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Shafiq I, Williams ZR, Vates GE. Advancement in perioperative management of pituitary adenomas-Current concepts and best practices. J Neuroendocrinol 2024:e13427. [PMID: 38964869 DOI: 10.1111/jne.13427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/30/2024] [Accepted: 06/16/2024] [Indexed: 07/06/2024]
Abstract
Pituitary adenomas are very common representing 18.1% of all brain tumors and are the second most common brain pathology. Transsphenoidal surgery is the mainstay of treatment for all pituitary adenomas except for prolactinomas which are primarily treated medically with dopamine agonists. A thorough endocrine evaluation of pituitary adenoma preoperatively is crucial to identify hormonal compromise caused by the large sellar mass, identifying prolactin-producing tumors and comorbidities associated with Cushing and acromegaly to improve patient care and outcome. Transsphenoidal surgery is relatively safe in the hands of experienced surgeons, but still carries a substantial risk of causing hypopituitarism that required close follow-up in the immediate postoperative period to decrease mortality. A multidisciplinary team approach with endocrinologists, ophthalmologists, and neurosurgeons is the cornerstone in the perioperative management of pituitary adenomas.
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Affiliation(s)
- Ismat Shafiq
- Division of Endocrinology, Diabetes, and Metabolism, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Zoë R Williams
- Department of Ophthalmology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - G Edward Vates
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Sampedro-Nuñez M, Herrera-Martínez AD, Ibáñez-Costa A, Rivero-Cortés E, Venegas E, Robledo M, Martínez-Hernández R, García-Martínez A, Gil J, Jordà M, López-Fernández J, Gavilán I, Maraver S, Marqués-Pamies M, Cámara R, Fajardo-Montañana C, Valassi E, Dios E, Aulinas A, Biagetti B, Álvarez Escola C, Araujo-Castro M, Blanco C, Paz DM, Villar-Taibo R, Álvarez CV, Gaztambide S, Webb SM, Castaño L, Bernabéu I, Picó A, Gálvez MÁ, Soto-Moreno A, Puig-Domingo M, Castaño JP, Marazuela M, Luque RM. Integrative clinical, hormonal, and molecular data associate with invasiveness in acromegaly: REMAH study. Eur J Endocrinol 2024; 190:421-433. [PMID: 38701338 DOI: 10.1093/ejendo/lvae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/18/2024] [Accepted: 03/04/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION Growth hormone (GH)-secreting pituitary tumors (GHomas) are the most common acromegaly cause. At diagnosis, most of them are macroadenomas, and up to 56% display cavernous sinus invasion. Biomarker assessment associated with tumor growth and invasion is important to optimize their management. OBJECTIVES The study aims to identify clinical/hormonal/molecular biomarkers associated with tumor size and invasiveness in GHomas and to analyze the influence of pre-treatment with somatostatin analogs (SSAs) or dopamine agonists (DAs) in key molecular biomarker expression. METHODS Clinical/analytical/radiological variables were evaluated in 192 patients from the REMAH study (ambispective multicenter post-surgery study of the Spanish Society of Endocrinology and Nutrition). The expression of somatostatin/ghrelin/dopamine system components and key pituitary/proliferation markers was evaluated in GHomas after the first surgery. Univariate/multivariate regression studies were performed to identify association between variables. RESULTS Eighty percent of patients harbor macroadenomas (63.8% with extrasellar growth). Associations between larger and more invasive GHomas with younger age, visual abnormalities, higher IGF1 levels, extrasellar/suprasellar growth, and/or cavernous sinus invasion were found. Higher GH1 and lower PRL/POMC/CGA/AVPR1B/DRD2T/DRD2L expression levels (P < .05) were associated with tumor invasiveness. Least Absolute Shrinkage and Selection Operator's penalized regression identified combinations of clinical and molecular features with areas under the curve between 0.67 and 0.82. Pre-operative therapy with DA or SSAs did not alter the expression of any of the markers analyzed except for DRD1/AVPR1B (up-regulated with DA) and FSHB/CRHR1 (down-regulated with SSAs). CONCLUSIONS A specific combination of clinical/analytical/molecular variables was found to be associated with tumor invasiveness and growth capacity in GHomas. Pre-treatment with first-line drugs for acromegaly did not significantly modify the expression of the most relevant biomarkers in our association model. These findings provide valuable insights for risk stratification and personalized management of GHomas.
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Affiliation(s)
- Miguel Sampedro-Nuñez
- Department of Endocrinology and Nutrition Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER GCV14/ER/12), Madrid, Spain
| | - Aura Dulcinea Herrera-Martínez
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, Córboba, Spain
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Córboba, Spain
| | - Alejandro Ibáñez-Costa
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Córboba, Spain
- Department of Cell Biology, Physiology, and Immunology, University of Córdoba, Córdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain
- Reina Sofia University Hospital, Córdoba, Spain
| | - Esther Rivero-Cortés
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Córboba, Spain
- Reina Sofia University Hospital, Córdoba, Spain
| | - Eva Venegas
- Unidad de Gestión de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Mercedes Robledo
- Hereditary Endocrine Cancer Group, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
| | - Rebeca Martínez-Hernández
- Department of Endocrinology and Nutrition Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER GCV14/ER/12), Madrid, Spain
| | - Araceli García-Martínez
- Alicante General University Hospital-Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Joan Gil
- Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Department of Endocrinology and Nutrition, Barcelona, Spain
| | - Mireia Jordà
- Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Department of Endocrinology and Nutrition, Barcelona, Spain
| | - Judith López-Fernández
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Inmaculada Gavilán
- Hospital Universitario Puerta del Mar de Cádiz, Department of Endocrinology, Cádiz, Spain
| | - Silvia Maraver
- Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | | | - Rosa Cámara
- Hospital Universitari i Politecnic La Fe, Department of Endocrinology, Valencia, Spain
| | | | - Elena Valassi
- Hospital Universitari Germans Trias i Pujol, Department of Endocrinology and Nutrition, Barcelona, Spain
| | - Elena Dios
- Virgen del Rocio University Hospital, Department of Endocrinology, Sevilla, Spain
| | - Anna Aulinas
- Hospital de la Santa Creu i Sant Pau, Department of Endocrinology, IIB-Sant Pau, CIBER de Enfermedades Raras (CIBER-ER), University of Vic-Central University of Catalonia, Barcelona, Spain
| | - Betina Biagetti
- Hospital Vall d'Hebron, Department of Endocrinology, Barcelona, Spain
| | | | | | - Concepción Blanco
- Hospital Universitario Principe de Asturias, Department of Endocrinology, Alcalá de Henares, Madrid, Spain
| | - de Miguel Paz
- Hospital Clinico San Carlos, Department of Endocrinology, Madrid, Spain
| | - Rocío Villar-Taibo
- Complejo Hospitalario Universitario de Santiago de Compostela, Department of Endocrinology, La Coruña, Spain
| | - Clara V Álvarez
- Centro de Investigación en Medicina Molecular y Enfermedades Crónicas (CIMUS), University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Sonia Gaztambide
- Biobizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country (UPV/EHU), CIBERDEM, CIBERER, EndoERN, Barakaldo, Bizkaia, Spain
| | - Susan M Webb
- Hospital de la Santa Creu i Sant Pau, Department of Endocrinology, IIB-Sant Pau, Research Center for Pituitary Diseases, CIBERER, Univ Autonoma Barcelona, Barcelona, Spain
| | - Luis Castaño
- Biobizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country (UPV/EHU), CIBERDEM, CIBERER, EndoERN, Barakaldo, Bizkaia, Spain
| | - Ignacio Bernabéu
- Complejo Hospitalario Universitario de Santiago de Compostela, Department of Endocrinology, Santiago de Compostela, A Coruña, Spain
| | - Antonio Picó
- Department of Endocrinology and Nutrition, Alicante General University Hospital, Alicante, Spain
- Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
- University Miguel Hernandez, CIBERER, Alicante, Spain
| | - María-Ángeles Gálvez
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, Córboba, Spain
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Córboba, Spain
| | - Alfonso Soto-Moreno
- Unidad de Gestión de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Manel Puig-Domingo
- Department of Endocrinology and Nutrition, Department of Medicine, Germans Trias i Pujol Research Institute and Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Justo P Castaño
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Córboba, Spain
- Department of Cell Biology, Physiology, and Immunology, University of Córdoba, Córdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain
- Reina Sofia University Hospital, Córdoba, Spain
| | - Mónica Marazuela
- Department of Endocrinology and Nutrition Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER GCV14/ER/12), Madrid, Spain
| | - Raúl M Luque
- Maimonides Biomedical Research Institute of Córdoba (IMIBIC), Córboba, Spain
- Department of Cell Biology, Physiology, and Immunology, University of Córdoba, Córdoba, Spain
- CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain
- Reina Sofia University Hospital, Córdoba, Spain
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Cetinalp NE, Akkus G, Seydaoglu G, Ozsoy KM, Akbaba M, Baykara O, Oktay K, Erman T. Early Predictors of Remission in Acromegaly Patients after Pure Endoscopic Endonasal Transsphenoidal Surgery. J Neurol Surg B Skull Base 2024. [DOI: 10.1055/a-2319-0344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Abstract
Objective Surgery is the first-line treatment in acromegaly but it takes months to confirm remission. It is crucial to determine remission early in order to inform the patient and plan further treatment options. We aimed to evaluate the predictors of remission at the early phase after endoscopic endonasal pituitary surgery in acromegaly patients.
Methods Fifty-four growth hormone (GH)-adenoma patients operated via pure endoscopic endonasal approach were analyzed in this observational study. We compared the basic clinical, radiological characteristics, and the preoperative and postoperative hormone levels in terms of remission according to current guidelines.
Results The surgical remission rate was 61.1%. When the patients were compared according to surgical remission, the age, gender, and immunohistochemical granulation type were found to be nonsignificant, while diabetes mellitus was more common (55.6 vs. 44.4%). The preoperative tumor volume (1.2 ± 0.9 vs. 4.1 ± 4.2 cm3) and postoperative GH and insulin-like growth factor-1 (IGF-1) levels were higher in the nonremission group (p < 0.05). We defined a number of cut-off values of both GH and IGF-1 levels to predict remission at the postoperative phase. Age standardized regression analyses showed that postoperative day 1 (POD-1) GH levels (odds ratio [OR]: 8.9; 95% confidence interval [CI]: 1.99–40.0, p = 0.004) and tumor volume (OR: 3.14; 95% CI: 1.09–9.0, p = 0.034) were found to be significant independent predictors for remission.
Conclusion We demonstrated that tumor volume and POD-1 GH levels are independent predictors of remission in acromegaly patients operated via the pure endoscopic endonasal technique and may be used as an early marker of remission, and this may lead to taking adjuvant medical therapies early into account to improve prognosis.
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Affiliation(s)
- Nuri Eralp Cetinalp
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Gamze Akkus
- Division of Endocrinology, Department of Internal Medicine, Cukurova University Faculty of Medicine, Adana, Türkiye
| | - Gulsah Seydaoglu
- Department of Biostatistics, Cukurova University Faculty of Medicine, Adana, Türkiye
| | - Kerem Mazhar Ozsoy
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Mevlana Akbaba
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Okay Baykara
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Kadir Oktay
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Tahsin Erman
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
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Araujo-Castro M, Rodríguez-Berrocal V, Dios E, Serramito R, Biagetti B, Bernabeu I. Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: Clinical recommendations on the perioperative management of pituitary tumors. ENDOCRINOL DIAB NUTR 2023; 70:592-608. [PMID: 37973522 DOI: 10.1016/j.endien.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/28/2023] [Indexed: 11/19/2023]
Abstract
Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7%-14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.
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Affiliation(s)
- Marta Araujo-Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Víctor Rodríguez-Berrocal
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Elena Dios
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBIS), Hospital Virgen del Rocío, Consejo Superior de Investigaciones Científicas (CSIC), Universidad de Sevilla, Sevilla, Spain
| | - Ramon Serramito
- Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, Spain
| | - Betina Biagetti
- Servicio de Endocrinología y Nutrición, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ignacio Bernabeu
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.
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Araujo-Castro M, Berrocal VR, Dios E, Serramito R, Biagetti B, Bernabeu I. Executive summary of the expert consensus document from the Spanish Society of Neurosurgery and the Spanish Society of Endocrinology and Nutrition: clinical recommendations on the perioperative management of pituitary tumors. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:292-307. [PMID: 37858619 DOI: 10.1016/j.neucie.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/11/2023] [Indexed: 10/21/2023]
Abstract
Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7-14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.
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Affiliation(s)
- Marta Araujo-Castro
- Servicio de Endocrinología y Nutrición, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Víctor Rodríguez- Berrocal
- Servicio de Neurocirugía, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Elena Dios
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Biomedicina de Sevilla (IBIS), Hospital Virgen del Rocío, Consejo Superior de Investigaciones Científicas (CSIC), Universidad de Sevilla, Sevilla, Spain
| | - Ramon Serramito
- Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, Spain
| | - Betina Biagetti
- Servicio de Endocrinología y Nutrición, Hospital Universitario Vall d'Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Ignacio Bernabeu
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.
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Zhao M, Li K, Niu H, Zhao Y, Lu C. Perioperative hormone level changes and their clinical implications in patients with pituitary adenoma: a retrospective study of 428 cases at a single center. Front Endocrinol (Lausanne) 2023; 14:1286020. [PMID: 37964947 PMCID: PMC10642766 DOI: 10.3389/fendo.2023.1286020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/13/2023] [Indexed: 11/16/2023] Open
Abstract
Objective This study employs case data analysis to elucidate alterations in hormone levels pre and post-surgery among patients with pituitary adenoma. Moreover, it investigates the influence of various associated factors on endocrine function. Methods A retrospective analysis was conducted on clinical data from 428 patients who underwent surgical treatment within a short period at a single center. Statistical methods were employed to examine detailed hormone level fluctuations before and after surgery in patients with pituitary adenoma, along with their interrelations with different factors. Results Between January 2016 and October 2022, a total of 428 consecutive patients with pituitary adenoma underwent surgical treatment. Of these, 232 were males and 196 were females, with an average age of 45.91 years (range: 16-84, standard deviation: 12.18). Univariate analysis indicated that females exhibited a higher susceptibility to preoperative endocrine dysfunction (p < 0.05). Conversely, males, patients with larger tumor volumes, and older patients were more prone to preoperative pituitary insufficiency. Postoperatively, the most substantial remission rate occurred in prolactin (77.4%), followed by growth hormone (GH) (71.8%) and cortisol (4/6). The highest recovery rate in functions was observed in growth hormone secretion function (80%), followed by pituitary-adrenal axis hormone secretion function (56.3%) and pituitary-thyroid axis hormone secretion function (47.5%). The most noteworthy incidence of newly developed postoperative endocrine deficiencies was found in the pituitary-adrenal axis (31.8%), while the occurrence rates of deficiencies in other axes were relatively low. The elevated postoperative remission rate of growth hormone correlated with a higher surgical resection rate and lower preoperative growth hormone levels. Additionally, lower preoperative prolactin levels corresponded to a higher remission rate of prolactin postoperatively. Furthermore, the restoration of postoperative thyroid hormone secretion function was associated with higher preoperative free thyroxine levels. Reduced postoperative cortisol secretion function was linked to multiple surgeries and an extended interval between hormone retesting and surgery. Conclusion Surgical intervention effectively ameliorates endocrine disorders in pituitary adenoma patients, thereby mitigating symptoms and enhancing their quality of life. Preoperative management of growth hormone and prolactin levels facilitates an increased remission rate of these hormones post pituitary adenoma surgery. Patients displaying preoperative thyroid hormone secretion dysfunction should be considered for active supplementation therapy. Whenever feasible, complete tumor resection is recommended. For patients undergoing reoperation or multiple surgeries, vigilant postoperative cortisol monitoring and supplementation should be thoughtfully administered.
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Affiliation(s)
| | - Kai Li
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
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Fleseriu M, Langlois F, Lim DST, Varlamov EV, Melmed S. Acromegaly: pathogenesis, diagnosis, and management. Lancet Diabetes Endocrinol 2022; 10:804-826. [PMID: 36209758 DOI: 10.1016/s2213-8587(22)00244-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 11/23/2022]
Abstract
Growth hormone-secreting pituitary adenomas that cause acromegaly arise as monoclonal expansions of differentiated somatotroph cells and are usually sporadic. They are almost invariably benign, yet they can be locally invasive and show progressive growth despite treatment. Persistent excess of both growth hormone and its target hormone insulin-like growth factor 1 (IGF-1) results in a wide array of cardiovascular, respiratory, metabolic, musculoskeletal, neurological, and neoplastic comorbidities that might not be reversible with disease control. Normalisation of IGF-1 and growth hormone are the primary therapeutic aims; additional treatment goals include tumour shrinkage, relieving symptoms, managing complications, reducing excess morbidity, and improving quality of life. A multimodal approach with surgery, medical therapy, and (more rarely) radiation therapy is required to achieve these goals. In this Review, we examine the epidemiology, pathogenesis, diagnosis, complications, and treatment of acromegaly, with an emphasis on the importance of tailoring management strategies to each patient to optimise outcomes.
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Affiliation(s)
- Maria Fleseriu
- Department of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Department of Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
| | - Fabienne Langlois
- Division of Endocrinology, Department of Medicine, Centre Intégré Universitaire de Santé et de Services Sociaux de l'Estrie-Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | | | - Elena V Varlamov
- Department of Medicine (Division of Endocrinology, Diabetes and Clinical Nutrition) and Department of Neurological Surgery, and Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Shlomo Melmed
- Department of Medicine and Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Donegan D, Algeciras-Schimnich A, Ashrafzadeh-Kian S, Erickson D. Insulin-Like Growth Factor 1 in the Early Postoperative Assessment of Acromegaly. Am J Clin Pathol 2022; 157:595-601. [PMID: 34665848 DOI: 10.1093/ajcp/aqab168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Assessment of surgical outcome in acromegaly is typically recommended at 3 to 6 months following surgery. The purpose of this study was to determine if insulin-like growth factor 1 (IGF-1) concentrations at 6 weeks were equally predictive of surgical outcomes compared with IGF-1 concentrations at 3 to 6 months postoperatively applying newer IGF-1 assays. METHODS Retrospective review of patients with newly diagnosed acromegaly who had surgery between 2013 and 2020 and had postoperative IGF-1 measured by 6 weeks and 3 to 6 months. RESULTS At 6 weeks, 20 (35%) of the total 57 had normal IGF-1 and became abnormal in 1 at 3 to 6 months, whereas 37 (65%) of 57 had abnormal IGF-1 concentrations at 6 weeks, which normalized in 1 patient by 3 to 6 months. In patients who changed clinical status, IGF-1 at 6 weeks was within ±0.1-fold of normal. Although a difference was seen between median IGF-1 concentrations (286 vs 267 ng/mL, P = .009) at 6 weeks and 3 to 6 months, the mean reduction was small (-19.9 ng/mL). CONCLUSIONS Compared with 3 to 6 months, use of IGF-1 at 6 weeks was associated with a change in clinical status in 3.5% of patients. Therefore, in most patients, IGF-1 at 6 weeks can be used to assess clinical outcome via newer assays.
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Affiliation(s)
- Diane Donegan
- Department of Endocrinology Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Endocrinology, Diabetes and Metabolism, Mayo College of Medicine, Rochester, MN, USA
| | | | | | - Dana Erickson
- Department of Endocrinology, Diabetes and Metabolism, Mayo College of Medicine, Rochester, MN, USA
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Cambria V, Beccuti G, Prencipe N, Penner F, Gasco V, Gatti F, Romanisio M, Caputo M, Ghigo E, Zenga F, Grottoli S. First but not second postoperative day growth hormone assessments as early predictive tests for long-term acromegaly persistence. J Endocrinol Invest 2021; 44:2427-2433. [PMID: 33837920 PMCID: PMC8502138 DOI: 10.1007/s40618-021-01553-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/10/2021] [Indexed: 10/24/2022]
Abstract
PURPOSE Postoperative assessment of acromegaly activity is typically performed at least 3 months after neurosurgery (NS). Few studies have evaluated the use of early postoperative growth hormone (GH) levels as a test to predict short- and long-term remission of acromegaly. Our objective was to evaluate the diagnostic performance of serum random GH on a postoperative day one (D1-rGH) and two (D2-rGH), particularly in predicting long-term disease persistence. MATERIALS AND METHODS Forty-one subjects with acromegaly who were undergoing NS were enrolled (mean age ± SD 47.4 ± 13.1 years at diagnosis; women 54%; macroadenomas 71%). The final assessment of disease activity was performed one year after NS. ROC curves were used to evaluate the diagnostic performance of D1-rGH and D2-rGH. RESULTS After a 1-year follow-up, the overall remission rate was 55%. ROC analysis identified an optimal D1-rGH cut-off value of 2.1 ng/mL for diagnosing long-term disease persistence (55.6% SE; 90.9% SP). The cut-off point became 2.5 ng/mL after maximizing specificity for disease persistence (yielding a 100% positive predictive value) and 0.3 ng/mL after maximizing sensitivity for disease remission. The optimal D2-rGH cut-off value was 0.6 ng/mL (81.8% SE; 50% SP); the cut-off point became 2.9 ng/mL after maximizing specificity and 0.1 ng/mL after maximizing sensitivity, with no clinical utility. CONCLUSIONS D1-rGH could be a highly specific test for the early diagnosis of long-term acromegaly persistence, which is predicted by a value > 2.5 ng/mL with a great degree of certainty. The diagnostic performance of D2-rGH was insufficient. Further research is required to validate these preliminary results prior to modifying the postoperative management of acromegaly.
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Affiliation(s)
- V. Cambria
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - G. Beccuti
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - N. Prencipe
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - F. Penner
- Division of Neurosurgery, Department of Neurosciences “Rita Levi Montalcini”, University of Turin, Turin, Italy
| | - V. Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - F. Gatti
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - M. Romanisio
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - M. Caputo
- Division of Endocrinology, Department of Translational Medicine, University of Eastern Piedmont “Amedeo Avogadro”, Novara, Italy
| | - E. Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - F. Zenga
- Division of Endocrinology, Department of Translational Medicine, University of Eastern Piedmont “Amedeo Avogadro”, Novara, Italy
| | - S. Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
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Sakata K, Nagata Y, Takeshige N, Kikuchi J, Shikata M, Ashida K, Nomura M, Morioka M. Early postoperative prediction of both disease remission and long-term disease control in acromegaly using the oral glucose tolerance test. Hormones (Athens) 2021; 20:515-526. [PMID: 33738782 DOI: 10.1007/s42000-021-00281-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/07/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the cornerstone of acromegaly treatment. Two biochemical parameters, growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels, sometimes diverge postoperatively; however, it is important to maintain disease control without further treatment, regardless of whether these parameters converge. This study investigated whether remission and long-term disease control could be predicted using early postoperative GH and IGF-1 levels. METHODS We reviewed 36 consecutive surgically treated patients with acromegaly. IGF-1 levels and minimum GH levels during an oral glucose tolerance test (OGTT) were evaluated at 2 weeks, as well as at 3 months postoperatively. After comparison between the remission and nonremission groups, we analyzed whether early postoperative parameters could predict remission and long-term disease control. RESULTS Twenty-five patients (69.4%, Group A) achieved remission within 1 year postoperatively. Of the remaining patients (median follow-up period, 53 months), seven (19.5%, Group B) maintained normal IGF-1 levels without treatment, whereas four (11.1%, Group C) required additional treatment. GH levels <1.5 ng/mL measured on the morning after surgery and nadir GH levels <0.7 ng/mL during the OGTT conducted at 2 weeks postoperatively were predictive of remission, with the latter demonstrating 95.2% sensitivity and 100% specificity. All group C patients had nadir GH levels ≥0.7 ng/mL during the OGTT and IGF-1 levels ≥SD +3 at 2 weeks postoperatively. CONCLUSION Early postoperative nadir GH levels during the OGTT and IGF-1 levels at 2 weeks postoperatively demonstrated excellent predictive value for both endocrinological remission and the necessity for additional treatment.
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Affiliation(s)
- Kiyohiko Sakata
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan.
| | - Yui Nagata
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Nobuyuki Takeshige
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Jin Kikuchi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Masato Shikata
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Kenji Ashida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
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11
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Torres A, Sanmillan JL, Lau R, Gabarros A. Final Outcome in Growth Hormone-Secreting Adenomas After Combination of Maximal Tumor Resection and Medical Treatment. World Neurosurg 2021; 154:e292-e301. [PMID: 34252630 DOI: 10.1016/j.wneu.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/04/2021] [Accepted: 07/05/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Gross total resection (GTR) is not always possible in acromegalic patients, especially in patients with invasive growth hormone-secreting adenomas. We analyzed the biochemical remission outcome in relation to extent of tumor resection and effectiveness of medical treatment in cases of remnant tumor. METHODS Retrospective analysis was performed of acromegalic patients operated on between 2002 and 2017. Preoperative imaging, tumor invasiveness, extent of resection, and biochemical remission were collected. Patients with tumor remnant not amenable to second surgery began medical treatment. The relationship between pituitary adenoma remnant volume and final biochemical outcome was analyzed. RESULTS Of 120 acromegalic patients operated on, 82 underwent transsphenoidal microsurgery and 38 underwent endonasal endoscopic approach. GTR was achieved in 72 cases (60%); subtotal resection (STR), 21 (17.5%) cases; and partial resection, 27 (22.5%) cases. There was a nonsignificant higher rate of GTR/STR in patients who underwent endonasal endoscopic approach. However, a significantly higher remission rate (89.45% vs. 67.1%) was achieved in these patients (P < 0.01). Greater tumor volume and invasiveness were associated with a lower remission (P < 0.05). Patients with tumor remnant who achieved biochemical remission with added medical therapy had a significantly smaller tumor volume (P < 0.001). CONCLUSIONS The more aggressive surgical resection is, the greater the chance of attaining final biochemical remission, whether or not GTR is achieved. Medical therapy effectiveness is enhanced in cases with STR. Invasive growth hormone-secreting macroadenomas that are not surgically amenable to total resection are best managed with a combination of safe STR and medical treatment.
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Affiliation(s)
- Alberto Torres
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain.
| | - Jose Luis Sanmillan
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain
| | - Ruth Lau
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain
| | - Andreu Gabarros
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain
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12
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Wang YY, Waqar M, Abou-Zeid A, Kearney T, Caputo C, Davis J, Trainer P, Higham C, Roncaroli F, Gnanalingham KK. Value of Early Post-Operative Growth Hormone Testing in Predicting Long-Term Remission and Residual Disease after Transsphenoidal Surgery for Acromegaly. Neuroendocrinology 2021; 112:345-357. [PMID: 34052822 DOI: 10.1159/000517476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 05/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Surgical remission for acromegaly is dependent on a number of factors including tumour size, invasiveness, and surgical expertise. We studied the value of early post-operative growth hormone (GH) level as a predictor of outcome and to guide early surgical re-exploration for residual disease in patients with acromegaly. METHODS Patients with acromegaly undergoing first-time endoscopic transsphenoidal surgery between 2005 and 2015, in 2 regional neurosurgical centres, were studied. Insulin-like growth factor-1 (IGF-1), basal GH (i.e., sample before oral glucose), and GH nadir on oral glucose tolerance test (OGTT) were tested at various time points, including 2-5 days post-operatively. Definition of disease remission was according to the 2010 consensus statement (i.e., GH nadir <0.4 μg/L during an OGTT and normalized population-matched IGF-1). Forward stepwise logistic regression was used to determine factors associated with remission. RESULTS We investigated 81 consecutive patients with acromegaly, 67 (83%) of which had macroadenomas and 22 (27%) were noted to be invasive at surgery. Mean follow-up was 44 ± 25 months. Overall, surgical remission was achieved in 55 (68%) patients at final follow-up. On univariate analysis, the remission rates at the end of the study period for patients with early post-operative GH nadir on OGTT of <0.4 (N = 43), between 0.4 and 1 (N = 28), and >1 μg/L (N = 8) were 88, 54, and 20%, respectively. Similar results were seen with basal GH on early post-operative OGTT. On multivariate regression analysis, pre-operative IGF-1 (odds ratio of 13.1) and early post-operative basal GH (odds ratio of 5.0) and GH nadir on OGTT (odds ratio of 6.8) were significant predictors of residual disease. Based on a raised early GH nadir and post-operative MR findings, 10 patients underwent early surgical re-exploration. There was reduction in post-operative GH levels in 9 cases, of which 5 (50%) achieved long-term remission. There was an increased risk of new pituitary hormone deficiencies in patients having surgical re-exploration compared to those having a single operation (60 vs. 14%). CONCLUSIONS An early post-operative basal GH and GH nadir on OGTT are reliable predictors of long-term disease remission. It can be used to guide patients for early surgical re-exploration for residual disease, although there is increased risk of hypopituitarism.
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Affiliation(s)
- Yi Yuen Wang
- Departments of Neurosurgery, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK
- Department of Neurosurgery, The University of Melbourne, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Mueez Waqar
- Departments of Neurosurgery, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK,
- Division of Neuroscience and Experimental Psychology, School of Biology, Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK,
| | - Ahmed Abou-Zeid
- Departments of Neurosurgery, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK
- Department of Neurosurgery, Ain Shams University, Cairo, Egypt
| | - Tara Kearney
- Department of Endocrinology, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK
| | - Carmela Caputo
- Department of Endocrinology, The University of Melbourne, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Julian Davis
- Department of Endocrinology, Manchester University NHS Foundation Trust, and Faculty of Biology, Medicine & Health, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Peter Trainer
- Department of Endocrinology, The Christie Hospital, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Claire Higham
- Department of Endocrinology, The Christie Hospital, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Federico Roncaroli
- Division of Neuroscience and Experimental Psychology, School of Biology, Faculty of Biology, Medicine and Health, Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, UK
| | - Kanna K Gnanalingham
- Departments of Neurosurgery, Greater Manchester Neurosciences Centre, Salford Royal Foundation Trust (SRFT), Manchester Academic Health Sciences Centre, Manchester, UK
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13
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Qiao N, Shen M, He W, He M, Zhang Z, Ye H, Li Y, Shou X, Li S, Jiang C, Wang Y, Zhao Y. Machine learning in predicting early remission in patients after surgical treatment of acromegaly: a multicenter study. Pituitary 2021; 24:53-61. [PMID: 33025547 DOI: 10.1007/s11102-020-01086-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Accurate prediction of postoperative remission is beneficial for effective patient-physician communication in acromegalic patients. This study aims to train and validate machine learning prediction models for early endocrine remission of acromegalic patients. METHODS The training cohort included 833 patients with growth hormone (GH) secreting pituitary adenoma from 2010 to 2018. We trained a partial model (only using pre-operative variables) and a full model (using all variables) to predict off-medication endocrine remission at six-month follow-up after surgery using multiple algorithms. The models were validated in 99 prospectively collected patients from a second campus and 52 patients from a third institution. RESULTS C-statistic and the accuracy of the best partial model was 0.803 (95% CI 0.757-0.849) and 72.5% (95% CI 67.6-77.5%), respectively. C-statistic and the accuracy of the best full model was 0.888 (95% CI 0.861-0.914) and 80.3% (95% CI 77.5-83.1%), respectively. The c-statistics (and accuracy) of using only Knosp grade, total resection, or postoperative day 1 GH level as the single predictor were lower than our partial model or full model (p < 0.001). C-statistics remained similar in the prospective cohort (partial model 0.798, and full model 0.903) and in the external cohort (partial model 0.771, and full model 0.871). A web-based application integrated with the trained models was published at https://deepvep.shinyapps.io/Acropred/ . CONCLUSION We developed and validated interpretable and applicable machine learning models to predict early endocrine remission after surgical resection of a GH-secreting pituitary adenoma. Predication accuracy of the trained models were better than those using single variables.
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Affiliation(s)
- Nidan Qiao
- Department of Neurosurgery, Shanghai Medical School, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Medical Science in Clinical Investigation, Harvard Medical School, Boston, USA
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Pituitary Tumor Center, Shanghai, China
| | - Ming Shen
- Department of Neurosurgery, Shanghai Medical School, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Pituitary Tumor Center, Shanghai, China
| | - Wenqiang He
- Department of Neurosurgery, Shanghai Medical School, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Pituitary Tumor Center, Shanghai, China
| | - Min He
- Department of Endocrinology, Shanghai Medical School, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhaoyun Zhang
- Department of Endocrinology, Shanghai Medical School, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongying Ye
- Department of Endocrinology, Shanghai Medical School, Huashan Hospital, Fudan University, Shanghai, China
| | - Yiming Li
- Department of Endocrinology, Shanghai Medical School, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuefei Shou
- Department of Neurosurgery, Shanghai Medical School, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Pituitary Tumor Center, Shanghai, China
| | - Shiqi Li
- Department of Neurosurgery, Shanghai Medical School, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Pituitary Tumor Center, Shanghai, China
| | - Changzhen Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fujian Medical University, 20 Chazhong Road, Fujian, China.
| | - Yongfei Wang
- Department of Neurosurgery, Shanghai Medical School, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China.
- Neurosurgical Institute of Fudan University, Shanghai, China.
- Shanghai Pituitary Tumor Center, Shanghai, China.
| | - Yao Zhao
- Department of Neurosurgery, Shanghai Medical School, Huashan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China.
- Neurosurgical Institute of Fudan University, Shanghai, China.
- Shanghai Pituitary Tumor Center, Shanghai, China.
- State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China.
- National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China.
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Cardinal T, Collet C, Wedemeyer M, Singer PA, Weiss M, Zada G, Carmichael JD. Postoperative GH and Degree of Reduction in IGF-1 Predicts Postoperative Hormonal Remission in Acromegaly. Front Endocrinol (Lausanne) 2021; 12:743052. [PMID: 34867787 PMCID: PMC8637049 DOI: 10.3389/fendo.2021.743052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Determine predictive factors for long-term remission of acromegaly after transsphenoidal resection of growth hormone (GH)-secreting pituitary adenomas. METHODS We identified 94 patients who had undergone transsphenoidal resection of GH-secreting pituitary adenomas for treatment of acromegaly at the USC Pituitary Center from 1999-2019 to determine the predictive value of postoperative endocrine lab values. RESULTS Patients underwent direct endoscopic endonasal (60%), microscopic transsphenoidal (38%), and extended endoscopic approaches (2%). The cohort was 63% female and 37% male, with average age of 48.9 years. Patients presented with acral enlargement (72, 77%), macroglossia (40, 43%), excessive sweating (39, 42%), prognathism (38, 40%) and frontal bossing (35, 37%). Seventy-five (80%) were macroadenomas and 19 (20%) were microadenomas. Cavernous sinus invasion was present in 45%. Available immunohistochemical data demonstrated GH staining in 88 (94%) and prolactin in 44 (47%). Available postoperative MRI demonstrated gross total resection in 63% of patients and subtotal resection in 37%. Most patients (66%) exhibited hormonal remission at 12 weeks postoperatively. Receiver operating characteristic (ROC) curves demonstrated postoperative day 1 (POD1) GH levels ≥1.55ng/mL predicted failure to remit from surgical resection alone (59% specificity, 75% sensitivity). A second ROC curve showed decrease in corrected insulin-like growth factor-1 (IGF-1) levels of at least 37% prognosticated biochemical control (90% sensitivity, 80% specificity). CONCLUSION POD1 GH and short-term postoperative IGF-1 levels can be used to successfully predict immediate and long-term hormonal remission respectively. A POD1 GH cutoff can identify patients likely to require adjuvant therapy to emphasize clinical follow-up.
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Affiliation(s)
- Tyler Cardinal
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- *Correspondence: Tyler Cardinal,
| | - Casey Collet
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Michelle Wedemeyer
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - Peter A. Singer
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | | | - Gabriel Zada
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
| | - John D. Carmichael
- University of Southern California (USC) Pituitary Center, Department of Neurosurgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
- Department of Medicine, Division of Endocrinology and Diabetes, Keck School of Medicine of University of Southern California, Los Angeles, CA, United States
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15
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Tsiberkin AI, Tsoy UA, Cherebillo VY, Polezhaev AV, Kuritsyna NV, Paltsev AA, Alkhazishvili AV, Grineva EN. [Early postoperative measurement of growth hormone level for prognosis of surgical outcomes in acromegaly]. TERAPEVT ARKH 2020; 92:48-53. [PMID: 33346479 DOI: 10.26442/00403660.2020.10.000490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 11/23/2020] [Indexed: 11/22/2022]
Abstract
AIM To investigate the value of 24 hours post-surgery measurement of growth hormone (GH) level for prognosis of surgical outcomes in acromegaly. MATERIALS AND METHODS A prospective cohort study included 45 patients with newly diagnosed acromegaly. The degree of parasellar extension was measured on the preoperative sellar magnetic resonance imaging according to the Knosps classification. All patients underwent a transsphenoid adenomectomy performed by one neurosurgeon. Basal GH level was measured at 24 hours after surgery. The efficacy of transsphenoidal adenomectomy evaluated at 12 months after surgery. RESULTS Acromegaly remission was achieved in 19 (42%) of 45 patients at 12 months after surgery. Pituitary microadenomas and the absence of paracellular invasion, corresponding to Knosp Grade 02, had low prognostic value for long-term remission due to low sensitivity (31.6%) and low specificity (38.5%), respectively. The highest prognostic value for acromegaly remission was showed for 24 hours post-surgery GH level with cut-off 1.30 ng/ml with sensitivity of 96.2% (95% confidence interval 81.199.8%) and specificity of 84.2% (95% confidence interval 62.494.4%). CONCLUSION The study demonstrated the possibility of using GH level at 24 after surgery as a predictor for acromegaly remission. GH level 1.30 ng/ml at 24 hours after surgery showed better predictive value for long-term remission compared with the presence of microadenomas and Knosp Grade 02. The absence of decrease of GH level on the first day after surgery may serve as a reason for more close monitoring of patients in the postoperative period. Further studies in a larger number of observers are required to confirm our findings.
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Affiliation(s)
| | - U A Tsoy
- Almazov National Medical Research Center
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16
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Asha MJ, Takami H, Velasquez C, Oswari S, Almeida JP, Zadeh G, Gentili F. Long-term outcomes of transsphenoidal surgery for management of growth hormone-secreting adenomas: single-center results. J Neurosurg 2020; 133:1360-1370. [PMID: 31604330 DOI: 10.3171/2019.6.jns191187] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/18/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Transsphenoidal surgery is advocated as the first-line management of growth hormone (GH)-secreting adenomas. Although disease control is defined by strict criteria for biochemical remission, the length of follow-up needed is not well defined in literature. In this report, the authors present their long-term remission rate and identify various predictive factors that might influence the clinical outcome. METHODS The authors conducted a single-institute retrospective analysis of all transsphenoidal procedures for GH-secreting adenomas performed from January 2000 to June 2016. The primary outcome was defined as biochemical remission according to the 2010 consensus criteria and measured at the 1-year postoperative mark as well as on the last recorded follow-up appointment.Secondary variables included recurrence rate, patterns of clinical presentation, and outcome of adjuvant therapy (including repeat surgery). Subgroup analysis was performed for patients who had biochemical or radiological "discordance"-patients who achieved biochemical remission but with incongruent insulin-like growth factor 1 (IGF-1)/GH or residual tumor on MRI. Recurrence-free survival analysis was conducted for patients who achieved remission at 1 year after surgery. RESULTS Eighty-one patients (45 female and 36 male) with confirmed acromegaly treated with transsphenoidal surgery were included. In 62 cases the patients were treated with a pure endoscopic approach and in 19 cases an endoscopically assisted microscopic approach was used.Primary biochemical remission after surgery was achieved in 59 cases (73%) at 1 year after surgery. However, only 41 patients (51%) remained in primary surgical remission (without any adjuvant treatment) at their last follow-up appointment, indicating a recurrence rate of 31% (18 of 59 patients) over the duration of follow-up (mean 100 ± 61 months). Long-term remission rates for pure endoscopic and endoscopically assisted cases were not significantly different (48% vs 52%, p = 0.6). Similarly, no significant difference in long-term remission was detected between primary surgery and repeat surgery (54% vs 33%, p = 0.22).Long-term remission was significantly influenced by extent of resection, cavernous sinus invasion (radiologically as well as surgically reported), and preoperative and early postoperative GH and IGF-1 levels (within 24-48 hours after surgery) as well as by clinical grade, with lower remission rates in patients with dysmorphic features and/or medical comorbidities (grade 2-3) compared to minimally symptomatic or silent cases (grade 1). CONCLUSIONS The long-term surgical remission rate appears to be significantly less than "early" remission rates and is highly dependent on the extent of tumor resection. The authors advocate a long-term follow-up regimen and propose a clinical grading system that may aid in predicting long-term outcome in addition to the previously reported anatomical factors. The role of repeat surgery is highlighted.
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17
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Agrawal N, Ioachimescu AG. Prognostic factors of biochemical remission after transsphenoidal surgery for acromegaly: a structured review. Pituitary 2020; 23:582-594. [PMID: 32602066 DOI: 10.1007/s11102-020-01063-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Biochemical control is the main determinant of survival, clinical manifestations and comorbidities in acromegaly. Transsphenoidal selective adenomectomy (TSA) is the initial treatment of choice with reported biochemical remission rates varying between 32 and 85%. Understanding the limiting factors is essential for identification of patients who require medical treatment. METHODS We reviewed the English literature published in Medline/Pubmed until Dec 31, 2019 to identify eligible studies that described outcomes of TSA as primary therapy and performed analyses to determine the main predictors of remission. RESULTS Most publications reported single-institution, retrospective studies. The following preoperative parameters were consistently associated with lower remission rates: cavernous sinus invasion by imaging, larger tumor size and higher GH levels. Young age and preoperative IGF-1 levels were predictive in some studies. When controlled for covariates, the best single preoperative predictor was cavernous sinus invasion, followed by preoperative GH levels. Conversely, low GH level in the first few days postoperatively was a robust predictor of durable remission. The influence of tumor histology (sparsely granular pattern, co-expression of prolactin and proliferation markers) on surgical remission remains to be established. Few studies developed predictive models that yielded much higher predictive values than individual parameters. CONCLUSION Surgical outcome prognostication systems could be further generated by machine learning algorithms in order to support development and implementation of personalized care in patients with acromegaly.
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Affiliation(s)
- Nidhi Agrawal
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, NYU School of Medicine, 550 First Avenue, New York City, NY, 10016, USA
| | - Adriana G Ioachimescu
- Department of Medicine and Neurosurgery, Emory University School of Medicine, 1365 B Clifton Road B-2200, Northeast, B6209, Atlanta, GA, 30322, USA.
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Ioachimescu AG, Handa T, Goswami N, Pappy AL, Veledar E, Oyesiku NM. Gender differences and temporal trends over two decades in acromegaly: a single center study in 112 patients. Endocrine 2020; 67:423-432. [PMID: 31677093 DOI: 10.1007/s12020-019-02123-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 10/22/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE To evaluate the impact of gender and year at surgery on clinical presentation and postoperative outcomes in acromegaly. METHODS Retrospective review of patients operated between 1994 and 2016 to compare presentation and outcomes in groups defined by gender and year of surgery. Kaplan-Meier survival analyses with a composite endpoint (recurrence, reoperation, and radiation) were used for gender comparison and Youden indices for biochemical remission rates changes during study period. RESULTS Primary indications for evaluation were phenotype, neurological symptoms, incidentaloma, hypogonadism, and galactorrhea. At surgery, men (N = 54) were younger (43.6 ± 12.7 years) than women (N = 58, 48.7 ± 12.3, P = 0.04). Male:female ratios before and after age 50 were 1.4 and 0.6 respectively. Men had higher mean IGF-1 levels (874 ± 328 vs 716 ± 296, P < 0.01) and smaller tumors (1.8 ± 1.3 cm vs 2.3 ± 1.5, P = 0.04). Postoperative remission rates were comparable (51% men, 56% women) and inversely associated with cavernous sinus invasion and GH levels. Women had longer mean follow-up (5.2 ± 3.4 years vs 3.6 ± 3.6 men, P = 0.02) and longer endpoint-free survival (P < 0.01). At last follow-up, 89.6% women and 70% men had normal IGF-1 levels (P = 0.03). Postoperative remission rates were higher in patients operated after February 15, 2011 (67.35 vs 43.5% previously, P = 0.01). In late vs early surgery group, physical changes as main indication for screening decreased (54 vs 30%, P < 0.01), while incidentaloma and hypogonadism increased. Median GH levels were lower in late vs early surgery group (P = 0.03). CONCLUSION We demonstrate gender-specific characteristics and an evolving spectrum of clinical presentation with implications for earlier diagnosis and personalized management of acromegaly.
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Affiliation(s)
- Adriana G Ioachimescu
- Dept of Medicine (Endocrinology), Emory School of Medicine, 1365 B Clifton Rd, Atlanta, GA, 30322, USA.
- Dept of Neurosurgery, Emory School of Medicine, 1365 B Clifton Rd, Atlanta, GA, 30322, USA.
| | - Talin Handa
- Emory College of Arts and Sciences, 1557 Dickey Dr., Atlanta, GA, 30322, USA
| | - Neevi Goswami
- Georgia Institute of Technology, North Ave NE, Atlanta, GA, 30332, USA
| | - Adlai L Pappy
- Emory School of Medicine, 201 Dowman Dr., Atlanta, GA, USA
| | | | - Nelson M Oyesiku
- Dept of Medicine (Endocrinology), Emory School of Medicine, 1365 B Clifton Rd, Atlanta, GA, 30322, USA
- Dept of Neurosurgery, Emory School of Medicine, 1365 B Clifton Rd, Atlanta, GA, 30322, USA
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Li YL, Zhang S, Guo XP, Gao L, Lian W, Yao Y, Deng K, Wang RZ, Xing B. Correlation analysis between short-term insulin-like growth factor-I and glucose intolerance status after transsphenoidal adenomectomy in acromegalic patients: a large retrospective study from a single center in China. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2019; 63:157-166. [PMID: 30916168 PMCID: PMC10522129 DOI: 10.20945/2359-3997000000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 02/17/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Our study aimed to investigate the associations of glucose tolerance status with insulin-like growth factor-I (IGF-I) and other clinical laboratory parameters of acromegalic patients before and after the patients underwent transsphenoidal adenomectomy (TSA) by conducting a single-center, retrospective study. SUBJECTS AND METHODS A total of 218 patients with acromegaly who had undergone TSA as the first treatment were retrospectively analyzed. Serum IGF-I, growth hormone (GH) and glucose levels were measured before and after surgery. RESULTS The follow-up levels for random GH, GH nadir, and the percentage of the upper limit of normal IGF-I (%ULN IGF-I) were decreased significantly. The percentages of normal (39.0%), early carbohydrate metabolism disorders (33.0%) and diabetes mellitus (28.0%) changed to 70.2%, 16.5% and 13.3%, respectively, after TSA. %ULN IGF-I at baseline was higher in the diabetes mellitus (DM) group than in the normal glucose tolerance group and impaired glucose tolerance (IGT) /impaired fasting glucose (IFG) groups before TSA, and the DM group exhibited a greater reduction in %ULN IGF-I value after surgery. The follow-up %ULN IGF-I value after surgery was significantly lower in the improved group, and Pearson's correlation analysis revealed that the reductions in %ULN IGF-I corresponded with the reductions in glucose level. CONCLUSION This study examined the largest reported sample with complete preoperative and follow-up data. The results suggest that the age- and sex-adjusted IGF-I level, which reflects altered glucose metabolism, and the change of it are associated with improved glucose tolerance in acromegalic patients both before and after TSA.
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Affiliation(s)
- Yi-Lin Li
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- Chinese Academy of Medical SciencesPlastic Surgery HospitalDepartment No. 16BeijingChinaDepartment No. 16, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Shuo Zhang
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Xiao-Peng Guo
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Lu Gao
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Wei Lian
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Yong Yao
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Kan Deng
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Ren-Zhi Wang
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
| | - Bing Xing
- Peking Union Medical College HospitalDepartment of NeurosurgeryPekingChinaDepartment of Neurosurgery, Peking Union Medical College Hospital, Peking, China
- The Ministry of Health Key Laboratory of EndocrinologyPekingChinaThe Ministry of Health Key Laboratory of Endocrinology, Peking, China
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Shen M, Tang Y, Shou X, Wang M, Zhang Q, Qiao N, Ma Z, Ye Z, He W, Zhang Y, Chen Z, Zhang Z, Ye H, Li Y, Li S, Zhao Y, Zhou X, Wang Y. Surgical Results and Predictors of Initial and Delayed Remission for Growth Hormone-Secreting Pituitary Adenomas Using the 2010 Consensus Criteria in 162 Patients from a Single Center. World Neurosurg 2018; 124:S1878-8750(18)32738-4. [PMID: 30500578 DOI: 10.1016/j.wneu.2018.11.179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND The factors associated with initial and delayed remission after growth hormone (GH)-secreting pituitary adenoma excision have not been completely elucidated. METHODS We recruited 185 consecutive patients who had undergone resection of GH-secreting pituitary adenomas from January 2013 to December 2014 and assessed their tumor characteristics and surgical outcomes. The criteria for initial or delayed remission (using the 2010 consensus criteria) were normalized insulin-like growth factor 1 (IGF-1) levels, GH levels <0.4 μg/L with an oral glucose tolerance test, and/or random GH levels <1.0 μg/L at or after the postoperative 3-month (PO3M) follow-up, without adjuvant therapy. RESULTS Remission was achieved in 92 of 162 patients (56.8%) after surgery alone and was associated with a lower Knosp grade of 0-2 and lower postoperative day 1 GH level on multivariate regression analysis. A baseline IGF-1 index (IGF-1 level/upper limit of normal) of <2.835 predicted for initial remission at the PO3M follow-up (positive predictive value, 95.3%; negative predictive value, 36.6%; P < 0.001). The PO3M IGF-1 index was significantly lower in the delayed remission group than in the nonremission group. Furthermore, the former had had fewer invasive tumors (1.23 ± 0.21 vs. 1.77 ± 0.37 [9.52% vs. 76.47%]; P < 0.001). A PO3M IGF-1 index of <1.485 predicted for delayed remission during subsequent follow-up (positive predictive value, 84.6%; negative predictive value, 92.3%; P < 0.001). CONCLUSIONS A lower Knosp grade of 0-2 and lower postoperative day 1 GH level were independent predictors of surgical remission. The baseline IGF-1 and PO3M IGF-1 indexes might predict for initial and delayed remission, respectively.
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Affiliation(s)
- Ming Shen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yifan Tang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Xuefei Shou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Meng Wang
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Qilin Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Nidan Qiao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Zengyi Ma
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Zhao Ye
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Wenqiang He
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yichao Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Zhengyuan Chen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Zhaoyun Zhang
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Hongying Ye
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yiming Li
- Department of Endocrinology and Metabolism, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Shiqi Li
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yao Zhao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Xiang Zhou
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China
| | - Yongfei Wang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China; Shanghai Pituitary Tumor Center, Shanghai, China.
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Antunes X, Ventura N, Camilo GB, Wildemberg LE, Guasti A, Pereira PJM, Camacho AHS, Chimelli L, Niemeyer P, Gadelha MR, Kasuki L. Predictors of surgical outcome and early criteria of remission in acromegaly. Endocrine 2018; 60:415-422. [PMID: 29626274 DOI: 10.1007/s12020-018-1590-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/30/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Transsphenoidal surgery (TSS) is the cornerstone of acromegaly treatment, however there are no robust predictors of surgical outcome and remission can only be defined three months after surgery. PURPOSE To analyze if biochemical, demographical, radiological, and immunohistochemical characteristics are predictors of surgical remission and investigate if immediate postoperative GH and IGF-I levels can help defining remission earlier. METHODS Consecutive acromegaly patients submitted to TSS between 2013-2016 were evaluated. Remission criteria was defined as normal IGF-I and GH <1 mcg/L three months after surgery. Data of age, sex, GH and IGF-I levels, tumor volume, cavernous sinus invasion, T2-weighted signal, Ki-67, and granulation pattern were correlated with remission status. GH and IGF-I levels at 24, 48 h, and one week postoperative were evaluated as early criteria of remission. RESULTS Sixty-nine patients were included (84% macroadenomas) and surgical remission was achieved in 45%. No difference between cured and not cured patients concerning age, gender, preoperative GH or IGF-I levels, tumor volume, T2-weighted signal, Ki-67 and tumor granularity was observed. Remission was obtained in 20 of 36 (56%) of the non-invasive tumors, and in 3 of 16 (19%) of the invasive tumors (p = 0.017). A GH <1.57 mcg/L 48 h after surgery was able to predict remission with 93% sensitivity and 86% specificity and an IGF-I < 231% ULNR one week after surgery predicted remission with 86% sensitivity and 93% specificity. CONCLUSION Cavernous sinus invasion is the only preoperative predictor of surgical remission. GH at 48 h and IGF-I one week after surgery can define earlier not cured patients.
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Affiliation(s)
- Ximene Antunes
- Neuroendocrinology Research Center / Endocrinology Division - Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nina Ventura
- Radiology Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Gustavo Bittencourt Camilo
- Radiology Division - Instituição Hospital e Maternidade Terezinha de Jesus -Juiz de Fora, Minas Gerais, Brazil
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center / Endocrinology Division - Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Andre Guasti
- Neurosurgery Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Paulo José M Pereira
- Neurosurgery Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Aline Helen Silva Camacho
- Neuropathology and Molecular Genetics Laboratory - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Pathology Division - Instituto Nacional do Câncer, Rio de Janeiro, Brazil
| | - Leila Chimelli
- Neuropathology and Molecular Genetics Laboratory - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Paulo Niemeyer
- Neurosurgery Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center / Endocrinology Division - Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrinology Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
| | - Leandro Kasuki
- Neuroendocrinology Research Center / Endocrinology Division - Medical School and Hospital Universitário Clementino Fraga Filho - Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
- Neuroendocrinology Division - Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.
- Endocrinology Division - Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil.
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Xia Z, Guo X, Zhou Q, Wu J, Lian W, Yao Y, Deng K, Feng M, Wang R, Xing B. Somatotrophic Adenoma in Children Younger than 14 Years: Clinical Features and Treatment of 22 Cases at a Large Pituitary Center. World Neurosurg 2018; 112:e561-e568. [DOI: 10.1016/j.wneu.2018.01.087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 12/17/2022]
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Kasuki L, Wildemberg LE, Gadelha MR. MANAGEMENT OF ENDOCRINE DISEASE: Personalized medicine in the treatment of acromegaly. Eur J Endocrinol 2018; 178:R89-R100. [PMID: 29339530 DOI: 10.1530/eje-17-1006] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 01/16/2018] [Indexed: 12/31/2022]
Abstract
Acromegaly is associated with high morbidity and elevated mortality when not adequately treated. Surgery is the first-line treatment for most patients as it is the only one that can lead to immediate cure. In patients who are not cured by surgery, treatment is currently based on a trial-and-error approach. First-generation somatostatin receptor ligands (fg-SRL) are initiated for most patients, although approximately 25% of patients present resistance to this drug class. Some biomarkers of treatment outcome are described in the literature, with the aim of categorizing patients into different groups to individualize their treatments using a personalized approach. In this review, we will discuss the current status of precision medicine for the treatment of acromegaly and future perspectives on the use of personalized medicine for this purpose.
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Affiliation(s)
- Leandro Kasuki
- Neuroendocrinology Research Center/Endocrine Section and Medical School, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Section, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
- Endocrine Unit, Hospital Federal de Bonsucesso, Rio de Janeiro, Brazil
| | - Luiz Eduardo Wildemberg
- Neuroendocrinology Research Center/Endocrine Section and Medical School, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Section, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mônica R Gadelha
- Neuroendocrinology Research Center/Endocrine Section and Medical School, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuroendocrine Section, Instituto Estadual do Cérebro Paulo Niemeyer, Secretaria Estadual de Saúde do Rio de Janeiro, Rio de Janeiro, Brazil
- Neuropathology and Molecular Genetics Laboratory, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
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Nagata Y, Inoshita N, Fukuhara N, Yamaguchi-Okada M, Nishioka H, Iwata T, Yoshimoto K, Yamada S. Growth hormone-producing pituitary adenomas in childhood and young adulthood: clinical features and outcomes. Pituitary 2018; 21:1-9. [PMID: 28849339 DOI: 10.1007/s11102-017-0836-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Growth hormone (GH)-producing pituitary adenomas (PAs) in childhood or young adulthood are rare, and the details surrounding these tumors remain enigmatic. We present the clinical, pathological and genetic features of this disease. METHODS We identified 25 patients aged 20 years or younger with GH-producing PAs who underwent surgery between 2003 and 2016 at Toranomon Hospital in Tokyo. We retrospectively reviewed the clinical data, treatment outcomes and pathological features of these patients to shed light on childhood acromegaly. RESULTS The cohort comprised 14 male and 11 female patients whose average age at the time of surgery was 17.3 years. Germline AIP mutations were present in 5 of 13 patients examined, and Carney complex was identified in 2 of 25 patients. The mean maximum tumor diameter was 26.7 mm, and total resection assessed during surgery was achieved in 17 patients. Based on their respective pathological findings, patients were divided into the following 4 groups: sparsely granulated adenomas (5), densely granulated (DG) adenomas (6), plurihormonal adenomas (9), and silent subtype 3 (SS3) adenomas (5). During the mean follow-up period of 50.3 months, complete endocrinological remission was achieved in 14 of 25 patients (56%) by surgery alone and in 19 patients (76%) after postoperative adjuvant therapy. CONCLUSIONS GH-producing PAs in young patients are intriguing and difficult to treat due to their distinct tumor characteristics, including a lower incidence of the DG subtype and a higher incidence of SS3 adenomas and genetic abnormalities. Therefore, multi-modal therapies are essential to achieve optimal clinical outcomes.
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Affiliation(s)
- Yuichi Nagata
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
| | - Naoko Inoshita
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | - Noriaki Fukuhara
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Mitsuo Yamaguchi-Okada
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Hiroshi Nishioka
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Takeo Iwata
- Department of Medical Pharmacology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Katsuhiko Yoshimoto
- Department of Medical Pharmacology, Graduate School of Biomedical Sciences, Tokushima University, Tokushima, Japan
| | - Shozo Yamada
- Department of Hypothalamic and Pituitary Surgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
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Endoscopic Transsphenoidal Approach for Acromegaly with Remission Rates in 401 Patients: 2010 Consensus Criteria. World Neurosurg 2017; 108:278-290. [DOI: 10.1016/j.wneu.2017.08.182] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 08/27/2017] [Accepted: 08/28/2017] [Indexed: 11/20/2022]
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Prete A, Corsello SM, Salvatori R. Current best practice in the management of patients after pituitary surgery. Ther Adv Endocrinol Metab 2017; 8:33-48. [PMID: 28377801 PMCID: PMC5363454 DOI: 10.1177/2042018816687240] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/12/2016] [Indexed: 12/25/2022] Open
Abstract
Sellar and parasellar masses are a common finding, and most of them are treated surgically via transsphenoidal approach. This type of surgery has revolutionized the approach to several hypothalamic-pituitary diseases and is usually effective, and well-tolerated by the patient. However, given the complex anatomy and high density of glandular, neurological and vascular structures in a confined space, transsphenoidal surgery harbors a substantial risk of complications. Hypopituitarism is one of the most frequent sequelae, with central adrenal insufficiency being the deficit that requires a timely diagnosis and treatment. The perioperative management of AI is influenced by the preoperative status of the hypothalamic-pituitary-adrenal axis. Disorders of water metabolism are another common complication, and they can span from diabetes insipidus, to the syndrome of inappropriate antidiuretic hormone secretion, up to the rare cerebral salt-wasting syndrome. These abnormalities are often transient, but require careful monitoring and management in order to avoid abrupt variations of blood sodium levels. Cerebrospinal fluid leaks, damage to neurological structures such as the optic chiasm, and vascular complications can worsen the postoperative course after transsphenoidal surgery as well. Finally, long-term follow up after surgery varies depending on the underlying pathology, and is most challenging in patients with acromegaly and Cushing disease, in whom failure of primary pituitary surgery is a major concern. When these pituitary functioning adenomas persist or relapse after neurosurgery other treatment options are considered, including repeated surgery, radiotherapy, and medical therapy.
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Affiliation(s)
- Alessandro Prete
- Unit of Endocrinology, Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy
| | - Salvatore Maria Corsello
- Unit of Endocrinology, Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy
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Yu M, Bruns DE, Jane JA, Nass RM, Oldfield EH, Vance ML, Thorner MO. Decrease of Serum IGF-I following Transsphenoidal Pituitary Surgery for Acromegaly. Clin Chem 2017; 63:486-494. [DOI: 10.1373/clinchem.2016.262592] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/12/2016] [Indexed: 01/09/2023]
Abstract
Abstract
BACKGROUND
In the immediate postoperative period following resection of growth hormone (GH)-secreting pituitary tumors, serum concentrations of GH have limited ability to predict remission of acromegaly. Since many actions of GH actions are mediated by insulin-like growth factor-1 (IGF-I), we aimed to determine the rates of fall of IGF-I during 72 h after surgical resection of pituitary tumors.
METHODS
We studied patients who were undergoing pituitary surgery for acromegaly. IGF-I was measured by LC-MS and GH by immunoassay. Remission was defined by the combination of serum GH <0.4 ng/mL during oral glucose tolerance testing performed 8 weeks after the surgical procedure and normal IGF-I at ≥8 weeks.
RESULTS
During the first 72 h after surgery, the mean (SD) rate of decline of IGF-I was 185 (61) ng/mL per 24 h in those who achieved remission (n = 23), with a mean (SD) apparent half-life of 55 (19) h. IGF-I had decreased to <65% of the preoperative IGF-I on postoperative day 2 in 20 of 23 remission patients (87%) vs none of 5 patients who did not achieve remission. GH was <2.7 ng/mL on day 2 in 21 of 23 remission patients (91%), but in none of the nonremission patients. The combination of IGF-I and GH on day 2 separated the remission and nonremission groups of patients.
CONCLUSIONS
Rapid decline of serum IGF-I during the immediate postoperative period warrants further study as an analytically independent adjunct to GH measurement for early prediction of biochemical remission of acromegaly.
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Affiliation(s)
- Min Yu
- Division of Laboratory Medicine, Department of Pathology
| | - David E Bruns
- Division of Laboratory Medicine, Department of Pathology
| | | | - Ralf M Nass
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine and Health System, Charlottesville, VA
| | | | - Mary Lee Vance
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine and Health System, Charlottesville, VA
| | - Michael O Thorner
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine and Health System, Charlottesville, VA
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Starnoni D, Daniel RT, Marino L, Pitteloud N, Levivier M, Messerer M. Surgical treatment of acromegaly according to the 2010 remission criteria: systematic review and meta-analysis. Acta Neurochir (Wien) 2016; 158:2109-2121. [PMID: 27586125 DOI: 10.1007/s00701-016-2903-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/19/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND In 2010, the Acromegaly Consensus Group revised the criteria for cure of acromegaly and thus rates of surgical remission need to be revised in light of these new thresholds. Two subgroups consisted of patients with discordant GH and IGF-1 levels and patients in remission according to the 2000 criteria, but not to the 2010 criteria, have been reported after adenomectomy and for these subgroups the precise incidence and management has not been established. The objective of the study was to update rates of surgical remission and complications and to evaluate the incidence, management, and long-term outcome of the two previously described subgroups of patients. METHODS Systematic review and meta-analysis of surgical series that defined remission according to the 2010 biochemical criteria. RESULTS We included 13 studies (1105 patients). The pooled rate of overall surgical remission was 54.8 % (95 % CI 44.4-65.2 %), and 72.2 % with previous criteria. Remission was achieved in 77.9 % (95 % CI 68.1-87.6 %) of microadenomas; 52.7 % (95 % CI 41-64.4 %) of macroadenomas; 29 % (95 % CI 20.1-37.8 %) of invasive and 68.8 % (95 % CI 60-77.6 %) of non-invasive adenomas. Complication rates were 1.2 % (95 % CI 0.6-1.9 %) for CSF leak, 1.3 % (95 % CI 0.6-2.1 %) for permanent diabetes insipidus, 8.7 % (95 % CI 4.8-12.5 %) for new anterior pituitary dysfunction and 0.6 % (95 % CI 0.1-1.1 %) for severe intraoperative hemorrhage. We identified an intermediate group of patients, defined as: (1) Remission according to one, but not the other biochemical criteria (GH or IGF-1) or 2010 criteria (14.3 % and 47.1 % cases), (2) Remission according to 2000, but not 2010 criteria (13.2-58.8 % cases). Two studies reported a remission rate of 56.5 % and 100 %, in the two subgroups respectively, in a long-term outcome without adjuvant therapy. CONCLUSIONS Overall remission with transsphenoidal surgery is achieved in ∼55 % of patients. For the intermediate group of patients, future prospective studies with long-term follow-up are required to determine the long-term biochemical remission rates and clinical implications.
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Affiliation(s)
- Daniele Starnoni
- Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Roy Thomas Daniel
- Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Laura Marino
- Service d'Endocrinologie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Lausanne, Switzerland
| | - Nelly Pitteloud
- Service d'Endocrinologie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Lausanne, Switzerland
| | - Marc Levivier
- Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Mahmoud Messerer
- Service de Neurochirurgie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne (Unil), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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