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Del Corso LM, Mesa Junior CO, Andrade VFC, Fidalski SZK, Boguszewski CL. Diagnostic, therapeutic, and prognostic characteristics of patients with acromegaly according to tumor size at diagnosis. Pituitary 2024:10.1007/s11102-024-01432-w. [PMID: 39088137 DOI: 10.1007/s11102-024-01432-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE To evaluate clinical, laboratory, radiological, therapeutic, and prognostic characteristics of patients with acromegaly according to the size of the growth hormone (GH)-secreting pituitary adenoma at diagnosis. METHODS Observational, retrospective, single-center study of patients with acromegaly followed at a tertiary center. Data were collected regarding clinical presentation, characteristics of the adenoma in the magnetic resonance imaging, GH and IGF-1 levels, and disease control after surgery or adjuvant treatment (normal IGF-1 levels). Patients were divided according to the adenoma size at diagnosis in: group I < 10 mm; II 10-19 mm; III 20-29 mm; IV 30-39 mm; and V ≥ 40 mm. Comparisons were made between the groups, and correlations of tumor size with disease parameters, ROC curves, and logistic regression analyses were performed to investigate tumor size and confounding factors that could impact the outcomes. RESULTS 117 patients were studied [59 women, age at diagnosis 43 ± 13 years; group I = 11 patients (9%); group II 54 (46%); group III 34 (29%); group IV 10 (9%); group V 8 (7%)]. Hypopituitarism, cavernous sinus invasion, GH levels, and use of somatostatin receptor ligands had their prevalence increased according to the adenoma size. Age showed a negative correlation with tumor size. A tumor diameter around 20 mm was the best predictor for the presence of hypopituitarism, invasiveness, need of adjuvant therapies, and poorer disease control. CONCLUSION Adenomas < 20 mm showed lower morbidity and better therapeutic response in acromegaly, while those ≥ 20 mm had similar clinical, therapeutic, and prognostic behavior.
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Affiliation(s)
- Leticia Marinho Del Corso
- SEMPR (Endocrine Division), Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
| | - Cleo Otaviano Mesa Junior
- SEMPR (Endocrine Division), Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
| | | | | | - Cesar Luiz Boguszewski
- SEMPR (Endocrine Division), Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil.
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Koylu B, Firlatan B, Sendur SN, Oguz SH, Dagdelen S, Erbas T. Giant growth hormone-secreting pituitary adenomas from the endocrinologist's perspective. Endocrine 2023; 79:545-553. [PMID: 36318446 DOI: 10.1007/s12020-022-03241-2] [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: 07/10/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Since giant (≥40 mm) GH-secreting pituitary adenomas are rarely encountered, data on their characteristics and treatment outcomes are limited. We aimed to investigate the characteristics of giant GH-secreting pituitary adenomas and to compare their clinical, biochemical, imaging and histopathological features with non-giant macroadenomas. MATERIALS AND METHODS We have evaluated 15 (six female/nine male) and 57 (29 female/28 male) patients with acromegaly in giant and <40 mm adenoma groups, respectively. Patients with <40 mm adenoma were further divided into subgroups with adenoma size 20-29 mm and 30-39 mm. RESULTS In giant adenoma group, median (IQR) preoperative maximal diameter of adenoma was 40 mm (5 mm), median preoperative GH level was 40 (153.4) ng/mL and median baseline IGF-1 level was 2.19 (1.88) × ULN for age and sex. The number of surgeries was significantly higher in giant adenoma group (median 2, IQR 2) in which 66.7% of patients underwent repeated surgeries (p = 0.014). Residual tumor was detected after last operation in all patients with giant adenoma. Total number of treatment modalities administered postoperatively increased as adenoma size increased (p = 0.043). After a median follow-up duration of 10 years (IQR 10), hormonal remission was achieved in six patients (40%) of giant adenoma group, while the rate of hormonal remission in non-giant adenoma group was 37%. Although preoperative GH and IGF-1 levels and Ki-67 index tended to be higher with increasing adenoma size, there was no statistically significant difference between groups in terms of these variables, as well as age, sex and invasion status. CONCLUSION Hormonal remission rates of acromegaly patients with ≥20 mm pituitary macroadenoma were comparable. However, giant GH-secreting pituitary adenomas require an aggressive multimodal treatment approach.
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Affiliation(s)
- Bahadir Koylu
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey.
| | - Busra Firlatan
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Suleyman Nahit Sendur
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Department of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara, Turkey
| | - Seda Hanife Oguz
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Department of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara, Turkey
| | - Selcuk Dagdelen
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Department of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara, Turkey
| | - Tomris Erbas
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
- Department of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara, Turkey
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Matsumoto T, Ono T, Onodera T, Oda M, Takahashi M, Omae T, Shimizu H. Transventricular Preforniceal Approach Combined with Endoscopic Transnasal Surgery for a Giant Pituitary Adenoma: A Case Report and Literature Review. NMC Case Rep J 2022; 8:827-833. [PMID: 35079555 PMCID: PMC8769444 DOI: 10.2176/nmccrj.cr.2021-0274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2021] [Indexed: 11/20/2022] Open
Abstract
Giant pituitary adenomas carry significant surgical risks when treated with transsphenoidal approaches or the transcranial approach alone. Combined transsphenoidal and transcranial approaches have been reported; however, removing adenomas extending into the third ventricle may still be challenging. We report a case of giant pituitary adenoma expanding into the third ventricle, which was removed using a combined transventricular preforniceal approach and an endoscopic endonasal transsphenoidal surgery (ETSS). A 41-year-old man with headache, nausea, and a 1-week history of a visual field defect was transferred to our hospital. He had a disturbed left visual acuity, right homonymous hemianopia, and choked disc in both eyes. Preoperative magnetic resonance imaging revealed a giant pituitary adenoma with a maximum diameter of 55 mm extending from the intrasellar to the suprasellar region, thus occupying the entire third ventricle and causing hydrocephalus. The space between the anterior commissure and the fornix was expanded. The foramen of Monro was shifted backward due to compression by the tumor. He underwent maximum surgical resection using a combined transventricular preforniceal approach and ETSS. Considering technical demands and reliability, the intra- to suprasellar parts were removed by ETSS while the intraventricular part was removed through the preforniceal approach. The residual tumor in the right cavernous sinus and behind the anterior communicating artery was treated with stereotactic radiotherapy. One year after the operation, the patient leads an independent life. The combined technique of the preforniceal approach and ETSS provided a direct view of the entire third ventricle and hemostasis in the present case.
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Affiliation(s)
- Tomohiro Matsumoto
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Takahiro Ono
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Tomo Onodera
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Masaya Oda
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Masataka Takahashi
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Tomoya Omae
- Department of Neurosurgery, Omagari Kosei Medical Center, Daisen, Akita, Japan
| | - Hiroaki Shimizu
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
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Penner F, Di Perna G, Baldassarre BM, Garbossa D, Zenga F. Endoscopic resection of supergiant pituitary adenoma. Surg Neurol Int 2021; 12:535. [PMID: 34754585 PMCID: PMC8571212 DOI: 10.25259/sni_630_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/17/2021] [Indexed: 11/27/2022] Open
Abstract
Background: Giant pituitary adenomas are a rare finding and the literature is inconclusive regarding the most appropriate approach. In supergiant adenomas, where the size of the tumor is exceptional, both a combine approach versus a solely transcranial or endoscopic approach have been reported.[2,3,5] Case Description: In this video, an entirely endoscopic resection of a supergiant pituitary adenoma is demonstrated. The exceptional size (4.5 × 5.8 × 5.4 cm) of the tumor and the peculiarity of the anatomical relations are documented in the video. The anterior cerebral arteries, both the A1 and A2 tracts, as well as the anterior communicating arteries are shown to be posteriorly dislocated and encased by the tumor which is pealed from the arteries themselves. Furthermore, the optic nerves are decompressed and cleaned from any residual tumor. The procedure is highly technically challenging since the furthermost part of the adenoma is also the one attached to the great intracranial arteries. A 45 optic and angle instruments were used for the major part of the surgery. Considering the high risk of postoperative CSF leak, a multilayer closure with nasoseptal flap was chosen. The postoperative MRI showed a gross total resection of the lesion in the absence of any complications and no new neurological nor endocrinological deficit appeared. Conclusion: Expanded endoscopic endonasal approach could represent a valuable way to face giant adenoma, providing a direct corridor toward the lesion and safe control of both the chiasmatic vasculature and the anterior communicating artery complex. Multilayer reconstruction is mandatory to avoid postoperative CSF leak.[1,4]
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Affiliation(s)
- Federica Penner
- Department of Neuroscience, Neurosurgery Unit, AOC Città Della Scienza e Della Salute, Turin, Italy
| | - Giuseppe Di Perna
- Department of Neuroscience, Neurosurgery Unit, AOC Città Della Scienza e Della Salute, Turin, Italy
| | - Bianca Maria Baldassarre
- Department of Neuroscience, Neurosurgery Unit, AOC Città Della Scienza e Della Salute, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience, Neurosurgery Unit, AOC Città Della Scienza e Della Salute, Turin, Italy
| | - Francesco Zenga
- Department of Neuroscience, Neurosurgery Unit, AOC Città Della Scienza e Della Salute, Turin, Italy
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Cambria V, Beccuti G, Prencipe N, Penner F, Gasco V, Gatti F, Romanisio M, Caputo M, Ghigo E, Zenga F, Grottoli S. First but not second postoperative day growth hormone assessments as early predictive tests for long-term acromegaly persistence. J Endocrinol Invest 2021; 44:2427-2433. [PMID: 33837920 PMCID: PMC8502138 DOI: 10.1007/s40618-021-01553-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/10/2021] [Indexed: 10/24/2022]
Abstract
PURPOSE Postoperative assessment of acromegaly activity is typically performed at least 3 months after neurosurgery (NS). Few studies have evaluated the use of early postoperative growth hormone (GH) levels as a test to predict short- and long-term remission of acromegaly. Our objective was to evaluate the diagnostic performance of serum random GH on a postoperative day one (D1-rGH) and two (D2-rGH), particularly in predicting long-term disease persistence. MATERIALS AND METHODS Forty-one subjects with acromegaly who were undergoing NS were enrolled (mean age ± SD 47.4 ± 13.1 years at diagnosis; women 54%; macroadenomas 71%). The final assessment of disease activity was performed one year after NS. ROC curves were used to evaluate the diagnostic performance of D1-rGH and D2-rGH. RESULTS After a 1-year follow-up, the overall remission rate was 55%. ROC analysis identified an optimal D1-rGH cut-off value of 2.1 ng/mL for diagnosing long-term disease persistence (55.6% SE; 90.9% SP). The cut-off point became 2.5 ng/mL after maximizing specificity for disease persistence (yielding a 100% positive predictive value) and 0.3 ng/mL after maximizing sensitivity for disease remission. The optimal D2-rGH cut-off value was 0.6 ng/mL (81.8% SE; 50% SP); the cut-off point became 2.9 ng/mL after maximizing specificity and 0.1 ng/mL after maximizing sensitivity, with no clinical utility. CONCLUSIONS D1-rGH could be a highly specific test for the early diagnosis of long-term acromegaly persistence, which is predicted by a value > 2.5 ng/mL with a great degree of certainty. The diagnostic performance of D2-rGH was insufficient. Further research is required to validate these preliminary results prior to modifying the postoperative management of acromegaly.
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Affiliation(s)
- V. Cambria
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - G. Beccuti
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - N. Prencipe
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - F. Penner
- Division of Neurosurgery, Department of Neurosciences “Rita Levi Montalcini”, University of Turin, Turin, Italy
| | - V. Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - F. Gatti
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - M. Romanisio
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - M. Caputo
- Division of Endocrinology, Department of Translational Medicine, University of Eastern Piedmont “Amedeo Avogadro”, Novara, Italy
| | - E. Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
| | - F. Zenga
- Division of Endocrinology, Department of Translational Medicine, University of Eastern Piedmont “Amedeo Avogadro”, Novara, Italy
| | - S. Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
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