Decreased quality of life in patients with acromegaly despite long-term cure of growth hormone excess

Role of radiotherapy in the management of acromegaly

Active acromegaly can be treated effectively by transsphenoidal surgery, radiotherapy and medical treatment in the form of somatostatin analogs and growth hormone receptor antagonists. Many patients will require a combination of treatment modalities to normalize growth hormone excess and associated increased mortality, and to improve comorbidity. Following postoperative radiotherapy, growth hormone and insulin-like growth factor-I levels gradually decrease and normalization of growth hormone and insulin-like growth factor-I is achieved in 50% of patients after 5 years and 75% after 10 years. Disadvantages of radiotherapy include the long interval until hormone levels have sufficiently decreased and the high incidence of radiation-induced hypopituitarism. Radiotherapy was associated with increased mortality in some but not other studies. Limitations in the design and confounding factors, such as years spent with active disease and changing treatment strategies, make it impossible to draw conclusions on this topic. Gamma knife radiosurgery may combine faster decline of growth hormone excess with a lower incidence of hypopituitarism in eligible cases, but long-term results of this radiation technique are lacking. At present, patients will preferentially be treated by primary surgery and/or somatostatin analog treatment, followed, if necessary, by growth hormone receptor antagonist treatment, while radiotherapy is reserved for selected cases only. The indications for radiotherapy and radiosurgery need to be revisited in the near future, when longer follow-up results for medical treatment and radiosurgery have become available. This review summarizes the recent literature on efficacy and side effects of radiotherapy and radiosurgery in acromegaly and discusses the place of radiation treatment in the treatment algorithm of acromegaly.

Quality of life in treated adult craniopharyngioma patients

OBJECTIVE

Quality of life (QoL) has become increasingly important in the evaluation of treatment of pituitary and hormonal diseases. A reduced QoL has been reported in childhood-onset craniopharyngioma; however, reports of QoL in adult craniopharyngioma patients are scarce. In the present study, we assessed QoL in adult patients successfully treated for craniopharyngioma in our centre.

DESIGN

This was a case-control study.

METHODS

In this study, we assessed QoL in 29 adult patients in remission during long-term follow-up after treatment for craniopharyngioma. Four validated health-related questionnaires (HADS, MFI-20, NHP and SF-36) were used, covering multiple aspects of physical, psychological and social functioning. Patient outcomes were compared to controls (n = 142) and to age-adjusted reference values derived from literature.

RESULTS

General fatigue, physical fatigue, energy, physical condition and physical mobility were significantly impaired, compared with controls. The main independent predictors for decreased QoL were visual field defects (depression, total HADS score, activity, motivation and energy), female gender (depression, motivation and pain), repeat surgery (role limitations due to emotional problems) and radiotherapy (mental fatigue) (the last two predictors to a lesser extent).

CONCLUSION

Adult patients treated for craniopharyngioma show persistent impairment in QoL, especially in the physical subscales.

Quality of life in acromegaly

Acromegaly is a disease with an important impact on health-related quality of life (HRQoL). Cross-sectional evaluation of HRQoL in patients with acromegaly using generic questionnaires and the specific questionnaire AcroQoL has confirmed severe impairment; active disease, female gender, ageing, disease duration, joint symptoms and prior radiotherapy are associated with worse HRQoL. The most affected dimension is appearance and the least affected, personal relations; comparable results have been observed in Spanish, Dutch, German, English and Turkish speaking patients. Patients with active acromegaly show a worse score (mean range 43-56) than those in remission (mean range 65-71). In longitudinal studies, in patients with stable acromegaly, no change was observed on retesting at 1 month, demonstrating a good test-retest reliability. In patients with active acromegaly, after 6 months of treatment, an improvement in the AcroQoL score was observed (56 +/- 20 to 66 +/- 18; p < 0.01). The internal consistency of AcroQoL was good (Cronbach's alpha >0.7). No correlation between AcroQoL and insulin-like growth factor-I/growth hormone levels was observed, even though a trend was found for the most affected dimension (appearance) and insulin-like growth factor-I (p = 0.051). In summary, HRQoL is severely affected in acromegaly, even in patients with controlled disease. Thus, to optimise management, not only biochemical and radiological parameters but also dimensions that reflect HRQoL should be evaluated in acromegaly.

Assessment of quality of life in patients with uncontrolled vs. controlled acromegaly using the Acromegaly Quality of Life Questionnaire (AcroQoL)

OBJECTIVE

Acromegaly is a chronic disease with an important impact on quality of life. An acromegaly disease-generated quality of life questionnaire (AcroQoL) has recently been developed. We aimed to confirm reliability, construct validity and disease-specificity of the AcroQoL questionnaire. Second, we investigated the effect of remission status on health-related quality of life (HRQoL) in patients with acromegaly.

DESIGN AND PATIENTS

Using a prospective, cross-sectional design, 33 patients with treated acromegaly and 22 patients with treated hormone-inactive pituitary adenoma under stable replacement therapy completed the German version of the AcroQoL questionnaire.

MEASUREMENTS AND RESULTS

Cronbach's alpha analysis showed high reliability of the total score and the different scales and subscales in patients with acromegaly (alpha ranging from 0.83 to 0.93, item-total correlation 0.41-0.84). Patients with hormone-inactive pituitary adenoma showed lower reliability (alpha ranging from 0.17 to 0.75). Exploratory factor analysis in patients with acromegaly suggested a two-factorial solution with item distribution largely matching the scaling of the original Spanish questionnaire. Multiple regression analysis revealed significantly lower results of the total score and the different scales and subscales (indicating worse HRQoL) in patients with persistent acromegalic activity compared to patients with acromegaly in remission or discordant remission status. Consistently, IGF-I was an independent negative predictor of the different scores of the questionnaire.

CONCLUSIONS

The AcroQoL questionnaire represents a reliable, construct valid and disease-specific tool for assessing health-related quality of life in patients with acromegaly. Patients with biochemically uncontrolled acromegaly showed significantly lower HRQoL than patients with acromegaly in remission or discordant remission status.

Long-term maintenance of the anabolic effects of GH on the skeleton in successfully treated patients with acromegaly

INTRODUCTION

The anabolic actions of growth hormone (GH) are well documented. In acromegaly, the skeletal effects of chronic GH excess have been mainly addressed by evaluating bone mineral density (BMD). Most data were obtained in patients with active acromegaly, and apparently high or normal BMD was observed in the absence of hypogonadism. Data on BMD are not available after successful treatment of acromegaly. Whether the positive effect of GH excess on bone mass is maintained in the long term after clinical and biochemical cure of acromegaly remains to be established.

PATIENTS AND METHODS

In a cross-sectional study design, lumbar spine and femoral neck BMD was measured in 79 acromegalic patients cured or well controlled on octreotide treatment (45 male and 34 female patients; mean age 57+/-1 years). Successful treatment (by surgery, radiotherapy and/or use of octreotide) was defined as normal age-adjusted IGF-I. Mean time after biochemical remission was 10.2+/-7 years.

RESULTS

Normal or increased BMD was observed at the femoral neck and lumbar spine in both men and women in remission after treatment for acromegaly. Similar results were obtained in patients in remission for 5 years or longer. Osteoporosis was present in 15% of the patients, with similar prevalence in men and women. There was no relationship between BMD and duration or severity of GH excess before treatment, gonadal status and presence of pituitary hormone deficiencies. Pituitary irradiation was a strong negative predictor of bone mass at the femoral neck. Long-term bone loss was observed only at the femoral neck.

CONCLUSION

Our data suggest that the anabolic effect of GH on trabecular and cortical bone remains demonstrable after remission of acromegaly, although it may not be maintained at cortical sites in the long term. In the present study, the lack of effect of gonadal status on BMD may be explained by the presence of only mild hypogonadism and by our policy of prompt hormonal replacement therapy for severe hypogonadism. The negative effect of pituitary irradiation on femoral neck BMD remains intriguing, although it is probably related to some degree of the diminished GH secretion frequently observed after this form of treatment.