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Durmuş ET, Kefeli M, Mete O, Çalışkan S, Aslan K, Onar MA, Çolak R, Durmuş B, Cokluk C, Atmaca A. Granulation Patterns of Functional Corticotroph Tumors Correlate with Tumor Size, Proliferative Activity, T2 Intensity-to-White Matter Ratio, and Postsurgical Early Biochemical Remission. Endocr Pathol 2024:10.1007/s12022-024-09819-y. [PMID: 39046680 DOI: 10.1007/s12022-024-09819-y] [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] [Accepted: 07/15/2024] [Indexed: 07/25/2024]
Abstract
Unlike somatotroph tumors, the data on correlates of tumor granulation patterns in functional TPIT lineage pituitary neuroendocrine tumors (corticotroph tumors) have been less uniformly documented in most clinical series. This study evaluated characteristics of 41 well-characterized functional corticotroph tumors consisting of 28 densely granulated corticotroph tumors (DGCTs) and 13 sparsely granulated corticotroph tumors (SGCTs) with respect to preoperative clinical and radiological findings, tumor proliferative activity (including mitotic count and Ki-67 labeling index), and postoperative early biochemical remission rates. The median (interquartile range (IQR)) tumor size was significantly larger in the SGCT group [16.00 (16.00) mm in SGCT vs 8.5 (9.75) mm in DGCT, p = 0.049]. T2-weighted signal intensity and T2 intensity (quantitative) did not yield statistical significance based on tumor granulation; however, the T2 intensity-to-white matter ratio was significantly higher in SGCTs (p = 0.049). The median (IQR) Ki-67 labeling index was 2.00% (IQR 1.00%) in the DGCT group and 4.00% (IQR 7.00%) in the SGCT group (p = 0.043). The mitotic count per 2 mm2 was higher in the SGCT group (p = 0.001). In the multivariate analysis, the sparse granulation pattern (SGCT) remained an independent predictor of a lower probability of early biochemical remission irrespective of the tumor size and proliferative activity (p = 0.012). The current study further supports the impact of tumor granulation pattern as a biologic variable and warrants the detailed histological subtyping of functional corticotroph tumors as indicated in the WHO classification of pituitary neuroendocrine tumors. More importantly, the assessment of the quantitative T2 intensity-to-white matter ratio may serve as a preoperative radiological harbinger of SGCTs.
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Affiliation(s)
- Elif Tutku Durmuş
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ondokuz Mayis University, 55200, Atakum Samsun, Turkey.
| | - Mehmet Kefeli
- Department of Pathology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ozgur Mete
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Pathology, University Health Network, 200 Elizabeth Street, 11 Floor, Toronto, ON, M5G 2C4, Canada
- Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Sultan Çalışkan
- Department of Pathology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Kerim Aslan
- Department of Radiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Mustafa Arda Onar
- Department of Radiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ramis Çolak
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ondokuz Mayis University, 55200, Atakum Samsun, Turkey
| | - Buğra Durmuş
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ondokuz Mayis University, 55200, Atakum Samsun, Turkey
| | - Cengiz Cokluk
- Department of Neurosurgery, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ayşegül Atmaca
- Department of Endocrinology and Metabolism, Faculty of Medicine, Ondokuz Mayis University, 55200, Atakum Samsun, Turkey
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Wang MY, Yu Y, Han Y, Yang Y, Jiang W, Liu J, Yan LF, Cui GB. The Diagnostic Value of Conventional MRI Combined With Diffusion-Weighted Imaging in Microprolactinomas. J Magn Reson Imaging 2024. [PMID: 38996369 DOI: 10.1002/jmri.29531] [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: 04/22/2024] [Revised: 06/21/2024] [Accepted: 06/21/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Turbo spin-echo (TSE) diffusion-weighted imaging (DWI) sequences may reduce susceptibility artifacts and image distortion in sellar region, allowing better visualization of small pituitary lesions, and may be used to assist in the diagnosis of pituitary microadenomas. PURPOSE To explore the application value of conventional MRI combined with DWI sequences in the diagnosis of microprolactinomas. STUDY TYPE Prospective. POPULATION Thirty-four patients in microprolactinomas with high signal on T2WI (HT2-PRL) group (34 females, 34 ± 7 years), 26 patients in microprolactinomas with equal or low signal on T2WI (ELT2-PRL) group (21 females, 34 ± 7 years), 35 patients with hyperprolactinemia (33 females, 32 ± 8 years), and 30 normal controls (25 females, 31 ± 7 years). FIELD STRENGTH/SEQUENCE TSE sequence at 3 T. ASSESSMENT Pituitary morphological parameters (such as length and volume), dynamic contrast-enhanced parameters (such as time to peak) and the apparent diffusion coefficients (ADCs) were measured in each group. STATISTICAL TESTS ANOVA and Mann-Whitney U test were used to compare parameters among groups. Spearman's coefficient was used to evaluate the correlation between variables. ROC analysis was used to assess the performance of the parameters. A P-value <0.05 was considered statistically significant. RESULTS The pituitary volume of patients in HT2-PRL, ELT2-PRL, and hyperprolactinemia group were 831.00 (747.60, 887.60), 923.63 ± 219.34, and 737.20 (606.40, 836.80) mm3. The pituitary maximum height in these three groups were 7.03 (6.43, 8.63), 8.03 ± 1.41, and 6.63 ± 1.28 mm, respectively. The lesion ADC value was significantly correlated with T2 relative signal intensity (the ratio of signal intensity of microprolactinoma or anterior pituitary to left temporal cortex) (r = 0.821). Compared with patients with hyperprolactinemia, the diagnostic efficacy of T2 relative signal intensity was higher in HT2-PRL group, with an AUC of 0.954, whereas the ADC value was the highest in ELT2-PRL group, with an AUC of 0.924. CONCLUSION DWI sequences can be used to assist in the diagnosis of pituitary microadenomas. EVIDENCE LEVEL 1 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Min-Yang Wang
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, The Military Medical University of PLA Airforce (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Ying Yu
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, The Military Medical University of PLA Airforce (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Yu Han
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, The Military Medical University of PLA Airforce (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Yang Yang
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, The Military Medical University of PLA Airforce (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Wan Jiang
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, The Military Medical University of PLA Airforce (Fourth Military Medical University), Xi'an, Shaanxi, China
- The Affiliated Hospital of Yan'an University School of Medicine, Yan'an, Shaanxi, China
| | - Jin Liu
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, The Military Medical University of PLA Airforce (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Lin-Feng Yan
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, The Military Medical University of PLA Airforce (Fourth Military Medical University), Xi'an, Shaanxi, China
| | - Guang-Bin Cui
- Department of Radiology & Functional and Molecular Imaging Key Lab of Shaanxi Province, Tangdu Hospital, The Military Medical University of PLA Airforce (Fourth Military Medical University), Xi'an, Shaanxi, China
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Marazuela M, Martínez-Hernandez R, Marques-Pamies M, Biagetti B, Araujo-Castro M, Puig-Domingo M. Predictors of biochemical response to somatostatin receptor ligands in acromegaly. Best Pract Res Clin Endocrinol Metab 2024; 38:101893. [PMID: 38575404 DOI: 10.1016/j.beem.2024.101893] [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] [Indexed: 04/06/2024]
Abstract
Although predictors of response to first-generation somatostatin receptor ligands (fg-SRLs), and to a lesser extent to pasireotide, have been studied in acromegaly for many years, their use is still not recommended in clinical guidelines. Is there insufficient evidence to use them? Numerous biomarkers including various clinical, functional, radiological and molecular markers have been identified. The first ones are applicable pre-surgery, while the molecular predictors are utilized for patients not cured after surgery. In this regard, factors predicting a good response to fg-SRLs are specifically: low basal GH, a low GH nadir in the acute octreotide test, T2 MRI hypointensity, a densely granulated pattern, high immunohistochemistry staining for somatostatin receptor 2 (SSTR2), and E-cadherin. However, there is still a lack of consensus regarding which of these biomarkers is more useful or how to integrate them into clinical practice. With classical statistical methods, it is complex to define reliable and generalizable cut-off values for a single biomarker. The potential solution to the limitations of traditional methods involves combining systems biology with artificial intelligence, which is currently providing answers to such long-standing questions that may eventually be finally included into the clinical guidelines and make personalized medicine a reality. The aim of this review is to describe the current knowledge of the main fg-SRLs and pasireotide response predictors, discuss their current usefulness, and point to future directions in the research of this field.
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Affiliation(s)
- Mónica Marazuela
- Department of Endocrinology and Nutrition Hospital Universitario La Princesa, Universidad Autónoma de Madrid,Instituto de Investigación Princesa, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER GCV14/ER/12), Madrid, Spain.
| | | | | | - Betina Biagetti
- Endocrinology & Nutrition Service, Vall d'Hebron University Hospital and Vall d'Hebron Research Institute (VHIR), Department of Medicine, Autonomous University of Barcelona, Reference Networks (ERN), 08035 Barcelona, Spain
| | - Marta Araujo-Castro
- Endocrinology & Nutrition Department. Hospital Universitario Ramón y Cajal, Spain & Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Manel Puig-Domingo
- Department of Endocrinology and Nutrition, Department of Medicine, Germans Trias i Pujol Research Institute and Hospital, Universitat Autònoma de Barcelona, Spain and Centro de Investigación Biomédica en Red de Enfermedades Raras CIBERER G747, Badalona, Spain
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Cheng J, Xie W, Chen Y, Sun Y, Gong L, Wang H, Li C, Zhang Y. Drug resistance mechanisms in dopamine agonist-resistant prolactin pituitary neuroendocrine tumors and exploration for new drugs. Drug Resist Updat 2024; 73:101056. [PMID: 38277755 DOI: 10.1016/j.drup.2024.101056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 12/11/2023] [Accepted: 01/16/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND The treatment of dopamine agonists (DA) resistant prolactinomas remains a formidable challenge, as the mechanism of resistance is still unclear, and there are currently no viable alternative drug therapies available. This study seeks to investigate the mechanism of DA resistance in prolactinomas and identify new potentially effective drugs. METHODS To explore the mechanism of DA resistance in prolactinomas, this study conducted transcriptome sequencing analysis on 27 cases of DA-resistant prolactinomas and 10 cases of sensitive prolactinomas. In addition, single-cell sequencing analysis was performed on 3 cases of DA-resistant prolactinomas and 3 cases of sensitive prolactinomas. Furthermore, to screen for potential therapeutic drugs, the study successfully established an organoids model for DA-resistant prolactinomas and screened 180 small molecule compounds using 8 organoids. The efficacy of the identified drugs was verified through various assays, including CCK-8, colony formation, CTG, and flow cytometry, and their mechanisms of action were confirmed through WB and IHC. The effectiveness of the identified drugs was evaluated both in vitro and in vivo. RESULTS The results of transcriptome sequencing and single-cell sequencing analyses showed that DA resistance in prolactinomas is associated with the upregulation of the Focal Adhesion (FA) signaling pathway. Additionally, immunohistochemical validation revealed that FAK and Paxillin were significantly upregulated in DA-resistant prolactinomas. Screening of 180 small molecule compounds using 8 organoids identified Genistein as a potentially effective drug for DA-resistant prolactinomas. Experimental validation demonstrated that Genistein inhibited the proliferation of pituitary tumor cell lines and organoids and promoted apoptosis in pituitary tumor cells. Moreover, both the cell sequencing results and WB validation results of the drug-treated cells indicated that Genistein exerts its anti-tumor effect by inhibiting the FA pathway. In vivo, experiments also showed that Genistein can inhibit subcutaneous tumor formation. CONCLUSION DA resistance in prolactinomas is associated with upregulation of the Focal Adhesion (FA) signaling pathway, and Genistein can exert its anti-tumor effect by inhibiting the expression of the FA pathway.
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Affiliation(s)
- Jianhua Cheng
- Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
| | - Weiyan Xie
- Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
| | - Yiyuan Chen
- Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
| | - Yingxuan Sun
- Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
| | - Lei Gong
- Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
| | - Hongyun Wang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
| | - Chuzhong Li
- Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China; Department of Neurosurgery, Beijing Tiantan Hospital affiliated with Capital Medical University, Beijing 100070, China; Beijing Institute for Brain Disorders Brain Tumor Center, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing 100070, China.
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China; Department of Neurosurgery, Beijing Tiantan Hospital affiliated with Capital Medical University, Beijing 100070, China; Beijing Institute for Brain Disorders Brain Tumor Center, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing 100070, China.
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Dzialach L, Sobolewska J, Zak Z, Respondek W, Witek P. Prolactin-secreting pituitary adenomas: male-specific differences in pathogenesis, clinical presentation and treatment. Front Endocrinol (Lausanne) 2024; 15:1338345. [PMID: 38370355 PMCID: PMC10870150 DOI: 10.3389/fendo.2024.1338345] [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: 11/14/2023] [Accepted: 01/22/2024] [Indexed: 02/20/2024] Open
Abstract
Prolactinomas (PRLomas) constitute approximately half of all pituitary adenomas and approximately one-fifth of them are diagnosed in males. The clinical presentation of PRLomas results from direct prolactin (PRL) action, duration and severity of hyperprolactinemia, and tumor mass effect. Male PRLomas, compared to females, tend to be larger and more invasive, are associated with higher PRL concentration at diagnosis, present higher proliferative potential, are more frequently resistant to standard pharmacotherapy, and thus may require multimodal approach, including surgical resection, radiotherapy, and alternative medical agents. Therefore, the management of PRLomas in men is challenging in many cases. Additionally, hyperprolactinemia is associated with a significant negative impact on men's health, including sexual function and fertility potential, bone health, cardiovascular and metabolic complications, leading to decreased quality of life. In this review, we highlight the differences in pathogenesis, clinical presentation and treatment of PRLomas concerning the male sex.
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Affiliation(s)
- Lukasz Dzialach
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Sobolewska
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Zuzanna Zak
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
| | - Wioleta Respondek
- Department of Internal Medicine, Endocrinology and Diabetes, Mazovian Brodnowski Hospital, Warsaw, Poland
| | - Przemysław Witek
- Department of Internal Medicine, Endocrinology and Diabetes, Medical University of Warsaw, Warsaw, Poland
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Tang Y, Xie T, Guo Y, Liu S, Li C, Liu T, Zhao P, Yang L, Li Z, Yang H, Zhang X. Analysis of Diffusion-Weighted and T2-Weighted Imaging in the Prediction of Distinct Granulation Patterns of Somatotroph Adenomas. World Neurosurg 2024; 182:e334-e343. [PMID: 38052365 DOI: 10.1016/j.wneu.2023.11.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVE The heterogeneity of the somatotroph adenomas, especially for sparsely granulated (SG) and densely granulated (DG) subtypes, has attracted great attention in identifying their imaging biomarker. The purpose of the current study was to compare the diagnostic performance of diffusion-weighted and T2-weighted magnetic resonance imaging (MRI) sequences for preoperatively distinguishing the granulation patterns of somatotroph adenomas. METHODS Thirty-two patients with a clinical diagnosis of somatotroph adenomas from October 2018 to March 2023 were included in this study. Coronal diffusion-weighted imaging (DWI) and T2-weighted MRI sequence data were collected from 3.0T MRI and compared between SG and DG groups. The immunohistochemistry was used to confirm the electron microscopy pathologic subtypes and Ki67 expression levels of somatotroph adenomas postoperatively. RESULTS Patients in the SG group had significantly higher signal intensity (SI) ratio of DWI (rDWI) (P < 0.001), lower SI ratio of apparent diffusion coefficient (rADC) (P < 0.001), and higher SI ratio of T2-weighted imaging (P = 0.011). The combined diagnosis index of rDWI and rADC had the highest diagnostic efficiency in predicting SG adenomas (sensitivity, 93.3%; specificity, 88.2%; P < 0.001). The rDWI and rADC values had positive and negative correlations with the Ki67 index and tumor maximum diameter, respectively. Lower rADC×103 was an independent predictor for SG adenomas. CONCLUSIONS Our results indicated that compared with previously used T2-weighted imaging, the DWI sequence, especially the combined diagnosis index of rDWI and rADC, could more efficiently distinguish the granulation patterns of somatotroph adenomas preoperatively.
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Affiliation(s)
- Yifan Tang
- Department of Neurosurgery, Fudan University, Shanghai, China
| | - Tao Xie
- Department of Neurosurgery, Fudan University, Shanghai, China; Department of Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China; The Innovation and Translation Alliance of Neuroendoscopy in the Yangtze River Delta, Shanghai, China
| | - Yinglong Guo
- Department of Radiology, Fudan University, Shanghai, China
| | - Shuang Liu
- Department of Neurosurgery, Fudan University, Shanghai, China
| | - Chen Li
- Department of Neurosurgery, Fudan University, Shanghai, China
| | - Tengfei Liu
- Department of Neurosurgery, Fudan University, Shanghai, China
| | - Puyuan Zhao
- Department of Neurosurgery, Fudan University, Shanghai, China
| | - LiangLiang Yang
- Department of Neurosurgery, Fudan University, Shanghai, China
| | - Zeyang Li
- Department of Neurosurgery, Fudan University, Shanghai, China
| | - Hantao Yang
- Department of Neurosurgery, Fudan University, Shanghai, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Fudan University, Shanghai, China; Department of Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China; Department of Digital Medical Research Center, Fudan University, Shanghai, China; The Innovation and Translation Alliance of Neuroendoscopy in the Yangtze River Delta, Shanghai, China; Shanghai Key Laboratory of Medical Imaging Computing and Computer Assisted Intervention, Shanghai, China.
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Marques-Pamies M, Gil J, Jordà M, Puig-Domingo M. Predictors of Response to Treatment with First-Generation Somatostatin Receptor Ligands in Patients with Acromegaly. Arch Med Res 2023; 54:102924. [PMID: 38042683 DOI: 10.1016/j.arcmed.2023.102924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/27/2023] [Accepted: 11/17/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND AND AIMS Predictors of first-generation somatostatin receptor ligands (fgSRLs) response in acromegaly have been studied for over 30 years, but they are still not recommended in clinical guidelines. Is there not enough evidence to support their use? This systematic review aims to describe the current knowledge of the main predictors of fgSRLs response and discuss their current usefulness, as well as future research directions. METHODS A systematic search was performed in the Scopus and PubMed databases for functional, imaging, and molecular predictive factors. RESULTS A total of 282 articles were detected, of which 64 were included. Most of them are retrospective studies performed between 1990 and 2023 focused on the predictive response to fgSRLs in acromegaly. The usefulness of the predictive factors is confirmed, with good response identified by the most replicated factors, specifically low GH nadir in the acute octreotide test, T2 MRI hypointensity, high Somatostatin receptor 2 (SSTR2) and E-cadherin expression, and a densely granulated pattern. Even if these biomarkers are interrelated, the association is quite heterogeneous. With classical statistical methods, it is complex to define reliable and generalizable cut-off values worth recommending in clinical guidelines. Machine-learning models involving omics are a promising approach to achieve the highest accuracy values to date. CONCLUSIONS This survey confirms a sufficiently robust level of evidence to apply knowledge of predictive factors for greater efficiency in the treatment decision process. The irruption of artificial intelligence in this field is providing definitive answers to such long-standing questions that may change clinical guidelines and make personalized medicine a reality.
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Affiliation(s)
| | - Joan Gil
- Endocrine Research Unit, Germans Trias i Pujol Research Institute, Badalona, Spain; Network Research Center for Rare Diseases, CIBERER, Unit 747, Instituto de Salud Carlos III, Madrid, Spain; Department of Endocrinology, Research Center for Pituitary Diseases, Hospital Sant Pau, IIB-SPau, Barcelona, Spain
| | - Mireia Jordà
- Endocrine Research Unit, Germans Trias i Pujol Research Institute, Badalona, Spain
| | - Manel Puig-Domingo
- Endocrine Research Unit, Germans Trias i Pujol Research Institute, Badalona, Spain; Network Research Center for Rare Diseases, CIBERER, Unit 747, Instituto de Salud Carlos III, Madrid, Spain; Department of Endocrinology and Nutrition, Germans Trias i Pujol University Hospital, Badalona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Petersenn S, Fleseriu M, Casanueva FF, Giustina A, Biermasz N, Biller BMK, Bronstein M, Chanson P, Fukuoka H, Gadelha M, Greenman Y, Gurnell M, Ho KKY, Honegger J, Ioachimescu AG, Kaiser UB, Karavitaki N, Katznelson L, Lodish M, Maiter D, Marcus HJ, McCormack A, Molitch M, Muir CA, Neggers S, Pereira AM, Pivonello R, Post K, Raverot G, Salvatori R, Samson SL, Shimon I, Spencer-Segal J, Vila G, Wass J, Melmed S. Diagnosis and management of prolactin-secreting pituitary adenomas: a Pituitary Society international Consensus Statement. Nat Rev Endocrinol 2023; 19:722-740. [PMID: 37670148 DOI: 10.1038/s41574-023-00886-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 09/07/2023]
Abstract
This Consensus Statement from an international, multidisciplinary workshop sponsored by the Pituitary Society offers evidence-based graded consensus recommendations and key summary points for clinical practice on the diagnosis and management of prolactinomas. Epidemiology and pathogenesis, clinical presentation of disordered pituitary hormone secretion, assessment of hyperprolactinaemia and biochemical evaluation, optimal use of imaging strategies and disease-related complications are addressed. In-depth discussions present the latest evidence on treatment of prolactinoma, including efficacy, adverse effects and options for withdrawal of dopamine agonist therapy, as well as indications for surgery, preoperative medical therapy and radiation therapy. Management of prolactinoma in special situations is discussed, including cystic lesions, mixed growth hormone-secreting and prolactin-secreting adenomas and giant and aggressive prolactinomas. Furthermore, considerations for pregnancy and fertility are outlined, as well as management of prolactinomas in children and adolescents, patients with an underlying psychiatric disorder, postmenopausal women, transgender individuals and patients with chronic kidney disease. The workshop concluded that, although treatment resistance is rare, there is a need for additional therapeutic options to address clinical challenges in treating these patients and a need to facilitate international registries to enable risk stratification and optimization of therapeutic strategies.
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Affiliation(s)
- Stephan Petersenn
- ENDOC Center for Endocrine Tumors, Hamburg, Germany.
- University of Duisburg-Essen, Essen, Germany.
| | | | | | - Andrea Giustina
- San Raffaele Vita-Salute University, Milan, Italy
- IRCCS Hospital San Raffaele, Milan, Italy
| | | | | | | | - Philippe Chanson
- Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | | | - Monica Gadelha
- Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Yona Greenman
- Tel Aviv-Sourasky Medical Center, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Mark Gurnell
- University of Cambridge, Cambridge, UK
- Addenbrooke's Hospital, Cambridge, UK
| | - Ken K Y Ho
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | | | | | - Ursula B Kaiser
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | | | - Maya Lodish
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Hani J Marcus
- National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ann McCormack
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Mark Molitch
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Alberto M Pereira
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | - Kalmon Post
- Mount Sinai Health System, New York, NY, USA
| | - Gerald Raverot
- Department of Endocrinology, Reference Centre for Rare Pituitary Diseases HYPO, "Groupement Hospitalier Est" Hospices Civils de Lyon, Bron, France
| | | | | | - Ilan Shimon
- Tel Aviv University, Tel Aviv, Israel
- Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
| | | | - Greisa Vila
- Medical University of Vienna, Vienna, Austria
| | - John Wass
- University of Oxford, Oxford, UK
- Churchill Hospital, Oxford, UK
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Durmuş ET, Atmaca A, Kefeli M, Çalışkan S, Mete O, Aslan K, Fidan M, Çolak R, Durmuş B. Age, GH/IGF-1 levels, tumor volume, T2 hypointensity, and tumor subtype rather than proliferation and invasion are all reliable predictors of biochemical response to somatostatin analogue therapy in patients with acromegaly: A clinicopathological study. Growth Horm IGF Res 2022; 67:101502. [PMID: 36115256 DOI: 10.1016/j.ghir.2022.101502] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/02/2022] [Accepted: 09/04/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine whether biochemical responses to long-acting forms of first-generation somatostatin analogue (SSA) therapy in patients with acromegaly could be predicted from baseline and postoperative hormone concentrations, and tumor radiological and histopathological characteristics. METHODS A total of 68 patients with acromegaly for whom postoperative SSA therapy was started were categorized according to their responses to treatment (SSA-responders vs. non-responders). The patients were compared based on their demographic characteristics, hormone levels, magnetic resonance imaging (MRI), and histopathological findings. Receiver-operating-characteristic (ROC) curves were constructed using the predictive factors that were significant in the univariate analysis to determinate the optimal cut-off values. RESULTS The SSA-responders were significantly older (p = 0.041). Lower GH at diagnosis (p = 0.036), the postoperative 1st-week GH level (p = 0.027), baseline GH, insulin-like growth factor-1 (IGF-1) and IGF-1% upper limit of normal (ULN) (p = 0.001, p = 0.006, p = 0.023, respectively) were associated with biochemical response. T2-hypointensity and lower tumor volume were more common in the SSA-responders (p = 0.018, p = 0.03, respectively). Compared to sparsely granulated somatotroph tumors, densely granulated somatotroph tumors and other PitNETs causing GH excess including mammosomatotroph and mixed somatotroph and lactotroph tumors were more likely to respond to SSA therapy (p = 0.026, p = 0.03, respectively). The cut-off values generated by ROC curve analysis were GH at diagnosis of ≤8.8 ng/mL, GH at baseline of ≤2.69 ng/mL, IGF-1 at baseline ≤461.5 ng/mL, IGF-1% ULN at baseline ≤180.4%, and tumor volume of ≤1.11 cm3 (all p < 0.05). There were no differences between the groups in terms of tumor invasiveness, proliferative activity (mitotic count per 2 mm2 and Ki-67 labeling index) and quantitative analyses of T2-weighted MRI. CONCLUSION This study underscores that advanced age, low baseline GH and IGF-1 at diagnosis, low tumor volume, densely granulated tumor subtype, and T2 hypointensity may help predict biochemical response to SSA therapy in cases of acromegaly. These variables should be assessed with utmost attention for all patients prior to SSA treatment. In cases of possible resistance to SSA therapy, therapeutic activity should be monitored more closely and other therapies should be administered immediately in the event of poor response.
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Affiliation(s)
- Elif Tutku Durmuş
- Ondokuz Mayis University, Faculty of Medicine, Department of Endocrinology and Metabolism, Samsun, Turkey.
| | - Ayşegül Atmaca
- Ondokuz Mayis University, Faculty of Medicine, Department of Endocrinology and Metabolism, Samsun, Turkey
| | - Mehmet Kefeli
- Ondokuz Mayis University, Faculty of Medicine, Department of Pathology, Samsun, Turkey
| | - Sultan Çalışkan
- Ondokuz Mayis University, Faculty of Medicine, Department of Pathology, Samsun, Turkey
| | - Ozgur Mete
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada; Department of Pathology, University Health Network, 200 Elizabeth Street, 11th Floor, Toronto, ON M5G 2C4, Canada; Endocrine Oncology Site Group, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Kerim Aslan
- Ondokuz Mayis University, Faculty of Medicine, Department of Radiology, Samsun, Turkey
| | - Murat Fidan
- Ondokuz Mayis University, Faculty of Medicine, Department of Radiology, Samsun, Turkey
| | - Ramis Çolak
- Ondokuz Mayis University, Faculty of Medicine, Department of Endocrinology and Metabolism, Samsun, Turkey
| | - Buğra Durmuş
- Ondokuz Mayis University, Faculty of Medicine, Department of Endocrinology and Metabolism, Samsun, Turkey
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10
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Fajardo-Montañana C, Villar R, Gómez-Ansón B, Brea B, Mosqueira AJ, Molla E, Enseñat J, Riesgo P, Cardona-Arboniés J, Hernando O. Recommendations for the diagnosis and radiological follow-up of pituitary neuroendocrine tumours. ENDOCRINOL DIAB NUTR 2022; 69:744-761. [PMID: 36428207 DOI: 10.1016/j.endien.2021.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/01/2021] [Indexed: 06/16/2023]
Abstract
Pituitary neuroendocrine tumours (PitNETs) constitute a heterogeneous group of tumours with a gradually increasing incidence, partly accounted for by more sensitive imaging techniques and more extensive experience in neuroradiology in this regard. Although most PitNETs are indolent, some exhibit aggressive behaviour, and recurrence may be seen after surgical removal. The changes introduced in the WHO classification in 2017 and terminological debates in relation to neuroendocrine tumours warrant an update of the guidelines for the diagnosis, preoperative and postoperative management, and follow-up of response to treatment of PitNETs. This multidisciplinary document, an initiative of the Neuroendocrinology area of the Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition] (SEEN), focuses on neuroimaging studies for the diagnosis, prognosis and follow-up of PitNETs. The basic requirements and elements that should be covered by magnetic resonance imaging are described, and a minimum radiology report to aid clinicians in treatment decision-making is proposed. This work supplements the consensus between the Neuroendocrinology area of the SEEN and the Sociedad Española de Anatomía Patológica [Spanish Society of Pathology] (SEAP) for the pathological study of PitNETs.
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Affiliation(s)
| | - Rocío Villar
- Departamento de Endocrinología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - Beatriz Gómez-Ansón
- Neurorradiología, Departamento de Radiodiagnóstico, Hospital Universitari Sant Pau, Barcelona, Spain
| | - Beatriz Brea
- Departamento de Radiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Antonio Jesús Mosqueira
- Departamento de Radiología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - Enrique Molla
- Departamento de Radiología, Hospital Universitario de la Ribera, Alcira, Valencia, Spain
| | - Joaquín Enseñat
- Departamento de Neurocirugía, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pedro Riesgo
- Departamento de Neurocirugía, Hospital Universitario de la Ribera, Alcira, Valencia, Spain
| | - Jorge Cardona-Arboniés
- Departamento de Medicina Nuclear, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Ovidio Hernando
- Departamento de Oncología Radioterápica, Centro Integral Oncológico Clara Campal, Madrid, Spain
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11
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Gruppetta M. A current perspective of pituitary adenoma MRI characteristics: a review. Expert Rev Endocrinol Metab 2022; 17:499-511. [PMID: 36373167 DOI: 10.1080/17446651.2022.2144230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION MR imaging is an essential and fundamental tool in the diagnosis, management, and follow-up of patients with pituitary adenomas (PAs). Recent advances have continued to enhance the usefulness of this imaging modality. AREAS COVERED This article focuses on signal intensity patterns of PAs and associated clinical characteristics, vertical extension patterns, and cavernous sinus invasion with a special focus on the clinical implications that arise. A search using Medline and Google Scholar was conducted using different combinations of relevant keywords, giving preference to recent publications. EXPERT OPINION A higher proportion of GH-secreting PAs are hypointense on T2 weighted images compared to other tumor subtypes. Hypointense tumors are generally smaller compared to hyperintense ones, and among the GH-secreting subgroup, a better response to somatostatin analogue treatment was noted together with an association for a densely granulated pattern. Nonfunctional PAs show a predilection to extend upwards while GH-secreting PAs and prolactinomas show a predominantly inferior extension growth pattern. Further studies to better understand the mechanisms responsible for this behavior are anticipated. Further development, refining and validation of predictive scoring systems for tumor behavior might be useful adjuncts in the management of patients with PAs.
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Affiliation(s)
- Mark Gruppetta
- Department of Medicine, Faculty of Medicine and Surgery, University of Malta, Mater Dei Hospital, Msida, Malta
- Department of Medicine, Neuroendocrine Clinic, Mater Dei Hospital, Msida, Malta
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12
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Szmygin H, Szydełko J, Matyjaszek-Matuszek B. Dopamine Agonist-Resistant Microprolactinoma—Mechanisms, Predictors and Management: A Case Report and Literature Review. J Clin Med 2022; 11:jcm11113070. [PMID: 35683457 PMCID: PMC9181764 DOI: 10.3390/jcm11113070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/10/2022] [Accepted: 05/27/2022] [Indexed: 01/09/2023] Open
Abstract
Objective: Prolactinomas are the most common type of functional, hormone-secreting pituitary adenomas that account for about 40% of total pituitary adenomas. Typical clinical presentations include loss of menstrual periods (amenorrhea) and galactorrhoea in women and sexual dysfunction in men. Prolactinomas are preferentially treated with dopamine agonists and respond to such therapy with hormonal normalisation and tumour shrinkage. However, about 10–20% of prolactinomas are resistant to dopamine agonists. The management of dopamine agonist-resistant prolactinomas poses a therapeutic challenge and includes several possible approaches. Design and Methods: In this study, we present a case report of a woman diagnosed with microprolactinoma at the age of 27 who did not fully respond either to treatment with dopamine agonists nor to transsphenoidal surgery. This was followed by a review of literature on the current state of knowledge about the mechanisms, predictors, and management of dopamine agonist-resistant prolactinomas on the basis of recent scientific literature published up to November 2021 and searches of the PubMed, Google Scholar, and Web of Science databases. Results and Conclusions: The exact mechanisms underlying dopamine agonists’ resistance in lactotroph tumours are not fully understood, yet refractory prolactinomas pose a great challenge in everyday clinical practice. Several predictive factors that contribute to poor response to medical treatment have been identified, among them the elevated Ki-67 index. Recently, various alternative medical treatments have been considered, but their usefulness remains to be evaluated. A return of menses can serve as a first clinical indication of successful medical treatment.
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13
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Ting Lim DS, Fleseriu M. Personalized Medical Treatment in Patients with Acromegaly: A Review. Endocr Pract 2022; 28:321-332. [PMID: 35032649 DOI: 10.1016/j.eprac.2021.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 12/23/2022]
Abstract
Acromegaly is associated with significant morbidity and mortality if not appropriately treated. In addition to insulin-like growth factor 1 (IGF-1) and growth hormone (GH) normalization, and tumor shrinkage, treatment goals include symptom relief, managing complications and improving quality of life. Surgical resection is a first-line treatment in most patients, with few being pretreated pre-operatively with medications. Somatostatin receptor ligands (SRLs), injectable and more recently oral capsules, have been the cornerstone of first-line medical therapy for persistent disease. However, several factors, including sparsely granulated adenomas, absent/low somatostatin receptor (SSTR2) status, imaging T2-hyperintensity, young age and aryl hydrocarbon receptor interacting protein mutations could predict first-generation SRL resistance. Patients with these characteristics may be better candidates for the GH receptor antagonist, pegvisomant, or in cases of large tumors the second-generation SRL, pasireotide. Combination therapy should be further pursued in patients who remain biochemically uncontrolled or have high remnant tumor after monotherapy. An efficacious and cost-effective pegvisomant dose-sparing effect of SRLs when used in combination has been demonstrated. With such a wide array of medical treatment options, it is increasingly important to tailor treatment to patients' unique characteristics as well as preferences, with a goal of personalizing management to achieve high quality outcomes.
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Affiliation(s)
| | - Maria Fleseriu
- Pituitary Center, and Departments of Medicine (Endocrinology, Diabetes and Clinical Nutrition) and Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA.
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14
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Lewis D, Roncaroli F, Kearney T, Coope DJ, Gnanalingham K. Quantitative Magnetic Resonance-Derived Biomarkers as Predictors of Function and Histotype in Adenohypophyseal Tumours. Neuroendocrinology 2022; 112:276-286. [PMID: 33902055 DOI: 10.1159/000516823] [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: 05/05/2020] [Accepted: 03/31/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) is the main modality to diagnose adenohypophyseal tumours, while biochemical assessment of pituitary hormones allows for their functional classification. In this retrospective exploratory cohort study, we investigated if quantitative differences in tumour MR signal intensity (SI) could be utilized to predict the function and histotype. METHODS Clinically acquired pretreatment MRI images were retrospectively analysed in 67 clinically non-functioning gonadotropinomas (NFG), 38 somatotropinomas, and 16 medically treated giant macroprolactinomas. Mean T1- and T2-weighted SI values were determined for each tumour and normalized against either centrum semiovale white matter or CSF to derive relative T1W and T2W SI values and the relative tumour T2/T1 SI ratio. Inter-group differences in quantitative MR parameters were compared, and the power of each parameter to discriminate tumour type and subtype was assessed using the area under the receiver operator characteristic curve (AUROC). In resected somatotropinomas, the relationship between tumour granulation status, relative MR SI values, and biochemical data was also compared. RESULTS Compared to somatotropinomas, NFG and macroprolactinomas displayed higher relative T2W SI (p < 0.001) and higher relative tumour T2/T1 SI ratio values (p < 0.001, ANOVA). Compared to intermediate/densely granulated tumours, sparsely granulated somatotropinomas were larger (p = 0.006, Mann-Whitney U test), had higher relative T2W SI (p ≤ 0.005), and higher relative tumour T2/T1 SI ratios (p ≤ 0.001, 2-tailed t test). Relative tumour T2W SI values and relative tumour T2/T1 ratio values demonstrated good discriminatory power in differentiating NFG from somatotropinoma (AUROC = 0.87-0.94) and predicting somatotropinoma subtypes (AUROC = 0.87-0.95). CONCLUSION Quantitative SI-based MR parameters derived using clinical acquisition MRI protocols may help non-invasively discriminate the functional status of adenohypophyseal tumours and the histological subtype of somatotropinomas.
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Affiliation(s)
- Daniel Lewis
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Division of Informatics, Imaging and Data Sciences, Wolfson Molecular Imaging Centre (WMIC), University of Manchester, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, United Kingdom
| | - Federico Roncaroli
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, United Kingdom
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Endocrinology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Tara Kearney
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Endocrinology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - David John Coope
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, United Kingdom
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Endocrinology, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Kanna Gnanalingham
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Geoffrey Jefferson Brain Research Centre, University of Manchester, Manchester, United Kingdom
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15
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Fajardo-Montañana C, Villar R, Gómez-Ansón B, Brea B, Mosqueira AJ, Molla E, Enseñat J, Riesgo P, Cardona-Arboniés J, Hernando O. Recomendaciones sobre el diagnóstico y seguimiento radiológico de los tumores neuroendocrinos hipofisarios. ENDOCRINOL DIAB NUTR 2021. [DOI: 10.1016/j.endinu.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Predicting Subtype of Growth Hormone Pituitary Adenoma based on Magnetic Resonance Imaging Characteristics. J Comput Assist Tomogr 2021; 46:124-130. [PMID: 35099144 PMCID: PMC8763249 DOI: 10.1097/rct.0000000000001249] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Supplemental digital content is available in the text. This study aimed to investigate the value of magnetic resonance (MR) characteristics in differentiating the subtypes of growth hormone pituitary adenomas.
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17
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Al Argan R, Ramadhan A, Agnihotram RV, Chankowsky J, Rivera J. Baseline MRI findings as predictors of hypopituitarism in patients with non-functioning pituitary adenomas. Endocr Connect 2021; 10:1445-1454. [PMID: 34636742 PMCID: PMC8630757 DOI: 10.1530/ec-21-0386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/11/2021] [Indexed: 11/08/2022]
Abstract
Hypopituitarism tends to occur in large pituitary adenomas. However, similar tumors could present with strikingly different hormonal deficiencies. In this study, we looked at MRI characteristics in non-functioning pituitary adenomas (NFPA), which could predict secondary adrenal insufficiency (SAI) and central hypothyroidism (CHT). We reviewed the files of patients with NFPA attending our clinic. Tumor size, invasiveness, MR-signal intensity, and gadolinium enhancement in preoperative MRI were recorded along with documented presurgical hypopituitarism profile. Logistic regression was used to predict SAI, CHT, or both (SAI/CHT) based on MRI and demographic parameters. Receiver operating characteristic curves were used to determine their diagnostic utility. One hundred twenty-one patients were included in the study. Older age (P = 0.021), male sex (P = 0.043), stalk deviation (P < 0.0001), contrast enhancement (P = 0.029), and optic chiasma compression (P = 0.012) were associated with SAI/CHT. Adenoma vertical height, largest diameter, and estimated volume were also strongly associated with SAI/CHT (P < 0.0001). These associations remained significant in a multivariate analysis. No tumor smaller than 12 mm in vertical height, 17 mm in largest diameter, or 0.9 cm3 in volume was associated with SAI/CHT. At cut-off ≥18 mm for vertical height, ≥23 mm for largest diameter, and ≥3.2 cm3 the sensitivity was around 90-92% for detecting SAI/CHT. Only vertical height was significantly associated with any one or more pituitary hormonal deficit (P = 0.001). In conclusion, adenoma size, independent of the measurement used, remains the best predictor of SAI/CHT in NFPA. Dynamic testing to rule out SAI is probably indicated in adenomas larger than 18 mm vertical height, 23 mm largest diameter and 3.2 cm3 adenoma volume.
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Affiliation(s)
- Reem Al Argan
- Endocrine Section, Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Khobar, Eastern Province, Saudi Arabia
| | - Abdulaziz Ramadhan
- Division of Endocrinology and Metabolism, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | | | - Jeffrey Chankowsky
- Department of Diagnostic Radiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Juan Rivera
- Division of Endocrinology and Metabolism, Department of Medicine, McGill University Health Center, Montreal, Quebec, Canada
- Correspondence should be addressed to J Rivera:
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18
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Wright K, Lee M, Escobar N, Pacione D, Young M, Fatterpekar G, Agrawal N. Tumor volume improves preoperative differentiation of prolactinomas and nonfunctioning pituitary adenomas. Endocrine 2021; 74:138-145. [PMID: 33966173 DOI: 10.1007/s12020-021-02744-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Both prolactinomas and nonfunctioning adenomas (NFAs) can present with hyperprolactinemia. Distinguishing them is critical because prolactinomas are effectively managed with dopamine agonists, whereas compressive NFAs are treated surgically. Current guidelines rely only on serum prolactin (PRL) levels, which are neither sensitive nor specific enough. Recent studies suggest that accounting for tumor volume may improve diagnosis. The objective of this study is to investigate the diagnostic utility of PRL, tumor volume, and imaging features in differentiating prolactinoma and NFA. METHODS Adult patients with pathologically confirmed prolactinoma (n = 21) or NFA with hyperprolactinemia (n = 58) between 2013 and 2020 were retrospectively identified. Diagnostic performance of clinical and imaging variables was analyzed using receiver-operating characteristic curves to calculate area under the curve (AUC). RESULTS Tumor volume and PRL positively correlated for prolactinoma (r = 0.4839, p = 0.0263) but not for NFA (r = 0.0421, p = 0.7536). PRL distinguished prolactinomas from NFAs with an AUC of 0.8892 (p < 0.0001) and optimal cut-off value of 62.45 ng/ml, yielding a sensitivity of 85.71% and specificity of 94.83%. The ratio of PRL to tumor volume had an AUC of 0.9647 (p < 0.0001) and optimal cut-off value of 21.62 (ng/ml)/cm3 with sensitivity of 100% and specificity of 82.76%. Binary logistic regression found that PRL was a significant positive predictor of prolactinoma diagnosis, whereas tumor volume, presence of cavernous sinus invasion, and T2 hyperintensity were significant negative predictors. The regression model had an AUC of 0.9915 (p < 0.0001). CONCLUSIONS Consideration of tumor volume improves differentiation between prolactinomas and NFAs, which in turn leads to effective management.
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Affiliation(s)
- Kyla Wright
- NYU Grossman School of Medicine, NYU Langone Health, 550 1st Ave, New York, NY, 10016, USA
| | - Matthew Lee
- Department of Radiology, NYU Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - Natalie Escobar
- NYU Grossman School of Medicine, NYU Langone Health, 550 1st Ave, New York, NY, 10016, USA
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Medical Center, 1st Avenue, New York, NY, 10016, USA
| | - Matthew Young
- Department of Radiology, NYU Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - Girish Fatterpekar
- Department of Radiology, NYU Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - Nidhi Agrawal
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Medical Center/ Bellevue Hospital Center, 550 1st Avenue, New York, NY, 10016, USA.
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19
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Kamimura K, Nakajo M, Bohara M, Nagano D, Fukukura Y, Fujio S, Takajo T, Tabata K, Iwanaga T, Imai H, Nickel MD, Yoshiura T. Consistency of Pituitary Adenoma: Prediction by Pharmacokinetic Dynamic Contrast-Enhanced MRI and Comparison with Histologic Collagen Content. Cancers (Basel) 2021; 13:cancers13153914. [PMID: 34359814 PMCID: PMC8345382 DOI: 10.3390/cancers13153914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Transsphenoidal resection of hard pituitary adenomas have a particularly high risk of residual tumor and complications. Therefore, prediction of tumor consistency is valuable for planning pituitary adenoma surgery. We prospectively examined whether quantitative pharmacokinetic analysis of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is useful for predicting consistency of pituitary adenoma in 49 participants. We found that the measure of volume of extravascular extracellular space per unit volume of tissue derived from DCE-MRI could predict the consistency of pituitary adenomas. Furthermore, the volume of extravascular extracellular space per unit volume of tissue was significantly positively correlated with histopathologic collagen content of the adenoma. Our results suggest that volume of extravascular extracellular space per unit volume of tissue derived from quantitative pharmacokinetic analysis of DCE-MRI has a predictive value for consistency of pituitary adenomas. Abstract Prediction of tumor consistency is valuable for planning transsphenoidal surgery for pituitary adenoma. A prospective study was conducted involving 49 participants with pituitary adenoma to determine whether quantitative pharmacokinetic analysis of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is useful for predicting consistency of adenomas. Pharmacokinetic parameters in the adenomas including volume of extravascular extracellular space (EES) per unit volume of tissue (ve), blood plasma volume per unit volume of tissue (vp), volume transfer constant between blood plasma and EES (Ktrans), and rate constant between EES and blood plasma (kep) were obtained. The pharmacokinetic parameters and the histologic percentage of collagen content (PCC) were compared between soft and hard adenomas using Mann–Whitney U test. Pearson’s correlation coefficient was used to correlate pharmacokinetic parameters with PCC. Hard adenomas showed significantly higher PCC (44.08 ± 15.14% vs. 6.62 ± 3.47%, p < 0.01), ve (0.332 ± 0.124% vs. 0.221 ± 0.104%, p < 0.01), and Ktrans (0.775 ± 0.401/min vs. 0.601 ± 0.612/min, p = 0.02) than soft adenomas. Moreover, a significant positive correlation was found between ve and PCC (r = 0.601, p < 0.01). The ve derived using DCE-MRI may have predictive value for consistency of pituitary adenoma.
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Affiliation(s)
- Kiyohisa Kamimura
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (M.N.); (M.B.); (D.N.); (Y.F.); (T.Y.)
- Correspondence: ; Tel.: +81-99-275-5417
| | - Masanori Nakajo
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (M.N.); (M.B.); (D.N.); (Y.F.); (T.Y.)
| | - Manisha Bohara
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (M.N.); (M.B.); (D.N.); (Y.F.); (T.Y.)
| | - Daigo Nagano
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (M.N.); (M.B.); (D.N.); (Y.F.); (T.Y.)
| | - Yoshihiko Fukukura
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (M.N.); (M.B.); (D.N.); (Y.F.); (T.Y.)
| | - Shingo Fujio
- Department of Neurosurgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (S.F.); (T.T.)
| | - Tomoko Takajo
- Department of Neurosurgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (S.F.); (T.T.)
| | - Kazuhiro Tabata
- Department of Pathology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan;
| | - Takashi Iwanaga
- Department of Radiological Technology, Kagoshima University Hospital, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan;
| | - Hiroshi Imai
- MR Research & Collaboration, Siemens Healthcare K.K., 1-11-1 Osaki, Shinagawa, Tokyo 141-8644, Japan;
| | | | - Takashi Yoshiura
- Department of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (M.N.); (M.B.); (D.N.); (Y.F.); (T.Y.)
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20
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Park YW, Eom J, Kim S, Kim H, Ahn SS, Ku CR, Kim EH, Lee EJ, Kim SH, Lee SK. Radiomics With Ensemble Machine Learning Predicts Dopamine Agonist Response in Patients With Prolactinoma. J Clin Endocrinol Metab 2021; 106:e3069-e3077. [PMID: 33713414 DOI: 10.1210/clinem/dgab159] [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] [Received: 12/22/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT Early identification of the response of prolactinoma patients to dopamine agonists (DA) is crucial in treatment planning. OBJECTIVE To develop a radiomics model using an ensemble machine learning classifier with conventional magnetic resonance images (MRIs) to predict the DA response in prolactinoma patients. DESIGN Retrospective study. SETTING Severance Hospital, Seoul, Korea. PATIENTS A total of 177 prolactinoma patients who underwent baseline MRI (109 DA responders and 68 DA nonresponders) were allocated to the training (n = 141) and test (n = 36) sets. Radiomic features (n = 107) were extracted from coronal T2-weighed MRIs. After feature selection, single models (random forest, light gradient boosting machine, extra-trees, quadratic discrimination analysis, and linear discrimination analysis) with oversampling methods were trained to predict the DA response. A soft voting ensemble classifier was used to achieve the final performance. The performance of the classifier was validated in the test set. RESULTS The ensemble classifier showed an area under the curve (AUC) of 0.81 [95% confidence interval (CI), 0.74-0.87] in the training set. In the test set, the ensemble classifier showed an AUC, accuracy, sensitivity, and specificity of 0.81 (95% CI, 0.67-0.96), 77.8%, 78.6%, and 77.3%, respectively. The ensemble classifier achieved the highest performance among all the individual models in the test set. CONCLUSIONS Radiomic features may be useful biomarkers to predict the DA response in prolactinoma patients.
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Affiliation(s)
- Yae Won Park
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
| | - Jihwan Eom
- Department of Computer Science, Yonsei University, Seoul, Korea
| | - Sooyon Kim
- Department of Statistics and Data Science, Yonsei University, Seoul, Korea
| | - Hwiyoung Kim
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Soo Ahn
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
| | - Cheol Ryong Ku
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
- Department of Endocrinology, Yonsei University College of Medicine, Seoul, Korea
| | - Eui Hyun Kim
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
- Department of Endocrinology, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Jig Lee
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Ho Kim
- Department of Neurosurgery, Ewha Womans University College of Medicine, Seoul, Korea
| | - Seung-Koo Lee
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, Korea
- Pituitary Tumor Center, Severance Hospital, Seoul, Korea
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21
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Liu CX, Heng LJ, Han Y, Wang SZ, Yan LF, Yu Y, Ren JL, Wang W, Hu YC, Cui GB. Usefulness of the Texture Signatures Based on Multiparametric MRI in Predicting Growth Hormone Pituitary Adenoma Subtypes. Front Oncol 2021; 11:640375. [PMID: 34307124 PMCID: PMC8294058 DOI: 10.3389/fonc.2021.640375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/16/2021] [Indexed: 01/14/2023] Open
Abstract
Objective To explore the usefulness of texture signatures based on multiparametric magnetic resonance imaging (MRI) in predicting the subtypes of growth hormone (GH) pituitary adenoma (PA). Methods Forty-nine patients with GH-secreting PA confirmed by the pathological analysis were included in this retrospective study. Texture parameters based on T1-, T2-, and contrast-enhanced T1-weighted images (T1C) were extracted and compared for differences between densely granulated (DG) and sparsely granulated (SG) somatotroph adenoma by using two segmentation methods [region of interest 1 (ROI1), excluding the cystic/necrotic portion, and ROI2, containing the whole tumor]. Receiver operating characteristic (ROC) curve analysis was performed to determine the differentiating efficacy. Results Among 49 included patients, 24 were DG and 25 were SG adenomas. Nine optimal texture features with significant differences between two groups were obtained from ROI1. Based on the ROC analyses, T1WI signatures from ROI1 achieved the highest diagnostic efficacy with an AUC of 0.918, the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 85.7, 72.0, 100.0, 100.0, and 77.4%, respectively, for differentiating DG from SG. Comparing with the T1WI signature, the T1C signature obtained relatively high efficacy with an AUC of 0.893. When combining the texture features of T1WI and T1C, the radiomics signature also had a good performance in differentiating the two groups with an AUC of 0.908. In addition, the performance got in all the signatures from ROI2 was lower than those in the corresponding signature from ROI1. Conclusion Texture signatures based on MR images may be useful biomarkers to differentiate subtypes of GH-secreting PA patients.
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Affiliation(s)
- Chen-Xi Liu
- Department of Radiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China.,Functional and Molecular Imaging Key Lab of Shaanxi Province, Xi'an, China
| | - Li-Jun Heng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Yu Han
- Department of Radiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Sheng-Zhong Wang
- Faculty of Medical Technology, Shaanxi University of Traditional Chinese Medicine, Xianyang, China
| | - Lin-Feng Yan
- Department of Radiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China.,Functional and Molecular Imaging Key Lab of Shaanxi Province, Xi'an, China
| | - Ying Yu
- Department of Radiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China.,Functional and Molecular Imaging Key Lab of Shaanxi Province, Xi'an, China
| | | | - Wen Wang
- Department of Radiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China.,Functional and Molecular Imaging Key Lab of Shaanxi Province, Xi'an, China
| | - Yu-Chuan Hu
- Department of Radiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China.,Functional and Molecular Imaging Key Lab of Shaanxi Province, Xi'an, China
| | - Guang-Bin Cui
- Department of Radiology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China.,Functional and Molecular Imaging Key Lab of Shaanxi Province, Xi'an, China
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22
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Akkaya E, Akgun MY, Sebnem Durmaz E, Aydın S, Mefkure Ozkaya H, Comunoglu N, Kizilkilic O, Gazioglu N, Kadioglu P, Tanriover N. T2-weighted magnetic resonance imaging as a novel predictor of surgical remission in newly diagnosed pituitary macroadenomas presenting as acromegaly. J Clin Neurosci 2021; 90:105-111. [PMID: 34275532 DOI: 10.1016/j.jocn.2021.05.058] [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: 03/05/2021] [Revised: 04/21/2021] [Accepted: 05/27/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Any preoperative diagnostic assessment that can predict the success of the operation in acromegaly will provide a positive impact on overall remission rates. The aim of this study is to reveal whether the signal intensity in T2-weighted Magnetic Resonance Imaging can predict postoperative results in acromegaly patients with macroadenoma. METHODS We analyzed our surgical results in regard to T2-weighted images in newly diagnosed consecutive 124 patients with acromegaly, operated between 2014 and 2019. The T2-intensity of the pure somatotroph macroadenomas was correlated with the clinical, radiological, surgical and histopathological characteristics of the acromegaly patients. RESULTS We found a predominance of T2-hyperintensity in our series (45%) and the T2-hypointense pure somatotroph adenomas were detected in only 34% of our patients. Total resection was performed in 72% of newly diagnosed acromegaly patients in this series. Accordingly, total resection was achieved in 69% of the T2-hyperintense group, 77% of the T2-hypointense group and 69% of the T2-isointense group. The surgical remission rates for the T2-hyper-, hypo- and isointense groups were 54.5%, 80.7%, and 68.7%, respectively. The surgical remission rate in the T2-hyperintense group was significantly lower than those of hypo- and isointense groups in newly diagnosed acromegaly patients. CONCLUSIONS This study demonstrates a close relationship between the T2 signal intensity and the surgical remission rates in acromegaly patients with macroadenoma. Preoperative T2-intensity images may predict the probability of post-surgical remission in patients with newly diagnosed acromegaly. Further support fort this idea comes from recent guidelines for acromegaly management in which the potential utility of using T2 intensity to optimize patient management has been emphasized.
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Affiliation(s)
- Enes Akkaya
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Emine Sebnem Durmaz
- Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Seckin Aydın
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hande Mefkure Ozkaya
- Department of Endocrinology and Metabolism, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey; Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nil Comunoglu
- Department of Pathology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Osman Kizilkilic
- Department of Radiology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey; Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nurperi Gazioglu
- Department of Neurosurgery, Faculty of Medicine, T.C Demiroglu Bilim University, Istanbul, Turkey
| | - Pinar Kadioglu
- Department of Endocrinology and Metabolism, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey; Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Necmettin Tanriover
- Department of Neurosurgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey; Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey.
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23
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Magnetic resonance fingerprinting for preoperative differentiation between gonadotroph and non-gonadotroph pituitary macroadenomas. Eur Radiol 2021; 31:8420-8428. [PMID: 33914117 DOI: 10.1007/s00330-021-07950-6] [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: 11/21/2020] [Revised: 02/26/2021] [Accepted: 03/25/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To use magnetic resonance fingerprinting (MRF)-derived T1 and T2 values to differentiate gonadotroph from non-gonadotroph pituitary macroadenomas based on the 2017 World Health Organization classification of pituitary adenomas. METHODS A total of 57 patients with suspected pituitary macroadenomas were enrolled for analyses in this study between May 2018 and January 2020. Conventional magnetic resonance imaging (MRI) and MRF were performed in all patients before surgery using a 3-T MRI scanner. MRF-derived T1 and T2 values were compared between the gonadotroph and non-gonadotroph pituitary macroadenomas using a Mann-Whitney U test. The Knosp classification was used to evaluate cavernous sinus invasion by the adenomas. Receiver operating characteristic analyses were used to determine the diagnostic performance of T1 and T2 values. RESULTS Quantitative T1 and T2 values yielded from MRF of gonadotroph pituitary macroadenomas were significantly higher than those of the non-gonadotroph pituitary macroadenomas (p < 0.001 and = 0.002, respectively). The AUC for the T2 value (0.888) was significantly greater than that for the T1 value (0.742) (p = 0.034). The AUC for combined T1 and T2 values was 0.885. Non-gonadotroph pituitary macroadenomas were more likely to invade the cavernous sinus than gonadotroph pituitary macroadenomas (55% vs 26%, p = 0.026). CONCLUSIONS MRF may help to preoperatively differentiate between gonadotroph and non-gonadotroph pituitary macroadenomas and may be useful in guiding the treatment of these adenomas. KEY POINTS • Somatostatin receptor type 3 is the most abundant receptor subtype in gonadotroph pituitary adenomas. • Magnetic resonance fingerprinting may help to preoperatively differentiate between gonadotroph and non-gonadotroph pituitary macroadenomas. • Magnetic resonance fingerprinting shows potential for guiding the treatment of pituitary macroadenomas.
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24
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Swanson AA, Erickson D, Donegan DM, Jenkins SM, Van Gompel JJ, Atkinson JLD, Erickson BJ, Giannini C. Clinical, biological, radiological, and pathological comparison of sparsely and densely granulated somatotroph adenomas: a single center experience from a cohort of 131 patients with acromegaly. Pituitary 2021; 24:192-206. [PMID: 33074402 DOI: 10.1007/s11102-020-01096-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Growth hormone-producing pituitary adenomas are divided into two clinically relevant histologic subtypes, densely (DG-A) and sparsely (SG-A) granulated. Histologic subtype was evaluated in a large cohort of patients with acromegaly, separating DG-A and SG-A, and correlated with clinicopathological characteristics. METHODS Patients with acromegaly undergoing surgery as initial therapy between 1995 and 2015 were identified. Histologic subtype was determined by keratin expression pattern with CAM5.2 and correlated with clinical and imaging parameters, somatostatin receptor subtype 2 (SST2) expression, post-surgical remission rate, and application of a prognostic scoring system incorporating proliferation and invasiveness. RESULTS One hundred thirty-one patients were included. Tumors were classified as DG-A (75, 57.3%), SG-A (29, 22.1%), intermediate (I-A) (9, 6.9%), and unclassified (18, 13.7%) when CAM5.2 was negative. DG-A and I-A were combined for analysis (DG/I-A) and compared to SG-A. Age, gender, proliferation, and post-surgical remission did not differ. SG-A were larger [2 vs. 1.5 cm (median), p = 0.03], more frequently invasive [65.5% vs. 32.9%, p = 0.004], associated with higher MRI T2-weighted signal ratio [1.01 vs. 0.82 (median), p = 0.01], showed lower SST2 expression (p < 0.0001), and scored higher in the prognostic classification (p = 0.004). Surgical remission occurred in 41.7% DG/I-A and 41.4% SG-A (p = 1.0). On multivariate analysis, absence of invasion (p = 0.009) and lower pre-operative IGF-1 index (p = 0.0002) were associated with post-surgical remission. CONCLUSION CAM5.2 allowed distinction between DG/I-A and SG-A in most but not all cases. Histologic subtype did not predict surgical outcome. Absence of invasion and lower pre-operative IGF-1 index were the only significant predictors of post-surgical remission in this cohort.
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Affiliation(s)
- Amy A Swanson
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | - Dana Erickson
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Diane Mary Donegan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, MN, USA
- Division of Endocrinology, Diabetes and Metabolism, Indiana University, Indianapolis, IN, USA
| | - Sarah M Jenkins
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Caterina Giannini
- Division of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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25
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Kim K, Park YW, Kim D, Ahn SS, Moon JH, Kim EH, Lee EJ, Ku CR. Biochemical Remission after Cabergoline Withdrawal in Hyperprolactinemic Patients with Visible Remnant Pituitary Adenoma. J Clin Endocrinol Metab 2021; 106:e615-e624. [PMID: 33079168 DOI: 10.1210/clinem/dgaa744] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Indexed: 12/13/2022]
Abstract
CONTEXT Dopamine agonists (DAs) are the first-line therapy for prolactinomas. Although pituitary tumors often do not completely disappear, discontinuing DAs in patients with no visible tumor on magnetic resonance imaging is advised. OBJECTIVE To analyze biochemical remission after cabergoline (CAB) withdrawal in patients with visible remnant pituitary tumors. DESIGN Retrospective cohort study. SETTING Severance Hospital. SUBJECTS We identified 734 patients with prolactinomas undergoing CAB therapy for at least 12 months from 2005 to 2018. We selected 44 patients with prolactinomas who discontinued CAB with normal prolactin levels; they were receiving a minimal CAB dose but had visible remnant tumors. RESULTS Median age at diagnosis was 32 (18-58) years, and most patients were women (95.45%). Median treatment duration was 32 (12-120) months. Of 44 patients, 33 continued to have normoprolactinemia, but 11 patients developed hyperprolactinemia after drug withdrawal within 26 (12-97) months. Age, sex, maximal and remnant tumor size, and treatment duration were similar between the groups. The initial prolactin level and chances of cavernous sinus (CS) invasion were higher in the recurrence group. CS invasion at diagnosis was associated with an increased recurrence rate. Although treatment response did not correlate with the initial and final signal intensity assessments, a significant decrease in T2 intensity ratio after 6 months of CAB therapy was observed in the remission group (P = .043). CONCLUSION In patients with visible tumors, the presence of CS invasion at diagnosis may be an unfavorable predictor for biochemical remission after CAB discontinuation.
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Affiliation(s)
- Kyungwon Kim
- Endocrinology, Institute of Endocrine Research, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yae Won Park
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Daham Kim
- Endocrinology, Institute of Endocrine Research, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Soo Ahn
- Department of Radiology and Research Institute of Radiological Science and Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ju Hyung Moon
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eui Hyun Kim
- Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Jig Lee
- Endocrinology, Institute of Endocrine Research, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Cheol Ryong Ku
- Endocrinology, Institute of Endocrine Research, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Nista F, Corica G, Castelletti L, Khorrami K, Campana C, Cocchiara F, Zoppoli G, Prior A, Rossi DC, Zona G, Ferone D, Gatto F. Clinical and Radiological Predictors of Biochemical Response to First-Line Treatment With Somatostatin Receptor Ligands in Acromegaly: A Real-Life Perspective. Front Endocrinol (Lausanne) 2021; 12:677919. [PMID: 34025586 PMCID: PMC8139627 DOI: 10.3389/fendo.2021.677919] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/19/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND First-generation somatostatin receptor ligands (fg-SRLs) represent the first-line medical treatment for acromegaly, recommended in patients with persistent disease after neurosurgery, or when surgical approach is not feasible. Despite the lack of strong recommendations from guidelines and consensus statements, data from national Registries report an increasing use of medical therapy as first-line treatment in acromegaly. OBJECTIVE We retrospectively evaluated the potential role of a large number of clinical and radiological parameters in predicting the biochemical response to 6-month treatment with fg-SRLs, in a cohort of naïve acromegaly patients referred to a single tertiary center for pituitary diseases. METHODS Univariable and multivariable logistic regression and linear regression analyses were performed. Biochemical response was defined based on IGF-1 levels, represented as both categorical (tight control, control, >50% reduction) and continuous (linear % reduction) variables. RESULTS Fifty-one patients (33 females, median age 57 years) were included in the study. At univariable logistic regression analysis, we found that younger age (≤ 40 years; OR 0.04, p=0.045) and higher BMI (OR 0.866, p=0.034) were associated with a lower chance of achieving >50% IGF-1 reduction. On the contrary, higher IGF-1 xULN values at diagnosis (OR 2.304, p=0.007) and a T2-hypointense tumor (OR 18, p=0.017) were associated with a significantly higher likelihood of achieving >50% IGF-1 reduction after SRL therapy. Of note, dichotomized age, IGF1 xULN at diagnosis, and T2-hypointense signal of the tumor were retained as significant predictors by our multivariable logistic regression model. Furthermore, investigating the presence of predictors to the linear % IGF-1 reduction, we found a negative association with younger age (≤ 40 years; β -0.533, p<0.0001), while a positive association was observed with both IGF-1 xULN levels at diagnosis (β 0.330, p=0.018) and the presence of a T2-hypointense pituitary tumor (β 0.466, p=0.019). All these variables were still significant predictors at multivariable analysis. CONCLUSIONS Dichotomized age, IGF-1 levels at diagnosis, and tumor T2-weighted signal are reliable predictors of both >50% IGF-1 reduction and linear % IGF-1 reduction after 6 month fg-SRL treatment in naïve acromegaly patients. These parameters should be considered in the light of an individualized treatment for acromegaly patients.
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Affiliation(s)
- Federica Nista
- Endocrinology Unit, Department of Internal Medicine and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Giuliana Corica
- Endocrinology Unit, Department of Internal Medicine and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | | | - Keyvan Khorrami
- Endocrinology Unit, Department of Internal Medicine and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Claudia Campana
- Endocrinology Unit, Department of Internal Medicine and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Francesco Cocchiara
- Endocrinology Unit, Department of Internal Medicine and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
| | - Gabriele Zoppoli
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessandro Prior
- Division of Neurosurgery, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Diego Criminelli Rossi
- Division of Neurosurgery, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianluigi Zona
- Division of Neurosurgery, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Diego Ferone
- Endocrinology Unit, Department of Internal Medicine and Center of Excellence for Biomedical Research, University of Genoa, Genoa, Italy
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- *Correspondence: Diego Ferone, orcid.org/0000-0002-1410-6143
| | - Federico Gatto
- Endocrinology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Pérez-López C, Palpán AJ, Saez-Alegre M, Zamarrón Á, Alfonso C, Álvarez-Escola C, Isla A. Volumetric Study of Nonfunctioning Pituitary Adenomas: Predictors of Gross Total Resection. World Neurosurg 2020; 147:e206-e214. [PMID: 33309892 DOI: 10.1016/j.wneu.2020.12.020] [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: 07/06/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Despite the efforts made to determine the achieved resection grade after pituitary adenoma surgery, there is a high level of disagreement among all the available classifications and measurement methods used. Our objective is to identify the factors that preoperatively could predict a gross total resection (GTR) of a clinically nonfunctioning pituitary adenoma through an endoscopic endonasal approach. METHODS Across 100 surgeries, we analyzed epidemiologic and clinical data, radiologic relevant data, extent of resection (EOR), and postoperative outcomes. The EOR was measured objectively through an accurate volumetric analysis. RESULTS The median presurgical volume was 8.58 cm3 (range, 0.5-58 cm3), the median maximum diameter was 27.3 mm (range, 7-67 mm), and the Knosp grade was 0 in 1 patient, 1 in 23%, 2 in 31%, 3 in 23% and 4 in 22% of patients. In the multivariate logistic regression analysis, we found 3 factors that significantly predicted the chances of a successful GTR: previous sellar surgery, Knosp grade, and tumor signal in the T2-weighted magnetic resonance imaging scan. Another 10 radiologic variables were analyzed and had no effect on the EOR. CONCLUSIONS Knosp grade (P < 0.001; odds ratio [OR], 25.65; 95% confidence interval, 7.19-91.52) is the most predictive factor for performing a GTR of nonfunctioning pituitary adenoma. Previous pituitary surgery (P = 0.023; OR, 5.81) and an isointense T2-weighted signal (P = 0.034; OR, 3.75) also negatively influenced the chances of GTR. We highlight the influence of T2-weighted signal in the chances of GTR.
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Affiliation(s)
- Carlos Pérez-López
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain.
| | - Alexis J Palpán
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - Miguel Saez-Alegre
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - Álvaro Zamarrón
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
| | - Carolina Alfonso
- Department of Otorhinolaryngology, Hospital Universitario La Paz, Madrid, Spain
| | | | - Alberto Isla
- Department of Neurosurgery, Hospital Universitario La Paz, Madrid, Spain
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Giustina A, Barkhoudarian G, Beckers A, Ben-Shlomo A, Biermasz N, Biller B, Boguszewski C, Bolanowski M, Bollerslev J, Bonert V, Bronstein MD, Buchfelder M, Casanueva F, Chanson P, Clemmons D, Fleseriu M, Formenti AM, Freda P, Gadelha M, Geer E, Gurnell M, Heaney AP, Ho KKY, Ioachimescu AG, Lamberts S, Laws E, Losa M, Maffei P, Mamelak A, Mercado M, Molitch M, Mortini P, Pereira AM, Petersenn S, Post K, Puig-Domingo M, Salvatori R, Samson SL, Shimon I, Strasburger C, Swearingen B, Trainer P, Vance ML, Wass J, Wierman ME, Yuen KCJ, Zatelli MC, Melmed S. Multidisciplinary management of acromegaly: A consensus. Rev Endocr Metab Disord 2020; 21:667-678. [PMID: 32914330 PMCID: PMC7942783 DOI: 10.1007/s11154-020-09588-z] [Citation(s) in RCA: 173] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/18/2022]
Abstract
The 13th Acromegaly Consensus Conference was held in November 2019 in Fort Lauderdale, Florida, and comprised acromegaly experts including endocrinologists and neurosurgeons who considered optimal approaches for multidisciplinary acromegaly management. Focused discussions reviewed techniques, results, and side effects of surgery, radiotherapy, and medical therapy, and how advances in technology and novel techniques have changed the way these modalities are used alone or in combination. Effects of treatment on patient outcomes were considered, along with strategies for optimizing and personalizing therapeutic approaches. Expert consensus recommendations emphasize how best to implement available treatment options as part of a multidisciplinary approach at Pituitary Tumor Centers of Excellence.
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Affiliation(s)
- Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital, Ospedale San Raffaele, Via Olgettina, 58, 20132, Milan, Italy.
| | - Garni Barkhoudarian
- Pacific Pituitary Disorders Center, Pacific Neuroscience Institute, Santa Monica, CA, USA
| | - Albert Beckers
- Department of Endocrinology, University of Liège, Liège, Belgium
| | - Anat Ben-Shlomo
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nienke Biermasz
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Beverly Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cesar Boguszewski
- SEMPR, Endocrine Division, Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Department of Endocrinology, University of Oslo, Oslo, Norway
| | - Vivien Bonert
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo, Sao Paulo, Brazil
| | - Michael Buchfelder
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - Felipe Casanueva
- Division of Endocrinology, Santiago de Compostela University and Ciber OBN, Santiago de Compostela, Spain
| | - Philippe Chanson
- Centre de Référence des Maladies Rares de l'Hypophyse and Université Paris-Saclay, Univ. Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, Paris, France
| | - David Clemmons
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Maria Fleseriu
- Departments of Medicine and Neurological Surgery, Pituitary Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital, Ospedale San Raffaele, Via Olgettina, 58, 20132, Milan, Italy
| | - Pamela Freda
- Department of Medicine, Columbia University, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Monica Gadelha
- Neuroendocrinology Research Center/Endocrinology Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Mark Gurnell
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Anthony P Heaney
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Ken K Y Ho
- The Garvan Institute of Medical Research, St. Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Adriana G Ioachimescu
- Department of Neurosurgery and Medicine, Division of Endocrinology, Metabolism and Lipids, Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Edward Laws
- Pituitary/Neuroendocrine Center, Brigham & Women's Hospital, Boston, MA, USA
| | - Marco Losa
- Department of Neurosurgery, San Raffaele University Health Institute Milan, Milan, Italy
| | - Pietro Maffei
- Department of Medicine, Padua University Hospital, Padua, Italy
| | - Adam Mamelak
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Moises Mercado
- Medical Research Unit in Endcrine Diseases, Hospital de Especialidades, Centro Médico Nacional, Siglo XXI, IMSS, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Mark Molitch
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Pietro Mortini
- Department of Neurosurgery, San Raffaele University Health Institute Milan, Milan, Italy
| | - Alberto M Pereira
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Kalmon Post
- Department of Neurosurgery, Medicine, Mount Sinai Health System, New York, NY, USA
| | - Manuel Puig-Domingo
- Germans Trias i Pujol Research Institute, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism and Pituitary Center, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Susan L Samson
- Departments of Medicine and Neurosurgery, Baylor St. Luke's Pituitary Center, Baylor College of Medicine, Houson, TX, USA
| | - Ilan Shimon
- Endocrine Institute, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Christian Strasburger
- Department of Medicine for Endocrinology, Diabetes and Nutritional Medicine, Charité Universitätsmedizin, Berlin, Germany
| | - Brooke Swearingen
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Peter Trainer
- Department of Endocrinology, The Christie NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Mary L Vance
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - John Wass
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Margaret E Wierman
- Pituitary, Adrenal and Neuroendocrine Tumor Program, Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Kevin C J Yuen
- Barrow Pituitary Center and Neuroendocrinology Clinic, Barrow Neurological Institute, University of Arizona College of Medicine, Creighton School of Medicine, Phoenix, AZ, USA
| | - Maria Chiara Zatelli
- Section of Endocrinology & Internal Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Shlomo Melmed
- Pituitary Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Varlamov EV, Wood MD, Netto JP, Thiessen J, Kim J, Lim DST, Yedinak CG, Banskota S, Cetas JS, Fleseriu M. Cystic appearance on magnetic resonance imaging in bihormonal growth hormone and prolactin tumors in acromegaly. Pituitary 2020; 23:672-680. [PMID: 32870441 DOI: 10.1007/s11102-020-01075-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
PURPOSE To investigate demographic, imaging and laboratory characteristics, and treatment outcomes of acromegaly patients who have bihormonal (BA) growth hormone (GH) and prolactin (PRL) immunoreactive adenomas compared to patients who have densely granulated GH adenomas (DGA) and sparsely granulated GH adenomas (SGA). METHODS Retrospective review of single-center surgically treated acromegaly patients; pathology was analyzed by a single neuropathologist using 2017 WHO criteria. Preoperative magnetic resonance imaging was assessed to evaluate tumor size, cystic component, invasion and T2 signal intensity. RESULTS Seventy-seven patients; 19 BA (9 mammosomatotroph and 10 mixed GH and PRL adenomas) were compared with 30 DGA, and 28 SGA. Patients with BA were older than SGA (49.6 vs 38.5 years, p = 0.035), had a higher IGF-1 index (3.3 vs 2.3, p = 0.040) and tumors were less frequently invasive (15.8% vs 57.1%, p = 0.005). BA more frequently had a cystic component on MRI than both SGA and DGA (52.6% vs 14.3%, and 22%, p = 0.005 and 0.033, respectively). When all histological types were combined, biochemical remission postoperatively was more common in non-cystic than cystic tumors (50% vs 22.5%, p = 0.042). Somatostatin receptor ligand response rate was 66.7%, 90.9% and 37.5% in BA, DGA and SGA patients, respectively (p = 0.053). CONCLUSION Imaging characteristics are an increasingly important adenoma behavior determinant. An adenoma cystic component may suggest that a GH adenoma is a BA. Cystic tumors exhibited lower rates of surgical remission in this series; therefore, optimized individual patient treatment is needed, as patients could be candidates for primary medical treatment.
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Affiliation(s)
- Elena V Varlamov
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 South Bond Ave, Portland, OR, 97239, USA
| | - Matthew D Wood
- Department of Pathology, Oregon Health & Science University, Portland, OR, USA
- Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Joao Prola Netto
- Department of Radiology, Oregon Health & Science University, Portland, OR, USA
| | - Jaclyn Thiessen
- Department of Radiology, Oregon Health & Science University, Portland, OR, USA
| | - Jung Kim
- Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 South Bond Ave, Portland, OR, 97239, USA
| | - Dawn Shao Ting Lim
- Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 South Bond Ave, Portland, OR, 97239, USA
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Christine G Yedinak
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 South Bond Ave, Portland, OR, 97239, USA
| | - Swechya Banskota
- Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 South Bond Ave, Portland, OR, 97239, USA
| | - Justin S Cetas
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 South Bond Ave, Portland, OR, 97239, USA
| | - Maria Fleseriu
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 South Bond Ave, Portland, OR, 97239, USA.
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Mooney MA, Sarris CE, Zhou JJ, Barkhoudarian G, Chicoine MR, Fernandez-Miranda JC, Gardner PA, Hardesty DA, Jahnke H, Kelly DF, Liebelt BD, Mayberg MR, Prevedello DM, Sfondouris J, Sheehy JP, Chandler JP, Yuen KCJ, White WL, Little AS. Proposal and Validation of a Simple Grading Scale (TRANSSPHER Grade) for Predicting Gross Total Resection of Nonfunctioning Pituitary Macroadenomas After Transsphenoidal Surgery. Oper Neurosurg (Hagerstown) 2020; 17:460-469. [PMID: 30649445 DOI: 10.1093/ons/opy401] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 12/31/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND A simple, reliable grading scale to better characterize nonfunctioning pituitary adenomas (NFPAs) preoperatively has potential for research and clinical applications. OBJECTIVE To develop a grading scale from a prospective multicenter cohort of patients that accurately and reliably predicts the likelihood of gross total resection (GTR) after transsphenoidal NFPA surgery. METHODS Extent-of-resection (EOR) data from a prospective multicenter study in transsphenoidal NFPA surgery were analyzed (TRANSSPHER study; ClinicalTrials.gov NCT02357498). Sixteen preoperative radiographic magnetic resonance imaging (MRI) tumor characteristics (eg, tumor size, invasion measures, tumor signal characteristics, and parameters impacting surgical access) were evaluated to determine EOR predictors, to calculate receiver-operating characteristic curves, and to develop a grading scale. A separate validation cohort (n = 165) was examined to assess the scale's performance and inter-rater reliability. RESULTS Data for 222 patients from 7 centers treated by 15 surgeons were analyzed. Approximately one-fifth of patients (18.5%; 41 of 222) underwent subtotal resection (STR). Maximum tumor diameter > 40 mm; nodular tumor extension through the diaphragma into the frontal lobe, temporal lobe, posterior fossa, or ventricle; and Knosp grades 3 to 4 were identified as independent STR predictors. A grading scale (TRANSSPHER grade) based on a combination of these 3 features outperformed individual variables in predicting GTR (AUC, 0.732). In a validation cohort, the scale exhibited high sensitivity and specificity (AUC, 0.779) and strong inter-rater reliability (kappa coefficient, 0.617). CONCLUSION This simple, reliable grading scale based on preoperative MRI characteristics can be used to better characterize NFPAs for clinical and research purposes and to predict the likelihood of achieving GTR.
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Affiliation(s)
- Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Christina E Sarris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - James J Zhou
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Garni Barkhoudarian
- Pacific Neuroscience Institute and Pituitary Disorders Center, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Michael R Chicoine
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Douglas A Hardesty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Heidi Jahnke
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Daniel F Kelly
- Pacific Neuroscience Institute and Pituitary Disorders Center, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, California
| | - Brandon D Liebelt
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Marc R Mayberg
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Daniel M Prevedello
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John Sfondouris
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - John P Sheehy
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - James P Chandler
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kevin C J Yuen
- Department of Neurology and Barrow Neuroendocrinology Clinic, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - William L White
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew S Little
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Varlamov EV, Hinojosa-Amaya JM, Fleseriu M. Magnetic resonance imaging in the management of prolactinomas; a review of the evidence. Pituitary 2020; 23:16-26. [PMID: 31659622 DOI: 10.1007/s11102-019-01001-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
PURPOSE This review aimed to evaluate data on the use of magnetic resonance imaging in the management of prolactinomas. METHODS Recent literature about prolactinoma behavior and magnetic resonance imaging in the management of prolactinomas is reviewed. RESULTS A review of evidence regarding prolactinoma pituitary MRI follow-up; techniques and sequences, recent data on possible gadolinium retention, the role and a review of T2-weighted images in the identification of prolactinomas and frequently encountered clinical scenarios, as well as MRI correlation with prolactin secretion, tumor growth and prediction of response to medical therapy are presented. CONCLUSION The underlying decision to perform serial imaging in prolactinoma patients should be individualized on a case-by-case basis. Future studies should focus on alternative imaging methods and/or contract agents.
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Affiliation(s)
- Elena V Varlamov
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 SW Bond Ave, Portland, OR, 97239, USA
| | - José Miguel Hinojosa-Amaya
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 SW Bond Ave, Portland, OR, 97239, USA
- Endocrinology Division, Department of Medicine, Hospital Universitario "Dr. José E. González", Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, Mexico
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University, Mail Code CH8N, 3303 SW Bond Ave, Portland, OR, 97239, USA.
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Lv L, Jiang Y, Yin S, Hu Y, Chen C, Ma W, Jiang S, Zhou P. Mammosomatotroph and mixed somatotroph-lactotroph adenoma in acromegaly: a retrospective study with long-term follow-up. Endocrine 2019; 66:310-318. [PMID: 31368083 DOI: 10.1007/s12020-019-02029-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Although well-documented from pathological aspect, the clinical features and outcomes of acromegaly with mammosomatotroph (MSA) and mixed somatotroph-lactotroph adenoma (MSLA) are seldom reported. Thus, in this study, we analyzed and reported the clinical data about MSAs and MSLAs. METHODS We retrospectively reviewed medical records of patients with acromegaly in our institution during 2008-2017. Growth hormone (GH)-secreting adenomas were categorized into pure somatotroph adenoma (PSA), MSA and MSLA based on inclusion and exclusion criteria. Clinical information and treatment outcomes during follow-up were analyzed by univariate and multivariate methods. RESULTS Among 94 patients within this cohort, PSAs, MSAs, and MSLAs accounted for 53, 28 and 13 cases, respectively. MSAs often had smaller size, lower frequency of cavernous sinus invasion and higher gross total resection (GTR) rate. MSLAs were characterized by bigger tumor size, higher frequency of preoperative hyperprolactinemia, and lower GTR rate. Thus, MSLAs had worse long-term biological remission rate than MSAs and PSAs (15.4% vs. 50.0% and 26.4%, p = 0.0371). Gender (male, OR = 0.784, p = 0.011) and tumor volume (OR = 0.784, p = 0.020) were independent predictors for long-term biological remission in binary logistic regression. Subgroup analyses indicated that postoperative nadir GH level (GH-7, HR = 1.242, p = 0.001) was the only risk factor for tumor recurrence for patients with GTR. CONCLUSIONS Our results provide valuable insights into clinicopathological features of acromegaly. MSAs were relatively smaller lesions with better prognosis. MSLAs were more aggressive with massive size, invasiveness and preoperative hyperprolactinemia. Tumor size and GH-7 were significantly associated with biological remission and tumor relapse after GTR, respectively.
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Affiliation(s)
- Liang Lv
- Department of Neurosurgery, Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, China
| | - Yong Jiang
- Department of Neurosurgery, Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, China
| | - Senlin Yin
- Department of Neurosurgery, Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, China
| | - Yu Hu
- Department of Neurosurgery, Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, China
| | - Cheng Chen
- Department of Neurosurgery, Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, China
| | - Weichao Ma
- Department of Neurosurgery, Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, China
| | - Shu Jiang
- Department of Neurosurgery, Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, China
| | - Peizhi Zhou
- Department of Neurosurgery, Pituitary Adenoma Multidisciplinary Center, West China Hospital of Sichuan University, Chengdu, China.
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Ezzat S, Caspar-Bell GM, Chik CL, Denis MC, Domingue MÈ, Imran SA, Johnson MD, Lochnan HA, Grégoire Nyomba BL, Prebtani A, Ridout R, Ramirez JAR, Van Uum S. PREDICTIVE MARKERS FOR POSTSURGICAL MEDICAL MANAGEMENT OF ACROMEGALY: A SYSTEMATIC REVIEW AND CONSENSUS TREATMENT GUIDELINE. Endocr Pract 2019; 25:379-393. [PMID: 30657362 DOI: 10.4158/ep-2018-0500] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: To clarify the selection of medical therapy following transsphenoidal surgery in patients with acromegaly, based on growth hormone (GH)/insulin-like growth factor 1 (IGF-1) response and glucometabolic control. Methods: We carried out a systematic literature review on three of the best studied and most practical predictive markers of the response to somatostatin analogues (SSAs): somatostatin receptor (SSTR) expression, tumor morphologic classification, and T2-weighted magnetic resonance imaging (MRI) signal intensity. Additional analyses focused on glucose metabolism in treated patients. Results: The literature survey confirmed significant associations of all three factors with SSA responsiveness. SSTR expression appears necessary for the SSA response; however, it is not sufficient, as approximately half of SSTR2-positive tumors failed to respond clinically to first-generation SSAs. MRI findings (T2-hypo-intensity) and a densely granulated phenotype also correlate with SSA efficacy, and are advantageous as predictive markers relative to SSTR expression alone. Glucometabolic control declines with SSA monotherapy, whereas GH receptor antagonist (GHRA) monotherapy may restore normoglycemia. Conclusion: We propose a decision tree to guide selection among SSAs, dopamine agonists (DAs), and GHRA for medical treatment of acromegaly in the postsurgical setting. This decision tree employs three validated predictive markers and other clinical considerations, to determine whether SSAs are appropriate first-line medical therapy in the postsurgical setting. DA treatment is favored in patients with modest IGF-1 elevation. GHRA treatment should be considered for patients with T2-hyperintense tumors with a sparsely granulated phenotype and/or low SSTR2 staining, and may also be favored for individuals with diabetes. Prospective analyses are required to test the utility of this therapeutic paradigm. Abbreviations: DA = dopamine agonist; DG = densely granulated; GH = growth hormone; GHRA = growth hormone receptor antagonist; HbA1c = glycated hemoglobin; IGF-1 = insulin-like growth factor-1; MRI = magnetic resonance imaging; SG = sparsely granulated; SSA = somatostatin analogue; SSTR = somatostatin receptor.
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34
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Liu W, Zahr RS, McCartney S, Cetas JS, Dogan A, Fleseriu M. Clinical outcomes in male patients with lactotroph adenomas who required pituitary surgery: a retrospective single center study. Pituitary 2018; 21:454-462. [PMID: 29936681 DOI: 10.1007/s11102-018-0898-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Lactotroph adenomas (LA) are the most frequently encountered pituitary tumors. Although more frequently observed in women, LAs in men were recently included in a more aggressive category regardless of histological grading, by the WHO. We aimed to perform a rigorous retrospective review of a single center's pre-operative evaluation, patient characteristics and outcomes of male LAs patients requiring pituitary surgery. METHODS A retrospective review, over 11 years, of patients who underwent resection of a pituitary adenoma at a single center was conducted. Predictors of persistent disease in male LAs patients along with a comparison to predictors of silent corticotroph adenomas (SCAs) patients who also underwent surgery at the center was also conducted. RESULTS Thirty-one male patients with LAs were identified. When compared to SCAs patients, LAs male patients were younger (41 vs. 50 years of age, p = 0.01). Men with LAs had more invasive tumors (75% vs. 44.7% p = 0.02). More LAs in men had residual tumor after surgery than patients with SCA (92.6% vs. 42.1%, p < 0.001). Male patients with LAs and patients with SCA had similar rates of requiring additional surgery (28.9% vs. 24.1%, p = NS) and radiation therapy (18.4% vs. 19.4%, p = NS). CONCLUSIONS High rates of DA resistance, invasive tumors and postoperative residual disease in male patients with LA who required surgery are shown. Surgery improved optic chiasm compression, PRL level and central hypogonadism but, not surprisingly, failed to normalize other pituitary hormones and/or eliminate need for DA therapy.
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Affiliation(s)
- Winnie Liu
- Department of Medicine, Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Roula Shraiky Zahr
- Department of Medicine, Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA
| | - Shirley McCartney
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Justin S Cetas
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Aclan Dogan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA
| | - Maria Fleseriu
- Department of Medicine, Division of Endocrinology, Diabetes & Clinical Nutrition, Oregon Health & Science University, Portland, OR, USA.
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR, USA.
- Northwest Pituitary Center, Oregon Health & Science University, Portland, OR, USA.
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