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Arlien-Søborg MC, Dal J, Heck A, Stochholm K, Husted E, Feltoft CL, Rasmussen ÅK, Feldt-Rasmussen U, Andreassen M, Klose MC, Nielsen TL, Andersen MS, Christensen LL, Krogh J, Jarlov A, Bollerslev J, Nermoen I, Oksnes M, Dahlqvist P, Olsson T, Berinder K, Hoybye C, Petersson M, Akerman AK, Wahlberg J, Ekman B, Engstrom BE, Johannsson G, Ragnarsson O, Olsson D, Sigurjónsdóttir HÁ, Fougner SL, Matikainen N, Vehkavaara S, Metso S, Jaatinen P, Hämäläinen P, Rintamäki R, Yliaska I, Immonen H, Mäkimattila S, Cederberg-Tamminen H, Viukari M, Nevalainen P, Nuutila P, Schalin-Jäntti C, Burman P, Jørgensen JOL. Acromegaly management in the Nordic countries: A Delphi consensus survey. Clin Endocrinol (Oxf) 2024; 101:263-273. [PMID: 38865284 DOI: 10.1111/cen.15095] [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: 02/19/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE Acromegaly is associated with increased morbidity and mortality if left untreated. The therapeutic options include surgery, medical treatment, and radiotherapy. Several guidelines and recommendations on treatment algorithms and follow-up exist. However, not all recommendations are strictly evidence-based. To evaluate consensus on the treatment and follow-up of patients with acromegaly in the Nordic countries. METHODS A Delphi process was used to map the landscape of acromegaly management in Denmark, Sweden, Norway, Finland, and Iceland. An expert panel developed 37 statements on the treatment and follow-up of patients with acromegaly. Dedicated endocrinologists (n = 47) from the Nordic countries were invited to rate their extent of agreement with the statements, using a Likert-type scale (1-7). Consensus was defined as ≥80% of panelists rating their agreement as ≥5 or ≤3 on the Likert-type scale. RESULTS Consensus was reached in 41% (15/37) of the statements. Panelists agreed that pituitary surgery remains first line treatment. There was general agreement to recommend first-generation somatostatin analog (SSA) treatment after failed surgery and to consider repeat surgery. In addition, there was agreement to recommend combination therapy with first-generation SSA and pegvisomant as second- or third-line treatment. In more than 50% of the statements, consensus was not achieved. Considerable disagreement existed regarding pegvisomant monotherapy, and treatment with pasireotide and dopamine agonists. CONCLUSION This consensus exploration study on the management of patients with acromegaly in the Nordic countries revealed a relatively large degree of disagreement among experts, which mirrors the complexity of the disease and the shortage of evidence-based data.
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Affiliation(s)
- Mai C Arlien-Søborg
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jakob Dal
- Department of Endocrinology, Aalborg University Hospital, Aarhus, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | | | - Kirstine Stochholm
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Eigil Husted
- Department of Endocrinology, Aalborg University Hospital, Aarhus, Denmark
| | | | | | | | | | | | | | | | | | - Jesper Krogh
- Copenhagen University Hospital, Kobenhavn, Denmark
| | - Anne Jarlov
- Copenhagen University Hospital, Kobenhavn, Denmark
| | | | | | | | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University and Norrlands University Hospital, Umea, Sweden
| | - Tommy Olsson
- Department of Public Health and Clinical Medicine, Umeå University and Norrlands University Hospital, Umea, Sweden
| | | | | | | | - Anna-Karin Akerman
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Sweden
- Department of Medicine, Örebro University Hospital, Örebro, Sweden
| | | | - Bertil Ekman
- Department of Endocrinology and the Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | - Gudmundur Johannsson
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg & Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Daniel Olsson
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg & Sahlgrenska University Hospital, Gothenburg, Sweden
- Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Helga Ágústa Sigurjónsdóttir
- The National University Hospital of Iceland, Gothenburg, Iceland
- School of Medicine, University of Iceland, Reykjavik, Iceland
| | - Stine Lyngvi Fougner
- Department of Endocrinology, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | | | | | - Saara Metso
- Tampere University Hospital, Tampere, Finland
| | | | | | | | | | | | | | | | | | | | | | | | - Pia Burman
- Skåne University Hospital, Lund University, Malmo, Sweden
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Shafiq I, Williams ZR, Vates GE. Advancement in perioperative management of pituitary adenomas-Current concepts and best practices. J Neuroendocrinol 2024:e13427. [PMID: 38964869 DOI: 10.1111/jne.13427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/30/2024] [Accepted: 06/16/2024] [Indexed: 07/06/2024]
Abstract
Pituitary adenomas are very common representing 18.1% of all brain tumors and are the second most common brain pathology. Transsphenoidal surgery is the mainstay of treatment for all pituitary adenomas except for prolactinomas which are primarily treated medically with dopamine agonists. A thorough endocrine evaluation of pituitary adenoma preoperatively is crucial to identify hormonal compromise caused by the large sellar mass, identifying prolactin-producing tumors and comorbidities associated with Cushing and acromegaly to improve patient care and outcome. Transsphenoidal surgery is relatively safe in the hands of experienced surgeons, but still carries a substantial risk of causing hypopituitarism that required close follow-up in the immediate postoperative period to decrease mortality. A multidisciplinary team approach with endocrinologists, ophthalmologists, and neurosurgeons is the cornerstone in the perioperative management of pituitary adenomas.
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Affiliation(s)
- Ismat Shafiq
- Division of Endocrinology, Diabetes, and Metabolism, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Zoë R Williams
- Department of Ophthalmology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - G Edward Vates
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Tsuneoka H, Tosaka M, Yamaguchi R, Tanaka Y, Mukada N, Shimauchi-Ohtaki H, Aihara M, Shimizu T, Yoshimoto Y. The Significance of the Intercarotid Distances for Transsphenoidal Pituitary Surgery: A Magnetic Resonance Imaging Study. World Neurosurg 2023; 175:e704-e712. [PMID: 37044207 DOI: 10.1016/j.wneu.2023.04.009] [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: 03/04/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023]
Abstract
OBJECTIVE We performed magnetic resonance imaging (MRI) to analyze the distance between the left and right internal carotid arteries (ICD) around pituitary tumors for transsphenoidal surgery (TSS). METHODS Measurements were performed using thin slice T2-weighted MRI, and/or time-of-flight (TOI) MR angiography imaging for 64 nonfunctioning pituitary neuroendocrine tumors (NF-pitNETs), 22 growth hormone-producing pitNETs (GH producing pitNETs), and 46 normal controls. We measured the ICD at 3 anatomic levels: at the distal dural ring (ICD-A); at the most concave point of the C4-C5 bend (ICD-B); and at the most convex point of the C4 bend (ICD-C). Additionally, we measured the sagittal distance between the tuberculum selle and the junction of the sellar floor and clivus on the midsagittal MRI (TS-C). RESULTS We found that ICD-B was the longest and that ICD-A was the shortest among the 3 distance parameters in all groups (P < 0.001). The comparison of the groups revealed that the NF-pitNET group had longer distances than the normal control group at all ICDs (P < 0.001). The GH producing pitNET group had longer distance than the normal control group at ICD-B (P < 0.001). Tumor volume was correlated with ICD-A and ICD-B in the NF-pitNET, and was correlated with ICD-C in the GH producing pitNET group. CONCLUSIONS Among the distance parameters, ICD-B is the longest, and was approximately twice the width of the TS-C. The shape of the sella is an ellipse that is widest in the lateral dimension in TSS. A horizontal based dural incision may be more rational than a conventional X-shaped dural incision.
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Affiliation(s)
- Haruka Tsuneoka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masahiko Tosaka
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yukitaka Tanaka
- Department of Neurosurgery, National Hospital Organization Takasaki General Medical Center, Takasaki, Gunma, Japan
| | - Naoto Mukada
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hiroya Shimauchi-Ohtaki
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Flowers KC, Shipman KE. Pitfalls in the Diagnosis and Management of Hypercortisolism (Cushing Syndrome) in Humans; A Review of the Laboratory Medicine Perspective. Diagnostics (Basel) 2023; 13:diagnostics13081415. [PMID: 37189516 DOI: 10.3390/diagnostics13081415] [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: 02/21/2023] [Revised: 03/28/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Biochemical confirmation of a diagnosis of hypercortisolism (Cushing syndrome) is vital to direct further investigations, especially given the overlap with non-autonomous conditions, such as pseudo-Cushing, and the morbidity associated with missed diagnoses. A limited narrative review was performed focusing on the laboratory perspective of the pitfalls of making a biochemical diagnosis of hypercortisolism in those presenting with presumed Cushing syndrome. Although analytically less specific, immunoassays remain cheap, quick, and reliable in most situations. Understanding cortisol metabolism can help with patient preparation, specimen selection (e.g., consideration of urine or saliva for those with possible elevations of cortisol binding globulin concentration), and method selection (e.g., mass spectrometry if there is a high risk of abnormal metabolites). Although more specific methods may be less sensitive, this can be managed. The reduction in cost and increasing ease of use makes techniques such as urine steroid profiles and salivary cortisone of interest in future pathway development. In conclusion, the limitations of current assays, particularly if well understood, do not impede diagnosis in most cases. However, in complex or borderline cases, there are other techniques to consider to aid in the confirmation of hypercortisolism.
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Affiliation(s)
- Kade C Flowers
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
| | - Kate E Shipman
- Department of Clinical Chemistry, University Hospitals Sussex NHS Trust, Worthing BN11 2DH, UK
- Department of Medical Education, Brighton and Sussex Medical School, University of Sussex, Falmer Campus, Brighton BN1 9PX, UK
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Tomkins M, Lawless S, Martin-Grace J, Sherlock M, Thompson CJ. Diagnosis and Management of Central Diabetes Insipidus in Adults. J Clin Endocrinol Metab 2022; 107:2701-2715. [PMID: 35771962 PMCID: PMC9516129 DOI: 10.1210/clinem/dgac381] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Indexed: 11/19/2022]
Abstract
Central diabetes insipidus (CDI) is a clinical syndrome which results from loss or impaired function of vasopressinergic neurons in the hypothalamus/posterior pituitary, resulting in impaired synthesis and/or secretion of arginine vasopressin (AVP). AVP deficiency leads to the inability to concentrate urine and excessive renal water losses, resulting in a clinical syndrome of hypotonic polyuria with compensatory thirst. CDI is caused by diverse etiologies, although it typically develops due to neoplastic, traumatic, or autoimmune destruction of AVP-synthesizing/secreting neurons. This review focuses on the diagnosis and management of CDI, providing insights into the physiological disturbances underpinning the syndrome. Recent developments in diagnostic techniques, particularly the development of the copeptin assay, have improved accuracy and acceptability of the diagnostic approach to the hypotonic polyuria syndrome. We discuss the management of CDI with particular emphasis on management of fluid intake and pharmacological replacement of AVP. Specific clinical syndromes such as adipsic diabetes insipidus and diabetes insipidus in pregnancy as well as management of the perioperative patient with diabetes insipidus are also discussed.
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Affiliation(s)
- Maria Tomkins
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sarah Lawless
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Julie Martin-Grace
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chris J Thompson
- Correspondence: Chris Thompson, Academic Department of Endocrinology, Beaumont Hospital and Royal College of Surgeons in Ireland, Dublin, Ireland.
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Inder WJ, Jang C. Treatment of Prolactinoma. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1095. [PMID: 36013562 PMCID: PMC9413135 DOI: 10.3390/medicina58081095] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 05/14/2023]
Abstract
Prolactinomas are the commonest form of pituitary neuroendocrine tumor (PitNET), representing approximately half of such tumors. Dopamine agonists (DAs) have traditionally been the primary treatment for the majority of prolactinomas, with surgery considered the second line. The aim of this review is to examine the historical and modern management of prolactinomas, including medical therapy with DAs, transsphenoidal surgery, and multimodality therapy for the treatment of aggressive prolactinomas and metastatic PitNETs, with an emphasis on the efficacy, safety, and future directions of current therapeutic modalities. DAs have been the mainstay of prolactinoma management since the 1970s, initially with bromocriptine and more recently with cabergoline. Cabergoline normalizes prolactin in up to 85% of patients and causes tumor shrinkage in up to 80%. Primary surgical resection of microprolactinomas and enclosed macroprolactinomas performed by experienced pituitary neurosurgeons have similar remission rates to cabergoline. Aggressive prolactinomas and metastatic PitNETS should receive multimodality therapy including high dose cabergoline, surgery, radiation therapy (preferably using stereotactic radiosurgery where suitable), and temozolomide. DAs remain a reliable mode of therapy for most prolactinomas but results from transsphenoidal surgery in expert hands have improved considerably over the last one to two decades. Surgery should be strongly considered as primary therapy, particularly in the setting of microprolactinomas, non-invasive macroprolactinomas, or prior to attempting pregnancy, and has an important role in the management of DA resistant and aggressive prolactinomas.
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Affiliation(s)
- Warrick J. Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba 4102, Australia
- Academy for Medical Education, Faculty of Medicine, The University of Queensland, Herston 4029, Australia
| | - Christina Jang
- Department of Endocrinology and Diabetes, Royal Brisbane and Women’s Hospital, Herston 4029, Australia
- Faculty of Medicine, The University of Queensland, Herston 4029, Australia
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