Familial nesidioblastosis as the predominant manifestation of multiple endocrine adenomatosis

Familial Nesidioblastosis as the Predominant Manifestation of Multiple Endocrine Adenomatosis

JAMES E. VANCE, Temple,

M.D.”

Texas

RALPH W. STOLL, M.D.t ABBAS

E. KITABCHI,

Ph.D., M.D.1

KEITH D. BUCHANAN, DANIEL

HOLLANDER,

M.B.P M.D.1

ROBERT H. WILLIAMS, Seattle,

M.D.

Washington

From the Department of Medicine, University of Washington, Seattle, Washington, and the Scott and White Clinic, Temple, Texas. This investigation was supported by U.S. Public Health Service Research Grants AM 024566-09 and AM 05020-13, a United Health Foundation grant, and a grant from the Scott, Sherwood and Brindley Foundation. A portion of the studies were conducted in the University of Washington Clinical Research Center, supported by the National Institutes of Health (Grant FR-37). Requests for reprints should be addressed to Dr. James E. Vance. Manuscript received November 13, 1970. * Present address: Department of Medicine, Indiana University Medical Center, Indianapolis, Indiana 46202. t Present address: Department of Medicine, University of Rochester, Rochester, New York 14627. $ Present address: V. A. Hospital and Departments of Medicine and Biochemistry, University of Tennessee, Memphis, Tennessee 38104. 9 Present address: Department of Medicine, Royal Victoria Hospital, Belfast, Ireland. 1 Present address: Wilford Hall Hospital, Lackland Air Force Base, Texas 78236.

Volume

52,

February

1972

The incidence of endocrine abnormalities in eight members of a family with multiple endocrine adenomatosis was compared with that in five nonrelated subjects with islet cell tumors and in seven normal control subjects. Three members of the family had documented islet cell hyperplasia, adenoma and/or carcinoma associated with hypoglycemia or the Zollinger-Ellison syndrome, and all but one member of the family was found to have hypersecretion of insulin, often associated with elevated blood glucagon and/or gastrin levels. Five members had hyperinsulinism but were asymptomatic, although several demonstrated glucose intolerance. Asymptomatic hypercalcemia and abnormal adrenal function were noted in some subjects. There was no evidence of primary abnormalities in pituitary function or of catecholamine and 5hydroxyindoleacetic acid levels in the family subjects. The nonfamily subjects with insulinoma had no other endocrine abnormalities. In one nonfamily subject, who may also have multiple endocrine adenomatosis, the Zollinger-Ellison syndrome was associated with high blood gastrin and insulin levels with glucose intolerance. It is proposed that the basic genetic defect in the family with multiple endocrine adenomatosis involves hyperplasia of the primordial cell of the islets of Langerhans (nesidioblastosis) with chronic oversecretion of one or more islet cell hormones. Secondary changes in other endocrine glands may then evolve as a consequence of the islet cell hormone excess(es). A high incidence of asymptomatic endocrine abnormalities was found in this and other studies. It is suggested that when abnormal growth or function of one endocrine gland is detected, a careful search for asymptomatic involvement of other glands should be made in the patient and his immediate relatives. Familial

neoplasia

been described

and hyperfunction of endocrine tissues has in the literature in at least two main clinical

211

FAMILIAL

NESlDlOELASTOSlS

-VANCE

ET AL.

patterns: (1) the syndrome of multiple endocrine adenomatosis involving the parathyroids, pituitary, pancreatic islets and adrenal cortex [l], and (2) the association of pheochromocytoma, medullary carcinoma of the thyroid and parathyroid tumors [2]. Steiner et al. [2] proposed that these two entities be referred to as “multiple endocrine neoplasia type 1 and type 2,” respectively. There is also a definite relationship between the ZollingerEllison syndrome and the total spectrum of multiple endocrine adenomatosis [ 1,3-51, and possibly certain forms of the carcinoid syndrome represent variants of multiple endocrine adenomatosis as well [6]. Most of the conclusions regarding the syndrome of multiple endocrine adenomatosis have been based upon reports of the incidence of clinical expression of various forms of the disease. In a comprehensive review of eighty-five cases of multiple endocrine adenomatosis, Ballard et al. [l] defined the disorder as the familial occurrence of multiple tulmors or hyperplasia of the endocrine organs. Most often affected are the parathyroid glands, pancreatic islets and pituitary; less frequent is involvement of the adrenal and thyroid glands. Hormonal overactivity may or may not be associated with the adenomatous glands. A recent study of several generations of both asymptomatic and symptomatic members of a family with multiple endocrine adenomatosis illustrated the frequent presence of asymptomatic hyperparathyroidism and an increasing incidence of manifestations of the multiple endocrine adenomatosis syndrome with age [7]. We have had the opportunity to study the hormonal status of a family with multiple endocrine adenomatosis (type l), and it is our purpose to present in detail the results of this study. In addition, other nonrelated subjects with functional islet cell tumors and multiple endocrine adenomatosis were studied in a similar manner. The most widely accepted theory as to the genetic defect in the multiple endocrine adenomatosis syndrome is that proposed by Wermer [4]. He suggests that the disorder is inherited as a dominant autosomal gene with high penetrance and that the abnormal gene results from a mutation and has a pleiotropic action resulting in a local effect of stimulation of excessive growth of the affected organs without mediation through humoral factors. This traditionally accepted theory of a pleiotropic genetic defect was recently contested by the results obtained in this laboratory in an extensive study of a family with multiple endocrine adeno-

212

matosis [8]. Evidence of widespread pancreatic islet cell dysfunction was found in both symptomatic and asymptomatic members of the family. It was proposed that the disorder may result from a single genetic defect involving the cytogenesis of the primordial cell of the islet, leading to islet cell hyperplasia (nesidioblastosis) and adenomatosis. It was also suggested that chronic overproduction of insulin, glucagon, gastrin and/or other polypeptide hormones by the hyperactive islet cells could then lead to secondary changes in other endocrine glands, resulting eventually in the clinical spectrum of multiple endocrine adenomatosis. SUBJECTS

AND

METHODS

Family with the Syndrome of Multiple Endocrine Adenomatosis. The pedigree of this family with multiple en-

docrine adenomatosis is depicted in Figure 1 (hereinafter referred to as “family”). The diagnosis was originally made after the surgical confirmation of the ZollingerEllison syndrome in one subject (R.H.) and hyperinsulinism with pancreatic islet cell adenomatosis and carcinomatosis in two of his three children (Ei.H. and A.H., respectively). These subjects and their relatives were asked to participate in a study designed to document and follow the functional status of the endocrine glands known to be involved in the multiple endocrine adenomatosis syndrome. A summary of the clinical status of the family members on whom detailed information has been obtained is shown in Table I. A more detailed description of the clinical course of some of the subjects has been reported [8]. R.H. was studied eleven months after undergoing total gastrectomy for the Zollinger-Ellison syndrome. Ei.H. was studied four years after she was shown to have a metastatic islet cell carcinoma. She has been maintained relatively free of hypoglycemic symptoms for four years by the use of oral diazoxide. The current studies were performed while she was receiving therapy and were repeated during temporary cessation of treatment. A.H. was studied at the time of clinical diagnosis of primary hyperparathyroidism and hyperinsulinism, again after undergoing subtotal parathyroidectomy for diffuse parathyroid hyperplasia, and after a total pancreatectomy for multiple pancreatic islet cell adenomas. Unless otherwise stated, the results given for Ei.H. were obtained while she was receiving diazoxide therapy and for A.H. before he was subjected to parathyroid or pancreatic surgery. Other Subjects with Islet Cell Tumors. Four unrelated

subjects with symptomatic hyperinsulinism and one subject with the Zollinger-Ellison syndrome and possible multiple endocrine adenomatosis were also studied in detail (hereinafter referred to as “nonfamily”). Their clinical summaries are shown in Table I. After forty-eight hours of fasting, one subject (W.O.) had an episode of coma associated with hypoglycemia, documented hyperinsulinism, a hypernormal insulin re-

The American Journal

of Medicine

FAMILIAL NESIDIOBLASTOSIS - VANCE ET AL.

ia

c.c. = Colon Ca

1% Q

C.V. A. = Cerebrovascular

~1 MALE

l---l

I

L-J

C.D.

FEMALE

1DECEASED

Figure 1.

Pedigree

= Chronic

D.M.

= Dlabstrs

I **.

=

P. P. = Postporfum Diarrhea

Meltitus

52,

February

1972

S.G. = Subtotal

Gaafrrctomy

T.

= Typhoid

Fever

U.

= Upper G.I. Ulcer

Z.E. = Zolllngrr

I nsullnomo

of family with multiple

sponse to intravenous tolbutamide administration (vide infra) and symptomatic hyperglycemia. Pancreatic surgery was not performed because the symptoms were alleviated by eating regular meals and because the patient had an iieal bladder, created several years ago because of recurrent pyelonephritis secondary to bladder outlet obstruction. One subject (S.B.) had a “diabetic” glucose tolerance curve on several occasions before gastrectomy. His father died following repeated bouts of gastrointestinal ulceration, and his brother had undergone total gastrectomy for similar symptoms, suggesting the familial multiple endocrine adenomatosis syndrome (more detailed clinical summary reported elsewhere [9]). The control subjects were healthy Control Subjects. young men and women of normal body weight and with no family history of diabetes mellitus. Tests were performed with them at bed rest in the University of Washington Clinical Research Center or at the Madigan General Hospital, Fort Lewis, Washington. All subjects were studied in Islet Cell Function Tests. the same manner. They consumed a high carbohydrate diet for three days before study. One or more of the following tests were then performed on different days and in random order in each subject: 100 gm oral glucose tolerance test, 25 gm intravenous glucose tolerance test, 1 gm intravenous tolbutamide test and 1 mg intravenous glucagon test. After an overnight fast, a thin-wall needle was inserted into an antecubital vein and kept patent with a slow infusion of saline solution for the duration of each test. After collecting three control blood samples through the indwelling needle, the subjects were allowed three minutes to consume the oral glucose or an intravenous agent was injected into the opposite antecubital vein over a two min-

Volume

Accidrnf

endocrine

Elllron

adenomatosis

Syndrome

(MEA).

ute period. The timing for the blood collection after administration of the test agent was started upon consumption of all of the oral glucose or at the midway point of the two minute injection. Subsequently, samples were removed from the indwelling needle into heparinized tubes and immediately chilled in crushed ice. The samples were centrifuged at 4”C, and the plasma was separated within two hours of collection and frozen for storage. Plasma for glucagon assay was stored frozen with Trasylol@ (4,000 Kallikrein Inhibitor Units per milliliter of plasma) to prevent degradation of the glucagon during storage and subsequent immunoassay. Plasma insulin levels were measured by a double antibody radioimmunoassay technic [lo] using human insulin (Novo) standards and expressed as microunits of immunoreactive insulin (IRI). Plasma immunoreactive glucagon (IRG) levels were measured by a similar technic developed in this laboratory [ll]. In vitro [ll] studies in this laboratory have suggested that the antibody utilized in this assay detects glucagon of both gut and pancreatic origin but the IRG levels in peripheral plasma probably reflect almost entirely “gut Plasma immunoreactive gastrin (IRGa) glucagon.” levels were measured by Dr. James McQuigan at Washington University in St. Louis, Missouri [12] and Dr. Rosalyn Yalow [13]. The k value for glucose after intravenous glucose administration was calculated by the formula k = 0.693 x 100/t%, and blood glucose was measured by the ferricyanide method [14] using a Technicon Auto Analyzer@. Plasma free fatty acid levels were estimated by a modified Dole procedure [15]. Other Endocrine Tests. The Bioscience Laboratories (Van Nuys, California) performed the following determinations: serum thyroxin, plasma cortisol, plasma immunoreactive growth hormone, twenty-four hour urine

213

FAMILIAL

TABLE

NESIDIOBLASTOSIS

I

-

VANCE ET AL.

Clinical Summary

Age(~0 Subject*

and Sex

Per Cent Ideal Body Weight

Family with Familial M.L.

41,F

L.V.Y. (2)

71,F

D.Ho. (5)

41,F

Course1

Symptoms and Diagnoses Nesidioblastosis

+6

Asymptomatic

(l-l%

+60

Asymptomatic

(2 years)

years)

+32

Asymptomatic

(2 years) (2% years)

E.H. (3)

42,F

+35

Asymptomatic

R.H. (4)

51,M

-36

Zollinger-Ellison syndrome, intermittent hypercalcemia

Relatively asymptomatic postgastrectomy 5 years ago; residual duodenal and pancreatic islet cell tumor tissue (5 years)

Ei.H. (6)

25,F

+28

Islet ceil hyperplasia, adenoma and carcinoma with hepatic metastasis; adrenal adenoma and hyperplasia with hirsutism and adrenocortical hyperfunction; persistent hypercalcemia; intermittent severe hypoglycemia

Relatively asymptomatic on diazoxide treatment for 6 years (19 years)

A.H. (7)

23,M

+27

Hypercalcemia with diffuse parathyroid hyperplasia; asymptomatic hypoglycemia with islet cell hyperplasia and adenomas

Asymptomatic thyroidectomy tectomy; diabetes

postsubtotal paraand total pancrea-

stable surgically induced mellitus on insulin

therapy; no evidence of malabsorption with pancreatic enzyme replacement therapy (4 years) K.F. (8)

20,F

-10

Asymptomatic intermittent hypercalcemia

(5 years)

Other Subjects with Islet Cell Tumors P.R.

40,M

+12

Symptomatic hypoglycemia, single islet cell adenoma; duodenal ulcer and hypertrophic mucosal folds on x-ray series of upper gastrointestinal tract

Asymptomatic postsubtotal pan. createctomy and removal of islet cell adenoma (2 years)

W.O.

17,M

+12

Symptomatic hypoglycemia, ileal bladder for bladder neck obstruction; insulinoma (based on tests)

Asymptomatic on high carbohy drate diet with frequent feedings (5 years)

McC.

52,F

Symptomatic hypoglycemia, cell adenoma

Asymptomatic after removal single islet cell adenoma

S.B.

51,M

islet

of

(1% years)

M.B.

72,M

+14

+2

Recurrent duode?al ulceration; Zollinger-Ellison syndrome with islet cell carcinoma; renal calculi; family history of multiple upper gastrointestinal ulceration; history of “mild diabetes”

Relatively asymptomatic after total gastrectomy; residual pancreatic and extrapancreatic islet cell adenomas and carcinoma

Symptomatic hypoglycemia; cell adenoma

Asymptomatic after removal of single islet cell adenoma and peripancreatic islet cell tissue

islet

(1% years)

(1 year) * Figures in parentheses f Figures in parentheses

214

indicate subject number in previous represent years of follow-up.

report 181.

The American

Journal

of Medicine

rAl\rlLIAL

900

Plasma IRG p

NESIDIOBl.4STOSIS

--

VANCE

ET

AL

.-k

1 450

p9hl 0 ..

80,

I

Plasma IRI 40 p

Figure 2. Fasting blood levels of immunoreactive glucagon (IRG), insulin (IRI) and glucase. Subjects’ initials are indicated along the lower line, with family subjects with multiple endocrine adenomatosis

in circumscribed

area.

U/ml o

Blood I50 Glucose 75

mg% 0

__-__ /MLLV

catecholamines and 5-hydroxyindoleacetic acid. The cortisol and aldosterone secretory rates were determined by double isotope derivative methods by the New England Nuclear Corporation (Worcester, Mass.). The twenty-four hour urinary 17.ketosteroids were measured by the Peterson modification [16] of the technic of Callow et al. [17] and the 17.ketogenic steroids by the method of Rutherford and Nelson [18]. The glucose area response Expression of Results. curves were calculated as described by Bagdale et al. [19], and the results are expressed as arbitrary Area Response Units. In all of the parameters studied, an abnormal response is defined as one that is greater or less than 2 standard deviations (SD) of the mean normal response.

DHo

EH

RH

EiH

AH

KF1

PR

WO

McC

SB

MB

Intravenous glucose tolerance test: The individual responses to intravenous glucose administration in the family members is shown in Figure 3 and the k value for glucose disappearance in Figure 4. There was no consistent change in IRG concentrations but all subjects except Ei.H. demonstrated an exaggerated IRI response. E.H. had only one slightly elevated IRI level ten minutes after glucose administration, and this was associated with

RH --._ E ” -

Ati

--

7

LVY ct.

..__

!

D ti -KF --

ML

RESULTS Fasting blood values: Islet Cell Function Studies. Individual and mean fasting values for each subject are shown in Figure 2. The shaded area depicts the mean fasting values of control subjects 12 SD as follows: immunoreactive glucagon (IRG) 222 -+ 330 mErg/ml (thirty-nine determinations in seven subjects), immunoreactive insulin (IRI) 16.5 t 25 ,IU/mI (101 determinations in eighteen subjects), glucose 76 it 27 mg/lOO ml (sixty determinations in twelve subjects). One family subject (A.H.) had fasting hyperglucagonemia. Two family subjects (Ei.H. and A.H.) and one nonfamily subject (W.O.) had fasting hyperinsulinemia. Fasting hypoglycemia was consistently observed in only one family subject (Ei.H. off diazoxide, Figures 11 and 12) and one nonfamily subject (P.R.). Note that A.H. had had elevated fasting IRG, IRI and IRGa levels (Table IV) with inconstant fasting hypoglycemia.

Volume

52,

February

1972

.-_____ -17

0

---I

30 Minutes

60

0

30

60

Minutes

Figure 3. Plasma hormone and glucose response curves of family subjects with multiple endocrine adenomatosis after a 25 gm intravenous glucose tolerance test. Subjects with surgically proved islet cell tumor(s) are depicted on the left.

215

FAMILIAL

NESIDIOBLASTOSIS

-

VANCE ET AL.

6Ly

OK

IV G.T T

u3

Value

3. I

0. 50

q Glucose Area

*

25 z

Figure 4. Glucose disappearance k value after intravenous glucose tolerance test (IVGTT) and area response units for

0

E zt-3

25IV

tg

3

GLUCAGON l

*

l

*

m

5o

4 @ 4

IV

IRI and glucose curves oral glucose tolerance (oral GTT), intravenous

* n

r-Y

O-==C’n-n-b

:

Area

+

Y

l

IRI

-470

0

TOLBUTAMIDE

cagon (I.V. glucagon) and intravenous tolbutamide (I.V. tolbutamide). Asterisk signifies response which is greater or less than 2 standard deviations ‘of the mean control values. Control response bars represent the mean -t2 standard deviations of seven subjects.

IRI Area

25

0

I CONTROL ML

LV

DHo.

3.0

R,H .,‘..._,

Plasma 2.0 [RG

mpg/ml

”

I,0

i

-

---‘Y.,,, ‘...,

E.H AH

EH

RH

EiH

AH

1.

KF

PR

WO

McC

SB

l-

--,

____

L”” EH D,,

-

__

I.5

K F .__M,L

Plasma IRG mug/ml

.. L-

1.0

..

.:.

0.5

:

Plasma IRI p/ml

.....

0

:.,

ulJ/ml

100

&

0

.

I__ ! f

.

‘::’

RR. 10 kc

-.-.-._.

s,a

--..-_

M.&

A

.. .. .. . . ....

i 7-G > :

‘\.\

‘,_

.x.-l_

.. ... . ...

,I\< r--. 1, ,’

I? ..

200

_______.

. . ..

300

Plasma IRI

after test glu-

b’ .::

60

0

60 120 Minutes

180

0

120 60 Minutes

180

Figure 5. Plasma hormone, glucose and free fatty acid response curves of family subjects after a 100 gm oral glucose tolerance test. Subjects with surgically proved islet cell tumor(s) are depicted on the left.

216

o-

0

60

120

I80

Ok----.60

120

I60

MlllUfe~

Figure 6. Plasma hormone and glucose response curves of nonfamily subjects with islet cell tumors after a ZOO gm oral glucose tolerance test (left) or a 1 gm intravenous tolbutamide test (right).

The American

Journal

of Medicine

FAMILIAL

TABLE

II

to Islet Cell Stimuli in Control

Responses F

15 min

30 min

309 i 320 17 * 22 73i 30

350 i- 240 38 i 36 99i- 22

45 min

2 min

F

357 x!z268 57 f 28 122 + 38

5 min

60 min

436 i 424 54 i 36 113 i 44

15 min

-

VANCE

ET

AL.

Subjects

Oral GlucoseTolerance IRG IRI Glucose

NESIDIOBLASTOSIS

150 min

_.__.~.__

180min

Test

369 i 350 49zt 32 107 & 28

30 min

120 min

90 min

45 min

336 _t 280 35 f 30 95 i 30

60 min

321* 302 37 f 30 89* 42

322 i 274 36 i 36 85 * 42

328 xt 258 29f 42 77 f 40

90 min

120min

150min

180 min

13 i 12 67 i 26

9&8 70 f 8

10 & 6 69 f 16

11 i 12 72 + 12

IntravenousGlucagonToleranceTest 12i8 74* 20

IRI Glucose

44+x54 8Oi 26

52i44 42zt42 92xt 10 114 zt 16

311 40 102 h 30

34 ZII16 85 i- 26

14 f 20 75 f 26

IntravenousTolbutamideTolerance IRG 126zt 126 100f 60 100f 28 193z-t318 138zt 72 133* 112 IRI 15 f 18 55& 54 67i 60 42i 32 21-1 21 32 f 11 Glucose 82 & 27 77zt 23 741t 20 62i- 19 60 f 19 57 I!=15 NOTE:

IRG

valuesgiven

=

immunoreactive in mg/lOO

glucagon,

values

given

in ppg/ml.

III

Subject Control* M.L. L.V. D.Ho. E.H. R.H. Ei.H. A.H. K.F. P.R. W.O. McC. S.B. M.B.

Timeand

Magnitudeof

IRI = immunoreactive

insulin,

173 f 182 11 f 12 67 z!z13 values

145 i 150 151f 148 10 z!=8 12 f 14 72 i 16 70 f 14

given

in pU/ml.

Glucose,

The areas circumscribed by the IRI and glucose response curves after the oral administration of glucose were calculated and compared with those in control subjects (Figure 4). Six of eight family and two of three nonfamily subjects tested had an excessive plasma IRI response to the oral administration of glucose. The excessive IRI responses were associated with increased glucose area responses in five of the family and both of the nonfamily subjects. One subject (D.Ho.) had an excessive glucose response associated with a normal IRI response whereas the reverse was seen in another (Ei.H.) during diazoxide therapy.

PeakResponses

Oral Glucose Tolerance Test

Intravenous Glucagon Tolerance Test

Peak IRI

Peak IRI

Minutes 30-45

Minutes 60 i

(150) (120) 30 30

(305) (264) (500)

(1;:)

(135) (315) (428) (100)

28

(3::)

(ii) 15-120

... (60)

“’ (289) (324)

(90)

NOTE: *Time

Figures in parentheses indicate of peak control response given

Volume

52,

February

209 i 328 13+ 8 64 zt 15

ml.

a high k value. The k value was low in Ei.H. while she was receiving diazoxide therapy. Oral glucose tolerance test: Figures 5 and 6 depict the results of oral glucose tolerance tests in the family and nonfamily subjects, respectively. Responses of the control subjects are shown in Table II. A rise in plasma IRG levels was demon strated in three family subjects (R.H., A.H. and D.H.) and in the only nonfamily subject who was so studied (McC.). Plasma free fatty acid levels were measured in the family subjects and fell as expected in response to oral glucose administration (Figure 5). TABLE

Test

... 22* 30 59* 12

1972

2-30

pU/ml

2-5 2

72 zt 46 100

30-45

(200) (183) (148) (182) (434) (462) (236) 77

(ii) 30 45

...

2 5 5 2 2 2 2 2

(141) 40

5 2 2 5

67 f

5 2

(200) (350)

32

(1:;)

2 15

(5::)

5

(185)

...

Nadir

Minutes

#ml

(142)

15 30

Glucose Peak IRI

5

5

Intravenous Tolbutamide Tolerance Test

abnormal response. as the range in minutes

(mean

+2

Minutes

mg % 49 *

38 :t 26

(34)

48 38

(;;)

(65) 60

(31)

180 Minutes % Fall 13 zt 24 0 22 15 (:$

(Z)

(216) 100

(1::) 45 45 30 45 30

(154) (248)

(90) (180)

(Z)

standard

14

% Fall

(30) 39 21 35

(25)

(Z) 55 47 38 58 48

(83) 35 22 18 32 9

(Z)

deviations).

217

FAMILIAL

NESlDlOl3LASTOSlS

-

”

.,

-___ -

VANCE

ET AL.

-.-LV,Y ---E.H D.H -KF __..__M,L

R.H. E”

AH.

Plasma IRI plJ/ml

1

50 0

1601

0’

160

r_

I

0

60

Minutes

120

’

160

1

O+r-z-xT

I80

Minutes

Figure

7. Plasma /RI and glucose response curves of subjects after a 1 mg intravenous glucagon tolerante test. Subjects with surgical/y proved islet cell tumor(s) are depicted on the left. family

The peak (or maximum) IRI response to the oral administration of glucose and the time at which it occurred in each subject are shown in Table III. Excessive peak IRI responses were observed in seven of the eight family subjects, and the time of the peak was delayed beyond the range of the control subjects in four of these seven. All three nonfamily subjects tested had excessive peak IRI responses, with a delayed onset in two of them. The oral glucose tolerance test was the only test that elicited an excessive peak IRI response in P.R. and S.B. intravenous glucagon test: The IRI and glucose responses to intravenous glucagon administration in the family subjects are shown in Figure 7. A.H. was the only one who failed to show an initial rise in blood sugar levels, and forty-five minutes after starting the test his blood su#gar level fell to 17 mg per cent. The hypoglycemia was asymptomatic except for emotional irritability. The IRI area responses for all subjects tested are shown in Figure 4. All but one (E.H.) of the family subjects had an excessive IRI response. Of the two nonfamily members whose area responses could be calculated, one had an excessive response (W.O.) and the other had a net negative area response (McC.) due to a fall in IRI values below the mean fasting level during the majority of the three hour test (curve not illustrated). The time and magnitude of the peak IRI response to the intravenous administration of glucagon are shown in Table III. Of the family subjects all but two (E.H. and Ei.H.) had excessive peak IRI

218

responses and one of the two nonfamily subjects (W.O.) responded excessively. The time of the IRI peak was normal in all subjects. Intravenous tolbutamide test: The IRG, IRI and glucose responses to intravenous tolbutamide administration in the family subjects are shown in Figure 8 and in nonfamily subjects in Figure 6. A rise in IRG levels was seen in two of the six family subjects (R.H. and A.H.) and in one of the two nonfamily subjects (P.R.) in whom IRG levels were measured. The IRI area response curves after intravenous tolbutamide administration are illustrated in Figure 4. Six of the eight family subjects and two of the four nonfamily subjects who were studied had excessive IRI responses. Table III illustrates the peak IRI and glucose responses to intravenously administered tolbutamide. In comparison with control subjects, seven of the eight family subjects studied had excessive peak IRI responses to the intravenous administration of tolbutamide. Only two of the four nonfamily subjects with insulinomas had excessive peak IRI responses, and the nonfamily subject with the Zollinger-Ellison syndrome (S.B.) had an increased response. The nadir of the blood glucose response, expressed as the per cent fall from the mean fasting RH, ___..E”

-

A H.

4.0

-----

LVY E.H

DH K.F . . . . ML

3.0 2.0 i

500 400 300

, -7 I ‘---, ‘\ 2001 ; ‘,,,,/--I 50 !‘.

Plasma IRI uulml 1oc

50

:,., lb

\;

100 ‘,...

50 1

‘....

OA 160

O5i--xAT

180

Mmutes

Plasma hormone and glucose response curves Figure 8. of family subjects after 1 gm intravenous tolbutamide test. Subjects with surgically proved is/et cell tumor(s) are shown on the left.

The

American

Journal

of Medicine

FAMILIAL

level, is also listed for each subject in Table III. An excessive absolute and/or per cent fall was seen in five of the family and two of the nonfamily subjects, the absolute change being abnormal more often than the per cent fall in blood sugar. The nadir of the blood glucose response to intravenous tolbutamide administration was observed by forty-five minutes in most subjects, although blood sugar levels progressively fell throughout the test in two (E.H. and M.B.). By the three hour point in the test, blood sugar levels had returned to within 37 per cent of the fasting level (mean normal +2 SD) in six of eight family and four of five nonfamily subjects. Effect of pancreatic surgery: Three subjects (A.H., P.R. and M.B.) were studied before (preop.) and after (postop.) surgical removal of their insulinoma (Figures 9 and 10). A.H. underwent subtotal parathyroidectomy and eight weeks later total pancreatectomy, subtotal gastrectomy and duodenectomy because of the existence of multiple adenomas throughout the pancreas. He was in good health receiving maintenance long-acting insulin and oral pancreatic enzyme replacement therapy at the time of the study after pancreatic surgery. At least six weeks were allowed for full recovery from surgery before retesting. Plasma 3’o1A

H ,,,,* j\

jPR

IRG j A& 1

v.u / ml

._;__~_;‘._..;._..;

-

PRE-OP.

___ POST-OP.

Plasma 3001A.H. h

Blood

4001A,H,

1P.R

.:‘?,

O+-z-0

120

Minulrl Figure 9.

1P.R.

,Y

IBO

%Ti-z-

180

Mhute9

Response curves after a 100 gm oral glucose tolerance test given before (.preop.) and after (postop.) surgical removal of an islet cell tumor(s). Subjects’ initials (A.H. and P.R.) are shown in upper left corner. A.H. underwent total pancreatectomy, duodenectomy and subtotal gastrectomy.

Volume

52,

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1972

NESIDIOBLASTOSIS

A.H.

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ET

AL.

RR.

Response curves after a 1 gm intravenous tolFigure 10. butamide test before (preop.) and after (postop) surgical removal of an islet cell tumor(s). Subjects’ initials are shown

in the upper right corner.

Following subtotal parathyroidectomy in A.H., serum calciulm levels returned to normal and remained normal throughout the one year postoperative follow-up period prior to this report. However, the abnormal fasting blood IRG, IRI, IRGa and glucose levels remained essentially unchanged after parathyroidectomy (results not illustrated). Total pancreatectomy in A.H. resulted in a fall in mean preoperative f’asting IRG levels of 0.770 to 0.130 mpg/ml postoperatively. Plasma IRG levels in P.R. dropped from a mean of 0.310 to 0.150 mpg/ml after removal of approximately half of the distal pancreas containing a solitary islet cell adenoma. Mean fasting IRI levels could not be properly evaluated in A.H. after surgery, but the pre- and postoperative values in P.R. were 26 and 10 ,JJ/ml and in M.B. 16 and 13 ,_U/ml, respectively. Mean blood glucose concentrations rose postoperatively in A.H. from 56 to 163 mg per cent, in P.R. from 44 to 83 mg per cent, and in M.B. from 92 to 104 mg per cent. The results of pre- and postoperative oral glucose tolerance tests are depicted in Figure 9. The rise in IRG levels seen in A.H. preoperatively was greatly increased during the test after pancreatectomy. Pancreatectomy virtually abolished the IRI response and led to a diabetic type of blood glucose curve. Preoperative IRG levels after oral glucose administration were not measured in P.R., but the postoperative IRI response was slightly diminished, and there was essentially no change in the blood glucose curve.

219

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NESlDlOBLASTOSlS

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I501

VANCE ET AL.

3.01

Minutes

Minutes

Figure 11. Effect of diazoxide treatment on the response to a 100 gm oral glucose tolerance test in ELH.

Figure 10 illustrates results of the pre- and postoperative intravenous tolbutamide tests. The rise in IRG levels noted preoperatively was not seen postoperatively in A.H., and there was no IRG response in P.R. before or after surgery. The rise in IRI levels and the fall in blood glucose levels were diminished in all three subjects tested; no IRI or glucose response was observed after pancreatectomy in A.H. Histologic examination of the islet cell tumors by light microscopy revealed no cellular distinctions between the tumors from family and nonfamily subjects. However, the three family subjects and the one nonfamily subject with multiple endocrine adenomatosis all had multiple pancreatic adenomas, islet cell hyperplasia and extrapancreatic extension of their tumor. By electron microscopy (courtesy of Dr. Raymond Pictet) a tumor nodule from A.H. was found to have three different 3.0

....

IRG '.' vg/ml1.0

-

on dlozoxlde off diazoxlde

0 6007

I RI IL”,m’

150

--a...._*

40 200

‘b

i:

0’ ,

‘t

‘*..._. . ..__ ______

-i

I

Mmules

I

1 i,

1

ya ..

%. ..*__..._._---.--.

0+

MlIlUkS

Figure 12. Effect of diazoxide treatment on the response to a 1 gm intravenous tolbutamide test (left) and a 1 mg intravenous glucagon test (right) in Ei.H.

220

cell types as determined by the appearance of the granules in each cell (not illustrated). Effect of diazoxide: Ei.H. was first studied while receiving diazoxide, 300 mg orally every six hours. She had been treated with diazoxide almost continuously for four years (the results of initial therapy have been reported previously [20]). Treatment was stopped abruptly, and twenty-four hours later the oral glucose tolerance test was repeated, followed on consecutive days by the intravenous tolbutamide test and the intravenous glucose tolerance test. The patient remained asymptomatic during the three days she did not receive diazoxide, except for transient unconsciousness during the intravenous tolbutamide test which was promptly abolished with the intravenous administration of 50 per cent glucose. Mean fasting values before and after discontinuance of diazoxide were as follows: plasma IRG 0.113 and 0.480 rnpgl’rnl, plasma IRI 41 and 109 &j/ml, blood glucose 114 and 56 mg per cent, and free fatty acids 1.85 and 0.85 pEq/ml. The results of the oral glucose tolerance test during diazoxide therapy and after it was stopped are shown in Figure 11. Plasma IRG levels remained essentially unchanged during both tests. The plasma IRI response was slightly greater during treatment, although the level dropped to 68 &j/ml at 180 minutes while the patient was receiving the drug and rose to 142 $J/ml at 180 minutes during the test when treatment was stopped. Blood sugar and free fatty acid levels were consistently higher while the patient was taking diazoxide, but abnormally elevated blood sugar levels during the latter part of the oral glucose tolerance test persisted during the second test when she was not taking the drug. Figure 12 shows the effect of diazoxide on the intravenous tolbutamide and glucagon tests. There was no IRG response during either test, and plasma IRI responses when the patient was receiving the drug and when she was not were quantitatively similar. Blood glucose levels fell progressively throughout the intravenous tolbutamide test during diazoxide therapy and rose in almost identical patterns after the intravenous administration of glucagon during diazoxide therapy and after its discontinuance. The mean fasting blood sugar level before the intravenous tolbutamide test and after discontinuance of diazoxide was 18 mg per cent and was associated with no symptoms. At fifteen minutes the subject became sleepy, and the blood sugar level had dropped to 11 mg per cent. She

The American

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FAMILIAL

TABLE

Serum Gastrin

IV

~~

Levels and Gastric Secretory

ControlS

_

M.L. D.Ho. E.H. R.H. Ei.H. A.H. Preop. Postop. K.F. P.R. W.O. S.B.7 ._ ___ __

(w/ml)

M F F F F M F M

425 k

272

Total Hydrochloride Basal

ET

AL.

(2;:)

(2,300) (1,175)

(106)

(1lON

(977)

(mEq/hour) Maximal

2.1 1.4 0 0.85 1.20 (25.50) 2.40 (13.30)§

79 65 0 50

(1.259) 426

38.33 AL 27.2

20.90 8.60 (72.60) 18.40 41.04

660 631

F M M M

VANCE

Response to Histalog*

Basal Volume (ml/hour)

IRGaf Sex

-

Studies Gastric Secretory

Subject

NESIDIOBLASTOSIS

(i.10)

1.7 36.00

(7:: to,

(7:. 23)

(1::) (178) (400)#

(458)

NOTE: Figures in parentheses indicate abnormal response. * 1.5 mg/kg body weight injected subcutaneously. t Measured by Dr. James McGuigin. Control expressed as mean 12 standard deviations. $ From Moore and Scarlata [62] and Laudano [63]. Expressed as mean f2 standard deviations. $ Measured three years prior to present studies. 7 From Dyck [9]. # Measured by Dr. Rosalyn S. Yalow (normal <200 ppg/ml).

then lapsed into coma, associated with a blood sugar level of 14 mg per cent at twenty minutes, at which point glucose was given intravenously and the patient promptly returned to full consciousness. Serum Gastrin Levels and Gastric Secretory Studies. Serum gqstrin levels: Fasting serum IRGa levels were elevated in four of the six family subjects who were studied and in the nonfamily Endocrine

TABLE V

subject with proved Zollinger-Ellison syndrome (S.B.), as shown in Table IV. The level remained elevated (851 ,upg/ml) after subtotal parathyroidectomy (not illustrated) but returned to normal after total pancreatectomy in A.H. The results of the gasGastric secretory studies: tric secretory studies are also shown in Table IV. Basal gastric secretory volumes were markedly elevated in both the family (R.H.) and nonfamily sub-

Function Tests Adrenal Function Urine Steroids (W24

Subjects Control M.L. L.V.Y. D.Ho. E.H. R.H. Ei.H. A.H. K.F. P.R. W.O. McC. S.B. M.B. NOTE:

Volume

52,

Catecholamines

7-17

6-22

10-30

50-250

103

.. ..,

... ...

... ...

... ...

...

9.3 7.2 8.4 16.2 18.5 13.6

9.2 10.3 5.3 14 18.6 16.8

10.2 14.5 25.6 18.6

107.8

...

... ...

41 42 18 84 87 77 40 ... ...

1972

(W24

(40) 12.4 (34)

... ... ..

... indicate

hr)

abnormal

(@I24

hr)

... ... (427.3) (313.8) 213 205.9

... ... ...

Parathyroid Function

Urinary

17.KS

in parentheses

February

Aldosterone Secretory Rate

17.KGS

. .

Figures

Cortisol Secretory Rate

hr)

(W24

hr)

..

Serum Calcium (mg/lOO ml)

Serum Phosphate (mg/lOO ml)

9-11 9.3 9.6 9.4 9.3

3.5-4.8

9-(12) 10.5-(11.5) 11.9-(12.2) 9.4-(11.2) 10.3 10.7 ... 9.5 9.0

.. 3.1 2.5 (2.$:.2 (2.6) (1.5-2.6) (1.9)-4.0 3.5 3.6 . .. (2.6)

response.

221

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NESIDIOBLASTOSIS-VANCE

ET AL.

ject (S.B.) with the Zollinger-Ellison syndrome and slightly increased in subjects Ei.H., A.H., K.F., P.R. and W.O. The two subjects with the Zollinger-Ellison syndrome had extremely increased basal and maximal gastric acid secretion, but only the basal levels were elevated in subjects A.H., P.R. and W.O. Other Endocrine Tests. Table V lists the results of the other endocrine tests that were performed in each subject. Adrenal function studies: Plasma and urine adrenal cortical hormone levels were normal in all subjects tested, but Ei.H. did not have a normal diurnal variation in her plasma cortisol levels (not illustrated). An increased aldosterone secretory rate was observed in Ei.H. and A.H. The clinical significance of this observation is unknown since both subjects had normal blood pressures and serum electrolytes. Twenty-four hour urine catecholamine levels were normal in all subjects. Parathyroid function tests: Intermittent hypercalcemia was discovered in four family subjects. In A.H. this progressed to sustained hypercalcemia with hyperparathyroidism secondary to diffuse parathyroid hyperplasia. S.B. had a history of renal calculi, but hypercalcemia was not noted during these studies, although his twenty-four hour urine calcium excretion was slightly increased. Four subjects had hypophosphatemia. Serum alkaline phosphatase levels and roentgenograms of bone were normal in all subjects tested (not illustrated). Miscellaneous endocrine tests: Plasma growth hormone, serum T4, roentgenograms of the sella turcica and twenty-four hour urine 5-hydroxyindoleacetic acid levels were all normal (not illustrated). COMMENTS The results of a comprehensive evaluation of the endocrine status of eight members from three generations of a family with multiple endocrine adenomatosis were compared with a similar study of five unrelated subjects with functioning islet ceil tumors. The diagnosis of multiple endocrine adenomatosis in the propositus (Ei.H.) and her immediate relatives was well documented. The predominant pathologic process was shown to be dysfunction and neoplastic growth of the islets of Langerhans. Except for the mother (E.H.) of the propositus, all other kin were found to have overproduction of one or more islet cell hormones. Parathyroid and adrenal abnormalities occurred with less frequency. The family pedigree (Figure 1) depicts the frequent history of ulcer disease in the paternal relatives of the propositus. The pa-

222

ternal grandfather and one of his brothers (father of M.L.) both died at an early age of severe recurrent upper gastrointestinal ulcer disease and presumably both had the Zollinger-Ellison syndrome. The paternal grandmother had hyperinsulinism which may have been due to her obesity (+60 per cent ideal body weight, Table I). The pattern of expression of laboratory and clinical evidence of endocrine disease in this family confirms previous reports of autosomai dominant inheritance with high penetrance [1,7]. Of the seven relatives with islet cell hormone overproduction, only two had symptoms which suggested organic disease-the proljositus had hypoglycemic seizures and her father had the Zollinger-Ellison syndrome. A.H., who had elevated fasting circulating giucagon, insulin and gastrin levels with hypoglycemia, hypercalcemia and excessive gastric acid secretion, suffered only from lethargy and emotional instability. The demonstration of the abnormal laboratory values alone led to the surgical diagnosis of parathyroid hyperplasia and multiple islet cell adenomas and hyperplasia. Likewise, two subjects (D.Ho. and Ei.H.) had elevated serum gastrin levels with normal gastric analysis. In contrast, ail four nonfamily subjects with insulinoma who were studied had symptoms which suggested the diagnosis. However, two nonfamily subjects had normal insulin responses to one or more islet cell function studies (P.R. and McC.). McC. had a hypernormal IRI response to the oral intake of glucose and a slightly increased response to the intravenous administration of glucagon. Symptomatic hypoglycemia developed during a three day fast. P.R. had a normal IRI response to all stimuli but a diagnostic blood glucose response to the intravenous administration of tolbutamide and fasting hypoglycemia. The fall in mean fasting IRI levels from 26 FU/ml preoperatively ,to 10 jkU/ml postoperatively suggests that the preoperative levels were inappropriately elevated in this subject, especially when associated with a low blood sugar concentration. S.B. had symptomatic Zollinger-Eliison syndrome and presuimabiy multiple endocrine adenomatosis, but there were no associated symptoms of hypoglycemia associated with the hyperinsulinism demonstrated in these studies. A similar observation of asymptomatic endocrine disease in a carefully studied family with multiple endocrine adenomatosis was reported by Johnson et al. [7]. They discovered no clinical evi-

The

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NESIDIOBLASTOSIS

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ET

AL.

dence of disease in any subject less than eighteen years old 3nd found the clinical and biochemical

tence ot a markedly elevated IRG response to oral glucoG,e adn:inistration postoperativeij, is com-

manifestations of abnormalities to increase with age. Our asymptomatic patients with abnormal Islet cell function tests may or may not have been in a preclinical stage of the disease. Glucose intolerance has been noted previously In subjects with irtsulinoma [Zl]. Abnormal blood sugar responses were observed in response to the oral administration of glucose in seven of eight family and nonfamily subjects with hyperinsulinism (Figures 4, 5 and 6). However, in each of these seven subjects the magnitude of the blood glucose response to totbutamide was normal, and of the five who were tested, all had a normal k value for glucose disappearance after the intravenous administration of glucose. These latter results imply that insulin resistance was not a significant factor in causing the glucose intolerance. Activation of counter-regulatory mechanisms in response to prolonged or repeated bouts of hypoglycemia would be expected in subjects with insulinoma, including hypersecretion of glucagon, growth hormone, glucocorticoids and catecholamines. Yet none of our subjects was found to have evidence of elevated growth hormone or catecholamine levels, and only two subjects (Ei.H. and A.H.) had increased cortisol secretory rates. Goldsmith, Yalow that a and Berson [221 recently demonstrated large percentage of the IRI in a patient with an insulinoma was composed of “big insulin” (presumably proinsulln). Hypersecretion of proinsulin, with its relatively high immunoreactive and low biologic potency compared with insulin [23], could account for the glucose intolerance after oral glucose admznistration in our subjects. Another possible explanation is offered by the finding of a delayed peak IRi release in five of the subjects. Glucose intolerance has been found in association with delayed IRI release in subjects with adultonset diabetes ilnd hyperinsulinism [24]. Subjects with glucagon-secreting alpha cell tumors have had glucose intolerance [25-271, but the role of the glucagon excess in our subjects could not be ascertained. A total pancreatectomy, duodenectomy and subtotal gastrectomy was performed in A.H. because of impending common bile duct obstruction by one of the large islet cell tumors in the immediately adjacent pancreas. Blood levels of IRG, IRI and IPGa were elevated preoperatively and returned to normal after surgery, suggesting that they were all secreted by the tumor. The persis-

patible with our previous observation [28; that a mater~al with glucagon-like immunnreactivity (Gl_I) is released from the gut during the oral glucose toierance tes!, We have also shown previously that GLI release is augmented by subtotal gastrectomy [29], and this may explain the abnormal IRG response in R.H. who was studied after total gastrectomy. The increased IRG levels during the oral glucose tolerance test in A.H. preoperatively and in D.Ho, may also be due to excessive release of “gut R.H. and A.H. (preop.) were the only glucagon.” subjects who showed an IRG response to tolbutamide. This response was abolished after pancreatectomy in A.H., confirming our previous observation in dogs that the IRG response to tolbutamide is of pancreatic origin [30]. Four of the seven family subjects in the genetic line of transmission showed evidence of hypersecretion of more than one islet cell hormone: D.Ho.: IRI, IRGa and possibly IRG. R.H.: IRI, IRGa and IRG. Ei.H.: IRI and IRGa. A.H.: IRI, IRGa and IRG. One nonfamily subject (S.B.) showed hypersecretion of IRI and IRGa. The family history of multiple gastrointestinal ulcerations in his brother and father, and the past history of renal calculi suggest that this subject also has multiple endocrine adenomatosis. P.R. had a duodenal ulcer and high gastric acid levels prior to removal of his insulinoma, and he may have had hypersecretion of gastrin, although these levels unfortunately were not measured. Secretion of more than one islet cell hormone by islet tumors has been reported by others [5,31-331. These tumors can also secrete other substances in addition to islet cell hormones, including serotonin [34], ACTH and MSH [35], and possibly an unknown hormone which causes severe diarrhea [36]. We did not detect evidence of excess secretion of nonislet cell hormone in our study. At the time of this study Ei.H. had received diazoxide for four years, and hypoglycemic symptoms were effectively prevented during this interval. The fasting IRI and glucose levels when she was receiving diazoxide and when she was not during the present studies are quite comparable to the levels at the time of initial therapy four years previously [20]. However, the free fatty acid levels were considerably higher at the time of the present studies. Apparent depression of fasting IRG levels by diazoxide was noted in the current evaluation,

Volume

52.

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1972

an effect

which

has not been

reported

previously.

223

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VANCE ET AL,

Even though the IRI responses during the various stimuli (Figures 11 and 12) were essentially unaffected by cessation of diazoxide therapy, the glucose responses were definitely altered. A similar observation was recently reported [37] in a patient with insulinoma who when given diazoxide exhibited depressed basal IRI levels but increased IRI responses to oral glucose administration. These observations support previous speculation that chronic diazoxide administration may impair glucose tolerance in ways other than inhibiting insulin secretion [38]. In addition to the high incidence of islet cell hyperfunction in this family with multiple endocrine adenomatosis, evidence of abnormalities of other endocrine glands was also found. Four of the eight family subjects had intermittent hypercalcemia (Table V) and one (A.H.) had diffuse parathyroid hyperplasia. There were no associated bone changes on roentgenograms or renal abnormalities in any of the subjects. No evidence of nonislet endocrine abnormalities was found in the nonfamily subjects. S.B. had presumptive multiple endocrine adenomatosis, and the history of renal calculi may have been associated with intermittent hypercalcemia and hypercalciuria which was not detected at the time of these studies. It appears from these observations that nonislet endocrine dysfunction is not regularly associated with functioning islet cell adenomas unless the subject has also inherited the basic defect in multiple endocrine adenomatosis. The basic mechanism for the pathogenesis of multiple endocrine adenomatosis is unknown. Wermer [4] proposed that the syndrome evolves from the inheritance of a pleiotropic genetic defect which directly stimulates cell growth in each of the glands. We evolved another hypothesis in our initial report of the abnormal islet function studies in this family [8], suggesting that the basic genetic defect involved primarily an overgrowth of the cells of the islets of Langerhans. Other endocrine gland dysfunction, it was proposed, results second’arily from chronic hypersecretion of one or more islet cell hormones. The basis for this hypothesis was the sequence and magnitude of islet cell dysgenesis and dysfunction in the propositus of this study and the demonstration of overproduction of one or more islet cell hormones in all of her siblings and paternal relatives who were studied. The concept that chronic hypersecretion of islet cell hormones may lead to secondary changes in

224

other endocrine glands is supported by the following reasoning. Glucagon is known to induce hypocalcemia [39], an effect which may be due in part to its direct calcitonin-releasing properties [40]. Parathyroid hyperplasia may result from calcitonin excess, as svggested by the association of parathyroid hyperplasia with calcitonin-secreting medullary carcinoma of the thyroid [41]. The observation that long-term glucagon administration will induce parathyroid hyperplasia [42] and the association of alpha cell hyperplasia with hyperparathyroidism [43] suggested to Paloyan et al. [43] that sustained elevation of circulating glucagon may lead to parathyroid hyperplasia and adenoma formation. This sequence of events may have occurred in A.H. of the present study, since he had islet cell hyperplasia and adenomas containing alpha cells and extractable IRG, hyperglucagonemia and parathyroid hyperplasia. The sustained elevation of basal IRG, IRI and IRGa levels after parathyroidectomy indicates that parathyroid hormone and/or hypercalcemia were not responsible for the hypersecretion of islet cell hormone. We propose that hyperglucagonemia due to islet cell hyperplasia may lead to hypocalcemia, in part due to calcitonin release. Secondary hyperparathyroidism resulting from the sustained hypocalcemia could evolve into autonomous parathyroid hyperplasia or adenoma formation with clinical hyperparathyroidism. In similar fashion, beta cell hyperplasia and hyperinsulinism lead directly or indirectly to activation of the pituitary-adrenal axis. Hyperplasia and adenomatous transformation of the pituitary and/or adrenal glands might ensue from chronic stimulation by hyperinsulinism. The published results of a symposium devoted to the role of hormones in tumor growth [44] summarized a large amount of clinical and experimental evidence that sustained, excessive hormone secretion can provoke tumor formation. Gastrin was identified by Gregory et al. [45] as the gastric secretagogue in nonbeta cell tumors associated with the Zollinger-Ellison syndrome. The radioimmunoassay technic has more recently been used to detect elevated circulating gastrin levels in the Zollinger-Ellison syndrome [46]. The immunofluorescent identification of gastrin in normal islet cells [47] suggests that these cells (delta cells) may be the ones which eventually proliferate in the formation of ZollingerEllison tumors. The reported pathophysiologic consequences of excessive gastrin production in the

The

American

Journal

of

Medicine

FAMILIAL

Zollinger-Eliison syndrome are gastric creatic hypersecretion, gastroduodenal

and panulceration

and steatorrhea. The long-term consequences of the insulin[48] and calcitonin[49] releasing properties of gastrin are not known but may contribute to the altered endocrine function in multiple endocrine adenomatosis, as already discussed. The recent report that hypercalcemia and hypoglycemia stimulate gastrin release provides additional insight into the complex interrelationships of hormone release [46]. The pathologic anatomy of the islet cell lesions in the three family members who had pancreatic surgery (R.H., Ei.H. and A.H.) provided additional support for our hypothesis of the pathogenesis of multiple endocrine adenomatosis. In each case enlargement and coalescence of essentially normal appearing islet cells were similar to the appearance of islet cell tumors reported in other studies [50,51]. In 1938 Laidlaw [50] proposed that islet cell hyperplasia and adenomas are generated from the pancreatic duct cell, and he coined the terms “nesidioblastosis” and “nesidioblastoma” to describe these two processes. He postulated that the pancreatic duct cell is the primordial cell of the pancreas and that this totipotential cell (termed nesidioblast, derived from Greek meaning “islet builder”) is capable of regenerating duct, acinar and islet cells at any time with stimulation. Ductule proliferation in continuity with islet tumor cells was observed by Laidlaw in association with insulin-secreting adenomas, and Bloodworth and Elliott [52] described a similar picture in islet adenomas in the Zollinger-Ellison syndrome. Hyperplasia and neogenesis of pancreatic islets have been observed in autopsy specimens from diabetic subjects receiving long-term sulfonylurea therapy [53], in infants of diabetic mothers [54] and in infants with erythroblastosis fetalis [54]. Similar findings have been produced experimentally with a variety of stimuli including corticosteroids [55], glucagon [56], chronic hyperglycemia with glucose infusion [57] and tolbutamide [58]. Using tritiated thymidine, Bunnag et al.

[58]

NESIDIOBLASTOSIS

showed that postnatal

-

VANCE ET AL.

islet neogenesis

most

likely evolves from the pancreatic ductal cell. Thus, islet cell hyperplasia, o’r nesidioblastosis, can be induced experimentally with a variety of stimuli. The stimulus for nesidioblastosis in multiple endocrine adeno,matosis is of course unknown. It has been speculated by Brown and Still [59] that chronic secretin excess may provoke nesidioblastosis in the Zollinger-Ellison syndrome. Against this hypothesis is the fact that secretin administration to subjects with the Zollinger-Ellison syndrome stimulates pancreatic exocrine secretion in excess of that in normal control subjects [60]. Such a response to exogenous secretin would not be expected if excessive endogenous secretin levels were present. However, it is known that an intestinal factor exerts a trophic effect on islet cell function [61]. The demonstration of an excessive “gut glucagon” response to orally administered glucose in two of our subjects with multiple endocrine adenomatosis and islet cell tumors (R.H. and A.H.) raises the question of a possible long-term effect of an intestinal factor on islet cell neogenesis. In conclusion, the predominant biochemical and pathologic manifestations in a family with multiple endocrine adenomatosis involved predominantly neoplasia and hyperfunction of the islets of Langerhans, termed nesidioblastosis. The results of this study and the work of other investigators have suggested a new hypothesis for the pathogenesis of multiple endocrine adenomatosis. It is proposed that the stimulus for nesidioblastosis is inherited as an autosomal genetic defect with high penetrance. Chronic hypersecretion of one or more islet cell hormones may then trigger neoplastic transformation of other endocrine glands in the body. The results of this study suggest that when a patient has evidence of excessive growth or function of the pituitary, parathyroids, adrenals or pancreatic islets, clinical and laboratory investigation of the status of the remainder of the endocrine system in the affected subject and his immediate relatives should be diligently pursued.

REFERENCES 1.

2.

3.

Volume

Ballard HS, Frame B, Hartsock RJ: Familial multiple endocrine adenoma-peptic ulcer complex. Medicine (Bait) 43: 481, 1964. Steiner AL, Goodman AD, Powers SR: Study of a kindred with pheochromocytoma, medullary thy roid carcinoma, hyperparathyroidism. and Cushing’s disease: mult/ple- endocrine neoplasia, type 2. Medicine (Bait) 47: 371, 1968. Schmid JR, Labhart A, Rossier PH: Relationship of

52. February

1972

4. 5.

6.

multiple endocrine ad,enomas to the syndrome of ulcerogenic islet cell adenomas. Amer J Med 31: 343, 1961. Wermer P: Endocrine adenomatosis and peptic ulcer in a large kindred. Amer J Med 35: 305. 1963. HuezengaKA, Goodrick WJM, Summerskill WHJ: Peptic ulcer with islet cell tumor. Amer J Med 37: 564,1964. Williams ED, Cefestin LR: The association of bron-

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9. 10.

11. 12.

13. 14. 15. 16.

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26.

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ET AL.

chial carcinoid and pluriglandular adenomatosis. Thorax 17: 120, 1962. Johnson GJ, Summerskill DM, Anderson VE, Keating FR Jr: Clinical and genetic investigation of a large kindred with multiple endocrine adenomatosis. New Eng J Med 277: 1379, 1967. I Vance JE, Stall RW, Kitabchi AE, Williams RH, Wood FC Jr: Nesidioblastosis in familial endocrine adenomatosis. JAMA 207: 1679, 1969. Dyck WP: Pancreatic hypersecretion in the ZollingerEllison syndrome. Gastroenterology 60: 90, 1971. Morgan CR, Lazarow A: Immunoassay of insulin: two antibody system, plasma insulin levels of normal, subdiabetic, and diabetic rats. Diabetes 12: 115, 1963. Hazzard WR, Crockford PM, Buchanan KD, Vance JE, Chen R, Williams RH: A double antibody immunoassay for glucagon. Diabetes 17: 179, 1968. McGuigan JE, Trudeau WL: lmmunochemical measurement of elevated levels of gastrin in the serum of patients with pancreatic tumors of the Zollinger-Ellison variety. New Eng J Med 278: 1308, 1968. Yalow RS, Berson SA: Radioimmunoassay of gastrin. Gastroenterology 58: 1, 1970. Hoffman WS: A rapid photoelectric method for the determination of glucose in blood. J Biol Chem 120: 51,1937. Trout DL, Estes EH Jr, Friedberg SJ: Titration of free fatty acids in plasma: a study of current methods and a new modification. J Lipid Res 1: 199, 1960. Peterson RE: Determination of urinary neutral 17. ketosteroids, Standard Methods of Clinical Chemistry, vol 4 (Seligson D, ed), New York, Academic Press, 1963, p 151. Callow NH, Callow RH, Enmens CW: Calorimetric determination of substances containing the grouping-CH,CO-in urine extracts as an indication of androgen content. Biochem J 32: 1312, 1938. Rutherford ER, Nelson DH: Determination of urinary 17-ketogenic steroids by means of sodium metayyer;date oxidation. J Clin Endocr 23: 533, Bagdade JD, Bierman EL, Porte D Jr: The significance of basal insulin levels in the evaluation of the insulin response to glucose in diabetic and nondiabetic subjects. J Clin Invest 46: 1549, 1967. Graber AL, Porte D, Williams RH: Clinical use of diazoxide and mechanism for its hyperglycemic effects. Diabetes 15: 143, 1966. Yalow RS, Berson SA: Dynamics of insulin secretion in hypoglycemia. Diabetes 14: 341, 1965. Goldsmith SJ, Yalow RS, Berson SA: Significance of human plasma insulin sephadex fractions. Diabetes 18: 834, 1969. Kitabchi AE: Biological and immunological properties of pork and beef insulin, proinsulin, and connecting peptide. J Clin Invest 49: 979, 1970. Yalow RS, Berson SA: Immunoassay of endogenous plasma insulin in man. J Clin Invest 39: 1157, 1960. McGarvan MH, Unger RH, Recant L, Polk HC, Kilo C, Levier ME: A glucagon-secreting alpha cell carcinoma of the pancreas. New Eng J Med 274: 1408, 1966. Yoshinaga T, Okuno Giichi 0, Yoshitake S, Tsujii T, Nishikawa M: Pancreatic A-cell tumor associated with severe diabetes mellitus. Diabetes 15: 709, 1966.

27.

28.

29.

30.

31. 32.

33.

34.

35.

36.

37.

38.

39. 40.

41.

42.

43.

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