Background: Complete tumor removal by transsphenoidal surgery is usually difficult for large nonfunctioning pituitary adenomas (NFPAs). A validated medical treatment may be useful for their management. This study evaluates the clinical efficacy of the dopaminergic agonist cabergoline for residual NFPA. Design, Setting, and Participants: We conducted a randomized, parallel, open-label clinical trial that compared cabergoline with nonintervention in patients with residual NFPA after transsphenoidal surgery over 2 years. The primary outcome was clinical efficacy (tumor reduction). The secondary outcome was the relationship between tumor dopamine D2 receptor (D2R) expression and clinical responsiveness. Tumor measurements and clinical evaluations were performed every 6 months. Results: In total, 59 and 57 individuals were randomly assigned to the study and control groups, respectively. At the end of the study, residual tumor shrinkage, stabilization, and enlargement were observed in 28.8%, 66.1%, and 5.1% of patients, respectively, in the medical-therapy group and in 10.5%, 73.7%, and 15.8% of patients, respectively, in the control group (P=0.01). The progression-free survival rate was 23.2 and 20.8 months for the study and control groups, respectively (P=0.01). D2R was not associated with cabergoline responsiveness. No major side effects were related to cabergoline use. Conclusions: Cabergoline was an effective drug for treating residual NFPA, and its use was associated with a high rate of tumor shrinkage (ClinicalTrials.gov NCT03271918).

The role of prolactin (PRL) in the CNS remains uncertain. We evaluated the presence of hyperprolactinemia, intracellular prolactin (ICP), and prolactin receptor (PRL-R) in primary CNS tumors, and their relationship with cellular replication with a prospective cross-sectional study of 82 consecutive patients with primary CNS tumors admitted for neurosurgical resection between October 2003 and September 2005. Patients submitted to a questionnaire, and venous blood samples were obtained for measurement of serum PRL and TSH. Immunohistochemical analyses were performed to evaluate the presence of ICP, PRL-R, and Ki-67. Serum PRL levels ranged from 2 to 70 ng/ml, and hyperprolactinemia was detected in 25 cases (30.5%). ICP was detected in 18 patients (21.9%), in whom PRL ranged from 2 to 32 ng/ml. A positive correlation was found between PRL levels and the presence of ICP (Student's t test, P = 0.022). The PRL-R was observed immunohistochemically in 32 cases (39%). The frequencies of hyperprolactinemia, ICP, and PRL-R were similar across the several histological types of CNS tumors. Ki-67 index was similar in all groups. Hyperprolactinemia and intracellular presence of PRL and PRL-R were common findings in this population, suggesting a role for PRL in CNS tumor genesis.

Introduction: The conversion of testosterone into dyhidrotestosterone is catalyzed by the 5 α reductase type 2 enzyme which plays a crucial role in the external genitalia virilization. It is encoded by the SRD5A2 gene. Allelic variants (AV) in this gene cause a 46,XY DSD with no genotype-phenotype relationship. It was firstly reported at early 70’s from isolated clusters. Since then, several cases have been reported. Putting together, it will expand the knowledge about the molecular bases of androgen regulation. Methods: We searched for SRD5A2 AV in the literature (Pubmed, EMBASE, Medline) and websites (ensemble, HGMD, ClinVar). Only cases with AV in both alleles, either in homozygous (HM) or compound heterozygous state (CH) and 5ARD2 phenotype were included. The AV were analyzed according to ethnicity, exon, domain, aminoacid (aa) conservation, age at diagnosis, sex assignment, gender change, external genitalia virilization and functional studies. External genitalia virilization was scored using Sinnecker scale. Conservation analysis was carried out using CONSURF platform. For categorical variables we used X2 test and Cramer’s V. Continuous variables were analyzed by t test or ANOVA. Concordance was estimated by Kappa. Results: We identified 434 cases of 5ARD2 deficiencies from 40 countries. Most came from Turkey (23%), China (17%), Italy (9%), and Brazil (7%). 69% were assigned as female. There were 70% of AV in HM and 30% in CH state. Most were missense variants (76%). However, small indels (11%), splicing (5%) and large deletions (4%) were all reported. They were distributed along all exons with exon 1 (33%) and exon 4 (25%) predominance. AV in the exon 4 (NADPH-binding domain) resulted in lower virilization (F=10.5; p<.0001). The positions 55, 65, 196, 235 and 246 are hotspots making up, 25% of all AV. Most AV (76%) were located at conserved aa. However, AV at non-conserved aa were more frequently indels (28% vs 6%; p<.01). The overall rate of gender change from female to male ranged from 16% to 70%. The lowest rate of gender change occurred in Turkey and the highest in Brazil. Virilization was similar between those who changed and kept their gender. The gender change rate was significantly different across the countries (V=0.44; p<.001) even with similar virilization scores. There was no concordance between genotype and phenotype in all recurrent AV (196, 235 and 246; k 0.6, 0.12 and 0.19). Conclusion: 5ARD2 deficiency has a worldwide distribution. AV at NADPH-ligand region cause lower virilization. Genitalia virilization influenced sex assignment but not gender change which was influenced by cultural aspects across the countries.

Kallmann syndrome (KS) is a developmental disease characterized by the association of isolated hypogonadotropic hypogonadism and anosmia/hyposmia. We report an unusual presentation of two females with KS and empty sella. These females, aged at 20 and 29-year-old, presented primary amenorrhea with prepubertal estradiol and low gonadotropin levels. No other significant clinical signs were observed. Empty sella was observed on MRI in both cases. Sequencing of FGFR1 gene, recently implicated in autosomal form of KS, was performed and one splicing mutation (IVS14 + 1G > A) was identified in one patient.

The role of serum calcitonin as part of the evaluation of thyroid nodules has been widely discussed in literature. However there still is no consensus of measurement of calcitonin in the initial evaluation of a patient with thyroid nodule. Problems concerning cost-benefit, lab methods, false positive and low prevalence of medullary thyroid carcinoma (MTC) are factors that limit this approach. We have illustrated two cases where serum calcitonin was used in the evaluation of thyroid nodule and rates proved to be high. A stimulation test was performed, using calcium as secretagogue, and calcitonin hyper-stimulation was confirmed, but anatomopathologic examination did not evidence medullar neoplasia. Anatomopathologic diagnosis detected Hashimoto thyroiditis in one case and adenomatous goiter plus an occult papillary thyroid carcinoma in the other one. Recommendation for routine use of serum calcitonin in the initial diagnostic evaluation of a thyroid nodule, followed by a confirming stimulation test if basal serum calcitonin is showed to be high, is the most currently recommended approach, but questions concerning cost-benefit and possibility of diagnosis error make the validity of this recommendation discussible.

AgradecimentosA todos os pacientes cujas histórias estão -em parte -contadas aqui.À professora Berenice Bilharinho de Mendonça, pela liberdade para a minha curiosidade. Por me apresentar o universo encantador do desenvolvimento, com o qual eu já me identificava antes mesmo de saber. Por ensinar que, tão importante quanto um diagnóstico, é entender como a pessoa se sente.À Marlene Inácio, pela generosidade em partilhar seus dados, seu conhecimento, sua alegria. Pela leveza. Cada pedaço desta tese é também desenhado por você.À Dra Sorahia Domenice e à Dra Elaine Frade Costa, por todos os ensinamentos, pelo acolhimento, por tantas oportunidades. We found an association between prenatal androgen exposure and major prevalence of male psychosexual outcomes and a higher incidence of female to male gender dysphoria. There was not difference in the psychosexual outcomes according by external genitalia virilization in male and in female individuals. There was an incidence of 19% of gender dysphoria (27 out from 144). In 93% (n=25), the gender change was from female to male (F to M). The ethological diagnosis related with F to M GD were 5α-RD2 deficiency (5ARD2) in 16/32 (50%), followed by 5/15 (33%) in 17β-HSD3 deficiency (17βHSD3). Others diagnosis related with F to M GD were: partial gonadal dysgenesis (n=3/24; 12%) and 3βHSD2 (n=1/3; 33%). Both cases of male to female (M to F) GD occurred in partial gonadal dysgenesis (8%; n=2/24). The median of GD age (desire to belong to another gender) was 8 years old (5-9), and the median of gender change itself was 15 years old (10.5 -20). In F to M GD, gender change was associated with prenatal androgen exposure (p<.001; V=0,461). The psychosexual components showed higher concordance index with final gender (GI -k=0.81; GI -k=0.65 and SO -k=0.85) then with the assigned sex (GI -k=0.1; GI -k=0.25 and SO -k=0.15). Conclusion: Prenatal androgen exposure affects the psychosexual development, favoring more male outcomes. This influence was observed in GI, GR and SO. The degree of external genitalia virilization did not influence the psychosexual development. Female to Male GD is common in 46,XY DSD raised in female social sex, especially in 5ARD2 and 17βHSD3 deficiencies. There is a strong relationship between prenatal androgen exposure and F to M GD. On the other hand, M to F gender change was rare in 46,XY DSD and occurred only in partial gonadal dysgenesis patients.

There is a high frequency of Testicular Germ Cell Tumors (TGCT) in 46,XY individuals with disorders of sexual development (46,XY DSD), which include Androgen Insensitivity Syndrome (AIS). That TGCT risk leads to pragmatic gonadectomy in these patients with several further implications. A better knowledge of TGCT tumorigenesis would be helpful either for alternative treatments or tumoral markers. Retrotransposons are mobile DNA elements that duplicate by retrotransposition, a “copy and paste” mechanism using an RNA intermediate. They composed around 50% of whole human genome. Retrotransposition has been proven as a tumorigenic mechanism in several human cancer cases due to its ability to cause genomic instability. Despite of that high frequency, they are repressed by DNA methylation through the piRNA pathway. The loss of that methylation could cause retrotransposons derepression and further tumor development. In order to analyze a possible role for epigenetic loss of piRNA machinery in seminomas from AIS patients, we performed a methylation analyses using bisulfite modification coupled to pyrosequencing of the 5’ end promoter CpG islands of the main PIWI protein genes (PIWI1, PIWI2 and PIWI4) and of the transposable element LINE-1 (long intersped element - 1) in gonads samples with anatomopathological seminoma from patients with proved AIS (AR mutations: c.2521C>G and c.384_385delGA; both with complete AIS). As control, we used the contralateral gonad of those patients, without any evidence of gonadal tumor. All samples were analyzed in quintuplicate. The methylation status was analyzed using QUMA webtool. The methylation of each CpG island was compared between tumoral versusnon-tumoral gonads. There was a hypermethylation of the PIWI protein genes (1, 2 and 4; p=0.03, 0.001, and 0.01 respectively). RT-PCR of PIWI genes showed a reduced expression of PIWI genes in tumoral samples in comparison with non-tumoral samples (1, 2, and 4; p=0.01, 0.02, and 0.0005 respectively). The opposite (hypomethylation) occurred with LINE-1 sequencing in tumoral samples (p<0.001). PIWI-family genes, together with the piRNAs are able to provoke DNA methylation leading to transposons silencing and genome integrity. In semonima from AIS, the PIWI genes hypermethylation reduced the PIWI genes expression which was related with transposable LINE-1 hypomethylation. These epigenetic alterations suggest LINE-1 as a possible mechanism for testicular tumors in AIS through PIWI/piRNA pathway disruption. As it happened in a context without any androgen action (complete AIS), it’s possible that epigenetic loss is an androgen-independent mechanism. These results open possibilities for further research on treatment based on transposable elements (as reverse transcriptase inhibitors) and for serum markers derivate from LINE-1 proteins and/or RNA.

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