Quantitative ultrasound at the hand phalanges in patients with acromegaly

Diagnosis and therapeutic approach to bone health in patients with hypopituitarism

The results of many studies in recent years indicate a significant impact of pituitary function on bone health. The proper function of the pituitary gland has a significant impact on the growth of the skeleton and the appearance of sexual dimorphism. It is also responsible for achieving peak bone mass, which protects against the development of osteoporosis and fractures later in life. It is also liable for the proper remodeling of the skeleton, which is a physiological mechanism managing the proper mechanical resistance of bones and the possibility of its regeneration after injuries. Pituitary diseases causing hypofunction and deficiency of tropic hormones, and thus deficiency of key hormones of effector organs, have a negative impact on the skeleton, resulting in reduced bone mass and susceptibility to pathological fractures. The early appearance of pituitary dysfunction, i.e. in the pre-pubertal period, is responsible for failure to achieve peak bone mass, and thus the risk of developing osteoporosis in later years. This argues for the need for a thorough assessment of patients with hypopituitarism, not only in terms of metabolic disorders, but also in terms of bone disorders. Early and properly performed treatment may prevent patients from developing the bone complications that are so common in this pathology. The aim of this review is to discuss the physiological, pathophysiological, and clinical insights of bone involvement in pituitary disease.

Determinants of skeletal fragility in acromegaly: a systematic review and meta-analysis

PURPOSE

Vertebral fractures (VFs) are a potential complication in acromegaly. However, the etiology of this skeletal fragility is unknown. This review aimed to evaluate the effect of acromegaly on VFs, bone turnover, areal bone mineral density (aBMD), and bone quality/microarchitecture. The effect of disease activity and gonadal status in these determinants of skeletal fragility was also evaluated.

METHODS

Articles published in English until September 6, 2020 on PubMed and Embase that reported at least one determinant of skeletal fragility in acromegalic patients, were included. Odds ratio (OR) to evaluate the risk of VFs and the standardized mean difference (SMD) to evaluate bone turnover, aBMD and bone quality/microarchitecture were calculated.

RESULTS

Fifty-eight studies met eligibility criteria, assembling a total of 2412 acromegalic patients. Of these, 49 studies were included in the meta-analysis. Acromegalic patients, when compared to non-acromegalic patients, had higher risk of VFs [OR 7.00; 95% confidence interval (CI) 2.80-17.52; p < 0.0001], higher bone formation (SMD 1.14; 95% CI 0.69-1.59; p < 0.00001), higher bone resorption (SMD 0.60; 95% CI 0.09-1.10; p = 0.02) and higher aBMD at the femoral neck (SMD 0.36; 95% CI 0.15-0.57; p = 0.0009). No significant differences were found regarding aBMD at lumbar spine. Considering the results of the different techniques evaluating bone quality/microarchitecture, the main reported alterations were a decrease in trabecular bone thickness and density, and an increase in trabecular separation. The presence of active disease and/or hypogonadism were associated with worst results.

CONCLUSION

Patients with acromegaly are at increased risk of VFs, mainly because of deterioration in bone microarchitecture.

Osteoporosis in pituitary diseases: lessons for the clinic

Osteoporosis is a systemic disease characterized by bone mass and density loss leading to fragility fractures. Osteoporosis due to endocrine disorders is an example of secondary osteoporosis. The harmful effects on bones are common in patients harboring pituitary tumors (acromegaly, prolactinoma, Cushing's disease) and suffering from hypopituitarism. Increased fracture risk and high healthcare costs of fractured patients are their consequences. The coexistence of some of these disorders and hypogonadism results in severe osteoporosis. The influence of the certain diseases, their activity and therapy and accompanying hypogonadism on bone turnover, bone mineral density and fracture incidence is presented.

Bone turnover, bone mineral density, and fracture risk in acromegaly: a meta-analysis

CONTEXT

GH excess causes an increase in bone turnover, but the consequences in terms of skeletal fragility have long been uncertain due to the heterogeneity of studies dealing with this topic.

OBJECTIVE

We conducted a meta-analysis of studies examining the effects of acromegaly on bone turnover, bone mineral density (BMD), and fractures. Furthermore, we evaluated the effects of sex, gonadal status, and activity of disease on skeletal end-points in acromegaly.

DATA SOURCES

We conducted MEDLINE and EMBASE systematic searches up to December 31, 2013.

STUDY ELIGIBILITY CRITERIA

Studies conducted in patients with acromegaly and reporting at least one determinant of skeletal fragility.

DATA EXTRACTION AND ANALYSIS

Study design, patient characteristics, interventions, and outcomes were independently extracted by two authors. We calculated the standardized mean difference (SMD) of bone turnover and BMD differences, whereas fractures were presented as relative frequencies in acromegaly and odds ratios between patients and controls.

RESULTS

Forty-one studies fulfilled eligibility criteria and were therefore selected for data extraction and analysis. A total of 1935 patients were included (eight to 206 per study). Acromegaly patients had higher bone formation (SMD, 1.49; 95% confidence interval [CI], 0.97-2.01; P < .0001) and bone resorption (SMD, 1.57; 95% CI, 1.03-2.10; P < .0001) as compared to control subjects, without significant differences in lumbar spine BMD. BMD at the femoral neck tended to be higher in acromegaly patients vs control subjects (SMD, 0.67; 95% CI, 0.07-1.27; P = .03). Patients with acromegaly had high frequency of vertebral fractures (odds ratio, 8.26; 95% CI, 2.91-23.39; P < .0001), in close relationship with male gender, hypogonadism, and active acromegaly.

LIMITATIONS

LIMITATIONS included heterogeneous study protocols with possible variability in the assessment of skeletal end-points.

CONCLUSIONS

Skeletal fragility is an emerging complication of acromegaly.

Pituitary disorders and osteoporosis

Various hormonal disorders can influence bone metabolism and cause secondary osteoporosis. The consequence of this is a significant increase of fracture risk. Among pituitary disorders such effects are observed in patients with Cushing's disease, hyperprolactinemia, acromegaly, and hypopituitarism. Severe osteoporosis is the result of the coexistence of some of these disorders and hypogonadism at the same time, which is quite often.

Bone quantitative ultrasound at hand phalanges of women following breast cancer surgery

Breast cancer surgery and its adjunctive therapy follow in lymphedema, decreased limb mobility and bone deterioration. The aim was to establish relation of postsurgical limb lymphedema with bone properties assessed by quantitative ultrasound (QUS) measurement of hand phalanges in postmenopausal women after breast cancer surgery. In all, 63 women aged 62.81 ± 8.83 years, after breast cancer surgery were compared with control group of 418 age-matched women. Their skeletal status was assessed by QUS measurements at proximal phalanges using DBM Sonic 1200. There were no statistically significant differences in QUS measurements (Ad-SoS) between groups of operated subjects and the controls, between limbs (operated vs. nonoperated side, with and without lymphedema), and regarding method of surgery. Ad-SoS was greater in estrogen-treated patients than in nontreated ones at the side with no breast surgery (1994.11 ± 67.83 vs. 1943.27 ± 58.34; P = 0.046). Ad-SoS was lower in patients with adjunctive antiestrogen therapy than without this therapy at the side of surgery (1937.35 ± 54.71 vs. 1966.78 ± 59.18; P = 0.0449), and nonbreast surgery side (1934.55 ± 52.06 vs. 1973.31 ± 57.17; P = 0.0066). Breast cancer surgery followed by concomitant therapies does not influence significantly QUS at hand phalanges. This was proven regarding method of surgery, side of surgery, and lymphedema. Additional hormonal treatment can influence phalangeal QUS in breast cancer survivors.

Seven-year follow-up in a case of primary hyperparathyroidism using quantitative ultrasound and dual X-ray absorptiometry

We have previously reported a case of a 36-year-old woman who was diagnosed with primary hyperparathyroidism following initial skeletal abnormalities in the hand phalanges and calcaneus revealed by quantitative ultrasound (QUS). Successful parathyroid adenoma surgery resulted in progressive increase of bone mineral density and QUS parameters within 6 months, 1 year and 2 years of follow-up. Now, 5 years after the last measurement and at the onset of her menopause, the study was repeated. It has shown further increase in some ultrasonic and densitometric parameters but decrease in others. This discrepancy could be associated with the early influence of perimenopause on trabecular bone. Based on the current report one can conclude that peripheral QUS used on the hand phalanges and calcaneus is a useful tool for the diagnosis and monitoring of skeletal alterations due to parathyroid dysfunction. Moreover, it can detect early changes associated with perimenopause.