Childhood craniopharyngioma

Craniopharyngiomas (CP) are partly cystic embryogenic malformations of the sellar and parasellar region. With an overall incidence of 0.5-2.0 new cases/million population/year, approximately 30-50 % of all cases represent childhood CP. Typical manifestations at diagnosis are headache, visual impairment, polyuria/polydypsia, growth retardation, puberty development disturbances, and significant weight gain. Therapy of choice in children with favorable tumor localization is complete resection with the intention to maintain optic nerve and hypothalamic-pituitary functions. In children with unfavorable tumor localization (hypothalamic involvement), a limited resection followed by local irradiation is recommended. Although overall surgical survival rates are high (92 %), recurrence after complete resection and progression after incomplete resection are typical post-surgical events. Particularly troublesome for the pediatric patient are the disturbances to their pubescent development and overall growth. Accordingly, the appropriate time point of irradiation after incomplete resection is under investigation in a randomized multinational trial (KRANIOPHARYNGEOM 2007). Quality of life is substantially reduced in approximately 50 % of long-term survivors due to sequelae, notably morbid hypothalamic obesity. CP should be recognized as a chronic disease requiring constant monitoring of the early life as well as post-pubescent consequences and appropriate medical resources for treatment in order to provide optimal quality of survival for patients.

National incidence and prevalence of TSH-secreting pituitary adenomas in Sweden

CONTEXT

TSH-secreting pituitary adenomas (TSHomas) are rare. Epidemiological data are scant and there are no reports on national incidence.

OBJECTIVE

The objective of the study was to estimate the national Swedish incidence and prevalence of TSHomas.

DESIGN

This was an observational study.

SETTING

The study was conducted at tertiary referral centers.

PATIENTS

The Swedish Pituitary Registry and World Health Organization International Statistical Classification of Diseases and Related Health Problems coding at all university hospitals were used to identify patients diagnosed with TSHomas 1990-2010. The identified patients' medical records were studied until the latest follow-up [median 5.0 years (range < 1-20 years)].

MAIN OUTCOME MEASUREMENTS

Incidence, prevalence, demographics, tumor characteristics, treatment outcome, and thyroid hormone level at diagnosis were measured.

RESULTS

The age-standardized national incidence of 28 TSHoma patients was 0.15 per 1 million inhabitants per year, with an increasing incidence over time (0.05 per 1 million per year in 1990-1994 to 0.26 per 1 million per year in 2005-2009). The national prevalence in 2010 was 2.8 per 1 million inhabitants, in which 0.85 per 1 million had active disease. Most patients (n = 22) underwent pituitary surgery, 5 had radiotherapy, and 6 had somatostatin analogues. Eighteen patients were considered cured at the latest follow-up; 25% remained uncontrolled. Subjects treated for putative primary hyperthyroidism prior to diagnosis had TSH levels more than double those with intact thyroid at diagnosis (P = .013). The median time to diagnosis was longer for women than men (4 vs < 1 year, P = .026). More women than men were treated surgically (94.1% vs 54.5%, P = .022).

CONCLUSION

This is the first estimate of a national incidence of TSHoma. Additional epidemiological studies are needed to compare these results with other geographical areas. This study suggests an increased incidence of TSHomas, in agreement with reports on other pituitary adenomas.

Effect of cabergoline on metabolism in prolactinomas

INTRODUCTION

Hyperprolactinemia has been implicated in the pathogenesis of obesity and glucose intolerance and is reportedly associated with an impaired metabolic profile. The current study aimed at investigating the effects of 12- and 60-month treatment with cabergoline (CAB) on metabolic syndrome (MetS) in patients with prolactinomas.

PATIENTS AND METHODS

61 patients with prolactinomas (13 men, 48 women, 41 with microadenoma, 20 with macroadenoma), aged 34.4 ± 10.3 years, entered the study. In all patients, prolactin (PRL) and metabolic parameters were assessed at diagnosis and after 12 and 60 months of continuous CAB treatment. MetS was diagnosed according to NCEP-ATP III criteria.

RESULTS

Compared to baseline, CAB induced a significant decrease in PRL with complete normalization in 93% of patients after the 60-month treatment. At baseline, MetS prevalence was significantly higher in patients with PRL above (34.5%) than in those with PRL lower (12.5%) than the median (129 μg/l, p = 0.03). MetS prevalence significantly decreased after 12 (11.5%, p = 0.039) and 60 (5.0%, p = 0.001) months compared to baseline (28.0%). At both evaluations the lipid profile significantly improved compared to baseline. Fasting insulin and homeostatic model assessment of insulin resistance significantly decreased after 1 year of CAB (p = 0.012 and p = 0.002, respectively) and further improved after 60 months (p = 0.000). The visceral adiposity index significantly decreased after the 60-month treatment (p = 0.000) compared to baseline. At the 5-year evaluation CAB dose was the best predictor of percent decrease in fasting insulin (t = 2.35, p = 0.022).

CONCLUSIONS

CAB significantly reduces MetS prevalence and improves the adipose tissue dysfunction index. The improvement in PRL, insulin sensitivity and other metabolic parameters might reflect the direct effect of CAB.

Increased prevalence of anxiety-associated personality traits in patients with Cushing's disease: a cross-sectional study

BACKGROUND/AIMS

Chronic hypercortisolism in Cushing's disease (CD) has been suggested to contribute to an altered personality profile in these patients. We aimed to test this hypothesis and attempted to determine the effects of disease- and treatment-related factors that might moderate an altered personality in CD.

METHODS

We assessed 50 patients with CD (74% biochemically controlled) and compared them to 60 patients with non-functioning pituitary adenomas (NFPA) and 100 age- and gender-matched mentally healthy controls. Personality was measured by two standardized personality questionnaires, TPQ (Cloninger personality questionnaire) and EPQ-RK (Eysenck personality questionnaire-RK).

RESULTS

Compared to mentally healthy controls, CD patients reported significantly less novelty-seeking behaviour, including less exploratory excitability and less extravagance. On harm avoidant subscales, they presented with more anticipatory worries and pessimism, higher fear of uncertainty, shyness with strangers, fatigability and asthenia. Moreover, CD patients appeared to be less extraverted, more neurotic and socially desirable. CD patients differed from NFPA patients in terms of higher neuroticism scores, and NFPA patients did not show altered novelty-seeking behaviour or extraversion. In the subgroup analysis, CD patients with persistent hypercortisolism displayed significantly higher fear of uncertainty, fatigability and asthenia, indicating high harm avoidance in total, than those in biochemical remission.

CONCLUSION

Patients with CD showed a distinct pattern of personality traits associated with high anxiety in combination with traits of low externalizing behaviour. Such personality changes should be taken into account in the diagnosis and treatment of CD patients, as they might interfere with the patient-physician communication and/or challenge the patients' social and psychological functioning.

Results of a single-center observational 10-year survey study on recurrence of hyperprolactinemia after pregnancy and lactation

CONTEXT

The current survey study investigated the recurrence rate of hyperprolactinemia after cabergoline (CAB)-induced pregnancy and after lactation as well as safety of CAB exposure during early gestation.

PATIENTS AND METHODS

From 1997-2008, 143 pregnancies were recorded in 91 patients with hyperprolactinemia (age 30.4 ± 4.7 yr, 76 microadenomas, 10 macroadenomas, and five nontumoral hyperprolactinemia). CAB therapy was discontinued within wk 6 of gestation in all. Pregnancies were monitored until delivery or termination, during and after lactation, twice yearly up to 60 months. The incidence of abortions, premature delivery, and fetal malformations was also analyzed.

RESULTS

Pregnancies resulted in 13 (9.1%) spontaneous abortions and 126 (88.1%) live births. No neonatal malformations and/or abnormalities were recorded. In 29 of 91 patients (three with macroadenomas), treatment with CAB had to be restarted within 6 months after lactation because of hyperprolactinemia recurrence, whereas in 68% of cases, no additional therapy was required up to 60 months. No tumor mass enlargement was observed. All patients but three were breastfeeding, 35 (38.5%) for less than 2 months and 56 (61.5%) for 2-6 months. Three months after cessation of lactation and 60 months after pregnancy, no difference in prolactin levels was found between patients nursing for less than 2 months and 2-6 months.

CONCLUSIONS

Fetal exposure to CAB at conception does not induce any increased risk of miscarriage or malformations. Pregnancy is associated with normalization of prolactin levels in 68% of patients. Breastfeeding does not increase the recurrence rate of hyperprolactinemia.

Changes in heart valve structure and function in patients treated with dopamine agonists for prolactinomas, a 2-year follow-up study

OBJECTIVE

The use of ergot-derived dopamine agonists (DA) to treat patients with prolactinomas has not been associated with an increased risk of significant heart valve dysfunction. Accordingly, the present study evaluated whether the long-term use of DA for hyperprolactinaemia may be associated with increased risk of significant valvular heart disease.

METHODS

A total of 74 patients (mean age 48 ± 1·4 years, 23% male) with prolactinoma treated with DA for at least 1 year were evaluated with 2-dimensional echocardiography at baseline. After 2 years of follow-up, a repeat echocardiography was performed to evaluate significant changes in valvular heart structure (thickening, calcifications and leaflet motion abnormalities) and function (regurgitation or stenosis). Patients were classified according to treatment: patients treated with cabergoline (group 1: n = 45), and patients not treated with cabergoline (group 2: n = 29).

RESULTS

At 2-year follow-up, no significant valvular stenosis was observed in any patient. In addition, the prevalence of any significant valve regurgitation did not change significantly (from 12% to 15%, P = NS). However, there was a significant increase in the prevalence of valvular calcifications (from 48% to 58%, P = 0·004) and, particularly, in the prevalence of aortic valve calcifications (from 39% to 53%, P = 0·002). In a per-treatment-based analysis, the group of patients treated with cabergoline had significantly higher prevalence of aortic valve calcification at 2 years follow-up as compared to the group of patients not treated with cabergoline (63%vs 38%, P = 0·016).

CONCLUSIONS

The long-term therapy with DA (cabergoline) of patients with prolactinoma is associated with an increased prevalence of valvular calcification. However, these structural changes were not accompanied by an increased prevalence of valvular dysfunction.

Adolescent acromegaly and decreased arterial distensibility despite successful treatment

OBJECTIVE

Cardiovascular complications that are probably related to the loss of arterial elasticity, such as secondary hypertension, occur frequently in patients with acromegaly and may persist after the condition has been treated. The aim of the study was to determine arterial compliance in adolescent patients with acromegaly who had undergone surgery to remove the adenoma in the pituitary gland. This is thought to be the first study on such patients.

PATIENTS

Sixteen patients (nine male, seven female; mean age at diagnosis, 17·6 ± 1·3 years; mean age at time of study, 23·3 ± 3·7 years) who had undergone surgery for acromegaly that was caused by a pituitary adenoma.

MEASUREMENTS

Arterial stiffness was measured by the standardized noninvasive QKd(100-60) method. In addition, blood pressure at rest was measured, ambulatory blood pressure was monitored over a 24-h period and transthoracic echocardiography was performed.

RESULTS

Adolescent patients who had been operated upon for acromegaly showed disadvantageous differences in 24-h ambulatory blood pressure monitoring (systolic blood pressure, P < 0·001; diastolic blood pressure, P < 0·02; mean blood pressure, P < 0·01) and in QKd(100-60) value (194 ± 4 vs 205 ± 5 ms, P < 0·03) compared with controls.

CONCLUSION

Despite successful treatment, the patients showed significantly decreased arterial distensibility as compared with controls, which might explain the observed differences in blood pressure. The findings show that such patients are at increased risk of developing cardiovascular diseases, despite their being youth and the restoration of normal secretion of growth hormone/insulin growth factor.

Paternal deprivation prior to adolescence and vulnerability to pituitary adenomas

It has been reported that women with prolactinoma were exposed, early in life, to an environment characterized by an absent or violent father. The present study was designed to evaluate whether paternal absence or violent paternal behavior were more prevalent in patients with pituitary adenomas (prolactinoma, acromegaly, non-secreting adenoma and Cushing's disease) compared to a control population. We conducted an observational case-control multicenter study. We interviewed 395 patients with prolactinoma (296 females and 99 males), 130 with acromegaly (87 females and 43 males), 237 with non-secreting adenoma (144 females and 93 males) and 68 with Cushing's disease (61 females and 7 males) and 365 patients from the same clinics with nodular thyroid disease or lymphocytic thyroiditis with euthyroidism as controls. Violent or absent fathers were significantly more prevalent in patients with prolactinoma or acromegaly than in controls (P = 0.001 and P = 0.002, respectively) but not in patients with non-secreting adenoma or corticotrophinoma. Absent fathers in prolactinoma and acromegaly versus controls: P = 0.001 and P = 0.119. Violent fathers in prolactinoma and acromegaly versus controls: P = 0.069 and P = 0.001. The prevalence of absent or violent fathers was also significantly higher in prolactinoma and acromegaly when compared to non-secreting adenoma (P = 0.039 and P = 0.033, respectively). Paternal deprivation before adolescence may be a risk factor for prolactinoma and acromegaly but not for non-secreting pituitary adenomas or Cushing's disease.

The bilateral supraorbital minicraniotomies for total removal of giant suprasellar-subchiasmatic tumors

Minimally invasive supraorbital approach through minicraniotomy have been proposed and developed for the treatment of anterior cranial fossa pathology and lesions around sellae. The author has used this concept of smaller operative corridors to treat the suprasellar tumors. In cases of large suprasellar tumors, mainly of subchiasmatic location, that radical removal could not be achieved with unilateral approach, an additional contralateral supraorbital approach was proceeded to accomplish radical removal. Through bicoronal incision, approach via bilateral supraorbital minicraniotomies was used to treat three cases of giant suprasellar-subchiasmatic tumors, with the greatest dimension of more than 4 cm, between 2005 and 2010. The result of treatment is satisfactory. There was no operative mortality or new major neurological deficit. All tumors were totally removed with marked improvement of visual deficit in two patients. No adjuvant radiotherapy was given. All were recurrence free 18 months, 4 years, and 5 years after the surgery. The major advantage of this approach is the excellent visualization and identification of the plane between the tumor and contralateral optic nerve through each corridor This will facilitate complete decompression of both optic nerves and enhance radical removal of the tumor while avoiding risk of injury to the nearby neurovascular structures. However, the approach-related disadvantage is the risk of olfactory dysfunction from bilateral olfactory nerve damage, which can be further improved by a refinement of the techniques.

Multiple endocrine neoplasia type 1 in Japan: establishment and analysis of a multicentre database

OBJECTIVE

Multiple endocrine neoplasia type 1 (MEN1) is less well recognized in Asian countries, including Japan, than in the West. The clinical features and optimal management of MEN1 have yet to be clarified in Japan. The aim of this study was to clarify the clinical features of Japanese patients with MEN1.

DESIGN/PATIENTS

We established a MEN study group designated the 'MEN Consortium of Japan' in 2008, and asked physicians and surgeons to provide clinical and genetic information on patients they had treated. Of 680 registered patients, 560 were analysed.

MEASUREMENTS

Clinical and genetic features of Japanese patients with MEN1 were examined.

RESULTS

Primary hyperparathyroidism, gastroenteropancreatic neuroendocrine tumours (GEPNET), and pituitary tumours were seen in 94·4%, 58·6% and 49·6% of patients, respectively. The prevalence of insulinoma was higher in the Japanese than in the West (22%vs 10%). In addition, 37% of patients with thymic carcinoids were women, while most were men in western countries. The MEN1 mutation positive rate was 91·7% in familial cases and only 49·3% in sporadic cases. Eight novel mutations were identified. Despite the availability of genetic testing for MEN1, the application of genetic testing, especially presymptomatic diagnosis for at-risk family members appeared to be insufficient.

CONCLUSIONS

We established the first extensive database for Asian patients with MEN1. Although the clinical features of Japanese patients were similar to those in western countries, there were several characteristic differences between them.

Comorbidity and cardiovascular risk factors in adult GH deficiency following treatment for Cushing's disease or non-functioning pituitary adenomas during childhood

OBJECTIVE

Cushing's disease (CD) and non-functioning pituitary adenoma (NFPA) are rare in paediatric patients. The aim of this study was to describe long-term consequences in adults with GH deficiency (GHD) treated for CD or NFPA during childhood.

DESIGN, PATIENTS AND METHODS

This was a retrospective analysis of data from KIMS (Pfizer International Metabolic Database). Background characteristics, anthropometry and comorbidity were studied in 47 patients diagnosed with childhood-onset (CO)-CD and 62 patients with CO-NFPA. Data from 100 ACTH-sufficient patients with CO-idiopathic hypopituitarism (CO-Idio) were used for comparison. Cardiovascular risk profile was analysed at baseline and at 1 year on GH treatment in a subgroup of patients (17 CO-CD, 24 CO-NFPA and 55 CO-Idio) not receiving GH treatment at study entry.

RESULTS

The median age at diagnosis of pituitary tumour was 14.0 years (range 10-17) in patients with CO-CD and 13.7 years (range 8-17) in CO-NFPA. In addition to GHD, 41% of patients with CO-CD had three or four other pituitary hormone deficiencies compared with 78% of patients with CO-NFPA (P<0.001). Eighty-nine per cent of patients with CO-CD had height SDS lower than 0 compared with 61% of patients with CO-NFPA (P=0.002). Hypertension was more common in CO-CD compared with CO-Idio (23 vs 9%, P=0.018). At 1 year on GH treatment, total- and low-density lipoprotein-cholesterol decreased significantly in CO-CD but not in CO-NFPA.

CONCLUSION

Adult patients with GHD following treatment for paediatric CD and NFPA have long-term adverse consequences. Despite more severe hypopituitarism in CO-NFPA, patients with CO-CD have more frequently compromised final stature.

Impaired aerobic exercise adaptation in children and adolescents with craniopharyngioma is associated with hypothalamic involvement

OBJECTIVE

Many patients treated for craniopharyngioma (CP) complain of a relative incapacity for physical activity. Whether this is due to an objective decrease in adaptation to exercise is unclear. We assessed exercise tolerance in children with surgically treated CP and appropriate pituitary hormone replacement therapy compared with healthy controls and we examined the potential relationships with hypothalamic involvement, GH replacement, and the catecholamine deficiency frequently observed in these subjects.

DESIGN AND METHODS

Seventeen subjects (12 males and five females) with CP and 22 healthy controls (14 males and eight females) aged 15.3±2.5 years (7.3-18 years) underwent a standardized cycle ergometer test. Maximum aerobic capacity was expressed as the ratio of VO(2max) to fat-free mass (VO(2max)/FFM), a measure independent of age and fat mass in children.

RESULTS

VO(2max)/FFM was 20% lower in children with CP compared with controls (P<0.05), even after adjustment for gender. Children with hypothalamic involvement (n=10) had a higher percentage of fat mass (P<0.05) than those without hypothalamic involvement (n=7) and lower VO(2max)/FFM (P<0.05), whereas children without hypothalamic involvement had VO(2max)/FFM close to that of controls (P>0.05). GH treatment was associated with a significant positive effect on aerobic capacity (P<0.05) only in the absence of hypothalamic involvement. No relationship was found between exercise capacity parameters and daily urine epinephrine excretion or epinephrine peak response to insulin-induced hypoglycemia.

CONCLUSIONS

Children with CP have a decrease in aerobic capacity mainly related to hypothalamic involvement. The hypothalamic factors altering aerobic capacity remain to be determined.

Pituitary incidentaloma

Pituitary incidentalomas (PIs) are commonly encountered in clinical practice. While most are microincidentalomas (<1 cm) and not functional, in some cases their identification may lead to discovery of unrecognized abnormalities such as pituitary hormonal deficiencies, excess hormone secretion or visual field defects. Although the majority are pituitary adenomas, the potential list of differential diagnosis is extensive. A limited biochemical work up for asymptomatic patients with microincidentalomas, to include measurement of prolactin and IGF-1, is reasonable, with further studies to be tailored based on the clinical picture. All patients with macroincidentalomas (≥1 cm) should be evaluated for hypopituitarism and undergo visual field testing if the sellar mass abuts or compresses the optic chiasm. Most PIs can be followed, closely without surgery over time, but some may require surgical removal, especially if they are found to be macroincidentalomas at presentation, encroaching on or abutting the optic chiasm, or are found to be functional, excluding prolactinomas. Recovery of pituitary function may be seen in some patients with mass effect following resection of a sellar mass. The association of headache and pituitary incidentalomas remains a diagnostic challenge. There are no randomized controlled studies to guide the follow up approach when surgery is not indicated; most of the follow up algorithms in the literature are based on personal experience. Most retrospective series on natural history indicate that microincidentalomas tend not to grow; without a need for long-term follow up unless the patient becomes symptomatic. Macroincidentalomas, on the other hand, have a propensity to grow and need a more aggressive follow up approach to minimize morbidity.

Evidence-based endocrinology: illustrating its principles in the management of patients with pituitary incidentalomas

Incidentally discovered pituitary lesions are commonly encountered in the current era of ever-increasing imaging. Individualizing a particular approach implies a thorough analysis of existing evidence and balancing it against different patient expectations. We will illustrate the application of principles of Evidence-Based Medicine to a case of a pituitary incidentaloma by formulating questions that are important to patient care and finding related evidence. Our objective is to reflect the opportunities and the challenges that an evidence-based clinical approach offers to clinicians and patients.

Prevalence of pituitary adenomas in macroprolactinemic patients may be higher than it is presumed

One form of prolactin (PRL) is macroprolactin with high molecular mass. Many macroprolactinemic patients have no pituitary adenomas and no clinical symptoms of hyperprolactinemia, it is controversial whether macroprolactinemia is a benign condition that does not need further investigation and treatment. In this study, we aimed to compare macroprolactinemic patients (group I) with the true hyperprolactinemic patients (group II) for the presence of pituitary adenoma. We investigated 161 patients with hyperprolactinemia, whose magnetic resonance imaging records of the pituitary were taken. All patients were questioned for irregular menses, infertility and examined for galactorrhea. Patients were screened for macroprolactinemia by polyethylene glycol precipitation, and a recovery of ≤40% and normal monomeric PRL level was taken as an indication of significant macroprolactinemia. Of 161 patients with hyperprolactinemia, 60 (37.26%) had macroprolactinemia. PRL levels of group II were lower than those of group I (P = 0.011), although monomeric PRL levels of group II were higher than those of group I (P = 0.0005). Of 60 macroprolactinemic patients, 16 (26.7%) had pituitary adenomas. The prevalence of pituitary adenomas was lower in group I, compared with group II (P = 0.0005). No significant differences were found between the prevalences of irregular menses and infertility of group I and II (P = 0.084, P = 0.361). Prevalence of galactorrhea in group I was lower than that in group II (P = 0.048). Prevalence of pituitary adenomas in macroprolactinemic patients is lower compared with the true hyperprolactinemic patients, but may be higher than that found in other recent studies and in the general population.

[Clinical trial of sexual dysfunctions in male patients with pituitary adenomas]

OBJECTIVE

To explore the clinical features and related factors of sexual dysfunctions in male patients with pituitary adenomas.

METHODS

The questionnaires of sexual functions were collected from 86 male patients with pituitary adenomas. We examined the clinical features of sexual dysfunctions and analyzed the correlations between sexual behaviors and age, tumor type, invasiveness, tumor size, serum levels of prolactin (PRL) and testosterone.

RESULTS

The incidence of sexual dysfunctions was 80.2% (69/86). Sexual dysfunctions were found in 84.6% (66/78) of the patients with functioning pituitary adenomas and 37.5% (3/8) of those with non-functioning pituitary adenoma respectively. In the PRL group, the incidence of erectile dysfunctions was 92.1% (35/38) and it was higher than those in the FSH (follicle-stimulating hormone) and GH (growth hormone) groups (P < 0.05). In the FSH group, the incidence of reduced sexual desire was 78.3% (18/23). In the GH group, the incidence of erectile dysfunctions was 70.6% (12/17) and the incidence of reduced sexual desire or ejaculation dysfunction was lower than that of the PRL/FSH group (P < 0.05).

CONCLUSION

The incidence of sexual dysfunctions is quite high in males with pituitary adenomas, especially for those with functioning pituitary adenomas. The clinical features of sexual dysfunctions vary in different types of functioning pituitary adenoma. The incidence of erectile dysfunctions is the highest in the PRL group. Pathological type of pituitary tumors is a major risk factor of sexual dysfunctions.

Optimal effective doses of cabergoline and bromocriptine and valvular leasions in men with prolactinomas

OBJECTIVES

Prolactinoma is the most common pituitary adenoma, and dopamine agonists( BRC, and CAB) is the primary therapy. Recently, the increased prevalance of cardiac valvular disease in patients treated with DAs for Parkinson's disease has raised concerns about the safety of this drug in patients with prolactinoma. CAB and pergolide are frequently reported to cause valvulopathy, there are very few studies showing this side effect in BRC administiration which has less potent agonism of 5-HT2B receptors. Male patients who are known to have higher prevalance of macroadenomas compared to women. The dosage of DAs administered were rarely evaluated.

METHODS

We performed a retrospective chart to evaluate the medical management and treatment outcomes of male patients with macro/giant prolactinomas. We evaluated 22 patients with prolactinoma managed with DAs therapy alone for at least 1 year. All patients were followed for a mean of 61 months. Pretreatment echocardiographic examination were not available at that time.

RESULTS

None of them had any resistance or intolerance to DAs. The mean tumor shrinkage was 62%. In three patients the macroprolactinoma disappeared, in two patients the tumor shrinkage was 93% and 70%. The DAs therapy was discontinued in these patient. After a follow up neither MRI showed a recurrence or enlargement of the adenoma, nor prolactin levels showed any elevation. The echocardiography were performed at the last visit of each patient and no valvulopathy in any of the patients on DAs therapy were detected.

CONCLUSIONS

DAs are effective, and safe for valve morphology with mean cumulative doses of 155 mg CAB, and 7 301 mg BRC in patients with macroprolactinoma.

High prevalence of radiological vertebral fractures in women with prolactin-secreting pituitary adenomas

Hyperprolactinemia may cause bone loss but data on fractures are scanty. The aim of this study was to evaluate the prevalence of vertebral fractures in women with prolactin (PRL)-secreting adenoma. In this cross-sectional study, 78 women (median age 45.5 years, range: 20-81) with PRL-secreting pituitary adenoma (66 with microadenoma and 12 with macroadenoma) and 156 control subjects, with normal PRL values and with comparable age to patients with hyperprolactinemia, were evaluated for vertebral fractures by a morphometric approach and for bone mineral density (BMD) by a dual-energy X-ray absorptiometry at lumbar spine. Vertebral fractures were shown in 25 patients with PRL-secreting adenoma (32.6%) and in 20 controls (12.8%, P < 0.001). Fractured patients were significantly older (P < 0.001) and had lower BMD T-score (P < 0.001), longer duration of disease (P < 0.001), higher serum PRL (P = 0.004) and lower serum IGF-I (P < 0.001) values as compared to patients who did not fracture. The prevalence of vertebral fractures was significantly (P < 0.001) higher in post-menopausal women with PRL-secreting adenoma as compared to pre-menopausal patients. Fractures occurred more frequently (P = 0.01) in patients with untreated hyperprolactinemia versus patients treated with cabergoline. Logistic regression analysis demonstrated that duration of disease maintained a significant correlation with vertebral fractures (odds ratio 1.16, C.I. 95% 1.02-1.33) even after correction for age, menopausal status, treatment with cabergoline, BMD, serum IGF-I and serum PRL values. Hyperprolactinemia is associated with high prevalence of radiological vertebral fractures in women with PRL-secreting adenoma.

[Non-functioning pituitary adenoma: is there an interest to treat a residue after surgery?]

Diagnosis of non-functioning pituitary adenoma is generally posted when there is a compression of the ophthalmic nerve or when a hypopituitarism occurred. Surgery will be the first treatment but complete removal can be achieved in less than 50% of the patients. In the great majority of the patients, there is a recurrence and a new treatment is proposed. The question is when we must treat a residue after surgery. We performed a retrospective study reviewing a series of 111 patients with a non-functioning pituitary adenoma. All patients had a pre- and post-operative MRI (1.5 T). A statistical analysis was done to determine the influence of the resection, the age of the patient on the recurrence. A complete removal was achieved for 45 patients and 11 of these present a recurrence. 39 patients out of 66 patients who had a partial removal presented also a recurrence. The mean age of the population is 53 years. The statistical analysis demonstrates that patients with a complete removal had less recurrence. Patient with an age below 60 years had more frequently a recurrence compared with older than 60 years old. In conclusion, treatment for non-functioning pituitary adenoma is a transsphenoidal approach surgery. A complete surgery must be the aim of the neurosurgeon. And when a residue is present, a secondary treatment must be given for patient with an age below 60 years old like radiosurgery or radiation therapy.

Can we ever stop imaging in surgically treated and radiotherapy-naive patients with non-functioning pituitary adenoma?

BACKGROUND

Non-functioning pituitary adenomas (NFAs) are slow-growing tumours with reported re-growth rates following surgical resection alone of up to 50% at 10 years. Currently, the desired length of follow-up surveillance imaging in un-irradiated patients is unclear.

AIM

To clarify the timing of re-growth in patients with NFAs, treated solely by surgery without post-operative pituitary radiotherapy, and also to clarify whether continued imaging is necessary in these patients.

METHODS

A case note analysis of all patients who underwent surgery alone for NFA between January 1984 and December 2007 was undertaken. Patients were followed for a minimum of 1 year. Re-growth was diagnosed on the basis of radiological appearances with or without associated manifestations.

RESULTS

One hundred and fifty-five patients (94 males, mean age at diagnosis 57.9 (range 18.3-88) years) were included. Twenty-nine were followed up for more than 10 years. The mean follow-up following surgery was 6.1 years (median 4.3 (range 1-25.8)). Re-growth was documented in 54 (34.8%) cases and 20.4% of these cases showed relapse/re-growth 10 or more years after the initial surgery. Kaplan-Meier analysis showed relapse rates of 23.1, 46.7 and 67.9% at 5, 10 and 15 years respectively. There was a significant increase in the re-growth rates if there was either pituitary tumour remnant observed on the first post-operative scan (P≤0.001) or a younger age at initial surgery (P=0.034).

CONCLUSION

These results suggest that patients with NFAs need to be closely monitored following surgery, particularly those with post-operative tumour remnants. With 20% of relapse occurring after 10 years, follow-up surveillance needs to be continued beyond this time.

High prevalence of AIP gene mutations following focused screening in young patients with sporadic pituitary macroadenomas

BACKGROUND

Aryl hydrocarbon receptor interacting protein (AIP) mutations (AIPmut) cause aggressive pituitary adenomas in young patients, usually in the setting of familial isolated pituitary adenomas. The prevalence of AIPmut among sporadic pituitary adenoma patients appears to be low; studies have not addressed prevalence in the most clinically relevant population. Hence, we undertook an international, multicenter, prospective genetic, and clinical analysis at 21 tertiary referral endocrine departments.

METHODS

We included 163 sporadic pituitary macroadenoma patients irrespective of clinical phenotype diagnosed at <30 years of age.

RESULTS

Overall, 19/163 (11.7%) patients had germline AIPmut; a further nine patients had sequence changes of uncertain significance or polymorphisms. AIPmut were identified in 8/39 (20.5%) pediatric patients. Ten AIPmut were identified in 11/83 (13.3%) sporadic somatotropinoma patients, in 7/61 (11.5%) prolactinoma patients, and in 1/16 non-functioning pituitary adenoma patients. Large genetic deletions were not seen using multiplex ligation-dependent probe amplification. Familial screening was possible in the relatives of seven patients with AIPmut and carriers were found in six of the seven families. In total, pituitary adenomas were diagnosed in 2/21 AIPmut-screened carriers; both had asymptomatic microadenomas.

CONCLUSION

Germline AIPmut occur in 11.7% of patients <30 years with sporadic pituitary macroadenomas and in 20.5% of pediatric patients. AIPmut mutation testing in this population should be considered in order to optimize clinical genetic investigation and management.

Obesity and craniopharyngioma

An epidemic of pediatric obesity has occurred across the world in recent years. There are subgroups within the population at high-risk of becoming obese and especially of having experience of precocious cardiovascular and metabolic co-morbidities of obesity. One of these subgroups comprises patients treated for childhood cancers and namely survivors of craniopharyngioma. The high incidence of obesity in this group makes these patients an important disease model to better understand the metabolic disturbances and the mechanisms of weight gain among cancer survivors. The hypothalamic-pituitary axis damage secondary to cancer therapies or to primary tumor location affect long-term outcomes. Nevertheless, the aetiology of obesity in craniopharyngioma is not yet fully understood. The present review has the aim of summarizing the published data and examining the most accepted mechanisms and main predisposing factors related to weight gain in this particular population.

Glaucoma-like optic neuropathy in patients with intracranial tumours

PURPOSE

To examine frequency and associated factors of glaucoma-like appearance of the optic nerve head in patients with intrasellar, suprasellar or parasellar tumours.

METHODS

This retrospective clinical observational study included patients who were consecutively treated for intrasellar tumours (n = 143), suprasellar tumours (n = 321), parasellar tumours (n = 36) or retrosellar tumour (n = 1), and all of whom had undergone fundus photography and full-threshold visual field examination. The tumour spectrum included 336 pituitary gland tumours, 32 meningiomas, 89 craniopharyngiomas, 9 chiasmal gliomas and 35 other types of tumours or lesions. An age-matched control group was formed from the population-based Beijing Eye Study. Using fundus photographs and visual field examinations, glaucoma was defined by a neuroretinal rim shape not following the ISNT rule (Disc glaucoma group) and by an abnormal rim shape plus glaucoma-like visual field defects (Field glaucoma group). Type and size of the tumours were assessed on neuroradiological images.

RESULTS

Five-hundred and one patients fulfilled the inclusion criteria. Disc glaucoma and Field glaucoma were detected significantly more frequently in the study population [34 (6.8%) patients and 31 (6.3%) patients, respectively] than in the population-based control group of the same ethnicity (1.3% ± 0.5%; p < 0.001). In multivariate analysis, presence of Disc glaucoma [odds ratio (OR) = 2.64; p = 0.016] and presence of Field glaucoma (OR = 3.01; p = 0.027) were significantly associated with tumour location [suprasellar > parasellar > intrasellar]. The same held true for tumour width (OR = 1.08; p = 0.002; and OR = 1.08; p = 0.003, respectively).

CONCLUSIONS

Large perisellar tumours were associated with a glaucoma-like appearance of the optic nerve head in eyes. It may diagnostically and pathogenetically be of importance.

Cancer risk in hyperprolactinemia patients: a population-based cohort study

OBJECTIVE

Experimental evidence indicates that prolactin might play a role in tumorigenesis of several human cancers, but data on cancer risk in hyperprolactinemia patients are sparse. The aim of this study was to investigate cancer risk in hyperprolactinemia patients. Design A population-based matched cohort study in Sweden.

METHODS

The hyperprolactinemia cohort consisted of patients hospitalized for hyperprolactinemia from 1987 to 1995 identified in the National Patient Register (n=585) and a hospital cohort of prolactinoma patients at Karolinska University Hospital (n=384). For each patient, ten matched individuals were identified via the Register of Population. Cancer occurrence was ascertained via the Swedish Cancer Registry. Hazard ratios (HRs) were estimated by Cox proportional hazards regression.

RESULTS

Seventy-three malignant tumors were identified in the hyperprolactinemia patients and 660 tumors in the comparison group (HR 1.31; 95% confidence interval (CI): 1.02-1.68), mainly attributed to an increased risk of upper gastrointestinal cancer in both males and females (HR 3.69; 95% CI: 1.70-8.03) and hematopoietic cancer in females (HR 3.51; 95% CI: 1.06-11.6). Twelve breast cancers occurred in the female patients, corresponding to an HR of 1.09 (95% CI: 0.60-1.99). Prostate cancer risk in hyperprolactinemia men was reduced (HR 0.40; 95% CI: 0.16-0.99).

CONCLUSIONS

An increased overall cancer risk was found in hyperprolactinemia patients, but no increased risk of breast cancer in women and a reduced risk of prostate cancer in men. These findings warrant further investigations and to be confirmed in larger studies but may indicate the importance of an active treatment strategy and follow-up of hyperprolactinemia patients.