Overview Endocrinology and VHL: The adrenal and the pancreas LAUREN FISHBEIN MD, PHD UNIVERSITY OF COLORADO SCHOOL OF MEDICINE DIVISION OF ENDOCRINOLOGY, METABOLISM AND DIABETES DIVISION OF BIOMEDICAL INFORMATICS AND PERSONALIZED MEDICINE OCTOBER 20, 2018 Definition of a hormone Adrenal gland Adrenal hormones gland hormones and enzymes Endocrine Glands Organs in our body that make hormones Master Gland Metabolism Energy BP/HR What is a hormone? Energy BP Metabolism Food breakdown and metabolism Signals for energy usage and stores Female hormones Male hormones https://s-media-cache-ak0.pinimg.com/736x/5e/eb/a4/5eeba4d996ec972d35980896fe5bb654.jpg 1
What is a hormone? Can you name some hormones? Hormones are chemical messengers in the body Send messages about a particular function from one cell to another Hormone Liver Common examples Thyroid hormone Estrogen Progesterone Testosterone FSH Several other hormones come from the adrenal and pancreas glands Adrenal gland Adrenal Histology 1. Capsule 2. zona glomerulosa 3. zona fasciculata 4. zona reticularis 5. Adrenal medulla cortex aldosterone glucocorticoids androgens Medulla adrenaline fight or flight http://cf.ydcdn.net/1.0.1.66/images/main/a5adrenalgland.jpg http://district.bluegrass.kctcs.edu/shirley.whitescarver/bio139lab http://dspace.udel.edu:8080/dspace/bitstream/19716/1826/2/cenamc1.gif 2
Adrenal Medulla Adrenal medulla hormones Also called adrenaline (TH) (PNMT) Rate limiting step Upregulated by cortisol Medulla is like a nerve ganglion and releases secretions (messages) directly into blood http://www.studyinukraine.eu/spinal-cord-spinal-nerves-and-autonomic-nervous-system-with-figures/ Adrenaline (metanephrines catecholamines) Pheochromocytoma (and Paraganglioma) Pheochromocytomas (pheos) Tumors in the adrenal medulla Make adrenaline hormones About 20% of patients with VHL will develop pheos Flight or flight response Paragangliomas Petri et al British Journal of Surgery 2009 Pheochromocytoma leads to high blood pressure, rapid heart rate, sweating, headache, anxiety, tremors, increased blood Some people with pheo have no symptoms Tumors in nerve bundles (ganglia) outside the adrenal gland Similar to pheos Rare in patients with VHL 3
Testing for pheochromocytoma VHL and Pheo test Plasma free metanephrines 24hr urine test Urine fractionated metanephrines VHL can be associated with bilateral pheochromocytomas Can I survive with one adrenal gland? If found to have pheo, need pre-op blocking with special blood pressure medication called alpha blocker before surgery Blocks effects of high adrenaline Ex: phenoxybenzamine, prazosin, doxazosin α-adrenergic receptor What about no adrenal glands? http://cf.ydcdn.net/1.0.1.66/images/main/a5adrenalgland.jpg Aldosterone Cortisol Androgens (Testosterone) aldosterone cortisol androgen Adrenal Insufficiency Caused by having no functional adrenal gland Salt/water balance Control BP Steroid hormone Male physical Controls immune system, characteristics BP, metabolism, bone health, Cortical sparing adrenalectomy sometimes used We have medications to replace all of these hormones as needed Fludrocortisone (Florinef) Aldosterone replacement aldosterone Salt/water balance hormone maintains BP and potassium/sodium levels Hydrocortisone/prednisone cortisol Cortisol replacement BP/metabolism/blood /other hormone Extra medication needed when sick or ill or before surgery sick day rules androgen 4
VHL and the pancreas Pancreatic Neuroendocrine Tumors (PNETs) VHL increases risk of several types of pancreatic masses and cysts Mass is solid Cyst is fluid filled Most will be benign One type of mass seen is a pancreatic neuroendocrine tumor 10-15% of all PNETs are associated with genetic syndromes ~9-17% of patients with VHL develop PNETs Also seen in other syndromes Multiple Endocrine Neoplasia Type 1 (MEN1) Neurofibromatosis Type 1 (NF1) Tuberous Sclerosis Complex (TSC) Pancreatic Neuroendocrine Tumors (PNETs) Functional (F) vs Non-functional (NF) Guidelines suggest removal of pancreatic masses over ~3cm in patients with VHL The vast majority of PNETs in patients with VHL are benign and non-functional F-PNETS Hormone elevated in blood + clinical syndrome NF-PNETS No clinical syndrome even if hormone detectable 5
Histology of pancreas Exocrine pancreas Endocrine pancreas Islet of Langerhans http://biocrine.com/wp-content/uploads/2011/09/dad2.png http://quasargroupconsulting.com/anatomy/pancreasecells.gif Hormones messengers Exocrine pancreas makes enzymes to digest food http://quasargroupconsulting.com/anatomy/pancreasecells.gif http://www.animatedpancreaspatient.com/en-pancreas/view/m501-s4-exocrine-pancreatic-insufficiency-epi-slide-show 6
Exocrine pancreas makes enzymes to digest food Hormones messengers Lack of nutrients for our body Can cause bloating and diarrhea http://www.animatedpancreaspatient.com/en-pancreas/view/m501-s4-exocrine-pancreatic-insufficiency-epi-slide-show http://quasargroupconsulting.com/anatomy/pancreasecells.gif Insulin Liver Glucagon Liver Insulin Glucagon Muscle Insulinoma low blood, confusion, vision changes, unusual behavior, rapid heart beat, sweating, shakiness, amnesia, eating every few hours, waking up at night to eat to avoid symptoms. Glucagonoma blood too high causing diabetes, weight loss, blood clots and a specific rash called necrolytic migratory erythema. 7
Somatostatin glucagon insulin Vasoactive Intestinal Polypeptide (VIP) Energy Somatostatin Liver glycogen VIP Nerve Decrease acid Slow motility Somatostatinoma results in dysregulation of many endocrine hormones. Lowers insulin leading to diabetes. Slows GI motility which can lead to gallstones, intolerance to fat in the diet and leads to fatty diarrhea. Secrete pituitary hormones bicarb VIPoma causes huge amounts of very watery diarrhea leading to dehydration, low potassium and chloride Pituitary picture from https://s-media-cache-ak0.pinimg.com/236x/3d/45/12/3d4512b044af3b0e5877a78499114d4e.jpg Majority of PNETs in VHL are non-functional Abnormal functioning pancreas So why am I talking about the hormones? A pancreas that is not functioning well or is absent due to surgery, may make too little hormone and enzymes We can replace these with medications Insulin is the main hormone of concern when absent Insulin deficiency causes diabetes mellitus We can replace insulin to control diabetes 8
Insulin Abnormal functioning pancreas Liver Absent exocrine pancreas is another concern Insulin Absent enzymes cause bloating and discomfort because food cannot be digested well Muscle We can control the symptoms with giving back the enzymes before each meal Exocrine pancreas makes enzymes to digest food Summary Definition of a hormone Adrenal gland Adrenal hormones gland hormones and enzymes http://www.animatedpancreaspatient.com/en-pancreas/view/m501-s4-exocrine-pancreatic-insufficiency-epi-slide-show http://cf.ydcdn.net/1.0.1.66/images/main/a5adrenalgland.jpg http://biocrine.com/wp-content/uploads/2011/09/dad2.png http://quasargroupconsulting.com/anatomy/pancreasecells.gif 9
Questions? 10