Endocrine incidentalomas--challenges imposed by incidentally discovered lesions

Endocrine glands are among the organs that most frequently harbor incidentally discovered lesions. Pituitary, thyroid, parathyroid and adrenal incidentalomas are increasingly encountered in everyday practice with variable clinical implications. The major concerns are the risks of malignancy and hormonal hypersecretion mostly in the form of subclinically functioning tumors. Pituitary incidentalomas are usually microadenomas and most of the time clinically unimportant; however, incidentally discovered larger lesions require a more careful diagnostic and therapeutic approach. Thyroid incidentalomas are extremely common; exclusion of malignancy is the main concern in this clinical setting. Although parathyroid adenomas are not uncommon, these lesions are frequently missed owing to their small size and due to clinical unawareness. Adrenal incidentalomas carry a small but finite risk of malignancy. An intriguing challenge regarding incidentally discovered adrenal lesions is that a substantial proportion is associated with hormonal alterations, mainly in the form of subtle cortisol excess. Although still largely controversial, evidence is emerging that so-called subclinical hypercortisolism may not be completely harmless. The best biochemical criterion of subtle cortisol excess remains elusive. Surgical intervention in selected cases results in some beneficial effects, but more data are required in order to routinely support surgery in this clinical setting. This Review provides a brief overview of the prevalence, clinical effect and management of endocrine incidentalomas with a focus on data regarding the diagnostic and therapeutic challenges imposed by incidentally discovered adrenal lesions.

Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients

The authors investigate the complications of transnasal transsphenoidal endoscopic surgery in the treatment of 301 patients with pituitary adenomas. A retrospective analysis of complications in 301 patients submitted to transsphenoidal transnasal endoscopic surgery at the General Hospital of Fortaleza, Brazil between January 1998 and December 2009. The complications were divided in two groups: anatomical (oronasofacial, sphenoid sinus, intrasellar, suprasellar and parasellar) and endocrinological complications (anterior and posterior pituitary dysfunctions). We observed a total of 81 complications (26.9%) in our series. Anatomical complications occurred in 8.97% (27 cases): 8 CSF postoperative leaks (2.6%), 6 cases (1.9%) of delayed nasal bleeding, 5 cases (1.6%) of sphenoidal sinusitis, 3 cases (0.9%) of carotid artery lesion, 2 cases of meningitis (0.6%) and one case (0.3%) of each of the uncommon following complications: intrasella-suprasella hematoma, pontine hematoma and chiasmaplexy. Endocrinological complications occurred in 17.9% (54 cases): additional postoperative anterior lobe insufficiency in 35 cases (11.6%), and postoperative diabetes insipidus in 19 cases (6.3%). In our series, 3 cases of deaths (not directly related to the procedure) were also observed. Endoscopic transsphenoidal surgery represents an effective option for the treatment of patients with pituitary tumor. Complications still occur and must be reduced as much as possible. Successful endoscopic pituitary surgery requires extensive training in the use of an endoscope and careful planning of the surgery. Additional improvement can be expected with greater experience and new technical developments.

Diabetes in acromegaly, prevalence, risk factors, and evolution: data from the French Acromegaly Registry

OBJECTIVES

The French Acromegaly Registry records data of acromegalic patients' since 1992 in French, Belgian (Liège), and Swiss (Lausanne) centers. We studied the prevalence of diabetes in this population looking for risk factors. Patients from one of the centers (Reims) were then analyzed more thoroughly.

METHODS

This study has been conducted on all the patients recorded from 1999 until 2004 (519 patients). Evolution of cohorts' was reassessed in 2009. Of the different variables recorded in the registry: age, sex, body mass index (BMI), duration of acromegaly, GH, IGF1 and prolactin levels, pituitary tumor size, hormonal deficiencies, presence, duration and treatment of diabetes, hypertension, and rheumatological disease were analyzed.

RESULTS

The prevalence of diabetes in the registry was 22.3%. Diabetic patients were older and had a higher BMI. Compared with the data of the French Social Security, acromegalic patients showed a more precocious apparition of diabetes and prevalence was higher in each age group. Compared with non-diabetic acromegalic subjects, diabetic patients had a more prolonged evolution of acromegaly before diagnosis. The levels of GH and IGF1 were not significantly different between the two groups. Only hypertension was significantly more frequent in diabetic patients.

CONCLUSIONS

In our population, the prevalence of diabetes was estimated to be 22.3%. The GH and IGF1 levels did not appear as predictive factors for the presence of diabetes. On the contrary, age, BMI, and hypertension were significant risk factors as in the general population of type 2 diabetics.

Carotid atheromatic plaque is commonly associated with hypopituitary men

Hypopituitarism increases the risks of many cardiovascular conditions and therefore, patients with this disease are more prone to cardiovascular disease. To our knowledge, there have been few studies on carotid artery plaque in male patients with hypopituitarism in assessing cardiovascular risks. The aim of this study was to specifically compare carotid artery plaque while examining other major cardiovascular risk factors between male patients with hypopituitarism and control subjects. Forty male patients aged 30-70 years with hypopituitarism and forty age, sex- matched control subjects were recruited at the Yonsei University Severance Hospital, Seoul, Korea. Carotid intima media thickness (IMT) and atheromatous plaque, anthropometry, lipid profile, and pituitary hormones were assessed. Atheromatous plaque in the carotid arteries was observed more frequently in patients with hypopituitarism than age- and sex-matched control subjects (59.5% vs. 2.5%, P<0.01) without differences of carotid IMTs. Patients with hypopituitarism also exhibited higher waist circumference, waist to hip ratio, total cholesterol and LDL cholesterol than control subjects. In subgroup analysis in male patients with hypopituitarism including GH deficiency, lower testosterone levels were associated with higher waist circumference (r=0.446, P=0.033). In conclusion, hypopituitary males exhibit an increased incidence of carotid artery plaque without differences of carotid IMTs, central obesity and higher total cholesterol level. Lower testosterone levels were associated with central obesity- a strong component of a metabolic syndrome, and unsubstituted testosterone deficiency might be an important cardiovascular risk factor in patients with hypopituitarism.

Coping strategies in patients after treatment for functioning or nonfunctioning pituitary adenomas

CONTEXT AND OBJECTIVE

Coping strategies may affect quality of life, which is decreased in patients after treatment for Cushing's disease, acromegaly, or nonfunctioning pituitary macroadenomas (NFMA). We aimed to explore coping strategies in these patients because this has never been done before.

DESIGN

We conducted a cross-sectional study.

SUBJECTS

We included patients treated for Cushing's disease (n = 42), for acromegaly (n = 80), and for NFMA (n = 61). These patients were compared with three reference populations: an a-select sample from the Dutch population (n = 712), patients with chronic pain (n = 59), and patients receiving primary care psychology services (n = 525). Furthermore, the three patient groups were compared with each other. Coping strategies were assessed by the Utrecht Coping List.

RESULTS

Compared with the a-select sample, patients with pituitary adenomas reported less active coping (P < 0.0001), sought less social support (P < 0.0001), and reported more avoidant coping (P = 0.008). In contrast, patients treated for pituitary adenomas reported somewhat better coping strategies than patients with chronic pain and those with psychological disease. When patients with different pituitary adenomas were compared, patients treated for Cushing's disease sought more social support than patients treated for NFMA (P = 0.035).

CONCLUSIONS

Patients treated for pituitary adenomas display different and less effective coping strategies compared with healthy controls. A targeted intervention might help to stimulate patients to use a more active coping strategy and to seek social support instead of an avoiding coping strategy. This might, in turn, improve their quality of life.

Natural history of nonfunctioning pituitary adenomas and incidentalomas: a systematic review and metaanalysis

CONTEXT

The natural history of pituitary incidentalomas (PIs) and nonfunctioning pituitary adenomas (NFPAs) remains poorly understood.

OBJECTIVE

The objective of the study was to synthesize the literature on the prognostic factors involved in the progression of PIs and NFPAs in patients followed up conservatively.

DATA SOURCES

We searched MEDLINE, EMBASE, and Cochrane CENTRAL. We sought to identify further studies by reviewing the reference lists from selected studies and reviews and by querying experts.

STUDY SELECTION

Eligible studies were longitudinal observational cohort studies that enrolled patients with PIs/NFPAs and followed them up without any treatment from the time of detection and reported on mortality, lesion progression, and development of pituitary hormonal deficiency, apoplexy, or visual field defects.

DATA EXTRACTION

Reviewers working independently and in duplicate determined studies' eligibility and collected descriptive, methodological quality, and outcome data. Event rates per 100 person-years (PYs) and associated 95% confidence intervals (CIs) were estimated from each study and pooled using the random-effects model.

DATA SYNTHESIS

The 11 included studies had noncomparative single-cohort design. Follow-up duration ranged from 3 to 15 yr. There was a greater tendency for tumor growth in macroadenomas (12.5 per 100 PYs; 95% CI 7.9, 17.2) and in solid lesions (5.7 per 100 PYs; 95% CI 2.3, 9.2) in comparison with microadenomas (3.3 per 100 PYs; 95% CI 2.1, 4.5) and cystic lesions (0.05 per 100 PYs; 95% CI 0.0, 0.2). The development of pituitary apoplexy and worsening of visual field defects were rare. The overall incidence of new endocrine dysfunction was 2.4 per 100 PYs; 95% CI 0.0, 6.4. The majority of these analyses were associated with significant heterogeneity. There was a trend that did not reach statistical significance for greater incidence of pituitary apoplexy and new endocrine dysfunction worsening in macroadenomas compared with microadenomas. The quality of the evidence (risk of bias) was very low due to heterogeneity, methodological limitations, and imprecision caused by the small number of events.

CONCLUSIONS

Despite the relatively high prevalence of PIs/NFPAs, the evidence on the natural history of these entities is scarce and of low quality. PIs/NFPAs seem to have fairly rare complications that may be more common when lesions are large (>10 mm) and solid.

Demographic differences in incidence for pituitary adenoma

Incidence estimates for pituitary adenomas vary widely, suggesting the effects of numerous risk factors or varying levels of tumor surveillance. We studied the epidemiology of pituitary adenomas using 2004-2007 data collected by 17 Surveillance, Epidemiology, and End Results Programs in the United States (N = 8,276). We observed that incidence rates generally increased with age and were higher in females in early life and higher in males in later life. Males are diagnosed with larger tumors on average than females. Diagnosis may be delayed for males, giving tumors a chance to grow larger before clinical detection. We also observed that American Blacks have higher incidence rates for pituitary adenomas compared with other ethnic groups. There are several potential explanations for this finding with some evidence that at least part of the effect may be due to differential diagnosis between races.

Management of recurrent craniopharyngioma

Craniopharyngioma accounts for approximately 1.2% to 4.6% of all intracranial tumours. Their close proximity to vital structures such as the hypothalamic-pituitary axis and optic apparatus makes them one of the most challenging and controversial management dilemmas in neurosurgery. Recurrence following initial transcranial resection is reported as 9% to 51% at a median time of 26 months to 96 months. Treatment options for recurrent craniopharyngioma include repeat surgery, radiotherapy, radiosurgery and intracystic therapies. We present a series of 54 recurrent craniopharyngiomas treated at The Royal Melbourne Hospital between 1991 and 2008 and discuss the management options now available.

Risk factors for obesity in childhood survivors of suprasellar brain tumours: a retrospective study

AIM

To characterize postdiagnosis changes in body mass index (BMI) among childhood survivors of suprasellar brain tumours, and to determine the risk factors associated with obesity.

METHODS

We conducted a retrospective analysis of 46 children (16 boys and 30 girls) with median (IQR) age of 7.49 (3.47-11.59) years at tumour diagnosis, and followed up for 3.93 (1.68-7.27) years. Survival analyses were used to identify risks of developing obesity.

RESULTS

There were no sex differences in age at tumour diagnosis, duration of follow-up, tumour types, endocrinopathies, treatment modalities or baseline BMI SDS. In the first year after tumour diagnosis, ΔBMI SDS (median; IQR) was greater in girls (1.32; 0.07-2.08) than in boys (0.48; -0.40 to 0.89) (p = 0.01). At diagnosis, 3/46 children (6%) were obese; this increased to 20/46 (43%) by last follow-up (p < 0.001) and was more common in girls (17/30; 57%) than in boys (3/16; 19%). Female gender (hazard ratio 5.0, 95% CI 1.2-21.7; p = 0.04) and greater than average baseline BMI (hazard ratio 4.7, 95% CI 1.1-20.8; p = 0.02) were risk factors for subsequent obesity.

CONCLUSION

Accurate prediction of obesity risk is important and would allow early targeted intervention in high-risk patients.

Acromegaly and pregnancy: a retrospective multicenter study of 59 pregnancies in 46 women

CONTEXT

Few data are available on pregnancy outcomes in women with acromegaly.

STUDY DESIGN

This was a retrospective multicenter study.

PATIENTS

The study included 46 women with GH-secreting pituitary microadenomas (n = 7) or macroadenomas (n = 39). Their mean age was 31.7 yr (±4.5 yr). Incomplete transsphenoidal surgical resection (n = 39) and pituitary radiation (n = 14) had been performed, respectively, 2.9 ± 2.6 and 7.3 ± 4.2 yr before pregnancy. The patients were receiving dopamine agonists (n = 25) and/or somatostatin analogs (n = 14), and GH/IGF-I hypersecretion was controlled and uncontrolled in, respectively, 23 and 34 cases. Five pregnancies followed the fertility treatment.

RESULTS

Fifty-nine pregnancies resulted in 64 healthy babies. Gestational diabetes and gravid hypertension occurred in four (6.8%) and eight (13.6%) pregnancies, respectively, and both were more frequent when GH/IGF-I hypersecretion was not controlled before pregnancy. Visual field defects were diagnosed during pregnancy in four women, three of whom were diagnosed with acromegaly during the pregnancy. Seven women had isolated headache. Magnetic resonance imaging performed 3.9 ± 0.3 months after delivery showed that the size of the adenoma had increased in three cases, decreased in two cases, and remained stable in 22 cases. Seventeen women breast-fed with no complications. Four women gave birth to a small-for-gestational-age infant; all had received somatostatin analogs, alone or in combination with dopamine agonists, during pregnancy. The mean IGF-I level fell significantly during the first trimester in 12 cases (before conception 588 ± 207 ng/ml, first trimester 319 ± 126 ng/ml, P = 0.002), whereas the GH concentration did not change significantly.

CONCLUSION

The following conclusions were reached: 1) pregnancy in women with active or uncontrolled acromegaly may be associated with an increased risk of gestational diabetes and gravid hypertension; 2) pregnancy is occasionally associated with symptomatic enlargement of GH-secreting pituitary macroadenomas; 3) changes in serum GH and IGF-I concentrations are variable during pregnancy, indicating that routine monitoring is not mandatory if the pregnancy is uneventful; and 4) GH-suppressive treatment can be safely withdrawn after conception in most acromegalic women.

Increased prevalence of psychopathology and maladaptive personality traits after long-term cure of Cushing's disease

CONTEXT AND OBJECTIVE

Psychopathology and maladaptive personality traits are often observed during the active phase of Cushing's disease (CD). We hypothesized that patients with long-term cure of CD show persistent psychopathology and maladaptive personality traits.

DESIGN

Four questionnaires on frequently occurring psychopathology in somatic illnesses were used, including the Apathy Scale, Irritability Scale, Hospital Anxiety and Depression Scale, and Mood and Anxiety Symptoms Questionnaire short-form. Personality was assessed using the Dimensional Assessment of Personality Pathology short-form (DAPPs).

PATIENTS AND CONTROL SUBJECTS

We included 51 patients cured of CD (16% men, 53 ± 13 yr) and 51 matched controls. In addition, we included 55 patients treated for nonfunctioning pituitary macroadenomas (55% men, 62 ± 10 yr), and 55 matched controls.

RESULTS

Mean duration of remission was 11 yr (range 1-32 yr). Compared with matched controls, patients cured from CD scored significantly worse on virtually all questionnaires. Compared with nonfunctioning pituitary macroadenoma patients, patients treated for CD scored worse on apathy (P < 0.001), irritability (P < 0.001), anxiety (P < 0.001), negative affect and lack of positive affect (P < 0.001 on both scales), somatic arousal (P < 0.001), and 11 of 18 subscales of the Dimensional Assessment of Personality Pathology short-form (P < 0.05).

CONCLUSIONS

Patients with long-term cured CD show an increased prevalence of psychopathology and maladaptive personality traits. These observations suggest irreversible effects of previous glucocorticoid excess on the central nervous system rather than an effect of pituitary tumors and/or their treatment in general. This may also be of relevance for patients treated with high doses of exogenous glucocorticoids.

Incidence of pituitary adenomas in Northern Finland in 1992-2007

CONTEXT

Data on the incidence of pituitary adenomas (PAs) are scant and outdated. A population-based regional cohort with thorough case identification was used to evaluate the incidence of clinically detected PAs in the era of magnetic resonance imaging.

OBJECTIVE

The objective of the study was to describe the age- and sex-specific incidence of all PA subgroups, with data on incidentally found PAs, pituitary apoplexies, and time trends.

DESIGN, SETTINGS, AND PATIENTS

This was a retrospective descriptive analysis of PA patients diagnosed during 1992-2007 in Northern Finland (NFi).

MAIN OUTCOME MEASURE

World Health Organization 2000-standardized incidence rates (SIRs) of PAs per 100,000 were measured.

RESULTS AND CONCLUSION

The final cohort consisted of 355 PAs. The incidence rates of the Oulu University Hospital regional district were used as a reference to assess the applicability of our case finding over the rest of NFi. Incidence rates of all PA subgroups except microprolactinomas were statistically equal between these areas; thus, all presented SIRs are based on the NFi's cohort except Oulu University Hospital regional district-based prolactinomas and PAs overall. Overall SIR of PAs was higher (4.0 per 100,000) than in previous reports. Prolactinomas had the highest SIR: 2.2 per 100,000, followed by clinically nonfunctioning PAs (1.0) and GH-secreting (0.34), ACTH-secreting (0.17), and TSH-secreting (0.03) PAs. The gender-specific SIR was 2.2 per 100,000 in males and 5.9 per 100,000 in females. Pituitary apoplexy occurred as a presenting symptom in 11% of clinically nonfunctioning PA patients. The SIR of incidentally discovered PAs increased significantly from 1992-1999 to 2000-2007 (0.59 to 1.6, respectively; P < 0.01), which accounted for the perceived increasing trend in the overall SIR of PAs (3.8 to 4.2; P > 0.05).

Outcome of 100 pregnancies initiated under treatment with cabergoline in hyperprolactinaemic women

CONTEXT

Data concerning the safety for pregnancy of cabergoline treatment in hyperprolactinaemic women are still scarce.

OBJECTIVE

To exclude a higher than normal risk for miscarriage and congenital malformation in pregnancies initiated under cabergoline treatment.

DESIGN

A retrospective study of 100 pregnancies in 72 hyperprolactinaemic women treated with cabergoline at the time of conception and follow-up of the 88 newborn children.

METHODS

Cabergoline was interrupted in 99 pregnancies and continued in one case. Foetal exposure dose to cabergoline was calculated for each pregnancy. Complications of pregnancy and neonatal status were compared to those observed in an age-and delivery time-matched control group of 163 women.

RESULTS

The mean foetal exposure dose to cabergoline was 3.6 +/- 4.7 mg. The rate of spontaneous miscarriages was 10%. Three medical terminations of pregnancy were performed for a foetal malformation (3%). Minor to moderate complications were observed in 31% of the pregnancies, a figure similar to that found in the control group. An increase in tumour size (2-8 mm) was observed in 17/37 evaluated cases, needing reintroduction of cabergoline during pregnancy in five patients. The 84 deliveries resulted in 88 infants, three of them presenting with a malformation (3.4%). Neonatal status was comparable to the control group, where a malformation rate of 6.3% was observed. Postnatal development of the children was normal.

CONCLUSION

Cabergoline treatment at the time of conception appears to be safe for both the pregnancy and the neonate, although more data are still needed on a larger number of pregnancies.

Pituitary carcinomas

Pituitary carcinoma is a extremely rare and is characterized by a very poor prognosis. Even if at diagnosis the presence of metastases is required to define a pituitary carcinoma, the lesion was almost invariably diagnosed first as a benign pituitary tumor, that after a variable period of latency, ranging from few months to many years, changed its natural course to an aggressive pituitary tumor poorly responsive to therapy. Recent studies have partially clarified its molecular pathogenesis and found possible markers of aggressiveness in order to make an earlier diagnosis, when still treatment could improve their prognosis. Most pituitary carcinomas are functioning, and ACTH- and PRL-secreting carcinomas are the most frequent. Treatment includes surgery, radiotherapy, medical therapy and chemotherapy, but the poor results with current therapies should prompt all investigators to better understand its pathogenesis and searching new molecular targets for treatments.

A heritable predisposition to pituitary tumors

Pituitary tumors are prevalent in the general population, with a frequency of nearly 1 in 5. The cause of most pituitary tumors remains unknown, although a genetic contribution is recognized for some. We analyzed the Utah Population Data Base (UPDB), a resource combining a computerized genealogy of the Utah population with a statewide tumor registry, to investigate familial clustering of pituitary tumors. We analyzed the genetic relationships among 741 individuals diagnosed with benign or malignant pituitary tumors who had Utah genealogy data. To test for evidence of genetic contribution to predisposition, we compared average relatedness between all pairs of individuals with pituitary tumors with the expected relatedness in this population. We also estimated relative risks (RRs) for pituitary tumors in close and distant relatives of cases by comparing observed and expected numbers of cases among relatives. Relative risks for first- and third-degree relatives were significantly elevated (RR = 2.83 and 1.63, respectively), while relative risk for second-degree relatives was not significantly different from 1.0 (RR = 0.83). The average pairwise relatedness of pituitary tumor cases was significantly higher than expected, even when close relationships were ignored. The significantly elevated risks to relatives as well as the significant excess distant relatedness observed in cases provide strong support for a genetic contribution to predisposition to pituitary tumors. Multiple high-risk pedigrees can be identified in the UPDB, and study of such pedigrees might allow identification of the gene(s) responsible for our observations. Recognizing genetic contribution to the disease may also help with counseling family members of affected individuals.

Prevalence of double pituitary adenomas in a surgical series: Clinical, histological and genetic features

BACKGROUND

The term double pituitary adenomas (DPA) is usually referred to those rare lesions showing two distinct cellular components. Genetic background may sustain the proliferation of more than one cell at the same time but no information is available on the presence of aip mutations in these patients.

AIM

We report the prevalence and the endocrinological, neuroradiological, histopathological and genetic features of DPA detected in a large surgical series. The contribution of pituitary transcription factor immunostains in DPA was also evaluated.

SUBJECTS AND METHODS

One-hundred-forty-four patients undergoing surgery for tumors of the sellar region were evaluated. Histopathology, immunohistochemistry and the mutational analysis for the entire coding region of the AIP and MEN1 genes were performed.

RESULTS

One-hundred-seventeen patients out of 144 had a pituitary adenoma. DPA was found in 3 (2.6%) out of 117 patients with pituitary adenoma. Immunohistochemistry and transcription factors analysis demonstrated two not yet described histotype associations in DPA. The coexistence of somatotroph-lactotroph and silent mammosomatotroph histotype in 1 case and the coexistence of sparsely granulated lactotroph and null cell adenomas in the remaining two cases were first identified. Sequencing data for the coding region of the aip and the menin gene resulted in wild type sequences in all patients with DPA.

CONCLUSIONS

The prevalence of DPA observed in our unselected surgical series is not negligible (2.6%). Furthermore, the evaluation of the treatment outcome would suggest that the clinical management of DPAs requires a careful diagnostic approach and follow- up.

Prevalence of pituitary adenomas: a community-based, cross-sectional study in Banbury (Oxfordshire, UK)

BACKGROUND

Pituitary adenomas (PAs) are associated with increased morbidity and mortality. The optimal delivery of services and the provision of care for patients with PAs require distribution of the resources proportionate to the impact of these conditions on the community. Currently, the resource allocation for PAs in the health care system is lacking a reliable and an up-to-date epidemiological background that would reflect the recent advances in the diagnostic technologies, leading to the earlier recognition of these tumours.

OBJECTIVES

To determine the prevalence, the diagnostic delay and the characteristics of patients with PA in a well-defined geographical area of the UK (Banbury, Oxfordshire).

PATIENTS AND METHODS

Sixteen general practitioner (GP) surgeries covering the area of Banbury and a total population of 89 334 inhabitants were asked to participate in the study (data confirmed on 31 July 2006). Fourteen surgeries with a total of 81,449 inhabitants (91% of the study population) agreed to take part. All cases of PAs were found following an exhaustive computer database search of agreed terms by the staff of each Practice and data on age, gender, presenting manifestations and their duration, imaging features at diagnosis, history of multiple endocrine neoplasia type 1 and family history of PA were collected.

RESULTS

A total of 63 patients with PA were identified amongst the study population of 81,149, with a prevalence of 77.6 PA cases/100,000 inhabitants (prolactinomas; PRLoma: 44.4, nonfunctioning PAs: 22.2, acromegaly; ACRO: 8.6, corticotroph adenoma: 1.2 and unknown functional status; UFS: 1.2/100,000 inhabitants). The distribution of each PA subtype was for PRLoma 57%, nonfunctioning PAs 28%, ACRO 11%, corticotroph adenoma 2% and UFS 2%. The median age at diagnosis and the duration of symptoms until diagnosis (in years) were for PRLoma 32.0 and 1.5, nonfunctioning PAs 51.5 and 0.8, ACRO 47 and 4.5 and corticotroph adenoma 57 and 7, respectively. PRLoma was the most frequent PA diagnosed up to the age of 60 years (0-20 years: 75% and 20-60 years: 61% of PAs) and nonfunctioning PA after the age of 60 years (60% of PAs). Nonfunctioning PAs dominated in men (57% of all men with PA) and PRLoma in women (76% of all women with PA). Five patients (7.9%) presented with classical pituitary apoplexy, with a prevalence of 6.2 cases/100,000 inhabitants.

CONCLUSIONS

Based on a well-defined population in Banbury (Oxfordshire, UK), we have shown that PAs have a fourfold increased prevalence than previously thought; our data confirm that PAs have a higher burden on the Health Care System and optimal resource distribution for both clinical care and research activities aiming to improve the outcome of these patients are needed.

The prevalence of benign and malignant neoplasms in acromegalic patients

INTRODUCTION

In acromegalic patients, the prevalence of certain benign and malignant neoplasms is higher than that in the healthy population. We retrospectively evaluated the prevalence of tumours in acromegalic patients treated at our department: the regional centre for acromegalic patients for the Małopolskie voivodeship in Poland.

MATERIAL AND METHODS

During the years 1983-2008, a hundred and one acromegalic patients (30 males and 71 women), of mean age 51.8 +/- 15.4 years, were diagnosed and treated. Pituitary macroadenoma and microadenoma were stated in 63.4% and 25.7% of these patients, respectively. In 10.9% of these patients no data on tumour diameter were available. The mean observation period was 9.4 +/- 6.5 years. The median levels of hGH and IGF-1 prior to neurosurgery were 20.2 (IQR = 34.9) ng/ml and 764.5 (IQR = 569.6) ng/ml, respectively.

RESULTS

In the studied group of patients, we found the following prevalence of various tumours: nodular goitre - 64/101 patients (63.0%), polyps of the colon - 13/101 patients (13.0%); uterine polyps - 4/101 patients (4.0%); and prostate adenoma - 2/101 patients (2.0%). Among malignant tumours, thyroid cancer, endometrium and cervix cancer were the most frequent, each of these occurring in 3 patients (3.0%). Colon cancer prevalence was 2.0% (in 2 patients).

CONCLUSIONS

From our retrospective study, we suggest an overall increase of tumour incidence in acromegalic patients. Prospective multicentre studies are required to resolve the significance of this observation. In our study group, the number of malignant neoplasms was significantly higher in patients with long-lasting uncontrolled disease (over 5 years), compared to patients with controlled disease. (Pol J Endocrinol 2010; 61 (1): 29-34).

Etiology, functional status and short term outcome of patients with pituitary lesions. An experience from a developing country

OBJECTIVE

To describe the etiology, functional status and short term outcome of patients with pituitary lesions (PL).

METHODS

Brain or pituitary MRI reports of 3753 patients were analyzed for PL over the period of 2000 to 2007, done at the Aga Khan University Hospital (AKUH), Karachi, Pakistan. MRIs with reported PL and all those ordered by Endocrinologists with or without pituitary abnormalities, were included in the analysis. This made a total of 338 (9%) MRI reports. PL were defined as pituitary tumors, cysts, haemorrhage, hypoplasia; and empty sella. Patients with these PL, were analyzed for symptoms, hormonal profile and short term outcome in the hospital retrospectively.

RESULTS

In the analysis of 338 MRI reports, 23% had normal pituitary gland on MRI examination. Hypogonadotrophic hypogonadism was the commonest (38.5%) endocrine abnormality seen with normal pituitary MRI, followed by hypopituitarism (5.1%). Most common PL identified were macroadenoma (38.7%), empty sella (16.5%) and microadenoma (12.7%). Patients with macroadenoma had 58% of non-functional tumours while 19.1% had hypopituitrism, 17.6% had acromegaly and 17.5% had prolactinoma. Majority of these lesions were causing headache and visual symptoms (42.7%) and were treated with surgery (75.5%). Patients with microadenoma included 39.5% prolactinomas, 18.6% cushing disease, 14% acromegaly, 4.7% hypogonadotrophic hypogonadism and 2.3% hypopituitrism. Majority of these lesions were treated with drugs and 37.3% were treated with surgery. In empty sella patients, 32% patients had endocrine abnormalities among which 21.4% had hypopituitrism, 2% had hypogonadotrophic hypogonadism, and only 6% patients had normal endocrine workup. A significant number of patients (62.5%) never had endocrine hormonal checkup.

CONCLUSION

Although PL are less common entities (9% in 3,753 reports) but they are associated with significant endocrinal abnormalities and need prompt treatment. Empty sella, which is not considered as a distinct abnormality, is also associated with significant endocrine deficiencies.

[Epidemiology of pituitary adenoma: results of the first Swiss study]

Epidemiological data concerning pituitary adenomas are very scarce and in some cases reports are even conflicting. This opinion is at present disputed. The aim of this study was, therefore, to evaluate in the urban area of Fribourg, the prevalence of relevant clinical pituitary adenoma. General practitioners, endocrinologists and gynaecologists were questioned concerning any patient within this agglomeration presenting with a pituitary micro- or macro-adenoma. Among the 44 adenomas, we observed 13 non secreting macro-adenomas, 16 micro- and 9 macro-prolactinomas, 4 cases of acromegaly and 2 ACTH-dependant Cushing diseases. In the studied area we found a prevalence of 80.5 pituitary adenomas per 100,000, or 1 case per 1241 corroborating a greater prevalence of pituitary adenomas than previously believed.

[Genetics of familial pituitary adenomas]

Pituitary adenomas were previously thought to be rare. However, a recent cross-sectional study conducted in Liège, Belgium, showed that clinically apparent pituitary adenomas were present in about 1 in 1000 inhabitants, which is 4 to 5 times the previously reported prevalence. Pituitary adenomas are generally sporadic, but some are associated with familial-isolated tumoral syndromes (mainly MEN1 and Carney complex). With the recent characterization of FIPA (Familial Isolated Pituitary Adenomas), familial pituitary adenomas are now thought to account for 5% to 8% of all pituitary tumors. New genetic mechanisms are being identified, improving our understanding of the complex manifestations and sometimes unpredictable outcome of pituitary adenomas.

Pituitary tumours: pituitary incidentalomas

Clinically non-functioning pituitary adenomas range from being completely asymptomatic, and therefore being detected either at autopsy or as incidental findings on head magnetic resonance imaging (MRI) or computed tomography (CT) scans performed for other reasons (often referred to as 'pituitary incidentalomas'), to causing significant hypothalamic/pituitary dysfunction and visual field compromise due to their large size. Patients with pituitary incidentalomas should all be screened for hypersecretion (prolactin (PRL), IGF-1, midnight salivary cortisol), and those with macroadenomas should also be screened for hypopituitarism (macroadenomas) and for visual field defects if the tumour abuts the optic chiasm. Growth of non-functioning pituitary adenomas without treatment occurs in about 10% of microadenomas and 24% of macroadenomas. In the absence of hypersecretion, hypopituitarism or visual field defects, patients may be followed up by periodic screening by MRI for enlargement. Growth of a pituitary incidentaloma is an indication for surgery.