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Sharifi G, Mohammadi E, Paraandavaji E, Tavangar SM, Dabbagh Ohadi MA, Jafari A, Jahanbakhshi A, Akbari Dilmaghani N, Davoudi Z, Smith TR, Banihashemi G, Azadi M, Hatami N, Zenonos GA, Mohajeri Tehrani M. Empty sella in somatotropic pituitary adenomas; a series of 23 cases. Front Surg 2024; 11:1350032. [PMID: 38500594 PMCID: PMC10944865 DOI: 10.3389/fsurg.2024.1350032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/08/2024] [Indexed: 03/20/2024] Open
Abstract
Purpose We aimed to investigate empty sella syndrome in somatotrophic pituitary adenoma for possible etiology, complications, and treatment options. Method Among over 2,000 skull base masses that have been managed in our center since 2013, we searched for growth hormone-producing adenomas. Clinical, surgical, and imaging data were retrospectively collected from hospital records to check for sella that lacked pituitary tissue on routine imaging. Result In 220 somatotrophic adenomas, 23 patients had an empty sella with surgical and follow-up data. The mean age of the sample was 46 years with the same male-to-female ratio. Five cases had partial empty sella and the rest were complete empty sellas. The most common simultaneous hormonal disturbance was high prolactin levels. Six had adenoma invasion into the clivus or sphenoid sinus and 10 had cavernous sinus intrusion. Peri-operative low-flow and high-flow cerebrospinal fluid (CSF) leaks were encountered in one and two patients, respectively, which were successfully sealed by abdominal fat. The majority of cases required growth hormone replacement therapy while it was controlled without any replacement therapy in nine patients. No pituitary hormonal disturbance occurred after transsphenoidal surgery except for hypothyroidism in one patient. Conclusion An empty sella filled with fluid can be detected frequently in pituitary adenomas, especially in the setting of acromegaly. The pituitary gland may be pushed to the roof of the sella and might be visible as a narrow rim on imaging or may be detected in unusual places out of the sella. The pathophysiology behind such finding originates from soft and hard tissue changes and CSF pressure alternations during abundant growth hormone production.
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Affiliation(s)
- Guive Sharifi
- Department of Neurosurgery, Loghman Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
- Skull Base Research Center, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Esmaeil Mohammadi
- Department of Neurosurgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Paraandavaji
- Skull Base Research Center, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Tavangar
- Department of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Ali Jafari
- Department of Neurosurgery, Loghman Hospital, Shahid Beheshti University of Medical Science, Tehran, Iran
- Skull Base Research Center, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amin Jahanbakhshi
- Skull Base Research Center, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nader Akbari Dilmaghani
- Skull Base Research Center, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Davoudi
- Skull Base Research Center, Loghman Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Timothy R. Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gelareh Banihashemi
- Department of Neurology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Azadi
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Neda Hatami
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Georgios A. Zenonos
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Mohammadreza Mohajeri Tehrani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Zendran I, Gut G, Kałużny M, Zawadzka K, Bolanowski M. Acromegaly Caused by Ectopic Growth Hormone Releasing Hormone Secretion: A Review. Front Endocrinol (Lausanne) 2022; 13:867965. [PMID: 35757397 PMCID: PMC9218487 DOI: 10.3389/fendo.2022.867965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Ectopic acromegaly is a rare condition caused most frequently by growth hormone releasing hormone (GHRH) secretion from neuroendocrine tumors. The diagnosis is often difficult to establish as its main symptoms do not differ from those of acromegaly of pituitary origin. OBJECTIVES To determine most common clinical features and diagnostic challenges in ectopic acromegaly. PATIENTS AND METHODS A search for ectopic acromegaly cases available in literature was performed using PubMed, Cochrane, and MEDline database. In this article, 127 cases of ectopic acromegaly described after GHRH isolation in 1982 are comprehensively reviewed, along with a summary of current state of knowledge on its clinical features, diagnostic methods, and treatment modalities. The most important data were compiled and compared in the tables. RESULTS Neuroendocrine tumors were confirmed in 119 out of 121 patients with histopathological evaluation, mostly of lung and pancreatic origin. Clinical manifestation comprise symptoms associated with pituitary hyperplasia, such as headache or visual field disturbances, as well as typical signs of acromegaly. Other endocrinopathies may also be present depending on the tumor type. Definitive diagnosis of ectopic acromegaly requires confirmation of GHRH secretion from a tumor using either histopathological methods or GHRH plasma concentration assessment. Hormonal evaluation was available for 84 patients (66%) and histopathological confirmation for 99 cases (78%). Complete tumor resection was the main treatment method for most patients as it is a treatment of choice due to its highest effectiveness. When not feasible, somatostatin receptor ligands (SRL) therapy is the preferred treatment option. Prognosis is relatively favorable for neuroendocrine GHRH-secreting tumors with high survival rate. CONCLUSION Although ectopic acromegaly remains a rare disease, one should be aware of it as a possible differential diagnosis in patients presenting with additional symptoms or those not responding to classic treatment of acromegaly.
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Affiliation(s)
- Iga Zendran
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Gabriela Gut
- Department of Endocrinology, Diabetes and Isotope Therapy, Students research association, Wroclaw Medical University, Wroclaw, Poland
| | - Marcin Kałużny
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
- *Correspondence: Marcin Kałużny,
| | - Katarzyna Zawadzka
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
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Growth hormone secreting pituitary microadenomas and empty sella - An under-recognized association? Clin Neurol Neurosurg 2014; 126:18-23. [PMID: 25194306 DOI: 10.1016/j.clineuro.2014.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 08/08/2014] [Accepted: 08/09/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe an association of growth hormone (GH) secreting pituitary microadenomas and empty sella (ES), which has been described in case reports - the underlying mechanisms are unclear. METHODS We retrospectively analyzed patients operated for GH-producing pituitary adenomas between February 2004 and February 2009. Magnetic resonance imaging (MRI), computed tomography (CT) imaging, and pituitary function testing were performed. All cases underwent transsphenoidal surgery (TSS). Mean follow up was 38 months (range 12-80 months). RESULTS Out of 152 patients with acromegaly due to GH-producing pituitary adenomas (female:male=73:79; age range 17-63 years), 69 patients had microadenomas (45.4%; 38 females, 31 males). We found 14 cases (14/69, 20.3%), all microadenomas, with presurgical evidence of ES - 10 females (71%) and 4 males (29%) (female:male=2.5:1). When compared with 103 patients with GH-negative microadenomas treated in the same time period (ES in 4 of 103; 3.9%), ES was highly significantly associated with GH production by the microadenoma (p=0.001). In acromegalics with empty sella, no cases of ectopic adenoma were found. Postoperatively, GH and IGF-1 levels fell in all patients, and 7 cases had random GH and IGF-1 levels consistent with cure. CONCLUSION The combination of GH-producing microadenomas and empty, enlarged sella is not rare. In this setting, preoperative CT scans are very useful and the transsphenoidal approach is efficient and safe. The mechanism underlying the association of GH-producing microadenomas and empty sella remains unclear and requires further studies.
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Ghazi AA, Amirbaigloo A, Dezfooli AA, Saadat N, Ghazi S, Pourafkari M, Tirgari F, Dhall D, Bannykh S, Melmed S, Cooper O. Ectopic acromegaly due to growth hormone releasing hormone. Endocrine 2013; 43:293-302. [PMID: 22983831 PMCID: PMC3553305 DOI: 10.1007/s12020-012-9790-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 08/31/2012] [Indexed: 12/20/2022]
Abstract
Acromegaly secondary to extra-pituitary tumors secreting growth hormone releasing hormone (GHRH) is rarely encountered. We review the literature on ectopic acromegaly and present the index report of ectopic acromegaly secondary to GHRH secretion from a mediastinal paraganglioma. Clinical and pathological manifestations and therapeutic management of 99 patients with ectopic acromegaly are reviewed. Acromegaly secondary to ectopic GHRH secretion is usually caused by a neuroendocrine tumor in the lung and pancreas. We report an additional cause of ectopic acromegaly from a mediastinal paraganglioma. Diagnostic criteria of ectopic GHRH syndrome include biochemical and pathologic tumoral confirmation of GHRH secretion and expression. Management of ectopic acromegaly consists of surgical resection of the primary tumor and biochemical normalization, with possible adjuvant use of somatostatin analogs. The review demonstrates that there are several tumor types, including paragangliomas which may secrete GHRH, leading to acromegaly. Clinical and laboratory manifestations of the syndrome and challenges in diagnosis and management of these rarely encountered patients require early diagnosis and appropriate treatment to prevent long-term morbidity and mortality with ectopic acromegaly.
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Affiliation(s)
- Ali A Ghazi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Amirbaigloo
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Azizollah Abbasi Dezfooli
- Department of Thoracic Surgery, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Navid Saadat
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siavash Ghazi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marina Pourafkari
- Department of Radiology, Taleghani General Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farrokh Tirgari
- Department of pathology, Imam Khomeini General Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Dheepti Dhall
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Serguei Bannykh
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shlomo Melmed
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Odelia Cooper
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Garby L, Caron P, Claustrat F, Chanson P, Tabarin A, Rohmer V, Arnault G, Bonnet F, Chabre O, Christin-Maitre S, du-Boullay H, Murat A, Nakib I, Sadoul JL, Sassolas G, Claustrat B, Raverot G, Borson-Chazot F. Clinical characteristics and outcome of acromegaly induced by ectopic secretion of growth hormone-releasing hormone (GHRH): a French nationwide series of 21 cases. J Clin Endocrinol Metab 2012; 97:2093-104. [PMID: 22442262 DOI: 10.1210/jc.2011-2930] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
CONTEXT Ectopic GHRH secretion is a rare cause of acromegaly, and case reports are mainly isolated. SETTING From the registry of the sole laboratory performing plasma GHRH assays in France, we identified cases of ectopic GHRH secretion presenting with acromegaly between 1983 and 2008. PATIENTS Twenty-one patients aged 14-77 yr were identified from 12 French hospitals. Median GHRH was 548 (270-9779) ng/liter. MAIN OUTCOME MEASURES Outcome measures included description of tumor features and outcome and the relation between plasma GHRH values and tumor site, size, and spread. RESULTS The primary neuroendocrine tumor was identified for 20 of 21 patients (12 pancreatic, seven bronchial, one appendicular). Tumors were large (10-80 mm), identified on computed tomography scan in 18 cases and by endoscopic ultrasound and somatostatin receptor scintigraphy in two. Somatostatin receptor scintigraphy had a similar sensitivity to computed tomography scan (81 vs. 86%). Tumors were all well differentiated; 47.6% had metastasized at the time of diagnosis of acromegaly. After a median follow-up of 5 yr, 85% of patients were alive. Ninety-one percent of patients whose tumor was completely removed were considered in remission, and most had normalized plasma GHRH. The remaining patients were treated with somatostatin analogs: IGF-I normalized except for one patient who required pegvisomant, but GHRH levels remained elevated. No correlations were found between GHRH levels and tumor site or size or the existence of metastases. Identification of increased plasma GHRH during follow-up was an accurate indicator of recurrence. CONCLUSIONS The prognosis of endocrine tumors responsible for GHRH secretion appears relatively good. Plasma GHRH assay is an accurate tool for diagnosis and follow-up.
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Mnif Feki M, Mnif F, Kamoun M, Charfi N, Rekik N, Naceur BB, Mnif L, Boudawara TS, Abid M. Ectopic secretion of GHRH by a pancreatic neuroendocrine tumor associated with an empty sella. ANNALES D'ENDOCRINOLOGIE 2011; 72:522-5. [PMID: 21963237 DOI: 10.1016/j.ando.2011.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 06/08/2011] [Accepted: 06/10/2011] [Indexed: 11/29/2022]
Abstract
Acromegaly is usually the result of a pituitary growth hormone cell-adenoma or is more rarely due to ectopic secretion of growth hormone releasing hormone (GHRH).We report the case of a 60-year-old woman with acromegaly due to a GH-RH-secreting pancreatic tumor. Laboratory evaluation confirmed the diagnosis of acromegaly. Magnetic resonance imaging revealed a partial empty sella with no signs of adenoma. Ultrasound sonography performed for abdominal pains showed a calcified large heterogeneous infrahepatic mass. Computed tomography scan discovered a heterogeneous pancreatic head mass with a diameter of 10cm. Measurement of fasting plasma GHRH was performed showing a high concentration of 604ng/L (normal 10-60). We therefore concluded that the acromegaly was caused by ectopic overproduction of GHRH likely due to the pancreatic tumor. The patient underwent a cephalic duodenopancreatectomy. Histology revealed a well-circumscribed tumor with organoid architecture. Immunohistochemistry demonstrated diffuse positivity for chromogranin A, neuronal specific enolase and synaptophysin and negative immunoreactivity for prolactin, GH and serotonin. These features were concordant with a well-differentiated neuroendocrine tumor of the pancreas. Surgical resection of this pancreatic tumor was followed by significant amelioration of acromegalic signs and normalization of GHRH and GH levels.
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Affiliation(s)
- Mouna Mnif Feki
- Endocrinology Department, Hedi Chaker Hospital, Magida Boulila Avenue, 3029 Sfax, Tunisia.
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Abstract
PURPOSE OF REVIEW Neuroendocrine tumors (previously referred to as carcinoids) are ill-understood, enigmatic malignancies that, although slow-growing compared with adenocarcinomas, can behave aggressively. In 2004, they comprised 1.25% of all malignancies; their incidence is increasing by approximately 6% per year. The present review provides an overview on neuroendocrine tumors and focuses on general features and current diagnostic and therapeutic options. RECENT FINDINGS Neuroendocrine tumors may present a considerable diagnostic and therapeutic challenge as their clinical presentation is nonspecific and usually late, when metastases are already evident. Topographic localization is by computed tomography, magnetic resonance imaging, somatostatin receptor scintigraphy, whole-body positron emission tomography or endoscopy/ultrasound. Bronchoscopy is useful to verify the diagnosis when lesions are located centrally in the bronchi. No curative treatment except for radical surgery (almost never feasible) exists. Palliative and symptomatic treatment is based on surgical debulking, tumor embolization, and biotherapy with somatostatin analogues. Chemotherapy and radiotherapy are usually ineffective, but novel drugs such as tyrosine kinase receptor inhibitors show promising results in phase II clinical studies. SUMMARY Tumors of the diffuse neuroendocrine system represent a significant and increasing clinical problem, and there is a need to develop both early diagnostic tests as well as to establish targeted therapeutic strategies.
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Biermasz NR, Smit JWA, Pereira AM, Frölich M, Romijn JA, Roelfsema F. Acromegaly caused by growth hormone-releasing hormone-producing tumors: long-term observational studies in three patients. Pituitary 2007; 10:237-49. [PMID: 17541749 PMCID: PMC2045692 DOI: 10.1007/s11102-007-0045-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We report on three newly diagnosed patients with extracranial ectopic GHRH-associated acromegaly with long-term follow-up after surgery of the primary tumor. One patient with a pancreatic tumor and two parathyroid adenomas was the index case of a large kindred of MEN-I syndrome. The other two patients had a large bronchial carcinoid. The first patient is still in remission now almost 22 years after surgery. In the two other patients GHRH did not normalize completely after surgery and they are now treated with slow-release octreotide. IGF-I normalized in all patients. During medical treatment basal GH secretion remained (slightly) elevated and secretory regularity was decreased in 24 h blood sampling studies. We did not observe development of tachyphylaxis towards the drug or radiological evidence of (growing) metastases. We propose life-long suppressive therapy with somatostatin analogs in cases with persisting elevated serum GHRH concentrations after removal of the primary tumor. Independent parameters of residual disease are elevated basal (nonpulsatile) GH secretion and decreased GH secretory regularity.
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Affiliation(s)
- Nienke R. Biermasz
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA The Netherlands
| | - Jan W. A. Smit
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA The Netherlands
| | - Alberto M. Pereira
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA The Netherlands
| | - Marijke Frölich
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA The Netherlands
| | - Johannes A. Romijn
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA The Netherlands
| | - Ferdinand Roelfsema
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA The Netherlands
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Gola M, Doga M, Bonadonna S, Mazziotti G, Vescovi PP, Giustina A. Neuroendocrine tumors secreting growth hormone-releasing hormone: Pathophysiological and clinical aspects. Pituitary 2006; 9:221-9. [PMID: 17036195 DOI: 10.1007/s11102-006-0267-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Hypothalamic GHRH is secreted into the portal system, binds to specific surface receptors of the somatotroph cell and elicits intracellular signals that modulate pituitary GH synthesis and/or secretion. Moreover, GHRH is synthesized and expressed in multiple extrapituitary tissues. Excessive peripheral production of GHRH by a tumor source would therefore be expected to cause somatotroph cell hyperstimulation, increased GH secretion and eventually pituitary acromegaly. Immunoreactive GHRH is present in several tumors, including carcinoid tumors, pancreatic cell tumors, small cell lung cancers, endometrial tumors, adrenal adenomas, and pheochromocytomas which have been reported to secrete GHRH. Acromegaly in these patients, however, is uncommon. The distinction of pituitary vs. extrapituitary acromegaly is extremely important in planning effective management. Regardless of the cause, GH and IGF-1 are invariably elevated and GH levels fail to suppress (<1 microg/l) after an oral glucose load in all forms of acromegaly. Dynamic pituitary tests are not helpful in distinguishing acromegalic patients with pituitary tumors from those harbouring extrapituitary tumors. Plasma GHRH levels are usually elevated in patients with peripheral GHRH-secreting tumors, and are normal or low in patients with pituitary acromegaly. Unique and unexpected clinical features in an acromegalic patient, including respiratory wheezing or dyspnea, facial flushing, peptic ulcers, or renal stones sometimes are helpful in alerting the physician to diagnosing non pituitary endocrine tumors. If no facility to measure plasma GHRH is available, and in the absence of MRI evidence of pituitary adenoma, a CT scan of the thorax and abdominal ultrasound could be performed to exclude with good approximation the possibility of an ectopic GHRH syndrome. Surgical resection of the tumor secreting ectopic GHRH should be the logical approach to a patient with ectopic GHRH syndrome. Standard chemotherapy directed at GHRH-producing carcinoid tumors is generally unsuccessful in controlling the activated GH axis. Somatostatin analogs provide an effective option for medical management of carcinoid patients, especially those with recurrent disease. In fact, long-acting somatostatin analogs may be able to control not only the ectopic hormonal secretion syndrome, but also, in some instances, tumor growth. Therefore, although cytotoxic chemotherapy, pituitary surgery, or irradiation still remain available therapeutic options, long-acting somatostatin analogs are now preferred as a second-line therapy in patients with carcinoid tumors and ectopic GHRH-syndrome.
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Affiliation(s)
- Monica Gola
- Endocrine Section, Department of Internal Medicine, University of Brescia, Brescia, Italy
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