Acromegaly

Corneal parameters, ocular biometers, and retinal and choroidal thickness in acromegaly patients

BACKGROUND

To compare ocular findings of acromegaly patients with healthy individuals and investigate the relation of serum levels of insulin-like growth factor (IGF-1) along with growth hormone (GH) and pituitary tumor (adenoma) dimensions (TD) with specific ocular parameters.

METHODS

The ocular parameters of acromegaly patients (n = 38) were compared with those of healthy subjects (n = 36). These parameters were intraocular pressure, keratometric (K1-K2) values, central corneal thickness (CCT), total axial length along with anterior chamber-lens-vitreous length, retinal nerve fiber layer (RNFL) thickness, central foveal thickness (CFT), choroidal thickness (CT), ganglion cell layer thickness (GCLT), and inner plexiform layer thickness (IPLT). Also investigated was whether there was a correlation between disease duration, TD, GH, IGF-I, CCT, RNFL, CFT, GCLT, IPLT, and CT.

RESULTS

The lens length of the acromegaly group was increased (p = 0.014). GH and IGF-1 levels were positively correlated with CT and CCT, respectively (p = 0.041, r = 0.343) (p = 0.03, r = 0.347). Analysis of TD also found a highly negative correlation with the mean RNFL thickness of the acromegaly patients (p < 0.01, r = -0.603). The mean value of the inner parts of GCLT and IPLT was negatively correlated with TD (p = 0.041, r = -0.343 and p = 0.025, r = -0.379, respectively).

CONCLUSION

Serum IGF-1 and GH levels might be determinant factors in CCT and CT, respectively. The pituitary adenoma size increasing may be prone to lead RNFL, ganglion cell layer, inner plexiform layer thinning. Increased lens thickness was found in the acromegaly group.

Polycystic ovary syndrome preceding the diagnosis of acromegaly: a retrospective study in 97 reproductive-aged women

BACKGROUND

Acromegaly is a disease of growth hormone excess that results in enlargement of extremities, abnormal glucose and lipid metabolism, and gonadal disruption. Manifestations of the disease are insidious and typically lead to a diagnostic delay of 7-10 years. Classically the polycystic ovary syndrome (PCOS) phenotype is described in women with irregular menses, clinical or biochemical evidence of androgen excess, and/or multiple ovarian follicles on pelvic ultrasonography. Women with acromegaly may present with some or all of these symptoms. Our objective was to evaluate the prevalence of PCOS in patients with acromegaly and to determine if diagnosis of PCOS results in a delay in diagnosing acromegaly.

METHODS

Using patient databases at two academic health centers, we identified 97 premenopausal women aged 18-49 years old presenting with acromegaly. Data were collected regarding pelvic sonography and reproductive history, including the diagnosis of PCOS. Patients carrying the diagnosis of PCOS before their diagnosis of acromegaly were identified and the remaining patients were screened using the Rotterdam criteria to identify additional patients meeting the criteria for PCOS prior to their diagnosis of acromegaly.

RESULTS

Mean age of the population (n = 97) at the time of diagnosis of acromegaly was 33.4 ± 7.5 years (SD). Thirty-three percent of patients (n = 32) either carried a diagnosis of PCOS or met diagnostic criteria for PCOS before their diagnosis of acromegaly. In the subset of patients in whom data on symptom onset were available, those who met criteria for PCOS were diagnosed with acromegaly a median of 5 years [4, 9] after the onset of symptoms compared to 2 years [0.92, 3] (p =  0.006) in the patients who did not meet criteria for PCOS.

CONCLUSIONS

Our data demonstrate a high prevalence of signs and symptoms of PCOS in reproductive-aged women with acromegaly and a longer time to diagnosis in women who meet the clinical criteria for PCOS. As screening for acromegaly is relatively simple and done with measurement of a random, non-fasting IGF-1 level that can be drawn at any time during the menstrual cycle, screening patients with PCOS for acromegaly may lessen the delay in diagnosis for reproductive-aged women with this disease.

Oral Manifestations and Maxillo-Facial Features in the Acromegalic Patient: A Literature Review

Background: Acromegaly is a chronic disease caused by an abnormal secretion of growth hormone (GH) by a pituitary adenoma, resulting in an increased circulating concentration of insulin-like growth factor 1 (IGF-1). The main characteristics are a slow progression of signs and symptoms, with multisystemic involvement, leading to acral overgrowth, progressive somatic changes, and a complex range of comorbidities. Most of these comorbidities can be controlled with treatment. The literature reveals that the most evident and early signs are those related to soft tissue thickening and skeletal growth, especially in the head and neck region. Methods: The authors reviewed the available literature on the clinical oro-dental features of acromegaly, selecting articles from PubMed and Google Scholar. The aim of this review was to summarize all the reported clinical oro-dental features of acromegalic patients. Results: The most common facial dimorphisms involved the maxillo-facial district, with hypertrophy of the paranasal sinuses, thickening of the frontal bones, and protruding glabella, which may be associated with joint pain and clicks. Regarding the oro-dental signs, the most frequent are dental diastema (40–43%), mandibular overgrowth (22–24%), mandibular prognathism (20–22%), and macroglossia (54–58%). These signs of acromegaly can be significantly reduced with adequate treatment, which is more effective when initiated early. Conclusions: Increased awareness of acromegaly among dentists and maxillo-facial surgeons, along with the early identification of oro-facial changes, could lead to an earlier diagnosis and treatment, thereby improving patients’ quality of life and prognosis.

Surgery for acromegaly: Indications and goals

Acromegaly is a disease that occurs secondary to high levels of GH, most often from a hormone-secreting pituitary adenoma, with multisystem adverse effects. Diagnosis includes serum GH and IGF-1 levels, and obtaining an MRI pituitary protocol to assess for a functional pituitary adenoma. Attempted gross total resection of the GH-secreting adenoma is the gold standard in treatment for patients with acromegaly for a goal of biochemical remission. Medical and radiation therapies are available when patients do not achieve biochemical cure after surgical therapy.

The intriguing giant deer from the Bate cave (Crete): could paleohistological evidence question its taxonomy and nomenclature?

The research describes for the first time a possible case of pituitary gigantism in fossil mammals, precisely in deer. The pathology was detected in 2 long bones (tibia and metatarsus) belonging to an individual of an unusual large size found at the Bate cave (Rethymnon, Northern Crete). It formed the basis of Candiacervus major, the largest among the endemic deer species recorded in the Pleistocene-Early Holocene of Crete. Radiological and histomorphological examinations highlighted a reduction in cortical bone thickness and the presence of wide lacunae inside of the bone tissue. The pathological conditions suggest a pituitary gigantism diagnosis also supported by some morphological evidence, such as the extremely elongated distal part of the metatarsal diaphysis, the proportionally small proximal epiphysis, and some bone gracility. The diagnosis of a case of pituitary gigantism as presumed responsible for the extraordinary elongation of the tibia and the metatarsal bone is intriguing as they are, respectively, the paratype and the holotype of the C. major. The species represents a case of a deviation from the "island rule" in Pleistocene large mammals. The new evidence recommends a taxonomic and nomenclatural revision of this species. The main outcomes of this research are as follows: (i) a case of pituitary gigantism is described for the first time in an extinct mammal; (ii) it is underlined that paleohistology may provide interesting clues for disentangling taxonomic and nomenclatural issues; (iii) one of the very few cases of gigantism in insular mammals is being questioned.

Increased risk of preneoplastic colonic lesions and colorectal carcinoma in acromegaly: multicenter case-control study

PURPOSE

Current international guidelines recommend colonoscopy in patients with acromegaly at the time of diagnosis, even though the risk of developing colorectal neoplasm is still controversial. The main objective of this Argentine multicenter study was to analyze through screening colonoscopy the presence of advanced neoplastic lesions considered as precancerous, in patients with acromegaly compared to a control group.

METHODS

This is a case-control retrospective study. Full length colonoscopy of 70 acromegalic patients and 128 control subjects were studied. Polyps were classified into non pre-cancerous lesions and advance neoplastic lesions which included advanced adenomas (preneoplastic) and colorectal carcinomas.

RESULTS

Thirty three out of 70 acromegalic patients and 32 out of 128 subjects controls presented polyps in the colonoscopy [47.1% vs 25%, p = 0.002, OR 2.68]. Non precancerous polyps were found in 11 (15.7%) and 23 (17.9%) (p = 0.690), while advanced neoplastic lesions were found in 22 (31.4%) and 9 (7.0%) (p = 0,0001 - OR: 6.06) patients and controls respectively. Advanced adenomas and colorectal carcinomas were found in 18 (27.3%) and 9 (7.0%) (p = 0,0006-OR: 4,57), and 4 (5.7%) and 0 (0.0%) p = 0.0063) of patients and controls respectively. The presence of insulin resistance was the only statistically significant associated factor among acromegalic patients with and without colonic polyps.

CONCLUSIONS

Our findings show an increased risk of preneoplastic colonic lesions and colorectal carcinoma in patients with chronic and sustained GH excess compared to a control group. This supports the recommendation to perform screening colonoscopy at diagnosis of acromegaly.

Evaluation of Ocular Hypoperfusion in Patients with Acromegaly by Using Optical Coherence Tomography Angiography

PURPOSE

This study aimed to evaluate the retinal blood vessel parameters and the foveal avascular zone (FAZ) area using optical coherence tomography angiography (OCTA) in patients with acromegaly in comparison with healthy controls.

METHODS

A total of 45 patients with acromegaly and 45 healthy controls were included in this study. In all patients, the vessel density (VD) of the deep and superficial macular vascular networks and the foveal avascular zone (FAZ) were measured using OCTA. The correlation of insulin-like growth factor 1 (IGF-1) level and disease duration with deep macular VD and FAZ values was analyzed. All parameters were registered. Results were assessed and compared between the two groups.

RESULTS

Deep macular plexus VD values were lower in patients with acromegaly compared to the control group. No significant differences in VD values in the superficial segment, except for that in the inferior parafovea (P = .01) were found between the two groups. Furthermore, patients with acromegaly showed enlargement in the superficial (P = .30) and deep FAZ areas (P < .001). IGF-1 level and disease duration showed a significant negative correlation with the deep whole image (R = -0.216, P = .041, R = -0.339, P = .001, respectively), deep parafovea (R = -0.271, P = .01; R = -0.372, P < .001, respectively), deep parafovea superior hemi (R = -0.342, P = .001; R = -0.350, P = .001, respectively), deep parafovea temporal (R = -0.224, P = .034; R = -0.234, P = .026, respectively), deep parafovea nasal (R = -0.320, P = .002; R = -0.361, P < .001, respectively), and deep parafovea superior VD values (R = -0.293, P = .005; R = -0.307, P = .003, respectively) and a significant positive correlation with the deep FAZ area values (R = 0.244, P = .02; R = 0.329, P = .002, respectively).

CONCLUSION

VD values in the deep macular capillary plexus were lower in patients with acromegaly, and the superficial and deep FAZ area enlarged. Patients with acromegaly may have an increased risk of developing ocular vascular complications. OCTA can be used to evaluate retinal blood VD in patients with acromegaly.

Rehabilitation of Occlusal Vertical Dimension in a Patient with Acromegaly: A Clinical Report

Acromegaly is a rare acquired disorder caused by excessive growth hormone production. Dentists play an important role in the diagnosis of this disorder because of intraoral and extraoral symptoms such as extreme growth of the mandible, enlargement of the maxilla, diastema between teeth, a tendency toward malocclusion, a wide and thick nose, a marked malar bone, and thick lips. The prosthetic treatment of these patients is challenging because growth in the condyles and rami can lead to the development of a severe class III jaw relationship. This case report describes the prosthetic treatment of a patient with acromegaly. A decreased occlusal vertical dimension and class III jaw relationship were determined by intraoral and extraoral examinations and cephalometric radiography. The occlusal vertical dimension was reestablished by increasing it approximately 10 mm, as per the esthetic and functional needs of the patient. Four years after treatment, the patient was functioning well, and neither occlusal disharmony nor temporomandibular disorder was observed.

A follow-up study on outcomes of endoscopic transsphenoidal approach for acromegaly

OBJECTIVE

A thorough follow-up study in which the same clinic presents the change in the surgical outcomes of acromegaly over the years, is still lacking in the endoscopic era. In this study, we intended to evaluate the clinical characteristics, radiological features, surgical and late remission rates of newly diagnosed acromegaly patients treated in our clinic between 2014 and 2019 in order to delineate the surgical remission status according to radiological, microscopic, and hormonal features. As a follow-up to our initial report, we also aimed to display the change of surgical remission rates over time in a tertiary center.

METHODS

A total of newly diagnosed 106 patients with acromegaly, who underwent endoscopic endonasal trans-sphenoidal approach (EETSA) in the last five years were retrospectively analyzed and presented in this study. Medical records were reviewed in clinical, biochemical, pathological, and radiological aspects to assess the relationship of preoperative patient characteristics with surgical remissions.

RESULTS

The percentages of the giant pituitary adenomas (≥4 cm), adenomas with suprasellar extension and adenomas with surgically proven invasion of the cavernous sinus in the present series were 13%, 34%, and 20%, respectively. Gross total resection was achieved in 80% of the patients. Surgical remission and late remission rates were 66% and 86%, respectively. Nine (9.4%) patients in our current report had postoperative transient diabetes insipidus. The mean follow-up period in this series was 36.1 ± 18.1 (range 12-59) months.

CONCLUSION

The presented surgical results are considerably better than our published initial series of acromegaly patients operated in the same clinic between 2007 and 2014. The improvement in surgical remission rate support a positive surgical volume - remission rate relationship for acromegaly in the era of endoscopic endonasal skull base approaches. One possible factor for better results may be the increasing surgical experience in EETSA, which follows a trend toward gradual improvement of long-term late remissions via a multidisciplinary approach.

A legendary sumo wrestler with gigantism or acromegaly? The case of Ikezuki Geitazaemon (1827-1850)

Sumo is a traditional Japanese full-contact wrestling sport. Among sumo wrestlers, Ikezuki Geitazaemon (1827-1850) was one of the most famous wrestlers due to his large body size. Here, we hypothesize that the legendary Japanese sumo wrestler could have had gigantism or acromegaly, which are disorders caused by the hypersecretion of growth hormone (GH). GH-secreting pituitary adenoma leads to the hypersecretion of GH and insulin-like growth factor-1 (IGF-1). If GH-secreting pituitary adenoma develops during childhood/puberty, it can cause gigantism. Adenomas also occur in over 95% of patients with acromegaly. Based on his substantial height (227 cm), Geitazaemon may have had gigantism, or acromegaly considering his characteristics of mandibular prognathism, enlarged fingertips, and heel pad thickness, as shown in woodblock prints (ukiyo-e). He would thus be the first recorded patient with gigantism or acromegaly in premodern Japan.

Titrating Growth Hormone Dose to High-Normal IGF-1 Levels Has Beneficial Effects on Body Fat Distribution and Microcirculatory Function Despite Causing Insulin Resistance

To clarify the mechanism underlying the described U-shaped relation of both low and high levels of IGF-1 with cardiovascular disease this study explores the effect of decreasing and increasing growth hormone dose in GH deficient adults on (micro)vascular function, body composition and insulin resistance. In this randomized clinical trial, thirty-two subjects receiving GH therapy with an IGF-1 concentration between -1 and 1 SD score (SDS) for at least one year were randomized to receive either a decrease (IGF-1 target level of -2 to -1 SDS) or an increase of their daily GH dose (IGF-1 target level of 1 to 2 SDS) for a period of 24 weeks. Microvascular endothelium (in)dependent vasodilatation and vasomotion, vascular stiffness by pulse wave analysis, and HOMA-IR were measured. At the end of the study 30 subjects (65.6% men, mean age 46.6 (SD 9.9) years) were analyzed. There was a favorable effect of increasing the IGF-1 level on waist circumference compared to decreasing the IGF-1 level (p=0.05), but a detrimental effect on insulin resistance (p=0.03). Decreasing IGF-1 level significantly lowered the endothelial domain of vasomotion (p=0.03), whereas increasing IGF-1 level increased the contribution of the neurogenic domain (p=0.05). This change was related to the favorable change in waist circumference. In conclusion, increasing IGF-1 levels was beneficial for body composition but detrimental with respect to insulin resistance. The contribution of the neurogenic vasomotion domain increased in parallel, and could be explained by the favorable change in waist circumference.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, identifier NCT01877512.

A Rare Association between Myasthenia Gravis and a Growth Hormone Secreting Pituitary Macroadenoma: A Single Case Report

Myasthenia Gravis (MG) is a chronic autoimmune neuromuscular disease. Although it is well known that patients with myasthenia gravis have a higher incidence of other autoimmune disorders, however, its association with pituitary adenomas is extremely rare. We believe that our case represents the 8th of this association and the 2nd case involving a GH-secreting adenoma. Here we report a case of a 45-year old Syrian woman who presented with typical complaints of myasthenia gravis as she was suffering from variable painless and effort-related dysphagia and dysarthria. Her complaints became more evident at the end of the day, while acromegaly only manifested as a 4-month history of headache and a special facies that was noted by the physician. Brain MRI scan demonstrated a 3.21 x 2.42 x 2.35 cm pituitary mass for which the patient underwent a trans-sphenoidal pituitary tumor resection. In addition, postoperative histopathological investigations confirmed the diagnosis of a GH-secreting macroadenoma. On following up, it was observed that her myasthenic symptoms improved significantly on Pyridostigmin and Prednisolone. In conclusion, the presence of headache in a myasthenic patient should raise the attention for other underlying causes including pituitary tumors.

The effectiveness of a therapist-oriented home rehabilitation program for a patient with acromegaly: A case study

BACKGROUND

Acromegaly causes numerous functional limitations that negatively impact patients' performance of activities of daily living (ADLs) and contribute to the deterioration of health-related quality of life (HRQoL). Thus, the purpose of the present case study was to evaluate the effect of therapist-oriented home rehabilitation (TOHR) for a patient with acromegaly.

CASE DESCRIPTION

We report the case of a 53-year-old man who was diagnosed with primary acromegaly 17 years ago. He complained of difficulties performing tasks that involved his hands, pain in the lower limbs, and fatigue when he climbed a few flights of stairs. Although he performed ADLs independently, he reported some difficulties or discomfort when performing them.

INTERVENTION AND OUTCOME

The patient underwent a booklet-guided physical exercise program that lasted two months (three times per week, 60 minutes per session). The activities included overall stretching, muscle strengthening, and endurance exercises, along with aerobic conditioning through functional circuit training. After two months of exercise, he reported improved HRQoL as assessed with the Acromegaly Quality of Life Questionnaire, with increases in quadriceps muscle strength and 6-min walking distance. However, none of these benefits remained when the patient was assessed after a 1-month washout period.

CONCLUSION

This study showed that patients with acromegaly may benefit markedly from TOHR, which could provide a novel therapeutic approach as an adjunct to hormone control therapy.

Pituitary Pathology and Gene Expression in Acromegalic Cats

The prevalence of GH-secreting pituitary tumors in domestic cats (Felis catus) is 10-fold greater than in humans. The predominant inhibitory receptors of GH-secreting pituitary tumors are somatostatin receptors (SSTRs) and D2 dopamine receptor (DRD2). The expression of these receptors is associated with the response to somatostatin analog and dopamine agonist treatment in human patients with acromegaly. The aim of this study was to describe pathological features of pituitaries from domestic cats with acromegaly, pituitary receptor expression, and investigate correlates with clinical data, including pituitary volume, time since diagnosis of diabetes, insulin requirement, and serum IGF1 concentration. Loss of reticulin structure was identified in 15 of 21 pituitaries, of which 10 of 15 exhibited acinar hyperplasia. SSTR1, SSTR2, SSTR5, and DRD2 mRNA were identified in the feline pituitary whereas SSTR3 and SSTR4 were not. Expression of SSTR1, SSTR2, and SSTR5 was greater in acromegalic cats compared with controls. A negative correlation was identified between DRD2 mRNA expression and pituitary volume. The loss of DRD2 expression should be investigated as a mechanism allowing the development of larger pituitary tumors.

Long-term follow-up of patients with elevated IGF-1 and nadir GH > 0.4 µg/L but < 1 µg/L

OBJECTIVE

To report the results of initial investigation and after 5 years of patients with a suspicious clinical scenario for acromegaly, elevated IGF-1, and nadir GH during an oral glucose tolerance test (OGTT) > 0.4 µg/L but < 1 µg/L.

SUBJECTS AND METHODS

Seventeen patients who had elevated IGF-1 (outside puberty and pregnancy) in two measurements and GH between 0.4 and 1 µg/L during OGTT were selected.

RESULTS

During initial assessment, only one patient had microadenoma on magnetic resonance imaging (MRI) of the pituitary. In this patient, IGF-1 returned to normal spontaneously after 5 years. In the remaining 16 patients, spontaneous normalization of IGF-1 was observed in four and IGF-1 continued to be elevated in 12 after 5 years. None of the latter patients developed a phenotype of acromegaly, changes in physiognomy or increase in IGF-1 and no tumor was detected by imaging methods. Two patients had nadir GH < 0.4 µg/L, while the nadir GH remained between 0.4 and 1 µg/L in 10 patients.

CONCLUSION

In patients (notably young adult or adult women) without a typical phenotype in whom IGF-1 is measured due to a suspicious clinical scenario and is found to be slightly elevated, even if confirmed and in the absence of other causes, a nadir GH cut-off value of 0.4 µg/L instead of 1 µg/L in the OGTT might be inadequate for the diagnosis.

The evaluation of central corneal thickness and intraocular pressure in conjunction with tear IGF-1 levels in patients with acromegaly

PURPOSE

To compare the central corneal thickness (CCT), intraocular pressure (IOP), and tear insulin-like growth factor 1 (IGF-1) levels between patients with acromegaly and a control group and to evaluate the possible effect of tear IGF-1 and duration of the disease on CCT and IOP.

METHODS

We included 31 patients with acromegaly (study group) and 40 age- and sex-matched controls in the study. Patients with acromegaly were divided into 2 subgroups based on disease status (active/inactive). All participants underwent complete ophthalmologic evaluation including CCT and IOP values. Basal tear samples were collected from both groups and tear IGF-1 levels were measured. The CCT, IOP, and tear IGF-1 levels were compared between groups and subgroups and the association between tear IGF-I levels and ocular parameters (CCT, IOP) and disease duration were also evaluated.

RESULTS

Central corneal thickness, IOP, and tear IGF-1 levels did not show a significant difference between study and control groups. We also did not find a significant difference in terms of CCT, IOP, or tear IGF-1 levels between subgroups of patients. Correlation analysis did not show an association between the duration of disease and tear IGF-1 levels with CCT or IOP.

CONCLUSIONS

There was no significant difference in tear IGF-1 levels between patients with acromegaly and controls. Additionally, there was no correlation between disease duration and tear IGF-1 levels with CCT or IOP levels. This lack of association may suggest that tear IGF-1 levels might not have an effect on CCT or IOP findings in patients with acromegaly.

Long-term outcomes of acromegaly treated with fractionated stereotactic radiation: case series and literature review

Background

Growth hormone (GH)-secreting pituitary adenomas represent an uncommon subset of pituitary neoplasms. Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) have been used as primary or adjuvant treatment. The purpose of this study is to report the long-term tumor control and toxicity from our institution and to perform a systematic literature review of acromegaly patients treated with FSRT.

Methods

We retrospectively reviewed all patients treated with FSRT (median dose 50.4 Gray [Gy], range 50.4-54 Gy) between 2005 and 2012 who had: 1) GH-secreting adenoma with persistently elevated insulin growth factor-1 (IGF-1) despite medical therapy and 2) clinical follow up >3 years after FSRT. Patients were treated with modern FSRT planning techniques. Biochemical control was defined as IGF-1 normalization. Systematic review of the literature was performed for FSRT in acromegaly.

Results

With a median follow-up of 80 months, radiographic control was achieved in all 11 patients and overall survival was 100%. Long-term biochemical control was achieved in 10 patients (90.9%) with either FSRT alone (36.4%) or FSRT with continued medical management (45.5%). No patient experienced new hypopituitarism, cranial nerve dysfunctions, or visual deficits. Our systematic review found published rates of biochemical control and hypopituitarism vary, with uniformly good radiographic control and low incidence of visual changes.

Conclusions

Adjuvant FSRT offered effective long-term biochemical control and radiographic control, and there was a lower rate of complications in this current series. Review of the literature shows variations in published rates of biochemical control after FSRT for acromegaly, but low incidence of serious toxicities.

Prescription patterns of long-acting somatostatin analogues

Background:

Acromegaly and endocrine tumors are uncommon morbidities that are currently treated with different drugs.

Objective:

To determine the prescription patterns of somatostatin analogues in patients affiliated with the Health System of Colombia.

Methods:

Retrospective cohort study of patients of any age and sex treated with octreotide or lanreotide between January 2011 and August 2015. Socio-demographic, clinical (indications) and pharmacological (comedications) variables were considered. Multivariate analysis was performed with SPSS 23.0.

Results:

We identified 289 patients, with a mean age of 56.6 ± 14.0 years and female predominance (59.5%), who underwent treatment during the 56 months of monitoring. Octreotide was used in 56.1% of cases, followed by lanreotide (43.9%), both at approved doses. We found that 4.5% of subjects changed from one drug to another over the course of therapy, which was associated with being diabetic and receiving insulin (odds ratio: 4.27; 95% confidence interval: 1.23–14.84; p = 0.014). The most common indications were acromegaly (52.2% of cases) followed by neuroendocrine tumors (15.9%). The most common comorbidities were hypertension (39.4% of cases), depression (27.3%), dyslipidemia (23.3%), diabetes mellitus (23.5%) and hypothyroidism (23.5%). Being male (odds ratio: 0.57; 95% confidence interval: 0.35–0.94; p = 0.029) and belonging to the age group between 45 and 65 years (odds ratio: 0.44; 95% confidence interval: 0.21–0.90; p = 0.024) were significantly associated with a lower risk of receiving comedications.

Conclusion:

Somatostatin analogues are being used at recommended doses, especially in patients with acromegaly and neuroendocrine tumors. Variables associated with change in therapy were identified.

Differential Effects of Hormones on Cellular Metabolism in Keratoconus In Vitro

Keratoconus (KC) is a corneal thinning disease with an onset commonly immediately post-puberty and stabilization by 40 to 50 years of age. The role of hormones in regulating corneal tissue structure in homeostatic and pathological conditions is unknown. Our group recently linked altered hormone levels to KC. Our current study sought to investigate and delineate the effects of exogenous hormones, such as androgen, luteotropin, and estrogen, on corneal stroma bioenergetics. We utilized our established 3D in vitro model to characterize the effects of DHEA, prolactin, 17β-estradiol on insulin-growth factor-1 and -2 (IGF-1, -2) signaling and metabolic function in primary corneal fibroblasts from healthy controls (HCFs) and KC patients (HKCs). Our data showed that exogenous DHEA significantly downregulated IGF-1 and its receptor in both HCFs and HKCs with HKCs showing consistently lower basal pentose phosphate flux. Prolactin caused no significant change in IGF-1 levels and an increase in IGF-2 in HKCs correlating with an increase in ATP and NADH levels. 17β-estradiol led to a significant upregulation in pentose phosphate flux and glycolytic intermediates in HCFs. Our results identified hormone-specific responses regulated in HKCs compared to HCFs revealing a novel role for hormones on bioenergetics in KC.

Genetic and clinical characteristics of Japanese patients with sporadic somatotropinoma

Most of acromegaly is caused by a sporadic somatotropinoma and a couple of novel gene mutations responsible for somatotropinoma have recently been reported. To determine the cause of sporadic somatotropinoma in Japanese patients, we analyzed 61 consecutive Japanese patients with somatotropinoma without apparent family history. Comprehensive genetic analysis revealed that 31 patients harbored guanine nucleotide-binding protein, alpha stimulating (GNAS) mutations (50.8%) and three patients harbored aryl hydrocarbon receptor interacting protein (AIP) mutations (4.9%). No patients had G protein-coupled receptor 101 (GPR101) mutations. The patients in this cohort study were categorized into three groups of AIP, GNAS, and others and compared the clinical characteristics. The AIP group exhibited significantly younger age at diagnosis, larger tumor, and higher nadir GH during oral glucose tolerance test. In all patients with AIP mutation, macro- and invasive tumor was detected and repetitive surgery or postoperative medical therapy was needed. One case showed a refractory response to postoperative somatostatin analogue (SSA) but after the addition of cabergoline as combined therapy, serum IGF-I levels were controlled. The other case showed a modest response to SSA and the switching to cabergoline monotherapy was also effective. These data suggest that although resistance to SSA has been reported in patients with AIP mutations, the response to dopamine agonist (DA) may be retained. In conclusion, the cause of sporadic somatotropinoma in Japanese patients was comparable with the previous reports in Caucasians, patients with AIP mutations showed unique clinical characteristics, and DA may be a therapeutic option for patients with AIP mutations.

Retina ganglion cell/inner plexiform layer and peripapillary nerve fiber layer thickness in patients with acromegaly

Increased secretion of growth hormone and insulin-like growth factor-1 in acromegaly has various effects on multiple organs. However, the ocular effects of acromegaly have yet to be investigated in detail. The aim of the present study was to compare retina ganglion cell/inner plexiform layer (GCIPL) and peripapillary nerve fiber layer thickness (pRNFL) between patients with acromegaly and healthy control subjects using spectral domain optical coherence tomography (SD-OCT). This cross-sectional, comparative study included 18 patients with acromegaly and 20 control subjects. All participants underwent SD-OCT to measure pRNFL (in the seven peripapillary areas), GCIPL (in the nine ETDRS areas), and central macular thickness (CMT). Visual field (VF) examinations were performed using a Humphrey field analyzer in acromegalic patients. Measurements were compared between patients with acromegaly and control subjects. A total of 33 eyes of 18 patients with acromegaly and 40 eyes of 20 control subjects met the inclusion criteria of the present study. The overall calculated average pRNFL thickness was significantly lower in patients with acromegaly than in control subjects (P = 0.01), with pRNFL thickness significantly lower in the temporal superior and temporal inferior quadrants. Contrary to our expectations, pRNFL thickness in the nasal quadrant was similar between acromegalic and control subjects. The mean overall pRNFL thickness and superonasal, nasal, inferonasal, and inferotemporal quadrant pRNFL thicknesses were found to correlate with the mean deviation (MD) according to Spearman's correlation. However, other quadrants were not correlated with VF sensitivity. No significant difference in CMT values was observed (P = 0.6). GCIPL thickness was significantly lower in all quadrants of the inner and outer macula, except for central and inferior outer quadrants, in the acromegaly group than that in the control group (P < 0.05). GCIPL thicknesses of the inferior inner and outer macula quadrants were found to correlate with MD, whereas no correlation was observed between other quadrants and VF sensitivity. We demonstrated that GCIPL thickness decreased in patients with acromegaly compared with that in control subjects. However, the nasal quadrant pRNFL thickness was similar in acromegaly, in contrast to our expectations. SD-OCT may have utility in the assessment of the effects of acromegaly on retinal structures.

Polymorphisms in MEN1 and DRD2 genes are associated with the occurrence and characteristics of pituitary adenomas

OBJECTIVE

Although pituitary adenomas (PAs) affect a significant proportion of the population, only a fraction have the potential to become clinically relevant during an individual's lifetime, causing hormonal imbalance or complications due to mass effect. The overwhelming majority of cases are sporadic and without a clear familial history, and the genotype-phenotype correlation in PA patients is poorly understood. Our aim was to investigate the involvement of genes known for their role in familial cases on drug response and tumor suppression in the development and pathology of PAs in a patient group from Latvia.

DESIGN

The study included 143 cases and 354 controls, we investigated the role of single-nucleotide polymorphisms (SNPs) in seven genes (SSTR2, SSTR5, DRD2, MEN1, AIP, GNAS, and PRKAR1A) associated with pituitary tumor occurrence, phenotype, and clinical symptoms.

METHODS

Genotyping of 96 tag and nonsynonymous SNPs was performed in the genomic regions of interest.

RESULTS

We discovered a significant association (OR=17.8, CI 0.95=2.18-145.5, P=0.0002) between a rare MEN1 mutation (rs2959656) and clinically active adenoma in our patients. Additionally, rs7131056 at DRD2 was associated with a higher occurrence of extrasellar growth in patients with prolactinoma and somatotropinoma (OR=2.79, CI 0.95=1.58-4.95, P=0.0004).

CONCLUSIONS

rs2959656, a nonsynonymous variant in MEN1, is associated with the development of clinically active PA. Furthermore, rs7131056 in DRD2 contributes to either faster growth of the adenoma or reduced symptomatic presentation, allowing PAs to become larger before detection.

Acromegaly in a patient with a pulmonary neuroendocrine tumor: case report and review of current literature

Background

Pulmonary neuroendocrine tumors (NET) form a heterogeneous group of rare diseases. In these tumors, paraneoplastic syndromes have been described to drive the course of the disease, among them acromegaly induced by paraneoplastic secretion of growth hormone-releasing hormone (GHRH).

Case presentation

We report the case of a 43 years old patient initially diagnosed with acromegaly accompanied by weight gain and acral enlargement. Subsequently, further diagnostic work-up identified a solitary pulmonary neuroendocrine tumor (NET). Laboratory tests revealed markedly increased growth hormone (GH) and insulin-like growth factor 1 (IGF-1) without GHRH elevation in the absence of pituitary pathologies confirming the paraneoplastic origin of clinical presentation with acromegaly. Curative surgery was performed leading to normalization of the elevated hormone levels and improvement of the clinical symptoms. Immunohistochemically, a typical carcinoid (TC) was seen with low proliferation index and abundant IGF-1 expression.

Conclusions

The association of acromegaly and pulmonary NET has only rarely been reported. We present an individual case of paraneoplastic GH- and IGF-1 secretion in a patient with pulmonary NET. Based on their rarity, the knowledge of paraneoplastic syndromes occurring in patients with pulmonary NET such as acromegaly due to paraneoplastic GH- and IGF-1 secretion is mandatory to adequately diagnose and treat these patients.

Comparison of low-normal and high-normal IGF-1 target levels during growth hormone replacement therapy: A randomized clinical trial in adult growth hormone deficiency

BACKGROUND

Current guidelines state that the goals of growth hormone (GH) therapy in adults should be an appropriate clinical response, avoidance of side effects, and an IGF-1 value within the age-adjusted reference range. There are no published studies on the target level for IGF-1 that offer specific guidance in this regard.

OBJECTIVES

To compare low-normal and high-normal target levels of IGF-1 on efficacy and safety of GH treatment.

METHODS

A randomized, open-label, clinical trial including thirty-two adults from one university hospital receiving GH therapy for at least one year with a stable IGF-1 concentration between -1 and 1 SD score (SDS). Subjects were randomized to receive either a decrease (IGF-1 target level of -2 to -1 SDS) or an increase of their daily GH dose (IGF-1 target level of 1 to 2 SDS) for a period of 24weeks. The effect on cardiovascular risk factors and physical performance, next to tolerability, was compared.

RESULTS

Thirty subjects (65.6% men, mean age 46.6 (SD 9.9) years) could be analyzed. In subjects with a high-normal IGF-1 target level, waist circumference decreased (p=0.05), and overall they felt better (p=0.04), compared to subjects with a low-normal IGF-1 target level. However, increasing IGF-1 levels led to more myalgia, and decreasing IGF-1 levels to more fatigue. There was a gender-dependent difference in effect on HDL cholesterol.

CONCLUSION

Although increasing GH dose to IGF-1 levels between 1 and 2 SDS improved waist circumference and well-being, safety was not guaranteed with the demonstrated effect on HDL cholesterol in men, and reported myalgia.

Incidence and prevalence of acromegaly in a large US health plan database

PURPOSE

Incidence and prevalence estimates of acromegaly in the United States (US) are limited. Most existing reports are based on European data sources. The objective of this study was to estimate the annual incidence and prevalence of acromegaly in a large US managed care population, overall and stratified by age, sex, and geographic region, using data from 2008 to 2012.

METHODS

Using administrative claims data, commercial health plan enrollees were identified with acromegaly if they had two or more medical claims with an acromegaly diagnosis code (ICD-9-CM: 253.0×) or one medical claim with an acromegaly diagnosis code in combination with one other claim for a pituitary tumor or pituitary procedure. The first date for an acromegaly-related claim set the index year. Incidence rates for each year were calculated by dividing the number of new acromegaly cases by the calculated person-time at risk. Annual prevalence estimates were calculated by dividing the number with any evidence of acromegaly by the total number of health plan enrollees enrolled for at least 1 day during each calendar year. Incidence and prevalence estimates were stratified by age (0-17, 18-44, 45-64, 65+ years), sex (male, female), and US geographic region of the health plan (Midwest, Northeast, South, West).

RESULTS

Overall annual incidence rates of acromegaly were relatively constant across 2008-2012 with ~11 cases per million person-years (PMPY). Rates increased with age, ranging from 3-8 cases PMPY among children aged 0-17 years old to 9-18 cases PMPY among adults aged 65 and older. Females had 12 cases PMPY on average compared to 10 cases PMPY among men. On average, the Midwest had the lowest incidence rates (7 cases PMPY) compared to the Northeast, South and West (14, 12, and 10 cases PMPY, respectively). The overall annual prevalence of acromegaly was relatively constant across the 5 years from 2008 to 2012 with approximately 78 cases per million each year. Annual prevalence estimates increased with age, ranging from 29-37 cases per million among children aged 0-17 years old to 148-182 cases per million among adults aged 65 years and older. Males and females were similarly affected; each with approximately 77 cases per million each year. The Northeast and South had the highest prevalence estimates (92 and 89 cases per million, respectively); while the estimates for the West and Midwest were lower (65 and 57 cases per million, respectively) each year.

CONCLUSION

This study examined 5 years of recent data to estimate the incidence and prevalence of acromegaly in a large geographically-diverse managed care population. The incidence rates were higher on average than published rates outside the US (11 vs. 3.3 PMPY), but prevalence estimates were consistent with previous reports. Incidence and prevalence both increased by age, did not differ for males and females, and varied slightly by US geographic region. The age and sex distribution of the selected population matched the known epidemiology of the disease. Using a claims-based approach, this analysis only captured acromegaly cases with an acromegaly-related medical claim. As a result, these estimates may underestimate the incidence and prevalence of acromegaly in US commercial health plans as they did not include individuals who were undiagnosed, in remission, undertreated, or not monitored during the study period. At the same time, these estimates may be viewed as an upper bound on the incidence of acromegaly in the US as the estimates did not include individuals who were in other health plans or uninsured during the study period. Additional evaluations are needed to identify the full extent of acromegaly in the US.

Laboratory investigation of acromegaly: is basal or random GH > 0.4 µg/L in the presence of normal serum IGF-1 an important result?

OBJECTIVE

To determine the frequency of indication of the GH suppression test and pituitary magnetic resonance imaging (MRI) in patients with clinical suspicion of acromegaly with GH concentrations > 0.4 µg/L despite normal serum IGF-1.

SUBJECTS AND METHODS

A total of 160 patients with clinical suspicion of acromegaly with normal IGF-1 were studied.

RESULTS

Basal GH > 0.4 µg/L was observed in 70/88 women (79.5%). Nadir GH > 0.4 µg/L was found in 21/70 women (30%) and these patients were submitted to MRI, which revealed a microadenoma in 2/21 women (9.5%). In these two women, IGF-1 continued to be normal in subsequent measurements and no clinical progression has been observed so far (time of follow-up until now 4 years). Basal GH > 0.4 µg/L was seen in 33/72 men (45.8%). Nadir GH was < 0.4 µg/L in all of them.

CONCLUSIONS

In patients with clinical suspicion of acromegaly, concern over GH concentration in the presence of normal IGF-1 results in the unwarranted complementary investigation in many cases, and even in possible equivocal diagnoses. It is only in exceptional cases that normal IGF-1 should not rule out acromegaly.

Cost-effectiveness analysis of two therapeutic schemes in the treatment of acromegaly: a retrospective study of 168 cases

PURPOSE

This study aimed to estimate the cost effectiveness of two therapeutic schemes, including preoperative medical therapy and surgery as primary therapy.

METHODS

A total of 168 acromegaly cases were retrospectively investigated for a comparative evaluation of surgery and preoperative medical therapy. A Markov model was developed to simulate treatment cost-effectiveness and progression of acromegaly.

RESULTS

Overall effectiveness of preoperative medical therapy was significantly higher than surgery in acromegalic patients with macroadenoma. In addition, life expectancy, and cost per life-year gained were slightly higher in the preoperative medical therapy group than in the initial surgery group when patients received surgery as a secondary treatment. Interestingly, preoperative medical therapy achieved a significant increase in life expectancy and reduced cost for patients who received long-term medical therapy as secondary treatment.

CONCLUSIONS

In acromegalic patients with macroadenoma, the cost-effectiveness analysis revealed more satisfactory outcomes in preoperative therapy, compared with primary surgery.

The problem of unrecognized acromegaly: surgeries patients undergo prior to diagnosis of acromegaly

PURPOSE

To reveal the variety of symptoms experienced by patients before acromegaly diagnosis and to emphasize unneeded surgeries that patients undergo related to acromegaly prior to diagnosis of the disease.

METHODS

In total, 490 consecutive adult patients with acromegaly who were treated at our institution between 1998 and 2014 were included in this cross-sectional study, of which 313 could be contacted. Participants were questioned about their complaints at initial consultation and at the time of diagnosis, the first medical professional who they consulted, interval between onset and diagnosis, and surgeries they had undergone.

RESULTS

This study included 313 participants, of whom 181 were women. The mean age was 48.8 ± 12.0 years. Patients most frequently presented with acral growth of hands and feet (32.6%) and headache (26.2%). Internists were the medical specialists who were most frequently first consulted (29.4%) then neurosurgeons (11.8%). Acromegaly was generally diagnosed by endocrinologists (55%), followed by neurosurgeons (23%). The median elapsed period prior to diagnosis was 24 months, interquartile range 6.0-48.0 months. Some 45.7% had undergone surgery; 35.2% were related to acromegaly symptoms: head and throat surgery (12.8%), nose surgery (9.3%), thyroidectomy (6.4%), carpal tunnel surgery (4.8%). The delay period for patients who had an operation prior to acromegaly diagnosis was significantly longer than for those who had no operations (p < 0.001).

CONCLUSIONS

Acromegaly patients mostly present to internal medicine professionals. Surgeries related to acromegaly complications and symptoms before diagnosis cause a long delay period before diagnosis. Medical staff must be more aware of the clinical aspects of acromegaly.

Studying Cat (Felis catus) Diabetes: Beware of the Acromegalic Imposter

Naturally occurring diabetes mellitus (DM) is common in domestic cats (Felis catus). It has been proposed as a model for human Type 2 DM given many shared features. Small case studies demonstrate feline DM also occurs as a result of insulin resistance due to a somatotrophinoma. The current study estimates the prevalence of hypersomatotropism or acromegaly in the largest cohort of diabetic cats to date, evaluates clinical presentation and ease of recognition. Diabetic cats were screened for hypersomatotropism using serum total insulin-like growth factor-1 (IGF-1; radioimmunoassay), followed by further evaluation of a subset of cases with suggestive IGF-1 (>1000 ng/ml) through pituitary imaging and/ or histopathology. Clinicians indicated pre-test suspicion for hypersomatotropism. In total 1221 diabetic cats were screened; 319 (26.1%) demonstrated a serum IGF-1>1000 ng/ml (95% confidence interval: 23.6–28.6%). Of these cats a subset of 63 (20%) underwent pituitary imaging and 56/63 (89%) had a pituitary tumour on computed tomography; an additional three on magnetic resonance imaging and one on necropsy. These data suggest a positive predictive value of serum IGF-1 for hypersomatotropism of 95% (95% confidence interval: 90–100%), thus suggesting the overall hypersomatotropism prevalence among UK diabetic cats to be 24.8% (95% confidence interval: 21.2–28.6%). Only 24% of clinicians indicated a strong pre-test suspicion; most hypersomatotropism cats did not display typical phenotypical acromegaly signs. The current data suggest hypersomatotropism screening should be considered when studying diabetic cats and opportunities exist for comparative acromegaly research, especially in light of the many detected communalities with the human disease.

Physical activities in daily life and functional capacity compared to disease activity control in acromegalic patients: impact in self-reported quality of life

OBJECTIVE

To evaluate the quality of life and its association with daily physical activity and disease control in acromegalic patients.

SUBJECTS AND METHODS

A cross-sectional, case series study, composed of 42 patients recruited from the Neuroendocrinology Unit of the University Hospital of Brasilia. Level of physical activity was accessed by the International Physical Activity Questionnaire (IPAQ 6-short-form), which evaluates the weekly time spent on physical activity of moderate to vigorous intensity in different contexts of life. Quality of life was evaluated by The Medical Outcome Study Questionnaire Short Form (SF-36). Data was compared to growth hormone (GH) and insulin-like growth factor (IGF-1) levels. Students' t test and Fisher test were used, p < 0.05, SPSS 17.0.

RESULTS

Twenty-two women, aged 51.33 ± 14.33 and 20 men, aged 46.2 ± 13.18 were evaluated. Arthralgia was present in 83% of cases. In men, the most common sites of pain were the knees (73%), spine (47% lumbar, and 53% thoracic and cervical segments), hands and wrists (40%). Higher scores on SF-36 were observed in patients with intermediate or high levels of physical activity, in the domains social functioning (75 CI 57.3-92.6), general health (75.5 CI 60.4-90.5), mental health (70 CI 57.8-82.1).

CONCLUSIONS

In this study, the presence and severity of physical disability and pain were not associated with initial GH and IGF-1 levels or time of exposure to GH excess. However, the patients considered controlled, with normal a normal age-adjusted IGF-1, presented higher scores in SF-36, in physical and emotional domains, compared with patients with persistent hypersomatotrophism. These findings suggest benefits of metabolic control in self-reported quality of life.

Microstructural brain changes in acromegaly: quantitative analysis by diffusion tensor imaging

OBJECTIVE

We examined brain diffusion changes of patients with acromegaly. We searched whether there are differences in apparent diffusion coefficient (ADC) and fractional anisotropy (FA) values between remission and non-remission patients with acromegaly and investigated any effect of time of hormone exposure on diffusion metrics.

METHODS

The values of FA and ADC were calculated in a total of 35 patients with acromegaly and 28 control subjects. Patients were subdivided into remission and non-remission groups. We looked at brain FA and ADC differences among the groups and looked for any relation between the diffusion changes and time of hormone exposure among the patients with acromegaly.

RESULTS

We found decreased FA and increased ADC values in some of the growth hormone responsive areas. There were no significant brain diffusion changes between remission and non-remission groups. The most affected areas were the hypothalamus, parietal white matter and pre-motor cortex in patients with acromegaly. In terms of hormone exposure time among the patients with acromegaly, there was no effect of disease duration on brain microstructural changes.

CONCLUSION

All patients with acromegaly showed increased brain diffusion with no relation to disease duration and treatment status. We suggested that in patients with acromegaly, brain damage had already occurred in the subclinical period before symptom onset.

ADVANCES IN KNOWLEDGE

This study contributes to the understanding of the mechanisms in acromegaly.

Corneal biomechanical properties of patients with acromegaly

PURPOSE

Growth hormone (GH) and insulin-like growth factor-1 (IGF-1) excess in acromegaly have various effects on many organs. The ophthalmologic effects of GH and IGF-1 excess have not yet been investigated in detail. The aim of the current study is to compare the corneal biomechanical properties of patients with acromegaly and those of healthy subjects.

METHODS

45 patients with acromegaly (F/M=27/18) and 42 age-matched and gender-matched healthy individuals (F/M=24/18) were enrolled in this cross-sectional study. Central corneal thickness (CCT), corneal resistance factor (CRF), corneal hysteresis (CH), corneal compensated intraocular pressure (IOPcc) and Goldmann correlated IOPG were measured in patients with acromegaly and in healthy individuals using the Ocular Response Analyser (ORA). GH and IGF1 values were also determined in the study group.

RESULTS

The mean CH and CRF values were higher in acromegalic patients (12.1±2.2 and 12.3±2.4, respectively) than in healthy subjects (11.0±1.6 and 10.8±1.5, respectively; for CH, p=0.014; for CRF, p=0.001). Mean IOPG measurement was higher in the acromegaly group than in the control group (p=0.017). There was no statistically significant difference in measured CCT (p=0.117) and IOPcc (p=0.594) values between acromegalic patients and healthy subjects.

CONCLUSIONS

These findings indicate that acromegaly has target organ effects on the eye. Consequently, it can change corneal biomechanical properties such as corneal hysteresis and the CRF. Corneal biomechanical properties are known to affect the accuracy of IOP measurements. These findings should be taken into account when measuring IOP values in acromegaly patients, as IOP readings may be overestimated.

Characteristics of acromegaly in Korea with a literature review

Acromegaly is a slowly progressive disease caused by excessive growth hormone (GH), which is related to a GH secreting pituitary tumor in most cases. Herein, we describe the epidemiology, clinical characteristics, and treatment of acromegaly in Korea with a literature review. The average annual incidence of acromegaly in Korea was 3.9 cases per million people, which was within the range of previous Western studies. The primary treatment for acromegaly was also transsphenoidal adenomectomy, which accounted for 90.4% of patients whose primary therapeutic options were known. The overall surgical remission rates were 89%, 87%, 64%, 70%, and 50% for modified Hardy classification I, II, IIIA, IIIB, and IV, respectively. An updated and larger study regarding the treatment outcome of medical/radiotherapy in Korean acromegalic patients is needed.

Predictors of endoscopic transsphenoidal surgery outcome in acromegaly: patient and tumor characteristics evaluated by magnetic resonance imaging

The availability of various first-line treatment modalities for acromegaly and evolving surgical techniques emphasize the need for accurately defined predictors of surgical outcome. We retrospectively analysed the outcome of 30 patients with acromegaly after initial endoscopic transsphenoidal surgery in two university hospitals from 2001 until 2009, and reviewed comparable literature investigating predictive tumor characteristics. Medical records were monitored for patient characteristics. Each pituitary magnetic resonance imaging (MRI) scan was revised independently by two neuroradiologists using a standardised analysis form to record distinctive predefined tumor characteristics. All characteristics were independently analysed as predictors for persistent disease, and a multivariable predictive model was created. Literature from 2000 onwards was searched for studies describing tumor characteristics predictive for surgical outcome. The cohort consisted of 27 macroadenomas with 90 % demonstrating signs of parasellar extension. The surgical cure rate overall was 30 %. Independently, next to male sex and increasing tumor size, infrasellar and parasellar extension based on MRI staging tended to increase the risk of persistent disease. In a multivariable analysis, sex and parasellar extension of the tumor were demonstrated to be the variables allowing for the best fitted predictive model for persistent disease. Earlier studies on preoperative tumor characteristics showed comparable results, although these were based on several different tumor classification systems. This retrospective study demonstrates that accurately defined tumor characteristics based on imaging, especially for cavernous sinus invasion, can be helpful in predicting surgical outcome. Comparative studies on different treatment modalities are essential for clinical practice within the scope of re-evaluation of the role of surgery in GH-secreting adenomas.

Into the wardrobe of Narnia: beyond HIV infection a world of cardiovascular risk

A 38-years-old HIV-hepatitis C virus (HCV) coinfected woman presented to us for dyslipidemia. Clinical, familial and laboratory data were consistent with the diagnosis of familial heterozygous hypercholesterolaemia. History, clinical examination and laboratory findings also supported suspected acromegaly. A pituitary MRI showed a sellar macroadenoma that was removed by transphenoidal surgery without complications. MRI carried out 6&emsp14;months after surgery showed almost complete removal of the adenoma. This case report describes an uncommon association of diseases, very different for aetiology--genetic for FH, infectious for HIV and HCV, caused by excessive hormone secretion for acromegaly--clinical features and therapy, but all sharing a significant impact on cardiovascular risk as a common feature.

The characteristics of acromegalic patients with hyperprolactinemia and the differences in patients with merely GH-secreting adenomas: clinical analysis of 279 cases

OBJECTIVE

The aim of this study is to evaluate clinical data from a large cohort of acromegalic patients with and without hyperprolactinemia.

DESIGN AND METHODS

Between January 2002 and June 2010, a set of data on 279 acromegalic patients undergoing transsphenoidal surgery was available. Based on preoperative GH and prolactin (PRL) levels, patients were divided into GH and GH+PRL groups. A stabilization or a further improvement of postoperative changes in clinical, hormonal, immunohistochemical, and magnetic resonance imaging parameters was observed in all patients throughout the follow-up period.

RESULTS

The GH group had significantly more coarse facial features, large hands and feet, hypertension, and diabetes mellitus compared with the GH+PRL group but significantly less menstrual disorders (13.8 vs 54.3%, P<0.001) and galactorrhea (3.1 vs 22.4%, P<0.001). The GH group had a higher age at diagnosis compared with the GH+PRL group (45.6 ± 13.9 vs 40.4 ± 11.4 years, P=0.001). The GH group had a smaller mean maximal diameter of the adenomas (2.2 ± 0.9 vs 2.6 ± 1.1 cm, P=0.004). There were no significant correlations between hormone levels and the immunohistochemical results. According to the criteria for hormonal cure of acromegaly, the surgical control rates in the GH and GH+PRL groups were 68.4 and 59.7% respectively (P=0.187). Tumor size was an important factor that affected the results of the operations. The rates of surgical control in GH and GH+PRL groups were 80.7 and 69.1% respectively (P=0.037), and the recurrence rates in the two groups were 7.1 and 11.3% respectively (P=0.185).

CONCLUSIONS

Compared with patients with merely GH-secreting adenomas, acromegalic patients with hyperprolactinemia are characterized by an earlier onset of disease, lesser acromegalic features, lower GH levels, but larger tumor sizes, whereas in female patients, GH-PRL secreting adenomas are associated with higher incidences of menstrual disorders and galactorrhea.

Characteristics of sleep-disordered breathing in Japanese patients with acromegaly

Sleep-disordered breathing (SDB), especially sleep apnea-hypopnea syndrome (SAS), is often observed in patients with active acromegaly. This complication is a risk factor for cardiovascular disease and associated with increased morbidity and mortality in acromegaly. However there is little information on SDB in Japanese patients with acromegaly. We investigated the prevalence of SDB and association between the severity of SDB and various features and biomarkers in Japanese patients with acromegaly. Twenty-four Japanese patients with active acromegaly underwent overnight cardiorespiratory monitoring, hormonal assays and cephalometric measurements on X-ray. A high prevalence of SDB was detected in acromegaly (87.5%). Log apnea-hypopnea index (AHI) correlated positively with soft palate length / body height (X-ray) (r=0.44, p=0.043), but not with log growth hormone levels and insulin-like growth factor type-1 standard deviation scores, size of pituitary adenoma, disease duration, body mass index, waist circumference, estimated visceral fat area, heel pad thickness / height, tongue thickness/ height, or oropharyngeal dimension/ height. In conclusion, our study demonstrated a high prevalence of SDB in Japanese patients with acromegaly, and its severity correlated with soft palate length. Based on the high incidence of SDB identified in the present study, we recommend that all patients with acromegaly are routinely screened for SDB for early diagnosis and treatment.

Surgery and radiosurgery for acromegaly: a review of indications, operative techniques, outcomes, and complications

Among multimodality treatments for acromegaly, the goals of surgical intervention are to balance maximal tumor resection while preserving normal pituitary function and maintaining patient safety. The resection of growth hormone-(GH-) secreting pituitary adenomas in the hands of experienced surgeons results in hormonal remission in 50-70% of patients. Acromegalic patients often have medical comorbidities and anatomical variations complicating anesthesia and surgical management. Despite these challenges, complications such as CSF leak or new hypopituitarism following surgery remain uncommon. Over the past decade, endoscopic approaches to pituitary tumors have improved visualization and facilitated identification of additional tumor using angled telescopes. Patients with persistent acromegaly following surgery require continued medical and/or radiation-based interventions. The adjunctive use of stereotactic radiosurgery offers hormonal remission in 40-50% of patients. In this article, the current preoperative evaluation, indications for surgery, surgical approaches, role of radiosurgery, complications, and remission criteria following operative resection of GH adenomas are reviewed.

Pure endoscopic transsphenoidal surgery for treatment of acromegaly: results of 67 cases treated in a pituitary center

Object

Acromegaly is a chronic disease related to the excess of growth hormone (GH) and insulin-like growth factor–I secretion, usually by pituitary adenomas. Traditional treatment of acromegaly consists of surgery, drug therapy, and eventually radiotherapy. The introduction of endoscopy as an additional tool for surgical treatment of pituitary adenomas and, therefore, acromegaly represents an important advance of pituitary surgery in the recent years. The aim of this retrospective study is to evaluate the results of pure transsphenoidal endoscopic surgery in a series of patients with acromegaly who were operated on by a pituitary specialist surgeon. The authors discuss the advantages, outcome, complications, and factors related to the success of the endoscopic approach in cases of GHsecreting adenomas.

Methods

The authors retrospectively analyzed data from cases involving patients with GH-secreting adenomas who underwent pure transsphenoidal endoscopic surgery at the Department of Neurosurgery of the General Hospital in Fortaleza, Brazil, between 2000 and 2009. Tumors were classified according to size as micro- or macroadenomas, and tumor extension was analyzed based on suprasellar/parasellar extension and sella floor destruction. All patients were followed up for at least 1 year. The criteria of disease control were GH levels < 1 ng/L after oral glucose tolerance test and normal insulin-like growth factor–I levels for age and sex.

Results

During the study period, 67 patients underwent pure endoscopic transsphenoidal surgery for treatment of acromegaly. Disease control was obtained in 50 cases (74.6%). The rate of treatment success was higher in patients with microadenomas (disease control achieved in 12 [85.7%] of 14 cases) than in those with larger lesions. Suprasellar/parasellar extension and high levels of sella floor erosion were associated with lower rates of disease control (p = 0.01 and p = 0.02, respectively). Complications related to the endoscopic surgery included epistaxis (6.0%), transitory diabetes insipidus (4.5%), and 1 case of seizure (1.5%).

Conclusions

Endoscopic transsphenoidal surgery represents an effective option for treatment of patients with acromegaly. High disease control rates and a small number of complications are some of the most important points related to the technique. Factors related to the success of the endoscopic surgery are lesion size, suprasellar/parasellar extension, and the degree of sella floor erosion. Although presenting important advantages, there is no conclusive evidence that endoscopy is superior to microsurgery in treatment of GH-secreting adenomas.