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Cetinalp NE, Akkus G, Seydaoglu G, Ozsoy KM, Akbaba M, Baykara O, Oktay K, Erman T. Early Predictors of Remission in Acromegaly Patients after Pure Endoscopic Endonasal Transsphenoidal Surgery. J Neurol Surg B Skull Base 2024. [DOI: 10.1055/a-2319-0344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Abstract
Objective Surgery is the first-line treatment in acromegaly but it takes months to confirm remission. It is crucial to determine remission early in order to inform the patient and plan further treatment options. We aimed to evaluate the predictors of remission at the early phase after endoscopic endonasal pituitary surgery in acromegaly patients.
Methods Fifty-four growth hormone (GH)-adenoma patients operated via pure endoscopic endonasal approach were analyzed in this observational study. We compared the basic clinical, radiological characteristics, and the preoperative and postoperative hormone levels in terms of remission according to current guidelines.
Results The surgical remission rate was 61.1%. When the patients were compared according to surgical remission, the age, gender, and immunohistochemical granulation type were found to be nonsignificant, while diabetes mellitus was more common (55.6 vs. 44.4%). The preoperative tumor volume (1.2 ± 0.9 vs. 4.1 ± 4.2 cm3) and postoperative GH and insulin-like growth factor-1 (IGF-1) levels were higher in the nonremission group (p < 0.05). We defined a number of cut-off values of both GH and IGF-1 levels to predict remission at the postoperative phase. Age standardized regression analyses showed that postoperative day 1 (POD-1) GH levels (odds ratio [OR]: 8.9; 95% confidence interval [CI]: 1.99–40.0, p = 0.004) and tumor volume (OR: 3.14; 95% CI: 1.09–9.0, p = 0.034) were found to be significant independent predictors for remission.
Conclusion We demonstrated that tumor volume and POD-1 GH levels are independent predictors of remission in acromegaly patients operated via the pure endoscopic endonasal technique and may be used as an early marker of remission, and this may lead to taking adjuvant medical therapies early into account to improve prognosis.
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Affiliation(s)
- Nuri Eralp Cetinalp
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Gamze Akkus
- Division of Endocrinology, Department of Internal Medicine, Cukurova University Faculty of Medicine, Adana, Türkiye
| | - Gulsah Seydaoglu
- Department of Biostatistics, Cukurova University Faculty of Medicine, Adana, Türkiye
| | - Kerem Mazhar Ozsoy
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Mevlana Akbaba
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Okay Baykara
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Kadir Oktay
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
| | - Tahsin Erman
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Balcali, Adana, Türkiye
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Theiler S, Hegetschweiler S, Staartjes VE, Spinello A, Brandi G, Regli L, Serra C. Influence of gender and sexual hormones on outcomes after pituitary surgery: a systematic review and meta-analysis. Acta Neurochir (Wien) 2023; 165:2445-2460. [PMID: 37555999 PMCID: PMC10477253 DOI: 10.1007/s00701-023-05726-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/07/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Although there is an increasing body of evidence showing gender differences in various medical domains as well as presentation and biology of pituitary adenoma (PA), gender differences regarding outcome of patients who underwent transsphenoidal resection of PA are poorly understood. The aim of this study was to identify gender differences in PA surgery. METHODS The PubMed/MEDLINE database was searched up to April 2023 to identify eligible articles. Quality appraisal and extraction were performed in duplicate. RESULTS A total of 40 studies including 4989 patients were included in this systematic review and meta-analysis. Our analysis showed odds ratio of postoperative biochemical remission in males vs. females of 0.83 (95% CI 0.59-1.15, P = 0.26), odds ratio of gross total resection in male vs. female patients of 0.68 (95% CI 0.34-1.39, P = 0.30), odds ratio of postoperative diabetes insipidus in male vs. female patients of 0.40 (95% CI 0.26-0.64, P < 0.0001), and a mean difference of preoperative level of prolactin in male vs. female patients of 11.62 (95% CI - 119.04-142.27, P = 0.86). CONCLUSIONS There was a significantly higher rate of postoperative DI in female patients after endoscopic or microscopic transsphenoidal PA surgery, and although there was some data in isolated studies suggesting influence of gender on postoperative biochemical remission, rate of GTR, and preoperative prolactin levels, these findings could not be confirmed in this meta-analysis and demonstrated no statistically significant effect. Further research is needed and future studies concerning PA surgery should report their data by gender or sexual hormones and ideally further assess their impact on PA surgery.
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Affiliation(s)
- Sven Theiler
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Saskia Hegetschweiler
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Antonio Spinello
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Giovanna Brandi
- Institute for Intensive Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland.
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Guo J, Cao W, Luo J, Huang R, Xiao Y. A retrospective study of the role of hypercapnia in patients with acromegaly. BMC Pulm Med 2023; 23:186. [PMID: 37244996 DOI: 10.1186/s12890-023-02488-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 05/22/2023] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Acromegaly is a multisystemic disease characterized by an excessive release of growth hormone (GH) and insulin-like growth factor-1. Obstructive sleep apnea (OSA) is a common consequence of acromegaly, and hypercapnia is frequently observed in patients with acromegaly, OSA, and obesity. However, the effects of hypercapnia on acromegaly remain unknown. This study was designed to investigate whether there are differences in clinical symptoms, sleep variables, and biochemical remission after surgery for acromegaly in patients with OSA with or without hypercapnia. METHODS A retrospective analysis was conducted involving patients with acromegaly and OSA. The pharmacotherapy history for acromegaly before surgery, anthropometric measures, blood gas, sleep monitoring data, and biochemical assays of hypercapnic and eucapnic individuals were collected 1-2 weeks before surgery. Univariate and multivariate logistic regression analyses were performed to determine the risk factors for failed postoperative biochemical remission. RESULTS In this study, 94 patients with OSA and acromegaly were included. Among them, 25 (26.6%) had hypercapnia. The hypercapnic group had higher body mass index (92% vs. 62.3%; p = 0.005) and poorer nocturnal hypoxemia index. No serological differences were found between the two groups. According to the post-surgery GH level, 52 patients (55.3%) reached biochemical remission. Univariate logistic regression analysis revealed that diabetes mellitus (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.02-6.55), instead of hypercapnia (OR, 0.61; 95% CI, 0.24-1.58), was associated with lower remission rates. Patients who received pharmacotherapy for acromegaly before surgery (OR, 0.21; 95% CI, 0.06-0.79) and had higher thyroid-stimulating hormone levels (OR, 0.53; 95% CI, 0.32-0.88) were more likely to have biochemical remission after surgery. Multivariate analysis further showed that only diabetes mellitus (OR, 3.29; 95% CI, 1.15-9.46) and preoperative pharmacotherapy (OR, 0.21; 95% CI, 0.06-0.83) remained significant. Hypercapnia, hormone levels, and sleep indicators had no effect on biochemical remission after surgery. CONCLUSIONS Single-center evidence shows that hypercapnia alone may not be a risk factor for lower biochemical remission rates. Correcting hypercapnia does not appear to be required before surgery. More evidence is needed to further support this conclusion.
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Affiliation(s)
- Junwei Guo
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing, 100730, China
| | - Wenhao Cao
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing, 100730, China
- Department of Respiratory and Critical Care Medicine, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jinmei Luo
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing, 100730, China
| | - Rong Huang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing, 100730, China
| | - Yi Xiao
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1 Shuaifuyuan Street, Dongcheng District, Beijing, 100730, China.
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Chiloiro S, Giampietro A, Gagliardi I, Bondanelli M, Epifani V, Milardi D, Ambrosio MR, Zatelli MC, Pontecorvi A, De Marinis L, Bianchi A. Systemic comorbidities of acromegaly in real-life experience: which difference among young and elderly patients? Endocrine 2023; 80:142-151. [PMID: 36447087 DOI: 10.1007/s12020-022-03261-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/10/2022] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Acromegaly is a rare but potentially life-threatening disease, if not promptly managed, for the systemic complications due to the GH/IGF-I hypersecretion. According to the increased population life span, the number of older acromegaly patients is growing. We aim to investigate clinical features of elderly acromegaly (elderly-ACRO) and to identify the risk factors for the occurrence of comorbidities in elderly-ACRO. MATERIALS AND METHODS A retrospective and multi-center study was performed on acromegaly patients. Acromegaly comorbidities were compared among elderly-ACRO (>65 years), young acromegaly patients (young-ACRO if ≤65 years) and a control group of age and gender-matched subjects. RESULT Fifty of the 189 enrolled patients were elderly-ACRO (26.5%). Cardiovascular, metabolic, neurological/psychiatric and joint/articular disorders, nodular thyroid disease, sleep apnoea syndrome and skeletal fragility occurred more frequently in elderly-ACRO as compared to controls. Cardiovascular and metabolic disorders, nodular thyroid disease occurred significantly more frequently in elderly-ACRO as compared to young-ACRO and controls. On the other hand, neurological/psychiatric, joint/articular disorders and bone fragility occur with a similar frequency among elderly and young-ACRO. We found that elderly-ACRO had an increased risk for the occurrence of systemic arterial hypertension (p < 0.001, OR: 5.4 95%IC:2.6-10.9), left ventricular hypertrophy (p = 0.01, OR: 3 95%IC: 1.5-5.8) and metabolic disorders (p = 0.006, OR: 4.1 95%IC: 2-8.3). CONCLUSION Our results may suggest that some acromegaly comorbidities may be predominantly due to acromegaly "per-se" rather than to aging. On the contrary, cardiovascular and metabolic disorders seem to be due to aging as well.
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Affiliation(s)
- Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Irene Gagliardi
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Marta Bondanelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Valeria Epifani
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico Milardi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Rosaria Ambrosio
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Maria Chiara Zatelli
- Section of Endocrinology, Geriatrics & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Via Fossato di Mortara 64/B, 44121, Ferrara, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology and Metabolism, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
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Zhang S, Chen J, Yao S, Akter F, Wang Z, Hu B, Zhu D, Duan C, Chen W, Zhu Y, Wang H, Mao Z. Predictors of postoperative biochemical remission in lower Knosp grade growth hormone-secreting pituitary adenomas: a large single center study. J Endocrinol Invest 2023; 46:465-476. [PMID: 36125731 DOI: 10.1007/s40618-022-01873-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/16/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Growth hormone-secreting pituitary adenomas (GH-PAs) with a low Knosp grade are typically associated with a good postoperative biochemical remission (BR) rate. However, a proportion of patients do not achieve remission. In this study, we aimed to investigate predictive factors of postoperative remission for lower Knosp GH-PAs. METHODS In this retrospective study, we enrolled 140 patients who were diagnosed with lower Knosp (0-2) GH-PAs and received trans-sphenoidal surgery between December 2016 and June 2021 from the largest pituitary tumor surgery center in southern China. The univariate, binary Logistic regression, and receiver operating characteristic curve (ROC) analyses were employed to determine independent predictors and cutoff values of remission. The postoperative outcome was defined as remission using the 2010 consensus criteria of acromegaly. RESULTS One hundred and thirty six patients (97.1%) achieved gross total resection. The postoperative long-term BR was 68.6%. Empty sella, tumor maximum diameter and postoperative GH levels were independent factors predicting remission. ROC revealed that postoperative 24 h GH ≤ 1.3 ng/mL and ≤ 1.23 ng/mL were valuable predictors for 3-month and long-term remission respectively, and that postoperative 3-month GH ≤ 1.6 ng/mL and tumor maximum diameter ≤ 17 mm were predictors for delayed remission. CONCLUSION Early postoperative GH levels can be used as predictors of remission. However, BR was not associated with preoperative somatostatin analogs therapy or Knosp grade (0-2). For patients without residual tumor or recurrence and whose GH levels are slightly elevated within 1 year after surgery, adjuvant treatments may not be necessary.
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Affiliation(s)
- S Zhang
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - J Chen
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - S Yao
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - F Akter
- Faculty of Arts and Sciences, Harvard University, Cambridge, MA, USA
| | - Z Wang
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - B Hu
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - D Zhu
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - C Duan
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - W Chen
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Y Zhu
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China.
| | - H Wang
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Z Mao
- Department of Neurosurgery, Center for Pituitary Tumor Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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Nie D, Fang Q, Wong W, Gui S, Zhao P, Li C, Zhang Y. The effect of endoscopic transsphenoidal somatotroph tumors resection on pituitary hormones: systematic review and meta-analysis. World J Surg Oncol 2023; 21:71. [PMID: 36859291 PMCID: PMC9976528 DOI: 10.1186/s12957-023-02958-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
PURPOSE Currently, endoscopic transsphenoidal surgery is the main treatment for pituitary neuroendocrine tumors (PitNETs). Excision of the tumor may have positive or negative effects on pituitary endocrine function, and the pituitary function of somatotroph tumors is a point of particular concern after the operation. This study aimed to conduct a meta-analysis on the effect of endoscopic transsphenoidal somatotroph tumor resection on pituitary function. METHODS A systematic literature search was conducted for articles that included the evaluation of pituitary target gland before and after endoscopic transsphenoidal pituitary tumor resection and were published between 1992 and 2022 in PubMed, Cochrane, and Ovid MEDLINE. RESULTS Sixty-eight studies that included biochemical remission rates in 4524 somatotroph tumors were concluded. According to the 2000 consensus, the biochemical remission rate after transsphenoidal endoscopic surgery was 66.4% (95% CI, 0.622-0.703; P = 0.000), the biochemical remission rate was 56.2% according to the 2010 consensus (95% CI, 0.503-0.620; P = 0.041), and with the rate of biochemical remission ranging from 30.0 to 91.7% with investigator's definition. After endoscopic resection, adrenal axis dysfunction was slightly higher than that before surgery, but the difference was not statistically significant. Hypothyroidism was 0.712 times higher risk than that before surgery (OR = 0.712; 95% CI, 0.527-0.961; P = 0.027). Hypogonadism was 0.541 times higher risk than that before surgery (OR = 0.541; 95% CI, 0.393-0.746; P = 0.000). Hyperprolactinemia was 0.131 times higher risk than that before surgery (OR = 0.131; 95% CI, 0.022-0.783; P = 0.026). The incidence of pituitary insufficiency was 1.344 times the risk before surgery after endoscopic resection of somatotroph tumors, but the difference was not statistically significant. CONCLUSIONS In patients with somatotroph tumors after undergoing endoscopic surgery, the risk of dysfunction and pituitary insufficiency tend to increase, while preoperative thyroid insufficiency, gonadal insufficiency, and hyperprolactinemia will be partially relieved.
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Affiliation(s)
- Ding Nie
- grid.24696.3f0000 0004 0369 153XBeijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Qiuyue Fang
- grid.24696.3f0000 0004 0369 153XBeijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Wakam Wong
- grid.24696.3f0000 0004 0369 153XBeijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Songbai Gui
- grid.24696.3f0000 0004 0369 153XDepartment of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peng Zhao
- grid.24696.3f0000 0004 0369 153XDepartment of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chuzhong Li
- grid.24696.3f0000 0004 0369 153XBeijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Yazhuo Zhang
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
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Papaioannou C, Druce M. Preoperative medical treatments and surgical approaches for acromegaly: A systematic review. Clin Endocrinol (Oxf) 2023; 98:14-31. [PMID: 35726150 PMCID: PMC10084190 DOI: 10.1111/cen.14790] [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: 04/14/2022] [Revised: 06/12/2022] [Accepted: 06/19/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Acromegaly is a condition characterized by an overproduction of growth hormone which infers high morbidity and mortality if left untreated. The objective of this review is to analyse and appraise the current evidence for the generalized use of preoperative medications and the various surgical approaches as described in the literature. DESIGN A thorough search from MEDLINE via PubMed, EMBASE, and Cochrane Library has been performed which identified a total of 37 papers. CONCLUSION The preoperative use of somatostatin receptor agonists (SAs) in acromegaly is a controversial topic with current guidelines suggesting against their generalized routine use. Most authors noticed an insignificant long-term remission of acromegaly when given SAs compared with nil preoperative therapy, except for invasive macroadenomas as SAs have been found to reduce the tumour volume and aid towards the total resection of the adenoma. Furthermore, according to the evidence available, endoscopic transsphenoidal surgery is the optimum method for hypophysectomy in terms of its remission and safety profile.
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Affiliation(s)
- Christos Papaioannou
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
| | - Maralyn Druce
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK
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The Prognostic-Based Approach in Growth Hormone-Secreting Pituitary Neuroendocrine Tumors (PitNET): Tertiary Reference Center, Single Senior Surgeon, and Long-Term Follow-Up. Cancers (Basel) 2022; 15:cancers15010267. [PMID: 36612263 PMCID: PMC9818833 DOI: 10.3390/cancers15010267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/25/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023] Open
Abstract
Postoperative deserved outcomes in acromegalic patients are to normalize serum insulin-like growth factor (IGF-1), reduce the tumoral mass effect, improve systemic comorbidities, and reverse metabolic alterations. Pituitary neuroendocrine tumors (PitNET) are characterized to present a heterogeneous behavior, and growth hormone (GH)-secreting PitNET is not an exception. Promptly determining which patients are affected by more aggressive tumors is essential to guide the optimal postoperative decision-making process [prognostic-based approach]. From 2006 to 2019, 394 patients affected by PitNET were intervened via endoscopic endonasal transsphenoidal approach by the same senior surgeon. A total of 44 patients that met the criteria to be diagnosed as acromegalic and were followed up at least for 24 months (median of 66 months (26-156) were included in the present study. Multiple predictive variables [age, gender, preoperative GH and IGF-1 levels, maximal tumor diameter, Hardy's and Knosp's grade, MRI. T2-weighted tumor intensity, cytokeratin expression pattern, and clinicopathological classification] were evaluated through uni- and multivariate statistical analysis. Sparse probability of long-term remission was related to younger age, higher preoperative GH and- or IGF-1, group 2b of the clinicopathological classification, and sparsely granulated cytokeratin expression pattern. Augmented recurrence risk was related to elevated preoperative GH levels, tumor MRI T2-weighted hyperintensity, and sparsely granulated cytokeratin expression pattern. Finally, elevated risk for reintervention was related to group 2b of the clinicopathological classification, Knosp's grade IV, and tumor MRI T2-weighted hyperintensity. In this study, the authors determined younger age, higher preoperative GH and- or IGF-1 levels, group 2b of the clinicopathological classification, Knosp's grade IV, MRI T2-weighted tumor hyperintensity and sparsely granulated cytokeratin expression pattern are related to worse postoperative outcomes in long-term follow-up patients affected with GH-secreting PitNET.
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Chhabra R, Kumar A, Virk RS, Dutta P, Ahuja C, Mohanty M, Dhandapani S. Outcomes in pituitary adenoma causing acromegaly following endoscopic endonasal transsphenoidal surgery. J Neurosci Rural Pract 2022; 13:696-704. [PMID: 36743751 PMCID: PMC9894003 DOI: 10.25259/jnrp-2022-3-28-r1-(2453)] [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: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 12/10/2022] Open
Abstract
Objectives The objectives of the study were to study the analysis of outcomes after endoscopic endonasal transsphenoidal surgery (EETSS) in acromegaly in terms of surgical complications, clinical improvement, endocrinological remission, achievement of prognostically critical growth hormone (GH) level, and requirement of additional treatment. Materials and Methods The study included 28 acromegaly patients, who underwent EETSS. A 2010 consensus criterion was used for defining remission. Assessment of prognostically critical GH level (random value <2.5 ng/ml), the extent of resection and additional treatment, was done at post-operative week (POW) 12. Results All adenomas were macroadenomas; with a mean volume of 16.34 cm3 (range, 0.4-99 cm3). Most adenomas had high-grade extensions. Most common suprasellar, infrasellar, anterior, and posterior extension grades were 3 (n = 13), 1 (n = 16), 1 (n = 14), and 0 (n = 20), respectively. Knosp Grade 3 was common on both sides (right, n = 9 and left, n = 8). One patient had already been operated on with EETSS, 1.5 years back from current surgery. Sixteen patients were on hormonal support, preoperatively. Four patients died during follow-up. Post-operative common complications were diabetes insipidus (DI, n = 18), cerebrospinal fluid rhinorrhea (n = 10), surgical site hematoma (n = 3), meningitis (n = 3), hydrocephalus (n = 2), and syndrome of inappropriate antidiuretic hormone (n = 1). The mean hospital stay was 11.62 days and 12.17 months were the mean follow-up period. At 12 POW, no improvement was seen in body enlargement and visual complaints, but all other complaints improved significantly except perspiration. Adenomas were decreased in all extensions except posterior and mean adenoma volume was reduced from 16.34 cm3 to 2.92 cm3 after surgery. Sub-total resection (STR, n = 10), near-total resection (NTR, n = 7), gross-total resection (GTR, n = 5), and partial resection (PR, n = 2) were achieved. Endocrinological remission and prognostically critical GH levels were attained in 29.17% (n = 7) and 66.67% (n = 16), respectively. NTR, GTR, STR, and PR were associated with 57.14%, 40%, 10%, and 0% endocrinological remission, respectively. Additional treatment was required in a total of 17 patients, three in GTR, nine in STR, three in NTR, and two in PR. Ten were treated with Gamma Knife radiosurgery along with medical treatment and seven with medical treatment alone. Conclusion A successful EETSS can reduce adenoma volume to achieve clinical improvement, endocrinologic remission, and prognostically critical GH level with some complications related to surgery. Pre-operative larger volume and higher extension grades affect these outcomes adversely.
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Affiliation(s)
- Rajesh Chhabra
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Kumar
- Department of Neurosurgery, Government Medical College and Hospital, Chandigarh, India
| | - R. S. Virk
- Department of Otorhinolaryngology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Ahuja
- Department of Neuroradiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Chhabra R, Kumar A, Virk RS, Dutta P, Ahuja C, Mohanty M, Dhandapani S. Outcomes in Pituitary Adenoma Causing Acromegaly Following Endoscopic Endonasal Transsphenoidal Surgery. J Neurosci Rural Pract 2022. [DOI: 10.1055/s-0042-1751226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Abstract
Objectives The objective of this study was the analysis of outcomes after endoscopic endonasal transsphenoidal surgery (EETSS) in acromegaly in terms of surgical complications, clinical improvement, endocrinological remission, achievement of prognostically critical growth hormone (GH) level, and requirement of additional treatment.
Materials and Methods The study included 28 acromegaly patients, who underwent EETSS. 2010 consensus criterion was used for defining remission. Assessment of prognostically critical GH level (random value less than 2.5 ng/mL), the extent of resection, and additional treatment was done at postoperative week (POW) 12.
Results All adenomas were macroadenomas, with the mean volume of 16.34 cm3 (range, 0.4–99 cm3). Most adenomas had high-grade extensions. Most common suprasellar, infrasellar, anterior, and posterior extension grades were 3 (n = 13), 1(n = 16), 1(n = 14), and 0 (n = 20), respectively. Knosp grade 3 was common on both sides (right, n = 9 and left, n = 8). One patient had already been operated on with EETSS, 1.5 years back from current surgery. Sixteen patients were on hormonal support, preoperatively. Four patients died during follow-up. Postoperative common complications were diabetes insipidus (n = 18), cerebrospinal fluid rhinorrhea (n = 10), surgical site hematoma (n = 3), meningitis (n = 3), hydrocephalus (n = 2), and syndrome of inappropriate antidiuretic hormone (n = 1). The mean hospital stay was 11.62 days, and 12.17 months was the mean follow-up period. At 12 POW, no improvement was seen in body enlargement and visual complaints, but all other complaints improved significantly except perspiration. Adenomas were decreased in all extensions except posterior, and mean adenoma volume was reduced from 16.34 to 2.92 cm3 after surgery. Subtotal resection (STR, n = 10), near-total resection (NTR, n = 7), gross-total resection (GTR, n = 5), and partial resection (PR, n = 2) were achieved. Endocrinological remission and prognostically critical GH levels were attained in 29.17% (n = 7) and 66.67% (n = 16), respectively. NTR, GTR, STR, and PR were associated with 57.14, 40, 10, and 0% endocrinological remission, respectively. Additional treatment was required in a total of 17 patients: 3 GTR, 9 STR, 3 NTR, and 2 PR patients. Ten patients were treated with gamma knife radiosurgery along with medical treatment and seven with medical treatment alone.
Conclusion A successful EETSS can reduce adenoma volume to achieve clinical improvement, endocrinological remission, and prognostically critical GH level with some complications related to surgery. Preoperative larger volume and higher extension grades affect these outcomes adversely.
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Affiliation(s)
- Rajesh Chhabra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashwani Kumar
- Department of Neurosurgery, Government Medical College and Hospital, Chandigarh, India
| | - R S Virk
- Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Ahuja
- Department of Neuroradiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sivashanmugam Dhandapani
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Taghvaei M, Fallah S, Sadaghiani S, Sadrhosseini SM, Tabari A, Fathi M, Zeinalizadeh M. Surgical complications of endoscopic approach to skull base: analysis of 584 consecutive patients. Eur Arch Otorhinolaryngol 2022; 279:3189-3199. [PMID: 35102476 DOI: 10.1007/s00405-022-07256-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE Endoscopic techniques have been widely applied for challenging cranial base surgeries in recent years. In this study, we evaluated the safety and efficacy of using the endoscopic endo-nasal route for various skull base pathologies in terms of postoperative complications. METHODS A total of 584 consecutive patients who underwent endoscopic skull base surgery were studied. Peri- and post-operative complications and risk factors affecting the occurrence of these complications were evaluated. RESULTS 648 endoscopic skull base surgical procedures were performed on 584 patients (47.8% females and 52.2% males) with the mean age of 41.2 years. Pituitary adenoma (69.3%) was the most common pathology. Post-operative mortality was 2.0%. The rates of post-operative permanent neurological deficit (one case of 6th nerve injury, two 12th nerve injuries and one hemiparesis) and visual deterioration were 0.6% and 1.5%, respectively. Ten patients (1.7%) were complicated with meningitis and it was the cause of death in 3. Systemic complications not directly attributable to skull base surgical access occurred in 2% (11 patients) with 5 mortalities. The rate of intra-operative vascular injury was 1% and among them one patient died due to PCA injury. The most common post-operative complications were diabetes insipidus (12.5%), anterior pituitary dysfunction (10.6%) and CSF leak (3.6%), respectively. In general, reoperation, malignant lesions, and level IV of surgical complexity were associated with a higher incidence of complications. CONCLUSION Endoscopic endo-nasal approach can be a safe and less-morbid first-line treatment of patients with various skull base lesions.
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Affiliation(s)
- Mohammad Taghvaei
- Brain and Spinal Injury Research Center (BASIR), Neuroscience Institute, Tehran University of Medical Sciences, Keshavarz Blvd, P. O. Box 1419733141, Tehran, Iran
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Fallah
- Brain and Spinal Injury Research Center (BASIR), Neuroscience Institute, Tehran University of Medical Sciences, Keshavarz Blvd, P. O. Box 1419733141, Tehran, Iran
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Shokufeh Sadaghiani
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mousa Sadrhosseini
- Department of Otolaryngology-Head and Neck Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Azin Tabari
- Department of Otolaryngology-Head and Neck Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Fathi
- Brain and Spinal Injury Research Center (BASIR), Neuroscience Institute, Tehran University of Medical Sciences, Keshavarz Blvd, P. O. Box 1419733141, Tehran, Iran
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi Zeinalizadeh
- Brain and Spinal Injury Research Center (BASIR), Neuroscience Institute, Tehran University of Medical Sciences, Keshavarz Blvd, P. O. Box 1419733141, Tehran, Iran.
- Department of Neurological Surgery, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran.
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12
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Araujo-Castro M, Acitores Cancela A, Vior C, Pascual-Corrales E, Rodríguez Berrocal V. Radiological Knosp, Revised-Knosp, and Hardy–Wilson Classifications for the Prediction of Surgical Outcomes in the Endoscopic Endonasal Surgery of Pituitary Adenomas: Study of 228 Cases. Front Oncol 2022; 11:807040. [PMID: 35127519 PMCID: PMC8810816 DOI: 10.3389/fonc.2021.807040] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/08/2021] [Indexed: 01/26/2023] Open
Abstract
Purpose To evaluate which radiological classification, Knosp, revised-Knosp, or Hardy–Wilson classification, is better for the prediction of surgical outcomes in the endoscopic endonasal transsphenoidal (EET) surgery of pituitary adenomas (PAs). Methods This is a retrospective study of patients with PAs who underwent EET PA resection for the first time between January 2009 and December 2020. Radiological cavernous sinus invasiveness was defined as a Knosp or revised-Knosp grade >2 or a grade E in the Hardy–Wilson classification. Results A total of 228 patients with PAs were included. Cavernous sinus invasion was evident in 35.1% and suprasellar extension was evident in 74.6%. Overall, surgical cure was achieved in 64.3% of patients. Surgical cure was lower in invasive PAs than in non-invasive PAs (28.8% vs. 83.1%, p < 0.0001), and the risk of major complications was higher (13.8% vs. 3.4%, p = 0.003). The rate of surgical cure decreased as the grade of Knosp increased (p < 0.001), whereas the risk of complications increased (p < 0.001). Patients with Knosp 3B PAs tended to achieve surgical cure less commonly than Knosp 3A PAs (30.0% vs. 56.0%, p = 0.164). Similar results were observed based on the invasion and extension of Hardy–Wilson classification (stage A–C 83.1% vs. E 28.8% p < 0.0001, grade 0–II 81.1% vs. III–IV 59.7% p = 0.008). The Knosp classification offered the greatest diagnostic accuracy for the prediction of surgical cure (AUC 0.820), whereas the invasion Hardy–Wilson classification lacked utility for this purpose (AUC 0.654). Conclusion The Knosp classifications offer a good orientation for the estimation of surgical cure and the risk of complications in patients with PAs submitted to EET surgery. However, the invasion Hardy–Wilson scale lacks utility for this purpose.
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Affiliation(s)
- Marta Araujo-Castro
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal & Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
- Department of Medicine, Universidad de Alcalá de Henares, Madrid, Spain
- *Correspondence: Marta Araujo-Castro, ; orcid.org/0000-0002-0519-0072
| | | | - Carlos Vior
- Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Eider Pascual-Corrales
- Neuroendocrinology Unit, Department of Endocrinology & Nutrition, Hospital Universitario Ramón y Cajal & Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Víctor Rodríguez Berrocal
- Department of Neurosurgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Neurosurgery, Hospital HM Puerta del Sur, Madrid, Spain
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Sakata K, Nagata Y, Takeshige N, Kikuchi J, Shikata M, Ashida K, Nomura M, Morioka M. Early postoperative prediction of both disease remission and long-term disease control in acromegaly using the oral glucose tolerance test. Hormones (Athens) 2021; 20:515-526. [PMID: 33738782 DOI: 10.1007/s42000-021-00281-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 03/07/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE Transsphenoidal surgery (TSS) is the cornerstone of acromegaly treatment. Two biochemical parameters, growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels, sometimes diverge postoperatively; however, it is important to maintain disease control without further treatment, regardless of whether these parameters converge. This study investigated whether remission and long-term disease control could be predicted using early postoperative GH and IGF-1 levels. METHODS We reviewed 36 consecutive surgically treated patients with acromegaly. IGF-1 levels and minimum GH levels during an oral glucose tolerance test (OGTT) were evaluated at 2 weeks, as well as at 3 months postoperatively. After comparison between the remission and nonremission groups, we analyzed whether early postoperative parameters could predict remission and long-term disease control. RESULTS Twenty-five patients (69.4%, Group A) achieved remission within 1 year postoperatively. Of the remaining patients (median follow-up period, 53 months), seven (19.5%, Group B) maintained normal IGF-1 levels without treatment, whereas four (11.1%, Group C) required additional treatment. GH levels <1.5 ng/mL measured on the morning after surgery and nadir GH levels <0.7 ng/mL during the OGTT conducted at 2 weeks postoperatively were predictive of remission, with the latter demonstrating 95.2% sensitivity and 100% specificity. All group C patients had nadir GH levels ≥0.7 ng/mL during the OGTT and IGF-1 levels ≥SD +3 at 2 weeks postoperatively. CONCLUSION Early postoperative nadir GH levels during the OGTT and IGF-1 levels at 2 weeks postoperatively demonstrated excellent predictive value for both endocrinological remission and the necessity for additional treatment.
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Affiliation(s)
- Kiyohiko Sakata
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan.
| | - Yui Nagata
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Nobuyuki Takeshige
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Jin Kikuchi
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
| | - Masato Shikata
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Kenji Ashida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Motohiro Morioka
- Department of Neurosurgery, Kurume University School of Medicine, Fukuoka, Japan
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Torres A, Sanmillan JL, Lau R, Gabarros A. Final Outcome in Growth Hormone-Secreting Adenomas After Combination of Maximal Tumor Resection and Medical Treatment. World Neurosurg 2021; 154:e292-e301. [PMID: 34252630 DOI: 10.1016/j.wneu.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/04/2021] [Accepted: 07/05/2021] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Gross total resection (GTR) is not always possible in acromegalic patients, especially in patients with invasive growth hormone-secreting adenomas. We analyzed the biochemical remission outcome in relation to extent of tumor resection and effectiveness of medical treatment in cases of remnant tumor. METHODS Retrospective analysis was performed of acromegalic patients operated on between 2002 and 2017. Preoperative imaging, tumor invasiveness, extent of resection, and biochemical remission were collected. Patients with tumor remnant not amenable to second surgery began medical treatment. The relationship between pituitary adenoma remnant volume and final biochemical outcome was analyzed. RESULTS Of 120 acromegalic patients operated on, 82 underwent transsphenoidal microsurgery and 38 underwent endonasal endoscopic approach. GTR was achieved in 72 cases (60%); subtotal resection (STR), 21 (17.5%) cases; and partial resection, 27 (22.5%) cases. There was a nonsignificant higher rate of GTR/STR in patients who underwent endonasal endoscopic approach. However, a significantly higher remission rate (89.45% vs. 67.1%) was achieved in these patients (P < 0.01). Greater tumor volume and invasiveness were associated with a lower remission (P < 0.05). Patients with tumor remnant who achieved biochemical remission with added medical therapy had a significantly smaller tumor volume (P < 0.001). CONCLUSIONS The more aggressive surgical resection is, the greater the chance of attaining final biochemical remission, whether or not GTR is achieved. Medical therapy effectiveness is enhanced in cases with STR. Invasive growth hormone-secreting macroadenomas that are not surgically amenable to total resection are best managed with a combination of safe STR and medical treatment.
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Affiliation(s)
- Alberto Torres
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain.
| | - Jose Luis Sanmillan
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain
| | - Ruth Lau
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain
| | - Andreu Gabarros
- Department of Neurological Surgery, Bellvitge University Hospital, Barcelona, Spain
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15
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Ghiam MK, Chyou DE, Dable CL, Katz AP, Eichberg DG, Zhang H, Ayala AR, Kargi AY, Komotar RJ, Sargi Z. 30-Day Readmissions and Coordination of Care Following Endoscopic Transsphenoidal Pituitary Surgery: Experience with 409 Patients. Skull Base Surg 2021; 83:e410-e418. [DOI: 10.1055/s-0041-1729980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Objective The study aimed to (1) quantify readmission rates and common causes of readmission following endoscopic transsphenoidal pituitary surgery (ETPS); (2) identify risk factors that may predict readmission within 30 days; (3) assess postoperative care coordination with endocrinology follow-up; and (4) identify patients for whom targeted interventions may reduce 30-day readmissions.
Methods Retrospective quality improvement review of patients with pituitary adenoma who underwent ETPS from December 2010 to 2018 at a single tertiary care center.
Results A total of 409 patients were included in the study, of which 57 (13.9%) were readmitted within 30 days. Hyponatremia was the most common cause of readmission (4.2%) followed by pain/headache (3.9%), cerebrospinal fluid leak (3.4%), epistaxis (2.7%), hypernatremia (1.2%), and adrenal insufficiency (1.2%). Patients with hyponatremia were readmitted significantly earlier than other causes (4.3 ± 2.2 vs. 10.6 ± 10.9 days from discharge, p = 0.032). Readmitted patients had significantly less frequent outpatient follow-up with an endocrinologist than the nonreadmitted cohort (56.1 vs. 70.5%, p = 0.031). Patients who had outpatient follow-up with an endocrinologist were at lower risk of readmission compared with those without (odds ratio: 0.46; 95% confidence interval: 0.24–0.88).
Conclusion Delayed hyponatremia is one of the most common causes of 30-day readmission following ETPS. Postoperative follow-up with an endocrinologist may reduce risk of 30-day readmission following ETPS.
Implications for Clinical Practice A multidisciplinary team incorporating otolaryngologist, neurosurgeons, and endocrinologist may identify patients at risk of 30-day readmissions. Protocols checking serum sodium within 1 week of surgery in conjunction with endocrinologist to tailor fluid restriction may reduce readmissions from delayed hyponatremia.
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Affiliation(s)
- Michael K. Ghiam
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Darius E. Chyou
- University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Cortney L. Dable
- University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Andrew P. Katz
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Daniel G. Eichberg
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Hang Zhang
- Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami, Florida, United States
| | - Alejandro R. Ayala
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Atil Y. Kargi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Ricardo J. Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, United States
| | - Zoukaa Sargi
- Department of Otolaryngology, Head and Neck Surgery, Sylvester Comprehensive Cancer Center, Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, United States
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16
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Degirmenci N, Bektas H, Senturk E, Ilhan M, Gunaldi A, Yetis EUM, Eren SB. Changes in olfactory function and olfactory bulb after treatment for acromegaly. Eur Arch Otorhinolaryngol 2021; 278:2357-2362. [PMID: 33386970 DOI: 10.1007/s00405-020-06515-5] [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: 10/08/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE This study aimed to investigate the olfactory functions of the acromegaly patients and to discuss the possible causes of olfactory dysfunction in acromegaly patients. METHODS A case-control study was carried out in a tertiary referral center. 52 patients with acromegaly (Acromegaly group) and 52 healthy individuals (Control group) were included in the study. All acromegaly patients included in the study were in the late postoperative period. The Connecticut Chemosensory Clinical Research Center (CCCRC) test was carried out and olfactory bulb (OB) volumes were measured in both of the groups. RESULTS There was a significant difference between the mean CCCRC total scores of the acromegaly and control groups (p = .000). The mean of right and left OB volumes in the acromegaly group was significantly higher than the control group (p = .004) CONCLUSION: In this study, we found that acromegaly patients are likely to experience olfactory dysfunction. It is important to examine these patients' olfactory functions at the time of diagnosis and clinic follow-up. CLINICAL TRIAL NUMBER NCT04138537.
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Affiliation(s)
- Nazan Degirmenci
- Department of Otorhinolaryngology and Head and Neck Surgery, Bezmialem Vakif University, Istanbul, Turkey.
| | - Hasan Bektas
- Department of Otorhinolaryngology and Head and Neck Surgery, Siirt State Hospital, Siirt, Turkey
| | - Erol Senturk
- Department of Otorhinolaryngology and Head and Neck Surgery, Bezmialem Vakif University, Istanbul, Turkey
| | - Muzaffer Ilhan
- Department of Endocrinology, Bezmialem Vakif University, Istanbul, Turkey
| | - Alev Gunaldi
- Department of Radiology, Maltepe University, Istanbul, Turkey
| | | | - Sabri Baki Eren
- Department of Otorhinolaryngology and Head and Neck Surgery, Bezmialem Vakif University, Istanbul, Turkey
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Agrawal N, Ioachimescu AG. Prognostic factors of biochemical remission after transsphenoidal surgery for acromegaly: a structured review. Pituitary 2020; 23:582-594. [PMID: 32602066 DOI: 10.1007/s11102-020-01063-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE Biochemical control is the main determinant of survival, clinical manifestations and comorbidities in acromegaly. Transsphenoidal selective adenomectomy (TSA) is the initial treatment of choice with reported biochemical remission rates varying between 32 and 85%. Understanding the limiting factors is essential for identification of patients who require medical treatment. METHODS We reviewed the English literature published in Medline/Pubmed until Dec 31, 2019 to identify eligible studies that described outcomes of TSA as primary therapy and performed analyses to determine the main predictors of remission. RESULTS Most publications reported single-institution, retrospective studies. The following preoperative parameters were consistently associated with lower remission rates: cavernous sinus invasion by imaging, larger tumor size and higher GH levels. Young age and preoperative IGF-1 levels were predictive in some studies. When controlled for covariates, the best single preoperative predictor was cavernous sinus invasion, followed by preoperative GH levels. Conversely, low GH level in the first few days postoperatively was a robust predictor of durable remission. The influence of tumor histology (sparsely granular pattern, co-expression of prolactin and proliferation markers) on surgical remission remains to be established. Few studies developed predictive models that yielded much higher predictive values than individual parameters. CONCLUSION Surgical outcome prognostication systems could be further generated by machine learning algorithms in order to support development and implementation of personalized care in patients with acromegaly.
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Affiliation(s)
- Nidhi Agrawal
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, NYU School of Medicine, 550 First Avenue, New York City, NY, 10016, USA
| | - Adriana G Ioachimescu
- Department of Medicine and Neurosurgery, Emory University School of Medicine, 1365 B Clifton Road B-2200, Northeast, B6209, Atlanta, GA, 30322, USA.
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Hanson M, Li H, Geer E, Karimi S, Tabar V, Cohen MA. Perioperative management of endoscopic transsphenoidal pituitary surgery. World J Otorhinolaryngol Head Neck Surg 2020; 6:84-93. [PMID: 32596652 PMCID: PMC7296486 DOI: 10.1016/j.wjorl.2020.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/19/2020] [Indexed: 11/12/2022] Open
Abstract
The contemporary embrace of endoscopic technology in the approach to the anterior skull base has altered the perioperative landscape for patients requiring pituitary surgery. Utility of a multi-disciplinary unit in management decisions facilitates the delivery of optimal care. Evolution of technology and surgical expertise in pituitary surgery mandates ongoing review of all components of the care central to these patients. The many areas of potential variability in the pre, intra and post-operative timeline of pituitary surgery are readily identifiable. Core undertakings and contemporary controversies in the peri-operative management of patients undergoing endoscopic transsphenoidal pituitary surgery are assessed against the available literature with a view to providing guidance for the best evidence-based practice.
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Affiliation(s)
- Martin Hanson
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Hao Li
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Eliza Geer
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Sasan Karimi
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Viviane Tabar
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
| | - Marc A Cohen
- Multidisciplinary Pituitary and Skull Base Tumour Program, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, USA
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Soliman MAR, Eaton S, Quint E, Alkhamees AF, Shahab S, O'Connor A, Haberfellner E, Im J, Elashaal AA, Ling F, Elbreki M, Dang T, Morassutti DJ, Shamisa A. Challenges, Learning Curve, and Safety of Endoscopic Endonasal Surgery of Sellar-Suprasellar Lesions in a Community Hospital. World Neurosurg 2020; 138:e940-e954. [PMID: 32298827 PMCID: PMC7195030 DOI: 10.1016/j.wneu.2020.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 04/04/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND OBJECTIVE Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting. METHODS We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018. RESULTS There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients. CONCLUSIONS EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.
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Affiliation(s)
- Mohamed A R Soliman
- Neurosurgery Department, Cairo University, Cairo, Egypt; Schulich School of Medicine and Density, Western University, London.
| | - Sydney Eaton
- Schulich School of Medicine and Density, Western University, London
| | - Elise Quint
- Schulich School of Medicine and Density, Western University, London
| | - Abdullah F Alkhamees
- Schulich School of Medicine and Density, Western University, London; Neurosurgery Department, Qassim University, Qassim, Kingdom of Saudi Arabia
| | - Saba Shahab
- Schulich School of Medicine and Density, Western University, London
| | - Avalon O'Connor
- Schulich School of Medicine and Density, Western University, London
| | | | - Jacob Im
- Schulich School of Medicine and Density, Western University, London
| | | | - Francis Ling
- Ear, Nose and Throat Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Mustafa Elbreki
- Ear, Nose and Throat Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Tommy Dang
- Neurosurgery Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Dante J Morassutti
- Neurosurgery Department, Windsor Regional Hospital, Western University, ON, Canada
| | - Abdalla Shamisa
- Neurosurgery Department, Windsor Regional Hospital, Western University, ON, Canada
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20
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Ambrosio MR, Gagliardi I, Chiloiro S, Ferreira AG, Bondanelli M, Giampietro A, Bianchi A, Marinis LD, Fleseriu M, Zatelli MC. Acromegaly in the elderly patients. Endocrine 2020; 68:16-31. [PMID: 32060689 DOI: 10.1007/s12020-020-02206-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Acromegaly is a rare disease characterized by a chronic exposition to growth hormone (GH) and insulin-like growth factor-1 (IGF-1), caused in most cases by a pituitary GH-secreting adenoma. Chronic GH excess induces systemic complications (metabolic, cardiovascular, respiratory, neoplastic, and musculoskeletal) and increased mortality if not appropriately treated. Recent epidemiological data report an improved life span of patients with acromegaly probably due to better acromegaly management; additionally, the number of pituitary incidentaloma in general population also increased over time due to more frequent imaging. Therefore, the number of elderly patients, newly diagnosed with acromegaly or in follow-up, is expected to grow in the coming years and clinicians will need to be aware of particularities in managing these patients. PURPOSE This review aims to explore different aspects of acromegaly of the elderly patients, focusing on epidemiology, diagnosis, clinical presentation, complications, and management options. METHODS Available literature has been assessed through PubMed (data until August 2019) by specific keywords. CONCLUSIONS Available data on acromegaly in the elderly patient are sparse, but point to important differences. Further studies are needed comparing elderly with younger patients with acromegaly to better define a tailored diagnostic and therapeutic management.
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Affiliation(s)
- Maria Rosaria Ambrosio
- Section of Endocrinology & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Irene Gagliardi
- Section of Endocrinology & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Sabrina Chiloiro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Marta Bondanelli
- Section of Endocrinology & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Antonella Giampietro
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Bianchi
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Endocrinology, Fondazione A Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Fleseriu
- Northwest Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Maria Chiara Zatelli
- Section of Endocrinology & Internal Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy.
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21
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Ioachimescu AG, Handa T, Goswami N, Pappy AL, Veledar E, Oyesiku NM. Gender differences and temporal trends over two decades in acromegaly: a single center study in 112 patients. Endocrine 2020; 67:423-432. [PMID: 31677093 DOI: 10.1007/s12020-019-02123-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 10/22/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE To evaluate the impact of gender and year at surgery on clinical presentation and postoperative outcomes in acromegaly. METHODS Retrospective review of patients operated between 1994 and 2016 to compare presentation and outcomes in groups defined by gender and year of surgery. Kaplan-Meier survival analyses with a composite endpoint (recurrence, reoperation, and radiation) were used for gender comparison and Youden indices for biochemical remission rates changes during study period. RESULTS Primary indications for evaluation were phenotype, neurological symptoms, incidentaloma, hypogonadism, and galactorrhea. At surgery, men (N = 54) were younger (43.6 ± 12.7 years) than women (N = 58, 48.7 ± 12.3, P = 0.04). Male:female ratios before and after age 50 were 1.4 and 0.6 respectively. Men had higher mean IGF-1 levels (874 ± 328 vs 716 ± 296, P < 0.01) and smaller tumors (1.8 ± 1.3 cm vs 2.3 ± 1.5, P = 0.04). Postoperative remission rates were comparable (51% men, 56% women) and inversely associated with cavernous sinus invasion and GH levels. Women had longer mean follow-up (5.2 ± 3.4 years vs 3.6 ± 3.6 men, P = 0.02) and longer endpoint-free survival (P < 0.01). At last follow-up, 89.6% women and 70% men had normal IGF-1 levels (P = 0.03). Postoperative remission rates were higher in patients operated after February 15, 2011 (67.35 vs 43.5% previously, P = 0.01). In late vs early surgery group, physical changes as main indication for screening decreased (54 vs 30%, P < 0.01), while incidentaloma and hypogonadism increased. Median GH levels were lower in late vs early surgery group (P = 0.03). CONCLUSION We demonstrate gender-specific characteristics and an evolving spectrum of clinical presentation with implications for earlier diagnosis and personalized management of acromegaly.
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Affiliation(s)
- Adriana G Ioachimescu
- Dept of Medicine (Endocrinology), Emory School of Medicine, 1365 B Clifton Rd, Atlanta, GA, 30322, USA.
- Dept of Neurosurgery, Emory School of Medicine, 1365 B Clifton Rd, Atlanta, GA, 30322, USA.
| | - Talin Handa
- Emory College of Arts and Sciences, 1557 Dickey Dr., Atlanta, GA, 30322, USA
| | - Neevi Goswami
- Georgia Institute of Technology, North Ave NE, Atlanta, GA, 30332, USA
| | - Adlai L Pappy
- Emory School of Medicine, 201 Dowman Dr., Atlanta, GA, USA
| | | | - Nelson M Oyesiku
- Dept of Medicine (Endocrinology), Emory School of Medicine, 1365 B Clifton Rd, Atlanta, GA, 30322, USA
- Dept of Neurosurgery, Emory School of Medicine, 1365 B Clifton Rd, Atlanta, GA, 30322, USA
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22
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Abreu C, Guinto G, Mercado M. Surgical-pharmacological interactions in the treatment of acromegaly. Expert Rev Endocrinol Metab 2019; 14:35-42. [PMID: 30595057 DOI: 10.1080/17446651.2019.1559729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/13/2018] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Acromegaly requires a multimodal treatment approach that includes surgery by an expert pituitary neurosurgeon, pharmacological treatment with one or more of the available drugs and radiation therapy. These treatment alternatives are not mutually exclusive but rather complement each other when properly indicated in the individual patient. In this review, we summarize and analyze the available data concerning the choice of the surgical approach (microscopy vs. endoscopy) and the interactions between medical treatment with somatostatin analogs and pituitary surgery. AREAS COVERED Technical aspects, complications and outcome of transsphenoidal surgery (TSS); Advantages and disadvantages of the microscopic and endoscopic approaches; Safety and efficacy of somatostatin analogs (SSA); Primary pharmacological therapy versus primary TSS; Benefits of the preoperative treatment with SSA; and the effect of surgical tumor debulking in the therapeutic response to SSA. EXPERT COMMENTARY Continuing efforts at improving surgical techniques and at generating more efficacious pharmacological therapies for acromegaly are likely to improve the outcome of these patients. However, an integral approach of the patient aimed not only at achieving biochemical criteria of cure but also at treating the individual comorbidities is mandatory to improve the quality of life of these patients and to reduce their mortality rate.
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Affiliation(s)
- Coralys Abreu
- a Endocrinology Service , Centro Medico Nacional 20 de Noviembre, ISSSTE , Mexico City , Mexico
| | - Gerardo Guinto
- b Neurological Center , American British Cowdray Medical Center , Mexico City , Mexico
| | - Moisés Mercado
- c Experimental Endocrinology Unit , Hospital de Especialidades, Centro Medico Nacional S. XXI, IMSS , Mexico City , Mexico
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