Sunteți pe pagina 1din 7

REVIEW

Pathology of Pituitary Tumors Update: With World Health


Organization new Classification 2017
Robert Y. Osamura, MD

(AJSP: Reviews & Reports 2017;22: 189–195) recommended in WHO 2017 classification. Instead, we encour-
age using the terminology of clinically aggressive adenoma.3

P ituitary adenomas constitute approximately 15% of all intra-


cranial neoplasms. The majority of pituitary tumors are adeno-
mas, which are benign and noninvasive (confined to the sella
The basic concepts of the new WHO classification of pitui-
tary adenomas are summarized in the following list.

turcica). Invasive adenomas are frequent. Pituitary carcinomas Basic concepts for WHO 2017 classification
are a rare condition, accounting for only 0.1% to 0.2% of all pitu-
itary endocrine tumors. The pituitary endocrine tumors are clini- 1. Pituitary adenomas are derived from committed mature pitui-
cally functioning with clinical hormonal symptoms, that include tary cells: somatotroph adenoma, transcription factors.
acromegaly, Cushing disease, Graves disease; or nonfunctioning 2. Electron microscopy is not used as routine procedure. Immuno-
without clinically apparent hormone production. Most of pituitary histochemistry is used for classification.
adenomas are benign, and metastases (pituitary carcinoma) are 3. “Atypical adenoma” is not recommended. Ki67 index should
very rare. However, aggressive or invasive behavior is not uncom- be analyzed. p53 is a good indicator of malignancy.
mon, and the tumor often (approximately 50%) extends beyond 4. Morphologic subclassification for prognostication: sparsely
the sellar region and reaches the sphenoid sinus and further to granulated somatotroph adenoma, Crooke cell (corticotroph)
the internal carotid artery. The pituitary adenomas are currently adenoma and others
classified according to the hormones they produce and to the basic 5. Multihormonal Pit-1–positive adenoma (previous silent sub-
features of electron microscopy (EM). Recently, pituitary ade- type 3 adenoma)
noma classification has changed regarding aggressive lesions. 6. Null cell adenomas—hormone negative and transcription
The previous World Health Organization (WHO) classification factor negative
published in 2004 consisted of typical adenomas, atypical ade- 7. Predictive biomarkers for therapy
noma, and carcinoma. The atypical adenoma was defined as a 8. Genetic predisposition
tumor with Ki67 index greater than 3% and strong p53 immu- Key issues in the new WHO 2017 classification include
nostaining.1 The incidence of the atypical adenomas is rela- (1) transcription factors that promote differentiation of the pitui-
tively low2,3 and not closely related to aggressive behavior,3 tary cells, (2) some morphologic features are associated with more
p53 mutation occurs predominantly in pituitary carcinoma, and aggressive behavior, (3) various genetic background is associated
pituitary adenomas lack its mutation.4 The carcinomas can be di- with pituitary adenomas, and (4) prognostic and predictive bio-
agnosed only when the tumor shows meningeal spread or metas- markers for pituitary adenomas.
tases, intracranial and extracranial.1 Now it has been clarified that
most of the “nonfunctioning” tumors are immunohistochemically
positive for hormones, that is, growth hormone (GH), prolactin Transcription Factors for Pituitary Hormone
(PRL) and adrenocorticotropic hormone (ACTH),1 or gonadotroph Production: Prop-1, Pit-1, Sf-1, Gata-2,
subunits or gonadotropin, that is, αSU, follicle stimulating hormone Tpit, NeuroD1
βSU, and luteinizing hormone βSU.2 The former group1 has been Now it is well known that the differentiation of pituitary
designated as “silent” adenoma,5,6 and the latter group2 has been hormone–producing cells is regulated by the transcription factors
most frequently seen in the clinically nonfunctioning adenoma. with synergistic effects of cofactors. The differentiation toward
The pituitary carcinomas are rare, but they produce PRL or ACTH GH, PRL, and PRL depends on the transcription factor, Pit-1, to-
when they produce hormones. ward ACTH on Tpit, and toward FSH on SF-1, as indicated in the
Since previous WHO classification was published in 2004, diagrams (Figs. 1 and 2). By immunohistochemistry, these tran-
new information has accumulated regarding pituitary adenomas scription factors are detected in the nuclei.8
that has been integrated in the new WHO 2017 classification For new WHO classification, the diagnosis of plurihormonal
(Table 1).7 Even though most terminology is based on the features Pit-1–positive adenomas, designated as silent subtype 3 adeno-
defined by EM, currently, immunohistochemistry is the method mas, needs to demonstrate Pit-1 in the tumor cells,9 and the di-
for diagnosis in most cases. The classification of “typical or agnosis of true null cell adenomas needs to be negative for
atypical adenoma,” which was based on Ki67 and p53, is not transcription factors in addition to negative pituitary hormones
or glycoprotein subunits.
Based on the transcription factors, it has been clarified that
the pituitary adenomas develop from the mature hormone-
International University of Health and Welfare, Graduate School, Tokyo and producing cells, that is, somatotrophs (GH), lactotrophs (PRL),
Department of Diagnostic Pathology, Nippon Koukan Hospital, Kawasaki,
Japan.
thyrotrophs [thyroid stimulating hormone (TSH)], and gonadotrophs
Reprints: Robert Y. Osamura, MD, Department of Diagnostic Pathology, (FSH, LH), and in the new WHO 2017 classification, we use termi-
Nippon Kokan Hospital, 1-2-1 Koukandori, Kawasaki-ku, Kawasaki, nologies such as “somatotroph adenoma,” “lactotroph adenoma,”
Kanagawa, Japan 210-0852. E‐mail: osamura@iuhw.ac.jp. “thyrotroph adenoma,” “corticotroph adenoma,” and “gonadotroph
The author has no funding or conflicts to declare.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
adenoma” instead of previous “GH-, PRL-, TSH-, ACTH-, and FSH-
ISSN: 2381-5949 producing adenomas” (Table 2). Regarding the null cell adenomas,
DOI: 10.1097/PCR.0000000000000180 Nishioka et al10 reported that 119 (95%) of hormone-negative adenomas

AJSP: Reviews & Reports • Volume 22, Number 4, July/August 2017 www.pathologycasereviews.com 189

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Osamura AJSP: Reviews & Reports • Volume 22, Number 4, July/August 2017

TABLE 1. Morphofunctional Classification of Pituitary Adenomas (WHO 2017 Classification)

Transcription Factors
Adenoma Type Immunophenotype and Other Cofactors
Somatotroph adenoma Densely granulated GH ± PRL ± α subunit PIT1
somatotroph adenoma*
LMWCK: perinuclear or diffuse
Sparsely granulated somatotroph adenoma GH ± PRL PIT1
LMWCK: fibrous bodies
Mammosomatotroph adenoma GH + PRL (in same cell) ± α subunit PIT1, ER-α
Mixed somatotroph and GH + PRL (in different cells) ± α subunit PIT1, ER-α
lactotroph adenoma
Lactotroph adenoma Sparsely granulated lactotroph adenoma* PRL PIT1, ER-α
Densely granulated lactotroph adenoma PRL PIT1, ER-α
Acidophilic stem cell adenoma PRL, GH (focal and inconstant)LMWCK:
fibrous bodies (inconstant)
Thyrotroph adenoma TSH-β, α subunit PIT1, GATA2
Corticotroph adenoma Densely granulated corticotroph adenoma* ACTH, LMWCK: diffuse pattern TPIT
Sparsely granulated corticotroph adenoma ACTH, LMWCK: diffuse pattern TPIT
Crooke cell adenoma ACTH, LMWCK: ring-like pattern TPIT
Gonadotroph adenoma Sparsely granulated FSH-β, LH-β, α subunit SF-1, GATA2,
gonadotroph adenoma* (various combinations) ER-α (variable)
Null cell adenoma — No markers None
Plurihormonal adenomas Plurihormonal PIT1-positive adenoma† GH, PRL, TSH-β ± α subunit PIT1
Adenomas with unusual Various combinations Other transcription
immunohistochemical combinations factors (variable)
Double adenomas Distinct adenomas Usually PRL and ACTH, respectively PIT1 and TPIT,
respectively
*Most common subtype.
†Previously called silent subtype 3 adenoma.

showed mutually exclusive lineage-specific differentiation as Pathologic Predictors of Prognosis


gonadotrophs (SF-1 positive), corticotrophs (Tpit positive), or
somatotrophs/mammosomatotrophs/lactotrophs/thyrotrophs In addition to proliferative activity associated with aggressive
(Pit-1 positive) in 79 cases (66.4%), 32 cases (26.9%), and 2 behavior of the pituitary adenomas,11 some morphological charac-
cases, respectively. Thus, the incidence of true null cell adenomas teristics are associated with more aggressive behavior. These fea-
should be very rare (Figs. 3 and 4). tures are sparsely granulated adenoma with fibrous bodies and

FIGURE 1. Differentiation of pituitary cells in rodents: transcription factors. Modified after Scully KM & Rosenfeld MG Science 2002.

190 www.pathologycasereviews.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


AJSP: Reviews & Reports • Volume 22, Number 4, July/August 2017 Pathology of Endocrine Tumors Update

FIGURE 2. Differentiation of pituitary cells in human: transcription factors. Modified after Osamura RY et al. Pituitary 1999;1(3–4):269-271.

Crooke cell adenoma, null cell adenoma, and plurihormonal Pit-1– immunohistochemistry for GH and keratin (CAM5.2) to dem-
positive adenoma (previous silent subtype 3 adenoma) (Fig. 5).12,13 onstrate GH and fibrous bodies.
(b) Crooke adenomas are defined as one of the subtypes of
(a) Sparsely granulated adenoma is the somatotroph adenoma corticotroph adenomas, which are characterized by ring-like ac-
originally defined by EM as the tumor with fewer numbers of cumulation of keratin in the cytoplasm of ACTH-positive tumor
secretory granules in contrast to densely granulated adenomas cells.14 For diagnosis, similarly, we need immunohistochemis-
with many dense secretory granules. The sparsely granulated try, ACTH, and CAM5.2.
adenomas are also characterized by the presence of fibrous (c) Plurihormonal Pit-1–positive adenoma (previous silent sub-
bodies. The fibrous bodies are small globular inclusions of type 3 adenoma) is the tumor that is frequently nonfunction-
keratin in the cytoplasm, demonstrated by immunohistochem- ing and is immunohistochemically positive for GH, PRL, and
istry. Thus, immunohistochemistry has substituted EM for sometimes TSH or ACTH. The tumor cells are positive for
the diagnosis of this category. For diagnosis, we need Pit-1. Usually, the tumors are macroadenoma and invasive.13

TABLE 2. Morphofunctional Classification of Pituitary Adenomas (WHO 2017 Classification)

Adenoma Type
Somatotroph adenoma Densely granulated somatotroph adenoma*
Sparsely granulated somatotroph adenoma
Mammosomatotroph adenoma
Mixed somatotroph and lactotroph adenoma
Lactotroph adenoma Sparsely granulated lactotroph adenoma*
Densely granulated lactotroph adenoma
Acidophilic stem cell adenoma
Thyrotroph adenoma
Corticotroph adenoma Densely granulated corticotroph adenoma*
Sparsely granulated corticotroph adenoma
Crooke cell adenoma
Gonadotroph adenoma Sparsely granulated gonadotroph adenoma*
Null cell adenoma
Plurihormonal adenomas Plurihormonal PIT1-positive adenoma†
Adenomas with unusual immunohistochemical combinations
Double adenomas Distinct adenomas
*Most common subtype.
†Previously called silent subtype 3 adenoma.

© 2017 Wolters Kluwer Health, Inc. All rights reserved. www.pathologycasereviews.com 191

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Osamura AJSP: Reviews & Reports • Volume 22, Number 4, July/August 2017

FIGURE 3. Densely granulated somatotroph adenoma. Acidophilic adenoma (left) and strong granular staining for GH in the cytoplasm of
the tumor cells (right).

Genetic Predisposition and Susceptibility and AIP, and it is known that the heterozygote knockout models
of these genes in rodents develop pituitary adenomas.
The majority of pituitary adenomas are sporadic. However, a
significant number of cases are related to germline genetic abnor-
malities, most commonly resulting in somatotroph and lactotroph Predictive Biomarkers
subtypes. Genetic background for the pituitary tumor development The detection of certain molecules can be predictive for the
includes multiple endocrine neoplasia type 1 (MEN1), MEN4, Car- selection of molecular target therapies.
ney complex, SDHx-related familial syndrome, McCune-Albright
syndrome, and Dicer syndrome.
With this background (familial pituitary tumor syndrome), Somatostatin Receptor
the pituitary tumors are frequently associated with PRL or GH
It is well known that there are 5 subtypes, that is, SSTR1,
production as follows.15 Clinical algorithm to approach this con-
SSTR2, SSTR3, SSTR4, and SSTR5. The pituitary adenomas,
dition has been proposed.15
particularly somatotroph adenomas, are frequently positive for
MEN1: lactotroph adenomas (60%), somatotroph adenomas (10%); SSTR2 and SSTR5. Recently, specific monoclonal antibodies
Carney complex: somatotroph adenoma and/or lactotroph ade- for immunohistochemistry are commercially available.17,18
nomas or hyperplasia; It has been widely known that the detection of SSTR2 may
Familial isolated pituitary adenoma: lactotroph adenoma, predict the effects of molecular target therapies, such as
somatotroph adenoma, or mixed GH/PRL-secreting adenomas octreotide (Fig. 6).
(41%, 30%, and 7%, respectively).

The unique situation in these syndromes is Dicer syndrome, MGMT and MSH6
which includes pituitary blastoma,16 in addition to the other Epigenetic silencing of the MGMT (O6-methylguanine–
various conditions. DNA methyltransferase) DNA repair gene by promoter methylation
The genetic background of these syndromes includes compromises DNA repair and has been associated with longer
germline mutations of MEN1, PRKAR1A, CDKN1A, SDHB, survival in patients with glioblastoma who receive alkylating

FIGURE 4. Sparsely granulated somatotroph adenomas. Less acidophilic tumor cells (left), GH localized at the periphery of tumor
cells (middle), keratin-positive fibrous bodies are seen in the cytoplasm (right).

192 www.pathologycasereviews.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


AJSP: Reviews & Reports • Volume 22, Number 4, July/August 2017 Pathology of Endocrine Tumors Update

FIGURE 5. Crooke cell adenoma H&E staining (left), ACTH (middle) and Keratin (CAM5.2) (right) Ring-like pink cytoplasm (left), peripheral
staining for ACTH (middle) and ring-like keratin staining (right).

agents such as temozolomide (TMZ).19 In the pituitary adenomas Transcription factors and cofactors: Pit-1, SF-1, ERa, Tpit,
and carcinomas, decreased staining for MGMT by methylation is GATA2, NeuroD1;
associated with response to TMZ therapy.20,21 Hirohata et al22 re- Predictive therapeutic factors: SSTR2, SSTR5, MGMT, MSH6.
ported the association of MSH6 immunostaining with the effects
of TMZ therapy in pituitary adenomas and carcinoma (Fig. 7).
Pathology report on pituitary adenomas should include SUMMARY
the following: In this review, we discussed key issues in the new WHO
morphofunctional classification of pituitary tumors, mainly adeno-
Classification of adenoma (WHO 2017 classification); mas (Tables 3 and 4). The new classification includes not only ad-
Size of tumor: microadenoma, macroadenoma, giant adenoma enoma types, but also immunophenotypes and transcription factors
clinically functioning, clinically nonfunctioning, silent with other cofactors. As atypical adenoma designation in 2004 is
invasive, noninvasive (Knosp grades 1–4); rare and does not predict behavior, the new WHO classification
Adenoma or carcinoma; does not recommend using this terminology. In addition to pro-
Immunohistochemistry for hormones and subunits-GH, PRL, liferative activity, other morphologic features suggest aggressive
TSHβSU, ACTH, follicle stimulating hormone βSU, luteiniz- behavior of pituitary adenomas, that is, sparsely granulated
ing hormone βSU, αSU; somatotroph adenoma and Crooke cell adenoma. Some pituitary
Immunohistochemistry, in addition to hormones and subunits: adenomas, frequently along the Pit-1 lineage with GH and PRL
chromogranin A, keratin (low molecular weight: CK7/8 positivity, occur in MEN1, Carney complex, and others. Immuno-
[CAM5.2], CK18); histochemical detection of SSTR2, MGMT, and MSH6 is impor-
Proliferative markers: Ki67, p53 (in some cases); tant to predict the therapeutic response to octreotide and TMZ.

FIGURE 6. Immunohistochemical staining of SSTR2-positive rate of SSTR2 and SSTR5. Strong positive staining on the cell membrane of the
adenoma cells (right). Positive rate of the staining of SSTR2 and SSTR5 in pituitary adenomas. SSTR2 is frequently positive in somatotroph and
thyrotroph adenomas (left panel of the left), SSTR5 is frequently positive in corticotroph adenoma and somatotroph adenomas (right panel of
the left).

© 2017 Wolters Kluwer Health, Inc. All rights reserved. www.pathologycasereviews.com 193

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Osamura AJSP: Reviews & Reports • Volume 22, Number 4, July/August 2017

FIGURE 7. Immunohistochemistry of MGMT and MSH6. Staining is negative when MGMT is methylated and lacks its function. The negative
MGMT staining is associated with response to TMZ. Nuclear staining for MSH6 is also associated with therapeutic response to TMZ in
pituitary adenomas and carcinomas.

TABLE 3. Additional Parameters That May Be Added to the Morphofunctional Types

Tumor size Microadenoma (<1 cm), macroadenoma (1–4 cm),


or giant adenoma (>4 cm)
Tumor’s clinical presentation Clinically functioning, clinically nonfunctioning, or silent
Invasiveness on magnetic resonance imaging (Knosp grade) Noninvasive (grade 1 or 2) or invasive (grade 3 or 4)
Metastasis or spinal spread Carcinoma
Additional immunohistochemistry • Chromogranin A
• Low-molecular-weight cytokeratin: CK7/8 (CAM5.2), CK18
• Proliferation markers: Ki67, p53 (in some cases)
• Transcription factors and cofactors: PIT1, SF-1, ER-α, TPIT,
GATA2, NeuroD1
• Predictive markers: SSTR2, SSTR5, MGMT, MSH6

TABLE 4. Genetic Predisposition to Pituitary Adenomas

Syndromic Diseases Isolated Pituitary Disease


MEN1 Familial isolated pituitary adenoma (somatotroph) (AIP)
Multiple endocrine neoplasia type 4 (CDKN1B) X-linked acrogigantism syndrome (GPR101)
SDH-related familial paraganglioma and pheochromocytoma syndromes Familial isolated pituitary adenoma (unknown)
(SDHA, SDHB, SDHC, SDHD, SDHAF2)
Carney complex (PRKAR1A, PRKACA)
McCune-Albright syndrome (mosaic GNAS)
Neurofibromatosis (very rare) (NF1)
Von Hippel-Lindau syndrome (VHL)
DICER1 syndrome (DICER1)

194 www.pathologycasereviews.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


AJSP: Reviews & Reports • Volume 22, Number 4, July/August 2017 Pathology of Endocrine Tumors Update

REFERENCES 12. Mete O, Ezzat S, Asa SL. Biomarkers of aggressive pituitary adenomas.
J Mol Endocrinol 2012;49:R69–R78.
1. Lloyd RV, Young WF Jr, Farrel WE, et al. Pituitary tumors. In:
WHO Classification of Tumors of the Endocrine Organs: Pathology and 13. Erickson D, Scheithauer B, Atkinson J, et al. Silent subtype 3 pituitary
Genetics of Endocrine Organs. Lyon, France: IARC Press; 2004. adenoma: a clinicopathologic analysis of the Mayo Clinic experience. Clin
Endocrinol (Oxf ) 2009;71(1):92–99.
2. Zada G, Woodmansee WW, Ramkissoon S, et al. Atypical pituitary
adenomas: incidence, clinical characteristics and implication. J Neurosurg 14. George DH, Scheithauer BW, Kovacs K, et al. Crooke's cell adenoma of the
2011;114:336–344. pituitary: an aggressive variant of corticotroph adenoma. Am J Surg Pathol
2003;27(10):1330–1336.
3. Chatzellis E, Alexandraki KI, Androulakis II, et al. Aggressive pituitary
tumors. Neuroendocrinology 2015;101:87–104. 15. Syro LV, Rotondo F, Ramirez A, et al. Progress in the diagnosis and
classification of pituitary adenomas. Front Endocrinol (Lausanne) 2015;6:97.
4. Tanizaki Y, Jin L, Scheithauer BW, et al. P53 gene mutations in pituitary
carcinomas. Endocr Pathol 2007;18:217–222. 16. Scheithauer BW, Horvath E, Abel TW, et al. Pituitary blastoma: a unique
embryonal tumor. Pituitary 2012;15(3):365–373.
5. Chinezu L, Jouanneau E, Vasiljevic A, et al. Silent GH pituitary tumor:
17. Brzana J, Yedinak CG, Gultekin SH, et al. Growth hormone granulation
diagnostic and therapeutic challenges. Ann Endocrinol (Paris) 2013;
pattern and somatostatin receptor subtype 2A correlate with postoperative
74(5–6):491–495.
somatostatin receptor ligand response in acromegaly: a large single center
6. Cooper O, Ben-Shlomo A, Bonert V, et al. Silent corticogonadotroph experience. Pituitary 2013;16(4):490–498.
adenomas: clinical and cellular characteristics and long-term outcomes.
18. Chinezu L, Vasiljevic A, Jouanneau E, et al. Expression of somatostatin
Horm Cancer 2010;1(2):80–92.
receptors, SSTR2A and SSTR5, in 108 endocrine pituitary tumors using
7. Lloyd RV, Rosai J, Kloppel G, et al. Pituitary tumors. In: WHO Classification immunohistochemical detection with new specific monoclonal antibodies.
of Tumors of the Endocrine Organs: Pathology and Genetics of Endocrine Hum Pathol 2014;45(1):71–77.
Organs. 4th ed. Lyon, France: IARC Press; 2017.
19. Hegi ME, Diserens AC, Gorlia T, et al. MGMT gene silencing and
8. Osamura RY, Egashira N, Kajiya H, et al. Pathology, pathogenesis and benefit from temozolomide in glioblastoma. N Engl J Med 2005;352:
therapy of growth hormone (GH)-producing pituitary adenomas: technical 997–1003.
advances in histochemistry and their contribution. Acta Histochem
20. Bengtsson D, Schrøder HD, Andersen M, et al. Long-term outcome and
Cytochem 2009;42(4):95–104.
MGMT as a predictive marker in 24 patients with atypical pituitary
9. Mete O, Gomez-Hernandez K, Kucharczyk W, et al. Silent subtype 3 adenomas and pituitary carcinomas given treatment with temozolomide.
pituitary adenomas are not always silent and represent poorly differentiated J Clin Endocrinol Metab 2015;100(4):1689–1698.
monomorphous plurihormonal Pit-1 lineage adenomas. Mod Pathol 2016;
21. Bush ZM, Longtime JA, Cunningham T, et al. Temozolomide treatment
29(2):131–142.
for aggressive pituitary tumors: correlation of clinical outcome with
10. Nishioka H, Inoshita N, Mete O, et al. The complementary role of O(6)-methylguanine methyltransferase (MGMT) promoter methylation
transcription factors in the accurate diagnosis of clinically nonfunctioning and expression. J Clin Endocrinol Metab; 95:E380–E390.
pituitary adenomas. Endocr Pathol 2015;26(4):349–355. 22. Hirohata T, Asano K, Ogawa Y, et al. DNA mismatch repair protein
11. Trouillas J, Roy P, Sturm N, et al. A new prognostic clinicopathological (MSH6) correlated with the responses of atypical pituitary adenomas and
classification of pituitary adenomas: a multicentric case-control study of pituitary carcinomas to temozolomide: the national cooperative study by
410 patients with 8 years post-operative follow-up. Acta Neuropathol 2013; Japan Society for Hypothalamic and Pituitary Tumors. J Clin Endocrinol
126:123–135. Metab 2013;98:1130–1136.

© 2017 Wolters Kluwer Health, Inc. All rights reserved. www.pathologycasereviews.com 195

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.