of patients (34% of women and 48,8% of men, p = 0.133). No significant difference between age, smoking history and indices of severity of COPD (GOLD and FEV1) was observed. A trend was seen for higher prevalence of DS with higher BODE quartile (1 = 30,5%, 2 = 31%, 3 = 60% and 4 = 63,6%; p = 0.06). However, a statistical significance (p = 0.009) was found when comparing quartiles of best (1+2), with those of worst (3+4) prognosis, the multivariate analysis showed that regardless of age, gender and clinical stage, the BODE index was significantly associated with DS, OR = 3,12 (95% CI 1,04 - 9,38)

            The prevalence of DS was high, and was associated with BODE that may suffer great influence of lean mass, since it is considered a parameter of physical capacity. A high prevalence of low BMD was found, and was correlated with lower fat free-mass and disease severity and prognosis. MVF was also highly prevalent. Therefore, early diagnosis of DS and low BMD, may result in interventions that enable prevention and early treatment to improve quality of life and decrease morbimortality of these patients.

 

Nothing to Disclose: TMDRLC, TD, TC, FC, CAK, LR, CB, VZB

21673 16.0000 SAT-240 A High Prevalence of Alterations in the Musculo-Skeletal System in Patients with Chronic Obstructive Pulmonary Disease: Relation with Disease Activity and Prognosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Marija Pfeifer*1, Manja Maver2 and Janez Tomazic2
1University Medical Center Ljubljana, Ljubljana, Slovenia, 2University Medical Centre Ljubljana, Slovenia, Ljubljana, Slovenia

 

Objective: With the advent of effective antiretroviral therapy (ART), the recognition and management of long-term complications of HIV infection and ART gain increasing importance. In the era of ART, co-morbidities affecting cardiovascular, central nervous system, kidney, liver, and bone have emerged as important causes of morbidity and mortality. The aim of our work was to determine the long-term efficacy of osteopenia/osteoporosis treatment in the Slovenian HIV-infected male population six years after the initial evaluation.

Study design: Sixty nine HIV-infected male patients were assessed for change in bone mineral density (BMD) using dual X-ray absorptiometry, and for markers of bone turnover. The effects of HIV associated factors (HIV duration, ART duration, viral load, CD4 cell count), changes in life-style risk factors (smoking, physical activity, alcohol consumption, amount of milk in the diet) and treatment of osteopenia/osteoporosis on bone health were also assessed. Treatment for osteopenia/osteoporosis had been prescribed to 29 patients: vitamin D and calcium supplementation to 17 patients with osteopenia and additionally bisphosphonates to 12 patients with osteoporosis. In the presence of hypogonadism testosterone replacement treatment had been introduced. 39 patients had not been treated. Treatment status for one patient was unknown. Treatment success was defined as maintenance of, or increase in BMD values six years after treatment initiation.

Results: Treatment of osteopenia/osteoporosis maintained or increased BMD values in 18 (66.7%) out of 27 patients, as compared to only 8 (25%) out of 32 patients without therapy (p=0,002). Mean lumbar spine BMD increased by 4.1% with treatment, as compared with an increase of 0.9% without any treatment (p=0,033). Mean total hip BMD increased by 2.6% with treatment, compared to a 1.95 % decrease without any treatment (p<0,0001). Significant increase in the physical activity and milk consumption in HIV-infected population was observed, while the smoking rate and alcohol consumption remained the same. The life-style changes did not show any significant effect on BMD change. Mean serum C-terminal telopeptide (CTX) concentration was significantly lower in the group treated with bisphosphonates and/or testosterone. According to the logistic regression analysis, long-term vitamin D and calcium supplementation was the most significant factor associated with maintaining or increasing BMD values (p=0,010; OR= 14.4).

Conclusions: Long-term treatment, especially with vitamin D and calcium, was efficient in treating osteopenia/osteoporosis in Slovenian HIV infected patients. Early vitamin D/calcium supplementation in persons with HIV is highly recommended.

There are no conflicts of interest to be declared.

 

Nothing to Disclose: MP, MM, JT

21833 17.0000 SAT-241 A Long-Term Osteopenia/Osteoporosis Treatment in Slovenian HIV Infected Male Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Namita Gupta*1, Shailender Singh2, Luciano M Vargas2, Timothy E Moore2, Valerie K Shostrom2 and Brian P Boerner1
1University of Nebraska Medical Center, Omaha, NE, 2University of Nebraska Medical Center

 

Background:  Chronic pancreatitis (CP) is associated with pain and loss of exocrine and endocrine function.  Patients with CP are at increased risk of low bone mineral density (BMD), partly due to nutritional deficiencies.  Other risk factors include alcohol, opioid medications, and possibly hypogonadism . Little data exists on prevalence or risk factors for low BMD in patients with CP in the United States.

Aim: Determine the prevalence of low BMD and potential risk factors, including hypogonadism, in a cohort of subjects with CP.

Study Design: Prospective, observational pilot trial conducted at the UNMC multidisciplinary pancreatobiliary diseases clinic.

Methods:  Subjects 19-75 years of age with a confirmed diagnosis of CP were enrolled.  The study was approved by the UNMC IRB. Serum vitamin D 25-OH, comprehensive metabolic panel, testosterone (males) and estradiol (females) were obtained. BMD was measured by dual energy x-ray absorptiometry (DXA) scan and subjects were queried about fragility fracture history. Low BMD was defined as: T-score < -1.0 in post-menopausal females and males age > 50; Z-score < -2.0 in pre-menopausal females and males age < 50; and/or history of fragility fracture.  Vitamin D level < 30 ng/ml was considered insufficient. Fisher’s Exact Test and Chi-Square were used to compare differences between groups.

Results: A total of 22 subjects were enrolled, 13 females and 9 males. No subjects had other malabsorptive disorders. Labs were obtained in 21/22 subjects and DXA scan in 19/22. Mean age (n = 22) was 47.5 ± 10.5 years and mean BMI was 26.32 ± 7.0.  Alcohol was the most common cause of CP (50%).  Vitamin D insufficiency was present in 42%.  Nearly all subjects (90%) were on daily opioid medications.  Interestingly, of males, 66% (6/9) were hypogonadal (mean serum testosterone 77.8 ± 27.6 ng/dl).  Of pre-menopausal females, 40% (2/5) were hypogonadal as noted by irregular menses ± low serum estradiol.  Low BMD was identified in 47% (9/19).  Subjects with low BMD tended to be older (P = 0.0037) with lower BMI (P = 0.0723)compared to the normal BMD group . Though not statistically significant, 56% of subjects with low BMD were post-menopausal females and 33% were otherwise hypogonadal (compared to 20% post-menopausal females and 10% hypogonadal in the normal BMD group).  Vitamin D levels were similar between the low and normal BMD groups (P = NS). CP etiology, duration of CP, alcohol use, smoking, and of diabetes were not different between the two groups (P = NS).

Conclusion: Low BMD is common in subjects with CP and risk factors include older age and lower BMI.  The rate of hypogonadism in CP subjects was high, possibly due to opioid medications, and many subjects with low BMD were post-menopausal or hypogonadal. Hypogonadism, and its potential affects on BMD, should be studied further in CP.

Disclosures: Nothing to disclose

 

Nothing to Disclose: NG, SS, LMV, TEM, VKS, BPB

21986 18.0000 SAT-242 A Bone Disease in Chronic Pancreatitis: A Complex Phenomenon 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Francisco J A de Paula*1, Adriana Lelis Carvalho2, Iana Mizumukai de Araujo3, Carlos Ernesto Garrido Salmon4, Jorge Elias Jr.5 and Marcello Henrique Nogueira-Barbosa6
1Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil, 2Medical School of Ribeirão Preto, USP, Ribeirão Preto, Brazil, 3Medical School of Ribeirão Preto, USP, Ribeirao Preto, Brazil, 4Ribeirão Preto Medical School, USP, Ribeirao Preto, Brazil, 5Ribeirao Preto Medical School, Ribeirão Preto, Brazil, 6Ribeirão Preto Medical School, USP, Ribeirao Preto, Brazil

 

Introduction: In obesity, the outflow of fat to muscle and liver has been associated with insulin resistance and local impairment of function. However, the relationship between subcutaneous and visceral adipose tissue with bone marrow fat still is to be elucidated. Noteworthy, increased BMAT has been described in patients with anorexia nervosa while there are conflicting results in obese individuals. In this context, BMAT and body fat mass have a controversial relationship. Objectives: Our aim is to evaluate lipid outflow effect on BMAT and bone mineral density (BMD) in normal weight, overweight and obese subjects. Material and Methods: Seventy non-diabetic subjects between 19 to 70 years old were enrolled in the present study (age: 50±14 years; weight: 72±15 kg; height: 1.66±0.09 m; BMI: 26±5 kg/m²). Blood sample was collected to measure glucose, triglycerides, cholesterol, HDL, HbA1c and 25-OHD. BMD and lean mass were measured by DXA. BMAT, visceral and liver fat were assessed in 52 individuals by MRI (1,5 Tesla). Results: The biochemical assessment shows: HbA1c: 5.5±0.4% (all individuals in normal range); Cholesterol: 201±34 mg/d; Triglycerides: 123±80 mg/dL; 25(OH)D: 25±9 ng/mL. The T-score values were normal in 41%, whereas 46% and 13% exhibited osteopenia and osteoporosis, respectively. Most individuals showed high percentage of body fat (77%), however only 11% had increased fat within liver. The mean values of % body fat, lean mass and liver fat rate were, respectively, 36±7%, 43±10 kg and 3.9±5.5 %. Visceral fat correlated positively with age (r=0.50; p<0.0001), liver fat (r=0.55; p<0.0001) as well as with BMAT (r=0.43; p<0.005). It was observed a trend of correlation between the rate of fat within the liver and BMAT (r= 0.25; p=0.06). Correlation between visceral fat and BMD was not found in this group. Yet, BMAT rate was positively correlated with age (r=0.57; p<0.0001), HbA1c (r=0.34; p<0.05), cholesterol (r=0.35; p<0.05), triglycerides (r=0.38;p<0.005), visceral fat, but no correlation was observed with lumbar spine BMD. The serum levels of insulin and the values of HOMA-IR were positively correlated with visceral (Insulin: r=0.42; p<0.005, HOMA-IR: r=0.46; p<0.001)) and hepatic fat (insulin: r=0.43; p<0.005; HOMA-IR: r=0.44; p<0.005). On the other hand, it was observed no association between circulatory insulin (r=0.01; p=0.9) and HOMA-IR (r=0.09; p=0.6) with BMAT. Conclusion: The present results call attention to the complex relationship between the BMAT with metabolic disturbances classically associated with insulin resistance. BMAT was correlated with circulatory levels of glucose, lipids, HbA1c and visceral fat. Curiously, it was not verified association between BMAT neither with the amount of fat in liver nor with insulin and HOMA-IR.  Further studies are necessary to elucidate the effect of insulin resistance and fat overflow on BMAT and BMD.

 

Nothing to Disclose: FJAD, ALC, IMD, CEGS, JE Jr., MHN

21993 19.0000 SAT-243 A The Influence of Insulin Resistance and Fat Reallocation on Bone Marrow Adipose Tissue and Bone Mineral Density 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM SAT 224-243 5968 1:00:00 PM Osteoporosis Poster


Nada El Ghorayeb*1, Ping Shi Zhu2, Jean-Philippe Mailhot2, Tania L Mazzuco3, Isabelle Bourdeau1, Eric Thérasse3 and Andre Lacroix2
1Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC, Canada, 2Centre hospitalier de l’Université de Montréal (CHUM), Université de Montréal, Montreal, QC, Canada, 3Centre de Recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada

 

Background: Sufficient lateralization of aldosterone oversecretion is required to recommend unilateral adrenalectomy in primary aldosteronism (PA). Adrenal vein sampling (AVS) remains the most reliable examination to differentiate between unilateral and bilateral source of aldosterone. Controversy persists as whether AVS should be performed as sequential or simultaneous procedure, with or without bolus or continuous ACTH infusion.

Objectives: Compare basal and post ACTH aldosterone and cortisol concentrations and ratios and the percentage of contralateral aldosterone suppression in patients with PA.

Methods: We studied 175 consecutive patients with confirmed PA in a single tertiary referral center. Bilateral simultaneous adrenal vein samples were obtained at -5, 0, + 5, 10 and 15 minutes after bolus of 250 μg of ACTH 1-24. Selectivity was defined by an adrenal to peripheral cortisol ratio (CA/CP) ≥ 5 post ACTH. Lateralization ratio: A/C of dominant side by A/C of opposite side (A/C)DOM/(A/C)OPP. Basal ratio value was the mean of T-5 and T0. Post-ACTH ratio value was the highest of T5, T10 or T15.  Contralateral suppression was evaluated by the ratio of A of each side/periphery (AOPP/AP, ADOM/AP) and by the ratios of A/C (AOPP/COPP)/(AP/CP).

Results: In 171 completed AVS, 114 cases (67%) reached bilateral basal selectivity using a CA/CP ratio ≥2. Post ACTH bolus, 156 cases (91%) achieved bilateral selectivity with a CA/CP ratio ≥ 5. From these 156 selective AVS, 53 (34%) had bilateral source, while 103 (66%) lateralized  (post-ACTH ratio ≥ 4); 57 cases (37%) lateralized on the left and 46 (29%) on the right. A discordance of lateralization between basal values (ratio 2) and post-ACTH values (ratio 4) was observed in 43 cases (42 %) (43/103). From these 43 cases: 32 cases lateralized basally and became bilateral post ACTH, 9 cases were basally bilateral but lateralized post ACTH and 2 unilateral cases basally lateralized to opposite side post ACTH. Contralateral aldosterone suppression in patients with aldosterone lateralization post ACTH ratio ≥4 was only found in 62% and 83% (64/103 and 85/103) using basal ratios (AOPP/COPP)/(AP/CP) <1 and <2 respectively, and in 6% and 41% (6/103 and 42/103) using basal ratios AOPP/AP <1 and <2 respectively. The mean of (AOPP/COPP)/(AP/CP) was 1.3±1.4 and the mean of AOPP/APwas 6.6±12 [p<0.005 (paired t-test)].

Conclusion: ACTH stimulation improves selectivity detection. However it can alter the lateralization ratios as a variable expression of ACTH receptors has been identified in each APA previously1. The incomplete contralateral aldosterone suppression in a high proportion of patients supports the frequent presence of zona glomerulosa hyperplasia adjacent to the dominant aldosteronomas reported recently2.  Therefore analyzing both basal and post ACTH aldosterone and cortisol values is important in posing an indication for unilateral adrenalectomy.

 

Nothing to Disclose: NE, PSZ, JPM, TLM, IB, ET, AL

19617 1.0000 SAT-534 A Importance of Basal Versus Bolus ACTH Stimulation and Contralateral Aldosterone Suppression during Bilateral Simultaneous Adrenal Venous Sampling in the Evaluation of Primary Aldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 534-541 5979 1:00:00 PM Renin-Angiotensin-System Poster


Yuichi Fujii*1, Norio Wada2, Takamasa Ichijo3, Yuichi Matsuda4, Kohei Kamemura5, Tatsuya Kai6, Tomikazu Fukuoka7, Ryuichi Sakamoto8, Atsushi Ogo8, Hironobu Umakoshi9, Mika Tsuiki9 and Mitsuhide Naruse10
1Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan, 2Sapporo City General Hospital, Sapporo, Japan, 3Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan, 4Sanda City Hospital, Sanda, Japan, 5Akashi Medical Center, Akashi, Japan, 6Saiseikai Tondabayashi Hospital, Japan, 7Matsuyama Red Cross Hospital, Matsuyama, Japan, 8Kyushu Medical Center, Fukuoka, Japan, 9National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 10Kyoto Medical Center, Kyoto, Japan

 

Background: Adrenal venous sampling (AVS) is recommended to decide indication of adrenalectomy in patients with primary aldosteronism (PA). It is however technically difficult in catheterization of the right adrenal vein compared to the left adrenal vein. The purpose of this study was to establish parameter that predicts unilateral aldosterone hypersecretion using data of the left adrenal vein and inferior vena cava (IVC) of AVS with ACTH stimulation. Methods: We utilized the AVS database of WAVES-J which includes AVS data done between January 2008 and December 2013 as a multicenter study. A total of 541 patients with PA who underwent AVS were enrolled. Subtype was diagnosed with lateralized ratio >2 and contralateral ratio <1 after ACTH stimulation as decision criteria. Plasma aldosterone and cortisol concentration in each adrenal vein and IVC after ACTH stimulation was measured. Results: Of the 357 patients with successful AVS, subtype was diagnosed as unilateral in 78 patients (28 right, 50 left) and bilateral in 279 patients. To determine subtype with data from the left adrenal vein and IVC, patients were divided into 2 groups based on the left adrenal vein A/C / IVC A/C: Group 1 with the ratio >1 and Group 2 <1. Group 1 was consisted of left unilateral and bilateral cases. Left adrenal vein PAC was significantly higher in the left unilateral cases than in the bilateral cases. From receiver operator characteristics (ROC) analysis, the optimum diagnostic cut-off of the left adrenal vein PAC was 44000 pg/mL with a sensitivity of 70% and specificity of 92% for left unilateral disease. In contrast, Group 2 was consisted of right unilateral and bilateral cases. Left adrenal vein PAC was significantly lower in the right unilateral cases than in the bilateral cases. From ROC analysis, the optimum diagnostic cut-off of the left adrenal vein PAC was 12684 pg/mL with a sensitivity of 93% and specificity of 62% for right unilateral disease. Conclusion: These results suggested that combination of the data of the left adrenal vein and IVC of AVS data predicts subtype of PA even in the luck of the data of the right adrenal vein. The results provide important information in making diagnosis of the subtype in PA patients with unsuccessful AVS.

 

Nothing to Disclose: YF, NW, TI, YM, KK, TK, TF, RS, AO, HU, MT, MN

20311 2.0000 SAT-535 A Combination of Aldosterone Concentration in the Left Adrenal Vein and Inferior Vena Cava Predicts Subtype of Primary Aldosteronism: A Multicenter Collaborative Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 534-541 5979 1:00:00 PM Renin-Angiotensin-System Poster


Takamasa Ichijo*1, Hironobu Umakoshi2, Kohei Kamemura3, Yuichi Matsuda4, Yuichi Fujii5, Tomikazu Fukuoka6, Tatsuya Kai7, Ryuichi Sakamoto8, Atsushi Ogo9, Norio Wada10, Kanako Nakao2, Mika Tsuiki2 and Mitsuhide Naruse11
1Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan, 2National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 3Akashi Medical Center, Akashi, Japan, 4Sanda City Hospital, Sanda, Japan, 5Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan, 6Matsuyama Red Cross Hospital, Matsuyama, Japan, 7Saiseikai Tondabayashi Hospital, Japan, 8National Hospital Organization Kyushu Medical Center, Fukuoka, Japan, 9Kyushu Medical Center, Fukuoka, Japan, 10Sapporo City General Hospital, Sapporo, Japan, 11Kyoto Medical Center, Kyoto, Japan

 

Primary aldosteronism (PA) is the most common endocrine hypertension and its prevalence is about 10% of all patients with hypertension. It is known that the cardiovascular risk with PA is much higher than blood pressure matched essential hypertension. The ACTH-loading adrenal venous sampling (AVS) is the gold standard for its subtyping according to both Japanese and US Endocrine Society’s guideline, and adrenalectomy is recommended as curable therapy for those patients with unilateral hyper-aldosteronism (UHA), mostly aldosterone producing adenoma (APA). On the other hand, mineral-corticoid receptor (MR) antagonists are recommended for bilateral hyper-aldosteronism (BHA), mostly hyperplasia so called idiopathic hyper-aldosteronism (IHA). However, the decision criteria of UHA are still controversial. While US Endocrine Society recommends the lateralized ratio (LR) ≥4, Japan Endocrine Society equally recommends LR≥2.6, plasma aldosterone concentration in the adrenal vein ≥1400 ng/dl and contralateral ratio (CR) <1.0. The interpretation of AVS results is varied among countries and medical centers. Moreover, subtype diagnosis by AVS can be dissociated depending on the criteria employed even in the same patient. Thus, we conducted a multicenter study for AVS by WAVES-J study group. We investigated 541 patients underwent AVS during the last 5 years in 9 medical centers. Success of the catheterization was verified by the selectivity index >5 or the cortisol concentration in adrenal vein ≥200 mg/dl after ACTH stimulation according to Japanese Endocrine Society’s guideline. After excluding those with unsuccessful AVS and those without ACTH stimulation, 421 cases (mean age: 53.9±11.5 years old; 190 males and 231 females) were subjected to analysis. We compared the ratio of subtype classification by AVS using 6 different criteria: 1) aldosterone concentration >1400 ng/dl, 2) LR>2.6,3) LR>3.0,4) LR>4.0,5) LR>5.0, and 6) CR<1.0, respectively. The ratio classified as UHA was 1) 40.1%, 2) 31.1%, 3) 27.8%, 4) 22.8%, 5) 19.2%, and 6) 28.7%, respectively. Thus, the ratio of UHA showed a wide variation among various criteria, with the highest ratio by the criteria 1) and the lowest ratio by the criteria 5). Moreover, when the 3 criteria recommended by Japan Endocrine Society, 1), 2) and 6), were used in combination, the ratio of UHA with 1)+2), 1)+6), 2)+6) , and 1)+2)+6) was 24.5%, 21.9%, 24.0%, and 21.1%, respectively. These results clearly demonstrated that subtype diagnosis shows enormous dissociation depending on the decision criteria and the type of combination of 2 criteria.  The dissociated results of subtype cause profound impact in making decision for the type of therapy. The worldwide standardization of the decision criteria of AVS is required.

 

Nothing to Disclose: TI, HU, KK, YM, YF, TF, TK, RS, AO, NW, KN, MT, MN

19819 3.0000 SAT-536 A Dissociation of Subtype Diagnosis By Various Decision Criteria of Adrenal Venous Sampling in Primary Aldosteronism: A Multicenter Collaborative Study in Japan (WAVES-J) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 534-541 5979 1:00:00 PM Renin-Angiotensin-System Poster


Mitsuhide Naruse*1, Hironobu Umakoshi1, Mika Tsuiki1, Norio Wada2, Takamasa Ichijo3, Kohei Kamemura4, Yuichi Matsuda5, Yuichi Fujii6, Tatsuya Kai7, Tomikazu Fukuoka8, Ryuichi Sakamoto9, Atsushi Ogo9 and Akira Shimatsu1
1National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 2Sapporo City General Hospital, Sapporo, Japan, 3Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan, 4Akashi Medical Center, Akashi, Japan, 5Sanda City Hospital, Sanda, Japan, 6Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan, 7Saiseikai Tondabayashi Hospital, Japan, 8Matsuyama Red Cross Hospital, Matsuyama, Japan, 9Kyushu Medical Center, Fukuoka, Japan

 

Context: Although adrenal vein sampling (AVS) is the reference standard test for subtype testing in primary aldosteronism (PA), details of the procedure have not been standardized. The Endocrine Society Clinical Guideline recommends to obtain blood sample from the junction of the inferior phrenic vein and left adrenal vein (common trunk). In contrast, Japan Endocrine Society Guideline recommends to obtain blood sample from the left adrenal central vein (central vein) distal to the junction of the inferior phrenic vein. Effects of different position of blood sampling in the left adrenal vein on PA subtype however remain unknown. Objective: Aim of the present study was to elucidate 1) the discordant rate of subtype diagnosis between the common trunk and the central vein and 2) the optimal sampling position from postoperative outcome in patients with discordant subtype diagnosis. Methods: The retrospective study was conducted as a part of multi-center collaborative study on AVS in Japan (WAVES-J). Of the total 533 patients with PA subjected to AVS in 9 centers, patients with 1) selectivity index³a5 after corsyntropin stimulation in both adrenal veins and 2) sampling data available in both common trunk and central vein were included in the study. Lateralized index³a4 was used as a diagnostic criteria for unilateral subtype and the subtype diagnosis was compared between the common trunk and central vein. In addition, the postoperative outcome was evaluated in patients with discordant subtype diagnosis. Results: 235 patients met the inclusion criteria. Fifty three patients (23%) in the common trunk and 47 patients (20%) in the central vein were diagnosed as having a unilateral PA, respectively. Total 10 of 235 (4%) patients showed a discordant subtype diagnosis between the common trunk and central vein. Eight patients showed a change in subtype diagnosis from unilateral to bilateral PA in the common trunk and 2 patients showed a change in subtype diagnosis from bilateral to unilateral PA in the central vein. Analyses of the postoperative outcome demonstrated that all patients showed a cure of PA after unilateral adrenalectomy. Conclusions: Subtype diagnosis in the common trunk and central vein of the left adrenal vein was concordant in majority of the patients and was closely correlated to clinical outcome after adrenal surgery. Considering its feasibility and safety, blood collection from the common trunk could be recommended in the left AVS in PA.

 

Nothing to Disclose: MN, HU, MT, NW, TI, KK, YM, YF, TK, TF, RS, AO, AS

19724 4.0000 SAT-537 A Optimal Position of Left Adrenal Vein Sampling in Primary Aldosteronism: Common Trunk or Central Vein? (A multicenter study in Japan (WAVES-J study)) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 534-541 5979 1:00:00 PM Renin-Angiotensin-System Poster


Norio Wada*1, Mitsuhide Naruse2, Mika Tsuiki2, Kanako Nakao2, Hironobu Umakoshi2, Yuichi Fujii3, Kohei Kamemura4, Tatsuya Kai5, Ryuichi Sakamoto6, Atsushi Ogo6, Yuichi Matsuda7, Tomikazu Fukuoka8 and Takamasa Ichijo9
1Sapporo City General Hospital, Sapporo, Japan, 2National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 3Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan, 4Akashi Medical Center, Akashi, Japan, 5Saiseikai Tondabayashi Hospital, Japan, 6Kyushu Medical Center, Fukuoka, Japan, 7Sanda City Hospital, Sanda, Japan, 8Matsuyama Red Cross Hospital, Matsuyama, Japan, 9Saiseikai Yokohamashi Tobu Hospital, Tokyo, Japan

 

Adrenal vein sampling (AVS) is presently the most reliable test for subtype diagnosis of primary aldosteronism (PA). Although adrenocorticotropic hormone (ACTH) loading is utilized for AVS in many centers in the world, the diagnostic significance has not been established. Aim of the present study was to elucidate the effects of ACTH loading on the success rate and subtype diagnosis of AVS. The study was conducted as a part of multi-center collaborative study on AVS in Japan (WAVES-J). AVS data of 533 patients with PA (243 male, 290 female, mean age 54.1 ± 11.1 yrs.) from 9 centers were studied. Cortisol concentration in both adrenal veins was significantly higher after ACTH loading than before ACTH loading (right: 930.1 ± 653.9 vs. 227.3 ± 322.6 µg/dl, p<0.0001; left: 854.5 ± 472.1 vs. 248.6 ± 320.3 µg/dl, p<0.0001). Selectivity index (SI) in both adrenal veins was significantly higher after ACTH loading than before ACTH loading (right: 42.2 ± 30.9 vs. 6.4 ± 20.2, p<0.0001; left: 40.6 ± 30.2 vs. 18.1 ± 21.2, p<0.0001). The bilateral success rate was significantly higher after ACTH loading than before regardless of the cut-off value of SI (i.e., 91.3 % vs. 56.1 % at cut-off of SI 3.0, 89.3 % vs. 41.5 % at 5.0, p<0.0001). Of the 533 patients, 281 patients met the criteria of SI > 2.0 before ACTH loading and SI >5.0 after ACTH loading in both adrenal veins. The proportion of the patients with higher side to lower side ratio of cortisol concentrations more than 3 was higher before ACTH loading than after ACTH loading (32.7 % vs. 7.1%, p<0.0001). Lateralized ratio (LR) was significantly decreased after ACTH loading (before: 10.50 vs. after: 6.01, p<0.0001), leading to a reversal of the dominant side in some patients. The proportions of unilateral subtype was significantly decreased after ACTH loading at various cut-off of LR (i.e., 59.1 % before ACTH vs. 40.2 % after ACTH at cut-off of LR 2.0, before 37.0 % vs. after 20.6 % at 4.0, p<0.0001). In conclusion, it was clearly demonstrated that ACTH loading improved the success rate of AVS and decreased variability of the cortisol concentrations in right and left adrenal veins. In addition, prevalence of unilateral subtype was significantly decreased after ACTH loading. Postoperative cohort study is needed to validate the accuracy, sensitivity, and specificity of the subtype diagnosis after ACTH loading in AVS.

 

Nothing to Disclose: NW, MN, MT, KN, HU, YF, KK, TK, RS, AO, YM, TF, TI

19425 5.0000 SAT-538 A Effects of Adrenocorticotropic Hormone Loading on Success Rate and Subtype Diagnosis of Adrenal Vein Sampling in Patients with Primary Aldosteronism: A Multi-Center Collaborative Study in Japan (WAVES-J) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 534-541 5979 1:00:00 PM Renin-Angiotensin-System Poster


Hironobu Umakoshi*1, Kanako Nakao1, Norio Wada2, Takamasa Ichijo3, Masakatsu Sone4, Takuyuki Katabami5, Kohei Kamemura6, Yuichi Matsuda7, Tatsuya Kai8, Tomikazu Fukuoka9, Mika Tsuiki1 and Mitsuhide Naruse10
1National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 2Sapporo City General Hospital, Sapporo, Japan, 3Saiseikai Yokohamashi Tobu Hospital, Tokyo, Japan, 4Kyoto University Graduate School of Medicine, Kyoto, Japan, 5St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama-shi Kanagawa, Japan, 6Akashi Medical Center, Akashi, Japan, 7Sanda City Hospital, Sanda, Japan, 8Saiseikai Tondabayashi Hospital, Japan, 9Matsuyama Red Cross Hospital, Matsuyama, Japan, 10Kyoto Medical Center, Kyoto, Japan

 

Context: Adrenal vein sampling (AVS) is a gold standard for subtype testing in primary aldosteronism (PA). While lateralized index (LI) indicates the dominant side of aldosterone excess, contralateral (CL) suppression indicates the non-dominant side of aldosterone suppression in AVS. LI, especially ≧4, has been most widely used in subtype diagnosis. The diagnostic significance of CL suppression, however, has not been well established. Objective: The aim of the study was to establish the diagnostic significance of CL suppression in patients with LI<4. Methods: This retrospective case control study was conducted as a multicenter collaborate study of 9 different referral centers in Japan. 124 patients with PA were subjected to unilateral adrenalectomy after successful AVS with corsyntropin stimulation between Jan 2008 and Sep 2013. Of the patients, 29 patients with LI<4 and not associated with other cause of secondary hypertension were included in the study. We divided the patients into two groups: Group A with CL suppression and Group B without CL suppression. We compared the postoperative PA outcome after 6 month between two groups. Postoperative outcome of PA was defined “cure” when patients met all 3 indices: 1) cure or improvement of hypertension, 2) normalization of ARR, and 3) normalization of hypokalemia. Results: Sixteen patients and 13 patients were classified as Group A and B, respectively. Cure or improvement rate of hypertension were higher in Group A than Group B (81% vs 46%; P=0.06). Rate of normalization of ARR was significantly higher in in Group A than Group B (100% vs 46%; P=0.004). Hypokalemia was normalized in all patients of Group A and B. Over all cure of PA were significantly higher in Group A than without Group B (81% vs 23%; P=0.003). The Odds ratio for cure of PA to non-cure of PA of CL suppression was 12.8 (95% CI, 1.9-127.4; P=0.003). Conclusions: The present study clearly demonstrated that CL suppression was significantly correlated with postoperative outcome in PA patients with LI<4. It is recommended to consider the CL suppress of aldosterone secretion when PA patients with LI<4 are indicated for adrenalectomy.

 

Nothing to Disclose: HU, KN, NW, TI, MS, TK, KK, YM, TK, TF, MT, MN

19154 6.0000 SAT-539 A Contralateral Suppression in Adrenal Vein Sampling Is Significantly Related to Clinical Outcome after Adrenalectomy in Primary Aldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 534-541 5979 1:00:00 PM Renin-Angiotensin-System Poster


Dina Protashchik* and Natalya Vorokhobina
North-Western State Medical University named after I.I.Mechnikov, Saint Petersburg, Russia

 

Primary aldosteronism (PA) is an adrenal disorder which is characterized by the overproduction of the mineralocorticoid hormones by the adrenal glands when not as a result of excessive renin secretion. The importance of case detection of PA among hypertensive patients is not a matter of controversy presently.

In our study we measured 18-hydroxycorticosterone (18OHB) level and evaluated it’s value in diagnosis and differential diagnosis of primary aldosteronism. 18OHB is a precursor of aldosterone which originate from the consequent conversion of progesterone by aldostherone synthase, although small amounts may be produced by the 11beta-hydroxylase in the glomerular zone of the adrenal cortex.

We evaluated 144 low-renin hypertensive patients and 30 normotensive subjects. We measured serum aldosterone and renin activity by radioimmuno assay; serum and urinary 18OHB by means of high-performance liquid chromatography. All patients underwent saline infusion test (SIT) and computed tomography (CT). Patients with confirmed PA underwent adrenal vein sampling (AVS).

Positive aldosterone-renin ration (ARR) had 115 low-renin hypertensive patients. Diagnosis of PA among them was based on SIT. PA was confirmed in 46 patients. By the AVS they were divided in 2 groups: 27 patients with aldosterone-producing adenoma (APA) and 19 patients with bilateral adrenal hyperplasia (BAH, idiopathic aldosteronism).

Patients with PA (both APA and BAH) displayed significantly higher levels of serum and urinary 18OHB compared with low-renin essential hypertensive patients (LREH). Furthermore, APA patients displayed higher levels of both serum and urinary 18OHB compared with patients with BAH (4,8±0,5 vs 2,2±0,5 ng/ml and 41,3±3,0 vs 17,4±2,0 mkg/sec respectively; g<0,001). In our groups we identified a cutoff value useful for the distinction among LREH and PA. In our data PA was confirmed in patients with serum 18OHB more than 3 ng/ml and u18OHB higher than 30 mkg/sec (sensitivity 63,2%, specificity 84,8%). Furthermore, we observed a cutoff level of serum 18OHB for APA patients which was 5 ng/ml (sensitivity 70,4%, specificity 94,4%). BAH patients had lower serum 18OHB than APA patients (3,4±0,4 vs 5,7±0,6 ng/ml respectively; g=0,02)

The measurements of serum and urinary 18OHB in patients with a positive ARR could be additional tests in confirmation and subtype differentiation of PA. This data will be useful to identify alternative strategies to AVS which is not readily available in many clinics.

 

Nothing to Disclose: DP, NV

20872 7.0000 SAT-540 A 18-Hydroxycorticosterone in Differential Diagnosis of Primary Aldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 534-541 5979 1:00:00 PM Renin-Angiotensin-System Poster


Wann Jia Loh1, Lih-Ming Loh1, Dawn Shao Ting Lim1, Xiao Li Zhao2 and Peng Chin Kek*1
1Singapore General Hospital, Singapore, Singapore, 2Singapore General Hospital

 

Primary aldosteronism has been reported to cause relative glomerular hyperfiltration. This study was to review the effect of surgical and medical treatment of PA on the glomerular filtration rate (GFR) in our local population in Singapore. The records of all patients who underwent adrenal venous sampling (AVS) in Singapore General Hospital from January 2003 to December 2013 were reviewed retrospectively. Eighty-one 81 patients with PA, confirmed by salt loading, underwent AVS. Bilateral cannulation was met with moderate success in our center at 55.6%. Adrenal vein cannulation was regarded as successful if adrenal-peripheral cortisol ratio was >5.  Positive lateralisation was defined as lateralised ratio (LR) ≥ 4 and/or contralateral ratio (CR) of <1. Patients with missing data for renal function and another who had cavernous haemangioma on histology were excluded from this analysis. Twenty one out of 29 patients with positive lateralization on AVS underwent adrenalectomy. There were 13 patients that underwent adrenalectomy although the diagnosis was inconclusive from AVS. All of these 34 patients were histologically confirmed to have adrenal adenoma, with no surrounding cortical nodularity to suggest adrenal hyperplasia. Medical therapy with aldosterone antagonists was instituted in 29 patients. They consisted of 8 with positive lateralisation but subsequently declined surgery, 5 with the diagnosis of bilateral adrenal hyperplasia (BAH) based on non-lateralization on AVS, and the remainder who had unsuccessful AVS. GFR was calculated using Cockroft-Gault equation. Paired T test SPSS v20 was used to compare the means of GFR pre and post treatment of primary aldosteronism. Mean GFR of the patients with PA that underwent surgery significantly decreased post-adrenalectomy from 99.25±33.38 to 79.20±27.5ml/min (n=31, p<0.001). This correlated with increase of serum creatinine from 73.29±24.5 to 90.82 ± 27.63umol/L (n=34, p<0.001).  When all medically treated patients were analyzed, there was a significant fall in GFR from 87.42 ± 4.06 to 80.81 ± 26.34 ml/min (n=25, p=0.015) and a significant increase in the creatinine from 79.76 ± 19.63 to 93.21 ± 31.73 (n=29, p=0.001). Treatment of PA was associated in a fall of GFR in our study for both surgically and medically treated group. Our study supports the finding that PA causes relative glomerular hyperfiltration and this is reversed after treatment.

 

Nothing to Disclose: WJL, LML, DSTL, XLZ, PCK

21812 8.0000 SAT-541 A Mean GFR Significantly Reduced after Surgical and Medical Treatment of  Primary Aldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 534-541 5979 1:00:00 PM Renin-Angiotensin-System Poster


Cheol-Young Park*1, Joong-Yeol Park2, Jongwon Choi3, Dae Jung Kim4, Kyong Soo Park5, Kun-Ho Yoon6, Moon-Kyu Lee7 and Sung-Woo Park8
1Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South), 2Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South), 3Merck Sharp & Dohme Corp Korea, Korea, Republic of (South), 4Ajou University School of Medicine, Suwon, Korea, Republic of (South), 5Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 6The Catholic University of Korea, Seoul, Korea, Republic of (South), 7Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South), 8Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea, Republic of (South)

 

Background: Higher serum ApoB-48 concentrations reflect increased levels of circulating chylomicrons and chylomicron remnants: the intestinally derived lipoproteins [1]. Specifically, ApoB-48 is associated with coronary artery disease (CAD) [2, 3]. Additionally, studies conducted among diabetic populations have shown that carotid plaque [4] and asymptomatic peripheral arterial diseases [5] are associated with ApoB-48.

Objective: To evaluate plasma apolipoprotein B (ApoB)-48 concentrations among Korean diabetic subjects with normal to moderately high levels of low-density-lipoprotein cholesterol (LDL-C).

Methods: This multicenter, cross-sectional study included subjects with LDL-C levels between 100 and 160 mg/dL who had not been treated with a lipid-lowering agent for over 6 weeks prior to baseline. Blood tests to assess lipid profile parameters were conducted in both fasting and postprandial states. This study compared ApoB-48 and other lipid profile parameters in diabetic and nondiabetic subjects.

Results: Of the 93 subjects enrolled, 88 (diabetic, 42; nondiabetic, 46) completed the study. Significantly higher mean incremental area under curve (0-6 h; iAUC0-6h) of postprandial ApoB-48 levels was noted among diabetic than nondiabetic subjects (p = 0.0078). The mean postprandial ApoB-48 peak level was higher in diabetic subjects; however, the difference was not statistically significant. The fasting ApoB-48 level was similar in both groups: 5.9 (3.5) in diabetics and 7.3 (5.8) in nondiabetics (p = 0.18). The iAUC0-6h of postprandial total cholesterol (TC), triglyceride (TG), LDL-C, non–high-density-lipoprotein cholesterol (non-HDL-C), ApoB-100, and remnant cholesterol were similar in both groups. The ApoB-48 level was moderately correlated with TG and non-HDL-C for both groups (p < 0.05).

Conclusion: Without lipid-lowering treatment, the postprandial increment in ApoB-48 level was significantly higher in Korean diabetic subjects compared with nondiabetic subjects, irrespective of similar LDL-C levels.

 

Disclosure: CYP: Investigator, Merck & Co.. JC: Employee, Merck & Co.. Nothing to Disclose: JYP, DJK, KSP, KHY, MKL, SWP

20873 2.0000 SAT-523 A Increased Postprandial Apolipoprotein B-48 Level after a Test Meal in Korean Diabetic Patients: A Multicenter, Cross-Sectional Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 522-533 5981 1:00:00 PM Lipids Poster


Yujie Li*1, Shudong Liu1, Fei Jing1, Yongfeng Song2, Chao Xu3 and Jiajun Zhao4
1Shandong Provincial Hospital affiliated to Shandong University, Department of Endocrinology and Metabolism, China ;, 2Shandong Provincial Hospital affiliated to Shandong University, Department of Endocrinology and Metabolism, China ;, Jinan, Shandong Province, 3Shandong Provincial Hospital affiliated to Shandong University, Department of Endocrinology and Metabolism, China ;, Jinan, Shandong, 4Shandong Provincial Hospital affiliated to Shandong University, Jinan, China

 

Background and Aims: Elevated thyrotropin (TSH) induces metabolic disorders of lipids and glucose. Our previous study found that TSH promoted the mRNA of sterol regulatory element-binding protein-2 (SREBP-2). SREBP-2 is the key regulator of 3-hydroxy-3-methyl-glutaryl-coenzyme A reductase (HMGCR), the rate-limiting enzyme in cholesterol biosynthesis. SREBP-2 and HMGCR are direct targets of AMPK, and TSH can inhibit the activity of AMPK, but the relationship among them is still unclear. Thus, we focused on exploring the effect and mechanism of SREBP-2 involved in TSH-induced hepatic cholesterol content.

Methods: As TSH function is mediated through the TSH receptor (TSHR), Tshr-/- mice (supplemented with thyroxine) were used in the present study. The effect of TSH on AMPK, SREBP-2 and CRTC2 was investigated in subclinical hypothyroidism (SCH) mice liver, as well as HepG2 cells. Hepatic cholesterol level was detected in Tshr-/- mice and SCH mice, also in HepG2 cells treated with TSH using cholesterol content assay and filipin staining. The molecules of AMPK regulation of SREBP-2 were measured in Tshr+/+ mice and HepG2 cellstreated with AICAR. The molecules of CRTC2 involved in cholesterol metabolism signaling pathways were measured in HepG2 cells transfected with overexpressed plasmid CRTC2 and CRTC2-RNAi.

Results: Compared with control group, SCH mice showed relatively higher cholesterol level, SREBP-2 and HMGCR. TSH also induced the cholesterol accumulation in HepG2 cells and promoted the mRNA and protein of SREBP-2 and HMGCR, especially the expression of SREBP-2 in nuclei. However, the mRNA and protein of HMGCR was decreased after silence of SREBP-2 in HepG2 cells even exposed to TSH. Simultaneously, we found that the increase of TSH-induced SREBP-2 and HMGCR were attenuated after treatment with AICAR (the AMPK activator) in AICAR-treated Tshr+/+ mice liver and HepG2 cells. Meanwhile, we observed that CRTC2, the critical regulator of glucose metabolism, was increased in SCH mice liver compared with control group, as well as in HepG2 cells exposed to TSH. Interestingly, overexpression of CRTC2 induced an increase of mRNA and protein of SREBP-2, HMGCR and cholesterol in HepG2 cells. However, silence of CRTC2 attenuated the increase of SREBP-2, HMGCR and cholesterol induced by TSH in HepG2 cells.

Conclusion: These findings indicated that TSH can regulate the hepatic cholesterol content via AMPK/SREBP-2/HMGCR and CRTC2/SREBP-2/HMGCR pathway, this may offer therapeutic strategies to combat dyslipidemia and glucose disorder associated with TSH.

 

Nothing to Disclose: YL, SL, FJ, YS, CX, JZ

21827 3.0000 SAT-524 A The Role of Srebp-2 in Process of TSH-Induced Cholesterol Accumulation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 522-533 5981 1:00:00 PM Lipids Poster


Zhongshang Yuan*1, Meng Zhao2, Bingchang Zhang3, Haiqing Zhang2, Xu Zhang2, Qingbo Guan2, Guang Ning4, Ling Gao2, Fuzhong Xue1 and Jiajun Zhao2
1School of Public Health, Shandong University, Jinan, China, 2Shandong Provincial Hospital affiliated to Shandong University, Jinan, China, 3Shandong Provincial Hospital affiliated to Shandong University, 4Rui Jin Hosp, Shanghai

 

Background A lot of researches have suggested that lipid abnormality might be a possible cause of renal dysfunction. In addition, hypothyroidism was confirmed to be associated with both dyslipidemia and renal dysfunction. However, the impact of thyroid function on the relationship between serum lipid levels and renal function has never been given sufficient attention. In this study, we aimed to detect the association between the ratio of triglyceride to high-density lipoprotein cholesterol (TG/HDL) and renal function parameters including serum creatinine (Cr), estimated glomerular filtration rate (eGFR) and chronic kidney disease (CKD) status, and further ascertain the modification of thyroid function on this relationship.

Methods This large-scale multicenter cross-sectional study was part of the REACTION program. A total of 22,133 participants from three centers were recruited for final analysis. The mixed model accounting for within-cluster correlation was employed to investigate the association between TG/HDL and renal function parameters.

Results Among total participants (7,806 males and 14,327 females), 268 subjects were diagnosed as CKD. The ratio of TG/HDL and the prevalence of hypothyroidism in CKD subjects were significantly higher than those in non-CKD ones (P<0.001). After adjustment for potential confounding factors, TG/HDL was shown to be significantly associated with serum Cr levels (β=0.551; 95%CI, 0.394–0.708), eGFR (β=-0.481; 95%CI, -0.731–-0.230) and the risk for CKD (odds ratio=1.20; 95%CI, 1.11–1.27). These significant associations were found among subjects with euthyroidism and hypothyroidism rather than hyperthyroidism. Furthermore, the associations between TG/HDL and Cr or CKD status were significantly greater in hypothyroidism than those in euthyroidism (P<0.05).

Conclusions Elevated TG/HDL ratio was associated with renal dysfunction; it exhibited a significantly stronger association with Cr and CKD in hypothyroidism than in euthyroidism. Lowering lipid medications should be prescribed for renal dysfunction patients, especially for those with hypothyroidism.

 

Nothing to Disclose: ZY, MZ, BZ, HZ, XZ, QG, GN, LG, FX, JZ

19733 5.0000 SAT-526 A Thyroid Function Modifies the Association Between the Ratio of Triglyceride to High-Density Lipoprotein Cholesterol and Renal Function 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 522-533 5981 1:00:00 PM Lipids Poster


Carolina Paz Garfias*1, Carolina A Loureiro2, Alejandro Martinez3, Hernan Garcia2, Carmen Campino2, Carolina Mendoza4, Clarita Ferrada4, Marlene Agnoly5, Rodrigo Bancalari2, Francisca Grob2, Carlos E Fardella2, Cristian A Carvajal2, Paulina Correa6 and Diego Carrillo7
1Pontificia Universidad Católica de Chile, School of Medicine, Santiago, Chile, 2Pontificia Universidad Catolica de Chile, Santiago, Chile, 3Pontificia Universidad Catolica de Chile, Santiago, 4Pontificia Universidad Católica de Chile, Santiago, Chile, 5Pontificia Universidad Católica de Chile School of Medicine., 6Institute of Nutrition and Food Technology, University of Chile, Santiago Chile, 7Pontificia Universidad Catolica de Chile, School of Medicine

 

Introduction: Thyroid dysfunction is a common condition in children and has been associated with metabolic syndrome, hypertension, cardiovascular disease and mortality.  Due to the obesity epidemic in pediatric population nonalcoholic fatty liver disease (NAFLD) is a condition associated with insulin resistance and metabolic syndrome. In adults it has been observed that elevated TSH, even within the normal range, are positively correlated with increased biochemical markers of NAFLD: alanine aminotransferase (ALT) and gamma glutamyl transferasa (GGT). In pediatric population there is little evidence of these o this  association. Objectives: To determine association between thyroid function and biochemical markers of NAFLD in pediatric population. Subjects and Methods: 82 children 57% (female), 13,5 years old (range 6,1-18,9 year) were studied. Anthropometry, systolic and diastolic blood pressure (SBP and DBP) and serum determination of TSH, FT4, aspartate aminotransferase (AST), ALT, GGT, glucose and lipid profile. Variables were transformed to log10 prior Pearson correlation. To perform statistical analysis we used STATA SE 12.0 for windows (college station,TX: StataCorp LP). Results: TSH and FT4 average was 3,16±2,06 SDS uU/ml and 1,26±0,19 SDS. No differences were observed in  TSH and FT4 levels between  eutrophic, overweight and obese children. There was a positive association between triglycerides and TSH (R2:0.42; p< 0.001) and a negative association between HDL and TSH (R2:-0.33; p <0.001). We found a positive association between AST (R2:0.11; p<0.001), ALT (R2:0.07; p<0.001) and GGT (R2:0.1; p<0.001) with TSH, but there was a weak association with FT4. There was no association between SBP, DBP and glycemiae with levels of TSH neither with FT4. Conclusions: Our  study  showed that TSH elevated n levels, even  discrete, are associated with markers of NAFLD in the pediatric population. The relationship persists after adjusting for body mass index, suggesting that the thyroid dysfunction could have  a direct effect on liver parenchyma independent of nutritional stage. Measurement of liver enzymes is useful for  identifying children with NAFLD risk that is a potentially serious chronic disease. More studies are needed to assess the causality of this association and the effect of treatment of thyroid dysfunction in the development of liver disease.

 

Nothing to Disclose: CPG, CAL, AM, HG, CC, CM, CF, MA, RB, FG, CEF, CAC, PC, DC

21457 6.0000 SAT-527 A Thyroid Dysfunction Asociated with Biochemical Markers of NON Alcoholic Fatty LIVER Disease (NAFLD) in Pediatric Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 522-533 5981 1:00:00 PM Lipids Poster


Mei Zhu*, Hao Wang, Qiuzi Zhang, Yaxin Liu and Yun Chai
Tianjin Medical University General Hospital, Tianjin, China

 

Background: Fatty acid deposition in the liver can activate a number of pro-inflammatory signaling pathways, such as the Toll-like receptor 4 (TLR4) pathway, which may be important in the pathogenesis of nonalcoholic steatohepatitis. 1,25(OH)2D3 downregulates the expression of TLR4 and may represent a novel treatment strategy for reducing hepatocyte injury. Therefore, we investigated the protective effects of 1,25(OH)2D3 on diabetic liver injury in vivo.

Methods: Streptozotocin (STZ)-induced diabetic rats were randomly divided into five groups and treated with low-dose 1,25(OH)2D3 (0.025 μg/kg/day), medium-dose 1,25(OH)2D3 (0.15 μg/kg/day), high-dose 1,25(OH)2D3 (0.3 μg/kg/day), insulin (protamine zinc insulin 16 U/kg/day, subcutaneous injection), or no intervention (the control group). Sixteen weeks later, the rats were sacrificed, and blood samples were obtained to test lipid profiles and hepatic function. The pathological features of inflammation and fibrosis, as well as the expression of TLR4, nuclear factor-kappa B (NF-κB), and tumor necrosis factor-α (TNF-α) in the liver were analyzed.

Results: High-dose 1,25(OH)2D3 administration for 16 weeks downregulated the expression of TLR4, NF-κB, and TNF-α in the liver tissue of diabetic rats and attenuated hepatic inflammation and fibrosis, as shown by histological examination.

Conclusions: 1,25(OH)2D3 exhibited protective effects against diabetes-related liver injury, possibly through downregulation of components of the TLR4 signaling pathway.

 

Nothing to Disclose: MZ, HW, QZ, YL, YC

20360 8.0000 SAT-529 A 1,25(OH)2D3 Ameliorates Liver Injury in Diabetic Rats through Downregulation of the Toll-like Receptor 4-Mediated Inflammatory Pathway 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 522-533 5981 1:00:00 PM Lipids Poster


Charlene Ann Vicencio Balili*1, Erick Sta. Rosa Mendoza2 and Leilani Basa Mercado-Asis3
1University of Santo Tomas Hospital, Manila, Philippines, 2University of Santo Tomas, Manila City, Philippines, 3University of Santo Tomas, Manila, Philippines

 

INTRODUCTION: Postprandial lipemia, characterized by a rise in triglyceride-rich lipoproteins after eating, is associated with increased risk of cardiovascular disease. Among diabetic patients, postprandial lipemia is often overlooked once fasting lipid parameters are within target. The aim of the study is to determine the correlation between glycemic control and postprandial glycemia and lipemia among patients with type 2 diabetes mellitus. The result of the study may have important implications on how dyslipidemia should be completely addressed.

METHODOLOGY: Retrospective chart review of 102 patients was performed. Subjects included adult patients with type 2 diabetes mellitus whose fasting lipid parameters were controlled with diet and/or medications. Plasma glucose and glycosylated hemoglobin (HbA1C) were independent variables while triglyceride, total cholesterol, low density lipoprotein (LDL) and high density lipoprotein (HDL) were dependent variables. Pearson correlation was used to determine the strength of relationships among the variables mentioned. A p-value <0.05 was considered significant.

RESULTS: Of the 102 patients, 52.9% and 47.1% achieved their target HbA1C and 2-hour postprandial plasma glucose, respectively. The plasma glucose, mean triglyceride, total cholesterol, LDL and HDL were 196.39 mg/dL, 189.06 mg/dL, 177.07 mg/dL, 122.40 mg/dL and 34.83 mg/dL, respectively. Glycosylated hemoglobin has strong positive correlation with (Pearson’s r=0.40) while the 2-hour plasma glucose has moderate positive correlation (Pearson’s r=0.34) with postprandial lipemia. Both relationships were considered significant (p-value <0.05).

CONCLUSION: A significant correlation of glycemic control and postprandial hyperglycemia with postprandial lipemia was observed. Our data suggest that despite achievement of optimal fasting lipid parameters, poor control of diabetes is positively correlated with abnormal elevation of postprandial triglyceride. Addressing both postprandial hyperglycemia and lipemia may improve cardiovascular outcome

 

Nothing to Disclose: CAVB, ESRM, LBM

20297 10.0000 SAT-531 A Postprandial Lipemia Is Significantly Correlated with Postprandial Hyperglycemia and Poor Glycemic Control Among Patients with Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 522-533 5981 1:00:00 PM Lipids Poster


Jae-Hwan Lee*1, Eun-Kyeong Shin2, Dongoh Lee2 and Eui-Bae Jeung3
1Chungdaero-1, Cheongju, Korea, Republic of (South), 2Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South), 3Chungbuk National University, Cheongju, Korea, Republic of (South)

 

Introduction: Pre-eclampsia (PE) is a medical condition characterized by high blood pressure and significant amounts of protein in the urine of a pregnant woman. In many cases PE syndrome is thought to be caused by a shallowly implanted placenta that becomes hypoxic. Hypoxia can result from a failure at any stage in the delivery of oxygen to cells. In peripheral tissues, oxygen again diffuses down a pressure gradient into cells and their mitochondria, where it is used to produce energy in conjunction with the breakdown of glucose, fats, and some amino acids. Methods: As an expression of beta-oxidation related gene, ACADVL was detected by gene-fishing technology using the placenta of human. First, we conducted in vitro experiments to confirm preliminary study. We induced hypoxic stress in BeWo cells cultured under 1% O2, 5% CO2, and balanced with N2. Continually, we maintained hypoxic condition for mice from GD 6.5 to GD 17.5 under 10% O2, 5% CO2, and balanced with N2. Expression of beta-oxidation related genes (ACADVL, EHHADH, HADH, ACAA) was observed using real-time PCR. Results: Expression of genes known as biomarkers for hypoxia, HIF-1α, was increased both in vitro and in vivo. The elevated level of HIF-1α is indicative that our experimental conditions closely mimicked those associated with preeclampsia. Expression of beta-oxidation related genes, ACADVL, EHHADH, and HADH was significantly increased by hypoxic stress in BeWo compared with normoxic control. Also, expression of ACADVL and EHHADH was increased in hypoxic pregnant mice. Conclusion: Further study is being conducted on the release of HIF-1α and its effect on the metabolism of beta-oxidation in vitro and in vivo. Taken together, these results indicate that changes of beta-oxidation related genes observed under hypoxic condition are similar to those associated with preeclampsia, and expression of beta-oxidation related genes was up-regulated by hypoxic stress. It may be involved in pathogenesis of preeclampsia during gestation.

 

Nothing to Disclose: JHL, EKS, DL, EBJ

20200 11.0000 SAT-532 A Expression of Beta-Oxidation Related Genes Under Hypoxic Condition Induced Preeclamptic Model in Vitro and in Vivo 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 522-533 5981 1:00:00 PM Lipids Poster


Byambaa Enkhmaa*1, Erdembileg Anuurad1, Wei Zhang1, Adnan Abbuthalha1, Sidika Emine Karakas2 and Lars Folke Berglund3
1University of California, Davis, 2University of California at Davis Medical Center, Sacramento, CA, 3University of California, Davis, Sacramento, CA

 

Levels of lipoprotein(a) [Lp(a)], an independent risk factor for cardiovascular disease, is genetically regulated by the apolipoprotein(a) [apo(a)] gene. The apo(a) gene has an extensive size variability impacting on Lp(a) levels. Beyond total plasma Lp(a) level, the allele-specific apo(a) level, that takes both genotypic and phenotypic characteristics of apo(a) into account, allows a more detailed assessment of cardiovascular risk. Sex hormones are among the few non-genetic factors with a potential to regulate Lp(a) levels and they are altered in polycystic ovary syndrome (PCOS). The impact of PCOS-associated hormonal changes on plasma Lp(a) levels and its atherogenicity in relation to apo(a) genetic variability is not well understood. In the present study, we assessed: 1) apo(a) genetic variability measured as Kringle (K) 4 repeat number; 2) plasma Lp(a) levels; 3) allele-specific apo(a) levels; and 4) sex hormone levels in 41 Caucasian women with PCOS. The diagnosis of PCOS was based on established NIH criteria. Lp(a) levels were measured by an apo(a) size insensitive ELISA assay and apo(a) size was determined by Western blotting. Allele-specific apo(a) levels were determined based on total plasma Lp(a) level and intensity of apo(a) protein expression on Western blot analyses.

The mean age in PCOS women was 32±6 yrs, and the mean BMI was 35±8, with a 66% of women falling into category of obese (BMI >30 kg/m2). The mean LDL cholesterol level was borderline high (130 mg/dL) and the mean HDL cholesterol level was low (41 mg/dL). As in the general population, the distribution of Lp(a) level was skewed towards lower levels, with a median level of 9.2 mg/dL (IQR: 2.6-27.7 mg/dL). Lp(a) levels were not correlated with subjects’ age, body weight, or BMI. The median allele-specific apo(a) level was 4.4 mg/dL (IQR: 1.3-13.0 mg/dL) and the median apo(a) size was 27 (IQR: 23-30) K4 repeats. Allele-specific apo(a) levels were significantly and inversely correlated with K4 repeat numbers (r=-0.298, p=0.007). Although there was a trend towards negative correlations between the levels of Lp(a) or allele-specific apo(a) with the levels of testosterone or DHEAS, these trends were not statistically significant. In addition, there were no significant correlations between Lp(a) or allele-specific apo(a) levels and other plasma lipids and lipoproteins, including total, LDL, and HDL cholesterol and apoB-100. In conclusions, the apo(a) genetic variability remains the major regulator of plasma Lp(a) levels in women with PCOS.

 

Nothing to Disclose: BE, EA, WZ, AA, SEK, LFB

18943 12.0000 SAT-533 A Lipoprotein(a) and Apolipoprotein(a) in Women with Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM SAT 522-533 5981 1:00:00 PM Lipids Poster


Maria Antonenko1, Natalya Volkova*2, Irina Dzherieva3, Ilia Davidenko4, Igor Reshetnikov5, Aida Gulmagomedova3 and Lilia Ganenko3
1Rostov State Med Univ, Rostov-on-don, Russia, 2The Rostov State Medical University, Rostov-on-Don, Russia, 3Rostov State Medical University, Rostov on Don, Russia, 4Rostov State Medical University, Rostov-on-Don, Russia, 5Rostov State Medical University, Rostov-on-Don, Russia

 

Endogenous Cushing syndrome is an immunosuppressive condition. It is well-known that after resolution of hypercortisolism patients have increased incidence of autoimmune diseases. Here we opposite present a clinical case of onset of rheumatoid arthritis (RA) in a patient with active Cushing Disease (CD). The patient female 46 y.o. was suspected to have Cushing syndrome in 2011 when dysplastic obesity, face plethora, decompensation of diabetes mellitus appeared. CD was established on 1-mg DST (plasma cortisol after test 458,9 nmol/l), UFC 843,3 mcg/day, midnight plasma cortisol (MPC) 386,4 nmol/l, basal ACTH 79 pg/ml and 129 pg/ml, and pituitary microadenoma 6mm. The diagnosis of CD was confirmed in tertiary endocrinology centre by usage of petrosal venous sinus catheterization. In 2012 there was performed transsphenoidal surgery by experienced neurosurgeon. However, postoperative adrenal failure didn’t develop. Six months after operation there was performed laboratory screening for CS: plasma cortisol after DST 1 mg 250 nmol/l, UFC 402 mcg/day, MPC 280 nmol/l, basal ACTH 65 pg/ml were consistent with persistent CD. Patient refused a second operation and escaped from medical control. After 6 months, she appeared with clear evident clinical features of hypercortisolism. She also complained of inability to raise hands due to severe pain. The diagnosis of persistent CD was again confirmed: plasma cortisol after DST 1 mg 450 nmol/l, UFC 832 mcg/day, MPC 423 nmol/l, basal ACTH 86 pg/ml. Patient chose medical treatment with steroidogenesis blockers (ketoconazole). In order to establish the cause of inability to raise hands there were performed neck CT and shoulder joints radiography. The specific signs of RA were detected. The diagnosis of RA was confirmed based on inflammatory arthritis involving more three joints and positive rheumatoid factor. When the diagnosis was established, and methotrexate was prescribed by rheumatologist, there appeared a serious clinical dilemma because of combined treatment with ketoconazole and methotrexate and, as a result, their potential hepatotoxicity. Because of patient refusal of pituitary and adrenal surgery, limited pasireotide availability and other medical treatment in Russia, the only way of treatment was to receive steroidogenesis blocker and symptomatic treatment for RA. Patient has already been on this therapy for one year and feels tolerable. Firstly, to best of our knowledge, there is a very limited data about onset of autoimmune diseases in severe and active hypercortisolism. Secondly, this case illustrates a serious clinical dilemma concerning treatment of hypercortisolism and concommitant autoimmune diseases because of high hepatotoxicity of commonly used treatment for both conditions. Best option in this case would have been the prescription of somatostatin analogues equal for as hypercortisolism as arthritis.

 

Nothing to Disclose: MA, NV, ID, ID, IR, AG, LG

20824 1.0000 SAT-379 A Clinical Dilemma of Rheumatiod Artritis Onset in a Patient with Severe and Active Cushing Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Derek Timothy O'Keeffe*, Spyridoula Maraka, Harry Cloft, David F Kallmes, Alice Y Chang, Dana Erickson and William F. Young Jr.
Mayo Clinic, Rochester, MN

 

Background: Pituitary-dependent Cushing syndrome (CS), referred to herein as Cushing disease (CD), is the most common cause of endogenous CS. The challenge for diagnosing CD includes difficulty identifying the often small pituitary tumors by MRI. In addition, the tumors responsible for ectopic corticotropin (ACTH) dependent CS may also be difficult to localize by imaging. Inferior petrosal sinus sampling (IPSS) plays a key role in these patients to determine if the source of ACTH hypersecretion is eutopic or ectopic.

Methods: We reviewed data on an extended cohort of 114 patients who have undergone IPSS at Mayo Clinic from 1997-2013. Data is presented as mean ± SD.

Results: Herein we report on the subset of 63 patients evaluated to date over 10 years (1997-2008). Four patients were excluded as age was < 16 yrs. The remaining cohort included 59 adults (39 women) with age of 45.64 ± 13.17 yrs. Baseline laboratory values included: serum ACTH of 76.5 ± 52.4 pg/mL; morning serum cortisol 27.7 ± 10.6 mcg/dL,; PM serum cortisol, 26.1 ± 11 mcg/dL; 24-hr urinary cortisol, 399.9 ± 661.9 mcg; serum potassium, 4.13 ± 0.611 mEq/L. Seven patients were excluded for either technical difficulties with IPSS (n=4) or lack of completion of all management (n=3).

Fifty-two patients had complete data available for analysis. Of these, 13 (25%) were found to have ectopic ACTH based on IPSS. Three underwent right thoracotomy and 10 underwent bilateral adrenalectomy because the ectopic source of ACTH could not be localized.

Of the 39/52 (75%) patients with CD, the surgical notes documented that 33/39 patients demonstrated surgically visible pathology lateralization; of the 6 that did not lateralize in the surgical field, 3 had adenomas with positive ACTH immunohistochemistry and 3 with no evidence of adenoma. Pituitary-directed MRI suggested a pituitary adenoma in 15 of the 39 patients (38.5%); 13 of these were consistent with intraoperative lateralization (13/33; 39.4%). However, IPSS lateralization data were consistent with intraoperative lateralization in 26 of 33 (78.7%) patients.

Conclusions: IPSS was successful in identifying 13 patients with ectopic ACTH-dependent CS, who subsequently avoided an unnecessary pituitary operation. Pituitary MRI did not identify a possible adenoma in 24 of our CD patients and IPSS was key in directing curative surgical management. In addition, in this selected patient group, IPSS was superior at lateralizing the pituitary adenoma compared to pituitary-directed MRI.

 

Nothing to Disclose: DTO, SM, HC, DFK, AYC, DE, WFY Jr.

21535 2.0000 SAT-380 A Efficacy of Bilateral Inferior Petrosal Sinus Sampling at Mayo Clinic (1997-2008) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Nirali Shah*1, Henry H Ruiz2, Yelena Lalazar3, Usman Zafar4, Pamela U. Freda5, Kalmon D. Post3, Christoph Buettner6 and Eliza B. Geer3
1Icahn School Of Medicine at Mount Sinai, New York, NY, 2Icahn School Of Medicine at Mount Sinai, Flushing, NY, 3Icahn School of Medicine at Mount Sinai, New York, NY, 4Icahn School Of Medicine at Mount Sinai, 5Columbia University, College of Physicians & Surgeons, New York, NY, 6Mount Sinai, New York, NY

 

BACKGROUND:

Glucocorticoids (GC) have strong anti-inflammatory properties.  Cushing’s disease (CD), a state of chronic excess GCs, is characterized by glucose intolerance, dyslipidemia, and cardiovascular disease, all of which are considered pro-inflammatory states, suggesting that chronic in vivo exposure to GCs may in fact result in increased systemic inflammation. The effects of chronic GC exposure due to CD on pro-inflammatory mediators have not been studied in a prospective CD cohort.

AIM:

To prospectively evaluate circulating pro-inflammatory cytokines in CD patients before and over time after surgical remission and in comparison to age, sex and BMI matched controls.

METHODS:

Plasma samples from 22 prospectively enrolled CD patients were compared during active disease to controls, and then studied over time after surgical treatment. 15 patients were studied during active disease (v1), 6 months after surgical treatment while taking post-operative physiologic GC replacement orally (v2) and again 6 months after discontinuation of GC replacement (v3). 7 CD patients were studied at v1 and v3 only. Mean time since surgery for all patients at v3 was 19.7 months. Controls were studied once. To assess systemic inflammation, plasma IL1-β, IL- 6, IL-8, IL-10, IL-17, and TNF-α were quantified using a multiplex high sensitivity assay (Millipore).

RESULTS:

Of the 22 patients enrolled, 5 were male and 17 female. Median age of the patients at v1 was 39 years (range 17-70 years) and median BMI 29.15 kg/m2(range 24.6-38.5kg/m2). Median age of controls was 40 years (20-66 years) and BMI 29.6 kg/m2(21.9-37.4 kg/m2). There were no significant differences in age (p=0.36) or BMI (p=0.67) between patients and controls. Mean plasma IL-6 was significantly higher in active CD (1.3±1.1 pg/ml, n=22) compared to controls (0.65±0.37pg/ml, p = 0.02), and IL-6 remained elevated in CD patients over time after remission at V3 (1.05±0.63 pg/ml, p=0.03 vs. controls) despite normalization of cortisol levels and significant decreases in BMI and insulin resistance, as measured by HOMA-IR. Among the 6 CD patients for whom data were available for all 3 visits and cytokine concentrations were in the detectable range at all visits, IL-6, IL-8,IL-17 and TNF-α were significantly elevated at baseline compared to controls, which persisted even after 19 months of remission (p<0.05 for all).

CONCLUSION:

Despite long term remission, patients with prior CD showed persistent elevations of circulating inflammatory cytokines, particularly IL -6. This may reflect an enduring state of low grade inflammation which could contribute to the higher risk of cardiovascular mortality despite surgical cure of CD.

 

Nothing to Disclose: NS, HHR, YL, UZ, PUF, KDP, CB, EBG

21157 3.0000 SAT-381 A Circulating Pro-Inflammatory Cytokines in Patients with Cushing's Disease: A Prospective Study before and after Surgical Remission 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Fabiola Costenaro1, Ticiana Costa Rodrigues2, Guilherme Alcides Flores Rollin3, Artur Boschi4, Nelson Pires Ferreira5 and Mauro Antonio Czepielewski*4
1PPG Endocrinologia, Porto Alegre, Brazil, 2Universidade Federal do Rio Grande do Sul/Hospital de Clinicas de Porto Alegre, Porto Alegre RS, Brazil, 3Faculdade de Medicina/UFRGS, Porto Alegre, Brazil, 4Faculdade de Medicina UFRGS, Porto Alegre, Brazil, 5Irmandade da Santa Casa de Misericórdia, Porto Alegre, Porto Alegre, Brazil

 

Background: The definition criteria of “mild” Cushing’s Disease (CD) are not established. However, it is important on clinical practice because the increased frequency of patients with mild forms of CD.  The cortisol dynamic of these patients after transphenoidal surgery is poorly described. Patients and Methods: we present an analysis of a cohort with 80 CD patients with 14 of them classified as mild CD based on 24h-Urinary free cortisol (24hUFC) less than 2 times the upper limit of normality (ULN). These patients underwent to transphenoidal surgery without hydrocortisone routine use on perioperative period (PO). Hydrocortisone was administered only if they presented clinical or laboratory adrenal insufficiency. Serum cortisol was performed in the morning of the surgery and each 6h for 48h after PO. Results:  Mild CD patients presented on diagnosis lower body mass index before surgery (33.1 ± 7.5 vs. 28.4± 3.7 kg/ m2, p=0.011), a higher age (43.6± 14 vs. 35.4±11 yrs, p=0.024), lower 2mg dexamethasone test (17.7±12.6 vs. 6.9±4.3 ug/dl, p=0.001) and between the remission patients a higher median peak of serum cortisol at 48h PO (27.2 ± 10.6 µg/dl vs. 9.2 ± 10.6  µg/dl, p=0.04) in comparison to patients with 24h UFC above 2 times the ULN. If we use the cut-off in 3 times or higher values in the ULN of the 24h UFC, these differences in cortisol dynamics were not observed. Clinical characteristics as plethora, supraclavicular pad, myopathy, comorbidities as diabetes, hypertension, osteoporosis/osteopenia, psychosis/depression and definitive adrenal insufficiency were not statistically different between the two groups. Conclusions: Important clinical characteristics of CD where not discriminative of severity of CD in this cohort. Patients with mild CD presented a higher level of serum cortisol in the first 48h after surgery, probably because of a lower previous suppression of normal corticotrophs nearby the adenoma. Therefore, in patients with mild CD a higher level of serum cortisol early after surgery is not an indicative of surgical failure, as it is for severe CD. In these cases the definition of CD remission  must be postpone to a week or a month  after surgery. Based on dynamic of PO serum cortisol we suggest that 24hUFC less than 2 times ULN is an criterium for definition of mild CD.

Grants: Fundo de Incentivo a Pesquisa do HCPA- FIPE.

 

Nothing to Disclose: FC, TCR, GAFR, AB, NPF, MAC

20167 4.0000 SAT-382 A Mild Cushing's Disease: Definition and Serum Cortisol Dynamics after Transphenoidal Surgery 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Nadine El Asmar*1, Katia Elsibai2, Ribal Al-Aridi2 and Baha M Arafah3
1UH Case Medical Center/ Case Western Reserve University, Cleveland, 2UH Case Medical Center/Case Western Reserve University, Cleveland, OH, 3UH Cleveland Medical Center/Case Western Reserve University, Cleveland, OH

 

Background: Successful removal of Corticotroph adenomas (CA) results in the development of adr-insuff during the first 48 postop hrs. However, up to 20% of such patients have a recurrence within 5 yrs(1). We recently reported that plasma ACTH levels of >20ng/L obtained when serum cortisol levels were ≤3 ug/dL predicted future disease recurrence(1). In this study, we examined dynamic alterations in DHEA and DHEA-S levels immediately after adenomectomy as additional predictors of future recurrence.

Methods: Two groups were studied: Patients with pit adenomas without Cushing’s and with NL-HPA function (n=182) and 41 patients with CA in whom nadir postop serum cortisol was ≤3 ug/dL. Levels of ACTH, cortisol, DHEA, and DHEAS were determined before and repeatedly after surgery and the cortisol/ DHEA (C/D) molar ratio was calculated. Patients with NL-HPA function did not receive any glucocorticoids (GC). Data on patients with CA were all obtained before GC therapy. During a mean follow up period of 9 years, 8/41 had recurrence (REC) while 33/41 did not (no-REC).   

Results: A parallel rise in cortisol and DHEA levels was noted postop in patients with NL-HPA that peaked at 6-8 hrs (38.6±13.5 ug/dL;9.3±8.6 ng/ml, respectively) and returned to baseline (14.9±7 ug/dL; 3.5±3.8 ng/dL, respectively) by 48 hrs such that the C/D molar ratio changed minimally. These changes were preceded by a rise in plasma ACTH (peak: 243.3 ng/L at 4 hours). In those patients, DHEA-S levels increased from 105.5±82.9 to 153.1±115.9 ug/dL at 12-18 hrs and returned gradually to baseline at 48 hrs. The alterations in patients with CA were drastically different. Patients with CA–no REC had a parallel and steady decline in DHEA, DHEA-S and cortisol levels reaching low levels at 36 hrs (1.4±1.2 ng/ml; 45.8±15.5 ug/dL; 2.9±2.4 ug/dL, respectively) such that the C/D molar ratio remained unchanged throughout. In contrast, patient with CA with REC had higher DHEA and DHEA-S levels (P<0.001) at all time-points even though the respective cortisol levels were similar to those with no-REC. The respective 36 hrs values in those with REC were: 3.7±2.2 ng/ml;154.4±37.7ug/dL and 3.3 ±1.9 ug/dl; respectively. At 36 hours, plasma ACTH levels were different between patients with REC and those with no-REC(33.3±7.5 VS 12.2±6.6 ng/L; P<0.001).  

Summary and Conclusion: The alterations in DHEA and DHEA-S immediately postop in patients with CA were different from those with NL-HPA.  Even within CA patients, a distinct difference was noted in these values between those who did and others who had no-REC. Although cortisol levels were similar at all postop time-points between the subgroups, DHEA and DHEA-S were higher in those who had REC. It is postulated that persistence of ACTH secretion in patients with REC explains higher DHEA and DHEA-S. Downregulation of ACTH receptors on fasciculata cells may explain the low cortisol observed in patients with REC despite NL ACTH levels.

 

Nothing to Disclose: NE, KE, RA, BMA

19053 5.0000 SAT-383 A Dynamic Alterations in Serum DHEA and DHEA-S Levels after Surgical Resection of ACTH-Secreting Pituitary Adenomas: Prediction of Future Recurrences 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Susmeeta T. Sharma*1 and Lynnette K. Nieman2
1Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2National Institutes of Health, Bethesda, MD

 

Background: Urine free cortisol (UFC) has been traditionally used as one of the first steps in the diagnostic evaluation of Cushing’s syndrome (CS) (1). False positive results, especially values less than twice the upper limit of normal (ULN), can be seen in uncontrolled diabetes, obesity, depression, alcoholism, increased fluid intake, overcollection and stress. False negative results have also been reported with incomplete collection, in mild or cyclic CS and in patients with renal insufficiency (2-3). We evaluated the diagnostic accuracy of UFC and 24-hour urine 17-hydroxycorticosteroids (17OHCS) in patients with CS.

Methods: Retrospective study of all CS patients evaluated at the National Institutes of Health (NIH) from 2009 to 2014. Screening tests used for CS included UFC, 17OHCS, late night salivary cortisol (LNSC), midnight serum cortisol and low dose (1mg overnight or 2-day 2mg/day) dexamethasone suppression test (DST). Values above reference range for UFC, 17OHCS and LNSC, a midnight serum cortisol ≥ 7.5 mcg/dL, and post-dexamethasone cortisol values ≥ 1.8 mcg/dL were considered abnormal. Hourly 24-hour sampling for cortisol was performed in a few cases with a mild clinical phenotype and equivocal test results. UFC was measured using liquid chromatography/tandem mass spectrometry (LC-MS/MS). 17OHCS was measured using colorimetric methodology with Porter-Silber reaction (reported as mg/g of creatinine). Mean of the first two UFC and 17OHCS values (appropriate collection by urine volume and creatinine) obtained within 30 days of initial NIH presentation were used for the purpose of this study.

Results: Seventy-two patients were diagnosed with CS (aged 18-77 years, 51 females). Of these, 51 had Cushing’s disease (CD), 10 had ectopic CS while 2 had an adrenal source of Cushing’s based on pathology. Biochemical tests including inferior petrosal sinus sampling (IPSS) suggested ectopic CS but no tumor was found (occult) in 6 patients. IPSS was indicative of a pituitary source in 2 patients with failed transsphenoidal surgery while one patient did not complete evaluation for ACTH-dependent CS. UFC results were available in all, 17OHCS in 70, LNSC in 21, midnight serum cortisol in 68 and DST results in 37 patients. UFC was falsely normal in six and only minimally elevated (< 2 x ULN) in 13 patients (normal renal function, no history of cyclicity, all had CD). Of these 19 patients, 24h 17OHCS was abnormal in all, LNSC was abnormal in 12, midnight serum cortisol was abnormal in 18 and DST was abnormal in 12 patients. Hourly 24-hour sampling for cortisol performed in 3 of these patients revealed abnormal nadir (> 7.5 mcg/dL) and mean daily serum cortisol (> 9 mcg/dL) levels.

Conclusion: UFC can be falsely normal or only minimally elevated in mild CS. Multiple collections and use of complimentary screening tests including 24-hour urine 17OHCS and LNSC can help make a diagnosis and prevent delay in treatment.

 

Nothing to Disclose: STS, LKN

21401 6.0000 SAT-384 A Does a Normal Urine Free Cortisol Result Rule out Cushing's Syndrome? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Ricardo R Correa*1, Mihail Zilbermint2, Annabel Sophie Berthon2, Stéphanie Espiard2, Maria Batsis2, Georgios Papadakis3, Constantine A Stratakis2 and Fabio R Faucz4
1National Institute of Health, Bethesda, MD, 2National Institutes of Health (NIH), Bethesda, MD, 3National Institutes of Health, 4National Institutes of Health, Bethesda, MD

 

*RC and MZ share the first co-authorship

**CAS and FRR share the senior authorship

Background: Primary macronodular adrenal hyperplasia (PMAH) is a rare type of Cushing syndrome (CS), which results in increased cortisol production and bilateral enlargement of the adrenal glands. Recent work has shown that the disease may occur due to mutations in the armadillo repeat containing 5 (ARMC5) gene, a likely tumor-suppressor gene on chromosome 16 (16p11.2). We present a case of a patient with PMAH, who underwent bilateral adrenalectomy, where we obtained samples from 20 different nodules and we found 15 different mutations; this is the most ever described in a single patient

Case: 42 years-old female presented with history of cessation of menses at the age of 38,  easy bruising, weight gain, hirsutism, proximal muscle weakness, moody behavior and thinning of the skin. Biochemical evaluation revealed elevated 24-hr urinary free cortisol (270 mcg/24 hr; normal range, 8-77), abnormal midnight serum cortisol level (21.8 mcg/dl) and suppressed plasma ACTH levels (<1pg/ml), absence of plasma cortisol suppression after 1 mg overnight dexamethasone test and absence of plasma cortisol changed with oCRH test. Imaging showed bilateral adrenal nodular hyperplasia. The diagnosis of PMAH, causing CS was made and the patient underwent laparoscopic bilateral adrenalectomy. Pathology confirmed PMAH with hyperplastic nodules consistent of predominantly clear cells with interspersed compact cell disposed in nest and cord-like arrangement. Nodules were microdissected and arranged by size; peripheral and tumor DNA were sequenced by standard techniques and allelic losses were recorded; a total of 20 nodules from both adrenals were studied. 

Results: We identified 15 ARMC5 coding sequence alterations; the mutation p.W476X was present in all analyzed tissues (i.e germline mutation); each of the 13 other mutations were found in different nodules. Six of the defects were frame-shift, 4 were nonsense, and 3 were non-conservative missense substitutions. Allelic losses were confirmed in 2 of the nodules.

Discussion: We present the tumor studies of a single patient with PMAH due to an ARMC5 germline mutation. There was extreme genetic variance between the 20 nodules studied, with each showing the germline mutation and a second, new, “private” and (in most cases) completely inactivating mutation in the other allele; where a mutation was not present, the normal allele was lost. We discuss implications of these findings on the understanding of how ARMC5 causes disease in the adrenal cortex.    

 

Nothing to Disclose: RRC, MZ, ASB, SE, MB, GP, CAS, FRF

21520 10.0000 SAT-388 A ARMC5 Gene Shows Extreme Genetic Variance in a Patient with Primary Macronodular Adrenal Hyperplasia and More Than 20 Tumors: Implications for ARMC5-Induced Tumorigenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Aarti Ravikumar*1, Gillian Mueller Goddard2, Eliza B. Geer1 and Alice C Levine1
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Lenox Hill Hospital, Bronxville, NY

 

Background: Adrenal incidentalomas are commonly noted on abdominal imaging, with a high incidence in patients > 70 years of age – up to 6.9%.  Recent reports indicate a large proportion (~30%) of these nodules hyper secrete cortisol. The most sensitive test to detect mild hypercortisolism from an adrenal nodule is the 1mg overnight low-dose dexamethasone suppression test (LDDST).  Although the cut-off has been controversial, recent studies suggest that a cortisol of > 1.8 ug/dL after LDDST is the most appropriate value to define mild hypercortisolism.  Mild hypercortisolism is associated with the metabolic syndrome, cardiovascular disease and increased mortality.  There are no guidelines regarding treatment.  Surgery is an option but there are also medical treatment options such as ketoconazole or mifepristone.  Mifepristone is a glucocorticoid receptor antagonist that is FDA approved for the treatment of glucose intolerance or diabetes due to Cushing’s syndrome.

Study Aim: To test the hypothesis that mifepristone treatment will improve insulin sensitivity and body composition in patients with mild adrenal hypercortisolism.

Methods:  Patients with benign appearing adrenal incidentalomas (<4cm) with either glucose intolerance or diabetes and evidence of mild hypercortisolism were enrolled in a 6 month study using mifepristone.  Patients were excluded if they had Cushing’s disease, co-secretion of other hormones, concern for malignancy,  pregnancy / lactation, had received metyrapone or ketoconazole in the past month or glucocorticoids in the past 6 months.  Mifepristone was started at 300mg daily and titrated up by 300mg based on clinical response and ACTH levels.  Fasting plasma glucose and lipids, HBA1c, HOMA-IR, BMI, waist circumference and quality of life were assessed before and again after 6 months of mifepristone treatment.  Paired t-test was used to compare follow up to baseline values.

Results:  To date, 11 patients have been enrolled.  Of those, 2 completed 6 months of the medication, 1 completed 2 months, 1 was unable to tolerate the medication, 3 are currently taking the medication and 4 are waiting to start.  All 3 patients who have finished taking the medication (including 1 who only used it for 2 months) showed improvement in HBA1c, waist circumference and HOMA-IR. There was a significant decrease of HBA1c at 3 months (p = 0.035) and in waist circumference at 6 months (p = 0.035).

Conclusion:  Mifepristone may ameliorate features of the metabolic syndrome in patients with mild adrenal hypercortisolism and should be considered as a treatment option.

 

Nothing to Disclose: AR, GMG, EBG, ACL

19090 12.0000 SAT-390 A Glucocorticoid Receptor Blockade with Mifepristone in Patients with Mild Adrenal Hypercortisolism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Ivy-Joan Madu1 and Dat Nguyen*2
1Diabetes Associates Medical Group, Orange, CA, 2Corcept Therapeutics, Menlo Park, CA

 

Background: Surgical resection of the underlying tumor remains the definitive therapy for Cushing’s syndrome (CS).  Hypertension (HTN), obesity, hyperglycemia, and other cardiometabolic manifestations of CS can increase surgical risk. Preoperative intervention to improve metabolic control in a patient scheduled for a BLA is described.

Case: A 42yo female with CS due ACTH producing carcinoid with lung metastasis was referred for preoperative optimization prior to a scheduled BLA. Chest CT showed numerous bilateral pulmonary nodules (largest up to 3.6 cm).

She presented with moon facies, purple striae, and weakness requiring a cane for ambulation.

Co-morbid conditions included obesity (BMI 44), HTN (152/114 mmHg), Diabetes (A1c 8.8%, blood glucose=266 mg/dL). She was treated with: octreotide LAR injection, levemir insulin 10units/d, metformin 1000mg BID, glipizide 10mg BID, amlodipine 10mg/d, hydrochlorothiazide 12.5mg/d, metoprolol 50mg BID, losartan 100mg/d.

Due to the progressive nature of the lung masses and the uncontrolled cortisol secretion, a BLA was scheduled.  Preoperative evaluation categorized the patient as high risk due to her co-morbid conditions, high probability of frail tissues and poor wound healing due to prolonged hypercortisolism.  Preoperative optimization goals were to reduce blood sugars, BP, and the effects of hypercortisolism in order to improve wound healing, reduce the peri-operative complications such as DVT and electrolyte imbalance.

Mifepristone (Korlym®, Corcept Therapeutics) 300mg/d, a competitive glucocorticoid receptor antagonist, was utilized for a total of 2 months, terminating right before surgery. After one month of mifepristone therapy, blood glucose ranged between 90-150 mg/dL and levemir insulin was discontinued. Two months later and just prior to surgery, BMI decreased (42.5), improvements were documented in BP (143/101 mmHg), A1c (8.0%), and glucose (149 mg/dL). No adrenal insufficiency was observed.

Despite her high risk, there were no major postoperative complications requiring extended hospitalization after the BLA (via the posterior approach). Only episodes of nausea and vomiting were observed.  BP and blood glucose improved, allowing amlodipine and glipizide to be discontinued. Metformin was reduced to 500mg/d and eventually discontinued. Patient was placed on steroid replacement therapy with hydrocortisone 20 mg BID and fludrocortisone 0.1 mg daily. 

Nine months post-surgery, BMI 43.8, BP (135/80 mmHg), A1c 6.8%, glucose 118 mg/dL, Na 142 mEq/L, K 4.4 mEq/L.

Conclusion: Two months therapy with mifepristone improved pre-operative clinical status in a high-risk BLA patient by reducing weight and improving diabetic control. Clinical trials with longer duration of therapy are needed to evaluate the impact of mifepristone on surgical risks, outcomes and length of hospitalization.

 

Disclosure: IJM: Clinical Researcher, Novo Nordisk, Clinical Researcher, Sanofi, Clinical Researcher, Astra Zeneca, Clinical Researcher, Mylan, Clinical Researcher, Amylin Pharmaceuticals, Clinical Researcher, Andromeda, Clinical Researcher, Merck & Co., Clinical Researcher, Takeda, Clinical Researcher, Grifols, Clinical Researcher, Jansen Pharmaceuticals. DN: Employee, Corcept.

19951 13.0000 SAT-391 A Pre-Surgical Use of Mifepristone for Ectopic Cushing's in a High-Risk Bilateral Adrenalectomy Candidate 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Michael Conall Dennedy*1, Anand K Annamalai2, Olivia Prankerd-Smith1, Andrew S Powlson2, Johann Graggaber3, Ashley Shaw4, David Halsall5 and Mark Gurnell6
1Cambridge University & National Institute for Health Research, Cambridge, Cambridge, United Kingdom, 2University of Cambridge, Cambridge, United Kingdom, 3Cambridge University, Cambridge, United Kingdom, 4Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom, 5University of Cambridge & Addenbrooke's Hospital, United Kingdom, 6University of Cambridge, Metabol, Cambridgeshire, United Kingdom

 

Context: Subclinical hypercortisolism (SH) occurs in 5-30% of incidentally-detected adrenal adenomas (AIs). Common screening tests for adrenocorticotropin (ACTH)-independent hypercortisolism have significant false positive rates, mandating further investigations that are both time and resource intensive.

Objective: We investigated whether a low basal dehydroepiandrosterone sulphate (DHEAS) level is a sensitive and specific screening test for the detection/exclusion of SH in patients with newly-diagnosed AI.

Patients/methods: 185 consecutive patients with AI referred to our clinic between 2006 and 2013 were screened for clinical and biochemical evidence of adrenal medullary (urinary and plasma metanephrines) and cortical (1 mg dexamethasone suppression test, 24h urinary free cortisol (UFC), serum DHEAS, paired plasma renin and aldosterone) hyperfunction. All positive dexamethasone suppression [>1.8 mcg/dL (50 nmol/L)] and UFC (> upper limit of reference range) results were further investigated, and we diagnosed SH when at least two of the following criteria were met: raised UFC, raised midnight serum cortisol, 48 h dexamethasone suppression test cortisol >1.8 mcg/dL (50 nmol/L). Plasma ACTH was <10 pg/mL (2.2 pmol/L) in all patients with SH.

Results: At presentation, 29 patients (16%) were diagnosed with SH. We calculated an age-and gender-specific DHEAS ratio (derived by dividing measured DHEAS by the lower limit of the respective reference range) for all patients in the cohort and found that a ratio ≤ 1.12 was a sensitive (100%) and specific (91.9%) screening test for the diagnosis of SH. In comparison, a cortisol level after a 1mg dexamethasone suppression test of 1.9 mcg/dL (53 nmol/L) was a sensitive (100%) screening test for SH, but had lower specificity (82.9%). 24 h UFC lacked sensitivity (69%)  and specificity (68%).

Conclusion: A single basal measurement of DHEAS offers comparable sensitivity and greater specificity to the existing gold-standard 1 mg dexamethasone suppression test for the detection of SH in patients with AIs.

 

Nothing to Disclose: MCD, AKA, OP, ASP, JG, AS, DH, MG

19572 14.0000 SAT-392 A Low DHEAS: A Sensitive and Specific Screening Test for the Detection of Subclinical Hypercortisolism in Adrenal Incidentalomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Flavia A. Costa-Barbosa*, Lilian F. Hayashi, Kelly C. Oliveira and Claudio E. Kater
Federal University of São Paulo, São Paulo, SP, Brazil

 

Introduction: The prevalence of subclinical hypercortisolism (SCH) among adrenal incidentalomas (AI) may be as high as 30%. Metabolic abnormalities (obesity, hypertension, hyperglycemia, dyslipidemia) are frequent in patients with SCH and can be corrected by surgical removal of the adenoma. Yet, both the characterization of SCH and the cutoff levels of screening tests used to classify this disorder are ill-defined. As for Cushing’s syndrome (CS), screening SCH among AI employs 24h-urinary free cortisol, late-night salivary cortisol (23hFsal), and mostly the 1mg overnight dexamethasone suppression test (1mgDST), either isolated or combined; but the likelihood of a false-positive 1mgDST is relatively high. Aim: to properly discriminate SCH among a series of patients with AI. Patients and methods: we investigated 335 consecutive patients with an AI (260F/75M, 15-87y, median: 54y) with the following procedures: 23hFsal and post-1mgDST serum and salivary cortisol. We also measured serum dexamethasone (Dex) concentration in all tests. All measurements were done by specific RIAs. Reference cutoff levels for 23hFsal (250ng/dl), pos-1mgDST serum (2.5µg/dL) and salivary cortisol (50ng/dl), and serum Dex (140ng/dL), were obtained from 164 control volunteers (108F/56M, 20-75y, median: 55y), whereas values obtained from 89 patients with proven CS (79F/10M, 15-72y, median: 41y) were used for comparison. Results: we defined SCH as the absence of Cushing’s stigmata in a patient with an AI who had a repeated post-1mgDST serum cortisol >2.5µg/dL (on validated 1mgDST, where Dex >140ng/dL) plus one elevated 23h or post-1mgDST salivary cortisol, and decreased basal ACTH or DHEAS levels. Among the 335 patients with AI, 88 (26.3%) had SCH, recognized by confirmed post-1mgDST serum cortisol >2.5 (3.9±1.5µg/dL; range 2.6-9.5µg/dL), elevated 23hFsal (in 36.1%) (316±292ng/dL; range 10-1,758ng/dL) and/or elevated post-1mgDST salivary cortisol (in 53.3%) (157±114ng/dL; range 10-491ng/dL). Decreased or suppressed ACTH and/or DHEAS were present in >70%. Patients with CS had post-1mgDST serum cortisol of 13.7±5.6µg/dL (range 2.5-35.7µg/dL) (distribution: 4% >2.5≤5; 32% >5≤10; 52% >10µg/dL). 23hFsal and post-1mgDST salivary cortisol were both high at 1,651±1,740ng/dL (range 70-6,960ng/dL) and 1,130±1,199ng/dL (range 50-6,756ng/dL), respectively. Conclusion: Based on the proposed definition, SCH was identified in a significant percentage (>26%) of patients with an AI. Validity of the 1mgDST was verified by concurrent determinations of serum Dex. As expected from a subclinical condition, post-1mgDST serum and salivary cortisol and 23hFsal values in SCH were halfway from normal controls and patients with confirmed CS. Patients so identified may benefit from surgical removal of the AI.

 

Nothing to Disclose: FAC, LFH, KCO, CEK

20280 15.0000 SAT-393 A Performance of the Overnight 1mg Dexamethasone Suppression Test Coupled with Serum Dexamethasone Measurement in Identifying Subclinical Hypercortisolism Among Patients with an Adrenal Incidentaloma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Fumihisa Miyauchi*1 and MIeko Miyoshi2
1Ehime Rosai Hospital, Niihama, Japan, 2University of Kochi, Kochi, Japan

 

Introduction

The previous study showed that the cortisol concentrations in plasma were affected by working at night in female nurses.   To evaluate the effects of working at night on the circadian rhythm of cortisol, cortisol concentrations in plasma were monitored from the beginning of the night shift work for three consecutive days.

Materials and Methods

 Nine female nurses working at night served as a experimental group and six female nurses being off-duty served as a control group volunteered for this study.  They were all healthy and had regular menstrual cycles.  Blood were obtained at the beginning of the first day of the night shift work (0 AM), and obtained every two hours from the end of the first day (8 AM) of the night shift work for 56 hours including the second day of the night shift work and the consecutive off-duty days.  In order to examine the effects of working at night on the circadian rhythm,  linear regression line was calculated with the concentrations obtained from  8 AM to 10 PM on each day.  The time when the linear regression line of each group crossed the concentration of 70ng/ml (middle point between the lowest and highest values) was calculated, and time gap was estimated compared to the time at 70ng/ml of the control group. 

Results

 From the linear regression line,  the correlation coefficient (γ) was 0.908 and the slope was -0.0692 in the control group.  The correlation coefficient (γ) was 0.771 in the night shift work day1 group, 0.915 in the night shift day 2 group, and 0.864 in the consecutive off-duty group, respectively.  The slope of the linear regression line was -0.0597 in the night shift work day1 group, -0.0678 in the night shift day 2 group, and -0.0778 in the consecutive off-duty group, respectively. 

 The time at 70ng/ml of the first day of the night shift was 1:07 PM, which was 61 min earlier than the control group.  The time at the 70ng/ml of the second day of the night shift work was 49min. earlier and that of the consecutive off-duty day was 49min earlier than that of the control group, respectively.

Conclusion 

 Plasma cortisol concentrations of the nurses of the night shift day1 and day2 groups declined earlier than those of the nurses of the control group.  This decline was also observed in the off-duty group.  These results suggest that working at night might affect the circadian rhythm of the plasma cortisol concentrations of the female nurses.

 

Nothing to Disclose: FM, MM

18429 16.0000 SAT-394 A Working at Night Accelerates Circadian Rhythm of Cortisol in Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Alejandro L Arregger*1, Estela Maria Cardoso2, Alfredo Zucchini3, Elvira Aguirre3, Rocio Sanchez3, Alicia Elbert4 and Liliana N Contreras5
1University of Buenos Aires, Buenos Aires CF, Argentina, 2IDIM- CONICET, 3IDIM A Lanari. University of Buenos Aires, 4CERHEA, 5University of Buenos Aires; IDIM-CONICET, Buenos Aires, Argentina

 

End stage renal disease is associated with functional changes of the HPA axis, however cortisol dynamics have not been fully investigated in earlier clinical stages. We evaluated the circadian variation of salivary cortisol (SAF) and the fast feed-back mechanism in 80 adults aged 18 to 65 y/o, at stages S1 to S4 of chronic renal disease (CKD), 20 in each stage (K/DOQI). None was on steroids, drugs that may affect adrenal function or anticonvulsants. The control group (C) consisted in 40 healthy subjects. Whole saliva samples were obtained at 08 h and 23 h in 2 non-consecutive days for SAF (SAF8 and SAF23, respectively). The fast feed-back was assessed through the overnight 1 mg oral dexamethasone (DEX) suppression test (1mg-DST) in saliva (SAFdex) and serum (total cortisol: Fdex  and free cortisol: FFdex). Serum DEX was simultaneously measured in all samples. Cortisol and cortisol binding globulin (CBG) were assessed by RIA and FF was calculated. DEX was determined by ELISA. Reference values: SAF23 ≤ 3.8 nM; SAF8 ≤ 18 nM; SAFdex ≤ 2.0nM;   Fdex ≤50nM; FFdex ≤ 2.0 nM; circadian variation of SAF is defined as SAF2 3≤ 50% SAF8. Statistics were performed using Mann-Whitney and Spearman tests; the intra-class coefficient of correlation (ICC) was estimated by ANOVA. Results:  Glomerular filtration rate correlated negatively and significantly with SAF 23 (r: -0,343), Fdex: (r: -0,325), SAFdex (r: -0,377) and FFdex (r: -0,436) p<0,004 in all patients. ICC in SAF8 and SAF23 was ≥ 0,83 in  all stages. Five CKD showed impairment of cortisol rhythm. SAF23 was significantly higher in S4 (2,38±1,0nM) and  S3 (2,12±0,8 nM)  than  S2 (1,75±1,1 nM ) and S1 (1,49±0,87nM ), p ≤0.003.  CBG concentrations did not vary either along the different stages of renal disease or between sexes.  SAFdex correlated positively and significantly with FFdex (r: 0,860) and Fdex (r:0,642) p< 0.0001. SAF23   correlated positively with SAFdex (r: 0,499), Fdex (r: 0,422) and FFdex (r: 0,426) p< 0.0001 in all. Two patients in S2, 3 in S3 and 3 in S4 failed to normally suppress. DEX concentrations did not differ between groups (S1: 1.14±0.47, S2: 1.22±057, S3: 1.24±0.47, and S4: 1.31±0.5; p>0.19, ranging from 0.6 to 2.5 ng/ml). DEX concentrations were similar in those who suppressed (DST+): 1.21 ±0.51 ng/ml, those who did not (DST-):  1.41±0.55 ng/ml) and C : 1.32±052 ng/ml; p>0.27. After 2 mg oral DEX all DST- suppressed F (≤50.0 nM ) and SAF (≤ 2.0 nM) reaching serum DEX  concentrations of 2.63±0.84 ng/ml, range 1.8-4.0; significantly higher than with 1 mg (p: 0.0019). These data show that the progressive renal impairment is associated with defects in the circadian variation of cortisol. Derangement of the feed-back mechanism seems not related to plasma DEX bioavailability; inhibition of the HPA axis with higher doses suggests involvement of central sensitivity.

 

Nothing to Disclose: ALA, EMC, AZ, EA, RS, AE, LNC

18988 17.0000 SAT-395 A Cortisol Dynamics in Outpatients with Chronic Kidney Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Christina M Lovato*1, Thierry Thevenot2, Sophie Borot2, Vincent Di Martino2, Clifford R. Qualls1, Frank K. Urban III3 and Richard I Dorin4
1University of New Mexico Health Sciences Center, Albuquerque, NM, 2University Hospital Jean Minjoz, Besancon cedex, France, 3Florida International University, Miami, FL, 4University of New Mexico School of Medicine, Albuquerque, NM

 

Chronic liver disease is associated with decreased cortisol binding proteins and impaired hepatic cortisol metabolism. To evaluate the clinical relationships of free cortisol metabolism and adrenocortical function in this clinical setting, we performed a post-hoc analysis to determine free cortisol half-life and maximal cortisol secretion rate (CSRmax) in patients with chronic liver disease. Subjects included 95 patients with Child-Pugh A (n=34), B (n=29), and C (n=32) liver disease, as well as 28 patients with sepsis and chronic liver disease with Child-Pugh score >8. Corticosteroid binding globulin (CBG), albumin, and total and free cortisol levels for these subjects were previously reported by Thevenot et al. (1). Free cortisol half-life and CSRmax were obtained by numerical modeling using least squares solution of simultaneous, non-linear differential equations (2,3). Input data included paired total cortisol concentrations measured before and following cosyntropin stimulation (ACTH1-24, 1 and 250 µg) and measured concentrations of free cortisol, CBG, and albumin. Results for free cortisol half-life and CSRmax were compared to those obtained in historical control subjects (n=21) (2). For liver disease subjects(Child-Pugh A-C groups plus sepsis subjects) free cortisol half-life was significantly (P<0.001) increased (9.0 ± 7.1 min, mean ± SD) compared to controls (2.2 ± 1.1 min). Free cortisol half-life was not significantly different between liver disease groups (P=0.10, for all comparisons). Mean CSRmax was 0.47 ± 0.56 nM/sec for liver disease subjects (Child-Pugh A-C groups plus sepsis subjects). CSRmax was significantly (P=0.003) reduced in more severe liver disease (Child-Pugh B and C groups pooled, 0.35 ± 0.22 nM/sec) compared to Child-Pugh A (0.56 ± 0.51 nM/sec, P=0.003) and control (0.44 ± 0.13 nM/sec, P=0.002) subjects. CSRmax was highly variable among subjects with liver disease and sepsis (0.63 ± 0.97 nM/sec). We conclude that relative to historical control subjects, the rate of free cortisol elimination is significantly decreased in both mild and more severe forms of chronic liver disease. The observed reduction in free cortisol elimination rate in chronic liver disease appears to be similar in magnitude to the reduced free cortisol elimination rates in septic shock (3) and the total cortisol clearance reported in critical illness (4). In addition, we observed a significant decrease in CSRmax among subjects with more advanced stages of chronic liver disease. The observed decrease in CSRmax in moderate to severe chronic liver disease may limit the ability to raise free cortisol concentrations under conditions of superimposed physiological stress, and therefore has implications for the diagnosis and treatment of critical illness-related corticosteroid insufficiency (CIRCI) in this clinical setting.

 

Nothing to Disclose: CML, TT, SB, VD, CRQ, FKU III, RID

20799 18.0000 SAT-396 A Reduced Free Cortisol Elimination Rate and Maximal Cortisol Secretion Rate in Chronic Liver Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Lisa A. Chin-Harty*1, Debbie S Thompson2, Clive Osmond3, David I.W. Phillips3, Tamika Y. Royal-Thomas2, Terrence E. Forrester2 and Michael S Boyne2
1The University of the West Indies, Jamaica, 2The University of the West Indies, Kingston, Jamaica, 3University of Southampton, Southampton, United Kingdom

 

Background:

Increased activity of the hypothalamo-pituitary-adrenal axis during early life is a potentially important mechanism underlying the development of the metabolic syndrome. We hypothesized that maternal size, birth size and childhood growth can influence the cortisol awakening response (CAR) in the offspring.

Methods:

The Vulnerable Windows Cohort is a birth cohort assembled in 1992-4 to investigate the relationship of maternal anthropometry and fetal/childhood growth on the risk of the metabolic syndrome. 569 healthy pregnant Jamaican women (age range 15-40 years, gestational age 7-10 weeks by ultrasound) were enrolled. Maternal anthropometry was measured each trimester. Anthropometry of the offspring was measured at birth, 6 weeks, 3 monthly to 2 years and then every 6 months. We measured CAR in 59 boys and 97 girls, aged 16-17 years old. Home salivary cortisol samples were taken upon awakening, 30 minutes and 60 minutes after awakening. We defined CAR as either the delta rise in cortisol (DeltaCort), area under the curve (AUC), or mean increase in cortisol (MnInc).

Results:

Girls tended to have higher cortisol levels at 30 mins (14.6 ± 8.7 vs. 12.3 ± 6.6 nmol/L), greater AUC (54.5 ± 28.1 vs. 45.0 ± 21.4 nmol/L; P = 0.03), but similar DeltaCort and MnInc. After adjusting for age and sex, there was no correlation of maternal factors (i.e. age, height, BMI in first trimester, weight gain in pregnancy) with DeltaCort, AUC or MnInc (P-values >0.06). Birth length, head circumference, gestational age and placental weight were not associated with any measure of CAR (P-values > 0.06) after adjusting for age and sex. BMI at birth was associated with DeltaCort (r = 0.18; P = 0.03) and MnInc (r = 0.17; P = 0.05). In the peri-pubertal period (i.e. ~mean age 11.6 years), BMI and fat mass were correlated with cortisol at 30 mins (r = -0.17; P = 0.05), 60 mins (r = -0.19; P = 0.03) and DeltaCort (r = -0.19; P = 0.03), but not AUC or MnInc. Waist circumference was associated with cortisol at 60 mins (r = -0.21; P = 0.01) and DeltaCort (r = -0.19; P = 0.03). In multi-linear regression models, growth in BMI during late infancy (age 6 months-2 years) was inversely correlated with MnInc (P= 0.04), but not DeltaCort or AUC. 

Conclusion:

Maternal size is not associated with CAR in healthy adolescents. Greater BMI at birth, faster growth in BMI during late infancy, as well as greater peri-pubertal BMI and fat mass are correlated with smaller awakening responses. These data infer that children who are larger at birth or who grow faster may have altered tissue cortisol metabolism or dysregulation of the neuroendocrine stress system.

 

Nothing to Disclose: LAC, DST, CO, DIWP, TYR, TEF, MSB

21137 19.0000 SAT-397 A The Association Between Early Life Factors and Cortisol Awakening Response in Adolescents 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Peter Herbert Kann*1, Mark Münzel2, Peyman Hadji3, Hanna Daniel4, Stephan Flache3, Peter Nyarango5 and Anneke Wilhelm3
1University Hospital Marburg, Marburg, Germany, 2University Marburg, Marburg, Germany, 3University Hospital Marburg, 4University Marburg, 5University of Namibia Windhoek

 

Diabetes mellitus is affecting Africa increasingly. This prospective, cross-sectional, diagnostic study was aimed to investigate whether urbanisation of the Ovahimba people in Namibia is associated with an increased prevalence of disorders of glucose metabolism, and may this be attributed to changes of cortisol homeostasis. Two groups of Ovahimba people participated: group 1 ‘urban’, n=60, 42 females, 46.3±11.3 years; group 2 ‘rural/semi-nomadic’ n=63, 44 females, 51.1±12.0 years (semi-nomadic). OGTT, sunrise/sunset saliva cortisol and metabolic parameters were performed/assessed, a questionnaire completed. The prevalence of disorders of glucose metabolism differed significantly: urban group n=17(28.3%) vs. rural group n=8(12.7%)(p=0.04). The saliva cortisol concentrations also differed significantly: sunrise 0.34±0.18 vs. 0.12±0.15 µg/dl, sunset 0.18±0.20 vs. 0.07±0.09 µg/dl, area under the curve 6.16±3.48 vs. 2.28±2.56 µg/dl*24h (all p<0.001). Further metabolic parameters were unfavourably changed in the urban group: hip circumference 105.5±14.1 vs. 97.7±10.2 cm (p<0.001), waist circumference 94.1±17.4 vs. 78.0±12.6 cm (p<0.001), body mass index 26.6±6.2 vs. 24.2±4.4 kg/m2 (p=0.014), systolic BP at rest 123.0±20.2 vs. 109.4±16.4 mmHg (p<0.001), diastolic BP at rest 81.7±13.7 vs. 74.8±10.3 mmHg (p=0.002), systolic BP after exercise 154.9±27.3 vs. 137.8±20.0 mmHg (p<0.001), heart rate after exercise 99.8±21.2 vs. 89.2±20.6 bpm (p=0.007), fasting glucose 5.3±0.8 vs. 4.9±0.7 mmol/l (p<0.001), 2-hours-glucose by OGTT 6.7±1.4 vs. 6.0±1.3 mmol/l (p=0.002), triglycerides 1.1±0.8 vs. 0.8±0.4 mmol/l (p=0.04), HDL-cholesterol 1.3±0.4 vs. 1.5±0.4 mmol/l (p=0.014), prevalence of the metabolic syndrome n=19/31.7% vs. n=5/7.9% (p<0.001). Physical activity was higher in the rural group, intake of fastfood and sweets in the urban group. In conclusion, urbanisation of the Ovahimba people is associated with an increasing prevalence of disorders of glucose metabolism and other unfavourable metabolic parameters. Besides changes of lifestyle, this may be attributed to an increased cortisol exposure of the Ovahimba people living in an urban environment.

 

Nothing to Disclose: PHK, MM, PH, HD, SF, PN, AW

19066 20.0000 SAT-398 A Alterations of Cortisol Homeostasis May Link Changes of the Sociocultural Environment to an Increased Diabetes and Metabolic Risk in Developing Countries: A Prospective Diagnostic Study Performed in Cooperation with the Ovahimba People of the Kunene Region / North-Western Namibia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Serena Pisani*1, Alaa Khalil Monjed2, Lisa-Ann Fraser1 and Stan Van Uum1
1Department of Medicine, Western University, London, ON, Canada, 2Department of Internal Medicine, Umm Alqura University, Makkah, Saudi Arabia

 

Background:

While florid endogenous Cushing Syndrome (CS) may be clinically obvious, milder presentations of CS are much harder to detect, and are therefore more likely to be over-looked. CS has been shown to be associated with significant morbidity; hence, prompt recognition and treatment are important. Published guidelines for the evaluation of CS suggest assessment for the presence, or absence, of the classic signs of the disease. However, it is not known if evaluation for these signs is useful for assessing the full spectrum of clinical presentation of CS, or if these only apply to severe or florid disease.  

Objectives:

1)   To validate the classic signs of CS [previously shown to have high positive likelihood ratios (LRs) for detecting endogenous CS] in all patients referred for screening for CS.

2)   Subgroup analysis to investigate if these classic signs are helpful in the assessment of patients with a low to medium pretest probability of CS (after excluding patients with high clinical suspicion).

Design and Methods:

We performed a retrospective observational chart review of all consecutive patients, >18 years of age, who underwent biochemical testing for endogenous CS between 2003 and 2009 in a tertiary care endocrine clinic. We determined the presence or absence of the classic clinical signs of CS including: easy bruising, facial plethora, proximal myopathy, purple striae, hypertension, osteoporosis and weight gain. CS was diagnosed based on the presence of at least two abnormal biochemical tests and/or pathological confirmation.  LRs were calculated for each clinical sign and compared to previously published LRs for CS1. For the subgroup analysis, we excluded patients with a high clinical suspicion of CS, defined as having ≥ 4 of the above classic clinical features, and again calculated LRs for comparison.

Results:

We reviewed the charts of 123 patients, 18 were excluded based on co-morbidities that interfered with accurate biochemical testing.  Of the 105 remaining patients, 14 (13.3%) were diagnosed with CS. Positive LRs for all patients with CS were similar to those previously published1: easy bruising 3.06 (95% CI 1.64-5.71), osteoporosis 9.75 (95% CI 1.78-53.29), facial plethora 3.08 (95% CI 1.76-5.38), hypertension 1.76 (95% CI 1.16-2.66), purple striae 6.50 (95% CI 1.45-29.08), and proximal myopathy 6.50 (95% CI 2.91-14.50).  

In the subgroup of patients with a low-moderate pretest probability of CS (n=92, of which 5 were diagnosed with CS), only proximal myopathy was found to be a useful clinical sign to predict disease: LR = +6.96 (95% CI 1.77-27.39).

Conclusion:

This retrospective study suggests that classic signs, known to have high positive LRs for CS, are helpful in identifying patients with florid CS; but are less useful when assessing for CS in patients with low to medium clinical suspicion. In this group, proximal myopathy is the most helpful clinical feature to identify patients with CS.

 

Nothing to Disclose: SP, AKM, LAF, SV

19833 21.0000 SAT-399 A Evaluation of the Classic Clinical Signs When Screening for Endogenous Cushing Syndrome: A Retrospective Validation Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Valentina D. Tarasova*1, Kinjal K Shah2, Michael D. White1, Robert J Anderson3 and Laura Anne Graeff Armas1
1Creighton University, Omaha, NE, 2VA-Nebraska Western Iowa Healthcare System, Omaha, NE, 3VA - Nebraska Western Iowa Healthcare System / Creighton University Medical Center, Omaha, NE

 

Objective: Activation of the hypothalamic-pituitary-adrenal (HPA) axis is a universal response to stressors and the cortisol level has been used to reflect the degree of stress. Cortisol increase has been well documented in critical illnesses, sepsis, trauma and surgery. Currently there are limited data available on the physiological cortisol response to cardiac catheterization.

Research design and methods: Twenty three subjects (18 males, 5 females, all Caucasians) ages 44 to 82 years without known history of adrenal insufficiency or HPA suppression had serial serum cortisols drawn on the day of elective cardiac catheterization. The first serum cortisol level was obtained prior to the procedure and the second, third and fourth levels during the procedure at 15 min, 30 min and at the end of the procedure, respectively). The fifth and final cortisol level was drawn approximately 4 hours after cardiac catheterization. Serum albumin level was also obtained with the initial blood draw. Anxiety and pain levels were assessed before the procedure. Study participants had a follow up blood sample 4-6 weeks after the procedure timed to coincide with the pre-procedure blood draw.

Descriptive statistics were generated using the statistics package, PASW Statistics 21.0. Nonparametric expressions were reported (Median and interquartile range [IQR]). Bivariate correlations were performed using Spearman’s rho.

This trial was registered on clinicaltrials.gov in March 2013 (NCT01822847).

Results: The median serum cortisol level prior to the procedure was 10.55 (6.43-14.58) mcg/dL with an albumin of 4 (3.8-4.1) g/dL. At 15 min during cardiac catheterization, the serum cortisol was 7.7 (4.9-9.5) mcg/dL, at 30 min, 6.1 (4.5-9.33) mcg/dL and at the end of the procedure, 6.3 (4.4-8.25) mcg/dL. Serum cortisol was 5 (3.65-7.7)mcg/dL about 4 hours after cardiac catheterization. Serum cortisol levels at 15 and 30 minutes and post catheterization were significantly correlated (p=0.002). The duration of the procedure was 44 min (range of 30-62). No complications were identified. Five subjects had coronary stents placed. The average dose of Fentanyl was 100 mcg (range of 75-100) and Midazolam (Versed) 4 mg (range of 3.25-6). Fentanyl and Versed doses were significantly correlated with cortisol levels obtained after cardiac catheterization by Spearman correlation (p=0.023 and p=0.046, respectively).

Conclusions: Serum cortisol levels decreased slightly during elective cardiac catheterization. The cortisol decrease can be explained by Fentanyl and Versed suppression of the HPA axis. On the other hand, cardiac catheterization could be perceived by patients as a minor, non-stressful procedure potentially due to sedative effects of Fentanyl and Versed.

 

Nothing to Disclose: VDT, KKS, MDW, RJA, LAGA

21306 22.0000 SAT-400 A Physiological Response of Cortisol to Cardiac Catheterization 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Dolores Clifton Goldney*1, Karina Danilowicz2, Marcos Manavela3, Carolina Cohen4, Sabrina Lucas4, Fabian Pitoia5, Graciela Cross6 and Oscar Domingo Bruno2
1Hospital de Clinicas "Jose de San Martin" Universidad de Buenos Aires, Buenos Aires, Argentina, 2Hospital de Clinicas, Buenos Aires, Argentina, 3Consultorios de Endocrinología Dr Manavela, Caba, Argentina, 4Hospital de Clinicas Jose de San Martin, 5Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina, 6Hospital de Clínicas “José de San Martín” Universidad de Buenos Aires, Argentina

 


Ectopic Cushing syndrome (ECS) causes approximately 10% of CS.  Diagnosis may be delayed. We retrospectively reviewed the clinical records of a group of Argentinean patients with ECS and analyzed clinical data, biochemical features, imaging findings, etiology and follow-up.

Among 358 patients with CS, 17 had ECS (5 %). The mean age at diagnosis was 35 yr (range 21-54). There was a mean delay in diagnosis of 32.2 months (range 2-180). Hypertension, obesity, and proximal myopathy were present in 75%, 54% and 47% respectively.

The mean 24hs-urinary free cortisol (UFC) was 1017µg/24hs (range 134-2337).ACTH levels (mean 106 pg/ml, range 34-235) were normal in 2/13. Only 4 had hypokalemia. Serum cortisol (F) post 1mg-dexamethasone test was evaluated in 12/17, all of them failed to suppress. Cortisol post 8mg-dexamethasone test was done in 16/17 patients, 26% with more than 50% supression. Inferior petrosal sinus sampling was done in 4 patients, no gradient was found. Tumors were located in all the patients by different imaging studies. 

The etiology of ECS was: bronchial carcinoids (BC,10, 59%), malignant paraganglioma (1,  6%), lung cancer (1, 6%), brain metastasis of neuroendocrine tumor (NET) (1,  6%), medullary thyroid cancer (MTC,3,  17%). One patient (6%) had no histological diagnosis but entered in remission after lung lobectomy.

Fifteen patients (88%) received medical treatment. Six of them were treated with ketoconazole alone, 2 with aminoglutethimide, 1 vandetanib, 1 with octreotide, 1 with cabergoline, 3 with aminoglutethimide and ketoconazole and  1 with octreotide and cabergoline. The patient with the malignant paraganglioma received chemotherapy. One patient died rapidly so no medical therapy was used.

Ten patients (59 %) were initially cured after surgery, all of them with BC. Five of these patients relapsed after 1 to 2 years and were  followed for 5 to 20 years. Three underwent adrenalectomy. Of these three, one  had a BC regrowth that led to lung surgery, another died immediately after adrenalectomy and the third was lost during follow-up, as the remaining 2 patients that relapsed.

Two patients (11%) had persistent ECS after surgery, both of them with metastatic MTC. One of them is being treated with vandetanib with biochemical remission. One patient had the initial diagnosis of ECS, but no follow-up.

Six patients (35%) died during follow-up(lung cancer, MTC, malignant paraganglioma, metastasic NET, BC).

In conclusion, ECS is diagnosed with a delay of approximately 3 years. UFC levels are in general greatly elevated. The high dose dexamethasone suppression test suggested a pituitary origin in 26% of the cases. The tumors were localized by imaging modalities. Most of the cases were due to BC, cured with surgery or controlled after adrenalectomy. Patients with ECS due to malignant tumors had a bad prognosis. Vandetanib appears as a new alternative for cortisol excess in MTC.

 

Disclosure: MM: Medical Advisory Board Member, Novartis Pharmaceuticals. Nothing to Disclose: DC, KD, CC, SL, FP, GC, ODB

21511 23.0000 SAT-401 A Ectopic Cushing Syndrome: A Retrospective Series of 17 Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Niki Margari*1, Alison Butler2, Jonathan Benjamin2, Sanjiv Chawda2, Zahra Khatami3, Eltayab Marouf4 and Nemanja D Stojanovic5
1University College London Partners, United Kingdom, 2Queens Hospital, 3Barking, Havering & Redbridge University Hospitals NHS Trust, London, United Kingdom, 4Barking, Havering & Redbridge University Hospitals NHS Trust, 5Queen's Hosp, London, United Kingdom

 

Background: Spinal epidural lipomatosis (SEL), a rare but well recognized complication of excessive steroid intake or production, is characterized by overgrowth of adipose tissue into the extradural space. Ultimately this pathological process can lead to spinal cord compression.

Clinical case: A 63-year old man presented with a two-month history of progressive bilateral leg weakness on a background of chronic back pain secondary to spinal canal stenosis from L2 to S1. He also suffered from Addison’s disease for which he had been taking hydrocortisone in a total dose of 100 mg daily since the diagnosis was made over 40 years ago. His steroid replacement therapy was managed by his primary care physician.  

Examination revealed an obese patient with marked centripetal fat deposition and Cushingoid features. A working diagnosis of proximal myopathy due to long-term steroid intake was made and the steroid dose was slowly tapered down.

Soon after the admission he developed an acute spastic paraparesis with loss of sensation restricted to the S1 distribution of the left leg. An MRI spine revealed SEL extending throughout the mid/lower thoracic and mid to lower lumbar spine causing multilevel compression of the cord from T4-5 to T9-10 as well as L2-3 to L4-5 levels. He underwent urgent T5-T8 thoracic laminectomy. Power in the lower limbs significantly improved thereafter to 4/5 over the next 10 days.

At discharge oral hydrocortisone had been reduced to the total dose of 60 mg daily, and the patient was advised to taper it down further to 25 mg daily in divided doses. He was given an outpatient endocrine follow up. 

Discussion:  SEL was first reported in 1975. Since then there have been 111 cases of SEL reported of which 49 cases were idiopathic and 62 were due to secondary causes. From the idiopathic cases 16 were noted in non-obese patients, 46 cases have been associated with exogenous steroid use while 16 were due to Cushing disease, hypothyroidism and prolactinoma.

Most patients are obese and more males than females are affected. SEL is caused by adipose tissue dysfunction mediated by insulin resistance. Secretion of proinflammatory adipokines by large adipocytes ultimately leads to spinal fat deposition. Weight reduction appears to be beneficial only to those with mild symptoms and no significant neurological signs. Surgical laminectomy is the treatment of choice when patients develop spinal cord compression. SEL should be considered in any patient on long-term steroids or active Cushing’s disease that develops neurological signs consistent with spinal cord compression or persistent back pain.

 

Nothing to Disclose: NM, AB, JB, SC, ZK, EM, NDS

20712 24.0000 SAT-402 A Spinal Epidural Lipomatosis Due to Excess Steroid Intake Leading to Spinal Cord Compression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Corina Galesanu*1, Alexandru Florescu1, Ilinka Grozavu1, Andra Loghin1, Didona Ungureanu1, Dan Niculescu2, Liliana Moisii2 and Cezara Botezatu3
1University of Medicine and Pharmacy, Iasi, Romania, 2University of Medicine and Pharmacy "Gr.t.Popa", Iasi, Romania, 3Clinical Psychiatric Hospital "Socola"

 

Backgraund: Cushing’s syndrome includes a variety of signs and symptoms which are related to the long-term exposure of the body to excess glucocorticoids.  It is well known that mortality in untreated patients with Cushing’s disease is high. The most frequently encountered causes of death include sepsis, cardio- and cerebro-vascular deaths, and suicide.

Clinical case: In december 2005 a 32 year old male was admitted in the endocrinology department for osscilatory blood pressure values, central obesity with typical moon-face and abdominal striae. Also he associated major depression with psychotic features ( depressed mood, anxiety and somatic complaints ). Physical examination showed obesity ( with supraclavicular fullnes and dorsocervical fat pad ), thin skin which bruised easily, facial plethora, purple abdominal striae ( 1 cm wide ) and muscle atrophy. His body mass index was 32 kg/m², heart rate – 90 bpm and his blood pressure was 145/80 mmHg. The blood tests revealed  Hb-16 mg/dl, triglycerids – 180 mg/dl. normal plasma cortisol level, with increased free urinary cortisol ( 350 μg/24h ). The imagistic exams showed a normal lateral skull x-ray and a 5 mm left adrenal tumour on the abdominal CT. The patient was sent to surgery department, where left adrenalectomy was performed ( AP exam – diffuse and nodular hyperplasia ).

During 2006-2009 period he suffered three surgical intervention on his adrenal glands (plasma cortisol levels between 487.3-639.2ng/mL and urinary free cortisol between1302-1545μg/24h)  and two transsphenoidal resections for hight plasma  level of ACTH: 302pg/mL and 265 pg/mL, and MRI pituitary adenomas.His psychiatric problems have varied this time depending on his cortisol values ( as long as the values were in normal range he had no symptoms, and when the cortisol level started to rise, the symptoms reappeared ).

Discussion: Cushing’s syndrome can present itself with a spectrum of symptoms; however, it is less recognized that psychiatric symptoms can form part of the clinical presenting features.

In the case we presented the patient presented at the hospital with major depression with psychotic features. There was a gradual decline in the mental state in the last two months and a background of no previous psychiatric diagnosis. By six weeks post first surgery, his psychosis had resolved and the patient was stabile till May 2006, when the symptoms reappeared. He started psychotropic medications that were maintained till 2009, with psychiatric follow-up.

Conclusion: In this case, also in literature, successful treatment of the physical signs of Cushing's syndrome, with lowering of the plasma cortisol, results in amelioration of the psychological abnormalities. This case highlights the importance of the consideration of Cushing’s syndrome as a differential diagnosis when ruling out medical causes in patients with either new or persistent mental disturbance.

 

Nothing to Disclose: CG, AF, IG, AL, DU, DN, LM, CB

18287 25.0000 SAT-403 A Psychiatric Symptoms As a Clinical Presentation of Cushing's Disease ( Case Report ) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Anindita Nandi1, Halis Sonmez*1, Erwyn Chua Ong1, Zijian Chen2, Alina B Gouller3 and Barnett Zumoff1
1Mount Sinai Beth Israel, New York, NY, 2Mount Sinai Diabetes Center, New York, NY, 3NYU School of Medicine, New York, NY

 

Introduction: There are no previously reported cases in adults of factitious CS due to self-administration of ACTH.   We report a patient who initially presented with what appeared to be severe ectopic-ACTH syndrome.  An unusual response to treatment allowed us to ultimately diagnose factitious CS due to self-administration of ACTH.

Clinical case: A 52-year-old male presented to the hospital with severe lower extremity edema (3+) and marked hypokalemia (2.3 mmol/L).  He was also found to have diabetes, mood disturbance, hypertension, hypogonadotrophic hypogonadism, osteoporosis, vertebral fracture, and abnormal thyroid function tests.  The patient denied exogenous steroid use, but admitted to use of “male health supplements” for 6 months prior to presentation. 

Laboratory evaluation showed elevated ACTH (69 pg/mL) and morning cortisol (38 ug/dL).  24-hour urine free cortisol (UFC) was 1769 mcg/24h (by liquid chromatography-tandem mass spectrometry).  There was incomplete suppression of plasma cortisol after 1 mg, 8 mg, and 32 mg dexamethasone. Petrosal sinus sampling failed to show a central-to-peripheral gradient.  MRI of the pituitary gland was normal. CT scan of the adrenals showed bilateral hyperplasia without focal nodules.  A 1.3 cm lung nodule was biopsied; it was benign and stained negative for ACTH. Whole-body PET and octreotide scans showed no focal uptake. These biochemical and imaging studies suggested ectopic-ACTH syndrome.

The patient was then started on ketoconazole. There was improvement of diabetes, blood pressure, and lower-extremity edema, and the 24-hour UFC decreased. However, he was unable to tolerate ketoconazole, so he was switched to mifepristone.  This resulted in normalization of all clinical signs of Cushing’s syndrome within 3 months. Unexpectedly, UFC and ACTH also normalized, an effect that mifepristone does not produce.  Four months after stopping mifepristone, UFC and ACTH remained normal and the clinical symptoms and signs did not recur.

Discussion/Conclusion: Factitious CS is rare. When it does occur, it is almost always due to self-administration of a corticosteroid, but self-administration of ACTH could also produce the picture of CS. Mifepristone, a cortisol receptor-blocker, ameliorates CS without decreasing the cortisol or ACTH levels. In our case, however, the UFC and ACTH normalized after mifepristone, which should not happen whether the CS is of pituitary, adrenal, or ectopic origin. The most likely explanation is that the patient stopped self-administering some unknown ACTH-containing preparation.

 

Nothing to Disclose: AN, HS, ECO, ZC, ABG, BZ

18920 26.0000 SAT-404 A A Case of Factitious Cushing's Syndrome (CS) Likely Due to Self-Administration of ACTH, Initially Presenting As Ectopic-ACTH Syndrome - First Adult Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Leslie Mae Kimura, Gina Capodanno and Harvey Kenn Chiu*
UCLA Mattel Children's Hospital, Los Angeles, CA

 

Carbamazepine is an commonly used anti-epileptic medication and effective treatment for bipolar disorder.  Oxcarbazepine differs structurally with the replacement of a carbohydrate group with a carboxy moiety, resulting in a safer and better tolerated product.  Carbamazepine has well been recognized to interfere with dexamethasone-suppression tests for Cushing’s Syndrome.   The effects of Oxcarbazepine, perhaps a preferred regimen over Carbamazepine, on Dexamethasone Suppression Tests have not been well described. 

We describe a 14 yo female with a history of bipolar disorder who was evaluated for Cushing’s syndrome.  Clinically, suspicion was not high for Cushing’s Syndrome, with no clearly violaceous striae, no peripheral atrophy, no moon facies, and no proximal muscle weakness.  However, as she had repeated endocrine consultations because the family was convinced that her psychiatric symptoms must be secondary to Cushing’s syndrome, our service was requested to address the family’s concerns.

The patient’s medication regimen included Oxcarbazepine 900 mg po bid and Lorazepam 1 mg po bid.  A simple overnight Dexamethasone suppression test was proposed to provide a definitive diagnosis.  After a baseline 0800 Cortisol level of 19 mcg/dL was drawn, that evening at 2300 Dexamethasone 1 mg po was given.  At 0800 the next morning, a non-suppressed Cortisol level of 15 mcg/dL was obtained.  Three days later, a 24-hour Urine Cortisol of 27.1 mcg/day (normal < 56 mcg/day) was resulted.

We conclude that this patient did not have Cushing’s Syndrome, and the false positive Cortisol level following an attempted Dexamethasone challenge was secondary to the use of Oxcarbazepine.

 

Nothing to Disclose: LMK, GC, HKC

19131 27.0000 SAT-405 A Oxcarbazepine Precludes a Dexamethasone Suppression Test for Cushing's Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Jasna Aleksova1, Kim Taubman2, Jason Tan3, Stephen Farrell2, Glenn Ward3, Richard James MacIsaac*4 and Nirupa Sachithanandan4
1St Vincent's Hospital Melbourne, Fitzroy, 2St Vincent's Hospital, Fitzroy, 3St Vincent's Hospital, 4St Vincent's Hospital Melbourne, Australia

 

Introduction: Diagnosis of hypercortisolaemia can be challenging and standard investigations may not always be helpful. The most common cause of endogenous hypercortisolaemia is ACTH-dependant pituitary disease with only 20% having ACTH-independent conditions.

Clinical Case: A 60 year old female with resistant hypertension and poorly controlled type 2 diabetes was referred for investigation of Cushing’s syndrome. She had multiple comorbidities including COPD requiring inhaled corticosteroids. Clinical examination revealed a BMI of 31, supine hypertension, truncal obesity, proximal muscle wasting and weakness but no evidence of striae, bruising, skin thinning or pigmentation, nor a buffalo hump or abdominal masses.

Investigations for secondary hypertension showed a normal aldosterone to renin ratio 18.6 (n<20), plasma metadrenaline 139pmol/L (n<500pmol/L) and normetadrenaline 92pmol/L (n<90 pmol/L). GH, IGF-1, thyroid function and plasma DHEAS was normal. Renal artery Doppler did not reveal significant stenosis.

24 hour urine free cortisol measurements were 181nmol/L and 454nmol/L (n<350nmol/L). Her ACTH remained undetectable on numerous occasions (<5pg/ml). Due to difficulty in ceasing inhaled steroids an overnight 1mg dexamethasone suppression test was performed whilst the patient was taking fluticasone/salmeterol, revealing a 8am cortisol of 278 nmol/L (n<120nmol/L). Persistent hypercortisolism was then confirmed with IV dexamethasone suppression testing1 performed after withholding inhaled fluticasone. An adrenal CT scan showed an enlarged left adrenal with an 8mm nodule at the inferior pole (Hounsfield unit <5).  Functional imaging with iodocholesterol under dexamethasone suppression showed bilateral uptake of labelled cholesterol. Adrenal vein sampling was performed 2, 3with results consistent with bilateral autonomous cortisol secretion. The patient subsequently underwent bilateral adrenalectomies. 

Histology of both adrenals was consistent with primary pigmented nodular adrenal hyperplasia (PPNAD). PPNAD is associated with Carney’s complex (CNC) in 90% of patients. CNC is an autosomal dominant multiple neoplasia syndrome typically presenting with the classic triad of myxomas, spotty skin pigmentation and endocrine overactivity. 60% of CNC is associated with germ-line inactivating mutations in the regulatory subunit 1-α of protein kinase A (PRKAR1A). Our patient is the oldest reported case of PPNAD. She has no other clinical manifestations of CNC, however does have a nephew who underwent bilateral adrenalectomies 20years previously. She is currently undergoing genetic testing for mutations in the PRKAR1A gene.

Conclusion: PPNAD is a rare cause of hypercortisolaemia, but should be considered in patients presenting during or after the third decade of life, especially if there is a positive family history of hypercortisolaemia.

 

Nothing to Disclose: JA, KT, JT, SF, GW, RJM, NS

19171 28.0000 SAT-406 A A Cushing's Conundrum: A Case of Primary Pigmented Nodular Adrenal Disease in a 60 Year Old Female 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Hani Shalabi*1, Feras Mohder2 and Wael Taha3
1Wayne state university, Detroit, MI, 2Wayne State University, 3Wayne State University, Detroit, MI

 

Background: we are reporting a patient with aldosterone producing adenoma (APA), Cushing’s disease and primary hyperparathyroidism

Clinical case: 48 year old African American female was referred to endocrinology for right adrenal incidentaloma which was found by abdominal ultrasound. She complained of gaining weight of about 20 kg in 8 months, fatigue, depression, chronic diffuse abdominal pain with history of bilateral kidney stones. She had facial hirsutism but for many years before her illness. Had history of uncontrolled HTN on amlodipine and lisinopril, DM and obstructive sleep apnea. Her Hga1c worsened from 5.9% to 7.5% in 12 months, requiring metformin and glipizide. Exam findings: BP 154/103, weight 327 lbs, BMI 56, had no striae,  Ferriman Gallway score 16/36, and pitting edema in her legs. Adrenal MRI showed 4.0 cm right adrenal adenoma and Bilateral nephrolithiasis. Labs: Calcium 10.3 mg/dl, Albumin 3.2 g/dl, iPTH 146 pg/ml (n 18-86), phosphorus 2.8 mg/dl (n 2.3-5.0), aldosterone 69 ng/dl (n<16.0 ng/dL), renin activity 3.4 ng/ml/hour (n 0.2-1.6 ng/mL/hr), aldosterone to renin ratio (ARR) 19.  8 am cortisol on two occasions 11.6 and 25 mcg/dl after 1 mg dexamethasone night before. Lisinopril and amlodipine were replaced with doxazocin and cardizem, repeated aldosterone level was 20 and renin 0.2 (ARR 105). 24 hr urine on 3 day-salt loading showed urinary aldosterone of 14.4 mcg/24hrs and urinary sodium of 210 mEq/day,  24 hour urine free cortisol was 491 cortisol mcg/g creatinine (n <=45.0). Serum ACTH was 16 and 25 pg/ml (n 6-58) on two occasions, DHEAS 45 mcg/dl (n 32-240), plasma  metanephrines were within normal, vitamin D 25 OH 17 ng/ml(n 30-100). She underwent parathyroid sestambi scan which showed increase uptake at right lower pole of thyroid gland. Right lower parathyroidectomy done, pathology confirmed parathyroid adenoma. iPTH at one month post operation was 42 pg/ml, calcium 9.4 mg/dl, albumin 3.2 g/dl. A repeat 8 am level was 9.1 mcg/dl and dexamethasone level 1020 ng/dl after 2 mg dexamethasone night before. By MRI of the pituitary, she had questionable 4 mm hypointense pituitary lesion. She underwent right adrenalectomy which was consistent with aldosterone producing adenoma by pathology. One month after surgery, her blood pressure was improved to 140/80 off medications. Same for blood glucose and was taken off sulfonylurea. Repeated am ACTH 35 pg/ml and cortisol level 3.2 mcg/dl (not sure if taken 1 mg dexamethasone). She had cortisol level of 0.5 mcg/dl (post 8 mg dexamethasone night before). Genetic testing for MEN syndrome and Immuno Histochemical Analysis of the adrenal adenoma are pending.

Conclusion: this is a case of APA likely co-secreting cortisol with relative elevation of ACTH which could be an assay related false positivity vs ACTH-dependent cushing.

 

Nothing to Disclose: HS, FM, WT

21476 29.0000 SAT-407 A Aldosterone Secreting Adrenal Adenoma with Primary Hyperparathyroidism and Cushing's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Tania Jaber*1, Mouhammed Amir Habra2, Lily J Kwatampora3, Li-Ling Hwang2, Nancy D Perrier2 and Naifa L Busaidy2
1The University of Texas Medical School at Houston, Houston, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3Lutheran Health Physicians, Fort Wayne, IN

 

Background:  The prognosis of Cushing’s Syndrome (CS) from ectopic ACTH secretion is abysmal, with an overall survival of <3 years and most deaths occurring from comorbidities associated with hypercortisolism (1). Controlling the hypercortisolism has historically been difficult to attain with medical therapy alone, especially in patients with unresectable metastatic ACTH-secreting tumors.

Clinical Case: A 58‐year-old woman with typical symptoms of CS was self-referred to our institution for second opinion on management of her metastatic carcinoid neuroendocrine tumor (NET). Her morbidities included difficult to control hypertension, newly diagnosed insulin-dependent diabetes mellitus, multiple infections requiring hospitalization for intravenous antibiotics, hypokalemia despite potassium supplementation, as well as significant weight gain.  She was seen at an outside institution where insulin, four blood pressure medications, and ketoconazole were initiated to control her presumed CS and its co-morbidities. With a diagnosis of an unresectable NET, she was also initiated on octreotide and everolimus. Her disease remained uncontrolled with worsening infections, declining performance, and inability to tolerate her chemotherapy.

At time of her presentation, she had already sustained significant comorbidities from a lacunar stroke secondary to uncontrolled hypertension, uncontrolled diabetes, multiple infections, and significant proximal myopathy forcing her to put her nursing job on hold and apply for disability. Her work-up was consistent with ACTH-dependent CS: elevated 24hr urinary cortisol secretion at 270 mcg/24hr (3.5-45) and an abnormal low dose dexamethasone suppression test (AM serum cortisol 33.9 mcg/dl (4.3-22.4), ACTH 176 pg/ml (<46) after 1 mg dexamethasone taken the night prior). Further work-up revealed a non-suppressible serum cortisol level after administration of 8 mg dexamethasone (AM serum cortisol 25.3 mcg/dl (4.3-22.4), ACTH 184 pg/ml (<46)) and a normal MRI of the brain. The diagnosis of ectopic CS from an unresectable NET was then made marking the beginning of a lifelong battle of disease-related comorbidities and treatment-related complications for her. She had already been treated with high doses of ketoconazole and metopirone was added with failure to control her symptoms with resultant liver and kidney dysfunction. Her case was discussed in multidisciplinary conference with consensus to proceed to bilateral adrenalectomy.

Clinical Lessons: This case demonstrates the significant morbidities associated with ectopic CS from an unresectable tumor, including the inability to tolerate therapies targeted at the primary disease. It emphasizes the need for a multidisciplinary approach and early referral for bilateral adrenalectomy as a definitive treatment option for hypercortisolism in this group of patients (2,3).

 

Nothing to Disclose: TJ, MAH, LJK, LLH, NDP, NLB

19860 30.0000 SAT-408 A ACTH-Dependent Ectopic Cushing's Syndrome from a Metastatic Carcinoid Neuroendocrine Tumor: How Early Is Too Early for a Bilateral Adrenalectomy? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Zeina Carolina Hannoush*
Jackson Memorial Hospital/university of Miami, Miami

 

Background

Hyperthyroidism has been associated with multiple metabolic manifestations including activation of the hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-testicular (HPT) axes. In some cases, thyrotoxicosis can also result in non-PTH mediated hypercalcemia.

 Case Report

We report a case of a 42 years old man with past medical history of hypertension and melanoma. After completing treatment with interferon, he developed insomnia, weakness and a 49 pounds unintentional weight loss. The physical exam was unrevealing except for hand tremors and a hyperactive precordium. Laboratory workup revealed severe PTH independent hypercalcemia (Ca 11.6 mg/dL, PTH <3 pg/mL, PTHrp <0.74 pmol/L) with hypercalciuria (657 mg/24h). On further evaluation he was also found to have newly diagnosed hyperthyroidism, hypercortisolinuria and elevated total serum testosterone levels (TSH: <0.006mcIU/mL, freeT4: >5.5 ng/dL, UFC: 72ug/24h, 24h testosterone: 1421 ng/dL, SHBG: 193.3 nmol/L).  Thyroid uptake scan revealed an elevated uptake of iodine of 32%, suggesting the presence of Grave’s disease as opposed to interferon-induced hyperthyroidism. The patient was diagnosed with Pseudo-Cushing’s syndrome secondary to severe hyperthyroidism. He was treated with metoprolol and methimazole with progressive improvement of his thyroid function tests. Upon achievement of euthyroid state, his hypercalcemia, hypercortisolinuria and elevated serum testosterone levels normalized.

Discussion and Conclusions:

Hypercalcemia and pseudohyperandrogenism are well known effects of hyperthyroidism. The effects of hyperthyroidism on the HPA axis are less well understood and scarcely reported in the literature.

Adrenal reserve, assessed by the corticosterone response to ACTH release, is significantly increased in short-term experimentally induced hyperthyroid rats. However, sustained hyperactivity of the HPA axis caused by long-term experimental hyperthyroidism seems to be associated with significant reduction in adrenocortical reserve. Therefore, in animals, the HPA responsiveness may partially depend on the exposure time to thyrotoxic state. It is likely that the effects of thyroid hormone on the HPA axis are mediated by the central nervous system. ACTH and β-endorphin in the anterior pituitaries of both short and long-term hyperthyroid animals, increase following the exposure to thyroid hormone in thyroidectomized rats. Our patient did not show any clinical evidence of adrenal insufficiency despite the long-term exposure to hyperthyroidism and his urinary cortisol only decreased with appropriate control of the hyperthyroidism.

Our case illustrates the direct correlation between thyroid over activity and hypercortisolism in humans. More importantly, it shows that that these effects can be sustained over time and are reversible upon resolution of the thyrotoxic state.

 

Nothing to Disclose: ZCH

20590 31.0000 SAT-409 A Pseudo Cushing's Syndrome in Thyrotoxicosis: HPA Axis Adaptations to Hyperthyroid Stress 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Jorge Javier Figueroa*1, Amy M DeGueme1, Iram Hussain2, Melissa Nelson3, Ugis Gruntmanis4 and Uma Gunasekaran5
1UT Southwestern Medical Center, Dallas, TX, 2University of Texas Southwestern Medical Center, Dallas, TX, 3UT Southwestern Medical Center, 4University of Texas, Southwestern Medical Center and University of Latvia, Dallas, TX, 5UT Southwestern Medical Center, Irving, TX

 

BACKGROUND: Cushing's syndrome can lead to severe morbidity and mortality if untreated. We describe a patient with untreated ACTH-Dependent Cushing’s syndrome who presented with adrenal insufficiency (AI) secondary to adrenal histoplasmosis six years after her initial diagnosis. Disseminated histoplasmosis commonly involves the adrenal cortex causing necrosis and is associated with adrenal enlargement on imaging, with up to 50% of patients developing AI.

CLINICAL CASE: A 55 year old woman with type 2 diabetes and hypertension was initially seen for evaluation of an elevated morning cortisol level of 24.8 mcg/dL (normal: 4.3-22.4 mcg/dL). At the time, her physical examination findings included dorsocervical fat pad, moon facies, abdominal striae, and hirsutism. Further biochemical evaluation revealed a 24 hour urinary free cortisol of 302 mcg/24hr (normal: 3.5-45 mcg/24hr), an inappropriately normal ACTH of 49 pg/mL (normal: 6-58 pg/mL), and a 1-mg overnight dexamethasone suppression test with a cortisol of 31.9 mcg/dL (normal: < 1.8 mcg/dL). An abdominal CT scan showed normal adrenal glands with no hyperplasia or nodules, and a pituitary MRI showed a partially empty sella without evidence of an adenoma. She was lost to follow up so treatment was not initiated for the ACTH-dependent Cushing’s syndrome.

Six years later, she was admitted for septic shock with a morning cortisol level of 3.2 mcg/dL and stress dose steroids were started. Pituitary MRI was negative for pituitary adenoma or hemorrhage. Abdominal CT scan showed diffusely enlarged adrenal glands, each measuring 6 cm. Subsequent abdominal MRI ruled out hemorrhage and confirmed adrenal gland hyperplasia. She was discharged on hydrocortisone for AI but was readmitted one month later for adrenal crisis (morning cortisol: 2.7 mcg/dL) and septic shock secondary to a urinary tract infection. Of note, her calcium level was 15.8 mg/dL (normal: 8.4 - 10.2 mg/dL), which prompted investigations for secondary causes of AI. Testing for tuberculosis, sarcoidosis, multiple myeloma and HIV was negative. Fungal serologies revealed an elevated histoplasma mycelia antibody of 1:64 (normal: < 1:8) and urinary histoplasma antigen was weakly positive, suggesting a chronic infection. An adrenal biopsy showed histoplasmosis infection. Itraconazole was started (with a plan to continue for one year), and hydrocortisone was tapered to home dosing.

CONCLUSION: This is the first case reported in the literature of a patient with ACTH-dependent Cushing’s syndrome that is “cured” by an adrenal histoplasmosis infection. An infection with Histoplasma capsulatum is usually asymptomatic or self-limited, however, this patient was immunocompromised due to hypercortisolemia. This case demonstrates the need to have a high index of suspicion for adrenal insufficiency in patients presenting with septic shock, despite a previous history of Cushing’s syndrome.

 

Nothing to Disclose: JJF, AMD, IH, MN, UG, UG

20630 32.0000 SAT-410 A ACTH-Dependent Cushing's Syndrome “Cured” By Histoplasmosis-Mediated Destruction of the Adrenal Glands Causing Adrenal Insufficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Ruth S Faircloth* and Jill Ellen Emerick
Walter Reed National Military Medical Center, Bethesda, MD

 

Introduction:

Inhaled corticosteroids (ICS) are frequently used for treatment of asthma and are considered fairly safe.  It is important for clinicians to be aware that at high doses these medications can cause iatrogenic Cushing syndrome and secondary adrenal insufficiency, a potentially life-threatening condition.

Case Summary:

A 13 year old girl presented with fatigue, facial fullness, 10 pound weight gain, and stretch marks over her thighs and lower legs that developed over 2-3 months.  She had been treated with low to medium doses of ICS for approximately 3 years.  For the preceding 4.5 months she had been on high dose ICS with a total daily dose of 640-920 mcg daily.   No Cushingoid features were noted on fluticasone/salmeterol or  budesonide/formoterol, but after 6 weeks of high dose inhaled fluticasone, 440mcg twice daily, the patient experienced weight gain and facial fullness.  The patient had never been treated with oral, IV or nasal steroids.  Her only other medications were cetirizine and albuterol. Two weeks prior to presentation her fluticasone was tapered to 220mcg twice daily.

Blood pressure was 119/77, 90% for height and age.  She had completed linear growth, height was 4%, and weight was 9%.   BMI was 29%, an increase  from 6% just 5 months prior.  Physical exam was remarkable for a round face and was significantly different from photographs the parents had taken several months prior.  On her inner thighs and lower legs there were dark, erythematous striae 2-7mm in width and 2-6cm in length.  Serum 8:00 am cortisol (0.1 mcg/dL), ACTH (<1.1 pg/mL), and DHEA-S (6 mcg/dL; ref 44-248) were low and indicative of adrenal suppression.

She was started on physiologic hydrocortisone replacement, 5mg twice daily (7.7 mg/m2/day) and instructed to use stress dose steroids for significant physiologic stress or febrile illness.   As her fluticasone dose was tapered, her energy level returned to normal, her face resumed its normal shape, her weight stabilized, and her striae seemed to be lightening.  After 3 months off fluticasone her morning cortisol increased to 8.4 mcg/dL, ACTH normalized at  37.4 pg/mL (7.2-63.3 pg/mL), and DHEA-S increased to 12 mcg/dL.

Conclusions:

It is important for clinicians to be aware that although ICS are a fairly safe method of treating asthma, at high doses of established therapeutic response ranges, iatrogenic Cushing syndrome and secondary adrenal insufficiency can occur.    Administration of excess glucocorticoids suppresses hypothalamic secretion of CRH and subsequently, decrease ACTH secretion by the pituitary gland.  After 4 weeks, this decrease of ACTH will result in secondary adrenal cortex atrophy and suppression with decreased secretion of cortisol and other adrenal steroids.  Patients requiring high doses of ICS should be monitored for cushingoid features and potential adrenal insufficiency.

 

Nothing to Disclose: RSF, JEE

21022 33.0000 SAT-411 A Iatrogenic Cushing Syndrome and Adrenal Suppression from Inhaled Corticosteroid Therapy in an Adolescent Girl 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Emad Ali*, Kenneth Nugent and Joaquin Lado
Texas Tech University Health Science Center, Lubbock, TX

 

Introduction

Iatrogenic Cushing’ s syndrome is one of the most common causes of Cushing’s syndrome and is mainly attributed to the wide use of corticosteroids in clinical practice. We report a case of Cushing’s syndrome secondary to interaction between a commonly used inhaled corticosteroid budesonide and the protease inhibitors ritonavir. The latter is a potent inhibitor of hepatic enzyme cytochrome P3A4. Co-administration can delay the clearance of inhaled corticosteroids leading to accumulation and suppression of hypothalamic-pituitary-adrenal axis.

Case description

45-year-old woman with past medical history of HIV, type 2 diabetes, and asthma presented to our clinic with extreme fatigue, swelling of legs, facial puffiness, and proximal muscle weakness. Symptoms had been present for one month and were getting worse. Physical examination showed Cushingoid facies, abdominal striae, leg edema, and a buffalo hump. An early morning serum cortisol level was 0.4 mcg/dl (reference range: 6.2-19.4 mcg/dl), and ACTH was <5 pg/ml (reference range: 6-50 pg/ml). Three months before presentation she had an asthma exacerbation with hospitalization. She was discharged on budesonide-formoterol inhaler at dose of 160 mcg-4.5 mcg/inhalation, 2 puffs twice daily. Patient had been on antiretroviral therapy for 7 years, including ritonavir as a booster protease inhibitor. After discussion with patient, the budesonide was discontinued, and she received glucocorticoid replacement therapy with tapering over 2 months. She slowly improved to her normal level of energy. Early morning serum cortisol levels at 4 and 8 weeks after finishing corticosteroid therapy were 4mcg/dl and 8.7mcg/dl, respectively. ACTH at eight weeks was 18 pg/ml.

Discussion

When seeing a case of Cushing’s syndrome, the clinician should always remember the possibility of drugs interactions. Corticosteroids are widely prescribed, and a history of inhaled, topical, or systemic corticosteroid use should be carefully investigated. Also the possibility of other medications that can potentiate glucocorticoids effect should be considered. Exogenous Cushing’s syndrome secondary to interaction between inhaled corticosteroids and ritonavir is well described in literature. However, most of the reported cases involved inhaled fluticasone instead of budesonide. In many cases budesonide was substituted for fluticasone with improvement or resolution of Cushing’s symptoms. Fluticasone is known to be more potent than budesonide. Our patient developed Cushing’s syndrome while on a moderate dose of budesonide and for short period of time. This can be explained by the fact that different corticosteroids have different sensitivities to cytochrome P3A4 inhibitors. Although our patient had partial recovery of the adrenal axis by 2 months, full recovery of adrenal function may take 9-12 months.

 

Nothing to Disclose: EA, KN, JL

21448 34.0000 SAT-412 A A Case of Iatrogenic Cushing's Syndrome Secondary to Interaction Between Inhaled Budesonide and Ritonavir 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 379-412 5988 1:00:00 PM Cushing's Syndrome Poster


Xiaopei Cao*, Juan Fu, Fenghua Lai, Xuesi Wan, Haipeng Xiao and Yanbing Li
First Affiliated Hospital, Sun Yat-sen University, China

 

Objective

Carney complex (CNC) is an extremely rare, multiple endocrine neoplasia syndrome with an autosomal dominant manner. The syndrome is of a great variety of clinical manifestations, which is predominantly characterized by spotty skin pigmentation, cardiac myxoma, endocrine overactivity. The most common affected endocrine gland is adrenal cortex, which manifested as primary pigmented nodular adrenocortical disease(PPNAD). It is reported that it has a correlation with inactivating heterozygous germline mutations of PRKAR1A gene.   We collected the clinical data and blood/tissue samples of a Chinese carney's complex pedigree and found a new mutation of PRKAR1A gene that leads to CNC in this pedigree.

Methods

Clinical data of two patients (the proband and her elder female cousin) who presented typical symptoms and signs of cushing’s syndrom were collected, including clinical history, physical examination, laboratory examination, imaging examination, as well as surgical pathology information. Then the clinical and laboratory data of family members in this pedigree were also collected. The peripheral blood of 10 members of this pedigree and the adrenal tissues removed from the two patients underwent adrenalectomy were collected for DNA/RNA extraction. PCR were applied to amplify all the exons and adjacent introns of PRKAR1A gene in every sample and the PCR products were sequenced  RT-PCR amplification of the coding sequence of PRKAR1A gene were performed and cDNA changed was detected by agarose gel electrophoresis (AGE) and sequence analysis.

Results

From detailed analysis of the clinical data, a CNC pedigree was comfirmed. Within the pedigree, ten CNC patients were clarified. All of the patients suffer with spotty skin pigmentation, the CNC typical skin lesion. The proband and her elder female cousin, the proband’s father, the proband’s elder aunt diagnosed PPNAD histologically and all of them received adrenalectomy. What’s more, the proband’s elder female cousin has an adrenal nerve fiber sheath tumors, the proband’s elder aunt has pituitary prolactin tumor. The DNA sequence analysis revealed that patients in this pedigree carry the heterozygous germline mutation of the PRKAR1A gene: c.440+5G>C, which located at intron 4a, the downstream of the exon4a/intron border. This is a new PRKAR1A gene mutation leads to CNC that has been reported. RNA experiments confirmed that c.440+5 G>C heterozygous mutation results in the skipping of exon 4a in CDS sequence of PRKAR1A gene, which means this mutation is a splice site mutation, with an inactivating affect of PRKAR1A gene, definitely a pathogenic mutation.

 

Conclusion

The family is confirmed to be a CNC pedigree with an inactivating heterozygous germline mutation of PRKAR1A gene: c.440 +5 G>C, a splice site mutation leading to the skipping of exon 4a in CDS sequence. This is the first time that this mutation has been reported..

 

Nothing to Disclose: XC, JF, FL, XW, HX, YL

20810 1.0000 SAT-354 A A New Mutation of PRKAR1A Gene C.440+5 G>C in Exon 4a Results in a Chinese Family with Carney's Complex 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Meral Mert1, Ozlem Soyluk2, Jerome Yves Bertherat3, Eric Laurent Clauser4 and Sema Yarman*5
1Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, 2Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey, 3INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France, 4Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France, Paris, France, 5Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

 

INTRODUCTION

Carney’s complex (CNC) is mostly related to germline inactivating mutation in the PRKAR1A gene, thought to be functioning as a tumor suppressor gene. The components of CNC include two or more of the conditions like cardiac-cutaneous myxoma, spotty mucocutaneus pigmentation, primary pigmented nodular adrenocortical dysplasia (PPNAD), testicular tumor, growth hormone-secreting adenoma, osteochondromyxoma. We hereby present a case of Carney’s complex with radiological features of nonexpansile sclerotic benign bone lesions which is not a classic manifestation of CNC.

CASE

This is a 27-year-old man, operated for bilateral testicular tumor with the histology of large cell calcifying sertoli cell tumor at the age of 6 years. At age of 17 years, when referred to our adult endocrinology clinic, typical skin lesions of CNC were noticed. He had significant cushingoid features. Basal serum cortisol and ACTH levels were 23 µg/dl and 6.7 pg/ml respectively. Neither low ( 2 mg 2 day) nor high dose dexamethasone (8 mg overnight) led to suppression of serum cortisol levels (15,5 µg/dl and 18,5 µg/dl, respectively). Abdominal MRI revealed multiple small nodules in both adrenal glands. Pituitary MRI showed a 4 mm pituitary adenoma. The patient underwent bilateral adrenalectomy with the diagnosis of ACTH independent Cushing’s syndrome. The histopathological examination of the adrenal specimens were compatible with PPNAD. The genetic study of the patient showed the mutation of c570 G>A in exon 7 of PRKAR1A. During follow-up annual transthoracic echocardiographies were all normal untill the age of 26 years when a suspicious finding on transthoracic echocardiography was detected. Transesophagial echocardiography showed 4x1.5 cm left atrial myxoma which is excised afterwards. Meanwhile chest X-ray and tomography showed sclerotic bone lesions located at 7. right, 10. left ribs. While bone scan showed slightly increased uptake, F18-FDG PET showed no abnormal activity in the locations of the skeletal lesions excluding malignancy. The lesions were accepted as benign bone lesions according to imaging findings as the patient did not accept biopsy of the lesions.

CONCLUSION

In addition to the presence of PRKAR1A gene mutation, our patient had the typical components of CNC. But the interesting finding of our case is the bone lesions determined after 21 years. Bone tumors associated with CNC are reported to be very rare and osteochondromyxoma is the most common one described in the literature which affects about %1 patients of CNC. The bone lesions in our case were sclerotic and without mass effect, unlike the classic features of osteochondrocytomas. The histopathological diagnosis is not known, but according to the imaging findings the lesions are accepted to be benign. Benign sclerotic bone lesions other than osteochondromyxomas may be seen during the follow-up of CNC.

 

Nothing to Disclose: MM, OS, JYB, ELC, SY

21293 2.0000 SAT-355 A Unusual Presentation of Bone Lesions in Carney's Complex with Testicular Tumor: Nonexpansile Sclerotic Benign Bone Lesions 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Seung Hee Yu*, Ji Hun Jeong and Ki Young Lee
Gachon University Gil Medical Center, Incheon, Korea, Republic of (South)

 

Background: Carney complex (CNC) is a hereditary disease with benign and malignant tumors of endocrine and non-endocrine organs. The 1A regulatory subunit of protein kinase-A (PRKAR1A) gene is the most common mutation site in CNC. We experienced a rare familial CNC with tumors of multiple endocrine and non-endocrine organs associated with a novel PRKAR1A mutation.

Clinical case: A 31-year-old man was referred due to Cushingoid features. Five years ago, he underwent surgery for right atrial and ventricular myxomas. Currently, the patient complained about both flank pain, easy bruising and weight gain. Also, he exhibited spotty skin pigmentation on the lips and buttocks. Serum cortisol was elevated (26.77 µg/dL, 4.30<n<22.40 µg/dL), ACTH decreased (1.6 pg/mL, 10<n<60 pg/mL), and 24-hour urinary cortisol excretion elevated (1119.47 µg/day, 55.5<n<286 µg/day). Serum cortisol was not suppressed by 1 mg dexamethasone (cortisol 25.92 µg/dL, n<2 µg/dL). Low-dose dexamethasone suppression test was compatible with Cushing’s syndrome. An adrenal CT shows nodular thickening in left adrenal gland and two small enhancing nodules in right adrenal gland. Adrenal vein sampling revealed elevated level of cortisol same in both adrenal glands (each cortisol >150 µg/dL). Bilateral adrenal nodules were removed by bilateral adrenalectomy and diagnosed with primary pigmented nodular adrenocortical disease. Skin pigmentation on the buttocks was also removed and confirmed as epithelioid blue nevus. These several manifestations were satisfied with diagnostic criteria of CNC (1). During follow-up for CNC, a scrotal USG shows three calcified lesions in left testis and result of biopsy suggested possibility of large-cell calcifying Sertoli cell tumor. In his family, a 34-year-old woman, the patient’s elder sister, underwent repeated surgeries about atrial myxomas for the past ten years. Multiple nodules in both breasts and 2 cm sized complex solid and cystic mass in left breast were found by breast USG. The result of biopsy was breast fibroadenoma. She had also spotty skin pigmentation on the lips, multiple nodules on both thyroid lobes and colon polyps. Gene analysis was carried out for the patient and his sibling and frame-shift mutation in PRKAR1A gene was found in all of them. Finally, they were diagnosed with a rare familial CNC characterized by skin pigmentation, multiple endocrine tumors, and non-endocrine tumors associated with a novel PRKAR1Amutation. Currently, the patients are followed up in the outpatient department for early detection of different clinical manifestations associated with CNC.

Conclusion: Because of gene mutation, especially PRKAR1A mutation, tumors of multiple organs are presented concurrently or sequentially in patients with CNC. It is important that the patients with suspected or diagnosed CNC are followed up closely for early identification of novel manifestations.

 

Nothing to Disclose: SHY, JHJ, KYL

18705 3.0000 SAT-356 A Familial Carney Complex with Tumors of Multiple Endocrine and Non-Endocrine Organs Associated with a Novel PRKAR1A Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Sawako Suzuki*1, Ichiro Tatsuno2, Hironobu Sasano3, Akitoshi Nakayama1, Eri Komai1, Akina Shiga1, Tomoko Takiguchi1, Seiichirou Higuchi1, Ikki Sakuma1, Hidekazu Nagano1, Naoko Hashimoto1, Hisashi Koide1, Koutaro Yokote1 and Tomoaki Tanaka1
1Chiba University Graduate School of Medicine, Chiba, Japan, 2Toho University Sakura Medical Center, Sakura-City, Japan, 3Tohoku University Graduate School of Medicine, Sendai, Japan

 

Corticotropin-independent Cushing's syndrome is usually due to adrenocortical adenomas and less often due to primary bilateral macronodular adrenal hyperplasia (BMAH). A recent report describing recurrent germline and somatic mutations of armadillo repeat containing 5 (ARMC5) in 55% of the AIMAH patients. On the other hand, Sato Y et al. reported that cAMP-independent activation of cyclic adenosine monophosphate (cAMP) / protein kinase (PKA) signaling by hotspot mutation (L206R) in PRKACA, which encodes the catalytic subunit of cAMP-dependent PKA, in more than 50% of cases with adrenocortical adenomas. There were no previous reports that adrenocortical adenomas and BMAH developed in the same patients. However, whether it is attribute to the differences of genetic background remains unknown. We herein present the case of a 48-year-old patient with BMAH who worsened from subclinical Cushing's syndrome to Cushing's syndrome. The pathology analysis and molecular biologic analysis in each adrenal nodules revealed that a new lesion of black adrenal Cushing adenoma developed among AIMAH nodules in parallel to the onset of the Cushing's syndrome. The black adrenal Cushing adenoma showed high expression of CYP11A1, CYP17A1 and HSD3B2 compared with AIMAH nodules, suggesting hypersecretion of cortisol from the black adrenal adenoma associated with Cushing`s syndrome. Genome analysis in each nodules revealed the defference of genetic background between AIMAH and black adrenal Cushing adenoma, providing insights into the development, diagnosis and therapeutics of these syndromes.

 

Nothing to Disclose: SS, IT, HS, AN, EK, AS, TT, SH, IS, HN, NH, HK, KY, TT

20139 4.0000 SAT-357 A Unusual Case of Bmah Who Developed Cushing's Syndrome Resulting from the Complication of Black Adrenal Adenoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Ji-Yeon Lee*1, Sujin Lee1, Sung-eun Park2, Sung-Kil Lim3 and Yumie Rhee4
1Yonsei University College of Medicine, Seoul, 2Yonsei University College of Medicine, 3Yonsei Univ. College of Med, Seoul, Korea, Republic of (South), 4Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Objective - The majority of ACTH-independent Cushing syndrome is from unilateral adrenal gland, and rarely from bilateral adrenal glands including bilateral macronodular adrenal hyperplasia (BMAH).

Methods – Ten Korean BMAH patients diagnosed at the Severance hospital from 2005 up to 2014 were included. All these patients were tested for the cortisol excess. To figure out the subtypes of the aberrant receptors, we used upright test, mixed meal test, ACTH test, LH/RH test, TRH test, Glucagon test, Vasopressin test, and Macperan test. The result of these tests were classified into 4 responses: Posture (Upright, Vasopressin, Macperan tests), GnRH, GIP (Mixed meal test, Glucagon test), TRH responses.

Results – All of the patients showed functional cortisol excess without overt Cushingoid features, but with deranged metabolic profiles. All the cases responded significantly to the posture test and 90% among them showed positively to vasopressin. Significant response to GnRH, GIP, and TRH were 30%, 20%, and none, respectively. Interestingly only 30% cases were positive to a single test, but rest of them responded to more than 2, 3, and 4 tests as 30%, 20%, and 20% each.

Conclusion – The Korean BMAH cases seem to highly express vasopressin receptors and moreover, 70% of cases have shown positive response to more than 2 tests meaning mixed expression of various receptors. Thus, regarding the future possibility of medical treatment, it is prudent to understand the exact expression profiles of BMAH.

 

Nothing to Disclose: JYL, SL, SEP, SKL, YR

20804 5.0000 SAT-358 A Mixed Subtypes of 10 Korean Bilateral Macronodular Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Jenna L. Sarvaideo*1, Herman E Blomeier2, Lynne Kaminer3, Richard A Prinz2 and Alexandra E Reiher4
1Medical College of Wisconsin, Milwaukee, WI, 2NorthShore University HealthSystem, Evanston, IL, 3Northshore University Healthcare System, 4NorthShore University Health System, Evanston, IL

 

Background:

Primary adrenal lymphoma is a rare extranodal lymphoma, with less than 120 cases in the literature. It typically presents with large, bilateral adrenal masses and associated primary adrenal insufficiency.1

Clinical Case:

A 61 year-old man presented to his physician with worsening left upper quadrant abdominal pain over the past year. Symptoms included a 20 pound weight loss, nausea, heat intolerance, dizziness, fatigue and weakness. 

On physical exam, his vitals were significant for a BP 111/62, pulse 88, and a BMI of 19.8 kg/m2. He appeared thin with tenderness to palpation of left upper quadrant. Skin exam revealed no hyperpigmentation or rashes.  His exam was otherwise unremarkable.

Initial laboratory results included a normal complete blood count and comprehensive metabolic panel. A CT of the abdomen with contrast revealed a right 2.2 x 1.7 x 1.6 cm adrenal nodule. On the left, a normal adrenal gland could not be identified. An 11.0 x 10.7 x 9.8 cm heterogeneous soft tissue mass was described in the expected location of the left adrenal gland, which displaced the pancreas, left kidney and encased the left renal artery. Initial enhanced CT attenuation value of the mass was 58 Hounsfield units (HU), and after three minute delay was 62 HU. No lymphadenopathy was identified.

Pheochromocytoma was excluded with normal 24 hour urine metanephrine and normetanephrine levels. A 1 mg dexamethasone suppression test revealed an elevated 8 AM cortisol of 8.3 ug/dL. ACTH was 14 pg/mL.

Imaging features and initial lab evaluation supported the diagnosis of adrenocortical carcinoma. He underwent surgery, which revealed the left adrenal mass was invading the left kidney and distal pancreas. Adrenalectomy, distal pancreatectomy, splenectomy and left radical nephrectomy were performed. Peri-operative hydrocortisone was given.

Final pathology revealed large B cell lymphoma. In addition, subsequent PET scan showed pericaval, aortocaval and para-aortic lymphadenopathy with hypermetabolism. Adjuvant chemotherapy was initiated with R-CHOP (Rituximab, Cyclophosphamide, Adriamycin, Vincristine, Prednisone). He was tapered off hydrocortisone one month after surgery.

Clinical Lesson: 

Both adrenocortical carcinoma and primary adrenal lymphoma are very rare adrenal tumors. Given the large left adrenal mass with elevated HU and hypercortisolism, adrenocortical carcinoma was high on the differential diagnosis in this patient. This led to subsequent surgery rather than initial treatment with chemotherapy. This case underscores the challenges in accurately diagnosing rare adrenal masses.

 

Nothing to Disclose: JLS, HEB, LK, RAP, AER

18700 6.0000 SAT-359 A A Unique Presentation of Adrenal Lymphoma in a Man with Abdominal Pain 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Geetanjali Kale*
University of Wisconsin, Madison, Madison, WI

 

Background: Myelolipomas are benign neoplasms comprised of adipose and myeloid tissue. While commonly presenting as a unilateral adrenal mass, very large bilateral lesions have been rarely reported. There is reported association of myelolipomas with congenital adrenal hyperplasia (CAH), often in the setting of treatment noncompliance, as well as with Addison’s disease and ACTH-dependent Cushing’s syndrome (1). This has raised speculation regarding a role of ACTH excess in tumor growth. Treatment of CAH entails lifelong glucocorticoid replacement to ensure adequate androgen suppression. Optimal dosing is challenging. Experience with bilateral adrenalectomy as an alternate treatment option is limited, but improved quality of life, lower glucocorticoid doses, and decreased incidence of obesity has been reported (2).

Case description: A 51-year-old male was diagnosed with classical salt-wasting CAH in infancy. He reported normal childhood growth and puberty. He had been prescribed prednisone 5 mg in the morning and 2.5 mg in the evening and fludrocortisone 0.1 mg daily since adolescence via his primary care physician without any biochemical monitoring. He reported excellent compliance with medications. He was obese and denied diabetes and hypertension. He had never attempted to have children.

He presented with chronic back pain and lower extremity paresthesias. Findings on MRI of the lumbar spine prompted an abdominal CT scan which described bilateral suprarenal masses: a left 31.1 x 18.1 x 16.1 cm mass with predominant fat attenuation and a right 13.7 x 6.6 x 10.6 cm mass with predominant complex fat attenuation. Adrenal glands were not identified. A PET scan showed low metabolic activity. Bilateral resection was performed due to concern of malignancy. Intraoperatively, adrenal glands were not visualized. Pathology revealed both retroperitoneal masses to be adrenal myelolipomas, with scattered normal adrenal tissue visualized in the specimen. The left tumor measured 34 x 20 x 13 cm and weighed 4.7 kg. The patient was treated with stress dose hydrocortisone perioperatively in tapering doses and fludrocortisone was resumed on post operative day 1. The patient had been on supra-physiologic steroid replacement doses for most of his life for management of adrenal androgen excess. Under the assumption that both adrenal glands were removed, his prednisone was lowered to physiologic replacement dosing at the time of discharge.

 Conclusion: Our case describes of one of the largest reported bilateral adrenal myelolipomas in the setting of CAH. Despite the working theory of ACTH-mediated tumor growth, it is notable that these tumors developed despite compliance with supraphysiologic steroid replacement. This case also highlights the importance of considering potential benefits of planned bilateral adrenalectomy while considering surgical versus conservative management of myelolipomas.

 

Nothing to Disclose: GK

18858 7.0000 SAT-360 A Gigantic Retroperitoneal Myelolipomas and Unintentional Bilateral Adrenalectomy in a Patient with Classic Salt-Wasting Congenital Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Sina Jasim1, Lily J Kwatampora*2, Khaled Elsayes3, Pheroze Tamboli3, Naifa L Busaidy4 and Mouhammed Amir Habra4
1Mayo Clinic, Rochester, MN, 2Baylor College of Medicine, Houston, TX, 3The University of Texas-MD Anderson Cancer Center, Houston, 4The University of Texas MD Anderson Cancer Center, Houston, TX

 

Introduction: Li-Fraumeni syndrome (LFS) is a rare familial cancer syndrome characterized by various early onset tumors. Breast cancer, sarcomas, leukemia, adrenocortical carcinoma (ACC), and brain tumors are the most common malignancies seen with LFS. Epithelioid angiomyolipoma (EAML), a variant of angiomyolipoma (AML), is an uncommon mesenchymal tumor with malignant potential that is typically found in the kidneys. Although extra renal disease has been described, AML arising from the adrenal gland is rare, and only a few cases have been reported. To our knowledge, this is the first report of EAML in a patient with LFS.

Clinical Case: A 26-year-old healthy woman was evaluated at an outside hospital for left flank pain associated with weight loss. Physical examination was unremarkable. CT abdomen showed a 16 cm heterogeneous and hypervascular left adrenal mass. Laboratory workup was all within normal reference range. She underwent open left adrenalectomy. The tumor was diagnosed as a stage 2 (T2 N0 M0) non-functioning ACC and she started adjuvant mitotane therapy. Because of the significant family history of cancer—mother with breast cancer at age 38 and later adenocarcinoma of the lung; younger sister died of medulloblastoma at age 3; two paternal uncles and grandfather diagnosed with liver cancer; and maternal aunt with breast cancer at age 40—there was suspicion of a familial cancer syndrome which subsequently fulfilled the Chompret criteria for diagnostic testing for LFS. Genetic counseling was provided, and comprehensive germline TP53 gene sequencing revealed a missense mutation of exon 8 [(C.817 C>T (p.Arg273 Cys)]. A screening mammography revealed multiple nodules in both breasts that on biopsy showed high nuclear grade bilateral ductal carcinoma in situ. PET-CT for staging revealed no evidence of FDG-avid lesions. She was then referred to our institution for a second opinion for ACC management. Pathologic review revealed large epithelioid tumor cells that stained positive for HMB-45, melan-A (A103), and MART-1 (Ab3) but stained negative for calretinin, cytokeratin, and S100. In addition, there were few smooth muscle cells with vacuolated cytoplasm. The morphologic features and immunohistochemical staining profile were consistent with EAML; thus, adjuvant mitotane therapy was withheld, and clinical observation was recommended. At last follow-up, 30 months after EAML resection, the patient was free of disease.

Clinical Lesson: The differential diagnosis of adrenal masses in patients with LFS includes ACC, benign adrenal adenoma, and metastatic tumors. An experienced pathological review and comprehensive immunohistochemical staining are needed to increase the diagnostic accuracy in adrenal tumors suspicious for ACC. Although EAML is uncommon in the adrenal gland, it should be considered as part the differential diagnosis of adrenal masses in patients with LFS.

 

Nothing to Disclose: SJ, LJK, KE, PT, NLB, MAH

21589 8.0000 SAT-361 A Epithelioid Angiomyolipoma Mimicking Adrenocortical Carcinoma in a Patient with Li-Fraumeni Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Thais Hissami Inoue Lima*1, Claudia de Mello Virmond2, Maria Carolina de Camargo Vieira2, Lucas do Prado Palmiro2, Patricia Pedini2, Fadlo Fraige3 and Lenira Cristina Stella2
1Hospital Beneficiencia Portuguesa de Sao Paulo, Sao Paulo, Brazil, 2Hospital Beneficiencia Portuguesa de Sao Paulo, 3Hospital Beneficence Portuguesa de Sao Paulo, Sao Paulo, Brazil

 

Introduction: Adrenal Incidentaloma (AI) is an adrenal mass discovered unexpectedly during a radiologic examination unrelated to adrenal disease. Its prevalence is increasing with the advances in imaging technology. Many authors do not consider that oncologic patients may have AI since this finding is actively sought during staging and follow-up. Hence, as well as in non-oncologic patients, the approach of these lesions with regard to its benign nature as well as its treatment strategies is mandatory.

Objective: Compare clinical and radiologic characteristics of AI in oncologic and non-oncologic patients.

Design: Evaluation of Abdominal Computed Tomographies (CT) and Aorta’s Angio CT performed in the Beneficencia Portuguesa Hospital of Sao Paulo in 2012. We excluded CTs with known adrenal pathologies, tumors of unknown etiology, insufficient data and more than one of the same patient. The patients with AI were divided in 2 groups: Oncologic and Non-Oncologic with regard to the patient’s background. The protocol evaluated gender, age, laterality, size and pre-contrast attenuation measured in Hounsfeld Units (HU). Suspect lesions for malignancy were masses > 4cm and/or attenuation > 20HU. The data were statistically analyzed through Chi-Square and Mann Whitney Rank Sum Tests.

Results: Among 6108 Abdominal TCs evaluated, 249 patients were found with AI (prevalence of 4%). The majority were females, 54,5% in the whole sample, and 55,4% among those with AI. The average age was 64,7 years old, 65,8% were >60 years old. There were 106 patients with an oncologic background and 143 without it. There was no statistical difference regarding gender, age (p=0,147) and laterality between both groups. Among 278 AI analyzed, including 11,6% bilateral masses, the smaller and lower pre-contrast attenuation lesions prevailed. There were 79 suspect lesions, statistically more frequent in the Oncologic group considering either size, p=0,005 (12,6% x 3,7%), or density, p<0,001 (34,4% x 11,5%). Hence, patients with a neoplastic background have an augmented risk of presenting with a suspect adrenal mass, Odds Ratio = 3,960 (CI 95%, p < 0,001).

Discussion: This study is concordant with the literature regarding the prevalence of AI and age or gender predilection. The Oncologic group had higher frequency of suspect lesions as 6 times higher, variable with the type of carcinoma. It is possible that radiological characteristics of adrenal mass in oncologic patients strengthen a surgical treatment compared to non-oncologic patients, owing to the investigation of metastasis while staging. Although the number of AI evaluated is expressive, there are limitations concerning the correlation of clinical, radiological and histo-pathological data.

 

Nothing to Disclose: THIL, CDMV, MCDCV, LDPP, PP, FF, LCS

19312 9.0000 SAT-362 A Adrenal Incidentalomas Characterization in Oncologic and Non Oncologic Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Deep Shikha*1, Bhavana Bajracharya1, Patricia Park2, Jocelyne Georges Karam2 and Christine A Resta2
1SUNY Downstate Medical Center, Brooklyn, NY, 2Maimonides Medical Center, Brooklyn, NY

 

BACKGROUND

Adrenal hematoma is a relatively rare cause of adrenal incidentaloma and is rarely suspected clinically. We present a case of giant adrenal hematoma presenting as severe anemia in a patient who had been asymptomatic for 20 years.

 CLINICAL CASE

A 67 year old female presented with one year history of fatigue, intermittent abdominal pain, severe anemia and large palpable abdominal mass. Laboratory data revealed severe anemia with hemoglobin of 6.4 g/dL. A computed tomography (CT) of abdomen showed a large heterogenous mass measuring 24 cm x 20 cm x 23 cm of mixed attenuation with areas of necrosis and increased density consistent with subacute blood products. Right adrenal gland was normal but left adrenal was not visualized. The mass was suspected to be arising from left adrenal gland. A low dose dexamethasone suppression test and 8 am cortisol levels were normal.  Serum aldosterone, plasma renin activity, DHEAS levels were normal. Plasma metanephrines and catecholamines were normal with slightly elevated 24-hour urinary metanephrines 1420 mcg (224-832 mcg/24 hours) and normetanephrines 1296 mcg (122-676 mcg/24 hours). The patient reported to have an abdominal CT 20 years ago, which showed a 2.8 cm left adrenal mass. Repeat abdominal CT five years ago showed a heterogeneous 8.2 cm left adrenal mass.

Due to severe ongoing anemia despite repeated blood transfusions, above CT findings and negative biochemical work up for subclinical Cushing syndrome and pheochromocytoma, the possibility of hemorrhage into adrenocortical carcinoma was strongly considered.  Patient underwent exploratory laparotomy with resection of the mass and en bloc left nephrectomy. Pathology revealed partially organizing intra-adrenal hematoma with no adrenal medullary cells and very few normal appearing adrenal cortical cells. Patient denied any trauma, recent infections or use of aspirin/anticoagulant agents.  Coagulation profile was normal. This led to the diagnosis of idiopathic adrenal hematoma with possible recurrent bleeds into a lipid poor adenoma over last 20 years.

Adrenal hematoma can be caused by trauma, stress, adrenal tumors, anticoagulation, pregnancy and hemorrhagic disorders. Presentation may vary according to amount and rate of bleeding and compressive effect on adrenal cortex. The radiological features on CT can help detect adrenal hemorrhage but these can mimic pheochromocytoma and adrenocortical carcinoma. These hematomas can regress spontaneously over time and can be monitored with serial imaging. But in cases like ours with a large size (> 4 cm) and ongoing anemia, the potential for malignancy cannot be excluded, thereby necessitating surgical resection.

CONCLUSION

Adrenal hematoma should be considered in differential diagnosis of adrenal incidentaloma especially in the setting of large size, heterogeneous appearance on imaging and recurrent anemia.

 

 

 

 

 

 

 

 

 

 

 

Nothing to Disclose: DS, BB, PP, JGK, CAR

20149 10.0000 SAT-363 A A GIANT Adrenal MASS Presenting As Anemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Grace Y Kim*, Sahar Nozad, Tipu Nazeer and Matthew C Leinung
Albany Medical College, Albany, NY

 

Introduction:  Ectopic cortisol-producing adrenocortical carcinoma is an extremely rare endocrine malignancy.  They are thought to originate from ectopic adrenal rest tissue, which represents adrenocortical embryonic remnants that have undergone tumoral transformation during development. 

Case report:  We present an unusual case of ectopic adrenocortical carcinoma that was found in the right kidney of a 50-year-old female who presented with Cushing’s syndrome and virilization.  Urine free cortisol and adrenal androgens were significantly elevated.  Contrast-enhanced abdominal computed tomography (CT) revealed a 12 x 10 x 12 cm mass located within the right kidney.  Subsequently, the patient underwent right nephro-adrenalectomy. 

Results:  Pathological findings: Histologically, the specimen showed a high grade neoplasm centered in the kidney with polymorphism, highly atypical nuclei, abundant mitotic activities and necrosis. Despite the remarkable atypia and polymorphism, the tumor cells maintained the histologic features of adrenal cortical tissue in some areas.  Immunohistochemically, neoplastic cells were strongly positive for inhibin, calretinin, vimentin, synaptophysin and MART-1.  The native adrenal gland was free of the tumor.  Postoperatively, her cortisol and adrenal androgen levels fell below normal. Her cushingoid and androgenous features improved quickly.

Conclusion:  We report an ectopic cortisol-producing adrenocortical carcinoma arising in an adrenal rest in the right kidney.  Gross total resection appears to be curative.  Immunohistochemical studies that include inhibin, calretinin, vimentin, synaptophysin and MART-1 were useful in the rendering of an accurate diagnosis.

 

Nothing to Disclose: GYK, SN, TN, MCL

20705 11.0000 SAT-364 A Ectopic Cortisol-Producing Adrenocortical Carcinoma Arising in Adrenal Rest Tissue in a Right Kidney: Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Ana Luize Merten*1, Priscila R M M Cardoso1, Stela L Matos1, Augusto Cezar Santomauro Jr.1, Priscila Sales Barroso2, Tatiana S Pelaes1 and Maria Adelaide Albergaria Pereira3
1Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil, 2Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, SAO PAULO, Brazil, 3Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Background:The association between solid tumors and primary renal disorders as a paraneoplastic effect of malignancy, usually membranous nephropathy, is known. However, the association of minimal change disease and ganglioneuroma has not been reported yet.

Clinical case: A 19‐year-old female was referred to our endocrinology service for evaluation of an adrenal incidentaloma. She was previously healthy and presented with 1-month history of progressive peripheral edema and urinalysis revealed heavy proteinuria but no cells, casts or hematuria. She denied the use of any drugs. The blood pressure was normal. Further investigation showed protein excretion 10.41 g/vol/24 hours (n <0.15 g/vol/24h), plasma albumin concentration 1.7 g/dL (n 3.4 a 4.8 g/dL), total cholesterol 380 mg/dL (n <200 mg/dL), LDL 235 mg/dL (n <130 mg/dL), triglycerides 189 mg/dL (n <150 mg/dL). Creatinine clearance 122 mL/min/1.73m² (MDRD). Antinuclear antibodies (ANA), complement (C3/C4), rheumatoid factor, syphilis serology, hepatitis B and hepatitis C serologies were normal.

The renal ultrasonography showed a lesion in the right adrenal topography with normal kidneys and urinary tract. MRI showed an adrenal mass with heterogeneous enhancement after gadolinium with 8.3x9.6x5.4cm. There were no symptoms suggestive of Cushing's syndrome, pheochromocytoma or hyperaldosteronism.

Evaluation for hormonal secretion was performed with: cortisol after 1 mg overnight dexamethasone suppression test < 1 mg/dL (n < 1.8 mg/dL), midnight salivary cortisol 0.08 µg/dL (n < 0.12 µg/dL) and plasmatic metanephrines <0.2 nmol/L (n <0.5 nmol/L).

The light microscopy of renal biopsy was normal and the immunofluorescence showed no evidence of immune complex deposition, suggesting minimal change nephropathy.

Patient was submitted to right adrenalectomy and mass resection.

Histopathological analysis demonstrated a ganglioneuroma, measuring 10x10x3 cm and normal right adrenal.

After 30 days the protein excretion was 2.05 g/vol/24 hours and 3 -month postoperative evaluation showed: plasma albumin concentration 3.6 g/dL, total cholesterol 233 mg/dL, LDL 91 mg/dL, triglycerides 130 mg/dL, protein excretion  1.41 g/vol/24 hours. 

In the seventh month postoperative follow-up, the patient remained asymptomatic with normal laboratory tests (protein excretion 0.07 g/vol/24 hours) without the need for lipid lowering drugs or corticoid use.

Conclusion: This is the first case report in the literature of ganglioneuroma causing nephropathy due to minimal change disease as paraneoplastic syndrome. After resection of the lesion, patient evolved with complete remission of the nephropathy without the need for corticosteroids.

 

Nothing to Disclose: ALM, PRMMC, SLM, ACS Jr., PSB, TSP, MAAP

21267 12.0000 SAT-365 A Ganglioneuroma Presenting As Adrenal Incidentaloma with Nephrotic Syndrome Due to Minimal Change Disease: Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Mustafa Unubol*1, Muzaffer Katar2, tugba Ilkem kurtoglu Ozcaglayan3, Ahmet orhan Celik3, Omer Ozcaglayan4, Zeliha Cansel Ozmen5, Volkan Yazak6 and Bilal Acar7
1Adnan Menderes University Faculty of Medicine, Department of Internal Medicine, Division of Endocrinology, Aydın, Turkey, Turkey, 2Tokat State Hospital, Clinical Biochemistry, 3Tokat State Hospital, Tokat, Turkey, 4Tokat State Hospital, Tokat, 5Gaziosmanpasa University, Faculty of Medicine-Clinical Biochemistry, Turkey, 6Nazilli State Hospital, Internal Medicine, Turkey, 7Cankiri State Hospital, Internal Medicine, Turkey

 

Aim: Fetuin-A (α2-heremans-schmid glycoprotein) is a circulating serum glycoprotein with a molecular mass of approximately 60 KDa. Like serum albumin, fetuin-A is predominantly liver-derived. Fetuin-A is associated with insulin resistance. High levels of fetuin-A have been associated with obesity, metabolic syndrome, type 2 diabetes mellitus (DM), non-alcoholic fatty liver disease and the occurence of ischemic stroke and myocardial infarction. Even though the clinical significance of adrenal incidentalomas is still unknown, recent reports have suggested that the risk of cardiovascular disease may be increased in patients with non-functional adrenal incidentalomas. In this study, we aimed to evaluate plasma fetuin-A level in patients with non-functional adrenal incidentalomas.

Method: Fourty-two patients with non-functional adrenal incidentalomas and 43 healthy controls were involved in the study. Fasting serum fetuin-A levels were evaluated.

Results: Fetuin-A concentrations were significantly increased in patients with non-functional adrenal incidentalomas compared to healthy control group (47.4 ± 6.6 vs. 19.2 ± 1.5 ng/ml; p = 0.007).

Conclusion: To the best of our knowledge this is the first study to report a clinical association between measured plasma Fetuin-A level and non-functional adrenal incidentalomas. Inconclusion, our results indicate that serum fetuin-A levels increase in patients with non-functional adrenal incidentalomas. Therefore, fetuin-A might have a role in the development of risk of cardiovascular disease inpatients with non-functional adrenal incidentalomas and   be tested in further studies.

 

Nothing to Disclose: MU, MK, TIKO, AOC, OO, ZCO, VY, BA

21322 13.0000 SAT-366 A Serum Levels of Fetuın-a Are Increased in patients with Non-Functional Adrenal Incidentalomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Andreina Rojas* and Violet Lagari-Libhaber
Miami Department of Veterans Affairs Medical Center

 

Background: Adrenal ganglioneuromas are rare, benign tumors of neural crest origin that usually present in the mediastinum and retroperitoneum. They rarely present in the adrenal glands and most are nonfunctional tumors. A small percentage may be hormonally active, presenting with hypertension.

Case: A 39-year old male presented to the ER complaining of back pain following blunt trauma. A lumbar MRI revealed an incidental adrenal mass. He presented to the endocrinology clinic for further evaluation. He had no prior medical history, and was not taking any medications or illicit drugs. On physical exam, he was a well appearing man. His blood pressure was 101/68 mm/Hg, pulse 67 beats/min and the rest of the exam was unremarkable. A CT scan of the abdomen with adrenal protocol demonstrated a large left adrenal mass measuring 5.7 x 2.9 cm with punctate calcifications, not fulfilling criteria for adenoma. An initial 24 hour (h) urine dopamine level was elevated at 616 mcg/24h (52-480 mcg/24h). The 24h urine metanephrines and cortisol levels were initially slightly elevated at 255mcg/24h (36-190mcg/24h) and 57 mcg/24h (4.0-50), respectively, but were normal on repeat evaluation. The 24h urine dopamine, however, remained elevated (601 and 623 mcg/24h) when repeated two more times. Other work up included an 8 am plasma renin and aldosterone, which were 1.81 ng/dl (0.25-5.82) and 2.0 ng/ml (<28 ng/dl).

Given the size and characteristics of the adrenal tumor, there was a concern for malignancy and the patient underwent surgical resection. He was not placed on any perioperative anti-hypertensive, given the dopamine secreting nature of the tumor and since the patient was never hypertensive. Postoperative histopathology revealed an adrenal ganglioneuroma of 6.5 x 6.0 x 2.5 cm. Following surgical removal of the tumor, the 24h urine collection for dopamine normalized (249 mcg/24h).

Conclusion: The final diagnosis was a dopamine secreting adrenal ganglioneuroma in an asymptomatic 39-year old healthy male patient.  Because adrenal tumors are usually diagnosed incidentally and their radiologic characteristics are not pathognomonic, a comprehensive evaluation including hormonal evaluation needs to be performed on every patient. Final histopathology is necessary to establish the diagnosis.

 

Nothing to Disclose: AR, VL

21473 14.0000 SAT-367 A A Rare Case of a Dopamine Producing Adrenal Ganglioneuroma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Danae Anastasia Delivanis*, Neena Natt, Dana Erickson, Spyridoula Maraka, Thomas D Atwell, Patrick W Eiken, Grant D Schmit, Taxiarchis Kourelis and Irina Bancos
Mayo Clinic, Rochester, MN

 

Background:Adrenal biopsy is an invasive procedure, rarely ordered by endocrinologists. Here we report our analysis of a large radiological database of adrenal biopsies.

Methods:This a retrospective study of 417 adrenal biopsies performed on 413 patients with adrenal masses at Mayo Clinic between 1994 and 2014.

Results: Patients included 155 women and 258 men with a median age of 68 (35-91) years old. A current or past history of malignancy was present in 69% of patients and suspicion for an adrenal mass malignancy was the main indication for biopsy in this group. A minority of the biopsies were ordered by endocrinologists (10%). The majority of adrenal masses were detected on CT imaging. Mean size was 3.4 cm (1.1-12 cm) and mean Hounsfield units (HU) 30 (-61 to 80). Histological diagnosis revealed 199 cases of metastasis (57% lung, 11% GI, 15% genitourinary, 4% melanoma, 2% breast and 11% other), 142 cases of benign adrenal adenomas, 15 cases of lymphoma and 13 cases of adrenocortical carcinoma. The rate of non-diagnostic biopsies was 5%. Twenty seven percent of patients were screened for pheochromocytoma. Of 5 non-screened patients with an ultimate diagnosis of pheochromocytoma, 1 had self limiting tremors at the time of the biopsy. The complication rate was 1% (4/417) which included 2 cases of small asymptomatic pneumothorax and a small self resolved hematoma. Of the 278 patients with malignant masses, 207 died at a median of 8.3 months (0.5-157 months) after the adrenal biopsy due to metastatic disease.

Allowing for occasional tumor heterogenicity, attenuation of more than 10 HU on unenhanced CT imaging had 100% sensitivity and 33.4% specificity in diagnosing malignant disease; whereas chemical shift on MRI had 100% sensitivity and 66.67% specificity. Out of 47 patients with adrenal masses showing HU≤10, 42 cases were benign and the other 5 were nondiagnostic on biopsy; 3 out of the 5 of these patients had adrenalectomy and pathology revealed adrenocortical adenoma.

Conclusion: Adrenal biopsies performed in a major referral center are safe procedures, with only 1% rate of minor complications. As expected, patients with malignant histology had a poor prognosis. At least 10% of adrenal biopsies could have been avoided by using a cutoff of 10 HU on unenhanced CT.

 

Nothing to Disclose: DAD, NN, DE, SM, TDA, PWE, GDS, TK, IB

21588 15.0000 SAT-368 A What Can Endocrinologists Learn from a Large Adrenal Biopsy Database? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Milldeanna Laguerta de Guzman*1, Myl Reyes Cabangon1 and Carolyn Navarcan Montano2
1Makati Medical Center, Makati, Philippines, 2Makati Medical Hospital, Makati, Philippines

 

Background: Primary Adrenocortical Carcinoma is a very rare and aggressive malignancy with annual incidence of 1 per 1 million. Two thirds of all ACC’s are hormonally active and tend to manifest with hypercortisolism and virilization.1 Rapid onset of symptoms of glucocorticoid excess in conjunction with virilization in women or feminization in men suggests an Adrenal Carcinoma as the cause of Cushing’s Syndrome

Clinical Case: A 67-year old female presented with increase abdominal girth.  Two years PTA, sudden onset of continuous back pain radiating to the right scapula. Abdominal UTZ showed gallbladder sludges and right perirenal pole mass lesion (adrenal etiology?). CT scan of abdomen was done showing Right adrenal mass (8.0 x 6.1 x 5.9cm) with central necrosis and was advised surgery. Bloodtests were done and showed normal urine VMA 22.umol/24 hour, serum cortisol (497.8 nmol/L, normal value 138-690 nmol/L), plasma aldosterone upright (3.739 ng/dl, normal value 4-31 ng/dl), plasma renin upright (0.349 ng/ml, normal value 1.9 – 6 ng/ml), and normal PAA/PRA 10.68. After a month, repeat plain abdominal CT scan showed decrease in size of adrenal mass (5.2 x 4.8 x 4.3cm from 8.0 x 6.1 x 5.9cm). Fine needle aspirate biopsy was done showing no inflammatory changes or atypical elements present. He was advised to repeat CT scan of the abdomen as surveillance. Three months PTA, patient developed enlarging abdominal girth, easy fatigability with weight loss and hirsutism (thickened eyebrows and moustache). Repeat CT scan showed increase right adrenal mass (15.8 x 13 x 18.1cm from 8.0 x 6.1 x 5.9cm) with feeding arteries and internal necrosis represent malignant process. Repeat bloodtests showed elevated 8 AM serum cortisol (1,181 nmol/L, normal value 138-690 nmol/L), elevated cortisol after 1 mg Dexamethasone suppression test (1,184 nmol/L, normal value <50 nmol/L), normal ACTH (1.569 pg/ml, normal value <50 pg/L), elevated DHEAS (37.628 umol/L, normal value 0.94-11.67 umol/L). Patient underwent Exploratory laparotomy with cholecystectomy, hepatectomy, right lobe; adrenalectomy, right; nephrectomy. Histological examination revealed Adrenocortical carcinoma with hemorrhage and necrosis, tumor size 16cm, lymphovascular invasion, one margin (diaphragmatic) positive for tumor involvement. Other surgical margins negative for tumor involvement. Immunohistochemical staining showed positive synaptophysin, vimentin, inhibin.

Conclusion: Primary Adrenocortical Carninoma, an uncommon and aggressive malignancy where women are more commonly affected than men, can arise from an initially benign, nonfunctional adrenal tumor to a highly aggressive, metastatic, functional ACC. This should be considered as a cause of Cushing’s syndrome when presented with a rapid onset of symptoms of glucocorticoid excess in conjunction with virilization in women or feminization in men.

 

Nothing to Disclose: MLD, MRC, CNM

21525 16.0000 SAT-369 A Primary Adrenocortical Carcinoma Arising from a Longstanding Adrenal Mass  2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Mongkontida Umphonsathien*1, Panudda Srichomkwun2, Patchaya Boonchayaanant3 and Thiti Snabboon1
1Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 2Hormonal and Metabolic Disorders Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 3King Chulalongkorn Memorial Hospital/Thai red cress society, Bangkok, Thailand

 

Background:Adrenocorticol tumors may present with hormonal hypersecretion but cortisol- and estrogen-co-secreting feminizing adrenocortical carcinoma (ACC) is very rare.

Clinical case:A 43-year-old male patient presented with bilateral gynecomastia with multiple acnetiform eruption for more than two years and recent rapidly progressing symptoms of hypercortisolism. He also had diabetes mellitus and hypertension, ischemic stroke, compression fracture, recurrent infections, severe hypokalemia and metabolic acidosis.

A large adrenal tumor was found incidentally on an ultrasound done for evaluation of complicated urinary tract infection. A CT scan showed a 13*12.5*10 cm left suprarenal mass with calcifications and necrosis, regional lymphadenopathy, left suprarenal vein and IVC thrombosis, two small lesions in the liver and multiple metastatic nodules in both lungs.

Hormonal evaluation showed increased 24-hour urinary free cortisol [606.02 µg/24hr(21-143)], low level of ACTH [<10 pg/ml(10-71)], very high level of estradiol [1,221 pmol/L(0-130)], high level of DHEAS [1,115 µg/dl(80-560)], and suppressed FSH [<0.1 IU/L(1.0-8.4)] and LH [<0.1 IU/L(1.0-10.5)] levels.

Left adrenalectomy, left nephrectomy, splenectomy and IVC thrombectomy were done. A pathological report showed an oncocytic ACC with extensive area of tumor necrosis and capsular and vascular invasion. Immunohistochemical staining revealed high proliferative rate (Ki67 index ≥10%). 

Estradiol level normalized after tumor resection. FSH and LH levels increased transiently and then fell back to be within the normal ranges. He had transient adrenal insufficiency with postoperative AM cortisol level of 1.7 μg/dL(7-25). His gynecomastia has partially regressed. Mitotane and chemotherapy was offered as an adjuvant therapy but he declined and then was lost to follow-up. He returned 6 months later with tumor progression in the liver and elevated estradiol level of 3,535 pmol/L and recurrent Cushing’s syndrome. At this point, his prognosis was deemed to be very poor.    

Conclusion: We present a rare case of cortisol- and estrogen-co-secreting feminizing ACC with bilateral gynecomastia and rapidly progressing Cushing’s syndrome. Early recognition of symptoms, diagnosis and intensive management are very important in this aggressive type of cancer.

 

Nothing to Disclose: MU, PS, PB, TS

19500 17.0000 SAT-370 A Cosecretion of Cortisol and Estrogen By a Feminizing Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Pankaj Sharda*1 and Jonathan Robert Anolik2
1Temple University Hospital, Philadelphia, PA, 2Temple University School of Medicine, Philadelphia, PA

 

Introduction:

Adrenocortical carcinomas (ACC) account for <5% of all adrenal tumors. ACC prevalence depends on tumor size, accounting for 25% of lesions > 6 cm. About 65% ACC’s are hormonally active and the majority present with virilizing and hypercortisolism features. Virilizing adrenal adenomas (VAA) are very rare with only 34 cases described in the world’s literature from 1925 – 1981. We present a rare case of a woman with rapid onset hirsutism found to have a 7 cm adrenal mass with high suspicion of ACC clinically and biochemically, but final pathology consistent with adrenal adenoma and androgens normalized post-operatively.

 Case Presentation:

A 39 year-old woman was evaluated for increased body hair on face, chest, lower abdomen along with scalp hair loss for about 10 months. She also noticed worsening acne, deepening of voice and menstrual irregularities. She denied blood pressure fluctuations, palpitations or flushing. She denied any significant past medical or family history of adrenal tumors.

Significant physical findings included coarse terminal hair on face, chest and lower abdomen.  Laboratory tests revealed DHEA-S 602 ug/dL (normal {NL} 35 – 430 ug/dL), total testosterone 562 ng/dl (NL < 73 ng/dL), free testosterone 55.1 pg/ml (NL 1-8 pg/ml), 17-hydroxyprogesterone 287 ng/dl(NL < 285 ng/dl) and androstenedione 2077 ng/dl (NL 30 – 235 ng/dl). Hyperaldosteronism and pheochromocytoma work-ups were negative. 24 hour urine cortisol = 45.3 mcg/24 hr (NL 4-50 mcg/24 h) and ACTH = < 5 pg/ml.

MRI abdomen showed a 7 cm left adrenal mass, heterogeneous and mildly enhancing suggesting non-benign characteristics. Given the dramatic presentation, large mass, and imaging characteristics, our presumptive diagnosis was ACC. Patient underwent robotic left total adrenalectomy with an uneventful post-operative course. The lesion was not infiltrative and was relatively straightforward to remove.  She was discharged home on maintenance steroids given suppressed ACTH pre-operatively. Surprisingly, her final pathology showed a 98g, 8.9 cm adrenal cortical neoplasm consistent with adrenal cortical adenoma with no capsular involvement.

On 6 week follow-up, she was clinically well and repeat labs showed androstenedione 38 ng/dl, DHEA-S < 15 ug/dl, total testosterone < 20ng/dl and 8AM serum cortisol 1.9 ug/dl.

Discussion:

VAA’s are extremely rare, estimated incidence 1 per 1.7 million, average about 4 cm in diameter and present commonly in middle-aged women. Marked hirsutism is common and duration of symptoms range between months to years. It is difficult to differentiate VAA from ACC on the basis of clinical and laboratory findings. Post-operatively, hirsutism decreases, menstrual cycle normalizes and elevated androgen levels return to normal.

Conclusion:

Not all large virilizing adrenal tumors are malignant but must be approached as if they are. Careful follow-up is recommended in VAA patients.

 

Nothing to Disclose: PS, JRA

19468 18.0000 SAT-371 A Rare Presentation of Virilizing Adrenal Adenoma: Not All Large Androgen Secreting Adrenal Tumors Are Malignant 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Tobias Akerstrom*, Rajani Maharjan, Per Hellman and Peyman Bjorklund
Uppsala University, Sweden

 

Adrenocortical carcinomas (ACCs) are rare malignancies associated with poor prognosis. While a majority of ACCs present with steroid hormonal excess only a few carcinoma with co-secretion of aldosterone and cortisol have been described. Genes that are frequently altered in ACCs include; ZNRF3, CTNNB1, TP53 and CDKN2A. CDKN2A encodes the cell cycle regulator p16, a well-known tumour supressor often mutated in different cancers. PRKACA encodes the catalytic subunit of a cAMP dependent kinase (protein kinase A). Recently, mutations in PRKACA were observed in cortisol producing adenomas. We present a patient with an ACC with subclinical Cushing syndrome and primary aldosteronism, carrying a novel PRKACA and CDKN2A mutation.

The patient was referred to the endocrine unit at Uppsala University hospital because of a blood pressure of 220/120 mmHg and spontaneous hypokalemia (2.3 mmol/L reference: 3.5-5.0 mmol/L). P-aldosterone was 1750 pmol/L (reference: 29-440 pmol/L) with a suppressed PRA of <0.3 μIU/mL (reference: 1.8-27.3 μIU/mL). The patient had no clinical signs of hypercortisolism, s-cortisol was in the normal range, but dexamethasone suppression test showed unsuppressed cortisol levels (160 nmol/L, reference: <70 nmol/L). The other laboratory tests did not reveal any abnormalities. CT-imaging demonstrated a 5 cm tumour on the left adrenal with suspicion of growth into the left renal vein. Metomidate PET showed a diffuse uptake in the tumour and a suspected lymph node metastasis. Because of the likelihood of malignancy the patient underwent surgery without delay. PAD showed an 8 cm ACC with intravascular growth and a high mitosis rate. Postoperatively, aldosterone levels normalized and the patient received cortisol substitution as well as streptozocin and lysodren treatment. The ACC recurred two years later, now producing sex steroids. Surgery was performed, removing multiple lymph node metastases and a 4 cm tumour. The patient progressed on different cytostatics and passed away 4 years after the initial surgery. Genetic analysis using a high density SNP array was carried out on the primary tumour and the recurring tumour. This showed that relatively few large CNVs occurred during progression. Analysis of PRKACA revealed a p.Pro102Leu mutation in both the primary tumour and the recurrence. This residue is evolutionary conserved and part of a hydrophobic pocket on the PKA protein. Analysis of the CDKN2A gene demonstrated a p.Arg98Gln mutation in both the recurring tumour and the primary tumour. CNV analysis also revealed copy number loss over the CDKN2A locus. No mutations in KCNJ5, ZNRF3, CTNNB1, ATP1A1, ATP2B3 or CACNA1D were observed.

We present the first case of an ACC with both a PRKACA mutation and CDKN2A mutation. Interestingly, the patient presented with both subclinical Cushing syndrome and primary aldosteronism. During progression a few large genetic alterations occurred.

 

Nothing to Disclose: TA, RM, PH, PB

21043 19.0000 SAT-372 A Prkaca and CDKN2A Mutations in a Patient with an Adrenocortical Carcinoma with Subclinical Cushing Syndrome and Primary Aldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Iuri Martin Goemann1, Rafael Machry1, Jorge Luiz Gross2 and Mauro Antonio Czepielewski*1
1Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil, 2Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil

 

Background: Adrenal carcinoma (ADCA) is one of the most aggressive malignant neoplasias. The prognosis is related to stage of the disease at diagnosis and dependent on early institution of therapy. The majority of patients present initially with signs and symptoms of hormonal overproduction (cushing syndrome, hyperandrogenism) or having local symptoms of tumor growth. Lungs are the most common local of metastasis, followed by liver and bones. Others sites are rare in less than 5%. We report a case with atypical presentation of this neoplasia not described in literature previously.  Case Report: A 58-year-old man was evaluated in an outpatient clinic because of progressive proptosis of the left eye. Hertel exophthalmometer values were 8 mm (right eye) and 14 mm (left eye). Computed tomography (CT) of the orbit revealed a left retrobulbar expansive lesion with dislocation of the optic nerve. An open biopsy was performed, which demonstrated a poor differentiated neoplasia with immunohistochemistry staining suggesting a neuroendocrine origin (Ki67  30% and synaptophysin positive). An investigation for cancer of  unknown primary site was started and abdominal CT revealed a 12 cm mass at topography of right adrenal gland invading inferior vena cava. [123I]metaiodo-benzylguanidine (MIBG) scanning showed no abnormal increased radiotracer uptake. Despite the patient had no signs or symptoms of hypercortisolism or androgen excess, hormonal profile revealed a level of ACTH  5 pg/mL, morning cortisol 16,3 mcg/dL, (4-22 mcg/dL), midnight serum cortisol of 14,5 mcg/dL,  24h urinary free cortisol  1014 mcg/24h (28-213 mcg/24h) testosterone 3,36 ng/mL (2,41-8,27 ng/mL), androstenedione > 10 ng/mL (0,6 – 3,1 ng/mL), 17-OH-progesterone 12,4 ng/mL (0,6-3,4 ng/ml), SDHEA 869 mcg/dL (80-560 mcg/L). Abdominal surgery was performed, with incomplete ressection of tumoral mass, since it may prolong survival in some patients. Histopathological examination revealed an ADCA with extensive necrosis. After surgery SDHEA was 27 mcg/dL (80-560 mcg/L), androstenedione 1,55 ng/mL (0,6 – 3,1 ng/mL) and patient was dependent of prednisone 10 mg/day. Mitotane was initiated progressively until 8g/day and prednisone necessity was increased to 30 mg/day with association of fludrocortisone 0.1 mg/day. Patient was referred to orbital radiotherapy. Genetic evaluation is being performed. Discussion: Fifty percent of the diagnosis of ADCA is done at advanced stages – III and IV of European Network for the Study of Adrenal Tumors (ENSAT), reflecting poor prognosis in several patients. Despite advanced disease, our patient had no simptoms other than ocular abnormalities delaying the diagnosis.  The presented case point attention in atypical presentations of the ADCA contributing to anticipate the diagnosis in this situations.  Neoplastic proptosis is a new atipical presentation in the spectrum of the adrenocortical cancer.

 

Disclosure: JLG: Investigator, Boehringer Ingelheim, Investigator, Eli Lilly & Company, Investigator, GlaxoSmithKline, Investigator, Mannkind, Investigator, Novo Nordisk, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Novo Nordisk. Nothing to Disclose: IMG, RM, MAC

21531 20.0000 SAT-373 A Neoplastic Proptosis As Initial Presentation of Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Maria Mercedes Pineyro*, Jimena Pereda, Luciana Sanchez and Raul Pisabarro
Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay

 

Background: Functional adrenal adenomas are usually cortisol or aldosterone secreting in contrast to functional adrenal carcinomas that often present with a combined hypersecretion of androgens and cortisol. Two kinds of virilizing adrenocortical tumors can be distinguished: tumors that produce high levels of dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEAS) and tumors with secretion of testosterone (TT). We present a rare case of a patient with pure testosterone-secreting adrenal adenoma.

Case: A 43 year-old Caucasian female presented with a 6-year history of amenorrhea and virilization. She noted progressive growth of coarse hair in face, abdomen and chest. She gained approximately 30 kg in 4 years. Menarche was at age 13 with regular periods until age 37, when her menses stopped. One year before, se was diagnosed with type 2 diabetes currently treated with metformin, with good glycemic control.  On physical exam, she had a BMI of 53. There was thick, black hair on face, abdomen, back and sacral area, with a modified Ferriman-Galleway Score of 10. She had androgenic temporal alopecia. She had no Cushingoid features. Pelvic exam was normal. Pelvic ultrasound revealed normal uterus and ovaries. Hormonal evaluation disclosed a marked elevated serum total TT of 412 ng/dl (6-82), plus elevated free TT 2.39 ng/ml (<0.04) and androstenedione 6.82 ng/ml (0.3-3.5).   Levels of DHEAS where normal: 36.5 μg/dl (35-430). In addition, a low dexamethasone suppression test showed a cortisol level of 4.1 mg/dl (<5mg/dl). Abdominal CT scan showed a left adrenal tumor measuring about 50 mm, which had a density of 25 Hounsfield units on the precontrast image, and a 25% contrast washout.  Given the high plasma concentration of TT with a normal DHEAS level an ovarian androgen-secreting tumor was suspected so a PET-CT was done. It detected a hypermetabolic left ovary mass as well as an ipsilateral adrenal one. During laparotomy a left annessectomy was performed. Histopathology study revealed normal ovary. Subsequently adrenalectomy was performed and histopathology study revealed a 50x45x40 adrenal adenoma. Serum TT and androstenedione levels dropped to normal after surgery, and remained normal. She noticed regression of her hirsutism. Three months later menses resumed.

Discussion: The most common etiology of virilization with very high TT levels (> 200 ng/dl) and normal DHEAS is an ovarian tumor. Virilizing adrenal tumors are usually malignant, although some benign tumors have been described. In those with production of DHEAS and/or androstenedione, virilizing symptoms ensue after peripheral conversion into TT.  In tumor cells that express TT synthesizing enzymes (3b-HSD,17b-HSD), TT can be generated by the tumors cells. Pure testosterone-secreting adrenal adenomas are very rare, and few cases have been reported.

Conclusion: Basal hormone levels not always precisely distinguish adrenal from ovarian tumors.

 

Nothing to Disclose: MMP, JP, LS, RP

21519 21.0000 SAT-374 A Pure Testosterone-Secreting Adrenal Adenoma: Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Naimah Alfaraj*1, Jamil Addas2 and Sabyasachi Sen3
1George Washington university, washington, DC, 2George Washington University, Alexandria, VA, 3The George Washington University, Washington, DC

 

Introduction:

Primary adrenal carcinoma(ACC) is very rare but has aggressive behavior.  The annual incidence is 1 per 1 million. It is more common in women with female: male ratio of 2.5 : 1. The mean age at onset is between 40 and 50 years, although men tend to be older at presentation. Approximately 50 percent of adult patients with ACC have relatively advanced disease stage. Around 60% of ACC are secretory, 45% will present with Cushing’s syndrome alone, 25% with overproduction of both glucocorticoids and androgens, fewer than 10% with virilization alone. Androgen producing adrenal tumor presents with hirsutism and virilization syndrome.

Clinical case:

41 year old African American female presented to the endocrine clinic because of increasing hirsutism. All her post pubertal life she had fine hair on her face, arms and legs, but 1-2months prior to her presentation she noticed increasing hair growth in her face including cheeks, upper and lower lips. She also had increasing hair on abdomen and pubic area. She gained 50 pounds over 6 months. She had no change in her voice, and no male pattern baldness. Of note, she was started on oral contraceptives one year prior to presentation. She had regular period every month which lasted for 4 days. She had no family history of hirsutism.

Our initial diagnosis was PCOS but a possibility of CAH and adrenal adenoma as differentials. We decided to get androgen biochemistry along with a pelvic ultrasound. She was found to have elevated total testosterone of 368 ng/dl  and DHEA-S of 981 ug/dl, elevated DHEA to 831 ng/dl and elevated androsteinodione of 2070 ng/dl but normal 17-hydroxyprogestrone level. MRI of the abdomen following initial US showed left 11.1 x 10.5 x 8.6 cm adrenocortical mass invading the upper pole of left kidney. She was sent for surgical evaluation.

Conclusion: Hirsutism, defined as excessive male-pattern hair growth, affects between 5-10% of women of reproductive age. The most common causes are benign which includes PCOS and idiopathic hirsutism. However when a female patient presents with acute onset of hirsutism, androgen secreting tumors should be suspected. Total testosterone values above 150 ng/dL should prompt additional evaluation for a testosterone-secreting ovarian or adrenal tumor. DHEA-S above 700mcg/dl indicates that it is adrenal source.

 

Nothing to Disclose: NA, JA, SS

21851 22.0000 SAT-375 A Adrenal Carcinoma Presented As Hirustism in a Young Female 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Joseph Michael Shulan*1, Caroline Chiu2, Adrienne Ruth Barnosky1 and Elena Barengolts3
1The University of Illinois-Chicago Medical Center, Chicago, IL, 2The University of Illinois-Chicago Medical Center, 3University of Illinois at Chicago, Chicago, IL

 

Background: Adrenal tumors are very common affecting 3-10% of the human population however adrenocortical carcinoma (ACC) is extremely rare and believed to have an incidence of 1-2 per million, though valid data is lacking(1). There have been only a handful of reported cases of Deoxycorticosterone (DOC) producing ACC tumors in the literature(2).

Case: A 53 year old male presented to the emergency department (ED) after being sent by his primary care physician for a potassium of 2.6 mmol/L on a routine laboratory draw. Over the previous three months he had developed difficult to control hypertension and was started on amlodipine 10mg and HCTZ 25mg daily. He developed hypokalemia at 2.9 mmol/L and was started on potassium chloride (KCL) which was titrated up to 60mEq daily. He reported about a 40lb unintentional weight loss and night sweats in the previous four months. In the ED, he was found to have a potassium of 2.5mmol/L, a sodium of 143mmol/L and admitted to the hospital for treatment and work up of his hypokalemia. While hospitalized, his serum aldosterone was elevated at 17ng/dL, Plasma renin activity was low at 0.31ng/mL, DHEA-sulfate was low at 69, am cortisol 15.86 with a 24 hour urinary free cortisol of 41.7mcg/24hr. A deoxycorticosterone (DOC) was obtained and found to be elevated at 29 ng/dL. Plasma and urinary metanephrines were both within the normal range. MRI of the abdomen showed a 6.6cm marginated right adrenal mass with heterogenous contrast enhancement with multiple areas of necrosis. Work up for metastastatic disease was unrevealing. He underwent a right sided adrenalectomy with pathology showing a 5.5cm adrenal cortical neoplasm w/ confluent necrosis, mitotic rate of 7/50 HPF, tumor capsular invasion, but tumor confined to the adrenal gland and margins free of disease. His modified Weiss Criteria was 4. He was given the diagnosis of an adrenocortical carnioma Stage 2- T2NxM0. Ki67 staining showed a <10% labeling index. Immediately postoperatively, his potassium was 3.3mmol/L with a sodium of 142mmol/L. He was started on spironolactone 50mcg daily, 20mEq of potassium chloride daily, lisinopril 40mg and amlodipine 10mg daily. Three weeks postoperatively after discontinuation of spironolactone and KCL, his potassium was 4.5mmol/L, aldosterone of 2mg/dL, DOC was <16 ng/dL. Adjuvant therapy was considered, however given the Mitotane's category 3 recommendation from the National Comprehensive Cancer Network guidelines and the side effects, it was decided with the patient not to pursue adjuvant treatment. He is to have surveillance with a CT scan of the chest, abdomen and pelvis as well as a DOC and ACTH every three months.

Conclusion: In patients who present with resistent hypertension and hypokalemia, though without physical manifestations of cortisol excess, suspicion should be high for hormonal overproduction and appropriate screening should be initiated without delay.

 

Nothing to Disclose: JMS, CC, ARB, EB

18305 23.0000 SAT-376 A A Case of a Deoxycorticosterone Producing Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Aung Naing*1, Mouhammed Amir Habra2, Rashmi Chugh3, Marian Ijzerman4, Marianne R Plaunt4, Pharis Mohideen5, Martin D Phillips5, Electron Kebebew6, Jeffrey Russell7, Martin Fassnacht8 and David C Smith9
1MDAnderson Cancer Center, Houston, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3University Of Michigan, Ann Arbor, MI, 4Atterocor, Inc, Ann Arbor, MI, 5Atterocor, Inc., Ann Arbor, MI, 6National Cancer Institute, NIH, Bethesda, MD, 7H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, 8University Hospital Wuerzburg, Wuerzburg, Germany, 9University of Michigan, Ann Arbor, MI

 

ATR-101 (Atterocor, Inc., Ann Arbor, MI, USA) is a selective inhibitor of ACAT1 (acyl coenzyme A:cholesterol acyltransferase) in clinical development for the treatment of adrenocortical carcinoma (ACC).  ACAT1 catalyzes cholesterol ester formation from cholesterol and long-chain fatty acyl-CoA and, in the adrenals, is particularly important in creating a reservoir of substrate for steroid biosynthesis.  ATR-101 selectively distributes to the adrenals, inhibits steroidogenesis and causes apoptosis of cells of the adrenal cortex, as well as in H295R ACC cells.

ACC is an ultra-rare malignancy, occurring in about 2 per million population annually.  ACC is frequently discovered in Stage 4 and the overall disease survival is approximately 17 months.  Tumors often overproduce steroids normally produced in the adrenal cortex and cause therapy-resistant Cushing’s syndrome.  Current therapies are toxic, difficult to administer, and poorly effective. 

ATR-101-001 is a phase 1 study being conducted at four centers in the United States and one in Germany.  It is a “3+3” design: 3 subjects with advanced ACC who have failed or declined existing therapies are enrolled at each dose level for 28 days.  If no Dose Limiting Toxicity is observed, three additional subjects are enrolled at a higher dose.  An expansion cohort of 20 subjects will be enrolled after the MTD has been determined. Subjects who appear to be deriving benefit may stay on ATR-101 indefinitely.  ATR-101 is taken by mouth.  The primary objective is to determine the safety and tolerability of ATR-101 in subjects with advanced ACC.  Secondary objectives include efficacy by RECIST, measurement of production of steroid hormones and intermediates, determination of pharmacokinetics, the Maximum Tolerated Dose and the recommended Phase 2 dose.  The study is open to patients age 18 and over with advanced ACC.  Patient’s mitotane level must be 5 µg/ml or less; the QTcF 470 ms or less; and if present, CNS metastases must be treated and inactive.

Full study information is available on ClinicalTrials.gov, Identifier NCT01898715.

 

Disclosure: MI: Employee, Atterocor, Inc.. MRP: Employee, Atterocor, Inc.. PM: Employee, Atterocor, Inc., Employee, Atterocor, Inc.. MDP: Employee, Atterocor, Inc., Employee, Atterocor, Inc.. MF: Advisory Group Member, Atterocor. Nothing to Disclose: AN, MAH, RC, EK, JR, DCS

21862 24.0000 SAT-377 A ATR-101 Phase 1 Clinical Study for Adrenocortical Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Anna Kasperlik-Załuska1, Andrzej Cichocki2, Maciej Otto3, Elzbieta Roslonowska4, Piotr Zdunowski5, Wojciech Jeske4 and Wojciech Zgliczynski*4
1Medical Centre of Postgraduate Education, Warsaw, Poland, 2M. Sklodowskiej-Curie Memorial Center of Oncology, Warsaw, Poland, Warsaw, Poland, 3Medical University of Warsaw, Warsaw, Poland, 4The Medical Centre of Postgraduate Education, Warsaw, Poland, 5Bielanski Hospital, Warsaw, Poland

 

Background: Mitotane, introduced in the treatment of adrenal cancer over 50 years ago, has been recommended mainly for unresectable or recurrent tumours. At our Department, we decided to administer mitotane shortly after surgery in all patients because of a risk of distant, occult metastases or local remnants.
This study aimed at comparing results of treatment with mitotane introduced within 2 months after surgery with data of patients referred from other endocrinological centers, in whom such treatment was delayed.

Material and Methods: In our registry, started in 1966, there are 253 patients with adrenal cancer, 11 to 81 years old. Between 1967 and 2012; 206 of them (140 women, 66 men), aged 11 – 76 years, were treated by surgery followed by adjuvant mitotane administration, in in 53 cases associated with chemotherapy (cisplatin and etoposide). In 140 patients regional and/or distant invasion was diagnosed. In 131 patients mitotane was given within 2 months after surgery and in 75 patients it was administered with a delay of >2 (till 24) months. A replacement therapy with hydrocortisone and fludrocortisone was administered concominantly.
The doses of mitotane ranged between 2.0 and 4.0 g daily in patients without evidence of invasion; and between 3.0 and 6.0 g in those in stages III and IV according to the MacFarlane classification.

In this study patients with fatal outcome prior or peri-surgery was not included.

Assessments: CT of the abdomen and chest, hormonal determinations (also ACTH and cortisol levels 2 hours after hydrocortisone administration), plasma mitotane (and its metabolites o,p’-DDE and o,p’ DDA in a part of them subpopulation) levels, transaminases , hematology, electrolytes.

Results: In the group treated with mitotane promptly after surgery there were 59 survivors (45%), in this number 19 patients observed >10 years, of whom 9 cases in stage III/IV of the MacFarlane classification. In the group treated with a delay exceeding 2 months after surgery there are only 4 survivors (5%), however in 3 other patients survival time ranged 6 – 11 years. The best results were obtained in patients with higher o,p’-DDE levels and normal ACTH concentration.

Conclusions:

  1. Mitotane given soon after surgery significantly increases the number of survivors in a long-term follow-up.
  2. Better results observed in patients with normal ACTH levels suggest that sufficient doses of hydrocortisone play an important role in the therapy protocol of adrenal cancer during mitotane administration.
  3. Higher mitotane levels were a good prognostic during adjuvant therapy.

 

Nothing to Disclose: AK, AC, MO, ER, PZ, WJ, WZ

20831 25.0000 SAT-378 A Superiority of Prompt Induction of Mitotane Post-Surgery for Adrenal Cancer over Delayed Treatment. 45 Years Experience 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM SAT 354-378 5989 1:00:00 PM Adrenocortical Tumors Poster


Khaled M AlDahmani*1, Churn-Ern Yip2, CHRIS Theriault3, Steve Doucette3, Syed Mohammed3, Fatima Imran3, David B Clarke2 and Syed Ali Imran2
1Tawam Hospital in affliation with Johns Hopkins, Alain, United Arab Emirates, 2Dalhousie University, Halifax, NS, Canada, 3Dalhousie University

 

Background: Sellar masses (SM) are mostly benign growths of pituitary or non-pituitary origin that are increasingly encountered in clinical practice. To date, no comprehensive population-based study has reported the epidemiology of SM from North America. 

Aim:  To determine the epidemiological trends of SM in the Province of Nova Scotia, Canada which has a stable population of about 1 million since 2000.

Methods:  Data from all pituitary-related referrals within the province are prospectively collected in interlinked computerized registries since November 2005. We conducted a retrospective analysis on all patients with SM seen within the Province between November 2005 and December 2013.

 

Results: A total of 1107 patients were identified and of those 1005 patients were alive and residing within the province by December, 2013. The mean age at presentation was 44.6 +/- 18 yrs with an overall female preponderance (62%) and a population prevalence rate of 0.1%. Of patients with SM 838 (83%) had pituitary adenomas and 167 (17%) had non-pituitary lesions.  The relative prevalence and standardized incidence ratio, respectively, of various SM were: nonfunctioning adenomas (38.4%; 2.34), prolactinomas (34.3%; 2.22), Rathke’s cyst (6.5%; 0.5), acromegaly (6.5%; 0.3), craniopharyngiomas (4.5%; 0.2), ACTH adenomas (3.8%; 0.2), meningiomas (1.9%) and others (3.9%; 0.21). At presentation 526 (52.3%) had masses > 1 cm, 318 (31.6%) with < 1 cm, 11 (1.1%) had no discernible tumour whereas tumour size data were unavailable in 150 (14.9%) patients. The commonest presenting features were: non-functioning adenoma (incidental, headaches and vision loss), prolactinomas (galactorrhea, menstrual irregularity and headache), acromegaly (enlarging extremeties and sweating), ACTH adenoma (easy bruising, muscle wasting and weight gain) and non-pituitary lesions (incidental, headaches and vision problems). Secondary hormonal deficiencies were common ranging from 19.6% - 65.7%) across different SM of which secondary hypogonadism, hypothyroidism and growth hormone deficiencies constituted the majority of hormonal abnormalities.

Conclusion: This is the largest North American study to date that assessed the epidemiology of SM in a large stable population.  The current data and the subsequent analysis will help us determine the appropriate approach to SM and allocate appropriate resources to their management.  

 

Nothing to Disclose: KMA, CEY, CT, SD, SM, FI, DBC, SAI

19843 1.0000 SAT-490 A Epidemiology of Sellar Masses in Province of Nova Scotia, Canada 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Tomas Thor Agustsson*1, Tinna Baldvinsdottir2, Márta Korbonits3, Paul V Carroll4, Jon G Jonasson2, Elinborg Olafsdottir5, Gunnar Sigurdsson2, Arni V Thorsson2 and Rafn Benediktsson1
1The University of Iceland, Reykjavik, Iceland, 2Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland, 3Barts and the London School of Medicine, London, United Kingdom, 4Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom, 5The Icelandic Cancer Registry, Reykjavik, Iceland

 

Introduction

Pituitary tumours are amongst the most common human neoplasm. Intensive population-based studies are needed to describe the epidemiology and assess the true disease burden of clinically significant pituitary tumours.  Iceland has a small well-defined population with easy access to clinical information.  The aim of this study is to describe the epidemiology of pituitary tumours in Iceland over an expanded period of time.

 

Patients and Methods

This is a retrospective observational study. All patients diagnosed with a pituitary tumour in Iceland between 1955-2012 were included. Extensive clinical information was gathered in a database.  Prevalence rates for all tumour subtypes were calculated along with standardized incidence rates (SIR). Sex ratios and relationships with tumour size, age, and symptoms were assessed.

Results

We identified 471 individuals, 190 men and 281 women.  Total prevalence in 2012 was 115.57/100,000, prolactinomas were most prevalent (54.37/100,000) followed by NFPAs (41.32/100,000), acromegaly (13.67/100,000), and Cushing´s disease (6.21/100,000).  Median age was 44 years and has not changed significantly.  Over the whole period NFPAs were most commonly diagnosed (43.0%) followed by prolactinomas (39.9%).  11.3% had acromegaly, and 5.7% Cushing´s Disease.  Women are diagnosed younger (median age: 37 years vs. 54 for men) with smaller tumours.  Macroadenomas were more common than microadenomas and present at a significantly higher age. Total SIR has increased significantly and is now 5.8/100,000/year compared with 0.6/100,000/year for the first years.  The peak SIR for women is at the age of 35-39 and at the age 70-74 for men. A minority of patients presented incidentally (16.1%).  The SIR for incidentally found tumours has risen in the last decades, but significantly less than for symptomatic tumours.

 

Conclusion

In this nation-wide epidemiological study on pituitary tumours spanning almost six decades we have confirmed their rising prevalence rates and standardized incidence rates noted in recent studies.  We found higher overall prevalence rates and incidences rate compared with previous studies, which is not explained by incidental findings.  There is a chronological relationship with the introduction of imaging modalities, but the vast majority of patients are symptomatic having appropriate investigations.  It is interesting to note that the prevalence in Iceland is now nearing half that of other much more recognized conditions, such as Type 1 Diabetes Mellitus.Higher prevalence and incidence rates underline the importance of increased awareness and education of all health care providers along with appropriate allocation of resources.

 

Nothing to Disclose: TTA, TB, MK, PVC, JGJ, EO, GS, AVT, RB

20888 2.0000 SAT-491 A The Epidemiology of Pituitary Tumours in Iceland 1955-2012: A Nation-Wide Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Andre Lacroix*1, Feng Gu2, Jochen Schopohl3, William H Ludlam4, Albert Kandra5, Alberto M Pedroncelli5, Karina Hermosillo Reséndiz4 and Rosario Pivonello6
1Centre de Recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada, 2Ministry of Health, Peking Union Medical College Hospital, Beijing, China, 3Ludwig-Maximilians University Munich, Munich, Germany, 4Novartis Pharmaceuticals Corporation, East Hanover, NJ, 5Novartis Pharma AG, Basel, Switzerland, 6Federico II University, Naples, Italy

 

Background: In a phase III study, pasireotide, a second-generation, multireceptor-targeted somatostatin analog, demonstrated significant decreases in urinary-free cortisol (UFC) levels and clinical signs of disease in patients with CD following SC BID administration (1, 2). At 6 months, 26% and 15% of patients treated with pasireotide SC 900 μg and 600 μg BID, respectively, had UFC levels at or below the upper limit of normal and were considered responders. Additionally, mean percentage reductions in tumor volume of 43.8% and 9.1% were observed in patients treated with pasireotide 900 μg and 600 μg, respectively, at 12 months (1).

Objective: We analyzed the effects of pasireotide SC on tumor volume reduction by randomized dose in patients enrolled in the phase III study who had measurable tumors at baseline on MRI.

Methods: Adenoma size was assessed by MRI at baseline and at months 6 and 12 (or at study drug discontinuation) and evaluated by a central reader.

Results: 28 patients in the pasireotide SC 900 μg group at 6 months had measurable tumor volume at baseline; 11 (39%) were UFC responders. After six months of treatment, 21 (75%) tumors decreased and 7 increased in size. Sixteen (57%) had reductions in tumor volume of ≥20%; 7 of the 16 (44%) were UFC responders. By contrast, only 5 patients (18%) had an increase in tumor volume of ≥20%; 1 (20%) was a UFC responder. There was no relationship noted between adenoma size at baseline and change of tumor size: of 13 tumors that were ≥0.2 cc at baseline, 10 (77%) had decreases in volume. Similarly, of 15 tumors that were <0.2 cc at baseline, 11 (73%) had a decrease in volume.

Tumor volume reduction was observed less frequently in the pasireotide SC 600 μg group. This may have, in part, been due to the very low number of responders in the sub group with measurable tumor volume. 25 patients in the 600-μg group at 6 months had measurable tumor volume at baseline; only 1 (4%) was a UFC responder. Overall, 11 of 25 tumors (44%) decreased in size and 14 (56%) increased in size. Four of 25 patients (16%) had reductions in tumor volume ≥20%, with no UFC responders. Ten (40%) had an increase in tumor volume ≥20%; with no UFC responders. Of 16 tumors that were ≥0.2 cc at baseline, 5 (31%) had a decrease in tumor volume. Of 9 tumors that were <0.2 cc at baseline, 6 (67%) had a decrease in tumor volume.   

Similar trends in tumor volume were observed for the 600-μg and 900-μg pasireotide SC groups at 12 months.

Conclusion: Our results demonstrate a measurable decrease in pituitary tumor volume in patients with CD who were treated with pasireotide SC 900 μg. There was no relationship noted between adenoma size at baseline and extent of tumor volume change in response to therapy.

 

Disclosure: AL: Speaker, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Medical Advisory Board Member, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals, Clinical Researcher, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals. FG: Principal Investigator, Ipsen, Speaker, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Speaker, Ipsen. JS: Lecturer, Ipsen, Lecturer, Pfizer, Inc., Researcher, Novartis Pharmaceuticals, Researcher, Ipsen, Researcher, Pfizer, Inc., Medical Advisory Board Member, Novartis Pharmaceuticals, Medical Advisory Board Member, Ipsen, Lecturer, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. AK: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. AMP: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. KH: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. RP: Principal Investigator, Hra pharma, Speaker, Shire, Speaker, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Consultant, Viropharma, Clinical Researcher, Viropharma, Coinvestigator, Novartis Pharmaceuticals, Principal Investigator, Novartis Pharmaceuticals, Coinvestigator, Ipsen.

21201 3.0000 SAT-492 A Tumor Volume Reduction in Patients with Cushing's Disease Treated with Pasireotide 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Maria Forsgren*1, Caroline Alkebro2, Margareta Lindgren3, Ann-Sofie Nilsson4, Helena Wiik5, Maria Wärn6 and Christina Dahlgren7
1Uppsala University Hospital, 2Örebro University Hospital, 3Norrlands University Hospital, 4Skåne University Hospital, 5Sahlgrenska University Hospital, Gothenburg, 6Karolinska University Hospital, Stockholm, 7Linköping University Hospital

 

The Swedish Pituitary Registry is a national quality registry founded in 1991 by the Swedish Pituitary Group. The purpose of the registry is to guarantee that all patients with pituitary diseases get equivalent evaluation and treatment, as well as a tool to evaluate given therapy. Since 2011 quality of life (EQ-5D) and sick leave are included. The total degree of sick leave in the Swedish general working population, 2013, was <5%, Statistics Sweden (SCB).

Mapping Quality of Life (EQ-5D) and sick leave in patients with pituitary tumors 1, 5 and 10 years after diagnosis in the Swedish Pituitary Registry.

Data from 693 EQ-5D and Visual Analogue Scale (VAS, 0-100) forms including sick leave (19% Acromegaly, 7% Mb Cushing, 45% Non Function Pituitary Adenoma (NFPA) and 29% Prolactinoma) registered 2011-2014 were evaluated. Selected variables are anxiety, pain and mobility as they are the most relevant for these patients.

Acromegaly: More than half had experience of pain after 1, 5 and 10 years. The degree of sick leave was the same (14%) after 1 and 5 years but higher (22%) after 10 years. Reduced mobility was evident for 26% of the patients after 1 and 10 years, and for 16% after 5 years. Patients experienced more anxiety after 5 and 10 years (30%) compared to 1 year (25%). VAS 80 was the same after 1, 5 and 10 years.

Mb Cushing: The degree of sick leave has a marked increase after 10 years (62%) compared to 1 (22%) and 5 years (36%). The pattern regarding pain shows highest degree after 10 years (78%) but high values are also observed after 1 (69%) as well as after 5 years (67%). Reduced mobility is somewhat higher after 10 years (42%) compared to 1 and 5 years (36-37%). Patients experienced more anxiety after 5 (64%) than after 1 and 10 years (56%). VAS (66-68-60) was lowest 10 years after diagnosis.

NFPA: Half are retired. The sick leave after 1 year (16%) increases to 23% after 5 and 29% after 10 years. The level of pain increases with time after diagnosis from 33% after 1 year to 42% after 5 and 45% after 10 years. Anxiety level is similar after 1 year, through 5 and 10 years after diagnosis (25-28%). VAS is also stationary at 80.

Prolactinoma: Less than 10% have problems with mobility. Anxiety level is high (47%) after 1 year but slightly lower after 5 and 10 years (33%). Pain is reported by 40% of the patients after 1, 5 and 10 years. Men feel worse than women after 1 and 5 years but feel better after 10 years. Low sick leave degree (<10% for both genders) apart from men after 5 years (24%). VAS is constant 80 after 1, 5 and 10 years.

Patients with pituitary tumors in the registry have a high rate of experience with anxiety and pain. The sick leave levels are also higher compared to the Swedish general working population. Despite that, VAS is high estimated in the registry apart from Mb Cushing who have the highest sick leave levels and also most low rated VAS.

 

Nothing to Disclose: MF, CA, ML, ASN, HW, MW, CD

20421 4.0000 SAT-493 A Quality of Life and Sick Leave in Patients with Pituitary Tumors in the Swedish Pituitary Registry 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Philip C. Johnston*1, Laurence Kennedy2, Amir H Hamrahian2, James Bena2 and Robert J Weil3
1Royal Victoria Hospital, Belfast, Ireland, 2Cleveland Clinic Foundation, Cleveland, OH, 3Geisinger Health System, Danville, PA

 

Background Cushing disease (CD) is usually associated with alterations in body mass index. Successful pituitary surgery can result in long term remission with sustained weight loss. We wished to determine rates of body weight changes (in the post-operative period within 6 months) in patients with active CD who underwent transsphenoidal surgery and the relationship of weight loss to remission status

Methods Clinical data was obtained from a CD database in addition to the online patient medical record. All patients with biochemically confirmed active CD underwent their first transsphenoidal surgery (TSS) by a single neurosurgeon (RJW) at the Cleveland Clinic between October 2004 and August 2013. None of the patients received glucocorticoids during surgery. Initial remission was defined by nadir cortisol <5 µg/dl, ACTH <5 pg/ml within the immediate post-operative period (72 hrs). Long term remission was defined as 24 hr UFC < ULN (upper limit of normal), and/or sequential midnight salivary cortisols <ULN, and 1mg DST cortisol <1.8 µg/dl. Statistical analyses wer performed using SAS software (Version 9.2;Cary, NC).

Results Data was available for 88 patients (F:63,M:25), mean age at presentation was 47 years (range 24-87 years), median follow up 52 months (12-118 months). No significant differences in baseline demographics including pituitary adenoma size (p=0.25) and BMI (p=0.21) were observed between the two groups. 64 had no visible tumor or pituitary microadenoma, 24 were macroadenoma, 74 (84%) patients had initial remission after surgery, during follow up 6 of those with initial remission had recurrence of CS. Those with initial remission had greater mean ± SD weight loss at 3 months (kg:-8.1 ± 11.3 [initial remission, n=59] v 0.8 ± 8.8 [non-remission, n=12], p=0.007) and at 6 months (kg:-14.5 ± 12.1 [initial remission, n=46] v -6.1 ± 12.1 [non-remission, n=12], p=0.045). There was evidence that less weight loss or weight gain at three (p=0.002) and six (p=0.014) months was associated with increased risk of relapse.

Conclusions After transsphenoidal surgery for CD, weight loss within the first six months is an additional early clinical indicator associated with initial biochemical remission.

 

Disclosure: AHH: Principal Investigator, Novo Nordisk, Consultant, Versartis. Nothing to Disclose: PCJ, LK, JB, RJW

21696 5.0000 SAT-494 A Initial Weight Loss after Transsphenoidal Surgery for Cushing Disease May be an Additional Clinical Indicator of Early Remission 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Mazhar Dalvi1, Brian R Walker2, Mark W J Strachan3, Nicola Zammitt3 and Fraser W Gibb*3
1Edinburgh Centre for Endocrinology and Diabetes, Edinburgh, United Kingdom, 2University of Edinburgh, Edinburgh, United Kingdom, 3Edinburgh Centre for Endocrinology & Diabetes, Edinburgh, United Kingdom

 

Testosterone deficiency is an increasingly common reason for referral to specialist endocrine services; disproportionately affecting older men, particularly those with T2DM or obesity.  Endocrine Society guidelines suggest anterior pituitary function testing and pituitary imaging can be reserved for those with morning total testosterone (TT) levels less than 5.2 nmol/L, based largely on relatively small cases series (1). 

 Our center has maintained pituitary imaging and function testing at higher TT levels than those suggested by Endocrine Society guidelines.  We retrospectively reviewed the presenting features, biochemistry and pituitary imaging of 281 consecutively presenting men with hypogonadotrophic hypogonadism (TT <10 nmol/L and LH < 10mU/L) and normal serum prolactin concentration. 

 From this cohort of 281 (median age 53 y [IQR 16], median BMI 30.0 kg/m2[IQR 6] and median TT  6.2 nmol/L [IQR 3]), we identified 4 macroadenomas (presenting TT: 7.7, 6.4, 0.5 and 7.9 nmol/L), 1 craniopharyngioma (presenting TT <0.3 nmol/L), 26 microadenomas and 6 patients with ‘empty sella syndrome’.  All patients with abnormal imaging had otherwise normal anterior pituitary function.  In total, 7 patients failed to achieve an appropriate cortisol response to ACTH stimulation; 6 of these patients were on opioid analgesia, all had normal pituitary imaging and in 2 cases repeat testing was normal. 

 Reduced libido, but not erectile dysfunction, was associated with differences in TT concentration at presentation (median difference -0.8 nmol/L, p 0.022).  Longer duration of symptoms was positively correlated with TT (R 0.136, p 0.023).  BMI was negatively correlated with TT (R -0.197, p 0.001), but not calculated free testosterone or SHBG.  Cigarette smokers had significantly lower TT than non-smokers (median difference -1 nmol/L, p 0.001).  Patients with T2DM had significantly lower TT (median difference -1 nmol/L) than non-diabetic men.  There was no significant association between age at presentation and TT, although SHBG was positively correlated with age (R 0.161, p 0.012). 

 The prevalence of incidental pituitary macroadenoma on MRI is approximately 0.2% (2); here, it was at least 1.7%.  Following current Endocrine Society guidelines would have prompted imaging in only 2 of 5 patients with significant pituitary pathology in this series.  It is debatable whether the additional expense associated with more use of pituitary imaging represents effective use of resources.

 

Nothing to Disclose: MD, BRW, MWJS, NZ, FWG

20550 6.0000 SAT-495 A Pituitary Pathology and Abnormal Anterior Pituitary Function in Men Presenting with Hypogonadotrophic Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Sabrina Chiloiro*1, Antonio Bianchi1, Antonella Giampietro2, Francesca Lugli2, Marilda Mormando1, Serena Piacentini2, Carmelo Anile2, Giulio Maira2, Francesco Doglietto3, Libero Lauriola2, Guido Rindi2, Alfredo Pontecorvi1 and Laura De Marinis2
1Catholic University of the Sacred Heart, Rome, Italy, 2Università Cattolica del Sacro Cuore, Rome, Italy, 3University of Brescia, Brescia, Italy

 

Introduction: Pituitary adenomas (PAs) are characterized by a variable biological behavior. It is difficult to predict progression potential and recurrence risk (RR) at diagnosis. In each functional PA subtypes, we investigated how neurosurgery outcome (NO) and recurrence should be influenced by p53, Cam5.2, Ki-67, immunohistochemical hormone (IHC) expression and tumor invasiveness.

Patients ant methods: A retrospective observational study was conducted on a series of consecutive PA referred to the Hypothalamic-Pituitary Disease Unit at Catholic University of Rome in the last 10-years. All patients underwent neurosurgery at the Department of Neurosurgery of the same institution. During the preoperative period and periodically during postoperative follow-up, all patients performed endocrine evaluation of the hypothalamic-pituitary function, ophthalmologic and neuroradiological examinations. Tissue specimens were examined for anterior pituitary hormones, p53, Cam 5.2 by immunohistochemistry and for proliferative activity by anti-Ki-67 monoclonal antibody. To compare qualitative variable Fisher exact test was applied. To assess the ability of Ki-67 to discriminate between patients who were going to develop a recurrence and those who were not, a ROC-curve was constructed with respect to patients who underwent a radical excision only. The cut-off point that had the optimal values for sensitivity and specificity was identified with respect to ROC curve.

Results: We analyzed data from 283 consecutive PAs (98 non-functioning PAs –NFPAs; 26 ACTH-secreting PAs –-ACTH-omas; 101 GH-secreting PAs –GH-omas and 58 PRL-secreting Pas-PRL-omas). In all PA subtypes reported in this series, IHC, p53 and Cam 5,2 expression did not correlate with SO and RR. PA dimension at diagnosis (macroadenoma) correlated with higher risk of partial neurosurgery in ACTH-omas and in PRL-omas (respectively p:0.02, OR: 15, 95%IC: 1.4-161 and p:0.02, OR: 15, 95%IC: 1.4-161). Tumor cavernous sinus extension correlated to higher risk of partial neurosurgery in NFPAs (p:0.001, OR: 4.47, 95%IC: 1.8-10.8), ACTH-omas (p=0.008 OR: 32, 95%IC: 2.29-447.8), GH-omas (p=0.03 OR: 8.2, 95%IC: 1.3-51.32) and PRL-omas (p=0.01 OR: 7.00 95%IC: 1.5-31.5). Optimal cut-off value to predict RR was identified at Ki-67 1.5% (p:0.004, area under the ROC curve (AUC): 0.6, 95%IC 0.4-0.78, sensitivity 43% and specifity 28%) in NFPAs, at Ki-67 2.5% (p:0.01, AUC: 0.88, 95%IC 0.4-0.78, sen. 80% and spec. 13%) in ACTH-omas and at Ki-67 1.5% (p:0.004, AUC: 0.72, 95%IC 0.5-0.88, sen. 92% and spec. 41%) in PRL-omas. As the area under the ROC curve was 0.53 (95% CI: 0.37 – 0.69) we failed to identify a Ki-67 optimal cut-off value for predicting RR, in GH-omas.

Conclusion: Our study suggest that according to PA functional subtypes, tumor cavernous sinus extension and Ki-67 expression seem useful to predict neurosurgery outcome and recurrence risk.

 

Disclosure: LD: Research Funding, Novartis Pharmaceuticals. Nothing to Disclose: SC, AB, AG, FL, MM, SP, CA, GM, FD, LL, GR, AP

21822 7.0000 SAT-496 A Tumor Cavernous Sinus Invasion and KI-67 As Markers of Neurosurgery Outcome and Recurrence Risk in a Single-Centre Pituitary Adenoma Series 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Gustavo Varela*1, Nicolás Picón2, Karina Danilowicz3, Marcos Manavela2, Graciela Elvira Arebalo de Cross4 and Oscar Domingo Bruno2
1Hospital de Clínicas “José de San Martín”. Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina, 2Hospital de Clínicas “José de San Martín”. Universidad de Buenos Aires., Buenos Aires, Argentina, 3Hospital de Clinicas, Buenos Aires, Argentina, 4Hospital de Clínicas “José de San Martín”. Universidad de Buenos Aires., Buenos Aires CF, Argentina

 

Introduction:

Non-functioning pituitary adenomas (NFPA) represent 30% of all pituitary tumors. Pituitary surgery (PS) is the first-line of treatment especially in macroadenomas (M) contacting the optic chiasm. Dopaminergic agonists (DA) have been mentioned as an option of medical treatment for postsurgical remnants.

Objective:

Our objective was analyze and compare the evolution of a group of patients with NFPA-M treated with cabergoline (CBG) as primary therapy, a group followed without treatment and a group that underwent PS.

Methods:

Among 1256 patients registered with neuroendocrine diseases, 925 pituitary adenomas were identified. 236 were due to NFPA (25.2%). We retrospectively analyzed the medical records, between 1992 - 2013, of those patients with NFPA-M (n= 82) with at least six months of follow-up (FU) and divided them in 3 groups: 1 (n=10) with primary medical treatment with DA, 2 (n=14) who received no treatment and 3 (n= 58) underwent PS.

Results:

Group 1 received CBG, range dose 0.5 to 2 mg/week, during a mean time of 24 months (6 to 54). Basally and after treatment, central hypogonadism (CH) was detected in 37.5% and 42.9%, low IGF1 in 50% and 37.5%, central hypothyroidism (H) 10% and 10%, and mild hyperprolactinemia (HPRL) in 87% and 25% respectively. None had secondary adrenal insufficiency (AI). The majority (90%) of patients had stable tumor or decreased after treatment (p= <0.001). 30% presented a decrease in size while 1 patient (7.1%) presented an increase. Basally, 30% had minimal visual abnormalities. All the patients showed stability on visual field (VF) examination or improved in 2 (p= 0.005).

In group 2 basal and FU biochemical evaluation showed CH in 25% and 14.3%, low IGF1 in 20% and 25%, AI in 16% and 14.3%, H 8.3% and 10%, and mild HPRL in 14.5% and 12.5% respectively. 92.9% of the tumors remained stable or decreased in 1 case on FU (p= <0.001). Basally, 35.7% had minimal visual abnormalities. All the patients showed stability on VF examination or improvement observed in 1 (p=0.005). The case with tumor shrinkage was due to apoplexy.

In group 3, biochemical evaluation basally and after surgery showed CH in 51.9% and 66.1%, low IGF1 in 29.4% and 48.6%, AI in 14.5% and 52.6%, H 19.2% and 56.4%, mild HPRL in 40.4% and 22.2% respectively and permanent diabetes insipidus after surgery in 6.9%. We observed a statistically significant difference in corticotroph and thyroid axis postsurgery (95%CI). 91.4% of the tumors remained stable or decreased (p= <0.001). 8.6% had a regrowth. Basally, 88.9% had visual abnormalities. 93.1% showed stability on VF examination or improvement (p= <0.001).

Conclusions:

We conclude that in NFPA primary medical therapy with CBG might be an option in those M without VF abnormalities, showing in 30% of the cases a decrease on tumor size. Surgery is the main treatment for reducing the tumor mass in the NFPA; however accompanied with more post-surgical deficits pituitary.

 

Disclosure: MM: Medical Advisory Board Member, Novartis Pharmaceuticals. Nothing to Disclose: GV, NP, KD, GEA, ODB

21761 8.0000 SAT-497 A Dopaminergic Agonists in Non-Functioning Pituitary Macroadenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Kosuke Mukai*1, Tetsuhiro Kitamura1, Daisuke Tamada1, Masahiko Murata1, Yukiko Tabuchi1, Toshiharu Onodera1, Yosuke Okuno1, Atsunori Fukuhara1, Satoru Oshino1, Youichi Saitoh1, Eiichi Morii1, Toshimitsu Hamasaki2, Michio Otsuki1 and Ichiro Shimomura1
1Osaka University Graduate School of Medicine, Suita, Japan, 2National Cerebral and Cardiovascular Center, Suita, Japan

 

Background: The differential diagnosis between prolactinoma (PRLoma) and non-functional pituitary adenoma (NFPA) with hyperprolactinemia (hyperPRL) is often difficult because both clinical features are similar, such as hyperPRL and the existence of pituitary tumor. There is no information about the relationship between serum basal prolactin (PRL) level and its tumor size in NFPA, while there is a positive correlation between basal PRL levels and its tumor size in PRLoma. With regards to the diagnosis of PRLoma, some reports suggested that the test of PRL secretory capacity such as TRH stimulation test is not useful. At present, we do not have precise diagnostic criteria to distinguish NFPAs with hyperPRL from PRLoma especially in mild to moderate hyperPRL. Therefore the treatment strategy for hyperPRL is not always the best.

Objective: To evaluate the clinical significance of basal serum PRL levels and its tumor size for the differential diagnosis between NFPA with hyperPRL and PRLoma. Methods: We examined basal serum PRL, tumor size and PRL secretory capacity by TRH stimulation test in patients with NFPA (n=39) and PRLoma (n=25) diagnosed by immunohistochemistry of PRL retrospectively. Tumor size was evaluated using a maximum diameter of tumor in MRI coronal section images.

Results: Tumor size was positively correlated with basal serum PRL levels in PRLoma (r = 0.43, P = 0.03), but not in NFPA. The median tumor sizes of NFPA patients with hyperPRL were ranged from 20 mm to 40 mm. In patients with NFPA, tumor size was negatively correlated with Δserum PRL levels (Δserum PRL level = peak serum PRL level – basal serum PRL level in TRH stimulation test) (r = -0.49, P < 0.005) while they were positively correlated with Δserum PRL levels in patients with PRLoma (r = 0.65, P < 0.005). Receiver operating characteristic curve analysis was performed using NFPA patients with hyperPRL (n = 11) and PRLoma (n = 25) in order to decide basal PRL levels and basal PRL levels/tumor size to diagnose PRLoma. The cut-off values of basal serum PRL levels and basal serum PRL level/tumor size were 73.9 ng/ml (sensitivity 88 %, specificity 100 %) and 3.9 (ng/ml)/mm (sensitivity 100 %, specificity 100 %) respectively. Finally PRL secretory capacity by TRH stimulation test in patients with hyperPRL was examined. There was not any significant difference in medium value of Δserum PRL levels between NFPA and PRLoma (25.4 ng/ml and 21.9 ng/ml, respectively).

Conclusions: We elucidated that the tumor sizes of NFPA patients with hyperPRL were ranged from 20 mm to 40 mm. This result indicated that PRL secretory capacity in NFPA declined if its tumor size was more than 40 mm. The present data suggest that measurement of basal serum PRL levels and basal serum PRL level/tumor size would become new strategy for differential diagnosis between NPFA and PRLoma.

 

Nothing to Disclose: KM, TK, DT, MM, YT, TO, YO, AF, SO, YS, EM, TH, MO, IS

19827 9.0000 SAT-498 A New Strategy for Differential Diagnosis Between Non-Functional Pituitary Adenoma and Prolactinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Seunghee Han*1, Cheol Ryong Ku2, Se Hee Park2, Sun Ho Kim2 and Eun Jig Lee3
1Yonsei University College of Medicine, Seoul, 2Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 3Yonsei University College of Medicine, Korea, Republic of (South)

 

Objective: Inferior petrosal sinus sampling (IPSS) is a very useful test to differentiate the Cushing’s disease from ectopic ACTH secreting neuroendocrine tumor. Although corticotropin releasing (CRH) is widely used stimulator during IPSS in patients with ACTH dependent Cushing syndrome, it is frequently unavailable due to the matter of manufacturer and expensive. In this study, we compared the stimulatory effects of desmopressin with those of CRH during IPSS.

Method: Basal ACTH level and post-stimulatory ACTH level during 15 min after CRH or desmopressin injection were analyzed. During IPSS, each ACTH was collected from peripheral, both interpetrosal, and both jugular venous sampling. Furthermore, inferior petrosal venous sampled (IPS) ACTH was normalized with prolactin. Thirty six patients with Cushing’s disease and 4 patients with simple obesity participated in this study.

Result: Among 36 patients with Cushing’s disease, stimulators during IPSS were injected in 27 patients with CRH and 9 subjects with desmopressin. There were no differences in age, sex, tumor size, basal ACTH, and 24hr urine cortisol between patients with each stimulatory agent. During IPSS, each stimulator showed the similar results in peak IPS ACTH level (1653 pg/mL; 821~2435 pg/mL vs. 1862 pg/mL; 1621~8571 pg/mL; median; interquartile range), IPS : peripheral ratio (19.5; 11.2~34.8 vs. 33.7; 20.5~58.6; median; interquartile range), and normalized ACTH/prolactin IPS : peripheral ratio (5.8; 8.2~10.8 vs. 19.8; 6.5~24.8; median; interquartile range). Furthermore, patients with simple obesity showed the similar IPS : peripheral ratio and normalized ACTH/prolactin IPS : peripheral ratiowith those of Cushing’s disease. In tumor localization, MRI showed the more accurate predictive value than IPSS (86.7% vs. 58.3%; P=0.037, respectively). However, there was no difference between each stimulator in prediction for tumor localization (75.0% and 50.0% in CRH and desmopressin, respectively).

Conclusion: Desmopressin showed the similar stimulatory effect compared with CRH. Further analysis should be needed with larger number of patients to evaluate the effects of desmopressin in IPSS.

 

Nothing to Disclose: SH, CRK, SHP, SHK, EJL

20369 10.0000 SAT-499 A Comparison of Corticotropin Releasing Hormone and Desmopressin As Stimulators in Inferior Petrosal Sinus Sampling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Abd Moain Abu Dabrh*, Alaa Al Nofal, Naykky Maruquel Singh Ospina, Wigdan H Farah, Maria Sarigianni, Arya Mohabbat, Barbara Gisella Carranza Leon, Khalid Benkhadra, Patricia Barrionuevo Moreno, Zhen Wang, Victor M Montori and Mohammad Hassan Murad
Mayo Clinic, Rochester, MN

 

BACKGROUND: Adult patients with Cushing’s disease are usually treated with surgery as a first-line treatment but biochemical remission and recurrence rates, and factors that might influence them are still unclear.

OBJECTIVE:  We conducted a systematic review and meta-analysis to synthesize the existing evidence about the efficacy of first-line Transsphenoidal surgery (TSS) in adult patients with Cushing’s disease.

METHODS:  We performed a comprehensive search in multiple databases, including Medline, EMBASE, and Scopus from early inception through July 2014. We included original controlled and non-controlled studies that enrolled adult patients (>18 years old) with Cushing’s disease and reported biochemical remission and recurrence. We pooled outcomes using the random-effects model and used the Altman and Bland test to conduct subgroup analysis. Because of the noncomparative nature of the included studies, we modified the Newcastle-Ottawa Scale to assess the risk of bias.

RESULTS: The final search yielded 30 studies enrolling 2142 patients. Remission rate in treatment-naïve patients with Cushing’s disease after TSS was 71% (64-79%) at the longest study follow up period. Higher remission rates after surgery were observed in patients with smaller adenoma size (microadenoma vs macroadenoma; 0.89 vs. 0.67, p < 0.01). None of the other evaluated variables, including gender, length of follow-up period, tumor-localization using MRI, ACTH-tumor histology, center experience and surgeon experience, predicted remission rate. Recurrence rate after TSS was 13% (8-21%) at the longest follow up period of the studies. None of the evaluated variables predicted recurrence rate.  The quality of this evidence was very low due to high heterogeneity, imprecision and high risk of bias.

CONCLUSIONS: In adult patients with Cushing’s disease, TSS is an effective first-line treatment. TSS is associated with low recurrence rate and high remission rate, especially in patients with microadenoma. The available literature does not support other predictors of good outcome.

 

Nothing to Disclose: AMA, AA, NMS, WHF, MS, AM, BGC, KB, PB, ZW, VMM, MHM

19991 11.0000 SAT-500 A Transsphenoidal Surgery in Adults with Cushing's Disease: Systematic Review and Meta-Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Leandro Kasuki*1, Nina Ventura1, Luiz Eduardo Wildemberg1, Paulo José de Mata1, Paulo Niemeyer1, Emerson L. Gasparetto2 and Mônica R. Gadelha3
1Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil, 2Instituto Estadual do Cérebro Paulo Niemeyer, 3Instituto Estadual do Cerebro Paulo Niemeyer, Rio de Janeiro, Brazil

 

Background: Pituitary microincidentalomas (< 10 mm) can be found in about 10-20% of brain computed tomography; however, pituitary macroincidentalomas (≥ 10 mm) are rarer (0.2%) (1). As the latter are more prone to have clinical consequences (2), it is important to acknowledge the frequency of these macroincidentalomas in patients submitted to magnetic resonance imaging (MRI), which is a technic with higher resolution. No study has evaluated its prevalence in brain MRIs in the Brazilian multiethnic population.

Aim: To evaluate the prevalence of pituitary macroincidentalomas in brain MRIs done for symptoms unrelated to the pituitary in a reference center in Brazil.

Methods: Retrospective evaluation of all brain MRIs performed from March to August 2014 in a neuroradiology reference center in Brazil. Patients were referred to our center from public units in the State of Rio de Janeiro (mainly primary care units). Images were obtained with a 1.5-tesla GE 450w Optima scanner, using the standard 8-channel phased-array head coil. The conventional MRI protocol included: axial fluid attenuation inversion recovery (FLAIR), sagittal T1-weighted-images, coronal T2-weighted-images, axial diffusion-weighted-images (DWI) and gadolinium-enhanced axial and coronal T1-weighted sequences. Subjects’ heads were stabilized with tape across the forehead and padding around the sides. Images were independently evaluated by a neuroendocrinologist and a neuroradiologist, both blinded to the clinical data.

Results: A total of 1097 brain MRIs were reviewed. Pituitary macroincidentalomas were found in six patients (0.55%).  Two were cystic lesions and four were solid lesions.  MRIs were ordered due to: seizures in two patients; memory loss in one patient; dizziness in one patient; headache in one patient and during an evaluation of an adenoid tumor in one patient.  There was 100% agreement between the two reviewers. All six patients were females and median age was 46 years (range: 21 – 65 years). Median maximal tumor diameter was 13.3 mm (range: 10.0 – 29.0 mm) and tumor volume was 8.4 mm3 (range: 3.1 – 43.7 mm3).

Conclusion: Macroincidentalomas can be incidentally found in 0.55% of brain MRIs.

 

Nothing to Disclose: LK, NV, LEW, PJD, PN, ELG, MRG

21273 12.0000 SAT-501 A What Is the Prevalence of Pituitary Macroincidentalomas in Brain Mris? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Nobuhiro Miki*1, Masami Ono1 and Tomokatsu Hori2
1Shin-Yurigaoka General Hospital, Kawasaki-city, Kanagawa, Japan, 2Shin-Yurigaoka General Hospital, Kawasaki-city, Japan

 

Context: A majority of prolactinoma develop in women of child-bearing age and present with microadenoma, while those in men occur throughout an entire period of adulthood and mostly are macroadenoma.

Objective: We studied clinical characteristics of prolactinoma in middle and advanced ages and examined efficacy of the first-choice dopamine agonist, cabergoline, in these patients.

Methods: Patients were 10 women and 32 men, who at the age of 50 years or older, developed an initial symptom or sign, or incidentally diagnosed because of unrelated illness or medical health checkup. We undertook an individualized high-dose cabergoline therapy based on serum PRL responsiveness.

Results: Initial symptoms were headache in eight patients, visual narrowing in six patients, decreased visual acuity in two patients, double vision in two patients, and galactorrhea in one patient and the remaining twenty-three were (55 %) asymptomatic. Of the 42 patients, 33 (79 %) had macroadenoma comprising of 5 females and 28 males. Of the 33 macroadenomas, 19 were large tumors greater than 2 cm in diameter and 16 of these 19 cases were male adenomas. Prior therapies to our cabergoline treatment were surgery, radiation, and bromocriptine alone or their combinations, but none could normalize hyperprolactinemia. Mean (±SE) serum PRL value before cabergoline was 2194 ± 488 mg/L overall, 2782 ± 586 mg/L in macroadenomas, and 101 ± 10 mg/L in microadenomas. Cabergoline normalized hyperprolactinemia in 38 of the 42 patients and completely recovered compression symptoms in all of the 12 non-operated patients with macroadenoma. The remaining 4 patients who did not achieve normoprolactinemia were those with macroadenoma and their post-cabergoline PRL levels were 26.4 - 33.0 ng/ml (normal range, 0.3 - 15). Pretreatment serum testosterone was diminished in 26 of the 32 men but recovered after cabergoline in all but two cases with post-surgical panhypopituitarism. Dose of cabergoline ranged from 0.5 to 15 mg /week and its mean dose was 3.5 mg/week in macroadenoma and 0.9 mg/week in microadenoma. Tumor shrinkage over 50 % was observed in all patients and 11 subjects were now in remission.

Conclusion: Prolactinoma in middle and advanced ages, unlike those in younger age group, is mostly macroadenoma, occurs more frequently in men than in women, and is often diagnosed as asymptomatic incidentaloma. It retains good responsiveness to cabergoline though not uniform in individual adenomas.

 

Nothing to Disclose: NM, MO, TH

20777 13.0000 SAT-502 A Prolactinoma in Middle and Advanced Ages: Clinical Characteristics and Efficacy of Cabergoline 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Ekaterina A Pigarova*1, Zhanna E Belaya2, Larisa K Dzeranova2, Julia Gallinger3, Liudmila Ya Rozhinskaya2, Galina A Melnichenko2, Ivan I Dedov2, Oksana Dmitrieva4 and Oggo Consortium5
1Endocrinology Research Centre, Moscow, Russian Federation, 2Endocrinology Research Centre, Moscow, Russia, 3Moscow State University, 4Aston Consulting, Mosсow, Russia, 5Federal Districts of Russian Federation, Russia

 

Introduction: Pituitary disorders exert deleterious effects on reproductive function. Consequently, pregnancy is infrequent in patients with hormone-active pituitary tumors and its outcome depends on the type of hormonal hyper secretion as well as used treatment modalities. The aim of this study was to analyze the outcome of pregnancies in women with hormone-active pituitary tumors from the Russian Registry.

Materials and Methods: Twenty three patients with pituitary adenoma who had pregnancy during active phase of the disease or its medical treatment were enrolled. These patients overall had 36 pregnancies (mean age at pregnancy 28±5 years, parity 2±1, in all cases with the exception of one pregnancy was naturally conceived): 3 cases in patients with acromegaly (AM), 9 – in patients with  Cushing disease (CD) and 24 pregnancy developed in patients with prolactinoma (PRL).

Results: Manifestation of the disease during pregnancy was observed in 6 out of 36 (17%) cases, 4 of which were seen in CD. 17% (6/36) of pregnancies were conceived after surgical treatment and 58% (21/36) cases developed during the medical therapy. Medical therapy for PRL in all 14 cases consisted of cabergoline which was discontinued during <4 weeks of pregnancy in 2 patients, during 4-6 weeks in 1, at >6 weeks in 11 patients (79%). In one case a gradual decrease of cabergoline dose was done by the patient till week 20, and one woman was unnecessarily advised to continue the drug during the whole pregnancy. Patients with pituitary adenomas experienced multiple complications of pregnancy, e.g. early and late gestational toxicosis, severe arterial hypertension, threatened miscarriage, intrauterine growth retardation, with the most prevalent complications in CD. Additionally, 22% (2/9) of patients with CD experienced low-traumatic fractures. 75% (27/36) of pregnancies ended in childbirth at 38±2 weeks of gestation, 17% (6/36) of patients had miscarriage, 8% (3/36) - abortion by choice.  Cesarean section was performed in 48% (14/29), but only in 20% of women it was absolutely required due to serious medical indication. Among these patients macroadenoma was presented only in 12.5%(3/24) of women, and after pregnancy the size of adenoma did not change in 60% (15/25), decreased in 20% (5/25) and increased in 20%. Clinically evident expansion of adenoma was seen only in one woman with CD.

Conclusions: Pregnancies in patients with pituitary adenomas carry a certain risk for mother and child and this data indicate an urgent need for establishment and implementation of proper medical care for them.

 

Nothing to Disclose: EAP, ZEB, LKD, JG, LYR, GAM, IID, OD, OC

22024 14.0000 SAT-503 A Pregnancies in Patients with Pituitary Tumors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Alfonso Manuel Soto-Moreno*1, Noelia Gros2, Eva Maria Venegas-Moreno3, Elena Dios2, David A Cano2, Natividad Garcia-Hernandez3, Ainara Madrazo-Atutxa2, Beatriz Gonzalez3, Manuel Polaina4, Ignacio Martin-Scheffer4, Eugenio Cardenas4, Ariel Kaen4, Florinda Roldan5 and Alfonso Leal-Cerro6
1Unidad de Gestión de Endocrinología y Nutrición. Hospital Universitario Virgen del Rocío, Sevilla, Spain, 2Unidad de Gestión de Endocrinología y Nutrición. Instituto de Biomedicina de Sevilla (IBiS), Consejo Superior de Investigaciones Científicas, Universidad de Sevilla. Hospital Universitario Virgen del Rocío, Sevilla, Spain, 3Endocrinology and Nutrition Unit, Institute of Biomedicine of Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Spain, 4Neurosurgery Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain, 5Servicio de radiología, UGC Diagnostico por la Imagen, Hospital Virgen del Rocío, Sevilla, Spain, 6Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío Seville, Sevilla, Spain

 

INTRODUCTION

The medical management of Cushing's disease (CD) poses a significant challenge for endocrinologists clinical practice, due to the limited available therapeutic approaches as well as the multiple comorbidities associated with this disease. 

OBJETIVE

The aim of this study is to retrospectively review the experience in the management of CD in a reference hospital during the last 35 years. 

MATERIAL AND METHODS

Retrospective observational study of 114 consecutive patients with CD diagnose between 1978 and 2013. The clinical variables analyzed were: sex, age and comorbilities, radiological and immunohistochemical characteristics of the tumor and  current status of the disease.

RESULTS 

Out of 114 CD patients, 78 patients are currently on follow-up. The overall rate of exitus is 4.38% (n = 5). 83.6% were women (n = 97). The mean age at diagnosis was 39.3 ± 15.09 years old. Magnetic resonance imaging (MRI) indicated that 54.63% of the adenomas were microadenomas (n = 53) and10.3%, macroadenomas (n = 10). No visible tumor was found in 27.8% (n = 26) of the patients. MRI results were not conclusive in 7% (n = 7) of the patients. 80.89% (n = 72) of the adenomas were positive for ACTH by immunohistochemistry. Of the 78 patients currently on follow-up, 78.20% are in complete remission (n = 61) of which 42.62% (n = 26) are on replacement therapy with hydrocortisone.  21.79% of the patients (n = 17) continue with persistent disease (10 patients with recurrence, 3 patients have had a persistence and 4 patients have not been operated), all being treated with ketoconazole for control of hypercortisolism.

Of the 74 patients that underwent surgery, 13 patients (17.6%) required a second surgical intervention and 19 patients (25.7%) were treated with radiotherapy. The major comorbities associated to CD included: hypertension (67.5 ;n = 56) , diabetes mellitus  (19.3%; n = 16) and osteoporosis (46.4%; n = 39).

CONCLUSION

CD in our cohort is more prevalent in young women. The most common cause is pituitary microadenomas. A significant proportion of patients develop comorbilities as a result of cortisol excess. The remission rate after surgery in our center is similar to that previously reported by other reference centers.

 

Nothing to Disclose: AMS, NG, EMV, ED, DAC, NG, AM, BG, MP, IM, EC, AK, FR, AL

21753 15.0000 SAT-504 A Management of Cushing's Disease: 35 YEARS of Experience 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Viveka Jyotsna*1, Devasenathipathy Kandasamy2, N Tandon3, Ariachery Ammini3 and N Gupta3
1All India Institute of Medical Scences, New Delhi, Delhi, India, 2AIIMS, New Delhi, India, 3AIIMS, New Delhi

 

Background: Transsphenoidal surgery in pituitary source of Cushings disease has a cure rate for microadenoma and macroadenoma of around 70% and 35% respectively varying at different centres. Second trans sphenoidal surgery, radiotherapy, medical therapy and bilateral adrenalectomy are the additional modalities used to control patients who are not cured or who have recurrence. Sometimes bilateral adrenalectomy might be the only option to salvage the patient and make him fit for a future definitive surgery for pituitary or ectopic Cushings.

Objectives: To study the profile of patient requiring bilateral pancreatectomy in ACTH dependant Cushings.

Methodology: Records of patients of ACTH dependant Cushings syndrome who were admitted for treatment to the Endocrinology ward from August 2012 to October 2014 were procured. Among them the cause of excess ACTH production and treatment patient received was noted.

Results: Out of a total of 63 patients with ACTH dependant Cushings, bilateral adrenalectomy was performed in 9 patients. Among them, six were cases of pituitary microadenoma, two of pituitary macroadenoma, two of ectopic Cushings and in one, no definite source was identified.

Among two patients with macroadenoma, one had undergone 3 procedures -  trans-sphenoidal surgery twice without cure followed by gamma knife radiotherapy the subsequent year without control of hypercortisolemia. The other presented very sick in a catabolic state with infection and to salvage her for a definitive surgery later, bilateral adrenalectomy was done. Post adrenalectomy all patients recovered well.

Among two patients of ectopic Cushings who underwent bilateral adrenalectomy, both were very sick. One patient expired post operatively and the other recovered well for a subsequent removal of an ectopic from the peripancreatic region.

In the five patients with pituitary microadenoma, we opted for bilateral adrenalectomy as they either had no cure or relapse after trans sphenoidal surgery. In one patient where source of ACTH could not be localized, but patient was sick, bilateral adrenalectomy was done.

Conclusions: Indications for bilateral adrenalectomy for ACTH dependent Cushings, included occult or unresectable source of ACTH secretion (pituitary or ectopic) or hypercortisolemia which does not improve after definitive surgery, radiotherapy or as a life saving measure to control hypercortolemia and stabilise the patient before a definitive surgery can be done.  

 

Nothing to Disclose: VJ, DK, NT, AA, NG

21169 16.0000 SAT-505 A Bilateral Adrenalectomy: Role in Management of ACTH Dependant Cushings 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Akira Shimatsu*1, Nicholas Sauter2, Roxzana Y Kelly2, Peter Unge3, Xin Zhi2 and Maria Fleseriu4
1National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 2Novartis Pharmaceuticals Corporation, East Hanover, NJ, 3Novartis Pharma AG, Basel, Switzerland, 4Northwest Pituitary Center, Oregon Health & Science University, Portland, OR

 

BACKGROUND

Despite recent novel therapies for CD, there is still an unmet need for highly efficacious drugs. Osilodrostat (LCI699) is a potent, oral inhibitor of 11β-hydroxylase synthase, the enzyme that catalyzes the final step of cortisol biosynthesis. In a phase II study, 22 wk of LCI699 treatment normalized urinary free cortisol (UFC) levels in 15/19 patients (pts) and was generally well tolerated. This phase III study is designed to further evaluate long-term safety and efficacy of LCI699 in a larger population of pts with CD.

METHODS

Patients: Adults (aged 18-75 y) with persistent, recurrent or de novo CD who are not considered surgical candidates or refuse to undergo surgery; target enrollment~132.

Design: Phase III, multicenter, double-blind, randomized withdrawal study of LCI699 following a 24 wk, single-arm, open-label dose titration (Period 1; wk 1-12) and stable treatment period (Period 2; wk 13-24). Periods 1 and 2: LCI699 will be initiated at 2 mg bid and dose adjusted (range: 1-30 mg bid) based on the mean of three 24-h UFC values (mUFC) measured every 2 wk. Dose will be increased if mUFC>ULN, maintained if mUFC≤ULN; and decreased / interrupted if mUFC<LLN or in lower part of normal range and/or if pt has symptomatic adrenal insufficiency. Period 3 (wk 26-34): A double-blind, placebo-controlled randomized withdrawal period. Pts with mUFC≤ULN at wk 24 and did not require dose increase above dose level established at wk 12 during Period 2, will be randomized (1:1) at wk 26 to continue LCI699 treatment at the same dose or to receive matching placebo. Non-randomized pts will continue to receive open-label LCI699. Non-responders (mUFC>1.5 ULN with UFC>1.5 ULN in ≥2 samples at a single visit) during Period 3 will discontinue from this study period, and resume open-label LCI699 treatment until wk 48. Period 4 (wk 34-48): A single-arm, open-label period. At wk 34, all pts will resume open-label treatment. LCI699 dose may remain unchanged, increased, decreased or withheld during this period depending on the mUFC levels and safety data. Safety will be assessed from study entry up to 28 days after the last dose of study treatment. Endpoints: Primary: proportion of randomized pts in each treatment group with normal mUFC (mUFC≤ULN) at wk 34; however, pts who discontinued or had a dose increase during Period 3 will not be included. Key secondary: proportion of pts with normal mUFC at wk 24 and with no dose increase above established dose level at wk 12 during Period 2.

CONCLUSION

This study design, which includes an 8-wk period of double-blind, placebo-controlled randomized withdrawal, after a 24-wk run-in period of open-label LCI699, will allow assessment of the long-term safety and efficacy of LCI699 in a larger group of pts with CD. This study design is well suited to pts with rare diseases when a long-term placebo control is not appropriate.

 

Disclosure: AS: Committee Member, Novartis Pharmaceuticals. NS: Employee, Novartis Pharmaceuticals. RYK: Employee, Novartis Pharmaceuticals. PU: Employer, Novartis Pharmaceuticals. XZ: Employee, Novartis Pharmaceuticals. MF: Researcher, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Cortendo, Researcher, Ipsen, Consultant, Ipsen, Researcher, Pfizer, Inc., Consultant, Pfizer, Inc., Consultant, Genentech, Inc..

19762 17.0000 SAT-506 A Study Design of a Phase III, Multicenter, Double-Blind, Randomized Withdrawal Study Following a 24-Week, Single-Arm, Open-Label Osilodrostat (LCI699) Treatment to Evaluate the Long-Term Safety and Efficacy of Osilodrostat in Patients with Cushing's Disease (CD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Feng Gu*1, Shoba Ravichandran2, Lillian Tseng2, Arun Subramanian2, YinMiao Chen2 and Christof Schöfl3
1Ministry of Health, Peking Union Medical College Hospital, Beijing, China, 2Novartis Pharmaceuticals Corporation, East Hanover, NJ, 3University Hospital Erlangen, Friedrich-Alexander University Erlangen- Nuremberg, Erlangen, Germany

 

Background:Hyperglycemia was a frequently observed adverse event in pasireotide clinical studies. Results from mechanistic studies in healthy-volunteers suggest that pasireotide-induced hyperglycemia is related to decrease in insulin and incretin hormone (glucagon-like peptide-1 [GLP-1] and glucose-dependent insulinotropic peptide [GIP]) secretion and can be managed most effectively with incretin-based therapy. This study was designed to investigate the optimal management of pasireotide-induced hyperglycemia in patients (pts) with Cushing’s disease (CD) or acromegaly with a focus on evaluating efficacy of incretin-based therapies versus insulin.

Methods: Patients: Pasireotide naïve adult pts with CD or acromegaly will start treatment with pasireotide s.c or pasireotide LAR, respectively; those previously treated with pasireotide are eligible if they have elevated fasting plasma glucose (FPG)>ULN or diabetes at screening. Pts with diabetes receiving anti-diabetic agents (ADA) other than incretin based therapies can enroll. Design: Phase IV, multi-center, randomized, open-label. Target enrollment ~133 pts. After study entry,  if average fasting self-monitored blood glucose (SMBG) is ≥126 mg/dL on 3 consecutive days (a) previously normo-glycemic pts will start metformin once diabetes is confirmed, if tolerated (b) pts on sub-maximal tolerated dose of metformin will titrate dose weekly up to maximal approved dose of metformin (c) pts on allowed oral ADAs other than incretin based therapies, will start on metformin, if tolerated and not contraindicated; metformin dose will be titrated weekly (at investigators’ discretion) up to maximal approved dose. If uncontrolled on stable, maximum tolerated dose of metformin for up to 8 weeks, pts will be randomized (1:1) to either incretin-based therapy (sitagliptin followed by liraglutide) or insulin for ~16 weeks. Dose of metformin should not be increased after randomization; dose of metformin can be reduced at any time based on investigator’s judgment for hypoglycemia. Maximum duration of core phase is 32 weeks. Pts receiving insulin at study entry will enter non-randomized observational arm. Endpoints: Primary endpoint: change in HbA1c from randomization to ~16 weeks in incretin-based therapy versus insulin arm. Secondary endpoints: At core end-of-phase, change from baseline in HbA1c and FPG by treatment group; proportion of patients with ≤0.3% HbA1c increase from baseline per randomized arm; change in HbA1cand FPG from randomization over time per randomized arm; proportion of pts requiring anti-diabetic rescue therapy with insulin in incretin-based therapy arm; safety.

Conclusions: Results from this study will provide a basis for optimal management of pasireotide-induced hyperglycemia in pts with acromegaly and CD, including those with diabetes at the start of pasireotide treatment.

 

Disclosure: FG: Principal Investigator, Ipsen, Speaker, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Speaker, Ipsen. SR: Employee, Novartis Pharmaceuticals. LT: Employee, Novartis Pharmaceuticals. AS: Employee, Novartis Pharmaceuticals. YC: Employee, Novartis Pharmaceuticals. CS: Advisory Group Member, Bristol-Myers Squibb, Speaker, Novo Nordisk, Advisory Group Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals.

19317 18.0000 SAT-507 A Management of Pasireotide-Induced Hyperglycemia in Patients with Cushing's Disease or Acromegaly: Study Design of a Randomized, Open-Label, Phase IV Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 490-507 5995 1:00:00 PM Pituitary Tumors- Non-Acromegaly Poster


Etienne Delgrange1, Alexandre Vasiljevic2, Anne Wierinckx3, Patrick François4, Emmanuel Jouanneau5, Jacqueline Trouillas6 and Gerald Raverot*7
1CHU Dinant-Godinne, Godinne, Belgium, 2Hospices civils de Lyon, Lyon, France, 3Université de Lyon 1, Lyon, France, 4CHU de Tours, Tours, France, 5Hospices Civils de Lyon, Lyon, France, 6Groupement Hospitalier Est, Bron, France, 7Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France

 

Context:A gender difference in the progression of prolactin (PRL) tumors has been disputed for years.

Objective:To compare tumor characteristics and postoperative clinical course between men and women, and correlate data to estrogen receptor alpha (ERα) expression status.

Design, Setting and Patients:Eighty-nine patients (59 women and 30 men) operated on for a PRL tumor and followed for at least 5 years were selected. Tumors were classified into 5 grades according to their size, invasion and proliferation characteristics. The ERα expression was detected by immunohistochemistry and a immunoreactive (IR) score (0-12) calculated as the product of the percentage of positive nuclei and their staining intensity.

Results:We found a significant preponderance of high grade tumors among men and a lower surgical cure rate in men (23%) than in women (71%). Patients resistant to medical treatment were mainly men (7/8), 6 of whom (5 men) showed tumor progression despite postoperative medical treatment which led to multiple therapies and eventually death in 3 men. The median score for ERα expression was 1 in men (range: 0-8) and 8 in women (range: 0-12) (p<0.0001).The expression of ERα as assessed by the IR score was inversely correlated with tumor size (r = - 0.59; p < 0.0001) and with Ki-67 index (r = - 0.36; p = 0.0010). If the tumors were divided into 2 groups according to the IR score (low and high ER expression being defined respectively by an IR score < or ≥ 6), low expression of ER protein was significantly more frequent in the tumor from men than those from women (p<0.0001). Tumors with lower ER expression had significantly higher mitotic count, Ki-67 index and p53 expression. All dopamin agonist-resistant tumors and all grade 2b (invasive and proliferative) tumors (ten from men and four from women) were characterized by low ERα expression.

Conclusions: PRL tumors in men are characterized by lower ERα expression which is related to higher tumor grade, resistance to treatment and an overall worse prognosis.

 

Nothing to Disclose: ED, AV, AW, PF, EJ, JT, GR

18619 1.0000 SAT-418 A The Expression of Estrogen Receptor Alpha Is Associated with Prolactin Pituitary Tumor Prognosis and Supports the Sex-Related Difference in Tumor Growth 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Erica Gentilin*, Teresa Gagliano, Katiuscia Benfini, Carmelina Di Pasquale, Simona Falletta, Ettore Ciro degli Uberti and Maria Chiara Zatelli
University of Ferrara, Ferrara, Italy

 

Pituitary adenomas are benign tumors of the pituitary gland. They can be divided in nonfunctioning pituitary adenomas, endocrinologically inactive, and functioning pituitary adenomas characterized by a specific pituitary hormones excess. ACTH-secreting adenomas account for 5-10% of  diagnosed pituitary tumors and frequently persist or recur making their clinical control hardly achievable. To date, little is understood about the molecular basis of neoplastic transformation. A better understanding of the pathogenesis of ACTH-secreting pituitary tumors may identify new pharmacological targets and prompt the development of innovative drugs, with a better chance to control the disease.

PRKCD is a serine-threonine kinase that regulates various physiological processes like proliferation, cell cycle, differentiation and apoptosis. Recently, we demonstrated that PRKCD is expressed at low level in human ACTH-secreting pituitary adenomas and that powerfully controls cell cycle in vitro.

In this study we evaluated the role of PRKCD in the setting of the murine ACTH-secreting pituitary adenoma cell line, AtT-20/D16v-F2 cells. We observed that PRKCD silencing is associated with morphological changes, increase in cell viability and alteration in protein expression of E-cadherin, b-catenin and GSK3b, proteins involved in both cell cycle control and transduction signaling. PRKCD silencing, in AtT-20/D16v-F2 cells, is also associated with an increase in protein levels of EGFR, a well known marker of tumor aggressive behavior. Moreover, human ACTH-secreting pituitary adenomas show high EGFR levels that correlate with low PRKCD levels suggesting that the latter play an important role in ACTH-secreting pituitary adenoma development. Our study provides new insights into potential contribution of PRKCD  to pituitary neoplastic transformation and suggests that PRKCD might be a possible target for therapeutic strategies.

 

Nothing to Disclose: EG, TG, KB, CD, SF, ECD, MCZ

19767 2.0000 SAT-419 A Role of Prkcd in ACTH-Secreting Pituitary Adenomas: In Vitro Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Jyoti Kapali*, Kelly L Schmidt, Brock Kabat and Buffy Sue Ellsworth
Southern Illinois University Carbondale, Carbondale, IL

 

FOXO1 belongs to a subclass of the forkhead family of transcriptional regulators. It is expressed in many tissues and has essential roles in metabolism, maintenance of hematopoietic stem cells, vascular development, regulation of cell cycle progression and promotion of apoptosis. Studies in our laboratory have demonstrated a role for FOXO1 in somatotrope differentiation and function. Foxo1 conditional knockout (Foxo1Dpit) mice exhibited significantly less growth hormone (GH) immunoreactivity and reduced expression of the growth hormone gene (Gh1) at embryonic ages 16.5 (e16.5) and 18.5 (e18.5) as compared to Foxo1 wildtype mice. At e16.5, there are no GH immunopositive somatotropes but a few cells are GH immunoreactive at e18.5. Based on this, we developed the hypothesis that FOXO1 drives expression of Gh1 or upstream regulators that control somatotrope differentiation, proliferation and/or function presumably by binding to FOXO1 consensus sites in the promoter regions of these genes. Therefore, we examined the effect of loss of FOXO1 on Pit1 and Neurod4 expression. Pit1 marks the pituitary progenitors committed to becoming somatotropes, thyrotropes or lactotropes. Also, Neurod4 is initially expressed at e13.5 shortly before differentiation of somatotropes and is required for normal Gh1 expression. Analysis of RNA levels revealed a significant decrease (p<0.05) in the expression of Neurod4 while Pit1 expression was unaffected in Foxo1Dpit embryos as compared to the WT littermates. Immunostaining for PIT1 showed no significant difference in the number of immunopositive cells at e16.5 and e18.5 between Foxo1Dpit and WT littermates. Despite the significant reduction in the number of somatotropes expressing GH during embryonic development, Foxo1Dpit mice do not exhibit any phenotypic changes related to Gh1 deficiency in adulthood. In order to determine at what age Gh1 expression recovers, we have included the postnatal day 3 age group (P3) in our sample repertoire. Neurod4 expression is repressed in this age group significantly (p<0.05) while Pit1 expression does not vary between the WT and Foxo1Dpit littermates. Similarly, Gh1 expression remains significantly reduced (p<0.05) in Foxo1Dpit mice but appear to be trending upward as the mice age. These findings suggest that FOXO1 is essential for committed progenitors to become terminally differentiated somatotropes and the loss of which delays somatotrope differentiation. Gh1 expression continues to be reduced through P3, but recovers by adulthood.

 

Nothing to Disclose: JK, KLS, BK, BSE

20080 3.0000 SAT-420 A FOXO1: Role in Somatotrope Differentiation and Function 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Masashi Higuchi*, Saishu Yoshida, Naoto Nishimura, Hiroki Ueharu, Takako Kato and Yukio Kato
Meiji University, Kawasaki, Kanagawa, Japan

 

The adenohypophysis consists of five types of hormone-producing cells and heterogeneous non-hormonal cells. Some non-endocrine cells are stem/progenitor cells which support the maintenance of hormone-producing cells in the pituitary tissue. Recently, by comparison with gene profiles in the murine pituitary tumor-derived non-endocrine cell lines, TtT/GF, Tpit/F1 and Tpit/E, we found the expression of Sox2, a stem/progenitor marker, in all cell lines and suggested that Tpit/E has characteristics of the epithelial stem/progenitor cells and TtT/GF has those of the mesenchymal cells with a capacity of differentiation into vascular endothelial cell and/or pericyte. Although characteristics of Tpit/F1 were obscure, Tpit/F1 is likely still to be in transiting state as it showed phenotypes of both epithelial and mesenchymal cells with stemness and moderate-high Sox2 expression. In this study, we have performed cultivation of Tpit/F1 for 1-20 days in the condition for neural stem cell consisting of the D/F medium containing B27 supplement and basic fibroblast growth factor. Observation during cultivation, real-time PCR for mRNAs and immunocytochemistry were performed. Ten-day-culture of Tpit/F1 cells formed floating embryonic stem cell-like clumps and then attached to the well bottom. Real-time PCR showed that Sox2 expression was two times higher in the clumps than in normally cultured Tpit/F1 cells, while Vimentin and Sca1 (a mesenchymal cell marker) were lower in the clumps. In addition, immunocytochemistry revealed that the clumps after 10-day culture have both stemness and proliferation capacity showing positive for SOX2 and Ki67, but negative for GH. Additional 10-day cultivation showed emergence of GH-positive cells, while other five pituitary hormones and S100 were negative. Notably, these GH-positive cells were negative for PIT1 and over-expression of Pit1 in Tpit/F1 cells could not induce Gh expression. Then, double immunostaining for PIT1 and GH was performed and found PIT1-negative GH-producing cells in the murine anterior lobe at low frequency. In summary, we demonstrated that Tpit/F1 cell line has characteristics of the pituitary stem/progenitor cells capable of forming Sox2-expressing embryonic stem cell-like clumps and differentiating partly into PIT1-independent GH-producing cells. These results suggest the presence of PIT1-independent route for differentiation into GH-producing cells.

 

Nothing to Disclose: MH, SY, NN, HU, TK, YK

20151 4.0000 SAT-421 A Murine Pituitary Tumor-Derived Non-Endocrine Cell Line, Tpit/F1, Is Capable of Differentiating into Growth Hormone-Producing Cell, but Is Not Dependent on Pit1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Lyvianne Decourtye*1, Erik Mire2, Maud Clemessy2, Victor Heurtier2, David Godefroy3, Tatiana Ledent2, Iain Robinson4, Annabelle Reaux Le Goazigo3, Patrice E Mollard5, Michael Joseph Meaney6, Sonia Garel7, Jacques P Epelbaum8, Yves Le Bouc9 and Laurent Kappeler10
1INSERM, Paris, France, 2UMRS 938 _ INSERM, Paris, France, 3UMRS 968_INSERM, Paris, France, 4MRC National Institute for Medical Research, London, United Kingdom, 5CNRS - INSERM, Montpelier, France, 6Douglas Hospital Research Center, Verdun, QC, Canada, 7IBENS, Paris, France, 8INSERM UMR-S 894, Université Paris Descartes, Paris, France, 9UMRS 938_ INSERM, AP-HP, Paris Cedex 12, France, 10INSERM, Sorbonne Universités, UPMC Univ Paris 06, IHU ICAN, Paris, France

 

Nutrition during lactation in the early postnatal period programs the activity of the somatotropic axis (GH/IGF-1), which regulates body growth during postnatal development and plays an important role on adult metabolism. Then an alteration of nutrition during this period permanently alters growth of mice and increases their susceptibility to develop cardiovascular and metabolic pathologies later in life. Mechanisms underlying this programming are thus of first importance for the life trajectory of the developing organism. Restricted pups present decreased plasmatic level of IGF-1 and Leptin. They also present a transient alteration of median eminence innervation by GHRH neurons at 10 days of age, followed by a permanent pituitary hypoplasia in somatotrophs cells (GH) by 20 days of age onward. The aim of the present study is to decipher if nutrition through its two major effectors, IGF-1 and leptin, can regulate the development of GHRH neurons.

In this way, we used C57B6j GHRH-GFP mice with litter sizes normalized at 6 or 10 pups per dam at birth, in order to have normally-fed or restricted pups during lactation. As IGF-1 is a proliferative factor with anti-apoptotic activity, we first checked by in situ hybridization if the GHRH neurons population was altered at 20 days of age. Our results indicate that IGF-1 do not alter their ontogeny or survival. We thus hypothesized an alteration of neurons development. Since leptin was previously demonstrated to stimulate development of NPY and POMC neurons and IGF-1 was involved in axon elongation in certain brain regions, we setup in vitro culture of arcuate nucleus explants, which contains neurons regulating both growth (GHRH) and food intake (NPY/POMC), from one week-old pups. Our results indicate that leptin is able to stimulate axon growth of both GHRH and whole arcuate neurons, labeled with neurofilament NF (Control vs Leptin: NF: 1.31±0.07 of relative stimulation, P<0.01, GHRH: 1.33±0.13, P<0.05, n=5-7 per group). However, IGF-1 seems to stimulate GHRH neurons only (Control vs IGF-I: NF: 1.11±0.04, NS, GHRH: 1.32±0.09, P<0.0001, n=6 per group). Interestingly, restriction during lactation abolishes in vitro arcuate neurons response to both leptin and IGF-1 (Control vs IGF-1: GHRH: 1.16±0.01, NS, Control vs Leptin: GHRH: 1.09±0.05, NS, n=6-8). The study of IGF-1 signaling pathways indicates that IGF-1 stimulate axon growth through both PI3K/AKT and MEK/ERK. Globally, our results indicate that nutrition in early postnatal period in mice programs growth through leptin and IGF-1, which stimulate axon growth of GHRH neurons. Leptin seems to present broad stimulating effects for all arcuate neurons while IGF-1 seems to present a specific effect for GHRH neurons. Interestingly, restriction of pups seems to induce long lasting effects remaining in vitro that prevent GHRH response to stimulating hormones.

 

Nothing to Disclose: LD, EM, MC, VH, DG, TL, IR, AR, PEM, MJM, SG, JPE, YL, LK

20323 5.0000 SAT-422 A Leptin and IGF-I Stimulate Axon Growth of Hypothalamic GHRH Neurons 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Sanne Franck*1, Federico Gatto2, Aart J. van der Lely3, Leo J. Hofland4 and Sebastian J.C.M.M. Neggers3
1Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands, 2Erasmus University Medical Center Rotterdam, Ronco Scrivia, Italy, 3Erasmus University Medical Center, Rotterdam, Netherlands, 4Erasmus Medical Center, Rotterdam, Netherlands

 

EFFECT OF COMBINATION TREATMENT WITH PEGVISOMANT AND SOMATOSTATIN ANALOGUES ON THE EXPRESSION OF SOMATOSTATIN RECEPTORS IN GH-SECRETING ADENOMAS.

Introduction: Growth hormone (GH) secreting pituitary adenomas (GHoma) express different types of somatostatin receptors (SSTRs), predominantly SSTR subtypes 2 and 5. GHomas of acromegalic patients that respond better to somatostatin analogues (SSA) have higher SSTR2 expression. The expression of SSTR2 on GHomas of patients treated with SSAs in combination with the GH receptor antagonist pegvisomant (PEGV) has never been studied. Feedback mechanisms of the PEGV-induced GH increase or the drop of IGF-I during treatment could influence the expression of SSTR2 and SSTR5 at the level of the GHoma.  

Aim of the Study: To assess and compare SSTR2 and SSTR5 expression between three groups of acromegalic patients: patients naïve for medical treatment (naïve group), patients using SSA monotherapy (mono SSA group) and patients who are treated with PEGV and SSAs (combi group).

Materials and methods: Acromegalic patients who underwent transsphenoidal neurosurgery were selected and clinical data were collected at our Pituitary Center Rotterdam. The GHoma tissues were collected and SSTR2 and SSTR5 expression was determined by immunohistochemistry. Semi-quantification of SSTR expression was done by calculating an immunoreactivity score (IRS), which takes into account both the percentage of the positive cells and staining intensity.

Results: Of the 45 GHoma tissue samples, 23 were surgically removed during a medication free status, 11 during monotherapy with SSA and 9 during a combination of SSA and PEGV. The patients characteristics; sex, age, tumor volume were not significantly different between the three groups. The IRS of the SSTR2 expression had a median score of 6.0 [IQR2.0-10.0] in the naïve group, a median of 6.0 [IQR3.0-12.0] in the mono SSA group and a median of 2.0 [IQR1.0-4.5] in the combi group, which was significantly lower (p=0.039). The median IRS of the SSTR5 expression in the naïve group was 10.5  [IQR 7.0-12.0], in the mono SSA group this median was 12.0 [IQR 8.0-12.0] and the combi group the median was 9.0 [IQR 7.0-12.0] (p=0.864).

Conclusion: The SSTR2 expression on GH-secreting pituitary adenomas is lower in acromegalic patients treated with a combination of SSA and PEGV, compared with naïve and monotherapy SSA patients. Additional analyses of IGF-I and GH levels will be done to understand if this decrease of SSTR2 expression may be a consequence of a feedback mechanism, or is related to the need for combined treatment because of a low response to SSA treatment.

 


 

Disclosure: AJV: Clinical Researcher, Pfizer, Inc., Consultant, Pfizer, Inc., Clinical Researcher, Ipsen, Consultant, Ipsen, Clinical Researcher, Novartis Pharmaceuticals. SJCMMN: Clinical Researcher, Ipsen, Clinical Researcher, Pfizer, Inc.. Nothing to Disclose: SF, FG, LJH

20355 6.0000 SAT-423 A Effect of Combination Treatment with Pegvisomant and Somatostatin Analogues on the Expression of Somatostatin Receptors in GH-Secreting Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Cristina BELLOTTI FORMIGA Bueno*1, Ericka Barbosa Trarbach2, Raquel S Jallad3, Felipe HG Duarte4, Marcio Carlos Machado5, Milena Caccelli6, Maria Candida B V Fragoso7 and Andrea Glezer8
1Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, HC-FMUSP, São Paulo, Brasil, 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Hosp das Clinicas Univ of Sao Paulo Medical School, Sao Paulo SP, Brazil, 4Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 5University of Sao Paulo Medical School, Sao Paulo, Brazil, 6Unidade de Neuroendocrinologia da Disciplina de Endocrinologia e Metabologia, HC-FMUSP, Sao Caetano do Sul -SP, Brazil, 7Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 8Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School., Sao Paulo, Brazil,, Sao Paulo, Brazil

 

Background: Pituitary adenomas express both dopamine and somatostatin receptors and can be medically treated with dopaminergic agonists (DA) and/or somatostatin analogues (SA). It was suggested that polymorphisms (SNPs) in genes encoding dopamine 2 receptor (D2R) and somatostatin receptors 2 and 5 (SSTR2 and 5) could be associated with variable effectiveness of DA and SA in the treatment of pituitary tumors.

Objective: To evaluate the potential influence of D2R and/or SSTR2/SSTR5 SNPs on the response to treatment with DA and/or SA, respectively, in patients with pituitary adenomas.

Methods: We evaluated D2R SNPs (rs1079597, rs1076560, rs1800497 and rs6275) in 198 patients using DA: 146 with prolactinoma, 26 with somatotrophinomas and 26 with corticotrophinomas. Polymorphisms in SSTR2 (rs998571 and rs1466113) and SSTR5 (rs3751830, rs4988487, rs169068, rs34037914, rs642249) were investigated in 51 acromegalic patients using SA. In addition, 71 patients with acromegaly on   DA/SA association treatment were genotyped for SNPs in D2R, SSTR2 and SSTR5. All polymorphisms were assessed by real time PCR genotyping using TaqMan probe based assay. No deviations from Hardy-Weinberg equilibrium for genotype distribution of all SNPs were detected.

Results and discussion: In patients with prolactinoma, DR2rs1079597 allele C or DR2 rs1800497 allele G were related to bromocriptine response (P= 0.009 and P=0.031, respectively), whereas patients with DR2 rs6275 allele A or DR2 rs1799732 allele ins C showed higher sensitivity to cabergoline (P=0.012 and P=0.014, respectively). Also, the presence of functional SNP rs1801028 allele C in these patients was associated to tumor shrinkage during treatment with cabergoline (P=0.048). Other studies failed to demonstrate the association of these D2R SNPs with response to DA, with exception of rs6275 allele T that was found to be more frequent in resistant prolactinomas (Filopanti et al, 2008). Regarding corticotrophinomas, none D2R SNPs showed significant association with response to DA treatment. In acromegaly, we found association between SSTR2 rs1466113 allele G and normalization of GH after combination treatment of SA and cabergoline (P=0.020). However, previous results correlated only the presence of SSTR5 variants, not SSTR2, with reduction of GH and IGF1 after treatment with SA (Ciganoka et al, 2011).

Conclusion: D2R and SSTR2 SNPs appears to have an influence on therapeutic response to DA and SA in patients with prolactinomas and somatotrophinomas, respectively. However, these results are inconsistent in the literature and more investigation is needed to determine the use of these polymorphic variants as genetic marker to drug response, mainly in acromegaly.

Acknowledgments: We thanks to Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) for the financial support (Grant number: 2011/19932-5).

 

Nothing to Disclose: CBFB, EBT, RSJ, FHD, MCM, MC, MCBVF, AG

20500 7.0000 SAT-424 A Influence of Dopamine Receptor Subtype 2 and Somatostatin Receptor Subtypes 2 and 5 Polymorphisms in Response to Treatment in Pituitary Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Renata Kikuchi Foltran*1, Ericka Barbosa Trarbach2, Felipe HG Duarte3, Ane Caroline Freire4, Thais P Sickler5, Cristina BELLOTTI FORMIGA Bueno6, Milena Caccelli7, Andrea Glezer8, Marcio Carlos Machado9, Maria Candida B V Fragoso10, Marcello D Bronstein11 and Raquel S Jallad12
1University of São Paulo Medical School, São Paulo, Brasil, Sao Paulo, Brazil, 2Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 3Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 4USP, 5Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School., Sao Paulo, Brazil, 6Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, HC-FMUSP, São Paulo, Brasil, 7Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Caetano do Sul -SP, Brazil, 81Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 9University of Sao Paulo Medical School, Sao Paulo, Brazil, 10Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 11University of São Paulo Medical School, São Paulo, Brazil, 12Hosp das Clinicas Univ of Sao Paulo Medical School, Sao Paulo SP, Brazil

 

Background:Pituitary adenomas are benign intracranial neoplasms, accounting for approximately 15% of all intracranial tumors. The majority of them occur sporadically. Molecular studies of these adenomas have identified genetic and epigenetic abnormalities that may have a role  on  its pathogenesis   and  treatment. Objective: To investigate the prevalence of mutations in AIP, CDKN1B and GNAS1, genes previously related to tumorigenesis in pituitary gland, in a cohort of Brazilian patients with sporadic pituitary adenomas. Subjects and methods: A total of 96 apparently sporadic pituitary adenomas were evaluated: 21 nonsecreting tumours (NFPA), 41 somatotropinomas, 28 corticotropinomas and 6 prolactinomas. Genomic DNA was extracted from tumors sample and used in mutational analysis of all coding region of AIP and CDKN1B, and GNAS1 hotspots in exons 8 and 9 by PCR amplification and automatic sequencing.Results: Three heterozygous somatic missense mutations were found in GNAS1: p.Arg201Cys (n=2 corticotropinomas; n=1 NFPA; 9 somatotropinomas), p.Gln227Leu (n=1 somatotropinoma) and p.Gln227Arg (n=1 somatotropinoma). These are well known activating mutations localized at α subunit of the G protein gene. As described in the literature, mutation at codon 201 was more frequent than the mutation at codon 227. The prevalence of these mutations in was 11% in somatotropinomas, 2% in corticotropinomas and 1% NFPA, much lower in comparison with previously described in other studies. Regarding to somatotropinomas, the prevalence of  adenomas harboring GNAS1 mutation did not show clinical and laboratorial finding and treatment outcome different from GNAS1- adenomas. No potentially pathogenic mutations were found in AIP or CDKN1B genes, only polymorphic variants previously described. Conclusions:  In according with previous reports, GNAS1 genetic abnormalities are the most common mutations observed in sporadic pituitary adenomas. The prevalence of this mutations was within the wide range already described in the literature (0 to 40%), pointing to ethnic differences amongst the studies.. However, the occurrence of mutations in AIP and CDKN1B genes appears to be a very rare event.

 

Nothing to Disclose: RKF, EBT, FHD, ACF, TPS, CBFB, MC, AG, MCM, MCBVF, MDB, RSJ

20547 8.0000 SAT-425 A Evaluation of AIP, CDKN1B and GNAS Mutations in Apparently Sporadic Pituitary Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Filip Gabalec*1, Vojtech Tambor2, Dai Long Vu2, Monika Drastikova1, David Netuka3, Vaclav Masopust3, Tomas Cesak1, Martin Beranek1, Jan Cap1 and Juraj Lenco2
1Charles University Hospital and Faculty of Medicine, Hradec Kralove, Czech Republic, 2University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, 3Charles University in Prague, Central Military Hospital, Prague, Czech Republic

 

The background: Proteomic studies of clinically non-functioning adenomas (CNFAs) are rare.  Most of the currently available use rather outdated methods with low potential for sufficient proteome coverage. In addition, studies comparing CNFAs to cadaver specimens have substantial limitations. Hu et al. in 2012 proposed several SELDI-based biomarkers, but their unambiguous identification as particular proteins was not possible due to technology used in this study. Until now, a reliable biomarker for CNFAs progression prediction is still lacking. The Aim of our pilot study was comparison of protein expression in CNFAs with and without progression after surgery. The Methods: 2 dimensional liquid chromatography – tandem mass spectrometry was used for comparative analysis of adenoma tissue from 6 patients who underwent transsphenoidal surgery for pituitary non-functioning macroadenoma. 3 patients were operated twice for progression of residual tissue in 1 year, 3 patients were without residual tissue progression. The Results: 3279 proteins were identified based on 19590 peptides on average. 1730 proteins were included for quantitative statistical analysis. Significant quantitative changes (p≤0.05) were found in 3 proteins: Ubiquitin carboxyl-terminal hydrolase isozyme L1 (UCHL1), Alpha-internexin and Tubulin polymerization-promoting protein family member 3. Alpha-internexin was more expressed in progressive group, the others had lower expression in progressive than stable group. Conclusion:  In our pilot analysis we identified at least 3 proteins which deserve further attention for their potential role in CNFAs progression evaluation. UCHL1 or filaments were not analyzed in CNFAs.

 

Nothing to Disclose: FG, VT, DLV, MD, DN, VM, TC, MB, JC, JL

20674 9.0000 SAT-426 A More Progressive Clinically Non-Functioning Adenomas Express Significantly Different Proteins 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Marie Helene Schernthaner-Reiter*1, Giampaolo Trivellin1, Laura C. Hernandez Ramirez2, Márta Korbonits2 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom

 

Introduction

Germline mutations in the Aryl hydrocarbon receptor-interacting protein (AIP) are the genetic cause of a subset of familial isolated pituitary adenomas, mostly early-onset, aggressive somatotropinomas (SM). AIP interacts with two phosphodiesterases as well as with G-proteins, suggesting a connection between AIP and the cAMP/PKA pathway. The cAMP/PKA pathway is frequently dysregulated in pituitary tumors, such as in sporadic SM carrying GNAS1 mutations, or Carney complex SM that are caused by mutations of the PKA regulatory subunit 1α (PRKAR1A), the R1α protein. We studied interactions between AIP and the PKA pathway and its role in pituitary tumor formation.

Methods

Co-immunoprecipitation (co-IP) was performed in HEK293 cells transiently overexpressing AIP-Myc, R1α-HA and HSP90-HA or HSP70-HA. Confocal immunofluorescence (IF) was performed on the rat somatomammotroph GH3 cell line probed with Aip and R1α antibodies. A cAMP-response element (CRE) reporter kit (Promega) was used to monitor the activity of the cAMP/PKA pathway in GH3 cells following transfection with Aip siRNA. Aip+/- mice were crossed with Prkar1α+/- mice. Serum IGF-1 was measured by ELISA.

Results

AIP physically interacts with R1α, independently as well as in complex with the chaperones HSP90 and HSC70, as demonstrated by co-IP experiments. Confocal IF reveals overlapping cytoplasmic areas of localization of endogenous Aip and R1α in GH3 cells. Aip knockdown in GH3 cells leads to significantly increased CRE activity. This effect is magnified during global PDE inhibition by IBMX, but only moderately increased during PDE4 inhibition by Rolipram. Currently, there are no differences in IGF-1 levels or weight of 28 weeks old Aip+/-;Prkar1α+/- mice compared to their Aip+/- littermates.

Conclusion

We show that AIP and R1α colocalize in the cytoplasm of pituitary somatotropes and they directly interact with each other. Reduced AIP levels lead to increased PKA pathway activity, which may be partially mediated by the known AIP interaction partner PDE4A5. We are currently collecting data on the pituitary phenotype of Aip+/-;Prkar1α+/- mice, which will contribute significantly to understanding the significance of the interaction between AIP and R1α in pituitary tumorigenesis.

 

Nothing to Disclose: MHS, GT, LCH, MK, CAS

20685 10.0000 SAT-427 A Interaction Between AIP and the cAMP-Dependent Protein Kinase (PKA) Pathway in Pituitary Tumor Formation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Woo Kyung Lee*1, YangJong Lee2, Cheol Ryong Ku1 and Eun Jig Lee1
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Yonsei University, Seoul, Korea, Republic of (South)

 

Background

Acromegaly results from the hypersecretion of GH, mostly caused by GH secreting pituitary adenoma. Although transsphenoidal adenomectomy is the treatment of choice, some patients do not achieve biochemical remission after surgery and need medical treatment. However, there are not many available drugs due to the limitations of rare diseases, which include the poorly understood pathogenesis and lack of a proper animal model. Recently, we developed an animal model that develop GH secreting pituitary adenoma, which has the deletion of the aryl hydrocarbon receptor interacting protein (AIP) in somatotroph.

Aims

To investigate the usefulness of somatotroph-specific AIP knock out (sAIPKO) mice in developing therapeutics for GH secreting pituitary adenoma, we evaluated the biochemical effects of somatostatin analogs on sAIPKO mice.

Methods

We generated sAIPKO mice using a Cre-loxp strategy. Eight male sAIPKO mice (mean age: 61.913.5 weeks) were assessed. The mice received a subcutaneous injection of octreotide LAR (320mg/kg, monthly: octreotide group, n=4) or pasireotide LAR (320mg/kg, monthly: pasireotide group, n=4). On the 1st, 14th and 28th days, serum IGF-1 levels were determined by ELISA. Body weight and blood glucose levels were also measured at that time. Furthermore, pituitary glands were obtained for biochemical analysis.

Results

On both the 14th and 28th days, there were significant decreases in serum IGF-1 level in the pasireotide group. However, serum IGF-1 levels in three mice among the octreotide group showed a decreasing trend, although it was not statistically significant. Body weight in the pasireotide group significantly decreased on the 14th day, not on the 28th day while there was no significant change in the octreotide group. There was no significant change in blood glucose in both groups.

Conclusions

Somatostatin analogs, especially pasireotide, had significant effects on biochemical activity in sAIPKO mice, which had no change in glucose homeostasis. This mouse model will be useful for drug development and efficacy evaluation in GH secreting pituitary adenoma.

 

Nothing to Disclose: WKL, YL, CRK, EJL

20698 11.0000 SAT-428 A The Biochemical Effect of Somatostatin Analogs on Somatotroph-Specific Aryl Hydrocarbon Receptor Interacting Protein Knock out Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Antonio Miguel Pico*1, Ruth Sanchez-Ortiga2, Laura Sanchez-Tejada2, Pedro Riesgo3, Javier Abarca4, Irene Monjas4, Rosa Camara5, Cristina Lamas6 and Carmina Fajardo7
1Hospital General Universitario Alicante - University Miguel Hernandez, Alicante, Spain, 2Hospital General Universitario de Alicante, Alicante, Spain, 3Hospital La Ribera, Alzira, 4Hospital General Universitario de Alicante, Alicante, 5Hospital la Fe, Valencia, Spain, 6Complejo Hospitalario de Albacete, Spain, 7Hospital La Ribera, Alzira, Spain

 

Purpose: E2F1 is the main member of E2F transcription factors family, which control the
expression of genes needed for the cellular cycle progression, as well as apoptosis. The
deregulation of the p16-cyclin D1-Rb-E2F1 pathway is one of the hallmarks of cancer. Pituitary
adenomas (PA) are a heterogeneous group of tumors that proceeds of differents cellular lines
and has an heterogeneous clinical behaviour. Most of them have an indolent behaviour but some
become very aggressive. Old data demonstrated that the loss of E2F-1 reduces tumorigenesis
and extends the lifespan of Rb1(+/-)mice (1). But today, there are no data about E2F1
expression in human PA subtypes. The oncogenic or suppressive attitude of the E2F1 depend on
context of tumoral cell. The aims of this study is to investigate the role of E2F1 in behaviour of
different PA subtypes.

Methods: In this cross-sectional descriptive study, we evaluated E2F1 by qRT-PCR analysis on
60 human PA samples: 29 gonadotrophs (GT), 15 somatotrophs (ST), 8 functioning corticotroph
(CT) and 8 silent corticotroph adenomas (SCA). 9 healthy pituitary from autopsies were used as
calibrator reference. Clinical, pathological and radiologic data were recovered. Aggressiveness
was graded according to invasiveness (Hardy’s grade IV) and Ki-67 gene expression (>2.590
fold change (FC)).

Results: E2F1 was overexpressed in 86.2% (25/29) of GT and 62.5% (5/8) of the SCA, while in
the CT and ST subtypes predominated the normal expression (62.5% (5/8) and 80% (12/15)
respectively) (p= 0.001). Thus, E2F1 was overexpressed in non-functioning PA (NFPA) vs
functioning PA (FPA) with an OR: 12.1 (3.5-42.1) (p= 0.000). Furthemore, tumor maximum
diameter was correlated with E2F1 expression (r= 0.353, p= 0.027). In fact, its fold change (FC)
increases significantly with the Hardy’s grade (II: 1.14 (0.70-1.53) FC; III: 2.02 (1.20-3.84) FC; IV:
2.53 (1.85-3.94) FC; p= 0.004). Moreover, we found a significantly relationship between E2F1
expression and aggressiveness (High: 2.54 (1.26-4.01) FC; Medium: 2.44 (1.69-3.82) FC; Low: 1.16
(0.70-2.42) FC; p= 0.006).

Conclusion: According with our results, E2F1 plays an important role in the behaviour on
humans PA, acting as oncogene and promoting the cellular cycle progression specially in NFPA,
in which there is a closed correlation with its aggressiveness. However, in FPA subtypes, other
molecular factors could be interfering in the deregulation of this pathway.


 

Disclosure: AMP: Advisory Group Member, Pfizer Global R&D. Nothing to Disclose: RS, LS, PR, JA, IM, RC, CL, CF

20922 12.0000 SAT-429 A E2F1 Is Overexpressed in Non-Functioning Pituitary Adenomas Related to Their Aggressive Behaviour 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Leonard Cheung*1, Michelle L. Brinkmeier1, Amanda Helen Mortensen1, Maria Ines Perez-Millan1, Hideyuki Okano2 and Sally A Camper1
1University of Michigan, Ann Arbor, MI, 2Keio University School of Medicine, Tokyo, Japan

 

Combined pituitary hormone deficiency (CPHD), or panhypopituitarism, is one of the most common forms of dwarfism, occurring in approximately 1 in every 4000 births (1).  CPHD causes severe short stature due to reduction in pituitary growth hormone (GH), and may cause other health problems such as hypothyroidism, infertility, or adrenal insufficiency. More than half of CPHD cases have no known etiology, but mutations in the transcription factor PROP1 are the most frequent identified cause (2).  PROP1 is a direct transcriptional regulator of two other genes which, when mutated, can cause CPHD. For this reason, we sought to identify genes that are differentially expressed in the pituitaries of Prop1 mutant mice (Prop1df/df).  We found that the transcription factors Sox2 and Sox21 are both upregulated in Prop1 mutants.  These genes have roles in regulation of stem cells and cell fate in a variety of tissues (3-5).  SOX2 is a marker for pituitary stem cells, but nothing is known about the role of SOX21 in the pituitary gland.  We have characterized the expression pattern of Sox21 in hypothalamic-pituitary development, and investigated its function using loss- and gain-of-function mouse models (6).  We detect SOX21 expression in the developing neural ectoderm and adult hypothalamus, including the arcuate and paraventricular nuclei.  Expression was not detectable during pituitary organogenesis, indicating that Prop1 deficiency induces ectopic Sox21 expression.  Sox21-/- mice are normally sized at birth, but are severely dwarfed by 1 month of age, with no evidence for sexual dimorphism in growth.  SOX21-deficient pituitary glands are smaller than their wild-type counterparts, due to reduced size of the lateral wings of the anterior lobe.  GH cells, as well as other pituitary hormone cell-types, are present in SOX21-null pituitary glands at 1 and 4 months of age.  GHRH axon terminals are present in the median eminence of Sox21-/- mice, and expression of liver insulin-like growth factor 1 (Igf-1) is similar between wild-type and mutant mice, suggesting GH release and signaling are intact.  We are evaluating hypothalamic-pituitary-thyroid axis function for a contribution to the growth insufficiency, and exploring the development and function of other organs regulated by hypothalamic-pituitary axes.  To determine whether ectopic Sox21 expression contributes to the arrested pituitary development characteristic of Prop1 mutants, we are developing a mouse model with inducible SOX21 overexpression.  Our studies indicate that PROP1 normally represses SOX2 and SOX21, and suggest that ectopic SOX21 expression could be a contributor to hypopituitarism and growth insufficiency.

 

Disclosure: HO: Consultant, San Bio Co. Ltd.. Nothing to Disclose: LC, MLB, AHM, MIP, SAC

21083 13.0000 SAT-430 A Elevated SOX21 Expression in PROP1-Deficient Mice: A Novel Candidate Gene for Combined Pituitary Hormone Deficiency (CPHD) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Melissa Rodriguez*1, Stephen F Betz2, Ana Karin Kusnetzow2, Yunfei Zhu2, Jacquelyn Fritz2, Scott Struthers2 and Agnes Schonbrunn3
1Univ of Texas-McGovern Medicial School, Houston, TX, 2Crinetics Pharmaceuticals, San Diego, CA, 3Univ of Texas-McGovern Med School, Houston, TX

 

Peptide somatostatin analogs (SA) such as octreotide and lanreotide decrease mortality and morbidity produced by acromegaly primarily by activating the sst2A somatostatin receptor subtype. However these somatostatin analogs also induce rapid desensitization and internalization of the receptor, thus reducing their therapeutic efficacy. Biased agonists are compounds that can selectively modulate receptor activation. We hypothesized that sst2A biased agonists that activate Gi-mediated signaling but do not induce receptor internalization could provide more effective therapeutic inhibition of GH secretion. Previously, retrospective analysis of a small molecule, nonpeptide somatostatin receptor agonist showed that it’s activities for Gi activation and receptor regulation were somewhat divergent, indicating that it was a partially biased agonist (Liu et al Mol.Pharm 68:90, 2005). We therefore began a medicinal chemistry effort to prospectively optimize agonist bias and characterize the resulting non-peptide biased agonists at the sst2a receptor. This led to highly potent agonists of the human sst2A receptor with varying degrees of agonist bias. Here we compared the activity of two nonpeptide sst2A agonists to octreotide. In an HEK293 cell line stably expressing rat sst2A receptors, octreotide potently inhibited cAMP production (EC50 = 0.02 nM) and stimulated sst2A receptor internalization (EC50 = 3.26 nM). In the same cells, two nonpeptide agonists, CRN297 and CRN310, inhibited cAMP production with similar potencies (EC50 = 20.8 nM and EC50 = 13.5 nM, respectively), although both were less potent at rat compared to human receptors.  However, whereas CRN310 induced sst2A receptor internalization (EC50 = 1.43 µM) CRN297 produced no receptor internalization even at 10 µM, the highest dose tested.  Importantly, both CRN297 and CRN310 inhibited VIP-stimulated growth hormone secretion by GH4C1 rat pituitary tumor cells.  These studies identify CRN297 as a fully biased non-peptide sst2A agonist that inhibits growth hormone secretion.

 

Nothing to Disclose: MR, SFB, AKK, YZ, JF, SS, AS

21200 14.0000 SAT-431 A Identification of a Fully Biased, Nonpeptide Agonist of Somatostatin Receptor Type 2A 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Antonio Miguel Pico*1, Laura Sanchez-Tejada2, Ruth Sanchez-Ortiga3, Pedro Riesgo4, Irene Monjas5, Javier Abarca5, Cristina Lamas6, Rosa Camara7 and Carmina Fajardo8
1Hospital General Universitario Alicante - University Miguel Hernandez, Alicante, Spain, 2Hospital General Universitario de Alicante, Alicante, Spain, 3Hospital General Universitario Alicante, Alicante, Spain, 4Hospital La Ribera, Alzira, 5Hospital General Universitario de Alicante, Alicante, 6Complejo Hospitalario de Albacete, Spain, 7Hospital la Fe, Valencia, Spain, 8Hospital La Ribera, Alzira, Spain

 

Purpose: MicroRNAs act as regulators of gene expression during development and
differentiation. Pri-miR-17~92 is a primary miRNA that gives rise to the mature miRNAs 17,
18a, 19a, 20a, 19b1 and 92a1 when processed. It is regulated by c-Myc and by factors of the
E2F family. They are capable of regulate tumour-suppressing genes as PTEN and p21, and also
oncogenes as JNK2 and E2F1, promoting growth and apoptosis. The aim of this study is to
investigate the contribution of these miRNAs to the pathogenesis of different PA subtypes.

Methods: In this cross-sectional descriptive study, we evaluated pri-miR-17~92, miR-17-5p and
miR-20a by qRT-PCR analysis on 60 human PA samples: 29 gonadotrophs (GT), 15
somatotrophs (ST), 8 functioning corticotroph (CT) and 8 silent corticotroph adenomas (SCA).
9 healthy pituitary from autopsies were used as calibrator reference. Clinical, pathological and
radiologic data were recovered. Aggressiveness was graded according to invasiveness (Hardy’s
grade IV) and Ki-67 gene expression (>2.590 fold change).

Results: In our complete series of PA, pri-miR-17~92 showed low expression levels in 93.3%
(56/60) of the tumours and it was lower as their mature miRNAs increased. This relationship
was variable depending on PA subtype, reaching a significant negative correlation in CT (r= -
0.857; p= 0.007). miR-17-5p and miR-20a were always strongly correlated together (r= 0.958,
p= 0.000). We did not find any association between pri-miR-17~92 or its mature miRNAs
neither with age, sex and maximun tumoral diameter on MRI. However, the miR-17-5p
expression pattern changed depending on aggressiveness grade. Thus, miR-17-5p was
overexpressed in 63.3%, 39.3% and 28.6% and was repressed in 9.1%, 10.7% and 47.6% of
high, medium and low grade of aggressiveness respectively (p= 0.011). Consequently, 51.4%
(19/37) of non-functioning PA (NFPA) (GT and SCA) overexpressed miR-17-5p vs 21.7%
(5/23) of functioning PA (ST and CT) with an OR: 3.8 (1.2-12.4), (p= 0.023).

Conclusion: pri-miR-17~92 seems to be processed differently among subtypes, perhaps due to
its own regulation. miR-17-5p could be playing an important role in aggressiveness of NFPA
subtypes, acting as oncoMiR and promoting the oncogenesis. Further studies on larger samples
are needed to clarify its role in each subtype.

 

Disclosure: AMP: Advisory Group Member, Pfizer Global R&D. Nothing to Disclose: LS, RS, PR, IM, JA, CL, RC, CF

21253 15.0000 SAT-432 A Mir-17-5p Plays a Role As Oncomir in Non-Functioning Pituitary Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Agata Baldys-Waligorska1, Iga Wierzbicka1, Dariusz Adamek1, Malgorzata Trofimiuk-Muldner*2, Alicja Hubalewska-D3 and Filip Golkowski1
1Jagiellonian University Medical College, Faculty of Medicine, Krakow, Poland, 2Jagiellonian University Medical College,, Krakow, Poland, 3Jagiellonian University Medical College, Krakow, Poland

 

Introduction

We investigated Ki-67, AIP (Aryl Hydrocarbon Receptor-Interacting Protein) and VEGF (Vascular Endothelial Growth Factor) as potential pathological markers to predict the invasiveness of pituitary adenomas.

Material and Methods:

Ki-67, AIP and VEGF indices were determined by immunochemistry in specimens from neurosurgically removed somatotropinomas. Histopathological material was examined from 31 patients (20 females and 11 males, mean age 43.3 ± 14.3 yrs.) with pituitary adenoma (23 macro- and 8 microadenomas) who underwent pituitary surgery. The mean value of maximum diameters of tumours in MRI was 22.84 ± 21.23 mm. Relations between staining indices and clinical symptoms, tumour features, and MR imaging, were analysed. In all studied adenomas GH expression was confirmed by immunostaining. Local invasiveness, defined as sella turcica destruction, cavernous sinus penetration, optic chiasm compression, was observed in 18/31 patients (58,1%).

Results

Expression of Ki-67, AIP and VEGF was revealed only in cells of pituitary tumours and was present in

81.0%, 87.0% and 90.3% of 31 cases, respectively. The median values of Ki-67, AIP and cytoplasmic VEGF indices were 1.23% [IQR=2.21], 21.16% [IQR=20.08] and 20.4% [IQR=15.4], respectively.

Ki-67, AIP and VEGF indices did not correlate with patient age nor gender (p>0.05). Significant difference between median values of Ki-67 indices of micro-and-macroadenomas was found (0.0%[IQR=1.32] vs 1.45%[IQR=1.81], p=0.015, respectively).

Values of Ki-67 indices correlated with tumour size (r=0.42, p=0.025). No correlation between AIP or VEGF expression with tumour size was found. In invasive, as compared with non-invasive somatotropinomas, significantly higher indices were found only for Ki-67 (mean values: 1.85 ± 1.33% vs 0.94 ±1.07%, p=0.024).

Expression of none of the markers was significantly influenced by presurgical treatment with somatostatin analogues, however expression of VEGF was much lower in treated group of patients (23.8 [IQR=23.24]% vs 9.6 [8.8]%, p=0.075).

 

Conclusions

While Ki-67, AIP and VEGF were expressed in most of the investigated pituitary tumours, only Ki-67 expression was related to tumour size. Only Ki-67 expression correlated with tumour invasiveness.

 

Nothing to Disclose: AB, IW, DA, MT, AH, FG

21352 16.0000 SAT-433 A Markers of Proliferation As Prognostic Factors in Somatotropinomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Ericka Barbosa Trarbach*1, Raquel S Jallad2, Felipe HG Duarte3, Alexander Augusto Lima Jorge1 and Marcello D Bronstein4
1Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 2Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, HC-FMUSP, São Paulo, Brasil, Sao Paulo SP, Brazil, 3Unidade de Neuroendocrinologia, Disciplina de Endocrinologia e Metabologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, HC-FMUSP, Sao Paulo, Brazil, 4University of São Paulo Medical School, São Paulo, Brazil

 

Introduction: SOCS2 (suppressor of cytokine signaling 2) is a STAT5b-regulated gene and one of its functions is to influence growth and development through negative regulatory effects on GH/IGF-1 pathway. SOCS2 polymorphisms could lead to increased GH sensitivity throughout the body. Recently, polymorphisms in SOCS2 have been associated with adult height variation in healthy individuals (nd girls with Turner syndrome treated with recombinant GH. It has also been suggested that SOCS2 variants may contribute to the development of acromegaly due to description of a patient with gigantism, without GH secreting  adenoma, harboring a mutation in this gene. Based on these results, we aimed at evaluating the presence of rs3782415, rs3816997, rs3825199 and rs11107116 SOCS2 polymorphisms in a cohort of acromegalic patients and to investigate their potential influence on clinical and laboratorial characteristics. Methods: A total of 186 patients (116 women, age range 26-88 years) with acromegaly were evaluated. SOCS2 polymorphisms were assessed by real time PCR using genotyping TaqMan probe based assay. No deviation from Hardy-Weinberg equilibrium was noted in any variant studied. A p value of <0.05 was considered significant. Results: Our data demonstrated no significant association of SOCS2 genotypes with any of the following clinical and laboratorial characteristics: age, sex, body mass index, comorbidities, basal GH (bGH), oral glucose tolerance test GH nadir (nGH), IGF-I, ULNR-IGF-I (upper limit of normal range-IGF-I). The only variable that affected basal GH was age (p = 0.022) whereas ULNR-IGF-I was influenced by log bGH (p = 0.044). Conclusion: Despite of the key role of SOCS2 in the regulation of GH receptor signaling, none of polymorphisms studied by us in its gene affected clinical or biochemical phenotypes of our acromegalic patients cohort.

 

Nothing to Disclose: EBT, RSJ, FHD, AALJ, MDB

21463 17.0000 SAT-434 A Genetic Analysis of SOCS2 Polymorphisms in Patients with Acromegaly 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


David A Cano*1, Mariola Mendez-Muros2, Eva Venegas2, Noelia Gros1, Elena Dios1, Natividad Garcia-Hernandez2, Ainara Madrazo-Atutxa1, Ignacio Martin-Scheffer3, Eugenio Cardenas3, Ariel Kaen3, Florinda Roldan4 and Alfonso Manuel Soto-Moreno5
1Unidad de Gestión de Endocrinología y Nutrición. Instituto de Biomedicina de Sevilla (IBiS), Consejo Superior de Investigaciones Científicas, Universidad de Sevilla. Hospital Universitario Virgen del Rocío, Sevilla, Spain, 2Endocrinology and Nutrition Unit, Institute of Biomedicine of Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Spain, 3Neurosurgery Unit, Hospital Universitario Virgen del Rocío, Sevilla, Spain, 4Servicio de radiología, UGC Diagnostico por la Imagen, Hospital Virgen del Rocío, Sevilla, Spain, 5Unidad de Gestión de Endocrinología y Nutrición. Hospital Universitario Virgen del Rocío, Sevilla, Spain

 

INTRODUCTION

            Pituitary adenomas are usually benign. However, a significant number of pituitary adenomas show an aggressive behavior, with local invasion, increased risk of recurrence after surgery and lack of therapeutic response. The pathogenic mechanisms responsible for this invasive behavior in pituitary adenomas remain largely unknown.

AIM

            To determine whether invasive and non-invasive pituitary adenomas display differences in clinical features and molecular parameters

METHODS.

In this retrospective descriptive study, we selected 46 pituitary adenomas and classified them as invasive (n=30) or non-invasive (n=16). Invasiveness was defined as invasion of surrounding structures like cavernous or sphenoidal sinus on the basis of magnetic resonance imaging and surgical findings. Clinical variables, histological subtype (including classification of aggressive histological subtypes) and need for radiotherapy were collected to analyze potential associations between these variables and tumor behavior. Quantitative PCR was used to measure the expression of several membrane receptors important for pituitary function: somatostatin receptors (SSTR1-SSTR5), dopamine receptors (DR1-DR5) including the long isoform of dopamine D2 receptor 2, GHRHR, GHSRS1, GHSRS1b. The expression of proliferation genes ki67 and PTTG1 (pituitary transforming tumour gene) was also measured. In addition, the expression of 3 housekeeping genes (HPRT, GAPDH and beta-actin) was measured.

RESULTS

30 invasive pituitary adenomas (63.3% Non-functioning pituitary adenomas; 23.3% GH-producing adenomas; 13.3% ACTH-producing ACTH) and 16 non invasive adenomas (37.5% Non-functioning pituitary adenomas; 43.8% GH-producing adenomas; ACTH-producing 18.75%) were analyzed. No statistically significant differences were observed in age and sex between invasive and non-invasive adenomas. Growth of tumor remnants (p<0,0001); and need for radiotherapy (p =0.016) was higher in invasive adenomas. Of all the genes analyzed, only SSTR3 (p=0,043), long isoform of dopamine D2 receptor 2 (p=0,048) and PTTG1 (p= 0,029) display significant differences between invasive and non-invasive adenomas. The same genes demonstrated different expression levels between microadenomas and macroadenomas. A comparison between aggressive and non-aggressive pituitary adenomas according to histological subtypes was also performed. SSTR1 (p=0.007), dopamine D2 receptor (p=0.019) and PTTG1 (p=0.039) expression was higher in histological subtypes of aggressive pituitary adenomas adenomas.

CONCLUSIONS

Our preliminary results indicate that invasive pituitary adenomas display differences in clinical features and gene expression. It remains to be determined whether these differences in gene expression might represent a mechanistic link to the invasion process.

 

Nothing to Disclose: DAC, MM, EV, NG, ED, NG, AM, IM, EC, AK, FR, AMS

21709 18.0000 SAT-435 A Clinical and Molecular Differences Between Invasive and Non-Invasive Pituitary Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Whitney Edwards*1, Leah Brennan Goldberg1 and Lori T Raetzman2
1University of Illinois Champaign Urbana, Urbana, IL, 2University of Illinois at Urbana-Champaign, Urbana, IL

 

The pituitary gland controls crucial physiological functions such as growth, metabolism and reproduction. The vast functions of the pituitary are executed through the six distinct hormone- producing cell types, which are tightly regulated during development and adulthood. However, the signaling pathways that direct their cell number remain unclear. Previously we have demonstrated that the Notch signaling pathway is necessary to preserve the progenitor cell population and is important for terminal differentiation of the hormone producing cell linages. However, the mechanism by which Notch controls the fate of these pituitary cell populations is unknown. To address this question, a microarray analysis of Notch2 conditional knockout (cKO) mice revealed a significant decrease in expression of the transcription factor Grainyhead Like 2 (GRHL2) compared to littermate controls. In various tissues GRHL2 has been shown to be important in cellular morphogenesis, cell adhesion and the regulation of cell proliferation and differentiation. Recently, studies have revealed that GRHL2 directly regulates expression of proliferative genes such as proliferating cell nuclear antigen (PCNA) and antigen KI-67 (Ki67). In addition, GRHL2 has been identified as a direct transcriptional regulator of cell-to-cell contact proteins including E-cadherin (CDH1) and Claudin 4 (CLDN4). Based on its function in other tissues, the regulation of Grhl2 mRNA may be a potential mechanism by which Notch maintains the pituitary progenitor cell niche and promotes progenitor proliferation. In our studies we profiled the expression of Grhl2 mRNA and examined GRHL2 protein localization in the developing mouse pituitary. We show that Grhl2 expression is most pronounced in the pituitary during the late embryonic and early postnatal time period and the protein appears to be present in progenitor cells.  In addition, we have confirmed that Notch signaling is necessary for full expression of Grhl2 mRNA and GRHL2 protein using Notch2 cKO mice and mice dosed with a chemical Notch inhibitor. Our data also suggests that that loss of Notch2 and subsequent reduction of GRHL2 in the postnatal pituitary results in decreased proliferation and mis-expression of CDH1. This may indicate that GRHL2 is necessary to maintain pituitary cell localization. Taken together, our studies define Grhl2 as a novel, Notch regulated gene in pituitary progenitors. In addition, our finding also indicate that GRHL2 may be a potential director of pituitary cell proliferation and localization.

 

Nothing to Disclose: WE, LBG, LTR

21923 19.0000 SAT-436 A Notch Signaling Regulates Expression of Grainyhead like 2: A Potential Mechanism for Controlling Progenitor Cell Fate in the Developing Mouse Pituitary 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Jean-Paul Herman*1, Nicolas Jullien1, Catherine Roche1, Thomas Graillon2, Anne Barlier3 and Thierry Brue4
1CNRS and Aix-Marseille Universite, Marseille, France, 2CHU Timone, Marseilles, France, 3Aix-Marseille University, Marseille, France, 4Hopital de la Timone, Marseille, France

 

We have reported previously that PIT-1(R271W) (PIT271), a dominant negative mutant of PIT-1 responsible of Combined Pituitary Hormone Deficiency in patients, induced cell death in somatolactotroph cells and in primary pituitary tumor cells. The mechanisms of this action and its relevance to the dominant-negative character of this mutant could, however,  not be established. To better understand this phenomenon, we established, using inducible lentiviral vectors, sublines of GH4C1 somatotroph cells that allow the blockade of the expression of endogenous PIT-1 and/or the expression of wtPIT-1 (PITWT) or PIT-1(R271W). Blocking expression of endogenous PIT-1 induced a marked decrease of cell proliferation. Overexpressing PITWT threefold led also to a decrease of cell proliferation that was accompanied by cell death. Expression of PIT271 induced a strong decrease of cell proliferation accompanied by a very pronounced cell death. These actions of PIT271 are independent on its interaction/competition with endogenous PIT-1, as they were unchanged when expression of endogenous PIT-1 was blocked. All these actions are specific for GH4C1 somatolactotroph cells, and could not be observed in heterologous CV1 cells.  On the other hand PITWT, similar to PIT271, induced also death of primary pituitary tumor cells. Cell death induced by PITWT or by PIT271 was accompanied by DNA fragmentation, but was not inhibited by inhibitors of caspases, autophagy or necrosis, suggesting that this cell death is a caspase-independent apoptosis. Altogether, our results indicate that under normal conditions PIT-1 is important for the maintenance of cell proliferation, while when expressed at supra-normal levels it induces cell death. Through this dual action, PIT-1 may play a role in the expansion/regression cycles of pituitary lactotroph population during and after lactation. Our results also demonstrate that the so-called  "dominant-negative" action of PIT271 is, at leat in part, independent of its competition with PIT-1 or a blockade of the actions of the latter, and are actions specific to this mutant variant of PIT-1.

 

Nothing to Disclose: JPH, NJ, CR, TG, AB, TB

21929 20.0000 SAT-437 A Dose-Dependent Dual Role of PIT-1 in Somatolactotroph Cell Proliferation and Apoptosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Laure Cazabat1, Sylvia L. Asa1 and Shereen Z Ezzat*2
1University Health Network, Toronto, ON, Canada, 2University Health Network, University of Toronto, Toronto, ON, Canada

 

We have previously shown that the zinc finger protein Ikaros interacts with the C-terminal binding protein 1 (CtBP1) to modulate pituitary cell growth and development.   Autotaxin (ATX)/Enpp2 has been shown to be estrogen-responsive in the hippocampus and is a known target of HOXA13 as well as CtBP1.  In the endocrine system, ATX/EnPP2  has been implicated in bone mineralization and insulin secretion.  We have also shown that loss of Ikaros/CtBP1 targets ATX/Enpp2.  In this study we focused on the role of ATX/Enpp2 in pituitary cell growth, survival and hormonal activity.  First we noted that Enpp2 is expressed in primary mouse anterior pituitary adenohypophysial cells.  Enpp2 mRNA and protein levels were also abundant in AtT20 and GH4 cell lines.  Thus, to examine their functional properties, these cell lines were used for stable silencing.  This forced down-regulation of Enpp2 resulted in significant reduction of pituitary hormone POMC in AtT20 and GH in GH4 cells. Down-regulation of Enpp2 also resulted in striking reduction of cellular growth in both cell types as determined by direct cell counting and formation of colonies in soft agar.  Flow cytometry revealed this to be the result of cell cycle arrest accompanied by altered Rb phosphorylation and p27 accumulation.  Additionally, loss of Enpp2 resulted in increased hypoxia-sensitivity accompanied by increases in the BAX and PERP apoptosis effectors.  Pharmacologically, down-regulation of Enpp2 abrogated the inhibitory effect of the somatostatin analog pasireotide; an effect which was rescued through treatment with lysophosphatidic acid.  These results uncover Enpp2 as a novel integrator linking a pituitary hypoxia transcriptional network with G-protein coupled signaling in the control of cellular growth and hormone secretion.

 

Nothing to Disclose: LC, SLA, SZE

22022 21.0000 SAT-438 A Enpp2 Links the Hypoxic Transcriptional Response with G-Protein Coupled Signaling to Control Pituitary Cell Survival and Hormone Secretion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Kirsten Eckstrum*1, Karen Weis2, Nick Baur3 and Lori T Raetzman4
1UIUC, Urbana, IL, 2University of Illinois Urbana-Champaign, 3UIUC, 4University of Illinois at Urbana-Champaign, Urbana, IL

 

The pituitary is a critical component of the hypothalamic-pituitary-gonadal (HPG) axis, utilizing signals from the hypothalamus to release luteinizing hormone (LH) and follicle stimulating hormone (FSH) from gonadotrope cells in the pituitary, which then influence circulating levels of sex steroids. It has been reported that serum levels of LH and FSH are different between male and female neonates. However, it is unclear what pituitary sex differences exist at the level of the transcriptome at the onset of HPG axis function and how these differences occur. We hypothesize that, as in the brain, the neonatal testosterone surge in males is able to influence the genetic signature of the pituitary leading to important sex differences during the early postnatal period. Lhb and Fshb mRNA levels are higher in female mice as early as the day of birth (postnatal day (PND)0). However, this is not due to differences in gonadotrope number. Therefore, we did a microarray analysis to see if there were any other differences at the mRNA level that may explain the striking differences in Lhb and Fshb mRNA levels. We discovered that at PND1, only three genes that are not sex chromosome linked were different between males and females; Lhb, Fshb, and Icam5. We analyzed the expression of these genes during the early postnatal period (PND0, 4, and 9) where Lhb and Fshb are higher in females and one time point just before puberty (PND20) where Lhb and Fshb are instead lower in females than males. Icam5, though not significantly different at PND0, was higher in females at every other age tested. Importantly, the expression of this intercellular adhesion molecule gene has not been documented in the pituitary nor has it been documented to be sexually dimorphic. Our next hypothesis was that the presence of prenatal and neonatal testosterone in males is responsible for suppressing Lhb, Fshb, and Icam5 at the pituitary, through local aromatization to estradiol.  To test this, two in vivo treatment paradigms in mice were employed: diethylstilbestrol (DES) administration from embryonic day 16.5 to 18.5 and 50μg/kg/day estradiol for one week beginning on PND0.  Preliminary data has shown a suppression of Icam5 acutely in exposure to estradiol and a persistent suppression of Icam5 mRNA levels with DES exposure in females, mimicking male expression patterns. To determine the role of hypothalamic or direct hormonal influences on expression of these genes in the pituitary, PND0 pituitaries were isolated and cultured. Sex differences between Lhb, Fshb, and Icam5 mRNA all persist, indicating the pituitary is able to maintain sex differences without influence from hormonal signaling. Overall, there are few differences in the transcriptome of male and female pituitaries during the early postnatal period despite the strong sexual dimorphism of Lhb and Fshb expression and the function of Icam5 warrants further exploration.

 

Nothing to Disclose: KE, KW, NB, LTR

22056 22.0000 SAT-439 A Few Sex Differences Exist in the Early Postnatal Pituitary Transcriptome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 418-443 6001 1:00:00 PM Biochemical, Genetic and Pharmacological Studies of the Pituitary and Hypothalamus Poster


Esti Charlap*1 and Christine A Resta2
1Downstate Medical Center, Brooklyn, NY, 2Maimonides Medical Center, Brooklyn, NY

 

Introduction:

Hyponatremia is an underappreciated presentation of sellar lesions. Here we discuss a patient who presented with severe hyponatremia and was found to have panhypopituitarism secondary to an intrasellar arachnoid cyst.

Clinical Case:

83 year old woman with a history of hypothyroidism was sent to the emergency department by her primary care doctor for a worsening pericardial effusion seen on echocardiogram. She had gone to her doctor one week earlier complaining of two weeks of generalized fatigue and weakness. Symptoms included abdominal pain, nausea, vomiting, and myalgias. No complaints of headaches or visual changes. Two weeks prior to admission, the patient stopped levothyroxine, as she felt it was causing her symptoms. Echo done at the time showed a small pericardial effusion. Repeat echo one week later showed increased size of the effusion and she was sent to the hospital. Admission exam showed a pale, lethargic, elderly woman. No skin or buccal hyperpigmentation seen. Exam was otherwise unremarkable. Vital signs were stable. Laboratory studies showed hyponatremia (Na 125 mmol/L: (136-145)) and hypothyroidism (TSH 6.26 Uiu/ml: 0.35-4.70(), FT4 0.47 ng/dl: (0.71-1.85 )).  

AM cortisol was ordered and was 1.7 ug/dl (4.0-22.0). She had lack of response to cosyntropin (1.7 -> 4.4). Na dropped further to 118 mmol/L. The diagnosis of adrenal insufficiency was made, and she was started on Hydrocortisone with immediate improvement in her symptoms. Levothyroxine was restarted as well. Her Na returned to normal after a few days and she was discharged home on maintenance dose of hydrocortisone. After discharge, remainder of her labs showed low ACTH (<5 pg/ml: (7.2-63.3)).  FSH, LH, and FT4 were also low, consistent with panhypopituitarism. Prolactin was normal. MRI pituitary showed a 4.3cm fluid filled mass that remodeled the sella and protruded into left sphenoid sinus, compatible with an arachnoid cyst. No mass effect on optic chiasm seen. She was referred to neurosurgery who recommended against surgical intervention given the fact that the cyst was likely long-standing and not threatening her vision.

Conclusion:

In this report we describe severe hyponatremia as a presenting finding of an intrasellar arachnoid cyst. Intrasellar arachnoid cysts are rare lesions, and hyponatremia is a relatively uncommon presenting sign.  Hyponatremia secondary to panhypopituitarism is an important diagnosis to make because it can  usually be corrected with hormone replacement. Appropriate glucocorticoid and thyroid hormone replacement therapy is key. The cause is multifactorial, with both secondary adrenal insufficiency and hypothyroidism contributing to severe hyponatremia, with the underlying mechanism attributed to elevated levels of ADH. In any patient presenting with hyponatremia without an obvious cause, pituitary hormonal testing should be done, followed by sellar imaging if indicated.

 

Nothing to Disclose: EC, CAR

20060 1.0000 SAT-444 A Intrasellar Arachnoid Cyst Presenting As Hyponatremia and Panhypopituitarism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Yasmin Khan*1 and Diana Barb2
1University of Florida, Gainesville, FL, 2University of Florida College of Medicine, Gainesville, FL

 

BACKGROUND:

The natural progression in the development of postpartum hypopituitarism is classically seen as a sequential loss of trophic hormones, with failure to lactate and amenorrhea being the earliest and most frequently observed clinical manifestation. We present a rare case of postpartum panhypopituitarism with preserved gonadal function, and review the interpretation of TSH levels and possible association with Brugada-type EKG pattern in this clinical setting.

CLINICAL CASE:

A 23 year old female was hospitalized for recurrent pneumonia and longstanding fatigue.  Interestingly, she reported a history of Brugada syndrome with presyncope episodes and tachycardia. Her symptoms began after an uncomplicated spontaneous vaginal delivery 15 months prior.  She was unable to lactate, however had resumed regular menses and was started on Depo-Provera for contraception.  At the time of evaluation, she was actively menstruating and received her last Depo-Provera injection over 3 months prior. She endorsed malaise, cold intolerance, constipation and a 50 pound unintentional weight loss. She denied treatment with systemic or inhaled steroids, headaches or vision changes. On exam, she had low-grade fever, mild hypotension without tachycardia and no visual field deficits. EKG demonstrated a type 3 Brugada pattern. BMP showed mild hyponatremia and hypokalemia. CBC demonstrated mild anemia.

Further tests showed a low cortisol (<0.5 mcg/dL, n AM 7-22, PM 3-9) and mildly elevated TSH (5.6 mIU/L, n 0.27-4.2). Repeat paired AM cortisol and ACTH were decreased at 0.6 mcg/dL and 5 pg/ml (n 6-58), respectively. ACTH stimulation test confirmed adrenal insufficiency with a cortisol of 2.7 mcg/dL at 60 minutes.  She had significantly decreased FT4 (0.4 ng/dL, n 0.93-1.7), TT3 (51 ng/dL, n 80-200), IGF-1 (74 ng/mL, n 87-368) and prolactin (0.3 ng/mL, n 4.8-23.3) levels.  Gonadal axis was consistent with the follicular phase (LH 2.6 mIU/ml, n 2.4-12.6; FSH 5.4 mIU/ml, n 3.5-12.5; estradiol 67, n 13-166). MRI showed pituitary atrophy on a background of partial empty sella. Panhypopituitarism with preserved gonadal function was diagnosed, likely secondary to postpartum apoplexy. Transbronchial biopsy showed eosinophillic pneumonia. Her symptoms resolved after steroid and thyroid replacement.

CONCLUSION:

While partial pituitary necrosis with preservation of some hormones have been described, there are very few reported cases of postpartum hypopituitarism with preserved ovarian axis in the literature to date. Intact menses in this condition can therefore be a misleading symptom. Paradoxically elevated TSH in pituitary disorders can also occasionally occur as an exaggerated response to TRH, but with secretion of biologically inactive isoforms. Lastly, Brugada phenocopy may be relevant in our patient with two reported cases of EKG normalization after treatment of adrenal crisis and hypothyroidism.

 

Nothing to Disclose: YK, DB

20797 2.0000 SAT-445 A Isolated Intact Ovarian Axis and Brugada Phenocopy in Postpartum Hypopituitarism with a Review of TSH Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Alison Patricia Butler*1, Niki Margari2, Zahra Khatani3, Sanjiv Chawda4, Jonathan Pollock5 and Frederick Nkonge6
1University College London Partnership, 2University College London Partners, United Kingdom, 3Queen's Hospital, 4Queen's Hospital, London, 5Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, United Kingdom, 6Barking, Havering & Redbridge University Hospitals NHS Trust

 

Background:

Wegener’s granulomatosis (WG) is a systemic vasculitis involving small and medium sized vessels, commonly affecting the kidneys, upper and lower respiratory tracts. Pituitary involvement presents primarily as cranial diabetes insipidus (CDI) and panhypopituitarism can rarely occur as a result of WG. Here we present a case of panhypopituitarism secondary to likely granulomatous infiltration in a patient with known WG.

Case:

A 64-year old man with a four year history of upper respiratory WG presented with a long history of profound lethargy. He had been treated with methotrexate and corticosteroids, and had required high doses of prednisolone (up to 60mg daily) for 12 months. Clinical examination revealed dry skin and sluggish reflexes. His hormone profile indicated panhypopituitarism, and water deprivation test revealed partial CDI. MRI showed a large enhancing cystic pituitary lesion with a thickened stalk, extending towards the optic chiasm.

The patient had been complaining of nocturia and erectile dysfunction for 3 years prior to the diagnosis of hypopituitarism, although MRI brain at this time did not show any pituitary pathology. He was seen in urology clinic and the symptoms were thought to be related to previous prostate surgery.

Retrospectively, in addition to nocturia he had been suffering from lethargy and loss of libido for 2-3 years. The diagnosis of anterior hypopituitarism was made by a consultant biochemist when thyroid function tests were checked as part of a routine investigation into the patient’s fatigue. The patient was referred urgently to the endocrine team who initiated hormone replacement, and his symptoms improved significantly. His upper respiratory symptoms persist but have improved, but his radiological findings have not resolved with treatment of the underlying pathology.

Discussion:

Hypopituitarism in Wegener’s granulomatosis was first described in 1953, and presented with isolated cranial diabetes insipidus. Since then there have been fewer than 50 reported cases of pituitary involvement in WG. The posterior pituitary is almost invariably affected, presenting as CDI, with additional anterior pituitary involvement in around two thirds of cases. Literature suggests symptoms improve with hormone replacement but there appears to be varying resolution of radiological findings, and most patients require lifelong hormone supplementation. Diagnosis may be delayed due to the nonspecific nature of the presenting symptoms, use of steroids and the multi-organ involvement of the disease. Although hypopituitarism is a rare complication of Wegener’s, it should be strongly suspected in any patient presenting with persistent nocturia.

 

Nothing to Disclose: APB, NM, ZK, SC, JP, FN

21326 3.0000 SAT-446 A Panhypopituitarism in Wegener’s Granulomatosis : A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Adriana Patricia Kuker*1, Melissa Sum2, Jamie A. Mullally3, Jessica Furst2, Gabrielle Page-Wilson1, John C Ausiello2 and Thomas P. Jacobs2
1Columbia University, College of Physicians and Surgeons, New York, NY, 2Columbia University College of Physicians and Surgeons, New York, NY, 3Columbia University College of Physicians & Surgeons, New York, NY

 

Background: Neurosarcoidosis can present with neuroendocrine dysfunction in the absence of systemic activity, rendering it a difficult diagnosis.

Clinical Case: A 56 year-old man with a history of a suprasellar mass, panhypopituitarism, central diabetes insipidus (DI), blindness of unclear etiology, and schizophrenia was admitted for evaluation and management of the suprasellar mass. The suprasellar mass, hypopituitarism, and DI had been diagnosed nine months prior at an outside hospital when he presented with hypernatremia. At the time, he was treated with steroids, levothyroxine, and desmopressin. Six months later, he presented to another hospital with hypernatremia. Repeat brain imaging showed significant interval decrease in the size of the mass. He underwent three lumbar punctures with negative results, and two suprasellar brain biopsies with inconclusive findings. His brain MRI upon transfer to our institution showed that the suprasellar mass had largely resolved and was replaced with irregular enhancement along the floor of the third ventricle and optic chiasm. Findings were concerning for an inflammatory or infectious process. Review of prior work-up was notable for intermittent hypercalcemia up to 12 mg/dL [8.7-10.2]. Our laboratory evaluation was consistent with panhypopituitarism. ACE, PTH, 1,25-OH vitamin D, HCG, and AFP levels were normal.  HIV, RPR, and quantiferon gold tests were negative. Lumbar puncture showed mildly elevated protein level with normal cell count; cytology and cultures were negative. Ophthalmologic exam revealed bilateral optic nerve pallor indicative of long-term visual compromise, and no discrete conjunctival lesions. Chest CT showed two 2 mm nodules in the right middle lobe as well as prominent mediastinal lymphadenopathy.  Biopsy of a right paratracheal lymph node revealed non-necrotizing microgranulomata. Given the patient’s history of hypercalcemia, shrinkage of the suprasellar mass after receiving steroids, lymphadenopathy, and granuloma on pathology, he was diagnosed with sarcoidosis involving the central nervous system, lungs, and mediastinum. He was not treated with immunosuppressive therapy given the low likelihood of recovery of the long-standing blindness and endocrine dysfunction, and lack of respiratory symptoms.  He was continued on replacement hydrocortisone, levothyroxine, and desmopressin, and was started on prescription free water to prevent further recurrences of hypernatremia.

Conclusion: This case demonstrates the importance of neurosarcoidosis as a diagnostic consideration in patients with neuroendocrine dysfunction and a suprasellar lesion. This case also highlights the importance of searching for extraneural tissue biopsy sites, which are less risky and can be of high diagnostic yield.

 

Nothing to Disclose: APK, MS, JAM, JF, GP, JCA, TPJ

21240 4.0000 SAT-447 A A Case Report: Neurosarcoidosis in a Man Who Presented with Panhypopituitarism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Winnie Wong*1 and Line Vautour2
1McGill University, Montreal, QC, Canada, 2McGill University Health Center, Montreal, QC, Canada

 

Background:

Pituitary hyperplasia in the context of hypothyroidism has been reported in the literature. We describe a case of severe primary hypothyroidism and pituitary tumorous hyperplasia mimicking a pituitary macroadenoma which regressed following levothyroxine therapy.

 

Case Presentation:

A 21 year old woman initially sought medical attention after sudden onset of right sided facial paralysis. She was diagnosed with Bell’s palsy and had additional evaluation with an MRI of the brain. It was reported to show a suspected pituitary macroadenoma extending to the suprasellar area and abutting the optic chiasm. The lesion measured 1.4 x 1.3 x 1.2 cm. The patient was referred for endocrinology consultation prior to proposed pituitary surgery.

There was a history of weight gain, cold intolerance, fatigue, hair loss, and oligomenorrhea. There were no complaints of headache or visual disturbances. Clinical examination and laboratory investigations were compatible with primary hypothyroidism. There was notable facial edema and slowed relaxation phase of deep tendon reflexes. Initial laboratory investigations revealed free T4 <1.90 pmol/L (N 8-18 pmol/L) and TSH >100 mIU/L (N 0.4-4.4 mIU/L). Prolactin was mildly elevated at 39.4 ug/L (N 3.3-26.7 ug/L). Anti-TPO antibodies were present at a significant titre of 346.80 IU/mL (N 0-9 IU/mL).

Dynamic testing of the hypothalamic-pituitary-adrenal axis was done with an insulin-induced hypoglycemia test prior to initiation of thyroid hormone therapy. Administration of regular insulin 0.1 units/kg led to an increase of cortisol from 261 nmol/L at baseline to 438 nmol/L at 90 minutes. The suspected diagnosis was Hashimoto’s thyroiditis with hyperprolactinemia and pituitary tumorous hyperplasia secondary to profound hypothyroidism. The patient was started on levothyroxine 50 mcg/day for two weeks which was then increased to 100 mcg/day. In follow up two months later, TSH decreased to 7.25 mIU/L (N 0.4-4.4 mIU/L), free T4 increased to 7.2 pmol/L (N 8-18 pmol/) and prolactin normalized. Levothyroxine was titrated up to 112 mcg/day and subsequent TSH and free T4 normalized. Repeat MRI of the brain 6 months from the previous showed a significant reduction in the size of the pituitary tumor, now measuring 1.2 x 1.3 x 0.7 cm.

 

Conclusion:

This case demonstrates that profound primary hypothyroidism can lead to the radiographic appearance of a pituitary macroadenoma and hyperprolactinemia. This was confirmed by normalization of prolactin and TSH in addition to regression of the pituitary pseudotumor after levothyroxine therapy. Recognition of this entity is important because diagnosis relies on detailed evaluation as neuroimaging alone is unreliable in differentiating pituitary tumorous hyperplasia from an actual tumor and treatment with medical therapy can lead to resolution thereby preventing unnecessary neurosurgical intervention.

 

Nothing to Disclose: WW, LV

21555 5.0000 SAT-448 A Regression of a Pituitary Pseudotumor after Treatment of Previously Undiagnosed, Severe Hypothyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Adriana Patricia Kuker*1, John C Ausiello2 and Sharon L. Wardlaw3
1Columbia University, College of Physicians and Surgeons, New York, NY, 2Columbia University College of Physicians and Surgeons, New York, NY, 3Columbia University College of Physicians & Surgeons, New York, NY

 

Background: Hemorrhage into an ACTH-secreting tumor resulting in pan-hypopituitarism, with eventual recovery of pituitary function is a rare occurrence.

Clinical Case: A 33 year-old woman presented with an acute headache. Two years prior, she had developed amenorrhea and had been diagnosed with polycystic ovary syndrome, hypertension, and type 2 diabetes. She was started on oral contraceptives, an ace inhibitor and metformin.  Over the past year, she had gained 70 pounds, and had noted worsening acne, hair loss, easy bruising, mood swings, and muscle weakness. Sitagliptin, liraglutide and insulin had been added due to poor glycemic control.  Low-dose and high-dose overnight dexamethasone suppression tests had been suggestive of Cushing’s disease. Brain MRI was recommended, but she developed a headache prior to the test prompting her to present to the emergency room for urgent evaluation. On exam, she was hemodynamically stable with normal visual fields. She was obese with thin extremities, round facies, cystic acne, dorsocervical fullness and purple abdominal striae. Laboratory values were notable for AM cortisol 20.4 ug/dL [5-25], ACTH 40 pg/mL [6-58], 24-hour urine free cortisol 466 ug/24 hours [<45], prolactin 0.8 ng/mL [1.9-25], TSH 0.3 mIU/L [0.32-4.05], free T4 0.88 ng/dL [0.7-1.24], LH 0.1 mIU/mL [<15], FSH 1.1 mIU/mL [<15], estradiol 34 pg/mL [10-400]. Brain MRI showed a 1.1 x 1.2 x 1.5 cm pituitary mass with hemorrhagic component. Her clinical picture was concerning for evolving hypopituitarism likely from an infarcting ACTH-secreting tumor. Neurosurgery recommended non-urgent resection of the mass. Three days later, she complained of a new headache, low energy, and weight loss. Her vital signs were stable, and she had a normal neurological exam. Head imaging was unchanged from prior. AM cortisol level was 7.6 ug/dL. It seemed that the tumor had further infarcted, and she was now cortisol deficient. Surgical intervention was deferred, and she was started on replacement hydrocortisone with clinical improvement. Brain imaging two months later showed a 4 x 3 mm pituitary adenoma without evidence of hemorrhage. Her labs were suggestive of recovery of pituitary function with AM cortisol 12.2 ug/dL, TSH 2.47 uIU/mL, free T4 1.29 ng/dL, prolactin 4.8 ng/mL, estradiol 63, FSH 5.0 mIU/mL, LH 2.3 mIU/mL. Currently, she is off hydrocortisone. We plan to monitor her pituitary function closely, especially for recurrence of Cushing’s disease.

Conclusion: This case describes a rare clinical entity with an atypical course. It illustrates the importance of having a high suspicion for secondary causes of obesity, diabetes, and hypertension in a young woman with signs of androgen excess. It also highlights the importance of closely monitoring ACTH levels after pituitary hemorrhage, as they can remain normal or elevated, and can subsequently decrease resulting in central adrenal insufficiency.

 

Nothing to Disclose: APK, JCA, SLW

20428 6.0000 SAT-449 A A Case Report: Remission of Cushing's Disease after Pituitary Hemorrhage Leading to Pan-Hypopituitarism with Eventual Recovery of Pituitary Function 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Mitali Talsania* and Robert Hal Scofield
University of Oklahoma, Oklahoma City, OK

 

Background:

Pituitary apoplexy, an uncommon complication of pituitary adenoma, is a medical emergency requiring rapid treatment with hormone replacement.  Anticoagulation with warfarin has been known to precipitate pituitary apoplexy.  Although there have been few case reports of pituitary apoplexy in patients on a heparin drip, only one case is reported of pituitary apoplexy in patients on warfarin.

Clinical Case:

69 year old man, on warfarin for atrial fibrillation, presented to the emergency room with a history of severe headache, fever, generalized weakness and hypotension.  He had no history of trauma or falls.  Initial CT head showed no signs of bleeding, but showed evidence of pituitary macroadenoma.  On admission, International normalized ratio (INR) was 4.47.  The patient was started on antibiotics empirically for bacterial meningitis.  He continued to have hypotension, confusion, and fever.  In addition, his glucose decreased to 66 mg/dl (n=70-110 mg/dl).  MRI done the next day showed evidence of pituitary apoplexy with supra-sellar mass size of 1.6 x 1.9 x 1.2 cm and hemorrhage inside the mass.  TSH was low normal at 0.43 (n=0.4-4.48uIU/ml) and free T4 was low at 0.59 (n=0.6-1.4ng/dl).  He had a normal FSH at 3.2 mIU/ml (n=1-19mIU/ml) and a low LH at 0.7 mIU/ml (n=1-9mIU/ml), with low testosterone at 1.1 ng/ml (n=2-7.5ng/ml).  Cortisol at 8 am was 13.4 mcg/dl (n=6.5-22.4 mcg/dl).  He was started on stress dose corticosteroids.  The patient did not have visual field changes.  Neurosurgery recommended conservative management.  Antibiotics were stopped as CSF cultures remained negative.  Cosyntropin stimulation test done 2 months later showed a cortisol at 60 minutes of 4.4 mcg/dl from 1.1 mcg/dl cortisol at baseline.  He continues to have hormone replacement with corticosteroids, levothyroxine and testosterone four years later.

Conclusion:

Pituitary apoplexy is a treatable condition that requires a high index of suspicion for diagnosis, since initial CT scan has low sensitivity, with rate of detection of 46%.(1)  Considering the low sensitivity of CT scan after the initial episode, it would be important not to reject the diagnosis of pituitary tumor apoplexy based on CT findings, if clinical assessments are suggestive. Predisposing factors, such as the use of anticoagulation, should be taken into account prior to ruling out pituitary apoplexy.  Early diagnosis and treatment can be lifesaving and improve prognosis.

 

Nothing to Disclose: MT, RHS

20763 7.0000 SAT-450 A Pituitary Apoplexy: Warfarin As Precipitating Factor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Narmada Movva*1, Sharleen Sidhu2, Boby G Theckedath2 and Janice L Gilden3
1Rosalind Franklin University of Medicine and Science/Chicago Medical School, North Chicago, 2Capt James A Lovell Federal Health Care Ctr, North Chicago, IL, 3Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL

 

Background:

Traumatic brain injury (TBI) has been documented to be a frequent cause of hypothalamic-pituitary function impairment. The incidence of hypopituitarism (Hypopit) following TBI is about  50 per 100,000 patients/ year.   Approximately  40% have been reported to have  neuroendocrine dysfunction with  15-90% reported to have varying degrees of hypopituitarism.  While growth hormone deficiency is the most common, gonadotropin and  somatotropin deficiencies may also occur,  followed by corticotropin and thyrotropin  deficiencies.  Chronic Hypopit  requiring  replacement therapy occurs in 20% of TBI patients,  especially  in those with more severe brain injuries.  However, syncope as a presenting symptom in  panhypopituitarism secondary to TBI has not been reported.

Case description:

The patient is a 67 yr old male who  was admitted  for dizziness.  He had episodic vertigo lasting for one hour every 3-4 weeks for the past 5 years.  Cardiology evaluation, including stress test and echocardiogram  were normal, as well as  Neurology and ENT evaluations.  Hormonal levels showed a low am cortisol  level  of  1.16  mcg/dl (Ref: 4.30-22.40). The  Cosyntropin Stimulation Test confirmed secondary adrenal insufficiency.  Other tests  were consistent with  panhypopituitarism  [ IGF 53 ng/ml (normal 75-228), FSH 1 mIU/ml (normal  1-18), LH < 1mIU/ml (normal 1-9), prolactin 3 ng/ml (normal  2-18), TSH 1.70 uIU/ml (0.34-4.82), free T4 1.53 ng/dl (0.77-1.61), free T3 1.6 pg/ml (2.3-4.2), growth hormone 0.1 ng/ml (0-10), total testosterone  2 ng/dl (250-1100), free testosterone 0.1 pg/ml (35-155)]. Therefore, he was started with replacement therapy with hydrocortisone, levothyroxine and Testosterone.   His symptoms resolved after replacement therapy with  no further episodes of syncope.  He later admitted to having had traumatic brain injury  about 40 yrs ago.

Conclusion :

Case reports of syncope with associated panhypopitutarism have been previously described due to  diffuse large cell lymphoma, complete heart block secondary to  Sjogren’s  syndrome,  and nonfunctioning pituitary macroadenoma .  However, our case demonstrates that syncope can be a presenting symptom for panhypopituitarism  occurring many years following the initial TBI.

 

Nothing to Disclose: NM, SS, BGT, JLG

20768 8.0000 SAT-451 A Syncope As the Presenting Symptom of Panhypopituitarism Due to Traumatic Brain Injury 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Lydia Kruge*1 and Ulrich K Schubart2
1Montefiore Medical Center, Bronx, NY, 2Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY

 

Background:  Severe hypothyroidism leading to colonic pseudo-obstruction has been well-documented in the literature.  However, there have been no published reports of colonic pseudo-obstruction requiring surgical intervention as the initial presentation of Sheehan’s syndrome.

Clinical case:  A 57 year-old woman presented with severe abdominal pain and altered mental status, and was found to have hypotension, tachycardia, and a distended and tympanic abdomen.  She was intubated and vasopressors were initiated.  A CT scan revealed severe dilatation of the sigmoid colon and a possible sigmoid volvulus.  The patient underwent an exploratory laparotomy, and was found to have a translucent colon dilated to approximately   without perforation, ischemia, or necrosis.  She underwent decompression of the sigmoid volvulus, resection of the sigmoid colon, and end colostomy.  Pathology later showed ischemic change, surface epithelial necrosis, and transmural edema.  Laboratory tests revealed 2AM cortisol 6.6 ug/dL (3-17.3 ug/dL), TSH 4.37 mlU/L (0.47-6.9 mIU/L), FT4 0.13 ng/dL (0.75-2 ng/dL), T3 0 ng/dL (60-181 ng/dL), and T4 0.7 ug/dL (4.5-12 ug/dL).  Further physical examination revealed periorbital edema, absence of axillary hair, trace non-pitting edema of her extremities, and normal deep tendon reflexes.  IV hydrocortisone and levothyroxine were initiated.  Further work-up revealed prolactin 1.52 ug/L (3-19 ug/L), FSH 9.8 IU/L (27.6-132.6 IU/L), LH 2.4 mIU/mL (30-72.6 mIU/mL), IGF-1 40ng/mL (53-287 ng/mL for age 51-60 years), ACTH 31 pg/mL (0-70 pg/mL).  An empty sella of normal size was seen on MRI.  On review of her chart, in 2006 she presented with severe constipation and was found to have sigmoid colon dilatation up to 9.3 cm on CT scan, and FT4 0.22 ng/dL (0.75-2 ng/dL) with TSH 7.64 mIU/L (0.47-6.9 mIU/L).  She was prescribed levothyroxine, however she was non-adherent.  The patient described severe constipation and fatigue for years, as well as depressive symptoms, dry hair, dry skin, poor appetite, and cold intolerance.  She admitted to post-partum hemorrhage with her second pregnancy 23 years prior.  She did not lactate post-partum but did have normal menses until menopause.  The constellation of panhypopituitarism, a history of post-partum hemorrhage, and an empty sella on MRI, led to a diagnosis of Sheehan’s syndrome.  The patient was eventually titrated off of vasopressors, extubated, and discharged home on cortisol and thyroid hormone replacement.

Conclusions:  Sheehan’s syndrome is an insidious disorder and may have multiple initial presentations, including severe prolonged constipation and colonic pseudo-obstruction.  If this patient had been diagnosed with panhypopituitarism at her initial hospitalization and had been adherent with her medical plan, surgical intervention for an extremely dilated colon would likely have been avoided.

 

Nothing to Disclose: LK, UKS

21796 9.0000 SAT-452 A A Case of Sheehan's Syndrome Presenting As Colonic Pseudo-Obstruction 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Hasan Ashraf*1, Sara E. Schwab2, Kashif M. Munir3 and Rana Malek3
1University of Maryland, 2University of Maryland School of Medicine, Baltimore, MD, 3University of Maryland Medical Center, Baltimore, MD

 

Background: Lymphomatous infiltration of the pituitary is a rare cause of hypopituitarism. The clinical presentation is usually asymptomatic given the pituitary’s reserve capacity, but can include mass effects including headaches, cranial nerve abnormalities, visual field defects, as well as clinical symptoms of hypopituitarism.

Clinical Case: A 55 year old woman diagnosed with diffuse large B-cell lymphoma (activated B-Cell variant, diagnosed at age 52 as stage IV) treated with multiple cycles of R-CHOP, and one cycle R-DHAP, was admitted for back pain, fever and headache. She also had symptoms of polyuria and polydipsia. Physical exam was notable for fever and dry mucous membranes. MRI of the brain showed a heterogeneously enhancing lesion, 20 x 9 mm, within the left side of the sella displacing the infundibulum and pituitary gland to the right without encroachment of the optic chiasm that had not been present on MRI in 2013. There was enhancement within the left internal auditory canal mildly protruding into the cerebellopontine angle approaching cranial nerve V, suggesting infiltration with lymphoma and leptominengeal spread of the neoplasm. Intrathecal chemotherapy with cytarabine and methotrexate was initiated along with hydrocortisone. Laboratory studies showed:  TSH  0.38 mIU/L (0.47-4.68) free T4 0.8 ng/ml (0.6-2.5), free T3 1.6 pg/ml (2.0-4.4), serum sodium 147 mEq/L, urine sodium 30 mEq/L, urine osmolarity 210 mEq/L, and serum osmolarity 299 mEq/L consistent with central diabetes insipidus and central hypothyroidism. Due to hydrocortisone administration, adrenal axis was not evaluated. Treatment with DDAVP 0.05mg PO qhs, levothyroxine 50mcg PO daily, and hydrocortisone 10mg qAM and 5mg qPM, resulted in clinical improvement. Hormone replacement was eventually discontinued with normal pituitary function two months after intrathecal chemotherapy.

Conclusion: Although lymphomatous metastasis to the pituitary is rare, diffuse B cell lymphomas are the most likely to metastasize (1). Pituitary insufficiency can occur, with central hypothyroidism being the most common abnormality, followed by diabetes insipidus and adrenal insufficiency. Recovery of pituitary function post-chemotherapy is usually partial, although complete resolution has been described (2). While rare, metastasis to the pituitary should be considered in the setting of a patient with a suspected or known history of lymphoma or other malignancies and clinical signs and symptoms of pituitary insufficiency. We describe a rare occurrence hypopituitarism due to metastasis of lymphoma, which completely resolved after chemotherapy.

 

Nothing to Disclose: HA, SES, KMM, RM

22106 10.0000 SAT-453 A Resolution of Hypopituitarism Secondary to Metastasis from Diffuse Large B-Cell Lymphoma after Chemotherapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Karen Gomez Hernandez*1, Ozgur Mete2, Sylvia L. Asa2 and Shereen Z Ezzat1
1University Health Network, University of Toronto, Toronto, ON, Canada, 2University Health Network, Toronto, ON, Canada

 

Introduction

Successful pregnancies have been previously reported in patients with von Hippel Lindau (VHL) and patients with isolated growth hormone deficiency (IGHD). Here, we describe the first report in the literature of a successful pregnancy in a woman with both conditions.

Case report

The proband’s parents had a consanguineous marriage. She was diagnosed with IGHD at two years of age and received GH therapy, but achieved an adult height of only 115 cm attributed to GH antibody formation. Molecular analysis of germline DNA revealed a deletion involving all 5 exons of one of the GH1 genes (c.1_1827del) and a deletion of the first four exons of the other GH1 gene (c.1_411del). Her younger sister was also diagnosed with IGHD type 1a and as a teenager, she also developed bilateral pheochromocytomas of a noradrenergic phenotype. Both the proband and her sister were diagnosed with VHL due to a c.193T>G mutation in the VHL gene. At age 31 the proband underwent right adrenalectomy and partial left adrenalectomy for symptomatic bilateral noradrenaline-producing pheochromocytomas. She remained in remission for 2.5 years when she became pregnant and developed episodes of anxiety, headaches, and palpitations. Her pre-pregnancy 24 hr urine collection revealed a slightly elevated dopamine/creatinine ratio; MRI of the residual left adrenal showed no abnormalities. Her brain MRI was normal while in her spine a small T3 hemangioma was identified.This lesion did not progress during pregnancy. During the third trimester of pregnancy, catecholamines and urine metanephrines became slightly elevated while maintaining normal plasma metanephrines. Her blood pressure increased from baseline averages of 90/50 mmHg to approximately 120/80 mmHg and a few measurements bordered in the hypertensive range. Amlodipine was started a week before planned cesarian delivery.  She did not have any complications during the surgery and delivered a healthy boy at 36 weeks of gestation. Three months postpartum her catecholamines and metanephrines returned to baseline. Of additional note, her undetectably low IGF-1 levels rose to 119 μg/L (n=182-481 μg/L) during pregnancy.

Conclusion

While previous reports indicate that pregnancy in women with VHL has a favourable outcome, life threatening complications include those associated with catecholamine excess, and SNC hemangioblastomas. Therefore it is important to ensure appropriate pre-conception treatment of functional pheochromocytomas as well as to monitor for any SNC complications during pregnancy. Our patient was monitored throughout her pregnancy and the mild biochemical abnormalities were likely false positive results as normalization was documented after delivery. The detection of circulating IGF-1 during her pregnancy emphasizes the role of placental growth hormone in regulating maternal production of this growth factor in patients with type 1a IGHD.

 

Nothing to Disclose: KG, OM, SLA, SZE

22014 11.0000 SAT-454 A Successful Pregnancy in a Woman with Von Hippel Lindau and Isolated Growth Hormone Deficiency Type 1 a 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Sana Shoaib Meah*, Elena Valerie Plummer and Beejal Ashok Shah
Phoenix VA Health Care System, Phoenix, AZ

 

Hypopituitarism: A Diagnosis in Disguise

Introduction: Hypopituitarism is a clinical syndrome of deficiency in pituitary hormone production resulting from disorders of the pituitary gland, hypothalamus or surrounding structures. Patients may have variable clinical presentation depending on the etiology, onset, and predominant hormone involvement.  Clinical features of hypopituitarism are subtle leading to delay in diagnosis. 

Case: 70 year old male with presented with complain of chronic fatigue, low libido, decreased strength for over decades. Patient was seen by a primary care physician in 2009 with similar complains. He was found to have low testosterone level and was started on testosterone replacement which he took it for 5 years without significant improvement.  He was referred to endocrinology for management of hypogonadism. Full pituitary hormonal evaluation was done since there was no previous workup done to determine cause of hypogonadism. Biochemical workup was consistent with hypopituitarism. MRI revealed partial empty sella.  Patient was started on replacement hormones which significantly improved his symptoms. 

Patient denied previous history of head trauma or intracranial mass. He reported a diagnosis of viral meningitis 15 years ago.  Patient presented to a community hospital at the time with complain of severe headaches, nausea, and vomiting. CT scan did not reveal acute intracranial process. He was given a diagnosis of viral meningitis and was treated symptomatically for few days in the hospital.  Upon reviewing the literature, we encountered case reports of pituitary apoplexy presenting as acute meningitis. In these case reports, patients presented with severe headaches, nausea, vomiting suggestive of possible meningitis. CT scan of head were unremarkable. CSF analysis findings were consistent with bacterial meningitis. Clinical signs and symptoms did not improve with initiation of antibiotics. Repeat imaging studies with MRI few days later lead to diagnosis of subacute pituitary apoplexy.  Reviewing these case reports have lead us to conclude that our patient was likely misdiagnosed with viral meningitis when he presented with pituitary apoplexy.

Conclusion: Clinical features of hypopituitarism are subtle, leading to delay in diagnosis. Patients may present to different specialties with vague complains. Male patients tend to have non-specific complaints which are often overlooked, misdiagnosed or partially diagnosed.  Hypogonadism seems like a popular diagnosis among primary care providers leading to increase use of testosterone supplementation.  Patients are started on testosterone replacement without a complete workup to evaluate for secondary causes.  With our case, we hope to heighten attention towards hypopituitarism as a differential diagnosis and pursuing a complete workup when evaluating patients with hypogonadism and vague complains.

 

Nothing to Disclose: SSM, EVP, BAS

20177 12.0000 SAT-455 A Hypopituitarism: A Diagnosis in Disguise 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Lih Ming Loh*1 and Peng Chin Kek2
1Singapore General Hospital, Singapore, Singapore, 2Singapore General Hospital, Singapore

 

Background

Pituitary stalk interruption syndrome (PSIS) is a rare congenital anomaly characterised by the triad of a very thin or interrupted pituitary stalk, an ectopic or absent posterior pituitary and hypoplasia or aplasia of the anterior pituitary on MRI. This can result in isolated GH deficiency (GHD) or multiple pituitary hormone deficiencies. The latter is reported to be more likely associated with other malformations. PSIS is usually a sporadic condition. Genetic mutations in HESX1 and LHX4 account for <5% of cases, all of which are familial. We report our observations in 3 patients seen at our centre.

Cases

Patient A presented to us at age 17 years for delayed puberty. There was a background of low birth weight, unilateral undescended testis and delayed developmental milestones. Patient had normal IQ, and did not have any dysmorphism or midline cranial defects. He was found to have panhypopituitarism. MRI showed a thin stalk with an ectopic neurohypophysis. There was also sclerotic basisphenoid-occipital synchondrosis. Despite markedly low IGF1 levels, patient was noted to have achieved normal adult height of 172 cm (mid parental height (MPH) 167 +/- 10cm).

Patient B was a 39 year old female at time of diagnosis. She had a background of hepatitis B cirrhosis, and had been multiply admitted for altered mental status attributed to hepatic encephalopathy. At one of these admissions, an endocrine consult was sought for hyponatremia and hypoglycemia, and workup revealed panhypopituitarism. MRI was consistent with PSIS. Patient gave a history of being investigated as a short child. She received GH therapy for less than two years, and subsequently was started on female hormone therapy for primary amenorrhea. As this was not successful, she stopped all forms of therapy since her mid teens. Despite suboptimal treatment with GH, she had noted continued height gain into early adulthood and was 158 cm (MPH 150.5 +/- 8.5 cm).

Patient C was 17 years old when he came for an opinion if GH therapy could  help achieve better height. He had a background of GHD diagnosed at age 3, and had GH therapy from then to age 13 years. He had spontaneous onset of puberty at age 13 and was at Tanner stage 3 when seen. GHD was confirmed on insulin tolerance test, but the rest of his pituitary hormones were normal. MRI showed PSIS. His height at presentation was 146 cm (MPH  171.5 +/- 10 cm).

Conclusions

Our first 2 patients confirm rare reports that patients with PSIS can continue to achieve good adult height despite GHD. Our 3rd patient is more typical of the classical GHD due to PSIS. We review the various postulates that have been proposed for the paradox of height gain despite GHD in PSIS.

 

Nothing to Disclose: LML, PCK

21889 13.0000 SAT-456 A The Paradox of Height Gain Despite Growth Hormone Deficiency in Pituitary Stalk Interruption Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Shayhira Suazo Herrera*1, Kenneth H Hupart2 and Salini Chellappan Kumar2
1Nassau University Medical Center, East Meadow, NY, 2Nassau Univ Med Ctr, East Meadow, NY

 

Background:

Neurosarcoidosis is a rare disease that occurs in 5-25 % of patients with Sarcoidosis. It’s prognosis is poor with a 10-18% mortality. Any part of the nervous system can be affected but cranial nerves, hypothalamus and pituitary are most commonly involved. The most common presentation is Diabetes insipidus and hypogonadotropic hypogonadism.

Case report:

A 39 year old female was diagnosed with Sarcoidosis with CNS and peripheral nervous system involvement in 2010. She developed obstructive hydrocephalus requiring a ventriculo-peritoneal shunt 3 weeks prior to her presentation in August 2014 with a progressive mental status decline and hypoglycemia with serum glucose of 28 mg/dL. Central adrenal insufficiency was diagnosed with serum cortisol of 10.5 mcg/dL and ACTH <5 pg/mL during an episode of hypoglycemia and borderline hypotension. With hydrocortisone therapy hypoglycemia resolved and her mental status improved. Thyroid tests were indicative of low T3 syndrome.

One week later the patient developed partial Diabetes Insipidus which responded to DDAVP; she was discharged to a skilled facility on prednisone and DDAVP. Two months later she was readmitted for urosepsis and treated with broad spectrum antibiotics and stress doses of glucocorticoids. During this admission, new onset central hypothyroidism was diagnosed with low levels of thyroid hormones and serial concentrations of TFT’s that were persistently low.

During a recent follow up in clinic, our patient was found to have developed hypogonadotropic hypogonadism; both prolactin and IGF-1 were in the low normal range.

Discussion:

Neurosarcoidosis is known to affect the hypothalamus and pituitary gland causing both posterior and anterior pituitary hormone deficiency syndromes. Our patient was diagnosed with neurosarcoidosis 4 years before our evaluation and came to our attention because of a clinical adrenal crisis. Soon after glucocorticoid therapy was instituted, she was found to have partial diabetes insipidus. This raises the possibility that diabetes insipidus was present for a longer time, but her free water clearance was diminished because of her adrenal axis deficiency. The time course of her development of diabetes insipidus suggests that is was unmasked by the administration of glucocorticoid replacement. Clinicians should be aware of the possibility of exposing diabetes insipidus when initiating therapy with glucocorticoids in patients with neurosarcoidosis.

 

Nothing to Disclose: SS, KHH, SCK

21860 14.0000 SAT-457 A Progressing Panhypopituitarism As a Consequence of Neurosarcoidosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Christina Glover*, Lane Frey, Shema R Ahmad and Jose S. Subauste
University of Mississippi Medical Center, Jackson, MS

 

Empty sellas are frequently found incidentally in the general population.  There are currently not clear guidelines for the assessment of these patients.  Most of the patients with empty sella remain asymptomatic throughout their life. However in those that exhibit adrenal insufficiency, fatality can be high.

A 38 year-old African American male with aplastic anemia and isolated ACTH deficiency diagnosed fifteen years earlier (ACTH < 5 pg/mL and cortisol <1 mcg/dL) presented with hypoglycemia, hypotension, and bradycardia.  Due to poor access to healthcare, he ran out of prednisone prior to presentation and has not been seen by an endocrinologist for three years.  Review of pharmacy records revealed longstanding noncompliance with steroid therapy.  Precipitating event for adrenal crisis was not elucidated.  For worsening and more frequent headaches, an MRI was obtained which demonstrated a partially empty sella but was otherwise normal.  In addition he reported diarrhea that was not unusual for him but denied fever, visual changes, weight changes, polydipsia, polyuria, or low libido.  ACTH was 1 pg/mL though he already received hydrocortisone.  Insulin-like growth factor-1 and prolactin were low at 30 ng/mL and 4.1 ng/mL, respectively.  Luteinizing hormone and follicle stimulating hormone were normal.

The patient received aggressive intravenous fluids as well as intravenous hydrocortisone 100mg every eight hours during his brief admission.  He was discharged on a quick prednisone taper with a final dose of 7.5mg daily as well as a dexamethasone emergency kit.  He was educated about the importance of medication compliance to prevent further adrenal crises as well as increasing his steroid dose during acute illness.

Partially empty sella is a very common condition.  At present there are not clear guidelines for initial management as well as follow up.  Adrenal insufficiency is associated with high morbidity and mortality.  Isolated ACTH deficiency is a rare form of central adrenal insufficiency.  Our case demonstrates the importance of a complete pituitary panel in the initial evaluation of patients with empty sella.  Isolated ACTH may represent a common association with empty sella and a high level of suspicion will help with diagnosis.

 

Nothing to Disclose: CG, LF, SRA, JSS

21897 15.0000 SAT-458 A Empty Sella and Isolated ACTH Deficiency: Is There an Association? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Anbar Ahmad*1, Moshe Bachar2 and Max E. Stachura2
1Georgia Regents University, Augusta, GA, 2Georgia Regents University

 

Introduction: Hypopituitarism requires early recognition and prompt treatment to avoid its potentially severe consequences. In adults, it is often undiagnosed due to non-specific symptoms of growth hormone deficiency, hypogonadism or mild deficiencies of other pituitary hormones. Underlying pituitary insufficiency can then manifest itself after infections or use of certain medications. We report a case of a female with unrecognized panhypopiutitarsim who presented with hypoglycemia and altered mental status after a urinary tract infection (UTI) and use of Cyproheptadine to stimulate her appetite.

Case: A 52 year old female presented to the ED after being found unresponsive at home. Her temperature was 38.1oC, heart rate 94 bpm and BP 98/69 mmHg. Basic metabolic panel was normal except for glucose of 37 mg/dl. The patient had been struggling with fatigue and anorexia, worsened by a recent UTI. Antibiotics were prescribed for the infection and Cyproheptadin initiated to stimulate appetite. Two weeks after starting Cyproheptadine, the patient was noted to be increasingly somnolent with changes in mental status that eventually led to unresponsiveness.

An ACTH stimulation test performed to evaluate adrenal function showed a baseline cortisol of 0.20 mcg/dl with 30 and 60 minute levels of 1.06 mcg/dl and 1.23 mcg/dl respectively.  Corresponding baseline glucose was 50 mg/dl with an ACTH of <5 pg/ml. Administration of stress dose steroids resulted in prompt resolution of hypoglycemia and improved mental status. She provided a history of difficulty conceiving 15 years ago and receiving hormone therapy to induce fertility. She also mentioned inability to breast feed after delivery.  Those symptoms were not evaluated further at that time. Over the subsequent years she experienced increasing fatigue, lightheadedness and inability to perform daily activities due to unexplained exhaustion. These historical details prompted further work up of her pituitary function revealing: TSH 2.7 mcIU/mL, free T4 0.59 dl ng/, LH 7.1 mIU/ml, FSH 13.62mIU/ml and IGF-1 30 ng/ml. An MRI of the head was normal. We concluded that the patient had underlying mild panhypopituitarism which was exacerbated by an infection and concurrent use of Cyproheptadine. Cyproheptadine is known to suppress ACTH and cortisol secretion and to decrease growth hormone response to hypoglycemia.

Conclusion: Clinical manifestations of pituitary insufficiency depend on the extent of hormone deficiency and may be non-specific. Cyproheptadine can reduce cortisol secretion in response to hypoglycemia. It can also lead to significant suppression of plasma ACTH and serum cortisol  response to CRH suggesting a direct inhibitory action of cyproheptadine at the pituitary level.  A detailed past medical history and recent use of medications is essential when pituitary insufficiency is suspected.

 

Nothing to Disclose: AA, MB, MES

19868 16.0000 SAT-459 A Underlying Pituitary Insufficiency Revealed By Treatment for Anorexia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Anthony Liberatore* and Ronald M Lechan
Tufts Medical Center, Boston, MA

 

Background: Carotid Cavernous fistulas (CCF) are rare vascular shunts that can cause pituitary enlargement, hypoperfusion and hypopituitarism.  Some of these abnormalities are reversible with surgical repair.

Clinical Case:  A 53 year old woman was hospitalized with a left, cranial nerve VI palsy and enlarged pituitary on head MRI.  She had a 3 month history of sinus pressure, eye redness and 2 weeks of acute onset diplopia.  Noncontrast head MRI revealed an enlarged pituitary (1.1x0.9x1.4cm) with upward convexity into the suprasellar cistern.  There was no cavernous sinus invasion, but bilateral, low signal foci in the cavernous sinus raised the question of aneurysms.  Initial BP was 137/67, and HR 65/min without postural change.  There was a notable, isolated, left, cranial nerve VI palsy, bilateral conjunctival injection with chemosis, and a delayed relaxation phase of her biceps reflex.  Testing revealed a serum sodium of 142 mEq/L (135-145), potassium 4 mEq/L (3.6-5.1), random cortisol <1 mcg/dL and ACTH 25 pg/ml.  Basal cortisol was 1 mcg/dL and 60 minute response to Cortrosyn 17.7 mcg/dL.  FT4 was borderline, 0.76 ng/L (0.7-1.48), and prolactin was elevated at 39.2 ng/mL (5.2-26.5).  Pituitary function was otherwise normal.  Glucocorticoids and levothyroxine were started.  MRA confirmed bilateral CCF, and she underwent fistula coiling.  Within 48 hours, her diplopia improved and she was discharged on hydrocortisone and levothyroxine.  Head MRI at 4 months showed that the pituitary size had decreased to 1.3x0.7x1.2cm.  AM cortisol 24 hours after last dose of hydrocortisone was 16.1 mcg/dL and FT4 1.5 ng/L.  Prolactin decreased to 14.9 ng/mL. Hydrocortisone and levothyroxine were discontinued.  Two weeks later, thyroid function tests showed persistent central hypothyroidism, and levothyroxine was resumed.  She was noted to have joint laxity and other features suggestive of Ehlers-Danlos and was referred to clinical genetics for confirmatory testing. 

Conclusion:  The cavernous sinus contains the internal carotid artery, cranial nerves III, IV, V1, V2, VI, sympathetic fibers and a venous plexus that drains the confluent veins emanating from anterior and posterior pituitary.  Elevated pressure within the cavernous sinus, as seen in CCF, may impair normal venous drainage from the pituitary and/or interfere with conveyance of hypothalamic releasing/inhibitory factors to the anterior pituitary as a result of increasing venous pressure in the portal system. Normalization of cortisol and prolactin following correction of the AV shunt in our patient supports this hypothesis, although ongoing central hypothyroidism raises concern that this condition can result in permanent deficits.  One should consider the possibility of CCF in patients with Ehlers-Danlos syndrome who present with hypopituitarism.

 

Nothing to Disclose: AL, RML

19903 17.0000 SAT-460 A Hypopituitarism Secondary to Bilateral Carotid-Cavernous Fistulas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Christian A. Koch*1 and Vetta Vedanarayanan2
1Univ of Mississippi Med Ctr, Jackson, MS, 2University of Mississippi Medical Center, Jackson, MS

 

Background: Micropenis has many etiologies and may be overlooked by providers or not further investigated. It may be due to hypogonadotropic hypogonadism which can be seen in Kallman's syndrome, typically combined with anosmia, resulting from incomplete migration of neuroendocrine gonadotropin-releasing hormone cells along the olfactory, vomeronasal, and terminal nerves. The spectrum of genotypes and phenotypes in patients with Kallman's syndrome is widening and one third of KS individuals have deafness. Hearing impairment can also be found in subtypes of Waardenburg-Hirschsprung (WH) syndrome for which recently mutations in the transcription factor SOX10 have been identified. WHS is characterized by hearing loss, pigmentation and musculoskeletal abnormalities, demyelinating polyneuropathy and Hirschsprung disease.

Case report: A 31 yo white man with WHS had been referred to us by neurology for micropenis and a low total testosterone of 72 ng/dl. The patient never had shaved and sexual intercourse and reported to masturbate and having sex drive. He stated that his ejaculate had no sperm and that he had midthoracic back pain. He denied fatigue, headaches, visual field changes, galactorrhea, and depression. WHS was diagnosed at birth and developed bilateral hearing impairment and progressive gait problems. His family history revealed that WHS also occurred in 2 brothers and his mother and was negative for pituitary, adrenal and thyroid disorders. He did not take any medications, was single, nonsmoker, no alcohol, no drugs, working as an artist. On exam, he was 167 cm, 53 kg, BP 106/70, pulse 87, impaired hearing, normal neck, nontender abdomen, increased waist line, hyporeflex deep tendon reflexes, no vitiligo or depigmentation, no gynecomastia, small testicles Prader orchidometer size 4, unerected 4 cm size penile length, normal pubic hair, no axillary hair, no beard, shoe size 9. His free testosterone was 2.2 ng/dl, total testosterone 196 ng/dl, LH 4.8, FSH 4.6, prolactin 10.5, TSH 2.5, free T4 1.3, cortisol 23 mcg, hematocrit 38%. We discussed testosterone replacement therapy, not so much for sexual reasons but to help improve his body composition including bone mass and muscular function. We are in the process of testing him and family members with WHS for mutations in SOX10.

Micropenis can be the presenting feature of hypogonadotropic hypogonadism without anosmia but with bilateral hearing impairment, seen in the context of WHS. Timely diagnosis and treatment of hypogonadotropic hypogonadism may help prevent secondary osteoporosis, metabolic syndrome, and worsening muscular function in these patients and also assist further subtyping various geno- and phenotypes of WHS and Kallman's syndrome.

 

Disclosure: CAK: Speaker, Ipsen, Speaker, Pfizer, Inc., Advisory Group Member, Bayer, Inc.. Nothing to Disclose: VV

21956 18.0000 SAT-461 A Micropenis Sox 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Aditi Khokhar*1, Vatcharapan Umpaichitra2 and Sheila Perez-Colon3
1SUNY upstate medical university, Syracuse, NY, 2SUNY Downstate Medical Center, Brooklyn, NY, 3SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY

 

Background: Septo-optic dysplasia (SOD) is a rare phenotypically heterogeneous condition defined by the association of two out of three features: mid-line brain abnormalities, optic nerve hypoplasia and hypothalamic-pituitary endocrine deficiencies. (1) Its reported incidence is 1/10,000 live births, with M:F ratio of 1:1. (2) SOD is multifactorial in nature with both genetic and environmental factors playing important role in its pathogenesis.(3,4) Genetic abnormalities are identified only in one percent of patients suggesting the role of environmental factors as well as other unidentified genetic mutations in SOD.(5,6)

Objective:

1. To describe varied clinical spectrum of SOD among five pediatric patients with different ethnic backgrounds living within same geographical location

2. To report common maternal and environmental factors amongst the five patients

Method: Retrospective chart review

Results: Five pediatric patients were diagnosed with SOD over a period of 15 months at our institution. Out of five patients, three were females and two were males. Three patients were African American, one Asian and one of Hispanic descent. Four patients were born full term and one patient was born premature (31.7 weeks of gestational age). All patients were first born children. Four mothers were primigravidae with age at child birth ranging from 19 to 21 years. One mother was 29 years old and had history of two prior miscarriages. None of the mothers reported smoking, drugs or alcohol use during pregnancy. Two patients were diagnosed at birth. Ages of diagnosis for the other three patients were 2, 3 and 7 years. Two of the five patients developed pituitary hormone abnormalities. Three patients had bilateral optic nerve hypoplasia; one patient had unilateral optic nerve hypoplasia. One patient had bilateral anopthalmia and SOX2 gene deletion. Four of the five patients had corpus callosum or septum pellucidum hypoplasia.

Discussion: We observed an increase in incidence of SOD at our institution which could be a reflection of increased awareness among physicians about this condition. As described earlier, we observed SOD to be more common in young primigravida mothers. Our patients are residents of Central Brooklyn which is a region with high population density, a setting that has been described to have higher incidence of SOD. (7) The patients that did not have hypopituitarism might develop endocrine abnormalities later in their life. These patients need to be followed periodically. Early diagnosis and treatment of this condition should decrease the disease related morbidity and mortality.

 

Nothing to Disclose: AK, VU, SP

19329 19.0000 SAT-462 A Septo-Optic Dysplasia in Central Brooklyn Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM SAT 444-462 6002 1:00:00 PM Hypopituitarism, Apoplexy, and other Pituitary Syndromes Poster


Esther Eisenberg*1, Louise M O'Brien2, Susan Jin3, Amy Linnea He3, Hao Huang4, Yolanda R Smith5, Michael P Diamond6, Richard S Legro7, Heping Zhang8 and Nanette Santoro9
1Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Bethesda, MD, 2Associate Professor at University of Michigan, 3Yale University, 4Yale University School of Medicine, New Haven, CT, 5University of Michigan, Ann Arbor, MI, 6Georgia Regents University, Augusta, GA, 7Penn State Univ Coll of Med, Hershey, PA, 8Yale University, New Haven, CT, 9University of Colorado-Denver, Aurora, CO

 

Sleep habits have not been studied systematically in infertile women. Yet PCOS, a common cause of infertility, has been associated with increased sleep disturbances. PCOS is frequently accompanied by obesity and metabolic abnormalities including insulin resistance, which have been implicated as risk factors for obstructive sleep apnea (OSA). 

Objective: To evaluate sleep parameters in infertile women with polycystic ovary syndrome (PCOS) and unexplained infertility (UI) and assess risk factors for OSA and disturbed sleep.

Methods: 1603 infertile women who were participants in the Reproductive Medicine Network’s randomized clinical trials Pregnancy in Polycystic Ovary Syndrome II (PPCOS II; N=739) and Assessment of Multiple Intrauterine Gestations from Ovarian Stimulation (AMIGOS; N=864) completed the Sleep Habits questionnaire prior to initiation of treatment. PCOS was defined by Rotterdam Criteria and women with UI by definition were ovulatory. Females in both cohorts were 18-40y, had at least 1 patent fallopian tube and normal uterine cavity, and a male partner with sperm concentration of at least 14 million/ml. Self-reported responses were compared by cohort (PCOS or UI). Multivariate logistic regression was conducted with sleep responses as outcome adjusted for BMI, Ferriman-Gallwey score, testosterone, measures of insulin resistance, smoking, alcohol consumption and history of heart disease, hypertension, waist circumference, ethnicity, SHBG, AMH and total antral follicle count.

Results: Women with PCOS were more likely to report short duration of sleep <6 hours (6.1% vs. 2.7%; P<.001), habitual snoring (37.8% vs. 19.0%; p<.001), and had more subjective sleepiness (12.0% vs. 8.6%; P<0.026) than those with UI; and had 4.54 (2.07-9.97) increased odds ratio (OR, 95%CI) of a previous diagnosis of OSA, 2.59 (1.87-3.60) OR of habitual snoring, 2.39 (1.43-3.98) OR of sleeping less than 6 hours and 4.71 (1.08-20.56) OR of breathing pauses (sleep apnea). After adjustment, PCOS and fasting insulin level >10 mIU/ml were associated with a diagnosis of OSA, whereas PCOS, insulin >10 mIU/ml, waist circumference >88 cm and current smoking were associated with self-reported habitual snoring.

Conclusions: Infertile women with PCOS more commonly report sleep disturbances than those with UI.  Measures of insulin resistance are associated with previous diagnosis of OSA, habitual snoring and shortened sleep duration of <6 hours per night. Obesity and increased waist circumference are associated with snoring/habitual snoring, and measures of hyperandrogenism are associated with perceived sleepiness.

 

Nothing to Disclose: EE, LMO, SJ, ALH, HH, YRS, MPD, RSL, HZ, NS

18358 2.0000 SAT-090 A Sleep Habits of Infertile Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Noy Halevy1, David H Barad2, Norbert Gleicher3 and Vitaly A. Kushnir*3
1Sackler School of Medicine, 2The Center for Human Reproduction, New York, NY, 3Center for Human Reproduction, New York, NY

 

Objective:  To evaluate the natural history of polycystic ovary syndrome (PCOS) and low functional ovarian reserve (LFOR) with advancing female age, based on testosterone levels, anti-Müllerian hormone (AMH), and sex hormone binding globulin (SHBG).

Methods:  We investigated in a retrospective cross-sectional study 31 PCOS and 43 age-matched infertile women with LFOR, further stratified into young (21 to 38 years) and old (≥39 years), and 14 young women with normal functional ovarian reserve (NFOR). Normality of data was tested for all continuous variables; those not normally distributed were log transformed. Values are shown as means and 95% confidence intervals (CI). One way ANOVA was used to evaluate differences between study groups.

Results: Young PCOS presents with a typical pattern of significant hyperandrogenemia and elevated AMH in comparison to young women with NFOR [total testosterone 44.0 (32.9-58.7) vs. 23.9 (20.3-28.1) ng/dL, (P<0.05); and AMH 7.7 (6.2-9.1) vs. 2.5 (2.0-3.0) ng/mL, (P<0.05)]. With advancing age, hyperandrogenemia in PCOS diminishes in comparison to young women with NFOR, resulting in similar testosterone levels [28.6 (19.7-37.5) vs. 23.9 (20.3-28.1) ng/dL]. In older PCOS, AMH, however remains significantly elevated in comparison young women with NFOR [4.0 (2.7-5.2) vs. 2.5 (2.0-3.0) ng/mL, (P<0.05)]. LFOR at young and old ages demonstrates no differences in total testosterone [17.6 (12.9-24.1) vs. 18.1 (13.6-24.1) ng/dL)] and AMH [0.4 (0.3-0.6) vs. 0.3 (0.2-0.5) ng/mL]. Younger and older LFOR patients demonstrate significantly lower AMH levels in comparison to young women with NFOR (P<0.05).  SHBG did not differ significantly between groups but trended opposite to testosterone.

Conclusions: In women with PCOS, testosterone declines more precipitously then AMH with advancing female age. At older age, AMH is a better marker of PCOS and LFOR than testosterone. This data support incorporation of AMH as diagnostic criterion for PCOS regardless of age, and imply that testosterone should not be relied upon in the diagnosis of PCOS in older women.

 

Disclosure: DHB: Owner, Fertility Neutraceuticals. NG: Owner, Fertility Neutraceuticals. Nothing to Disclose: NH, VAK

18435 6.0000 SAT-094 A The Relative Importance of AMH and Androgens in Women with a Non-Obese PCOS Phenotype Changes with Advancing Age 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Do Kyeong Song*, Jee-Young Oh, Hyejin Lee, Young Sun Hong and Yeon-Ah Sung
Ewha Womans University School of Medicine, Seoul, Korea, Republic of (South)

 

Although increased serum anti-Müllerian hormone (AMH) levels have been suggested as surrogate markers of polycystic ovarian morphology (PCOM), association with polycystic ovary syndrome (PCOS) is controversial and optimal threshold is not determined. The aim of this study was to observe the relationship of AMH and PCOS phenotypes and to determine the optimal cutoff point of AMH for diagnosis of PCOS in young Korean women.

 We recruited 207 PCOS women (aged 17-38 yr; 120 with PCOM and 87 without PCOM) and 220 regular cycling, normoandrogenic women (aged 17-38 yr; 100 with PCOM and 120 without PCOM). Reproductive hormonal measurements and ovarian ultrasound were performed.

 Women with PCOS had higher serum AMH levels compared to controls (P<0.05). Women with PCOM had higher serum AMH levels than women without PCOM, regardless of PCOS (P<0.05). The optimal AMH cutoff point for diagnosis of PCOS was 10.5 ng/dl (68% sensitivity, 74% specificity), and the area under the receiver-operating characteristic curve was 0.78 (95% confidence interval 0.74-0.82). Serum AMH levels did not differ according to 5 age groups (<20, 20-24, 25-29, 30-34, >35 yr). It was significantly correlated with total testosterone (r=0.329, P<0.001) and free testosterone (r=0.161, P=0.022) in women with PCOS after adjustment for age. In a linear regression analysis, serum AMH was an independent determinant of the total testosterone after adjustment for age, BMI, and the number of menses/year (β=0.314, P<0.001). In a logistic regression analysis, odds ratio of AMH was 1.29 (95% CI 1.15-1.43) for predicting PCOS after controlling for age, BMI, total testosterone, and the number of menses/year.

 AMH was associated with hyperandrogenism only in women with PCOS but not with regular cycles independent of presence of PCOM, and serum AMH levels can be useful for diagnosis of PCOS at any age group. The optimal cutoff point for diagnosis of PCOS was 10.5 ng/ml in young Korean women.

 

Nothing to Disclose: DKS, JYO, HL, YSH, YAS

20326 7.0000 SAT-095 A Serum Anti-Müllerian Hormone Levels in Young Korean Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Osamu Yoshino*1, Sayaka Ogura-Nose2, Ikumi Akiyama3, Yutaka Osuga4 and Shigeru Saito2
1The University of Toyama, Toyama, Japan, 2University of Toyama, 3University of Tokyo, 4The University of Tokyo, Tokyo, Japan

 

Objectives:  Serum concentration of AMH is used as a biomarker in practical clinics. Therefore, it is important to elucidate the mechanism by which AMH is regulated in granulosa cells (GC). An important first step in understanding AMH regulation is to determine which factors up-regulate AMH expression.

Study design: Experiment (Exp) 1. Human GC, obtained from in vitro fertilization patients, were stimulated with various intraovarian cytokines including BMP-2, -6, -7 -15, activin-A and GDF-9 (100 ng/ml). The expression of AMH mRNA was evaluated with quantitative PCR, and AMH protein in cultured supernatant was measured with EIA kit. (Exp 2) Serum concentration of BMP cytokines, AMH and FSH in 25 infertility patients were measured with EIA or ELISA.

Results: (Exp 1) BMP-2, -6, -7 and -15, but not activin-A and GDF-9, significantly induced AMH expression in GC at mRNA and protein level, while all stimuli increased FSH receptor mRNA level.

(Exp 2) Among 25 infertile patients, serum BMP-2, -6, and -7 were detected only in 10, 3, 7 patients respectively, while AMH was detected in 24 out of 25 patients. There was no relation between BMP cytokines and AMH concentration in serum.

Conclusions: Among TGF-b superfamily, BMP-2, -6, -7 and -15 significantly induced AMH expression in human GC. The detection rate of these BMPs in serum was much lower than that of AMH. Serum concentration of BMP-2, -6, -7 could not estimate serum AMH level. As AMH is derived from GC, serum concentration of AMH might be an integral of the effect of ovarian BMP cytokines. Further study is needed if BMP cytokines might increase the concentration of AMH in vivo.

 

Nothing to Disclose: OY, SO, IA, YO, SS

18559 8.0000 SAT-096 A AMH Is Induced By Bone Morphogenetic Proteins (BMP) Cytokines in Human Granulosa Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Joseph A Cacioppo*, Po-Ching Patrick Lin, Patrick R Hannon, Arnon Gal and CheMyong Ko
University of Illinois at Urbana-Champaign, Urbana, IL

 

Successful ovulation is inherently dependent upon a myriad of intrinsic ovarian and extrinsic factors that signal for follicular growth, vascularization, leukocyte invasion, and ultimately oocyte rupture prior to fertilization. Prior to ovulation, granulosa cells of periovulatory follicles transiently produce the potent vasoconstrictor EDN2, a gene product of endothelin-2 (edn2). We previously showed that antagonization of the Endothelin receptor pathway significantly reduces ovulation, indicating a potential role of contraction in ovulation. To determine the significance of EDN2 production in the granulosa cells, we selectively ablated the edn2 gene by crossbreeding a floxed edn2 mouse with an esr2-iCre mice that express iCre under the promoter of estrogen receptor beta (esr2). In the ovary, esr2 expression begins during follicular recruitment in the primary follicle stage and is spatially limited to the granulosa cells. We hypothesized that the loss of edn2 in granulosa cell results in reduced ovulation and therefore smaller litter size. We found that ablation of edn2 by esr2-iCre significantly reduced the numbers of ovulated oocytes compared to wild type littermates when treated with gonadotropins for ovulation induction (3.75±0.88 vs 16.36±1.85 oocytes/ovary, p=0.001, respectively). Furthermore, edn2 ablation resulted in smaller litters than controls (4.50±1.18 vs 8.50±0.60, p=0.016, respectively). Though fecundity was decreased, the number of pregnancies to term per pairing was not different between groups (p=0.812), implying that some follicles ovulated successfully in the absence of edn2 expression. Histological examination showed that the ovaries of the conditional edn2 knockout mice had significantly more antral follicles and fewer corpora lutea than controls (p=0.019 and p=0.013, respectively), suggesting that follicles progress to the antral stage but some are unable to rupture at the time of ovulation. To ensure the findings from this study were due to the selective loss of edn2 expression in the granulosa cells, we likewise ablated edn2 using a cyp19-iCre mouse. Expression of cyp19 begins during the secondary follicular stage in granulosa cells as estrogen production increases, slightly later than esr2 induction. We observed that these mice remained fertile but showed a decrease in fecundity following edn2 ablation (4.67±0.71 pups/litter, p=0.022). These data strengthen the hypothesis that the local EDN2 signaling cascade is an important player in driving ovarian follicle rupture at the time of ovulation.

 

Nothing to Disclose: JAC, PCPL, PRH, AG, CK

21222 9.0000 SAT-097 A Intraovarian Endothelin-2 Expression Is Fundamental for Normal Ovulation and Subsequent Fecundity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Thippeswamy Gulappa*1, Bindu Menon1 and Jairam K M Menon2
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI

 

We have shown that Luteinizing hormone receptor mRNA expression in the ovary is regulated post-transcriptionally by LH receptor mRNA binding protein (LRBP). Mechanistic studies revealed that LRBP interacts with eukaryotic initiation factor 5A (eIF5A) which undergoes hypusination, a unique post-translational modification and leads to ligand-induced LHR mRNA downregulation (1, 2). The present study examined the upstream LH/hCG-induced signaling pathway involved in eIF5A hypusination and LHR mRNA downregulation.  Superovulation was induced in 23 day old rats by subcutaneous injection of 50 IU PMSG, followed 56h later with 25 IU hCG. On day 5 of superovulation, the rats were treated with PKA inhibitor H89 (100 mg/kg, s.c) or ERK1/2 inhibitor UO126 (10 mg/kg, s.c) followed 1h later with 50 IU hCG. Another group of rats were treated with eIF5A hypusination inhibitor GC7 (16 mg/kg, i.p) before treatment with 50 IU hCG. Ovaries were harvested 2, 4 and 6h after hCG treatment. EIF5A hypusination was examined by western blot analysis and 3[H]-spermidine incorporation followed by fluorography after 12% SDS-PAGE gel electrophoresis. The results showed significant (p<0.05) increase in eIF5A hypusination during hCG-induced downregulation of LHR at all the time intervals examined. This increase was significantly inhibited (70-80%) by pretreatment with PKA inhibitor, ERK1/2 inhibitor or hypusination inhibitor. Further studies using real-time PCR and Western blot analyses showed that hypusination inhibition caused by GC7 pretreatment resulted in significant abolishment of hCG-induced LRBP mRNA and protein expression. Additionally, RNA electrophoretic mobility shift assay (REMSA) results showed that inhibition of eIF5A hypusination significantly inhibited hCG-induced LHR mRNA binding to LRBP during LHR downregulation. From these results we conclude that during hCG-induced downregulation of LHR, activation of cAMP-PKA-ERK1/2 signaling pathway stimulated eIF5A hypusination which, in turn, leads to LHR mRNA degradation.

 

Nothing to Disclose: TG, BM, JKMM

22018 10.0000 SAT-098 A Hypusination of Eukaryotic Initiation Factor 5A Via cAMP-PKA-ERK1/2 Pathway Is Required for Ligand-Induced Downregulation of LH Receptor mRNA Expression in the Ovary 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Osamu Suzuki*
Natl Inst of Biomed Innovation, Ibaraki, Japan

 

[Aim] Strain/individual differences in superovulation efficiency with gonadotropins constitute a serious problem in mouse reproduction (Ref. 1). Recent studies suggest that tachykinins are involved in mammalian folliculogenesis (reviewed by, e.g., Ref. 2). In this study, as the first step to examine a role of tachykinins in superovulation efficiency in mice, ovarian protein contents of two kinds of tachykinin receptors (NK1R and NK2R) were compared among three strains with different responses to superovulation induction. [Method] Three mouse strains, A/J, C3H/HeJ, and B6D2F1 were used as low, intermediate, and high responders to gonadotropin-induced ovulation, respectively. Ovarian NK1R and NK2R protein contents in 4-week-old females of these strains were measured by quantitative Western blots with GAPDH as an internal control using whole ovary homogenates (see Ref. 3 for details). Sources of antibodies were: anti-NK1R and anti-NK2R antibodies from Abcam; anti-GAPDH antibodies from Millipore; HRP-conjugated secondary antibodies from Jackson ImmunoResearch. [Results] Ovarian NK1R protein contents normalized per GAPDH protein contents were 1.5±0.1a (arbitrary unit, mean±SEM, n=4), 1.0±0.1b, and 1.3±0.1ab in A/J, C3H/HeJ, and B6D2F1, respectively. Ovarian NK2R protein contents per GAPDH were 5.2±0.4a, 2.6±0.8b, and 2.0±0.5b in A/J, C3H/HeJ, and B6D2F1, respectively. Values with different superscripts in each receptor were significantly different by Tukey tests (p<0.05). [Discussion] Significant strain differences were found in both NK1R and NK2R receptors. Although ovarian NK1R contents did not differ between low (A/J) and high (B6D2F1) responders, significantly more ovarian NK2R contents was detected in a low responder (A/J) than in intermediate (C3H/HeJ) and high (B6D2F1) responders. This reverse correlation of ovarian NK2R contents and superovulation efficiency suggest that the NK2R pathway suppresses the number of ovulated oocytes at gonadotropin-induced ovulation. Therefore, as the next step, the effect of NK2R antagonists, rather than NK2R agonists, should be examined for better superovulation in A/J mice.

 

Nothing to Disclose: OS

20188 11.0000 SAT-099 A Strain Difference in Protein Contents of Tachykinin Receptors in Mouse Ovaries 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Yogeshwar Makanji*1, Duaa Al-Muhana2, Sin Young Oh2, Jared Mamrot3, Peter Temple-Smith2, Craig Anthony Harrison1, David Walker3 and Hayley Dickinson3
1MIMR-PHI Institute of Medical Research, Clayton, Australia, 2Monash University, Clayton, Australia, 3MIMR-PHI Institute, Clayton, Australia

 

Spiny mice are precocial and exhibit advanced ovarian maturity compared to altricial species like C57BL/6 F1 mice. In addition, the germ-cell nest breakdown in the ovary and establishment of ovarian reserve in spiny mice occurs in utero, similar to humans. The typical estrous cycle and gestation period in the spiny mouse is longer than in F1 mice (~20 days vs 4–5 days and 11 days vs ~39 days, respectively). The aims of this study were to establish a three-dimensional culture model for spiny mouse follicles and determine the role of activin A during ovarian follicle growth, in vitro.

In this study, secondary (130-150 mm) follicles were mechanically isolated from spiny mouse ovaries and encapsulated in alginate hydrogels. Individual encapsulated follicles were cultured in defined culture medium containing activin (100 ng/ml), activin specific antagonist (1µg/ml) or vehicle control for up to 18 days at 5% CO2, 37C. Medium was refreshed every other day and follicles were imaged. Cultured medium was stored at -80C for hormone analysis. Follicles were imaged every other day and diameter was measured using NIH ImageJ software. Pre-ovulatory follicles (~500 mm) were removed from alginate hydrogel and incubated overnight in medium containing hCG/EGF. Following maturation, oocyte meiotic competence was assessed under the microscope.

Spiny mouse follicles treated with activin A or vehicle control grew at similar rates. Interestingly, on day 12 of culture activin A treated follicles had higher survival rates compared to vehicle control (82% vs. 50%). Follicle survival was further diminished (35%) in the activin specific antagonist treatment group. In addition, follicles treated with the activin specific antagonist were reduced in diameter and failed to form an antrum.

In conclusion, three-dimensional in vitro culture of spiny mouse follicles provides insights into folliculogenesis of a unique species. Interestingly, treatment with activin A improved follicle survival and not follicle growth. The mechanism of this improved follicle survival due to activin A treatment is being explored. The activin specific antagonist will be useful in determining the specific paracrine roles of activin during folliculogenesis.

 

Nothing to Disclose: YM, DA, SYO, JM, PT, CAH, DW, HD

21740 12.0000 SAT-100 A Activin a Improved Survival of Spiny Mouse (Acomys cahirinus) Ovarian Follicles Cultured in Three-Dimensional Alginate Hydrogels 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


So-Youn Kim*1, Katherine Ebbert1, Megan Romero1, Marilia Cordeiro1, Vanida Serna2, Teresa K Woodruff3 and Takeshi Kurita4
1Northwestern University, Chicago, IL, 2Ohio State University, Columbus, 3Feinberg School of Medicine, Northwestern University, Chicago, IL, 4Ohio State University, Columbus, OH

 

Previously, imatinib, an ABL kinase inhibitor, was shown to protect primordial follicles against cisplatin. Accordingly, the phosphorylation of TAp63 by c-Abl/ABL1 has been implicated as the key pathway of chemotherapy-induced oocyte death. We have demonstrated that oocytes specific conditional knockout (cKO) mice for Trp63 gene, encoding TAp63, were insensitive to cisplatin-induced follicle loss, supporting the essential role of TAp63 in cisplatin-induced oocyte apoptosis. On the other hand, involvement of c-Abl in oocyte apoptosis was indirectly supported by inhibitor studies: Two Abl kinase inhibitors with different modes of action, imatinib and GNF-2, protected primordial follicles from cisplatin.

In our previous study, induction of c-Abl by cisplatin was significantly attenuated in Trp63 null oocytes, suggesting that c-Abl might be a down-stream of TAp63. Moreover, cisplatin did not induce hyperphosphorylation of TAp63, which occurred in g-irradiated oocytes. These observations prompted us the generation of Abl1 cKO mice to explore the function and requirement of c-Abl in the TAp63-regulated apoptosis of premature oocytes. Surprisingly, primordial follicles of oocyte specific Abl1 cKO mice underwent apoptosis in response to cisplatin, indicating that oocytic c-Abl is dispensable for the cisplatin-induced oocyte death. Moreover, hyperphosphorylation of TAp63 was induced by radiation in the absence c-Abl, indicating that the previously proposed role of c-Abl in phosphorylation of TAp63 was incorrect. The presence and absence of TAp63 hyperphosphorylation in the apoptosis of oocytes induced by radiation and cisplatin, respectively, strongly suggested that these two anti-cancer treatments activated TAp63 through different molecular mechanisms. Indeed, imatinib and GNF-2, which effectively protected oocytes from cisplatin, did not inhibit radiation-induced apoptosis and TAp63 hyperphosphorylation in oocytes. In contrast, the radiation-induced oocyte death and TAp63 phosphorylation were effectively blocked by a CHK2 inhibitor, Chk2 Inhibitor II hydrate, suggesting that radiation activates TAp63 via phosphorylation by CHK2. Interestingly, although cisplatin did not induce hyperphosphorylation of TAp63, the CHK2 inhibitor II hydrate still protected primordial follicles from cisplatin, suggesting that kinases activity that are inhibited by Chk2 Inhibitor II hydrate is essential for cisplatin-induced apoptosis in primordial oocytes. Our study elucidated that anti-cancer therapies with different mode of action induce apoptosis of immature oocytes by activating TAp63 through different mechanisms. Since Chk2 Inhibitor II hydrate effectively protects oocyte against cisplatin as well as radiation, Chk2 Inhibitor II hydrate treatment might be a promising treatment for the prevention of ovarian reserve loss in women undergoing anti-cancer therapy.

 

Nothing to Disclose: SYK, KE, MR, MC, VS, TKW, TK

20074 13.0000 SAT-101 A Cisplatin and Radiation Induce Loss of Ovarian Reserve By Activation of TAp63 through Different Mechanism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Raymond J Rodgers*1, Melanie J Ceko1, Katja Hummitzsch1, Nicholas Hatzirodos1, Wendy Bonner1, Jade B Aitken2, Darryl L Russell1, Michelle Lane1 and Hugh H Harris1
1University of Adelaide, Adelaide, Australia, 2University of Sydney, Sydney, Australia

 

Selenium (Se) is a trace element and an essential component of selenoproteins, playing an important role in biological functions including antioxidant defence, formation of thyroid hormones, immune response, DNA synthesis, fertility and reproduction. Studies of Se deficiency and supplementation have suggested that Se is necessary for fertility but how precisely is not known. The elemental distribution of Se in the bovine ovary (n = 45 sections) was identified by X-ray fluorescence (XRF) imaging, a synchrotron-based technique. Se was consistently localized to the granulosa cell layer of large (> 10 mm) healthy follicles. Mean Se concentrations were determined using Inductively Coupled Plasma - Mass Spectrometry. Higher levels were observed in the bovine follicle wall at 26 ± 5.0 ppm compared to corpora lutea which contained only 2.6 ± 1.3 ppm of Se. Microarray data from granulosa cells from small (n = 10) and large (n = 4) healthy follicles was analyzed to identify possible selenoproteins that could account for the high levels of selenium in large follicles. A short list of genes containing glutathione peroxidase 1 (GPX1), glutathione peroxidase 3 (GPX3), VCP-interacting membrane protein (VIMP), also known as selenoprotein S (SELS); and selenoprotein M (SELM) was examined further. qRT-PCR expression analysis of selenoprotein genes GPX1, GPX3, VIMP and SELM in bovine granulosa cells revealed that GPX1 was significantly up regulated in large healthy follicles compared to the small healthy or atretic follicles (P < 0.05); the other genes examined showed no significant differences. Immunohistochemistry confirmed that VIMP was localized to the granulosa and thecal cell region of large follicles irrespective of their stage of growth. Western immunoblotting identified GPX1 protein in bovine granulosa cells of large healthy follicles, but not of small healthy follicles. To determine if GPX1 was important in human follicles, cumulus cells from women undergoing IVF/ICSI with single embryo transfer were collected. Oocytes and embryos were cultured and transferred independently in 30 patients undergoing elective single embryo transfer. Gene expression of GPX1 was significantly higher in human cumulus cells from cumulus-oocyte complexes yielding a pregnancy (P < 0.05). We conclude that Se and selenoproteins are present in large healthy follicles when the steroidogenic enzymes are up regulated and likely to be producing reactive oxygen species.  Therefore GPX1 and selenium may play a critical role as antioxidants during late follicular development.

 

Disclosure: ML: Inventor of product that have a licence to, Vitrolife. Nothing to Disclose: RJR, MJC, KH, NH, WB, JBA, DLR, HHH

18537 14.0000 SAT-102 A X-Ray Fluorescence Imaging and Other Analyses Identifies Selenium and GPX1 in Ovarian Follicular Cells As up Regulated in the Later Stages of Follicle Development and Important for Oocyte Quality 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Christopher Ball II*
University of North Carolina at Chapel Hill

 

A hypomorphic mutant of the RNA binding protein ZFP36L2, resulting from a 29 amino acid N-terminal truncation (ΔN-Zfp36l2), exhibits a severe defect in oocyte maturation in 129SV mice. Females of the 129SV background (F3) that are homozygous for the ΔN-Zfp36l2 mutation do not respond to superovulation protocols and fail to ovulate. Additionally, oocytes collected directly from ovaries from homozygous females and freed from the follicles do not resume meiosis when allowed to mature ex vivo. These oocytes exhibit high levels of cAMP when compared to WT oocytes, a characteristic feature of immature oocytes arrested at meiotic prophase I. Previously, we have demonstrated that ZFP36L2 is involved in the down regulation of Luteinizing Hormone Receptor (LHR) mRNA, which encodes a Gαs-coupled GPCR that stimulates cAMP production upon stimulation by LH (1). In our mouse model, we showed that after the LH surge, the typical LHR down regulation that results in decreased cAMP is impaired.  Thus, low levels of ZFP36L2 are insufficient to bring down the amount of LHR mRNA. Here we report that the mRNA of cGMP-inhibited 3’, 5’-cyclic phosphodiesterase 3a, or PDE3a, may be a potential target of regulation by ZFP36L2. ZFP36L2 binds Adenine-Uridine Rich Elements (ARE) located mainly within the 3’UTR of many mRNA transcripts, and is thought to stimulate their deadenylation and degradation. The PDE3a mRNA contains one putative ARE in its 3’ UTR. PDE3a has been shown to be essential to both the maintenance of meiotic arrest at prophase I in maturing oocytes and the subsequent resumption of meiosis in mature oocytes ahead of ovulation in response to pubertal hormones (2). While a high level of cAMP is a feature of meiotic arrest in maturing oocytes, meiotic resumption is characterized by a decrease in cAMP, carried out by PDE3a and other players. Resumption of meiosis is to a limited extent dependent on the careful regulation of extant maternal mRNA transcripts, as transcription is turned off in the mature oocyte. Abnormal post-transcriptional regulation of PDE3a by ZFP36L2 may possibly contribute to the inability of ΔN-Zfp36l2 mice to resume meiosis.

 

Nothing to Disclose: CB II

22051 15.0000 SAT-103 A PDE3a mRNA, a Potential Target of Regulation By the RNA Binding Protein ZFP36L2 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Junchul David Yoon*1, Eunsong Lee2 and Sang Hwan Hyun1
1Chungbuk National University, Cheongju, Korea, Republic of (South), 2Kangwon National University, Chuncheon, Korea, Republic of (South)

 

Growth Differentiation Factor 8(GDF8) is a member of the transforming growth factor-β that has been identified as an undifferentiation factor and physiological regulator. We investigated nuclear maturation, intracellular gluthatione (GSH), reactive oxygen species (ROS) levels from matured oocytes, specific gene transcription levels in matured oocytes and cumulus cells after maturation, and subsequent embryonic development after parthenogenic activation (PA) and in vitro fertilization (IVF). Each concentration (0, 1, 10, and 100 ng/ml) of GDF8 was added in maturation medium during process of in vitro maturation. After 44 h of IVM, no significant difference was observed on nuclear maturation from the different concentration (0, 1, 10, and 100 ng/ml) of GDF8 treatment groups (85.5%, 85.9%, 89.4%, and 87.6%, respectively) compared with the control (P<0.05). The 10- and 100 ng/ml GDF8 treated group showed a significant (P<0.05) decrease in intracellular ROS levels compared with other groups. In the assessment of gene expression, the 10- and 100ng/ml GDF8 treated group showed significantly increased POU5F1 and Nrf2 mRNA transcription level from matured oocytes. The 10- and 100 ng/ml treatment group analyzed highly increased PCNA and Nrf2 mRNA levels, and the 1- and 10 ng/ml treatment group observed significantly increased Ptx3 and TNFAIP6 mRNA expression level from cumulus cells after IVM. In PA embryo development, the 10- and 100 ng/ml treatment group showed a significantly (p<0.05) higher cleavage rates (67.5% and 69.1%, respectively) compared with control group (53.7%). The 10- and 100 ng/ml treatment group also, showed a significantly (p<0.05) higher blastocyst formation rate (50.5% and 52.7%, respectively) compared with other groups (34.5% and 35.8%). In IVF embryo development, only 10 ng/ml treatment group showed increased blastocyst formation rate and total cell numbers then control (21.5% and 131.3 vs 15.0% and 92.6, respectively). In conclusion, treatment of 10 ng/ml GDF8 during IVM significantly improved the developmental potential of PA and IVF porcine embryos by decreasing the intracellular ROS level and changed the specific genes transcription levels while processing of IVM.

 

Nothing to Disclose: JDY, EL, SHH

20933 16.0000 SAT-104 A The GDF8 Treatment during Oocyte in Vitro Maturation Affects Specific Gene Transcription Level and Subsequent Embryonic Development 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Seon-Ung Hwang*1, Eunsong Lee2 and Sang Hwan Hyun1
1Chungbuk National University, Cheongju, Korea, Republic of (South), 2Kangwon National University, Chuncheon, Korea, Republic of (South)

 

Ganglioside is an acidic glycosphingolipid which has a sialic acids residues, and this is known to play an important role such as cell differentiation, adhesion, regulating growth and signal transduction. GT1b expression was observed that addition of GT1b into culture media of rat hippocampal cells or neuroblastoma–glioma hybridoma (NG108-15) cells temporarily activated CaMKll. Although there have been several studies relating to GT1b in mouse embryos, studies have not been conducted investigating porcine embryos. In the present study, we investigated the mechanism of GT1b treatment on porcine oocyte maturation. Ganglioside GT1b were treated on IVM that concentration was 0 (control), 5, 10 and 20nM and it was stained using TCM199 with 5μM Fluo-4, AM. Data were analyzed by ANOVA followed by Duncan using SPSS (Statistical Package for Social Science) mean ± SEM. We confirmed the level of intracellular Ca²⁺ in the oocytes according to cell stages using confocal laser microscope. The result showed that the level of intracellular Ca²⁺ in the oocytes at GVBD or MI stage was significantly (P<0.05) higher than that of other stages. We also measured the level of intracellular Ca²⁺ in oocytes with the treatment of different concentration of GT1b. It was significantly (P<0.05) increased with higher concentration of GT1b in dose-dependent manner. Next, to analyze the mechanism of GT1b effect on IVM, we identified the existence of B2R known to increase intracellular Ca²⁺ concentration stimulated by GT1b. As a result, we identified the expression of B2R in cumulus cell but not in oocyte. To examine the expression of PCNA, pluripotency-associated gene (POU5F1), apoptosis-associated genes (Bax, Bcl2, Caspase-3), B2R, CaMKIIγ and CaMKIIδ gene in matured cumulus cells and oocytes. In cumulus cells, the treatment of 20nM GT1b significantly (P<0.05) decreased the expression of B2R and CaMKIIδ, and PCNA. The treatment of 5nM GT1b significantly (P<0.05) decreased expression of CaMKIIδ. In oocytes, the treatment of 5nM GT1b significantly (P<0.05) decreased Bcl2, CaMKIIγ and POU5F1, pluripotency-associated gene, was decreased significantly (P<0.05). However, the treatment of 20nM GT1b significantly (P<0.05) increased expression of POU5F1. Finally, we examined after development (parthenogenesis, in vitro fertilization) using oocytes matured with GT1b in IVM stage. However, there were no significant developmental difference in the two experiments. In conclusion, increase of intracellular Ca²⁺ level in the oocyte stimulated cell cycle so that expression of POU5F1 expression also increased. GT1b is thought to regulate of level of Ca²⁺ in oocytes in dose-dependent manner, and be associated with another mechanism of controlling the level of intracellular Ca²⁺.

 

Nothing to Disclose: SUH, EL, SHH

21455 17.0000 SAT-105 A The Effect of Ganglioside GT1b to the Distribution of Calcium in Cytoplasm of Porcine Oocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Eunhye Kim*1, Sang Hwan Hyun1 and Eunsong Lee2
1Chungbuk National University, Cheongju, Korea, Republic of (South), 2Kangwon National University, Chuncheon, Korea, Republic of (South)

 

Germanium (Ge) is one of trace elements, and compounds of Ge are classified into organic and inorganic forms, which are present in certain plants, such as ginseng, shiitake mushroom, pearl barley, waternut and garlic. Among the many organogermanium compounds, carboxyethylgermanium sesquioxide (Ge-132), exhibits low toxicity and elevated biological activity, thereby attracting the attention of researchers. In this study, we examined the effect of 50-, 100- and 200 μg/ml Ge-132 on in vitro culture (IVC) of porcine embryos analyzing embryonic development after in vitro fertilization (IVF) and derived subsequent primed embryonic stem cells (ESCs). Although there was no significant difference was observed in cleavage rates, the supplementation of the in vitro culture medium with 100 μg/ml Ge-132 was suitable for porcine IVF embryo development compared to control group. In the result of cleavage patterns, IVF embryos cultured with 100 μg/ml Ge-132had significantly higher 4-5 cells and lower fragmentation rates than the control group. It had no significantly higher total cell numbers in IVF blastocyst (76.1 vs. 94.3) but had higher blastocyst formation rates (26.9% vs. 32.8%) than the control group. The porcine ESC line was successfully derived from porcine IVF embryos cultured in 100 μg/mlGe-132. Our results suggested that 100μg/ml Ge-132 supplementation during IVC enhanced the developmental competence of IVF porcine embryos and it might help the derivation of porcine primed ESCs.

 

Nothing to Disclose: EK, SHH, EL

21443 18.0000 SAT-106 A The Effect of Carboxyethylgermaniumsesquioxide (Ge-132) on Porcine Preimplantation Embryos Produced By in Vitro fertilization and Subsequent Derivation of Putative Embryonic Stem Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Hyunju Yoo*1, Sang Hwan Hyun1 and Eunsong Lee2
1Chungbuk National University, Cheongju, Korea, Republic of (South), 2Kangwon National University, Chuncheon, Korea, Republic of (South)

 

The ultrastructure of porcine embryonic stem cells (pESCs) and porcine fetal fibroblasts (PFFs) was analyzed by transmission electron microscopy (TEM). The aim of this study was to compare the features of organelles in in vitro fertilization-derived pESCs (IVF-pESCs) and somatic cell nuclear transfer-derived pESCs (SCNT-pESCs). Also, the features of organelles in high-passage IVF-pESCs were compared with those in low-passage cells. The ultrastructure of all pESC lines, including SCNT-pESCs, showed the presence of microvilli with various lengths and frequencies on the cell surfaces, low or high cytoplasm-to-nucleus ratios, ribosomes, rough endoplasmic reticulum (rER), a nonprominent Golgi apparatus, lysosomes and elongated or round mitochondria. Furthermore, all pESCs lines showed deeply infolded nuclei with one to two reticular-shaped nucleoli and a nuclear envelope. Long stalks of ribosome-studded rER were observed in IVF-pESCs. By contrast, rER was rarely observed in SCNT-pESCs. The Golgi apparatus was rarely observed and had flattened cisternae in all pESCs lines. Phagocytic vacuoles and lysosomes were observed frequently in SCNT-pESCs, but autophagic vacuoles were not observed in the cytoplasm in any pESC line. Furthermore, mitochondria in pESC lines showed differences in size and shape and had mostly tubular cristae. Intercellular junctions were observed in SCNT-pESCs, but not in IVF-pESCs. High-passage IVF-pESCs showed irregularly shaped intercellular junctions, pyknosis and numerous lysosomes associated with autophagic vacuoles. TEM analysis of high-passage IVF-pESCs revealed signs of apoptosis. In conclusion, this study confirms that the ultrastructural characteristics of pESCs differ depending on their origin. These ultrastructural characteristics might be useful in biomedical research using pESCs. Furthermore, these results could be used to establish naïve pESC lines.

 

Nothing to Disclose: HY, SHH, EL

21487 19.0000 SAT-107 A Ultrastructural Comparison of Porcine Embryonic Stem Cells Derived By in Vitro fertilization and Somatic Cell Nuclear Transfer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Lian Cai*1, Eunsong Lee2 and Sang Hwan Hyun1
1Chungbuk National University, Cheongju, Korea, Republic of (South), 2Kangwon National University, Chuncheon, Korea, Republic of (South)

 

G-CSF was produced from decidual tissue and that could increase trophoblast cells proliferation. In addition, G-CSF could be a predictor of embryo implantation for IVF outcome and also have important role on maintain pregnancy. In this study, we performed IVF using MII maturated oocytes and subsequently the embryos were cultured in FBS free-culture medium supplemented with various concentrations of hrG-CSF (0, 10, 50 and 100ng/ml, respectively). At result, the cleavage rate and the blastocysts formation rate were significantly (p<0.05) higher in 10ng/ml group (70.53% and 22.79%) compared with control group (66.14% and 13.72%). However, the rate were significantly (p<0.05) lower in 50ng/ml (44.20%) and 100ng/ml (43.50%) groups than control (66.14% and 13.72%). In addition, the embryos were cultured with 10ng/ml hrG-CSF for Days 0 to 3 (early stage), Days 4 to 7 (late stage), and Days 0 to 7 (whole stage). At present experiment, the blastocysts formation rates were significantly increased in early, late and whole stage groups (17.65%, 18.32% and 21.98%) compared with control (14.81%). In conclusion, the above data indicate that 10ng/ml hrG-CSF may have a beneficial physiological role during porcine IVF embryos development.

 

Nothing to Disclose: LC, EL, SHH

21458 20.0000 SAT-108 A The Effects of Human Recombinant Granulocyte–Colony Stimulating Factor (hrG-CSF) on Porcine in Vitro Fertilization (IVF) Embryos 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Masao Izawa*, Fuminori Taniguchi and Tasuku Harada
Tottori University Faculty of Medicine, Yonago, Japan

 

[Background]

Secretion of biologically active estrogen in situ through conversion of circulating precursor androgens has been demonstrated to play important roles in normal extraovarian tissues. This in situ secretion has also been demonstrated to play important roles for pathogenesis and development in estrogen dependent disease.

In fallopian tube, estrogen has been accepted to play important roles during a series of fertilization process including capacitation of sperm, ovum fertilization, embryo development and delivery of embryo to uterus. However, the molecular basis has not been fully understood.

[Objective]

To evaluate the estrogen environment in fallopian tube, we challenged to demonstrate the key molecules cytochrome P450 aromatase and estrogen receptor (ER) using primary cell culture system.

[Methods]

Patients: We obtained the informed consent from all patients. The fallopian tube of patients with endometriosis was the source of tissues. These patients had received no hormonal treatment before surgery.

Cell preparation: Stromal cells were collected from the ampulla of fallopian tube. In brief, the tissues were minced and digested with 0.5% collagenase, and the dispersed cells were filtered through a 70-mm nylon mesh to remove the undigested tissue pieces containing the glandular epithelium. The filtered fraction was separated further from epithelial cell clumps by differential sedimentation at unit gravity. The medium containing stromal cells was filtered through a 40-mm nylon mesh.

RT-PCR and Western blot: Expression of mRNA and protein was estimated using conventional RT-PCR and Western blot analysis, respectively. For the promoter assay of CYP19 and ESR1, Exon I-specific RT-PCR using unique Exon I primers and Exon II primers were employed.

DNA methylation assay: Cellular DNA prepared from fallopian tube cells was digested with HpaII or McrBC, and then used as templates for PCR (1).

Estrogen assay: Using EIA, 17b-estradiol (E2) was estimated in culture medium.

[Results]

1) Aromatase mRNA was expressed depending on 3 promoters: PII, I.3 and I.6. 2) E2 was secreted within 6 hr after addition of testosterone into cell culture. 3) The CpG sequence at 20kb upstream from CYP19 exonII was mostly unmethylated. 4) ERαmRNA was dominant in contrast to the marginal expression of ERβ. 5) The expression depends on 3 promoters, B, C and F. 6) A 55KD form of ERα was observed.

[Conclusion]

We demonstrated the intracrine estrogen secretion depending on aromatase expression in human fallopian tube cells for the first time. At the same time, we found that ERα was a major estrogen receptor in the cells. These molecules seem to become clues to further understand the role of estrogen in the female sex organ. 


 

Nothing to Disclose: MI, FT, TH

20228 21.0000 SAT-109 A Intracrine Estrogen Secretion Depending on Aromatase Expression in Human Fallopian Tube Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Sara Sinha Morelli*, Amanda N Resnikoff, Jack Haberl, Andrea Wojtczuk, Pranela Rameshwar and Laura T Goldsmith
Rutgers - New Jersey Medical School, Newark, NJ

 

The endometrium is a remarkably dynamic tissue, undergoing repeated cycles of proliferation, differentiation, and degeneration.  Cyclic regeneration of all endometrial cellular compartments is an absolute requirement for successful reproduction, but the mechanisms of regeneration remain poorly understood.  We have previously demonstrated that bone marrow (BM) cells are a source of multiple parenchymal endometrial cell types in a murine model.  However, whether BM-derived endometrial cells respond to estrogen, the major regulator of endometrial growth and/or differentiation, is unknown. The current studies were performed to determine whether BM-derived cells in murine endometrium express estrogen receptor alpha (ERα).  A murine BM transplant model was used, in which BM cells, harvested from transgenic mice expressing Green Fluorescent Protein (GFP), were injected via tail vein into irradiated, syngeneic immature female mice.  Flow cytometry was performed on peripheral blood of recipient mice to determine hematopoietic reconstitution with GFP+ cells. Five recipient mice with successful hematopoietic reconstitution (>90% chimerism) were sacrificed at 12 months post BM transplant and hysterectomy was performed.  Immunohistochemistry, using specific anti-GFP and anti-ERα antibodies, and confocal laser microscopy, were used to localize and quantitate BM-derived (GFP+) cells in the endometrial stromal and epithelial compartments of uterine tissue sections, and to determine whether BM-derived cells in the endometrium express ERα.  All data reported herein are the total numbers of cells counted in the 5 animals.  Of the 18,315 endometrial stromal compartment cells counted, 1,888 cells (10.3%) were derived from BM, of which 814 cells (43.1%) expressed ERα.  Of the 9,483 luminal epithelial cells counted, only 6 cells (0.06%) were derived from BM, of which 5 cells (83.3%) expressed ERα.  Of the 2,848 glandular epithelial cells counted, only 20 cells (0.7%) were derived from BM, of which 8 cells (40.0%) expressed ERα.  These data demonstrate that a substantial number of bone marrow-derived cells engrafting multiple cellular compartments of the endometrium express ERα.  These data suggest, for the first time, an important role for estrogen in the function of bone marrow-derived endometrial cells.

 

Nothing to Disclose: SSM, ANR, JH, AW, PR, LTG

20163 22.0000 SAT-110 A Bone Marrow-Derived Cells in Murine Endometrium Express Estrogen Receptor Alpha 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Yuechao Zhao*1, Yiru Chen1, Milan K Bagchi1, Robert N Taylor2, Kendall W Nettles3, John A Katzenellenbogen1 and Benita S Katzenellenbogen1
1University of Illinois at Urbana-Champaign, Urbana, IL, 2Wake Forest Schl of Med, Winston-Salem, NC, 3Scripps Research Institute, Jupiter, FL

 

Endometriosis is a common estrogen-dependent gynecological disorder affecting millions of women of reproductive age in which endometrial tissue forms inflammatory lesions at extra-uterine, ectopic sites. Its initiation and progression are driven by estrogen receptor (ER) signaling and by inflammation. Using a preclinical mouse model in which uterine tissue is transplanted into a syngeneic, immune system-intact host, we found that estradiol (E2) promoted marked infiltration of macrophages and other immune cells (e.g., T cells) into the endometriotic lesions, causing greatly elevated cytokine production (e.g., IL6, CCL2, CCL5), and engendered inflammatory signaling and neuroangiogenesis. Depletion of macrophages from host animals by liposome-encapsulated clodronate treatment greatly impeded the establishment and progression of endometriotic lesions, and eliminated much of the cytokine production normally stimulated by E2. Furthermore, in co-culture experiments of human endometriotic stromal cells (hESCs) with macrophages, we found that the conditioned media of hESCs treated with E2 and TNFα promoted cytokine production by macrophages. Two structurally distinctive ER ligands, chloroindazole and oxabicycloheptene sulfonate, blocked immune cell infiltration into the lesions and suppressed cytokine production and NFκB and COX2 expression; they were effective in preventing establishment of endometriotic lesions and in eliciting regression of established lesions. Likewise, these compounds blocked the stimulatory effects of E2 and TNFα on the macrophage-hESC interaction. Our findings indicate the importance of immune cell crosstalk with cells in the endometriotic lesions in promoting progression of endometriosis. Interrupting this crosstalk with ER ligands having dual anti-estrogenic and anti-inflammatory activity may provide a new therapeutic point of intervention for the treatment of endometriosis.

 

Nothing to Disclose: YZ, YC, MKB, RNT, KWN, JAK, BSK

20559 23.0000 SAT-111 A Suppression of Endometriosis By Interrupting Crosstalk Between the Endometriotic Lesion and the Host Immune System 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Adriana Lofrano-Porto*1, Andrew Dauber2, Olivia Laquis de Moraes3, Petra Ariadne Trindade Araujo4, Ana Paula Abreu5, Ceres Nunes Resende Oyama6, Michael Guo7, Silviene F Oliveira8, Charles Lee8, Rona S. Carroll9 and Ursula B. Kaiser10
1University of Brasilia, Brasilia DF, Brazil, 2Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 3University of Brasilia, Faculty of Health Sciences, Brasilia, Brazil, 4University of Brasilia, Faculty of Health Sciences, Molecular Pharmacology Laboratory, Brasilia, 5Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 6Department of Gynecology and Obstetrics, Faculty of Medicine, University of Brasilia,, Brasilia, Brazil, 7Boston Children's Hospital, Boston, MA, 8Jackson Laboratory for Genomic Medicine, Farmington, CT, 9Brigham and Women's Hospital/Harvard Med School, Boston, MA, 10Brigham Women's/Harvard Med School, Boston, MA

 

The female reproductive tract (FRT), which consists of the oviducts, uterus, cervix and vagina,  is essential for the perpetuation of the species in mammals. Abnormalities in the formation of the FRT are estimated to occur in 0.1 to 3% of live births and may present with infertility or recurrent miscarriages. In the present study, comprehensive genetic screening was performed in a family in which three sisters, born from a consanguineous marriage, presented with normal pubertal development, primary amenorrhea, uterine and endometrial hypoplasia resistant to estrogen treatment, and spontaneous tubal pregnancies. Our aim was to search for genetic defects underlying this rare FRT developmental anomaly. From whole exome sequencing (WES) data, we selected novel homozygous variants present in all three affected sisters that were not homozygous in their unaffected sister. Based on this analysis, two novel missense variants were identified: p.V108F in the OSR1 gene and p.R48H in HS1BP3. OSR1 encodes the transcription factor Odd-Skipped Related 1, which is expressed in the intermediate mesoderm during early embryogenesis, and has been associated with embryonic heart and urogenital development. HS1BP3 encodes HS1 Binding Protein, an adapter protein whose functions are fairly unknown. Array-CGH excluded the existence of copy number variants that might be associated with the phenotype. Familial segregation of the mutations was confirmed by Sanger sequencing and corroborated the autosomal recessive inheritance, in which both variants segregated together. Homozygosity mapping was obtained from WES data and identified a block of homozygozity that included OSR1 and HS1BP3 on chromosome 2. Gene priorization analysis using Endeavour was performed independently of the exome variant analysis, based on a list of 13 genes previously implicated in uterine development as the training set. We prioritized all genes found in the strech of homozigosity. Among those, OSR1 ranked very highly (6 out of 126; p-value 0.00702), as the most probable candidate associated with the developmental process of FRT formation.  HS1BP3 ranked lower (87 out of 126, p-value 0.41). A possible association between OSR1 and FRT development has not been described previously. OSR1 is a developmental pair-rule gene that has a role in temporospatial body segment patterning. It is expressed in the intermediate mesoderm and is involved in urogenital development. We hypothesize that OSR1 may regulate/mediate termporospatial HOX and/or WNT gene expression during embryogenesis. The possibility of oligogenicity and gene interaction between OSR1 and HS1BP3 should also be considered. The mutations underlying the rare phenotype observed in these sisters may represent a unique model for the identification of novel molecular pathways involved in the formation and differentiation of  mesoderm-derived structures.

 

Nothing to Disclose: AL, AD, OLDM, PAT, APA, CNRO, MG, SFO, CL, RSC, UBK

21368 24.0000 SAT-112 A Identification of Novel Gene Candidates Associated with Familial Endometrial Hypoplasia and Spontaneous Tubal Pregnancies By Whole Exome Sequencing Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Hsiao-Li Wu*1, Tung-Yueh Chuang1, Ayman Al-Hendy2, Michael P Diamond1, Ricardo Azziz2 and Yen-Hao Chen1
1Georgia Regents University, Augusta, GA, 2Augusta University, Augusta, GA

 

Uterine leiomyomas are benign smooth muscle cell tumors of the myometrium, and serve as the most common pelvic tumors in women. In the United States, the estimated economic burden for uterine leiomyomas ranges from $5.9 to $34.4 billion yearly. Currently, there are no approved, effective, or long-term medicinal treatments for these tumors. Berberine (BBR), a natural alkaloid, is a traditional Chinese herb with antineoplastic effects in a variety of human cancers. However, the effects of BBR in uterine leiomyoma remains unclear. In a recent study, we observed that BBR inhibited human uterine leiomyoma (UtLM) cell proliferation by inducing G2/M cell cycle arrest and apoptosis. In addition,  cell cycle G2/M phase-related genes were altered by BBR treatment, and the expression of Cyclin A1, Cyclin B1 and Cdk1 was down-regulated, while that of Cdk4, p21 and p53 was up-regulated. BBR-treated cells stained positively for Annexin V, and manifested increased BAX expression. Furthermore, estradiol (E2)-induced UtLM cell proliferation was blocked by BBR treatment. In marked contrast, even the highest concentration of BBR (50 µM) did not influence cell proliferation in normal human uterine smooth muscle cells. We conclude that BBR selectively inhibits proliferation, and blocks E2-induced proliferation in human uterine leiomyoma cells, but not in normal human uterine smooth muscle cells. In addition, BBR did not demonstrate cytotoxic effects on normal human uterine smooth muscle cells. Our results lend further evidence to BBR’s potential utility as a therapeutic agent in the treatment of uterine leiomyomas.

 

Nothing to Disclose: HLW, TYC, AA, MPD, RA, YHC

20596 25.0000 SAT-113 A Berberine (BBR) Inhibits Human Uterine Leiomyoma Cell Proliferation in Vitro 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Jordan Elise Read*1, Victoria Cabrera-Sharp1, Samantha Mary Mirczuk1, Phoebe Kitscha1, Amelie Geddis1, Judith Cartwright2, Robert C Fowkes1 and Amanda de Mestre1
1The Royal Veterinary College, London, United Kingdom, 2St George's, University of London, United Kingdom

 

Chorionic Gonadotrophin (CG) is a placental hormone critical for maintenance of early pregnancy. It is secreted by specialised terminally differentiated cells known as binucleate trophoblast in horse and syncytiotrophoblast in human. However, regulation of its production is poorly understood.  The aim of this study was to identify transcription factors that may play a role in regulation of eCG in equine placenta.

Equine conceptuses, obtained from early pregnancy days 27 - 34 by uterine lavage, were dissected into separate tissue components before snap freezing for RNA and protein extraction. An Agilent 44K equine microarray was performed using RNA extracted from Chorionic Girdle and Chorion (as a control) from pregnancy days 27, 30, 31 and 34 (n=5 each timepoint) and validated using multiplex RT-qPCR. Analysis via Genespring (Agilent) and Ingenuity Pathway Analysis (Qiagen) identified 15 up-regulated and 7 down-regulated transcription factors with a fold-change >2 (P<0.05) at day 34 compared to day 27 that were specific to the Chorionic Girdle. Of these, 7 were identified with a significant correlation to eCGβ expression (R2 > 0.75) and with binding sites available in the proximal 2500bp eCGβ promoter, including Nkx2-5 (fc=8.8, R2=0.86), RELA (fc=2.4, R2=0.75) and XBP1 (fc=6.1, R2=0.87).  Further analysis of identified transcription factors using expression studies and ChIP will allow us to determine whether they directly interact with the eCGβ promoter, thus potentially regulating its activity.

GCM1 has been identified as a candidate regulator of eCGβ expression. Microarray analysis demonstrates a 32-fold up-regulation in Chorionic Girdle at day 34 compared to day 27. We confirmed, by RT-qPCR, that GCM1 mRNA expression is rapidly induced during differentiation of binucleate trophoblast in vivo.   Furthermore, our results demonstrate a close correlation between the expression levels of GCM1 and eCGβ in chorionic girdle tissue (R2=0.552, P=0.0049).

Interrogation of the 2500 bp promoter of eCGβ revealed five exact match consensus sites for GCM1 binding. A 335 bp fragment, containing the two proximal GCM1 sites, was cloned into pGL3 luciferase vector and sequenced. BeWo choriocarcinoma cells transiently transfected with pGL3-335 demonstrated a 23-fold increase in luciferase activity relative to control transfected cells (P<0.05). Co-transfection of a GCM1 expression vector (pEGFP-GCM1) with pGL3-335, in increasing concentrations, resulted in a dose dependent increase in luciferase activity, supporting our hypothesis that GCM1 may directly regulate eCG expression.

Further investigation into the activity of the above identified factors and their interactions with the eCGβ promoter will enable a greater understanding of the transcriptional regulation of eCG, thus offering insight into the maintenance of early pregnancy and where miss-regulation may occur in early pregnancy loss.

 

Nothing to Disclose: JER, VC, SMM, PK, AG, JC, RCF, AD

19787 26.0000 SAT-114 A Transcriptional Regulation of the Chorionic Gonadotrophin &beta Subunit in the Equine Placenta 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Cherie A Kessler1 and Stuart Handwerger*2
1Cincinnati Children's Hosp, Cincinnati, OH, 2University of Cincinnati/Cincinnati Childrens Hospital Medical Center, Cincinnati, OH

 

During villous trophoblast differentiation, mononuclear cytotrophoblast cells (CTB) differentiate to mutinucleated syncytiotrophoblast cells (STB). As the CTB undergo syncytialization, the cells begin to express abundant amounts of chorionic gonadotropin (hCG), placental lactogen (hPL) and other hormones and growth factors. Several published studies demonstrating that epidermal growth factor (EGF) induces hCG release in cultured CTB cells undergoing spontaneous differentiation suggest that EGF stimulates the terminal differentiation of CTB. However, several other published studies found no effect of EGF on hCG secretion and CTB differentiation. To determine whether EGF induces CTB differentiation, we examined whether EGF stimulates hCG protein release at multiple times during CTB differentiation and whether EGF induces the mRNA levels of several genes known to be specific markers of terminally differentiated STB. A highly purified preparation of CTB (>95% as determined by cytokeratin 7 immunohistochemistry) was prepared by enzymatic dispersion of term placenta followed by isopycnic centrifugation through a Percoll gradient. The cells (triplicate wells) were then cultured for 1, 2, 4 or 6 days in control medium or medium containing EGF (50 ng/ml). The levels of hCG protein increased in the control cells from <1.5 mIU/ML at day 0 to 395.4 mIU/ml on day 6; and hCG mRNA levels increased by 156-fold over the same time interval. The mRNA levels for the STB marker genes hPL, growth hormone variant (hGHv), coticotropin releasing hormone (CRH) and pregnancy specific glycoprotein 1 (PSG1) increased by 15.6 to 38.9-fold compared to control cells (p<0.001 in each instance). The CTB exposed to EGF secreted 2.4-fold more hCG protein (RIA) than control cells with the initial increase in hCG noted at day 2. However, the EGF-treated CTB expressed markedly less mRNA for hCG (27% of control values) and each of the other marker genes (10-37% of control, p<0.001). The inhibition of each of the STB marker mRNAs was noted at 2, 4 and 6 days. EGF however had no effect on actin and GAPDH mRNA levels. Western blot analyses indicated that EGF also inhibits the expressions of the STB-marker proteins. Similar findings with EGF were observed with cultured CTB from two other term placentas. Taken together, these studies support the hypothesis that EGF inhibits terminal CTB differentiation to a STB phenotype. The reason(s) for the different effects of EGF on hCG protein and mRNA levels is currently unknown. Since trophoblast cells are know to release protease inhibitors, the increase in hCG in the medium in response to EGF may result from the induction of a protease inhibitor(s) by EGF that blocks the degradation of secreted hCG.

 

Nothing to Disclose: CAK, SH

19862 27.0000 SAT-115 A EGF Inhibits Terminal Differentiation of Human Villous Cytotrophoblast Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 089-115 6005 1:00:00 PM Hyperandrogenic Ovarian Dysfunction and Female Reproductive Tract Poster


Stine Agergaard Holmboe*1, Eleni Vradi2, Tina Kold Jensen1, Allan Linneberg3, Lise Lotte Nystrup Husemoen4, Thomas Scheike5, Niels Erik Skakkebaek1, Anders Juul6 and Anna-Maria Andersson7
1University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Denmark, Copenhagen, Denmark, 2Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark, 3Rigshospitalet Glostrup University Hospital, The Capital Region, Glostrup, Denmark, 4Research Centre for Prevention and Health, Glostrup University Hospital, 5University of Copenhagen, Copenhagen, Denmark, 6University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark, 7University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Department of Growth and Reproduction, Denmark, Copenhagen, Denmark

 

Low testosterone is associated with risk factors for cardiovascular disease (CVD) and a number of studies have investigated the association between testosterone levels and subsequent mortality, however with conflicting results. Luteinizing hormone (LH) is the primary stimulator of testosterone production, and the ratio between LH and testosterone (LH/T) is a clinical marker of Leydig cell function. The male capacity to produce testosterone generally has a large buffer and if Leydig cell function is compromised, a normal or near normal testosterone level can be sustained by increased LH levels, as seen in the clinical entity ‘compensated primary hypogonadism’. Whether such a compensated state is associated with morbidity or increased mortality remains unknown. Thus, the aim of this study was to investigate associations between serum reproductive hormones, including serum LH and testosterone levels, with subsequent mortality in a comprehensive data material of 5,350 randomly selected men with up to 30 years of follow-up. Main outcomes of interest were all-cause mortality and CVD mortality obtained from almost complete national registries. A total of 5,323 men with serum samples from four cohorts were included in the study with a mean follow-up of 18.5 years (25th: 12.0; 75th: 25.3). 1,533 men (28.8%) died during the follow-up period out of which 428 deaths were caused by CVD. Cox proportional hazard models revealed that men in the highest LH quartile had an increased risk of dying from all causes (HR=1.32, 95% CI: 1.14-1.53) compared to lowest quartile. Likewise, increased quartiles of LH/T increased the risk of all-cause mortality (HR=1.23,95% CI: 1.06-1.43). No association to testosterone levels was found. Furthermore, a negative linear association was seen between total testosterone and CVD mortality with a reduction in risk for men with total testosterone in the highest quartile (HR=0.72, 95% CI: 0.53-0.98), while no significant differences in CVD risk were seen for the other hormones. In conclusion, in this large population-based study we observed that primary hypogonadism with increased LH and LH/T ratio was associated with increased all-cause mortality, whereas secondary hypogonadism characterized by low testosterone, without increased LH, was a predictor of CVD mortality. Our findings emphasize the importance of not focusing solely on testosterone, but include LH levels as well in the clinical work-up of male patients seeking help for androgen insufficiency.

 

Nothing to Disclose: SAH, EV, TKJ, AL, LLNH, TS, NES, AJ, AMA

PP34-4 19820 4.0000 SAT-119 A Primary Hypogonadism with Increased LH/Testosterone Ratio Is Associated with All-Cause but Not Cardiovascular Disease Mortality; A Long Term Follow-up Study of Danish Men from the General Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Michael Zitzmann*1 and Farid Saad2
1University Clinics Muenster, Muenster, Germany, 2Bayer Pharma AG, Berlin, Germany

 

Background:

The intramuscular injection of the long-acting ester testosterone undecanoate (TU) offers a convenient modality for testosterone substitution. The effects of such a therapy on body composition have been well documented but long-term effects and inter-patient variability remain to be elucidated.

Methods:

We report data from a total cohort of 422 patients who received treatment by testosterone undecanoate 1000 mg (intramuscular injections) for a treatment time of a median of 5 years. Of these, 155 men (37%) were overweight (BMI 25-30 kg x m-2) and 209 men (50%) were obese (BMI 25-30 kg x m-2). Increased waist circumference (94-102 cm) was seen in 89 men (21%) and a substantially increased waist circumference in 282 men (67%).

Results:

Individual dosing intervals ranged from 10 to 14 weeks. Serum T concentrations increased from an average of 4.8 nmol/L to stable trough levels of 13.1 nmol/L within the first year of treatment and further on to levels between 15 and 16 nmol/l thereafter. Obese patients were not significantly different in this regard from overweight patients or normal weight patients. The proportion of men fulfilling the new Harmonized Criteria for definition of the Metabolic Syndrome decreased from initially 89% to 67% within the first year and further on to 46% within 6 years (Chi-square for trend: p<0.001). During the maximal duration of treatment, an overall favourable change from baseline was visible for a multitude of parameters related to androgen effects/metabolic risk, especially lipid parameters (HDL-cholesterol, LDL-cholesterol, triglycerides), blood pressure and fasting glucose levels (all with p<0.001 in ANOVAs). These changes were a function of individual weight loss and loss of waist circumference in multiple regression models. Overall loss of weight and waist circumference were log-linear functions of initial weight over time: i.e. the more obese patients were, the more pronounced was the observed change in weight and waist circumference. Advancing age was attenuating the effect of weight loss, but not completely. In summary, changes of class was seen over time. 71 of 155 men changed from overweight to normal weight and 112 of 209 men from obese to overweight.

Conclusion:

Intramuscular injections of testosterone undecanoate represent a feasible, safe and well tolerated modality of androgen substitution in hypogonadal men of a wide age-range, substantiated by a long experience, facilitating a decrement of metabolic/cardiovascular risk factors.

 

Disclosure: MZ: Investigator, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma.

19432 5.0000 SAT-120 A Long-Term Treatment of Overweight or Obese Hypogonadal Men Using Intramuscular Testosterone Undecanoate: Long-Term-Experience of 5 Years 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Rosana J Ayoub*1, Stephanie T. Page2, Ronald S. Swerdloff1, Peter Y Liu1, John K. Amory2, Andrew Leung3, Laura Hull1, Diana Lynn Blithe4, Alicia Armstrong4, William J Bremner2 and Christina Wang1
1Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 2University of Washington, Seattle, WA, 3LABioMed at Harbor-UCLA Medical Center, Torrance, CA, 4National Institute of Child Health and Human Development, Bethesda, MD

 

Context: Dimethandrolone Undecanoate (DMAU) is being developed as a male hormonal contraceptive. DMAU is hydrolyzed to the active compound dimethandrolone (DMA, 7α,11β-dimethyl-19-nortestosterone) that has both androgenic and progestational activities which may enhance gonadotropin suppression. DMAU is not 5 alpha-reduced and may have less effect on prostate growth.  Both these attributes make DMAU an attractive candidate male oral contraceptive. Our prior single-dose PK study showed that DMAU formulated as powder in a capsule was well tolerated without serious adverse events at any dose up to 800 mg.

Objective: To compare the safety and PK of single, escalating doses of oral DMAU in three different formulations administered with food in healthy men.

Design, Setting, Participants and Intervention: We conducted a randomized, placebo-controlled, double-blind study of DMAU in healthy men. For each dose, 12 male volunteers received either DMAU (n=10), or placebo (n=2) at one of two participating academic medical centers. Single, escalating, oral doses of DMAU were given (100 mg, 200 mg, and 400 mg) with a high fat meal (50% calories from fat). DMAU capsules were formulated as powder alone, or in castor oil/benzyl benzoate or SEDDS (self-emulsifying drug delivery system).  Serial serum samples were collected during the 24-hour period following dosing. Serum DMAU and DMA were measured by LC-MS/MS.

Results: All three formulations were well tolerated without serious adverse events and no clinically significant change in vital signs or safety laboratory tests. Data were analyzed by mixed model analyses examining the effect of dose, formulation and the interaction. For all formulations, DMA and DMAU showed higher Cmax (P<=0.007 for each), AUC (P<=0.0002 for each) and DMA/DMAU AUC ratio (P=0.027) at the 400 mg dose, compared with the 200 mg dose. Time to reach maximum DMA (P=0.026) and DMAU (P=0.0455) concentrations were significantly delayed with powder in capsule compared with SEDDS. Powder in capsule, compared with drug solubilized in castor oil, resulted in higher DMAU Cmax (P=0.025) and AUC (P=0.0071) but a lower proportion of DMAU in powder formulation converted to DMA (DMA: DMAU AUC ratio) in serum (P=0.027) compared with both castor oil and SEDDS formulations.

Conclusions: DMAU administered orally at 200 and 400 mg with food resulted in dose incremental serum DMAU and DMA levels. DMAU administered in a powder formulation reached peak levels more slowly and had less conversion to DMA compared to the other two formulations. Additional repeat dose studies of DMAU will be required to determine the efficacy of gonadotropin suppression and safety/tolerability of this novel androgen.

 

Disclosure: STP: Investigator, Abvie, Investigator, Besins. RSS: Investigator, Antares, Consultant, Novartis Pharmaceuticals, Consultant, Aptys, Investigator, Lipocine, Consultant, Antares, Consultant, Quest Diagnostics, Investigator, AbbVie, Investigator, Novartis Pharmaceuticals, Investigator, Endo Pharmaceuticals, Investigator, Lipocine, Medical Advisory Board Member, Clarus, Consultant, Aptys, Investigator, Clarus, Consultant, Antares, Consultant, Clarus, Investigator, Antares, Investigator, AbbVie, Consultant, Quest Diagnostics. PYL: Investigator, Clarus. JKA: Investigator, Clarus, Investigator, Clarus. CW: Investigator, Clarus, Investigator, Antares. Nothing to Disclose: RJA, AL, LH, DLB, AA, WJB

19661 6.0000 SAT-121 A Comparison of the Pharmacokinetics (PK) and Safety of Three Oral Formulations of Dimethandrolone Undecanoate (DMAU): A Potential Male Oral Contraceptive 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Alan D Rogol*1, Nathan Bryson2 and Natalia Tkachenko2
1University of Virginia, Charlottesville, VA, 2Acerus Pharmaceuticals, Mississauga, ON, Canada

 

Objective: To evaluate efficacy and safety of testosterone nasal gel in hypogonadal males

Design: 90-day, randomized, open-label, dose-ranging study, including potential dose titration, with 90- and 180-day sequential safety extensions

Setting: 39 outpatient sites, all in the United States 

Subjects: among other eligibility criteria, subjects were required to have at least 2 fasting morning total serum testosterone levels <300 ng/dL. Out of 306 men randomized (n=228 to twice-daily (BID) and n=78 to three-times-daily (TID) dosing arms) 205 completed the BID arm (n=122 on BID dosing and 83 on TID (transferred from BID at day 45 because of low testosterone levels) and 69 the TID arm. The safety extensions completers for 90 and 180 days included 107 and 30 subjects on BID dosing and 138 and 37 on TID respectively. Discontinuation rates for adverse events were 2.1% (BID) and 3.7% (TID).

 Intervention: Testosterone gel was self-administered intranasally, using multiple-dose dispenser, as 2 or 3 daily doses (5.5 mg per nostril, 11.0 mg single dose). Thus the total daily doses were 22.0 mg (BID) or 33.0 mg (TID).

 Main Outcome Measure: The percentage of subjects with Day 90 serum total testosterone average concentration (Cavg) value within normal range (≥300 ng/dL, ≤1050 ng/dL). This is a standard FDA criterion for efficacy.

 Results:  Percentages (95% CI) of subjects whose Cavg was within normal range included 90% (83%, 97%) of TID and 71% (62%, 79%) of BID subjects in the intent-to-treat (ITT) population, and 91% (84%, 98%) of TID and 75% (66%, 83%) of BID subjects in the per-protocol population. At Day 90, 88.6% of ITT patients had serum total testosterone Cmaxvalues ≤1500 ng/dL. The incidence of treatment-emergent adverse events was similar in both treatment groups. Eight (2.6%) patients had a serious adverse event (SAE); no serious treatment-emergent event was considered related to study medication. Out of 99 subjects who completed the survey on patient experience with intranasal administration 74.7% reported having no issues with testosterone nasal gel administration and 83.8% were feeling confident about administering the product within 2 days of starting treatment.

  Conclusions: Testosterone nasal gel restored normal serum total testosterone levels in hypogonadal men at total daily doses of 22.0 or 33.0 mg, administered as a BID or TID regimen, respectively. Treatment was well tolerated, with low rates of adverse events related to local tolerance and androgenic therapy effects. These results indicate that testosterone nasal gel is an effective and practical alternative to other available testosterone replacement therapy products.

 

Disclosure: ADR: Ad Hoc Consultant, Novo Nordisk, write material, Up To Date, Ad Hoc Consultant, SOV Therapeutics, Ad Hoc Consultant, Trimel Pharmaceuticals, Ad Hoc Consultant, Versartis. NB: Chief Scientific Officer, Trimel. NT: Clinical Researcher, Trimel Pharmaceuticals.

19015 7.0000 SAT-122 A A Novel Testosterone Nasal Gel Formulation Normalizes Androgen Levels in Hypogonadal Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Rowena Irene Howard* and Elaine Barrington-Ward
Wellington Hospital, Wellington, New Zealand

 

Background

Chromosomal abnormalities can rarely present in men with normal external genitalia and associated primary hypogonadism. The most common chromosomal abnormality associated with male hypogonadism is Klinefelter’s syndrome, which occurs in 1 in 500 – 1000 live male births. Men are counseled that this is a possibility when karyotype analysis is requested. Other unexpected karyotypes, however, can be identified.

 Clinical case

A 35-year old highly functioning man presented with a 10-year history typical of hypogonadism. Puberty had been normal, with development of normal male secondary sexual characteristics. He subsequently developed erectile dysfunction and reduced libido at age 26 and presented due to concerns about fertility. Clinical features were of a phenotypic male with hypogonadism; examination revealed a height of 1.67cm with normal arm span, mild gynecomastia, 3ml volume testes bilaterally, and a normal penis. 8am testosterone was 2.2 nmol/L (9-25), LH 17.3U/L (1-10) and FSH 53.5 U/L confirming primary hypogonadism. Metabolic, structural, infective and iatrogenic causes were excluded. Semenalysis showed normal viscosity and reduced volume (0.6mL (2-6)). No spermatozoa were seen on microscopy. Karyotyping was requested (following appropriate counseling as to the possibility of of Klienfelter’s syndrome) and demonstrated 46,XX.ish der(X)t(X;Y)(p22.3;p11.31)(SRY+) on FISH analysis. Testosterone therapy has been commenced, and the patient has been referred to a fertility specialist for discussion of options including donor sperm.  Additional genetic counseling has been provided in light of this diagnosis.

Clinical lesson

46, XX testicular disorder of sex differentiation occurs in 1 in 20000 to 30000 males1.  90% have Y chromosome material usually translocated to the distal tip of the short arm of the X-chromosome or an autosomal chromosome2. The SRY gene that encodes sex-determining region Y protein is the only known gene associated with 46, XX DSD, although other as yet unidentified genes are likely to be implicated in some cases2. The genetic material required for spermatogenesis is absent; thus, testicular sperm extraction is not indicated.

This case reinforces the need to request a karyotype during the assessment of otherwise unexplained male hypogonadism, and the need to counsel the patient prior to testing about the possibility of unexpected chromosomal abnormalities.

 

Nothing to Disclose: RIH, EB

20150 8.0000 SAT-123 A An Unusual Cause of Hypogonadism: A Case Addressing the Importance of Karyotype Investigation in a Young Man with Primary Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Ronald Wiehle*1, Gregory K Fontenot2, Jennifer Nydell1, Jaye Thompson1, Martin Sandel1 and Andrew McCullough3
1Repros Therapeutics, The Woodlands, TX, 2Repros therapeutics, The Woodlands, TX, 3Urological Institute of Northeastern New York, Albany, NY

 

Introduction and Objective: It was our aim to evaluate oral enclomid (enclomiphene citrate or Androxal) as an alternative to a currently-available topical testosterone replacement therapy for men with secondary hypogonadism.

Methods:These trials (ZA-304 and ZA-305) were randomized, double blind, placebo- and active-control, multi-center phase III studies in 224 men between 25 and 60 years of age with secondary hypogonadism. Men received 12.5mg or 25mg of enclomid as a daily capsule and were provided with a placebo gel.  Other men received AndroGel 1.6% and placebo capsules.  Placebo men received placebo capsules and gels.

Results: Subjects needed to have initial testosterone (T) values below 300ng/dL at least twice. At End of Study (EOS), 16 weeks, there was a statistically significant rise in T in men receiving either enclomid or topical testosterone product into the normal range (see table). Placebo subjects did not change. Enclomid did not decrease sperm counts unlike the topical gel. As we have seen before, enclomid increased LH and FSH while men in the topical arm showed decreases (not shown). All men were similar at baseline in testes volume (p=0.94, ANOVA) by orchidometry. Men on topical testosterone demonstrated decreases in mean testicular volume (-0.86 cm3) in both studies and a significant decrease overall compared to the enclomid (p<0.05) or placebo (p<0.05).

Conclusions: Enclomid led to no deleterious effects on sperm counts or testes size by orchidometry.  It also significantly increased total serum testosterone, LH and FSH which suggests that the drug normalized endogenous testosterone production through the hypothalamic-pituitary-testicular axis and supported the natural continuation of sperm number and testes volume.     Supported by Repros Therapeutics Inc.

 

Disclosure: RW: Chief Scientific Officer, Repros Therapeutics. GKF: Researcher, Repros therapeutics. JN: Management Position, Repros Therapeutics. JT: Board Member, Repros Therapeutics, Employee, Repros Therapeutics. MS: Employee, Repros Therapeutics. AM: Coinvestigator, Repros Therapeutics, Medical Advisory Board Member, Repros Therapeutics.

21261 9.0000 SAT-124 A Enclomid and Topical Testosterone Elevate Testosterone in Hypogonadal Men but Enclomid Does Not Decrease Testes Size 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Babette Carlson Glister*
Walter Reed National Military Medical Center, Bethesda, MD

 

The diagnosis and management of hypogonadism has become commonplace as treatment options have improved, yet barriers to satisfactory replacement still exist. These include significant cost, pain, inconvenience, and variable efficacy. Rare reports in the literature suggest that subcutaneous (SQ) injection of oil-based testosterone, already administered widely via intramuscular injection, may be better tolerated and absorbed than previously believed. We report three cases of established symptomatic hypogonadism switched to SQ testosterone once or twice weekly, after failure or intolerance to other regimens. None of the cases had evidence of liver toxicity, lower urinary tract symptoms, or polycythemia during any of these treatment phases.

Case #1: 62 y.o. male with primary hypogonadism on Androgel 1% 50mg dose chronically with total T of 210-374 ng/dl, then increased to a range of 578-1241 ng/dl on maximal dose. Skin irriration led to transition to SQ testosterone cypionate, with total T trending from 1088 to760 on dose de-escalation from 50mg to 30mg weekly. He continues down-titration to 20mg SQ weekly with no pain or irritation at injection site and with good symptomatic relief.

Case #2: 38 y.o. male with primary hypogonadism and prior variable absorption of both Androgel and Testim 1% gel at 50-100 mg doses (14.9-1214 ng/dl with average fasting peak total T of 450).  On SQ Testosterone cypionate twice weekly, day #2-3 levels were a total T of 665-713 ng/dl on 50mg (with pre-injection trough of 572 ng/dl), total T of  570 at 40mg, total T of 434 at 30mg. He reports stable improved muscle mass and less fatigue on this regimen.

Case #3: 43 y.o. male with primary hypogonadism treated chronically with Androderm 8 mg patches but with variable control (total T 174-378 ng/dl) and poor symptom resolution. Upon switch to Fortesta 40mg topical gel his total T was 475 but significant pruritis limited continuation. He changed to SQ testosterone cypionate 50mg once weekly with total T 321 (and calc. free T 82.8, nl 50-155). He increased recently to 60 mg once weekly without injection site issues.

In conclusion, these three cases add to literature suggesting that SQ testosterone in currently available preparations may be a convenient, safe and cost-effective alternative to standard topical or IM preparations. Long-term, prospective comparisons will be needed to substantiate these favorable observations.

 

Nothing to Disclose: BCG

21802 10.0000 SAT-125 A Stable Biochemical Control of Hypogonadism with Subcutaneous Delivery of Testosterone 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Melany Castillo*1 and Alejandro Ayala2
1University of Miami, Miami, FL, 2Univ of Miami Schl of Med, Bay Harbor Islands, FL

 

CHARGE syndrome: Ocular synkinesis, hypogonadotropic hypogonadism and anosmia caused by a novel X31p.A2137 CHD7 gene mutation

Background:  CHARGE syndrome is a rare cause of hypogonadotropic hypogonadism caused by mutations of the  CHD7 gene (60%–70% of the cases) which encodes for the chromodomain  helicase DNA binding protein 7.

Clinical case: We present the case of a 22-year-old Hispanic male evaluated for long standing developmental delay and severe hypogonadotropic hypogonadism. The patient was the first child of non-consanguineous parents of Hispanic origin.  He had undergone surgery for cleft palate at 18 months of age and used hearing aids for neurosensorial deafness.  His past medical history also revealed growth hormone deficiency, hypogonadotropic hypogonadism requiring testosterone replacement, short stature, hip dysplasia, right facial palsy and asymmetric nipples.  On physical examination he displayed cleft lip and bilateral palate repair, grade 1 microtia , type 1 dysplasia of the auricles, unilateral facial palsy with spams, anosmia and ocular synkinesis.  He had pre pubertal testes, a small penis and scant genital hair. Endocrine evaluation revealed a decreased total testosterone of 32 ng/dl (250-1100), normal comprehensive metabolic profile, CBC,  ACTH, free T4,  IGF-1 and TSH. MRI of the brain revealed absence of the semicircular canals. Genetic evaluation revealed a novel mutation X31p.A2137 CHD7 gene confirming the diagnosis of CHARGE syndrome.

We report the first case of CHARGE caused by a mutation of the X31.A2137 CHD7 gene resulting in anosmia,  hypogonadotrophic hypogonadism and ocular synkinesia, a rare ocular manifestation caused by congenital aberrant innervation of the ocular muscles reported in  approximately 9 % of affected patients.

Conclusion: We report the firest case of CHARGE syndrome with ocular synkinesis, anosmia and hypogonadotropic hypogonadism  in a patient with a novel mutation X31p.A2137 CHD7 gene.

 

Nothing to Disclose: MC, AA

19544 11.0000 SAT-126 A Charge Syndrome: Ocular Synkinesis, Hypogonadotropic Hypogonadism and Anosmia Caused By a Novel X31p.A2137 CHD7 Gene Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Olivia Papacostea* and Maria Ramos-Roman
UT Southwestern Medical Center, Dallas, TX

 

Testosterone replacement has been increasingly promoted over the past years and currently there is insufficient data regarding the potential associated cardiovascular morbidity. Potential mechanisms of cardiovascular toxicity are: atherogenic, thrombotic, vasospastic and direct myocardial injury. We highlight the case of a young patient that presented with new onset congestive heart failure in the context of using supraphysiological doses of intramuscular testosterone.

A 52 year old previously healthy man presented to our hospital with worsening dyspnea on exertion for 2-3 weeks, 2 pillow orthopnea and paroxysmal nocturnal dyspnea accompanied by “band like” chest pain.  His past medical history was only positive for “low testosterone” and he denied smoking, habitual alcohol use or drug use. He is a firefighter and was previously very active with no limitations. His home medications were: inhaled albuterol, montelukast and injectable intramuscular testosterone. On physical examination patient was noted to be very muscular, looking younger than his stated age. Exam was otherwise unremarkable except for bilateral rales in both lung bases. Laboratory data revealed polycythemia with an elevated hematocrit level (62.9, n 37.0-50.0 %). An echocardiogram showed a severely depressed left and right ventricular function and further cardiac workup revealed a non-ischemic etiology. A total testosterone level was obtained because of the polycythemia and was noted to be markedly elevated (2240 ng/dL n 240-950 ng/dL). On further interview patient disclosed that he was taking testosterone 200mg intramuscularly every 4 days and was not following up regularly with his physician to check testosterone levels. He was self-dosing the testosterone based on symptoms of low energy. Patient was started on treatment with intravenous lasix and underwent phlebotomy with improvement in the symptoms and hematocrit level. Testosterone injections were discontinued. The testosterone levels remained very elevated for more than 3 weeks after the last intramuscular testosterone injection, most likely because of the stacking effect of the frequent self-administered doses. He was seen in follow up after a few months and at that time his systolic function had significantly improved.

This case illustrates the fact that supraphysiological levels of testosterone could be associated with new onset congestive heart failure in young fit men on testosterone replacement therapy.  A testosterone level should be obtained in these patients as part of the workup.  Testing should be considered even in patients that do not disclose testosterone use.

 

Nothing to Disclose: OP, MR

19173 12.0000 SAT-127 A When Testosterone Can Break Your Heart 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Yi Xian Chan1, Matthew W Knuiman1, Joseph Hung1, Mark L Divitini1, David J Handelsman2, John P Beilby3, Brendan McQuillan1 and Bu Beng Yeap*1
1University of Western Australia, Perth, Australia, 2University of Sydney, Sydney NSW, Australia, 3Sir Charles Gairdner Hospital, Perth, Australia

 

Context

Clarifying relationships of sex hormones to carotid intima-media thickness (CIMT) and carotid atheroma could illuminate pathways by which low circulating testosterone (T), or its metabolites dihydrotestosterone (DHT) and estradiol (E2), are associated with cardiovascular event and mortality risk.

Objectives

To determine sex hormone profiles associated with CIMT and carotid atheroma, in cohorts of men with and without known coronary artery disease (CAD).

Participants and methods

Fasting early morning sera from 492 community-based men aged 20-70 years (Group A) and from 426 men with angiographically proven CAD aged <60 years (Group B) were assayed for T, DHT and E2 using liquid chromatography-tandem mass spectrometry. CIMT and carotid plaque was assessed ultrasonographically. Linear and logistic regression analyses were performed with adjustment for age, smoking, body mass index, other cardiovascular risk factors, lipids and C-reactive protein.

Results

Mean (±SD) age (Group A vs Group B: 53.8±12.6 vs 49.6±5.1 years) and circulating T (A vs B: 10.8±4.2 vs 11.0±3.8 nmol/L), DHT (A vs B: 1.10±0.64 vs 1.01±0.44 nmol/L) and E2 (A vs B: 99.1±43.8 vs 88.9±45.4 pmol/L) were comparable between the two groups. In fully-adjusted analyses, higher T was associated with reduced CIMT in Group A (-0.011 mm per 1 SD increase in hormone, p=0.042) but not in Group B (0.004 mm per 1 SD increase, p=0.531). Higher E2 was  associated with increased CIMT in Group A (0.013 mm per 1 SD increase, p=0.011) but not Group B (-0.003 mm per 1 SD increase, p=0.567). DHT was not associated with CIMT in either group. Higher T was associated with reduced odds of carotid plaque in Group A (fully-adjusted odds ratio [OR] per 1 SD increase in hormone, OR=0.68, 95% CI=0.51-0.92) but not Group B (OR=1.00, 95% CI=0.80-1.25). Higher DHT was associated with reduced odds of carotid plaque in Group B (OR=0.77, 95% CI=0.61-0.97) but not Group A (OR=0.91, 95% CI=0.71-1.17). Higher E2 was associated with reduced odds of carotid plaque in Group B (OR=0.75, 95% CI=0.61-0.93) but not Group A (OR=0.93, 95% CI=0.73-1.18).

Conclusions

In community-dwelling men, but not men with established CAD, higher T is associated with more favourable CIMT and lower likelihood of carotid plaque. By contrast, higher E2 is associated with less favourable CIMT in community-dwelling men. Higher DHT or higher E2 are associated with reduced plaque prevalence in men with CAD. T, DHT and E2 exhibit differential associations with preclinical atherosclerosis, which are specific for underlying cardiovascular phenotypes. Interventional studies are needed to examine differential effects of exogenous T and its metabolites DHT and E2, on atherosclerosis risk in early and advanced disease.

 

Nothing to Disclose: YXC, MWK, JH, MLD, DJH, JPB, BM, BBY

19297 13.0000 SAT-128 A Testosterone, Dihydrotestosterone and Estradiol Are Differentially Associated with Carotid Intima-Media Thickness and the Presence of Carotid Atheroma in Men with and without Coronary Artery Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Benjumin Hsu*1, Robert G Cumming1, Fiona M Blyth2, Vasi Naganathan2 and David J Handelsman3
1University of Sydney, Sydney, Australia, 2Concord Hospital & University of Sydney, Sydney, Australia, 3University of Sydney, Sydney NSW, Australia

 

Objectives: It is unclear whether declining sexual function in older men is a cause or consequence of reduced androgen status. Longitudinal associations were examined between circulating reproductive hormones and sexual function in older men.

Methods: Men aged 70 years and older from the Concord Health and Ageing in Men Project (CHAMP) were assessed at baseline (n=1705) and 2-year follow-up (n=1367). At both visits, serum testosterone (T), dihydrotestosterone, estradiol (E2), and estrone (E1) were measured by liquid chromatography-tandem mass spectrometry, and SHBG, LH, and FSH by immunoassay. Sexual functions (erectile function, sexual activity and sexual desire) were self-reported via standardized questions.

Results: In longitudinal analyses, although baseline hormones (T, DHT, E2 and E1) did not predict decline in sexual activity, sexual desire and erectile function, the decline in serum T (but not DHT, E2 or E1) over 2-years were strongly related to the change in sexual activity and desire (but not erectile function). For each 1-SD decrease in T from baseline to 2-year follow-up, there was a multivariate-adjusted odds ratio of 1.23 (95%CI: 1.12-1.36) for an additional risk of further decline in sexual activity. However, the magnitude of the decrease in serum T was strikingly small (<10%). Similar associations were found for changes over 2-years in serum T and decline in sexual desire but not for erectile function. At baseline, 2-year and pooled cross-sectional data, there were significant univariate associations between T and sexual activity and sexual desire, which persisted after multivariate-adjustment, but not for DHT, E2 or E1 with or without multivariate-adjustment.

Conclusion: Our findings suggest that the decline in sexual activity and desire, but not in erectile function, among older men followed over 2-years may be the cause rather than the consequence of the accompanying small decrease in serum T but not DHT, E2 and E1.

 

Nothing to Disclose: BH, RGC, FMB, VN, DJH

19521 14.0000 SAT-129 A Longitudinal Relationship of Sexual Function and Androgen Status in Older Men: The Concord Health and Ageing in Men Project 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Christopher Westley*1, Richard Amdur2 and Michael Scott Irwig3
1George Washington University School of Medicine and Health Sciences, Washington, DC, 2Georgetown University School of Medicine, 3George Washington Univ, Washington, DC

 

Men referred for borderline testosterone levels have high rates of depression

Christopher J Westleya BS, Richard L Amdurb  PhD and Michael S Irwigc MD

aSchool of Medicine and Health Sciences, bMedical Faculty Associates,

cCenter for Andrology and Division of Endocrinology,

The George Washington University, Washington DC, United States

  

Background: Studies have shown inconsistent results regarding a possible association between depression and serum testosterone levels. There are few published studies on adult men who are referred for management of borderline testosterone levels, although this is a very common clinical scenario. We hypothesized that men referred for borderline testosterone levels would have higher rates of depression and depressive symptoms than the general population. 

Methods: Subjects were 200 adult men (age range 20-77 years old) referred for management of borderline testosterone levels, defined as total testosterones between 200-350 ng/dl (6.9-12 nmol/L). All men had a repeat measurement of total testosterone and an assessment of depressive symptoms or depression [scores from the validated Patient Health Questionnaire 9 (PHQ-9) and/or an established diagnosis of depression or current use of an antidepressant]. Collected data included demographic information, medical histories, medication use, and signs and symptoms of hypogonadism.

Results: Using a score of ≥10 on the PHQ-9, 56% of the population had either significant depressive symptoms and/or a known diagnosis of depression and/or use of an antidepressant. The PHQ-9 identified depressive symptoms (scores ≥10) in 7% of the study population in which these men denied depressive symptoms or having depression. Men referred for borderline total testosterone levels had rates of depressive symptoms that were markedly higher than those seen in several reference populations using the same validated instrument. For example, rates of depressive symptoms (PHQ9 scores ≥10) ranged from 15-22% in an ethnically diverse sample of primary care patients and was 5.6% among overweight and obese US adults from the 2005-6 NHANES. The population was also notable for a high prevalence of overweight (39%), obesity (40%) and physical inactivity as over half (51%) did not engage in regular exercise that did not involve walking. The most common symptoms reported were erectile dysfunction (78%), low libido (69%) and low energy (52%).

Conclusions: Men referred for borderline testosterone levels have higher rates of depression and depressive symptoms than the general population. This study underscores the utility of a validated instrument to screen for depression, especially as some subjects may deny signs and symptoms during the interview. Appropriate referrals should be made for formal evaluation and treatment of depression.

 

Nothing to Disclose: CW, RA, MSI

18364 15.0000 SAT-130 A Men Referred for Borderline Testosterone Levels Have High Rates of Depression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


E. David Crawford1, Wendy Poage2, Allen Nyhuis3, David Alan Price3, Sherie A Dowsett3 and David Muram*3
1University of Colorado, 2Prostate Conditions Education Council, 3Eli Lilly and Company

 

Introduction

The Endocrine Society recommends against screening for hypogonadism in the general population and suggests that clinicians limit testing to men with certain clinical conditions in which the prevalence of low total testosterone (TT) is high (i.e., men with disease of sellar region, HIV-associated weight loss, end-stage renal disease, chronic obstructive lung disease, osteoporosis or low trauma fracture at a young age, or type 2 diabetes mellitus [T2DM], and men receiving chronic glucocorticoid and opioids) (1). Recently, race, obesity, exercise frequency, and ED were identified as factors that might help predict men with/at risk of hypogonadism; findings from that study were used to develop the Male Androgen Deficiency Syndrome (MADS) Screening Questionnaire (2). However, many of these factors are interrelated and it is not clear which are driving the increased risk for hypogonadism. We use multivariate analysis to identify which of those factors included in the MADS questionnaire could predict at risk populations for hypogonadism.

Methods

The study sample comprised men who elected to be screened during the 2013 Prostate Cancer Awareness Week (PCAW), a US community-based prostate cancer screening program sponsored by the Prostate Conditions Educational Council (PCEC). Men undergoing screening provided informed consent, completed a series of health questionnaires, including the IPSS, underwent a medical evaluation and, for a large subset, had blood drawn for laboratory assays, including measurement of TT levels. For statistical analysis, the dichotomous response variable was low endogenous TT: yes (<300 ng/dl) (n=145) or no (n=286) as determined from blood samples drawn 8AM to 2PM. Stepwise logistic regression, with α=.05, was used to determine the best-fitting predictive model for low TT. A total of 27 possible predictors, mostly dichotomous variables, were entered into the model. Chi-square analysis was used for confirmatory comparisons, comparing the low TT percentages for the significant predictors.

Results

In the final model, a history of T2DM (p=0.0003) and being overweight by more than 20lb (p<0.0001) were predictive of low TT. Men with T2DM were 3.7 times (95% CI 1.8-7.4) more likely to have low TT; men who considered themselves to be more than 20lb overweight were 2.9 times (95% CI 1.7-4.8) more likely to have low TT. To confirm these predictors, of the 45 men who had T2DM, 67% had low TT, and of the 382 who did not have T2DM, 30% had low TT (p<0.0001). Of the 82 men who were 20lb or more overweight, 56% had low TT, and of the 314 not overweight, 28% had low TT (p<0.0001).

Conclusion

Being overweight and having a history of T2DM were the strongest predictors of low TT. The Endocrine Society recommends screening for low TT in men with T2DM (1) and the current study aligns with this recommendation. However, screening for low TT in overweight men is currently not supported by guidelines.

 

Disclosure: EDC: Consultant, Bayer, Inc., Consultant, MDx, Consultant, Genomic Health, Consultant, Jansen Pharmaceuticals, Consultant, Dendreon, Consultant, Ferring Pharmaceuticals, Employee, Ferring Pharmaceuticals. WP: Collaborator, MDx Health, Collaborator, Strand Diagnostics, Collaborator, Genomic Dx, Collaborator, Abbott Laboratories, CME Programming, Independent Contractor, Bayer, Inc.. AN: Employee, Eli Lilly & Company. DAP: Employee, Eli Lilly & Company. SAD: Employee, Eli Lilly & Company. DM: Employee, Eli Lilly & Company.

18986 16.0000 SAT-131 A Screening for Hypogonadism: Identifying at Risk Populations Using Multivariate Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Cem Haymana*1, Alper Sonmez1, Aydogan Aydogdu1, Serkan Tapan1, Yalcin Basaran2, Coskun Meric1, Kamil Baskoy3, Mustafa Dinc1, Mahmut Yazici1, Abdullah Taslipinar1, Cem Barcin1, Mahmut Ilker Yilmaz1, Sinasi Erol Bolu4 and Omer Azal1
1Gulhane School of Medicine, Ankara, Turkey, 2Gulhane School of Medicine, Turkey, 3GATA Haydarpasha Training Hospital, Istanbul, Turkey, 4Memorial Atasehir Hospital, Istanbul, Turkey

 

Objective:

Endothelial dysfunction, inflammation and insulin resistance are prevalent in hypogonadism, increasing the cardiovascular and metabolic risk. Visceral adiposity index (VAI) is a simple surrogate marker of visceral adipose dysfunction and show strong association with cardiovascular disease (CVD). Triglyceride /High Density Lipoprotein cholesterol (TG/HDL-C) ratio is a clinical indicator of insulin resistance and strongly predictive of CVD. We investigated the role of VAI and TG/HDL-C ratio in predicting endothelial dysfunction, inflammation and insulin resistance in an unconfounded population of congenital hypogonadotrophic hypogonadism.

Design: Retrospective study, performed in the database of department of Endocrinology, Gulhane School of Medicine.

Methods: Treatment naive young male patients with CHH (n=60, mean age 21.83 ± 2.2 yrs) and age matched healthy control subjects (n=70, mean age 21.32 ± 1.1 yrs) were enrolled. The demographic parameters, fasting glucose, lipids, insulin, Asymmetric dimethylarginine (ADMA), high sensitive C reactive protein (hs-CRP) levels were measured in patients and controls. Insulin sensitivity was estimated by homeostatic model assessment (HOMA-IR) formula. VAI and TG/HDL-C ratio was also calculated in patients and controls.

Results: The Waist Circumferences (WC)(p=0.009), Triglycerides (p=0.03), VAI (P=0.005), ADMA, insulin and HOMA-IR levels (p<0.001 for all) were significantly higher when compared to the healthy controls. The VAI levels were significantly correlated to the ADMA, HOMA-IR, hs-CRP, total testosterone levels, while the TG/HDL ratio levels had no significant associations. In the linear regression analysis, the total testosterone and WC levels were the significant independent determinants of the ADMA, HOMA-IR or CRP levels while the VAI or TG/HDL ratio had no predictive role.

Conclusion: The results of the present study show that endothelial dysfunction, inflammation and insulin resistance are present in very young and treatment naïve patients with CHH. The results also show that the TG/HDL ratio and the VAI are not applicable as predictors of endothelial dysfunction, inflammation or insulin resistance in this specific patient population.

 

Nothing to Disclose: CH, AS, AA, ST, YB, CM, KB, MD, MY, AT, CB, MIY, SEB, OA

20047 17.0000 SAT-132 A The Role of Visceral Adiposity Index and TG/HDL-C Levels in Predicting Endothelial Dysfunction, Inflammation and Insulin Resistance in Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Yu Wang*, Wen Ji, Wei Wang, Luyao Zhang and Zhihong Liao
1st Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China

 

Objectives: Testicular volume was tightly correlated with its function and was a crucial indexes to estimate the treatment efficacy for idiopathic hypogonadotropic hypogonadism (IHH). There was confliction about the precise of Prader orchidometer (PO). We investigated the accuracy of PO for measuring testicular volume and analyzed its convertibility using  ultrasonic testing (US) data as standard.

Methods: Twenty seven IHH male (average age:25±5yr ) participated in the longitudinal follow-up of hormone treatment. Their bilateral testicular volumes were examed with PO and US simultaneously before therapy and at every visit of 3-month interval. 87 inspections, 164 readings of bilateral testicular volume were obtained, 64 of them also had the testis elasticity records from ultrasonic scan.

Results: The mean testicular volume for 164 readings were 7.5±3.6ml and 3.0±2.1ml for PO measurements and ultrasonic testing respectively. A strong correlation was found between the volumes obtained from PO and US(r=0.738,P<0.001). Unfortunately, comparing with US, PO over-estimated the testicular volume by 4.5±2.7ml (equivalent to 3.2 times larger than US). The elasticity Index (EI) and size of testes impacted on the difference between PO and US. The lower the EI, the smaller the difference between PO and US based on a multiple linear regression analysis. The shorter the testicular length, the greater the difference between PO and US.

Conclusions: Testicular volume obtained by PO over-estimated the testicular volume greatly as for IHH subjects. No formula was developed to convert PO to US properly. We firstly noticed that the smaller differences of testicular volume between the two kinds of measurement when EI was lower and the testicular length was longer.

 

Nothing to Disclose: YW, WJ, WW, LZ, ZL

20840 18.0000 SAT-133 A The Large Error of Prader Orchidometer Compared to Ultrasonic Testicular Volume in Idiopathic Hypogonadotropic Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Swaytha Yalamanchi*1, Adrian Sandra Dobs2 and Cynthia Munro3
1John Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, 3Johns Hopkins University School of Medicine, Baltimore, MD

 

The neurocognitive phenotype in Klinefelter’s Syndrome (KS) is highly variable with differences speculated to be related, in part, to genetics. Overall intellectual functioning has been reported to be low-normal or normal, with poorer verbal than non-verbal abilities most often described. Impairment in verbal cognitive function has been thought  to partially explain the lower education level achieved by KS patients.  

We retrospectively reviewed the multidisciplinary evaluation of 10 men (age range 15-50 years) with KS at Johns Hopkins Hospital from 2013-2014, all of whom had detailed neurocognitive assessment, including IQ testing. We found that the mean overall intelligence (mean full scale IQ = 99, range 82 – 109) was solidly average based on normative data from the general population (mean = 100, SD = 15). Similarly, non-verbal intelligence (mean = 100, range 90 – 109) was also entirely normal. Verbal intelligence, however, was variable. Whereas the mean verbal IQ was 99, scores ranged from borderline (72) to superior (125). Review of individual cases indicated that men with the 3 lowest verbal IQ scores (72, 85, and 88) all had a family history of speech problems, developmental delay, learning disabilities, and/or dyslexia. Three individuals with average verbal IQ scores (93, 96, and 108) also had a family history of ADHD, dyslexia, and learning disorders respectively. In contrast, men with the highest verbal IQ scores (122 and 125) had no family history of learning disorders.

Consistent with previously published studies, we found that men with KS had mean overall IQ scores in the average range. We also found that individuals with the lowest verbal IQ scores had strong family histories of learning disabilities, dyslexia, and/or speech impairments, whereas men with the highest verbal IQ scores had no family history of learning difficulties. Our findings suggests that a family history of learning disabilities may confer a genetic and/or environmental susceptibility to poorer cognition in men with KS and may be required in order to produce the verbal learning deficits often reported in this disorder.

 

Nothing to Disclose: SY, ASD, CM

21859 19.0000 SAT-134 A Cognition in Men with Klinefelter’s Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Farid Saad*1, Ahmad Haider2, Karim Sultan Haider2, Gheorghe Doros3 and Abdulmaged M Traish4
1Bayer Pharma AG, Berlin, Germany, 2Private Urology Practice, Bremerhaven, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA

 

Introduction and Objectives:

Hypogonadism is associated with cardiometabolic risk. Studies suggest that hypogonadism increases the risk of all-cause and cardiovascular mortality. While some short-term studies have been performed in men with CVD, there are no data on long-term effects of testosterone (T) therapy in men with CVD.

Methods:

In a prospective, cumulative, observational registry study from a single urologist’s office, 340 men with T ≤12.1 nmol/L received TU injections for up to 87 months. In this subgroup analysis, 68 men with a previous diagnosis of coronary artery disease (CAD; n=40) and/or a history of myocardial infarction (MI; n=40) and/or stroke (n=6) were analyzed. These patients are considered high-risk patients by any definition.

Results:

Mean age was 60.76±4.94 years. The mean observation time was 72 months. All men except four were obese. 68 men were included for 3 years, 59 for 4 years, 54 for 5 years, 44 for 6 years, and 28 for 7 years. Declining numbers reflect the nature of the registry but not drop-out rates.

Weight (kg) decreased from 115.07±13.71 to 90.79±8.92. Waist circumference (cm) decreased from 112.07±7.97 to 99.14±6.53. BMI decreased from 37.27±4.45 to 29.58±3 (p<0.0001 for all). Mean weight loss was 18.75±0.71%.

Fasting glucose decreased from 108.74±17.08 to 96.14±2.01 mg/dl, HbA1c from 7.81±1.16 to 5.86±0.49% (p<0.0001 for both).

Total cholesterol decreased from 304.66±34.09 to 187.75±7.6, LDL from 184.28±37.51 to 120.64±29.29, triglycerides from 308.38±56.3 to 187.04±7.65 mg/dl. HDL increased slightly from 63.79±17.79 to 67.14±16.71 (p<0.0001 for all). The total cholesterol:HDL ratio declined from 5.16±1.55 to 2.97±0.77 (p<0.0001).

Liver enzymes: aspartate transaminase (AST) decreased from 42.16±14.13 to 19.71±2.17, alanine transaminase (ALT) from 42.56±15.55 to 19.39±3.25 U/L (p<0.0001 for both).

Systolic BP decreased from 167.82±11.01 to 142.39±9.54, diastolic BP from 102.28±8.23 to 80.07±7.13 mmHg (p<0.0001 for both). Pulse pressure declined from 65.54±5.24 to 62.32±5.15 (p<0.0001).

C-reactive protein (CRP) decreased from 3.97±4.73 to 0.32±0.44 mg/dl.

Haemoglobin increased from 14.45±0.68 to 15.03±0.45 g/dl, haematocrit from 43.51±2.86 to 48.86±1.41%.

In no patient testosterone was discontinued or interrupted. There were no major cardiovascular events during the observation time.

Conclusion:

T treatment in hypogonadal men with CVD was well tolerated and resulted in significant and sustained improvements of cardiometabolic risk factors. Medication adherence was excellent.

 

Disclosure: FS: Employee, Bayer Schering Pharma. AH: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. Nothing to Disclose: KSH, AMT

19443 20.0000 SAT-135 A Obese Hypogonadal Men with Cardiovascular Diseases (CVD) Benefit from Long-Term Treatment with Testosterone Undecanoate (TU): Observational, Real-Life Data from a Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Farid Saad*1, Claudia Heitmann2 and Ahmad Haider3
1Bayer Pharma AG, Berlin, Germany, 2Private Dermatology Practice, Bremerhaven, Germany, 3Private Urology Practice, Bremerhaven, Germany

 

Introduction:

The potential role of hypogonadism has been discussed for several auto-immune disease such as rheumatoid arthritis, chronic obstructive pulmonary disease, Crohn’s disease, and lupus erythematosus. To our knowledge, there are no data on psoriasis. An association of psoriasis with metabolic syndrome and obesity is becoming more and more obvious, and the bi-directional relationship between obesity and hypogonadism is well established.

Methods:

Single-center, cumulative, prospective, registry study of 347 hypogonadal men (total testosterone ≤ 12.1 nmol/L). Among a variety of comorbidities, 15 men had a previous diagnosis of psoriasis. All men received TU injections every 12 weeks following an initial 6-week interval for up to 93 months (8 years). 2 men were followed for 93 months, 4 men for 90 months, 2 men for 87 months, 1 man for 63 months, 1 man for 48 months, 2 men for 45 months, 1 man for 42 months, and 2 men for 30 months.

The following measures were taken at every or every other visit: weight, waist circumference, BMI, Psoriasis Area and Severity Index (PASI), Physician Global Assessment for Psoriasis (PGA), and C-reactive protein (CRP) as an indicator of inflammation.

Results:

7 patients were obese and 8 overweight.

Weight decreased in all patients by 6 to 24 kg. The average weight loss was – 12.5 kg.

Waist circumference decreased in all patients by 1 to 13 cm. The average reduction in waist circumference was – 7.1 cm.

Average baseline CRP was 6.32 mg/dl (minimum: 0.7; maximum: 55.7 mg/dl). At the end of the observation time, average CRP decreased by 5.75 to 0.57 mg/dl (minimum: 0.1; maximum: 2.9 mg/dl).

PASI decreased from an average baseline 19.3 to an average 2.3 at the last observation. PGA decreased from an average baseline 4.9 to an average 1.1 at the last observation. The major changes for both instruments occurred during the first 2 years of testosterone treatment.

No patient dropped out.

Conclusions:

In hypogonadal men with psoriasis, long-term testosterone therapy progressively and sustainably improves weight, waist circumference, and the disease-specific instruments PASI and PGA. Reduction of CRP under testosterone treatment supports the anti-inflammatory effect of testosterone. Modern treatment options for psoriasis include monoclonal antibodies targeting TNF-α. Testosterone has been shown to effectively reduce TNF-α. In our registry, we did not measure TNF-α as they were not designed to look at auto-immune diseases.

Our observational results from a registry study should be verified by controlled studies.

 

Disclosure: FS: Employee, Bayer Schering Pharma. AH: Investigator, Bayer Schering Pharma. Nothing to Disclose: CH

21884 21.0000 SAT-136 A Hypogonadal Men with Psoriasis Benefit from Long-Term Testosterone Replacement Therapy (TRT) in – a Series of 15 Case Reports 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 116-136 6015 1:00:00 PM Male Hypogonadism - Causes and Treatments Poster


Maria Papagianni*1, Dimitrios T Papadimitriou2, Zadalla Mouslech1 and Georgios Mastorakos2
1Aristotle University of Thessaloniki, Thessaloniki, Greece, 2Athens Medical School, Athens, Greece

 

Background: The coexistence of cataract and hypogonadism in childhood is a rare condition. Molecular karyotyping can be helpful in identifying the underlying molecular abnormality.

Clinical case: A 10-year-old girl, the first child of apparently healthy and non-consanguineous parents, presented for evaluation of short stature. She was born at term, AGA, after an uneventful pregnancy with normal vaginal delivery and her birth weight was 3720gr. She was following the 25th percentile regarding both the height and the weight while her target height (mid-parental height – 6.5 cm) was between the 75th and the 90th percentile. She was suffering from mild asthma since her 2nd year of life. At the age of 8 yrs she was diagnosed with cataract bilaterally and underwent surgery 1.5 year later. Her family history was unremarkable. Her mother had menarche at the age of 12 yrs and her father had apparently constitutional delay of growth and puberty. On examination, she was prepubertal without any dysmorphic features. Her initial investigation tests did not reveal any abnormal results apart from high basal FSH levels 11mIU/ml and low, but in the pubertal range, basal LH 0.5mIU/ml. Her bone age was delayed by 2.5 yrs. Further evaluation was recommended but unfortunately she showed up 4.5 yrs later. At the age of 14.5 yrs her height was already below the 3rd percentile while still prepubertal (Tanner stage: Breast 1, Pubic Hair 2-3, Axillary Hair 2) and with a bone age now delayed by 3.5 yrs. Very high levels of FSH (87.4 mIU/ml) and LH(20.4 mIU/ml)  were found. Hypoplastic uterus and streak gonads were revealed in the pelvic ultrasound and the standard karyotype was normal 46XX. Molecular karyotype (array CGH) revealed deletions in the genomic areas 6p25.3 and 7q36.3. The forkhead transcription–factor gene (FOXC1) is located in the first genomic area while the Sonic Hedgehog (SHH) gene is located in the second one. Mutations in FOXC1 have been shown to cause defects of the anterior chamber of the eye. Moreover, the SHH gene takes part in the signaling pathway of follicles and oophorus cumulus. The patient after initiation of hormonal replacement therapy with natural estrogens increased her height velocity and progressed to puberty having her menarche at the age of 16.5yrs. At the age of 17 yrs, her height is 160cm (between 25th and 50th centile) and she is still growing.

Conclusion: To our knowledge, this is the first case demonstrating the association of cataract and female hypogonadism with coexisting deletions in genomic areas 6p25.3 and 7q36.3 where FOXC1 and SHH genes are located.

 

Nothing to Disclose: MP, DTP, ZM, GM

21319 1.0000 SAT-169 A Deletions in Genomic Areas, Where FOXC1 and SHH Are Located, Are Associated with Cataract and Female Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Kristine Santos de Luna* and Leilani Mercado Asis
University of Santo Tomas Hospital, Manila, Philippines

 

BACKGROUND: It is important to recognize whether precocious puberty is gonadotropin-dependent or gonadotropin-independent because of the differences in treatment. Patients with this disorder have premature pubertal growth spurt and advanced bone maturation leading to reduced height in adulthood, and body disproportion. These effects can be corrected if treatment is administered early. Aside from these long-term physical derangements, these patients are prone to have psychosocial impairments leading to social isolation, and loss of self-esteem. These patients are also vulnerable to sexual abuse, and pregnancy due to early sexual maturation. Prompt diagnosis and early appropriate treatment and follow-up are therefore necessary in order to achieve normal physical and psychosocial development in these children.

CLINICAL CASE: We present two cases of precocious puberty in girls. The first case, secondary to a tuber cinereum hamartoma, was detected in the late stage of the disorder. The stature and weight by age are already above 95th percentile. There was also full-blown development of secondary sexual characteristics and psychosocial impairment. In the second case, precocious puberty was detected early. A tuber cinereum hamartoma is suspected to be the etiology. Length and weight by age are still within the normal limits.

The first case is a 5 years old female presenting with vaginal bleeding and breast enlargement since 2 years old. Psychosocial problems are also present. On examination, the breasts and pubic hair are at Tanner 3 stage. The stature and weight is above 95th percentile. Further work-up revealed elevated estradiol at 278 pg/mL (n <5 pg/mL), FSH 5 mIU/mL (n < 3 mIU/mL), and LH 6.81 U/mL (n < 3 U/mL). Patient bone age is advanced. MRI of the brain showed a tuber cinereum hamartoma measuring 9 x 10 x 8 mm. Leuprolide every 3 months and follow-up to assess the effect were advised. 

The second case is a 1 year and 7 months old female with enlargement of both breasts since 5 months old. Her grandmother became aware when she saw the first case on TV. On physical examination, breasts are at Tanner stage 3. Patient’s length by age is acceptable at the 25th percentile. Weight by age is also acceptable at 75th percentile. Upon work-up, serum estradiol is on the high normal level at 25 pg/mL (n 6 to 27 pg/mL). FSH is slightly elevated at 5 mIU/mL (n 1 to 4.2 mIU/mL).  A tuber cinereum hamartoma is suspected so a brain MRI is contemplated in this case. Caregiver was told to follow-up with the results.

CONCLUSION: The comparison of the two cases tells that the early detection and optimal treatment of precocious puberty regardless of the cause is indispensable to prevent adult height loss and body disproportion. Adverse psychosocial outcomes can also be resolved with timely treatment. Awareness of the existence of the condition by caregivers of children is also important for its prompt recognition.

 

Nothing to Disclose: KSD, LMA

21423 2.0000 SAT-170 A A Report of Two Cases of Precocious Puberty: Comparison Between Early Versus Late Diagnosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Marina Cunha Silva*1, Vinicius N. Brito2, Carolina de Oliveira Ramos3, Delanie B. Macedo2, Danielle de Souza Bessa2, Lorena Guimaraes Lima1, Berenice B Mendonca2 and Ana Claudia Latronico4
1Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, 4Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Background: Testotoxicosis or familial male -limited precocious puberty is a rare cause of peripheral precocious puberty in boys caused by germline constitutive activating mutations of the LHCG receptor gene. Affected patients have usually normal gonadotropin profile and fertility in the adult life. Aim: To describe the long-term evaluation of a unique male patient with severe testotoxicosis. Case report: A 24 year-old male patient with diagnosis of testotoxicosis at 2.5 year-old manifested by penile enlargement, frequent erections, accelerated growth, deepening voice, and aggressive behavior was evaluated. At the diagnosis, height was 113.3 cm (6 SDS) and weight was 24.3 kg. Penile length was 10.3 cm, testicular size was 2.5 x 1.0 cm at right and 2.0 x1.0 at left, Tanner stage I , and pubic hair was Tanner stage IV. Bone age was 6 yr. Basal testosterone levels ranged from 392–975 ng/dL (prepubertal range: < 30 ng/dL). Basal and GnRH-stimulated serum LH and FSH levels were both undetectable (LH < 0.6 U/L and FSH < 1.0 U/L). The hCG-stimulated testosterone levels showed an insignificant increment and selective venous catheterization revealed very high levels of testosterone in both testicular veins when compared with peripheral veins. Bilateral testicular biopsy revealed abundant number of mature Leydig cells and some seminiferous tubular development with spermatogenesis up to spermatocytes. DNA sequencing showed a de novo activating mutation in the LH receptor (p. L457R) at the third transmembrane helix of the LH receptor. He was first treated with ketoconazole (600 mg/day) during two consecutive years. After that, he was treated with cyproterone acetate (100 mg/m2) for 4 years. Aromatase inhibitor (anastrazol 2 mg/day) was added in the last 2 years. At the end of treatment, chronological age was 9.5 years, bone age 17 years and height was 157.6 cm (-4 SDS). Final height was 161.4 (-2 SDS) and target height was 177.7 cm (0.4 SDS). In addition, at adulthood, AMH and inhibin B levels were very low (< 0.4 mg/dL and 15 pg/mL, respectively). Currently, his testosterone levels remains extremely high with undetectable gonadotropins measured by ultrasensitive assays. Sperm clinical analysis showed 1.5 million sperm/mL; total of 0.75 million of sperm with 72% of motility. Conclusion: We evidenced normal spermatogenesis in an adult male patient who experienced severe testotoxicosis associated with persistently suppression of gonadotropin levels. This case illustrates the potential role of the testosterone in the spermatogenesis.

 

Nothing to Disclose: MCS, VNB, CDOR, DBM, DDSB, LGL, BBM, ACL

21515 3.0000 SAT-171 A : Long-Term Evaluation of a Unique Patient with Testotoxicosis: Evidence of Spermatogenesis Despite Persistently Suppressed FSH Levels 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Emir Tas1, Svetlana A Yatsenko2 and Jadranka Popovic*3
1Childrens Hospital Pittsburgh of UPMC, Pittsburgh, PA, 2University of Pittsburgh, Pittsburgh, PA, 3Children's Hospital of Pittsburgh, Pittsburgh, PA

 

Introduction: Turner syndrome (TS) is characterized by short stature and premature ovarian failure. Genetic component of TS patients with diagnosis of Inflammatory Bowel Disease has not been largely studied.

Case Report: A 9 4/12-year old girl with history of Crohn’s disease was evaluated for short stature. Her disease was well controlled with medications, however she continued with linear growth failure. Medical history included frequent ear infections, speech delay, ADHD and learning and emotional support.  She was short (height <2SD), had hypertelorism, micrognathia, overcrowding of teeth, high arched palate, low posterior hairline, dysplastic nails, cubita valga and widely spaced nipples. She was pre-pubertal with normal female external genitalia without clitoromegaly. Karyotype from peripheral blood showed mosaicism for a 45,X cell line in ~11% of the cells and 46,XY male chromosome complement in ~89% of metaphase cells. FISH analysis using the X chromosome centromere specific and the SRY probes showed that ~80% of the interphase cells had both X and Y chromosomes with the intact SRY gene. FISH analysis on a urine sample demonstrated monosomy X in ~44% of the cells, while 56% of cells showed signals for both X and Y chromosomes. FISH analysis on the buccal smear showed Monosomy X in ~41% of the cells with 59% of cells showing signals for both X and Y on the Right side; and Monosomy X in ~24% of the cells and 76% of cells showing signals for both X and Y on the Left side. Pelvic US showed presence of uterus. No gonads were identified. She had low testosterone(<0.1 ng/dl), LH(0.46 mIU/ml), Anti-Mullerian Hormone(<0.03 ng/ml) and inhibin(<10 pg/ml). FSH was elevated(29.8 mIU/ml).

Gonadal biopsy revealed streak gonad with ovarian-like elements on the right and streak gonad with gonadal blastoma on the left. Gonadal karyotype is pending.

Conclusion:  Approximately 5-10% of the TS patients have 46,XY cell line. Phenotype is variable depending on the type and function of the gonadal tissue. Our patient is a phenotypic female despite a predominant male chromosome complement in the peripheral blood, however the level of cells with monosomy X in the urine and buccal smear are significantly higher. Our data indicate the necessity of studying more than one tissue from each patient to reveal a tissue-specific differences in the proportion of cells with different chromosome complement.

 

Nothing to Disclose: ET, SAY, JP

22139 4.0000 SAT-172 A 46,XY Female with Turner Syndrome, Gonadoblastoma, Crohn’s Disease and Low Level Mosaicism for Monosomy X 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Hwal Rim Jeong*1, Hae Sang Lee1, Young Seok Shim2, Jungsub Lim3, Eun Byul Kwon4 and Jin Soon Hwang5
1Ajou University School of Medicine, Suwon, Korea, Republic of (South), 2Hallym University Medical Center, College of Medicine, Hallym University, Seoul, Korea, Republic of (South), 3Korea Cancer Ctr Hosp, Seoul, Korea, Republic of (South), 4Ajou University Hospital, Suwon, Korea, Republic of (South), 5Ajou University, School of Medicine, Suwon City, Korea, Republic of (South)

 

Background: Familial precocious puberty is defined by the existence of more than one affected member either in the proband generation or in the pedigree. Recently, several gene mutation cause familial CPP is elucidated, gain of function mutations in KISS1 and KISS1R, loss of function mutations in the MKRN3, the feature of familial precocious puberty is not fully understood.

Objective: To investigate the clinical characteristics of familial precocious puberty (FPP) and the response of GnRH agonist treatment compared to sporadic precocious puberty (SPP). 

Method: This study was conducted retrospectively. 62 sibling pateints with familial precocious puberty and 60 patients with sporadic precocious puberty was included. We reviewed their auxological data, family history and laboratory finding and also analyzed the response of GnRH agonist treatment and change of predicted adult height.

Results: The onset of precocious puberty was not available. Baseline characteristics including age, bone age, height SDS, the bone age advancement, body mass index (BMI), Tanner stage, LH peak on GnRH stimulation test and PAH revealed no significant difference between familial CPP and sporadic CPP. Target height , paternal height and maternal age at menarche were lower in FPP group than SPP group (158.58 ± 3.33 and 160.12 ± 3.44(cm), 170.88 ± 4.50 and 173.10 ± 5.32(cm), 12.60 ± 1.329 and 13.19 ± 1.02 (yr) respectively, p < 0.05). PAH after GnRH agonist was greater in familial CPP group than sporadic group (165.21 ± 5.29 and 162.28 ± 4.80 (cm), p < 0.05).

Conclusion: Familial precocious puberty was characterized by significantly lower target height, paternal height and maternal age at menarche than sporadic precocious puberty. GnRH agonist treatment can improve the growth outcome of FPP. Detailed family history, close follow up of growth and pubertal changes in the younger siblings is necessary.

 

Nothing to Disclose: HRJ, HSL, YSS, JL, EBK, JSH

19735 5.0000 SAT-173 A Familial Precocious Puberty: Clinical Characteristics and GnRH Agonist Response 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Bernadette Pivarunas*1, Kristen J Nadeau2, Rachael E Van Pelt3, Allison Hilkin4, Justin Chosich4, Laura Pyle3, Philip S. Zeitler5, Nanette Santoro3 and Megan Moriarty Kelsey4
1Colorado State University, 2Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, 3University of Colorado Anschutz Medical Campus, Aurora, CO, 4University of Colorado School of Medicine, Aurora, CO, 5University of Colorado/Children's Hospital Colorado, Aurora, CO

 

Youth-onset type 2 diabetes (T2D) is on the rise, is a disease of pubertal onset, and, for unknown reasons, disproportionately affects females. To assess potential interactions among pubertal hormone changes and changes in glucose metabolism, we examined associations among insulin sensitivity (Si), beta-cell function, and sex steroids in lean and obese early pubertal girls.

Subjects were otherwise healthy lean and obese girls in Tanner stage 2-3 breast development by palpation. Si, insulin secretion (AIRg), and disposition index (DI) were assessed by 3-hour intravenous glucose tolerance test (IVGTT). Urinary gonadotropins, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), were measured using a DELFIA immunoflourometric assay platform and urinary estradiol metabolites (E1c) were measured using an in-house ELISA. All urine was collected from an overnight sample and assays were normalized to creatinine. Serum dehydroepiandrosterone sulfate (DHEA-S) and sex hormone binding globulin (SHBG) were measured by radioimmunoassay.

Participants were 13+1 years of age and 60% were Tanner 2. Median (25th, 75th%ile) BMI-z was -0.11 (-0.54, 0.6) for lean (n = 21) and 2.02 (1.92, 2.32) for obese (n = 24) subjects. Si was negatively (r = -0.28, p = 0.08) and AIRg positively (r = 0.56, p < 0.001) associated with BMI-z. E1c was significantly higher in obese than lean (20.49 [10.5, 45.2] vs. 12.1 [4.2, 19.8] ng/mgCr, p < 0.05); SHBG was significantly lower in obese than lean (20.0 [16.5, 27.0] vs. 62.0 [37.0, 75.0] nmol/l, p < 0.001). Although not statistically significant, gonadotropins (FSH and LH) in the lean were twice as high as those in the obese girls (p = 0.23).  Controlling for Tanner stage, AIRg was inversely associated with SHBG (R2 = 0.38, p < 0.001) and Si was inversely associated with DHEA-S (R2 = 0.17, p < 0.01). There was a trend toward a positive association between LH and DI (R2 = 0.12, p = 0.09).

Collectively, these results suggest reproductive dysfunction early in puberty in obese girls. Furthermore, the associations of AIRg with SHBG and Si with DHEA-S, and the trend toward association between LH and DI all suggest that sex steroids may play a critical role in glucose metabolism early in puberty.

 

Nothing to Disclose: BP, KJN, REV, AH, JC, LP, PSZ, NS, MMK

20215 6.0000 SAT-174 A Evidence for Gonadal Dysfunction in Obese Girls Early in Puberty 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Young Suk Shim*, Min Jae Kang, Yeon Joung Oh, Seung Yang and Il Tae Hwang
Hallym University College of Medicine, Seoul, Korea, Republic of (South)

 

Objectives

It has been suggested that GnRHa treatment might reverse or suppress psychosocial behaviors associated with precocious puberty. Few studies have reported on psychosocial outcomes in girls with precocious puberty treated with GnRHa. We investigate psychosocial changes after GnRHa in girls with CPP

Methods

The clinical records of 66 Korean girls with precocious puberty who received GnRHa at Hallym University Kang Dong Sacred Heart Hospital in Seoul, Korea between September, 2011 and December, 2012 were reviewed. Precocious puberty was defined as Tanner stage 2 or greater for breast development before the age of 8 years, accelerated growth velocity in height, and advancement of bone age (BA) by at least 1 year compared with chronological age (CA). Diagnosis was confirmed by a peak luteinizing hormone (LH) level ≥ 5 IU/L in a GnRH stimulation test. K-Child Behavior Check List (K-CBCL) and Children’s Depression Inventory (CDI) were reported to assess psychosocial behavior at the start of treatment and at the 1 year after GnRHa treatment.  K-CBCL was assessed in 66 subjects. CDI was assessed in 61 subjects. Sixty-six patients were administered of subcutaneous leuprolide acetate or triptorelin acetate (100 μg/kg) every 4 weeks.

Results

GnRHa treatment improved problem behavior total scales (54.68 to 48.77, p <0.001), internalization scales (54.08 to 49.33, p <0.001), externalization scales (53.97 to 49.94, p <0.001), social immaturity (54.88 to 53.55, p <0.038), and other problems (57.50 to 53.98, p <0.001). After 1 year of GnRHa treatment, affective problems, anxiety problems, and oppositional defiant problems in DSM oriented scales were improved from 54.61 to 51.91(p =0.003), from 56.15 to 53.95 (p =0.018), and from 55.02 to 53.42, respectively. In problem behavior special scale, post-traumatic stress syndrome was improved from 55.75 to 54.12 (p =0.024). Of adaptation scale, academic performance was improved from 52.15 to 54.83 (p =0.003). CDI was improved 6.5 to 4.9 after 1 year of GnRHa treatment. Thirty two percent (21 of 66) of patients were in borderline clinical range at the start of treatment and 14% (9 of 66) of patients were at 1 year after GnRHa treatment (p =0.013, OR = 0.34, 95% CI = 0.141, 0.810).

Conclusion

GnRHa treatment improves most of K-CBCL scales and CDI score. GnRHa Treatment in girls with PP may improve psychosocial changes as well as physical symptoms


 

Nothing to Disclose: YSS, MJK, YJO, SY, ITH

20243 7.0000 SAT-175 A Psychosocial Changes after GnRH Analogue Treatment in Girls with Precocious Puberty 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Lorenzo Iughetti*1, Laura Lucaccioni1, Jane McNeilly2, Avril Mason3, Andreas Kyriakou4, M G Shaikh5 and S F Ahmed6
1Department of Medical and Surgical Sciences of the Mother, Children and Adults, University of Modena and Reggio Emilia, Modena, Italy, 2Queen Elizabeth University Hospital, Glasgow, United Kingdom, 3Developmental Endocrinology Research Group, Royal Hospital for Sick Children, University of Glasgow, G3 8SJ, UK, Glasgow, United Kingdom, 4Developmental Endocrinology Research Group, Royal Hospital for Sick Children, University of Glasgow, G3 8SJ, UK, United Kingdom, 5Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, UK., 6Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, UK

 

Background/Aims: With improvements in assays and an increasing need for non-invasive out-patient based investigations, there is a renewed interest in the use of urinary gonadotrophins (uGn) for assessing pubertal progress. This study aims to establish the relationship between serum (both basal and peak during LHRH stimulation test) and urinary LH (uLH) and FSH (uFSH) in young people undergoing investigation or management of pubertal disorders.

Methods: 65 patients (25 M, 40 F,   aged 14.8 yrs (range 7.9-17.2) and 9.2 yrs (2.9-18.1) respectively), who were being evaluated for concerns regarding puberty at the Royal Hospital for Sick Children of Glasgow, supplied at least one non-timed spot urine sample as part of the routine endocrine assessment (117 in total). Population included: 27 (18 M, 9 F) cases referred for pubertal delay, 29 (3 M, 26 F) with early puberty and 9 (4 M, 5F) with gender identity disorder. 25 patients (5 M, 20 F) were receiving GnRH-agonist (GnRH-a) treatment. 43 urine samples (19 M, 24 F) were collected before the performance of LHRH stimulation test; in other 10 cases (5 M, 5 F) matched serum samples for basal LH and FSH determination were also available. uLH and uFSH were corrected for creatinine excretion and compared to previously published reference data. Gonadotrophins were measured by a chemiluminescent microparticle immunoassay.  

Results: A significant correlation was found between basal serum LH and uLH:uCr (ρ, 0.82; p<0.0001) and basal serum FSH and uFSH:uCr (ρ,0.93; p<0.0001). Based on ROC curve analysis the cut-off value of uLH:uCr (0.0515) was determined to detect a LH peak > 5 UI/ml with  a sensitivity (0.86) and specificity (0.72) . In our pubertal boys and girls (LH peak > 5 UI/ml),  median uLH:uCr was 0.27 (0.27-0.28) for male and 0.17 (0.09-0.43) for female, and median uFSH:uCr was 0.51 (0.41-0.60) for male and 1.1 (0.21-2.44) for female, higher compared to pre-pubertal reference ranges (p uLH:uCr = 0.005 and p uFSH:uCr =0.041 for male; p uLH:uCr = 0.0001 and p uFSH:uCr =0.0001 for female). In 25 patients on GnRH-a, median uLH:uCr was 0.02 (0.01-0.02) for male and 0.02 (0.004-0.07) for female, and median uFSH:uCr was 0.07 (0.05-0.09) for male and 0.27 (0.09-0.54) for female, similar to the pre-pubertal reference range (p uLH:uCr = 0.64 and p uFSH:uCr =0.051 for male; p uLH:uCr = 0.27 and p uFSH:uCr =0.28 for female). 

Conclusion: UGn reflect serum gonadotrophin concentrations and may represent a useful non-invasive method of assessing puberty and monitoring effectiveness of puberty suppressive therapy.

 

Nothing to Disclose: LI, LL, JM, AM, AK, MGS, SFA

20487 8.0000 SAT-176 A Urinary Gonadotrophins for Assessment and Management of Pubertal Disorders 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Marina Cunha Silva*1, Priscilla Cukier2, Vinicius N. Brito3, Ana Claudia Latronico4, Delanie B. Macedo5, Danielle de Souza Bessa3, Ivo J P Arnhold6, Berenice B Mendonca7 and Carolina de Oliveira Ramos8
1Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 5Unidade de Endocrinologia do Desenvolvimento e Laboratório de Hormônios e Genética Molecular/LIM42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 6University of Sao Paulo, São Paulo, Brazil, 7Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil, 8Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo

 

Background: Hypothalamic hamartoma (HH) is the most common organic cause of central precocious puberty (CPP) in both sexes and long-acting GnRH analogs (GnRH-a) represent the first-line therapy for CPP. Data from long-term follow-up of these patients after discontinuation of GnRH-a therapy and in adulthood are scarce. Aims:  To describe the anthropometric, metabolic, reproductive and neuropsychological parameters of patients with CPP due to HH treated with GnRH-a in the adult life. Patients and Methods: We performed a retrospective and cross-sectional analysis of 10 patients (6 males) with CPP due to HH treated with long-acting GnRH-a followed until final height (FH). One patient had a severe local reaction to GnRH-a with failure of hormonal suppression and progression of pubertal signs and was withdrawn from the analysis. Results: The mean duration of GnRH-a treatment was 8 years (ranging from 3.3 to 10 yr) in both sexes. The male group was evaluated at mean chronological age of 22.2 ± 2.1 yr and the female group at 24.5 ± 4.2 yr. All patients reached their final height (FH) within target height range (TH) and the mean D SDS FH minus SDS TH were 0.5 ± 1.2 for males, and 0.6 ± 0.6 for females. The mean body mass index (BMI) was 20.2 ± 1.1 kg/m2 for males and 29 ± 5.4 kg/m2 for females (p < 0.05). Three out of 4 female patients were either overweight (n=2) or obese (n=1). Bioelectrical impedance analysis was measured only in 3 female and 1 male patients. The mean percentual of body fat mass for women was 36.8 ± 0.75% (NR18-28) and low for male, 3.4% (NR 10-20). One female patient had hypercholesterolemia with high LDL levels. Paternity was informed by one male patient. All women had regular menstrual cycles with gonadotropins and sexual steroids within normal adult range and normal pelvic ultrasound with no clinical or laboratorial evidence of hyperandrogenism. Epilepsy was present in only 2 male patients who are under anticonvulsivant therapy. Seven out of the 9 patients underwent cognitive evaluation. Six patients without seizures had intelligent quocient (IQ) scores ranging from low average to high. One patient with epilepsy had borderline IQ score. The other patient with epilepsy was unable to complete cognitive evaluation due to social phobia. Finally, the patient with local reaction to GnRH-a was treated with cyproterone acetate and achieved FH below TH and the follow-up was lost. Conclusions: Long-acting GnRHa was effective for treatment of CPP due to HH. Long-term follow-up of these patients revealed high prevalence of overweight/obesity in female patients. In addition, metabolic alterations were rare, reproductive abnormalities were absent and epilepsy was infrequent  in this cohort.

 

Nothing to Disclose: MCS, PC, VNB, ACL, DBM, DDSB, IJPA, BBM, CDOR

21456 9.0000 SAT-177 A Long-Term Follow-up of Patients with Central Precocious Puberty Due to Hypothalamic Hamartoma: Anthropometric, Metabolic, Reproductive and Neuropsychological Outcomes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Corinna Grasemann*1, Lena Baeder2, Cordula Kiewert3, Michael Schuendeln4 and Berthold P Hauffa5
1Kinderklinik II, UK-Essen, Essen, Germany, 2University of Duisburg-Essen, Essen, 3University Hospital Essen, Essen, 4University of Duisburg-Essen, Essen, Germany, 5University Hospital Essen, Essen, Germany

 

Introduction: Osteocalcin (OC) is a skeletal hormone, which is secreted by osteoblasts. OC directly and indirectly stimulates insulin secretion and lipolysis. More recently OC was shown to stimulate testosterone production by Leydig cells in mice.

Aim: To investigate OC levels in children with normal and altered pubertal development, plasma OC was measured in 244 children (122 boys) with different underlying endocrine disorders. Methods: Patients were seen by a pediatric endocrinologist at a tertiary center (University Children's Hospital Essen, Germany). The study was approved by the ethics committee of the medical faculty, University of Duisburg-Essen. Statistical Analysis was performed using SAS release 9.4.

Results: Mean age was 11.87 + 3.77 years; Breast/testicular volume SDS was 0.14 + 1.11 and -0.56 + 1.57, respectively. Pubic hair (PH) SDS was 0.01 + 1.13 in girls and 0.20+ 0.96 in boys. There was no significant difference between patients with different endocrine disorders.

In this cohort, a significant positive correlation for OC with PTH (r=0.72; P=<0,0001; n=62) and with total serum alkaline phosphatase (r=0.56; P=<0.0001; n=128) was found, as well as a negative correlation with serum leptin (r= - 0.24; P=0.0002; n=244).

In boys, a positive correlation of OC with the testicular volume SDS (r=0.24; P =0.019; n=92) as a marker for the timing of pubertal progression was observed, but not with testicular volume itself or testosterone levels. No correlation between OC and markers of pubertal development was detectable in girls. There was no difference in OC levels between children with accelerated or delayed bone age.

Summary: In this cohort, the known interactions of OC with the skeletal and the metabolic system are reproducible. Additionally, OC levels vary with the timing of pubertal development in boys, but not with other biochemical markers or clinical landmarks throughout pubertal development. Although the influence of pubertal timing must be considered when OC is measured, OC is probably of little value as a parameter for individual diagnostic workup in altered pubertal development.

 

Nothing to Disclose: CG, LB, CK, MS, BPH

21823 10.0000 SAT-178 A Plasma Osteocalcin Levels Are Associated with the Timing of Pubertal Progress in Boys 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Mark Daniel DeBoer*1, Meena Thayu2, Hannah E. Agard3, Robert Baldassano4, Lee A Denson5, Babette S. Zemel6 and Mary B Leonard7
1Univ of Virginia, Charlottesville, VA, 2Janssen Pharmaceuticals, Whitehouse Station, NJ, 3Univ. of Virginia, Charlottesville, VA, 4Children's Hospital of Philadelphia, Philadelphia, PA, 5Cincinatti Children's Hospital, Cincinatti, 6The Children's Hospital of Philadelphia, Philadelphia, PA, 7Stanford University, Palo Alto, CA

 

Background: Children with Crohn’s disease frequently have a delayed timing of pubertal events.  While basic science studies have shown a negative effect of systemic inflammatory cytokines on sex hormone regulation, clinical data are lacking.

Methods:  In a cohort of children and adolescents with Crohn’s disease, we compared gonadotropin and sex hormone levels before and 10 weeks and 1 year after initiation of treatment with infliximab.  We then used mixed-model linear regression to evaluate relationships between hormone levels and systemic inflammation and fat mass Z –scores as measured by DXA at baseline and 1-year.

Results:  We assessed data from 85 children (40% female) with Crohn’s disease with median (intraquartile range) age of 14.6 (12.0, 16.6), of whom 84.7% were Tanner 2-5.  Among female participants 61.8% had reached menarche.  Among male adolescents Tanner 2-5 followed from baseline to 10-weeks after infliximab, there were increases in Tanner-stage-specific testosterone Z -scores in boys (median [intraquartile range]: baseline -0.36 [-0.67, 0.52], 10-week 0.40 [-0.27, 1.77], p<0.05) corresponding to overall median (intraquartile range) levels at baseline of 118 ng/mL (5, 405) and at 10-weeks of 203 (31, 523).  Among females Tanner 2-5 there were increases in bone-age-specific estradiol Z -scores (baseline -0.35 [-0.91, 0.09]; 10 week -0.02 [-0.39, 1.49], p<0.01), corresponding to overall median (intraquartile range) levels at baseline of 10 ng/mL (2, 50) and at 10-weeks of 38 (10, 100).  In mixed model regression analysis, testosterone Z-scores were inversely related to levels of IL-6, TNF-a alpha, IL-6, ESR and CRP (all p<0.05) over the course of the study, while estradiol was inversely related to IL-6, TNF-a alpha, IL-6 and ESR (all p<0.05).  Levels of both LH and FSH were inversely related to level of TNF-a and CRP (p<0.05).  There was no such relationship between hormone levels and fat mass or BMI Z -scores over the course of the experiment.

Conclusions:  Adolescents with Crohn’s disease exhibit inverse relationships between sex hormone levels and systemic inflammation but not fat mass.  These data may have implications regarding sex hormone regulation in the setting of chronic inflammatory disease.

 

Disclosure: MT: Employee, Jansen Pharmaceuticals. RB: Researcher, Jansen Pharmaceuticals. Nothing to Disclose: MDD, HEA, LAD, BSZ, MBL

19469 11.0000 SAT-179 A Increases in Testosterone and Estradiol Are Associated with Lower Systemic Inflammation Following Initiation of Infliximab Treatment in Pubertal Adolescents with Crohn's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Lisa Kenigsberg*1, Chhavi Agarwal1, Sanghun Sin1, Keivan Shifteh2, Carmen R Isasi2, Susan M Coupey1, Rubina Heptulla1 and Raanan Arens1
1Children's Hospital at Montefiore, Bronx, NY, 2Montefiore Medical Center, Bronx, NY

 

The Rotterdam criteria used for diagnosis of polycystic ovary syndrome (PCOS) require the presence of two of the following three features: 1) oligoovulation or anovulation, 2) hyperandrogenism (clinical or biochemical), and 3) polycystic ovaries [volume >= 10 cm3and/or follicle count >12]. Assessment of polycystic ovaries is traditionally accomplished by ultrasound (US). For adolescent girls, however, ovarian imaging may be limited by inability to perform transvaginal US in virgins, central adiposity limiting resolution on transabdominal imaging, and technician variability. MRI may allow more precise imaging of ovarian morphology in this age group. For this study, we aimed to perform a detailed assessment of ovarian ultra-structure using 3-dimensional volumetric MRI in adolescents with and without PCOS and to assess utility of MRI compared with US for diagnosis of PCOS. 

Thirty-nine girls aged 13-18 years with PCOS diagnosed by their physicians based on findings of oligoovulation or anovulation and biochemical hyperandrogenism had pelvic MRI performed; of these, 33 also had either transvaginal (n=12) or transabdominal (n=21) US. All studies were performed prior to treatment initiation. A control group of 22 girls aged 13–18 years without PCOS also had pelvic MRI. A radiologist blinded to diagnosis evaluated ultrastructure of each ovary independently. We used Student t test or Mann-Whitney U test as appropriate to compare outcomes.

Mean age was similar between PCOS and control groups [16.68 ±1.56 vs. 16.56 ±1.77 years, p=0.97] as was mean BMI z-score [1.84 ± 0.92, vs. 2.02 ±0.64, p=0.78], respectively. Analysis of ovarian ultra-structure by MRI indicated that mean ovarian volumes were larger [13.6 ±8.5 vs. 7.4 ±3.4 cm3, p<0.001] and mean follicle counts were higher [12.7 ±4.0 vs. 7.7 ±4.4; p<0.001] in subjects with PCOS compared to controls. In subjects with PCOS who had both imaging modalities performed, mean ovarian volumes measured by MRI were larger than volumes measured by US [14.0 ±9.1 vs. 10.97 ±8.6 cm3, p=0.05]. We were unable to assess follicle count by US due to poor image quality. Of subjects with PCOS, 91% met radiologic criteria for polycystic ovaries [volume >= 10 cm3or follicle count >12 in at least 1 ovary] based on MRI, while only 52% of the same subjects met criteria based on US.

In this sample of primarily obese adolescent girls with PCOS, we found that ultrasound imaging underestimated ovarian size as compared to MRI and did not allow for an accurate follicle count. Radiologic criteria for polycystic ovaries are more likely to be detected by MRI, and may be under diagnosed if US imaging is used. For adolescents in whom diagnosis of PCOS remains uncertain based on clinical and laboratory evaluation, we advocate MRI as the preferred imaging tool.

 

Nothing to Disclose: LK, CA, SS, KS, CRI, SMC, RH, RA

18808 12.0000 SAT-180 A Clinical Utility of Magnetic Resonance Imaging and Ultrasonography for Diagnosis of Polycystic Ovary Syndrome in Adolescent Girls 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 169-180 6018 1:00:00 PM Puberty Disorders Poster


Christina Wu1 and Matthew C Leinung*2
1Albany Medical College, Albany, NY, 2Albany Med College, Albany, NY

 

The biologic basis for transgender identity is unknown. There are reports of sexually dimorphic neuroanatomical regions in transgendered patients resembling their non-natal (i.e., trans) gender, but these findings do not suggest etiology.  Previous research has shown that the ratio of the length of the 2nd and 4thdigits (2D4D) is influenced by gender, with a lower value in males.  A lower 2D4D ratio has also been found to be associated with behavioral characteristics that are more common in males.  While the developmental basis of these digit ratios remains uncertain, it appears to be dependent upon the balance of androgen to estrogen signaling during a narrow window of digit development.  Data on 2D4D ratios in transgendered individuals are scarce and contradictory. We sought to see if there was an association with 2D4D ratio and transgender identity in our transgendered clinic population in Albany, NY.

Between October 2012 and July 2014 patients seen in our transgender clinic had their 2nd and 4thdigits measured in both hands. All 50 female to males (FTM) seen were measured, and 68 male to females (MTF) were measured. All measurements were done in triplicate by one investigator (ML) using digital calipers (Neiko 01407A), measuring from the middle of the proximal digit skinfold to the tip of the straightened finger.  We also measured the dominant hand digits of volunteers as controls (18 females, 19 males).  Ratios were calculated and analyzed with unpaired t test.

FTM subjects (0.983±0.023) had a smaller 2D:4D ratio compared to same natal sex (female) controls (0.998±0.021, p=0.029). There was no difference in 2D:4D ratio between MTF subjects (0.978±0.043) compared to same natal sex (male) controls (0.972±0.036, p=0.434).  There was no statistical difference between FTM subjects and male controls.  We also found no difference between right and left hands or dominant and non-dominant hands in transgender subjects.

In summary, we found that in FTM subjects the digit ratio was similar to non-natal (male) gender.  These findings are consistent with a biologic basis for transgender identity and the possibility that FTM transgender identity is affected by prenatal androgen activity, but that MTF transgender identity has a different basis.

 

Nothing to Disclose: CW, MCL

20539 1.0000 SAT-081 A The Biologic Basis of Transgender Identity: Finger Length Ratios in Transgender Individuals Implicates a Role for Prenatal Androgen Activity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 081-088 6022 1:00:00 PM Basic and Clinical Aspects of Sexual Development Poster


Flávia Siqueira Cunha*1, Tania A Bachega1, Mariana F A Funari2, Mirian Y Nishi1, Maria Helena Palma Sircili1, Berenice B Mendonca1, Elaine M F Costa1 and Sorahia Domenice1
1Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Universidade de São Paulo, São Paulo, Brazil

 

Background: Female-to-male transsexualism (FtM-T) is considered the most extreme form of gender dysphoria in biological women. Although a multifactorial etiology is probable, reports comprising twin and non-twin sibling transsexuals reinforced the involvement of genetic factors in this disorder. The action of testosterone, directly or by its aromatization, determines virilization in the fetal brain, and this condition might predispose to FtM-T development in female fetus. The polymorphic CAG repeat numbers (nCAG) of the androgen receptor (AR) gene present an inverse correlation with the AR transactivation activity, and longer alleles were previously associated with male-to-female transsexualism. Objective: to investigate the nCAG of AR in a relatively large cohort of FtM transsexuals followed in a single center. Patients: Thirty-five FtM transsexuals and 89 non-transsexual female controls were evaluated. All patients had 46, XX karyotype. Methods: DNA samples were extracted from peripheral leukocytes. The CAG repeat regions were PCR amplified, products were submitted to capillary electrophoresis and analyzed by GeneMapper software. Shorter and longer CAG alleles were defined by ≤ 19 and ≥ 25 repeat numbers, respectively. Student's t and Chi-square tests were used in the statistical analysis. Results: Eighteen different nCAG alleles were identified in FtM transsexuals (range 13 to 29 repeats) and female controls (range 10 to 29 repeats); the nCAG alleles presented a normal distribution in both groups. Nine controls (10%) and two FtM transsexuals (5.7%) were homozygous for the nCAG. Frequency of shorter nCAG alleles was significantly higher in FtM transsexuals than controls, 30% versus 17.4%, respectively (p=0.02). Additionally, the frequency of longer nCAG alleles was significantly lower in FtM transsexuals than controls, 13% versus 18.5%, respectively (p<0.02). The nCAG biallelic mean was only marginally significantly lower in FtM transsexuals than controls, 21 ± 2.0 versus 22 ± 2.3, respectively (p=0.054); however, the sample size effect cannot be ruled out. Conclusion: Our preliminary findings suggest an influence of higher androgen receptor activity, modulated by the shorter CAG polymorphic tract, in the susceptibility for the female-to-male transsexualism.

 

Nothing to Disclose: FSC, TAB, MFAF, MYN, MHPS, BBM, EMFC, SD

21014 2.0000 SAT-082 A Short CAG Repeats of the AR Gene Are Associated with Female-to-Male Transsexualism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 081-088 6022 1:00:00 PM Basic and Clinical Aspects of Sexual Development Poster


Benjamin Boh*, John H Turco and Richard J Comi
Dartmouth-Hitchcock Medical Center, Lebanon, NH

 

Transgender people are individuals whose gender identity does not match their biologic sex. An ingenious endocrinologist, by the name of Harry Benjamin, was the first to use cross-sex hormones in transsexual patients in the 1950s. Current treatment with endocrine manipulation and cross-sex hormonal administration is an effective treatment of gender dysphoria.1Transgender men are assigned female at birth, however they have a male gender identity. Treatment of these individuals involves testosterone administration, typically by intramuscular route as a biweekly injection for the remainder of their lifetime. Intramuscular injections are painful and difficult to perform independently, particularly for younger patients. Healthcare providers and patients have started administering testosterone into the subcutaneous tissues, however there is a paucity of data on effectiveness and technique description.

We hypothesize that subcutaneous testosterone administered via weekly injection will result in a serum testosterone level within the normal male range with excellent tolerability. From July 1,2013 until November 1, 2014, 26 transsexual males between the ages of 16-50 (mean 27 years), were started on subcutaneous testosterone at a dose of 50 mg per week. As of November 8, 2014, twelve subjects have reported for follow up testosterone levels. Ten of these patients were naïve to testosterone use (one subject was switched from intramuscular to subcutaneous testosterone administration, and one subject had used testosterone >2 years before being seen in our clinic). Approximately four months after starting testosterone the dose was titrated to achieve total, serum testosterone levels within the normal male range (280-800 ng/dL). The average weekly dose of testosterone was 57.9 mg (range 25-100mg), representing 0.73 mg of testosterone per kilogram of body weight resulting in an average total testosterone level of 601 ng/dL (range 187-1078 ng/dL). The average time to menstrual cessation was 3 months from testosterone initiation. One participant reported minor skin irritation at the injection site, which resolved within 1 week and has not recurred. No other adverse reactions were reported in this study population.

This case series of transsexual males demonstrates total testosterone levels within the normal male range with low-dose, subcutaneous testosterone (0.73 mg/kg) administered weekly. Subcutaneous injection is likely to be an effective delivery route for testosterone esters. More frequent, lower-dose injections may also provide a more stable serum testosterone level. there were no significant adverse reactions with subcutaneous administration in our study population. We speculate that the low rate of adverse reactions may be attributed to the low dose of testosterone used in this study (62.1 mg per week).

 

Nothing to Disclose: BB, JHT, RJC

21249 3.0000 SAT-083 A New and Improved Testosterone Administration: A Clinical Case Series of Subcutaneous Testosterone Use in 26 Transsexual Males 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 081-088 6022 1:00:00 PM Basic and Clinical Aspects of Sexual Development Poster


Flávia Siqueira Cunha*, Elaine M F Costa, Maria Helena Palma Sircili, Mirian Y Nishi, Maria Aparecida Medeiros, Berenice B Mendonca and Sorahia Domenice
Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Introduction: Transsexualism is a gender identity disorder and its diagnostic criteria were recently revised on Manual of Mental Disorders (DSM V). According to the current DSM, the presence of the disorders of sexual development and chromosomal abnormalities is no longer an exclusion criterion to establish the diagnosis of transsexualism.  This criterion, still present in the current International Classification of Diseases (ICD-10), has raised discussion in the literature about the necessity of routinely performing chromosome studies in transgender population. Few studies have evaluated the presence of chromosomal abnormalities in transsexuals and concluded that their prevalence is low, varying from 1.5% to 2.45%. No study so far has evaluated the prevalence of chromosomal polymorphic variants in transsexuals. Objective: To determine the prevalence of numerical and structural chromosomal abnormalities in a population of transsexuals treated at a Brazilian tertiary care hospital and to characterize the identified chromossomal variants. Methods: One hundred and eleven patients, 79 male-to-female (MTF) and 32 female-to-male (FTM) transsexuals were evaluated. Patients were diagnosed according to ICD-10/DSM criteria by the mental health team specialized in gender dysphoria. Chromosome abnormalities were performed by conventional cytogenetic study using the G-banding technique (analyses of 20 metaphases). Results: All FTM transsexuals had 46, XX karyotype, and 18.7% of which presented heteromorphisms involving chromosomes 9, 15, 16, 21 and 22. A numerical chromosomal abnormality (47, XXY / 46, XY) was diagnosed in one MTF transsexual (1.3%), establishing the diagnosis of Klinefelter syndrome. The remaining MTF subjects showed 46, XY karyotype (78 cases) and in 32% of them heteromorphisms were identified on chromosomes 1, 9, 14, 15, 16, 21, 22 and Y. Heteromorphisms on 9, 15 and long arm of the Y chromosomes were the most frequently variants observed. Seven patients had more than one heteromorphic chromosome. Conclusion: The prevalence of chromosomal abnormalities is low in transgender individuals, but the presence of heteromorphisms was common in this group of patients, especially in MTF transsexuals. Although chromosomal polymorphic variants are not considered pathological, some of them have been associated with infertility and recurrent miscarriage, especially when they involve genes located in heterochromatin’s regions. So far, the accurate significance of the presence of polymorphic variants on chromosomes of transgender individuals has not been evaluated.

 

Nothing to Disclose: FSC, EMFC, MHPS, MYN, MAM, BBM, SD

21824 4.0000 SAT-084 A Chromosome Abnormalities in Patients with Gender Dysphoria 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 081-088 6022 1:00:00 PM Basic and Clinical Aspects of Sexual Development Poster


Luize Giuri Palaoro*1, Vanessa Porto Araujo2, Stela L Matos3, Carmen L G F Alves1, Vinicius N. Brito4, Flávia Siqueira Cunha5, Berenice B Mendonca6, Sorahia Domenice7, Jose Antonio Marcondes8 and Elaine M F Costa9
1Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil, Brazil, 2Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil, 3Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil, 4Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/ LIM42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 5Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 6Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo FMUSP, São Paulo, Brazil, 7University of São Paulo, Hospital das Clinicas, São Paulo, Brazil, 8Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 9Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil

 

Introduction: Cross-sex hormone treatment and sex reassignment surgery are important components of medical treatment in transsexual people. Testosterone is the key hormone in female-to-male transsexual (FTM) endocrine treatment. Regulation of gonadotropins secretion involves a complex balance between hypothalamic GnRH stimulation, inhibitory feedback by gonadal sex steroids (testosterone - T and estradiol – E2), inhibin B and anti-mullerian hormone, and autocrine/paracrine modulation by hormones within the pituitary. It is well established that in chronic hyperandrogenemia situations, such as polycystic ovary syndrome, basal LH levels are increased and basal FSH levels are diminished. However, the effects of long term testosterone administration and gonadectomy on gonadotropins secretion in FTM individuals are poorly described. Objective: Our aim was to report the effects of long-term short-acting testosterone administration every 2 or 3 weeks before and after oophorectomy on gonadotropins secretion in FTM indivíduals. Patients and methods: We conducted a retrospective analysis of 13 FTM taking short-acting testosterone esters IM in a dose that ranged from 200-250 mg every two or three weeks for at least 3 years before and after oophorectomy and evaluated LH, FSH, T and E2 levels. Numerical variables were compared by one-way analysis of variance (ANOVA) followed by post-hoc Tukey’s test. Statistical significance was set at p<0.05. Results: Our data showed that long term testosterone treatment in FMT subjects resulted in significantly increase of serum T levels from 50.53 ± 28.46 ng/dl in the basal levels to 505.5 ± 161.7 ng/dl post 3 years treatment (p=<0.001). LH levels decreased from 6.65 ± 4.52 U/L in basal state to 2.06 ± 2.13 U/L after testosterone treatment (p =0.51). FSH level decreased from 6.0 ± 2.66 in basal state to 5.52 ± 8.89 U/L after testosterone replacement (p=0.99). Interestingly, the mean serum LH and FSH levels after gonadectomy was significantly higher than before gonadectomy, even during testosterone treatment - 15.4 ± 15.1 U/L (p=0.014) and 32.8 ± 32.4 U/L (p=0.012), respectively.  No statistical difference in T and E2 levels was found – mean of 439.7 ± 265.7 ng/dl (p=0.702) and 39.8 ± 37.1 ng/dl (p=0.28), respectively. Discussion and conclusion: As expected, serum T levels after long term testosterone treatment were higher than prior to treatment and were maintained after gonadectomy. Therefore, the slight suppressive effects of high T levels on LH levels prior to gonadectomy were attributable to androgen action rather than to androgen-derived estrogen action, since the basal E2 levels were similar to the ones after testosterone treatment.  We also demonstrated an increase in gonadotropin levels after gonadectomy, despite the maintenance of testosterone levels, suggesting the influence of another hormonal factors related to the ovaries on gonadotropins levels.

 

Nothing to Disclose: LGP, VPA, SLM, CLGFA, VNB, FSC, BBM, SD, JAM, EMFC

21924 5.0000 SAT-085 A Effects of Long Term Testosterone Administration and Gonadectomy on Gonadotropin Secretion in Female to Male Transsexuals 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 081-088 6022 1:00:00 PM Basic and Clinical Aspects of Sexual Development Poster


Maja Marinkovic*1 and Ron S Newfield2
1University of California San Diego, La Jolla, CA, USA/Rady Children's Hospital, USA, San Diego, CA, 2University of California San Diego, La Jolla, CA, USA/Rady Children's Hospital, San Diego, CA

 

Introduction: Transgender is a broad term that includes people incongruent with their “assigned” (natal) gender which is causing in many gender dysphoria (GD) with persistent, insistent and consistent desire to change one’s “assigned” gender into affirmed one.  Although management of transgender adolescents has been provided sporadically in our institution in the past, since we established a formal GeM clinic in mid-2012 the number of referrals has increased dramatically. It became obvious that the need for experienced endocrinologists, therapists, psychiatrist and surgeons in this area is high.

Method: This is an observational, longitudinal study. 55 patients have been referred to our clinic since 10/2011. Data was gathered by chart review from 42 patients consented/assented into the IRB-approved Endocrine Database and most have been followed prospectively.

Results: Of 42 consented patients, 28 were female-to-male (FTM), 13 male-to-female (MTF) and one gender fluid (GF). The average age at the first visit was 15.5yrs (15.4yrs for FTM; 15.7yrs for MTF) with ratio of MTF to FTM of 1:2.1. After assessment for GD by experienced mental health professional, 38 patients started treatment, 7 with GnRH agonist and 32 with cross-gender hormones, with only 2 patients on both. The average age of starting pubertal suppression was 12.5yrs (9.4-15.1) at Tanner stages 2-5. Patients received either depot-leuprolide injections (usually every 3 months) or histrelin implant. Cross-gender hormones were started on average at 16.5yrs (13.7 - 18.2). To date none of the patients expressed regret or stopped therapy. Our single GF patient (natal female) recently desired to start testosterone treatment. Vast majority of FTM patients received depot-testosterone injections every 1-2 weeks. MTF patients were treated with 17ß-estradiol orally/sublingually BID and some received spironolactone. Two FTM patients had bilateral mastectomy (“top surgery”) at 16.3 and 18yrs. Several others wish to get surgery but the lack of local experienced surgeons and insurance coverage were not permissive. Twelve patients (29 %) have legally changed name to be congruent with their affirmed gender. Many patients (62%) suffered from depression, cutting and/or anxiety; 27 % had additional psychiatric/behavioral problem (ADHD, Asperger, bipolar). In many, depression and/or anxiety improved significantly with recognition and treatment of GD.

Conclusion: Pediatric transgender care, though provided in more US centers, is still sporadic. Research and systematic monitoring as done at our and other centers, may help standardize transgender care of youth. Our fast growing GeM Clinic is providing endocrine care to large number of children and adolescents with GD. These patients are in need of experienced therapists, psychiatrists and surgeons. It is essential to increase awareness and accessibility to care for this minority group.

 

Disclosure: MM: Advisory Group Member, AbbVie. Nothing to Disclose: RSN

19591 6.0000 SAT-086 A Gender Management Clinic (GeM) for Children and Adolescents in San Diego: A Growing Experience 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 081-088 6022 1:00:00 PM Basic and Clinical Aspects of Sexual Development Poster


Andresa De Santi Rodrigues*, Aline Zamboni Machado, Mirian Y Nishi, Flávia Siqueira Cunha, Rosana Barbosa Silva, Elaine M F Costa, Luciane C Carvalho, Berenice B Mendonca and Sorahia Domenice
Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Androgen insensitivity syndrome (AIS) is a heterogeneous disorder with a wide spectrum of clinical manifestation. AIS patients may present female external genitalia (Complete AIS), ambiguous genitalia (Partial AIS) or normal male external genitalia (Mild AIS). Numerous mutations into androgen receptor (AR) gene have been identified and identical mutations may result in significantly different phenotypes. Modifier factors and somatic mosaicisms of AR gene have been related with this condition. Aim: to describe 3 AIS patients in whom heterozygous AR mutations were identified. Patients: Three patients with ambiguous genitalia were investigated for AR mutations. Patient 1 was a 19 yrs-old female that presented normal breast development, clitoromegaly (3.5 cm), two perineal openings and bilateral inguinal testis. The hormonal analysis showed elevated levels of LH and FSH and normal male testosterone (T) level. Her karyotype was 47,XXY. Patient 2 was a 31 yrs-old female who underwent to bilateral gonadectomy and female external genital reconstruction at 14 yrs of age. No information about hormonal study was available. Her karyotype is 46,XY. The third patient was a 3.5 yr-old boy. He presented micropenis (2.7 cm, - 4SD), proximal hypospadias and bilateral inguinal testis. The hCG stimulation test showed normal T increment without precursors accumulation and normal T∕DHT ratio. His karyotype was 46,XY. Methods and Results G banding karyotypes were confirmed after analyses of 50 metaphases. Direct sequencing of the AR gene using genomic DNA of the 3 patients and of the mother of the third patient was performed. DNA analyses of the 3 patients showed allelic variants of AR with heterozygous pattern. The allelic variants identified were p.Asn849Lysfs*30 mutation, p. E128* and c.1769-1 G>C in patient 1, 2 and 3 respectively. Only the mutation p.Asn849Lysfs*30 was previously described in one Complete AIS patient. The analyses of DNA mother from patient 3 did not show the AR mutation. In cases 2 and 3, the analyses were also performed in oral mucosa DNA and confirmed the leukocytes DNA results.  Conclusion: Apparently, the expression of the wild-type AR plays a crucial role in the degree of virilization by shifting the AIS subtype to a higher external genitalia virilization than expected from the mutant allele. Heterozygous mutation in AR gene due to mosaicism can be found in AIS patients and can influence the genotype-phenotype correlation. In addition, we describe here an unusual association, a 47,XXY AIS patient as a novel cause of heterozygous pattern of AR defects.

 

Nothing to Disclose: ADSR, AZM, MYN, FSC, RBS, EMFC, LCC, BBM, SD

21095 7.0000 SAT-087 A Heterozygous AR Gene Mutations Identified in Patients with Ambiguous Genitalia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 081-088 6022 1:00:00 PM Basic and Clinical Aspects of Sexual Development Poster


Carmen L G F Alves*1, Stela L Matos1, Vanessa Porto Araujo2, Luize Giuri Palaoro1, Vinicius N. Brito3, Flávia Siqueira Cunha4, Sorahia Domenice4, Berenice B Mendonca5 and Elaine M F Costa6
1Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil, Brazil, 2Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil, 3Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/ LIM42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 4Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 5Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil, 6Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil

 

Introduction: It has been described that two thirds of women with 46,XY DSD have osteopenia and the main modifiable factor that is associated with bone integrity is compliance with HRT. The effect of oestrogen on bone is dose dependent and a higher dose of oestrogen in young woman has been considered. Early generous oestrogen replacement may improve the catch up bone growth but whether a normal peak bone mass will be achieved is not established. Objective: Our aim was to evaluate the bone density in 46,XY DSD women at oestrogen replacement with standard doses of conjugated equine estrogens. Patients and Methods: A retrospective analysis was conducted of 61 women with 46, XY DSD. The patients were divided into 2 groups: high testosterone level disorders (HTLD) and low testosterone level disorders (LTLD). All patients were submitted to gonadectomy before puberty, followed by oestrogen therapy with oral conjugated equine estrogens at standard doses (0.625mg/day). The time of treatment ranged from 2 to 31 years (mean of 14.2 years). Bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) were measured and compared with female reference populations (T score). Results: In patients of HTLD group, the mean T score of femur neck, total femur and lumbar spine was 0.166, 0.100 and -1.308, respectively and in those of the LTLD group, the T score was -0.764, -0.712 and -1,514, respectively. The T-score in lumbar spine was similar in both groups (p=0.599). Regarding the femur sites, bone density in femur neck was similar in both groups (p=0,06), however, the bone density in total femur was significantly low in LTLD (p=0.014). Discussion: In general, patients in HTLD group showed slightly higher bone density than those in LTLD group, even after long-term estrogen therapy. These data suggest an important role for pre-natal androgens in bone mass and higher doses of estrogens may be considered for replacement therapy in these patients.  Conclusion: Oestrogen replacement with standard doses of conjugated estrogens is effective in maintaining proper bone density in 46,XY DSD women.

 

Nothing to Disclose: CLGFA, SLM, VPA, LGP, VNB, FSC, SD, BBM, EMFC

21847 8.0000 SAT-088 A Effect of Long-Term Replacement Therapy with Standard Doses of Conjugated Equine Estrogens on Bone Density of Women with 46,XY Disorders of Sex Development (DSD). 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM SAT 081-088 6022 1:00:00 PM Basic and Clinical Aspects of Sexual Development Poster


Katie L O'Sullivan*, Carmen D Mironovici, Christine H Yu and Siri Atma W Greeley
University of Chicago, Chicago, IL

 

Background: Hyperthyroidism is extremely rare in children under 4 years old, but because it presents with non-specific symptoms such as tachycardia and failure to thrive, diagnosis can be a challenge. However, if not recognized, uncontrolled hyperthyroidism can have serious detrimental effects on growth and development.  

Objective: To present a case of delayed diagnosis of hyperthyroidism in a toddler found to have dilated cardiomyopathy, severely advanced skeletal maturity and concern for craniosynostosis.

Case Description: A 23 month-old boy presented to urgent care with acute emesis and acute-on-chronic diarrhea. Over the preceding 6 months he had several visits to the emergency department with recurrent diaphoresis, tremulousness and tachycardia, as well as progressively apparent proptosis and failure to thrive. A maternal second cousin had Graves' Disease. Growth velocity was accelerated to 25.8 cm/year (50th percentile for age = 8 cm/year). He was afebrile with tachycardia (166 bpm), hypertension (131/89 mmHg) and a loud systolic murmur. Exophthalmos, a symmetrically enlarged thyroid, and a palpable metopic ridge concerning for craniosynostosis were appreciated on careful examination.

Laboratory studies revealed severe hyperthyroidism: decreased thyrotropin (TSH) <0.01 mcU/mL (0.6-6.2) with increased free thyroxine (fT4) >7.77 ng/dL (0.7-1.7), thyroxine (T4) 46 mcg/dL (7.3-15), and triiodothyronine (T3) 2277 ng/dL (80-195). Thyroid stimulating and thyrotropin receptor antibodies were positive. Ultrasound revealed a diffusely enlarged thyroid with increased vascularity. Plain radiographs revealed advanced radiological bone age of 7.5 years. Echocardiogram revealed moderate mitral valve regurgitation, dilated left ventricle and dilated left atrium.

Upon hospitalization, beta blockade with propranolol, as well as methimazole improved the tachycardia; however, switch to propylthiouracil to decrease T4 to T3 conversion resulted in near normalization by hospital day 5, with fT4 5.63 ng/dL, T4 14.6 mcg/dL and T3 332 ng/dL. Craniofacial 3D Head CT is planned when the thyroid disease is controlled.

Conclusion: This case illustrates the importance of early identification of hyperthyroidism in young children in order to prevent serious sequelae such as advanced skeletal maturity, premature craniosynostosis, cardiac insufficiency and psychomotor delay.

 

Nothing to Disclose: KLO, CDM, CHY, SAWG

20713 1.0000 SAT-028 A Delayed Diagnosis of Thyrotoxicosis Complicated By Dilated Cardiomyopathy and Accelerated Growth Velocity in a 23 Month-Old Boy with Recurrent Diarrhea and Tachycardia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Ali Alexandru Achira*1, Wael Taha2 and Maria Diab3
1Wayne State University/ Detroit Medical Center, Detroit, MI, 2Wayne State University, Detroit, MI, 3Wayne State University/ Detroit Medical Center., Detroit, MI

 

A 29 year-old Middle Eastern male was brought in with altered mental status and auditory hallucinations for 2 days. According to family, the patient has been expressing odd behaviour, particularly insomnia, polyphagia, and excessive smoking. Patient has a history of Hashimoto's hypothyroidism and is not compliant with his levothyroxine, 50mcg. He hasn't seen a physician for over a year. On presentation, vital signs were within normal limits. Patient was alert, oriented to person only, and agitated. He had normal speech and gait, pupils were round and reactive bilaterally, strength was 5/5 in all 4 extremities, normal reflexes. Kernig and Brudzinski were negative. The remainder of his exam was benign. A non-contrast head CT did not show any abnormalities. A comprehensive metabolic panel and CBC were normal. Serum and urine drug screens were negative. TSH was elevated at 13.9; T3 and T4 were normal; anti-peroxidase antibody (anti-TPO) was elevated at 823 (normal <60); thyroid microsomal, thyroglobulin, and TSH receptor antibodies were not detected. A lumbar puncture showed normal glucose, protein, and cytology; it was negative for microbiology. B12 level was normal; antinuclear antibodies and HIV and Syphilis ELISA were negative. Patient was given 100mcg of levothyroxine intravenously and continued on oral 50mcg. 500mg of intravenous methylprednisolone twice daily was added for Hashimoto's encephalopathy and was continued for 3 days. Patient's symptoms resolved. A repeat anti-TPO after 3 days was decreased to 518. Patient was discharged home on 50mcg of levothyroxine and a 7-day course of 60mg of daily oral prednisone.

Conclusion : Hashimoto Encephalopathy is rare but very serious illness. The incidence is probably underestimated because of the low overall awareness about the disease. Because of the autoimmune origin of the disease , conrticosteroid treatment usually provides a dramatic recovery.


 

Nothing to Disclose: AAA, WT, MD

18194 2.0000 SAT-029 A Acute Psychosis? Don't Forget Your Thyroid: An Interesting Case of Hashimoto's Encephalopathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Mark Anthony Jara*1, Kaushik Chatterjee2, Kadapalakere Reddy3 and Ajay Chaudhuri4
1University at Buffalo, Buffalo, NY, 2Suny at Buffalo, 3State University of New York at Buffalo, Amherst, NY, 4Suny at Buffalo, Williamsville, NY

 

Case Presentation: A 36 years old male was referred to the endocrine clinic for management of type 1 DM and thyroid disorder. Along with insulin and atorvastatin he was also on levothyroxine 100 mcg daily which was started by his PCP about a year ago. His thyroid function tests (TFT) just prior to consultation showed a TSH of 2.72 mIU/L (0.4-4.5) and a FT4 of 3.9 ng/dl (0.8-1.8). He reported frequent palpitations on exertion, 15 lb weight loss over 6 months and fatigue. Physical examination was unremarkable except for mild thyromegaly. Due to elevated FT4 and some hyperthyroid symptoms, his levothyroxine dose was decreased to 50 mcg daily. TFTs in 3 months showed FT4 3.6 ng/dl, total T3 245 ng/dl (75-165), total T4 18.8 mcg/dl (4.5-12), T3 uptake 36.9% (24-37) and TSH of 10.92 mIU/L. For persistent hyperthyroid symptoms and above TFTs, levothyroxine was discontinued. Repeated TFTs were similar in 2 months with thyroid microsomal antibody of 4479 units/ml (0-35), FT4 of 4.8 ng/dl (0.8-2.7) by equilibrium dialysis and normal TBG. Mild fatigue persisted but no further weight loss or palpitations were reported. TSH producing pituitary adenoma was ruled out by Alfa subunit to TSH ratio of 0.7 and normal pituitary MRI. Thyroid hormone resistance was suspected which was confirmed by heterozygous positive c.1358_1359insC mutation in the THRB gene. Over months TSH trended down to 8 mIU/L and thyroid hormone levels remained elevated, however the patient started to experience severe fatigue. Physical examination findings of blunt affect and symmetrically diminished DTRs supported clinical hypothyroidism. The patient was restarted back on levothyroxine at 50 mcg daily which improved his energy significantly without causing any hyperthyroid symptoms. Repeated TFTs in 2 months showed TSH of 3.28 mIU/L and FT4 of 3.0 ng/dl. Genetic counselling was obtained for the patient and family members.

Discussion: Clinical manifestations of thyroid hormone resistance are variable depending on type of resistance (pituitary or generalized) and effectiveness of compensatory mechanism to overcome variable degree of tissue hyposensitivity. Elevated thyroid hormone level with normal (unsuppressed) TSH is pathognomonic. Gross elevation of TSH with frank clinical hypothyroidism were only reported where patients inappropriately received antithyroid treatment. In presence of autoimmune thyroiditis in our patient, his capacity to produce endogenous thyroid hormones to compensate the resistance is probably decreasing, thus resulting in clinical hypothyroidism requiring exogenous thyroid supplementation. 

Conclusion: We are reporting a case of thyroid hormone resistance in association with autoimmune thyroiditis presenting with clinical hypothyroidism. Though rare, physicians should be aware of the coexistence of these two conditions and the nuances of managing similar cases.

 

Nothing to Disclose: MAJ, KC, KR, AC

20112 3.0000 SAT-030 A Thyroid Hormone Resistance Associated with Autoimmune Thyroiditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Jung Hoon Lee*1, Chul Yun Park2, Eui Dal Jung Sr.3, Ji Hyun Lee3, Ho Sang Shon Sr.3 and Eon Ju Jeon3
1Catholic university of Daegu, school of medicine, 2Catholic University of Daegu, School of Medicine, Dague, Korea, Republic of (South), 3Catholic University of Daegu School of Medicine, Korea, Republic of (South)

 

Background: Graves’ disease and Hashimoto’s thyroiditis are the autoimmune disease of thyroid gland. We report a rare case of Graves’ opthalmopathy following chronic hypothyroidism due to Hashimoto’s thyroiditis.

Clinical case: A 53-year women underwent a health examination in 2014 and a polyp of the rectum was found by a colonoscopy. She was admitted to the division of gastroenterology for the eondoscopic mucosal resection of it. She had a history of primary hypothyroidism due to Hashimoto’s thyroiditis and has been treated with levothyroxine 100 µg for 5 years. Physical examination of neck revealed a diffusely enlarged thyroid gland. On laboratory findings, the results of the thyroid function test (TFT) were as follow: TSH levels were 0.005 uIU/mL (0.4-4.7), T3 1.59 ng/dL (0.80-2.00), and free T4 levels were 2.63 ng/dL (0.80-1.90). Thyrotoxicosis factitious due to exogenous thyroid hormone was suspected. Therefore, the levothyroxine was administered by 50 µg. On follow up, TFT showed still decreased TSH levels and elevated free T4 levels. Even after the levothyroixne withheld, thyrotoxicosis was sustained and she was reassessed. Thyroid scan showed increased uptake and TSH receptor antibody levels were 24.14 IU/L (<1.22). Thyroid USG showed a heterogenous parenchyma and an increased blood flows. In addition, she presented with exophthalmos of the left eye. The results were compatible with Graves’ opthalompathy. She was treated with high-dose intravenous steroids.

Conclusions: This is a rare case demonstrating the possible development of Graves’ opthalmopathy following Hashimoto’s thyroiditis. It can be delayed considering it as an over replacement with thyroid hormone. The autoimmune alteration after Hashimoto’s thyroiditis may lead to the development of Graves’ opthalmopathy in the susceptible patients.

 

Nothing to Disclose: JHL, CYP, EDJ Sr., JHL, HSS Sr., EJJ

20808 4.0000 SAT-031 A Graves' Opthalmopathy Following Hashimoto's Thyroiditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Justin Jo*1 and David Joseph Howard2
1University of Nevada School of Medicine, 2University of Nevada School of Medicine, Reno, NV

 

Introduction: Thyroid disease is common and affects many organs, including the heart.  Abnormal thyroid hormone levels can lead to significant cardiovascular manifestations.  Hypothyroidism can cause many adverse cardiovascular effects including low cardiac output from decreased heart rate and stroke volume, reduced systolic and diastolic function, decreased preload, and increased risk of cardiovascular disease.  We report on a case of pulseless electrical activity (PEA) associated with profound hypothyroidism in a young male.

Clinical Case: A 26 year old male presented with altered mentation, nausea, and vomiting to a community hospital and was found to be in diabetic ketoacidosis.  Little was known about his medical history aside from a history of Type 1 Diabetes Mellitus and heroin abuse. He was treated in the ICU over the next 48 hours with resolution of his ketoacidosis. On discharge, the patient reported dizziness upon standing.  Within minutes, the patient lost consciousness and went into cardiac arrest.  The initial cardiac arrest rhythm was PEA.  The patient had a return of spontaneous circulation after 10 minutes of CPR and a single dose of epinephrine. He was intubated and placed on mechanical ventilation with pressor support. Diagnostic Evaluation: A chest x-ray, CT pulmonary angiogram, CT head, echocardiogram, and lower extremity Doppler ultrasound did not indicate any acute pathology.  EKG revealed a QTc interval of 474 ms, but otherwise showed no findings indicating a cause of pulseless electrical activity.  Serial cardiac enzymes indicated a slight increase from 0.02 to 0.06, which was attributable to chest compressions. The patient had a negative urine drug screen on admission.  Thyroid studies were obtained; the patient was found to have a TSH of 461.145 mIU/L (0.358-3.740 mIU/L), a free T4 of 0.13 µg/dL (0.76-1.46 µg/dL), and a free T3 of <0.4 µg/dL (2-4.4 µg/dL). Treatment/Follow Up:  The patient was treated with IV levothyroxine (100 mcg daily) prior to transitioning to oral replacement.  His vitals improved, he was extubated, and taken off pressor support.  Upon awakening, the patient admitted to long-term hypothyroidism with poor medication compliance.  Thyroid levels at discharge indicated a TSH decreased to 237.13 mIU/L with a free T4 increased to 0.65 ug/dL.  A follow-up EKG revealed resolution of his prolonged QTc interval.

Conclusion: There are many documented case reports of arrhythmias attributed to hypothyroidism, including ventricular tachycardia (6-12), Torsades de Pointes (10, 13-18), and ventricular fibrillation (11-12, 18).  Upon review, we find no previous case reports of PEA attributed to hypothyroidism. PEA is a potentially fatal form of cardiac arrest, of which the cause should be thoroughly examined.  Hypothyroidism should be considered in the differential in patients that present with all cardiac arrest, including PEA.

 

Nothing to Disclose: JJ, DJH

20544 5.0000 SAT-032 A Severe Hypothyroidism Associated with Pulseless Electrical Activity: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Tripti Joshi*1, Felicity Park2 and Christy Paul Sankoorikal1
1John Hunter Hospital, New Lambton, Australia, 2John Hunter Hopsital, New Lambton, Australia

 

Background: A molar pregnancy associated with a live fetus is extremely rare.

Clinical Case: A 30-year-old Caucasian female, pregnant with her first child at 13 weeks gestation was found to have abnormal cystic placenta along with a single live fetus on an ultrasound scan. It showed an irregular hyper echoic area measuring 8 cm to the right of uterus suspicious of molar pregnancy.

The lady’s past medical history was significant for ovulation-induced conception, infertility, PCOS and Varicella.

The chorionic villi sampling at 13 weeks was suspicious for triploidy. However, the amniocentesis at 16 weeks showed a nuchal translucency of 2.1 mm, low risk, FISH showed a normal 46 XY karyotype on the fetus. No karyotyping was undertaken of the molar tissue due to risks of bleeding at the time.

She also developed thyrotoxicosis at 12 weeks. She was managed on propylthiouracil in the first trimester followed by carbimazole from the second trimester onwards. The FT4 and FT3 followed the rise in HCG levels. The patient was at risk of preeclampsia and gestational trophoblastic disease. Discussions were held with the patient regarding the risks associated with continuation of pregnancy, however, the patient decided to continue the pregnancy with close monitoring. She was monitored closely for blood pressure and hyperthyroidism. She delivered a healthy baby at 35 weeks followed by resolution in her thyroid function tests.

Conclusion: The complete molar pregnancy is a type of gestational trophoblastic disease. It comprises diploid karyotype of the fetus. It is a premalignant condition. The Incidence in the US is 0.5-2.5 per 1000 pregnancies. It is more common with Asian or Latin American heritage, maternal age < 15 or > 50 years, previous molar pregnancy and assisted reproductive techniques (1). The risks associated with a molar pregnancy are: miscarriage, antepartum hemorrhage, preterm labor, preeclampsia, thromboembolic disease, hyperthyroidism, and gestational trophoblastic disease. The classic treatment of such cases is termination of pregnancy.

The live birth rate varied between 21-40% and rate of gestational trophoblastic disease ranged between 19-50 % for a complete mole in different series (5,6,7)

There is 25-64% prevalence of increased thyroid function and 5% of clinical hyperthyroidism. (1,2) The alpha subunit of HCG bears a homology to TSH. 1 unit of HCG has 0.0013-uU activity of TSH (3). In gestational trophoblastic disease HCG has 3.72-4.68 uU equivalent activity of HCG (4). The molar HCG shows molecular heterogeneity; more basic forms and partially desialated isoforms. They have higher biologic to immunologic ratio, greater thyrotrophic potency and a decreased half-life. The levels of HCG are closely correlated with TSH, T3. Treatment is with anti-thyroid medications. Removal of the molar tissue results in prompt reduction in HCG and TSH (1,2).

 

Nothing to Disclose: TJ, FP, CPS

22041 6.0000 SAT-033 A A Peculiar Case of Molar Pregnancy with Live Fetus Associated with Thyrotoxicosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Andrew R. Crawford*1, Paige Meizlik2 and Caroline S. Kim3
1Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 2Hospital of the University of Pennsylvania, Philadelphia, PA, 3Hospital of the University of Pennylvania, Philadelphia, PA

 

PERTINENT CLINICAL CASE SUMMARY:

Background:

Thyroid storm is an unusual presentation in patients with metastatic follicular thyroid carcinoma.

Clinical Case:

A 59 year-old woman with known metastatic follicular thyroid carcinoma status post total thyroidectomy and radioactive iodine 4 years prior presented to the hospital for shortness of breath and abdominal pain. She had known lung and bone metastases that were not iodine-avid, and had recently completed external beam radiotherapy for metastases to the right shoulder, left knee and pelvis 5 weeks prior. Two days before presentation, she had undergone full body CT scans with IV contrast administration for disease staging. 

Outpatient labs showed fluctuating total T4 levels from 4.52 to 20.64 ug/dL (4.6-12) over the preceding 6 months. This raised concern that the patient was not taking the correct dose of levothyroxine, however her levels continued to rise despite discontinuation of levothyroxine. Initially the patient was clinically stable, but shortly after admission she decompensated in the setting of tachypnea, hypoxia, and supraventricular tachycardia, which necessitated mechanical ventilation and pharmacologic cardiac support including vasopressors, IV esmolol and amiodarone. Her labs revealed TSH <0.01 uIU/mL (0.27-4.2), free T4 >7.7 ng/dL (0.93-1.7), total T4 >25 ug/dL (4.6-12.0) and T3 uptake >5 (0.76-1.25). Additional labs were notable for an elevated total T3 level at >6.51 ng/mL, (0.8-2). Antibodies typical for Graves’ disease (TRAB) were also elevated at >40 IU/L (<1.75). She was treated with super saturated potassium iodine (SSKI), propylthiouracil and cholestyramine with a concomitant decrease in thyroid hormone levels: total T4 13.81 ug/dL (4.6-12), total T3 2.33 ng/mL (0.8-2)

Despite aggressive treatment, her clinical condition deteriorated and comfort care measures were implemented. Post-mortem autopsy revealed widely metastatic follicular carcinoma with spread to the lungs, liver, kidney, adrenal gland, pancreas, myocardium, stomach, and vertebral bodies.

Conclusion:

Patients with an extensive disease burden from metastatic follicular carcinoma may develop thyroid storm in rare instances. In this case, the potential etiologies included over-replacement with thyroid hormone, tumor destruction, or functional tumor. Metastatic follicular carcinoma can rarely have active thyroid deiodinases in the presence of thyroid stimulating autoantibodies, and patients with an extensive disease burden may be at high risk for developing clinically significant thyrotoxicosis.

 

Nothing to Disclose: ARC, PM, CSK

19005 7.0000 SAT-034 A Thyroid Storm Induced in Metastatic Follicular Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Anupam Kotwal*, Uzma Mohammad Siddiqui and Shirin Haddady
University of Massachusetts Medical School, Worcester, MA

 

Introduction: Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism characterized by episodic muscle weakness and hypokalemia, which can progress to respiratory insufficiency or cardiac arrhythmias. This condition has been most commonly reported in Asian populations, with an incidence of 2 % and a higher predilection for men.

Clinical case: Here we present a 20 year-old Vietnamese gentleman without any past medical history, who presented to the emergency department for sudden onset of severe generalized weakness shortly after waking up. He also reported heart palpitation and tremors for 2 months prior to this event. Family history was significant for hyperthyroidism of unclear etiology in his sister. He had tachycardia and severe muscle weakness at initial presentation. The thyroid gland was 1.5 times normal size, non-tender and without bruit. Laboratory workup revealed low serum potassium of 2.1 mmol/L (reference 3.5-5.3), low TSH of 0.03 uIU/mL (reference 0.28-3.89), high free T4 of 3.45 ng/dL (reference 0.58-1.64) and high total T3 of 190 ng/dL (reference 87-178). He received intravenous potassium chloride, oral propranolol and methimazole, and muscle weakness resolved. He continued to show improvement of thyrotoxic symptoms and was sent for total thyroidectomy nine months after initial presentation. Before the surgery, Thyroglobulin antibody, Thyroid Peroxidase antibody and Thyroid Stimulating Immunoglobulin were within the normal range. Thyroid ultrasound revealed bilateral subcentimeter cystic and hypoechoic nodules without calcification or increased vascularity. Thyroid scan showed patchy Radioactive Iodine uptake with uptake of 70.6 % in 23 hours. These findings were suggestive of toxic multinodular goiter. After the thyroidectomy, potassium supplement was discontinued and he did not develop hypokalemia or muscle paralysis again.

Conclusion: TPP should be considered as a differential diagnosis in patients with muscle weakness, hypokalemia and thyrotoxicosis. Complete motor recovery usually occurs after the correction of hypokalemia, combined with anti-thyroid and beta-blocking agents. Definitive management of the etiology of hyperthyroidism is essential to prevent future episodes of paralysis and hypokalemia.

 

Nothing to Disclose: AK, UMS, SH

20649 8.0000 SAT-035 A Thyrotoxic Periodic Paralysis Due to Toxic Multinodular Goiter 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Anupam Kotwal*, Sarika Rao and Richard Allen Haas
University of Massachusetts Medical School, Worcester, MA

 

Introduction: Hypophysitis has emerged as an immune related adverse effect (IRAE) of anti-CTLA 4 antibodies like Ipilimumab, occurring in approximately 11% of cases with a higher predilection for males (1).

Clinical case: A 68 year old gentleman presented to the Oncology clinic with headache, diplopia, fatigue, nausea, hot flashes and anorexia following the third cycle of 3mg/kg Ipilimumab for metastatic melanoma. He had a thyroidectomy for hyperthyroidism 40 years ago and was on Levothyroxine replacement. Before initiating Ipilimumab, thyroid function tests had been normal but adrenal function was not checked. Physical exam revealed proximal muscle weakness. Laboratory workup revealed low total Testosterone of 11 ng/dL (reference 241-827), low TSH of 0.09 uIU/mL (0.28-3.89), normal free T4 of 1.15 ng/dL (0.58-1.64) and normal electrolytes. Brain MRI showed new heterogeneous enhancement of the pituitary. Based on these findings, he was diagnosed with Ipilimumab induced hypophysitis (IH), and started on 90 mg Prednisone & testosterone gel. He also developed IRAEs of dermatitis and colitis, and did not receive further Ipilimumab therapy. On follow up MRI, the pituitary fullness resolved after three months. Prednisone was gradually tapered over five months but an attempt at discontinuation worsened the fatigue. He was then evaluated by Endocrinology and hormonal investigations revealed low AM Cortisol of 1.4 mcg/dL (reference 6.7-22.6), low ACTH of <5 pg/mL (ref <46), abnormal ACTH-stimulation test showing Cortisol response to 11.4 mcg/dL (≥18), low Prolactin of 0.6 ng/mL (2.6-13.3), low total Testosterone of <10 ng/dL, normal IGF-1 of 40 ng/dL (17-246) and inappropriately normal LH of 1.4 mIU/mL (1.2-8.6). Serum and urine osmolality as well as electrolytes were normal. He received Hydrocortisone replacement of 30 mg a day in divided doses, and Testosterone gel which he had stopped by himself was resumed. Fatigue was the only symptom that persisted and that too resolved after starting CPAP for his obstructive sleep apnea. Eight months after the diagnosis of IH, he remained asymptomatic on physiologic dose hydrocortisone and testosterone replacement.

Conclusion: This case represents IH causing anterior hypopituitarism. An unusual feature is preserved Somatotroph function despite profound central hypoadrenalism and hypogonadism. The worsening of symptoms after discontinuation of steroids five months after presentation, and the improvement after reinitiating them, suggest that the hypopituitarism is permanent even though MRI findings resolve (2). A recent study implicated pituitary antibodies (3) as a possible method of detection in addition to MRI and hormone studies. There is not enough evidence to support the routine need for discontinuing Ipilimumab or the superiority of initial high dose versus physiologic steroid and hormone replacement in the management of IH (1).

 

Nothing to Disclose: AK, SR, RAH

20169 9.0000 SAT-036 A Ipilimumab Induced Hypophysitis May Not Affect All Pituitary Cell Lines: A Case Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Anupam Kotwal*1, Basel Touchan2, Kavita Y Seetharaman1, Uzma Mohammad Siddiqui1 and Richard Allen Haas1
1University of Massachusetts Medical School, Worcester, MA, 2University of Aleppo

 

Introduction: Amiodarone induced thyrotoxicosis (AIT) has been associated with increased mortality in older individuals with impaired ventricular function (1), underlying the importance of rapid restoration and maintenance of euthyroidism. Plasmapheresis for treating thyrotoxicosis refractory to medical therapy has shown mixed results (2, 3).

Clinical case: A 61 year old gentleman was hospitalized for progressively worsening dyspnea, palpitations, tremor and generalized weakness. He had a history of atrial fibrillation, coronary artery disease, ischemic cardiomyopathy, refractory heart failure and type 2 diabetes mellitus. He had been diagnosed with AIT four months prior to admission, after which Amiodarone was discontinued, and he was started on Prednisone and Methimazole which was later changed to Propylthiouracil. Physical examination revealed irregular tachycardia, lid lag, fine hand tremor, proximal muscle weakness, pedal edema and a small, smooth, non-tender thyroid gland without bruit. Hormonal investigations revealed low TSH at <0.01 uIU/mL (reference 0.28-3.89), high free T4 at 5.78 ng/dL (reference 0.58-1.64), high free T3 at 5.4 pg/mL (reference 2.5-3.9) and normal total T3 at 114 ng/dL (reference 87-178). Antibodies against TPO, Thyroglobulin and the TSH receptor were undetectable, making autoimmune etiologies unlikely. Echocardiogram revealed reduced left ventricle ejection fraction of 25 %. Thyroid ultrasound showed a bilaterally heterogeneous, hypovascular and hypoechoic gland. RAIU scan revealed low uptake of 1.5 % at 5 hours and 0.9 % at 24 hours. These findings were suggestive of destructive type 2 AIT. However, the lack of a good response to steroids argued for type 1 AIT. Given his poor response to medical therapy and increased cardiovascular risk for an urgent thyroidectomy, plasmapheresis was instituted in an attempt to lower the thyroid hormone levels. Seven cycles of plasmapheresis provided only modest clinical and biochemical improvement with free T4 eventually decreasing to 4.54 ng/dL. He then underwent total thyroidectomy, and within 24 hours, free T4 decreased to 3.25 ng/dL, free T3 to 3.7 pg/mL and total T3 to 67 ng/dL. Histopathology of the thyroid demonstrated intrafollicular histiocytes, patchy fibrosis and involuted follicles, suggestive of destructive thyroiditis. On follow up 2 months later, he remained clinically euthyroid on levothyroxine replacement with stable cardiac status.

Discussion: AIT has been divided based on the underlying mechanism into type 1 (excess thyroid hormone synthesis), type 2 (excess release of T4 and T3 due to destructive thyroiditis) and mixed (1). Our case represents mixed AIT of protracted duration refractory to thionamides and steroids. Plasmapheresis only modestly lowered the free T4 in our patient, suggesting the limitations of utilizing this therapeutic modality prior to definitive treatment in AIT.

 

Nothing to Disclose: AK, BT, KYS, UMS, RAH

21595 10.0000 SAT-037 A Plasmapheresis for Refractory Amiodarone Induced Thyrotoxicosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Lisa Underland*1 and Leslie S Lam2
1Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, NY, 2Montefiore Medical Center, Bronx, NY

 

Background  Hyperthyroidism is rare in children under 15 years and is noted to be more common in pubertal patients compared to prepubertal (1). Thyroid storm is even more unusual (incidence in 0.2 per 100,000 hospitalized patients per year (2)). When it does occur, it is generally precipitated by illness. Cardiac manifestations can be noted in cases of thyroid storm, most commonly tachycardia and atrial fibrillation (10-20% in adults (1)). Cardiomyopathy is rare even in adult patients in whom thyroid storm is more common. While the association of Grave’s disease with autoimmune mediated kidney diseases such as membranoproliferative glomerulonephritis has been reported previously (3), there are no reported cases of Graves disease associated with post streptococcal glomerulonephritis.

Clinical Case A 5 year old African male presented with a 9 day history of lethargy, fever, vomiting, weight loss and diarrhea. The week before presentation he was diagnosed with strep throat, and had been placed on antibiotics but was noncompliant. At presentation, he had  fever, hypertension, and tachycardia. He was noted to be tall and thin with a goiter and prominent proptosis. He was agitated and restless on exam. Chest X ray showed cardiomegaly.  Echocardiogram revealed a dilated cardiomyopathy.  Thyroid function tests were drawn and he was admitted to the PICU for cardiac monitoring. TSH was <0.005 uU/mL (Normal 0.4-4.6) and Free T4 was 7.77 ng/dL (Normal 0.8-1.7). Based on clinical presentation he was diagnosed with thyroid storm and was started on Atenolol and Methimazole. Labs showed positive thyroid stimulating immunoglobulin and negative anti thyroglobulin and anti thyroperoxidase antibody titers as well as low complement levels with hematuria which persisted throughout the hospitalization. He was presumed to have glomerulonephritis and was started on antibiotics for a partially treated strep throat infection. Over the next several days his heart rate, agitation, and blood pressure improved and his fever resolved. His thyroid function tests also showed significant improvement. Complement levels drawn in clinic 6 weeks later returned to normal, which supported the diagnosis of post-streptococcal glomerulonephritis. Repeat echocardiogram showed improvement in his cardiomyopathy and cardiac function as well. He was presumed to have longstanding hyperthyroidism which triggered thyroid storm in the presence of a secondary infection (strep throat which was later complicated by post-streptococcal glomerulonephritis.)

Conclusion  This is the first reported case of thyroid storm with cardiomyopathy triggered by post streptococcal glomerulonephritis. Clinicians should be aware of this unusual association of thyroid storm, cardiomyopathy, and post-strep glomerulonephritis  in the pediatric population.

 

Nothing to Disclose: LU, LSL

21044 11.0000 SAT-038 A A Pediatric Case of Cardiomyopathy and Thyroid Storm Associated with Post-Streptococcal Glomerulonephritis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Janice Ho*, Pamela Katz, Donna Sutherland and William D Leslie
University of Manitoba, Winnipeg, MB, Canada

 

Background: Ectopic thyroid develops at early stages of thyroid gland embryogenesis due to failure of migration from the floor of the primitive foregut to the pre-tracheal position.  Iatrogenic ectopic thyroid can arise from previous surgery due to inadvertent tissue implantation.  The most common sites of ectopic thyroid tissue are lingual, sublingual, thyroglossal, laryngotracheal, and lateral neck.  Ectopic intratracheal thyroid accounts for 1% of all ectopic thyroid cases.[1]

Clinical case: An 86 year old female presented with gradually increasing shortness of breath and stridor. Thirty-five years earlier she had undergone right hemithyroidectomy for a benign nodular goiter and was on a stable low-dose levothyroxine. She was clinically and biochemically euthyroid (TSH 0.69; Normal: 0.4-4.2 mU/L). CT of the neck showed a right-sided 1.6 cm intratracheal nodular thickening causing tracheal narrowing.  The left lobe of the thyroid was enlarged, displacing the trachea to the right.  At endoscopy, there was evidence of right vocal cord paralysis with complete compensation on adduction from the left vocal cord.  Urgent tracheostomy was required for airway management.  Biopsy of the intratracheal mass showed thyroid follicular tissue with no evidence of malignancy.

Several therapeutic options were considered.  Surgical resection was felt to be excessive given the patient’s age and comorbidities, and might increase aspiration risk due to the immobile right vocal cord.  The location was not amenable to CO2 laser ablation. Therefore, radioiodine ablation was considered with the goal of achieving reduction in the size of the tissue.  Although transient worsening due to radiation thyroiditis is a potential side effect, the patient had a tracheostomy providing a secure airway.

The thyroid was scanned with Iodine-123 following levothyroxine withdrawal, and the ectopic subglottic right thyroid tissue demonstrated radioiodine uptake consistent with functioning thyroid tissue. The patient received Iodine-131 at a dose of 100 mCi (3.7 GBq).  Treatment was uncomplicated and 6 weeks later the patient required an increased levothyroxine dose consistent with successful ablation of thyroid tissue.

Clinical lesson: The primary treatment for ectopic intratracheal thyroid is surgical excision.[2] However, if iodine-avid, radioiodine ablation may be an option in those who are not a candidate for surgery or other treatment options.

 

Nothing to Disclose: JH, PK, DS, WDL

18669 12.0000 SAT-039 A First Case Reported of Ectopic Intratracheal Thyroid Treated with Radioactive Iodine 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Nitika Malhotra*1, Saleh Aldasouqie2 and Naveen Kakumanu3
1Michigan State University, Lansing, MI, 2Michigan State University, 3Michigan State University, Okemos, MI

 

Background: Post-surgical thyrotoxicosis occurring in patients following parathyroidectomy due to primary hyperparathyroidism have been reported in several cases but has rarely been described in tertiary hyperparathyroidism.

Clinical Case:

A 19 year old woman with end stage renal disease underwent parathyroidectomy for tertiary hyperparathyroidism. Her baseline parathyroid hormone (PTH) level before surgery was 1800 pg/ml (11-54 pg/ml). She had no known history of thyroid disease. 

Postoperative thyroid function tests were measured that demonstrated low thyroid stimulating hormone (TSH) of 0.12 uIU/ml (0.35-4.01 uIu/ml) with elevated free thyroxine (T4) of 2.46 ng/dl (0.61-1.37 ng/dl) and elevated free triiodothyronine (T3) of 5.5 pg/ml (2.5-3.9 pg/ml). 

Thyroid stimulating immunoglobulin, thyrotropin receptor antibody and anti-thyroid peroxidase antibody titers were undetectable. 

Thyroid ultrasound with doppler demonstrated normal gland without increased vascularity.

Thyroid functions tests were reassessed in a few days which showed that free T4 and free T3 levels were trending down and subsequently normalized.

Follow up labs:

Thyroid function tests on post op day 7: TSH (0.35-4.01uIU/ml) 0.12, free T4 (0.61- 1.37ng/dl) 2.46, free T3 (2.5-3.9pg/ml) 5.5

Thyroid function tests on post op day 10: TSH 0.29, free T4 1.37, free T3 5.4

Thyroid function tests on post op day 20: TSH 0.33, free T4 1.07, free T3 4.1

Thyroid function tests 8 months post op: TSH 2.92, free T4 1.08

Patient had no symptoms of thyrotoxicosis and she remained euthyroid without any management with antithyroid drugs or beta blockers.

Conclusion:

Transient thyrotoxicosis or hyperthyroxinemia should be considered as a potential complication of total parathyroidectomy for tertiary hyperparathyroidism due to manipulation of thyroid gland during parathyroid surgery. It has also been proposed that high levels of preoperative PTH have a greater association with postoperative thyrotoxicosis and patients with tertiary hyperparathyroidism have much higher preoperative levels of PTH. To our knowledge there has been only two reported cases of thyrotoxicosis after parathyroidectomy for tertiary hyperparathyroidism. It is mostly self limiting and may not require any treatment. Anti thyroid medications are unlikely to be of any value in these cases and awareness of this complication prevents unnecessary treatment to these patients.


 

Nothing to Disclose: NM, SA, NK

21984 13.0000 SAT-040 A Hyperthyroxinemia after Parathyroidectomy for Tertiary Hyperparathyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Smriti Manandhar*
Medical College of Wisconsin, Oconomowoc, WI

 

Introduction: 

Grave’s disease can affect multiple organ systems.  Grave’s ophthalmopathy, osteopathy, and dermopathy are known manifestations, but rarely will Grave’s also cause bone marrow suppression leading to pancytopenia.

Clinical case:

A 24-year-old woman with no significant past medical history presented with an unintentional  80-pound  weight loss after  four months. She also complained of fatigue, excessive sweating, heat intolerance, tremors, palpitations and an increased frequency of loose stools. She denied symptoms of anterior neck compression, eye prominence, use of over-the-counter thyroid supplements or iodine products, or exposure to iodinated contrast dye. There was no family history of thyroid disease. She denied any recent viral illness or taking any medications. Upon examination, her pulse rate was 90/min, she had a mild stare but no lid lag or proptosis, her thyroid gland was enlarged symmetrically to twice the normal size , no nodules were palpable, and a bruit was heard over the gland. She was hyporeflexive and had tremors of the outstretched hands.

Initial  laboratory tests showed a WBC count of 3800/mcL ( 4000-10000/mcL)  with 57% neutrophils,  Hemoglobin (Hb) of 10.2 g/dl (11.2-15.7 g/dL), Hematocrit (Hct) of 31% ( 34-45%), and platelet count of 156000/mcL (163000-369000/mcL). TSH was 0.007 uIU/ml ( 0.45-4.5 uIU/mL),  free T4 was >7.77 ng/dl ( 0.82-1.77 ng/dl) and free T3 >32.6 pg/ml ( 2.0-4.4 pg/ml).  AST was 38 U/L (10-32 U/L), ALT was 28 U/L,(8-33 U/L), bilirubin was 1.3  mg/dl (0.2-1.2 mg/dl), and TSI antibodies were positive at 349%. Other hematologic workups for pancytopenia were unremarkable. A pregnancy test was negative.

The patient was started on methimazole at 30 mg daily and atenolol at 50 mg twice a day. After 6 weeks of therapy, there was improvement in symptoms, thyroid function tests and the pancytopenia resolved. TSH was <0.005 uIU/ml, free T4 was 1.79 ng/dl, WBC count was 4500/mcL, Hb was 11.5 g/dl, Hct  was 36%, and platelet count was 178000/mcL. Liver transaminases and bilirubin also returned to normal.

Conclusion:

Grave’s disease should be considered in the differential diagnosis of pancytopenia. Even though anti-thyroid medications can cause agranulocytosis as a side effect, their  use is supported in these patients, as cases reported in the literature had a resolution of their hematological disorder after treatment with anti-thyroid medication.

 

Nothing to Disclose: SM

19902 14.0000 SAT-041 A Grave's Disease and Pancytopenia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Krithikaa Nadarajan*1, Joan J C Khoo2 and Shui Boon Soh1
1Changi General Hospital, Singapore, Singapore, 2Changi General Hospital, Singapore

 

Title: Painless severe cholestatic jaundice: An unusual presentation of hyperthyroidism

Background:Painless severe cholestatic jaundice is an uncommon presentation of thyrotoxicosis. We report a patient who presented with painless cholestatic jaundice to the surgical department and was eventually found to have Graves’ disease.

Case report:A 54-year-old woman presented with painless jaundice for two months, associated with weight loss. She was found to have right heart failure and atrial fibrillation (AF) with pulse rate 150 beats/minute.   Raised serum bilirubin 395 µmol/L (NR 5.0-30) and raised Alkaline phosphatase 215 U/L (NR 32-103) with normal transaminases suggested cholestasis and hepatic congestion Suppressed TSH below 0.004 mU/L (NR 0.400-4.00), raised free T4 70.58 pmol/L (NR 10.00- 20.00) and TRAb above 40 mU/L (NR<2.0 U/L) were consistent with Graves’ disease. Propylthiouracil (PTU), Lugol's iodine and hydrocortisone were prescribed for severe thyrotoxicosis. After the loading dose of PTU, computed tomography (CT) scan of the abdomen with intravenous contrast was done to evaluate suspected extrahepatic biliary obstruction, which showed hepatic congestion with no gallstones or pancreatic mass. Two hours after the CT scan, she developed worsening AF with cardiogenic shock and pulmonary edema which required intubation. Transthoracic echocardiogram showed a depressed ejection fraction of 20% with right ventricular dilation. Magnetic resonance cholangio-pancreaticography, viral hepatitis serology and autoimmune liver disease markers were negative. PTU and hydrocortisone were continued with cautious dosing of digoxin. She recovered from thyroid storm with normalization of free T3, T4 and liver function after two weeks of PTU.

Learning Point:Though uncommon, hyperthyroidism should be excluded in patients presenting with severe cholestasis as treatment normalizes liver function. As high iodine content in IV contrast may increase the risk of decompensation of thyrotoxicosis, contrasted CT scans should be performed with caution in patients with severe untreated thyrotoxicosis.

 

Nothing to Disclose: KN, JJCK, SBS

18967 15.0000 SAT-042 A Painless Severe Cholestatic Jaundice: An Unusual Presentation of Hyperthyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Rebecca C Pace*, Shema R Ahmad, Michael W. Morris Jr. and Naveed Ahmad
University of Mississippi Medical Center, Jackson, MS

 

Background:

Ectopic anterior mediastinal goiters are rare, and the presence of a native gland in addition to an ectopic gland in that location is exceedingly rare. Ectopic thyroid is usually located along the normal path of thyroid gland descent, but rarely can also be found in mediastinum, heart, esophagus, or diaphragm. We present a unique case of a patient with a multinodular goiter located in the anterior neck with a separate large anterior mediastinal ectopic goiter.

Clinical Case:

This is a 53 y/o woman referred to Endocrinology clinic for a multinodular thyroid goiter with substernal extension. This was found on a CT thorax during the workup for chest pain and dyspnea. Initial imaging revealed a large multinodular goiter with a 3.5cm isthmus mass, tracheal deviation to the right, and an 8.3cm substernal extension of the right lobe of the thyroid gland. The patient denied exposure to external beam radiation and family history of thyroid disease. On examination, her trachea was deviated to the right due to a large goiter.  TSH, Free T4, and Thyroid peroxidase antibody were normal. A thyroid ultrasound revealed a 1 cm ill-defined, solid nodule with foci of internal calcifications at the junction of the left lower lobe and isthmus. An FNA biopsy revealed a benign follicular nodule.

The patient was referred for total thyroidectomy because of compressive symptoms. Intra-operative findings demonstrated a thyroid goiter with an enlarged right inferior horn. A non-recurrent right laryngeal nerve was encountered during dissection. After extirpation of the entire gland an anterior mediastinal mass was visualized without direct connection to the thyroid.  Removal of the mass from a cervical approach with a known left sided arch was not felt to be safe during the initial operation.

Postoperative CT scan was obtained and demonstrated a large anterior mediastinal mass resting on the aorta between a bovine arch. The patient was taken back for re-exploration on post-operative day 3 and the mediastinal mass was removed through the original thyroidectomy incision. Repeat operation at such a short interval allowed exposure and dissection of superior mediastinal structures through the neck with the help of a cardiothoracic surgeon. The ectopic gland was successfully removed and patient clinically improved. Pathology was consistent with a multinodular goiter.

Conclusion:

Ectopic anterior mediastinal multinodular goiter is a rare condition among thyroid disorders, and even more rare when present in addition to a native, anatomically correctly located thyroid gland. Recognizing that thyroid tissue can occur in the anterior mediastinum completely detached from the native thyroid is important to both clinicians and surgeons during the diagnostic workup for an anterior mediastinal mass. This patient is now doing well and her shortness of breath and chest pain has improved.

 

Nothing to Disclose: RCP, SRA, MWM Jr., NA

20752 16.0000 SAT-043 A A Unique Case of a Cervical Multinodular Goiter with an Isolated Ectopic Thyroid Goiter in the Anterior Mediastinum 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Goral Panchal*1, Corrado Minimo2, Sarah Perloff3 and Nissa Blocher1
1Albert Einstein Medical Center, Philadelphia, PA, 2Albert Einstein Medical Center, Phialdelphia, 3Albert Einstein Medical Center, Philadelphia

 

BACKGROUND

Tuberculosis (TB) of thyroid is very uncommon even in endemic areas.  The estimated incidence of the disease is 0.1-0.4% in histologically diagnosed thyroid specimens. The thyroid gland is thought to be especially resistant to infection by Mycobacterium tuberculosis possibly due to bactericidal action of colloid, high vascularity with subsequent highly oxygenated mileu, presence of iodine and antituberculous activity of thyroid hormone. There are about 200 cases of TB thyroid in English literature of which we found 2 cases with associated thyrotoxicosis or Graves’ disease.

Primary TB of the thyroid may present as one or more nodules, thyroid pain or rarely with symptoms of hyperthyroidism or hypothyroidism. Diagnosis requires histological examination, as clinical and radiological features are non-specific.

We present a case of simultaneous Graves’ disease and thyroid nodule found to have non caseating granulomas due to tuberculosis.

CLINICAL CASE

59 year old African American female was evaluated for unintentional weight loss of about 30 pounds in 2 months with episodes of palpitations and chest pain. Her past medical history was significant for hypertension on chlorthalidone. She also had uveitis for which she was getting intraocular dexamethasone injections. Her sister had history of Graves’ disease.  

She was found to be hyperthyroid with TSH <0.01 mcIU/ml (N 0.35-4.94) and FT4 2.4 ng/dL (N 0.70-1.48). She was started on Methimazole 10 mg daily. On ultrasound of the thyroid, she was found to have a diffusely hypervascular gland consistent with Graves’ disease.  In addition was found a 2.4 x 1.8 x 2 cm  nodule on the left lobe. The nodule was solid and isoechoic with some hypoechoic areas. TSI antibody level was elevated at 431 (N <140%baseline).

When she presented for FNA three months later, she had developed a new, enlarged, posterior cervical lymph node 2.6 cm palpable on exam. FNA of the thyroid nodule showed Follicular lesion of undetermined significance (FLUS).   So she underwent total thyroidectomy and lymph node excisional biopsy.

Pathology showed changes consistent with Graves’ disease, but also a few non-caseating granulomas with central necrosis in one of them. AFB stain was negative.  Lymph node pathology showed similar granulomas and microbiological culture grew Mycobacteium tuberculosis.

On further review of her history, she mentioned that she had positive PPD test in the past, but was not treated for it. She had a history of exposure to TB as her adopted son was treated for it when he was young. She is now euthyroid on levothyroxine and was started antituberculous treatment for disseminated tuberculosis and is recovering well.

CONCLUSION

Thyroid tuberculosis is very rare but should be considered in the differential of granulomatous lesions in thyroid.  Clinical thyrotoxicosis is rare with TB thyroid and this will be only the third case of the kind.

 

Nothing to Disclose: GP, CM, SP, NB

21189 17.0000 SAT-044 A A Case of Synchronous Graves' Disease and Thyroid Tuberculosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Theodora Pappa*1, Jesper Johannesen2, Neal H Scherberg3, Maricel Torrent4, Alexandra M Dumitrescu1 and Samuel Refetoff1
1The University of Chicago, Chicago, IL, 2Herlev University Hospital, Copenhagen, Denmark, 3University of Chicago, Chicago, IL, 4Abbvie, Chicago

 

Background: TSH deficiency due to mutations in the TSHβ gene is a rare cause of congenital central hypothyroidism. To date, nine different TSHβgene mutations have been reported, all with evident clinical manifestations. 

Clinical case: The proband is a 4-year-old male, the youngest of a consanguineous Pakistani family. Fatigue led to thyroid function testing that revealed undetectable serum TSH despite normal thyroid hormone levels and absence of clinical signs of hypothyroidism. His 10-year-old brother had the same thyroid function profile, whereas their older siblings and mother were biochemically and phenotypically normal. Following sequencing of the TSHβ gene, both brothers were found to be homozygous for a single nucleotide substitution in exon 3 (c.223A>G) resulting in the replacement of normal arginine-55 with glycine in the mature TSHβ protein. Their brother and mother were heterozygous and their sister homozygous for the normal allele. This variant was found in two out of 1324 alleles from whole-exome sequencing of European individuals as part of the ClinSeq project. However, the number of Pakistani individuals in this population is unknown. Serum TSH levels of the two brothers were measured by five different automated platforms (Roche Elecsys, Siemens Immulite 2000, Siemens Centaur, Beckman Coulter DXI and Abbott Architect) and were undetectable only in two produced by Siemens. Interestingly, in the two Siemens assays, the TSH levels of the heterozygous brother and mother were half compared to the TSH measurements using other platforms. Based on the PolyPhen-2 prediction, this missense mutation is not expected to significantly impact the protein’s function. In silico  structure modeling showed that the mutation does not affect the ”seat belt” region of TSHβ, critical for the interaction with the α-subunit, and therefore, is not expected to alter the activity of the heterodimer. To mimic the effect of the mutation, human serum with normal TSH levels was exposed to phenylglyoxal, which leads to arginine modification and loss of the amino acid properties. Measurement of TSH with the Siemens platforms showed  a reduction from 4.1 to 0.16 mU/L following phenylglyoxal treatment. This further supports that replacement of arginine-55 is responsible for the loss of immunoreactivity when using that specific proprietary monoclonal antibody to detect the TSHβ molecule, the consequence being falsely low TSH measurements.   

Conclusion: To our knowledge, this is the first report of a TSHβ gene mutation that impairs the immunoreactivity of the protein without affecting its biological activity. From a clinical standpoint, this mutation results in spuriously low TSH measurements. A test method which does not recognise the mutant amino acid could lead to an erroneous diagnosis of incoherent thyroid function tests, most likely in populations when this TSHβ variant is more prevalent.

 

Nothing to Disclose: TP, JJ, NHS, MT, AMD, SR

20000 18.0000 SAT-045 A A Novel Tsh&beta Gene Mutation with Impaired Immunoreactivity but Normal Bioactivity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 028-045 6028 1:00:00 PM Thyroid Clinical Poster


Shuchie Jaggi Jain*1, Sandra Aleksic2, Shashank Jain2 and Maya P Raghuwanshi3
1Temple Hospital, Philadelphia, PA, 2Rutgers-New Jersey Medical School, Newark, NJ, 3UMDNJ-NJ Med Sch, Newark, NJ

 

Introduction:A rare and commonly under-recognized cause of delirium is Hashimoto’s encephalopathy, characterized by cognitive decline and elevation in anti-thyroid antibodies without evidence of stroke, tumor or central nervous system infection.

Case Presentation:54 year old female with past medical history of morbid obesity and hypothyroidism presented to the emergency department for rectal bleeding. The patient was unable to respond to questions and only groaned on occasion. Patient’s family described that the patient was responsive and verbal a month prior to this presentation. Pertinent positives on physical exam were vertical nystagmus, 1+ pitting edema in bilateral lower extremities and external hemorrhoids. She was admitted for sepsis due to urinary tract infection (Urinalysis with WBC >182) and rectal bleeding deemed to be from external hemorrhoids. She was also noted to have severe hypothyroidism with a TSH of 36.9 (0.27-4.0uu/ml), Free T4 of <0.4 (0.7-1.5ng/dl), T3 of 0.3 (0.6-1.6ng/dl), thyroid peroxidase of 67 (0-34IU/ml) and anti-thyroglobulin antibodies of 73.6 (0-0.9IU/ml). Throughout the next few days of the hospital course, despite the use of appropriate antibiotics and stable hemoglobin, she remained somnolent and unresponsive with a Glasgow coma scale of 7 (E4V2M1). An EEG was obtained showing a low amplitude study with moderate slowing with no epileptiform activity. CSF was positive for elevated protein of 166 (15-45mg/dl) Despite administration of the adequate dose of intravenous (IV) levothyroxine changed from 25 mcg orally (outpatient) to 100 mcg IV, patient’s mental status did not improve. Her TSH improved to 4.99. A CT scan of the head showed mild cerebral volume loss while MRI was without obvious structural brain abnormality although consistent with atrophy of white matter. Patient was subsequently started on IV steroids, which led to significant improvement in mental status. It was decided to keep her on long-term oral steroid therapy.

Conclusion: Hashimoto’s encephalopathy should be considered as a potential cause of delirium of unclear etiology in a patient with hypothyroidism whose mental status fails to improve with adequate dose of intravenous levothyroxine, particularly if there is elevated protein level in CSF in the absence of CNS infection. The prompt treatment with corticosteroids is warranted as residual cognitive impairment occurs in up to 25 percent with long-standing untreated disease.

 

Nothing to Disclose: SJJ, SA, SJ, MPR

21996 1.0000 SAT-001 A A Case of Reversible Delirium Secondary to Hashimoto's Encephalopathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Sandra Aleksic*1, Shuchie Jaggi Jain2, Michael Magnotti3 and Arpita Patel4
1Rutgers-New Jersey Medical School, Newark, NJ, 2Temple Hospital, Philadelphia, PA, 3Hackensack University Medical Center, Hackensack, NJ, 4Rutgers - New Jersey Medical School, Newark, NJ

 

Background:

Thyroid-type carcinoma arising in struma ovarii is an extremely rare ovarian malignancy without defined optimal therapeutic approach.

Clinical case:

A 60-year old woman with a history of laparoscopic hysterectomy for uterine fibroids presented with two weeks of progressive urinary frequency and suprapubic pain. The abdominal exam was significant for suprapubic fullness, while rectovaginal exam showed a mobile cystic mass. CT of the abdomen and pelvis with intravenous contrast showed 10-cm cystic adnexal mass. The pelvic ultrasound demonstrated a 3-4cm solid-appearing nodule with some vascular flow within the mass. CA-125 level was 33U/mL (normal <35U/mL).

Laparoscopic bilateral salpingo-oophorectomy was performed and the torsed left ovarian mass was resected. The intraoperative pathology exam reported the cyst with benign-appearing epithelial lining. However, the final pathology report was consistent with a 3mm conventional type thyroid papillary carcinoma with psammomatous calcifications, arising in struma ovarii. No angiolymphatic invasion or other teratomatous elements were noted.

Thyroid exam was normal, without thyroid nodules or cervical lymphadenopathy. Thyroid ultrasound was normal. TSH level was 1.63μIU/mL (normal 0.45-4.5μIU/mL). It was decided to follow up the patient with conservative monitoring without further therapeutic interventions.

Conclusion:

Being extremely rare malignancy with nonspecific clinical presentation, thyroid-type carcinoma arising in struma ovarii warrants high clinical suspicion and detailed pathologic exam of tissue samples.  In the absence of evidence-based guidelines, the proposed treatment for micropapillary carcinoma arising in struma ovarii is to be managed as its thyroid counterpart, with surgical removal followed by conservative monitoring and without TSH suppression.

 

Nothing to Disclose: SA, SJJ, MM, AP

21613 2.0000 SAT-002 A Expecting the Unexpected: A Micropapillary Thyroid-Type Carcinoma Arising in Struma Ovarii 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Umal Azmat*1, David Liebner1, Amy Joehlin-Price1, Amit Agrawal2 and Fadi Nabhan2
1Ohio State University, Columbus, OH, 2The Ohio State University, Columbus, OH

 

Background

Cytotoxic T-lymphocyte antigen-4 (CTLA-4) is a receptor that down regulates T cell signaling and proliferation. This can lead to tolerance of tumor-associated antigens.  Ipilimumab is a human monoclonal antibody directed against CTLA-4 and by blocking it this can enhance the anti-tumor effects of T cells.    However, due to this mechanism it can also cause decreased immune self-tolerance and hence immune-related adverse events such as endocrinopathies.   The most common reported endocrinopathy is hypophysitits with an incidence of 8%, followed by hypothyroidism and thyroiditis at 6%. Graves’ disease occurs more rarely without a clear rate in the literature.  

Clinical Case:

We present a 67 year old male with metastatic melanoma involving cervical lymph nodes and lungs, who had normal thyroid function tests prior to starting ipilimumab at a dose of 3 mg/kg every 3 weeks.   After 2 cycles, he developed clinical and biochemical hyperthyroidism.   The picture was consistent with Graves’ disease evident by elevated thyroid stimulation immunoglobulin and homogenous increased I-123 thyroid uptake.  Ipilimumab was held, and he was started on methimazole.  Restaging CT scans showed persistent cervical adenopathy, but resolution of his lung nodules consistent with a response to ipilimumab. Once his hyperthyroidism was controlled on methimazole, he received two additional cycles of ipilimumab.   Methimazole was continued during this time and hyperthyroidism remained controlled.   He then underwent a left radical neck dissection for residual metastatic melanoma limited to the neck along with total thyroidectomy.   The decision to perform total thyroidectomy as a definitive treatment of hyperthyroidism in this patient was influenced by the fact that he was undergoing neck surgery for melanoma; the left thyroid lobe was in close proximity to the melanoma lymph nodes, potential need for future therapy with ipilimumab, and patient preference.  Pathology revealed nodular and papillary hyperplasia of the thyroid,  consistent with Graves’ disease, with incidental papillary thyroid micro carcinoma.

Conclusion:

Our case is the first patient that we are aware of who was treated with total thyroidectomy for  Graves’ disease that he developed after starting ipilimumab.  Graves’ disease is rare, with the most common thyroid adverse events being subclinical/mild hypothyroidism and thyroiditis associated with ipilimumab.  Although ipilimumab has not been noted to worsen pre-existing thyroid disease, it is possible that our patient may have had preexisting thyroid non-clinical disease that became apparent after starting ipilimumab.  No specific guidelines exist for the management of Graves’ disease in this setting or concerning the use of ipilimumab in patients being treated with methimazole.  In our case the patient was successfully treated with methimazole, continuation of ipilimumab, and total thyroidectomy.

 

Nothing to Disclose: UA, DL, AJ, AA, FN

18471 3.0000 SAT-003 A Treatment of Ipilimumab Induced Graves ' Disease in a Patient with Metastatic Melanoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Umal Azmat*1, John Phay2 and Fadi Nabhan2
1Ohio State University, Columbus, OH, 2The Ohio State University, Columbus, OH

 

Background:

Thyroid hemiagenesis is very rare.  Some reports estimate a prevalence of 0.02%.  The prevalence is higher in women.   Left lobe hemiagenesis is found in 80% of the cases.  There is agenesis of isthmus in about 40-50% of cases.   Associated thyroid disorders are commonly seen with hemiagenesis and are usually the reason for diagnosis of hemiagenesis, with hyperthyroidism being the most common disorder.  While papillary thyroid carcinoma has been reported in the literature in these patients, it is extremely rare. 

Clinical Case:

A 32 year-old woman presented to our clinic while 3 months pregnant for evaluation of a left sided neck mass that she had felt about 10 months prior to presentation.   She noticed that the mass had grown slightly in size since then.   She denied symptoms of dysphonia, dyspnea and dysphagia. A neck ultrasound showed an absent right thyroid lobe and isthmus. The left thyroid lobe showed several nodules with the largest being 4.3 cm along with left lateral malignant appearing adenopathy (largest 3.6 cm).  Fine needle aspiration biopsy of the left lateral lymph node was done which was consistent with papillary thyroid carcinoma.    The patient had normal thyroid function tests.    She then underwent during her 20th week of pregnancy a left hemithyroidectomy, left central neck dissection and left lateral neck dissection including levels II-IV.  Pathology revealed multifocal papillary thyroid carcinoma with largest focus at 5.2 cm with extensive vascular invasion and focal extrathyroidal extension.  Five out of twelve lymph nodes were involved.   The patient continued to have detectable thyroglobulin.  After delivery of a healthy baby, ultrasound examination noted a new left level II malignant appearing lymph node. Preoperative neck CT suggested the presence of a lingual thyroid.  Future plans include reoperation to remove the node and lingual thyroid prior to radioactive iodine treatment.

Conclusion:

This is a case of thyroid hemiagenesis involving the right lobe with papillary thyroid carcinoma in the remaining left lobe.   Right thyroid hemiagenesis is found in only 20% of patients with thyroid hemiagenesis, which itself a condition that is very rare and is only prevalent at 0.02%.   This association between papillary thyroid carcinoma and right thyroid lobe hemiagenesis is extremely rare and to our knowledge this is the third reported case of a similar association.

 

Nothing to Disclose: UA, JP, FN

18476 4.0000 SAT-004 A Right Thyroid Lobe and Isthmus Agenesis Coexisting with Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Charlene Ann Vicencio Balili* and Sjoberg Ang Kho
University of Santo Tomas Hospital, Manila, Philippines

 

INTRODUCTION: Struma ovarii is a monodermal teratoma predominantly composed of mature thyroid tissue. Histologic features of thyroid cancer, papillary being the most common, are found only in 5-37% of cases. Presently, there is no consensus on the optimal treatment, surgical approach, need for total thyroidectomy, and radioactive iodine ablation of malignant struma ovarii.

CASE PRESENTATION: Our patient is a 77 year old female who presented with intermittent postmenopausal vaginal spotting. Ultrasound revealed endometrial thickening, uterine leiomyoma and incidental finding of a complex left adnexal mass measuring 14 x 9 x 11 cm. Patient then underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, infracolic omentectomy, bilateral lymph node dissection, and adhesiolysis. Histopathologic examination revealed endometrial polyps, adenomyosis with intramural leiomyoma, and papillary carcinoma in a struma ovarii, left, with tumor size of 14 cm with no lymphovascular and capsular invasion. The right ovary, bilateral fallopian tubes, uterus, omentum, and all 21 lymph nodes were negative for metastasis or tumor spread.  CA-125 was normal. She was also clinically and biochemically euthyroid. Subsequent ultrasound of the thyroid gland showed bilateral solid subcentimeter nodules on both lobes of the thyroid gland, a cyst on the midsegment of the left lobe of the thyroid measuring 3 x 2 x 2 cm and bilateral cervical and submandibular lymph nodes measuring 1.4 cm in largest dimension with no malignant features.

Our patient was diagnosed with malignant struma ovarii post-operatively with no gross extraovarian extension, regional lymph node and distant metastases.  The therapeutic dilemma at this point was to determine the need to proceed with adjuvant total thyroidectomy and radioiodine ablation. There was no absolute indication for thyroid surgery or tissue biopsy based on her ultrasound results. On review of related literature, the pooled recurrence rate was 7.5% at 25 years in patients who did not undergo thyroid surgery and radioiodine therapy. On the contrary, another review showed recurrence rate of 35% at 4 years in patients with malignant struma ovarii who did not undergo further intervention after initial pelvic surgery. The option of thyroidectomy followed by radioiodine therapy was offered to the patient but she refused. Patient was started on levothyroxine with goal of maintaining TSH at the low-normal range. Pelvic imaging will also be done periodically to document disease recurrence.

CONCLUSION: The optimal management of patients with malignant struma ovarii remains controversial. Thus, management and subsequent follow-up must be individualized based on the patient’s risk of recurrence, extent of tumor spread, preference, surgical risk, and presence of synchronous thyroid malignancy.

 

Nothing to Disclose: CAVB, SAK

20176 5.0000 SAT-005 A Elderly Female with Incidental Finding of Malignant Struma Ovarii: A Therapeutic Dilemma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Katherine Anne Cruz Banal* and Victor Ruben G Kasala
The Medical City, Pasig City, Philippines

 

Papillary thyroid carcinoma (PTC) has a relatively favorable prognosis, and distant metastases, primarily to the lungs and bone, occur infrequently. Brain metastases are seen in only 0.1 to 5% of cases, and metastases to the sellar-parasellar region have been reported in only a few individuals.

A 63-year-old Filipina with a history of PTC was admitted for debulking of a recurrent neck mass. Post-operatively, the patient developed persistent hypotension associated with a low cortisol level (9.7 ug/dL), which promptly improved upon administration of hydrocortisone. On the fifth post-operative day, the patient complained of bilateral lower extremity weakness. Diagnostic exams revealed marked hypernatremia (Na=183 mmol/L) and hypokalemia (K=1.9 mmol/L), and a low urine osmolality (216 mOsm/kg). She was noted to have increasing urine output and, upon further investigation, a history of polydipsia in the preceding months was discovered, supporting a diagnosis of diabetes insipidus. The patient was given desmopressin which lead to clinical improvement. A cranial MRI showed a sellar-suprasellar midline mass, along with other cerebral nodules suggestive of metastases. She was discharged stable on oral prednisone and desmopressin, with a plan for further metastatic work-up and external beam radiation therapy.

This case illustrates the value of a thorough evaluation of a patient with an unusually aggressive PTC. Diabetes insipidus is a common presenting feature of malignancies with metastases to the sellar-suprasellar region. However, this condition appears to be less common in PTC; only two cases of diabetes insipidus associated with sellar metastases from PTC have been previously described.

 

Nothing to Disclose: KACB, VRGK

19174 6.0000 SAT-006 A Metastatic Papillary Thyroid Carcinoma Complicated By Adrenal Insufficiency and Diabetes Insipidus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Maria Batool*1 and Amir Moheet2
1University of Minnesota Medical Center, Minneapolis, MN, 2University of Minnesota Medical Center

 

Warthin-like variant of papillary thyroid cancer- an uncommon tumor variant with good prognosis

Maria Batool MD , Amir A Moheet MD

Background:

Warthin-like variant of papillary thyroid carcinoma was first reported by Apel et al (1) in 1995 as a rare variant of papillary thyroid cancer. It is now classified by WHO as one of the known variants of papillary thyroid cancer but still remains relatively uncommon. Here we present a case of  Warthin- like variant of papillary thyroid cancer.

 Case presentation:

A 54  year old Caucasian female was seen in consultation for multiple thyroid nodules. She was initially noted to have a goiter on physical examination, which was followed by thyroid U/S and FNA of the right sided thyroid nodule which was benign. She presented to our endocrine clinic 2 year later with symptoms of fatigue and weight gain. A follow up U/S was done which showed that compared to the U/S 2 year ago, the right sided nodule had enlarged  to 3.7 cm from 3 cm and the left sided nodule had enlarged  to 1.7 cm from 1 cm. She had no history of head or neck radiation and no family history of thyroid cancer. TSH was 2.17mU/L ( 0.4-4.00 mU/L). Upon reviewing her US images, the left sided nodule ( no prior FNA) appeared to have irregular borders and micro calcifications. FNA of both the right and left nodules was done and results showed a benign right sided nodule and papillary thyroid cancer in the left sided nodule. She underwent total thyroidectomy and surgical pathology came back positive for Warthins tumor- like variant of papillary thyroid cancer. There was no extra thyroidal extension, lymph vascular invasion or lymph node involvement (pT3N0M0).

Warthin-like tumors are thought to arise from salivary gland rests , owing to their remarkable histological similarity. Majority of the initial cases described arose in glands with chronic lymphocytic thyroiditis. In a recent single institution retrospective analysis of 16 patients with this variant, none of the tumors metastasized, 11 had associated thyroiditis, 7 had lymph node metastasis and none had any recurrence or metastasis in the 37 month follow up period. Other reviews have shown similar favorable prognostic features.

 Conclusion:

Although Warthin-like tumor variant of papillary thyroid cancer is uncommon, it essentially has a prognosis very similar to classical papillary thyroid cancer. The presence of this variant does not confer an increased risk of metastasis or tumor recurrence. For this reason, it is important to differentiate it from tall cell and Hurthle call variants of PTC which may have some overlapping histological features with this variant but behave more aggressively.

References:

1) Apel RL, Asa SL, LiVolsi VA: Papillary Hürthle cell carcinoma with lymphocytic stroma. “Warthin-like tumor” of the thyroid. Am J Surg Pathol 1995, 19:810-814

 

Nothing to Disclose: MB, AM

18946 7.0000 SAT-007 A Warthin-like Variant of Papillary Thyroid Cancer- an Uncommon Tumor Variant with Good Prognosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Ashkan Zand*, Alejandro Gonzalez Campos, Eugene L Son, Susan D McCammon, Nahal Boroumand and Ligia Belalcazar
University of Texas Medical Branch, Galveston, TX

 

Background: Papillary thyroid carcinoma is the most common thyroid malignancy. About a third of patients have lymph node extension at the time of surgery, and undergo near-total thyroidectomy, lymph node dissection and postoperative 131I therapy. We describe the case of a patient with papillary thyroid carcinoma found within a recurrent neck cyst in the absence of a palpable thyroid nodule. Solitary cystic neck masses in young adults are usually benign, and branchial cleft cysts constitute the majority. Branchial cleft cysts arise from failure of the pharyngobranchial ducts to obliterate during fetal development. The case speaks to the diverse manifestation of this tumor and highlights the need to individualize therapy for primary papillary microcarcinomas.

Case: A 30-year-old Hispanic male presented with a 2 centimeter cystic mass in the right neck that had been present for 11 months and that recurred after initial drainage 5 months prior to visit. He denied cough, fever, weight change, dysphagia, or recent trauma. There was no history of radiation to the neck, and no family history of thyroid cancer.  Thyroid exam was unremarkable. The mobile and non-tender mass, 3-4 cm in diameter, was located in the right anterior neck and was not associated with skin color changes. Neck CT was initially reported to show 2 hypodense enlarged lymph nodes (right level IIb of the neck) with necrotic appearance; no thyroid nodules were identified. Fine needle aspirate was obtained, showing macrophages and cyst lining cells with atypical non-diagnostic changes. The mass was surgically excised yielding a 3.5 x 1.9. unilocular cyst with papillary excrescences and yellow viscous fluid; its wall was fibrotic with lymphocytes, cholesterol clefts and foreign body giant cell reaction. A papillary lesion with nuclear features characteristic of papillary thyroid carcinoma and positive thyroid transcription factor-1 immunostain was attached to the cyst wall. No normal thyroid tissue was found in the entire specimen. Findings were consistent with a branchial cleft cyst with metastatic papillary thyroid carcinoma. The patient underwent total thyroidectomy with removal of a single observed enlarged lymph node. A unifocal classic type papillary thyroid carcinoma, 2 mm in greatest diameter, was found in the right thyroid lobe. The left lobe and the removed lymph node were negative for malignancy. There was no evidence of perineural invasion or lymphovascular invasion. The tumor was classified as a stage T1A, N0, M1. Patient was evaluated postoperatively, and decision to proceed with 131I therapy is being discussed.

Conclusion: Papillary thyroid carcinoma may present clinically in the form of an isolated neck cyst. A sub-centimeter primary papillary thyroid carcinoma with extrathyroidal compromise limited to a branchial cyst represents an instance in which the use of radioactive iodine therapy needs to be better defined.

 

Nothing to Disclose: AZ, AG, ELS, SDM, NB, LB

22152 8.0000 SAT-008 A Recurrent Neck Cyst in a Young Adult As an Initial Manifestation of Papillary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Shruti Bhandari*1 and Asha Thomas2
1Sinai Hospital of Baltimore, Baltimore, MD, 2Sinai Hospital, Baltimore, MD

 

Introduction:

Bone lesions are uncommon in sarcoidosis and the incidence varies from 1% to 13%. Osseous sarcoidosis is most often seen in the short tubular bones of hands and feet.[1] An association between Papillary Thyroid Cancer (PTC) and sarcoidosis has been described in case reports.[2] We discuss an unusual manifestation of sarcoidosis in the setting of Papillary Thyroid Cancer.

Case:

A 68 year old woman initially presented with toxic multinodular goiter with FNA of a cold nodule showing PTC. She underwent total thyroidectomy (Stage IV - T4a, N0, M0) and histology revealed 1.2 x 1.0 x 0.4 cm locally invasive (to the cricoid) unifocal low-grade papillary thyroid cancer. She received I-131(102.5 mCi) radioactive iodine therapy after surgery. Post ablation scan showed tracer uptake in the bed of the thyroid and possibly in cervical lymph nodes. Neck ultrasound showed no abnormal mass or lymph nodes. Subsequent stimulated thyroglobulin was 10 ng/ml(1.6-59.9 ng/ml) with negative thyroglobulin antibodies and a negative I-131 whole body scan. A 10 month follow up stimulated thyroglobulin was 72 ng/ml. Given the rising thyroglobulin and negative whole body scan, she had a PET/CT which revealed multiple hypermetabolic skeletal lesions, hypermetabolic hilar and mediastinal nodes, indeterminate right pulmonary nodules. Skeletal survey showed no lytic lesions. MRI of multiple skeletal sites showed hypermetabolic lesions in the proximal right humeral diaphysis measuring 1.4 x 1.0 x 0.7 cm and 4 lesions scattered in the left femur, suspicious for metastatic disease. The patient did not have significant skeletal pain or symptoms. Subsequent CT-guided core biopsy showed non-caseating granuloma suggesting sarcoidosis but no evidence of metastatic thyroid disease. On further review of history, patient had a mediastinal biopsy in 1990 consistent with sarcoidosis but has been asymptomatic and has never required any intervention or treatment for sarcoidosis. She was subsequently empirically treated with I-131(100 mCi) radioactive iodine therapy for elevated thyroglobulin and was referred for sarcoidosis evaluation.

Discussion:

Skeletal sarcoidosis is rare and can lead to false positive appearance of metastatic disease on PET/CT [3]. In this case, there was clinical discordance between the thyroglobulin level and skeletal burden seen on PET/CT. Inflammatory conditions like sarcoidosis should be considered in the differential diagnosis during the evaluation of skeletal lesions in thyroid cancer.

 

Nothing to Disclose: SB, AT

18570 9.0000 SAT-009 A An Unusual Presentation of Skeletal Lesions in Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Louis Bondaz* and Afshan Zahedi
Women's College Hospital, Toronto, ON, Canada

 

Background:

Bone metastases occur in 1.4-7%(1) of papillary thyroid cancer (PTC) and alter quality of life and prognosis(2). A serious complication of such lesions is spinal cord compression. We report three cases that underline the various presentations of this complication.

Case #1

A 71-year-old man had thyroidectomy for a 5.3 cm moderately differentiated tall cell PTC with lymphovascular invasion (LVI) and extrathyroidal extension (ETE). Post operative thyroglobulin levels were very high. He developed lower limb weakness, paraplegia and urinary retention. A L1 compressive bone lesion was found, with multiple other bone metastases. He was treated with dexamethasone, external-beam radiation therapy (EBRT) and radioactive iodine (RAI). He remained paraplegic, showed disease progression and died a few months later.

Case #2

A 79-year-old woman seen in the emergency room for neck pain and arm paresthesia was found to have a C6 mass causing narrowing of the spinal canal. Biopsy revealed a metastasis of thyroid origin. She underwent cervical corporectomy and EBRT. Her symptoms resolved. Thyroidectomy was later performed and pathology showed a 2 cm poorly differentiated insular PTC with LVI and no ETE. She received RAI. Two years later, she remained asymptomatic. A recent thyroglobulin level rise led to the discovery of a T3 bone lesion that was treated with EBRT.

Case #3

A 59-year-old man had thyroidectomy and RAI for a 2.8 cm PTC with positive surgical margins, capsular invasion and multifocality, but no ETE or LVI. He received RAI therapy and remained disease-free for 6 years, until onset of rising thyroglobulin. Lung nodules were identified. He received a second dose of RAI. Thyroglobulin titers kept rising, without progression in lung disease. A third RAI dose was given, which precipitated exacerbation of a recent onset neck pain and development of neurological symptoms. A C2 lesion was identified. He had surgical decompression and EBRT. Symptoms cleared for three years, until new onset of leg pain and increasing thyroglobulin level led to the discovery of a L2 lesion. He received EBRT with resolution of pain.  

Conclusion:

Spinal cord compression secondary to bone metastases presents in multiple ways at different times in the evolution of PTC. Clinicians should be aware of its occurrence. Management should focus on rapid symptom control and recovery of cord integrity. Directed therapy (EBRT, surgery or other modalities) should be used as a first step before RAI therapy to improve neurological outcome. From our case series, it appears that advanced age, high risk histology and vascular invasion are common risk factors for cord compression. As it is not recommended in current guidelines, we raise the pertinence of more extensive imaging of spine in these patients to get an early diagnosis and prevent spinal cord compression symptoms due to growth of metastatic lesions or acute inflammation post RAI therapy.

 

Nothing to Disclose: LB, AZ

18660 10.0000 SAT-010 A Bone Metastases of Papillary Thyroid Cancer Causing Spinal Cord Compression: Three Cases Demonstrating Different Clinical Presentations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Bhargavi Patham*1, Keith C Bible2, Steven G Waguespack3 and Maria E Cabanillas3
1Baylor College of Medicine, Houston, TX, 2Mayo Clinic, Rochester, MN, 3The University of Texas MD Anderson Cancer Center, Houston, TX

 

Introduction: Selective BRAFi, like vemurafenib (VEM), have shown early promise in treating advanced BRAF-mutated PTC. All BRAFi—VEM, sorafenib (SOR), dabrafenib—are associated with squamous cell carcinoma of the skin, the apparent mechanism being paradoxical activation of MAPK signaling. Non-dermatologic tumors (lung, trachea, colon, pancreatic) have also been reported. We have previously reported a case of ATC-t in a pt receiving VEM. Here we report 2 more cases of ATC-t of PTC arising during VEM treatment (tx).

Case 1: A 58 y/o woman was diagnosed with a 5 cm PTC (T3NxM0 Stage I) at age 36, undergoing subtotal thyroidectomy and I131 tx. Later, locoregional recurrence was treated with radical neck dissection and external beam radiation. She subsequently required 2 neck dissections over a 5 yr timespan.  20 yrs after her initial diagnosis, she reported dysphagia; CT showed an infiltrative tumor surrounding the left common carotid artery, involving esophagus and C3/C4 vertebrae. Pathology revealed well-differentiated BRAF V600E-mutated PTC. VEM was started and best response was stable disease. Despite VEM, she required stereotactic radiation to the C-spine at multiple levels due to progression in bone. VEM was continued for 10 mos until she incurred progression in the spine leading to surgery, with pathology demonstrating squamous dedifferentiation (ATC-t) retaining a BRAF V600E mutation, suggesting lineage-identity with her previous PTC.

Case 2: An 80 y/o woman was diagnosed with a 1.7 cm invasive PTC (T4aNxM0, stage IVA) at age 67. She underwent total thyroidectomy and received I131. Post-tx scan showed uptake in the neck. She was later found to have hilar metastases on CT 2 yrs after initial diagnosis, and was treated with  I131. She was thereafter treated with 3 neck dissections over an 8 yr timespan, all revealing well differentiated PTC.  Initial tumor did not reveal any mutations; however, tumor resected 8 yrs later was found to harbor BRAF V600E mutation. 12 yrs after initial diagnosis, she developed rapidly progressive disease in the right lower lung; VEM was started. 8 mos later the right lower lung progressed. She was switched to SOR, an anti-angiogenic kinase inhibitor with lesser activity against BRAF. While on SOR she had worsening hemoptysis and biopsy of the right lower lung mass showed ATC-t. She underwent 3 cycles of palliative radiation to the lung mass, but succumbed shortly after.

Conclusion: Herein we report 2 pts who developed ATC-t of their PTC while receiving a BRAFi.  Although potentially coincidental, because BRAFi have been implicated in the development of cutaneous and noncutaneous cancers, these cases may have been causally associated with the use of this class of drug. Treating physicians should therefore be aware of the potential for development of ATC-t in this setting, and biopsy sites of rapidly progressive thyroid cancer in pts on BRAFi.

 

Disclosure: MEC: Advisory Group Member, Bayer, Inc., Principal Investigator, Roche Pharmaceuticals. Nothing to Disclose: BP, KCB, SGW

19010 11.0000 SAT-011 A Anaplastic Transformation (ATC-t) of Papillary Thyroid Cancer (PTC) after Treatment with BRAF Inhibitors (BRAFi) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Shehla N. Chaudhry*1, Mary-Anne Doyle2 and Teik Chye Ooi1
1University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada, 2University of Ottawa, Ottawa, ON, Canada

 

Background: Thyroid lymphoma accounts for less than 5% of all thyroid malignant neoplasms.1 Patients typically present with a rapidly growing neck mass, compressive symptoms and occasionally hypothyroidism. Clinical diagnosis based on fine-needle aspiration biopsy (FNAB) can be challenging as a high percentage of patient also have an associated Hashimoto’s thyroiditis. The most common subtype is diffuse large B cell lymphoma (DLBCL) which responds well to chemotherapy.      

Clinical Case: An 83-year-old female presented with a gastrointestinal (GI) bleed and symptoms of upper airway obstruction from a thyroid mass. She described a 4-month history of a rapidly growing neck mass, dysphagia and vocal hoarseness. She was started on levothyroxine 50 mcg daily 4 months prior for a new diagnosis of hypothyroidism. On examination the thyroid was greater than 100g and non-tender. It was predominantly enlarged on the right but extended bilaterally beyond the sternocleidomastoid muscles. TSH was elevated at 78 mU/L (0.35-4.94) and FT4 <5.1 pmol/L (9.0-19.1). A CT scan of the neck revealed a heterogeneous non-calcified enhancing lesion measuring 4.5 x 6.0 x 8.0 cm with left sided deviation and compression of the trachea. There was no cervical lymphadenopathy. The initial ultrasound guided FNAB was non-diagnostic. A second FNAB was consistent with Hashimoto’s thyroiditis and a third FNAB revealed atypical cells and possible lymphoma. A CT scan of the abdomen revealed irregular thickening of the gastric wall in multiple areas with loss of normal mucosal enhancement concerning for neoplasm. The gastric pathology revealed DLBCL.

Prior to the start of treatment the patient was readmitted to hospital with a recurrent GI bleed. A CT scan demonstrated a further increase to 5.0 x 4.1 x 11.2 cm of the thyroid mass in 5 weeks. Within a week of initiating chemotherapy (rituximab, cyclophosphamide, vincristine and prednisone) the patient noted a significant improvement in her compressive symptoms. One month from initiation of therapy a repeat CT scan of the neck demonstrated a 60% interval decrease in the thyroid mass (4.4 x 3.1 x 6.9 cm) consistent with a thyroid lymphoma and indicating a positive treatment response.

Clinical Lessons:  Lymphoma is an uncommon form of thyroid malignancy. This case highlights the importance of considering lymphoma in a patient with a rapidly growing thyroid mass, Hashimoto’s thyroiditis and hypothyroidism despite inconsistent FNAB results. Although FNAB is the procedure of choice for pathological diagnosis of thyroid masses, diagnosis of thyroid lymphoma is challenging and may require additional investigations such as flow cytometry to improve diagnostic accuracy. The rapid resolution of symptoms demonstrated in this patient draws attention to the need for prompt diagnosis and timely initiation of appropriate therapy to prevent compressive complications and improve outcomes.

 

Nothing to Disclose: SNC, MAD, TCO

18225 12.0000 SAT-012 A Thyroid Lymphoma: A Diagnostic Challenge 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Napatt Kanjanahattakij*1, Sasilaphat Chontong1, Wasana Kanoksil2, Chutintorn Sriphrapradang1 and Palapong Chayangsu2
1Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 2Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Introduction: Thyroid metastasis is a rare presentation of lung cancer, and can usually be diagnosed using fine-needle aspiration cytology. However, in the presence of poorly differentiated malignant cells, cytopathological features alone may not be sufficient to distinguish thyroid metastasis from primary thyroid cancer. We demonstrate a case of advanced lung cancer with thyroid metastasis misdiagnosed as poorly differentiated thyroid carcinoma.

Clinical case: A 73-year-old female presented with a neck mass she had had for 3 years, recently enlarging with compressive symptoms and weight loss. Examination showed an irregular, ill-defined border mass with a diameter of 4 cm. CT scan of the neck showed a large lobulated enhancing thyroid mass with central necrosis and multiple small calcifications which has epicenter at left and pyramidal thyroid lobes, measuring 5.6x2.9x6.8 cm, accompanied by multiple necrotic cervical and mediastinal lymphadenopathies. Thyroid function tests showed FT4 1.64 μg/dL (0.7-1.48), T3 74 ng/dL (58-159) and TSH 0.015 mIU/L (0.35-4.94). Fine-needle aspiration cytopathological report revealed sheets of neoplastic cells with enlarged hyperchromatic slightly pleomorphic nuclei, prominent nucleoli and brownish pigment inside the tumor cells. Definitive diagnosis could not be made from cytology without immunohistochemical studies, which were positive for thyroglobulin, thyroid transcription factor 1 (TTF-1) but negative for calcitonin. Further imaging studies found brain, lung and bone metastases. The diagnosis of poorly differentiated thyroid carcinoma with distant metastasis was made. The patient underwent total thyroidectomy with radical neck dissection. The pathological report showed nodular goiter and small foci of carcinoma in glandular and papillary formations in left thyroid lobe. Immunohistochemical studies were positive for cytokeratin 7, TTF-1, slightly positive for thyroglobulin and negative for cytokeratin 20. The final diagnosis was changed to poorly differentiated lung adenocarcinoma metastasis to thyroid gland. After surgery, the patient received palliative whole-brain radiation therapy. Unfortunately, she passed away seven months after diagnosis.

Conclusion: Evaluating poorly differentiated malignant neoplasm of thyroid gland is a challenge, due to overlapping cytopathological features of poorly differentiated primary thyroid cancer and thyroid metastasis.  Immunohistochemical stains such as TTF-1 help confirm either thyroid or lung origin, whereas thyroglobulin is highly specific for thyroid cancer. However, thyroglobulin can be falsely positive, possibly from contamination of colloid. Physicians should be aware of the possibility of thyroid metastasis when evaluating poorly differentiated primary thyroid carcinoma, even with suggestive immunohistochemical studies.

 

Nothing to Disclose: NK, SC, WK, CS, PC

18532 13.0000 SAT-013 A False-Positive Thyroglobulin Immunohistochemical Study on Thyroid Metastasis from Lung Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Sonia Cheng-Oviedo*1, Sylvia L. Asa2 and Shereen Z Ezzat3
1University of Alberta, Edmonton, AB, Canada, 2University Health Network, Toronto, ON, Canada, 3University Health Network, University of Toronto, Toronto, ON, Canada

 

Background. Thyroid cancer is the most frequent endocrine tumor. Its incidence has increased significantly in the past decades, mainly due to increased detection of low risk tumors. With a 98% 5-year survival rate, the caveat for its management lies in risk stratification at diagnosis and appropriate treatment of high-risk cases.  Characterization of biomarker expression and association with tumor behavior can improve risk stratification and pave the way for personalized therapeutic approaches for high-risk thyroid cancer patients.

Methods. We examined the protein expression of the 4 members of the fibroblast growth factor receptor (FGFR) family, androgen receptor (AR) and estrogen receptor (ER) α and β in 401 thyroid cancer samples using a tissue microarray platform, digital image capture and automated analysis (Cheng, 2011). Using the cBioportal for Cancer Genomics from the Computational Biology Center at Memorial Sloan-Kettering Cancer Center (Cerami, Gao et al. 2012, Gao, Aksoy et al. 2013), we analyzed information on mutations, putative copy-number alterations, mRNA expression z scores and protein/phosphoprotein levels of these genes in 502 additional thyroid cancers available in the TCGA database.

Results:  FGFR4 was the only member of the family to be more frequently expressed in males; none of the other markers, including AR and ERs, correlated with age, gender or both. ERβ, AR, FGFR2 and FGFR4 were more frequently expressed in cases characterized as follicular variant and in BRAF-WT tumors; they also were more frequently positive in patients with follicular variant tumors that had no evidence of residual or recurrent tumor at outcome. Among the group of BRAFV600E mutant tumors, expression of AR and FGFR2 correlated with no residual/recurrent tumor at outcome. FGFR1 and FGFR3 expression were more frequent in cases with residual/recurrent tumor at outcome whereas FGFR2 expression correlated with no tumor at outcome overall.  Multinomial regression analysis showed FGFR1 (p = 0.014) and FGFR3 (p = 0.028) expression as associated with the presence of tumor at outcome.

Conclusion: Our data predict that expression of FGFRs, AR and ER isoforms can be used for risk stratification and potentially for personalized treatment of high-risk thyroid cancers.

 

Nothing to Disclose: SC, SLA, SZE

21586 14.0000 SAT-014 A Fibroblast Growth Factor Receptors and Steroid Hormone Receptors As Biomarkers in Risk Stratification of Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Jian Yu Xu*1, Michelle Jackson2, Steven G Waguespack1, Camilo Jimenez1, Robert F Gagel1, Rena V. Sellin1, Elizabeth G Grubbs1 and Steven I Sherman1
1The University of Texas MD Anderson Cancer Center, Houston, TX, 2University of Texas M.D. Anderson Cancer Center, Houston, TX

 

Background: Multiple endocrine neoplasia type 2 (MEN2) is an autosomal dominant inherited syndrome caused by an activating mutation of the RET proto-oncogene. Knowledge regarding specific RET mutations is critical for better understanding of the risk of medullary thyroid cancer (MTC), the principal feature of MEN2. The K666N RET variant has been reported rarely in relatively indolent MTC cases; however, its oncogenic significance remains unknown. RET pathogenic variant, K666E, had enhanced oncogenic potential caused by polymorphism G691S in an in vitro study but there is no report of coexistence of K666N variant and polymorphism in humans.

Clinical cases: The clinical data of six subjects with a germline RET K666N variant, four index patients with MTC and two additional family members, were assessed. Case 1: 34-yr old woman with a 10 yr history of enlarged right neck lymph nodes underwent total thyroidectomy which showed unifocal MTC (0.6 cm) and metastasis to 30/39 nodes and the sternum, with doubling of the sternal metastasis size over 7 months. RET sequence analysis revealed an intronic sequence polymorphism IVS2608-24G>A in addition to the K666N variant. The patient’s 57-yr old mother was found to have a serum calcitonin of 26 pg/mL (normal <5) and a subcentimeter thyroid nodule by ultrasound. Case 2: 55-yr-old woman had MTC diagnosed at age 22, treated with surgery followed by radiotherapy. During >30 yrs of follow-up, calcitonin remained mildly elevated but without structural disease identified. The patient had no additional polymorphisms identified. Her daughter underwent prophylactic total thyroidectomy at age 20. Pathology revealed a 0.5 mm focus of C-cell hyperplasia. Case 3: 73-yr old woman had MTC treated first at age 49 and required left modified neck dissection for recurrent disease at age 64. Her sister had hyperparathyroidism; no genetic analysis was done. Case 4: 59-yr old man had a total thyroidectomy for papillary thyroid cancer (stage IVa) with an incidentally identified 1.5 mm MTC and C-cell hyperplasia. No information on RETpolymorphisms were available for cases 3, 4 or other family members.  None of the 6 subjects had evidence of a pheochromocytoma or hyperparathyroidism.

Conclusion: In this largest case series to date, the RET K666N variant appears to be associated with hereditary MTC. This study, coupled with previous studies demonstrating potent transforming activity of the K666N RETvariant, indicates that this is a pathogenic variant. It is unclear whether the IVS2608-24G>A polymorphism contributes to the aggressive clinical manifestations in case 1. The presence of hyperparathyroidism in the sibling of case 3 and in another case report suggests that this mutation can be associated with hyperparathyroidism.

 

Nothing to Disclose: JYX, MJ, SGW, CJ, RFG, RVS, EGG, SIS

19248 15.0000 SAT-015 A Medullary Thyroid Carcinoma Associated with Germline RET K666N Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Rupendra T Shrestha1 and Lynn A Burmeister*2
1University of Minnesota Medical Center, Minneapolis, MN, 2University of Minnesota, Minneapolis, MN

 

Familial medullary thyroid carcinoma (FMTC) due to missense point mutation in exon 8 of the RET gene (1597G-->T) is a rare disorder that has been described in some families. However, no case has been documented to have pituitary tumor. We present a 73 year old female of Greek Ancestry who was diagnosed with medullary carcinoma of the thyroid at age 46. She was found to have 3 cm thyroid nodule, cold on thyroid scan, with cytology positive for Medullary Carcinoma. Pathology from total thyroidectomy showed bilateral medullary thyroid carcinoma with C-cell hyperplasia. She later underwent 3 additional neck operations because of persistent hypercalcitoninemia and positive cervical lymph node involvement. At age 59 she was found to have pituitary activity on a whole body octreotide scan. Pathology obtained at transphenoidal hypophysectomy showed rare benign epithelial cells embedded within amorphous material and a minute fragment of adenohypophysis. RET testing in 2001 (at age 60 ) was negative. A cousin, 2 years younger, was later diagnosed with MCT at age 64. Serial follow up showed stable subcentimeter lung nodules, stable subcentimeter liver masses, slowly rising calcitonin, CEA and chromogranin A and slow progression/regrowth of the pituitary mass. Pituitary related labs are normal with FSH 45 IU/L (post menopausal 23-116), LH 23 IU/L (postmenopausal 16-54), prolactin 7 mcg/L (3-27), IGF1 119 (29-204 ng/ml), alpha subunit 0.75 ng/ml (< 3.56), cortisol 6.5 mcg/dl. At age 67, RET was re- tested and was found to have 1597G-->T base change, an exon 8 mutation, resulting in amino acid change Gly533Cys. This mutation, first reported in 2003, has been found in FMTC, MEN2A involving MTC and pheochromocytoma. In particular, it has been found in populations with Greek ethnicity, such as our patient. However, pituitary tumor has never been reported in association with this mutation. We now report this case of rare MEN 2a mutation 1597G T with associated pituitary tumor. It is not certain whether this represents a true association or if these are merely coincidental and futher evaluation in these families may be warranted if this is a true association.

 

Nothing to Disclose: RTS, LAB

19936 16.0000 SAT-016 A Familial Medullary Thyroid Carcinoma Due to a Rare Mutation 1597G T Associated with Pituitary Tumor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Joanna L. Spencer-Segal*1, Kelly Malloy2, Ka Kit Wong2, Thomas J Giordano2 and Craig Alan Jaffe2
1University of Michigan, Ann Arbor, NY, 2University of Michigan, Ann Arbor, MI

 

Background: Transaxillary robotic thyroid surgery is a relatively new technique that eliminates the need for a cervical scar. The role and risks of this procedure are not fully defined, and we report a previously unreported complication of this surgery.

Clinical Case: A 37 year old woman with a strong family history of thyroid cancer was seen with a chief complaint of several small lower right neck and upper chest wall masses. Eighteen months earlier the patient had undergone transaxillary robotic right thyroid lobectomy for a 4.5 cm thyroid mass at another institution. The gross description of the surgical specimen was that of an intact right thyroid lobe that consisted primarily of a well-circumscribed nodule having a well-defined capsule. Histopathology was that of a benign follicular adenoma. The patient reported rapid growth of multiple nodules over the right neck, clavicle, upper chest and axilla beginning 10 months after surgery. The nodules were tender and the patient was concerned about their cosmetic appearance. Excisional biopsy of the largest palpable lesion at an outside institution revealed benign ectopic thyroid tissue. Thyroid function tests were within normal limits. Review of the thyroid nodule and ectopic tissue histopathologies at our institution confirmed the original diagnoses. I-123 SPECT-CT imaging revealed normal uptake in the left thyroid lobe, as well as multiple deposits of iodine-avid tissue measuring up to 2 cm in the right sternocleidomastoid, periclavicular, pectoralis and axillary regions. CT scanning showed no enlarged lymph nodes. The patient underwent completion thyroidectomy via a cervical approach, including resection of an intact right thyroid lobe suggesting that the nodule was enucleated rather than excised via hemithyroidectomy, and surgical excision of all palpable thyroid deposits. Histopathology of the ectopic deposits and the completion thyroidectomy revealed benign thyroid tissue. Postoperative hypothyroid imaging showed interval growth of the smaller deposits, and she underwent radioactive iodine ablation with 50 mCi of I-131.

Conclusion: Although ectopic seeding of benign nodular thyroid tissue has been described following surgery or trauma, to the best of our knowledge, this is the first report of ectopic benign thyroid tissue following transaxillary robotic thyroid surgery. Due to the nature of the transaxillary approach, spilled thyroid tissue is dispersed along a more extensive surgical field and presents a greater challenge in terms of subsequent local control. 

 

 

Disclosure: TJG: Consultant, Interpace Diagnostics, Clinical Advisory Board member, Asuragen. Nothing to Disclose: JLS, KM, KKW, CAJ

21948 17.0000 SAT-017 A Thyroid Seeding after Transaxillary Thyroid Surgery  2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Ana E Espinosa*, Kathleen M Marshall, Diana S. Dean, M. Regina Castro, Vahab Fatourechi, Mabel M Ryder, John C Morris III and Marius N Stan
Mayo Clinic, Rochester, MN

 

Background - Thyroid nodules are present in 20-67 % of the population.  Their evaluation often requires fine needle aspiration (FNA) biopsy, depending on clinical and ultrasound (US) characteristics. When FNA is non-diagnostic (NDFNA), approximately 10-20% of all thyroid FNAs, the risk of malignancy is not well defined (2-14%).  Predictors of malignancy in nodules with non-diagnostic biopsies are unknown. 

Methods - The aim of the study was to identify the prevalence of thyroid cancer in non-diagnostic nodules (Bethesda classification 2007) and to determine the clinical and cytological factors associated with malignancy.

In this retrospective cohort study we identified patients that had an US-guided NDFNA of a thyroid nodule between January 2004 and December 2010 at Mayo Clinic Rochester. The final diagnosis of benign versus malignant disease was based on one of the following: 1) final surgical pathology following thyroidectomy; 2) a repeat FNA or core biopsy or 3) clinically if a nodule was stable in size for at least 3 years following biopsy.  Patients without follow up information available were contacted by mail to ascertain their thyroid nodule outcome. Herein we report the results of the nodules with follow up information at Mayo Clinic.

Results - We identified 714 nodules (solid or mixed) with an initial non-diagnostic FNA from 679 patients.  The rate of non-diagnostic results was 11.2% of all thyroid FNAs.  Mean age was 59 years and 71.7% were females.  There was follow up information available for 357 nodules: 120 (33.6%) had surgery, 196 (54.9%) had a repeat diagnostic biopsy and 41 (11.5%) nodules were followed and remained stable in size. Median change in size was -0.2 cm with IQR -1.2 cm to 0 cm (follow up minus baseline).  The diagnosis of thyroid cancer was confirmed on 15 nodules (13 papillary carcinomas, 1 follicular carcinoma and 1 medullary thyroid cancer). The rate of malignancy of the nodules with available follow up was 4.2%. The patients with thyroid cancer compared to those without thyroid cancer, were younger, median age 50 years compared to 59 years (p=0.04), respectively.  There was no statistically significant difference in the additional cytological features reported in the first FNA, such as presence of colloid, macrophages, blood or acellular aspirate, between the malignant and benign nodules. After a mean follow up of 5.47 years none of the 15 cancers had evidence of recurrence after initial treatment.  Twenty seven nodules had at least a second non-diagnostic FNA and none of these were found to be cancer at follow up.        

Conclusions - In this selected cohort with extensive follow-up at a tertiary care center the prevalence of thyroid cancer in non-diagnostic nodules is similar to the estimated prevalence in all thyroid nodules. However, the risk of thyroid cancer greatly declines with repeated non diagnostic results. Younger age was a predictor of malignancy in non-diagnostic nodules.

 

Nothing to Disclose: AEE, KMM, DSD, MRC, VF, MMR, JCM III, MNS

20631 18.0000 SAT-018 A Long-Term Risk of Malignancy in Thyroid Nodules with Non-Diagnostic Fine Needle Aspiration – a Retrospective Cohort Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Muhammad Mujammami*, Louise Rochon, Stephen Probst, Richard Payne and Michael Tamilia
McGill University, Montreal, QC, Canada

 

Introduction:The term collision tumor refers to the coexistence of two histologically distinct neoplastic tumors within the same mass. Collision tumor of the thyroid (also referred to as tumor-to-tumor metastasis) of a primary colorectal carcinoma to a preexisting thyroid tumor is exceedingly rare.  Preoperative diagnosis of this disorder is exceedingly difficult.

Clinical case: We describe a 67-year-old male  patient with metastatic  colorectal cancer and a  collision tumor within a pre-existing  thyroid adenomatoid nodule .  The tumor-to-tumor metastasis  was discovered in real time by serial positron emission tomography with CT scans (PET/CT).  Ultrasound (US) -guided fine needle aspiration (FNA) biopsies of the collision tumor of thyroid  were performed and analyzed  for cytologic-immunologic-and molecular tumor phenotyping. The samples revealed adenocarcinoma of the colon  (Tg-negative, TTF-1-negative, HBME-1-negative, galectin-3 negative, CEA-positive, CK-20 positive ). KRAS gene analysis of the metastatic lesion was also performed. The patient was then brought to surgery for a left hemithyroidectomy and ipsilateral central compartment node dissection. Final histology revealed metastatic colonic carcinoma, invading the benign adenomatoid nodule and infiltrating the normal thyroid parenchyma and perithyroidal soft tissue. His recovery was uneventful and the post-op chemotherapeutic regimen was guided by the KRAS analysis of the tumor.

Conclusion:Once a collision tumor of the thyroid gland is suspected on PET/CT, the lesion should be corroborated by sonography of the thyroid gland. Fine needle aspiration with combined cytological, immunocytochemical and when necessary KRAS gene analysis can lead to a timely diagnosis and a treatment plan. In the context of limited systemic malignant disease and good performance status, palliative thyroidectomy with or without combined chemotherapy may control local disease and prevent tracheal invasion.

 

Nothing to Disclose: MM, LR, SP, RP, MT

19581 19.0000 SAT-019 A Metachronous Collision Tumors of the Thyroid Gland Unveiled in Real Time By a Change in the Thyroid Nodule Phenotype 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Seher Tanrikulu*1, Gulsah Yenidunya Yalin2, Arthur Salmaslioglu3, Gulcin Yegen3, Nakiye Ozturk3 and Sema Yarman1
1Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey, 2Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey, 3Istanbul University, Istanbul Faculty of Medicine

 

Introduction: The thyroid gland is a known site for metastatic tumors from various primary sites, and microscopic metastasis are encountered in 4% to 9% of autopsy studies of the patients with malignant neoplasm. The most frequent tumors which metastasize to thyroid gland  are breast, lung, melanoma, and kidney carcinomas. We  hereby present a very unique case of colon carcinoma metastasis to the right thyroid lobe five years after colon resection.

Case: A 63-year-old female was admitted to our outpatient clinic with shortness of breath, fatigue,  and complaints of a painful mass in the  right side of neck  which was present for 15 days.  On medical history, five years ago she had diagnosis of colon adenocarcinoma, and 4 years later she was found to have lung and bone  metastases which were treated with chemotherapy and radiotherapy. On physical examination,  the lesion occupied almost the entire right  lobe of the thyroid, which was painful, enlarged and firm, resembling thyroiditis. Thyroid function tests (TSH, fT4) were within normal range, but anti-TPO level was elevated( 427mIU/L, range 0-115). ESR was normal. Ultrasonography of the neck visualized a 16,6×17.9 mm, hypoechoic solitary  mass with microcalcifications on the right lobe. Additionally an ipsilateral 10×8,7 mm lymph node which also contained microcalcifications was detected. Fine needle aspiration cytologies from the right lobe mass and pathologic lymph node  revealed adenocarcinoma metastasis from colon cancer.  Due to probability of a mechanic airway obstruction caused by the rapid development of the thyroid mass despite chemotherapy, the patient was referred to surgery. The aim of the surgery was to avoid further deterioration in the respiratory distress, which was already present because of the lung metastasis.

Conclusion: Metastases to the thyroid should be considered in the differential diagnosis of thyroid lesions with the coexistence of  any history of malignancy. Colon adenocarcinoma metastasis to the thyroid gland can also be detected several years after colectomy. In these cases, thyroid surgery may be indicated as a palliative treatment for airway obstruction.

 

Nothing to Disclose: ST, GYY, AS, GY, NO, SY

21091 20.0000 SAT-020 A Thyroid Metastasis from Colon Cancer Presenting As an Acute and Painful Mass in the Neck 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Bekir Ucan*1, Müyesser Sayki Arslan1, Mustafa Caliskan2, Güleser Saylam1, Esra Tutal1, Taner Demirci1, Erman Cakal1, Mustafa Özbek1, Mustafa Sahin3 and Tuncay Delibasi4
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Diskapi Yildirim Beyazit Teaching and Research Hospital, Ankara, Turkey, 3Ankara University School of Medicine, Ankara, Turkey, 4Hacettepe University,School of Medicine (Kastamonu)

 

Background : Papillary thyroid carcinoma is the most common malignancy of the thyroid. Thyroid carcinomas of 15 mm or less in maximal diameter or not diagnosed with classical methods are established as occult carcinomas or microcarcinomas of primary thyroid tumors. Occult papillary thyroid carcinomas can be presented cystic lymph node metastasis in large diameter as a first and sole sign at diagnosis.  This rare condition should be considered at the step of differantial diagnosis of neck masses due to the histopathologic reports of benign solitary cystic lesions of neck as metastasis of thyoid papilary carcinomas.  It needs to be done second surgery and causes time and financial losses.   

Case Report : A 32 year old woman was referred to our endocrinology outpatient clinic for evaluation of a neck mass. Ultrasound (US) of the left servical region was demonstrated a 4x7x7 mm lymphadenopathy in diameter without an echogenic hilum and right servical region was demonstrated lymp nodes with features of 6x19x22 mm and 9x10x10mm in diameter,  lacking in homogeneity, and containing several microcalcifications. The large lymp node was also included cystic components and macrocalcifications. However, the thyroid US was normal (Figure 1,2). US-guided fine-needle aspiration cytology of the cystic lymph node was performed and cytology was diagnosed as thyroid papillary carcinoma metastasis.  The patient underwent total thyroidectomy with right and central lymph node dissection. Pathological evaluation was reported as thyroid papillary carcinoma in 3 centers located in the right lobe and the maximal diameter was 4 mm and 2 metastatic lymph nodes was also found compatible with preoperative servical US.

Conclusion: Cystic lymph node metastasis of thyroid papillary carcinoma should be considered in a young patient presented with neck multiple cystic mass. When radyologic and cytopathologic evaluations resulted a suspicious condition for thyroid metastasis, thyroid gland must be investigated even if includes no lesion.

 

Nothing to Disclose: BU, MSA, MC, GS, ET, TD, EC, MÖ, MS, TD

21987 21.0000 SAT-021 A Metastatic Papillary Thyroid Carcinoma Presented with a Cystic Lymph Node: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Scheherezada Wendolyne Urban McCarthy*1, Maureen Koops1, Maria Luisa Policarpio-Nicolas2, Alfredo A. Santillan2 and Sara Ahmadi1
1University of Texas Health Science Center San Antonio, San Antonio, TX, 2University of Texas Health Science Center San Antonio

 

Background: Hyalinizing trabecular tumor (HTT) is a very rare thyroid tumor (<1%) of follicular cell origin. It was formerly called hyalinizing trabecular adenoma by Carney et al in 1987 because of the characteristic trabecular growth pattern with marked intratrabecular hyalinization.  This lesion was also designated as “paraganglioma-like adenoma of the thyroid” because of its histologic architectural resemblance to a neuroendocrine tumor.  Most importantly, the tumor cells have nuclear grooves, clear elongated nuclei, intranuclear inclusions, as well as micronucleoli, which are characteristic features of papillary carcinoma (PTC).  Hence, it is a diagnostic pitfall on fine needle aspiration (FNA) cytology.

Clinical case: A 55 y/o Iranian female presented to the Endocrinology Clinic with a 7-month history of a right neck mass. Physical examination revealed a mass in the right thyroid lobe with no palpable lymphadenopathy. There was no prior history of thyroid disease or radiation exposure; and no family history of thyroid disease or cancer. Thyroid function tests were normal. Thyroid ultrasound showed multiple thyroid nodules, with a dominant hypervascular right thyroid nodule measuring 3.8 x 2.3 x 3.1 cm. Ultrasound-guided FNA of the right thyroid nodule was suspicious for papillary thyroid carcinoma (PTC). Patient underwent total thyroidectomy and central neck dissection. Histopathological examination revealed a 2.5 cm unifocal hyalinizing trabecular tumor in a background of lymphocytic thyroiditis. The tumor was limited to thyroid parenchyma, with no lymphovascular invasion and with negative margins of resection. There was no evidence of malignancy in the thyroid gland or lymph nodes. Thus, a diagnosis of hyalinizing trabecular tumor was rendered, which is known for its benign behavior. Given the results of the surgical pathology report, further postoperative radioiodine remnant ablation therapy and suppression therapy with levothyroxine were not provided.

Conclusion: Hyalinizing trabecular tumor arising from the thyroid gland is a rare and controversial entity with sporadic cases reported in the literature. The diagnosis of HTT represents a challenge as it is frequently misdiagnosed as papillary thyroid carcinoma by FNA cytology findings. On histologic sections, they share architectural similarities with neuroendocrine tumors like paraganglioma and medullary thyroid carcinomas. A correct diagnosis is crucial to provide proper management and avoid surgical overtreatment. Given the benign clinical course of this tumor, further postoperative suppression with levothyroxine, radioiodine remnant ablation therapy and subsequent follow up with serial thyroglobulin antibody levels are no required. This case highlights the importance of a thorough clinical, cytological and histopathological examination in order to render an accurate diagnosis.

 

Nothing to Disclose: SWU, MK, MLP, AAS, SA

18408 22.0000 SAT-022 A Hyalinizing Trabecular Tumor: A Diagnostic Challenge in Pathology 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Nicole Van Rossum* and Rabia Temmar
CHUS, Sherbrooke, QC, Canada

 

A 31 year old female had a hemithyroidectomy for a nodule showing a follicular lesion with atypia of unknown significance on two fine needle aspirations.  The final pathology report described a follicular variant of a papillary cancer of 2,6 cm, with vascular invasion but no extrathyroidal extension.  After completion of her thyroidectomy, wich had a 3 mm papillary microcarcinoma in the other thyroid lobe, she was prepared for her radioiodine ablative treatment.  Her pre-treatment scan showed significant uptake in her left ovary, measuring 2,5 cm, and some thyroid bed uptake, but no other distant metastases.  A pelvic ultrasound showed a 1,7 cm solid hyperechoic left adnexial mass, with images suggesting calcifications.  After laparoscopic resection, the final pathologic report showed a mature teratoma, with multiple tissue, including hair.  No normal thyroid tissue nor papillary cancer metastasis was found in the specimen, even after meticulous examination.   She finally received her ablative radioiodine treatment.  Post-treatment scan showed only thyroid bed uptake.  Her stimulated thyroglobulin was at 18,2 mcg/L before and 4,2 mcg/L after her ovarian resection.  Her thyroglobulin antibodies were negative.  A few cases have been described with uptake in an ovarian teratoma or other tumors, some with thyroid tissue but others without any thyroid cells.  Although no thyroid tissue was found in her tumor, significant uptake in the left ovary and decrease in thyroglobulin after resection suggests that the mature teratoma was containing cells capable of transporting iodine and producing some thyroglobulin.

 

Nothing to Disclose: NV, RT

21502 23.0000 SAT-023 A Extrathyroidal Radioiodine Uptake: Where Is It Coming from? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Muhammad Mujammami*1, Ahmed Alghamdi1, Roger Tabah1 and Line Vautour2
1McGill University, Montreal, QC, Canada, 2McGill University Health Center, Montreal, QC, Canada

 

Background: Benign cystic teratomas are the most common ovarian germ cell tumors. However, they are very rarely associated with hyperandrogenism and hirsutism. On the other hand, struma ovarii is an uncommon teratoma in which thyroid tissue is the dominant component. Moreover, malignant struma ovarii is an even rarer existence.

Case presentation: Here, we describe a 59-year-old woman who presented with hirsutism and a symptomatic right pelvic mass. Laboratory evaluations, an endovaginal ultrasound and a computed tomography scan were performed leading to a diagnosis of bilateral ovarian tumors. The patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy and bilateral pelvic lymph node dissection.  The final pathological analysis revealed a malignant struma ovarii with a 6.5 cm follicular variant papillary thyroid carcinoma in the right ovary and a 1.4 cm mature cystic teratoma in left ovary. Post-ovarianectomy, the patient’s biochemical hyperandrogenism resolved. Ultrasonography of the thyroid gland showed multiple bilateral thyroid nodules, with a dominant 1.7-cm nodule in the right thyroid lobe. As the ovarian tumor was large, the patient underwent a total thyroidectomy to prepare for possible 131I therapy and to assist in her follow-up. Histology of the thyroid gland revealed bilateral micro-papillary thyroid carcinomas and a right lower parathyroid gland adenoma as an incidental finding.

Conclusion: This case emphasizes the importance of keeping a high index of suspicion for rare etiologies such as an androgen-producing neoplasm in a patient with unexplained hyperandrogenism. This case also supports the recommendation of thyroidectomy whenever 131I therapy is considered or indicated in a patient with malignant struma ovarii. As far as we know, the simultaneous presence of hyperandrogenism and mature cystic teratoma in one ovary in addition to a papillary thyroid carcinoma in the other ovary as well as the thyroid gland has not been reported in the literature yet.

 

Nothing to Disclose: MM, AA, RT, LV

20128 24.0000 SAT-024 A Hirsutism Revealing Concomitant Mature Cystic Teratoma and Papillary Thyroid Carcinoma of Both Ovary and Thyroid Gland 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Arshpreet Kaur*1, Michelle T Barati2, Xiu Yang3 and Betty Cheng Villafuerte1
1University of Louisville, Louisville, KY, 2University of Louisville, Louisville, 3University of Louisville

 

Background:  Insulin resistance is associated with increased thyroid volume and nodule prevalence, but whether the increasing incidence of thyroid cancer is linked etiologically to obesity and/or insulin resistance remains inconclusive.  Therefore, investigating the thyroid molecular milieu induced by insulin resistance is of great interest.   Insulin and insulin-like growth factor-1 (IGF-1) have been shown to act synergistically with TSH to induce thyroid cell proliferation through the phosphatidylinositol 3-kinase (PI3K) pathway.  We previously identified Insulin response element-binding protein-1 (IRE-BP1) as a transcription factor that binds and transactivates multiple insulin-responsive genes, and have shown that IRE-BP1 is a target of insulin signal transduction downstream of the PI3K-Akt pathway.  IRE-BP1 appears to be a glucoregulatory factor involved in the metabolic actions of insulin, with a significantly reduced level of expression in tissues of insulin-resistant obese and diabetic rats compared to lean rats.  Moreover, over-expression in liver lowered both fasting and post-prandial glucose levels in diabetic rats.  Our preliminary findings indicate that IRE-BP1 appears to be involved in cell differentiation.

Objective: To determine whether the expression of IRE-BP1 differs in normal thyroid, benign adenomatoid nodules, and papillary carcinoma of the thyroid.  To determine whether the action of insulin has therapeutic implication, we also investigated the expression of the Sodium/Iodide symporter (NIS) in the samples.

Methods: IHC using a COOH-terminal antibody to IRE-BP1 and a commercial antibody to NIS  were used to detect the expression of IRE-BP1 and  NIS in surgically resected tissues.

Results:  IRE-BP 1 was detected in the cytoplasm of follicular cells in normal thyroid (n=5) but not in the cells of adenomatoid nodules (n=3) or papillary carcinoma (n=5). Furthermore, we found high NIS expression in the membrane of the follicular cells in normal thyroid tissue, but not in the papillary carcinoma.

Conclusion:  IRE-BP1 was detected by immunohistochemistry in normal  thyrocytes  but neither in the cells of benign nor malignant tumors of the thyroid. Whether the reduced expression of a factor that mediates the metabolic actions of insulin provides a link between insulin resistance and the pathogenesis of thyroid nodular disease or thyroid cancer, and its relationship to NIS expression remains to be investigated.

 

Nothing to Disclose: AK, MTB, XY, BCV

21524 25.0000 SAT-025 A Insulin Response Element Binding Protein-1 Expression in Thyroid: A Link Between Insulin Resistance and Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Edwin Antonio Wandurraga*1, Daniela Niño2, Alvaro Herrera3 and Maria Emma Garcia4
1Universidad Autonoma de Bucaramanga (UNAB), Bucaramanga, Colombia, 2Universidad Autonoma de Bucaramanga UNAB, Bucaramanga, Colombia, 3Fundación Oftalmológica de Santander Clinica Carlos Ardila Lulle FOSCAL, Bucaramanga, Colombia, 4Fundación Oftalmológica de Santander Clínica Carlos Ardila Lulle FOSCAL, Bucaramanga, Colombia

 

Less than 2% of all malignant thyroid tumors are lymphomas (1). These tumors prevail in women, with a ratio of 4:1(2) and the mean age at diagnosis is from 65 to 75 years (3). Non-Hodgkin type is the most common (3). Hashimoto’s thyroiditis is the unique risk factor that appears to be associated with thyroid lymphoma presenting in more than half of cases. Among patients with Hashimoto´s Disease the risk of having thyroid lymphoma is 60 times higher than a healthy subject (3).

A 59 years old man noticed a neck bulk with progressive growing six months ago. The ultrasonography displayed goiter and a heterogeneous solid nodule (2,7x1,5 cms) located in the left thyroid lobe. Lymph nodes enlargement were not found. His TSH and FT4 levels were normal and the anti-peroxide and anti-thyroglobulin antibodies were positive. Fine needle biopsy described increased cellularity with lymphoid appearance but Hashimoto’s thyroiditis was not concluded. It was reported as Bethesda III, so, left hemithyroidectomy was performed. Pathology found out a poorly differentiated small round cell tumor, most probably based on hematolymphoid origin (plasma cell neoplasm Vs lymphoma with extended plasmocytic differentiation). Immunohistochemistry described a thyroid extranodal lymphoid mature cell tumor compatible with plasmocytic differentiated B cell lymphoma (MALT). CBC and LDH were normal. Neck, thorax and abdomen computed tomography did not show evidence of metastatic nodes or organomegaly. Residual thyroidectomy will be performed in a few weeks.

Primary thyroid lymphoma, although a rare condition, must be considered as a differential diagnosis in a patient with a lymphoid lesion of the thyroid, specially with a medical history of Hashimoto´s Disease.

 

Nothing to Disclose: EAW, DN, AH, MEG

21618 26.0000 SAT-026 A Extranodal Marginal Zone B Cell Lymphoma of the Thyroid: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Maria Chiara Zatelli*1, Martina Rossi2, Matilde Bozzoli2, Mattia Buratto1, Stefania Bruni3, Paola Franceschetti4, Federico Tagliati5, Roberta Rossi2, Giorgio Trasforini4 and Ettore Ciro degli Uberti6
1University of Ferrara, Ferrara, Italy, 2Section of Endocrinology, University of Ferrara, Ferrara, Italy, 3S.Anna Hospital, Cona, Italy, 4University Hospital of Ferrara, Cona, Italy, 5Section of University of Ferrara, Ferrara, Italy, 6Section of Endocrinology, University of Ferrara, Italy

 

Papillary thyroid carcinoma (PTC) is the most frequent thyroid cancer, that can be characterized in 45-80% of cases by the BRAFV600E somatic mutation. While the diagnostic value of this mutation is now consolidated, its prognostic value is still a matter of debate. We therefore aimed at analyzing the influence of BRAFV600E mutation on PTC patients outcome in a case-control prospective study. To this purpose, 156 PTC patients were enrolled: 80 PTCs displaying the BRAFV600E mutation (BRAF +), 40 without (N0) and 40 with lymphnode metastases (N1); 76 PTCs not displaying the BRAFV600E mutation (BRAF-), 40 without (N0) and 36 with lymphnode metastases (N1). The BRAF + patients matched the BRAF- patients concerning sex age, PTC histotype, disease stage by TNM. We found that the incidence of microPTC was the same in BRAF+ and BRAF- patients. BRAF + patients displayed lymphnode metastases independently of tumor diameter, while BRAF- patients were more frequently multifocal. We also observed that the choice to submit the patient to radio-iodine ablation (RAI) was influenced by the presence of lymphnode metastases and not by the presence of the BRAFV600E mutation. Among patients undergoing RAI, the presence of the BRAFV600E mutation and/or lymphnode metastases did not influence the outcome at 6-8 months, 2 and 5 years in terms of locoregional recurrence (as assessed by neck ultrasound), and of biochemical persistence (assessed as basal thyroglobulin levels in the absence of anti-thyroglobulin antibodies). Among patients not undergoing RAI, no difference was found in terms of locoregional recurrence and of biochemical persistence. Therefore, the outcome of PTC patients (with or without RAI) does not depend on BRAF status. However, BRAF+ patients with morphological or biochemical persistence had a more aggressive disease, that needed a more intensive treatment. 

These data indicate that the BRAFV600E mutation may not have a prognostic value in terms of morphological and biochemical persistence of PTC, but may identify more aggressive cases.

 

Nothing to Disclose: MCZ, MR, MB, MB, SB, PF, FT, RR, GT, ECD

20765 27.0000 SAT-027 A Lack of Prognostic Value for BRAFV600E in a Cohort of 156 Patients: A Prospective Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 001-027 6029 1:00:00 PM Thyroid Cancer Poster


Jesse D Pasternak*1, Natalie Seiser1, Insoo Suh1, Wen Shen2, Quan-Yang Duh3 and Jessica E Gosnell4
1UCSF, 2UCSF, San Francisco, CA, 3University of California, San Francisco, San Francisco, CA, 4University of California, San Francisco

 

Background:

Intrathyroidal metastasis as the sole site of recurrent metastatic melanoma is exceedingly rare.  To our knowledge, we present the first reported case of a rapidly growing compressive substernal toxic multinodular goiter secondary to metastatic melanoma.

Clinical Case:

A 58 year old male with a longstanding toxic multinodular goiter on Methimazole (5mg daily) presented to a tertiary care endocrine surgery unit with dyspnea.  A  surveillance PET/CT for a previous subungal melanoma identified a massively enlarged substernal thyroid gland causing substantial constriction of the trachea and spanning the mediastinum to below the aortic arch.  Four years previously, he had an amputation of the right great toe for a 16mm deep melanoma and one right groin lymph node found to be positive for metastatic disease.  Clinically more recently, the patient had progressive dyspnea and had not been able to lie flat for 3 months.  Pemberton’s sign was positive.  Total thyroidectomy with sternotomy was performed which relieved his compressive symptoms.  Post-operative thyroid hormone replacement rendered the patient euthyroid. Pathologic analysis of the specimen revealed multifocal metastatic melanoma with negative margins.

Conclusion:

To our knowledge, this is the first reported case of rapid growth and tracheal compression of a toxic multinodular goiter secondary to metastatic melanoma.  This multifocal metastatic melanoma was the only site of recurrence 4 years after initial treatment and after resection of the thyroid mass, the patient continues to be disease-free by PET/CT surveillance.

 

Nothing to Disclose: JDP, NS, IS, WS, QYD, JEG

21622 1.0000 SAT-046 A Rapid Compressive Substernal Growth of a Toxic Multinodular Goiter Due to Multicentric Metastatic Melanoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Charles F Sharp Jr.*
Keck School of Medicine of USC, Pasadena

 

Granulomatous Thyroiditis in a Chernobyl Survivor presenting as acute cervical radiculiti

Background:DeQuervain (granulomatous) thyroiditis presents in a notoriously protean manner and is therefore often misdiagnosed. This patient presented with acute cervical pain and paresthesias and had nodular thyroid disease upon imaging of the cervical spine.

Case Presentation: A 35 year old woman awoke with acute onset of severe diffuse neck pain accompanied by tingling paresthesias of both arms and hands. Neurological evaluation was urgently obtained. Aside from tenseness, tenderness and spasm of the paracervical and sternocleidomastoid musculature, neurological examination was unremarkable, with normal DTR’s, motor strength and sensory testing. MRI scanning of the cervical spine revealed an osteophyte at C7 without foraminal stenosis; however, the thyroid gland was incidentally noted to contain two discrete nodules, one in the right mid lobe and another in the thyroid isthmus. The patient became aware of a palpable lesion in the right thyroid lobe. On examination a firm, nontender nodular excrescence could be felt on swallowing. Thyroid ultrasound confirmed the presence of 2 masses in the background of a heterogeneous signal throughout the rest of the gland; there were no suspicious calcifications. CBC was normal, TSH 1.72, FT3 3.6 pg/ml (3.5-4.2), and FT4 3.4 ng/dl (0.9-2.0). No sedimentation rate was initially performed. Anti-thyroid peroxidase Ab returned below the limit of significance; Anti-thyroglobulin Ab titer was also negative; however, serum Thyroglobulin was 68.8 pg/ml (1.3-31.8) Fine needle aspiration biopsy of the two mass lesions was performed under ultrasonic guidance. Both the right dominant mass lesion and the midline isthmus lesion displayed identical pathological features that included abundant multinucleated giant cell histiocytes, epitheliod histiocytes, abundant colloid in a background of mixed inflammatory cells and debris consistent with granulomatous thyroiditis. No malignant cells were seen. The patient was a native of Kiev, Ukraine which is 60 km downwind of Chernobyl. At age 8, the patient was present during the nuclear disaster of 1986. The incidence of benign and malignant thyroid lesions in residents of Northern Ukraine is well-documented. Most cases of radiation-exposure thyroiditis have been classified as Hashimoto’s thyroiditis, but sporadic case reports of DeQuervain Thyroiditis have appeared. By the time of endocrinological evaluation, the patient’s symptoms had resolved. Follow-up thyroid ultrasound, palpation, and laboratory studies 1 year later were normal. 

Conclusion:  This case illustrates the protean manifestations of subacute thyroiditis and should remind physicians to enquire about previous radiation exposure when this condition is suspected

 

Nothing to Disclose: CFS Jr.

21629 2.0000 SAT-047 A Granulomatous Thyroiditis in a Chernobyl Survivor Presenting As Acute Cervical Radiculitis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Pakhadi H. Buddhadev* and Mihir Sanjay Shah
St Francis Hospital, Evanston, IL

 

Introduction:

Hyperthyroidism can cause symptoms like palpitations, sweating, tremors, diarrhea and weight loss. We present an unusual case of a patient with toxic multi nodular goiter with shortness of breath who was found to have chylothorax.

Case:

35 year old male was presented to the Emergency room for progressive shortness of breath for last 3 months. A family member also noticed a lump in the neck 4 weeks ago. Other symptoms included weight loss of 20 lbs despite a good appetite, occasional palpitations, increased sweating and cold intolerance. Patient had no past medical history; surgical history was significant for appendectomy at age 9 years. He was a current every day smoker, with frequent alcohol binges on weekends, no history of drug abuse. Family history was significant for a thyroid disease in mother and maternal aunt.

On exam, his pulse was 98/min, respiration 20/min, temperature 98.3F, BP 132/86 mm Hg. He appeared anxious, thin, had significant proptosis and exophthalmos. The neck appeared swollen, with a thyroid gland that was enlarged and non-tender. Multiple nodules were felt, with the largest nodule measuring about 5X4 cm on right side. The isthmus was palpable. He had fine tremor in his hands. Reflexes were brisk. Rest of the exam was normal.

Lab tests showed WBC of 6.8(4-11k/mm3), Hb of 11.2(13-16g/dl), normal platelets, MCV and MCH. TSH was <0.005, FT4 was 7.89(0.8 - 1.8 ng/L), FT3 was 6.2(2.3- 4.2 pg/mL), Thyroid Stimulating Antibody (TSI) was 375(n <130%), FT4 index was 6(1.0 -4.3 U), TPO antibody was normal.

Chest X-ray showed a right side pleural effusion and a diagnostic tap was performed. The pleural fluid appeared thick and milky white. Cell count showed WBC of 30/mm3, RBC 178/mm3 with 69%lymphocytes, 26% neutrophils and 5% monocytes. Fluid triglyceride was 182 mg/dl.

Patient was started on Methimazole 10 mg thrice daily. He was symptomatically better on day 3 of admission and discharged with outpatient follow up.

Discussion:

Chylothorax occurs when there is an obstruction in or disruption of the thyroid duct. Chylous fluid is rich in triglycerides and chylomicrons. The diagnosis of chylothorax requires that the pleural fluid triglyceride level is >110 mg/dl and if equivocal, then lipoprotein analysis for chylomicrons should be done. Chylothorax is a rare but known complication of a thyroid goiter. Large goiters can compress the thoracic duct and brachiocephalic vessels which can cause chylothorax. Other complications include dysphagia, respiratory distress and respiratory failure, recurrent phrenic nerve palsy and Horner’s syndrome. It can also cause thyrocervical steal syndrome and cerebral hypoperfusion. Our patient had a therapeutic pleural tap and was started on antithyroid therapy. He had outpatient follow up for hyperthyroidism. Recurrence of chylothorax would warrant thyroidectomy in such cases.

 

Nothing to Disclose: PHB, MSS

18455 3.0000 SAT-048 A An Unusual Case of Chylothorax 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Amanda J Brahm*1, Lisa-Ann Fraser2, Matthew R Ban3, Adam D McIntyre3, Jian Wang3 and Robert Alexander Hegele3
1Western University, London, ON, 2Division of Endocrinology and Metabolism, Department of Medicine, Western University, London, Canada, 3Robarts Research Institute, London, ON, Canada

 

Background: Thyroid hormone resistance syndrome (RTH) and normophosphatemic familial tumoral calcinosis (NFTC) are individually very rare conditions, with only ˜3000 cases and 6 kindreds, reported respectively.  They have never before been reported together in a single individual.   RTH is an autosomal dominant condition, primarily caused by mutations in thyroid hormone receptor beta (THRB) gene, leading to defective sensing and response to thyroid hormone.  It is characterized by clinical euthyroidism, elevated free thyroid hormone levels and a non-suppressed TSH.  NFTC is an autosomal recessive condition characterized by the development of nodules containing precipitated calcium salts, generally arising in areas that have experienced recent inflammation. 

Clinical Case: A 67-year old Caucasian female presented with an 8 year history of progressive calcific tumors affecting the small joints of her hands, bilateral shoulders, left elbow, and right axilla, with the largest on her right hip (40cm).  CT and plain film imaging, biopsy samples, and physical exam findings supported the diagnosis of tumoral calcinosis.   Alkaline phosphatase levels and c-telopeptide levels were significantly elevated, and a bone scan revealed increased activity in the areas of tumoral calcinosis.  Rheumatological screen, CRP, ESR, PTH, creatinine, calcium and, notably, phosphate were normal; indicating a normophosphatemic tumoral calcinosis, with no identifiable secondary cause.  A trial of zolendronic acid, 5mg, was given intravenously.   This normalized alkaline phosphatase and c-telopeptide levels, and halted progression of her tumoral calcinosis.  Targeted DNA sequencing of candidate genes, namely GALNT3, FGF23, Klotho and SAMD9 revealed no potentially pathogenic mutations. 

The patient had also been recently diagnosed with idiopathic severe CHF (EF <20%), which remained unexplained despite cardiac biopsy and MRI.  TSH was normal with elevated free hormone levels; she was clinically euthyroid, other than a 30 year history of tachycardia and palpitations.  Targeted DNA sequencing found a known RTH-associated mutation (E460K) in THRB.

Clinical Lessons: This is the first case of NFTC reported outside the Jewish-Yemenite population and also the first reported without a mutation in SAMD9, the only gene linked to NFTC thus far.  This suggests that there may be other molecular factors, perhaps detectable by exome sequencing, involved in the etiology of NFTC.

We also suggest a possibly effective therapy for this poorly understood condition in the form of bisphosphonate infusion which was correlated with improvement in bone turnover markers and a halt in disease progression.

This case also generates the hypothesis that THRB mutations could lead to the development of tachycardia-induced cardiomyopathy via thyrotoxic effects on cardiac tissue, which predominately expresses functional THR-alpha receptors. 

 

Nothing to Disclose: AJB, LAF, MRB, ADM, JW, RAH

18879 4.0000 SAT-049 A Lightning Strikes Twice: Thyroid Hormone Resistance Beta and Normophosphatemic Familial Tumoral Calcinosis in a Single Subject 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Jennifer Concepcion*1, Maja Marinkovic2 and Jane Jin-Hee Kim3
1Rady Children's Hospital, San Diego, CA, USA/University of California San Diego, La Jolla, CA, USA, 2University of California San Diego, La Jolla, CA, USA/Rady Children's Hospital, USA, San Diego, CA, 3Rady Children's Hospital, San Diego, CA, USA/University of California San Diego, La Jolla, CA, USA, La Jolla, CA

 

Title:

Rapid Recovery of ANC after Using GCSF to Treat Dose-Related Methimazole-Induced Agranulocytosis in a Pediatric Graves’ Disease Patient

Background: 

Graves’ disease is the leading cause of hyperthyroidism in children and adolescents with an annual incidence of 0.9 per 100,000 children less than 15 years old.  Treatment choices include anti-thyroid drugs, radioactive iodine and thyroidectomy.  The initial mainstay treatment in pediatrics, in addition to propranolol, is methimazole (MMI).  Agranulocytosis is a rare but well-described complication of methimazole; it is dose-related and more likely to occur during the first three to four months of treatment.  There are several reports that describe the use of recombinant human granulocyte-colony stimulating factor (GCSF) for the treatment of MMI-induced agranulocytosis, with an average recovery time of 7-10 days.

Clinical Case:

A 10-year old Filipino girl presented with typical symptoms of hyperthyroidism.  Her laboratory results were consistent with Graves’ disease showing suppressed TSH <0.03 uIU/mL (0.35-5.00 uIU/mL), total T3 229 ng/dL (94-213 ng/dL), thyroid-stimulating immunoglobulin 258% of basal activity (<140%), thyroid peroxidase antibody >1000 IU/mL (<9 IU/mL), and thyroglobulin antibody 7 IU/mL (≤1 IU/mL).  Baseline CBC and LFTs were normal.  Methimazole 10 mg daily was started, but as her follow up tests revealed no demonstrable improvement, the MMI dose was increased to 20 mg daily.  Subsequently at 2.5 weeks into treatment, MMI was increased to 30 mg daily (~0.9 mg/kg/day) due to continued symptoms of hyperthyroidism.  Five days later, she developed fever, palpitations and marked tachycardia, without other infectious symptoms.  Her ANC at that time was 0 (neutrophil antibodies were negative).  Propanolol was started, and MMI discontinued.  She was given GCSF and had rapid hematologic recovery after two doses of GCSF: after dose #1, ANC was 34; after dose #2, ANC was 2844.  She received a definitive treatment of her hyperthyroidism with I-131, and has been asymptomatic since. 

Conclusion:

This case supports two conclusions: 1) There is a real risk of MMI-induced agranulocytosis with high-dose methimazole, and 2) There is a benefit seen from the use of GCSF to treat methimazole-induced agranulocytosis.

 

Nothing to Disclose: JC, MM, JJHK

19106 5.0000 SAT-050 A Rapid Recovery of ANC after Using GCSF to Treat Dose-Related Methimazole-Induced Agranulocytosis in a Pediatric Graves' Disease Patient 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Shipra Bansal*1, Aditi Khokhar2, Salvador Castells3 and Sheila Perez-Colon1
1SUNY Downstate Medical Center and Kings County Hospital Center, Brooklyn, NY, 2SUNY upstate medical university, Syracuse, NY, 3Kings County Hospital Center, Brooklyn, NY

 

Background: In children with Grave's disease (GD), TSI are shown to have 100% sensitivity and 92% specificity (1). Compared to an automated third generation binding assay (TBII), TSI are also more sensitive in the diagnosis of untreated pediatric GD (1,2). Continued remission is seen in patients who normalize their TSI/TBII levels while on thioanamides(3,4).  123I uptake helps in distinguishing mild Graves' disease from other causes of hyperthyroidism(5). We report an unusual course of GD in an adolescent male who initially had positive TSI and went into remission. He relapsed within 2 weeks of discontinuation of treatment, while TSI and TBII continue to be negative. GD relapse was confirmed with 123I uptake.

Clinical Case: 16 year old African American male presented with history, exam, laboratory [(TSH= 0.005 mIU/mL, Free thyroxine (FT4) =6.09 ng/dL, total Tri-iodothyronine (TT3) =524.3 ng/dL, TSI =318 (Reference Range <140% Baseline)] and ultrasound findings consistent with GD. He was promptly started on treatment and dosage subsequently titrated to maintain euthyroidism. After ~4 months of diagnosis, he was on low dose methimazole (5mg OD), he presented with excessive weight gain and hypertension without any other symptoms/signs of GD. At this time, Thyroid function tests were consistent with hypothyroidism (TSH= 9.6 mIU/mL, FT4=0.6 ng/dL, TT3=45.18 ng/dL, TSI=94). Methimazole was discontinued and patient was assessed, most likely, to be in apparent remission. However, within 2 weeks, TFT were again suggestive of GD, although no symptoms except elevated BP(TSH 0.017 mIU/mL, FT4=2.32 ng/dL and TT3=199.1 ng/dL) . Interestingly, TSI and TBII were both negative [TSI =75, TBII=12.2 %(<16)]. 123I uptake showed an increased, diffuse homogenous uptake (66%), confirming the diagnosis of GD. He was restarted on methimazole and continues to do stable.

Conclusion: We report this case due to his unusual course of GD such that the patient had GD relapse within 2 weeks of discontinuing treatment after sero-reversion of TSI.

 

Nothing to Disclose: SB, AK, SC, SP

19845 6.0000 SAT-051 A Sero-Reversion of Thyroid Stimulating Immunoglobulins in an Adolescent Male with Grave's Disease Relapse 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Sana Hasan* and Cyrus V Desouza
University of Nebraska Medical Center, Omaha, NE

 

Introduction:

The significance of thyroid hormone in cardiac physiology has been studied extensively. Altered thyroid hormone metabolism (low Free T3 index/Reverse T3) has been reported previously in chronic heart failure. Thus far, only a few studies reported the use of Liothyronine (T3) following cardiac arrest and cardiopulmonary bypass in patients without underlying thyroid dysfunction. To our knowledge, this is the first case report of short term T3 administration in cardiogenic shock induced by hypothyroidism.

Case:

 A 23 year-old, previously healthy female, presented in cardiogenic shock.  Her symptoms prior to presentation consisted of cough, weight gain, orthopnea and lower extremity edema which progressed over a period of 2 months. Physical examination was notable for BP 84/56, delayed relaxation phase of DTR, JVD to mid neck, few bibasilar crackles and 1+ pitting edema in lower extremity. Thyroid function tests were consistent with profound hypothyroidism [Free T4-0.2 ng/dL (0.6-1.5), TSH-23.54 mcIU/mL (0.4-5.0), TPO Ab-1340 IU/mL (0-9), Free T4 by dialysis < 0.2 ng/dL (0.8-2.7) ]. Cardiac catheterization was negative for ischemia, revealed an EF of 5% and bi-ventricular failure suggestive of dilated cardiomyopathy.  She was started on inotropic support (Dopamine and Dobutamine) and levothyroxine 100 mcg IV daily. In addition, she underwent Intra-Aortic Balloon placement. Microbiology and viral serologies were negative and cardiac biopsy did not reveal any histologic evidence of myocarditis, granulomatous or infiltrative cardiomyopathy. Further evaluation for hematologic and rheumatologic disorders was negative. She remained critically ill, subsequently requiring RVAD and LVAD implantation. After 2 weeks of hospitalization, she continued to deteriorate despite the normalization of Free T4 (1.0). She did not qualify for cardiac transplantation due to Obesity.  At this point, she was started on T3 infusion (3mcg/hour for 6 hrs) for cardiac resuscitation. During the next couple days, patient became hemodynamically stable and was weaned off inotropes as left ventricular (LV) function continued to improve (EF 15-20%). After 7 weeks of hospitalization, patient was stable for discharge.  Furthermore, a year and a half later, she remains clinically euthyroid and has had significant recovery of her native LV function and her EF is nearly normal.

Conclusion:

We found that acute, short term T3 administration did improve cardiovascular function and resulted in decreased inotropic requirement. This case highlights the significance of the role of T3 in acute cardiac setting. Large, multicenter prospective studies are needed to determine the protocol and dosage of T3 analogs.

 

Nothing to Disclose: SH, CVD

20033 7.0000 SAT-052 A The Role of Liothyronine in Acute Cardiac Setting 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Aditi Gupta*1, Mahmoud Alsayed2, Boby G Theckedath3 and Janice L Gilden4
1Chicago Medical School, North Chicago, IL, 2Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A. Lovell Federal Health Care Center, North Chicago, IL, 3Rosalind Franklin University of Medicine and Science/ Chicago Medical School, and Captain James A. Lovell Federal Health Care Center, North Chicago, IL, 4Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL

 

Background:

Syncope is a transient loss of consciousness due to global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery1. Neural mechanisms and cardiovascular disease are the most important causes of syncope. We describe an unusual case of syncope associated with coronary vasospasm secondary to hyperthyroidism.

 

Clinical Case:

A 56 year male, with past medical history of hypertension, presented with 2 episodes of syncope 1 week apart, which were preceded by retrosternal chest pain and palpitations without seizure-like symptoms. Medications included Amlodipine 10mg daily for Hypertension. He did not smoke, drink alcohol, or use illicit drugs, but drank 2 cups of coffee daily. There was no family history of thyroid disease.  On exam, there was no goitre, but he had fine bilateral hand tremors.  He was admitted to ICU for further evaluation where he went into sinus bradycardia and then received atropine. Normal sinus rhythm was restored.  Later, he had a cardiac arrest, for which he received CPR .  The EKG showed ST elevation in leads I and aVL. He was successfully resuscitated and his EKG returned to baseline. Cardiac evaluation showed Troponin I levels <0.04 ng/ml (0.04-0.10), CKMB levels <0.5 ng/ml (0-3.6), and a normal Transthoracic Echocardiogram. Coronary angiogram did not show evidence of obstructive stenosis of the coronary arteries. Thyroid function was evaluated, which showed a low TSH of <0.01 uIU/ml (0.34-4.82), elevated free T4 of 3.80 ng/dl (0.59-1.61), TSI – 99% (0%-140%), TBII – 29% (0%-15.9%).   The patient was subsequently diagnosed with Graves' disease. Methimazole (MMI) 20mg twice daily was initiated.  After 6 months of MMI, he became hypothyroid with a high TSH of 39.28 uIU/ml (0.358-3.74), and low Free T4 of 0.05ng/dl (0.76-1.46). MMI was discontinued and he became euthyroid. After 16 months of being euthyroid, he developed heat intolerance with a weight loss of 8 lbs. Subsequent labs showed recurrence of hyperthyroidism with  TSH <0.005 L uIU/mL (0.358-3.74), Free T4 -3.45 (0.76-1.46), FreeT3 - 15.10 pg/mL (2.18-3.98). The patient was restarted back with MMI 10mg daily therapy. TSH and FT4 then re-normalized. There were no further episodes of syncope or angina after starting MMI.

Conclusion:

Our case emphasizes the importance of evaluating thyroid function and recognizing the possibility of hyperthyroidism as a diagnosis in patients who present with syncope or variant angina.

 

Nothing to Disclose: AG, MA, BGT, JLG

20710 8.0000 SAT-053 A Graves' Disease Presenting As Syncope Associated with Coronary Vasospasm 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Aditi Gupta*1 and Janice L Gilden2
1Chicago Medical School, North Chicago, IL, 2Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL

 

Background:

Hypercalcemia is an important clinical manifestations of hyperthyroidism but in clinical practice, this finding is rarely recognized. Pathogenesis of hypercalcemia in thyrotoxicosis is multifactorial. It has been attributed mostly to increased osteoclast activity. Nonetheless, other humoral mechanisms, like a hyperadrenergic state could also contribute to hypercalcemia. Increased sensitivity of beta-adrenergic receptors to catecholamines by thyroid hormone is another possible mechanism. The mainstay of treatment of hypercalcemia is to control hyperthyroidism. Treatment options like RAI can sometimes exacerbate hyperthyroidism and hypercalcemia. We present a case of hyperthyroidism accompanied by various other metabolic abnormalities and challenges.

Clinical case:

A 53 year old Puerto Rican female presented with palpitations, tremors and weight loss of 7-10 pounds of 2 months duration.  She also reported increased hair loss, irritable mood and secondary amenorrhea for previous 1 year.  She noticed swelling of her neck causing mild swallowing problems. She claimed an improvement in her symptoms after taking Thyrosoothe on her own accord. Past history includes breast cancer 8 years ago with lumpectomy and refusal of chemotherapy and radiation therapy. She is a former smoker but denied any alcohol or illicit drug use.  Her daughter was recently diagnosed with hyperthyroidism. Initial lab tests revealed suppressed TSH of <0.005 uIU/ml (0.270 – 4.200) with elevated FT4 -5.23ng/dl (0.70-2.00), FT3-20.84pg/ml (1.70-4.20), Total T3 >557.0pg/ml (80.0-200.0), and TSI – 311% (0%-140%). She was diagnosed with hyperthyroidism secondary to Graves' disease. Anti-thyroid medications were considered but could not be started due to patient’s elevated Liver function tests (AST-412 IU/L, ALT-69 IU/L, Alkaline Phosphatase – 154 IU/L, T. bilirubin - 0.3mg/dl). Her labs also showed Calcium levels of 11mg/dl(8.6-10.3) and decreased PTH of 7.4(12.4-76.8). Considering past history of breast cancer, malignancy was considered. Further evaluation for elevated Liver Function Tests included imaging studies which were negative for any suspicious lesions. Liver biopsy and mammogram were normal. Patient’s elevated LFTs and hypercalcemia was attributed to hyperthyroidism. Methimazole(MMI) 5mg TID and beta blockers were started due to refusal of other therapies. After 1 month of treatment, calcium, LFTs and TFT normalized. 

Conclusion:

In summary, this case highlights the fact that hyperthyroidism can cause hypercalcemia and elevated liver enzymes which resolve after treatment for this disorder.

 

Nothing to Disclose: AG, JLG

20732 9.0000 SAT-054 A Hypercalcemia in a Patient with Hyperthyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Francis Bryant Go Chua*
The Medical City, Metro Manila, Philippines

 

The co existence of graves disease and SLE is rare. In one cohort of SLE patients the prevalence of graves disease was ~0.1%. (other studies, put range) Here we present what we believe to be the first reported case of SLE presenting as Evans Syndrome in a patient with Graves Disease in the Philippines. Our patient is 28 year old female with hyperthyroidism for 5 years, was admitted at our institution due to fever, arthralgias, discoid rash and jaundice of two weeks duration. On admission: BP 130/90 CR 100s sinus. Sclerae were icteric and thyroid diffusely enlarged but non-tender. Left knee was inflammed with a small effusion. Workup showed the following: TSH 0 uIU/mL (NV 0.35-4.94) fT3 4.19 pg/mL (NV 1.71 - 3.71 pg/mL) fT4 4.9 ng/dL (NV 0.7 - 1.48 ng/dL). Hgb 44 WBC 14 N L Plt 88,000 TB 13.48 B1 10.24 B2 3.29. Direct and indirect Coombs test was positive. Although hemolysis can occur among patients with autoimmune thyroid disease, a search for a systemic cause was carried out given the clinical course and PE findings. G6PD levels, Anti-DS DNA 24.9 IU/mL (Negative <10; equivocal 10-15; positive >15) Anti-smith 21.9 IU/mL, ANA (EIA: Negative <0.7 IU/mL; Equivocal 0.7-1; Positive >1). TSH-Receptor Antibody 4.03 U/mL Anti-TPO 1800 U/mL, C3 (). She was diagnosed with SLE with Evan's Syndrome and Graves Disease. She was given methimazole, and propranolol for the hyperthyroidism and pulse methylprednisolone IV x 3 days for the hemolyic anemia. Hyperthyroid symptoms, rashes and arthritis improved rapidly. However, the anemia and thrombocytopenia improved slowly so she was transfused with packed RBC and platelet concentrate and was started on mycophenolate mofetil . She was discharged improved after 10 days in the hospital. Autoimmune diseases may have an overlap of clinical manifestations and laboratory abnormalities. Some of these findings may or may not indicate co-occurrence of 2 disease states. With Graves Disease and SLE, there are several hypothesis regarding the relationship: co-occurrence, predisposition, increased risk or benefit of anti-thyroid drug therapy to incidence of SLE. There is still much that we still need to know regarding the relationship of the two diseases.

 

Nothing to Disclose: FBGC

20813 10.0000 SAT-055 A SLE Presenting As Evan's Syndrome in a Young Female with Grave's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Fatima Alkaabi*1, Maha Alketbi1 and Muhammad Houri2
1Al Ain Hospital , United Arab Emirates, 2Al Ain Hospital, Al Ain, United Arab Emirates

 

Introduction

Hyperthyroidism is a common diagnosis, it is association with pulmonary hypertension (PAH) has been reported in literature but not will know to clinicians.

Case presentation:

47 yrs old female, presented with shortens of breath, lower limb edema, atypical chest pain, palpitation and anxiety. Work up reveled   Hyperthyroidism, heart failure, pulmonary hypertension m Graves’ disease. 

Echo showed:   EF:55 %  ,severe  TR  , PSAP: 45 mmHg , mild pulmonary hypertension  ,  Dilated right heart .  BNP: 1.591 ng /L , LFT impairment  

   Work up for pulmonary hypertension didn’t reveal any lung pathology

    Chest CT and  V/Q scanning  were  negative  and   Doppler US both legs  was negative

Work up for hyperthyroidism:  TSH: < 0.01  mili IU/L   T4:  63.4  pnmol/L     Thyroid receptor AB: Positive .US thyroid showed: Multinodular goiter

Pt started on treatment for her heart failure and hyperthyroidism. Follow up Echo showed great improvement .TR reported as mild TR. RVSP 40  mmHg ,which is normal  . Her TSH: 0.01 and T: 19.2  pnmol/L   improved , patient  after that referred  for radioiodine treatment .

 

Discussion:

 Both hyperthyroidism and hypothyroidism can produce cardiovascular changes. In almost all cases these cardiovascular changes are reversible when the underlying thyroid disorder is recognized and treated.

PAH has been associated with thyroid dysfunction, but primarily with hyperthyroidism. The exact mechanism is not well established. However, this combination has a good prognosis, because the increase in the pulmonary artery pressure is usually mild and reverses after the treatment of the thyroid disease.

Our patient presented with heart failure symptoms and found to have hyperthyroidism & PHA. PHA improved dramatically after the treatment of hyperthyroidism.

Since there is a high prevalence of thyroid disease in patients with PAH, thyroid function tests should be considered in the work up for PAH.

 

Nothing to Disclose: FA, MA, MH

20868 11.0000 SAT-056 A Association Between Hyperthyroidism and Pulmonary Hypertension 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Claire Bradman* and Francesco S. Celi
Virginia Commonwealth University, Richmond, VA

 

Background: Postsurgical hypothyroidism is a common condition successfully treated with levothyroxine (LT4) replacement therapy. Allergic reactions to thyroid hormone replacement therapy are rare and poorly described events, often associated with underlying autoimmunity. Here we present a case of urticarial reaction associated with LT4 tablets resolved by switching the therapy to a LT4 soft capsule formulation.

Clinical Case: A 39 year old female underwent total thyroidectomy for toxic multinodular goiter with compression symptoms in 2010. The patient was prescribed initially  75mcg  and then 100 mcg (1.0 mcg/Kg) LT4 tablet daily regimen by her primary care physician in the absence of other medications or dietary supplements. Approximately six months later the patient  developed urticarial lesions on her hands, arms, legs soles of her feet, chest and abdomen. No episode of angioedema was observed. No member of the household experienced similar episodes. Diet, soap and laundry detergent were all changed at different intervals, with no relief from the symptoms. The patient was treated with oral steroids with little to no improvement. The patient noted that whenever she skipped her LT4 tablet the symptoms improved dramatically, relapsing with the assumption of LT4 tablets. The patient thus attributed her symptoms to LT4 allergy and became non-compliant with the regimen. A referral was thus made to our Division to provide alternative therapeutic options. When the patient came to our observation she was profoundly hypothyroid (TSH  46.8 mcIU/ml) and had gained 15.3 Kg since the thyroidectomy. Diffuse areas of urticarial lesions were observed on the forearms and chest. An initial attempt to substitute the LT4 with two 50 mcg formulation (white tablets, no dye) did not result in any appreciable change in her symptoms. While considering parenteral weekly administration, a last attempt of providing oral therapy was performed using a 100 mcg soft gel capsule LT4formulation. Since then the urticarial rash has disappeared, and the patient has noted a net improvement in her overall symptomatology, along with a 2 Kg weight loss.  The dosage is currently being titrated, and the latest TSH was 18.2 mcIU/ml).

Conclusions: Allergy to LT4 is a rare and controversial finding, often associated with an underlying autoimmune diathesis. This case provides strong circumstantial evidence of the existence of this condition, and of the potential therapeutic use of LT4 soft gel capsule formulation as a viable therapeutic alternative in patients who cannot tolerate conventional tablet formulations.

 

Disclosure: FSC: Advisory Group Member, Akrimax pharmaceutical, Ad Hoc Consultant, Jansen Pharmaceuticals. Nothing to Disclose: CB

21160 12.0000 SAT-060 A Resolution of Urticarial Reaction to Levothyroxine Tablet Formulation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Sangeeta Chandramahanti*1 and Ayman Hussein Elkadry2
1Marshall University - Joan C Edwards School of medicine, Huntington, WV, 2Marshall University School of Medicine

 

Graves’ Ophthalmopathy in Hashimoto’s Thyroiditis.
Sangeeta Chandramahanti MD, Ayman Elkadry MD
Department of Medicine, Section of Endocrinology, Joan C. Edwards School of
Medicine, Huntington, WV.

Introduction:
Graves’ Ophthalmopathy, also called as Thyroid associated ophthalmopathy is an
autoimmune disorder of the extraocular muscles and surrounding orbital tissue and fat
and is generally associated with Graves’ disease, but rarely accompanies to euthyroid
or hypothyroid chronic autoimmune thyroiditis.

Presentation:
66 y/o Caucasian female initially presented to walk in clinic for evaluation of diplopia,
which is worse on upward gaze. She denied headache, dizziness, focal numbness or
weakness. She was evaluated for vasculitis which was negative. She subsequently had
an MRI which was notable for bilateral proptosis, left greater than right with increased
fullness of inferior rectus muscle and increased intraconal fat bilaterally, suggestive of
Graves’ ophthalmopathy. She was then referred to endocrinology for evaluation of
ophthalmopathy. She has history of hypothyroidism and has been on levothyroxine
replacement for about twenty five years. She denies any history of hyperthyroidism. She
never had history of head and neck radiation. Her family history was significant for
Graves’ disease in her maternal aunt. She had no history of goiter. She denied any
compressive symptoms. She was clinically and biochemically euthyroid on
levothyroxine replacement. She had high titres of thyroid antibodies including thyroid
peroxidase, thyroglobulin and thyrotropin receptor antibodies. She was then referred to
ophthalmologist and has been placed on high doses of corticosteroids. She eventually
had significant improvement in her symptoms.

Conclusion:
Thyroid associated Ophthalmopathy can sometimes occur in Hashimoto’s thyroiditis,
and awareness of this atypical form is important, as glucocorticoid treatment results in
significant improvement of this disorder.

 

Nothing to Disclose: SC, AHE

21403 13.0000 SAT-061 A Graves' Ophthalmopathy in Hashimoto's Thyroiditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Krista Lucille Gonzales*1, Kaveh Ehsanipoor1 and Edwin Gunn2
1Memorial University Medical Center, Savannah, GA, 2Mercer University School of Medicine Savannah Campus

 

Introduction: Isolated TSH resistance to thyroid hormone is a very rare disorder and only a few cases have been previously reported. 1 in 40,000 live births have a THRβ mutation. This disorder can be due to mutations of THRα, THRβ, though non α/β have also been reported. THRβ mediates the negative feedback for T3 on TSH, and its mutation can result in isolated TSH resistance to thyroid hormone which is associated with elevated T4, T3, and normal or elevated TSH. This mutation yields variable symptoms.

Case: An 18 year old Caucasian female was brought to endocrinology clinic by her father for suspected hyperthyroidism. The patient’s father was previously treated with RAI for hyperthyroidism and was referred to us for difficult to control post ablative hypothyroidism. He required supraphysiologic doses of LT4 to maintain a normal TSH. He reported witnessing his daughter suffer from symptoms similar to those he had prior to his own ablation. On initial presentation she had palpitations, weight loss, heat intolerance, and tremors. Physical exam revealed diffuse goiter with no exopthalmous. Labs revealed FT4 of 2.08 ng/dl (nl 0.89-1.8 ng/dl), total T3 of 212 ng/dl (nl 80-210 ng/dL), and TSH of 2.97 IU/mL (nl 0.35-5.5 IU/mL).A heightened index of suspicion for isolated TSH resistance to thyroid hormone was made, the following work up was performed: Alpha subunit was 0.3ng/mL (nl<1.0 ng/mL), Anti TPO Ab <2.0 IU/mL (nl<2.0 IU/mL), Antithyroglobulin Ab <2.0 IU/mL (nl<2.0 IU/mL), thyroid I123 uptake was 37.5% at 4 hours and 55.5% at 24 hours and scan revealed diffuse goiter. MRI of the brain was performed which was inconclusive. TRH stimulation test revealed a peak TSH response of 30.6µU/mL at 30 minutes. TSH response to TRH with pretreatment of T3 and HCG therapy was absent. THRβ analysis showed R320C mutation. Ultimately, due to patient’s noncompliance to antithyroid drug therapy for a greater than 15 year period, and persistent symptomatic hyperthyroidism, RAI ablation was performed with 10.5 mCi of I131. She became hypothyroid and is currently on replacement therapy with 50mcg of Levothyroxine, being monitored by FT4 only.

Conclusion: This case highlights a clinical presentation of a rare syndrome with widely variable symptoms based on thyroid hormone receptor β gene mutation. The ability to recognize this particular clinical syndrome has important clinical implications on treatment. In our patient unveiling the cause of her hyperthyroid state largely altered monitoring of her RAI induced hypothyroidism by monitoring FT4 levels rather than TSH. Although our patient presented in a hyperthyroid state, others have been described in literature with euthyroid goiter.

 

Disclosure: KE: Clinician, Santarus, Clinician, Takeda, Clinician, Astra Zeneca. Nothing to Disclose: KLG, EG

21509 14.0000 SAT-062 A Isolated TSH Resistance to Thyroid Hormone: a Rare Syndrome with Common and Highly Variable Symptoms 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Silvia Gra Menendez and Sabina Casula*
University of Miami, Miller School of Medicine, Miami, FL

 

BACKGROUND:

Hyperthyroidism is usually characterized by a suppressed TSH with concomitant elevation of serum levels of thyroxine (T4) and/or triiodothyronine (T3). The diagnosis of hyperthyroidism can be challenging when thyroid function tests are within the normal limit. We report a case of a patient, biochemically euthyroid, with clinical symptoms suggestive of hyperthyroidism that was found to have a toxic multinodular goiter.

SUMMARY:

A 40 years old woman was referred to us for a second opinion due to thyroid nodules. She was previously advised to undergo fine needle aspiration of her dominant nodule. Patient was complaining of palpitations, heat intolerance, SOB on exertion, anxiety and difficulty gaining weight. Her symptoms started a few months earlier. On physical examination her HR was 95. The thyroid was palpable, soft, slightly enlarged with some nodularity on the left side. Serum TSH, FT4, FT3 levels were normal at 0.58 (0.45-4.50 mIU/L), 1.02 (0.82- 1.77 ng/dL) and 3.05 (1.57-4.71 pg/mL) respectively. Her thyroid function tests were repeated several times in the last few months and they were always within a normal range. Antithyroid peroxidase antibodies were negative. Thyroid ultrasonography revealed multinodular goiter. Thyroid uptake and scan showed bilateral hot nodules with an uptake at 50.5% after 24 hours. The patient was treated with 24.8 mCi of radioactive iodine that resulted in complete resolution of her symptoms.

CONCLUSIONS:

It may be challenging to diagnose patients with toxic multinodular goiter in the presence of normal thyroid function tests. Current guidelines recommend a thyroid scan only if TSH is below the lower limit of normal. Nevertheless a recent retrospective study suggests that a normal TSH does not completely rule out the presence of autonomous functioning thyroid nodules and that such a diagnosis could be missed in up to 70% of patients.

The clinical presentation of our patient, in the setting of normal thyroid function tests, and her clinical response to treatment suggest that there is a wide range of individual sensitivity to minimal changes in thyroid homeostasis. It also underlines the importance of the clinical history in the medical decision-making process for the assessment of thyroid nodules. Most significantly, this case emphasizes the importance of clinical symptoms in guiding the physician when deciding to pursue treatment, even in the presence of a normal TSH.

 

Nothing to Disclose: SG, SC

21542 15.0000 SAT-063 A Toxic Multinodular Goiter in Patient Biochemically Euthyroid 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Karla Cristina Borromeo Detoya*1, Denise Sese2, Rabih Nayfe3 and Daniela Ciltea4
1Akron General Medical Center, Cleveland Clinic Affiliate, Akron, OH, 2Akron General Medical Center, Akron, OH, 3Akron General Medical Center; Northeast Ohio Medical University, Akron, OH, 4Akron General Partners Physician Group, Akron, OH

 

Background

Hashimoto’s encephalopathy (HE) is a rare and underdiagnosed clinical entity presenting as a neuropsychiatric syndrome, associated with serologic evidence of antithyroid antibodies after other causes of encephalopathy are excluded. The main hallmark of HE is its good prognosis and responsiveness to steroids and immunosupressants. We report a case of a patient with elevated thyroid antibodies presenting with aphasia, confusion and lethargy, dramatically improved after steroid therapy.

Clinical Case

A 58 year old Caucasian male, with history of stroke and left sided residuals, diabetes mellitus type 2, uncontrolled hypertension and hypothyroidism, presented with sudden expressive aphasia, confusion and lethargy. No acute infarct or intracranial pathology was seen on CT of the head, brain MRI and MRA of the head and neck. EEG revealed diffuse slowing of background frequencies, with no epileptiform discharges. The patient also had leukocytosis at 16.7 thou/cmm (nl: 4.4-9.7), with no organisms growing on blood cultures. No source of infection was identified on physical examination, pancultures, echocardiogram, chest xrays and CT of the abdomen and pelvis. The patient was then empirically treated with vancomycin and ceftriaxone, with no improvement in mental status on antibiotic therapy. He was on maximal antiplatelet therapy with aspirin 325 mg and clopidogrel 75 mg daily. On further evaluation, the patient had low TSH at 0.332 uIU/mL (nl: 0.358-3.740 uIU/mL) and low T4 at 4.6 ug/dL (nl:4.7-13.3ug/dL), while thyroid peroxidase antibody level and thyroglobulin antibody were elevated at 2442.9 IU/ml (nl: 0-60 IU/mL) and 3770.3 IU/mL (nl:0-60 IU/mL), respectively. Pending lumbar puncture, a diagnosis of Hashimoto’s encephalopathy was made. The patient was started on IV methylprednisolone, with abrupt improvement in mental status. He was discharged on oral prednisone. 

Conclusion

HE is a fluctuating encephalopathy that should be suspected when diagnostic investigation fails to yield a neurologic cause. Diagnostic criteria include impaired consciousness, absence of evidence of infection in the CSF, and a high serum concentration or titer of antithyroid antibodies. The pathogenesis of HE is believed to be due to multi-focal or generalized vasogenic cerebral edema. Its great response to steroids further supports this hypothesis.This patient presented with acute onset aphasia, progressive confusion and lethargy, with EEG and brain MRI findings consistent with HE. High dose corticosteroids are the first line of treatment for HE, with eventual tapering to avoid side effects.

There should be a high index of suspicion for HE in patients with autoimmune thyroid disease presenting with acutely relapsing neurologic symptoms.This is especially important as prognosis is good with early steroid intervention, significantly decreasing morbidity and mortality.

 

Nothing to Disclose: KCBD, DS, RN, DC

21730 16.0000 SAT-064 A Autoimmune Thyroid Disease Associated with Steroid-Responsive Encephalopathy: A Case Report on    Hashimoto′s Encephalopathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Karla Cristina Borromeo Detoya*1, Tarandeep Kaur2, Anis Rehman1 and Daniela Ciltea3
1Akron General Medical Center, Cleveland Clinic Affiliate, Akron, OH, 2Akron General Medical Center, Akron, OH, 3Akron General Partners Physician Group, Akron, OH

 

Background

Hashimoto’s Encephalopathy, an autoimmune, rare and underdiagnosed encephalitis, is steroid responsive and associated with autoimmune thyroiditis. It has a relapsing and remitting course, characterized by stroke like symptoms, seizures and slow progressive cognitive decline. Diagnosis is based on elevated levels of anti-thyroid peroxidase antibodies and exclusion of infectious, toxic and metabolic etiologies. We report a case of relapsing Hashimoto’s encephalopathy while being maintained on oral steroids.

Clinical Case

A 46 year old Caucasian male with history of seizure disorder, hypothyroidism and Hashimoto’s encephalopathy presented with postural instability, confusion, jerky movements of extremities and episodes of psychosis described as auditory hallucination. He was maintained on tapered oral prednisone for Hashimoto’s encephalopathy, initially diagnosed through CSF examination and elevated TPO antibodies.  He was also on levothyroxine for hypothyroidism and levetiracetam for seizure prevention. On work-up, the patient was noted to have elevated thyroid peroxidase antibody at 945 IU/ml (0-60 IU/ml) and thyroglobulin antibody at 758 IU/ml (0-60 IU/ml), normal TSH at 3.7 uIU/ml (0.358-3.740 uIU/ml), free T3 at 2.8 pg/ml (2.2-4.0 pg/ml), free T4 at 0.86 ng/dl (0.76-1.46 ng/dl). CSF analysis did not show any signs of infection, based on cultures and cell count. The CSF protein was elevated at 132 mg/dL (15-45 mg/dL), without pleocytosis. The 24 hour screen for heavy metals was negative. Neuroendocrine syndrome and other paraneoplastic encephalopathies were ruled out, with normal levels of urine catecholamines, metanephrines and 5-HIAA, serum immunoglobulin A and glutamyl decarboxylase, voltage-gated calcium, anti-Ma1, anti-Ma2, VGKC and neuronal nuclear antibodies. No epileptiform discharges were recorded on electroencephalogram. CT of the head and MRI of the brain did not show any acute intracranial abnormalities. Given the clinical and laboratory findings, the patient was treated for relapsing Hashimoto’s encephalopathy with intravenous immunoglobulin (IVIG) for five days. There was notable improvement in the mental status, gait and balance during the course of treatment.  The patient was discharged with improved neurological function.

Conclusion

Hashimoto’s Encephalopathy typically responds to steroids. Many patients remain disease free after discontinuation of steroids but patients who relapse require either additional course, continuous treatment with steroids or immunomodulatory therapy to maintain remission. Although steroid therapy provides a favorable long- term prognosis, immunoglobulin therapy should be considered as an alternative treatment approach or rescue therapy, as it has been reported to be effective, safe and convenient in established cases of steroid-resistant Hashimoto’s encephalopathy.

 

Nothing to Disclose: KCBD, TK, AR, DC

21869 17.0000 SAT-065 A A Case of Steroid-Resistant and IVIG-Responsive Relapsing Hashimoto′ s Encephalopathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Abdulrahman Alwagdani* and Joshua Lewis Cohen
The George Washington University School of Medicine and Health Sciences, Washington, DC

 

Introduction: Silent thyroiditis (ST) is an uncommon cause of thyrotoxicosis. Recurrences of post-partum thyroiditis may occur with subsequent pregnancies. However, recurrent ST is otherwise uncommon in the US.  We report a patient with recurrent episodes of ST not associated with pregnancy.

Case report: A 59 years old woman presented in 2005 with a one week history of palpitations and was found to be in an atrial flutter.  She denied other symptoms of thyrotoxicosis. She denied neck pain and had no recent illnesses or prodromal symptoms. She reported a previous episode of transient hyperthyroidism in 2001. Thyroid scan done then reportedly showed normal radioiodine uptake (RAIU); she was diagnosed with resolving Graves disease vs. thyroiditis.  Her past history was also noteworthy for recurrent episodes of atrial fibrillation as a result of valvular heart disease and cardiac surgery. She had not received amiodarone.  Laboratory studies included: free T4 2.4 ng/dl (nl 0.8 – 1.8), free T3 7.7 pg/ml (nl 2.8 – 5.3), TSH <0.08 μIU/ml (nl 0.4 – 4.7), TSI 97% (nl <125), anti-TPO Ab 51 IU/ml (nl <35), Westergren ESR 4 mm/h (nl <30). Thyroid scan revealed uniformly decreased tracer distribution.  The 24 hour RAIU was 2.2% (nl 10 - 30).  The thyrotoxicosis was presumed due to ST.  The free T4 returned to normal in 6 weeks and the TSH was normal at 3 months. In 2008 she presented with recurrence of rapid atrial fibrillation as well as heat sensitivity and nervousness.  The free T4 was 1.8 ng/dl and the TSH was 0.09 μIU/ml. The RAIU was low.  She was treated with a β-blocker. The TSH remained suppressed for 3 months and then returned to normal.  Thyrotoxicosis recurred in 2014 when a suppressed TSH was found during a routine office visit.  She had noted rapid heart rate and increased palpitations recently.  EKG revealed sinus tachycardia. The free T4 was 2.4 ng/dl initially and returned to normal within one month.  TSH receptor antibodies were not detectable.

Discussion: The distinctive features of this case were the multiple episodes of thyrotoxicosis, 4 times in 10 years, causing exacerbation of supraventricular arrhythmia. Cases of recurrent ST have been reported in Japan, but less commonly in the US. One study noted that male gender, higher peak freeT4, earlier onset, absence of goiter and presence of autoantibody were possible risk markers for recurrence.  Thyrotoxicosis with low RAIU has been associated with lithium, amiodarone, interferon and etanercept. SLE, idiopathic thrombocytopenic purpura, rubella and seasonal allergies have also been reported to be associated with ST. None of these medications or diseases was present in our patient.

ST is generally self-limited and can be treated symptomatically with β-blockade.  However, if the patient with recurrent ST is at high risk for morbidities from the recurrences of thyrotoxicosis, then, following resolution of the suppressed RAIU phase, radioiodine ablation could be considered.

 

Nothing to Disclose: AA, JLC

21891 18.0000 SAT-066 A Recurrent Episodes of Silent Thyroiditis Presenting As Atrial Tachyarrythmias 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 046-066 6030 1:00:00 PM Thyroid Clinical II Poster


Yanyun Chen*1, Miguel Toledo2, Jeffrey Witkin1, Vanessa Barth1, Charlie Changzhi Hu1, Karen Rash1, Michael A Ansonoff3, John E Pintar3, Celia Lafuente2, Alma Jimenez2, Ana Benito2, Maria Martinez-Grau2 and Michael Statnick4
1Eli Lilly & Co, Indianapolis, IN, 2Eli Lilly & Co, Spain, 3University of Medicine and Dentistry of New Jersey, Piscataway, NJ, 4Eli Lilly and Company, Indianapolis, IN

 

Nociceptin is a 17 amino acid peptide highly homologous to the opioid peptide dynorphin and is the endogenous ligand of the ORL1/NOP receptor.  Nociceptin has been shown to modulate a variety of physiological functions in rodents including feeding behavior.  LY2940094 is a potent, selective, orally bioavailable ORL1/NOP receptor antagonist that exhibited CNS activity.  When examined in a receptor occupancy assay, LY2940094 occupied ORL1/NOP receptors in the hypothalamus with an ED80 of 0.3 mg/kg and with a T1/2 of 12 hours following oral administration of 1 mg/kg doseFasting/re-feeding assay performed in wild type and ORL1/NOP receptor knockout mice oral administration of LY2940094 demonstrated statistically significant reductions in fasting-induced hyperphagia in wild type mice but not in knockout mice.  Moreover, under vehicle conditions fasting-induced feeding was reduced in ORL1/NOP KO mice compared to wild type littermate control mice.  The findings demonstrate that LY2940094 induces specific ORL1-mediated activity when examined in vivoIn dietary induced obese (DIO) mice, a statistically significant decrease in caloric intake of the high energy diet was observed for at least 24 hours after a single oral administration of LY2940094In lean chow fed rats, LY2940094 inhibited the over consumption of a highly palatable diet (another model of hyperphagia), reducing the caloric intake to control chow levels.  LY2940094 was administered to 30% caloric restricted DIO rats for 4 days.   LY2940094 inhibited hyperphgia on day 4 when the caloric restriction was lifted.  These findings suggest that a nociceptin receptor antagonist may be useful in treating disorders of appetitive behavior such as binge eating disorder and obesity.

 

Disclosure: YC: Employee, Eli Lilly & Company. MT: Employee, Eli Lilly & Company. JW: Employee, Eli Lilly & Company. VB: Employee, Eli Lilly & Company. CCH: Employee, Eli Lilly & Company. KR: Employee, Eli Lilly & Company. JEP: Collaborator, Eli Lilly & Company. CL: Employee, Eli Lilly & Company. AJ: Employee, Eli Lilly & Company. AB: Employee, Eli Lilly & Company. MM: Employee, Eli Lilly & Company. MS: Employee, Eli Lilly & Company. Nothing to Disclose: MAA

19816 2.0000 SAT-543 A A Selective Nociceptin Receptor Antagonist Inhibits Feeding Behavior in Rodent Models of Hyperphagia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Paula Beatriz Marangon*1, Jose Antunes-Rodrigues2 and Lucila Elias2
1Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil, 2School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil

 

Developmental programming can be defined as a stimulus during a critical period, when the central nervous system is still plastic and may show susceptibility to environmental effects. Ghrelin is a peptide expressed in the embryo since the morula stage and is able to increase cell proliferation in cells derived from different brain regions. Using the manipulation of litter size as a model of nutritional programming we investigated in male Wistar rats plasma ghrelin levels and the hypothalamic responsiveness to ghrelin. After birth, litters were adjusted as follows: small (3 pups-SL), normal (10 pups-NL) and large (16 pups-LL). Weaning was on day 21 and animals were kept in cages with standard rat chow. All experiments were performed on day 60 after birth. Blood samples were collected at 8 am for basal plasma ghrelin determination by Elisa. Animals were treated with ghrelin (40 µg/Kg ip) or saline at 5 pm. Food intake and body weight gain were evaluated 24h later. In another set, 60min after treatment, rats were decapitated and the mediobasal hypothalamus was dissected for p-AMPK and UCP-2 Western blotting analysis. Another set of animals was kept for 24h in individual metabolic cages, in order to record basal metabolic status. Thereafter, they were treated with either ghrelin or saline and data were obtained for another 24h. Finally, rats were decapitated and the brown adipose tissue (BAT) was collected. Data were analyzed using two-way ANOVA, followed by Tukey post-hoc test, or Student’s paired t-test. Difference was set at p<0.05 (n=8-12). SL animals had higher, whereas LL had lower body weight gain during lactation, compared to NL (NL:41.9±4.5g; SL:59.1±12.6g; LL:32.3±3.6g). SL rats maintained the increased body weight in adulthood, while LL rats reached the same body weight as NL ones at 60th day (NL:408.5±8.5g; SL:476.5±14.9g; LL:381.8±8.4g). Plasma acylated ghrelin (pg/mL) was increased in SL and LL rats, compared to NL (NL:27.4±1.3; SL: 39.2±3.1; LL: 36.7±2.4). After ghrelin treatment, NL rats increased food intake (11.1±0.4 g/100g bw vs 9.6±0.4), and body weight gain (12.3±1.1g vs 5.1±2.1), compared to saline treatment. Ghrelin was unable to modify food intake in SL rats (9.7±0.4 g/100g bw vs 9.7±0.4), but there was a reduction in body weight gain (2.6±2.0g vs 9.5±1.9), compared to the respective vehicle group. Ghrelin did not change food intake nor body weight gain in LL rats. In the hypothalamus, ghrelin increased p-AMPK only in NL rats and UCP-2 in NL and SL rats. There was an increase in VO2, VCO2, RER and indirect calorimetry after ghrelin treatment only in SL animals, compared to the basal condition. Also, there was an increase in UCP-1 in the BAT only in SL rats 24h after ghrelin treatment. Our data suggest that changes in food availability during neonatal life modify hypothalamic ghrelin responsiveness in obese animals in adulthood, with long lasting effects on energy homeostasis.

 

Nothing to Disclose: PBM, JA, LE

19180 3.0000 SAT-544 A Ghrelin Increases Energy Expenditure in Obese Rats Programmed By Changes in Perinatal Nutrition 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Hiroyuki Shimizu*
International University of Health and Welfare, Nasushiobara, Japan

 

Nesfatin/nucleobindin-2 (Nesf/NUCB2), a precursor molecule of nesfatin-1, an anorexigenic protein in the hypothalamus, is ubiquitously expressed in peripheral tissues including liver and pancreas. However, an exact role of nesf/NUCB2 has not been established in the periphery.  The present study was undertaken to investigate a possible role of nesf/NUCB2 in the metabolism of peripheral tissues by using nesf/NUCB2-transgenic mouse. Nesf/NUCB2 transgenic (Tg) mouse were generated, and changes of body weight and daily food intake of male nesf/NUCB2-Tg mouse and their nontransgenic litter mates fed normal chow diet or 45% high fat containing diet (HFD) (started from 6 week of age) were observed by age of 20 week. Overexpression of nesf/NUCB2 was confirmed in the liver, pancreas, skeletal muscle, and brain of nesf/NUCB2-Tg mice. By 20 weeks of age, there was no difference in daily food intake, and body weight between nesf/NUCB2-Tg mice and their nontransgenic litter mates fed normal chow diet. On the sacrifice at age of 20 week, no difference was found in blood glucose and serum insulin levels between both genotypes fed normal chow diet. Serum nesfatin-1 levels, measured by ELISA, were not different between nesf/NUCB2-Tg mice and their nontransgenic litter mates at age of 20 week, although nesf/NUCB2 expression was 18.7 times higher in skeletal muscle of nesf/NUCB2-Tg mouse than their nontransgenic litter mates. In contrast, nesf/NUCB2-Tg mice fed HFD showed a significantly higher increase in body weight than their nontransgenic litter mates fed HFD, although no difference was found in daily food intake between both genotypes. On the sacrifice at age of 20 week, a significant increase of the weight of liver, subcutaneous fat, and brown adipose tissue was observed in nesf/NUCB2-Tg mice fed HFD. Although blood glucose levels of nesf/NUCB2-Tg mice fed HFD were at the same levels as their nontransgenic litter mates fed HFD, nesf/NUCB2-Tg mice fed HFD showed a significantly higher insulin levels than their nontransgenic litter mates fed HFD, indicating the development of insulin resistance in those Tg mice.  Histological study demonstrated a selective, and marked fat deposition in the hepatocytes around hepatic central veins. The data obtained herein indicated that nesf/NUCB2 is involved in the development of insulin resistance and fat deposition in the liver, independently of the modulation of energy intake.

 

Nothing to Disclose: HS

20206 4.0000 SAT-545 A Transgenic Mice Overexpressing Nesfatin/Nuclebindin-2 (Nesf/NUCB2) Are Susceptible to High Fat Diet (HFD)-Induced Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Caroline A. Maguire*1, Katherine Leclair2, Rona S. Carroll1, Alexander S. Banks3, Ursula B. Kaiser4 and Victor M. Navarro5
1Brigham and Women's Hospital/Harvard Med School, Boston, MA, 2Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 3Brigham and Women's Hospital and Harvard Medical School, 4Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 5Harvard Medical School and Brigham and Women's Hospital, Boston, MA

 

Food intake is controlled by the interaction of central and peripheral metabolic cues at the hypothalamic level to maintain body homeostasis. These metabolic cues are often important modulators of reproductive function, which involves elevated energy demands. Recently, we uncovered a role for the tachykinins substance P (SP) and neurokinin A (NKA), both encoded by Tac1, in the timing of puberty onset and fertility in mice. Interestingly, adult male and female Tac1 knockout (KO) animals fed a standard rodent chow exhibited lower body weight (BW) in comparison to age-matched wild type (WT) animals, suggesting a role of SP/NKA in energy balance. However, the mechanism of action of SP/NKA to regulate BW remains unknown. In this study, first, we exposed Tac1KO males and control littermates to a 60% high-fat diet (HFD) for 16 days in order to exacerbate the differences in BW. At the end of the treatment, KO mice gained significantly less BW than WT (as percentage of the initial BW), in agreement with previous studies in SP receptor (NK1R)-deficient animals, pointing to SP as the primary candidate to exert this metabolic role. Second, in order to investigate if these differences in body weight and body composition are due to changes in the metabolic rate and/or food intake, WT and KO mice were placed in the comprehensive lab animal monitoring system (CLAMS) and fed a 60% HFD for four days. These studies revealed that both groups of animals display similar metabolic rates in terms of O2 consumption, CO2 production and respiratory quotient, as well as similar locomotor activity. However, food intake was significantly reduced in KO animals in comparison to the WT animals. Moreover, whole-body MRI measurements determined that Tac1KO mice have significantly lower fat mass and significantly more lean mass per gram of BW than WT after the HFD treatment. These results suggest that SP is involved in the central control of food intake acting as an orexigenic peptide possibly through regulatory actions on known hypothalamic regulators of energy balance.

 

Nothing to Disclose: CAM, KL, RSC, ASB, UBK, VMN

20430 5.0000 SAT-546 A The Role of Substance P in the Central Control of Food Intake 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Lucia Recinella, Claudio Ferrante, Sheila Leone, Chiara Di Nisio, Rugia Shohreh, Annalisa Chiavaroli, Adriana Ricciuti, Giustino Orlando, Michele Vacca and Luigi Brunetti*
G. d'Annunzio University, Chieti, Italy

 

Context:Irisin is a cleaved and secreted fragment of fibronectin type III domain containing protein 5 (FNDC5), which is synthesized primarily in the heart muscle, as well as in adipose tissue. Irisin is a thermogenic protein that causes a significant increase in energy expenditure by converting white to brown adipose tissue. The co-localization with neuropeptide Y (NPY) in the paraventricular neurons of the hypothalamus suggests a possible role of irisin in the regulation of energy balance.

Objectives:We aimed to investigate the effects of the acute injection of irisin into the arcuate nucleus (ARC) of the hypothalamus on feeding behavior and gene expression of orexigenic [agouti-related peptide (AgRP), neuropeptide Y and orexin A] and anorexigenic [cocaine and amphetamine-regulated transcript (CART) and proopiomelanocortin (POMC)] peptides in male Wistar rats fed a standard laboratory diet. In addition, we evaluated the effects of irisin on hypothalamic dopamine (DA), norepinephrine (NE) and serotonin (5-hydroxytriptamine, 5-HT) concentrations.

Design: 48 rats were injected into the ARC, at 09:00 a.m., with either vehicle (saline) or irisin (50-200 nM). Food intake was recorded 24 hours after injection, thereafter animals were sacrificed. Total RNA was extracted from hypothalami and reverse transcribed to evaluate the gene expression of hypothalamic peptides by real-time reverse transcription polymerase chain reaction.  DA, NE and 5-HT steady state concentrations (ng/mg tissue) in the rat hypothalamus homogenate were evaluated by high performance liquid chromatography (HPLC). Food intake, neuropeptide and monoamine activity data were analyzed by analysis of variance (ANOVA) followed by Newman-Keuls post-hoctest.

Results: Compared to vehicle, intrahypothalamic injection of irisin induced a significant inhibition of food intake (ANOVA, P<0.0001), in the 24 hours following administration. Irisin treatment was associated with a significant reduction of orexin-A (ANOVA, P<0.05) and increase of  POMC (ANOVA, P<0.01) gene expression in the hypothalamus. In addition, irisin (200 nM) increased CART (ANOVA, P<0.05) gene expression and decreased DA (ANOVA, P<0.05) and NE (ANOVA, P<0.05) levels compared to vehicle.

Conclusions: Irisin plays an anorectic role in the rat hypothalamus which could be partially related to decreased orexin-A, DA and NE and increased POMC and CART levels.

 

Nothing to Disclose: LR, CF, SL, CD, RS, AC, AR, GO, MV, LB

18981 6.0000 SAT-547 A Effects of Irisin on Feeding Behavior and Hypothalamic Neuromodulators in the Rat 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Belinda A Henry*1, Alexandra Kolasinksi2, Charmaine Diep2 and Iain J. Clarke3
1Monash University, Victoria, Australia, 2Monash University, Clayton, Australia, 3Monash University, Melbourne, Australia

 

Photoperiod influences food intake and body weight in various species including sheep. In rams, food intake is higher in long days (LD) than short days (SD), but effects on adiposity do not align with intake (1).  Accordingly, energy expenditure (especially thermogenesis) may also change with photoperiod. In humans,  brown adipose tissue activity is correlated to day length (2). We aimed to determine whether exposure to LD or SD photoperiod influences thermogenesis in ovariectomized ewes. Groups (n = 5) were exposed to SD (8h light: 16h dark) or LD (16h light: 8h dark) for 16 weeks, at ambient temperature. Baseline and post-prandial thermogenesis was measured by implanted probes. Baseline thermogenesis was lower but post-prandial thermogenesis was higher (P<0.05) in skeletal muscle and sternal fat in SD vs LD (Skeletal muscle: SD 1.1±0.1 vs LD 0.75±0.2; Sternal fat: SD 2.1±0.75 vs 1.1±0.1). This was associated with decreased adiposity, despite increased food intake. There was no effect of photoperiod retroperitoneal fat temperature.  At 16 weeks, protein and mRNA expression of uncoupling protein (UCP) 1 in adipose tissue, and UCP3, sarcoplasmic reticulum Ca2+ ATPases and ryanodine 1 receptors in skeletal muscle were similar in SD and LD animals. Photoperiod increased neuropeptide Y gene expression in LD animals (3.4 fold; P<0.05).  Plasma triiodothyronine (T3) and thyroxine (T4) levels were similar in SD and LD groups. Hypothalamic type II iodothyronine deiodinase (DIO) expression was increased (12.5 fold; P<0.05) in LD animals, which may allow greater T3 effect. In conclusion, post-prandial thermogenesis increases in SD, but the underlying mechanisms remain to be elucidated. This may be related to NPY or DIO activity in the hypothalamus.

 

Nothing to Disclose: BAH, AK, CD, IJC

21415 7.0000 SAT-548 A Endocrine and Cellular Pathways That Underpin Photoperiod-Induced Changes in Thermogenesis in Ovariectomized Female Sheep 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Bolaji Seffou1, Isabelle Seugnet1, James Bowers1, Maria Jesus Herrero Ramon1, Stéphanie Decherf1, Jérémy Terrien1, Ghozlane Assoui1, Chakib Djediat1, Marie-Stéphanie Clerget-Froidevaux1 and Barbara Demeneix*2
1Muséum National d’Histoire Naturelle, Paris CEDEX 05, France, 2Muséum National d’Histoire Naturelle, Paris CEDEX 05, France

 

Previous studies demonstrate that mammals with lower circulating thyroid hormones (TH) have longer lifespans. This observation also holds for humans, as offspring of healthy nonagenarians show lower circulating total thyroxin (tT4) and higher thyroid-stimulating hormone (TSH) levels. These correlations require further research to identify underlying mechanisms. The wild-derived strain of laboratory mice, WSB/EiJ (WSB), is long-lived and though euthyroid, has very low tT4. Furthermore, these mice are resistant to diet-induced obesity (DIO). Given the role of THs in control of energy homeostasis, we tested the hypothesis that these phenotypic characteristics are inter-related. Also, mitochondria are central players in metabolism and THs act directly and indirectly on mitochondrial activity. Our hypothesis was that modifications of mitochondrial activity in hypothalamic nuclei (Paraventricular, PVN, and Arcuate, ARC) could provide insight into the metabolic phenotype of WSB mice. Moreover, as several studies show high-fat diet (HFD) to induce inflammatory responses in peripheral and central tissues, our analysis also focused on the role of a potential resistance to inflammation in the DIO-resistant phenotype of WSB mice as this effect could be associated with a longer lifespan. We compared 3-month old male C57BL/6J (controls, median tT4 and longevity) and WSB (lower tT4, higher longevity) mice on different diets: control (10% Kcal from fat), short-term or long-term high fat diet (HFD) (3 days or 8 weeks 45% Kcal from fat).

We analyzed mitochondrial respiration (Seahorse Bioscience) and applied transmission electron microscopy (TEM) to identify mitochondrial and inflammatory differences at the level of different hypothalamic regions. WSB mice under HFD displayed increased mitochondrial plasticity (condensed to orthodox-type mitochondria) and differences in inflammatory markers (blood vessel-associated microglia), as compared to C57/Bl6. Moreover, lipid droplets were found in cells lining the third ventricle region in C57BL/6J in both control and HFD conditions, but never in WSB mice.

To compare hypothalamic inflammatory responses, we used double-staining immunohistochemistry to quantify astrocyte (GFAP-Ab) and microglia (Iba1-Ab) numbers and microglia structure as this varies according to inflammatory status in both ARC and PVN. Inflammatory cytokines in sera and hypothalamic regions were also investigated, as were hypothalamic TH concentrations.

In line with previous studies demonstrating rapid induction of central inflammation as a protective response to HFD, our work shows that differential regulation of central inflammatory and mitochondrial responses to HFD could underlie the resistance of WSB mice to DIO, and this could contribute to their increased longevity.

 

Nothing to Disclose: BS, IS, JB, MJ, SD, JT, GA, CD, MSC, BD

21691 8.0000 SAT-549 A Role of Mitochondrial Activity and Hypothalamic Inflammation in the Diet-Induced-Obesity Resistance of Wsb/Eij Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Matheus Porceban*1, Jose Antunes-Rodrigues2 and Lucila Elias2
1University of São Paulo, 2Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil

 

It is known that ADX leads to reduced body weight and hypophagia, however, there are no data on interaction of glucocorticoids and ghrelin, hormone synthesized in the stomach, with orexigenic action. Thus, we evaluated in this study the response to ghrelin stimulus in adrenalectomized rats with or without corticosterone replacement. Adult male Wistar rats (Ethical Committee on Animal Experiments of Ribeirão Preto Medical School, Nº 104/2012, 7 to 10 animals per group) were subdivided into ADX (0.5% ethanol in 0.9% NaCl), ADX+B (25 mg/L of corticosterone in 0.5% ethanol and 0.9% NaCl) or Sham (0.5% ethanol  in water) groups and treated for 7 days. The animals were acclimatized in metabolic cages and on 7th day, the food was removed at 4h30pm and 1 hour later the rats were treated with ip injection of vehicle (0.9% NaCl) or ghrelin (39µg/Kg). The food intake was measured 1 hour after the injection. Another group of animals, 7 days after surgery, was decapitated at 5:30pm for blood sample collection for measurement of serum concentration of acylated ghrelin, by ELISA. The stimulus with ghrelin increased (p<0.05) food intake in the three groups (saline vs ghrelin: Sham: 0.97 ± 0.1 g/100g vs 1.6 ± 0.1 g/100g of body weight; ADX: 0.5 ± 0.1 vs 1.0 ± 0 of body weight; ADX+B: 1.0 ± 0.1 g/100g vs 1.5 ± 0.2 g/100g of body weight). Though the ADX group showed the orexigenic effect of ghrelin, it was lower than in Sham and ADX+B groups, since the anorexigenic effect of ADX was maintained after ghrelin treatment. There was no difference in the serum concentration of ghrelin among the three groups (Sham: 107.6 ± 1.9; ADX: 107.9 ± 1.0; ADX+B: 106 ± 0.9 pg/ml).  In conclusion, glucocorticoid deficiency induced by ADX does not affect the production of acylated ghrelin. Although ghrelin is able to induce food intake after ADX, this effect is attenuated by the absence of endogenous glucocorticoids. These data indicate that hypophagia in primary adrenal insufficiency is associated with lower appetitive ingestive behavior, at least in part, due to lower ghrelin action on  food intake, which seems to be modulated by glucocorticoids.

 

Nothing to Disclose: MP, JA, LE

20704 9.0000 SAT-550 A Adrenalectomy (ADX) Reduces the Orexigenic Response to Ghrelin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Leonardo Domingues Araújo*1, Fernanda B. Coeli-Lacchini1, Silvia Ruiz Roa2, Ana Carolina Bueno de Queiroz Arruda3, Rogério Lenotti Zuliani1, Ernane Torres Uchoa1, Ayrton C. Moreira1, Jose Antunes-Rodrigues1, Lucila Elias1, Paula C. L. Elias1 and Margaret De Castro1
1Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 2Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil, 3Ribeirao Preto Medical School - University of Sao Paulo, São Paulo, Brazil

 

Introduction: Food access restriction can change the expression of circadian clock genes. Objective: To evaluate the expression of main loop- Clock, Bmal1, Per1, Per2, Per3, Cry1, Cry2,- and auxiliary loop- Rev-erbα and Ror- clock genes in PVN and ARC hypothalamic nuclei and liver of rats submitted to different feeding patterns. Methods and results: Rats were divided into Control (CG) food ad libitum, Food Restriction (FR) food from Zeitgeber time (ZT)12-14 (1800-2000h), and Food Shift (FS) food from ZT3-5 (0900-1100h) groups for 21 days with light/dark cycle (lights on 0600h–ZT0). Rats were decapitated at ZT3 and ZT11 (0900 and 1700h). Corticosterone (B, µg/dL) was evaluated by RIA and gene expression by qPCR (2-ΔΔCT). CG showed greater weight (g) compared to FR and FS (385.4±55.4 vs 245.5±32.0 vs 227.9±40.9; respectively, P<0.0001). Lower B levels were observed at ZT3 in CG (1.0±0.6 vs 14.1±8.1) and FR (3.6±2.6 vs 20.7±7.6), with opposite finding in FS (22.7±6.2 vs 10.6±5.7). In PVN, CG showed higher Pers 1, 2 and 3 (1.2±0.7 vs 3.2±2.6, 1.0±0.4 vs 2.2±1.0, 1.1±0.2 vs 1.8±0.8; respectively, P=0.006) expression at ZT11, similar pattern was observed in FR on Per1 and 2 (1.4±1.1 vs 2.2±1.8, 1.0±0.2 vs 1.4±0.5; P=0.02); however FS lost this pattern. In ARC, CG showed higher Per1 expression at ZT11 (1.0±0.2 vs 1.7±0.6; P=0.0002), similar pattern in FR on Per1, 2 and 3 (1.1±0.7 vs 1.6±0.3, 1.2±0.4 vs 1.8±0.7, 1.1±0.4 vs 1.3±0.3; respectively, P=0.007), but Per1 inverted the CG pattern in FS (1.0±0.2 vs 0.5±0.1; P<0.0001). In PVN and ARC, there was no difference in Clock, Bmal1, Cry1, 2, Rev-erbα and Ror expression among groups. In liver, CG showed higher Clock, Bmal1, Cry1 and Rev-erbα expression at ZT3 (1.1±0.1 vs 0.5±0.1, 1.1±0.3 vs 0.0±0.0, 1.1±0.3 vs 0.6±0.2, 1.0±0.1 vs 0.6±0.1; respectively, P=0.01). Per1, 2, 3 and Rev-erbα expression was higher at ZT11 (1.5±0.8 vs 12.3±6.5, 1.4±0.5 vs 3.4±1.0, 0.9±0.3 vs 22.2±10.2, 1.1±0.6 vs 11.7±4.5; respectively, P=0.004). FR showed similar pattern on Clock and Bmal1 expression (1.0±0.2 vs 0.5±0.1; 1.0±0.1 vs 0.0±0.0, respectively, P=0.004). Per1, 2, 3, Cry1, 2 and Rev-erbα expression also was higher at ZT11 (1.1±0.8 vs 13.1±5.9, 1.0±0.4 vs 13.8±7.4, 1.1±0.6 vs 39.1±12.1, 1.0±0.2 vs 2.6±0.8, 1.0±0.4 vs 2.9±0.9, 1.0±0.4vs1.7±0.3; respectively, P=0.002). However, In FS the pattern of Bmal1 expression was inverted being higher at ZT11 (1.0±0.4 vs 21.1±3.7; P=0.0002), the inversion was also observed on Per1, Per2, Per3, Cry2, Rev-erbα and Ror with higher expression at ZT3 (1.1±0.4 vs 0.2±0.1, 1.2±0.6 vs 0.7±0.3, 1.0±0.3 vs 0.0±0.0, 1.0±0.3 vs 0.6±0.3, 1.0±0.3 vs 0.0±0.0, 1.0±0.2 vs 0.7±0.1; respectively, P=0.04). Conclusions: FR maintained but FS inverted or lost the CG pattern of several clock genes suggesting that restricted feeding schedules have effect in central and peripheral oscillators involved with food intake, independently of the light cycle influences in SCN.

 

Nothing to Disclose: LDA, FBC, SRR, ACBDQA, RLZ, ETU, ACM, JA, LE, PCLE, MD

20552 10.0000 SAT-551 A Altered Feeding Patterns Entrain Clock Genes in Brain and Peripheral Oscillators 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Ligia D Prezotto*1, Jennifer F Thorson2, Pawel P Borowicz1, Sheri T Dorsan1, Jena L Peine1, Clay A Lents2, Joel S Caton1 and Kendall C Swanson1
1North Dakota State University, Fargo, ND, 2USDA, ARS, USMARC, Clay Center, NE

 

Maternal nutrient restriction during gestation exerts long-term effects on offspring health and performance. Energy utilized by fetal visceral tissues can be altered in response to changes in maternal feed intake. Prolonged nutritional changes during early pregnancy can impact hypothalamic neuropeptide mRNA and protein expression of proopiomelanocortin (POMC), agouti-related peptide (AgRP) and neuropeptide Y (NPY) in the offspring. Arginine supplementation has been shown to rescue some of the negative effects of intra-uterine growth restriction on the fetus. We tested the hypothesis that maternal arginine supplementation from d 54 of pregnancy until parturition would rescue the deleterious effects of nutrient restriction on hepatic and jejunal energy use and hypothalamic protein expression of POMC, NPY, and AgRP in female offspring (n = 18). Multiparous ewes (54 ± 4 days of gestation) were randomly assigned to dietary treatment; 100% of requirements (control, CON), 60% of control (restricted, RES), or RES plus rumen-protected arginine (180 mg/kg; RES-ARG). At parturition, offspring were immediately removed from their dam and placed on a common diet. At 54 ± 3 days of age, lambs were weighed and euthanized. The liver and jejunum were recovered and weighed. In vitro O2 consumption was conducted to estimate energy use in liver and jejunum samples (n = 6 per treatment). Liver O2 consumption (mol/min/liver and mol/min/kg BW) was reduced (P ≤ 0.02) in the RES and RES-ARG group when compared with CON. Immunohistochemistry assays were conducted to analyze NPY and AgRP protein content in the paraventricular nucleus (PVN) of the hypothalamus, and POMC protein content in the arcuate nucleus (ARC; n = 3-4 per treatment). Intensity of staining for NPY tended to be reduced (P = 0.10) in RES and RES-ARG when compared with CON. Number of POMC cells in the ARC were reduced (P ≤ 0.03) in the RES group when compared with RES-ARG. In conclusion, maternal nutrient restriction did not influence lamb BW, liver and jejunum mass, jejunum energy use, NPY or AgRP protein content in the PVN, and POMC protein content in the ARC. Further, supplementation of arginine to the gestating ewe failed to influence hepatic energy use in lambs from restricted ewes; however, number of POMC-containing cells was increased in the ARC, which could potentially influence feeding behavior and gross energy metabolism.

 

Nothing to Disclose: LDP, JFT, PPB, STD, JLP, CAL, JSC, KCS

19877 11.0000 SAT-552 A Effects of Maternal Nutrition and Arginine Supplementation on Postnatal Liver and Jejunal Oxygen Consumption and Hypothalamic Neuropeptide Content in Ovine Offspring 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Julie-Ann P De Bond1, Kristen P Tolson2, Alexander S Kauffman2 and Jeremy Troy Smith*1
1The University of Western Australia, Perth, Australia, 2University of California, San Diego, La Jolla, CA

 

Kisspeptin controls reproduction by stimulating GnRH neurons via its receptor Kiss1r. Kiss1r is expressed in other areas of the brain and in peripheral tissues, predicating a non-reproductive role. We recently examined the role of kisspeptin signaling in energy balance by characterizing the metabolic profile of Kiss1r KO mice. These KO mice developed an obese and diabetic phenotype compared to wild type (WT) littermates. Our aim here was to investigate why Kiss1r KOs develop this metabolic phenotype. We hypothesized that expression of hypothalamic metabolic genes will be altered in Kiss1r KOs. Hypothalamic samples were obtained from both genders in gonadectomized obese Kiss1r KO and WT mice (20 week old) and also in gonad intact (8 week old) mice prior to obesity onset. Relative gene expression was quantified by qRT-PCR. Neuropeptide genes examined were neuropeptide Y (Npy), agouti-related protein (Agrp) (orexigenic neuropeptides), pro-opiomelanocortin (Pomc) and cocaine and amphetamine-related transcript (Cart) (anorexigenic neuropeptides). Receptor genes analyzed included leptin receptor (Lepr), ghrelin receptor (Ghsr), and melanocortin receptor 3 and 4 (Mc3r, Mc4r).  At 20 weeks of age, female Kiss1r KO were significantly heavier than their WT littermates and there was a significant decrease in Pomc mRNA expression compared to WT females. At this age, there was no other significant genotype difference in any other hypothalamic genes tested. Interestingly, at 8 weeks of age (before obesity onset) Pomc expression was significantly increased in KO mice. We subsequently examined key metabolic genes in peripheral tissues of gonad intact 8 week old mice. We found reduced expression of adiponectin mRNA in white adipose tissue (p<0.01), and surprisingly, an increase in uncoupling protein 1 expression in brown adipose tissue (p<0.05) of female KO mice. In the liver, Kiss1r KO mice of both sexes had significantly decreased (p<0.05) gluconeogenesis enzyme phosphoenolpyruvate carboxykinase (PCK1) compared to WT. Thus, the obesity in Kiss1r KO mice may be  due in part to altered liver glucose metabolism. Overall, these data reveal changes in hypothalamic modulators of food intake and metabolism in Kiss1r KO mice. Moreover, we identify changes in peripheral organs, which may reflect a direct or indirect impact of kisspeptin signaling on peripheral glucose metabolism, with probable implications for diabetes and obesity.

 

Nothing to Disclose: JAPD, KPT, ASK, JTS

19289 12.0000 SAT-553 A Altered Central and Peripheral Metabolic Gene Expression in Obese Kisspeptin Receptor Knockout Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Britt Christensen*, Birgitte Nellemann, Jens Otto Lunde Jørgensen and Niels Jessen
Aarhus University Hospital, Aarhus C, Denmark

 

Erythropoietin (Epo) is well known for its erythropoesis stimulating effects, but are furthermore proposed to be a pleiotropic hormone. In mice, Epo is shown to exert positive effects on white adipose tissue (WAT) leading to decreased body weight, improved serum lipid profile, and increased mitochondrial content in WAT. In humans, we have previously shown that Epo treatment increases resting energy expenditure, slightly increase serum FFA levels, and prolonged treatment leads to accumulation of lipids in the liver (1,2). The direct effects of Epo treatment on human WAT have so far not been established. The aim of the current study was to investigate both the acute and prolonged effects of Epo treatment on human WAT.

Two studies were included; 1) an acute study with collection of biopsies 1h post administration of high-dose recombinant human Epo (rHuEpo, 400 IU/kg), and 2) a prolonged study where subjects were treated with the erythropoietin stimulating agent (ESA) Darbepoietin-alpha for 10 weeks. The biopsies were collected from subcutaneous WAT on the abdomen and analyzed for relevant protein levels by western blotting. A new and highly specific antibody (A82, amgen) was used to evaluate the presence of Epo receptor (Epo-R) in WAT, furthermore, activation of signaling cascades downstream of the Epo-R (Akt, STAT5, p70s6k, LYN, and p38MAPK) and activation of lipolytic pathways (ATGL, HSL, CGI-58, G0S2, Perilipin, Cidea, Cidec, AMPK, and ACC) were analyzed.

None of the above-mentioned parameters changed due to either acute or prolonged treatment with rHuEpo/ESA. Thus, in contradiction to previous animal studies, treatment with Epo within a physiological relevant range in humans does not affect lipolysis in subcutaneous WAT.

 

Nothing to Disclose: BC, BN, JOLJ, NJ

20367 16.0000 SAT-557 A Erythropoietin Treatment Does Not Activate Erythropoietin Receptor Signaling or Lipolytic Pathways in Human Subcutaneous White Adipose Tissue 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Michael Paul Rogowski*1, Boyd Butler1, Erin Brown1 and Fariba M Assadi-Porter2
1Texas Tech University, Lubbock, TX, 2University of Wisconsin Madison, Madison, WI

 

3-iodothyronamine (T1AM) is a recently discovered endogenous hormone like molecule. Recent research indicates that chronic, low-dose T1AM is able to induce sustained weight loss in obese mice through elevated fat oxidation and decreased fatty acid synthesis. The mechanism by which T1AM induces these changes is unknown. We sought to gain further insight into the mechanism of T1AM’s action by using an in vitro cell model with 3T3-L1 mouse adipocyte cell line. Treated differentiated 3T3-L1 cells with 1µM showed decreased adipocyte cell size compared to controls. Cellular imaging using TRITC conjugated T1AM (T1AM-T) revealed rapid cellular uptake of T1AM, suggesting T1AM enters the cell via a facilitated diffusion mechanism. This rapid rate of uptake was confirmed via flow cytometry, with peak detection of T1AM-T steadily rising until reaching peak signal and equilibrium at 20 minutes; rate of uptake and total signal was dose dependent. Cellular imaging using confocal microscopy with T1AM-T revealed intercellular mitochondrial co-localization, with a lack of nuclear translocation. This suggests mitochondria as a potential site of action for T1AM. Up-regulation of fat oxidation is further supported through gene expression changes in differentiated 3T3-L1 cells treated with 1µM displayed increased expression levels of PPARg, Sirt1, Sirt5, IRS, and Plln. T1AM displayed extremely low cytotoxicity in growing 3T3-L1 preadipocytes, with an IC50 in excess of 100µM along the growth curve, suggesting wide margin of safety above the observed effective concentrations. Taken together these findings suggest that T1AM interacts with adipocytes through cellular internalization via a rapid facilitated uptake mechanism where it co-localizes to the mitochondria. The in vitro 3T3-L1 model supports previous in vivo observations of upregulated fat oxidation via decreased adipocyte size as well as upregulated transcription profile, supporting the potential use of T1AM as a therapeutic agent for correcting metabolic disease related to diminished fat utilization.

 

Nothing to Disclose: MPR, BB, EB, FMA

21228 17.0000 SAT-558 A 3-Iodothyronamine (T1AM) Upregulates Fat Oxidation Metabolism in Adipocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Julian Tristan Schwartze*1, Kathrin Landgraf1, Denise Rockstroh1, Dennis Löffler1, Kathrin Scheuermann1, Jürgen Kratzsch2, Matthias Blüher2, Wieland Kiess1 and Antje Körner1
1University of Leipzig, Dept. of Women´s & Child Health, Leipzig, Germany, 2University of Leipzig, Leipzig, Germany

 

Rationale: C1q tumor necrosis factor-related protein 5 (C1QTNF5, encodes CTRP5) has recently been identified as a novel adipocytokine. We aimed to assess the potential role of CTRP5 in obesity and related alterations in children.

Results: To evaluate the relationship with adipose tissue composition, we assessed relative C1QTNF5 mRNA expression in subcutaneous (sc) adipose tissue (AT) samples obtained from lean (N=150, aged 0.15-20.68 years) and obese (N=89, aged 0.14-18.43 years) children and adolescents. Relative C1QTNF5 mRNA levels was 3.4-fold (P=0.01) increased in sc AT samples from obese compared to lean children and positively correlated with BMI SDS (R=0.18, p=0.007) as well as mean adipocyte size (r=0.46, P=0.005) and was strongly related to age (R=0.23, p<0.001) in multivariate analyses.

In addition, C1QTNF5 expression correlated age-independently with the number of AT-infiltrating macrophages (R=0.168, p=0.029) suggesting a relationship between C1QTNF5 expression and obesity-related inflammation. TNFα stimulation (10 ng/ml) of human adipocytes in vitro for 24 h resulted in a 4-fold C1QTNF5 expression increase (p<0.001) whereas ADIPQ and PPARG expression strongly decreased. In concordance with this, we found significantly higher C1QTNF5 levels in visceral (vis) AT compared to sc AT in adults, which decreased after weight loss following bariatric surgery.

Circulating CTRP5 levels from lean children (N=71, aged 13.0±3.0 years) and obese children (N=107, aged 11.9±2.9 years) assessed by ELISA and were not associated with obesity or metabolic or cardiovascular alterations including the HOMA-index, endothelial function, and carotide intima media thickness.                

Conclusion: Our data indicate that C1QTNF5 expression in sc AT, but not circulating CTRP5 levels, is related to obesity and associated inflammation of AT in children, which may be driven TNFα from resident macrophages.

 

Nothing to Disclose: JTS, KL, DR, DL, KS, JK, MB, WK, AK

19768 18.0000 SAT-559 A C1QTNF5 Expression in Human Adipose Tissue Is Related to Adipose Tissue-Infiltrating Macrophages in Children and Is Regulated By Tumor Necrosis Factor (TNF)Alpha 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Grant Gase*, Ross Comisford, Edward O List, John J Kopchick and Darlene E Berryman
Ohio University, Athens, OH

 

The Seahorse XFe24 Analyzer is an instrument that measures the oxygen consumption rate (OCR) and extracellular acidification rate (ECAR) of various cells and tissues.  Measuring OCR and ECAR is useful in determining the amount of mitochondrial respiration and glycolysis, respectively, occurring within the cells/tissue in question, shedding light on its metabolic activity.  This information is crucial to the study of metabolic disorders such as diabetes and obesity, as well as helping to determine the mechanism of action of a variety of therapeutic agents used to treat these disorders.  The use of whole adipose tissue is advantageous as it provides a more physiologically relevant measurement than that which can be obtained from cultured adipocytes or isolated mitochondria.  To optimize this assay with whole tissue, several factors were evaluated including: the size and shape of tissue samples, the depot from which the tissue is taken, the location of the sample within the depot, the age and sex of the mice from which samples are taken, media composition, washing methods, and time to perform the assay.  Here, we report preliminary data addressing these variables.  Basal respiration rates from several depots have been successfully obtained and demonstrate differences in respiration rates in relation to both age and depot locale.  Specifically, brown, retroperitoneal, and mesenteric adipose tissue depots had higher basal respiration rates than did both subcutaneous inguinal and perigonadal adipose tissues.  Additionally, tissue samples from young mice had basal respiration rates that were greater than that of older mice.  Size and shape of the tissue sample as well as the time to perform the assay also influenced respiration rates. These results suggest that adipose tissue metabolism changes with respect to age in a depot-specific manner and provides useful methodological information for other studies on adipose tissue.  By using adipose tissue instead of cultured cells, this assay allows for a more complete metabolic profile of various fat depots within Mus musculus and other animal models.  A deeper understanding of how adipose depots differ in the consumption of oxygen at different ages may reveal key insights into the metabolic changes that occur within the tissue throughout life.

 

Nothing to Disclose: GG, RC, EOL, JJK, DEB

21979 19.0000 SAT-560 A Optimizing Methods for the Measurement of Oxygen Consumption Rate in Whole Adipose Tissue Reveals Depot and Age Dependent Differences in Oxygen Consumption 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Chihiro Ebihara*1, Ken Ebihara1, Megumi Aizawa Abe2, Mingming Zhao2, Valentino Milton Gumbilai2, Yuji Yamamoto2, Kiminori Hosoda2 and Kazuwa Nakao3
1Jichi Medical University, Tochigi, Japan, 2Kyoto University Graduate School of Medicine, Kyoto, Japan, 3Medical Innovation Center, Kyoto, Japan

 

Seipin is a protein encoded by BSCL2 gene whose homozygous mutation causes the most severe variety of congenital generalized lipodystrophy (CGL). CGL is a disease characterized by a near total lack of adipose tissue from birth. Patients with CGL frequently develop severe insulin resistance, hypertriglyceridemia, and fatty liver. While phenotypes of patients with BSCL2 homozygous mutation are well known, there is no report on heterozygous mutation of BSCL2. Recently, we generated a Bscl2/Seipin knockout (SKO) rat using the method with ENU (N-ethyl-N-nitrosourea) mutagenesis. Homozygous SKO rats developed generalized lipodystrophy and its related phenotypes, which were strikingly similar to those of patients with BSCL2 homozygous mutation. In this study, we analyzed heterozygous SKO rats to elucidate the pathophysiological roles of Bscl2 haploinsufficiency. Under standard diet, there was no significant difference of body weight between wild type (WT) and heterozygous SKO rats at any age. Therefore, we tried to induce obesity with high fat diet (HFD) or mating with leptin deficient Lepmkyo/Lepmkyo rats (Physiol Genomics 2013). Both under HFD and on Lepmkyo/Lepmkyo background, body weight of heterozygous SKO rats was mildly but significantly lower than that in WT rats. At this time, glucose tolerance at IPGTT was better in heterozygous SKO rats than in WT rats. This is the first report on Pathophysiological role of Bscl2 haploinsufficiency in adiposity and metabolism.

 

Nothing to Disclose: CE, KE, MAA, MZ, VMG, YY, KH, KN

20912 20.0000 SAT-561 A Pathophysiological Role of Bscl2/Seipin Haploinsufficiency in Adiposity and Metabolism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Keun Woo Ryu*1, Xin Luo1, Tulip Sunil Nandu2 and W Lee Kraus1
1UT Southwestern Medical Center, Dallas, TX, 2University of Texas Southwestern Medical Center, Dallas, TX

 

Adipose tissue plays a central role in metabolic homeostasis, as well as the development of obesity and insulin resistance.  Adipogenesis is tightly regulated by the sequential regulation of a set of key adipogenic transcription factors.  Although the major transcription cascades and protein factors that regulate this process have been identified, our understanding of the precise molecular mechanisms of adipogenesis, particularly for the early stages of differentiation, is incomplete.  Recent studies have shown that enzymes involved in nuclear nicotinamide adenine dinucleotide (NAD+) signaling pathways play important roles in adipogenesis, including poly(ADP-ribose) polymerase 1 (PARP-1).  PARP-1 is a major nuclear NAD+ consuming enzyme, which catalyzes the covalent attachment of poly(ADP-ribose) (PAR) chains on target proteins using NAD+ as a donor of ADP-ribose.  The enzymatic activity of PARP-1 is supported by nicotinamide mononucleotide adenylyl transferase-1 (NMNAT-1), a nuclear NAD+ synthase, which makes NAD+from ATP and nicotinamide.  How PARP-1 and NMNAT-1 function together to control adipogenesis is unknown.  

To elucidate the transcriptional regulatory functions of nuclear NAD+ signaling in adipogenesis, we are using a variety of biochemical and molecular assays as well as RNA-seq in preadipocyte cells.  We have found that (1) the poly(ADP-ribosyl)ation activity of PARP-1 fluctuates during adipogenesis, (2) RNAi-mediated depletion of PARP-1 or NMNAT-1 alters adipogenesis-related gene expression and modulates the differentiation of adipocytes, (3) NMNAT-1 is required for PARP-1 enzymatic activity during adipogenesis, and (4) PARP-1 PARylates C/EBPβ, a key adipogenic transcription factor, and regulates its DNA binding activity and subsequent target gene expression. We are now conducting additional experiments to elucidate the exact role and regulatory mechanisms of NAD+ signaling in adipogenesis. Collectively, these studies are helping to elucidate the adipogenic regulatory network, as well as shed light on the mechanisms by how nuclear NAD+ signaling can regulate transcription to affect cellular lineage determination and differentiation.  These studies have the potential to reveal new aspects of the pathogenesis of obesity and the potential therapeutic benefits of inhibitors for the NAD+dependent enzymes.

 

Nothing to Disclose: KWR, XL, TSN, WLK

22142 21.0000 SAT-562 A Nuclear NAD+ Signaling Controls Preadipocyte Lineage Determination and Adipogenesis through Poly(ADP-ribose) Polymerase 1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Yuanyuan Zhang*, Ruifeng Teng and Constance Noguchi
National Institutes of Health

 

Erythropoietin (EPO) is a glycoprotein playing an indispensable role in stimulating red blood cell production. Recent studies have shown that EPO carries out metabolic functions beyond erythroid tissues, such as promoting weight loss and ameliorating insulin sensitivity in rodents. However, detailed mechanism of EPO-regulated adipocyte modeling is still unclear. Herein, we treated C57BL/6J mice on regular chow diet (RCD) or high fat diet (HFD) with 3000 units EPO per kg body weight for 3 weeks, and measured the size of adipocytes isolated from epididymal fat pad. We found that although EPO treatment significantly decreased fat mass and weight gain, fat cell size was larger in EPO-treated mice than PBS-treated mice. Consistently, mice with EPO signaling restricted to erythroid tissues (EpoRE mice) exhibited increased fat mass, accompanied with smaller fat cells than wild type (WT) mice on RCD. Further studies showed that EPO treatment increased adipogenic gene expression, but suppressed adipocyte differentiation in vitro. Therefore, our data suggest a new model of EPO effect on adipocyte modeling: EPO suppresses adipocyte differentiation and adipocyte number while increasing lipid accumulation in adipocytes, which contributes to the decrease in total fat mass and weight gain in mice. Since hyperplasia is more prominent than hypertrophy in HFD-induced obesity, the weight loss effect of EPO is more obvious in mice on HFD than those on RCD.

 

Nothing to Disclose: YZ, RT, CN

21102 22.0000 SAT-563 A Erythropoietin Modulates Adipocyte Differentiation and Lipid Accumulation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Silvana Duran Ortiz*1, Adam Jara1, Xiaoyu Liang2, Nicole E Brooks1, Ellen R Lubbers1, Edward O List1, Fabian Benencia1, Lonnie Welch2, John J Kopchick1 and Darlene E Berryman1
1Ohio University, Athens, OH, 2Ohio University

 

Inappropriate adipose tissue (AT) angiogenesis may contribute to the negative effects of obesity by altering several AT characteristics such as immune cell infiltration, fibrosis and plasticity. Growth hormone (GH) also has a significant impact on AT plasticity. That is, disruption of GH action increases AT mass while increased GH action, such as in bovine GH (bGH) mice, decreases AT mass in a depot-specific manner. GH has been implicated in angiogenesis in several tissues; however, the effect of GH on angiogenesis in AT remains unstudied. Therefore, this study used RNA-seq technology to compare the levels of expression of several angiogenic genes in subcutaneous (inguinal) and visceral (epididymal) AT depots of male bGH mice compared to wild type (WT) controls. To take full advantage of the RNA-seq approach, this work also grouped the significantly altered genes into predominant cellular processes, networks and pathways. The results revealed that the subcutaneous depot of bGH mice have a significant down-regulation of four angiogenic genes including leptin, vascular endothelial growth factor A, vascular endothelial growth factor B, and metalloproteinase inhibitor 4 when compared to WT mice.  Additionally, the pathway and network RNA-seq analysis showed that the subcutaneous AT depot of bGH mice had more significantly altered genes, indicating a greater impact of GH action on this depot. Furthermore, in the visceral AT depot, the biological process and pathway analysis suggested that GH may down-regulate processes related with basic metabolism and organelle organization and biogenesis. In contrast, the subcutaneous AT analyses revealed that the up-regulated genes were related with immune cell activation; particularly, the most significantly altered pathways were those related with T helper and T cytotoxic cells. We conclude that GH has a negative impact on the angiogenesis status of the subcutaneous AT depot of bGH mice. Moreover, GH appears to decrease the expression levels of genes related with adipocyte differentiation, and increase the expression level of genes associated with T cell activation and regulation. Confirmation of these preliminary results is ongoing.

 

Nothing to Disclose: SD, AJ, XL, NEB, ERL, EOL, FB, LW, JJK, DEB

21526 23.0000 SAT-564 A Impact of Growth Hormone on Angiogenesis and Intracellular Signaling Pathways in Subcutaneous and Visceral Adipose Tissue from Wild Type and Bovine Growth Hormone Transgenic Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


María Guillermina Zubiría*1, Yesica Romina Frontini López2, María Amanda Rey2, Griselda Moreno3, Ana Alzamendi1, Eduardo Spinedi4 and Andres Giovambattista1
1IMBICE (CONICET-CICPBA-UNLP), La Plata, Argentina, 2IMBICE (CONICET-CICPBA), La Plata, Argentina, 3IIFP (CONICET-UNLP), La Plata, Argentina, 4CENEXA (UNLP -CONICET - FCM), La Plata, Argentina

 

It is well-known that GC excess favors abdominal adipose tissue (AAT), but not subcutaneous adipose tissue (SCAT) accumulation. However, the effect of GC pre-exposition on stromal vascular fraction (SVF) cells from both depots remains unexplored. In the present study we evaluated the impact of dexamethasone (DXM) on the adipogenic potential of APCs from AAT (retroperitoneal) and SCAT (inguinal) pads. For this aim, SVF cells were isolated from AAT and SCAT pads (aseptically dissected from adult male S-D rats), and cultured up to reach confluence. Then DXM (0.25-2.5 µM) was added in culture for 48 h (pre-treatment) and the number of cells with adipogenic potential (defined as CD34+) was determined by flow cytometry. Specific adipocyte competency (PPAR-γ2 and Zfp 423), pro- (MR, GR) and anti- (Wnt10b) adipogenic gene markers were quantified in cultured cells (qPCR Real Time). Additionally, induction of differentiation was performed and, parameters of differentiated cells were measured on different differentiation days (Dd): a) adipocyte markers (PPAR-γ2 and C/EBPα, by qPCR) on Dd 4; and b- intracellular lipid content (Oil-Red O) on Dd 10. Our data indicate an increment in PPAR-γ2 gene expression in DXM pre-treated cells (Dd 0, P<0.05) from both AT pads, resulting higher (P<0.05) in AAT than SCAT. Moreover, adipogenic cell population (CD34+) enhanced in DXM-pre-treated AAT cells, but not in those from SCAT. Concordantly, MR and GR gene expression levels were increased by DXM-pre-treatment although only in cultured cells from AAT (P<0.05). Whereas, Wnt10b and Zfp423 gene levels were not affected, regardless of the depot examined. Differentiated cells pre-treated with DXM displayed increased (P<0.05) mRNA levels (Dd 4) of PPAR-γ2 and C/EBPα, and intracellular lipid content (Dd 10). Interestingly, the later parameters were even higher in cells derived from AAT than SCAT (P<0.05). It is concluded that GC pre-exposition impacts on APCs from AAT and SCAT in a different way, by changing CD34+ cell population density and competency in AAT, whereas only cell competency was modified in SCAT. DXM impacts on SCAT and AAT APCs activities by enhancing their adipogenic capacity, more markedly in AAT than in SCAT APCs. Our study suggests that a GC-rich endogenous environment will further contribute to enhance AT mass expansion at the AAT rather than at the SCAT level, which may help to delay the appearance of AAT cell dysfunction, as seen in the human phenotype of Cushing's Syndrome.

 

Nothing to Disclose: MGZ, YRF, MAR, GM, AA, ES, AG

20664 24.0000 SAT-565 A Depot-Specific Reprogramming of Adipocyte Precursor Cells (APCs) Induced By Glucocorticoid (GC) Exposure 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Yen-Hao Chen*1 and Ricardo Azziz2
1Georgia Regents University, Augusta, GA, 2Augusta University, Augusta, GA

 

Krüppel-like factors (KLFs) are a family of zinc-finger transcription factors which are associated with various disorders including obesity, inflammatory conditions, and metabolic dysfunction. Among KLFs, KLF15 in adipose tissue is down-regulated in obese mice, and down-regulation of KLF15 in adipocytes reduces expression of Adipolin/Complement C1q Tumor necrosis factor-Related Protein 12 (CTRP12), a novel insulin-sensitizing adipokine that regulates glucose metabolism in adipose tissue. Polycystic Ovary Syndrome (PCOS) is a pro-inflammatory condition associated with obesity, diabetes, dyslipidemia and atherosclerosis in women. In addition, marked changes in adipokine secretion and action are observed in this condition. Therefore, we hypothesized that the expression of KLF15 is reduced in the adipose tissue of PCOS women. To test this hypothesis we analyzed KLF15 mRNA expression in adipose tissues from 14 non-PCOS and 15 PCOS women. We found that in the non-PCOS group expression of KLF15 was reduced in women with obesity or insulin resistance (IR). However, regardless of obesity or IR, women with PCOS had lower expression of KLF15 in adipose tissue compared to non-PCOS women without obesity and IR. In conclusion, our data indicates that KLF15 in adipose tissue is down-regulated in obese women, similar to the results observed in obese mice. In addition, we confirm our hypothesis that KLF15 in adipose tissue is down-regulated in women with PCOS. As KLF15 regulates adipolin/CTRP12 expression in adipocytes, in future work we will determine the expression of adipolin/CTRP12 in adipose tissue in PCOS.

 

Nothing to Disclose: YHC, RA

20568 25.0000 SAT-566 A Reduced Expression of the Transcription Factor Krüppel-like Factor 15 (KLF15) in Adipose Tissue from Polycystic Ovary Syndrome (PCOS) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Barbara Gisella Carranza Leon*, Maria Morgan-Bathke and Michael Dennis Jensen
Mayo Clinic, Rochester, MN

 

Title:

Regional differences on free fatty acid storage between upper body and lower body obese women at high free fatty acid concentration

Background:

 Adults with  upper body obesity (UBO) are at an increased risk for hypertension, diabetes and hyperlipidemia while  individuals with lower body obesity (LBO) remain relatively free of the metabolic consequences of obesity. We have found that the direct free fatty acid (FFA) storage pathway in adipose tissue may explain some of the variations in body fat distribution. We hypothesize that at high FFA concentrations direct FFA storage is regulated by enzymes such as acyl-CoA synthetase (ACS) and diacylglycerol acetyltransferase (DGAT). Differences in activity of these enzymes could favor FFA storage in upper body (UBSQ) or lower body  subcutaneous (LBSQ) tissue. Understanding adipocyte FFA storage will help refine our comprehension of how different body fat distributions develop and thereby develop  strategies to prevent or reduce unhealthy fat deposition.

Hypothesis:

UBO women will have a greater direct FFA storage rates in UBSQ but not in LBSQ compared to LBO when FFA concentrations are high

Methods:

8 UBO and 6 LBO premenopausal women participated in this study. Direct FFA storage rates in UBSQ and LBSQ adipose tissue (AT) were measured in the presence of high FFA concentrations created by infusing somatostatin to suppress insulin secretion together with  epinephrine. Palmitate storage rates were measured using a bolus/biopsy technique - a continuous [U-13C]palmitate infusion to measure palmitate flux together with a [3H] or [14C]palmitate bolus exactly 30 min before the biopsies.  Palmitate storage rates, ACS and DGAT activities were measured.

Results:

Very high concentrations of palmitate (UBO 352 ± 19 vs. LBO 354 ± 22 p=0.8) were achieved in both groups.  There was no difference in palmitate storage rate in UBSQ (UBO 1.44 ± 0.24  vs. LBO 1.31 ± 0.23 p=0.85) or LBSQ  (UBO 1.29 ± 0.18  vs. LBO 1.12 ± 0.10 p=0.5) AT between groups. However, DGAT activity (pmol/mg lipid/min) was greater in both UBSQ (UBO 6.9 ± 1.1 vs. LBO 14.0 ± 1.6 p=0.008) and LBSQ  (UBO 6.1 ± 0.8 vs. LBO 13.7 ± 2.1 p=0.007) AT in LBO women.  There was no difference in ACS activity (UBSQ AT p=0.22 and LBSQ AT p=0.22) between groups.  Palmitate concentrations correlated with UBSQ (UBO R2 0.87 LBO R2 0.62) and LBSQ  (UBO R2 0.69 LBO R2 0.51) AT palmitate storage rates.

Conclusion:

The combination of hypoinsulinemia and epinephrine results in much greater adipose tissue DGAT activity in LBO compared with UBO women, not greater rates of direct FFA storage in LBO at these FFA concentrations.

 

Nothing to Disclose: BGC, MM, MDJ

18856 26.0000 SAT-567 A Regional Differences on Free Fatty Acid Storage Between Upper Body and Lower Body Obese Women at High Free Fatty Acid Concentration 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Jing H. Chao*1, Stephanie T. Page2, Derek K. Hagman3, Mario Kratz3 and Katya B. Rubinow1
1University of Washington, Seattle, WA, 2University of Washington and Harborview Medical Center, Seattle, WA, 3Fred Hutchinson Cancer Research Center, Seattle, WA

 

Objective: Macrophages accumulate in adipose tissue with increasing obesity and metabolic dysregulation.  During adipose tissue expansion, adipose tissue macrophages (ATM) undergo phenotypic shifts and secrete cytokines which may promote tissue inflammation and reduce adipocyte insulin sensitivity (1, 2, 3).  In addition to and independent of obesity, aging appears to exert an effect on ATM cytokine expression, and the incidence of both type 2 diabetes and obesity rises with age (4).  CD11c, a member of the beta2-integrin subfamily, plays critical roles in leukocyte extravasation, tissue migration, activation, proliferation, survival, and phagocytosis and has been implicated in ATM accumulation (5, 6).  Studies have demonstrated an increase in ATM CD11c expression in obesity and as a marker of insulin resistance in obese women (7, 8).  However, no studies have characterized ATM CD11c expression in healthy men.  We evaluated ATM cell surface marker expression, including CD11c, in subcutaneous adipose tissue from healthy men and examined whether ATM CD11c expression was associated with adiposity, BMI, age, and glucose tolerance.  Methods: Adipose tissue biopsies were performed on 40 healthy, non-diabetic men (ages 22-55, BMI 18.2-32.4 kg/m2).  ATM were quantified and immunophenotyped using flow cytometry.  Body composition was assessed by dual energy X-ray absorptiometry, and glucose tolerance was determined through a 2-hour, 75gm glucose challenge. Correlations between ATM CD11c expression and metabolic parameters were analyzed using Spearman’s correlation coefficients.  Results: The numbers of CD11c+ ATM present in each gram of adipose tissue as well as the relative percentage of leukocytes that were CD11c+ ATM were found to be positively associated with three parameters: percentage of total body fat (r=-0.4475; p=0.0055), BMI (r=0.3980, p=0.011), and age (r=0.4327, p=0.0053). No significant relationship was found between ATM CD11c expression and blood glucose in the fasting state or 2 hours after a 75g oral glucose load.  Conclusions: Observed correlations of ATM CD11c expression with body fat and BMI support the role of CD11c as an ATM marker of progressive adiposity in healthy men.  The biological importance of CD11c expression in tissue macrophages requires further investigation.  Additional functional insights could be gained through characterization of adipose tissue lipid metabolism and cytokine expression as well as phenotyping of other tissue immune cell populations.

 

Disclosure: STP: Investigator, Besins, Investigator, Abvie. Nothing to Disclose: JHC, DKH, MK, KBR

20535 27.0000 SAT-568 A Adipose Tissue Macrophage Expression of CD11c Correlates with Body Fat and Age in Healthy Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Diana Vargas1, Wendy Rosales2, Jeison Garcia2 and Fernando Lizcano*1
1Universidad de La Sabana, Chia, Colombia, 2Universidad de La Sabana, Chia Cundinamarca, Colombia

 

The activation energy expenditure in adipose tissue has become an important point of study in order to find new approaches for treating obesity. This tissue while maintaining energy homeostasis, has gained importance because it contains mesenchymal stem cells that are useful in the medical field. It has been reported that it is possible to activate the caloric expenditure of these cells differentiate into adipocytes after chronic treatment with PPARg full agonists. Additionally they can respond to cold by activating the thermogenic program in the absence of catecholamines. In the present study we determined the effect of partial agonism of PPARg and temperature reduction on the metabolic activity of ADMSCs obtained from human adipose subcutaneous tissue. Assessment of gen expression involved in thermogenesis by RT-PCR and Western blot was performed. We found that adipogenesis induction was observed by total and partial  PPARg agonism. Subsequently adipocytes differentiated with different agonists were subjected to 31 ° C and was found that these cells are able to respond to cold significantly increasing the expression of thermogenic proteins UCP1, PGC1 and CITED1 a molecule characterized as marking beige phenotype. Additiaonally, we found that cells ADMSC subjected to cold had a reduction in triglycerides and increase in adiponectin  levels. These data confirm the promising role of ADMSCs as a treatment for metabolic disorders such as it is possible to induce them to mature adipocytes and modulate their phenotype to a cell with high energy expenditure and metabolic beneficial effect.

 

Nothing to Disclose: DV, WR, JG, FL

22039 28.0000 SAT-569 A Metabolic Effects of Inducing Human Admsc to Beige Adipocyte 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Rebecca Anne Ohman-Hanson*1, Melanie Green2, Megan Moriarty Kelsey3, Daniel H. Bessesen4, Teresa Sharp5, Laura Pyle6, Rocio Ines Pereira7 and Kristen J Nadeau2
1Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, 2Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, 3University of Colorado School of Medicine, Aurora, CO, 4University of Colorado School of Medicine, Anschutz Medical Campus, Denver, CO, 5University of Northern Colorado, School of Human Sciences, Greeley, CO, 6University of Colorado Anschutz Medical Campus, Aurora, CO, 7University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO

 

There is a greater risk of insulin resistance (IR) and type 2 diabetes in Hispanic (H) vs.  Non-Hispanic White (NHW) populations.  Adiponectin, an adipokine with known antidiabetic and antiatherogenic effects, appears to be lower in IR, male sex and during puberty. Limited data demonstrates lower adiponectin in H vs. NHW, suggesting a possible role of adiponectin in the development of metabolic dysfunction.  However, studies examining the interaction of ethnicity and sex across the lifespan are lacking.

We aimed to compare ethnic and sex differences in adiponectin across the lifespan, independent of BMI.  

Adiponectin, fasting insulin, glucose and HOMA-IR were measured in 351 non-diabetic subjects of varied age (8-57 years) and ethnicity (58.0% NHW and 42.0% H).  Life stage was defined as pre-pubertal (Tanner 1 or 2, 27.9%), mid-pubertal (Tanner 3 or 4, 16.2%), late-pubertal (Tanner 5 and <21 years, 25.4%) or adult (Tanner 5 and age ≥21 years, 30.5%). 

Adjusted for BMI Z-score, adiponectin was negatively associated with HOMA-IR (r2=-0.27, p=0.009). Overall, adjusting for BMI z-score (BMIz), adiponectin was lower in late puberty vs. other life stages [pre-pubertal least squares geometric mean 8.77 ug/mL (95% CI 7.96-9.65)], mid-pubertal 9.05 (7.96-10.28), late-pubertal 7.15 (6.42-7.96), adult 7.71 (7.0-8.48), p=0.008 for association with lifespan]. When broken down by ethnicity, lifespan differences remained only in the H group (p=0.0007), such that adiponectin was lower in late-pubertal and adult stages (pre-pubertal 8.6 (p<0.003 vs. late-pubertal and vs. adults), mid-pubertal 8.8 (p<0.007 vs. late pubertal and vs. adults), late-pubertal 6.2, adults 5.8). There were ethnic differences across the lifespan by gender, when adjusting for BMIz. In NHW females, adiponectin dipped in late puberty and was highest in adults (p<0001). In contrast, in NHW males it began to fall in late puberty and fell further in adults (p=0.048). Similarly, in H males, adiponectin was lowest in adults (p=0.006).  However, H females had a unique pattern where adiponectin dipped lowest in late puberty and stayed lower in adults (p=0.005).

This study uniquely assesses interactions among adiponectin, ethnicity, and gender across the lifespan. As expected, adiponectin was inversely and independently associated with IR in this diverse cohort. Overall, adiponectin was lowest in late-puberty when controlled for BMI. However, gender and ethnic differences existed, such that in all males, adiponectin was lowest in adults. In NHW females, adiponectin was lowest in late puberty and highest in adults. In contrast, H females had a more “male “pattern, where adiponectin dropped in late puberty but did not recover in adulthood. These results suggest that adiponectin may relate to the greater risk for cardiometabolic disease seen in H females, independent of BMI. Future studies are needed in a larger cohort to confirm these results.

 

Nothing to Disclose: RAO, MG, MMK, DHB, TS, LP, RIP, KJN

18684 29.0000 SAT-570 A Ethnic and Sex Differences in Adiponectin Across the Lifespan 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Seamus Webb*, Brenda McDermott, Tal Murthy, Julie Donaldson, Collin Shaw, Nirja Patel, Stacy Dion and Martin Blankfard
ALPCO, Salem, NH

 

Adiponectin (ADP) is a hormone which has been demonstrated to play a vital role in many biological functions, particularly glucose metabolism and insulin sensitivity. It is secreted from adipose tissue and is among the most abundant hormones in circulation. ADP circulates, predominately, in three isomeric forms, a homotrimer [low molecular weight (LMW)], a hexamer [medium molecular weight (MMW)], and as a dodecamer and above [high molecular weight (HMW)]. Each isomer is comprised of individual ADP monomers, which contain a globular head and a collagen tail. Studies have shown the most biologically active ADP molecule is the HMW through AMPK activation. In addition, studies have demonstrated an inverse correlation of HMW ADP to body mass index. This has led many researchers to believe HMW and/or the ratio of HMW to total ADP (HMWR), is important with regards to the study of insulin resistance. Accurately generating HMWR is a challenge, because it requires the ability to measure HMW ADP specifically in order to compare to the total amount of ADP present in the sample. Two common methods for determining this ratio are through a laborious gel filtration process, with subsequent qualitative western blot analysis, and quantitative sandwich ELISA assays.

Determining total and HMW ADP in the same assay, utilizing the same reagents to measure total and HMW ADP, is of utmost importance in determining HMWR accurately. To that point, the aim of this study was to evolve the revolutionary Multimeric ADP Assay, first introduced in 2006, into a single, robust, and reproducible chemiluminescence ELISA. This new assay still employs enzymatic sample digestion to isolate HMW ADP; however, it offers the end user more robust results without requiring multiple buffers, standards, or exotic dilution schemes.

Analytical sensitivity and LOQ were 0.08 ng/mL and 0.25 ng/mL, respectively. Sample linearity for human serum and plasma (EDTA, heparin, citrate) samples across 3 dilutions ranged, on average, from 103-112% (total adiponectin) and 99%-113% (HMW adiponectin). Human serum and plasma (EDTA, heparin, citrate) samples were spiked with 3 levels of adiponectin and recovered between 96-105% (total and HMW adiponectin), Inter-assay and intra-assay precision are 5.4%-8.4% and 10.1-11.8% respectively. The assays can be completed in 3.5 hours, which offers the end user a simple, quick, and reliable method for determination of total, HMW and HMWR ADP.

 

Nothing to Disclose: SW, BM, TM, JD, CS, NP, SD, MB

19826 30.0000 SAT-571 A Two Broad-Ranged and Highly Sensitive Chemiluminescence Elisas for Measuring Total and High Molecular Weight (HMW) Adiponectin Levels: Important Tools to Characterize Adiponectin Function and Modulation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 542-571 6036 1:00:00 PM Energy Balance: Control of Adiposity and Feeding Poster


Patrick M. O'Neil*1, Ken Fujioka2, Rafael Violante Ortiz3, Birgitte Claudius4, Christine Bjørn Jensen4 and Arne Astrup5
1Medical University of South Carolina, Charleston, SC, 2Scripps Clinic, La Jolla, CA, 3Instituto Mexicano del Seguro Social, Cuidad Madero, Mexico, 4Novo Nordisk A/S, Søborg, Denmark, 5University of Coponhagen, Frederiksberg C, Denmark

 

SCALE Obesity and Prediabetes (NCT01272219), a 56-week, randomized, double-blind, placebo-controlled trial evaluated the efficacy and safety of liraglutide 3.0 mg in weight management. Overweight/obese individuals (BMI ≥27 with ≥1 comorbidity or ≥30) without T2D were randomized 2:1 to liraglutide 3.0 mg (n=2487) or placebo (n=1244) as an adjunct to diet and exercise. This subgroup analysis compared key efficacy and safety outcomes of responders (≥5% weight loss from baseline at week 56) vs non-responders (<5% weight loss from baseline at week 56).

Mean overall baseline characteristics were age 45 years, 79% female, body weight 106 kg, BMI 38 kg/m2. Change from baseline data are LS means with LOCF.

At week 56, significantly more individuals on liraglutide vs placebo were weight loss responders (63.2% vs 27.1%; P<0.0001). Weight change for responders vs non-responders was -11.7% vs -1.7% with liraglutide, and -10.0% vs +0.1% with placebo. Responders had greater improvements than non-responders across a range of efficacy outcomes (e.g. glycemic, cardiometabolic and HRQoL). Waist circumference decreased more for responders vs non-responders in both treatment groups (liraglutide: -11.0 vs -3.3 cm; placebo: -10.0 vs -1.7 cm). Reduction in FPG was greater with liraglutide vs placebo for responders (-8.3 vs -2.8 mg/dl, respectively) as well as non-responders (-5.0 vs. +1.1 mg/dl, respectively). Liraglutide was also associated with a greater reduction in systolic blood pressure (SBP) vs placebo in both responders (-5.5 vs -3.4 mmHg, respectively) as well as non-responders (-2.0 vs -0.8 mmHg, respectively). Change in overall physical health scores (SF-36) for liraglutide and placebo were +4.3 vs +4.1 for responders and +2.1 vs +1.3 for non-responders, respectively.

Amongst AEs with a frequency ≥2%, the most common were gastrointestinal in nature which were higher on liraglutide, but equivalent in responders (liraglutide: 69.2%; placebo: 44.4%) vs non-responders (liraglutide: 67.2%; placebo: 39.6%). Responders were associated with lower rates of AEs leading to withdrawal (liraglutide: 4.5%; placebo: 0.9%) vs non-responders (liraglutide: 17.0%; placebo: 4.8%) in both treatment arms. Serious AEs were equivalent in responders (liraglutide: 6.7% vs placebo 5.7%) vs non-responders (liraglutide: 5.2% vs placebo 4.8%). Mean (SD) change in pulse rate from baseline was +2.5 (9.8) vs -1.6 (9.1) for responders and +2.9 (9.5) vs +0.4 (9.6) bpm for liraglutide and placebo, respectively.

Overall a higher proportion of patients on liraglutide 3.0 mg achieved weight loss ≥5%, with a greater weight loss seen in the responder population. In both groups, responders had greater improvements in glycemic, cardiometabolic and HRQoL outcomes. The rates of AEs were largely equivalent in responders and non-responders.

 

Disclosure: PMO: Investigator, Orexigen Therapeutics, Investigator, Weight Watchers International, Investigator, Novo Nordisk, Speaker, Eisai, Speaker, Novo Nordisk, Speaker, Fleishman-Hillard, Speaker, Vindico CME, Speaker, Practicing Clinicians Exchange, Speaker, Weight Watchers International, Advisory Group Member, Medscape CME. KF: Advisory Group Member, Isis, Advisory Group Member, Nazura, Advisory Group Member, Novo Nordisk, Advisory Group Member, Zafgen, Advisory Group Member, Enteromedics, Speaker Bureau Member, Abbott Laboratories, Speaker Bureau Member, Vivus USA, Speaker Bureau Member, Eisai, Speaker Bureau Member, Takeda, Investigator, Eisai, Investigator, Novo Nordisk, Investigator, Orexigen, Investigator, Enteromedics, Investigator, Shire, Investigator, WeightWatchers. RV: Advisory Group Member, Merck Sharp & Dohme, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Novo Nordisk, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Astra Zeneca, Advisory Group Member, Eli Lilly & Company, Investigator, Eli Lilly & Company, Investigator, Novo Nordisk, Speaker Bureau Member, Merck Sharp & Dohme, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Astra Zeneca. BC: Employee, Novo Nordisk, Employee, Novo Nordisk. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. AA: Advisory Group Member, BioCare, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Pathway Genomics, Advisory Group Member, Vivus USA, Board Member, Dentacom Aps, Consultant, Arena Pharmaceuticals, Consultant, Basic Research, Consultant, Gedeon Richter Plc, Consultant, Gelesis, Consultant, Gerson Lehrman Group, Consultant, Novo Nordisk, Consultant, Orexigen Therapeutics Inc, Consultant, Pfizer Global R&D, Consultant, S-Biotek, Consultant, TwinLab, Director, Nordea Foundation Research Centre OPUS, LIFE/SCIENCE, Investigator, Nordea Foundation Research Centre OPUS, LIFE/SCIENCE, Investigator, Gelesis SrL, Investigator, Novo Nordisk, Investigator, Rhythm Pharmaceuticals, Investigator, S-Biotek, Shareholder in this spin-out company from Faculty of Life Sciences, Copenhagen University, Mobile Fitness A/S, , Rights to patents registered in collaboration with the University of Copenhagen, University of Copenhagen.

19545 1.0000 SAT-572 A Efficacy and Safety of Liraglutide 3.0 Mg in Adult Overweight and Obese Weight Loss Responders without Diabetes: Results of the Randomised, Double-Blind, Placebo-Controlled 56-Week Scale Obesity and Prediabetes Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Sarah Anne Robert*1, Rohana Abdul Ghani2, Suehazlyn Zainudin1, Shamsul Azhar Shah3, Wan Nazaimoon Wan Mohamud4 and Nor Azmi Kamaruddin1
1Universiti Kebangsaan Malaysia Medical Centre, Malaysia, 2Universiti Teknologi Mara, Malaysia, 3Universiti Kebangsaan Malaysia, Malaysia, 4Institute of Medical Research, Malaysia

 

Binge eating behaviour (BEB) is characterised by eating a large amount of food uncontrollably without purging. While stress is traditionally associated with ‘emotional eating’, this relationship is not fully understood. This study examined the possible relationship between cortisol levels and binge eating behaviour among obese participants. It also investigated the changes in cortisol levels after treatment of binge eating with liraglutide. 

Binge eating questionnaires were distributed to obese, non-diabetic subjects and they were categorised into binge eaters (score >17) and non-binge eaters (score ≤ 17). Following an overnight 12 hour fast, a two-point-profile of salivary cortisol, before and after ingestion of a nutritionally complete meal (460kcal) was done at time -15, and 120 minutes. Appetite ratings including hunger and fullness were also obtained. Binge eaters were subsequently randomised to either daily injection of 1.8mg liraglutide vs control groups for 12 weeks. The meal challenge test together with the salivary cortisol profile were repeated after 12 weeks of treatment.

Both groups of binge and non-binge eaters were of comparable age, 33years (29-37.5) p=0.225 and body-mass index, 35.9 kg/m2 (33.2-38.8) p=0.866. There was no difference in the AUC of salivary cortisol levels between the two groups, p=0.623, however cortisol levels decreased significantly 2 hours post prandial within the participants with BEB p<0.01. A correlation analysis performed showed that there was a moderate correlation between salivary cortisol levels and binge eating severity among the participants with BEB: r=0.33 (p=0.027). After 12 weeks of treatment, the percentage change in salivary cortisol levels from pre- to postprandial was significantly different in the liraglutide group (18.33%±52.88 vs 42.11%±29.81, p=0.014) but not in the control group, p=NS.

Among those with BEB, cortisol levels correlated well with BEB severity and decreased after a meal. Salivary cortisol, as a marker of stress reduced significantly in those with BEB following treatment with liraglutide.

 

Nothing to Disclose: SAR, RA, SZ, SAS, WNW, NAK

21068 2.0000 SAT-573 A Improvement in Binge Eating Following Liraglutide Therapy Is Accompanied By a Drop in Salivary Cortisol Levels 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Sarah Anne Robert*1, Rohana Abdul Ghani2, Suehazlyn Zainudin1, Shamsul Azhar Shah3, Wan Nazaimoon Wan Mohamud4 and Nor Azmi Kamaruddin1
1Universiti Kebangsaan Malaysia Medical Centre, Malaysia, 2Universiti Teknologi Mara, Malaysia, 3Universiti Kebangsaan Malaysia, Malaysia, 4Institute of Medical Research, Malaysia

 

Liraglutide is a GLP-1 analogue with 97% structural homology to human GLP-1. It is used in the treatment of type 2 diabetes to regulate glucose levels by stimulating glucose-dependent insulin secretion, suppressing glucagon secretion, delaying gastric emptying, and promoting satiety. To our knowledge, there has not been any study that examined the effect of liraglutide on postprandial insulin secretion and glucose levels in non-diabetic obese individuals.

This study examined the effects of a 3-month administration of liraglutide, a glucagon-like peptide 1 (GLP-1) analogue on fasting and postprandial insulin and glucose levels in non-diabetic obese individuals following the consumption of a standard test meal.

This was a 12-week randomised, controlled, open-label trial conducted in a tertiary institution.  Forty-two healthy participants with mean age of 34±9 years and body mass index of 35.9±4.2kg/m2 were randomly assigned to either daily injection of Liraglutide which was titrated to 1.8mg dose vs control group. Baseline clinical and biochemical characteristics were comparable in both groups. All participants received standard advice for diet and exercise. A seven-point-profile of serum insulin and glucose following an overnight 12 hour fast, before and after ingestion of a nutritionally complete meal (460kcal) was performed at time -15, 0, 15, 30, 60, 90, and 120 minutes. The clinical and biochemical parameters were obtained at baseline and at the end of the study.

There was a significant decrease in fasting [5.10 mmol/L (IQR 4.70-5.50) to 4.60 mmol/L (IQR 4.40-5.15), p= 0.005] and postprandial [6.70 mmol/L (IQR 5.25-7.50) to 5.80 mmol/L (IQR 5.55-6.30), p= 0.010] blood glucose in the liraglutide group. No change was observed in the control group. Subjects who received liraglutide showed significant increase in AUC insulin [10039.28 uIu/ml.min (IQR 6209.40-14039.63) to 11392.65 uIu/ml.min (IQR 7660.69-17228.63), p=0.013]. There was no change in insulin resistance parameters (as measured by HOMA) in both groups at baseline and at the end of the study. In the liraglutide group, there were decrease in body weight, BMI, waist circumference, systolic blood pressure and total cholesterol (p<0.05) while the control group showed no changes. 

Twelve weeks' therapy with liraglutide, in  non-diabetic obese subjects, significantly reduced fasting and postprandial glucose levels. In addition, there was an increase in insulin levels without any accompanying change in insulin resistance state. In conclusion, short term liraglutide is a potential therapeutic option for obese patients to improve their glycaemic parameters and prevent the development of diabetes.

 

Nothing to Disclose: SAR, RA, SZ, SAS, WNW, NAK

21103 3.0000 SAT-574 A Liraglutide Increased Postprandial Insulin Secretion with Improvement in Glucose Levels in Non-Diabetic Obese Subjects: Potential for Diabetes Prevention 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Neil Poulter*1, Stephen Bain2, Ian Caterson3, Jorge Luiz Gross4, Jason Hatch5, John House6, Adam Salisbury7, Anne Bloch Thomsen8, Christine Bjørn Jensen8 and Steven Marso9
1Imperial College and St Mary's Hospital, London, United Kingdom, 2Swansea University, Swansea, United Kingdom, 3Dept Biochemistry G08, Camperdown NSW, Australia, 4Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil, 5CardioVascular Institute of North Colorado, Banner Health, Loveland, CO, 6Saint Luke's Mid America Heart Institute, Kansas City, MO, 7Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, 8Novo Nordisk A/S, Søborg, Denmark, 9Clinical Heart Center, Dallas, TX

 

The cardiovascular safety of liraglutide among overweight/obese individuals and those with type 2 diabetes (T2D) is unknown. We therefore performed a meta-analysis of all available individuals from five phase II/III liraglutide weight management (WM) trials, including follow-up through a 120-Day Safety Update. A meta-analysis of 21 trials from T2D development programs, in which liraglutide was used as a treatment, provided further supportive information. The maximum dose of liraglutide investigated in the WM program was 3.0 mg, whereas the maximum dose was 1.8 mg in the T2D trials.

The primary endpoint was first occurrence of adjudicated major adverse cardiovascular events (MACE) (non-fatal myocardial infarction, non-fatal stroke or CV death) on liraglutide (any dose) or pooled comparator (placebo, active) and was analysed using a Cox proportional hazards model stratified by trial. Prospective adjudication (blinded, independent) was implemented in three of the WM trials; post-hoc adjudication was conducted for all other trials. Individuals who did not experience an event during the treatment period or within 30 days after last dose were censored at last treatment date plus 30 days. Multiple sensitivity analyses were conducted to confirm the robustness of the primary analysis.

Across WM trials (liraglutide: n=3,872; comparator: n=2,036), baseline characteristics were: 71% women; history of CV disease, 9%; mean age, 47 yrs; mean BMI, 38 kg/m2. Across T2D trials (liraglutide: n=5,511; comparator: n=2,748): 43% women; history of CV disease, 13%; mean age, 56 yrs; mean BMI, 30 kg/m2.

In WM trials, the overall number of adjudicated MACE was low and numerically lower with liraglutide (any dose: 10 events, frequency 0.2%, 0.2 events/100 patient-years of exposure [PYE]; liraglutide 3.0 mg: 7 events, 0.2%, 0.2 events/100 PYE) than with comparator (total comparator: 10 events, 0.5%, 0.4 events/100 PYE; placebo: 10 events, 0.5%, 0.4 events/100 PYE). Hazard ratios (HR) and 95% confidence intervals (CI)] for liraglutide (any dose) vs. total comparator: 0.40 [0.16; 1.01]; liraglutide 3.0 mg vs. placebo: 0.33 [0.12; 0.90]. As expected, high event rates were observed across T2D trials: (liraglutide [any dose]: 26 events, 0.5%, 0.6 events/100 PYE vs. total comparator: 23 events, 0.8%, 1.3 events/100 PYE vs. total comparator): HR [95% CI]: 0.6 [0.35, 1.15].

In conclusion, based on these data, there was no indication of an increased risk of MACE with liraglutide up to doses of 3.0 mg once-daily in overweight/obese individuals, or in those with T2D.

 

Disclosure: NP: Advisory Group Member, Novo Nordisk, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Merck Sharp & Dohme, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Merck Sharp & Dohme, Investigator, British Heart Foundation, Investigator, Diabetes UK, Investigator, HTA, Investigator, Servier, Investigator, Pfizer Global R&D. SB: Advisory Group Member, Astra Zeneca, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Janssen, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Merck Sharp & Dohme, Advisory Group Member, Novo Nordisk, Advisory Group Member, Omnia-Med, Advisory Group Member, Sanofi, Board Member, Glycosmedia. IC: Committee Member, EXSCEL Trial Operations Committee, Speaker Bureau Member, Servier. JLG: Investigator, Boehringer Ingelheim, Investigator, Eli Lilly & Company, Investigator, GlaxoSmithKline, Investigator, Mannkind, Investigator, Novo Nordisk, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Novo Nordisk. AS: Clinical endpoint adjudication, Novo Nordisk. ABT: Employee, Novo Nordisk, Employee, Novo Nordisk. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. SM: Consultant, Novo Nordisk, Consultant, St Jude Medical, Investigator, Novo Nordisk, Investigator, Terumo, Investigator, Medicines Company, Investigator, Astra Zeneca, Investigator, Bristol-Myers Squibb. Nothing to Disclose: JH, JH

19530 4.0000 SAT-575 A Cardiovascular Safety of Liraglutide: Meta-Analysis of Major Adverse Cardiovascular Events Across Weight Management and T2D Development Programs 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Ken Fujioka*1, Richard Mauritz Bergenstal2, Matthias Blüher3, Ralph DeFronzo4, Alfredo Halpern5, Robert Kushner6, Carel W Le Roux7, Ofri Mosenzon8, Patrick M. O'Neil9, Trine Vang Skjøth10, Christine Bjørn Jensen10 and Melanie Davies11
1Scripps Clinic, La Jolla, CA, 2HealthPartners Institute, Minneapolis, MN, 3University of Leipzig, Leipzig, Germany, 4University of Texas Health Science Center, San Antonio, TX, 5Universidade Sao Paulo, Sao Paulo, Brazil, 6Northwestern University FSM, Chicago, IL, 7University College Dublin, Dublin, Ireland, 8Hadassah University Hospital, Jerusalem, Israel, 9Medical University of South Carolina, Charleston, SC, 10Novo Nordisk A/S, Søborg, Denmark, 11University of Leicester, Leicester, United Kingdom

 

This analysis aimed to identify an early treatment milestone that optimizes sensitivity and specificity for predicting ≥5% weight loss at week (W) 56 in obese/overweight individuals with and without type 2 diabetes (T2D) on once-daily liraglutide 3.0 mg, as an adjunct to lifestyle modification. Here we present W56 data from individuals identified as early responders to liraglutide 3.0 mg (≥4% weight loss from baseline at W16) in the phase 3a SCALE Obesity and Prediabetes and SCALE Diabetes trials.

A total of 2910 individuals on liraglutide 3.0 mg were included: 2487 without T2D (BMI ≥30 or 27–29.9 kg/m2 with ≥1 comorbidity; 45.2 yrs; 78.7% female; mean BMI 38.3 kg/m2; 61.4% with prediabetes) from SCALE Obesity and Prediabetes (clinicaltrials.gov ID NCT01272219), and 423 with T2D (BMI ≥27 kg/m2; 55.0 yrs; 48.0% female; 37.1 kg/m2) from SCALE Diabetes (NCT01272232). Liraglutide was dose-escalated weekly in 0.6 mg increments to a maintenance dose of 3.0 mg. Based on pooled analysis, ≥4% weight loss from baseline at W16 (after 12W on the 3.0 mg maintenance dose) had the highest sensitivity and specificity for predicting ≥5% weight loss at W56 with liraglutide 3.0 mg. Using this criterion, 77% of individuals without T2D and 63% with T2D were early responders to liraglutide 3.0 mg. Efficacy and safety data below are for 56W completers. A logistic regression model was used to estimate categorical weight loss. Data are presented as least squares means or estimated proportions.

Early responders without T2D achieved mean weight loss of 10.8% (11.2 kg) with liraglutide 3.0 mg after W56. Proportions of early responders achieving ≥5%, >10% and >15% weight loss at W56 with liraglutide 3.0 mg were 84%, 50% and 21%, respectively. Early non-responders (<4% weight loss from baseline at W16) without T2D lost 3.0% (3.2 kg) at W56, at which time 28%, 6% and 2% had achieved ≥5%, >10% and >15% weight loss, respectively.

Early responders with T2D achieved mean weight loss of 8.5% (9.0 kg) with liraglutide 3.0 mg after at W56. Proportions of early responders achieving ≥5%, >10% and >15% weight loss at W56 with liraglutide 3.0 mg were 74%, 38% and 10%, respectively. Early non-responders with T2D lost 3.1% (3.2 kg) at W56, at which time 29%, 5% and 2% had achieved ≥5%, >10% and >15% weight loss, respectively.

Across both trials, greater improvements in cardiometabolic risk factors were observed in early responders than early non-responders, consistent with greater weight loss. The overall frequencies of adverse events (AEs) and serious AEs observed were generally comparable between early responders and early non-responders. Gastrointestinal AEs were more frequent in early responders vs. early non-responders with T2D.

In conclusion, ≥4% weight loss at W16 with liraglutide 3.0 mg is a strong predictor of clinically meaningful weight loss after 1 year.

 

Disclosure: KF: Advisory Group Member, Isis, Advisory Group Member, Nazura, Advisory Group Member, Novo Nordisk, Advisory Group Member, Zafgen, Advisory Group Member, Enteromedics, Speaker Bureau Member, Abbott Laboratories, Speaker Bureau Member, Vivus USA, Speaker Bureau Member, Eisai, Speaker Bureau Member, Takeda, Investigator, Eisai, Investigator, Novo Nordisk, Investigator, Orexigen, Investigator, Enteromedics, Investigator, Shire, Investigator, WeightWatchers. RMB: Advisory Group Member, Abbott Laboratories, Investigator, Abbott Laboratories, Advisory Group Member, Bayer, Inc., Investigator, Bayer, Inc., Advisory Group Member, Valeritas Inc, Investigator, Becton Dickinson, Advisory Group Member, Boehringer Ingelheim, Investigator, Boehringer Ingelheim, Advisory Group Member, Bristol-Myers Squibb, Investigator, Bristol-Myers Squibb, Advisory Group Member, Calibra, Investigator, Calibra, Advisory Group Member, Eli Lilly & Company, Investigator, Eli Lilly & Company, Advisory Group Member, Halozyme, Investigator, Halozyme, Advisory Group Member, Helmsley Trust, Investigator, Helmsley Trust, Advisory Group Member, Hygieia, Investigator, Hygieia, Advisory Group Member, Johnson &Johnson, Investigator, Johnson &Johnson, Advisory Group Member, Medtronic Minimed, Investigator, Medtronic Minimed, Investigator, Merck & Co., Advisory Group Member, Novo Nordisk, Investigator, Novo Nordisk, Investigator, NIH, Investigator, ResMed, Advisory Group Member, Roche Pharmaceuticals, Investigator, Roche Pharmaceuticals, Advisory Group Member, Sanofi, Investigator, Sanofi, Advisory Group Member, Takeda, Investigator, Takeda. MB: Advisory Group Member, Astra Zeneca, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Novo Nordisk, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Sanofi, Consultant, Astra Zeneca, Consultant, Boehringer Ingelheim, Consultant, Novartis Pharmaceuticals, Consultant, Eli Lilly & Company, Consultant, Novo Nordisk, Consultant, Berlin-Chemie, Consultant, Sanofi, Investigator, Boehringer Ingelheim, Investigator, Riemser, Investigator, ALTANA, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Novartis Pharmaceuticals, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Sanofi, Speaker Bureau Member, Pfizer Global R&D, Speaker Bureau Member, Johnson &Johnson, Speaker Bureau Member, Reimser. RD: Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Takeda, Advisory Group Member, Amylin Pharmaceuticals, Advisory Group Member, Novo Nordisk, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Lexicon Pharmaceuticals, Inc., Advisory Group Member, Astra Zeneca, Investigator, Amylin Pharmaceuticals, Investigator, Takeda, Investigator, Bristol-Myers Squibb, Investigator, Boehringer Ingelheim, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Jansen Pharmaceuticals. AH: Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Investigator, Novo Nordisk. RK: Advisory Group Member, Novo Nordisk, Advisory Group Member, Vivus USA, Advisory Group Member, Zafgen, Advisory Group Member, Retrofit, Consultant, Eisai, Consultant, Takeda, Investigator, Weight Watchers, Investigator, Aspire Bariatrics. CWL: Advisory Group Member, Novo Nordisk, Advisory Group Member, GI Dynamics, Advisory Group Member, Fractyl. OM: Investigator, Novo Nordisk, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Sanofi, Speaker Bureau Member, Novartis Pharmaceuticals, Speaker Bureau Member, Merck Sharp & Dohme, Advisory Group Member, Astra Zeneca, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Novo Nordisk, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Sanofi, Advisory Group Member, Novartis Pharmaceuticals. PMO: Investigator, Orexigen Therapeutics, Investigator, Weight Watchers International, Investigator, Novo Nordisk, Speaker, Eisai, Speaker, Novo Nordisk, Speaker, Fleishman-Hillard, Speaker, Vindico CME, Speaker, Practicing Clinicians Exchange, Speaker, Weight Watchers International, Advisory Group Member, Medscape CME. TVS: Employee, Novo Nordisk, Employee, Novo Nordisk. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. MD: Advisory Group Member, Novo Nordisk, Consultant, Novo Nordisk, Investigator, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Advisory Group Member, Sanofi, Consultant, Sanofi, Investigator, Sanofi, Speaker Bureau Member, Sanofi, Advisory Group Member, Eli Lilly & Company, Consultant, Eli Lilly & Company, Investigator, Eli Lilly & Company, Speaker Bureau Member, Eli Lilly & Company, Advisory Group Member, Merck Sharp & Dohme, Consultant, Merck Sharp & Dohme, Speaker Bureau Member, Merck Sharp & Dohme, Advisory Group Member, Boehringer Ingelheim, Consultant, Boehringer Ingelheim, Speaker Bureau Member, Boehringer Ingelheim, Advisory Group Member, Astra Zeneca, Consultant, Astra Zeneca, Speaker Bureau Member, Astra Zeneca, Advisory Group Member, Janssen, Consultant, Janssen, Speaker Bureau Member, Janssen, Speaker Bureau Member, Mitsubishi Tanabe Pharma Corp.

19291 5.0000 SAT-576 A Early Weight Loss with Liraglutide 3.0 Mg As an Adjunct to Diet and Exercise Predicts 1-Year Weight Loss 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Harriette Rosen Mogul*1, Ruth G Freeman2 and Khoa Nguyen3
1New York Med Coll, Valhalla, NY, 2Montefiore Med Ctr, New Rochelle, NY, 3New York Medical College, Valhalla, NY

 

BACKGROUND Progressive midlife weight gain is associated with diabetes(1) and all-cause mortality(2) and preventive interventions targeting high risk populations are critically needed. We previously reported that Carbohydrate Modified Diet (CMD) and insulin sensitizers reduced body weight (BW) and modulated Metabolic Syndrome measures at 6-months in EMPOWIR (Enhance the Metabolic Profile of Women with Insulin Resistance, a 3-phase, 3-arm, double-blind, placebo controlled trial of normoglycemic women with midlife weight gain and hyperinsulinemia.(3) The trial (NCT00618072) was conducted to test the hypotheses that progressive midlife weight gain represents an early manifestation of insulin resistance and hyperinsulinemia in a distinct subset of women, and strategies to decrease insulin elevations will reduce BW and attenuate risks of diabetes and related comorbidities.

METHODS Subjects meeting inclusion criteria: age 35-55; 20lb weight gain; increased glucose-mediated AUC-insulin, and normal GTT, attended 4 weekly nutrition workshops (Phase 1) at 2 study sites to introduce the CMD: a food exchange program (40% carbohydrates-40% protein-20% fat) promoting increased intake of vegetables, low-glycemic index fruits, low-fat protein & dairy products, elimination of free sugars, & notable restriction of 3 additional carbohydrates (starches) to after 4PM.  Participants were then randomized to 1 of 3 arms: CMD+metformin (M) 2000mg/day for 12 months; CMD+metformin & 2 mg rosiglitazone (R) for 12 months; or CMD alone for 6 months (Phase 2), with rerandomization to 1 of the 2 active treatment arms for months 7-12 (Phase 3). In this analysis, we compare BW at baseline(B), 6- and 12-months in all 32 study completers (mean age 46.7, BMI 30.8kg/m2, HA1c 5.4%, 54.3% white) with repeated measure ANOVA’s, and Bonferroni adjustment to assess additional main effect differences (SPSS 20).

RESULTS Mean BW decreased from baseline to 6 months (m) for the total group, but did not change significantly from 6 to 12 months; means (CI): 83.7(79.8-87.6) vs. 78.9(74.6-83.1) vs. 77.9(73.7-82.1)Kg. Notably, BW decreased significantly at 12 months in the M arm: respective means at B, 6- and 12-m: 85.1(79.9-90.2), 80.5(75.9-85.2), and 79.8(74.3-85.2)Kg. (B vs. 6; P= .008; B vs. 12, P=.008; 6 vs. 12; P=1.000(NS), with 54% of variance explained (VE) by M treatment. In contrast, BW increased significantly from 6 to 12m in M+R group: 76.8(65.7-88.0) to 78.4(67.8-88.9)Kg, P=.027, with 62% VE.

CONCLUSIONS This pilot data suggests that, in combination with a novel carbohydrate modified diet, metformin enhanced 12 month weight loss in a diverse sample of normoglycemic, hyperinsulinemic women with progressive midlife weight gain. The ease of implementation and durability of the study diet, and its enhanced efficacy with metformin, could have important clinical and public health implications and merit additional study.

 

Nothing to Disclose: HRM, RGF, KN

18923 6.0000 SAT-577 A Metformin Enhanced Weight Loss at 12 Months in EMPOWIR (Enhance the Metabolic Profile of Women with Insulin Resistance): A Randomized Trial of Normoglycemic Women with Midlife Weight Gain 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Ruth G Freeman*1, Harriette Rosen Mogul2 and Khoa Nguyen3
1Montefiore Med Ctr, Bronx, NY, 2Westchester Medical Center, Hawthorne, NY, 3New York Medical College, Valhalla, NY

 

BACKGROUND Progressive midlife weight gain is associated with diabetes(1) and all-cause mortality(2) and preventive interventions targeting high risk populations are critically needed. We previously reported that Carbohydrate Modified Diet (CMD) and insulin sensitizers reduced body weight and modulated Metabolic Syndrome measures at 6-months in EMPOWIR (Enhance the Metabolic Profile of Women with Insulin Resistance), a 3-phase, 3-arm, double-blind, placebo controlled trial of normoglycemic, hyerinsulinemic women with midlife weight gain.(3) The trial, NCT00618072 was conducted to test the hypotheses that progressive midlife weight gain represents an early manifestation of insulin resistance and hyperinsulinemia and strategies to decrease insulin elevations will improve body composition (BC) and attenuate risks of diabetes and related comorbidities. DXA is widely used to assess fat compartments in clinical trials.(4) Accordingly, android, fat measured from the rib cage to the iliac crest, is an accepted surrogate measure of Visceral adipose tissue (VAT) whereas gynoid, fat measured from iliac crest to mid femur, is considered a marker of non-metabolically adverse fat.(5) 

METHODS Subjects meeting inclusion criteria: age 35-55; 20lb weight gain; increased glucose-mediated AUC-insulin, and normal GTT, attended 4 weekly nutrition workshops (Phase 1) at 2 study sites to introduce the CMD: a food exchange program (40% carbohydrates-40% protein-20% fat) promoting increased intake of vegetables, low-glycemic index fruits, low-fat protein & dairy products, elimination of free sugars, & notable restriction of 3 additional carbohydrates (starches) to after 4PM.  Participants were then randomized to 1 of 3 arms: CMD+metformin (M) 2000mg/day for 12 months; CMD+metformin & 2 mg rosiglitazone (R) for 12 months; or CMD alone for 6 months (Phase 2), with re-randomization to 1 of the 2 active treatment arms for months 7-12 (Phase 3). Body Composition (BC) was measured by GE Lunar Prodigy DXA at baseline and 12 months following randomization.  Paired t-tests (SPSS 22) were used to compare means in 27 of 32 study completers with available data. 

RESULTS Mean % total fat, % trunk fat, and % android fat decreased significantly from baseline to 12 months, respectively: 46.83±6.69 to 44.00± 7.90, P= .026, 48.00±6.73 to 45.19±8.38 P=.007, and 51.64±6.60 to 47.65±9.18, P=.001. In contrast, % gynoid fat was unchanged: 53.07±6.42 to 52.91±6.76, P= .894.

DISCUSSION This pilot data suggests that the EMPOWIR diet independently, and in combination with metformin improved android and trunk fat, reported surrogate measures of VAT(4) and insulin resistance (5), in a diverse sample of normoglycemic, hyperinsulinemic midlife women.  

CONCLUSIONS Effective, easily implemented dietary interventions and pharmacotherapies could have important clinical and public health implications and merit additional study.

 

Nothing to Disclose: RGF, HRM, KN

18930 7.0000 SAT-578 A Carbohydrate Modified Diet and Insulin Sensitizers Decrease Visceral Adipose Tissue at 12 Months in EMPOWIR (Enhance the Metabolic Profile of Women with Insulin Resistance (NCT00618071); A Randomized Clinical Trial of Women with Midlife Weight Gain and Hyperinsulinemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Bhavana Bajracharya*1, Deep Shikha1, Miriam Cohen2 and Morana Poljak-Varenika2
1SUNY Downstate Medical Center, Brooklyn, NY, 2VA NY Harbor Healthcare System, Brooklyn, NY

 

Objective: To examine the effects of Orlistat on renal function and weight loss in obese patients at the Brooklyn VA Hospital.

Background: Obesity is fast becoming a worldwide epidemic. Orlistat has widely been used in the US for the management of obesity since being approved by the FDA in 1999. Recent studies indicated that Orlistat has been associated with hepatic dysfunction. Consequently in May 2010, the FDA approved a revised label for Xenical to include new safety information about cases of severe liver injury with its use. More recently, reports have suggested oxalate nephropathy and acute kidney injury associated with Orlistat use. To date, there have been no large studies in the US, demonstrating an association between Orlistat and renal dysfunction.

Methods: We conducted a retrospective case control analysis of the effect of Orlistat in obese patients. We included patients on Orlistat who were enrolled in the MOVE clinic (Managing Overweight/Obesity in Veterans Everywhere) at the Brooklyn VA Hospital, NY from October 2006 to May 2012. Exclusion criteria were pre-existing renal dysfunction, chronic kidney disease, use of drugs with potential nephrotoxicity or the use of Orlistat for less than six months. Patients were provided education and consultation. Consistency in renal function (BUN, Creatinine & eGFR) over one year were analyzed with the intraclass correlation coefficient (ICC). Differences in weight loss were compared between the groups treated with Orlistat to that of a matched control group not on Orlistat using analysis of variance. 

Results: Sixty-six patients were enrolled in the study, thirty on Orlistat and thirty-six not on Orlistat. Data were analyzed with SPSS Version 15. There were no differences at baseline between groups in age, gender, race or Body Mass Index (BMI). Change in BMI from baseline to 6 months was significant in the Orlistat group (p<0.001), but not in the group receiving education and consultation alone. This change was sustained over one year. BUN, Creatinine and eGFR maintained consistency in patients on Orlistat over the study period (ICC range 0.83-0.90, p <0.001).

Conclusions: Orlistat does not appear to have any direct nephrotoxic effects, as measured by BUN, Creatinine and eGFR over one year of treatment. Patients on Orlistat lost more weight and were able to maintain the weight loss more effectively than patients treated with education and consultation alone.

 

Nothing to Disclose: BB, DS, MC, MP

20390 8.0000 SAT-579 A Effect of Orlistat in Obese Veterans at the Brooklyn VA Hospital, Correlation with Weight Loss and Renal Dysfunction 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Farid Saad*1, Ahmad Haider2, Karim Sultan Haider2, Gheorghe Doros3 and Abdulmaged M Traish4
1Bayer Pharma AG, Berlin, Germany, 2Private Urology Practice, Bremerhaven, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA

 

Introduction:

Associations between testosterone deficiency and the MetS are well established. Hypogonadism is highly prevalent in men with MetS and has been shown to predict the onset of MetS.

Methods:

237 men with obesity grade I, II and III from a single-center, prospective, cumulative registry study of 340 hypogonadal men received TU injections for up to 7 years. Of the total group of 340 hypogonadal men, 70% were obese.

Results:

Grade I (n=103, mean age: 58 years, mean observation time: 56 months): Fasting glucose (FPG) decreased from 100.73 to 96.12 mg/dl, HbA1c from 6.79 to 5.7%. Total cholesterol (TC) decreased from 279.99 to 185.85, LDL from 158.98 to 105.18, triglycerides from 270.89 to 185.53. HDL increased from 54.45 to 59.09 mg/dl. TC:HDL ratio declined from 5.56 to 3.31. Systolic blood pressure from 149.06 to 134.38, diastolic blood pressure from 88.44 to 76.76 mmHg. C-reactive protein (CRP, mg/L) declined from 2.79 to 0.23. Liver enzymes: aspartate transaminase (AST) decreased from 32.63 to 19.53, alanine transaminase (ALT) from 35.64 to 20.24 (p<0.0001 for all).

Grade II (n=97, mean age: 60 years, mean observation time: 59 months): FPG decreased from 107.17 to 96.12 mg/dl, HbA1c from 7.55 to 5.9%. TC decreased from 299.36 to 188.15, LDL from 177.21 to 120.04, triglycerides from 291.77 to 186.85. HDL increased from 64.54 to 73 mg/dl. TC:HDL ratio declined from 4.9 to 2.76. Systolic blood pressure from 161.86 to 138.77, diastolic blood pressure from 97.18 to 78.12 mmHg. C-reactive protein (CRP, mg/L) declined from 4.06 to 0.38. Liver transaminases: AST decreased from 41.12 to 19.73, ALT from 42.12 to 20.54 (p<0.0001 for all).

Grade III (n=36, mean age: 60 years, mean observation time: 69 months): FPG decreased from 108.61 to 97.5 mg/dl, HbA1c from 7.47 to 5.92%. Total cholesterol (TC) decreased from 311.78 to 189.13, LDL from 196.69 to 123.13, triglycerides from 324.53 to 190.25. HDL increased from 68.28 to 74.5 mg/dl. TC:HDL ratio declined from 4.72 to 2.62, Systolic blood pressure from 164.81 to 143.75, diastolic blood pressure from 100.58 to 81 mmHg. C-reactive protein (CRP, mg/L) declined from 4.39 to 0.27. Liver transaminases: AST decreased from 47.03 to 19.75, ALT from 48.06 to 18.75 (p<0.0001 for all).

Conclusions:

All changes were clinically meaningful and sustained for the full observation time. Testosterone therapy seems to be effective to improve MetS and cardiovascular risk profile in obese hypogonadal men.

 

Disclosure: FS: Employee, Bayer Schering Pharma. AH: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. Nothing to Disclose: KSH, AMT

19441 9.0000 SAT-580 A Improvement of Metabolic Syndrome (Mets) Parameters in 237 Obese Hypogonadal Men upon Long-Term Treatment with Testosterone Undecanoate (TU) Injections: Observational Data from a Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Farid Saad*1, Ahmad Haider2, Karim Sultan Haider2, Gheorghe Doros3 and Abdulmaged M Traish4
1Bayer Pharma AG, Berlin, Germany, 2Private Urology Practice, Bremerhaven, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA

 

Introduction:

Testosterone (T) and obesity are inversely associated. Obesity has a greater impact on T decrease than advancing age.

Methods:

Single-center, prospective, cumulative registry study of 340 hypogonadal men. 237 men with obesity grade I-III were selected. All men received TU injections for up to 7 years.

Results:

Grade I (n=103, mean age: 58 years): Weight decreased from 102.79 to 85.41 kg. Changes were statistically significant vs. previous year for six years. Change from baseline was -17.27 kg, percent change from baseline -16.81%. Waist circumference (WC) decreased from 104.74 to 95.24 cm. Changes were significant vs. previous year for six years. Change from baseline was -8.93 cm. BMI decreased from 32.85 to 27.65 kg/m2, change from baseline -5.5 kg/m2.

Grade II (n=97, mean age: 60 years): Weight decreased from 116.67 to 92.19 kg. Changes were significant vs. previous year for six years. Change from baseline was -25.15 kg, percent change from baseline -21.52%. WC decreased from 111.97 to 100.96 cm. Changes were significant vs. previous year for five years. Change from baseline was -12.53 cm. BMI decreased from 37.33 to 29.88 kg/m2, change from baseline –8.06 kg/m2.

 Grade III (n=36, mean age: 60 years): Weight decreased from 128.92 to 100.75 kg. Changes were significant vs. previous year for six years. Change from baseline -29.3 kg, percent change from baseline -22.79%. WC decreased from 117.56 to 103.63 cm. Changes were significant vs. previous year for six years. Change from baseline was -12.93 cm. BMI decreased from 41.99 to 33.23 kg/m2, change from baseline -9.59 kg/m2.

Conclusions:

All changes were more pronounced with increasing obesity grade. All changes were in a clinically meaningful magnitude and sustained for the full observation period. T therapy is an effective approach to achieve sustained weight loss in obese hypogonadal men, thereby potentially reducing cardiometabolic risk.

 

Disclosure: FS: Employee, Bayer Schering Pharma. AH: Investigator, Bayer Schering Pharma. GD: statistical analyses, Bayer Schering Pharma. Nothing to Disclose: KSH, AMT

19440 10.0000 SAT-581 A Weight Loss and Reduction of Waist Size in 237 Hypogonadal Men with Obesity Grades I-III Under Long-Term Treatment with Testosterone Undecanoate (TU): Observational Data from a Registry Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM SAT 572-581 6044 1:00:00 PM Obesity - Clinical Trials Poster


Alexandra Gkourogianni*1, Maya Beth Lodish1, Mihail Zilbermint1, Ninet Sinaii2 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2National Institutes of Health, Bethesda, MD

 

Background

Cushing disease (CD) due to ACTH-producing pituitary adenomas, accounts for more than 75% of Cushing syndrome (CS) in children. Transsphenoidal surgery (TSS) is the treatment of choice. Sustained postoperative resolution of hypercortisolism, verified by low morning serum cortisol and plasma ACTH levels, low 24h urinary free cortisol (24h UFC) and normal ovine CRH test (oCRH test), may predict cure. No data exist for ethnic/racial differences in the time required for recovery of the hypothalamic-pituitary-adrenal axis (HPAA) after successful TSS.

Methods

This was a retrospective study of 122 pediatric CD patients, admitted to the National Institutes of Health (NIH) from 1999 to 2013. Data were collected from a subgroup of 98 children (48 females and 50 males, median 13±3yr) who had remission of CD after successful TSS. Endocrine and anthropometric assessments were performed prior to TSS, in order to confirm CD, while morning serum cortisol and plasma ACTH levels, 24h UFC and oCRH testing were repeated after patients’ last TSS in order to prove cure of CD. Patients who reached full recovery after the 1st or the 2ndTSS and with no persistent disease after final TSS or disease recurrence during the first 6 months after final TSS were included in the statistical analysis. Patients with previous pituitary surgery or radiation were excluded. All TSS were performed at the NIH and the presence of a tumor was confirmed by ACTH staining of the pituitary tissue.

Results             

Preoperative levels of average 8:00 am serum cortisol (p=0.0138) and plasma ACTH levels (p=0.0017) were higher in the Hispanic/Latino group (Hisp/Lat). Moreover Hisp/Lat had higher levels of serum cortisol in the UFC preoperatively and reached the minimum value of serum cortisol levels later than all other (AO) ethnic/racial groups (p=0.0005).  Post-operatively Hisp/Lat had still higher plasma ACTH levels and took significantly longer to reach lower levels of both ACTH and cortisol associated with recovery of HPAA axis (p<0.0001 and p=0.0136, respectively).

Conclusions

Reasons behind the increased cortisol and ACTH levels associated with CD in the Hisp/Lat population are unclear. We speculate delayed diagnosis and treatment, or less access to medical care for underserved patients referred to our center. The above results should be verified in a larger population of children.

 

Nothing to Disclose: AG, MBL, MZ, NS, CAS

19479 1.0000 SAT-144 A Transsphenoidal Surgery in Pediatric Cushing Disease: Disparities in Disease Severity in the Hispanic Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Alessandra Chesi*1, Heidi J. Kalkwarf2, Frank D. Mentch3, Joan M. Lappe4, Vicente Gilsanz5, Sharon E Oberfield6, John A. Shepherd7, Jonathan P. Bradfield3, Soroosh Mahboubi3, Sani M. Roy1, Jonathan A. Mitchell8, Rosetta Chiavacci3, Andrea Kelly9, Hakon Hakonarson3, Babette S. Zemel1, Struan F.A. Grant10 and Shana E. McCormack1
1The Children's Hospital of Philadelphia, Philadelphia, PA, 2Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 3Children's Hospital of Philadelphia, 4Creighton University, Omaha, NE, 5Children's Hospital Los Ange, Los Angeles, CA, 6Columbia University College of Physicians and Surgeons, New York, NY, 7University of California San Francisco, San Francisco, CA, 8University of Pennsylvania, 9Childrens Hosp of Philadelphia, Philadelphia, PA, 10The Children's Hospital of Philadelphia

 

Background: Skeletal maturation is a complex process influenced by many factors including sex steroids, growth hormone and body composition. Clinically, skeletal maturity is assessed using a bone age x-ray of the left hand that is compared against age- and sex-based references. Although pubertal timing is a heritable trait, the genetic etiology of pediatric skeletal maturation remains to be elucidated.  

Objective: To identify genetic factors influencing skeletal maturation by performing a sex-stratified trans-ethnic genome-wide association study of bone age.

Design/Methods: The Bone Mineral Density in Childhood Study (BMDCS) has been described previously. Bone age x-rays were available for 1,108 BMDCS participants (5-17y, 570 girls and 538 boys; 78% White, 22% African American). These samples were genotyped with the Illumina Human OmniExpressExome BeadChip. In a second cohort, participants were enrolled through the Center for Applied Genomics (CAG) at the Children’s Hospital of Philadelphia. The subset with clinically obtained bone age films was included (2-16y, 714 girls and 805 boys; 61% White, 33% African American, 6% other). Bone age was determined by pediatric radiologists using the Greulich and Pyle method and converted into a Z-score using standards from the Brush Foundation study. Anthropometrics were obtained at the same visit (BMDCS) or abstracted from the electronic medical record (CAG). BMI Z-scores were calculated using Center for Disease Control 2000 reference data.

Results: In BMDCS, two loci associated with bone age in females (8p22, near LOC101929028, rs17123050, P=3.7x10-8, β=-0.42; Xq21.33, nearest flanking genes MIR548M and DIAPH2, rs5949637, P=1.67x10-8, β=0.60). These two loci achieved at least nominal significance in the CAG replication cohort (rs17123050; P=0.04; rs5949637; P=0.007) and reached genome-wide significance in a meta-analysis of the two cohorts (rs17123050; P=4.2x10-9; rs5949637; P=3.0x10-10). In males, one locus associated with bone age achieved genome-wide significance in the meta-analysis (1p34.3; rs61342841; P=2.9x10-8), with similar effects in both cohorts (BMDCS: β=-0.55; CAG: β=-0.58). All three loci continued to be associated with bone age when adjustments for BMI were made. In females, one additional locus achieved genome-wide significance in the meta-analysis when adjusting for BMI (5q14.3, nearest flanking genes ARRDC3 and NR2F1; rs73133103; P=8.0x10-9), with similar effects in both cohorts (BMDCS: β=-0.32; CAG: β=-0.29).

 Conclusions: We report four novel sex-specific loci associated with skeletal maturity in children. Interestingly, the signal associated with bone age in males lies in an intron of the RHBDL2 gene, close to (but not in linkage disequilibrium with) a known menopause locus. Further functional characterization of these signals is required to elucidate the mechanism underlying these observations.

 

Nothing to Disclose: AC, HJK, FDM, JML, VG, SEO, JAS, JPB, SM, SMR, JAM, RC, AK, HH, BSZ, SFAG, SEM

20555 2.0000 SAT-145 A Loci Influencing Skeletal Age in Children and Adolescents Identified through a Trans-Ethnic Appraisal of Both Common and Rare Genetic Variants 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Nursen Gurtunca*1 and Selma Feldman Witchel2
1Childrens Hosp of Pittsburgh of UPMC, Pittsburgh, PA, 2Children's Hosp of Pittsburgh of UPMC, Pittsburgh, PA

 

Premature pubic hair development (PP), advanced bone age (BA), acne, hirsutism, and irregular menses can be associated with non-classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency (NCAH). Identification of girls with NCAH is important because of the increased risks for progressive symptoms of androgen excess, infertility, and need for genetic counseling (1). Adrenal crisis may occur when ACTH-stimulated cortisol responses are < 18 mcg/dl. To characterize typical clinical features, we classified 8 girls with NCAH into 3 groups according to CYP21A2 genotype: 1) homozygous for mild mutations; 2) heterozygous for a mild mutation and I172N; and 3) heterozygous for a mild mutation and a severe mutation.

Four girls (age range 6-10.3 yrs) presented with PP and advanced BA. A 13.6 yo girl presented with acne unresponsive to treatment. Three girls (age range 14-17.5 yrs) presented with secondary amenorrhea. Two of 8 girls had minimal clitoromegaly. Basal and ACTH-stimulated 17-OHP levels were elevated in all girls, (mean ± SD; 1900±2491 ng/dl and 8401 ± 6816 ng/dl, respectively). Androstendione levels were elevated for age in 6/7 girls. DHEAS was normal in 6/7 girls. ACTH-stimulated cortisol level was < 18 mcg/dl in 4 girls; 3 girls had presented with PP and carried a mild mutation on one allele and a severe mutation on their second allele. The 4th girl carried a mild mutation on one allele and I172N on her other allele. The 3 girls homozygous for mild mutations (V281L or P30L) had ACTH-stimulated cortisol levels >20 mcg/dl; all 3 girls were > 13 yo. Younger age at presentation was correlated with more severe genotype, p<0.05. Basal (p<0.005) and ACTH-stimulated cortisol (p<0.05) were inversely correlated with severity of mutations.

Symptoms of androgen excess due to NCAH can mimic isolated premature adrenarche in prepubertal girls and PCOS in older girls. In our patients, basal 17-OHP and androstendione levels were elevated. DHEAS levels were not elevated despite increased adrenal androgen secretion. Therapy for girls with NCAH can include hydrocortisone (HC) replacement and/or oral contraceptives (OCPs) in adolescent girls. Three girls who presented with PP had advanced BA, ACTH-stimulated cortisol responses < 18 mcg/dl, and carried a severe mutation on one allele. These younger girls have been started on HC therapy to slow the rate of BA maturation, decrease risk of adrenal crisis, and preserve height potential. In contrast, homozygosity for mild mutations was associated with later age at presentation and normal ACTH-stimulated cortisol response indicating lower risk for acute adrenal insufficiency. OCPs may be sufficient to control the symptoms of androgen excess in the older girls. Nevertheless, knowledge of NCAH improves outcome for live born infants for women with NCAH (2). Most importantly, therapy for girls with NCAH needs to be individualized.

 

Nothing to Disclose: NG, SFW

19061 3.0000 SAT-146 A ACTH-Stimulated Cortisol Responses and CYP21A2 Genotype in Girls with Non-Classical Congenital Adrenal Hyperplasia (NCAH) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Richard J Ross*1, Oliver Blankenstein2, Sarah Spielmann3, Martin J Whitaker4 and Heiko Krude5
1Univ of Sheffield, Sheffield, United Kingdom, 2Charité Universitätsmedizin Berlin, Berlin, Germany, 3Charité Universitätsmedizen Berlin, Germany, Berlin, Germany, 4University of Sheffield, 5Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany

 

Background: Treatment of neonates and infants with adrenal insufficiency is unsatisfactory as unlicensed hydrocortisone formulations are used that are frequently out of the recommended dosage ranges.  To address this we undertook a survey of current prescribing practice and developed a novel hydrocortisone formulation, Infacort®. Methods: Through the monthly newsletter of ESPE (European Society of Paediatric Endocrinology), healthcare providers across Europe were asked to specify their current practice in the treatment of neonates, infants and children under 6 years of age with adrenal insufficiency by answering a short online questionnaire. The survey comprised eleven questions with options for comments. To guide development of a new hydrocortisone formulation the questionnaire included an open question for criteria of an “optimised hydrocortisone-preparation”. Results: Over a period of six months 67 participants from 16 countries participated in the online survey, with the majority of replies coming from Germany (48%). 92% of participants were health care professionals, 46% stated that they were working in a university hospital setting and 25% in a specialized paediatric endocrine practice. The most commonly used hydrocortisone formulation was “licensed tablets to be divided” (60%), followed by prescription of individualized capsules (55%). The prescribed dosage of hydrocortisone for children with adrenal insufficiency varied from 0.5mg to 5mg given once to four times daily, with 1mg and 2mg being the most common doses (82% and 68%). The majority of responders recommended administration at fixed intervals (64%) or with meals (19%). Schemes of administrating hydrocortisone once or twice daily were also reported using tablets licensed for adult use. The use of a liquid suspension was the most favoured answer with respect to the use of “other” forms of administration. Conclusions: A wide variety of hydrocortisone treatment regimens are administered to neonates and infants. Dosage varies between 0.5 to 5 mg, most common being 1 & 2 mg. In some cases, adult tablets are being used with a lower dosage frequency (once or twice daily) and the practice of dividing adult tablets into halves or quarters and the dispensing of capsules containing crushed tablets is common. Clinicians favoured the development of a liquid formulation. A new preparation of hydrocortisone – Infacort® - dry granules with a taste masking layer stable for at least 5 minutes in aqueous media and produced in unit doses of 0.5, 1, 2 and 5 mg was developed. A dry preparation rather than liquid was chosen as it has greater stability and was considered easier to administer accurately. Infacort® has been shown to be safe, well tolerated, of neutral taste, and bioequivalent to hydrocortisone licensed for adults in adult human volunteer studies.

 

Acknowledgements: Funded by the European Commission (HEALTH-FP7; Project No: 281654)

 

Disclosure: RJR: Board Member, Diurnal. MJW: Employee, Diurnal. Nothing to Disclose: OB, SS, HK

19765 4.0000 SAT-147 A Paediatric Endocrinologists' Survey on Current Glucocorticoid Treatment of Adrenal Insufficiency in Neonates and Infants and Development of Infacort® Oral Hydrocortisone Granules 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Richard J Ross*1, Silvia Hummel2, Roberta Ara2, Susannah Sadler2, Simon Dixon2 and Martin J Whitaker3
1Univ of Sheffield, Sheffield, United Kingdom, 2University of Sheffield, Sheffield, United Kingdom, 3University of Sheffield

 

Aim: Patients with Congenital Adrenal  Hyperplasia (CAH) have poor health  outcomes and this has a profound effect on patients’ lives and on the associated costs for healthcare providers.  CAH directly affects patients’ health related quality of life, puts them at risk of potentially life-threatening adrenal crisis , and increases their risk of cardiovascular disease (CVD), bone fractures (due to the side effects of long-term steroid use),  obesity and infertility, relative to the general population (1). This study estimates the lifetime disease burden associated with classic CAH in adults, including excess mortality.

Methods: In order to estimate the lifetime burden of all the clinical manifestations of CAH, a mathematical modelling approach was used to bring together existing evidence.  The model was developed in Excel and comprises several sub-models, each addressing different health consequences of CAH for adults from age 18 years.   The model synthesises evidence from multiple clinical and epidemiological studies describing the health outcomes for diseases related to classic CAH.

Results: Preliminary results show on average adults with CAH will implement “sick day rules” (doubling or tripling glucocorticoid and/or use of parenteral therapy) 171 times over their lifetime, and attend hospital for adrenal crisis on 11 occasions. In a population of 1,000, over 200 will die of a condition complicated by adrenal crisis resulting, on average, in a loss of 7 years of life. CAH patients may also suffer from excess CVD events and mortality. Treatment with glucocorticoids almost doubles the risk of bone fractures in CAH patients compared to the general population, leading on average to an additional 0.8 fractures per CAH patient over their lifetime.  Exploratory modelling suggests over 20% of women with classic CAH are likely to seek assisted conception, although overall only 13.5% will achieve fertility, with or without treatment.  Potential effects CAH and its treatment on the risk of diabetes were also considered.

Conclusions: This is the first attempt to model the clinical pathway and overall disease burden of CAH and naturally has the limitations of using historical cross-sectional data from different populations. Development of the model has highlighted gaps in the evidence, particularly intensity of care for CAH and adrenal crisis, and the relationship between control of CAH and risks of CVD, osteoporosis, diabetes and infertility. This modelling approach has the potential to assess the long-term impact of therapeutic improvements in terms of clinical events and costs.

 

  1. Han TS, Walker BR, Arlt W, Ross RJ. Treatment and health outcomes in adults with congenital adrenal hyperplasia. Nat Rev Endocrinol. 2014;10(2):115-24.

Acknowledgements: Funded by the European Commission (FP7-HEALTH; TAIN No:281654)

 

Disclosure: RJR: Board Member, Diurnal. MJW: Employee, Diurnal. Nothing to Disclose: SH, RA, SS, SD

20357 5.0000 SAT-148 A A Model of the Health Burden of Congenital Adrenal Hyperplasia in Adults 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Ahmed M Khattab*, Mabel Yau and Ariella Genny Barhen
Icahn School of Medicine at Mount Sinai, New York, NY

 

Congenital adrenal hyperplasia (CAH) owing to 21-hydroxylase deficiency is caused by the autosomal recessive inheritance of mutations in the CYP21A2 gene.  CYP21A2 mutations lead to variable impairment of the 21-hydroxylase enzyme, in turn, dictating three clinical phenotypes, namely salt wasting, simple virilizing, and non-classical CAH. 

We herein, review the medical and social long term outcome of three 46,XX males with classical simple virilizing CAH, confirmed clinically, geneticaly and hormonally.

The first patient is a now 27 year old 46,XX patient who was raised continiously as a male since birth. He was diagnosed at age 5 years when he presented with Pubic hair, axillary hair and odor. He underwent bilateral mastectomy, right neprectomy, hysterectomy, salphingo-oophorectomy, vaginectomy, urogenital sinus & chordee and prosthetic testicular implantationat age 12 years. A year later, he underwent second stage hypospadias repairfollowed by a urethroplasty.  He is currently happily married with a reported normal sexual life and considering adoption.

The second patient, who is now 49 years old, presented at 28 years of age for medical support to legally reassign sex from female to male on his birth certificate. The history of the patient revealed that he was was legally assigned at birth to the male sex and was then reassigned to the female sex by a pediatric endocrinologist after the diagnosis of SV CAH was made at the age of 4 months and the patient underwent a clitoral resection and vaginolasty. Although his birth certificate was changed to that of a female, he nevertheless continued to be raised as a male by his family. After years of poor compliance, the patient reappeared at 11 years of age extremely virilized and menstruating. Further clitoral resection and vaginolasty were performed with parental consent but against the patient's own wishes. By adulthood, the patient had a firmly established male gender identity and was sexually attracted to females. The patient is now happily married to a female who has two children. His wife reports him to be an excellent father.

The third patient is now 26 years old and an avid soccer player. He was diagnosed at 8 years of age. He was continuously raised as a male since birth eventhough his parents knew of his 46,XX karyotype. The parents continue to raise him as a male because he was the breadwinner for the family as a soccer player.  

The sex of rearing and reassignment in 46,XX males is a very complex problems that requires multidiscplinary care.

 

Nothing to Disclose: AMK, MY, AGB

21252 6.0000 SAT-149 A Three 46,XX Males with Classical Congential Adrenal Hyperpasia. Data Includes: Genotype, Phenotype and Psycosocial Evaluations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Fernanda Cavalieri Costa*1, Marilia Almeida Cardoso2, Nathalie Oliveira Santana2, Guiomar Madureira1, Berenice B Mendonca2, Larissa Garcia Gomes2 and Tania A Bachega2
1Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2School of Medicine, Sao Paulo University, Sao Paulo, Brazil

 

CAH therapy is mainly based on glucocorticoid (GC) and/or mineralocorticoid replacements. Even those patients with good adherence may fluctuate periods of hyperandrogenism and hypercortisolism. Patients can also develop central precocious puberty. All together may compromise CAH patient final height (FH), usually ~ -1.4 SD below normal population. Ciproterone acetate (CP) is an antiandrogenic drug, with glucocorticoid and progestin activities, which might be useful in controlling bone maturation and CAH puberty development; and therefore improving FH. Objective: To analyze the impact of CP therapy on final height of CAH. Patients: 33 patients (16 Fem): 13 of them with the salting wasting (SW), 11 with the simple virilizing (SV) and 9 with the nonclassic (NC) form. The diagnosis of SW patients was at neonatal period, the SV and NC patients at mean chronological age (CA) of 2.7±2 and 7±2 yrs, respectively. Mean CA and bone age (BA) at the beginning of CP therapy was 7.3±2.2 yr and 10.8±2.5 yr, respectively, and mean SD of height adjusted for BA of classical (CL) and NC patients were -2.4±1.2 and -1.0±0.4, respectively. All patients, except one, had basal serum LH > 0,6 U/L or after-LHRH > 6,9 U/L. CP was started at mean doses of 75 mg/m²/d and, subsequently, GC doses were adjusted.  Hormonal control aimed to maintain testosterone levels <14 ng/dL and androstenedione levels <2 ng/mL, without 17OHP suppression. Height was described as SD and predicted FH was evaluated by average Bayley-Pinneau method.  In the statistical analyses t-test was used. Results: Mean duration of CP therapy was 3.3±1.9 yr and mean BA advancement was 1.7±1.7 yr. Mean CP dose was 69.7±19 mg/m²/d, mean cortisone acetate dose decreased from 19±5 to 10±4.8 mg/m²/d in CL patients and from 15±4 to 5.6±2 mg/m²/d in NC patients. Predicted FH for females at the beginning and the end of CP therapy were 146±7.2 and 153±8.3 cm, respectively, and for males were 155.4±10.6 and 160.6±10.4 cm, respectively (p<0.02 for both comparisons; power of  test 0.99). The mean height gain during CP therapy was 15 ± 6 cm. FH was achieved in 22 (16F) patients, there was no difference between mean FH and mean target height (TH) (160±10.5 and 165±9.8 cm, respectively, p>0.05). Mean SD of FH was -0.9±1.1 and mean SD of TH was -0.5±1.0. Except for weight gain in 2 patients, no adverse effects were observed. Conclusion: CP therapy was efficient in controlling BA maturation in pubertal CAH patients with advanced bone age. Moreover, CP therapy restores the growth potential for achievement of FH within the normal range of TH.

 

Nothing to Disclose: FCC, MAC, NOS, GM, BBM, LGG, TAB

21797 7.0000 SAT-150 A Ciproterone Acetate Improves the Final Height Achievement of Patients with Congenital Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Juilee Rege*1, Adina F. Turcu2, Robert Chomic1, Richard J. Auchus1, Paul Jerome Bernard3 and William E. Rainey1
1University of Michigan, Ann Arbor, MI, 2The University of Michigan, Ann Arbor, MI, 3Pediatric Endocrine Specialists of Georgia, Duluth, GA

 

Context: Adrenarche refers to the gradual increase of adrenal dehydroepiandrosterone (DHEA) and DHEA-sulfate (DHEA-S) around 6 years of age and results from the expansion and differentiation of the human adrenal zona reticularis (ZR). The phenotypic hallmark of adrenarche is the appearance of axillary and pubic hair. Sulfotransferase type 2A1 (SULT2A1) is localized in the human ZR where it sulfonates the 3β-hydroxyl group of the Δ5-steroids and is thus responsible for the biosynthesis of DHEA-S. SULT2A1, along with DHEA-S, has also been known to be a marker for the onset of adrenarche. Although SULT2A1 has a broad substrate specificity that includes other Δ5-steroids, little is known about the adrenal production of other Δ5-steroid sulfates during adrenarche.

Objective: To profile the levels of Δ­5-steroid sulfates including pregnenolone sulfate (Preg-S), 17α-hydroxypregnenolone sulfate (17OHPreg-S), 5-androstenediol sulfate (Adiol-S) and DHEA-S before and after the onset of adrenarche.

Methods: Serum samples were collected from 14 children from ages 2-6 years (7 girls and 7 boys), 14 children from the ages 7-10 years (7 girls and 7 boys), and 16 children from the ages 11-14 years (8 girls and 8 boys). LC-MS/MS was used to quantify serum Δ5-steroid sulfates. In short, 10 μL serum was extracted by 50:50 (v/v) chloroform/2-butanol mixture, the organic phase was evaporated to dryness under nitrogen and reconstituted in 200 μL of 50:50 (v/v) MeOH/ water. 20 μL of the reconstituted samples was applied to a biphenyl column and eluted with a mobile-phase gradient of 15–98% methanol in water. The column eluent was subjected to electrospray ionization, and the analytes were detected by a triple quadrupole mass spectrometer.

Results: DHEA-S was the most abundant Δ5-steroid sulfate in all age groups, followed by Adiol-S, Preg-S and 17OHPreg-S respectively. Serum DHEA-S levels were lowest during ages 2-6 years (18.9±6.8 μg/dL) after which they increased by 2.3-fold during ages 7-10 years, followed by a further 3-fold rise between ages 11-14 years. An age-related increase in circulating Adiol-S was also observed. In contrast, Preg-S remained constant during the first decade of life after which it showed a significant increase between ages 11-14 years; whereas 17OHPreg-S levels did not change between ages 2-14 years.  

Conclusion: The current study quantifies four Δ5-steroid sulfates by LC-MS/MS during adrenarche. Our data indicate that the onset of adrenarche can be characterized by increases in both Adiol-S and the conventional marker DHEA-S. These data also suggest that in addition to DHEA-S, Adiol-S may provide a substrate for peripheral tissue production of more potent androgens, including testosterone.

 

Disclosure: RJA: Consultant, Corcept, Investigator, Novartis Pharmaceuticals, Investigator, Quest Diagnostics, Advisory Group Member, Laboratory Corporation of America. WER: Scientific Board Member, Atterocor. Nothing to Disclose: JR, AFT, RC, PJB

21920 8.0000 SAT-151 A Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) Analysis of Serum Δ5-Steroid Sulfates during Human Adrenarche 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Kenichi Miyako*, Yuichi Mushimoto and Atsuko Kawano
Fukuoka Children's Hospital, Fukuoka, Japan

 

Background: Hyperpigmentation of the skin is an important symptom of life-threatening adrenal insufficiency, and is caused by increased ACTH secretion. However, babies with hyperpigmented skin often present with normal adrenocortical function. Here, we report a detailed analysis of adrenocortical function in babies with hyperpigmented skin.

Case 1: A 4-month-old boy was born by normal delivery without complications. Newborn screening for congenital adrenal hyperplasia was normal. At the age of 4 months he was referred to our hospital due to hyperpigmentation of the skin. He had no symptoms of adrenal insufficiency or abnormalities in serum electrolytes.  Endocrinological evaluations were as follows: ACTH, 154 pg/ml; cortisol, 13.6 μg/dl; and 17α-hydroxyprogesterone, 0.3 ng/ml. A CRH provocation test showed normal ACTH (44.0 → 73.7 pg/ml) and cortisol (15.9 → 21.4 μg/dl) responses. The circadian periodicity of plasma ACTH and cortisol levels were also normal. Ultrasonography revealed no hypertrophy of the adrenal gland. He was diagnosed with normal adrenocortical function; the skin pigmentation is decreasing at the age of 7 months.

Case 2: A 3-month-old boy was born by normal delivery without complications. At the age of 1 month he had hyperpigmented skin, and was referred aged 3 months. He had no symptoms of adrenal insufficiency and serum electrolytes were normal. Endocrinological evaluations were as follows: ACTH, 31.3 pg/ml; cortisol, 12.6 μg/dl; and 17α-hydroxyprogesterone, 0.7 ng/ml. An ACTH provocation test showed normal cortisol (12.6 → 31.3 μg/dl) and 17α-hydroxyprogesterone (0.7 → 2.1 ng/ml) responses. The circadian periodicity of plasma ACTH and cortisol levels were normal, and ultrasonography revealed no hypertrophy of the adrenal gland; therefore, he was diagnosed with normal adrenocortical function. At the age of 5 months his skin remains hyperpigmented.

Case 3: A girl aged 19 months was born without complications, but was followed due to skin hyperpigmentation since birth. Normal CRH and ACTH provocation test results, ultrasonography, and circadian periodicity of plasma ACTH and cortisol levels revealed that she had normal adrenocortical function.

Conclusion: Despite the possibility of life-threatening adrenal insufficiency, some babies with hyperpigmented skin have normal adrenocortical function. Although the cause of skin hyperpigmentation in such babies remains unclear, it might be caused by hypersensitivity to stress or hyper-responsiveness of the ACTH/MSH receptor.

 

Nothing to Disclose: KM, YM, AK

18611 9.0000 SAT-152 A Analysis of Adrenocortical Function in Babies Who Present with Hyperpigmentation of the Skin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Marilza Leal Nascimento*1, Laura Burigo Lima1, Genoir Simoni1, Edson Cechinel1, Rose Marie Linhares1, Juliana van de Sande Lee1, Denise Bousfield da Silva2, Jose Antonio de Souza2 and Paulo Cesar Silva1
1Joana de Gusmao Childrens Hospital, Florianopolis, Brazil, 2Joana de Gusmao Childrens Hospital, Florianopolis

 

Introduction: Adrenocortical cancer is rare, but the incidence in Southern Brazil is 10 to 15 times higher than worldwide. The reason for the increased incidence is not yet fully understood, but the presence of a germ line mutation in the tumor suppressor gene p53, found in most of the affected children, appears to be associated with a higher risk.

Objective:To evaluate the clinical and epidemiological profile, treatment and the presence of p53 gene mutation of children with adrenal cortical cancer at a pediatric reference center in Southern Brazil.

Patients and Methods: Descriptive, retrospective study of 56 children with adrenal cortical cancer treated at Hospital Infantil Joana de Gusmão, Florianópolis, Santa Catarina, Brazil from January 1980 to December 2013. The data analyzed were age at diagnosis, sex, clinical presentation, the presence of p53 gene mutation, staging and treatment performed.

Results: The mean age at diagnosis was 3 years and 3 months. Of the 56 cases, 58.9% were girls. The most frequent manifestation was isolated virilization, in 64.3% of the patients, followed by virilization with Cushing in 25% of the cases. Stage I was found in 32.1% of cases, stage IV in 21.4% and in 21.4% staging was not specified. Isolated surgical treatment was performed in 55.3% of patients, surgery with chemotherapy in 37.5%. Three patients did not undergo surgery because of unresectable tumor. Fourteen patients (25%) died and of these, 71.4% were stage IV at diagnosis. None were stage I. The mutation of the p53 gene was found in 80% of the 20 patients in whom it was performed.

Conclusion: Adrenocortical cancer occurred mostly in very young children and its main clinical presentation was virilization. Girls were slightly more affected than boys. It’s a highly aggressive type of tumor, with a poor prognosis in advanced stages. The p53 gene mutation is very frequent in our patients.

 

Nothing to Disclose: MLN, LBL, GS, EC, RML, JVDSL, DBD, JAD, PCS

21453 10.0000 SAT-153 A Adrenocortical Cancer: Experience of a Pediatric Reference Center in Southern Brazil 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Monica Grover*1, Richard D. Stevenson2, Mark R Conaway3 and Christine M. Houlihan4
1University of Virginia, Charlottesville, VA, 2University of Virginia, VA, 3University of Virginia, 4Children's Hospital of The King's Daughters, VA

 

Objective:

To evaluate bone density and strength using peripheral QCT (pQCT), in pre-pubertal children with cerebral palsy (CP) from ages 5-10 years compared to age and sex matched healthy controls longitudinally. Children with CP typically have smaller bones with thinner cortex. Hence, areal bone density as measured by Dual energy x-ray absorptiometry (DXA) is not an accurate tool.

Methods:

Children with CP were grouped based on Gross Motor Function Classification System (GMFCS) into I-II (community ambulation) and III-V (limited or no ambulation). Exclusion criteria included bisphosphonate use, known genetic disorder or chronic medical diseases affecting growth and bone health. 3 scans using Stratec XCT-2000 device (Orthometrix, White Plains, NY)  were obtained at 12 months interval over 2 years.

The length of radius and tibia was measured using a segmometer. Initial scout view was obtained to place the reference line at the proximal border of the growth plate. Trabecular analysis was obtained at 4% and cortical analysis at 20% proximal to reference line. General linear mixed model was used for statistical analysis and p<0.05 was considered significant.

Results:

66 scans (29 children, 11 males) on controls and 23 scans (13 children, 6 males) on children with CP were obtained. Mean age of children with CP and controls was not statistically different. As compared to controls, CP GMFCS III-V had significantly lower cortical bone mineral content (BMC) (p 0.002), bone mineral density (BMD) (p 0.013), cortical area (p 0.004), periosteal circumference (p 0.004) and polar Strain Strength Index pSSI (p 0.005) at tibial 20% site. There was a trend toward lower cortical thickness (p 0.08) in GMFCS III-V but endosteal circumference was not significantly different as compared to controls. Rate of change of periosteal and endosteal circumference was less in CP GMFCS III-V (p of 0.036 and 0.023 respectively). As compared to controls, CP GMFCS III-V had significantly lower trabecular BMC (p 0.017), bone strength index (BSI) (p 0.05), and area (p 0.013) at tibial 4% site.

Discussion: Radiation exposure of pQCT is comparable to DXA and it provides volumetric and geometric data. Tibial cortical and trabecular bone was worse as expected in non-weight bearing children with CP GMFCS III-V. Endosteal bone needs to be resorbed to form new periosteal bone and this process may be affected in children with CP. Biomechanical studies have demonstrated correlations between fracture load and bone strength indices measured by pQCT. We need larger cohort and longer duration of studies to further elucidate the mechanism and fracture risk. By understanding the pathophysiology in this patient population better, we can hope to optimize preventive strategies, early gains, and reduce subsequent bone loss, fracture risk and the associated morbidity.

 

Nothing to Disclose: MG, RDS, MRC, CMH

20678 11.0000 SAT-154 A Accrual of Bone Mineral Density in Children with Cerebral Palsy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Katherine K Barnett*1, Patricia Poitevien1, Resmy Palliyil Gopi2 and Bina Shah3
1New York University School of Medicine, 2NYU School of Medicine, New York, NY, 3New York University School of Medicine, New York, NY

 

Background:

Cyclic intravenous pamidronate therapy has been successfully used to treat children and adolescents with Osteogenesis Imperfecta (OI) and other bone disorders.  Zoledronic acid (ZOL) is a newer bisphosphonate with higher potency and shorter infusion time that has been indicated for the treatment of adult osteoporosis.  However, there is limited data on its side effect profile and effect on bone turnover in children and adolescents with bone disorders.

Methods:

We performed a retrospective chart analysis of clinical and biochemical findings in 8 children and adolescents who were treated with ZOL.  They included 5 children with OI, 1 with osteoporosis with fractures, and 2 with avascular necrosis (AVN) of the femoral head.  Subjects received an initial dose of 0.0125 mg/kg if they were bisphosphonate-naïve or 0.025 mg/kg if bisphosphonate non-naïve infused over 30 to 60 minutes.  Patients received 3 or 4 cycles of ZOL for a total dose of 0.1 mg/kg over approximately 6 months. All patient charts were reviewed for side effects.  Bone turnover markers, serum alkaline phosphatase and osteocalcin, before and after treatment were assessed for all patients.  In addition, for the OI group, DEXA scan lumbar spine (LS) BMD Z-scores and fracture history were reviewed before and after treatment.

Results:

Mean age at start of ZOL treatment was 10.1 years (range 2 to 16).  Average duration of treatment was 7 months (range 5 to 11).  Four patients had received prior treatment with pamidronate. During ZOL treatment, 3 patients developed transient post-infusion hypocalcemia, 1 developed mild hyperkalemia, 2 developed low-grade fever, and 3 had other symptoms including nausea, vomiting, fatigue, body aches, headache, dyspepsia, abdominal pain, and foot pain.  Serum total alkaline phosphatase levels decreased on average by 24% after three infusions (p=0.037).  There was no significant change in the serum levels of osteocalcin before and after treatment.

In the OI group, average LS BMD Z-score increased from -3.8 to -2.1 after ZOL therapy.  There was reduction in the number of fractures after ZOL therapy compared to baseline. Mean number of fractures pre-treatment since birth was 8.3, whereas mean number of fractures during ZOL treatment and follow-up for 12 months was 0.75.  Two patients had significant improvement in mobility after ZOL.  Growth was normal, with no change in mean height Z-score at baseline and follow-up in all patients. 

Conclusions:

Intravenous ZOL demonstrates short-term safety and efficacy in the treatment of children and adolescents with OI and offers a more convenient infusion protocol than pamidronate. Our study shows that ZOL therapy promotes both clinical and radiological benefit in the form of reduction of number of fractures and increase in bone mineral density on DEXA scan. Further studies are necessary to establish long-term safety and efficacy of ZOL for OI and other pediatric bone disorders.

 

Nothing to Disclose: KKB, PP, RP, BS

18206 12.0000 SAT-155 A Safety Assessment and Biochemical Marker Response Following Intravenous Zoledronic Acid in Children and Adolescents with Osteogenesis Imperfecta and Other Bone Disorders 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Christine Therese Ferrara* and Michael A. Levine
The Children's Hospital of Philadelphia, Philadelphia, PA

 

Acrodysostosis is an autosomal dominant skeletal dysplasia characterized by short stature, bracydactyly, and characteristic facial features.  Resistance to multiple hormones (ADOHR) that utilize cAMP signaling is common in patients with PRKAR1A mutations, which encodes cAMP-dependent protein kinase type 1α regulatory subunit protein, but not in patients with mutations in PDE4D.  ADOHR shares many features with Pseudohypoparathyrodism type 1a, in which inactivating mutations in the maternal allele of GNAS also disrupt cAMP-dependent signaling. Hence, these two disorders are incomplete phenocopies. We performed a comprehensive biochemical and molecular analysis of affected members of a three-generational family in which short stature and multi-hormone resistance were maternally inherited. The proband was an ex-26 week female born to nonconsanguineous parents of European background. On day of life 7, she developed severe hypocalcemia (Ca 5.6 mg/dL, ionized Ca 0.85 mmol/l) and elevated phosphorus (7.4 mg/dL).  She was subsequently noted to have elevated levels of intact PTH (422 pg/mL) and 1,25(OH)2D (127 pg/mL) with normal 25(OH)D (37.3 ng/mL) and begun on calcitriol therapy. The newborn screen showed a low thyroxine level at 4.5 mcg/dL (normal >6 mcg/dL) and an elevated TSH 17.6 uIU/mL (normal <28.5 uIU/mL), and L-thyroxine therapy was imitated. Over the past five years of life she has remained in the 5%ile (Z -1.5 to -2.2) for height and 5-15%ile (Z -0.5 to -1) for weight. She does not have bracydactyly, specific craniofacial features, or subcutaneous ossifications. Growth factors IGF-1 and IGFBP3 have been in the normal range for age throughout life. The patient’s mother is 65” and has bracydactyly type E with shorting of the 4th metacarpals bilaterally as well as hypothyroidism. The maternal grandmother is 64” and has shortened thumbs and 4thmetacarpals (bracydactyly type D and E) without thyroid or parathyroid abnormalities; one maternal aunt has hypothyroidism and bracydactyly type E.  Family history is notable for a lack of calcium abnormalities and both mother and maternal grandmother had normal menstrual cycles. Analysis of the GNAS locus, including sequencing of GNAS exons 1 through 13 and evaluation of methylation of differentially methylated regions (DMRs) for NESP55, XL, and A/B were normal, ruling out PHP types 1a and 1b. Whole exome sequencing of affected subjects revealed a novel PRKAR1A missense mutation (c.727C>T) that leads to an amino acid substitution (p.R243W) in cAMP binding domain A that is predicted to impair dissociation from the catalytic unit of protein kinase A. Remarkably, this family demonstrates genetic anticipation in the development of the endocrine manifestations of the PRKAR1A mutations in affected members. Moreover, this family further emphasizes the confusing overlap between ADOHR and PHP 1a, and demonstrates the utility of genetic diagnosis.

 

Nothing to Disclose: CTF, MAL

18871 13.0000 SAT-156 A Acrodysostosis with Hormone Resistance Due to a Novel PRKAR1A Mutation: Clinical Overlap with Pseudohypoparathyroidism Type 1A 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Gregory Goodwin* and David T Miller
Children's Hospital of Boston, Boston, MA

 

Background: Atypical presentations of disease causing mutations may elude diagnosis based on clinical findings only.  The presence of multiple disease causing mutations may further elude diagnostic precision.  Whole exome or genome sequencing (WES/WGS)can be an extremely useful technology for rendering accurate diagnosis in complex cases with multisystem disorders.

 A now 6 year old male infant was found to have severe dry skin shortly after birth and he was diagnosed with ichthyosis and treated effectively with moisturizers. At 6 weeks of age he was admitted to the hospital for failure to thrive and was found to have hyperphosphatemia, hypocalcemia and low parathyroid hormone (PTH).  His hypoparathyroidismwas effectively treated with calcitriol, calcium supplements and low phosphate formula.  He was subsequently diagnosed with global developmental delays and expressive speech delay. He had failed a newborn hearing screen and subsequent hearing evaluations ultimately rendered a diagnosis of mild to moderate bilateral hearing loss.  Hearing aids were prescribed at 4 years of age.

In follow up he was also noted to have short stature (1% )while the mid-parental height was 75%. The patient had several negative diagnostic tests, including karyotype, chromosomal microarray,22q11 deletion studies and CASR sequencing.  His Igf-1 and Igf-BP3 were normal.  WGS  followed by analysis using commercial software (Ingenuity) and Sanger confirmation of reported variants revealed a de novo novel GATA3 c.192C>A;p.Tyr64Term nonsense mutation, and a novel maternally inherited hemizygous STS c.1679A>G/p.Gln560Arg missense mutation. GATA3 mutations are associated with HDR syndrome (hypoparathyroidism, deafness, renal disease).  Our patient did not have renal disease but HDR cases without renal disease have been described.  Developmental delay and short stature have also been reported in this syndrome.  Mutations in the steroid sulfatase gene STS cause X-linked ichthyosis in males. 

 Conclusion: WGS identified two novel mutations, one causing hypoparathyroidism and hearing loss (HDR syndrome) and the other causing X-linked  ichthyosis, demonstrating the power of WGS in identifying the etiology of complex multisystem clinical disorders.

 

Nothing to Disclose: GG, DTM

21292 14.0000 SAT-157 A A Case of Congenital Hypoparathyroidism, Congenital Ichthyosis, Hearing Loss and Short Stature. the Utility of Whole Genome Sequencing in Identifying Novel Disease Causing Mutations 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Yasuko Tanaka*1, Yasuhiro Naiki2, Akiko Yamamoto1, Masaki Takagi3, Tomonobu Hasegawa4 and Reiko Horikawa5
1National Center for Child Health and Development, Tokyo, Japan, 2Natl Ctr for Child Hlth & Dev, Tokyo, Japan, 3Tokyo Metropolitan Children's Medical Center, Tokyo, Japan, 4Keio Univ Sch of Medicine, Tokyo, Japan, 5Natl Cntr Child Health & Dev, Tokyo, Japan

 

Background: OI is a disorder of increased bone fragility due to low bone mass that varies in clinical severity. Currently, OI is categorized into 15 types. OI type X is an autosomal recessive disorder due to biallelic inactivating mutations in SERPINH1 gene, which encodes collagen-binding protein that functions as a chaperone in endoplasmic reticulum (ER). Clinically, OI type X is characterized by multiple bone deformities and fractures, generalized osteopenia, dentinogenesis imperfecta, and blue sclera.

Here we report the siblings with OI type X diagnosed by gene analysis, who showed mild to moderate clinical feature.

Cases:  The proband is a 3-year-old boy. He showed IUGR and was identified to have mild bowing of femurs and bell-shaped chest in utero. He was born by cesarean section in 34 weeks of gestation without any fractures.  Radiological findings during newborn period showed markedly thin cranium, bowings of long bones of extremities, and thin diaphysis of tubular bones. In newborn period, Clinical and radiological diagnosis was OI type I/III. Genetic analysis was performed and novel compound heterozygous mutations (R222H/D416E) were identified in SERPINH1 gene.  R222H mutation locates in HSP47 legion and D416E mutations locates in RDEL ER retention signal legion. In vitro analysis revealed that D416E mutation caused retention failure of HSP47 in ER and loss-of-function as a chaperone. The genetic diagnosis was made as OI type X.  The parents were confirmed to be heterozygous carriers. The patient has blue sclera and dentinogenesis imperfecta.  He has been treated with cyclical bisphosphonate infusion from 1 month old. During first 15 months he experienced bone fracture 6 times, but no fractures during next 2 years. Bisphosphonate treatment was discontinued at 2 years of age.  DEXA scan at 3 years 7 months old showed BMD 0.268 g/cm2.   

A younger sister, now is 1 years old, was born small for gestational age after IUGR in utero. She did not show any deformity in long bones, thorax, nor blue sclera. Genetic analysis revealed that she has same compound heterozygous mutation in SERPINH1 gene. Radiological findings showed thin cranium and diaphysis of long bones, however, she has not experienced bone fractures so far.

Conclusion:  We report second and third sibling cases with OI type X. Their phenotype is mild ~ moderate, when compared to the first reported case who died at age 3, suggesting the wide phenotypic variation in OI type X.

 

Nothing to Disclose: YT, YN, AY, MT, TH, RH

19550 15.0000 SAT-158 A Mild to Moderate Phenotype in Siblings with Osteogenesis Imperfecta (OI) Type X Caused By Novel Mutations in SERPINH1 Gene 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Maria Eleni Nikita*, Robert M Sheets and Carla Demeterco-Berggren
UCSD/Rady Children's Hospital, San Diego, CA

 

Background: Pseudohypoparathyroidism (PHP) is a heterogeneous group of disorders whose common feature is end-organ resistance to PTH. PHP type 1a syndromes, are due to inactivating mutations in the gene GNAS1 encoding the α subunit of the stimulatory G protein. Patients with PHP-1a may also present with resistance to other hormones and with Albright hereditary osteodystrophy (AHO) features. Individuals with paternally inherited GNAS mutations have features of AHO without hormonal resistance, and have been described to have pseudopseudohypoparathyroidism (PPHP), progressive osseous heteroplasia or osteoma cutis based on the clinical phenotype. We report a case of PPHP with a probable novel mutation in GNAS 1 gene with associated gouty arthritis.

Clinical case: The patient is a Hispanic male who presented at 13 years with developmental delay, short stature, soft tissue calcifications and heterotopic bone consistent with AHO. Physical examination was significant for obesity, short fourth metacarpal and brachydactyly. The diagnosis of PHP was entertained but evaluation was negative for hormonal resistance. Interestingly the patient was found to have autoimmune thyroiditis. GNAS1 gene testing was requested that revealed a probable novel mutation, IVS4+1A>T in the intronic region of exon 4. At age 17 he was admitted to the hospital with fever, edema and pain in his left knee and on the left first MTP joint. Upon admission, uric acid level was significantly elevated. Aspiration of the left knee revealed uric acid crystals. A biopsy of the synovium was consistent with granulomatous changes of gout. He was started on prednisone and symptoms improved. Family history is negative for gout or other rheumatologic conditions.

Conclusion To our knowledge this is the first report of association of PPHP and gouty arthritis. A large variety of mutations in the GNAS1 gene have been identified to cause PHP and AHO. The novel mutation in our case could add to the spectrum of mutations associated with this disorder.

 

Nothing to Disclose: MEN, RMS, CD

19651 16.0000 SAT-159 A A Case of Pseudopseudohypoparathyroidism and Gouty Arthritis Associated with a Novel Mutation in GNAS1 Gene 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Arham Ali*1, Celeste C. Finnerty2, Heriberto Juarez3, Josef McLean2, Sylvia Ojeda4, David N. Herndon2 and Walter J. Meyer III2
1Surgery, University of Texas Medical Branch, Galveston, TX, 2University of Texas Medical Branch, Galveston, TX, 3University of Texas Medical Branch, 4Shriners Hospital for Children, Galveston, TX

 

Introduction: In children, linear growth is dependent on a number of factors including nutrition, hormone balance, and energy utilization. Children with severe burn injury have been shown to exhibit growth arrest for at least one year post burn injury despite appropriate nutrient supplementation.(1) Insulin, administered to attenuate hyperglycemia in this population, has been shown to increase bone mineral content and muscle strength.(2) However, the effects of insulin on bone maturation and growth has not been described.

Methods: Data was collected from 33 children with burns covering ≥30% of the total body surface area enrolled in a study investigating the effects on insulin on burn outcomes. Bone age was determined using the Greulich and Pyle (1959) standard for bones of the hand and wrist. Subsequently, the Pyle and Hoerr (1969) standard for determination of knee bone age was used if the first method was not applicable. Bone ages and heights were measured up to two years following burn. This study was restricted to males between 3.75-12.25 years of age, and females between 3.75-10 years of age to avoid the effects of puberty on growth. All patients received standard of care treatment at our institution and were divided into two cohorts- one receiving insulin to decrease blood glucose (Insulin; n=21) and one not requiring insulin (No Insulin; n=12).

Results:  Age, gender, and total body surface area burned were similar between groups. Children on insulin received a cumulative total of 990 ± 710 IU from admission to discharge for a duration of 18 ± 20 days. The ratio between bone age and chronological age (BA:CA) at hospital discharge was significantly lower in the insulin group (0.77 ± 0.22 vs. 0.94 ± 0.17; p<0.05), but increased over two years to become similar to those who did not receive insulin during hospitalization (0.93 ± 0.16 vs. 0.97 ± 0.08; p=0.59). Furthermore, percent change in the BA:CA ratio over two years was significantly higher in the insulin group (38 ± 40 vs. 5 ± 20 %; p<0.05). Insulin us was associated with a significant increase in height velocity at 18 months post burn (6.7 ± 2.4 vs. 3.3 ± 2.1 cm/year; p<0.01).

Conclusion: Insulin administered to pre-pubescent children during hospitalization to attenuate post-burn hyperglycemia improved bone maturation and height velocity, two years after initial injury. The effects on insulin on ultimate adult height in this population remain yet to be seen.

 

Nothing to Disclose: AA, CCF, HJ, JM, SO, DNH, WJM III

20512 17.0000 SAT-160 A Effects of Insulin on Bone Maturation and Growth in Pediatric Burn Survivors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Bach-Mai Katherine Vu* and Lefkothea P Karaviti
Baylor College of Medicine, Texas Children's Hospital, Houston, TX

 

Background:  Hypophosphatasia is a rare disorder of bone and dental mineralization caused by deficient tissue-nonspecific alkaline phosphatase (TNAP).  Variable penetrance and expression result in a broad spectrum of phenotypes, making timely diagnosis of these patients challenging.  We describe a girl who presented with premature loss of dentition and her affected family members, in order to illustrate the importance of hypophosphatasia in the differential of a number of bone and skeletal abnormalities that may appear throughout the life span.  We also searched the literature to identify other presentations of hypophosphatasia from infancy to adulthood and to review recent advances in therapy.

Case:  A previously healthy Caucasian girl presented at two years of age with premature loss of primary teeth and frontal bone prominence.  She was growing well without fractures, weakness, or musculoskeletal pain.  Family history was notable for juvenile periodontitis in the mother and a similar but undiagnosed phenotype in the paternal grandfather.  Laboratory studies showed a TNAP level of 76 mg/dl (normal 129-291), normal calcium and mildly decreased vitamin D levels.  Radiography showed normal mineralization and no rachitic changes.

Discussion:  The variety and frequent subtlety of clinical presentations seen in hypophosphatasia underline the need for a high index of suspicion among clinicians, including dentists treating refractory periodontal disease or early loss of dentition, as found in this patient and her relatives.  Our literature review reveals a paucity of data on treatment outcomes in children with hypophosphatasia, although recent years have seen the emergence of several novel therapeutic approaches, including bone-targeted enzyme replacement therapy.  The use of these therapies is still investigational and largely limited to adults or to children with life-threatening disease.  Larger-scale therapeutic trials, data on long-term outcomes, and inclusion of less severely affected children is needed.  In addition, this case illustrates the need for multidisciplinary collaboration by dental, genetic, endocrine, and occasionally orthopedic specialists for family counseling and long-term monitoring and management of dental, skeletal, growth, and developmental abnormalities.

 

Nothing to Disclose: BMKV, LPK

20573 18.0000 SAT-161 A Hypophosphatasia: Clinical Challenges and Advances in the Field 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Hakan Doneray*1, Takeshi Usui2, Avni Kaya1 and Ayse Sena Donmez1
1Ataturk University Faculty of Medicine, Erzurum, Turkey, 2National Hospital Organization Kyoto Medical Center, Kyoto, Japan

 

Introduction:

HDR syndrome is a rare autosomal dominant genetic disorder that is characterized by a triad of conditions, namely Hypoparathyroidism, sensorineural Deafness, and Renal disease.  We, here, present the first Turkish case with HDR syndrome.

Case study:

A two month old boy was referred with hypocalcemic convulsion. The patient was born at 39 gestational weeks by vaginal delivery after unremarkable pregnancy. There was no family history of deafness or renal insufficiency. Physical examination findings were unremarkable.  His body weight, length and head circumference were 4470 g (25. P.), 59 cm (50 .P.), and 39 cm (50 .P.), respectively. Laboratory studies showed BUN: 17.7 mg/dl; Cr: 1.3 mg/dl; Na: 140 mmol/l; K: 4.6 mmol/l; Ca: 6.4 mg/dl; P: 7.2 mg/dl; ALP: 408 U/l; Mg: 1.8 mg/dl; PTH: 7 pg/ml, and 25-OH-Vitamin D: 28.3 ng/ml. Urogram revealed urine density: 1007; pH: 6.5; protein (+2); glukoz (-); and ketone (-). Spot urine Ca/Cr was 0.01. Hemogram and blood gases were unremarkable. There was thymus tissue on the neck ultrasonography (USG). Urinary USG and DTPA were normal. The brainstem-evoked response audiometry (BERA) work was normal. The hypocalcemic convulsion was controlled intravenous calcium gluconate therapy. It was followed by 50 mg/kg/day elementary calcium lactate and 0.25 mg/day calcitriol. Serum creatinine level and proteinuria on urogram persisted as 0.8-1.2 mg/dl and trace, respectively. A nonsense mutation (R367X; CGA>TGA) in the GATA3 gene was found. The patient is followed for renal and hearing functions.

Conclusions: Our patient is the first Turkish case with HDR syndrome. Renal functions and urogram findings in cases with hypoparathyroidism should be carefully examined. It should be kept in mind that HDR syndrome has a large clinical spectrum.

 

Nothing to Disclose: HD, TU, AK, ASD

21055 19.0000 SAT-162 A Hypoparathyroidism-Deafness-Renal Disease (HDR) Syndrome: The First Case Report from Turkey 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Chong Kun Cheon*1 and Gu-Hwan Kim2
1Pusan National University Children's Hospital, Pusan, Korea, Republic of (South), 2Asan Medical Center Children’s Hospital, Seoul, Korea, Republic of (South)

 

Hypoparathyroidism, deafness, and renal dysplasia (HDR) syndrome is a rare condition inherited as autosomal dominant trait and characterized by hypoparathyroidism, sensorineural deafness, and renal dysplasia. HDR syndrome is caused by haploinsufficiency of the GATA3 gene located on chromosome 10p15. Here, we report the case of a 32-day-old Korean male with HDR syndrome. He was presented due to repeated seizures over the previous 3 days. The patient was born after 40 weeks of gestation with birth weight of 2,930 g, and was the first-born baby of healthy Korean parents. Hypoparathyroidism was first noticed due to seizure. A multicystic left dysplastic kidney and vesicoureteral reflux were detected by ultrasound after birth. Auditory brainstem response (ABR) testing revealed that the patient had moderate sensorineural deafness, with hearing losses of 80 dB at the mid and higher frequencies for both ears. Echocardiography finding revealed secundum atrial septal deftect. Based on biochemical results and clinical findings, a presumptive diagnosis of HDR syndrome was made. GATA3 mutation analysis identified a heterozygous deletion, c.153del (p.Phe51Leufs*144) in exon 1 causing a frameshift mutation, which is a novel de novo mutation. Therefore, we suggest HDR syndrome should be considered in the differential diagnosis in symptomatic or asymptomatic patients with hypoparathyroidism, and that renal ultrasound or ABR testing be performed to prevent a missed diagnosis. Here, the first Korean patient with confirmed HDR syndrome by genetic analysis is reported with novel mutation.

 

Nothing to Disclose: CKC, GHK

21335 20.0000 SAT-163 A The First Korean Case of HDR Syndrome Confirmed By Clinical and Molecular Investigation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Tal Grunwald*, Francesco De Luca and Elizabeth A Suarez
St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA

 

DiGeorge syndrome, often caused by a microdeletion in 22q11.2, is characterized by an impaired development of the 3rd and 4thpharyngeal arches. Its most salient features include cardiac abnormalities, hypocalcemia due to hypoparathyroidism, palatal dysfunction and immune deficiency due to thymic hypoplasia or aplasia. Despite its association with autoimmune disorders and gastrointestinal complaints, it is rarely reported in association with inflammatory bowel disease (IBD). We present a case of a 9 year old male with DiGeorge syndrome diagnosed with inflammatory bowel disease.

Clinical Case
PC presented at 9 days of life with hypocalcemic seizures due to hypoparathyroidism and was started on calcium and calcitriol. FISH revealed a microdeletion in 22q11.2, consistent with DiGeorge syndrome. Associated findings included T cell immune deficiency, facial dysmorphism, and cardiac abnormalities (ASD and aberrant right subclavian artery).

 At 9 yrs of age, he was admitted at St. Christopher’s Hospital for Children after presenting with a two-week history of worsening watery, malodorous diarrhea, abdominal pain and weight loss. These symptoms were preceded by 1 year of gastrointestinal complaints, including constipation and poor weight gain.

Pertinent physical findings included diffuse abdominal tenderness without associated organomegaly. Laboratory investigation revealed low serum albumin of 2.7 g/dl (normal, 3.8-5.4), low hemoglobin of 8.6 g/dl (12-15) and occult blood in his stool. He was also found with elevated ESR of 105 mm/hr (<10) and C-reactive protein of 3.94 mg/dl (<0.15).  His fecal calprotectin was also elevated (150 mcg/g Normal < 120), suggesting inflammatory bowel disease. PC then underwent endoscopy and colonoscopy; pathology studies revealed chronic active colitis with crypt abscesses, consistent with Crohn’s disease. Extra-intestinal manifestations of Crohn’s disease were excluded and screening tests for other autoimmune disorders (including autoimmune hypothyroidism and celiac disease) were negative. He was managed with mesalamine and a course of prednisolone.

Discussion

The increased risk of autoimmune disorders in patients with DiGeorge syndrome, especially in those with T cell immunodeficiency, is thought to be due to dysregulated immune system. The most commonly described autoimmune conditions include thrombocytopenia, JRA, and Graves’ disease. While gastrointestinal symptoms are often described in patients with DiGeorge syndrome (reflux, dysmotility, constipation and cholelithiasis), they are considered secondary to impaired mucosal permeability rather than autoimmune inflammatory diseases. Our patient suggests the need for a thorough gastroenterology work-up aimed to rule out IBD in case of children with DiGeorge syndrome presenting with gastrointestinal complaints and/or weight loss.

 

Nothing to Disclose: TG, FD, EAS

21808 21.0000 SAT-164 A A Child with Digeorge Syndrome and Crohn's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 144-164 6053 1:00:00 PM Pediatric Adrenal & Bone Disorders Poster


Carina Preskill*1, Vinaya Simha1, Pankaj Shah1, Ravinder J. Singh2 and Adrian Vella1
1Mayo Clinic, Rochester, MN, 2Mayo Clinic

 

Introduction:  Surreptitious insulin use remains an important, and often overlooked, cause of hypoglycemia.  This can easily be distinguished from other causes of hyperinsulinemic hypoglycemia by the suppression of C-peptide and proinsulin with concomitant elevation of insulin.  However if insulin levels are not accurately detected, the diagnosis can be missed.

Clinical Cases: We discuss three patients who presented with new onset hypoglycemia.  The first, a 48-year-old woman with a history of bipolar disorder and prior hospitalizations for suicidal ideation, experienced several episodes of weakness and altered mental status with blood glucose around 40 mg/dL.  She was eventually admitted to the hospital for a 72 hour fast, which was normal.  Insulin, C-peptide, and proinsulin levels were all appropriately suppressed, ketones were elevated, and glucagon did not induce a significant rise in glucose after the fast.   Cortisol level was normal and insulin secretagogues screen was negative.   The second case is a 42-year-old woman with Type 1 diabetes on an insulin aspart pump.  She continued to experience hypoglycemia almost every morning despite disconnecting her insulin pump overnight.  Her hypoglycemia was so severe that she had loss of consciousness and seizures.  She underwent a 72 hour fast, which again did not reveal any evidence of endogenous hyperinsulinemia.  The third case is a previously healthy 46-year-old woman who suffered from multiple episodes of hypoglycemia with loss of consciousness and convulsions, leading to recurrent hospitalizations.  She experienced hypoglycemia during a 72-hour fast and was found to have a low insulin, C-peptide, and proinsulin.  In all three cases, initial measurement of insulin concentrations at the time of hypoglycemia had been performed using the Roche electrochemiluminescence insulin assay.  Due to suspicion for surreptitious insulin use, serum obtained at the time of hypoglycemia was retested using the Beckman chemiluminescence assay, which uses different monoclonal antibodies that are able to detect insulin analogs in addition to human insulin.  With the second assay, high levels of insulin were measured, consistent with exogenous use.  The surreptitious administration of synthetic insulin analogs was not detected by the initial insulin assay.

Conclusion: In each of these cases, the diagnosis of factitious hypoglycemia was delayed due to the use of a more specific insulin assay.  As insulin analogs are prescribed with increasing frequency, these cases highlight the need for providers to be aware of the insulin assay used and when an assay with higher sensitivity is indicated to evaluate hypoglycemia, particularly in cases where surreptitious insulin use is suspected.

 

Nothing to Disclose: CP, VS, PS, RJS, AV

21042 1.0000 SAT-586 A The Assay Matters: Detecting Hypoglycemia Induced By Insulin Analogs 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Varun Rajeev Mehta*1, Jacqueline A Gutierrez2, Morgan Robertson2, Gary Considine2, Tatsuyoshi Kono2 and Carmella Evans-Molina1
1Indiana University School of Medicine, Indianapolis, IN, 2Indiana University

 

INTRODUCTION

The antibiotic Doxycycline (DOXY) has been linked with the development of hypoglycemia, however the mechanism responsible for this effect is unknown.

CLINCAL CASE

A 56 yo female with a medical history notable for cirrhosis and end stage renal disease on dialysis was prescribed a two-week course of DOXY for the management of cellulitis. On the 9th day of her antibiotic regimen, she was transferred from an extended care facility to the emergency department for an episode of acute encephalopathy. She was found to have a venous blood glucose of 13 mg/dL that resolved with intravenous dextrose. While her medical history was significant for a previous diagnosis of Type 2 diabetes mellitus, she was not currently on any treatment for this condition. Adrenal insufficiency was ruled out with an ACTH stimulation test, and her hypoglycemia resolved after cessation of DOXY. To determine the etiology of DOXY-induced hypoglycemia, 8 week old CD-1 mice were treated with i.p. DOXY at a dose of 30 mg/kg for 2 doses timed 12 hrs apart.  Fasting blood glucose was significantly lower in DOXY-treated mice.  Next, insulin tolerance tests were performed following intraperitoneal injection of regular insulin at a dose 0.75 u/kg with timed blood collection at 0, 15, 30, 45, 60 and 90 minutes.  Interestingly, DOXY-treated mice exhibited a trend towards increased insulin sensitivity compared to PBS-treated control mice (glucose area over the curve: 7918 vs 3938, p=0.06).  To determine effects on insulin secretion, rat insulinoma (INS-1 832/13) cells were incubated with 2.5 and 11 mM glucose +/ DOXY in escalating doses (0.2-10 ug/mL); no increase in insulin secretion was noted with DOXY treatment.

CONCLUSION

Doxycycline can be used for the empiric treatment of cellulitis, particularly in patients at risk for MRSA.  A handful of case reports have been published linking this drug with hypoglycemia.  Our results suggest these effects are due to increased insulin sensitivity as opposed to increased insulin secretion from the pancreatic b cells.  This finding is consistent with a previous report performed in pancreatectomized dogs where the hypoglycemic effect was still apparent.  While the precise molecular pathway responsible for increased insulin sensitivity remains to be determined, DOXY has been reported to act as an inhibitor of matrix metalloproteinases (MMPs). MMPs have been shown to cleave the extracellular domain of the insulin receptor and may limit insulin signaling in skeletal muscle.  Clinical characteristics that increase susceptibility to this side effect are not apparent from published reports.  DOXY undergoes both renal and hepatic clearance, so it is possible that DOXY pharmacokinetics may have been altered in our patient. Our report underscores the importance of carefully considering a patient’s medication list during the evaluation of hypoglycemia of unknown origin.

 

Nothing to Disclose: VRM, JAG, MR, GC, TK, CE

20658 2.0000 SAT-587 A Doxycycline-Induced Hypoglycemia in a Patient with Cellulitis, Cirrhosis, and Renal Insufficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Manivel K Eswaran*1 and Randall J Urban2
1UTMB, Galveston, TX, 2Univ of TX Med Branch, Galveston, TX

 

Type1 Diabetes mellitus and bone marrow transplantation

Presentation:

31 year old Caucasian female with history of Type 1 DM, presented to clinic for regular follow up. She uses Insulin pump for her Diabetes and it was decently controlled with HbA1C of 7.2. She had a friend who was recently diagnosed with leukemia and she wanted to know if she can be bone marrow donor. She was worried if her Diabetes is a contraindication for transplantation and will it be passed on to the recipient. She does not have any other major medical issues and she does not have any complications from diabetes.

Discussion:

Type 1 Diabetes mellitus results from autoimmune destruction of the insulin-producing beta cells in the islets of Langerhans. It generally occurs in genetically predisposed subjects with environmental factors playing a role as well. Cellular immunity also has a role.  Upon review of International Bone Marrow Transplantion Registry it was noted that Type 1 DM was passed on to the donors. 15 bone-marrow donors with diabetes were identified from about 17000 transplantations. In nine donors, the diagnosis of type-1 diabetes was unequivocal. There were three long term survivors of which two developed Type 1 DM.  The recipient gets myeloablation before they receive the bone marrow. After the bone marrow transplantation, the immune system of the donors destroys the b cells of the recipients.. It usually takes few years to see the clinical effect.  Late onset of diabetes in recipients indicates that b-cell destruction is slow. Similarly progressive b-cell destruction has also been reported when segmental pancreatic isografts were done without immunosuppression between identical twins with long-term discordance for type-1 diabetes. Thus the risk of contracting type-1 diabetes from bone-marrow transplantation is small but present.

Conclusion:

Since leukemia is a life threatening disease and bone marrow transplantation is a life saving therapy, it should not be a contra indication due to Type 1 Diabetes. This was discussed with our patient and she decided to proceed as a bone marrow donor.

 

Nothing to Disclose: MKE, RJU

18910 3.0000 SAT-588 A Type 1 Diabetes and Bone Marrow Transplantation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Maha Alhusseini*1 and Berhane Seyoum2
1Detroit Medical Center/Wayne State University, Detroit, MI, 2Wayne State University

 

Intro: Patients with pancreatic cancer presenting for preoperative counseling regarding future pancreatic surgery frequently inquire about expected complications including the development of new-onset diabetes mellitus (NODM) post surgery. The incidence of NODM in the literature varies from 5% to 45%.  In this study, we hope to measure the incidence of NODM undergoing partial pancreatic resection for pancreatic cancer at our institution allowing for more effective preoperative counseling and anticipation of care needs.

Methods: In this retrospective chart review, we examined 41 patients with pancreatic cancer who underwent resection of their cancer in the last five years at our institution.  The data collected was used to calculate the frequency of  NODM as well as exocrine deficiency (steatorrhea).

Results:  Out of 41 patients, 28 did not have diabetes preoperatively.  Post-operatively, one patient (3.6%) developed diabetes (power >80%).  The overall prevalence of diabetes was 34% (p=0.2). Forty-four percent (18/41) developed steatorrhea post-operatively.

Conclusion:  Patients who undergo pancreatic resection do not need to be counseled on the development of NODM since the incidence is not increased from the general population, but steatorrhea is more expected.

 

Nothing to Disclose: MA, BS

18266 4.0000 SAT-589 A New Onset Diabetes Mellitus after Partial Pancreatectomy for Pancreatic Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Alice Abraham*1, Mishaela Ruth Rubin1, Domenico Accili2, John P Bilezikian1 and Utpal Pajvani1
1College of Physicians and Surgeons, Columbia University, New York, NY, 2Columbia University, New York, NY

 

Background: Insulin, proinsulin, and C-peptide levels increase with sulfonylurea exposure but the degree and acuity of increase has not been described in patients on dialysis.

Clinical case: We describe a 73 year old man with ESRD on peritoneal dialysis, without history of diabetes, who presented with hypoglycemia. Past medical history includes multiple myeloma for which he last received treatment 9 months prior to presentation, congestive heart failure and hypertension. In the ER, he was diaphoretic, weak, and found to have a fingerstick glucose of 43 mg/dL; his symptoms resolved immediately upon normalization of blood glucose but hypoglycemia was recurrent and persistent for approximately 48 hours requiring continuous dextrose infusion.

The patient denied prior neuroglypenic symptoms.  He denied recent changes to his dialysate or symptoms of infection or adrenal insufficiency. His medications include a beta-blocker, folic acid, nephrovite and omeprazole. Two weeks prior to presentation, his beta blocker dosage was increased; otherwise there were no additions or changes. He lives with two family members with Type 2 Diabetes on sulfonylurea (glipizide), but he denied ingestion. Physical exam was notable for normal vital signs and acanthosis nigricans. Laboratory evaluation included normal cosyntropin stimulation testing, negative infectious workup including peritoneal dialysate fluid cultures and negative insulin antibodies.

At initial presentation, his blood glucose was 47 mg/dL, with concomitant elevations in the following: C-peptide 30.5 (nl:  0.8-3.5 ng/mL), insulin 76 (nl:  3-19 uIU/mL) and proinsulin 83.3 (nl:  <=8.0 pmol/L).  During a subsequent 72 hour fast, insulin declined to within normal limits (to 12 uIU/mL); proinsulin (to 12.1 pmol/L) and C-peptide (to 7.2 ng/mL) levels also decreased but remained abnormally high, but he completed the 72 hour fast without hypoglycemia.  The sulfonylurea screen from admission returned positive for glipizide. Although his family denied giving the patient glipizide, the patient was discharged with all new prescriptions.  When the patient returned for fasting C-peptide and proinsulin levels one week later, they were persistently elevated and equivalent to values at the end of the fast. He denied any recurrent hypoglycemia symptoms.

Conclusion: Although C-peptide levels are known to increase with ESRD and sulfonylurea therapy, to our knowledge, this is the first reported case which characterizes the chronic elevation of proinsulin in a patient with ESRD, as well as its dramatic increase after a first and presumed solitary exposure to sulfonylurea. Further, the 72 hour fast conducted allows for determination of the kinetics of C-peptide and proinsulin clearance in ESRD after sulfonylurea ingestion.

 

Nothing to Disclose: AA, MRR, DA, JPB, UP

18309 5.0000 SAT-590 A Hypoglycemia Secondary to Sulfonylurea Ingestion in a Patient with End Stage Renal Disease (ESRD): Results from a 72 Hour Fast 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Prapaipan Putthapiban, Weera Sukhumthammarat and Chutintorn Sriphrapradang*
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Introduction: Hypoglycemia is not an uncommon event occurring in diabetes mellitus (DM) type 2, which can put these patients into serious morbidities and mortalities. The health self-management in elderly especially Asians are influenced by herbal treatment. We report on a case of DM type 2 with recurrent hypoglycemia associated with the use of adulteration of Chinese herbal medicines (CHMs) with conventional drugs.

Clinical case: A 73-year-old man has had well-controlled type 2 DM for over 30 years. His type 2 DM was previously controlled with metformin 1,000 mg/day and sitagliptin 50 mg/day. His fasting plasma glucose and HbA1C were 95 mg/dL and 5.66%, respectively. He developed severe hypoglycemia 1 year ago which led to discontinuation of oral hypoglycemic drugs and initiated self-monitored blood glucose concentration. He reported frequent low capillary blood glucose (CBG) ranging from 39-45 mg/dL with no neuroglycopenic or neurogenic symptoms other than fatigue. Therefore, the 72-hour fasting was scheduled for diagnosis of hypoglycemia and his CHM was stopped 3 days prior to the fasting test. His plasma glucose decreased below 60 mg/dL at 50 hours after fasting without any neuroglycopenic or neurogenic symptoms. The venous glucose was 48 mg/dL while measuring C-peptide, insulin and beta-hydroxybutylate were 1.29 mmol/L, 12.7 mU/mL and 3.0 mmol/L, respectively. He admitted to have taken a CHM purported to enhance glycemic control and kidney protection for the past 5 years. On the drug label, therapeutic substances are several traditional Chinese herbs along with 2.5 mg of glyburide and 500 mg of metformin per 10 pills. After cessation of the CHM, his CBG was measured between 100 to 120 mg/dL. We inferred that he had hyperinsulinemic hypoglycemia from adulterated herbal medicine with synthetic hypoglycemic agent.

Conclusions: Controlling blood sugar aiming to decrease complication of DM while being aware of hypoglycemia is a great challenge for practitioners. Since CHMs are publicly believed to be natural and nontoxic, a number of patients chose to take them as an alternative or an addition to synthetic drugs. Contamination of CHMs with conventional pharmacological compounds can lead to a harmful event such as hypoglycemia.

 

Nothing to Disclose: PP, WS, CS

18620 6.0000 SAT-591 A Recurrent Hypoglycemia from Chinese Herbal Medicine Containing Synthetic Antidiabetic Agent 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Yousuf Khan*1, David S Schade1, Christina M Lovato2 and Patricia L Kapsner2
1University of New Mexico School of Medicine, Albuquerque, NM, 2University of New Mexico Health Sciences Center, Albuquerque, NM

 

Background

Hypoglycemia is a potentially debilitating and life threatening condition. The causes of hypoglycemia in patients not on therapy for diabetes are diverse. When factitious disease and hyperinsulinemia are excluded, identifying the etiology is challenging. We present a case of recurrent hypoglycemia in a young woman who demonstrated not one, but two separate etiologies causing hypoglycemia.

Clinical Case

A 20 year old female with a history of isolated renal glucosuria diagnosed in early childhood was evaluated for recurrent episodes of symptomatic hypoglycemia beginning in adolescence. They occurred primarily in the fasting state and responded to carbohydrate intake. Her BMI was 19 and physical exam was normal. Eight am cortisol, 2 hour OGTT, A1C, fructosamine, and thyroid function tests were all normal. GAD, insulin and IA2 antibodies were negative. Labs collected during a symptomatic phase of a 72 hour fast showed a plasma glucose of 54 mg/dl (NL: 60-90 mg/dl), C-peptide 0.7 ng/ml (NL: 0.9-6.9), insulin level 3 IU/ml (NL: 3-25), pro-insulin less than 1.5 pmol/L (NL: less than 28.9) and beta-hydroxybutyrate 27 mg/dl (NL: 0-3.0). Plasma and urine sulfonylurea screens were negative. An abdominal CT showed no pancreatic lesions.

The patient was readmitted following an overnight fast to the outpatient treatment center for further evaluation. The fast was discontinued after 4 hours due to palpitations, shakiness, light-headedness and POC glucoses of 51 and 48 mg/dl with simultaneous plasma glucose of 55 mg/dl. The urine glucose monitored throughout the fast persisted at >500 mg/dl. There were appropriate epinephrine, growth hormone, and cortisol responses to hypoglycemia; however, all glucagon levels throughout the fast were undetectable. Additional evaluation of glucagon secretion was undertaken. Glucagon response to arginine stimulation showed undetectable glucagon levels at all-time points (1). Glucose and insulin levels however increased appropriately in response to intravenous glucagon.

Conclusion

This patient has both an isolated renal glucose leak plus a deficiency in glucagon secretion leading to recurrent, severe episodes of hypoglycemia. Both conditions are relatively rare. Glucagon deficiency alone is exceedingly rare with only two other cases reported in the literature (2,3). Our patient had normal growth and development with no evidence of any autoimmune disease or diabetes. In patients without hyperinsulinemia, it may be helpful to assess counter regulatory hormones such as glucagon in the rare, complex cases of recurrent hypoglycemia. Identifying glucagon deficiency may prevent additional expensive and invasive testing for hypoglycemia.

 

Nothing to Disclose: YK, DSS, CML, PLK

19018 7.0000 SAT-592 A Renal Glucosuria Plus Glucagon Deficiency: A Rare Cause of Severe, Non-Diabetic Hypoglycemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Lama Ghassan Amer* and Abdulrahman Ghiatheddin Alkabbani
King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

 

Introduction:

Type 2 diabetes consists of variying degrees of insulin resistance and relative insulin deficiency. Excess hepatic glucose ouput therefore plays a key role in the pathogenesis of type 2 diabetes. We hereby present a case of fructose -1,6-bisphosphatase deficiency, a genetic disorder associated with impaired gluconeogenesis and fasting hypoglycemia, in which the patient developed type 2 diabetes.

Case:

A 21-year-old man was diagnosed with fructose -1,6-bisphosphatase deficiency at 1 year of age, when he presented with episodic somnolence, reduced level of activity and frequent vomiting. Investigations at the time showed significant hypoglycemia with lactic acidosis. His sister who was 3 years older, was diagnosed with the same condition shortly after her birth, therefore his diagnosis was clear and fructose tolerance test was confirmatory. With frequent feeding and avoidance of dietary fructose, he did well and his development was appropriate for age except for obesity as his weight was above the 95th percentile since he was 4.

At age 18, he developed polydipsia and polyuria with lethargy and vomiting. He was hospitalized and found to have diabetes (presented with DKA most likely). On insulin therapy (mixed insulin then NPH and regular), he was not well controlled, thus he was referred to our center.

On his first visit, he was on 150 units of insulin per day. He weighed 131 kg (BMI 39.1) and his HbA1c was 9%. He was switched to insulin glargine 80 units at bedtime, and insulin aspart 30 units with meals. On his second visit, his HbA1c was higher (9.5%) so insulin doses were increased to 100 units of glargine, 60 units of aspart with meals, and metformin was started. A month later, he started experiencing hypoglycemia for the first time, typically early morning or pre-lunch, so insulin doses were reduced but he continued to experience hypoglycemia and his HbA1c dropped to 7.6%. He was then admitted to the hospital for further investigation.

With controlled caloric intake, prandial insulin at an IC ratio of 1:7 was adequate, a dose much less than what he was taking before. Glargine was stopped altogether and he had excellent blood glucose profile with normal fasting glucose level. A fasting test was conducted and he developed symptomatic spontaneous hypoglycemia after 12 hours that failed to respond to glucagon as expected. Genetic testing was positive for homozygous insertion of c. 117_118insACCTGC in the FBP1 gene.

Discussion

The enzyme fructose -1,6-bisphosphatase is at the center of the regulation of glycogenolysis and gluconeogenesis in the liver, and patients who have deficiency of this enzyme present with fasting hypoglycemia. To our knowledge, this is the first case of established type 2 diabetes in a patient known to have this enzyme deficiency, and diabetes seems to be mainly due to postprandial hyperglycemia rather than both fasting and postprandial hyperglycemia.

 

Nothing to Disclose: LGA, AGA

22114 8.0000 SAT-593 A Diabetes with a Twist: How Fructose-1,6-Bisphosphatase Deficiency Can Alter the Principles of Type 2 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Michelle M Mangual*1, Madeleine Gutierrez2, Joel Nieves3, Maria de Lourdes Miranda2, Jose Hernan Martinez2, Coromoto Palermo2, Alfredo Sanchez4, Rafael Trinidad2, Carmen V Rivera2, Paola Mansilla2, Ernesto Sola Sanchez3, Michael Cruz3 and Aixa Dones3
1Sa, San Juan, PR, 2San Juan City Hospital, San Juan, PR, 3San Juan City Hospital, 4San Juan City Hospital, PR

 

Background:Type 1 diabetes mellitus (T1DM) is a disorder of glucose metabolism that is caused by insulin deficiency. Organ-specific autoantibodies have been found in patients with T1DM disclosing a relationship with a wide spectrum of immunological diseases. Autoimmune hepatitis (AIH) has been reported to occur in patients with T1DM. Since AIH is an inflammatory condition it is associated to elevated ferritin level. Here in we describe a case in which the diagnosis of AIH was challenged by the presence of elevated ferritin and transferrin saturation.

Clinical Case:This is a 36 year-old female with T1DM. She began to notice choluria, pale stools, jaundice, scleral icterus, bilateral pitting edema and mild epigastric discomfort two weeks before admission to the hospital. Physical exam showed jaundice and scleral icterus. She denied IV drug use, OTC medications or supplements, recent travel, alcohol consumption, and multiple sexual partners. Laboratories were remarkable for hepatocellular pattern without leukocytosis. Hepatitis profile, drug screen, ceruloplasmin, anti-mitochondrial antibodies, anti-smooth muscle antibodies, anti-LKM1, alpha 1 antitrypsin, p-anca and c-anca were all within normal limits.  Patient coagulation profile was normal at admission. Imaging studies such as abdominal ultrasound and CT scan were unremarkable for any acute pathology.  Ferritin level was 5,000 ng/ml and transferrin saturation was 91% which suggested a diagnosis of hemochromatosis. Phlebotomy was initially performed. Five days after admission she started to present hepatic failure. Patient was referred for liver transplant evaluation.  Upon re-evaluation ANA was the only antibody to be positive (1:160) and CT scan showed advanced liver disease. The patient developed hepatic encephalopathy, acute respiratory failure and fulminant hepatic failure, which required liver transplant. Macroscopic liver evaluation showed liver collapse. Histopathologic exam demonstrated lymphoplasmacytic infiltrate and marked hepatocyte necrosis. These findings suggested a diagnosis of AIH.  Patient tolerated transplant adequately and recovered successfully. 

Conclusion:A high index of suspicion for AIH should be kept in patients with T1DM who develop liver failure given the autoimmune nature of the condition, and the female sex predominance (female:male ratio 3.6 : 1) compared to hemochromatosis which is more common in men (female:male ratio, 1 : 2). Hemochromatosis is associated to end-organ damage such as the kidney, heart and gonads which were not involved in this patient. Elevated ferritin level is expected given that this is an acute phase reactant. Transferrin saturation above 45% suggests a diagnosis of hemochromatosis which makes the diagnosis a challenge requiring an extensive work-up. Liver biopsy should be done promptly to avoid delay in diagnosis and start treatment in a timely manner.

 

Nothing to Disclose: MMM, MG, JN, MDLM, JHM, CP, AS, RT, CVR, PM, ES, MC, AD

21757 9.0000 SAT-594 A Type 1 Diabetes Mellitus Related to Acute Liver Failure: a Challenging Diagnosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Kelsey Burr*1, Anh-Thu Qui Nguyen2 and Neda Rasouli3
1University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, 2VA - Nebraska Western Iowa Healthcare System / Creighton University Medical Center, Omaha, NE, 3University of Colorado Anschutz Medical Campus, Aurora, CO

 

Learning Objective

To recognize the risk of euglycemic ketoacidosis as a potential side effect of canagliflozin.

Patient Description

A 50 y/o woman with type 2 diabetes (T2DM) complicated by gastroparesis presented to the ED with worsening nausea, vomiting (N/V) and abdominal pain for 4 days. The patient reported a 65lb weight loss in the previous 6 months due to recurrent, severe GI symptoms and food intolerance. She denied h/o alcohol abuse.  The patient had been taking glipizide and metformin for diabetes management until 2 days prior to the onset of symptoms when canagliflozin 300mg daily was added due to poor glycemic control (A1c 11%). Patient received only 6 doses of canagliflozin and stopped taking it due to N/V.  On presentation, she had a blood glucose level of 68 mg/dL, an anion gap of 19, moderate serum ketones, and serum bicarb of 9 mg/dL with a normal lactate level suggestive of ketoacidosis. She was also noted to have glucosuria (>500 mg/dL).

Hospital Course

The patient was treated with IV fluids, bicarb, and insulin infusion along with dextrose 5%. She required insulin drip (up to 8 units/hr) along with dextrose to prevent hypoglycemia for 24 hours to normalize the anion gap. She was transitioned to SQ basal/bolus insulin with optimal blood glucose control.  However, following a large meal, which exacerbated symptoms of gastroparesis, patient had recurrence of ketonemia.  Interestingly, despite stopping canagliflozin prior to hospitalization, she continued to have glucosuria (>500 mg/dL) with normal blood glucose for 11 days after the last dose canagliflozin.  Normalization of urine glucose coincided with increasing serum glucose and resolution of ketosis, despite the patient having continued N/V and abdominal pain. She was discharged from the hospital after 7 days when her GI symptoms and metabolic abnormalities resolved and she could tolerate a PO diet.

Discussion

Canaglifozin belongs to a new class of anti-diabetes medications known as Sodium Glucose Transporter-2 (SGLT2) inhibitors. SGLT2 is expressed in the proximal tubules of the kidney and effectively reabsorbs glucose in order to prevent urinary glucose excretion. SGLT2 inhibitors improve glycemic control in T2DM by increasing urinary glucose excretion. The half-life of canagliflozin at maximum recommended dose is 10-13 hrs; however, we observed persistent glucosuria in the absence of hyperglycemia 11 days after stopping canagliflozin, suggesting a delayed reversibility of SGLT2 transport inhibition.

In addition, ketosis has been reported as rare side effect of this class of medication without known mechanism.  This case was complicated by gastroparesis, which caused severe GI symptoms and weight loss, suggesting that “starvation” might have played a role in activating the ketosis pathway in this patient.  Future investigation on effects of SGLT2 inhibitors on the ketosis pathway is recommended.

 

Nothing to Disclose: KB, ATQN, NR

21461 10.0000 SAT-595 A A Case Report of Ketoacidosis Associated with Canagliflozin (Invokana) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Lucy Xiao*1 and Nicole M Ehrhardt2
1Fort Belvoir Community Hospital, Fort Belvoir, VA, 2George Washington University School of Medicine and Health Sciences, Washington, DC

 

Background: Recently several small studies have showed the use of Glucagon-like peptide-1 (GLP-1) agonists in addition to insulin in patients with type 1 diabetes (T1DM) reduce total daily insulin, potentially reduce HbA1c  and enhance weight loss.(1) However, these studies generally evaluated patients with well controlled diabetes, BMIs on average 25kg/ m2  or less and  total daily insulin <0.7 units/kg.  Nausea was often the limiting feature in use. The prevalence of obesity (BMI >30 kg/m2) in patients with type I diabetes has risen sharply since 2007. One recent study did examine use in the obese population  but total daily insulin requirements were still <1.0u/kg.(2) Here we report on two cases of obese patients  with T1DM on insulin doses >1.0 units/kg and GLP-1 agonists. 

Clinical cases: Patient A was 25 year old female with history of T1DM for 14 years on insulin pump. Prior to starting liraglutide her weight was 80.8kg (BMI 29.49 kg/m2), total daily insulin average of 90 units (1.1 units/kg) and HbA1c of 8.7%(nl 4.8 to 5.9 %).  She was started on liraglutide 0.6 mg per day with slow titration given nausea to 1.2 mg. At 16 week follow-up, her weight was 74kg (8.0% reduction in body weight), total daily insulin of 45 units (0.6units/kg) and HbA1c 7.9. Continuous glucose monitoring performed prior to starting therapy and on 1.2mg liraglutide showed decreased variability of glucose and no increase in hypoglycemia.

Patient B was a 36 year old female with a history of T1DM for 25 years on insulin pump for the last 11 years. Her diabetic complications include retinopathy and peripheral neuropathy. Her total daily insulin use was on average 250 units (2.5units/kg), her weight was 86kg (BMI 33.7kg/ m2), and HbA1c 10.1%. She was started on pramlintide but was not compliant secondary to multi-dose regimen. She was started on liraglutide and tolerated titration to 0.9mg. Initially she did not tolerate 1.2mg dose secondary to vomiting but was able to increase by 0.1mg increments to reach 1.2mg by 12 week follow-up. At that time her total daily insulin average was 200 units (2.5units/kg), her weight was 81kg (4.6% reduction in body weight), HbA1c 8.5%, and  Fructosamine 275 mcmol/L (nl 205-285 mcmol/L).

In summary, each patient had significant weight loss, reduction of HbA1c by 0.9% or greater despite total average daily insulin reduction of 20-50%. Nausea was the main side-effect in both patients but was alleviated by slow titration.

Conclusions: GLP-1 agonists may play an important role in improving glycemic control without hypoglycemia and enhancing weight loss in obese and overweight patients with Type 1 diabetes. Nausea maybe overcome with slow titration.

 

Nothing to Disclose: LX, NME

21442 11.0000 SAT-596 A Glucagon-like Peptide-1 Agonists Use in Patients with Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Yu Kuei Lin*1, Philip C. Johnston2, Matthew Walsh3, Tyler Stevens3, Rita Bottino4, Massimo Trucco4 and Betul Hatipoglu1
1Cleveland Clinic, Cleveland, OH, 2Royal Victoria Hospital, Belfast, Ireland, 3Cleveland Clinic, 4University of Pittsburgh

 

Background: Hypoglycemia has been described in patients who receive total pancreatectomy (TP) and islet cell autotransplantion (IAT). Most of the episodes in this patient population are mild and self-corrected. The underlying pathogenesis is not well understood. We are describing an unusual case of severe hypoglycemia following islet cell transplantation.

Clinical Case: A 24 years old female with ERCP related chronic pancreatitis underwent TP and hepatic IAT, and subsequently achieved insulin independence. Eight months after surgery, she developed episodes of post-exertional and fasting hypoglycemia. The hypoglycemic episodes were manifested by fingerstick measurements between 30-50 mg/dL, with both neurological and neuroglycopenic symptoms, which reversed with food intake. She ate five to six snacks daily to avoid hypoglycemia, yet still had multiple hospital admissions for confirmed severe hypoglycemic episodes, with blood glucose ranging between 34 and 45 mg/dL. In evaluation, her adrenal and thyroid function tests were normal. Late into a 72-hour fasting test, she developed hypoglycemia with neurological symptoms around blood glucose of 59 mg/dL (70-99 mg/dL), with serum insulin 1.38 mcU/mL (4-30 mcU/mL), serum proinsulin 2.2 pmol/L (3-20 pmol/L), serum c-peptide 0.3 ng/mL (0.9-4.2 ng/mL), serum glucagon 33 pg/mL (≤ 80 pg/mL). Followed by 1 mg glucagon vial administration intramuscularly, her blood glucose improved from 63 mg/mL to 77 mg/dL, 78 mg/dL and 76 mg/dL at 10, 20 and 30 minutes, respectively. After eating, her blood glucose improved to 172 mg/dL within 20 minutes. At discharge, she was initiated on scheduled food intake. She continued to experience hypoglycemia with milder manifestations.

Conclusion: Glucose homeostasis is altered by IAT. Prior literature demonstrated that mild hypoglycemia in TP with hepatic IAT patients may be secondary to loss of glucagon secretion. This is the first case with severe hypoglycemia requiring hospital and ICU stay. The physiology of hypoglycemia in this patient population requires further investigation.

 

Nothing to Disclose: YKL, PCJ, MW, TS, RB, MT, BH

20695 12.0000 SAT-597 A Recurrent Hypoglycemic Episodes after Total Pancreatectomy and Hepatic Islet Cell Autotransplantation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Nancy L Mora*
Wexner Medical Center at the Ohio State University, Columbus, OH

 

Background

Treatment of type 2 diabetes mellitus (T2DM) may require high insulin doses, particularly in severely obese patients. Insulin pumps provide more effective glycemic control than multiple insulin injections and can decrease the total daily insulin requirement. V-GO® is currently the only widely reimbursed insulin delivery device in adults with T2DM. It has a maximum capacity of 76 units of U-100 insulin that may limit its use in diabetic patients with high insulin requirements. The usage of U-500 insulin can potentially solve this problem but its utility in V-GO® has not been reported.

Case description

We present a 46-year old woman with hypertension, hyperlipidemia, severe obesity and T2DM diagnosed at age of 38, complicated by neuropathy. She was managed on insulin therapy alone.  Two years prior to presentation, she received a total daily insulin dose of 35 units, and her HbA1c was 6.5%.  In the subsequent years, the HbA1c rose to 14%, requiring repeated upward insulin adjustments.  She monitored her glucose levels 4 times per day and sent glucose logs regularly.  She eventually transitioned to insulin U-500 and required up to 525 units (1.05 mL) daily, but continued to have persistent hyperglycemia.  She had recurrent admissions for uncontrolled symptomatic hyperglycemia which were successfully controlled by lower doses of IV insulin (88 units per day).  However, upon discharge, self-monitored glucose levels would again rise sharply.  She was an active participant in diabetes education, including injection teaching on repeated occasions.  She reported adherence to a limited carbohydrate diet, denied missing insulin doses, and had no technical difficulty with insulin injections.  There was no evidence of lipohypertrophy, lipodystrophy or psychiatric disorder. She transitioned to V-GO 40® insulin infusion device with a total of 275 units (0.55 mL) of U-500 per day.  Within 3 days, blood glucose levels were in the 100 mg/dL range and the patient switched to V-GO 30® and finally V-GO 20® with a total daily dose of 175 units of U-500 insulin (0.35 mL). Twenty days after the transition to V-GO, the fructosamine level was normal at 274 µmol.

Conclusions

This report is the first to describe the use of U-500 insulin in a V-GO® insulin pump.  Previously refractory to therapy, the patient demonstrated dramatic improvements in glycemic control and insulin requirements.

 

Nothing to Disclose: NLM

19140 13.0000 SAT-598 A Marked Improvement in Glycemic Control and Insulin Requirements in a Severely Insulin Resistant Patient with Type 2 Diabetes Mellitus - a Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Jonathan Sagum*1, Carmel Maria Fratianni2 and Michael G Jakoby IV2
1SIU School of Medicine, Springfield, IL, 2Southern Illinois University School of Medicine, Springfield, IL

 

Background: Factors that predispose patients with diabetes to foot infections -- hyperglycemia, leukocyte dysfunction, peripheral neuropathy, and diminished local blood flow – are also risk factors for hand infections.  However, much less is published in the peer reviewed literature regarding diabetic hand infections than foot infections.  We present an unusual case of hand infection complicated by fungal osteomyelitis in a patient with long standing and poorly controlled Type 1 diabetes mellitus.

Case: A 69-year-old female was admitted to hospital for management of septic arthritis of the right fourth proximal interphalangeal (PIP) joint and cellulitis extending onto the dorsum of the hand.  The patient could not recall an injury to her hand.  Medical history was notable for Type 1 diabetes mellitus of nearly 50 years duration and with generally suboptimal glycemic control (HbA1c 9-11%), proliferative retinopathy, peripheral neuropathy, Stage 3A chronic kidney disease, and rheumatoid arthritis managed with methotrexate.  A large area of fusiform fluctuance over the PIP joint was incised and drained, and wound culture yielded methicillin sensitive Staphylococcus aureus.  Plain films of the right hand failed to show bony changes indicative of osteomyelitis.  However, despite treatment with ceftriaxone and improved glycemic control with a basal/bolus insulin regimen, joint swelling and purulent drainage persisted.  Metacarpal ray amputation of the fourth digit was eventually performed, and bone cultures grew Candida glabrata.  The patient was transferred to an extended care facility on dicloxacillin and micafungin.  No signs of continued infection were apparent after completion of antimicrobial therapy.

Conclusions: Hand infections are an underappreciated complication of diabetes mellitus.  Approximately 10% of patients admitted to hospital with serious hand infections in a recent series had co-morbid diabetes mellitus.  In this case, both uncontrolled Type 1 diabetes and methotrexate were risk factors for infection.    Polymicrobial infections predominate, with S. aureus the most commonly isolated bacterium.  Candida species are isolated in only 10-15% of cases.  Hand infections in the setting of diabetes commonly propagate to deep soft tissues, tendons, and bone, and amputation rates in published case series range from 10-40%.  However, Candida osteomyelitis of the upper extremity is rare, and there is only one other case of C. glabrata osteomyelitis of the hand documented in the peer reviewed literature.   Prompt surgical debridement, wound culture, antimicrobial therapy, hand elevation, and tight glycemic control are required to prevent diabetic hand infections from resulting in severe morbidity and long term disability.  Co-existing fungal involvement should be considered when diabetic hand infections fail to respond to appropriate treatment.

 

Disclosure: MGJ IV: Speaker, Sanofi. Nothing to Disclose: JS, CMF

19344 14.0000 SAT-599 A Fungal Osteomyelitis of the Hand As an Unusual Complication of Poorly Controlled Type 1 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Karla M Arce*1 and Kevin M Pantalone2
1Cleveland Clinic, Cleveland, OH, 2Cleveland Clinic, Stow, OH

 

Background

Neonatal diabetes, defined as persistent hyperglycemia occurring in the first months of life, is a rare cause of hyperglycemia and often misdiagnosed as type 1 diabetes mellitus (DM).  Heterozygous activating mutations in the KCNJ11 gene, which encodes the Kir6.2 subunit of the KATP channel, have been implicated and account for 30% to 58% of cases of permanent diabetes diagnosed in patients less than 6 months of age [1]. Several reports have shown that the successful transition from insulin to sulfonylurea agents can be achieved in up to 90% of patients with neonatal diabetes [1].  

Clinical Case

A 37-year-old male with history of poorly controlled diabetes with multiple microvascular complications presented to our institution for further evaluation. He was diagnosed with “type 1 DM” when he was 2 weeks old and multiple daily injections of insulin were initiated to control glycemia. The patient reported a strong family history of early-onset insulin-dependent diabetes in both of his siblings. The patient’s medical and family history garnered a strong suspicion for neonatal diabetes. His HbA1c was 7.7%, C-peptide <0.2 ng/ml (range 0.8-3.2 ng/ml) with corresponding blood glucose of 80 mg/dl (60-100 mg/dL)). Testing for pancreatic islet cell and glutamic acid decarboxylase antibodies was negative. As genetic testing could not be afforded by the patient at this time, a trial of sulfonylurea (SU) therapy was offered. Glimepiride 2 mg daily was initiated and slowly titrated up to 8 mg twice daily over a 3-month period with an observed increase in C-peptide from undetectable to 0.7 ng/dl (glucose 176 mg/dl). Insulin therapy with insulin detemir and insulin lispro was slowly decreased as the dose of SU therapy was increased. Glycemic control improved significantly, and we were able to reduce his total daily insulin dose from 64 units/ day to 24 units/ day. Repeat HbA1c was 7% with average blood sugars ranging in the 80-150 mg/dl range. Even though the patient was unable to discontinue insulin therapy, the addition of low dose SU resulted in enough endogenous insulin production to reduce his glycemic variability and insulin requirements considerably.

Conclusion

We report the case of a patient with long-standing poorly controlled diabetes initially misdiagnosed and treated as having type 1 DM. Many patients with neonatal diabetes treated with insulin-only therapy behave as brittle diabetics, with difficult to control glycemia leading to complications. The addition or transition to SU therapy may help some of these patients achieve better glycemic control, while requiring less dependence on insulin therapy. Our case highlights the importance of history taking in the management of patients with diabetes, especially the need to conduct a thorough family history, as the early recognition of neonatal diabetes can profoundly impact the DM-related management of both the patient and their family members.

 

Disclosure: KMP: Speaker Bureau Member, Astra Zeneca, Consultant, Merck & Co., Consultant, Eli Lilly & Company, Speaker Bureau Member, Eli Lilly & Company, Principal Investigator, Novo Nordisk, Speaker Bureau Member, Bristol-Myers Squibb, Research Funding, Novo Nordisk. Nothing to Disclose: KMA

20696 15.0000 SAT-600 A Neonatal Diabetes: Not All Diabetes in Infants Is Type 1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Giovanna Mozardo Duarte*1, Christiane Andrade de Azevedo2, Ana Heloisa Correia Bresque3, Victor Sousa da Silveira2, Vanessa Castro Ramos2, Evandro S Portes4, Michele Molina Mari Salvariego2 and Marcio Faleiros Vendramini1
1Hospital do Servidor Público Estadual de São Paulo, 2Hospital do Servidor Público Estadual, 3Hospital do Servidor Público Estadual, Sao Paulo, Brazil, 4Hospital do Servidor Publico Estadual de Sao Paulo

 

Extreme subcutaneous and intramuscular insulin resistance at type 1 diabetes mellitus (DRIASM) is a rare condition characterized by resistance to insulin administered subcutaneously or intramuscularly and normal or near to normal sensitivity to intravenous insulin administration. DRIASM leads to frequent ketoacidosis and recurrent hospitalization for administration of intravenous insulin. Its pathophysiology remains unknown and treatments until now proposed are ineffective and associated with frequent fails and complications.

We report here a case of DRIASM in a 12-year female patient that had diagnosis of type 1 diabetes in March 2013 and started to present difficult glycemic control after 6 months even not having classical conditions related to insulin resistance such as obesity and dyslipidemia. The patient had 13 hospitalizations and 3 ketoacidosis episodes from September 2013 to November 2014. In August 2013, during hospitalization, despite 4.5 U/kg/day of lispro analog subcutaneous use, she showed severe hyperglycemia.

Since the diagnosis, the proposed treatments had been subcutaneous insulin basal-bolus therapy,  lispro insulin through an external pump,  intramuscular insulin,  corticosteroid therapy with Prednisone 1mg/kg/day for 30 days, , subcutaneous hyaluronidase followed by  subcutaneous insulin and continuous ambulatory  intravenous insulin through a PICC (Peripherally inserted central cateter) that was attempted after numerous hospitalization. All of these treatments were ineffective, except for the last.

In conclusion, even considering our satisfactory results with PICC, further studies with long-term follow-up are needed to find an effective and safe treatment to DRIASM, because there are several potential complications related to this technique, including thrombosis and infection. In this context, the pancreatic transplantation has been proposed as a good therapeutic option for this rare condition.

 

Nothing to Disclose: GMD, CADA, AHCB, VSDS, VCR, ESP, MMMS, MFV

20645 16.0000 SAT-601 A Intravenous Insulin Therapy in a Type 1 Diabetes Patient with Subcutaneous and Intramuscular Resistance to Insulin 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


V. Sri Nagesh*1, Ravi Shankar Kanithi2, Andrew Hattersley3, Sian Ellard4 and Satyasree Teki2
1CARE Out Patient Centre, CARE Hospital, Hyderabad, 2Soumya Children's Hospital, 3University of Exeter, Exeter, United Kingdom, 4University of Exeter Medical School, United Kingdom

 

Introduction: Neonatal diabetes can often present to the clinician with myriad manifestations. Here, we present a case of neonatal diabetes presenting with hemorrhagic infarct on 7th day of life.

BACKGROUND: A 7 day old male infant, born full term by normal vaginal delivery was referred to the neonatal unit with history of poor feeding  lethargy and seizure since the fourth day of life. The infant had been born to non-consanguineous parents and had a birth weight of 2.2 kg and there was no birth asphyxia. At presentation, the baby was dull looking and had a staring look, had a tense looking anterior fontanel and had tachypnoea. After initial stabilization, investigations were done, which revealed a blood glucose of 33 mmol/lt. Blood gas analysis showed metabolic acidosis with a pH of 7.285, bicarbonate of 15 mmol/lt and base excess of -12 mmol/lt. urine ketones were 2+. He was provisionally diagnosed as neonatal diabetes with ketoacidosis, ventilated  and started on fluids and insulin infusion and was also treated for sepsis. Blood glucose levels were gradually controlled, but general condition did not improve. MRI brain was performed, which revealed a large cerebral hemorrhage/hemorrhagic -infarct in the right fronto-temporo-parietal region with mass effect and shift of midline structures to the right. Meanwhile, blood of the child and his parents had been sent for genetic testing and analysis revealed a novel heterozygous missense variant (p.R29H) in the baby’s KCNJ11 gene. This mutation was maternally inherited and his father did not carry the mutation. In view of the poor general condition of the infant and poor prognosis, his parents consented to taking him off life support. The parents have been advised to go in for genetic testing prior to planning another pregnancy.

Conclusion: This is the first case to have demonstrated a novel maternally inherited KCNJ11 mutation and highlights the point that infarct and hemorrhage can be a presentation of neonatal diabetes. Also, neonatal diabetes can be maternally inherited and this could herald a new avenue of genetic research into this relatively unexplored, but not very uncommon disorder with high mortality. 

 

Nothing to Disclose: VSN, RSK, AH, SE, ST

21236 17.0000 SAT-602 A A Case of Neonatal Diabetes Presenting As Intractable Seizures and Cerebral Hemorrhage 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Teresa Rodriguez-Calvo*1, Jessica Suwandi2, Natalie Amirian1, Florence Anquetil1, Somayeh Sabouri1 and Matthias von Herrath1
1La Jolla Institute for Allergy and Immunology, La Jolla, CA, 2Leiden University, Leiden, Netherlands

 

Introduction: Type 1 diabetes (T1D) is an autoimmune disease in which autoreactive T cells destroy the insulin-producing beta cells in the pancreatic islets of Langerhans. One of the main pathological features of T1D is the hyper-expression of MHC class I by beta cells which does not affect all the islets. This heterogeneity hinders the study of T1D pathology. Elevated expression of MHC-I makes beta cells more prone to autoimmune destruction and seems to precede immune infiltration (insulitis) of the islets. Typically, islet infiltration is dominated by CD8 T cells but little is known about their overall specificities and frequencies present in the islets. These specificities might be reflected in the B cell repertoire thus circulating autoantibodies.

Clinical Case: In this report we studied the case of a 22-year old non-diabetic male in which autoreactive antibodies against GAD and IA-2 were detected in the peripheral blood. People having two or more islet-related autoantibodies are, according to epidemiological studies, at high risk of developing T1D. Therefore this subject was possibly in a pre-diabetic state. To investigate if this donor showed characteristics of early T1D, sections through the entire pancreas were analyzed for signs of inflammation using immunofluorescent staining. Multiple insulin containing islets were identified which hyper-expressed MHC-I being the islet density and this expression very lobular within the same section and region. Islet abnormalities were found in 15 % of the islets in head and body and in 9 % of the islets in the tail of the pancreas. In addition, islets with elevated and hyper-expression of MHC-I presented higher levels of CD8 T cell infiltration than normal islets.

Conclusion: Based on our data, at an early pre-diabetic stage, MHC-I expression and CD8 infiltration are lobular and do not follow a specific pattern. Additional studies will be needed to find a possible cause or trigger for these abnormalities. We believe that this work emphasizes the importance of further understanding the pathological events that occur during the pre-diabetic phase.

 

Disclosure: NA: Spouse of recipient, Novo Nordisk. MV: Vice President, Novo Nordisk. Nothing to Disclose: TR, JS, FA, SS

21072 18.0000 SAT-603 A Heterogeneity and Lobularity during the Pre-Diabetic Phase: A Case Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Guillermo Martínez Díaz-Guerra1, Gonzalo Allo Miguel2, Mercedes Aramendi Ramos1, Sonsoles Guadalix Iglesias1, Soledad Librizzi1, Carlos Jiménez1 and Federico G Hawkins*3
112 de Octubre University Hospital, 212 de Octubre Hospital, 3Hospital Universitario 12 de Octubre, Madrid, Spain

 

INTRODUCTION: Decreased bone formation has been proposed as a mechanism involved in the higher risk of fractures in diabetes mellitus. Sclerostin is an osteocyte-derived inhibitor of the Wnt/beta-catenin signaling pathway (acting as a negative regulator of bone formation). Some clinical studies have found increased serum sclerostin in patients with type 1 and type 2 diabetes , but there are no information about the relationship between sclerostin and new onset diabetes after transplantation (NODAT). So, the aim of our study is to evaluate sclerostin serum levels in a cohort of patients with liver transplantation (LT).

PATIENTS AND METHODS: 85 LT patients (50 males, 35 females) without previous diabetes mellitus were included in this single-center and cross-sectional study. A 75 g oral glucose tolerance test was performed (OGTT) and diagnostic ADA criteria were followed. Biochemical data included: Plasma glucose (PG), serum insulin and C-peptide (baseline, 60 and 120 min after OGTT); glycated hemoglobin (HbA1c), creatinine and 25-hydroxyvitamin D 25(OH)D. Serum sclerostin was measured in fasting samples (Enzyme immunoassay, TECOmedical). Data are presented as mean (± SD). Pearson’s correlation and multiple regression analysis were used to assess the relationships between variables. Significance level was 0.05.

RESULTS: Mean age was 58.6±12.5 years. Minimum time since LT was 6 months and mean time since LT was 9.7±5.7 years. 48 patients (64%) showed normal glucose tolerance (NGT), 31 patients (36.4%) prediabetes and 6 patients (7.05%) diabetes (NODAT). Mean sclerostin were: 0.78±0.38 ng/ml in the total group; 0.69±0.28 ng/ml in patients with NGT; 0.81±0.26 ng/ml in patients with prediabetes and 1.36±0.88 ng/ml in patients with NODAT. Statistically significant differences were found in sclerostin levels between NGT and NODAT patients (p<0.001) and prediabetes and NODAT patients (p<0.01). Significant correlations were found between sclerostin and age (r=0.36; p=0.001); fasting PG (r=0.33; p=0.002); 60-minute PG (r=0.34; p=0.002); 120-minute PG (r=0.43; p<0.001) and creatinine (r=0.218; p=0.04). In multiple regression analysis only age and fasting PG remained as independent predictors of sclerostin (standardized beta 0,29, p=0.006; 0.24, p<0.05 respectively).

CONCLUSIONS: Our preliminary results show that sclerostin was significantly higher after LT in patients with NODAT than in patients with prediabetes or NGT. Also, we have found that sclerostin was significantly correlated with plasma glucose (fasting and after OGTT) and age. Based on our results, we suggest large-scale studies to investigate the plausible link of higher levels of sclerostin in NODAT patients and increased fracture risk.

 

Nothing to Disclose: GM, GA, MA, SG, SL, CJ, FGH

21682 19.0000 SAT-604 A Patients with New Onset Diabetes after Liver Transplantation Have Higher Sclerostin Levels Than Patients with Normal Glucose Tolerance or Prediabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM SAT 586-604 6090 1:00:00 PM Diabetes Case Reports II Poster


Anery Patel*1, Muzafar A Macha2, Whitney S Goldner2 and Surinder K Batra3
1University Of Nebraska Medical Center, Omaha, NE, 2University of Nebraska Medical Center, Omaha, NE, 3University of Nebraska Medical Center, Oamha, NE

 

Background:

Papillary thyroid cancer (PTC) (>80%) is the most common thyroid cancer and is usually associated with slow growth and good prognosis, however 10% to 15% of cases can display aggressive behavior, characterized by early metastasis and increased mortality rates. Presently used clinicopathologic variables for prognosis and staging are not uniformly predicting tumor behavior. Therefore, there is urgent need for identification of more reliable and novel prognostic markers. Mucins (MUC) are large glycoproteins which are expressed by several normal tissues epithelium and has been shown to be over expressed in numerous cancers including pancreas, colon, lungs and ovary.

Several studies have shown over expression of MUC1 and MUC4 in thyroid cancer. However use of nonspecific detection methods (antibodies) have limited their prognostic values in thyroid cancer.

Aim:

To investigate the incidence of mucin positivity in thyroid cancer cell lines and tissue microarray.

Methods:

Using semi quantitative reverse-transcriptase PCR and western blot analysis we screened a panel of thyroid cancer cell lines representing papillary thyroid cancer (BCPAP, TPC P18 and KTC-1), anaplastic thyroid cancer (C643 and Hth-7) cells and immortalized normal thyroid cancer cells (N-thy). For western blot analysis, specific monoclonal antibodies against MUC 1 , 4 , 5AC and MUC 16 was used.  MUC 4 immunohistochemical analysis was done on a commercially available tissue microarray (TMA) obtained from 68 patients.

Results:

Our western blot and RT-PCR analysis revealed mild expression of only MUC16 in PTC cells only. None of the cell lines showed expression of MUC 1, 4, 5AC as determined by immunoblot analysis.  While at mRNA level, faint expression of MUC4 was observed in 4/6 (TPC, BCPAP and Hth-7) cell lines and normal cells (Nthy). Our immunohistochemical analysis revealed over expression of MUC4 in 11.7% (8/68) of thyroid cancer tissues.

Conclusion:

Our preliminary results showed underexpression of mucins in thyroid cancer cell lines and tissue samples.

We understand limitations of using cell lines and therfore these results should be validated in a large tissue cohort.

 

Nothing to Disclose: AP, MAM, WSG, SKB

21413 1.0000 SAT-067 A Mucin Expression Profile of Thyroid Cancer Cell Lines and Patient Samples 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Christopher Paul Gilfillan1, Michael Mond2, Maria Alexiadis3 and Peter J Fuller*2
1Box Hill Hospital and Monash University, Box Hill VIC, Australia, 2MIMR-PHI Institute of Medical Research, Clayton VIC, Australia, 3Hudson Institute of Medical Research, Clayton, Australia

 

Background: The circadian clock is involved in the regulation of a range of physiological and metabolic processes including the cell cycle. Disruptions in the molecular circadian clock are increasingly recognized in cancer. Rev-erba is a key regulator of the circadian clock and links the clock to a variety of metabolic pathways. Up-regulation of Rev-erba has been reported in a subset of aggressive ERBB2 –positive breast cancers where it was associated with changes in cellular metabolism (1). We have previously reported marked overexpression of Rev-erba in a subset of BRAFV600E positive papillary thyroid cancers (PTC) (2).

Aim: We sought to determine whether Rev-erba overexpression is associated with changes in the expression of other clock genes and/or downstream targets of Rev-erba in PTC.

Methods: RNA was isolated from 21 PTC (12 BRAFV600E and 9 wild-type BRAF) and 6 multinodular goiters (MNG). A custom low density array was designed which included gene expression assays for 8 core thyroid, 21 metabolic (identified as genes regulated by Rev-erba), 11 circadian clock and 8 internal control genes. This panel was profiled by quantitative real time PCR. Gene expression data was normalized to internal controls and analyzed using StatMiner software. Protein expression for the core clock component, Bmal1, was examined by immunohistochemistry (IHC) on tissue microarrays comprising benign and malignant thyroid tissues.

Results:  The expression of a number of clock genes was significantly different in PTC compared with MNG. In contrast, significant differences were not observed for the majority of metabolic genes examined. In addition to Rev-erba overexpression, the expression of Bmal1 was significantly higher in PTC than MNG. The expression of the clock output genes, Period 1 (Per1), cryptochrome 2 (Cry2) and hepatic leukemia factor (HLF) was significantly lower in PTC. The changes in circadian clock gene expression were predominantly in BRAFV600E positive PTC. The expression levels of two clock genes (albumin D-box binding protein (DBP) and thyrotrophic embryonic factor (TEF)) and two metabolic genes (fatty acid synthase (FASN) and fatty acid elongase 5 (Elovl5)) were strongly correlated with Rev-erba expression in the BRAFV600E positive PTC. IHC localized Bmal1 expression to epithelial cells and expression was predominantly nuclear. Overall, staining was higher in malignant than benign tissues and all but one PTC demonstrated moderate to strong intensity staining.

Conclusion Our study has demonstrated alterations in the expression of key clock components and clock output genes in PTC. The changes were predominantly in BRAFV600E positive PTC. These findings suggest a potential link between MAP kinase pathway activation and circadian clock dysregulation in PTC. Mechanistic studies may help further elucidate this connection and uncover potential novel therapeutic targets for PTC.

 

Nothing to Disclose: CPG, MM, MA, PJF

20212 2.0000 SAT-068 A Rev-Erb Alpha and the Expression of Circadian and Metabolic Genes in Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Chunxiao Yu*1, Tong Jin2, Fang Yan3, Lifang Zhao4, Shanshan Shao5, Ling Gao3 and Jiajun Zhao3
1Provincial Hospital affiliated to Shandong University, China, 2Qilu Hospital, Shandong University, 3Shandong Provincial Hospital affiliated to Shandong University, Jinan, China, 4Shandong Provincial Hospital affiliated to Shandong University, 5Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, Shandong

 

Background MiR-146b has been reported to be over-expressed in papillary thyroid cancer (PTC) tissues and showed association with aggressive PTC. It is regarded as a relevant diagnostic marker for this type of cancer. MiR-146b-5p has been confirmed to increase cell proliferation by repressing SMAD4, however as the other expression of miR-146b, detailed functional analysis of miR-146b-3p has not been carried out. In this study, we aimed to identify miR-146b-5p and miR-146b-3p differentially expressed in PTC with more aggression, such as lymph node metastasis and further elucidate the contribution and mechanism of miR-146b in the process of PTC metastasis.

Methods Expression of miR-146b-5p and miR-146b-3p were assessed in formalin-fixed paraffin-embedded (FFPE) tissues samples of PTC patients. BHP10-3 cells were cultured and over-expressed miR-146b-5p or miR-146b-3p with microRNA mimics. The cell abilities of migration and invasion were detected by RTCA assay and transwell assay. Direct downstream target of miR-146b-3p was analyzed by luciferase reporter assay and western blot.

Results MiR-146b-5p and miR-146b-3p expression was significantly higher in thyroid cancer tissues and cell lines compared to normal thyroid tissue and cells. Moreover, expression of miR-146b-5p and miR-146b-3p was further higher in thyroid metastatic nodes than thyroid cancer. After overexpression of miR-146b-5p or miR-146b-3p in BHP10-3, papillary thyroid cancer migration and invasion were increased. Notably, miR-146b-3p increased cell migration and invasion more obviously than miR-146b-5p. Luciferase reporter assay revealed that NF2 was a downstream target of miR-146b-3p in PTC cells as miR-146b-3p bound directly to the 3’ untranslated region of NF2, thus reducing protein levels of NF2. Over-expression of NF2 reversed the enhanced aggressive effects of miR-146b-3p.

Conclusions Over-expression of miR-146b-5p and miR-146b-3p was associated with PTC metastasis. MiR-146b-3p could enhance cell invasion and metastasis more obviously than miR-146b-5p through the suppression of gene NF2. These findings suggest a diagnosis and therapeutic benefit in PTC metastasis.

 

Nothing to Disclose: CY, TJ, FY, LZ, SS, LG, JZ

19761 3.0000 SAT-069 A Microrna-146b-3p Promotes Cell Metastasis By Directly Targeting NF2 in Human Papillary Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Elena Izkhakov*1, Orli Sharon2, Ester Knoll3, Asaf Aizic1, Dan Fliss1, Rona Limor1, Naftali Stern1 and Dalia Somjen2
1Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 2Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, 3Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

 

Background: Sorafenib is aproved for the treatment of patients with progressive radioactive iodine-refractory differentiated thyroid cancer (DTC). Sorafenib significantly improves progression-free survival, but causes severe side effects.

Estrogens may enhance thyroid cancer cell growth. Our group has recently reported that a novel anti-estrogenic compound cD-tboc retards growth of both human thyroid carcinoma cell lines and cultured human carcinoma cells. Vitamin D receptor (VDR) is expressed in epithelial cells of the normal thyroid gland. Furthermore, VDR is expressed in malignant dividing cells and responds to 1.25D by decreased proliferative activity in vitro.

Aims: To evaluate the effects of different doses of sorafenib alone and in combination with cD-tboc and 1.25D on cell proliferation (CP) in cultured human papillary thyroid carcinoma (PTC) compared to cultured normal thyroid cells.

Methods: CP was determined by direct measurement in 8 cultured PTC and normal thyroid specimens harvested during thyroidectomy from the same patients.

Results: Sorafenib inhibited CP dose-dependently, and cancer cells were more sensitive than normal cells to this inhibitory activity.  Combined treatment with sorafenib (200 µg/ml) with low concentration of cD-tboc (0.3 µM) reduced CP in cancer cells, whereas this effect was much smaller in normal thyroid cells. Combined treatment of sorafenib (200 µg/ml) with low concentration of 1.25D (50 nM) reduced CP in cancer cells only. Most importantly, the inhibitory effect of sorafenib on CP in cancer cells was amplified after addition of cD-tboc and 1.25D; so that not only was the maximal inhibition larger (-53% vs. -61% P<0.05 and -53% vs. -67% P<0.05 respectively), but it was attained at a 10 fold lower concentration of sorafenib (20 µg/ml).

Conclusions: This is the first report that low concentration cD-tboc and 1.25D markedly amplifies the inhibitory effect of sorafenib and allows the use of a 10 fold lower concentration sorafenib on the growth of human PTC derived from patients. This finding might form the basis for the use of a new combined treatment for progressive radioactive iodine-refractory DTC.

 

Nothing to Disclose: EI, OS, EK, AA, DF, RL, NS, DS

20220 4.0000 SAT-070 A A Sorafenib Sparing Effect in the Treatment of Thyroid Carcinoma Attained By Co-Treatment with the Isoflavone Derivative 7-(O)-Carboxymethyl Daidzein Conjugated to N-t-Boc-Hexylenediamine (cD-tboc) and 1,25 Dihydroxyvitamin D (1.25D) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Frances E Carr*1, S. Kaleem Zaidi2, Philip Tai2, Jeffrey H White1, Jennifer Tomczak1, Thomas Taber1, Michael Barnum2, Katharine S. Evans2, Diane M Jaworski1, Jane B Lian1, Janet L. Stein1 and Gary Stephen Stein1
1University of Vermont College of Medicine, Burlington, VT, 2University of Vermont College of Medicine

 

The spectrum of non-medullary epithelial thyroid cancers is linked with a pattern of cumulative cellular dysregulation, distinct molecular profiles and altered nuclear architecture. The regulatory factors of thyroid tumor progression and invasion as well as the nuclear microenvironment in which they function are not yet elucidated.  Two transcription factors, runt-related transcription factor 2 (Runx2) and thyroid hormone receptor β (TRβ) have been implicated in tumorigenesis. Runx2 has been functionally linked with tumor progression in breast, prostate, as well as thyroid cancers. TRβ is a possible tumor suppressor because mutated or deleted TRs have been linked with aggressive tumors in breast and prostate. Mutations in TRβ have also been linked with thyroid tumorigenesis. Significantly, restoration of TRβ has been associated with inhibition of thyroid tumor progression. Our previous studies revealed differential gene expression of these transcription factors in human benign, papillary, follicular and anaplastic thyroid cell lines. In the context of the onset of thyroid cancer, a compelling question is whether there is coordinated expression of TRβ and Runx2 and if TRβ tumor suppressor activity is mediated in part through modulation of Runx2. In the present study, we determined that TRβ (high in normal) and Runx2 (high in malignant) proteins are reciprocally expressed in benign and malignant thyroid cells and in tumors in human tissue arrays. TRβ protein levels progressively decreased while Runx2 protein levels progressively increased in differentiated and de-differentiated cancer cells. T3 exposure induced a time and concentration dependent decrease in Runx2 protein levels in both benign and malignant thyroid cells. Conversely, siRNA knockdown of TRβ resulted in an increase in Runx2 in both benign and malignant cells.  These results implicated a direct regulation of Runx2 by TRβ. We identified three putative TREs (-105/+133) within the Runx2 promoter sequences. TRβ, both purified protein and nuclear extracts, specifically bound to the Runx2 promoter (by electrophoretic mobility shift assays). The binding was lost with mutation of the putative TREs. Functional validation of this direct TRβ interaction with the Runx2 promoter was demonstrated by TRβ suppression of Runx2 promoter activity using a luciferase assay in TR-deficient COS cells. These findings indicate that TRβ modulates Runx2 in thyroid cells, consistent with the loss of TRβ contributing to Runx2 oncogenic actions in thyroid tumorigenesis. The discovery of this TRβ-Runx2 signaling pathway provides a novel target for therapeutic intervention.

 

Nothing to Disclose: FEC, SKZ, PT, JHW, JT, TT, MB, KSE, DMJ, JBL, JLS, GSS

21418 5.0000 SAT-071 A Thyroid Hormone Receptor β (TRβ) Mediates Runt-Related Transcription Factor 2 (Runx2) Expression in Thyroid Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Athanasios Bikas*1, Kirk Ernest Jensen2, John Costello2, Aneeta Patel2, Kenneth Burman3 and Vasyl Vasko2
1MedStar Georgetown University Hospital, Washington, DC, 2Uniformed Services University of the Health Sciences, Bethesda, MD, 3MedStar Washington Hospital Center, Washington, DC

 

Background:

Metformin increases progression free survival in diabetic patients with thyroid cancer and is considered a possible adjuvant treatment for thyroid cancer. Metformin’s growth inhibitory effects on breast, prostate and ovarian cancer cells depend on the glucose concentration in the extracellular milieu. The effect of glucose on thyroid cancer cells’ response to metformin has not been examined.

Objective:

To determine the effects of glucose concentrations in culture medium on the efficacy of metformin treatment in thyroid cancer cell lines.

Design:

Thyroid cancer cells (FTC133, TPC1 and BCPAP) were cultured in hyperglycemic (20 mM) and normoglycemic (5 mM) conditions before treatment with metformin. Expression of molecules controlling glycolysis and mitochondrial respiration was assessed by real-time PCR and/or Western Blot.  Activation of thyroid oncogene-inducible signaling pathways was examined using phospho-antibodies. Vi-Cell analysis and caspase-3 cleavage assays were performed to measure cellular proliferation and apoptosis.

Results:

Metformin inhibited cellular proliferation in hyperglycemic and induced cell death in normoglycemic media.  In normoglycemic media metformin increased expression of molecular markers of endoplasmic reticulum stress (BIP and CHOP) and decreased expression of p62 indicating autophagy. The level of PI3K/AKT and MAPK/ERK activation was not affected by switching from hyper- to normoglycemic conditions. However, AMPK activation was induced in thyroid cancer cells cultured in normoglycemic medium for 48 hours. Treatment with millimolar concentrations (5mM – 10mM) of metformin was required for inhibition of p-p70/pS6 signaling in hyperglycemic conditions, while micromolar concentrations (50 mM-500 mM) of metformin were sufficient to block p-p70/pS6 in normoglycemic medium. Metformin had no significant effect on the mRNA level of glycolytic molecules (Glut1, HK2, PKM1, PKM2 and LDHA). However, metformin increased the rate of glucose uptake from the normoglycemic as well as from hyperglycemic medium. Metformin also prompted lactate production with rapid acidification of medium, indicating activation of glycolysis. Supplementation of normoglycemic media with glucose (20 mM) reversed metformin-inducible morphological and molecular changes. Treatment with an inhibitor of glycolysis (2-deoxyglycose) dramatically increased thyroid cancer cell sensitivity to metformin. The combination of 2DG with metformin at clinically achievable concentrations (10-20 mM) led to massive cell death in all examined cell lines.

Conclusion:

We have demonstrated that glucose concentration in the cellular milieu is a factor modulating metformin’s anti-cancer activity. These data suggest that the combination of metformin with inhibitors of glycolysis could represent a new strategy for the treatment of thyroid cancer.

 

Nothing to Disclose: AB, KEJ, JC, AP, KB, VV

21603 6.0000 SAT-072 A Glucose Concentration Underlies the Efficacy of Treatment with Metformin in Thyroid Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Yusuf Tohma1, Mujde Akturk*1, Alev E. Altinova1, Emine Yassibas2, Ethem Turgay Cerit1, Ozlem Gulbahar1, Metin Arslan1, Nevin Sanlier2 and Fusun Toruner1
1Gazi University Faculty of Medicine, Ankara, Turkey, 2Faculty of Health Sciences, Gazi University, Ankara, Turkey

 

Background and aim: There is no sufficient information about orexin-A, nesfatin-1, agouti related peptide (AgRP) and neuropeptide Y (NPY,) which are peptides related with appetite, in hyperthyroidism. To investigate the effects of hyperthyroidism on basal metabolic rate (BMR), food intake, orexin-A, nesfatin-1, AgRP and NPY levels and their relationships with each other as well as appetite.

Subjects and methods: Twentyone patients with overt hyperthyroidism and 33 healthy controls were included in the study.  In this prospective study, patients were evaluated in hyperthyroid and euthyroid states in comparison with healthy subjects.

Results: The amount of calorie intake in hyperthyroid state was found to be higher than euthyroid state in patient group (p=0.039). BMR was higher in hyperthyroid patients than control group (p=0.018). Orexin-A was lower and nesfatin-1 was higher in hyperthyroid patients compared to the controls (p<0.001), while orexin-A increased and nesfatin-1 decreased after euthyroidism (p=0.003, p<0.001). No differences were found in AgRP and NPY levels between hyperthyroid and euthyroid states and controls (p>0.05). Orexin-A was correlated negatively with nesfatin-1 (p=0.042), BMR (p=0.013), freeT3 (p<0.001), freeT4 (p<0.001) and positively with TSH (p<0.001). Nesfatin-1 was correlated negatively with orexin-A (p=0.042), TSH (p<0.001) and positively with freeT3 (p=0.005), freeT4 (p=0.001). In the regression analysis, ‘diagnosis of hyperthyroidism’ was the main factor affecting orexin-A (p<0.001).

Conclusion: Although, it seems that no relationship exists between orexin-A, nesfatin-1 and increased appetite in hyperthyroidism, orexin-A and nesfatin-1 levels are markedly affected by hyperthyroidism.

 

Nothing to Disclose: YT, MA, AEA, EY, ETC, OG, MA, NS, FT

18366 7.0000 SAT-073 A Circulating Levels of Orexin-a and Nesfatin-1 in Patients with Hyperthyroidism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Assim A Alfadda*1, Hicham Benabdelkamel1, Afshan Masood1, Mark W Duncan2, Anwar A Jammah3 and Aishah A Ekhzaimy4
1College of Medicine, King Saud University, Riyadh, Saudi Arabia, 2University of Colorado Denver, Aurora, CO, 3King Saud University, Riyadh, Saudi Arabia, 4King Saud University,King Khalid Univesity Hospital, Riyadh, Saudi Arabia

 

Background: Thyroid hormone is a potent stimulator of metabolism, it plays a critical role in regulating energy expenditure, and in key physiological mechanisms such as growth and development.  Although administration of thyroid hormone in the form of levothyroxine has been used to treat hypothyroidism for many years, the precise molecular basis of its physiological actions remains uncertain.

Objective: Our objective was to define the changes in circulating protein levels that characterize alterations in thyroid hormone status. To do this, an integrated untargeted proteomic approach with network analysis was used.  

Methods: This study included 12 age-matched subjects (7 females and 5 males; 42.2 + 14.6 years) with newly diagnosed overt hypothyroidism (i.e., FT4 = 9.6 + 4.9 PM/L, TSH = 35.4 + 14.5 MIU/L (mean + SD)). Blood was collected from subjects at baseline and at intervals post treatment with levothyroxine until they were euthyroid (i.e., FT4 = 19.4 + 4.9 PM/L, TSH, 1.4 + 0.6 MIU/L (mean + SD)).

Results: Plasma protein levels were compared by two-dimensional difference in gel electrophoresis (2D DIGE) pre- and post-treatment. Twenty differentially expressed protein spots (ANOVA test, p≤0.05; fold-change ≥1.8) were detected. Thirteen were identified, and were found to be unique protein sequences by MALDI-TOF mass spectrometry. Ten proteins were more abundant in the hypothyroid vs. euthyroid state: i.e., complement C2, serotransferrin, complement C3, Ig kappa chain C region, alpha-1-antichymotrypsin, complement C4-A, haptoglobin, fibrinogen alpha chain, apolipoprotein A-I and Ig alpha-1 chain C region. Three proteins were decreased in abundance in the hypothyroid vs. euthyroid state: i.e., complement factor H, paraneoplastic antigen-like protein 6A and alpha-2-macroglobulin. The differentially abundant proteins were investigated by Ingenuity Pathway Analysis (IPA) to reveal their associations with known biological functions. The connectivity map included two central nodes, namely IL-6 and TNF alpha, and the pathway identified with the highest score is involved in neurological disease, psychological disorders and cellular movement. Differences in the abundances of three proteins involved in the network were confirmed by immunoblotting: i.e., complement C3, haptoglobin, alpha-1-antichymotrypsin.

Conclusion: A comparison of the plasma proteome in the hypothyroid vs. euthyroid states reveals differences in the abundance of proteins involved in the regulation of the acute phase response. These proteins were increased in the hypothyroid state and decreased after thyroid hormone replacement.

 

Nothing to Disclose: AAA, HB, AM, MWD, AAJ, AAE

21614 8.0000 SAT-074 A Differences in the Plasma Proteome of Primary Hypothyroid Patients before and after Thyroid Hormone Replacement: A Proteomic Analysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Kaushik Biswas*1, Sumit Kumar Chakrabarti2, Sujoy Ghosh3 and Subhankar Chowdhury4
1IPGME&R, 2Institute of Postgraduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, India, 3Institute Of Post Graduate Medical Education & Research,SSKM Hospital, 4Institute of Post Graduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, India

 

In some patients an optimal daily  of LT4 does not  restore TSH into the normal range. Non-adherence to LT4 is the commonest cause of treatment failure which is very difficult to diagnose if the patient does not volunteer to state the same. In our study, we compared  thyroxine absorption pattern in newly diagnosed hypothyroid patients and in those who despite the treatment with  high daily dose of L-T4 ( >1.8 μg /kg ) had failed to normalize TSH. We included 15 patients in each group  without known disorders or medications that  interferes with LT4 absorption. None were positive on screening for coeliac disease. 11.2 μg /kg  LT4 was given orally under supervision after an overnight fast. Blood was collected at baseline for fT4 ,TSH (just before ingestion of LT4) and  every 60-min intervals thereafter for up to 300 min for fT4 measurement. The patients of non-adherent group were given the same weekly dose of L-T4 for a total of 4 weeks under supervision.TSH was rechecked 1 week after the final dose.No statistically significant difference was observed in age, weight, height, BMI and sex distribution among study subjects. In non-compliant group fT4 peak occurred in 26% cases in 2 hours and 40% cases in 3 hours. In drug-naïve group fT4 peak occured in 33% cases in 2 hour and 60% cases in 3 hour. Significant elevation of serum FT4 was observed among both the study groups in different time interval (p < 0.001).The newly diagnosed group showed a significant increase in serum FT4 level at 1 hour (26.85%; 0.92±0.09 vs 1.17±0.28), 2 hrs (26.97%; 0.92±0.09 vs 1.45±0.23) , 3 hrs (63.35%; 0.92±0.09 Vs 1.5±0.17) , 4hrs (56%; 0.92±.09 vs 1.42±0.12) and 5 hrs (54%; 0.92±0.09 Vs 1.41±0.13) as compared to their baseline value. Similarly, the non-adherent group showed a significant elevation of serum FT4 at 1 hr (18.73%; 0.93±0.1 Vs 1.1 ±0.21), 2 hrs (22%; 0.93 ±0.1 Vs 1.33 ± 0.23) , 3 hrs (53%; 0.93 ± 0.1 Vs 1.41±0.22) , 4hrs (49%; 0.93±0.1 Vs 1.37±0.15) and 5(46%; 0.93±0.1 Vs 1.34±0.17) hrs as compared to their baseline value. In both group the highest elevation occurred at 3 hours. There was no statistically significant change in serum FT4 level at similar time interval (baseline: 0.92±0.09 Vs 0.93±0.1,  p = 0.633; 1 hr: 1.17±0.28 Vs  1.1 ±0.21, p = 0.967; 2hr: 1.45±0.23 Vs 1.33 ± 0.23, p= 0.140; 3hr: 1.5±0.17 Vs 1.41±0.22, p = 0.261; 4hr:1.42±0.12 Vs 1.37±0.15,  p = 0.358; 5hr:1.41±0.13 Vs 1.34±0.17, p = 0.326) in between both the study groups. Thyroxine absorption profile was almost similar in both groups. After four weeks of intervention, the noncompliant group showed a significant decrease in serum TSH level compared to their baseline values (17.44±15.26 to 3.33 ±1.32 ; p= 0.004).Our study showed that thyroxine absorption test can be used as a tool to identify non-adherence and supervised weekly dosing in subsequence can successfully restore the euthyroid state.

 

Nothing to Disclose: KB, SKC, SG, SC

21645 9.0000 SAT-075 A Utility of Levothyroxine Absorption Test in the Management of Primary Hypothyroid Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


V Daniel Castracane*1, Christopher G Maguire2, William Meachum2 and Robert Porter Kauffman3
1Texas Tech University Health Sciences Center at the Permian Basin, Odessa, TX, 2TX Tech University Health Sciences Center of the Permian Basin, Odessa, TX, 3Texas Tech University Health Sciences Center of Amarillo, Amarillo, TX

 

Introduction: Thyroid hormones in nonpregnant individuals can have a profound effect on body weight.  With the increasing concern of obesity in pregnancy, we wished to establish whether thyroid hormones differed among lean and obese pregnant women during pregnancy.  We conducted a longitudinal study to compare changes in these thyroid hormones during gestation.  Given the effect of hCG on thyroid function, we included hCG levels in our study.

Materials and Methods:  Normal pregnant women, either lean or obese, were enrolled at 8 weeks of gestation and blood samples were obtained at two week intervals throughout gestation.   Thyroid hormones and hCG were measured using a chemiluminescent automated instrument (Immulite; Siemens).  Data was analyzed using 2-way mixed measures ANOVA.

Results: Obese women (BMI ≥30 kg/m2 before pregnancy) recorded lower TSH (p=0.001) and free T4 levels (P<0.001) during the course of pregnancy compared to lean counterparts (prepregnancy BMI 18.5-24.9 kg/m2).  Total T4 values were similar.  Obese women, paradoxically, had higher hCG levels throughout pregnancy (P>0.001).

Conclusions:  TSH and free T4 levels are lower and hCG concentrations higher throughout the course of normal pregnancy in obese women compared to their lean counterparts.   A larger cross-sectional study is warranted to validate these findings and the clinical implications.

 

Nothing to Disclose: VDC, CGM, WM, RPK

19365 10.0000 SAT-076 A Comparison of Thyroid Hormones (TSH, T4, and fT4) and Hcg in Lean and Obese Pregnant Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Sumit Kumar Chakrabarti*1, Satinath Mukhopadhyay2, Subhankar Chowdhury3, Sandip Banerjee4 and Kaushik Biswas5
1Inst of PG, Med Educ and Rsrch, Calcutta, India, 2IPGME&R, Calcutta, 3IPGMER, Calcutta, India, 4KPC Medical College, Jadavpur, Kolkata., 5IPGME&R

 

 

Title : Oxidative stress in primary hypothyroid patients and the possible role of antioxidant supplementation

Abstract : Oxidative stress resulting from production of excessive reactive oxygen species(ROS) can cause peroxidation of membrane-derived lipids. Thyroid hormones influence mitochondrial free-radical generation. Hypothyroid state might alter oxidative stress related processes.

Available data concerning oxidative stress in hypothyroidism are scanty and inconclusive.

Methods : We assessed the pre and post (L-Thyroxine) treatment changes in serum malondialdehyde (MDA) levels, a lipid peroxidation marker, among patients with primary hypothyroidism, along with the possible role of antioxidant supplementation in the form of selenium.

  We included 60 treatment naive patients (age>18 years) with comparable baseline parameters and divided them into groups A & B, each comprised of 30 patients. Appropriate exclusion criteria were followed. Group A received L-Thyroxine and placebo and group B received L-Thyroxine and selenium supplementation(200mcg/day). Study duration was 6 months. The dose of L-Thyroxine was 1.6mcg/kg bodyweight. fT4, T3 and TSH were measured at the beginning, then after 3and after 6 months. MDA was assessed at the beginning and after 6 months of treatment. 

Results : MDA levels showed reduction after treatment in both the groups, mean reduction in Gr A was 39.5% and in Gr B was 45.4%, which was statistically significant. Unlike the intragroup reduction, the intergroup reduction did not reach statistical significance. We observed that treatment with L -Thyroxine was effective. Addition of selenium did not appear beneficial in terms of its antioxidant effects. Further studies with a larger sample size are needed for conclusive results.

 

 

 

Nothing to Disclose: SKC, SM, SC, SB, KB

20869 11.0000 SAT-077 A Oxidative Stress in Primary Hypothyroid Patients and the Possible Role of Antioxidant Supplementation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM SAT 067-077 6103 1:00:00 PM Thyroid Hormone Action, Cancer and Clinical Thyroid Poster


Rajeev Thirunagari* and Kathleen Bethin
University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY

 

Background: Hashimoto’s encephalopathy associated with autoimmune thyroiditis is a rare entity first described in 1966. Diagnostic criteria are controversial and include impaired mental status, presence of antithyroid antibodies and absence of any other etiology.  The disease improves with glucocorticoids and is associated with thyroid antibodies. Thyroid antibodies have also been associated with chronic urticaria. The pathophysiology in either condition is not fully understood. The proposed mechanisms include endocrinopathy, autoimmune process or vasculitis.

Case:  A 14-year-old girl with a history of longstanding incoordination and gait instability and 2 year history of headaches, dizziness and peripheral neuropathy was admitted to the hospital for GTC seizures with worsening headache and vomiting.  She also complained of hives that had recently begun.   Head MRI was normal. She was treated with anti-epileptics and discharged home. She was readmitted 3 weeks later when she developed severe bilateral headaches and left-sided hemianopsia and weakness. Laboratory workup included normal ANA, SSA, ESR, ANCA, CPK, chromosomal microarray, testing for Friedreich’s ataxia, TSH and total T4. TPO antibodies were 67 U/mL (15-35). Repeat head MRI showed a non-enhancing gyriform signal abnormality in the right occipital lobe without mass effect. EEG showed periodic lateralized epileptiform discharges (PLEDs) with right occipital epileptiform discharges. CT angiogram showed focal leptomeningeal enhancement in the left occipital area. CSF protein was 75 mg/dl (15-45). She was treated with intravenous Solumedrol (1 g per day x 5 days) and intravenous immunoglobulin (IVIG). She developed hallucinations (body/limb distortions) and visual disturbances (flashing lights in the left occipital regions) at the beginning of treatment, but symptoms improved prior to discharge.  She was discharged home on IVIG therapy. Two months later she was hospitalized for a severe right-sided headache with bitemporal vision loss. MRI showed increased signal abnormality in the right posterior thalamus and occipital lobe. CSF protein was 188 mg/dL (15-45).  Repeat TSH was normal.  She was treated with Solumedrol (1 g per day x 5 days) followed by a 4 month steroid wean and monthly IVIG.  Because of the association of urticaria and thyroid autoimmunity, she was started on 25 mcg of levothyroxine despite normal thyroid function. At follow-up, her symptoms have shown improvement.

Conclusions: Hashimoto’s encephalopathy should be considered in all children with complex neuropsychiatric presentations and urticaria. Without a known history of Hashimoto thyroiditis, the diagnosis requires a high index of suspicion.

 

Nothing to Disclose: RT, KB

21204 1.0000 SAT-165 A Abnormal Mental Status and Urticaria- Consider Hashimoto's Encephalopathy in the Differential Diagnosis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 165-168 6116 1:00:00 PM Pediatric Thyroid & Growth Disorders II Poster


Angela Delaney*1, Maria Batsis2, Fabio R Faucz1, Rebecca L. Hicks1 and Constantine A Stratakis2
1National Institutes of Health, Bethesda, MD, 2National Institutes of Health (NIH), Bethesda, MD

 

Background: Isolated central hypothyroidism rarely presents in adolescence in the absence of intracranial pathology or irradiation. Loss-of-function mutations in the immunoglobulin superfamily 1 (IGSF1) gene have been shown to cause an X-linked form of central hypothyroidism with macroorchidism, delayed puberty, and variably low prolactin levels, but the full phenotypic spectrum of IGSF1mutations is not yet known.

Clinical Case: A previously healthy 16 and ½-year-old male presented for an evaluation of hypogonadism.  Symptoms began 9 months prior to evaluation, and included fatigue, depressed mood, cold intolerance, and decreased libido. Pubertal onset was normal, and family history was non-contributory. Growth data was limited but there was no linear growth over the previous year with an increase of 1.5 kg in weight. Physical examination revealed an ill-appearing young man with bradycardia (HR 49), blood pressure 102/51, and was otherwise significant for a normal thyroid exam, dry skin, and Tanner stage V pubic hair with 15 mL testes bilaterally and no gynecomastia. Initial evaluation revealed a bone age of 16 years, TSH was 1.86 mcIU/ml (0.4 – 4.0), T3 was 79 ng/dL (90 – 215), and free T4 was 0.9 ng/dL (0.8 – 1.5).  LH was 1.0 U/L (1 – 8), FSH was 3.3 U/L (1 – 11), and total testosterone was 103 ng/dL (252-1593). CBC, ESR, CRP and CMP were within normal limits, as were prolactin (9.3 mcg/L, 2-25), IGF-1 (339 ng/ml, 226-903), GH (baseline 3.8 with peak 10.5 ng/mL 60 minutes after arginine), and cortisol (baseline 10.6, stimulated to 24.5 mcg/dL at 60 minutes after ACTH). MRI of the brain and pituitary was normal and EKG revealed sinus bradycardia. 

The patient was diagnosed with central hypothyroidism (CeH) and hypogonadotropic hypogonadism (HH), and levothyroxine 100 mcg/day was prescribed to determine whether his HH was secondary to CeH.  He had a remarkable response with resolution of all symptoms, improved growth, with an additional 4 cm gained over the subsequent year with final height and weight at the 50thpercentile, consistent with familial height. TSH after 6 weeks was 0.36 mcIU/ml (0.3 – 5.0), T3 was 130 ng/dL (80-200), and free T4 was 1.16 ng/dL (0.7-2.0). After four months on therapy, he reported normal sexual function and libido and total testosterone was 376 ng/dL (262-1593). The patient has remained in good health on levothyroxine therapy.

To determine the etiology of this clinical presentation of CeH with testicular enlargement despite biochemical evidence of HH, we collected genomic DNA and sequenced the IGSF1 gene by Sanger sequencing.  No mutations in IGSF1 were identified.

Conclusion: This patient’s testicular volume was likely normal due to the onset of HH occurring in late puberty, and does not represent macroorchidism in combination with CeH due to a mutation in the coding sequence of IGSF1.  This suggests that late-onset CeH may not be associated with IGSF1 mutations.

 

Nothing to Disclose: AD, MB, FRF, RLH, CAS

21277 2.0000 SAT-166 A Late-Onset Isolated Central Hypothyroidism Presenting with Post-Pubertal Hypogonadism Was Not Caused By a Mutation in IGSF1: A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 165-168 6116 1:00:00 PM Pediatric Thyroid & Growth Disorders II Poster


Rajan Senguttuvan*, Cindy Chin, Salaheddin Elrokhsi and Mark Wheeler
University of Arizona, Tucson, AZ

 

Background

Gigantism refers to GH excess that occurs during childhood when open epiphyseal growth plates allow for excessive linear growth. In contrast, acromegaly occurs when GH excess presents after epiphyseal closure. The incidence of acromegaly is estimated at 3 - 4 cases per million per year1, whereas gigantism is extremely rare, with approximately 100 reported cases to date.2This is probably an underestimate of the true number as many cases go unreported. We present a case of gigantism secondary to a GH-secreting pituitary tumor.

Clinical Case

17 year 10 month old female presented for evaluation of overgrowth. Per adoptive mother she had been growing quickly during her adolescent years and was continuing to grow. Four months prior to her visit, she developed excessive and daily vaginal bleeding. Oral contraceptive therapy did not resolve the bleeding. She did not report any visual disturbances, headaches or galactorrhea. Review of her growth charts showed linear growth tracking at greater than the 97th percentile since the age of 11 years. Past medical history was significant for mild scoliosis, sleep apnea and anemia. Physical exam was remarkable for a tall (Ht > 97%, Z= +3.90 SD above mean) and obese (> 97%, Z= +2.43 SD above mean) female with coarse facial features and very large hands and feet. She also had soft puffy palms.

Laboratory evaluation showed elevated IGF-1 level at 893 ng/mL (268-430). Growth hormone suppression test showed a GH level at 10.9 ng/mL (< 1), 2 hours after glucose load, consistent with GH excess. She had low free T4 levels at 0.57 ng/dL (0.61 - 1.12) with inappropriately normal TSH at 2.06 uIU/mL (0.38 – 4.8) consistent with central hypothyroidism. Prolactin levels were elevated at 68.4 ng/mL (2.8-26.0). Her 8 AM cortisol level was normal at 16.2 mcg/dL (4.2-38.4 mcg/dL). The LH (< 0.1 mIU/mL) and FSH (<0.3 mIU/mL) levels were suppressed. Brain MRI revealed a pituitary mass measuring 2.6 cm x 2.3 cm x 2.1 cm. The clinical presentation was consistent with gigantism due to the sellar mass.

Ophthalmologic evaluation revealed bitemporal hemianopsia. Neurosurgery and ENT performed surgical excision of the mass via the endonasal route. Postoperative course was marked by the development of diabetes insipidus (DI) requiring desmopressin. Histopathology confirmed a prolactin and growth hormone producing adenoma. MRI of the brain performed 3 months post surgery showed postoperative gliosis and granulation tissue. Repeat IGF-1 levels obtained in the immediate postsurgical period and 4 months later were within normal limits. The patient continues to demonstrate DI and central hypothyroidism but is otherwise doing well with no further linear growth.  

Conclusion

Clinicians must keep a high level of suspicion for prompt recognition and management of overgrowth syndromes to mitigate the medical and psychological complications of this disease.

 

Nothing to Disclose: RS, CC, SE, MW

19386 3.0000 SAT-167 A Gigantism Secondary to Growth Hormone (GH) Secreting Pituitary Tumor 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 165-168 6116 1:00:00 PM Pediatric Thyroid & Growth Disorders II Poster


Yeon Joung Oh*, Young Suk Shim, Min Jae Kang, Seoung Yang and Il Tae Hwang
Hallym University College of Medicine, Seoul, Korea, Republic of (South)

 

Objectives: It has been reported that human growth hormone receptor (GHR) gene exon 3 and -202 IGFBP3 promotor region polymorphism may affect the response to recombinant human growth hormone (rhGH) therapy in some causes of short stature, but the results varied across studies. This study was aimed to assess influences of GHR-exon 3 and -202 A/C IGFBP3 polymorphism on treatment outcomes in patients with growth hormone deficiency (GHD).

Methods: In 72 (39 boys) children confirmed with GHD (peak stimulated GH < 10 ng/mL), genotyping and serial measurements of auxological and endocrine parameters were performed. And, 49 patients who remained prepubertal at 1-year after GH treatment were analyzed. Changes of height and height standard deviation score (SDS), body mass index (BMI), IGF-I and IGFBP-3 levels were compared in these patients according to the genotypes: exon-3 genotypes (d3/d3 and d3/fl group vs fl/fl group) and -202 IGFBP3 genotypes (A/A group vs A/C and C/C group).

Results: Prevalence of GHR exon 3 genotype in 72 patients was as follow: d3/d3 genotype 2/72 (2.8%), d3/fl genotype 11/72 (15.3%), fl/fl genotype 59/72 (81.9%). Frequency of -202 A/C IGFBP3 genotype was as follow: A/A genotype 40/72 (55.5%), A/C genotype 28/72 (38.9%), CC genotype 4/72 (5.6%). In the comparison of d3/d3 and d3/fl group vs fl/fl group, there was no significant difference in height gain (9.6±2.7 cm vs 8.2±2.5 cm, P=0.08), changes in height SDS, BMI SDS, IGF-I SDS and IGFBP-3 SDS at the first year of GH treatment. Likewise, among A/A group vs A/C and C/C groups, no significant differences were observed in height gain (8.3±2.0 cm, 8.3±1.7 cm, P=0.97), changes in height SDS, BMI SDS, IGF-I SDS and IGFBP-3 SDS after 1 year follow-up. Combined analysis showed that GHR exon3 and -202 A/C IGFBP3 genotype had no significant interactive influence on the first year height gain {(d3/d3 and d3/fl) and A/A group vs (d3/d3 and d3/fl) and (A/C and C/C) group vs fl/fl and A/A group vs fl/fl and (A/C and C/C) group, 10.1±1.8 cm vs 8.5±2.8 cm vs 7.9±1.9 cm vs 8.3±1.6 cm, P=0.19}.   

Conclusions: In our study, 1-year treatment outcomes were similar among GHD patients with each genotypic variation, suggesting that the GHR exon 3 and -202 A/C IGFBP3 polymorphisms may not be major factors to affect the responsiveness to GH therapy in Korean GHD children.

 

Nothing to Disclose: YJO, YSS, MJK, SY, ITH

19439 4.0000 SAT-168 A Influences of Growth Hormone Receptor Exon 3 and -202 a/C IGFBP3 Polymorphism on 1-Year Follow-up Outcome of Growth Hormone Treatment in Korean Children with Growth Hormone Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM SAT 165-168 6116 1:00:00 PM Pediatric Thyroid & Growth Disorders II Poster


Fangzhen Xia*1, Ningjian Wang2, Bing Han1, Qin Li1, Chunfang Zhu1, Yingchao Chen1, Yi Chen2, Xiaoqi Pu1, Zhen Cang1, Chaoxia Zhu3, Meng Lu1, Ying Meng1, Hui Guo1, Chi Chen1, Dongping Lin1, Weiping Tu4, Bin Li5 and Ling Hu6
1Shanghai Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, 2Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, 3The First Affiliated Hospital of Henan University of Science and Technology, 4Shangyu People's Hospital, 5Fengcheng Hospital, 6the Third Affiliated Hospital of Nanchang University

 

Background: aging is associated with the variation of pituitary-gonadal axis hormones, but how it affects them and whether it has difference between aging men and women is not very clear.

Objective: To investigate the changes of pituitary-gonadal hormones with age and the feedback abilities of gonadal in adult men and women in east of China.

Design: This was a cross-sectional survey on adults aged 25 and above from the study SPECT-China (Survey on Prevalence in East China for Metabolic Diseases and Risk Factors (SPECT-China)) in three provinces of east of China. The characteristics data and sex hormones including total testosterone (TT), free testosterone (FT), sex hormones binding globlin (SHBG), estradiol (E2), follicule-stimulating hormone (FSH) and luteinizing hormone (LH) of participants who have no diseases effected these hormones and with no exogenous supplement were picked out for analysis.

Results: There are 6840 subjects met the conditions (men: 2919, women: 3921). ①In men, levels of TT FT have no changes during age 25 to 55 and the concentrations of the two hormones are similar. After the age of 55, levels of FT decrease with age, but those of TT, E2 increase with age. Unadjusted annual age trends (β) for free T was -0.199pmol/liter.yr (P <0.001); total T, 0.079 nmol/liter.yr (P <0.001); E2, 1.774 pmol/liter.yr (P <0.001); SHBG levels in adult men increase with age at about 30 years old and the unadjusted annual age trends is 1.118nmol/liter. yr (P<0.001). ②In female, levels of E2 decline sharply when post-menopause at about age 55 and maintain at a low level state after their sixties. Levels of total T remain in a low state and had no cross-sectional age trend.③The decline of sex hormones feedback to pituitary and lead to rise of FSH and LH in men and women. FSH increases more obviously than LH. The former increase 7.11%per annum in men and 12.76%per annum in women but the latter increase only about 4.00% per annum in both genders.④Both the baseline levels and the age related increase speed of FSH are higher in women than those in men.

Conclusion: Ageing influence HPG axis function, but the degree is not the same in both genders. It decreases men’s gonadal function mainly through the increased SHBG. While in women, the post-menopause leads to sharply decline of estradiol levels, which in turn raise the pituitary gonadotropin FSH levels significantly. The pituitary feedback ability is stronger in aging women than that in aging men.

 

Nothing to Disclose: FX, NW, BH, QL, CZ, YC, YC, XP, ZC, CZ, ML, YM, HG, CC, DL, WT, BL, LH

22441 1.0000 LBS-064 A Age Related Changes of Pituitary-Gonadal Axis in Adult Men and Women: Results from SPECT-China Study, 2014 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Anupam Kotwal* and Neil Aronin
University of Massachusetts Medical School, Worcester, MA

 

Introduction: Malignant Pheochromocytoma (PCC) has a 5-year survival of less than 50% without treatment (1). In light of growing evidence that PCC of the Adrenal Gland Scaled Score (PASS) (2) is not a perfect tool to define malignancy (3), the current accepted indicator is local invasion or distant metastases (1), which may occur as long as 20 years after resection. Open resection is recommended for large (e.g., >6 cm) or invasive PCC to ensure complete tumor resection, prevent tumor rupture and avoid local recurrence (4).

Clinical case: A 34 year old man, who had undergone partial right adrenalectomy for PCC 2 years ago, was evaluated for recurrence of episodic headache, palpitations and diaphoresis, sometimes interrupting his sleep. He did not have any other medical conditions or family history of endocrine diseases. Examination was significant only for post-surgical abdominal scars. Urine studies revealed high Normetanephrine of 38080 nmol/day (273-3548), mildly elevated Metanephrine of 2240 nmol/day (152-1775), high Norepinephrine of 344 mcg/day (0-100) and normal Dopamine of 407 mcg/day (40-440). Plasma studies showed high Normetanephrine of 8 nmol/L (0-0.89), normal serum electrolytes and normal liver tests. These findings were concerning for recurrence of PCC, and MRI of the abdomen revealed a 7 x 6 x 6 cm solid enhancing round mass within the right hepatic lobe containing a 2 cm hemorrhagic focus, along with effacement of the inferior vena cava and narrowing of the right portal vein. Differential considered was primary adrenal mass with direct hepatic invasion versus hematogenous metastasis to the liver; however, primary hepatocellular neoplasm could not be entirely excluded. An MIBG scan revealed focal uptake in the right hepatic lobe, compatible with a neuroendocrine tumor. Carcinoembryonic antigen and Alpha-fetoprotein tumor markers were negative. Phenoxybenzamine was initiated in addition to Nebivolol which he had been on since his previous surgery. He then underwent laparotomy with right adrenalectomy, partial hepatectomy and partial caval resection. Histopathology demonstrated high cellularity, focal necrosis, hyperchromasia and lymphovascular invasion involving the hepatic vessels and inferior vena cava. Immunochemistry was positive for Synaptophysin, Chromogranin-A and S100, with a Ki-67 index <1%. Following this, metanephrine and normetanephrine levels normalized and his symptoms resolved. He did not have skin neurofibromas hence NF1 was unlikely to be involved. He tested negative for RET and VHL gene mutations. On follow up by MRI and Chromogranin-A over 3 years, he did not show any features of recurrence.

Conclusion: Our patient’s episodic symptoms, elevated catecholamines and MIBG uptake suggested PCC which was confirmed by histology and immunochemistry. Hepatic involvement and a PASS of >4 suggested malignant recurrence of the previously resected PCC.

 

Nothing to Disclose: AK, NA

22731 2.0000 LBS-065 A Malignant Pheochromocytoma with Hepatic and Vascular Involvement 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Shuiqing Lai*, Jian Kuang, Xiaoying Fu, Jianhao Pei and Liang Chen
Guangdong Academy of Medical Sciences/Guangdong General Hospital, Guangzhou

 

Posterior reversible encephalopathy syndrome (PRES) is a clinical-neuroradiological entity of central nervous system usually occurs in the context of acute severe hypertension or other acute conditions. PRES following pheochromocytoma is never reported. Catecholamine-induced cardiomyopathy after pheochromocytoma is well-recognized and can be life-threatening, yet rare.

A 28-year-old male patient presented to hospital with decreased vision and severe headache 3 months ago. His blood pressure (BP) was extremely high, visual acuity decreased and ophthalmological examination with fundoscopy showed hypertensive retinopathy with exudates and hemorrhages. Betaloc and amlodipine were prescribed for BP lowering, but didn’t work. MRI scan axial T2WI image showed hyper-intensities at the bilateral cerebellar hemisphere, cerebellar vermis, bilateral temporal lobe, bilateral Occipital lobe, bilateral parietal lobe, right frontal lobe and left thalamus, consistent with PRES. Fosinopril, carvedilol and nifedipine were added for BP control, his headache settled gradually and visual acuity improved, though BP remained high and fluctuating.

The patient was referred to doctor again for progressive exertional dyspnea and a 5-days history of orthopnea one month ago. Chest radiograph revealed cardiomegaly and pulmonary congestion. No ischemia or infarction was seen on ECG. UCG revealed diffuse left ventricular hypokinesia, left atrium and left ventricle dilatation, an estimated LVEF of 0.24. Coronary angiogram showed normal coronary arteries. Treatment with lasix, digoxin, and antihypertensive drugs controlled the symptoms of congestive heart failure.

Abdominal ultrasound was performed for the unsatisfied BP control, revealing a huge mass on the right adrenal gland. Computed tomography of the abdomen showed a heterogeneous, dense mass above the right kidney, consistent with a pheochromocytoma. Catecholamine metabolites tests found remarkably elevated plasma metanephrines and 24-hour urinary vanilly mandelic acid, led to the diagnosis of pheochromocytoma and adrenergic alpha blockers was recommended. His BP was very well controlled remained within normal limits on his regular dose of doxazosin 4mg q8h only. The patient underwent a right adrenectomy 2 weeks after the BP controlled and the pathology confirmed the diagnosis of pheochromocytoma.

Follow-up at 6 month showed BP was normal and no heart failure symptoms without any medications. MRI brain showed complete resolution of the previously documented abnormality. UCG revealed normal heart dimensions, his LVEF had increased to 0.64 dramatically.

To the best of our knowledge, this is the first case of RPES complicated with cardiomyopathy due to pheochromocytoma. In our case we emphasized the early diagnosis of pheochromocytoma and prompt treatment to achieve the complete reversibility of the cardiomyopathy and PRES.

 

Nothing to Disclose: SL, JK, XF, JP, LC

22325 3.0000 LBS-066 A Pheochromocytoma Complicated with Posterior Reversible Encephalopathy Syndrome and Cardiomyopathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Shao Ling Zhang*1, Tong Feng Luo2, Yin Liang3 and LI Yan2
1Sun Yat-sen University, Sun Yat-sen Memorial Hospital, Guangzhou, China, 2Sun Yat-sen University, Sun Yat-sen Memorial Hospital, 3Sun Yat-sen university

 

Subtype diagnosis of primary aldosteronism (PA) is still a challenge for clinicians. Adrenal vein sampling (AVS) is recommended as the golden standard test to differentiate between unilateral aldosterone producing adenoma (APA) and idiopathic bilateral aldosteronism (IAH) before a unilateral adrenalectomy. As an invasive procedure, it remains markedly underused due to its challenging technique, difficulties to interpret and a lack of uniformly accepted standards. To determine whether APA can be predicted from clinical, biological, and radiological characteristics in patients with PA before surgery, a retrospective study was performed at the department of Endocrinology in Sun Yat-sen Memorial hospital from August 2007 to July 2014. Sixty-six patients with PA who have complete clinical and radiological data and finally underwent unilateral adrenalectomy were included. It would be diagnosed as PA with an elevated aldosterone after the captopril challenge test or/and saline infusion test. Final APA diagnosis was confirmed by postoperative pathology revealed a well-encapsulated adrenal cortical adenoma and immunohistochemical examinations of the adrenal samples. Variables that were associated with final APA diagnosis significantly in the univariate analysis were entered into multivariate logistic regression models to establish a clinical prediction score. The patients with APA (n=44) had increased adenoma diameter in imaging (16.50±5.97 vs. 12.18±7.26 mm; P=0.002), baseline plasma aldosterone concentration [49.95(31.58-93.05) vs. 22.65(13.50-41.80) ng/dl; P=0.001], daily urine potassium excretion [70.60(45.36-120.90) vs. 36.82(26.69-45.53) mmol/24h; P=0.000] and systolic blood pressure (186.45±23.24 vs. 171.14±25.83 mmHg; P=0.022) compare to those with IAH (n=22). The clinical prediction score was finally calculated as follows: maximum adenoma diameter in imaging ≥ 10mm, 2 points; baseline plasma aldosterone concentration ≥ 25ng/dl, 2 points; urine potassium ≥ 50mmol/24h, 2 points; and systolic blood pressure ≥ 180mmHg, 1 point. Receiver operating characteristic (ROC) curve analysis for the ability to distinguish between APA and IAH showed that a score of above 5 points had 81.8% sensitivity and 72.7% specificity to predict APA, while score of 4 points had a sensitivity of 88.6% and a specificity of 63.6%. The area under the ROC curve was 0.851 (95% confidence interval, 0.749–0.954). If a patient meets at least three of four characteristics listed above, it would be considered to have an APA. This new clinical prediction score may have a role in selecting patients who need a unilateral adrenalectomy, when AVS is not available.

 

Nothing to Disclose: SLZ, TFL, YL, LY

22328 4.0000 LBS-067 A A New Clinical Prediction Score for Aldosterone Producing Adenoma Confirmed By Pathology 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Lauren R Bigoney* and Francesco S. Celi
Virginia Commonwealth University, Richmond, VA

 

Background: Iatrogenic adrenal insufficiency (AI) secondary to exogenous systemic corticosteroid administration is well documented. Several reports demonstrated the association of  secondary AI from intra-articular injections or inhaled steroids, but little is known about the association of  AI with intrathecal steroids administration. Intrathecal steroid administration  could affect  the hypothalamic-pituitary-adrenal axis causing AI, but documented cases are rare (1).

Case:  A 50 year old female with history of metastatic breast cancer was admitted for hypotension, nausea, and lightheadedness.  She had a past history of treatment for T1c N3 M1, triple-negative carcinoma of the left breast. Dexamethasone was  administered as antiemetic at the time of systemic chemotherapy. The patient had completed successfully the treatment and appeared to be disease free.  One year later the patient  was diagnosed with isolated leptomeningeal recurrence and began a treatment with intrathecal methotrexate and hydrocortisone, 50mg/dose. Prior to the admission she had received a total of 4 doses (the last two weeks prior to the presentation), but no oral or systemic corticosteroids.  No pituitary or hypothalamic lesion was evident at the MRI.

At the time of admission, she was afebrile and her blood pressure was 90/40 mmHg with a heart rate of 133 bpm. Physical exam and basic chemistry were otherwise unremarkable. She did not respond to intravenous fluid resuscitation and infectious disease work-up was negative. A Cosyntropin stimulation test showed a baseline serum cortisol of 4.8 ug/dL, which only rose to 7.2 ug/dL at 60’.  The diagnosis of secondary AI was made and the patient was treated with hydrocortisone replacement.  Blood pressure promptly rose to and the tachycardia resolved, with a significant improvement of the symptomatology. The patient was discharged home on oral hydrocortisone replacement to be continued for the duration of intrathecal chemotherapy.

Conclusion: This case demonstrates that secondary AI is a possible and potential lethal complication of intrathecal chemotherapy when used in combination with steroids, even for a short period, suggesting a profound central inhibition of the hypothalamic-pituitary-adrenal axis. Clinicians should maintain a low threshold to test for adrenal insufficiency in this patient population since the symptoms are nonspecific and often attributed to chemotherapy.  Diagnosing AI in cancer patients could lead to improved quality of life and prevent life threatening emergencies.

 

Nothing to Disclose: LRB, FSC

22732 5.0000 LBS-068 A Iatrogenic Adrenal Insufficiency from Short-Term Intrathecal Hydrocortisone Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Toshihide Yamamoto*
Yao Tokushukai General Hospital, Osaka, Japan

 

Background: Though many patients with diabetes mellitus and thyroid disorders are seen at endocrine clinics every week, patients with Addison’s disease are seldom encountered. Adrenal insufficiency presumably results from progressive impairment of the adrenals and Addison’s disease is situated at the end stage of this evolution. Pituitary neurosurgeons and critical care specialists have been interested in latent PAI. However, latent PAI has not attracted the attention of physicians in other medical sectors presumably because of the nonspecific nature of presentation and the resultant low-level index of suspicion.

Patients and Methods: Latent PAI was sought in three situations: group 1, recurrent, non-specific gastro-intestinal symptoms in stress-associated circumstances; group 2, musculoskeletal symptoms not proved as rheumatic disease; group 3, weight loss and hypotension. After having been screened by morning cortisol level less than 11 µg/dl, patients suspected of latent PAI were examined by a provocation test, either insulin-induced hypoglycemia test or low-dose (1 µg) i.v. corticotrophin test (cutoff levels, 20 and18 µg/dl, respectively). Patients found to show subnormal cortisol response were supplemented with hydrocortisone, 15 mg/day or less. While cortisol withheld for two days after amelioration of symptoms, another provocation test was done to confirm impaired cortisol response. Provocation test was not done in one patient with high ACTH and low cortisol levels.

Results: Two of them had elevated basal levels of ACTH and four had low basal cortisol levels (<5µg/dl). Seventeen patients, thirteen in group 1, three in group 2, and one in group 3, were found. Three patients were excluded because of dissociation of the results of two provocation tests.

Conclusion: A majority of patients with latent PAI presented with stress-related health changes and a few sought medical help for non-rheumatic musculoskeletal symptoms. Only a few had high ACTH and low basal cortisol levels. The observed feature is quite different from that of Addison’s disease. If this observation is widely acknowledged and latent PAI is sought with anti-adrenal antibody test and/or provocation tests, more patients with latent PAI will be detected. Then, patients with latent PAI will be benefited in two ways, i.e. improved quality of life by glucocorticoid supplementation and better preparedness for acute illness, injury, surgery, or psychosocial stress.

 

Nothing to Disclose: TY

22666 6.0000 LBS-069 A Latent Primary Adrenal Insufficiency (PAI): Three Modes of Clinical Presentation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Edison So*1 and Hilary Whitlatch2
1Warren Alpert Medical School of Brown University, East Providence, RI, 2Alpert Medical School of Brown University, East Providence, RI

 

Background:  

Pheochromocytomas are catecholamine-secreting tumors arising from the adrenal medulla.  They are rare, occurring in < 0.2% of hypertensive patients.  Prompt diagnosis and treatment is essential to prevent clinical sequelae, including life-threatening hypertension. While surgery is preferred, there are case series of successful percutaneous intervention, including radiofrequency, microwave, and cryo-ablation, primarily in those with metastatic disease. We report a case of successful microwave ablation of a large primary pheochromocytoma.

Case report:

A 74-year-old woman with non-small cell lung cancer and chronic obstructive pulmonary disease (COPD) presented for evaluation of pheochromocytoma. 3 months prior, she was admitted to an outside facility with a COPD exacerbation. A chest CT revealed a 1.7 cm left upper lobe lung mass and a 4.7 cm left adrenal mass.  Given elevated blood pressure, she was prescribed captopril and bisoprolol-hydrochlorothiazide. 

Given the adrenal mass was presumed to be a metastatic lesion from a lung primary, she underwent a CT-guided left adrenal biopsy. The pathology was consistent with pheochromocytoma. An I-123 Metaiodobenzylguanidine scan revealed intense uptake in the left adrenal gland. A 24-hour urine collection demonstrated elevated normetanephrine at 1250 mcg (88-444 mcg) and norepinephrine at 121 mcg (15-80 mcg). She had a CT-guided biopsy of the lung lesion, which was consistent with non-small cell lung cancer. Given COPD severity, she was a poor surgical candidate and had a microwave ablation of the lung lesion.

She presented to our outpatient endocrinology clinic for pre-medication prior to a planned left adrenal microwave ablation. Her anti-hypertensives were stopped, and she was prescribed phenoxybenzamine 10 mg twice a day. Metoprolol 50 mg twice a day was added to control tachycardia. Pre-ablation metyrosine was planned but cost prohibitive. She then underwent CT-guided microwave ablation under general anesthesia.  After 2 minutes, systolic blood pressure rose to 280 mmHg. She received intravenous esmolol and labetalol with effective blood pressure control. Ablation was completed uneventfully.

1 week later, the alpha-blocker was changed to doxazosin 4 mg daily. 2 weeks later, a 24 hour urine collection demonstrated normal urine metanephrine at 39 mcg (52-341) and normetanephrines at 310 mcg. Plasma normetanephrines was mildly elevated at 169 pg/mL (< 148). Currently, her blood pressure is well-controlled on doxazosin and metoprolol, and orthostasis has resolved.

Conclusion:

Although larger studies are needed to confirm safety and efficacy, percutaneous ablation may be considered for primary pheochromocytoma in patients who are poor surgical candidates, as well as those with metastatic disease. Despite pre-treatment with alpha and beta blockers, hypertensive emergency remains a potential complication.

 

Nothing to Disclose: ES, HW

22779 7.0000 LBS-070 A A Case of Pheochromocytoma Treated with Percutaneous Microwave Ablation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Nancy L Mora*1 and Kyaw Kyaw Soe2
1Wexner Medical Center at the Ohio State University, Columbus, OH, 2The Ohio State University Wexner Medical Center, Hilliard, OH

 

Background

Adrenocortical carcinomas (ACCs) are rare, sporadic and aggressive endocrine tumors with incidence of 0.7 to 2.0 cases per million population. Women are more commonly affected (55-60%). ACCs can be hormonally functional in about 63% of cases and present commonly as Cushing’s syndrome (45%), virilization (10%) and primary hyperaldosteronism. Among bi-functional ACCs, co-secretion of cortisol with androgens is more common, while co secretion of aldosterone and cortisol is extremely rare. We are reporting a patient with ACC that presented with refractory hypertension and was found to have both Cushing’s syndrome and primary hyperaldosteronism.

Case discussion

36-year-old woman presented with 7-month history of refractory HTN requiring 5 anti-hypertensive medications including spironolactone, hypokalemia, progressive proximal weakness and newly diagnosed T2DM.  On exam she was hypertensive (185/103), obese (BMI 33) with rounded-face and abdominal striae. Laboratory tests were significant for severe hypokalemia (2.6 mmol/Lt), metabolic alkalosis and hyperglycemia. AM cortisol level was high (42 mcg/dL) and low ACTH < 5 pg/ml. The 1 mg overnight dexamethasone suppression test and 24-hr urine free cortisol level were significantly high. Plasma renin activity was 4.34 ng/ml/h (ref. range 0.25-5.82) with remarkably high serum aldosterone of 346 mg/dl (ref. range 3-28) resulting in high aldosterone renin ratio. Plasma and 24-hour urine metanephrine and normetanephrine, 17-hydroxyprogesterone, DHEA-S, and estradiol were all normal.

Abdominal CT and MRI showed 4.7 x 7 x 9.4 cm multi-lobulated right adrenal mass invading the right suprarenal vein and IVC. CT-guided adrenal mass biopsy confirmed adrenal neoplasia with mitotic activity and focal necrosis. Immunohistochemical stains were positive for inhibin, synaptophysin and CD56. Chest CT revealed numerous bilateral lung nodules and metastatic ACC confirmed by CT-guided lung biopsy. Debulking surgery was successfully performed, achieving significant improvement in blood pressure and glycemic control. Daily insulin requirement decrease from 27 units daily to 1-2 units daily and she required two anti-HTN medications without spironolactone.  

Conclusion

ACC has poor prognosis with 5-years survival rate of 10-25% in advance stage disease. It can present as hormonal active tumor with rapid onset of clinical symptoms due to hormonal excess. It is unusual for ACCs to produce more than one hormone since the majority of adrenal tumors are monoclonal in origin. However, ACCs producing more than 2 hormones have been reported in literature. Over-production of glucocorticoids and androgens or aldosterone and estrogen have been reported in 25% and 10% of cases, respectively. Surgery is the mainstay of treatment for non-metastatic ACC. The treatment for advance ACC has been debulking surgery with adjuvant chemotherapy.

 

Nothing to Disclose: NLM, KKS

22788 8.0000 LBS-071 A Adrenocortical Carcinoma Presented As Cushings Syndrome and Primary Hyperaldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


VIctor Srougi*1, Bruno Aragao Rocha1, Fabio Y. Tanno2, Maria Claudia N Zerbini2, Madson Q. Almeida3, Jose Luiz Chambo2, Berenice B Mendonca4, Ronaldo Hueb Baroni5 and Maria Candida B V Fragoso6
1Sao Paulo University, Sao Paulo, Brazil, 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil, 5University of Sao Paulo, Sao Paulo, Brazil, 6Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

Background:To avoid hormonal replacement after partial adrenalectomy, it is essential to establish the precise limit of the adrenal resection. Using a 3D-printed adrenal replica, the surgeon can get familiarized with the gland anatomy and improve the resection accuracy, fastening surgery functional recovery.

Clinical case: A 68-year man presented subclinical Cushing’s syndrome due to sporadic primary macronodular adrenal hyperplasia (PMAH). Additionally, the patient had uncontrolled blood hypertension and diabetes. Serum exams showed light hypercortisolism ACTH-independent: elevated morning cortisol (F = 28 mcg/dL; n = 5-25 mcg/dL), unsuppressed 1 mg dexamethasone overnight test (F = 6,3 mcg/dL; n <1,8 mcg/dL) and ACTH below the normal levels (ACTH < 5 pg/mL; n 7,2-63 pg/mL). Salivary and 24h urine cortisol were within the normal range. Computed tomography evidenced bilateral enlargement of the adrenal glands with typical nodules of PMAH (adrenal volume measurement: left = 19,1 ml; right = 8,44 ml). Bilateral adrenalectomy was performed, after adrenal glands 3D-image reconstruction and print, with partial resection of the right gland and total resection of the left gland. Using the right adrenal replica, the surgeon could precisely determine the limit of the resection and estimate the volume of residual adrenal gland. The pathological analysis confirmed bilateral PMAH. Immediately after surgery the patient initiated cortisol replacement. Fifty-two days after the procedure hormonal reposition was interrupted. With two months of follow-up, he lost 10 kg, reduced the number of anti-hypertensive drugs from 5 to 1 and was no longer using medications for diabetes. The cortisol and ACTH levels were respectively 8,7 mcg/dL and 88 pg/mL.

Conclusion: Considering PMAH, 3D-printing may be a useful tool for the surgeon when performing partial adrenalectomy.

 

Nothing to Disclose: VS, BAR, FYT, MCNZ, MQA, JLC, BBM, RHB, MCBVF

22812 9.0000 LBS-072 A The Use of 3D Printing to Guide Partial Adrenalectomy in a Patient with Primary Macronodular Adrenal Hyperplasia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Priyanka Chandrasekhar Iyer*, Shruti Bhandari and Sally M Pinkstaff
Sinai Hospital of Baltimore, Baltimore, MD

 

Introduction:

The use of opioids for managing chronic pain has escalated over the past two decades with 259 million prescriptions written in 2012. In conjunction with this rise in narcotic use has been the recognition of several endocrine associated disorders.  Opioid-induced central hypogonadism is well described but there is little data regarding the effects of opioids on the hypothalamic-pituitary-adrenal axis (HPA).  We present a patient on chronic opioid therapy with low random cortisol levels and symptoms suggestive of adrenal insufficiency (AI).    

Case Presentation:

Our patient is a 56 year old man with narcotic-induced central hypogonadism and Hashimoto’s hypothyroidism on adequate thyroxine replacement who presented with fatigue, anorexia, and a 25 lb weight loss.   Chronic meds for low back pain included methadone and hydrocodone.  A random cortisol at noon was 2.8 mcg/dL with ACTH of 34 pg/mL.  Two months later, he had lost an additional 11 lb and was orthostatic with supine BP 118/70, sitting 94/68, and standing 88/64.  An ACTH stimulation test showed a normal response with a 30' cortisol of 21 mcg/dL and a 60' cortisol of 23.5 mcg/dL.  He was started on 10 mg of hydrocortisone qAM and an oCRH test using 100 ug was ordered.   Five years previously he had undergone an ACTH stimulation test because of his narcotic-induced hypogonadism.   These results showed:  baseline cortisol of 3.1 mcg/dL, 30' cortisol of 18.8 mcg/dL, and 60' cortisol of 21.1 mcg/dL with baseline ACTH of 19.0 pg/mL.   Clinically, he had been stable for five years without any symptoms suggesting AI.  His hydrocortisone was stopped one week prior to the oCRH test which showed:  cortisol level at baseline of 8.8 mcg/dL, 18.7 mcg/dL at 30', and 21.1 mcg/dL at 60'. The corresponding ACTH values were 30.6 pg/mL, 72.2 pg/mL, and 84.4 pg/mL respectively, indicating a normal response.   One month later, his weight was stable and his symptoms had resolved without continuation of hydrocortisone.

Discussion:

The effects of chronic opioid therapy on the human HPA axis are not well understood. Studies have suggested that narcotic dose, chronicity, and extra hypothalamic effects may all be involved. Cases of AI with chronic narcotic therapy have been reported. In our patient, despite symptoms suggestive of AI, oCRH testing was normal and ACTH testing was stable five years later.  This suggests that multiple stressors over time resulted in stimulatory effects on CRH neural systems including the hypothalamus (1).  This may explain the rarity of AI in patients treated with chronic opioids.  Further studies are needed.

Conclusions:

1. Although chronic opiate therapy can alter the HPA axis, adrenal insufficiency is rarely seen.

2. Normal oCRH testing suggests that neuro-stimulation of CRH remains intact even with long-term opioid therapy.

3. Patients on chronic narcotics and their physicians need to be educated about the possibility of AI under very severe stress.

 

Nothing to Disclose: PCI, SB, SMP

22828 10.0000 LBS-073 A Chronic Opioid Dependence Associated with Low Random Cortisol but Normal Response to Ovine Cortico-Tropin Releasing Hormone (oCRH) Stimulation Test 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Jaydira Del Rivero*1, Barbora Hamplova1, Tomas Zelinka2, David Taieb3, Anouk van Berkel4 and Karel Pacak1
1National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, 2General Faculty Hospital, Prague, Czech Republic, 3La Timone University Hospital, Marseille Cedex 05, France, 4Radbound University Hospital

 

Pheochromocytomas and paragangliomas (PHEOs/PGLs) are rare neuroendocrine tumors arising either from chromaffin cells in adrenal medulla or chromaffin cells associated with autonomic paraganglia. More than one third of PHEOs/PGLs is caused by hereditary predispositions. These predispositions are very often due to germline inactivating mutations in succinate dehydrogenase (SDH) genes, mostly SDHB and SDHD. SDHD mutations are found mainly in patients with head and neck PGLs, which are usually associated with benign disease.  PHEOs/PGLs with SDHB mutations are linked to more aggressive behavior with a higher rate of metastases formation than those caused by SDHD mutations.
The aim of the present study is to determine whether there are differences in clinical presentation and outcome of SDHD patients suffering from only head and neck PGLs (1), those with non-head and neck PHEOs/PGLs (2) and combination of both categories (3).
Thirty-four patients with SDHD-related PHEOs/PGLs were included in the present retrospective study. All of these patients had objective follow up during year 2014 which included blood test, urine test, and whole-body imaging studies such as magnetic resonance imaging (MRI), computed tomography (CT) and/or PET imaging.
Patients in categories 2 and 3 developed metastatic disease in 29.2% of cases while in patients with only head and neck PGLs it was 20%. Moreover, metastatic disease at the first presentation of tumor occurred more frequently in categories 2 and 3 (12.5%). None of the patients with only head and neck PGLs had metastatic disease at the time of the first tumor presentation. Interval between diagnosis and metastases manifestation in categories 2 and 3 was shorter (6.4 years) than in category 1 (24 years).  Of all the patients enrolled in the present study one died as a result of lethal arytmia one day after surgery; this patient had combination of parasympathetic and sympathetic PHEOs/PGLs.
The patients suffering from only head and neck PGLs were diagnosed slightly earlier; the average age of diagnosis was 28.7 years old, while average age in other two categories was 31.5 years old. Very similar results can be seen regarding average age at the time of first symptoms.
In conclusions, non-head and neck PHEOs/PGLs in SDHD patients are associated with more aggressive behavior compared with SDHD patients with only head and neck PGLs. The rate of metastases formation of SDHB-related PHEOs/PGLs is between 34% and 71%. Based on the results of this study, the risk of metastasis in SDHD patients suffering from non-head and neck PHEOs/PGLs or their combination with head and neck PGLs is approaching the risk seen in SDHB patients, however a large-scale study is needed to confirm the present data.

 

Nothing to Disclose: JD, BH, TZ, DT, AV, KP

22925 11.0000 LBS-074 A Outcomes of Patients with Sdhd-related Parasympathetic and Sympathetic Pgls: Retrospective Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Enzo Anthony Ragucci*1 and Michele Lamerson2
1Enzo Ragucci, MD Diabetes and Endocrinology, West Nyack, NY, 2Corcept Therapeutics, Greenlawn, NY

 

Background:Nonalcoholic fatty liver disease is frequent among people with obesity, type II diabetes, insulin resistance and dyslipidemia. These metabolic aberrations are also common in Cushing’s syndrome (CS), leading researchers to investigate the contributions of cortisol. Rockall et al.(1) previously confirmed hepatic steatosis on CT scans in 20% of patients with active CS. However, it is not known if successful treatment of CS can reverse the incidence and progression to NASH (nonalcoholic steatohepatitis).

Herein, we detail a patient with CS and NASH who saw a significant improvement in liver function tests (LFTs) after successful treatment of CS with mifepristone(Korlym®, Corcept Therapeutics), a competitive glucocorticoid receptor antagonist.

Clinical Case:  A 47-yr old woman with a past medical history of hypertension (142/90 mmHg), pre-diabetes (A1c 5.9%), dyslipidemia [Tchol 274 mg/dL, LDL 203 mg/dL, TG 132 mg/dL) and NASH was found to have a right adrenal adenoma on a routine CT scan she had for evaluation of nephrolithiasis.  She previously had a cholescystectomy (due to chronic cholecystitis & cholelithias) and liver biopsy showing steatohepatitis and diffused steatosis.  Her medications included amlodipine/olmesartan medoxomil and rosuvastatin calcium.

The CT scan revealed a right adrenal adenoma measuring 2.9 X 1.9 X 2.5cm with benign radiologic characteristics.  She did not have overt features of CS but complained of persistent abnormal weight gain (BMI 30.6 kg/m2) with central obesity. Biochemical testing was negative for pheochromocytoma and primary aldosteronism. Hormonal testing for autonomous cortisol secretion showed a mildly elevated UFC (62.6 µg/d), failure to suppress on successive 1-mg Dexamethasone suppression tests (13.2 µg/dL, 12.5 µg/dL), elevated midnight salivary cortisol (0.19 µg/dl), suppressed ACTH < 5 pg/mL(5-45pg/mL), and low DHEA-S 20 µg/dL((42-290µg/dL).  Baseline LFTs were elevated; AST 110 U/L (nl 2-40 U/L), ALT 232 U/L (nl 2-60 U/L). 

She declined adrenalectomy. Mifepristone was initiated at 300mg/d and increased to 900mg/d over 20 weeks.

At 4 weeks, antihypertensive medications were discontinued. At week 20, her BP was stable (120/82 mmHg) and her weight decreased from 178 to160 lbs. Marked improvement in her liver enzymes was noticed during mifepristone therapy with normalization by week 20 (AST 32 U/L [nl , 10-35U/L], ALT 45U/L[nl 6-29 U/L]).

Conclusion:  In a patient with a unilateral cortisol producing adenoma, medical therapy with mifepristone was effective in reducing associated co-morbidities related to persistent hypercortisolemia- including reductions in weight and normalization of BP with discontinuation of antihypertensive medication.  Additionally, successful management of CS led to marked improvement in the liver enzymes of a patient with long standing NASH.

 

Disclosure: ML: Employee, Corcept. Nothing to Disclose: EAR

22960 12.0000 LBS-075 A Marked Improvement in Liver Enzymes during Medical Therapy with Mifepristone for Cushing's Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Adrenal HPA Axis Saturday, March 7th 3:00:00 PM LBS 064-076 6273 1:00:00 PM Late-Breaking Adrenal/HPA Axis III Poster


Jessica Lopes Nobre*1, Fernanda Quitete2, Janaine C Cavalcante2, Patricia C Lisboa3, Egberto Gaspar Moura4 and Elaine de Oliveira3
1Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil, Rio de janeiro, 2Department of Physiological Sciences, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil, 3Department of Physiological Sciences, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil, Brazil, 4Department of Physiological Sciences, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil, Rio de Janeiro, Brazil

 

There is a great interest in identify nutritional changes associated with the obesity epidemy, in order to design new strategies to prevent or treat this disease. Recently, it has been showed an association between low serum calcidiol and obesity. We hypothesized that vitamin D could act on the adipogenesis, but we do not know if this effect is a direct calcitriol action on the adipose tissue.  We showed that calcium supplementation has an anti-obesity effect in obese rats programmed by early weaning (EW) and this effect seems to be mediates by the inhibition of serum calcidiol.  In the adipose tissue calcidiol is converted to calcitriol (1.25 dihydroxyvitamin D) by 1-α-hydroxylase and binds to VDR and could regulates adipogenic proteins, such as C/EBP-β and PPARg. Here we decided to study the effect of calcitriol upon adipose tissue in vivo and in vitro systems upon these proteins. In our in vivo experiment, obese rats (EW), at 120 days-old, received calcium supplementation during two months. In our in vitro experiments, we used 3T3L1 cell line incubated with calcitriol and/or leptin in different doses. EW caused higher adipocyte area, 1-α-hydroxylase, C/EBP-β and PPARg expression (n=6; p<0.05) and lower VDR expression (n=6; p<0.05) in adult life, all alterations were prevented by calcium supplementation. Both leptin and calcitriol decreases 1-α-hydroxylase, but only calcitriol increases VDR (n=5; p<0.05). The 1.25 dihydroxyvitamin D incubation decreased 3T3L1 proliferation in MTT assay (n=3; p<0.05), but annexin-V positive cells did not differ between groups (n=3; p>0.05), demonstrating that there was no apoptosis. Despite apparent high calcitriol conversion in EW fat tissue, since VDR expression is lower and probably calcitriol content is also lower, calcitriol has an ineffective action in this tissue. Calcium supplementation during 2 months was effective in normalize adipogenesis in EW group, improving calcitriol action through VDR in EW fat tissue. In fact, calcitriol seems to be anti-obesogenic since in vitro calcitriol incubation decreases adipocyte proliferation.

 

Nothing to Disclose: JLN, FQ, JCC, PCL, EGM, EDO

22479 1.0000 LBS-033 A Calcium Supplementation Reduces Adipogenesis in Obese Rats Programmed By Early Weaning Increasing VDR and Calcitriol  Antiproliferative Effect in Adipocyte 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Todd Anthony Astorino*1 and Eric T Harness2
1CSU--San Marcos, San Marcos, CA, 2Project Walk, Carlsbad, CA

 

Background:  Dramatic bone loss in the lower extremity is one severe complication of spinal cord injury (SCI).  Various exercise modalities have been identified to slow bone loss, yet their efficacy is equivocal.  Prevalence of vitamin D deficiency has been reported to be as high as 93 % in SCI, which may contribute to accelerated bone resorption.  It is unknown if intense, multimodal exercise can be used to potentially modify this metabolic disruption promoting marked bone loss and enhanced risk of fracture in SCI. 

Aim:  To examine changes in 1,25 (OH)2vitamin D (VITD) in response to 6 mo of activity based therapy (ABT) in persons with SCI.

Methods:  Thirteen men and women with SCI (age and duration of injury = 29.7 ± 7.8 yr and 1.9 ± 2.7 yr, respectively) completed 6 mo of ABT consisting of resistance training, locomotor training, functional electrical stimulation, and core exercise a minimum of 4 h/wk (mean volume of training = 7.8 ± 2.7 h/wk and > 2 d/wk) at a local rehabilitation facility.  Training was supervised by certified staff and individualized for each participant based on injury level and function as well as adaptation to training.  Prior to and at 3 and 6 mo of training, blood samples were taken after an overnight fast and 24 h abstention from exercise for determination of serum levels of 1-25 OH vitamin D, which was assessed through ELISA.  Samples were run in duplicate and the coefficient of variation was < 9 %.  In addition, dual-energy x-ray absorptiometry was completed to assess bone mineral density of the whole body as well as bilateral hip/knee and lumbar spine.  A 4 d food log including 2 weekend days was also completed to monitor habitual dietary intake.  One-way analysis of variance with repeated measures was used to examine differences in variables across time.

Results:  Ten persons with SCI completed the study as three withdrew due to transportation issues (n = 1) and an unrelated injury (n = 2).  There was a trend (p = 0.10, η2 = 0.21) for differences in VITD from 0 - 6 mo of ABT, as it increased from 30.0 ± 10.6 pg/mL at baseline to 37.9 ± 22.6 pg/mL to 40.3 ± 14.3 pg/mL at 3 and 6 mo.  No interactions were evident (p ~ 0.10) for duration/severity of injury on changes in VITD.  Total-body BMD declined by 2.5 % (p = 0.003, η2 = 0.47, range = -4.9 – 1.8 %) from 0 – 6 mo which was accompanied by significant reductions (- 6.1 %) in total hip BMD (p = 0.001, η2 = 0.59) at both 3 and 6 mo.  Total-body BMC decreased by 2.2 % during the study (p = 0.07).  Spine BMD increased by 4.8 % (p = 0.006, η2 = 0.44, range = 0.9 – 15.8 %) at 6 mo of training compared to baseline.  BMD at the distal femur and proximal tibia declined, but these differences were not significant (p = 0.13 and 0.29).  Calcium intake was unchanged (p = 0.10) at 3 (765.6 ± 264.7 mg) and 6 months (890.2 ± 383.7 mg) of the study versus baseline (726.0 ± 265.0 mg).

Conclusion:  VITD may positively respond to intense exercise training in persons with SCI, although further study is merited.

 

Nothing to Disclose: TAA, ETH

22651 2.0000 LBS-034 A Effect of Six Months of Activity Based Therapy on Changes in 1,25 (OH)2 Vitamin D in Persons with Spinal Cord Injury (SCI) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Rokshana R Thanadar*1, Ameya Hodarkar2, Anupam Kotwal1 and Shirin Haddady1
1University of Massachusetts Medical School, Worcester, MA, 2Memorial Hospital of Rhode Island, Alpert Warren Medical School of Brown University, Pawtucket, RI

 

Background

Hypercalcemia is a known, though often overlooked, cause of acute pancreatitis. An association between hypercalcemia and pancreatitis has been noted as early as 1903 and well documented since the 1950s. 1°HPT occurs in 0.2-0.5% of the general population. Prevalence of acute pancreatitis in 1°HPT has been estimated to be 1.5-13%. Patients with both 1°HPT and hypercalcemia are at 10-fold risk of suffering acute pancreatitis. Several mechanisms have been postulated to explain acute pancreatitis in patients with hypercalcemia. Persistent hypercalcemia increases the calcium content of pancreatic secretions, which results in de novo conversion of trypsinogen to trypsin, triggering pancreatic inflammation and auto-digestion of the pancreas. Hypercalcemia may cause pancreatic calculi, ductal obstruction, and subsequent attacks of pancreatitis. Also a predisposition to pancreatitis in patients with elevated calcium associated with SPINK1, CFTR and CaSR mutations has been observed.

Clinical case

A 58 year old white female with prior history of atrial fibrillation and deep vein thrombosis was admitted to the intensive care unit for acute pancreatitis, hypoxia, and altered mental status. In a different hospital, she had a laparoscopic bilateral salpingo-oophorectomy for ovarian cysts two days prior to admission. She had no history of ethanol use and had cholecystectomy more than 10 years prior. Her only medication before surgery was Coumadin. She was found to have a lipase of 9302 U/L (n 23-300U/L). Upon admission serum calcium was 9.1 mg/dL (n 8.7-10.7 mg/dL), albumin 2.7 g/dL (n 3.5-4.8 g/dL), corrected calcium was 10.5 mg/dL, phosphorus 1.2 mg/dL (n 2.5-4.5 mg/dL) and triglycerides 78 mg/dL (n <150 mg/dL). Serum calcium on the day of surgery was 10.2 mg/dL and 11.2 mg/dL six months prior to admission. Initial abdominal CT scan showed severe diffuse pancreatic edema with no ductal dilation, calcifications, necrosis or pseudocysts.  Magentic resonance cholangiopancreatography demonstrated necrotizing pancreatitis with pseudocysts. She had a long hospital course and slow recovery with two readmissions for recurrence of pancreatitis. The corrected serum calcium fluctuated between 8.9 to 12.2 mg/dL during hospitalization. Two months after first presentation, endocrinology was consulted. Further evaluation showed an intact PTH of 93 pg/dL (n 14-64 pg/dL ), while Vitamin D 25,OH was 12 ng/mL (n >30ng/mL ) and 24 hour urinary calcium 78 mg/day (n 100-300 mg/day). We suspected hypercalcemia due to 1°HPT was the possible triggering factor for acute pancreatitis and its slow recovery.

Clinical Lesson

It is important to consider hypercalcemia and 1°HPT as a cause of non-bilious non-alcoholic pancreatitis, especially when etiology is not clear. Hypocalcemia is common in acute pancreatitis, so serum calcium may be normal at the time of presentation in patients with baseline hypercalcemia.

 

Nothing to Disclose: RRT, AH, AK, SH

22868 3.0000 LBS-035 A Hypercalcemia and Primary Hyperparathyroidism Associated with Severe, Long Standing Pancreatitis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Qianqian Pang*
Chinese Academy of Medical Sciences,Peking Union Medical College Hospital, Beijing, China

 

Background: Osteopetrosis is a group of genetic bone disorders, which is caused by defects in osteoclast formation and function. Mutations in CLCN7 lead to defect in the chloride channel, which give rise to osteopetrosis with varying degrees of severity ranging from asymptomatic to relatively mild symptoms in autosomal dominant osteopetrosis (ADO-II), to the very severe phenotype in autosomal recessive osteopetrosis (ARO). Heterozygous mutations in CLCN7 are related to ADO-II, homozygous and compound heterozygous mutations in CLCN7 result in ARO and intermediate autosomal recessive osteopetrosis (IARO). To date, few IARO cases have been identified throughout the world, and only one of them is from Chinese population which was related with a homozygous mutation of CLCN7. In the present study, we reported six unrelated ADO-II families and two ADO-II/IARO patients from Chinese population, and elucidate the characteristics of CLCN7 gene mutations in these patients. Methods: All 25 CLCN7 exons and exon-intron boundaries from genomic DNA were amplified and sequenced in 8 affected individuals suffering from ADO-II/IARO and their families. We also evaluated the clinical, biochemical and radiographic findings and compared the differences between ADO-II and IARO both in genotype and phenotype. Results: We found seven novel mutations in these ADO-II/IARO patients, six heterozygous missense mutations (p.L224R, p.S290Y, p.R326G, p.G347R, p.S473N and p.L564P) and a novel splice mutation (p.K691FS) at the splice donor site, which resulted in 20 amino acids lacking. Conclusion: This is the first study of IARO with compound heterozygous mutation in the Chinese population. Our findings enriched the database of CLCN7 mutations.

 

Nothing to Disclose: QP

22387 4.0000 LBS-036 A Novel Mutations of CLCN7 Cause Autosomal Dominant Osteopetrosis Type II (ADO-II) and Intermediate Autosomal Recessive Osteopetrosis (IARO) in Chinese Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Anette Merke*1, Juergen Merke1, Winfried März2 and Stefan Pilz3
1Thyroid Center Bergstrasse, Bensheim, Germany, 2Ruprecht Karls University Heidelberg, Mannheim, Germany, 3Medical University of Graz, Graz, Austria

 

Background:Vitamin D is a risk factor for increased mortality and morbidity, including cardiovascular and cerebrovascular events, cancer, infectious and autoimmune diseases. Data on Vitamin D are mainly derived from studies with a single determination of 25-hydroxyvitamin D (25(OH)D). The DETECT study is a cross-sectional, prospective epidemiological, primary care-based study in Germany between 2003 and 2004 with two annual determinations of 25(OH)D.

Objective:We therefore evaluated the association of baseline 25(OH)D levels with follow-up levels after one year and the prevalence of Vitamin D deficiency in German primary care patients.

Methods:Baseline examinations including blood draw for 25(OH)D were carried out in September 2003 with a follow-up after 12 months. We included 2454 non-smoking participants of DETECT with a complete set of Vitamin D. Blood samples were immediately deep-frozen at -70 ºC and analyzed in 2010. We performed Pearson correlation analyses between 25(OH)D levels in 2003 and 2004 and analysis of variance (ANOVA) for continuous variables and χ²/Fischer exact test for categorical data.

Results:Mean age was 59.7±13.8 years with 72% females. Vitamin D deficiency, defined as 25(OH)D<20ng/mL, was demonstrated in 16.6% of subjects in 2003 and 28.9% in 2004. The Pearson coefficient between 25(OH)D for consecutive examinations was 0.61 ( P<0.001). Vitamin D deficiency was significantly associated with older age, female sex and higher BMI.

Conclusions:We were able to demonstrate that 25(OH)D levels collected in two consecutive years show a good correlation. Even though 2003 was an exceptionally UV intensive year and 2004 an average year regarding the UV index in Germany the Vitamin D levels were comparable and reveal a significant prevalence of Vitamin D deficiency in primary care patients in Germany.

 

Nothing to Disclose: AM, JM, WM, SP

22631 5.0000 LBS-037 A Vitamin D Levels in Primary Care in Germany: The Detect Study (Diabetes Cardiovascular Risk Evaluation Targets and Essential Data for Commitment of Treatment) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Fathelrahman Hussein Ahmed*1, Mohamed H Ahmed2 and Asif Ali2
1Milton Keynes NHS Foundation trust, Milton Keynes, United Kingdom, 2Milton Keynes NHS foundation trust, Milton Keynes, United Kingdom

 

Extreme hyperparathyroidism causing cardiac arrest in a young woman

Fathi Ahmed, Mohamed H Ahmed, Asif Ali

Department of Medicine, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, United Kingdom

A 43 year old previously healthy woman was brought to the emergency department having had a cardiac arrest leading to collapse. She was found to be in ventricular fibrillation and was treated with cardiopulmonary resuscitation and defibrillation as per protocol. Her family reported episodes of vomiting a few days prior to her collapse. There was no significant family history of note.  Her blood tests revealed a corrected calcium level of 17.4 mg/dl, an intact PTH of 2035.8 pg/ml (12.1 – 86.8) and acute kidney injury with a creatinine of 2.5 mg/dl. A CT scan of head, thorax, abdomen and pelvis was unremarkable.

She was treated in the intensive care unit with full cardiorespiratory support. She also needed extracorporeal membrane oxygenation for her severe adult respiratory distress syndrome.  Her hypercalcemia was treated with Pamidronate, Cinacalcet and intravenous fluids. As her calcium was resistant to medical treatment after 6 days, she underwent an emergency parathyroidectomy and a partial thyroidectomy. This resulted in the rapid normalization of her calcium and her PTH. The histology of the tumour revealed a benign parathyroid adenoma. The tumour was removed in entirety.  She made a gradual recovery and underwent a period of rehabilitation for her critical illness neuropathy. The mutational analysis results for known monogenic causes of hyperparathyroidism are pending.

Reports of cardiac arrest due to hypercalcemia of primary hyperparathyroidism are very rare. This case is unusual in a number of ways - the age of presentation, the severity of the hypercalcemia and mode of presentation. Emergency parathyroidectomy is a treatment option that should be considered where there is suboptimal response to medical treatment. Despite the benign histology, parathyroid carcinoma remains a possibility as the hyperparathyroidism in this case was extreme. Depending on the mutational analysis results, family screening may be warranted.

 

Nothing to Disclose: FHA, MHA, AA

22973 6.0000 LBS-038 A Extreme Hyperparathyroidism Causing Cardiac Arrest in a Young Woman 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Dawn Phillips*1, Donna Griffin2, Tracy Przybylski3, Erica Morrison3, Amy L Reeves3, Marc Vallee4, Kenji Fujita5, Katherine L Madson3 and Michael P. Whyte6
1University of North Carolina, Chapel Hill, NC, 22Shriners Hospital for Children, St. Louis, MO, 3Shriners Hospital for Children, St. Louis, MO, 4Alexion Pharmaceuticals, Cheshire, CT, 5Alexion Pharmaceuticals, Inc., Cheshire, CT, 6Shriners Hospitals for Children, St. Louis, MO

 

Hypophosphatasia (HPP) is the rare disease caused by loss-of-function mutation(s) in the tissue-nonspecific alkaline phosphatase (ALP) gene. Resultant low ALP activity can cause a wide spectrum of sequelae in children, including premature loss of primary teeth, rickets, poor growth, pain, muscle weakness, and compromised physical function, including an unusual gait pattern (1).

Here, we report on clinical gait assessments based on archival video recordings in a subset (n=6) of children enrolled in a larger retrospective non-interventional natural history study of children (N=32) with onset of HPP symptoms from ≥6 months and documented HPP-related skeletal abnormalities. Those who had ≥2 clinical videos of basic mobility available between ages 5–15 years were eligible for inclusion in this substudy. Gait performance including pattern, trunk sway, walk stance, was assessed using the 12-point Performance-Oriented Mobility Assessment (POMA-G; 2), modified to provide improved sensitivity for HPP-related impairments in the components, including trunk sway, step length and step continuity (MPOMA-G; 12 = no impairment; lower scores indicate greater impairment). A physical therapy descriptor checklist and chart review provided additional information concerning physical function. Data are reported as median (min, max).

All participants were boys from 1 study center. 5/6 had bowing of the long bones between ages 5–15 y, and all 6 had gait disturbances. Age at first assessment (FA) and last assessment (LA) was 6.2 y (5.3, 10.7) and 11.1 y (8.2, 14.9), respectively. Thus, gait assessments spanned a median of 4.1 y (2.0, 5.9). At FA, total MPOMA-G score was 6.0 (3.0, 11.0); all patients (pts) had trunk sway or compensatory patterns in the trunk or arms to increase stability, 5/6 had a steppage gait pattern, 4/6 a reduced step size and continuity, 3/6 a widened base of support, and 1 had step asymmetry. At LA, MPOMA-G score was 7.5 (4.0, 11.0) [median change from FA: +1.5 (0.0, +2.0); p = 0.0625]. There was no major or consistent pattern of change in any MPOMA-G component. All pts utilized compensatory running patterns, and at LA, 4/6 were unable to achieve a period-of-flight (both feet not in contact with the ground). At LA, all required self-support with a hand to transition from the floor to standing. Time standing on 1 foot ranged from 1.5 to 5.6 sec, lower than for healthy age-matched peers (3). Deficits in hip abductor and extensor muscle strength and a positive Trendelenberg sign were common, indicative of proximal muscle weakness. All reported limitation of activity by pain/fatigue.

As demonstrated by this gait analysis study, children with HPP can have clinically significant and persistent gait impairments indicative of reduced strength and balance, and proximal muscle weakness. The burden of disease in these children impacts their community participation and ability to perform activities of daily living

 

Disclosure: DP: Researcher, Alexion. MV: Employee, Alexion. KF: Employee, Alexion. KLM: Coinvestigator, Alexion. MPW: Principal Investigator, Alexion. Nothing to Disclose: DG, TP, EM, ALR

22842 7.0000 LBS-039 A Gait Assessment in Children with Childhood Hypophosphatasia: Impairments in Muscle Strength and Physical Function 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Sharifah Faradila Wan Muhamad Hatta*1, Kian Guan Goh2, Idris Zamhuri3, Rohaya Abdul Razak4, Rohana Abdul Ghani5 and Shireene Ratna Vethakkan6
1Universiti Teknologi MARA, Malaysia, 2Universiti Malaya, 3Universiti Teknologi MARA, 4Universiti Teknologi MARA, Shah Alam, Malaysia, 5Universiti Teknologi Mara, Malaysia, 6University Malaya Medical Centre, Kuala Lumpur, Malaysia

 

Purpose: Research on Vitamin-D status and dose-requirements have focused on high-latitude Caucasian populations with scarcity of data in postmenopausal-osteoporosis(PMO) women  in equatorial Southeast-Asia, where despite year-long sunshine exposure, ethnicity modulates cutaneous Vitamin-D synthesis via differences in skin-pigmentation and religio-cultural practices that influence clothing. We aimed to determine the incidence and predictors of Vitamin-D status in Vitamin-D supplemented PMO women living in  tropical Malaysia.

Methods: In this cross-sectional study, 190 PMO women within a multi-ethnic cohort, attending an osteoporosis clinic in Kuala Lumpur(2˚30′N),Malaysia,  who claimed compliance with  vitamin-D3(cholecalciferol) supplements and osteoporosis-therapy for >3months were studied. Demographic, anthropometric and clinical characteristics were documented including data on vitamin D dose and sun-exposure.  Vitamin-D deficiency was defined as Serum 25(OH)D <20ng/ml and insufficiency as  <30 ng/ml.

Results: Mean age, BMI, waist circumference and sun index(body surface area x hours per week spent in the sun(1)) were 67.4±0.47 years, 23.9±0.32 kg/m2, 82.3±0.82 cm and 1.09±0.09 respectively. The median skin colour (according to Von Luschan Chart(2)) was 26. 57.4%(N=109) of subjects were Chinese, 16.3%(N=31)Malay and 26.3%(N=50)Indian. All Muslim-Malays wore headscarf. Doses of VitD3 supplement varied with 12.1%(N=23) subjects receiving <400IU Vitamin-D/day, 38.4%(N=73) subjects had 400-800IU/day and 49.5%(N=94) subjects were on >800IU/day. Median serum 25(OH)D was  38.7ng/ml; 3.7% of the study cohort were Vitamin-D-deficient and 21.6% were insufficient. The incidence of vitamin-D insufficiency was higher amongst Indians in comparison to the Malays (p=0.04 95%CI 0.23-7.94) and Chinese(p=0.001 95%CI1.93-8.44). A multiple regression analysis showed sun exposure index as a significant predictor to Vitamin D insufficiency(p=0.04 95%CI 0.07-4.47).

Conclusions: More than a quarter of the study cohort of Vitamin-D-supplemented PMO women had Vitamin-D insufficiency. Importantly, sun exposure index independently predicted Vitamin-D status. Our preliminary findings (requiring confirmation by interventional dosing-studies) suggest darker skin-pigmentation of Indians and Malays, associated with conservative clothing of Muslim-Malays may necessitate higher-dose Vitamin-D therapy.

 

Nothing to Disclose: SFW, KGG, IZ, RA, RA, SRV

22693 8.0000 LBS-040 A Incidence and Predictors of Vitamin D Insufficiency in Postmenopausal Malaysian Women Receiving Vitamin D Supplementation and Osteoporosis Therapy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Edna Eliana Mancilla*, Michael A. Levine and N. Scott Adzick
The Children's Hospital of Philadelphia, Philadelphia, PA

 

Background: Primary hyperparathyroidism (PHPT) is far less common in pediatric than adult patients, but is more often symptomatic. Multiglandular disease is typical in neonates, due to genetic defects in calcium-sensing receptor signaling, and is characteristic in young adults with MEN1 or MEN2a, and requires extensive parathyroid surgery. By contrast, most children and adolescents have sporadic PHPT with a single parathyroid adenoma (PA), suggesting that MIP (2 cm central collar incision) as used in adults with a single PA might be suitable. Objectives: To review the outcomes of MIP, aided by pre-operative imaging for localization and intraoperative measurement of PTH (ioPTH) for confirmation of completion, at CHOP.  A secondary objective was to compare the sensitivity of preoperative localizing imaging studies. Methods: We conducted a retrospective chart review of patients with sporadic PHPT who underwent parathyroidectomy at CHOP between Jan 1, 2009 and Oct 31, 2014, with follow-up data 3-12 months post-surgery.  Results: We identified 15 patients aged 8 to 17 years (9 female, 6 male); no patient had a family history of PHPT or other features of MEN. Preoperative calcium (12.1 ± 0.9, mean ± SD), phosphate (3.5 ± 0.8 mg/dL) and PTH (181.6 pg/mL ± 124.8) levels met criteria for PHPT in all patients. Urine Ca/creat was mildly elevated in 11 of 14 patients (mean 0.27 ± 0.11). Sestamibi scanning identified a single PA in 11/15 patients (73%), including an intrathymic adenoma in 1 case. The negative studies were in 3 patients with eutopic PAs that were smaller (130-270 mg) and 1 patient with an intrathymic adenoma. Preoperative neck ultrasound (US) was performed in 14 patients, and was positive in 9 (64%); both patients with intrathymic PAs had negative US. Overall, US or sestamibi localized an adenoma in 87%, and co-localized an adenoma in 50%. Two patients had an intrathymic adenoma, one located in the mediastinum and removed through a cervical incision, and one in the upper thymus resected by MIP. One patient was a reoperative case following a likely ruptured adenoma at initial resection 3 years earlier at another institution and underwent standard parathyroidectomy. The median weight of the PAs was 324.5 mg (130-2440 mg). IoPTH was performed in 14 of 15 patients, and all patients showed > 50% decrease in PTH levels 10-30 min post resection of a PA, including one patient with an intrathymic adenoma that had not been localized by pre-op imaging.  Follow up data at 3-12 months shows normal serum calcium 9.85 ± 0.41 (range 9.2-10.4) in all available patients (11/15). Conclusions: Young patients with sporadic PHPT typically have a single PA that in most cases can be localized by sestamibi scan and/or US. MIP is an appropriate alternative operation to standard neck exploration in children. Moreover, ioPTH can confirm complete resection and predict PHPT cure, and is especially useful when imaging studies are negative.

 

Nothing to Disclose: EEM, MAL, NSA

22660 9.0000 LBS-041 A Minimally Invasive Parathyroidectomy (MIP) Is an Effective Procedure in Pediatric Patients with Sporadic Primary Hyperparathyroidism: The Children's Hospital of Philadelphia (CHOP) Experience 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Marya S. Sabir*1, Zainab Khan1, Christopher M. Dussik1, Angelika Dampf Stone1, Shane F. Batie1, Michael A. Galligan1, G. Kerr Whitfield2, Mark R. Haussler2 and Peter W. Jurutka1
1Arizona State University, Glendale, AZ, 2University of Arizona College of Medicine, Phoenix, AZ

 

The vitamin D hormone, 1,25-dihydroxyvitamin D (1,25D), initiates its bioeffects by binding to the nuclear vitamin D receptor (VDR) and driving heterodimerization with retinoid X receptors (RXRs). Liganded VDR-RXR modulates gene transcription in 1,25D target tissues, including the colon and kidney, thus regulating epithelial cell proliferation, differentiation, and effecting chemoprevention. The significance of vitamin D in numerous facets of health stresses the importance of elucidating the molecular mechanism of 1,25D-VDR signaling modulators (e.g., resveratrol and sirtuin -1). Resveratrol (Res) is a potent activator of NAD-dependent deacetylase sirtuin-1 (SIRT1), an enzyme associated with longevity in animal models. The current study employed mammalian-two-hybrid (M2H) and vitamin D responsive element (VDRE)-based transcriptional assays to investigate the potential effects of Res and SIRT1 on VDR signal transduction. Results from VDRE-based assays indicated that Res and SIRT1 potentiate 1,25D-VDR activity via cell and promoter-specific pathways. In addition, 1,25D displacement experiments revealed an increase in VDR-bound radiolabeled 1,25D in the presence of Res, suggesting that Res may potentiate VDR transactivation by stimulating 1,25D binding. M2H assays in HEK293 cells were utilized to assess levels of interaction between VDR and VDR comodulators, including RXR, SRC-1, and DRIP-205. Both Res and SIRT1 increased the ability of VDR to associate with RXR; however, SRC-1 and DRIP-205 interactions were not enhanced. To analyze the acetylation status of VDR, the activity of a novel, non-acetylatable VDR mutant, K413R, was probed in VDRE-luciferase assays, revealing that K413R possesses amplified transactivation capacity in comparison to WT VDR in the presence of 1,25D. A specific SIRT1 inhibitor, EX-527, was also used to suppress endogenous SIRT1 levels, resulting in significantly decreased VDR transactivation. Finally, qRT-PCR in HEK293 cells was employed to examine how the 1,25D-dependent expression of an endogenous VDR target gene, CYP24A1 is affected by Res, SIRT1, and Res+SIRT1.  Results revealed that 1,25D induction of CYP24A1 expression was further enhanced (185%) by co-expression of SIRT1, while Res increased 1,25D-dependent CYP24A1 expression by 394%.  In the presence of 1,25D, SIRT1, and Res, CYP24A1 expression increased by 426% over 1,25D alone. We conclude that acetylation of VDR comprises a negative feedback loop that attenuates 1,25D/VDR signaling. This negative loop is suppressed by resveratrol/SIRT1-catalyzed deacetylation of VDR, restoring full VDR activity. These influences of 1,25D and Res on VDR may possibly benefit healthspan. In summary, this study illuminates a coordinated interaction between two nutritionally-derived lipids, vitamin D and resveratrol, thereby identifying a link between 1,25D-VDR signaling and SIRT1 function.

 

Nothing to Disclose: MSS, ZK, CMD, AD, SFB, MAG, GKW, MRH, PWJ

22605 10.0000 LBS-042 A Resveratrol and SIRT1 Are Novel Positive Modulators of Vitamin D Signaling Via Apparent Deacetylation of VDR 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Patricia Haydee Rodriguez*, Evangelina Giacoia, Silvia Seleme, Olga Eugenia Vidal Armijo, Silvia Irene Cabrera, Viviana Bacchini and Mirta Susana Corino
Hospital Nac. Prof. A. Posadas, Buenos Aires, Argentina

 

Background: Low levels of 25-OH-vitamin D (Vit D) during pregnancy are related to adverse results for the health of both mother and fetus1. Hypovitaminosis during pregnancy is associated with an increase in the risk of either pre-eclampsia, gestational diabetes, indication of cesarean birth or bacterial vaginosis2.

Due to a greater screening of Vit D levels in pregnancy the number of patients with hypovitaminosis D have increased. The present therapeutic goal is to maintain a level of vitamin D higher than 30 ng/ml3 .

 Objective: To establish the prevalence of hypovitaminosis D in a population of high-risk pregnancy women who attended our hospital.

 Materials and method:A cross-section analysis with a review of the clinical record and an interview were performed to 170 pregnant women, who attended the Endocrinology Service from August 2012 to April 2013,

High-risk patients with Gestational Diabetes, Pregestational Diabetes, pregnancy-induced Hypertension, and threatened preterm labor were included.

Those who were not considered high-risk patients such as patients with Abortion in progress, Diagnosis of Malabsorption Syndrome, Hypoparathyroidism, Hyperparathyroidism, heart, kidney or liver failure, or on vit D supplementation, were excluded.

In 128 patients we assessed: age, week of pregnancy, body mass index (BMI) , dairy intake (1 ration = 250 mg calcium/day) and Vit D levels.

 Vit D levels were measured with chemiluminescence (LIAISON®, DiaSorin ) considering the month of the year.

 We define deficit as < to 10 ng/ml, insufficient 11 to 29 ng/ml and sufficient > or equal to 30 ng / ml.

The statistic analysis was based in the exploration of the assessed variables.

Average or median values were used for the quantitative variables with their respective dispersion (standard deviation or range)

Qualitative variables were expressed as percentages.

 Results:The overall prevalence of hypovitaminosis D was 80%, Deficit 16%, Insufficient 64%, Sufficiency 20%

After performing a logistic regression evaluating: BMI, week of pregnancy, dairy intake; no predictor variables were found.

When we analyzed the presence of Gestational diabetes, pregnancy-induced hypertension and threatened preterm labor, there was no statistically significant relation between any of them and vitamin D levels

Vitamin D levels from November to April were higher than from August to October (p<0.01).

Conclusion: In our population of high-risk pregnancy patients the prevalence of hypovitaminosis D was 80% with lower levels between August and October.

 

Nothing to Disclose: PHR, EG, SS, OEV, SIC, VB, MSC

22730 11.0000 LBS-043 A Prevalence of Hypovitaminosis D in a Population of High-Risk Pregnancy Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Arti Bhan*1, Indira Brar2, shi-Jing Qiu3, Saroj Palnitkar2 and D. Sudhaker Rao4
1Henry Ford Health System., Detroit, MI, 2Henry Ford Health System, Detroit, MI, 3Henry Ford Health System, detroit, MI, 4Henry Ford Hosp, Detroit, MI

 

With the advances in the treatment of human immunodeficiency virus (HIV) infection, concerns have emerged regarding long-term consequences of chronic HIV infection and its treatment with highly active antiretroviral therapy (HAART).  Although hypophosphatemia and renal tubular acidosis (RTA) are well known complications of long term HAART, symptomatic osteomalacia (OM) due to tenofovir-induced hypophosphatemia has been reported only once recently. We describe 2 patients with tenofovir(TDF) induced Fanconi's syndrome(FS), with bone biopsy confirmed OM. FS is characterized by a generalized transport defect in the proximal tubules, leading to renal losses of glucose, phosphate, uric acid and other organic compounds, leading to glycosuria, aminoaciduria and phosphaturia.  

A 41y old woman and 42y old man, both Caucasian, and both with transfusion acquired HIV, presented with muscle weakness, fatigue, and diffuse bone pain associated with severe hypophosphatemia of 1.0 – 1.7 mg/dl; (RR: 2.5-4.5 mg/dl), and rising serum alkaline phosphatase (AP) levels (peak values 285 & 332 IU/L respectively; normal <120 IU/L) and high bone specific AP (139 & 206 respectively; RR<40 IU/L). Both had phosphaturia and reduced tubular maximum for phosphate reabsorption (<1.7 mg/GFR; RR >2.5 mg/GFR). Serum 25-OHD was normal (35 ng/ml with a PTH of 38) in the man, but low at 13 ng/ml in the woman with a PTH level of 88 pg/ml (RR <75 pg/ml). A technetium pertechnetate bone scan was performed for the woman showed focally increased radiotracer uptake within bilateral ribs, feet and ankle regions.

Trans-iliac bone biopsy, following double tetracycline labeling revealed severe OM in both patients with increased osteoid indices: surface (60 & 76% respectively; RR <20%), thickness (24µm & 37µm respectively; RR <15µm), and volume (30% & 10% respectively; RR <2.5%) with absent tetracycline labeling indicating severe mineralization defect due to hypophosphatemia. There was no evidence of increased resorption indicating absence of PTH effect. The bone biopsy findings were identical to other hypophosphatemic disorders.

Following therapy with oral phosphate and withdrawal of tenofovir, there was a prompt normalization of serum phosphate (3.2mg/dl) and improvement in clinical symptoms over the next several weeks. It is speculated that TDF interferes with replication of mitochondrial DNA in the proximal renal tubule. Individuals with underlying mitochondrial DNA mutations or polymorphisms may be more susecptible to TDF induced toxicity.

Conclusions: Tenofovir-induced hypophosphatemia can cause severe symptomatic OM. To the best of our knowledge, this is the second time OM was confirmed by a detailed tetracycline labeled bone histomorphometry.  Bone density changes in HIV are well known, but symptomatic OM has not been commonly reported.

 

Nothing to Disclose: AB, IB, SJQ, SP, DSR

22892 12.0000 LBS-044 A Tenofovir-Induced Hypophosphatemic Osteomalacia: Report of Two Cases with Detailed Bone Histomorphometry 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Susana Garrido*1, José Carlos Oliveira2 and Andre Carvalho2
1Hospital de Santo António, Centro Hospitalar do Porto, Porto, 2Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal

 

Background:There is growing evidence of the many benefits of vitamin D. Despite that, there is a paucity of epidemiological data on the vitamin D status in Portugal.

Aims: To evaluate the serum 25(OH)D concentration of adult patients followed at the outpatient clinic of Hospital de Santo António, Centro Hospitalar do Porto (North Portugal),  and to analyze possible clinical and demographic predictors of moderate to severe 25(OH)D deficiency.

Methods: Retrospective analysis of clinical data from 3591 adult patients evaluated during 2013 at the outpatient clinic of Hospital de Santo António with available serum 25(OH)D measurements (67.6% women, median age 53 years, range 18-97 years). Moderate and severe vitamin D deficiencies were defined as 25(OH)D values between 25 and 50 nmol/L and bellow 25 nmol/L, respectively. Statistical analysis was performed using descriptive and inferential statistics.

Results:The median (IQR; range) concentration of 25(OH)D was higher among women than men - 47.0 (41; 7.5-1461) vs 45.5 (41; 7.5-1309) nmol/L (p=0.049). The prevalence of moderate and severe vitamin D deficiencies among the population was 33.8% and 21.4% respectively, with no differences between genders. The median (IQR; range) concentration of 25(OH)D was different by age-group (18-40, 41-53, 54-65 and >65 years) - 51.0 (40.9; 7.5-1461) nmol/L, 48.0 (39.5; 7,5-339.6) nmol/L, 47.0 (39.0; 7.5-354.0) nmol/L and 38.0 (44.3; 7.5-257.5) nmol/L, respectively (p<0.001). The prevalence of vitamin D deficiency was higher among the older age-group (p<0.001), with severe vitamin D deficiency reaching 33.4%. The median (IQR; range) concentration of 25(OH)D in spring, summer, autumn, and winter was 38.0 (35.0; 7.5-354) nmol/L, 52.0 (44.0; 7.5-1309) nmol/L, 55.0 (39.3; 7.5-257.4) nmol/L, and 43.0 (36.8; 7.5-1461) nmol/L, respectively. The prevalence of severe vitamin D deficiency was higher in winter-spring (26,9%) than in summer-autumn (15,0%) - p<0.001.

Conclusion: Vitamin D deficiency is highly prevalent in this portuguese outpatient setting. Older age and blood draw during winter-spring seasons were predictors for vitamin D deficiency.

 

Nothing to Disclose: SG, JCO, AC

22891 13.0000 LBS-045 A Vitamin D Status in the Outpatient Setting of Northern Portugal 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Saturday, March 7th 3:00:00 PM LBS 034-047 6276 1:00:00 PM Late-breaking Bone, Calciotropic Hormones & Vitamin D III Poster


Aleksander Jan Kus1, Konrad Szymanski1, Beata Jurecka-Lubieniecka2, Edyta Pawlak-Adamska3, Dorota Kula2, Piotr Stefan Miskiewicz1, Magdalena Niedzwiedzka1, Kornelia Hasse-Lazar2, Jacek M Daroszewski4, Rafal Ploski1, Barbara Maria Jarzab2 and Tomasz Marcin Bednarczuk*1
1Medical University of Warsaw, Warsaw, Poland, 2Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland, 3Polish Academy of Sciences, Wroclaw, Poland, 4Wroclaw Medical University, Wroclaw, Poland

 

BACKGROUND: The role of the TPO gene polymorphism in the susceptibility to Graves' disease (GD) remains unclear. Recently, single nucleotide polymorphisms (SNPs) near TPO have been associated with TPOAbs serum levels in two independent population-based genome-wide association studies conducted in Caucasian and Asian populations [1,2]. Since the appearance of TPOAbs often precedes the development of an overt autoimmune thyroid disease including GD, we assessed the association of rs11675434 SNP located near TPO with susceptibility to and phenotype of GD in a cohort of 647 GD patients from the Polish population. Although rs11675434 was not associated with the susceptibility to GD, we observed a strong association between rs11675434 SNP and the presence of clinically evident Graves' orbitopathy (GO) [3]. Interestingly, the TPO gene expression in retrobulbar tissues and an association between TPOAbs and the development of GO have been suggested in previous reports. The aim of the current study was to reevaluate the association between rs11675434 and GO in an extended group of well-characterized patients with GD from 3 cohorts: Warsaw, Gliwice and Wroclaw.  

METHODS: We investigated the association of rs11675434 with susceptibility to GD and GO in a total of 1099 patients with GD and 967 healthy controls from the Polish Caucasian population. Clinically evident GO was defined as: proptosis, extraocular muscle dysfunction, exposure keratitis and optic neuropathy (NOSPECS ≥3).

RESULTS: rs11675434 showed no association with the susceptibility to GD (OR = 1.07, 95% CI = 0.95 - 1.22, P = 0.2749), whereas the T allele was significantly more frequent in patients with GO (OR = 1.23, 95% CI = 1.02 - 1.48, P = 0.0332), which was consistent with our previous findings [3]. Further analyses performed in subgroups of patients showed that the association with GO was significant in patients with age of GD onset ≥ median (45 years, OR = 1.32, 95% CI = 1.02 - 1.72, P = 0.0364) but not in patients with earlier onset of the disease (OR = 1.09, 95% CI = 0.82 - 1.44, P = 0.5608). Moreover, a strong association was present in males (OR = 2.07, 95% CI = 1.37 - 3.13, P = 0.0005), whereas it was absent in females (OR = 1.07, 95% CI = 0.87 - 1.32, P = 0.5367).

CONCLUSIONS: The results of our study further suggest that rs11675434 SNP located near TPO may be associated with the development of clinically evident GO, especially in males and patients with later age of GD onset. These findings require replication in other populations and functional studies.

 

Nothing to Disclose: AJK, KS, BJ, EP, DK, PSM, MN, KH, JMD, RP, BMJ, TMB

22390 1.0000 LBS-001 A Association of the rs11675434 Single Nucleotide Polymorphism Near TPO with Susceptibility to Graves' Orbitopathy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Cristina Preda1, Gabriela Delia Ciobanu2, Maria Christina Ungureanu1, Letitia Elena Leustean2, Alexandru Grigorovici1, Radu Danila2, Cipriana Stefanescu2, Voichita Mogos1 and Carmen Vulpoi*1
1University of Medicine and Pharmacy, Iasi, Romania, 2University of Medicine and Pharmacy, Iasi

 

Background: The association between primary hyperparathyroidism (pHPT) and thyroid tumors as medullary carcinoma or familial papillary thyroid carcinoma (PTC) are well known but the concurrence of pHPT and PTC is extremely rare. 

Clinical case 1: A 39-year-old woman investigated for a mild, chronic, hypercalcemia (11 mg/dL, reference range 8.4-10.2 mg/dL) revealed on thyroid ultrasound a hypoechoic 0.26 ml nodule at the inferior pole of the right lobe. High PTH level (294 pg/mL, reference range 10-69 pg/mL) confirmed pHTP and surgery was performed. The pathology did not identify parathyoid tissue and revealed thyroid tissue with limphocitic infiltration specific for autoimmune thyroiditis. Calcium (12 mg/dL) and PTH (139.9 pg/mL) level remained high. A second intervention was performed and the patient was found to have right inferior parathyroid adenomatous hyperplasia and an 8 mm thyroid papillary microcarcinoma - pT1NxMx-G1. After second surgery serum calcemia and phosphatemia normalized and PTH decreased to 43 pg/mL. Due to the size, extension and position of the PTC in the thyroid lobe, no radioiodine therapy was required. No signs of recurrence appeared in an interval of 3 years follow-up.

Clinical case 2: A 67-year-old woman with multinodular goiter, hypercalcemia (11.24 mg/dL, hypophosphatemia (2.4 mg/dL, normal range 2.5-4.7 mg/dL) and high PTH (119 pg/mL). 99mTc-sestamibi parathyroid scintigraphy revealed an area with increased uptake in the upper right thyroid lobe. Total thyroidectomy was performed and histopathological examination showed that the mass from the right upper thyroid lobe was a parathyroid adenomatous hyperplasia and the nodular conglomerate from the left lobe was an invasive papillary carcinoma (pT3Nx-G1). The patient received 83.16 mCi 131I followed by treatment with suppressive doses of thyroxine. No signs of recurrence in an interval of 4 years follow-up.

Conclusion: Even though synchronous hyperparathyroidism and thyroid carcinomas are extremely rare we have documented two cases with more unusual features: case one which associated autoimmune thyroiditis and case 2 may be considered as exceptional due to the extent of thyroid disease. It is possible that this coexistece of pHPT and PTC it is not a random one but a possible new pathology. Clinicians should be aware of this rare associations and search for a possible thyroid pathology in patients with pHPT.

 

Nothing to Disclose: CP, GDC, MCU, LEL, AG, RD, CS, VM, CV

22676 2.0000 LBS-002 A Thyroid Papillary Carcinoma and Primary Hyperparathyroidism: A Random Association ? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Nan Yu1, Ying Gao*1, Xuesong Li2, Xiaohui Guo1, Liqun Zhou2, Cuijian Zhang2, Yi Song2 and Zhisong He2
1Peking University First Hospital, Beijing, China, 2Peking University 1st Hospital

 

Objective: Sunitinib is an oral multitargeted tyrosine kinase inhibitor. It has received the approval for treatment of  metastatic renal cell carcinoma(RCC) and imatinib-resistant or –intolerant gastrointestinal stromal tumors(GIST). The adverse reaction of thyroid dysfuction caused by sunitinib has aroused doctors’ attention. The aim of our study was to investigate the prevalence and clinical presentation of thyroid dysfunction in patients with sunitinib therapy. Methods: Data from 29 patients with metastatic renal cell carcinoma treated with sunitinib were collected from June 2008 to April 2011 in Peking University First Hospital. Thyroid function were detected regularly every 28 days. Results: Of the 29 patients, 22 patients developed thyroid dysfunction, 13 patients developed sub-clinical hypothyroidism and 8 presented clinical hypothyroidism. 4 patients experienced transient and mild TSH suppression. In four patients, sera TgAb was detected positive only in one patient and TPOAb positive in two. The ultrasonic sound showed that the thyroid size was normal or decreased after sunitinib therapy. The frequency of adverse reaction related to sunitinib therapy in patients with thyroid dysfunction was significantly higher than that of euthyroid patients (P=0.021). Conclusions: Thyroid dysfunction was common in patients with sunitinib therapy. And regular surveillance of thyroid function should be done in patients using this drug.

 

Nothing to Disclose: NY, YG, XL, XG, LZ, CZ, YS, ZH

22363 3.0000 LBS-003 A Follow-up Study of the Thyroid Function of 29 Renal Cell Carcinoma Patients after Sunitinib Treatment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Yang Yu, Jing Zhang, Nan Yu, Ting Li, Guizhi Lu, Hong Zhang, Ying Gao*, Yanming Gao and Xiaohui Guo
Peking University First Hospital, Beijing, China

 

Background: It has been reported that Hashimoto’s thyroiditis(HT) can be divided into IgG4-positive HT and IgG4-negative HT on the basis of immunohistochemistry. The aim of our study was to find suitable non-invasive markers to differentiate the two different immunophenotypes.

Methods: A total of 86 cases of HT with stored serum samples before operation were collected to detect IgG4 and IgG expression by immunohistochemical staining from 2009 to 2014 in Peking University First Hospital. There were 10 male and 76 female patients with an average age of 45.9 years. Serum total IgG, IgG4, TPOAb IgG, TgAb IgG, TPOAb IgG4 and TgAb IgG4 levels were detected by ELISAs.

Results: Based on immunohistochemistry for IgG4 and IgG (> 20/HPF IgG4-positive plasma cells and a IgG4/IgG ratio> 20%), 21 cases of IgG4 (+) HT and 65 cases of IgG4 (-) HT were identified in our study. The patients in the IgG4 (+) HT group were significantly younger (39±2.37 yrs) than those in the IgG4 (-) HT group (48.1±1.49 yrs)(P = 0.003). There were no significant differences in the sex distribution, disease duration and distribution of thyroid functional status between the two groups. 

  No significant differences were found in the levels of serum IgG4, total IgG, and IgG4/IgG ratio. However, the levels of TgAb IgG4, TPOAb IgG4, and the ratios of TgAb IgG4/TgAb IgG, TPOAb IgG4/TPOAb IgG were significantly higher in the IgG4 (+) HT group than those in the IgG4 (-) HT group, respectively (P <0.05). The areas under the receiver operating characteristic curve (ROC) of TgAb IgG4, TgAb IgG4/TgAb IgG, TPOAb IgG4, TPOAb IgG4/TPOAb IgG for discriminating the two different immunophenotypes were 0.727 (sensitivity= 76.2%, specificity= 67.7%), 0.689 (sensitivity= 81%; specificity= 55.4%), 0.758(sensitivity= 47.1%, specificity= 95.4%), 0.714 (sensitivity= 81%; specificity= 55.4%), respectively. 

  Serum IgG4 levels were higher than 135mg/dl in twelve of the 86 HT patients, three(3/21) were found in IgG4 (+) HT group and the other nine (9/65)were in the IgG4 (-) HT group. Furthermore, among the IgG4 (-) HT group (n=65), we found that these nine patients also had significantly higher IgG concentrations in serum than the other 56 patients whose serum IgG4 concentrations are lower than 135mg/dl (P=0.000),while the IgG4/IgG ratio did not differ between the two groups (P=0.353). 

Conclusion:Our study indicates that HT can be divided into IgG4 (+) and IgG4 (-) HT. The levels of serum IgG4 binding to specific thyroid antigens(thyroglobulin and thyroid peroxidase), might be practical and useful non-invasive markers to identify IgG4 (+) thyroiditis instead of immunohistochemistry. However, it is not reasonable to classify these two different immunophenotypes only by serum IgG4 concentrations.

 

Nothing to Disclose: YY, JZ, NY, TL, GL, HZ, YG, YG, XG

22625 4.0000 LBS-004 A Serum IgG4 Binding to Specific Thyroid Antigens Might be Suitable Non-Invasive Markers to Identify IgG4 Thyroiditis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Anila Mustafa*
Hershey Medical center, Hershey, PA

 

Introduction:

Thyroid nodules are frequently–encounter entities in clinical practice. While around 95% of thyroid nodules are benign but certain histological, laboratory & sonographic features raise the suspicion of malignancy. It is not uncommon for a patient with a solitary thyroid nodule to be diagnosed with hyperthyroidism. In this setting, the thyroid nodule may represent a solitary hyper functioning thyroid nodule in an otherwise normal thyroid gland. Hyper functioning nodules of the thyroid are thought to rarely harbor thyroid cancer & thus are infrequently biopsied. We are presenting a case of a patient with hyper functioning thyroid nodule harboring thyroid cancer with negative fine needle biopsy.

Case Presentation:

54 year Caucasian female evaluated for hyperthyroidism secondary to toxic nodular goiter. She underwent FNA of the dominant right lobe nodule reported as “suspicious for adenoma“. Due to 15-30% risk of underlying thyroid cancer, she underwent 1-131 uptake & scan. That test showed increased  4 hours and 24 hours uptake with increased radiotracer trapping in the area of the prominent nodule (suggesting hot nodule) with decreased radiotracer trapping in the rest of the thyroid gland with no definitive photopenic area (suggesting cold nodule). Due to early FNA report, she opted for right lobectomy. Surgical pathology reported as follicular variant of papillary thyroid cancer with no lymph vascular, capsular & lymph node involvement. The largest focus was 3.6 cm in the right lobe with small focus 0.1 cm in the same lobe that put her in P0T2NxMX. Due to the above pathology; she underwent complete thyroidectomy a month later. Post-op, she was placed on thyroid harmon replacement.

Pre-surgery lab had TSH of < 0.02 uiu/ml (0.47-4.68), Free T3 of 6.6 pg/ml (2.8-5.3), Free T4 of 1.52 pg/ml (5.5-11.0). Thyroglobulin antibodies were 2 with antiTPO level was <1. Post surgery repeat lab had TSH of 0.08 uiu/ml (goal TSH was around 0.1) with Free T4 of 0.57. She was scheduled for thyroid harmon withdrawal radioactive iodine ablation as an adjunct.

Discussion:

Recent literature review of surgical patient with solitary hyper-functioning thyroid nodule managed by thyroid resection revealed an estimate of 3.1% prevalence of malignancy. Of these, 78% were female &  mean age at the time of diagnosis was 47 years, mean nodule size was 4.13 +/- 1.68 cm. Histology was consistent with papillary thyroid cancer in 57.1%, follicular thyroid cancer in 36.4% & hurtle cell cancer in 7.8%. Thus, hot thyroid nodule harbor a low but not trivial rate of malignancy. We recommend that hot nodules that are not treated surgically be considered for biopsy if the high risk is historical &/or  sonographic features are present or nodule grew over time.

 

Nothing to Disclose: AM

22687 5.0000 LBS-005 A a Solitary Hyper-Functioning Thyroid Nodule Harboring Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Daya K Hazra*1 and Padmamalika Hazra2
1Boston Medical Center, Agra, India, 2St Johns College, Agra, India

 

These case reports exemplify a clinical phenomenon sometimes observed during the treatment of hypothyroidism

viz. the precipitation and/or  first presentation of migraine during the correction of hypothyroidism.

 Case 1.R D 35, Asian female ,presented with weight gain, tiredness, slowness of thought. Height 1.7 metres

 with a weight 75 kg, Blood Pressure 136/90 mm Hg. EKG showed low voltage complexes , Serum

 Thyroxine  2.5 micrograms/decilitre.  TSH  34 Units/Litre.Anti- thyroid microsomal (TPO) antibodies 3500 Units;

 Fine Needle Aspiration Cytology (FNAC) showed lymphocytic infiltration.

 Hashimoto’s thyroiditis with hypothyroidism diagnosed.

Prescribed Thyroxine 25 microgram daily, escalated over a period of 4 weeks to 100 micrograms daily.

Patient improved with weight loss and decreased pedal oedema but developed repeated

 headaches, throbbing, hemicranial-right or left sided  which was severe, pulsating and

accompanied by photophobia. MRA revealed no abnormalities in the intracranial vasculature.

Presumptive diagnosis of Migraine. Put on Flunarazine 10 mg at bedtime

and Propranolol 40 mg thrice daily,  with resolution of headache within 4 days.

Case 2.  K P 20 year male  presented with a  goitre noticed by his friends. On

 examination, 80 kg in weight, with  a typical myxoedematous look,  and pedal edema.

 Thyroid workup confirmed  hypothyroidism TSH  400  Units /Litre, Serum Thyroxine 3.5 micrograms/ decilitre.

FNAC showed colloid goitre.

Put on Thyroxine replacement therapy, starting with 50 micrograms daily ,

 gradually escalated to 150 micrograms daily.  Patient improved  as regards facies and

 TSH normalised to 1.5 Units/Litre, but  developed  throbbing headaches,  from the first day.

 Again responded to Propranolol  20 mg twice daily.

Comment:

Propranolol has been used to treat hyperthyroidism. It has also been a part of the treatment of migraine.

Migraine is not classically described in hyperthyroidism .However, the  precipitation

of migraine during normalisation of hypothyroidism in these two cases with

different etiology  suggested that propranolol should be  useful.

These cases exemplify the precipitation of  migraine during normalisation of hypothyroid  status which

we have often observed in our Thyroid Clinic.

 It is prudent  that a new headache or exacerbation of migraine  should be enquired

about whenever  a hypothyroid subject is treated with thyroxine.

 

Nothing to Disclose: DKH, PH

22723 6.0000 LBS-006 A Migraine Precipitation during Treatment to Normalise Hypothyroid Subjects 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Robert Becker, Joshua Brody, Elena Motuzko, William Klump and Maryam I Khan*
Cooper University Hospital, Camden, NJ

 

 

Introduction: Primary thyroid lymphoma (PTL) is rare, with an estimated annual incidence of 2 per 1 million. It presents as a rapidly enlarging goiter, often with compressive symptoms. Definitive diagnosis requires cytology and immunohistochemistry, but certain features on thyroid ultrasound should increase suspicion for the disease. This case review highlights the imaging characteristics that could aid in the differential diagnosis of rapidly enlarging masses and guide a prompt diagnosis and management plan.

Clinical Case: A 64-year-old man presented to an urgent care clinic with 3 weeks of neck swelling, pain, and hoarse voice. On physical examination identified to have large (10cm) firm right thyroid mass. A CT of the neck showed enlargement of the right thyroid lobe to 6.3 x 5.6 x 10 cm with low attenuation, localized extension, distortion of adjacent facial planes and deviation of airways. Thyroid ultrasound revealed a heterogeneous right lobe mass that was hypoechoic with echogenic septa and architectural distortion. Thyroid function tests were normal, but thyroperoxidase and thyroglobulin antibodies were highly elevated. Flow cytometry and cytology of a fine needle aspirate from the mass identified it as diffuse large B-cell lymphoma, and bone marrow biopsy showed no evidence of the lymphoma.  Over the next few days, patient noticed worsening shortness of breath with evidence of tracheal compression on repeat CT scan. Patient started chemotherapy with R CHOP resulting in significant improvement of compressive symptoms within few weeks and reduction in size of right thyroid mass on follow up PET/CT in 6 months.

Conclusion: Rapidly enlarging neck masses with compressive symptoms necessitate prompt diagnosis to initiate management plan. PTL exhibits complicated and diverse imaging characteristics, making it difficult to distinguish from other thyroid disease including anaplastic thyroid carcinoma. PTL can be classified as nodular, diffuse, or mixed on ultrasound. Nodular PTL lesions are generally unilateral with hypoechoic, homogenous, pseudocystic internal echoes and posterior acoustic enhancement. Enhanced posterior echoes help distinguish lymphoma from other thyroid lesions. The border between these lesions and normal thyroid tissue is distinct. CT neck demonstrates localized mass with increased T2 signal intensity. When PTL presents as a solitary mass, it can resemble anaplastic thyroid carcinoma (ATC) but it lacks the heterogeneity, calcifications, necrosis, or cystic degeneration often found in ATC. US features of hypoechogencity, homogenous architecture with septations and posterior acoustic enhancement should raise suspicion for PTL prompting timely initiation of chemotherapy upon diagnosis. Our patient initiated R CHOP immediately with improvement in compressive symptoms and as a result, has a predicted 4-year progression-free survival of 80%.

 

Nothing to Disclose: RB, JB, EM, WK, MIK

22783 7.0000 LBS-007 A Rapidly Enlarging Neck Masses:  Imaging Characteristics of Primary Thyroid Lymphoma to Guide Acute Management 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Bekir Ucan*1, Coskun Yüksek1, Rıdvan Erten2, Fatime Demir2, Fatih Atik2, Rabia Altınordu2, Zuhal Mercan2 and Gözde Konuk2
1Ministry of Health A.İ.B.U İzzet Baysal Training and Research Hospital, Bolu, Turkey, 2Ministry of Health A.İ.B.U İzzet Baysal Training and Research Hospital, Bolu

 

İntroduction: Antithyroidal drugs (ATD), radioactive iodine and surgery are the treatment regimens that are used in treatment of hyperthyroidy related to graves disease. Although methimazole is mainly used in treatment hyperthyroidi, propylthiouracil can be used in special conditions. Methimazole is a drug commonly observed side effects. It should be keep in mind that myopathy is also a rare side afects of methimazole. In this article, it is presented that a patient who has muscle enzyme elevations seen after use of methimazole.

Case: 32 years old man patient was admitted to our polyclinic with palpitation, tremor, fatigue and significant weight loss. In his laboratuary results TSH <0,005 µIU/mL (0,27-4,2 µIU/mL), sT3: 16,53 pg/dL (2,6-4,8 pg/dL), sT4: 3,74 ng/dL (0,93-1,7 ng/dL), antiTPO: 132 IU/mL (0-34 IU/mL), antitiroglobulin antibody : 772 IU/mL (0-115 IU/mL), TSI: 32,72 U/L (0-14 U/L) were detected. İn his thyroidal ultrasound, heterojenite in thyroid paranchyme, pseudonodularity and increase in blood flow of thyroid gland were detected. Methimazole 20 mg / day was started to patient with hyperthyroidy related to graves disease. After 1 month of treatment the patient applied to our polyclinic with intolerable muscle cramps and pain that takes about 2-3 hours especially in evenings. In his laboratuary results TSH: 0,219 µIU/mL, sT3: 2,83 pg/dL, sT4: 0,784 ng/mL CK (creatin kinase): 3775 U/L (30-200 U/L) were detected. Liver functions tests and serum electrolites were in normal range. Methimazole dosage was dropped to 5 mg/day. The value of CK that seen 4 day after dropping the methimazole dosage regressed to 704 U/L. Muscle pain and cramps were dissapeared and CK concentration regressed by reducing dosage of methimazole. Because methimazole could not be found,  propylthiouracil had to be used  for patient. Muscle cramps and muscle pain again started and CK value increased.

Result: . Methimazole and propylthiouracil are drugs that  have several side effects. It should be keep in mind that myopathy, myalgia and CK elevations are also rare side afects of methimazole and propylthiouracil. These symptoms can be eliminated by reducing the dosage of these drugs. Changing methimazole to propylthiouracil regimen is not effective in improvment of muscle symptoms and CK elevation.

 

Nothing to Disclose: BU, CY, RE, FD, FA, RA, ZM, GK

22838 8.0000 LBS-008 A Elevation of Serum Creatin Kinase during Methimazole Treatment in the Patient with Graves Disease : A Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Sushma Kadiyala* and Colleen Rose Digman
University of Florida, Gainesville, FL

 

BACKGROUND:

Hydatidiform mole (HM) occurs with an incidence of 1:1000 in the United States, however higher rates are noted in Mexico and Southeast Asia. Molar pregnancies are categorized as partial or complete moles, with a complete mole caused by one or two sperm fertilizing a single egg without DNA. Hyperthyroidism is a rare complication of molar pregnancy. We present a case of hyperthyroidism in a woman with a complicated HM.

CLINICAL CASE: 

A 35 year-old Phillipino, P1021 patient presented at 6+1 weeks gestation with vaginal bleeding, severe nausea, sinus tachycardia, diaphoresis, and fine tremors. Laboratory findings showed elevated liver function tests and β-hCG (910592 mIU/mL) Trans-abdominal ultrasound documented an enlarged 23-week uterus with a solid collection of echoes and numerous anechoic spaces, as well as clusters of swollen trophoblastic villi consistent with a complete HM. Karyotype analysis confirmed a 46XX diploid. Thyroid function panel on presentation was: TSH 0.01 mIU/L, fT4 >7.71 ng/dL, and tT3 444 ng/dL. She was admitted and initiated on methimazole, propranolol and SSKI.  On day 6 the patient underwent dilatation and curettage followed by significant symptom improvement. Postoperatively, her TSH was 0.01 mIU/L, fT4 2.67 ng/dL and tT3 227 ng/dL. She was discharged home hospital day 8 with two additional days of methimazole and propranolol.

In follow-up, TFTs normalized however hCG rebounded 2 weeks postoperatively, prompting empiric treatment with methotrexate. By 6 weeks, slowly declining hCG levels prompted a CT scan that demonstrated an enhancing heterogeneous mass involving the fundal endo/myometrium with associated pulmonary nodules concerning for choriocarcinoma. At 4 months follow-up, hCG levels continue to trend down (10015mIU/mL) and the patient remains asymptomatic on methotrexate with the potential for initiation of  dactinomycin if levels do not reach zero.

CONCLUSION:

Hyperthyroidism is a rare complication of molar pregnancy. Increased suspicion is warranted in woman of childbearing age, particularly amongst those of Mexican and Asian decent. The majority of HMs are benign, however some cases may be due to choriocarcinoma. Lack of HCG normalization is concerning for persistent trophoblastic disease and/or choriocarcinoma. This case underscores the importance of complete pathologic, biochemical, and if necessary radiographic follow-up to verify resolution.

 

Nothing to Disclose: SK, CRD

22880 9.0000 LBS-009 A A Rare Case of Hyperthyroidism Secondary to a Complicated Molar Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Kranthi Andhavarapu1, M. Osman Salim2, Khalid Salim2, Manal Zabad3 and Mohamad Hosam Horani*4
1Banner Baywood Hospital, 2Midwestern University, AZ, 3Mesa Community Collage, Chandler, 4Alsham Endocrinology, Chandler, AZ

 

A 66-year old Caucasian female with recent history of meningioma resection presents due to referral from psychiatrist for severely depressed TSH levels.  The patient has had history of Hashimoto’s thyroiditis for more than 30 years and been on same synthroid dosage of 100 mcg daily. She presented with new symptoms of weight loss of 20 lbs, anxiety, lower extremity edema since her surgery. Her vitals on admission were normal. On physical exam, no exophthalmos, or enlarged goiter or tenderness of thyroid gland. Upon admission, TSH was < 0.01 (normal 0.45-4.5),  T4  7.5 (normal 0.8-1.7), T3 393 (normal 80-200), free T3 19.6 (normal 2-4.8), TSI < 89, thyroglubulin level 22, thyroglubulin ab < 20, antimicrosomal antibody < 10. Also, of note she had leucopenia with WBC of 2.5 ( normal 4-11) on admission.  Patient also underwent imaging with CT angio for her meningioma surgery which contains iodine load. This prompted us to performs thyroid uptake scan which showed depressed 24 hr thyroid uptake at 0.3% which was way below normal (3-16%).  Thyroid US showed decreased size and coarsened echotexture with mild hypervascularity in both lobes.  Severe iatrogenic thyrotoxicosis was suspected secondary to recent iodine load and history of autoimmune hashimoto’s thyroiditis. Antithyroid medications were held due to leukopenia.  Decadron was initiated.  Upon further questioning  with patient’s daughter, we verified the color of pills and called her pharmacy. It was found that pt was taking her dog thyroid hormone medication for last 3 months.

The dosage requirements in dogs are substantially higher than in humans. The recommended starting dose of levothyroxine for hypothyroidismin dogs is 44 mcg/kg/d, far more than the 1.7 mcg/kg/d inhumans.Commercially available levothyroxine tabs for dogs come in dosage strengths of up to 1000 MCG   tabs ( high dose for humans).Accidental thyrotoxicosis caused by inadvertent ingestion of levothyroxine “dog-tabs” must be suspected in patients that have pets. Early diagnosis and treatment are crucially important in preventing complications.

 

Nothing to Disclose: KA, MOS, KS, MZ, MHH

22881 10.0000 LBS-010 A Sicker Than a Dog :  Accicedntal Thyrotoxicosis from Ingesting Pet's Medications 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Natalia Chaar Tirado*1 and Alejandra N Santiago2
1Hospital Damas, Ponce, 2Hospital Damas, Ponce, PR

 

Background: Primary thyroid lymphomas are rare and account for 2% of all malignant thyroid tumors. The majority are diffuse large B-cell lymphoma. The only known risk factor is preexisting Hashimoto’s thyroiditis. Epstein-Barr virus has been implicated as an environmental factor for the malignant B cell transformation.

Clinical case: A 62 year old man presented to our hospital complaining of a rapid growing mass in the anterior neck with progressive shortness of breath and difficulty swallowing for approximately one month of evolution. He had a 10 months history of Hashimoto’s thyroiditis. TPO and Td Ab were positive. A thyroid sonogram one year before symptoms reported a multinodular goiter. Two months prior to hospitalization he had flu like symptoms; mono test and EBV Ab (negative and positive, respectively). Afterwards he started to notice night sweats, general malaise, decreased appetite and substantial weight loss accompanied with a rapidly growing mass in the anterior neck. Thyroid sonogram one month before admission reported a severely enlarged hypervascular mass like thyroid with diffusely disorganized internal thyroid architecture.

On physical examination patient had a hard non tender mass in the anterior and both sides of the neck (6 cm x 10 cm) that seemed to be fixed to adjacent structures. Otherwise the physical examination was unremarkable. Initial laboratory testing (CBC, CMP, UA, TSH, FT4, lipid profile and HIV) were all within normal limits. Clinical diagnosis of a thyroid mass was made. CT scan of the neck without contrast reported a large soft tissue involving the anterior and both sides of the neck mass (5.5 cm x 9.5 cm) that appeared to originate from the thyroid gland and was deviating the larynx and the trachea towards the left. A FNAB was performed which reported a lymphoproliferative disorder. Thyroidectomy performed.

Pathology department described a 258 gm irregular mass (13 x 7.5 x 7 cm) identified as malignant DLBCL-GC type; EBV negative. IHC analysis confirmed the diagnosis with CD 10 weakly positive and CD 20, BCL2 and BCL6 positive with a Ki67 of 90%. Chemotherapy regimen R-CHOP was started; radiotherapy followed.  Six months after initial diagnosis the patient started to suffer blurry vision in the right eye that progressed to diplopia and ptosis. MRI of the brain described a 1.0 x 0.7 cm enhancing mass at the origin of the right facial nerve in the right pons, abnormal signal on FLAIR and T2- weighted images in the mid pons and right side of the pons and an abnormal enhancing lesion in the right Meckle’s cave. Patient died due to aspiration.

Conclusion: Primary thyroid lymphomas are rare and should always be considered in the differential diagnosis of male patients with thyroid pathologies, especially, with history of preexisting Hashimotos’ thyroiditis and EBV exposure. Thorough history taking and physical exam are key components for the diagnosis.

 

Nothing to Disclose: NC, ANS

22932 11.0000 LBS-011 A Primary Thyroid Lymphoma with Secondary Central Nervous System Disease: A  Case Report 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Ingrid C E Wilkinson*1 and Jill Campbell2
1Norfolk and Norwich University Hospitals NHS Trust, Norwich, United Kingdom, 2Norfolk and Norwich University Hospital NHS Trust, Norwich

 

Background: Symptoms of attention deficit hyperactivity disorder (ADHD) and its treatment may resemble thyrotoxicosis, delaying diagnosis. (1) When both conditions co-exist, diagnosis and management is further complicated, and may impair treatment response to ADHD therapy. (1) We present the management challenges encountered in an 8 year-old girl with both ADHD and thyrotoxicosis.

Case Report: Y, a girl aged 8 years with severe attention deficit hyperactivity disorder (ADHD), unresponsive to behavioural management and methylphenidate over the preceding 2 years, was noted to be losing weight.  Y was investigated and found to have autoimmune thyrotoxicosis [TSH <0.01mIU/L, fT4 22pmol/L, fT3 8.9pmol/L, Thyroid peroxidase and thyroid receptor antibody positive]. She was commenced on carbimazole (CBZ), and was well-controlled.  Her ADHD symptoms also improved. Treatment was stopped after 3 years, but she relapsed within 3 months, symptomatically and biochemically [TSH <0.01, fT4 26, fT3 12.8]. Y was recommenced on CBZ 3.75mg od, but remained symptomatically and biochemically thyrotoxic, requiring dose escalation (CBZ 15mg od), propranolol 10mg tds, and, preparatory to emergency thyroidectomy, iodine 5% with potassium iodide 10%, 0.1mL tds. Her ADHD symptoms remained refractory.

Post-surgery, her immediate recovery was complicated by acute hypoparathyroidism [PTH 0.3pmol/L (1.6-6.9)], with severe hypocalcaemia [Ca 1.67mmol/L (2.10-2.60)], requiring intravenous calcium.  Y was commenced on 1-alfa-calcidol and dietary calcium supplements, and subsequently, thyroxine, on which she remains stable.  Y has severe fatigue symptoms post-operatively, but a trial off methylphenidate resulted in intolerable ADHD symptoms.

Conclusion: ADHD may mask thyrotoxicosis, and weight loss may be ascribed to known drug side-effects, leading to delayed diagnosis. Despite being stable on CBZ for 3 years, Y’s relapse after stopping therapy was resistant even to high dose CBZ with propranolol, necessitating iodine/potassium iodide pre-operatively.  Unfortunately, her post-operative course was further complicated by acute hypoparathyroidism.

 

Nothing to Disclose: ICEW, JC

22962 12.0000 LBS-012 A ADHD and Relapsed Refractory Thyrotoxicosis in a Child: Management Challenges 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Janete P Moura*1, Walter Bloise2, Lidia Y Mimura3, Wilian Nicolau4, Elaine Oliveira Dias5, Mario Luiz Ribeiro Monteiro6 and Sheila Siqueira7
1FMUSP & FMUSF, Sao Paulo, Brazil, 2Hosp das Clinicas Schl of Med, Sao Paulo, Brazil, 3Hosp das Clinicas FMUSP, Sao Paulo, Brazil, 4HCFMUSP, Sao Paulo, Brazil, 5Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 6Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 7HCFMUSP, Sao Paulo

 

Background: Euthyroid Graves´ ophtalmopathy (GO) associated with papillary carcinoma (PCA).  Thyroid  autoimmunity  evidences were not found and the link between these two conditions remains  a matter of speculation.

Objective- To report three patients with GO and PCA in a histologycal and functioning nomal  thyroid gland  and to describe a  hypothetical  pathogenetic link between them.

Patients findings - 2  patients, 33 and 62  years old  presented  blurring of vision and diplopia. Ophthalmological examination and  orbital CT  featured  severe assymetric  Graves´ ophthalmopathy.They were treated with  intravenous and oral  prednisone, orbital decompression and orbital radiotherapy. Both patients presented  thyroid nodules diagnosed as  Papillary Carcinoma.

Surprisingly in both patients the carcinoma was surrounded by normal thyroid tissue. In both  thyroid function was normal  and thyroid antibodies(anti TPO, anti TG and TRAB) were  negative. The third patient a 49 years old female  complaining of exposed and tearing left eye in the last 3 months.  She presented  3 mm upper left eyelid retraction and small edema of the lower lid and  no symptoms or signs  of thyroid disfunction. Orbital CT detected enlargement  of the superior extra ocular muscle in the left eye. She had   presented a thyroid  nodule  in left lobe  diagnosed PCA.  Thyroid's histology of the whole gland  showed that the PCA was surrounded by normal thyroid tissue.  This patient also had  normal  thyroid function  and negatives anti - thyroid antibodies.   After one year the regression of the eye left  signs  was  registered. Immunohistochemical analysis of  tumor specimens of the all the 3 patients revealed IGF-1 and IGF-1 receptor(IGF-1R) positiviity.

Summary – Our study reports  3 euthyroid  patients with papillary thyroid carcinoma harboured in whole  normal thyroid tissue whose neoplastic cells were positive to IGF-1 and IGF-1R. They developed eye disease similar to the Graves´ophthalmopathy and one of them  showed spontaneous regressssion of eyes signs. The conjecture is that the IGF-1/IGF-1R system considered one pathogenic component  of Graves´ ophthalmopathy  could be involved in this unnusual clinical problem.

 

Nothing to Disclose: JPM, WB, LYM, WN, EOD, MLRM, SS

22980 13.0000 LBS-013 A Opthalmopathy  and Papillary Thyroid Carcinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Saturday, March 7th 3:00:00 PM LBS 001-014 6279 1:00:00 PM Late-breaking Thyroid/HPT Axis III Poster


Mehmet Calan*1, Tuncay Kume2, Ozgur Yilmaz3, Pinar Yesil4, Muzaffer Temur3, Tamer Altindag3, Ozge Dokuzlar2, Kemal Aygun2, Ozlem Gursoy Calan5 and Gokcen Kocabas6
1bozyaka training and research hospital, 2Dokuz Eylul University Medical School, Izmir, Turkey, 3Manisa Merkezefendi Hospital, Manisa, 4Ege University, Izmir, Turkey, 5Dokuz Eylul University Hospital, Izmir, 6Bozyaka Training and Research Hospital, Izmir, Turkey

 

Context: Adropin is a peptide hormone that appears to regulate energy homeostasis and holds therapeutic potential in diabetes and obesity. The pro-inflammatory cytokine TNF-α regulates the secretion of certain peptides which play a crucial role in glucose and lipid homeostasis.

Objective: To investigate whether there is a link between adropin and TNF-α in the pathogenesis of polycystic ovary syndrome (PCOS).

Design and Setting: Cross-sectional study conducted in a secondary referral center.

Participants: 92 women with PCOS and 88 age- and body mass index (BMI)-matched eumenorrheic controls.

Main Outcome Measures: Adropin and TNF-α in the sera of participants were measured using ELISA.

Results: Adropin levels were lower in the PCOS group (7.53 ± 0.73 ng/ml), compared with the control group (7.82 ± 0.57 ng/mL) (P=0.004), and were inversely correlated with TNF-α, hs-CRP, BMI and homeostasis model assessment of insulin resistance (HOMA-IR) in both groups. Furthermore, adropin levels were negatively correlated with atherogenic lipid profiles in women with PCOS. Binary logistic regression analysis revealed that decreased adropin levels were significantly associated with high odds of having PCOS, although, after adjustment for TNF-α, this link vanished. Additionally, multiple regression analysis indicated a negative association between adropin and HOMA-IR (β=-0.134; 95% confidence interval (CI)=-0.440 to 0.326; P=0.019) which disappeared following TNF- α adjustment (β=-0.027; 95% CI=-0.065 to 0.010; P=0.155).

Conclusions: Serum adropin levels are significantly decreased in PCOS and are inversely associated with TNF-α. Further dissection of the nature of this association can open new therapeutic options for metabolic diseases.

 

Nothing to Disclose: MC, TK, OY, PY, MT, TA, OD, KA, OGC, GK

22362 1.0000 LBS-015 A A Possible Connection Between TNF-α and Adropin Levels in Polycystic Ovary Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM LBS 015-023 6282 1:00:00 PM Late-breaking Reproductive Endocrinology III Poster


Aishah A Ekhzaimy*1, Zeinab Muthana Abotalib2, Samiha Mohammed Aljetaily3, Tarfah Al-Obaidan4 and Fareeha Abdulwali5
1King Saud University,King Khalid Univesity Hospital, Riyadh, Saudi Arabia, 2King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia, 3King Saud University, Riyadh, 4king Saudi University, 5Alfaisal University, Riyadh, Saudi Arabia

 

Clinical Characteristics of Polycystic Ovary Syndrome among Saudi Women

Polycystic ovary syndrome (PCOS) is the most common cause of infertility. Clinical presentation of the PCOS varies widely, and it is a complex presentation. The prevalence is variable worldwide. It is dependent on the diagnostic criteria used and the ethnic background.

We decided to study the most common clinical features of polycystic ovary syndrome among Saud women. This would help the health care provider to diagnose the disorder early to prevent many metabolic complications associated with it. Moreover, The studies on PCOS in the Saudi populations are very few.

It is a retrospective study. 182 charts of Saudi women diagnosed with polycystic ovary syndrome using Rotterdam criteria were reviewed. The initial data of the PCOS women in reproductive age group (18-45 years old) attending the infertility and gynecology clinics at King Khalid University Hospital in Riyadh (affiliated with King Saud University) between 2005 -2013 was collected from the Assessment Form that included history, physical examination, BMI (Body Mass Index), Laboratory results of the hormonal and metabolic profiles and pelvis ultrasound findings.

 We found BMI and menstrual irregularities were considered the main phenotypic clinical presentations that are positively associated with PCOS diagnosis in Saudi women. Irregular cycles was positively associated with Infertility, Hyperandrogenemia, and failure of ovulation (RR>1, OR>1, P value <0.001, Beta -0.176/-0.359, Std. Error 0.042, t= - 4.240). But, it had a non-significant positive association with PCOS morphology in the pelvic ultrasound. BMI >25 Kg/m2 was positively associated with failure of ovulation and abnormal pelvic ultrasound ( RR>1, OR>1, P value <0.001, Beta 0.153/0.184, Std. Error 0.039, t=3.897),however, it had non-significant positive association with hyperandrogenism and had a non-significant negative association with fertility (R= 0.845, R2= 0.714, Adjusted R2= 0.636, P<.0001).We concluded that BMI>25 Kg/m2 and menstrual irregularities are the most alarming clinical presentation in  young Saudi females in their reproductive age with a high likelihood of having PCOS, especially if it is associated with a history of infertility. These cases should be recognized and managed early to avoid associated metabolic complications

 

Nothing to Disclose: AAE, ZMA, SMA, TA, FA

22537 2.0000 LBS-016 A Clinical Characteristics of Polycystic Ovary Syndrome Among Saudi Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM LBS 015-023 6282 1:00:00 PM Late-breaking Reproductive Endocrinology III Poster


Hanako Kakuta* and Tomomi Sato
Yokohama City University, Yokohama, Japan

 

     Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in reproductive-aged women. Its most typical form is the association of hyperandrogenism with chronic anovulation without specific underlying diseases of the adrenal or pituitary glands. Several possible causes have been proposed, such as neuroendocrine abnormalities accompanied with excessive luteinizing hormone (LH) stimulation and dysregulation of steroidogenesis in the ovary. However, the pathophysiology of PCOS still remains unclear.

     Theca cells (TC) of large antral and ovulatory follicles are the main source of ovarian androgens and express P450c17α, encoded by Cyp17a1, which converts progesterone to 17α-hydroxypregnenolone and androstenedione. Although LH induces Cyp17a1 mRNA expression, P450c17α is reduced in lutenizing TC to form corpus luteum. It is known that Cyp17a1 mRNA expression in TC from PCOS women is up-regulated under the influence of hypersecretion of LH.

     To investigate the regulation of Cyp17a1 in TC by LH, 3-month-old female C57BL/6J mice were treated with PMSG at diestrus and 48 h later with hCG. Ovaries were collected at 0, 4, 8, 12, 16, 20 and 24 h after hCG. TC isolated from 21-25-day-old mice were pre-cultured for 24 h and then cultured in the RPMI culture medium with or without LH (1, 10, 100 or 1000 ng/ml), and collected at 0, 8, 12, 24 and 48 h. Total RNA was isolated from ovaries or TC and real-time RT-PCR was performed. Histological observation was examined in the ovary by HE staining. The numbers of small and large antral follicles, ovulatory follicles, and corpora lutea were counted.

     In 3-month-old mice, the number of antral follicles was gradually decreased but the percentage of small antral follicles tended to be increased after hCG. The numbers of large antral and ovulatory follicles from 0 to 8 h after hCG were not changed, however, the expression of Cyp17a1, Hsd17b1, and Cyp19 mRNA was reduced at 8 h compared to the ovary at 0 h (0.14, 0.19 and 0.08 folds, respectively). These results suggest that a decrease of Cyp17a1 was induced prior to luteinization. In contrast, the expression of Cyp17a1 mRNA in TC was induced by addition of LH and remained high at 48 h in vitro. Thus, the expression of Cyp17a1 mRNA is differently regulated by LH in vivo and in vitro. The LH surge acts on ovulatory follicles to terminate the gene expression associated with folliculogenesis and rapidly induces genes involved in ovulation. In fact, several factors from granulosa cells (GC) and oocytes such as inhibin, activin and BMPs can regulate Cyp17a1 expression and androgen synthesis in the ovary. Dysregulation of  androgen synthesis in TC may be due to the loss of cell-to-cell communication (GC-TC interaction) in the early stage of luteinization.

 

Nothing to Disclose: HK, TS

22561 3.0000 LBS-017 A Regulation of Cyp17a1 expression in the Theca Cell of Mice in Vivo and in Vitro. 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM LBS 015-023 6282 1:00:00 PM Late-breaking Reproductive Endocrinology III Poster


Karin Jezebel Terauchi* and Tomomi Sato
Yokohama City University, Yokohama, Japan

 

In mice, an ovarian follicle usually consists of a single oocyte surrounded by multiple layers of somatic cells. Neonatal exposure to synthetic estrogen, diethylstilbestrol (DES), induces the polyovular follicle (PF) which has more than two oocytes in a follicle. DES disrupts cyst breakdown and results in PFs via estrogen receptor beta (ER beta), however, the mechanism of DES action has not been clearly demonstrated yet.

   Notch signaling pathway is known to play important roles in cell fate decision, including folliculogenesis of the ovary. Disruption of notch signaling induces PFs in the mouse ovary. To investigate the involvement of notch signaling pathway in the PF induction by DES, the effects of DES on notch signaling pathway were examined using the organ-culture system. Neonatal C57BL mouse ovaries were dissected on the day of birth (day 0) and organ-cultured on the collagen gels with or without 1 µg DES or 20 µM Notch signaling inhibitor (DAPT) for 5 days. To examine the PF induction, the organ-cultured ovaries were grafted under the kidney capsule of adult host mice for 20 days. For gene expression analysis, total RNA was isolated from organ-cultured ovaries with or without 1 µg DES or 20 µM DAPT for 5 days and real-time RT-PCR was performed.

   At 5 day of organ-culture, the number of oocytes was significantly increased in DES-treated ovary compared with that in control ovary. In contrast, the number of oocytes in DAPT-treated ovary was not altered, and degenerating oocytes were significantly increased. At day 20 post-grafting, the number of follicles in organ-cultured ovary with DES was similar to that in control ovary. The incidence of PFs was significantly increased by DES (14.13±1.555 vs. 8.00±0.950 %; P=0.003; n=12 per group), and PFs which had more than three oocytes in a follicle were frequently observed. Although addition of 20 µM DAPT suppressed the expression of Hey2, being target gene of Notch signaling, it did not alter the PF incidence at day 20 post-grafting (5.66±0.741 vs. 7.02±1.330 %;P=0.380; n=14 per group). DES stimulated Hey2 expression, however, the expression of Notch-related genes was not altered by DES, suggesting that DES and Notch signaling regulates Hey2 expression independently. Thus, PFs induced by DES are not mediated through Notch signaling. DES and Notch signaling pathway may affect independently on folliculogenesis in the neonatal mouse ovary.

In the various mouse tissues, Hey2 is regulated by several other factors including Hedgehog signaling pathway. In fact, the expression of Hedgehog signaling related genes is found in the neonatal mouse ovary. At day 20 post-grafting, the incidence of PFs in the organ-cultured ovary with cyclopamine, an inhibitor of Hedgehog signaling, was similar to that in DES-treated ovary. Taken together, Hey2 and Hedgehog signaling may be involved with the induction of PFs by DES in the neonatal mouse ovary.

 

Nothing to Disclose: KJT, TS

22562 4.0000 LBS-018 A Induction of Polyovular Follicles By Diethylstilbestrol and Notch Signaling Pathway in the Ovary of Neonatal Mouse 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM LBS 015-023 6282 1:00:00 PM Late-breaking Reproductive Endocrinology III Poster


Maeve C Durkan*1 and Bernard Kennedy2
1Galway University Hospital Group, Galway, Ireland, 2NUIGalway, Ireland

 

This retrospective review of all adult women referred  to a dedicated University clinic for presumed PCOS ( Polycystic Ovarian Syndrome) aims to determine (1) the  true  PCOS prevalence  and (2) to evaluate baseline demographics by diagnostic criteria and their relationship to metabolic & Cardiovascular risk parameters. All charts were reviewed. The diagnosis of PCOS rests on excluding another endocrinopathy, and fulfilling any two of the three criteria as per the Rotterdam statement i.e. oligomenorrhoea, hyperandrogenism and/or polycystic ovaries. We reviewed coexistent hypertension, dyslipidemia, dysglycaemia, metabolic syndrome (MetS) & NAFLD in the proven PCOS cohort. The cohort was also divided  into 3 groups based on their  inclusion criteria: Group 1( oligomenorrhoea & hyperandrogenism), Group 2 (Oligomenorrhea & polycystic ovaries ), Group 3( hyperandrogenism and polycystic ovaries) & these factors  assessed per category. 250 women were referred with a presumed diagnosis of  PCOS. 134 (54%) had confirmed PCOS. The other 116 (46%) included  ectopic Cushings, prolactinoma, nonclassical CAH, PIH, POF ,Hypothalamic & obesity driven oligomenorrhoea. The PCOS cohort had a mean systolic BP 124.78 (Sd 15.8) & a mean diastolic BP 75.46 (Sd 9.4) . Mean age was 27.74 years (Sd 6.7 years) . Mean BMI was 31 (Sd 8.34) . 30.4% of the PCOS group were normal weight or underweight (BMI< 24.9) .  71.6%  had a BMI > 24.9 (21.6% overweight & 48% obese) . Metabolic datasets were incomplete but 2.5% had pre-diagnosed DM2 and 1 patient was diagnosed at presentation. 9/54 patients evaluated had ↑ ALT/GGT.  120 patients met Group 1 criteria, 6 met Group 2 criteria ,4 met Group 3  criteria and 14  patients only met all three. 124/134 PCOS women had hyperandrogenism either biochemically alone (8) , phenotypically alone (4) but most (113) having both . Hypertension was more prevalent in Group 1  (20/120) vs Group 2  (0/6) vs Group 3 (0/4). The BMI range was higher in Group 1 (31.42+8.28) & Group 3 (33.89+14.77) vs Group 2 (25.52 +5.59) raising a question of a relationship to hyperandrogenism. Equally Group 1 were more likely to have ↑ Tg levels ( 18/120 vs 1/6 vs 0/4) , ↓ HDL ( 30/120 vs 1/6 vs 1/6) & MetS ( 10/120 vs 1/6 vs 0/6). 38 women having a BMI of <25 had no hypertension or MetS . Of 60 women with a BMI > 35 , 13 had hypertension & 11 had MetS.This is the first review of an Irish cohort .It is striking that 30% of proven PCOS patients have a normal BMI undermining the assumption of obesity as a prerequisite phenotype . 90% were diagnosed with oligomenorrhoea & hyperandrogenism alone . In keeping with the international literature, this cohort has greatest metabolic risk mandating  focused risk assessment & intervention . Our data is weakened by sporadic metabolic testing but nonetheless supports new guidelines recommending this .Finally, our results reiterate the principle of PCOS as a diagnosis of exclusion with almost 50% having a different underlying diagnosis.

 

Disclosure: MCD: Study Investigator, Amgen, Advisory Group Member, Astra Zeneca, Speaker, Merck & Co., Advisory Group Member, Sanofi, Other activities, please specify:, Novo Nordisk. Nothing to Disclose: BK

22394 5.0000 LBS-019 A The PCOS Demographic in a Dedicated University Clinic 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM LBS 015-023 6282 1:00:00 PM Late-breaking Reproductive Endocrinology III Poster


Martin Auster*1, Swaytha Yalamanchi2 and Adrian Sandra Dobs3
1Johns Hopkins University, School of Medicine, 2John Hopkins University School of Medicine, Baltimore, MD, 3Johns Hopkins School of Medicine

 

Introduction: Hyperandrogenism in older women can be difficult to diagnose and to detect its source.  We present two women with the initials IC and GW, who were evaluated for two to three years duration of hirsuitsm with increased hair growth over their breasts and abdomen, lowering of the voice, increased libido, and mild clitoromegaly.  The baseline testosterone in patient IC was 301 ng/dl and in patient GW was 202 ng/dl (normal<45 ng/dl). In both situations, no abnormalities of the adnexa were palpated or detected on Computed Tomography (CT) examination.  Without a clear source of the androgens, adrenal and ovarian vein sampling were performed in collaboration with Interventional Radiology to detect the specific location of the excess secretion.  

Methods: CT of the abdomen and pelvis with intravenous contrast using an adrenal protocol demonstrated enlargement of the left adrenal gland with a small 6 mm enhancing nodule in patient IC and an 8 mm adrenal nodule in patient GW.  No abnormalities were detected in the adnexa on CT.  In patient IC, an endovaginal ultrasound exam reviewed a sold mass in the right ovary measured 2.3 X 1.5 x 1.6 cm with increased intra-tumoral blood flow with the mass.  In patient GW, the endovaginal ultrasound was negative.

Results:  Since it was unclear whether the androgen source was from the ovarian or adrenal mass, adrenal and ovarian vein sampling were performed by Interventional Radiology. Figure 1 and 2 illustrate the angiographic finding.  In patient IC, the testosterone levels from the adrenal veins and left ovarian vein were between 111 and 441 ng/dl.  There were two samples >1600 ng/dl in the right ovarian vein. Pathologic examination of the ovary were consistent with a steroid cell tumor with positive immunostains for inhibin, calretinin, and CD56. Her post-operative total testosterone was 8 ng/dl. In patient GW, the right ovarian vein total testosterone was 925 ng/dl and the left ovarian vein and the adrenal veins were all in the low 200s. Pathology revealed histologic normal ovaries with a benign paraovarian cyst of 0.7 cm.  Post-operative total testosterone levels fell to 24 ng/dl.  

Conclusions: Locating the source of hyperandrogenism in post-menopausal women can be challenging.  We present two women whose initial cross-sectional imaging for an androgen source was inconclusive. We eventually detected an ovarian etiology after an experienced interventional radiologist used minimally invasive techniques.  Thus, adrenal and ovarian vein sampling provided an important diagnostic tool in locating the source of hyperandrogenism in two older women.

 

Nothing to Disclose: MA, SY, ASD

22859 6.0000 LBS-020 A Ovarian and Adrenal Vein Sampling to Detect the Source of Hyperandrogenism in Two Post-Menopausal Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM LBS 015-023 6282 1:00:00 PM Late-breaking Reproductive Endocrinology III Poster


Yuki Shimizu* and Tomomi Sato
Yokohama City University, Yokohama, Japan

 

Androgens are synthesized by STAR, CYP11, CYP17 and HSD3B in the theca cells of the ovary under the influence of luteinizing hormone (LH) secreted from the pituitary gland. Other factors are also involved with androgen synthesis such as Vitamin A, which is essential for development, vision, and reproduction. Vitamin A deficiency decreases activity of CYP11A1 in the rat ovary. Retinol and retinoic acid (RA), a metabolite of retinol, increase androgen synthesis and the expression of the steroidogenic enzymes in the theca cells from polycystic ovary syndrome (PCOS) women in vitro. Furthermore, granurosa and luteal cells of rats treated with PMSG/hCG are capable of RA synthesis. These results suggest that RA signaling may be involved with steroidogenesis in the ovary.

In this study, to investigate whether RA signaling was activated in the ovary of adult mice, the expression of genes related to RA synthesis and degeneration was examined by real-time RT-PCR. Three-month-old ICR mice were checked estrus cycles by vaginal smear, and ovaries were collected at the estrus and diestrus. The expression of retinol dehydrogenase (Rdh) 1, 10 and alcohol dehydrogenase (Adh) 1, retinal dehydrogenase (Raldh) 1, 2 and 3, RA receptors (Rars) and retinoid X receptors (Rxrs), and Cyp26a1 and b1, RA degenerating enzymes, was found in the mouse ovary. These genes were not altered in the ovary during estrus cycles. Furthermore, RDH10 and RALDH2 were mainly located in the interstitial and theca cells. The expression of cellular retinoic acid binding proteins (Crabps), which deliver RA to nucleic RARs, was also found in the ovary, suggesting that RA may be synthesized and activated in the mouse ovary, and it was not affected by estrous cycles.

To investigate whether RA signaling was activated, the transgenic mice in which LacZ reporter gene was inserted into the downstream of RARE (RARE- LacZ mice) were used and RA signaling was visualized in vivo by X-gal staining. Positive staining was not observed in the ovary, however, LacZ mRNA was slightly increased compared with that in the wild-type (WT) mouse ovary (5.4 folds relative to WT; n=4 per group). RA degenerating enzymes, Cyp26s, and Crabp1, substrate of CYP26s, were found in the ovary, therefore, it was possible that RA was degenerated and its signaling was weakened. Thus, RA may be synthesized in the theca and interstitial cells of the mouse ovary, and RA signaling is probably weakly activated. The synthesis and degeneration of RA may be regulated in the ovary of intact mice.

 

Nothing to Disclose: YS, TS

22670 7.0000 LBS-021 A Synthesis of Retinoic Acid and Its Signaling in the Mouse Ovary 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM LBS 015-023 6282 1:00:00 PM Late-breaking Reproductive Endocrinology III Poster


Misung Jo*1, Birendra Mishra2 and Jiyeon Park2
1Univ of KY Chandler Med Ctr, Lexington, KY, 2University of Kentucky, Lexington, KY

 

Progesterone (P4) acting through its nuclear receptor PGR plays an essential role in ovulation by mediating the expression of genes involved in ovulation and/or luteal formation. To identify ovulatory specific PGR-regulated genes, a preliminary microarray analysis was performed using rat granulosa cells treated with hCG ± RU486 (PGR antagonist). The transcript most highly down-regulated by RU486 was an EST gene that matches with predicted sequence for Xlr5c-like mRNA. Since nothing is known about Xlr5c-like, we first characterized the expression of Xlr5c-like in the rat ovary. The expression of Xlr5c-like is transiently up-regulated in granulosa cells of periovulatory follicles after hCG stimulation in PMSG-primed rat ovaries. The transient induction of Xlr5c-like expression was mimicked by hCG treatment in cultured granulosa cells from preovulatory ovaries. We further demonstrated that the LH-activated PKA, MEK, PI3K, and p38 signaling is involved in Xlr5c-like expression.  The increase in Xlr5c-like transcription was abolished by RU486.  The inhibitory effect of RU486 was reversed by MPA (synthetic progestin), but not by Dexamethasone (synthetic glucocorticoid).  Furthermore, mutation of SP1/SP3 and PGR response element sites in the promoter region of Xlr5c-like decreased Xlr5c-like reporter activity. RU486 treatment also inhibited Xlr5c-like reporter activity. ChIP assay verified the binding of PGR and SP3 to the Xlr5c-like promoter in periovulatory granulosa cells. Functionally, siRNA-mediated Xlr5c-like knockdown in granulosa cell cultures resulted in reduced levels of mRNA for Snap25, Cxcr4, and Adamts1. Recombinant Xlr5c-like protein expressed using an adenoviral approach was localized dominantly to the nucleus and lesser extent to the cytoplasm of rat granulosa cells. In conclusion, this is the first report showing the spatiotemporally regulated expression of Xlr5c-like by hCG in rat periovulatory ovaries.  P4/PGR mediates the LH-induced increase in Xlr5c-like expression. In turn, Xlr5c-like is involved in regulating the expression of specific ovulatory genes such as Snap25, Cxcr4, and Adamts1, possibly acting in the nucleus of periovulatory granulosa cells.

 

Nothing to Disclose: MJ, BM, JP

22861 8.0000 LBS-022 A X-Linked Lymphocyte Regulated Gene 5c-like (Xlr5c-like) Is a Novel Target of Progesterone Action in Granulosa Cells from Periovulatory Rats 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM LBS 015-023 6282 1:00:00 PM Late-breaking Reproductive Endocrinology III Poster


Ji Yeon Park*1, Linah Al-Alem1, Katherine L. Rosewell1, Mats Brannstrom2, James W. Akin3, Thomas E. Curry Jr1 and Misung Jo1
1University of Kentucky, Lexington, KY, 2University of Gothenburg, Sweden, 3Bluegrass Fertility Center, Lexington, KY

 

Ovulation is a complex process requiring the coordinate action of various factors induced by the LH surge in preovulatory follicles. This process includes prostaglandin secretion, chemokine and cytokine production, and leukocyte infiltration.  A chemokine CXC motif receptor 4 (CXCR4) is known to exert potent chemotactic activity for immune cells by binding to its ligand, stromal cell-derived factor-1 (SDF-1). Previous studies have documented the increase in Cxcr4 expression in periovulatory ovaries of mouse and horse, but little is known about the expression and regulation of CXCR4 in the human ovary. In the present study, we hypothesized that CXCR4 expression is induced by the LH surge in the human periovulatory follicles and plays a role in the ovulatory process. To characterize the expression of CXCR4 in the human ovary, patients undergoing laparoscopic tubal sterilization were recruited and their follicular growth was monitored by ultrasonography.  Patients with normal cycles were placed into 4 groups (preovulatory, early ovulatory, late ovulatory, and post ovulatory). The preovulatory stage was defined as an ovary containing a growing dominant follicle (14-18 mm) prior to the LH surge. The early, late, and post-ovulatory stages were defined at 12-18h, 18-34h, and 44-70h after rhCG administration, respectively. Granulosa and theca cells were isolated from dominant follicles surgically retrieved. Real-time PCR revealed that levels of CXCR4 mRNA were increased in granulosa cells obtained at the late ovulatory stage. Theca levels of CXCR4 mRNA were not changed prior to ovulation, but the level was decreased in post ovulatory follicles. Similarly, strong immunopositive staining for CXCR4 protein was localized to granulosa and theca cells of late ovulatory and post ovulatory follicles. To determine the regulation of CXCR4 expression, human granulosa-lutein cells (hGLCs) were obtained from women undergoing in vitro fertilization. The cells were cultured in media alone for 7 d prior to hCG. The level of CXCR4 mRNA was transiently increased by hCG, peaking at 12h. hCG also increased the level of CXCR4 protein. Next, we determined whether progesterone (P4) regulates CXCR4 expression by treating hGLCs with RU486 (PGR antagonist) with or without hCG. The hCG-induced CXCR4 mRNA expression was inhibited by RU486. Lastly, to investigate the potential function of CXCR4, hGLCs were treated with SDF-1 and AMD3100 (CXCR4 specific antagonist). hCG stimulated P4 production, but the stimulatory effect of hCG was inhibited by SDF-1, but not by ADM3100. In summary, the present study demonstrated for the first time that the LH surge increases the expression of CXCR4 in human periovulatory follicles and this increase depends on P4/PGR. The activation of CXCR4 by SDF1 may play a role in modulating P4 production in human granulosa cells.

 

Nothing to Disclose: JYP, LA, KLR, MB, JWA, TEC, MJ

22875 9.0000 LBS-023 A The Expression and Regulation of Chemokine CXC Motif Receptor 4 (CXCR4) in the Human Ovary during the Periovulatory Period 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Saturday, March 7th 3:00:00 PM LBS 015-023 6282 1:00:00 PM Late-breaking Reproductive Endocrinology III Poster


Casper P. Hagen*1, Kaspar Sørensen1, Mikkel Grunnet Mieritz1, Trine Hom Johannsen1 and Anders Juul2
1University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Department of Growth and Reproduction, Denmark, Copenhagen, Denmark, 2University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark

 

Context: Puberty is initiated by withdrawal of hypothalamic inhibition. Genetic studies of familiar central precocious puberty have suggested makorin RING-finger protein 3 (MKRN3) to be a major inhibitor of GnRH secretion during childhood. Serum levels of MKRN3 have never been reported in animal models or humans.

Objective: To evaluate if serum levels of MKRN3 declined prior to pubertal onset in healthy girls.

Design: 1) Population-based longitudinal study of healthy Danish girls; 2) Cohort study of early maturing girls.

Setting: 1) General community; 2) Tertiary referral centre for pediatric endocrinology.

Patients or Other Participants: Healthy girls (n=38) aged 9.3 (5.9 – 11.3) years at baseline followed for 6.0 (2.7 – 7.6) years with blood sampling every 6 months. Early maturing girls (n=13) with breast development < 8.3 years of age.

Main outcome Measures: Serum levels of MKRN3 were measured in 354 samples (median 9, range 2 – 14 per girl).

Results: MKRN3 concentrations declined preceding pubertal onset; geometric mean (95% CI) 3 years prior to pubertal onset vs. last visit before pubertal onset: 304 (264 – 350) vs. 257 (243 – 273) pg/mL, corresponding to a reduction of MKRN3 of 15% (1 – 27%) (p = 0.033). In prepubertal girls (Tanner stage B1), circulating MKRN3 correlated negatively with gonadotropin levels; FSH: r = -0.262 (p = 0.015) and LH: r = -0.226 (p = 0.037). After adjustment, MKRN3 levels were lower in early maturing girls compared to age-matched prepubertal girls: 171 (< 25 – 333) vs. 262 (94 – 624) pg/mL, p = 0.051.

Conclusions: Declining levels of circulating MKRN3 preceded pubertal onset. The negative correlation between MKRN3 and gonadotropins in prepubertal girls further support MKRN3 as a major regulator of HPG activity during childhood. In a subgroup of patients with central precocious puberty, MKRN3 was low or undetectable. This may imply a causal relationship.

 

Nothing to Disclose: CPH, KS, MGM, THJ, AJ

22565 1.0000 LBS-024 A Circulating MKRN3 Levels Decline Prior to Pubertal Onset and through Puberty: A Longitudinal Study of Healthy Girls 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM LBS 024-030 6285 1:00:00 PM Late-breaking Pediatric Endocrinology III Poster


Marina E Goldis*, Molly Oliver Regelmann, Elizabeth Burtman, Lindsey Waldman, Elizabeth Wallach and Robert Rapaport
Pediatric Endocrinology and Diabetes, Icahn School of Medicine at Mount Sinai, New York, NY, New York, NY

 

Background: The apparent increased incidence of congenital hypothyroidism (CH) is likely multifactorial, and in part related to demographic changes, rise in premature births and an increased detection of mild CH (MCH), defined as an elevated TSH <25 uIU/mL and normal thyroxine (T4). There is no consensus about diagnosis, management or long term consequences of MCH. Previous reports have suggested a degree of persistent CH in some diagnosed with MCH. We recommend treatment of MCH in infancy and re-evaluation after the age of 3 years. 

Aim: Report the persistence of MCH after the age of 3 years

Methods: Retrospective chart review of patients with CH evaluated at Mount Sinai Medical Center from 2008-2014. Patients included were treated with levothyroxine (LT4) for persistently elevated TSH <25 uIU/mL and normal free T4 (fT4). Children with syndromic features were excluded.  Prematurity was defined as gestational age <37 weeks. Persistent MCH was defined as abnormal thyroid function tests and/or clinical symptoms of hypothyroidism after LT4 withdrawal for >30 days.

Results: Eight (1 premature, 4 male) of the 24 patients (11 male) re-evaluated at >3 years had persistently elevated TSH values when LT4 was withdrawn and resumed LT4. Prior to initiation of treatment in infancy with LT4, thyroid functions were similar in both groups; persistent MCH had a mean TSH of 9.07±3.3 uIU/mL and fT4 of 1.09±0.1 ng/dL and transient MCH mean TSH of 10.32±5.7 uIU/mL and fT4 of 1.24±0.3 ng/dL. At reevaluation, the mean peak TSH for persistent MCH was 12.04±3.3 uIU/mL and fT4 0.92±0.2 ng/dL (transient MCH TSH 5.35±2.4 uIU/mL, fT4 0.95±0.1 ng/dl). Mean TSH prior to restarting LT4 for persistent MCH was 10.92±3.7 uIU/mL, fT4 0.88±0.2 ng/dL and the mean lowest TSH for transient MCH was 4.34±0.9 uIU/mL, fT4 0.96±0.1 ng/dL. 

Of the 8 with persistent MCH, 6 had an imaging study performed in infancy, 4 123I scan and 2 ultrasounds (US). 123I scans were abnormal in 2 out of 3 patients with completed scans, 1 patient had an incomplete scan with normal 4 hr uptake; 1 US was normal and the other showed a “small” gland.  Of the 16 patients with transient MCH, 10 had imaging in infancy; 6 out of 7 123I scans were abnormal, 1 out of 3 of the 99mTc scans was abnormal; all 4 ultrasounds reported “small” glands.

Conclusions:  In the population presented, one third of the patients with MCH had evidence of persistent thyroid dysfunction after 3 years.  Previous reports of genetic abnormalities in patients with MCH and transient CH, coupled with our results, suggest MCH should be recognized as part of the spectrum of CH and likely deserve treatment with LT4 even if transiently.  The value of diagnostic imaging in the MCH population remains to be determined.

 

Nothing to Disclose: MEG, MOR, EB, LW, EW, RR

22793 2.0000 LBS-025 A Mild Congenital Hypothyroidism: Persistence Beyond 3 Years 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM LBS 024-030 6285 1:00:00 PM Late-breaking Pediatric Endocrinology III Poster


Tero Varimo*1, Matti Hero1, Eeva-Maria Laitinen2, Johanna Tommiska2, Anders Juul3 and Taneli Raivio4
1Helsinki University Hospital (HUH), Helsinki, Finland, 2University of Helsinki, Helsinki, Finland, 3University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark, 4Helsinki University Central Hospital (HUCH), Helsinki, Finland

 

BACKGROUND

Congenital hypogonadotropic hypogonadism (CHH), a rare genetic disorder characterized by low gonadotropin and sex steroid levels, provides a model to study the impact of early sex steroid deficiency on childhood growth. Herein, we characterized childhood growth in patients with CHH with special emphasis on growth during the first few months of life, i.e.during the postnatal testosterone (T) surge also known as the minipuberty of infancy.

PATIENTS AND METHODS

Growth charts of 38 men with CHH (28 from Finland and 10 from Denmark) were evaluated; the most recent national growth reference data (1,2) were used for comparisons. Fourteen men (37 %) had molecular genetic diagnosis of CHH (FGFR1 mutations in 4, KAL1 mutations in 7, GNRHR in 2, CDH7 in 1, and PROK2 in 1 patient). Fifteen (39 %) patients had representative height measurements during the 1st year of life; 8 of them had micropenis and/or cryptorchidism.  

RESULTS

In CHH patients, the height standard deviation score (SDS) decreased significantly (mean D= -0.6 SDS, P<0.01 at 3 months of age, and D= -0.8 SDS, P<0.02 at 6 mo) during the first few months of life. Subjects with early signs of profound GnRH deficiency tended to show greater height SDS deflection than the other CHH patients (D at 3mo, -0.9 SDS vs. -0.3, P=0.09; D at 6mo, -1.1 SDS vs. -0.4, P=0.1, respectively). In mid-childhood, CHH patients were slightly shorter than the general population (mean height SDS= -0.8, P<0.01). Height SDS reached its nadir (mean -1.8 SDS) at an average of 15.8 years of age; however, the mean final height in all patients was normal. No apparent correlations between the genotype and childhood growth patterns emerged.

CONCLUSIONS
Growth in length during the minipuberty of infancy is moderately protracted in males with CHH, a finding probably reflecting early T deficiency supporting a role for T as one of the growth modulators in early childhood.

 

Nothing to Disclose: TV, MH, EML, JT, AJ, TR

22704 3.0000 LBS-026 A Childhood Growth of Boys with Congenital Hypogonadotropic Hypogonadism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM LBS 024-030 6285 1:00:00 PM Late-breaking Pediatric Endocrinology III Poster


Christopher E Gibson*1, Kara E Boodhansingh1, Arupa E Ganguly2 and Charles A Stanley3
1Children's Hospital of Philadelphia, Philadelphia, PA, 2University of Pennsylvania, School of Medicine, Philadelphia, PA, 3The Children's Hospital of Philadelphia, Philadelphia, PA

 

Introduction: The incidence of congenital hyperinsulinism (HI) appears to be increased in girls with Turner’s syndrome (TS).  There have been a small number of congenital hyperinsulinism (HI) cases reported in girls with Turner’s syndrome (TS) to date. KDM6A , a transcription factor on the X chromosome (Xp11.2) which modulates expression of a second transcription factor, MLL2 on chromosome 12 (12q13.12), is a possible connection between HI and the X chromosome since mutations in either gene are associated with Kabuki syndrome, a rare dysmorphic disorder with an increased frequency of HI. Furthermore, there have been reports in the literature describing physical features similar to those seen in Kabuki Syndrome in TS patients. To examine the association between TS and HI, we examined 7 TS cases with HI for evidence of a possible deletion or mutation of the KDM6A locus.

Methods: We reviewed all cases of girls with HI and TS seen at The Children’s Hospital of Philadelphia during the past 40 years.

Results: Seven TS girls who also had HI were identified. Six presented with hypoglycemia during the first 7 months of life and one at 18 months. Three were responsive to treatment with diazoxide and 3 were treated with subtotal pancreatic resection. All 7 cases were negative for mutations in the 4 genes most commonly associated with congenital HI (ABCC8, KCNJ11, GLUD1, and GCK). Karyotyping revealed monosomy X in 3 patients and mosaicism in 4 patients; 2 of the patients with mosaicisms contained ring X chromosomes and the other 2 had marker X chromosomes confirmed to be ring X chromosomes in addition to cells with 45,X0. All of the 7 cases retained the X-inactivation region (XIST). Three of the 4 patients with ring chromosomes lost their KDM6A gene, but retained their X-inactivation sites (XIST, Xq13.2); the fourth retained both the KDM6A and XIST genes. Direct sequencing of her KDM6A gene failed to identify a point mutation. As karyotyping of the blood showed that 15-20% of cells had monosomy X without ring chromosome, it is possible that this population of cells is responsible for the HI in this case.

Conclusion: These results show that all 7 cases described here had haploinsufficiency for KDM6A, including the mosaic case which retained KDM6A on the ring chromosome as a portion of her cells were 45,X0.  Therefore, KDM6A is a plausible explanation for the increased incidence of HI seen our TS population and hyperinsulinism should be considered in children with TS.

 

Nothing to Disclose: CEG, KEB, AEG, CAS

22797 4.0000 LBS-027 A Congenital Hyperinsulinism in Turner's Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM LBS 024-030 6285 1:00:00 PM Late-breaking Pediatric Endocrinology III Poster


Iee Ho Choi*1, Min Sun Kim2, Sun Young Kim1 and Dae-Yeol Lee2
1Department of Pediatrics, Chonbuk National University Medical School, Jeonju 561-712, Korea, 2Department of Pediatrics, Chonbuk National University Medical School, Jeonju 561-712, Korea, Jeonju, Korea, Republic of (South)

 

Background : The number of patients with central precocious puberty is increasing in Korea. But the diagnosing and follow-up screening tests after treatment puts psychological, financial, and time burdens on patients. This study aimed to investigate and simplify the gonadotropin-releasing hormone (GnRH) stimulation test for assessing pubertal activation and suppression.

Methods : We identified 72 girls diagnosed with central precocious puberty who were treated with a GnRH analogue (GnRHa). They were evaluated using the GnRH stimulation test. These patients underwent a physical examination comprising body weight and height, body mass index, and Tanner stage and a bone age evaluation according to the Greulich–Pyle method.

Results : Before GnRHa treatment, the mean luteinizing hormone (LH) level was higher at the 30-minute test time point than at baseline or the 15, 60, 90, and 120-minute points (P < 0.001). After GnRHa treatment, the LH levels were suppressed in 62 patients (86.1%) and inadequately suppressed in 10 (13.9%). The LH level was higher at the 30-minute test time point than those at baseline or the 45 and 60-minute level (P < 0.001). The area under the curve in a post-GnRHa treatment was greatest at 30 minutes.

Conclusion : The simplified GnRH test is adequate for evaluating pubertal activation (30 and/or 45-minute time points of the GnRH test) and suppression (the 30-minute time point).

 

Nothing to Disclose: IHC, MSK, SYK, DYL

22813 5.0000 LBS-028 A A Gonadotropin-Releasing Hormone Stimulation Test before and after Gonadotropin-Releasing Hormone Analogue Treatment for Central Precocious Puberty: Has the Gonadotropin-Releasing Hormone Test Been Adequately Simplified? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM LBS 024-030 6285 1:00:00 PM Late-breaking Pediatric Endocrinology III Poster


Dimitrios T Papadimitriou*1, Emmanouil Manolakos2, Georgios Zoupanos3, Christina Bothou4, Ioannis Papoulidis2, Filippos Skarmoutsos3, Chisanthi Bakoula3, Anastasios Papadimitriou5 and Fumihiko Urano6
1Athens Medical Center, Athens, Greece, 2Access to Genome, ATHENS, Greece, 3Athens Medical Center, Marousi, Greece, 4Medical School, Athens University, Greece, 5Attikon University Hospital, Athens, Greece, 6Washington University School of Medicine, St. Louis, MO

 

Introduction: Wolfram Syndrome (WS) is a rare autosomal recessive genetic disorder characterized by juvenile-onset diabetes mellitus (DM), diabetes insipidus (DI), optic nerve atrophy, deafness, and neurodegeneration (1). Some patients present hypogonadism of various severity and urinary tract problems, such as neurogenic bladder, as well as neurological and psychiatric disorders later in life. Two causative genes for this genetic disorder have been identified and named WFS1 and CISD2 (WFS2). WFS1 gene, mapped to chromosome 4p, encodes transmembrane protein localized to the endoplasmic reticulum (ER). It has been shown that mutations in the WFS1 gene lead to dysregulated ER calcium homeostasis and ER stress, leading to apoptosis (2). Acute correction of DI induces atrial natriuretic peptide (ANP) over-secretion and renal salt wasting (RSW), instituting a vicious cycle with severe and persistent hyponatremia which is resistant to standard treatment. This is due to the secondary mineralocorticoid deficiency caused by the suppression of zona glomerulosa steroidogenesis by ANP. Fludrocortisone treatment has been reported to restore Na+ levels, decrease excessive urine output, reverse severe dehydration and effectively resolve the RSW syndrome (3). Clinical case: A 10-year-old female with Type 1 DM since the age of 6 years was admitted to our hospital with a palpable abdominal mass. Neurogenic bladder (4 L) and hydronephrosis were found. After catheterization, a high urine output of 8 L in 12 hours led to the diagnosis of DI. Desmopressin acetate 300 mcg thrice daily p.o. was needed to achieve maximal diuresis of 2 ml/Kg/h. Subsequently she developed excessive natriuresis, with elevated ANP, low renin and aldosterone, which were coped with fludrocortisone 100 mcg twice daily and NaCl 3 g/day per os successfully. NaCl was stopped within a month and fludrocortisone was gradually withdrawn within 4 months. Further clinical investigation revealed a visual acuity of 4/10 bilaterally and sensorineural loss of high frequencies. The parents reported polyuria and polydipsia since the age of 4, but not further investigated. Her parents and 15-year-old brother were healthy. Genetic analysis confirmed the diagnosis of WS showing a novel homozygous c.1348_1350delinsTAG (p.His450*) variant in the WFS1 gene. Since this mutation is predicted to produce truncated WFS1 protein, it is most likely a disease causing mutation. The mother was a carrier but not the father, which led us to check and confirm the occurrence of maternal uniparental disomy (UPD) of chromosome 4. Conclusion: A novel disease causing mutation in the WFS1 gene due to maternal UPD 4 is reported. This case could be a unique disease model for DI complicated by RSW. We suggest fludrocortisone as a first line treatment in this complex disorder.

 

Nothing to Disclose: DTP, EM, GZ, CB, IP, FS, CB, AP, FU

22954 6.0000 LBS-029 A Maternal Uniparental Disomy of Chromosome 4 and Homozygous Novel Mutation in the WFS1 Gene in a Pediatric Patient with Wolfram Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Saturday, March 7th 3:00:00 PM LBS 024-030 6285 1:00:00 PM Late-breaking Pediatric Endocrinology III Poster


Andrew M. Hinson*1, Samuel F. Hohmann2, Donald L. Bodenner1 and Brendan C. Stack Jr.1
1UAMS, Little Rock, AR, 2Rush University, Chicago, IL

 

Introduction

Thyroid surgery is increasingly being performed by high-volume centers demonstrating higher cure rates, fewer complications, lower mortality, and shorter hospital stays. The University HealthSystem Consortium (UHC) database was used to generate a descriptive report of geographic trends in distance traveled for care and thyroidectomy volume across the US.

Methods

The UHC represents 90% of non-profit academic medical centers and more than 300 of their affiliated hospitals. UHC data from 2010 to 2013 were compiled. 67,374 patients undergoing thyroid surgery in the US were identified. The patient’s state of residence versus state where surgery was performed, age, sex, race, insurance, comorbidities, complications, discharge status, length of stay, and location (state specific) of hospital admission were collected.

Results

Ten percent of Americans undergoing thyroidectomy traveled to another state for surgery. Less than 3% of patients traveled to another region of the US (Northeast, Midwest, South, West). There was no statistically significant association (P=0.36) between a patient’s regional residence and their likelihood of leaving their home state (or region) for care. Massachusetts, Pennsylvania and Florida performed nearly a quarter of all out-of-state thyroidectomy cases. In 10 states across the US, out-of-state cases increased the state’s thyroidectomy volume by 10% or more.

Discussion

This dataset represents the largest series of geography-specific thyroidectomy volume in the US. The vast majority of Americans undergoing thyroidectomy choose surgeons in their home state. However, out-of-state thyroidectomy cases comprise a relatively large proportion of case volume in several states. Future research is focused on how consolidation of thyroid surgery into higher-volume centers impacts patient care.

 

Nothing to Disclose: AMH, SFH, DLB, BCS Jr.

22355 1.0000 SAT-184 A Domestic Travel Patterns and Thyroidectomy Volume in the United States 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Saturday, March 7th 3:00:00 PM SAT 184-189 6286 1:00:00 PM Late-breaking Endocrine Healthcare Delivery and Education Poster


Sarar Mohamed*, Hala Omer, Amir Babiker, Hessah Al Otaibi, Shaikh Mohamed Iqbal, Mohamed Elfaki Osman, Ayman Al-Eyadhy, Mohamed Al-Othman, Abdulrahman Al Nemri, Yasser Sami Amer, Lubna Alansary, Khalid Alswat, Fahad Al-Zamil and Nasir Al-Juryyan
King Saud University, Riyadh, Saudi Arabia

 

Background:Clinical practice guideline (CPG) could standardize management, decrease inter–physician variations, and improve patient care and outcome.

Objectives:To determine the impact of implementation of CPG on the length of hospital stay of children and adolescents admitted with Diabetic Ketoacidosis (DKA) at a tertiary hospital in Riyadh, Saudi Arabia.

Methods:This was a case-control retrospective chart review study conducted at King Saud University Medical City, Riyadh, Saudi Arabia (January 2008 to January 2014). All children less than 16 years of age who presented with DKA between January 2011 and January 2014 were recruited and treated using CPG adopted from National Institute for Health and Clinical Excellence (NICE). Patients with DKA who were admitted from January 2008 to December 2010 (before implementation of  the CPG ) were used as a control group.

Results: Sixty-three episodes of DKA in 41 patients were treated using CPG compared to 40 episodes in 33 patients treated before implementation of guidelines (control group).

The baseline characteristics of the two groups are similar regarding age, sex, number of newly diagnosed patients, number of patients with recurrent DKA, severity of DKA and the mean glycosylated hemoglobin level.

The mean length of hospital stay (±SD) was 68.6±53.1 hours after implementation of CPG compared with 107.4±65.6 hours before implementation (P <0.001). The reduction in the hospital stay is equivalent to 1700 bed days per year per 1000 patient admitted with DKA.

Conclusion: Use of CPG for DKA decreased the length of hospital stay in a tertiary hospital.

 

Nothing to Disclose: SM, HO, AB, HA, SMI, MEO, AA, MA, AA, YSA, LA, KA, FA, NA

22409 2.0000 SAT-185 A Substantial Reduction in Length of Hospital Stay of Patients with Diabetic Ketoacidosis after Implementation of Clinical Practice Guidelines at a University Hospital in Saudi Arabia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Saturday, March 7th 3:00:00 PM SAT 184-189 6286 1:00:00 PM Late-breaking Endocrine Healthcare Delivery and Education Poster


Nisarg Shah1 and Jennifer Pennock Holst*2
1Allegheny general hospital, Pittsburgh, PA, 2Allegheny general hospital, McMurray, PA

 

Background: Diabetic retinopathy (DR) is the leading cause of visual disability and blindness in developed countries among people who are less than 50 years old.1 In 2005–2008, of adults with diabetes aged 40 years or older, 4.2 million (28.5%) people had diabetic retinopathy. 2  An estimated economic burden of DR is around $493 million per year. 3 The American Academy of Ophthalmology, American Diabetes Association and National Institute of Health recommend routine, annual dilated eye examination for persons with diabetes. 4-6  Among adults with diagnosed diabetes, nonadherence to the recommended annual eye examinations was 23.5%. 7

Aim: Our project intends to improve adherence to an annual retinal exam in a diabetes specialty center with an on-site screening for diabetic retinopathy.

Methods : This is an observational study in a diabetes specialty center to evaluate the effect of  an on-site screening  for DR.  The on-site screening for diabetic retinopathy was a collaboration between three entities 1) TreVia, a health care company that provides digital DR screenings  2) Highmark, a health insurance company, and 3) Allegheny Health Network, a large health network  We began providing the retinal screening Jan 8, 2014, and we are reporting the first 9 months of results.

On-site retinal screening was offered to patients seen at our diabetes specialty center to those patients with diabetes who had not had a retinal exam within the last year.  The on-site screening was performed by a medical assistant and included vision testing, glaucoma screening, and fundus photos.  An ophthalmologist at our institution evaluated the results within 48 hours, and sent a report to the ordering provider.  The ordering provider notified the patient if further evaluation by an eye professional was necessary.

Results : In the first quarter of 2014 (Jan-March 2014) - there were a total of 783 patient visits, and 117 patients (15%) underwent on-site retinal screening.   In the second quarter (April-June 2014), there were 783 patient visits, and 61 patients (8%) underwent screening.  In the third quarter (July-September 2014),there were 854 patient visits, and 56 patients(6.6%) underwent on screening.  Of the 234 patients who had on-site screening, 21 (9%) had poor quality images, and required evaluation.  76 patients (32%) had findings that required further evaluation.

Conclusion : In the first quarter (Jan –March 2014) when we began offering on-site retinal screenings, about 15% of patients had not seen an eye care professional within the 12 months.  As the year progressed, (in the second and third quarter of 2014) a smaller percentage of patients required the on-site retinal screening, likely because their retinal screening had already been performed within the year.  A large percentage (41%) of our patients who had an on-site retinal screening still required a follow-up visit with an eye care professional.

 

Nothing to Disclose: NS, JPH

22449 3.0000 SAT-186 A A Fast and an Effective Method for Screening Diabetic Retinopathy and Other Ophthalmic Conditions in Diabetes By Using a Non-Mydriatic Camera 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Saturday, March 7th 3:00:00 PM SAT 184-189 6286 1:00:00 PM Late-breaking Endocrine Healthcare Delivery and Education Poster


Meryl Brod*1, Jonas Håkan-Bloch2, Lise Højbjerre2, Suzanne Lessard Alolga1, Alise Nacson1, Michael Højby Rasmussen2 and Lars Nordholm2
1The Brod Group, Mill Valley, CA, 2Novo Nordisk A/S, Søborg, Denmark

 

Background: Children with GHD, in addition to short stature, may experience other physiological symptoms as well as social and emotional problems. However, treatment focus has traditionally been on improving height and these other important disease impacts have been largely ignored. This qualitative study explored the full spectrum of the burden of pediatric GHD and treatment.

Methods: Focus groups and interviews were conducted with 39 children (age 8 -12) with GHD and 34 parents of children (age 4 to 12) with GHD in Germany, UK and the US. Interviews were transcribed, analyzed, and coded thematically, based on adapted grounded theory, to identify overarching themes and sub-concepts. Based on the analysis, expert interviews, and literature review, a conceptual model of burden of disease was developed.

Results: Both children and parents reported consistent physical, social, and emotional symptoms/impacts of disease. For the physical domain, major impacts included strength or endurance (48%), appetite (48%), and energy or activity level (36%). Social impacts included juvenalization (51%), teasing/bullying (33%), and being left out of or holding back from activities (25%). Emotional impacts included lack of self-confidence (45%) and worry or concern (34%). Social and emotional impacts were often linked, with social impacts precipitating emotional distress. Importantly, children who began treatment later experienced more intense emotional and social impacts than those who started treatment at a younger age. For almost all children in the study, treatment was associated with improvements in physical, social and/or emotional impacts. Many participants reported fears about taking shots or anxiety about needles, but those fears generally dissipated after beginning treatment.  Findings did not differ substantively among countries suggesting that the cultural influences are not major. The conceptual model identifies the impacts of disease and treatment as well as factors which may act as modifiers to the severity of burden, such as age of diagnosis and start of treatment or other children in family with GHD.

Conclusions: The overall burden of disease for children with GHD is considerable, and includes social and emotional impacts. Of note is that the physical impact of GHD is not limited to lack of growth, as appetite, energy, and muscle strength are also impacted. Further, as older children experienced more acute social impact and emotional distress than younger children, beginning treatment earlier may alleviate the psychological stress and social impacts associated with GHD. Accurate and reliable assessment of  impacts would help clinicians to better address burden of disease, assess treatment effect, and may improve the quality of doctor-patient communications. A well designed measure of the full range of impacts identified in this study does not currently exist and should be developed. 

 

Disclosure: MB: Consultant, Novo Nordisk. JH: Employee, Novo Nordisk. LH: Employee, Novo Nordisk. SLA: Consultant, Novo Nordisk. AN: Consultant, Novo Nordisk. MHR: Employee, Novo Nordisk. LN: Employee, Novo Nordisk.

22482 4.0000 SAT-187 A Growth Hormone Deficiency (GHD): Burden of Disease and Impact of Treatment in Children and Adolescents in 3 Countries   2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Saturday, March 7th 3:00:00 PM SAT 184-189 6286 1:00:00 PM Late-breaking Endocrine Healthcare Delivery and Education Poster


Anne C Kitchens*, Amanda J Stevens, Amale A Lteif and James P Walsh
Indiana University School of Medicine, Indianapolis, IN

 

Background: Electronic consultations provide specialist recommendations without a face-to-face clinic appointment.  Providers enter consultations and a staff endocrinologist determines whether the question necessitates an in-person appointment or can be managed with an electronic consultation. If the consult is handled electronically, recommendations are based solely on review of the electronic medical record.  The few published studies of electronic consultations have focused on patient and provider satisfaction.  To evaluate the efficacy of care provided by electronic consultations, we retrospectively reviewed the records of patients referred to the endocrinology clinic at a large VA Medical Center. 

Methods: Endocrine consultations over a three year period were reviewed. There were 4576 endocrine consultations, of which 1736 were answered electronically.  Outcomes of 80 consults answered electronically, 40 for thyroid questions and 40 for low testosterone, were compared to 80 consults for these same conditions that were referred for a clinic visit.  The primary outcomes were the frequency with which recommendations were made and followed, and the timeliness of any recommended diagnostic testing or therapeutic intervention.

Results:  There were no significant group differences with regard to age, sex, ethnicity, race, weight, BMI, referring facility, or travel distance to our facility.  Consults referred for a clinic appointment had slightly more comorbid conditions than consults answered electronically (4.2 versus 3.5, p=0.04).  Consults from midlevel providers were more likely to be answered electronically than consults from physicians (26/80 versus 13/80, p=0.03). The median time from consult placement to implementation of specialist recommendations was 6 days in the electronic consultation group versus 34 days in the clinic appointment group (p<0.001).  More patients in the electronic consultation group had a specialist recommendation carried out than in the group referred for a clinic visit, but the difference only reached borderline significance (69/80 versus 59/80, p=0.07).  In these instances, no recommendation was implemented due to inability to contact the patient, missed clinic visits, or other patient noncompliance. There was documentation of referring provider attempts to implement electronic consult recommendations in almost all cases.

Conclusions: Electronic consultations led to timelier implementation of endocrinologist recommendations than traditional in-person clinic visits.  Recommendations were carried out at least as frequently after electronic consultation as after referral for a clinic visit.  In appropriately selected patients, electronic endocrine consults may provide outcomes as effective as face-to-face appointments.

 

Nothing to Disclose: ACK, AJS, AAL, JPW

22657 5.0000 SAT-188 A Outcomes of Electronic Consultations at an Academic VA Medical Center 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Saturday, March 7th 3:00:00 PM SAT 184-189 6286 1:00:00 PM Late-breaking Endocrine Healthcare Delivery and Education Poster


Po-Yin Chang*, Fay S Saechao, Jimmy Lee, Susan M Frayne and Jennifer S. Lee
VA Palo Alto Health Care System, Palo Alto, CA

 

Objectives:  Fractures lead to greater morbidity, disability, mortality, and cost, especially for aging women. The impact of fractures is less known in women veterans (WVs). Our objective was to characterize the prevalence and risk of fractures in WVs within the Veterans Health Administration (VHA). We characterized the relationships between having a fracture diagnosis and age, race/ethnicity, and health services-related factors.

Methods:  Cross-sectional analyses were conducted in 355,352 WVs, aged 18 or older, who used VHA in fiscal year (FY) 2012.  Using national VA databases, a WV was counted as having a fracture diagnosis if she had an inpatient or outpatient ICD-9 code for fracture in VA or through fee-basis care in FY2012. We included the following variables in multivariable logistic regression modeling to estimate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for having a fracture diagnosis: age (18-44 years, 45-64 years and 65+ years), race/ethnicity (non-Hispanic White (NHW), Black, Hispanic, American Indian/Alaska Native (AI/AN), and Asian/Pacific Islander (Asian/PI)), urban/rural residence, number of primary care visits, number of mental health care visits, and service-connected disability.

Results:  In FY2012, most WVs were NHW (56%) or Black (27%) women, with 86% of WVs over age 65 years being NHW. Prevalence of any fracture diagnosis or hip fracture was 2.65% or 0.15%, respectively, in all WVs. Diagnosis of any fracture was most common in NHW (3.4%, 6,551 of 187,875) and AI/AN women (3.2%, 122 of 3,660), regardless of age, and least in Black (1.7%, 1,525 of 90,535) and Asian WVs (1.4%, 54 of 3,882). Age-specific prevalence of any fracture diagnosis was 1.8% (18-44 years), 3.1% (45-64 years), and 4.1% (65+ years).

In multivariable models, Black (aOR = 0.49, CI: 0.46-0.52), Hispanic (aOR = 0.75, CI: 0.66 - 0.82) and Asian/PI (aOR = 0.61, CI: 0.51-0.73) WVs had lower odds of any fracture diagnosis, compared to NHW WVs. Compared to WVs who had no primary care visits in FY2012, WVs with 2-4 visits had a 1.8-fold (CI: 1.64-2.03) greater odds, and those with 5 or more visits had a 3.3-fold (CI: 2.99 – 3.72) greater odds of having any fracture diagnosis. Compared to WVs who had no mental health care visit, WVs with 2-4 visits had aOR of 1.35 (CI: 1.27-1.44), and those with 5+ visits had aOR of 1.55 (CI: 1.46-1.64). Service-connected disability and large urban residence were associated with having any fracture diagnosis (P < 0.05).

Conclusions:  Having a fracture diagnosis was most common in NHW and AI/AN WVs. WVs who had any fracture diagnosis had more primary care visits, especially 5+ visits, and more mental health visits in FY2012, independent of age, race/ethnicity, residence, and service-connected disability.

Impacts: Preventative and management strategies appear to be of particular importance for NHW and AI/AN WVs and might reduce health care utilization needs.

 

Nothing to Disclose: PYC, FSS, JL, SMF, JSL

22760 6.0000 SAT-189 A Prevalence and Risk of Fracture Diagnosis in Women Veteran 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Endocrine Healthcare Delivery and Education Saturday, March 7th 3:00:00 PM SAT 184-189 6286 1:00:00 PM Late-breaking Endocrine Healthcare Delivery and Education Poster


Coralie Eugenie Poulard*, Yixin Hu and Michael R Stallcup
Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA

 

Nuclear receptors regulate transcription of their target genes by recruiting coregulator proteins to the promoter or enhancer regions of their target genes. Many of coregulators function in both activation and repression of transcription, depending on the circumstances. However, the mechanisms that allow the switch between activation and repression are unknown and remain a fundamental question. The lysine methyltransferase G9a is one of the coregulators that can activate or inhibit transcription in different circumstances. Indeed, G9a catalyzes the methylation of H3K9, a well-known repressive mark, but can also act as a coactivator of nuclear receptors. Interestingly, G9a is known to be auto-methylated on lysine 185 (human G9a numbering) and phosphorylated in vitro by the Aurora kinase B on threonine 186 in the N terminal domain of the protein. The purpose of this study is to identify the impact of these two post-translational modifications of G9a on the switch between its coactivator and corepressor function.  In transient reporter gene assays, we demonstrated that mutations (K185R, K185A) of the methylation site significantly decreased the transcriptional activity of GR and ERα, and also diminished the interaction between G9a and HP1γ. Inversely, inhibition of Aurora kinase B increased the interaction between G9a and HP1γ, associated in preliminary results with an increase of the transcriptional activity of GR on the reporter gene. Preliminary data indicate that inhibition of the kinase activity of Aurora kinase B or depletion of the kinase by siRNA increase the expression of GR target genes positively regulated by G9a. But depletion of HP1γ inhibits their expression. These preliminary exciting results indicate that G9a methylation and subsequent recruitment of HP1γ are required for G9a coactivator function while phosphorylation opposes this effect. This competition could be involved in the switch between the coactivator and corepressor functions.

 

Nothing to Disclose: CEP, YH, MRS

22609 1.0000 LBS-048 A Impact of Post-Translational Modifications of G9a on the Switch Between Its Coactivator and Corepressor Function 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Saturday, March 7th 3:00:00 PM LBS 048-050 6289 1:00:00 PM Late-breaking Nuclear Receptors and Steroid Hormone Action III Poster


Chin Voon Tong*1, Zanariah Hussein2, Masni Binti Mohamad3, Nurain Mohd Noor4 and Azraai Nasruddin5
1Malacca General Hospital, Malaysia, 2Hospital Putrajaya, Putrajaya, Malaysia, 3Hospital Putrajaya, Wilayah Persekutuan, Malaysia, 4Putrajaya Hospital, Putrajaya, Malaysia, 5Hospital Putrajaya

 

Background: In patients with insulinomas which are not amenable to surgical resection, medical therapy is a useful option to prevent hypoglycemia. However, these therapies may have variable and unpredictable results.

Clinical case: We report a case of a 50 year old lady who presented at the age of 45 with severe, symptomatic hypoglycemia. Prolonged fasting test confirmed that she has endogenous hyperinsulinemic hypoglycemia with elevated levels of C-peptide (3906 pmol/l, n 298-1423 pmol/l) and insulin (125 uIU/ml, n 1.4-14.0 uIU/ml) when her random blood glucose was 1.4 mmol/l.  MRI of pancreas was normal.  An arterial stimulation and venous sampling (ASVS) failed to localize her insulinoma. Endoscopic ultrasound (EUS) however showed 3 hypoechoiec lesions at the body of the pancreas. She underwent distal pancreatectomy. Histopathology examination of nodules removed was consistent with neuroendocrine tumor. Unfortunately she continued to have hypoglycemic episodes after her surgery.  Subsequently she underwent 2 further surgeries removing remnant of her pancreas, finally leaving only the head of pancreas. Hypoglycemic episodes persisted. Patient declined further surgery; opting instead for medical therapy. She was given oral diazoxide 200 mg tds as well as phenytoin 300 mg on.  Medical therapy controlled her symptoms only partially and she continued to experience recurrent severe hypoglycemia. Unexpectedly HbA1c monitoring showed gradual increment towards diabetic range (8.2%-10.2%) despite recurrent hypoglycemia. This may be contributed by diazoxide and defensive eating. CGM was performed and showed that she had predominantly nocturnal hypoglycemia and daytime hyperglycemic surges. A trial of subcutaneous octreotide injection and adjusted doses of diazoxide were given in a sequential manner on different days with CGM monitoring. Finally, a combination of higher dose of diazoxide (400 mg) at bedtime together with meal planning which included frequent meals with complex carbohydrate resolved her hypoglycemia and glucose fluctuations.

 Conclusion: This case demonstrates that medical therapy in insulinoma requires individualization and the usefulness of CGM in deciding the best therapy.

 

Nothing to Disclose: CVT, ZH, MBM, NM, AN

22566 1.0000 LBS-056 A Continuous Glucose Monitoring (CGM) - a Useful Tool in Tailoring Treatment for Insulinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM LBS 056-063 6292 1:00:00 PM Late-breaking Tumor Biology III Poster


Oscar L Morey-Vargas*1, Naykky Maruquel Singh Ospina2, Raul Ruiz Esponda1, Dana Erickson2, Alice Y Chang2 and William F. Young Jr.2
1Mayo Clinic Rochester, Rochester, MN, 2Mayo Clinic, Rochester, MN

 

Background:

Ectopic ACTH syndrome (EAS) is an uncommon cause of Cushing syndrome associated with either highly malignant tumors or with a variety of less aggressive neuroendocrine tumors. Patients with EAS typically present with signs and symptoms of severe hypercortisolism and symptoms related to their underlying neoplasm. A retrospective review of patients with EAS seen at Mayo Clinic Rochester between 1956 and 2013 was conducted. The etiology, degree of hypercortisolism at presentation, and course of the disease are reported.

Results:

EAS was identified in 179 patients (median age 51 years, 53.9% women). Bronchial carcinoid was the most common cause of EAS (24%), followed by pancreatic neuroendocrine tumors (NETs) (13%) and small-cell lung carcinoma (SCLC) (13%). Other tumors associated with EAS included medullary thyroid carcinoma (8%), disseminated neuroendocrine tumors of unknown primary source (8%), thymic carcinoid (5%), and pheochromocytoma (2%). In 21% of patients the source of ectopic ACTH was not found. Curative tumor resection was possible in 24 patients (20 patients with bronchial carcinoid, 3 patients with pheochromocytoma, and 1 patient with intestinal carcinoid). One-hundred and nine (61%) patients were treated with bilateral adrenalectomy. Ketoconazole was the most common medication used in patients on medical therapy for hypercortisolism who did not undergo bilateral adrenalectomy. The median morning serum cortisol levels at the time of diagnosis of EAS were 40 μg/dL (range, 14 to 136 μg/dL), 63 μg/dL (range, 28 to 149 μg/dL), and 81 μg/dL (range, 30 to 142 μg/dL) for bronchial carcinoid, pancreatic NETs and SCLC, respectively. The median serum ACTH levels were 135 pg/mL (range, 40 to 839 pg/mL) for bronchial carcinoid, 300 pg/mL (range, 48 to 1700 pg/mL) for pancreatic NETs, and 568 pg/mL (range, 92 to 1711 pg/mL) for SCLC. There were clinically important differences in long-term prognosis based on the underlying neoplasm; 74% of patients with bronchial carcinoid were alive 3 years after the diagnosis of EAS, while only 17% of patients with pancreatic NETs were alive at 3 years. Ninety-six percent of patients with SCLC died within 3 years of the diagnosis of EAS.

Conclusion:

Patients with EAS are a heterogeneous group with different prognosis based on the type of the ACTH-producing tumor and the degree of hypercortisolism. Treatment strategies should consider these prognostic factors. Some patients are expected to live for several years after the diagnosis of EAS, while some have a very poor prognosis. In each case the benefits, potential complications and costs of bilateral adrenalectomy with subsequent glucocorticoid and mineralocorticoid replacement, versus long-term medical therapy of hypercortisolism, should be discussed with the patients. The experience of the medical team taking care of these complicated cases should also be taken into consideration.

 

Nothing to Disclose: OLM, NMS, RR, DE, AYC, WFY Jr.

22879 2.0000 LBS-057 A Ectopic Corticotropin (ACTH) Syndrome: 58-Year Experience at Mayo Clinic 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM LBS 056-063 6292 1:00:00 PM Late-breaking Tumor Biology III Poster


Libu Varughese*, Robert Jackson, Anna Romualda Boron and Michael Roberts
St Joseph Hospital and Medical Centre, Phoenix, AZ

 

Background

Li-Fraumeni syndrome (LFS) is predominantly an inherited cancer predisposition syndrome and linked to germline mutations of the TP53 tumor suppressor gene. The mutations can be inherited, or can arise from de novo mutations early in embryogenesis, or in one of the parent's germ cells. Incidence of de novo mutations causing Li-Fraumeni has been reported from 1% to 20% (3). In this case report we present a 28-year-old female patient with possible de novo Li-Fraumeni syndrome, who developed multiple primary malignancies including recurrence of papillary thyroid cancer within the span of one year.

                                                       

Case Summary

28-year-old female with PMH of phyllodes tumor, s/p lumpectomy (5 months prior), presented to the endocrine clinic for evaluation of a thyroid nodule. Thyroid nodule and lymph node biopsy revealed papillary thyroid cancer. Patient underwent near-total thyroidectomy with right neck dissection. Final pathology noted PTC, classical variant, stage IVA (T3, N1b), metastatic to level III and IV lymph nodes. Subsequently, she underwent I-131 ablation of thyroid remnant.

Post operatively, she was started on treatment for iatrogenic hypoparathyroidism. Then as a part of follow up for the phyllodes tumor, a chest CT was done, which revealed 6 cm incidental adrenal tumor. Hormonal work up was concerning for cortisol secreting adenoma with suppressed ACTH and lack of the suppression of cortisol level on 1 mg Dexamethasone suppression test. Left adrenalectomy report revealed adrenocortical carcinoma.

Lynch syndrome was ruled out by a negative mismatch repair protein test. Genetic testing for TP53  showed heterogenous mutations of undetermined significance indicating possible de novo LFS. Subsequent PET scans showed increased metabolic activity within the bed of adrenal tumor, right neck lymphadenopathy, right thyroid bed, and colon. Pt was diagnosed with recurrent papillary thyroid cancer, for which modified neck dissection and subsequent I-131 ablation was done.                                                                               

Conclusion

Review of literature shows that de novo mutation of TP53 is on the rise, however the classical diagnostic criteria does not take this into account. Our patient showed heterogeneous TP53 mutation (p.A278G variant) of undetermined significance. At variance with other malignancies, p53 mutations are not frequently seen in thyroid cancers and are believed to mainly be responsible for cancer progression to poorly differentiated and aggressive phenotype. A higher frequency of de novo TP53 mutations increases the need for liberal screening strategies and recognition patterns. It may be of benefit to consider TP53 testing in all patients, below 30-40 years, who develop multiple primary cancers.

 

Nothing to Disclose: LV, RJ, ARB, MR

22617 3.0000 LBS-058 A De Novo Li Fraumeni like Syndrome from TP53 Mutation of Undetermined Significance 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM LBS 056-063 6292 1:00:00 PM Late-breaking Tumor Biology III Poster


Sarah S.R. Kim*1, Sylvia L. Asa2 and Anthony P Heaney3
1UCLA David Geffen School of Medicine, Los Angeles, CA, 2University of Toronto, Toronto, ON, Canada, 3University of California, Los Angeles, Los Angeles, CA

 

Background:  Most sellar masses are pituitary adenomas, craniopharyngiomas or Rathkes cleft cysts. We describe a sellar neurocytoma secreting antidiuretic hormone (ADH) presenting with profound hyponatremia.
 
Case:  A 17 year old male presented with nausea, vomiting and dysarthria. Initial serum sodium (Na) was 104 mmol/L, improving to 129 mmol/L following five days of IV saline. Brain MRI revealed a 3 x 3.5 cm sellar/suprasellar mass with optic chiasm compression and clival and bilateral cavernous sinus invasion.  Hormonal testing demonstrated a low total testosterone (190 ng/dL), reduced FT4 0.74 (0.77-1.37 mg/dL) and inappropriately normal TSH 1.04 (0.43-4.20 uIU/mL).  At an outside hospital, endoscopic trans-sphenoidal surgery achieved near total mass resection.  Immediate post-operative Na was 125 mmol/L.  Following tolvaptan 15 mg, Na rose to 144 mmol/L over 10 h, reaching 163 mmol/L by 24 h.  Despite intravenous D5/Water and DDAVP 0.1mg x 2, he developed altered mental status and seized.  On transfer, Na was 129 mmol/L and brain MRI demonstrated pontine and extrapontine myelinolysis.  Supportive therapies included gentle Na correction with 3% saline, fludrocortisone and oral salt with free water restriction.  Fluorodeoxyglucose and Gallium-68 DOTATATE-PET scans revealed moderate uptake in remnant tumor.
 
Histopathology identified a well differentiated tumor composed of epithelioid cells with abundant neuropil and focal calcification;  immunohistochemistry was negative for pituitary hormones and transcription factors excluding pituitary adenoma. The tumor expressed NeuN, neurofilaments, and S-100 consistent with neurocytoma.  Positivity for TTF1 and vasopressin proved posterior lobe origin and explained  the profound hyponatremia.  Na normalization and intense rehabilitation returned neurologic function to almost baseline.
 
Conclusion:  This is the second case of a neurocytoma producing ADH and the third originating in the sella.   The immunoprofile provides evidence of hypothalamic origin.  This case reminds us that while the rise in sodium levels after a single dose of vasopressin receptor antagonists is typically 1 to 5 meq/L, rapid correction of sodium in patients with longstanding or severe hyponatremia can be seen.  The response to tolvaptan may have been enhanced in this case due to tumor-derived overproduction of ADH. If an abrupt rise in sodium level following vasopressin receptor antagonists occurs, central line placement with aggressive fluid replacement to match urine output is paramount and DDAVP administration appears largely ineffective in this scenario. 
Fortunately, despite the severity of initial neurological insult, with supportive care, the natural prognosis of extrapontine myelinolysis is good.  Finally, advances in functional imaging such as PET-based somatostatin receptor imaging may facilitate choice of targeted therapy in neuroendocrine tumors.

 

Nothing to Disclose: SSRK, SLA, APH

22884 4.0000 LBS-059 A Severe Hyponatremia in a Patient with Vasopressin-Producing Sellar Neurocytoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM LBS 056-063 6292 1:00:00 PM Late-breaking Tumor Biology III Poster


Maria de Lurdes Matos*1, Jorge Brito2, Rui Bettencourt3, Ana Carvalho4, Silvia Silva4, Ana Crespo4, Paula Tavares4 and Jose Mario Coutinho4
1Hospital Curry Cabral, Lisbon, Portugal, 2Clinica Medica Praia da Vitoria, Praia da Vitoria, Portugal, 3Hospital Angra do Heroismo, Angra do Heroismo, Portugal, 4Hospital Curry Cabral, Lisboa, Portugal

 

Introduction:

Paragangliomas are neuroendocrine tumors of paraganglia, associated with sympathetic tissue in adrenal (pheochromocytomas or PCCs about 80%) and extra-adrenal (sympathetic paraganglioma of thorax, abdomen and pelvis or sPGLs about 20%) or parasympathetic tissue of the head and neck paragangliomas. Sympathetic tumors tend to hypersecrete catecholamines (up to 90%). The diagnosis of a rare disease as pelvic paragangliomas can be a challenge for clinicians.

Case report:

We report a case of a 64-year-old woman, presenting hypertension controlled with losartan/hydrochlorothiazide and elevated catecholamines. 24-h urinary catecholamines:  total 953 μg (14-606), Noradrenaline 85 μg (12-86), Adrenaline 5 μg (2-22) and Dopamine 863  μg (< 498). 24-h urinary fractionated metanephrines: total 4815  μg (329-1263) Metanephrine 288 μg ( 64-302)  Normetanephrine 1562  μg ( 162-527), 3-Methoxytyramine 2965  μg (103-434). Cromogranine A negative. Other hormonal studies were negatives, including 5-HIAA.

I 123-MIBG scintigraphy and 1st abdominal MRI presented no evidence of adrenal or extra-adrenal mass.  In 111- Octreoscan revealed a median low abdominal mass positive for somatostatine receptors. 2nd abdominal MRI presented a pelvic mass, solid with 4 cm suggesting a GIST with exophitic growth. Enterographic CT scan confirmed a pelvic mass related with the sigmoid and/or the small intestine. Colonoscopy showed at 45 cm, a compressive but not invasive mass out of the colon.

The patient underwent preoperative blockade with fenoxibenzamine. Laparotomy was performed with complete resection of the mass, located in the mesenterium adherent to the sero-muscular sigmoid wall. Histopathology confirmed a paraganglioma, capsulated without necrosis or vascular invasion and positive for sinaptophisin, chromogranin A and S100 protein, Ki-67 < 1%.

Discussion:

Our patient presented a pelvic tumor with elevated catecholamines but for differential diagnosis others abdominal tumors, including  GIST were considered.  Abnormal tumor location in pelvis and imaging studies presented no clear criteria for a diagnosis. Paraganglioma was confirmed only after histopathology.

Although most PGL/PCCs are benign, factors such tumor size, tumor location, high metanephrines levels and genetic background are associated with metastatic disease.

This case was a sporadic pelvic paraganglioma in a 64-years-old woman but as the risk of malignancy is greater in sPGLs than PCCs, we consider a genetic study in view of follow-up.

 

Nothing to Disclose: MDLM, JB, RB, AC, SS, AC, PT, JMC

22714 5.0000 LBS-060 A A Pelvic Sympathetic Paraganglioma Presenting As an Intestinal Mass and Mimicking a Gastrointestinal Stromal Cell Tumor (GIST) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM LBS 056-063 6292 1:00:00 PM Late-breaking Tumor Biology III Poster


Fariba Rahnema*1, Dolores Chavez2 and Dat Nguyen2
1Valley Endocrinology, Las Vegas, NV, 2Corcept Therapeutics, Menlo Park, CA

 

Background:The recognition and treatment of Cushing’s syndrome (CS) can be challenging. Diagnostic testing and tumor localization (especially ectopic) can be a lengthy and complex process. In the interim, management of the manifestations of CS is needed.

We detail the successful treatment with mifepristone (MIFE, Korlym®, Corcept Therapuetics), a competitive glucocorticoid receptor antagonist, in a patient suspected of ectopic CS without localization.

Case:A 53-y/o woman with hypogammaglobulinemia on IV Ig presented in the ED with new onset hypokalemia (2.2 mEq/L) and congestive heart failure. She had facial hirsutism, moon facies, lower extremities swelling, skin hyperpigmentation, headache, fatigue, easy bruising and muscle weakness (requiring a cane) that started 3-4mos before the ED visit. She also had resistant hypertension (144/90 mmHg), BMI 27.1 (127lbs), and a recent diagnosis of diabetes (A1c 9%, fasting blood glucose (FBG) >200mg/dL).

Abdominal CT: bilateral upper lung opacities, bilateral adrenal hyperplasia, multiple liver and ovarian cysts. CT angiography: multiple pulmonary nodules (15mm right upper lobe (possible lung cancer), 28mm left upper lobe, 13 mm left mid lung lobe).

Brain MRI: diminutive pituitary; empty sella.

Labs: abnormal AST 88U/L, normal ALT 55U/L; UFC 2378 µg/24h, AM cortisol 99µg/ml, PM cortisol 106µg/ml, successive ACTH values of 115 & 127pg/mL. 

Relevant medication history: levothyroxine 50mcg/d, metformin 100mg BID, Humalog 4U before dinner, Levemir 10U qhs. After the ER visit, furosemide and hydralazine were discontinued.  Losartan 50mg/d, aldactone 100mg BID, and KCL 200meq/d were added to amlodipine 10mg and atenolol 50mg/d.

The tumor could not be localized but ectopic CS was suspected due rapidly evolving Cushing's with negative MRI/empty sella, severe hypokalemia, edema, high ACTH and cortisol.

MIFE was initiated at 300mg/d and titrated every 2 weeks to the current dose of 1200mg/d. After 3 months: the patient weighed 121 lbs (BMI 23.9), stable BP (116/77 mmHg), FBG decreased (125 mg/dl), normal A1c (5.7%), normal LFTs (ASTs 16U/L, 42U/L) and normal K (4.7 mEq/L).

Several antidiabetic and antihypertensive meds were discontinued: humalog, levemir, atenolol, and losartan.  KCL was reduced from 200 to 40 meq/d. She reported experiencing pruritus during therapy.

Although still using a cane, the patient reported feeling more energetic (significant improvement in lower extremity edema), and more engaging with better concentration.

With stabilization, octreotide scan and additional MRIs are scheduled to localize the ectopic tumor.

Conclusion: The addition of mifepristone provided control and improvements in several manifestations of CS (A1C, weight, BP, LFTs, appearance) while eliminating the need for several antidiabetes and antihypertensive medications, representing a viable option for patient whom tumor localization is difficult.

 

Disclosure: DC: Employee, Corcept. DN: Employee, Corcept. Nothing to Disclose: FR

22958 6.0000 LBS-061 A Treatment of Ectopic Cushing's Syndrome with Mifepristone While Pending Tumor Localization 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM LBS 056-063 6292 1:00:00 PM Late-breaking Tumor Biology III Poster


Sira Korpaisarn*, Hugo Akabane and Vineetha Jose
MetroWest Medical Center, FRAMINGHAM, MA

 

Introduction
           MEN type 1 is an autosomal dominant syndrome, which generally involves parathyroid glands, anterior pituitary gland and entero-pancreatic endocrine cells. Particular nonendocrine tumors are common manifestations including angiofibromas, collaginomas and lipomas. We hereby report a case of mucoepidermoid carcinoma of parotid gland, a nonendocrine tumor, in MEN type 1 patient who is eight-year postradiation therapy for pituitary macroadenoma.

Clinical case
           A 39-year-old male, with history remarkable for multiple endocrine neoplasia type 1 diagnosed at age of 17, was accidentally found with mass in left parotid gland from MRI head. The patient was completely asymptomatic. There was neither palpable parotid mass nor facial nerve defect. His MEN type 1 was continually active during the past couple years. He has history of pituitary macroadenoma, parathyroid adenomas, gastrinoma, mestastatic carcinoid tumor to liver, bilateral adrenocortical adenomas and meningioma. He underwent multiple operations including pituitary adenoma resection followed by radiation therapy eight years ago, parathyroidectomy and partial gastrectomy for gastrinoma. MRI of head was done due to a complaint of headache and it revealed a 2.6 x 2.3 x 2.9 cm lobulated mass in deep segment of the left parotid gland. Both parotid glands are otherwise unremarkable. No pathologically enlarged lymph nodes were seen. The tumor was finally resected followed by radiation therapy. The pathological study showed intermediate grade mucoepidermoid carcinoma of parotid gland, which is nonendocrine tumor.

Discussion
           Mucoepidermoid carcinoma is malignant epithelial tumor of salivary glands. Thus far, there is no published report regarding relationship between salivary gland tumor and MEN type 1 yet. Although the interval is too short, the only risk factor in this patient is a radiation of pituitary macroadenoma, which was done eight years ago. This clinical vignette raises the awareness of possible sequelae of head and neck radiation, which should be attended along with the main disease.

 

Nothing to Disclose: SK, HA, VJ

22766 7.0000 LBS-062 A Mucoepidermoid Carcinoma of Parotid Gland in Multiple Endocrine Neoplasia Type 1 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM LBS 056-063 6292 1:00:00 PM Late-breaking Tumor Biology III Poster


Loes Moernaut1, Tatjana Sajevets2, Martine Cools3, Katleen Dewaele2, Saskia Van Der Straaten2, Sandra Janssens4, Guy G. T'Sjoen5 and Bruno Lapauw*5
1Ghent University Hospital, 2UZ Gent, 3Univ Hosp Ghent, Ghent, Belgium, 4UZGent, 5Ghent University Hospital, Gent, Belgium

 

Background.

Activating mutations of the RET proto-oncogene can give rise to Multiple Endocrine Neoplasia type 2 (MEN2) as well as Hirschsprung’s disease. The penetrance and severity of the associated disease, especially with respect to medullary thyroid cancer (MTC), strongly depends on the underlying RET mutation. Based on this genotype-phenotype correlation, screening protocols for documented carriers have been proposed1 and the ATA has issued a risk classification level to guide decision making with respect to prophylactic thyroidectomy.2

Today, more than 150 different RET sequence changes relevant to MEN2 syndromes have been reported, however for many of them a clear description of the MEN2 phenotype and age of onset of MTC is lacking.3 We now describe the clinical phenotype of a large MEN2A-family with a pathogenic mutation in exon 10, codon 611 (Cys611Arg (c.1831 T>C)), which has previously only been reported in one patient with Hirschsprung’s disease, one 52-yr old female patient with MTC and one 57-yr old female patient with bilateral pheochromocytoma.

Clinical report

In this family, the mutation was first detected in a newborn who died of sepsis following Hirschsprung’s disease. Further genetic testing of the family revealed a positive carrier status in the maternal grandfather (66yr, G1), the newborn’s mother and 4 out of 5 of her siblings (aged 29-42 yrs, G2), as well as in 1 brother, 2 cousins and 2 nieces (1.8-15y, G3). 

After clinical and biochemical screening, the grandfather had no evidence of disease. In the 2nd generation (G2), screening revealed a pheochromocytoma in 2 subjects (age of youngest subject 38 yrs), and MTC in 3 subjects (all pT1N0M0; age of youngest subject: 28 yrs; all had strongly elevated calcitonin levels). All patients were free of active disease after surgery. In G3, all children had normal calcitonin levels and a normal thyroid ultrasound. Together with the mild clinical phenotype and the family’s preference, prophylactic thyroidectomy was delayed in these children and calcitonin-based surveillance was initiated. No subjects presented with elevated calcium levels.

Conclusion

This previously unclassified variant, affecting a cysteine residu in codon 611 within exon 10 of the RET proto-oncogene, can now be considered to cause MEN2A syndrome. This family presents with a rather mild clinical phenotype, with a first, non-metastasized MTC detected at 29 years and a first pheochromocytoma at 38 years of age. Although ATA guidelines suggest performing prophylactic thyroidectomy in carriers of a 611 RET-mutations at young age, a more individual approach with delayed thyroidectomy and calcitonin-based surveillance of children and adults can be considered in certain genotypes.

 

Nothing to Disclose: LM, TS, MC, KD, SV, SJ, GGT, BL

22845 8.0000 LBS-063 A Revealing an Unclassified 611 Variant of the RET Proto-Oncogene As a Disease-Causing Mutation: Clinical Phenotype and Management of a MEN2A-Family 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Saturday, March 7th 3:00:00 PM LBS 056-063 6292 1:00:00 PM Late-breaking Tumor Biology III Poster


Alexander Terence Faje*1, Jun Ma1, Xianling Wang1, Brooke Swearingen2, Nicholas A Tritos1, Lisa B Nachtigall1, Xun Zhang2 and Anne Klibanski2
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts General Hospital and Harvard Medical School, Boston, MA

 

Ipilimumab (Ipi), an immunotherapeutic agent used in the treatment of metastatic melanoma, is a monoclonal antibody that blocks cytotoxic T-lymphocyte antigen-4 (CTLA-4) and enhances T cell activation.  Patients treated with Ipi have a substantial risk of hypophysitis, but this treatment complication occurs very rarely with immune checkpoint inhibitors that target other receptors.  Pituitary expression of CTLA-4 may mediate hypophysitis in patients receiving Ipi through activation of the classical complement pathway.  Engagement of CTLA-4 by Ipi may also activate antibody-dependent cellular cytotoxicity.

Objective: To (1) characterize CTLA-4 gene expression in human pituitary adenomas and (2) assess whether CTLA-4 gene expression predicts tumor behavior or correlates with histologic markers for prognosis.

Design and Methods: CTLA-4 gene expression was measured by reverse transcription quantitative real-time PCR (RT-qPCR) in surgical specimens obtained from 81 patients (55 males and 26 females) with macro- and giant adenomas and compared to measurements in 7 normal patients.  Patient medical records, including provider encounters, laboratory results, radiologic images, and pathology results were reviewed.

Results: CTLA-4 gene expression varied widely in adenomas (2,725-fold range) and was comparable to that seen in normal pituitary glands (median 1.19-fold elevation in adenomas, normalized to the mean expression in normal pituitary glands, p=0.57).  One-quarter of adenomas demonstrated at least a 10-fold elevation of CTLA-4 RNA levels compared to the mean expression in normal pituitary glands.  CTLA-4 levels generally did not differ according to hormone immunostaining patterns, though expression was mildly higher in tumors which stained positively for prolactin (median 1.75-fold elevation vs 0.55-fold, p=0.03).  CTLA-4 expression did not differ according to gender, age, Ki-67 labelling index, p53 immunopositivity, mitotic index, tumor size, or in those patients requiring additional surgery and/or radiation therapy.  Median tumor size was 2.5 centimeters (cm) (interquartile range [IR] 2.0 to 3.0 cm).  Median duration of patient followup was 22 months (IR 9.4 to 42.4 months).

Conclusions:  CTLA-4 RNA levels varied substantially within both tumors and normal pituitary glands.  This variability may underlie the clinical observation that a only significant minority of patients treated with Ipi develop hypophysitis.  It is unknown whether CTLA-4 expression in the normal pituitary gland predicts the likelihood of developing Ipi-induced hypophysitis.  The high expression levels of CTLA-4 in a subset of tumors raises the possibility that CTLA-4 may represent a novel direct therapeutic target for the treatment of aggressive pituitary tumors in selected patients.  The physiologic role of CTLA-4 in the pituitary is unknown, as is its long term value as a predictor of tumor behavior.

 

Disclosure: LBN: Advisory Group Member, Genentech, Inc., Study Investigator, Ipsen. Nothing to Disclose: ATF, JM, XW, BS, NAT, XZ, AK

22634 1.0000 LBS-077 A Cytotoxic T-Lymphocyte Antigen-4 Gene Expression in Human Pituitary Adenomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Martin Bidlingmaier*1, Alicia Algeciras-Schimnich2, Philipp Grimminger3, David Brésart4 and Phillip Monaghan5
1Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany, 2Mayo Clinic, Rochester, MN, 3Medizinische Klinik und Poliklinik IV, Ludwig-Maximilian University, Munich, Germany, 4Immunodiagnostic Systems, 5Christie Hospital NHS Foundation Trust

 

Maintaining consistency of results over time is a challenge in laboratory medicine. A recent study had identified problems with standard tests applied by laboratories to detect lot-to-lot variability concerning a frequently used IGF-I assay. A drift in the assay invalidates the application of reference intervals established with previous assay lots. To investigate the appropriateness of a new reagent lot for the IDS-iSYS IGF-I immunoassay for use with the recently published assay specific normative data we applied different methods: First, every new lot was compared to the previous lot independently by 3 laboratories through parallel analysis of clinical samples (including samples from patient with GH deficiency, acromegaly and diabetes mellitus) by both lots. Second, clinical samples assessed at the time the reference intervals were established (1/2010) were re-analysed 36 months later (1/2013) using a different reagent lot. Third, we determined the distributions of a large number of reported patient results (median, SDS) for different lots of reagents at one major reference laboratory. Results from 7 lot-to-lot comparisons conducted by 3 independent laboratories using clinical samples revealed good agreement: Slope between the results from different batches in the respective laboratories (mean, range) was 1.02 (0.96-1.11), 1.01 (0.97-1.04) and 1.02 (0.95-1.09), respectively, while bias (mean%, range) was found at -2.01 (-5.80-0.86), -1.34 (-4.58-0.76) and 0.30 (-3.96-4.48), respectively. The results for clinical samples (n=95) first assessed in 1/2010 agreed and correlated well (slope 1.03, R2=0.95) with the corresponding results obtained 3 years later in 1/2013 (with the new lot 1448). In 61,986 samples analysed between 3/2013 and 6/2014 using 5 different lot numbers, the all patients median IGF-I ranged from 139 – 146 ng/mL, with a mean slope for lot-to-lot comparison of 1.011 (range 0.984-1.05). In samples analysed between April and August 2014 (n=23,838), SD scores were calculated according to the published normative data. Mean SD score was -0.028, with 8.75% of the samples above +2SD and 9.82% below -2SD, with no significant variation over the 2 reagent lots used during that period. In summary, our data suggest that between lot variability in the IDS-iSYS IGF-I assay is low. Furthermore, the agreement found between different reagent lots in the comparative analysis of samples in 3 laboratories before release of the lots was confirmed by the consistency of the median patient results seen over several lot numbers in a huge set of samples analysed at a major reference laboratory. Prospective analysis of future data must reveal whether results from the direct comparison in clinical samples can predict the impact of new reagent lots on distribution of patients’ results in large series.

 

Disclosure: MB: Consultant, Immunodiagnostic Systems, Investigator, Immunodiagnostic Systems. DB: Employee, Immunodiagnostic Systems. Nothing to Disclose: AA, PG, PM

22929 2.0000 LBS-078 A Lot-to-Lot Stability of the Ids-Isys IGF-I Immunoassay: Evaluation through Parallel Assessment of Samples and Monitoring of Patient Results Distribution 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Ma. Conchitina Manas Fojas*1 and Luma Ghalib2
1The Ohio State University Wexner Medical Center, Columbus, OH, 2The Ohio State Univeristy, Columbus, OH

 

Introduction

One third of patients with Renal Cell Carcinoma (RCC) have attributes of paraneoplastic syndrome. There are numerous endocrinopathies and clinical syndromes associated with RCC. Patients with RCC represent a high risk population that requires closer follow ups and continued investigation.

Case

Cancer staging of a 32 year-old female with RCC, clear cell type, revealed a pituitary microadenoma. She presented at the endocrinology clinic with worsening headache and a 30 pound weight gain in 3 months. Physical exam was pertinent for abdominal striae. Hormonal screening showed normal pituitary function and 24 hour urinary free cortisol (UFC), 29 mcg/24hr (ref:0-50 mcg/24 hr).  ACTH was elevated, 99 pg/ml (ref:9.0 - 50.0 pg/mL). Additional tests again showed normal UFC and midnight salivary cortisol levels which were marginally elevated at 101 and 110 ng/dL (ref:<100 ng/dL) respectively. Dexamethasone 1 mg suppression test was inappropriately elevated, measuring 4.2 mcg/dL(ref:<1.8 mcg/dL). Repeat MRI of the brain showed cystic changes concerning for apoplectic features versus metastasis. She underwent endonasal resection of the pituitary mass. Pathology revealed an ACTH positive pituitary adenoma. Post operatively, the cortisol level reached a nadir of <1.2 mcg/dL(ref:3.0-22.4 mcg/dL) and the ACTH normalized. She developed adrenal insufficiency and was discharged on hydrocortisone.

Discussion

Renal cell carcinoma (RCC) is one of the most interesting and multifaceted oncologic disorders. Historically known as the “great masquerader”, RCC can present with diverse clinical syndromes, including endocrinopthies. By itself, RCC accounts for 2% of all neoplasms responsible for Cushing’s syndrome. The ectopic pathology involves the enzymatic conversion of pro-opiomelanocortin (POMC) to ACTH by the tumor. Symptomatic metastases to the pituitary from RCC are rare, they are seen in 1% of resections. Metastatic disease presents as severe hypopituitarism and visual dysfunction. However, it can also present with typical symptoms and signs of pituitary macroadenoma. Of note, diabetes insipidus, a common finding of pituitary metastases, can be absent. Differentiating disease pathologies using neuroimaging alone can be challenging. Patients with RCC pose a clinical dilemma, due to the protean manifestations of the disease.

This case involved a patient with RCC and an isolated ACTH secreting pituitary adenoma, Cushing’s disease, rather than the more commonly reported ectopic Cushing’s syndrome in RCC. The diagnosis entailed integration of the clinical picture and systematic elimination of differential diagnoses. The case highlights the challenges of caring for a patient with RCC due to the wide spectrum of endocrinopathies associated with it. It is imperative to reevaluate patients with clinical suspicion of Cushing’s disease, as initial screening may be negative.

 

Nothing to Disclose: MCMF, LG

22399 3.0000 LBS-079 A The Great Masquerader a Case of Renal Cell Carcinoma and Cushing's Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Weera Sukhumthammarat, Prapaipan Putthapiban, Napatt Kanjanahattakij and Chutintorn Sriphrapradang*
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Introduction: Giant prolactinoma is a rare tumor. It is defined as a prolactinoma with a maximum diameter more than 4 cm, massive extrasellar extension and very high prolactin concentrations (> 1,000 ng/mL). Symptoms are related with tumor mass effect. We herein report a patient who initially presented with epistaxis but giant prolactinoma was later found.

Clinical case: A 69 year-old male had presented with bleeding from his right nostril for 1 month. He had chronic generalized headache. Biopsy of mass at the right middle turbinate was done. The pathology was reported as a round cell tumor. Additional immunohistochemical staining was compatible with pituitary adenoma with results of positive results for AE1/AE3, synaptophysin, chromogranin, CD56, NSE and negative for S100, CD3 and CD20.  Further examination, he had no cerebrospinal fluid (CSF) rhinorrhea. Visual field examination showed left superior temporal hemianopia. MRI of the pituitary revealed a 3.8x5.2x3.8 cm mass invading the skull base, bilateral cavernous sinuses, the posterior nasal cavities and the posterior maxillary sinuses. His hormonal evaluation included morning cortisol 13.4 mcg/dL, FT4 0.91 ng/dL (0.79-1.48), TSH 1.3 mIU/L (0.35-4.94), FSH 5.5 mIU/mL (0.95-11.95), LH 2.66 mIU/mL (0.5-12.07), testosterone 196 ng/mL and IGF-1 143 ng/mL (69-200). Platelet count and coagulogram were within normal ranges. Serum prolactin was more than 20,000 ng/mL. Bromocriptine, the only dopamine agonist that available in our country, was started at an initial dosage of 2.5 mg/day and titrated up to 15 mg/day. Serum prolactin levels were 1,447 and 428 ng/mL at 1 and 3 weeks after treatment, respectively. His headache was improved and the tumor rapidly decreased in size.

Conclusions: Pituitary macroadenoma can present with epistaxis and should be considered as the differential diagnosis along with other uncommon causes. The treatment of choice of all macroprolactinomas is dopamine agonist to achieve a significant reduction in prolactin levels and tumor size. However, the rapid reduction in tumor size may be accompanied by serious complications such as CSF rhinorrhea, pituitary apoplexy, tension pneumocephalus, cerebral and/or optic chiasm herniation into the sella turcica associated with seizure and/or visual disturbances.

 

Nothing to Disclose: WS, PP, NK, CS

22413 4.0000 LBS-080 A Epistaxis Caused By Invasive Giant Prolactinoma 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Justin Andrew Seltzer*1, Thomas C Scotton1, John D. Carmichael2 and Gabriel Zada2
1Keck School of Medicine of USC, Los Angeles, CA, 2University of Southern California, Los Angeles, CA

 

Prolactinomas are the most common functional pituitary adenomas (PAs). They are responsible for a hypersecretion endocrinopathy often characterized by amenorrhea/galactorrhea in women or reduced sexual function in men. Currently, they are diagnosed by clinical symptoms and serum hyperprolactinemia. Like all PAs, they are further classified by immunostaining, tumor size, invasiveness, and grade. First line treatment is dopamine agonist therapy, with surgery typically reserved for drug-refractory tumors.

The diagnosis and classification of prolactinomas remains somewhat rudimentary, without an understanding of the genetic and epigenetic subsets and drivers of these tumors. A systematic review of the literature from 1990 to the present was performed to identify over- and under-expressed genes and proteins in prolactinomas. An initial screen resulted in 1,392 primary results.  Of these, 200 were found to be relevant based on the title and abstract and underwent full-text analysis. Fifty-seven studies were included in the analysis following application of the inclusion and exclusion criteria. Six additional manuscripts were found outside of the formal search, of which one was included. In total, 58 manuscripts were analyzed.

Results from the systematic literature review showed that compared with the normal pituitary gland, 35 genes and 30 proteins were over-expressed in prolactinomas, whereas 92 genes and 24 proteins were under-expressed. Nine miRNAs were over-expressed and 10 were under-expressed. Of the over-expressed genes identified, PIT1, HMGA2, HST, and SNAP25, along with their respective proteins, were further analyzed due to a clear association with hypersecretion and PA formation as well as potential therapeutic value. Under-expressed genes UGT2B7, HPGD, CDKN1B, CDKN2C, GADD45B, and GADD45G, and their respective proteins, along with the miRNAs Let7 and mir-493 were analyzed due to involvement with cell cycle regulation and tumor suppression. PPARG/NR1C3 and its protein PPARγ were also explored outside of the analysis due to strong therapeutic potential despite inconsistent expression results. 

Due to their relative prevalence, improved diagnosis and treatment of prolactinomas, especially drug-resistant, invasive and recurrent prolactinomas, represent areas of clinical need. The genes and proteins identified not only represent opportunities for further understanding prolactinomas, but also are mostly untested potential targets for new medical therapies. Prolactinomas and other PAs share much in common with tumors found elsewhere in the body,with important differences such as responsiveness to medical therapy and a mostly benign tumor behavior that merit further tumor research.

 

Disclosure: JDC: Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Genentech, Inc.. Nothing to Disclose: JAS, TCS, GZ

22935 5.0000 LBS-081 A Gene and Protein Expression in Prolactinomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Huiwen Tan* and Yerong Yu
West China Hospital, Sichuan University, Chengdu, China

 

Objective

Excess of growth hormone (GH) leads to insulin resistance in acromegaly. The present study aims to evaluate the insulin sensitivity and insulin secretion in Chinese patients with acromegalic pituitary adenoma.

Methods

A total of 68 patients (35 males and 33 females, aged 46.75 +/- 12.16 years) with acromegalic pituitary adenoma in West China Hospital from Jan 1.2009 to Nov 1.2014 were analyzed retrospectively.  Based on oral glucose tolerant test (OGTT), which glucose, serum insulin, growth hormone  and insulin-liked growth factor1 (IGF-1) were collected before and 30, 60, 90 and 120 min after the ingestion of 75 g glucose, we classify all cases of preoperative acromegaly into three groups: normal glucose tolerance (NGT), impaired fasting glucose and (or) impaired glucose tolerance (IFG/IGT) and diabetes mellitus (DM). Groups were compared for differences in the clinical symptoms and signs, pituitary CT/MRI images, hormonal tests and pathological results.

Results

21 cases (30.88%) in pituitary adenoma patients with acromegaly complicated with secondary DM, while 35 (51.47%) had IFG/ IGT and 12(20.69%) could be typed as NGT. The basic blood GH level of acromegalic pituitary adenoma with DM , IFG/IGT and NGT were ( 42. 83 ± 8. 70 ) ng /ml , ( 40.25 ± 11.56) ng /ml and ( 38. 91 ± 12. 69 ) ng /ml respectively. There was statistically significant difference among the three groups (p = 0. 031 ), as well as the IGF-1 levels, even GH and IGF-1 progressively and significantly increased in all groups. Pituitary MRI showed that adenoma size were microadenomas, macroadenomas and giantadenomas,  there were no significant differences (p=1.000). The percentage of positive TSH immunoreactivity in acromegalic patients with secondary diabetes was significantly higher than that of IFG/IGT and NGT (61.9% v.s. 34.3% p= 0. 000, 61.9% v.s. 18.8% p= 0. 000, respectively).

Conclusions

In summary, the present data suggest that there is a marked variation of somatostatin response to glucose load and GH production in patients with acromegaly, leading to changes in insulin secretion and glucose metabolism. Abnormal growth hormone and IGF-1 secretory pattern to glucose load is characteristic of acromegaly. Some of them may be more prone to develop as secondary diabetes in the early stages. This study indicates that further efforts to reduce the occurrence of diabetes must be focused upon earlier diagnosis of acromegaly and intervention in adult individuals with high GH and or IGF-1 secretion.

 

Nothing to Disclose: HT, YY

22700 6.0000 LBS-082 A The Insulin Sensitivity and Insulin Response to Glucose Load in Pituitary-Adenoma Patients with Acromegaly in China 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Lesly Portocarrero-Ortiz*1, Alejandro Terrones- Lozano2, Ricardo A Ortiz-Reyes2 and Jazmin Martinez2
1Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Distrito Federal, Mexico, 2Instituto Nacional de Neurologia y Neurocirugia

 

Introduction

Dexamethasone infusion test has a sensibility between 95-100% and specificity between 70-90% for Cushing’s syndrome diagnosis.

Objectives

To describe the experience of dexamethasone infusion test for ACTH dependent Cushing’s syndrome diagnosis in  association  with tumoral size.

Materials and Methods

All records of ACTH dependent Cushing’s disease patients diagnosed with dexamethasone infusion test from 2004 to 2013 of the diagnostic protocol were reviewed. Biemond diagnosis criteria was used for the procedure and interpretation, results were compared with tumoral size. Tumoral size evaluated with magnetic resonance image (MRI was classificated as : microadenoma < 10mm, macroadenoma >10mm and giant adenoma >40 mm)

Results: 45 patients were diagnosed with ACTH dependent Cushing’s disease, in 18/45 where diagnosed by dexamethasone infusion test (1 mg > 1.8 µg/dL). Female 15/18 (83.33%) diagnosis mean  age 38.7 years (14-68). Tumoral size: microadenoma 10/18 (55.5%), macroadenoma 6/18 (33,33%), giant adenoma 1/18 (5.55%). Two patients were summited to an inferior petrosal sinus sampling procedure (microadenomas < 6 mm).  Day 1: baseline average: 25.56 µg/dL (46.77-14.43),  day 2: 61.1 % (n=11) cortisol levels > 275 nmol/L (> 10 µg/dL); 16.6% (3/18) indeterminate values obtained for the test and 22.2% (n=4) cortisol levels < 83 nmol/L (< 3 µg/dL). Patients with hypercortisolism (n=11), 36.36% (n=4) presented microadenoma; 54.54% (n=6) macroadenoma and 9.09% (n=1) giant tumor; patients with indeterminate value, 100 % (n=4) presented microadenoma. Patients were hypercortisolism cannot be demonstrated, 66.66% (n=2) had microadenoma and 33.33% (n=1) macroadenoma. Cortisol final values in day 1: average of 9.80 µg/dL (0.90-33.41), 66.66 % (n=12) suppressed 50% in relation to basal cortisol and 33.33% (n=6) did not suppress. Within the population that does not suppress, 50% (n=3) did not present an absolute difference of 6.8 µg/dL. Patients with a suppression > 50% related to baseline cortisol final cortisol on day 1 of the test, 66.66% (n=8) presented microadenomas and 33.33% (n=4) macroadenomas.

The relationship between suppression < 50% from baseline cortisol – final cortisol on day 1 of the test and tumor size demonstrated that 33.32% (n=2) presented microadenomas, 49.98% (n=3) macroadenomas and 16.66% (n=1) giant tumor.

Of the patients who did not had an absolute difference ≥ 187.61 nmol/L (6.8 µg/dL), 66.66% (n=2) had macroadenoma and 33.33% (n=1) giant tumor. In this population were no patients with microadenoma.

Conclusions

The level of suppression based on both criteria may suggest the presence of a microadenoma or macroadenoma. In cases where suppression was at least 50%, it suggests a macroadenoma or giant tumor. When cortisol levels are indeterminate on the second day of the test, it could relate to a microadenoma and when they are higher than 10 µg/dL to a macroadenoma.

 

Nothing to Disclose: LP, AT, RAO, JM

22939 7.0000 LBS-083 A Dexamethasone Infusion Test for Diagnosis of Cushing Disease ACTH Dependent and Their Relation with Tumoral Size, Experience Instituto Nacional De Neurologia Y NeurocirugÍa Manuel Velasco SuÁrez 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Leila Pedroso De Paula*1, Mauro Antonio Czepielewski2, Jorge Luiz Gross3, Jaderson Costa Da Costa4 and Geraldo Rizzo5
1Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil, 2Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil, 3Universidade Federal do Rio Grande do Sul, Porto Alegre-RS, Brazil, 4Hospital São Lucas da PUC, Porto Alegre, Brazil, 5Hospital Moinhos de Vento, Porto alegre, Brazil

 

Background: Following 2009/ 2010 pandemic H1N1 vaccine campaign, several children and adolescents had onset of symptoms of narcolepsy-cataplexy (1). Narcolepsy is a disorder affecting the brain's ability to regulate sleep-wake cycles by the loss of hypothalamic neurons that produce the neuropeptide orexin (hypocretin). There is a hypothesis that this phenomenom is auto-imune, children are positive for human leukocyte antigen (HLA)-DQB1*0602, and probably produce anti-hypothalamus antibodies. It was described obesity and precocious puberty associated with narcolepsy-cataplesy in children (2,3) and this clinical case reports a H1N1 vaccine related narcolepsy with other endocrine associated symptoms.

Case Report: Eight weeks after pandemic influenza vaccination, a 5 year old brazilian girl developed classic symptoms of narcolepsy-cataplexy with: daytime sleepiness with "sleep atacks", episodes of cataplexy, hypnagogic hallucinations and sleep paralysis. She was investigated by neurologists and the polysomnography, the multiple sleep latency test and Epworth scale were diagnostic of narcolepsy-cataplexy. Her latency to stage I and REM sleep were respectively 3.5 and 7.0 minutes. She was treated daily with venlafaxin, metilphenidate and modafinil.

At the diagnosis she had been in 50th percentile of height and weight since birth, but after that she started gaining weight (plus 48.9 pounds in 2 years) and developed obesity while she reduced growth rate and grew only 3 centimeters the following year, decreasing to 25th height percentile. Finally she was refered to an endocrinologist. It was excluded Cushing disease, hypoleptinemia (leptin 21- normal 0.6 to 16.8) and insulin resistance (glycemia 85 mg/dl, insulinemia 5.4 and HOMA indice 1.1). Her evaluation showed a hypothalamic-pituitary disfunction with central hypothyroidism, total T4: 3.8 mcg/dl (normal 6.0-12), Free T4 0.7 ng/dl (normal 0.9-1.8), TSH 2.6 mcUI/ml (normal 0.6-4.4), TBG 21 (normal 14-31) altered TRH test and growth hormone deficiency. She had a normal MRI and IGF-1 of -0.6 z score, but because of her growth rate she was submitted to a GH stimulation test with clonidine without response (0.59/ 0.24/ 0.64/ 1.12/ 0.85 GH ng/ml). Three years after the vaccine she is hypotonic, looking like a non-GH treated Prader Willi girl, reflecting her hypothalamic disfunction as well. The family is postponing GH treatment, afraid of side effects.

Conclusion: The major neuroendocrine alterations associated with short sleep are an upregulation of appetite, with lower leptin and insulin sensitivity. This clinical case reports a H1N1 vaccine related narcolepsy with no precocious puberty, no lower leptin or insulin sensitivity but with symptoms, signs and tests consistent with hypothalamic endocrine dysfunction, suggesting that orexin neurons may play a role as one of the multifactorial mechanisms involved in the endocrine system.

 

Nothing to Disclose: LPD, MAC, JLG, JCD, GR

22423 8.0000 LBS-084 A Influenza Vaccination Adverse Effect: Hypothalamic-Pituitary Disfunction Associated with Narcolepsy-Cataplexy in a Little Girl 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Jakob Dal*1, Ulla Feldt-Rasmussen2, Marianne Andersen3, Lars Oestergaard Kristensen4, Peter Laurberg5, Olaf M Dekkers6 and Jens Otto Lunde Jørgensen7
1Aarhus University Hospital, 2Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 3Odense University Hospital, Odense C, Denmark, 4Herlev Hospital, Copenhagen, 5Aalborg University Hospital, Aalborg, Denmark, 6Leiden University Medical Center, Netherlands, 7Aarhus University Hospital, Aarhus C, Denmark

 

Introduction: Acromegaly is a rare disease caused by GH hypersecretion from a pituitary adenoma. Accurate estimates of incidence and prevalence are scarce and not based on nationwide populations. Furthermore assessment of comorbidity requires complete follow-up and access to data from the background population to ensure proper comparisons.

Aim: To calculate population based incidence and prevalence rates and morbidity in patients with acromegaly

Method: The Danish health care system offers universal tax supported treatment and care and each individual is assigned a unique ID which enables complete follow-up and linkage to other health-related databases and to hospital records. Finally large comparison cohorts from the general population can easily be tailored to compare patient outcome measures. In this setting all identified cases of acromegaly in Denmark (1991-2010) were retrieved electronically and confirmed by patient charts review. We used Cox regression, and computed hazard ratios (HR) with 95% confidence intervals (95% CI).

Results: A stable mean acromegaly incidence rate of 3.8 cases /million/year (95% CI 3.6-4.1) was recorded with a prevalence of 85-118 cases/million. The mean age at diagnosis was 48 years (CI 95% 47-50) with a sex distribution on 47% females.  Patients with acromegaly were at increased risk of diabetes mellitus  [HR 3.7 (CI95% 2.5-5.5)], heart failure [HR 2.5 (CI95% 1.4-4.5)], venous thromboembolism [HR 2.3 (CI95% 1.1-5.0)], sleep apnoea [HR 11.7 (CI95% 7.0-19.4)] and osteoarthritis [HR 2.1 (CI95% 1.6-2.6)], whereas the risk of stroke [HR 1.1 (CI95% 0.6-2.0)] and myocardial infarction [1.0 (CI95% 0.5-1.9)] were normal. This increased multi-morbidity risk was present even before diagnosis and several risk estimates peaked in the three-year pre-diagnostic period.

Conclusion: 1) The incidence rate of acromegaly has remained stable from 1991 – 2010, 2) Significant multi-comorbidity is prevalent even before acromegaly is diagnosed, 3) our data emphasize the importance of prompt diagnosis and treatment of acromegaly

 

Disclosure: JD: Teacher, Pfizer Global R&D, Speaker, Ipsen. Nothing to Disclose: UF, MA, LOK, PL, OMD, JOLJ

22705 9.0000 LBS-085 A Multi-Comorbidity Is Prevalent in Acromegaly Prior to Its Diagnosis: A Population-Based Study from Denmark 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Lesly Portocarrero-Ortiz*1, Sara Patricia Pérez-Reyes1, Sandra Aideé Gómez-Acosta2, Verónica Anaya-Martínez3 and Francisca Pérez-Severiano1
1Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Distrito Federal, Mexico, 2Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Distrito Federal, 3UNAM, Distrito Federal, Mexico

 

Introduction: Pituitary adenomas are monoclonal tumours arising in adenohypophyseal cells and are the most frequent tumors in sellar region. Although considered benign, as many as 25–55% are invasive  and some exhibit clinically aggressive behaviour. Although several histological markers for early detection of aggressiveness have been evaluated, no marker can conclusively predict the clinicopathological behaviour. Also,  biomarkers expression can lead to new terapeutic options.

Objective: to evaluate the expression of D2R,  VEGF, KDR in different subtypes of  pituitary adenomas.

Material and methods: From January to December 2013 we collected pituitary adenoma samples from patients who underwent surgery, we performed  immunohistochemistry and western blot (WB). By inmunohistochemistry VEGF, KDR and D2R staining intensity was scored as 0 (negative), 1 (weak), 2 (medium), 3 (strong), 4 (very strong), extent of staining was scored as 0 (0%), 1 (1–25%), 2 (26-50%), 3 (51-75%), and 4 (76-100%) according to the percentages of the positive staining areas in relation to the whole area. All the patients underwent MRI,  hormonal and ophthalmological assessment before surgery and at 3, 6, and 12 months postoperatively. Tumoral size was evaluated with volumetry.

Results: 63 patients were included, non-functioning pituitary adenomas (NFPA)

47/63, GH 12/63, ACTH 3/63, GH y PRL: 1/63. Mean age at diagnosis 46.77 years (19-72). Male: 32/63 (50.8%). Most frequent clinical onset: visual disturbances (82.5%) and headeache (62%). At diagnosis: hypogonadism 36/63 (57%), hypothyroidism 16/63 (25%), and hypocortisolism 7/63 (11%). Type of surgery: endoscopic endonasal 42/63 (66.7%), microscopic transsphenoidal 17/63 (27%), transcraneal 4/63 (6.3%). All were macroadenomas, mean preoperatory volume: 12.36 cm3 (1.66-51.8), after surgery: 4.88 cm3  (0-25). WB expression: VEGF: 61.9%,  KDR: 74.46%, D2R: 43%, and Ki67: 88%, the major expression of ki67 was in NFPA. Inmunohistochemistry: all expressed VEGF (intensity: 1: 78%, 2: 12%), KDR was expressed in all the samples (1: 31.7%, 2: 56%, 3: 9.8%. 4: 2.4%), D2R was expressed in 89%. There were no differences in VEGF expression in the different types of adenoma (p=0.89), and with tumoral volume (p=0.256).

Conclusions: There were no differences between diferent subtypes of adenoma and VEGF and KDR expression. D2R was found in 89% of pituitary tumor samples, VEGF and KDR were expressed in all. The presence of these biomarkers can represent terapeutical targets.

References:

Di Ieva A, Weckman A, Di Michele J, Rotondo F, Grizzi F, Kovacs K, et al. Microvascular morphometrics of the hypophysis and pituitary tumors: from bench to operating theatre. Microvascular research. 2013;89:7-14.

Salehi F, Agur A, Scheithauer BW, Kovacs K, Lloyd RV, Cusimano M. Biomarkers of pituitary neoplasms: a review (Part II). Neurosurgery. 2010;67(6):1790-8; discussion 8

 

Nothing to Disclose: LP, SPP, SAG, VA, FP

22798 10.0000 LBS-086 A Expression of D2R, VEGF, KDR in Functioning and Non-Functioning  Pituitary Adenomas in a Third Level Center, Instituto Nacional De Neurología y Neurocirugía, Mexico City 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Ishita Singh*1 and Tannaz Moin2
1David Geffen School of Medicine at UCLA, Los Angeles, CA, 2David Geffen School of Medicine at UCLA; VA Greater Los Angeles Healthcare Systems; VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Los Angeles, CA

 

Introduction

Pituitary adenomas are the most common intracranial tumors with an incidence of 1 in 1000 worldwide. Only 5% of these tumors are giant pituitary adenomas, defined as ≥ 4cm in size, thought to be more aggressive and with overall poorer prognosis.

Clinical Case

61 yo male with a history of hypogonadism presented to ophthalmology with worsening peripheral vision (left>right). Visual field exam showed marked loss of visual acuity in the left eye and temporal loss in the right. Optical coherence tomography showed temporal thinning of the nerve fiber layers concerning for a compressive etiology. MRI brain revealed a large heterogeneous, multilobulated, enhancing mass arising from the sella with suprasellar extension. Midline component measured 5×2.8cm, with a large 4.3×5.4×3.6cm extension into the left middle cranial fossa causing mass effect on the left midbrain, optic chiasm and a 4 mm midline shift. He was referred to endocrinology for further evaluation. Detailed history was notable for olfactory hallucinations, described as episodes of strange, altered odor perception, and mild right arm weakness.

Vitals and physical exam were largely unremarkable, except for visual loss and mild, bilateral gynecomastia. Laboratory evaluation showed cortisol 11.95 µg/mL(4-22), fT4 0.89 ng/dL(0.66-1.73), IGF-I 95 ng/mL(75-228), GH 1.5 ng/mL(<10.1), prolactin 10.87 ng/mL(2.1-17.7), 9 ng/mL after 1:5 dilution, LH <0.1 mIU/mL(1.5-9.3), FSH 2.31 mIU/mL(1.4-18.1) and total testosterone 290.56 ng/dL(241-827) on replacement. The differential for this large nonfunctioning tumor included craniopharyngioma, giant pituitary adenoma, rathke’s cleft cyst and primary brain tumor. Neurology recommended levetiracetam for his olfactory hallucinations as these can represent simple partial seizures. The temporal lobe extension necessitated a craniotomy for de-bulking and optic nerve decompression. Histopathology suggested a nonfunctioning pituitary adenoma. Immunohistochemistry was negative for ACTH, PRL, GH, FSH, LH, TSH, GFAP (Glial fibrillary acidic protein), vimentin and p53. Ki-67 was 3%. The patient had an uneventful post-operative course and post-operative MRI showed a residual enhancing sellar tumor, 4.2×2.2cm in size invading the sphenoid sinuses. Repeat HPA axis testing remains intact at 1-month post–op, except for low gonadotropin and total testosterone levels.

Conclusions

The combination of visual changes, olfactory hallucinations and right arm weakness is an unusual presentation for pituitary adenomas. Giant pituitary adenomas can exhibit growth in any direction leading to neuroimaging findings similar to various primary brain and nasal tumors. Classified as “atypical” when the Ki-67 is ≥ 3%, Ki-67 can be used as a marker of aggressiveness for invasive giant adenomas. Close follow up with repeat imaging and laboratory testing is important for giant pituitary adenomas.

 

Nothing to Disclose: IS, TM

22506 11.0000 LBS-087 A Olfactory Hallucinations, Visual Loss and Arm Weakness: An Unusual Presentation of a Giant Pituitary Adenoma  2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Abosede Olatoyosi Adeoshun*, Victoria Loseva, James N Sullivan and Jon H Levine
Meharry Medical College, Nashville, TN

 

Successful Spontaneous Pregnancy Following Diagnosis of Lymphocytic Hypophysitis. Authors: Abosede Adeoshun, MD; Victoria Loseva, MD; James Nelson Sullivan, MD; Jon H. Levine, MD. Background:  Lymphocytic hypophysitis (LYH) is the most common cause of hypopituitarism in the post partum period. The autoimmune basis of the disease has been widely accepted and it is characterized by inflammation and infiltration of the pituitary gland by lymphocytes and plasma cells leading to pituitary dysfunction.

Case description: A 28-year-old woman presented with 3 week history of persistent vomiting, diffuse non-radiating abdominal pain, and generalized weakness following a 20 pound weight loss over several months. Two years earlier, she had a normal pregnancy and delivery of her first child through a cesarean section without any complication, after which she was unable to lactate and became amenorrheic.  She also developed loss of appetite and generalized weakness with increasing difficulty in performing her activities of daily living. She felt particularly weak if she missed a scheduled meal.

Physical examination revealed a thin woman, ill appearing, pale with dry mucous membranes. Abdominal examination was positive for non-specific abdominal tenderness. Vitiligo was noted on both arms and legs.

Initial laboratory studies showed negative beta HCG, routine laboratory results showed sodium of 142, potassium 3.9, chloride 98, bicarbonate 20, BUN 13, and creatinine 0.5, glucose of 43. Serum prolactin level was <0.3.  Random serum cortisol was 0.4; Subsequent ACTH stimulation test showed serum cortisol of 2.3 and 2.7 at 30 and 60 minutes respectively. TSH was 3.59 with free T4 of 1.05. FSH and LH were 6.0 and 2.7 respectively. Pituitary MRI showed a small pituitary gland with no mass.

A diagnosis of lymphocytic hypophysitis was made based on the onset of her symptoms following pregnancy, hypoprolactinemia, hypocortisolemia and atrophic pituitary gland. Replacement therapy with hydrocortisone and levothyroxine was commenced and patient showed remarkable clinical improvement. She was discharged home on the 5thday of admission.

Post discharge, she resumed normal menstruation and became pregnant without ovulation induction 6 months after the initiation of therapy. She successfully delivered a healthy baby but was unable to lactate thereafter.

Conclusion: Most diagnosis of LYH are made clinically, as we did with our patient. Tissue confirmation is usually unnecessary. This case underscores the importance of making the appropriate diagnosis of LYH in young patients who present with amenorrhea, hypoprolactinemia, hypocortisolemia and atrophic pituitary gland without excessive blood loss during labor. Recognition of this syndrome is crucial, since patients can be successfully treated with hormone replacement therapy and may resume normal menstruation and have normal conception and delivery.

 

Nothing to Disclose: AOA, VL, JNS, JHL

22636 12.0000 LBS-088 A Successful Spontaneous Pregnancy Following Diagnosis of Lymphocytic Hypophysitis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Neuroendocrinology and Pituitary Saturday, March 7th 3:00:00 PM LBS 077-089 6295 1:00:00 PM Late-breaking Neuroendocrinology and Pituitary III Poster


Ha Nguyen*1, Fady Riad1 and Rose Ann Salata2
1University of Pittsburgh Medical Center, pittsburgh, PA, 2University of Pittsburgh Medical Center, Pittsburgh, PA

 

Introduction: Hyponatremia is a very common laboratory abnormality found in hospitalization. It is important to differentiate between hypoosmotic hyponatremia and pseudohyponatremia. Here we report a case of concomitant hyponatremia and pseudohyponatremia caused by the syndrome of inappropriate antidiuretic hormone secretion (SIADH) with an unusually high level of low density lipoprotein (LDL-C) from cholestatic disease.

Case presentation: A 67 year old female presented with scleral icterus and a 4cm mass in the head of the pancreas on abdominal imaging. Blood tests were notable for a cholestatic pattern on liver function test and a serum sodium of 127 mM/l. Further evaluation showed a urine osmolality of 622 mOsm/kg, urine sodium 131 mMol/l and measured serum osmolality 292 mOsm/kg. Calculated serum osmolality was 275 mOsm/kg, resulting in osmolar gap of 17 mOsm/kg. Other endocrine causes of hyponatremia including hypothyroidism and adrenal insufficiency were excluded: TSH 2.195 uIU/ml, free T4 1.14 ng/dl and AM cortisol 16 ug/dl respectively. The results were consistent with SIADH, however, this did not explain her osmolar gap and normal serum osmolality. Additional testing excluded significant hyperglycemia, hypergammaglobulinemia and azotemia. A fasting lipid panel demonstrated total cholesterol of 848 mg/dl, LDL-C of 784 mg/dl, triglyceride of 173 mg/dl, and high density lipoprotein cholesterol (HDL-C) of 29 mg/dl. Of note, her lipid profile 2 years prior was within normal range. She was therefore diagnosed with both hyponatremia from SIADH and pseudohyponatremia from severe hyperlipidemia. The patient did not demonstrate any symptoms of hyperviscosity syndrome. Her SIADH was thought to be secondary to her pancreatic cancer. The extreme hypercholesterolemia was likely due to her cholestasis.  She underwent biliary stenting and was discharged on fluid restriction with recommendation to recheck sodium and lipid panel in 1 week.

Discussion: This case demonstrates the importance of following a stepwise approach in evaluating hyponatremia. Causes such as marked hyperglycemia, azotemia, alcohol, hyperproteinemia, and hyperlipidemia should be investigated in cases of hyponatremia with normal or high serum osmolality. Direct potentiometry can minimize the artifact caused by these disorders in measuring electrolytes. This patient’s extremely high LDL-C value is likely from cholestatic liver disease. Lipoprotein (Lp) X has been described as the cause of hyperlipidemia in such situations. The mechanism of LpX formation is not clearly understood; however, it was shown to be immunochemically distinct from LpA and LpB. The presence of LpX can produce a marked increase of both LDL-C and HDL-C. This case also underlines that the presence of one etiology of a disorder does not exclude others and therefore a thorough review of patient’s information is warranted.

 

Nothing to Disclose: HN, FR, RAS

22339 1.0000 LBS-090 A Hickam 's Dictum: Can the Syndrome of Inappropriate Antidiuretic Hormone Secretion and Pseudohyponatremia Coexist? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM LBS 090-092 6298 1:00:00 PM Late-breaking Cardiovascular Endocrinology III Poster


Lissette Arguinzoniz1, Alejandra Vizuet*2, Nelly Altamirano2, Carolina rojas Barrera2, María de la Luz Ruiz Reyes2, Sian Hortensia Fernandez2, Ana Miriam Guerrero Mendez2, Vladimir Gonzalez Lopez2, Berenice Aguirre2, Raúl Calzada Leon2, Nadia Mata2 and Guadalupe Delgado2
1Instituto Nacional de Pediatría, Mexico City, Mexico, 2Instituto Nacional de Pediatria, Distrito Federal, Mexico

 

Lipoprotein Lipase Deficiency

Familial lipoprotein lipase deficiency presents in childhood, it is characterized by very severe hypertriglyceridemia with episodes of abdominal pain, recurrent acute pancreatitis, eruptive cutaneous xanthomata, and hepatosplenomegaly. Clearance of chylomicrons from the plasma is impaired, causing triglycerides to accumulate in plasma and have a milky or lipemic appearance. Symptoms usually resolve with restriction of total dietary fat to ≤20 grams/day.

Female patient 2 months old, family history of  both grandmothers and father with hypercholesterolemia that improves on diet. At birth neonatal screening control was performed with no results, a blood count was reported as lipemic sample, the laboratory performed a screening, reporting cholesterol 1384 mg/dl and TG 16408 mg/dl confirmed later. Hyperhydration and insulin pump was started, with appropiate control. Our patient was evaluated for cardiovascular risk and pancreatitis, ophthalmoligic evaluation reported rectified vasculature, silver glitter, datawire involvment. Transfontanelar  ultrasound is normal, abdominal ultrasound reported  enlarged liver at the expense of the right lobe, no focal or diffuse lesions observed, porta-choledocus relationship is appropriate. Gallbladder is pyriform, thin-walled, spleen parenchyma in regular shape, homogeneous, major axis in 60 mm. 

Inborn metabolism service started on a special diet with reduced TG, prevent fatty acid deficiency essential long chain.

23.07.14 Chol 1384 mg/dl TG 16408 mg/dl, APO 300 mg / dl, APO B 160 mg / dl, TSH 3.04 T3T154, 10.1 T4, FT4 1.4

24.07.14 chol 1411 mg/dl TG 16487 mg/dl, ammonium 122

26.07.14 chol 680 mg/dl TG 8200 mg/dl, HDL 8 mg/dl

28.07.14 chol 206 mg/dl TG 5243 mg/dl, lipase 45, amonium 307, not coagulate

29.07.14 chol 166 mg/dl TG 394 mg/dl, HDL 22.1 mg/dl, LDL 65.2 mg/dl, Uric acid 3.9, glucose 100, creatinine 0.1, urea 2.4, A Phosphatase 221, GGT 14, AST 33 ALT 22 Total Bilirubin 0.86, direct bilirubin 0.21 Na 133 K 5.6 Cl 133 106 P 6.1 Mg 3.5, BC: Leucocytes 14,100, PMN 27% L 65%  Hb13.4 HTO 25%  Platelets 575,000.

30.07.14 chol 152 mg/dl TG 2957 mg/dl, amylase 6.1, lipase 45, ammonium 307

31.07.14 chol 197 mg/dl TG 1020 mg/dl, HDL 22.3 mg/dl, LDL 29.1 mg/dl,

03.08.14 TG 283 mg/dl, ammonium 94

05.08.14: ammonium 67

Dad: Glucose 93, cholesterol 296, triglycerides 693, HDL 33.6, 123.8 LDL, VLDL 138

Mom: Glucose 97, cholesterol 152, triglycerides 111, HDL 38.3, 91.5 LDL, VLDL 22.2

VS: HR 120x RR 40x BP 90/60 mm/Hg, Temp 36.5 ° C

Female patient, normotensive fontanelle, well hydrated, neck with palpable thyroid without cardiopulmonary compromise, soft abdomen, no palpable hepatosplenomegaly Tanner I/I, eutrophic.

Hypertriglyceridemia and hypercholesterolemia

Lipoprotein lipase  deficiency

Chylomicronemia syndrome

We request support for molecular study for Lipoprotein lipase defect and genetic treatment if available.

 

Nothing to Disclose: LA, AV, NA, CR, MDLLR, SHF, AMG, VG, BA, RC, NM, GD

22532 2.0000 LBS-091 A Lipoprotein Lipase Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM LBS 090-092 6298 1:00:00 PM Late-breaking Cardiovascular Endocrinology III Poster


Paulina Cruz Bravo*1 and Anne Carol Goldberg2
1Washington University in St. Louis, St Louis, MO, 2Washington University, Saint Louis, MO

 

Background: Low HDL cholesterol (HDL-C) is a risk factor used to assess cardiovascular risk. Although low HDL-C is very common, levels < 20 mg/dl are rare in clinical practice.

Clinical Case: A 77-year-old woman with history of hyperlipidemia presented with symptoms of acute stroke. She was on aspirin 81 mg daily, vitamin D and fish oil at home. Initial evaluation was consistent with a left middle cerebral artery stroke, and no etiology was identified. Her initial lipid panel showed total cholesterol 105 mg/dL, LDL-C 54mg/dL, HDL-C 7 mg/dl and triglycerides 218 mg/dl.  She had four clinical presentations of stroke within the next 10 months despite standard therapy. Neurological deficits included left-side neglect, left side homonymous hemianopia and cognitive decline. MRI examination was consistent with multiple areas of new infarction at each presentation. Laboratory studies showed normal liver enzymes, TSH, fibrinogen, PT/PTT; Apo-B 130 (48-124), Lp(a) 28 (<30 mg/dl). Hepatitis serologies, HIV, ANA and cardiolipins were negative. Her HDL-C remained below 10 mg/dl. Ultimately a brain biopsy showed diffuse B-cell type intravascular lymphoma. CT of chest, abdomen and pelvis was negative. She received chemotherapy with R-CEOP. After treatment her HDL-C increased to 44 mg/dl. She has remained stable during a 12-month follow up period. 

Discussion: In humans, very low HDL-C usually considered <20 mg/dl. A prior HDL-C level of 68 mg/dl ruled out a primary deficiency.  In the absence of severe hypertriglyceridemia, the differential diagnosis of acquired HDL-C deficiency includes medications like anabolic steroids, hyperthyroidism, acquired LCAT deficiency from severe liver dysfunction, critical illness, artifact, certain infections (HIV, leishmaniasis) and malignancy. Cases of paradoxical very low HDL-C with the use of PPAR-γ agonists have also been reported.  Artifactual very low levels can be seen in the setting of paraproteinemia which our patient did not have. Studies have associated hematological malignancies with very low HDL-C levels. Hematologic malignancies are characterized by mobilization of hematopoietic stem and multipotential progenitor cells (HSPC) from the bone marrow. Three studies consistently showed recovery of HDL-C to normal levels only in the patients that achieved remission. In mice this pathway seems to be mediated by ABCA1/ABCG1 which is crucial in the early cholesterol efflux to ApoA-I into nascent HDL-C. Other known causes of acquired HDL-C deficiency were ruled out. Recovery of HDL-C to near normal levels after treatment suggests a potential direct effect of tumor cells on HDL-C efflux pathways.

Conclusion: Very low HDL-C is associated with hematological malignancies and could be a marker of disease activity. To our knowledge, this is the first case of recovery of very low HDL-C levels after treatment of intravascular B-cell lymphoma of the brain.

 

Nothing to Disclose: PC, ACG

22614 3.0000 LBS-092 A Very Low HDL Cholesterol Level Associated with Intravascular B-Cell Lymphoma of the Brain 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Saturday, March 7th 3:00:00 PM LBS 090-092 6298 1:00:00 PM Late-breaking Cardiovascular Endocrinology III Poster


Faiza Bensmaine1, Kristell LE Mapihan2, Olivier Ernst3, Georges Lion4, Corinne Vigouroux5, Pascal Pigny6 and Marie-Christine Vantyghem*3
1Lille Nord de France University Hospital, Lille, France, 2Lille University hospital, Lille, France, 3Lille Nord de France University Hospital, Lille, 4Lille Nord de France University Hospital, 5Pierre and Marie Curie University, Paris, 6Lille Nord de france University Hospital, Lille

 

Irisin is a myokine, which displays a day-night rhythm, is correlated with lean body mass, and increases after exercise in healthy young individuals, despite an association with major adverse cardiovascular events and polycystic ovary disease (Mantzoros 2014). Increased skeletal muscle volume associated with distal lipoatrophy sparing cervico-facial area has been reported in women with familial partial lipodystrophies (FPLD) (Ji JCEM 214). Our aim was to determine whether irisin could be a marker of FPLD, which is characterized by a decreased fat mass and an increased lean mass. Methods and patients: Circulating irisin levels  (EIA Phoenix) were measured in 20 LMNA-related FPLD, 19 healthy normal-weighed controls (H) and 13 obese non-diabetic (OND) patients, and correlated with body composition (assessed with DEXA and MRI) and metabolic (fasting blood glucose (FBG), insulin, A1c, lipid, transaminases, leptin) and inflammatory (leukocytes CD4, CD8, CRP) parameters (Clin.gov2009-AO-1169-48/PHRC 2009_09/094). Results: Irisin medians differed significantly between the 3 groups (p: 0.0076) and were higher in OND (p: 0.0099) and FPLD (p: 0.047) than in H groups, without any difference between FPLD and OND. Irisin levels, similar between male and female, were positively correlated mainly to lean mass (g)/ height2 (r = 0.51; p<0.0001), BMI (r=0.45; p: 0.0008), triglycerides (r=0.49; p: 0.0002) and to a lesser extent to insulin (r=0.42; p: 0.0026), body weight (r=0.38; p:0.005), lean mass in grams (r=0.33; p: 0.01), MRI-intra-abdominal fat mass (r=0.34; p: 0.01), MRI-intra-abdominal/ MRI-total fat mass (r=0.39; p: 0.0069), FBG (r=0.33; p: 0.01), A1c (r=0.34; p: 0.01), total cholesterol (r=0.39; p: 0.0039), and ASAT (r=0.33; p: 0.01). The ratio “lean mass/height2” differed significantly between the 3 groups (p<0.0001) with higher values in OND (p<0.0001) and FPLD (p: 0.03) compared to H groups, without any difference between FPLD and OND. Leptin levels were significantly higher in OND compared to H and FPLD (p<0.0001), without any difference between these 2 groups. The ratio « irisin/leptin » differed significantly between the 3 groups (p<0.0001) with higher values in FPLD and H (both p<0.0001) compared to OND, without any difference between FPLD and H. Irisin was not correlated with leptin and inflammatory parameters. Conclusion: FPLD are characterized by high irisin and low leptin levels and OND by both high leptin and irisin levels. Irisin levels are increased in diseases characterized by higher lean mass whatever the amount of fat mass. Its unexpected correlation with the ratio intra-abdominal/total fat mass » suggests irisin could be a marker of imbalance between the lean and intra-abdominal fat mass, in concordance with its known role on adipocyte beiging (Weber JCEM 2014).

 

Nothing to Disclose: FB, KL, OE, GL, CV, PP, MCV

22717 1.0000 LBS-093 A Irisin Levels in Lmna-Mutated Partial Lipodystrophies, Compared to Obese and Healthy Control Groups 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM LBS 093-096 6301 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite III Poster


Mayumi Yamamoto*1, Akihiro Nishio1, Aki Kanoh2 and Ryo Horita1
1Gifu University, Gifu, Japan, 2Gifu Univ, Gifu, Japan

 

[Background] The prevalence of diabetes is increasing worldwide among younger people. To prevent this increase, we need more valuable information regarding glucose tolerance in young adults. To investigate the prevalence of high risk group of diabetes, we assessed annual health check-up data in university students.

[Subjects and Methods] Annual health check-up data of 1,204 Gifu University students including 705 male, 499 female, and 83 international students (age range, 18–29 years) were analyzed. Abdominal circumference, body mass index (BMI), blood analysis data; GOT, GPT, LDL/HDL cholesterol, triglyceride, uric acid, fasting plasma glucose (FPG), and fasting serum insulin level were analyzed by chi-square test. Insulin-resistance, HOMAR, was calculated by FPG (mg/dl) x IRI / 405.

[Results] There were no significant differences in background data, between the men and the women, or the Japanese and the international students except HDL levels. The prevalence of obesity in international students was significantly higher than in Japanese students. Only three students had HbA1c levels over 5.9% and were diagnosed with pre-diabetes (IGT) by 75gOGTT. On the other hands, 68 (10.2%) of Japanese men, 9 (23.0%) of international men, 88 (19.3%) of Japanese women, and 9 (20.5%) international women, had insulin resistance with HOMA-R above 2.5. There were no significant differences with FPG or HbA1c in each student groups or in each BMI levels. However, the average of HOMAR levels was increased correlated with the BMI level increase. The increase value of HOMAR in Japanese men was the biggest in four groups. Additionally, the percentage of individuals with insulin resistance was significantly higher in obese students than that in non-obese students. We traced the body weight of these students. During campus life, from entry to graduation, mainly 4 or 6 years, students with obesity increased their body weight and students with lean decreased their body weight. This trends were typical in international men and Japanese women students.

[Discussion] The prevalence of diabetes was low in university students. However, the number of students with insulin resistance and obesity were not low. For the screening of high risk group of diabetes in younger population, HbA1c levels over 5.9% was not strong enough, HOMA-R above 2.5 evaluation of insulin resistance could be useful. If there were any barrier of insulin measurement, the body weight following up might be useful to select the high risk people as a target for intervention of diabetes prevention. In university, urgent anti-diabetes action is need, education avoiding body weight increase for students might be effective. To slowing the increase of diabetes patients, early detection and early prevention / intervention are important.

 

Nothing to Disclose: MY, AN, AK, RH

22833 2.0000 LBS-094 A Obesity in University Students from Annual Health Checkup Data: Difference Between Japanese and International Students 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM LBS 093-096 6301 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite III Poster


Ashley Hall Shoemaker*1, Joseph Proietto2, M. Jennifer Abuzzahab3, Tania Paulette Markovic4, Jaret Malloy5 and Dennis D Kim5
1Vanderbilt University, Nashville, TN, 2Austen Health, Bulleen Victoria, Australia, 3Childrens Hospitals and Clinics of Minnesota, Saint Paul, MN, 4Boden Institute, Bellevue Hill NSW, Australia, 5Zafgen, Inc., Boston, MA

 

Beloranib is a methionine aminopeptidase 2 inhibitor that potently reduces body weight (BW), hunger, and restores balance to the production/utilization of fat; prior studies have shown ~11 % BW loss over 12 wks in exogenously obese patients.  Hypothalamic injury associated obesity (HIAO) presents most commonly in patients with craniopharyngioma, following surgical resection and radiation therapy. HIAO patients fail to regulate metabolism and food intake, resulting in rapid intractable BW gain, treatment resistant severe obesity, and associated comorbidities.

This was a randomized, double‐blind, placebo-controlled study. Fourteen adults with HIAO from 4 study sites were randomized to receive twice weekly SC doses of 1.8 mg (n=8) of beloranib, or placebo (n=6) for 4 wks. All patients had radiographic evidence of hypothalamic damage with documentation of subsequent rapid and significant BW gain. Those completing 4 wks of randomized blinded therapy were offered an open-label extension for 4 additional wks, during which all patients were to receive 1.8 mg of beloranib. No diet/exercise counseling was provided.

Thirteen out of 14 patients (9 females, age 31.9 yr, BMI 42.8 kg/m2, BW 126.4 kg) completed 8 wks of follow up. One patient randomized to placebo discontinued treatment prematurely during the randomized portion of the study due to a suspected allergic reaction. Another patient randomized to placebo was excluded from efficacy analysis due to a dosing error, leaving 12 patients (8 on beloranib, 4 on placebo) in the pre-specified per protocol efficacy population and are presented here. After 4 wks of randomized blinded therapy, patients on 1.8mg of beloranib lost an average (±SEM) of -3.40 ± 0.6 kg of BW vs. -0.25 ± 0.9 kg for placebo (p=0.01). After 4 additional wks of open label treatment, patients originally randomized to beloranib lost a total of -6.15 ± 0.9 kg of BW. Patients originally randomized to placebo lost -3.0 ± 0.9 kg during the 4-wk open label extension; this rate of BW loss is similar to that seen during beloranib treatment in the randomized period.  Known markers of beloranib response (lipid profile and markers of inflammation) also were improved at 4 and 8 wks, commensurate with beloranib treatment. There were no serious adverse events reported in the study and almost all reported adverse events were of mild intensity and transient. No patients treated with beloranib withdrew due to adverse events. All safety measures (laboratory, vital signs, ECGs) were unremarkable.

This Phase 2 study demonstrated proof-of-concept for the safety and effectiveness of beloranib on BW and cardiovascular risk markers in 14 adult patients with HIAO over 4 wks of treatment. Open label extension results suggest no apparent waning of effect within 8 wks. These results support a novel extra-hypothalamic mode of action of beloranib to mediate improvements in BW and cardiometabolic profile.

 

Disclosure: JM: Employee, Zafgen, Inc.. DDK: Employee, Zafgen, Inc.. Nothing to Disclose: AHS, JP, MJA, TPM

22774 3.0000 LBS-095 A Randomized, Double-Blind, Placebo Controlled 4 Week Proof of Concept Trial of Beloranib Resulted in Rapid and Significant Weight Loss in Patients with Hypothalamic Injury Associated Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Saturday, March 7th 3:00:00 PM LBS 093-096 6301 1:00:00 PM Late-breaking Obesity, Adipocyte Biology and Appetite III Poster


Somlak Chuengsamarn*1, Suthee Rattanamongkolgul2, Sivaporn Wannaiampikul3, Vipavee Anupunpisit4, Luminata H. Pojoga5, Gordon H. Williams5 and Thep Himathongkam6
1Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakornnayok, Thailand, 2Department of Preventive and Social Medicine, Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakornnayok, Thailand, 3Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand, 4Department of Anatomy, Faculty of Medicine, Srinakharinwirot University, Bangkok,Thailand, 5Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts, USA, 6Theptarin Hospital, Bangkok, Thailand

 

Background and rationale: Pre-diabetes (Pre-DM) and type 2 diabetes (T2DM) representing as insulin resistance (IR) together with or without hypertension (HT) were defined to increase risk of cardiovascular disease and mortality rate thus any method in early detection of genetic variant of single-nucleotide polymorphism (SNP) related to these diseases was extremely benefit of genetic data base for a physician to choice of the best treatment for these patients. By our literature review, we have remained to be found only one publication by Williams G. and Pojoga L. shown in the Caucasian hypertensive cohort, minor allele carriers of two cav1 SNP (rs 926198, rs 3807959) associated with IR and HT whereas cav1 knockout mouse displayed higher blood pressure levels and IR. However, the association between the variation of SNP (rs 926198, rs 3807959) and IR with or without HT remains controversial by a role of ethnic differences or may be affected by insulin function thus it must remain to be proven in these relationships of other ethnic differences in Caucasian and particularly, in other Asian ethnicities.

Objective: Our study aim to prove the cav1gene polymorphism of two SNP (rs 926198, T/C) and (rs 3807959, A/G) in Thai population associated with metabolic dysfunction (IR and/or HT).

Methodology: A case control study was performed by separation into three groups as the following: T2DM with or without HT (N=320), pre-DM plus HT (N=170), and control group defined as non-T2DM and/or non-pre-DM and non-HT (N=290). We used polymerase chain reaction- restriction fragment length polymorphism (PCR-RFLP) for detection of two cav1SNP (rs 926198, T/C) and (rs 3807959, A/G).

Results:

The odds ratio (ORs), 95% confidence intervals (CI), and p-value of the SNP (rs 926198, T/C) for TC and CC versus TT genotype were 1.65 (1.10-2.48); p=0.02 and 3.66 (0.73-18.31); p=0.11, 2.01 (1.28-3.15); p <0.00001 and 6.39 (1.27-32.15); p=0.02, and 1.70 (1.23-2.57); p <0.001 and 4.65 (1.03-20.98); p=0.05 whereas the SNP (rs 3807959, A/G) for AG and GG versus AA genotype were 0.98 (0.70-1.37); p=0.89 and 0.65 (0.29-1.47); p=0.30, 1.07 (0.72-1.58); p=0.75 and 0.57 (0.20-1.60); p=0.29, and 1.01 (0.74-1.37); p =0.95 and 0.62 (0.30-1.29); p=0.20 into three groups of T2DM, pre-DM plus HT, and overall (T2DM and pre-DM plus HT), respectively. Our result indicated that only in the variation of SNP (rs 926198, T/C) but not SNP (rs 3807959, A/G) variant was significantly statistic related to IR and/or HT.  

Conclusions: In Thai population (Southeast Asia), the variation of SNP (rs 926198, T/C) is associated with IR and/or HT but not in the SNP (rs 3807959, A/G). We could be summarized to application of SNP (rs 926198, T/C) variant for early screen and detection in Thai population with high risk to development of metabolic dysfunction (IR and/or HT).

 

Nothing to Disclose: SC, SR, SW, VA, LHP, GHW, TH

22858 1.0000 LBS-097 A Caveolin-1(CAV1) Gene Variant Associated with Pre-Diabetes Plus Hypertension and Type 2 Diabetes in Thai Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Siobhan Bacon1, Britta Engelbrecht2, Jasmin Schmid2, Shona Pfeiffer2, Caoimhín Concannon2, Ailbhe McCarthy1, Marie Burke3, Jochen H.M. Prehn4 and Maria Michele Byrne*1
1Mater Misericordiae University Hospital, Dublin 7, Ireland, 2Royal College of Surgeons in Ireland, Dublin 2, Ireland, 3Mater Misericordiae University Hopsital, Dublin 7, Ireland, 4Royal College of Surgeons in Ireland, Dublin 2

 

Aims: MicroRNA (miRNA) are a unique class of non-coding, 19-25 nucleotide RNA that are critical for network-level regulation of gene expression. miRNAs are secreted from cells and can serve as paracrine signalling molecules. miRNAs have been identified as potential biomarkers for micro- and macrovascular complications with the potential to be of clinical utility in diabetes care [1-3].  HNF1A-maturity-onset diabetes of the young (HNF1A-MODY) is the most common monogenic form of diabetes resulting from mutations in the gene encoding the pancreatic transcription factor hepatocyte nuclear factor 1α (HNF1A). We have recently demonstrated that induced suppression of endogenous HNF1A function in INS-1 cells, a cellular model of HNF1A-MODY, increased the levels of two specific miRNAs; miR-103 and miR-224 [4]. The role of circulating miRNA in diabetes has been studied almost exclusively using whole blood, serum and plasma of human subjects. The aim of this current study was to obtain proof-of-concept that miR-103 and miR-224 are also detectable in the urine of HNF1A-MODY carriers, and to determine whether these diabetes-associated miRNA are also elevated in the urine of patients with type 1 and type 2 diabetes mellitus. Finally, we sought to correlate urinary levels of miRNA with indices of renal disease.

Methods: Absolute levels of miR-103 and miR-224 were determined in the urine of n=144 individuals including HNF1A-MODY carriers, participants with type 1 and type 2 diabetes mellitus and normal controls. miRNA expression levels were correlated with clinical parameters. Serial miRNA measurements were performed in a subset of participants.

Results: miR-103 was significantly elevated in the urine of HNF1A-MODY carriers and participants with type 1 and type 2 diabetes mellitus, and miR-224 in the urine of HNF1A-MODY carriers and participants with T1DM when compared to normal controls. We noted highest expression levels and a significant correlation between miR-103 and miR-224 levels (ρ=0.57, p=<0.01 and ρ=0.41, p=<0.01) in the HNF1A-MODY and type 1 diabetes mellitus groups. There was no correlation with clinical indices of renal function. There was no significant difference noted on serial urinary miR-103 and miR-224 measurements. These particular urinary miRNA appear to be robust and independent of dietary restriction which is important in a clinical setting.

Conclusion: We here provide the first proof-of-concept that diabetes-associated miRNA can be readily detected in the urine of HNF1A-MODY carriers and participants with T1DM, T2DM when compared to controls. The differential expression levels miR-103 and miR-224 in insulin deficient states in particular, in T1DM and HNF1A-MODY may be an attempt to compensate for beta cell demise. The monitoring of miR-103 and miR-224 may prove to be insightful for detecting beta cell failure.

 

Nothing to Disclose: SB, BE, JS, SP, CC, AM, MB, JHMP, MMB

22393 2.0000 LBS-098 A Diabetes-Associated Mirnas Are Readily Detectable in Urine of Individuals with Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus, and HNF1A-Mody 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Luciene de Carvalho Cardoso Weide*1, Anderson Martins Tavares2, Christiane Bensusan2 and Giselle Fernandes Taboada1
1Universidade Federal Fluminense, Rio de Janeiro, Brazil, 2Universidade Federal Fluminense, Niterói, Brazil

 

In T2DM, the decrease in antioxidant capacity and soluble forms of RAGE (sRAGE) levels might be associated with the severity of micro and macrovascular complications. The oxidative stress due to excessive ROS production and low antioxidant SOD and GPx activities are related to impaired glucose metabolism and the development of diabetes complications. Several pathophysiological mechanisms have been implicated in the genesis of chronic complications of T2DM. Among them, the formation of advanced glycation end products (AGEs) seems to have a key role, through their interaction with their surface receptor (RAGE) leading to an increased expression of cytokines, inflammatory response and oxidative stress induction. On the other hand, soluble forms of RAGE (sRAGE) which are the result of alternative splicing or cleavage of RAGE, prevents AGE-RAGE interaction, acting as a protective factor. It has been demonstrated that recombinant sRAGE can prevent and reverse micro and macrovascular complications of diabetes. Moreover, the association between sRAGE levels with the degree of glycemic control and antioxidant enzymes are not yet well established.  Herein we have evaluated the correlation between sRAGE levels and the activities of antioxidant enzymes with HbA1c levels in 27 TDM2 patients. Patients (58.6 ±2.28 years old) were distributed according to their HbA1c levels in 3 groups: well controlled diabetes (HbA1c <7%), poorly controlled diabetes (7≤HbA1c ≥9%) and uncontrolled diabetes (HbA1c > 9%). sRAGE serum levels were evaluated through ELISA assay KIT, while SOD and GPx activities were assessed by colorimetric assays. In HbA1c <7% patients, sRAGE serum levels were 295 ± 14.6 pmol/µl,  SOD and GPx activities, 11.35± 3.37U/ml and 71.82±11.22 nmol/h/ml, respectively. In 7≤HbA1c ≥9%, sRAGE serum concentration was 502 ± 250,3 pmol/µl, SOD activity 7.72±3.10 U/ml and GPx activity 68.51±4.20 nmol/h/ml, respectively. In HbA1c > 9% group, sRAGE serum concentration was 290,2 ± 12.7 pmol/µl, SOD and GPx activities were 9.87±2.13 U/ml and 61.17±6.68 nmol/h/ml, respectively. We have found a significant increase in sRAGE serum levels (p <0,01) in 7≤HbA1c ≥9% group, when compared to the other two groups, while SOD and GPx activities were not statistically different. In conclusion, the increased sRAGE levels found in poorly controlled diabetes compared to well controlled diabetes might be an attempt to remove the excesses of AGEs levels, as it has scavenger properties. On the other hand, the lowest sRAGE levels found in uncontrolled diabetes was unexpected and might be related to the development of the complications.

 

Nothing to Disclose: LDCCW, AMT, CB, GFT

22484 3.0000 LBS-099 A Evaluation of Soluble Forms of RAGE and Antioxidant Capacity in Patients with Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Irfan Nuhoglu*1, Cihangir Erem2, Mustafa Kocak3, H Onder Ersoz4 and Nadim Civan4
1KTU Medical Faculty, trabzon, Turkey, 2KTU Medical Faculty, Istanbul, Turkey, 3KTU Medical Faculty, Trabazon, 4KTU Medical Faculty, Trabzon

 

Abstract:
The objectives of this study were to determine the prevalence of diagnosed and undiagnosed diabetes mellitus (DM), prediabetes and to evaluate the associated risk factors in the sample of adult Turkish population.
This was a cross-sectional population based study.
A total of 4000 eligible study subjects aged 20 or older, chosen by multistage sampling on a field were selected. Of those 3721 subjects (2139 women and 1582 men) participated in the study. The study was performed between 2010-2012 in Trabzon providiece. Anthropometric and demographic data of all subjects enrolled in the study were filled in forms and physical evaluations were performed in the residences according to the study procedure. The persons included in the questionnaire were invited to the local medical centers for blood examination following 12 h of fasting.
The prevalences of prediabetes and DM were found to be as 6.4% and 10.4% (new diagnosed 3.6%), respectively. There was no a significant difference between men and women for the prevalence of diabetes. Also, the prevalence was similar residential areas. Diabetic prevalence was found to increase significantly by aging in both genders (p<0.0005). The prevalence reached its peak level in age group of ≥70 years (29.2%). In multivariate logistic regression analysis, advanced age (OR:26.7 in the group 70 years and over), marriage(OR:2.05), housewifes (OR:1.34), high monthly income (OR:2.52 in the group of income≥2250 TL), positive family history of diabetes (OR:2.84), overweight (OR:1.61), obesity (OR:2.25), hypertension (OR:1.42) and dyslipidemia (OR:1.38) were independent risk factors for the development of diabetes.
The prevalence of diabetes is increasing in our region as well as our country and the world. New diagnosed diabetic patients who are unaware of their status are at high risk. To control DM and associated risk factors, effective public health education, providing a well- balanced diet and increasing physical activity are needed.

 

Nothing to Disclose: IN, CE, MK, HOE, NC

22497 4.0000 LBS-100 A The Prevalence of Diabetes and Associated Risk Factors Among Adult Population in a Turkish Population (Trabzon City) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Gustavo Francisco Gonzales*1, Carmen Maldonado1 and Lijia Xu2
1Universidad Peruana Cayetano Heredia, Lima, Peru, 2Institute of Medicinal Plant Development (IMPLAD), Beijing, China

 

Diabetes mellitus (DM) is a chronic disease whose rates are increasing significantly worldwide (1). Type 2 diabetes mellitus is associated with a subclinical systemic inflammation. Increased levels of interleukin (IL) 6, a pro-inflammatory cytokine, were associated with DM and with impaired glucose tolerance (2). Consumption of maca (Lepidium meyenii), a brassicaceae from the Peruvian highlands, is associated with reduced serum IL 6 levels in adult men and women (3). Further study in diabetic male mice treated with Black maca (BM) extract during 8 days decreased blood glucose levels (4). In the present study we demonstrate a dose-response and time response effect of black maca on glucose levels in male rats with and without DM.

For this, three months old male rats of the Wistar strain were induced to diabetes with one dose of nicotinamide (120 mg/Kg) (ip) and streptozotocin (50 mg in 0.1 m Citrate buffer) (ip). Animals were divided in 5 control groups and 5 diabetic groups, with 6 male rats per group. All groups received one of the following treatments: 1) vehicle, 2) black maca 10 mg, 3) black maca 50 mg, 4) black maca 250 mg or 5) metformin 300 mg. Blood glucose was measured at days 1, 7 and 14 of treatment. Maca or metformin had no effect on glucose levels in normal adult male rats. Treatment with maca extract or metformin but not vehicle reduced glucose concentration over time in diabetic male rats. All three dose of black maca reduced glucose at days 7 and 14 of treatment, but a dose response effect was observed only with 10 and 50 mg black maca. To demonstrate if the effect of black maca is inhibiting insulin resistance (IR) at hepatic level, the effect of Maca extract powder on improving insulin resistance in hepatocellular carcinomic cells (HepG2) was investigated.

The HepG2 cells were treated at high concentration of glucose (55 mmol/L) to establish the insulin resistance cell model (5). The glucose consumption was measured by glucose oxidase and peroxidase (GOD-POD) assay. For this experiment, it was assessed two maca varieties: red maca and black maca.

Red Maca increased the glucose consumption at the concentration of 80-100ug/mL and Black Maca increased the glucose consumption at a lower concentration of 40-60ug/mL (99.69±7.98% and 105.23±13.35%, respectively)(P<0.01 vs control) in HepG2 cells with induced insulin resistance. This effect of maca extracts was not observed in HepG2 cells without IR. Conclusion: Extracts of maca can reduce glycemia in rats with DM, through an improvement in the insulin resistance as observed in IR-HepG2 cells. The detailed molecular mechanism still needs to be explored in the future.

 

Nothing to Disclose: GFG, CM, LX

22515 5.0000 LBS-101 A Extracts of Black Maca Reduces Glycemia on Streptozotocin-Induced Diabetes in Male Rats and Reduces Insulin Resistance (IR) in HepG2 Cell Line in Vitro 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Havva Gonca Tamer*1, Banu Isbilen2, Burcu Dogan2, Osman Kostek2 and Ozge Telci Caklili2
1Medeniyet University, Göztepe Training and Research Hospital, Istanbul, Turkey, 2Istanbul Medeniyet University Goztepe Training and Research Hospital

 

Objectives: T helper (Th)1 cells are known to have important roles in the destruction and/or dedifferentiation of β-cells in type 1 diabetes (T1D). We aimed to investigate the relationship between Th1 cytokines (IFN-γ, IL-2 and TNF-α ) and T1D and the effect of those cytokines on β-cell function.

Material and Methods: The study included 98 type 1 diabetic patient(T1DP)s and 30 healthy subjects. β-cell function of  98 T1DPS was assessed by measuring C -peptide levels after mixed-meal tolerance test (MMTT). T1DPs were divided into 3 groups according to the C-peptide levels after MMTTs and the groups were as follows: patients with undetectable ≤0.1 ng/mL (group 1a, n=30) C-peptide; minimal 0.1-0.8 ng/mL (group1b, n=30); and sustained ≥0.8ng/mL (group1c, n=38) C-peptide levels which increased at the 90th minute after the meal 150% of fasting C-peptide level.  Serum IFN-γ, IL-2 and TNF-α levels were measured using ELISA method. Serum levels of those cytokines in T1DPs were compared with those in controls.  Also, cytokine levels of group 1a, group1b and group 1c were compared with each other.

Results Serum IFN-γ and IL-2 levels of T1DPs were higher (p<0,05, p<0,05, respectively) and TNF-α levels were lower (p<0,05) in T1DPs than in control subjects. There were no differences among IFN-γ , IL-2 and TNF-α levels of group 1a, group 1b and group1c ( p>0,05 p>0,05, p>0,05, p>0,05, respectively).

Conclusion:   IFN-γ, IL-2 and TNF –α may have roles in the initiation of the T1D pathogenesis, however they may not have an effect on the progress of β-cell dysfunction.

 

Nothing to Disclose: HGT, BI, BD, OK, OT

22551 6.0000 LBS-102 A Role of T-Helper 1 Cytokines in Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Winifred P Wong1, Keith W MacRenaris2 and Malek El Muayed*3
1Northwestern University, Chicago, IL, 2Northwestern University, Evanston, IL, 3Northwestern University School of Medicine, Chicago, IL

 

Introduction: Type-2 diabetes is a multifactorial disease. Contributing factors include genetic predisposition, life style, as well as environmental factors. Accumulation of non-essential transition metals in insulin producing islets of Langerhans due to environmental exposure is a potential contributor towards islet dysfunction and the development of diabetes mellitus.  This is supported by epidemiologic evidence including a recently published analysis of the NHANES data by us that showed a positive association between urinary cadmium (Cd) excretion –a marker of Cd exposure- and prediabetes. We previously reported that cadmium accumulates avidly in insulin producing beta cells, leading to an impaired function. Herein, we report the content of the non-essential transition metals Cd, arsenic (As), and lead (Pb), in human insulin producing islets from the general US population. Methods: islets were obtained through the NIH supported integrated islet distribution program (IIDP) and analyzed by inductively coupled plasma mass spectroscopy (ICP-MS). One Cd content outlier of more than 2 standard deviations from the mean at 469 nmol/g protein was omitted from the gender and age correlation analysis. Results: The average islet Cd content was lower compared to the Ni content at 31.35 +/- 9.0 nmol/g protein (n=48). The average islet As and Pb contents were low at 5.6 +/- 1.7 nmol/g protein (n=15) and 4.5 +/- 1.1 nmol/g protein (n-23) respectively. A significantly higher islet Cd content was found in islets from women compared to men (29.7 +/- 4.1 vs 19.36 +/- 2.49 nmol/g protein respectively, p=0.043). There was a non-significant trend towards a positive correlation between age and islet Cd content (n=51, P=0.07, R2 = 0.0824).

 

Nothing to Disclose: WPW, KWM, ME

22598 7.0000 LBS-103 A Levels of Cadmium, Arsenic, and Lead in a Sample of Human Insulin Producing Islets of Langerhans from the General US Population 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Rajneesh Nath*1, Kirk W Johnson2, Julie M Roessig1, Ken Der1, Ann C. Neale1, Paul Rubin3 and Ira D Goldfine3
1XOMA (US) LLC, Berkeley, CA, 2XOMA (US) LLC, Berkely, CA, 3XOMA Corporation, Berkeley, CA

 

Hyperinsulinemic hypoglycemia (HH), a complication of non-resectable insulinomas and Congenital Hyperinsulinism, remains a serious medical concern with limited therapeutic options.  We recently described a fully human IgG2 monoclonal antibody XOMA 358 to the human insulin receptor (InsR) that allosterically inhibits insulin action both in vitro and in HH mice (mAbs 6:262, 2014).  We herein report results from a Phase 1, Double-blind, Placebo-controlled, Single Ascending Dose Study to Assess the Safety, Tolerability, Pharmacokinetics and Pharmacodynamics of intravenous doses of XOMA 358 in Healthy Adult Male Subjects. 4 subjects in the sentinel cohort were to receive 4 active drug and 2 were to receive placebo; 3 subjects in subsequent cohorts were to receive active drug and one was to receive placebo. Doses of 0.1, 0.3, 1, 3, 6 and 9 mg/kg were scheduled for administration in sequential cohorts, with dose escalation based on safety and pharmacokinetic (PK) review. Serum insulin, glucose, β-hydroxy butyrate, C-peptide and glucagon levels were monitored as potential biomarkers. Mixed meal tests (MMTs) were scheduled pre-dose at day -1 and post-dose at days 1, 2, 3 and 6. Once changes in insulin and glucose consistent with induced insulin resistance were observed in a cohort, a 15 minute insulin tolerance test (ITT) was performed in subsequent cohort(s) pre-dose on day-1 and post-dose on days 1, 2, 3 and 5 to assess insulin sensitivity. Subjects remained in-patient from day -1 or day -2 (cohorts with ITT) until day 7 after drug administration. Dosing was stopped at cohort 4 (3 mg/kg) after observation of pharmacologic effects consistent with drug-induced insulin resistance; overall, 14 active and 5 placebo doses were administered to a total of 19 subjects. XOMA 358 appeared to be well-tolerated; there were no serious adverse events or severe adverse events. 11/14 subjects experienced adverse events. All drug-related adverse events were mild (43/46) or moderate (3/46), and none required either concomitant medication or invasive procedures for management. The PK was linear with a drug half-life of approximately 14 days.  Dose-related increases in post-prandial glucose levels as measured in the MMTs were observed through day 6 following drug infusion, with the Day 3 glucose AUC nearly 80% greater than placebo at the 1 mg/kg dose level. Fasting HOMA-IR values, a measure of XOMA 358-induced insulin resistance, were likewise elevated by XOMA 358 in a dose-dependent manner and at peak time points, ranged from 2 to 9-fold over baseline for 0.1 to 3 mg/kg doses, respectively. A marked reduction in insulin sensitivity was verified via the ITT procedure at the 3 mg/kg dose level; markedly reduced KITT values in the XOMA 358-treated subjects were observed relative to either placebo or baseline values. The safety and clinical pharmacology of XOMA 358 may justify further exploration in patient population(s) with HH.

 

Disclosure: RN: Employee, XOMA LLC. KWJ: Employee, XOMA LLC. JMR: Employee, XOMA LLC. KD: Employee, XOMA LLC. ACN: Employee, XOMA LLC. PR: Employee, XOMA LLC. Disclosure Not Provided: IDG

22934 8.0000 LBS-104 A Xoma 358, a Novel Treatment for Hyperinsulinemic Hypoglycemia: Safety and Clinical Pharmacology from the First in Human Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Sri Prakash L Mokshagundam*1, Leila Gobejishvili2, Deepa Mokshagundam2, Vatsalya Vatsalya2, Maiying Kong2 and Shirish S Barve2
1Robley Rex VA MEdical Center, Louisville, KY, 2University of Louisville, Louisville, KY

 

The role of the gut microbiome in the pathophysiology of Type 2 Diabetes Mellitus (T2DM) and its complications has been gaining increasing recognition. Increased gut permeability and microbial translocation are postulated to play a significant role in mediating the effect of the gut microbiome on diabetes through their effects on inflammatory pathways. Soluble CD14 (sCD14) is useful marker of microbial translocation and macrophage activation. The serum sCD14 levels increase during the systemic response to bacterial invasion and endotoxin. The association between multiple markers of inflammation and several micro and macrovascualr complications of T2DM have been well recognized. However, individuals with T2DM often have multiple complications, both micro and macrovascular, concurrently. The Diabetes Clinical Severity Index (DCSI) is a useful and validated tool that incorporates multiple complications to assess individual's risk of adverse outcomes. 

Methods:17 subjects with T2DM between 25 – 80 yrs were recruited for the study from a diabetes specialty clinic. Clinical documentation from charts were used to calculate DCSI. Blood samples were drawn in the fasting state for measurements of gut permability markers (endotoxin and sCD14) and inflammatory markers (IL-6,IL-8, TNF, MCP-1, PAI-1). To assess the relationship between gut permeability markers , inflammation markers, and DCSI, multiple linear regressions were used.  

Results: There were 9 male and 8 female subjects recruited (Age - 61.1 +/- 10.4 years, BMI 36.1 +/- 7.1, and A1c 9.1 +/- 1.9 %). sCD14 showed significant association with IL-6 (R2 = 0.276, p = 0.021) and IL-8 (R2 = 0.287, p = 0.019). The DCSI score was 1.94 +/- 1.4. DCSI measure did not show any significant association with MCP-1 (p = 0.102) with MCP-1 as the contributing variable in the regression model.   However,  this association augmented to significant  level when sCD14 and PAI-1 were included as covariates (R2 = 0.364, p= 0.022). Similarly, DCSI showed significant association with IL-8 (p = 0.046) when CD14 with TNF-a was included in the analysis, and IL6 showed nearly significant association with DCSI (p = 0.078) when sCD14 and TNF were included in the analysis.

Discussion: The complex associations between sCD14, inflammatory markers and DCSI suggest a pathway wherein microbial translocation leading to immune activation and inflammation lead to poor outcomes in diabetes. The precise sequence of events and the nature of these interactions need further elucidation. The earliest step is likely to be microbial translocation due to increased gut permeability. Understanding the nature of these interactions and developing interventions that could favorably alter these pathways will likely lead to better outcomes in T2DM.

 

Nothing to Disclose: SPLM, LG, DM, VV, MK, SSB

22493 9.0000 LBS-105 A Association of Soluble CD14 with Inflammatory Markers and Disease Severity in Type 2 DM 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Wolfgang Moritz*1, Irina Agarkova1, Richard Prazak1, Simon Messner1, Roger Lehmann2 and Jens Kelm1
1InSphero AG, Schlieren, Switzerland, 2University Hospital Zurich, Zurich, Switzerland

 

Primary pancreatic islets are an important source for in-vitro research related to diabetes and metabolic disorders. The quality of pancreatic islets with respect to purity and viability can vary significantly between different isolations particularly from human sources depending on donor characteristics, cause of death and other confounding factors. Exocrine tissue impurities, size heterogeneity and partial cell death are the main factors which negatively affect data robustness obtained from experiments using freshly isolated pancreatic islets. Here we present a new in vitro model of standardized human or rat pancreatic islets of homogeneous size and cell composition for improved data robustness and reproducibility.

Islet Microtissues are produced from single cell suspensions of freshly isolated human or rat islets and subsequent re-aggregation in hanging drop cultures. After spheroid formation microislets are transferred into 96-well GravityTRAP™ plates (InSphero) at 1 microislet per well for further culture and analysis. This production procedure yields islets of identical cellular composition at a predefined size, depending on the number of cells initially seeded into the hanging drop with a size variation of less than 10% in diameter. Islets microtissues can be cultured on non-adhesively coated GravityTRAP™ plates for up to 5 weeks with sustained viability (3-5pmol ATP/IEQ) and functionality. Glucose stimulated insulin secretion from 5 consecutive human donor preparations was 0.04±0.03 fmol/min*IEQ at 2.8 mM glucose and 0.35±0.15 fmol/min*IEQ at 16.5 mM glucose, with a stimulation factor ranging from 5-19 fold. GLP-1 further enhanced insulin secretion at high glucose by a factor 1.1-2.0. Conversely, glucagon secretion was inversely correlated with glucose concentration. Treatment of human and rat islet microtissues with therapeutic doses of Tacrolimus and Rapamycin confirmed their diabetogenic effect as glucose-stimulated insulin secretion was blunted in both species.

Their longevity, metabolic and secretory performance, responsiveness to co-secretagogues in combination with a high degree of standardization promote microsislets for large scale screening campaigns for both, diabetes research and drug safety testing, while sparing tedious islet picking by hand.

 

Disclosure: WM: Management Position, InSphero AG. IA: Employee, InSphero AG. RP: Employee, InSphero AG. SM: Employee, InSphero AG. JK: Management Position, InSphero AG. Nothing to Disclose: RL

22683 10.0000 LBS-106 A Standardized Rat and Human Pancreatic Microislets for Diabetes Research and Drug Safety Assessment 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Nancy Fawzy Nakhoul*1, Hani Tamim1, Youssef Mouneimne2, Lara Nasreddine2, Mohamad Ghassan Abiad2, Hussain Ismaeel1 and Mona Philippe Nasrallah1
1American University of Beirut, Beirut, Lebanon, 2American University of Beirut

 

INTRODUCTION: The Middle-East is described to have the fastest rate of rise of T2D (1). There are no longitudinal studies in Lebanon to measure the time-trend of diabetes prevalence and hence to demonstrate an increase.  We have conducted a cross-sectional study of screening for diabetes and compared our findings  to a similar study, conducted 10 years earlier (2), to estimate the overall prevalence of diabetes and to determine whether the latter is indeed increasing over time.

METHODS: This was a cross-sectional, community-based study using multistage probability sampling, of a representative sample of 501 adult Lebanese men and women residing in the Greater Beirut Area. Subjects who agreed to participate had medical history, anthropometric measures, and laboratory data including FPG and HbA1C collected at the American University of Beirut. Participants were classified as with definite diabetes (DD) if they had history of diabetes and/or both FPG ≥126 mg/dl and HbA1C≥ 6.5%;  probable diabetes (PD) if they had history of diabetes and/or either FPG ≥126 mg/dl, or HbA1C≥ 6.5%; at risk for diabetes (prediabetes) if FPG between 100 and 125 mg/dL or HbA1C between 5.8 and 6.49% without previous diabetes history. The data was analyzed using IBM SPSS statistics version 20.0.0.

RESULTS: The sample had 65% women and 35 % men, mean age 45.3 ±15 years, mean BMI: 29.4 ± 5.9 Kg/m2. Prevalence of DD was 15.1% (95% CI: 11.9% to 18.2%), PD 18.2% (95%CI: 14.8% to 21.6%), and prediabetes  40.4% (95%CI: 36.1% to 44.7%) in the overall sample.  Out of the PD, 5.1 % (or 28 % of total PD) were not previously known. Subjects with PD were more obese: mean BMI 33 ± 6.2 Kg/m2. The prevalence did not statistically differ between genders (P=0.24); however, it increased with age. In subjects aged 40 years or more (n=296) the prevalence increased to 26.9% (95%CI: 21.83% to 31.97%), out of which 7.8%  were newly diagnosed. In order to compare to a previous cross-sectional study, when HbA1C was removed as a criterion for diagnosis, the PD prevalence for people ≥ 40 y/o decreased to 23.7% (95%CI: 18.85% to 28.55%). The community-based study conducted 10 years earlier on Lebanese adults aged above 40 years,  using history of diabetes or FPG as criterion had prevalence of 15.8 % in Greater Beirut area, out of which 4.5 % were newly diagnosed (2).

CONCLUSION: By comparing two-cross-sectional studies conducted with very similar set-ups, we conclude that the prevalence of T2D has increased by an absolute 7.9 % (from 15.8 to the current 23.7%) over a 10-year period, which represents a 50 % increase in prevalence, in the Greater Beirut area. The percent of unknown diabetes remains the same over time at 28% out of the total. Its risk factors are also concurrent with previous studies (3). Our study cannot be generalized to a national level and may be affected by selection bias. Nonetheless, Lebanon seems to be affected by the rapid rate of rise in T2D observed in the rest of the Middle-East.

 

Nothing to Disclose: NFN, HT, YM, LN, MGA, HI, MPN

22740 11.0000 LBS-107 A Is the Prevalence of Diabetes Increasing in Lebanon? 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Manindra Singh* and Fabian Benencia
Ohio University, Athens, OH

 

The epidemic of obesity presents a concerning scenario worldwide due to its association with diseases, such as type II diabetes, ischemic heart disease, atherosclerosis and some cancers. Adipose tissue acts as an active endocrine organ and secretes a number of bioactive peptides commonly known as adipokines that regulate a variety of functions including glucose and lipid metabolism, insulin sensitivity, blood clotting, and inflammation. Adipokines mediate paracrine crosstalk between adipocytes and endothelial cells (ECs) in the adipose microenvironment and guide vascular growth and angiogenic processes. Previous studies indicated a link between cardiovascular diseases and hyper-vascularization of adipose tissue, and the application of anti-angiogenic agents reduced adipose hypertrophy in mice (1), suggesting a close proliferative link between vasculature and adipose tissue. But the function of adipokines for the regulation of angiogenesis at the level of adipose vasculature is unknown. In this study, we examined the function of adipokines visfatin, vaspin and leptin for their capacity to induce angiogenic response in ECs. To identify the growth factors and chemokines secreted by vascular ECs under the treatment of these adipokines, a protein microarray was performed. Cell-culture supernatant harvested after the adipokine treatment was used for the detection of secreted growth factors by microarray and ELISA. Additionally, the expression of angiogenesis-associated factors– matrix metalloprotease-2 and -9 (MMPs), vascular endothelial growth factor (VEGF), VEGF164, basic fibroblast growth factor, angiogenin and heparanase, was measured using real-time qPCR. In addition, MMPs isolated from adipokine-treated endothelial cells were further examined by the zymography analysis in the absence of protease inhibitors. Further, the function of these adipokines was examined for their capacity to induce the proliferation of endothelial cells to participate in the formation of vascular-like structures by cell-cultures on collagen I coated plates. The production of VEGF at protein level was upregulated w.r.t. control in response to all three adipokines: visfatin (114%), vaspin (83%) and leptin (140%) (n=5), suggesting a role of these adipokines in VEGF-mediated proliferative responses in vascular endothelial cells. Visfatin treatment upregulated the production of MMP-9 at RNA level (p<0.01, n=5). Overall our results confirm the role of these adipokines for the regulation of angiogenic responses in vascular endothelial cells. Investigation of adipokine function to regulate angiogenesis will help identify potential link between vascular growth and adipogenesis, and may identify potential molecules for therapeutic intervention of obesity-related disorders by the targeting of vascular compartment of adipose tissue.

 

Nothing to Disclose: MS, FB

22807 12.0000 LBS-108 A Investigation of Adipokine-Induced Angiogenic and Proliferative Responses in Vascular Endothelial Cells: Linking Angiogenesis to Adipogenesis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Nasser M. Rizk*1, Elham Sharif1, Amina Saleh Fadel1, Basma Ba'Omar1, Haneen Shublaq1 and Azza Khder2
1Qatar University, Doha, Qatar, 2Hammad Medical corporation, Doha, Qatar

 

Normal pregnancy is characterized by an increase in free radical production and lipoperoxidation towards the end of the pregnancy compared to healthy non-pregnant women. Women with gestational diabetes mellitus are expected to have an imbalance of pro-oxidant-antioxidant balance than normal pregnant women. The aim of the current study is to measure the level of  oxidative stress  (ROS) markers in gestational diabetic women and compare their levels with healthy control pregnant women at 24-28 weeks of gestation, and to further correlate their results with the newborns outcome.  A cross-sectional study was performed on 61 pregnant women between 24-28 weeks of gestation; of which 21 were diagnosed with GDM and 40 were healthy control pregnant women. They were recruited from antenatal care- women hospital at HMC, Qatar.Elisa technique was performed on the following markers; lipoidperoxidation(MDA) and the antioxidant buffer system including the total antioxidant capacity (TAC), antioxidant enzymes: superoxide dismutase (SOD), glutathione reductase (GPx) and myeloperoxidase MPO). Anthropometric analysis was performed on newborns such as height, weight, head circumference, Ponderal index and Apgar score.  Control and GDM pregnant women were matched for age, BMI, and blood pressure. The median and the interquartile (25%-75%) plasma concentrations of TAC in GDM was 11.19(9.32- 12.49) mol/μl and in control of 11.83(10.27- 12.40) mol/μl, (p=0.5085), GPx activity of GDM was 1.74(0.78- 3.94) mU/ml and in control was 3.59(1.97-6.78), (P =0.0790). SOD activity of GDM 90.24(74.73- 113.02) and control 86.12(79.83- 98.05) and (p value=0.8665), MPO of GDM 7324.57(2160.18- 9836.98) pg/ml and control 8162.04(844.104- 15140.94) pg/ml (P =0.4916). A significant increase of MDA was present in GDM 14.00(11.62- 28.31) nmol/ml than in control 14.167(11.83- 17.67) nmol/mlvalue of 0.048. No significant associations of the neonatal birth weight, Apgar score and ponderal index with ROS markers in both GDM and control. These data suggest an imbalance in pro-oxidant-antioxidant balance among GDM in late gestation. GDM is characterized by an increase in lipoidperoxidation (MDA), without a corresponding increase in the anti-oxidant buffer system (TCA, SOD, Glutathione reductase and MPO).  Further longitudinal studies are needed to highlight the long-term effects on GDM subjects as they are pre-diabetic to type 2 DM.

 

Nothing to Disclose: NMR, ES, ASF, BB, HS, AK

22942 13.0000 LBS-109 A Increased Lipid Peroxidation in Gestational Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Ivan De Backer*1, Christopher Holton2, Yue Ma3, Stephen R Bloom1 and James V Gardiner1
1Imperial College London, London, United Kingdom, 2Imperial College London, United Kingdom, 3Imperial College London

 

Background: Glucokinase (GK) is an essential component of glucose sensing, including in the brain. GK is expressed in the dorsal vagal complex (DVC) of the brainstem, a structure composed of several nuclei including the medial nucleus tractus solitarius (mNTS). GK in the mNTS is believed to be involved in glucose sensing, but its role has yet to be determined.

Aims and hypothesis: This study aims to investigate the role of GK in the mNTS. We hypothesize that GK in the mNTS is a regulator of energy homeostasis.

Experimental approach: The role of mNTS GK in energy homeostasis was examined by genetic GK knockdown (iNTS-GKAS) using stereotactic injection of a viral vector encoding for GK antisense (rAAV-GKAS). Long-term food and 10% (w/v) glucose solution intake, as well as body weight, were measured. Knockdown of mNTS GK was quantified using in situ hybridization and a GK activity assay.

Results and discussion: GK knockdown in the mNTS had no effect on either body weight or food or glucose consumption. However, it significantly increased the total energy intake (chow + glucose) of iNTS-GKAS rats compared to green fluorescent protein-injected control rats (iNTS-GFP), suggesting that mNTS GK may act as a negative regulator of energy intake. In situ hybridization revealed that rAAV-GKAS was accurately injected in the mNTS and was localized to this region while a GK activity assay exposed a significant reduction in mNTS GK activity in iNTS-GKAS rats compared to iNTS-GFP controls. Together, the data collected suggests that GK located in the mNTS is involved in energy homeostasis.

 

Nothing to Disclose: ID, CH, YM, SRB, JVG

22536 14.0000 LBS-110 A Investigating the Physiological Role of Glucokinase in the Nucleus Tractus Solitarius in the Regulation of Energy Homeostasis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Lingdan Chen1, Emily Dinning2 and Ayotunde O Dokun*3
1University of Virginia Health System, Charlottesville, 2University of Virginia, Charlottesville, 3University of Virginia Health System, Charlottesville, VA

 

Diabetes mellitus (DM) is associated with poor peripheral arterial disease (PAD) outcomes in humans and in preclinical model of PAD, but the mechanisms involved are poorly defined. We recently identified ADAM12 as a gene that is upregulated in ischemia and sufficient to improve PAD outcomes in mice following experimental PAD. Moreover, miR29a was recently implicated in the regulation of ADAM12 in fibroblasts, but its role in ischemia induced ADAM12 expression is not known. Here we tested the hypothesis that DM may alter ADAM12 expression through modulation of miR-29a.

In vitro we assessed whether miR-29a could regulate ADAM12 expression in primary human endothelial cells under simulated ischemia (hypoxia and serum starvation) by transfection of miR29a mimic followed by quantitative RT-PCR analysis of mRNA expression. In vivo we compared ischemia induced upregulation of ADAM12 mRNA, protein and miR29a expression in day 3 post ischemic hind limbs of mice with no diabetes, type 1 diabetes (DM1) and type 2 DM (DM2) following experimental PAD.

MiR-29a mimic transfection suppressed ischemia induced upregulation of ADAM12 expression (ADAM12 mRNA/HPRT=0.98±0.02, control vs, 0.16±0.01 mimic, n=4, p<0.01). In mice with no DM miR-29a was downregulated in ischemic hind limbs (ischemic vs non-ischemic =0.05 ± 0.02 vs 0.21 ± 0.09, n=6/grp, p<0.05) and this downregulation was associated with upregulation of ADAM12 (ischemic vs non-ischemic: mRNA/HPRT=0.5 ± 0.2 vs 0.02± 0.01, n=4/grp, p<0.05). However in mice with DM1 or DM2 there was no downregulation of miR29a expression (DM1 vs non DM: ischemic/non-ischemic =1.18 ± 0.083 vs 0.24 ± 0.029, n=4/grp, p<0.01 and DM2 vs non DM: ischemic/non-ischemic =1.9±0.4 vs 0.8±0.3, n=8/grp, p<0.05) and this was associated with blunted upregulation of ADAM12 protein (DM1 vs non DM: protein/actin= 0.3±0.1 vs 0.6±0.19; DM2 vs non DM: protein/actin=0.50±0.04 vs 1.4±0.2, n=3-4/grp, p<0.05). Analysis of ADAM12 mRNA showed less mRNA in ischemic DM1 hind limbs but no change in ischemic DM2 mRNA (DM1 vs non DM: mRNA/HPRT=2.5±0.6 vs 5.0±0.7; n=4-6/grp, P<0.05; DM2 vs non DM: mRNA/HPRT= 0.5±0.16 vs 0.5±0.16, n=4/grp, NS ).

Impaired ischemia induced upregulation of ADAM12 in DM1 and DM2 may contribute to the poorer outcomes observed in diabetic mice following experimental PAD and may be a mechanism contributing to poor PAD outcomes in humans.

 

Nothing to Disclose: LC, ED, AOD

22781 15.0000 LBS-111 A A Molecular Mechanism Involved in Poor Perfusion Recovery in Diabetes; Role of Impaired Regulation of miR29a in Ischemia 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Laura Daniela Ratner*1, Carla Agustina Marcial2, Guillermina Stevens2, Matti Poutanen3, Ilpo T. Huhtaniemi4, Ricardo S Calandra2 and Susana Beatriz Rulli1
1Institute of Biology and Experimental Medicine, Buenos Aires, Argentina, 2Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina, 3University of Turku, Turku, Finland, 4Imperial College London, London, United Kingdom

 

Transgenic female mice overexpressing the human chorionic gonadotropin β-subunit (hCGβ+) exhibit constitutively elevated levels of hCG, develop hyperprolactinemia, infertility and obesity with the presence of abdominal fat at adulthood. The females show hyperinsulinemia, hypertriglyceridemia, glucose intolerance and insulin resistance at 6 months of age. The aim of this study was to analyze the influence of hyperprolactinemia on the glucose and lipid metabolism in adult hCGβ+ females. To this end, the dopamine agonist, cabergoline was administered to 5-week-old hCGβ+ females every other day (500 µg/kg; vía i.p.) during one week (hCGβ+cab). We have previously demonstrated that this treatment was able to correct hyperprolactinemia and infertility of hCGβ+ females (1). At six months of age, intraperitoneal glucose tolerance test (IGTT) was performed in mice fasted for 6 hs (2 g/kg glucose, via i.p.), and insulin tolerance test (ITT) was performed after 4 hs fasting (0,75 IU/kg insulin, via i.p.); serum glucose levels were determined at 0, 30, 60 and 90 min post-injection. Cabergoline treatment produced a complete reversion of glucose intolerance and insulin resistance, as determined by normalization of the IGTT and ITT curves, as well as a significant reduction in insulin and triglyceride levels (p<0,001). On the other hand, the gene expression of preproinsulin (Ins-1, Ins-2) and glucagon (Gcg) in pancreas was analyzed by quantitative reverse transcription polymerase chain reaction (qRT-PCR). The hCGβ+cab females showed a significant decrease in Ins-1 e Ins-2 gene expression levels in comparison to hCGβ+ females (p<0,05), without changes in Gcg. In conclusion, a short-term treatment with cabergoline at young ages effectively prevented the hyperprolactinemia-associated metabolic dysfunctions of hCGβ+ mice, which were manifested at adulthood. These findings provide strong evidence that elevated prolactin levels have a key role for the metabolic alterations in hCG overproducing females.

 

Nothing to Disclose: LDR, CAM, GS, MP, ITH, RSC, SBR

22547 16.0000 LBS-112 A The Effect of Hyperprolactinemia on Glucose and Lipid Metabolism in a Transgenic Mouse Model with Human Chorionic Gonadotropin (hCG) Hypersecretion 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Naresh Ramesh*1, Haneesha Mohan2 and Suraj Unniappan3
1Laboratory of Intergrative Neuroendocrinology, Saskatoon, SK, Canada, 2Laboratory of Integrative Neuroendocrinology, Saskatoon, SK, 3University of Saskatchewan, Saskatoon, SK, Canada

 

Nesfatin-1 (82 amino acid) is a peptide encoded in a secreted precursor, nucleobindin-2 (NUCB2). It is an anorexigenic and insulinotropic peptide found abundantly in the brain, gastric oxyntic mucosa, and the endocrine pancreas. Exogenous nesfatin-1 decreases food intake, and stimulates insulin secretion. Nucleobindin-1 (NUCB1) is a protein with very high similarity to NUCB2. Human NUCB1 exhibits 62% amino acid sequence identity with NUCB2. NUCB1 also encodes a very conserved nesfatin-1 like peptide (NLP). The NUCB1 sequences also retain the proposed prohormone convertase (PC) cleavage sites. The cytoplasmic presence of NUCB1 and the fact that it is a secreted protein suggest a potential endocrine function for NUCB1 and/or its encoded peptides. We hypothesized that the NLP region of NUCB1 is biologically active. The main objectives of this research are to determine if NUCB1 is present in the pancreatic islets of mice, and to test the effects of synthetic NLP on insulin secretion. In silico analysis using SignalP 4.1 server found a signal peptide cleavage site at position 25 (Arg) and 26 (Val) preceding the NLP region in NUCB1 sequence. Further analysis using ProP 1.0 server showed potential proprotein convertase cleavage sites at Lys-Arg (KR), forming a 77 amino acid NLP. This was reaffirmed using NeuroPred™ cleavage site and protein mass prediction tool. Immunofluorescence based analysis detected NUCB1-like immunoreactivity in a murine pancreatic beta cell line (MIN6 cells). NUCB1 is co-localized with insulin in the pancreatic islet beta cells. RT-PCR analysis found NUCB1 mRNA in both pancreas and MIN6 cells. In order to assess the effects of synthetic NLP on preproinsulin mRNA expression and insulin secretion, MIN6 cells (2X105 cells/well, n=8 wells/treatment; 3 separate studies) were incubated for 1 hour with synthetic rat NLP. At 1 hour post-incubation, insulin secretion (ELISA/RIA) into the culture media, and expression preproinsulin mRNA expression (quantitative RT-PCR) were determined. NLP significantly upregulated preproinsulin mRNA expression at 10 nM (~1.6 fold) and 100 nM (~2.7 fold) doses. Concurrently, insulin secretion was also stimulated at 10 nM (87.7±2.57 ng/mL) and 100 nM (92.7±4.5 ng/mL) NLP compared to untreated controls (67.8±2.5 ng/mL, p<0.05). In identical experiments using MIN6 cells and a scrambled peptide derived from the NLP, the scrambled peptide at the doses tested did not elicit any effects on preproinsulin mRNA expression or insulin secretion. Based on our results, NLP appears as another endogenous insulinotropic peptide. Future studies examining endogenous NLP and its mechanism of action in regulating glucose homeostasis and insulin secretion warrant consideration.

 

Nothing to Disclose: NR, HM, SU

22918 17.0000 LBS-113 A Nucleobindin-1 (NUCB1) Encodes an Insulinotropic Nesfatin-1-like Peptide 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Asim Hassan1, Muhammad Shoaib Zaidi*2, Samir Ouizi3, Mohammad AlDerwish4 and Emadeddin Raddaoui5
1King Abdul Aziz University Hospital, Riyadh - K.S.A., 2King Abdul Aziz University Hospital, Riyadh, KSA, Saudi Arabia, 3King Abdul Aziz University Hospital,, Riyadh, Saudi Arabia, 4KING ABDUL AZIZ UNIVERSITY HOSPITAL, RIYADH, Saudi Arabia, 5King Khalid University Hospital, Riyadh, Saudi Arabia

 

Background:

Diabetes has been linked with malignancies like colon, rectum, liver, biliary tract, pancreas, kidney, leukemia and melanoma. Melanoma can sometimes manifest as a diabetic foot ulcer. A recent large cohort study found that colon, rectum, liver, biliary tract, pancreas, kidney, leukemia, and melanoma are significantly elevated among men with diabetes.5 In 1985,O'Mara et al 6 noted a

raised risk of melanoma and nonmelanoma skin cancers in women with diabetes.


Clinical Case:

 A 67 years old Saudi male with Type 2 diabetes for 9 years & hypertension, presented to the foot clinic of our University Diabetes centre in October 2012 with a non-healing,painful, right heel ulcer,for 9 months before the presentation. According to the patient there was no preceding foot trauma & he was receiving optimum wound care before, without  satisfactory results. He was retired, a non-smoker and led a sedentary lifestyle. He was on Gliclazide  80mg BD,Metformin500mg BD and an unknown antihypertensive.

On examination our patient was fully conscious & comfortable. He was of average built and height and hemodynamically stable. Weight 78 kgs. Overall general physical examination was normal.  

The gross systemic examination related to cardio-respiratory, gastro-intestinal, genito-urinary systems was also quite unremarkable.    

The podiatric exam revealed a roundish hyperpigmented ,bleeding ulcer( 2x2cms) with macerated edges at the lateral border of the heel of right foot(Grade 2B University of Texas) It was tender, malodorous & discharging &  was associated with right leg edema & redness. The hair in the legs was scanty and toe nails were dystrophic. The big toe showed a hallux limitus deformity.The patient was found to be wearing ill-fitted shoes.

Both the dorsalis pedis & posterior tibial pulses were faintly palpable bilaterally. The ankle-brachial indices & toe pressures were normal on both sides(ABI--L/R, 1.13 vs 1.10,toe pressures L/R,76/77mmHg).There was loss of  protective sensations in both the feet{Neurology Disability Score(NDS) < 6/10,VibrationPerceptionThreshold( VPT) (L/R) > 30 vibration units)}. His HbA1c was 8.7%(<7%) All the baseline investigations, including  Xrays feet were unrevealing.

The patient underwent  three punch biopsies  of the skin by the dermatologist and that was reported as Invasive Malignant Melanoma (epidermal ulcer, with 3mm Breslow thickness).

Our patient was finally referred to the plastic surgeon, who did a complete excision of the heel lesion, along with removal of the regional lymph nodes and skin grafting.    

Take-Home Message:

A chronic,non-healing ulcer in a diabetic foot should be taken seriously.A low threshold for foot biopsy should be kept for an atypical, non-healing ulcer esp.in the absence of neuropathy & vasculopathy,to rule out malignant melanoma.Delay in diagnosis may lead to the spread of lesions, or limb amputations in case of distal changes.


 

Nothing to Disclose: AH, MSZ, SO, MA, ER

22407 18.0000 LBS-114 A Diabetes & Malignancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Saturday, March 7th 3:00:00 PM LBS 097-116 6304 1:00:00 PM Late-breaking Diabetes & Glucose Metabolism III Poster


Yufang Bi*, Weiqing Wang, Tiange Wang, Min Xu, Jieli Lu, Yu Xu and Guang Ning
Rui Jin Hospital, Shanghai, China

 

Importance: Whether exposure to bisphenol A increases the risk of diabetes has become a major public health concern. Current human studies to evaluate the relationship between bisphenol A and diabetes were mostly based on cross-sectional data, and yielded controversial findings because of differences in population characteristics and study design.

Objective: To examine the association between bisphenol A exposure and diabetes development.

Design, setting and participants: Between June and August 2009, 3,423 residents aged 40 years or older from Shanghai, China were enrolled in a prospective study. Among 2,336 diabetes-free participants at baseline, 2,209 completed follow-up investigations between March and May 2013.

Main outcome: Type 2 diabetes was determined by oral glucose tolerance test and supplemented by a definite diagnosis by physicians.

Results: During the 3.7-year follow-up period, 241 participants developed diabetes (incidence rate: 2.9/100 person-years). The multivariate-adjusted hazard ratios (95% confidence intervals) for incident diabetes were 0.77 (0.54-1.09), 0.58 (0.40-0.85), and 0.70 (0.48-1.003) for urinary bisphenol A quartile 2, 3 and 4, respectively, as compared with the first quartile. A 1-standard deviation increase in bisphenol A was not significantly associated with incident diabetes (hazard ratio, 0.91; 95% confidence interval, 0.80-1.04). Propensity-score-adjusted analysis and propensity-score-matched analyses further confirmed the lack of association between bisphenol A and incident diabetes.

Conclusions: This may be the first prospective study to examine whether bisphenol A exposure is associated with the development of type 2 diabetes in community settings.

 

Nothing to Disclose: YB, WW, TW, MX, JL, YX, GN

22786 1.0000 LBS-051 A Bisphenol a Exposure and Incident Diabetes: A Prospective Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM LBS 051-055 6307 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals & Gene Regulation Poster


Giampaolo Trivellin*1, Ivana Bjelobaba2, Adrian F Daly3, Albert Thiry4, Chiara Villa5, Darwin Omar Larco6, Leticia F. Leal7, Fabio R Faucz2, Marie Helene Schernthaner-Reiter8, Martha M Quezado9, William E. Farrell10, T John Wu6, Stanko S Stojilkovic11, Benjamin Feldman2, Albert Beckers3 and Constantine A Stratakis11
1National Institute of Health, Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3CHU de Liège-University of Liège, Liège, Belgium, 4Centre Hospitalier Universitaire de Liège, Liège, Belgium, 5University of Liège, Liège, Belgium, 6Uniformed Services University, Bethesda, MD, 7Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 8National Institutes of Health (NIH), Bethesda, MD, 9National Cancer Institute, Bethesda, MD, 10Keele University, Stoke on Trent, Staffordshire, United Kingdom, 11Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD

 

Background: We recently showed that Xq26.3 microduplications are associated with early childhood-onset gigantism, a condition we named X-linked acrogigantism (X-LAG). Patients with X-LAG present with mixed GH/PRL secreting pituitary macroadenomas and/or hyperplasia. The smallest region of overlap for the microduplications include 4 coding genes, of which only one, an orphan G protein coupled receptor named GPR101, is highly expressed in tumor tissue. So far, very little is known regarding GPR101’s exact localization or expression, particularly in humans.

Aim of the study: To study GPR101 expression across different species, with a particular focus on the hypothalamus and pituitary gland.

Patients and methods: GPR101 expression was investigated at the mRNA and protein level, by qRT-PCR/whole in situ hybridization and immunostaining, respectively, in human, rat, rhesus monkey, and zebrafish tissues.

Results: GPR101 was found to be expressed at very low levels or was not expressed in almost all adult human tissues examined, with the exception of specific regions of the brain, including the nucleus accumbens. High expression of GPR101 was observed in the human fetal pituitary but not in adult pituitary tissue and in pituitary tumors other than those with Xq26.3 defect. In contrast to human tissues, adult pituitaries of both rhesus monkey and rat express GPR101. However, the pituitary cell type expressing this receptor differs: gonadotrophs in monkeys and somatotrophs in rats express GPR101. In the developing zebrafish embryo, GPR101 showed a bimodal expression pattern: expression levels progressively waning during the first cell divisions (presumably representing maternal transcripts) and then gradually rising with the appearance of the first somites. Beginning at 48h post-fertilization a strong and brain-specific staining including part of the hypothalamus and pituitary was seen.

Conclusions: This study shows that the brain is the major site of GPR101 expression across different species, although divergent species-specific expression patterns are evident, especially concerning the pituitary. These findings suggest that the receptor may play an important role in both brain and pituitary development (zebrafish and human data), and that its expression in the pituitary is regulated in a cell type- and developmental stage-specific manner in different species (rat, monkey, and human data). These differences might reflect the very different growth, development and maturation patterns among species. It is also interesting to note that the highest GPR101 expression levels in adult human tissues were observed in the nucleus accumbens, which plays an important role as the reward center, hinting that GPR101 might also be involved in the regulation of behavior, such as food seeking.

 

Disclosure: AFD: Clinical Researcher, Pfizer, Inc., Ad Hoc Consultant, NPS. AB: Medical Advisory Board Member, Novartis Pharmaceuticals, Investigator, Ipsen, Clinical Researcher, Pfizer Global R&D. Nothing to Disclose: GT, IB, AT, CV, DOL, LFL, FRF, MHS, MMQ, WEF, TJW, SSS, BF, CAS

22590 2.0000 LBS-052 A Characterization of GPR101 Expression Across Different Species 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM LBS 051-055 6307 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals & Gene Regulation Poster


Susan Euling*, Todd Blessinger, Glinda Cooper, Matt Lorber and Linda Phillips
US Environmental Protection Agency, Washington, DC

 

The preliminary materials for EPA’s Integrated Risk Information System (IRIS) Toxicological Review of DIBP were recently developed. DIBP is a plasticizer that confers flexibility and durability in industrial and consumer products. A systematic literature search of several databases identified a limited data set for DIBP. The available epidemiological studies assessed the relationship between urinary concentrations of the DIBP metabolite mono-isobutyl phthalate (MIBP) and a range of health endpoints including developmental, neurodevelopmental, immunological, reproductive, metabolic, and breast cancer outcomes. Animal toxicological studies include those that assessed “phthalate syndrome” male reproductive developmental endpoints after in utero DIBP exposure. Data from the largest developmental toxicology study, Saillenfait et al. (2008), shows changes in anogenital distance, male reproductive organ weights, and litter incidence of phthalate syndrome endpoints in the lower dose range after early gestational exposure in rats. Other studies observed increased fetal mortality, male postnatal and adult growth decrements, decreased fetal testicular testosterone and changes in expression of genes in androgen production pathways, cholesterol transport, and Insl3. The developmental reproductive effects observed in animal studies are consistent with the reduced testicular testosterone mode of action that has been well characterized for the developmentally-toxic phthalates. Other rodent studies reported effects on liver and kidney weight and function in both male and female adults. Priority research needs include epidemiologic studies that examine DIBP exposure, testosterone levels, and phthalate syndrome outcomes throughout development; multigenerational reproductive toxicity studies; and cancer bioassays. (Disclaimer: The views expressed are those of the authors and do not necessarily reflect the views or policies of the US EPA.)

 

Nothing to Disclose: SE, TB, GC, ML, LP

22941 3.0000 LBS-053 A Hazard Potential of Di-Isobutyl Phthalate (DIBP) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM LBS 051-055 6307 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals & Gene Regulation Poster


Anna-Maria Andersson*1, Ulla Nordström Joensen2, Jacob Pontoppidan Thyssen2, Niels Jørgensen2 and Hanne Frederiksen2
1University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark, 2Copenhagen University Hospital, Copenhagen, Denmark

 

Background: Filaggrin is an epidermal protein that is crucial for skin barrier function. Up to 10% of Europeans and Asians carry filaggrin gene (FLG) loss-of function mutations which cause dry skin and likely facilitate transfer of allergens such as nickel and chromium across the epidermis. We have previously hypothesized that these individuals also have increased transdermal uptake of endocrine disruptors and accordingly showed significantly higher urinary excretion of several of the most common phthalate metabolites in FLG-loss-of function mutation carriers when compared to controls with no mutations(1).

Objectives: Here, we investigated urinary excretion of parabens, phenols and UV-filters in men with and without FLG loss-of-function mutations.

Methods: By TurboFlow-LC-MS/MS 8 simple phenols, 6 parabens and 9 UV filters were analyzed in urine samples from 65 FLG loss-of-function mutation carriers and 130 randomly selected non-carriers in a nested case-control study from our cohort of young Danish men from the general population.

Results: 13 out of the 23 compounds were detectable in more than half the men.  After adjusting for urinary dilution, date and time of participation, and smoking, we found that FLG mutation carrier status was significantly associated with on average 78% (13-180%) higher urinary concentrations of methyl paraben and 87% (13-219%) higher concentrations of n-propyl paraben. For several other compounds, including benzophenone-1, benzophenone-3 and triclosan there was a tendency towards higher urinary excretion for FLG mutation carriers as well, but none of these tendencies were statistically significant.

Conclusion: Our results indicate that FLG loss-of-function mutation carriers have a higher internal exposure to some non-persistent endocrine disrupting chemicals such as phthalates and parabens, and possibly other types of compounds. This may be due to increased trans-epidermal absorption and/or elevated skin exposure to moisturizers. FLG loss-of-function mutation carriers seem to constitute a susceptible group in which special attention to trans-epidermal absorption of chemicals and medication may be warranted.

 

Nothing to Disclose: AMA, UNJ, JPT, NJ, HF

22543 4.0000 LBS-054 A Increased Urinary Levels of Non-Persistent Endocrine Disruptors in Carriers of the Filaggrin Gene Null Mutation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM LBS 051-055 6307 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals & Gene Regulation Poster


Elaine de Oliveira*1, Ana Paula Santos Silva2, Cintia Rodrigues Pinheiro2, Jessica Lopes Nobre3, Egberto Gaspar Moura4 and Patricia C Lisboa1
1Department of Physiological Sciences, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil, Brazil, 2Department of Physiological Sciences, State University of Rio de Janeiro, RJ, Brazil, 3Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil, Rio de janeiro, 4Department of Physiological Sciences, Roberto Alcantara Gomes Biology Institute, State University of Rio de Janeiro, Rio de Janeiro, RJ, 20551-030, Brazil, Rio de Janeiro, Brazil

 

Bisphenol A (BPA), an endocrine disruptor with wide distribution in environment, binds to nuclear receptors such as estrogen, androgens, glucocorticoids and thyroid hormones receptors. BPA has been found in placenta, amniotic fluid and breast milk and its exposure in early life is associated with precocious puberty and future obesity development, but until this moment, it is still not known the dose capable to cause these disorders. To understanding the long-term effects of different doses of PBA exclusively given through the milk during lactation, we carried out an experimental model where lactating rats were divided into four groups: 1. Control (C): dams receiving daily subcutaneous injections of the vehicle sesame oil; 2. Low dose (LD): dams receiving subcutaneous injections of BPA (0.05 mg/kg/day); 3. Medium dose (MD): dams receiving subcutaneous injections of BPA (5 mg/kg/day); 4. High dose (HD): dams received subcutaneous injections of BPA (50 mg/kg/day). The treatment occurred between the 3rd and 15th days of lactation. Offspring were killed at 180 days old. The use of animals was approved by the Animal Care and Use Committee of the Biology Institute of the State University of Rio de Janeiro (CEUA/005/2013). In males and females adult offspring of C, LD, MD and HD groups, we analyzed the estrous cycle, food intake, body mass, adipose tissue mass, leptin expression in adipose tissue, serum insulin, glucose, estradiol, progesterone and testosterone. Adult male offspring from mothers exposed to LD presented lower food intake, body mass and HOMA IR; male MD offspring had lower visceral adipose mass and HOMA IR, with higher brown adipose tissue; male HD offspring had lower body mass, visceral adipose mass, HOMA IR, estradiol, progesterone and testosterone, with higher brown adipose tissue. In adulthood, female LD offspring showed higher cumulative food intake and lower insulin; female MD offspring had lower leptin expression in subcutaneous fat mass, lower serum insulin, glucose, HOMA IR and progesterone; female HD offspring had lower body weight, leptin expression in subcutaneous fat mass, lower serum insulin, glucose, HOMA IR, progesterone and higher frequency of estrus (ovulatory phase). Maternal exposure to different doses of BPA during lactation affects the endocrine and metabolic regulation in the adult progeny in a gender dependent manner.

 

Nothing to Disclose: EDO, APSS, CRP, JLN, EGM, PCL

22834 5.0000 LBS-055 A Endocrine Dysfunctions in Adult Offspring Whose Mothers Were Exposed to Bisphenol a during Lactation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, March 7th 3:00:00 PM LBS 051-055 6307 1:00:00 PM Late-breaking Endocrine Disrupting Chemicals & Gene Regulation Poster


Michael L Goodson*1, Chelsea A Snyder1, Briana M Young1, Amy Catherine Schroeder2 and Martin Lawrence Privalsky3
1University of California, Davis, Davis, CA, 2Genetech, Inc., San Francisco, CA, 3UC Davis, Davis, CA

 

The corepressor proteins SMRT and NCoR bind to a variety of nuclear receptors to mediate transcriptional repression (typically in the absence of ligand). Our lab and others previously observed that both SMRT and NCoR are subject to extensive alternative mRNA splicing, which created corepressor isoforms that differed in the number and spacing for interaction motifs for nuclear receptors (called CoRNR boxes) These differences resulted in substantial differences in their ability of corepressor isoforms to interact with a diverse array of nuclear receptors. The expression of two isoforms of NCoR (NCoRω and NCoRδ) was regulated during adipogenesis and played opposing roles in regulating adipocyte differentiation.

We generated knock-in mice that selectively ablated the expression of either NCoRω or NCoRδ, while otherwise leaving overall expression of NCoR and SMRT unperturbed. Ablation of the three CoRNR box-containing NCoRω isoform resulted in significantly enhanced weight gain and increased adiposity, which is further exacerbated on a high-fat diet. NCoRω-/- mice also had profoundly more liver steatosis than WT mice. Counterintuitively, these mice were dramatically protected from the diet-induced glucose intolerance normally observed in C57BL/6 mice, this despite having a similar level of impairment to insulin sensitivity to wild type mice. RNA-seq analysis revealed that alternative splicing of NCoR regulated the expression of key metabolic enzymes in fatty acid metabolism, storage and transport.

Intriguingly, loss of NCoRδ resulted in a unique array of metabolic phenotypes that were distinct from those observed with the loss of the NCoRω isoform. Consistent with reciprocal roles for the two isoforms, the NCoRδ-/- mice were leaner, gained less weight on a high fat diet and were protected from high fat diet-induces liver steatosis. However, these mice also had a less impaired glucose tolerance than wild type mice (albeit less dramatically than was observed in the NCoRω-/- mice). Unlike the NCoRω-/- mice, the NCoRδ-/- mice were more insulin sensitive than their wild type counterparts on a high fat diet, suggesting a more conventional mechanism for the improvement in glucose tolerance.

Together these results demonstrate that both NCoRω and NCoRδ each have distinct functions and identify a critical roles for the regulated alternative splicing of NCoR in controlling both glucose and lipid homeostasis and protecting against diet-induced diabetes.

 

Disclosure: CAS: Intern, Genentech, Inc.. ACS: Intern, Genentech, Inc.. Nothing to Disclose: MLG, BMY, MLP

OR39-1 21235 1.0000 A Alternatively Spliced Isoforms of the Corepressor Ncor Regulate Weight Gain, Fatty Acid Metabolism and Glucose Homeostasis in Mice Via Distinct Mechanisms 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR39 5927 9:30:00 AM Nuclear and Peptide Regulators of Glucose Metabolism Oral


Sara M McMillin*1, Nathan E White1, Ling He1, Sally Radovick1 and Fredric Edward Wondisford2
1Johns Hopkins School of Medicine, Baltimore, MD, 2Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

 

Impaired regulation of hepatic gluconeogenesis is a major contributor to hyperglycemia in both type 1 and type 2 diabetes. Since gluconeogenesis is largely regulated at the level of gene expression, this impairment is thought to be due to a lack of insulin mediated suppression and an increase in glucagon mediated stimulation of gluconeogenic gene expression. Although the role of transcriptional activators such as FOXO1 and CREB has been well characterized, the relative contribution of the transcriptional co-activators CBP, P300, and CRTC2 to gluconeogenesis is less well understood. Using a mouse model in which the R1alpha regulatory subunit of protein kinase A (PKA) can be selectively deleted in the liver, we induced a state of constitutive PKA activation mimicking that of high glucagon signaling to the liver. This resulted in a robust increase in the expression of the gluconeogenic enzyme genes Pck1 and G6pc (~10 and 4 fold, respectively), increased fasting blood glucose levels (~2 fold), and increased glucose production in a pyruvate challenge test. However, insulin sensitivity remained unchanged. By using adenoviruses coding for shRNAs against CBP, P300, or CRTC2, we knocked down the expression of each transcriptional co-activator individually and in various combinations in this mouse model. While the individual knock down of either CBP or P300 had little impact on glucose production, the simultaneous knock down of both reduced gluconeogenic gene expression and fasting blood glucose levels to those of the control group.  Furthermore, pyruvate tolerance was significantly improved. The individual knock down of CRTC2 reduced fasting blood glucose levels but had little impact on pyruvate tolerance. Finally, the simultaneous knock down of all three co-activators decreased gluconeogenic gene expression, fasting blood glucose, and pyruvate tolerance to the level of the control group, suggesting that the loss of these three coactivators inhibits PKA stimulated glucose production. These data, along with future studies, will also help to differentiate the roles of these different co-activators in glucose production. Since insulin sensitivity remains intact, our model is unique in that we can identify the contributions of these co-activators to the pathways stimulated by PKA without the concomitant effects of insulin resistance. Future work will compare their roles in this model to those in a model of hepatic insulin resistance in order to better understand the mechanisms by which glucagon stimulation and insulin resistance lead to an increase in hepatic gluconeogenesis.

 

Nothing to Disclose: SMM, NEW, LH, SR, FEW

OR39-2 21994 2.0000 A Assessing the Relative Contributions of Three Transcriptional Co-Activators to Hepatic Gluconeogenesis in Vivo 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR39 5927 9:30:00 AM Nuclear and Peptide Regulators of Glucose Metabolism Oral


Noor Shafina Mohd Nor*1, SoJung Lee2 and Silva A Arslanian3
1Universiti Teknologi MARA (UiTM), Shah Alam, Malaysia, 2Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 3Children's Hosp of Pittsburgh of UPMC, Pittsburgh, PA

 

Background: The gold standard for measuring insulin sensitivity is the hyperinsulinemic-euglycemic clamp.  With the growing childhood obesity epidemic and its consequence of insulin resistance, the need for simple surrogate estimates of insulin sensitivity to be used in epidemiological studies is on the rise.  In adults, the TyG index reflects insulin sensitivity and is useful in identifying individuals with insulin resistance at high risk of developing diabetes.  We examined the TyG index and its relationship to in vivo insulin sensitivity measured with the clamp in obese adolescents along the spectrum of glucose tolerance from normal to prediabetes to diabetes.  

Methods: A cross-sectional study of 225 obese adolescents, 10 to 20 years old, 122 black and 103 white, 114 males and 111 females [156 with normal glucose tolerance (OB-NGT), 37 with prediabetes (OB-preDM), and 32 with type 2 diabetes mellitus (OB-T2DM)].  Participants completed a 3-hour hyperinsulinemic (80mu/m2/min)-euglycemic clamp.  We evaluated the TyG index, calculated as Ln[fasting triglycerides (mg/dl) x fasting glucose (mg/dl)/2], and its correlation with insulin-stimulated glucose disposal (Rd) during the clamp, and the area under the receiver operating characteristic (ROC) curves for the sensitivity and specificity of the TyG index. 

Results: Rd declined across the glycemic groups from OB-NGT to OB-preDM to OB-T2DM (mean + SD : 6.6 + 2.2, 5.5 + 2.3, 4.0 + 2.1 mg/kg/min, p<0.0001), with a corresponding increase in TyG index (8.3 + 0.5, 8.6 + 0.5, 8.9 + 0.6, p<0.0001).  Blacks had lower TyG index compared with whites (8.3 + 0.5 vs. 8.7 + 0.5, p <0.0001).   Spearman correlation coefficient between the TyG index and Rd in the total group was -0.419 (p<0.0001), in blacks -0.366 (p<0.0001), and in whites -0.530 (p<0.0001).  The correlations in each glycemic group were (OB-NGT -0.321, p<0.0001, OB-preDM -0.236, p 0.173, and OB-T2DM -0.383, p 0.033).  In ROC analyses, a TyG index cut-point of 8.52, 69.1% sensitivity and 71.7% specificity, best predicted insulin resistance (Rd <2 SD of normal weight peers) in the total population, 8.93 in whites and 8.43 in blacks.  The area under the ROC curve for TyG index was 0.750 (p<0.0001) in the total population, 0.797 (p<0.0001) in whites and 0.713 (p<0.0001) in blacks.  In multiple regression analysis, 51.4% of the variance in Rd (p<0.0001) was explained by TyG index, BMI z-score, sex, glycemic group and race, with TyG index independently contributing to the model (partial r = -0.412, p<0.0001).

Conclusion: In obese adolescents, the TyG index, might afford an easily available laboratory method as a surrogate estimate of insulin sensitivity that could be used in large-scale pediatric observational and/or interventional cohorts with simplicity of repeated measurements.

 

Nothing to Disclose: NSM, SL, SAA

OR39-3 18228 3.0000 A Triglyceride Glucose (TyG) Index As a Surrogate Measure of Insulin Sensitivity in Obese Adolescents 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR39 5927 9:30:00 AM Nuclear and Peptide Regulators of Glucose Metabolism Oral


Fraser W Gibb*1, Abdullah Faqehi2, Rita Upreti2, Natalie Z Homer3, Brian R Walker3 and Ruth Andrew3
1Edinburgh Centre for Endocrinology & Diabetes, Edinburgh, United Kingdom, 2Centre for Cardiovascular Science, Edinburgh, United Kingdom, 3University of Edinburgh, Edinburgh, United Kingdom

 

Low serum testosterone is associated with an increased risk of type 2 diabetes in men (1).  Previous hyperinsulinemic euglycemic clamp studies have demonstrated a positive association between testosterone and insulin sensitivity ‘M value’(2), but have not dissected whether low testosterone associates with hepatic, adipose or muscle insulin resistance or whether the associations are confounded by obesity. 

To address these questions, we performed low (10 mU/m2/min) and high (40 mU/m2/min) dose hyperinsulinemic euglycemic clamp studies, with stable d2-glucose and d5-glycerol tracers, in eugonadal men (healthy volunteers [n=49] and non-diabetic men presenting for assessment of benign prostatic hyperplasia [n=11]) and measured morning plasma testosterone by LC-MS/MS.  Subcutaneous adipose biopsies were performed in 38 men to assess mRNA transcript levels.

The mean age of subjects was 38 years (95% CI 34 – 43) and the mean BMI was 25.7 kg/m2 (95% CI 24.7 – 26.8).  Testosterone was strongly positively correlated with glucose disposal during low (R 0.480, p <0.001) and high dose insulin infusion (R 0.301, p 0.02).  Testosterone was not significantly associated with endogenous (hepatic) glucose production.  Testosterone was postively associated with higher fasting free fatty acid (FFA) concentration (R 0.422, p <0.001) and higher basal rate of appearance of glycerol (R 0.341, p 0.009) but not with insulin-mediated suppression of FFA or glycerol appearance.  Testosterone was strongly negatively associated with age (R -0.498, p <0.001) but not, in this healthy non-obese group, with BMI or plasma leptin concentration. Plasma testosterone was negatively correlated with adipose mRNA expression of hormone-sensitive lipase (R -0.358, p 0.02), PPARγ (R -0.399, p 0.01) and SREBF2 (R -0.473, p 0.001) but positively correlated with PGC1α (R 0.336, p 0.03).

Associations of testosterone with glucose disposal during low dose insulin infusion and with fasting FFA and glycerol turnover were independent of age and BMI.  These findings suggest that low testosterone exerts adverse effects upon insulin sensitivity by direct action on skeletal muscle, rather than in liver or through changes in body composition.  In addition, testosterone may influence adipose tissue lipolysis independently of insulin.  These mechanisms likely contribute to associations of testosterone with metabolic disease.

 

Nothing to Disclose: FWG, AF, RU, NZH, BRW, RA

OR39-4 20119 4.0000 A Low Serum Testosterone in Men Is Associated with Peripheral Not Hepatic Insulin Sensitivity, Independently of Obesity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR39 5927 9:30:00 AM Nuclear and Peptide Regulators of Glucose Metabolism Oral


Esben T Vestergaard*1, Niels Jessen2, Niels Møller2 and Jens Otto Jørgensen2
1Aarhus University, Aarhus, Denmark, 2Aarhus University Hospital, Aarhus C, Denmark

 

Background–Acyl ghrelin (AG), which is the endogenous ligand for the growth hormone (GH) secretagogue receptor (1), has been shown to induce insulin resistance independently of GH, but it is unknown if this effect depends on stimulation of lipolysis (2,3). 

Objective–To investigate the impact of pharmacological antilipolysis (acipimox) on AG-induced insulin resistance (primary endpoint) and on energy expenditure and glucose metabolism (secondary endpoints) in hypopituitary patients on stable GH and hydrocortisone replacement therapy.

Research Design and Methods–Eight hypopituitary men (age 53 ± 5 years, BMI 30.3 ± 1.9 kg/m2) were investigated. The study was a randomized double blind and placebo-controlled cross-over study. Each subject was investigated in the post-prandial period during 4 different conditions: AG infusion (1 pmol/min/kg i.v.) [A], saline infusion [B], AG and short-term co-administration of acipimox (4 x 250 mg p.o.) [C], and acipimox [D]. Insulin sensitivity as determined by the rate of glucose infusion (the value) was measured after a 3-hr hyperinsulinemic euglycemic (HE) clamp period. Energy expenditure and glucose metabolism were assessed in the basal state and after the HE clamp.

Results–The M value (mg/kg/min) was reduced by AG as compared to saline: 2.73 ± 0.46 [A] vs. 3.08 ± 0.46 [B], P = 0.03. Pharmacological antilipolysis counteracted the effect of AG on the M value: 2.73 ± 0.46 [A] vs. 4.12 ± 0.72 [C], P = 0.01. During maximal antilipolysis AG did not impact on the Mvalue: 4.12 ± 0.72 [C] vs. 4.67 ± 0.75 [D], P = 0.10.

AG infusion and acipimox increased the respiratory quotient in the HE clamp 0.94 ± 0.02 [C] vs. 0.90 ± 0.01 [D], P = 0.04, but did not impact on energy expenditure.

Glucose disposal rate (Rd) was similar in the basal state (mg/kg/min): 1.51 ± 0.09 [A], 1.46 ± 0.08 [B], 1.40 ± 0.11 [C], and 1.41 ± 0.15 [D] but was suppressed by AG infusion in the HE clamp: 3.2 ± 0.4 [A] vs. 3.9 ± 0.6 [B], P = 0.008, and 4.3 ± 0.6 [C] vs. 4.9 ± 0.7 [D], P = 0.04.

Serum free fatty acids were suppressed during the clamp in all 4 situations.

Conclusions and Discussion

  1. AG-induced insulin resistance in skeletal muscle is partly abrogated by short-term acipimox (pharmacological antilipolysis)
  2. We hypothesize that the intracellular effect of acipimox occurred some hours before the clamp procedure
  3. AG may partition glucose utilization from insulin-dependent tissues (muscle) to insulin-independent tissues (brain) during conditions of energy shortage.

 

Nothing to Disclose: ETV, NJ, NM, JOJ

OR39-5 19065 5.0000 A Effects of Acyl Ghrelin Infusion in Hypopituitary Patients on Insulin Sensitivity: The Role of Lipolysis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR39 5927 9:30:00 AM Nuclear and Peptide Regulators of Glucose Metabolism Oral


Jeppe Skov*1, Michael Pedersen1, Jens J Holst2, Bo Madsen1, Jens P Goetze2, Soren Rittig1, Thomas Jonassen2, Jørgen Frøkiær1, Anders Dejgaard3 and Jens Sandahl Christiansen1
1Aarhus University Hospital, Denmark, 2University of Copenhagen, Denmark, 3World Diabetes Foundation, Denmark

 

Liraglutide is a long-acting glucagon-like peptide-1 (GLP-1) receptor agonist, which in addition to the blood glucose lowering effect has moderate antihypertensive properties. Native GLP-1 induces natriuresis in healthy subjects and GLP-1 therapy is nephroprotective in rodents. Limited information is available on the renal effects of liraglutide in humans.

This study investigated the short-term effects of a single-dose 1.2 mg liraglutide and was performed as a placebo-controlled, double-blind, cross-over study in 11 male patients with type 2 diabetes. Measurements included 51Cr-EDTA plasma clearance estimated glomerular filtration rate (GFR) and MRI-based renal blood flow (RBF), renal blood perfusion and oxygenation. Urine was collected to measure lithium and electrolyte clearance rates. 

Liraglutide had no effect on ΔGFR (95% CI -6.8 to 3.6 ml/min/1.73m2) or ΔRBF (95% CI -39 to 30 ml/min) and did not change blood perfusion or oxygenation in either cortex or medulla. The fractional excretion of lithium increased 14% (p=0.01) and there was a tendency towards increased sodium clearance (p=0.06). Initially, the urinary sodium concentration increased 35% (p=0.004) while diuresis tended to decrease (p=0.07). Liraglutide increased diastolic and systolic blood pressure (3 and 6 mm Hg) and heart rate (3 min-1) (all p<0.05). Angiotensin II concentration decreased 21% (p=0.02), but there were no significant effects on renin, aldosterone, angiotensinogen, atrial natriuretic peptide (ANP), mid-region proANP, N-terminal B-type natriuretic peptide and methanephrines or the urinary excretion of angiotensinogen, adrenalin and noradrenalin.

In conclusion, short-term liraglutide treatment did not affect renal hemodynamics or oxygenation in patients with type 2 diabetes. The proximal tubular sodium reabsorption decreased which tended to increase sodium clearance. Blood pressure increased as opposed to the effects reported during long-term treatment. Liraglutide did not affect catecholamine levels and the results could not support the existence of a GLP-1 – ANP axis in humans. Angiotensin II level decreased, which may contribute to renal protection.

 

Disclosure: JS: Clinical Researcher, Novo Nordisk. AD: Stock owner, Novo Nordisk. JSC: Advisory Group Member, Novo Nordisk. Nothing to Disclose: MP, JJH, BM, JPG, SR, TJ, JF

OR39-6 19602 6.0000 A Short-Term Effects of Liraglutide on Kidney Function and Vasoactive Hormones in Type 2 Diabetes: A Randomized Clinical Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR39 5927 9:30:00 AM Nuclear and Peptide Regulators of Glucose Metabolism Oral


Guanghui Li*1, Weiping Wang2, Li Zhang3, James C Rose4 and Weiyuan Zhang5
1Beijing Obstetrics and Gynecology Hospital,Capital Medical University, Beijing, China, 2Peking University, Beijing, China, 3Beijing Obstetrcis and Gynecology Hospital,Capital Medical University, Beijing, China, 4Wake Forest School of Med, Winston Salem, NC, 5Beijing Obstetrics and Gynecology Hospital, Capital Medical University

 

Gestational diabetes mellitus (GDM) affects up to10% of all pregnancies. Maternal adiponectin(APN) concentrations are decreased in GDM, independently of maternal BMI. The mechanisms responsible for decreased adiponectin expression are unknown. Abnormally elevated activity of JNK signaling pathway plays an important role in the pathogenesis of type2 diabetes (T2DM). However, whether abnormal activation of JNK is associated with decreased adiponectin expression in GDM remains unclear. We performed this study to determine effects of JNK pathway activation on modulating decreased APN gene expression in insulin resistance (IR) adipocytes from GDM patients. Western Blot was used to measure phosphorylation extent of insulin receptor substrate (IRS)1/2-Ser312 and c-Jun N-terminal kinase (JNK) in omental fat and placental tissue from 8 GDM patients and 8 normal pregnant women(age,BMI equally matched). Adipose-derived mesenchymal cells were harvested from the omental adipose tissue from GDM patients and were induced into mature adipocytes. A model of insulin resistance (IR) cells was established in these adipocytes by treating with 35mmol/L glucose and 1×10-6mol/L insulin. IR cells were treated with the JNK activator, anisomycin (10ug/ml) and JNK inhibitor SP600125 (20uM) for 8h、16h and 24h respectively, and then the phosphorylation levels of JNK kinase or IRS1(Ser312), IRS1(Tyr895) were detected by Western Blot and the expression levels of the genes for APN and IRS1/2 were determined by semi-quantification RT-PCR.Finally, IR cells were treated with exogenous adiponectin or transfected with small interfering RNA (siRNA-adiponection) to inhibit endogenous adiponectin expression. Changes of phosphorylation levels of the above factors were detected by Western Blot. We found that JNK activity and IRS1/2-Ser312 were significantly elevated in the omental fat and placental tissue in GDM patients compared with normal pregnant women. Phosphorylation levels of JNK kinase or IRS1 (Ser312) were increased  significantly,while IRS1(Tyr895) was slightly decreased in IR cells treated with JNK activator, anisomycin. These changes were reversed with JNK inhibitor SP600125. APN gene expression was attenuated (23.8%) in IR cells by anisomycin, p<0.05. In contrast, SP600125 elevated APN gene expression (12.6%), significantly reduced JNK activity and enhanced insulin receptor signaling capacity, p<0.05. JNK activity and insulin receptor signaling capacity were reduced significantly after transfecting with siRNA -adiponectin. Our data suggest that JNK signaling plays a crucial role in down regulation of APN gene expression. APN also influences JNK signaling and insulin receptor signaling capacity in insulin resistance adipocytes from GDM patients.

 

Nothing to Disclose: GL, WW, LZ, JCR, WZ

OR36-1 19520 1.0000 A C-Jun NH2-Terminal Kinase (JNK) Inhibits Adiponectin Gene Expression in Insulin Resistance Adipocytes from GDM Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR36 5934 9:30:00 AM Metabolism and Gestational Diabetes Oral


Jennifer Huynh*, Julia Wenger, Ravi Thadhani and Rhonda Bentley-Lewis
Massachusetts General Hospital, Boston, MA

 

Objective:Gestational diabetes mellitus (GDM) is associated with an increased risk of type 2 diabetes (T2DM) and hypertension (HTN). Moreover, gestational dysglycemia is associated with an increased risk of T2DM. Because the association between gestational dysglycemia and HTN subsequent to pregnancy has not been established, we set out to examine this relationship. Also, because race/ethnicity modifies the relationship between GDM and subsequent T2DM, we aimed to elucidate the impact of race/ethnicity on gestational dysglycemia and subsequent HTN.

Methods: We conducted an analysis of a prospective observational cohort of 17,655 women with self-reported race/ethnicity and full-term, live births followed from 1998 to 2007. A 1-hr 50g oral glucose challenge test (GCT) and 3-hr 100g oral glucose tolerance test (GTT) enabled 3rd trimester stratification of women into one of four glucose tolerance groups: 1) normal (GCT < 140 mg/dl, n=15,056); 2) abnormal GCT (GCT ≥140 mg/dl and normal GTT, n=1,558); 3) abnormal GCT and one abnormal GTT (abnormal GCT/GTT; n=520); and 4) GDM (GCT ≥140 mg/dl and 2 or more abnormal GTT; n=521). Women were then followed for a mean ± SD of 4.1 ± 2.9 years after delivery for the development of HTN.

Results: Women with abnormal GCT (hazard ratio [ 95% confidence interval]: 2.38 [1.41, 4.03]; p=0.001), abnormal GCT/GTT (3.07 [1.56, 6.02]; p=0.001) and GDM (13.89 [9.06, 21.29]; p<0.001) had a significantly increased risk of T2DM after adjusting for age, race, parity, systolic blood pressure, body mass index, gestational weight gain, birth weight for gestational age, smoking, breastfeeding, marital status, education, and follow-up time compared to the normal GTT group. Only Hispanic women had a significantly greater risk of T2DM with non-GDM dysglycemia relative to Hispanic women with normal GCT: abnormal GCT (3.27 [1.71, 6.22]; p<0.001) and abnormal GCT/GTT (4.48 [2.02, 9.93]; p<0.001). The number of Asian and black women was insufficient to examine in this way. Although all women with GDM were more likely to develop HTN after pregnancy (1.58 [1.02, 2.45]; p=0.04), non-GDM dysglycemia predicted HTN only among black women with abnormal GCT relative to black women with normal GCT (4.52 [1.24, 16.52]; p=0.02).

Conclusions: Our findings confirm the association between gestational dysglycemia and T2DM. Among the dysglycemic groups, only GDM was associated with an increased risk of HTN after pregnancy. Hispanic women with any degree of dysglycemia had significantly greater risk of T2DM, but not HTN, relative to their normal GCT, ethnicity-specific counterparts. However, Black women with abnormal GCT were at a greater risk for HTN compared to those with normal GCT. These data suggest differential risk of HTN based on degree of glucose intolerance. Further research on the implications of the intersection of race/ethnicity and gestational dysglycemia on subsequent HTN is warranted.

 

Nothing to Disclose: JH, JW, RT, RB

OR36-2 18786 2.0000 A Hypertension Risk Subsequent to Gestational Dysglycemia Is Modified By Race/Ethnicity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR36 5934 9:30:00 AM Metabolism and Gestational Diabetes Oral


Olubukola Ajala*1, Louise Jensen2, Edmond A Ryan1 and Constance L Chik1
1University of Alberta, Edmonton, AB, Canada, 2University of Alberta, Canada

 

Background: Previous gestational diabetes is an established risk factor for the development of type 2 diabetes and increased metabolic risk. The link however with vascular dysfunction is not as clear. This study therefore examined the vascular function in women with a normal postpartum oral glucose tolerance test (OGTT), four to ten years after an initial diagnosis of gestational diabetes.

Methods: Of a total of 1084 women with gestational diabetes in the index pregnancy and a normal postpartum OGTT, we studied 90 women without an interval diagnosis of diabetes, glucose intolerance or cardiovascular disease. These women were matched on age with 59 controls. We examined differences in adiposity (Body mass index-BMI, Waist-Hip-Ratio-WHR), Total Cholesterol: High density Lipoprotein Cholesterol (HDLc) ratio, Triglycerides and Low density lipoprotein cholesterol (LDLc). We also compared markers of vascular function via levels of C - reactive protein (CRP) and vascular compliance via pulse wave analysis. For the latter we measured large artery elasticity, small artery elasticity, total vascular impedance and systemic vascular resistance. To compare cardiovascular function, we measured pulse rate, mean arterial pressure and cardiac output and finally, to detect differences in glycemic function, we measured fasting glucose, post-prandial glucose and Insulin resistance.

Results:Women with a prior history of GDM had higher measures of adiposity (BMI 28.9±6.5 vs 26.5±6.9 p 0.04, WHR 0.85±0.06 vs 0.79±0.07 p<0.001), higher markers of dyslipidemia (LDL 2.78±0.64 vs 2.41±0.56 p<0.001, Cholesterol: HDL 3.93±1.2 vs 3.21±0.82 p<0.001) and higher incidence of abnormal glucose metabolism (51% had impaired glucose tolerance/Type 2 diabetes versus 12% in the control group). Multivariate analysis of variance indicated no difference between the pGDM (‘GDM group’)and CG (‘Control group’) on all the measures of vascular function (for the combined variables: F=0.54, P=0.704; Wilks’ Lambda=0.99; partial eta squared=0.02, not significant using a Bonferroni adjusted alpha level of .013). Finally multiple standard and hierarchical regressions indicated no significant contribution to systemic vascular resistance, small artery elasticity and large artery elasticity from glycemic status even after controlling for possible effects of measures of adiposity, blood pressure, lipid profile and CRP.

Conclusion: A previous history of GDM in women with a normal postpartum OGTT is not associated with an increased risk of vascular dysfunction 4 to 10 years post partum provided there is no interval diagnosis of cardiovascular disease or impaired glycaemia.

 

Nothing to Disclose: OA, LJ, EAR, CLC

OR36-3 18398 3.0000 A Impact of Gestational Diabetes on Long-Term Vascular Function 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR36 5934 9:30:00 AM Metabolism and Gestational Diabetes Oral


Erica B Mahany*, Nicole H Bellefontaine and Carol F Elias
University of Michigan, Ann Arbor, MI

 

The prevalence of obesity has increased dramatically in recent years, with an estimated 50% of pregnant women classified as overweight or obese.  These women are at increased risk for pregnancy complications, including miscarriage, gestational diabetes, preeclampsia, preterm delivery, congenital anomalies, stillbirth, and neonatal death.  To gain insight into the underlying mechanisms, we utilized a mouse model of obesity (and diabetes)- induced miscarriage to unravel potential genes differentially expressed in placentas from obese mice.  We selectively restored the leptin receptor in the ventral premammilary nucleus of the hypothalamus in mice otherwise null for the leptin receptor with target injections of a viral vector, allowing for the improvement of fertility without altering the obese and diabetic phenotype.  Of 11 injected mice, 6 underwent puberty and had copulatory plugs after breeding with wild type males with proven fertility, and tissue was harvested 10 days after copulation (E10.5).  Only two of these females became pregnant, however, both showed some degree of embryo resorption.  Histological analysis of the placentas showed massive necrosis of the labyrinth in the obese mice when compared to control mice.  A real-time qPCR array was performed and several genes were found to be differentially expressed in the pathologic mouse placentas.  Interestingly, many genes associated with vascular functions such as angiogenesis, vasodilation, tissue remodeling, and inflammation were upregulated in the placentas from obese/diabetic dams, including Angpt2, Flt4/Vegfr2, Pappa2, Apln, Bcl6, Clu, Eng, and Plgf.  Sod1, which is important for the maintenance of pregnancy, was found to be downregulated in the pathological placentas.  Dcn and Fstl3, which are important for angiogenesis and adhesion, respectively, were downregulated in the resorbed placentas.  Further analysis of the pathological placentas by RT-qPCR revealed an increase in Tlr4 expression, a key player in the transcription of proinflammatory cytokines.  Together, the data show that increased adiposity and/or diabetes alters the expression of genes related to vascular growth and inflammation from the early stages of pregnancy and sets the stage for poor pregnancy outcome.

 

Nothing to Disclose: EBM, NHB, CFE

OR36-4 19835 4.0000 A Genes Related to Vascular Growth and Inflammation Are Differentially Expressed in Placentas from Obese, Diabetic Mice with Poor Pregnancy Outcome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR36 5934 9:30:00 AM Metabolism and Gestational Diabetes Oral


Yasmin Morán-Auth1, Marissa Penna-Martinez2 and Klaus Badenhoop*3
1University Hospital Frankfurt am Main, Germany, 2University Hospital, Goethe-University Frankfurt am Main, Germany, 3Goethe-University Hospital, Frankfurt, Germany

 

Introduction: Type 1 diabetes (T1D) is a Type 1 T-helper cell (TH1)-mediated autoimmune disease. During its pathogenesis TH1 transcription factors (STAT1 and T-bet) contribute to inflammatory processes by inducing TH1 cytokines such as interferon (IFN)–γ. IFN-γ in turn stimulates via STAT1 phosphorylation the T-bet expression. Additionally, 1,25(OH)2D3 (but not 25(OH)D3) has been shown to inhibit IFN-γ transcription, whereas the direct gene  regulation of STAT1 by these vitamin D metabolites in purified T-helper (TH) cells is still unclear. Furthermore, the CYP27B1 gene (encoding the 1-a-hydroxylation of vitamin D) promoter SNP rs10877012 confers susceptibility to T1D. Our study objective was to investigate the modulatory effects of both vitamin D metabolites and the CYP27B1 SNP on STAT1 and T-bet at transcription levels in TH cells. Materials and Methods: Purified TH cells from T1D patients (n = 24, genotyped for the CYP27B1 SNP) were cultured for 72h with or without the vitamin D metabolites (1,25(OH)2D3 or 25(OH)D3).  After TH cell culture gene expression levels of STAT1 and T-bet and 18sRNA were measured by Taqman assay and CT-values were defined as 2-[CTtarget–CT18sRNA]. Results: STAT1 and T-bet gene expression levels were significantly inhibited by 1,25(OH)2D3 in TH cells from T1D patients (STAT1: 953 vs. 705  2-ΔCTx106;pcorrected (c) = 7x10-5  and T-bet: 145 vs.  93 2-ΔCTx106; pC = 1 x10-3).  In contrast, no regulation on the STAT1 and T-bet transcription was observed by 25(OH)D3 in cultured TH cells from T1D patients. However, by stratifying gene expression levels according to the CYP27B1 SNP, significantly lower T-bet expression levels were observed in 25(OH)D3 cultured TH cells from T1D patients with  the protective CYP27B1 “AA” genotype than those with the susceptible “CC” genotype (CC=163, AC=120, AA=47 2-ΔCTx106; pC = 0.05). Conclusion: 1,25(OH)2D3 inhibits STAT1 and T-bet transcription in TH cells of T1D patients. This inhibition with the most active vitamin D metabolite is independent of the CYP27B1 SNP. In contrast, 25(OH)D3 inhibitory effects appears to be modulated by the CYP27B1 SNP with lower T-bet gene expression levels in TH cells. The promoter SNP may therefore regulate the cell specific activation of the vitamin D metabolite. In conclusion, the gene expression of the investigated TH1-specific transcription factors appears to be regulated by 1,25(OH)2D3 and under functional modulation of the CYP27B1 SNP to metabolise 25(OH)2D3.

 

Nothing to Disclose: YM, MP, KB

OR36-5 20862 5.0000 A TH1 Lymphocyte Transcription Factors Are Regulated By Vitamin D Metabolites and the CYP27B1 Promoter SNP in Type 1 Diabetes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR36 5934 9:30:00 AM Metabolism and Gestational Diabetes Oral


Alexandra Moser*1, Amy Christensen1, Mafalda Cacciottolo2, Todd E Morgan2, Caleb E Finch1 and Christian J Pike1
1University of Southern California, Los Angeles, CA, 2University of Southern California

 

The etiology of Alzheimer’s disease (AD) is complex and not well understood, however, a number of risk factors for the disease have been identified. For one, women have an increased risk of AD, and sex has previously been shown to interact with the greatest genetic risk factor for AD; the ε4 allele of apolipoprotein E (Saunders et al., 1993; Strittmatter et al., 1993). That is, apoE ε4 is a greater risk factor for AD in women than it is in men (Altmann et al., 2014), and the association between apoE ε4 and cognitive deficits is stronger in women (Beydoun et al., 2012; Sundermann et al., 2012). The relationship between apoE genotype and sex extends beyond AD risk, such that they interact in determining mortality risk and lifespan (Rosvall et al., 2009; Kulminski et al., 2014). In addition, interactions between apoE genotype and sex have been demonstrated in a number of studies using human apoE targeted replacement mice (Leung et al., 2012; Reverte et al., 2012; Koutseff et al., 2014). Furthermore, sex steroid hormones have also been found to interact with apoE genotype to drive cognitive impairments and AD risk (Raber et al., 2002; Pfankuch et al., 2005, Panizzon et al., 2014). Therefore, findings in both the human and experimental literature point to an interaction between sex and apoE genotype. The goal of the present study was to test sex differences in the apoE-familial AD (EFAD) mouse, a transgenic model of AD, in which mouse apoE has been replaced with human apoE ε3 or ε4 (Youmans et al., 2012). A number of measures of AD-like neuropathology were assayed in male and female ε3- and ε4FAD mice at 6 months of age. Here we demonstrate that ε4FAD mice have greater AD-like pathology than ε3FAD mice in all brain regions examined, including entorhinal cortex, frontal cortex, and in the hippocampal subfields, subiculum and CA1-3. Importantly, the effect of apoE ε4 on AD outcomes is exacerbated in females. These data were confirmed by both amyloid β ELISA and Thio-S staining. In addition, female EFAD mice exhibited significantly greater cerebrovascular amyloidosis than males.  These data demonstrate that apoE ε4 and sex independently and cooperatively modify AD-related outcomes, and point to the  importance of sex differences in disease modification.

 

Nothing to Disclose: AM, AC, MC, TEM, CEF, CJP

OR36-6 22093 6.0000 A Apolipoprotein E4 Interacts with Sex to Modulate Alzheimer's Disease Neuropathology in Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM OR36 5934 9:30:00 AM Metabolism and Gestational Diabetes Oral


Jacqueline L. Cartier*1 and Elena Barengolts2
1University of Illinois at Chicago, Chicago, IL, 2Jesse Brown VAMC, Chicago, IL

 

Background: The contribution of vitamin D insufficiency to the occurrence of common chronic conditions remains controversial.  African American men (AAM) have a higher risk of vitamin D insufficiency than Caucasian men (CAM) as well as a high burden of chronic disease yet they are relatively under-represented in research studies. 

Objective: The objective of the study was to examine whether vitamin D insufficiency was a predictor of prevalent and/or incident common chronic conditions in AAM and CAM.

Methods: 1,117 men were recruited at an urban VA medical center and followed prospectively. Vitamin D insufficiency was defined as 25(OH)D <30ng/ml. Chronic conditions that were evaluated included obesity (BMI >30kg/m2), type 2 diabetes (T2D), cardiovascular disease (CVD, including coronary artery disease [CAD], cerebrovascular accident [CVA], and congestive heart failure [CHF]), cancer (including lung, prostate, and colon), and fractures (traumatic and non-traumatic). Multivariate logistic regression was performed to determine predictors of prevalent common chronic conditions controlling for socio-demographic variables.

Results:This analysis was limited to 955 men (65.4% AAM, 27.2% CAM, 6.4% Hispanic, 0.4% Native American and 0.3% Asian) who had at least 1 yr of follow up (mean 5.4 yrs, range 1.0 – 7.1 yrs). Comparison of AAM vs CAM showed no differences in prevalent obesity (42 vs 41%), T2D (40 vs 35%), CVD (48 vs 50%) or cancer (33 vs 31%) but AAM had lower prevalence of fractures (11 vs 17%, p=0.01). Univariate analysis of the entire group showed 25(OH)D correlated with BMI as well as with T2D.  Serum 25(OH)D was not found to have a relationship with prevalent CVD (including separate analysis for CAD, CVA and CHF), cancer, fractures, and all-cause mortality. Multivariate analysis of the entire group identified 25(OH)D as an independent predictor of obesity, Odds Ratio (OR) (95% Confidence Interval) 0.962 (CI 0.949-0.976). The additional independent determinants of obesity included age (OR 0.975, CI 0.964-0.987) and current smoking (OR 0.446, CI 0.296-0.671).  Similar results were seen in AAM and CAM subgroups. The independent predictors of prevalent common chronic conditions (combined T2D, CVD and cancer) included increasing age (OR 1.095, CI 1.076-1.113), smoking (OR 1.577, CI 0.973-2.559), past alcohol use (OR 1.613, CI 1.085-2.397), past polysubstance use (OR 0.574, CI 0.382-0.863), and BMI (OR 1.054, CI 1.025-1.083) but not 25(OH)D.  Unexpectedly, there was a trend for higher 25(OH)D predicting fractures (p=0.063), probably explained by longer hours outside (and therefore higher sun exposure) spent in activities with higher risk of fractures.

Conclusion: Circulating 25(OH)D was an independent predictor for BMI but not for common chronic conditions in this urban population of male veterans. 

 

Nothing to Disclose: JLC, EB

OR45-1 20673 1.0000 A Lower Serum 25-Hydroxyvitamin D Is an Independent Predictor for Obesity but Not for Common Chronic Conditions: An Observational Study of African American and Caucasian Male Veterans 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Sunday, March 8th 11:00:00 AM OR45 5956 9:30:00 AM What Is New in Vitamin D? Oral


Marie-Laure Kottler*1, Arnaud Molin2, Martin Kaufmann3, Anatoly N Tiulpakov4 and Glenville Jones3
1University Hospital, Caen, France, 2Caen University Hospital, Caen, France, 3Queen's University, Kingston, ON, Canada, 4Endocrinology Research Centre, Moscow, Russia

 

Background: Homozygous or compound heterozygous mutations of CYP24A1(which encodes the catabolic 25-hydroxyvitamin D3-24-hydroxylase) have recently been reported to cause hypercalcemia with suppressed PTH due to increased intestinal absorption of calcium.

Objective : 1) Evaluation of the frequency of CYP24A1 mutation in a cohort of patients; 2) Evaluation of the clinical utility of simultaneous assay of multiple vitamin D metabolites by liquid chromatography tandem mass spectrometry (LC-MS/MS); 3) Investigation of patients harboring CYP24A1 mutation in a heterozygous state to better understand the role of CYP24A1 haploinsufficiency in the occurrence of hypercalcemia.

Patients and Methods: We studied 72 index cases (38 males (53%) and 34 females (47%)), presenting with hypercalcemia (>2.6 mmol/L) and low PTH levels (<20 pg/mL). We also included 22 relatives. Biochemical data and CYP24A1 sequencing were obtained with routine methods. Serum 25-hydroxyvitamin D3 (25-OH-D3) and 24,25-dihydroxyvitamin D3 (24,25-(OH)2D3) were assessed by LC-MS/MS using 100 µL of serum (1); results were expressed as a ratio (R) of 25-OH-D3:24,25-(OH)2D3. Values under 25 were considered as normal.

Results: We identified 25 patients (35%) harboring mutations in the coding sequence of CYP24A1. Twenty patients (28%) have bi-allelic mutations that were found more frequently in patients with renal disease (67%) (nephrocalcinosis or renal stones) than in patients without renal symptoms (23%). Patients with bi-allelic CYP24A1 mutations have very low 24,25-(OH)2 D3 levels and exhibit a dramatic increase in R (mean [range] :105 [48.8-173.4] n = 7) providing evidence “in vivo” for the loss of 24-hydroxylase activity. We found 5 patients (7%), all neonates, harboring CYP24A1 mutations in a heterozygous state raising the question of a dominant trait. In contrast with children harboring bi-allelic mutations, none presented with renal pathology. Probands (n=3) as well as relatives (n=14) harboring heterozygous mutations, have measurable amounts of 24,25-(OH)2D3 and R below 25, suggesting functional CYP24A1 activity. Last, probands without CYP24A1 mutations have measurable amounts of 24,25-(OH)2D3 and normal R.

Conclusion: CYP24A1 mutation are frequently found in patients presenting hypercalcemia with low or suppressed PTH especially in patients with nephrocalcinosis or renal stones. We confirm the accuracy and effectiveness of a novel blood test estimating the ratio between relevant vitamin D metabolites 25-OH-D3 and 24,25-(OH)2D3 as a useful screening tool for CYP24A1 mutation. Even so most of heterozygous patients with CYP24A1 mutation remain asymptomatic, this study leads to recommend preventive measures including restriction of vitamin D supplementation that could protect affected relatives particularly during the neonatal period.

 

Nothing to Disclose: MLK, AM, MK, ANT, GJ

OR45-2 21081 2.0000 A CYP24A1 Molecular Analysis and Simultaneous Assay of Multiple Vitamin D Metabolites By LC-MS/MS in Patients with Hypercalcemia and Suppressed PTH : a Cohort Study 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Sunday, March 8th 11:00:00 AM OR45 5956 9:30:00 AM What Is New in Vitamin D? Oral


Murugan R Pandian*1, Jothi Pandian1, Zoltan Seres2 and Alan N Elias3
1Pan Laboratories, Irvine, CA, 2Immunodiagnostic System Ltd, Bolden, United Kingdom, 3Pan Laboratories, Laguna Beach, CA

 

Title:  Bioavailable fractions are better markers than 25 hydroxy vitamin D for monitoring vitamin D status during Pregnancy.

Objective

 Comparison of bioavailable 25-hydroxy vitamin D (25OH-D) and bioavailable calcitriol (1,25 dihydroxy vitamin D) with PTH and CTX in pregnancy serum.

 Introduction         

Pregnancy is associated with major changes in calcium homeostasis. Vitamin D and PTH play important roles during pregnancy. Currently, serum 25OH-D is used in monitoring vitamin D status during pregnancy. Calcitriol is the active form of vitamin D. The level of 25OH-D and calcitriol vary due to changes in maternal serum vitamin D binding protein(DBP). Serum concentrations of bioavailable and free vitamin D are not influenced by DBP. Therefore, we measured total, bioavailable, and free fractions of 25OH-D or calcitriol in pregnant serum samples and correlated them with serum calcium, PTH and  CTX (C-terminal collagen degradation product) .

Methods

Bioavailable 25OH-D or bioavailable calcitriol are fractions not bound to DBP. They are the combined fractions of albumin bound and the free fractions of 25OH-D or calcitriol. To obtain the bioavailable fraction, total vitamin D (25OH-D or calcitriol) was quantitated using immunoassays (IDS reagents ). DBP was quantitated by an ELISA using reagents from R&D systems. Using the affinity constants of 25OH-D and calcitriol for DBP, and the affinity constants of 25OH-D or calcitriol for serum albumin, bioavailable 25OH-D, bioavailable calcitriol, free 25OH-D and free calcitriol were calculated. PTH and CTX assays were performed in pregnancy serum samples using IDS kits. Pregnant serum samples (n=51) were collected between 27 to 38 weeks of pregnancy.

 Results

Total 25OH-D was significantly lower in pregnant women( 24.7 ± 1.1 ng/ml) despite a significant increase in DBP (410 ± 30 ug/ml vs 276 ± 15 in non-pregnant serum). Bioavailable and free 25OH-D levels during pregnancy were lower than non-pregnant women(n=53)although the levels of PTH and CTX were in the normal range.The correlation between PTH with total 25OH-D was poor (r2= 0.3).There was also poor correlation between PTH and bioavailable or free 25OH-D (r2= <0.5). Calcitriol was high in the pregnancy samples (127.5 ± 15.5 pg/ml) compared to non-pregnant samples (36.2 ± 5.6 pg/ml), and the DBP-corrected bioavailable and free calcitriol was twofold higher than non-pregnant controls. Calcitriol and its fractions (bioavailable and free of calcitriol) correlated well with serum PTH and CTX  (r2 = >0.9).

Conclusion

The current practice of assessing vitamin D in pregnancy consists of measurement of 25OH-D. However, 25OH-D as an indicator of sufficiency does not correlate well with calcium homeostasis markers in pregnancy. Calcitriol correlates better with PTH and CTX in pregnancy. It appears that bioavailable and free fractions of calcitriol are the best markers for determining vitamin D status in pregnant women.   

 

Nothing to Disclose: MRP, JP, ZS, ANE

OR45-3 21223 3.0000 A Bioavailable Fractions Are Better Markers Than 25 Hydroxy Vitamin D for Monitoring Vitamin D Status during Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Sunday, March 8th 11:00:00 AM OR45 5956 9:30:00 AM What Is New in Vitamin D? Oral


Sri Harsha Tella1, J Christopher Gallagher2, Shervin Yousefian3 and Vinod Yalamanchili*4
1National Institutes of Health, Bethesda, MD, 2Creighton University Medical Center, Omaha, NE, 3Creighton University, 4Creighton University School of Medicine, Omaha, NE

 

BACKGROUND:Calcium and vitamin D supplements are widely recommended for prevention of osteoporosis in postmenopausal women, however there are no systematic studies on effect of different doses of vitamin D and calcium supplementation on hypercalcemia and hypercalciuria and no comparison between African Americans and Caucasians.

METHODS:We conducted two randomized, placebo-controlled trials in women with vitamin D insufficiency (serum 25-hydroxyvitamin D ≤20 ng/dl [50 nmol/liter]). In the older group (273 Caucasian and African American women) the age range was 57-90 years. In the younger women (198 Caucasian and African American) the age range was 25–45 years and. Older women were randomly assigned to placebo, vitamin D3 400, 800, 1600, 2400, 3200, 4000, or 4800 IU daily; calcium supplements were given if needed to maintain a total daily calcium intake of 1200-1400 mg/day. Younger women were randomized to placebo, 400, 800, 1600 and 2400IU/d and calcium intake maintained at 1000mg/day. The average calcium supplement in older women was 600mg and in younger women was 340mg.

Serum and 24-hour urine calcium were collected every 3 months; any test result above the laboratory upper normal range represented an episode of hypercalcemia or hypercalciuria (24h urine calcium >300 mg /24 hour in Caucasians and >270 mg/24 hour in African Americans). Calcium absorption was measured by a single isotope Ca45 method. Mixed-effects models were used to estimate the effects of time and dose on urine and serum calcium.

RESULTS:In the older women, hypercalcemia occurred in 8.8% of Caucasian and 7% of African American women. In the younger women, hypercalcemia occurred in 1% of African American women and 0% of Caucasian women. In older women hypercalciuria occurred in 30.6% of Caucasian and 15% of African American women.  In younger women hypercalciuria occurred in 20% of Caucasian and 15% of African American vitamin D treated women. In the placebo group that received only calcium, hypercalcemia occurred in 2.7% and hypercalciuria in 21 % occurred in the placebo group. In both studies no relationship was found between episodes of hypercalcemia or hypercalciuria and vitamin D3 dose or serum 25OHD level. Calcium absorption was measured in the younger women. It was normal in all women and 4% lower in African Americans. There was a small decrease in bone resorption marker N-telopeptide.

CONCLUSION: The risks of hypercalcemia and hypercalciuria are higher in Caucasian women compared to African Americans and higher in older women. The risk is not related to the vitamin D dose, serum 25OHD level, calcium absorption or bone resorption. Even in the placebo group on a total daily calcium intake of 1200 or 1000 mg there is an increased risk of hypercalcemia and hypercalciuria; thus, even a modest calcium supplementation of 350 in young or 600mg/day in older women may be too high.

 

Nothing to Disclose: SHT, JCG, SY, VY

OR45-4 19047 4.0000 A Incidence of Hypercalciuria and Hypercalcemia during Vitamin D and Calcium Supplementation in Older and Younger Women: A Comparison Between Caucasians and African Americans in Two Randomized Trials 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Sunday, March 8th 11:00:00 AM OR45 5956 9:30:00 AM What Is New in Vitamin D? Oral


Peng Wang*1, JoDell E Wilson2, Weijia (William) Wu3 and Patrick William Mason3
1Medstar Georgetown University Hospital, Washington, DC, 2Quest Diagnostics, 3Quest Diagnostics, Chantilly, VA

 

Background. 25-hydroxyvitamin D (25(OH)D) determinations are used to determine vitamin D status: deficient <20, insufficient 20-29, and  optimal  30-100 ng/mL (Holick, JCEM 2011). Approximately 77% of US adults have suboptimal vitamin D levels, based on NHANES 2001-2004 data (Ginde, Arch Intern Med, 2009). The Institute of Medicine (IOM, 2010) and the Endocrine Society (Holick, JCEM 2011) recently recommended increased vitamin D dietary reference intake. Additionally, vitamin D3 (cholecalciferol) became more readily available as the main form of vitamin D supplement, and at higher doses. Between 2002 and 2011, sales of vitamin D supplements jumped >10x—from $42 million to $605 million (Nutrition Business Journal 2014 Supplement Business Report). To investigate changes in vitamin D levels after the guideline updates and increases in vitamin D3 supplementation, we analyzed vitamin D results for all adults tested in a national reference laboratory (Quest Diagnostics Nichols Institute, Chantilly, VA) during a 12-month period in 2009-2010 (pre-guidelines) and 2013-2014 (post-guidelines). Additionally, the suppression effects of 25(OH)D on intact parathyroid hormone (iPTH) levels, we evaluated iPTH in  the two study periods.   

Method. Total 25(OH)D was determined using liquid chromatography—tandem mass spectrometry. We evaluated all 25(OH)D tests performed for adults (≥18 years old) for a 12-month period starting in November 2009 (1.6 million tests)  and August 2013 (1.2 million tests). Intact PTH was measured by a chemiluminescence-based assay. The results were compared using Z-test after Box-Cox transformation to satisfy the Gaussian distribution assumption.

Results. The mean 25(OH)D value increased from 27.2±0.02 ng/mL pre-guidelines to 32.5±0.03 ng/mL post-guidelines (P <0.0001). The proportion of patients with deficient vitamin D levels decreased significantly from the pre-guideline period to the post-guideline period (22.1% vs 14.5%), as did the proportion with insufficient levels (33.7% pre-guidelines vs 28.1% post-guidelines) (both P <0.0001). No clinically significant changes in vitamin D2 levels were noted between pre- and post-guideline groups. The percentage of iPTH results above the upper limit of the reference range decreased from 50% in 2009 to 39% in 2014 (P <0.0001).

Conclusion. We observed an increase in the mean value of 25(OH)D in the adult population, with concomitant decreases in the percentage of patient specimens classified as deficient or insufficient 25(OH)D post-guidelines. Possible explanations for these results include 1) a positive impact on patient 25(OH)D concentrations after introduction of the new guidelines; or 2) testing may have shifted to people who were more likely to have optimal levels of 25(OH)D in the post-guideline period. The fall in the percent of elevated iPTH results corresponds, as expected, to the rise in the 25(OH)D levels.

 

Nothing to Disclose: PW, JEW, WW, PWM

OR45-5 18803 5.0000 A Higher Levels of 25-Hydroxyvitamin D Following New Vitamin D Intake Guidelines 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Sunday, March 8th 11:00:00 AM OR45 5956 9:30:00 AM What Is New in Vitamin D? Oral


Chizelle Onochie*1, Irina Ciubotaru2, Angela Domenico1, Yuval Eisenberg3, Subhash C Kukreja2, Arfana Kouser4 and Elena Barengolts4
1University of Illinois at Chicago, 2UIC Section of Endocrinology, Chicago, IL, 3University of Illinois at Chicago, Chicago, IL, 4Jesse Brown VAMC, Chicago, IL

 

BACKGROUND: The observational studies suggest association between higher levels of 25-hydroxyvitamin D [25(OH)D >36 ng/ml) and the risk of cardiovascular disease and all-cause mortality. There are no detailed reports of serious adverse events (SAEs) from long-term randomized controlled trials (RCT) using high doses of vitamin D supplementation.

OBJECTIVE: The aim of this study was to assess long-term safety of high dose vitamin D2 (ergocalciferol) supplementation.

METHODS: We collected SAEs (emergency room visits and hospitalizations) for subjects in RCT of vitamin D Intervention at VA (DIVA, NCT01375660). In DIVA African American male (AAM) veterans with dysglycemia (HbA1C 5.7-6.9%, no anti-diabetes medications) and hypovitaminosis D [25(OH)D 5-29 ng/ml] were randomized to receive placebo (PL) or 50,000 IU vitamin D2 (VD) for a year.  In addition, all men received 400 IU D3 (cholecalciferol) daily. The SAEs were collected at three time points: a year prior (T0), a year of the trial (T1), and a year after the trial (T2). The Chi-square analysis was used to compare SAEs frequencies.

RESULTS: Overall 173 subjects (N=86 in PL and N=87 in VD) completed the trial. Disease burden was relatively high, averaging 4 medical conditions (range 0 - 8) and 6.5 (range 0 - 17) medications per person, respectively, as well as 2.1 Charlson index of chronic disease. The mean [SD] D2 dose was 62,762 [10,772] (range 50,000 - 88,460 IU per week). At baseline serum 25(OH)D (ng/ml) was similar in both groups, PL vs VD 14 [4.8] vs 14.7 [4.7], while at study completion 25(OH)D was significantly lower in PL vs VD 19.9 [7.3] vs 48.1 [18.4] (p<0.001) (overall range 6 - 109 ng/ml). A total of 335 SAEs (119 hospitalizations and 216 emergency room visits) over a 3-year period were equally distributed among T0 (N=110), T1 (n=112) and T2 (N=113). On average there were 23 hospitalizations and 42 emergency room visits per 100 subjects per year. There was no difference in SAEs between PL vs VD groups at any time point: T0 55% vs 45% (p=0.34); T1 46% vs 54% (p=0.34); and T2 50% vs 50% (p=0.45). The most common SAE-related conditions were musculoskeletal (26%), psychiatric (21%), respiratory (13%) and cardiovascular (10%). There were no differences in the SAEs reasons between PL and VD groups and no SAEs were deemed related to vitamin D supplementation.

DISCUSSION: We found high frequency of hospitalizations and emergency room visits in subjects of DIVA trial, that were two-fold higher than those reported by CDC for non-Federal acute care hospitals. Despite of DIVA trial subjects being at high risk for SAEs, high dose vitamin D treatment resulting in relatively high serum 25(OH)D levels did not cause excessive SAEs during active period of treatment or during extended follow up.

CONCLUSION: High dose vitamin D2 supplementation for a year was efficacious and safe for treating hypovitaminosis D in African American men with high burden of chronic disease.

 

Nothing to Disclose: CO, IC, AD, YE, SCK, AK, EB

OR45-6 21529 6.0000 A High Dose Vitamin D2 Supplementation for a Year Does Not Cause Serious Adverse Events Including Emergency Room Visits and Hospitalizations in African American Men with High Burden of Chronic Disease 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Bone, Calciotropic Hormones & Vitamin D Sunday, March 8th 11:00:00 AM OR45 5956 9:30:00 AM What Is New in Vitamin D? Oral


Xian Liu*1, Zheng Zhu2, Chaitanya K Gavini3, Colleen M Novak3 and Haifei Shi2
1Miami Univ, Oxford, OH, 2Miami University, Oxford, OH, 3Kent State University

 

Estradiol Increases Central Brain-Derived Neurotrophic Factor-Induced Energy Expenditure by Enhancing Sympathetic Activity 

Sex differences exist in the regulation of energy homeostasis. Brain-derived neurotrophic factor (BDNF), an important anorexigenic factor, and estrogen receptor α are colocalized in the ventromedial hypothalamus (VMH). Bdnf gene expression in the VMH is regulated in an estradiol-sensitive manner, as VMH mRNA level of Bdnf is reduced by ovariectomy (OVX) which decreases endogenous circulating estrogens. Such repression of Bdnf gene expression can be normalized by cyclic replacement of estradiol (E2) at a physiological dose (2 µg E2 subcutaneous injection every four days), which mimics the normal changes in plasma E2 levels across estrous cycle. Additionally, OVX rats with E2 replacement (OVX+E2) respond to a lower dose of central BDNF administration (0.1 µg/µl, i3vt) to suppress feeding than OVX rats with oil injections (OVX+Oil). Thus, E2 modulates the anorectic effects of BDNF.  In this study, we first hypothesized that BDNF differentially regulates energy expenditure in OVX rats with or without estradiol replacement. Vehicle saline or 0.1 µg/µl BDNF was administered i3vt into OVX+Oil or OVX+E2 rats and energy expenditure was measured using indirect calorimetry during the first 24 hours following the injection.  BDNF-injected OVX+E2 rats, but not OVX+Oil rats, significantly increased oxygen consumption during light and dark phases comparing to vehicle-injected controls. Thus, a low dose of BDNF injection increased energy expenditure in E2-replaced OVX rats, but not in oil-treated OVX rats. This finding suggested that E2 promotes BDNF-induced increase in energy expenditure. We secondly hypothesized that the increase in energy expenditure was due to enhanced sympathetic activity. Norepinephrine turnover (NETO) assay was used to assess sympathetic drive to metabolic tissues after NE synthesis was blocked. Central administration of 0.1 µg/µl BDNF increased NETO at brown adipose tissue, white adipose tissue, the liver, and the heart of sham-operated female rats (Sham/BDNF) compared to vehicle-injected group (Sham/Veh). BDNF-treated OVX+Oil rats (OVX+Oil/BDNF) had similar NETO as Sham/Veh group, whereas BDNF-administrated OVX+E2 rats (OVX+E2/BDNF) had similarly increased NETO as Sham/BDNF group. Thus, BDNF administration increased tissue NETO in Sham and OVX+E2 rats, but not in OVX+Oil rats.  This finding suggested that physiological level of E2 facilitates BDNF-induced increase in sympathetic drive to peripheral tissues. We conclude that estradiol regulates BDNF-induced energy expenditure, at least partially, via enhancing sympathetic drive to peripheral metabolic tissues.

 

Nothing to Disclose: XL, ZZ, CKG, CMN, HS

OR43-1 19641 1.0000 A Estradiol Increases Central Brain-Derived Neurotrophic Factor-Induced Energy Expenditure By Enhancing Sympathetic Activity 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM OR43 5970 9:30:00 AM Steroids in Brain, Pain and Development Oral


Mengxi Jiang* and Wen Xie
University of Pittsburgh, Pittsburgh, PA

 

Chronic inflammatory liver diseases are associated with estrogen excess and feminization in men. This was thought to be due to liver damage that weakens the liver’s ability to breakdown estrogen, an anti-inflammatory hormone. In this study, we showed that the steroid sulfatase (STS), which converts inactive estrogen sulfates to active estrogens, may have mediated the inflammation-induced estrogen excess in chronic liver disease. Gene expression and immunohistochemistry (IHC) analyses demonstrated that STS was induced in liver samples from patients of chronic inflammatory liver diseases. We further demonstrated that the expression of human STS gene, but not the mouse Sts gene, was induced by inflammatory stimuli in liver cells. Mechanistically, STS was established as a novel NF-κB target gene, whose induction facilitated the conversion of inactive estrogen sulfates to estrogens, and thus attenuated inflammatory response. In contrast, genetic or pharmacological inhibition of STS or a direct blockade of estrogen signaling sensitized liver cells to the transcriptional activation NF-κB and inflammation. Our results defined a novel STS-mediated inflammatory regulation of estrogen homeostasis that leads to increased estrogen activity and attenuation of inflammatory response.

 

Nothing to Disclose: MJ, WX

OR43-2 18201 2.0000 A Inflammatory Regulation of Steroid Sulfatase, a Novel Mechanism to Control Estrogen Homeostasis and Inflammation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM OR43 5970 9:30:00 AM Steroids in Brain, Pain and Development Oral


Amanda C Swart*, Liezl Margaretha Bloem, Therina du Toit, Riaan Ehlers and Karl-Heinz Storbeck
University of Stellenbosch, Stellenbosch, South Africa

 

11β-hydroxyandrostendione (11OHA4) is an adrenal C19 steroid that has been overlooked for decades and not considered as a metabolite in the adrenal androgen pathway. Recently shown to be produced by CYP11B1 and B2 and  to be a major adrenal androgen (1, 2), 11OHA4’s downstream metabolism, and that of 11β-hydroxytestosterone (11OHT), in prostate cancer (PCa) cells yielded steroids capable of activating the androgen receptor (AR) (3). In addition, 11βHSD2 catalyzed the conversion of 11OHA4 and 11OHT, novel substrates for this enzyme traditionally linked to the inactivation of glucocorticoids. 11OHA4 and 11OHT are metabolized to 11-ketoandrostenedione (11KA4) and 11-ketotestosterone (11KT) in LNCaP cells and converted by the same enzymes catalyzing dihydrotestosterone (DHT) biosynthesis, yielding 11β-hydroxyDHT (11OHDHT) and 11-ketoDHT (11KDHT), the latter exhibiting androgenic activity comparable to DHT (1,3,4).

The intratumoral metabolism of adrenal androstenedione yielding DHT has been implicated in PCa progressing to castration resistant prostate cancer (CRPC) (5). It is in this scenario that 11OHA4 and its metabolites add to androgenic ligands in PCa, suggesting potential mechanisms of resistance (6). Analyses of PSA, a known PCa marker, showed that 11OHA4 and 11OHT as well as their keto metabolites increased PSA levels in LNCaP cells. While the increase in PSA levels by 11OHA4 was not significant, 11KA4, 11OHT and 11KT resulted in significant increases (2-fold and higher). Of note is the 2-fold decrease detected in PSA levels when cells were incubated with 11OHT and dutastride which inhibits the steroid’s conversion to 11OHDHT. The conversion of 1uM 11OHA4 and 11OHT and their 5α-reduced metabolites, 11OH-5α-dione and 11OHDHT, resp., was assayed in LNCaP cells, incubated for 72h. Steroids were deconjugated and total steroid metabolites analysed by UPLC-MS/MS. The following profiles were detected: 11OHA4 metabolites included 11KA4>11KT>11K-5α-dione>11KAST (400, 100, 96, 21 nM) with 30nM 11OHA4 remaining; 11OHT metabolites included 11KT>11OHA4>11KA4>11OH-5α-dione>11K-5α-dione (207, 197, 45, 25, 9 nM) with 198 nM 11OHT remaining; 11OH-5α-dione metabolites included 11K-5α-dione>11KDHT>11KAST>11OHAST (297, 60, 79, 39 nM) with 88 nM 11OH-5α-dione remaining; 11OHDHT metabolites included 11KDHT>11K-5α-dione>11KAST>11OH-5α-dione (272, 82, 45, 33 nM) with 69 nM 11OHDHT remaining. Further downstream investigations showed 11OH-5α-dione, 11K-5α-dione and 11KDHT are inactivated by 3αHSD while the enzyme did not reduce 11OHDHT. Impeded inactivation and glucuronidation of these C11-hydroxy and C11-keto C19 steroids suggests another parameter impacting on PCa. Our findings clearly demonstrate 11OHA4’s clinically relevant contribution to the androgen pool, and the prominent activating role played by 11βHSD2, providing novel ligands for the AR.

 

Nothing to Disclose: ACS, LMB, TD, RE, KHS

OR43-3 21707 3.0000 A Adrenal 11beta-Hydroxyandrostendione Contributes Novel Androgenic Ligands to the Prostate Tumor Microenvironmen 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM OR43 5970 9:30:00 AM Steroids in Brain, Pain and Development Oral


Susanne U Miedlich*1, Francesco Caiazza2, Melissa Young Rasar3 and Stephen R Hammes4
1University of Rochester Medical Center, Rochester, NY, 2University College, Dublin, Ireland, 3Yale School of Medicine, New Haven, CT, 4University of Rochester, Rochester, NY

 

Steroid-triggered Xenopus oocyte maturation serves as an elegant yet simple physiologic model of nongenomic steroid signaling, as it proceeds completely independent of gene transcription. Our lab previously demonstrated that androgens are the main physiologic stimulator of oocyte maturation (aka meiotic progression) in Xenopus oocytes, and that the versatile adaptor protein paxillin plays a crucial role in mediating steroid-induced MAPK kinase signaling and subsequent oocyte maturation. In fact, we found that paxillin regulates MAPK signaling and subsequent oocyte maturation by acting upstream of kinases to enhance Mos protein (germ cell equivalent of Raf) translation from its extensively polyadenylated mRNA. Based on these observations, we hypothesized that paxillin might enhance translation by interacting with the polyadenylation binding protein ePABP. Accordingly, knockdown of ePABP phenocopies the findings seen with paxillin knockdown, with reduced Mos protein expression, decreased downstream MAPK signaling, and less oocyte maturation. We find that, in both Xenopus oocytes and mammalian cells (HEK 293), Xenopus paxillin and ePABP constitutively interact. Interestingly, testosterone (Xenopus) or EGF (HEK 293) treatment leads to paxillin phosphorylation and reduced ePABP binding to paxillin, while  ePABP binding to Mos mRNA (Xenopus) increases.  We propose that phosphorylation of paxillin allows for its dissociation from ePABP, allowing ePABP to bind to polyadenylated Mos mRNA and enhance Mos protein expression, MAPK activation and ultimately oocyte maturation. Thus, the dynamic interaction of paxillin with ePAPB regulates steroid-induced protein expression in Xenopus oocytes in a transcription-independent fashion. As other polyA-binding proteins, such as the closely related PABP1, similarly interact with paxillin in mammalian cells, we speculate that the kinase-regulated dynamic interaction of paxillin and ePABP provide a universal mechanism of posttranscriptional control of protein expression.

 

Nothing to Disclose: SUM, FC, MY, SRH

OR43-4 19631 4.0000 A Paxillin and Epabp Engage to Regulate Androgen-Dependent Xenopus Oocyte Maturation - a Model of Kinase-Dependent Regulation of Protein Expression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM OR43 5970 9:30:00 AM Steroids in Brain, Pain and Development Oral


Natalie Z Homer*1, Sanjaykumar Kothiya2, Brian R Walker1 and Ruth Andrew1
1University of Edinburgh, Edinburgh, United Kingdom, 2Endocrinology Unit, Edinburgh

 

Profiling urinary metabolites of adrenal and gonadal steroids has been used for many years to diagnose inborn errors of metabolism and more recently adrenal tumours and also in research studies of the hypothalamic-pituitary-adrenal axis. The detection method of choice is Mass Spectrometry (MS). Within steroid pathways there are  isomeric and isobaric compounds presenting analytical challenges. The resolving power of Gas Chromatography (GC) is yet to be matched by liquid chromatography and as such GC remains the best separation method prior to MS analysis. In addition, the wide range of concentrations of steroids presents issues regarding limits of quantitation (LOQ). Tandem mass spectrometry (MS/MS) can be used to reduce background noise from the biological matrix and hence lower LOQs and potentially sample volume.  

Here we present a GC-MS/MS method using a ThermoFisher TSQ Quantum Ultra instrument fully validated for the quantitative analysis of glucocorticoids; cortisol, cortisone, tetrahydroglucocorticoids, cortols and cortolones and androgens; androstenedione and aetiocholanolone. Urine (20 mL) was fortified with internal standards (20 μg) ; epi-THF, epi-F and 3α,5α-androstenedione, subjected to enzyme hydrolysis to deconjugate, and extracted using Sep-pak® C18 cartridges. Methoxime-trimethylsilyl derivatives of the analytes were prepared and injected onto the GC-MS/MS system, separated on a DB-17MS (30m, 0.25mm, 0.25µm) column over 30 minutes (120-280C) and operated in positive electron impact mode (Source Temp= 280C, EI=70 eV). Parent-product mass transitions were optimised. Calibration curves were generated for all analytes and least squares regression analysis performed on peak area ratios of analyte to internal standard.  Quality Control (QC) samples were fortified with all reference standards at three concentrations; 0.1 (LOQ), 2.5 and 30 μg for the androgens and tetrahydroglucorticoids (Group I) and 0.05 (LOQ), 1 and 5 μg for cortisol, cortisone and the cortol and cortolones (Group II).

The on column LOQs were as follows; tetrahydroglucocorticoids, cortols and cortolones (0.25 μg), androgens ( 0.1 μg), cortisol and cortisone (0.05 μg). The method was linear (R2=0.994-0.999) over the dynamic ranges (LOQ-5 μg for group I and LOQ – 30 ug for group II), appropriate for analysis of <10mL urine. The intra-day (n=6) precision (% Relative Standard Deviation) was 0.6-20.0%, while the accuracy (%bias) was 80.0-115.3%, respectively. Data were reproducible following storage of urine for one day and 1 and 6 months at -20oC; 95.1-97.2, 93.4-96.8 and 87.2-94.1% original values respectively.

The validated method for the analysis of glucocorticoids and androgens in urine allowed separation of all steroids of interest and the use of MS/MS analysis enhanced the precision, accuracy and sensitivity of the assay compared to earlier methods allowing analysis of smaller sample volumes.

 

Nothing to Disclose: NZH, SK, BRW, RA

OR43-5 21364 5.0000 A Advances in Analysis of Urinary Steroids Using Gas Chromatography Tandem Mass Spectrometry 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM OR43 5970 9:30:00 AM Steroids in Brain, Pain and Development Oral


Nasser Dhayat*1, Bernhard Dick1, Brigitte Frey1, Claudia d`Uscio1, Bruno Vogt1, Valentin Rousson2 and Christa E. Fluck3
1University of Bern, Bern, Switzerland, 2University of Lausanne, Lausanne, Switzerland, 3Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

 

Background: Urinary steroid profiling is used in pediatrics for diagnostic and research purposes of steroidogenic disorders for over 30 years. However, normative data during early childhood development are scarce. The aim of this study was to provide comprehensive normative values for the urinary steroid metabolome of healthy newborns at short time intervals in the first year of life and to describe the metabolome with respect to the underlying developmental biology.

Methods: 67 urinary steroid metabolites were measured in 17 male and 19 female term healthy newborns at 13 time points from week 1 to week 49 of life by GC-MS. The age and sex dependency of each steroid and of steroid groups was described through a linear mixed model selection process, and the 10th, 50th and 90th percentiles were estimated for each steroid and for steroid groups and time points, and also separately for male and female newborns in case of sex differences.

Results: 61 steroids showed age specificity and 15 steroids showed sex specificity. Highest creatinine corrected urinary steroid concentrations were found in both sexes for progesterones, in particular 20α-DH-5α-DH-progesterone, and for highly polar 6α-hydroxylated glucocorticoids. The steroids peaked at week 3 and decreased to one fifth by week 25 in both sexes. The decline of progesterones, androgens and estrogens was more pronounced than of glucocorticoids and mineralocorticoids whereas the excretion of corticosterones remained constant during the first year of life. The metabolome thus mirrored underlying developmental changes in steroid production.

Conclusions: This study characterizes a large number of compounds of the urinary steroid metabolome during the first year of life for the first time allowing new insights into their potential biological role and diagnostic importance.

 

Nothing to Disclose: ND, BD, BF, CD, BV, VR, CEF

OR43-6 19531 6.0000 A Glucocorticoids and Progesterones Dominate the Urinary Steroid Metabolome in the First Year of Life in Healthy Children 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM OR43 5970 9:30:00 AM Steroids in Brain, Pain and Development Oral


Patricia Virginia Elizalde*1, Leandro Venturutti2, Lucía Romero2, Alejandro Urtreger3, María Florencia Chervo2, María Florencia Mercogliano4, Rosalia Ines Cordo Russo1, Matías Gonzalo Pereyra2, Gloria Inurrigarro5, Victoria Sundblad6, Maria Celeste Diaz Flaque7, Juan Carlos Roa8, Pablo Guzmán9, Elisa Bal de Kier-Joffe3 and Roxana Schillaci10
1Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina, 2IBYME - CONICET, Buenos Aires, Argentina, 3Institute of Oncology “Angel H. Roffo”, Buenos Aires, Argentina, 4Instituto de Biología y Medicina Experimental, CONICET, Buenos Aires, Argentina, 5Servicio de Patología, Sanatorio Mater Dei., Buenos Aires, Argentina, 6IBYME-CONICET, Buenos Aires, Argentina, 7Instituto de Investigaciones Biomedicas, UCA-CONICET, Buenos Aires, Argentina, 8Universidad de la Frontera, Temuco, Chile, 9Departamento de Anatomía Patológica (BIOREN), Universidad de La Frontera, Temuco, Chile, 10Inst. Biologia Medic Exptal, Buenos Aires, Argentina

 

Membrane ErbB-2 (MErbB-2) overexpression or gene amplification account for a clinically aggressive breast cancer (BC) subtype (ErbB-2 positive BC), with poor prognosis and increased incidence of metastases. We and others have also disclosed the role of nuclear ErbB-2 (NErbB-2) in BC, whose presence we identified as a poor prognostic factor in MErbB-2-positive tumors. The signal transducer and activator of transcription 3 (Stat3), another major player in the BC scenario, has long been recognized as a downstream mediator of ErbB-2 action in BC metastatic dissemination. On the other hand, high levels of microRNA-21 (miR-21), a well-known oncomiR, have also been reported to actively promote tumor invasion and metastasis in BC cell lines and tissues. In this study, we describe a novel hierarchical interaction between Stat3, ErbB-2 and miR-21, underlying the metastatic phenotype of ErbB-2-positive BC. We disclosed that Stat3 acts as an upstream regulator of ErbB-2 expression and function. We found, using a panel of cell lines corresponding to different BC subtypes, that Stat3 was recruited to its response elements (called GAS) at the ErbB-2 promoter, and thereby induced ErbB-2 expression at the transcriptional level. We also demonstrated that Stat3 co-opted NErbB-2 function, recruiting it as a coactivator, to assemble a transcriptional complex at the GAS sites of the miR-21 promoter, which induced miR-21 expression. We showed that miR-21 increased levels, in turn, downregulated the expression of the metastasis suppressor protein PDCD4, a previously validated miR-21 target. To assess the physiological relevance of our molecular findings, we developed an in vivo model of ErbB-2-overexpressing metastatic BC, in which Stat3 activation was inhibited by transfection with a Stat3 dominant negative variant (Stat3Y705F) or its expression was silenced by siRNAs. Through reconstitution assays, we demonstrated that ErbB-2 and miR-21 were necessary downstream mediators of Stat3-induced metastases development. Furthermore, we explored the clinical significance of our findings in a cohort of ErbB-2-positive primary invasive BC patients and demonstrated that Stat3 and ErbB-2 nuclear co-expression was associated with low PDCD4 expression levels, and that this correlated with the presence of nodal metastases. Altogether, our experimental and clinical findings shed light on the molecular mechanisms underlying BC metastasis and highlight targeting either Stat3 or NErbB-2 as novel therapeutic strategies for ErbB-2-positive BC patients.

 

Nothing to Disclose: PVE, LV, LR, AU, MFC, MFM, RIC, MGP, GI, VS, MCD, JCR, PG, EB, RS

OR37-1 18384 1.0000 A Stat3 Regulates ErbB-2 Expression and Co-Opts Nuclear ErbB-2 Function to Induce Mir-21 Expression, PDCD4 Downregulation and Breast Cancer Metastasis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Sunday, March 8th 11:00:00 AM OR37 5975 9:30:00 AM Metastasis and Tumor Progression Oral


Minako Sakurai*1, Yui Kawahara2, Yasuhiro Miki3, Kiyoshi Takagi4, Takashi Suzuki5 and Hironobu Sasano6
1Tohoku University, Graduate School of Medicine, Sendai, Japan, 2Tohoku University, Sendai, Japan, 3International Research Institute of Disaster Science, Tohoku University, Sendai, Japan, 4Tohoku University Graduate School of Medicine, Sendai, Japan, 5Tohoku Univ Sch of Hlth Sci, Sendai, Japan, 6Tohoku Univ Sch of Med, Miyagi, Japan

 

Normal mammary adipose tissues and, as with many developmental pathway, adipocytes are also being recognized as potentially important component of the cancer microenvironment. Adipocytes adjacent to carcinoma cells often acquire altered characteristics, termed as “Cancer-associated adipocytes (CAA)”. Though phenotypic changes of CAA such as reduced lipid and adipogenic markers, or increased cytokine production have been reported, a key regulator that mediates an interaction between carcinoma cells and CAAs remains unclarified. Thus, we evaluated comprehensive DNA expression patterns of breast carcinoma cells using 2D co-culture system with primary human adipocytes. We have previously confirmed that breast carcinoma cell proliferation was partly regulated by an interaction with CAA in histopathological and in vitro analysis using MCF-7 (Estrogen Receptor α (ER)-positive) (ENDO2014, Chicago). In this study, we identified significant overexpression of lipocalin-2 (LCN2; 4.75-fold) in MDA-MB-231, (ER-negative) following the cocultivation with adipocytes. LCN2 was recently identified as adipokine and known to be over-expressed in various tumors. To determine the roles of LCN2 expression in microenvironment of human breast carcinoma tissues, we immunolocalized LCN2 in a total of 150 breast cancer patients. LCN2 expression was inversely associated with age and ER status, while positively correlated with Ki-67 LI and histological grade. Consistent with our clinicopathological analysis, both carcinoma cell proliferation and migration rate were significantly increased in ER-negative breast carcinoma cell lines after stimulated by adipocyte-derived factors. We then hypothesized that LCN2-inducing factor, such as IFN-γ and TNF-α mediate up-regulation of LCN2, via STAT1 or p65, a NF-κB subunit in paracrine manner based on previous reports. Subsequently, quantitative RT-PCR demonstrated that STAT1 and p65 were both up-regulated in MDA-MB-231 after co-cultured with adipocytes, suggesting that LCN2 expression was promoted by IFN-γ and TNF-α in paracrine manner. To understand the downstream cascade of LCN2, we further demonstrated elevated expressions of LCN2 and VEGF in adipocytes cocultivated with carcinoma cells by adipokine array. Interestingly, LCN2 has been previously linked to Vascular Endothelial Growth Factor (VEGF), a key angiogenic activator in breast carcinoma cell lines. In addition, the expression of LCN2 was positively correlated with CD31, an angiogenic marker in breast carcinoma tissues, suggesting that CAA-derived LCN2 was possibly associated with angiogenesis in breast cancer cells. Collectively, our results showed that LCN2 was overexpressed in ER-negative carcinoma cells and its expression is directly and/or indirectly mediated via inflammatory cytokine signaling pathways from CAA, to promote breast cancer pathogenesis.

 

Nothing to Disclose: MS, YK, YM, KT, TS, HS

OR37-2 19653 2.0000 A Induction of Adipocytokine, Lipocalin-2 in Breast Carcinoma Cells By an Interaction with Adipocytes 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Sunday, March 8th 11:00:00 AM OR37 5975 9:30:00 AM Metastasis and Tumor Progression Oral


Shannon Terrell Bailey*1, Thomas Westerling1 and Myles Brown2
1Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA, 2Dana-Farber Cancer Institute, Boston, MA

 

Breast cancer is a disease that affects thousands of women worldwide, and despite a number of treatment options, death results from metastasis and disease resistance. Two-thirds of all breast cancer cases involve dysregulation of estrogen receptor (ER) signaling; thus, a number of treatment strategies employ using compounds that affect its activity. Included in these drugs is the selective ER modulator (SERM) tamoxifen, which binds ER, leading to its association with DNA and the recruitment of corepressor proteins that inhibit ER signaling. While therapies involving tamoxifen are useful in controlling the disease, resistance inevitably occurs, rendering these treatments ineffective. Thus, other compounds are used such as selective ER down regulators (SERDs), which leads to ubiquitin-mediated ER degradation and complete loss of its signaling. Because resistance to these compounds also occurs, other methods for regulating ER signaling must be explored.

In this study, we report loss in ER protein expression in response to treatment with doxorubicin and MG132. We found that treatment of the human breast cancer cell lines MCF7 and T47D with doxorubicin plus MG132 leads to ER protein expression loss as demonstrated by western blotting. In contrast, no ER protein expression loss was observed by treatment with either drug alone. RNA-Seq analysis of cells treated with this drug combination demonstrated loss in downstream ER targets, confirming suppressed ER signaling. As MG132 inhibits both the proteasome and calpain activity, we next sought to determine which of these protease activities was involved. Cells were treated in the presence of the proteasome inhibitors bortezomib and lactacystin, and no effect on ER expression was found with doxorubicin treatment, suggesting that the proteasome does not play a role in the ER loss. In contrast, treatment with doxorubicin plus the calpain-specific inhibitors PD 150606 and EST led to ER protein expression loss, confirming that calpain activity is involved in ER protein regulation. Next, to determine which calpains were specifically involved in the loss of ER protein, we knocked down several calpain proteins found to be expressed in MCF7 cells including calpains 1, 7, 8, 9, and 13 and the regulatory subunit CAPNS1. While knockdown of calpains 1, 7, 8, 9, and 13 had no effect on ER protein expression in the presence of doxorubicin, knockdown of CAPNS1 led to a loss in ER that was similar to treatment with calpain inhibitors in the presence of doxorubicin.

In conclusion, this study identifies a new pathway by which ER stability is affected i.e., DNA damage induction plus calpain inhibition, suggesting a novel chemotherapeutic treatment paradigm that may overcome resistance in patients with breast cancer. Thus, future studies will focus on identifying the proteins and mechanisms directly responsible for ER loss as well as analyzing preclinical in vivo mouse models

 

Nothing to Disclose: STB, TW, MB

OR37-3 22074 3.0000 A Estrogen Receptor Stability Is Modulated By Calpain Activity in Breast Cancer Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Sunday, March 8th 11:00:00 AM OR37 5975 9:30:00 AM Metastasis and Tumor Progression Oral


Zara Zelenko1, Valentina Belardi1, Yemisi Dina1, Yemisi Dina1, Aviva Tobin-Hess2, Jeffrey Blank1, Emily Jane Gallagher*1 and Derek LeRoith1
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Icahn School of Medicine at Mount Sinai, NY

 

Women with Type 2 diabetes (T2D) have an increased risk of breast cancer and a higher mortality rate compared with women without T2D. We used the female MKR mouse to study the effects of hyperinsulinemia on breast cancer progression. Compared to control mice, the MKR mice have a significant increase in tumor size and lung metastasis. We found that the primary tumors from the MKR mice have significantly higher vimentin protein expression compared to primary tumors from control mice. In this study, we aimed to determine if silencing vimentin in the tumor cells would lead to either decreased tumor growth or pulmonary metastasis. Lentiviral shRNA of target vimentin and non-coding sequence was used to generate the vimentin knockdown (KD) and control MVT-1 (c-Myc/vegf overexpressing) cells, respectively. Successful knockdown of vimentin was validated by analyzing gene expression by qRT-PCR (90% KD) and analyzing protein expression by Western Blotting (70% KD). Both the control MVT-1 cells (Ctrl) and the vimentin knockdown MVT-1 cells proliferated at the same rate over a 72 hour time course. Both the knockdown and control MVT-1 cells had similar signaling responses to 15min 10nM insulin stimulation, with an increase in phosphorylation of AKT, a downstream target of the insulin signaling pathway. In order to assess the effects of these cells in vivo 100,000 MVT-1 control and 100,000 MVT-1 vimentin knockdown cells were injected orthotopically into 8-10 week old control and MKR mice. MVT-1-Ctrl primary tumors were larger in MKR mice (249.68±28mm3) compared to WT mice (183.17±7mm3), p<0.05. There was no difference between the primary tumor volumes of the MVT-1-KD tumors in MKR and WT mice. As expected based on previous published work, the MKR mice with MVT-1-Ctrl tumors had increased pulmonary metastases (22.9±3.5 surface metastases/lung) compared to WT mice with MVT-1-Ctrl tumors (7.75±3.6 surface metastases/lung), p<0.05. The MKR mice with MVT-1-KD tumors had significantly decreased number of pulmonary metastasis (10.2±2.6 surface metastases/lung) compared to the MKR mice with MVT-1-Ctrl tumors. These results demonstrate that silencing vimentin in the MVT-1 cell line leads to a decrease in pulmonary metastasis in the hyperinsulinemic mice. These observations provide insight into vimentin, a possible downstream element of the insulin signaling pathway, which could be used as a potential target for cancer therapy in hyperinsulinemic patients.

 

Nothing to Disclose: ZZ, VB, YD, YD, AT, JB, EJG, DL

OR37-4 20513 4.0000 A Silencing Vimentin Decreases the Number of Breast Cancer Pulmonary Metastasis in a Hyperinsulinemic Mouse Model 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Sunday, March 8th 11:00:00 AM OR37 5975 9:30:00 AM Metastasis and Tumor Progression Oral


Koen Dreijerink*1, Anna Groner1, Prakash Rao1, Jennifer Cook1, Jaime Reyes1, Charles Lin1, Henry Long1 and Myles Brown2
1Dana-Farber Cancer Institute, 2Dana-Farber Cancer Institute, Boston, MA

 

Patients with multiple endocrine neoplasia type 1 (MEN1) develop tumors in various endocrine tissues. Among the manifestations of MEN1 are pituitary adenomas and breast cancer. MEN1 is caused by inactivating germ line mutations of the MEN1 tumor suppressor gene. The MEN1 gene product, menin, is a component of KMT2A-B (MLL1-2) containing protein complexes that can trimethylate lysine 4 of Histone H3 (H3K4me3), a mark of active transcription. Although the exact mechanism of disease in MEN1 is not known, aberrant H3K4me3 is considered to contribute to MEN1 tumor development.

In order to study the mechanism of action of menin, we used an integrative menin and H3K4me3 ChIP-seq and RNA-seq approach to identify menin-H3K4me3 target genes in MCF-7 breast cancer cells. We found that menin, along with the KMT components, is present at transcription start sites (TSS) of most actively transcribed genes. However, knock down of the MEN1 mRNA resulted in loss of H3K4me3 and transcription of only a small subset of these genes. Strikingly, genes that had menin-dependent H3K4me3 at their TSS showed simultaneous menin binding at enhancer loci that are also occupied by typical mammary transcription factors such as ERalpha, FOXA1 and GATA3. Treatment of MCF-7 cells with estradiol increased menin recruitment to ERalpha bound enhancer sites.

The integrative analysis identified the ESR1 gene as one of the top ranked menin-H3K4me3 target genes. After knock down of menin, ESR1 messenger RNA and ERalpha protein levels were indeed down regulated and estradiol-dependent growth was attenuated in a number of ERalpha expressing breast cancer and pituitary adenoma cell lines. Use of a menin-KMT2A inhibitor did also cause down regulation of ERalpha in MCF-7 cells. Thus, menin seems to have a proliferative function in sporadic breast cancer cell lines. We studied the tumor suppressive role of MEN1 in primary human luminal progenitor cells and found that this is probably not related to ERalpha.

Our results show that the presence of menin at mammary-specific enhancers determines menin-H3K4me3 target gene specificity in MCF-7 cells. An enhancer-dependent role could explain the tissue-specific functions of menin. Targeting menin may offer opportunities for the treatment of ERalpha positive sporadic breast cancer.

 

Nothing to Disclose: KD, AG, PR, JC, JR, CL, HL, MB

OR37-5 20282 5.0000 A Towards Understanding Tissue-Specificity in Multiple Endocrine Neoplasia Type 1: Menin Enhancer Binding Determines Target Gene Histone H3K4 Trimethylation and mRNA Expression 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Sunday, March 8th 11:00:00 AM OR37 5975 9:30:00 AM Metastasis and Tumor Progression Oral


Jenny Qian Dai-Ju*1, Yan-He Lue2, Ronald S. Swerdloff1, David Shackelford3, Yue Jia1, Pinchas Cohen4 and Christina Wang1
1LABioMed at Harbor-UCLA Medical Center, Torrance, CA, 2LABioMed at Harbor-UCLA Med Ctr., Torrance, CA, 3UCLA David Geffen School of Medcine, Los Angeles, CA, 4University of Southern California, Los Angeles, CA

 

Background: Humanin (HN) is a mitochondrial derived peptide with cytoprotective effects in normal cells challenged by various stressors. We recently showed that the potent synthetic HN analog (HNG, HN-S14G) attenuates male germ cell apoptosis induced by cyclophosphamide (CP) treatment in rodents while suppressing CP-induced tumor growth in a mouse lung B16 melanoma metastasis model. HNG has been shown to activate several signal transduction pathways, including promoting AMPK signaling. We hypothesized that a possible mechanism for HNG enhanced chemotherapy-induced tumor suppression is by changing the energy/nutrient availability by activating AMPK, and suppressing mTOR (mammalian target of rapamycin) dependent pathway.

Methods: Adult male mouse (n=5/group) were seeded with mouse B16 melanoma cells (200,000 cells/mouse) via tail vein on day 1. One week after melanoma cell inoculation, mice were treated either with a single intraperitoneal injection (IP) of CP (200mg/kg), or daily IP injections of HNG (5mg/kg), or both for 14 days. Mice were sacrificed at day 21 and lungs were fixed in formaldehyde.  Immunohistochemistry was performed on lung metastases with antibodies against phosphorylated- AMPK (p-AMPK), p-4E-BP1 (downstream effector of mTOR) and Ki-67 antigen (a marker of cell proliferation).

Results: Compared to non-treated mice, HNG decreased number of metastatic lung tumors by ~23%, CP by ~50 % and HNG+CP by ~61%. The percent p-AMPK positive cells in metastatic lung melanoma treated with HNG alone (40.3± 10.7, mean±SD) and HNG+ CP (38.0±13.0) were significantly increased compared to CP alone (11.3±15.6, p<0.22). Expression of mTOR downstream effector for proliferation, p-4E-BP1, within the metastatic tumors was very variable and not significantly different among groups. The mean Ki-67 index was significantly lower (p =0.0036) in CP treated (30.0±16.2) and CP+ HNG groups (35.8±12.8), compared to untreated (62.0±14.8) and HNG groups (60.0±14.1SD). Co-administration of HNG with CP did not appear to further inhibit Ki-67 index.

Conclusion: HNG activates the key energy homeostasis regulator AMPK without affecting tumor mTOR signaling. The residual tumor cells that survived chemotherapy may have adapted to energy deprivation. AMPK activation may initially lead to mTORC1 (mTOR complex 1) inactivation, followed by mTORC2 mediated reactivation of mTORC1 resulting in increased p-AMPK with no detectable change in p-4EBP1 expression in the tumor after CP±HNG treatment. Other pathways may also be involved to antagonize the inhibition of mTOR by AMPK in the tumor. This suggests that AMPK activation may be sufficient to reduce tumor growth without mTOR suppression. Importantly HN may have differential actions by modulating the host via both AMPK and mTOR pathways mimicking reduced nutrient availability in caloric restriction but increase AMPK signaling only in the tumor.

 

Disclosure: PC: Consultant, CohBar Inc.. Nothing to Disclose: JQD, YHL, RSS, DS, YJ, CW

OR37-6 21662 6.0000 A Adenosine Monophosphate-Activated Protein Kinase (AMPK) Pathway Maybe Involved in Hng Treatment in Pulmonary Mouse Metastatic Melanomas 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Tumor Biology Sunday, March 8th 11:00:00 AM OR37 5975 9:30:00 AM Metastasis and Tumor Progression Oral


Janet H Leung*1, Mohammad Ashbir Zammeri2, Gordon H Williams3 and Jonathan S Williams4
1Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, 2Brigham and Women's Hospital, 3Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 4Brigham & Women's Hospital, Harvard Medical School, Boston, MA

 

Decades of research have identified that dietary salt is associated with increased blood pressure. However, physiology studies of salt sensitivity reveal significant interpersonal variability, especially among individuals of African ancestry. Prior analyses from the International Hypertension Pathotypes Group (HyperPath), a multinational, multi-decade study of the genetic underpinnings of hypertension, had identified associations between dietary salt intake, blood pressure, and polymorphisms in both the serum- and glucocorticoid-inducible kinase 1 (SGK1) and  the lysine-specific demethylase-1 (LSD1) genes.  SGK1 is a regulator of epithelial Na+ channel (ENaC) activity and aldosterone-induced sodium reabsorption. LSD1 is a histone modifying enzyme that modifies salt-aldosterone interaction in human and animal models. We tested the combined effects of variation at both SKG1 and LSD1 susceptibility loci on salt sensitivity of blood pressure in participants of African ancestry in HyperPath.

As per protocol, participants were washed off antihypertensive medications for up to 3 months prior to consuming a low salt (<20 mmol/day) then a liberal salt diet (> 200 mmol/day) for 7 days each. The main study outcome was the change in systolic blood pressure (ΔSBP) between the liberal and low salt diets.  Statistical comparison of ΔSBP by previously described susceptibility loci (SGK1 rs2758151 (1) and LSD1 rs671357 (2)) were analyzed assuming a dominant inheritance model adjusting for age, gender, BMI, and sibling-pair relatedness.

A total of 81 individuals were identified who had SBP data, demographic, and genotype information. The LSD1 risk allele at rs671357 was associated with greater salt sensitivity of BP (mean ΔSBP 10.2 ± SE 1.6 mmHg, v. 20.4 ± 2.6, p = 0.0008). The SGK1 risk allele rs2758151 was not associated with a statistically significant difference in ΔSBP (13.1 ± 1.9 v. 12.7 ± 2.0, p = 0.9), unlike what was previously seen in Caucasian hypertensive populations. In testing the combined effects of both loci, in individuals who were homozygotes for the SGK1 risk allele (n = 40), carrying the LSD1 risk allele was associated with greater salt sensitivity of ΔSBP (7.7 ± 2.2 v. 24.8 ± 3.6, p = 0.0004). Similar analysis in the Caucasian cohort (n = 510) did not find the same enhanced effect of having both risk genotypes (p = 0.8).

Thus, the presence of risk genotypes for both SGK1 and LSD1 was associated with a greater change in ΔSBP between low and liberal salt diets than either genotype alone in participants of African, but not Caucasian, descent in the HyperPath cohort.  The cumulative effect of genetic susceptibility may in part explain blood pressure heterogeneity within a population, and is consistent with a polygenic model of hypertension. Future work will explore the possible epigenetic interaction of LSD1 on SGK1 gene function and underlying effects on aldosterone and salt sensitivity.

 

Nothing to Disclose: JHL, MAZ, GHW, JSW

OR38-1 19201 1.0000 A Combination of SGK1 and LSD1 Risk Alleles Is Associated with Salt Sensitive Blood Pressure in Individuals of African Descent 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Sunday, March 8th 11:00:00 AM OR38 5978 9:30:00 AM Mineralocorticoids: Receptors, Hypertension and Novel Mechanisms Oral


Masao Omura*1, Kohzoh Makita2, Seishi Matsui3, Jun Inoue3, Maki Nagata3, Yoko Matsuzawa4, Jun Saito4 and Tetsuo Nishikawa4
1Yokohama Rosai Hospital, Yokohama, Kanagwa, 2Hikarigaoka Hospital, Tokyo, 3Yokohama Rosai Hospital, Yokohama, Japan, 4Yokohama Rosai Hosp, Yokohama, Japan

 

Introduction: Adrenal venous sampling (AVS) is essential to decide how to treat primary aldosteronism (PA). However, AVS cannot differentiate bilateral aldosterone-producing adenomas (Blt-APAs) from idiopathic hyperaldosteronism (IHA), because both of them show bilateral hyper-secretion of aldosterone. Therefore, most cases with Blt-APAs have been medically treated. We diagnosed Blt-APAs by performing a new AVS method, and we attempted to perform sequential surgical treatment for Blt-APAs.

Cases and methods: We preoperatively diagnosed Blt-APAs by ACTH-stimulated adrenal tributary sampling (ATS) obtaining adrenal effluents at more than 2 tributary veins in each adrenal gland after ACTH stimulation. Cases with Blt-APAs were treated by unilateral partial adrenalectomy. After the surgery, we performed 123I-adosterol adrenal sintigraphy to confirm that residual tissues of partially resected adrenals are functional. We tried to treat them by unilateral adrenalectomy of contralateral adrenals at the next step.

Results: We performed ATS in 300 cases with PA and there were 104 cases with unilateral APA, 38 of CT-undetectable aldosterone-producing microadenoma, 13 of unilateral hyperplasia, 103 of IHA, and 42 of Blt-APAs. Thirty-two cases among 42 Blt-APAs underwent unilateral partial adrenalectomy and 24 cases became normotensive for up to 3 years after the operation. Other 8 cases still showing persistent hypertension after the first operation were examined by adrenal scintigraphy, revealing functional in the residual adrenal glands in 7 cases. One among 3 cases demonstrating  severe hypertension also underwent unilateral partial adrenalectomy of contralateral adrenal gland 6 months after the first surgery. After second surgery the case became normotensive and normo-aldosteronemia without complicating adrenal insufficiency.

Discussion:  The prevalence of Blt-APAs was unexpectedly high among PA cases, however, hypertension could be improved in more than half of cases with Blt-APAs for a few years after first unilateral partial adrenalectomy. Therefore, we might not necessarily have to perform single-stage bilateral adrenalectomy to treat Blt-APAs, and we had better to consider second adrenalectomy in hypertensive cases after first unilateral partial adrenalectomy.

 

Nothing to Disclose: MO, KM, SM, JI, MN, YM, JS, TN

OR38-2 19712 2.0000 A We Should Not Miss Bilateral Aldosterone-Producing Adenomas Among Cases with Bilateral Hyperaldosteronism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Sunday, March 8th 11:00:00 AM OR38 5978 9:30:00 AM Mineralocorticoids: Receptors, Hypertension and Novel Mechanisms Oral


Ingrid Lema*1, Larbi Amazit1, Khadija Lamribet1, Anne Blanchard2, Marc Lombes1, Nadia Cherradi3 and Say Viengchareun1
1INSERM U693, Le Kremlin Bicêtre, France, 2INSERM CIC 9201, Paris, France, 3INSERM U1036, Grenoble, France

 

The Mineralocorticoid Receptor (MR) mediates sodium-retaining action of aldosterone in the distal nephron in which prevail large variations in extracellular tonicity generated by the renal corticopapillary gradient. Molecular mechanisms regulating renal MR expression remain sparse. We previously demonstrated that MR abundance in renal KC3AC1 cells is drastically reduced by hypertonicity (500 mOsm/L) while hypotonicity (150 mOsm/L) increases MR expression (1). We recently provided evidence that posttranscriptional events participate to the control of MR expression. We showed that hypertonicity increases endogenous expression of the RNA-Binding Protein Tis11b which physically interacts with the 3’-untranslated region (3’-UTR) of MR transcript, leading to repression of MR expression, as demonstrated both in vitro and in vivo experiments in mice. Hypertonicity also impaired MR signaling by blunting aldosterone-stimulated target gene expression in renal cells (2).

Here, we aim at deciphering posttranscriptional regulatory mechanisms involved in hypotonicity-induced MR expression. We identified HuR, another RNA-Binding Protein, known to stabilize target transcripts by binding to their 3’-UTR on U rich sequences. RNA interference strategy enabled us to unambiguously demonstrate that HuR protein increases MR expression under hypotonicity. Interestingly, we showed that hypotonicity induced a very rapid (5 min) and fully reversible nuclear export of HuR in KC3AC1 cells, as monitored and quantified by high throughput microscopy. These data are consistent with previous reports showing that HuR activity mostly relies on its subcellular localization. Luciferase activities of full length or truncated MR 3’-UTR sequences cloned downstream of the reporter gene significantly increased when cotransfected with HuR expressing plasmid in HEK 293T cells. Using RNA-IP, we also showed that HuR bound crucial UU motifs within MR 3’-UTR. Site-directed mutagenesis is ongoing to precisely delineate specific interacting motifs. Importantly, aldosterone responsiveness was exacerbated when apical surface of renal cells was exposed to hypotonic conditions mimicking reduction in luminal tonicity as revealed by the potentiation of aldosterone-stimulated increase in MR target gene expression. We are currently investigating whether and how hypotonicity-induced increase of MR expression impacts renal mineralocorticoid signaling pathway in vivo.

Altogether, our data bring new insights into molecular mechanisms controlling MR expression and action under variations of the extracellular tonicity. Such new regulatory processes might have important pathophysiological relevance in a context of kidney diseases, hypertension or mineralocorticoid resistance.

 

Nothing to Disclose: IL, LA, KL, AB, ML, NC, SV

OR38-3 19811 3.0000 A Potentiation of Renal Aldosterone Responsiveness Via Hypotonicity-Induced Mineralocorticoid Receptor Expression By the mRNA Binding Protein Hur 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Sunday, March 8th 11:00:00 AM OR38 5978 9:30:00 AM Mineralocorticoids: Receptors, Hypertension and Novel Mechanisms Oral


Suman Srinivasa*1, Kathleen V Fitch1, Kimberly Wong1, Martin Torriani1, Caitlin Mayhew2, Takara L. Stanley3, Janet Lo1, Gail K. Adler4 and Steven K. Grinspoon1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, 3Massachusetts General Hospital and Harvard Medical School, Boston, MA, 4Brigham and Women's Hospital, Harvard Medical School, Boston, MA

 

Emerging evidence suggests that renin-angiotensin-aldosterone system (RAAS) dysregulation in adipose tissue may be linked to insulin resistance. Little is known about the relationship between human RAAS physiology and the visceral depot. The HIV population is at significant risk for metabolic disease related to lipodystrophic changes and visceral fat accumulation. We hypothesized that insulin resistance in HIV patients with excess visceral adipose tissue (VAT) would be associated with RAAS activation. 20 HIV-infected and 10 non-infected subjects were prospectively recruited. VAT was assessed by MRI. Subjects underwent two graded angiotensin (ang) II infusions each preceded by a standardized sodium restricted or loaded diet. Fasting glucose and insulin, plasma renin activity (PRA), serum aldosterone under basal and ang II stimulated conditions, and 24 hour urinary aldosterone excretion were evaluated during both controlled diets. Further analyses were performed after cohorts were substratified by median VAT into those with and without excess VAT. Subjects were well-matched with respect to age, gender, and VAT. Creatinine and potassium did not differ. Following the salt restricted diet, similar 24 hour urinary sodium levels were achieved among both groups (P=0.77), whereas basal aldosterone levels were significantly increased among HIV subjects compared to controls (13.8[9.7, 30.1] vs. 9.2[7.6, 13.6] ng/dL, P=0.03*). After substratification, aldosterone levels measured during sodium restriction were higher in HIV subjects with excess VAT (27.2[13.0, 36.9] ng/dL) compared to HIV subjects without excess VAT (11.4[9.4, 13.8] ng/dL), controls with excess VAT (9.2[8.1, 21.5] ng/dL), and controls without excess VAT (8.5[7.0, 12.8] ng/dL) (overall trend across groups P=0.02*). In contrast, aldosterone did not differ by HIV status or VAT following sodium loading or ang II infusion. Serum aldosterone positively correlated with PRA (P=0.001) among the HIV cohort during controlled low salt conditions. In addition to VAT (P=0.007), serum aldosterone (P=0.03) and PRA (P=0.05) were significantly associated with HOMA-IR in the HIV cohort during sodium restriction. Multivariate modeling demonstrated that serum aldosterone (P=0.047) and VAT (P=0.004) were independent predictors of HOMA-IR (overall P=0.0004) in the salt restrictive state among HIV subjects. These novel data suggest that HIV subjects have higher stimulation of aldosterone during conditions of relative salt restriction. Furthermore, increased aldosterone under this condition is uniquely associated with the visceral depot and insulin resistance in HIV and may be renin-dependent. To that end, mineralocorticoid blockade may have therapeutic potential to reduce metabolic complications in HIV patients in whom aldosterone levels are increased. (*P-value for assessing differences in log-transformed values.)

 

Nothing to Disclose: SS, KVF, KW, MT, CM, TLS, JL, GKA, SKG

OR38-4 19961 4.0000 A Increased Aldosterone Concentrations Are Associated with Visceral Adiposity and Insulin Resistance Among HIV-Infected Patients 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Sunday, March 8th 11:00:00 AM OR38 5978 9:30:00 AM Mineralocorticoids: Receptors, Hypertension and Novel Mechanisms Oral


Tomaz Kocjan*1, Milenko Stankovic1, Andrej Janez1, Gaj Vidmar2 and Mojca Jensterle1
1University Medical Centre Ljubljana, Ljubljana, Slovenia, 2University Rehabilitation Institute, Ljubljana, Slovenia

 

Context: Adrenal venous sampling (AVS) is currently the only consistent method to distinguish bilateral from unilateral primary aldosteronism (PA). Regardless of its diagnostic value, AVS has several drawbacks, not limited to high cost and invasiveness, so it is reasonable to avoid this procedure when it would not influence clinical management.

Objective: We aimed to identify a new clinical criterion that can reliably predict bilateral aldosterone hypersecretion (BAH) before AVS.

Patients and methods: We conducted a cross-sectional study in 69 patients (aged 56.3 ± 8 years, 21 females) with PA that underwent AVS. PA was confirmed with the saline infusion test (SIT). AVS was performed sequentially during continuous ACTH infusion. 67 patients (97%) had a successful AVS and were included in the statistical analysis.

Results: A total of 39 patients (58%) had BAH according to AVS. Absence of hypokalemia, low post-SIT plasma aldosterone concentration (PAC), lack of laterality on CT imaging findings, and absence of typical Conn's adenoma were statistically significantly associated with BAH (P<0.05). The combined criterion of serum potassium ≥ 3.5 mmol/l, post-SIT PAC < 500 pmol/l (< 18 ng/dL) and either no or bilateral tumor found on CT imaging achieved perfect specificity (and thus 100% positive predictive value), saving an estimated 16% of the patients (11/67) from unnecessary AVS. Best overall classification accuracy (50/67=75%) was achieved using the post-SIT PAC level < 500 pmol/l (< 18 ng/dL) alone, which yielded 74% sensitivity and 75% specificity for predicting BAH.

Conclusions: Our clinical prediction criterion accurately determined a subset of patients with bilateral PA who should have avoided unnecessary AVS and immediately commenced with medical treatment. Some valuable health resources could be spared if our results are validated on an independent sample.

 

Nothing to Disclose: TK, MS, AJ, GV, MJ

OR38-5 22115 5.0000 A A New Clinical Prediction Criterion Accurately Determines a Subset of Patients with Bilateral Primary Aldosteronism before Adrenal Venous Sampling 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Sunday, March 8th 11:00:00 AM OR38 5978 9:30:00 AM Mineralocorticoids: Receptors, Hypertension and Novel Mechanisms Oral


Guanghong Jia*1, Javad Habibi1, Annayya R. Aroor1, Zhe Sun2, Lixin Ma3, Vincent G. DeMarco1, Luis A. Martinez-Lemus2, Gerald A. Meininger2, Iris Z Jaffe4 and James R. Sowers5
1University of Missouri, Columbia, MO, 2University of Missouri, 3University of Missouri - School of Medicine, 4Tufts Medical Center, Boston, MA, 5Harry S Truman VA Hospital and University of Missouri, Columbia, MO

 

Obesity, especially in post-menopausal women, is associated with increased plasma aldosterone, which may promote insulin resistance and cardiovascular (CV) stiffness. Enhanced CV mineralocorticoid receptor (MR) signaling impairs insulin metabolic signaling, promotes CV stiffness and attenuates vascular and cardiac relaxation. However, the specific role of endothelial cell MR (ECMR) signaling in promoting these maladaptive cardiovascular effects have not been explored.  Accordingly, we hypothesized ECMR contributes to western diet (WD)- induced impairment of  insulin signaling,  increased aortic stiffness, cardiomyocyte hypertrophy, cardiac stiffness and impaired diastolic relaxation. Further, we posited that benefits of ECMR KO involve reducing growth, pro-fibrotic signaling pathways, and maladaptive pro-inflammatory responses. Four week-old female ECMR KO and littermate wild type (WT) control mice were fed a mouse chow (CD) or WD containing   excess fat (46%) and fructose (17.5%) for 16 weeks. ECMR KO mice prevented WD-increased aortic as well as EC and vascular smooth muscle cell stiffness as determined by in vivo pulse wave velocity and ex vivo atomic force microscopy techniques, respectively. Also, ECMR KO mice improved the aortic vasodilation responses to Ach, SNP (10-9-10-4 mol/L), and insulin (0.1- 300 ng/ml), which were impaired by WD. The elevated aortic stiffness was accompanied by increased expression of inflammatory cytokines IL-17 and MCP-1 and M1 markers CD 86, and CD11b.  Furthermore, ECMR KO restored WD- induced diastolic dysfunction  by high resolution cardiac MRI and echocardiography (LV diastolic relaxation time 37.5 ms for WDWT versus  24.38 ms for WD ECMR KO, p<0.01; Initial filling rate 0.12 µl/ms for WDWT versus 0.39µl/ms for WD ECMRKO, p<0.01). These functional changes were related to cardiomyocyte hypertrophy, myocardial oxidative stress, and interstitial fibrosis, which showed to enhance activation of the S6 kinase-1, Erk 1/2, serine phosphorylation of insulin receptor substrate-1, inactivation of PI3K-AKT-eNOS signaling pathways, and the pro-fibrotic transforming growth factor (TGF)-β1/Smad2/3 or Smad7 signaling pathway, and increase macrophage pro-inflammatory polarization in cardiac tissues.  Interestingly, EC MR KO markedly attenuated the CV functional changes and signaling induced by a WD. These findings support the hypothesis that increased EC MR signaling play a key role in WD induced insulin metabolic impairment, adaptive proinflammatory response, macrophage polarization and associated aortic stiffness and cardiac diastolic dysfunction that results from consuming a WD.

 

Nothing to Disclose: GJ, JH, ARA, ZS, LM, VGD, LAM, GAM, IZJ, JRS

OR38-6 20601 6.0000 A Endothelial Cell Mineralocorticoid Receptor Knockout Corrects Western Diet - Induced Aortic Stiffness and Cardiac Diastolic Dysfunction in Female Mice 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Cardiovascular Endocrinology Sunday, March 8th 11:00:00 AM OR38 5978 9:30:00 AM Mineralocorticoids: Receptors, Hypertension and Novel Mechanisms Oral


George Mskhalaya*1, Elena Eltsova1, Victoria Zaletova1, Daria Gusakova2 and Svetlana Kalinchenko3
1Center for Reproductive Medicine MAMA, Moscow, Russia, 2Research Institute of Urology, Moscow, Russia, 3People's Friendship University of Russia, Moscow, Russia

 

Poor ovarian response is considered to be one of the most acute problems in reproductive medicine. Several studies were published suggesting the role of androgens in increasing the number and maturity of oocytes, pregnancy and birth rates after controlled ovarian stimulation (COS) for IVF. No studies considering oral form of testosterone undecanoate (Andriol, Organon) as a possible therapy were published.  The aim of the study was to evaluate the efficacy of testosterone treatment before COS on clinical pregnancy rate in poor responders undergoing IVF/ intracytoplasmic sperm injection (ICSI). 

Materials and Methods: 44 women, mean age 39 years, with poor ovarian response, defined based on ESHRE consensus/the Bologna criteria of low ovarian response were included. Anti-Mullerian hormone (AMH), testosterone, sex-hormone binding globulin (SHBG) was measured before starting testosterone treatment. Testosterone undecanoate oral form 40 mg (Andriol) was given to all patients daily for at least 40 days (mean - 48 days) preceding COS for IVF. Starting FSH dose, total dose of gonadotropins, number oocytes retrieved, blastocysts per cycle, pregnancy rates in a previous IVF cycle were compared to those during COS for IVF after testosterone treatment.

Statistical research was made using a software package statistics (StatSoft Inc. U.S., version 6.0). Quantitative data are presented as medians and quartile range. When comparing the quantitative data of two groups Wilcoxon test was used. Values were considered statistically significant if p <0.05.

Results: There was a significant increase in total serum testosterone level (1.01 [0.69;1.14] vs 2,150 [1.32; 2,47] nmol/l , p<0.001) and calculated free testosterone level (12 [8;15] pmol/l vs 36 pmol/l [20;39], p<0.001). There was no significant difference in AMH, starting FSH dose or total dose of gonadotropins administered. There was a significant increase in number of  oocytes retrieved (1,8 [0,0; 3,0] vs 2,7 [1,0;3,0], p=0,046) and blastocysts per cycle (0,4 [0,0;1,0] vs 1,4 [0,0; 2,0], p<0,001) after the treatment. The clinical pregnancy rate was 27% per cycle and 43% per embryo transfered.

Conclusion: Testosterone treatment with oral form of testoterone undecanoate may improve response to COS and pregnancy rate in women with poor ovarian response undergoing IVF/ICSI.

 

Nothing to Disclose: GM, EE, VZ, DG, SK

OR42-1 20653 1.0000 A The Effect of Oral Testosterone Undecanoate Therapy on Controlled Ovarian Stimulation and IVF Outcome in Women with Poor Ovarian Response 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Sunday, March 8th 11:00:00 AM OR42 6008 9:30:00 AM Pregnancy-Related Reproductive Endocrinology Oral


Beverly S Chilton*1, Natachi Iwuoha1, Lisa A Smith2, Gurvinder Kaur1, Rebecca A Helmer1 and Jannette Marie Dufour1
1Texas Tech University Health Sciences Center, Lubbock, TX, 2TTUHSC, Lubbock, TX

 

Alternative splicing – a molecular mechanism known to increase proteomic diversity – can also promote homeostasis at the fetal-maternal interface. Helicase-like transcription factor (Hltf) gene splicing is an example.  Loss of Hltf in the mouse leads to cardiac defects, persistent hypoglycemia and perinatal lethality. Hltf is alternatively spliced to yield isoform 1 (exons 1-25) that encodes a protein with DNA damage repair capabilities, and isoform 2 (exons 1-21 with exon 21 extended via a partial intron retention event) that encodes a C-terminal truncation mutant lacking the DNA repair domain.  Because placental insufficiency and cardiac defects impact each other, the placental transcriptome was evaluated for Hltf loss effects. Splice variant quantification of wild-type term (E18) mouse placenta (n=5) revealed Hltf isoform 2 is the only isoform expressed in fetal and maternal cells. Expression of the Hltf isoform whose protein product is incapable of DNA damage repair suggested a permissive role in trophoblast giant cell endoreduplication and directed a target search in Hltf null placenta (n=5). Here, endocycle-promoting transcripts (Senp2, E2f1, E2f7, and p57) were reduced. Hltf’s role in differentiation of trophoblast giant cell (TGC) subtypes was shown in the Hltf null placenta where decreased expression of Hand1 coupled with down regulation of the Gata2/3 transcription factors that induce trophoblast fate correlated with reduced PL-1 gene expression. Reduced expression of this marker for parietal (P)-TGCs suggests failed expansion of differentiated giant cells.  In conjunction with Hand1 down regulation, transcripts for the Ascl1 (Mash2) gene whose protein product antagonizes Hand1 were up regulated.  Kcnq1ot1*, a long ncRNA that is antisense to an interior portion of Kncq1 and silences it in cis to block transcription of Ascl2, was also down regulated.  Reduced transcripts for Senp2-Mdm2 correlated with reduced Ctsq gene expression, a marker for sinusoidal TGCs.  Genes for trophoblast proliferation (Lepr) and invasion (Lifr) were down regulated in conjunction with known targets (Snat4*). The most dramatic effect of Hltf silencing was a decrease in the G1/S transition (part 2) of the cell cycle (p = 3.505E-09) via the Egfr↓/PI3K/Akt3↓/CCND1↓ pathway in fetal endothelial cells of the labyrinth. This decrease in the number of cyclin-D1 expressing endothelial cells –  potentially limits proliferation toward the end of pregnancy –  was accompanied by reduced expression of genes required for normal vascularization (Tsc1, Mdm2), placental nutrient supply (Igf2*), arterial markers (Hey1, Gja4), endothelial sprouting and proliferation (Efnb2), branching morphogenesis (Cdkn1c), and axon path finding genes (Slit2, Ntn5, Pbfibp1) involved in vascularization. The growth promoting capabilities of Hltf are underscored by its regulation of paternally (*) imprinted genes.

 

Nothing to Disclose: BSC, NI, LAS, GK, RAH, JMD

OR42-2 21259 2.0000 A Helicase-like Transcription Factor (Hltf) Is a Key Regulator of  Trophoblast Lineage Determination and Transcription of Related Placental Hormones 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Sunday, March 8th 11:00:00 AM OR42 6008 9:30:00 AM Pregnancy-Related Reproductive Endocrinology Oral


Suneeta Senapati*1, Mary D Sammel1, Christos Coutifaris1, Marisa Bartolomei2, Temidayo Adedji-Fajobi1 and Samantha F Butts3
1Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 2University of Pennsylvania, Philadelphia, PA, 3Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

 

Background:  Mounting evidence supports an association between vitamin D deficiency and fetal growth restriction, but the underlying mechanisms have not been elucidated.  Since in vitro studies in human trophoblasts suggest a role for calcitriol in regulation of hCG production, serum hCG patterns in early pregnancy may represent an early marker of vitamin D deficiency-related placental dysfunction.

Objective:  To compare the absolute levels and kinetics of first trimester serum hCG, stratified by peri-conceptional vitamin D status in women with viable intrauterine pregnancies.

Design: Prospective cohort study of women attempting to conceive naturally or following IVF treatment for infertility.

Setting: Academic infertility practice.

Methods: Total 25 (OH)D was measured using liquid chromatography-tandem mass spectrometry within one month before or after conception. Serum hCG was measured as early as 11 days after conception with each subject contributing an average of three measurements in the first trimester of pregnancy.  Subjects were classified into Vitamin D (VitD) status groups: sufficient (=> 75 nmol/L), insufficient (< 75 nmol/L) or deficient (< 50 nmol/L).  Kruskal wallis, χ2, and Fisher exact testing was used to evaluate differences in demographic characteristics according to VitD status. Random effects linear regression models were used to assess the impact of peri-conceptional ViD status on hCG level and change (slope) over time.

Results:  Sixty-three women with viable singleton intrauterine gestations were studied, 24 were VitD sufficient (38.1%), 28 were VitD insufficient (44.4%) and 11 were VitD deficient (17.5%).  Deficient VitD status was significantly associated with non-white race (p=0.01) and natural conception (p=0.04); the association between deficient VitD and obesity reached borderline significance (p=0.09).  VitD deficiency was associated with a 3.5 fold higher Day 11 serum hCG concentration compared to VitD sufficiency (Geometric Mean Ratio 3.53, 95% CI (1.35-9.23), p=0.01) indicating preferential trophoblast differentiation towards villous, non-invasive syncytiotrophoblasts. However, the hCG rise (slope) was similar across VitD status groups (p=0.18) suggesting similar trophoblast growth patterns between groups.  

Conclusions: This is the first epidemiologic study showing an association between 25(OHD) and hCG in a population of women early in gestation. Our findings suggest that VitD deficiency results in increased cell differentiation towards the villous/non-invasive rather than the extravillous/invasive trophoblast phenotype. Such an effect may have a significant impact on placentation and fetal growth, thus explaining the correlation of intrauterine growth restriction and VitD deficiency.


 

Nothing to Disclose: SS, MDS, CC, MB, TA, SFB

OR42-3 19713 3.0000 A Peri-Conceptional Vitamin D Status and Serum Hcg Concentration in the First Trimester of Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Sunday, March 8th 11:00:00 AM OR42 6008 9:30:00 AM Pregnancy-Related Reproductive Endocrinology Oral


Chien-Cheng Chen*1 and Carole R Mendelson2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Med Ctr, Dallas, TX

 

Progesterone (P4) acting through PR plays a crucial role in maintaining myometrial quiescence throughout pregnancy by suppressing NF-κB activation of genes encoding proinflammatory cytokines and contraction-associated proteins (CAP; e.g. COX-2, OXTR, CX43). By contrast, increased myometrial contractility near term is associated with a decline in PR function, resulting in enhanced NF-κB activation and induction of proinflammatory cytokine and CAP genes. Notably, the mechanisms whereby P4/PR inhibits inflammatory/CAP gene expression during pregnancy have not been fully defined. Using immortalized human myometrial cells (hTERT-HM) stably expressing wild-type PR-B (PR-BWT), treatment with P4 significantly inhibited IL-1β induction of NF-κB target genes, COX-2, IL-6 and IL-8. P4/PR-BWT transrepression activity occurred at the level of transcription initiation and was mediated by decreased recruitment of NF-κB p65 and RNA Pol II to the COX-2 and IL-8 promoter regions. However, in cells stably expressing a PR-B DNA-binding domain (DBD) mutant (PR-BmDBD), P4-mediated repression was significantly reduced, suggesting that the PR DBD serves a critical role in P4-mediated repression. ChIP analysis of hTERT-HM cells stably expressing PR-BWT and PR-BmDBD revealed that both PR-BWT and PR-BmDBD were equivalently recruited to the COX-2 and IL-8 promoters with P4 treatment, suggesting that inhibitory effects of PR were not mediated by direct PR DNA binding. Thus, we postulated that nuclear proteins interacting with the PR-DBD may play an important role in P4/PR transrepression activity. To identify nuclear proteins that interact with PRWT but not with PRmDBD, we used immunoprecipitation, followed by mass spectrometry analysis. We identified a transcriptional repressor, GATAD2B, that interacted strongly with PR-BWT, but poorly with PR-BmDBD. Notably, P4 treatment of PR-BWT hTERT-HM cells, caused enhanced recruitment of endogenous GATAD2B to COX-2 and IL-8 promoters. Moreover, with siRNA-mediated knockdown of endogenous GATAD2B in PR-BWT hTERT-HM cells, P4-mediated transrepression of COX-2 and IL-8 expression was significantly reduced. Previously, we reported that the microRNA (miR)-200 family, which increases in pregnant myometrium near term, promotes a decline in PR function and increases CAP gene expression (1-3). Intriguingly, GATAD2B is a predicted target of the miR-200 family. Accordingly, transfection of miR-200 mimics into hTERT-HM cells reduced GATAD2B mRNA and protein levels. Together, our findings suggest that GATAD2B serves as a novel mediator of P4/PR suppression of proinflammatory and CAP gene expression during pregnancy. We propose that during late gestation, miR-200 suppression of GATAD2B contributes to the decline in PR function, leading to labor.

 

Nothing to Disclose: CCC, CRM

OR42-4 20607 4.0000 A GATAD2B Serves As a Novel Corepressor of Progesterone Receptor (PR) Suppression of Myometrial Contractile Gene Expression during Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Sunday, March 8th 11:00:00 AM OR42 6008 9:30:00 AM Pregnancy-Related Reproductive Endocrinology Oral


Jennifer Joan Adibi*1, Myoung Keun Lee1, Naimi I. Ashley2, Emily Barrett3, Ruby Nguyen4, Sheela Sathyanarayana5, Mari-Paule Thiet6, Sarah J Janssen7, Laurence Baskin8, J. Bruce Redmon9 and Shanna H Swan10
1University of Pittsburgh, Pittsburgh, PA, 2McGill University, Montreal, QC, Canada, 3University of Rochester, Rochester, NY, 4University of Minnesota, 5University of Washington, 6University of California, San Francisco, 7University of California, San Francisco, CA, 8University of California, San Francisco, San Francisco, CA, 9Univ of MN Med Sch, Minneapolis, MN, 10Mount Sinai School of Medicine, New York, NY

 

Background. Human chorionic gonadotropin (hCG) is a sexually dimorphic placental secreted hormone that is essential to normal differentiation of the fetal testes. Mothers of cryptorchid neonates had 20% lower circulating hCG in the first trimester versus controls. An endocrine disrupting compound, mono-n-butyl phthalate (MnBP), increases expression of the hCG alpha subunit in female placentas and decreases expression in male placentas. In male infants, prenatal phthalate exposure is associated with shorter anogenital distance (AGD) at birth-- a marker of hormonal action in utero and fetal sex differentiation. The primary aim was to evaluate associations of hCG with a) AGD in male and female neonates, and with b) urinary phthalates. The secondary aim was to test the hypothesis that phthalates disrupt male sexual differentiation through their action on hCG.

Methods. Subjects were enrolled in multicenter prospective pregnancy cohort. Phthalates and hCG were measured in urine and serum samples, respectively, collected in the first trimester (N=362).  Neonatal exams were performed by trained study staff.  Multivariate linear regression was used to estimate sex-specific associations of the placental hormones with AGD (males: AS: anus to scrotum, AP: anus to penis; females AF: anus to fourchette; AC: anus to clitoris), birthweight for gestational age z-score, and 5 urinary phthalate concentrations including MnBP, mono-isobutyl phthalate (MiBP), monobenzyl phthalate (MBzP), monoethylhexyl phthalate (MEHP), and monoethyl phthalate (MEP). To combine data across centers, we generated z-scores of the analyte values. We applied causal inference methods to estimate the total effect of phthalates and hCG on AGD, and compared it to the controlled direct effect (CDE) of the phthalates after removing the hCG effect.  

Results. Higher hCG was associated with lower AGD-AS in males (-0.64 mm per 1 unit increase in the hCG z-score, standard error (SE) 0.31) but not females (interaction of hCG by fetal sex p=0.03). Higher MnBP and MBzP were associated with higher hCG expression in female fetuses and lower expression in males (interaction p-value=0.01). AGD-AP and AGD-AC were not correlated with first trimester placental hormones. In Aim 2, for every log unit increase in urinary MEHP and MnBP, male AGD decreased by 1.2 mm.  If we administered a hypothetical substance that completely blocked the effect of hCG, then MEHP and MnBP would induce only a 0.87 mm and 0.99 mm decrease in AGD respectively.  

Conclusion. The early placenta is a site of endocrine disruption, and a contributor to the development of the fetal genitalia.  hCG may partially mediate the effects of phthalates on fetal genitalia.  By monitoring of first trimester hCG, normalized by fetal sex, we may have the opportunity to identify abnormal development, intervene and improve the health of the child.

 

Nothing to Disclose: JJA, MKL, NIA, EB, RN, SS, MPT, SJJ, LB, JBR, SHS

OR42-5 22124 5.0000 A Placental Human Chorionic Gonadotropin Is Associated with Sex-Specific Development and the Response to Endocrine Disruptors 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Sunday, March 8th 11:00:00 AM OR42 6008 9:30:00 AM Pregnancy-Related Reproductive Endocrinology Oral


Margaret Flynn Lippincott*1, Diana X. Tran2, Nigel J. Clarke2, Michael J. McPhaul2, David E. Cantonwine3, Richard E. Reitz2, Thomas F. McElrath4 and Stephanie Beth Seminara1
1Massachusetts General Hospital, Boston, MA, 2Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 3Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, 4Brigham and Women's Hospital, Boston, MA

 

The hypothalamic hormone kisspeptin is best known as a gatekeeper for sexual maturation and reproductive function across mammalian species.  However, kisspeptin and its receptor are also highly expressed in the placenta, suggesting a role in placentation and pregnancy.  The purpose of this study was to measure kisspeptin levels using a novel proteomic assay in plasma samples longitudinally collected from pregnant women with normal pregnancy outcomes. 

Kisspeptin concentrations in healthy pregnant women (n = 60, 30 Caucasian, 30 African American) were quantified at 10, 24, and 35 weeks' (± 2 weeks) gestation using mass spectrometry. At the time of collection, 83% of patient samples were processed in less than 4 hours. Sample preparation for analysis consisted of mixing 200uL of patient plasma with methanol and isotopically labeled internal standard. After vortexing and spinning, 100 uL of supernatant was injected into the HPLC-MS/MS system (AB 6500). Analysis on the mass spectrometer was in MRM mode. Transitions for the three known variants were measured (RR, RP, PP). The lower limit of quantitation (LLOQ) was 281 pmol/L. The CVs were <11%. All samples were assayed in duplicate. Differences of means were assessed by ANOVA with multiple pairwise comparisons. 

Total plasma kisspeptin (including kisspeptin-54 and its degradation products kisspepin-53 and -52) was above the LLOQ in 89% of the samples. Mean (SD) concentrations of kisspeptin were 1008 (701), 1949 (1244), and 3245 (2237) pmol/L at 10, 24, and 35 weeks, respectively. These levels were significantly different between the time points (One-way ANOVA, p < 0.001). There was no effect of race on total kisspeptin levels across the three trimesters (Two-way ANOVA, p = 0.22). Kisspeptin-53 and kisspeptin-52 represented the bulk of the total concentration (44% and 47%, respectively), while kisspeptin-54 only represented 9% of the total.

In summary, concentrations of kisspeptin-54 and its degradation products can be measured by mass spectrometry. The ability to obtain accurate information on the concentrations of different kisspeptin fragments and their relative abundance is an important step in understanding its physiology.

 

Disclosure: DXT: Employee, Quest Diagnostics. NJC: Employee, Quest Diagnostics. MJM: Principal Investigator, Quest Diagnostics. RER: Employee, Quest Diagnostics. Nothing to Disclose: MFL, DEC, TFM, SBS

OR42-6 21916 6.0000 A Proteomic Analysis of Kisspeptin during Pregnancy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Reproductive Endocrinology Sunday, March 8th 11:00:00 AM OR42 6008 9:30:00 AM Pregnancy-Related Reproductive Endocrinology Oral


Andrea Estrada*1, Alison M Boyce2, Beth Brillante3, Lori C. Guthrie4, Rachel I Gafni5 and Michael T. Collins6
1NIDCR/NICHD, NIH, Bethesda, MD, 2Children’s National Health System, Washington, DC, 3National Institutes of Health, 4Section on Skeletal Disorders and Mineral Homeostasis, Bethesda, MD, 5National Institute of Dental and Craniofacial Research/NIH, Bethesda, MD, 6NIDCR, NIH, Bethesda, MD

 

Background:  McCune-Albright syndrome (MAS) is a rare disorder arising from somatic activating mutations in GNAS, resulting in a clinical spectrum that includes fibrous dysplasia of bone, café-au-lait macules, and hyperfunctioning endocrinopathies.  Approximately 85% of girls with MAS experience gonadotropin-independent precocious puberty due to recurrent estrogen-secreting ovarian cysts. The aromatase inhibitor letrozole was shown to be effective treatment in a short-term pilot study of 9 girls.  In the pilot study, one subject developed ovarian torsion, a known complication of MAS and other conditions associated with ovarian enlargement.  Objective:  To determine the long-term efficacy and safety of letrozole for treatment of precocious puberty in girls with MAS.  Methods: Clinical and radiographic data from subjects enrolled in a long-term, ongoing MAS natural history study were reviewed.  Studies included history and physical exam, bone age, and pelvic ultrasonography.  Main Outcome Measures: Efficacy outcomes included change in skeletal advancement, height standard deviation (SD) score, and predicted adult height SD score.  Results are presented as mean ± SD (range). Safety outcomes included change in uterine size as determined by craniocaudal dimension, and ovarian size as determined by mean ovarian volume.  Results: Twenty-two girls with MAS-associated precocious puberty received treatment with letrozole. At the last data collection point, seven subjects (32%) had completed letrozole treatment and fifteen (68%) were still on therapy.  Mean age at letrozole initiation was 4.6 ± 1.8 y (2.0-8.3).  Mean treatment duration was 3.8 y ± 2.6 (0.3–9) and mean time since letrozole initiation was 4.3 ± 3 y (0.3–11.2), for a total of 95.7 person-years of follow-up.  Mean BA/CA declined from 1.7 ± 0.5 at baseline to 1.2 ± 0.2 after treatment, consistent with a significant reduction in skeletal advancement (p<0.001).  Mean height SD declined from 1.4 ± 1.3 at treatment start to 0. 5 ± 1.6 (p <0.0001), and predicted adult height SD increased significantly from -2.3 ± 2.3 to -1.3 ± 1.9 (p <0.0001).  There was no change in uterine size or ovarian volume over the treatment period.  Letrozole was well-tolerated and there were no additional cases of ovarian torsion.  Conclusions: In this study, which represents the longest follow-up to date of the treatment of precocious puberty in MAS, letrozole appears to be safe and effective treatment.     

 

Nothing to Disclose: AE, AMB, BB, LCG, RIG, MTC

OR41-1 21982 1.0000 A Long-Term Outcomes of Letrozole Treatment for Precocious Puberty in Girls with Mccune-Albright Syndrome 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Sunday, March 8th 11:00:00 AM OR41 6017 9:30:00 AM Pediatric Endocrinology Oral


Jaakko J Koskenniemi*1, Helena E Virtanen1, Katrine Bay2, Niels Erik Skakkebaek3, Anna-Maria Andersson2, Katharina M Main2 and Jorma Toppari4
1Univ of Turku, Turku, Finland, 2Rigshospitalet, Copenhagen, Denmark, 3University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Denmark, Copenhagen, Denmark, 4University of Turku, Turku, Finland

 

Cryptorchidism i.e. undescended testis is a common birth defect. However, almost half of the cases with congenital cryptorchidism recover spontaneously during the physiological postnatal surge of sex-hormones in the first months of life. Conversely, some children who are born with testes in the scrotum show acquired cryptorchidism later during childhood. Androgens and insulin-like peptide 3 (INSL3) are important regulators of the testicular descent.

We analyzed testicular location data collected in a prospective cohort study on congenital cryptorchidism performed at Turku University Hospital in 1997-20021. In the study testicular distance was measured with a ruler from the upper edge of the pubic bone to the upper poles of the testes after a gentle pull. A total of 1,717 boys were examined at birth and 1,626 boys at 3 months of age. A subset of 519 boys was also examined at the age of 18 months in a nested case-control study. INSL3 was measured in cord blood (n=101 boys), and  serum INSL3, testosterone, sex hormone binding globulin (SHBG), LH, and FSH levels were measured at 3 months of age (n=449 boys). Free testosterone (FreeT) was calculated with Vermeulen’s formula. Differences in testicular distance between ages were compared with paired samples t-test, and correlations between hormones and testicular distance were assessed with Spearman’s rhos.

At birth the mean testis distance was 63.4± 8.1 mm (mean± SD) for term boys born appropriate for gestational age and having no genital malformations. Testicular distance increased with 19.4 mm (95% CI 18.9–19.8 mm, p<0.001) from birth to the age of 3 months, after which a testicular ascent of 3.7 mm (95% CI 2.6–4.8 mm, p<0.001) was observed by the age of 18 months. INSL3 at birth and LH, FSH, testosterone, and FreeT at 3 months correlated significantly with testicular distance at birth (Rs=0.42, p<0.001; Rs=-0.16, p=0.001; Rs=-0.20, p<0.001, Rs=-0.11, p=0.02 and Rs=-0.15, p=0.001 respectively). INSL3 at birth, LH and FSH at 3 months correlated significantly with testicular distance at 3 months (Rs=0.36, p<0.001; Rs=-0.12, p=0.01, and Rs=-0.12, p=0.01 respectively). INSL3 at birth, and FSH and inhibin B at 3 months correlated with testicular distance at 18 months (Rs=0.53, p<0.001; Rs=-0.13, p=0.02 and Rs=0.18, p=0.001, respectively). Testosterone, FreeT and FSH correlated with the change of testicular distance from birth to 3 months (Rs=0.17, p<0.001; Rs=0.20, p<0.001 and Rs=0.10, p=0.05, respectively). Notably, INSL3 at 3 months did not correlate with testicular distance at any age.

Our results indicate that testicular distance both in cryptorchid and healthy boys is dynamic and mirrors the changes in sex hormone levels. This suggests that sex hormone levels influence the testicular position after birth, and some cases of early acquired cryptorchidism could be due to insufficient sex hormone drive to maintain scrotal position.

 

Nothing to Disclose: JJK, HEV, KB, NES, AMA, KMM, JT

OR41-2 20881 2.0000 A Testicular Position in Healthy and Cryptorchid Boys Is Dynamic and Mirrors Changes in Sex Hormone Levels, Including INSL3 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Sunday, March 8th 11:00:00 AM OR41 6017 9:30:00 AM Pediatric Endocrinology Oral


Shanlee Marie Davis*1, Najiba Lahlou2, Martha D Bardsley3, Marie-Christine Temple2, Karen Kowal4 and Judith L. Ross4
1University of Colorado/Children's Hospital Colorado, Aurora, CO, 2Hopital Cochin-Université Paris-Descartes, Paris, France, 3Nemours/A.I.DuPont Hospital for Children, 4Thomas Jefferson University/duPont Hospital for Children, Philadelphia, PA

 

Background: Klinefelter syndrome (KS) occurs in 1/600 males and typically results in gonadal failure during adolescence, although the underlying pathophysiology is unknown.  Whether gonadal dysfunction exists in childhood remains unsettled.

Objective:To evaluate biomarkers of gonadal function longitudinally in boys with KS and to investigate early predictors of sertoli and/or leydig cell dysfunction.

Study design:In this double-blind, placebo-controlled clinical trial (2005-2011, NCT00348946), 93 boys with KS, 4-12 years, were randomized to oxandrolone or placebo, and were evaluated every 6 months for a 2 year period.  Baseline biomarkers of gonadal function measured included luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone (TT), anti-mullerian hormone (AMH) and inhibin B (INHB) (n=89), and were compared to reference ranges for age.     

Results: Baseline median values for all biomarkers were within age-appropriate normal ranges, however many boys had gonadotropin and gonadal peptide levels that fell well outside the normal limits.  In particular, 13% had elevated gonadotropins even as young as 4 yrs of age, 31% had low INHB, 28% had elevated AMH, and 15% had low AMH.  LH, FSH and TT weakly correlated with age (r=0.31-0.37, p<0.001), while AMH and INHB levels did not. INHB strongly correlated with AMH levels (r=0.7, p<0.001). Based on baseline AMH and INHB levels, four distinct groups emerged: Normal AMH/Low INHB (18%), Low AMH/Low INHB (13%), High AMH/Normal INHB (28%), and Normal AMH/Normal INHB (42%). Chronological and bone ages in the four groups were similar.  When compared to the Normal AMH/Normal INHB group, the Low AMH/Low INHB group had lower baseline LH (p=0.016), a trend for lower TT (p=0.07) and smaller testes (-1.8 vs -1.0 SDS), and was less likely to reach gonadarche or pubarche during the two-year study. This Low AMH/Low INHB group also had higher LDL (p=0.004) and a trend toward greater % body fat.  In contrast, the group with high AMH levels (median 1,522 pmol/L) tended to have a more normal BMI, higher HDL, and lower triglycerides compared to the Normal AMH/Normal INHB group.

Conclusions: Although median values for gonadal function biomarkers are within the reference values for age in boys with KS, ages 4-12, two groups emerged with abnormal biomarkers of sertoli cell function and unique phenotypes.  The first group had gonadal peptide levels consistent with early sertoli cell failure (low INHB and AMH) and an associated unfavorable physical phenotype of higher percent body fat and LDL levels.  The second group had elevated AMH levels and may have a more favorable metabolic profile. These findings highlight abnormal sertoli cell function in a subset of boys with KS that may be related to their physical phenotype and may suggest earlier prepubertal testicular failure.

 

Nothing to Disclose: SMD, NL, MDB, MCT, KK, JLR

OR41-3 18905 3.0000 A Longitudinal Study of Boys with Klinefelter Syndrome Gives Evidence of Prepubertal Testis Defect 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Sunday, March 8th 11:00:00 AM OR41 6017 9:30:00 AM Pediatric Endocrinology Oral


Danielle de Souza Bessa*1, Delanie B. Macedo1, Ana Paula Abreu2, Andrew Dauber3, Leticia Gontijo Silveira1, Francis de Zegher4, Priscila C. Gagliardi5, Korcan Demir6, Carlos Alberto Longhi7, Carla Rosenberg8, Ana Cristina V. Krepischi8, Berenice B Mendonca9, Vinicius N. Brito1, Sonir Roberto Antonini10, Ursula B. Kaiser2 and Ana Claudia Latronico1
1Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 3Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 4University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium, 5Nemours Children's Clinic, Jacksonville, FL, 6Children's Hospital, Gaziantep, Turkey, 7Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil, 8Instituto de Biociências da Universidade de São Paulo, São Paulo, Brazil, 9Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil, 10Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, Brazil

 

Background: Central precocious puberty (CPP) in boys is defined by the development of secondary sexual characteristics before the age of 9 years due to early activation of the hypothalamic–pituitary–gonadal axis. Notably, the idiopathic form of CPP is a rare condition in boys. Recently, the importance of genetic factors was demonstrated in the etiology of CPP in both sexes. Objective: To review the clinical, hormonal and genetic findings in boys with idiopathic CPP. Patients and methods: We studied 14 boys with idiopathic CPP from different origins (Brazil, Turkey, USA and Belgium). Clinical and hormonal data were obtained from all patients. Central nervous system magnetic resonance imaging was normal in all of them. All cases were previously screened for MKRN3 and KISS1 mutations. Whole exome sequencing was performed in 8 patients, including 2 brothers. In addition, comparative genomic hybridization array (CGH array) was performed in 3 boys with CPP. Results: The median age of pubertal onset was 6.5 years (range 0.9 - 9.0 years), but the first signs of puberty are notably more difficult to determine in boys than in girls. Five patients had family history of premature sexual development. At the first evaluation (median 8.7 years), the patients had genital Tanner stage 2-4 at physical examination and median bone age advancement of 1.9 years. All 14 boys had pubertal levels of basal LH (median 1.6 IU/L, range 0.7 - 6.7 IU/L) and testosterone (median 92 ng/dL, range 19 - 548 ng/dL). Loss-of-function MKRN3 mutations were identified in all 5 familial cases, including 2 frameshift mutations (p.Arg213Glyfs*73, p.Ala162Glyfs*14) and 1 missense mutation (p.Arg365Ser). The boys with MKRN3 defects presented with signs of puberty from 5.9 to 8.5 years. One sporadic case, with very early pubertal onset (1.0 year), had a KISS1 missense mutation (p.Pro74Ser). The CGH-array performed in 3 Turkish boys with sexual development before 5 years showed no abnormalities. Conclusion: Loss-of-function mutations in MKRN3 gene represent a prevalent cause of CPP in boys without hypothalamic lesions, particularly in familial cases. A detailed family history is critical for the diagnosis in boys with apparently idiopathic CPP.

 

Nothing to Disclose: DDSB, DBM, APA, AD, LGS, FD, PCG, KD, CAL, CR, ACVK, BBM, VNB, SRA, UBK, ACL

OR41-4 21402 4.0000 A Idiopathic Central Precocious Puberty in Boys: Clinical, Hormonal and Genetic Findings 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Sunday, March 8th 11:00:00 AM OR41 6017 9:30:00 AM Pediatric Endocrinology Oral


Kristina Derrick*1, Robert Charles Gensure1 and William Gomes2
1Children's Hospital at Montefiore, Bronx, NY, 2Montefiore Medical Center, Bronx, NY

 

Patients with a diagnosis of short stature (SS)/growth hormone deficiency (GHD) routinely undergo brain MRI prior to starting growth hormone therapy to evaluate for structural abnormality or pituitary lesion. When a pituitary microadenoma is identified, it can be challenging for the clinician to determine the clinical significance of the lesion. The current Endocrine Society guidelines for pituitary incidentaloma recommend evaluation of pituitary hormones and repeat brain MRI yearly for three years if the labs are negative. However, it is not clear how these guidelines should be applied in pediatric patients who have a defined pituitary hormone abnormality.

We investigated the course of pituitary microadenomas in patients with SS/GHD to determine the progression of the lesion, particularly in the setting of growth hormone therapy, which has the potential to exacerbate the lesions.

We performed a retrospective chart review of patients evaluated at our facility with an ICD-9 code for SS (783.43) or GHD (253.3) and who had a brain MRI performed as part of their evaluation for short stature, in 2000-2013. We reviewed the radiology reports for descriptions consistent with a pituitary microadenoma. When available, we reviewed results of all follow up MRIs to determine clinical outcomes.

We identified 65 patients with SS/GHD who had a pituitary microadenoma on MRI. Of these, 33 had a follow-up MRI report available for review. Repeat imaging showed  61% of the lesions were no longer identified, 24% were unchanged, 6% were smaller, and 9% were classified as other lesions (pars intermedia cyst, Rathke cleft cyst). None of the lesions were larger. 24 of these patients were treated with growth hormone. Of patients treated with growth hormone, 71% of the lesions were no longer identified, and 13% were smaller. Again, no patients had growth of the lesion. The plan for growth hormone treatment was affected in at least 11 patients (17%) by the identification of the microadenoma, due to parental discomfort, insurance denial, or provider recommendation for neurosurgery clearance and/or follow-up MRI.

Overall, our retrospective chart review indicates that microadenomas rarely increase in size in children, even in the setting of growth hormone therapy. This suggests that pituitary microadenomas might be of limited clinical significance in patients with SS/GHD and should not be a contraindication to growth hormone therapy.

 

Nothing to Disclose: KD, RCG, WG

OR41-5 19200 5.0000 A Outcomes of Pituitary Microadenomas in Pediatric Patients with Short Stature/Growth Hormone Deficiency 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Sunday, March 8th 11:00:00 AM OR41 6017 9:30:00 AM Pediatric Endocrinology Oral


Katherine Lord*1, Jerilynn Radcliffe1, Paul R. Gallagher1, N. Scott Adzick1, Charles A Stanley1 and Diva D. De Leon2
1The Children's Hospital of Philadelphia, Philadelphia, PA, 2Children's Hospital of Philadelphia, Philadelphia, PA

 

Children with the most common and severe type of congenital hyperinsulinism (HI) frequently require pancreatectomy to control the hypoglycemia.  Limited resection in the focal form is curative, but the diffuse form requires a near total pancreatectomy.  While surgical therapy may alleviate the hypoglycemia in the short-term, pancreatectomy increases the risk for diabetes in these children.  Recurrent and severe hypoglycemia in infancy also places them at risk of developmental delays and neurocognitive dysfunction. The prevalence of these complications is not well-defined.

To determine the prevalence of diabetes and neurobehavioral deficits in surgically treated HI, a cross-sectional study was conducted of individuals with HI who underwent a pancreatectomy between 1960 and 2008 and received care at the Children’s Hospital of Philadelphia. Clinical data was gathered through patient interview and medical record review.  Neurobehavioral outcomes were assessed through the Adaptive Behavior Assessment System – 2nd Ed. (ABAS-II) and, for subjects 3 - 18 years old, the Child Behavior Checklist (CBCL).

121 subjects were enrolled in the study at a median age of 8.2 years (range 3.5-50.7 years).  Mean age at pancreatectomy was 0.47 years +/- 1.12.  Pancreatic histology revealed diffuse HI in 59 (49%) subjects, focal HI in 54 (45%) and other histology in 8 (7%).  Subjects with diffuse HI had a significantly greater percent pancreatectomy than those with focal HI (95% [range 75-99%] vs. 50% [range 1-98%], P < 0.0005).  44 (36%) subjects had diabetes.  8 subjects developed diabetes immediately post-pancreatectomy. Of the remaining 36 subjects, the median age at diabetes diagnosis was 7.65 years (range 8 months-43 years) and the median hemoglobin A1c at diagnosis was 7.4% (range 6.5-12.6). 38 (86%) subjects with diabetes required insulin. Subjects with diabetes were more likely to have diffuse HI than focal (84% vs. 14%, P < 0.0005) and they had a greater percent pancreatectomy than those subjects who did not develop diabetes (95% [range 65-98] vs. 65% [1-98]). Neurobehavioral abnormalities were reported in 58 (48%) of subjects, including 16 (13%) with seizures, 22 (18%) with speech delay, 19 (16%) with a learning disability, 13 (11%) with a physical disability and 25 (21%) with behavioral issues.  Of 71 subjects who completed the ABAS-II, 19 (28%) had abnormal scores (defined as 1 standard deviation below the mean).  Of 62 subjects who completed the CBCL, 10 (16%) had abnormal scores (defined as 1 standard deviations above the mean).

Children with surgically treated HI, particularly those with the diffuse form, are at high risk of developing diabetes, neurobehavioral problems and deficits in adaptive skills. Annual diabetes screening is necessary for children who undergo near-total pancreatectomy. For all children with HI, developmental assessment is essential.  

 

Nothing to Disclose: KL, JR, PRG, NSA, CAS, DDD

OR41-6 19852 6.0000 A High Risk of Diabetes and Neurobehavioral Deficits in Individuals with Surgically Treated Hyperinsulinism 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Pediatric Endocrinology Sunday, March 8th 11:00:00 AM OR41 6017 9:30:00 AM Pediatric Endocrinology Oral


Shinichi Suzuki*1, Satoru Suzuki1, Toshihiko Fukushima2, Izumi Nakamura2, Hiroki Shimura3, Sanae Midorikawa3, Tetsuya Ohira3 and Shunichi Yamashita3
1Fukushima Medical University, Fukushima, Japan, 2Fukushima Medical University, Fukushima-shi, Japan, 3Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical University, Fukushima, Japan

 

Introduction: The Fukushima Health Management (FHM) Survey was implemented after TEPCO’s Fukushima Daiichi Nuclear Power Plant accident on March 11, 2011. The Japanese general public became particularly concerned with the possibility of a similarly increased risk of childhood thyroid cancer to that observed following the Chernobyl nuclear accident in 1986. The thyroid ultrasound examination (TUE), which was part of the detailed FHM survey, began on October 9, 2011 and reached completion on March 31, 2014, three years after the disaster. Materials and Methods: The TUE covered around 360,000 residents who were aged 0 to 18 years at the time of the accident. The initial screening, the TUE’s preliminary baseline survey, started on October 9, 2011 and was completed by March 31, 2014. Results:The preliminary survey of 296,026 participants (80.5%) was completed at the end of June 2014, of which 2,237 (0.8%) were recommended to undergo a confirmatory TUE. Of the 485 patients who underwent fine needle aspiration cytology, 104 were diagnosed as having a malignant tumor or were suspected to have malignancy. Fifty eight cases of these patients were confirmed a benign thyroid nodule and 57 had thyroid cancers after surgical treatment until the end of June 2014.The cause of these cancers was considered not to be related to the radiation exposure after the accident. Conclusion: This is the first large-scaled report on the baseline TUE survey, which employs sophisticated ultrasound screening. Our results will become the gold standard of future comparative TUEs in Fukushima, Japan whether the risk of childhood thyroid cancer will increase or not in future on a basis of well designed epidemiological study.

 

Nothing to Disclose: SS, SS, TF, IN, HS, SM, TO, SY

OR44-1 19703 1.0000 A Three-Year Results and Future Scope of the Fukushima Thyroid Ultrasound Examination after the Fukushima Nuclear Power Plant Accident 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Sunday, March 8th 11:00:00 AM OR44 6024 9:30:00 AM Thyroid Cancer Oral


Norra Kwong*1, Marco Medici2, Trevor E Angell1, Ellen Marqusee1, Matthew Ian Kim1, Mary C Frates1, Carol B Benson1, Edmund S Cibas1, Justine Barletta1, Jeffery F Krane1, Daniel T Ruan1, Nancy L. Cho1, Atul Gawande1, Francis D. Moore1 and Erik Karl Alexander3
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 2Erasmus Medical Center, Rotterdam, Netherlands, 3Brigham & Women's Hospital, Harvard Medical School, Boston, MA

 

Background:  Oncogenic mutations are common in thyroid cancers and diagnostic molecular panels are increasingly recommended for pre-operative nodule assessment.  When a mutation is indentified, surgery is often recommended.  However, observational studies suggest all mutations may not be equally oncogenic.  Specifically, the clinical phenotype of RAS-positive nodules is uncertain.  

Methods: We performed a prospective, blinded trial investigating the cytologic and molecular profiles of 362 clinical relevant (>1cm) thyroid nodules.  Fine needle aspiration (FNA) was performed for cytologic analysis, and an additional needle stick analyzed for molecular mutations (miRInform Thyroid, Asuragen, Inc).  Surgery was performed for malignant or indeterminate nodules.  We separately analyzed all RAS-positive, cytologically benign nodules for change in size during repeated sonographic measurements, or for prior FNA’s.

Results: In a population with 9.1% malignancy prevalence, 17 of 362 nodules were positive for K-, N- or H- RAS mutations.  Nine separate nodules harbored BRAF mutations.  While 100% of nodules BRAF-positive proved malignant, only 8 of 17 (47%) RAS-positive nodules were malignant on blinded analysis.  Furthermore, all RAS-positive malignancies were low risk – all follicular variants of PTC, and all without extrathyroidal extension, metastases, or lymphovascular invasion.  Interestingly, RAS-positivity was associated with malignancy in younger patients (p=0.04), while older patients were more likely benign.  Of the 9 RAS-positive, benign nodules, 5 had long-term sonographic follow-up.   Over a mean of 8.3 years, no growth or sonographic signs of malignancy were detected.  4 of the cytologically benign nodules were similarly aspirated at an average of 5.8 years previously.  All were benign previously and benign on current aspiration, confirming no evidence of malignant transformation.

Conclusion:  While mutations in the RAS oncogene increase malignant risk, these data confirm a variable yet generally low-risk phenotype among RAS-positive nodules.  Furthermore, cytologically benign, yet RAS-positive nodules should not be viewed as universally pre-malignant.  A non-operative, observational strategy may be reasonable in select, older patients.

 

Disclosure: EM: Investigator, Veracyte, Inc.. EKA: Consultant, NPS, Consultant, Veracyte, Inc., Principal Investigator, Asuragen Inc, Scientific Board Member, Asuragen Inc. Nothing to Disclose: NK, MM, TEA, MIK, MCF, CBB, ESC, JB, JFK, DTR, NLC, AG, FDM

OR44-2 19367 2.0000 A The Variable Phenotype and Low-Risk Nature of RAS-Positive Thyroid Nodules 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Sunday, March 8th 11:00:00 AM OR44 6024 9:30:00 AM Thyroid Cancer Oral


Myriem Boufraqech*1, Sudheer Kumar Gara1, Naris Nilubol1, Lisa Zhang1, Martha M Quezado2 and Electron Kebebew1
1National Cancer Institute, NIH, Bethesda, MD, 2National Cancer Institute, Bethesda, MD

 

Epithelial–mesenchymal transition (EMT) is associated with cancer progression and metastasis. Anaplastic thyroid cancer (ATC) is one of the most lethal human malignancies. Over two-thirds of patients with ATC present with locally advanced and metastatic disease, and this is thought to be mediated by EMT. We previously reported that lysyl oxidase (LOX) is overexpressed in ATC and regulates cancer progression and metastasis, and is a marker of prognosis in patients with differentiated thyroid cancer.  Although LOX is thought to mediate EMT, the molecular mechanism by which it does this is unknown. Thus, in this study we investigated the effect of LOX on established mediators (vimentin, N-cadherin, E-cadherin, and transcription factors – SNAIL1, SLUG, ZEB1) of EMT. Using functional studies we found that LOX knockdown decreased SLUG mRNA and protein expression in anaplastic, breast cancer cell lines and HeLa cell cells. Furthermore, knockdown of LOX in a metastatic ATC mouse model reduced SLUG expression. Interestingly, inhibition of LOX catalytic activity with BAPN did not affect SLUG expression. Thus, we next investigated whether LOX directly regulates the transcription of SLUG. Using Chromatin immunoprecipitation assay, we found that LOX binds the SLUG promoter in ATC and breast cancer cell lines. We then tested whether LOX could transactivate the Slug promoter. Knockdown of LOX significantly reduced Slug promoter-luciferase activity as compared to control luciferase vector. We then determined whether there was an association of LOX and SLUG expression human thyroid cancer samples. We found a significant positive correlation between SLUG and LOX expression in thyroid cancer samples (p<0.0091, r= 0.35) by RT-PCR and validated this association in a public genomic dataset (GEO dataset) (p<0.0001, r=0.70). Moreover, analysis of expression of SLUG in thyroid cancer samples, showed overexpression in ATC as compared to normal and papillary thyroid cancer (PTC) (ATC vs. PTC p=0.02, Normal vs. PTC p=0.01). Immunohistochemistry staining revealed co-localization of LOX and SLUG protein in aggressive thyroid cancers (ATC and tall-cell variant of PTC). As stromal cells are important in cancer progression we next asked if SLUG expression is associated with tumor stromal cells content. Using the Cancer Genome Atlas database of thyroid cancer, we found a significant positive correlation between SLUG expression level and the percentage of stromal cells (r=0.25, p<0.0001). These results provide the first evidence that LOX is a new transcriptional regulator of the EMT transcription factor SLUG and that a LOX-SLUG axis is important in thyroid cancer progression and in other solid malignancies.

 

Nothing to Disclose: MB, SKG, NN, LZ, MMQ, EK

OR44-3 19009 3.0000 A Lysyl Oxidase (LOX) Regulates Slug Expression in Anaplastic Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Sunday, March 8th 11:00:00 AM OR44 6024 9:30:00 AM Thyroid Cancer Oral


Steven P Weitzman*1, Katherine T. Peicher2, Ramona Dadu1, Mimi I-Nan Hu1, Camilo Jimenez1, Carly Gardner1, Aliya Qayyum1, Mike Hernandez1 and Maria E Cabanillas1
1The University of Texas MD Anderson Cancer Center, Houston, TX, 2The University of Texas Health Science Center at Houston, Houston, TX

 

Background: Treatment options for patients (pts) with locally advanced or metastatic MTC have been limited in the past. Fortunately, 2 antiangiogenic TKIs (aTKI) were approved by the FDA for this indication and several others appear promising. However, it is virtually universal that pts on TKIs experience progression or toxicity requiring a change in therapy. Given the dearth of available agents, changing to another TKI has become a common practice. This study is intended to help determine whether this is an effective strategy.

Methods: This is a retrospective analysis performed at MD Anderson Cancer Center. We queried our TKI database to identify adult pts with progressive, metastatic or locally advanced MTC treated with at least 2 sequential aTKIs. For inclusion, pts needed to have imaging both at baseline and during treatment. A single radiologist reviewed all images. Overall best response (OBR) was defined as percent change in the sum of target lesions compare with baseline: partial response (PR) ≥30% decrease, progressive disease (PD) ≥20% increase and stable disease (SD) between +19% and -29% using RECIST v1.1. TTF was defined as the time from start of drug to progressive disease or unacceptable drug toxicity leading to its discontinuation.

Results: We identified 13 MTC pts who met inclusion criteria. The mean age was 56, 77% were men and 84% white. Germline RET mutation was performed in all pts (10 sporadic, 3 familial). At treatment start, neck metastases were present in 12/13 (92%), liver in 9/13 (69%), lung in 7/13 (54%) and bone in 7/13 (54%) of pts. Median calcitonin and CEA was 3106 (range 228-14,500) and 139 (range 1.9-645), respectively.  Two pts received prior systemic chemotherapy before aTKIs. Vandetanib was the most frequently used first-line aTKI in 5/13 (38%), followed by lenvantinib in 3/13 (23%), motesanib in 2/13 (15%), sunitinib in 1 (8%), cabozantinib in 1 (8%) and sorafenib plus tipifarnib in 1 (8%) of pts. Twelve pts discontinued first line aTKI due to PD and 1 due to AEs (liver toxicity). Salvage TKI was most often cabozantinib in 7/13 (54%), followed by vandetanib in 5/13 (38%) and lenvantinib in 1 (8%) of pts. OBR to first TKI was a PR in 31%, SD in 69%, and 0% PD. OBR with salvage therapy was a PR in 23%, SD in 62%, and PD in 15%. Median TTF for the first TKI was 1.4 years (95% CI 0.7, 1.7) and 2.0 years (95% CI 0.2, 3.9) for salvage TKI. Drug hold and dose reductions were needed in 3/13 (23%) and 3/13 (23%) pts during first line treatment and in 2/13 (15%) and 4/13 (30%) during salvage therapy.

Conclusions: We showed that despite progression on 1st line aTKI, pts continue to have a clinically meaningful response to 2nd line aTKI.  Salvage therapy seems to be a useful strategy for those pts who failed 1st line aTKI and were well enough to receive a 2nd aTKI, supporting the practice of using this approach in pts with locally advanced or metastatic MTC.

 

Disclosure: MINH: Investigator, Astra Zeneca. CJ: Principal Investigator, Exelixis, Inc.. MEC: Principal Investigator, Exelixis, Inc., Consultant, Astra Zeneca, Consultant, Exelixis, Inc.. Nothing to Disclose: SPW, KTP, RD, CG, AQ, MH

OR44-4 21894 4.0000 A Salvage Therapy: When a Tyrosine Kinase Inhibitor (TKI) Fails in Advanced Medullary Thyroid Cancer (MTC) 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Sunday, March 8th 11:00:00 AM OR44 6024 9:30:00 AM Thyroid Cancer Oral


Athanasios Bikas*1, Priya Kundra2, Jason Adam Wexler3, Mihriye Mete4, Sameer Desale5, Lynette Wray6, Christina Barett6, Brandon Clark6, Leonard Wartofsky7 and Kenneth Burman7
1MedStar Georgetown University Hospital, Washington, DC, 2Washington Hospital Center, Washington, DC, 3MedStar Washington Hospital Center, Silver Spring, MD, 4MedStar Health Research Institute, Hyattsville, MD, 5Medstar Health Research Institute, Hyattsville, MD, 6MedStar Health Research Institute, 7MedStar Washington Hospital Center, Washington, DC

 

Background:

Sunitinib is a multikinase inhibitor that targets the vascular endothelial growth factor receptor (VEGFR), platelet-derived growth factor receptor (PDGFR), FLT3, KIT, and RET. It is approved by the FDA for the treatment of advanced renal cell carcinoma, imatinib-refractory gastrointestinal stromal tumors (GIST) after disease progression, and progressive pancreatic neuroendocrine tumors.  We report the results of our completed phase II trial of sunitinib for advanced differentiated thyroid carcinoma.

Objective

The primary objective was to assess treatment effect with respect to progression-free survival (PFS) per RECIST. Secondary endpoints included best response rate, measurement of serum thyroglobulin (Tg), and toxicity evaluation.

Methods: 

This was a single center, nonrandomized, open-label, phase 2 clinical trial (NCT: 00668811) for preliminary evaluation of the efficacy and safety of Sunitinib following at least one course of radioactive iodine treatment (RAI) in patients with advanced stage differentiated thyroid cancer who have recurrent, residual or progressive disease. 23 patients were enrolled and were treated with a starting daily, oral dose of 37.5 mg of Sunitinib. Patients were evaluated with imaging, laboratory tests, and physical examination every two to three months per protocol.

Results:

The study completed enrollment in 10/2014. 16 (70%) patients had papillary thyroid cancer, and 7 (30%) patients had follicular and poorly differentiated thyroid cancer. Lung metastasis was documented in 21 (91%) patients, with bone metastasis in 8 (35%) patients. The overall median PFS was 241 days (95% CI, 114-506). When compared to historical controls from the literature, the survival curve was more favorable and it showed a statistically significant difference (p=0.02). The mean best response was a decrease of 16.9% (Standard Deviation: 22.5) in tumor sum from baseline. 6 (26%) patients achieved a partial response (PR), and 13 (57%) had stable disease (SD) for a clinical benefit rate (PR + SD) of 83%. Tg levels at the end of treatment, when compared to baseline values, decreased in 12/23 (52%) and increased in 6/23 (26%) patients, while the remaining 5 patients could not be evaluated (3 due to Tg antibodies). No statistically significant difference was observed between the medians of the baseline and post-treatment Tg values (p=0.24). The most common adverse events included grade 1 and grade 2 decreases in blood cell counts (especially leukocytes), diarrhea, fatigue, hand–foot skin reaction, nausea, musculoskeletal pain and hypertension.

 Conclusions:

Our data demonstrate that Sunitinib exhibits significant anti-tumor activity in patients with advanced differentiated thyroid cancer. Since Sunitinib was relatively well tolerated, there is the potential for clinical benefit in these patients, and further investigation of this agent is warranted.

 

Nothing to Disclose: AB, PK, JAW, MM, SD, LW, CB, BC, LW, KB

OR44-5 22000 5.0000 A Phase II Clinical Trial of Sunitinib As Adjunctive Treatment in Patients with Advanced Differentiated Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Sunday, March 8th 11:00:00 AM OR44 6024 9:30:00 AM Thyroid Cancer Oral


Bruce Gregory Robinson1, Martin Schlumberger2, Steven I Sherman3, Makoto Tahara4, Lori Wirth*5, Marcia S Brose6, Rossella Elisei7, Mouhammed Amir Habra3, Corina E Dutcus8, Junming Zhu8 and Kate Newbold9
1Kolling Institute of Medical Research, University of Sydney, New South Wales, Australia, Sydney NSW, Australia, 2Gustave Roussy and University Paris-Sud, Villejuif, France, 3The University of Texas MD Anderson Cancer Center, Houston, TX, 4National Cancer Center Hospital East, Kashiwa, Japan, 5Massachusetts General Hospital, Boston, MA, USA, 6University of Pennsylvania, Philadelphia, PA, 7University of Pisa, Pisa, Italy, Pisa, Italy, 8Eisai Inc., Woodcliff Lake, NJ, 9Royal Marsden Hospital National Health Service Trust London

 

Background: The previously reported results of the SELECT trial demonstrated that lenvatinib significantly prolonged progression-free survival (PFS) in patients with 131I-refractory differentiated thyroid cancer (RR-DTC) compared with placebo (hazard ratio 0.21, 99% confidence interval [CI] 0.14–0.31; P<0.0001). Median PFS was: lenvatinib, 18.3 months; placebo, 3.6 months. Here we report the results of the open-label extension phase of SELECT.

Methods: In the SELECT trial, patients with RR-DTC, independent radiologic documentation of disease progression within 13 months, and 0 or 1 prior VEGFR-targeted therapies were randomized 2:1 to lenvatinib (24 mg/d, 28-d cycle) or placebo. Upon independent radiologic confirmation of disease progression, patients in the placebo arm could crossover to the optional open-label lenvatinib treatment period. Between Oct/3/2011–Feb/15/2013, the open-label starting dose of lenvatinib was 24 mg/d; the starting dose was subsequently modified, first to 20 mg/d, and then back to 24 mg/d. This analysis examines the more mature dataset of patients who started treatment at the 24-mg lenvatinib dose.

Results: 82 Patients received open-label lenvatinib at the 24-mg dose level; 75.6% of these patients were naïve to VEGF-targeted therapies. At data cutoff (Nov/15/2013), the median follow-up was 11.0 months. 43.9% Of patients were still undergoing treatment, 22.0% had discontinued treatment due to disease progression, and 19.5% discontinued due to treatment-emergent adverse events (TEAEs). Median PFS (from start of open-label treatment) was 12.4 months (95% CI 8.3–not evaluable), with 6-, 12-, and 18-month PFS rates of 71.1%, 50.8%, and 47.6% respectively. Overall response rate was 54.9% (1 complete and 44 partial responses). 17.1% Of patients also achieved durable stable disease ≥23 weeks. Median duration of treatment was 8.9 months (range, 0–25) with a median dose intensity of 19.4 mg/d/patient (range, 7–24 mg/d). 93.9% Of patients experienced a treatment-related TEAE (TR-TEAE); 85.4% experienced Grade ≥3 TR-TEAEs. Most common TR-TEAEs were hypertension (54%), diarrhea (52%), decreased appetite (43%), decreased weight (39%), and fatigue (38%). Grade ≥3 TR-TEAEs included hypertension (24%), decreased weight (9%), proteinuria (7%), asthenia and fatigue (6% each). Lenvatinib dose was reduced in 43.9% and interrupted in 70.7% of patients due to TEAEs. There were 8 (9.8%) fatal TEAEs, with 4 deemed treatment-related by the investigators (respiratory failure [n=2], dyspnea [n=1], and death [n=1]).

 Conclusions: Patients who had an independently verified additional progression event on the placebo arm of SELECT achieved a median PFS of 12.4 months with open-label lenvatinib treatment. Toxicities were substantial, but were generally managed with medications, dose interruption, and dose reductions.

 

Disclosure: BGR: Advisory Group Member, Astra Zeneca, Advisory Group Member, Bayer, Inc.. MS: Consultant, Genzyme Corporation, Consultant, Eisai, Consultant, Bayer, Inc., Consultant, Astra Zeneca. SIS: Consultant, Novo Nordisk, Consultant, Genzyme Corporation, Consultant, Exelixis, Inc., Consultant, Eli Lilly & Company, Consultant, Eisai, Consultant, Bayer, Inc., Consultant, Amgen, Consultant, Veracyte, Inc., Clinical Researcher, Pfizer, Inc., Consultant, Astra Zeneca. MT: Advisory Group Member, Bayer, Inc., Speaker, Bristol-Myers Squibb, Advisory Group Member, Merck & Co.. LW: Consultant, Novartis Pharmaceuticals, Consultant, Eisai. MSB: Research Funding, Roche Pharmaceuticals, Research Funding, Novartis Pharmaceuticals, Consultant, Exelixis, Inc., Research Funding, Bayer, Inc.. RE: Consultant, Genzyme Corporation, Consultant, Bayer, Inc., Consultant, Exelixis, Inc., Consultant, Astra Zeneca. CED: Employee, Eisai. JZ: Employee, Eisai. KN: payment of registartion fees and flight to attend European Thyroid Association Annual Meeting topresent work arising from this trial in September 2014 , Eisai. Nothing to Disclose: MAH

OR44-6 19510 6.0000 A Open-Label Extension Phase Outcomes of the Phase 3 Select Trial of Lenvatinib in Patients with 131I-Refractory Differentiated Thyroid Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Thyroid/HPT Axis Sunday, March 8th 11:00:00 AM OR44 6024 9:30:00 AM Thyroid Cancer Oral


Alexis Graham*1, Mathias Christian Schlogl1, Jonathan Krakoff2 and Marie S Thearle3
1Phoenix Epidemiology and Clinical Research Branch, NIDDK/NIH, Phoenix, AZ, 2Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, 3National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ

 

Background: Macronutrient composition of the diet may augment individual variation in the energy expenditure (EE) response to caloric intake above energy needs contributing to differences in adiposity.

Methods: Sixty subjects (12AA/19C/10H/19NA, 14F/46M, 28.6±10.1% body fat, 37.7±10.3y; mean±SD) with normal glucose regulation had measures of 24h EE and macronutrient oxidation in a whole room indirect calorimeter during six 24h dietary interventions, given in random order, and including energy balance (EB) and 5 different overfeeding (OF) diets providing 200% of energy needs with macronutrient composition variations as follows: 26% carbohydrates  (C), 44% fat (F), 30% protein (P) (HPF); 50% C, 30% F, 20% P (BOF); 75% C, 5% F, 20% P (CNP); 20% C, 60% F, 20% P (FNP); 51% C, 46% F, 3% P (LPF). There was a 3-day washout period between interventions.  Urinary cortisol was determined for each 24h diet, and a visual analogue scale to determine feelings of hunger was given the morning after each diet.

Results: Compared to EB, EE increased with OF (9.8±7.2%; p=<.0001) with 41% of the variance explained by individual responses to OF. The individual increase in EE, as a percent, averaged over all 5 OF diets was negatively associated with %fat (ρ =-0.34; p=0.003) even after adjusting for age, sex, race, and diet. Protein content of the OF diets explained 38% of the variance between the low (3%), normal (20%), and high (30%) protein diets with increases in EE of 3.1±6.6%, 10.4±6.0%, and 14.4±7.2%, respectively. When protein content was held constant, the increase in EE was highest with the high carbohydrate (CNP) diet compared to the high fat (FNP) or normal protein (BOF) diets (14.3±6.0%, 7.9±8.0%, 10.4±6.0% respectively; p<.0001). There was no difference in the EE increase between the high protein (HPF) and high carbohydrate (CNP) diets (p=0.9). Protein oxidation positively associated with 24h urinary cortisol (ρ =0.34, p<0.0001), even after accounting for age, sex, race, diet and body composition, but negatively with hunger scores the following morning (ρ =-0.26, p=0.03).

Conclusion: Ability to increase energy expenditure in response to overconsumption may be magnified by the macronutrient composition of calories consumed. Although overconsumption of protein leads to increased energy expenditure and increased satiety, it also results in increased cortisol production. This increase in cortisol may be due to increased demands on the body to process the consumed protein, a macronutrient for which it has minimal storage capacity compared to carbohydrates and fat.

 

Nothing to Disclose: AG, MCS, JK, MST

OR40-1 19236 1.0000 A Increased Protein Intake during Overfeeding Increases Energy Expenditure, Satiety, and Urinary Cortisol 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Sunday, March 8th 11:00:00 AM OR40 6040 9:30:00 AM Obesity: Human Studies in Body Weight Regulation Oral


Elizabeth A. Lawson*1, Dean A. Marengi2, Rebecca L DeSanti1, Tara M Holmes3, David A Schoenfeld1 and Christiane J Tolley1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts General Hospital, Boston, MA, 3Massachusetts General Hospital/Harvard Medical School

 

Background: In animal models, the hypothalamic peptide hormone, oxytocin (OT), is anorexigenic. Central OT administration in rats reduces food intake; this effect is reversed by an OT antagonist. Preclinical studies also indicate that OT has beneficial metabolic effects. OT’s effect on nutritional intake and metabolism in humans is unclear. We hypothesized that single-dose intranasal administration of OT would reduce caloric intake in men (primary endpoint). We also hypothesized that OT would reduce appetite and alter levels of appetite-regulating hormones. Finally, we explored metabolic effects of OT.

Methods: We performed a randomized, double-blind, placebo-controlled crossover study of single-dose administration of intranasal OT (24 IU) in 25 healthy men (13 normal-weight and 12 overweight or obese). After receiving OT/placebo (fasting visits, order randomized), subjects selected breakfast from a menu and were given double portions. Caloric content of food consumed was measured. Visual analogue scales were used to assess appetite and fasting blood draws were performed for appetite regulating hormones (leptin, ghrelin, and peptide YY), insulin and glucose before and after OT/placebo. Indirect calorimetry was used to measure resting energy expenditure (REE) and substrate utilization.

Results: Mean age was 27.1±1.5 (mean±SEM) years old. Recorded food intake in the 72 hours leading up to OT and placebo visits did not differ within subjects. Intranasal OT reduced caloric intake at the breakfast meal by 122±51 kcal (p=0.03). OT preferentially decreased consumption of fat (-8.7±3.8 g, p=.03; NS after controlling for multiple comparisons). Group (NW vs. OB) did not affect results. There was no effect of OT on appetite or appetite-regulating hormones. While REE was not impacted by OT, RQ was reduced (p=0.02). OT decreased carbohydrate utilization (p=0.03) and increased fat utilization (p=0.04). In addition, OT reduced average insulin levels over the three time points (-1.7±0.8 uU/mL, p=0.04), but had no effect on glucose levels, indicating an increase in insulin sensitivity. There were few adverse events in the study, none of which was severe, with no difference between OT and placebo conditions.

Conclusions: A single dose of intranasal OT reduces caloric intake and has beneficial metabolic effects in men without concerning side effects. The efficacy and safety of sustained OT administration in the treatment of obesity warrants investigation.

 

Nothing to Disclose: EAL, DAM, RLD, TMH, DAS, CJT

OR40-2 18928 2.0000 A Oxytocin Reduces Caloric Intake in Men 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Sunday, March 8th 11:00:00 AM OR40 6040 9:30:00 AM Obesity: Human Studies in Body Weight Regulation Oral


Esben Stistrup Lauritzen*1, Thomas Voss1, Ulla Kampmann2, Annette Mengel1, Mikkel Holm Vendelbo1, Jens Otto Lunde Jørgensen2, Niels Møller2 and Esben T Vestergaard1
1Aarhus University, Aarhus, Denmark, 2Aarhus University Hospital, Aarhus C, Denmark

 

Circulating acylghrelin levels are suppressed by insulin and increase in response to hypoglycemia in healthy adult volunteers

Context: Ghrelin has glucoregulatory and orexigenic actions, but its role in acute hypoglycemia remains uncertain.

Objective: To investigate circulating levels of acylghrelin (AG) and unacylated ghrelin (UAG) secretion in response to hyperinsulinemia and to hypoglycemia.

Design: A randomized, single blind, placebo controlled crossover study including three study days.

Setting: The study was performed at a university hospital clinical research center.

Patients and interventions: Nine healthy men completed three study days: I) saline control (CTR), II) hyperinsulinaemic euglycemia (HE) (bolus insulin 0.1 IE/kg i.v. and glucose 20% i.v. for 105 minutes, plasma glucose ≈ 5 m­mol/l), and III) hyperinsulinaemic hypoglycemia (HH) (bolus insulin 0.1 IE/kg i.v.).

Main outcome measures: Plasma levels of AG and UAG.

Results: HH and HE suppressed AG concentrations at t=45-60 min as compared to CTR (P<0.05). At t=90 min a rebound increase in AG was observed in response to HH as compared to both HE and CTR (P<0.05). UAG also decreased during HH and HE at t=45 min (P<0.05), whereas the AG-to-UAG ratio remained unaffected.

Conclusions: This study demonstrates that AG and UAG are directly suppressed by hyperinsulinemia and that AG concentrations increase after a latency of ≈ 1 h in response to hypoglycemia, suggesting a potential counterregulatory role of AG.

 

Nothing to Disclose: ESL, TV, UK, AM, MHV, JOLJ, NM, ETV

OR40-3 19459 3.0000 A Circulating Acylghrelin Levels Are Suppressed By Insulin and Increase in Response to Hypoglycemia in Healthy Adult Volunteers 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Sunday, March 8th 11:00:00 AM OR40 6040 9:30:00 AM Obesity: Human Studies in Body Weight Regulation Oral


José Orlando Alemán*1, Neil M Iyengar2, Jeanne Walker1, Juana Gonzalez1, Ginger L Milne3, Dilip D Giri2, Clifford A Hudis2, Jan L Breslow1, Peter R Holt1 and Andrew J Dannenberg4
1Rockefeller University, New York, NY, 2Memorial Sloan Kettering Cancer Center, New York, NY, 3Vanderbilt University, Nashville, TN, 4Weill Cornell Medical College, New York, NY

 

Context: Obesity is associated with subclinical white adipose tissue inflammation which has been linked to cardiometabolic disease and possibly cancer. The inflammatory state is characterized by crown-like structures (CLS) consisting of dead or dying adipocytes encircled by macrophages. In mice (Kosteli A et al. JCI, 2010), acute weight loss stimulates lipolysis resulting in the accumulation of adipose tissue macrophages (CLS). In humans, gradual weight loss leads to resolution of CLS but the effect of acute weight loss is uncertain.

Objective: To determine the effects of acute medically supervised weight loss through a Very Low Calorie Diet (VLCD) on macrophage infiltration of subcutaneous adipose tissue in obese postmenopausal women.

Design, Setting, Participants and Outcome Measurements: We conducted a prospective cohort study of medically supervised weight loss to 10% from baseline in obese postmenopausal women with BMI 35-50 in a single study center. Ten women were recruited for primarily inpatient admission for an average of 46 days.  The primary endpoint was quantification of CLS (CD68 immunohistochemistry) in abdominal subcutaneous adipose tissue biopsies at baseline and following VLCD-mediated weight loss. Secondary endpoints included clinical parameters, plasma metabolomic analysis, adipose tissue transcriptional profiling (RNA-seq) and quantification of urinary eicosanoids.

Results: Ten participants completed the study: average 60.6 years of age and BMI 38.8 kg/m2 at baseline. Subjects lost a mean of 10.43 kg (9.9% of baseline) over 46 days to a BMI 35.1 kg/m2. Acute medically supervised weight loss by VLCD was accompanied by improvements in systemic markers including fasting glucose (mean±SD 103.4±17.6 to 89.6±14.9 mg/dL, p<0.05), HOMA-IR (3.30±0.59 to 2.28±0.60, p<0.05), and C-reactive protein (0.68±0.42 to 0.44 ±0.24 mg/L, p<0.02). Urinary levels of tetranor PGD-M and F2-Isoprostanes-M declined suggesting a reduction in systemic inflammation and oxidant stress, respectively. CLS numbers increased significantly in subcutaneous adipose tissue (1.78±3.59 to 5.33±4.56 CLS/cm2, p<0.02) without evidence of an associated increase in levels of pro-inflammatory mediators. Finally, acute weight loss was associated with increased circulating levels of nonesterified fatty acids and glycerol consistent with enhanced lipolysis; these changes correlated with the extent of macrophage infiltration.

Conclusions: Consistent with prior findings in mice, we show for the first time in obese postmenopausal women that acute weight loss leads to enhanced lipolysis and macrophage accumulation in subcutaneous adipose tissue.  These macrophages may buffer local increases in free fatty acids contributing to improved insulin sensitivity. 

 

Nothing to Disclose: JOA, NMI, JW, JG, GLM, DDG, CAH, JLB, PRH, AJD

OR40-4 19831 4.0000 A Acute Weight Loss Stimulates Lipolysis and Macrophage Infiltration in the Subcutaneous Adipose Tissue of Obese Women 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Sunday, March 8th 11:00:00 AM OR40 6040 9:30:00 AM Obesity: Human Studies in Body Weight Regulation Oral


Chee W. Chia*, Kristofer S Gravenstein, David D. Liu, Olga D. Carlson, Eleanor M. Simonsick, E. Jeffrey Metter and Josephine Mary Egan
National Institute on Aging, Baltimore, MD

 

Artificial sweeteners (AS) are widely used for weight control and are often recommended for individuals with diabetes. Scientific data, however, does not consistently support these recommendations as some studies report an association between AS consumption and incident obesity, metabolic syndrome and diabetes.  Possible mechanisms explaining the link between AS consumption and metabolic dysregulation are emerging. Suez et al. report that AS causes glucose intolerance in mice by altering the composition and function of intestinal microbiota (1). Another possible mechanism may involve over-activation of the enteroendocrine system by AS, specifically K and K/L cells, leading to increased secretion of glucose-dependent insulinotropic polypeptide (GIP). Increased GIP secretion during nutrient challenge has been documented in type 2 diabetes (2). GIP promotes triglyceride storage in adipocytes, enhances lipoprotein lipase activity in human adipocytes and promotes preadipocyte differentiation (3-6). We tested the hypothesis that AS consumption over time leads to higher post-prandial GIP secretion in 276 participants (42% AS users) from the Baltimore Longitudinal Study of Aging with food diary records, 2-hr oral glucose tolerance (OGTT) samples and no history of diabetes that were seen from 2001 onwards. Sixty-six (45% AS users) had more than one follow-up visit. Plasma samples from OGTT (t = 0, 20, 40, 60, 80, 100, and 120 min) were assayed for glucose, insulin and GIP levels. Participants (nonAS users vs. AS users) had the following characteristics at baseline: age (64 ± 14 vs. 65 ± 12 years), male (40 % vs. 26 %), BMI (25.7 ± 4.4 vs. 26.5 ± 4.5 kg/m2), fasting plasma glucose (FPG) (91 ± 6 vs. 90 ± 7 mg/dL), 2-hr glucose (103 ± 20 vs. 103 ± 19 mg/dL), fasting insulin (7.3 ± 5.2 vs. 6.8 ± 4.0 µU/mL) 2-hr insulin (38.9 ± 29.4 vs. 39.0 ± 30.2 µU/mL) , fasting GIP (35 ± 31 vs. 34 ± 26 pg/mL), 2-hr GIP (179 ± 90 vs. 187 ± 97 pg/mL). Race, physical activity level and smoking status were comparable in nonAS and AS users. A baseline cross-sectional snapshot of plasma glucose, insulin and GIP levels at all time-points during OGTT showed no difference in plasma glucose or insulin between the two groups with only slightly higher GIP levels in AS users. Using linear mixed-effects models adjusted for age, sex, race, BMI, smoking history and physical activity, we found a significant increase in GIP during OGTT over an average follow-up of 5-years in AS users versus nonAS users (P < 0.001).  A similar trend was observed in plasma insulin during OGTT between the two groups (P = 0.052). No difference was observed in plasma glucose.  These results support the hypothesis that AS use modulates the enteroendocrine system leading to increased GIP secretion during food intake.  These results are subject to the limitations of an observational study. An intervention study would need to be conducted to determine causality.

 

Nothing to Disclose: CWC, KSG, DDL, ODC, EMS, EJM, JME

OR40-5 20467 5.0000 A Artificial Sweetener Consumption May Modulate the Enteroendocrine System Leading to Increased Secretion of Glucose-Dependent Insulinotropic Polypeptide 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Sunday, March 8th 11:00:00 AM OR40 6040 9:30:00 AM Obesity: Human Studies in Body Weight Regulation Oral


Shan Luo*1 and Kathleen Alanna Page2
1University of Southern California, Los Angeles, CA, 2University of Southern California, Diabetes and Obesity Research Institute, Los Angeles, CA

 

The peripheral hormones, insulin, glucagon-like polypeptide-1 (GLP-1) and peptide YY (PYY) rise in response to glucose ingestion and provide satiety signals to the brain. Prior reports suggest that they also act centrally to reduce the reward value of food. However, insulin resistance may impair insulin’s suppressive effects on brain reward processing. The aims of this study were to determine relationships between: 1) circulating glucose, insulin, GLP-1 and PYY levels and brain reward responses to food cues after glucose ingestion, and 2) insulin resistance and brain reward responses to food cues after glucose ingestion. We hypothesized that higher circulating levels of peripheral appetite regulating hormones would be correlated with reduced brain reward responsivity, and that insulin resistance would be correlated with greater brain reward responsivity.

24 healthy volunteers (14 female; age 16 to 25 yrs; BMI 19.6 to 45.4 kg/m2) underwent an fMRI session after ingestion of glucose (75g in 300 mL water) in the morning after a 12-hr fast. Scanning was performed while participants viewed images of high-calorie (HC) foods and non-food (NF) items. Brain responses to HC food vs. NF cues were determined using whole-brain analysis corrected for multiple comparisons (Z>2.3, p<. 05). A priori region-of-interests were selected based on prior reports showing their role in food reward responsivity. Plasma glucose, insulin, GLP-1 and PYY were measured fasting, +30min and +60min after glucose ingestion. Insulin resistance was calculated from fasting glucose and insulin levels using the homeostasis model assessment (HOMA-IR). Pearson correlation analyses were performed between: 1) circulating glucose, insulin, PYY, and GLP-1 levels and brain reward responses to food cues after glucose ingestion; 2) insulin resistance and brain reward response to food cues after glucose ingestion.

Brain responses to HC food compared to NF cues after glucose ingestion were greater in the medial prefrontal cortex, orbital frontal cortex (OFC), insula, amygdala, hippocampus and visual cortex. Higher circulating insulin levels predicted greater OFC response to food cues after glucose preload (r=. 477, p=. 018) whereas higher circulating GLP-1 levels predicted lower amygdala responses to food cues after glucose preload (r= -.435, p=. 034). Circulating glucose and PYY levels were not correlated with brain responses. Insulin resistance positively correlated with OFC responses to food cues after glucose preload (r=. 626, p<. 01). The association remained significant after controlling for BMI (p<. 01).

Our findings support a modulatory role of circulating insulin and GLP-1 on brain reward processing of food cues and suggest that insulin resistance modulates OFC responsivity, independent of BMI.

 

Nothing to Disclose: SL, KAP

OR40-6 21932 6.0000 A The Roles of Circulating Peripheral Appetite Hormones and Insulin Resistance on Brain Reward Responses to Food Cues 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Obesity, Adipocyte Biology and Appetite Sunday, March 8th 11:00:00 AM OR40 6040 9:30:00 AM Obesity: Human Studies in Body Weight Regulation Oral


Danni Li*, Tricia Tang, Gerri Klein, Ehud Ur and Thomas Elliott
University of British Columbia, Vancouver, BC, Canada

 

Objective: To examine the impact of a 6-month nurse case manager (NCM) intervention compared to standard care (SC) on glycemic control and diabetes distress in a Canadian tertiary care setting.

Methods: One hundred and thirty four adults with type 2 diabetes and A1C > 8% who were recently discharged from two tertiary care hospitals in Vancouver or referred by hospital-affiliated endocrinologists completed a self-report survey, provided a blood sample and were randomized to: 1) a 6 month NCM intervention in addition to SC or 2) SC by the primary endocrinologists. The intervention involved an initial 60-minute face-to face consultation by the NCM conducted at BCDiabetes, a Vancouver-based diabetes care facility, followed by bi-weekly support contacts via telephone, email, or face-to-face.  During contacts, the NCM provides patient education, behavioral and emotional support, medication and/or insulin adjustment, monitoring, and care coordination. Assessments are conducted at baseline and 6 months.  Primary outcomes include A1c and diabetes distress.

Results: At 6 months follow-up, A1C was obtained for 130 subjects and distress data was obtained for 120 subjects. Both the NCM group and the SC achieved significant reductions in mean A1C (NCM: from 10.45% (sd=2.13) to 7.72% (sd=1.43), p < 0.01; SC: from 10.52% (sd=2.08) to 8.46% (sd=2.29), p < 0.01).  Comparing the two groups, the NCM group achieved a significantly lower mean A1C at 6 months than the SC group, a difference of -0.73%, controlling for baseline (p = 0.03, n = 130).  In terms of diabetes distress, the NCM group had a significantly lower mean distress score at the 6 months follow-up compared to the start of the intervention, whereas the SC group had a decrease in mean distress score that was not deemed statistically significant (NCM: from 1.90 (sd=0.77) to 1.37 (sd=0.38), p < 0.01; SC: from 1.92 (sd=0.84) to 1.78 (sd=0.91), p = 0.23).  As such, the NCM group achieved a significantly lower mean distress score at 6 months than the SC group, a difference of -0.40, controlling for baseline values (p < 0.01, n = 120).

Conclusion: Compared to standard care, nurse case management appears to be more effective in improving glycemic control and reducing diabetes distress. Future studies should explore NCM as a viable adjunct to standard diabetes care in the tertiary care setting particularly for high risk and poorly controlled patients.

 

Disclosure: DL: Clinical Researcher, Sanofi. TT: Coinvestigator, Sanofi. GK: Clinical Researcher, Sanofi. EU: Coinvestigator, Sanofi. TE: Investigator, Sanofi.

LB-OR02-1 22612 1.0000 A Diabetes Nurse Case Management in a Canadian Tertiary Care Setting: Results of a Randomized Controlled Trial 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM LB-OR02 6269 9:30:00 AM Glucose Metabolism: From Bedside to Bench Oral


Carol H Wysham*1, Jay Lin2 and Louis Kuritzky3
1Rockwood Center for Diabetes and Endocrinology, Spokane, WA, 2Novosyshealth, Flemington, NJ, 3University of Florida, Gainesville, FL

 

When patients with T2DM are suboptimally controlled on oral antidiabetes agents plus basal insulin, clinicians must choose from a variety of next-step treatments. Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have been used as add-on to basal insulin in T2DM patients due to their advantage in improving glycemic control, with lower risk of hypoglycemia and less weight gain compared with intensified insulin regimens. This meta-analysis compared the efficacy and safety of the addition of GLP-1 RA to basal insulin (GLP-1 RA group) versus further insulin intensification (basal insulin ± rapid-acting insulin [RAI]; Insulin group).

Peer-reviewed literature was searched using PubMed and EMBASE, as well as abstracts presented at the American Diabetes Association and European Association for the Study of Diabetes meetings from 2009–2013. Endpoints included A1C levels, hypoglycemia, change in body weight, fasting plasma glucose (FPG), and postprandial plasma glucose (PPG) levels. Composite endpoints included endpoint A1C < 7.0% without symptomatic hypoglycemia, and/or without weight gain.

A total of 15 randomized controlled trials involving 4,557 T2DM patients (48.2% female) were included. Patients were aged 42.5–61.0 years, had A1C levels of 7.7–8.8%, and a body mass index of 25.3–41.1 kg/m2.

A1C levels were reduced in the GLP-1 RA group versus the Insulin group (difference in means: −0.50%; P < 0.0001 [95% CI −0.72 to −0.29]). Patients in the GLP-1 RA group had an increased likelihood of achieving A1C ≤ 7.0% compared with patients in the Insulin group (odds ratio [OR] 3.22; 95% CI 1.99–5.19). Compared with patients in the Insulin group, patients in the GLP-1 RA group were more likely to achieve the composite endpoint of A1C levels ≤ 7.0% without symptomatic hypoglycemia (OR 4.75; 95% CI 3.33–6.78), although the risk of symptomatic hypoglycemia was comparable between the two groups (OR 1.08; 95% CI 0.75–1.56). In contrast with weight gain in the Insulin group, patients in the GLP-1 RA group showed a reduction in body weight (difference in means: −3.09 kg; 95% CI −4.14 to −2.05 kg). Similarly, GLP-1 RA therapy was associated with a greater likelihood of attaining A1C ≤ 7.0% without weight gain (OR 3.48; 95% CI 1.75–6.92), and A1C levels ≤ 7.0%, without weight gain and symptomatic hypoglycemia (OR 6.05; 95% CI 2.55–14.37). Furthermore, the GLP-1 RA group was more effective in reducing FPG and PPG levels in comparison with the Insulin group (difference in means; FPG: −0.36 mmol/L [95% CI −0.72 to 0.00]; and PPG: −2.75 mmol/L [95% CI −4.30 to −1.19]).

GLP-1 RA therapy is a viable option to complement insulin therapy as the addition of a GLP-1 RA to basal insulin improved glycemic control compared with insulin intensification in T2DM patients. This combined approach can be particularly valuable for T2DM patients who are treated with basal insulin and have insufficient glycemic control or issues with weight gain.

 

Disclosure: CHW: Speaker, Astra Zeneca, Consultant, Astra Zeneca, Speaker, Boehringer Ingelheim Pharmaceuticals, Speaker, Lilly USA, LLC, Speaker, Jansen Pharmaceuticals, Consultant, Jansen Pharmaceuticals, Speaker, Novo Nordisk, Speaker, Sanofi, Consultant, Sanofi. JL: Researcher, Sanofi. LK: Consultant, Novo Nordisk, Consultant, Lilly USA, LLC, Consultant, Jansen Pharmaceuticals, Speaker Bureau Member, Jansen Pharmaceuticals, Consultant, Sanofi, Consultant, Boehringer Ingelheim Pharmaceuticals.

LB-OR02-2 22820 2.0000 A A Meta-Analysis of the Safety and Efficacy of a Glucagon-like Peptide-1 Receptor Agonist Added to Basal Insulin Therapy Versus Basal Insulin with or without a Rapid-Acting Insulin in Patients with Type 2 Diabetes Mellitus 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM LB-OR02 6269 9:30:00 AM Glucose Metabolism: From Bedside to Bench Oral


Yan Zhao1, Xinli Zhang2, Jiezhong Chen3, Renfu Shao4, Chunxia Yan5 and Chen Chen*2
1Xi'an Medical University, Xi'an, China, 2The University of Queensland, Brisbane, Australia, 3University of Queensland, Brisbane, Australia, 4University of The Sunshine Coast, Maroochydore, Australia, 5Xi'an Jiaotong University, Xi'an, China

 

Diabetes mellitus is characterized by the functional and/or absolute deficiency of plasma insulin, which is synthesized and secreted by pancreatic β-cells. Mitochondrial functions are crucial for the β-cell survival and glucose-induced insulin secretion. Evidence indicates that mitochondrial dysfunction in islet β-cells is the major pathological reason for the development of diabetes. Protection of mitochondria in β-cell may therefore help the treatment of diabetes. Hexarelin (Hex) is a synthetic small peptide ghrelin analogue, which has been shown to protect cardiomyocytes from ischemia and hyperglycaemia. In this study, we used in vitro and in vivo models of streptozotocin (STZ)-induced β-cell damage to study the possible protective effect of Hex and the underlying mechanisms in β-cells. STZ treatment produced a cytotoxic effect in a dose (0.5-2 mM)- and time (1-6 h)-dependent manner in the mouse β-cell line MIN6 cells in culture. Hex (1.0 mM) decreased the STZ-induced damage in β-cells and maintained cell viability. Rhodamine 123 assay and superoxide DHE production assay revealed that Hex ameliorated STZ-induced mitochondrial damage and superoxide accumulation in cultured β-cells. STZ treatment of MIN6 cells caused apoptosis through increased ratio of pro-apoptotic protein Bax to anti-apoptotic protein Bcl2 and activation of caspase 3 and 9. Hex significantly reduced expression of cleaved caspase 3, 9 and the ratio of Bax to Bcl2 in STZ-treated MIN6 β-cells. Further investigation of the in vivo effect of Hex in a rat diabetes model induced by STZ (65 mg/kg body weight) intra peritoneal injection. Hex ameliorated STZ-induced decrease in plasma insulin and protected the structure of pancreatic islets from STZ-induced disruption. Ratio of β-cell / α-cell in pancreatic islets was significantly reduced by STZ treatment but recovered markedly by Hex treatment. In conclusion, these data indicate that STZ damages pancreatic β-cells by causing mitochondria dysfunction, superoxide accumulation, and cell apoptosis. Hex is able to partially restore STZ-induced β-cell damage via its protective actions on β-cell mitochondria, reduction of superoxide levels and anti-apoptosis. Hex may serve as a potential protective agent for the treatment of diabetes.

 

Nothing to Disclose: YZ, XZ, JC, RS, CY, CC

LB-OR02-3 22533 3.0000 A Hexarelin Protects Streptozotocin-Induced Rodent β-Cell Damage through Mitochondrial Pathways in Vitro and in Vivo 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM LB-OR02 6269 9:30:00 AM Glucose Metabolism: From Bedside to Bench Oral


Mehul Dalal*1, Mahmood Kazemi1 and Fen Ye2
1Sanofi US, Inc., Bridgewater, NJ, 2TechData Service LLC, King of Prussia, PA

 

Hypoglycemia and fear of hypoglycemia remain major barriers to persistence with insulin therapy. This retrospective cohort study of electronic medical record (EMR) data examined if patients with type 2 diabetes mellitus (T2DM) who experience hypoglycemia soon after insulin initiation are at a greater risk of insulin discontinuation.

The Predictive Health Intelligence diabetes dataset integrates anonymous de-identified EMR patient level data from 20 Integrated Delivery Networks with > 325 hospitals and 300,000 providers (including some of the largest integrated delivery networks in the US), and was used to identify adult patients with T2DM who initiated basal insulin therapy (defined as having no prescription of basal insulin ≥ 12 months before initiating insulin glargine, insulin detemir, or NPH insulin) between January 2008 and March 2013. Hypoglycemic events were identified by health care encounters with ICD-9-CM diagnosis codes for hypoglycemia, or blood glucose values ≤ 70 mg/dL during the first 6 months of basal insulin use. Discontinuation was defined as a gap of > 45 days in insulin prescription coverage. A baseline was established using 12-month patient-level data prior to insulin initiation and the follow-up period was 6–24 months; all data were reported descriptively. Data were adjusted for confounders using Cox regression analysis for time to basal insulin discontinuation.

Of 49,062 patients with T2DM identified, 5,159 (10.5%) experienced hypoglycemia within the first 6 months of insulin use; 44% were identified using ICD-9-CM diagnosis codes and the remaining 56% using blood glucose values. The patients experiencing hypoglycemia were: older (mean age: 63 vs 60 years; P < 0.0001) with 49% aged ≥ 65 years; had more comorbidities (Charlson Comorbidity Index: 1.21 vs 0.67; P < 0.0001); had more experience of hypoglycemia during the baseline period (18.9% vs 4.5%; P < 0.0001); and a greater proportion had a health care utilization during the baseline period (inpatient visits: 20.1% vs 8.7%; P < 0.0001). During the follow-up period, 68.1% of those patients with hypoglycemia experienced their first event in the first 3 months of treatment. In those patients experiencing hypoglycemia, discontinuation of insulin therapy was higher at 6 months (58.7% vs 45.5%; P < 0.0001) and at 12 months (68.1% vs 53.9%; P < 0.0001). Data adjusted for confounders showed that patients with hypoglycemia had almost twice the risk of discontinuation over 12 months (hazard ratio 1.90; 95% CI 1.82–1.98; P < 0.0001).

This study illustrates the differences in baseline characteristics of those patients who experience hypoglycemia soon after initiating basal insulin, and that these patients are at greater risk of discontinuation of their basal insulin therapy.

 

Disclosure: MD: Employee, Sanofi, Employee, Sanofi. MK: Employee, Sanofi, Employee, Sanofi. FY: Independent Contractor (including contracted research), Sanofi.

LB-OR02-4 22824 4.0000 A Hypoglycemia in Patients Newly-Initiated on Basal Insulin: Impact on Treatment Discontinuation 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM LB-OR02 6269 9:30:00 AM Glucose Metabolism: From Bedside to Bench Oral


Siobhan Bacon1, Jasmin Schmid2, Ailbhe McCarthy1, Jackie Edwards3, Aileen Fleming3, Brendan Thomas Kinsley4, Richard G Firth5, Bridgette Byrne6, Claire Gavin7 and Maria Michele Byrne*1
1Mater Misericordiae University Hospital, Dublin 7, Ireland, 2Royal College of Surgeons in Ireland, Dublin 2, Ireland, 3Rotunda Maternity Hospital, Dublin 7, Ireland, 4Coombe Women and infants University Hospital, Dublin 8, Ireland, 5National Maternity Hospital, Dublin 2, Ireland, 6Coombe Women and Infants University Hospital, Dublin 8, Ireland, 7National Maternity Hospital, Dublin 7, Ireland

 

 

Objective: Women with Maturity Onset Diabetes of the Young (MODY) are often first identified and diagnosed with diabetes during pregnancy. Genetics and hyperglycemia play an important role in determining fetal size in MODY pregnancies (1,2). Observational data on glycemic control and fetal outcomes in pregnancies complicated by glucokinase (GCK) and (hepatocyte nuclear factor-1 alpha) HNF-1α MODY mutations are lacking. The aim of the current study was to determine the outcomes and clinical management of hyperglycemia using home blood glucose monitoring (HBGM) in MODY pregnancies.

Study Design: A retrospective chart review of 37 women with a GCK or a HNF-1α mutation was conducted. There were 132 pregnancies in these women. Data on variables such as birth weight, mode of delivery and the treatment of hyperglycaemia was recorded. Complications which included congenital anomaly, birth injury, admission to neonatal intensive care unit (NICU) and prolonged neonatal hypoglycemia were recorded. Genotyping of 36 offspring was known. The HBGM recordings of a subset of these women, who were all managed according to our current guidelines for diabetes in pregnancy, with a GCK or HNF-1α mutation referred to one of the three tertiary centres were analysed. The median of the highest and lowest blood glucose value for each day, at each time point, was averaged over a seven day period. This was performed for each trimester.

Results: The birth weight in non-effected GCK offspring was significantly higher than in the effected GCK offspring (4.8 kg (4.1-5.2) vs. 3.2 kg (3.1-3.7), p=0.01). Seven point home blood glucose monitoring (HBGM) over a seven day period in each trimester demonstrated higher fasting and post prandial glycemic excursions in the 1st trimester of GCK pregnancies when compared to HNF-1α pregnancies (Fasting; 5.8 mmol/l (5-6.4) vs 4.7 mmol/l (4.3-4.9), p=0.01 and Post-prandial: 8.6 mmol/l (7.5-10.9) vs 6.2 mmol/l (5.6-7.3), p=0.04) despite insulin treatment. There was a higher percentage of miscarriages in the GCK group when compared to the HNF1A-MODY group (33.3% vs 14%, p=0.07) which was similar to the background population. Insulin initiated at an early gestation appeared to lower the incidence of macrosomia in GCK non-effected offspring.

Conclusions: To date, this is the largest study performed specifically looking at glycemic excursions in pregnancies complicated by GCK and HNF-1α MODY. This study demonstrates that the current management of HNF-1α pregnancies appears to be appropriate. In GCK pregnancies, however, the glycaemic variability that we have clinically noted warrants attention. There was an increased percentage of both macrosomia and miscarriages in GCK pregnancies highlighting the importance of a diagnosis of GCK-MODY in women prior to conception and the necessity for pre-conception care.

 

Nothing to Disclose: SB, JS, AM, JE, AF, BTK, RGF, BB, CG, MMB

LB-OR02-5 22392 5.0000 A The Clinical Management of Hyperglycemia in Pregnancy Complicated By Maturity Onset Diabetes of the Young 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM LB-OR02 6269 9:30:00 AM Glucose Metabolism: From Bedside to Bench Oral


Geetali Pradhan*1, Jong Han Lee2 and Yuxiang Sun3
1baylor college of medicine, Houston, TX, 2Baylor college of medicine, Houston, 3Baylor College of Medicine, Houston, TX

 

The incidence of Type 2 Diabetes (T2D) is increasing at alarming rate. Ghrelin, only known circulating orexigenic hormone, is secreted mainly from the gut and at lower levels from the pancreas. We and others have previously demonstrated ghrelin’s role in glycemic regulation: ghrelin deletion increases insulin secretion, improves glucose intolerance and insulin sensitivity (Sun 2006). Thus, blockade of ghrelin signaling has been proposed to be a promising treatment for T2D patients. Growth Hormone Secretagogue Receptor (GHS-R) is the known ghrelin receptor. Interestingly, we observed Ghsr deletion reduces fasting plasma glucose and insulin (Sun 2008), showing normal glucose intolerance but improved insulin sensitivity (Lin 2011). The disparate glycemic phenotypes exhibited by ghrelin and GHS-R ablation indicate that further detailed investigation is needed.

In this study, we investigated the glycemic phenotype of young Ghsr null mice (Ghsr-/-). We studied the Ghsr-/- mice in vivo to assess glucoregulatory hormones and whole body glucose and insulin tolerance. We further analyzed the pancreatic islets from Ghsr-/- mice ex vivo to study the signaling cascade mediating glucose stimulated insulin secretion (GSIS).

Both fasting plasma insulin and glucagon of Ghsr-/- mice were significantly lower compared to controls. Ghsr null mice exhibit normal glucose tolerance but reduced insulin secretion, supporting improved insulin sensitivity. Ex vivo studies indicated that GSIS was significantly reduced in pancreatic islets of Ghsr-/- mice, even though the total insulin content* of the whole pancreas and islets was increased. We detected reduced Glut2 mRNA expression in islets of Ghsr-/- mice, suggesting decreased efficiency of glucose transport. We also found that altered GSIS in islets of Ghsr-/- mice can be rescued by treatment with a membrane depolarizing agent KCl, which suggests that Ghsr ablated islets have inefficient depolarization. Lastly, we observed that ATP/ADP ratio in the islets of Ghsr-/- mice was reduced without change in mitochondrial DNA content, suggesting reduced GSIS observed is likely linked to islet mitochondrial function but not mitochondrial content per se.  

Collectively we have showed, blocking ghrelin signaling by deleting the Ghsr gene reduces fasting glucose, insulin, glucagon; improves insulin sensitivity. We further demonstrated that GSIS by the islets of Ghsr-/- mice is decreased, which is likely due to islet impairments in glucose transport, depolarization and/or mitochondrial function. Thus, while GHS-R ablation improves insulin sensitivity, it reduces insulin secretion; this suggests that blockade of GHS-R has positive effect on insulin resistance but negative effect on hyperglycemia. This cautions that the therapeutic application of GHS-R antagonists for T2D has to be used in tissue/stage-specific manor.

 

Nothing to Disclose: GP, JHL, YS

LB-OR02-6 22735 6.0000 A The Role of Ghrelin Receptor in Regulation of Glucose Homeostasis 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Diabetes & Glucose Metabolism Sunday, March 8th 11:00:00 AM LB-OR02 6269 9:30:00 AM Glucose Metabolism: From Bedside to Bench Oral


Raymond E Soccio*1, Eric R Chen1, Satyajit R Rajapurkar1, Pegah Safabakhsh1, Jill M Marinis1, Joanna R Dispirito1, Erika R Briggs1, Bin Fang1, Logan J Everett1, Hee-Woong Lim1, Kyoung Jae Won1, David J Steger1, Ying Wu2, Mete Civelek3, Benjamin F Voight1 and Mitchell A Lazar1
1University of Pennsylvania, Philadelphia, PA, 2University of North Carolina, Chapel Hill, NC, 3University of California Los Angeles, Los Angeles, CA

 

Single nucleotide polymorphisms (SNPs) affecting the risk of diseases, including diabetes, obesity, and dyslipidemia, often reside in non-coding regions of the genome, and their function is generally poorly understood.  We have compared white adipose tissue from C57BL/6 and 129S1/SvIm inbred mice and show that SNPs are highly enriched at strain-selective binding sites for the transcription factor (TF) PPARγ, a nuclear receptor for antidiabetic drugs.  Many such SNPs affect PPARγ occupancy by altering the binding motifs for PPARγ itself or its cooperating TFs, including C/EBP and the glucocorticoid receptor.  Importantly, these variant PPARγ binding sites are functional in regulating nearby genes, whose expression differs between the inbred strains and is imbalanced in heterozygous F1 mice.  Moreover, genetically-determined selective binding of PPARγ accounts for strain-specific transcriptional effects of TZD drugs, providing proof-of-concept for a personalized pharmacogenomic approach to therapies that target nuclear receptors for hormones and drugs.  Genetic variants that determine individual drug response not only affect the drug target itself, or drug levels via transporters and metabolizing enzymes, but also the transcriptional response to drug via regulatory SNPs.  These findings were extended to human adipose tissue, where motif-altering SNPs also caused differential PPARγ binding.  Furthermore, these human SNPs in PPARγ sites were enriched at previously-defined human adipose expression quantitative trait loci (eQTLs), thus demonstrating function and providing a molecular mechanism for how these eQTL SNPs determine nearby gene expression.  Finally, human adipose PPARγ site SNPs were enriched in loci associated with dysmetabolic traits in genome-wide association studies (GWAS).  One PPARγ site motif-altering SNP was associated with HDL cholesterol and triglyceride levels, waist-hip ratio, blood pressure, and diabetes, suggesting a mechanism for genetic risk of multiple metabolic syndrome parameters.  These findings demonstrate that natural genetic variation in PPARγ genomic occupancy determines individual disease risk and drug response.

 

Disclosure: MAL: Board Member, Eli Lilly & Company, Ad Hoc Consultant, Novartis Pharmaceuticals, Board Member, Pfizer, Inc., Ad Hoc Consultant, Merck & Co., Ad Hoc Consultant, Vanda Pharmaceuticals Inc., Ad Hoc Consultant, BioU, LLC, Ad Hoc Consultant, Jansen Pharmaceuticals. Nothing to Disclose: RES, ERC, SRR, PS, JMM, JRD, ERB, BF, LJE, HWL, KJW, DJS, YW, MC, BFV

LB-OR03-1 22581 1.0000 A Genetic Variation Determines Pparγ Function and Antidiabetic Drug Response in Vivo 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM LB-OR03 6270 9:30:00 AM Advances in the Mechanistic Understanding of Endocrine Disease Oral


Martin C Sadowski*1, Amy A Lubik2, Jennifer Ann Locke2, Stephen C Hendy2, Julien E Davies3 and Colleen C. Nelson1
1Queensland University of Technology - Translational Research Institute, Brisbane, Australia, 2University of British Columbia, Vancouver, BC, Canada, 3University of British Columbia

 

Objectives

Androgen signaling via the androgen receptor (AR) is the major driver of metabolic pathways in prostate cancer (PCa) cells. Androgens induce de novo lipogenesis via the master transcriptional regulator, sterol response element binding protein (SREBP) and the downstream targets acetyl CoA carboxylase (ACC) and fatty acid synthase (FASN).Overexpression of FASN underpins tumor cell survival, treatment resistance and progression to castrate-resistant PCa. Current treatment of advanced PCa is based on AR targeted therapies. Yet, adaptive changes to AR activity contribute to treatment resistance, highlighting the need for alternative approaches to target AR signaling. Here we describe the discovery that FASN inhibition antagonizes critical aspects of the androgen signaling cascade.

Methods

Cell growth, viability and metabolic activity were determined in real-time with IncuCyte technology and by MTS and Alamar Blue endpoint assay, respectively. Cell death and cell cycle progression were investigated by flow cytometry. Expression of key lipogenic genes was interrogated by qRT-PCR and validated by Western blotting. Changes to lipid homeostasis were determined by Nile Red staining and fluorescence microscopy. Transmembrane androgen transport was measured by DHT-uptake assay. Androgen receptor (AR) translocation was investigated by fluorescence microscopy with an INCell 2200 analyzer. AR transcription activity was assessed by luciferase reporter assay. Secreted PSA levels were quantified by ELISA.

Results

Small molecule inhibition of FASN or mRNA silencing of FASN caused a substantial reduction of AR protein in LNCaP cells, indicating a functional relationship between AR signaling and FASN activity. Furthermore, non-cytotoxic levels of inhibitors targeting fatty acid synthesis via ACC and FASN suppressed androgen-induced proliferation, G1-S phase cell cycle progression, and metabolic activity. In addition, the androgen-induced increase in cellular lipid content (phospholipids, neutral lipids and lipid droplets) and expression of key AR-regulated genes of lipid metabolism were efficiently blocked in LNCaP cells, suggesting a functional dependence of AR-mediated transcription on active fatty acid synthesis. Indeed, AR transactivation activity and KLK3/PSA mRNA and protein expression were strongly reduced by inhibitors of lipogenesis. Moreover, FASN inhibition blocked the androgen-induced translocation of AR into the nucleus, suggesting that AR activity was interrupted early in the signaling cascade. Consistent with this notion, we discovered that the cellular uptake of DHT was efficiently blocked in LNCaP cells by the FASN inhibitor triclosan.

Conclusions

Inhibitors of de novo fatty acid synthesis suppress AR signaling in LNCaP cells, thereby providing a rationale for co-targeting AR and FASN in advanced, treatment-resistant PCa.

 

Nothing to Disclose: MCS, AAL, JAL, SCH, JED, CCN

LB-OR03-2 22752 2.0000 A Inhibition of Fatty Acid Synthase Suppresses Androgen Signaling in LNCaP Cells 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM LB-OR03 6270 9:30:00 AM Advances in the Mechanistic Understanding of Endocrine Disease Oral


Michael B. Stout*1, Glenda L. Evans1, Michael J. Jurczak2, Yi Zhu1, Ming Xu1, Allyson K. Palmer1, Tamar Pirtskhalava1, Thomas A. White1, Ravinder J. Singh1, Nathan K. LeBrasseur1, Tamara Tchkonia1, Gerald I. Shulman2 and James L. Kirkland1
1Mayo Clinic, 2Yale University

 

Aging is the leading risk factor for most chronic diseases and is associated with perturbations in systemic metabolism and inflammatory status (1). These hallmarks of advancing age are further exacerbated by obesity, which has markedly increased in older adults in recent decades (2). White adipose tissue (WAT) plays a central role in metabolic dysfunction through modulation of macronutrient homeostasis and systemic inflammation. Both obesity and chronological aging are linked with declines in WAT insulin responsiveness and inflammatory status (3). These declines contribute to the expansion of visceral adiposity and ectopic lipid accumulation which are strong risk factors for metabolic disease throughout the lifecycle (4, 5). Effective weight loss strategies in young adults, most notably calorie restriction (CR) and exercise regimens, are often less practical in older adults due to existing co-morbidities (6). Despite these challenges, reductions in adiposity in older adults can have beneficial effects on metabolism, inflammation, and physical parameters (7). These observations highlight the need for pharmacological interventions that modulate metabolic and inflammatory pathways similar to CR or exercise. 17α-estradiol (17α-E2), a naturally occurring, nonfeminizing (8) enantiomer of 17β-estradiol (17β-E2), has been shown to reduce bodyweight and extend lifespan in male mice (9). The goal of this study was to evaluate the effects of 17α-E2 on metabolic and inflammatory profiles in 18 month old male mice. We found that 17α-E2 prevents gains in body weight and adiposity despite equivalent calorie intake between treated and untreated groups over a 15 week period. These observations occurred in conjunction with dramatic reductions in visceral adiposity and hepatic triglyceride deposition. Mice administered 17α-E2 also had significant reductions in several pro-inflammatory markers in visceral WAT and plasma. These phenotypes translated into dramatic improvements in fasting glucose and insulin, HbA1c, glucose tolerance, and insulin sensitivity. We also discovered that 17α-E2 increased AMPK and reduced mTOR activity in visceral WAT. AMPK lies at the core of integrated signaling networks that modulate aging, metabolism, and inflammation due to its inhibitory effects on mTOR and NFkB (10, 11). AMPK activity declines with aging, which likely contributes to enhanced mTOR and NFkB activity (10, 11) and may also explain the lifespan extending effect of 17α-E2. Supporting the contention that 17α-E2 is nonfeminizing was the observation that chronic administration did not alter plasma testosterone or 17β-E2, nor seminiferous tubule or gonadal mass. Collectively, our findings suggest 17α-E2 may alleviate aging- and/or obesity-related WAT dysfunction and improve systemic metabolic homeostasis through reductions in adiposity and inflammation in an AMPK-dependent manner.

 

Nothing to Disclose: MBS, GLE, MJJ, YZ, MX, AKP, TP, TAW, RJS, NKL, TT, GIS, JLK

LB-OR03-3 22496 3.0000 A Alleviation of Age-Related Metabolic Dysfunction By 17α-Estradiol: A Novel Therapeutic Strategy 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM LB-OR03 6270 9:30:00 AM Advances in the Mechanistic Understanding of Endocrine Disease Oral


David Rincon Fernandez*1, Manuel D. Gahete1, Virginia Ruiz1, Raul M. Luque2 and Justo Pastor Castano3
1University of Córdoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, and CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain, 2Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain, 3University of Cordoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain

 

Ghrelin gene originates, through alternative splicing mechanisms and post-translational modifications, various peptides that regulate multiple, key pathophysiological processes, including tumoral processes. Our group has recently discovered a splicing variant of the ghrelin system, named In1-ghrelin, which results from the retention of intron 1. In1-ghrelin variant shares the initial portion of 13aa of its peptide sequence with native ghrelin, including the first 5-aa, which is the minimum sequence required for ghrelin acylation by ghrelin-O-acyl-transferase enzyme and for binding and activation of GHSR1a; whereas, the aa sequence of the C-terminal tail of In1-ghrelin is totally altered due to the retention of intron 1. In1-ghrelin variant has found to be overexpressed in breast cancer samples compared to control tissue, and its expression correlates with proliferation markers, suggesting the possible involvement of the In1-ghrelin in the development and/or progression of breast cancer. However, the role that In1-ghrelin plays in the regulation of key processes involved in the development and/or progression of breast cancer such as proliferation, migration and cell dedifferentiation [epithelial-mesenchymal transition (EMT) and mammosphere formation] is still unknown. The aim of this study was to determine the functional consequences associated with these tumor malignancy processes induced by the overexpression (using specific vector containing In1-ghrelin peptide) and/or silencing (using specific siRNAs of In1-ghrelin) of this variant by using the breast cancer cell line MDA-MB-231. 

Overexpression of both In1-ghrelin and native ghrelin in MDA-MB-231 cells stimulated proliferation rate compared to control cells (72h after transfection; p =0.013 and 0.012, respectively). However, overexpression of In1-ghrelin, but not ghrelin, and also treatment with In1-ghrelin peptides increased the migratory ability of MDA-MB-231 cells (p=0.002) and also, induced an increase in p-ERK1/2 and a decreased in p-Akt. Migratory and proliferation ability is often associated to a change in cell differentiation status and, therefore, we determined the percentage of cells with mesenchymal-like phenotype and found that overexpression of In1-ghrelin, but not ghrelin, increased the number of cells with mesenchymal phenotype (p=0.013). We also studied the formation of mammospheres and found that only In1-ghrelin overexpression led to the formation of more, and bigger, mammospheres which could imply a greater proliferative capacity of cancer stem cells and, thus, a greater tumor growth and recurrence. Finally, we also found that In1-ghrelin silencing decreased proliferation and migration capacities of MDA-MB-231 cells. Altogether, our data demonstrate that In1-ghrelin variant overexpression increases malignancy features in breast cancer cells.

 

Nothing to Disclose: DR, MDG, VR, RML, JPC

LB-OR03-4 22990 4.0000 A In1-Ghrelin Splicing Variant Overexpression Increases Malignancy Features in the Breast Cancer Cell Line MDA-MB-231 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM LB-OR03 6270 9:30:00 AM Advances in the Mechanistic Understanding of Endocrine Disease Oral


Fumin Lin*1, Kathrina Marcelo1, Kimal Rajapakshe1, Cristian Coarfa2, Brian York2 and Anthony R Means1
1Baylor College of Medicine, 2Baylor College of Medicine, Houston, TX

 

Among cancers, hepatocellular carcinoma (HCC) is responsible for the third highest number of cancer-related deaths worldwide. However, the mechanisms underlying HCC onset and progression are poorly understood. Ca2+/CaM signaling has been reported to influence HCC, but the detailed mechanisms are largely unknown. As Ca2+/CaM-dependent Kinase Kinase 2 (CaMKK2) is the proximal member of the CaM kinase cascade, phosphorylates CaMK1, CaMK4 and AMPK and markedly influences liver metabolism and inflammation, we evaluated this kinase in HCC. Here, we report that CaMKK2 is significantly up-regulated in human HCC and negatively correlated with HCC patient survival. CaMKK2 protein is highly expressed in all eight HCC cell lines we evaluated and markedly up-regulated relative to normal primary hepatocytes. Cellular ablation of CaMKK2 using RNA interference yields a gene signature that signifies marked improvement in HCC patient survival. Ablation or pharmacological inhibition of CaMKK2 significantly impaired proliferation and colony formation of the HCC cell lines in a dose-dependent manner. Additionally, the growth defect caused by loss of CaMKK2 can be rescued by ectopic expression of wild type CaMKK2 but not by kinase-inactive mutants. To interrogate the importance of CaMKK2 for HCC in vivo, control and CaMKK2-deficient cells were injected into nude mice. Loss of CaMKK2 dramatically delayed tumor occurrence and reduced tumor size. Furthermore, administration of  the selective CaMKK2 inhibitor STO-609 into tumor-bearing mice attenuated progression of established tumors. In addition, CaMKK2 expression is up-regulated in a time-dependent manner in the DEN-induced mouse HCC model and STO-609 prevented and even regressed tumor progression. Mechanistically, we found that CaMKK2 serves a scaffolding role for bringing together one of its key substrates, CaMK4, with key components of the mTOR/S6K pathway to positively regulate de novo protein synthesis via protein phosphorylation. Collectively, our studies highlight CaMKK2 as an essential coordinator of protein synthesis in HCC and identify CaMKK2 as an attractive and druggable target for therapeutic intervention.

 

Nothing to Disclose: FL, KM, KR, CC, BY, ARM

LB-OR03-5 22645 5.0000 A The CaMKK2/CaMK4 Relay Is an Essential Regulator of Hepatic Cancer 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM LB-OR03 6270 9:30:00 AM Advances in the Mechanistic Understanding of Endocrine Disease Oral


Elizabeth Ann Wellberg1, Andrew S Lewis1, Kristina Terrell2, Evan Dale Abel3, William J Muller4 and Steven Mathias Anderson*1
1University of Colorado Denver, Aurora, CO, 2University of Colorado Anschutz Medical Campus, Aurora, CO, 3Carver College of Medicine, University of Iowa, Iowa City, IA, 4McGill University, Montreal, Canada

 

Alterations in tumor cell metabolism have been investigated for decades, and include changes in glucose utilization, as well as changes in mitochondrial and fatty acid metabolism; however, it is unclear at what point during the process of tumorigenesis these metabolic changes occur.  We hypothesized that elevated glucose uptake represents the first metabolic adaptation to transformation, and thus may be a target for the prevention of breast cancer.  The GLUT1 transporter is expressed in breast cancer cells and is responsible for the majority of their glucose uptake.  Not surprisingly, breast cancer patients with high levels of GLUT1 have a poorer clinical outcome than those with lower levels, likely due to the association between glucose uptake and high tumor grade.  We previously showed that the reduction of GLUT1 in established tumor cells resulted in a 50% decrease in glucose consumption and lactate generation.  There was a corresponding decrease in proliferation in both two and three-dimensional culture, and in tumor growth in immunodeficient mice. 

 To test the hypothesis that elevated glucose uptake is required very early in the process of tumor formation, we crossed the MMTV-NIC mice, which contain activated NeuNT, an internal ribosome entry site (IRES), and Cre recombinase, to mice bearing floxed alleles of GLUT1, and monitored tumor development.  All of the control MMTV-NIC mice developed tumors in less than 200 days.  In contrast, none of the MMTV-NIC,GLUT1fl/fl mice developed mammary tumors even after eighteen months.  We anticipated that loss of one allele of GLUT1 would significantly delay mammary tumorigenesis, however, we did not observe any tumors in these mice, even when the mice reached eighteen months of age.  Tumors that formed in the MMTV-NIC mice displayed a histology typical of Neu-dependent tumors observed in similar transgenic mice, and there was evidence of preneoplastic lesions in the non tumor-bearing mammary glands.  The mammary ductal tree developed normally in MMTV-NIC,Glut1fl/fl and MMTV-NIC,Glut1fl/+ mice.  Mice lacking one allele of Glut1 had increased mammary epithelial content compared to mice lacking both Glut1 alleles; however, no palpable tumors ever formed in either group.  These results suggest that loss of a single allele of GLUT1 is sufficient to suppress Neu-induced mammary tumorigenesis and that there is an absolute requirement for GLUT1 at the earliest stages of tumorigenesis. 

 A small molecule inhibitor of GLUT1, WZB117, reduced the proliferation of established human breast cancer cells of all molecular subtypes by approximately 50%, which is consistent with our previous studies using shRNA knockdown of GLUT1 in mouse mammary tumor cells.  These data suggest that GLUT1 may be required for the initial stages of tumorigenesis, but that the relative dependence of breast cancer cells on this transporter may lessen with tumor progression.

 

Nothing to Disclose: EAW, ASL, KT, EDA, WJM, SMA

LB-OR03-6 22982 6.0000 A GLUT1 Is Required for Induction of Mammary Tumorigenesis By Activated ErbB2/Her2/Neu 2015-03-08 San Diego 2015-03-02 97th Annual Meeting of the Endocrine Society Nuclear Receptors and Steroid Hormone Action Sunday, March 8th 11:00:00 AM LB-OR03 6270 9:30:00 AM Advances in the Mechanistic Understanding of Endocrine Disease Oral
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