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Background. Radiotherapy after surgery for non-functioning pituitary macroadenomas (NFMAs) is still under debate.Aim. To appreciate the best timing for postoperative high voltage radiotherapy (hRT) in different type of NFMAs (classified using immunohistochemistry (IHC)).Subjects and Methods. Of 97 patients with a remnant (>1 cm) and IHC for anterior pituitary hormones, 41 patients (groups A & B) were submitted to hRT and followed up at least 5 years. RT was performed in 20/41 patients (Group A) within the first year after surgery, 21/41 patients (Group B) afterwards while in control group C, 56 patients were followed up without hRT. The progression of postoperative remnant was defined as a change of minimum of 25% of any diameter (transversal or vertical) by serial imaging studies.Results. The IHC of NFMAs revealed the following: 38 (39%) null cell, 29 (30%) gonadotropinomas, 12 (12%) silent plurihormonal, 11 (11%) silent corticotroph and 7 (7%) silent GH/PRL adenomas.Immunoreactive adenomas have relapse rate higher than null cell adenomas (ACTH> GH/ PRL> FSH/ LH> null cell) with a significant rate for silent ACTH 6/8 (75%). The null cell adenoma relapse rate was 6/23 (26%), p<0.009 in group without hRT. The relapse rate was significantly lower in group AB with hRT than in group without RT (p=0.025), at five years. Immediate hRT (applied within in first years) improved the control of the tumour growth in 90% (18/20) cases. In the group A, 10 % (2/20) patients relapsed than 24% (5/21) patients in group B and 39% (22/56) patients, Group C.Conclusion. An optimal time for radiotherapy is within the first year after the partial surgical removal of NFMAs, particularly if a large amount of residual tumour remains. Patients with silent corticotroph adenoma require special attention.

Since medullary thyroid carcinoma is an aggressive cancer, it is important to have an early detection based on stimulated calcitonin (CT), especially when basal-CT is slightly elevated. The objective of this work was to set specific thresholds for basal-CT- and calcium-stimulated calcitonin for prediction of thyroid malignancy in female population. The study included 2 groups: group A-women with elevated basal-CT (>9.82 pg/ml) and group B-women with normal basal-CT (control group). After calcium stimulation test precise protocol, histopathological reports of those that required surgery were correlated with both basal and stimulated calcitonin. The best basal and stimulated calcitonin cut-offs for distinguishing female patients with medullary thyroid carcinoma or C-Cell-hyperplasia from other pathologies or normal cases were: 12.9 pg/ml, respectively 285.25 pg/ml. For basal-CT above 30 pg/ml, malignancy was diagnosed in 9/9 patients (100%): 9 MTC. For stimulated calcitonin above 300 pg/ml, malignancy was diagnosed in 17/21 patients (80.95%): 12 MTC and 5 papillary thyroid carcinomas. The smallest nodule that proved to be medullary thyroid carcinoma had only 0.56/0.34/0.44 cm on ultrasound, with no other sonographic suspicious criteria. In conclusion, we have identified in Romanian female population basal and stimulated calcitonin thresholds to discriminate medullary thyroid carcinoma or C-Cell-hyperplasia from other cases. We recommend thyroid surgery in all women with stimulated calcitonin above 285 pg/ml. Further studies on larger groups are necessary to establish and confirm male and female cut-offs for early diagnosis of medullary thyroid carcinoma, and interestingly, maybe for macro-papillary thyroid carcinomas alike. The calcium administration has minimum side-effects, but continuous cardiac monitoring is required.

At least one fifth of pituitary adenomas exhibit plurihormonality when using immunohistochemistry for anterior pituitary hormones. However, the correlation with clinical features is weak, without an agreement upon pathological predictors of tumor behavior. The aim was to determine the immunoreactivity for anterior pituitary hormones and alpha subunit in 276 consecutive pituitary adenomas patients, aged 22-79 years (44.3 ± 8), 154 F/ 122 M: 83 acromegalics (ACM), 173 nonfunctioning adenomas (NFA) and 20 prolactinomas (PRM) submitted to surgery via transfrontal (81) or transsphenoidal (195) along 10 years (1995-2005). In addition, clinical data, hormonal secretion and tumour size were evaluated before pituitary surgery. Local ethical committee approved the study design. The immunoreactivity performed by the avidin-biotin-complex method was evaluated for beta FSH, LH, TSH, alpha subunit, PRL and GH, using a semiquantitative scale of stained cells: strong (>20%), positive (10-20%), weak (5-10%) and negative (<5%). CT or MRI tumor size (less than 1 cm, 1-2 cm, 2-4 cm and over 4 cm on maximal diameter) were considered together with the Hardy neuroradiological stage. The results showed that 16/83 ACM, 53/173 NFA and 4/20 PRM exhibited immunoreactivity for beta FSH and LH. TSH immunoreactivity was positive in 13/83 ACM, 11/173 NFA and 1/20 PRM. Tumor size in gonadotrophin-positive group (> 10% of stained cells) was between 1-2 cm in 6 ACM, 21 NFA and 2 PRM, while positive bigger tumors (2-4 cm) were in 7 ACM, 24 NFA and 2 PRM. Giant, over 4 cm tumors were positive in 3 ACM, 8 NFA and no PRM. A similar trend of the tumor size distribution was observed in the monohormonal or null cell adenomas. In conclusion, tumor size and gonadotrophin plurihormonality are independent factors in the management of pituitary adenomas.

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